Determinants of perinatal mortality in public secondary health facilities, Abuja municipal area council, Federal Capital Territory, Abuja, Nigeria

  • Pan African Medical Journal, Volume 37, Year 2020

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Study Justification:
The study aimed to investigate the determinants of perinatal mortality in public secondary health facilities in Abuja Municipal Area Council, Nigeria. This research was justified by the high perinatal mortality rate observed in Nigeria, particularly in health facilities. By identifying the factors influencing perinatal deaths in this specific setting, the study aimed to inform interventions and strategies to reduce perinatal mortality.
Highlights:
1. Perinatal mortality rate: The study found a perinatal mortality rate of 129.5 per 1000 births in the studied hospitals. This indicates a significant problem that needs to be addressed to improve the health outcomes of newborns and their mothers.
2. Leading causes of perinatal deaths: The majority of perinatal deaths were attributed to asphyxia (34.0%), neonatal infection (20.0%), and prematurity (17.3%). These findings highlight the importance of addressing these specific causes through targeted interventions and improved healthcare practices.
3. Determinants of perinatal death: The study identified several factors associated with an increased risk of perinatal death. These factors include unbooked antenatal care status, antepartum hemorrhage, previous perinatal death, and maternal age ≥ 35 years. Understanding these determinants can help healthcare providers identify and target women at risk of pregnancy complications, ultimately reducing perinatal deaths.
Recommendations:
Based on the study findings, the following recommendations are proposed:
1. Improve antenatal care attendance: Efforts should be made to increase the number of pregnant women accessing and utilizing antenatal care services. This can be achieved through community awareness campaigns, improved accessibility of healthcare facilities, and targeted interventions to address barriers to antenatal care.
2. Strengthen healthcare staff capacity: Healthcare providers should be trained to identify and manage high-risk pregnancies and pregnancy complications. This includes early detection and management of antepartum hemorrhage, as well as appropriate management of asphyxia and neonatal infections.
3. Enhance referral systems: Strengthening the referral systems between primary healthcare facilities and secondary health facilities is crucial. This will ensure timely access to comprehensive obstetric and newborn care for pregnant women in need.
Key Role Players:
To address the recommendations, the following key role players are needed:
1. Ministry of Health: The Ministry of Health should provide leadership and support in implementing interventions to reduce perinatal mortality. They can coordinate efforts, allocate resources, and monitor progress.
2. Healthcare Providers: Obstetricians, gynecologists, pediatricians, and other healthcare providers play a crucial role in identifying and managing high-risk pregnancies and providing quality care during childbirth and the neonatal period.
3. Community Health Workers: Community health workers can play a vital role in promoting antenatal care attendance, educating pregnant women about pregnancy complications, and facilitating referrals to healthcare facilities.
4. Non-Governmental Organizations (NGOs): NGOs can support the implementation of interventions by providing resources, training programs, and community outreach initiatives.
Cost Items for Planning:
While the actual cost of implementing the recommendations will vary, the following cost items should be considered in planning:
1. Training and Capacity Building: Budget for training healthcare providers on high-risk pregnancy management, emergency obstetric care, and neonatal care.
2. Awareness Campaigns: Allocate funds for community awareness campaigns to promote antenatal care attendance and educate the community about perinatal mortality and its prevention.
3. Infrastructure and Equipment: Consider the cost of improving healthcare facilities, including the provision of necessary equipment and supplies for obstetric and neonatal care.
4. Monitoring and Evaluation: Allocate resources for monitoring and evaluation activities to assess the impact of interventions and make necessary adjustments.
5. Research and Data Collection: Budget for research activities, data collection, and analysis to monitor progress and inform evidence-based decision-making.
It is important to note that these cost items are estimates and may vary depending on the specific context and resources available.

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Introduction: in Nigeria, perinatal mortality rate remains high among births at the health facility. Births occur majorly at the secondary healthcare level in Abuja Municipal Area Council (AMAC) of the Federal Capital Territory (FCT). Identifying factors influencing perinatal deaths in this setting would inform interventions on perinatal deaths reduction. We assessed perinatal mortality and its determinants in public secondary health facilities in AMAC. Methods: delivery and neonatal data from two selected public secondary health facilities between 2013 and 2016 were reviewed and we extracted maternal socio-demographics, obstetrics and neonatal data from hospital delivery, newborns´ admissions and discharge registers. Data were analyzed using descriptive statistics and Cox proportional hazard models (α = 5%). Results: perinatal mortality rate was 129.5 per 1000 births. Asphyxia 475 (34.0%), neonatal infection 279 (20.0%) and prematurity 242 (17.3%) accounted for majority of the 1,398 perinatal deaths. Unbooked status [aHR = 1.8 (95% CI 1.4-2.2)], antepartum haemorrhage [aHR = 2.8 (95% CI 1.2 6.7)], previous perinatal death [aHR = 2.3 (95% CI 1.7-3.1)] and maternal age ≥ 35 years [aHR= 1.4 (95% CI 1.0-1.8)] were associated with increased risk of perinatal death. Conclusion: perinatal mortality in the studied hospitals was high. Determinants of perinatal death were unbooked antenatal care (ANC) status, antepartum haemorrhage, previous perinatal death and high maternal age. Reducing perinatal deaths would require improving antenatal care attendance with healthcare staff identifying and targeting women at risk of pregnancy complications.

