Saving Mothers and Babies: Introduction to maternal and perinatal mortality


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker – Miriam Adhikari, South African Journal of Child Health, Primary Newborn Care was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: Mother and Baby Friendly Care describes gentler, kinder, evidence-based ways of caring for women during pregnancy, labour and delivery. It also presents improved methods of providing infant care with an emphasis on kangaroo mother care and exclusive breastfeeding. It covers: Saving Mothers and Babies was developed in response to the high maternal and perinatal mortality rates found in most developing countries. Learning material used in this book is based on the results of the annual confidential enquiries into maternal deaths and the Saving Mothers and Saving Babies reports published in South Africa. It addresses: the basic principles of mortality audit, maternal and perinatal mortality, managing mortality meetings, ways of reducing maternal and perinatal mortality rates, This book should be used together with the Perinatal Problem Identification Programme (PPIP).

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Saving Mothers and Babies: Introduction to maternal and perinatal mortality

  1. 1. 1 Introduction to maternal and perinatal mortalityBefore you begin this unit, please take the MORTALITYcorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 1-1 What is mortality?the unit, to evaluate what you have learned. Mortality means death. The mortality in a Objectives given area is the number of people who die in that area. Mortality is the most important measurable outcome in a health service. When you have completed this unit you should be able to: 1-2 What is a mortality rate? • Explain the importance of mortality rates. This is the number of people who die, • Describe the concept of a mortality audit. expressed as a proportion of all the people in • List the important steps of a mortality that area. For example, if 10 people die in a audit. community of 1500 people, the mortality rate • Keep a detailed birth register. is 10 per 1500. • Describe information which can be obtained from a birth register. The mortality rate is the proportion of people • Understand the importance of the low who have died. birth weight rate. 1-3 How is mortality rate expressed? Mortality rates are usually expressed per 1000 or 100 000 individuals (i.e. as a proportion). For example, the mortality rate for newborn infants is usually given per 1000 infants delivered alive while the mortality rate for
  2. 2. INTRODUCTION TO MATERNAL AND PERINATAL MOR TALITY 13pregnant women is usually given per 100 000 Similarly, rates are higher in developing thanpregnant women who deliver. in industrialised countries.1-4 How can mortality rate be applied to 1-8 Do mortality rates remain the same?groups of people? No. Mortality rates may also differ betweenA mortality rate is usually given for a specific different time periods. In most countriesgroup of people, e.g. pregnant women or mortality rates have fallen over the past years.newborn infants, and for a specific area or Unfortunately this is not always the case inservice, e.g. a town or clinic. Mortality rates some African countries.may also be applied to people falling in aspecific age group such as children, teenagers 1-9 Why is it often better to know theor the elderly. mortality rate rather than simply theFor example, the mortality rate could be number of people who die?calculated only for pregnant women between Knowing the rate if often more useful thanthe age of 20 and 25 years of age who live in a simply knowing the number of individualscertain town. who die, as it allows you to compare the size of the problem between different areas Mortality rates are often calculated for a specific or over different periods of time. A small hospital with only a few patients each year section of the population only. can then be compared to a large hospital with many patients.1-5 What is the annual mortality rate? For example, if 10 patients die out of the 1000This is the mortality rate calculated over patients admitted to a small hospital, and 100the period of one year. Mortality is usually patients die out of the 10 000 patients admittedexpressed as an annual rate. Sometimes the to the large hospital each year, then the annualmortality rate may be expressed over a longer mortality rate of both hospitals is the same (i.e.period such as 10 years. 10 per 1000), even though more patients died in the larger hospital. Therefore, the mortality rates of two very different sized hospitals can1-6 Should the mortality rate be calculated be fairly compared.for a special area?Yes. The mortality rate is usually calculated It is often more useful to know the mortality ratefor a given health district or region. In orderto determine the mortality rate for a health than just the number of people who have died.district or region, all the births and deathsin each part of that service (each clinic and 1-10 Why would one want to know thehospital) must be added together. Sometimes mortality rate?the mortality rate is calculated for a whole Knowing the mortality rate helps to determineprovince or country by combining the results both the amount of illness in a communityof many regions. as well as the standard of the health care provided. A high mortality rate suggests either1-7 Is the mortality rate the same for all a poor standard of health or a poor standard ofhealth districts? health care. Mortality rates are, therefore, veryNo. The mortality rate often differs markedly useful in assessing the needs of a communitybetween health districts. Usually the rates are and the efficiency of the health service.higher for poor than industrialised districts.
