背景:坦桑尼亚是围产期死亡率最高的国家之一,城市妇女与农村妇女的风险较高。了解城市卫生机构围产期死亡的特点,研究目标是:I.评估达累斯萨拉姆公共卫生机构围产期死亡的发生率,并将其分类为a)机构前死产(进入研究医疗机构时没有胎儿心脏张力)和b)机构内围产期死亡出院前;以及II.通过比较两组围产期死亡与健康新生儿中的每一组来确定围产期死亡的决定因素。
方法:这是一项回顾性队列研究,在五个城市,达累斯萨拉姆的公共卫生设施。I.根据常规收集的医疗机构记录和围产期问题识别数据库,计算了2020年围产期死亡的发生率。II.在出生体重≥2000g的单胎亚人群中进行了一项嵌入式病例对照研究(不包括先天性畸形的新生儿);将设施前死产和设施内围产期死亡与“健康新生儿”进行了比较(1岁时Apgar评分≥8,5分钟时≥9,并活着出院)。进行描述性和逻辑回归分析以探讨死亡的决定因素。
结果:2020年共记录了37,787例新生儿。出院前围产期死亡率为每1000名新生儿38.3例:死产率为每1000名新生儿27.7例,机构内新生儿死亡率为每1000名活产10.9例。院前死产占死产的88.4%。病例对照研究包括2,224名妇女(452个机构前死产;287个机构内围产期死亡和1,485个对照),其中99%参加了产前诊所(75%的访问超过3次)。院前死胎与低出生体重(cOR4.40;(95%CI:3.13-6.18)和母亲高血压(cOR4.72;95%CI:3.30-6.76)相关。围产期内死亡与臀位相关(aOR40.3;95%CI:8.75-185.61),第二阶段的并发症(aOR20.04;95%CI:12.02-33.41),低出生体重(aOR5.57;95%CI:2.62-11.84),子宫颈扩张穿过产图作用线(aOR4.16;95%CI:2.29-7.56),产时护理期间的高血压(aOR2.9;95%CI1.03-8.14),在其他因素中。结论:五所城市医院围产期死亡率与产前和产时护理质量的差距有关,在研究的卫生设施和较低级别的转诊诊所。需要采取紧急行动,实施针对具体情况的干预措施,并开展实施研究,以加强从怀孕到产后的整个连续护理过程中的城市转诊系统。妊娠期高血压疾病作为围产期死亡的关键决定因素的作用强调了城市环境中孕产妇-围产期健康的复杂性。
BACKGROUND: 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.