Perinatal Deaths in Rural a Health Area, Case of the Health District of Kadiolo, Mali

The perinatal mortality is a public health issue in developing countries. In fact, the perinatal death rate seems the highest in a Malian rural area. The ob-jective of this work was to study the perinatal mortality in a rural area of Mali (Kadiolo). Methodology: It was a cross-sectional descriptive study conducted in Kadiolo over 12 months. The study took place from April 1, 2016 to March 31, 2017. We have included in our study all dead fetuses in gestational age ≥ 28 weeks of amenorrhea (WA) or weight ≥ 500 grams (g) and infants died during the first week of life. Mothers who have experienced a perinatal death were included. Results: During the 12 months of study period, we have recorded a total of 2212 births out of which we have collected 205 perinatal deaths, a perinatal mortality rate of 205/2212 with 93 per 1000. The stillbirth rate was 152/2212 with 69‰ and the early neonatal mortality rate was 53/2212 with 24‰. The sociodemographic characteristic of the patients was: patient who has been evacuated 71.70%, unschooled 77.1%, coming out of the city Kadiolo 76%, young women 65% and patient who did not receive antenatal care 35%. Conclusion: Our study confirms the high rates of perinatal deaths in rural areas. The implementation of a coherent and efficient care strategy should help in reducing the still high rates.


Introduction
Pregnancy and delivery are physiological phenomena that can be accompanied by serious complications and thus leading to maternal or perinatal mortality.
The perinatal mortality (PNM) remains, in general, an under looked public health issue and less documented in Sub-Saharan Africa particularly in Mali [1] [2]. In fact, according to the World Health Organization (WHO), four million of newborns die before one-month-old among them two-third during the first week of life; and for each early neonatal death, there is delivery of at least one fresh or macerated stillborn baby. The perinatal pathologies constitute the leading cause of deaths in children under one year in developing countries [3]. In 2013 the neonatal mortality rate (NMR) was estimated to 35‰, according to the report of the Malian Demographic and Health Survey (MDHS), fifth edition [4].
The neonatal mortality is a very sensitive indicator of the availability, the usage and the feasibility of treatments in perinatal health. Aware of the magnitude of perinatal and maternal mortality, the Malian authorities have adopted strategies to fight against the mortality of both mother and infant. In 1994, a national perinatal program was implemented. Its implementation on the ground has led to the organization of the Referral-Evacuation (RE) and the Counter-Referral System with the obstetrical and perinatal emergency management as a portal. This led in 2005 to the decision of free caesarean sections all over the country in order to fight against perinatal and maternal mortality. However, in our country, the scale of the problem and the importance that is focused on it is in contrast to the few works and resources devoted to it. At the national level, only MDHS estimates the perinatal mortality rate. The sanitary district in Mali constitutes the operational level of new health policies implementation. In fact, the health district of Kadiolo executes these strategies of fighting against perinatal mortality through antenatal consulting, neonatal and obstetrical emergency care, the functionality of RE, developed strategies in Reproduction Health, the integration and maintenance of community health workers. Despite those different strategies, the perinatal mortality rate is still high. To date, no study has been conducted in the circle of Kadiolo to precise the magnitude of perinatal mortality. This work aimed to study the perinatal mortality and to point out the characteristics of women victim of perinatal deaths in a sanitary structure in Malian rural area.
That will permit to give orientation for preventing strategies.

Description of the Study Framework
This work has been conducted in the circle of Kadiolo at the health reference center of the district of Kadiolo. It is located at 400 km from Bamako and at 10 km from the border between Mali and Ivory Coast. It's a cross-border area sharing border with Ivory Coast and Burkina Faso. Figure 1 shows the limits on a sanitary map of Kadiolo district.

The Study Population
The study population was the overall recorded births in the sanitary structures that may monitor a pregnancy and/or practice a delivery and post-natal monitoring. It can be women who have been referred or come by themselves for antenatal consultation, delivery or post-natal care. In 2016, the total population covered by the referral health center of Kadiolo was estimated to 300,000 by the National Institute of statistics of Mali (NISTAT). The women of childbearing age represented 66,000 whereas the women expecting babies, among this population, was numbered to 3300.

Inclusion and Non-Inclusion Criteria
 Inclusion criteria: were included in our study: -Dead fetuses in at least gestational age ≥ 28 weeks of amenorrhea or weight ≥ 500 grams and the dead newborns during the first week of life.
-The mothers who experienced perinatal deaths  Non-inclusion criteria: were excluded from this study: -The expulsion cases of the product of conception before 28 weeks or weight < 500 g; -The perinatal death cases that have not occurred in the service;  Sample size: Sample size was estimated using Schwartz size formula base on the perinatal mortality rate in Sikasso region.

Data Collection
o Data collection tools: the data has been collected from delivery record, partograph, obstetrical files, admission records, the operative report record.
o Data collection techniques: For each delivery, qualitative and quantitative information were documented on the tools. Next, the data were recorded on individual sheet of survey developed for this purpose.
o Data handling and analysis: the data were recorded on Word processing software then analyzed on the software SPSS.20 version. Statistical analyses performed were the proportions, the Chi 2 with the statistical significance p = 0.05.

Operational Definitions
Perinatal mortality consists of stillbirths and early neonatal mortality. Indeed, it poses a problem of definition because of the variability of the lower limit of viability of the fetus according to the countries. It is in order to harmonize these definitions that the World Health Organization (WHO) recommended in 1993 that children weighing at least 500 g should be registered, or at least one gestational age equal to 22 SA or a height of at least 25 cm.

