Challenge of Reducing Perinatal Mortality in Rural Congo: Findings of a Prospective, Population-based Study

Journal of Health, Population and Nutrition, Volume 29, No. 5, Year 2011

Interpretation

Each year, an estimated six million perinatal deaths occur worldwide, and 98% of these deaths occur in low- and middle-income countries. These estimates are based on surveys in both urban and rural areas, and they may underrepresent the problem in rural areas. This study was conducted to quantify perinatal mortality, to identify the associated risk factors, and to determine the most common causes of early neonatal death in a rural area of the Democratic Republic of the Congo (DRC). Data were collected on 1,892 births. Risk factors associated with perinatal deaths were identified using multivariate analysis with logistic regression models. Causes of early neonatal deaths were determined by physician-review of information describing death. The perinatal mortality rate was 61 per 1,000 births; the stillbirth rate was 30 per 1,000 births; and the early neonatal death rate was 32 per 1,000 livebirths. Clinically-relevant factors independently associated with perinatal death included: low birthweight [odds ratio (OR)=13.51, 95% confidence interval (CI) 7.82-23.35], breech presentation (OR)=12.41; 95% CI 4.62-33.33), lack of prenatal care (OR=2.70, 95% CI 1.81-4.02), and parity greater than 4 (OR=1.93 95% CI 1.11-3.37). Over one-half of early neonatal deaths (n=37) occurred during the first two postnatal days, and the most common causes were low birthweight/prematurity (47%), asphyxia (34%), and infection (8%). The high perinatal mortality rate in rural communities in the DRC, approximately one-half of which is attributable to early neonatal death, may be modifiable. Specifically, deaths due to breech presentation, the second most common risk factor, may be reduced by making available emergency obstetric care. Most neonatal deaths occur soon after birth, and nearly three-quarters are caused by low birthweight/prematurity or asphyxia. Neonatal mortality might be reduced by targeting interventions to improve neonatal resuscitation and care of larger preterm infants. © International Centre For Diarrhoeal Disease Research, Bangladesh. The DRC is the fourth most populous country in Africa. Despite vast natural resources, unstable political leadership compounded by wars and civil unrest have resulted in the DRC ranking in the bottom 10 countries in the world on the human development index (8). The rural province of Equateur, where this study was conducted, has a health system characterized by limited resources and barriers to accessing healthcare. The primary site of care is the health centre where there is usually no electricity or plumbing. The health centres typically have primitive laboratory facilities and inadequately-stocked pharmacies. Access is limited by long distances between many villages and health centres and a total lack of public transportation. Since most services must be purchased by families and patients, poverty also limits access to healthcare. The population in this province is among the poorest in the country. One third of the population is in the lowest economic quintile in the country. These factors result in a population with poor health outcomes. The acute malnutrition rate is 11%; severe stunting occurs in nearly one-third of young children (9). The mortality rate is 3.9 deaths per 10,000 inhabitants per day among children aged 6-59 months (De Radigues X and Alberti K. Personal communication, 2003). This prospective, population-based, observational study was nested within a cluster-randomized controlled trial—the FIRST BREATH Trial—, conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Global Network for Women’s and Children’s Health Research (10). The FIRST BREATH Trial investigated the benefits of implementing a package of neonatal care practices in community settings. As part of this study, birth attendants were trained to collect basic data on maternal, foetal and neonatal outcomes, which included demographics, mode of delivery, birthweight, gestational age, need for resuscitation, and details of adverse events. Data for the study reported in this paper were collected during the baseline period of the FIRST BREATH Trial (June-December 2005), after training on infant examination and data-collection but before the first intervention. The FIRST BREATH Trial ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT00136708″,”term_id”:”NCT00136708″}}NCT00136708) is registered with a clinical trials database (www.ClinicalTrials.gov). Ten communities participated in the study. Pregnant women were enrolled at their first antenatal visit, which was typically by 24 weeks of gestation, or at the onset of labour for those who did not attend antenatal care. Community Coordinators, specially-trained nurses, oversaw data-collection by birth attendants in the community. After each delivery, the Community Coordinators collected data recorded by the birth attendants. Traditional birth attendants (TBAs) were women who assisted during childbirth. TBAs received variable training, which was usually limited to an apprenticeship with an