Better than nothing? Maternal, newborn, and child health services and perinatal mortality, Lubumbashi, democratic republic of the Congo: A cohort study

Background: The Democratic Republic of Congo (DRC) has a high rate of perinatal mortality (PMR), and health measures that could reduce this high rate of mortality are not accessible to all women. Where they are in place, their quality is not optimal. This study was initiated to assess the relationship between these suboptimal maternal, newborn and child health (MNCH) services and perinatal mortality (PM) in Lubumbashi, DRC’s second-largest city. Methods: We conducted a prospective cohort study, comparing women who had no, low, moderate, or high numbers of antenatal care (ANC) visits; three different levels of delivery care; and who did or did not attend postnatal care (PNC). Women were followed for 50days after delivery, with PM as the primary endpoint. Results: Uptake of recommended prenatal interventions was between 11-43% among ANC attenders, regardless of the frequency of their visits. PM was 26 per 1000. ANC attendance was associated with PM. Newborns of mothers who had the lowest attendance had a mortality two times higher than newborns of women who had not attended ANC (low visits: adjusted odds ratio (aOR)=2.2; 95% confidence interval (CI)=1.4-3.8). However, moderate (aOR=1.4; 95% CI =0.7-2.2) and high (aOR=1.3; 95% CI 0.7-2.2) attendance were not statistically significantly associated with PM. PNC attendance was not significantly associated with lower PM (relative risk 0.4, 95% CI 0.1-2.6). Emergency obstetric and newborn care (EmONC) was significantly associated with a reduction in mortality (aOR=0.2; 95% CI=0.2-0.8), with an 84.4% reduction among newborns at risk, and an overall reduction in mortality of 10% for all births. Conclusion: Perinatal mortality was high among the infants of women in the cohort under study (26 per 1000 live births). Availability of MNCH, specifically EmONC, was associated with lower perinatal mortality, and if this association is causal, might avert 84.4% of perinatal deaths among newborns at high-risk. Lubumbashi is the capital of the province of Katanga. In 2010, its population was estimated at 1,548,923 inhabitants in an area of 747 square kilometers [17]. It has 11 health zones (HZ) and 267 health facilities, of which only 180 have a maternity ward [18]. Each HZ has a hospital and comprises both urban and rural areas. Within each HZ, facilities were purposively chosen for inclusion in the study. Each of the ten general reference hospitals (GRH) and the one provincial reference hospital was chosen, and in the corresponding HZ, one health center or private clinic (≥30 deliveries per month) in an urban setting and one in a rural (or urban-rural) setting was selected. Thus, apart from Lubumbashi (1 GRH, 1 provincial hospital, two health centers) and Kowe HZ (one health center), each HZ had 3 facilities participating in the study. We conducted a prospective cohort study, comparing women who delivered in one of the study facilities and had received various levels of ANC with women who delivered in those same facilities but had not received ANC. The study took place over a 5-month period from October 2010 to February 2011. Women who did not use ANC were recruited at their admission to the maternity unit. Those who attended ANC were recruited at their first prenatal visit. They were followed at ANC visits. At the end of scheduled prenatal visits, they were sought in the maternity wards where they had planned to give birth according to their expected date of delivery. Women were also encouraged to contact the research team in case of premature birth. Women who had not attended the ANC were recruited at the time of their admission during the same period and in the same maternity units as women of the ANC group. At the ANC, like in the maternity unit, women were recruited by nurses and doctors trained in the study procedures. The admission of a woman to a maternity unit did not automatically guarantee her inclusion in the study; written informed consent was first obtained. All women included in the study were followed until 50 days after delivery. The follow-up consisted of verification of care received during the stay in the maternity unit, and, after the stay, use of postnatal care and assessment of maternal and neonatal survival. In the ANC group, women were monitored to assess the quality of care received during pregnancy. They were recruited during ANC; only pregnant women attending their first visit were enrolled in the study. In Lubumbashi, the minimum number of women expected at ANC annually is about 60,000. Allowing for a significance level of 5 % and loss to