Prevalence and factors associated with preterm birth in a rural district hospital, Rwanda

The Pan African medical journal, Volume 43, Year 2022

Interpretation

Introduction: globally, the leading cause of neonatal mortality is preterm birth which may hinder the achievement of Sustainable Development Goal 3.2 target. We aimed to determine the prevalence and factors associated with preterm delivery at Kabutare hospital, Rwanda. Methods: a cross-sectional study was conducted between August and September 2020. Mothers were interviewed using a standard pretested semi-structured questionnaire and additional data were extracted from medical records of obstetric files. Gestational age was assessed using the Ballard score. Adjusted Odds Ratios and their 95% confidence intervals were calculated for multivariable logistic regression analysis to take care of all potential confounders. Results: the prevalence of preterm birth was 17.5% (95% CI: 12.9% – 22.9%). The independent factors associated with preterm birth after considering multiple logistic regression were husband being a smoker (adjusted Odds Ratio (aOR) = 5.9; 95% CI; 1.9-18; p= 0.002), antenatal care (ANC) attendance ≤ 3 visits (aOR=3.9; 95% CI; 1.1-13.8; p=0.04) and low mother’s Mid Upper Arm Circumference (MUAC) < 23cm (aOR=5.6, 95% CI; 1.8-18.9; p=0.004). Conclusion: preterm delivery was high in Huye district. Thus, we recommend ANC sessions to emphasize on maternal nutritional education which is of good quality and quantity, discourage maternal alcohol consumption as well as passive smoking. Study design and setting: this was a facility based cross-sectional study done among preterm babies delivered at Kabutare hospital, Huye district, Rwanda. Study variables included maternal socio-demographic characteristics, pregnancy lifestyle factors by preterm birth, antenatal and obstetric factors associated with preterm birth. Kabutare hospital is a district hospital which receives many high-risk pregnancies referred from 12 health centers of which some are preterm babies. It has a busier maternity department and registers about 300 births every month. It equally has a busy neonatal unit that provides specialized neonatal care (SNC) services. The hospital SNC is comprised of medical staffs: paediatricians (2), medical officers (2) and 12 nurses (12). Kabutare district hospital is located in Huye district, southern province of Rwanda, at 126 km from the capital Kigali. Huye district has a population of 328,605 inhabitants covering an area of 581.5 km2. Its density population is 510.3 inhabitants per km2. Study population: the study population comprised of postnatal women who delivered preterm babies between August and September 2020. The sample size was determined using single population proportion formula by considering confidence level (95%), margin of error = 0.04 and proportion of preterm rate in Rwanda being 10% [7]. By adding 10% non-response rate, the final sample size was 240. Inclusion/exclusion criteria: consenting postnatal women aged between 18 and 49 years who had delivered a singleton preterm baby within the study period were included. On the other hand, non-consenting postnatal women, mentally unstable, those who had memory loss or those who were sick thus unable to participate were excluded from the study. Study variables: the dependent variable was spontaneous preterm birth. The independent variables were as follows: (i) maternal socio-demographic characteristics (age, residence, marital status, religion, level of education, family size, occupation and Mid-Upper Arm Circumference [MUAC]); (ii) maternal pregnancy lifestyle factors (smoking during pregnancy, alcohol consumption, husband being cigarette smoker, husband drinks alcohol; (iii) antenatal care (ANC)-related factors (frequency of ANC visits, gestational age of first visit, prior pregnancy danger signs and maternal HIV status) and obstetric-related factors (parity, inter-delivery interval, onset of labour, gestational age, previous preterm birth, anaemia during pregnancy). Operational definitions: preterm birth was the commencement of labor with an intact or pre-labor rapture of the membrane and birth before 37 weeks of gestational age. The inter-delivery was defined as the number of months since the previous birth. It was considered as either being short or optimal if the birth interval was ≤ 24 months or ≥ 25 months, respectively. Study procedure: we conducted a systematic sampling which enabled us recruit all mothers who had delivered within 24 hours at Kabutare hospital from August to September 2020. Informed consent was obtained from the mothers whose babies had been admitted to the newborn care unit (NBU). A semi-structured pre-test questionnaire was administered to the mothers while additional data were obtained from the mothers' and babies' obstetric and neonatal records for those admitted as required, respectively. Data were collected from medical records by two trained research assistants who were supervised by the principal investigator. For every case, information was collected regarding socio-demographic characteristics, medical history, antenatal care attendance (ANC), medical conditions diagnosed before or during current pregnancy and details of lifestyle and anthropometric measurements and maternal and perinatal outcome including complications. Maternal nutritional status was assessed by measuring the left mid-upper arm circumference (MUAC) using non-stretchable MUAC tapes used for screening pregnant mothers. A low MUAC was defined as a measurement of less than 23 cm. While, gestational age was calculated using last menstrual period and confirmed within 24 hours of birth by clinical assessment using the Ballard Score. Ethical considerations: ethical approval was obtained from Mount Kenya University Kigali, Rwanda The School of Postgraduate studies, Mount Kenya University, Kigali first approved the research proposal and ethical clearance was obtained from the Institutional Research and Ethics committee of Mount Kenya University (N°: MKU04/DVCARA/2019-2020/077). After obtaining ethical approval, permission was obtained from the director general of Kabutare district hospital for authorization to proceed with the data collection. The participants were told about the study objectives and that their participation was voluntary and they could withdraw at any time, without giving any reason. Written informed consent was obtained for participation in the study. No inducements or rewards were given to participants to join the study. Confidentiality was maintained at all times. Data collected as part of the study were not linked to individual or personal identifiers and was reported in accordance with the STROBE guidelines. Data analysis: data were entered into Microsoft Access database, cleaned and uploaded into a password protected android tablet. The outcome variables were dichotomized and coded as 0 and 1, representing those that did not have a preterm birth and those that had a preterm birth, respectively. Data were analyzed using Stata version 17 Univariate analysis was done to include frequencies and proportions that was displayed in form of tables and figures. Bivariate analysis using Chi-square test was conducted to identify the association between the independent and dependent variables. Adjusted Odds Ratios, and their 95% confidence intervals were deliberated for multivariable logistic regression analysis to take care of all potential confounders. The goodness of fit was assessed using Hosmer-Lemeshow test with Chi-square value 1.74 and p-value of 0.884 which indicated that the fitted model was adequate.

