Maternal height and age: risk factors for cephalopelvic disproportion in Zimbabwe

Risk factors for seizures in the vigorous term neonate: A population-based register study of singleton births in Sweden

Background

Neonatal seizures have been associated with increased mortality and impaired neurodevelopment and, knowledge about risk factors may be useful for prevention. Clear associations have been established between labor-related risk factors and seizures in asphyxiated neonates. However, there is limited information about why some vigorous term-born infants experience seizures.

Objectives

Our aim was to assess antepartum and intrapartum risk factors for seizures in vigorous term-born neonates.

Methods

This was a national cohort study of singleton infants born at term in Sweden from 2009–2015. Vigorous was defined as an Apgar score of at least 7 at 5 and 10 minutes. Data on the mothers and infants were obtained from the Swedish Medical Birth Register and the Swedish Neonatal Quality Register. A diagnosis of neonatal seizures was the main outcome measure and the exposures were pregnancy and labor variables. Logistic regression analysis was used and the results are expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results

The incidence of neonatal seizures was 0.81/1,000 for 656 088 births. Seizures were strongly associated with obstetric emergencies (aOR 4.0, 95% CI 2.2–7.4), intrapartum fever and/or chorioamnionitis (aOR 3.4, 95% CI 2.1–5.3), and intrapartum fetal distress (aOR 3.0, 95% CI 2.4–3.7). Other associated intrapartum factors were: labor dystocia, occiput posterior position, operative vaginal delivery, and Cesarean delivery. Some maternal factors more than doubled the risk: a body mass of more than 40 (aOR 2.6, 95% CI 1.4–4.8), hypertensive disorders (aOR 2.3, 95% CI 1.7–3.1) and diabetes mellitus (aOR 2.6, 95% CI 1.7–4.1).

Conclusion

A number of intrapartum factors were associated with an increased risk of seizures in vigorous term-born neonates. Obstetric emergencies, intrapartum fever and/or chorioamnionitis and fetal distress were the strongest associated risks. The presence of such factors, despite a reassuring Apgar score could prompt close surveillance.

Obstetric dimensions of the female pelvis are less integrated than locomotor dimensions and show protective scaling patterns: Implications for the obstetrical dilemma

OBJECTIVES

The "obstetrical dilemma" hypothesis assumes that the modern human female pelvis serves two discrete functions: obstetrics and locomotion. We investigate whether these differing functions create observable patterns of morphological covariation and whether those patterns differ by height, weight, and age. This allows evaluation of evidence for canalization and phenotypic plasticity relevant to obstetric and locomotor function among a living female population.

METHODS

Landmarks (N = 86) were collected and inter-landmark distances were calculated (N = 36) on the pelvis and proximal femur of CT scans of living women aged 20 to 90 years (M = 93) receiving a routine CT scan. Partial least squares and relative SD of eigenvalues analyses were used to evaluate integration overall and within locomotor and obstetric modules, respectively. Ordinary Least Squared regression was used to evaluate scaling relationships between inter-landmark distances and height, weight, and age.

RESULTS

The obstetric pelvis was significantly less internally integrated than the locomotor pelvis. Many obstetric measurements were constrained in absolute terms relative to height; shorter women had relatively larger birth canal dimensions, and several key obstetric dimensions showed relative freedom from height. Lower weight women had some relatively larger obstetric and locomotor dimensions. Regarding age, younger women showed a few relatively larger outlet dimensions.

CONCLUSIONS

This study suggests that the obstetric pelvis and the locomotor pelvis function are morphologically distinct, with the obstetric pelvis showing relatively greater flexibility. These relationships between relative constraints support the hypothesis that the modern female pelvis shows evidence of both canalization and phenotypic plasticity in obstetric and locomotor structures.

Developmental origins of variability in pelvic dimensions: Evidence from nulliparous South Asian women in the United Kingdom

OBJECTIVES

Pelvic growth may be sensitive to early-life nutrition, with implications for maternal risk of obstructed labor. However, the "developmental origins" of adult pelvic variability require further investigation. We tested whether adult pelvic dimensions are associated with two components of height, indexing different periods of linear growth: tibia length, a proxy for early postnatal growth, and height-residual (height regressed on tibia length), a proxy for later growth. We also tested whether adult pelvic dimensions are associated with birth weight, a marker of nutritional investment in utero.

METHODS

In this cross-sectional study, data were obtained on 68 nulliparous young women of South Asian ancestry. Pelvic dimensions (bi-iliac and bi-acetabular breadth, anteroposterior pelvic inlet and outlet, interspinous and intertuberous diameter) were measured using magnetic resonance imaging. Height and tibia length were measured manually. Birth weight and gestational age were obtained by recall. Multivariable regression models were fitted with a given pelvic dimension regressed on height-residual, tibia, and birth weight, with the latter adjusted for gestational age.

RESULTS

Controlling for birth weight, height-residual was predictive of bi-acetabular breadth, bi-iliac breadth, and the pelvic inlet, while tibia length significantly predicted all dimensions except interspinous diameter. Controlling for the linear growth variables, birth weight was predictive of bi-iliac breadth only.

CONCLUSIONS

Markers of linear growth during both early and later development were associated with adult pelvic dimensions, whereas size at birth was poorly predictive. Efforts to reduce stunting in early life may facilitate the attainment of maximum potential growth for both height and the pelvis.

Term spontaneous trial of labor in nulliparous women of short stature: A hospitals-based cohort study

OBJECTIVES

To study the mode of delivery in a well selected cohort of short nulliparous women.

STUDY DESIGN

Hospitals-based cohort study between 2010-2018. The threshold (150 cm, i.e 2,3°p), for the short stature was chosen before the analysis by corresponding to - 2SD of the average population size distribution of all women who delivered over the same period: 2010-2018. Were included nulliparous women with a heigh ≤ 150 cm in term spontaneous labor with a single livung fetus in vertex presentation without malformation. Exclusion criteria were: multiparous, scarred uterus, twin pregnancy, induced labor, preterm delivery (< 37 W P), non-vertex pregnancy, medical termination of pregnancy, stillbirth, severe fetal malformations, pre-labor cesarean, and late dating ultrasound. The main outcome was the mode of delivery. Univariate and multivariate analysis adjusted on potential confounding variable were performed to investigate the risk of intrapartum CS.

