A risk assessment for pregnancy using the World Health Organization classifying form in primary health-care facilities in Enugu,Nigeria

Introduction

Early identification of women at risk of obstetric complications and prompt intervention remain the cornerstone of good obstetric practice. Risk assessment in antenatal care attempts to identify women with a higher than normal risk of developing obstetric complications. In communities with limited resources and poor logistics, such as those in developing countries, early identification of such parturients allows for timely referral to centres that can provide adequate care. Early referral often determines the difference between maternal survival and mortality. Poor pregnancy outcomes in developing countries are closely related to poor antenatal care and late referral of women with complications in pregnancy. ^1–3 Nigeria has a very high rate of maternal mortality and severe morbidity, with women who are unbooked having the worst prognosis. ^3,4 The World Health Organization (WHO) developed a screening tool, the classifying form, for excluding women at high risk from the basic component of the focused antenatal care programme and, consequently, primary health care. ⁵ The WHO classifying form was used in this study to examine the risk pattern of women attending antenatal care in maternity homes in Enugu, southeastern Nigeria and the influencing factors.

Patients and methods

This was a cross-sectional study carried out among parturients in maternity homes. Of the twenty registered with the Enugu state Health Management Board, 10 maternity homes in Enugu (the capital of Enugu state, southeastern Nigeria) were randomly selected. The minimum sample size was calculated using the formula p × q/(SE), ² where p = prevalence, q = 100−p and SE = sampling error tolerated. ⁶ Using a prevalence of 50% and sampling error of 5%, the minimum sample size required was 100. Three hundred parturients were studied in order to attain a better representation of each maternity home. The first 30 consenting parturients were surveyed while waiting to be attended to by midwives in each selected maternity home between March and September 2004. The survey was with a pretested interviewer administered questionnaire adapted from the WHO classifying form. The questionnaire had sections on biostatistical data, past obstetric history, medical and surgical history and the history of the current pregnancy. The ante natal records were reviewed and results of investigations documented. Adaptations made to the classifying form in order to facilitate the study were the inclusion of all types of caesarean section in the high-risk category due to the lack of accurate operation details, and the expansion of the information in the biostatistical data in order to comply with the survey. Medical students specially trained for the survey administered the questionnaires.

Data entry and analysis were done using the Epi-info statistical software program version 5 (Center of Disease Control, Atlanta, USA). The chi-square test was used for testing the statistical significance. The statistical significance was considered present at P value of ≤0.05.

Results

None of the selected maternity homes had a standard risk screening tool. Two hundred and ninety-nine women were studied as only twenty-nine parturients could be recruited within the study period in one of the selected maternity homes. The age of the parturients ranged from 16 to 42 years with a mean of 27.8 ± 6.7 years. Table 1 shows the distribution of age, religion, educational attainment and parity of the women surveyed. Eighty-eight (29.4%) parturients were nulliparous, 160 (53.5%) were multiparous and 51 (17.1%) were grandmultiparous. The majority of the women (93.6%) were Christians. Most (52.5%) had only received a primary school education.

One hundred and twenty (40.1%) women were not qualified for antenatal care at the primary health-care level using the classifying form. Table 2 shows the distribution of high-risk pregnancies among the women surveyed. The most common risk factor in the 120 women in the high-risk category was their being in the Rhesus D-negative blood group – 42 (35.0%) parturients. A Rhesus negative blood group was combined with a previous history of child loss, a previous caesarean section and multiple pregnancies in 10 of the 42 women. A previous perinatal death was reported by 27 (11.8%) women in the high-risk category, while multiple pregnancy occurred independently in 11 (4.8%). Other high-risk factors were hypertension (7.5%), symptomatic heart disease (3.3%) and diabetes mellitus (2.5%).

Table 3 shows the frequency of high-risk pregnancies in relation to the maternal age, parity and educational attainment. There was a significant relationship between high-risk pregnancy, maternal parity and age (P < 0.05). The attainment of a secondary school education or above did not reduce the frequency of high-risk pregnancies. Significantly more women with at least a secondary education were high risk when compared with those had received a lower education.

Discussion

Maternal risk in pregnancy involves the probability of death or experiencing serious complications as a result of the pregnancy or childbirth. ⁷ About two decades after the Safe Motherhood Initiative was launched in Kenya in 1987, maternal mortality and severe morbidity remain high in developing countries. ^2,4,8 Risk screening during antenatal care identifies any predisposing factors for obstetric complications and allows for the institution of appropriate preventive measures. Although it is true that every pregnant woman faces risks in pregnancy, some obstetric conditions are often associated with higher rates of poor maternal and perinatal outcomes as well as the need for surgical intervention.

The effectiveness of antenatal risk screening in ensuring the rational use of maternity services and the prevention of maternal deaths has previously been questioned. ^7,9 A review conducted in 1992 by WHO's maternal health and safe motherhood research programme concluded that risk screening failed to achieve these objectives. ⁹ Risk assessment tools commonly used at that time relied mostly on sociodemographic and physical characteristics in order to classify women. ⁵ These characteristics were not necessarily indicative of obstetric complications. The classifying form used in this study is based on well-established obstetric risk factors and weighs all the risk factors equally. A limitation of the equal weighting of risk factors is the possible over inclusion of women into the high-risk category.

Using the form, 40.1% of the women surveyed in this study were high risk and so ineligible for antenatal care at the primary health-care level. Very serious high-risk conditions were seen, sometimes even in combinations, in the women. Parturients with multiple pregnancies, pre-eclampsia and diabetes mellitus were attended to in the maternity homes. Women with medical diseases in pregnancy, a previous caesarean section, teenage pregnancy and other similar high obstetric risk conditions are without doubt best managed in centres with multidisciplinary specialist care services and facilities allowing easy recourse to surgical delivery. It is obvious that not all parturients will have access to a secondary or tertiary hospital delivery in most developing countries. ^10,11 Furthermore, in many developing countries women are reluctant to seek antenatal care outside their immediate community, as transportation facilities are poor and travelling at night can be dangerous. Therefore, women with high-risk pregnancies should be encouraged to have planned deliveries. Many of such parturients, if adequately motivated, are able to stay with extended family members who reside close to specialist centres, or in shelters where available, as they get close to term.

The older, more parous women disregarded their high-risk status and remained in maternity homes in this study. High-risk conditions were surprisingly more common in women with at least a secondary school education than in those with a poorer education. Secondary school education is generally seen to improve the utilization of maternity services. ^12,13 In sub-Saharan Africa the effect of secondary education on maternal services utilization has been noted to be much less than in other developing areas. ¹⁴ This seems to be corroborated by the findings in this study. It appears that previous experience, rather than formal education, was the more important factor in determining where to receive maternity services among the women studied.

The outcome of this study illustrates the pattern of obstetric risk factors seen at the primary health-care level in a region where standardized antenatal risk screening is not routinely practiced. The importance of risk assessment at the primary health-care level in order to avoid preventable morbidity and mortality cannot be over-emphasized. Such screening should be followed by the proper counselling of women in the high-risk category. The willingness of identified women to use the referral hospital determines the extent of success in antenatal care programmes based on risk screening. ¹⁵

The institution of effective antenatal risk screening requires an acceptance of the practice, motivation of local care providers and the updating of their knowledge of the prevalent statistics resulting from obstetric complications and poor obstetric care in their locality. Apart from adequate motivation, close supervision and appropriate sanctions may be needed. Prereferral counselling is essential in order to enhance the patient's compliance and reverse the false confidence arising from presumptive experience in child bearing among women of higher parity.