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The impact of free antenatal care on perinatal mortality
International Journal of Gynecology & Obstetrics 71 Ž2000. 205᎐207
Brief communication
The impact of free antenatal care on perinatal mortality S. Ebrahim, A. DaponteU , F. Guidozzi Department of Obstetrics and Gynecology, Uni¨ ersity of Witwatersrand Medical School, Parktown, South Africa Received 8 December 1999; received in revised form 17 February 2000; accepted 17 February 2000
Keywords: Obstetrics; Tertiary center developing world; Free antenatal care; South Africa; Perinatal mortality; Avoidable factors
In view of the recent introduction in 1995 of free maternity care in South Africa, an evaluation of the level of obstetric care at Johannesburg Hospital, a 2000-bed tertiary care facility with 100 maternity beds, was conducted. A retrospective descriptive study was undertaken over a 3-year period Ž1 January 1994᎐31 December 1996.. All perinatal deaths Žstillbirths of weight G 1000 g and neonatal deaths up to and including the 6th day of life. were audited, to determine the perinatal mortality rate ŽPMR. and avoidable factors for perinatal losses. Deaths were classified according to obstetric causes and avoidable factors were sought. Data were extracted from relevant files and analyzed with a specific computer program w1x.
U
Corresponding author. Tel.: q27-11-488-3179 or 646 3563; fax: q27-11-646-3563.
During the study period there were 21 004 deliveries of which 559 resulted in 494 stillbirths and 95 early neonatal deaths ŽTable 1.. Due to missing records a total of 541 Ž97%. of cases were reviewed. The PMR for each year of study is shown in Table 1. Of interest, is the increase in early neonatal deaths in 1995 as compared to 1994 and then a return to lower levels in 1996. This difference proved statistically significant Ž P-value 0.0008. and possibly reflects the introduction of free maternity care without the necessary accompanying increases in general resources. The decrease in 1996 reflects organizational changes implemented within the departments of obstetrics and pediatrics in order to facilitate coping with the increased demand on services. The five most common causes of death were in order of frequency, unexplained intrauterine death Ž33%., antepartum hemorrhage Ž18%., in-
0020-7292r00r$20.00 䊚 International Federation of Gynecology and Obstetrics. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 0 . 0 0 2 1 2 - 5
S. Ebrahim et al. r International Journal of Gynecology and Obstetrics 71 (2000) 205᎐207
206
Table 1 Total number of deliveries and perinatal mortality Year
Total deliveries
Still births
Early neonatal deaths
Total perinatal deaths
PMRr 1000 births 26 28.9 22.7
1994 1995 1996
6125 7053 7826
143 162 159
26 50 19
169 212 178
Total
21 004
464
95
559
fection, mainly syphilis Ž13%., asphyxia Ž10%. and preterm labor Ž9%.. Avoidable factors were implicated in 31.3% of
all perinatal deaths ŽTable 2.. Patient orientated factors were the most common, with non-attendance being the most prevalent problem. Problems related to medical management and administration are further outlined in Table 2. These remained constant before and after free antenatal care were introduced. Whilst we are currently a long way from achieving a PMR similar to first world standards ŽPMR in the United Kingdom in 1995 was 7᎐8 in 1000 w2x., this audit has enabled us to highlight our unique problems. Areas that were identified and that are currently being addressed are; better patient education about the benefits of regular antenatal attendance Žfree care did not automati-
Table 2 Occurrence of avoidable factors Avoidable factors
Occurrences
Patient Unbooked patient Delay in seeking medical attention during labor Booked late in pregnancy Inappropriate response to antepartum hemorrhage Inappropriate response to rupture of membranes Attempted termination of pregnancy Infrequent visits to antenatal clinic Inappropriate response to poor fetal movements
118 71 20 12 6 3 3 2 1
21.8 13.1 3.7 2.2 1.1 0.6 0.6 0.4 0.2
Medical personnel Fetal distress not detected because fetus was not monitored Fetal distress not detected ᎏ signs interpreted incorrectly Medical personnel underestimated fetal size Medical personnel overestimated fetal size No response to maternal hypertension No response to positive syphilis serology test Poor progress in labor ᎏ partogram interpreted incorrectly Delay in nursing staff calling for expert assistance No response to history of stillbirths, abruptio, etc. No response to maternal glycosuria Poor progress in labor and partogram not used correctly
42 12 7 6 3 3 3 3 2 1 1 1
7.7 2.2 1.3 1.1 0.6 0.6 0.6 0.6 0.4 0.2 0.2 0.2
Administrati¨ e problems Lack of transport ᎏ hospitalrclinic Inadequate theater facilities Result of syphilis screening not returned to hospitalrclinic Inadequate facilities in neonatal care unit Že.g. ventilator.
10 4 4 1 1
1.8 0.7 0.7 0.2 0.2
170
31.3
TOTAL
Deaths Ž%.
S. Ebrahim et al. r International Journal of Gynecology and Obstetrics 71 (2000) 205᎐207
cally lead to regular service usage.; structured continuous in-service staff training at all levels; and constant communication with administration to optimize facilities within budgetary constraints. References w1x Pattinson RC, Makin JD, Shaw A, Delport SD. The value of incorporating avoidable factors into perinatal audits. S Afr Med J 1995;85:145᎐147.
207
w2x Neale R. Intrapartum stillbirths and deaths in infancy: the first CESDI report. In: Studd J, editor. Progress in obstetrics and gynaecology, vol. 12. Edinburgh: Churchill-Livingstone, 1997:193᎐211.
