Incidence and determinants of perinatal mortality among women with obstructed labour in eastern Uganda: a prospective cohort study

Decreased renal function among children born to women with obstructed labour in Eastern Uganda: a cohort study

BACKGROUND

Over two million children and adolescents suffer from chronic kidney disease globally. Early childhood insults such as birth asphyxia could be risk factors for chronic kidney disease in later life. Our study aimed to assess renal function among children aged two to four years, born to women with obstructed labour.

METHODS

We followed up 144 children aged two to four years, born to women with obstructed labor at Mbale regional referral hospital in Eastern Uganda. We used serum creatinine to calculate estimated glomerular filtration rate (eGFR) using the Schwartz formula. We defined decreased renal function as eGFR less than 90 ml/min/1.73m2.

RESULTS

The mean age of the children was 2.8 years, standard deviation (SD) of 0.4 years. Majority of the children were male (96/144: 66.7%). The mean umbilical lactate level at birth among the study participants was 8.9 mmol/L with a standard deviation (SD) of 5.0. eGFR of the children ranged from 55 to 163 ml/min/1.73m2, mean 85.8 ± SD 15.9. Nearly one third of the children (45/144) had normal eGFR (> 90 ml/Min/1.73m2), two thirds (97/144) had a mild decrease of eGFR (60-89 ml/Min/1.73m2), and only two children had a moderate decrease of eGFR (< 60 ml/Min/1.73m2). Overall incidence of reduced eGFR was 68.8% [(99/144): 95% CI (60.6 to 75.9)].

CONCLUSION

We observed a high incidence of reduced renal function among children born to women with obstructed labour. We recommend routine follow up of children born to women with obstructed labour and add our voices to those calling for improved intra-partum and peripartum care.

Perinatal care and its association with perinatal death among women attending care in three district hospitals of western Uganda

BACKGROUND

Provision of effective care to all women and newborns during the perinatal period is a viable strategy for achieving the Sustainable Development Goal 3 targets on reducing maternal and neonatal mortality. This study examined perinatal care (antenatal, intrapartum, postpartum) and its association with perinatal deaths at three district hospitals in Bunyoro region, Uganda.

METHODS

A cross-sectional study was conducted in which a questionnaire was administered consecutively to 872 postpartum women before discharge who had attended antenatal care and given birth in the study hospitals. Data on care received during antenatal, labour, delivery, and postpartum period, and perinatal outcome were extracted from medical records of the enrolled postnatal women using a pre-tested structured tool. The care received from antenatal to 24 h postpartum period was assessed against the standard protocol of care established by World Health Organization (WHO). Poisson regression was used to assess the association between care received and perinatal death.

RESULTS

The mean age of the women was 25 years (standard deviation [SD] 5.95). Few women had their blood tested for hemoglobin levels, HIV, and Syphilis (n = 53, 6.1%); had their urine tested for glucose and proteins (n = 27, 3.1%); undertook an ultrasound scan (n = 262, 30%); and had their maternal status assessed (n = 122, 14%) during antenatal care as well as had their uterus assessed for contraction and bleeding during postpartum care (n = 63, 7.2%). There were 19 perinatal deaths, giving a perinatal mortality rate of 22/1,000 births (95% Confidence interval [CI] 8.1-35.5). Of these 9 (47.4%) were stillbirths while the remaining 10 (52.6%) were early neonatal deaths. In the antenatal phase, only fetal examination was significantly associated with perinatal death (adjusted prevalence ratio [aPR] = 0.22, 95% CI 0.1-0.6). No significant association was found between perinatal deaths and care during labour, delivery, and the early postpartum period.

CONCLUSION

Women did not receive all the required perinatal care during the perinatal period. Perinatal mortality rate in Bunyoro region remains high, although it's lower than the national average. The study shows a reduction in the proportion of perinatal deaths for pregnancies where the mother received fetal monitoring. Strategies focused on strengthened fetal status monitoring such as fetal movement counting methods and fetal heart rate monitoring devices during pregnancy need to be devised to reduce the incidence of perinatal deaths. Findings from the study provide valuable information that would support the strengthening of perinatal care services for improved perinatal outcomes.

Decreased renal function among children born to women with obstructed labour in Eastern Uganda: a cohort study

Background

Over two million children and adolescents suffer from chronic kidney disease globally. Early childhood insults such as birth asphyxia could be risk factors for development of chronic kidney disease in infancy. Our study aimed to assess renal function among children aged two to four years, born to women with obstructed labour.

