Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.

BACKGROUND: Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. METHOD: A cross-sectional survey was conducted in 2011 as part of the 'Response to Accountable priority setting for Trust in health systems' (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. RESULTS: A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76). CONCLUSIONS: Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey.

BACKGROUND: Maternal mortality continues to be a heavy burden in low and middle income countries where half of all deliveries take place in homes without skilled attendance. The study aimed to investigate the underlying and proximate determinants of health facility childbirth in rural and urban areas of three districts in Kenya, Tanzania and Zambia. METHODS: A population-based survey was conducted in 2007 as part of the 'REsponse to ACcountable priority setting for Trust in health systems' (REACT) project. Stratified random cluster sampling was used and the data included information on place of delivery and factors that might influence health care seeking behaviour. A total of 1800 women who had childbirth in the previous five years were analysed. The distal and proximate conceptual framework for analysing determinants of maternal mortality was modified for studying factors associated with place of delivery. Socioeconomic position was measured by employing a construct of educational attainment and wealth index. All analyses were stratified by district and urban-rural residence. RESULTS: There were substantial inter-district differences in proportion of health facility childbirth. Facility childbirth was 15, 70 and 37% in the rural areas of Malindi, Mbarali and Kapiri Mposhi respectively, and 57, 75 and 77% in the urban areas of the districts respectively. However, striking socio-economic inequities were revealed regardless of district. Furthermore, there were indications that repeated exposure to ANC services and HIV related counselling and testing were positively associated with health facility deliveries. Perceived distance was negatively associated with facility childbirth in rural areas of Malindi and urban areas of Kapiri Mposhi. CONCLUSION: Strong socio-economic inequities in the likelihood of facility childbirths were revealed in all the districts added to geographic inequities in two of the three districts. This strongly suggests an urgent need to strengthen services targeting disadvantaged and remote populations. The finding of a positive association between HIV counselling/testing and odds in favor of giving birth at a health facility suggests potential positive effects can be achieved by strengthening integrated approaches in maternal health service delivery.

WHO multicentre study for the development of growth standards from fetal life to childhood: the fetal component.

BACKGROUND: In 2006 WHO presented the infant and child growth charts suggested for universal application. However, major determinants for perinatal outcomes and postnatal growth are laid down during antenatal development. Accordingly, monitoring fetal growth in utero by ultrasonography is important both for clinical and scientific reasons. The currently used fetal growth references are derived mainly from North American and European population and may be inappropriate for international use, given possible variances in the growth rates of fetuses from different ethnic population groups. WHO has, therefore, made it a high priority to establish charts of optimal fetal growth that can be recommended worldwide. METHODS: This is a multi-national study for the development of fetal growth standards for international application by assessing fetal growth in populations of different ethnic and geographic backgrounds. The study will select pregnant women of high-middle socioeconomic status with no obvious environmental constraints on growth (adequate nutritional status, non-smoking), and normal pregnancy history with no complications likely to affect fetal growth. The study will be conducted in centres from ten developing and industrialized countries: Argentina, Brazil, Democratic Republic of Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand. At each centre, 140 pregnant women will be recruited between 8 + 0 and 12 + 6 weeks of gestation. Subsequently, visits for fetal biometry will be scheduled at 14, 18, 24, 28, 32, 36, and 40 weeks (+/- 1 week) to be performed by trained ultrasonographers.The main outcome of the proposed study will be the development of fetal growth standards (either global or population specific) for international applications. DISCUSSION: The data from this study will be incorporated into obstetric practice and national health policies at country level in coordination with the activities presently conducted by WHO to implement the use of the Child Growth Standards.

Obstetric fistula in 14,928 Ethiopian women.

OBJECTIVES: Obstetric fistulas are severe sequelae of prolonged obstructed labor, a widespread but incompletely documented problem of low-income countries. Here, we characterize women with obstetric fistula, test the hypothesis that primi- and multipara represent different profiles and that fetal size is an important factor in developing fistula. DESIGN: Hospital registry statistics and questionnaire. POPULATION: A total of 14,928 Ethiopian women with obstetric fistula in 1974-2006 and 434 admitted in 2007-8. METHODS: Self-reported age, marital status, education, distance from home to health facility, parity, duration of labor, neonatal outcome and sex, lag time to treatment; measurement of weight, stature, extent of lesion and clinical assessment of continence before hospital discharge. OUTCOME MEASURES: Duration of labor, extent of pelvic injury and neonatal survival, cure rate. RESULTS: Primi- were more common than multiparous cases (56.8 vs. 43.2%). They were of similar age at marriage (17 years) and stature at hospital admission, but shorter than the population average (152.7 vs. 156.5 cm). Primipara had longer labor than multipara (50.5% > 3 days vs. 27%), larger uro-vaginal fistula, more stillbirths (95 vs. 88%), recto-vaginal fistula, vaginal scarring, persistent incontinence after repair and were more commonly divorced. Male fetuses were involved in 76.7% of obstructed deliveries but in only 44.6% of a previous uneventful delivery in multipara. Educational attainment positively influenced outcomes. CONCLUSIONS: Obstetric fistula is more commonly associated with primiparous than subsequent pregnancies. Primipara have a longer and more damaging labor. A causative role for cephalo-pelvic disproportion is supported by the observation that male fetuses are more commonly involved in obstructed labor.

