This study demonstrates the highly difficult and worrisome situation of perinatal medicine in the Republic of Guinea. In the most developed referral clinic of obstetrics of the whole country, to which the most complicated pregnancies and deliveries are referred to, a stillbirth rate of 82/1000 deliveries was measured. Almost 18% of all live born infants needed a higher degree of neonatal resuscitation, 8.2/1000 LB died under resuscitation and 17.5% of all LB had to be transferred to a neonatal clinic for ongoing care.
The high rate of stillbirths is particularly important to highlight, as this specific death rate is often neglected in hospital or national statistics, in which neonatal mortality and U5MR are reported in relation to LB. Data from the regional hospital of Kindia in Guinea showed a stillbirth rate of 47.7 per 1000 deliveries (14). According to the ‘Every newborn action plan’, developed by UNICEF and WHO, the stillbirth rate should decrease in each country to ≤ 12 stillbirths/1000 total births by 2030 (4). Today, it is estimated that each year worldwide 2.6 million fetus are stillborn (2). The few documented stillbirth rates in hospitals are usually higher than those estimated in the community (15). Nevertheless, the here reported stillbirth rate with 82 stillbirths /1000 total births is very high in comparison to other countries and hospital reports (15–17). A large meta-analysis about stillbirth reports from 50 countries showed a variety of causes. Data from low-income countries showed antepartal haemorrhage with 9.3%, hypoxia with 11.6% and infection with 15.8% as the most important identified causes, whereas in the vast majority of situations (63.3%) no clear causes have been described (18). Unfortunately, the data available in this study are too incomplete to identify the reasons for intrapartal stillbirths. It is also not possible to analyse, if improved intra-hospital care and/or an accelerated delivery could decrease the high intrapartum stillbirth rate, or if the problem is mainly due to a delayed arrival of the pregnant woman at the hospital. The latter reason is supported by the high rate of emergency caesarean section. A further indicator of insufficient late pregnancy control and delayed transfer to the hospital were the high rate of macerated stillbirths, the increased number of post mature infants and infants with a BW of > 4000 g.
Caesarean section rate
The here described hospital CS rate with > 50% is very high. In contrast to high-income countries with high elective CS rates, in this study it is mainly due to a high number of emergency CS (19). There is hardly any other emergency treatment available for life threatening situations, either for mothers, nor for foetuses, then to terminate pregnancy by CS. No vaginal deliveries with instrumentation (forceps or vacuum extraction) were performed. The lack of therapeutical options other than termination of pregnancy is also decipherable in the context of preterm births. Whereas the overall prematurity rate is comparable to international values (20), the distribution according to preterm age groups and the causes for prematurity are quite different. In only 20% prematurity was medically indicated and provoked, in particular because of maternal reasons like retroplacentar haematoma or haemorrhage due to placenta praevia or in the context of pre- or eclampsia (21). The high rate of spontaneous preterm birth indicated that the pregnant women were referred to the hospital in situations where there was no time for preventable therapies like tocolysis or maternal antibiotic therapy in order to stabilize pregnancy to gain days or weeks. Such interventions to prevent prematurity would be even more important in countries like Guinea, in which very preterm and extremely preterm infants have almost no chances to survive.
Birth weight anomalies
Whereas the rate of LBW infants of 14% was similar to other African countries, macrosome infants were overrepresented with 10% compared to macrosome rates of 2–4% (22–25). LBW as well as macrosomia are both independent risk factors for hospitalization in a neonatal unit (26); LBW infants due to immaturity, risk for hypothermia, hypoglycaemia, and respiratory distress; infants with BW > 4000 g due to increased risk for birth trauma, asphyxia and metabolic problems (25).
Need for neonatal resuscitation
The rate of infants needing resuscitation manoeuvres is very high, compared to other settings (27). This might indicate that improved examination of fetal intrapartum wellbeing and delivery management would be required. Almost 30% of all newborn infants needed any kind of resuscitation manoeuvres (tactile stimulation and/or airway aspiration), 2/10 of all infants needed additional bag and mask ventilation, and 7.5% were treated with chest compressions. In a similar setting in Tanzania, spontaneous respiration initiated in 84% of all LB infants, in 8% respiration commenced after tactile stimulation and/or suctioning and only in 8% bag and mask ventilation was necessary to start spontaneous respiration (28). Comparable data from three Norwegian hospitals are even lower with 17.5% for any resuscitation manoeuvres, 4.9% needing bag and mask ventilation and 0.1% chest compression (27). Chest compressions do not take part in the “Helping Babies Breathe” training and resuscitation program, which was taught at two occasions two years before the study period at this hospital (29). Our data do not support the use of chest compressions, as they didn’t show a beneficial effect for improved postnatal adaptation. In contrary, respiratory support (airway cleaning and manual ventilation) hat a beneficial affect on improved Apgar score at 10 minutes after suppressed and delayed postnatal cardiopulmonary adaptation. It would be important to re-analyse neonatal resuscitation according to the proven beneficial resuscitation program “Helping Babies Breathe” (30).
