3D display of stillbirth in Indonesia obstetrics. Part 3: antenatal visits as preventive determinant.

In 2 previous reports the risk of stillbirth in Indonesian university obstetrics over the 1978-80 period was given as a bivariate function of the 6 possible binary combinations of 4 factors: 1) birth weight 2) complication of delivery 3) maternal morbidity and 4) registration states. This "closed tetravariate control system" (QUARTET) showed prolonged/obstructed labor to be a major contributor to the absolute "top referral" risk of stillbirth (SB) (54.9/1000). Elimination of this category of primary complication would lead to an absolute risk of SB of only 44.8/1000. 26.5% of all stillbirths (536/2020) were associated with prolonged/obstructed labor as a primary complication which in turn constituted 10.0% of all singleton births. Booked cases with prolonged/obstructed labor showed a low risk of SB (14.7/1000) as compared with not booked cases (122.5/1000) midwife referrals (164.1/1000) physician referrals (224.0/1000) and emergency admissions (452.8/1000)--a risk chain with a factor of 30.80. Since booked cases generally imply some form of pregnancy care the next analytical step is to co-control for antenatal visits (AV). This pictorial "3-D feedback" illustrates patterns of stillbirth risk by antenatal visits and the 4 co-controls noted above. Together with the 2 previous reports a "closed 5-factor control system" (QUINTET) of SB is thus obtained. The material and method is unchanged. The only sources are standard computer outputs from the Maternity Care Monitoring library pertaining to deliveries from 1978 to 1980. 20 of 22 control categories reveal risk profiles dependent on antenatal visits the 2 exceptions being placenta abruptio and very low birth weight. A systematic confrontation of relative risks obtained across antenatal visits with relative risks obtained within the 4 co-control variables highlights AV as being an important preventive determinant of late fetal death. In a 2nd step a clinical baseline of "NOCARE" women shows a very strong association with education and a weak association with family planning within controlled education categories. 2 hypotheses are derived. Since family planning precedes AV the next analytical focus is on FP (CONUSE). If co-controlled with the 5 control factors used thus far the QUINTET will lead to a "closed 6 variable control system (SEXTET) of the risk of stillbirth.