The epidemiology and risk factors for postnatal complications among postpartum women and neonates in Southwestern Uganda: a prospective cohort study

<br/><strong>Background:</strong> Sub-Saharan Africa accounts for two-thirds of the global burden of maternal and newborn deaths. Adverse outcomes among postpartum women and newborns occurring in the first six weeks of life are often related, though data co-examining patients are limited. This study is an exploratory analysis describing the epidemiology of postnatal complications among postpartum women and newborns following facility birth and discharge in Mbarara, Uganda.<br/> <br /><strong>Methods: </strong> This single-site prospective cohort observational study enrolled postpartum women following facility-based delivery. To capture health information about both the postpartum women and newborns, data was collected and categorized according to domains within the continuum of care including (1) social and demographic, (2) pregnancy history and antenatal care, (3) delivery, (4) maternal discharge, and (5) newborn discharge. The primary outcomes were readmission and mortality within the six-week postnatal period as defined by the WHO. Multivariable logistic regression was used to identify risk factors. <br /> <br /><strong>Findings: </strong> Among 2930 discharged dyads, 2.8% and 9.0% of women and newborns received three or more postnatal visits respectively. Readmission and deaths occurred among 108(3.6%) and 25(0.8%) newborns and in 80(2.7%) and 0(0%) women, respectively. Readmissions were related to sepsis/infection in 70(88%) women and 68(63%) newborns. Adjusted analysis found that caesarean delivery (OR:2.91; 95%CI:1.5–6.04), longer travel time to the facility (OR:1.54; 95%CI:1.24–1.91) and higher maternal heart rate at discharge (OR:1.02; 95%CI:1.00–1.01) were significantly associated with maternal readmission. Discharge taken on all patients including maternal haemoglobin (per g/dL) (OR:0.90; 95%CI:0.82–0.99), maternal symptoms (OR:1.76; 95%CI:1.02–2.91), newborn temperature (OR:1.66; 95%CI:1.28–2.13) and newborn heart rate at (OR:1.94; 95%CI:1.19–3.09) were risk factors among newborns. Readmission and death following delivery and discharge from healthcare facilities is still a problem in settings with low rates of postnatal care visits for both women and newborns. Strategies to identify vulnerable dyads and provide better access to follow-up care, are urgently required. <br /> <br /><strong>Data Collection Methods:</strong> This prospective cohort study aimed to enroll women presenting in labor at >28 weeks’ gestation who delivered liveborn infants and were routinely discharged together home with their infants. Following delivery, we obtained written consent to complete a structured questionnaire in-person and a follow-up questionnaire over the phone six weeks later. Specifically, following enrolment, research nurses prospectively collected study variables previously identified through two systematic reviews on risk factors for re-admission and mortality among postpartum women and infants, as well as through discussion with colleagues and other experts. Given the interactive health relationship between postpartum women and infants, variables were collected and categorized according to relevant time points across the continuum of care. A total of 86 variables were collected and broadly categorized into five domains: (1) social and demographic, (2) pregnancy history and antenatal care, (3) delivery, (4) maternal discharge, and (5) neonatal discharge (Table 4A-E). Apart from discharge measurements, we prioritized gathering data from the hospital medical record, followed by interviews with the postpartum women and finally confirmation with the medical team if there were discrepancies, missing information, or questions the postpartum woman was unable to answer. With respect to discharge measurements, we obtained and recorded clinical data for both mother and their newborns on every dyad discharged together from the hospital. Blood pressure was measured using a Welch Allyn Vital Signs Monitor 