Report on perinatal deaths in South Africa

In late 2016, two reports reflecting perinatal population statistics were released in South Africa: April newsletter_Evidence summary_image 1Perinatal Deaths in South Africa, 2014, which is
the second annual report by Statistics South Africa (the government department mandated to produce statistical information) and the fifth Rapid Mortality Surveillance Report, 2015 by the Burden of Disease Research Unit of the South African Medical Research Council. These reports provide the most recent national picture of the trends and causes of death of the perinatal population.

This summary, written by Dr Natasha R Rhoda, Senior Neonatal Consultant at Groote Schuur Hospital in Cape Town and the chairperson of the National Perinatal Mortality and Morbidity Committee in South Africa, concentrates on the most recent data for the period 2012 to 2014 and will summarise the findings of the Perinatal Deaths in South Africa, 2014 report.

Perinatal deaths in South Africa, 2014

Acronyms and abbreviations

ENNDR                        Early neonatal death rate

PNMR                          Perinatal mortality rate

SBR                              Stillbirth rate

Notes on the definition of stillbirths, early neonatal deaths and perinatal deaths

These types of deaths are defined as the following (see Appendix A of the report, p.34):

  • Stillbirth: “A stillborn in relation to a child, means that it has at least 26 weeks of intra-uterine existence but showed no sign of life after complete birth”.
  • Early neonatal death: “The death of [a] live-born infant during the first seven completed days of life”.
  • Perinatal death: “Perinatal deaths are a combination of foetuses of at least 26 weeks that are born dead (stillbirths) and infants that die within the first week after live birth (early neonatal deaths)”.

Data source and analysis

  • The data came from the civil registration system maintained by the Department of Home Affairs. The focus was on aggregate numbers of registered stillbirths and infant deaths occurring during the first week of life, as well as trends in the number of perinatal deaths from 1997 to 2014 (over 18 years) and causes of perinatal deaths between 2012 and 2014, specifically underlying causes of death.
  • Descriptive analyses were conducted, including “frequency and percentage distributions, sex ratios, cross-tabulations[…], death rates” (p.3) and ranking the causes of death.

Data trends

  • In 2014, early neonatal deaths accounted for a third (34%) of all perinatal deaths while stillbirths accounted for the majority of all perinatal deaths at 66% or two thirds.
  • There was an overall increase in the number of perinatal deaths from 1997 to 2009, with the highest number of perinatal deaths recorded in 2009 (25,296). Since 2009, there has been no consistency in the pattern of perinatal deaths.
  • Here are the patterns for stillbirths, early neonatal deaths and perinatal deaths over the last few reporting years up to 2014:
    • The number of stillbirths remained static between 14,000 and 15,000 deaths each year.
    • There was a recorded decline in early neonatal deaths by 2.9% between 2013 and 2014, from 7, 716 in 2013 to 7,495 in 2014.
    • The number of perinatal deaths decreased by 3.6% between 2013 and 2014, from 22,274 in 2013 to 21,908 in 2014.

Figure 1: Number of stillbirths, early neonatal deaths and perinatal deaths by year of death, 2012 to 2014*Knowledge summary_MDSR AN_April newsletter_figure 2

 

* Data between 2012 and 2013 were updated with late registrations/delayed death notification forms, which were processed in 2014-15.

  • These patterns in the total numbers of deaths between 2012 and 2014 also represented similar patterns in the rates of deaths for every 1,000 live births, as shown in Figure 2.

Figure 2: Stillbirth (SBR), early neonatal death (ENNDR) and perinatal mortality (PNMR) rates, 2012 to 2014*Knowledge summary_MDSR AN_April newsletter_figure 1

* Data for 2002-2013 were updated with late registrations/delayed notification forms, which were processed in 2014-15.

** The denominators used to calculate stillbirth and perinatal mortality rates included both live births (mid-year estimates) and stillbirths (from death notification forms). The denominators used for early neonatal death rates were live births only (mid-year estimates).

