Pregnant Women In Low- And Middle-income Countries Research Articles

Cultural food practices and sources of nutrition information among pregnant and postpartum migrant women from low- and middle-income countries residing in high income countries: A systematic review.

Women in low- and middle-income countries (LMICs) may engage in a range of cultural food practices during pregnancy, including restricting or avoiding foods high in protein and iron, and foods rich in vitamins and minerals. While research has explored the cultural food practices of pregnant women in LMICs, there is less understanding of the continued cultural food practices of women who migrate to high-income countries and then become pregnant. This systematic review explores the existing research on cultural food practices and sources of nutrition information among pregnant and postpartum migrant women from LMICs, residing in high-income countries. A systematic search was conducted in April 2024 across Global Health, CINAHL, and MEDLINE, published in English, with no date restrictions. Eligible studies included those focused on pregnant and postpartum women who had migrated from LMICs to high-income countries. Studies were excluded if they comprised of non-immigrant women or did not involve LMIC participants. Screened were studies for eligibility, data were extracted, and study quality was assessed. In total, 17 studies comprising qualitative (n = 10) and quantitative (n = 7) approaches were included. In 14 studies participants adhered to cultural food practices, wherein certain nutritious foods were restricted during pregnancy or the postpartum period; three studies noted limited adherence due to support, acculturation, and access to traditional foods. Most studies (n = 10) reported traditional "hot" and "cold" food beliefs during pregnancy and postpartum, aiming to maintain humoral balance for maternal and child health and to prevent miscarriage. Nutrition advice was sought from family members, friends, relatives, healthcare providers, and media sources, with a preference for advice from family members in their home countries. There is a need for culturally appropriate nutrition education resources to guide pregnant migrants through healthy and harmful cultural food practices and overall nutrition during this crucial period. (PROSPERO Registration: CRD42023409990).

Effectiveness of mHealth Interventions for Monitoring Antenatal Care among Pregnant Women in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Antenatal care (ANC) is essential in maternal and child health since it provides care to pregnant women from conception through to labour in order to ensure a safe pregnancy and childbirth. In recent years, mobile health (mHealth) interventions have emerged as a promising solution to improve maternal and child health outcomes in low- and middle-income countries (LMICs). The present study aimed to conduct a systematic review and meta-analysis of trials to evaluate the effectiveness of mHealth interventions to monitor prenatal care among pregnant women in LMICs. A systematic literature review was conducted using the databases CINHAL, Embase, MEDLINE, and PsycINFO on the effectiveness of mHealth interventions in monitoring the antenatal care of pregnant women. The study selection, data extraction of the included articles, and quality appraisal were assessed. Our study included six studies considering 7886 participants. All articles were from low- and middle-income countries (LMICs). Antenatal mothers who used a mobile health intervention were more likely (RR = 1.66, 95%CI = 1.07-2.58, I2 = 98%) to attend ANC check-ups when compared with the women who did not use any mobile health applications or did not receive any short message services. mHealth technologies are being utilised more and more to increase care accessibility and improve maternal and fetal health. Policymakers should prioritise the integration of mHealth interventions into maternal healthcare services in LMICs, ensuring that they are cost-effective, accessible, and sustainable and that healthcare workers are trained to deliver these interventions effectively.

Interventions to enhance healthcare utilisation among pregnant women to reduce maternal mortality in low- and middle-income countries: a review of systematic reviews

