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Factors Associated with Adverse Pregnancy Outcomes Among Home and Health Facility Deliveries in Lamu County, Kenya: a Comparative Cross Sectional Study

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Factors Associated with Adverse Pregnancy Outcomes Among Home and Health Facility Deliveries in Lamu County, Kenya: a Comparative Cross Sectional Study JOGECA 2018; 30(2) FACTORS ASSOCIATED WITH ADVERSE PREGNANCY OUTCOMES AMONG HOME AND HEALTH FACILITY DELIVERIES IN LAMU COUNTY, KENYA: A COMPARATIVE CROSS SECTIONAL STUDY Authors Maawiya HA1; Ogutu O1; Osoti A1; Ayieko P3 ; Kireki O1; Koigi PK 2; Kosgei RJ1; Kihara AB1; Gwako GN1; Kilonzo MK1; Ndavi PM1; Odawa FX1 Institutional affiliations: 1. University of Nairobi, College of health sciences, Department of Obstetrics and Gynaecology. 2. The Nairobi Hospital 3. Private consultant statistician, UK Correspondence: [email protected] Key words: Lamu; adverse obstetric outcomes; home delivery; hospital delivery Abstract Introduction: The burden of adverse perinatal and maternal outcomes is still unacceptably high in low- and middle-income countries. Although much is known on the risk factors, very little is known about specific aspects in Lamu County. This is compounded by the fact that the maternal mortality ratio in Lamu almost doubles the national rate. This study was aimed at providing a framework to assess the probable risk factors for adverse pregnancy outcomes in the County following both hospital and home deliveries. Methodology: Study design: Comparative cross-sectional study. Setting: Lamu County, both home and hospital deliveries. Study population: Female residents of Lamu County interviewed within a month of data collection, having delivered in the year 2017 at gestation age of ≥28 weeks and age ≥14 years. Sample size: Using Fleiss formula for comparative cross-sectional study; the sample size was approximated to be 400 participants after adjusting for attrition. Data collection and management: Data were collected using a questionnaire by trained research assistants, and entered into an Excel spreadsheet. Data analysis: Analysis was done using Statistical Package for Social Sciences (SPSS) version 20. Relevant tests of significance were applied. Results: The most prevalent adverse obstetric outcomes were post-partum hemorrhage (PPH) requiring transfusion of at least 2 units of blood and preterm births. PPH was more common following home delivery. Pre-existing medical conditions, other obstetric emergencies (OR 128.17, CI 14.88 – 110.4, p< 0.001) and long distance were associated with adverse obstetric outcomes. There was no significant difference in the prevalence of adverse outcomes between home and hospital deliveries (OR 0.94, C.I 0.55-1.61, p= 0.812). Conclusion: Multiple factors are associated with adverse obstetric outcomes in Lamu. There is a need to: raise awareness on the need for greater facility-based skilled birth attendance; build capacity of facilities to provide comprehensive emergency obstetric care and to train traditional birth attendants to become ambassadors for early referral. Journal of Obstetrics and Gynaecology of Eastern and 11 Central Africa JOGECA 2018; 30(2) INTRODUCTION: of Lamu County revealed lack in continuity of care (mostly attributed to unfavorable terrain and hence There has been a global decline in the number of poor access) and adverse social beliefs making people maternal deaths and stillbirths. However, the numbers abstain from seeking medical care (e.g. skeptism remain unacceptably high in sub-Saharan Africa towards HIV/AIDS)(14) . This study sought to look (1). Several risk factors increase the chances of at the risk factors for adverse obstetric outcomes adverse perinatal and maternal outcomes. Stillbirths following both home and hospital deliveries in Lamu have been associated with poverty, low education, County. maternal age (<20years/ >35years), parity (<1/>5), BOX 1: Location of Lamu and its divisions in Kenya METHODOLOGY: prematurity, previous history of stillbirth, and low birth weight (2). Maternal factors like antepartum Study design: This was a comparative cross- hemorrhage (APH), post-partum hemorrhage (PPH), sectional study. eclampsia, obstructed labor, cord prolapse and pre- Study setting: Lamu County, Kenya, both in the existing medical conditions have also been shown to community and hospital setting. Hospitals included increase the risk of poor obstetric outcomes (1)(3) all public health facilities (five in number) that (4)(5)(6)(7)(8). In Kenya, in addition to the above provide a minimum of basic emergency obstetric risk factors; un-employment, single parenthood, lack care, i.e. King Fahad County referral hospital (level of antenatal attendance, restricted access to health 5), Mpeketoni, Faza (level 4), Kiunga and Witu (level facilities, malaria infection, poor staffing and staff 3). Access to the interior of mainland (Mkomani) attitudes have also been associated with