The perinatal morbidity and mortality survey of Jamaica 1986-1987

The Jamaican Perinatal Morbidity and Mortality Survey was conducted between September 1986 and August 1987. A total of 10310 consecutive birth were identified and mothers interviewed in the first 2 months (main cohort study), 1405 neonatal admissions were evaluated over a 6-month period (morbidity study), and 1855 perinatal deaths and 73 late neonatal deaths identified over 12 months (mortality study - 55 por ciento of the deaths were given postmortem examinations. The perinatal mortality rate for the cohort study was 38.1 por ciento per 1000 births. This was 36.6 percent higher than the 1982 estimate of 27.9/1000 based on deliveries at the Victoria Jubilee Hospital, a specialist maternity institution which has at least 13 000 deliveries per annum

An evaluation of perinatal services in institutions in Jamaica

An evaluation of perinatal services in institutions was undertaken as part of the perinatal morbidity and mortality survey of Jamaica 1986-1987. Observations were made of obstetric practice and immediate neonatal care on five randomly selected days during September and October 1986 using a standard questionnaire based on the WHO guidelines on appropriate technology for birth. Of 140 deliveries 18 per cent (95 per cent CI 12 per cent - 25 per cent) were unattended (i.e. head not controlled on the perineum). Median bed utilisation was 68 per cent with a range of 0 - 93 per cent. Thirty-five per cent of institutions had maternity beds with more than one patient to a bed. Only 7 per cent of babies were put to the breast immediately following delivery and 47 per cent within two hours. Eighty-four per cent of newborns received adequate cord care. There was a shortage of nursing staff with 53 per cent, 77 per cent, 82 per cent, and 86 per cent of registered nurses and midwifery posts filled at CRH, VJH, Spanish Town Hospital and UHWI respectively. The findings indicate the need for immediate measures to improve the standard of care.

An evaluation of the domiciliary midwifery services in Jamaica

A random sample of 78 district midwives, representing 24 por ciento of all district midwives in the government health service, were interviewed to assess their knowledge and practice of domiciliary midwifery as part of the Jamaican Perinital Morbidity and Mortality Survey in 1986. A standard questionnaire based on the WHO guidelines on appropriate technology for birth was used. Records of their preceding home deliveries were examined and their delivery bags inspected for availability of basic supplies and equipment. A mean of 21.5 home deliveries were attended by each rural midwife in 1986 compared with 3.8 in the urban areas. Routine laboratory were not done on many mothers and there were long delays in getting results. Midwives' knowledge was average overall with one third of them showing poor knowledge of high risk factors in infants and newborn care. Most midwives routinely shave and give enemas to mothers. Unavailability of equipment and supplies, including vitamin K and eye drops, is common. 24 por ciento of midwives made no prenatal home visit in the previous month and 80 por ciento fell short of the set norm of 5 postnatal home visits. 84 por ciento of midwives put the baby to the mother's breast within one hour of delivery. Essential supplies and lab investigations need to be provided and measures taken to improve domiciliary midwifery through a programme of continuing education and better supervision of midwives. A strategy to promote home deliveries under specified conditions needs to be considered.

Social conditions and health of pregnant Jamaican women

This study analysed data from a national sample of 10,428 mothers who had births occuring in Jamaica in September and October 1986 in order to identify which socio-economic and environmental features best predicted health problems of the mother and the baby. The four categories of problems arising during pregnancy (bleeding, vaginal infection/discharge, 'other problems', antenatal hospital admission) showed the reverse pattern to the one expected: mothers who were more highly educated and lived in better sanitary conditions tended to be those reporting more problems. Features of the mothers which could not be due to a perception bias (short stature and low haemoglobin levels) were more clearly associated with socio-economic deprivation. In addition, the clear-cut adverse outcomes of pregnancy - pre-term delivery and growth retardation - showed strong consistent associations with the conjugal union status of the mother, her usual employment status, the household expenditure on food and a newly derived social status classification based on the occupation warrants testing in other situations in Jamaica.

Environmental factors associated with pre-term delivery in Jamaica

Social and environmental factors were related to preterm delivery in a national population of 10,330 singleton births occuring in the Jamaican National Perinatal Morbidity and Mortality Survey of 1986. Among women certain of their dates, the preterm delivery rate was 14.2 por ciento . Initial two-way tabulations indicated that the significant associations with preterm delivery were the marital status of the mother, her educational level, the job of the major wage earner, whether she was herself the major wage earner, her usual employment status, the food expenditure per person in the household and the parish in which she resided. In addition, there were associations with tobacco smoking (positive) and alcohol consumption (negative). Mothers who were in work at the time of quickening had a reduced risk of of preterm delivery. There was no association with coital rate at quickening. Mothers who were young or relatively old (35+) also had an increased risk of preterm delivery. Logistic regressiion was used to determine the statistically significant independent associations. These were found to be: parish of residence, maternal age, marital status of the mother, the job of major wage earner in the household, maternal cigarette smoking and the amount spent on food in the household. There were no independent associations with maternal education level or alcohol ingestion.