RESULTS

178 nulliparous women were included. The mean height was 148 cm. The rate of spontaneous vaginal delivery, operative vaginal delivery a nd intrapartum CS were :35,4 %, 35,4 % and 29,2 % respectively. Intrapartum CS was performed during the first stage labor in 15 (28, 8 %) women and during the second stage in 37 (71, 2 %) women. An arrest of labor was significantly more frequent in the active labor than the early labor stage: 62,1 % vs. 33.3 % (p = 0, 02). In univarate analysis were associated with intrapartum CS : Gestational diabetes, birthweight> 3,5 kg, individual adjusted birthweight >90°p, occiput posterior, oxytocin use, cephalic circumference. After adjustment on birthplace and overweight (BMI over 25), only a birthweight > 3,5 kg remains associated with the risk of intrapartum CS (aOR4.3 ;95 %CI 1.96-10.2).

CONCLUSION

An attempt of vaginal birth is a reasonable option for short stature women. Maternal height could be included in the selection criteria for planned birth center or home birth. The customized gestational-related optimal weigh could be useful to identify large of gestational age fetus.

Three-dimensional camera anthropometry to assess risk of cephalopelvic disproportion-related obstructed labour in Ethiopia

Cephalopelvic disproportion (CPD)-related obstructed labour requires delivery via Caesarean section (C/S); however, in low-resource settings around the world, facilities with C/S capabilities are often far away. This paper reports three low-cost tools to assess the risk of CPD, well before labour, to provide adequate time for referral and planning for delivery. We performed tape measurement- and three-dimensional (3D) camera-based anthropometry, using two 3D cameras (Kinect and Structure) on primigravida, gestational age ≥ 36 weeks, from Addis Ababa, Ethiopia. Novel risk scores were developed and tested to identify models with the highest predicted area under the receiver-operator characteristic curve (AUC), detection rate (true positive rate at a 5% false-positive rate, FPR) and triage rate (true negative rate at a 0% false-negative rate). For tape measure, Kinect and Structure, the detection rates were 53%, 61% and 64% (at 5% FPR), the triage rates were 30%, 56% and 63%, and the AUCs were 0.871, 0.908 and 0.918, respectively. Detection rates were 77%, 80% and 84% at the maximum J-statistic, which corresponded to FPRs of 10%, 15% and 11%, respectively, for tape measure, Kinect and Structure. Thus, tape measurement anthropometry was a very good predictor and Kinect and Structure anthropometry were excellent predictors of CPD risk.

Female Nutritional Status across the Life-Span in Sub-Saharan Africa. 2. Causes and Consequences

This article reviews existing data concerning the causes and consequences of female malnutrition in sub-Saharan Africa. As in most parts of the world, the primary cause of female malnutrition is household food insecurity compounded by low household and individual incomes. Gender-specific factors that further undermine women's nutritional status are the severe physiological burden of frequent child-bearing and the continuous long hours of energy-intensive work. Negative consequences of malnutrition among females include high rates of mortality and morbidity, impaired learning, low birthweights, and reduced energy for discretionary activities. We question the conclusion of other studies that African women have developed special “adaptive mechanisms” to compensate for nutritional deprivation, and recommend that further research investigate the hidden individual and societal costs of malnutrition among women.

Female Nutritional Status across the Life-Span in Sub-Saharan Africa. 1. Prevalence Patterns

This article reviews and synthesizes existing nutritional studies that provide gender-disaggregated data from sub-Saharan Africa. The analytic focus is on female nutritional status across the life-span. However, it was found that available data are biased towards preschool children and women of reproductive age. As in other economically disadvantaged parts of the world, the two most prevalent nutritional deficiencies among females in sub-Saharan Africa are iron-deficiency anaemia and protein-energy malnutrition. In comparison with other regions of the world, sub-Saharan African females seem to be nutritionally better off than females in South Asia, but as malnourished as, or more malnourished than, females elsewhere. Indirect indicators of nutritional status, such as birthweight and maternal mortality, suggest that the nutritional situation of women in Western Africa is poorer than that of women in Eastern and Southern Africa. In comparison with males in sub-Saharan Africa, however, no consistent pattern of female nutritional disadvantage was found.

Seizures in newborn infants without hypoxic ischemic encephalopathy - antenatal and labor-related risk factors: a case-control study

Objective: To identify antepartum and intrapartum risk factors for neonatal seizures in the absence of hypoxic ischemic encephalopathy (HIE).Methods: Population-based case-control study. Of 98 484 births, 40 newborns at 34 gestational weeks or later had seizures within the first 7 days of life. Cases (n = 40) and controls (n = 160) were retrieved from the University hospitals of Örebro for 1994-2013 and Uppsala for 2003-2013. Demographics and characteristics of pregnancy, labor, delivery, and neonatal data were analyzed. Crude odds ratio (OR) and adjusted odds ratios (AOR) with 95% confidence intervals (CIs) for antenatal and intrapartum factors were calculated using logistic regression analysis. Main outcome measure was neonatal seizures within the first 7 days of life.Results: The incidence of neonatal seizures without HIE was 0.41/1000 live births. Antenatal risk factors for neonatal seizures were as follows: short maternal stature (AOR: 5.4; 1.8-16.5); previous caesarean section (AOR: 4.8; 1.5-15.0); and assisted fertilization (AOR: 6.8; 1.3-35.2). Intrapartum risk factors were as follows: induction of labor (AOR: 5.7; 1.8-17.7); preterm birth (AOR: 13.5; 3.7-48.9); and head circumference >37 cm (AOR: 6.9; 1.4-34.8).Conclusions: Preterm birth was the strongest risk factor for neonatal seizures in the absence of HIE. The results also indicate that feto-pelvic disproportion is associated with the occurrence of seizures.Rationale: Antepartum and intrapartum risk factors for newborn seizures in the absence of HIE were investigated in a case-control study. Out of 98 484 births at 34 gestational weeks or more, 40 newborns had seizures without HIE. All had a normal Apgar score although they later presented with seizures. Preterm birth was the strongest risk factor (OR: 13.5; 95% CI: 3.7-48.9). Our results also indicate that feto-pelvic disproportion is of importance. Furthermore, a history of prior caesarean was associated with seizures. This is the first study to assess obstetric risk factors for newborn seizures separate from those with seizures and concomitant HIE. The distinction is of importance due to different etiologies, treatments, and preventive strategies.

