Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India

Substantial increase in stillbirth rate during the COVID-19 pandemic: results from a population-based study in the Indian state of Bihar

INTRODUCTION

We report on the stillbirth rate (SBR) and associated risk factors for births during the COVID-19 pandemic, and change in SBR between prepandemic (2016) and pandemic periods in the Indian state of Bihar.

METHODS

Births between July 2020 and June 2021 (91.5% participation) representative of Bihar were listed. Stillbirth was defined as fetal death with gestation period of ≥7 months where the fetus did not show any sign of life. Detailed interviews were conducted for all stillbirths and neonatal deaths, and for 25% random sample of surviving live births. We estimated overall SBR, and during COVID-19 peak and non-peak periods per 1000 births. Multiple logistic regression models were run to assess risk factors for stillbirth. The change in SBR for Bihar from 2016 to 2020-2021 was estimated.

RESULTS

We identified 582 stillbirths in 30 412 births with an estimated SBR of 19.1 per 1000 births (95% CI 17.7 to 20.7); SBR was significantly higher in private facility (38.4; 95% CI 34.3 to 43.0) than in public facility (8.6; 95% CI 7.3 to 10.1) births, and for COVID-19 peak (21.2; 95% CI 19.2 to 23.4) than non-peak period (16.3; 95% CI 14.2 to 18.6) births. Pregnancies with the last pregnancy trimester during the COVID-19 peak period had 40.4% (95% CI 10.3% to 70.4%) higher SBR than those who did not. Risk factor associations for stillbirths were similar between the COVID-19 peak and non-peak periods, with gestation age of <8 months with the highest odds of stillbirth followed by referred deliveries and deliveries in private health facilities. A statistically significant increase of 24.3% and 68.9% in overall SBR and intrapartum SBR was seen between 2016 and 2020-2021, respectively.

CONCLUSIONS

This study documented an increase in SBR during the COVID-19 pandemic as compared with the prepandemic period, and the varied SBR based on the intensity of the COVID-19 pandemic and by the place of delivery.

Effectiveness of a continuum of care in maternal health services on the reduction of maternal and neonatal mortality: Systematic review and meta-analysis

Background

Sustainable Development Goals -3 (SDG - 3) were to ensure healthy live and promote well-being by reducing global maternal and neonatal deaths. These were to be implemented through the concept of continuum of care in maternal health program framework to improve health outcomes. There is a paucity of published evidences; as such, this review is designed to assess the effectiveness of the concept of continuum of care in maternal and neonatal health services on the reduction of maternal and neonatal mortality.

Methods

A search was conducted using the key words; maternal and neonatal, health services, continuum of care, maternal and neonatal mortality. Search focused on PubMed, Cochrane, MEDLINE and Google Scholar. Extractions of articles were done based on predetermine criteria. Data were compiled, and screened, entered and analysis was done using STATA 13 and Rev. Man. software. Effects of the intervention package were determined and the result was interpreted in random effect RR with 95%CI. The publication bias was determined by using funnel plot, Egger and Bagger test, heterogeneity, and sensitivity test.

Results

A total of 4685 articles were retrieved of these 20 articles reviewed. Articles on 631,975 live births (LBs) were analyzed. Results showed the distribution as follows; 23,126 newborns died within 28 days resulting [NMR = 35/1000LBs among the intervention group whereas NMR = 39/1000LBs among the control group]. The pooled effect of the intervention was significantly reduced neonatal mortality (RR = 0.84; 95%CI: 0.77-0.91). Similarly, 1268 women died during the pregnancy period up to 42 days after childbirth that resulted [MMR = 330/100,000LBs among the intervention group whereas MMR = 460/100,000LBs among the control group]. The pooled effect of the intervention was not a statistically significant association with maternal mortality (RR = 0.64; 95%CI: 0.41-1.00).

Conclusion

Adoption of continuum of care concepts in maternal health services reduced maternal and neonatal mortality. We recommend strengthening and effective implementation of a continuum of care in maternal health services to improve maternal and neonatal health care outcomes.

What necessitates obstetric transfers? Experience from a secondary care hospital in India

Background:

India attributes to about 15% of the maternal mortality globally. Many a time poor maternal and neonatal outcomes occur unanticipated during intrapartum and postpartum period. An efficient referral system identifies the indications necessitating prompt referrals besides ensuring patient friendliness and continuity of care.

