Retrospective Analysis of Neonates and Stillbirths1).pdf · of neonatal deaths it was decided to research the causes of the stillbirths as well. This study

PREPARED FOR

The Maternal and Child Health DepartmentMinistry of Health, Brickdam, Georgetown

Retrospective Analysis of Neonates and Stillbirths From FIVE HOSPITALS in Guyana, South America, 2007 December 2008

Retrospective Analysis of Neonates and Stillbirths

From FIVE HOSPITALS in Guyana, South America, 2007

December 2008

PREPARED FOR

The Maternal and Child Health DepartmentMinistry of Health, Brickdam, Georgetown

Layout and design by luCa Design, www.lucadesign.ca

ISBN# 978-976-95064-3-5

Retrospective Analysis of Neonates and Stillbirths From FIVE HOSPITALS in Guyana, South America, 2007 December 2008

i NEONATAL STUDY REPORT 2007 i

UN United NationsUNFPA United Nations Population FundUNICEF United Nations Children’s FundVDRL Venereal Disease Research LaboratoryWHO World Health Organization

Acronyms

AIDS AcquiredImmuneDeficiencySyndromeBP Blood PressureBCG Bacille Camille GuerinCaps CapsulesCBC Complete Blood CountFHS FamilyHealthServicesGMO GovernmentMedicalOfficerGPHC Georgetown Public Hospital Corporation LGA LargeforgestationalageLAC Latin America and the CaribbeanLSCS LowerRateCaesareanSectionHb HemoglobinHep B Hepatitis BIMCI IntegratedManagementofChildhoodIllnessIUD IntraUterineDeviceIUGR Intra Uterine Growth RetardationIV IntravenousHIV HumanImmunodeficiencyVirusMCH MaternalandChildHealthMTCT MothertoChildtransmissionMC MaternalClinicMDG MillenniumDevelopmentGoalsMOH MinistryofHealthNMR NeonatalMortalityRate (N) NegativeSGA SmallforgestationalageSIDS SuddenInfantDeathSyndromeSTIs SexuallyTransmittedInfectionsTB Tuberculosis (P) PositivePET Pre-EclampticToxaemiaPID PelvicInflammatoryDiseasePIH Pregnancy Induced HypertensionPAHO Pan American Health OrganizationPMTCT PreventionofMothertoChildTransmissionPPH Postpartum HaemorrhageRh Rhesus RBS RandomBloodSugar

ii NEONATAL STUDY REPORT 2007 iii NEONATAL STUDY REPORT 2007 iii

List of figures Figure 1:SurveyDataonNeonatalDeathsFigure 2: NationalDataonstillbirthandneonataldeathsfor2001forthefivehospitalsFigure 3:AgerangeofmothersandpregnancyoutcomesFigure 4: PercentageofstillbirthsandneonataldeathsFigure 5: EducationalstatusofmothersFigure 6: EthnicityofmotherandpregnancyoutcomesFigure 7: Antenatal CareFigure 8: Old antenatal chart usedFigure 9:NutritionalStatusofMothersFigure 10:EthnicitylevelincomparisontoHblevelFigure 11:NutritionallevelandlocationofmothersFigure 12: Blood Pressure on admissionFigure 13:PercentageofDiabeticMothersFigure 14: Diabetes and Pregnancy OutcomesFigure 15: HIV screening during pregnancyFigure 16:ParityofMothersFigure 17:DeliverieslocationofmothersFigure 18:TypeofdeliveriesofmothersFigure 19: Pregnancy complicationsFigure 20:DistributionoftypeofcomplicationsinthemothersFigure 21:GestationalweeksofmothersandtimeofruptureofmembranesFigure 22:ComparisonoftimeofruptureofmembranesandwhetherantibioticsweregivenFigure 23:TypeofantibioticsgiventomothersFigure 24: Prolonged labour and Pregnancy OutcomesFigure 25:Percentagedistributionofbirthweightsofneonataldeaths/stillbirths2007.Figure 26: Birthweightandpregnancyoutcomeofbabiesin2007Figure 27: DiagramillustratingifstillbirthwasweighedatbirthFigure 28:ApgarscoresofneonatesFigure 29 & 30:Comparisonofbabieswhowerestillbirths/neonataldeaths,prematureorhad normal gestation ageFigure 31: Gestationalweeksofthemotherswhohadneonataldeaths/stillbirthsFigure 32:UseofartificialheatafterbirthofthebabyFigure 33:TimeofdeathofneonatesFigure 34: RecordingofimmunizationstatusinthehospitalchartFigure 35: Causesofneonataldeathson2007atthefivefacilitiesFigure 36: PercentageillustratingwhetherresuscitationwasperformedadequacyFigure 37:Comparisonofwhetherresuscitationwasperformedandneonataldeaths.

tAbLe of contents

Abstract.................................................................................................................................................... iv

Acknowledgements...............................................................................................................................vi

OverviewofStudy.................................................................................................................................. 1

LiteratureReview.................................................................................................................................... 2

SituationAnalysisinLatinAmericaandtheCaribbean................................................................... 3

Lesson Learned.............................................................................................................................. 4

Methodology ......................................................................................................................................... 10

Results & Findings .............................................................................................................................. 14

Antenatal Care............................................................................................................................. 18

NutritionalStatus........................................................................................................................ 19

ComparisonofHbLevelsandLocationofMothers.............................................................. 20

Blood Pressure During Pregnancy........................................................................................... 20

ScreeningforHIVDuringPregnancy...................................................................................... 22

ParityoftheMothers.................................................................................................................. 22

Intranatal Care............................................................................................................................. 23

TypeofDeliveries....................................................................................................................... 23

Pregnancy Complications.......................................................................................................... 24

Prolonged Labour and Pregnancy Outcome........................................................................... 26

Postnatal Care.............................................................................................................................. 27

Birth Weight and Pregnancy Outcome.................................................................................... 28

ApgarScore.................................................................................................................................. 29

Prematurity and Outcome......................................................................................................... 29

TimeofDeath.............................................................................................................................. 31

CausesofNeonatalDeathsintheStudy.................................................................................. 32

ResuscitationPerformedAfterDelivery.................................................................................. 32

Data Analysis............................................................................................................................... 33

Antenatal Care............................................................................................................................. 35

Intranatal Care............................................................................................................................. 37

Immediate Postnatal Period...................................................................................................... 38

References .............................................................................................................................................. 44

Appendix 1: Questionnaire for the neonatal study ....................................................................... 47

iv NEONATAL STUDY REPORT 2007 v NEONATAL STUDY REPORT 2007 v

dl.One-hundredandtwelve (88%)of themothersscreenedforHIVwerenegative forHIV,pregnantmotherswhodeliveredeitherastillbirthorneonatewhodiedwereattendedtobyaqualifiedhealthworkerthatisamidwife,doctorormedexfromthefivehospitalsWhileonly2(1.6%)weredeliveredathome.Sixtythree(82%)oftheneonatesdiedwithintheearlyneonatalperiod,thatis,7daysafterdelivery,10(13%)diedduringthelateneonatalperiodandthetimeof4(5%)neonataldeathswasnotstated.Thesefindingswereinkeepingwithinternationalandnational standards

Significantfindingswereninetyfourpercentofthestillbirthswereweighedatbirthandhadhigherbirthweightthantheneonateswhodied.Thiswasverysignificantatachi-squarevalueof11.7251,df8andaprobabilityof0.1639.Twomotherswhohadmembranesrupturedover1weekwerenotgivenanyantibiotics.Thiswassignificantatachi-squarevalueof23.5815,df.12andprobabilityof0.0232.

Morethanhalfofthemothersinthestudyhadcomplicationsduringdelivery.Nineteen(37%)had blood pressure >140/100mmhg and 5 (10%) had blood pressure greater than 130/90mmhg.

The five leading causes of neonatal deaths from the hospitals were acute respiratorydistress,bacterialsepsisofthenewborn,birthasphyxia,prematurityandbrainhaemorrhage(subarachnoidhaemorrhageduetotheinjuriesoftheheadofthefoetus.Birthinjuriestotheliverandbraindamageoccurredinelevencases.Theseissuespointtoqualityofcareduringintranatalcare.

Socio-economicvariablessuchaseducation,ageofmotherandparitydidnothaveanysignificantimpactontheoutcomeofthepregnancy.Sincetheoldchartwasusedtocollectdataandsomeofthis informationcouldnothavebeenobtained.Causalrelationshipswereassociatedwithbirthweightandpregnancyoutcomes,haemoglobinlevelsandethnicitygroups,prematurityandwhether themotherswere given antibiotics. In the five regions studied,mostmothersdeliveredinahealthinstitutionandsuchgeographicallocationdidnotposeanydirectcausaleffecttotheoutcome.

Complicationsduringpregnancysuchashighbloodpressure,anaemiaandprematurityhadapositiveeffectonthepregnancyoutcomes.Thisinevitabilityledtoprematurity,stillbirthsandneonataldeaths.

Thequestionaskedonreviewingoftheintranataldatais“Iftherewasover87%ofhighlytrainedmidwiferystaffaccordingtothedatawhydidthestillbirthsinmostoftheregionsoutnumbertheneonataldeaths?”Highlytrainedstaffsaccordingtopreviousresearchareknowntoreducetheincidenceofdeathsandsicknessofneonatesandofstillbirths.Notonlywastherehighlytrained staffpresentduringdeliverybut themothersdeliveredat a comprehensive levelof

AbstrActRetrospectiveanalysisofneonataldeathsandstillbirthsinfivehospitalsinGuyana,December2007

ThepurposeofthisstudywastodeterminethecausesofneonataldeathsinRegionalHospitalsandtheGeorgetownPublicHospitalCorporation(GPHC)andtheattributingfactors to thisadverseeffect.

Thisstudywasconductedinfivehospitalsnamely:GeorgetownPublicHospitalCorporation(GPHC)andthefourRegionalHospitals:NewAmsterdam,WestDemerara,SuddieandLindenMcKenzie.Thesehealthfacilitiesofferbasicandcomprehensiveobstetriccaretomothers.Theresults of this studywould serve to inform theMaternal andChildHealthDepartment onthe issuesrelatedtothecausativefactorsonneonataldeathsandthe implicationsofservicerecommendationsforthehealthsector.

Initially,thisstudywasonlydesignedtoreviewneonataldeathsfrom2006and2007.However,becauseofthelargenumberofstillbirthsinsomeregionsincomparisontotheaveragenumberofneonataldeathsitwasdecidedtoresearchthecausesofthestillbirthsaswell.Thisstudywill examine the reasonswhy both stillbirths and neonatal deaths occurred aswell as theinterrelationshipsamongthecausativeagents.

Maternityandneonatalchartswereusedtoobtaindatawhichwasthenusedtofillthepreparedquestionnaires.Thequestionnaireconsistedofbothclosedandopenendedquestions.Variablesweredividedintodemographic,antenatal,intranatalandpostnatal.ThisdatawasthenenteredintotheEpiInfo2003database.ThedatawasanalyzedusingEpiInfoanalysis,usingchi-squaretodeterminewhetherthevariableshadanysignificanceatachi-squarevalueofgreaterthan5.Analysisofthedatawasdoneundersimilarheadingsastheresultsofthestudy.Histograms,barcharts,frequencyandlinegraphswereusedtopresentthedata.

Atotalof127chartswerereviewed,77wereneonataldeathsand50werestillbirths.Therewasinadequatedocumentationofrecords.Insomehospitals,eventhoughthenumbersofdeathswererecorded,thechartsweremisplaced.Only2007chartswerereviewedduetootheryearsnotbeingconsistentforallthehospitals.Themajorityofmothersinthisstudywerebetweentheagesof18-35yearswhilemothersyoungerthanagesixteen(<16years)weretheminority.TheAfro-Guyanesewastheleadingethnicgroupinthestudywith43(34%),followedbytheIndo-Guyaneseandthemixedgroups,37(29%)and28(22%)mothersrespectivelywhileonly9(7%)wereAmerindians.