AI Digest

Study Justification:

– Preterm birth is a leading cause of neonatal mortality globally and can hinder the achievement of Sustainable Development Goal 3.2.
– Understanding the prevalence and factors associated with preterm birth in a specific setting, such as Kabutare hospital in Rwanda, is crucial for developing effective interventions and reducing preterm birth rates.

Study Highlights:

– The study found that the prevalence of preterm birth at Kabutare hospital was 17.5%.
– Factors associated with preterm birth included husband being a smoker, antenatal care attendance of ≤ 3 visits, and low mother’s Mid Upper Arm Circumference (MUAC) < 23cm.
– These findings highlight the importance of addressing maternal nutritional education, discouraging maternal alcohol consumption, and passive smoking to reduce preterm birth rates.

Study Recommendations:

– ANC sessions should emphasize maternal nutritional education of good quality and quantity.
– Maternal alcohol consumption should be discouraged.
– Measures should be taken to reduce passive smoking exposure among pregnant women.

Key Role Players:

– Medical staff: paediatricians (2), medical officers (2), and 12 nurses.
– Research assistants: trained individuals responsible for data collection.
– Principal investigator: oversees the study and supervises research assistants.

Cost Items for Planning Recommendations:

– Training and capacity building for medical staff and research assistants.
– Printing and distribution of educational materials on maternal nutrition.
– Awareness campaigns to discourage maternal alcohol consumption.
– Implementation of measures to reduce passive smoking exposure.
– Data collection and analysis expenses.
– Monitoring and evaluation of intervention effectiveness.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design is a cross-sectional study, which is appropriate for determining prevalence and identifying factors associated with preterm birth. The sample size of 240 is adequate for this type of study. The study used a standardized questionnaire and extracted data from medical records, which enhances the reliability of the findings. The statistical analysis included multivariable logistic regression to control for potential confounders. However, there are a few areas that could be improved. First, the study could have included a larger sample size to increase the generalizability of the findings. Second, the study could have used a prospective design to establish temporal relationships between the factors and preterm birth. Lastly, the abstract does not provide information on the representativeness of the study population, which could affect the external validity of the findings. To improve the evidence, future studies could consider these suggestions and provide more details on the representativeness of the study population.

