Study: maternal history is useful for identifying high-risk pregnancies and at-risk neonates

Women who already had one infant die at birth were more likely to have a subsequent infant die at birth than women who had no history of neonatal death, a large cohort study in India has shown.

In an analysis of 127,336 singleton live births from multiparous women between the ages of 15 and 49 years, a maternal history of neonatal death was associated with over a 2-fold increased risk of having a second infant die at birth at an adjusted odds ratio (OR) of 2.23 (95% CI, 1.96-2.55), reported Mudit Kapoor, PhD, Indian Statistical Institute, New Delhi, India and colleagues report in JAMA Network Open.

Women who had had more than one infant die at birth had an even higher, 3.5-fold risk of having a subsequent infant die at birth, at an adjusted OR of 3.50 (95% CI, 2.78-4.41), investigators added.

“India accounts for more than one-fourth of 2.6 million neonatal deaths worldwide,” Kapoor and colleagues pointed out.

“These findings suggest that maternal history of neonatal death is a potentially useful risk factor to identify women and neonates who may need extended and enhanced pregnancy care,” they advised.

Data was collected from the 4th round of the National Family Health Survey, a large-scale nationally representative survey of rural and urban Indian households.

The survey was conducted between 2015 and 2016 and data were analyzed between Nov. 2018 and Jan. 2020.

“Our primary outcome was neonatal mortality, defined as death between 0 to 27 completed days in the most recent live birth in the 5 years before the survey,” investigators explained.

The mean age of the cohort was 28.8 years and 8.7% overall reported a history of neonatal death.

However, approximately one quarter at 22.8% of subsequent neonatal deaths occurred among mothers with a history of neonatal death.

Mothers with a history of neonatal death were more likely than mothers without a history of neonatal death to be as follows:

  • Poorer at 40.1% versus 26.2% (P<0.001).
  • Have no schooling at 49% versus 33.5% (P<0.001).
  • Have received no antenatal care at 24% versus 19.4% (P<0.001).
  • Have a neonate not weighted at birth at 29.4% versus 20.2% (P<0.001).
  • Have a preterm delivery at 7.8% versus 6.4% (P<0.001).
  • Have a birth interval of less than 18 months at 19.1% versus 8.7% (P<0.001).
  • Have a neonate with a very small birth size at 4.4% versus 2.7% (P<0.001).

Interstate Variations

Investigators also noted that there were significant interstate variations in the proportion of live births among women who reported a history of neonatal death.

These variations ranged from a low of 1.4% (95% CI, 0.6-2.1%) in the state of Kerala to a high of 13.75% (95% CI, 13.2-14.2%) in the state of Uttar Pradesh.

The association of maternal history of neonatal death and subsequent risk of another neonatal death was also stronger for earlier periods of life.

For example, for neonatal deaths that occurred within 0 to 2 days of life, the risk of neonatal death was almost 2.5-fold higher at an adjusted OR of 2.45 (95% CI, 2.09-2.86).

For neonatal deaths that occurred within 3 to 6 days of life, the risk of neonatal death was less than 2-fold higher at an adjusted OR of 1.93 (95% CI, 1.41-2.63).

For neonatal deaths that occurred within 7 to 27 days of life, the risk of neonatal death was about 1.5-fold higher at an adjusted OR of 1.54 (95% CI, 1.09-2.18), as researchers noted.

“These findings have important implications for clinicians as well as policy makers,” they observed.

For physicians, identifying pregnant women who have experienced a prior neonatal death may help them better manage high-risk pregnancies as well as neonates born to high-risk women.

“Our findings… also suggest policy makers should incorporate the presence of history of neonatal death as one of the criteria for identifying high-risk pregnancies,” investigators concluded.

Limitations of the study include the fact that it was cross-sectional in nature and thus a history of neonatal death can only be seen as an association with subsequent neonatal death and not the cause of it.

Significant Contributor

Commenting on the findings, Janine Khan, MD, Feinberg School of Medicine, Northwestern University, Chicago, Illinois and Keith Dookeran MD, PhD, University of Wisconsin, Milwaukee, pointed out that early neonatal death — defined as death occurring between birth to 7 days of age — has emerged as a significant contributor to infant mortality in children under the age of 5 years.

Low and middle-income countries also account for most of these deaths, they noted.

“It is not surprising that adverse outcomes of previous pregnancies, including miscarriages and stillbirths, would be indicators of risk for future pregnancies,” they wrote.

Nevertheless, results from this study suggest that a past adverse obstetric history may well be a harbinger of adverse perinatal outcomes to come.

“Maternal history of neonatal death warrants recognition as an important risk factor of high neonatal mortality rate (NMR)… in India,” Khan and Dookeran pointed out.

“[A]nd Kapoor et al present a compelling argument for incorporating it in future strategies aimed at reducing NMR in this context as it provides a low-cost pragmatic course of action that can be seamlessly implemented by policy makers for early pregnancy-related assessment,” they concluded.

  1. Women with a history of even one — but especially more than one — neonatal death were at higher risk for subsequent infants to die at birth than women who had no history of neonatal death.

  2. A previous history of neonatal death identified women as high-risk pregnancies who require extended and enhanced pregnancy care.

Pam Harrison, Contributing Writer, BreakingMED™

Neither the authors nor the editorialists had any conflicts of interest to declare.

Cat ID: 138

Topic ID: 85,138,730,41,138,192