|Year : 2019 | Volume
| Issue : 2 | Page : 35-41
Effect of gestational age at booking on feto-maternal outcome at a Nigerian tertiary hospital
J Zaman1, DA Isah2, AY Isah2
1 Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja, Nigeria
2 Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital; Department of Obstetrics and Gynaecology, College of Health Sciences, University of Abuja, Abuja, Nigeria
|Date of Submission||02-Nov-2018|
|Date of Decision||12-Dec-2018|
|Date of Acceptance||03-Apr-2019|
|Date of Web Publication||20-Jan-2020|
D A Isah
Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital/College of Health Sciences, University of Abuja, Abuja
Source of Support: None, Conflict of Interest: None
Background: Antenatal care (ANC) is one of the pillars of safe motherhood initiative aimed at preventing adverse pregnancy outcome. Early initiation of ANC may provide avenue for early identification and management of many medical illnesses in pregnancy with the resultant better feto-maternal outcome. The objective of the study was to determine the average gestational age (GA) at booking and to determine the effect of GA at booking on the feto-maternal outcome. Materials and Methods: This was a prospective cohort study of 414 women consecutively recruited at the booking clinic of the Teaching Hospital from September 2016 to July 2017. This was divided into two arms, early and late booking. However, only 186 and 189 women in the early and late booking women, respectively, completed the study and their data were available for analysis, and they were followed up to delivery. Results: The mean GA at booking in the study was 19.4 ± 8.14 weeks. The incidence rate of low-birth-weight was 8.3%. The recorded incidence rate of low-birth-weight of 7.8% among early attendees was similar to 8.8% recorded among those that booked late in pregnancy (P = 0.373). The overall stillbirth rate in this study was 29.33/1000 birth. The cumulative incidence of hypertensive disorders in pregnancy in the study was 12.8%. The overall mean packed cell volume (PCV) at booking was 33.6 ± 3.2 and similar to the respective PCV at booking in both early and the late booking women. The PCV at delivery was, however, significantly higher among those women that booked early when compared with those that booked late. Conclusion: The mean GA at booking in our unit is 19.4 ± 8.14. Early booking and access to routine hematinics may guarantee sustenance of this recorded higher PCV at delivery. Furthermore, educated and less parous women tend to book early from this study.
Keywords: Early booking, gestational age, late booking, outcome
|How to cite this article:|
Zaman J, Isah D A, Isah A Y. Effect of gestational age at booking on feto-maternal outcome at a Nigerian tertiary hospital. Arch Med Surg 2019;4:35-41
|How to cite this URL:|
Zaman J, Isah D A, Isah A Y. Effect of gestational age at booking on feto-maternal outcome at a Nigerian tertiary hospital. Arch Med Surg [serial online] 2019 [cited 2020 May 24];4:35-41. Available from: http://www.archms.org/text.asp?2019/4/2/35/276183
| Introduction|| |
Antenatal care (ANC) is a specialized pattern of care organized for pregnant women to enable them to attains and maintain a state of good health throughout pregnancy. It improves the chances of having a safe delivery of a healthy infant to a healthy mother. It is one of the pillars of safe motherhood launched in 1987 at Nairobi Kenya, which was aimed at improving pregnancy outcome for both the mother and the fetus.,
This service usually provides a range of opportunities for delivering health information and interventions that could significantly enhance the health of expectant mothers.
Pregnancy, a normal physiological event is sometimes complicated by pathological processes that may be detrimental to the health of the mother or the fetus in about 5%–20% of all pregnancies. Thus, a good and timely ANC is the hallmark of prevention or reduction of significant maternal and fetal morbidity and mortality.,
Unbooked emergencies are said to constitute the main high-risk group for maternal mortality in Nigeria, making up to no fewer than 70% of all hospital maternal deaths in the country.,,
Early antenatal booking has been shown to be associated with many benefits including but not limited to accurate dating, early detection of medical disorders that could threaten the pregnancy and its outcome, and objective assessment of maternal baselines such as weight, blood pressure, and urinalysis that may provide a picture of the prepregnancy condition of the woman. It has been associated with optimal utilization and appreciable reduction of perinatal morbidity and mortality, irrespective of the place of care.,,
Antenatal care also provides entry point to a wide range of programs and interventions such as prevention, control, and treatment of conditions such as malaria, HIV/AIDS, and tuberculosis that could potentially cause adverse events to either the woman or her baby.,
The World Health Organization (WHO) recommends a minimum of eight antenatal visits, comprising interventions such as tetanus toxoid vaccination, intermittent preventive therapy for malaria, screening and treatment for infections, and identification of warning signs during pregnancy and health education, with emphasis on the benefits of booking in the first trimester of pregnancy. This is because ultrasound scan done between 10 weeks 0 days and 13 weeks 6 days will determine gestational age (GA) with the minimal error margin of 3–5 days unlike when this is done in the second trimester when the error margin could be as high as 2 weeks. It detects multiple pregnancies and also determines its chorionicity. This will ensure consistency of GA assessment; numbers of fetuses carried and reduced the incidence of induction of labor for prolonged pregnancy., The ANC policy in Nigeria follows the latest WHO approach to promote safe pregnancies, recommending at least four ANC visits for women without complications;, with many centers still transiting from the traditional approach to this focused ANC approach.
