Monitoring pregnancy for improved perinatal outcome in Mozambique

The general aim was to monitor pregnancy for improved perinatal outcome in Mozambique. A cohort of 817 Mozambican pregnant women were followed from their first antenatal clinic visit to the end of the perinatal period in two suburban/semirural antenatal clinics in Maputo. Nine percent were lost to follow-up. This cohort was used for anthropometric monitoring of fetal growth to enable the drawing of an SFD growth chart. When selecting sub-populations, nulliparous women were found to lie 0.6 cm below multiparous women. Women with or without overt morbidity showed no difference in the SFD growth charts. Women with BMI <19 and women with BMI >27 had approximately I cm lower and I cm higher curves, respectively, than women with normal BMI.

Enhancement of the sensitivity for detecting SGA was possible by adjustments for parity and midupper- arm-circumference, but at the expense of reducing the specificity. The sum of the sensitivity and specificity is almost the same (116 % and 115%, respectively). Mathematically, by using the linear function for optimal adjustment of the enhancement of sensitivity, the latter was improved to 70 % with specificity of 59 % and sum 129 %. It may be argued that this formula has mere academic interest. It shows however that there is a possibility to enhance the sensitivity and specificity by adjustments.

The same obstetric cohort was followed until the 7th day post-partum to elucidate perinatal outcome. The main outcome variables were LBW, preterm delivery, intrauterine fetal death, perinatal death and being small for gestational age. Low maternal weight, low weight gain during pregnancy and not having a living child were risk factors for LBW. Low weight gain during pregnancy and malaria in the perinatal period were risk factors for preterm birth. Perinatal death occurred in 5.4% and 9.7% delivered SGA newborns. The obstetric cohort monitored provided valuable baseline data to be used as reference.

To create an alternative syphilis screening among pregnant women two antenatal clinics were nominated "control" clinics and two "intervention" clinics and were compared regarding syphilis screening and treatment. A total of 929 pregnant women with positive RPR test were enrolled. In control clinics the normal routine regarding syphilis screening was adhered to. In intervention clinics the nurse/midwives performed on-site RPR test. The seropositive cases were immediately treated and the partners were invited to come any afternoon for treatment. The number of perinatal deaths was significantly higher in the control group than in the intervention group. The seroconversion results at delivery show that the intervention group had significantly more negative RPR results.

In a case control study in the maternity of Central Hospital in Maputo regarding the risk of gestational diabetes among women suffering late fetal death we found a high prevalence of GDM, 11.0 % in the group with fetal death and 7.1 % in the referent group. The high prevalence of GDM in our study is of great concern, as we know that the prevalence of infectious diseases, mainly HIV, hepatitis, tuberculosis, malaria and syphilis, is high and complex among pregnant Mozambican women. There are reasons to believe that GDM could be a risk factor in ascending intrauterine infections. Filter strip test of HbA1c, adapted to low income countries without refrigerators, together with proper diabetes education, may be the most appropriate and cost-effective way of monitoring of GDM.

Sulfadoxine-pyrimethamine given as treatment dose to adolescent pregnant women at the first antenatal clinic visit and again at the beginning of the third trimester was highly effective in reducing malaria infection in the mothers and their placentas. With this treatment there were few side effects, and no serious ones, and it was a cost-effective way to prevent placental malaria and malariaassociated fetal and maternal morbidity.

List of scientific papers

I. Challis K, Osman NB, Nystrom L, Nordahl G, Bergstrom S (2002). Symphysis-fundal height growth chart of an obstetric cohort of 817 Mozambican women with ultrasound-dated singleton pregnancies. Trop Med Int Health. 7(8): 678-84.
https://pubmed.ncbi.nlm.nih.gov/12167094

II. Challis K, Bique Osman N, Cotiro M, Nordahl G, Bergstrom S (2002). "The impact of adjustment for parity and mid-upper-arm circumference on sensivity of symphysis-fundus height measurements to predict SGA fetuses in Mozambique." Trop Med Int Health (Accepted)

III. Osman NB, Challis K, Cotiro M, Nordahl G, Bergstrom S (2000). Maternal and fetal characteristics in an obstetric cohort in Mozambique. Afr J Reprod Health. 4(1): 110-9.
https://pubmed.ncbi.nlm.nih.gov/11000714

IV. Osman NB, Challis K, Cotiro M, Nordahl G, Bergstrom S (2001). Perinatal outcome in an obstetric cohort of Mozambican women. J Trop Pediatr. 47(1): 30-8.
https://pubmed.ncbi.nlm.nih.gov/11245348

V. Bique Osman N, Challis K, Folgosa E, Cotiro M, Bergstrom S (2000). An intervention study to reduce adverse pregnancy outcomes as a result of syphilis in Mozambique. Sex Transm Infect. 76(3): 203-7.
https://pubmed.ncbi.nlm.nih.gov/10961199

VI. Challis K, Melo A, Bugalho A, Jeppsson JO, Bergstrom S (2002). Gestational diabetes mellitus and fetal death in Mozambique: an incident case-referent study. Acta Obstet Gynecol Scand. 81(6): 560-3.
https://pubmed.ncbi.nlm.nih.gov/12047312

VII. Challis K, Bique Osman N, Cotiro M, Nordahl G, Dgedge M, Bergstrom S (2002). Impact of a double dose of sulfadoxine-pyrimethamine to reduce the prevalence of pregnancy malaria in southern Mocambique. [Submitted]