Trends in perinatal deaths from 2010 to 2013 in the Guatemalan Western Highlands
Garces et al. Reproductive Health
Trends in perinatal deaths from 2010 to 2013 in the Guatemalan Western Highlands
Ana Garces 0 2 3
Elizabeth M Mcclure 1 3
K Michael Hambidge 3 5
Nancy F Krebs 3 5
Lester Figueroa 2 3
Marta Lidia Aguilar 2 3
Janet L Moore 1 3
Robert L Goldenberg 3 4
0 Francisco Marroquin University , Guatemala City , Guatemala
1 Research Triangle International , NC , USA
2 FANCAP , Guatemala City , Guatemala
3 Authors' details
4 Columbia University , New York, NY , USA
5 University of Colorado , Denver, CO , USA
Background: While progress has been made in reducing neonatal mortality in Guatemala, stillbirth and maternal mortality rates remain high, especially among the indigenous populations, which have among the highest adverse pregnancy-related mortality rates in Guatemala. Methods: We conducted a prospective study in the Western Highlands of Guatemala from 2010 through 2013, enrolling women during pregnancy with follow-up through 42-days postpartum. All pregnant women were identified and enrolled by study staff in the clusters in the Chimaltenango region for which we had 4 years of data. Enrolment usually occurred during the antenatal period; women were also visited following delivery and 42-days postpartum to collect outcomes. Measures of antenatal and delivery care were also obtained. Results: Approximately four thousand women were enrolled annually (3,869 in 2010 to 4,570 in 2013). The stillbirth rate decreased significantly, from 22.0 per 1000 births (95% CI 16.6, 29.0) in 2010 to 16.7 (95% CI 13.5, 20.6) in 2013 (p-value 0.0223). The perinatal mortality rate decreased from 43.9 per 1,000 births (95% CI 36.0, 53.6) to 31.6 (95% CI 27.2, 36.7) (p-value 0.0003). The 28-day neonatal mortality rate decreased from 28.9 per 1000 live births (95% CI 25.2, 33.2) to 21.7 (95% CI 17.5, 26.9), p-value 0.0004. The maternal mortality rate was 134 per 100,000 in 2010 vs. 113 per 100,000 in 2013. Over the same period, hospital birth rates increased from 30.0 to 50.3%. Conclusions: In a relatively short time period, significant improvements in neonatal, fetal and perinatal mortality were noted in an area of Guatemala with a history of poor pregnancy outcomes. These changes were temporally related to major increases in hospital-based delivery with skilled birth attendants, as well as improvements in the quality of delivery care, neonatal care, and prenatal care.
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Background
Each year, families in low and middle income (LMIC)
countries face the death of approximately 4 million
newborns, 3 million fetuses and 300,000 pregnant women
(99% of those that occur worldwide) [1-4]. Millennium
Development Goal 4 (MDG4), which called for a
twothirds reduction in child mortality by 2015, depended in
large part on the reduction of neonatal deaths, which
made up 37% of child mortality in 1990 and 42% in 2014
[1,5]. The main causes of neonatal mortality in LMIC are
preterm birth, birth asphyxia and infections; one third of
deaths occur during the first 24 hours of life [3,6-8].
There is evidence of accelerating declines in neonatal
mortality from 2000 to 2010 in many LMIC; reasons for
these decreases include the introduction of national
policies to promote development and increased access to
health care, rising income of families and improved
maternal education [9].
Third trimester stillbirths are a relatively common
adverse pregnancy outcome in LMIC that in many
instances, are potentially preventable [10-12]. Up to 70%
of these deaths occur in the the intra-partum period in
LMIC [8,12]. The main causes of stillbirths are asphyxia
due to obstructed labor, placental abruption, preclampsia
or eclampsia and umbilical cord complications [7].
Despite their high frequency, stillbirths were not included
in the MDGs or in the Countdown to 2015 and are often
not considered when pregnancy outcomes are reported
from LMIC [12,13]. Because of their common causality,
interventions that reduce stillbirths frequently reduce
maternal and neonatal mortality [12].
An estimated 60 million women give birth each year
outside of health facilities, mainly at home [8]; fifty-two
million of these births occur without the assistance of a
skilled birth attendant, frequently by traditional birth
attendants (TBAs) or a family member [14]. In an effort
to improve pregnancy outcomes overall, the World
Health Organization (WHO) recommends the use of
skilled birth attendants for delivery, as TBA training for
the reduction of stillbirths and neonatal deaths has not
been proven to be effective [7]. TBAs in Guatemala,
known as comadronas, have a large role as providers of
reproductive health services, in addition to being
community leaders [14]. Eighty five percent of TBAs in the
Chimaltenango region report one month or less of formal
training, 60% are illiterate and less than one fourth report
using a stethoscope for heart rate auscultation [14].
Chimaltenango is one of 22 states in Guatemala.
Located in the western highlands, it has a popu (...truncated)