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