Background
Each year, an estimated 2.9 million babies die during the neonatal period [
1] and another 2.6 million babies are stillborn [
2] around the world. About three-fourths of the neonatal deaths occur within the first week of life [
3,
4]. In developing countries, about two-thirds of stillbirths occur before the onset of labor [
5] and one third during labor [
2,
5]. Almost all perinatal deaths, which encompass neonatal deaths in the first week of life and stillbirths, occur in the developing world [
2,
5]. The main causes of neonatal deaths include preterm related complications, intrapartum-related complications, and infections [
1,
4,
6]. Impaired placental function is the main causal pathway proposed for stillbirths [
2]. The primary known risk factors of stillbirths are presence of hypertensive disorders during pregnancy, obstetric complications, infections, placental dysfunction, and congenital defects [
7‐
9]. Notably, many of these risk factors are also determinants of the main causes of neonatal deaths [
4,
5].
Thus, a substantial proportion of perinatal deaths appear to have their origins in maternal complications during pregnancy. The most common complications are hemorrhage, hypertensive disorders of pregnancy, and infections [
6,
10‐
13]. Antepartum hemorrhage beyond the first trimester is most often caused by placental abnormalities or incompetent cervix, and can result in stillbirth [
6] and maternal death [
10,
11]. The leading cause of hemorrhage during pregnancy is placental abruption which occurs in 1% of pregnancies and is associated with a perinatal case fatality of 10–30% [
14]. Up-to 10% of women experience hypertensive disorders of pregnancy [
15] and this condition can be associated with stillbirths, preterm birth, and neonatal or maternal deaths [
15,
16]. Maternal infections such as malaria, syphilis, urinary tract infection, and bacterial vaginosis are also important causes of stillbirths [
17‐
19] and important determinants of early neonatal deaths. Early onset neonatal infections may be acquired vertically during pregnancy or during delivery [
20,
21].
In developing countries, where health systems are weak and care-seeking from health facilities is low, pregnant women often do not receive basic preventive and curative care when complications arise, or may delay care seeking [
22] – such practices can result in stillbirths or neonatal deaths [
23]. Understanding the associations between prevalent maternal complications during pregnancy and perinatal deaths is critical to guiding the development of strategies and programs to deliver maternal interventions of proven efficacy. The objective of this analysis is to examine patterns of maternal complications during pregnancy and associated risks of perinatal deaths in rural Bangladesh using household survey data of women who had a recent birth.
Results
Of the 6,285 women, about a third (31.3%) of the women reported a symptom consistent with at least one of the three antepartum complications examined in this study (Table
1). Approximately 6% of women reported a symptom consistent with two or more of the antepartum complications (data not shown). Socio-demographic characteristics of study participants are presented in Table
2. The mean (±SD) age of women was 28.1 (±6.1) years. Large proportions of women (41.2%) and their husbands (46.2%) did not attend school. Higher proportions of women with or without a maternal complication sought antenatal care and delivered in a facility or with a skilled attendant, but these proportions were low in both groups.
