Direct maternal morbidity and the risk of pregnancy-related deaths, stillbirths, and neonatal deaths in South Asia and sub-Saharan Africa: A population-based prospective cohort study in 8 countries
Authors: Fahad Aftab, Imran Ahmed, Salahuddin Ahmed, Said Mohammed Ali, Seeba Amenga-Etego, Shabina Ariff, Rajiv Bahl, Abdullah H. Baqui, Nazma Begum, Zulfiqar A. Bhutta, Godfrey Biemba, Simon Cousens, Vinita Das, Saikat Deb, Usha Dhingra, Arup Dutta, Karen Edmond, Fabian Esamai, Amit Kumar Ghosh, Peter Gisore, Caroline Grogan, Davidson H. Hamer, Julie Herlihy, Lisa Hurt, Muhammad Ilyas, Fyezah Jehan, Mohammed Hamad Juma, Michel Kalonji, Rasheda Khanam, Betty R. Kirkwood, Aarti Kumar, Alok Kumar, Vishwajeet Kumar, Alexander Manu, Irene Marete, Usma Mehmood, Nicole Minckas, Shambhavi Mishra, Dipak K. Mitra, Mamun Ibne Moin, Karim Muhammad, Sam Newton, Serge Ngaima, Andre Nguwo, Muhammad Imran Nisar, John Otomba, Mohammad Abdul Quaiyum, Sophie Sarrassat, Sunil Sazawal, Katherine E. Semrau, Caitlin Shannon, Vinay Pratap Singh, Sajid Soofi, Seyi Soremekun, Atifa Mohammed Suleiman, Venantius Sunday, Thandassery R. Dilip, Antoinette Tshefu, Yaqub Wasan, Kojo Yeboah-Antwi, Sachiyo Yoshida, Anita K. Zaidi
Journal: PLoS Medicine (2021)

Background Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa. Methods and findings This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman’s self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes. Conclusions Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths. Trial registration The study is not a clinical trial.