Editorial/Opinion

Reducing perinatal deaths

By Sarah Hannan

In the road to achieving high healthcare standards and providing universal healthcare coverage to its citizens, Sri Lanka has placed the reduction of perinatal deaths within the foremost of tasks of the health agenda. In order to closely monitor the causes and how the services and knowledge of staff could be improved to prevent perinatal deaths, the Ministry of Health, through its Family Health Bureau, assigned its Maternal and Child Morbidity and Mortality Surveillance Unit (MCMMSU) a surveillance mechanism to follow.

According to the recent report, Sri Lanka’s national perinatal mortality rate reduced to reach a rate of 6.8 per 1,000 births in the year 2017. The country’s perinatal mortality rate, when compared with that of many developed countries, is considered to be on par. For example, the same rate stands at 6.6 in the UK for the year 2016.

The initiative was backed by the country office of UNICEF, which collaborated in preparing the index report which included an analysis of perinatal death data reported from the entire country for the years 2014-2017.

While the generic perinatal period spans from the 20th week of gestation to the 28th day after the birth of a child, for the purpose of this survey, the observances took place from 28 weeks of gestation to the seventh day after the birth of the child. Stillbirths and early neonatal deaths occurring in this period are known as perinatal deaths.

The mechanism which commenced in 2006 is considered to be the only perinatal death surveillance and response system in South Asia. Over the years, several indicators were added to improve the monitoring mechanisms, and by 2013, the mechanism was introduced to all target hospitals in the country, achieving 100% coverage. By 2014, individual death reporting was introduced, and in 2015, ICD-Perinatal Mortality classification was included in the mechanism. By 2016, a national database was established with the introduction of pathological postmortems.

All hospitals have by now complied with reporting perinatal deaths on the system where the obstetrician or a paediatrician can provide the relevant data of the deaths. Following that, each perinatal death is discussed and actions to prevent similar deaths are formulated at a monthly perinatal mortality conference conducted at all specialised hospitals.

Identifying the cause

The Sunday Morning contacted MCMMSU National Programme Manager Dr. Kapila Jayaratne to understand the actions taken to prevent perinatal deaths and what causes perinatal deaths in Sri Lanka.

“In order for us to understand and prevent perinatal deaths, we had to look at the descriptions of the cause of death for early neonatal deaths (ENND) and foetal deaths (FD). Therefore, since 2014, we closely monitored the cause of death for FDs and ENNDs,” he explained.

Dr. Jayaratne revealed that with the implementation of the improved surveillance mechanism, in 2014 alone, the cause of death was made available for 87.4% of the ENNDs and only 10.9% of the FDs would record the cause of death. He further stated that perinatal deaths occurred most commonly due to congenital malformations in the years 2014 (31.7%) and 2016 (28.4%), low birth weight/prematurity in 2015 (32.4%), and unspecified causes in 2017 (32.5%).

“For each year, the cause of death specified for FDs were listed as congenital malformations, intrauterine hypoxia and complications, unspecified causes, and disorders related to foetal growth. The leading causes for ENNDs were congenital abnormalities, low birth weight and prematurity, and respiratory and cardiovascular disorders,” Dr. Jayaratne informed.

Increased complexity of reporting

With the increased complexity of the reporting format the surveillance mechanism reflected, a reduction of causes of death were reported under congenital malformations, infections, and low birth weight/prematurity, and a rapid increase in the “unspecified COD” group was observed.

Yet, the data analysed for ENNDs returned results that the commonest congenital malformations were due to heart and great vessel-related anomalies followed by musculoskeletal system and brain and spinal cord-related anomalies. This was followed by predominant anomalies such as congenital heart disease followed by diaphragmatic hernia, lung hypoplasia, anencephaly, renal anomalies/Potter’s disease, and hydrocephalus.

In contrast, congenital anomalies were fewer in FDs, with the commonest being anencephaly and Trisomy 21. The proportion of babies having congenital malformations was slightly higher among younger mothers compared to older ones, but this difference was not statistically significant.

Achieving global benchmarks

It is shown that 33% of stillbirths and 71% of newborn deaths can be averted annually with increased coverage and quality interventions such as antenatal care and skilled birth attendance, detection and management of pregnancy-induced disorders, and intrauterine growth restriction and management of preterm labour. The World Health Organisation (WHO) recommended community-based, cost-effective newborn care interventions in this regard. Consequently, a renewed commitment to dramatically improve the health and survival of newborn babies and end preventable stillbirths in the next two decades was made – Every Newborn Action Plan (ENAP): 2015-2035. It focuses on a target to reduce neonatal mortality to fewer than 10 deaths per 1,000 live births, and stillbirth rates to fewer than 10 per 1,000 total births by 2035. These targets are expected to result in global averages of seven and eight, respectively. ENAP has further laid out an interim post-2015 goal, calling for a reduction of newborn deaths and stillbirths to a level as low as 12 by 2030 (WHO, 2014).

In order to achieve the global targets of ENAP: 2015-2035 (WHO, 2014) for South Asian countries, the goal is set by UNICEF Regional Office for South Asia to reduce neonatal deaths from 28 per 1,000 live births in 2016 to 21 per 1,000 live births by 2021 (UNIGME, 2017).

In order to achieve the same, Sri Lanka aims to reach the following (FHB, 2017; FHB, 2016):

•To reduce neonatal deaths to 3.4 per 1,000 live births by 2025 and further, to less than 2.2 by 2030

•To reduce stillbirths to 3.5 per 1,000 total births by 2025 and to less than two by 2030

This country-specific goal on neonatal mortality was determined based on the average annual rate of reduction (AARR) of 4.35% from 2000 to 2012. Given a lesser rate (2.33%) for the period 2007-2013 based on data reported by the FHB, intense attention would be required if the 2030 goal is to be achieved (FHB, 2015).

Strategic plan in effect

The National Maternal and Newborn Health Strategic Plan 2017-2025 identifies the objective of a programme that tracks and is accountable for every mother, fetus, and newborn by ensuring the surveillance systems provide timely information to provide timely responses.

To achieve that, the following activities are to be carried out:

•Upgrade maternal mortality, infant mortality, perinatal death, and birth defect surveillance systems

•Link the surveillance systems (maternal mortality, perinatal mortality, birth defects surveillance, infant death investigation) with each other and with routine information systems (IMMR, RH-MIS) to ensure uniformity of data and prevent duplication (electronic, web-based, and/or paper-based systems)

•Disseminate information on surveillance data timely for action

Furthermore, this is achieved by enhancing the monitoring and evaluation capacity and usage of data for decision-making and planning at different levels by: developing the capacity of healthcare workers at all levels to monitor and interpret data; establishing expert panels at national and district levels to analyse and review service delivery using available data, conducting/strengthening regular maternal and child health (MCH) reviews, hospital progress reviews, and MOH conferences to monitor service provision using data, disseminating data to all levels for decision-making and planning, and creating intersectoral accountability and linkages to report, share, and use accurate data.