Background
Pregnancy is a state of having implanted products of conception located either in the uterus or elsewhere in the body. It ends through either spontaneous or elective abortion or delivery. During this time, the mother’s body goes through immense changes involving all organ systems to sustain the growing fetus [
1]. Along with this, a woman has either successful or adverse birth outcomes [
2]. Adverse birth outcome is the loss of newborns during early and late pregnancy, give birth earlier than the anticipated date, and deliver low birth weight [
3]. It also leads to neonatal and infant morbidity and mortality [
4]. Approximately 15 million babies were born prematurely every year globally and nearly 90% and 80% of preterm occurred in Low and Middle-Income countries and sub-Saharan Africa, respectively [
5]. Approximately 20 million low birth weight babies were born annually, developing countries and sub-Saharan Africa accounts 17% and 9.76% respectively. Globally, around two million babies are stillborn annually and, about 84% and 75% of stillbirth contributed by low and lower-middle income and Sub-Saharan Africa respectively. About more than 40% of stillbirth occurred immediately after onset of labor and about extra 20 million stillbirths is predicted to be occur before 2030. Preterm delivery leads to newborn under-five deaths and the survivors remain suffering from lifetime physical, neurological or educational disability with pronounced cost to families and societies. Likewise, the common cause of LBW in developed and developing countries is preterm and Intrauterine Growth Restriction (IUGR) respectively. Moreover, stillbirth leads to psychological cost and financial consequence on women, families and societies [
6]. In Ethiopia and Gondar about 30% and 11.2% of the babies born with LBW respectively with rate of one infant die per ten second due LBW [
7]. Birth weight is a good health indicator and determinant of the future health status of the infant’s physical, survival and mental growth. However, low attentions was given to improve birth weight in Ethiopia [
8]. Besides, the magnitude of stillbirth in 2019 in Ethiopia and Gondar was 90,323 and 7.1% respectively [
9].
In Prior study, extreme parity, previous history of preterm or abortion, younger maternal age, inadequate of prenatal care, antepartum hemorrhage, premature rupture of membrane and induced labor were predictors of preterm birth [
9,
10]. Besides, previous study showed that prematurity, previous history of adverse birth outcome, maternal age, and lack of antenatal care (ANC) follow up, twin pregnancy, anemia and inadequate food intake during pregnancy, mothers with a history of abortion and rural residents were predictors of LBW [
11,
12].
Moreover, preterm birth, advanced maternal age, history of stillbirth, extremes of neonatal birth weight, cesarean delivery, lack of antenatal care visit, assisted breach delivery and operational vaginal delivery were predictors of stillbirth [
9,
13] Adverse birth outcomes are critical public health issue in Gondar (23%) [
9] Generally, the global targets to reduce still birth of late third trimester is reaching 12 to fewer per 1,000 total live births in each country by 2030 [
6], by develop strategic plan for maternal and child health and generate base line data for further research. Therefore, this study aimed to assess the magnitude and associated factor of adverse birth outcomes among women who gave birth at university of Gondar comprehensive specialized hospital.
Discussion
The present study showed the prevalence and associated factors of adverse birth outcome among mothers who gave birth at University of Gondar Comprehensive Specialized Hospital. Maternal factors such as age, residence, antenatal care follow-up, preterm delivery, antepartum hemorrhage, having fever ≥ two weeks, multiple pregnancy, perinatal death history and premature rupture of membrane were statistically significant predictors of adverse birth outcome.
In this study prevalence of adverse birth outcome was found to be high. This finding was consistent with report of similar study done in North Wollo [
18] and pooled prevalence of Sub-Saharan Africa [
22]. However; this result was lowered as compared to similar study done in Wollo [
13] and in Gamo Gofa [
20]. The difference could be study participants variation. Most of study participants in Gamo Gofa were rural dwellers indeed, rural dwellers women are more likely to have adverse birth outcome due to women from rural dwellers are more exposed to social restrictions, unemployment, overwork, literacy, lack of health care decision making participation and access to maternal health service than women of urban dwellers [
23]. This implies urban dwellers of women have low influence on adverse birth outcome. The other possible reason for the discrepancy might be in Gamo Gofa, majority (94.5%) women gave a birth within before seven month of gestation [
20] whereas in this study around three-fourth of birth were preterm deliveries since preterm birth are greatly contributed to adverse birth outcome [
24].
