DOI: 10.7272/q6zg6qfc
title: Pregnancy outcomes in facility deliveries in Kenya and Uganda: A large cross-sectional analysis of maternity registers illuminating opportunities for mortality prevention

description: Introduction As facility-based deliveries increase globally, maternity
 registers offer a promising way of documenting pregnancy outcomes and
 understanding opportunities for perinatal mortality prevention. This study
 aims to contribute to global quality improvement efforts by characterizing
 facility-based pregnancy outcomes in Kenya and Uganda including maternal,
 neonatal, and fetal outcomes at the time of delivery and neonatal
 discharge outcomes using strengthened maternity registers. Methods Cross
 sectional data were collected from previously strengthened maternity
 registers at 23 facilities over 18 months. Pregnancy outcomes were
 classified as live births, early stillbirths, late stillbirths, or
 spontaneous abortions according to birth weight or gestational age.
 Discharge outcomes were assessed for all live births. Outcomes were
 assessed by country and by infant, maternal, and facility characteristics.
 Maternal mortality was also examined. Results Among 50,981 deliveries,
 91.3% were live born and, of those, 1.6% died before discharge. An
 additional 0.5% of deliveries were early stillbirths, 3.6% late
 stillbirths, and 4.7% spontaneous abortions. There were 64 documented
 maternal deaths (0.1%). Preterm and low birthweight infants represented a
 disproportionate number of stillbirths and pre-discharge deaths, yet very
 few were born at ≤1500g or &lt;28w. More pre-discharge deaths and
 stillbirths occurred after maternal referral and with cesarean section.
 Half of maternal deaths occurred in women who had undergone cesarean
 section. Conclusion Maternity registers are a valuable data source for
 understanding pregnancy outcomes including those mothers and infants at
 highest risk of perinatal mortality. Strengthened register data in Kenya
 and Uganda highlight the need for renewed focus on improving care of
 preterm and low birthweight infants and expanding access to emergency
 obstetric care. Registers also permit enumeration of pregnancy loss
 &lt;28 weeks. Documenting these earlier losses is an important step
 towards further mortality reduction for the most vulnerable infants.
description: Data were collected as part of the East Africa Preterm Birth
 Initiative (PTBi). This initiative is a partnership between the University
 of California San Francisco, Kenya Medical Research Institute, University
 of Rwanda, Rwanda Biomedical Center, and Makerere University in Uganda. In
 Kenya and Uganda specifically, PTBi is conducting a randomized cluster
 trial to evaluate the impact of an intrapartum quality improvement package
 on neonatal survival in preterm and low birthweight infants
 (clinicaltrials.gov, NCT03112018). The full study
 protocol is available elsewhere (Otieno et al 2018). This cross-sectional
 analysis includes both control and intervention sites and is not an
 evaluation of the impact of the trial. Maternity
 register data was gathered from 23 health facilities including 17 in
 Migori county in western Kenya and six in Busoga region in eastern Uganda.
 Anonymized patient level delivery data were extracted monthly from
 maternity registers. Pre-existing national maternity registers were used
 for this study. However, prior to the study period, data strengthening
 efforts were completed as part of the PTBi trial to improve the accuracy
 and completeness of these maternity registers. These efforts included
 provision of supplies (pregnancy wheels, tape measures, digital scales)
 with skill building sessions, monthly training and mentoring of labor and
 delivery staff on standard indicator definitions, and monthly feedback on
 the completeness of registers. Particular emphasis was placed on the
 accuracy of gestational age assessments, which were estimated by labor and
 delivery providers based on reported last menstrual period, fundal height,
 or antenatal records carried by the mother. Ultrasound was not universally
 available during antenatal care or at the time of delivery.
 Register entries were identified as deliveries if at least one of
 the following indices was documented: 1-minute Apgar score, birth weight,
 infant sex, birth outcome, or discharge status. Pregnancy outcomes were
 then classified as 1) live birth, 2) early stillbirth, 3) late stillbirth,
 or 4) spontaneous abortion. Live births were defined in
 this study as infants born with signs of life (as noted by the health care
 provider at the time of birth and validated by non-zero 1-minute Apgar
 score) weighing ≥500 grams or, if no birth weight was recorded, ≥24 weeks
 completed gestation. Stillbirths were classified as
 early or late. The WHO definition of stillbirth was used to define late
 stillbirths in this analysis-- infants born without signs of life weighing
 ≥1000 grams or, if no birth weight was recorded, ≥28 weeks completed
 gestation (2). Early stillbirths were defined as infants born without
 signs of life weighing between 500 and 999 grams or, if no birth weight
 was recorded, between 24 and 27 weeks completed gestation. Some
 stillbirths were further identified as fresh (i.e. intrapartum) or
 macerated based on infant appearance to the provider at the time of
 delivery, although not a required field in registers.
 Entries excluded from this analysis included 1) births before
 arrival (n=606), as the aim was to characterize facility-based outcomes
 and 2) births with no documented birth weight or gestational age (n=36),
 as this prohibited outcome classification. Mothers were excluded if 1)
 they delivered before arrival (n=562) or 2) were discharged pregnant
 (n=9202). A unique maternal identification code was used to link maternal
 and neonatal data. Data were collected in
 ODK, preliminary cleaning and matching was done in SQL, and the dataset
 was exported to Stata for analysis.