الفهرس Only 14 pages are availabe for public view
 |  | from | 168 |  |  |
| | | from | 168 | | |
Abstract
The fourth Millennium Development Goal (MDG) entails the reduction of child mortality by two-thirds by the year 2015, from the base year of 1990. About 40% of the 10•8 million annual deaths of children younger than 5 years (under-5) take place in the neonatal period, and the relative importance of these deaths increases as child mortality is reduced. When under-5 mortality is less than 35 per 1000, more than 50% of all children dying are neonates. This situation is present in 62% of the world’s countries classified in the middle-income group. These countries, where neonatal mortality rates are 20 per 1000 or below, will fail to reach the MDG unless they succeed in preventing neonatal deaths.
Meta-analysis is a statistical procedure that integrates the results of several independent studies considered to be ”combinable. Well conducted meta-analyses allow a more objective appraisal of the evidence than traditional narrative reviews, provide a more precise estimate of a treatment effect, and may explain heterogeneity between the results of individual studies. Ill conducted meta-analyses, on the other hand, may be biased owing to exclusion of relevant studies or inclusion of inadequate studies.
The aims of the study were:
1. To investigate the association between the peri-natal mortality and the identified risk factors among study sample in Elshatby hospital.
2. To perform a meta-analysis through statistical pooling of available similar studies concerning peri-natal mortality risk factors assessment with study results obtained from the first aim.
The present study was conducted in two phases:
Phase 1: Case control study for perinatal and neonatal mortality risk factors.
Phase 2: Meta analysis of related studies.
Phase I: case control study:
The case control study was performed at the following settings:
- Elshatby Hospital of Obstetrics and Gynecology.
- Elshatby Hospital of Pediatrics.
The target populations were mothers with peri-natal or neonatal deaths (from the 28th week of pregnancy to less than 28th day after birth) attending Elshatby Hospital of Obstetrics and Gynecology (cases) and mothers with live births aging 28 days and more (up to two months to avoid recall bias) attending Elshatby Hospital of Pediatrics (controls).
Data were collected using Interview questionnaire of mothers. It included the following information:
- Personal and socio-demographic data for both parents.
- Medical history of the mothers.
- Smoking status.
- Past obstetrical history.
- Present obstetrical history.
- Antenatal care and doctor visits.
- Causes of perinatal and neonatal deaths.
The results of the study were presented as follow:
- The study sample comprised 300 mothers from which 150 cases and 150 controls.
- Among the cases there were 93 (62.0%) stillbirths and 57(38.0%) neonatal deaths.
- The mean age among the control fathers (31.6 years) was less than that among cases fathers (33.5 years).
- Cases were of a higher mean of pregnancy numbers (3.7 pregnancies) compared to controls (2.9 pregnancies).
- Controls received higher numbers of the toxoid vaccination compared to cases during the index pregnancy.
- Controls received better prenatal care (the mean number of prenatal visits was 8 visits) compared to cases (4 visits).
- Mothers with young age (≤ 20 years) were of high risk to have perinatal or neonatal deaths (OR= 4.1) compared to those of middle age (> 20-30 years).
- Mothers with advanced age (> 35 years) were more risky to have perinatal or neonatal deaths (OR= 6.7) compared to those with middle age (> 20-35 years).
- Middle socioeconomic class and urban residence were insignificantly associated with perinatal and neonatal deaths.
- Illiterate fathers or mothers and those with some educational level (primary, preparatory or secondary) were of higher risk to have perinatal or neonatal deaths (OR ranged from 1.2-4.7).
- Mothers with a chronic disease had a double risk for perinatal or neonatal deaths compared to those were healthy (OR = 2.3).
- The most prevalent health problem among both cases and controls was anaemia (18.7% and 13.3% respectively).
- Mothers experienced any previous pregnancy troubles were of triple risk to have perinatal or neonatal deaths compared to those with safe previous pregnancies (OR = 2.9) especially those experienced pre-eclampsia (OR =5.5), pregnancy induced hypertension (OR = 3.6) and gestational diabetes (OR = 3.0).
- Mothers with a history of previous delivery complications recorded a 2.5 times risk to have perinatal or neonatal deaths compared to those without (OR = 2.6). Mothers with a history of intrapartum hemorrhage were the most risky to have the adverse pregnancy outcome (OR = 7.9) where malpresentation, PROM and prolonged labour were of a little risk.
- About 40% of cases recorded any of the pregnancy complications during the index pregnancy compared to 20% of controls with OR = 2.7. pregnancy induced hypertension was the most common problem among cases (26.7%) which was associated with doubled risk to have perinatal or neonatal deaths (OR = 2.4). Anaemia and gestational DM were the second most common pregnancy problem recorded among cases. Pre-eclampsia was the highest significant risk factor among cases (OR = 7.3). Regarding controls, anaemia and pregnancy induced hypertension were the most prevalent complications (30.0% for each).
- Those mothers who received inadequate antenatal care (up to three visits) were of five folds risk to have perinatal or neonatal deaths compared to those received adequate care (more than 3 visits) (OR = 4.3).
- Cesarean section was found to be an insignificant risk factor for adverse pregnancy outcomes compared to vaginal delivery (OR = 1.2).