Abstract

Study design and setting: this was a facility based cross-sectional study done among preterm babies delivered at Kabutare hospital, Huye district, Rwanda. Study variables included maternal socio-demographic characteristics, pregnancy lifestyle factors by preterm birth, antenatal and obstetric factors associated with preterm birth. Kabutare hospital is a district hospital which receives many high-risk pregnancies referred from 12 health centers of which some are preterm babies. It has a busier maternity department and registers about 300 births every month. It equally has a busy neonatal unit that provides specialized neonatal care (SNC) services. The hospital SNC is comprised of medical staffs: paediatricians (2), medical officers (2) and 12 nurses (12). Kabutare district hospital is located in Huye district, southern province of Rwanda, at 126 km from the capital Kigali. Huye district has a population of 328,605 inhabitants covering an area of 581.5 km2. Its density population is 510.3 inhabitants per km2. Study population: the study population comprised of postnatal women who delivered preterm babies between August and September 2020. The sample size was determined using single population proportion formula by considering confidence level (95%), margin of error = 0.04 and proportion of preterm rate in Rwanda being 10% [7]. By adding 10% non-response rate, the final sample size was 240. Inclusion/exclusion criteria: consenting postnatal women aged between 18 and 49 years who had delivered a singleton preterm baby within the study period were included. On the other hand, non-consenting postnatal women, mentally unstable, those who had memory loss or those who were sick thus unable to participate were excluded from the study. Study variables: the dependent variable was spontaneous preterm birth. The independent variables were as follows: (i) maternal socio-demographic characteristics (age, residence, marital status, religion, level of education, family size, occupation and Mid-Upper Arm Circumference [MUAC]); (ii) maternal pregnancy lifestyle factors (smoking during pregnancy, alcohol consumption, husband being cigarette smoker, husband drinks alcohol; (iii) antenatal care (ANC)-related factors (frequency of ANC visits, gestational age of first visit, prior pregnancy danger signs and maternal HIV status) and obstetric-related factors (parity, inter-delivery interval, onset of labour, gestational age, previous preterm birth, anaemia during pregnancy). Operational definitions: preterm birth was the commencement of labor with an intact or pre-labor rapture of the membrane and birth before 37 weeks of gestational age. The inter-delivery was defined as the number of months since the previous birth. It was considered as either being short or optimal if the birth interval was ≤ 24 months or ≥ 25 months, respectively. Study procedure: we conducted a systematic sampling which enabled us recruit all mothers who had delivered within 24 hours at Kabutare hospital from August to September 2020. Informed consent was obtained from the mothers whose babies had been admitted to the newborn care unit (NBU). A semi-structured pre-test questionnaire was administered to the mothers while additional data were obtained from the mothers' and babies' obstetric and neonatal records for those admitted as required, respectively. Data were collected from medical records by two trained research assistants who were supervised by the principal investigator. For every case, information was collected regarding socio-demographic characteristics, medical history, antenatal care attendance (ANC), medical conditions diagnosed before or during current pregnancy and details of lifestyle and anthropometric measurements and maternal and perinatal outcome including complications. Maternal nutritional status was assessed by measuring the left mid-upper arm circumference (MUAC) using non-stretchable MUAC tapes used for screening pregnant mothers. A low MUAC was defined as a measurement of less than 23 cm. While, gestational age was calculated using last menstrual period and confirmed within 24 hours of birth by clinical assessment using the Ballard Score. Ethical considerations: ethical approval was obtained from Mount Kenya University Kigali, Rwanda The School of Postgraduate studies, Mount Kenya University, Kigali first approved the research proposal and ethical clearance was obtained from the Institutional Research and Ethics committee of Mount Kenya University (N°: MKU04/DVCARA/2019-2020/077). After obtaining ethical approval, permission was obtained from the director general of Kabutare district hospital for authorization to proceed with the data collection. The participants were told about the study objectives and that their participation was voluntary and they could withdraw at any time, without giving any reason. Written informed consent was obtained for participation in the study. No inducements or rewards were given to participants to join the study. Confidentiality was maintained at all times. Data collected as part of the study were not linked to individual or personal identifiers and was reported in accordance with the STROBE guidelines. Data analysis: data were entered into Microsoft Access database, cleaned and uploaded into a password protected android tablet. The outcome variables were dichotomized and coded as 0 and 1, representing those that did not have a preterm birth and those that had a preterm birth, respectively. Data were analyzed using Stata version 17 Univariate analysis was done to include frequencies and proportions that was displayed in form of tables and figures. Bivariate analysis using Chi-square test was conducted to identify the association between the independent and dependent variables. Adjusted Odds Ratios, and their 95% confidence intervals were deliberated for multivariable logistic regression analysis to take care of all potential confounders. The goodness of fit was assessed using Hosmer-Lemeshow test with Chi-square value 1.74 and p-value of 0.884 which indicated that the fitted model was adequate.

Materials

N/A

Innovations

Based on the research findings, the following innovations can be developed to improve access to maternal health:

1. Innovation 1: Comprehensive and high-quality antenatal care (ANC) sessions
– Develop ANC sessions that prioritize maternal nutritional education, emphasizing both the quality and quantity of nutrition during pregnancy.
– Provide information on the dangers of maternal alcohol consumption and passive smoking, as these were identified as independent factors associated with preterm birth.

2. Innovation 2: Strengthen smoking cessation programs
– Implement targeted interventions to support pregnant women and their partners in quitting smoking.
– Provide counseling services, nicotine replacement therapy, and community-based support programs.

3. Innovation 3: Improve access to and utilization of ANC services
– Implement community outreach programs and mobile clinics to ensure pregnant women have access to ANC services.
– Provide transportation support for pregnant women in rural areas to encourage attendance at the recommended number of ANC visits.

