Causes and prevalence of prenatal and neonatal mortality in the District Dera Ismail Khan, Khyber Pakhtunkhwa, Pakistan

INTRODUCTION

One of the global concerns is the health problems which mainly affect human well-being and their activities.^[1] The most critical period in an individual’s life is the perinatal period which has the highest mortality rate.^[2] Over 25% and 75% of mortality of neonates take place before the completion of the first 24 h of birth and the 1^st week of life, respectively, globally.^[3-5] More than two-thirds of all infants as well as about 50% of all children aged <5 years died as neonates.^[3,6] It is estimated that the neonates (27.8 million) will die between 2018 and 2030,^[7,8] if efforts are not successful to reduce neonates’ mortality.

Global 99% of death of neonates occurs in undeveloped and less developed countries,^[9] whereas South Asia and sub-Saharan Africa contributed about 77% of all stillbirths.^[10,11] Ten countries including Pakistan (ranks third) accounted for over 65% of the total neonatal deaths globally and are estimated to contribute 300,000/year newborn deaths globally.^[4,12]

Hypoxic ischemic encephalopathy (HIE) occurs when an infant’s brain does not get enough oxygen before or shortly after birth. Prematurity is birth before 37 weeks of pregnancy. Senile prostatic enlargement (SPE) is the enlargement of the prostate gland at birth. Low birth weight (LBW) and heavier low birth weight (HLBW) are the weight of an infant <2500 g and <1500 g within hours of birth. Respiratory distress syndrome (RDS) is a common breathing disorder in neonates. Birth asphyxia (BA) is characterized by the infant not getting adequate oxygen before, during, or just after birth. Non-nutritive sucking (NNS) is the sucking of a pacifier or fingers. Neonatal jaundice (NNJ) shows yellowing of the skin and whites of the eyes of a newly born infant. Congenital heart defects (CHDs) are malformations of the heart or large blood vessels near the heart. Meconium aspiration syndrome (MAS) is because meconium (the earliest stool/feces of the newborn) get into the lungs. Neonatal tetanus (NNT) is newborn muscle spasms. Dilated cardiomyopathy (DCM) is a disorder of heart muscles. Melnick-Needles syndrome (MNS) is a rare disorder of the gene of the bones and skull abnormalities. Protein-calorie malnutrition (PCM) occurs when both a child’s calorie and protein intake are inadequate. Hemolytic disease of the newborn (HDN) is a blood disorder. Sepsis or neonatal sepsis (NNS) is the body’s extreme response to an infection. Late-onset sepsis (LOS) is a sepsis onset after 72 h of stillbirth. Down syndrome is a chromosomal disorder. Haemophilus influenza type b (Hib) is a bacterial infection. Myelomeningocele (MMC) is a congenital birth defect of the spine and spinal cord. Lower respiratory tract (LRT) disease is a disorder of mainly the lungs. Protein C Deficiency Next-Generation Sequencing (PCNGS) varies is a congenital deficiency of protein C caused by alterations in the PROC gene. Postpartum hemorrhage (PPH) is a woman’s heavy bleeding after delivery.

As the author know the present research is the first study in Khyber Pakhtunkhwa to determine different causes of perinatal mortality as well as the first study to know relative prevalence of perinatal mortality in Pakistan.

MATERIALS AND METHODS

RESULTS

Prevalence and comparison of prenatal and neonatal mortality during 2013–2021

Overall 11,554 cases including prenatal mortality (34.2%) and neonatal mortality (65.8%) were recorded during 2013–2021 [Table 2], and the highest overall mortality 15.4% occurred in 2019, followed by 2021 (14.4%) and 2018 (14.1%), and the lowest mortality occurred in 2013 (6.8%) during the study period.

The neonatal mortality is higher than prenatal mortality during 2013–2021 except in 2014 [Table 2 and Figure 1] in the study area, whereas relative percentage mortality demonstrated neonatal mortality was highest (85.8%) in 2013, followed by 84.1% (2020) and the lowest 19% (2014) [Figure 1]. The highest relative prenatal mortality was 81% (2014) and was lowest 14.2% in 2013 [Figure 1]. The higher rate of neonatal mortality relative to prenatal mortality [Figure 1] indicated the comparatively higher risk of mortality in the neonates than stillbirth in the study area.

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Figure 1:

Relative percentage of prenatal (stillbirth) and neonatal mortality in Dera Ismail Khan.

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DISCUSSION

Perinatal mortality is the sum of prenatal death which is the in utero death of a fetus during pregnancy at 20 or more weeks of gestation,^[15] and early neonatal death, i.e., death of a live newborn in the first 7 days of life.^[16] While infant deaths are classified into neonatal death (during 0–28 days of age) and post-neonatal death (during 29–364 days of age). A global target under the sustainable development goal of 2030^[7,8] is the decrease in the death of neonates (12 out of 1000 live births) by 2030^[17] as well as to reduce stillbirths and early neonatal deaths to end preventable child deaths by 2030.^[18]

The previous literature showed most of the work carried out is on the risk factors of stillbirth/neonatal mortality or risk factors of their causes, and few studies were conducted to determine the causes of both prenatal and neonatal mortality in Pakistan. Moreover, previous studies on the seasonal, monthly/yearly-based, or relative prevalence of mortality (stillbirth and neonates) have not been found globally.