Thenutritionalstatusof themothersshowedthat52 (40.9%) in thisstudyhadanutritionalstatusof11gramsandover,followedby47(37%)motherswithnutritionalstatusof7–10.99g/

vi NEONATAL STUDY REPORT 2007 1 NEONATAL STUDY REPORT 2007 1

overview of study LocAL context Theneonatalmortalityrateisapproximately75%oftheinfantmortalityrate.Thoughmanyadversepregnancyoutcomes(maternalandneonatal)deatharereportedbytertiarycarefacilities,many of these high-riskpregnantwomen and their neonatesmayhave been referred fromotherinstitutions.ToreducethehighneonatalmortalityratestheMinistryofHealththroughtheMaternalandChildHealthDepartmentembarkedonaSafeMotherhoodstrategyfocusingonantenatal,intranatalandpostnatalcareofpregnantwomenandtheirbabies.However,anintensivestudyneededtobeundertakentodeterminetheetiologicalfactorsandpredisposingfactors to thehighprevalenceofneonatalmortalityandstillbirths.Criteria selection for thestudyincludedaretrospectivestudyofmotherswhodeliveredwithinthelastyear,2007inthefivemainhospitals.Fromthisgroup,allmotherswerestudiedonwhethershehadaneonataldeathoranabortion.

This study has as its goal: Todeterminetheextentofneonataldeaths/stillbirthsinfiveregionalhospitalsandthe GPHCandtheattributingfactorstothisadverseeffect

objectives Todeterminethefrequencyofadversepregnancyoutcomes(neonataldeaths)among1.pregnantwomen.Todeterminethemaincausesofwhyneonatesdiewithinthe28daysperiod.2.Todeterminewhetherpoverty,lowersocialeconomicstatusoranyothercontributing3.factorshaveadirectcausalrelationshiptoneonataldeath.Todeterminewhetherthegeographicalaccesstoserviceshasanydirectrelationshipto4.neonataldeaths.To determine if complications during pregnancy have any adverse effects on the5.pregnancyoutcome.

TheresultsofthisstudywouldservetoinformtheMaternalandChildHealthDepartmentonthe issuesrelatedtothecausativefactorsonneonataldeathsandthe implicationsofservicerecommendationsforthehealthsector.Initially,thisstudywasonlyslatedtoreviewneonataldeathswithinthetwoyearperiodthatisfrom2006and2007.However,becauserecordswerenotavailable foryearsbeyond2007 insomehospitalsdue to infrastructuralchanges, itwasdecidedtodoaretrospectiveanalysisof2007dataonly.Alsobecauseofthelargenumberofstillbirths in some regions in comparison to the neonatal deaths it was decided to research the causesof thestillbirthaswell.Thisstudywillexaminethereasonswhybothstillbirthsandneonataldeathsoccurredaswellastheinterrelationshipwithalltheknowncausativeagents.Firstly,thestudywilllookatpreviousresearchtoreviewthecausativeagentsandthenlinkthemtotheanalysisofthedataofthisstudy.

obstetriccareservicesinthehospitalwhileonly1.6%deliveredathome.Theleadingcausesofdeathsoftheseneonatesdespitehighlytrainedstaffwerebirthasphyxia,respiratorydistress,birthinjuriesduringdeliveryandsepsis.Thesecausespointtotheissuesofinadequatequalityofcare.Eventhoughtheresearchdidnotattempttoaddresstheissueofadequatestaffatthesehospitalsortimeofreferral,thesefactorsshouldbeexploredinfurtherstudies.

RecommendationswerebasedontheWHOneonatalmortalityscenariofordevelopingcountries.Theuseof thepartographduring labour to identifycomplicationsearlyand thusminimizecomplications for themotherandchild. ImplementationofaneonatalchartbasedonWHOmodule isessential.HealthWorkersmustadhere tostandardsandprotocolsofcareduringintranatalcare.Improvementofdeliverytechniquesduringlabourbypracticaldemonstrationswiththeuseofmannequinsisnecessary.EnhancingIMCIattheperipherallevelstoincreasetheskillsofhealthworkersisalsoimportant.Healthworkersshouldhavecontinuoustraininginthemanagementofhighriskcomplicationsofpregnancyanddefinitionsofcare.

AcknowLedgementsGratitudeandappreciationisextendedtoallthosepersonswhoparticipatedinthisresearch.

SpecialthankstoDr.ShamdeoPersaud,ChiefMedicalOfficer,forthereviewofthestudy.

Special thanks toDr. JaniceWoolford,MCHDirector forhervaluable time in the technicalinputofthestudyandensuringthatthisresearchwascompleted.

Dr. Denis Davis for his consultancy in this research and ensuring the completion of thisreport.

Dr.LuisSeoane,MCHAdvisorPAHO/WHOforhisinvaluablecontribution.

Thefieldofficerswhocollectedtheinformation,Ms.EsameSemple,Mr.NoelHolder,NurseLornaBrowneandNurseMartin.

Totheclericalstaffwhoassistedwithobtainingtheinformation,aspecialthankyou.

TotheChiefExecutiveOfficers,RegionalHealthOfficers,SeniorHealthVisitorsandMatronofthehospitalsintheregions,aspecialthankyou.

Appreciationisextendedtothemidwivesanddoctorsofthematernityandpediatricwardsofallthehospitals.

Tothetypistandallthosewhoassistedinonewayoranother,thankyou.

Dr.CurtisLaFleurforhisvaluablecontributioninmakingthispossible.

FinallytoUNICEFfortheirsupportinthisresearch.

2 NEONATAL STUDY REPORT 2007 3 NEONATAL STUDY REPORT 2007 3

Thesepracticescanprevent3outof4newborndeaths(SaveTheChildren,2006).OnSeptember12,2005thenewglobalPartnershiponMaternal,NewbornandChildHealth(PMNCH)wasofficiallylaunched.Thisnewpartnershipmarksamilestoneinanintensiveandgrowingglobalfocusonthehealthofwomen,newbornsandchildren.TheaimofthePMNCHistoharmonizeand intensify actions at country, regional andglobal levels in support ofMDGs 4 and 5 tosavethelivesofmillionsofwomenandchildrenbyexpandingaccesstoproven,cost-effectiveinterventions.

situAtion AnALysis in LAtin AmericAn And the cAribbeAn

neonAtAL cAre issues

Neonatalmortality, defined as death in the first 28 days of life, for LatinAmerica and theCaribbean(LAC)isestimatedat15per1,000,showinganarrowrangeof14(SouthAmerica)to19(theCaribbean)per1000livebirths(WHO,2006).Inaddition,itisestimatedthat,inthisregion,thestillbornrate(foetaldeath)approximatestheneonatalmortalityrate(NMR).

Newbornmortality,accountsfor60%ofinfantdeathsand36%ofunder-5mortalityalthoughexactproportionsvaryinindividualcountriesyetthemajorityofthesedeathsareavoidable.Mortality rates are highest in Haiti, Bolivia, Guyana, Dominican Republic and Guatemala,whereratesare5-6timeshigherthaninthecountrieswiththelowestmortalityrates,suchasChile,CostaRica,CubaandUruguay.

Theruralandurbanpoor,othermarginalizedcommunitiesaswellasindigenousandAfro-descendentpopulationsexperiencedisproportionatelyhighneonatalmortality.

Neonatal survival has not received enough attention, because these deaths are virtuallyinvisible,occurringathomeandoftengoinguncountedinofficialstatistics.Inmanysocieties,neonataldeathsandstillbirthsarestillnotperceivedasaproblem,largelybecausetheyareverycommon.Manycommunitieshaveadaptedtothissituationbynotrecognizingthenewbornasanindividualandbynotnamingthechild,untilthenewbornhassurvivedtheinitialperiod.Thestagnationintheneonatalmortalityratealsoisdueinparttoalackofprogramsspecificallytargetingneonates.Theevidencesuggeststhatthefirstweekoflifeisthemostvulnerableintermsofneonatalmortalityriskandthatthefirst24hoursoflifearedeterminantsforthefuturesurvivalofthechild.Childsurvivalprogramshaveprimarilyfocusedonimportantcausesofdeathafterthefirstfourweeksoflife.

cAuses of neonAtAL deAth

ThetopthreeleadingcausesofneonataldeathinLatinAmericaandtheCaribbeanregionfor2004includeinfections(32%),asphyxia(29%)andprematurity(24%)(PAHO,2004).

LiterAture review regionAL context TheRegion of theAmericas hasmade great strides in reducing child and infantmortality.However,neonatalmortalitytrendshavenotshownanyprogressoverthepasttenyears.Assuch,thereisconsiderableinequitybetweencountriesandwithincountries.TheMillenniumDevelopment Goal for child survival (MDG-4)will not be achievedwithout an equivalentreduction in neonatal mortality. Clear evidence-based and cost-effective interventions toimproveneonatalhealthhavebeen identifiedandare feasible even in settingswith limitedresources.However,theseinterventionsarestillnotreachingthosemostinneed,inpartduetofragmentedeffortstargetingeithermaternalorchildhealth,withtheneonates“fallingbetweenthecracks”(WHO,2005).

gLobAL context, mAndAtes And initiAtives

TheMillenniumDevelopmentGoals(MDGs)arethemostwidelyratifiedhealthanddevelopmenttargetsinhistory.Almostallnationshaveagreedtoreachtheseeightinterlinkinggoals,nearlyhalfofwhichconcerndifferentaspectsofhealth—directlyorindirectly.

Thefourthgoal(MDG-4)commitstheinternationalcommunitytoreducingmortalityinchildrenagedyoungerthan5yearsbytwo-thirdsbetween1990and2015.Between1960and1990,theriskofdyinginthefirst5yearsoflifewashalved-amajorachievementinchildhealth.Therehasbeenrelativelylittledecreaseintheneonatalperiod(thefirst28daysoflife)anddeathsinthefirstweekoflifehaveshowntheleastprogress.Itisalsoimportantinthecontinuumofcaretoapproachacknowledgethe linkbetweenthehealthofmothersandneonates inachievingprogresswithMDG-5.

To meet MDG-4, a substantial reduction in the neonatal mortality rates in high mortalitycountriesisneeded,andreducingdeathsinthefirstweekoflifewillbeessentialtoprogress(WHO 2003). Success in reducing neonatal deaths is possible in low-income countries andwithouthighlydevelopedtechnologybystrengtheningnewborncarewithinexistingchildandmaternalhealthprogramsandbyprovidingmoreattentiontoreachingthosewhohavebeenignored.