Although Apgar score at 1 minute is a bad predictor for outcome, 88% of the 75 newborns with a very low 1-min-Apgar-score (0–3) remained instable and needed a transfer to the neonatal unit for further neonatal care. Apgar score at 5 minutes, however, was shown to be a strong predictor for death and cerebral palsy. Compared to children with 5 min Apgar scores of 7–10, those with a score of 0–3 had an almost 400 times increased risk for death and a 50–100x higher risk for cerebral palsy (31, 32). Indeed, seven of the nine newborns with 5 min Apgar 0–3 died within the first postnatal hour. Casey et al found a 13x increased risk for neonatal death in preterm and 53x increased risk in term infants, respectively, if 5-minute Apgar was 4–6 compared to 7–10 (33). This group of children (Apgar at 5 min 4–6) representing almost 9% of the study population, fulfil also one of the clinical criteria for mild to moderate asphyxia. Unfortunately, no other clinical or laboratory criteria for the diagnosis of asphyxia were available in the study population. It would be very important to create a neonatal unit in close contact to the delivery room, in order to hospitalize, stabilize and better monitor by clinical and point of care laboratory measures all these newborn infants with adaptation problems for a longer time period, than just the first hour as it is use now.
Lacking a neonatal unit at the same location, 17.6% of all live born infants had to be transferred postnatally. Indication for referral were mainly prematurity (85%), respiratory distress (62%) and in 11% neonatal infection. The high rate of respiratory distress corresponds to data presented by McEvoy et al in Western Switzerland (34). However, whereas in Switzerland respiratory support is guaranteed during transportation in a fully equipped and medicalized ambulance, professional neonatal transport does not exist in Conakry. The emergency transports of suffering infants were all performed by private vehicles or public taxis, without medical or paramedical assistance and without any kind of respiratory support. This might lead to a serious deterioration of the respiratory status, with some infants arriving dead at their destination. A study performed in a similar neonatal referral context from Dakar described mortality during transport in 2.3%. Additional 4.6% of transferred newborns presented with cardiorespiratory arrest just at arrival (35). Such data strongly suggest the creation of a medicalized neonatal transport system for the Conakry area.
Perinatal morbidity and mortality
Despite resuscitation manoeuvres, nine of the 1091 live born infants did not survive the first minutes of postnatal life, representing a resuscitation mortality of 8.2/1000 LB. Unfortunately, no data are available about the short and long term outcome of the transferred newborns. However, in a retrospective study of the second university maternity existing in Conakry (Donka National Hospital), mortality rate of the transferred newborn infants to the same neonatal intensive care unit, was shown to be 41.7% (36). In a separate evaluation performed at the INSE during the same year as the presented study, a total mortality rate of 39.9% of all admitted newborn infants was measured. For the infants referred from the Ignace Deen University Hospital, a mortality rate within the first seven days after hospitalisation at the INSE was at 33% (unpublished data). Taken all this data together, the perinatal mortality accounts as follows: of the 1189 deliveries, there are 98 stillbirths and nine infants died during resuscitation. With an early neonatal mortality (within the seven first postnatal days) rate of 33%, of the 192 transferred infants additional 64 fatal outcomes would have to be added. Altogether, the number of stillbirths, of the direct postnatally deceased infants and of these neonatal deaths within the first week of life, the total perinatal death rate rises to 143.8/1000 total births, or one dead infant in seven births.
Limitations of this study
There were quite a number of limitations added to this study. Being limited to the data of this maternity hospital, information about the outcome of the newborn infants is lacking. The calculated mortality rates are not representative for the whole population of Guinea. However, the results of this study were meant to give some indicators for policy makers and health care providers how the regional perinatal network collaboration could be improved in order to reduce this very high perinatal mortality rate.