Vol. 21, No. 1 Printed in Great Britain
International Journal of Epidemiology © International Epidemiotogical Association 1992
Perinatal Mortality in Jeddah, Saudia Arabia WALEED A MILAAT* AND CHARLES DU V FLOREYf
Little is known about the risk factors and causes of death in the perinatal period in many areas of the Arab World. The World Health Organization estimated the infant mortality rate for Saudi Arabia in 1987 to be 72 per 1000,' which lies in the midrange of Arab world rates. The perinatal mortality rate (PMR) is not routinely recorded in Saudi Arabia, although death certificates are collected and retained. Causes of perinatal mortality and their associated risk factors are not available either as routinely published data or from specialized studies. The present study was conducted in Jeddah, the second city of Saudi Arabia. We estimated the PMR from deaths recorded in the city for three separate years to determine the level and to assess the trend over time. We also obtained baseline data on births and deaths in the city's major hospital and have identified the risk factors related to a consecutive series of perinatal deaths in this hospital.2
MATERIAL AND METHODS The Perinatal Mortality Rate Estimation Perinatal deaths defined as stillbirths (deaths from the 28th week of pregnancy) and deaths within the first week of life, and the total number of livebirths for the Islamic calendar years of 1393, 1400 and 1408 (4 February 1973 to 24 January 1974, 21 November 1979 to 8 November 1980 and 26 August 1987 to 13 August 1988) were abstracted from the logbooks of vital events registered in the three governmental statistical health offices in Jeddah. The PMR for the city was calculated for these years. No certificates were available to confirm the logbook entries, nor was it possible to ascertain whether there had been any change in registration methods over the 16-year period. No data were available to distinguish infants of residents of Jeddah from those who lived elsewhere. However, since birth registration is essentially obligatory whereas death registration is not, the mortality rates are likely to be underestimated.
•Department of Community Medicine and Primary Health Care, The Medical School, King Abdulaziz University, Jeddah, Saudi Arabia. tDepartment of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK. Reprint requests to: Dr Waleed Milaat PO Box 984 Jeddah, 21421 Saudi Arabia.
The Case-Control Study The Maternal and Child Hospital (MCH) is the main hospital in Jeddah. It serves more than 60% of this sector of the City's population and about 14000 infants are delivered there each year. Maternity services for the remainder are provided by two military 82
Downloaded from http://ije.oxfordjournals.org/ at University of Ulster on January 4, 2015
Milaat W A (Department of Community Medicine and Primary Health Care, The Medical School, King Abdulaziz University, Jeddah, Saudi Arabia) and Florey C du V. Perinatal mortality in Jeddah, Saudi Arabia. International Journal of Epidemiology 1992; 21: 82-90. The objective of the study was to estimate the perinatal mortality rate and to determine the antenatal and intrapartum risk factors associated with perinatal mortality in Jeddah, Saudi Arabia. A hospital-based, case-control study was carried out in a 40-week period in 1987-1988 in Jeddah at the Maternal and Child Health Hospital (MCH). The subjects comprised 323 perinatal deaths and 486 controls. The perinatal mortality rate (PMR) for Jeddah showed a decline from 42.5 in Islamic Calendar Year 1393H (1973) and 49.5 in 1400H (1979-1980) to 31.4 per 1000 live and stillbirths in 1408H (1987-1988). The risk factors independently associated with perinatal death included low birth weight, complications during labour, ethnic origin and mother's age being 35 and over. In addition to lethal deformities, direct causes of perinatal death were related to low birthweight, mechanical causes, antepartum haemorrhage and neonatal infection. No antenatal care was received by 36.5% of both cases and controls. The high mortality and the failure to attend for antenatal care suggest a need for closer surveillance of women throughout their pregnancies and for improvements in both obstetric services and neonatal management.