BackgroundMaternal mortality in low- and middle-income countries (LMIC) has reduced considerably over the past three decades, but it remains high. Effective interventions are available, but their uptake and coverage remain low. We reviewed and synthesised evidence from systematic reviews on interventions to increase healthcare services utilisation to reduce maternal mortality in LMICs.MethodsWe searched Medline PubMed and Cochrane Library databases for systematic reviews published between January 2014 and December 2021, investigating interventions to increase healthcare services uptake among pregnant women in LMICs. We used the AMSTAR tool (A Measurement Tool to Assess Systematic Reviews) to assess the methodological quality of the included reviews. We extracted data on the interventions and their effects and grouped them into broad groups based on the outcomes reported in each systematic review.ResultsWe retrieved 4,022 articles. After removing duplicates and screening, we included 14 systematic reviews.Male-partner interventions were effective in increasing skilled birth attendance (SBA) postnatal visits and maternal antiretroviral (ART) uptake for HIV-positive pregnant women. However, there was no evidence of their effectiveness on increased early ANC initiation or adequate ANC visits.Mobile health interventions were effective in increasing adequate ANC visits, SBA, facility-based service utilisation, early ANC initiation, and adherence to nutritional supplements.Incentive-based interventions, particularly financial incentives, were effective in increasing the number of ANC visits but not postnatal visits.Facility-based interventions were effective in increasing postnatal visits, maternal ART initiation and uptake, immunisation uptake and follow-up ANC visits. None of the reviews assessed their impact on SBA or adequate ANC visits.Community-based interventions were effective in increasing SBA, ANC service utilisation, ART initiation and uptake, and nutritional supplements and immunisation uptake.ConclusionOur findings show that the different interventions effectively improved different outcomes on the maternal healthcare continuum. Implementing these interventions in combination has the potential to enhance healthcare service uptake further.

Effects of mHealth Interventions on Improving Antenatal Care Visits and Skilled Delivery Care in Low- and Middle-Income Countries: Systematic Review and Meta-analysis.

BackgroundThe poor coverage of essential maternal services, such as antenatal care (ANC) and skilled delivery care utilization, accounts for higher maternal and infant mortality in low- and middle-income countries (LMICs). Although mobile health (mHealth) interventions could potentially improve the service utilization in resource-limited settings, their effectiveness remains unclear.ObjectiveThis review aimed to summarize the effect of mHealth interventions on improving the uptake of ANC visits, skilled birth attendance at the time of delivery, and facility delivery among pregnant women in LMICs.MethodsWe conducted a comprehensive search on 9 electronic databases and other resources from inception to October 2020. We included individual randomized controlled trials and cluster randomized controlled trials that assessed the effectiveness of mHealth interventions for improving perinatal health care utilization among healthy pregnant women in LMICs. We performed a random-effects meta-analysis and estimated the pooled effect size by using risk ratios (RRs) with 95% CIs. In addition, 2 reviewers independently assessed the risk of bias of the included studies by using the Cochrane risk of bias tool and the certainty of the evidence by using the Grading of Recommendation, Assessment, Development and Evaluation approach.ResultsA total of 9 studies (10 articles) that randomized 10,348 pregnant women (n=6254, 60.44% in the intervention group; n=4094, 39.56% in the control group) were included in this synthesis. The pooled estimates showed a positive effect of mHealth interventions on improving 4 or more ANC visit utilizations among pregnant women in LMICs, irrespective of the direction of interventions (1-way communications: RR 2.14, 95% CI 1.76-2.60, I2=36%, 2 studies, moderate certainty; 2-way communications: RR 1.17, 95% CI 1.08-1.27, I2=59%, 3 studies, low certainty). Only 2-way mHealth interventions were effective in improving the use of skilled birth attendance during delivery (RR 1.23, 95% CI 1.14-1.33, I2=0%, 2 studies, moderate certainty), but the effects were unclear for 1-way mHealth interventions (RR 1.04, 95% CI 0.97-1.10, I2=73%, 3 studies, very low certainty) when compared with standard care. For facility delivery, the interventions were effective in settings where fewer pregnant women used facility delivery (RR 1.68, 95% CI 1.30-2.19, I2=36%, 2 studies, moderate certainty); however, the effects were unclear in settings where most pregnant women already used facility delivery (RR 1.01, 95% CI 0.97-1.04, I2=0%, 1 study, low certainty).ConclusionsmHealth interventions may contribute to improving ANC and skilled delivery care utilization among pregnant women in LMICs. However, more studies are required to improve their reproducibility and efficiency or strengthen the evidence of different forms of mHealth interventions because of the considerable heterogeneity observed in the meta-analyses.Trial RegistrationPROSPERO CRD42020210813; https://tinyurl.com/2n7ny9a7

