Is preterm birth associated with intimate partner violence and maternal malnutrition during pregnancy in Ethiopia? A systematic review and meta analysis

Heliyon, Volume 7, No. 10, Year 2021

Interpretation

Background: Despite remarkable progress in the reduction of under-five mortality, preterm birth associated mortality and morbidity remains a major public health problem in Sub-saharan Africa. In Ethiopia, study findings on the association of preterm birth with intimate partner violence and maternal malnutrition have been inconsistent. Therefore, this systematic review and meta-analysis estimates the pooled effect of intimate partner violence and maternal malnutrition on preterm birth. Methods: International databases including PubMed, Web of Science, SCOPUS, CINAHL, PsycINFO, Google Scholar, Science Direct, and the Cochrane Library, were systematically searched. All identified observational studies and/or predictors were included. I2 statistics and Egger’s test were used to assess the heterogeneity and publication biases of the studies. A random-effects model was computed to estimate the prevalence and its determinants of preterm birth. Results: The random effects meta-analysis showed that a pooled national prevalence of preterm birth was 13% (95% CI: 10.0%, 16.0%). The highest prevalence of preterm birth was 25% (95% CI: 21.0%, 30.0%) in Harar, and the lowest prevalence was 8% in Southern Nations Nationalities People of Representatives. The meta-analysis suggested a decrease in preterm birth of up to 61% among women receiving antenatal care [POR = 0.39 (95% CI: 0.21, 0.72)]. Women who experienced intimate partner violence [POR = 2.52 (95% CI: 1.68, 3.78)], malnutrition during pregnancy [POR = 2.00 (95% CI: 1.16, 3.46)], and previous preterm birth [POR = 3.73 (95% CI: 2.37, 5.88)] had significantly higher odds of preterm birth. Conclusion: One in every eight live births in Ethiopia were preterm. Women who experienced intimate partner violence, malnutrition, and had previous preterm exposure were significantly associated with preterm birth. Thus, improving antenatal care visits and screening women who experience previous preterm birth are key interventions. The Federal Ministry of Health could be instrumental in preventing intimate partner violence and improving the nutritional status of pregnant women through proper and widespread implementation of programs to reduce preterm birth. The findings of this systematic review and meta-analysis have been reported based on the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2009 statement checklist (S1 Table) [39]. All published articles were searched from major international databases including: PubMed, Cochrane Library, Web of Science, Science Direct, Google Scholar, African Journals Online databases, and Google hand searches. Additionally, a search was made for the reference list of studies already identified in order to retrieve additional articles. The PECO (Population, Exposure, Comparison, and Outcomes) search formula was used for this review. The population of interest was all live births delivered between 28 weeks of gestation and 37 weeks of gestation in Ethiopia. The exposure determinants of preterm birth included maternal area of residence, presence of antenatal care visits, frequency of antenatal care visits, IPV, malnutrition during pregnancy, and previous exposure of preterm birth. Comparisons were defined for each predictor with the respective reported reference group for each predictor per variable. The outcome of interest was preterm birth. The secondary outcomes included the predictors and adverse perinatal or neonatal outcomes of preterm birth. For each of the selected components of PECO, electronic databases were searched using the keyword search and the medical subject heading [MeSH] words. The keywords include preterm birth, adverse perinatal outcomes, determinants, predictors, associated factors, and Ethiopia. The search terms are combined by the Boolean operators “OR” and “AND”. Preterm birth is defined as a newborn being born between 28 and 37 weeks of gestation. IPV is defined as “any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. Such behaviour includes acts of physical aggression, such as slapping, hitting, kicking and beating, as well as psychological abuse, such as intimidation, constant belittling and humiliation, and forced intercourse and other forms of sexual coercion based on the WHO definition. It can involve various controlling behaviours, such as isolating a person from their family and friends, monitoring their movements, and restricting their access to information [40]. Malnutrition during pregnancy was defined based on the mid-upper arm circumference (MUAC). MUAC <23 cm (cm) was considered as being malnourished [41]. This review included studies that reported preterm birth or predictors, antenatal care visits, IPV, and previous preterm birth. All published studies published in the English language until the end of our search on July 4, 2020 have been retrieved to assess eligibility for inclusion in this review and critical assessment. The review excluded studies that were case reports of populations, surveillance data (Demographic Health Surveys), abstracts for conferences, and articles without full access. First, through title, abstract, and full review, the two reviewers (MD and FA) evaluated the articles for inclusion. Any disagreement between the two reviewers was resolved by consensus. There was then a full-text analysis of those potentially qualifying studies, whether or not the specified set of criteria had been met, and for duplicated records. During the encounter of duplication, only the full-text article was retained. The Newcastle-Ottawa Scale (NOS) quality assessment tool was used to assess the quality of the included studies based on three components: the selection of the study groups, comparability of the study groups, and ascertainment of exposure or outcome [42]. The main component of the tool was graded from five stars and mainly emphasized the methodological quality of each primary study. The other component of the tool graded from two stars and mainly scored the comparability of each study, and the last component of the tool graded from three stars and was used to evaluate the results and statistical analysis of each original study. The NOS included three categorical criteria with a maximum score of 9 points. The quality of each study was assessed using the following score algorithms: ≥7 points was considered “good”, 4 to 6 points was considered “moderate”, and ≤3 points was considered “poor” quality studies. In order to improve the validity of this systematic review result, only primary studies of fair to good quality were included. The two reviewers (MD and TYA) independently assessed or extracted articles for overall study quality and/or included in the review articles using a standardized data extraction format. The data extraction format included primary author, year of publication, geographic region of the study, sample size, the reported outcome (preterm birth), and the number of cases of live births developing the respective outcome. Selected predictors of preterm birth including association with antenatal care visits, IPV, previous preterm birth, and adverse neonatal outcomes were also extracted. Publication bias was assessed using the Egger's [43] and Begg's [44] tests with a p-value of less than 0.05. The I [2] statistic was used to assess heterogeneity between studies, and a p-value of less than 0.05 was used. As a result of the presence of heterogeneity, a random-effects model was used as a method of analysis [45] resulting in the use of a random-effects meta-analysis model to estimate the pooled effect based on the metaprop software of the double arcsine transformations [46]. The proportions contain inadmissible values near the boundary resulting in computation of confidence intervals not being possible. Hence, the estimated standard error is set to zero and one. Data were extracted in Microsoft Excel and exported to Stata version 11 for analysis. Subgroup analysis was conducted by geographic region and study design. A meta-regression model based on sample size, geographic region, study design, and year of publication was used to identify the sources of random variations in the included studies. The effect of selected determinant variables was analyzed using separate categories of meta-analysis [47]. The findings of the meta-analysis were presented using a forest plot and Odds Ratio (OR) with 95% confidence intervals (CI). In addition, we conducted a sensitivity analysis to assess whether the pooled prevalence estimates were influenced by individual studies.

