PERINATAL HEALTH INDICATORS
Fetal and neonatal health may be considered as a reliable indicator of health standards in a community and usually measured in terms of following indicators:
Stillbirth rate (SBR) refers to total number of stillbirths gt;28 weeks or 1000gm/total live births 1000.
It is primarily an indicator of the quality of antenatal and obstetrical care in the community. Current SBR in India is estimated as ~ 3/1000 as per sample registration survey (SRS 2022), though seems to be much higher due to frequent non-reporting of stillbirths in rural areas. Congenital malformations and fetal distress are predominant causes of stillbirths.Perinatal mortality rate (PNMR) is defined as total number of late fetal deaths(LFD) gt;28 week + early neonatal death (END) till 7th day, expressed as a rate per 1000 live births per year.
However as precise assessment of gestation is difficult, a more practical definition has replaced gestation with corresponding birth weight, i.e. 1000 gm, for international comparisons, as follows:
LFDs + ENDs gt;1000 gm x1000
PMR =-----------------------------------------
Total live births gt;1000 gm
TABLE 12.1: Causes of perinatal mortality
• Antenatal:
- Maternal malnutrition
- Maternal infections and illnesses
- Local pelvic
- Uterine diseases
- Obstetric complications, e.g. eclampsia, APH
- Fetal malformations
• Intranatal:
- Complicated
- Obstructed labor
- Birth asphyxia/injury
• Postnatal:
- Prematurity
- Low birth weight
- Neonatal infections
- Congenital malformations
• Others
APH: Antepartum hemorrhage
All still/live births lt; 28 weeks, 1000 gm or 35 cm length are excluded from numerator as well as denominator, due to unlikelihood of their survival.
Current status: Current PMR in India is 18/1000 live births (SRS 2022), being higher in rural areas than in urban areas.
Despite declining trend in recent years, current PMR is still higher than that in developed countries.Causes: About 60-70% of perinatal deaths relate to complications of LBW, followed by birth asphyxia and neonatal sepsis in the descending order (Table 12.1). Congenital malformations are emerging as important cause of PMR, after control of other factors.
Prevention: PMR may be considered as single best indicator of fetal and neonatal health in a community. Important measures to reduce PMR include:
• Pre-conceptional:
- Nutritional and health care of adolescents and reproductive-age females.
- Appropriate birth spacing
• Antenatal:
- Adequate antenatal care including TT immunization, nutritional counseling/ supplementation and iron/ folic acid supplements.
- Early detection and treatment of maternal/ obstetrical complications
- Identification of high-risk mothers and referral for institutional delivery
• Peri-partum:
- Safe and clean delivery practices
- Adequate fetal monitoring/neonatal resuscitation
• Post-natal:
- Essential newborn care including breastfeeding
- Identification of high-risk newborns with appropriate treatment/timely referral
Neonatal mortality rate (NMR) denotes total number of neonatal deaths lt;28 days of life, expressed as a rate per 1000 live births per year, calculated as follows:
Total neonatal deaths gt;1000 gm ? 1000
NMR = --------------------------------------------------
Total live births gt;1000 gm
NMR is further divided as Early neonatal mortality rate (ENMR), i.e. early neonatal deaths lt; 7 days/1000 live births) and Late neonatal mortality rate (LNMR), i.e. late neonatal deaths between 8th and 28th day/1000 live births.
Considering improved survival of extreme preterms/ low birth weights in recent years, a new term Extended neonatal mortality rate (ExNMR) is also in use to include all newborns gt;500 gm instead of 1000 gm for calculations.
Current NMR in India is 20/1000 live births including an ENMR of 15/1000 and LNMR of 5/1000 (SRS 2022). Throughout the world, NMR is higher in male newborns, perhaps due to biological fragility of male sex.
Low birth weight and related complications, birth asphyxia/injury, sepsis and congenital malformations are four major killers in newborn and important measures to reduce NMR are same as those for PNMR.
Low birth weight rate: Pre-conceptional and antenatal maternal health and nutrition are major determinants of birth weight, which is also influenced by frequency of intrauterine infections.
As all these factors are adversely prevalent in India, low birth weight rate is considered as important indicator of maternal and neonatal health. Current low birth weight rate in India is 18% (NFHS-5, 2021).
Maternal mortality rate (MMR) is an indicator of risk to the women's death due to puerperal causes, computed as total number of female deaths due to puerperal causes*/ total number of live births ? 1000.
*Puerperal deaths include all female deaths due to obstetrical complications of pregnancy, childbirth/abortion or within 42 days of delivery/abortion (incidental/accidental deaths due to unrelated causes excluded).
Current MMR in India is 99/1000 live births (SRS 2022), highest in Uttar Pradesh and lowest in Gujarat.
Common causes of MMR in order of frequency include—(a) severe bleeding, (b) infection, (c) unsafe abortions, (d) eclampsia, and (e) obstructed labor. MMR is also related to many social factors, e.g. women's age, parity, birth interval, nutrition, and quality of antenatal care.
12.3