Frequencies
During the 12 months of study period, we have recorded a total number of 2212 of deliveries among them 205 perinatal deaths have been compiled with a perinatal mortality rate of 93‰ (205/2212). The stillbirth rate was 69‰ (152/2212) that of the early neonatal mortality rate was 24‰ (53/2212).  (Table 4 and Table 5)

Causes of Perinatal Mortality
The possible causes of perinatal deaths and the factors associated with fetal status at birth are described in Table 4 and Table 5 below.
The eventual causes were determined according to the international and statistical classification of diseases and health issues (ICD-10) during the analysis of obstetrical files by the staff meeting of the service. Table 4 shows information about the causes of perinatal deaths of this study. In fact, the four deadly pathologies for fetuses and newborn babies in our study were high blood pressure and its complications (30%), acute fetal distress (23%), the neonatal infections (14.1%) and the prematurity (10%). We studied also the factors associated

Commentary and Discussion
The results have been commented and discussed on the basis of literary data. In this study, the results obtained provide with four types of messages.

Perinatal Mortality Rate in Kadiolo
The first message was about the rate of perinatal mortality and was 93‰. That

Distribution of Perinatal Mortality on the Basis of the Characteristics of Mothers, Fetuses and Newborns
The second message was about the women with perinatal deaths. The perinatal deaths were more common in mothers aged 20 to 30 years either 65%. Kanoute, D. et al. [14] have obtained (66.5%) for women aged between 20 -34 years old; (20%) for adolescents and (13.5%) for women aged 35 years old or more respec-

PNM(%0)
PNM cio-economic context. According to Montue S.C. [15] the higher the perinatal death was, the lower is the socio-economic level. Studies on perinatal mortality have confirmed that in many countries, the perinatal mortality was high in the lowest income social groups [15]. In developing countries, the low socio-economic conditions and the low level of education were essential risk fac-

The Eventual Causes of Perinatal Mortality
The third message was about the eventual causes of perinatal deaths. In Table 4, it appeared that the four leading causes of perinatal death in our study were sim- In our study it was eventual causes determined from the context and risk factors related to pregnancy during the staff meeting. The HBP and its complications represented the first rank and were responsible for 29% of perinatal deaths and followed respectively by AFD (23%), neonatal infection (14%), anemia (10%).
The study done by Ravaoarison, L. in Antananarivo in 2014 showed out results more or less close to those of our study. The fetal distress, fetal growth retardation (weight at birth < 2500 g) the neonatal infection and the low indication of Apgar (<7) constituted the primary factors of perinatal deaths [8] [18]. All the causes found out were avoidable on condition to perform a good quality of prenatal monitoring of women, to refer them in time to delivery structures, to proceed a good quality of delivery and a good management of newborn. That has been clearly illustrated by the results of this study. In fact, the most vulnerable newborns to perinatal deaths were those whose mothers lived in rural area. The high risk of rural areas is confirmed by national health statistics showing 93 per 1000 of perinatal deaths % in rural area against 56% in urban area in Mali [4].
The qualification of the delivery agent and the causes of perinatal death were strongly associated with fetal status at birth. These two factors have been confirmed by many studies [

Methodological Aspects
The fourth message was related to the methodological approach. In fact, no study was done on perinatal mortality in the sanitary district of Kadiolo. This survey was cross sectional and prospective and lasted a year. This permitted to collect a representative number of perinatal mortality cases. All the women with their newborns should be received in post-natal consultation in the third and seventh day. The aim was to see the state of health of the mother and the newborn. We have recorded some women lost to follow-up and were excluded from the study. In fact, there is difficulty in finding some mothers after their discharge from a maternity unit. The survey was accepted by all the team of the maternity unit that has fully contributed to the success of this study. Thanks to the good organization, the questionnaire was filling in by sending an SMS announcing the perinatal death to the student in charge of study. In fact, this permitted him to get quickly to the place of delivery to better collect the data. For the completeness of the questionnaire, we have proceeded by the active research of perinatal mortality cases.

The Limits of This Study
We have carried out an analytical cross-sectional study to describe this phenomenon which is perinatal mortality and to produce some associated factors. By conducting a case-control study, risk factors for perinatal mortality will be well identified. Prevention actions can focus on major factors. The main difficulty was the problem of appointments on the 7th day. This limit could be corrected by the sensitization of the population and the implication of the mayors in the establishment of certificates of death and birth certificates. There could be a recruitment bias linked to the framework of the reference center to be avoided by the active search of cases in the population at ceremonies of baptism, death, at the town hall, at the morgue, from the religious authorities. There is a problem of definition that is real. The definition of mortality perinatal has varied both geographically and temporally. The jurisdictions differ with respect to the lower limit of gestational age or birth weight for stillbirth registration. Therefore, although the tenth revision of the classification The International Disease Commission reported that perinatal mortality includes still births and neonatal deaths that occurred in the first week of life, international differences exist and make interpretations difficult.

Conclusion
Our study confirms the rates of perinatal mortality in Malian rural areas. The causes and factors related to the mother are various and avoidable. The implementation of a coherent strategy and based on effective cares should permit to fall the rates that are still high. Information of women on the list of danger of pregnancy and delivery should also be strengthened. The follow-up of the prenatal condition, the delivery service and the post-natal consultation should be of high quality. It would be necessary to conduct a case-control study in order to bring precision about risk factors of perinatal mortality in Kadiolo.

Public Declaration of Interests
I, the underlined, Dr FANE Seydou, declare not to have any direct or indirect financial interest or in nature with private, industrial and commercial organization in relation to the topic presented.