AI Digest

Study Justification:

– Preterm birth associated mortality and morbidity is a significant public health problem in Sub-Saharan Africa, including Ethiopia.
– In Ethiopia, there have been inconsistent findings on the association of preterm birth with intimate partner violence and maternal malnutrition.
– Understanding the relationship between these factors and preterm birth is crucial for developing effective interventions and reducing preterm birth rates.

Study Highlights:

– The study conducted a systematic review and meta-analysis to estimate the pooled effect of intimate partner violence and maternal malnutrition on preterm birth in Ethiopia.
– The study found that the national prevalence of preterm birth in Ethiopia was 13%.
– The highest prevalence of preterm birth was observed in Harar (25%), while the lowest prevalence was in the Southern Nations Nationalities People of Representatives (8%).
– The study identified several factors associated with preterm birth, including lack of antenatal care visits, intimate partner violence, maternal malnutrition, and previous preterm birth.

Recommendations for Lay Reader:

– Improving access to and utilization of antenatal care visits can significantly reduce the risk of preterm birth.
– Addressing intimate partner violence is crucial in preventing preterm birth. Programs and interventions should be implemented to prevent and respond to intimate partner violence during pregnancy.
– Improving the nutritional status of pregnant women through proper screening and interventions can help reduce the risk of preterm birth.
– Women who have previously experienced preterm birth should be closely monitored and provided with appropriate care during subsequent pregnancies.

