Research Proposal On

Pregnancy Complication and Mode of Delivery Differed in Public and Private Hospital in Bangladesh

Dr. Ummul Khair Alam Roll No: 13 Course: MPH (RCH) Session 2011 2012

Department of Maternal and Child Health

National Institute of Preventive and Social Medicine

(NIPSOM)
Mohakhali, Dhaka 1212.

Contents
Chapter 1: introduction
1.1 Introduction of the study 1.2 Background of the study 1.3 Justification of the study 1.4 Research questions 1.5 Objectives 1.6 List of key variables 1.7 Operational definitions 1.8 Limitations of the study Chapter II: literature review Chapter III: literature review 3.1 Study design 3.2 Place of study 3.3 Study period 3.4 Study population 3.5 Sample size 3.6 Sampling procedure 3.7 Data collection technique 3.8 Data collection instrument 3.9 Data handling and processing 3.10 Ethical implication

1.1 Introduction:

In Bangladesh, like many other developing countries among the major underlying factors leading to poor maternal situation include very low percentages of women actually seek professional medical assistance for pregnancy related care, deliveries and complications. to identify the factors associated with modes of delivery assistance in Bangladesh. To reach our goal this study is done. It was observed that almost all the deliveries (88.8%) took place at the homes of the women and most of them (85.6%) were assisted by untrained traditional birth attendants, relatives or neighbours in unsafe and unhygienic conditions. Only 14.4% of the deliveries were assisted by the medically trained persons such as registered physicians, nurses or paramedics. The rate of receiving assistance from medically trained personnel was lower among mothers utilizing insufficient antenatal health care services. Middle aged women received delivery assistance more from medically trained personnel than the adolescents and women with higher age group. The main contributing factors likely to affect delivery practices were mass media exposure, husband's occupation, education, antenatal care received, type of toilet facilities and household quality index. The high-risk group such as adolescents and higher aged women need special care and the existing health management system may be strengthened to create awareness among mothers of these groups for seeking appropriate measures from the beginning of pregnancy. There is need to ensure the availability of maternal health care centres for providing antenatal care and expand and improve the quality of normal delivery at home by trained providers and introduce post-partum visits. It is equally important that education for women is emphasised to bring about a lasting impact on the overall health condition of women.Safe motherhood begins before conception with proper nutrition and a healthy lifestyle and continues with appropriate prenatal care, the prevention of complications, and the early and effective treatment of complications. The ideal result is a full-term pregnancy, the delivery of a healthy infant, and a healthy postpartum period in a positive environment that supports the physical and emotional needs of the woman, infant, and family.

Unfortunately, pregnancy complications still do occur. CDCs Division of Reproductive Health conducts research to understand the burden of maternal complications and death and to decrease disparities among populations at risk of death and complications from pregnancy.A woman dies from complications in childbirth every minute about 529,000 each year -- the vast majority of them in developing countries. A woman in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth, compared to a 1 in 4,000 risk in a developing country the largest difference between poor and rich countries of any health indicator. This glaring disparity is reflected in a number of global declarations and resolutions. In September 2001, 147 heads of states collectively endorsed Millennium Development Goals 4 and 5: To reduce child mortality rate by 2/3 and maternal mortality ratio by 3/4 between 1990 and 2015. Strongly linked to these is Goal 6: To halt or begin to reverse the spread of HIV/AIDS, malaria and other diseases. The direct causes of maternal deaths are haemorrhage, infection, obstructed labour, hypertensive disorders in pregnancy, and complications of unsafe abortion. There are birth-related disabilities that affect many more women and go untreated like injuries to pelvic muscles, organs or the spinal cord. At least 20% of the burden of disease in children below the age of 5 is related to poor maternal health and nutrition, as well as quality of care at delivery and during the newborn period. And yearly 8 million babies die before or during delivery or in the first week of life. Further, many children are tragically left motherless each year. These children are 10 times more likely to die within two years of their mothers' death. Another risk to expectant women is malaria. It can lead to anaemia, which increases the risk for maternal and infant mortality and developmental problems for babies. Nutritional deficiencies contribute to low birth weight and birth defects as well. HIV infection is an increasing threat. Mother-to-child transmission of HIV in lowresource settings, especially in those countries where infection in adults is continuing to grow or has stabilised at very high levels, continues to be a major problem, with up to 45 per cent of HIV-infected mothers transmitting infection to their children. Further, HIV is becoming a major cause of maternal mortality in highly affected countries in Southern Africa. A majority of these deaths and disabilities are preventable, being mainly due to insufficient care during pregnancy and delivery. About 15 per cent of pregnancies and childbirths need emergency obstetric care because of complications that are difficult to predict. Access to skilled care during pregnancy, childbirth and the first month after delivery is key to saving these women's lives and those of their children. Helping improve emergency obstetric care. Almost half of births in developing