- Home delivery was found to be a significant risk factor with a triple risk compared to delivery at hospital or MCH unit (OR = 2.6). Delivery by physician was found to be a protective factor against perinatal or neonatal deaths compared to delivery by no help (OR = 8.0), delivery by nurse (OR = 6.2) and delivery by daya (OR = 1.5).
- Mothers with high multiparity (> 5 deliveries) were found to be of higher risk to have perinatal and neonatal deaths compared to those with 5 deliveries or less (OR = 3.4). Delivery complications were found to be significant risk factors for perinatal and neonatal deaths (OR = 4.6) especially intrapartum haemorrhage that increased the risk to about 7 times followed by malpresentation, PROM and prolonged labour (OR = 5.9, 4.4 and 3.5 respectively).
- By asking about the cause of perinatal or neonatal death it was found that the most common cause of stillbirths congenital anomalies (30.1%) followed by preterm baby (24.7%) while at 21.5% we didn’t recognize any cause. As regard neonatal deaths, respiratory distress was the most common cause of death (22.8%) followed by preterm baby (19.3%).
Phase 2: Meta analysis of related studies:
Data from the present study have been included with data from other related studies discussing perinatal or neonatal mortality risk factors in the systematic pooling.
It was performed using the computer program review managers version 5 (RevMan-5) and comprehensive meta analysis 2 (CMA 2).
Meta analysis was conducted in four steps:
- Identification of the related studies.
- Defining eligibility criteria for inclusion and exclusion of these studies.
- Abstraction of the data.
- Systematic pooling of the abstracted data.
The results of the meta analysis were presented as follow:
- Medline search resulted in 197 studies from which only 28 studies were fulfilling the eligibility criteria and included in the meta analysis with our case control study.
- Of the 29 meta analyzed studies there were 15 case control studies that were published during the period from 1994–2008. There also were 10 retrospective cohort studies that published during the period from 1997-2005. Finally the remaining 4 studies were cross sectional studies that published during the period from 1996-2004.
Sociodemographic risk factor:
- Meta analysis of studies concerned maternal age revealed that mothers with young age (≤20 years) were of more risk to have perinatal and neonatal deaths (Pooled OR = 1.5) compared to those of middle age (>20-35). The risk size is nearly the same for those with old age (Pooled OR = 1.55).
- Studies that considered socioeconomic status showed by meta analysis that mothers with low socioeconomic status had 1.5 folds risk to have perinatal or neonatal deaths compared to those living at middle thru high socioeconomic status.
- Rural residence by meta analysis proved to be a significant risk factor for perinatal and neonatal deaths (Pooled OR = 1.16) in comparison with urban residence.
- Illiterate mothers were of higher risk to have perinatal or neonatal deaths compared to educated mothers. Meta analysis of the related studies revealed that pooled OR = 1.48.
Obstetric and delivery risk factors:
- Meta analysis of the studies that considered the relation between inter pregnancy intervals and perinatal or neonatal deaths provided that very narrow intervals (<12 months) or very wide intervals (>24 months) increased the risk to have perinatal or neonatal deaths compared to intermediate interval (12-24 months) (Pooled OR = 2.1).
- Systematic pooling of the studies concerned the effect of the presence of any of the index pregnancy complications on the pregnancy outcome proved its risky association as mothers experienced any of the index pregnancy complications recorded nearly doubled risk to have perinatal or neonatal deaths (Pooled OR = 2.56).
- Mothers experienced any troubles during the index delivery showed 5 folds risk to have perinatal or neonatal deaths compared to those with safe delivery (Pooled OR = 5.02).
Medical care factors:
- Meta analysis performed on studies concerning the effect of poor antenatal care (<3 visits) confirmed that mothers who received poor antenatal care were of a triple risk to have perinatal or neonatal deaths compared to those received adequate care (Pooled OR = 3.34).
- It was found that home delivery doubled the risk of having perinatal or neonatal deaths in comparison to hospital or MCH unit delivery (Pooled OR = 2.8).
- Delivery by dayas made the risk of having perinatal or neonatal deaths about 6 times compared to those who delivered by physician (Pooled OR = 6.4).
- Systematic pooling of the studies concerned the type of delivery revealed that C.S was a protective factor against perinatal or neonatal deaths compared to vaginal delivery (Pooled OR = 0.86).
Heterogeneity among the pooled studies was overcame either by sensitivity analysis according to the factor of heterogeneity (study design or study quality score) or by meta regression that controlled the heterogeneity factors.
Accordingly, the following recommendations are suggested:
- More attention should be paid to illiterate mothers and those of law social class.
- Improving access and quality of health services may have a positive impact in the reduction of early neonatal death.
- Adequate monitoring of women during the gestational period, whereby risk factors may be identified and minimized.
- Implementing preconception education and counseling programs to ensure more widespread pregnancy planning in high risk women.
- Increasing levels of care during delivery.
- Increase the knowledge about the importance of the appropriate interpregnancy intervals to avoid the risk of having perinatal deaths.
- Further efforts showed done to discover advanced tools to identify the high risk foetus.
- Policymakers need to know about neoborn mortality in their communities and the costs and feasibility of health care options.
- Parents need to be educated about what they can do to save their neoborns’ lives.