Methodology:

The descriptive, retrospective study was done in a secondary care hospital of a teaching institution in South India, run by primary care physicians, obstetricians and pediatricians. It describes the referrals from labour room in a year, identifying the referral rate, indications, maternal and neonatal outcomes.

Results:

The referral rate was found to be 3 per cent. The most common indication for the referrals was hypertensive disorders of pregnancy (54.5 percent). Among the women referred, there were no maternal deaths and majority had uncomplicated postpartum period. Eleven women developed postpartum hemorrhage. Neonatal outcome reflected a good trend as 83 per cent had an uneventful hospital stay. There were eight early neonatal deaths.

Conclusion:

The hospital could reduce the referral load to its tertiary care due to adequate training of primary care post graduates in basic obstetrics and anaesthesia skills, establishing standardized referral protocol and monitoring with regular clinical audits. Patient experience could be improved with inter referral unit communication and linking the health information system.

Outcomes of pregnancy-related referrals from rural health facilities to two central hospitals in Harare, Zimbabwe: a prospective descriptive study

BACKGROUND

Between the years 2000 and 2017, the global maternal mortality rate dropped by 38% however, 94% of maternal deaths still emanated from low-to middle-income countries. Rural women are at a significantly higher risk of dying from pregnancy when compared to their urban counterparts. Early detection of complications and prompt referral to higher levels of care can reduce the associated maternal and perinatal mortality. This study aimed to determine the maternal and perinatal outcomes of pregnancy-related referrals from rural health facilities to central hospitals in Harare, Zimbabwe.

METHODS

A prospective descriptive study was conducted using a sample of 206 patients. All mothers who were referred from rural healthcare facilities were recruited for participation. Data were extracted from patient notes using a structured questionnaire and missing information was obtained from the mother after she had recovered. Bivariate analysis was done using IBM SPSS.

RESULTS

The average age of study participants was 27.4 ± 7.7 years. 87.4% had booked for antenatal care and 81.6% presented to the tertiary facility with their referral notes. The major reasons for referring patients were previous cesarean section (20.4%) and hypertensive disorders in pregnancy (18.4%). There were nine maternal deaths thus a case fatality rate of 4.4% while the perinatal mortality rate was 151/1000 live births. Young mothers were at a higher risk of having adverse perinatal outcomes while primiparous mothers were more likely to have a blood transfusion. Mothers who traveled for > 100 km to the tertiary facility and those who did not attend any antenatal visit were more likely to need blood transfusion. Delivering at the rural health facility was significantly associated with receiving a blood transfusion at the tertiary facility. Mothers who did not attend antenatal visits were more likely to have negative perinatal outcomes.

CONCLUSION

The proportion of obstetric patients being referred from rural facilities to tertiary institutions for complications reveals how primary and secondary healthcare facilities in Zimbabwe are falling short of offering the services they should be offering. Equipping these facilities with skilled human resources as well as contemporary equipment could help decongest the central hospitals consequently reducing the adverse maternal and perinatal outcomes.

Rates and risk factors for preterm birth and low birthweight in the global network sites in six low- and low middle-income countries

Background

Preterm birth continues to be a major public health problem contributing to 75% of the neonatal mortality worldwide. Low birth weight (LBW) is an important but imperfect surrogate for prematurity when accurate assessment of gestational age is not possible. While there is overlap between preterm birth and LBW newborns, those that are both premature and LBW are at the highest risk of adverse neonatal outcomes. Understanding the epidemiology of preterm birth and LBW is important for prevention and improved care for at risk newborns, but in many countries, data are sparse and incomplete.

Methods

We conducted data analyses using the Global Network’s (GN) population-based registry of pregnant women and their babies in rural communities in six low- and middle-income countries (Democratic Republic of Congo, Kenya, Zambia, Guatemala, India and Pakistan). We analyzed data from January 2014 to December 2018. Trained study staff enrolled all pregnant women in the study catchment area as early as possible during pregnancy and conducted follow-up visits shortly after delivery and at 42 days after delivery. We analyzed the rates of preterm birth, LBW and the combination of preterm birth and LBW and studied risk factors associated with these outcomes across the GN sites.

