Maternal Morbidity in Jordan (2006-2008)

In Jordan, there is limited information on maternal morbidity. The present study is the first comprehensive assessment of maternal morbidity at the national level and hopefully will be useful for policy development, planning, assessment of progress, and program evaluation.

 

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 in maternal morbidity among the three regions and the different health sectors in Jordan.

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 offering high quality services to clients with maternal morbidity in various health care facilities.

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

 

A cohort design was used to achieve the above objectives. A national sample of pregnant women was enrolled before their twenty second week of gestation between January 15 and April 15, 2007 and followed up throughout pregnancy, labor, and post partum. A total of 4,501 women were finally included in the study (about 10% of the eligible pregnant women in the country during the period of recruitment) with a response rate over 81%. A structured questionnaire and data sheet were developed for the purpose of this study; and a group of experts in the field assessed the study instrument for content validity. A total of 80 physicians, 72 of whom were obstetricians from various health sectors and governorates, were responsible for completing the questionnaire and data sheet for their patients. The principal investigators visited the study sites and held meetings with the study teams of physicians During these meetings, the principal investigators discussed relevant issues including the purpose of the study, the study protocol, the study instrument, data confidentiality, and the timeframe for reporting. Adherence to the study protocol, answering all questions, and encouraging the study teams to contact the study investigators for any inquiry or clarification were stressed and achieved. The principal investigators were actively involved in the monitoring progress through telephone calls and/or site visits as needed throughout the study period.

 

The study main findings indicated that the overall morbidity rate during all current pregnancy, labor, delivery, and post partum, was 60.8%. Morbidities ranged from mild conditions to severe life threatening complications.

 

- The total morbidity rate during current pregnancy was 41.3%.

- A total of 34.5% of women suffered from at least one morbidity during current labor and delivery.

- During current post partum, 18.7% of women suffered from one or more morbidities. The rate of cesarean sections was higher in this study (27.7%) compared to previous reports, and also the 2007 Jordan Population and Family Health Survey (18.5%).

Prevalence rates of anemia (Hb <11 gm/di) at enrollment and delivery were 20.1% and 26.3%, respectively. Although still high, these rates are well below previously reported national figures (about 35% in 2002, MOH) and suggest that progress has been achieved in this regard. The national flour fortification with iron and folic acid and the supplementation of pregnant women with iron and folic acid could among of contributing factors to this decline in anemia. It should be noted that most cases of anemia were mild anemia which means Hb between 10<12mg/d1 with only 5.9% of women having hemoglobin levels less than 10 gm/d1.

Urinary tract infections (20.2%) and genital infections (19.4%) were the commonest morbidities during current pregnancy.

Compared to women from the middle region and after controlling for potential confounders using multivariate logistic regression, southern region women showed higher morbidity during pregnancy and post partum, while northern region women showed higher intrapartum morbidity.

After controlling for potential confounders, intrapartum morbidity was lowest in the private sector, with no differences between various sectors in the study related to pregnancy or puerperal morbidity.

Higher parity (>3) was independently related to increased morbidity during pregnancy and labor but not during post partum, after controlling for potential confounders.

Among the encouraging findings in this study is the absence of any maternal mortality among this large cohort of pregnant women (4501 subjects), indicating that all serious morbidities and related complications have been successfully managed and did not lead to death. Furthermore, a significant low rate of serious obstetric complications such as severe genital lacerations and ruptured uterus was reported in the study (only one case of ruptured uterus).

 

Based on the results of the study, the following recommendations may be offered:

The single most important finding of this study is the sharp rise of cesarean section. There is a need to conduct a thorough investigation of the underlying causes of this finding. The rise in cesarean delivery has accompanied the recent introduction of new technologies for fetal monitoring. Are there any deficiencies related to these technologies? Are they properly implemented? Are there clear unified criteria or guidelines to use? Are they known to all users? Was there any formal training for users? These are examples of possible questions related to this issue. The attitudes of obstetricians and their competence particularly in instrumental delivery are likely areas for inquiry. Are there any clinical audits as regards to cesarean delivery?

 

- Based on the observed lower intrapartum morbidity in the private sector and to an extent at the Royal Medical Services (RMS) in comparison with the MOH, it is recommended to study the circumstances and potential causes of this finding.

- There is also a need to study factors responsible for the observed higher intrapartum morbidity in the Northern region.

- As parity >3 was a significant predictor of pregnancy and intrapartum morbidity, efforts for making family planning services and information available and more accessible should be promoted.

- An in-depth study of urinary and genital infections during pregnancy is needed to elucidate the underlying causes, types, risk factors, and prevailing microorganisms and their sensitivities. The protocol for the detection and management of these infections should be examined for its appropriateness and applicability.

- Future studies should focus on well-defined maternal morbidities and differentiate these from preexisting medical conditions and conditions with a weak link to childbearing and childbirth. Severity of morbidities should be considered in such studies.