Recommendations for Policy Maker:

– The Federal Ministry of Health should prioritize the prevention of intimate partner violence and the improvement of the nutritional status of pregnant women.
– Implementation of programs and interventions to reduce preterm birth should be widespread and properly executed.
– Adequate resources should be allocated to improve access to and utilization of antenatal care services.
– Collaboration with relevant stakeholders, including healthcare providers, community organizations, and NGOs, is essential for the successful implementation of interventions to reduce preterm birth.

Key Role Players:

– Federal Ministry of Health
– Healthcare providers (doctors, nurses, midwives)
– Community organizations
– Non-governmental organizations (NGOs)
– Researchers and academics
– Policy makers and government officials

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers
– Development and implementation of intervention programs
– Awareness campaigns and educational materials
– Screening tools and equipment
– Monitoring and evaluation systems
– Collaboration and coordination efforts
– Research and data collection activities

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The systematic review and meta-analysis followed the PRISMA guidelines and conducted a comprehensive search of major international databases. The study included a large sample size and used appropriate statistical methods. The findings are presented clearly with relevant statistics. However, the abstract could be improved by providing more details on the quality assessment of included studies, such as the number of studies rated as good, moderate, or poor quality. Additionally, it would be helpful to include information on the limitations of the study and potential sources of bias. To improve the evidence, the authors could consider conducting a sensitivity analysis to assess the influence of individual studies on the pooled prevalence estimates. Overall, the evidence is strong, but these suggested improvements would enhance the robustness and transparency of the findings.