  3. 3. 14 SAVING MOTHERS AND BABIES 4. Perinatal mortality rate (stillbirths plus The mortality rate reflects both the amount of early neonatal deaths). illness in a community as well as the standard of health care. Additional rates, which may be added, are: 5. Neonatal mortality (infants who die in the NOTE Under special circumstances such as first month of life). revolution, widespread crime or war, the 6. Infant mortality rate (infants who die in mortality rate may also be influenced by social the first year of life). and political factors leading to the violent deaths of healthy people. 1-14 Why is it important to know why1-11 Why would you want to compare the mothers and infants die?mortality rates between two areas? It is very important to know, not only theThis will tell you about the differences in living mortality rates, but also why mothers andconditions and standards of health care in the infants die in order that these deaths cantwo areas. The area with the higher mortality be prevented by avoiding or correcting therate either has poorer living conditions or a causes of death.less efficient health care service. The area withthe higher rate may also have some specific Only when the causes of death are known canillness such as malaria or a specific health steps be taken to prevent further deaths.problem such as famine.1-12 Why would you want to compare 1-15 What are primary causes of death?mortality rates at different times? The primary cause of maternal and earlyIt is very useful to compare the mortality rates neonatal deaths as well as stillbirths is thein a health care service between two periods obstetric factor or condition which resultedof time. In some hospitals or health districts in the death, i.e. it is the reason why thethe mortality rate may be improving while in death occurred. For example, if a pregnantanother it may be getting worse. An increasing woman has a placental abruption and themortality rate indicates a fall in living fetus dies, the primary cause of the stillbirthconditions or a fall on the standard of health is antepartum haemorrhage. Similarly, acare. Sometimes an increasing mortality rate severe antepartum haemorrhage could alsomay indicate the arrival of a specific disease be the primary cause of death of the mother.such as AIDS or cholera. Knowing the primary causes of death helps to identify important medical conditions that1-13 Which mortality rates are usually need to be prevented and bad clinical practicesrecorded in a maternity service? which need to be improved.The maternal and perinatal mortality rates.The perinatal mortality rate includes both The primary cause of death is the condition whichstillbirths and infant deaths in the first week led to the maternal or perinatal death.of life. The following mortality rates shouldalways be recorded: 1-16 What are final causes of death?1. Maternal mortality rate (women who die during or shortly after pregnancy). The final cause of maternal or early neonatal2. Stillbirth rate (infants born dead). death is the event which actually caused the3. Early neonatal death rate (infants that die death (a final complication of the disease soon after birth, i.e. in the first week of life). process), i.e. how the patient died. For
  4. 4. INTRODUCTION TO MATERNAL AND PERINATAL MOR TALITY 15example, if a woman has an induced abortion For example, in the audit of a maternityand dies of septic shock, the primary cause service, the total number of deliveries and theof the maternal death is the induced abortion method of each delivery would be important.but the final cause of death is septic shock.Similarly, if a newborn infant dies as a result of 1-19 What is a mortality audit?hypoxia (lack of oxygen) caused by eclampsia,the primary cause of death is eclampsia but the This is a detailed assessment of all the patientsfinal cause of death is hypoxia. Knowing the that have died. Both a maternal and perinatalfinal causes of death helps to identify facilities mortality audit is necessary in a maternityand resources, which need to be improved to service.prevent medical conditions resulting in death. A mortality audit is a detailed assessment of the The final cause of death is the final event patients who have died. which actually resulted in the maternal or early neonatal death. 1-20 Why are mortality audits important?Note that a final cause of death is usually not Because they measure the size of the problemrecorded for stillbirths. (the number of people who die) and indicate where the problem lies (what causes the deaths). By understanding the problem better1-17 What is the value of knowing both the (what errors might have been made) solutionsprimary and final causes of death? can often be found to reduce the risk of similarBecause the correct diagnosis and deaths in future. By decreasing the numbermanagement of the primary cause may prevent of patients who die, the standard of care willthe complication which resulted in the death automatically improve for all patients.while diagnosing and treating the complicationmay prevent the final cause of death. For 1-21 What are the important steps of aexample, it would be best if placental mortality audit?abruption or eclampsia were preventedaltogether or correctly diagnosed and treated 1. Documenting the number of people whoas early as possible. If this was not possible, it is have died.important that fetal hypoxia can be prevented 2. Collecting the basic information on theor diagnosed early, and correctly managed. people who have died.Every effort should be made to prevent both 3. Calculating the mortality rate.the primary and final causes of death. 