Biometric assessment.

Ultrasound is used to assess foetal age, foetal weight and growth. The error of such measurements is considerable, but the technique of averaging repeat measurements restricts random error. The use of customised foetal weight charts, that is, adjusting for ethnicity and maternal and foetal factors helps in classifying foetal weight appropriately. Commonly used cross-sectional reference ranges are useful for the foetal weight assessment at any stage of pregnancy, but not for foetal growth. Growth assessment requires serial measurements and longitudinal reference ranges, which provide conditional terms for individual foetuses. That is, an initial measurement is used for calculating individual ranges for the rest of pregnancy. Compared to the ranges for the entire population, the conditional ranges for a small foetus are narrower and skewed in the direction of the initial measurement. Quality control is recommended to ensure that such methods work when applied to the local population.

Fetal growth restriction is associated with prioritization of umbilical blood flow to the left hepatic lobe at the expense of the right lobe.

Eighty to 85% of the venous perfusion to the fetal liver is from the umbilical vein, the rest from the portal vein. Umbilical venous flow to the liver is essential for intrauterine growth, and is impaired in placental insufficiency. We hypothesized that in growth-restricted fetuses portal blood flow compensates for insufficient umbilical blood flow to the liver. In 29 fetuses with fetal growth restriction (estimated fetal weight < or =5th percentile), we used ultrasound to measure blood flows in the umbilical vein, ductus venosus, left portal vein, and main portal stem. Compared with normal fetuses, both absolute and normalized total venous liver blood flows were reduced in growth-restricted fetuses, related to the degree of placental compromise and equally affecting both liver lobes. However, portal replaced umbilical flow to the right lobe, in a manner graded according to placental vascular resistance; in extreme cases, the right lobe received no umbilical perfusion. In fetal growth restriction, the liver suffers from venous hypoperfusion, and portal blood partially replaces umbilical flow to the right lobe; this will result in right liver lobe hypoxemia. This striking prioritization in nutrient delivery of left over right lobes suggests an adaptive response to poor placental perfusion that may have functional consequences.

Fetal age assessment based on 2nd trimester ultrasound in Africa and the effect of ethnicity.

BACKGROUND: The African population is composed of a variety of ethnic groups, which differ considerably from each other. Some studies suggest that ethnic variation may influence dating. The aim of the present study was to establish reference values for fetal age assessment in Cameroon using two different ethnic groups (Fulani and Kirdi). METHODS: This was a prospective cross sectional study of 200 healthy pregnant women from Cameroon. The participants had regular menstrual periods and singleton uncomplicated pregnancies, and were recruited after informed consent. The head circumference (HC), outer-outer biparietal diameter (BPDoo), outer-inner biparietal diameter and femur length (FL), also called femur diaphysis length, were measured using ultrasound at 12-22 weeks of gestation. Differences in demographic factors and fetal biometry between ethnic groups were assessed by t- and Chi-square tests. RESULTS: Compared with Fulani women (N = 96), the Kirdi (N = 104) were 2 years older (p = 0.005), 3 cm taller (p = 0.001), 6 kg heavier (p < 0.0001), had a higher body mass index (BMI) (p = 0.001), but were not different with regard to parity. Ethnicity had no effect on BPDoo (p = 0.82), HC (p = 0.89) or FL (p = 00.24). Weight, height, maternal age and BMI had no effect on HC, BPDoo and FL (p = 0.2-0.58, 0.1-0.83, and 0.17-0.6, respectively). When comparing with relevant European charts based on similar design and statistics, we found overlapping 95% CI for BPD (Norway & UK) and a 0-4 day difference for FL and HC. CONCLUSION: Significant ethnic differences between mothers were not reflected in fetal biometry at second trimester. The results support the recommendation that ultrasound in practical health care can be used to assess gestational age in various populations with little risk of error due to ethnic variation.

Three-dimensional endoanal ultrasound assessment of the anal sphincters during rest and squeeze.

BACKGROUND: Current ultrasound assessment of the anal sphincter is based on measurements during rest. However, active constriction plays a role in maintaining continence. Here we assess female anal dimensions during rest and squeeze. METHODS: Thirty women were recruited for a cross-sectional endoanal ultrasound study after written consent according to an ethically approved protocol: nine 0-gravida, 10 with normal vaginal delivery, and 11 with complicated vaginal delivery (babies >4,500 g, operative vaginal delivery or perineal rupture). Endoanal three-dimensional (3D)-ultrasound volume was obtained during rest and squeeze. Length of anal canal and volume of the external and internal sphincters were determined. RESULTS: In the 0-gravida group, the mean anal canal at rest was 3.28 cm (SD: +/-0.63) compared with 2.30 (+/-0.77) in those who had given birth (p =0.002). Correspondingly, the volume of the external sphincter was 7.61 cm(3) (+/-2.63) versus 4.80 (+/-2.02) (p =0.004), and for the internal sphincter 2.63 (+/-1.18) versus 2.68 (+/-1.30) (p =0.98). There were no differences between rest and squeeze within the 0-gravida, but after a traumatic vaginal delivery the internal sphincter was smaller during squeeze (p =0.01), and the overlap between external and internal sphincter was 0.76 cm (+/-0.41), insignificantly shorter (p =0.09) than in the 0-gravida group at 1.21 (+/-0.62). CONCLUSIONS: Women with vaginal delivery had a shorter anal canal and smaller external sphincter than 0-gravida. Active squeeze had no effect on the dimensions of the sphincter apart from a reduction of the internal sphincter in those who had undergone a complicated delivery, possibly due to a dislodging upwards during squeeze.