Antenatal Doppler screening for fetuses at risk of adverse outcomes: a multicountry cohort study of the prevalence of abnormal resistance index in low-risk pregnant women

IntroductionFew interventions exist to address the high burden of stillbirths in apparently healthy pregnant women in low- and middle-income countries (LMICs). To establish whether a trial on the impact of...

Barriers to uptaking HIV testing among pregnant women attending antenatal clinics in low- and middle-income countries: A systematic review of qualitative findings.

Human immunodeficiency virus (HIV) testing is a gateway to HIV treatment, care and preventive services for pregnant women attending antenatal clinics. Despite this, uptake of HIV testing is not optimal among pregnant women in many low- and middle-income countries (LMICs) and it could negatively impact the effectiveness of prevention of mother-to-child transmission of HIV programs. To understand the factors that hinder the uptake of HIV testing among pregnant women attending antenatal clinics in LMICs. A systematic search of the CINAHL, EMBASE, JSTOR, Medline, PubMed and Web of Science electronic databases was performed. We limited the search to peer-reviewed qualitative studies including mixed method studies. The titles and abstracts of the retrieved publications were screened for relevance then information was extracted. Our search yielded 2179 citations, out of which 312 full-text articles were reviewed and 22 studies that met the eligibility criteria were included in this review. We found that a lack of HIV testing kits, poor health infrastructure and shortage of healthcare workers were the main health system-related factors. Poor HIV knowledge, fear of HIV test results, HIV-related stigma and social exclusion negatively influenced pregnant women's decision to be tested for HIV. This review has identified that pregnant women faced a wide range of health system, individual, social and lack of women's empowerment related challenges that negatively influenced the uptake of HIV testing among pregnant women in LMICs. Our findings would be useful in developing strategies to overcome barriers that could enhance the uptake of HIV testing among pregnant women.

Interventions on Food Security and Water Uses for Improving Nutritional Status of Pregnant Women and Children Younger Than Five Years in Low-Middle Income Countries: A Systematic Review.

Malnutrition is a global health issue concerning children and pregnant women in low- and middle-income countries (LMICs). The aim of this review was to assess the health-impact outcomes of interventions addressing food security, water quality and hygiene in order to address the improvement of the nutritional status in children below five years and pregnant women in LMICs. Using PRISMA procedures, a systematic review was conducted by searching in biomedical databases clinical trials and interventions for children and pregnant women. Full articles were screened (nf = 252) and critically appraised. The review included 27 randomized and non-randomized trials and interventions. Based on the analysis, three agents concerning nutritional status were identified. First, exclusive breastfeeding and complementary feeding were fundamental elements in preventing malnutrition. Second, provision of sanitation facilities and the promotion of hygienic practices were also essential to prevent infections spread and the consequent deterioration of nutritional status. Finally, seasonality was also seen to be a relevant factor to consider while planning and implementing interventions in the populations under study. In spite of the efforts conducted over last decades, the improvement in food insecurity rates has remained insufficient. Therefore, the development of global health programs is fundamental to guide future actions.

Impact of Dietary Interventions during Pregnancy on Maternal, Neonatal, and Child Outcomes in Low- and Middle-Income Countries.