Table 1
Prevalence of self-reported maternal complications during pregnancy
Antepartum hemorrhage | 168 | 2.7 |
Probable infectiona
| 904 | 14.4 |
High fever | 681 | 10.8 |
Foul smelling discharge | 310 | 4.9 |
Probable pregnancy-induced hypertensionb
| 1,281 | 20.4 |
Convulsion | 161 | 2.6 |
Swelling of feet or face | 1,169 | 18.6 |
Any of three complications | 1,970 | 31.3 |
Table 2
Socio-demographic and delivery-related characteristics of the study population
Women’s age | <0.001 |
< 25 years | 1,763 (28.1) | 1,242 (28.8) | 521 (26.5) |
25–29 years | 2,010 (32.0) | 1,414 (32.8) | 596 (30.3) |
30–34 years | 1,339 (21.3) | 918 (21.3) | 421 (21.4) |
≥ 35 years | 1,173 (18.6) | 741 (17.2) | 432 (21.9) |
Parity |
1–2 | 2,163 (34.4) | 1,491 (34.6) | 672 (34.1) | <0.010 |
3–4 | 1,936 (30.8) | 1,382 (32.0) | 554 (28.1) |
5–6 | 1,200 (19.1) | 779 (18.1) | 421 (21.4) |
7+ | 986 (15.7) | 663 (15.4) | 323 (16.4) |
Women’s education | 0.948 |
No education | 2,591 (41.2) | 1,773 (41.1) | 818 (41.5) |
Primary complete | 1,926 (30.7) | 1,326 (30.7) | 600 (30.5) |
Above primary | 1,768 (28.1) | 1,216 (28.2) | 552 (28.0) |
Husbands’ education |
No education | 2,904 (46.2) | 2,004 (46.4) | 900 (45.7) | 0.760 |
Primary complete | 2,093 (33.3) | 1,437 (33.3) | 656 (33.3) |
Above primary | 1,288 (20.5) | 874 (20.3) | 414 (21.0) |
Household asset index |
1 (Lowest) | 1,102 (17.5) | 787 (18.2) | 315 (16.0) | <0.010 |
2 | 1,190 (18.9) | 843 (19.5) | 347 (17.6) |
3 (Middle) | 1,252 (19.9) | 866 (20.1) | 386 (19.6) |
4 | 1,334 (21.2) | 908 (21.0) | 426 (21.6) |
5 (Highest) | 1,407 (22.4) | 911 (21.1) | 496 (25.2) |
ANC visits |
0 | 2,142 (34.1) | 1,673 (38.8) | 469 (23.8) | <0.001 |
1–3 | 3,253 (51.8) | 2,172 (50.3) | 1,081 (54.9) |
4+ | 890 (14.2) | 470 (10.9) | 420 (21.3) |
Place of delivery |
Home delivery | 5,396 (85.9) | 3,825 (88.6) | 1,571 (79.8) | <0.001 |
FWC/UHC | 417 (6.6) | 239 (5.5) | 178 (9.0) |
Hospital/Clinic | 431 (6.9) | 227 (5.3) | 204 (10.4) |
Other | 41 (0.6) | 24 (0.6) | 17 (0.9) |
Birth attendant |
Untrained | 3,767 (60.0) | 2,675 (62.0) | 1,092 (55.4) | <0.001 |
TBA | 1,573 (25.0) | 1,111 (25.8) | 462 (23.5) |
Skilled birth attendanta
| 945 (15.0) | 529 (12.3) | 416 (21.1) |
Unadjusted rates and 95% CIs of adverse perinatal outcomes are presented in Table
3. The rate of stillbirths was 31 per 1,000 births (95% CI 27.0–35.6), rate of early neonatal deaths was 26 per 1,000 live births (95% CI 22.7–30.8), and the overall perinatal deaths rate was 57 per 1,000 births (95% CI 51.2–62.6). Notably, the rate of perinatal deaths was almost five times higher for women with APH (202.4 per 1,000 births, 95% CI 148.3–269.9) compared to those who had none of the three maternal complications (44.5 per 1,000 births, 95% CI 38.7–51.1).
Table 3
Rates of stillbirths, early neonatal deaths, and perinatal deaths by presence of maternal complications during pregnancy
APH | 20 (119.0, 78.1–177.3) | 16 (94.6, 56.8–153.4) | 34 (202.4, 148.3–269.9) |
Probable infection | 35 (38.7, 27.9–53.5) | 37 (41.4, 30.0–56.9) | 71 (78.5, 62.7–98.0) |
Probable PIH | 64 (50.0, 39.3–63.3) | 43 (33.7, 24.9–45.4) | 105 (82.0, 68.1–98.3) |
Any of three complications | 94 (47.7, 39.1–58.1) | 70 (37.3, 29.6–46.9) | 164 (83.2, 71.8–96.3) |
None of three complications | 101 (23.4, 19.3–28.4) | 93 (21.6, 17.6–26.4) | 192 (44.5, 38.7–51.1) |
Overall rate | 195 (31.0, 27.0–35.6) | 161 (26.4, 22.7–30.8) | 356 (56.6, 51.2–62.6) |
Table
4 shows adjusted incidence rate ratios (IRR), corresponding 95% CIs, and PAF for adverse perinatal outcomes associated with each of the three maternal complications. Women who had experienced APH had a significantly higher likelihood of their fetus or neonate having an adverse outcome, either perinatal death (IRR = 3.5, 95% CI 2.4–4.9), stillbirth (IRR = 3.7, 95% CI 2.3–5.9), or early neonatal death (IRR = 3.5, 95% CI: 2.0–6.1) compared to those who did not experience APH. Probable PIH was a significant risk factor for perinatal deaths (IRR = 1.5, 95% CI: 1.2–1.9) primarily due to higher likelihood of having a stillbirth (IRR = 1.8, 95% CI 1.3–2.5). Probable maternal infection was a significant risk factor for early neonatal deaths (IRR = 1.5, 95% CI: 1.1–2.2).
