Perinatal and Infant

Mortality

Agustin Kusumayati
Working Group on Reproductive Health
Faculty of Public Health University of
Indonesia
Proximate Determinant Framework

Mosley and Chen (1983) mengembangkan model

proximate determinant kematian bayi dan balita yang
mencakup berbagai faktor:
Faktor ibu: umur, paritas, jarak kelahiran
Kontaminasi lingkungan: air, kulit, tanah, insektisida,
dll
Kekurangan zat gizi: kalori, protein, vitamin dan
mineral
Kecelakaan: trauma
Kontrol penyakit individu: pencegahan dan
pengobatan penyakit.
DETERMINAN KEMATIAN BALITA DAN BAYI BARU LAHIR
Socioeconomic determinants

Maternal Environmental Nutrient Injury

factors contamination deficiency

Healthy Sick

Prevention
Treatment
Personal Growth Mortality
Illness faltering
control

Sumber: Mosley and Chen, 1985

 KERANGKA KONSEP PENURUNAN
TINGKAT KEMATIAN & KESAKITAN NEONATAL

Maternal Neonatal Neonatal 50%

care care death
Abortus
Essential Low birth
 Stillbirth newborn care: weight
 40% Survive
•EBF
 •Keep the
Birth trauma 30%
 Live birth baby warm
20% Birth
•Prevention
asphyxia
of infection
• BDC •Management Congenital
• BEONC of sick defect
• CEONC neonates
• Clean and safe delivery Healthy
• Resuscitation
Neonate 30%
• Prevention of hypothermia
• Initial breastfeeding
• Prevention of infection
Persalinan Normal Asuhan Antenatal Asuhan Persalinan Asuhan
Pascapersalinan
Kunjungan ke NAKES Pertolongan
• Imunisasi Persalinan oleh Kunjungan ke Petugas
• Kecukupan Gizi Tenaga Terampil • Pemberian ASI
• Suplementasi Gizi • Persalinan bersih eksklusif
• Deteksi dan • Pencegahan • Hangatkan bayi
pengobatan PMS hipotermia • Perawatan tali
• Pencegahan dan • Pemberian ASI pusat
pengobatan Malaria segera • Imunisasi
• Koseling ASI • Pemberian tetes • Pelihara gizi ibu
• Persiapan bersalin mata profilaksis • Konseling KB

TANDA-TANDA BAHAYA

Komplikasi Ibu Asfiksia lahir BBLR Infeksi dan

Asuhan Khusus

dan Bayi • Resusitasi • Penghangatan masalah lain

• Pencegahan • Penanganan • Metode • Antibiotik
penularan pasca- kangguru • Perawatan
HIV/AIDS resusitasi • Perawatan tali yang sesuai
• Penangana • Rujukan bila pusat • Terapi anti
komplikasi perlu • Rujukan bila retroviral
obstetrik dan perlu bila perlu
neonatal • Rujukan bila
perlu
 DEFINITION

 PERINATAL PERIOD = the time interval just prior to, during,

and after birth  characterized by a peak in the mortality of
the fetus and newborn infant.
 PERINATAL DEATHS = the number of stillbirths (= fetal
deaths of 28 weeks or more gestation) and the number of
deaths within the first week of life per 1000 births (births =
livebirths plus stillbirths)
 For international comparison WHO recommends the use of
standard perinatal statistics in which both the numerator and
denominator of the rate are restricted to fetuses and infants
weighing 1000 g or more (or corresponding gestational age
of 28 weeks, or crown-heel length of 35 cm).
 OCCURRENCE
IN TIME AND PLACE

 Perinatal Mortality has been markedly reduced since 1950.

 In Denmark, Findland, Sweden, Norway and Japan there
was a steady and continuing decline especially since 1960.
 The most stricking feature of this figure is the relative fall in
the perinatal mortality rate for Japan, which parallels similar
strides in the post World War II growth of the Japanes
economy.
OCCURRENCE IN TIME AND PLACE

SEASONALITY
 In Norwegia PM is lower in late spring and early fall,
and higher during late fall and winter months 
17.0/1000 in September vs. 23.2/1000 in January.
 In USA the peak mortality occurs between July-October,
while in Europe between February-May.
 If conception occurs when the risks of the common viral
and bacterial infections are least, then fetal growth and
development may be more nearly optimal.
OCCURRENCE IN TIME AND PLACE