follow-up of 20 %, with a power of 80 % to detect a reduction of PM with ANC attendance of ≈ 22.1 % [5], we needed to recruit at least 1812 pregnant women (906 per group). However, taking into account the analysis in subgroups planned to assess the impact of ANC on the maternal-fetal prognosis, the number of women was multiplied by 3 (number of ANC subgroups), which gave a minimum number of 2745 pregnant women to be recruited [19]. The number of women enrolled by each health facility was proportional to the ANC capacity of the facility (in 2009), relative to the total number of women attending ANC during the same year, across all selected health facilities [19, 20]. These women were followed by the research team according to the WHO ANC program [21], operating in the health facilities. During this monitoring period, meetings were held with women in the health facilities on the occasion of their prenatal visits. Women were not sought at home when they were absent from the appointment given by the health personnel. There was no interference from investigators in the organization of activities at a prenatal visit. No intervention was proposed to the women during this period. The fiftieth day post-partum marked the end of this monitoring period. During the monitoring period, the investigators interviewed women to obtain information about the date of their last menstrual periods (LMP), their use of home health practices, and advice and examinations they received during ANC visits. Investigators also reviewed ANC records to record which recommended interventions were administered, obstetric history, and morbidity during pregnancy. A total of 2823 pregnant women was recruited into this group. During the follow-up period, 5 women (0.2 %) experienced a miscarriage, and 424 (15 %) were lost to follow-up (not found even at home). There was no statistically significant difference in the profile of the women who remained in the study and those lost to follow-up. No maternal deaths were recorded before delivery. At delivery, the remaining 2,394 women were compared with those who had not attended ANC. According to the model of focused ANC, women should make at least four prenatal visits [21, 22]. The interventions received depend not only on the frequency of these visits, but on when the visits occur. For most developing countries, the recommended gestational ages for ANC attendance are ≤ 16 weeks, ≤ 28 weeks, ≤32 weeks, and ≤ 36 weeks since LMP [21, 22]. Thus, if a woman gives birth prematurely, at 34 weeks, she would be expected to have made three visits to ANC. We calculated the adequacy of visits according to gestational age at delivery to classify women as low, moderate, or high ANC attenders. A low ANC attender was one who attended only one of either 3 or 4 expected visits, for an adequacy of 25 or 33 % (912 women, 38.1 %). A moderate ANC attender was one who attended one of two or three of 3 or 4 expected visits, for an adequacy of 50, 66, or 75 % (748 women, 31.2 %). A high ANC attender was one who attended all, or more than, the expected visits (734 women, 30.7 %). There were 1,910 women who delivered at a study facility but who had not attended ANC, for a total of 4,304 women in the study. Written informed consent was obtained from each woman prior to inclusion in the study and was reassessed at each contact. Literacy is low in DRC (a recent estimate put it at 67 %), especially among women (52 %), and especially among those with less education and lower socioeconomic status [3]. For those whose reading ability and understanding of French were low, the consent form was read and explained to the woman in one of the local languages (Swahili, Tshiluba or Lingala), in the presence of a witness. This protocol was approved by the Comité d’Éthique Medicale (CEM; Medical Ethics Committee) of the University of Lubumbashi (CEM-UNILU: UNILU/CEM/010/2011). The women were followed from their admission to the maternity unit until 50 days after delivery. Women in the ANC group were sought in maternity facilities where they had followed the ANC program at the time of their estimated date of delivery. Those with a telephone were contacted at this date to confirm their stay in the maternity facility. Women not found in the facility where they had attended ANC (11.8 %) were sought at their homes. At the maternity facility, we interviewed women to get data relating to pregnancy for women who had not attended ANC, and the circumstances in which the woman had arrived at the facility, including time of leaving home, means of transport, and difficulties at admission for both groups of women. From maternity records, we collected data related to the diagnosis at admission, type of