METTU UNIVERSITY
FACULTY OF PUBLIC HEALTH AND MEDICAL SCIEINCES
DEPARTEMENT OF CLINICAL NURSIN
RETROSPECTIVE ASSESSMENT OF RISK
FACTORS AND MANAGEMENT APPROACH OF INTRA UTERINE FETAL DEATH
AT METTU KARL REFERRAL HOSPITAL,ILLU ABBA BORA ZONE, OROMIA
REGIONAL STATE, SOUTH WEST ETHIOPIA 2018 G C.
BY: ABEZASH KORSA
A RESEARCH PROPOSAL SUBMITTED TO METTU UNIVERSITY, FACULTY OF
PUBLIC HEALTH AND MEDICAL SCIENCES DEPARTMENT OF MIDWIFERY, IN
PARTIAL FULFILLMENT OF THE REQUIREMENT OF BACHELOR SCIENCE
DEGREE IN MIDWIFERY.
FEBRUARY, 2018,
METTU, ETHIOPIA
ACKNOWLEDGEMENT
I would like to thank my advisors, Mr. Semeregazu(BSC) for the very detail, exhaustive and
constructive comments and advices they gave me for the preparation of this research proposal
and in advance for their willing in helping and giving valuable comments in the subsequent time.
I am also grateful for the assistance of staff at the medical library for their assistance in literature
searches and Department of midwifery for giving this chance to conduct the research proposal.
Background: Preterm birth is defined as all births before 37 completed weeks of gestation or fewer than 259
days since the first day of a woman’s last menstrual period. Of the estimated 130 million babies born each year
globally, approximately 15 million are born preterm. Worldwide, 13 million babies are born preterm annually.
Rates are generally the highest in low and middle income countries, and increasing in some middle and high in
come countries.
Objective: To assess the magnitude of preterm birth and associated factors among pregnant women who gave
birth in
Methodology: A hospital based cross-sectional study was conducted on 250 pregnant women in Jimma
university medical center. Systematic sampling technique was used to select study participants. Data was
collected using a structured interview, administered questionnaire and additionally secondary data was
extracted from maternal records. The Collected data was checked for completeness and consistency and then
compiled; tallied and analyzed by using scientific calculator manually finally, the analyzed data was presented
by pie chart, bar graph and statement
WORK PLAN: - the period will be from May 12- 26, 2017.
BUDGET: - it needs around 3,931 Ethiopian
Key word: Preterm birth, Prevalence, associated factor
Table of Contents
ABSTRACT...................................................................................................................................................I
Acknowledgement........................................................................................................................................II
Acronyms......................................................................................................................................................V
CHAPTER: INTRODUCTION.....................................................................................................................1
1.1. Background.............................................................................................................................................1
1.2 Statement of the problem.........................................................................................................................2
1.3 Significance of the study.........................................................................................................................3
CHAPTER TWO: LITERATURE REVIEW...............................................................................................4
2.2 Risk Factors...........................................................................................................................................5
2.2.1Socio-DemographicFactors:..................................................................................................................5
2.2.2 Pregnancy related and maternal illness Risk Factors...........................................................................6
CHAPTERS THREE: OBJECTIVES...........................................................................................................8
3.1 General objective.....................................................................................................................................8
3.2 Specific objectives................................................................................................................................8
CHAPTER FOUR: METHODS AND MATERIALS...................................................................................9
4.1. Study area...............................................................................................................................................9
4.2 study period.............................................................................................................................................9
4.3. Study design............................................................................................................................................9
4.3. Source population.................................................................................................................................10
4.4 Study population....................................................................................................................................10
4.5. Sample population................................................................................................................................10
4.6 Inclusion and exclusion criteria.............................................................................................................10
4.6.1 Inclusion criteria.................................................................................................................................10
4.6.2 Exclusion Criteria...............................................................................................................................10
4.6. Study variables......................................................................................................................................10
4.6.1 Dependent variables............................................................................................................................10
4.6.2 Independent variables.....................................................................................................................10
4.7 Operational terms...................................................................................................................................11
4.8 Sample size determination.....................................................................................................................11
4.9 Sampling technique and procedures......................................................................................................12
4.10 Data Collection tool.............................................................................................................................12
4.11 Data Collection procedure...................................................................................................................12
4.12 Data process, analysis and presentation...............................................................................................13
4.13 Data quality assurance.........................................................................................................................13
4.14 Ethical Considerations.........................................................................................................................13
4.15 Dissemination of finding.....................................................................................................................13
CHAPTER FIVE: RESULTS..........................................................................................................................
