Outcome of unbooked pregnancies at the Federal Medical Centre, Owerri, Nigeria

Onwube OC.[1], Nzeribe EA[1]

[1]Department of Obstetrics and Gynaecology, Federal Medical Centre,  Owerri – Nigeria

ABSTRACT
Background: Booking in pregnancy has been found to significantly influence the maternal and perinatal outcome of pregnancy. Unbooked pregnancies contribute to adverse maternal and perinatal outcomes. Some paturients in Owerri, South eastern Nigeria and environs have the erroneous idea that booking was not important for safe motherhood.

Objectives: The study was to determine the maternal and perinatal outcomes of unbooked versus booked  pregnancies.The maternal outcomes examined included normal deliveries, instrumental vaginal deliveries, caesarean sections and maternal mortality. The perinatal outcomes included an evaluation of Apgar scores and perinatal mortality.
Design: It was a retrospective comparative study
Setting: The study was carried out at the Federal Medical Center,Owerri South-eastern Nigeria between January, 2010 and December, 2011.

Methodology: The labour ward records of all deliveries in the Centre between January 2010 and December 2011were examined and data collected from the theatre and Special care baby unit to determine the maternal and perinatal outcomes. Paturients who registered their pregnancies and received antenatal care in the Centre were termed booked, while those seen in labour for the first time irrespective of whether they registered elsewhere or not, were termed unbooked. Data was analysed using standard electronic calculators.

Results: There were a total of Six thousand, six hundred and seventy five (6675) deliveries within the period under review with a total of 680 unbooked pregnancies giving an overall incidence of 10.2%. The incidence was10.12% for 2010 and 10.24% for 2011respectively. In all the indices used to assess maternal and perinatal outcome, there was a more favourable outcome in the booked parturients compared to those who were unbooked.

Conclusion: The study goes on to re- emphasize the contribution of the unbooked mother to bad obstetric indices. The unbooked mother increases the risk of operative deliveries, maternal mortality, birth asphyxia and perinatal mortality.

INTRODUCTION
A pregnant woman is said to have been 'booked' or have appropriate antenatal care (ANC) if she has had at least four antenatal visits and received among other things tetanus immunization[1,2]. The unbooked mother is one who did not register her pregnancy for antenatal care or one who delivers within three visits or less. It has been established that antenatal care provides an opportunity for risk assessment and monitoring of pregnancy and this is expected to result in improved maternal and fetal/perinatal outcome[3]. Reports from Benin City, Nigeria revealed that lack of antenatal care increased the maternal mortality risk bymorethantenfold[4].
Antenatal care being one of the pillars of safe motherhood initiative is expected to positively contribute to the achievement of the third sustainable development goal which is good health and wellbeing.  Despite this, the unbooked pregnancy continues to constitute a huge health burden to the obstetricians and health system in the developing countries. They have been credited with contributing no fewer than 70% of all hospital maternal deaths in Nigeria[2,5,6].General and health education as well as improved transport, antenatal care  and health care facilities has been suggested as a means of improving utilization of antenatal care services[7].

In the developing countries, the combination of poverty, illiteracy, religious beliefs, unskilled health care providers, relatives and traditional birth attendants continue to contribute to the problem. This issue is not much of a problem in the developed countries as result of more awareness, higher literacy rates among mothers and availability of health insurance as well as affordable cost for better antenatal care services. In a study done in Papua New Guinea, financial reasons were given for unbooked status as well as a lack of education[8]. However, in South Africa and Saudi Arabia where the antenatal services are free, a good number of women remain unbooked[5,9] any reason for this?.

The reason why the unbooked mother has not bothered to attend the antenatal clinic has been repeatedly asked[2] as well as how her non-attendance might affect the outcome of her pregnancy, especially in view of the high perinatal and fetal wastage among these mothers.[7,8,9] It is against the backdrop of the latter that this study sought to find out the incidence, and maternal and perinatal outcomes of unbooked pregnancies in our area of practice. This will provide data for use by health care providers and government for proper advocacy while advocating for the pregnant mother to book for antenatal care.

MATERIALS AND METHODS
This was a retrospective comparative study of the outcome of unbooked pregnancies managed at the Federal Medical Centre, (FMC) Owerri in South eastern Nigeria.
The delivery records of all women who delivered  between January 2010 and December 2011 were recovered and analyzed using standard electronic calculators. The booking status, mode of delivery (caesarean section/Spontaneous Vaginal Delivery / Instrumental Vaginal Delivery), and maternal mortality incomplete statement. The perinatal outcome includes an assessment of live birth, apgar score and fresh or macerated still birth. Patients who registered their pregnancies and received antenatal care at least four or more times in FMC were termed booked, while other women seen in labour for the first time irrespective of whether they registered elsewhere or not were termed unbooked. However, women who attended antenatal care at least four times with a qualified caregiver outside FMC were also considered booked. The hospital receives patients from private clinics, general hospitals, mission homes and maternity centres from Owerri and surrounding villages and even from neighbouring states of Abia, Anambra and Rivers. Emergency care is rendered for the first 24 hours irrespective of the patients financial capabilities.

