Identifying risk factors for perinatal death at Tororo District Hospital, Uganda: a case-control study

Abstract

Background Sub-Saharan Africa faces a disproportionate burden of perinatal deaths globally. However, data to inform targeted interventions on an institutional level is lacking, especially in rural, non-academic settings. The objective of this study is to identify risk factors for perinatal death at a resource-limited hospital in Uganda. Methods This is a case-control study at a district hospital in eastern Uganda using birth registry data. Cases were admissions with stillbirths or neonatal deaths within 7 days of birth. Controls were admissions immediately preceding and following each case. We compared demographic and obstetric factors between cases and controls to identify risk factors for perinatal death. Subgroup analysis of twin compared to singleton gestation was also performed. Chi square, Fisher's exact, T, and Wilcoxon-Mann-Whitney rank sum tests were utilized for bivariate analysis, and multiple logistic regression for multivariate analysis. Results From January 2014 to December 2014, there were 185 cases of perinatal death, of which 36% (n=69) were macerated stillbirths, 40% (n=76) were fresh stillbirths, and 25% (n=47) were neonatal deaths. The rate of perinatal death prior to discharge was 35.5 per 1,000 deliveries. Factors associated with increased odds perinatal death included: prematurity (adjusted odds ratio (aOR) 19.7, 95% confidence interval (CI) 7.2-49.2), breech presentation (aOR 7.0, CI 1.4-35.5), multiple gestation (aOR 4.0, CI 1.1 – 13.9), cesarean delivery (aOR 3.8, CI 2.3 – 6.4) and low birthweight (aOR 2.5, CI 1.1-5.3). Fresh stillbirth and neonatal deaths were more associated with nulliparity (p = 0.03), grand multiparity (p = 0.01), low birthweight (p = 0.01) and cesarean delivery (p <0.001) than macerated stillbirths. Subgroup analysis of twin pregnancies revealed that compared to singletons, twins were more likely to have a fresh stillbirth (68.4% vs 36.8%, p = 0.01). Conclusions The rate of perinatal death at a rural district hospital was higher than national rates, and the 67% of cases were fresh stillbirths or neonatal deaths. Significant risk factors for perinatal death were prematurity, breech presentation, and multiple gestation. Targeted interventions to identify these higher risk pregnancies, such as the prenatal identification of twins, may reduce the rate of perinatal death in rural settings.