Determinants of Preterm Birth among Women Who Gave Birth in Amhara Region Referral Hospitals, Northern Ethiopia, 2018: Institutional Based Case Control Study

Development and validation of a prognosis risk score model for preterm birth among pregnant women who had antenatal care visit, Northwest, Ethiopia, retrospective follow-up study

BACKGROUND

Prematurity is the leading cause of neonatal morbidity and mortality, specifically in low-resource settings. The majority of prematurity can be prevented if early interventions are implemented for high-risk pregnancies. Developing a prognosis risk score for preterm birth based on easily available predictors could support health professionals as a simple clinical tool in their decision-making. Therefore, the study aims to develop and validate a prognosis risk score model for preterm birth among pregnant women who had antenatal care visit at Debre Markos Comprehensive and Specialized Hospital, Ethiopia.

METHODS

A retrospective follow-up study was conducted among a total of 1,132 pregnant women. Client charts were selected using a simple random sampling technique. Data were extracted using structured checklist prepared in the Kobo Toolbox application and exported to STATA version 14 and R version 4.2.2 for data management and analysis. Stepwise backward multivariable analysis was done. A simplified risk prediction model was developed based on a binary logistic model, and the model's performance was assessed by discrimination power and calibration. The internal validity of the model was evaluated by bootstrapping. Decision Curve Analysis was used to determine the clinical impact of the model.

RESULT

The incidence of preterm birth was 10.9%. The developed risk score model comprised of six predictors that remained in the reduced multivariable logistic regression, including age < 20, late initiation of antenatal care, unplanned pregnancy, recent pregnancy complications, hemoglobin < 11 mg/dl, and multiparty, for a total score of 17. The discriminatory power of the model was 0.931, and the calibration test was p > 0.05. The optimal cut-off for classifying risks as low or high was 4. At this cut point, the sensitivity, specificity and accuracy is 91.0%, 82.1%, and 83.1%, respectively. It was internally validated and has an optimism of 0.003. The model was found to have clinical benefit.

CONCLUSION

The developed risk-score has excellent discrimination performance and clinical benefit. It can be used in the clinical settings by healthcare providers for early detection, timely decision making, and improving care quality.

Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis

BACKGROUND

Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment.

METHODS

We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals.

RESULTS

The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia.

CONCLUSION

Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.

The interaction between no folic acid supplementation during early pregnancy and preeclampsia increased the risk of preterm birth

OBJECTIVES

To explore if there is a positive additive interaction between no folic acid (FA) supplementation in early period of pregnancy and preeclampsia which increases the risk of preterm birth (PTB).

METHODS

We matched 1471 women who had live-birth singleton preterm infants with 1471 women who had live-birth singleton term infants at 15 Chinese hospitals in 2018. We excluded women who took folic acid less than 0.4 mg/d or less than 12 weeks in early stage, women with gestational hypertension, chronic hypertension, or preeclampsia during previous pregnancy. We calculate odds ratios for PTB by performing conditional logistic regression comparing preterm group with term group.We quantified the interaction between 2 exposures by synergy (S) and relative excess risk due to interaction (RERI).

RESULTS

Approximately 40% of preterm cases did not take FA in early pregnancy. After adjusting confounding factors by logistic regression, when the 2 exposures (no early FA supplementation and preeclampsia) co-existed, the risk of all PTB increased significantly (aOR11=12.138; 95% CI 5.726-25.73), the interaction between 2 exposures was positive (S=1.27) and increased 2.385-fold risk of all PTB (RERI=2.385); and there were similar results on iatrogenic PTB (aOR11=23.412; 95% CI 8.882-60.71, S=1.18, RERI=3.347).

CONCLUSION

Our multicenter study showed, for the first time, that there was a positive additive interaction between no FA supplementation in early pregnancy and preeclampsia which increased the risk of all PTB, especially iatrogenic PTB.

Prevalence and associated risk factors of preterm birth among neonates in referral hospitals of Amhara Region, Ethiopia

INTRODUCTION

Preterm birth (PTB) is the largest direct cause of neonatal mortality and the second leading cause of under-five mortality following pneumonia. Although there are studies conducted before, the magnitude of PTB remains a major issue in most developing countries including Ethiopia. Therefore, this study aims to assess the prevalence and associated factors of premature birth among newborns delivered in Amhara Region Referral Hospitals, Northern Ethiopia.

