1 improving perinatal outcomes in zimbabwe: a new focus on prematurity feresu s.a, gillispie b,...

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Improving Perinatal Improving Perinatal Outcomes in Outcomes in

Zimbabwe: A New Zimbabwe: A New Focus on Focus on

PrematurityPrematurity

Feresu S.A, Gillispie B, Sowers M. F, Johnson T.R.B & Harlow S. D,

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BACKGROUND TO ZIMBABWE

LOCATION

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BACKGROUND TO ZIMBABWE

CLIMATE AND TERRAIN

POLITICS

POPULATION - 11.8 million WOMEN OF REPRODUCTIVE AGE

- 1,228,442 (20%)

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ZIMBABWE- GEOGRAPHY

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ZIMBABWE- ECONOMICSTRENDS OF GOVERNMENT HEALTH EXPENDITURE 1980-1997

0

10

20

30

40

50

60

70

YEAR

Z$ E

xp x

cap

ita

Series1

Series1 36 41 39 37 36 39 41 43 45 51 58 51 44 38 38 36 41

1980/81

1981/82

1982/83

1983/84

1984/85

1985/86

1986/87

1987/88

1988/89

1989/90

1990/91

1991/92

1992/93

1993/94

1994/95

1995/96

1996/97

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ZIMBABWE - HEALTH INDICATORS 1962-1997

Indicator 1962 Census 1982 Census 1992 Census 1997 ICDS Total population (million)

3.9 7.6 10.4 11.8

Crude birth rate/1000

48.0 44 43.5 34.7

Total fertility rate /1000

7.8 6.2 5.9 4.3

Crude death rate/1000)

15.0 10.8 9.4 12.2

IMR/1000

- 86 (1980) 66 80

Life expectancy at birth

Males 49.1 Females 52.5 Total 50.8

55.7 59.1 57.4

58 62 61 (1990)

53 57 55

Rural/urban population

- R 74% U 26% R 69% U31% R 68% U32%

Dependency ratio - 101.3 94 87 Adopted from National Health strategy for Zimbabwe 1997-2005 In this table, the dependency ratio is defined as the sum of all persons aged under

15 years and over 64 years divided by the number of persons aged 15-64 multiplied by 100

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ZIMBABWE- HEALTH CONDITIONS

HIV, AIDS RELATED CONDITIONS (ARC) AND TB 1989 - 1996

0

5000

10000

15000

20000

25000

30000

35000

40000

CASE

S

AIDS

ARC

TB

AIDS 1131 4362 4557 8180 9174 10647 13356 12029

ARC 1570 17383 22872 20062 26430 19780

TB 6812 9132 12198 15237 20125 23959 30831 35735

1989 1990 1991 1992 1993 1994 1995 1996

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ZIMBABWE- HEALTH SERVICES

CENTRAL HOSPITALS (5)

PROVINCIAL HOSPITALS (10)

DISTRICT HOSPITALS (55)

RURAL HOSPITALS AND CLINICS

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HARARE CITY

CAPITAL

POPULATION IN HARARE - 1,219,655 - WOMEN 606,169 - WOMEN OF REPRODUCTIVE

AGE 121,234

38 DISTRICTS

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HARARE- CITY HEALTH

MADE UP OF 23 SATELITE CLINICS AND 2 INFECTIOUS DISEASES HOSPITALS

12 OFFER MATERNITY SERVICES

WORKS WITH GOVERNMENT HEALTH FACILITIES, AND PRIVATE HOSPITALS AND CLINICS

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HARARE MATERNITY UNIT OLDEST AND LARGEST REFERRAL

HOSPITAL IN ZIMBABWE

UNIVERSITY TRAINING HOSPITAL AND ALSO FOR NURSES

DELIVERS ABOUT 50-60 PER DAY POPULATION FROM ALL OVER

ZIMBABWE

RURAL REFERRALS, BYPASSERS, FEW FROM LOW-DENSITY SUBURBS

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HMH – ANTENATAL CARE (ANC) OR PRENATAL CARE SERVICES

ANC- TIMING 20, 24, 28, 30, 32, 34, 36 AND WEEKLY THEREAFTER

COVERAGE- HIGH PROVIDERS MOSTLY MIDWIVES CARE- BP CHECKS, URINE TESTS

FOR ALBUMIN AND SUGAR, WEIGHT

EXAMINATION - FETAL LAY, HEART, FUNDAL SIZE

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HMH - ANC SERVICES SCREENING- MEDICAL DISEASES AND

OBSTETRIC COMPLICATIONS

TESTS - HB, WR, ABO, RHESUS, URINALYSIS FOR GLUCOSE AND ALBUMIN, AND MICROSCOPY WERE INDICATED

SUPPLIMENTS- IRON, FOLATE, MULTIVITAMINS

PHYSICAL- EXERCISES

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INTRODUCTION FETAL OUTCOME IS LINKED