Study area and setting: the study was conducted in Abuja Municipal Area Council, one of the six area councils in the FCT, Abuja. Abuja is the capital city of Nigeria and is located in the geographical centre of the country. In 2016, the population of the FCT and Abuja Municipal Area Council was estimated to be 3,419,323 and 1,894,513 respectively. Women of child bearing age and pregnant women were projected to be 416,793 and 94,726 respectively in the area council. Abuja Municipal Area Council has six public secondary health facilities. This study was conducted in two public secondary health facilities namely: Asokoro District Hospital and Nyanya General Hospital randomly selected by balloting. These health facilities have specialist obstetrics and gynecology departments as well as paediatric departments with new born special care units. They offer 24 hour emergency obstetric and newborn special care. These centers each have an annual delivery of between 1200 and 1500 and they are usually the health facilities where most pregnant women resident in the area council present for comprehensive obstetric and newborn care. They also serve as referral centers for the many primary health care facilities located within and outside the area council. Study design: this study involved a 4-year retrospective review of records in the selected public secondary health facilities covering the period from January 1st, 2013 to December 31st, 2016. Study population: the study population was babies delivered after 28 weeks gestation in public secondary health facilities in Abuja Municipal Area Council of the FCT and their mothers. Inclusion criteria: all babies delivered after 28 weeks of gestation between 1st January, 2013 and 31st December, 2016, in the selected health facilities as well as their mothers were included in the study. Babies admitted within the first seven days of birth at the newborn special care units of the selected health facilities over the study period were also included in the study. Study Instruments: a structured data collection form consisting of the following sections: maternal socio-demographic data, obstetric history, prenatal interventions/treatment, intrapartum findings, fetal and perinatal outcome was used for data collection. Data collection procedure: data from the mothers´ delivery registers as well as the babies´ admission and discharge registers at the newborn special care units of the selected health facilities were extracted and entered into the structured data collection form. Data extracted included maternal age, antenatal booking status, parity, educational status, employment status, previous obstetric history, antenatal antepartum conditions, intrapartum complications, gestational age at delivery, birth weight, first- and fifth-minute Apgar scores, fetal sex, newborn special care unit admission, perinatal complications and probable causes of perinatal deaths. Data analysis: data were coded and statistical analysis conducted using Microsoft Excel and Epi info version 7.1.5.2 software. Frequencies and proportions were computed as descriptive statistics. The perinatal mortality rate, stillbirth rate and early neonatal death rate were equally computed. A modified version of the Wigglesworth classification of causes of perinatal mortality was used to classify the probable causes of perinatal mortality [11]. At the level of bivariate, the association between perinatal mortality and explanatory variables was determined using Cox proportional hazard model (α=5.0%). Variables that were found to be significant at the level of bivariate were included in the multivariate analysis in order to identify the determinants of perinatal mortality. The indicator of the status variable are the cases of perinatal mortality. The time to event variable is the life span of the fetus which covers the period of 28 weeks of gestation and the first week after delivery. Any dead fetus within this interval will attract a code 0 and 1 if otherwise. However, fetus where information on the survival status between 28 weeks of gestation and the first week after delivery could not be ascertained is said to be censored and the Cox proportional hazard model factors this in during iteration. Ethical considerations: ethical approval for the study was sought and obtained from the Health Research Ethics Committee of the Health and Human Services Secretariat of the Federal Capital Territory Administration (FCTA), Abuja (FHREC/2016/01/64/26-08-16). Permission to access hospital data was sought and obtained from the managements of the selected secondary health facilities. Consent was not obtained from the mothers because there was no direct individual contact with patients; however, all data were de-identified before entry into the data collection form to ensure confidentiality.

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Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals for pregnant women, allowing them to receive prenatal care and consultations without having to travel long distances to healthcare facilities.

2. Mobile health (mHealth) applications: Developing mobile applications that provide pregnant women with information, reminders, and educational resources about prenatal care, nutrition, and warning signs during pregnancy can help improve maternal health outcomes.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in rural or underserved areas can help improve access to maternal health services.

4. Transportation services: Establishing transportation services, such as ambulances or mobile clinics, to transport pregnant women to healthcare facilities for prenatal care visits and emergency obstetric care can help overcome geographical barriers and improve access to maternal health services.