Perinatal mortality in Jamaica 1986-1987

A large population-based study of all stillbirths and neonatal deaths occuring on the island of Jamaica during a 12 month period is described. During this time, 2069 perinatal deaths were identified from an estimated population of 54,400 total births giving a perinatal death rate of 38.0 per 1000 total births. The death rate was 5 times higher among twins than singletons. An attempt was made to obtain detailed postmortem examination of as many deaths as possible. In the event, 51 por ciento of perinatal deaths received such a postmortem examination, for the most part by 3 specially trained pathologists working in the capital. Postmortem rate was affected by sex, multiplicity of the infant, month of death and area of delivery. Deaths were classified using Wigglesworth scheme. The distribution categories was similar in the months when the postmortem rate was 70 por ciento to the rest of the time period when the post-mortem rate was only 40 por ciento . The Wigglesworth classification of deaths identified those associated with intrapartum asphyxia as the most important group, accounting for over 40 por ciento of deaths. This simple classification is important as it focusses attention on details of labour and delivery that may require change and is useful in planning future delivery of obstetric and neonatal care.

Perinatal mortality in Jamaica: the role of intrapartum asphyxia and birth trauma

Data from the Jamaican Perinatal Morbidity and Mortality Survey, 1986-1987, were analysed in order to examine the frequency of pathological markers of asphyxia and birth trauma amongst fresh stillbirths and neonatal deaths in babies coming to necropsy. A total number of 1112 necropsies were performed. There were 295 normally formed fresh stillbirths and 463 neonatal deaths, 264 of whom died on the last day of life. One hundred and seventy (57.6 por ciento ) fresh stillbirths showed signs of asphyxia and 64 (21.7 por ciento ) had evidence of birth trauma. Signs of asphyxia were common in all the birth weight groups in 1st day neonatal deaths, being least common in the 0-999g group (19.6 por ciento ) and most common in those weighing 2500-3499g (48.7 por ciento ). Birth trauma was most common in infants with birth weights of over 2500g. It is of great concern that a large proportion of mature fresh stillbirths and neonatal deaths in Jamaica show pathological evidence of intrapartum asphyxia or birth trauma at necropsy. The problems underlying these deaths and the methods of preventing them need urgent attention.

Fatal malformations in Jamaica

Babies with major malformations were identified during the Jamaica Perinatal Morbidity and Mortality Survey. They were in 96 (8.6 por ciento ) of 1112 perinatal and neonatal deaths coming to necropsy and in 25 (2.35 por ciento ) of 1085 other deaths. The central nervous system was not most commonly affected, followed by the renal, gastro-intestinal and cardiovascular system in decreasing order of frequency. Many infants had abnormalities in more than one system and 10 malfomation syndromes/sequences were identified. Although at the present time, major malformations make only a small contribution to perinatal and neonatal mortality in Jamaica, its importance will increase as there is a fall in deaths related to perinatal asphyxia, currently the major cause of perinatal mortality in Jamaica. Although many malformations are currently untreatable, it is important to take account of gastro-intestinal defects when planning surgical services for the newborn, since these are the most easily remediable.

Incidence of anencephaly in Jamaica

Information was collected on 2,197 stillbirths and neonatal deaths on the island of Jamaica during a 12 month period September 1986 to August 1987 as part of the population based nationwide Jamaican Perinatal Morbidity and Mortality Survey. There were 14 cases of anencephalus giving an incidence of 0.26 per 1000 total births. There was no detectable association with social class, maternal age or parity. The rate in Jamaica is considerably lower than found in any other population study.

A cluster of central nervous system defects in Jamaica

Information was collected on all stillbirths and neonatal deaths on the island of Jamaica during the 12 month period September 1986 to August 1987. There were 33 such deaths with anencephaly, spina bifida and hydrocephalus out of an estimated population of 54,400 total births. There was a statistically significant cluster in respect to time of conception in one small rural area of the island. There were no obvious differences between parents involved in the cluster and the rest of the population, but particular Jamaican fruit and vegetables have been shown to be teratogenic in animals. It is postulated that the cluster may have been associated with an unripe crop.

