A prospective review of perinatal mortality at Hospital Nacional Guido Valadares (HNGV).

BACKGROUND: Timor-Leste has one of the highest perinatal mortality rates in the Asia-Pacific region. Consistent and accurate data collection improves understanding of perinatal outcomes and facilitates the development of interventions to reduce stillbirths and early neonatal deaths. AIMS: (1) To identify changes in the rates of stillbirth and early neonatal deaths from previous published data. (2) To determine if prospective data collection and the application of the simplified Causes Of Death and Associated Conditions (CODAC) classification allows better identification of perinatal deaths in Timor-Leste. METHODS: A prospective audit of perinatal deaths of women delivering at Hospital Nacional Guido Valadares (HNGV) was undertaken from January to June 2016 inclusive. The hospital birth registry, maternal and neonatal records were reviewed to determine the most likely aetiology and classification of perinatal deaths using the simplified CODAC system. RESULTS: One hundred and ten stillbirths and 28 early neonatal deaths were identified. Fifty-four percent of perinatal deaths occurred antepartum, 26% intrapartum and 20% were early neonatal deaths. Cause of death among stillbirths could not be ascertained in 40% of cases. Intrapartum asphyxia was the commonest identified aetiology of intrapartum and early neonatal deaths. CONCLUSION: There has been limited improvement in the rate of stillbirths and early neonatal deaths at HNGV. Intrapartum hypoxia and maternal hypertensive conditions were the most common identified aetiologies highlighting areas where targeted interventions may help reduce high perinatal mortality rates. Aetiology of perinatal deaths, particularly antepartum stillbirths was difficult to discern even when well-tested classification systems are used.

Reducing newborn mortality in the Asia-Pacific region: Quality hospital services and community-based care.

Improving newborn health and survival is an essential part of progression toward Millennium Development Goal 4 in the World Health Organization Western Pacific and South East Asian regions. Both community and facility-based services are required. Strategies to improve the quality of care provided for newborns in health clinics and district- and referral-level hospitals have been relatively neglected in most countries in the region and in the published literature. Indirect historical evidence suggests that improving facility-based care will be an increasing priority for improving newborn survival in Asia and the Pacific as newborn mortality rates decrease and health systems contexts change. There are deficiencies in many aspects of newborn care, including immediate care and care for seriously ill newborns, which contribute substantially to regional newborn morbidity and mortality. We propose a practical quality improvement approach, based on models and standards of newborn care for primary-, district- and referral-level heath facilities and incorporated within existing maternal, newborn and child health programmes. There are examples where such approaches are being used effectively. There is a need to produce more nurses, community health workers and doctors with skills in care of the well and the sick newborn, and there are World Health Organization models of training to support this, including guidelines on emergency obstetric and newborn care and the Pocket Book of Hospital Care for Children. There are also simple data collection and analysis programmes that can assist in auditing outcomes, problem identification and health services planning. Finally, with increased survival rates there are gaps in follow-up care for newborns at high risk of long-term health and developmental impairments, and addressing this will be necessary to ensure optimal developmental and health outcomes for these children.

Three years of neonatal morbidity and mortality at the national hospital in Dili, East Timor.

AIM: The aim of this study was to undertake a retrospective review of admissions and discharges to the neonatal unit at the National Hospital Guido Valadares, Dili, in order to gain insight into the epidemiology of hospitalised neonates in East Timor, as the information cannot be obtained from the hospital health management information system. METHOD: Data were sourced from unit registers for 3 years, 2008-2010 inclusive. Demographic characteristics and diagnoses were related to the risk of dying using stepwise multivariate logistic regression and adjusting for potential confounders of age, sex and weight. RESULTS: Two thousand eighty-eight babies were admitted to the unit over the study period. Over a quarter of babies weighed <2.5 kg on admission. Almost half were admitted from emergency or outpatient departments and only 27% were admitted within their first week of life. The most common reasons for admission were sepsis and respiratory disease (38 and 22%, respectively). Overall mortality was 11.4%, mainly attributed to prematurity (28%), infection (26%) and asphyxia (24%). Home birth, male gender, very low weight, young age and a short duration of hospitalisation were independently associated with an increased risk of death. Half of all babies weighing <1.5 kg died. Two-thirds of deaths occurred within 2 days of admission. CONCLUSIONS: The study provides, for the first time, an insight into the admissions and outcomes of the largest neonatal unit in East Timor. It is a baseline from which improvements to the quality of clinical care and data collection can be made.

