Perinatal Mortality among All Deliveries in a Tertiary Care Center: A Descriptive Cross-sectional Study

ABSTRACT Introduction: Perinatal mortality comprises the number of stillbirths and death of newborns within seven days of life which is the main contributor to infant and maternal mortality. The aim of this study was to find out the prevalence of perinatal mortality among all the deliveries in a tertiary care center of a remote part of Nepal. Methods: This was a descriptive cross-sectional study conducted in a tertiary care center located in Jumla among 3798 deliveries (childbirth) from August 2014 to April 2020. Ethical approval was taken from the institutional review committee (2076/2077/05) of the same institution. A convenience sampling technique was used and the data were collected from the medical record section and then entered and analyzed in Statistical Package for Social Sciences version 16. Point estimate at 95% Confidence Interval was calculated along with frequencies and percentages for binary data. Results: The prevalence of perinatal mortality was 187 (4.92%) (4.23-4.60 at 95% Confidence Interval) among 3798 deliveries. Regarding the primary causes; the highest proportion was intrapartum hypoxia 62 (33.3%), spontaneous preterm labor 40 (21.5%), and congenital anomalies 38 (20.4%). Similarly, about the final cause; the highest proportion was birth asphyxia 64 (34.2%), intrauterine fetal death 51 (27.3%), congenital anomalies 35 (18.7%), and complication of prematurity 32 (17.1%). Conclusions: The perinatal mortality was quite high in this study with respect to similar studies done in other countries. The finding of this study showed that quality antenatal care with rural ultrasound service is essential to reduce the causes of perinatal mortality.


INTRODUCTION
Perinatal deaths are pregnancy losses occurring after 22 weeks of gestation (stillbirths) and deaths of live births within seven days of life. 1 Stillbirth and prematurity contributed significantly to perinatal mortality. 2 Although neonatal mortality is declining in Nepal, it will take another 50 years for the poorest group to attain 2030 every newborn action plan target. Reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families. 3 Perinatal mortality is an important indicator of maternal care, maternal health, and nutrition, and also reflects the quality of obstetric and pediatric care available. 1 This study aimed to find out the prevalence of perinatal mortality in a tertiary care center in a remote area of Nepal.

METHODS
A descriptive cross-sectional study was used to find out the prevalence of perinatal death in Karnali Academy of Health Sciences teaching hospital in Jumla, which is a tertiary care facility in Karnali Province. The data were collected from 2014 August to 2020 April. This research was conducted after getting ethical approval from the institutional review committee (2076/2077/05) of the Karnali Academy of Health Sciences. The sample size was calculated using the following formula: n= Z 2 x p x q / e 2 = (1.96) 2 x 0.5 x (1-0.5) / (0.02) 2 = 2401 Where, n= minimum required sample size Z= 1.96 at 95% Confidence Interval (CI) p= 50%, for maximum sample size calculation q= 1-p e= margin of error, 5% The calculated minimum sample size is 2401. We included 3798 deliveries admitted in the maternity ward by using the convenience sampling method.
Medical records of all women who gave childbirth between gestational ages 22 weeks and 7 days of birth and whose records were available were selected. Stillborn babies with gestational age >22weeks or weight ≥500 grams and early neonatal deaths till 7 days of life were included in the study. Document review was done by using a structured questionnaire (format) based on maternal and perinatal death surveillance and response (MPDSR) form used by the government of Nepal in every health institution.
The collected data was entered and analyzed by using Statistical Package for Social Science (SPSS) version 16. Point estimate at 95% Confidence Interval along with descriptive statistics such as frequency, percentage for binary data was calculated.

DISCUSSION
Regarding the maternal age; more than half 114(61%) belong to 20 to 29 years, 43(23%) were less than 20 years, 28(15%) were of 30 to 39 years and 2(1.1%) were above 40 years. In Duhok, 52.6% were 20-29 and 35.3% were 30-39 years old. 8 Another study done in Sikkim revealed that 57.5% were of 18-25 years and 32.5% were above 35 years of age had more perinatal deaths, 9 10 which is in contrast to this study. About the gravida of mother; 75 (40.1%) were primigravida, 62 (19.8%) were multi gravida and 50 (13.4%) were grand multigravida. A study done in Jhansi showed that the perinatal mortality in multigravida is relatively higher than primigravida, 10 which looks similar to this study. Likewise, about parity of mother; 85(45.5%) were nulliparous, 87(46.5%) were multipara and 15(8.0%) were grand multiparous. According to the study of Sikkim, more perinatal losses occurred in multiparous women (61%) as compared to primiparous women (39%), 9 that is in contrast to this study found. In this study the majority (79.1%) had a normal vaginal delivery and 14.4% had a cesarean section. According to a study conducted in Iran, 73.1% had a normal vaginal delivery and 26.9% had a cesarean section. 11 This shows that a similar finding was found in vaginal delivery and contrast in cesarean section.

CONCLUSIONS
The perinatal mortality was quite high in this study with respect similar studies done in other countries. The finding of this study showed that quality antenatal care with rural ultrasound service is essential to reduce the causes of perinatal mortality. Regarding the primary causes of perinatal death; the highest proportion had intrapartum hypoxia, spontaneous preterm labour, and congenital anomalies. Similarly, about the final cause of perinatal death, the highest proportion had birth asphyxia, IUFD, congenital anomalies, and complications of prematurity. Likewise, about the Wigglesworth classification, the highest proportion had asphyxia conditions including stillbirth, followed by normally formed macerated stillbirth, conditions associated with prematurity, and lethal congenital malformation. In conclusion, quality antenatal care with rural ultrasound service is essential to identify and reduce the different causes of perinatal death. Therefore, quality maternity care service is required from gross root level to improve the utilization of quality maternity service and reduce the perinatal mortality in Karnali Province.