Epidemiology, diagnosis, and care-seeking related to risk factors for intrapartum-related fetal and neonatal death in rural Nepal

Intrapartum-related complications are the second leading cause of neonatal death. To better target this cause, this thesis examines the epidemiology of intrapartum-related mortality and morbidity in rural Nepal, and assesses the feasibility of community-based antenatal diagnosis of risk factors for intrapartum-related complications, including non-cephalic presentation, multiple gestation, and placenta previa. The research was nested in the Nepal Oil Massage Study, conducted in rural Sarlahi District, Nepal. The research consisted of several components: 1) a community-based prospective cohort study to examine the incidence of third-trimester obstetric risk factors and their associations with adverse pregnancy outcomes, 2) a community-based cross-sectional survey to understand the awareness and utilization of obstetric ultrasonography in the study area, 3) a community-based validation study to examine how accurately lower-level health workers with limited training can use portable ultrasound to detect three major risk factors of adverse intrapartum-related pregnancy outcomes: non-cephalic position, multiple gestation, and poor placental position / placenta previa, 4) in-depth interviews with mothers who recently experienced a non-cephalic birth and/or female decision-makers in their household to discuss their care-seeking behavior and risk perception toward non-cephalic presentation, and 5) focus groups with women in the community pertaining to the same topic. We observed a very high risk of adverse intrapartum-related outcomes associated with non-cephalic and multiple birth respectively. Many women who experienced these conditions were undiagnosed prior to delivery. Only about a quarter of the women in our community received an obstetric ultrasound exam during their most recent pregnancy. Lower-level health workers with limited training were able to diagnose non-cephalic position and multiple gestation with high validity using ultrasonography. Despite the very high adverse outcome rate among non-cephalic births, the perceived risk of the condition varied widely. Fetal and neonatal mortality and morbidity attributable to intrapartum-related complications have fallen at a much slower pace than those attributable to other causes. We highlighted here the potential for targeting low-prevalence, but high-risk obstetric risk factors to reduce the health burden in low-resource settings caused by intrapartum-related complications