552 SAMJ VOL 19 4 MEI1991

Perinatal mortality an intervention study

D. WILKINSON

Summary Results

Perinatal mortality is high in rural hospitals in South Africa. Inpart this is due to less than optimal care. This study deter­mined the perinatal mortality experienced by a rural hospitaland its clinics. Avoidable causes of death are described andvarious intervention strategies that effectively and rapidlyprevented such deaths, reducing perinatal mortality by one­third, are outlined.

During the study there were 2 193 consecutive hospital andclinic births among which 90 perinatal deaths occurred - aperinatal mortality rate of 41/1000 total births (stillbirth rate22/1000).

This compares with a perinatal mortality rate of 60/1 000 inthe pilot study. Perinatal mortality thus fell by almost one­third (Table I).

S Atr Med J 1991; 79: 552-553.

The percentage of deaths considered avoidable over thestudy period was 13%. This compares with 30% during thepilot study. Chi-square comparison (of actual numbers) showedthis fall to be highly significant (P < 0,05).

The 11 perinatal deaths considered avoidable are detailed inTable 11.

x' = 9,30dl= 1

P<0,OO5

TABLE I. COMPARISON OF STUDIES

Pilot study,19881989 study

!x' = 3,877

6:: 21:: :'~~~:Odl= 1P< 0,05

11 12

Perinatal deaths'Preventable' perinataldeaths

Total births c;;. 1000 g)

Case Facility1 Clinic

2 Clinic

3 Hospital

4 Hospital5 Clinic

6 Clinic

7 Clinic

8 Hospital

9 Clinic

TABLE 11. DETAILS OF PERINATAL DEATHS

Cause of perinatal deathAnaemia - Hb 5,20 gldl untreated,stillbirth 3 wks laterAnaemia - Hb 6,10 gldl untreated,intra-uterine death 10 days laterCord prolapse - failure to performcaesarean section for footling breech at4 cm dilatationFailed resuscitation - equipment missingSevere pre-eclampsia - not referred anddied 2 days laterAntenatal blood not·taken - intra-uterinedeath, VDRL-positive, clinically congenitalsyphilisAntenatal blood not taken - intra-uterinedeath, VDRL-positive, clinically congenitalsyphilis .

Congenital syphilis - VDRL-positive treat­ed as gonorrhoea. Intra-uterine death 1moo laterAntenatal blood not taken - intra-uterinedeath, VDRL-positive, clinically congenitalsyphilis

10 Hospital Asphyxia - slow delivery of head atcaesarean section

11 Hospital severe pre-eclampsia - not reported dur-ing labour. Stillbirth

Patients and methods

Perinlltal mortality is a useful measure of the socio-economicstatus of a community and the standard of obstetric careprovided within the community. Much has been wrinen aboutthe causes of perinatal mortality and their importance in boththe developed and the developing world. 1-4

To rural health workers perinatal mortality rates are crucialbecause some of the factors that lead to perinatal death stemfrom less than optimal care. 5 These statistics can be used as aform of audit and anempts can be made to lower perinatalmortality by improving care.

Over a 3-month period in 1988 a pilot study was performedat Jane Furse Hospital, Lebowa, in which 640 consecutivehospital and clinic deliveries were analysed. Perinatal mortalitywas 60 per I 000 total births (~ I 000 g). In 30% of theperinatal deaths basic errors or omissions in care had occurred.These included failure to perform antenatal blood tests, failureto react to abnormal results appropriately (50% of clinic mid­wives believed the VDRL test was for gonorrhoea and sub­sequently undertreated syphilis) and failure to refer patients'with elevated blood pressure. Inappropriate per vaginamexaminations were often carried out in patients with pervaginam bleeding or premature rupture of the membranes.Many of these deaths could be considered avoidable and are atarget for prevention.

In 1989 a perinatal mortality intervention study was under­taken, with the aim of reducing perinatal mortality by elimi­nating these avoidable deaths through the introduction of avariety of intervention strategies.