On the other hand, this findings’ of adverse birth outcome was higher as compared to study done in Hosanna, Ethiopia [
25] and Suhul hospital Tigray [
26]. The possible justification for the discrepancy might be study area difference. The former studies included general hospital. Majority rural women give birth at health centers which located in a rural area to provide services to rural women who are usually unemployed, overworked and have poor access to antenatal care, labor, and delivery services and when those women develop obstetric complication usually they were referred to referral hospital [
26]; since this study was conducted in comprehensive specialized hospital in which referral case are more predominant, that increase adverse birth outcome cases at referral hospital than general hospital. This implies attention has to give for general hospital to decrease referral case and timely management of adverse birth outcome. The other reason for the variation might be due to study participant’s characteristics difference. In this study, only half percent of women who had adverse birth outcome didn’t have ANC follow-up visit for the recent pregnancy whereas study in Hosanna, at Negest Elene Mohammed Memorial General Hospital and Tigray Suhul hospital revealed that only about 16.2% and 18% of women who had adverse birth outcome didn’t have ANC follow-up visit respectively. Scholars suggested that lack of ANC follow-up visit leads to adverse birth outcome [
25,
26]. This indicates great emphasis has to offer to health centers and general hospitals to provide focused ANC follow up to curb adverse birth outcome.
The prevalence of still birth was 84 per 1,000 total births. This finding is congruent with similar study done in Dessie referral hospital [
18], Amhara Region [
27], Negest Elene, General Hospital in Hosanna Town [
25] and Southern Ethiopia [
28]. However; this result was higher as compared study done in Amhara region [
29] Ghana [
30], Systematic review in Sub Saharan Africa [
31], Axum [
32], Niger [
33] Tanzania [
34] and Hiwot Fana Specialized University Hospital, Ethiopia [
35]. The possible explanation for the variation might be maternal health service, health facility, logistic parameters, methodological, community awareness and socio-cultural factors. Since this study was conducted in referral hospital, whereas the worldwide annual report of still birth rate comprising communities and it is believed that most normal deliveries carried out in health center whereas women who experienced obstetric complication referred to referral hospital that contribute to a higher rate of adverse birth outcome at referral hospitals. In addition, ,delays from pregnant women’s health seeking behaviors due to lack of awareness and cultural restriction, and weak referral system in primary hospital and health centers attributed to increased rate of still birth in the referral comprehensive hospital even though better health services and high skilled professional avail in the referral comprehensive hospital [
36].
On the other hand, this finding’ of still birth rate was lowered as compared to the report of Southeast Asia (48.5%) [
22]. The discrepancy might be due to most still birth in the community were under-reported in this study even it is common problems in SSA including Ethiopia [
37] whereas study done in Southeast Asia was community based. In general, the inspiring to have evidence about still birth is due to the fact that most still births are preventable through strict antenatal care follow-up and its intervention [
38].
The current study prevalence of preterm birth was found to be 22.9% which was higher as compared to study done in Iran [
38] Tanzania [
39], Gondar Ethiopia [
9] and Dessie Ethiopia [
18]. The difference might be due to the variation of methodological, study population, study period and working set up.
Furthermore; the magnitude of low birth weight was found to be 10.11% which was consistent with previous study done in northern Tanzania [
40], Dangla, Ethiopia [
8], Ghana [
41], the pooled prevalence in Sub-Saharan Africa [
42] and United Arab Emirates [
43]. However; it was lower than previous study done in Gondar [
44].
This study finding revealed that women with middle aged 20–34 years have lower odds to have adverse birth outcome particularly still birth as compared to those women whose age above 35 years. This finding was in line with study conducted in Wollo [
13], Hawassa [
45] and Ghana [
41]. Study done in Hawassa, Ethiopia showed that women whose age group 35–45 years were two fold high risk than those women in age group 20–34 years [
45]. The possible explanation for this variation might be due to the fact that young women who got pregnancy for the first time are higher early seeker of antenatal and medical care than counterparts. In addition, coupled with age 20–34 years women may have good chance to have maternal nutrition, socio-economic status and sufficient ANC attendance. Moreover, non-modifiable risk factors, advanced maternal age had higher odds to have adverse birth outcome [
25].
The odds of women with rural residents to give low birth weight newborn were four folds higher as compared to those women with urban residents. It was in line with study done in Gondar [
9], Gamo Gofa [
20], and Hosana town [
46] and Wollo [
13]. Report from Wollo revealed that the odds of women with rural residents to have adverse birth outcome was two times higher than urban residents [
47]. The discrepancy might be due to variation in cultural taboos, education, overwork, unemployment, healthcare decision making and access to maternal health service. Most women in rural areas are commonly affected by the cultural/ traditional taboos on nutritional practice via inhibition; in contrary urban dwellers women have better lifestyle of balance diet practice. Urban resident women have more chance to access health facility visit and more informed about pregnancy, labor and delivery because they obtain maternal health education via different media than rural dwellers women [
13]. Similar study done in Ghana [
30] and Hosanna Ethiopia [
25] revealed that women from rural dwellers increase risk of low birth weight. Likewise, study undertaken in Gamo Gofa Zone showed that rural women are exposed to home level overwork that attributed to adverse birth outcome [
20]. Moreover; women in urban areas have higher participation in decision making of health care seeking than rural dwellers. Demography health survey of Sub Saharan Africa report showed that women with lack of participation in health care decision making were high risk to have adverse birth outcome than women participated in decision making due to the fact that women failed and low involvement in healthcare decision making was linked to low utilization of antenatal care and institutional delivery and this greatly contributed to adverse birth outcome [
48].
