Intrauterine foetal and child growth in the context of Ethiopian Health system: Implications for Prenatal care : Intrauterine foetal growth and child linear growth in Ethiopia
Doctoral thesis
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https://hdl.handle.net/11250/3053808Utgivelsesdato
2023-03-09Metadata
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Sammendrag
Fostervekst og vekst hos små barn på den etiopiske landsbygd.
Etiopia er fortsatt et av verdens fattigste land, og bruken av helsetjenester er lav. Mødre dødeligheten er også høy. Og, mange barn har både akutt og kronisk underernæring. Det er derfor behov for studier til å bedre forståelsen av fostervekst og barns vekst. Bedre innsikt av intrauterin fostervekst er en viktig for tidlig identifisering av normal og unormal fostervekst, noe som kan påvirke fødselsvekt ved fødselen og vekst i tidlig barndom. Målsetningen med denne avhandlingen var å måle intrauterin fostervekst, og se hvorledes barns lengdevekst var i de første to leveår. Avhandlingen vurderer også hvorledes slike mål kan brukes i den eksisterende mødre- og barnehelsetjenesten på den etiopiske landsbygd.
Studien ble utført i den sentrale delen av Riftdalen i Etiopia. Omtrent 700 gravide kvinner ble undersøkt, og deres barn ble fulgt opp til de var omtrent to år. Studieområdet er et typisk landbruksområde, har gjentatte ganger vært rammet av tørke og hungersnød.
Selv om det har vært matmangel i området, viser studien at intrauterin vekst er sammenlignbart med Verdens helseorganisasjon (WHO) og INTERGROWTH-21st referansene. Imidlertid er det mange barn som får en lav lengdevekst de først to år. Dette kan forklares både med faktorer under graviditeten og årsaker som oppstår i de tidlige barneårene.
I den siste artikkelen i avhandlingen beskrives og analyseres hvorledes svangerskapsomsorgen fungerer sammenlignet med de nasjonale og WHOs retningslinjer. Det er betydelige mangler med dagens graviditetskontroller. Det er derfor viktig å styrke mor-barn helsearbeidet. Introduction
Ethiopia is a country with a low coverage of antenatal care services. In 2019, only 43% of pregnant women had the recommended four antenatal care (ANC) visits during their pregnancy while 24% of women in Ethiopia had no ANC visits at all. Different national initiatives are underway to expand and improve maternal health services utilization. These are aligned with international and national agendas and goals.
In the first 1000 days of life, starting from the time of conception, growth is viewed as a continuum between the foetal period, infancy, and early childhood. Foetal growth is dynamic. Defining normal or abnormal foetal growth requires the taking of serial measurements. If the foetal growth is abnormal, it can result in low birth weight or prematurity. Low birth weight and prematurity are major contributors of neonatal and infant mortality and morbidity.
ANC is an important care point that has a positive influence in identifying pregnancy-related complications. It can also contribute to improved pregnancy outcomes. Ethiopia implemented the World Health Organization’s (WHO) focused ANC (FANC) model at all health facilities until February 2022, which was a goal orientated approach to delivering evidence-based interventions carried out at four critical times during pregnancy.
Population specific foetal growth charts that can be used to monitor foetal growth patterns are lacking, particularly in areas affected by food insecurity and drought such as are found in Ethiopia. Moreover, the influence of intrauterine uterine growth on birth weight and early childhood growth has not been examined in this country. In addition, even though ANC is taken as an opportunity for influencing the well-being of pregnant mothers and growing foetus, the evidence supporting a relationship between ANC and adverse pregnancy outcomes is unclear in Ethiopia.
Objective
The overall objective of this thesis was to examine intrauterine and child growth in a drought-affected rural area of Ethiopia in the context of the country’s health system. The first objective was to assess intrauterine uterine growth patterns in comparison to the WHO and the INTERGROWTH 21st intrauterine uterine growth standards. The second objective was to examine the influence of intrauterine foetal growth on length-for-age Z-score and weight-for-length Z-score in early childhood 11–24 months of age. The third objective was to assess the compliance of ANC utilization with national and WHO guidelines and whether adverse pregnancy outcomes were associated with the use of antenatal care services.
Methods
We conducted a prospective cohort study in the rural community of Adami Tullu district in the Oromia Regional State in south central Ethiopia from July 2016 to November 2018. We included 704 pregnant women, with a gestational age of less than 24 weeks and followed them to delivery. We followed the children until they were 24 months postnatal.