These effective, low-cost interventions include:Diphtheriatetanusimmunizationsforpregnantwomen,•Skilledattendantatchildbirth,•Resuscitationofnewbornbabies,•Preventionandmanagementofhypothermia,•Skintoskincontactforlowbirthweightbabies,•Prompttreatmentofnewborninfections,•Immediateandexclusivebreastfeeding,•Educationabouttheimportanceofproperhygieneandwarmthamongothers.•


has been expanded to include essential neonatal care (Bolivia,Honduras,Nicaragua, Peru,GuatemalaandParaguay),integratingthemanagementofneedsforskilledpersonnel,supplies,community support and referral processeswhere indicated. In addition, national standardsandclinicalguidelines forneonatalcareneedtobeupdatedperiodically toreflect the latestevidenceaboutessentialnewborncareinterventions.

cAre And Access to skiLLed birth AttendAnce

On average, 79% of deliveries in LAC occur at the facility level, although there are widedisparities between andwithin countries, especiallywith respect to disadvantaged groups.Inruralareas,accesstoskilledbirthattendants,supplies,functioningequipmentandreferralservices is frequently limited. In addition, a significant proportion of rural births may beattendedbyauxiliarynurseswhodonothavethenecessarymidwiferyskills,equipmentandsupplies.

integrAted mAnAgement of chiLdhood iLLness ApproAch

TheIntegratedManagementofChildhoodIllness(IMCI)strategybeganasameanstoimprovethe management of common childhood illnesses with proper nutrition and immunization.Currently,preventiveandpromotionalapproachestoimprovetheskillsofhealthworkers,thehealthsystem,andfamilyandcommunitypracticeshavebeenincorporatedintothestrategy.IntheLACregion,IMCIismoredevelopedatthecommunityandfacilitylevels.IMCI improves the practices of treatment and care and permits an adequate quality in theevaluation,classification,treatmentandmonitoringoftheillnessesthataffectthehealthofthemotherandofthenewborn.TheneonatalcomponentofthecommunityIMCIconstitutesanimportanttooltoaddressthechallengeofreducingneonatalmortalityintheAmericasasithelpsreducetheincidenceofillnessesanddiminishestheoccurrenceofsequelaeorcomplications.

immunizAtion

Immunizations havemade significant contributions to the reduction of neonatal and childmortalitythroughoutLAC.Since1990,mortalityfrommeasles,neonataltetanusandbacterialmeningitiscausedbyHaemophilusinfluenzahasbeenreducedbygreaterthan95%comparedwith1990figures,andmortalitycausedbypertussisdecreasedbymorethan80%.Maternalimmunizationhasalsoplayedanimportantroleinreducingneonataltetanus,andvaccinationagainstrubellahascontributedtoadecreaseincongenitalrubellasyndromeprevalence.

micronutrients

Micronutrient deficiencies are common inwomen of reproductive age.Manywomen enterpregnancywithinadequatemicronutrientreserveswithothermanifestationsofdeficiencythatcouldseriouslyaffecttheirhealthaswellasthatoftheirnewborn.AccordingtoWHO,43%ofallwomenaged15to49indevelopingcountrieshaveanaemiaduringpregnancy.Anaemiaisarecognizedriskfactorformaternalmortality.VitaminAandZincdeficiencymaycontributetoperinatalsepsisbyimpairingthephysiologicalresponsetoinfections.Folicaciddeficiencyduringthepreconceptionperiodisrelatedtoneuraltubedefectsandduringpregnancycouldberelatedtopretermdelivery.

Otherindirectcausesincludesocio-economicfactorssuchaspoverty,pooreducation,especiallymaternaleducation,lackofempowerment,pooraccessandhinderingtraditionalpractices.

Poverty is the root causeofmanymaternalandneonataldeaths, eitherbecause it increasestheprevalenceofriskfactorssuchaspoornutritionalmaternalstatus,maternalinfectionsorbecause it reduces access to care.Uneducatedmothers are at a severedisadvantage, as aretheirbabies.Motherswhomissedoutonschoolingaremorelikelytobepoor,togetpregnantyoungerandmoreoften,tohavehigherratesofnewbornandmaternalmortality.Babiesbornto mothers with little or no education are at greater risk during birth and especially during the vulnerableearlydaysoflife.Practices,suchasinadequatecordcare,lettingthebabystaywetandcold,discardingcolostrumandfeedingfluids/otherfood,aredeeplyrootedintheculturalfabricofsocietiesandinteractinwaysthatarenotalwaysunderstood.ItisimportanttonotethatthisisnotamajorprobleminGuyana.

mAternAL fActors Affecting neonAtAL heALth

Anothermajorfactorinfluencingofnewborndeathsispoormaternalhealth,especiallyduringpregnancy,deliveryandtheearlypostpartumperiod.

Manypregnantwomensufferfrommalnutrition,areoverworkedandmaystillberecoveringfrom a previous pregnancy resulting from a short interval between pregnancies. Formanymothers,healthcareduringthecriticalperiod-particularlyduringandimmediatelyafterbirthisvirtuallynonexistent.

Othermaternal factorsaffectingneonatalhealth includematernal infectionsuchas sexuallytransmitteddiseases(includingHIV/AIDSandsyphilis),otherinfectionssuchasurinarytractinfections,malaria,theageofthemother(lessthan18yearsorolderthan35years);aparityofmorethan5,thirdtrimesterhaemorrhageandcomplicationsindelivery(prolonged/obstructedlabour).

Lessons LeArned

poLicies And heALth systems reform

The health sector reform process provides an opportunity to scale up highly effective andfeasibleMNCHessential interventions. If these interventionsarepartof thenationalhealthpackageandlinkedtotargetsandbudgetlines,thennationalownership,sustainability,andaccountabilityshouldoccur.

These reforms focus on the continuity of care acrosswomen and children’s health (Brazil),maternalandchildnationalhealthinsuranceinitiatives(Bolivia)andfreematernityprograms(Ecuador).Duetothecloselinkbetweenmaternalandnewbornhealth,essentialobstetriccare


Second,itindicatesthatcarehastobeprovidedinaseamlesscontinuumthatspansthehome,thecommunity,thehealthcentreandthehospital.Opportunitiesforstrengtheningcareinthehouseholdmaybemissedbecausefamiliesarenotinformedornotempoweredtoactonhealthychoices,orthesocioeconomicconditionsinwhichtheyliveimpedehealthychoices.Finally,theContinuumofCareapproachalsoencompassesaseamlessspanofinterventionsfromhealth promotion, disease prevention and control, treatment, rehabilitation and socialreinsertion.

The key elements for a functioning continuum of care system include:

1) Pre-pregnancy care to all women of childbearing ageQualityhealthservicesforadolescentsandaccesstothoseservices.•Immunizations(e.g.Rubellavaccination,HepatitisBvaccination).•Essentialnutritionforgirlsandwomen,andcontrolofnutritionaldisorders(obesity•prevention),includingfolicacidsupplementation.Preventivevisits,riskassessmentandcounselling(e.g.drugandsubstanceabuse•prevention;riskbehaviours).Familyplanning,includingpromotinghealthytimingandspacingofpregnancy.•Screeningandtreatmentforsexuallytransmittedinfections,includingHIV/AIDS.•Treatment of chronic conditions (e.g. diabetes management, hypothyroidism•management).IncludeMalaria,TBandChagasfortheregion.

2) Prenatal CareFour-visit prenatal care package, including:

Historyandphysicalexaminationwithassessmentofbloodpressure,weighgain,and•fundalheight;urinescreenforprotein(multipledipstick).Screenforanaemia(Haemoglobinlevel).•BloodtypeandRh.•Twotetanusimmunizations.•Ironandfolatesupplementation.•CounsellingandtestingforHIV,drugabuse,syphilisscreeningandtreatment.•Identificationandreferralofmultiplepregnancy,abnormallie,preeclampsia-eclampsia.•Birthplanningandemergencypreparedness.•Prenatalcounselling,safedelivery,andpreparationforbreastfeeding.•Informationcounsellingandsupportforwomenexperiencingviolence.•Communitymobilizationandengagement.•Identificationandtreatmentofcommonmaternalinfections(i.e.urinaryinfections).•

breAstfeeding Earlyandexclusivebreastfeedingisrecognizedasakeyfactorinnewbornandinfanthealth.Whileanestimated90%ofmothers inLACbreastfeed theirnewborns,only35%breastfeedexclusivelyforsixmonths.Inaddition,givingnewbornteasorotherfluidsbeforebreastmilkortheearlyintroductionofotherfluidsiscommonpracticeintheRegionwhichcanbeharmful.

mother to chiLd trAnsmission of hivSincetheearly1990’stheHIVepidemichasbecomeaseriousthreattochildsurvivalinLatinAmericaandtheCaribbeanmainlyduetomother-to-childtransmission(MTCT). OnecosteffectiveinterventiontostopthespreadofHIVisthepreventionofmothertochildtransmission(PMTCT).QualityandfocusedprenatalcareisakeyentrypointforHIVtesting,careandtreatment.Ifintegratedintoprenatalcare,PMTCTmaypreventatleast50%ofHIVinfectioninchildrenandmaycontributetothetimelyidentificationandreferralofwomenforantiretroviraltherapy(ART).Currently,severalcountriesinLatinAmericaandtheCaribbeanofferPMTCTin100%oftheirprenatalservices.

surveiLLAnce

AnongoingchallengefortheRegionistoimprovetheregistrationofstillbirthsandneonataldeaths in the official record system. It is important that the same standards/definitions forcollectingdatabeusedsothatcomparisonscanbemadewithincountriesandintheRegion.Inmanycountries,astillbirthornewbornbabywhodiesisnotconsideredapersonneedingtobeofficiallyregistered.At thepresent time,withincertainCaribbeancountries, therestillpersistssomeconfusionastothedefinitionofastillborn.MostLACcountriesdonotroutinelymonitortheindicatorsusedfordatacollection.Localreview,analysisanduseoftheinformationcollectedfordecision-makingarealsogrosslyinadequate.

Ongoingmonitoringofcompliancewithstandardsofnewborncarebyprovidersinhospitalsandhealthcentresisanotherstrategythathasproveneffectiveformakingprovidersawareofgapsinqualityofcareandstimulatingactionstoimprovehealthcarequality.

the continuum of mAternAL, newborn And chiLd cAre ApproAch

Therationaleforacontinuumofcareapproachisbasedonthecloselinkbetweenthehealthandwell-beingoffamilies,women,newborns,children,andadolescents.Thegoaloftheframeworkis to ensure availability and access to evidence-based interventions to improve maternal,newbornandchildhealth.Thecontinuumofcareapproachhasatleastthreedimensions.First, itmeans carehas to beprovided as a continuum throughout the life cycle, includingadolescence,preconception,pregnancy,childbirthandchildhood,therebybuildingupontheirnaturalinteractions.


3) Childbirth CareSkilled care during labour and delivery, including:

Activemanagementofthirdstageoflabour.•Useofpartograph.•Monitormaternalandfoetalwell-being;encouragementofsupportivecompanion.•Ensurecleandeliverypracticesandbeneficialpractices.•Delaycordclamping(upto3minutes).•Clinicalmanagement and referral ofmaternal or newborn complications (emergency•obstetriccareatfirstlevel);newbornresuscitationifrequired.Emergencyobstetriccarepackage(secondandthirdlevel).•

4) Postnatal and Newborn CareEssential newborn care for all newborns should ensure:

Birthinasafeenvironmentwithaccesstocompleteobstetricandneonatalcare.•Avoidunjustifiedseparationfromthemother.•Earlyandexclusivebreastfeeding:earlysuckling,positioningandattachingthebabyto•thebreast; rooming-inandunrestricted feeding; tensteps to successfulbreastfeeding;safehumanmilkbanking.Warmthprovisionandavoidanceofbathingduringfirst24hours.•Infectioncontrol,includingcordcareandhygiene.•PostpartumvitaminAprovidedtomother.•Eyeprophylaxistopreventgonococcalopthalmia.•Informationandcounsellingforhomecareandemergencypreparedness.•

Extra care for small babiesExtrahomevisits;supportforbreastfeeding,thermalcare,andhygieniccordcare.•Extraattentiontowarmth,feedingsupport,andearlyidentificationandmanagementof•complications.Skintoskinthermalcare(kangaroomothercare).•VitaminKadministrationatbirth.•Facility-based clinical care of ill newborn babies, particularly those with infections,•prematurity,andbirthasphyxia.Shortandlongtermfollowup.Earlyneurodevelopmentstimulation.•

Pre-discharge package (at facility level or before birth attendant leaves the mother in the case of a home delivery)

Carefulassessmentofhighriskfactors/dangersigns(forbothmotherandnewborn).•Counselling for mother and family in preventive care, recognition of danger signs,•provisionofcare(whattodoandwheretogo).Promotionandreferralforearlypostnatalcare.•

Follow-up care for birth spacing, immunization, nutrition (breastfeeding), growth•monitoringanddevelopmentofbaby.

Assure appropriate care in the home for the mother and newbornEffective empowerment, participation and communication strategies including•communityinvolvementinplanningMNCHprograms.Communitymobilization and engagement, and antenatal and post natal domiciliary•behaviour change communications to promote: evidence-based care practices(breastfeeding,thermalcare,andcleancordcare),careseeking,anddemandforqualityclinicalcare.