Acronyms
ANC -Antenatal Clinic
APH -Ante partum Hemorrhage
C/S -Caesarean Section
IUGR -Intrauterine Growth Restriction
LBW -Low Birth Weight
LMP -Last Monthly Period
NICU -Neonatal Intensive Care Unit
PIH -Pregnancy Induced Hypertension
PLBW -Preterm Low Birth Weight
PMTCT -Prevention of Mother to Child Transmission of HIV
PROM -Prelabour Rupture of Membranes
PPROM -Preterm Prelabour Rupture of Membranes
SGA -Small for Gestational Age
SVD -Spontaneous Vertex Delivery
UTI -Urinary Tract Infection
WHO -World Health Organization
CHAPTER: INTRODUCTION
1.1. Background
WHO estimated 130 million babies born each year globally; approximately 15 million are born
preterm. Worldwide, 13 million babies are born preterm annually. Rates are generally the highest
in low and middle income countries, and increasing in some middle and high income countries.
The highest rates of preterm birth occurred in Africa and North America. (1).According to the
World health organization (WHO), Preterm birth is birth of the baby before 37
completed weeks of gestational age. physicians have been unsuccessful in
determining the cause of preterm labor(1-2). The etiology of preterm is still
unclear, despite many attempts to identify possible causes preterm birth,
several factors have contributed to the overall rise in the incidence of preterm
birth (3)
Preterm labor are very challenging obstetriccomplications encountered by
obstetricians, as are pretermneonates for the pediatricians, PTL is one of the
most common reasons for hospitalization of pregnant women, but identifying
women with preterm contractions who will deliver preterm is an inexact
process(4-5).
Risk factors for PTB have been reported in research these factors include
increasing rates of multiple births, placental abruptions, early induction due to
health problems like diabetes or pre-eclampsia, preterm ruptured membranes,
and preterm cervical effacement and dilation without labor ,use of assisted
reproduction techniques, and more obstetric intervention term births
decreased the risk of PTB in subsequent pregnancies (6).
In Ethiopia about 12% of under- five deaths is attributed to preterm birth , According to Ethiopian
profile of preterm and low birth weight prevention and care, in Ethiopia, 320,000 babies are born
too soon each year and 24,000 children under five die due to direct preterm complications(7).
The major cause of preterm delivery were low monthly income, absent or inadequate prenatal
care, no contraceptive use, caesarean delivery and clinical complications during pregnancy (8)
1.2 Statement of the problem
Preterm birth is a global problem with WHO estimating the prevalence to range between 5-18%
across 184 countries. Brazil, the United States of America, India and Nigeria are among the top
ten countries with the highest numbers. In addition, of the 11 countries with preterm birth rates of
over 15%, all but two are in sub-Saharan Africa(1).Report on annual neonatal death depict that
28% of death were due to prematurity ,which is not attributed to malformation (9).
Prematurity is a major determinant of neonatal mortality and morbidity as well as a significant
contributor to long term adverse health outcomes. For instance, of the estimated 3.1 million
neonatal deaths that occurred globally in 2010, about 1.08 million (35%) were directly related to
preterm birth. complications of preterm birth are the single largest direct cause of neonatal deaths
and the second most common cause of under-5 deaths after pneumonia(10).
Preterm babies suffer increased morbidity from conditions such as RDS, NEC, retinopathy of
prematurity and anemia of prematurity, neonatal jaundice, sepsis and feeding difficulties among
others. Long term complications such as cerebral palsy, intellectual impairment, chronic lung
disease, and vision and hearing loss also occur exerting a high toll on individuals born preterm,
their families and the communities in which they live. Prematurity is a major hindrance to the
attainment of the sustainable development goal target given its contribution to neonatal mortality.
