Maternal Morbidity Study

2007 - 2008

Study Team:

Dr. Ahmad QutaitatDr. Abdalmalik Abdalmalik

Dr. Isam Shraideh

Dr. Ahmad AlghweeryDr. Hiam Alnashash

Funded:UNFPA

- Jordan’s Total Population : 5.924.312

- Female in Reproductive Age(15 – 49) year 1,423,000

- Family Size : 5.4

- Total Fertility Rate: 3.6

- Maternal Morbidity Rate : 41/ 100.000

Any ill health resulting from or aggravated by pregnancy,

labor and post partum.

Any departure, subjective or objective from a state of

physiological or psychological well-being

(during pregnancy, child birth and the post partum period up to 42

days).

Assessment of the magnitude of the problem.

Monitor progress and assess the effectiveness of

interventions and programs.

Identify underlying causes and risk factors of

maternal morbidity.

1. To determine the overall incidence of maternal morbidity.

2. To identify the spectrum of maternal morbidity and the incidence of

the main diseases and complications.

3. To identify possible discrepancies among the three regions and

different health sectors.

4. To assess potential risk factors and predictors of maternal morbidity

such as parity age, educational level and employment status

5. To explore potential limitations in providing in health care delivery.

6. To report on the incidence and complications of miscarriage.

Design of the study

Sample of the study

Study Tool

Field work methodology

Design of the study:

1. The study is a prospective cohort study through the use of

detailed questionnaire follow-up on the study samples.

2. A number of health disorders related to pregnancy, delivery

and post partum were specified.

Sample of the study:

Target population is pregnant women, since the beginning of pregnancy, within the first 21 weeks of pregnancy.

◦ The estimated pregnant number of women in Jordan per year is (200000).

◦ The size of the sample statistically represented is between(5-10 %).

◦ 5500 study questionnaires were distributed and 4865 were collected back.

◦ 4501 of questionnaires fulfilled the conditions of the study and 364 (6.6%) did not comply with the conditions of the study.

MOH

48%

R.M.S

24%

Private and

UNRWA

27%

University of

Jordan

1%

Sample distribution by health sector

34.5

7.2

19.8

0.5

15.5

3.6

0.6

89.2

4.4

1.22.8

0

5

10

15

20

25

30

35

40

Amman Balqa Zarqa Madaba Irbid Mafraq Jarash Ajloon Karak Tafela Ma’an Aqaba

Middle North South

%

An integrated questionnaire to meet the objectives of the study was

classified as sections:

i. Health biography of respondent.

ii. Data on sickness suffered during previous pregnancies and last one.

iii. Follow-up sample on current pregnancy.

iv. Data on the current pregnancy complications.

v. Data on the current delivery.

vi. Data on complications during current delivery 1st 2nd and 3rd stage

vii. Data on post partum period which also includes data on breast feeding

and information on the new born.

Study Tool:

Field work teams were trained to the methodology of this study to

achieve a standardization:

MOH 35 obstetricians / gynecologist

8 family medicine and general

doctors.

R.M.S 18 obstetricians /gynecologists

Private 15 obstetricians /gynecologists

University of Jordan 2 obstetricians / gynecologists

UNRWA 2 obstetricians /gynecologists

Field work methodology:

Research team has set a date for the launch of random samples

starting at 15.1.2007 – lasting for 4 months.

Pregnancy cases registered should not be more than 21weeks.

Registrations of cases ended on 15.4.2007.

January 2008 has been set as the time for completion of the field

study.

Field work methodology:

A period of 40 days was needed for the collection of the

completed questionnaires.

A programming expert has been assigned to prepare a

computer program to respond to the nature of the study and

special codification, date entry (CSPro)

Total morbidity during current pregnancy, labor

and postpartum

0

10

20

30

40

50

60

70

Pregnancy Labor Postpartum Overall

%

Anemia during current pregnancy based on

hemoglobin measurement at the first visit:

20.1%

5.9%

Hb < 11 gm/dl Hb < 10 gm/dl

Morbidity N Percent

Urinary tract infections 908 20.2

Vaginal infections 872 19.4

Anemia 492 10.9

Early bleeding 268 6

Hypertension 264 5.9

Gestational diabetes 136 3

Pre-eclampsia 118 2.6

Late bleeding 78 1.7

Multiple pregnancy 72 1.6

Kidney diseases 57 1.3

Thyroid disorders 38 0.8

Disseminated intravascular coagulopathy 30 0.7

Heart disease 13 0.3

Others 93 2.1

Any morbidity 1861 41.3

Variable First stage Second stage Either stage

N % N % N %

Hypertension 137 3.4 89 2.2 145 3.6

Uterine hemorrhage 90 2.2 32 0.8 99 2.4

Seizure and coma 4 0.1 3 0.1 6 0.1

Uterine rupture 1 0.0 0 0.0 1 0.0

Other 19 0.5 6 0.1 22 0.5

Intrapartum complications of current pregnancy 1st & 2nd stage:

