2. 1 Improving Perinatal Outcomes in Zimbabwe: A New Focus on Prematurity Feresu S.A, Gillispie B, Sowers M. F, Johnson T.R.B & Harlow S. D,

3. 2 BACKGROUND TO ZIMBABWE  LOCATION

4. 3

5. 4 BACKGROUND TO ZIMBABWE  CLIMATE AND TERRAIN  POLITICS  POPULATION - 11.8 million  WOMEN OF REPRODUCTIVE AGE- 1,228,442 (20%)

6. 5 ZIMBABWE- GEOGRAPHY

7. 6 ZIMBABWE- ECONOMICS

8. 7 ZIMBABWE - HEALTH INDICATORS 1962-1997

9. 8 ZIMBABWE- HEALTH CONDITIONS

10. 9 ZIMBABWE- HEALTH SERVICES CENTRAL HOSPITALS (5) PROVINCIAL HOSPITALS (10) DISTRICT HOSPITALS (55) RURAL HOSPITALS AND CLINICS

11. 10 HARARE CITY  CAPITAL  POPULATION IN HARARE  -1,219,655  -WOMEN 606,169  -WOMEN OF REPRODUCTIVE AGE 121,234  38 DISTRICTS

12. 11 HARARE- CITY HEALTH  MADE UP OF 23 SATELITE CLINICS AND 2 INFECTIOUS DISEASES HOSPITALS  12 OFFER MATERNITY SERVICES  WORKS WITH GOVERNMENT HEALTH FACILITIES, AND PRIVATE HOSPITALS AND CLINICS

13. 12 HARARE MATERNITY UNIT  OLDEST AND LARGEST REFERRAL HOSPITAL IN ZIMBABWE  UNIVERSITY TRAINING HOSPITAL AND ALSO FOR NURSES  DELIVERS ABOUT 50-60 PER DAY  POPULATION FROM ALL OVER ZIMBABWE  RURAL REFERRALS, BYPASSERS, FEW FROM LOW-DENSITY SUBURBS

14. 13 HMH – ANTENATAL CARE (ANC) OR PRENATAL CARE SERVICES  ANC- TIMING 20, 24, 28, 30, 32, 34, 36 AND WEEKLY THEREAFTER  COVERAGE- HIGH  PROVIDERS MOSTLY MIDWIVES  CARE- BP CHECKS, URINE TESTS FOR ALBUMIN AND SUGAR, WEIGHT  EXAMINATION - FETAL LAY, HEART, FUNDAL SIZE

15. 14 HMH - ANC SERVICES  SCREENING- MEDICAL DISEASES AND OBSTETRIC COMPLICATIONS  TESTS - HB, WR, ABO, RHESUS, URINALYSIS FOR GLUCOSE AND ALBUMIN, AND MICROSCOPY WERE INDICATED  SUPPLIMENTS- IRON, FOLATE, MULTIVITAMINS  PHYSICAL- EXERCISES

16. 15 INTRODUCTION  FETAL OUTCOME IS LINKED TO MATERNAL AND CHILD HEALTH CARE SERVICES IN A GIVEN COUNTRY  PREMATURITY AND LBW ARE IMPLICATED AS CAUSES OF INFANT MORTALITY AND MORBIDITY

17. 16 INTRODUCTION (cont)  THESE CONDITIONS ARE ASSOCIATED WITH MANY RISK FACTORS, WHICH ARE OF REPRODUCTIVE, OBSTETRICAL, MEDICAL, SOCIO-DEMOGRAPHIC AND LIFESTYLE IN NATURE  ANTENATAL CARE ALWAYS AN ISSUE IN DEVELOPING COUNTRIES

18. 17 INTRODUCTION  HOWEVER A FEW STUDIES HAVE EXAMINED THE FREQUENCY OF POOR BIRTH OUTCOMES OR THE DISTRIBUTION OF RISK FACTORS ASSOSIATED WITH THESE CONDITIONS IN ZIMBABWE

19. 18 INTRODUCTION  THIS STUDY IS PART OF SERIES OF STUDIES WE CARRIED OUT IN ZIMBABWE  STUDYI: RECORD REVIEW OF ONE YEAR OF DELIVERIES  STUDYII: THE VALIDATION OF THE BALLARD AND DUBOWITZ METHODS TO ASSESS GESTATIONAL AGE  STUDY III: A CASE CONTROL STUDY OF PREMATURITY

20. 19 INTRODUCTION  THESE STUDIES ARE THE FIRST FOCUSING ON THE EPIDEMIOLOGY OF PREMATURITY AND OTHER POOR BIRTH OUTCOMES IN ZIMBABWE

21. 20 TITLE OF STUDY 1  INCIDENCE, DEMOGRAPHIC AND REPRODUCTIVE RISK FACTORS OF STILLBIRTH, PREMATURITY AND LOW BIRTHWEIGHT IN ZIMBABWEAN WOMEN

22. 21 OBJECTIVES  To assess birth outcomes over a one-year period at Harare Central Hospital Maternity Unit. The major aim was to describe the frequency of adverse birth outcomes including stillbirth, low birthweight and pre-term births at this hospital in Zimbabwe.

