A 50-year audit of maternal mortality in the Peninsula Maternal and Neonatal Service, Cape Town (1953-2002).

OBJECTIVE: To audit trends in maternal mortality in the Peninsula Maternal and Neonatal Service (PMNS) over a 50-year period, with respect to rates and patterns of causation. DESIGN: Retrospective and prospective audit. SETTING: The PMNS, an integrated perinatal service composed of primary, secondary and tertiary facilities in Cape Town. Population All women giving birth in the area of the Cape Peninsula served by the PMNS over the 50-year period. METHODS: Data on maternal deaths were collected for 1953-2002 inclusive, from annual obstetric and gynaecological reports. Three triennia (1954-1956, 1981-1983 and 1999-2001) were selected for a detailed comparison of trends in rates and causes of death. MAIN OUTCOME MEASURES: Maternal mortality rates (MMRs). Causes of maternal deaths. RESULTS: Total deliveries increased from 7315 in 1953 to 27,575 in 2002. The MMR declined from 301 deaths per 100,000 deliveries in 1953 to 31.2 in the triennium, 1987-1989. From 1999, the MMR increased, reaching 112 in 2002. Comparing 1954-1956 (MMR of 253.9) with 1981-1983 (MMR of 43.8), there was a marked decline in the MMR related to hypertension (80.4 to 11.3), haemorrhage (50.8 to 4.2), abortion (55 to 4.2), suspected pulmonary embolism (25.4 to 2.8), pregnancy-related sepsis (8.5 to 4.2) and cardiac disease (21.2 to 2.8). Comparing 1981-1983 (MMR of 43.8) with 1999-2001 (MMR of 59.4), there was a decline in the MMR associated with abortion (4.2 to 0). The MMR for haemorrhage, suspected pulmonary embolism and cardiac disease remained the same. There was a slight increase in the MMR attributed to hypertension (11.3 to 14.5) and pregnancy-related sepsis (4.2 to 7.3). There was a marked increase in the MMR associated with non-pregnancy-related infections/AIDS (4.2 to 18.2). CONCLUSIONS: The MMR for all causes of maternal death declined significantly from 1953 to 1981 as a result of several interventions. From 1999, there has been a non-significant increase in MMR, predominantly due to the burden of HIV/AIDS-related mortality.

Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns.

AIM: Conventional care of prematurely born infants involves extended maternal-infant separation and incubator care. Recent research has shown that separation causes adverse effects. Maternal-infant skin-to-skin contact (SSC) provides an alternative habitat to the incubator, with proven benefits for stable prematures; this has not been established for unstable or newborn low-birthweight infants. SSC from birth was therefore compared to incubator care for infants between 1200 and 2199 g at birth. METHODS: This was a prospective, unblinded, randomized controlled clinical trial; potential subjects were identified before delivery and randomized by computerized minimization technique at 5 min if eligible. Standardized care and observations were maintained for 6 h. Stability was measured in terms of a set of pre-determined physiological parameters, and a composite cardio-respiratory stabilization score (SCRIP). RESULTS: 34 infants were analysed in comparable groups: 3/18 SSC compared to 12/13 incubator babies exceeded the pre-determined parameters (p < 0.001). Stabilization scores were 77.11 for SSC versus 74.23 for incubator (maximum 78), mean difference 2.88 (95% CI: 0.3-5.46, p = 0.031). All 18 SSC subjects were stable in the sixth hour, compared to 6/13 incubator infants. Eight out of 13 incubator subjects experienced hypothermia. CONCLUSION: Newborn care provided by skin-to-skin contact on the mother's chest results in better physiological outcomes and stability than the same care provided in closed servo-controlled incubators. The cardio-respiratory instability seen in separated infants in the first 6 h is consistent with mammalian "protest-despair" biology, and with "hyper-arousal and dissociation" response patterns described in human infants: newborns should not be separated from their mothers.

Low birth weight in urban Harare.

