Caesarean section among referred and self-referred birthing women: a cohort study from a tertiary hospital, northeastern Tanzania.

BACKGROUND: The inequity in emergency obstetric care access in Tanzania is unsatisfactory. Despite an existing national obstetric referral system, many birthing women bypass referring facilities and go directly to higher-level care centres. We wanted to compare Caesarean section (CS) rates among women formally referred to a tertiary care centre versus self-referred women, and to assess the effect of referral status on adverse outcomes after CS. METHODS: We used data from 21,011 deliveries, drawn from the birth registry of a tertiary hospital in northeastern Tanzania, during 2000-07. Referral status was categorized as self-referred if the woman had bypassed or not accessed referral, or formally-referred if referred by a health worker. Because CS indications were insufficiently registered, we applied the Ten-Group Classification System to determine the CS rate by obstetric group and referral status. Associations between referral status and adverse outcomes after CS delivery were analysed using multiple regression models. Outcome measures were CS, maternal death, obstetric haemorrhage ≥ 750 mL, postpartum stay > 9 days, neonatal death, Apgar score < 7 at 5 min and neonatal ward transfer. RESULTS: Referral status contributed substantially to the CS rate, which was 55.0% in formally-referred and 26.9% in self-referred birthing women. In both groups, term nulliparous singleton cephalic pregnancies and women with previous scar(s) constituted two thirds of CS deliveries. Low Apgar score (adjusted OR 1.42, 95% CI 1.09-1.86) and neonatal ward transfer (adjusted OR 1.18, 95% CI 1.04-1.35) were significantly associated with formal referral. Early neonatal death rates after CS were 1.6% in babies of formally-referred versus 1.2% in babies of self-referred birthing women, a non-significant difference after adjusting for confounding factors (adjusted OR 1.37, 95% CI 0.87-2.16). Absolute neonatal death rates were > 2% after CS in breech, multiple gestation and preterm deliveries in both referral groups. CONCLUSIONS: Women referred for delivery had higher CS rates and poorer neonatal outcomes, suggesting that the formal referral system successfully identifies high-risk birth, although low volume suggests underutilization. High absolute rates of post-CS adverse outcomes among breech, multiple gestation and preterm deliveries suggest the need to target self-referred birthing women for earlier professional intrapartum care.

Recording of maternal deaths in an East African university hospital.

OBJECTIVE: To trace all maternal deaths at a tertiary East African university hospital with a systematic registration of all births. DESIGN: Descriptive study. SAMPLE: One hundred and nineteen cases of maternal death which occurred in the period from 2000 to 2007 (including). METHODS: Identification through the birth registry and separate manual tracing of all case records. Account of practical problems concerning identification of cases and analysis of time trends, mothers' domicile, occurrence by phase of pregnancy, birth and puerperium, and diagnoses. RESULTS: There was considerable under-reporting of deaths in the medical birth registry. Twenty of 119 mothers died before 23 weeks' gestational age, most of them of unsafe abortion. Other prevalent direct causes of death were hemorrhage, eclampsia and other hypertensive complications. HIV/AIDS was primary cause in 20 cases. CONCLUSION: Even with relatively complete ascertainment of births, single hospital-based medical birth registries have limitations in studies of maternal deaths. They may identify risks among women who arrive for delivery at the hospital, but are not well suited for estimation of total maternal mortality within the hospital walls. This would require additional data. Extending the birth registry monitoring system to all health institutions with obstetrical services in a region will give more reliable estimates to be followed over time and serve as a basis for regular auditing, to the benefit of mothers and their children.

Making stillbirths count, making numbers talk - issues in data collection for stillbirths.

BACKGROUND: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. DISCUSSION: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. SUMMARY: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.

Determinants for high maternal mortality in multiethnic populations in western China.

