Recurrence of adverse perinatal outcomes in developing countries

Racial and ethnic differences in the risk of recurrent preterm or small for gestational age births in the United States: a systematic review and stratified analysis

BACKGROUND

The risk of recurrent adverse birth outcomes has been reported worldwide, but there are limited estimates of these risks by social subgroups such as race and ethnicity in the United States. We assessed racial and ethnic disparities in the risk of recurrent adverse birth outcomes, including preterm birth, low birthweight, fetal growth restriction, small for gestational age, stillbirth, and neonatal mortality in the U.S.

METHODS

We searched MEDLINE, CINAHL Complete, Web of Science, and Scopus from the date of inception to April 5, 2022. We identified 3,540 articles for a title and abstract review, of which 80 were selected for full-text review. Studies were included if they focused on the recurrence of any of the six outcomes listed in the objectives. Study quality was assessed using the NIH Study Quality Assessment Tool. Heterogeneity across studies was too large for meta-analysis, but race and ethnicity-stratified estimates and tests for homogeneity results were reported.

RESULTS

Six studies on recurrent preterm birth and small for gestational age were included. Pooled comparisons showed a higher risk of recurrent preterm birth and small for gestational age for all women. Stratified race comparisons showed a higher but heterogeneous risk of recurrence of preterm birth across Black and White women. Relative risks of recurrent preterm birth ranged from 2.02 [1.94, 2.11] to 2.86 [2.40, 3.39] for Black women and from 3.23 [3.07, 3.39] to 3.92 [3.35, 4.59] for White women. The evidence was weak for race and ethnicity stratification for Hispanic and Asian women for both outcomes.

CONCLUSIONS

Disparities exist in the recurrence of preterm birth, and race/ethnicity-concordant comparisons suggest race is an effect modifier for recurrent preterm birth for Black and White women. Due to the small number of studies, no conclusions could be made for small for gestational age or Hispanic and Asian groups. The results pose new research areas to better understand race-based differences in recurrent adverse birth outcomes.

The association between increased fetal movements in the third trimester and perinatal outcomes; a systematic review and meta-analysis

BACKGROUND

Fetal movement monitoring is one of the strategies used to assess the fetus's health. Until now, most studies focused on the decreased fetal movement and neonatal outcome, although this systematic review and meta-analysis is designed to assess the association between increased fetal movements (IFM) with perinatal outcomes.

METHOD

The electronic databases including PubMed, Scopus, Web of Science, and EMBASE were systematically searched for studies investigating the perinatal outcome of women with increased fetal movements from inception to July 2023. Following that, a random-effect meta-analysis model was used to obtain the combined diagnostic and predictive parameters including perinatal mortality (still birth and early neonatal mortality), operative delivery, Apgar score, neonatal resuscitation at birth and NICU Admission.

RESULTS

After the initial screening, seven studies examining the association between increased third trimester fetal movement and various perinatal outcomes were included. Meta-analysis revealed a significant reduction in the risk of cesarean delivery among patients with IFM compared to controls, suggesting a potential protective effect during childbirth. However, no statistically significant difference was observed in birth weight, small or large for gestational age births, neonatal intensive care unit admission, maternal age, umbilical cord around the neck, gestational diabetes mellitus, and hypertension, indicating that IFM may not be a major predictor of adverse perinatal outcomes or maternal conditions. Notably, IFM was significantly associated with a higher likelihood of labor induction.

CONCLUSION

The findings suggest that IFM may have a protective effect against cesarean delivery. Additionally, IFM does not appear to be significantly associated with maternal age, umbilical cord around the neck, gestational diabetes mellitus and hypertension. However, the observed significant association with labor induction warrants further investigation.

A case of complex balanced chromosomal translocations associated with adverse pregnancy outcomes

Complex chromosomal rearrangements (CCR) are rare chromosomal structural abnormalities. The chromosomal structural variants in CCR carriers are one of the factors contributing to a history of adverse pregnancy and childbirth. In this study, we report a patient with a history of adverse pregnancy and childbirth who exhibited complex balanced chromosomal translocations. The female patient was phenotypically and intellectually normal; in her first pregnancy, the embryo was damaged, and a histological examination of the chromosomes of the embryos revealed a deletion of approximately 4.66 Mb at 1p32.3p32.2, a duplication of approximately 1.02 Mb at 1p22.2p22.1, a duplication of approximately 1.46 Mb at 6q27 and a deletion of approximately 7.78 Mb at 9p24.3p24.1. Chromosomal examinations of the patient revealed the karyotype to be 46,XX,(1;9)(p32; p34). In the second pregnancy, the foetus was diagnosed prenatally with three or more positive ultrasound soft indicators. The patient's karyotype was re-examined and further confirmed by fluorescence in situ hybridisation as 46,XX,t(1;9;6)(p31;p22;q27), revealing this patient was a carrier of complex balanced chromosomal translocations. Carriers of CCR have a higher risk of spontaneous abortion, and genetic counselling clinicians should consider the karyotype analyses of such patients in clinical practice and recheck their chromosomes if necessary.

Risk of recurrent stillbirth and neonatal mortality: mother-specific random effects analysis using longitudinal panel data from Indonesia (2000 - 2014)

Background

Despite significant government investments to improve birth outcomes in low and middle-income countries over the past several decades, stillbirth and neonatal mortality continue to be persistent public health problems. While they are different outcomes, there is little evidence regarding their shared and unique population-level risk factors over a mother’s reproductive lifespan. Data gaps and measurement challenges have left several areas in this field unexplored, especially assessing the risk of stillbirth or neonatal mortality over successive pregnancies to the same woman. This study aimed to assess the risk of stillbirth and neonatal mortality in Indonesia during 2000–2014, using maternal birth histories from the Indonesia Family Life Survey panel data.

Methods

Data from three panels were combined to create right-censored birth histories. There were 5,002 unique multiparous mothers with at least two singleton births in the sample. They reported 12,761 total births and 12,507 live births. Random effects (RE) models, which address the dependency of variance in births to the same mother, were fitted assuming births to the same mother shared unobserved risk factors unique to the mother.

Results

The main finding was that there having had a stillbirth increased the odds of another stillbirth nearly seven-fold and that of subsequent neonatal mortality by over two-fold. Having had a neonatal death was not associated with a future neonatal death. Mothers who were not educated and nullipara were much more likely to experience a neonatal death while mothers who had a prior neonatal death had no risk of another neonatal death due to unmeasured factors unique to the mother.

Conclusions

The results suggest that for stillbirths, maternal heterogeneity, as explained by a prior stillbirth, could capture underlying pathology while the relationship between observed risk factors and neonatal mortality could be much more dependent on context. Establishing previous adverse outcomes such as neonatal deaths and stillbirth could help identify high-risk pregnancies during prenatal care, inform interventions, and improve health policy.

Prediction of preterm delivery in threatened preterm labour with short cervical length

In this study, we evaluated the value of the uterocervical angle (UCA), myometrial thickness (MT), sICAM-1, sVCAM-1, soluble E-selectin (sE-selectin) and pentraxin 3 (PTX3) levels in women with threatened preterm labour (TPL) in predicting spontaneous preterm birth (sPTB) within 14 days in symptomatic women with cervical length (CL) measurements between 10 and 25 mm. Forty-six patients diagnosed with TPL, 47 healthy pregnant women were evaluated in a case-control study. sE-selectin (AUC = 0.744, p = .007) and PTX3 (AUC = 0.711, p = .019) were found to be effective in predicting preterm delivery within 14 days. In conclusion, maternal sE-selectin and PTX3 levels may be helpful in identifying pregnancies that will deliver within 14 days in symptomatic women with CL measurements between 10 and 25 mm. However, maternal sICAM-1 and sVCAM-1 levels, MT and UCA are not effective in the prediction of sPTB in TPL pregnancies. Impact StatementWhat is already known on this subject? Aetiology of spontaneous preterm birth (sPTB) is unclear and believed to be multifactorial, infection, inflammation, vascular endothelial dysfunction and uteroplacental ischaemia are all considered to be related to preterm delivery syndrome. Transvaginal cervical length (CL) measurement is a good indicator of increased risk of sPTB. Inflammation is accepted to have a central role in the process of labour.What do the results of this study add? soluble E-selectin (sE-selectin) and pentraxin 3 (PTX3) levels may be helpful in identifying pregnancies that will deliver within 14 days in symptomatic women with CL measurements between 10 and 25 mm.What are the implications of these findings for clinical practice and/or further research? This study will help understand the important role of the inflammatory process in predicting spontaneous preterm birth.