Results

A total of 272,192 live births were included in the analysis. The overall preterm birth rate was 12.6% (ranging from 8.6% in Belagavi, India to 21.8% in the Pakistani site). The overall LBW rate was 13.6% (ranging from 2.7% in the Kenyan site to 21.4% in the Pakistani site). The overall rate of both preterm birth and LBW was 5.5% (ranging from 1.2% in the Kenyan site to 11.0% in the Pakistani site). Risk factors associated with preterm birth, LBW and the combination were similar across sites and included nulliparity [RR − 1.27 (95% CI 1.21–1.33)], maternal age under 20 [RR 1.41 (95% CI 1.32–1.49)] years, severe antenatal hemorrhage [RR 5.18 95% CI 4.44–6.04)], hypertensive disorders [RR 2.74 (95% CI − 1.21–1.33], and 1–3 antenatal visits versus four or more [RR 1.68 (95% CI 1.55–1.83)].

Conclusions

Preterm birth, LBW and their combination continue to be common public health problems at some of the GN sites, particularly among young, nulliparous women who have received limited antenatal care services.

Trial registration The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475.Trial registration: The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475.

Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000-17

BACKGROUND

India has made substantial progress in improving child survival over the past few decades, but a comprehensive understanding of child mortality trends at disaggregated geographical levels is not available. We present a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the India National Health Policy (NHP) and Sustainable Development Goal (SDG) targets for child mortality.

METHODS

We assessed the under-5 mortality rate (U5MR) and neonatal mortality rate (NMR) from 2000 to 2017 in 5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sources including surveys with subnational geographical information. The 31 states and groups of union territories were categorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burden of Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using the coefficient of variation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from 2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and 25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). We assessed the causes of child death and the contribution of risk factors to child deaths at the state level.

FINDINGS

U5MR in India decreased from 83·1 (95% uncertainty interval [UI] 76·7-90·1) in 2000 to 42·4 (36·5-50·0) per 1000 livebirths in 2017, and NMR from 38·0 (34·2-41·6) to 23·5 (20·1-27·8) per 1000 livebirths. U5MR varied 5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied 4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88%) districts had a U5MR of 40 or more per 1000 livebirths and 291 (93%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate of change from 2010 to 2017 varied among the districts from a 9·02% (95% UI 6·30-11·63) reduction to no significant change for U5MR and from an 8·05% (95% UI 5·34-10·74) reduction to no significant change for NMR. Inequality between districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states for NMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to 2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either of the NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districts for NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 death in India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediate decline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude of decline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which 68·2% (65·8-70·7) of under-5 deaths and 83·0% (80·6-85·0) of neonatal deaths in India could be attributed in 2017; 10·8% (9·1-12·4) of under-5 deaths could be attributed to unsafe water and sanitation and 8·8% (7·0-10·3) to air pollution.

INTERPRETATION

India has made gains in child survival, but there are substantial variations between the states in the magnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality between districts within states has increased for the majority of the states. The district-level trends presented here can provide crucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survival targets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the risk factors in this Article provide a comprehensive reference for further planning of child mortality reduction in India.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Exploring women's experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths in Pakistan: A qualitative study

Understanding key healthcare system challenges experienced by women during pregnancy and birth is crucial to scale up available interventions and reduce perinatal mortality. A community perspective about preferences and experience of care during this period can be used to improve community-based programs to reduce perinatal mortality. Using a qualitative exploratory approach, we examined women's experience of perinatal loss, aiming to understand the main factors, as perceived and experienced by women, leading to perinatal loss. Qualitative in-depth Interviews were conducted with 25 mothers with a recent perinatal loss, three family members, six healthcare officials, and two focus group discussions with 17 lady health workers. Data were analysed using inductive and deductive coding, by thematic analysis. Our findings revealed three distinct but interrelated themes, which include: 1) poor access to care during pregnancy and birth, 2) unavailability of appropriate healthcare services, and 3) poor quality of care during pregnancy and birth. Women frequently delayed seeking formal care around birth because of delays by themselves, their family members, or the local traditional birth attendants who frequently induced births at women's homes without recognising the dangers to the mothers or their babies. Preference for private care was common, however they often could not bear the cost of care when they needed caesarean section or in-patient care for their sick newborns because these services were absent in public health facilities of the district. Referral to the regional tertiary care hospital was often not officially arranged leading to risky births in small and crowded private clinics. Women's views about negative staff attitudes and the lack of attention given to them in public health facilities highlighted a lack of quality and respectful antenatal care. Improvement in women's access to essential care during pregnancy and around birth, availability of emergency obstetric and newborn care, improving the quality of maternal and newborn care in both public and private health facilities at the district level might reduce perinatal mortality in Pakistan.