Area variation in perinatal mortality in Jamaica: association with type of hospital services available

Information on the area of maternal residence of 1856 singleton perinatal deaths occurring during a 12 month period (September 1986 - August 1987) were compared with those of 9933 singleton births born during a two month period (September-October 1986) and surviving the first week of life (The Jamaican Perinatal Morbidity and Mortality Survey). The overall mortality ratio of deaths to estimated survivors was 35.7 per 1000. When the area of residence was categorised according to the type of facilities available, there was a clear trend - births to mothers resident in areas with specialist hospital facilities available, had a mortality ratio of 32.0 per 1000, substantially less than those areas with some obstetric and paediatric facilities (rate 39.2 per 1000) or those with only a cottage hospital and no obstetricians (35.8 per 1000). Categorisation of the deaths using the Wigglesworth classification showed significant variation with intrapartum anoxia. This could not be explained by differences in birthweight, or demographic features of the population. It is concluded that access to a specialist hospital results in a significant reduction in mortality associated with intrapartum asphyxia, but not with other types of perinatal death.

The hypertensive disorders of pregnancy in Jamaica

Information on the signs and symptoms of the hypertensive disorders of pregnancy was collected for over 10,000 pregnant women as part of the Jamaican Perinatal Study. The women in the study comprised all those living in Jamaica who delivered singletons weighing more than 1000g after 27 weeks gestation during the months of September and October 1986 (n=10,185). In this population the incidence of antenatal diastolic hypertension was 10.4 por ciento , the incidence of antenatal proteinuric pre-eclampsia was 4.0 por ciento and the incidence of eclampsia was 7.1 per 1000. Risk factors for developing antenatal diastolic hypertension included primiparity, maternal age over 30 years, abnormal weight gain during pregnancy, a history of prior hypertensive disorders of pregnancy and the maternal region of residence. Risk factors for developing proteinuric pre-eclampsia were maternal age over 25 years for primiparae and maternal age over 35 years, abnormal maternal weight gain and a history of hypertensive disorders of pregnancy in multiparae. These results are compared with those from the WHO Collaborative Study on the Hypertensive Disorders of Pregnancy.

Predicting eclampsia, perinatal mortality and low birthweight using antenatal measures of blood pressure, proteinuria and oedema

Data on over 10,000 pregnant women from the Jamaican Perinatal Survey have been used to determine the combinations of blood pressures, proteinuria or oedema that are best at predicting poor pregnancy outcome (eclampsia, perinatal mortality, low birthweight and fetal growth retardation). The combination that best predicted eclampsia (any two signs of a diastolic >80, proteinuria or oedema) was very different from that which best predicted the other outcomes (a systolic >140 or a diastolic >90). Proteinuric pre-eclampsia (PPE) was a relatively poor predictor of all four outcomes.

Maternal mortality in Jamaica: health care provision and causes of death

During the Jamaian Perinatal Mortality and Morbidity Survey, details of 62 maternal deaths occurring in the 12 month period September 1987 to August 1988 were compared with a control population of 95 por ciento of all births on the island in September and October 1987. The incidence (11.5 per 10,000 livebirths) had not fallen since a study 5 years previously. The mothers who died showed the expected trends with advanced maternal age and high parity. The major cause of maternal mortality was hypertension, (3.5 per 10,000 livebirths) followed by haemorrhage and infection. There was little evidence that these mothers had delayed their first attendance for antenatal care but they were more likely to have reduced access to basic facilities such as health centres and public transport. The risk of maternal death varied with grade of hospital facilities available, particularly for hypertension-related deaths, being lowest in areas with access to a specialist hospital and highest in areas where there were no obstetricians available.

Maternal mortality in Jamaica: socioeconomic factors

Socioeconomic factors relating to all maternal deaths identified during the 12 months of the Jamaican Perinatal Morbidity and Mortality Survey were compared with a control population of over 10,000 women. The maternal mortality rate was 11.5 per 10,000 livebirths. Initial analyses showed (a) a negative trend in risk of maternal death with increasing maternal education level, (b) that mothers who lived in households with direct pumped water and/or flush toilets enjoyed a reduced risk, (c) mothers who were themselves the major wage earner and (d) those living in households where the major wage earner was a farmer were at increased risk of maternal death. A previous analysis showed that the mothers age, her parity and variables indicating access to medical care were important. Logistic regression showed that only maternal age and toilet facilities were independently associated with maternal mortality.