4. Determining the causes of mortality (or morbidity). 5. Looking for avoidable factors and missedAUDIT opportunities. 6. Planning ways in which these deaths can be avoided in future.1-18 What is an audit? 7. Write a mortality report.This is a systematic assessment (an 1-22 How can it be determined why aexamination or review). In a clinical service, patient has died?it is a count of the number of patients andwhat happens to them. An audit helps one to All the information about the patient mustunderstand the health related problems which be very careful reviewed. Only then can apatients have in a service and how effective the likely cause of death be decided upon. Thisservice is in managing these problems. information consists of:
  5. 5. 16 SAVING MOTHERS AND BABIES1. The history. Plans to improve patient care is based on the2. The examination of the patient. mortality report.3. Special investigations.4. A post mortem examination, if this has been done. 1-26 What is morbidity?1-23 What is a mortality meeting? Morbidity includes all the clinical problems or illnesses that patients suffer but have notThis is a meeting, attended by as many of the died from, e.g. postpartum hemorrhage whichmedical and nursing staff as possible, where did not kill the woman or severe pneumoniathe mortality audit is discussed, i.e. all the facts which did not kill an infant. Morbidity mayrelating to the deaths are carefully examined. result in temporary or permanent damage.Mortality meetings are needed so that themanagement of patients who have died can NOTE Unlike death, which is a definite end point, morbidity can sometimes be difficult to definebe reviewed. At the mortality meeting a cause accurately.of each death must be looked for and possibleavoidable factors identified for each personwho has died. 1-27 Why is it important to document morbidity? While it is important to identify and prevent At a mortality meeting the cause of death and any problems which kill patients, it is also avoidable factors are identified and discussed. important to address problems, which cause illness without death. To get a complete view of problems in a health service, both mortality1-24 What is a mortality report? and morbidity must be considered. BecauseThis is an important document, which reports morbidity is far commoner that mortality,on the mortality audit. It gives the details deaths are only the ‘tip of the iceberg’. Byof the audit and should also summarise the studying morbidity, it is possible to get a bettermain findings and make recommendations. idea of the pattern of disease or incorrectIt is best to write the report at the end of the management which results in mortality.mortality meeting when all the information is Where deaths are uncommon, it is particularlystill available. Usually all the mortality reports useful to study patterns of morbidity. Theover a year are used to prepare an annual causes and avoidable factors of mortality andmortality report. morbidity are usually the same. A mortality report is the summary of the findings Deaths can often be prevented by reducing of a mortality audit. morbidity.1-25 Why is the mortality report so 1-28 Who is responsible for collecting andimportant? analysing mortality information?The information in the mortality report is Everyone in the service should be involved inused to identify problems within a clinical keeping good notes and collecting mortalityservice and plan interventions to reduce or data. Usually one specific person is responsibleremove the causes of those problems. An for making sure that all the important dataaccurate mortality report is essential if the care has been collected and is presented at theprovided to patients is to be improved. mortality meetings. That person usually also records and analyses the information from
  6. 6. INTRODUCTION TO MATERNAL AND PERINATAL MOR TALITY 17the mortality meetings and then writes the 6. The infant’s birth weight and gender.mortality report. 7. Whether the infant was born alive or dead and whether live born infants died in the1-29 What is a confidential enquiry? first week of life. 8. Any maternal deaths.This is an analysis of deaths where thenames of the people involved with the care Additional information which is oftenof the patient are kept confidential, i.e. their recorded in a birth register is the mother’snames are not made known. The names of address and contact phone number, herthe individuals who have died are also kept gravidity and parity, and whether she wasconfidential. A confidential enquiry is an referred from somewhere else.important method of collecting the true facts NOTE The HIV positive rate is becoming a veryand of finding the cause of a death. Without important measure of the spread of the diseasea confidential enquiry, many people may be in each community and each woman’s HIV statusafraid of providing all the correct information may also be included in the register, providedfor fear that they may be punished or that the result is kept strictly confidential.embarrassed. A confidential enquiry isparticularly useful in the investigation of 1-32 What useful information can bematernal deaths. calculated from information in a NOTE In South Africa, the first confidential enquiry birth register? into maternal deaths was conducted in 1998. 