Abstract

The findings of this systematic review and meta-analysis have been reported based on the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2009 statement checklist (S1 Table) [39]. All published articles were searched from major international databases including: PubMed, Cochrane Library, Web of Science, Science Direct, Google Scholar, African Journals Online databases, and Google hand searches. Additionally, a search was made for the reference list of studies already identified in order to retrieve additional articles. The PECO (Population, Exposure, Comparison, and Outcomes) search formula was used for this review. The population of interest was all live births delivered between 28 weeks of gestation and 37 weeks of gestation in Ethiopia. The exposure determinants of preterm birth included maternal area of residence, presence of antenatal care visits, frequency of antenatal care visits, IPV, malnutrition during pregnancy, and previous exposure of preterm birth. Comparisons were defined for each predictor with the respective reported reference group for each predictor per variable. The outcome of interest was preterm birth. The secondary outcomes included the predictors and adverse perinatal or neonatal outcomes of preterm birth. For each of the selected components of PECO, electronic databases were searched using the keyword search and the medical subject heading [MeSH] words. The keywords include preterm birth, adverse perinatal outcomes, determinants, predictors, associated factors, and Ethiopia. The search terms are combined by the Boolean operators “OR” and “AND”. Preterm birth is defined as a newborn being born between 28 and 37 weeks of gestation. IPV is defined as “any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. Such behaviour includes acts of physical aggression, such as slapping, hitting, kicking and beating, as well as psychological abuse, such as intimidation, constant belittling and humiliation, and forced intercourse and other forms of sexual coercion based on the WHO definition. It can involve various controlling behaviours, such as isolating a person from their family and friends, monitoring their movements, and restricting their access to information [40]. Malnutrition during pregnancy was defined based on the mid-upper arm circumference (MUAC). MUAC <23 cm (cm) was considered as being malnourished [41]. This review included studies that reported preterm birth or predictors, antenatal care visits, IPV, and previous preterm birth. All published studies published in the English language until the end of our search on July 4, 2020 have been retrieved to assess eligibility for inclusion in this review and critical assessment. The review excluded studies that were case reports of populations, surveillance data (Demographic Health Surveys), abstracts for conferences, and articles without full access. First, through title, abstract, and full review, the two reviewers (MD and FA) evaluated the articles for inclusion. Any disagreement between the two reviewers was resolved by consensus. There was then a full-text analysis of those potentially qualifying studies, whether or not the specified set of criteria had been met, and for duplicated records. During the encounter of duplication, only the full-text article was retained. The Newcastle-Ottawa Scale (NOS) quality assessment tool was used to assess the quality of the included studies based on three components: the selection of the study groups, comparability of the study groups, and ascertainment of exposure or outcome [42]. The main component of the tool was graded from five stars and mainly emphasized the methodological quality of each primary study. The other component of the tool graded from two stars and mainly scored the comparability of each study, and the last component of the tool graded from three stars and was used to evaluate the results and statistical analysis of each original study. The NOS included three categorical criteria with a maximum score of 9 points. The quality of each study was assessed using the following score algorithms: ≥7 points was considered “good”, 4 to 6 points was considered “moderate”, and ≤3 points was considered “poor” quality studies. In order to improve the validity of this systematic review result, only primary studies of fair to good quality were included. The two reviewers (MD and TYA) independently assessed or extracted articles for overall study quality and/or included in the review articles using a standardized data extraction format. The data extraction format included primary author, year of publication, geographic region of the study, sample size, the reported outcome (preterm birth), and the number of cases of live births developing the respective outcome. Selected predictors of preterm birth including association with antenatal care visits, IPV, previous preterm birth, and adverse neonatal outcomes were also extracted. Publication bias was assessed using the Egger's [43] and Begg's [44] tests with a p-value of less than 0.05. The I [2] statistic was used to assess heterogeneity between studies, and a p-value of less than 0.05 was used. As a result of the presence of heterogeneity, a random-effects model was used as a method of analysis [45] resulting in the use of a random-effects meta-analysis model to estimate the pooled effect based on the metaprop software of the double arcsine transformations [46]. The proportions contain inadmissible values near the boundary resulting in computation of confidence intervals not being possible. Hence, the estimated standard error is set to zero and one. Data were extracted in Microsoft Excel and exported to Stata version 11 for analysis. Subgroup analysis was conducted by geographic region and study design. A meta-regression model based on sample size, geographic region, study design, and year of publication was used to identify the sources of random variations in the included studies. The effect of selected determinant variables was analyzed using separate categories of meta-analysis [47]. The findings of the meta-analysis were presented using a forest plot and Odds Ratio (OR) with 95% confidence intervals (CI). In addition, we conducted a sensitivity analysis to assess whether the pooled prevalence estimates were influenced by individual studies.

Materials

Innovations

Based on the information provided, here are some potential innovations that could be considered to improve access to maternal health:

1. Telemedicine and Telehealth: Implementing telemedicine and telehealth services can improve access to maternal health by allowing pregnant women in remote or underserved areas to receive virtual consultations, prenatal care, and monitoring from healthcare professionals.

2. Mobile Health (mHealth) Applications: Developing mobile health applications that provide educational resources, appointment reminders, and personalized health information can empower pregnant women to take an active role in their own healthcare and improve access to maternal health services.

3. Community Health Workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in their communities can help bridge the gap in access to maternal health services, especially in rural areas.

4. Maternal Health Vouchers: Implementing voucher programs that provide financial assistance for maternal health services, such as antenatal care visits, delivery, and postnatal care, can help reduce financial barriers and improve access for low-income women.

5. Mobile Clinics: Setting up mobile clinics that travel to remote or underserved areas can provide essential maternal health services, including prenatal care, screenings, and vaccinations, to women who may not have easy access to healthcare facilities.

6. Public-Private Partnerships: Collaborating with private healthcare providers and organizations to expand access to maternal health services can help leverage resources and expertise to reach more women in need.

7. Maternal Health Education Campaigns: Launching targeted education campaigns to raise awareness about the importance of maternal health, early prenatal care, and healthy behaviors during pregnancy can help improve access by encouraging women to seek care and make informed decisions.

It’s important to note that the specific implementation of these innovations would require careful planning, coordination, and consideration of local context and resources.