METHODS

A hospital-based cross-sectional study was undertaken from February to April 2020. A systematic sampling technique was used to select 482 mother-newborn pairs. The data were collected by interviewing the mothers and reviewing their charts using a structured and pretested questionnaire. The outcome variable was preterm birth. Data were entered using Epi-data version 4.6 and then analyzed using STATA software (version 14). Bivariable and multivariable logistic regression analyses were done to determine the risk factors associated with premature birth.

RESULTS

In this study, the prevalence of premature birth was 11.41% (95% CI: 8.9, 14.6%). In multivariable logistic regression model; maternal age < 20 years (Adjusted odds ratio (AOR) = 7.8: 95% CI 2.3-26), preeclampsia (AOR = 5: 95% CI 2.3-11), premature rupture of membrane (AOR = 3.9: 95%CI 1.6-9.0), chronic medical illness (AOR = 4.6:95% CI2.1-10), and history of stillbirth (AOR = 2.7: 95% CI 1.1-7.3) were significantly associated with preterm birth.

CONCLUSION

The study indicates preterm birth is a major public health problem among newborns delivered in Amhara region referral hospitals. The risk factors associated with preterm birth are maternal age <20 years, preeclampsia, premature rupture of membranes, chronic medical illness, and history of stillbirth. Therefore, public health interventions have to be made to reduce the burden of prematurity through early detection and management of preeclampsia, premature rupture of membranes, and chronic medical illness. Obstetric care providers should give due attention to women with an age of <20 years and a history of stillbirth.

Developing and validating a risk prediction model for preterm birth at Felege Hiwot Comprehensive Specialized Hospital, North-West Ethiopia: a retrospective follow-up study

OBJECTIVE

To develop and validate a risk prediction model for the prediction of preterm birth using maternal characteristics.

DESIGN

This was a retrospective follow-up study. Data were coded and entered into EpiData, V.3.02, and were analysed using R statistical programming language V.4.0.4 for further processing and analysis. Bivariable logistic regression was used to identify the relationship between each predictor and preterm birth. Variables with p≤0.25 from the bivariable analysis were entered into a backward stepwise multivariable logistic regression model, and significant variables (p<0.05) were retained in the multivariable model. Model accuracy and goodness of fit were assessed by computing the area under the receiver operating characteristic curve (discrimination) and calibration plot (calibration), respectively.

SETTING AND PARTICIPANTS

This retrospective study was conducted among 1260 pregnant women who did prenatal care and finally delivered at Felege Hiwot Comprehensive Specialised Hospital, Bahir Dar city, north-west Ethiopia, from 30 January 2019 to 30 January 2021.

RESULTS

Residence, gravidity, haemoglobin <11 mg/dL, early rupture of membranes, antepartum haemorrhage and pregnancy-induced hypertension remained in the final multivariable prediction model. The area under the curve of the model was 0.816 (95% CI 0.779 to 0.856).

CONCLUSION

This study showed the possibility of predicting preterm birth using maternal characteristics during pregnancy. Thus, use of this model could help identify pregnant women at a higher risk of having a preterm birth to be linked to a centre.

Maternal and dietary behavior-related factors associated with preterm birth in Southeastern Terai, Nepal: A cross sectional study

Background

Preterm birth (PTB) is a global issue although its burden is higher in low- and middle-income countries. This study examined the risk factors of PTB in Southeastern Terai, Nepal.

Methods

In this community-based cross-sectional study, a total of 305 mothers having children under the age of 6 months were selected using systematic random sampling. Data were collected by structured interviewer-administered questionnaires and maternal antenatal cards from study participants for some clinical information. Predictors of PTB were identified using multi-level logistic regression analysis at a P-value < 0.05.

Results

Of the total 305 mother-live-born baby pairs, 13.77% (42/305) had preterm childbirth. Maternal socio-demographic factors such as mothers from Dalit caste/ethnicity [adjusted odds ratio (AOR) = 12.16, 95% CI = 2.2-64.61] and Aadibasi/Janajati caste/ethnicity (AOR = 3.83, 95% CI = 1.01-14.65), family income in the first tercile (AOR = 6.82, 95% CI = 1.65-28.08), than their counterparts, were significantly positively associated with PTB. Likewise, other maternal and dietary factors, such as birth order first-second (AOR = 9.56, 95% CI = 1.74-52.53), and birth spacing ≤ 2 years (AOR = 5.16, 95% CI = 1.62-16.42), mothers who did not consume additional meal (AOR = 9.53, 95% CI = 2.13-42.55), milk and milk products (AOR = 6.44, 95% CI = 1.56-26.51) during pregnancy, having <4 antenatal (ANC) visits (AOR = 4.29, 95% CI = 1.25-14.67), did not have intake of recommended amount of iron and folic acid tablets (IFA) (<180 tablets) (AOR = 3.46, 95% CI = 1.03-11.58), and not having adequate rest and sleep (AOR = 4.83, 95% CI = 1.01-23.30) during pregnancy had higher odds of having PTB than their counterparts.