The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi, India

Introduction

Ambulance-based emergency medical systems (EMS) are expensive and remain rare in low- and middle-income countries, where trauma victims are usually transported to hospital by passing vehicles. Recent developments in transportation network technologies could potentially disrupt this status quo by allowing coordinated emergency response from layperson networks. We sought to understand the barriers to bystander assistance for trauma victims in Delhi, India, and implications for a layperson-EMS.

Methods

We used qualitative methods to analyse data from 50 interviews with frontline stakeholders (including taxi drivers, medical professionals, legal experts and police), one stakeholder consultation and a review of documents.

Results

Respondents noted that most trauma victims in Delhi are rapidly brought to hospital by bystanders, taxis and police. While ambulances are common, they are primarily used for interfacility transfers. Entrenched medico-legal practices result in substantial police presence at the hospital, which is a major source of harassment of good Samaritans and interferes with patient care. Trauma victims are often turned away by for-profit hospitals due to their inability to pay, leading to delays in treatment. Recent policy efforts to circumscribe the role of police and force for-profit hospitals to stabilise patients appear to have been unsuccessful.

Conclusions

Existing healthcare and medico-legal practices in India create large systemic impediments to improving trauma outcomes. Until India’s ongoing health and transport sector reforms succeed in ensuring that for-profit hospitals reliably provide care, good Samaritans and layperson-EMS providers should take victims with uncertain financial means to public facilities. To avoid difficulties with police, providers of a layperson-EMS would likely need official police sanction and carry visible symbols of their authority to provide emergency transport. Delhi already has several key components of an EMS (including dispatcher coordinated police response, large ambulance fleet) that could be integrated and expanded into a complete system of emergency care.

Mode of delivery among nulliparous women with single, cephalic, term pregnancies: The WHO global survey on maternal and perinatal health, 2004-2008

OBJECTIVE

To determine risk factors associated with cesarean delivery among nulliparous women in spontaneous labor with a single, cephalic, term pregnancy (Robson group 1).

METHODS

Data were assessed from the WHO Global Survey of Maternal and Perinatal Health conducted in 2004-2008.

RESULTS

Among 82 280 women in Robson group 1, 67 698 (82.3%) had vaginal and 14 578 (17.7%) had cesarean delivery. In adjusted analyses, maternal factors associated with cesarean included age older than 18 years, being overweight or obese, being married or cohabitating, attending four prenatal visits or more, and being medically high risk (P<0.001). Women who were obstetrically high risk, referred during labor, or at 39 gestational weeks or more were also more likely to undergo cesarean (all P<0.001). Facility-level factors associated with cesarean were availability of an anesthesia service 24/7, being a teaching facility, requirement of fees for cesarean, availability of electronic fetal monitoring, and having providers skilled in operative vaginal delivery (all P<0.01).

CONCLUSION

The analysis highlights the importance of maintaining a healthy pre-pregnancy and pregnancy weight, optimizing management of women with medical problems, and ensuring clear referral mechanisms for women with intrapartum complications. The association between fees and cesarean delivery warrants further exploration.

Trends and determinants of increasing caesarean sections from 2010 to 2013 in a prospective population-based registry in eastern rural Maharashtra, India

OBJECTIVE

Our objective was to describe trends in caesarean section (CS) rates, characteristics of women delivering by CS, reasons for CS and impact of CS on perinatal mortality, in a rural Indian population.

DESIGN

Secondary data analysis using a prospective population-based registry.

SETTING

Four districts in Eastern Maharashtra, India, 2010 to 2013.

PARTICIPANTS

39 026 pregnant women undergoing labour and delivery.

MAIN OUTCOMES

CS, single most likely reason, perinatal mortality.

RESULTS

Overall, 20% of the women delivered by CS. Rates increased from 17.4% in 2010 to 22.7% in 2013 (p<0.001) with an absolute risk increase from 1% to 5% during this time-period. Women aged 25+ years old, being nulliparous, having at least a secondary school education, a body mass index 25+ and a multiple gestation pregnancy were more likely to deliver by CS. Perinatal mortality was higher among babies delivered vaginally than those delivered by CS (4.5% vs 2.7%, p<0.001). Prolonged and obstructed labour as the reported reason for CS increased over time for both nulliparous and multiparous women (p<0.001), and 6% to 10% women had no clear reason for CS. Perinatal mortality was higher among babies born vaginally than those delivered by CS (adjusted OR: 0.65, 95% CI 0.56 to 0.76, p<0.001).

