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