83
PERINATAL MORTALITY IN JEDDAH, SAUDI ARABIA
Data Analysis The Statistical Package for the Social Sciences (SPSS-X)3 was used for simple descriptive analyses comparing cases with controls. GLIM4 was used for multiple logistic regression analysis to determine the association of cases with several independent variables. All significant (P^0.05) variables in the univariate analyses were included in a regression model in which perinatal mortality was a binary dependent variable. By backward elimination, all nonsignificant independent variables were excluded from the model. RESULTS Perinatal Mortality Rate Estimate The total numbers of births and perinatal deaths increased over the three years 1393H, 1400H and 14O8H, whereas the PMR was markedly lower in 1408H, the most recent year studied (Table 1). These rates were considered indicative rather than exact because of the nature of the data from which they were calculated (see Material and Methods).
TABLE 1 Perinatal mortality rate" in Jeddah for the Islamic calendar years 1393 (1973), 1400 (1979-1980), and 1408 (1987-1988) Year
Total births
Perinatal deaths
Perinatal mortality rate per 1000 births
1393 1400 1408
14 214 20411 39 219
604 1010 1232
42.5 49.5 31.4
f o r all births and deaths occurring in Jeddah.
The Case-Control Sample The sample consisted of the 323 perinatal deaths (132 stillbirths and 191 early neonatal deaths, of which 46 were delivered by caesarean section) and 486 control deliveries. The larger number of controls than cases was intended to increase the power to detect associations between risk factors and perinatal mortality but practical difficulties made it impossible to collect the intended two controls per case. Perinatal deaths over the study period accounted for 75.5% of total perinatal deaths in MCH over the year, with an average of 8.1 deaths per week. Cases and controls were compared on various possible risk factors grouped according to whether they were general maternal characteristics, to do with the pregnancy itself or to do with the child (Table 2). Mothers' age, parity and babies' birthweights are given in subsequent Tables. Because of the possibility of bias affecting the comparison of cases and controls due to the exclusion from the controls of mothers who had caesarean sections, we compared the distributions of the antenatal variables of the cases delivered vaginally with those delivered by caesarean section. We were unable to demonstrate any differences of either biological or statistical significance between the two groups, except that those who had had caesarean sections were more likely to have had previous sections (P8 visits (ft) Pregnancy complications Hypertension (>85 mmHg diastolic) (%) Bleeding (ft) Labour complications with complications (ft) Induction induced (ft)
320 14.7 36.9 48.4 205 24.9 203 10.8 8.9 0.5 2.0 222 36.5 47.3 16.2 205 14.6 229 22.3 316 66.2 316 29.4
480 9.9 42.0 48.7 438 10.7 438 11.4 2.7 0.9 0.7 482 36.5 42.1 21.4 306 8.5 484 3.3 486 22.8 486 19.8
322 53.4 261 32.6 (5.6)
486 49.2 152 38.3 (2.8)
0.08 NS
0 . 0 1 **0.01>P>0.001 "V-cO.001 NS Not significant * Due to missing data, numbers available for each variable were often less than the maximum.
