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Chapter 9 Risk Factors Chapter 9 Risk factors 9.1 Introduction The previous chapters have all focused on adverse pregnancy and birth outcomes as risk factors for foetal loss and neonatal death. The present chapter takes the discussion and analysis one layer further to the underlying risk factors for the selected adverse pregnancy and birth outcomes themselves. These risk factors are more remote in the causal chain and include maternal factors, complications of the placenta, cord, and membranes, and birth complications. These have been referred to earlier, in Chapter 3, in the operationalisation of the conceptual model (Figure 3.6). Besides their direct effect on pregnancy/birth outcome, they are believed to affect foetal loss (i.e. spontaneous abortion and stillbirth), both directly and indirectly, and neonatal death indirectly through the intermediate outcomes (i.e. adverse pregnancy and birth outcomes). As became clear in Chapter 3, many different causes and risk factors underlie the adverse pregnancy and birth outcomes, but what appear to be main risk factors? Are these risk factors also important in regions in transition and, more specifically, in Kerala? Moreover, does the relative importance of these risk factors change during the epidemiologic transition? A region’s position within the transition could very well be reflected by its specific combination of underlying risk factors. Factors such as infections and malnutrition are likely to be important during the early of the transition, while others such as diabetes and advanced maternal age may become more significant during later stages. This could lead to a redefinition of the concepts of endogenous and exogenous mortality (see Chapter 2). For example, preterm birth, which is generally regarded as an endogenous or intrinsic cause, has been associated with maternal infection (exogenous or external) during pregnancy (see Section 3.4.2). The current chapter identifies and discusses several main risk factors for the adverse pregnancy and birth outcomes. In Section 9.2, the following risk factors are selected for further analysis: hypertensive disorders of pregnancy, diabetes, maternal infections, smoking and alcohol consumption, anaemia, advanced maternal age, antepartum haemorrhage, and prolonged and obstructed labour. Before the results from the hospital survey in Kerala are presented, Section 9.2 defines and describes these risk factors on the basis of a brief literature review. In addition, some figures from secondary sources are presented on the frequency of these risk factors in developed countries, i.e. the EME region. Subsequently, Section 9.3 analyses data from the survey in SAT Hospital, Thiruvananthapuram, Kerala. Again, the relative importance is assessed at both the individual level and the population level. Finally, the results of the chapter are summarised and discussed in Section 9.4. Combining the results EARLY LIFE CHANGES with previous findings in Chapter 8 yields an understanding of important pathways to stillbirth and neonatal death in Kerala, a region in transition. 9.2 Risk factors Risk factors for the selected adverse pregnancy and birth outcomes (congenital anomalies, LBW, preterm birth, IUGR/SGA, and birth asphyxia) that are repeatedly mentioned in the literature include: infections during pregnancy (a long list including rubella and cytomegalovirus), diabetes (diabetes mellitus and gestational diabetes), hypertensive disorders (e.g. pregnancy-induced hypertension, pre-eclampsia), small maternal size (weight and height), medication, alcohol and smoking, (mal)nutrition, placental problems (e.g. placenta praevia), and cord problems (e.g. cord entanglement). Furthermore, advanced maternal age is frequently seen as a cause of chromosomal anomalies, such as Down’s syndrome, while complications at birth (e.g. malpresentation, shoulder dystocia, cephalo-pelvic disproportion) increase the probability of birth asphyxia. Obviously, these factors do not only increase the risk of adverse pregnancy and birth outcome but are also the risk factors for foetal loss and neonatal death. Additional risk factors for mortality include maternal anaemia, antepartum haemorrhage, maternal epilepsy, maternal drug use, and rhesus immunisation. Risk factors that were indicated by local informants in Kerala and Karnataka during the feasibility study in 1998 (see Chapter 4 and Appendix D) included: (mal)nutrition, maternal hypertensive disorders, maternal anaemia, infections (maternal, antepartum, neonatal), antepartum haemorrhage, small maternal size (height and weight), and antepartum care and care during delivery. However, the informants did not believe that advanced maternal age, smoking, and alcohol consumption play a role in South India. The present study focuses on