Assessment of obstetric high risk factors in a developing country

High-risk pregnancies and their association with severe maternal morbidity in Nepal: A prospective cohort study

Background

The early identification of pregnant women at risk of developing complications at birth is fundamental to antenatal care and an important strategy in preventing maternal death. This study aimed to determine the prevalence of high-risk pregnancies and explore the association between risk stratification and severe maternal morbidity.

Methods

This hospital-based prospective cohort study included 346 pregnant women between 28–32 gestational weeks who were followed up after childbirth at Koshi Hospital in Nepal. The Malaysian antenatal risk stratification approach, which applies four color codes, was used: red and yellow denote high-risk women, while green and white indicate low-risk women based on maternal past and present medical and obstetric risk factors. The World Health Organization criteria were used to identify women with severe maternal morbidity. Multivariate confirmatory logistic regression analysis was performed to adjust for possible confounders (age and mode of birth) and explore the association between risk stratification and severe maternal morbidity.

Results

The prevalence of high-risk pregnancies was 14.4%. Based on the color-coded risk stratification, 7.5% of the women were categorized red, 6.9% yellow, 72.0% green, and 13.6% white. The women with high-risk pregnancies were 4.2 times more likely to develop severe maternal morbidity conditions during childbirth.

Conclusions

Although smaller in percentage, the chances of severe maternal morbidity among high-risk pregnancies were higher than those of low-risk pregnancies. This risk scoring approach shows the potential to predict severe maternal morbidity if routine screening is implemented at antenatal care services. Notwithstanding, unpredictable severe maternal morbidity events also occur among low-risk pregnant women, thus all pregnant women require vigilance and quality obstetrics care but high-risk pregnant women require specialized care and referral.

Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries

BACKGROUND

A maternity waiting home (MWH) is a facility within easy reach of a hospital or health centre which provides emergency obstetric care (EmOC). Women may stay in the MWH at the end of their pregnancy and await labour. Once labour starts, women move to the health facility so that labour and giving birth can be assisted by a skilled birth attendant. The aim of the MWH is to improve accessibility to skilled care and thus reduce morbidity and mortality for mother and neonate should complications arise. Some studies report a favourable effect on the outcomes for women and their newborns. Others show that utilisation is low and barriers exist. However, these data are limited in their reliability.

OBJECTIVES

To assess the effects of a maternity waiting facility on maternal and perinatal health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 January 2012), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to January 2012), EMBASE (1980 to January 2012), CINAHL (1982 to January 2012), African Journals Online (AJOL) (January 2012), POPLINE (January 2012), Dissertation Abstracts (January 2012) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials including quasi-randomised and cluster-randomised trials that compared perinatal and maternal outcome in women using a MWH and women who did not.

DATA COLLECTION AND ANALYSIS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

MAIN RESULTS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of maternity waiting facilities for improving maternal and neonatal outcomes.

Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries

BACKGROUND

A Maternity Waiting Home (MWH) is a facility, within easy reach of a hospital or health centre which provides Emergency Obstetric Care (EmOC). Women may stay in the MWH at the end of their pregnancy and await labour. Once labour starts, women move to the health facility so that labour and giving birth may be assisted by a skilled birth attendant. The aim of the MWH is to improve accessibility and thus reduce morbidity and mortality for mother and neonate should complications arise. Some studies report a favourable effect on the outcomes for women and their newborn. Others show that utilisation is low and barriers exist. However these data are limited in reliability.

OBJECTIVES

To assess the effects of a maternity waiting facility on maternal and perinatal health.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009), CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHL (1982 to April 2009), African Journals Online (AJOL) (April 2009), POPLINE (April 2009), Dissertation Abstracts (April 2009) and the National Research Register archive (March 2008).

SELECTION CRITERIA

Randomised controlled trials including quasi-randomised and cluster-randomised trials that compared perinatal and maternal outcome in women using a MWH and women who did not.

DATA COLLECTION AND ANALYSIS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

MAIN RESULTS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of Maternity Waiting Facilities for improving maternal and neonatal outcomes.