pregnancy, fetal presentation, mode of delivery, the occurrence of complications, the weight of the newborn and the fetal-maternal prognosis. During an interview with the health staff who managed the delivery, a table with information on the organization and access to obstetric and neonatal care in the health facility, as well as the availability of care at the time of delivery, was filled in. This table evaluated the availability of staff with surgical skills, as well as the availability of drugs and equipment (blood, oxytocin, antibiotics, surgical kits, oxygen, an incubator, magnesium sulfate, phototherapy, nasogastric tube, a partograph, an ‘Ambu’ bag, a bulb syringe and vacuum extraction cup) for each delivery. The availability of these latter varied according to the ability of the woman or her family to pay for (≥ US $20–60) and obtain them, and were not characteristics of the facility. After women and their infants returned home, the study team visited them 8, 30, and 50 days after delivery. At these visits, we assessed the vital status of mother and child and the use of postnatal care at 7, 21 and 42 days after delivery. The study data were double-entered and analyzed using Stata v.11.0 (College Station, TX). As described above, the use of ANC was evaluated in terms of the number of visits. A woman was considered at high risk of PM if she had at least one complication occurring before, during, or after delivery. Also, a fetus or a newborn was considered to be at high risk of dying if born to a woman at risk, or if it experienced a complication at birth or during the neonatal period [21, 23–25]. To study the impact of the management of delivery on maternal-fetal and neonatal survival, we identified three care groups. The first we called Essential Care–Low Risk (EC-LR), which was the general care given to women and newborns at low risk. This care included clean birth practices, labor monitoring using a partograph, the active management of the third stage of labor (AMTSL), hygienic methods to cut and tie off the cord, basic thermal care, immediate breastfeeding, prevention of mother-to-child transmission of HIV (PMTCT), and increasing the satisfaction and comfort of the mother. The second group received the same care, but were determined to be high-risk; this group was called Essential Care-High Risk (EC-HR). The third group was that which received emergency obstetric and neonatal care (EmONC), as defined by WHO [23, 24]. The PNC visits were evaluated according to whether the women had attended them or not [4]. The level of risk of the pregnancy was determined by the presence during pregnancy of at least one factor of poor prognosis for mother and child. The criteria were those of the WHO, as well as others observed by us previously in Lubumbashi [5, 23]. They included age < 20 and > 37 years, primigravidity, miscarriage of the previous pregnancy, previous infant born at less than 2500 g, fetal or neonatal death at previous delivery, the occurrence of complications or Caesarean section at previous delivery, hypertension, diabetes, maternal malnutrition, sexually transmitted infections, or HIV during the current pregnancy, and type of pregnancy (singleton vs. multiple pregnancy). Thus, every woman having least one of these factors or complications was considered as having a high-risk pregnancy [23]. PM was defined as all stillbirths (≥28 weeks gestational age) and early neonatal deaths (≤7 days) [26]. For women who had multiple pregnancies, only one infant was selected at random to be included in the univariate and multivariate analyses. Usual descriptive statistics were used to describe groups. Comparisons of the mean or median between groups involved ANOVA or Kruskal-Wallis tests, as appropriate [20]. The association between use of MNCH services and PM was measured by calculating a relative risk (RR), the significance of which was tested using a chi-square test, with a significance level of 5 %. The adjusted odds ratios (aOR) were calculated by forward stepwise logistic regression. Confidence intervals at 95 % were calculated for crude RR and aOR. All variables with an unadjusted p-value ≤ 0.10 had the opportunity to enter into the multivariable logistic regression analysis. Model fit was checked by the Hosmer-Lemeshow test [27]. The impact of each MNCH component in reducing PM was assessed by the fraction of risk prevented in newborns at high risk (FRPc) and the fraction of risk prevented in all births (FRPA) for all variables significantly associated with the reduction of PM. The total fraction of risk prevented, FRPt, for all MNCH was calculated using the following formula: Where FRPSi = fraction of risk prevented with a given MNCH service [28–31].