KARACHI: Pakistan has been found to have significantly higher rates of maternal mortality, stillbirth, seven-day and 28-day neonatal mortality as compared to Kenya, Zambia, Guatemala, India and Argentina in a recent study.

Titled A prospective study of maternal, foetal and neonatal deaths in low and middle income countries the three-year study was aimed at quantifying maternal, foetal and neonatal mortalities, identifying the period and conditions when deaths occur and ascertaining relationships between maternal deaths and stillbirths and neonatal deaths.

The department of community health sciences of the Aga Khan University (AKU) from Pakistan collaborated in the study along with other partner institutions.

The study was done in 106 communities in six sites in five low-income countries (Chimaltenango, Guatemala; Nagpur district and Karnataka district, India; Western Province, Kenya; Thatta district, Pakistan; and Lusaka, Zambia) and at one site in a middle-income country (Corrientes, Argentina). Each site included between six and 24 distinct communities from where over 200,000 pregnant women were enrolled and followed until six weeks post-natal.

According to the research findings, most maternal, foetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes.

In total, 336 maternal deaths occurred among the 214,070 women, which corresponded to an overall maternal mortality ratio of 168 per 100,000 live births.

The maternal mortality ratio was 168 per 100,000 live births, ranging from 69 per 100,000 in Argentina to 316 per 100,000 in Pakistan.

Around 21 per cent of pregnant women died before delivery, whereas 29pc died during or immediately following delivery and an additional nine per cent died on the day after delivery. Thereafter, the number of maternal deaths decreased slowly throughout the following six weeks.

“Maternal deaths were due to haemorrhage in 26pc women; pre-eclampsia or eclampsia in 16pc; sepsis in 12pc; suicide or accident in 6.8pc; anaemia in 6.5pc; infection with, for example, malaria or HIV in 6.3pc; heart disease in 4.8pc; obstructed labour in 3.6pc; other medical causes such as gestational diabetes or cancer in 1.5pc; and an unknown cause in 17pc,” the study says.

Maternal death, the study points out, increased the risk of perinatal and neonatal death. Overall, if the mother died during pregnancy or within the six weeks after delivery, about half of their foetuses or neonates also died.

The two extremes in the study were Argentina and Pakistan, where Pakistan had generally four-fold to five-fold higher mortality than Argentina.

Stillbirths, death of neonates

Overall there were 6,213 stillbirths, which corresponded to a rate of 29.7 per 1,000 births; the figure ranged from 14.1 per 1,000 births in Argentina to 56.1 per 1,000 in Pakistan.

There were 4,208 seven-day neonatal deaths, which corresponded to a rate of 20.9 per 1,000 live births; the figure ranged from 8.2 per 1,000 live births in Argentina to 40.6 per 1,000 in Pakistan.

Altogether, there were more than 10,000 perinatal deaths (ie stillbirths and neonatal deaths up to seven days after delivery) and the overall perinatal mortality rate was 50.1 per 1,000 births; the figure ranged from 22.3 per 1,000 births in Argentina to 95.3 per 1000 in Pakistan.

In total, 34pc of neonatal deaths occurred on the day of delivery, 14pc occurred on the following day and an additional 28pc occurred during the remainder of the first week of life.

It was assumed that foetal death occurred before labour in 30pc of stillbirths that were macerated (a macerated stillbirth was defined as one with skin not intact or macerated, implying a death over 12 hours before delivery). The remaining 70pc probably occurred close to delivery or while the woman was in labour.

“Stillbirth is a major problem in Pakistan. We have more cases of fresh stillbirth (a stillbirth that occurs during labour or after delivery) that mainly happens because of poor quality care or lack of timely medical intervention,” said Dr Sarah Saleem, an associate professor at the AKU department of community health sciences and the lead researcher from Pakistan.

Suggesting how the country could improve the depressing situation, she said: “Although there is a need to make the whole healthcare delivery system efficient, programmes that focus on improving emergency obstetric and neonatal care close to the time of birth appear to have the greatest chance of reducing all three types of pregnancy-related mortality — maternal, foetal and neonatal.”

Published in Dawn, November 6th, 2014