a Department of Public Health and Clinical Medicine, Epidemiology, Umeå University, Umeå, Sweden.
b Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
c Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Reprint requests to: Tobias Andersson, Department of Public Health and Clinical Medicine, Epidemiology, Umeå University, 901 85 Umeå, Sweden. E-mail: tobias.andersson{at}epiph.umu.se
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Abstract |
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Method The study design was a community-based cohort study. In all, 4876 perinatal deaths were recorded among 116 211 newborns in the districts of Sundsvall and Skellefteå in northern Sweden during the years 18311899. Relative risks, 95% CI, population attributable proportions and prevented fractions were calculated.
Results The overall perinatal mortality rate was 42.0 per 1000 births. A previous stillbirth represented one of the most important risk factors (RR = 3.25, 95% CI : 2.973.56), with a population attributable proportion of 7%. Two or more previous stillbirths gave an RR of 8.50 (95% CI : 7.589.53) and a population attributable proportion of 4%. There was an increased risk of perinatal mortality for mothers over 35 years old, the primiparous and the unmarried, while grandparous women had a higher perinatal mortality that was accounted for completely by a poor history of previous stillbirths and infant deaths among these women. The children of crofters, farmers and workers had higher perinatal mortality, but area had no significant impact. During the years 18811890 and 18911899, the prevented fractions of midwifery were 15% and 32%, respectively.
Conclusion Poor reproductive history, particularly previously high perinatal mortality, is associated with high perinatal mortality. Midwifery-assisted at home deliveries successfully reduced perinatal mortality.
Keywords Nineteenth century, developing countries, epidemiology, history of medicine, perinatal mortality, preventive health services, reproductive medicine
Accepted 8 November 1999
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Introduction |
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Data regarding perinatal mortality in developing countries derive mainly from hospital-based studies. This fact hampers an assessment of the causes of poor child outcomes because the vast majority of births in rural areas in low-income countries occur at home, attended by relatives or traditional birth attendants.5,6 However, the information on perinatal mortality coming from today's impoverished countries can be supplemented by examining historical cohorts from periods of high mortality in currently affluent countries. Sweden is one of the few countries offering reliable historical vital statistics for population studies.
In developing countries, it may be difficult to refer at risk neonates to hospital, and birthing women may have to resort to domiciliary care, intervention through primary health care and female community health workers.7 The community-based study in Matlab, Bangladesh, showed a perinatal mortality of 75 per 1000. A controlled study found that family planning and maternal health service programmes significantly reduced perinatal mortality, offering support for the inclusion of a strong maternity care component in primary health care strategies.8 In Sweden, in the nineteenth century, the authorities also campaigned for obstetric competence among primary health care doctors and for the assistance of licensed midwives at home deliveries. The competence of the midwives was improved in 1829 when they were licensed to use forceps, sharp hooks and perforators, and in 1881, when by law (The Antiseptic Decree), antiseptic techniques were instituted at midwifery-assisted home deliveries, thus preventing septic as well as non-septic maternal deaths in rural areas.9
The aim of this study was to analyse perinatal outcomes in nineteenth-century Sweden and to evaluate the impact of a community-based intervention.
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Subjects and Methods |
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This database was used to examine all live births and stillbirths from 18 parishes in northern Sweden in the years 18311899. Altogether, 116 211 births of 32 184 parturients were recorded during the period. The following data were obtained for this study: the mother's date of birth and marital status, the birth order of the child, each child's date of birth, previous reproductive outcome (such as previous stillbirths), previous infant deaths (011 months), the occupation of the father (foundry proprietor, academic, military, employee, civil servant, farmer, worker, crofter, etc.) domicile, and presence of midwife at birth. Information on midwife's assistance was not available for all parishes until the second half of the century.
Stillbirths were registered in the database. Perinatal mortality was defined as the total number of stillbirths and deaths within 7 days of birth per 1000 live and stillbirths. Infant mortality was defined as all deaths within the first year of life per 1000 live births. Perinatal and infant deaths were calculated using the data of birth and date of death registrations in the database.