5) Integrated Management of Childhood IllnessScaling up of implementation of IMCI especially in rural and impoverished communities •includingthecriticalfirstweekoflife.

effective community bAsed interventions

Recent reviews of the evidence regarding community-based interventions for improvingperinatalandneonatalhealthoutcomesindevelopingcountriesrecommendedanintegratedapproachtosafemotherhoodandnewbornhealth.


methodoLogy

Thisstudywasconductedinfivehospitals,namelytheGeorgetownPublicHospitalCorporation(GPHC)andthefourRegionalHospitals:NewAmsterdam,WestDemerara,SuddieandLindenMackenzie.ThesehealthfacilitiesoffercomprehensivehealthcaretomothersandchildrenandtheyarereferralcentresforallhealthfacilitieswithintherespectiveregionsandinthecaseofGPHCitisthenationalreferralhospital.

Aretrospectivestudywasdonebyreviewingthechartsofpregnantmotherswhosebabiesdiedintheneonatalperiodin2007.Allchartsofpregnantwomenattendingthesefacilitieswhohadaneonataldeathwerereviewed.Variablesinthestudyconsistedofdemographic,antenatal,intra-natalandpostnatalinformationwhichwasextractedintoastructurequestionnaire.

DatawasthenenteredintoEpiInfoversion3.2.2,2003.Thesocio-demographic,obstetricandthe adverse pregnancy outcomes among high risk pregnant womenwere described in theunivariate analysis. Factors impacting on adverse pregnancy outcomeswill be determinedin thebivariateanalysisusing thechi square,dfandprobability todetermine the statisticalsignificanceofthosevariablesontheoutcomeofthepregnancy.

ethicAL considerAtion

The names of pregnant women were not recorded on the questionnaire. All charts werereviewedatthehealthfacilitiesandnocopiesofthechartsweremade.Onlypersonsaffiliatedtotheresearchprojecthadaccesstothedata.Eachmotherwasgivenanumberfollowedbytheyear,incasethechartsneededtobereviewedatanothertime.

dAtA coLLection

ThedatacollectionprocesscommencedonJunetoNovember2008inallthefivemainhospitals;seebelowforthedetailsonhowthiswasdoneforeachregion.

methodoLogy


region 2: oscAr joseph’s hospitAL And suddie pubLic hospitAL

ForRegion2,datawascollectedfromtheOscarJoseph’sHospitalatLindenandSuddiePublicHospital.AtOscarJoseph’sHospitalallmaternitychartsincludinginfantchartswerestoredtogetheraccordingtotheyear.Theteamwasgiventhechartsforeachyearbetween2003to2007andthenidentifiedthechartsforthestudy.Atotaloffourhundredandseventytwocharts(472)chartswereexamined.However,datawasonlyrecordedfortheneonataldeathsfor2007sinceinmanyofthechartstherewasmissinginformation.Theresearchershadtocheckotherareasofthechartsforsuchinformation.

At SuddieHospital the neonatal death charts alongwithmost of thematernal chartswerecompiledaccordingtotherespectiveyears,2003to2007,thusgivingtheresearchereasyaccesstothecharts.Atotaloffortyeight(48)deathswererecordedfrom2003-2007.For2007,therewereatotalof17neonataldeaths.However,onlythe2007datawasusedsincetheotherregionsdidnothavedataontheseyears.

region 3: west demerArA regionAL hospitAL

Recordedinformationonthenumberofdeathswereavailablefrom2003-2007.Neithermaternitynorneonatalchartscouldbeobtainedfromtheperiodbeyond2006sincetheywereputinanarea thatwasnot accessible topersons, as told by thehead clerk of theunit.However theneonataldeathschartsweremadeavailablebythestatisticalclerkwhopulledthemfromtherecords.Therewereatotalof5neonataldeathsand24stillbirthsintheyear2007.Thesewerecodedasthesamenumberonthemother’scharts.

region 6: new AmsterdAm regionAL hospitAL

Atotalof37stillbirthsand10neonataldeathswererecordedfor2007.Dataforalltheneonataldeathschartswasnotavailableasthesechartswerewiththepathologistwhowasconductingpost-mortemexaminations.Datawasnotobtainedfortheneonataldeathseventhoughitwaspromisedonseveraloccasions.

region 10: Linden hospitAL compLex

Therewere a total of 17 stillbirths and 2 neonatal deaths in Region 10 for 2007. Datawasobtainedfromthematernityregisterwhichwaswellkept.UnliketheotherhospitalsLindenHospitalComplexformerlyrunbyLimineBauxiteCompany,aPrivateagencywerenotusinganyneonatalchartswhichmadetheprocessofobtainingdatacomplex.Althoughthestudyperiodwas2003-2007itwasnotpossibletoobtaindatafromtheyearsbefore2007.Thelabourwardregisterprovidedamonthlysummaryofalltheperinatalinformationanddeliveries.

Theneonatalandmaternitychartswereusedtoobtainthedatafortheneonatalandstillbirthcases.Althoughdatawasonlyobtainedfor50%ofcharts,datafrombothchartswasextractedforthepreparedquestionnairewhichnoted127stillbirthsand125neonataldeaths.

Allthechartswerefoundfor2007withthecorrespondingmother’schart.However,therewerecertaindeficiencies in the information thatwasrecordedon thecharts.Therewasaregisterofneonataldeathsandstillbirthsinthestatisticaldepartment.Thesewerecodedasthesamenumberofthemother’schartseventhoughtheywerefiledseparately.

Theneonatalandmaternitychartswereusedtoobtainthedatafortheneonatalandstillbirthcases.Usingbothchartsdatawasextractedintothepreparedquestionnaire.

region 4: georgetown pubLic hospitAL corporAtion (gphc)GeorgetownPublicHospitalisthelargesthospitalandisthereferralhospitalforallregions.Datawascompletedforthepreviousyearonthecomputer.Aprintoutoftheyear2007wasmadethenthechartwaspulledbasedontheirregistrationnumber.Thereweresomedifficultiesinobtainingsomeofthechartsforthishospitalbutusingdatafromtherecords,informationwasextractedforthequestionnaire

LimitAtions of dAtA Someinformationwasnotrecordedonthechartsforexampletheweightortimeofdeath•oftheneonate.Sometimes therewasno information concerning themonitoringof themotheror the•neonate’scondition.Somemotherswereadmittedinthesecondstagesoflabourandlimitedinformationwas•recordedaboutthemother.ForHighriskmothersforexamplepreviousPPHordiabetesseemnottobemonitored•adequatelyduringpregnancy.Infewcasesitwasrecordedthatthemotherhadprenatalcareataspecifiedhealthcentre,•butthenumberofantenatalvisitswasnotstated.Absenceofmothers’chartcausedlimitedinformationtobegatheredaboutthemothers.•

use of the oLd perinAtAL chArts: Someinformationwasnotrecordedonthechartsfore.g.theweight,timeofdeathofthe•neonate.Somemothers’chartswerenotlocatedasthemotherwaseithertransferredtoahospital•ortheinfantwastransferredfromotherhealthfacility.Assuchlimitedhistorytakingwasdoneaboutthemother.Thecauseofdeathanddateofdeathinsomecaseswerenotrecordedintheareaprovided•onthechart.Thenumberofantenatalvisitswasnotmarked,sincenoparticularspacingwasavailable•intheoldchart.


This survey reviewed data from 2007 of all neonatal deaths and stillbirths from one

national hospital and four regional hospitals namely: Georgetown Public Hospital (Region

4, Georgetown), Linden Hospital Complex (Region 10), McKenzie Hospital (Region 10),

New Amsterdam Hospital (Region 6), Public Hospital Suddie (Region 2) and West Demerara

RegionalHospital(Region3).

DataobtainedfromthenumberofneonataldeathswereinclosecorrelationwiththenationaldatafromtheMinistryofHealthStatisticalDepartment2007.Althoughthestudydidnotintendtodeterminethecausesofthestillbirthsthereweremorestillbirthsthantheneonataldeathinallareas,hencetheresearchersdecidedtoincludethisareainthestudy.

0102030405060708090

100110120

GPHC WDRH Mackenzie Suddie New Amsterdam H

NATIONAL SURVEY

Figure 1: Data on Neonatal Deaths

Datawasalsoreviewedfrom2003-2006fromallhospitalswheredatawasobtained.Datawasnotobtainedfromsomefacilitiessincethechartscouldnotbelocatedeventhoughthenumberofdeathswasrecorded.

Therewerea totalof169recordedneonataldeaths in2007fromthefivehospitals;howeverchartswereonlyobtainedfor77ofthesecases.MostofthedatawasobtainedfromhospitalsexcepttheGeorgetownandNewAmsterdamHospitals.Thestillbirthsnumberfarexceededthe neonatal deaths as clearly seen in Figure 2.

resuLts & findings


0

20

40

60

80

100

120

140

GPHC WDRH Suddie New Amsterdam Mackenzie

STILLBIRTHS NEONATAL DEATHS

Figure 2: National data on stillbirths and neonatal deaths for 2007 from the five hospitals

National data shows thatwith the exception of Region 2 and Region 10 the stillbirths outnumberedtheneonataldeaths.

Not Stated

>35

18 - 35

16 - 17

<16

0

NEONATAL DEATHS

STILL BIRTH

20 40 60

<16

4

2

16 - 17

8

3

18 - 35

56

38

>35

5

7

Not Stated

4

0

Figure 3: Age range of mothers and pregnancy outcomes

Figure 3showsthatthemajority(74%)ofmothersinthisstudywerebetweentheagesof18-35whilemothersyoungerthanagesixteen(<16years)weretheminority.Teenagepregnanciesbelow18yearscomprised14%ofthemothersinthestudy.TheageofmotherandthepregnancyoutcomewassignificantataChi-square=5.9071,df5,probability0.3154.

STILL BIRTHS NEONATAL DEATHS

Figure 4: Percentage of stillbirths and neonatal deaths

Figure 4showsthat50(39%)werestillbirthsand70(61%)werebabieswhowerebornaliveandsubsequentlydied.

NOT STATED PRIMARY SECONDARY TERTIARY

Figure 5: Educational status of mothers

Theeducationlevelinthestudyrevealedthat26(20%)ofthemothershadsecondaryeducation,24(19%)hadprimaryeducationwhilefor75(59%)ofthemothersthiswasnotstated.Thisisbecausetheoldperinatalchartswereusedtorecordthedatainthestudy(refer Figure 5).


AFRO-GUYANESE

AMERINDIAN

INDO-GUYANESE

MIXED

NOT STATED

43, 34%

10, 8%

28, 22%

37, 29%

9, 7%

NEONATAL DEATHS

STILL BIRTH

Afro-Guyanese

27

16

Indo-Guyanese

17

20

Mixed

17

11

Not Stated

8

2

Amerindian

8

1

Not Stated

Mixed

Indo-Guyanese

Amerindian

Afro-Guyanese

0 10 20 30

Figure 6: Ethnicity of the mothers and pregnancy outcomes TheAfro-Guyanesewastheleadingethnicgroupinthestudywith43(34%),followedbytheIndo-Guyaneseandthemixedgroupswith37(29%)and28(22%)mothersrespectively.Ninemothers(7%)wereAmerindianswhilefortheremaining10(8%)ethnicitywasnotrecorded.Indo-Guyanese from the research tended to have higher stillbirths than neonatal deaths asillustrated in Figure 6.MixedandAfro-Guyaneseshowedalowerlevelofstillbirthsbutmoreneonatal deaths. The onemotherwhodelivered a twin, onewas a neonatal death andonestillbirthwasinthemixedgroup.

AntenAtAL cAre

MORE THAN 4 VISITS

LESS THAN 4 VISITS

NOT STATED65, 51%

43, 35%

18, 14%

Yes, 98

No, 9

Not Stated,

20

Figure 7: Antenatal Care Figure 8: Old antenatal chart used

Figure 7showsthat44(35%)ofmothershadmorethan4visitsforantenatalcare,whilefor65(51%)thiswasnotstatedbecausetheoldantenatalchartswereused.

nutritionAL stAtus

Thenutritionalstatusofthemothersshowedthatmorethanhalfofthemothersofwhomthenutritionalstatuswasstated,52(40.9%)hadanutritionalstatusof11g/dlandoverfollowedby47(37%)motherswithnutritionalstatusof7–10.99g/dl(referFigure 9).