Timely and adequate ANC is generally acknowledged to be an effective method of preventing adverse outcomes in pregnant women and their babies.,,
It also provides the obstetrician the opportunity to know previous and current obstetric problems as well as medical, social, familial, and surgical problems related to the pregnancy at the booking clinic., It appeared there are scanty literature on studies that measure the effect of the timing of the first ANC visit on birth outcomes and where they exist, the results are conflicting. This study is, therefore, aimed at demonstrating whether the GA at booking has similar effects and correlation among our pregnant women as were reported in developed nations.
| Materials and Methods|| |
This was a prospective cohort study of all consecutive eligible women who attended antenatal booking clinic from September 2016 to July 2017 after obtaining ethical clearance from the ethical and human research committee of the hospital. Gestational age at booking was calculated according to the woman's reported last menstrual period. However, where women either did not know or were uncertain of the date of their last menstrual period, the GA at booking was estimated from an ultrasound scan. Eligible women were recruited into the study at the booking clinic. Four hundred and fourteen eligible women who gave consent and met the inclusion criteria were recruited into the study by simple random sampling. The minimum sample size for a simple proportion in each arm of the study with 5% accuracy and 95% confidence interval was calculated using the formulae:
n = minimum sample size
P 0 = 0.50 was the proportion of the participants in the unexposed group (early booking) who are expected to exhibit the outcome of interest
P 1 = 0.65 was the proportion of the participants in the exposed group (late booking) expected to exhibit the outcome of interest
Zα = 1.65 standard value from Z table at confidence level 0.05
Zβ = 1.28 standard value from Z table at acceptable power of 80% or 0.80
F = 10% (0.1) Proportion of study participant who was expected to leave the study for any reason other than the outcome under investigation.
Inserting the required information into the formula gives:
1.1 × 186.483 = 207.
Each arm of the study group (early and late booking) had 207 women population. Therefore, the total number of women recruited for the study was 414.
Structured interviews were conducted at the first contact to collect information on demographic characteristics, clinical, and obstetric history of each participant. Patients were followed till delivery, and feto-maternal outcomes variables were analyzed. Feto-maternal outcomes such as low-birth-weight, preterm delivery; stillbirths, hypertensive disorders in pregnancy, and maternal anemia at delivery were obtained for statistical analysis. Other outcomes such as the Apgar scores, special care baby unit (SCBU) admissions were also analyzed. Primary outcome measures were low-birth-weight, hypertensive disorders of pregnancy, and maternal anemia whereas secondary outcome measures included GA at delivery, mode of delivery, APGAR scores, and SCBU admission.
Data on the primary and secondary feto-maternal outcome variables (low-birth-weight and hypertensive disorders of pregnancy, etc) for early and late booking were analyzed, and the test of association between these variables were ascertained using the Chi-square test to compare for statistical levels of significance using Statistical Package for Social Sciences (SPSS) package version 20.0, August 2016 (SPSS 20.0, IBM, Armonk, NY, United States of America). Tests of association between categorical variables were ascertained using the Chi-square test (or Fischer's exact test when appropriate) whereas continuous variables were compared using the Student's t-test. Value of P ≤ 0.05 was considered statistically significant at 95% confidence interval.
| Results|| |
Four hundred and fourteen women were recruited into the study and divided into two arms, early and late booking. However, only 186 and 189 women in the early and late booking women, respectively, completed the study, and their data were available for analysis. Data were not available for 21 women (10.1%) in early booking group and 18 women (8.69%) in late booking group. This was due to loss to follow-up of 11 (5.31%), spontaneous miscarriages in 8 women (3.86%), and failure to deliver in our facility in 2 women (0.96%) in the early booking group while loss to follow-up in 18 women (8.69%) was recorded in the late booking group [Flow Chart 1].
The overall mean age of women in the two groups (early and late booking) was 29.8 ± 4.9 years with no statistically significant difference when the mean ages in the two groups were compared (29.7 ± 5.3 vs. 29.9 ± 4.6 years, P = 0.638). Women that booked early had significant lower parity and higher levels of formal education when compared to those that booked later [Table 1].
The overall mean GA at booking is 19.4 ± 8.14 whereas the mean GA at delivery was 38.4 ± 3.0, and the overall mean birth weight was 3.1 ± 0.6 kg as shown in [Table 2]. Women that booked late had significant more macrosomic neonates than their late counterpart as shown in [Table 3].