Optimal nutrition plays a crucial role in pregnancy. Maternal malnutrition is a risk factor for maternal, fetal, and neonatal complications and is more prevalent in low and middle-income countries (LMICs). This review aims to study the effectiveness of antenatal macronutrient nutritional interventions on maternal, neonatal, and child outcomes. We searched the CENTRAL, PubMed, Embase, and other databases for randomized controlled trials and quasi-experimental designs on healthy pregnant women in LMICs. We also searched grey literature and reports from Google Scholar, Web of Science, and websites of different organizations. Title/abstract screening, full-text screening, and data extraction filtered 15 studies for inclusion. Balanced energy protein (BEP) supplementation (n = 8) studies showed a reduced incidence of perinatal mortality, stillbirths, low birth weight (LBW) infants, small for gestational age (SGA) babies and increased birth weight. Food distribution programs (FDPs) (n =5) witnessed reduced rates of SGA, stunting, wasting, and increased birth weight and birth length. Studies on intervention for obesity prevention (n = 2) showed reductions in birth weight. Other findings were statistically insignificant. Subgroup analyses were conducted to study the effectiveness of supplementation between regions, location, the timing of supplementation and nutritional status; however, there were a limited number of studies in each subgroup. Data from our review supports the antenatal supplementation of BEP and FDP for the prevention of adverse maternal, neonatal, and child outcomes that can be utilized for future policymaking. However, more research is required before recommending obesity prevention programs.

Maternal immunization in Malawi: A mixed methods study of community perceptions, programmatic considerations, and recommendations for future planning

BackgroundSafe, effective vaccines are given to pregnant women to protect their infants and/or themselves against certain infectious agents; however, apart from tetanus vaccination, maternal immunization in low- and middle-income countries (LMICs) remains low. Tetanus toxoid vaccine is integrated into antenatal care services in Malawi with high coverage and provides an opportunity to identify factors that facilitate successful immunization delivery to pregnant women in LMICs. MethodsPATH and the University of Malawi’s Centre for Social Research conducted a mixed-methods study in 2015 to document community perceptions of maternal immunization, using tetanus vaccine as an example, and to identify factors perceived to be important to successfully introducing other maternal vaccines, such as influenza vaccine, in Malawi. We conducted 18 focus group discussions with pregnant and recently pregnant women and their family members and 76 semi-structured interviews with pregnant and recently pregnant women, community leaders, health workers, public health program managers, non-governmental partners, and policy makers. ResultsWe identified factors perceived to support the introduction of new maternal vaccines, including strong maternal vaccine acceptance in the community, an existing strategy for maternal tetanus vaccine delivery, and positive health workers’ views about the introduction of additional maternal vaccines. Potential challenges to adoption and acceptance included identifying and tracking the target population and monitoring adverse events, and the need to ensure operational capacity of the health system to support the introduction and wide-scale use of an additional vaccine. For influenza vaccine specifically, additional challenges included limited awareness of influenza disease and its low prioritization among health needs. ConclusionsLessons from the successful delivery of maternal tetanus immunization in Malawi may be informative for similar countries considering new vaccines for pregnant women or striving to optimize the delivery of those currently provided.

Interventions for reducing and/or controlling domestic violence among pregnant women in low- and middle-income countries: a systematic review

BackgroundDomestic violence (DV) during pregnancy is recognized as a global health problem associated with serious health consequences for both the mother and her baby. Several interventions aimed at addressing DV around the time of pregnancy have been developed in the last decade, but they are primarily from developed countries. Low- and middle-income countries (LMICs) are facing both a mounting burden of DV as well as severe resource constraints that keep them from emulating some of the effective interventions implemented in developed settings. A systematic review was conducted to examine the approaches and effects of interventions designed for reducing or controlling DV among pregnant women in LMICs.MethodsElectronic databases were systematically searched, and the search was augmented by bibliographic reviews and expert consultations. Two reviewers assessed eligibility and quality of the studies and extracted data independently. The third reviewer was involved to resolve any discrepancies between the reviewers. Due to the limited number of studies and varied outcomes, a meta-analysis was not possible. Primary outcomes of this review included frequency and/or severity of DV and secondary outcomes included mental health, safety behaviours, and use of community resources. In addition, findings from the critical appraisal of studies were utilised to inform the initial draft of Theory of Change (ToC).ResultsOnly five studies (two randomized trials and three non-randomized trials) met the eligibility criteria. The interventions consisting of supportive counselling demonstrated a reduction in DV and an improvement in use of safety behaviours. One study has embedded the DV intervention into an existing program on human immunodeficiency virus (HIV). Limited evidence could be drawn for outcomes such as quality of life and the use of community resources.DiscussionThis review attempted to address the knowledge gap by collating evidence on interventions aimed at addressing DV among pregnant women in LMICs. The development of a ToC was critical in understanding how certain activities led to the desired outcomes. This ToC can guide the design of future research and development of practice guidelines. The participatory involvement of the stakeholders is recommended to refine the current ToC to support its further development for practice.Systematic review registrationPROSPERO, CRD42017073938