experienced TBA. Skilled birth attendants were nurses, midwives, or doctors who provided obstetric care. If a delivery was not attended by either a TBA or a skilled birth attendant, data describing the circumstances of birth were collected retros-pectively (usually within one day), and the infant was weighed at this time. We collected data describing maternal factors that might influence the pregnancy outcomes. These factors included those for which data were readily available, likely to be highly reliable, and could be expressed numerically or categorically. Variables included the mother’s age, education, and living circumstances and also the pregnancy and intrapartum factors. The places of delivery included hospitals, health centres, homes (including the birth attendant’s home), or other (in transit). A woman was considered to have participated in antenatal care if she attended at least one visit with a skilled birth attendant. The inclusion criteria required birth in a study community and a birthweight of 1,000 g or more. We defined early neonatal death (END) as death of a liveborn infant at or before seven days of life (11). Since times of births were not recorded, the age at death was calculated by subtracting the date of birth from the date of death. A stillbirth was a newborn of at least 1,000 g of birthweight or corresponding to approximately 28 weeks of gestation or more, with no signs of life at birth, i.e. no breathing, no heart rate, and no movement. To ensure the proper differentiation between a stillbirth and a neonatal death, all the birth attendants were trained to check for foetal and neonatal vital signs by auscultating the abdomen of every pregnant woman before delivery and after delivery by feeling the infant’s umbilical cord for a pulse, auscultating the lungs for breath sounds, and assessing for any movement. This training also included the identification of physical findings necessary to differentiate a fresh from a macerated stillbirth. All instructions used a train-the-trainer model outlined previously (7). Birthweights were obtained within 48 hours of delivery using the spring Salter Scales (model 145555) of the United Nations Children’s Fund (UNICEF) provided for the study. The gestational age was determined using the mother’s last menstrual period, when available. A single physician assigned a cause for each neonatal death using descriptions of the circumstances of death provided by the Community Coordinators. Clinical data were not collected in a uniform manner; laboratory data, e.g. blood smears or cultures, were rarely available. This assignment was based on the physician’s knowledge of diseases in the community, assisted by operational definitions. Birth asphyxia was assigned when death followed the inability to breathe spontaneously or sustain breathing soon after birth (12). Low birthweight (LBW) and prematurity were combined as a potential cause of death and were assigned if mortality occurred in an infant who weighed less than 2,500 g at birth or had the appearance of a premature infant according to the Ballard morphologic criteria (13). Infection was assigned in the following circumstances: maternal infection diagnosed during pregnancy and treated without success, prolonged rupture of the membranes, foul-smelling amniotic fluid, maternal fever during labour, or fever or other signs of newborn infection during the first week of life. These signs included lethargy, rapid breathing, and mottled skin. Neonatal tetanus was assigned if mortality occurred in an infant with a normal abili-ty to suck and cry during the first two days of life but thereafter could not suck normally and became stiff or had jerking of the muscles. Congenital defects were assigned as the cause of death when they were presumed to be incompatible with life. Data were first collected on paper forms and then entered into an electronic database in Equateur. Digitized data were then transmitted electronically to the Data Coordinating Center (RTI International, Research Triangle Park, NC, USA). Data were analyzed using the SAS software (version 9.2). Factors potentially associated with perinatal mortality were grouped into obstetric and sociodemographic maternal characteristics of the infant, type of birth attendant, location of the delivery, and characteristics. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using logistic regression models with generalized estimating equations adjusting for cluster to assess the relationship between perinatal mortality and each selected variable. Factors associated with stillbirths and neonatal deaths were not examined independently because of limitations of the sample-size and the relative infrequency of these outcomes. Reference categories were determined for each group. A multivariate logistic regression model with generalized estimating equations adjusting for cluster was used for computing adjusted ORs and 95% CI adjusting for all the variables. The study was approved by the institutional ethics review committees of the Kinshasa School of Public Health, University of North Carolina, and RTI International. Verbal informed consent was obtained from mothers at the time of enrollment.