The overall incidence of the hypertensive disorder in pregnancy was 12.8% with no statistically significant difference between the separate values of each group. The overall mean packed cell volume (PCV) at booking was 33.6 ± 3.2 similar to the respective PCV at booking in both early and the late booking women. The PCV was significantly higher among those women that booked early; P ≤ 0.001 is shown in [Table 4].
|Table 4: Comparing of packed cell volume at booking and at delivery for the two groups|
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The mean GA at delivery was 38.4 ± 3.0. There was no statistically significant difference when respective mean GA at delivery was compared between the two groups (38.1 ± 2.7 vs. 38.6 ± 3.3; P = 0.138).
The number of live and stillbirth among the two study groups did not show any significant difference. There were more significant SCBU admissions among the early booking than late booking women in this study (P = 0.032) as shown in [Table 5].
| Discussion|| |
The mean GA at booking at the University of Abuja Teaching Hospital was 19.4 ± 8.14. This finding was comparable to the findings from the 2013 National Demographic Health Survey and hospital-based studies in Markudi, Osogbo, and Abuja. However, other institutions recorded slightly higher GAs at booking.,,,,,
The mean age at booking was 29.8 ± 4.9 years and similar to the finding of previous work in Abuja  and Makurdi, Nigeria as well as other studies across Nigeria.,, Perhaps, the similarity in the sociocultural factors in the native inhabitant of the North-Central region of Nigeria may have contributed to the similar findings in this study. Those previous studies, just as the current study were all hospital-based studies in capital cities. A more elaborate study to include remote areas across Nigeria may provide a much wider avenue for a better sociodemographic comparison. There were 74 (39.8%) primigravidae who booked early and 45 (23.8%) primigravidae that booked late. This was consistent with findings in Abakaliki and Makurdi (32.3%)., There was statistically significant difference comparing primigravidae who booked early in the early and late booking group (P < 0.001). The high incidence of late booking among the multiparous women in the late booking group may be attributable to the perceived “overconfidence” that might have been displayed by these women. In general, majority of the women in both study groups were multipara (110 [59.1%] vs. 131 [69.3%]) with mean parity of (1.2 ± 1.3 vs. 1.8 ± 1.6); P < 0.001.
Majority of the women who booked had at least secondary education (93.0% vs. 87.8%) for early and late groups, respectively. The cosmopolitan nature of Abuja city with the possibility of “high” working class women may explain the high level of literacy above. This was also similar to other studies at Abakaliki, Makurdi and the study in South Western Nigeria by Adekanle et al.,, Women with no formal education and primary level of education constitute only 2.7% and 6.9% for the early and late booking women, respectively. There were more Christian women who attended the booking clinic than Muslim women; P = 0.03, in this study, raising suspicion of perhaps, religious influence on attendance of ANC! This may be a subject of further research considering the already known benefits of supervised pregnancy and delivery.
The mean PCV at booking in the study was 33.6% ± 3.2%. The high level of socioeconomic status, early commencement of hematinic in pregnancy by most women before antenatal clinic booking, and perhaps, good nutrition could have contributed for the high PCV at booking in this study. This finding is appealing as it is relatively above the reference value of hemoglobin concentration <11.0 g/dl or PCV of <33.0% to define anemia during pregnancy by the WHO., There was a significantly higher PCV at delivery among women that booked early than found in those that booked late (P ≤ 0.001). Early initiation of hematinic and administration of intermittent preventive therapy for malaria in pregnancy among early booking women may be responsible for these remarkable differences in PCV at delivery. This finding could be considered one of the benefits of ANC received by early booked women, contrary to late booked women who might have missed this opportunity of care during pregnancy.
The incidence of hypertensive disorders of pregnancy in this study was 12.8% which did not show any statistically significant difference when compared to the women in either study group; P = 0.953 [Table 6]. There was also no statistically significant difference in the occurrence of preeclampsia recorded in the two groups. Previous studies across Nigeria have shown comparable variation in incidences of hypertensive disorders and preeclampsia.,,, However, other studies around the world have quoted a range of 5%–10%.,,
|Table 6: Development of hypertensive disorders of pregnancy in the study population|
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Majority of women in both study groups had term deliveries, and their babies had normal birth weights, and there was no statistically significant difference; P = 0.020 and 0.006, respectively. Although the incidence of preterm deliveries was 11.8% among those who booked early as against those that booked late 6.9%, this did not show any statistically significant difference; P = 0.099.