Predictors of adverse perinatal outcome among women who gave birth at Medical Center of Southwest Ethiopia: a retrospective cohort study

OBJECTIVES

The aim of this study was to determine predictors of adverse perinatal outcome among women who gave birth at Medical Center of Southwest Ethiopia.

SETTING

Institutional based retrospective cohort study was conducted among women who gave birth at Medical Center of Southwest Ethiopia.

PARTICIPANTS

Medical record of 777 women was included in the study by using maternity HMIS logbook as entry point. Simple random sampling technique without replacement was employed to select individual medical record using computer generated random numbers.

PRIMARY OUTCOME MEASURED

Predictors of adverse perinatal outcome were examined using modified Poisson regression with a robust SE.

RESULTS

Majority, 74.1% of the participants were in the age group of 21-34 years and the median age was 26 (IQR=7) years. More than one-third, 35.9% of the mothers were primigravida and only 21.2% of them had above four antenatal cares (ANC) visit. The overall incidence of adverse perinatal outcome was 31.5% (95% CI: 28.3 to 34.9). Maternal age less than 20 years (adjusted risk ratio, aRR=1.3; 95% CI: 1.01 to 1.5), rural residence (aRR=1.27; 95% CI: 1.04 to 1.59), presence of antepartum haemorrhage in current pregnancy (aRR=1.7; 95% CI: 1.38 to 2.07), maternal anaemia (aRR=1.25; 95% CI: 1.03 to 1.53), lack of ANC visit (aRR=2.29; 95% CI: 1.35 to 3.90), induced labour (aRR=1.77; 95% CI: 1.43 to 2.19) and being positive for venereal disease research laboratory (VDRL) test in current pregnancy (aRR=2.0; 95% CI: 1.16 to 3.38) were found to be significantly associated with adverse perinatal outcome.

CONCLUSION

The incidence of adverse perinatal outcome in the study area is high and maternal age less than 20, rural residency, maternal anaemia, antepartum haemorrhage in the current pregnancy, inadequate ANC visit, induction of labour and being positive for VDRL test were found to predict occurrence of adverse perinatal outcome. Majority of these problems can be managed by providing quality antenatal, intrapartum and post-natal care.

The unspoken grief of multiple stillbirths in rural Pakistan: an interpretative phenomenological study

Background

Pakistan has the highest rate of stillbirth (30.6 stillbirths per 1000 total births) as compared to other South Asian countries. The psychological impact of stillbirths on bereaved women is well documented; however, there is a dearth of literature on lived experiences of women with multiple stillbirths in Pakistan.

Objective

The purpose of this research is to understand the lived experiences of women who had multiple stillbirths in Thatta, Pakistan.

Methods

An interpretative phenomenological study was conducted in district Thatta with eight women who experienced more than one stillbirth. A semi-structured in-depth interview guide was used for data collection. The data were analyzed by using thematic analysis approach.

Results

The results of this study show that experiencing multiple stillbirths has a devastating impact on women’s mental and social wellbeing. The women who experienced multiple stillbirths are stigmatized as “child-killer” or cursed or being punished by God. They are avoided in social gatherings within the families and community, because of these social pressures these women seek spiritual and religious treatment, and struggle to conceive again to deliver a live baby. It was observed that the psycho-social and medical needs of these bereaved women remain unaddressed not only by the healthcare system but also by the society at large.

Conclusions

The physical, social and mental well-being of women who experience multiple stillbirth are at stake. These women are being considered social outcast. Health care providers including physicians, lady health workers, and traditional birth attendants should be trained on provision of psychosocial support along with the routine care that they provide in communities and health facilities. The health care providers should also inform the bereaved women about the biomedical causes of stillbirths that would be helpful to mitigate the stigma associated with stillbirths. Moreover, the health care providers should also counsel family members especially in-laws of these sorrowful women about the biomedical causes of stillbirths that would also be helpful to mitigate the stigma associated with stillbirths.

The effect of inter-pregnancy interval on stillbirth in urban South Ethiopia: a community-based prospective cohort study

BACKGROUND

Stillbirth is an invisible and poorly understood adverse pregnancy outcome that remains a challenge in clinical practice in low-resource settings. It is also a key concern in Ethiopia where more than half of pregnancies occur shortly after preceding childbirth. Whether the interval between pregnancies has an effect on stillbirth or not is unclear. Therefore, we aimed to assess the effect of inter-pregnancy interval on stillbirth in urban South Ethiopia.

METHODS

A community-based prospective cohort study was conducted among 2578 pregnant women and followed until delivery. Baseline data were collected at the household level during registration and enrolment. End-line data were collected from hospitals during delivery. Exposed groups were pregnant women with inter-pregnancy intervals < 18 months and 18-23 months. Unexposed group contains women with inter-pregnancy intervals 24-60 months. A generalized linear model for binary outcome was applied, using R version 4.0.5 software. Relative risk (RR) was used to estimate the effect size with a 95% confidence level. Attributable fraction (AF) and population attributable fraction (PAF) were used to report the public health impact of exposure.

RESULTS

The overall incidence of stillbirth was 15 per 1000 total births, (95% CI: 11, 20%). However, the incidence was varied across months of inter-pregnancy intervals; 30 (< 18 months), 8 (18-23 months) and 10 (24-60 months) per 1000 total births. The risk of stillbirth was nearly four times (ARR = 3.55, 95%CI: 1.64, 7.68) higher for women with inter-pregnancy interval < 18 months as compared to 24-60 months. This means, about 72% (AF = 72, 95%CI: 39, 87%) of stillbirth among the exposed group (inter-pregnancy interval < 18 months category) and 42% (PAF = 42, 95%CI: 23, 50%) of stillbirth in the study population were attributed to inter-pregnancy interval < 18 months. These could be prevented with an inter-pregnancy interval that is at least 18 months or longer.

CONCLUSIONS

Inter-pregnancy interval under 18 months increases the risk of stillbirth in this population in urban South Ethiopia. Interventions targeting factors contributing to short inter-pregnancy intervals could help in reducing the risk of stillbirth. Improving contraceptive utilization in the community could be one of these interventions.

Direct maternal morbidity and the risk of pregnancy-related deaths, stillbirths, and neonatal deaths in South Asia and sub-Saharan Africa: A population-based prospective cohort study in 8 countries

BACKGROUND

Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa.

METHODS AND FINDINGS

This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman's self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes.

CONCLUSIONS

Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths.

TRIAL REGISTRATION

The study is not a clinical trial.