Our purpose of this study was to investigate determinants and patterns of associations with high maternal mortality in poor and multiethnic populations from the Xinjiang Uigur autonomous region of Western China. The researcher found that the maternal mortality ratio of Xinjiang was very high; almost half of the participants delivered at home without clean delivery, and nearly one-fifth of the participants had not received any medical treatment. Eighty-seven percent of maternal deaths were among ethnic minority groups. In multiethnic areas in Xinjiang, social-culture factors, lack of health resources, and low health services utilization were related to high maternal mortality.

Birthweight and perinatal mortality among singletons and twins in north-eastern Tanzania.

BACKGROUND: Low birthweights as well as high perinatal mortality rates are common in most African populations. Little is known, however, about how low birthweight corresponds with higher mortality rates within African populations. Twins are known to have lower birthweights and higher perinatal mortality rates than singletons. If lower birthweights represent higher perinatal risk per se, small twins within a population with generally lower birthweights should have critically increased risks. METHODS: In total, 15,255 births in a Tanzanian hospital during 1999-2006 were analysed to determine birthweight distribution and examine perinatal mortality rates (including stillbirths and neonatal deaths within 24 hours) by birthweight in twins and singletons. Referral births from outside the district where the hospital was situated were excluded from analysis. RESULTS: The mean birthweight for births within an estimated normal distribution was 3,172 g, with a standard deviation of 462 g. The overall perinatal mortality rate was 43.9 per 1,000 births (95% confidence interval: 40.7-47.2). Perinatal mortality rates among twins and singletons were 91.0 and 41.1 per 1000 babies respectively, corresponding to a relative risk of 2.2 (95% confidence interval: 1.7-2.8). The birthweight distribution for twins was shifted to lower birthweights. Twins had a generally lower birthweight and an excess of extremely small births as compared to singletons. The increased mortality rate for twins appeared to be independent of birthweight. CONCLUSIONS: The two-fold increased risk of perinatal death for twins was observed across the whole birthweight distribution, and very small twins appeared to have an excess perinatal risk that was almost similar to that of larger twins.

Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study.

BACKGROUND: Tanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period. METHODS: A case-control study was done in two administrative divisions in Mbulu and Hanang districts in rural Tanzania. Forty-five cases of maternal death were found through a comprehensive community- and health-facility based study in 1995 and 1996, while 135 antenatal attendees from four antenatal clinics in the same population, geographical area, and time-span of 1995-96 served as controls. The cases and controls were compared using multivariate logistic regression analyses. Odds ratios, with 95% confidence intervals, were used as an approximation of relative risk, and were adjusted for place of residence (ward) and age. Further adjustment was done for potentially confounding variables. RESULTS: An increased risk of maternal deaths was found for women from 35-49 years versus 15-24 years (OR 4.0; 95%CI 1.5-10.6). Women from ethnic groups other than the two indigenous groups of the area had an increased risk of maternal death (OR 13.6; 95%CI 2.5-75.0). There was an increased risk when women or husbands adhered to traditional beliefs, (OR 2.1; 95%CI 1.0-4.5) and (OR 2.6; 95%CI 1.2-5.7), respectively. Women whose husbands did not have any formal education appeared to have an increased risk (OR 2.2; 95%CI 1.0-5.0). CONCLUSION: Increasing maternal age, ethnic and religious affiliation, and low formal education of the husbands were associated with increased risk of maternal death. Increased attention needs to be given to formal education of both men and women. In addition, education of the male decision-makers should be given high priority in the community, especially in matters concerning pregnancy and delivery preparedness, since their choice greatly affects the survival of the pregnant and delivering women.

Validity of non-invasive assessment of anaemia in pregnancy.