HIE showed the highest mortality [Table 1] in the present study (39.8%), followed by premature (15.4%), SPE (10%), LBW/HLBW (9.3%), BA 27 (5.3%), NNJ (4.5%), RDS (4.3%), NNS (3.5%), CHD (2.4%), MAS (1.8%), and NNT (0.6%), whereas LOS, Down syndrome, Hib, MMC, LRT, and PCNGS are reported each with 1 case (0.2%) and 2 unknown cases (0.4%). The highest mortality (22.4%) occurred in August, whereas the lowest was in October (13.4%).

The three main causes of neonatal mortality are HIE, prematurity, and infections.^[3] Jehan et al.^[19] found death by premature birth (34%) and intrapartum asphyxia (21%), immaturity related (26%), BA or hypoxia (26%), and infection (23%) in urban areas in Pakistan. Manzar et al.^[20] reported specific infections accounted for neonates mortality (47.9%), followed by prematurity (31.9%) and BA (15.9%) in Karachi (Pakistan). Quddus. et al ^[21] reported 36 neonatal deaths, out of 1547 live births due to tetanus in Loralai (Pakistan).

Abdulrasol et al.^[22] reported neonatal mortality rate was 42.9 and 38 (per 1000 live birth) in 2020 and in 2021, respectively, in Babylon hospitals (Iraq) and found RDS accounted for 48% in 2020 and 55.2% in 2021 neonatal mortality, followed by LBW preterm resulted in neonates mortality (25.8% in 2020 and 10.3% in 2021). Chowdhury et al.^[23] reported prematurity/LBW mortality (30%), followed by difficult labor (16%), unhygienic birth practices (16%), others (4%), and unknown (34%) in neonates, and recorded direct causes were sepsis (32%), BA (26%), tetanus (15%), respiratory distress (6%), others (6%), and unknown (14%) in Bangladesh.

Ersdal et al.^[24] reported 49 neonatal deaths within the first 24 h of birth out of 256 infants in Northern Tanzania and found mortality by BA (61%), followed by prematurity (18%), LBW (8%), infection (2%), congenital abnormalities (8%), and unclear reason (2%). Mangu et al.^[25] reported the death of neonates contributed 11.3% including 87.5% of mortalities occurred in the 1^st week of life in Tanzania and recorded BA contributed 22.3%, followed by RDS (20.8%) to early neonatal death, whereas sepsis accounted for 29.1%, followed by RDS (20.0%) of late neonatal death in Tanzania. Iyoke et al.^[26] found 636 (16.9%) were preterm births out of 3,760 live birth in southeast Nigeria, including spontaneous preterm births approximately 57% of preterm births, and provider-initiated births (43%), and further found the adjusted perinatal mortality rate for preterm babies in the study center was 46.1% (236/512), the stillbirth rate was 22% (149/678), and the early neonatal death rate was 24% (87/363). John et al.^[27] found 114 cases (54.8%) of neonatal deaths occurred within the first 24 h and 94 neonates (45.2%) died after 24 h of admission and found BA resulted in 46.6% of neonatal deaths, followed by prematurity (23.1%) and sepsis (17.8%) in Owo (Nigeria).

Al-Sheyab et al.^[8] reported respiratory and cardiovascular disorders resulted in 43% in death, followed by LBW and pre-term accounted for 33% of death in pre-discharge neonates, while LBW and pre-term led to 42% of the post-discharge neonatal mortality in Jordan. Erchick et al.^[28] concluded that sepsis caused 47% of neonatal deaths, followed by BA (16.6%), preterm birth (13.3%), and LBW (5.0%) and also found 27.2% of neonatal deaths occurred during 24 h of birth and 64.8% between days 1 and 6 of the newborn in Nepal. Ramos et al.^[29] found prematurity contributed 43%, followed by infections (22%) including one case of congenital syphilis, BA (14%), and chromosome abnormality (7%: 1 case) of perinatal death, and respiratory disorder contributed (45%), whereas gastrointestinal infections (28%) of infant deaths in Natal (Brazil). Camara et al.^[30] recorded that overall, neonatal mortality rate and perinatal mortality rate were 19.3/1,000 live births and 26.1/1,000 total births, respectively, and reported severe clinical infections and BA accounted for 37% and 31% of neonatal deaths, respectively, in urban Gambia.

The current study showed a higher prevalence of neonatal mortality than prenatal mortality. Figure 1 indicates the reason may be the low level of neonatal care atleast in the said hospital in the D. I. Khan.

CONCLUSION

HIE showed the largest share of 39.8% of prenatal (stillbirths) and neonatal mortality in the nursery ward, followed by premature (15.4%), SPE (10%), LBW/HLBW (9.3%), BA (5.3%), NNJ (4.5%), RDS (4.3%), MNS (3.5%), CHD (2.4%), and MAS (1.4%) during the study period. The remaining causes resulted in each in ≤0.6% mortality. August showed the highest mortality (22.4%), and October had the lowest (13.4%).

Isolation ward showed (48.5%) cases of prenatal and neonatal mortality, followed by labor room (42.4%) cases. Overall neonatal mortality accounted for 65.8%, while prenatal mortality was 34.2%. The highest mortality of 15.4% occurred in 2019 and the lowest in 2013 (6.8%). Relative year-wise percentage of both prenatal and neonatal mortality showed comparability during 2015-2019 and 2021. Neonatal mortality has an annual higher rate than prenatal mortality during 2013-2021 except in 2014.

Recommendations

The prevalence of a high rate of HIE followed by preterm births associated with perinatal mortality may reflect a lack of antenatal and postnatal care, and an improper delivery system in the study area, and needs to improve antenatal care services for pregnant women and newborns to provide high-quality services and health care in special care units and enhance common access to the quality of health services in Khyber Pakhtunkhwa to reduce perinatal/infant mortality as well as women mortality during delivery and after birth.