Joint Modeling of Singleton Preterm Birth and Perinatal Death Using Birth Registry Cohort Data in Northern Tanzania

Understanding independent and joint predictors of adverse pregnancy outcomes is essential to inform interventions toward achieving sustainable development goals. We aimed to determine the joint predictors of preterm birth and perinatal death among singleton births in northern Tanzania based on cohort data from the Kilimanjaro Christian Medical Center (KCMC) zonal referral hospital birth registry between 2000 and 2017. We determined the joint predictors of preterm birth and perinatal death using the random-effects models to account for the correlation between these outcomes. The joint predictors of higher preterm birth and perinatal death risk were inadequate (<4) antenatal care (ANC) visits, referred for delivery, experiencing pre-eclampsia/eclampsia, postpartum hemorrhage, low birth weight, abruption placenta, and breech presentation. Younger maternal age (15-24 years), premature rupture of membranes, placenta previa, and male children had higher odds of preterm birth but a lessened likelihood of perinatal death. These findings suggest ANC is a critical entry point for delivering the recommended interventions to pregnant women, especially those at high risk of experiencing adverse pregnancy outcomes. Improved management of complications during pregnancy and childbirth and the postnatal period may eventually lead to a substantial reduction of adverse perinatal outcomes and improving maternal and child health.

Prediction of perinatal death using machine learning models: a birth registry-based cohort study in northern Tanzania

OBJECTIVE

We aimed to determine the key predictors of perinatal deaths using machine learning models compared with the logistic regression model.

DESIGN

A secondary data analysis using the Kilimanjaro Christian Medical Centre (KCMC) Medical Birth Registry cohort from 2000 to 2015. We assessed the discriminative ability of models using the area under the receiver operating characteristics curve (AUC) and the net benefit using decision curve analysis.

SETTING

The KCMC is a zonal referral hospital located in Moshi Municipality, Kilimanjaro region, Northern Tanzania. The Medical Birth Registry is within the hospital grounds at the Reproductive and Child Health Centre.

PARTICIPANTS

Singleton deliveries (n=42 319) with complete records from 2000 to 2015.

PRIMARY OUTCOME MEASURES

Perinatal death (composite of stillbirths and early neonatal deaths). These outcomes were only captured before mothers were discharged from the hospital.

RESULTS

The proportion of perinatal deaths was 3.7%. There were no statistically significant differences in the predictive performance of four machine learning models except for bagging, which had a significantly lower performance (AUC 0.76, 95% CI 0.74 to 0.79, p=0.006) compared with the logistic regression model (AUC 0.78, 95% CI 0.76 to 0.81). However, in the decision curve analysis, the machine learning models had a higher net benefit (ie, the correct classification of perinatal deaths considering a trade-off between false-negatives and false-positives)-over the logistic regression model across a range of threshold probability values.

CONCLUSIONS

In this cohort, there was no significant difference in the prediction of perinatal deaths between machine learning and logistic regression models, except for bagging. The machine learning models had a higher net benefit, as its predictive ability of perinatal death was considerably superior over the logistic regression model. The machine learning models, as demonstrated by our study, can be used to improve the prediction of perinatal deaths and triage for women at risk.

Magnitude and trend of perinatal mortality and its relationship with inter-pregnancy interval in Ethiopia: a systematic review and meta-analysis

Background

Perinatal mortality remains a problem in Ethiopia. Findings of primary studies varied on level of perinatal mortality and its predictors including inter-pregnancy interval. The aim of this review was to estimate the pooled perinatal mortality rate, its trend overtime and verify the association with inter-pregnancy interval in Ethiopian context.

Methods

Studies were accessed through the electronic web-based search strategies from PubMed, ScienceDirect, Hinari for health via Research4Life, Google and Advanced Google search, and retrieving via relevant references using a combination of medical subject headings (MeSH terms) and key words related with inter-pregnancy interval. R version 3.4.3 software was used for the meta-analysis. A forest plot and I² test were done to assess heterogeneity. Sensitivity analysis and subgroup analysis were done to deal with heterogeneity. A weighted inverse variance random-effects model was applied to estimate pooled effect sizes. A funnel plot and Egger’s regression test were done to check publication bias.

Results

A total of 34 studies used to answer review questions (30 for perinatal mortality rate and its trend estimation from 1997 to 2019 and 8 for its relationship with inter-pregnancy interval). The pooled perinatal mortality rate was 51.3 per 1000 total births (95% CI: 40.8–62.8). The pooled stillbirth rate was 36.9 per 1000 births (95% CI: 27.3–47.8) and early neonatal mortality rate was 29.5 per 1000 live births (95% CI: 23.9–35.6). Increasing trend was seen in stillbirth rate (23.7 to 36.9 per 1000 births) while decreasing trend in early neonatal mortality rate (51 to 29.5 per 1000 live births). Slight reduction trend was observed in overall perinatal mortality rate (66 to 51.3 per 1000 births). An inter-pregnancy interval less than 15 months was found to be statistically significantly associated with perinatal mortality; pooled OR = 2.76 (95% CI: 2.1–3.62). Spacing pregnancy for at least 15 months was related with reducing perinatal mortality by 64% (95% CI: 52.38, 72.38%).

Conclusions

In Ethiopia, perinatal mortality rate remains high. Insignificant reduction trend was observed in overall perinatal mortality rate. Counseling couples about the importance of spacing pregnancy and intensifying long-acting contraceptive use will help in reducing perinatal mortality related to poor pregnancy spacing.

Predictors of perinatal death in the presence of missing data: A birth registry-based study in northern Tanzania

Background

More than five million perinatal deaths occur each year globally. Despite efforts put forward during the millennium development goals era, perinatal deaths continue to increase relative to under-five deaths, especially in low- and middle-income countries. This study aimed to determine predictors of perinatal death in the presence of missing data using birth registry data from Kilimanjaro Christian Medical Center (KCMC), between 2000–2015.

Methods

This was a retrospective cohort study from the medical birth registry at KCMC referral hospital located in Moshi Municipality, Kilimanjaro region, northern Tanzania. Data were analyzed using Stata version 15.1. Multiple imputation by fully conditional specification (FCS) was used to impute missing values. Generalized estimating equations (GEE) were used to determine the marginal effects of covariates on perinatal death using a log link mean model with robust standard errors. An exchangeable correlation structure was used to account for the dependence of observations within mothers.

Results

Among 50,487 deliveries recorded in the KCMC medical birth registry between 2000–2015, 4.2% (95%CI 4.0%, 4.3%) ended in perinatal death (equivalent to a perinatal mortality rate (PMR) of 41.6 (95%CI 39.9, 43.3) deaths per 1,000 births). After the imputation of missing values, the proportion of perinatal death remained relatively the same. The risk of perinatal death was significantly higher among deliveries from mothers who resided in rural compared to urban areas (RR = 1.241, 95%CI 1.137, 1.355), with primary education level (RR = 1.201, 95%CI 1.083, 1.332) compared to higher education level, with <4 compared to ≥4 antenatal care (ANC) visits (RR = 1.250, 95%CI 1.146, 1.365), with postpartum hemorrhage (PPH) (RR = 2.638, 95%CI 1.997, 3.486), abruption placenta (RR = 4.218, 95%CI 3.438, 5.175), delivered a low birth weight baby (LBW) (RR = 4.210, 95%CI 3.788, 4.679), male child (RR = 1.090, 95%CI 1.007, 1.181), and were referred for delivery (RR = 2.108, 95%CI 1.919, 2.317). On the other hand, deliveries from mothers who experienced premature rupture of the membranes (PROM) (RR = 0.411, 95%CI 0.283, 0.598) and delivered through cesarean section (CS) (RR = 0.662, 95%CI 0.604, 0.724) had a lower risk of perinatal death.

Conclusions

Perinatal mortality in this cohort is higher than the national estimate. Higher risk of perinatal death was associated with low maternal education level, rural residence, <4 ANC visits, PPH, abruption placenta, LBW delivery, child’s sex, and being referred for delivery. Ignoring missing values in the analysis of adverse pregnancy outcomes produces biased covariate coefficients and standard errors. Close clinical follow-up of women at high risk of experiencing perinatal death, particularly during ANC visits and delivery, is of high importance to increase perinatal survival.