To accelerate achievement of this sustainable development goal, there is need to reduce preterm
birth(11).
The risk of neonatal death due to complications of preterm birth is at least 12 times higher for an
African baby than for a European baby. For example, over 90% of extremely preterm babies (<28
weeks) born in low-income countries die within the first few days of life while only less than 10%
of babies of this gestation die in high-income settings(12).
Therefore, since Ethiopia is one of the countries those affected by preterm birth, this study will be
beneficial in reducing the magnitude and severity of the problem.
1.2 Statement of the problem
Preterm birth is a global problem with WHO estimating the prevalence to range between 5-18%
across 184 countries. Brazil, the United States of America, India and Nigeria are among the top
ten countries with the highest numbers. In addition, of the 11 countries with preterm birth rates of
over 15%, all but two are in sub-Saharan Africa(1).Report on annual neonatal death depict that
28% of death were due to prematurity ,which is not attributed to malformation (9).
Prematurity is a major determinant of neonatal mortality and morbidity as well as a significant
contributor to long term adverse health outcomes. For instance, of the estimated 3.1 million
neonatal deaths that occurred globally in 2010, about 1.08 million (35%) were directly related to
preterm birth. complications of preterm birth are the single largest direct cause of neonatal deaths
and the second most common cause of under-5 deaths after pneumonia(10).
Preterm babies suffer increased morbidity from conditions such as RDS, NEC, retinopathy of
prematurity and anemia of prematurity, neonatal jaundice, sepsis and feeding difficulties among
others. Long term complications such as cerebral palsy, intellectual impairment, chronic lung
disease, and vision and hearing loss also occur exerting a high toll on individuals born preterm,
their families and the communities in which they live. Prematurity is a major hindrance to the
attainment of the sustainable development goal target given its contribution to neonatal mortality.
To accelerate achievement of this sustainable development goal, there is need to reduce preterm
birth(11).
The risk of neonatal death due to complications of preterm birth is at least 12 times higher for an
African baby than for a European baby. For example, over 90% of extremely preterm babies (<28
weeks) born in low-income countries die within the first few days of life while only less than 10%
of babies of this gestation die in high-income settings(12).
Therefore, since Ethiopia is one of the countries those affected by preterm birth, this study will be
beneficial in reducing the magnitude and severity of the problem.
1.3 Significance of the study
To accelerate the sustainable development goal the burden of preterm birth must be urgently
addressed. The findings of this study will
Contribute to the body of knowledge regarding factors associated with preterm birth
Help policy makers to formulate relevant and practical measures to tackle this preterm
birth
Help program managers, Woreda Health office, stake holders, and obstetric care
providers to design appropriate interventions to reduce preterm birth and decrease
newborn morbidity and mortality.
Also help to fill the research gaps in the study area and will be used as base line information for
other researchers who conducts similar studies.
CHAPTER TWO: LITERATURE REVIEW
2.1 Magnitude of preterm birth
In worldwide estimates the prevalence of preterm birth to be 12.9 million (9.6%) of all birth, were
preterm. Approximately 11 million (85%) of these preterm births were concentrated in Africa and
Asia, Thestudy done in rural Bangladeshi among all live births, 22.3% were delivered preterm
birth. The highest rates of preterm birth were in Africa 11.9% (13). Study show that the prevalence
of preterm birth in Kenyatta nation hospital was found to be 18.3%(14). Study done in our country
inDebremarkos town health institutionshowthat the prevalence of pre term birth 11.6% from the
total 422 mothers(15).
Brazilian a prevalence of preterm birth in Brazil of 6.5% in 2009(16). It is a retrospective
observational study conducted neigrihms India in 2008 to 2013.The incidence of preterm birth is
found to be 10.23%(16).In Nigeria prospective study Prevalence and perinatal mortality associated
with preterm births in a tertiary medical center in South East Nigeria, 3,760 live births over the 5-
year study period out of which 636 involved preterm deliveries giving a preterm birth rate of
16.9%(17). In Kenya national hospital Nairobi hospitalized cross sectional study conducted, A
total of 322 mother-baby pairs were enrolled into the study prevalence of preterm birth in Kenya
National Hospital was 18.3% (18)
2.2 Risk Factors
Some of the factors which are associated with preterm birth are previous pretermbirth, multiple
gestation, maternal age and parity, interpregnancy interval, ANC attendance, maternal nutritional
status, APH, PIH, maternal infections(19).