Brief communication
The impact of free antenatal care on perinatal mortality S. Ebrahim, A. DaponteU , F. Guidozzi Department of Obstetrics and Gynecology, Uni¨ ersity of Witwatersrand Medical School, Parktown, South Africa Received 8 December 1999; received in revised form 17 February 2000; accepted 17 February 2000
Keywords: Obstetrics; Tertiary center developing world; Free antenatal care; South Africa; Perinatal mortality; Avoidable factors
In view of the recent introduction in 1995 of free maternity care in South Africa, an evaluation of the level of obstetric care at Johannesburg Hospital, a 2000-bed tertiary care facility with 100 maternity beds, was conducted. A retrospective descriptive study was undertaken over a 3-year period Ž1 January 1994᎐31 December 1996.. All perinatal deaths Žstillbirths of weight G 1000 g and neonatal deaths up to and including the 6th day of life. were audited, to determine the perinatal mortality rate ŽPMR. and avoidable factors for perinatal losses. Deaths were classified according to obstetric causes and avoidable factors were sought. Data were extracted from relevant files and analyzed with a specific computer program w1x.
U
Corresponding author. Tel.: q27-11-488-3179 or 646 3563; fax: q27-11-646-3563.
During the study period there were 21 004 deliveries of which 559 resulted in 494 stillbirths and 95 early neonatal deaths ŽTable 1.. Due to missing records a total of 541 Ž97%. of cases were reviewed. The PMR for each year of study is shown in Table 1. Of interest, is the increase in early neonatal deaths in 1995 as compared to 1994 and then a return to lower levels in 1996. This difference proved statistically significant Ž P-value 0.0008. and possibly reflects the introduction of free maternity care without the necessary accompanying increases in general resources. The decrease in 1996 reflects organizational changes implemented within the departments of obstetrics and pediatrics in order to facilitate coping with the increased demand on services. The five most common causes of death were in order of frequency, unexplained intrauterine death Ž33%., antepartum hemorrhage Ž18%., in-
0020-7292r00r$20.00 䊚 International Federation of Gynecology and Obstetrics. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 0 . 0 0 2 1 2 - 5
S. Ebrahim et al. r International Journal of Gynecology and Obstetrics 71 (2000) 205᎐207
206
Table 1 Total number of deliveries and perinatal mortality Year
Total deliveries
Still births
Early neonatal deaths
Total perinatal deaths
PMRr 1000 births 26 28.9 22.7
1994 1995 1996
6125 7053 7826
143 162 159
26 50 19
169 212 178
Total
21 004
464
95
559
fection, mainly syphilis Ž13%., asphyxia Ž10%. and preterm labor Ž9%.. Avoidable factors were implicated in 31.3% of
all perinatal deaths ŽTable 2.. Patient orientated factors were the most common, with non-attendance being the most prevalent problem. Problems related to medical management and administration are further outlined in Table 2. These remained constant before and after free antenatal care were introduced. Whilst we are currently a long way from achieving a PMR similar to first world standards ŽPMR in the United Kingdom in 1995 was 7᎐8 in 1000 w2x., this audit has enabled us to highlight our unique problems. Areas that were identified and that are currently being addressed are; better patient education about the benefits of regular antenatal attendance Žfree care did not automati-
Table 2 Occurrence of avoidable factors Avoidable factors
Occurrences
Patient Unbooked patient Delay in seeking medical attention during labor Booked late in pregnancy Inappropriate response to antepartum hemorrhage Inappropriate response to rupture of membranes Attempted termination of pregnancy Infrequent visits to antenatal clinic Inappropriate response to poor fetal movements
118 71 20 12 6 3 3 2 1
21.8 13.1 3.7 2.2 1.1 0.6 0.6 0.4 0.2
Medical personnel Fetal distress not detected because fetus was not monitored Fetal distress not detected ᎏ signs interpreted incorrectly Medical personnel underestimated fetal size Medical personnel overestimated fetal size No response to maternal hypertension No response to positive syphilis serology test Poor progress in labor ᎏ partogram interpreted incorrectly Delay in nursing staff calling for expert assistance No response to history of stillbirths, abruptio, etc. No response to maternal glycosuria Poor progress in labor and partogram not used correctly
42 12 7 6 3 3 3 3 2 1 1 1
7.7 2.2 1.3 1.1 0.6 0.6 0.6 0.6 0.4 0.2 0.2 0.2
Administrati¨ e problems Lack of transport ᎏ hospitalrclinic Inadequate theater facilities Result of syphilis screening not returned to hospitalrclinic Inadequate facilities in neonatal care unit Že.g. ventilator.
10 4 4 1 1
1.8 0.7 0.7 0.2 0.2
170
31.3
TOTAL
Deaths Ž%.
S. Ebrahim et al. r International Journal of Gynecology and Obstetrics 71 (2000) 205᎐207
cally lead to regular service usage.; structured continuous in-service staff training at all levels; and constant communication with administration to optimize facilities within budgetary constraints. References w1x Pattinson RC, Makin JD, Shaw A, Delport SD. The value of incorporating avoidable factors into perinatal audits. S Afr Med J 1995;85:145᎐147.
207
w2x Neale R. Intrapartum stillbirths and deaths in infancy: the first CESDI report. In: Studd J, editor. Progress in obstetrics and gynaecology, vol. 12. Edinburgh: Churchill-Livingstone, 1997:193᎐211.