several main risk factors. The following risk factors are selected for further analysis: • hypertensive disorders of pregnancy (pre-existing and pregnancy-related), • diabetes (diabetes mellitus and gestational diabetes), • maternal infections during pregnancy, • smoking and alcohol consumption, • anaemia, • advanced maternal age, • antepartum haemorrhage (including placenta praevia and abruptio placentae), and • prolonged and obstructed labour (i.e. birth complications). These fall within the categories of maternal factors, complications of placenta, cord, and membranes, or birth complications. They are believed to have a direct effect on pregnancy/birth outcome and have been presented as such in the operationalisation of the conceptual model in Chapter 3 (see Figure 3.6). Out of the factors, maternal infections and anaemia are assumed to be more relevant to the earlier stages of the epidemiologic transition. In this, anaemia is regarded as an indicator of a mother’s nutritional status. Conversely, hypertension (pre-existing), diabetes, smoking and alcohol consumption, and advanced maternal age gain importance during later stages of the transition. The relationship of the 296 CHAPTER 9: RISK FACTORS remaining risk factors (i.e. antepartum haemorrhage, and prolonged and obstructed labour) to an epidemiologic or health transition may be unclear. The sections below briefly define, describe, and discuss the selected risk factors. A large part of the information is derived from Cunningham et al. (1993), Treffers et al. (1995)1, Murray and Lopez (1998)2, and Symonds and Symonds (1998). Additional sources were: Roberts et al. (2003) for hypertensive disorders; Moore (1999), and Colhoun and Chaturvedi (2002) for diabetes; Holzel (1993), Klein and Remington (1995), and Gotoff (1996) for infections; Surgeon General (1981) and Rall Chomitz et al. (1995) for smoking and alcohol consumption; Lao and Pun (1996) and Verster (1996) for anaemia; and Berendes and Forman (1991) and Den Ouden et al. (1997) for advanced maternal age. It should be noted that the figures found on the frequency of the risk factors are generally unclear as to whether they refer to prevalence or incidence. Therefore, the indications and denominators used below have generally been copied from the sources where available. 9.2.1 HYPERTENSIVE DISORDERS OF PREGNANCY Hypertensive disorders of pregnancy (HDP) is a group of health problems that all refer to high blood pressure during pregnancy. The classification and definition of HDP are complicated due to lack of conformity between publications. An important distinction is between pregnancy-induced hypertension and pre-existing hypertension. Pregnancy-induced hypertension (PIH) occurs after the 20th week of gestation and regresses within several days after birth. The condition is sometimes also referred to as gestational hypertension. When the hypertension is accompanied by proteinuria (protein in urine) and/or oedema, it has progressed into pre-eclampsia. Pre-eclampsia is generally divided into subcategories on the basis of its severity. However, the condition may develop further into eclampsia. Eclampsia is diagnosed as pre-eclampsia accompanied by convulsions. Without prompt treatment, the condition may result in the death of the woman. In contrast to PIH, pre-existing hypertension is unrelated to pregnancy and is already present before the pregnancy and therefore before 20 weeks of gestation. It is sometimes referred to as chronic hypertension or essential hypertension. It is important to note that, in some cases, pre-existing hypertension is not recognised before pregnancy and that true diagnosis may be masked by the tendency of blood pressure to decrease in early pregnancy (Roberts et al. 2003). Pre-existing hypertension may be aggravated by pregnancy and may result in superimposed pre-eclampsia and/or superimposed eclampsia. The diagnosis of HDP is based on blood pressure measurements, urine testing, and clinical observations of seizures and convulsions. Hypertension is generally diagnosed when systolic blood pressure is greater than or equal to 140 mmHg, or when diastolic pressure is 90 mmHg or above. These values should be measured on at least two occasions several hours apart. Some definitions also include an increase of 30 mmHg or more in the systolic pressure 1 To be more specific, Chapters 10, 11, and 13: by Bennebroek Gravenhorst et al. (1995), by Visser et al. (1995), and by Aarnoudse et al. (1995) respectively. 2 To be more specific, Chapters 4, 6, and 7: by AbouZahr (1998a), by AbouZahr and Guidotti (1998), and by AbouZahr (1998b) respectively. 297 EARLY LIFE CHANGES values or an increase of 15 mmHg or more in the diastolic pressure values. Furthermore, proteinuria is generally defined as the presence of
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