2.2.1Socio-DemographicFactors:
The socio-demographic factors which are associated with preterm birth include extremes of
maternal age, low level of education, low socioeconomic status and occupation, single marital
status.Studies show that atUnited Kingdom found that maternal age more than 39 years and
prenatal smoking were significantly associated with preterm delivery. In Pakistan, Irshad
Mohammed and colleagues in a study of 205 preterm births found that about 25% of the mothers
were aged 35 years and above. a study of 164 preterm admitted in a NICU in Nepal found that
35% of mothers who delivered prematurely were teenagers(20).
The results showed that women with high school education (≥ 10 years of education) had 36%
lower odds of having preterm birth compared with women with no primary education
while maternal age was not significantly associated with preterm birth. A study of 200 preterm and
200 term infants by Jandaghiet al inIran showed that 74% of preterm births occurred among
women from a low socioeconomic background. In a study of 185 preterm babies done at Ilorin
Teaching Hospital, Nigeria, in which about 52% of preterm births were early preterm’s (<34weeks
gestation), maternal age >35 years was significantly associated with premature birth(21).
In the same country, S.J. Etuk and colleagues27 in a study of 217 cases and a similar number of
controls, found that being unmarried was strongly associated with preterm delivery. A study in
Kilimanjaro Christian Medical Centre, Tanzania by J. E.Siza and others30 involving 460 LBW
babies (91% of whom were preterm), showed that women who had no formal education were 4
times more likely to deliver LBW(22).
2.2.2 Pregnancy related and maternal illness Risk Factors
Study in Tehran fond that,38.8%prematureruptureofmembrane,19.3%APH,5.2%PIH,9.3%history
of preterm delivery,22% abortion and 7.1% multiple pregnancy were significantly associated
factor withpreterm birth, study in tertiary hospital in Pakistan found that 61% of causes were
associated with PROM,30% had previous preterm birth 31% had previous pregnancy loss ,36%
had APH and 4%had a history of burning sensation(23).
A study of 315 preterm babies in India found that previous history of preterm delivery and
recurrent maternal UTI were significantly associated with preterm birth. In a comparative cross-
sectional study in the Iran in 2008, found that history of previous preterm birth, maternal anemia,
PROM, placental abruption and UTI were significantly associated with premature birth. Among
singleton deliveries in a tertiary hospital in the United Kingdom, found that history of previous
preterm birth was significantly associated with preterm birth (24).
In a study of 164 preterm babies admitted in NICU Nepal found that 52% of mothers had
inadequate antenatal care (<3visits), 23% had APH while PI(25)and multiple pregnancies
accounted for 13% each. In the same study, maternal UTI occurred in 3% of cases and was not
significantly associated with preterm birth unlike the findings in Egypt which showed that UTI in
pregnancy had a significant association with preterm birth and LBW. In a study of second births in
Scotland among mothers who conceived within 5 years of the first birth, found that about 5% had
an inter pregnancy interval of less than 6 months (25).
Compared with those with an interval of 18-23 months, these women as well as those with
intervals of 24-59 months had significantly higher risk of severe (<32 weeks gestation) preterm
birth. These findings are comparable to those of a meta-analysis of 67 studies on birth spacing and
prenatal outcomes done by Agustin Coned and colleagues in 2006 that showed that inter
pregnancy intervals shorter than 18 months and longer than 59 months were associated with
increased risk of preterm birth, LBW and SGA (17).