Usefulness of risk scoring at booking for antenatal care in predicting adverse pregnancy outcome in a rural African setting

Antenatal care (ANC) attempts to screen and provide surveillance and treatment to individuals according to the level of need. We assessed the value of antenatal risk allocation made at the first visit in identifying women who will experience pregnancy complications in a rural area in Zimbabwe. As part of an ANC trial women were allocated into low- and high-risk categories based on medical, demographic and obstetric history. All highrisk women were recommended hospital delivery. This evaluation is based on 5223 women who received traditional care from nurse-midwives in 12 rural health centres, of whom 2890 (55%) were classified as high risk by the traditional risk markers, including 1618 nulliparous women. Complications occurred in 924 (17.7%) women 577 (62.4%) of whom had risk markers identified at booking. Twenty per cent (577/2890) of women classified as high risk developed complications. There was a high recurrence of complications, such as hypertensive disorders, operative delivery and preterm delivery. Nulliparity was a risk for low birth weight, operative delivery and hypertensive disorders, whereas grandmultiparity (> or =6) was a risk for hypertension in pregnancy. Young age (< or =16 years) was)a risk factor for low birth weight and perinatal death. Age above 35 years was not an independent risk factor. The traditional risk allocation system, with a likelihood ratio of 1.16, was not effective in identifying women at risk of pregnancy complications and resulted in too large a risk group for referral.

How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.

Morbidity and mortality in booked women who deliver outside orthodox health facilities in Calabar, Nigeria

Women who booked for antenatal care at the University of Calabar Teaching Hospital (UCTH), Calabar, but delivered outside orthodox health facilities were studied. The aims were to determine the pattern of maternal morbidity and mortality in them and to compare this with the pattern in women who booked and delivered at UCTH. One hundred and eighteen of the defaulters traced (35.1%) had complications compared with 34 (10.1%) of the control. Only 32.2% of these defaulters with complications presented in orthodox health facilities for treatment. The major complications in the study group were: perineal tear (19.0%); primary postpartum haemorrhage (12.5%); and puerperal sepsis (5.4%). These were significantly higher in the study group than in the controls (P<0.001). Maternal mortality ratio of 6.0 per 1000 live births was recorded in the study group, but there was no death in the control. Health education and public enlightenment campaigns emphasising universal antenatal care along with delivery in orthodox health facilities are strongly advocated.

Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey)

OBJECTIVE

To compare maternal morbidity and mortality in two urban populations with contrasting availability of health care, and to test the hypothesis that differences in maternal outcome result mainly from the management of delivery in health facilities.

DESIGN

A population-based study of a cohort of pregnant women which was part of a multicentre study of maternal morbidity in six countries of western Africa (MOMA).

SETTING

Two different urban areas of Senegal (Saint-Louis and Kaolack).

POPULATION

3,777 pregnant women who were followed up throughout pregnancy, delivery and puerperium.

MAIN OUTCOME MEASURES

Maternal morbidity and mortality: morbidity was assessed from women's recall at each visit by the investigator and from obstetric complications diagnosed by the birth attendant within health facilities.

RESULTS

Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centres, usually assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities went principally to the regional hospital and were usually assisted by midwives (874 and 151 maternal deaths per 100,000 live births, respectively, P < 0 x 01). Maternal morbidity, however, was higher in Saint-Louis than in Kaolack area, especially for births in health facilities (9 x 50 and 4 x 84 episodes of obstetric complications per 100 live births, respectively, P < 0 x 01). Univariate and multivariate analyses showed that morbidity was mainly associated with the training of the birth attendant in facility deliveries and that antenatal care had no effect.

CONCLUSION

Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to low fatality rates. This could explain differences in maternal outcome between two urban centres with contrasting health care availability. These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labour.

Are clinical criteria just proxies for socioeconomic status? A study of low birth weight in Jamaica

OBJECTIVE

To determine if the clinical risk factors for low birth weight are independent of socioeconomic risk factors in a population based sample from a developing country.

DESIGN

Survey data from patient reported socioeconomic measures and their most recent pregnancy history.

SETTING

A national sample of randomly selected households in Jamaica.

SUBJECTS

All women aged 14-50 in the household who had a pregnancy lasting seven months in the past five years (n = 952).

MAIN OUTCOME MEASURE

Birth weight.

