of perinatal mortality in Marondera district, Mashonaland East Province of
Zimbabwe, 2009: a case control study
Tachiweyika Emmanuel1,&, Gombe Notion1, Shambira Gerald1, Chadambuka Addmore1, Tshimamga Mufuta1, Zizhou Simukai2
1University of Zimbabwe, Department of Community Medicine PO Box A178 Avondale Harare,
Zimbabwe, 2Ministry of Health and Child Welfare, Zimbabwe
of Zimbabwe, Department of Community Medicine PO Box A178 Avondale Harare,
3 million babies die in the first seven days of life (early neonatal period). It
is estimated that more than 3.3 million babies are stillborn every year; one in
three of these deaths occurs during delivery and could largely be prevented. In
the less developed countries, which account for 98% of perinatal deaths, these
deaths are not always registered . World Health
Organization (WHO) defines perinatal mortality as deaths occurring during late
pregnancy (>22 weeks of gestation), during birth and within seven days after
delivery . The perinatal period is considered the most
critical phase of life [3,4]. It
reflects the general health and the various socio-biological features of
mothers and babies. Perinatal mortality rate gives a good indication of the
extent of pregnancy wastage and the quality and quantity of health care
available to mother and the newborn .
would be difficult to achieve Millennium Development goal of reducing child
mortality by two thirds by 2015 without reducing perinatal deaths . Perinatal mortality rates are highest in Africa where it
is more than six times higher than in developed regions. Perinatal mortality
rates of around 10 deaths per 1000 total births are recorded in developed
regions compared to 50 per 1000 in developing regions and over 60 per 1000 in
least developed countries . Perinatal deaths result from
complications of preterm birth, asphyxia or trauma during birth, infections,
severe malformations and other causes. Maternal health is important for
neonatal health, and maternal infections contribute to adverse pregnancy
outcomes . The benefits of treating medical problems and
complications of pregnancy are greatest when there is a continuum of care
throughout pregnancy, child birth and immediate postpartum period. Although
care during childbirth is most critical, antenatal care plays an important
role, primarily because it provides an important means of addressing other
health care needs, such as prevention and treatment of HIV, other sexually
transmitted infections and malaria . While international
attention, statistics and interventions focus on infants born alive, stillborn
infants have largely been overlooked . A conceptual
framework developed by Mosley was used to guide the study. It consists of
distant factors (socio-economic factors, and pre-pregnancy conditions),
pregnancy specific factors (nutritional status, maternal morbidity, intrapartum
conditions, and antenatal care), and fetal factors (fetal biological factors
and accidents at delivery) interacting leading to a perinatal death .
2007, Marondera District recorded 190 perinatal deaths and 3 242 live births,
translating to a perinatal mortality ratio of 58.6 per 1000 live births. In
2008, the district recorded 145 perinatal deaths and 2 243 live births,
translating to a perinatal mortality ratio of 64.6 per 1000 live births. These
figures were above the provincial perinatal mortality ratio of 32 per 1000 in
2007 and 36 per 1000 in 2008 and the national perinatal mortality ratio which
was estimated to be 27 per 1000 in 2008. These ratios might however be
underestimates of the real problem given the gross underreporting of perinatal
deaths and the high proportion of non-institutional deliveries in the district.
determined factors associated with perinatal mortality focusing on
socio-demographic factors, intrapartum factors, obstetric factors and health
1:2 unmatched case control study was carried out in eleven health facilities in
Marondera District in June and July 2009. A case was any mother who delivered a
stillbirth or whose baby died within seven days of delivery in Marondera
District from 01 August 2008 to 31 July 2009. A control was a mother whose baby
survived the perinatal period in Marondera District during the same period. A minimum
sample of 92 cases and 185 controls was calculated. We interviewed 103 cases
and 206 controls.
stratified sampling was used to select health centers. The only district
hospital and rural hospital were purposefully selected. One urban out of two
urban clinics and eight out of 15 rural clinics were randomly selected using
the lottery method. Maternity delivery registers were used to develop line
lists of perinatal deaths which were used as sampling frames. Every second
client on the perinatal death line lists was selected until the required number
of cases was reached. Proportional sampling was used to determine the number of
participants to be selected from each health center. Every second mother
reporting for postnatal care was systematically selected as a control.
administered questionnaires were used to collect data from study participants.
Key informant interviews were done with provincial reproductive health managers,
nurse managers and medical doctors. Discharged patients were followed up in
their homes. A review of delivery registers, death notification forms and case
notes was done. Epi-Info 3.3.2 was used to capture and analyze quantitative
data. Stepwise logistic regression analysis was done to determine independent
determinants of perinatal mortality. Qualitative data was analyzed for content.
characteristics of study participants
hundred and three cases and two hundred and six controls were interviewed. The
median years for cases was 25 years (Q1=22, Q3=30) and
controls was 24 (Q1=20, Q3=28). Table 1 shows the socio-demographic information of the cases and controls.
of index pregnancies amongst cases
five (43.7%) of deliveries were live births and the remainder were stillbirths.