The mean birth weights in the two study groups were 3.1 ± 0.6 kg and 3.2 ± 0.6 kg; P = 0.177 for early and late booking, respectively. Perhaps, the equality and quality of standard of care accorded both groups without discrimination during pregnancy and labor might have contributed to the aforementioned advantage. The overall incidence of low-birth-weight rate, in this study, was 8.3%. This was lower than reported rate from Maiduguri with an incidence of 16.9%. Could the coincidental and protracted insurgency in Maiduguri and its environ during their study could have hindered normal healthy living during pregnancy and therefore predisposed them to maternal malnutrition during pregnancies? It could also be that women did not have access to health care needs during those pregnancies thus resulted in low-birth-weight babies. These might be a subject of further research. The incidence of macrosomic babies delivered to the study participants was 5.5%. There were significantly higher macrosomic babies among the late booking women as compared with their early counterpart (P = 0.015) and were mostly to the multiparous women in 71.4% of cases. This was consistent with several studies that related increasing parity with macrosomic babies and late booking with increased operative deliveries.,
There were 385 babies delivered in the study. There was no statistically significant difference in the live birth among the two study groups; P = 0.780. Perhaps, equal attention to both study groups without prejudice to late booking both during the ANC and delivery may have led to this deserved outcome.
The stillbirth rate, in this study, was 29.33/1000 live birth. The stillbirth among the two groups was comparable and had no statistically significant difference; P = 0.780. This was similar to Okeudo et al., Mairami and Audu, Dassah et al. and Ekure et al. who reported 18, 34, 59, and 14.3/1000 in South Eastern Nigeria, Abuja, Ghana, and Lagos, respectively, but lower than the one reported by Omo-Aghoja et al. who reported a rate of 6.1/1000.,,,
However, in some general studies (not comparing early and late booking), the incidence of stillbirth rate as high as 22.4 to 127/1000 have been reported in Pakistan, Zimbabwe, and Nigeria, whereas in developed countries, it is been reported to be between 2 and 8.7/1000 live birth.
There were 24 babies admitted into the SCBU with statistical significant difference among the two study groups (17 [8.9] vs. 7 [3.6]); P = 0.032. Twelve babies (50%) had moderate-to-severe asphyxia, whereas the remaining SCBU admissions were due to fetal macrosomia at risk of hypoglycemia and low-birth-weights. The overall incidence of perinatal asphyxia in this study was 3.1%. Of the 385 babies delivered for the early and late booking, 5 (2.6%) and 7 (3.6%) for early and late booking, respectively, had moderate asphyxia which necessitated SCBU admission. This may not be related directly to or associated with early or late booking but could be due to the accoucher's experience, delay in decision delivery interval for cesarean sections, and the quality of resuscitation given at delivery.
Majority of the women, 290 (77.3%) had a spontaneous vaginal delivery, whereas 85 (22.7%) had an intervention at delivery. Of the 290 women who had a spontaneous vaginal delivery, 142 (37.9%) booked early and 148 (39.5%) booked late; similarly, of the 85 women who had intervention, 43 (50.6%) had cesarean section in the early booking group, whereas 40 (47.1%) in the late booking had cesarean section. There were only two vacuum deliveries (1 in each study group). Overall, there was no statistically significant difference in maternal outcome in the early and late booking group for spontaneous vaginal deliveries, instrumental vaginal deliveries, and cesarean sections (P = 0.650, 0.991, and 0.649), respectively.
Maternal morbidities such as perineal tears, retained placenta, intrapartum and postpartum hemorrhage, eclampsia, sepsis, and anemia were not observed in either of the study group, and there was also no mortality recorded. These could be attributed to early detection or recognition of complications, early intervention, good intra and postpartum care to all women who booked and delivered in our setting. This was consistent with findings by Okunlola et al. who found that GA at booking as a sole factor for predicting the pregnancy outcome was found to be insignificant as the outcome was same for early and late bookers.
The benefits of early antenatal clinic booking such as early ultrasound scanning for the determination of GA, health education and enlightenment, early iron and folate supplementations, intermittent preventive therapy for malaria among many other benefits might have been lost at late antenatal clinic booking ,
The study also highlighted that majority of the women who booked late adduced their late booking to not being sick (P < 0.001). Most of the women were multipara who had successful deliveries in the past. Majority of the women whose index pregnancies were their first pregnancy, booked early 77 (41.4% vs. 2.6%); P < 0.001. Financial constraints also appeared to have played a significant role among the early group and showed statistically significant difference when compared to late booking women; P < 0.001. Educational status did not affect the decision to book early or late as most the women in both study arms had secondary and tertiary levels of education 173 (90.0) versus 166 (87.8) for early and late booking, respectively.
| Conclusion|| |
The mean GA at booking in our unit was 19.4 ± 8.14. Other than the recorded appreciable higher PCV among early booking women, the study demonstrated no significant difference in other feto-maternal parameters of interest in this study. Early booking and access to routine hematinics may guarantee sustenance of this recorded higher PCV at delivery. Educated and less parous women tend to book early from this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]