RESULTS

Clinical risk factors for low birth weight, such as parity age, are independent of socioeconomic determinants, such as consumption and where a mother lives. Women who are nulliparous, 35 or older, poor, or living in certain areas are more likely to have lower birth weight children than those that do not have these characteristics (t statistics > 2.0). The addition of socioeconomic factors to the multiple regression does not alter the estimates for the clinical risk factors for low birth weight. Thus, the effect of being nulliparous can be offset by being in the highest consumption quintile and, conversely, the risk of being older will be compounded if women are poor.

CONCLUSIONS

Both clinical and socioeconomic risk factors should be used to target women at risk. In terms of the quality of care, this study links clinical and socioeconomic risk factors to poor outcomes. Further studies are needed, however, to link the quality of care at various locations to these outcomes.

Risk factors for primary postpartum haemorrhage. A case control study

The objective of the study was to determine which background factors predispose women to primary postpartum haemorrhage (PPH) at the Obafemi Awolowo University Hospital. The study consisted of 101 women who developed PPH after a normal vaginal delivery and 107 women with normal unassisted vaginal delivery without PPH Both cases and controls were investigated for sociodemographic risk factors, medical and obstetric histories, antenatal events and labour and delivery outcomes. Data were abstracted from the medical and delivery records and risks were estimated by multivariate logistic regression. The results of the univariate analysis revealed a number of potential risk factors for PPH but after adjustment by logistic regression three factors remained significant. These were prolonged second and third stages of labour and non-use of oxytocics after vaginal delivery. Previously hypothesised risk factors for PPH such as grand multiparity, primigravidity and previous episodes of PPH were not significantly associated with PPH. We conclude that primary PPH in this population is mostly associated with prolonged second and third stages of labour and non use of oxytocics. Efforts to reduce the incidence of PPH should not only be directed at proper management of labour but also training and retraining of primary health care workers and alternative health care providers in the early referral of patients with prolonged labour.

Effects of a maternity waiting home on adverse maternal outcomes and the validity of antenatal risk screening

OBJECTIVES

To evaluate the effect of a maternity waiting home (MWH) on adverse maternal outcomes and the validity of antenatal risk criteria in predicting dystocia.

METHOD

A hospital-based cohort study was conducted at a district hospital in Zimbabwe. Information on the presence of antenatal risk factors, stay at an MWH, and mode and outcome of delivery was collected for each woman delivering at the hospital during 1989-1991.

RESULTS

The risk of obstructed labor was 16 times higher for those not attending an MWH (n = 2915) than for those who did attend an MWH (n = 1573) (1 vs. 0.06%, P < 0.005). Among the non-users, 0.3% suffered a ruptured uterus compared with none of the MWH users. The presence of any one of the antenatal risk criteria used in Zimbabwe had a sensitivity of 78%, a specificity of 51% and positive predictive value of 25% for predicting dystocia.

CONCLUSION

MWHs and antenatal risk screening are policy options for safe motherhood programs in settings where emergency obstetric services are not easily accessible.

Antenatal screening: its use in assessing obstetric risk factors in Zimbabwe

STUDY OBJECTIVE

To assess the predictive utility of obstetric risk factors for identifying before the onset of labour those women at high risk of obstetric complications in a developing world setting, where home deliveries predominate and emergency transport is scarce.

DESIGN

Risk factors derived from two population based, case-control studies (one of cephalopelvic disproportion and one of post partum haemorrhage), carried out in Zimbabwe were used to construct weighted and unweighted scores, a variety of screening algorithms, and sets of probabilities estimated from logistic regression models. These screening tests were evaluated for sensitivity, specificity, positive predictive value, and "cost" (the proportion of the population testing positive). Each complication was evaluated separately and the two were then pooled.

PARTICIPANTS

All were Harare residents with singleton, vertex deliveries and spontaneous onset of labour. A total of 201 experienced cephalopelvic disproportion, 150 had post partum haemorrhage, and 299 had normal, unassisted deliveries.

MEASUREMENTS AND MAIN RESULTS

Largely because of the very low incidence of the two complications studied (1% or less), positive predictive values were low (less than 7%). Holding "cost" constant at 10%, a screening test for cephalopelvic disproportion could predict 42.3% of cases compared with only 35.0% of those with post partum haemorrhage. Weighted scores had little advantage over unweighted ones, and probabilities from the logistic regression models did not differentiate cases from controls very well.