Variation by DAY of the week

 In Norway the total number of births is higher in the
middle of the week and lower on weekends, especially
Sunday.
 In England & Wales and Scotland it is lower during the
week and higher during weekends.
 When spontaneous births were examined separately,
the variation by day of the week is practically non-
existent.
 OCCURRENCE IN TIME AND PLACE
Variations by HOUR of Day
 There is a consistent relationship between the hour of birth and
perinatal mortality.
 In New York and England the highest rate of perinatal mortality
occurred for infants born between noon and midnight  this time
period is also coincided with the highest rate of induced births.
 In Swedia it is lower from midnight to noon, increases during the
day and evening, until it reaches a peak between 18.00 and
midnight.
 Minimum perinatal mortality is achieved with births occuring in
the early morning hours.
 The chances of survival for the newborn during the first critical 12
hours after birth should be maximized if maternal care can be
provided during a period of daylight and increase individual
alertness.
 BIRTHWEIGHT and PERINATAL
MORTALITY
 Birthweight distributions in Norway and Sweden are nearly
identical.
 Norway has a higher birthweight-specific perinatal mortality
rate than Sweden, particularly for average-sized infants
weighing between 2500-4000 g.
 This mortality differences most likely reflect real differences
in the chances of survival.
 SOCIAL CLASS and
PERINATAL MORTALITY
 In Englans, Wales, USA the risks of perinatal death and
LBW increase from higher SOCIAL CLASS through lower
social class  no explanation.
 Movement between classes  women brought up in higher
social class who marry into lower social class men are
shorter, have poorer physiques, have lower dietary intakes,
leave school earlier, achieve lower score on IQ tests, enter
less prestigious schools, and run higher risk of perinatal loss
than those who marry within their social class.
 Male OCCUPATION are associated with different risks of
perinatal deaths.
 SOCIOECONOMIC STATUS and
PERINATAL MORTALITY
 It seems more probable that the effect of occupation is
indirect, thus is, mediated by the different socioeconomic
conditions.
 Features of MOTHER EMPLOYMENT that appear to be
associated with poor perinatal outcome: a long working
week, standing during work, having few work break, having
lengthy and difficult journey to and from work, and
performing especially tiring work.
 How is the effect of unpaid housework  unemployed
women put in at least 40-hour working week of housework!
 No clear conclusion on the effect of HOUSING, INCOME,
ETHNICITY, MARITAL STATUS and SEXUAL ACTIVITY.
 OTHER DETERMINANTS

 Short (<6 months) and Long interval between pregnancies

are associated with an increased risk of perinatal death and
other adverse outcomes of pregnancy.
 Smoking during pregnancy reduces birthweight. There is a
debate on whether the apparent differences in mortality are
due to the act of smoking or to characteristics of those who
smoke.
 Fetal alcohol syndrome will occur when the alcohol
consumption is approximately 30 ml per day. Relatively low
consumption may cause spontaneous abortion. Influence
on mortality is only demontrated in animal experiments.
 MATERNAL BIOLOGIC FACTORS

 Parity  U-shaped association with perinatal mortality

 Age  Also U-shaped since parity and maternal age are
closely interrelated
 Favourable age and parity reduce perinatal mortality by
9% in Sweden, by 23% in USA, and by 7% in Scotland.
 Tendency to repeat perinatal death  mothers with a
perinatal death at first birth have a relative risk for a
subsequent perinatal death of 4.5; while mothers with 2
previous perinatal deaths have the RR 7.3.
 MATERNAL DISEASES

Maternal Diseases during pregnancy Number Perinatal Deaths

of births Number Per 1000
Diabetes 727 30 41.3
Blood incompatibility 857 19 22.2
Urinary infection 1,969 20 10.2
Renal diseases 263 10 38.0
Pre-eclampsia and eclampsia 15,099 213 14.1
All births 189,228 1,822 9.6
COMPLICATIONS DURING DELIVERY
Complications during delivery Number Perinatal Deaths
of births
Number Per 1000
Placenta previa/abruptio placenta 2,061 203 98.5
Pelvis anomalies, CP discrepancy 7,335 53 7.2
Fetus malpresentation 2,969 53 17.9
Prolonged labor 14,276 112 7.8
Uterine rupture 51 11 215.7
Complication of umbilical cord 391 38 97.2
Fetal complications 11,703 327 27.9
No complications 125,440 757 6.0
 CAUSE-SPECIFIC
PERINATAL MORTALITY
Primary Cause of Death Birthweight (grams)
<=1500 1501-2500 >2500
Complications during pregnancy 63.9 13.8 0.3
Placenta praevia etc. 243.0 40.4 1.5
Complications during delivery 252.6 26.8 0.7
Congenital malformations 48.0 23.0 1.0
Asphyxia 54.4 13.8 0.1
Premature births 80.7 3.3 ---
Other causes 35.2 13.8 0.5
Total perinatal mortality rate 777.8 134.8 4.1