PERCENTAGE

Hb LEVEL

<7 g/dl

1.6%

2

7 - 10.99 g/dl

37.0%

47

11 g/dl and over

40.9%

52

Not Stated

20.5%

26

0 20 40 60

Not Stated

11g/dl and over

7-10.99 g/dl

<7 g/dl

Figure 9: Nutritional Status of Mother

Twomothers(1.6%)hadanutritionalstatusof<7g/dlwhilefor26(20.5%)ofmotherstheHblevelwasnotstated.

201816141210

86420

Afro-Guyanese

0

20

15

8

Indo-Guyanese

1

14

18

4

Mixed

1

8

15

4

Not Stated

0

0

2

8

Amerindian

0

5

2

2

<7 g/dl

7-10.99 g/dl

11g/dl and over

Not Stated

Figure 10: Ethnicity level in comparison to Hb level Onexaminationofthehaemoglobinlevelsduringpregnancy,itwasfoundthatthe20Afro-GuyanesehadlowHblevels(lessthan11g/dl)thananyothergroupandwereanaemic,18Indo-GuyanesehadhigherHblevel(over11g/dl),26(20.5%)Hblevelsofthemothersthatwasnotstated(refer Figure 11).


compArison of hb LeveLs And LocAtion of mothers

25201510

50

< 7 g/dl

0

0

0

1

1

11g/dl and over

4

1

25

14

8

Not Stated

7

3

6

5

5

7 - 10.99 g/dl

6

8

23

3

7

Region 2

Region 3

Region 4

Region 6

Region 10

Figure 11: Nutritional level and location of the mothers (n=127) TwentythreemothersfromRegion4(GPHC)hadanaemiaincomparisontotherestofregions.The2motherswhohadsevereanaemiacamefromRegions6–BerbiceandRegion10bothofwhichareruralareas.FourteenmothersfromRegions2and3,hadHblevelsbetween7–10.99g/dl.MothersfromRegion4–GeorgetownhadhigherHblevels(over11g/dl)thananyotherregion(referFigure 11).

bLood pressure during pregnAncy

>120/80 mmhg

>130/90 - 140/100 mmhg

120/80 - 130/90 mmhg

>140/100 mmhg

Figure 12: Stated blood pressure on admission

Twenty(39%)ofthemothersforwhomtheirbloodpressurewasrecordedhadpressures>120/80mmHg,20(39%)andnineteen(37%)hadbloodpressure>140/100mmhg.Fivemothers(10%)hadbloodpressuregreaterthan130/90mmhgwhilefor76mothers,thiswasnotstated(referFigure 12).

NO DIABETES NA NOT STATED DIABETES

Figure 13: Percentage of diabetic mothers Forty–eightmothers(38%)statedtheywerenotdiabeticwhileeight(6%)statedthattheywere.Theremainingseventy(55%)didnotrecordwhetherornottheywerediabetic(referFigure 13).

605040302010

0

No Diabetes

32

16

Not Stated

12

58

Diabetic

6

2

Not Applicable

0

1

STILL BIRTH

NEONATAL DEATHS

Figure14: Diabetes and pregnancy outcomes Figure 14illustratesthat50babieswerestillbirthsofwhich6motherswerediabeticincomparisonwiththeneonataldeathswhereonlytwomotherswerediabeticoutof77.Fortyeightmotherswhodeliveredbothstillbirthsandneonataldeathsdidnothavediabeteswhilefor70mothersthiswas not stated.Diabetes duringpregnancy and its outcomewas significant chi–squarevalueof36.7839,df6.


screening for hiv during pregnAncy

Negative11288%

Unknown12

10%

Positive3

2%

Figure 15: HIV screening during pregnancy Itisnoteworthythat112(88%)ofthemothersscreenedforHIVfromthedatareviewofthehospitalinpatientrecordandwerenegativeforHIV,whileonly3(2%)werepositiveforHIVand10%oftheresultswasunknown(referFigure 15).

pArity of the mothers

>1 CHILD

5 OR MORE

1 TO 4 CHILDREN

NOT STATED

47, 37%

22, 17%

12, 10%

46, 36%

Figure16: Parity of mothers

Atleast47(37%)ofthemothershadonepreviouschild,46(36%)had1to4children,while12(10%)weregrandmultiparouswomen.

intrAnAtAL cAre

Accordingtothesurveydatafortheneonataldeathsandstillbirths,110(87%)pregnantmotherswhodeliveredeitherastillbirthorneonataldeathwasattendedtobyaqualifiedhealthworker(midwife,doctorormedex)fromthefivehospitalswhileonly2(1.6%)weredeliveredathome(referFigure 17)andfor15(12%)itwasnotstatedwhoattendedtothem.

0

20

40

60

80

100

120

QUALIFIED HW

AT HOME

NOT STATED

110, 87%

15, 12%

2, 1.6%

Figure 17: Delivery locations of the mothers

type of deLiveries

120

100

80

60

40

20

0

Breech

6.3%

8

LSCS

9.4%

12

Normal

78.7%

100

Not Stated

4.7%

6

Foot

0.8%

1

PERCENTAGE

NUMBER

Figure 18: Type of deliveries of mothers Seventyninepercentofthemothershadnormaldeliveryandweredeliveredbyatrainedhealthprofessional,12(9%)hadsurgicalinterventionoflowersegmentcaesareansectionwhichwashigherthantheprevalenceoffootlingandbreechdelivery1(0.8%)and8(6.3%)respectively(referFigure 18).


pregnAncy compLicAtions

NO NOT STATED

PREGNANCYCOMPLICATIONS

60

40

20

0

21, 17%

51, 40% 55, 43%

Figure 19: Pregnancy complications in the mothers

Figure 19 illustrates that 55 (43%) of themotherswho delivered stillbirths or had neonataldeathshadcomplicationsduringpregnancywhilefor51(40%)itwasnotstatedwhethertheyhadcomplicationandonly21(17%)didnothaveanycomplications.

type of compLicAtions in pregnAncy

PIH

APH

ASTHMA

ANAEMIA

PREMATURITY

DIABETIC

FETAL DISTRESS

ACUTE GASTROENTERITIS

Figure 20: Distribution of type of complications in the mothers The leading complication in this studywasPregnancy InducedHypertension (PIH). Thirty(55%)ofthemothershadPIHorhypertensioninpregnancy,6(11%)haddiabetesinpregnancy,5(9%)hadante-partumhaemorrhage(AbruptioPlacentaandorPlacentaPrevia),while2(4%)hadpostmaturity(refer Figure 20).

premAture rupture of membrAnes

20

18

16

14

12

10

8

6

4

2

0> 28

weeks

15

19%

28 - 34weeks

8

10%

38 - 40weeks

17

22%

> 41weeks

7

9%

36 - 38weeks

20

26%

34 - 36weeks

10

13%

Number

Percentage

Figure 21: Gestational weeks of pregnancy and time of rupture of membranes Themajorityofmothers37(48%)hadnormalruptureofmembranesthatisattermthatisat40weeks(36weeksandover).Thirtythree(42%)ofmothers’membranesrupturedbeforeterm(lessthan36weeks).Fifteenmothers(19%)hadprematurerupturedofmembranes(before28weeks).Sevenmothers(9%)hadmembranesruptureafter41weeks(referFigure 21).

353025201510

50

> 1 week

1

0

1

0

< or = 1 week

3

1

3

6

Membranenot intact

on admission

1

0

0

0

Not Stated

7

2

33

8

Just before or arounddelivery

25

4

24

8

NOT GIVEN

NOT APPLICABLE

NOT STATED

ANTIBIOTICSGIVEN

Figure 22: Comparison of time of rupture of membranes and whether antibiotics were given Figure 22illustratesthatthetotalnumberofmotherswhoweregivenantibioticswastwentythree.Ofthis23,6mothersweregivenantibioticslessthanoneweek,8justarounddeliveryand for8mothers itwasnot stated. It is surprising that2motherswhosemembraneswererupturedover1weekwerenotgivenantibiotics.Foronemother,itwasnotstatedandfortheothermother,thiswasnotgiven.Onlyonemother’smembranewasintactonadmissiontothelabourward.Sixtythreemothershadtheirmembranesrupturejustbeforeorarounddelivery.


Thisimpliesthattheyhadspontaneousruptureofthemembranesbeforedelivery.Thiswassignificantatachi-squarevalueof23.5815,df12andprobabilityof0.0232.

109876543210

Ampicillin(IV or

Capsules)

10

40%

InjectionGentomycin

andCrystapen

1

4%

Ampicillinand

Seclopen

1

4%

Amoxcil

4

16%

Amoxcil +

Flagyl

8

32%

Number

Percentage

Figure 23: Type of antibiotics given to mothers (n=23) Outofthe23motherswhoweregivenantibiotics,10(40%)weregivenAmpicillin(intra-venousorcapsules)foreitherprematureruptureofthemembraneoranyothercomplicationduringpregnancy.ThesecondmostcommonantibioticusedwasAmoxilandFlaggylcombination.Eight (32%)mothersweregiven thesedrugswhile twomothersweregivenAmpicillinandSeclopencombinationsandonewasgivenGentamycinandCrystapeninjection(referFigure 23).

proLonged LAbour And pregnAncy outcome

Still Birth

24

22

4

Still Birth %

48

44

8

NeonatalDeaths

55

21

1

NeonatalDeaths %

71.4

27.3

1.3

No Prolonged Labour

Not Stated

Prolonged Labour

0

10

20

30

40

50

60

70

80

Figure 24: Prolonged labour and pregnancy outcome (still birth/neonatal deaths)

Inresponsetothequestion,“Waslabourprolonged?”,thatisover12hoursinaprimigravidaandover6hoursinamultiparous,itwasseenthat4(8%)ofthestillbirthshadprolongedlabourincomparisonto1(1.3%)oftheneonataldeaths.Itisnoteworthythatnoprolongedlabourwasmorecommonintheneonataldeathsthanstillbirths.Thiswassignificantatachi-squarelevelof8.6381,df2andprobabilityof0.0133(referFigure 24).

postnAtAL cAre birth weight

< 1500 g 1500 - 2500 g > 2500 g Not Stated

Figure 25: Percentage distribution of birth weight of neonatal deaths/stillbirths 2007

Figure 25 showsthat69(54%)ofthebabiesinthestudyhadabirthweightoflessthan2,500gramsaccordingtoWHOInternationalStandardsonpostnatalcare,whileonly39(31%)hadabirthweightofover2,500grams.Itisimportanttoknowthat26(20%)hadabirthweightoflessthan1,500gramswhile43(34%)didnothavetheirweightstated.

Whenthiswascrosstabulatedwiththeoutcomeoftheinfant,itwasseenaccordingtoFigure 26,that21(43%)stillbirthswereinfantswithabirthweightofover2,500gramsascomparedwiththeneonataldeathswhichshowedthat theneonataldeathshadasmallernumberofbabieswitha lowerbirthweight.Asamatterof fact20 (25.9%)of theneonataldeathshadabirthweightoflessthan2,500grams.


birth weight And pregnAncy outcome

< 1500g

6

20

Still Birth

Neonate

1500 - 2500g

16

27

> 2500g

21

18

Not Stated

7

12

3025201510

50

Figure 26: Birth weight and pregnancy outcome of the babies in 2007 (SB n=50, ND n=77)

Thiswasverysignificantatachi-squareof11.7251,df8andaprobabilityof0.1639.

STILL BIRTH WEIGHED AT BIRTH NOT STATED NO

Figure 27: Diagram illustrating if stillbirth was weighed at birth (n=50) Figure 27illustratesthat45(90%)ofthestillbirthswereweighedatbirthwith2(4%)notstatedand3(6%)notweighed.

ApgAr score Figure 28showsthat17(22%)oftheneonateshadanapgarscoreof10minutesafterbirth,theremaining88%hadanapgarscoreoflessthan10minutes.