Table 4
Incidence rate ratios and population attributable fractions of stillbirths, early neonatal deaths, and perinatal deaths during pregnancy by maternal complications
APH | 3.7 (2.3–5.9) | 7.5 (3.6–11.2) | 3.5 (2.0–6.1) | 6.2 (2.1–10.2) | 3.5 (2.4–4.9) | 6.8 (4.2–9.3) |
Probable infection | 1.1 (0.7–1.6) | – | 1.5 (1.1–2.2) | 7.8 (0.1–14.9) | 1.3 (1.0–1.7) | – |
Probable PIH | 1.8 (1.3–2.5) | 14.7 (6.4–22.3) | 1.3 (0.9–1.8) | – | 1.5 (1.2–1.9) | 10.4 (4.7–15.7) |
Total | | 20.7 (12.3–28.2) | | 13.1 (5.3–20.2) | | 16.2 (10.4–21.5) |
The PAF of perinatal mortality was about 6.8% for APH and 10.4% for probable PIH, lower than corresponding stillbirth PAF of 7.5% for APH and 14.7% for probable PIH. PAF of early neonatal mortality risk was 6.2% for APH and about 7.8% for probable infection. The PAF of perinatal deaths, stillbirths and early neonatal deaths were 16.2, 20.7 and 13.1% for all three complications combined.
Discussion
We studied prevalence of three self-reported antepartum complications in rural Bangladeshi women and examined the risks of perinatal mortality associated with them. The burden of at least one of the three complications examined in this study i.e., APH, probable infection, and probable PIH, based on self-reported symptoms, was high (31.3%) and these antepartum complications were significantly associated with perinatal deaths. More specifically, APH was associated with increased risk of both stillbirths and early neonatal deaths, probable infection was associated with increased risk of early neonatal deaths, and probable PIH with an increased risk of having a stillbirths. Together with the high perinatal mortality and high PAF estimated for APH and PIH, these findings highlight the importance of promoting recognition of, care-seeking for, and management of antepartum complications.
Our findings show similar higher risks of perinatal deaths associated with APH and probable PIH as reported earlier from Bangladesh [
12] and elsewhere [
11,
16]. Mamun et al. [
12] examined the patterns of maternal complications during different stages of gestation and their association with perinatal deaths using data from a community based clinical trial. After adjusting for potential confounders, the study documented that perinatal mortality was 2.7 times higher (95% CI 1.5–4.9) among women who had hypertension during pregnancy and 5.0 times higher (95% CI 2.3–10.8) among those who had experienced antepartum hemorrhage [
12]. Two facility based studies, one conducted in South Africa and the other in Northwest Ethiopia demonstrated higher risk of stillbirths with hypertension and antepartum hemorrhage [
11,
16]. Allanson et al. reported [
16] that APH was significantly more common in women who had stillbirths (16.3%) compared to the women who had early neonatal deaths (7.4%). Similarly more women who had stillbirths had reported hypertension (23.6%) compared to women who had early neonatal deaths (8.1%) [
16]. Adane et al. conducted a study [
11] in Northwest Ethiopia and reported that stillbirths were significantly associated with both APH (AOR 8.4, 95% CI 1.3–55.3) and hypertension (AOR 9.5, 95% CI 2.1–44.3) [
11]. The prevalence of maternal complications in both South African and Ethiopian studies were higher than our study likely due to differences in setting and populations studied.
