Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial

BACKGROUND

Despite achieving relatively high rates of antenatal care, institutional delivery, and HIV antiretroviral therapy for women during pregnancy, neonatal mortality has remained stubbornly high in Zimbabwe. Clearer understanding of causal pathways is required to inform effective interventions.

METHODS

This study was a secondary analysis of data from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, a cluster-randomized community-based trial among pregnant women and their infants, to examine care during institutional and non-institutional deliveries in rural Zimbabwe and associated birth outcomes.

RESULTS

Among 4423 pregnant women, 529 (11.9%) delivered outside a health institution; hygiene practices were poorer and interventions to minimise neonatal hypothermia less commonly utilised for these deliveries compared to institutional deliveries. Among 3441 infants born in institutions, 592 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside institutions. Among mothers delivering at home who reported their reason for having a home delivery, 221/293 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference.

CONCLUSIONS

Preterm birth is common among all infants in rural Zimbabwe, and extremely high among infants born outside health institutions. Our findings indicate that premature onset of labor, rather than maternal choice, may be the reason for many non-institutional deliveries in low-resource settings, initiating a cascade of events resulting in a two-fold higher risk of stillbirth and neonatal mortality amongst children born outside health institutions. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov, number NCT01824940.

Maternal Decision-Making Autonomy, Mental Health, Gender Norm Attitudes, and Social Support During Pregnancy Predict Child Care-Giving and Stunting in Rural Zimbabwe

Objectives

To determine the predictive association of 7 maternal capabilities during pregnancy [physical and mental health (PH, MH), social support (SS), decision making autonomy (DMA), gender norm attitudes (GNA), mothering self-efficacy (MSE), and time stress (TS)] with subsequent child care behaviors and child length-for-age Z (LAZ) and stunting (LAZ&lt; −2.0) at 18 months.

Methods

Capabilities were assessed by questionnaire among 4667 pregnant women enrolled in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE). Child care behaviors and LAZ were assessed at infant ages 1, 3, 6, 12, and 18 months. We used logistic regression or generalized estimating equation models accounting for within-cluster correlation and adjusted for pre-specified covariates to test the association between each maternal capability and each outcome.

Results

Food security was associated with stronger maternal capabilities, across all seven domains. Mothers with more egalitarian GNA were more likely to have an institutional delivery, initiate breastfeeding early, exclusively breastfeed (EBF) to 6 months, and have soap and water at a handwashing station. Mothers with TS were less likely to EBF. Mothers with greater SS were more likely to have an institutional delivery and feed their child a diverse diet; depressed mothers were less likely to have an institutional delivery and a fully immunized child. In fully adjusted analyses, GNA and SS were significantly associated with child LAZ at 18 months and DMA and SS were significantly associated with stunting (LAZ&lt; −2.0). Depression was more weakly associated with LAZ (P = 0.08).

Conclusions

Mothers who hold more equitable GNA; who are empowered to independently make decisions affecting themselves and their children; who know someone they can count on for help during times of need; and who are not depressed, are more likely to provide optimal care for their children and their children are less likely to be stunted at 18 months of age. Interventions to strengthen these maternal capabilities within nutrition programs will likely increase impact on child nutritional status and health.

Funding Sources

Bill & Melinda Gates Foundation (OPP1021542, OPP1143707); UK Department for International Development, Wellcome Trust (09,3768/Z/10/Z,108,065/Z/15/Z), Swiss Agency for Development and Cooperation (8,106,727).

Determinants of Urogenital Schistosomiasis Among Pregnant Women and its Association With Pregnancy Outcomes, Neonatal Deaths, and Child Growth

Background

Schistosoma haematobium is a parasitic helminth that causes urogenital pathology. The impact of urogenital schistosomiasis during pregnancy on birth outcomes and child growth is poorly understood.

Methods

Risk factors for urogenital schistosomiasis were characterized among 4437 pregnant women enrolled in a cluster-randomized community-based trial in rural Zimbabwe. Infection was defined via urine microscopy (≥1 S. haematobium egg) and urinalysis (hematuria). Associations between infection and pregnancy outcomes were assessed in case-control analyses using conditional logistic regression. The association of maternal infection with birthweight and length-for-age Z scores (LAZ) at 1 and 18 months of age were assessed using generalized estimating equations.

Results

Urogenital schistosomiasis (egg positive and/or hematuria positive) was detected in 26.8% of pregnant women. Risk factors significantly associated with infection were maternal age, education, marital status, and religion; household drinking water source and latrine; study region; and season. Urogenital schistosomiasis was not significantly associated with adverse pregnancy outcomes (miscarriage, stillbirth, preterm, and small-for-gestational age), birthweight, neonatal death, or LAZ.

Conclusions

Including pregnant women in antihelminthic treatment programs would benefit a large number of women in rural Zimbabwe. However, clearance of the low-intensity infections that predominate in this context is unlikely to have additive benefits for pregnancy outcomes or child growth.

Clinical Trials Registration

NCT01824940.