Three years of paediatric morbidity and mortality at the National Hospital in Dili, East Timor.

AIM: The aim of this study was to undertake a retrospective review of admissions and discharges to the paediatric wards at the National Hospital Guido Valadares, Dili, as the epidemiology of hospitalised children in East Timor cannot be easily understood from the hospital health management information system. METHOD: Data were sourced from unit registers for 3 years, 2008-2010 inclusive. Demographic characteristics and principal diagnoses were related to the risk of dying using stepwise multivariate logistic regression. RESULTS: There were 5909 children admitted to the wards over the study period and 60% were <2 years of age. The commonest reasons for admission were lower respiratory tract infections (LRIs) and gastroenteritis (43% and 16%, respectively). Severe malnutrition (MN) was recorded in only 5% of admissions. Overall, 6% of children died, mainly attributed to LRI (28%), central nervous system infections (16%) and MN (11%). Younger age, residence outside of Dili and admission during a busier period were independently associated with an increased risk of death. Nine per cent of hospitalised infants aged 1-6 months of age died and half of all deaths occurred within 2 days of admission. CONCLUSIONS: The study provides, for the first time, an understanding of the admissions and outcomes of the busiest paediatric inpatient unit in East Timor. It emphasises important health system issues which impact on both data quality and hospital outcomes.

Direct and indirect effects of COVID-19 on perinatal outcomes in low- and middle-income countries.

Similar to previous outbreaks, the coronavirus disease 2019 (COVID-19) pandemic will have both direct and indirect effects on perinatal outcomes, especially in low- and middle-income countries. Limited data on the direct impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy shows women who are Black, obese and with co-morbidities are at higher risk of hospitalisation due to COVID-19. Younger age groups in Africa and South Asia have shown increased COVID-19 mortality. Indigenous pregnant women in Pacific Island countries are likely to be high risk for severe outcomes from COVID-19 due to high rates of diabetes and obesity. It is important to involve pregnant women in research, especially with regards to vaccine development and therapeutics.

An Australian Aboriginal birth cohort: a unique resource for a life course study of an Indigenous population. A study protocol.

BACKGROUND: The global rise of Type 2 diabetes and its complications has drawn attention to the burden of non-communicable diseases on populations undergoing epidemiological transition. The life course approach of a birth cohort has the potential to increase our understanding of the development of these chronic diseases. In 1987 we sought to establish an Australian Indigenous birth cohort to be used as a resource for descriptive and analytical studies with particular attention on non-communicable diseases. The focus of this report is the methodology of recruiting and following-up an Aboriginal birth cohort of mobile subjects belonging to diverse cultural and language groups living in a large sparsely populated area in the Top End of the Northern Territory of Australia. METHODS: A prospective longitudinal study of Aboriginal singletons born at the Royal Darwin Hospital 1987-1990, with second wave cross-sectional follow-up examination of subjects 1998-2001 in over 70 different locations. A multiphase protocol was used to locate and collect data on 686 subjects with different approaches for urban and rural children. Manual chart audits, faxes to remote communities, death registries and a full time subject locator with past experience of Aboriginal communities were all used. DISCUSSION: The successful recruitment of 686 Indigenous subjects followed up 14 years later with vital status determined for 95% of subjects and examination of 86% shows an Indigenous birth cohort can be established in an environment with geographic, cultural and climatic challenges. The high rates of recruitment and follow up indicate there were effective strategies of follow-up in a supportive population.

Survey of childhood malnutrition at Dili National Hospital, East Timor.

