Pregnancy outcome and mortality patterns among women in Cape Verde

Abstract

Objective: To evaluate pregnancy outcome, risk factors for pregnancy complications, genital infections among pregnant women, health seeking behavior and causes of deaths among women of reproductive age in a low income country.

Methods: Risk factors and pregnancy outcomes were studied prospectively in a cohort comprising 8% of all pregnant women registered for antenatal care (ANC) in the county of Praia, Cape Verde. The specific maternal and fetal risk factors for perinatal death were assessed in an area-based case-control study in the same area. In a cross-sectional survey, 350 subjectively healthy pregnant women in the Praia county were examined to assess the prevalence of Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT) and Bacterial vaginosis. Different laboratory techniques, including PCR method, were used to detect CT and NG. Sociodemographic risk factors for genital infections were investigated. Through verbal autopsy lay persons were interviewed regarding the perceived causes and contributing factors of a death of a family member or friend. Thereby, and using hospital data when available, the cause of death of fertile age women was assessed, and the theoretical avoidability estimated. This study comprised 80% of the Cape Verde's female population.

Results: Adverse outcome complicated 32% of the pregnancies, low birth weight (LBW) 9%, and preterm birth 13%. Alleged risk factors were registered in 74% of all pregnancies, high risk factors in 9%. Eighty-three percent of the affected, and 70% of the unaffected pregnancies, had presented risk factors. Young age, nulliparity, and previous LBW infant associated significantly with LBW. Previous hypertension and seizures related to preterm birth. The perinatal mortality rate was 37-46 per 1,000 births. First pregnancy, previous hypertensive disease, previous perinatal death, pre-eclampsia, breech delivery, male infant, and postpartum maternal fever were significantly associated with perinatal death. The detection rates of NG, CT, and BV were 5%, 13% and 31%, respectively. PCR technique yielded higher detection rates than did microscopy and culture (NG), or direct immuno-fluorescence (CT). Young age and currently living alone were significant risk factors for infection. Common diagnoses among deceased fertile age women were cardiovascular disorders, external causes, maternal causes, infectious diseases and neoplasms. The maternal mortality ratio (MMR) was 127 per 100,000 live births. The vast majority of severely ill female patients were treated at the appropriate health service level, but 17% delayed their arrival to a health facility intentionally.

Conclusions: The studied ANC risk classification is not effective. Several significant risk factors were demonstrated, but the sample sizes prohibited the assessment of rare risk factors. Preterm births, postpartum maternal fever and high prevalence of chlamydial genital infection raise suspicions of widespread genital infections in the pregnant population. Routine genital examinations of pregnant women, and laboratory facilities for CT detection are recommended. The MMR was three times higher than estimated, due to misclassification. Future surveys on maternal deaths need to investigate all female deaths in the reproductive ages. Traffic accidents and gender violence are public health matters of importance. Interventions addressing the quality of emergency and intensive care units are needed.