PERCENTAGE

NEONATAL DEATHS

10 mins

5 to 9 mins

Less than 5 mins

0 min

0 10 20 30 40 50

0 min

0%

0

Less than 5 mins

19%

15

5 to 9 mins

58%

45

10 mins

22%

17

Figure 28: Apgar scores of neonates (n=77) Theapgarscoreofoneoftheneonateswhowasatwinwasnotstated.Thestillbirthswhichnumbered50hadanapgarscoreof0asaccordingtotheinternationalWHOdefinition.Thechi-squarevalueofthecomparisonofneonataldeathsandapgarscorewas127anddf24andwassignificant.

premAturity And outcome

STILL BIRTH NEONATAL DEATH

Premature 28 wks - 37 wks

Not Stated

NA

No

0

29

12

7

2

10 20 30

Still Birth

Premature 28 wks - 37 wks

Not Stated

NA

No

0

45

18

14

0

2010 30 5040

Neonatal Death

Figure 29 & 30: Comparison of babies who were stillbirths/neonatal deaths premature (28 weeks to

<= 37 weeks) or had normal gestation age


Figure 29 and 30showthat45(58.4%)ofthebabieswereprematureatbirthandsubsequentlydied,incomparisonto28(57.1%)stillbirths.Asapercentagethisratioisapproximatelyequalto1.Therewasnosignificantvariationoftheoutcomeofthepregnancywhetheritwasastillbirthorneonataldeath.Itisalsonoteworthythat12(24.4%)ofthebabieswhowerestillbirthswerefullterm,incomparisonto18(23.3%)ofthebabieswhowereneonataldeaths.

28 - 37 WEEKS 37 - 40 WEEKS 40+ NOT STATED

Figure 31: Gestational weeks of mothers who had neonatal deaths/stillbirths

Figure 31showsthat74(58%)ofthemothersdeliveredduringthegestationalweeksof28-37weeks,30 (24%)between the37-40weeksand3 (2%)mothersdeliveredwereover the40thgestationalweek.

ArtificiAL heAt used After birth

NO HEAT NOT APPLICABLE NOT STATED HEAT USED

Figure 32: Use of artificial heat after birth of the baby Figure 32 illustrates that 62 (49%) of babies had artificial heat used after birthwhile only 9(7%)hadnoartificialheatused.Thisisexpectedsinceover87%ofthebabiesweredeliveredinahealthfacility.Thiswasnotapplicablefor50(38%)ofthebabiessincetheyhadnormaltemperatureatbirth.

time of deAth

WITHIN 7 DAYS OF BIRTH

BETWEEN 7 AND 28 DAYS OF BIRTH

NOT STATED

Figure 33: Time of death of neonates Figure 33illustratesthat63(82%)oftheneonatesdiedwithinearlyneonatalperiod(7daysafterdelivery),10(13%)diedduringthelateneonatalperiodandthetimeofneonataldeathsof4(5%)wasnotstated.

immunizAtion recording

NO NOT STATED YES

Figure 34: Recording of the immunization status in the hospital chart Figure 34illustratesthat113(89%)ofthemothersinthestudydidnothavetheirimmunizationstatusrecordedinthehospitalchartssincetheoldhospitalchartswereusedwhileonly11(9%)hadtheirimmunizationrecorded.


cAuses of neonAtAL deAths in the study

Macerated SBFetal Distress

Not StatedTrue Knot

Brain Haemorrhage Postmaturity

Necrotizing Entercolitis of FetusValium During Labour

MalformationsPrematurity

Cardiac FailureBroncho Aspiration/Pneumonia

Birth InjuriesBirth Asphyxia

Bacterial SepsisAspiration Pneumonitis

Acute Respiratory DistressAbruptio Placenta

0 5 10 15 20 25 30

Figure 35: Causes of neonatal deaths in 2007 at the five health facilities The five leading causes of neonatal deaths from the hospitals were acute respiratorydistress,bacterialsepsisofthenewborn,birthasphyxia,prematurityandbrainhaemorrhage(subarachnoidhaemorrhage)duetothetraumaoftheheadofthefoetus.Birthinjuriestotheliverandbraindamageoccurredinelevencases(referFigure 35).

resuscitAtion performed After deLiveryInresponsetothequestionas towhetherresuscitationwasadequatelyperformed,68(53%)recordsrevealedthattheinfantwasdried,wrappedandsuctionedatbirth,asthecriteriaofperforminggoodresuscitation.In10(7.9%)recordsitwasnotstatedwhetherresuscitationwasadequatelyperformed(referFigure 36).

Not Applicable

49

38.6%

Not Stated

10

7.9%

Resuscitation Performed

68

53.5%

NUMBER

PERCENT

70605040302010

0

Figure 36: Percentage illustrating whether resuscitation was performed adequately

Onwhetherresuscitationwasperformedattheoutcomeofthepregnancy,itwasrecordedthat68(88%)ofthehealthworkersperformedresuscitationtechniquesadequately,for9(11%),thiswasnotstated(referFigure 37).

Not Applicable

0

0

Not Stated

9

11.7

ResuscitationPerformed

68

88.3

NEONATAL DEATHS

PERCENTAGE

100

80

60

40

20

00 0

9 11.7

68

88.3

Figure 37: Comparison of whether resuscitation was performed and neonatal deaths (n=77)

dAtA AnALysisDemographicdata revealed that thehighestnumberofneonataldeathsandstillbirthswererecordedat thenational referral hospital,GeorgetownPublicHospitalCorporation and theNewAmsterdamHospital.Thisisinkeepingwiththenationaldatasincebothofthesehospitalsattendtoover85%ofthedeliveriesinthecountry.Eventhoughthenumberofneonataldeathsandstillbirthswererecordedbymonthandyear,thereweredifficultiesinobtainingthehospitalchartsforsomeoftheneonataldeathsandstillbirths.

Dataobtained from the researchwas in close correlationwith thenationaldatawith a fewexceptionswhere a lower number of neonatal deathswere found in cases of the numbersreported.

Itwasintendedtoreviewonlytheneonataldeathsatthestartofthestudybutitwasdiscoveredinsomehospitalsthanthestillbirthsdoubledtheneonataldeaths,suggestingthatthisneededtoberesearchedaswell.

Therewasnoproperinformationsystemforrecordingofthestillbirths.Insomehospitalsthiswas recorded as a separate chart within the mother’s hospital chart while in another there were nocharts.Thereisneedforasystemtoproperlyrecordthestillbirthsinallhospitals.Fortheneonataldeathsthiswasrecordedinmostofthehospitalsexceptforafew.Aseparatechartwasused to record theneonataldeathswhichwere found in themother’schart. ItmustbenotedthattheWestDemeraraRegionalHospital,MackenzieHospitalandtheSuddieHospital,


allhad their recordsproperlykeptand thedatawas foundveryeasily.There isneed forareviewoftherecordkeepingatthehospitalsAndattentionshouldbepaidinensuringthatthechartsareproperlyfilledin.

TheneedfortheimmediatetransitiontotheNewPerinatalRecordsatallhospitalsisclearlyshown.All hospitals shoulduseupdated informationmaterials that are available.Thenewinformationchartcontainsdetailedinformationonthenumberofantenatalvisits,immunizationstatus,antenatalcarereceivedatthelocalhealthfacility.Byusingthenewchartsacontinuumofmaterial,newbornandchildcareisensured.Atthesametimeallcategoriesofworkersareabletoreviewthepatientchartateverystageofthepregnancyanddelivery.

Theageofthemotherswhodeliveredwhetherastillbirthoraneonataldeathwasinthe18-35yearsagegroup.Thehigheragegroupwhichwasover35yearsdidnothaveanyimpactontheoutcomeofpregnancy.Thisshowsthatneonataldeathsandstillbirthsareoccurringinthechildbearingageandnotinelderlywomen.

Indo-GuyanesetendedtohavehigherstillbirthsthanneonataldeathsasillustratedinFigure 6.TheothermixedandAfro-Guyanesecategoriesshowedalowerlevelofstillbirthsbutmoreneonatal deaths.Onemother ofmixed ethnicitydelivered twins, onewas a neonatal deathwhiletheotherwasastillbirth.Thisdataneedstobefurtherstudiedtodeterminethecausessincethisdidnotrepresentanareabutfiveregionsofthecountry.

Theeducationallevelofthemothersinthestudyrevealedthat26(20%)ofthemothershadsecondaryeducation(referFigure 5),24(19%)ofthemothershadprimarywhilefor75(59%)ofthemothersthiswasnotstatedastheoldperinatalchartswereusedtorecorddata.Therewasnosignificantvariationintheeducationlevelofthemothersincetheratioofprimarytosecondaryeducationwas1to1.

Amongthedemographic factors,only theethnicityshowedscientificallysignificanceon theoutcomeofthepregnancy.Locationofneonataldeathsandstillbirthswereskewedsincethesearethereferralhospitalsanditisexpectedthatthemajorityofdeathswouldoccurthere.

Properhygieneandaseptictechniquesduringdeliveryandpostnatalcareisvitallyimportantfortheneonatetosurvivebeyondthecritical28daysperiod,bacterialsepsisofthenewbornaccountedfor16oftheneonates.Thisresearchhasalsoshownthatrespiratorydistressandbirthasphyxiastillremaintheleadingcauseofneonataldeathsasitoccursinternationally.Accordingtotheliteraturereview,thetopthreeleadingcausesofneonataldeathinLatinAmericaandtheCaribbeanregionfor2004includeinfections(32%),asphyxia(29%)andprematurity(24%).

Thereisneedforbetterresuscitationtechniquesduringtheintranatalphaseofdelivery.Facilitiesalso need to be better providedwith equipment and supplies to dealwith the respiratory

complicationsof theneonates.This is coupledwith the fact that88%of theneonates in thestudyhadanapgarscoreoflessthan10minutesand63(50%)oftheneonatesdiedwithintheearlyneonatalperiodthatiswithin7daysoflife.

Thefirstsevendaysoflifeinaneonateisthemostcriticalperiodwhentheytrytocopewithnewsurroundingsandtheabilitytobreatheontheirown,thusthehealthpersonnelmustbeeffectiveinensuringthattheneonateisgiventhebestcareduringthisperiod.

AntenAtAL cAreTheWorldHealthOrganisationhas outlined a fourprenatal visit package of care thatwillreducetheincidenceofneonataldeathsandstillbirthsinthecountry.Overthelast10yearstherehadbeentremendouseffortsbythetechnicalstafftoensurethatthepackageofcareisavailable.TheNewPerinatalChartwhichwasintroducedinlate2007seekstosingleouttheindicatorofantenatalvisits.Thenumberofantenatalvisitscanberecordedwiththevariousother parameters. Even though the data showed that 35%of themothers hadmore than 4antenatalvisitsinthestudy,thiscannotbetakenasatruereflectionoftheantenatalcaresincethisoldantenatalchartwasusedin98%ofthecases.Thereisaneedtorapidlyimplementthenewperinatalinformationsystem.

OtherprerequisitesforgoodantenatalservicesarethetakingoflaboratoryspecimensincludingHIV testing of themothers. Laboratory screening of the antenatal mothers are done twiceduringpregnancyforalltheroutinetestssuchasHaemoglobin(Hb),SickleCelltest,RHfactor,BloodGroupandHIV (this isoptionalandnotmandatory).Fifty two (40%)of themothershadnormalhaemoglobin levels in thestudyandwerenotanaemic.Themotherswhowereconsideredanaemic,thatiswithanHblevel7-10.99g/dlwere47(37%)andsevereanaemia2 (1.6%).Thirtysevenpercentofmotherswereanaemicduringpregnancyandmoreeffortsshouldbeconcentratedinensuringthattheycomplywiththeirironandfolicsupplementationduringpregnancy.Agoodhaemoglobinlevelduringpregnancyenablesthepregnantwomentobetterdealwith the complicationsofpregnancy andpreventspostpartumhaemorrhagewhichistheleadingfactorinGuyana’smaternalmortalityoverthelastfiveyears.