4. Innovation 4: Strengthen collaboration between district hospitals and health centers
– Improve the referral system and ensure effective communication and coordination between health centers and district hospitals.
– Ensure that pregnant women receive appropriate and timely care, reducing the risk of preterm birth.

5. Innovation 5: Enhance capacity and resources in neonatal care
– Strengthen neonatal care services in busy maternity departments and neonatal units.
– Increase the number of trained medical staff, such as pediatricians and nurses, and ensure the availability of necessary equipment and resources for specialized neonatal care.

By implementing these innovations, there is a potential to improve access to maternal health and reduce the prevalence of preterm birth, ultimately contributing to the achievement of Sustainable Development Goal 3.2 target and reducing neonatal mortality rates.

AI Innovations Description

Based on the research findings, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement comprehensive and high-quality antenatal care (ANC) sessions: ANC sessions should prioritize maternal nutritional education, emphasizing both the quality and quantity of nutrition during pregnancy. This can help address the association between low mother’s Mid Upper Arm Circumference (MUAC) and preterm birth. ANC sessions should also provide information on the dangers of maternal alcohol consumption and passive smoking, as these were identified as independent factors associated with preterm birth.

2. Strengthen smoking cessation programs: Given that husband being a smoker was identified as a significant factor associated with preterm birth, it is important to implement targeted interventions to support pregnant women and their partners in quitting smoking. This can include providing counseling services, nicotine replacement therapy, and community-based support programs.

3. Improve access to and utilization of ANC services: The study found that ANC attendance of ≤ 3 visits was associated with preterm birth. Efforts should be made to ensure that pregnant women have access to and are encouraged to attend the recommended number of ANC visits. This can be achieved through community outreach programs, mobile clinics, and transportation support for pregnant women in rural areas.

4. Strengthen collaboration between district hospitals and health centers: Kabutare hospital, being a district hospital, receives high-risk pregnancies referred from health centers. To improve access to maternal health, it is important to strengthen the referral system and ensure effective communication and coordination between health centers and district hospitals. This can help ensure that pregnant women receive appropriate and timely care, reducing the risk of preterm birth.

5. Enhance capacity and resources in neonatal care: Given the high prevalence of preterm birth, it is crucial to strengthen neonatal care services, particularly in busy maternity departments and neonatal units. This can include increasing the number of trained medical staff, such as pediatricians and nurses, as well as ensuring the availability of necessary equipment and resources for specialized neonatal care.

By implementing these recommendations, there is a potential to improve access to maternal health and reduce the prevalence of preterm birth, ultimately contributing to the achievement of Sustainable Development Goal 3.2 target and reducing neonatal mortality rates.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, you can consider the following methodology:

1. Define the target population: Identify the population that will be affected by the recommendations. This could include pregnant women in the study area, specifically those who are at risk of preterm birth.

2. Collect baseline data: Gather data on the current status of access to maternal health in the study area. This can include information on ANC attendance, smoking rates among husbands, maternal MUAC, and other relevant factors associated with preterm birth.

3. Develop intervention strategies: Based on the recommendations, design and implement intervention strategies to improve access to maternal health. This can include implementing comprehensive and high-quality ANC sessions, strengthening smoking cessation programs, improving access to and utilization of ANC services, enhancing collaboration between district hospitals and health centers, and enhancing capacity and resources in neonatal care.

4. Implement the interventions: Roll out the intervention strategies in the study area. This can involve training healthcare providers, establishing ANC sessions, implementing smoking cessation programs, improving transportation support, and strengthening collaboration between healthcare facilities.

5. Monitor and evaluate the impact: Collect data on the implementation of the interventions and monitor their impact on access to maternal health. This can include tracking ANC attendance rates, smoking cessation rates, changes in maternal MUAC, and other relevant indicators.

6. Analyze the data: Analyze the collected data to assess the impact of the interventions on improving access to maternal health. This can involve statistical analysis, such as calculating adjusted odds ratios and their confidence intervals, to determine the effectiveness of the interventions.

7. Compare the results: Compare the data collected after implementing the interventions with the baseline data to determine the extent of improvement in access to maternal health. This can help evaluate the success of the interventions and identify areas for further improvement.

8. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the impact of the interventions on improving access to maternal health. Make recommendations for further actions or modifications to the interventions to maximize their effectiveness.

9. Publish the findings: Share the results of the simulation study in a scientific publication or report to contribute to the existing knowledge on improving access to maternal health and inform future research and policy decisions.

By following this methodology, you can simulate the impact of the main recommendations on improving access to maternal health and contribute to the body of evidence on effective interventions in this area.

Authors & Co-Authors

Statistics:

Authors: 4

Identifiers:

DOI: 10.11604/pamj.2022.43.173.34113

Research Areas:

Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Substance Abuse

Study Countries:

Kenya, Multi-Countries, Rwanda

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female