Antenatal and Intrapartum Causes of Perinatal Asphyxia and
Stillbirths in Developing Countries
October 6, 2006,
Small Group Discussions
Breakout Group Meetings were held on three topics:
Chaired by Karin Nelson, NIH, U.S.A.; and Alvin Zipursky, The Programme for Global Paediatric ResearchTM, Canada
This group was asked to discuss the definition and incidence of stillbirths and perinatal asphyxia in developing countries
The group first discussed the definition of stillbirths and recommended acceptance of the WHO definition (death of a foetus of 22 weeks gestation or later).
The incidence and cause of stillbirths in developing countries are grossly underreported. It was recommended that a means of obtaining accurate data would be best developed by training health care workers in communities to report stillbirths and provide information on causes.
It is likely that stillbirth data are incomplete both in terms of incidence and cause. In order to study the problem of stillbirths in developing countries data on incidence and cause must be available. Health care workers in villages in many low income communities are being trained to diagnose and care for perinatal problems. However it has not been their responsibility to record stillbirths. To do so would require that health care workers follow each pregnant woman during her pregnancy and if stillbirth occurs it should be recorded and the cause described. Workers should be able to document signs and symptoms such as fever, amniotic fluid leak, prolapsed cord etc. This would require organization and training in verbal autopsy.
Organization, illiteracy etc are major problems limiting the above approach. In addition, it was pointed out that as many as 80% of women in Bangladesh do not accept even minimally trained birth attendants. It may be necessary to establish sentinel studies in specific regions in order to obtain accurate data.
If specific studies are to be established it was recommended that the histopathology of the placenta should be included in such studies. Arrangements could be made for these studies to be performed at a central laboratory.
It was recommended that neonatal encephalopathy should be clearly defined. It was suggested that the Oxford Vermont definition should be accepted: infant of 35 weeks gestation or more; a disturbed state of consciousness, judged by lack of normal focused attention of the infant; inability to rouse (a state of stupor) or profound coma.
There is still an issue of defining and recording stillbirths. In many communities it is difficult to be certain that what has been recorded is stillbirth rather than neonatal death. The WHO definition of intrapartum stillbirth is: “Stillbirths occurring intrapartum or fresh stillbirths (skin still intact, implying death less than 12 hours before delivery), weighing more than 1000 g or after more than 28 weeks of gestation, but excluding those with severe lethal congenital abnormalities.”
There is a need for each country or community to obtain accurate data, especially separating antepartum from intrapartum deaths. In order to raise the profile of this problem there should be sentinel studies in selected areas which will provide samplings so that there can be accurate data on prevalence and etiology. Such studies would require enlistment of the mother early in pregnancy and the use of a well developed verbal autopsy. It was recommended that the verbal autopsy should be further expanded and that these sentinel programs should include placental analysis. If that is not available cord blood should be obtained.
Chaired by Matthew Ellis, University of Bristol. U.K.; and Somsak Suthutvoravut, Ramathi Bodi Hospital, Thailand
This group was asked to discuss the etiology of stillbirths and perinatal asphyxia in developing countries.
The group first considered the high incidence and causes of stillbirths in low and mid-income countries. It was recommended that the recording of stillbirths should include weight and gestation age; this could provide evidence of growth retardation and hence evidence of prolonged foetal illness prior to death.
The group felt that there were two major issues to be considered in the etiology of stillbirths: infection and nutrition. Concerning infection the following studies were suggested: epidemiologic study of the pattern of vaginal carriage; rate of funisitis in stillbirths versus normal deliveries; and study of placental pathology.
The group identified the need to understand the role of micronutrient deficiency on foetal health. Although there are studies of iron and folic acid supplementation which demonstrate a need, critical studies of other micronutrients are also needed. One recent study in Nepal suggested that micronutrient supplementation was not beneficial and indeed may be harmful.
The group then discussed defects in the health system which lead to a high incidence of stillbirths. It was suggested that in each community it should be determined whether the fault lay in recognition of the problem; transportation; and/or reception and care at the referred centre. Accordingly it was felt that a community audit should be performed to analyze these issues.
Additional recommendations from group 2 were:
Further development and validation of verbal autopsies
Further training of birth attendants with special attention to means of comprehensive coverage
Further development and application of partography
Evaluation of foetal movement monitoring
Subsequently the workshop plenary group recommended that a study of mothers monitoring foetal movement should be carried out. This would have to involve about 30,000 women in cluster form of randomization. Previous studies in developed countries have shown conflicting results however it was felt that these studies need not apply to the need for and potential of studies in low and mid income countries.