A need for an update of Polish birth weight reference norms

The indicators of perinatal outcome are birth weight and gestational age. The standard method of assessing the outcome is comparing the newborn’s birth weight with the reference system, presented in the form of percentile charts. Acceleration or delay in prenatal development, which are associated with environmental changes, stress the need to validate the developmental norms. The goal of this study is to evaluate the need to construct new and accurate reference standards. The study includes data of newborns from singleton pregnancies: 4919 born in 2000 and 3683 born in 2015. Study variables included gestational age, sex, and birth weight. Percentile values estimated for two groups of infants born in years separated by a 15-year period, born in 2000 and in 2015, were compared. Birth weight percentiles, from the 28th to the 42nd week of gestation, were calculated using the Lambda Mu Sigma method. Estimated values revealed the birth weight standards in different weeks of gestational age for both years: 2000 and 2015. Comparison among medians estimated for infants born in these years showed the existence of significant differences among boys in the 28th, 36th, and 39th weeks and among girls in the 34th and 41st weeks of gestational age. As the period between the two measurements involves several years, environmental changes during this time period might have significantly affected the course of pregnancy and thus the birth weight. Hence, there is a need to validate the developmental norms. The reference standards should be renewed, and must be done on a periodical basis.

Predictors of neonatal mortality: development and validation of prognostic models using prospective data from rural Bangladesh

Objective

To assess the extent to which maternal histories of newborn danger signs independently or combined with birth weight and/or gestational age (GA) can capture and/or predict postsecond day (age>48 hours) neonatal death.

Methods

Data from a cluster-randomised trial conducted in rural Bangladesh were split into development and validation sets. The prompted recall of danger signs and birth weight measurements were collected within 48 hours postchildbirth. Maternally recalled danger signs included cyanosis (any part of the infant's body was blue at birth), non-cephalic presentation (part other than head came out first at birth), lethargy (weak or no arm/leg movement and/or cry at birth), trouble suckling (infant unable to suckle/feed normally in the 2 days after birth or before death, collected 1-month postpartum or from verbal autopsy). Last menstrual period was collected at maternal enrolment early in pregnancy. Singleton newborns surviving 2 days past childbirth were eligible for analysis. Prognostic multivariable models were developed and internally validated.

Results

Recalling ≥1 sign of lethargy, cyanosis, non-cephalic presentation or trouble suckling identified postsecond day neonatal death with 65.3% sensitivity, 60.8% specificity, 2.1% positive predictive value (PPV) and 99.3% negative predictive value (NPV) in the development set. Requiring either lethargy or weight <2.5 kg identified 89.1% of deaths (at 39.7% specificity, 1.9% PPV and 99.6% NPV) while lethargy or preterm birth (<37 weeks) captured 81.0% of deaths (at 53.6% specificity, 2.3% PPV and 99.5% NPV). A simplified model (birth weight, GA, lethargy, cyanosis, non-cephalic presentation and trouble suckling) predicted death with good discrimination (validation area under the receiver-operator characteristic curve (AUC) 0.80, 95% CI 0.73 to 0.87). A further simplified model (GA, non-cephalic presentation, lethargy, trouble suckling) predicted death with moderate discrimination (validation AUC 0.74, 95% CI 0.66 to 0.81).

Conclusion

Maternally recalled danger signs, coupled to either birth weight or GA, can predict and capture postsecond day neonatal death with high discrimination and sensitivity.

Syndemic of Lifetime Mental Illness, Substance Use Disorders, and Trauma and Their Association With Adverse Perinatal Outcomes

Adverse perinatal outcomes are a significant contributor to neonatal and infant deaths. Mental illness, substance use disorders, and interpersonal trauma are often prevalent within obstetrical populations. Previous literature has documented the individual associations between these psychosocial factors and adverse perinatal outcomes. The co-occurrence of these three psychosocial factors might represent a syndemic among pregnant women, although they have not been described as such in the literature. Analysis of the interrelatedness and aggregate effect of these factors may allow for a more effective screening process that may reduce adverse perinatal outcomes. The objective of this article is to examine whether psychosocial factors (mental illness, substance use disorders, and interpersonal trauma) were independently and synergistically associated with adverse perinatal outcomes. This is a retrospective cohort study of 1,656 pregnant women at a single institution. Perinatal outcome and psychosocial data were abstracted from each participant's electronic medical record. Univariate and bivariate analyses, and multiple logistic regression were performed. Mean age was 27.5 (SD = 6.2) years. The majority was Black (60.6%) and single (58%). Psychosocial factors were reported in 35% of women. The incidence of adverse perinatal outcomes increased with greater number of psychosocial factors: 21.2% if no psychosocial factor, 27.0% if one psychosocial factor, 27.4% if two, and 35.3% if all three (for trend, p = .01). Women who reported all three psychosocial factors had twice the odds of adverse perinatal outcomes (adjusted odds ratio = 2.04, 95% confidence interval = [1.09, 3.81], p = .03) compared with those who reported none. Our data suggest there is a synergistic relationship between the psychosocial factors that is associated with increased adverse perinatal outcomes. A validated screening tool is needed to stratify patient's risk of adverse perinatal outcomes based on psychosocial factors. Such screening could lead to tailored interventions that could decrease adverse perinatal outcomes.

Prevalence and maternal socio-demographic factors associated with stillbirth in health facilities in Anambra, South-East Nigeria

Background

Stillbirth is a major adverse perinatal outcome especially in low and middle income countries across the globe. Certain factors relating to mothers from such countries may be associated with this adverse condition.

Objectives

To determine the prevalence of stillbirth and also explore the maternal socio-demographic factors associated with stillbirth among mothers in rural communities in Anambra Central Senatorial District of Anambra State Nigeria who gave birth between January 2012 and December 2016.

Methods

All case files of mothers who were delivered of their babies were accessed at the sampled health facilities in the district. Data were collected using a structured proforma. A total of 313 stillbirth cases were recorded across the health facilities from 2012–2016.

Results

The highest prevalence of stillbirth was recorded in 2012 (38.07 per 1,000 total births). The prevalence of stillbirth was significantly associated with the maternal level of education, occupation, age and type of health facility the mother utilized (p<0.05).

Conclusions

We recommend that women empowerment should be a priority at both family and community levels to enable women to seek and obtain necessary care during pregnancy and delivery.

Prediction of preterm birth and adverse perinatal outcomes after cervical pessary placement in singleton pregnancies with short cervical length

OBJECTIVES

To identify ultrasound-assessed cervical characteristics, modified after pessary placement, which could be predictive of spontaneous preterm birth (sPTB) at < 34 weeks of gestation (WG) or severe adverse perinatal outcomes (APO).

STUDY DESIGN

This prospective observational study conducted at Vall d'Hebron Universitary Hospital assessed multiple cervical characteristics in women with short cervical length (CL). All participants were examined by transvaginal ultrasound before and immediately after a cervical pessary was placed. Cervical assessment included CL, uterocervical angles (UCA), and cervical consistency indexes (cervical consistency index (CCI) and cervical length consistency index (CLCI)). Pregnancy outcomes were recorded to determine the capacity of these variables for predicting sPTB at < 34 WG and severe APO.

RESULTS

Thirty-one women with short CL, 17 (54.8%) with asymptomatic midtrimester short CL, and 14 (45.2%) after arrested threatened preterm labor were enrolled. After pessary placement, transvaginal ultrasound detected four participants in whom the pessary was not correctly placed around the cervix (12.9%); additionally, significant changes were observed in most cervical baseline characteristics, with CL, anterior UCA (A-UCA), CLCI, and intersegmentary angle (ISA) being predictive of sPTB at <34 WG and severe APO. Receiver operator curves were calculated to compare the predictive capacity of these variables, with CL and A-UCA after pessary placement being the best predictive parameters with an area under the curve of 0.88 and 0.87, respectively.