Global inequities in dietary calcium intake during pregnancy: a systematic review and meta-analysis.

BackgroundEvidence shows that adequate calcium intake during pregnancy reduces the risk of hypertensive disorders of pregnancy. In most low‐ and middle‐income countries (LMICs) the daily calcium intake is well below recommendations. Mapping calcium intake during pregnancy worldwide and identifying populations with low calcium intake will provide the evidence base for more targeted actions to improve calcium intake.ObjectiveTo assess dietary calcium intake during pregnancy worldwide.Search strategy MEDLINE and EMBASE (from July 2004 to November 2017).Selection criteriaCross‐sectional, cohort, and intervention studies reporting calcium intake during pregnancy.Data collection and analysisFive reviewers working in pairs independently performed screening, extraction, and quality assessment. We reported summary measures of calcium intake and calculated the weighted arithmetic mean for high‐income countries (HICs) and LMICs independently, and for geographic regions, among studies reporting country of recruitment, mean intake, and total number of participants. When available, inadequate intakes were reported.Main resultsFrom 1880 citations 105 works met the inclusion criteria, providing data for 73 958 women in 37 countries. The mean calcium intake was 948.3 mg/day (95% CI 872.1–1024.4 mg/day) for HICs and 647.6 mg/day (95% CI 568.7–726.5 mg/day) for LMICs. Calcium intakes below 800 mg/day were reported in five (29%) countries from HICs and in 14 (82%) countries from LMICs.ConclusionThese results are consistent with a lack of improvement in calcium dietary intake during pregnancy and confirm the gap between HICs and LMICs, with alarmingly low intakes recorded for pregnant women in LMICs. From the public health perspective, in the absence of specific local data, calcium supplementation of pregnant women in these countries should be universal.Tweetable abstractDespite dietary recommendations, women in LMICs face pregnancy with diets low in calcium.

Interventions for domestic violence among pregnant women in low- and middle-income countries: a systematic review protocol

BackgroundViolence during pregnancy is a global problem, associated with serious health risks for both the mother and baby. Evaluation of interventions targeted for reducing or controlling domestic violence (DV) is still in its infancy, and the majority of findings are primarily from high-income countries (HICs). Therefore, there is an urgent need for generating evidence of DV interventions among pregnant women in low- and middle-income countries (LMICs).MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be employed to structure the review. A comprehensive search will be carried out via electronic databases including MEDLINE, CINAHL, Scopus, Embase, Web of Science, PsycINFO, and The Cochrane library. Gray literature will also be scrutinized for potential articles. An optimal search strategy has been developed following consultations with subject-matter experts and librarians. This search strategy will be adapted to the different databases. Experimental studies evaluating DV interventions among pregnant women from LMICs will be included in the review. The review will only include literature written in English. Two reviewers will independently screen and assess studies for inclusion in the review. A third author will resolve any discrepancies between the reviewers. Risk of bias will be assessed based on the Cochrane risk of bias assessment tool, and overall quality of the evidence will be judged using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Findings will be presented with the narrative synthesis, and if applicable, they will be further quantified using random-effects meta-analysis. Effect size, risk ratio for dichotomous variables, and standardized mean differences for continuous variables will be calculated for each outcome using Review Manager 5.3.DiscussionSystematic reviews to evaluate the efficacy of interventions to address DV within the perinatal context have been limited. Hence, no one intervention has emerged as substantially effective towards addressing perinatal DV and associated health consequences. The evidence generated from this systematic review will inform researchers and policy makers about the effectiveness of existing DV interventions among pregnant women in LMICs and provide recommendations for future research in this area. This in turn will contribute towards violence prevention in LMICs.Systematic review registrationPROSPERO CRD42017073938

Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review.

IntroductionMaternal and neonatal mortality remains high in many low- and middle-income countries (LMIC). Availability and use of mobile phones is increasing rapidly with 90% of persons in developing countries having a mobile-cellular subscription. Mobile health (mHealth) interventions have been proposed as effective solutions to improve maternal and neonatal health. This systematic review assessed the effect of mHealth interventions that support pregnant women during the antenatal, birth and postnatal period in LMIC.MethodsThe review was registered with Prospero (CRD42014010292). Six databases were searched from June 2014–April 2015, accompanied by grey literature search using pre-defined search terms linked to pregnant women in LMIC and mHealth. Quality of articles was assessed with an adapted Cochrane Risk of Bias Tool. Because of heterogeneity in outcomes, settings and study designs a narrative synthesis of quantitative results of intervention studies on maternal outcomes, neonatal outcomes, service utilization, and healthy pregnancy education was conducted. Qualitative and quantitative results were synthesized with a strengths, weaknesses, opportunities, and threats analysis.ResultsIn total, 3777 articles were found, of which 27 studies were included: twelve intervention studies and fifteen descriptive studies. mHealth interventions targeted at pregnant women increased maternal and neonatal service utilization shown through increased antenatal care attendance, facility-service utilization, skilled attendance at birth, and vaccination rates. Few articles assessed the effect on maternal or neonatal health outcomes, with inconsistent results.ConclusionmHealth interventions may be effective solutions to improve maternal and neonatal service utilization. Further studies assessing mHealth’s impact on maternal and neonatal outcomes are recommended. The emerging trend of strong experimental research designs with randomized controlled trials, combined with feasibility research, government involvement and integration of mHealth interventions into the healthcare system is encouraging and can pave the way to improved decision making on best practice implementation of mHealth interventions.

Micronutrients in pregnancy in low- and middle-income countries.

Pregnancy is one of the more important periods in life when increased micronutrients, and macronutrients are most needed by the body; both for the health and well-being of the mother and for the growing foetus and newborn child. This brief review aims to identify the micronutrients (vitamins and minerals) likely to be deficient in women of reproductive age in Low- and Middle-Income Countries (LMIC), especially during pregnancy, and the impact of such deficiencies. A global prevalence of some two billion people at risk of micronutrient deficiencies, and multiple micronutrient deficiencies of many pregnant women in LMIC underline the urgency to establishing the optimal recommendations, including for delivery. It has long been recognized that adequate iron is important for best reproductive outcomes, including gestational cognitive development. Similarly, iodine and calcium have been recognized for their roles in development of the foetus/neonate. Less clear effects of deficiencies of zinc, copper, magnesium and selenium have been reported. Folate sufficiency periconceptionally is recognized both by the practice of providing folic acid in antenatal iron/folic acid supplementation and by increasing numbers of countries fortifying flours with folic acid. Other vitamins likely to be important include vitamins B12, D and A with the water-soluble vitamins generally less likely to be a problem. Epigenetic influences and the likely influence of micronutrient deficiencies on foetal origins of adult chronic diseases are currently being clarified. Micronutrients may have other more subtle, unrecognized effects. The necessity for improved diets and health and sanitation are consistently recommended, although these are not always available to many of the world’s pregnant women. Consequently, supplementation programmes, fortification of staples and condiments, and nutrition and health support need to be scaled-up, supported by social and cultural measures. Because of the life-long influences on reproductive outcomes, including inter-generational ones, both clinical and public health measures need to ensure adequate micronutrient intakes during pregnancy, but also during adolescence, the first few years of life, and during lactation. Many antenatal programmes are not currently achieving this. We aim to address the need for micronutrients during pregnancy, the importance of micronutrient deficiencies during gestation and before, and propose the scaling-up of clinical and public health approaches that achieve healthier pregnancies and improved pregnancy outcomes.