OBJECTIVE: To test the accuracy of clinical symptoms and signs for anaemia in pregnant women, as assessed by nurse-midwives, in two locations in Northern Tanzania. METHODS: One location was at 1000 m above sea level, the other at 1800 m. Midwives performed examinations and conducted structured interviews to detect severe anaemia at the first antenatal care visit before haemoglobin (hb) results were revealed; 369 and 535 women of all parities were examined in consecutive order at the two locations. Severe anaemia was defined as hb <75 g/l in the first and <80 g/l in the second (higher) location, based on altitude effect on hb distributions. RESULTS: Hb distribution differed substantially between the two locations, with much higher hb levels among those living at 1800 m. Sensitivities for detection of severe anaemia based on individual signs (pallor, conjunctiva, etc.) were 0.85, but only 0.33 to 0.44 for those living at lower and for those at higher altitudes, respectively. Conversely, specificities were around 0.90 at higher and 0.55 at lower altitudes, respectively. Symptoms (headache, dizziness, palpitations, etc.) were too common among those without anaemia to be useful as distinguishing features. Changing the definition of severe anaemia to higher cut-off hb values did not materially alter the results. CONCLUSION: Validity of non-invasive tests to detect severe anaemia in pregnant women varies by locality. In a high-altitude area detection rate was low (sensitivity around 40%). In lower-lying areas detection rate was high, at the cost of low specificity (around 45% false positive tests). Symptoms like headache, dizziness and fatigue were too common to discriminate those with severe anaemia.

A medical birth registry at Kilimanjaro Christian Medical Centre.

OBJECTIVE: To establish a medical birth registry intended to serve clinical, administrative and research purposes. METHODS: Starting in July 2000, every birth at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania has been recorded in a separate database. The information is obtained through personal interviews with each mother, conducted by specially trained midwives, and supplied with data from the medical records. A secretary enters the data into the electronic file. Data are collected about the mother and father: education, occupation and living conditions, mother's health before and during present pregnancy, expected date of delivery, smoking and drinking (alcohol) habits, use of drugs, plus HIV and syphilis status (if known). This is followed by particulars on the delivery: spontaneous or induced, and complications; the child or children: weight, height and Apgar score, malformations and other diagnoses. Mode of birth: spontaneous or operative intervention. If perinatal death: when? Transfer to intensive neonatal unit? The mother's reproductive history (births, miscarriages, ectopic pregnancies) is also recorded, with outcomes. RESULTS: We describe the process based on more than six years' experience, including obstacles and how they were overcome. The registry serves as a monitoring tool, with a set of key activities and events being issued monthly, indicating changes and trends in, e.g., bleeding complications, caesarean section rates and perinatal mortality, as early warning signs. Monthly reports on key issues are presented. Confidentiality and data protection are key issues. Day-to-day recording of births is vulnerable to personnel shortage, whether from disease or holidays. CONCLUSIONS: Validation and quality checks leave the overall impression that the database is largely accurate and credible. There are plenty of opportunities for research. Clinicians and epidemiologists will profit from using the database to test hypotheses and clarify problem issues, to the ultimate benefit of labouring women and their children.

Maternal smoking does not affect fetal size as measured in the mid-second trimester.

BACKGROUND: Cigarette smoking during pregnancy is causally related to birthweight, but we do not know whether fetal growth restriction is a continuous process or, if not, at what stage of pregnancy it affects weight gain. MATERIAL AND METHODS: A random sample of para 1 and 2 mothers, drawn from the population of pregnant women in Bergen and Trondheim, Norway, and Uppsala, Sweden, were examined by a detailed questionnaire concerning smoking habits, menstrual history and pregnancy dating, and subjected to morphometric sonography of their fetuses in or around week 17. Of the 547 study participants, 31.9% were smokers. Gestational age was primarily determined by the last menstrual period [LMP], except in those with irregular cycles, and in 30 cases (6.6% of those with regular cycles) in whom the biparietal diameter [BPD]-determined age deviated >14 days from the LMP-based date. RESULTS: The analysis did not reveal any statistically significant differences between the fetuses of non-smokers, light smokers (0-9 cigarettes per day) and heavy (10+ cigarettes per day) smokers, regarding BPD, mean abdominal diameter [MAD] femur length [FL], and a 'body contour index': [BPD+FL]/MAD. CONCLUSION: Tobacco-induced fetal growth restriction probably begins after gestational week 17.