0.27 NS >100. •
12.7 to 42.1 1.88 to > > 1 0 0 48.8(1)
1.665
0.2460
5.3"*
3.26 to 8.56 8.8 (2)
0.908 1.785
0.5296 0.6437
2.5 6.0**
0.88 to 7.00 1.69 to 21.0
-0.036 -0.501 -0.525 -0.066 -0.943 0.456 0.309 0.787 -0.306 -0.578
0.4431 0.4988 0.4785 0.5086 0.5357 0.5515 0.6295 0.6313 0.7969 0.7463
1.0 0.6 0.6 0.9 0.4 1.6 1.4 2.2 0.7 0.6
0.40 0.23 0.23 0.35 0.14 0.54 0.40 0.64 0.15 0.13
13.9(10) to to to to to to to to to to
2.30 1.61 1.51 2.54 1.11 4.65 4.68 7.57 3.51 2.42
*The x J values test the significance of the whole composite variable when it is entered last into the model. AD composite variables were significant predictors of mortality except parity, after allowing for the other variables in the model. •0.05>P>0.01 •*0.01>/»>0.001 •••P
International Journal of Epidemiology © International Epidemiotogical Association 1992
Perinatal Mortality in Jeddah, Saudia Arabia WALEED A MILAAT* AND CHARLES DU V FLOREYf
Little is known about the risk factors and causes of death in the perinatal period in many areas of the Arab World. The World Health Organization estimated the infant mortality rate for Saudi Arabia in 1987 to be 72 per 1000,' which lies in the midrange of Arab world rates. The perinatal mortality rate (PMR) is not routinely recorded in Saudi Arabia, although death certificates are collected and retained. Causes of perinatal mortality and their associated risk factors are not available either as routinely published data or from specialized studies. The present study was conducted in Jeddah, the second city of Saudi Arabia. We estimated the PMR from deaths recorded in the city for three separate years to determine the level and to assess the trend over time. We also obtained baseline data on births and deaths in the city's major hospital and have identified the risk factors related to a consecutive series of perinatal deaths in this hospital.2
MATERIAL AND METHODS The Perinatal Mortality Rate Estimation Perinatal deaths defined as stillbirths (deaths from the 28th week of pregnancy) and deaths within the first week of life, and the total number of livebirths for the Islamic calendar years of 1393, 1400 and 1408 (4 February 1973 to 24 January 1974, 21 November 1979 to 8 November 1980 and 26 August 1987 to 13 August 1988) were abstracted from the logbooks of vital events registered in the three governmental statistical health offices in Jeddah. The PMR for the city was calculated for these years. No certificates were available to confirm the logbook entries, nor was it possible to ascertain whether there had been any change in registration methods over the 16-year period. No data were available to distinguish infants of residents of Jeddah from those who lived elsewhere. However, since birth registration is essentially obligatory whereas death registration is not, the mortality rates are likely to be underestimated.
•Department of Community Medicine and Primary Health Care, The Medical School, King Abdulaziz University, Jeddah, Saudi Arabia. tDepartment of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK. Reprint requests to: Dr Waleed Milaat PO Box 984 Jeddah, 21421 Saudi Arabia.
The Case-Control Study The Maternal and Child Hospital (MCH) is the main hospital in Jeddah. It serves more than 60% of this sector of the City's population and about 14000 infants are delivered there each year. Maternity services for the remainder are provided by two military 82
Downloaded from http://ije.oxfordjournals.org/ at University of Ulster on January 4, 2015
Milaat W A (Department of Community Medicine and Primary Health Care, The Medical School, King Abdulaziz University, Jeddah, Saudi Arabia) and Florey C du V. Perinatal mortality in Jeddah, Saudi Arabia. International Journal of Epidemiology 1992; 21: 82-90. The objective of the study was to estimate the perinatal mortality rate and to determine the antenatal and intrapartum risk factors associated with perinatal mortality in Jeddah, Saudi Arabia. A hospital-based, case-control study was carried out in a 40-week period in 1987-1988 in Jeddah at the Maternal and Child Health Hospital (MCH). The subjects comprised 323 perinatal deaths and 486 controls. The perinatal mortality rate (PMR) for Jeddah showed a decline from 42.5 in Islamic Calendar Year 1393H (1973) and 49.5 in 1400H (1979-1980) to 31.4 per 1000 live and stillbirths in 1408H (1987-1988). The risk factors independently associated with perinatal death included low birth weight, complications during labour, ethnic origin and mother's age being 35 and over. In addition to lethal deformities, direct causes of perinatal death were related to low birthweight, mechanical causes, antepartum haemorrhage and neonatal infection. No antenatal care was received by 36.5% of both cases and controls. The high mortality and the failure to attend for antenatal care suggest a need for closer surveillance of women throughout their pregnancies and for improvements in both obstetric services and neonatal management.