Methods

We followed up 144 children aged two to four years, born to women with obstructed labor at Mbale regional referral hospital in Eastern Uganda. We used estimated glomerular filtration rate (eGFR) by the Schwartz formula to calculate eGFR (0.413*height)/ serum creatinine as a measure of renal function. eGFR less than 90 ml/min/1.73m2 was classified as decreased renal function.

Results

The mean age of the children was 2.8 years, standard deviation (SD) of 0.4 years. Majority of the children were male (96/144: 66.7%). The mean umbilical lactate level at birth among the study participants was 8.9 mmol/L with a standard deviation (SD) of 5.0. eGFR values ranged from 55 to 163ml/min/1.72m2, mean 85.8 ± SD 15.9. One third (31.3%) 45/144 had normal eGFR (> 90 ml/Min/1.72m2), two thirds (67.4%) 97/144 had a mild decrease of eGFR (60-89 ml/Min/1.72m2), and only 2/144 (1.4%) had a moderate decrease of eGFR. Overall incidence of reduced eGFR was 68.8% (99/144).

Conclusion

We observed a high incidence of impaired renal function among children born to women with obstructed labour. We recommend routine follow up of children born to women with obstructed labour and add our voices to those calling for improved intra-partum and peripartum care.

Maternal and umbilical cord blood lactate for predicting perinatal death: a secondary analysis of data from a randomized controlled trial

BACKGROUND

In high resource settings, lactate and pH levels measured from fetal scalp and umbilical cord blood are widely used as predictors of perinatal mortality. However, the same is not true in low resource settings, where much of perinatal mortality occurs. The scalability of this practice has been hindered by difficulty in collecting fetal scalp and umbilical blood sample. Little is known about the use of alternatives such as maternal blood, which is easier and safer to obtain. Therefore, we aimed to compare maternal and umbilical cord blood lactate levels for predicting perinatal deaths.

METHODS

This was secondary analysis of data from a randomized controlled trial assessing the effect of sodium bicarbonate on maternal and perinatal outcomes among women with obstructed labour at Mbale regional referral hospital in Eastern Uganda. Lactate concentration in maternal capillary, myometrial, umbilical venous and arterial blood was measured at the bedside using a lactate Pro 2 device (Akray, Japan Shiga) upon diagnosis of obstructed labour. We constructed Receiver Operating Characteristic curves to compare the predictive ability of maternal and umbilical cord lactate and the optimal cutoffs calculated basing on the maximal Youden and Liu indices.

RESULTS

Perinatal mortality risk was: 102.2 deaths per 1,000 live births: 95% CI (78.1-130.6). The areas under the ROC curves were 0.86 for umbilical arterial lactate, 0.71 for umbilical venous lactate, and 0.65 for myometrial lactate, 0.59 for maternal lactate baseline, and 0.65 at1hr after administration of bicarbonate. The optimal cutoffs for predicting perinatal death were 15 0.85 mmol/L for umbilical arterial lactate, 10.15mmol/L for umbilical venous lactate, 8.75mmol/L for myometrial lactate, and 3.95mmol/L for maternal lactate at recruitment and 7.35mmol/L after 1 h.

CONCLUSION

Maternal lactate was a poor predictor of perinatal death, but umbilical artery lactate has a high predictive value. There is need for future studies on the utility of amniotic fluid in predicting intrapartum perinatal deaths.

Mortality Rate and Predictors Among Women With Obstructed Labor in a Tertiary Academic Medical Center of Ethiopia: A Retrospective Cohort Study

Introduction

Obstructed labor is one of the most common preventable causes of maternal morbidity and mortality. In Ethiopia, 36% of maternal mortality was due to obstructed labor with uterine rupture. Thus, this study proposed to measure predictors of maternal mortality among women with obstructed labor in a tertiary academic medical center in Southern Ethiopia.

Methods

An institution-based retrospective cohort study was conducted at Hawassa University Specialized Hospital from July 25 to September 30, 2018. Women who had obstructed labor from 2015 to 2017 were recruited. A pretested checklist was used to retrieve data from the woman's chart. A multivariable logistic regression model was employed to identify variables associated with maternal mortality, and variables with a p-value <.05 were considered significant at 95% CI.