TO MATERNAL AND CHILD HEALTH CARE SERVICES IN A GIVEN COUNTRY

PREMATURITY AND LBW ARE

IMPLICATED AS CAUSES OF

INFANT MORTALITY AND

MORBIDITY

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INTRODUCTION (cont) THESE CONDITIONS ARE

ASSOCIATED WITH MANY RISK

FACTORS, WHICH ARE OF

REPRODUCTIVE, OBSTETRICAL,

MEDICAL, SOCIO-DEMOGRAPHIC

AND LIFESTYLE IN NATURE

ANTENATAL CARE ALWAYS AN

ISSUE IN DEVELOPING COUNTRIES

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INTRODUCTION HOWEVER A FEW STUDIES

HAVE EXAMINED THE

FREQUENCY OF POOR BIRTH

OUTCOMES OR THE

DISTRIBUTION OF RISK

FACTORS ASSOSIATED WITH

THESE CONDITIONS IN

ZIMBABWE

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INTRODUCTION THIS STUDY IS PART OF SERIES OF

STUDIES WE CARRIED OUT IN ZIMBABWE

STUDYI: RECORD REVIEW OF ONE YEAR OF DELIVERIES

STUDYII: THE VALIDATION OF THE BALLARD AND DUBOWITZ METHODS TO ASSESS GESTATIONAL AGE

STUDY III: A CASE CONTROL STUDY OF PREMATURITY

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INTRODUCTION

THESE STUDIES ARE THE FIRST FOCUSING ON THE EPIDEMIOLOGY OF PREMATURITY AND OTHER POOR BIRTH OUTCOMES IN ZIMBABWE

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TITLE OF STUDY 1

INCIDENCE, DEMOGRAPHIC AND REPRODUCTIVE RISK FACTORS OF STILLBIRTH, PREMATURITY AND LOW BIRTHWEIGHT IN ZIMBABWEAN WOMEN

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OBJECTIVESTo assess birth outcomes

over a one-year period at Harare Central Hospital Maternity Unit. The major aim was to describe the frequency of adverse birth outcomes including stillbirth, low birthweight and pre-term births at this hospital in Zimbabwe.

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METHODS Study Type: Prevalence study on a

total of 17,174 births  Period: October 1, 1997 through

September 30, 1998 Study Site: Harare Central Hospital

Maternity Unit Data Collection Technique:

Abstraction from Birth log Records

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RISK FACTORS

Demographic risk factors– Mother’s residential area of the mother– the maternal age;

Obstetric risk factors– parity – estimated gestation– birthweight– sex– vital status of the baby– type of gestation– booking status

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OUTCOMES 1. STILLBIRTH

2. PRE-TERM BIRTH

3. LOW BIRTHWEIGHT BIRTHS (LBW)

4. HIGH BIRTHWEIGHT BIRTHS(HBWT)

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DEFINITIONS1. STILLBIRTH: any death

of an infant born at 20 or more weeks of gestation, weighing 500 grams or more, who died in utero or within the first hour of life.

2. Pre-term births: a birth occurring before 37 completed weeks of gestation

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3. LOW BIRTHWEIGHT BIRTHS

LBW: a birth weighing less than 2500 grams irrespective of gestational age

LBW SUB-CATEGORIES Term LBW: a birth occurring at 37

completed weeks or more of gestation and weighing less than 2500 grams

Pre-term LBW: a birth occurring before 37 completed weeks of gestation and weighing less than 2500 grams.

Very LBW:a birth weighing below 1500 grams at birth.

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OTHER OUTCOMES

4. Post-term birth- a birth occurring after 44 weeks of gestation

5. High birthweight births - A birth weighing above

3500 at birth.