[External anthropometric measurement and pelvimetry among nulliparous women in Lubumbashi: risk factors and predictive score of mechanical dystocia]

INTRODUCTION

Maternal and perinatal morbi-mortality is higher in most of sub-Saharan Africa compared to the rest of the world. All women at risk for mechanical dystocia should be screened before labor and referred to a better equipped Hospital for childbirth. This would reduce morbi-mortality. This study aims to develop a predictive score of mechanical dystocia during childbirth among nulliparous Congolese women.

METHODS

We conducted a cross-sectional study of nulliparous women with single pregnancy in 7 Maternity Units in the city of Lubumbashi (DRC). Women' size, weight, and external pelvimetry results were collected and analyzed. Univariate and multivariate analyses were performed. Discrimination score was assessed using the ROC curve.

RESULTS

We included in the study 535 nulliparous women, of whom 126 (23.55%) had given birth by cesarean section due to mechanical dystocia. After logistic modelling, three criteria emerged as predictive factors for mechanical dystocia: maternal height <150 cm (adjusted OR=2.96 [1,49-5,87]), bi-ischiatic diameter <8 cm (adjusted OR =15.96 [3,46-73,56]), and Trillat's pre-pubic diameter <11 cm (adjusted OR =2.34 [1,36-4,01]). The area under the ROC curve of the score was 0.6549 with a sensitivity of 23.81%, a specificity of 97.80% and a positive predictive value of 76.92%.

CONCLUSION

It has been observed that 10th percentile of the three maternal anthropometric measures was predictive of mechanical dystocia. When they were used together, these three values allowed for the development of lowest-cost screening score for use in low income settings.

A safe, low-cost, easy-to-use 3D camera platform to assess risk of obstructed labor due to cephalopelvic disproportion

Cephalopelvic disproportion (CPD)-related obstructed labor is accountable for 3-8% of the maternal deaths worldwide. The consequence of CPD-related obstructive labor in the absence of a Caesarian section (C/S) is often maternal or perinatal mortality or morbidity to the mother and/or the infant. Accurate and timely referral of at-risk mothers to health facilities where C/S is a delivery option could reduce maternal mortality in the developing world. The goal of this work was to develop and test the feasibility of a safe, low-cost, easy-to-use, portable tool, using a Microsoft Kinect 3D camera, to identify women at risk for obstructed labor due to CPD. Magnetic resonance imaging (MRI) scans, 3D camera imaging, anthropometry and clinical pelvimetry were collected and analyzed from women 18-40 years of age, at gestational age ≥36+0 weeks with previous C/S due to CPD (n = 43), previous uncomplicated vaginal deliveries (n = 96), and no previous obstetric history (n = 148) from Addis Ababa, Ethiopia. Novel and published CPD risk scores based on anthropometry, clinical pelvimetry, MRI, and Kinect measurements were compared. Significant differences were observed in most anthropometry, clinical pelvimetry, MRI and Kinect measurements between women delivering via CPD-related C/S versus those delivering vaginally. The area under the receiver-operator curve from novel CPD risk scores base on MRI-, Kinect-, and anthropometric-features outperformed novel CPD risk scores based on clinical pelvimetry and previously published indices for CPD risk calculated from these data; e.g., pelvic inlet area, height, and fetal-pelvic index. This work demonstrates the feasibility of a 3D camera-based platform for assessing CPD risk as a novel, safe, scalable approach to better predict risk of CPD in Ethiopia and warrants the need for further blinded, prospective studies to refine and validate the proposed CPD risk scores, which are required before this method can be applied clinically.

Distributional change of women's adult height in low- and middle-income countries over the past half century: An observational study using cross-sectional survey data

BACKGROUND

Adult height reflects childhood circumstances and is associated with health, longevity, and maternal-fetal outcomes. Mean height is an important population metric, and declines in height have occurred in several low- and middle-income countries, especially in Africa, over the last several decades. This study examines changes at the population level in the distribution of height over time across a broad range of low- and middle-income countries during the past half century.

METHODS AND FINDINGS

The study population comprised 1,122,845 women aged 25-49 years from 59 countries with women's height measures available from four 10-year birth cohorts from 1950 to 1989 using data from the Demographic and Health Surveys (DHS) collected between 1993 and 2013. Multilevel regression models were used to examine the association between (1) mean height and standard deviation (SD) of height (a population-level measure of inequality) and (2) median height and the 5th and 95th percentiles of height. Mean-difference plots were used to conduct a graphical analysis of shifts in the distribution within countries over time. Overall, 26 countries experienced a significant increase, 26 experienced no significant change, and 7 experienced a significant decline in mean height between the first and last birth cohorts. Rwanda experienced the greatest loss in height (-1.4 cm, 95% CI: -1.84 cm, -0.96 cm) while Colombia experienced the greatest gain in height (2.6 cm, 95% CI: 2.36 cm, 2.84 cm). Between 1950 and 1989, 24 out of 59 countries experienced a significant change in the SD of women's height, with increased SD in 7 countries-all of which are located in sub-Saharan Africa. The distribution of women's height has not stayed constant across successive birth cohorts, and regression models suggest there is no evidence of a significant relationship between mean height and the SD of height (β = 0.015 cm, 95% CI: -0.032 cm, 0.061 cm), while there is evidence for a positive association between median height and the 5th percentile (β = 0.915 cm, 95% CI: 0.820 cm, 1.002 cm) and 95th percentile (β = 0.995 cm, 95% CI: 0.925 cm, 1.066 cm) of height. Benin experienced the largest relative expansion in the distribution of height. In Benin, the ratio of variance between the latest and earliest cohort is estimated as 1.5 (95% CI: 1.4, 1.6), while Lesotho and Uganda experienced the greatest relative contraction of the distribution, with the ratio of variance between the latest and earliest cohort estimated as 0.8 (95% CI: 0.7, 0.9) in both countries. Limitations of the study include the representativeness of DHS surveys over time, age-related height loss, and consistency in the measurement of height between surveys.