Twenty four (41.4%) of the stillbirths were macerated and 34 (58.6%) were
the early neonatal deaths, 24 (53.3%) died in the first 24 hours of delivery,
18 (40%) died between 24 and 72 hours and 3 (6.7%) died between 72 hours and
seven days. Of the 45 early neonatal deaths recorded, 27 died of severe
prematurity, 26 of respiratory distress syndrome, 16 of neonatal septicaemia, 16
of birth asphyxia and 2 of congenital malformations. Some cases had more than
one cause of death (Figure 1).
of antenatal care booking
nine (57.2%) of cases and 181 (87.8%) controls had booked for antenatal care
(p=0.000). Six (10.1%) cases and 35 (19.3%) controls booked in the first
sixteen weeks of pregnancy. Forty (67.7%) cases and 102 (56.3%) controls booked
between 16 and 27 weeks of gestation. Thirteen (22.2%) cases and 45 (24.4%)
controls booked after twenty seven weeks of gestation (p=0.000).
of partographs during labor
(36.8%) cases and 84 (40.7%) controls had their labor monitored using
of perinatal mortality in bivariate analysis
carried out bivariate analysis to determine factors associated with perinatal
factors associated with increased the risk of perinatal mortality were having
maternal primary or no education (OR= 5.40, 95 % CI (3.14 – 9.33)), being in a
polygamous marriage (OR=5.40, CI (1.62 – 11.26)), maternal parity greater than
4 (OR=4.80, CI (1.62 – 14.23)), living on a farm or in rural areas (OR=3.32, CI
(1.93 – 5.74)), belonging to apostolic sect (OR=2.94, CI (1.70 – 5.08)) and
maternal unemployment (OR=2.17, CI (1.24 – 3.75)). Living within 5 km of a
health facility (OR=0.41, CI (0.22 – 0.77)) and having a gainfully employed
husband (OR=0.36, CI (0.20 – 0.63)) reduced the risk of perinatal mortality.
determinants increasing the risk of perinatal mortality were having a history
of early neonatal death (OR=7.22, CI (2.98 – 20.77)), having suffered from
pregnancy complications (OR=7.04, CI (4.05 – 12.23)), having suffered from
ante-partum haemorrhage (OR=5.60, CI (2.21 – 14.57)), maternal HIV infection
(OR=5.30, (CI 2.68 – 10.56)), maternal history of pregnancy induced
hypertension (OR=4.81, CI (2.59 – 8.99)), maternal history of stillbirth
(OR=4.34, CI (2.26 – 8.37)), maternal history of abortion (OR=3.36, CI (1.90 –
5.96)) and having suffered from malaria during pregnancy (OR=4.32, CI (2.17 –
9.50)). Having booked for antenatal care (OR=0.19, CI (0.10 – 0.34)) reduced
the risk of perinatal mortality.
age < 36 weeks (OR=15.1, CI (8.24 – 27.54)), home delivery (OR=7.38, CI
(4.03 – 13.68)), birth weight <2500g (OR= 6.26 (3.55 – 11.03)), baby having
congenital malformation(s) (OR=5.62, CI (2.10 – 15.57)), and having multiple
pregnancy (OR=3.26, CI (1.36 – 7.88)) were fetal determinants that increased
the risk of perinatal mortality.
related determinants of perinatal mortality were experiencing labor
complications (OR=7.56, CI (4.38 – 13.06)), delivery by breech extraction
(OR=3.59, CI (1.89 – 6.84)) and use of anesthesia during labor (OR=5.70, CI
(1.34 – 27.77)), aggressive resuscitation of baby (OR=1.91, (CI 0.90 – 4.81))
and delivery by caesarian section (OR=2.39, CI (0.76 – 7.59)) increased the
risk of perinatal mortality although they were not statistically significant.
Having a spontaneous labor (OR=0.16, CI (0.02 – 0.89)) reduced the risk of perinatal
analysis of determinants of perinatal mortality
association between birth weight and perinatal mortality was modified by
gestational age. Preterm babies whose birth was < 2500g were more likely to
die (OR= 11.43, CI (3.02 – 43.26)) than term babies (OR= 1.45, CI (0.62 –
3.59)) of low birth weight. Delivering at home was a confounder in the
association between birth weight and perinatal mortality. Home delivery was
causing an overestimate of the strength of association. Parity was a confounder
in the association between pregnancy complications and perinatal mortality
resulting in an overestimate of the strength of association.