1. Teenage pregnancy rate. 2. Rate of attending antenatal care (‘booking rate’).BIRTH REGISTER 3. Syphilis rate. 4. Assisted delivery rate. 5. Caesarean section rate.1-30 What is a birth register? 6. Asphyxia rate (low Apgar scores).This is a book in the labour ward where daily 7. Low birth weigh rate.records of all deliveries are kept. The birth 8. Stillbirth, early neonatal and perinatalregister is very important as it is the formal mortality rates.record of all deliveries. It is essential that 9. Perinatal care index.every delivery is included in the register. 10. Referral rate.Every labour ward must have its own register. 11. Maternal mortality rate.Women who deliver in theatre must also be 12. Percentage of pregnant women aged 35recorded in the labour ward birth register. years or more. 1-33 What is a minimal data set? The birth register is a most important record of all deliveries. This is the basic information which must be collected from the birth register at every clinic or hospital which delivers mothers:1-31 What information should be recorded 1. The number of live born and stillbornin the birth register? (fresh and macerated) infants as well as1. The mother’s name, hospital or clinic the number of early neonatal deaths by number and age. weight category.2. Whether the mother had antenatal care. 2. The number of women less than 18 years3. The mother’s VDRL status. or older than 34 years.4. The method of delivery. 3. Syphilis status of the mother (negative,5. The Apgar scores. positive or unknown). If possible, it is
  7. 7. 18 SAVING MOTHERS AND BABIES also important to record the HIV status of of South Africa less than 50% of pregnant each mother. women are screened for syphilis. A low rate of4. Method of delivery: normal vaginal, syphilis screening indicates poor antenatal care. assisted (vacuum or forceps), breech or caesarean section.5. The number of infants born before arrival A low rate of syphilis sceening indicates poor at the clinic or hospital. antenatal care.6. The number of women who have received no antenatal care. 1-37 Why is the HIV rate determined?7. The number of maternal deaths. The need for screening all women for HIV isA summary of the minimal data set is usually becoming very important, as monitoring thepresented and discussed at the start of each HIV rate in pregnant women is one of theperinatal mortality meeting. The minimal data best ways of documenting the spread of HIVset reflects the activities of the health centre. in a community. The use of antiretrovirals to reduce the risk of mother to child1-34 What is the value of knowing the transmission of HIV must be encouragednumber of young and older mothers? while the management of pregnancy, labourThe teenage pregnancy rate indicates the and delivery, and the newborn infant maywell being of a community. A high teenage need to be changed in HIV positive women.pregnancy rate indicates many social problems A high rate of HIV counselling and screeningin a community. These problems need to be indicates a good antenatal care service.addressed, especially in the schools.Older mothers have a higher rate of twins and 1-38 What is the use of documenting theinfants with congenital abnormalities. caesarean section rate? The caesarean section rate in a developing1-35 Why measure the rate of women country should be about 15%. It will beattending antenatal care? much higher in a referral hospital. A lowWomen who do not attend antenatal care rate may indicate inadequate care in labourhave a much higher perinatal mortality rate. and can be associated with an increasedThere are many reasons for not attending number of intrapartum deaths due to labourantenatal clinic, including ignorance, lack of complications. A very high rate usuallytransport, inability to get away from work, indicates that many unnecessary caesareanfear of revealing the pregnancy, denial of the sections are being done.pregnancy, lack of antenatal care servicesnearby, unfriendly service at the clinic, 1-39 Why is it important to documentand laziness. All these factors need to be whether the mother has been referred?addressed to ensure that mothers come early This information helps to establish the referralin pregnancy for care. pattern. In turn this is important in planning good perinatal services.1-36 Why is the number of women who arescreened for syphilis important? A high rate of infants ‘born before arrival’ (BBA) indicates poor communications andIt is essential to screen all pregnant women for transport services.syphilis as this infection is a common causeof perinatal death in some communities. It ischeap and easy to screen for syphilis and treatthe condition during pregnancy. In many parts