countries take place without a skilled birth attendant. That ratio rises to 65 per cent in South Asia. Research shows the single most important intervention for safe motherhood is to make sure that a trained provider with midwifery skills is present at every birth that transport is available to referral services, and that quality emergency obstetric care is available. UNICEF works with the United Nations Population Fund (UNFPA), the World Health Organization (WHO) and other partners in countries with high maternal mortality in a well-defined supporting role as part of an emerging global partnership for maternal, newborn and child health. to ensure that emergency obstetric care is a priority in national health plans,including Poverty Reduction Strategy Papers (PRSPs) and Sector-Wide Approaches (SWAps), and assists its partners and governments with assessments, training and logistics. Laying the foundations for good prenatal care. Out of 100 women aged 15-40, 30 do not have antenatal care 46 in South Asia and 34 in sub-Saharan Africa. The results of this deficiency include untreated hypertensive disorders leading to death and disability, or unmarked mal- or sub-nutrition. Iron deficiency anaemia among pregnant women is associated with some 111,000 maternal deaths each year. Some 17 per cent of infants in developing countries had low birth weight in 2003,and these babies are 20 times more likely to die in infancy. provide information to women and their families on signs of pregnancy complications, on birth spacing, timing and limiting for nutrition and health, and on improving the nutritional status of pregnant women to prevent low birth weight or other problems. A comprehensive community programme also promotes and helps provide anti-malarial therapy and insecticide-treated bed nets. Tetanus, a bacterial disease thats a result of unhygienic and unsafe childbirth delivery practices, killed 200,000 newborns and 30,000 mothers in 2001 alone. Along with buying and helping provide tetanus immunizations for pregnant women, to stave off anaemia and birth defects all of which lead to healthier mothers and babies. Helping prevent mother-to-child transmission of HIV for prevention of mother-tochild transmission (PMTCT) programmes within existing maternal and child services in resource-poor settings. This includes advocacy on distributing ARV to young women and parents with HIV/AIDS as part of UNICEF's support of the 3 by 5 Initiative program with the World Health Organization, which aims to ensure that 3 million people have access to antiretroviral treatment by the end of 2005. Services may also include voluntary and confidential counselling and testing for HIV/AIDS. If an expectant mother has the virus or AIDS, she is counselled on how to help prevent transmitting the disease to her child, including safer breastfeeding practices.

Getting girls to school. Helping governments provide a quality primary school education, a UNICEF priority, also benefits maternal and infant health particularly education for girls. Educating girls for six years or more drastically and consistently improves their prenatal care, postnatal care and childbirth survival rates. Educating mothers also greatly cuts the death rate of children under five. Educated girls have higher self-esteem, are more likely to avoid HIV infection, violence and exploitation, and to spread good health and sanitation practices to their families and throughout their communities. And an educated mother is more likely to send her children to school. Data on skilled attendants at delivery is available for only 74 per cent of live births in the developing world. The evidence we do have shows that, apart from Sub-Saharan Africa, delivery care has improved significantly in all regions, though not all countries have shared equally in improvements. Only 17 per cent of countries are on track to meet their Goals. In developing countries as a whole, the per cent of births attended by a skilled health professional has increased by more than a quarter - that is, from 42 per cent to 53 per cent over the decade. From 1990 to 2000, the percentage of births attended by a medical professional in Asia rose 35 per cent. Unfortunately, in Sub-Saharan Africa where maternal mortality is highest, the levels have improved only 5 per cent. Since 1999, 32.7 million women at risk have been protected against tetanus by a twodose course. And UNICEF is now working in 158 countries for girls education. By the end of 2004, more than 100 countries had established PMTCT programs, of which 13 had achieved national coverage.