Three-dimensional endoanal ultrasound assessment of the anal sphincters: reproducibility.

OBJECTIVE: Volume measurement of the anal sphincter can be a future method for assessing volume loss, muscle atrophy or laceration. Three-dimensional (3D) endoanal ultrasound is a technique for assessing the volume of the anal sphincters, but the reproducibility of the method is scarcely known. DESIGN: Cross-sectional, repeated measurements. SAMPLE: Twenty women were recruited for the study after written consent according to an ethically approved protocol, nine 0-gravida and 11 with traumatic vaginal deliveries. METHOD: Endoanal 3D-ultrasound volume was obtained during rest and squeeze. The length of the anal canal and the volume of the external and internal sphincters were determined by two observers. Observer 1 repeated the measurements three times for all 20 women, and observer 2 for the nine 0-gravida, and intra- and inter-observer variation was assessed. RESULTS: During rest, the anal length measurement had intra-class correlation coefficients of 0.91 for observer 1 and 0.85 for observer 2. The limits of agreement for inter-observer measurement were (-0.81 to 1.61) measured in centimeters. For the external anal sphincter volume, the intra-class correlation coefficients and the limits of agreement were correspondingly: 0.89, 0.78 and (-7.29 to 6.03) measured in cm(3), and for the internal anal sphincter volume: 0.85, 0.69 and (-1.72 to 2.95). The variation in identifying the external anal sphincter could rise to a corresponding 30% error in volume measurement. CONCLUSION: Although intra-class correlation coefficients showed good reproducibility for endoanal ultrasound measurements, the limits of agreement were less reassuring with sizeable variation in the volume assessment, probably due to uncertainty in landmark identification.

Fetal age assessment based on femur length at 10-25 weeks of gestation, and reference ranges for femur length to head circumference ratios.

BACKGROUND: The aim of the present study is to establish new reference charts for gestational age assessment based on fetal femur length (FL), and new reference ranges for FL to head ratios at gestational weeks 10-25, and to determine the effect of maternal and fetal factors on these charts. METHODS: Six hundred fifty low-risk women with regular menstrual periods and singleton pregnancies were recruited to a prospective cross-sectional study after obtaining written consent. FL, outer-outer biparietal diameter (BPD), and head circumference (HC) were measured at 10-25 weeks of gestation. We used regression analysis in order to construct mean curves and to assess the effect of maternal and fetal factors on age assessment. RESULTS: The new chart for age assessment by means of FL was based on 636 measurements. The 95% CI of the mean corresponded to <1 day. The variation between the mean and the 90th percentile was 5, 6, and 7 days at 13, 18, and 23 weeks, respectively, similar to the results when using BPD or HC. Maternal age modestly influenced gestational age assessment (1.3 days/10 years, P = 0.005), whereas smoking, height, body mass index, multiparity, fetal sex, cephalic index, and breech presentation had no impact. Reference charts for FL to head ratios have been presented. Maternal age, fetal sex, and cephalic index influenced the FL/BPD ratio, whereas only fetal sex influenced FL/HC. CONCLUSIONS: Fetal age assessment based on FL is an equally robust method as using HC. FL/HC is a more robust ratio to characterize fetal proportions than is FL/BPD.

Fetal age assessment based on ultrasound head biometry and the effect of maternal and fetal factors.

BACKGROUND: Maternal height and weight have increased during the past 20 years, as has birthweight. The aim of the present study was to establish new reference charts for gestational age (GA) assessment using fetal biparietal diameter (BPD) and head circumference (HC), and to determine the effect of maternal and fetal factors on age assessment. METHODS: This was a prospective, cross-sectional study of 650 healthy women with regular menstrual periods and singleton uncomplicated pregnancies, recruited after written consent. BPD (outer-outer) and HC were measured at 10-24 weeks of gestation. We used regression analysis to construct mean curves and assess the effect of maternal and fetal factors on age assessment. RESULTS: BPD and HC were successfully measured in 642 participants. Using BPD and HC before 20 weeks, the new charts gave 3-8 days higher GA assessment than the charts presently in use, and <1 day difference compared to other recently established charts. Maternal age, multiparity, fetal gender, breech position and shape of fetal head affect GA estimation by 1-2 days when using BPD (p = 0.0001-0.02). Only maternal age and fetal gender affected GA estimation when using HC (