Intrapartum monitoring of the foetal heart is important and the use of the Doptone was discussed. It was recommended that it should be widely available. There is now a wind- up Doptone which should be made available and tested.
Clearly all the above studies will involve large numbers and long periods of time. For those reasons long-term committed funding is necessary.
Micronutrients were discussed and reference was made to the WHO study of nutrition in pregnancy and to the the following paper, recently published as a supplement to Pediatrics: Bhutta, ZA et al Pediatrics 115 (2 Suppl.): 519-617, 2005.
Chaired by Sujeewa Amarasena, Sri Lanka; and Robert Pattinson, University of Pretoria, South Africa
This group was asked to discuss interventions for preventing stillbirths and perinatal asphyxia in developing countries.
The group pointed out that interventions for preventing stillbirths and perinatal asphyxia in developing countries depend on knowledge of the incidence and etiology of disease in each country. Since this varies, different strategies will be used in different countries, depending on their needs.
It is necessary to determine the incidence of specific infectious diseases such as syphilis, vaginitis, Chlamydia and bacterial vaginitis.
In approaching these problems the following fundamental questions need to be answered.
1. What is the meaning of stillbirths in various societies?
Are they considered to be important and what is the value of the baby? Indeed, is perinatal death considered to be a tragedy? Accordingly, if foetuses and babies are not valued, no intervention will be successful.
This question will have to be explored by qualitative studies (interviews/focus groups) of individuals who have lost babies, of pregnant women, of community members, of health workers at all levels, and of administrators and representatives of government.
2. Why are the effective interventions not being used?
The barriers to participatory research and implementation of health care are many. It may be the health system or the response of the community and of women themselves. This needs to be determined. Clearly, facility-based deliveries are safer than home-based deliveries (even in developed countries). In moderate-income countries the trend is to birth in clinical facilities. What are the barriers to this in low-income countries?
3. Are perinatal and maternal mortality reviews of value and, specifically, are they being used to improve health care?
The group recommended that a randomized control trial be performed to determine the value of perinatal audit on reducing mortality. This should be done in an area where basic mortality data is accurately collected as part of an already established system. The trial will have to be superimposed on such a system. For example, Pakistan has a mapping system that would be suitable
4. What is the quality of antenatal/intrapartum care? This should be validated in each community and should include examination of the quality and content of health care workers’ training in each community
5. What effective intrapartum care modalities reduce stillbirths and asphyxia? How should prolonged labor be evaluated?
a. What is the best way of evaluating prolonged labor in the home? Can TBAs be taught to evaluate descent of the head, cervical dilation (by vaginal or rectal examination)?
What do TBAs do with patients with meconium stained liquor?
c. Monitoring foetal heart rate
Ideally this should be available at a village level. Use of the Doptone is recommended and since there are now wind-up doptones they could be used in villages without electricity. Unfortunately universal availability of doptones is being held up because of patent problems.
d. Caesarean section
Clearly Caesarian section should be available in cases of difficult deliveries. Its use and rate varies greatly and the reasons for this should be explored. Symphysiotomy is a simpler technique than Caesarian section and has a lower morbidity. There is need to consider a trial studying its use in developing countries in order to evaluate perinatal and maternal morbidity and mortality. The technique of performing symphysiotomy is found in not only in older obstetric textbooks but also in more recent reviews.
e. Determination of the causes of neonatal asphyxia.
Since this syndrome can arise from infection there is need to study the possibility of infectious etiology by the use of gastric aspirate for leucocytes as well as placental smear between chorion and amnion looking for leucocytes to distinguish infection from hypoxia. Also studies of the histology of the placenta and of the cord should be used.
In order to “scale up” the system the following questions should be answered:
1. How to get the maximum coverage for a pregnant population for each effective screening and treatment modalities for specific diseases.
This should included consideration of availability of medication, organization of health systems and availability of appropriate technology.
2. How far down the health system can an intervention be devolved safely and effectively? Responsibility and feasibility of training for diagnosis and therapy of perinatal problems.
Other important questions:
1. Foetal movement: There is an urgent need for a randomized controlled trial of foetal movement monitoring by the mother.
2. What caesarean section capacity (facility, human resource, budget) do you need to have, to have a reduction in SB/BA? In a geographical area/ in a country?
3. Is it necessary to screen for diabetes in low-income countries?
4. The value and feasibility of ultra sound evaluation in developing countries
5. Prophylactic antibiotics Should every pregnant woman receive penicillin and erythromycin at 16 weeks to reduce stillbirths?
5. Verbal autopsy: Does a verbal autopsy work and does it reduce the stillbirth rate?