[Self-decided abortion--different interpretations of 12 weeks of gestation]. / Selvbestemt abort--ulik fortolkning av "12 fullgåtte uker".

BACKGROUND: By the end of 12 gestational weeks, Norwegian women may decide on their own if they want to terminate their pregnancy. According to the abortion law, the upper gestational age is defined as 12 completed weeks or 84 days calculated from the first day of the last menstrual period (LMP). Using ultrasound, the recommended upper limit of the crown rump length (CRL) is 66 mm and the outer-to-outer biparietal diameter 26 mm. METHOD: In a questionnaire survey we asked how Norwegian hospital departments that offer pregnancy termination define 12 completed weeks and the upper limit of the CRL, and what method they use in case of a discrepancy in gestational length between LMP and ultrasound. RESULTS: All but one of the 46 hospitals we addressed nationwide completed the questionnaire (97.8%). More than half had a wider definition of 12 gestational weeks than the law, the upper limit for CRL varied between 50 and 73 mm, while all used ultrasound in case of a discrepancy. INTERPRETATION: Even if clinical practice varies between hospitals, most of them interpret gestational age liberally. Women with the same length of gestation around 12 weeks, may be managed differently depending on where they are referred for a pregnancy termination.

Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions?

OBJECTIVE: Preeclampsia, gestational hypertension, and unexplained intrauterine growth restriction may have similar determinants and consequences. In this study, we compared determinants and perinatal outcomes associated with these obstetric conditions. STUDY DESIGN: We analyzed 39,615 pregnancies (data from the WHO Antenatal Care Trial), of which 2.2% were complicated by preeclampsia, 7.0% by gestational hypertension, and 8.1% by unexplained intrauterine growth restriction (ie, not associated with maternal smoking, maternal undernutrition, preeclampsia, gestational hypertension, or congenital malformations). We compared the risk factors associated with these groups. Fetal death, preterm delivery, and severe neonatal morbidity and mortality were the primary outcomes. Logistic regression analyses were adjusted for study site, socioeconomic status, and (if appropriate) birth weight and gestational age. RESULTS: Diabetes, renal or cardiac disease, previous preeclampsia, urinary tract infection, high maternal age, twin pregnancy, and obesity increased the risk of both hypertensive conditions. Previous large-for-age birth, reproductive tract surgery, antepartum hemorrhage and reproductive tract infection increased the risk for gestational hypertension only. Independent of maternal age, primiparity was a risk factor only for preeclampsia. Both preeclampsia and gestational hypertension were associated with increased risk for fetal death and severe neonatal morbidity and mortality. Mothers with preeclampsia compared with those with unexplained intrauterine growth restriction were more likely to have a history of diabetes, renal or cardiac disease, chronic hypertension, previous preeclampsia, body mass index more than 30 kg/cm2, urinary tract infection and extremes of maternal age. Conversely, unexplained intrauterine growth restriction was associated with higher risk of low birth weight in previous pregnancies, but not with previous preeclampsia. Both conditions increased the risk for perinatal outcomes independently but preeclampsia was associated with considerable higher risk. CONCLUSION: Preeclampsia and gestational hypertension shared many risk factors, although there are differences that need further evaluation. Both conditions significantly increased morbidity and mortality. Conversely, preeclampsia and unexplained intrauterine growth restriction, often assumed to be related to placental insufficiency, seem to be independent biologic entities.

Haemoglobin and serum ferritin in pregnancy--correlation with smoking and body mass index.