5. Health education campaigns: Conducting targeted health education campaigns to raise awareness about the importance of prenatal care, birth preparedness, and the signs of pregnancy complications can help empower pregnant women to seek timely and appropriate healthcare services.

6. Strengthening referral systems: Improving the coordination and communication between primary healthcare facilities and secondary healthcare facilities can ensure timely referrals for high-risk pregnancies, enabling pregnant women to receive specialized care when needed.

7. Quality improvement initiatives: Implementing quality improvement initiatives in healthcare facilities, such as training healthcare providers on evidence-based practices for maternal health and ensuring the availability of essential equipment and supplies, can help improve the overall quality of care provided to pregnant women.

These innovations can help address the identified determinants of perinatal mortality and improve access to maternal health services in the study area.
AI Innovations Description
Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve antenatal care attendance: One of the determinants of perinatal death identified in the study is unbooked antenatal care (ANC) status. To address this, an innovation could be developed to increase antenatal care attendance among pregnant women. This could involve implementing community-based ANC programs, providing incentives for attending ANC visits, and raising awareness about the importance of ANC through targeted health education campaigns.

2. Enhance early detection and management of antepartum hemorrhage: Antepartum hemorrhage was found to be associated with an increased risk of perinatal death. An innovation could focus on improving the early detection and management of antepartum hemorrhage in secondary health facilities. This could include training healthcare providers on recognizing the signs and symptoms of antepartum hemorrhage, ensuring the availability of necessary equipment and supplies for managing hemorrhage, and implementing standardized protocols for the management of antepartum hemorrhage.

3. Implement risk assessment and targeted interventions for women with previous perinatal death: Women with a history of previous perinatal death were found to be at an increased risk of perinatal death. An innovation could involve implementing a risk assessment tool to identify women with a history of previous perinatal death and providing targeted interventions to reduce the risk of perinatal death in subsequent pregnancies. This could include close monitoring during pregnancy, specialized care plans, and counseling on lifestyle modifications and preventive measures.

4. Address the needs of pregnant women aged 35 years and above: Maternal age of 35 years and above was associated with an increased risk of perinatal death. An innovation could focus on addressing the specific needs and challenges faced by pregnant women in this age group. This could include providing specialized antenatal care services, promoting healthy lifestyle choices, and offering counseling and support for managing pregnancy complications that may be more common in older women.

Overall, the innovation should aim to improve access to maternal health services, enhance the quality of care provided, and reduce the risk of perinatal death by addressing the identified determinants and implementing targeted interventions.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen Antenatal Care (ANC) Services: Focus on improving antenatal care attendance by providing comprehensive and accessible ANC services. This can include increasing the number of ANC clinics, ensuring availability of skilled healthcare staff, and promoting community awareness about the importance of ANC.

2. Enhance Emergency Obstetric and Newborn Care: Improve the capacity of public secondary health facilities to provide emergency obstetric and newborn care. This can involve training healthcare providers in emergency obstetric procedures, ensuring availability of essential equipment and supplies, and establishing effective referral systems.

3. Target High-Risk Pregnancies: Identify and target women at risk of pregnancy complications, such as those with unbooked antenatal care status, antepartum hemorrhage, previous perinatal death, and high maternal age. Implement interventions to closely monitor and manage high-risk pregnancies to reduce the risk of perinatal mortality.

4. Improve Health Information Systems: Strengthen the health information systems in public secondary health facilities to ensure accurate and timely collection, analysis, and reporting of maternal and neonatal data. This can help in identifying trends, monitoring progress, and making evidence-based decisions for improving access to maternal health.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Baseline Data Collection: Collect data on the current status of maternal health access, including indicators such as antenatal care coverage, facility delivery rates, perinatal mortality rates, and other relevant metrics.

2. Define Simulation Parameters: Determine the specific parameters to be simulated, such as the increase in ANC coverage, the improvement in emergency obstetric care services, and the reduction in high-risk pregnancies.

3. Model Development: Develop a simulation model that incorporates the baseline data and the defined parameters. This model should simulate the impact of the recommendations on the selected indicators of maternal health access.

4. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the simulation model by varying the input parameters and evaluating the resulting changes in the simulated outcomes.

5. Scenario Testing: Test different scenarios by adjusting the parameters in the simulation model to explore the potential impact of various combinations of recommendations on improving access to maternal health.

6. Evaluation and Interpretation: Analyze the simulation results and evaluate the potential impact of the recommendations on improving access to maternal health. Interpret the findings to inform decision-making and prioritize interventions for implementation.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. The above steps provide a general framework for conducting such a simulation.

Statistics:
Citations: 1
Authors: 8
Identifiers:
DOI: 10.11604/pamj.2020.37.114.17108
Research Areas:
Community Interventions, Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Nigeria
Study Design:
Cohort Study, Cross Sectional Study, Grounded Theory
Study Approach:
Quantitative
Participants Gender:
Female
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