Inadequate prenatal care and the risk of stillbirth in the Peruvian Amazon

Abstract

Major risk factors for stillbirth include lack of skilled birth attendants, low socioeconomic status, poor nutrition, prior stillbirth, advanced maternal age, and the lack of prenatal care [1]. The World Health Organization has published a prenatal care model that includes 4 routine visits for women with no specific risk condition or risk factor, and additional visits for women with health problems or risk factors [2]. During these visits, risk factors should be ascertained (e.g., syphilis screening, measurement of blood pressure) and treatments administered (e.g., iron supplementation). In Peru, the Ministry of Health recommends a schedule of 6 routine prenatal care visits with a series of assessments or interventions to be performed at specific visits [3]. However, for various reasons, the availability, accessibility, and utilization of prenatal care services may be less than optimal. In order to best inform prenatal care services in the Amazon region of Peru, where poverty remains high, we sought to identify risk factors associated with stillbirth in women delivering at the Hospital Iquitos "César Garayar Garcia" in Iquitos, the capital city of Loreto.Data were obtained from a cohort study of birth outcomes, where a random sample of mother-baby medical records had been drawn from the hospital birth registry [4]. Demographic information, admission diagnosis, observations during delivery, and discharge diagnosis were abstracted. Gestational age was determined from date of last menstrual period (LMP). If this information was missing, the gestational age recorded at admission was used; women were excluded from the study if both LMP and gestational age were missing. We also excluded women whose pregnancy was shorter than 28 weeks and those with no information on prenatal care.Two separate analyses were carried out: (1) to examine the association between having completed the recommended number of prenatal care visits according to gestational age and the risk of stillbirth, using all neonates as the denominator; and (2) to examine the association between the number of visits completed and the risk of stillbirth, using those babies born between 36 and 40 weeks of gestation whose mothers should have had 5 prenatal care visits (according to the Ministry of Health's recommendation) as the denominator. Odds ratios and 95% confidence intervals were computed from logistic regression analysis. Factors showing an association with stillbirth in simple regressions at P b 0.10 were included in multiple regression analysis. Final models included variables that were statistically significant at P b 0.05. A parity variable was also included because of its confounding effect on the association between maternal age and the risk of stillbirth.The protocol was approved by the Research Ethics Committee of the Research Institute of the McGill University Health Centre and by the Comité de Bioética of the Hospital Iquitos.A total of 4220 mothers were included. Of these, 6% had had no prenatal care visit at all during their pregnancy. The p...

Causes of and factors associated with stillbirth in low‐ and middle‐income countries: a systematic literature review

“…found that inadequate antenatal care increased the risk of stillbirth in a Tunisian population with an adjusted OR of 3.50 (95% CI 1.07–11.43). Similar results were reported from Peru (OR 3.39; 95% CI 1.57–7.74), Nigeria (OR 7.23; 95% CI 3.94–13.26), Jamaica (OR 2.0; 95% CI 1.3–3.1) and Vietnam (OR 2.56; 95% CI 1.25–5.23) …”

“…For mothers 40 years or older in Peru, Gilbert et al. reported an increased risk of stillbirth with adjusted OR of 5.46 (95% CI 1.19–25.13) . Conversely, in a study from Nigeria that examined pattern and correlates of stillbirth in a hospital setting, young maternal age (<20 years) was reported to increase the risk of stillbirth (OR 2.50; 95% CI 1.22–5.14) but this was not corrected for other risk factors .…”

“…Advanced maternal age (generally described as the age of 35 years and above) was reported as a significant risk factor associated with stillbirth in many developing countries, with an Odds Ratio (OR) of up to 2.31 (95% CI 1.81–2.95) reported from India . For mothers 40 years or older in Peru, Gilbert et al.…”

Stillbirth in Nigeria: Rates and Risk Factors Based on 2013 Nigeria DHS

“…Estimates from hospital-based studies are very likely to be inflated because majority of these pregnancies are usually difficult ones referred for further management in those referral centers; since four of the seven studies whose estimates were used for modeling stillbirths in Nigeria are in the teaching hospitals which are the highest referral centers in Nigeria. In fact, Adimora reported an estimate of stillbirth rate of 68per 1000 births [16]. Secondly, the stillbirth rate in these hospital-based studies was based on total deliveries and not based on total pregnancies of at least 7 months of gestation (or 28 weeks).…”

Socioeconomic status can affect pregnancy outcomes and complications, even with a universal healthcare system

“…Previous studies have revealed that low SES is associated with pregnancy complications such as abortion, preterm delivery, preeclampsia, eclampsia, and gestational diabetes [ 3 – 6 ]. Inadequate prenatal care is associated with poor obstetric outcomes, including preterm delivery, preeclampsia, and stillbirth [ 1 , 4 – 7 ], and women with low SES are less likely to receive prenatal care [ 1 , 2 , 8 ]. In fact, the risk of preterm delivery, preeclampsia, and gestational diabetes increases with both inadequate prenatal care and low SES [ 3 – 5 ].…”