The determinants for risk factor analysis were categorized as follows: maternal age (<35/>34); parity (I,IIIV/V+); previous stillbirth or not; previous infant death or not; married or unmarried; father's profession as white-collar worker, farmer, craftsmen, crofter and worker; domicile (the town of Sundsvall, the agricultural parish of Skellefteå, the agricultural parishes of the Sundsvall region [Ljustorp, Hässjö, Tynderö, Sättra, Indal, Tuna, Attmar and Selånger], the old iron foundry communities [Galström, Lögdö, Lagfors], and the new booming industrial sawmill communities [Alnö, Skön, Timrå, Svartvik, Njurunda]). Information on parental education was not considered valid for analysis.11
For the risk factor assessment, surviving children with exposure to risk were compared with the number of surviving children within the group at least risk by relative risks (RR) with 95% CI (Epi-Info 6.04B, 1997) Population attributable proportion (= p(RR 1)/[1 + p(RR 1)], where p = the proportion exposed in the population) was calculated when appropriate. Interactions between age, parity and previous reproductive history (stillbirths and/or infant deaths) were analysed by stratification and logistic regression.
The impact of intervention was analysed by stratifying background factors for midwifery-assisted home deliveries and other deliveries. The final model for analysis was stratified by time period and the impact of midwifery was adjusted for marital status, reproductive history, age, parity and area. Adjusted rates in the final model were calculated by multiple logistic regression (SPSS for Windows 7.0, 1997). The prevented fraction is defined as the quotient of prevented cases (cases that would have occurred in the absence of exposure minus the cases that did occur) and the cases that did occur.
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Results |
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Discussion |
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Underreporting of vital statistics, stillbirths, and early neonatal deaths is common in low-income countries because of home deliveries and early discharge from puerperal care. The results of this study could contribute to gaining a comparable perspective as well as to identifying perinatal risks in high mortality societies. The perinatal mortality of 42.0 in the current study was in the same range as that found in the Matlab survey.12 In the latter study, previous stillbirths represented the most important risk factor for perinatal mortality. Even in high-income countries, obstetric history is of importance in perinatal death.13
The Matlab study found no increase in perinatal death with high parity when age was taken into account.12 Our study showed a risk increase for multiparity, even when stratified by age, while a gradient by increasing age was evident. However, the important finding of our study in this respect was that multiparity as a risk factor was confounded by bad reproductive history. Previous stillbirths were associated with the highest risk for subsequent perinatal death. This finding is consistent with recent findings from Malawi, where previous fetal or neonatal deaths had a population attributable risk of 14%.14 The conclusion should therefore be that multiparity per se is not a risk factor for perinatal death.
The causes of death were not available for the study. However, from 1870 to 1875, 46 of 213 infant deaths in Linköping were due to causes closely related to birth, such as prematurity, convulsions, congenital syphilis, weakness, malformations and apoplectic stroke, whereas 136 deaths were caused by infection.15
The chances of perinatal survival improve with socioeconomic status, as measured by such indicators as parental education and parental occupation.1618 A relatively low-risk gradient by parental socioeconomic level was observed. This corresponds to the study in rural Bangladesh, where no measures of socioeconomic status could be related to perinatal mortality.12 In our study perinatal mortality was not analysed in relation to parental education. However, reading ability and comprehension have been included in the basic parish education in Sweden since the seventeenth century and marriage was not allowed without an approved certificate of reading ability and preparation for confirmation.
