TY - JOUR
T1 - Malpresentation in low- and middle-income countries
T2 - Associations with perinatal and maternal outcomes in the Global Network
AU - the NICHD Global Network for Women's and Children's Health Research
AU - Duffy, Cassandra R.
AU - Moore, Janet L.
AU - Saleem, Sarah
AU - Tshefu, Antoinette
AU - Bose, Carl L.
AU - Chomba, Elwyn
AU - Carlo, Waldemar A.
AU - Garces, Ana L.
AU - Krebs, Nancy F.
AU - Hambidge, K. Michael
AU - Goudar, Shivaprasad S.
AU - Derman, Richard J.
AU - Patel, Archana
AU - Hibberd, Patricia L.
AU - Esamai, Fabian
AU - Liechty, Edward A.
AU - Wallace, Dennis D.
AU - McClure, Elizabeth M.
AU - Goldenberg, Robert L.
N1 - Funding Information:
Using the Global Network for Women's and Children's Health Research's prospective, multi-country, population-based maternal-newborn registry of pregnancy outcomes from 2010 to 2016, we analyzed outcomes by presentation and mode of delivery in singleton pregnancies. The Global Network's Maternal and Newborn Health Registry (MNHR) is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Investigators at seven rural or semi-urban sites in six LMIC (India [two sites, Nagpur and Belagavi], Pakistan, Guatemala, Zambia, Kenya, Democratic Republic of Congo) oversee the MNHR. The Democratic Republic of Congo site initiated enrollment in the MNHR in 2014, whereas all other sites began enrollment prior to 2010. The methods of the MNHR have been previously described. In brief, this prospective registry began in 2008 to record pregnancy services and outcomes in low-resource settings where quality health records are often lacking. The MNHR aims to capture all pregnant women in well-defined geographic clusters and follows their care and pregnancy outcomes through to six weeks postpartum. Each of the seven study sites comprises between eight and 20 communities with approximately 300-500 births annually within the catchment area of a primary healthcare center. The MNHR employs a local registry administrator for each community who, with the aid of local leaders and healthcare providers, seeks to enroll every pregnant woman in their area by 20 weeks, gestation. Every pregnant woman who lives in the community is eligible, regardless of whether she delivers at home or in a health center or hospital. Each participant must provide informed consent for study participation prior to enrollment. In total, the MNHR tracks approximately 60 000 pregnancies per year. For the purposes of the current analyses, pregnancies were excluded from analysis if a miscarriage or medical termination of pregnancy occurred, if a maternal death occurred prior to labor and delivery, if the pregnancy was multiple (including twins and triplets) or if information on fetal presentation or mode of delivery was not available. Gestational age at delivery was characterized as term (≥37 weeks’ gestation) or preterm (<37 weeks’ gestation) according to the best gestational age estimate. Stillbirth was defined as birth of a fetus greater or equal to 20 weeks, gestation with no apparent signs of life such as breathing, crying, heartbeat or movement. Our data collection instrument did not distinguish between breech presentations and other malpresentations, such as transverse or oblique lie. We used the terms malpresentation and non-cephalic presentation synonymously. Other outcomes and covariates were consistent with World Health Organization definitions. This analysis included descriptive statistics and relative risks of adverse perinatal and maternal outcomes associated with malpresentation compared with cephalic presentation at the time of delivery. We hypothesized that perinatal outcomes would be worse among pregnancies with malpresentations at the time of delivery. Our primary outcomes were stillbirth and neonatal mortality. Secondary outcomes included maternal morbidity and some procedures (postpartum hemorrhage, dilation and curettage, hysterectomy and unplanned hospitalization) and maternal mortality. These outcomes were analyzed overall, as well as by geographic region (India [two sites], Pakistan [one site], Guatemala [one site] and Africa [three sites]). The decision to combine the two Indian study sites and to combine the three African study sites was undertaken after review of site-specific data which yielded overall similar outcomes among the two Indian sites and then the three African sites. This both allowed for larger numbers in the analyses, as some outcomes by site were small, and for less cumbersome tabular presentation of the data. We examined outcomes stratified by gestational age and mode of delivery adjusted for each geographic region. We estimated the risk of stillbirth, neonatal mortality, and postpartum hemorrhage associated with malpresentation after adjusting for relevant confounders using Robust Poisson regression analysis. Finally, we examined rates and trends in cesarean delivery for pregnancies with malpresentation by geographic region and year. The indication for cesarean delivery was only available for a portion of the study period, from 2010 to 2013, and was therefore not included in our regression analysis. All analyses were performed using SAS v.9.4 (SAS Institute, Cary, NC, USA). The appropriate institutional review boards or ethics research committees of participating centers approved the MNHR. Data were collected, edited and entered into research computers locally at each study site and transmitted securely to a central data-coordinating center (RTI International) for further central editing and analyses. An independent data monitoring committee, appointed by the NICHD, oversees and reviews the study semi-annually.