OBJECTIVES: To describe the characteristics and short-term outcomes of children with malnutrition admitted to Dili National Hospital (DNH), East Timor. METHODS: A prospective observational survey using caretaker interviews and medical record review was conducted on the paediatric ward at DNH for 12 months from March 2002. Patients were children aged 2 months to 12 years, admitted with moderate to severe malnutrition as either a primary or secondary diagnosis. RESULTS: Malnutrition was present in 31.8% (280/880) of paediatric admissions during the study period. Sixty-one per cent of the malnutrition cases were severe malnutrition (weight-for-height below -3 Z-scores and/or oedema) and 53.7% were both wasted and stunted. The hospital case-fatality rate was 12.9% (36/280). Immunization coverage was low, with 39% of cases never immunized and 29% incompletely immunized according to the national immunization schedule. CONCLUSIONS: There is a high rate of malnutrition among paediatric inpatients at DNH, consistent with results of anthropometric surveys in the newly independent East Timor. Despite the introduction of a standardized protocol following WHO guidelines and associated training on the management of severe malnutrition, the hospital case-fatality rate for severe malnutrition was still high (12.9%).

Risk factors for reduced lung function in Australian Aboriginal children.

AIM: To determine the influence of perinatal and childhood exposures on lung function in a cohort of Australian Aboriginal children. METHODS: This was a cross-sectional study of 547 Northern Territory Aboriginal children, aged 8-14 years, belonging to a birth cohort. Assessment included physical examination and spirometry as well as retrospective review of centralised hospital records. The effect of select perinatal and childhood exposures on lung function outcomes (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and forced expiratory flow between 25 and 75 s (FEF25-75)) adjusted for age, sex, height and other measures of size was examined using multiple regression. RESULTS: Non-urban residence (FEV1 -5% (95% confidence interval, CI 0.91-0.99), FVC -9% (95% CI 0.87-0.95)), current cough (FEV1 -6% (95% CI 0.91-0.97), FVC -4% (95% CI 0.93-0.97), FEF25-75 -8% (95% CI 0.86-0.98)) and hospitalisations for respiratory disease (FEV1 -10% (95% CI 0.86-0.95), FEF25-75 -12% (95% CI 0.70-0.87)) all had significant negative effects on adjusted lung function measures. Children with a non-Aboriginal ancestor had significantly better lung function. No perinatal exposure other than neonatal lung disease had any significant effect on adjusted lung function. CONCLUSIONS: For Northern Territory Aboriginal children factors related to the childhood environment are more important than perinatal factors in determining childhood lung function.

Growth and morbidity in children in the Aboriginal Birth Cohort Study: the urban-remote differential.

OBJECTIVES: To describe the prevalence of markers of growth, chronic and infectious disease in peripubertal Aboriginal children living in the Darwin Health Region in the "Top End" of the Northern Territory, and to compare prevalence between children living in urban and remote areas. DESIGN: Cross-sectional survey nested in a prospective birth cohort. SUBJECTS: 482 children living in the region who were recruited at birth (Jan 1987 to Mar 1990) and were followed up between 1998 and 2001, when aged 8-14 years. MAIN OUTCOME MEASURES: Selected parameters of growth and nutrition, infectious disease and potential markers of chronic adult disease were compared between children living at follow-up in suburban situations in Darwin-Palmerston (urban) and those living in rural communities with an Aboriginal council (remote). RESULTS: Remote children were shorter than urban children (mean height, 141.7 v 146.3 cm; P < 0.001), lighter (median weight, 30.3 v 37.1 kg; P < 0.001) and had lower body mass index (median, 15.3 v 17.9 kg/m(2); P < 0.001) and haemoglobin level (mean, 125.1 v 130.9 g/L; P < 0.001). Some potential markers of adult chronic disease were higher in urban than remote children: systolic blood pressure (mean, 109.6 v 106.2 mmHg; P = 0.004), and levels of total cholesterol (4.3 v 4.0 mmol/L; P < 0.001), high-density lipoprotein cholesterol (mean, 1.4 v 1.2 mmol/L; P < 0.001) and insulin (median, 7 v 4 mU/L; P = 0.007). Diastolic blood pressure, levels of red cell folate, serum glucose and low-density lipoprotein cholesterol, and urinary albumin-creatinine ratio did not differ by location. The prevalence of visible infections was also higher in remote than urban children (P < 0.05). CONCLUSION: As some markers of health differ between peripubertal Aboriginal children living in urban areas and those in remote areas, results of surveys in remote areas cannot be generalised to urban Aboriginal populations.