300 Series (Welch Allyn, New York, USA). Oxygen saturation (SpO2) and heart rate was measured using the Masimo iSpO2® (Masimo Corporation, California, USA) and respiratory rates were measured using the RRate Application. Maternal hematocrit was quantified using a microhematocrit centrifuge. Random blood glucose was measured on mother and newborn using the FreeStyle Optimum Xceed (Abbott Healthcare, Massachusetts, USA). Anthropometric data of infants (length, weight, mid-upper arm circumference (MUAC), head circumference) were also measured and recorded. All dyads received routine care during admission and were discharged at the discretion of their medical teams. Six weeks following discharge, women who were discharged with their newborns were contacted by phone to determine the status of the mother and newborn and timing and frequency of postnatal care visits. For children who died, the cause of death was collected, as reported by the caregiver (mother or other family member). In addition to vital status, details surrounding the timing, frequency and length of stay pertaining to readmissions and health seeking were also recorded. Data were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at the BC Children’s Hospital Research Institute in Vancouver, Canada.<br /> <br /><strong>Data Processing Methods:</strong>The initial cleaned data file was created using R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria). Further processing to obtain the final dataset used for analysis including creating new columns, removing redundant columns, and removing duplicate data were also performed in R in the R scripts titled “MBEPI2024_DataManipulations_Code_SD.R” and “MBEPI2024_CombinedDatasetforOR_Code_SD.R” . All analyses were conducted using R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria)<br/> <br /><strong>Ethics Declaration:</strong> Institutional review boards at the University of British Columbia (H18-02523), the Mbarara University of Science and Technology (14/09-18), and the Uganda National Council for Science and Technology (SS 4853) approved the study.<br />

背景：撒哈拉以南非洲承担了全球三分之二的母婴死亡负担。产后女性与新生儿在出生后最初六周内发生的不良结局往往存在关联，但同时考察两类患者的数据较为有限。本研究为探索性分析，旨在描述乌干达姆巴拉拉地区机构分娩并出院的产后女性及新生儿的产后并发症流行病学特征。<br/> <br/>方法：本研究为单中心前瞻性队列观察性研究，纳入机构分娩后的产后女性。为收集产后女性与新生儿的健康信息，研究依据连续护理领域对数据进行采集与分类，包括（1）社会人口学特征；（2）妊娠史与产前护理；（3）分娩情况；（4）产妇出院信息；（5）新生儿出院信息。主要结局指标为世界卫生组织（WHO）定义的产后六周内再入院率与死亡率。研究采用多变量逻辑回归分析识别风险因素。<br/> <br/>结果：在2930对出院母婴配对（dyads）中，分别有2.8%的女性和9.0%的新生儿接受了三次及以上产后访视。新生儿的再入院率与死亡率分别为3.6%（108例）和0.8%（25例），女性则为2.7%（80例）和0%（0例）。在再入院病例中，88%（70例）的女性与63%（68例）的新生儿与败血症/感染相关。校正分析显示，剖宫产（比值比OR:2.91；95%置信区间CI:1.5–6.04）、前往机构的行程时间较长（OR:1.54；95%CI:1.24–1.91）及出院时产妇心率较高（OR:1.02；95%CI:1.00–1.01）与产妇再入院显著相关。新生儿的风险因素包括出院时采集的所有患者数据，如产妇血红蛋白水平（每克/分升，OR:0.90；95%CI:0.82–0.99）、产妇症状（OR:1.76；95%CI:1.02–2.91）、新生儿体温（OR:1.66；95%CI:1.28–2.13）及新生儿心率（OR:1.94；95%CI:1.19–3.09）。在产后女性与新生儿访视率均较低的环境中，机构分娩出院后的再入院与死亡仍是一个突出问题。目前迫切需要制定策略以识别脆弱母婴配对，并改善其随访护理可及性。<br/> <br/>数据采集方法：本前瞻性队列研究旨在纳入孕周>28周、分娩活产婴儿且与婴儿一同常规出院回家的女性。分娩后，研究人员获取书面知情同意，通过面对面结构化问卷及六周后的电话随访问卷收集数据。具体而言，入组后，研究护士前瞻性采集研究变量——这些变量通过两项关于产后女性与婴儿再入院及死亡风险因素的系统综述，以及与同事和其他专家的讨论确定。考虑到产后女性与婴儿间的健康互动关系，研究根据连续护理过程中的相关时间点对变量进行采集与分类。共采集86个变量，大致分为五个领域：（1）社会人口学特征；（2）妊娠史与产前护理；（3）分娩情况；（4）产妇出院信息；（5）新生儿出院信息（表4A-E）。除出院测量数据外，研究优先从医院病历中收集数据，其次通过访谈产后女性获取，若存在数据差异、缺失或产后女性无法回答的问题，则最终向医疗团队确认。对于出院测量数据，研究获取并记录了每对一同出院母婴的临床数据：血压使用美国纽约Welch Allyn公司的Welch Allyn 300系列生命体征监测仪测量；血氧饱和度（SpO2）与心率使用美国加利福尼亚Masimo公司的Masimo iSpO2®设备测量；呼吸频率使用RRate应用程序测量；产妇红细胞压积通过微量红细胞压积离心机定量；产妇与新生儿的随机血糖使用美国马萨诸塞州雅培医疗公司的FreeStyle Optimum Xceed血糖仪测量；婴儿的人体测量数据（身长、体重、上臂中段围（MUAC）、头围）也被测量并记录。所有母婴配对在入院期间接受常规护理，出院时间由其医疗团队决定。出院六周后，研究人员通过电话联系与新生儿一同出院的女性，以确定母婴状态及产后访视的时间与频率。对于死亡儿童，研究收集照料者（母亲或其他家庭成员）报告的死亡原因。除生命状态外，研究还记录了再入院与就医行为的时间、频率及住院时长等细节。数据通过加拿大温哥华不列颠哥伦比亚省儿童医院研究所托管的研究电子数据采集系统（REDCap）进行采集与管理。<br/> <br/>数据处理方法：初始清理数据文件使用奥地利维也纳R统计计算基金会开发的R语言4.2.1版本创建。为获得用于分析的最终数据集，后续处理（包括创建新列、删除冗余列及重复数据）同样通过R语言完成，对应的R脚本为《MBEPI2024_DataManipulations_Code_SD.R》与《MBEPI2024_CombinedDatasetforOR_Code_SD.R》。所有分析均使用R语言4.2.1版本进行。<br/> <br/>伦理声明：本研究经不列颠哥伦比亚大学机构审查委员会（IRB，编号H18-02523）、姆巴拉拉科学技术大学机构审查委员会（编号14/09-18）及乌干达国家科学技术委员会（编号SS 4853）批准。<br/>