Conclusion

Some socio-demographic, maternal, and dietary behavior-related factors were independently associated with PTB. These factors should be considered while designing targeted health interventions in Nepal. In addition, we recommend specific measures such as promoting pregnant women to use available antenatal care and counseling services offered to them, as well as having an adequate diet to a level that meets their daily requirements.

A Scoping Review of Preterm Births in Sub-Saharan Africa: Burden, Risk Factors and Outcomes

Preterm births (PTB) are the leading cause of neonatal deaths, the majority of which occur in low- and middle-income countries, particularly those in Sub-Saharan Africa (SSA). Understanding the epidemiology of prematurity is an essential step towards tackling the challenge of PTB in the sub-continent. We performed a scoping review of the burden, predictors and outcomes of PTB in SSA. We searched PubMed, Embase, and three other databases for articles published from the database inception to 10 July 2021. Studies reporting the prevalence of PTB, the associated risk factors, and/or its outcomes were eligible for inclusion in this review. Our literature search identified 4441 publications, but only 181 met the inclusion criteria. Last menstrual period (LMP) was the most commonly used method of estimating gestational age. The prevalence of PTB in SSA ranged from 3.4% to 49.4%. Several risk factors of PTB were identified in this review. The most frequently reported risk factors (i.e., reported in ≥10 studies) were previous history of PTB, underutilization of antenatal care (<4 visits), premature rupture of membrane, maternal age (≤20 or ≥35 years), inter-pregnancy interval, malaria, HIV and hypertension in pregnancy. Premature babies had high rates of hospital admissions, were at risk of poor growth and development, and were also at a high risk of morbidity and mortality. There is a high burden of PTB in SSA. The true burden of PTB is underestimated due to the widespread use of LMP, an unreliable and often inaccurate method for estimating gestational age. The associated risk factors for PTB are mostly modifiable and require an all-inclusive intervention to reduce the burden and improve outcomes in SSA.

Determinants of neonatal mortality among preterm births in Black Lion Specialized Hospital, Addis Ababa, Ethiopia: a case-cohort study

BACKGROUND

Preterm neonatal death is a global burden in both developed and developing countries. In Ethiopia, it is the first and fourth cause of newborn and under-5 deaths, respectively. From 2015 to present, the government of Ethiopia showed its effort to improve the survival of neonates, mainly preterm births, through the inclusion of high-impact life-saving neonatal interventions. Despite these efforts, the cause of preterm neonatal death is still not reduced as expected. Therefore, this study aimed to identify determinants of preterm neonatal mortality.

METHODS

An institution-based retrospective case-cohort study was conducted among a cohort of preterm neonates who were born between March 2013 and February 2018. A total of 170 cases were considered when the neonates died during the retrospective follow-up period, which was confirmed by reviewing a medical death certificate. Controls were 404 randomly selected charts of neonates who survived the neonatal period. Data were collected from patient charts using a data extraction tool, entered using EpiData V.3.1 and analysed using STATA V.14. Finally, a multivariate logistic regression analysis was performed, and goodness of fit of the final model was tested using the likelihood ratio test. Statistical significance was declared at a p value of ≤0.05.

RESULTS

In this study, the overall incidence rate of mortality was 39.1 (95% CI: 33.6 to 45.4) per 1000 neonate-days. Maternal diabetes mellitus (adjusted OR (AOR): 2.3 (95% CI: 1.4 to 3.6)), neonatal sepsis (AOR: 1.6 (95% CI: 1.1 to 2.4)), respiratory distress (AOR: 1.5 (95% CI: 1.1 to 2.3)), extreme prematurity (AOR: 2.9 (95% CI: 1.61 to 5.11)), low Apgar score (AOR: 3.1 (95% CI: 1.79 to 5.05)) and premature rupture of membranes (AOR: 2.3 (95% CI: 1.8 to 3.5)) were found to be predictors.

CONCLUSION

In this study, the overall incidence was found to be high. Premature rupture of membranes, maternal diabetes mellitus, sepsis, respiratory distress, extreme prematurity and low Apgar score were found to be predictors of neonatal mortality. Therefore, it should be better to give special attention to patients with significantly associated factors.