Perinatal distress in women in low- and middle-income countries: allostatic load as a framework to examine the effect of perinatal distress on preterm birth and infant health.

In low- and middle-income countries (LMIC), determinants of women’s and children’s health are complex and differential vulnerability may exist to risk factors of perinatal distress and preterm birth. We examined the contribution of maternal perinatal distress on preterm birth and infant health in terms of infant survival and mother–infant interaction. A critical narrative and interpretive literature review was conducted. Peer-reviewed electronic databases (MEDLINE, Embase, Global Health, CINHAL), grey literature, and reference lists were searched, followed by a consultation exercise. The literature was predominantly from high-income countries. We identify determinants of perinatal distress and explicate changes in the hypothalamic–pituitary–adrenal axis, sympathetic, immune and cardiovascular systems, and behavioral responses resulting in pathophysiological effects. We suggest cultural–neutral composite measures of allostatic mediators (i.e., several biomarkers) of maternal perinatal distress as objective indicators of dysregulation in body systems in pregnant women in LMIC. Understanding causal links of maternal perinatal distress to preterm birth in women in LMIC should be a priority. The roles of allostasis and allostatic load are considered within the context of the health of pregnant women and fetuses/newborns in LMIC with emphasis on identifying objective indicators of the level of perinatal distress and protective factors or processes contributing to resilience while facing toxic stress. We propose a prospective study design with multiple measures across pregnancy and postpartum requiring complex statistical modeling. Building research capacity through partnering researchers in high-income countries and LMIC and reflecting on unique ethical challenges will be important to generating new knowledge in LMIC.

A Risk Prediction Model for the Assessment and Triage of Women with Hypertensive Disorders of Pregnancy in Low-Resourced Settings: The miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) Multi-country Prospective Cohort Study

Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications. From 1 July 2008 to 31 March 2012, in five LMICs, data were collected prospectively on 2,081 women with any hypertensive disorder of pregnancy admitted to a participating centre. Candidate predictors collected within 24 hours of admission were entered into a step-wise backward elimination logistic regression model to predict a composite adverse maternal outcome within 48 hours of admission. Model internal validation was accomplished by bootstrapping and external validation was completed using data from 1,300 women in the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) dataset. Predictive performance was assessed for calibration, discrimination, and stratification capacity. The final miniPIERS model included: parity (nulliparous versus multiparous); gestational age on admission; headache/visual disturbances; chest pain/dyspnoea; vaginal bleeding with abdominal pain; systolic blood pressure; and dipstick proteinuria. The miniPIERS model was well-calibrated and had an area under the receiver operating characteristic curve (AUC ROC) of 0.768 (95% CI 0.735-0.801) with an average optimism of 0.037. External validation AUC ROC was 0.713 (95% CI 0.658-0.768). A predicted probability ≥25% to define a positive test classified women with 85.5% accuracy. Limitations of this study include the composite outcome and the broad inclusion criteria of any hypertensive disorder of pregnancy. This broad approach was used to optimize model generalizability. The miniPIERS model shows reasonable ability to identify women at increased risk of adverse maternal outcomes associated with the hypertensive disorders of pregnancy. It could be used in LMICs to identify women who would benefit most from interventions such as magnesium sulphate, antihypertensives, or transportation to a higher level of care.