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"Perinatal mortality"
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Induction of labour at 41 weeks versus expectant management until 42 weeks (INDEX): multicentre, randomised non-inferiority trial
To compare induction of labour at 41 weeks with expectant management until 42 weeks in low risk women.
Open label, randomised controlled non-inferiority trial.
123 primary care midwifery practices and 45 hospitals (secondary care) in the Netherlands, 2012-16.
1801 low risk women with an uncomplicated singleton pregnancy: randomised to induction (n=900) or to expectant management until 42 weeks (n=901).
Induction at 41 weeks or expectant management until 42 weeks with induction if necessary.
Primary outcome was a composite of perinatal mortality and neonatal morbidity (Apgar score <7 at five minutes, arterial pH <7.05, meconium aspiration syndrome, plexus brachialis injury, intracranial haemorrhage, and admission to a neonatal intensive care unit (NICU). Secondary outcomes included maternal outcomes and mode of delivery. The null hypothesis that expectant management is inferior to induction was tested with a non-inferiority margin of 2%.
Median gestational age at delivery was 41 weeks+0 days (interquartile range 41 weeks+0 days-41 weeks+1 day) for the induction group and 41 weeks+2 days (41 weeks+0 days-41 weeks+5 days) for the expectant management group. The primary outcome was analysed for both the intention-to-treat population and the per protocol population. In the induction group, 15/900 (1.7%) women had an adverse perinatal outcome versus 28/901 (3.1%) in the expectant management group (absolute risk difference -1.4%, 95% confidence interval -2.9% to 0.0%, P=0.22 for non-inferiority). 11 (1.2%) infants in the induction group and 23 (2.6%) in the expectant management group had an Apgar score <7 at five minutes (relative risk (RR) 0.48, 95% CI 0.23 to 0.98). No infants in the induction group and three (0.3%) in the expectant management group had an Apgar score <4 at five minutes. One fetal death (0.1%) occurred in the induction group and two (0.2%) in the expectant management group. No neonatal deaths occurred. 3 (0.3%) neonates in the induction group versus 8 (0.9%) in the expectant management group were admitted to an NICU (RR 0.38, 95% CI 0.10 to 1.41). No significant difference was found in composite adverse maternal outcomes (induction n=122 (13.6%)
expectant management n=102 (11.3%)) or in caesarean section rate (both groups n=97 (10.8%)).
This study could not show non-inferiority of expectant management compared with induction of labour in women with uncomplicated pregnancies at 41 weeks; instead a significant difference of 1.4% was found for risk of adverse perinatal outcomes in favour of induction, although the chances of a good perinatal outcome were high with both strategies and the incidence of perinatal mortality, Apgar score <4 at five minutes, and NICU admission low.
Netherlands Trial Register NTR3431.
Journal Article
Active perinatal care of preterm infants in the German Neonatal Network
ObjectiveTo determine if survival rates of preterm infants receiving active perinatal care improve over time.DesignThe German Neonatal Network is a cohort study of preterm infants with birth weight <1500 g. All eligible infants receiving active perinatal care are registered. We analysed data of patients discharged between 2011 and 2016.Setting43 German level III neonatal intensive care units (NICUs).Patients8222 preterm infants with a gestational age between 22/0 and 28/6 weeks who received active perinatal care.InterventionsParticipating NICUs were grouped according to their specific survival rate from 2011 to 2013 to high (percentile >P75), intermediate (P25–P75) and low (
Journal Article
Predictive Modeling for Perinatal Mortality in Resource-Limited Settings
The overwhelming majority of fetal and neonatal deaths occur in low- and middle-income countries. Fetal and neonatal risk assessment tools may be useful to predict the risk of death.
To develop risk prediction models for intrapartum stillbirth and neonatal death.
This cohort study used data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Network for Women's and Children's Health Research population-based vital registry, including clinical sites in South Asia (India and Pakistan), Africa (Democratic Republic of Congo, Zambia, and Kenya), and Latin America (Guatemala). A total of 502 648 pregnancies were prospectively enrolled in the registry.
Risk factors were added sequentially into the data set in 4 scenarios: (1) prenatal, (2) predelivery, (3) delivery and day 1, and (4) postdelivery through day 2.
Data sets were randomly divided into 10 groups of 3 analysis data sets including training (60%), test (20%), and validation (20%). Conventional and advanced machine learning modeling techniques were applied to assess predictive abilities using area under the curve (AUC) for intrapartum stillbirth and neonatal mortality.
All prenatal and predelivery models had predictive accuracy for both intrapartum stillbirth and neonatal mortality with AUC values 0.71 or less. Five of 6 models for neonatal mortality based on delivery/day 1 and postdelivery/day 2 had increased predictive accuracy with AUC values greater than 0.80. Birth weight was the most important predictor for neonatal death in both postdelivery scenarios with independent predictive ability with AUC values of 0.78 and 0.76, respectively. The addition of 4 other top predictors increased AUC to 0.83 and 0.87 for the postdelivery scenarios, respectively.