Survival and mortality of preterm neonates in a neonatal intensive care unit in Northern Ethiopia: a retrospective cohort study

The purpose of this study was to assess the predictors of preterm neonatal survival in a neonatal intensive care unit (NICU). A cohort study was conducted retrospectively on 1017 preterm neonates using medical records from January 2014 through December 2018. The Kaplan–Meier model was used to estimate mean survival time and cumulative survival probability. Furthermore, Multivariable Cox regression analysis was run to identify predictors of preterm neonatal mortality using an adjusted hazard ratio (AHR) at P < 0.05 and 95% confidence interval (CI). During the follow-up period in the NICU, the mean survival time of the preterm neonates was 47 (95% CI (43.19–48.95)) days. Compound presentation (AHR = 2.29, 95% CI (1.23–4.24)), perinatal asphyxia (AHR = 2.83, 95% CI (1.75–4.58)), respiratory distress syndrome (AHR = 3.01, 95% CI (1.80–5.01)), 1-min APGAR score (AHR = 0.78, 95% CI (0.62–0.98)), and birth weight (AHR = 0.32, 95% CI (0.17–0.58)) were found to be significant predictors of time to preterm neonatal mortality. In conclusion, the survival probability of preterm neonates showed a considerable decrement in the first week of life. Fetal presentation, gestational age, birth weight, 1-min APGAR score, perinatal asphyxia and respiratory distress syndrome found as independent predictors of preterm neonatal mortality.

Is preterm birth associated with intimate partner violence and maternal malnutrition during pregnancy in Ethiopia? A systematic review and meta analysis

BACKGROUND

Despite remarkable progress in the reduction of under-five mortality, preterm birth associated mortality and morbidity remains a major public health problem in Sub-saharan Africa. In Ethiopia, study findings on the association of preterm birth with intimate partner violence and maternal malnutrition have been inconsistent. Therefore, this systematic review and meta-analysis estimates the pooled effect of intimate partner violence and maternal malnutrition on preterm birth.

METHODS

International databases including PubMed, Web of Science, SCOPUS, CINAHL, PsycINFO, Google Scholar, Science Direct, and the Cochrane Library, were systematically searched. All identified observational studies and/or predictors were included. I2 statistics and Egger's test were used to assess the heterogeneity and publication biases of the studies. A random-effects model was computed to estimate the prevalence and its determinants of preterm birth.

RESULTS

The random effects meta-analysis showed that a pooled national prevalence of preterm birth was 13% (95% CI: 10.0%, 16.0%). The highest prevalence of preterm birth was 25% (95% CI: 21.0%, 30.0%) in Harar, and the lowest prevalence was 8% in Southern Nations Nationalities People of Representatives. The meta-analysis suggested a decrease in preterm birth of up to 61% among women receiving antenatal care [POR = 0.39 (95% CI: 0.21, 0.72)]. Women who experienced intimate partner violence [POR = 2.52 (95% CI: 1.68, 3.78)], malnutrition during pregnancy [POR = 2.00 (95% CI: 1.16, 3.46)], and previous preterm birth [POR = 3.73 (95% CI: 2.37, 5.88)] had significantly higher odds of preterm birth.

CONCLUSION

One in every eight live births in Ethiopia were preterm. Women who experienced intimate partner violence, malnutrition, and had previous preterm exposure were significantly associated with preterm birth. Thus, improving antenatal care visits and screening women who experience previous preterm birth are key interventions. The Federal Ministry of Health could be instrumental in preventing intimate partner violence and improving the nutritional status of pregnant women through proper and widespread implementation of programs to reduce preterm birth.

Preterm birth and its associated factors in Ethiopia: a systematic review and meta-analysis

Background

Preterm birth is a public health concern globally. In low- and middle-income countries, like Ethiopia, preterm birth is under reported and underestimated. Therefore, this systematic review and meta-analysis assessed the pooled prevalence and associated risk factors for preterm birth in Ethiopia.

Methods

In this review the databases used were PubMed, Google scholar, EMBASE, HINARI and African journal online. Publication bias was checked using a funnel plot and Eggers test.

Results

A total of 30 studies were included in this systematic review and meta-analysis. The overall pooled prevalence of preterm birth in Ethiopia was 11.4% (95% CI; 9.04, 13.76). On pooled analysis, preterm birth was associated with pregnancy-induced hypertension being HIV-positive, premature rupture of membrane, rural residence, the mother having a history of abortion, multiple pregnancies, and anemia during pregnancy.

Conclusion

The national prevalence of preterm birth in Ethiopia was low. Early identifying those pregnant women who are at risk of the above determinants and proving quality healthcare and counsel them how to prevent preterm births, which decrease the rate of preterm birth and its consequences. So, both governmental and non-governmental health sectors work on the minimization of these risk factors.