83
PERINATAL MORTALITY IN JEDDAH, SAUDI ARABIA
Data Analysis The Statistical Package for the Social Sciences (SPSS-X)3 was used for simple descriptive analyses comparing cases with controls. GLIM4 was used for multiple logistic regression analysis to determine the association of cases with several independent variables. All significant (P^0.05) variables in the univariate analyses were included in a regression model in which perinatal mortality was a binary dependent variable. By backward elimination, all nonsignificant independent variables were excluded from the model. RESULTS Perinatal Mortality Rate Estimate The total numbers of births and perinatal deaths increased over the three years 1393H, 1400H and 14O8H, whereas the PMR was markedly lower in 1408H, the most recent year studied (Table 1). These rates were considered indicative rather than exact because of the nature of the data from which they were calculated (see Material and Methods).
TABLE 1 Perinatal mortality rate" in Jeddah for the Islamic calendar years 1393 (1973), 1400 (1979-1980), and 1408 (1987-1988) Year
Total births
Perinatal deaths
Perinatal mortality rate per 1000 births
1393 1400 1408
14 214 20411 39 219
604 1010 1232
42.5 49.5 31.4
f o r all births and deaths occurring in Jeddah.
The Case-Control Sample The sample consisted of the 323 perinatal deaths (132 stillbirths and 191 early neonatal deaths, of which 46 were delivered by caesarean section) and 486 control deliveries. The larger number of controls than cases was intended to increase the power to detect associations between risk factors and perinatal mortality but practical difficulties made it impossible to collect the intended two controls per case. Perinatal deaths over the study period accounted for 75.5% of total perinatal deaths in MCH over the year, with an average of 8.1 deaths per week. Cases and controls were compared on various possible risk factors grouped according to whether they were general maternal characteristics, to do with the pregnancy itself or to do with the child (Table 2). Mothers' age, parity and babies' birthweights are given in subsequent Tables. Because of the possibility of bias affecting the comparison of cases and controls due to the exclusion from the controls of mothers who had caesarean sections, we compared the distributions of the antenatal variables of the cases delivered vaginally with those delivered by caesarean section. We were unable to demonstrate any differences of either biological or statistical significance between the two groups, except that those who had had caesarean sections were more likely to have had previous sections (P8 visits (ft) Pregnancy complications Hypertension (>85 mmHg diastolic) (%) Bleeding (ft) Labour complications with complications (ft) Induction induced (ft)
320 14.7 36.9 48.4 205 24.9 203 10.8 8.9 0.5 2.0 222 36.5 47.3 16.2 205 14.6 229 22.3 316 66.2 316 29.4
480 9.9 42.0 48.7 438 10.7 438 11.4 2.7 0.9 0.7 482 36.5 42.1 21.4 306 8.5 484 3.3 486 22.8 486 19.8
322 53.4 261 32.6 (5.6)
486 49.2 152 38.3 (2.8)
0.08 NS
0 . 0 1 **0.01>P>0.001 "V-cO.001 NS Not significant * Due to missing data, numbers available for each variable were often less than the maximum.
0.27 NS >100. •
12.7 to 42.1 1.88 to > > 1 0 0 48.8(1)
1.665
0.2460
5.3"*
3.26 to 8.56 8.8 (2)
0.908 1.785
0.5296 0.6437
2.5 6.0**
0.88 to 7.00 1.69 to 21.0
-0.036 -0.501 -0.525 -0.066 -0.943 0.456 0.309 0.787 -0.306 -0.578
0.4431 0.4988 0.4785 0.5086 0.5357 0.5515 0.6295 0.6313 0.7969 0.7463
1.0 0.6 0.6 0.9 0.4 1.6 1.4 2.2 0.7 0.6
0.40 0.23 0.23 0.35 0.14 0.54 0.40 0.64 0.15 0.13
13.9(10) to to to to to to to to to to
2.30 1.61 1.51 2.54 1.11 4.65 4.68 7.57 3.51 2.42
*The x J values test the significance of the whole composite variable when it is entered last into the model. AD composite variables were significant predictors of mortality except parity, after allowing for the other variables in the model. •0.05>P>0.01 •*0.01>/»>0.001 •••P