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LBW AND PRE-TERM BIRTHS

IUGR

PRE-TERM

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RESULTS Stillbirth based on 17,174 births Incidence of stillbirth 61/1000 live

births Pre-term births, LBW & High BWT

based on 16,403 births Incidence of all pre-term births

168/1000 live births Incidence of LBW 199/1000 live births Incidence of high BWT 111/ 1000 live

births.

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Low Birthweight Frequencies; based on 16.043 Live births

Incidence of LBW 199/1000

Incidence of IUGR 92/1000

Incidence of pre-term LBW 108/1000

Incidence of very LBW <1500 grams 34/1000

Incidence of high BWT 111/ 1000 live births.

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Pre-term birth Frequencies; 16,043 Live Births

Incidence of all pre-term births 168/1000

Incidence of pre-term births 32 weeks 121/1000

Incidence of pre-term births < 32 weeks 47/1000 Incidence of pre-term births 28-32 weeks 31/1000

Incidence of pre-term births < 28 weeks 16/1000

Incidence of post-term births 2/1000 live births.

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Table 1. Distribution of Stillbirth by Demographic and Obstetric

Characteristics Still birth

n=986, 5.7 % RR (95% C I)

Total n = 17,174 % Mother’s age Below 20 20 to 35 above 35

4.4 5.8 8.7

0.75 (.063 – 0.89) 1.0 1.49 (1.22 – 1.82)

Sex

Male Female

5.6 6.5

1.04 (0.92 – 1.18) 1.0

Residence

Urban Rural

5.6 6.9

1.0 1.24 (1.06 – 1.46)

Antenatal Care Received (booked)

Did not (unbooked)

4.9

12.5

1.0 2.54 (2.21 – 2.92)

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Table 1 (cont) Still birth

n=986, 5.7 % RR (95% C I)

Total n = 17,174 % Parity Para 0 Para 1-2 Para above 2

5.0 6.0 7.0

0.83 (0.73 – 0.95) 1.0 1.17 (0.99 - 1.37)

Gestation Type Singleton Multiple

5.8 5.3

1.0 0.92 (0.70 – 1.19)

Delivery type NVD Breech Instrumental C/section Face to Pubis

5.4

17.9 6.3 3.1 3.9

1.0 3.34 (2.83 – 3.93) 1.18 (0.79 – 1.75) 0.58 (0.47 – 0.72) 0.73 (0.37 – 1.46)

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Table 2. Distribution of Stillbirth by Gestational Age

Stillbirth n=986, 5.7%

Crude RR (95% CI)

Total n = 17,174 % Term normal birthweight a

2.3 1.0

All pre-terms 17.0 7.26 (6.28 – 8.39)

32 to <37 weeks 28 to <32 weeks 20 to <28 weeks Post-term>44 weeks

9.8

24.9

38.0

3.1

4.17 (3.49 – 4.98) 10.62 (8.88 – 12.71) 16.21 (13.70 –19.18) 1.33 (0.19 – 9.21)

a Reference group for all comparisons includes births 2500 to 3500 grams ,and

gestation 37 to <45 weeks

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TABLE 3 Adjusted a Relative Risks of Stillbirth by Gestational Age

Relative Risk

95% CI

37 44weeksc 1.0

32 <37 weeks 3.06 2.55, 3.67

28 <32 weeks 8.54 7.00, 10.43

20 <28 weeks 13.26 10.74, 16.38

>44 weeks 1.18 0.17, 8.38

a adjusted for maternal age, sex, residence, booking status, parity and type of delivery in two models

b Reference group term births 37 weeks † model significant at p = < 0.0001

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Table 4. Distribution of Stillbirth by Birthweight and Gestational Age Categories

Stillbirth n = 986, 5.7%

Crude RR (95% CI)

Total n = 17,174 %

Term normal birthweight a

2.3 1.0

Term <2500 grams 7.9 3.37 (2.74 – 4.15)

Term >3500 grams 2.6 1.11 (0.82 – 1.51)

Pre-term 2500 grams 6.5 2.76 (2.12 –3.59)

Pre-term <2500 grams 21.8 9.29 (8.02 –10.75)

Pre-term <1500 gramsb 34.8 14.85 (12.76 – 17.29)