BACKGROUND: Little is known about factors which may influence haemoglobin (Hb) and ferritin levels in pregnancy. AIM: To analyse if haemoglobin and ferritin levels during pregnancy are influenced by maternal age, body mass index, cigarette smoking, and iron supplementation. METHODS: A random sample of 561 parous pregnant women were recruited from the catchment areas of three Scandinavian university hospitals. The analyses were based on 5024 haemoglobin and 1529 ferritin measures sampled from the first trimester to 42 weeks of gestation. Multilevel modelling was used to construct mean and percentile curves for haemoglobin and ferritin by gestational age. RESULTS: Women aged 25-34 years had significantly higher haemoglobin values than older and younger women. Haemoglobin values were significantly lower for women with body mass index < 19 kg/m(2) than for women with body mass index > or =19. Smokers had significantly lower haemoglobin values throughout pregnancy compared to non-smokers, with the lowest values among women who smoked 1-9 cigarettes per day. There were no similar associations between ferritin and maternal age, body mass index, or smoking. Women with iron supplementation throughout pregnancy had a higher relative increase in haemoglobin concentration toward the end of pregnancy. In non-supplemented women the decline in ferritin concentration was significantly steeper than in those who received iron supplementation. CONCLUSIONS: Haemoglobin levels during pregnancy are significantly associated with maternal age, cigarette smoking, body mass index, and iron supplementation. No such associations were found with ferritin levels, except for iron supplementation.

Heterogeneity of perinatal outcomes in the preterm delivery syndrome.

OBJECTIVE: Our aim was to document the differential neonatal morbidity and intrapartum and neonatal mortality of subgroups of preterm delivery. METHODS: This analysis included 38,319 singleton pregnancies, of which 3,304 (8.6%) were preterm deliveries (less than 37 completed weeks) enrolled in the World Health Organization randomized trial of a new antenatal care model. We classified them as preterm deliveries after spontaneous initiation of labor, either with or without maternal obstetric and medical complications; preterm deliveries after prelabor spontaneous rupture of amniotic membranes (PROM), either with or without obstetric and medical complications; and medically indicated preterm deliveries with maternal obstetric and medical complications. Severe neonatal morbidity and neonatal mortality were the primary outcomes. RESULTS: Fifty-six percent of all preterm deliveries were spontaneous, without maternal complications. Small for gestational age was increased only among the medically indicated preterm delivery group (22.3%). Very early preterm delivery (less than 32 weeks of gestation) was highest among PROM with complications (37%). For intrapartum fetal death and neonatal death, after adjusting by gestational age and other confounding variables, we found that the obstetric and medical complications preceding preterm delivery predicted the different risk levels. Conversely, for severe neonatal morbidity the clinical presentation, ie, PROM or medically indicated, predicted the increased risk. CONCLUSION: There are differential neonatal outcomes among preterm deliveries according to clinical presentation, pregnancy complications, gestational age at delivery, and its association with small for gestational age. This syndromic nature of the condition should be considered if preterm delivery is to be fully understood and thus reduced.

Human chorionic gonadotropin in maternal serum in relation to fetal gender and utero-placental blood flow.

BACKGROUND: To investigate whether fetal gender differences in human chorionic gonadotropin (hCG) in maternal serum and the presence of hCG receptors in the wall of the uterine arteries influence the utero-placental blood flow. METHOD AND MATERIAL: Sixty-six healthy women with singleton uncomplicated pregnancies were examined at 8-10, 16-19 and 31-37 weeks of gestation. The pulsatility index (PI) was measured in the uterine arteries, simultaneously with sampling of peripheral maternal blood for hCG determination. Volume flow in the uterine arteries was determined in the second and third trimesters only. RESULTS: In the first and second trimesters no gender differences in the hCG levels were observed. From the second to the third trimester the hCG levels increased significantly in pregnancies with female fetuses (P < 0.05), while in pregnancies with male fetuses the hCG levels tended to decline. The PI declined significantly from the first to the third trimester in both genders (P < 0.001). In the first and third trimesters no gender differences were seen. In the second trimester the PI values were significantly higher in pregnancies with male fetuses than in those with female fetuses (P < 0.02). The flow volume increased significantly in both genders from the second to the third trimester (P < 0.001). In the third trimester the flow volume was higher in pregnancies with female fetuses than in those with male fetuses (P = 0.05). CONCLUSION: The gender differences in uterine artery PI and flow volume were not correlated to maternal serum hCG levels.