Determinants of perinatal mortality among cohorts of pregnant women in three districts of North Showa zone, Oromia Region, Ethiopia: Community based nested case control study

This study was conducted in three districts of North Showa Zone of Oromia Regional State (Degem, Kuyu, and Wara Jarso). The zone is situated 100km from the capital, Addis Ababa. Most of the population in the study area were farmers. Around 84,558 women of reproductive age group (15-49) lived in the study area in 2010 [11], from which an open cohort of 4,438 pregnant women was established by mid-2010 in the three districts. The cohort was formed by Maternal and Newborn Health Partner in Ethiopia (MaNHEP) in collaboration with the Ethiopian Federal Ministry of Health, Emory University and Addis Ababa University [11].

Maternal and Newborn Health Partner in Ethiopia (MaNHEP) is a non-governmental organization, working to implement a health extension program by building the skills of frontline health workers and developing the systems needed to deliver quality maternal and newborn health care. It works in three districts of Oromia region, namely Degem, Kuyu, and Wara Jarso districts, and is led by Emory University, in collaboration with John Snow Research and Training Institute and Addis Ababa University, under the leadership of the Federal Ministry of Health.

Twenty-seven kebeles (lower administrative units) were selected from the three districts, (8 kebeles from Degem district, 10 kebeles from Kuyu district and 9 kebeles from Wara Jarso district). The districts were among the most populous areas of the zone with a total population of 98, 2018 in Degem district, 126,546 in Kuyu district and 148,771in Wara Jarso district [12]. Kuyu hospital is the only hospital located in the study area. There were two health centers in each district and two health posts in each kebele (Fig. 1).

Pregnant women were enrolled in the cohort when they were around 28 weeks of gestation. The pregnant women were identified for the cohort by trained frontline health workers. Once in the cohort, every pregnant woman and their close family members (mothers, mothers-in-law, and husbands) received repeated training on care during pregnancy, labour, and delivery by the volunteers. Following delivery, they stayed in the cohort until they received postnatal care for the first 48 hours.

The project has developed an integrated program of maternal and newborn health training, quality improvement and behavioral change communications to ensure that the care reaches all women and newborn, in time, and every time. The main, objectives and key interventions of the project are described in Fig. 2.

Figure 3 shows a schematic of the sampling procedure for this study.

Data was collected using the World Health Organization verbal autopsy questionnaire for neonatal death after adapting it to the local context [13]. The instrument contains about 12 sections, which includes the respondents’ basic demographic information, the deceased infants’ demographics, pregnancy history, delivery history and information about the family wealth. One experienced data collector was recruited for each district and trained for five days. Data from the controls was collected after gathering data from the cases using the sample frame which contained a list of all mothers who gave birth in the three districts. Mothers who lost their newborns were interviewed at least forty days after the death of the newborn in order to ensure their recovery from their bereavement. Face to face interview technique was used to gather the necessary information. The questionnaire was translated into the regional working language, Afaan Oromo, for easy comprehension. All data was collected by going to the house of each study respondent.

Perinatal death was the outcome variable. Pregnancy losses occurring after seven completed months of gestation (28 weeks) were considered as stillbirths. Deaths occurring to live births within the first seven days of life were considered as early neonatal death. Perinatal death is therefore defined as the sum of stillbirth and early neonatal death.

The independent variables under the socio-demographic factors were: the age of the mother, marital status, educational status, occupation, size of the household, and household financial situation. In addition, pregnancy, labour and delivery related variables such as gestational age (calculated from the last menstrual period), birth spacing, place of delivery, parity, history of neonatal death, history of abortion (both spontaneous and medically induced termination of pregnancy before the 28^th week of gestation) were included under demographic factors.

During the study period, a follow up was made to 4438 pregnant women. 55 (1.2%) of these mothers were lost to follow-up and their pregnancy outcome are unknown. A total of 73 (1.7%) mothers lost their newborns during the perinatal period, of which 47 (63.4%) were early neonatal deaths, and 26 (35.6%) were stillbirths.

Overall perinatal mortality rate was 16.5 per 1000 total birth (95% CI: 13.0-20.6). The stillbirth rate was 5.9 per 1000 births (95% CI: 3.9-8.4). Early neonatal mortality rate was 10.2 per 1000 live births (95% CI, 3.9-8.4). The majority, 211 (96.35%), of the respondents were mothers, 7 (3.2%) were fathers and 1 (0.5%) was a sibling of the baby.