Observations

  • The majority of stillbirths, neonatal and perinatal deaths were classified by population group as black African (over 80%), which is similar to the population distribution in South Africa.
  • Male predominance: Between 1997 and 2014, there were more male deaths compared to female deaths among stillbirths, early neonatal deaths and perinatal deaths. The sex ratio is the number of male deaths per 100 female deaths. In 2014, all provinces had sex ratios higher than 100 for all deaths. The highest sex ratios by provinces were found to be in Gauteng for stillbirths (131), in Eastern Cape for early neonatal deaths (145) and in Free State for perinatal deaths (131). Mpumalanga had the lowest sex ratios between 105 and 108 for all deaths.
  • In 2014, the most populated provinces, Gauteng and KwaZulu-Natal, had the highest number of stillbirths, early neonatal deaths and perinatal deaths. See Table 3.6 (p.14) for greater detail about the number and distribution of stillbirths, early neonatal deaths and perinatal deaths by province of death occurrence and province of usual residence.Knowledge summary_MDSR AN_April newsletter_Image 2

Causes, place, time and weight at death

  • Early neonatal deaths
    • Nine of the ten leading underlying natural causes of deaths from 2012 to 2014 were the same for all years. The first six leading causes had the same rank order.
    • The top three leading underlying natural causes of deaths between 2012 and 2014 were (p.23):
      1. “Respiratory and cardiovascular disorders specific to the perinatal period”
      2. “Disorders related to the length of gestation and foetal growth”
      3. “Foetus and newborn affected by maternal factors and by complications of pregnancy, labour and delivery.”
    • Proportion of deaths occurring in health facilities (including hospitals, emergency rooms or as outpatients; and in nursing homes): 72%.
      • Timing of deaths for 2014: 55% occurred in the first day of life and 70% of deaths within 48 hours.
      • Weight at death: Not captured.
  •  Stillbirths
    • Nine of the ten leading underlying natural causes were the same from 2012 to 2014. Only three of the leading causes had the same ranking.
    • The top three leading underlying natural causes of death between 2012 and 2013 were (p.18):
      1. “Foetus and newborn affected by maternal factors and by complications of pregnancy, labour and delivery”
      2. “Disorders related to length of gestation and foetal growth”
      3. “Respiratory and cardiovascular disorders specific to the perinatal period”
    • The top three leading underlying natural causes of death in 2014 were (p.18):
      1. “Foetus and newborn affected by maternal factors and by complications of pregnancy, labour and delivery”
      2. “Respiratory and cardiovascular disorders specific to the perinatal period”
      3. “Disorders related to length of gestation and foetal growth”
    • Proportion of stillbirths that took place in health facilities (including hospitals, emergency rooms or as outpatients; and in nursing homes): 68%.
    • Timing of deaths for 2014: Unavailable as each death was not coded as fresh or macerated.
    • Weight: In 2014, 16% of stillbirths weighed less than 1,000 grams, 52% weighed less than 2,500 grams at birth (defined by the United Nations as ‘low-birth weight’ regardless of the gestational age2) and 19% weighed 2,500 grams or over. However, for 30% of all stillbirths, the birth weight was not specified.
  • No seasonal variation was observed in 2014 for any death category. Stillbirths, early neonatal deaths and perinatal deaths were distributed by month of occurrence. The proportion of all deaths that occurred by month ranged between 7-10%, with the highest proportion of deaths taking place in January and the lowest towards the end of year.
  • Ratio of stillbirths to early neonatal deaths in 2014 was 2:1.

Comments

  • Incompleteness of data for place of death and weight of stillbirth, with gaps in data higher than 20% for both, makes analysis difficult and means results must be interpreted with caution.
  • The data:
    • Underestimates late neonatal deaths, as the focus is specifically of the neonate’s first week of life.
    • Does not count unregistered stillbirths or infant deaths, which is an important factor in South Africa with a growing immigrant population displaced from neighbouring countries.
  • This report highlights that for 2014 the majority of deaths were due to natural causes, mainly attributed to the main group of underlying causes of deaths: “Certain conditions originating in the perinatal period” (p.31). Targeted interventions for this time period should help reduce mortality in all stillbirths and early neonatal deaths.

To view and download the Perinatal Deaths in South Africa, 2014 report, click here.

References

1 Statistics South Africa. (2016). Perinatal Deaths in South Africa 2014. Pretoria: Statistics South Africa

2 United Nations. (2014). Principles and recommendations for a vital statistics system: Revision 3. New York: United Nations