AI Digest

Study Justification:

– Perinatal mortality is a significant global health issue, with the majority of deaths occurring in low- and middle-income countries.
– Previous surveys may have underestimated the problem in rural areas, highlighting the need for more accurate data.
– This study aimed to quantify perinatal mortality, identify risk factors, and determine the most common causes of early neonatal death in a rural area of the Democratic Republic of the Congo (DRC).

Study Highlights:

– The study collected data on 1,892 births in a rural province of the DRC.
– The perinatal mortality rate was found to be 61 per 1,000 births, with a stillbirth rate of 30 per 1,000 births and an early neonatal death rate of 32 per 1,000 live births.
– Risk factors associated with perinatal death included low birthweight, breech presentation, lack of prenatal care, and high parity.
– The most common causes of early neonatal deaths were low birthweight/prematurity, asphyxia, and infection.

Recommendations for Lay Readers:

– The high perinatal mortality rate in rural communities in the DRC, particularly early neonatal deaths, can be reduced through targeted interventions.
– Making emergency obstetric care available can help reduce deaths due to breech presentation.
– Improving neonatal resuscitation and care of larger preterm infants can help reduce neonatal mortality.

Recommendations for Policy Makers:

– Allocate resources to improve access to emergency obstetric care in rural areas to address deaths due to breech presentation.
– Implement interventions to improve neonatal resuscitation and care of larger preterm infants to reduce neonatal mortality.
– Strengthen prenatal care services to ensure early identification and management of risk factors associated with perinatal deaths.

Key Role Players:

– Health authorities and policymakers in the DRC.
– Healthcare providers, including doctors, nurses, and midwives.
– Community health workers and traditional birth attendants.
– Non-governmental organizations (NGOs) working in maternal and child health.

Cost Items for Planning Recommendations:

– Training programs for healthcare providers on emergency obstetric care and neonatal resuscitation.
– Equipment and supplies for emergency obstetric care and neonatal resuscitation.
– Strengthening prenatal care services, including training and capacity building for healthcare providers.
– Community outreach and education programs to raise awareness about the importance of prenatal care and early neonatal care.
– Monitoring and evaluation systems to assess the impact of interventions and track progress in reducing perinatal mortality.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a prospective, population-based study with a large sample size. The study collected data on 1,892 births and used multivariate analysis with logistic regression models to identify risk factors associated with perinatal deaths. The causes of early neonatal deaths were determined by physician-review of information describing death. The study provides specific rates of perinatal mortality, stillbirth, and early neonatal death, as well as clinically-relevant factors associated with perinatal death. The abstract also suggests actionable steps to improve the high perinatal mortality rate in rural communities in the Democratic Republic of the Congo, such as making emergency obstetric care available and targeting interventions to improve neonatal resuscitation and care of larger preterm infants. However, to further improve the evidence, the abstract could include more details about the study methodology, such as the sampling strategy and data collection procedures. Additionally, providing information about the generalizability of the findings and potential limitations of the study would enhance the overall strength of the evidence.