Studies in Nigeria had shown that high parity, PROM, maternal UTI, previous preterm delivery,
APH, PIH, multiple gestation and anemia were significant determinants of preterm birth. In
Rwanda,Bayingana et al found that previous preterm birth was strongly associated with preterm
delivery of LBW (about 4-fold increase in risk) (26).In Tanzania found that mothers who had
antenatal anemia and those who did not attend ANC were more likely to deliver preterm and LBW
babies as were those who were HIV positive whose risk was 2 times higher(19-20).
Our country Gondar town Out of 540 mothers 50.9% were primigravida. Regardless of anemia of
the mother 15.17% were anemic, HIV infection 9.3% were positive for the infection,5% have
urinary tract infection and Those women with pregnancy induced hypertension were 5 times more
likely to deliver preterm than those women without pregnancy induced . Mean birth weight of the
infants was 2.9 kg (range 1.5 to 4.3). The mean gestational age of the newborns was 39.49 weeks
with minimum 31 and maximum 44 weeks. The prevalence of low birth weight was found to be
17.4%(27).Study in Debremarkos health institution Presence of chronic Illness 4.5%, problem in
current pregnancy 2.9%, premature ruptureof membrane 2.6%,has antenatal follow up 0.24%),
and hematocrit level <33%, 7.2% were found to be significantly Associated with preterm birth on
the multivariate logistic regression(28).
2.2.3 Behavioral and Nutrition factorsSebayang et al in Lombok, Indonesia, analyzed data from
the Supplementation with Multiple
Micronutrient Intervention Trial (SUMMIT), a double-blind cluster-randomized controlled trial
of a cohort of 14,040 singleton births to examine determinants of preterm birth, LBW and SGAa
retrospective study of 1,194 infants in Japan noted that the risk of preterm birth was significantly
increased if mothers smoked during any trimester of pregnancy. Study in Italy in a case control
study demonstrated that moderate prenatal alcohol consumption (>3 drinks per day) was
associated with a significant risk of preterm birth(29).
CHAPTERS THREE: OBJECTIVES
3.1 General objective
To assess the prevalence of preterm birth and associated factors among pregnant women who give
birth in Jimma university medical center, Jimma, Ethiopia, 2018.
3.2 Specific objectives
To determinethe prevalence of preterm birth, in Jimma university medical center.
To identifyfactorsassociated with preterm birth in Jimma university medical center
CHAPTER FOUR
4. METHODOLOGY
4.1 Study area
The study will be conducted in Mettu town administration governmental health
institution (Mettu Karl Hospital).Mettu town administration is found in Illu Abba
Bora Zone, Southwest Ethiopia. The town is 600 Km far away from Addis Ababa,
total population living in Mettu Town is 940,000 population . There is one Hospital,
one health centres’, one health science, one TTC and one University found in Mettu
town.MKH is established in 1956 E.C.At that hospital called rular hospital.In 1986-
1993 reformed called MKH.The hospital changes to referral hospital in
2004 .E.C .The hospital serves more than 8000 pregnan t women per year
according to data found from Mettu town health bureau.
4.2. Study design and period
Facility based, cross sectional descriptive Retrospective study will be conducted to
determine the Assessment of risk factors and management approach of intra uterine
fetal death in Mettukarl referral hospital over the last 1 year cases will be used. The
study will conduct from February 25 to March 25, 2018.
4.3 populations
4.3.1. Source population
All mothers who were give births in mettukarl referral hospital over 1year period
from September 2016 to September 2017, will be the source population
4.3.2. Study population
A mother who was give births in mettukarl referral hospital over 1year period from
September 2016 to September 2017 .
4.4. Inclusion and exclusion criteria
4.4.1. Inclusion Criteria
Mothers who was give birth over 1year period from September 2016 to September
2017 with greater than 28 wks of GA in MKRH.
mother who have a complete record or documentation
4.4.2. Exclusion criteria
Mothers who were not have complete documentation
Lost documents/folders will be excluded from the study
GA less than 28
4.6. Study variables
4.6.1 Dependent variables
Preterm birth
4.6.2 Independent variables
Socio-demographic characteristics age, residence area, educational status, income,
occupation, marital status, ethnicity and religion.
Behavioral factors: smoking and alcohol drinking
Maternal illness: infections, chronic diseases
Pregnancy related problems
Nutrition: variety of foods, frequency of feeding.