Besides, women who didn’t have ANC visit for the recent pregnancy have high adverse birth outcome than those ANC service users. This result was consistent with study carried out in Wollo [
13], Hawasa, Ethiopia [
15], in Dessie referral Hospital, Ethiopia [
18] in Dilla Town, Southern Ethiopia [
12], systematic review and meta-analysis [
49] and Sub Saharan Africa report showed that women who had ANC follow-up visit for current pregnancy were less likely to have adverse birth outcome than counterparts of women who had no follow-up visits [
22]. The possible explanation for the difference might be due to ANC checkup helps to identify high risk pregnancies like intrauterine growth restriction, to received information related to nutritional counseling and supplementation of nutrient fortified foods. Besides, ANC follows up visits provide opportunity to identify disease like HIV/AIDS, syphilis, malaria and intestinal helminthiasis infection might greatly affect fetal birth outcome. Furthermore, hypertension during pregnancy might be responsible for preterm deliveries and immature newborn that could attribute to still birth and ANC follow up help to early identification of women with hypertension and take appropriate intervention to control it [
50]. In general, regular ANC follow up visit allowed a chance for pregnant women to seek early treatment for those high potential pregnancy related health problems and provide access of preconception care intervention although, WHO recommended preconception care, it is not yet launched and implemented in Ethiopia health care system [
51]. Hence, promote enhancement of quality of ANC and mobilization of pregnant women based on WHO current recommendations of focused care approach and preconception care intervention for pregnant women to decrease adverse birth outcome and ensuring the attainment of sustainable development goals [
45].
In addition, gestational age was another independent factors affecting adverse birth outcome particularly; still birth and low birth weight. In the current study, the odds of preterm newborn to end-up with still birth were two folds higher as compared to term deliveries. Previous study finding in Gondar [
9], Jimma Jone, Southwest Ethiopia [
52], Dangla, Ethiopia [
8], systematic review and meta-analysis [
49], and Sub Saharan Africa [
53] supported this finding. Study done in Gondar showed that preterm newborn were six times more likely to be born as stillbirth. Mostly, preterm newborn are immature and unable to survive until birth [
54].
Women with current pregnancy complication (premature rupture of fetal membrane and antepartum hemorrhage) and history of fever more than two weeks were found to have higher risk of experiencing adverse birth outcomes( low birth weight, preterm delivery and still birth) as compared to those without pregnancy complication. This result was congruent with similar study conducted in China [
55], Iran [
56], Zambia [
50] and, previous study of Gondar, Ethiopia [
9],. Previous study in Gondar showed that pregnant women that encountered antepartum hemorrhage during pregnancy were eight folds high risk to had still birth as compared to women without antepartum hemorrhage [
9]. The plausible explanation might be due to the fact bleeding during pregnancy causes anemia that leads to intra-uterine oxygen deprivation and this greatly affect the well-being of fetus in the uterus [
57].
Moreover, women with multiple pregnancies had higher odd of low birth weight as compared to those women of singleton births. This finding agreed with study done in northwest Ethiopia [
58] Jimma Zone, Southwest Ethiopia [
52] and in Sub-Saharan Africa [
22]. The possible explanation might be due to the fact that intrauterine growth restrictions, birth defects, and mechanical factors (obstructed labor, uterine rupture, mal-presentations, and mal-position) are more common in multiple pregnancies that increased the risk of still birth. Hence, twin pregnancy is referred as high-risk pregnancy that needs great attention, and birth and complication preparedness counseling should be given for pregnant women [
22].
Furthermore, women who had history of perinatal death had three fold odds to have low birth weight than those women who never had history. This finding was supported by similar study report in Hawassa [
45] and Shire town, north Ethiopia [
26], portrayed that women who had history of child related abnormal birth outcome are more likely to have adverse birth outcome. In the recent study, about 22.9% (103) women had history of perinatal death. There is well-known evidence that showed women having history of previous abnormal birth outcome are more likely to have abnormal birth outcome in subsequent pregnancies. Evidence-based clinical practice revealed that preconception maternal care intervention provides the chance for health care providers to screen out such risk factors prior to high risk women gets conception and it reduced occurrence of similar abnormal birth outcome in the subsequent pregnancies [
51]. .
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