Abstract

The DRC is the fourth most populous country in Africa. Despite vast natural resources, unstable political leadership compounded by wars and civil unrest have resulted in the DRC ranking in the bottom 10 countries in the world on the human development index (8). The rural province of Equateur, where this study was conducted, has a health system characterized by limited resources and barriers to accessing healthcare. The primary site of care is the health centre where there is usually no electricity or plumbing. The health centres typically have primitive laboratory facilities and inadequately-stocked pharmacies. Access is limited by long distances between many villages and health centres and a total lack of public transportation. Since most services must be purchased by families and patients, poverty also limits access to healthcare. The population in this province is among the poorest in the country. One third of the population is in the lowest economic quintile in the country. These factors result in a population with poor health outcomes. The acute malnutrition rate is 11%; severe stunting occurs in nearly one-third of young children (9). The mortality rate is 3.9 deaths per 10,000 inhabitants per day among children aged 6-59 months (De Radigues X and Alberti K. Personal communication, 2003). This prospective, population-based, observational study was nested within a cluster-randomized controlled trial—the FIRST BREATH Trial—, conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Global Network for Women’s and Children’s Health Research (10). The FIRST BREATH Trial investigated the benefits of implementing a package of neonatal care practices in community settings. As part of this study, birth attendants were trained to collect basic data on maternal, foetal and neonatal outcomes, which included demographics, mode of delivery, birthweight, gestational age, need for resuscitation, and details of adverse events. Data for the study reported in this paper were collected during the baseline period of the FIRST BREATH Trial (June-December 2005), after training on infant examination and data-collection but before the first intervention. The FIRST BREATH Trial ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT00136708″,”term_id”:”NCT00136708″}}NCT00136708) is registered with a clinical trials database (www.ClinicalTrials.gov). Ten communities participated in the study. Pregnant women were enrolled at their first antenatal visit, which was typically by 24 weeks of gestation, or at the onset of labour for those who did not attend antenatal care. Community Coordinators, specially-trained nurses, oversaw data-collection by birth attendants in the community. After each delivery, the Community Coordinators collected data recorded by the birth attendants. Traditional birth attendants (TBAs) were women who assisted during childbirth. TBAs received variable training, which was usually limited to an apprenticeship with an experienced TBA. Skilled birth attendants were nurses, midwives, or doctors who provided obstetric care. If a delivery was not attended by either a TBA or a skilled birth attendant, data describing the circumstances of birth were collected retros-pectively (usually within one day), and the infant was weighed at this time. We collected data describing maternal factors that might influence the pregnancy outcomes. These factors included those for which data were readily available, likely to be highly reliable, and could be expressed numerically or categorically. Variables included the mother’s age, education, and living circumstances and also the pregnancy and intrapartum factors. The places of delivery included hospitals, health centres, homes (including the birth attendant’s home), or other (in transit). A woman was considered to have participated in antenatal care if she attended at least one visit with a skilled birth attendant. The inclusion criteria required birth in a study community and a birthweight of 1,000 g or more. We defined early neonatal death (END) as death of a liveborn infant at or before seven days of life (11). Since times of births were not recorded, the age at death was calculated by subtracting the date of birth from the date of death. A stillbirth was a newborn of at least 1,000 g of birthweight or corresponding to approximately 28 weeks of gestation or more, with no signs of life at birth, i.e. no breathing, no heart rate, and no movement. To ensure the proper differentiation between a stillbirth and a neonatal death, all the birth attendants were trained to check for foetal and neonatal vital signs by auscultating the abdomen of every pregnant woman before delivery and after delivery by feeling the infant’s umbilical cord for a pulse, auscultating the lungs for breath sounds, and assessing for any movement. This training also included the identification of physical findings necessary to differentiate a fresh from a macerated stillbirth. All instructions used a train-the-trainer model outlined previously (7). Birthweights were obtained within 48 hours of delivery using the spring Salter Scales (model 145555) of the United Nations Children’s Fund (UNICEF) provided for the study. The gestational age was determined using the mother’s last menstrual period, when available. A single physician assigned a cause for each neonatal death using descriptions of the circumstances of death provided by the Community Coordinators. Clinical data were not collected in a uniform manner; laboratory data, e.g. blood smears or cultures, were rarely available. This assignment was based on the physician’s knowledge of diseases in the community, assisted by operational definitions. Birth asphyxia was assigned when death followed the inability to breathe spontaneously or sustain breathing soon after birth (12). Low birthweight (LBW) and prematurity were combined as a potential cause of death and were assigned if mortality occurred in an infant who weighed less than 2,500 g at birth or had the appearance of a premature infant according to the Ballard morphologic criteria (13). Infection was assigned in the following circumstances: maternal infection diagnosed during pregnancy and treated without success, prolonged rupture of the membranes, foul-smelling amniotic fluid, maternal fever during labour, or fever or other signs of newborn infection during the first week of life. These signs included lethargy, rapid breathing, and mottled skin. Neonatal tetanus was assigned if mortality occurred in an infant with a normal abili-ty to suck and cry during the first two days of life but thereafter could not suck normally and became stiff or had jerking of the muscles. Congenital defects were assigned as the cause of death when they were presumed to be incompatible with life. Data were first collected on paper forms and then entered into an electronic database in Equateur. Digitized data were then transmitted electronically to the Data Coordinating Center (RTI International, Research Triangle Park, NC, USA). Data were analyzed using the SAS software (version 9.2). Factors potentially associated with perinatal mortality were grouped into obstetric and sociodemographic maternal characteristics of the infant, type of birth attendant, location of the delivery, and characteristics. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using logistic regression models with generalized estimating equations adjusting for cluster to assess the relationship between perinatal mortality and each selected variable. Factors associated with stillbirths and neonatal deaths were not examined independently because of limitations of the sample-size and the relative infrequency of these outcomes. Reference categories were determined for each group. A multivariate logistic regression model with generalized estimating equations adjusting for cluster was used for computing adjusted ORs and 95% CI adjusting for all the variables. The study was approved by the institutional ethics review committees of the Kinshasa School of Public Health, University of North Carolina, and RTI International. Verbal informed consent was obtained from mothers at the time of enrollment.

Materials

N/A

Innovations

Based on the findings of the study, the following recommendations can be developed into innovations to improve access to maternal health:

1. Improve access to emergency obstetric care: This could involve training healthcare providers in rural communities to handle emergency deliveries and providing necessary equipment and supplies.