1.2 Background of the study: Complications of pregnancy are the symptoms and problems that are associated with pregnancy. There are both routine problems and serious, even potentially fatal problems.

Conditions or pathological processes associated with pregnancy. They can occur during or after pregnancy, and range from minor discomforts to serious diseases that require medical interventions. They include diseases in pregnant females, and pregnancies in females with diseases. The routine problems are normal complications, and pose no significant danger to either the woman or the fetus. Serious problems can cause both maternal death and fetal death if untreated. Pregnancy Warning Sign :Back pain
y y

Common, particularly in the third trimester when the patient's center of gravity has shifted. Treatment: mild exercise, gentle massage, heating pads, paracetamol (acetaminophen), and (in severe cases) muscle relaxants or narcotics

Carpal tunnel syndrome

y

Occurs in between an estimated 21% to 62% of cases, possibly due to edema.[1]

Constipation
y

Cause: decreased bowel motility secondary to elevated progesterone (normal in pregnancy), which causes the "smooth muscle" along the walls of the intestines to relax. Thus, making sure that the future mother will absorb as much nutrients from her diet as possible in order to nourish the fetus and herself. As a side effect the feces can get extremely dehydrated and hard to pass.[2] Treatment: increased PO fluids, stool softeners, bulking agents Drinking plenty of water and eating fruit and fiber enriched foods often help

A woman experiencing sudden defecation should report this to her practitioner. Contractions
y y y y

occasional, irregular, painless contractions that occur several times per day are normal and are known as Braxton Hicks contractions Caused by: dehydration Treatment: fluid intake regular contractions (every 10-15 min) are a sign of preterm labor and should be assessed by cervical exam.

Dehydration
y y

Caused by: expanded intravascular space and increased Third spacing of fluids Treatment: fluid intake

Complication: uterine contractions, which may occur because dehydration causes body release of ADH, which is similar to oxytocin in structure. Oxytocin itself can cause uterine contractions and thus ADH can cross-react with oxytocin receptors and also cause contractions.

Edema
y y

Caused by: compression of the inferior vena cava (IVC) and pelvic veins by the uterus leads to increased hydrostatic pressure in lower extremities. Treatment: raising legs above the heart, patient sleeps on her side.

Gastroesophageal Reflux Disease (GERD)

y y

Caused by: relaxation of the lower esophageal sphincter (LES) and increased transit time in the stomach (normal in pregnancy) Treatment: antacids, multiple small meals a day, avoid lying down within an hour of eating, H2 blockers, proton pump inhibitors

Hemorrhoids
y

Caused by: increased venous stasis and IVC compression leading to congestion in venous system along with increased abdominal pressure secondary to constipation. Treatment: topical anesthetics, steroids, treatment of constipation

Pica
y

cravings for nonedible items such as dirt or clay. Caused by Iron deficiency which is normal during pregnancy and can be overcome with Iron supplements or prenatal vitamins. Commonly, avoid ice chips; it may worsen anemia

Lower abdominal pain

y y

Caused by: rapid expansion of the uterus and stretching of ligaments such as the round ligament. Treatment: paracetamol (acetaminophen)

[edit] Increased urinary frequency

y

Caused by: increased intravascular volume, elevated GFR (glomerular filtration rate), and compression of the bladder by the expanding uterus. Patients are advised to continue fluid intake despite this. Urinalysis and culture should be ordered to rule out infection, which can also cause increased urinary frequency but typically is accompanied by dysuria (pain when urinating).