All perinatal deaths occurring over a 7-month period wereanalysed in detail, prospectively. In particular, a search wasmade for error or omission in management and their contri­bution to the perinatal death was considered.

Intervention strategies were introduced at the start of thestudy. The strategies were devised using information from thepilot study and from any further avoidable deaths that occurredduring the intervention study.

Jane Furse Hospital, Lebowa, TvlD. WILKINSON, B.Se., M.B. CH.B. (MANe.), DIP. P.Re. (SA) (Present address:206 Bramhall Lane South, Stockport, UK)

Accep,ed 13 Sep' 1990.

Discussion

The pilot study performed in 1988 confirmed the high perinatalmortality rate experienced in a rural hospital such as JaneF:urse. It also showed that fundamental flaws in basic mid­wifery and obstetric care contributed to much of the mortality.No specific intervention measures were undertaken at thisstage, although in common with everyday clinical practice,mistakes were highlighted and discussed.

The concept of avoidability is important and it may beimpossible to know if the absence of an avoidable factor willprevent a particular death. 5,6 In this study the reasonableassumption was made that receiving antenatal care is betterthan not receiving it,7 and that such care should be correctlycarried out.8 It is deaths occurring in association with deviationfrom such care that are considered avoidable, although this is asubjective decision.

A number of intervention strategies were employed duringthe study period. A community obstetrics guide was developed,which contained simple, dogmatic guidelines on managementand referral thresholds for clinic midwives to follow. Thisguide was introduced at training days for the midwives.Instructions on the correct management of anaemic andVDRL-positive patients were given, and a policy was initiatedto admit all pre-eclamptic patients with a diastolic bloodpressure of;;:: 100 mmHg.

With the help of the hospital administration, a regularsystem of blood collection from and result delivery to theclinics was organised. This replaced the ad hoc and inefficientsystem previously in use, ensuring blood results could be actedupon within 2 weeks of booking. Abnormal results were thusacted upon swiftly and correctly.

Hospital-based midwives were given instruction in neonatalresuscitation (including the preparation of necessary equip­ment) and management of labour room emergencies (e.g.breech delivery and shoulder dystocia).

Although other variables, such as seasonal variation, medicalstaff'mg changes, everyday attempts to improve clinical practice,and comparison between a 3-month and a 7-month period

SAMJ VOL 79 4 MAY 1991 553

must be considered as influencing the results described, themajor influence seems to have been the introduction of specificintervention strategies with a subsequent reduction in thenumber of deaths associated with error or omission. Thisproduced.a fall in perinatal mortality of almost one-third.

Rural hospitals are busy and understaffed. Perinatal mortalityaudit as used here is an effective method of detecting easilypreventable deaths and thus can be used to direct scarce timeand manpower resources to maximum effect. Maintained overa year, the results achieved here prevent 76 perinatal deaths inthis hospital (prevention of 19 deaths per 1000 in 4000 annualdeliveries).

Conclusion

The contribution of suboptimal care to perinatal mortality isoften not obvious to busy staff. Careful audit demonstrates theproblems well and indicates areas for improvement. Inter­vention will reduce perinatal mortality and, reproducedcountry-wide, this could be a highly cost-effective method ofreducing perinatal mortality.

REFERENCES

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4. Rip MR, Keen CS, Woods DL. Binhs and perinatal deaths in Mitchell'sPlain. S AIr Med] 1986; 70: 827-830.

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enquiries into perinatal deaths in the Mersey region. Lancer 1982; I:491-494.

7. Ross SM, Macpherson TA, Naeye RL, Khatree MHD, Wallace JA. Causesof fetal and neonataJ monality in a South African black community. S AIrMed] 1982; 61: 905-908.

8. Beiscber NA, Mackay EV. ObSlerrics and the Newborn: An lllustrated Text­book. 2nd ed. London: Bailliere Tindall, 1986: 46-62.