The World Health Organization conducted a large facility based cross-sectional survey on maternal and newborn health in 29 countries in Asia, Africa, Latin America, and the Middle East and reported on perinatal indicators and risks of perinatal deaths in the presence of hemorrhage, infections, hypertensive disorders and other maternal complications [
7]. Since this was a facility based survey, more detailed information on maternal complications were available and therefore, the results are not directly comparable to our study findings. The study reported that vast majority of perinatal deaths in participating facilities occurred in the presence of a maternal complication and concluded that understanding these relationships are critical in settings where maternal complications are often common, under-diagnosed, and/or under-treated and where perinatal mortality rates are high [
7].
Our study has several limitations. We recognize that the data is somewhat old, however, health indicators in our study division (Sylhet) of Bangladesh did not change much in the last decade suggesting that our data and findings are still relevant. According to Bangladesh demographic and health survey (BDHS) 2007, perinatal mortality rate (PMR) in our study area was 69 per 1000 live births. PMR was 63 per 1000 live births according to BDHS 2014. Early neonatal mortality rate did not change (22/1,000 live birth in BDHS 2007 vs 23/1,000 live birth in BDHS 2014) [
30,
31]. The cross sectional study design has its inherent limitations to imply causality. However, the strength of the study is population-based data and large sample size. The data were collected retrospectively, however we feel that recall bias was not a major issue as the recall period was short. Nonetheless, it is possible that mothers who experienced perinatal deaths were more likely to recall antepartum complications compared to mothers who did not experience a complication (selective recall).
Our data on antepartum complications are self-reported by the mothers and this raises concern regarding potential misclassification of the reported complications. Our prevalence estimates for probable PIH and probable infection were higher than those reported in the literature based on clinical examinations [
32]. Clinical measures of complications are difficult to obtain outside health facilities, and our survey was conducted in a population where most women delivered at home and only few sought care from health facilities for antepartum complications. We acknowledge that the reported antepartum complications in our study was likely to be an over-estimate compared to the rate from other studies conducted in hospital/health care settings. However, we restricted our assessment of antepartum complications to only three conditions that have specific clinical signs that are easily recognizable by women and make these maternal conditions highly probable. We had information on a limited number of potential confounders of the relationships of interest in this study, and this may have led to an overestimation of the risk of perinatal deaths associated with antepartum complications and corresponding PAF. For example, we did not examine key maternal conditions known to increase the risk of stillbirths and early neonatal deaths including malnutrition, history of smoking, and diabetes. Misclassification of early neonatal deaths as stillbirths may be of concern as babies who die immediately after birth might have been reported as stillbirths irrespective of the place of delivery. To alleviate this problem, we measured the risks of the three maternal complications of interest and PAF for the composite indicator of perinatal mortality in addition to examining stillbirths and early neonatal deaths separately.
Conclusions
The burden of antepartum complications in our population was high and since these conditions were shown to significantly increase the risk of perinatal mortality, their prevention and management in a timely manner are crucial to reducing perinatal mortality in Bangladesh and in similar settings. The utilization of antenatal care and facility delivery rate, which is a proxy for managent of antenatal complicatons were low and remained low in the study areas [
33]. An integrated community and facility based interventions to increase utilization of ANC; timely recognition of antenatal complications and care seeking for managment of complications [
6,
7] will be key strategies in reducing perinatal mortality in Bangladesh and similar settings. This will require creation of demand for these sevices including addressing barriers to access and improving avaialbility and quality of ANC and trained care for antenatal compliactions. Our study findings need to be replicated by future studies using objective measures of antepartum complications based on clinical examination and diagnosis.
Acknowledgements
We thank the entire Projahnmo study team for their enthusiastic hard work; representatives of the Bangladesh Ministry of Health and Family Welfare and the non-government organizations, including Shimantik, Save the Children (US), Dhaka Shishu Hospital, and the Institute of Child and Mother Health; and Johns Hopkins Bloomberg School of Public Health for their valuable inputs. The authors also acknowledge the participation of the study families for their participation in the study.