[edit] Varicose veins

y y y y

Caused by: relaxation of the venous smooth muscle and increased intravascular pressure. Treatment: elevation of the legs, pressure stockings relieve swelling and pain with warm sitz bath. Avoid obesity, lengthy standing or sitting, constrictive clothing and constipation and bearing down with bowel movements

[edit] Diastasis recti or abdominal separation

y y

Caused by: excessive stretching of the abdominal muscles. Treatment: paliative care, surgery and/or rehabilitation after childbirth

[edit] Serious maternal problems The following problems originate mainly in the mother. [edit] Pelvic girdle pain (PGP)
y

Caused by: PGP disorder is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers from peripheral or central nervous system, altered laxity/stiffness of muscles, laxity to injury of tendinous/ligamentous structures to mal-adaptive body mechanics. Musculo-Skeletal Mechanics involved in gait and weightbearing activities can be mild to grossly impaired. PGP can begin peri or postpartum. For most women PGP resolves in weeks after delivery but for some it can last for years resulting in a reduced tolerance for weightbearing activities. Treatment: The degree of treatment is based on the severity. A mild case would require rest, rehabiltation therapy and pain is usually manageable. More severe cases would also include mobility aids, strong analgesics and sometimes surgery. One of the main factors in helping women cope is with education, information and support. Many treatment options are available.

[edit] Severe hypertensive states Further information: Gestational hypertension Potential severe hypertensive states of pregnancy are mainly:
y y y y

Preeclampsia = gestational hypertension, proteinuria (>300 mg), and edema. Severe preeclampsia involves a BP over 160/110 (with additional signs) Eclampsia = seizures in a preeclamptic patient HELLP syndrome = Hemolytic anemia, Elevated liver enzymes and low platelet count Acute fatty liver of pregnancy is sometimes included in the preeclamptic spectrum.

[edit] Deep vein thrombosis For more info on DVT and pregnancy, see Deep vein thrombosis. Deep vein thrombosis (DVT) has an incidence of 0.5 to 7 per 1,000 pregnancies, and is the second most common cause of maternal death in developed countries after bleeding.[3]
y y

Caused by: Hypercoagulability as a physiological response to potential massive bleeding at childbirth. Treatment: Prophylactic treatment, e.g. with low molecular weight heparin may be indicated when there are additional risk factors for deep vein thrombosis.[3]

[edit] Serious fetal problems The following problems occur in the fetus or placenta, but may have serious consequences on the mother as well. [edit] Ectopic pregnancy (implantation of the embryo outside the uterus) Main article: Ectopic pregnancy
y y

Caused by: Unknown, but risk factors include smoking, advanced maternal age, and prior damage to the Fallopian tubes. Treatment: If there is no spontaneous resolution, the pregnancy must be aborted either surgically or by the drug methotrexate.

[edit] Placental abruption (separation of the placenta from the uterus) Main article: Placental abruption
y y

Caused by: Various causes; risk factors include maternal hypertension, trauma, and drug use. Treatment: Immediate delivery if the fetus is mature (36 weeks or older), or if a younger fetus or the mother is in distress. In less severe cases with immature fetuses, the situation may be monitored in hospital, with treatment if necessary.

[edit] Multiple pregnancies Main article: Multiple birth#Risks Multiples may become monochorionic, sharing the same chorion, with resultant risk of twin-to-twin transfusion syndrome. Monochorionic multiples may even become monoamniotic, sharing the same amniotic sac, resulting in risk of umbilical cord compression and entanglement. In very rare cases, there may be conjoined twins, possibly impairing function of internal organs.

[edit] n No. 1: Bleeding During Any Trimester Pregnancy Warning Sign No. 2: Severe Nausea and Vomiting Pregnancy Warning Sign No. 3: The Babys Activity Level Significantly Declines Pregnancy Warning Sign No. 4: Contractions Early in the Third Trimester Pregnancy Warning Sign No. 5: Your Water Breaks Pregnancy Warning Sign No. 6: A Persistent Severe Headache, Abdominal Pain, Visual Disturbances, and Swelling During Your Third Trimester Pregnancy Warning Sign No. 7: Flu Symptoms During pregnancy, you may face three diabetes-related health risks:
y

Vision and kidney complications. Vision problems due to retinopathy can sometimes worsen during pregnancy. In addition, some women experience high blood pressure by the third trimester of pregnancy. High blood pressure can lead to kidney damage. Keeping your blood glucose under tight control before and during pregnancy can help prevent these complications. Childbirth problems. If your baby is larger than normal, your doctor may ask you to give birth a little earlier or to have a cesarean delivery. This is because a very large baby can be bigger than the actual birth canal, so a standard childbirth approach might cause injury to you and your baby. Hypoglycemia. If you are trying to keep your blood glucose in tight control, you may sometimes have hypoglycemia. Although low blood glucose does not harm your developing baby, repeated hypoglycemia episodes might create health problems for you.