Anaemia is associatedwithmaternalmalnutrition, “small fordates”babies (less than 2,500gramsatbirth)and tosomeextentprematurity.The fact that54%of thebabieshadabirthweightoflessthan2,500gramscouldhavebeenassociatedwithanaemiainpregnancy.Thisalsodependsonthesocio-economic,ethnicandculturaldiversity.Whenthiswascomparedwiththeethnicgrouping,itwasfoundthat20Afro-GuyanesehadHblevelslessthan11g/dl,morethananyothergroup.Thisfactorneedstobefurtherresearchedinotherstudies.

CrosstabulationofregionsillustratedthattheruralareashadlowerHblevelsthanRegion4(Georgetown).Thisisprobablybecausethelargersamplesizecamefromthenationalreferral


hospital.ThemajorityofmotherswhohadsevereanaemiawerefromRegions2and6.

IronandfolicsupplementationisveryimportantduringantenatalcareandhasbeenpartofthepackageofcareasrecommendedbyWHOandUNICEFforantenatalmothersinGuyanasincetheearlier1980s.Asamatteroffact,theuseofsprinkles(ironsupplementforpregnantwomen)hasbeentriedasapilotnutritionprojectinsomehealthfacilities.Thefactthat20.5%ofthemothersdidnothavetheirHbstatedcouldhavebeenbecauseHbtestwerenotbeingdoneortheresultswerenotavailableatthetime.

Roundwormsoranywormsinfestationisacauseofanaemiainpregnancy.Thefactthatoneofthemotherswhosebabydiedhadroundworminfestationandatrueknotmighthavebeenacontributingfactortothepregnancyoutcomeeventhoughthepercentagewaslow.Guyana,unliketherestoftheCaribbeancountrieshasaddedheliminthstreatmentinthesecondtrimesterofpregnancytoalleviatethisproblem.

Asmentionedpreviously,screeningforHIVduringpregnancy ispartof theDepartmentofMaternalandChildHealthmandateas it seeks topromote child survivalandpreventHIVtransmissionfrommothertochild.HIVtestingisapartofaroutinescreeningwhichisofferedvoluntarilytothemotherduringantenatalcare.Only3(2.4%)motherswerepositiveforHIVduringpregnancy.Thisdatamoreorlesscorrespondstointernationalstatistics.HIVcounsellingandtestingserviceshasformedpartofGuyana’santenatalservicessince2001.

Parityofthemotherhadnodirectrelationshiptotheoutcomeofwhethertheoutcomewasastillbirthorneonataldeath.Fortysevenmothers(37%)hadonepreviouschildwhileonly12mothersweregrandmultiparous,whohadover5pregnancies.

High blood pressure during pregnancy is known to be associated with poor pregnancy outcomes such as neonatal deaths and stillbirths. Nineteen (37%) mothers had blood pressure > 140/100 mm hg and 5 (10%) had blood pressure greater than 130/90 mmhg (refer Figure 12). Thus could have been the attributing cause for the stillbirths and neonatal deaths.

Only a small percentage of the mothers in the study had diabetes in pregnancy 8 (6%). Of these eight mothers, 6 pregnancy outcomes were stillbirths in comparison to 2 neonatal deaths. There were more stillbirths born to mothers who were diabetic in comparison to the mothers who delivered babies. Even though this number was small, this was significant at a chi-square value of 36.7839, df 6.

InreviewingthesectiononantenatalcareasitrelatestoneonataloutcomesandtheWHOpre-packagedfourantenatalvisits,itcanbeseenthattheprogrammehasintroducedtheWHOandUNICEFguidelines.However,thefocusshouldbeconcentratedonimprovingtheweakareas.

intrAnAtAL cAreThequestionaskedonreviewingoftheintranatalcaredatais“Iftherewasover87%ofhighlytrainedmidwifery staff according to thedatawhydid the stillbirths inmost of the regionsoutnumber the neonatal deaths?” According to previous research highly trained staff areknowntoreducetheincidenceofdeathsandsicknessinneonatesandstillbirths.Notonlywastherehighlytrainedstaffbutthemothersdeliveredatacomprehensivelevelofobstetriccareservicesinthehospitalwhileonly1.6%deliveredathome.Inspiteofhighlytrainedstaffandaccordingtothedatatheleadingcausesofdeathwerebirthasphyxia,respiratorydistress,andbirthinjuriesduringdeliveryandsepsis.Thesecausespointtothefactofqualityofcare.Eventhoughtheresearchdidnotattempttoaddresstheissueofadequatestaffingatthesehospitals,thisfactorshouldalsobelookedatinfurtherstudies.Shortageofstaffeventhoughtheyarehighlytrained,cancontributetopoorqualityofcarebydecreasingthepatienttohealthworkerratioaccordingtointernationalstandardsofcare.

GuyanahasmadegreateffortsinfollowingtheWHOandUNICEFrecommendedguidelinesofintranatalcarebyintroducingsafemotherhoodstrategyattheprimaryhealthcarelevels,thus seeking to build the bridge between primary and secondary care obstetric and paediatric services.Organisedemergencyobstetriccarefornursesandotherhealthworkers,ensuredthatactivemanagement of labour is adhered toduring the third stage of labour, theuse of thepartogramduringlabourisimplementedandemergencycarefortheneonatesisprovided.Theissueofdelayedclampingoftheumbilicalcordshouldbereinforcedinallthehospitals.Thereisalsoneedformoreintensivecareneonatalunitsatthehospitalssinceonlyoneexistsatthenationalreferralhospital.

AprevioussituationalanalysisconductedbyPAHOatGPHCandNewAmsterdamHospitalin2005revealedthattherateofLSCSwaslowerthantheacceptablerateof15%.InthisstudytherateofLSCSwasalsoinkeepingwithpreviousresearchat9.4%.However,Breechdeliverywasthesecondleadingtypeofdeliverywith6.3%.Theresearcherdidnotattempttoverifyifthishadanydirectrelationshiptotheoutcomeofthepregnancy.

According to thedata, the leadingcausesofneonataldeaths/stillbirths in themothersarepregnancy induced hypertension or hypertension in pregnancy and bleeding during pregnancy (AntePartumHaemorrhage).InGuyanaoverthelast5yearshypertensionduringpregnancyhas been the leading cause of death not only of the neonate but themother aswell.Moreaggressivetreatmentandadherencetoprotocolsofcareneedstobedoneathospitalsandalsoattheprimaryhealthcarelevel.

Prematureruptureofthemembranesbeforedeliveryover1weekwithouttheuseofantibioticsisknowntobeassociatedwithbacterialsepsisofthenewbornandearlyneonataldeaths.Thefactthattwomothersinthestudyhadruptureofthemembranesoveroneweekanddidnothave


anyantibioticsaccordingtothedatacouldhavebeenattributedtoeithertheneonataldeathsorstillbirths.Eightytwopercentoftheneonatesdiedwithinthefirstsevendaysaccordingtotheresearch.Thisisinkeepingwithinternationalstatistics.

Preventionofinfectionisthekeytodecreasethemortalityandmorbidityofneonates.Oneoftheleadingcausesofneonataldeathswasbacterialsepsisofthenewbornaccordingtothedataandthiscouldhavebeenpreventedwiththeuseofantibioticsandaseptictechniquesattheappropriatetime.ThemostcommonantibioticsgivenwereAmoxilandFlaggylforthepurposeoftheprematureruptureofthemembranes.

Prolongedlabouraccordingtothedatawasmorefrequentinstillbirthsthanneonataldeaths.Goodmonitoringofthepartogrambythenursesduringlabourforpregnantwomenaidsinrecognitionofthesignsofmaternalandfoetaldistresssothatquickactioncanbetaken.Theneedtorapidlyroleoutthenewinformationsystemisseenmoreinthelightofgoodmonitoringduringlabour.

immediAte postnAtAL periodPostnatal care is the care given from delivery of the baby up to 6 weeks. The immediatepostpartumperiodisthetimeuptofourhoursafterdelivery.Thisincludestheweighingofthe neonates, immunizations, keeping them warm, observations for any danger signs andassessmentoftheapgarscores.Themajorityofthebabiesinthestudyhadabirthweightoflessthan2,500grams.Thisisnoteworthyandinkeepingwithpreviousresearchthatbabieswithabirthweightofover2,500gramstendtohaveabetterchanceofsurvival.Babieswhowerebornwithalowbirthweightdevelopanumberofcomplicationsanddiedwithinthefirstsevendaysoflifeasrevealedinthisresearch.Eightytwopercentoftheneonatesdiedwithintheearlyneonatalperiodwhile10(13%)diedduringthelateneonatalperiod.Lowbirthweightpredisposestheneonatetorespiratorycomplicationssincetheirlungslackadequatesurfactanttodealwiththerespiratoryneeds.Lowbirthweightandprematurityalsopredisposetheinfanttosepsisduringthefirstweeksoflife.Thecausesandfindingsofthisstudydirectlycorrespondtopreviousresearchesinthisfieldofneonataldeaths.

The five leading causes of neonatal deaths from the hospitals were acute respiratorydistress,bacterialsepsisofthenewborn,birthasphyxia,prematurityandbrainhaemorrhage(subarachnoidhaemorrhageduetothetraumaoftheheadofthefoetus).Birthinjuriestotheliverandbraindamageoccurredinelevencases(referFigure 35).Theseleadingcausesofdeathclearlyillustrateddeficienciesinqualityofcareduringtheintranatalperiodsince87%ofthepersonsweredeliveredbyatrainedheathprofessional(doctor,nurseormedex)whileonly2%ofthedeliveriesoccurredathome.Thefactthatbirthinjuriesduringdeliverye.g.braindamageandliverdamageoccurredin12babies,illustratesthattechniquesduringdeliveryneedtobe

improvedimmediately.Allaspectsof theobstetricandpaediatriccarewhichpromotegoodqualityshouldbeaddressed,suchasthenumberofhumanresourcesatthetimeofdelivery,theratioofdeliveriestohealthpersonnel,thetimeanddate,thenumberofspecialistsonduty,responding to calls promptly and the equipment and supplies used during the emergency response.A situational analysis of these issueswould certainly improve thequalityof caresinceastheresearchrevealed87%ofstillbirthsandneonataldeathsweredeliveredbyhighlytrainedpersonnel.

Thequestiononemightthenaskis“Whatcanbedonetoimprovethequalityofcareatourhealthinstitutions?”Theanswertothisquestionrevolvesaroundafunctioninghealthsystemwithallthenecessaryresources,supplies,policiesandthewillandpurposeofourhealthpersonneltoattainthebesthealthforallbeforetheendof the21stcentury.Standardsofresuscitationtechniquesneedtobereinforcedatthehospitals.Specialneonatalintensivecarefacilitiesareneededatall thehospitals,not just thenational referralhospitalsaswell as theavailabilityofhighlytrainedneonatalstaffwhichincludedoctorsandnurses.Clinicalauditofneonatalconditions should form thebasisof themonitoringandevaluationof everyhospital inourcountry.

Thehealthworkersmustbecongratulatedforfollowingprotocolsofpostnatalcareas90%ofthestillbirthswereweighedatbirth.However,whatwasnotexplainedwaswhybabieswithalargerbirthweightwerebornasstillbirthsasagainstneonataldeaths.

InfantswithApgarscoreofover10minutesatbirthareabletosurviveintheneonatalperiod.However,inthisstudy88%oftheneonateswhodiedhadanApgarscoreoflessthan10minutes.ThestillbirthshadanApgarscoreof0atbirthinkeepingwithinternationalstandards.

WHOhasillustratedthatearlyneonataldeathscontributeto50%oftheinfantmortalityrateinourcountries.Datareviewedshowedthat82%ofourneonatesdiedwithinthefirstsevendays.

Prematurebabies(28weekstothe37weeks)havealowerchanceofsurvivalthanbabieswhoarebornover37weeks.Datareviewedthatmoreneonataldeathsthanstillbirthwerepremature.Asseenearlierthestillbirthshadahigherbirthweightandwerefreshstillbirths,indicatingtheneedforfurtherstudy.

