Incidence and determinants of perinatal mortality in five urban hospitals in Dar es Salaam, Tanzania: a cohort study with an embedded case–control analysis

Brenda Sequeira Dmello*, Thomas Wiswa John, Natasha Housseine, Dan Wolf Meyrowitsch, Jos van Roosmalen, Thomas van den Akker, Monica Lauridsen Kujabi, Charles Festo, Daniel Nkungu, Zainab Muniro, Idrissa Kabanda, Rukia Msumi, Luzango Maembe, Mtingele Sangalala, Ester Hyera, Joyce Lema, Scolastica Bayongo, Johnson Mshiu, Hussein Lesio Kidanto, Nanna Maaløe

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review

Abstract

Introduction: Tanzania has one of the highest burdens of perinatal mortality, with a higher risk among urban versus rural women. To understand the characteristics of perinatal mortality in urban health facilities, study objectives were: I. To assess the incidence of perinatal deaths in public health facilities in Dar es Salaam and classify these into a) pre-facility stillbirths (absence of fetal heart tones on admission to the study health facilities) and b) intra-facility perinatal deaths before discharge; and II. To identify determinants of perinatal deaths by comparing each of the two groups of perinatal deaths with healthy newborns. Methods: This was a retrospective cohort study among women who gave birth in five urban, public health facilities in Dar es Salaam. I. Incidence of perinatal death in the year 2020 was calculated based on routinely collected health facility records and the Perinatal Problem Identification Database. II. An embedded case–control study was conducted within a sub-population of singletons with birthweight ≥ 2000 g (excluding newborns with congenital malformations); pre-facility stillbirths and intra-facility perinatal deaths were compared with ‘healthy newborns’ (Apgar score ≥ 8 at one and ≥ 9 at five minutes and discharged home alive). Descriptive and logistic regression analyses were performed to explore the determinants of deaths. Results: A total of 37,787 births were recorded in 2020. The pre-discharge perinatal death rate was 38.3 per 1,000 total births: a stillbirth rate of 27.7 per 1,000 total births and an intra-facility neonatal death rate of 10.9 per 1,000 live births. Pre-facility stillbirths accounted for 88.4% of the stillbirths. The case-control study included 2,224 women (452 pre-facility stillbirths; 287 intra-facility perinatal deaths and 1,485 controls), 99% of whom attended antenatal clinic (75% with more than three visits). Pre-facility stillbirths were associated with low birth weight (cOR 4.40; (95% CI: 3.13-6.18) and with maternal hypertension (cOR 4.72; 95% CI: 3.30-6.76). Intra-facility perinatal deaths were associated with breech presentation (aOR 40.3; 95% CI: 8.75-185.61), complications in the second stage (aOR 20.04; 95% CI: 12.02-33.41), low birth weight (aOR 5.57; 95% CI: 2.62-11.84), cervical dilation crossing the partograph’s action line (aOR 4.16; 95% CI:2.29-7.56), and hypertension during intrapartum care (aOR 2.9; 95% CI 1.03-8.14), among other factors. Conclusion: The perinatal death rate in the five urban hospitals was linked to gaps in the quality of antenatal and intrapartum care, in the study health facilities and in lower-level referral clinics. Urgent action is required to implement context-specific interventions and conduct implementation research to strengthen the urban referral system across the entire continuum of care from pregnancy onset to postpartum. The role of hypertensive disorders in pregnancy as a crucial determinant of perinatal deaths emphasizes the complexities of maternal-perinatal health within urban settings.

Original languageEnglish
Article number62
Pages (from-to)1-15
Number of pages15
JournalBMC Pregnancy and Childbirth
Volume24
DOIs
Publication statusPublished - 13 Jan 2024

Bibliographical note

Funding Information:
This article forms part of the PhD thesis for BSD, and contributes to the situational analysis of the PartoMa project, which is funded by the Danida Fellowship center, Ministry of Foreign Affairs, Denmark (Danida project 18–08-KU).BSD is employed at CCBRT as Technical Advisor of the maternal and newborn healthcare program through the generous support from Global Affairs Canada that supported the Maternal and newborn healthcare program and the perinatal death audits in Dar es Salaam before and during the COVID-19 pandemic (2014–2021).