  8. 8. INTRODUCTION TO MATERNAL AND PERINATAL MOR TALITY 191-40 What is the use of knowing the rate of 1-44 What is the low birth weight rate?asphyxiated infants? The low birth weight rate is the percentageThe percentage of infants with a low 1 minute of infants with a birth weight less than 2500Apgar score (i.e. neonatal asphyxia) is a useful g. The low birth weight rate is expressed perindex of care in labour. Many asphyxiated 100 births (as a percentage), unlike perinatalinfants usually indicates poor labour care. mortality rates, which are expressed per 1000The percentage of asphyxiated infants who births. The low birth weight rate is calculateddie gives an idea of the standard of newborn as follows:resuscitation. Number of infants weighing less than 2500 g at birth × 100LOW BIRTH WEIGHT Total number of infants delivered1-41 How may infants be divided into 1-45 What is the importance of the lowgroups by their birth weight? birth weight rate?It is very useful to divide infants into birth The low birth weight rate varies widelyweight categories. This requires little extra between different communities and is a veryeffort. Usually 500 g categories are used. The sensitive marker of the socioeconomic statuscommonly used birth weight categories are of that community. In an industrialised500–999 g, 1000–1499 g, 1500–1999 g, 2000– country the low birth weight rate is usually2499 g and 2500 g or more. around 7%. However, in a poor country theBirth weight categories can be used to low birth weight rate is usually 15% or moreinvestigate stillbirths, neonatal deaths and (e.g. 30% in India). Knowing the low birthperinatal deaths. weight rate of different communities helps to identify those communities in greatest need of socioeconomic support.1-42 What is a low birth weight infant?All infants weighing less than 2500 g at birthare called low birth weight (LBW) infants. The low birth weight rate reflects theThis includes all live born and stillborn infants socioeconomic status of the community.weighing between 500 and 2499 g. Bothpreterm delivery and slow intrauterine growthcan result in a low birth weight infant. 1-46 What is the low birth weight rate in South Africa? NOTE Infants weighing less than 1500 g are classified as very low birth weight (VLBW) infants The average low birth weight rate for South while infants weighing less than 1000g are called Africa is about 15% which is typical for a poor extremely low birth weight (ELBW) infants. country. In some very poor areas the low birth weight rate is as high as 25%.1-43 Why is it important to identify all lowbirth weight infants? In South Africa the low birth weight rate is aboutBecause they commonly have problems in the 15%.first weeks of life and, therefore, need to beassessed for additional care. They often needmore than primary care and are transferred toa level 2 or 3 nursery.
  9. 9. 20 SAVING MOTHERS AND BABIES1-47 How does the low birth weight rate 4. Why would it have been important toinfluence the perinatal mortality rate? know if the perinatal mortality rate had increased over 10 years?The perinatal mortality rate is higher forinfants who weigh less than 2500 g at birth. Because it would draw the attention of the health care authorities to a serious deterioration in health or health care servicesCASE STUDY 1 or both in the town over the past ten years.All the perinatal deaths during a 2 year period 5. Why is it also important to document thein a small town are recorded. An attempt is also cause of perinatal deaths?made to discover the cause of each death. There Only if the common causes of perinatal deathswere 25 perinatal deaths out of a total of 500 are known can plans be made to preventdeliveries in the 2 years. Ten years before, the those deaths. It is very difficult to reduce theperinatal mortality rate was reported to be 75. mortality rate if the causes of death are not known. Therefore, it is very important to1. What is the present mortality rate? establish the causes of perinatal death in eachTwenty five deaths out of 500 deliveries, i.e. health district.25/500. As the perinatal mortality rate isusually expressed per 1000 births, the rate is 6. What is the difference between the50 per 1000. Knowing the mortality rate is primary and final cause of death?more helpful than simply knowing the number The primary cause of death is the medicalof perinatal deaths. condition that lead to that death while the final cause is the complication which actually caused2. Should the rate be expressed over the the death. For example, in a pregnant woman,two year period? hypertension may be the primary cause ofThe number of deaths can be counted over any death but a cerebral haemorrhage would beperiod of time but the rate is usually expressed the final cause of death. Correct diagnosis andper year. Therefore, the annual perinatal management of hypertension would preventmortality rate in this small town is 50/1000. the primary cause of death. Failing this, theIt is far better to know the annual mortality correct treatment of the haemorrhage mayrate for the whole town than just in a clinic or prevent the final cause of as it gives a more accurate indicationof what is happening in the community. CASE STUDY 23. What is the value of knowing theperinatal mortality rate ten years earlier? At a regular monthly perinatal mortality meeting in a regional hospital, the infor-As the perinatal mortality rate has fallen from mation from the birth register is used to75 to 25 per 1000 over 10 years, either the present an audit of maternal and perinatalhealth of pregnant women and their newborn care provided. Important items from theinfants has improved or the standard of health minimal data set are is better. This is a most important way ofdocumenting changes in a health care service. 1. What is a monthly perinatal mortalityA comparison of the perinatal mortality rate audit?with that of neighbouring towns would also bevery useful in assessing whether the town’s rate It is an assessment of all the stillbirths andwas higher or lower than expected. early neonatal deaths which have occurred