All births <2500 gramsc 16.1 6.85 (5.94 – 7.91)

a Reference group for all comparisons includes births 2500 to 3500 grams ,and gestation 37 to <45 weeks

b ubset of pre-term births <2500 grams c Includes term and pre-term births <2500 grams

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TABLE 5. Adjusted a Relative Risks of Stillbirth by Birthweight and

Gestational Age Relative

Risk 95% CI

Term normal birthweightb 1.0

Term <2500 grams

3.37 2.68, 4.23

High birthweight births >3500 grams 0.92 0.65, 1.31

Pre-term 2500 grams

2.46 1.82, 3.32

Pre-term <2500 grams

8.90 7.48, 10.59

a adjusted for maternal age, sex, residence, booking status, parity and type of

delivery in two models b Reference group includes births 2500 to 3500 grams and gestation 37 to 44

weeks † model significant at p = <0.0001

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FIGURE 1. The Probability of Stillbirth by Gestational Age and Prenatal Care for deliveries at

Harare Maternity Hospital, October 1997 to September 1998

0

0.2

0.4

0.6

0.8

1

Gestational Age

Pro

bab

ilty

BOOKED

UNBOOKED

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FIGURE 2.

f or Caesar i an Sect i on ver sus Vagi nal del i ver y

PROB1

0. 000. 020. 040. 060. 080. 100. 120. 140. 160. 180. 200. 220. 240. 260. 280. 300. 320. 340. 360. 380. 40

BWT

1000 2000 3000 4000

1

2

3

4

KEY OF BOOKI NG AND DELI VERY TYPE1 UNBOOKED C/ S2 UNBOOKED VAGI NAL3 BOOKED VAGI NAL4 BOOKED C/ S

95% Confi dence I nt er val s at 1500 and 2500 gr ams

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Table 6. Distribution of demographic characteristics by Birthweight

See transparency

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TABLE 7. Adjusted Odds Ratios of Pre-term births for Live Births by Demographic and Obstetric

CharacteristicsAll PRE-TERMS PRE-TERMS UNDER 28 WEEKS

Risk Factor RR (95% C I) RR (95% CI)Mother’s age Below 15 16 to 24 25 to 29 above 30

1.01.45(0.97 –2.17)

2.03(0.77 – 5.35)1.01.44(1.00 – 2.07)1.85(1.15 – 2.97)

Residence Urban High Rural

1.01.18(1.04 -1.34)

1.01.05(0.70 – 1.57)

Booking status Booked Unbooked

1.03.65(3.23 – 4.13)

1.013.14(9.96 – 17.35)

Parity Para 0 Para 1-2 Para above 2

0.89(0.80 –0.98)1.01.01(0.87-1.16)

1.05(0.75-1.46)1.00.54(0.34-0.89)

Gestation Type Singleton Multiple

1.06.03(5.11 –7.12)

1.09.08(6.15-13.42)

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SUMMARY Lack of antenatal care is

associated stillbirth, pre-term births and LBW

Prematurity is the main factor associated with stillbirth

A combination of both prematurity and lack of antenatal care increase risk of stillbirth.

Mothers who did not attend antenatal care and were delivered by Caesarian section were at highest risk of stillbirth

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ACKNOWLEDGEMENTS

– Dr Harlow ; Chair– Dr Sowers– Dr Gillespie– Dr Johnson

Kathy Welch The University of Michigan The University of Zimbabwe Ministry of Health Zimbabwe Harare Hospital Maternity Unit My research assistants

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ACKNOWLEDGEMENTS FUNDING AGENCIES:

– THE W. K KELLOGG FOUNDATION– THE UNIVERSITY OF MICHIGAN– THE UNIVERSITY OF ZIMBABWE– THE MEDICAL ACTURIAL RESEARCH

FOUNDATION- ZIMBABWE– THE MICHAEL GELFAND MEDICAL

RESEARCH FOUNDATION- ZIMBABWE– DEUSCHE GESELLSCHAFT FUR

TECHNISCHE ZUSAMMENARBEIT (GTZ)

– ZVITAMBO PROJECT -ZIMBABWE

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FINAL

THANK YOU I AM HAPPY TO TAKE QUESTIONS OR

MAKE CLARIFICATIONS AFTER WHICH – HAVE A GOOD EVENING