Mean age of mothers for both cases and controls was 27.01 years + 6.22 and 26.37 years + 4.70 respectively. Most of the mothers of controls were not able to read and write compared to mothers of cases during the perinatal period. Higher proportion of the family sizes of the cases were 35(47.9%) Three to Five, compared to the controls 77(52.7%) (Table 1).

In the study area, better health care service utilization patterns were observed in general compared to what other non-intervention sites the area. The majority of the respondents had a history of attending antenatal visits, 56 (76.7%) among cases and 121 (82.9%) among controls. Around 47 (64.4%) of the cases and 105 (71.9%) of the controls were vaccinated for tetanus toxoid, 51 (69.9%) of the cases and 119 (81.5%) of the controls had more than a two-year birth interval, and the majority of the births, 56 (76.7%) of the cases and 136 (93.2%) of the controls, were delivered at home (Table 2).

A high number of the cases [50 (68.5%)] and the controls [106 (72.6%)] had had parity greater than three. Less than half, 28 (38.4%) of the cases and 21 (14.4%) of the controls had a history of neonatal mortality. Similarly, a minority, 11(15.1%) of the cases and 7 (4.8%) of the controls were preterm deliveries (Table 3).

To identify potential predictors of perinatal mortality, binary logistic regression models were run independently for socio-demographic factors and maternal-related factors.

It was found that, babies born to mothers aged 35 years and older were 7 times more likely to die during the perinatal period than those babies born to younger mothers [AOR 7.59, (95% CI, 1.913-30.102)]. Newborns from families with six or more family members had a higher chance of surviving the perinatal period than those babies born to families with five or fewer family members [AOR 0.083, (95% CI, 0.014-0.488)] (Table 4).

On the other hand, babies born to mothers with a history of neonatal mortality had a higher risk of perinatal death compared to those babies born to mothers without a history of neonatal mortality [AOR 5.425, (95% CI, 2.271-12.960)]. Preterm births had a higher risk of death within the perinatal period than term babies [AOR 8.583, (95% CI, 2.275-32.386)]. Male babies were more likely to sustain perinatal death [AOR 5.478, (95% CI, 2.502-11.99 7)] than female babies. Multiple births were 3 times more likely to die within the perinatal period than singleton births [AOR 3.599, (95% CI, 1.200-10.798)]. Home delivery, however, was found to reduce the chance of perinatal death when compared to facility delivery [AOR 0.233, (95% CI, 0.081-0.6720)] (Table 5).

Asphyxia and sepsis were the major causes of early neonatal death (Table 6). The majority of the stillbirths resulted from chorioamnionitis and antepartum hemorrhage (Table 7).

In this community based nested case control study, it was found that the perinatal mortality rate was 16.5 per 1000 total births. This finding was lower than previously reported in a review of community-based studies conducted in Ethiopia between 1974 and 2013, which gave a perinatal mortality rate of 40 per 1000 total births [9]. This observed reduction in this study may be related to the increase in Antenatal Care (ANC) coverage in the study area as a consequence of the MaNHEP intervention. A substantial increase in key health service coverage was observed during the intervention period in the study area compared to at baseline, for example, there was an increase in the ANC coverage in the study area because of the MaNHEP intervention [14]. A birth audit conducted in the study area reported that first ANC visit increased from 38% at baseline (November 2010), to 85% at end line (June 2012) [14]. The percentage of women receiving a postnatal care (PNC) visit within two days of delivery increased from 1% at baseline (November 2010) to 73% at end line (June 2012) [14]. This figure is seven times higher than the 2011 EDHS reported for postnatal care visit in the same study area [8]. In addition, the same study revealed 90%, 76% and 79% of births were conducted in a clean place, with clean helpers, and clean pregnant woman respectively even though most deliveries (89%) were at home [14].

Facility-based studies tend to overestimate the actual community-based perinatal mortality rate. For example, studies from Jimma and Hawasa referral hospitals from Ethiopia, reported perinatal mortality rates of 130 per 1000 live birth [7] and 85 per 1000 total delivery [10] respectively, while a review of hospital-based studies from Ethiopia, from 1974 to 2013, reported a perinatal mortality rate of 90 per 1000 total delivery [9]. These figures are much higher than the findings of the present study. This could be due to mothers presenting to hospital very late and with serious obstetric complications following referral from a primary health facility.

In this study, a statistically significant association was observed between mothers older than 35 years and perinatal mortality. This may be related to the fact that women who lose their newborns will try to catch up by having another child immediately after their loss [15]. This may increase the likelihood of perinatal mortality. A qualitative study conducted in the same area, as a part of this study, reported that women who lost their newborns decided to have another child as a replacement, this usually resulted in the subsequent death of the newborn [15]. This finding was in keeping with prospective cohort studies from rural Pakistan [16] and Tanzania [17].