Models based on prenatal or predelivery data had predictive accuracy for intrapartum stillbirths and neonatal mortality of AUC values 0.71 or less. Models that incorporated delivery data had good predictive accuracy for risk of neonatal mortality. Birth weight was the most important predictor for neonatal mortality.
Journal Article
Association of socioeconomic disadvantage and ethnicity with perinatal neonatal, and infant mortality in Slovakia
Background
Infant mortality rates are reliable indices of the child and general population health status and health care delivery. The most critical factors affecting infant mortality are socioeconomic status and ethnicity. The aim of this study was to assess the association between socioeconomic disadvantage, ethnicity, and perinatal, neonatal, and infant mortality in Slovakia before and during the COVID-19 pandemic.
Methods
The associations between socioeconomic disadvantage (educational level, long-term unemployment rate), ethnicity (the proportion of the Roma population) and mortality (perinatal, neonatal, and infant) in the period 2017–2022 were explored, using linear regression models.
Results
The higher proportion of people with only elementary education and long-term unemployed, as well as the higher proportion of the Roma population, increases mortality rates. The proportion of the Roma population had the most significant impact on mortality in the selected period between 2017 and 2022, especially during the COVID-19 pandemic (2020–2022).
Conclusions
Life in segregated Roma settlements is connected with the accumulation of socioeconomic disadvantage. Persistent inequities between Roma and the majority population in Slovakia exposed by mortality rates in children point to the vulnerabilities and exposures which should be adequately addressed by health and social policies.
Journal Article
Perinatal death in the Nordic countries in relation to gestational age: The impact of registration practice
Introduction Although perinatal death rates in the Nordic countries are among the lowest in the world, the risk of perinatal death is unevenly distributed across the Nordic countries, despite similarity in health care systems and pregnancy care. Birth registration practices across countries may explain some of the differences. We investigated differences in national registration of perinatal mortality within the Nordic countries and its impact on perinatal mortality according to gestational age. Material and Methods Each country provided information by answering a questionnaire about registration of perinatal deaths. Furthermore, we collected aggregated count data based on Medical Birth Registries (MBR) from all Nordic countries in 2000 to 2021. Perinatal mortality was defined as stillbirth or neonatal death occurring within first 7 days of life. Data were grouped into six groups by gestational age (GA): extremely preterm (>28 + 0 weeks, subdivided into 22 + 0–23 + 6 and 24 + 0–27 + 6), very preterm (GA 28 + 0–31 + 6), moderate preterm (GA 32 + 0–33 + 6), late preterm (GA 34 + 0–36 + 6), term (GA 37 + 0–40 + 6) and late term or post‐term birth (GA ≥ 41 + 0). Perinatal mortality rate and risk ratio with 95% confidence intervals were calculated per country for each gestational age group. For Denmark, separate analyses included and excluded induced abortions. Results The study included 6 343 805 live births, 22 727 stillbirths and 8932 liveborn infants who died within the first week of life after GA 22 + 0. Further 25 057 births were included with GA < 22 + 0, unknown GA and as a result of induced abortion. Overall, perinatal mortality rates decreased during year 2000–2021 in all Nordic countries. After exclusion of induced abortions, the perinatal mortality rate was similar in the five Nordic countries. The perinatal mortality rate for extremely preterm born infants was highest in Denmark, whereas the highest rate among infants born late term/post‐term was in Sweden. Conclusions The perinatal mortality rate in the Nordic countries is still decreasing, especially in the group of extremely preterm born infants. This study supports the need for further standardization of birth registration practices to ensure the validity of international comparisons. Perinatal mortality differs among the Nordic countries, especially in newborns with borderline viability. Registration practice may contribute in relation to induced abortions, live‐births before 22 weeks and twin pregnancies with fetal demise. Standardization and harmonization of definitions are highly recommended.