Justification of the study:

Its a public health important issue. Many studies had done regarding this topic in the past. I will do this study for further improvement of the issue by providing baseline information to the policy maker.

Research question:
Is there any difference between private and public hospital in case of mode of delivery due to pregnancy complications ?

Objectives:
General objective: To compare the mode of delivery related to pregnancy complications between private and public hospital. Specific objectives: 1. To find out the mode of delivery and pregnancy complications in public hospital. 2. To find out the mode of delivery and pregnancy complications in private hospital. 3. To compare the study between private and public hospital. 4. To find out the socio-demographic factors of the respondence.

List of key variables:

a. Variables related to socio-economic status: I. II. III. IV. V. VI. VII. VIII. IX. Age Sex Religion Educational status Marital status Personal income Occupational status Monthly family income Housing.

b. Variables related to pregnancy complications: c. Variables related to mode of delivery d. Variables related to comparison between private and public hospital.

Operational definitions:
Age: in completed years. Mother: age between 15-45 years Pregnancy complications: all the complications that hampers normal pregnancy. Mode of delivery: Normal delivery, facilitated delivery, caeserian section.. Formal education Monthly income Chronic disease Private hospital Public hospital

Limitations of the study:

1. One of the limitations of the study was that it was conducted on a small sample size and the study place was selected purposively due to time constraint and it did not necessarily reflect the situation of the whole country. 2. Limitation in resource and time. 3. Recall bias.

Materials and Methods

A cross sectional comparative study will be conducted to find out the difference between private and public hospital in case of mode of delivery due to pregnancy complications will be selected from Dhaka Medical College Hospital and Central Hospital, Dhaka. This study will be accomplished as per following methodology:

Study design: This study will be carried out by cross sectional comparative study in Dhaka Medical College Hospital and Central Hospital, Dhaka. . Study Place: Dhaka Medical College Hospital and Central Hospital, Dhaka.
. Study period: from January, 2012 to June, 2012.

3.4

Study Population

Depending upon the availability and other facility, size of the sample will be determined.

3.4.1 Inclusion Criteria

It is proposed that all the women who are willing to participate

3.4.2 Exclusion Criteria

y y Unwilling to participate Physically and mentally unfit women

3.5 Sample size: Sample size will be determined by using the following formula

3.6

Sampling procedure

Sampling will be done by purposively.

3.7 Data collection technique: phase to phase technique with administration of written question and record review. 3.8 Data collection instrument: questionnaire

3.9 Data handling and processing

At the end of each day of data collection, each questionnaire will be checked to see whether it is filled completely and consistently. The data entry will be started

immediately after completion of data collection. Data processing and analyses will be done using SPSS (Statistical Package for Social Sciences) version 17. Data will be analyzed according to the objectives of the study. The test statistics used to analyze the

data will be descriptive statistics, Chi square (x2), t test and ANOVA . The results will be presented in the form of tables and graphs.

Ethical implications
The study will be done through collection of data using questionnaire and neither any intervention nor any invasive procedures will be undertaken. However, prior to initiation of the study ethical clearance will be taken from appropriate Ethical Committee. Before initiation of the interview a brief introduction on the aims and objectives of the study will be presented to the respondents. They will be informed about their full right to participate or refuse to participate in the study. The researcher would assure the respondents that there will be as no invasive procedure included in the study and all the findings of the study would be used to guide the service providers and policy makers for the improvement of rural women. A complete assurance will be given to them that all information provided by them would be kept confidential and their names or anything which can identify them would not be published or exposed anywhere. Their participation and contribution will be acknowledged with due respect. After completion of these procedures the interview will be started with their due consent.