23. 22 METHODS  Study Type: Prevalence study on a total of 17,174 births  Period: October 1, 1997 through September 30, 1998  Study Site: Harare Central Hospital Maternity Unit  Data Collection Technique: Abstraction from Birth log Records

24. 23 RISK FACTORS  Demographic risk factors – Mother’s residential area of the mother – the maternal age;  Obstetric risk factors – parity – estimated gestation – birthweight – sex – vital status of the baby – type of gestation – booking status

25. 24 OUTCOMES  1.STILLBIRTH  2. PRE-TERM BIRTH  3. LOW BIRTHWEIGHT BIRTHS (LBW)  4. HIGH BIRTHWEIGHT BIRTHS (HBWT)

26. 25 DEFINITIONS 1. STILLBIRTH: any death of an infant born at 20 or more weeks of gestation, weighing 500 grams or more, who died in utero or within the first hour of life. 2. Pre-term births: a birth occurring before 37 completed weeks of gestation

27. 26 3. LOW BIRTHWEIGHT BIRTHS  LBW:a birth weighing less than 2500 grams irrespective of gestational age  LBW SUB-CATEGORIES  Term LBW:a birth occurring at 37 completed weeks or more of gestation and weighing less than 2500 grams  Pre-term LBW:a birth occurring before 37 completed weeks of gestation and weighing less than 2500 grams.  Very LBW:a birth weighing below 1500 grams at birth.

28. 27 OTHER OUTCOMES 4. Post-term birth - a birth occurring after 44 weeks of gestation 5. High birthweight births  - A birth weighing above 3500 at birth.

29. 28 LBW AND PRE-TERM BIRTHS IUGR PRE-TERM

30. 29 RESULTS  Stillbirth based on 17,174 births  Incidence of stillbirth 61/1000 live births  Pre-term births, LBW & High BWT based on 16,403 births  Incidence of all pre-term births 168/1000 live births  Incidence of LBW 199/1000 live births  Incidence of high BWT 111/ 1000 live births.

31. 30 Low Birthweight Frequencies; based on 16.043 Live births  Incidence of LBW 199/1000  Incidence of IUGR92/1000  Incidence of pre-term LBW108/1000  Incidence of very LBW <1500 grams 34/1000  Incidence of high BWT 111/ 1000 live births.

32. 31 Pre-term birth Frequencies; 16,043 Live Births  Incidence of all pre-term births 168/1000  Incidence of pre-term births  32 weeks 121/1000  Incidence of pre-term births < 32 weeks 47/1000   Incidence of pre-term births 28-32 weeks 31/1000  Incidence of pre-term births < 28 weeks 16/1000  Incidence of post-term births2/1000 live births.

33. 32 Table 1. Distribution of Stillbirth by Demographic and Obstetric Characteristics

34. 33 Table 1 (cont)

35. 34 Table 2. Distribution of Stillbirth by Gestational Age

36. 35 TABLE 3 Adjusted a Relative Risks of Stillbirth by Gestational Age

37. 36 Table 4. Distribution of Stillbirth by Birthweight and Gestational Age Categories

38. 37 TABLE 5. Adjusted a Relative Risks of Stillbirth by Birthweight and Gestational Age

39. 38 FIGURE 1. The Probability of Stillbirth by Gestational Age and Prenatal Care for deliveries at Harare Maternity Hospital, October 1997 to September 1998

40. 39 FIGURE 2.

41. 40 Table 6. Distribution of demographic characteristics by Birthweight  See transparency

42. 41 TABLE 7. Adjusted Odds Ratios of Pre-term births for Live Births by Demographic and Obstetric Characteristics

43. 42 SUMMARY  Lack of antenatal care is associated stillbirth, pre-term births and LBW  Prematurity is the main factor associated with stillbirth  A combination of both prematurity and lack of antenatal care increase risk of stillbirth.  Mothers who did not attend antenatal care and were delivered by Caesarian section were at highest risk of stillbirth

44. 43 ACKNOWLEDGEMENTS – Dr Harlow ; Chair – Dr Sowers – Dr Gillespie – Dr Johnson  Kathy Welch  The University of Michigan  The University of Zimbabwe  Ministry of Health Zimbabwe  Harare Hospital Maternity Unit  My research assistants

45. 44 ACKNOWLEDGEMENTS  FUNDING AGENCIES: – THE W. K KELLOGG FOUNDATION – THE UNIVERSITY OF MICHIGAN – THE UNIVERSITY OF ZIMBABWE – THE MEDICAL ACTURIAL RESEARCH FOUNDATION- ZIMBABWE – THE MICHAEL GELFAND MEDICAL RESEARCH FOUNDATION- ZIMBABWE – DEUSCHE GESELLSCHAFT FUR TECHNISCHE ZUSAMMENARBEIT (GTZ) – ZVITAMBO PROJECT -ZIMBABWE

46. 45 FINAL  THANK YOU  I AM HAPPY TO TAKE QUESTIONS OR MAKE CLARIFICATIONS AFTER WHICH – HAVE A GOOD EVENING