Publisher Copyright:
© 2018 Nordic Federation of Societies of Obstetrics and Gynecology
PY - 2019/3
Y1 - 2019/3
N2 - Introduction: Uncertainty exists regarding the impact of malpresentation on pregnancy outcomes and the optimal mode of delivery in low- and middle-income countries. We sought to compare outcomes between cephalic and non-cephalic pregnancies. Material and methods: Using the NICHD Global Network's prospective, population-based registry of pregnancy outcomes from 2010 to 2016, we studied outcomes in 436 112 singleton pregnancies. Robust Poisson regressions were used to estimate the risk of adverse outcomes associated with malpresentation. We examined rates of cesarean delivery for malpresentation and compared outcomes between cesarean and vaginal delivery by region. Results: Across all regions, stillbirth and neonatal mortality rates were higher among deliveries with malpresentation. In adjusted analysis, malpresentation was significantly associated with stillbirth (adjusted relative risk [aRR] 4.0, 95% confidence interval [CI] 3.7-4.5) and neonatal mortality (aRR 2.3, 95% CI 2.1-2.6). Women with deliveries complicated by malpresentation had higher rates of morbidity and mortality. Rates of cesarean delivery for malpresentation ranged from 27% to 87% among regions. Compared with cesarean delivery, vaginal delivery for malpresentation was associated with increased maternal risk, especially postpartum hemorrhage (aRR 5.0, 95% CI; 3.6-7.1). Conclusions: In a cohort of deliveries in low- and middle-income countries, malpresentation was associated with increased perinatal and maternal risk. Further research is needed to determine the best management of these pregnancies.
AB - Introduction: Uncertainty exists regarding the impact of malpresentation on pregnancy outcomes and the optimal mode of delivery in low- and middle-income countries. We sought to compare outcomes between cephalic and non-cephalic pregnancies. Material and methods: Using the NICHD Global Network's prospective, population-based registry of pregnancy outcomes from 2010 to 2016, we studied outcomes in 436 112 singleton pregnancies. Robust Poisson regressions were used to estimate the risk of adverse outcomes associated with malpresentation. We examined rates of cesarean delivery for malpresentation and compared outcomes between cesarean and vaginal delivery by region. Results: Across all regions, stillbirth and neonatal mortality rates were higher among deliveries with malpresentation. In adjusted analysis, malpresentation was significantly associated with stillbirth (adjusted relative risk [aRR] 4.0, 95% confidence interval [CI] 3.7-4.5) and neonatal mortality (aRR 2.3, 95% CI 2.1-2.6). Women with deliveries complicated by malpresentation had higher rates of morbidity and mortality. Rates of cesarean delivery for malpresentation ranged from 27% to 87% among regions. Compared with cesarean delivery, vaginal delivery for malpresentation was associated with increased maternal risk, especially postpartum hemorrhage (aRR 5.0, 95% CI; 3.6-7.1). Conclusions: In a cohort of deliveries in low- and middle-income countries, malpresentation was associated with increased perinatal and maternal risk. Further research is needed to determine the best management of these pregnancies.
KW - breech presentation
KW - cesarean section
KW - developing countries
KW - labor presentation
KW - obstetric delivery
KW - pregnancy outcomes
UR - http://www.scopus.com/inward/record.url?scp=85058860177&partnerID=8YFLogxK
U2 - 10.1111/aogs.13502
DO - 10.1111/aogs.13502
M3 - Article
C2 - 30414270
AN - SCOPUS:85058860177
SN - 0001-6349
VL - 98
SP - 300
EP - 308
JO - Acta Obstetricia et Gynecologica Scandinavica
JF - Acta Obstetricia et Gynecologica Scandinavica
IS - 3
ER -