The rise in the perinatal mortality rates during the 1860s reflects an increase in general mortality, especially infections, during these decades, which was partly due to food shortages. Both perinatal mortality and maternal mortality increased in parallel with the general mortality. Epidemics of infectious diseases such as scarlatina and diphtheria were on the increase and contributed to the infant and under 5 mortality in Sundsvall during the 1860s and 1870s.19 The last peak of smallpox epidemics also occurred during this period.20
This study shows that, after 1881, a developed midwifery organization, with licensed midwives assisting at home deliveries, proved to be a successful intervention with a considerable preventive fraction of 1532% among those exposed to risk. The increased risk before 1881 should be interpreted in the light of the dangers of intervention without knowledge of asepsis. Success was the product of a two-century effort towards improved perinatal care. Johan von Hoorn, the founder of the first midwifery school in Sweden, had stated in 1711 that Of 100 stillbirths, 80 could have been prevented if a competent midwife had been with them. My heart sheds tears of blood every time these innocent souls are lost in death. From this point on, the objective was to have home deliveries assisted by a licensed midwife. In the middle of the nineteenth century, the authorities added additional regulations for midwives. It was decided that their duties should not be limited only to childbirth, but should also comprise subsequent care of the infant. Further, the education in basic neonatal care at the midwifery school was improved with an emphasis on warmth, neonatal resuscitation with tactile stimulus for asphyctic children, daily care of the umbilicus, and early breastfeeding.21 Doctors and midwives in nineteenth-century Sweden campaigned for breastfeeding in areas where cows' milk feeding was common, and succeeded in reducing infant mortality by 20%.22 Swedish midwifery was firmly established in the rural areas, since midwives were explicitly recruited from the families of farmers. Thus, this intervention overcame technical constraints and demonstrated good social representation, enabling a successful implementation of obstetric techniques within the specific cultural context.23 By the turn of the nineteenth century, two out of every three deliveries was attended by a licensed midwife (Table 3).
Perinatal mortality can be seen as a proxy for maternal health. Effective antenatal health care not only reduces maternal morbidity and mortality, but also saves children at birth. Up to now, community-based data on interventions have not been available, but hospital-based intervention has been successful in reducing perinatal mortality. For example, a Zimbabwean (30.6 per 1000) programme for reducing perinatal mortality included: (1) an educational programme to convince all pregnant women to attend antenatal care at least once, (2) closer monitoring of fetal conditions during labour, and (3) skilful management of dystocia.24 Abnormal presentations, which comprised 4.5% of deliveries in a teaching hospital in Nigeria, has a perinatal mortality of 1618%. Close and thorough supervision of the patients during the antenatal period and labour to detect abnormal presentations could reduce perinatal mortality.24 A medical audit of perinatal deaths could be successful in improving clinical judgements in maternity care and in the utilization of hospital services, thus reducing perinatal mortality, especially intrapartum fetal mortality.24 Reduced access to obstetric care, however, increases perinatal mortality.24 One way to overcome the logistics of providing this could be maternity waiting shelters, which might improve perinatal outcomes.24
The success of the Swedish intervention should be viewed in the perspective of a well-organized health care system, from national level to parish level. The intervention cannot be transferred directly to developing countries that lack health care resources or in which the majority of the births are attended by traditional, rather than trained, birth attendants. Nevertheless, we believe that the Swedish experience is of interest, especially in terms of what could be achieved by community-based midwifery services.
The critical points are: (1) the quality of care at home deliveries, (2) recognition of the need for referral, (3) access to transport, and (4) the quality of care in rural hospitals. Traditional birth attendants can recognize birth asphyxia, and with suitable training they should be able to deal with it.24 The Swedish experience from the late nineteenth century testifies to the importance of the quality of care at the primary level and community-based intervention in successfully reducing perinatal mortality. In this sense, perinatal survival is a suitable index of health.24 Early neonatal mortality is still unacceptably high in developing countries, and it is estimated that the majority of neonatal deaths could be avoided by intervention.
To conclude, this study indicates that high perinatal mortality in nineteenth-century Sweden was associated with advanced maternal age, single marital status and low social class. However, the strongest risk factor for perinatal death was previous stillbirths. Multiparity was not a risk factor. In home deliveries, intervention by midwives to prevent perinatal deaths was a successful approach.
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Acknowledgments |
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References |
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