Journal Article
Trends in perinatal mortality and its determinants in Ethiopia using longitudinal data from the demographic surveillance system (2009–2016)
In Ethiopia, the reduction in perinatal mortality rates is still falling short of national and global targets set for 2030. Additionally, accurate recording is challenging, as many births occur at home. This study aimed to assess the trends and determinants of perinatal mortality using population-based longitudinal data from 2009 to 2016 across three Health and Demographic Surveillance Systems (HDSS) in Ethiopia: Gelgel-Gibe, Dabat, and Kilite-Awlaelo. Data on vital events and pregnancies were continuously collected at these HDSS sites. The study utilized follow-up data from prospective linked pregnancy and birth cohorts from January 2009 to December 31, 2016. Perinatal mortality was defined as deaths occurring from 28 weeks of gestation until six days after birth, measured per 1000 live births. Relevant health, demographic, and socioeconomic data were included in the analysis. Poisson regression was employed to assess factors associated with perinatal mortality. Out of 38,691 pregnancies that led to births, there were 1214 perinatal deaths (456 stillbirths and 758 early neonatal deaths), resulting in a perinatal mortality rate of 31 deaths per 1000 total births. The early neonatal death rate was higher, at 19.6 deaths per 1000 total births, compared to the stillbirth rate of 11.8 per 1000 total births. The perinatal mortality rate declined from 40.6 in 2009 to 29.1 per 1000 total births in 2016, reflecting an average annual rate reduction of 2.4%. Determinants of perinatal mortality included being a male newborn, multiple births, first-time pregnancies (primi-gravidity), lack of antenatal care visits, absence of delivery services, and residing in tropical zones. The primary causes of death were asphyxia, sepsis, and preterm birth. Overall, perinatal mortality rates were high in the three HDSS sites, with slow reductions over time and significant variations between them. Addressing the issue of stillbirths and improving the availability and quality of emergency obstetric care are crucial. Continuous home visits in rural communities to prevent stillbirths and newborn deaths, are also essential.
Journal Article
Predictors and prevalence of perinatal mortality in Ghana: a systematic review and meta-analysis
Background
Ghana has consistently reported a high perinatal mortality rate. This has raised concerns regarding the country’s ability to achieve the Sustainable Development Goals 3 target 2 by 2030. This comprehensive review presents the pooled prevalence and predictors of perinatal mortalities in Ghana guided by the Anderson’s framework of healthcare utilization.
Methods
A comprehensive literature search was conducted mainly from four electronic databases; PubMed, Web of Science, Scopus and CINAHL as they collectively index > 90% of relevant maternal health journals in Africa and also eases the burden of screening. Eligible studies, published from 1st January 2010 to 30th June, 2024, were charted and synthesized, with focus on the three primary domains of Anderson’s framework: pre-disposing factors, enabling factors and need factors. Meta-analysis was conducted to estimate the pooled prevalence of perinatal mortality rate within each of the sub-regions. Significant heterogeneity was detected among the various surveys (I2 > 50%), hence a random effect model was reported. Sub-group and meta-regression were performed to identify the sources of heterogeneity observed in the study.
Results
A total of 2,184 articles were initially identified for review, but after multiple rounds of screening and deduplication, only 30 full-text articles were finally included. The most frequent study design was cross-sectional, accounting for 23.3% of the studies. The Pooled estimate of perinatal mortality is 44.8 (95%CI: 15.4–74.2) per 1000 births in Ghana, with very high heterogeneity (I
2
> 99.97,
p
< 0.0001) among the studies. The predictors of perinatal mortality included advanced maternal age, pre-existing health conditions, poor quality ANC, access to healthcare facilities and environmental exposures.
Conclusion
This review presents the complex interplay of factors determining perinatal mortality in Ghana. In addition to the predictors identified, the review reveals gaps in literature particularly the lack of case-control studies in rural settings and inadequate focus on healthcare quality, socio-economic influences, and policy impacts. Future studies should address these gaps using a holistic approach that takes into account Ghana’s diverse social and geographical factors to better reduce perinatal mortality.
Systematic Review Registration.
The review protocol was registered in PROSPERO (CRD42024564968).
Journal Article
Preterm birth in Latvia: Two‐decade national trends, structure, and risk factors
Introduction Latvia, alongside other Baltic and Nordic countries, exhibits some of the world's lowest preterm birth (PTB) rates. We sought to identify the factors sustaining this stability and to examine how PTB structure, trends, and risk factors have evolved in Latvia over time, amid the nation's significant socioeconomic transformation in recent decades. Material and Methods This retrospective study analyzed all term and PTBs in Latvia from 2000 to 2023, using data from the Disease Prevention and Control Centre's Health Statistics database. We evaluated records at 5‐year intervals, assessing temporal trends in PTB and term birth outcomes, including neonatal and perinatal mortality, labor onset (spontaneous or indicated), and prematurity subgroups, alongside known PTB risk factors (n = 16). Joinpoint regression identified significant trend shifts, with statistical significance set at p < 0.05. Results Latvia's overall PTB rate remained stable at 5.5% from 2000 to 2023, with no significant trend, while the proportion of spontaneous versus indicated PTB changed over time. Spontaneous extremely PTB decreased by 0.7% every 5 years, from 8.5% in 2000 to 5.2% in 2023 (p = 0.005), and very to moderate PTB declined by 1.3% every 5 years, from 26.2% to 19.5% over the same period (p = 0.011). A significant upward trend was identified in the total indicated PTB rate, with an increase of 3.3% every 5 years, rising from 12.5% in 2000 to 29.2% in 2023 (p = 0.036), driven by the increase in late indicated PTBs. Perinatal mortality for PTB in Latvia declined significantly by 1.21% every 5 years, from 13.15% in 2000 to 7.09% in 2023 (p = 0.005). Primiparity, smoking, urinary tract infections, and lower education levels among PTB mothers decreased significantly, while maternal age, previous cesarean sections, and intrauterine growth restriction as PTB risk factors increased. Conclusions Despite PTB structure and risk factor shifts, Latvia's 5.5% PTB rate remained stable over two decades, with indicated PTB rising due to expanded late preterm indications. Improved neonatal and perinatal mortality reflect effective guidelines, socioeconomic growth, and care investments, countering adverse trends. Latvia maintained a stable preterm birth (PTB) rate of 5.5% over two decades. While spontaneous PTB declined, indicated PTB increased. Advancements in maternal and neonatal care, supported by clinical guidelines and socioeconomic development, contributed to a significant reduction in perinatal and neonatal mortality despite evolving risk profiles.
