Some aspects of perinatal and maternal mortality in Albania

Summary

Objective:
Evaluation of antenatal care, perinatal mortality, neonatal mortality, maternal mortality, number of births, the incidence of low birth weight infants in Albania.

Design of the study:
Retrospective study.

Setting:
Queen Geraldine University Hospital of Tirana, Albania.

Methods:
The population of this country is estimated to be approximately 3,2 milion and comprises very young people. Twenty five percent of the population is under 15 years of age and 46% is under 25 years [2]. The fertility rate in 2009 was 1.6 children per woman of childbearing age. The urban population accounts for 45% and the rural population for the remaining 55% of the total population [2]. The health care system is spread across nearly the entire territory and is classified as primary (villages and small towns), secondary (several cities) and tertiary (in the capital, University Hospital). Primary health care is provided at 2327 health care units. The chief activity of the family doctors and general practitioners working in such units are focused on providing health care for mother and children. Ten percent of the annual births are delivered at the Maternity Hospital of Tirana (tertiary care) which has 300 beds and another 40 beds particulary for premature infants. More than 50% of the high risk pregnancies from other districts are referred to the Maternity Hospital of Tirana.

Results:
The annual live births in Albania was in (2010) 33 856. The total perinatal mortality rate is 10,9 per 1000 live births. The total neonatal mortality rate in 2010 was 9.7 per 1000 live births. The early postnatal mortality rate was 6.1 per 1000 births. Number of maternal deaths for 100 000 live births was 6.0 in 2010.

Key words:
perinatal care, perinatal, neonatal mortality, maternal mortality in Albania.

INTRODUCTION

Improvement of maternal and child health a challenges faced by the Albanian government and collaborating donor agencies in improving health wellbeing of the Albanian population.

International publications are the best platform for exchange of various opinions on the subject. This exchange of opinions is important because perinatal medicine in developing countries rather differ from that in western countries in some regards. In most cases, the reason for this difference is the poor compliance with perinatal medicine guidelines in developing countries and the socioeconomic level, which is a major factor.

Demographics

Albania is located in southeastern Europe, and is bordered by Greece, Macedonia, Kosovo and Montenegro. The population of this country is estimated to be approximately 3.2 million and comprises very young people. Twenty five percent of the population is under 15 years of age and 46% is under 25 years [2]. The fertility rate in 2009 was 1.6 children per woman of childbearing age. The urban population accounts for 45 % and the rural population for the remaining 55% of the total population [2].

PERINATAL HEALTH SERVICES

The health care system is spread across nearly the entire territory, and is classified as primary (villages and small towns), secondary (several cities), and tertiary (in the capital, University Hospital). Some difficulties are encountered in accessing remote populated especially during the winter. Prenatal and pediatric clinics are mostly located in close proximity to the health care centers; each hospital district has obstetric and pediatric wards. Deliveries in major hospitals account for approximately one third of all the deliveries. Ten percent of the annual births are delivered at the Maternity Hospital of Tirana (tertiary care), which has 300 beds and another 40 beds particularly for premature infants. More than 50% of the high- risk pregnancies from other districts are referred to the Maternity Hospital of Tirana [4].

Occasionally, referral to a better center is based on the doctor’s advice and the availability of the hospital vehicle for transport. Primary health care is provided at 2327 health care units; the chief activity of the family doctors and general practitioners working in such units are focused on providing health care for mothers and children. Medical personnel provide prenatal care to 97% of pregnant women with 4.5% as the average rate of consultations per pregnancy. More than 97% of the deliveries are assisted in an obstetrical ward or in a village delivery house; only 3% of all pregnancies are delivered at home without any assistance [3]. It is worthwhile to discuss the quality of prenatal care to reduce morbidity due to pregnancies. It is highly important to ensure safe deliveries in these institutions. The number of cesarean section deliveries has shown a tendency to increase [4].

To date, standards for the quality of perinatal care have not been established. The lack of adequate health care services for pregnant women and neonates is a major factor associated with the high perinatal mortality.

Health facilities play an important role in the reduction of fetal and neonatal mortality, but medical interventions may be ineffective if they are not accompanied by improvement in the socio economic status. However, we think that the percentage of preventable fetal and neonatal mortality (within the existing resources) is considerably high.

Some widely agreed indexes of the quality of the obstetric and neonatal care are as follows:

perinatal mortality (PM), order of births, the incidence of low birth weight infants, percentage of women not receiving adequate care, the distribution of different handicapped infants in the post neonatal period, etc.

At the same time, socio-economic factors clearly play an undeniable role in the health status of the population. However, to a great extent infant mortality remains an indicator of socio-economic conditions. PM is highly related to prenatal and postnatal care. However, our observations in Albania were as follows:

increase in PM and especially increase in neonatal mortality, high natality that remains almost constant, high incidence of low-birth-weight, identification of a greater number of handicapped infants.

Natality will continue to be high in Albania for certain reasons as follows:

The majority of the population is young; therefore, the number of newly married couples and children is high.

In rural communities, the need to bear a child especially boys, is exaggerated.