A previous history of neonatal mortality was a strong determinant of perinatal mortality in this study. This finding is consistent with a population-based study from Missouri (USA), which showed that women with a previous infant mortality had an elevated risk of subsequent stillbirth, with the most profound increase observed among black women [18]. Mothers with a history of neonatal mortality during their first pregnancy were 5 times more likely to experience stillbirth in the second pregnancy [19, 20]. Other studies from Zimbabwe [19] and Sweden identified that previous stillbirth was one of the most eminent risk factors for perinatal mortality [21].

Preterm births were at an increased risk of perinatal mortality in this study. The overall proportion of preterm babies in this study was 8%, and 15% of all perinatal deaths were among the preterm babies. This finding is higher than in a study conducted in Addis Ababa in selected public health facilities, which reported 7.1% of perinatal deaths were in preterm births [22]. The difference seen may be attributed to home delivery and limited access to higher-level health care in this study, as it was conducted in a rural area. A study from Nepal also indicated similar findings [23]. Other studies from North East India and Tanzania revealed that the risk of perinatal death was high among preterm babies [17, 24], and a study from São Paulo concluded that preterm birth was the most significant risk factor for early neonatal mortality [25].

The study also found that male babies were at higher risk of perinatal death than their female counterparts, this was also found in an analysis of 22 years of cohort data from Butajira in rural Ethiopia [26] and in a similar study from the Netherlands [27]. Similarly, as in most developing countries, male child mortality exceeds female counterparts [5]. Infant and neonatal mortality were also higher in males, as found in community-based cohort studies from Zimbabwe [28], Australia and New Zealand [29], Pakistan [16] and Ethiopia [30]. This is also true among the whole population, presumably because of biological factors affecting the male infants [31, 32]. The excess of male deaths observed in this study may be as many/the majority were born to women who were at both extremes of age (<19 and >35) compared to female babies.

Multiple birth babies were more than four times at risk of death than singletons in this study. This is consistent with other studies and is a known risk factor for perinatal mortality? [30, 33].

The leading cause of perinatal deaths identified in this study was birth asphyxia, which accounted for approximately 30% of early neonatal deaths. This may be due to the fact that most of the deaths (75%) occurred at home and were attended by unskilled birth attendants who lack the skills and equipment to help resuscitate asphyxiated babies at birth. This finding was substantiated by study findings from other developing countries like Pakistan [16, 34] and Bangladesh [35], where asphyxia ranked first among the leading causes of perinatal deaths.

Infections such as sepsis, tetanus, and pneumonia combined contributed to a similar number of deaths as birth asphyxia in this study. The high proportion of cases of sepsis may be related to unhygienic birthplace, unhygienic cord care at birth including cord cutting and tying materials, and cultural taboos related to taking babies out of the home even when the newborn is sick. In this study, tetanus made a relatively small contribution to perinatal death, which may be linked to better Tetanus Toxoid (TT) immunization at ANC due to national campaigns by the Federal Ministry of Health (FMOH), at different times in the study area. Studies elsewhere [13, 16, 34‐36] reported similar findings although infection/sepsis were the most common cause of perinatal death. The discrepancy between the current study findings and other study reports may be due to differences in the demography of the study population, the health care system and perhaps, more importantly, the methodology used for assigning a cause of death. In this study, assignment of the cause of perinatal death was based on the local physician’s knowledge and familiarity with the expected diseases in the region so our data should be interpreted with caution.

Identified major causes of stillbirths were chorioamnionitis, antepartum hemorrhage, and hypertensive disorder during pregnancy, which are linked to maternal causes of death. This is similar to findings from India and Ethiopia [24, 7]. Information related to causes of death for stillbirths in this study may be less reliable since mothers themselves may not be able to remember what happened due to the stress and pain or their level of consciousness at the time of birth.

It should be noted that this study was conducted in a rural area, where pregnancy notification is viewed as taboo. Though all necessary efforts were made to track every perinatal death in the study, there may be missed cases due to the harsh/complex nature of the study area. Data was collected based on the respondents’ answers to the questions; hence there may be misclassification of stillbirths and early neonatal deaths. Information related to causes of death for stillbirths in this study may be less reliable since mothers themselves were more likely to be unable to recall the history of signs and symptoms of the stillbirths at the time of birth. Gestational ages were calculated based on the last menstrual period. Birth weight data were not collected.

Note: This study demonstrates the status of perinatal mortality during the study period, which may have altered by the present time.