Stillbirth rates at 1975 levels

Although a good start in life begins well before birth, it is just before, during, and in the very first hours and days after birth that life is most at risk. Babies continue to be vulnerable throughout their first week of life, after which their chances of survival improve markedly. (Taken from The World Health Report 2005: Make every mother and child count, p79).

Senior doctors at the Port-of-Spain (PoSGH) and San Fernando General Hospitals (SFGH) have expressed concern about the steady rate of stillbirths and deaths during the first week of life.

Head of the Neonatal Unit, at PoSGH, Dr Petronella Manning-Alleyne said, "Since 1982 I’ve been at PoSGH and there has been absolutely no variation in the still-birth rate. We still range somewhere between 12-17 stillbirths per 1,000 on a yearly basis."

The stillbirth rate last year was 11.9 per 1,000.

It is interesting to note that a Ministry of Health report for 1975 showed the national stillbirth rate was 15.8 per 1,000.

The US National Stillbirth Society defines stillbirth as "intrauterine death and subsequent delivery of a developing infant that occurs beyond 20 completed weeks of gestation." Common causes of stillbirths include placental problems, birth defects, growth restrictions and infections. Manning-Alleyne, a consultant neonatologist, said one of the reasons for no decline in the rate has been the inability to constantly monitor women in labour.

Detecting any problems in pregnancy is done through foetal monitoring. A foetal monitor measures the baby’s heartbeat against the force of the contractions, and is used to catch foetal distress. Quick delivery of babies in distress is important to minimise the consequences of oxygen deprivation.

Three methods of foetal monitoring are available at PoSGH — using a pinnard, doppler or electronic foetal monitor. The pinnard is a trumpet-like stethoscope which is placed on the mother’s abdomen to listen to the baby’s heartbeat every 15-30 minutes during the first stage of labour and after every contraction during the second stage.

A doppler is a hand-held ultrasound machine that measures the baby’s heart rate. The electronic foetal monitor used in TT is an external monitor with two receivers being held in place by belts around the waist and hips. One receiver measures the baby’s heartbeat while the other records the contractions.

Manning-Alleyne said constant monitoring is done using the electronic monitor. Sunday Newsday learnt that PoSGH has six monitors but only two are working. The others need parts. Manning-Alleyne said the electronic monitors were unable to "withstand the test of time."

Sunday Newsday learnt from another source, who preferred not to be named, that the use of the monitors is "prioritised according to patients’ needs." (There is also only one ultrasound in the Obstetric and Gynaecology Department. The other is housed at the X-ray department). Routine ultrasounds are also used to detect problems.

At SFGH, the perinatal mortality rate, which includes stillbirths and babies dying within the first week, has fluctuated but remains high. This facility has only one very old electronic foetal monitor.

Dr Jehan Ali, head of the Obstetric and Gynaecology Department of SFGH said the crude perinatal mortality (stillbirths and babies dying within the first week) for the SFGH stood at 45.3 per 1,000 births in 1997 and went down to 33.1 per 1,000 in 2000. Ali said the rate started going up from 2001. The decrease coincided with the receipt of the new foetal monitors (1997-1999). Ali said the perinatal mortality was four times that of developed countries and twice as high as PoSGH and Mt Hope.

Another factor contributing to the stillbirth rate at SFGH is the absence of a dedicated surgical theatre for babies experiencing problems.

Ali said the Obs and Gyn Department has to compete with other health areas for the same emergency theatre. Emergency deliveries as well as newborns in need of surgery are competing for theatre time with general surgery and plastic surgery, neurosurgery cases.

A study conducted at the SFGH before 2002 to assess the decision/delivery interval, found there was a two-hour gap. Ali said the two-hour interval accounted for why some babies were born in poor condition or died.

He said the World Health Organisation has determined that a baby is viable from 24 weeks. It can weigh approximately 500 grammes at this stage.

"Quality babies are those who have no cerebral or other damage. They don’t end up handicapped. If deliveries are done earlier, that would help."

There are certain medical conditions which require delivery to be done in less than half an hour — the time recommended by the Royal College of Obstetricians and Gynaecologists.

Ali said the obstetric theatre, which was commissioned in October 2003, was used for just a month. Emergency Caesarian sections and elective cases were done Monday to Friday between 8 am and 4 pm. Ali said he was told there was a shortage of anaesthetists and the nurses assigned to the theatre were returned to the nursing pool for the main operating theatre and service came to a halt.

Ali said C-section cases were put on the gynaecology surgical list with hysterectomy and other cases. Meanwhile, the obstetric theatre is being utilised for dilation and curettage (scraping of the uterus) cases while its theatre is refurbished.