Improving Birth Outcomes Meeting the Challenge in the Developing World (2003) / Chapter Skim
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4. Reducing Fetal Mortality
4. Reducing Fetal Mortality
Pages 134-162
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Many of the interventions described in the previous chapter are also effective in reducing fetal mortality. An estimated 4 million late fetal deaths1 occur each year, 98 percent of them in developing countries (Save the Children, 2001; World Health Organization, 1996~.
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137 of .
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FACTORS CONTRIBUTING TO LATE FETAL DEATHS In settings where most women give birth without skilled assistance, fetal mortality is high, and the proportion of fetal deaths that occur during labor and delivery is high (Conde-Agudelo et al., 2000~. These are intrapartum fetal deaths (IPFDs)
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In a study in Mozambique, the fetal death rate for 1,275 women with hypertensive disease of pregnancy was 5.7 percent compared with 2.3 percent for the more than 43,000 women without hypertensive disease (Merz et al., 1992~. In a study in Shanghai, China, 8,852 of 158,790 pregnancies involved hypertensive disease; 44 percent were classified as moderate or severe, and the adverse outcomes included 48 antepartum fetal deaths and 12 late fetal deaths (Huang, 2001~.
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Asphyxia can be broadly defined as progressive hypoxaemia and hypercapnia with a significant metabolic acidaemia (Low, 1997; Bax and Nelson, 1993~. In the early 1990s, the Jamaican Perinatal Mortality Survey found intrapartum asphyxia to be the cause of 23 percent of fetal deaths in which the fetus weighed at least 2,500 g (Escoffery et al., 1994~.
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This difference may in part reflect a lower quality of care provided to patients who do not pay for services. Antepartum Fetal Deaths The risk factors reported for APFDs include maternal conditions, obstetric complications, and advanced maternal age.
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This risk can be substantially reduced with appropriate antenatal care and management of labor and delivery (Sun et al., 2001; Smith et al., 1996~; however, this level of care is not generally available in the countries where sickle cell disease is most prevalent. Infections Fetal mortality is associated with a variety of maternal infections including sexually transmitted diseases, bacterial infections of the genitourinary tract, and rubella2 (Goldenberg et al., 1997; Gibbs, 2002~.
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For antepartum fetal deaths, the PAR was 38 percent for syphilis (McDermott et al., 1993~. Syphilis was the attributed cause of 10 percent of late fetal deaths in a case-control study of 315 consecutive late fetal deaths in Papua New Guinea (Amoa et al., 1998~.
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As fetal mortality due to more preventable causes decreases, the proportion of fetal deaths associated with malformations increases (De Galan-Roosen et al., 1998~. Maternal age and parity Several studies show an increase in fetal deaths with advanced maternal age (Fretts et al., 1995; Huang, 2000; Andersen et al., 2000; Seoud et al., 2002; Sheiner et al., 2000; Amoa et al., 1998; Khandait et al., 2000~.
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Heavy alcohol consumption during pregnancy has been associated with fetal alcohol syndrome,5 fetal alcohol effects, and increased fetal and neonatal mortality (Jacobson et al., 1993; Faden et al., 1997; Sulaiman et al., 1988; Warren and Bast, 1988~. There are no conclusive data on the minimum amount of alcohol ingestion during pregnancy 4The committee recognizes that female feticide, which generally occurs early in pregnancy, accounts for significant numbers of fetal deaths.
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et al., 2002~. The first, a retrospective study involving nearly 10,000 live births and about 3,300 fetal deaths in the United States, found that women who consumed more alcohol also smoked more, and were younger and less educated than those who consumed no alcohol or a lower level.
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study of more than 600 late fetal deaths in Wales found that maternal smoking was associated with an increased risk (odds ratio tOR]
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, who systematically investigated perinatal deaths in a district of Zimbabwe, found that 76 percent of the fetal deaths he reviewed were potentially preventable. Many late fetal deaths were found to be complicated by conditions that are amenable to treatment: hypertension, diabetes, syphilis, or amniotic fluid infection.
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In order to reduce IPFDs, facilities for basic essential obstetric care should monitor labor; manage major obstetric complications, such as severe pre-eclampsia and eclampsia, obstructed labor, and hemorrhage; and address other complications, such as diabetes mellitus, that are associated with high rates of fetal mortality. Facilities offering comprehensive essential obstetric services can reduce fetal deaths by providing cesarean delivery and blood transfusion, in addition to the services discussed above under basic essential obstetric care.
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. These methods should also reduce the number of fetal deaths due to chronic
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Lack of antenatal care is associated with a marked increase in late fetal deaths (CondeAgudelo, 2000~. Early initiation of antenatal care (before 20 weeks of gestation)
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In Jamaica, for example, researchers found that only 13 percent of late fetal deaths and 25 percent of infant deaths had been registered, compared with 94 percent of live births (McCaw-Binns et al., 1996~. In Thailand, a comparison of official records with a communitybased survey showed that only 55 percent of infant deaths and none of the late fetal deaths recorded in the survey had been officially registered (Lumbiganon et al., 1990~.
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They also address priority interventions for reducing fetal mortality. Surveillance of fetal deaths is even more limited than for neonatal deaths.
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The recommendations and research priorities presented in the next chapter emphasize the need to recognize fetal deaths as part of an overall effort to improve birth outcomes. REFERENCES Aiken CG.
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1988. Cigarette smoking as a risk factor for late fetal and early neonatal death.
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1987. Fetal deaths in Alabama, 19741983: a birth weight-specific analysis.
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2000. Determinants of unexplained antepartum fetal deaths.
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2000. A casereferent study on fetal bacteremia and late fetal death of unknown etiology in Lithuania.
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2000. Fetal deaths in Jamaica: findings from the 1986-1987 Perinatal morbidity and mortality survey.
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2000. Determining risk factors for intrapartum fetal death.
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2001. Sickle cell disease in pregnancy: twenty years of experience at Grady Memorial Hospital, Atlanta, Georgia.
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1997. Sex differentials in perinatal mortality in China and Finland.
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