CONCLUSIONS

The findings of this study indicate that the population-level distribution of women's height does not stay constant in relation to mean changes. Because using mean height as a summary population measure does not capture broader distributional changes, overreliance on the mean may lead investigators to underestimate disparities in the distribution of environmental and nutritional determinants of health.

Human Variation in Pelvic Shape and the Effects of Climate and Past Population History

The human pelvis is often described as an evolutionary compromise (obstetrical dilemma) between the requirements of efficient bipedal locomotion and safe parturition of a highly encephalized neonate, that has led to a tight fit between the birth canal and the head and body of the foetus. Strong evolutionary constraints on the shape of the pelvis can be expected under this scenario. On the other hand, several studies have found a significant level of pelvic variation within and between human populations, a fact that seems to contradict such expectations. The advantages of a narrow pelvis for locomotion have recently been challenged, suggesting that the tight cephalo-pelvic fit might not stem from the hypothesized obstetrical dilemma. Moreover, the human pelvis appears to be under lower constraints and to have relatively higher evolvability than other closely related primates. These recent findings substantially change the way in which we interpret variation in the human pelvis, and help make sense of the high diversity in pelvic shape observed within and among modern populations. A lower magnitude of covariance between functionally important regions ensured that a wide range of morphological variation was available within populations, enabling natural selection to generate pelvic variation between populations living in different environments. Neutral processes such as genetic drift and differential migration also contributed to shaping modern pelvic diversity during and after the expansion of humans into and across the various continents. Anat Rec, 300:687-697, 2017. © 2017 Wiley Periodicals, Inc.

The New "Obstetrical Dilemma": Stunting, Obesity and the Risk of Obstructed Labour

The "obstetrical dilemma" refers to the tight fit between maternal pelvic dimensions and neonatal size at delivery. Most interest traditionally focused on its generic significance for humans, for example our neonatal altriciality and our complex and lengthy birth process. Across contemporary populations, however, the obstetrical dilemma manifests substantial variability, illustrated by differences in the incidence of cephalo-pelvic disproportion, obstructed labour and cesarean section. Beyond accounting for 12% of maternal mortality worldwide, obstructed labour also imposes a huge burden of maternal morbidity, in particular through debilitating birth injuries. This article explores how the double burden of malnutrition and the global obesity epidemic may be reshaping the obstetrical dilemma. First, short maternal stature increases the risk of obstructed labour, while early age at marriage also risks pregnancy before pelvic growth is completed. Second, maternal obesity increases the risk of macrosomic offspring. In some populations, short maternal stature may also promote the risk of gestational diabetes, another risk factor for macrosomic offspring. These nutritional influences are furthermore sensitive to social values relating to issues such as maternal and child nutrition, gender inequality and age at marriage. Secular trends in maternal obesity are substantially greater than those in adult stature, especially in low- and middle-income countries. The association between the dual burden of malnutrition and the obstetrical dilemma is therefore expected to increase, because the obesity epidemic is emerging faster than stunting is being resolved. However, we currently lack objective population-specific data on the association between maternal obesity and birth injuries. Anat Rec, 300:716-731, 2017. © 2017 Wiley Periodicals, Inc.

Cesarean section indications and anthropometric parameters in Rwandan nulliparae: preliminary results from a longitudinal survey

INTRODUCTION

Maternal anthropometric parameters as risk factors for cesarean section have always been a matter of interest and concern for obstetricians. Some of these parameters have been shown to be predictors of dystocia. This study aims at showing the relationship between cesarean section indications and anthropometric parameters sizes in Rwandan nulliparae for the purpose of comparison and appropriate recommendations.

METHODS

A cross-sectional and analytical study was made on data collected from 32 operated patients among 152 nulliparae with singleton pregnancy at term and vertex presentation. Concerned anthropometric parameters were height, weight and six pelvic distances. Fisher exact and Student's tests were used to compare observed proportions and mean values, respectively.

RESULTS

Findings were as follows: 1) the overall cesarean section rate was 21.05%; 2) acute fetal distress (31.3 %), generally contracted pelvis (28.1 %), and engagement failure (25%) were the most frequent indications of cesarean section; 3) all patients ≤ 145 cm tall were operated on for general pelvis contraction whose proportion was significantly higher in them than in the others (p < 0.01); 4) more than half of pelvis contraction cases were observed in patients weighing ≤ 50 kg, but the difference with other weight categories was not significant; 5) considered external pelvic diameters but the Biiliac Diameter displayed average measurements smaller in clinically contracted pelvis than in other CS indications.

CONCLUSION

External pelvimetry associated with specific other anthropometric parameters could be helpful in the screening of generally contracted pelves, and consequently pregnancies at high risk of cephalopelvic disproportion in nulliparous women, particularly in developing countries with limited resources. Further investigations are requested to deal with this topic in depth.

Adult height, nutrition, and population health

In this review, the potential causes and consequences of adult height, a measure of cumulative net nutrition, in modern populations are summarized. The mechanisms linking adult height and health are examined, with a focus on the role of potential confounders. Evidence across studies indicates that short adult height (reflecting growth retardation) in low- and middle-income countries is driven by environmental conditions, especially net nutrition during early years. Some of the associations of height with health and social outcomes potentially reflect the association between these environmental factors and such outcomes. These conditions are manifested in the substantial differences in adult height that exist between and within countries and over time. This review suggests that adult height is a useful marker of variation in cumulative net nutrition, biological deprivation, and standard of living between and within populations and should be routinely measured. Linkages between adult height and health, within and across generations, suggest that adult height may be a potential tool for monitoring health conditions and that programs focused on offspring outcomes may consider maternal height as a potentially important influence.

Pregnancy length: Secular trends and patterns of variation in Sweden, 1982–2005

Anthropological and medical studies rarely investigate the existence of secular trends in the duration of human pregnancy, which is widely assumed to show less variation than traits such as body size, menarche or lifespan. Here we analyze pregnancy duration in the Swedish population between 1982 and 2005, and correlation patterns of four variables: pregnancy length, maternal height, newborn weight and newborn head circumference. Results reveal positive trends of very small magnitude in the four traits. Although bivariate correlations were all significant and positive, multiple linear regression shows a positive independent contribution of newborn size (both weight and head circumference) and a negative independent contribution of maternal height to pregnancy length. We propose that the very weak and negative independent contribution of maternal height to pregnancy duration, in contrast to the stronger and positive contribution of newborn size, explain the absence of significant secular trends in pregnancy duration in Sweden. The results confirm some of the predictions of the maternal investment hypothesis, the ‘obstetrical dilemma’, and Ellison's metabolic crossover hypothesis. Due to the weak association between pregnancy length and maternal height, we hypothesize that pregnancy length is expected to show limited secular change even in a population undergoing strong secular trends in maternal height.