CONCLUSIONS

With simple algorithms based on maternal height, parity, and obstetric history, more than one third of women at risk for potentially fatal complications could be identified at relatively small cost to themselves or the health care system.

Too far to walk: maternal mortality in context

The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.

Postpartum haemorrhage in Zimbabwe: a risk factor analysis

OBJECTIVES

To identify risk factors associated with postpartum haemorrhage (PPH) in order to improve the effectiveness of antenatal screening.

DESIGN

A population-based case control study.

SETTING

Harare, Zimbabwe.

SUBJECTS

Two groups of women, one group consisting of those with postpartum haemorrhage after a normal vaginal delivery and the other of women with normal unassisted vaginal delivery without PPH.

METHOD

Data abstracted from the medical records; relative risks were estimated by multivariate logistic regression.

RESULTS

Low parity, advanced maternal age, and antenatal hospitalisation were among the strongest risk factors, with more modest associations for history of poor maternal or perinatal outcomes and borderline anaemia at the time of booking. No association with grand multiparity was found.

CONCLUSIONS

These findings confirm the importance of previously recognised factors such as low parity, poor obstetric history, anaemia, and prolonged labour, but call into question the significance of grand multiparity. Previously undocumented factors such as maternal age greater than 35 years and occiput posterior head position emerged as predictors worthy of further investigation.

Emergency symphysiotomy for the trapped head in breech delivery: indications, limitations and method

Careful case selection can avoid most obstetrical emergencies. However, even with optimum management of breech labour, the fetal head may become trapped. Since doctors in developing nations must be prepared for this dire situation, this article reviews breech case selection and outlines the steps in breech delivery, illustrating symphysiotomy for the entrapped head. The limitations and precautions associated with symphysiotomy are stressed.

Puerperal sepsis: its contribution to maternal mortality

Puerperal sepsis is the second most common cause of maternal mortality in the developing world. In this paper the extent of the problem is described and factors affecting puerperal sepsis are identified. Methods of reducing the incidence of puerperal sepsis are suggested. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop in Kobe, Japan, October, 1990.

Postpartum haemorrhage: its contribution to maternal mortality

Postpartum haemorrhage is the major cause of maternal mortality in the developing world. This paper presents the incidences and discusses the causes and strategies for its prevention. The paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop in Kobe, Japan, Oct, 1990.

Use of antenatal cards for literate health personnel and illiterate traditional birth attendants: an overview

A review of the existing literature on various risk-oriented antenatal cards developed during the last 15 years, makes apparent a multitude of action-oriented cards available for trained health personnel (obstetric nurses, midwives and doctors). Few antenatal cards, however, have been developed for use by illiterate traditional birth attendants (TBAs). A revised version of an illiterate antenatal card is presented, that has been developed over the past 3 years in Mali. It contains some important improvements, notably its use at the various levels of the health care pyramid both by illiterate TBAs and by trained midwives. It also includes specific 'standing orders', based on generally accepted 'at-risk' criteria. Suggestions for its adaptation elsewhere in Africa as part of current Safe Motherhood policies are discussed.

Factors affecting desired family size among preliterate New Guinea mothers

A random sample of 331 Enga mothers in Papua New Guinea perceived that an average of 5.96 live births (S.D. = 1.88) were needed to achieve their mean desired completed family size (DFS) of 4.65 children (S.D. = 1.32). The mean of the personal child mortality rates projected by the individual mothers. 194/1000, is very close to the rate of 198/1000 (224 deaths among 1134 live births) experienced by the women as a group and the 177/1000 documented in a 1972 prospective study in the area. This suggests that as a group preliterate women may possess an accurate estimate of prevailing child mortality rates. Considerable interest in family planning was shown. However for cultural or linguistic reasons, the majority (except in the case of the pill and tubal ligation) expressed no opinions about their readiness to use specific modern methods. The mean parity of 43 women seeking tubal ligation was 5.98 (S.D. = 1.81). An integrated maternal health and family planning program focusing on the health benefits to mother and child of the current 3-4-year birth interval seems indicated.