Results

With a response rate of 96.3%, 156 moms who experienced labor obstruction were included in the study. Obstructed labor caused the deaths of 14 women, resulting in a maternal mortality rate of 8.9% (95% CI: 7.15, 16.4). Maternal mortality from obstructed labor was reduced in women who received antenatal care visits (AOR = 0.25, 95% CI: 0.13, 0.76) and blood transfusions (AOR =  0.49, 95% CI: 0.03, 0.89). Women who experienced uterine rupture (AOR =  6.25, 95% CI: 5.3, 15.6) and antepartum hemorrhage (AOR = 14, 95% CI: 2.45, 70.5) had a greater risk of maternal mortality than women who did not have the corresponding morbidity.

Conclusions

The center had a higher rate of maternal mortality due to obstructed labor. Early screening and improving the care for women at greatest risk of antenatal and postnatal co-morbidities like uterine rupture and shock were the major priorities and fundamental strategies to decreasing maternal mortality. It also showed that antenatal care visits, early referral, and blood transfusion for women with obstructed labor should be amended in order to lower maternal mortality.

Improved maternal-fetal outcomes among emergency obstetric referrals following phone call communication at a teaching hospital in south western Uganda: a quasi-experimental study

BACKGROUND

Emergency obstetric referrals develop adverse maternal-fetal outcomes partly due to delays in offering appropriate care at referral hospitals especially in resource limited settings. Referral hospitals do not get prior communication of incoming referrals leading to inadequate preparedness and delays of care. Phone based innovations may bridge such communication challenges. We investigated effect of a phone call communication prior to referral of mothers in labour as intervention to reduce preparation delays and improve maternal-fetal outcome at a referral hospital in a resource limited setting.

METHODS

This was a quasi-experimental study with non-equivalent control group conducted at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda from September 2020 to March 2021. Adverse maternal-fetal outcomes included: early neonatal death, fresh still birth, obstructed labour, ruptured uterus, maternal sepsis, low Apgar score, admission to neonatal ICU and hysterectomy. Exposure variable for intervention group was a phone call prior maternal referral from a lower health facility. We compared distribution of clinical characteristics and adverse maternal-fetal outcomes between intervention and control groups using Chi square or Fisher's exact test. We performed logistic regression to assess association between independent variables and adverse maternal-fetal outcomes.

RESULTS

We enrolled 177 participants: 75 in intervention group and 102 in control group. Participants had similar demographic characteristics. Three quarters (75.0%) of participants in control group delayed on admission waiting bench of MRRH compared to (40.0%) in intervention group [p =  < 0.001]. There were significantly more adverse maternal-fetal outcomes in control group than intervention group (obstructed labour [p = 0.026], low Apgar score [p = 0.013] and admission to neonatal high dependency unit [p =  < 0.001]). The phone call intervention was protective against adverse maternal-fetal outcome [aOR = 0.22; 95%CI: 0.09-0.44, p = 0.001].

CONCLUSION

The phone call intervention resulted in reduced delay to patient admission at a tertiary referral hospital in a resource limited setting, and is protective against adverse maternal-fetal outcomes. Incorporating the phone call communication intervention in the routine practice of emergency obstetric referrals from lower health facilities to regional referral hospitals may reduce both maternal and fetal morbidities.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR20200686885039.

Rural-urban correlates of skilled birth attendance utilisation in Sierra Leone: evidence from the 2019 Sierra Leone Demographic Health Survey

OBJECTIVES

Understanding the rural-urban context-specific correlates of skilled birth attendance (SBA) is important to designing relevant strategies and programmes. This analysis aimed to assess for the rural-urban correlates of SBA in Sierra Leone.

SETTING

The latest nationally representative Sierra Leone Demographic and Health Survey of 2019.

PARTICIPANTS

The study included a weighted sample of 7326 women aged 15-49 years. Each of them had a live birth within 5 years prior to the survey (4531 in rural areas and 2795 women in urban areas).

PRIMARY AND SECONDARY OUTCOME MEASURE

SBA (primary) and predictors of SBA (secondary).