Protection of obstetric dimensions in a small-bodied human sample

In human females, the bony pelvis must find a balance between being small (narrow) for efficient bipedal locomotion, and being large to accommodate a relatively large newborn. It has been shown that within a given population, taller/larger-bodied women have larger pelvic canals. This study investigates whether in a population where small body size is the norm, pelvic geometry (size and shape), on average, shows accommodation to protect the obstetric canal. Osteometric data were collected from the pelves, femora, and clavicles (body size indicators) of adult skeletons representing a range of adult body size. Samples include Holocene Later Stone Age (LSA) foragers from southern Africa (n = 28 females, 31 males), Portuguese from the Coimbra-identified skeletal collection (CISC) (n = 40 females, 40 males) and European-Americans from the Hamann-Todd osteological collection (H-T) (n = 40 females, 40 males). Patterns of sexual dimorphism are similar in the samples. Univariate and multivariate analyses of raw and Mosimann shape-variables indicate that compared to the CISC and H-T females, the LSA females have relatively large midplane and outlet canal planes (particularly posterior and A-P lengths). The LSA males also follow this pattern, although with absolutely smaller pelves in multivariate space. The CISC females, who have equally small stature, but larger body mass, do not show the same type of pelvic canal size and shape accommodation. The results suggest that adaptive allometric modeling in at least some small-bodied populations protects the obstetric canal. These findings support the use of population-specific attributes in the clinical evaluation of obstetric risk.

Development of risk scoring scheme for prediction of cesarean delivery due to cephalopelvic disproportion in Lamphun Hospital, Thailand

AIM

To develop a simple risk scoring scheme for the prediction of cesarean delivery due to cephalopelvic disproportion (CPD) in Lamphun Hospital, Thailand.

METHODS

A case-control study was conducted including 116 pregnant women with cesarean delivery due to CPD and 307 pregnant women delivering by normal labor. Obstetric information was retrieved from medical records. Risk indicators measurable at the time of admission were analyzed by a stepwise logistic regression to obtain a set of statistically significant predictors. Regression coefficients were transformed into item scores and added up to a total score. Risk of cesarean delivery due to CPD was analyzed using total scores as the only predictor.

RESULTS

A risk scoring scheme was developed from five obstetric predictors: maternal age, height, parity, pregnancy weight gain and symphysis-fundal height. Item scores ranged from 0 up to 3.5 and the total score from 0-14.5. The scheme explained, by the area under the receiver operating characteristic curve, 88% of cesarean delivery due to CPD. The likelihood of cesarean delivery due to CPD in pregnant women with low risk (scores below 5), moderate risk (scores 5-9.5) and high risk (scores 10 and over) were 0.09, 0.86 and 10.11, respectively.

CONCLUSIONS

The risk of cesarean delivery due to CPD may be forecasted by a simple scoring scheme using five predictors that correctly identified women with low, moderate and high risk. This scheme may be applicable to physicians and midwives for identifying high-risk pregnant women in order to take appropriate action.

Anthropometric measurements in the diagnosis of pelvic size: an analysis of maternal height and shoe size and computed tomography pelvimetric data

BACKGROUND

To determine whether measurements of maternal height and shoe size are predictors of pelvic size, using erect lateral computerized tomography (CT) pelvimetry as gold standard.

MATERIALS AND METHODS

Three hundred and fifty three obstetric patients out of a sequential population of 6112 (5.8%) had CT pelvimetry performed between January 1990 and December 1991 at the Department of Obstetrics and Gynecology, York District Hospital, United Kingdom. Multivariable logistic regression models were built using maternal height (n = 322), shoe size (314) and weight at last clinic visit (n = 318). The reference standard for pelvic size was CT Pelvimetry. Pelvic adequacy was defined as an anterior-posterior diameter of the inlet of > or =11 cm and an anterior-posterior diameter of the outlet > or =10 cm on erect lateral CT pelvimetry. Women with values lower than these were regarded as having an inadequate pelvis. The diagnostic accuracy of the models was determined by the area under the receiver operating characteristic curve (AUC).

RESULTS

The area under the curve (AUC) for maternal height (0.768) was not significantly greater than that for shoe size (0.686, p = 0.163 for the difference in AUC's) and weight at the last clinic visit (0.655, p = 0.057 for the difference in the AUCs). The change in the AUC for each of the models (the full model with height, shoe size and weight [0.769]; model for height and shoe size [0.767] model for just height [0.768]) was also not significantly different.

CONCLUSIONS

Measurements of maternal height, shoe size and weight at the last clinic visit are not useful for the identification of women with inadequate pelvis.

The diagnostic accuracy of external pelvimetry and maternal height to predict dystocia in nulliparous women: a study in Cameroon

OBJECTIVE

In many developing countries, most women deliver at home or in facilities without operative capability. Identification before labour of women at risk of dystocia and timely referral to a district hospital for delivery is one strategy to reduce maternal and perinatal mortality and morbidity. Our objective was to assess the prediction of dystocia by the combination of maternal height with external pelvimetry, and with foot length and symphysis-fundus height.

DESIGN

A prospective cohort study.

SETTING

Three maternity units in Yaoundé, Cameroon.

POPULATION

A total of 807 consecutive nulliparous women at term who completed a trial of labour and delivered a single fetus in vertex presentation.

METHODS

Anthropometric measurements were recorded at the antenatal visit by a researcher and concealed from the staff managing labour. After delivery, the accuracy of individual and combined measurements in the prediction of dystocia was analysed.

MAIN OUTCOME MEASURES

Dystocia, defined as caesarean section for dystocia; vacuum or forceps delivery after a prolonged labour (>12 hours); or spontaneous delivery after a prolonged labour associated with intrapartum death.