CONCLUSIONS

Transvaginal ultrasound after pessary placement detects incorrect pessary placement after pessary insertion and during follow-up. APO and sPTB can be predicted by measuring CL, A-UCA, CLCI, and ISA immediately after pessary placement, being CL and A-UCA more accurate and easier to be measured. Our results help to better identify women in whom the pessary is more likely to fail. Further research is required to assess the effectiveness of applying alternative, sequential or additional treatments to reduce prematurity and our results could be considered when designing such studies.

Incidence and recurrence risk of low birth weight in Northern Tanzania: A registry based study

Background

Low birth weight (LBW) is an important indicator of newborn survival. It is associated with higher risk of morbidity, mortality and long-term health consequences. Little has been done on incidence and recurrence risk of LBW in developing countries including Tanzania. This study aimed to determine the incidence and recurrence risk of LBW among women who delivered at Kilimanjaro Christian Medical Center (KCMC), Tanzania.

Methods

A hospital-based prospective cohort study was conducted using maternally-linked data from KCMC birth registry between 2000 and 2010. A total of 26,191 women delivered singleton live babies during the study period. Of these, 4,603 (17.6%) had subsequent pregnancies. The recurrence risk of LBW was estimated using a multivariable log-binomial regression model. A robust variance estimator was used to account for correlation between births of the same mother.

Results

The incidence of LBW was 7.1%. The absolute recurrence risk of LBW was 28.1%. This corresponds to a relative risk (RR) of 5.08-fold, 95% CI 4.01–6.45). Antenatal care visits (<4) (RR: 5.00; 95% CI 3.58–6.98), preterm birth (RR: 4.55; 95% CI 3.21–6.43), positive HIV status (RR: 7.49: 95% CI 3.91–14.36) and preeclampsia (RR: 4.37; 2.60–7.35) in the first pregnancy were important predictors of LBW recurrence.

Conclusion

The incidence of LBW and its recurrence was high in the study population. Women with previous history of LBW had higher risk of recurrent LBW in subsequent pregnancies. Identification of factors associated with LBW recurrence, proper post-partum care management to ensure Healthy Timing and Spacing of Pregnancy, Pre-conception care and close clinical follow-up during subsequent pregnancy may help reduce LBW recurrence.

Adverse pregnancy outcomes, 'stillbirths and early neonatal deaths' in Mutare district, Zimbabwe (2014): a descriptive study

Background

Perinatal deaths account for 7% of the global burden of disease, with developing countries contributing about 98% of deaths. The aim of this study was to describe the prevalence and factors contributing to adverse pregnancy outcomes, particularly perinatal death, among women at Sakubva hospital, Mutare district, Zimbabwe from January to June 2014.

Methods

We conducted a retrospective review of 346 patient records, of women who delivered at Sakubva hospital and those referred from Mutare district facilities to Mutare Provincial Hospital, between January and June 2014. Descriptive statistics was used to explore the contributors to stillbirths and early neonatal deaths in Mutare.

Results

Of the 346 women, 54 (15.61%) experienced an adverse pregnancy outcome (stillbirth or early neonatal death). Contributing factors to adverse pregnancy outcomes included birthweight, gestational age, delivery complications and delivery methods. These factors are preventable if quality focused antenatal care, intrapartum care is provided. Identification of pregnancy complications and facilitation of proper method of delivery is key to improve quality of care. Caesarean section provision to all women who need it improves outcomes.

Conclusions

High prevalence of adverse pregnancy outcomes in Mutare district could be reduced through the provision of quality antenatal care throughout the continuum of care, pre-, intra and postpartum. Further studies to explore risk factors associated with high adverse outcomes are recommended.

Maternal near-miss and the risk of adverse perinatal outcomes: a prospective cohort study in selected public hospitals of Addis Ababa, Ethiopia

Background

Presence of maternal near-miss conditions in women is strongly associated with the occurrence of adverse perinatal outcomes, but not well-understood in low-income countries. The study aimed to ascertain the effect of maternal near-miss on the risk of adverse perinatal outcomes in Ethiopia.

Methods

A prospective cohort study was conducted in five public hospitals of Addis Ababa, Ethiopia. Women admitted from May 1, 2015 to April 30, 2016 were recruited for the study. We followed a total of 828 women admitted for delivery or treatment of pregnancy-related complications along with their singleton newborn babies. Maternal near-miss was the primary exposure and was ascertained using the World Health Organization criteria. Women who delivered without complications were taken as the non-exposed groups. The main outcome was adverse perinatal outcomes. Data on maternal near-miss and perinatal outcomes were abstracted from medical records of the participants. Exposed and non-exposed women were interviewed by well-trained data collectors to obtain information about potential confounding factors. Logistic regressions were performed using Stata version 13.0 to determine the adjusted odds of adverse perinatal outcomes.

Results

A total of 207 women with maternal near-miss and 621 women with uncomplicated delivery were included in the study. After adjusting for potential confounders, women with maternal near-miss condition had more than five-fold increased odds of adverse perinatal outcomes compared to women who delivered without any complications (AOR = 5.69: 95% CI; 3.69–8.76). Other risk factors that were independently associated with adverse perinatal outcomes include: rural residence, history of prior stillbirth and primary educational level.

Conclusions

Presence of maternal near-miss in women is an independent risk factor for adverse perinatal outcomes. Hence, interventions rendered at improvement in maternal health of Ethiopia can lead to an improvement in perinatal outcomes.

Effects of prenatal exposure to ambient air pollutant PM10 on ultrasound-measured fetal growth

Background

Limited epidemiological studies have investigated the relationship between prenatal exposure to ambient particulate matter and risk of abnormal fetal growth, and have reached inconclusive results. No study has been conducted in areas with very high air pollution levels. We investigated the hypothesis that exposure to high levels of particulate matter with aerodynamic diameter no larger than 10 µm (PM10) during pregnancy increases the risk of abnormal fetal growth.

Methods

A birth cohort study was performed in Lanzhou, China, 2010-12, including 8877 pregnant women with 18 583 ultrasound measurements of four fetal growth parameters during pregnancy, including biparietal diameter (BPD), femur length (FL), head circumference (HC) and abdominal circumference (AC). Mixed-effects modelling was used to examine the associations between PM10 exposure and risk of abnormal fetal growth.

Results

When average PM10 exposure from conception until the ultrasound examination exceeded 150 µg/m3, there were significant increases in standardized FL (β = 0.095, P = 0.0012) and HC (β = 0.090, P = 0.0078) measures. When average PM10 exposure was treated as continuous variable, we found a significant decrease in standardized BPD (β = -0.018, P = 0.0016) as per 10 µg/m3 increase in PM10. After examining the associations by various exposure windows, positive associations between higher levels of PM10 and fetal overgrowth were consistently seen for HC measures.

Conclusions

Our study suggested that prenatal exposure to high levels of ambient PM10 increased the risk of abnormal fetal growth. The findings from our study have important public health implications and also call for future studies to explore the underlying mechanisms and post-natal consequences of these findings.

Adverse pregnancy outcomes and imbalance in angiogenic growth mediators and oxidative stress biomarkers is associated with advanced maternal age births: A prospective cohort study in Ghana

Background

Advanced maternal age (AMA) has been associated with negative pregnancy outcomes. Oxidative stress (OS) and defective placental dysfunction are contributing factors. This study determined the association between AMA and adverse pregnancy outcomes, OS biomarkers and angiogenic growth mediators (AGMs) in normal pregnancies.

Methods

This prospective cohort study conducted at the Obstetrics and Gynaecology (O&G) Department of the Komfo Anokye Teaching Hospital (KATH) finally included 175 normal pregnant women comprising, 58 AMA (35–45 years), 55 (30–34 years) and 62 optimal childbearing age (20–29 years). Venous blood samples were collected at 28–32 weeks for soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PIGF), 8-epiprostaglandinF2-α (8-epi-PGF2α) and total antioxidant capacity (TAC) assays.