Nutritional-Related Predictors of Preterm Birth in North Shewa Hospitals, Central Ethiopia: A Case-Control Study

Background

Preterm birth (PTB) is the leading cause of newborn death and the second cause of mortality among under-five children. Globally, about 15 million infants are born preterm every year. However, there is a lack of data on the nutritional-related predictors of preterm birth among Ethiopian women. The objective of the study was to identify nutritional-related predictors of preterm birth among women who gave birth at North Shewa public Hospitals in central Ethiopia.

Methods

A case–control study was undertaken in public hospitals in the North Shewa zone, central Ethiopia. Interviewer-administered questionnaire was used to gather data, which was then entered into EPI INFO version 7 and then exported to SPSS version 23 for analysis. Data were presented using texts, tables, and proportions. To find predictors of preterm birth, researcher used binary and multiple logistic regression models. The presence of a relationship between PTB and predictor factors was determined using the adjusted odds ratio (AOR), 95% confidence interval (CI), and p-value <0.05.

Results

A total of 161 cases and 322 controls participated in the study making a response rate of 97.6%. Unable to get iron folic acid (IFA) (AOR=2.26, 95% CI: 1.22, 4.18), not eating additional meals (AOR=2.63, 95% CI: 1.1, 4.62), restriction of foods (AOR=2.85, 95% CI: 1.58, 5.12), not taking dark green leafy vegetables (DGLV), (AOR=4.46, 95% CI: 1.72, 11.61), and mid upper arm circumference of mother (MUAC) <23 centimeters (AOR=3.7, 95% CI: 2.25, 6.11) had statistically significant association with premature birth.

Conclusion

IFA supplementation, additional meals, food taboo, frequency of DGLV, and MUAC were identified predictors of preterm birth. Encouraging such women to eat additional meals, varieties of diets like vegetables, and fruits during pregnancy, and adhering to culturally appropriate nutrition education to reverse food taboo is compulsory.

Determinants of preterm birth among women delivered in public hospitals of Western Ethiopia, 2020: Unmatched case-control study

BACKGROUND

Worldwide, preterm birth accounts for 1 million deaths of infants each year and 60% of these deaths occur in developing countries. In addition to the significant health consequences on the infant, preterm birth can lead to economic costs. There was a lack of study in western Ethiopia, and most of those studies conducted in other parts of a country were based on card review with a cross-sectional study design. The risk factors of preterm birth may vary from region to region within the same country due to variation in socioeconomic status and health care service coverage. Therefore, this study aimed to identify determinants of preterm birth in western Ethiopia.

METHODS

An institutional-based case-control study was conducted from February 15 to April 15, 2020, in western Ethiopia. The eligible 188 cases and 377 controls were randomly selected for this study. Cases were women who gave birth after 28 weeks and before 37 completed weeks of gestation, and controls were women who gave birth at and after 37 weeks of gestation from the first day of the last normal menstrual period. Data were collected by a structured interviewer-administered questionnaire. The collected data were entered into Epi info version 7 and exported to SPSS version 21 for analysis. Multivariable logistic regression was used to identify determinants of preterm birth at P-value <0.05.

RESULTS

From a total of 565 eligible participants, 516 (172 cases and 344 controls) participated in this study with a response rate of 91.3%. The result of the multivariable analysis shows that mothers who developed pregnancy-induced hypertension (AOR = 3.13, 95% CI; 1.78, 5.50), only one time ANC visits (AOR = 5.99, 95% CI; 2.65, 13.53), experienced premature rupture of membrane (AOR = 3.57, 95% CI; 1.79, 7.13), birth interval less than two years (AOR = 2.96, 95% CI; 1.76, 4.98), developed anemia during the current pregnancy (AOR = 4.20, 95% CI; 2.13, 8.28) and didn't get dietary supplementation during the current pregnancy (AOR = 2.43, 95% CI; 1.51, 3.91) had statistically significant association with experiencing preterm birth.

CONCLUSION

Antenatal care service providers should focus on mothers with pregnancy-induced hypertension, premature rupture of membrane, and anemia during pregnancy, and refer to the senior experts for early management to reduce the risk of preterm delivery. Antenatal care services such as counseling the mother on the benefit of dietary supplementation during pregnancy, antenatal care follow up, and lengthening birth interval should be integrated into the existing health extension packages. New and inclusive strategies such as the establishment of comprehensive mobile clinic services should also be designed to reduce the burden of preterm birth among women living in the rural community. Lastly, we recommend future researchers to conduct longitudinal and community-based studies supplemented with qualitative methods.