RESULTS

Ninety-eight women (12.1%) had dystocia. The combination of a maternal height less than or equal to the 5th percentile or a transverse diagonal of the Michaelis sacral rhomboid area less than or equal to the 10th percentile resulted in a sensitivity of 53.1% (95% CI 42.7-63.2), a specificity of 92.0% (95% CI 89.7-93.9), a positive predictive value of 47.7% (95% CI 38.0-57.5) and a positive likelihood ratio of 6.6 (95% CI 4.8-9.0), with 13.5% of all women presumed to be at risk. Other combinations resulted in inferior prediction.

CONCLUSION

The combination of the maternal height with the transverse diagonal of the Michaelis sacral rhomboid area could identify, before labour, more than half of the cases of dystocia in nulliparous women.

Embodied responsibilities: pregnancy in the eyes of Japanese ob-gyns

This article explores the correlation between the social, cultural and political setting in which Japanese women gestate their babies and the kind of maternal responsibilities they are expected to exercise. By focusing on prenatal care, I look at ways in which Japanese gynaecologists formulate ideas about women's accountability for pregnancy outcomes and show how these ideas shape the practical strategies through which pregnancy is managed in medical institutions. While interrogating the perspectives these professionals bring into play, I am interested in the relationships between biomedicine, culture and the embodiment of women's roles. My findings reveal a broad range of physiological phenomena for which women are held accountable and a host of instructions they are expected to follow once they engage in prenatal care. Medical narratives render the pregnant body as the physical and mental environment that creates the foetus and highlights women's behaviour and health (rather than genes and chromosomes) as the major factors of foetal health. I show how the embodied mode of maternal responsibilities expected of women is mutually constituted by four interconnected realms of discourse and practice: the medical realm, cultural conceptions of self, national reproductive politics and the gendered division of labour.

Obstructed labor: using better technologies to reduce mortality

OBJECTIVE

To identify, from the best available evidence, underutilized and promising technologies that may reduce maternal mortality from obstructed labor.

METHODS

The author sought systematic reviews of randomized trials, individual randomized trials, and, in the absence of randomized data, non-randomized studies and clinical consensus. Data were presented according to the level of the evidence.

RESULTS

Obstructed labor causes approximately 8% of maternal deaths, and indirectly contributes to a greater percentage. Proven or widely accepted technologies that help reduce mortality from obstructed labor include contraception, external cephalic version, the partogram, augmentation of labor, selective amniotomy, selective episiotomy, vacuum extraction, caesarean section, symphysiotomy, and destructive procedures for non-viable fetuses. Technologies of uncertain usefulness include maternal height and shoe size, vaginal cleansing, upright posture for delivery and vaginal lubrication. Unuseful technologies include pelvimetry, estimating fetal weight, early labor induction, routine amniotomy and augmentation, routine episiotomy, and starvation during labor.

CONCLUSION

Access to well-established technologies, particularly safe caesarean section, can reduce maternal mortality in resource-poor countries.

Human birthweight evolution across contrasting environments

We explore from both theoretical and empirical perspectives the hypothesis that a significant part of the worldwide variability in human birthweight results from adaptive responses to local selective pressures. We first developed an agent-based model to simulate the process of evolutionary selection on life history strategy, and then we performed a comparative analysis across 89 countries worldwide. The model illustrates that optimal birthweight depends on which fitness-reducing risk locally predominates (somatic diseases, parasitic diseases or adverse environmental conditions). When fitness variations between individuals mainly result from somatic diseases (e.g. industrialized countries), or conversely from infectious and parasitic diseases (e.g. developing countries), selection is expected to favour individuals producing larger children. Conversely, when environmental risks increase in relative importance, selective pressures for producing children with high birthweight are reduced. The comparative analysis supports these theoretical expectations, in particular the finding that birthweight is higher than predicted in highly parasitized countries.

Nutritional interventions during pregnancy for the prevention or treatment of maternal morbidity and preterm delivery: an overview of randomized controlled trials

This overview assesses the effectiveness of nutritional interventions to prevent or treat maternal morbidity, mortality and preterm delivery. Cochrane systematic reviews and other up-to-date systematic reviews and individual randomized controlled trials were sought. Searches were carried out up to July 2002. Iron and folate supplements reduce anemia and should be included in antenatal care programs. Calcium supplementation to women at high risk of hypertension during pregnancy or low calcium intake reduced the incidence of both preeclampsia and hypertension. Fish oil and vitamins E and C are promising for preventing preeclampsia and preterm delivery and need further testing. Vitamin A and beta-carotene reduced maternal mortality in a large trial; ongoing trials should provide further evaluation. No specific nutrient supplementation was identified for reducing preterm delivery. Nutritional advice, magnesium, fish oil and zinc supplementation appear promising and should be tested alone or together in methodologically sound randomized controlled trials. Anema in pregnancy can be prevented and treated effectively. Considering the multifactorial etiology of the other conditions evaluated, it is unlikely that any specific nutrient on its own, blanket interventions or magic bullets will prevent or treat preeclampsia, hemorrhage, obstructed labor, infections, preterm delivery or death during pregnancy. The few promising interventions for specific outcomes should be tested or reconsidered when results of ongoing trials become available. Until then, women and their families should receive support to improve their diets as a general health rule, which is a basic human right.

Dystocia: a study of its frequency and risk factors in seven cities of west Africa

OBJECTIVES

To determine the incidence of dystocia in seven west African cities, to attempt to discover what, if any, factors at the prenatal visit might identify women at risk of dystocia, and to assess the utility of such screening.

METHOD

This prospective population study of 20326 pregnant women in west Africa (MOMA) analyzed risk factors for dystocia on the basis of deliveries in health care facilities.

RESULTS

Incidence of dystocia was 18.3%. In the multivariate analysis, the risk factors were small stature, previous cesarean, and nulliparity. As screening tools these factors have inadequate positive predictive values, either singly or combined.

CONCLUSION

It is almost impossible to predict the occurrence of dystocia before the onset of labor. Therefore, labor must be carefully monitored, and there must be health care facilities available that can manage complications, especially cesarean deliveries. If such facilities are not accessible, an effective referral system must be established.