Results

Pregnancies of AMA had a significantly higher levels of sFlt-1, 8-epi-PGF2α and 8-epi-PGF2α: PIGF ratio but a reduced level of PIGF, TAC and PIGF: sFlt-1 ratio compared to 20–29 years (p<0.0001). A significant negative correlation between AMA and PIGF (r = -0.294; p = 0.038); TAC (r = -0.215; p = 0.001) and PIGF: sFlt-1 ratio (r = -0.457; p<0.0001) and a positive correlation with sFlt-1 (r = 0.269; p = 0.017), 8-epiPGF2α (r = 0.277; p = 0.029) and 8-epi-PGF2: PIGF ratio (r = 0.461; p<0.0001) levels were observed. The adjusted odds ratio (aOR), and 95% confidence interval, and p value for the significant independent adverse outcomes associated with AMA were emergency caesarean section [21.7 (5.9–121.3), p<00001], elective caesarean section [2.7(0.9–5.8), p = 0.0105], stillbirth [12.6(1.4–82.1), p<0.0001], post-partum haemorrhage [4.3(1.1–18.5), p = 0.0094], preterm delivery [8.2(3.5–28.4), p<0.0001], low birth weight babies [9.7(2.8–29.3), p<0.0001], birth asphyxia [3.8(1.6–12.7), p = 0.0054], Apgar score ≤ 7 after 5 min for babies [10.1(4.7–23.2), p<0.0001], placental abruption [3.5(1.3–8.4), p = 0.0117] and intrauterine growth restriction (IUGR) [4.6(2.3–12.9), p = 0.0001].

Conclusion

AMA pregnancies correlate with adverse pregnancy outcomes and imbalance in OS biomarkers and AGMs. It is incumbent on health care givers to provide effective antenatal care among AMA mothers as early identification of these imbalance and treatment can prevent adverse pregnancy outcomes.

Cervical pessary to reduce preterm birth <34 weeks of gestation after an episode of preterm labor and a short cervix: a randomized controlled trial

BACKGROUND

To date, no intervention has proved effective in reducing the spontaneous preterm birth rate in singleton pregnancies following an episode of threatened preterm labor and short cervix remaining.

OBJECTIVE

This study was designed to ascertain whether cervical pessaries could be useful in preventing spontaneous preterm birth in women with singleton pregnancies and a short cervix after a threatened preterm labor episode.

STUDY DESIGN

This open randomized controlled trial was conducted in 357 pregnant women (between 24⁰-33⁶ weeks) who had not delivered 48 hours after a threatened preterm labor episode and had a short cervix remaining (≤25 mm at 24⁰-29⁶ weeks; ≤15 mm at 30⁰-33⁶ weeks). Patients were randomly assigned to cervical pessary (179) or routine management (178). The primary outcome was the spontaneous preterm birth rate <34 weeks. Spontaneous preterm birth <28 and 37 weeks and neonatal morbidity and mortality were also evaluated in an intention-to-treat analysis.

RESULTS

No significant differences between the pessary and routine management groups were observed in the spontaneous preterm birth rate <34 weeks (19/177 [10.7%] in the pessary group vs 24/175 [13.7%] in the control group; relative risk, 0.78; 95% confidence interval, 0.45-1.38). Spontaneous preterm birth <37 weeks occurred less frequently in the pessary group (26/175 [14.7%] vs 44/175 [25.1%]; relative risk, 0.58; 95% confidence interval, 0.38-0.90; P = .01). Preterm premature rupture of membranes rate was significantly lower in pessary carriers (4/177 [2.3%] vs 14/175 [8.0%]; relative risk, 0.28; 95% confidence interval, 0.09-0.84; P = .01). The pessary group less frequently required readmission for new threatened preterm labor episodes (8/177 [4.5%] vs 35/175 [20.0%]; relative risk, 0.23; 95% confidence interval, 0.11-0.47; P < .0001). No serious adverse maternal events occurred; neonatal morbidity and mortality were similar in both groups.

CONCLUSION

Pessary use did not significantly lower the spontaneous preterm birth rate <34 weeks in women with a short cervix remaining after a threatened preterm labor episode but did significantly reduce the spontaneous preterm birth rate <37 weeks, threatened preterm labor recurrence, and the preterm premature rupture of membranes rate.

Pregnancy-related morbidity and risk factors for fatal foetal outcomes in the Taabo health and demographic surveillance system, Côte d'Ivoire

Background

Reliable, population-based data on pregnancy-related morbidity and mortality, and risk factors for fatal foetal outcomes are scarce for low- and middle-income countries. Yet, such data are essential for understanding and improving maternal and neonatal health and wellbeing.

Methods

Within the 4-monthly surveillance rounds of the Taabo health and demographic surveillance system (HDSS) in south-central Côte d’Ivoire, all women of reproductive age identified to be pregnant between 2011 and 2014 were followed-up. A questionnaire pertaining to antenatal care, pregnancy-related morbidities, delivery circumstances, and birth outcome was administered to eligible women. Along with sociodemographic information retrieved from the Taabo HDSS repository, these data were subjected to penalized maximum likelihood logistic regression analysis, to determine risk factors for fatal foetal outcomes.

Results

A total of 2976 pregnancies were monitored of which 118 (4.0%) resulted in a fatal outcome. Risk factors identified by multivariable logistic regression analysis included sociodemographic factors of the expectant mother, such as residency in a rural area (adjusted odds ratio (aOR) = 2.87; 95% confidence interval (CI) 1.31–6.29) and poorest wealth tertile (aOR = 1.79; 95% CI 1.02–3.14), a history of miscarriage (aOR = 23.19; 95% CI 14.71–36.55), non-receipt of preventive treatment such as iron/folic acid supplementation (aOR = 3.15; 95% CI 1.71–5.80), only two doses of tetanus vaccination (aOR = 2.59; 95% CI 1.56–4.30), malaria during pregnancy (aOR = 1.94; 95% CI 1.21–3.11), preterm birth (aOR = 4.45; 95% CI 2.82–7.01), and delivery by caesarean section (aOR = 13.03; 95% CI 4.24–40.08) or by instrumental delivery (aOR = 5.05; 95% CI 1.50–16.96). Women who paid for delivery were at a significantly lower odds of a fatal foetal outcome (aOR = 0.39; 95% CI 0.25–0.74).

Conclusions

We identified risk factors for fatal foetal outcomes in a mainly rural HDSS site of Côte d’Ivoire. Our findings call for public health action to improve access to, and use of, quality services of ante- and perinatal care.

Risk of stillbirth, preterm delivery, and fetal growth restriction following exposure in a previous birth: systematic review and meta-analysis

BACKGROUND

Little is known about the risk of non-recurrent adverse birth outcomes.

OBJECTIVES

To evaluate the risk of stillbirth, preterm birth (PTB), and small for gestational age (SGA) as a proxy for fetal growth restriction (FGR) following exposure to one or more of these factors in a previous birth.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Maternity and Infant Care, and Global Health from inception to 30 November 2016.

SELECTION CRITERIA

Studies were included if they investigated the association between stillbirth, PTB, or SGA (as a proxy for FGR) in two subsequent births.

DATA COLLECTION AND ANALYSIS

Meta-analysis and pooled association presented as odds ratios (ORs) and adjusted odds ratios (aORs).

MAIN RESULTS

Of the 3399 studies identified, 17 met the inclusion criteria. A PTB or SGA (as a proxy for FGR) infant increased the risk of subsequent stillbirth ((pooled OR 1.70; 95% confidence interval, 95% CI, 1.34-2.16) and (pooled OR 1.98; 95% CI 1.70-2.31), respectively). A combination of exposures, such as a preterm SGA (as a proxy for FGR) birth, doubled the risk of subsequent stillbirth (pooled OR 4.47; 95% CI 2.58-7.76). The risk of stillbirth also varied with prematurity, increasing three-fold following PTB <34 weeks of gestation (pooled OR 2.98; 95% CI 2.05-4.34) and six-fold following preterm SGA (as a proxy for FGR) <34 weeks of gestation (pooled OR 6.00; 95% CI 3.43-10.49). A previous stillbirth increased the risk of PTB (pooled OR 2.82; 95% CI 2.31-3.45), and subsequent SGA (as a proxy for FGR) (pooled OR 1.39; 95% CI 1.10-1.76).