Funding Information:
The authors would like to recognize the leadership, collaboration and tremendous support of DSM Regional and Municipal health offices, the health facility management teams of the five study HF’s and the management of CCBRT. The authors sincerely appreciate the efforts of the Dar es Salaam perinatal case-control study team for their significant time, effort, and commitment in supporting the perinatal deaths case-file retrieval, case-file audits, and data entry. The participating health facilities and list of members of the perinatal case control study team are here listed: Regional Referral Hospital: Daniel Nkungu, Luzango Maembe, Ester Hyera, Hilda Haule, Aurelia Temba, Lumuliko Nyika and Julius Nyambarino, Zainabu Muniro, Subira Maulid, Nuswe Ambokile, Mayasa S. Issah, Mtingele Sangalala, Scolastica Bayongo. Municipal Maternity Hospitals: Rukia Msumi, Judith Mrosso, Meri Kebwe, John Shayo, Idrissa Kabanda, Joyce Lema, Mashaka John. We thank Imani Iremi for development of the perinatal case control database and the data entry form, as well as supporting data quality and cleaning. We are also grateful to Sidney Mboya, who manages the perinatal problem identification database (2014- 2020) and provided the annual birth and perinatal outcome data. We appreciate the extensive work done by Anna Macha in completing data entry and data cleaning. We thank Andreas Kryger Jensen, PhD, Associate Professor, University of Copenhagen, Section of Biostatistics, for reviewing the paper. Patients and public were not involved.

Publisher Copyright:
© 2024, The Author(s).

Funding

This article forms part of the PhD thesis for BSD, and contributes to the situational analysis of the PartoMa project, which is funded by the Danida Fellowship center, Ministry of Foreign Affairs, Denmark (Danida project 18–08-KU).BSD is employed at CCBRT as Technical Advisor of the maternal and newborn healthcare program through the generous support from Global Affairs Canada that supported the Maternal and newborn healthcare program and the perinatal death audits in Dar es Salaam before and during the COVID-19 pandemic (2014–2021). The authors would like to recognize the leadership, collaboration and tremendous support of DSM Regional and Municipal health offices, the health facility management teams of the five study HF’s and the management of CCBRT. The authors sincerely appreciate the efforts of the Dar es Salaam perinatal case-control study team for their significant time, effort, and commitment in supporting the perinatal deaths case-file retrieval, case-file audits, and data entry. The participating health facilities and list of members of the perinatal case control study team are here listed: Regional Referral Hospital: Daniel Nkungu, Luzango Maembe, Ester Hyera, Hilda Haule, Aurelia Temba, Lumuliko Nyika and Julius Nyambarino, Zainabu Muniro, Subira Maulid, Nuswe Ambokile, Mayasa S. Issah, Mtingele Sangalala, Scolastica Bayongo. Municipal Maternity Hospitals: Rukia Msumi, Judith Mrosso, Meri Kebwe, John Shayo, Idrissa Kabanda, Joyce Lema, Mashaka John. We thank Imani Iremi for development of the perinatal case control database and the data entry form, as well as supporting data quality and cleaning. We are also grateful to Sidney Mboya, who manages the perinatal problem identification database (2014- 2020) and provided the annual birth and perinatal outcome data. We appreciate the extensive work done by Anna Macha in completing data entry and data cleaning. We thank Andreas Kryger Jensen, PhD, Associate Professor, University of Copenhagen, Section of Biostatistics, for reviewing the paper. Patients and public were not involved.

FundersFunder number
DSM Regional and Municipal health offices
Dar es Salaam perinatal case-control study team
Municipal Maternity Hospitals
Sidney Mboya
Udenrigsministeriet18–08-KU
Udenrigsministeriet

    Keywords

    • CCBRT
    • Dar es Salaam
    • Hypertensive disorders in pregnancy
    • Neonatal deaths
    • PartoMa
    • Perinatal deaths
    • Quality of care
    • Stillbirths
    • Tanzania
    • Urban health

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