Maternal height and newborn size relative to risk of intrapartum caesarean delivery and perinatal distress

OBJECTIVE

To estimate the changes, in risk of intrapartum caesalrean delivery and perinatal distress that may be introduced through increased birth size, resulting from interventions such as improving nutrition of the mother; and to characterise delivery risk relative to maternal stature by birth size.

DESIGN

Model these risks using data from the Guatemalan Perinatal Study.

SETTING

The antenatal clinic of the Gynaecology and Obstetrics Hospital of the Guatemalan Social Security Institute in Guatemala City serving predominantly working class women.

POPULATION

Women who had their first prenatal visit between April 1984 and January 1986.

METHODS

Multivariate logistic regression models were developed to estimate incidence of intrapartum caesarean delivery and perinatal distress and used to calculate changes in risk associated with changes in size.

MAIN OUTCOME MEASURES

Incidences of intrapartum caesarean delivery and perinatal distress.

RESULTS

A woman of 146cm height (-1 SD) relative to another of 160 cm (+1 SD) has a 2.5 times higher risk of intrapartum caesarean delivery. An increase in newborn head circumference and weight (from -1 SD to +1 SD) are each independently associated with an increase in risk of intrapartum caesarean delivery (2.0 times and 1.5 times. respectively). An increase in birthweight from 2,450 g to 2,550 g is associated with a decrease in risk of perinatal distress of 34/1,000 cases and an increase in risk of intrapartum caesarean delivery of 8/1,000 cases.

CONCLUSIONS

Increases in fetal growth comparable to those attributable to improved nutrition during pregnancy are associated with a larger decrease in risk of perinatal distress relative to the increase in risk of intrapartum caesarean delivery for the mother. Greater maternal stature is associated with lower risk of intrapartum caesarean delivery.

Human fertility variation, size-related obstetrical performance and the evolution of sexual stature dimorphism

In several animal species, change in sexual size dimorphism is a correlated response to selection on fecundity. In humans, different hypotheses have been proposed to explain the variation of sexual dimorphism in stature, but no consensus has yet emerged. In this paper, we evaluate from a theoretical and an empirical point of view the hypothesis that the extent of sexual dimorphism in human populations results from the interaction between fertility and size-related obstetric complications. We first developed an optimal evolutionary model based on extensive simulations and then we performed a comparative analysis for a total set of 38 countries worldwide. Our optimization modelling shows that size-related mortality factors do indeed have the potential to affect the extent of sexual stature dimorphism. Comparative analysis using generalized linear modelling supports the idea that maternal death caused by deliveries and complications of pregnancy (a variable known to be size related) could be a key determinant explaining variation in sexual stature dimorphism across populations. We discuss our results in relation to other hypotheses on the evolution of sexual stature dimorphism in humans.

Nutrition and obstructed labor

Obstructed labor is one of the most common preventable causes of maternal and perinatal morbidity and mortality in developing countries. Among the common causes are cephalopelvic disproportion, malpresentation, and malposition. Recognizing the causes of obstructed labor is important if the complications are to be prevented. Adequate prevention, however, can be achieved only through a multidisciplinary approach aimed in the short term at identifying high-risk cases and in the long term at improving nutrition. Early motherhood should be discouraged, and efforts are needed to improve nutrition during infancy, childhood, early adulthood, and pregnancy. Improving the access to and promoting the use of reproductive and contraceptive services will help reduce the prevalence of this complication.

Do big females have big pelves?

Previous studies have shown that maternal stature is a correlate of both pelvic size and reproductive efficiency. This study addresses the issue of body size and obstetric advantage. The relationship between pelvic size and three nonpelvic measures of body size is determined for females and males. The skeletal sample consists of blacks, whites, and Native Americans. The variables include 28 measures of the pelvis, length and head diameter of the femur, and clavicular length. The coefficient of multiple determination (CMD) is computed for each pelvic measure using multiple regression, with the three nonpelvic measures serving as the independent variables. Partial correlation coefficients are also calculated between each pelvic and nonpelvic variable, while controlling for the other two nonpelvic variables. The results show that all CMDs in females and all but one CMD in males are "low," i.e., below 33%. The sexes are nonsignificantly different in their CMDs for 22 of the 28 pelvic variables; of the six variables that are significantly different, five are of the midplane. The sexes are also broadly comparable in their partial correlations. The results are explained as follows. First, the concordance between the sexes in the relationship between pelvic size and nonpelvic measures of body size is due to their genetic similarity for homologous structures. Second, as pelvic size is at the minimum at the midplane, the sexual differences in CMDs are the result of selection with respect to obstetrics. Third, four explanations for the low CMDs are discussed: 1) lack of populationally or racially specific analysis; 2) nonlinear relationship between pelvic size and nonpelvic measures of body size; 3) combination of negative allometric selection between newborn body weight and maternal stature and weight with positive selection for maternal pelvic size; and 4) hormonally induced increase in pelvic capacity during parturition.

Nutrition and maternal mortality in the developing world

This review relates nutritional status to pregnancy-related death in the developing world, where maternal mortality rates are typically >/=100-fold higher than rates in the industrialized countries. For 3 of the central causes of maternal mortality (ie, induced abortion, puerperal infection, and pregnancy-induced hypertension), knowledge of the contribution of nutrition is too scanty for programmatic application. Hemorrhage (including, for this discussion, anemia) and obstructed labor are different. The risk of death is greatly increased with severe anemia (Hb <70 or 80 g/L); there is little evidence of increased risk associated with mild or moderate anemia. Current programs of universal iron supplementation are unlikely to have much effect on severe anemia. There is an urgent need to reassess how to approach anemia control in pregnant women. Obstructed labor is far more common in short women. Unfortunately, nutritional strategies for increasing adult stature are nearly nonexistent: supplemental feeding appears to have little benefit after 3 y of age and could possibly be harmful at later ages, inducing accelerated growth before puberty, earlier menarche (and possible earlier marriage), and unchanged adult stature. Deprived girls without intervention typically have late menarche, extended periods of growth, and can achieve nearly complete catch-up growth. The need for operative delivery also increases with increased fetal size. Supplementary feeding could therefore increase the risk of obstructed labor. In the absence of accessible obstetric services, primiparous women <1.5 m in height should be excluded from supplementary feeding programs aimed at accelerating fetal growth. The knowledge base to model the risks and benefits of increased fetal size does not exist.