CONCLUSION

The risk of stillbirth, PTB, or SGA (as a proxy for FGR) was moderately elevated in women who previously experienced a single exposure, but increased between two- and three-fold when two prior adverse outcomes were combined. Clinical guidelines should consider the inter-relationship of stillbirth, PTB, and SGA, and that each condition is an independent risk factor for the other conditions.

TWEETABLE ABSTRACT

Risk of adverse birth outcomes in next pregnancy increases with the combined number of previous adverse events.

PLAIN LANGUAGE SUMMARY

Why and how was the study carried out? Each year, around 2.6 million babies are stillborn, 15 million are born preterm (<37 weeks of gestation), and 32 million are born small for gestational age (less than tenth percentile for weight, smaller than usually expected for the relevant pregnancy stage). Being born preterm or small for gestational age can increase the chance of long-term health problems. The effect of having a stillbirth, preterm birth, or small-for-gestational-age infant in a previous pregnancy on future pregnancy health has not been summarised. We identified 3399 studies of outcomes of previous pregnancies, and 17 were summarised by our study. What were the main findings? The outcome of the previous pregnancy influenced the risk of poor outcomes in the next pregnancy. Babies born to mothers who had a previous preterm birth or small-for-gestational-age birth were more likely to be stillborn. The smaller and the more preterm the previous baby, the higher the risk of stillbirth in the following pregnancy. The risk of stillbirth in the following pregnancy was doubled if the previous baby was born both preterm and small for gestational age. Babies born to mothers who had a previous stillbirth were more likely to be preterm or small for gestational age. What are the limitations of the work? We included a small number of studies, as there are not enough studies in this area (adverse birth outcomes followed by adverse cross outcomes in the next pregnancy). We found very few studies that compared the risk of small for gestational age after preterm birth or stillbirth. Definitions of stillbirth, preterm birth categories, and small for gestational age differed across studies. We did not know the cause of stillbirth for most studies. What are the implications for patients? Women who have a history of poor pregnancy outcomes are at greater risk of poor outcomes in following pregnancies. Health providers should be aware of this risk when treating patients with a history of poor pregnancy outcomes.

Mother's education and the risk of several neonatal outcomes: an evidence from an Italian population-based study

Background

Maternal socioeconomic disparities strongly affect child health, particularly in low and middle income countries. We assessed whether neonatal outcomes varied by maternal education in a setting where healthcare system provides universal coverage of health services to all women, irrespective of their socioeconomic status.

Methods

A population-based study was performed on 383,103 singleton live births occurring from 2005 to 2010 in Lombardy, an Italian region with approximately 10 million inhabitants. The association between maternal education, birthplace and selected neonatal outcomes (preterm birth, low birth weight, small-for-gestational age, low 5-min Apgar score, severe congenital anomalies, cerebral distress and respiratory distress) was estimated by fitting logistic regression models. Model adjustments were applied for sociodemographic, reproductive and medical maternal traits.

Results

Compared with low-level educated mothers, those with high education had reduced odds of preterm birth (Odds Ratio; OR = 0.81, 95% CI 0.77–0.85), low birth weight (OR = 0.78, 95% CI 0.70–0.81), small for gestational age (OR = 0.82, 95% CI 0.79–0.85), and respiratory distress (OR = 0.84, 95% CI 0.80–0.88).

Mothers born in a foreign country had higher odds of preterm birth (OR = 1.16, 95% CI 1.11–1.20), low Apgar score (OR = 1.18, 95% CI 1.07–1.30) and respiratory distress (OR = 1.19, 95% CI 1.15–1.24) than Italian-born mothers. The influence of maternal education on neonatal outcomes was confirmed among both, Italian-born and foreign-born mothers.

Conclusions

Low levels of education and maternal birthplace are important factors associated with adverse neonatal outcomes in Italy. Future studies are encouraged to investigate factors mediating the effects of socioeconomic inequality for identifying the main target groups for interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1418-1) contains supplementary material, which is available to authorized users.

Cause of and factors associated with stillbirth: a systematic review of classification systems

INTRODUCTION

An estimated 2.6 million stillbirths occur worldwide each year. A standardized classification system setting out possible cause of death and contributing factors is useful to help obtain comparative data across different settings. We undertook a systematic review of stillbirth classification systems to highlight their strengths and weaknesses for practitioners and policymakers.

MATERIAL AND METHODS

We conducted a systematic search and review of the literature to identify the classification systems used to aggregate information for stillbirth and perinatal deaths. Narrative synthesis was used to compare the range and depth of information required to apply the systems, and the different categories provided for cause of and factors contributing to stillbirth.

RESULTS

A total of 118 documents were screened; 31 classification systems were included, of which six were designed specifically for stillbirth, 14 for perinatal death, three systems included neonatal deaths and two included infant deaths. Most (27/31) were developed in and first tested using data obtained from high-income settings. All systems required information from clinical records. One-third of the classification systems (11/31) included information obtained from histology or autopsy. The percentage where cause of death remained unknown ranged from 0.39% using the Nordic-Baltic classification to 46.4% using the Keeling system.

CONCLUSION

Over time, classification systems have become more complex. The success of application is dependent on the availability of detailed clinical information and laboratory investigations. Systems that adopt a layered approach allow for classification of cause of death to a broad as well as to a more detailed level.

Intimate partner violence during pregnancy and its association with preterm birth and low birth weight in Tanzania: A prospective cohort study

Introduction

Intimate partner violence (IPV) is a public health problem that affects millions of women worldwide. The role of violence as an underlying factor in poor birth outcomes remains an area where strong evidence is lacking. The aim of this study was to determine the association between intimate partner violence (IPV) and preterm delivery (PTB) and low birth weight (LBW).

Materials and methods

A prospective cohort study was conducted among 1112 pregnant women attending antenatal care in Moshi–Tanzania. The women were enrolled before 24 weeks gestation, followed-up at week 34 to determine exposure to violence during pregnancy, and after delivery to estimate gestation age at delivery and birth weight. Logistic regression analysis was performed to assess the association between exposure to IPV during pregnancy and PTB and LBW while adjusting for possible confounders. In addition, stratified analysis based on previous history of adverse pregnancy outcome was performed.

Results

One-third of the women experienced IPV during pregnancy, 22.3% reported emotional, 15.4% sexual and 6.3% physical violence. Women exposed to physical IPV were three times more likely to experience PTB (AOR = 2.9; CI 95%: 1.3–6.5) and LBW (AOR = 3.2; CI 95%: 1.3–7.7). Women with previous adverse pregnancy outcomes and exposure to physical IPV had a further increased risk of PTB (AOR = 4.5; CI 95%: 1.5–13.7) and LBW (AOR = 4.8; CI 95%: 1.6–14.8) compared to those without previous history of adverse outcome.

Conclusion

Women who are exposed to IPV during pregnancy are at increased risk of PTB and LBW. The risk is even stronger if the women additionally have suffered a previous adverse pregnancy outcome. Interventions addressing IPV are urgently needed to prevent occurrence and reoccurrence of PTB and LBW.

Pre-pregnancy high-risk factors at first antenatal visit: how predictive are these of pregnancy outcomes?

OBJECTIVE

To determine relationships between pre-pregnancy risk factors at first antenatal visit booking and pregnancy outcomes.