At enrolment, we collected data on maternal, sociodemographic and household characteristics. We also collected data on maternal weight, blood pressure, mid upper arm circumference (MUAC), haemoglobin, and malaria test results at 26, 30, and 36 weeks of gestation. We obtained foetal biometric measurements (head circumference, biparietal diameter, abdominal circumference, and femoral length) and estimated foetal weight using ultrasound at each visit. We subsequently followed the new-borns postnatally and measured their lengths and weights once at the age of 11-24 months.
Foetal weight was estimated using the Hadlock algorithm, and the 5th, 10th, 25th, 50th, 75th, 90th, and 95th centiles were generated from this model. We compared the Z-scores and percentiles of biometric measurements and estimated foetal weight with the INTERGROWTH 21st and WHO multicentre foetal growth reference standards (Paper I).
After birth, we measured the weights and lengths of 554 children at age of 11–24 months. The birth-weight-for-gestational-age Z-score was calculated using INTERGROWTH 21st international new-born birth standards. We determined Z-scores of length-for-age, weight-for-age and weight-for-length of the children using the 2006 WHO child growth standards. We used a multilevel mixed effect linear regression model to examine the influence of foetal biometric measurements, new-born (birth weight, gestational age at delivery, sex), maternal (age, height, education, occupation, parity) and household (household wealth, family size) characteristics on birth weight, child length-for-age and weight-for-age (Paper II).
We used the WHO and national ANC guidelines to compare the service utilization patterns, and collected data on ANC utilization among 704 pregnant women at three prescheduled visits during pregnancy and at birth. Data on the extent of antenatal care content received, timing of antenatal care, location of antenatal care, and location and mode of delivery were obtained by interviewing the pregnant women. Adverse pregnancy outcomes was computed as the sum of preterm birth, intrauterine foetal deaths, and stillbirths (Paper III).
Results
The distribution of biometric measurements and estimated foetal weight in our study were similar to the WHO and INTERGROWTH-21st references. Most measurements were between -2 and +2 of the reference Z-scores. Based on the smoothed percentiles, the 5th, 50th, and 95th percentiles, our study had similar distribution patterns to the WHO chart, and the 50th percentile was similar to the INTERGROWTH-21st chart (Paper I).
We found that foetal factors, duration of pregnancy, child age, maternal height and family size were the main predictors of linear growth. Both birth weights and linear growth were influenced by early intrauterine foetal growth. Birth weight was also influenced by foetal growth during late pregnancy. Environmental factors had more influence on the child’s linear growth compared to their effect on birth weight. We observed a large variation in length-for-age Z-score (30%) and weight-for-length Z-score (22%) among kebeles (local wards) than in the birth weight of new-borns (11%) indicating more heterogeneity in clusters for length-for-age Z-score and weight-for-length Z-score than for birth weight (Paper II).
We found that pregnant mothers had a poor compliance of ANC utilization compared to the national and the WHO guidelines. In addition, we found that the current FANC utilization status were not associated with the adverse pregnancy outcomes that we measured (Paper III).
Conclusions
In conclusion, this thesis demonstrated that; (i) foetal growth patterns were similar to the INTERGROWTH-21st and the WHO multicentre foetal growth reference standards, (ii) early intrauterine foetal growth affected both birth weight and linear growth while foetal growth during late pregnancy influenced birth weight only. In addition, there was more influence of environmental factors on child linear growth compared to their effects on birth weight and, (iii) ANC service utilization is low in the context of national and WHO guidelines. In addition, there was no association between the current focused antenatal health care service and adverse pregnancy outcomes.
Består av
Paper I: Meselech Roro, Wakgari Deressa and Bernt Lindtjørn. Intrauterine growth patterns in rural Ethiopia compared with WHO and INTERGROWTH-21st growth standards: A community-based longitudinal study. PLoS ONE (2019), 14(12): e0226881. The article is available at: https://hdl.handle.net/1956/23748.Paper II: Meselech Roro, Wakgari Deressa, Bernt Lindtjørn. Influence of intrauterine factors on birth weight and on child linear growth in rural Ethiopia: a prospective cohort study. PLoS ONE (2022), 17(8): e0272620. The article is available at: https://hdl.handle.net/11250/3028874.
Paper III: Meselech Roro, Wakgari Deressa, Bernt Lindtjørn. Antenatal care utilization and compliance with national and WHO guidelines in rural Ethiopia: a cohort study. BMC Pregnancy and Childbirth (2022), 22:849. The article is available at: https://hdl.handle.net/11250/3040102.