CONCLUSION

Rates of CS increased over time in rural Maharashtra, exceeding WHO recommendations. Characteristics associated with CS and outcomes of CS were similar to previous reports. Further studies are needed to ensure accuracy of reported reasons for CS, why obstructed and prolonged labour leading to CS is increasing in this population and what leads to CS without a clear indication. Such information may be helpful for implementing the Indian Government mandate that no CS be performed without strict medical indications, while ensuring that the overall CS rates are appropriate.

TRIAL REGISTRATION NUMBER

NCT01073475.

Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar

BACKGROUND

The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths.

METHODS

Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment.

RESULTS

The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days.

CONCLUSIONS

To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.

Deferred and referred deliveries contribute to stillbirths in the Indian state of Bihar: results from a population-based survey of all births

BACKGROUND

The India Newborn Action Plan (INAP) aims for < 10 stillbirths per 1000 births by 2030. A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population.

METHODS

Detailed interviews were conducted in a representative sample of all births between January and December 2016 from 182,486 households (96.2% participation) in 1657 clusters in the Indian state of Bihar. A stillbirth was defined as foetal death with gestation period of ≥ 7 months wherein the foetus did not show any sign of life. The association of stillbirth was investigated with a variety of risk factors among all births using a hierarchical logistic regression model approach.

RESULTS

A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1000 births, respectively. Detailed interview was available for 20,152 (84.2% participation) births including 275 stillbirths (81.4% participation). In the final regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of ≤ 8 months (OR 11.36, 95% CI 8.13-15.88), for first born (OR 5.79, 95% CI 4.06-8.26), deferred deliveries wherein a woman was sent back home and asked to come later for delivery by a health provider (OR 5.51, 95% CI 2.81-10.78), and in those with forceful push/pull during the delivery by the health provider (OR 4.85, 95% CI 3.39-6.95). The other significant risk factors were maternal age ≥ 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities (OR 1.75, 95% CI 1.19-2.56) and home (OR 2.60, 95% CI 1.87-3.62). Varied risk factors were associated with antepartum and intrapartum stillbirths. Birth weight was available only for 40 (14.5%) stillborns. Among the facility deliveries, the women who were referred from one facility to another for delivery had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43).

CONCLUSIONS

We found an increased risk of stillbirths in deferred and referred deliveries in addition to demographic and clinical risk factors for antepartum and intrapartum stillbirths, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise these findings to further strengthen its approach to meet the stillbirth reduction target by 2030.

Maternal anemia and underweight as determinants of pregnancy outcomes: cohort study in eastern rural Maharashtra, India

OBJECTIVES

To study the trend in the prevalence of anaemia and low BMI among pregnant women from Eastern Maharashtra and evaluate if low BMI and anaemia affect pregnancy outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Catchment areas of 20 rural primary health centres in four eastern districts of Maharashtra State, India.

PARTICIPANTS

72 750 women from the Nagpur site of Maternal and Newborn Health Registry of NIH's Global Network, enrolled from 2009 to 2016.

MAIN OUTCOME MEASURES

Mode of delivery, pregnancy related complications at delivery, stillbirths, neonatal deaths and low birth weight (LBW) in babies.

RESULTS

Over 90% of the women included in the study were anaemic and over a third were underweight (BMI <18 kg/m2) and with both conditions. Mild anaemia at any time during delivery significantly increased the risk (Risk ratio; 95% confidence interval (RR;(95% CI)) of stillbirth (1.3 (1.1-1.6)), neonatal deaths (1.3 (1-1.6)) and LBW babies (1.1 (1-1.2)). The risks became even more significant and increased further with moderate/severe anaemia any time during pregnancy for stillbirth (1.4 (1.2-1.8)), neonatal deaths (1.7 (1.3-2.1)) and LBW babies (1.3 (1.2-1.4)).,. Underweight at anytime during pregnancy increased the risk of neonatal deaths (1.1 (1-1.3)) and LBW babies (1.2;(1.2-1.3)).The risk of having stillbirths (1.5;(1.2-1.8)), neonatal deaths (1.7;(1.3-2.3)) and LBW babies (1.5;(1.4-1.6)) was highest when - the anaemia and underweight co-existed in the included women. Obesity/overweight during pregnancy increased the risk of maternal complications at delivery (1.6;(1.5-1.7)) and of caesarean section (1.5;(1.4-1.6)) and reduced the risk of LBW babies 0.8 (0.8-0.9)).

CONCLUSION

Maternal anaemia is associated with enhanced risk of stillbirth, neonatal deaths and LBW. The risks increased if anaemia and underweight were present simultaneously.

TRIAL REGISTRATION NUMBER

NCT01073475.