Artificialheatwasusedfor49%neonatesaccordingtothedatainthestudy.Thetypeofheatusedwastheincubator.RecordingoftheBCGvaccineafterdeliverywasabsentin89%ofthemotherssincetheoldchartwasusedtoobtainthisinformation.ThisisnotatruereflectionofthelevelofBCGimmunizationcoverage.


recommended for the country LeveL (Guyana) Activities bAsed on who mortALity scenArio

Mortality SettingsNMR is between 15 - 19

TheneonatalmortalityrecommendationsfromWHOforcountriesarestatedbelow.Thesewereusedtodeterminethelevelofthecountryandtheneedformoreactivitiesatthecountrylevel.Somespecificrecommendationsbasedonthefindingsofthestudywerealsoaddressed.

IMMEDIATE STRATEGIES (2009–2013)

WHO Recommendations Study Recommendations

heALth informAtion system

Utilize the Perinatal InformationSystemforrecordingofobstetric and neonatal information.(WHOhaspatternsofhospitalcharts that are being used that can be adaptedtothecountry).

Trainingonhealthinformationisessential

GuyanahasalreadystartedtheuseofthePerinatalObstetrichospitalrecordsformaternitycases,butnottheneonatalcharts.Currently,allofthefivehospitalsinthestudyareusingthePerinatalcharts.However,thisneedstobestrengthenedsincenotallthedataisbeingrecorded.Atthetimeofthestudytheoldchartswereused.Theuseofthepartographduringlabourstillneedstobereinforcedatalllevels,sincethiswillidentifyemergenciesduringlabour.ThereisneedtoadapttheWHOneonatalchartforthehospitalsthatwouldrecordneonataldataandstillbirthswithalltherelevantinformation.All neonatal deaths recording should be coded with the mother’s deliverychart,sointheeventthatthechartisneededforfurtherreferenceitcanbefoundeasily.Aregistershouldbemadeoftheneonatalandstillbirthsonthelabourwardwiththeregisternumberbeingthesameasthatofthemother’schart.(GoodexampleisMackenzieHospitalandWestDemeraraHospital).Onmothersdischargefromtheward,theneonatalandstillbirthchart should be placed in the mother’s chart and sent to the records department.Thisneonatal/stillbirthrecordshouldbeenteredseparatelyinrecordsinalogbookandfilledaccordingtomonthandyear.Trainingshouldbedonefortheclerksandthenursesinthematernitywardsontheuseofthechartsanddefinitionsofcare.Hospitalsshouldreviewthenumberofstillbirthsandneonataldeathsonamonthlybasisandseekwaystodecreasethenumbers.

principLes

Universalizeoutreachandfamilyandcommunity care as wellasskilledcare;strengthen care in facilitiesdowntothefirstreferral.

Over90%oftheantenatal,intranatalandpostnatalcaresareconductedinthemainhospitals.TheprinciplesofcarearebasedontheWHOsafe-motherhoodpackage.Thefourpronepackageofantenatalcareseekstopromoteearlyvisits,laboratorytests,screeningforanaemiaandHIV,theuseofiron,sprinklesandfolicacidsduringpregnancy.GuyanahadimplementedthisWHOpackagebutwhatneedstobedoneisfurtherreinforcement.Guyana,unlikeanyotherCaribbeancountryhasalsoimplementedanti-helminthes treatment during pregnancy to combat anaemia problems.ImprovementinhealthservicesbasedonthedatainthestudyisneededintheareaoftimelyHbresultssincesomeoftheresultswere not known and more compliance is needed as it relates to the useofironandfolicacidsincemotherswereanaemic.SpecialattentionmustalsobeplacedonthenutritioneducationofantenatalmothersstressingtheuseofappropriateironrichfoodswhichwouldenhancetheirHblevels.


cLinicAL

Attainfullcoveragewithskilledattendance,targeting un-reached populations;ensureemergency obstetric and neonatal care at peripheralfacilities;developcomprehensiveobstetric and neonatal care at district hospi-tals;improvequalityand cultural accept-abilityofobstetricandperinatalcare.

Guyanarateswell,havingover87%ofthestaffskilledinobstetricduringthisstudy.However,thequalityofintranatalcareshouldbeaddressedimmediately,sincethemajorityofneonataldeathsand stillbirths occurred in the hospitals as consistent with national andsurveydata.GoodMCHachievementisthatthepopulationhasrecognizedtheimportanceofhealthandareseekingcareasneededsincemorebirthsoccurinthehospitalthanathome.Strengtheningoftheintranatalservicesinthehospitalbasedontheoutcomeofthisstudyisbasedonimprovingthequalityofcareduringdelivery,payingspecialattentiontothetechniquesofthedeliveryprocess.Theuseofmannequinstodemonstratedeliverytechniquesonaregularbasismustbeencouragedonthelabourwards.(ALARMobstetric training currently in process is intended to address this issue).Trainingofmedicaldoctorsinspecialistcareisalsoimpor-tant.Thereiscurrentlynoneonatologistinanyofthehospitals.Moremannequinsmustbeboughtandplacedonthelabourward.Asamatteroffact,anareamustbesetasideasapracticeareainthelabourwardineachhospital.Thiswouldgreatlyincreasetheskillsofthetrainedstaff.Protocolsshouldbeadheredtoasitrelatestothemanagementofcomplicationsofpregnancyforexample,useofantibioticsearlyinprematureruptureofthemembranesbeforedelivery,preven-tionofprolongedlabourbypropermonitoringofhypertensioninpregnancyandante-partumhaemorrhage.Theuseofthepartogramduringlabourwillassistinearlyidentifi-cationoffoetaldistress.Theuseofdelayedclampingoftheumbili-calcordshouldbeimplementedduringdelivery.Attheprimaryhealthcarelevels,IMCIwouldbedonewithafocusontheneonatalcomponent.Thiswouldleadtoidentifica-tionofdangersignsintheneonateandtheassessmentofhighriskcasesinthemotherforearlyreferral.Availabilityofsuppliesforneonatalcareandthemonitoringofthefetalheartduringlabourarenecessary.Itwasquiteobviousthatnopropermonitoringofthepatientsisbeingdoneduringlabour,sincemostofthecaseswerefreshstillbirths.Fordevelopingcoun-tries,theuseofthepartographcanmakeagreatimpactinidentifi-cationofcomplicationsduringlabour.Obstetricandneonatalintensivecareisonlyavailableattwoofthesehospitals,NewAmsterdamandGeorgetownPublicHospital.

AdvocAcy

Develop specific poli-cies to address neonatal care.Manuals and standards at facility and commu-nity levels.

Family Planning Policy was done in 2007 and addresses specific policies on neonatal care.These policies must be reinforced at all hospitals and facilities.Video documentary of maternity and neonatal care should be provided to the general public advising them of the program and where to seek care.

outreAch

Achieve full coverage with antenatal care targeting un-reached populations; consider introducing additional antenatal care interven-tions

Antenatal care is available for 90% of the population. Outreach activities are conducted to remote areas.Strengthening outreach activities to remote areas is vitally impor-tant and also training of the lower cadre of staff to recognize high risk conditions and prompt referrals.

FAmily And community

Continue to promote health home behaviours and care seeking.

The promotion of good home care could be reinforced using the IMCI component which included teaching the parents how to care for their children and when to return in an event of complications.


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Appendix 1: QuestionnAire for the neonAtAL study

MaternalandChildHealthQuestionnaireforNeonatalStudyJuly2008

(Answers to be obtained from records)1. Region_________________________________________________

HealthFacility___________________________________________ RecordNo._____________________________________________

DEMOGRAPHICDATA

2. Age of mother (years) a)<16 □ b)16-17 □ c)18-35 □ d)morethan35 □

3. Ethnicity a)Afro–Guyanese □ b)Amerindian □ c)Indo-Guyanese □ d)Mixed □

e)Other(pleasespecify)___________________________________ 4. Education level of mother a)Primary □ b)Secondary □ c)Tertiary □ d)Notstated □

5 . If (d) to (4), was the old chart used? a) Yes □ b) No □ c) NA □


13. If Yes to (12), what was result? a)Positive □ b)Negative □14. Was mother screened for syphilis? a)Yes □ b)No □ c)Notstated □

15. If Yes to (14), what was result? a)RPRPositive □ b)RPRNegative □ c)NA □

16. Was mother diabetic? a)Yes □ b)No □ c)Notstated □

17. Was mother hypertensive before pregnancy or during pregnancy? a)Yes □ a)(i)Statebloodpressurereadingonadmission_______________ b)No □ c)Notstated □

18. Was there any complication during pregnancy? a)Yes □ b)No □ c)Notstated □

19. If Yes to (18), what was the complication? (please state)

_____________________________________________________________

LABOUR AND DELIVERY

20. At what time of gestation (28 to 37 weeks) did the membrane rupture ? a)Stateweeks___________ b)Notstated □

6. State parity of mother? a)1orless □ b)>1–4 □ c)5ormore □

IMMUNIZATION STATUS

7. Was immunization status recorded? a)Yes □ b)No □ c)NA □

8. If Yes to (7), was mother adequately immunized against Tetanus and Diphtheria? (Received 2 doses in pregnancy, had 5 doses before pregnancies, etc.) a)Yes □ b)No □ c)Notstated □

9. If b and c to (8), was the old chart used? a)Yes□ b)No□ c)NA□

ANTENATAL CARE

10. Nutritional Status of mother (level of Hb) a)<7g/dl □ b)7–10.99g/dl □ c)11gramandover □

11. Antenatal care (clinic attendance) a)Adequate(>4visits) □ b)Inadequate(<4visits) □ c)Notstated □

12. Screening for infectious disease (HIV) a)Yes □ b)No □ c)Notstated □


21. Was antibiotics given?

Pleasestate(specify)________________________________________

22. How long was the membrane ruptured before delivery? a)Justaroundorbeforedelivery □ b)<or=1week □ c)>1week □ d)2weeks □ e)>2weeks □ f)Notstated □ 23. Was antibiotics given?

Pleasestate(specify)________________________________________

24. Who attended to mother at birth? a)Qualifiedprofessional(Nurse,Midwife,Doctor,Medex)□

b)Other(specify)____________________________________________

25. Was labour prolonged (>24 hours)? a)Yes □ b)No □ c)Notstated □

26. Was delivery normal? a)Yes □ b)No □

27. If No to (26), what type of delivery was it? a)Breech □ b)Foot □ c)Hand □ d)Shoulder □

e)Other(pleasestate)_______________________________________ f)NA □

28. Was caesarean section done? a)Yes □ b)No □ c)NA □

POSTNATAL

29. Was baby born alive? a)Yes □ b)Stillbirth □

29.1 If stillbirth was ticked, was the stillbirth weighed at birth? a)Yes □ b)No □ c)NA □

IfYesto(29.1)writethestillbirthweight______________________

30. If Yes to (29), what was the APGAR score of infant after 5 minutes? ___________________________________________________

31. Was baby preterm greater than or equal to 28 weeks but before 37 weeks? a)Yes □ a)(i)Stategestationweeks__________________________________ b)No □ c)Notstated □

32. What was baby’s weight at birth? State weight _______________ a)<1500g □ b)1500–2500g □ c)>2500g □

33. Was resuscitation adequately performed (skin dried, nostrils cleared or suction, infant kept warm)? a)Yes □ b)No □ c)Notstated □


34. Was artificial source of heat used on infant? a)Yes □ b)No □

35. If Yes to (33), what source was used? a)Lamp □ b)Incubator □ c)Other(specify)____________________________________________

36. Was baby breastfed after birth? a)Yes □ b)No □ c)IfNo,(statereasons) ___________________________________________________________

37. When did baby die? a)Within7daysofbirth □ b)Between7and28daysofbirth □ c)Notstated □

38. What was the cause of death? (specify)

_____________________________________________________________

39. Was the baby given BCG vaccines after birth? a)Yes □ b)No □ c)Notstated □

Documents

Retrospective Analysis of Neonates and Stillbirths1).pdf · of neonatal deaths it was decided to research the causes of the stillbirths as well. This study