Maternal infection and risk of intrapartum death: a population based observational study in South Asia
- Equal contributors
1 Bureau of International Medical Cooperation, Japan, National Center for Global Health and Medicine, Medicine 1-21-1, Toyama, Shinjuku-ku, Tokyo, Japan
2 UCL Institute for Global Health, University College London, 30 Guilford St, London WC1N 1EH, UK
3 Centre for Child and Adolescent Health, School of Social and Community Medicine, Oakfield House, Oakfield Grove, University of Bristol, Bristol BS28 2BN, UK
4 UCL Centre for Sexual Health and HIV Research, Institute of Epidemiology & Health Care, University College London, London, UK
5 Perinatal Care Project, Bangladesh Diabetic Samity, Diabetic Association of Bangladesh, Dhaka, Bangladesh
6 Ekjut, Ward, Number 17, Plot 556B, Potka, Po-Chakradharpur, District West Singhbhum, Jharkhand 833102, India
BMC Pregnancy and Childbirth 2013, 13:245 doi:10.1186/1471-2393-13-245Published: 28 December 2013
Approximately 1.2 million stillbirths occur in the intrapartum period, and a further 717,000 annual neonatal deaths are caused by intrapartum events, most of which occur in resource poor settings. We aim to test the ‘double-hit’ hypothesis that maternal infection in the perinatal period predisposes to neurodevelopmental sequelae from an intrapartum asphyxia insult, increasing the likelihood of an early neonatal death compared with asphyxia alone. This is an observational study of singleton newborn infants with signs of intrapartum asphyxia that uses data from three previously conducted cluster randomized controlled trials taking place in rural Bangladesh and India.
From a population of 81,778 births in 54 community clusters in rural Bangladesh and India, we applied mixed effects logistic regression to data on 3890 singleton infants who had signs of intrapartum asphyxia, of whom 769 (20%) died in the early neonatal period. Poor infant condition at five minutes post-delivery was our proxy measure of intrapartum asphyxia. We had data for two markers of maternal infection: fever up to three days prior to labour, and prolonged rupture of membranes (PROM). Cause-specific verbal autopsy data were used to validate our findings using previously mentioned mixed effect logistic regression methods and the outcome of a neonatal death due to intrapartum asphyxia.
Signs of maternal infection as indicated by PROM, combined with intrapartum asphyxia, increased the risk of an early neonatal death relative to intrapartum asphyxia alone (adjusted odds ratio (AOR) 1.28, 95% CI 1.03 – 1.59). Results from cause-specific verbal autopsy data verified our findings where there was a significantly increased odds of a early neonatal death due to intrapartum asphyxia in newborns exposed to both PROM and intrapartum asphyxia (AOR: 1.52, 95% CI 1.15 – 2.02).
Our data support the double-hit hypothesis for signs of maternal infection as indicated by PROM. Interventions for pregnant women with signs of infection, to prevent early neonatal deaths and disability due to asphyxia, should be investigated further in resource-poor populations where the chances of maternal infection are high.