Maternal and perinatal Health Research Collaboration, India (MaatHRI): methodology for establishing a hospital-based research platform in a low and middle income country setting

Maternal and fetal factors associated with stillbirth in singleton pregnancies in 13 hospitals across six states in India: A prospective cohort study

OBJECTIVE

This study aimed to investigate the incidence of and risk factors for stillbirth in an Indian population.

METHODS

We conducted a secondary data analysis of a hospital-based cohort from the Maternal and Perinatal Health Research collaboration, India (MaatHRI), including pregnant women who gave birth between October 2018-September 2023. Data from 9823 singleton pregnancies recruited from 13 hospitals across six Indian states were included. Univariable and multivariable Poisson regression analysis were performed to examine the relationship between stillbirth and potential risk factors. Model prediction was assessed using the area under the receiver-operating characteristic (AUROC) curve.

RESULTS

There were 216 stillbirths (48 antepartum and 168 intrapartum) in the study population, representing an overall stillbirth rate of 22.0 per 1000 total births (95% confidence interval [CI]: 19.2-25.1). Modifiable risk factors for stillbirth were: receiving less than four antenatal check-ups (adjusted relative risk [aRR]: 1.75, 95% CI: 1.25-2.47), not taking any iron and folic acid supplementation during pregnancy (aRR: 7.23, 95% CI: 2.12-45.33) and having severe anemia in the third trimester (aRR: 3.37, 95% CI: 1.97-6.11). Having pregnancy/fetal complications such as hypertensive disorders of pregnancy (aRR: 1.59, 95% CI: 1.03-2.36), preterm birth (aRR: 4.41, 95% CI: 3.21-6.08) and birth weight below the 10th percentile for gestational age (aRR: 1.35, 95% CI: 1.02-1.79) were also associated with an increased risk of stillbirth. Identified risk factors explained 78.2% (95% CI: 75.0%-81.4%) of the risk of stillbirth in the population.

CONCLUSION

Addressing potentially modifiable antenatal factors could reduce the risk of stillbirths in India.

Characteristics and outcomes of pregnant women hospitalized with severe maternal outcomes in eastern Ethiopia: Results from the Ethiopian Obstetric Surveillance System study

OBJECTIVE

The aim of the present study was to identify facility-based incidence of severe obstetric complications through a newly established obstetric surveillance system in eastern Ethiopia.

METHODS

Monthly registration of obstetric hemorrhage, eclampsia, uterine rupture, severe anemia and sepsis was introduced in 13 maternity units in eastern Ethiopia. At each hospital, a designated clinician reported details of women admitted during pregnancy, childbirth or within 42 days of termination of pregnancy from April 01, 2021 to March 31, 2022 developing any of these conditions. Detailed data on sociodemographic characteristics, obstetric complications and status at discharge were collected by trained research assistants.

RESULTS

Among 38 782 maternities during the study period, 2043 (5.3%) women had any of the five conditions. Seventy women died, representing a case fatality rate of 3.4%. The three leading reasons for admission were obstetric hemorrhage (972; 47.6%), severe anemia (727; 35.6%), and eclampsia (438; 21.4%). The majority of the maternal deaths were from obstetric hemorrhage (27/70; 38.6%) followed by eclampsia (17/70; 24.3%).

CONCLUSION

Obstetric hemorrhage, severe anemia and eclampsia were the leading causes of severe obstetric complications in eastern Ethiopia. Almost one in 29 women admitted with obstetric complications died. Audit of quality of care is indicated to design tailored interventions to improve maternal survival and obstetric complications.

Women's awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study

BACKGROUND

Mental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women's awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India.

METHODS

Focus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis.

RESULTS

Seven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported.

CONCLUSIONS

Women face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in 'real world' antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.