STUDY DESIGN

This was a multicenter, cross-sectional study involving women admitted for singleton delivery from July 1 until October 31 (3 months), 2013, at nine major maternity clinics in Kinshasa, Democratic Republic of Congo. All women were checked for hereditary, community, and personal medical/surgical risk situations and mother/infant problems in previous pregnancies. Maternal and perinatal complications related to current/just-terminated pregnancy were analyzed according to pre-pregnancy risk factors in order to establish their prediction concerning maternal and perinatal complications related to current/just-terminated pregnancy (odds ratios). Results are given with 95% confidence intervals, and P<0.05 was considered significant.

RESULTS

The study sample comprised 2,086 women. Primiparity (36.5%), single relationship status (26.4%), and maternal age ≥35 years (18.3%) were the most important non-pathologic risk factors, while arterial hypertension in family (34.3%), previous miscarriage (33.2%), overweight/obesity (21.9%), diabetes in family (21.1%), previous cesarean section (15.7%), previous postpartum hemorrhage (13.1%), low birth weight (10%), previous macrosomia (10%), and previous premature rupture of membranes (6.2%) predominated among pathologic risk factors. Major adverse outcomes recurred in some women, with recurrence rates of 21/37 (57%), 111/208 (53%), 74/208 (36%), 191/598 (32%), 132/466 (28%), 24/130 (18%), and 4/65 (6%) for prematurity, low birth weight, macrosomia, preeclampsia/eclampsia, cesarean section, premature rupture of membranes, and stillbirth, respectively. Outcomes that were significantly influenced by non-pathologic risk factors were also significantly influenced by pathologic risk factors.

CONCLUSION

Pregnancy adverse outcomes are strongly influenced by either non-pathologic or pathologic pre-pregnancy risk factors at first antenatal visit booking. The recurrence potential of complications is one reason to establish the predictability and preventability of morbidity such that the most appropriate referrals and best options throughout the pregnancy can be determined.

Causes of and factors associated with stillbirth in low- and middle-income countries: a systematic literature review

BACKGROUND

Annually, 2.6 million stillbirths occur worldwide, 98% in developing countries. It is crucial that we understand causes and contributing factors.

METHODS

We conducted a systematic review of studies reporting factors associated with and cause(s) of stillbirth in low- and middle-income countries (2000-13). Narrative synthesis to compare similarities and differences between studies with similar outcome categories.

MAIN RESULTS

A total of 142 studies with 2.1% from low-income settings were investigated; most report on stillbirths occurring at health facility level. Definition of stillbirth varied; 10.6% of studies (mainly upper middle-income countries) used a cut-off point of ≥22 weeks of gestation and 32.4% (mainly lower income countries) used ≥28 weeks of gestation. Factors reported to be associated with stillbirth include poverty and lack of education, maternal age (>35 or <20 years), parity (1, ≥5), lack of antenatal care, prematurity, low birthweight, and previous stillbirth. The most frequently reported cause of stillbirth was maternal factors (8-50%) including syphilis, positive HIV status with low CD4 count, malaria and diabetes. Congenital anomalies are reported to account for 2.1-33.3% of stillbirths, placental causes (7.4-42%), asphyxia and birth trauma (3.1-25%), umbilical problems (2.9-33.3%), and amniotic and uterine factors (6.5-10.7%). Seven different classification systems were identified but applied in only 22% of studies that could have used a classification system. A high percentage of stillbirths remain 'unclassified' (3.8-57.4%).

CONCLUSION

To build capacity for perinatal death audit, clear guidelines and a suitable classification system to assign cause of death must be developed. Existing classification systems may need to be adapted. Better data and more data are urgently needed.

[Epidemiology of loss pregnancy]

OBJECTIVES

Study of epidemiology of pregnancy loss.

MATERIALS AND METHOD

A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies.

RESULTS

The occurrence of first trimester miscarriage is 12% of pregnancies and 25% of women. Miscarriage risk factors are ages of woman and man, body mass index greater than or equal to 25kg/m(2), excessive coffee drinking, smoking and alcohol consumption, exposure to magnetic fields and ionizing radiation, history of abortion, some fertility disorders and impaired ovarian reserve. Late miscarriage (LM) complicates less than 1% of pregnancies. Identified risk factors are maternal age, low level of education, living alone, history of previous miscarriage, of premature delivery and of previous termination of pregnancy, any uterine malformation, trachelectomy, existing bacterial vaginosis, amniocentesis, a shortened cervix and a dilated cervical os with prolapsed membranes. Fetal death in utero has a prevalence of 2% in the world and 5/1000 in France. Its main risk factors are detailed in the chapter.

A quasi-experimental assessment of the effectiveness of the Community Health Strategy on health outcomes in Kenya

Background

Despite focused health policies and reform agenda, Kenya has challenges in improving households’ situation in poverty and ill health; interventions to address the Millennium Development Goals in maternal and child health, such as focused antenatal care and immunization of children, are yet to achieve success. Research has shown that addressing the demand side is critical in improving health outcomes. This paper presents a model for health systems performance improvement using a strategy that bridges the interface between the community and the health system.

Methods

The study employed quasi-experimental design, using pre- and post-intervention surveys in intervention and control sites. The intervention was the implementation of all components of the Kenyan Community Health Strategy, guided by policy. The two year intervention (2011 and 2012) saw the strategy introduced to selected district health management teams, service providers, and communities through a series of three-day training workshops that were held three times during the intervention period.

Baseline and endline surveys were conducted in intervention and control sites where community unit assessment was undertaken to determine the status of health service utilization before and after the intervention. A community health unit consists of 1000 households, a population of about 5000, served by trained community health workers, each supporting about 20 to 50 households. Data was organized and analyzed using Excel, SPSS, Epi info, Stata Cal, and SAS.

Results

A number of health indicators, such as health facility delivery, antenatal care, water treatment, latrine use, and insecticide treated nets, improved in the intervention sites compared to non-interventions sites. The difference between intervention and control sites was statistically significant (p<0.0001) for antenatal care, health facility delivery, water treatment, latrine use, use of insecticide treated nets, presence of clinic card, and measles vaccination. Degree of improvement across the various indicators measured differed by socio-demographic contexts. The changes were greatest in the rural agrarian sites, compared to peri-urban and nomadic sites.

Conclusion

The study showed that most of the components of the strategy were implemented and sustained in different socio-demographic contexts, while participatory community planning based on household information drives improvement of health indicators.

Recurrence of perinatal death in Northern Tanzania: a registry based cohort study

Background

Perinatal mortality is known to be high in Sub-Saharan Africa. Some women may carry a particularly high risk which would be reflected in a high recurrence risk. We aim to estimate the recurrence risk of perinatal death using data from a hospital in Northern Tanzania.

Methods

We constructed a cohort study using data from the hospital based KCMC Medical Birth Registry. Women who delivered a singleton for the first time at the hospital between 2000 and 2008 were followed in the registry for subsequent deliveries up to 2010 and 3,909 women were identified with at least one more delivery within the follow-up period. Recurrence risk of perinatal death was estimated in multivariate models analysis while adjusting for confounders and accounting for correlation between births from the same mother.

Results

The recurrence risk of perinatal death for women who had lost a previous baby was 9.1%. This amounted to a relative risk of 3.2 (95% CI: 2.2 - 4.7) compared to the much lower risk of 2.8% for women who had had a surviving baby. Recurrence contributed 21.2% (31/146) of perinatal deaths in subsequent pregnancies. Preeclampsia, placental abruption, placenta previa, induced labor, preterm delivery and low birth weight in a previous delivery with a surviving baby were also associated with increased perinatal mortality in the next pregnancy.

Conclusions

Some women in Tanzanian who suffer a perinatal loss in one pregnancy are at a particularly high risk of also losing the baby of a subsequent pregnancy. Strategies of perinatal death prevention that target pregnant women who are particularly vulnerable or already have experienced a perinatal loss should be considered in future research.