risk factors for perinatal mortality
that were independently associated with perinatal mortality were labor
complications, belonging to apostolic sect, having a home delivery, maternal
HIV infection, low birth weight and antenatal care booking (Table 2).
informants comprised of five nurse managers, three medical doctors, and one
reproductive health coordinator. Their median years in service was 13 years (Q1=4,
Q3=19). It was evident from the interviews that perinatal mortality
meetings were not held according to schedule because of lack of funding. Key
issues discussed during meetings included patient care, teaching of fellow
health workers and perinatal mortality surveillance. Practical interventions
for reducing avoidable deaths were discussed. Major causes of perinatal mortality
highlighted include prematurity, HIV infection, birth asphyxia, pregnancy
induced hypertension and home deliveries. Shortages of human and material
resources were contributed to perinatal mortality.
independent determinants of perinatal mortality were belonging to apostolic
sect, antenatal care booking, home deliveries, experiencing labor
complications, maternal HIV infection and low birth weight. Some apostolic
sects do not use the formal health care system for obstetric care. Women from
these apostolic sects deliver at home under the care of untrained midwives.
invariably places the women and their babies at risk of complications and
death. One of the pillars of the ‘Safe motherhood initiative’ is to have a
clean delivery in a health institution under the care of trained health
personnel . Women who had booked for antenatal care
(ANC) were less likely to experience perinatal mortality than those who had not
booked. Antenatal care affords pregnant women the opportunity to have their
pregnancies monitored and potential complications addressed. Women who
delivered at home were more likely to experience perinatal mortality than those
who delivered in health institutions. Home deliveries were often conducted by untrained
birth attendants and in unsanitary conditions. Asphyxiated babies would not be
resuscitated because of absence of equipment. There is an increased risk of
neonatal infections and hypothermia in home delivered babies especially preterm
babies. These factors are known risk factors for perinatal mortality .
who experienced labor complications had higher risk of perinatal mortality.
Several studies have shown that complications (cord prolapse, mal-presentation,
APH and eclampsia) to be associated with perinatal mortality. Babies delivered
by breech extraction were often traumatized and asphyxiated during delivery.
Babies delivered by caesarian section could die from the underlying
complications that prompted emergency caesarian section rather than the
procedure itself. Ferresu et al in 1998 however found that stillbirths were
less likely to be delivered by caesarian section in a study to determine the
incidence of perinatal deaths and their associated factors .
The risk of obstetric complications tends to increase with increasing parity
thereby increasing the risk of perinatal mortality. Maternal parity greater
than four was a risk factor for perinatal mortality. Pregnancy Induced Hypertension
(PIH) and ante-partum hemorrhage (APH) increase the risk of perinatal
mortality. APH is usually caused by placenta abruption and this result in fresh
stillbirths. PIH reduces nutrient supply to the fetus due to restricted blood
flow resulting in intrauterine growth retardation (IUGR). Such fetuses are too
small and have high risk of dying in the perinatal period [14-15].
Similar findings were obtained in a study to determine the causes of perinatal
mortality in WHO collaborating centers in Argentina, Egypt, Peru, India, South
Africa and Vietnam in 2004 .
birth weight babies were more likely to die during perinatal period.
Prematurity was the major cause of low birth weight. Preterm babies often died
of hypothermia and respiratory distress syndrome. Premature low birth weight
babies were however more likely to die during the perinatal period than low
birth-weight term babies. Term babies would have better immunity and mature
respiratory systems with adequate surfactant production and are able to
regulate their body temperature . Maternal infections
increase the risk of perinatal mortality. Malaria causes placental
insufficiency which leads to IUGR and sometimes intra-uterine death. Although
Marondera District is considered a non-malaria area, several pregnant women
referred from neighboring malaria infested districts would present with malaria
at Marondera Hospital. Several studies have demonstrated that malaria is a risk
factor for perinatal mortality .
HIV infection destroys the mother’s immune system and the infant depends on
maternal antibodies to fight infection. The chances of survival are very low because
of the compromised immunity passed on from the mother. Studies have shown that
HIV infection increases perinatal mortality . These
observations can be related to social determinants of health. Women
experiencing perinatal deaths are most likely to come from poor background.
They may have to travel long distance on poor roads either on foot or rarely by
vehicles for antenatal booking and care at a health care facility . Where health facilities exist and are accessible, the
quality of health care offered may be poor, due to understaffing or
de-motivated health personnel.
naturally prevents them from doing so even if they are knowledgeable of the benefits
of ANC but deprives them the opportunity for early identification and
management of pregnancy related problems and may further influence their choice
of where to deliver. Because of poverty, women are less likely to afford a
nutritious diet to take care of their needs and those of the growing foetus
which in turn leads to low birth weight (LBW). Malnutrition increases risk of
infection which leads to LBW babies with greater probability for mortality . Residents living in regions with more poverty, more
unemployment, and more income inequality are more likely to report poor health
This is true of most rural areas in developing countries.