adverse where the referral hospital is located is by foot or obstetric outcomes(9)(10)(11). Lamu County is one donkey rides, as the narrow roads restrict vehicular of the 47 Counties in Kenya; it has a population of access to the sea shore. The stretch of tarmacked road approximately 101,000 people(12). Lamu County in the entire county is only 6kms, the rest being earth has the 7th highest maternal mortality ratio of road. Given these logistical access challenges, most 676/100,000 live births: almost twice the national deliveries in Lamu County are conducted at home. average. Being an archipelago, it poses unique The map of Lamu County showing its constituencies geographical challenges in accessing health care is shown in Box 1 below. (13). There are no published studies in Lamu County on risks for adverse maternal or perinatal outcomes. Study population: Eligible participants included An in-depth interview on unique challenges faced by willing residents of Lamu aged ≥14 years at ≥ 28 non-governmental organizations in the health system completed weeks of gestation who delivered either in Journal of Obstetrics and Gynaecology of Eastern and 12 Central Africa Maawiya HA, et al a hospital or at home within a month of the interview. Relevant tests of significance were applied and a p In the event of a maternal death, immediate 1st degree value <0.05 was considered statistically significant. relative was interviewed. There were no exclusion Ethical considerations: Ethical and administrative criteria used. approvals were sought from the Kenyatta National Sample size determination: Sample size was Hospital /University of Nairobi ethics research calculated using Fleiss formulas (15) proportion committee and the Lamu County government of facility (unexposed) deliveries at 46% (16) and respectively. proportion of home (exposed) deliveries at 54% (16) RESULTS P1 the estimated proportion of adverse pregnancy outcomes (obstetric complications in facility A total of 478 women were approached. Seventy- deliveries in Nepal, India) in the unexposed (facility eight women were excluded as they did not meet deliveries) population at 24% and p2 the estimated the eligibility criteria. 400 participants were finally interviewed using a standard questionnaire as shown proportion of adverse pregnancy outcomes (obstetric in Figure 1. Of these, 215 women had had home complications in rural Hyderabad, Pakistan) in the deliveries in four divisions sampled randomly: 1 exposed (home deliveries) population at 38%. Hence, in Lamu East (Faza) and 3 in Lamu West (Witu, the number of home deliveries estimated in this Mpeketoni, Mkunumbi). This was based on population study was 197 participants while 169 were facility ratios being 1:3 respectively. The remaining 185 deliveries. After adjusting for attrition the calculated women were interviewed consecutively across 5 sample size was 185 and 215 for health facility and public health facilities until the desired sample size home deliveries respectively. was achieved. There were two maternal mortalities Independent Dependent (out- in the hospital setting, and their spouses were (exposure) variables come) variables interviewed. Age (<19 and >35) Stillbirth (macerated Level of income and fresh) Table 1 shows the socioeconomic and demographic Education level Early neonatal death Marital status (within 1 week factors associated with the venue of delivery of Religion of delivery), early History of gender based onset neonatal sepsis the study participants. Home deliveries were more violence, (with in 72 hours of common among those ≥30 years in comparison Smoking, alcohol and or delivery), preterm drug abuse in pregnancy birth women aged 29 and below (42% vs 28%). Majority Parity Maternal death / of participants professed the Islamic faith, with Distance to a health MNM facility more delivering at home rather than in the hospital Obstetric emergency in index pregnancy* (74% vs 64%, p= 0.028). Other factors significantly Presence of pre-existing associated with home delivery were: single status, medical condition^ primary or lower level of education (88% vs 80.8%, Box 2 Study variables p= 0.001, low median level of income (p <0.001), Key: *antepartum hemorrhage, postpartum hemorrhage, parity >1 (86% vs. 64%, p= 0.001, and a previous eclampsia, obstructed labor, cord prolapse successful vaginal delivery (99% vs. 81%, p <0.001). ^ Hypertension, diabetes, anemia, epilepsy Overall, most pregnancies resulted in live births “Transfusion of two or more units of blood, referral for ICU care, dialysis, hysterectomy due to uterine atony or followed by preterm births as shown in Figure 1. There infection was no significant difference in adverse perinatal and MNM: maternal and neonatal mortality maternal outcomes with regard to place of delivery (OR 0.94, 95% C.I 0.55-1.61, p= 0.812). However, Data collection procedure and management: half of the participants 52% with adverse pregnancy Data were
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