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

Abstract

Background There has been rising concern on the number of maternal and neonatal deaths in Lamu County with no published article on the factors contributing to such poor outcomes. Compounding this problem are the unique features specific to Lamu County: the fact that it is an archipelago, shortage of staff linked to the recent terror attacks, the cultural aspects of Lamu County and the narrow roads as well as sparsity of tarmacked land. This study aimed to evaluate the socio-demographic, economic and cultural factors associated with place of delivery, role of preexisting medical conditions and obstetric emergencies on adverse pregnancy outcomes and to determine if there is any difference in the factors associated with adverse pregnancy outcomes depending on place of delivery i.e. hospital versus non-hospital. The adverse outcomes assessed were: premature deliveries, early onset neonatal sepsis, still births, intra uterine fetal demise (IUFD), maternal death, blood transfusion of 2 or more units, hysterectomy done due to post-partum hemorrhage (PPH) and pregnancy related stroke. Broad objective To determine the factors contributing to adverse pregnancy outcomes following health facility and home deliveries at gestational age of 28 weeks or higher in Lamu County in the year 2017. Methodology: Study design This was a comparative cross sectional study in which factors associated with adverse pregnancy outcomes and place of delivery were determined among 185 facility and 215 home deliveries between February and October 2017 in Lamu County, Kenya in 2017. Study site Hospital setting: post-natal wards of: King Fahad, Faza, Mpeketoni County hospitals, Witu and Kiunga health centers. (All the public hospitals in the County that provide a minimum of basic obstetric care) Home setting: 4 randomly selected divisions; deliveries were traced through community health workers in the area. Study population A community survey of female residents of Lamu County who delivered either at home or in a health facility in the year 2017 at gestation age of 28 weeks or greater. Sample size Using Fleiss formula for comparative cross sectional study; the sample size was approximated to be 400 participants after adjusting for attrition. xiii Data collection A structured questionnaire in line with the study objectives was used. Data analysis Data analysis was conducted using SPSS (IBM version 20). Continuous variables were summarized using means and standard deviations or medians and interquartile ranges for skewed variables. Categorical variables were summarized using counts and proportions and compared between those with and without adverse pregnancy outcomes or home versus facility delivery using Pearson’s chi-square tests or Fisher's exact tests as appropriate. Statistical significance was based on an alpha cut-off level of 0.05.Multivariable analysis was conducted using logistic regression for binary outcomes after adjusting for confounders. Odds ratios and 95% confidence intervals were reported from the multivariable analysis. Significance of the study Since there is no published article on the factors contributing to adverse pregnancy outcomes despite a high MMR and IMR of almost double the national rate. Also home deliveries are more prevalent than health facility deliveries in the County as per K.D.H.S 2014 54 versus 56% respectively. This study will help in identifying the key areas that need dire attention and also act as a baseline research and key indicators for and interventions in the County. Results Between February 2017 and October 2017 we interviewed 400 participants: 185 following a hospital delivery and 215 following a non-hospital delivery. In Lamu County, women that are more likely to deliver at home are: older (≥30yrs), with a prior normal vaginal delivery, multiparous (>3), with a low level of education and a low level of income. The overall prevalence in adverse outcomes did not differ statistically between women who had a hospital or a non-hospital delivery. However, occurrence of severe PPH with transfusion of two or more units of blood in the index pregnancy, was almost twice more common following a home delivery (54.5% Vs 23.3% P 0.014). Also, obstetric emergencies (OR 19.94, 95% CI 9.47-41.98, P 0.001), pre-existing medical conditions like hypertension (OR 12.53, 95% CI 4.12-38.09, P 0.001), diabetes, anemia and epilepsy ( OR 11.07, 95% CI 3.57-34.27, P <0.001), social characteristics like teenage pregnancies and single parenthood, distance to the nearest health facility of >5Km ( OR 3.63, 95% CI 1.27-10.38, P 0.016) ; were associated with adverse maternal and perinatal outcomes. Conclusion: In Lamu County, a home delivery was more common among women who were: older (≥30yrs), with a prior normal vaginal delivery, multiparous (>3), low education and income level. Contributors to adverse outcomes were: obstetric emergencies, pre-existing medical conditions like hypertension, diabetes, anemia and epilepsy, social characteristics like teenage pregnancies, single parent-hood and distance to the nearest health facility of >5kms. Interventions to reduce adverse outcomes should focus on: education on need for hospital delivery, upgrading of health centers to provide comprehensive obstetric care, as well as working with traditional birth attendants to act as ambassadors in referring patients in labor to deliver in a hospital setting.