OBJECTIVES: 1. To measure the incidence of low birth weight from all institutional deliveries in a defined catchment area of urban Harare. 2. To estimate the relative proportions of preterm and small for gestational age (SGA). DESIGN: The study was descriptive and was conducted during the last three months of 1986. SETTING: The low risk maternity units in three high density suburbs, Highfield, Glen Norah and Glen View and the referral centre Harare Central Hospital. SUBJECTS: All babies born to women residing in the study areas in the maternity clinics and those transferred to the referral hospital were identified and weighed. MAIN OUTCOME MEASURES: For low birthweight babies gestation was estimated by the Dubowitz method and perinatal outcome was recorded. RESULTS: During the three month study period in 1986, 2,056 babies in total were born; 223 (10.8%) of which were low birthweight. Of these 65 (44%) were preterm and 55 (37%) were SGA. CONCLUSION: The findings show a lower percentage of low birthweight and SGA babies than in many developing countries but higher than the norm for developed countries. The study demonstrates a need for resources to prevent low birthweight delivery and improve care for low birthweight babies.

PIP: A 1986 descriptive study of all institutional deliveries in a defined catchment area of urban Harare, Zimbabwe, investigated the incidence of low birth weight (LBW, under 2500 grams), and the relative contributions of preterm and small-for-gestational-age (SGA, gestational age 37 weeks or above plus LBW) deliveries to LBW. Since most LBW statistics are based on deliveries from central hospitals that serve as referral centers for distant rural areas, they cannot be considered representative of a particular urban population. The high-density, low-income Harare suburbs of Highfield, Glen Norah, and Glen View were selected for the analysis. During the 3-month study period, there were 2056 registered births in the 3 communities. 1101 of these deliveries occurred at the 3 low-risk maternal clinics serving these areas and 955 took place, after referral, at the high-risk Harare Central Hospital. There were 223 LBW infants (10.8%), 50 of whom were delivered in the clinics and 173 in the referral hospital. All 17 infants weighing under 1000 grams were delivered at the hospital. 148 LBW infants (including 13 stillbirths, 6 early neonatal deaths, and 14 sets of twins) were selected for further study. 44% of these infants were preterm and 37% were SGA; the remainder were appropriate for gestational age. When the data were adjusted to conform with the Villa/Belizan categories, 5.3% were LBW/preterm and 5.5% were LBW/intrauterine growth retardation. Overall, the LBW pattern identified in this study falls between that of a developed and a developing country, which is presumably reflective of the high level of general development in Harare.

Booked and unbooked mothers delivering at Harare Maternity Hospital, Zimbabwe: a comparison of maternal characteristics and foetal outcome.

This study was prompted by the poor maternal and foetal outcome at Harare Maternity Hospital, Zimbabwe, in unbooked mothers compared to women who had booked for antenatal care. Comparison was made of 195 recently delivered unbooked mothers with 196 booked mothers. Unbooked mothers were significantly more likely to be younger, of lower parity, be single, have lower socio-economic status, live in or migrate from rural areas, be uneducated and have an unwanted pregnancy. Their infants were significantly more likely to preterm and/or of low birth weight and had a higher perinatal mortality. The major reasons cited by the women for not booking were lack of money and delivery occurring before the intended time of booking. Discussion focuses on how to improve outcome in unbooked mothers.

PIP: Levels of perinatal and maternal mortality in the Greater Harare Maternity Unit in Harare, Zimbabwe, are markedly higher among women who do not book for antenatal care compared to women who do book. The authors used a case-control approach to determine which factors are related to unbooked and booked mothers, respectively, and reasons for the failure to book for antenatal care. 195 recently delivered unbooked mothers were compared against 196 booked mothers over the period January-March 1986, during which there were a total of 40,379 deliveries at the hospital. Data were collected via personal interview on the day of delivery or the day after. Unbooked mothers were significantly more likely to be younger, of lower parity, single, of lower socioeconomic status, live in or migrate from rural areas, be uneducated, and have an unwanted pregnancy. Their infants were significantly more likely to be preterm and/or of low birth weight and had an higher level of perinatal mortality. Major reasons cited by the women for not booking were lack of money and delivery occurring before the intended time of booking. The discussion focuses upon how to improve outcomes in unbooked mothers. Unbooked mothers are an high-risk group which should be targeted for antenatal care and early booking. Concern is also expressed that the universal introduction of user charges for maternity care under the Economic Structural Adjustment Program will further deter the high-risk group from availing themselves of antenatal care.