Maternal and perinatal mortality in Rural Guinea-Bissau – Factors associated with home deliveries

Start date: 22 October, 2014 End date: 18 December, 2014 Project type: Master's Thesis (prior to 2018) Project code: A27593 Institutions: University of Copenhagen (UCPH), Denmark Grant recipient: Anne Sofie Pinstrup Jørgensen Total grant: 20,000 DKK



Background: Guinea-Bissau is one of the countries in the world with the highest maternal and perinatal mortality. WHO recommends that all births are attended by health professionals, but a study from rural Guinea-Bissau found an excess maternal mortality associated with hospital deliveries. An explanation could be reversed causality - that laboring women experiencing complications are transferred to hospital while births without complications mainly take place at home  - resulting in high mortality after hospital delivery. Comparing intended and actual place of delivery may serve as an indicator of reversed causality.

Objectives: The overall aim of the study was to compare intended place of delivery with actual place of delivery, and identify factors associated with intended place of delivery in rural Guinea-Bissau as well as factors associated with a deviance from intended home delivery. In addition, maternal and perinatal mortality in relation to delivery place was investigated as a background for the study.

Methodes: We identified 9308 pregnancies from 2009-2014 registered in the Bandim Health Projects (BHP) rural Health and Demographic Surveillance system (HDSS), in the regions of Oio, Biombo, Cacheu and Saõ Domingos and assessed the rates of maternal and perinatal mortality. In addition a field study of 516 pregnant women identified through the BHP registers, was initiated in November 2014. The women were asked a supplementary set of questions regarding intended place of delivery and socio-demographic characteristics. Place of delivery was obtained after birth through linkage to the BHP child registers. Logistic regression was used to access the factors associated with intended home delivery and deviation from intended home delivery.  Perinatal mortality was calculated according to intended and actual place of delivery.

Results: Delivering at a hospital was associated with a 3-fold higher perinatal mortality rate compared with home deliveries. Further, the maternal mortality rate was almost 10-fold higher among hospital deliveries relative to home deliveries. Distance(>2km) to nearest health institution, older age of mother (>35 years old), having no maternal education and being circumcised were associated with intended home delivery. Out of the 350 women who gave birth before the end of follow-up (29th of May 2015), 20% deviated from intended home delivery. Some of the factors associated with deviance was lower and higher maternal ages, nulliparous women, higher wealth, having some education and having someone else deciding on the intended home delivery. In the field study deviating from intended home delivery was associated with a significantly higher risk of perinatal mortality compared with women who intended to deliver at the hospital and did accordingly (RR=6.56 (CI95%:1.34-32.1)).

Conclusion: Delivering at the hospital in Guinea-Bissau is associated with an increased risk of both perinatal and maternal mortality. The present study suggests that reversed causality may be part of the explanation; however, other factors are also likely to be of significance. Assuming that the high mortality after hospital delivery is due to reversed causality, which the data of present study indicates, it would be beneficial to have all women delivering at the hospital to avoid the delay caused by transferal.