Variable N Percent %

Uterine hemorrhage 191 4.7

Retained placenta 52 1.3

Serious vaginal lacerations 33 0.8

Urinary injury 9 0.2

Others 13 0.3

Intrapartum complications of current pregnancy 3rd stage:

Variable N Percent %

Pre-eclampsia 102 2.5

Severe anemia 94 2.3

Clotting disorder 9 0.2

Deep vein thrombosis 7 0.2

Pulmonary thrombosis 5 0.1

Renal failure 1 0.0

Liver failure 1 0.0

Others 23 0.6

General complications of current labor & delivery:

Morbidity N Percent %

Anemia 313 7.7

Gynecological inflammations 269 6.6

Breast engorgement 247 6.1

Hypertension 122 3

Bleeding 84 2.1

Psychological problems 54 1.3

Deep vein thrombosis 5 0.1

Others 47 1.2

Any morbidity 756 18.7

Complications during post partum:

Public

76%

Private

23%

Others

1%

Spontaneous

vaginal

69%

Vaccum

or forceps

3%

Caesarean

28%

Method of Delivery

Information on current delivery:

Place of Delivery

Information on current delivery… cont’.

26.30%

5.80%

Hb < 11 gm/dl Hb < 10 gm/dl

Anemia measured at delivery

Main reasons for cesarean section:

27.7

18

13.6

10.3

5.1

4.6

3.1

2.2

1.5

1.3

1.2

0.9

0.9

0.7

0.5

5.4

2.7

0 5 10 15 20 25 30

More than one previous Cesarean section

Malpresentation

Fetal distress

Failure of progress in labor

Multiple pregnancy

Pre-Eclampsia

Post-date pregnancy

Cephalopelvic disproportion

Antepartum hemorrhage

Prolapsed umbilical cord

Large baby

Placenta previa

Patient request

Early separation of the placenta

Previous Myomectomy

Others

Missing

•Percent

Reason for admission N Percent %

Spontaneous bleeding 245 70.2

Induction of missed abortion 83 23.8

Others 21 6

Total 349 100

Reasons and complication of miscarriage:

Complication N Percent %

Impaired clotting 18 5.2

Severe bleeding 5 1.4

Pelvic inflammatory disease 1 0.3

Cervical lacerations 1 0.3

Retained tissue that needed re-evacuation 1 0.3

None 323 92.6

Total 349 100

Complication of current miscarriage :

Variable MoH RMS Private sector P –

Value

Pregnancy morbidity % 41.5 73.2 39.4 0.167

Intrapartum morbidity % 38.7 33 29.3 0.000

Postpartum morbidity % 18.8 19 18.1 0.845

Overall morbidity 65.4 54.2 59.8 0.000

Comparison between different health sectors in any

morbidity during pregnancy labor and postpartum:

Variable Middle North South P-

Value

Pregnancy morbidity % 41.2 31.5 53.2 0.000

Intrapartum morbidity % 32.6 40.5 34.1 0.001

Postpartum morbidity % 16.8 15.1 29.3 0.000

Overall morbidity 61.7 55.1 64.2 0.000

Comparison between different regions in any morbidity

during current pregnancy, labor and postpartum

Variable Morbidity P – Value

Age

<20

20-29

30-39

40-49

61.5

58.4

63.3

69.7

0.004

Education of woman

Illiterate

< Secondary

Secondary +

68.3

64.7

58.6

0.000

Employment

Employed

Not employed

56.9

61.9

0.004

Gestational period at enrollment

<8 weeks

8 -15

16 +

61.6

63.1

57.7

0.006

Overall morbidity of current pregnancy labor

& postpartum by selected variables

Variable Morbidity P – Value

Education of husband

illiterate

< Secondary

Secondary +

70.6

64

58.3

0.000

Parity

0

1-3

4+

59.4

59.2

67

0.000

Mode of current delivery

spontaneous

vacuum or forceps

breech

cesarean section

56.4

69.8

87

63.1

0.000

Overall morbidity of current pregnancy labor &

postpartum by selected variables….Cont.

Variable Adjusted Odds Ratio P – Value

Number of births

O

1-3

4+

1

1.14

1.76

0.000

0.129

0.000

Region

middle

north

south

1

1.41

1.03

0.001

0.000

0.734

Mode of delivery

spontaneous

vacuum of forceps

breech

cesarean section

1

1.31

0.66

1.32

0.004

0.202

0.425

0.001

Education

illiterate

less than secondary education

secondary +

1

0.89

0.71

0.009

0.620

0.140

Factors independently related to intrapartum maternal morbidity

of current pregnancy using multivariate logistic regression:

Predictors of morbidity observed in the study:

◦ Parity

◦ Education

◦ Mode of delivery

◦ Cesarean Section …30% in morbidity

◦ Number of follow-up visits

The most important single findings was the sharp rise of Cesarean Sections.

Further exploration regarding reasons of observed lower intrapartum morbidity in the

private sector

Need to study factors responsible for observed higher intrapartum morbidity in the north

region.

As parity >3 was a significant predictor of pregnancy and intrapartum morbidity, efforts

of family planning should be promoted by all means.

An in depth study of urinary and genital infections during pregnancy is needed.