India, the Government started a National Maternity Benefit Scheme (NMBS)
program under which Rs. 500/-was given towards better food to every pregnant
mother during the antenatal check-up as a measure to prevent malnutrition and
another scheme that provided money for travel depending on distance from health
facility. This increased interest in ANC, financial capability for ANC and
timely transfer to referral facilities resulting in a decrease in perinatal
mortality . Maternal education is a factor that is
considered valid for international comparisons. Studies from different European
countries reported maternal education to be the most important social predictor
of an adverse pregnancy outcome [25,26].
a review of studies from the Nordic countries showed educational level of the
mother was the most important social factor associated with pregnancy outcomes
 though in our study it was not independently
associated. Perinatal mortality can be related to the paternal and maternal
characteristics which may be related to gender power structures in families.
But in programming very little focus is put on men’s role as partners in most
aspects of reproductive health. Men play a critical role in contraception,
abortion, control of sexually transmitted diseases, antenatal and delivery
clinic attendance, and child mortality and should therefore be actively engaged
to impact on women’s access to healthcare . Most
perinatal deaths were stillbirths and more than 58% of the stillbirths were
fresh. A majority of these babies could have died during labor. Use of
partographs for monitoring of labor was low and this could be attributed to
shortage of midwives. More than 50% of early neonatal deaths occurred within 24
hours of delivery. Marondera Hospital had one incubator and sometimes up to
three neonates would be nursed in one incubator. Simple interventions such as
kangaroo care have the potential to reduce early neonatal deaths. The major
causes of early neonatal deaths were prematurity, respiratory distress
syndrome, neonatal septicemia and birth asphyxia.
records of labor were not complete and we could not get information concerning
labor from the actual health workers who conducted the deliveries because of
the retrospective nature of our study.
independent determinants of perinatal mortality in Marondera District include
belonging to apostolic sect, experiencing labor complications, maternal HIV
infection, home delivery, low birth weight and antenatal care booking. A
majority of perinatal deaths were fresh stillbirths. Most early neonatal deaths
occurred during the first 24 hours after delivery. Complications of prematurity
and respiratory distress syndrome were the major causes of perinatal mortality
in the district. Shortage of midwives and neonatal resuscitation equipment in
most health facilities was contributing to poor outcomes in resuscitated
babies. Transport and communication network in the district was poor. Perinatal
mortality meetings were not being held according to schedule at all levels of
health care. However in order to impact on perinatal mortality, it is important
to look at the determinants in the context of health system and social
circumstances that surround pregnancy and delivery.
recommended that nurses should intensify health education to women on the
importance of antenatal care booking and delivering in hospital. Hospital
managers should ensure adequate provision of equipment and drugs for use in
emergency obstetric and neonatal care. The District Nursing Officer
should ensure that non-midwives in rural health centers are attached to the
busy maternity unit at Marondera Hospital. The District Medical Officer (DMO)
should urgently repair non-functional telephones and radios in peripheral
health centers. Nurses should advocate for Kangaroo care method for preterm
babies. Health workers should comprehensively manage neonates in the first 24
hours of delivery. Hospital and clinic managers should ensure that perinatal
mortality meetings are held according to recommended schedule.
Provincial Nursing Officer should consider re-opening of Marondera Hospital
School of Midwifery so as to train more midwives. The reproductive health
coordinator should ensure health worker training in Emergency Management of
Obstetric and Neonatal Complications. The District Medical Officer (DMO) should
increase the fleet of ambulances to efficiently service all health centers. The
DMO should ensure adequate supply of neonatal resuscitation equipment and drugs
in all health centers. The District Health Executive should consider construction
of waiting mothers’ shelters because the district had none.
authors declare no competing interests. Source of funding: University of
Zimbabwe, MPH Programme
like to acknowledge the study participants for their valuable contributions
that made this study a success.
Tachiwenyika: He was responsible for the conception of the problem, design,
collection, analysis and interpretation of data and drafting the final article.
Notion T. Gombe: He was responsible for the conception of the problem, design,
analysis and interpretation of data and drafting the final article. Gerald
Shambira: He was responsible for the conception of the problem, design,
collection, analysis and interpretation of data and drafting the final article.
Tshimanga: Had oversight of all the stages of the research and critically
reviewed the final draft for academic content. Addmore Chadambuka: Participated
in the design, analysis and interpretation of data and drafting the final
article and critical review of the final draft. Simukai T Zizhou: He was
responsible for the design, analysis and interpretation of data and drafting
the final article.
Table 1: Socio-demographic information of cases and controls in Marondera District,
Table 2: Independent determinants of perinatal mortality in Marondera District,
Figure 1: Causes of Early Neonatal Deaths among the Cases in Marondera District,
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