Abstract
BackgroundThe major causes of maternal and neonatal mortality in the Philippines are hemorrhages and obstructed labor due to placental implantation abnormalities (PIAs), twin pregnancies and fetal malpresentations. All of which are all easily detected by ultrasound. However, women in rural areas and low-income groups do not have access to ultrasound during their prenatal care. We aimed to provide additional evidence on the benefits of handheld ultrasound (HU) for screening pregnancy related abnormalities in order to avert maternal and neonatal deaths.MethodsUsing a HU, we trained community healthcare workers (CHWs) to identify 5 obstetrical conditions: fetal viability and number, placental localization, amniotic fluid volume (AFV) and fetal presentation. Women, between 20th and 24th weeks age of gestation from 2 regions of the Philippines, were scanned using the HU and the GE Logic 5 Premium ultrasound machine for validation. Maternal and neonatal deaths averted were estimated as health outcome measures of the study.ResultsFour hundred sixty women were scanned of which 146 (31.7%) showed abnormal ultrasound readings consisting of 17 PIAs, 123 fetal malpresentation, 3 twins and 3 AFV abnormalities. The use of HU could have possibly averted 29 (6.3%) maternal deaths and 14.6% neonatal deaths at the time of delivery. Thirty-two out of the 460 women (~7%) delivered at home and 93% in hospitals or birthing facilities/lying–in centers. We observed approximately 95% agreement between the ultrasound readings of the trainees and the trainers, and 99% agreement between the readings made from the HU with the validation machine.ConclusionCHWs could be trained in the use of HU for scanning 5 obstetrical parameters. Early detection of abnormalities in these 5 obstetrical parameters can lead to early referral to facilities that are better equipped to manage obstetrical emergencies. Prenatal ultrasound can be an excellent point of care test for screening pregnant women at risk for possible complications and even death during labor and delivery.Trial registrationThai Clinical Trial Registry identification number TCTR20171128004, retrospectively registered November 28, 2017.
Highlights
The major causes of maternal and neonatal mortality in the Philippines are hemorrhages and obstructed labor due to placental implantation abnormalities (PIAs), twin pregnancies and fetal malpresentations
Neverthleless, there was a dramatic decrease in June 2015 to 115/100,000 livebirths which was still short of the 2015 Millennium Development Goal (MDG) of 15 per 100,000 livebirths
The different causes of maternal deaths worldwide have been attributed to hemorrhage (27%) of which 17% occurred in the postpartum period, sepsis (10.7%), obstructed labor (2.8%), hypertensive disorders (14%), and complications of unsafe abortion (7.9%)
Summary
The major causes of maternal and neonatal mortality in the Philippines are hemorrhages and obstructed labor due to placental implantation abnormalities (PIAs), twin pregnancies and fetal malpresentations. Based on a 2013 UNICEF Philippine Report, 13 mothers die every day in the country from pregnancy-related complications [1] It reported a high maternal death rate of 162 per 100,000 livebirths in 2000 escalating further to 221/100,000 livebirths in 2011 [1]. Placental implantation abnormalities (PIAs) namely, placenta previa, marginal/low lying placenta, placenta accreta vasa previa and velamentous cord insertion account for both intrapartum and postpartum maternal hemorrhages [4] They are identified by ultrasound, which normally can be done anytime between 18 and 22 weeks [4]. The trend for neonatal mortality rate (NMR) of the Philippines or deaths in the newborn before they reach 28 days of life showed a downward trend from 20 per 1000 livebirths in 1990 to 12.6 per 1000 livebirths in 2015. A separate study in 2011 reported the under-ultilization of ultrasound imaging in many developing countries and the lack of trained sonographers as a challenge in delivering quality maternal healthcare [9]
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