Journal Article
Neonatal outcomes in twin pregnancies in Finland from 2008 to 2023
Twin pregnancies are associated with higher risks of adverse maternal and neonatal outcomes compared to singleton pregnancies. This retrospective nationwide cohort study analyzed trends in twin pregnancy outcomes in Finland from 2008 to 2023 using data from the Finnish Medical Birth Register. Outcomes assessed included perinatal mortality, stillbirths, neonatal mortality, neonatal intensive care unit (NICU) admissions, and hospitalization rates at one week of age. A total of 23,588 twin births were included, with an overall stillbirth rate of 9.0 per 1000 and a perinatal mortality rate of 16.0 per 1000. Neonatal mortality rates declined significantly, with term twins showing a rate of 0.9 per 1000 and preterm twins 4.6 per 1000 in the latest years of 2022–2023. NICU admission rates remained stable for preterm twins but showed an increasing trend for term twins. The rate of hospitalized neonates at the age of seven days decreased over time.
Conclusion
: These trends align with improved antenatal care and Finland’s reputation for low neonatal mortality. However, increasing maternal age and obesity rates may contribute to rising NICU admissions in term twins. The study highlights the need for continuous monitoring of neonatal outcomes to ensure high standards of care in the context of declining fertility and delivery rates in Finland.
What is Known:
• Twin pregnancies are associated with higher risks of adverse maternal and neonatal outcomes compared to singleton pregnancies.
• Finland has one of the lowest neonatal mortality rates globally.
What is New:
• Neonatal mortality rates declined significantly both in term and preterm twins from 2008 to 2023.
• NICU admission rates remained stable for preterm twins but showed an increasing trend for term twins.
Journal Article
Risk factors and outcomes associated with pregnancy-related acute kidney injury in a high-risk cohort of women in Nigeria
Introduction
Despite a decline in developed countries, pregnancy-related acute kidney injury (PRAKI) remains a significant contributor to maternal mortality and adverse fetal outcomes in resource-constrained settings. Little is known about the impact of pregnancy-related acute kidney injury in Nigeria. Therefore, this study aimed to assess the incidence and maternal-fetal outcomes associated with pregnancy-related acute kidney injury among a cohort of high-risk women in Nigeria.
Methods
This prospective multicenter study included women at high risk of acute kidney injury, who were more than 20 weeks pregnant or within 6 weeks postpartum and admitted to the Obstetrics and Gynecology units of two large public hospitals between September 1, 2019, and July 31, 2022. Acute kidney injury was defined and classified using the Kidney Disease Improving Global Outcomes (KDIGO) criteria.
Results
A total of 433 women, with mean age (± standard deviation) of 28 ± 6 years, were included in the evaluation. Pregnancy-related acute kidney injury occurred in 113 women (26.1%; 95% confidence interval [CI]: 21.1%-30.2%). The leading cause was preeclampsia (
n
= 57; 50.1%); 19 women died (4.4%), with 17 deaths (15%) occurring in the PRAKI group. Increasing severity of pregnancy-related acute kidney injury was independently associated with maternal mortality: adjusted odds ratio (aOR) for KDIGO stage 2 = 4.40; 95% CI 0.66–29.34,
p
= 0.13, and KDIGO stage 3 aOR = 6.12; 95% CI 1.09–34.34,
p
= 0.04. The overall perinatal mortality was 15% (
n
= 65), with 28 deaths (24.8%) occurring in the PRAKI group. Pregnancy-related acute kidney injury was also associated with an increased risk of perinatal mortality, aOR = 2.23; 95 CI 1.17–4.23,
p
= 0.02.
Conclusions
The incidence of pregnancy-related acute kidney injury was high, and significantly associated with maternal and perinatal mortality. The leading causes were hypertensive disorders of pregnancy.
Graphical abstract
Journal Article