  10. 10. INTRODUCTION TO MATERNAL AND PERINATAL MOR TALITY 21during the past month. It is important that 6. What does morbidity mean?regular audits of both maternal and perinatal While mortality means death, morbiditydeaths be conducted in all health facilities. means illness and clinical problems which are still important problems but are not severe2. What is a birth register? enough to cause death. Morbidity wouldThis is a book which is kept in each labour include problems such as antepartum andward where daily records of all births are post partum haemorrhage where the motherkept. The birth register is very important, as does not die. The causes of mortality andit is the formal record of what happens to all morbidity are the same. Therefore, high ratesmothers and their infants who are cared for for morbidity are of great concern as theyin that service. suggest that problems, which could be fatal, are occurring frequently.3. What is the minimum data set?This is the most important information which CASE STUDY 3must be recorded in the birth register. Itincludes the number of maternal deaths, live In a health service consisting of one hospitalbirths, stillbirths and early neonatal deaths, and five clinics, the results of each monthlytogether with the method of delivery and mortality audit are used to write an annualimportant details of each woman, such as her mortality report. As there were a number ofage and VDRL status. The birth register also maternal deaths during the year, a confidentialincludes other less important information, enquiry is requested.which is usually not given in the minimumdata set, such as the gender (sex) and Apgarscore of each infant. 1. When are the monthly mortality reports written?4. What useful information can be After all the deaths are discussed at the monthlycalculated from the birth register? mortality meeting. At the meeting the number and causes of the deaths are discussed. TheThe information from the birth register can mortality report is a summary of the mortalitybe used to calculate important rates, such as meeting.the maternal, stillbirth, early neonatal deathand perinatal mortality rates. Other analysesinclude the caesarean section, low birth weight 2. What is an annual mortality report?and teenage pregnancy rates. It is a report which is written each year and is based on the monthly mortality reports.5. What is the value of knowing the rate of The annual mortality report summarises thewomen who attend for antenatal care? causes of death and indicates which factors associated with the deaths that they couldGood antenatal care is most important as have been avoided. For example, improvingit lowers both the maternal and perinatal the attendance at antenatal clinics may havemortality and morbidity rates. If many women reduced the deaths due to syphilis. Theare not attending antenatal care, every effort annual mortality report is useful in planningmust be made to find out why they are not ways to improve the perinatal care providedattending and make plans to increase the by the service.attendance rate.
  11. 11. 22 SAVING MOTHERS AND BABIES3. What are the steps of a mortality audit? 1. What is a low birth weight infant?The information about each death has to be Any infant that weighs less than 2500 g at birth.collected and the important mortality indicescalculated. Then the cause and possible 2. What is the low birth weight rate?avoidable factors for each death must belooked for. Finally, ways of avoiding similar The percentage of all infants born who have adeaths are discussed. low birth weight.4. How can the cause of death be 3. Why is it important to know the low birthdetermined? weight rate?By documenting and discussing the results of Low birth weight infants have a high risk ofthe history, examination and special investi- morbidity and mortality and, therefore, oftengations, together with the result of the and post need more than just primary care. The low birthmortem examination, if this has been done. weight rate is increased in poor communities and is a sensitive marker of the socioeconomic status of that community. The low birth weight5. What is a confidential enquiry into a rate often varies widely between differentmaternal death? communities, regions and countries.This is a detailed investigation into the causeand possible avoidable factors in a maternal 4. What are the low birth weight rates indeath. It is confidential as the names of poor and industrialised countries?the staff who cared for the patient are keptsecret. By keeping the personal details of Most poor countries have a low birth weightthe investigation and the staff involved rate of 15% or more while the rate is usuallyconfidential, it is more likely that the true about 7% in industrialised countries.findings will be uncovered. 5. What is the low birth weight rate in South Africa?CASE STUDY 4 South Africa has a low birth weight rate of 15%. This suggests that most of theThe birth weight of each infant is recorded communities in the country are the labour ward register. At the monthlyperinatal mortality meeting, the number oflow birth weight infants delivered are countedand the low birth weight rate calculated.