RESULTS

SBA was higher in urban areas at 94.9% (95% CI 94.1% to 95.7%) compared with 84.2% (95% CI 83.8% to 85.9%) in rural areas. Rural women resident in the Southern, Northern and Eastern regions, with postprimary education (adjusted OR (aOR) 1.8; 95% CI 1.3 to 2.5), exposure to mass media (aOR 1.5; 95% CI 1.1 to 1.9), not having difficulties with distance to the nearest health facility (aOR 2.3; 95% CI 1.7 to 3.0) were associated with higher odds of SBA. Urban women resident in the Southern, Eastern region, with households having less than seven members (aOR 1.5; 95% CI 1.1 to 2.3), exposure to mass media (aOR 1.8; 95% CI 1.1 to 2.9) and not having difficulties with distance to the nearest health facility (aOR 1.6; 95% CI 1.1 to 2.5) were associated with higher odds of SBA.

CONCLUSION

Given the observed differences, improving SBA requires programmes and strategies that are context-specific.

Continuum of care for maternal health in Uganda: A national cross-sectional study

Introduction

A continuum of maternal care approach can reduce gaps and missed opportunities experienced by women and newborns. We determined the level of coverage and factors associated with the continuum of maternal care in Uganda.

Methods

We used weighted data from the Uganda Demographic and Health Survey (UDHS) 2016. We included 10,152 women aged 15 to 49 years, who had had a live birth within five years preceding the survey. Stratified two-stage cluster sampling design was used to select participants. Continuum of maternal care was considered when a woman had at least four antenatal care (ANC) visits, had delivered in a health facility and they had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression analysis to determine factors associated with completion of the continuum of maternal care using SPSS version 25.

Results

The level of coverage of complete continuum of maternal care was 10.7% (1,091) (95% CI: 10.0–11.2). About 59.9% (6,080) (95% CI: 59.0–60.8) had four or more antenatal visits while 76.6% (7,780) (95% CI: 75.8–77.5) delivered in a health facility and 22.5% (2,280) (95% CI: 21.5–23.2) attended at least one postnatal care visit within six weeks. The following factors were associated with continuum of maternal care; initiating ANC in the first trimester (AOR 1.49, 95% CI: 1.23–1.79), having secondary level of education (AOR 1.60, 95% CI: 1.15–2.22) and tertiary level of education (AOR 2.08 95% CI: 1.38–3.13) compared to no formal education, being resident in Central Uganda (AOR 1.44, 95% CI:1.11–1.89), Northern Uganda (AOR 1.35, 95% CI: 1.06–1.71) and Western Uganda (AOR 0.61, 95% CI: 0.45–0.82) compared to Eastern Uganda, and exposure to newspapers and magazines.

Conclusion

The level of coverage of the complete continuum of maternal care was low and varied across regions. It was associated with easily modifiable factors such as early initiation of ANC, exposure to mass media and level of education. Interventions to improve utilisation of the continuum of maternal care should leverage mass media to promote services, especially among the least educated and the residents of Western Uganda.

Exposure to different types of mass media and timing of antenatal care initiation: insights from the 2016 Uganda Demographic and Health Survey

BACKGROUND

Early initiation of antenatal care (ANC) within the first trimester is highly recommended in the current 2016 World Health Organization (WHO) guidelines. Mass media has the potential to promote early initiation of ANC because it has been used successfully in several programs. However, there is paucity of literature on the effect of exposure to different types of media on the timing of ANC initiation in Uganda. Our study aimed at exploring associations between exposure to different types of mass media and timing of ANC initiation among women in Uganda.

METHODS

We used a cross sectional study design, to conduct a secondary analysis of data collected in the 2016 Uganda Demographic and Health Survey (UDHS). We included weighted data of all the 10,152 women of reproductive age (15-49 years). Multistage stratified sampling was used to select study participants. Multivariable logistic regression was used to determine the association between exposure to different types of mass media and early initiation of ANC.

RESULTS

Almost a third of the women (2953/10,152, 29.1%, 95% CI 27.9-29.6) initiated their first ANC contact in the first trimester. Women who listened to radio at least once a week (adjusted OR (aOR 1.14, 95% CI 1.01-1.30) and those who watched television less than once a week (aOR 1.28, 95% CI 1.07-1.53) had higher odds of initiating ANC earlier compared to their counterparts not exposed to radio and television respectively.

CONCLUSION

Exposure to radio and television is associated with timing of ANC initiation in Uganda. Importantly, the two types of mass media have the potential to reach women with low levels of education and encourage them to utilize maternal health services. The Ugandan government needs to prioritize and intensify the use of radio and television to promote the benefits associated with timing of ANC initiation.