High infant mortality also leads to high fertility.

Finally, the failure to use all the family-planning methods.

Live births in the years shows Figure 1 [4].

Although progress in some areas (infrastructure, facilities and personnel qualification) has been observed, PM has not significantly altered. We observed a slight decline, in the prenatal/neonatal mortality rate during the last 5 years. This is attributable to some international financing and professional assistance received mostly in terms of neonatal care. Modern respiratory assistance received for the newborn has been provided since 1990, since then, it has improved prenatal/neonatal mortality at the capital (tertiary service) and at the same time, it has become a common practice in 3–4 hospitals (secondary service). The number of prenatal deaths is gradually increasing, chiefly because of poor compliance. Another reason may be the high number of high risk fetuses.

Perinatal mortality per 1000 live births for 2010 shows Figure 2 [1].

The total perinatal mortality rate is one of the highest in Europe. It is 10.9 per 1000 births. Postnatal mortality rate in first week of live is high 6.1 per 1000 births. We registered a reduced number of mortality during birth in the last years but the prenatal mortality is still high.

Although infant mortality is a strong indicator of the socio-economic standards. PM is closely linked with socio-economic conditions and the lack of adequate prenatal and postnatal care. Interventions for the improvement of health care often solve certain medical problems. For example, the application of anti-D globulin reduced morbidity because of rhesus incompatibility.

Neonatal mortality from 1993 to 2010 shows Figure 3 [4].

Little has been achieved in terms of reducing in mortality of preterm and low-birth-weight infants. The high incidence of low-birth-weight deliveries is a major contributor to infant mortality and morbidity. The lack of prevention and treatment of health problems in the perinatal period influences infant growth, development, physical and mental abilities, and school performance, thereby adding a burden to the families, society, and social institutions.

The frequency of delivery of low-birth-weight infants is undoubtedly related to the percentage of women who receive inadequate prenatal care. A high number of low-birth-weight infants is in itself a major factor influencing infant mortality and morbidity.

In the past neonatal mortality was 7.14 per 1.000 live births (1988), and at present, neonatal mortality is 9.7 per 1.000. The fact is that the previous statistical data were manipulated.

Premature deliveries from 2007 to 2009 shows Figure 4 [4].

HEALTH CARE AND MATERNAL MORTALITY

The program for maternal health and family – planning services, which started in Albania in 1991, aimed to improve maternal health care and to provide information about family planning by educating people. We have already obtained satisfactory results of the work in the maternal and infant consulting centers for preventing unwanted pregnancies and educating women and children about good nutrition habits, as well as stressing on the importance of vaccination, domestic hygiene, and medical help. However, for a further decrease in maternal and infant mortalities an extensive program should be developed.

Numbers of abortions from 1993 to 2010 is at Table 1 [3].

Since June 1991, abortion has become legal, and can be performed at the request of women up to 12 weeks of pregnancy. This reduced the maternal mortality caused by abortion. The influence of changes in the health policies of our country is directly reflected in the changes in maternal mortality indicators in general, as well as in the chief causes of women’s death. While deaths from abortions have decreased considerably, deaths from causes such as high blood pressure during pregnancy, obstetrical hemorrhages, and anemia have increased. Data from the National Nutrition Program show that 53% of pregnant women were anemic.

Figure 5 contains data of maternal deaths per 100 000 live births [1].

CONCLUSIONS

Improvement of the quality of care is associated with measures to reform the health care system and improvement of the management practices in hospitals. (Accreditation and funding of hospitals on the basis of their performance by the Health Insurance Institute was planned) [1].

Establishment of a well-functioning referral system that can provide improved care to patients in regional hospitals and to patients in Tirana Maternity Hospitals that provides the best neonatal intensive care service.

The systems of perinatal care need to be improved on the basis of primary prenatal care clinics where the majority of the staff consists of midwives; further, district and regional hospitals for care of mothers and newborns and management of pregnancy – related complications need to be established.

Better services and greater priority should be given to pregnant women all over the country to ensure diagnosis and treatment of conditions and complications during pregnancy, labor, and after birth, with special attention to anemia, high blood pressure, and prevention of premature births and treatment of premature infants.

The establishment of family-planning centers was a very important event in our country; however, for the success of these centers, special programs to reduce infant mortality, especially neonatal mortality, will need to be developed (these centers mainly focus on abortion – related issues).

Along with regionalization, set standards and regulations need to be established for maternity units. Further, a statewide consultation-education program needs to be developed as an important part of the continuous medical education for health professionals, nurses, midwives, and specialists in Obstetrics – Gynecology. Thus, more interventions in this field need to be developed.

Práce podpořena Ministerstvem zahraničních věcí ČR při vypracování projektu ke snížení PÚ v Albánii, Všeobecnou fakultní nemocnicí a 1. LF UK v Praze při organizaci stáží albánských lékařů v ČR.

Halim Kosova, M.D.

Queen Geraldine University Hospital

Bulevardi Zogu I.

Tirana

Albania

e-mail: halim_K50@yahoo.com