AI Innovations Description

Based on the findings of this systematic review and meta-analysis, several recommendations can be made to improve access to maternal health and reduce the prevalence of preterm birth in Ethiopia:

1. Increase access to antenatal care: The meta-analysis showed that women who received antenatal care had a significantly lower risk of preterm birth. Therefore, it is important to improve access to antenatal care services, especially in regions with higher prevalence rates.

2. Implement screening and intervention programs for intimate partner violence (IPV): The meta-analysis found that women who experienced intimate partner violence had significantly higher odds of preterm birth. To address this issue, it is crucial to implement screening programs for IPV during pregnancy and provide appropriate interventions and support for affected women.

3. Improve nutritional support for pregnant women: The meta-analysis also revealed that maternal malnutrition during pregnancy was associated with an increased risk of preterm birth. Therefore, it is important to improve the nutritional status of pregnant women through proper counseling, education, and access to nutritious food.

4. Enhance awareness and education: It is important to raise awareness among pregnant women and their families about the risks and consequences of preterm birth. This can be achieved through community-based education programs, health campaigns, and the involvement of local leaders and influencers.

5. Strengthen healthcare infrastructure: To ensure effective implementation of the above recommendations, it is essential to strengthen the healthcare infrastructure in Ethiopia. This includes improving the availability and quality of healthcare facilities, training healthcare providers, and ensuring the availability of necessary resources and equipment for maternal health services.

By implementing these recommendations, it is possible to improve access to maternal health services, reduce the prevalence of preterm birth, and ultimately improve maternal and child health outcomes in Ethiopia.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Increase access to antenatal care: The meta-analysis suggests that women who received antenatal care had a decreased risk of preterm birth. Therefore, it is important to improve access to antenatal care services for pregnant women, especially in areas with high prevalence of preterm birth.

2. Address intimate partner violence: The meta-analysis found that women who experienced intimate partner violence had significantly higher odds of preterm birth. It is crucial to implement programs and interventions that aim to prevent intimate partner violence and provide support for women who are at risk.

3. Improve nutritional support during pregnancy: The meta-analysis also showed that maternal malnutrition during pregnancy was associated with an increased risk of preterm birth. Enhancing nutritional support and education for pregnant women can help improve their overall health and reduce the risk of preterm birth.

4. Screen for previous preterm birth: Women who had previous preterm birth had significantly higher odds of experiencing preterm birth again. Implementing screening programs to identify women with a history of preterm birth can help provide appropriate care and interventions to reduce the risk of recurrence.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population that will be the focus of the simulation, such as pregnant women in a particular region or community.

2. Collect baseline data: Gather data on the current access to maternal health services, prevalence of preterm birth, rates of intimate partner violence, and nutritional status of pregnant women in the target population. This data will serve as a baseline for comparison.

3. Develop a simulation model: Create a mathematical or computational model that represents the target population and simulates the impact of the recommendations. The model should incorporate factors such as antenatal care utilization, rates of intimate partner violence, nutritional status, and previous preterm birth.

4. Implement the recommendations in the model: Introduce the recommended interventions, such as increasing access to antenatal care, addressing intimate partner violence, improving nutritional support, and implementing screening programs for previous preterm birth. Adjust the relevant parameters in the model to reflect the expected changes resulting from these interventions.

5. Run the simulation: Use the model to simulate the impact of the recommendations over a specified time period. The simulation should generate data on outcomes such as changes in access to maternal health services, reduction in preterm birth rates, and improvements in maternal and neonatal health outcomes.

6. Analyze the results: Evaluate the simulation results to assess the effectiveness of the recommendations in improving access to maternal health. Compare the simulated outcomes with the baseline data to determine the extent of the impact.

7. Refine and iterate: Based on the analysis of the simulation results, refine the model and interventions as necessary. Repeat the simulation process to further explore different scenarios and optimize the recommendations for maximum impact.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. The steps outlined above provide a general framework for conducting such a simulation, but additional considerations and adjustments may be needed based on the specific research question and available resources.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1016/j.heliyon.2021.e08103

ISSN: 24058440

Research Areas:

Community Interventions, Food Security, Genetics and Genomics, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Female