Maternal birth weight and cesarean delivery in four race-ethnic groups

OBJECTIVE

We hypothesized that maternal birth weight was associated with the risk of cesarean delivery for nulliparous women.

STUDY DESIGN

In a population-based cohort study, maternal birth data were linked to a Washington State database, including the birth certificates of 18,905 first-born singleton infants (1987-1995).

RESULTS

Among non-Hispanic white subjects, maternal birth weight of 2500 to 3999 g was associated with a 20.9% risk of cesarean delivery, which was the lowest risk, compared with 24.5% for a maternal birth weight <2500 g (P <.05) and 24.0% for a maternal birth weight > or =4000 g (P <.05). Similar patterns of risk were noted among Hispanic and Native American subjects, although the associations did not reach statistical significance. Risk of cesarean delivery was not associated with maternal birth weight among African American subjects. Among non-Hispanic white subjects, the risk of cesarean delivery was 3.23 times greater with a maternal birth weight <2500 g and an infant birth weight > or =4000 g compared with pregnancies with both maternal and infant birth weights between 2500 and 3999 g (P <. 001). Adjustment for socioeconomic factors did not alter these results.

CONCLUSION

Low and high maternal birth weights exert an intergenerational risk of cesarean delivery in nulliparous non-Hispanic white women.

Maternal height as a risk factor for Caesarean section due to failure to progress in labour

We examined for a regional sample of the New Zealand population, the relationship between maternal height and an increased risk of emergency Caesarean section due to arrested labour, to identify a height below which the risk of Caesarean section increases markedly and to quantify the risk of a Caesarean section for a range of maternal heights. The data of nulliparous singleton pregnancies over the period 1994-1998 was sorted into 2 study groups, one resulting in emergency Caesarean section for arrested labour and the other a group of women who had normal vaginal delivery requiring no intervention. The means and standard deviations of these 2 groups were found and 99% confidence intervals calculated. They were analysed for statistical difference and then a logistical regression calculation tried to identify a height at which the risk of a Caesarean section increased suddenly. There were 81 women in the Caesarean section group and 997 in the normal vaginal delivery group. Mean heights and confidence intervals were 161.0 cm (158.9-163.1) and 164.6 cm (164.0-165.2) respectively. There was a statistically significant difference between these means (p<0.001) but logistic regression analysis showed that risk of Caesarean section increased gradually with decreasing height, and even then did not reach more than 30% risk until a height of less than 140 cm. Low maternal height was associated with increased risk of Caesarean section due to labour arrest. Because the likelihood of having a normal vaginal delivery was still very good (>80 %) at modest degrees of short stature, this risk factor alone is unlikely to affect management. However the combination of other risk factors with maternal height may be of clinical use.

Observed versus expected obstetric complications: an assessment of coverage of obstetric care in developing countries

The objective of this study was to evaluate access to obstetric care in a rural district in East Africa using easily collected and evaluated data and avoiding expensive field surveys, complicated study design or statistical methods. The number of observed obstetric complications occurring during 12 months in a rural East African district hospital (the only institution with surgical facilities and access to blood transfusion in the district) were compared to the number of expected complications the district should 'generate'. Of the expected > 10000 deliveries < 25% took place in the district hospital. The place of confinement for the other deliveries was not determined. As compared to the total number of expected conditions within the study district < 25% of the breech and < 45% twin deliveries took part in the district hospital and < 10% of pregnancies complicated by placental abruptions and < 5% of the pregnancies complicated by placenta praevia were managed in the district hospital. Comparing the number of serious pregnancy complications which were managed in the hospital to the total expected number for a particular region allows a simple assessment of the accessibility of obstetric care. This ratio might be more useful when evaluating obstetric care than traditional parameters as it stresses the importance of accessibility of care for the whole community.

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

STUDY OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Determinants of adolescent fertility and its consequences for maternal health, with special reference to rural Bangladesh

The second section of this paper set forth a theoretical model relating adolescent growth and development to family formation patterns and their implications for maternal and child health. Subsequent sections of the paper examine the evidence to support specific relationships hypothesized in the model, focusing on longitudinal data from Matlab, Bangladesh. Despite the emphasis on developing country populations, literature from developed countries was also reviewed. The weight of the evidence suggests that in the developed countries, while there is a positive relationship between reproductive maturation and subsequent reproductive behavior, the negative effects of young maternal age on pregnancy outcome is confounded with socioeconomic factors. Teenage pregnancy, or at least teenage birth, occurs disproportionately among the socially and economically disadvantaged. Moreover, teenage childbearing in the U.S., especially when it occurs outside of marriage, violates social norms, at least in the white population. Poor diet may be a problem in the U.S. but it does not appear to result in notable delays in physical growth and development, delayed or compromised adolescent growth, or late age at menarche. Limited evidence suggests that early menarche may be associated with more rapid onset of mature menstrual cycle activity but these findings have not been replicated elsewhere. In developing countries the situation is quite different. First, early marriage and childbearing are desired and common across most segments of society. Second, malnutrition is widespread, and is sufficiently severe to delay the adolescent growth spurt and raise average age at menarche by two to three years compared with developed country populations. This is certainly the case in Bangladesh. In this setting, several observations regarding the relationship of nutritional status, adolescent development and reproduction have been made. First, undernutrition delays growth and reproductive maturation, and women who mature early (i.e., women with young age at menarche) marry at younger ages than later maturers. In addition, body weight appears to have an independent effect on age at marriage, net of age at menarche, such that relatively heavy women marry at younger ages than their lighter counterparts. Explanations for this finding include correlation between body weight and development of secondary sex characteristics, and perhaps a cultural perception that heavier (i.e., normal body weight) women are more attractive, or healthier, mates. The effect of menarche and nutritional status on marriage gives rise to concern that an improvement in nutritional status, and an increase in the age at menarche, would lead to younger marriage and first birth, and higher lifetime fertility.(ABSTRACT TRUNCATED AT 400 WORDS)

Postpartum haemorrhage in Zimbabwe: a risk factor analysis

OBJECTIVES

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

DESIGN

A population-based case control study.

SETTING

Harare, Zimbabwe.

SUBJECTS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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