2. Target interventions to improve neonatal resuscitation and care: This could involve training healthcare providers in neonatal resuscitation techniques and ensuring that necessary equipment and supplies are available in healthcare facilities.

3. Improve access to prenatal care: This could involve setting up mobile clinics or outreach programs to reach remote communities and providing financial support or incentives for pregnant women to seek prenatal care.

4. Address socioeconomic factors: This could involve providing financial assistance or health insurance coverage for pregnant women, improving transportation infrastructure to facilitate access to healthcare facilities, and implementing poverty alleviation programs.

These innovations aim to reduce perinatal mortality rates in rural areas of the Democratic Republic of the Congo by improving access to essential maternal health services.

AI Innovations Description

Based on the findings of the study, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve access to emergency obstetric care: Breech presentation was identified as a significant risk factor for perinatal death. To reduce deaths due to breech presentation, it is recommended to make emergency obstetric care available in rural areas. This could involve training healthcare providers in rural communities to handle emergency deliveries and providing necessary equipment and supplies.

2. Target interventions to improve neonatal resuscitation and care: The study found that most neonatal deaths occurred soon after birth and were caused by low birthweight/prematurity or asphyxia. To reduce neonatal mortality, interventions should be targeted towards improving neonatal resuscitation and the care of larger preterm infants. This could involve training healthcare providers in neonatal resuscitation techniques and ensuring that necessary equipment and supplies are available in healthcare facilities.

3. Improve access to prenatal care: Lack of prenatal care was identified as a risk factor for perinatal death. To improve access to prenatal care, efforts should be made to increase the availability and affordability of prenatal care services in rural areas. This could involve setting up mobile clinics or outreach programs to reach remote communities and providing financial support or incentives for pregnant women to seek prenatal care.

4. Address socioeconomic factors: Poverty was identified as a barrier to accessing healthcare in rural areas. To improve access to maternal health, it is important to address socioeconomic factors that limit access, such as providing financial assistance or health insurance coverage for pregnant women, improving transportation infrastructure to facilitate access to healthcare facilities, and implementing poverty alleviation programs.

Overall, the innovation should focus on improving access to emergency obstetric care, targeting interventions to improve neonatal resuscitation and care, improving access to prenatal care, and addressing socioeconomic factors that limit access to maternal health services in rural areas.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the target population: Identify the rural areas in the Democratic Republic of the Congo (DRC) where access to maternal health services is limited. This could involve mapping out the areas with the highest perinatal mortality rates and limited healthcare infrastructure.

2. Collect baseline data: Gather information on the current state of access to maternal health services in the target population. This could include data on the availability of emergency obstetric care, neonatal resuscitation training, prenatal care services, and socioeconomic factors that limit access.

3. Develop intervention strategies: Based on the recommendations from the study, design specific interventions to improve access to maternal health services. This could involve training healthcare providers in rural communities on emergency obstetric care and neonatal resuscitation techniques, setting up mobile clinics or outreach programs to provide prenatal care services, and implementing poverty alleviation programs to address socioeconomic barriers.

4. Implement interventions: Roll out the intervention strategies in the target population. This could involve partnering with local healthcare facilities, training healthcare providers, and establishing support systems for pregnant women to access prenatal care.

5. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on their impact. This could include tracking the number of emergency obstetric care cases handled in rural areas, assessing the improvement in neonatal resuscitation practices, measuring the increase in prenatal care utilization, and evaluating the effectiveness of poverty alleviation programs.

6. Analyze data and assess impact: Analyze the collected data to determine the impact of the interventions on improving access to maternal health services. This could involve comparing the baseline data with the post-intervention data to identify any improvements in perinatal mortality rates, stillbirth rates, and early neonatal death rates.

7. Adjust and refine interventions: Based on the findings from the data analysis, make any necessary adjustments or refinements to the interventions. This could involve scaling up successful strategies, addressing any challenges or barriers identified during the implementation phase, and continuously improving the interventions to maximize their impact.

By following this methodology, it would be possible to simulate the impact of the main recommendations on improving access to maternal health in rural areas of the DRC. The data collected and analyzed would provide valuable insights into the effectiveness of the interventions and guide future efforts to further enhance access to maternal health services.

Author

Dima Health

Statistics:

Citations: 14

Identifiers:

DOI: 10.3329/jhpn.v29i5.8908

ISSN: 16060997

Research Areas:

Community Interventions, Disparities, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Congo

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female