The table of the relevant standard care data submitted to the Ministry is seen in Table S4
Table 3 shows the stillbirths and Table 4 shows the neonatal deaths by individual case analysis in the study group to ascertain the primary etiology ,assign CODAC code for retrieval in future studies ,and determine where corrective measures could be instituted We noted that the majority of perinatal deaths (17/29; 58.6%) were caused by failure to recognize antepartum and intrapartum risk factors, leading to delayed delivery. In a few cases (3/12; 25%), it appears that women reported late for reduced perception of fetal movements or were post-dates and presented with an intrauterine demise at the hospital 3/12 (25%).There was one death due to poorly managed labour for a breech delivery. We identified 10/17 (58.8%) cases where the neonatal facility of the hospital was ill-equipped to manage the neonate, contributing to neonatal mortality.
It was alarming to see the number of adverse events even in the study group and it was thought necessary to review some protocols of obstetric management in the study cohort following the Royal College of Obstetrician and Gynaecologists professional guidelines19,20