4.7 Operational terms
Preterm birth: All births before 37 completed weeks of gestation or fewer than 259 days since
the first day of a woman’s last menstrual period, Or, whose ultrasound result for dating is
indicated below 37 weeks.
PPROM is defined as spontaneous rupture of the membranes at less than 37 weeks’ gestation
before the onset of contractions.
Low Birth Weight: Birth weight less than 2500 grams Inter-pregnancy interval.
Parity: The total number of times a woman has been pregnant regardless of the outcome.
4.8 Sample size determination
The minimum required sample size is estimated based on a prevalence of 19.3 % from which
similar study conducted in Debre Markos 2013 institutional based cross sectional study(31).
By using the standard statistical calculation;
The formula n =
Where:
n = minimum sample size required for the study
= Confidence interval – 95% = 1.96
p=prevalence of the preterm= 19.3%
d=margin of error (5%) = 0.05
q=1- p = 1-0.193 =0.807
Then n= =239
By assuming 5% non-response rate the final estimated sample size will be, n= 239+5% (11) =250
4.9 Sampling technique and procedures
A systematic random sampling technique was used considering N(the total birth Attendants of
two months period in the Jimma university medical center which 504 and n (required minimum
sample size 250 which gives a k of ..) : K = N/n= 504/250 =2 To start data collection, the two
women who will give birth the hospital on the first day of data collection was given numbers from
1-2 and one of them was selected by lottery method, then we get 1 by lottery method and women
will then be included in the study starting from one then continue every two until we get
minimum sample size.
4.10 Data Collection tool
The data was collected by using face to face exit interview using a structured questionnaire and
patient chart was reviewed. The questionnaire consists of four parts named, socio-demographic,
obstetric, nutritional and behavioral factors. Additional information such as presence of any
obstetric complications and antenatal profile was extract from the mother’s file and/or antenatal
record. The questionnaire is prepared in English. The questionnaire was adapted from a
literature(31).
4.11 Data Collection procedure
Using the birth registers, all mothers who have delivered in Jimma university medical center was
identified and trace to the postnatal wards within 24 hours of giving birth. The first mother was
selected using lottery method and the subsequent considering the ‘K’ value based on their
sequence of delivery. Then, all mothers who met the inclusion criteria was informed about the
purpose of survey and was asked to participate by obtaining consent. Those who give their consent
was interviewed during their exit from labor ward. If patients are admitted for more than 12 hours,
they was contacted and interviewed at the bed side.
4.12 Data process, analysis and presentation
All the questionnaires was checked visually, tally was done manually and was analyzed. The data
was presented with graph, figure, table and chart. Frequencies and percentage will also be used.
4.13 Data quality assurance
The Investigator was obtained permission from the relevant authorities and introduce. The
investigators were given orientation for one day on the data collection instrument and ways of
interview and how to deal with challenges likely to be faced during the data collection phase, and
easily means of interviewing. The investigator will also ensure that all materials need to be
available and will supervise the data collection process. Checking the consistency of data every
day and discuss about the problem every day then solve problem for next day and continue every
day in this form, washeld.
4.14 Ethical Considerations
Ethical clearance wasobtained from Jimma University, institute of health, department of
midwifery. A formal written cooperation letter wasgiven to Jimma university medical center.
Verbal consent wasobtained from each study participants and an ascent wassecured from
guardians for women under 18 years. Women wereinformed that it wastheir right tochoose
whether to participate in the study or not and even withdraw from the study at any time. This
would not affect the care they and their babies would receive. No inducements or reward wasgiven
because of their participation than indirectly benefited from the outcome of the study.
Confidentiality wasstressed at all times. No personal identifier wasused during recording and all
information given will only be used for research purposes. There were no invasive procedures
carried out on the participants, so no physical risks will beencountered.
4.15 Dissemination of finding
The final finding of this research wasdirectly reported to Jimma university institute of health,
department of midwifery, Jimma university medical center, Jimma university institute of health
library and if possible it waspublished on health journals and waspresented in seminar place.