RESULTS
Over the two year period, there were a total of 6,675 deliveries out of which 680 were unbooked pregnancies giving an overall incidence of 10.19%. The year specific incidence of unbooked pregnancies was 10.12% for 2010 and 10.24% for 2011 respectively.

The caesarean section rate for the whole population in 2010 was 19.62%. For the booked population, caesarean section rate was 16.6% in 2010 while that for the unbooked population was 46.44%. The likelihood for Caeserean section was 2-3 times more in the unbooked than the booked paturient. (Table 3 and 4) these tables should have been up beneath the table of“gross data” for 2010
The maternal mortality rate in 2010 for the booked population was 191 per 100,000 registered live births while in the unbooked population it was 2,373 per 100,000 registered live births.
The maternal mortality rate for the general population was 446 per 100, 000 births in 2010 and 266 per 100, 000 births in 2011. However, in the unbooked population it was 2,373 per 100, 000 births in 2010 and 1818 per 100,000 births in 2011(Tables 3 and 4).
In 2010, there were 55 cases of vacuum delivery, 39 were in the booked population while 16 were in the unbooked population. The rate of vacuum delivery was 1.49% in the booked population and 5.42% in the unbooked population. Therefore, an unbooked woman was 4 times more likely to have a vacuum delivery than in the booked patient in 2010.
In 2011, of the 85 cases of vacuum delivery, 62 were in the booked population while 23 were in the unbooked population. The rate of vacuum delivery was 1.84% in the booked population and 5.97% in the unbooked population. Therefore, an unbooked mother was 3 times more likely to undergo vacuum delivery than a booked mother in 2011.

Perinatal morbidity as reflected by perinatal asphyxia was also noted to be much higher in the unbooked pregnancies. Perinatal asphyxia was diagnosed when the 5th minute APGAR score was less than 6 and good APGAR score was diagnosed when the 5th minute APGAR score was 6 or greater. Seventy-seven (25.58%) neonates of unbooked mothers in 2010 and 85 (21.04%) neonates of unbooked mothers in 2011 were asphyxiated.(See Table 5 and 6).

In the booked population, 3.6% (95) of neonates were asphyxiated in 2010 while 2.28% (77) of neonates were asphyxiated in 2011. Therefore, the neonate of an unbooked mother was seven times more likely to be asphyxiated in 2010 and nine times more likely to be asphyxiated in 2011 than the neonate of a booked mother.  A summation of the fetal outcome irrespective of the year of occurrence is more relevant.The stillbirth rate for the unbooked pregnancies in 2010 was 256/1000 births or 25.6% and increased to 309/1000 births or 30.9% in 2011. This is in sharp contrast with the booked population where the stillbirth rate in 2010 for the booked population was 53/1000 births or 5.3% and decreased to 17/1000 births or 1.7% in 2011. So while the stillbirth rate in the unbooked population increased, the rate in the booked population drastically reduced.

DISCUSSION
Unbooked pregnancies constitute a huge obstacle to achieving sustainable development goals number 3 which focuses on good health and well being. The incidence of the unbooked pregnancy in FMC Owerri was found to be approximately 10%. This is lower than in Abia State University Teaching Hospital (17%)[3], Universty of Benin Teaching Hospital (21%)[4], and Obafemi Awolowo University Teaching Hospital (29%)[10]. It is the same as at University of Uyo Teaching Hospital (10.3%)[2].
At the University of Calabar Teaching Hospital in 2012, C.U. Iklaki et al reported an incidence of 27.4%11, but this was essentially the incidence among teenage pregnant women. This is not surprising looking at the demographics for unbooked mothers. The unbooked mother is most likely to be young, unemployed and most likely to be from a lower socio-economic class.[11]
Unbooked pregnancies have been found to correlate directly with increased perinatal and maternal morbidity and mortality.[12,13,14,15]. This is because the unbooked mother was most likely referred to the hospital after complications have arisen. The parameters used to assess the maternal outcome included caesarean section rate, rate of instrumental vaginal deliveries and maternal mortality. In 2010, the maternal mortality rate in the booked population was 446/100000 births while it was 2373/100000 births in the unbooked population. In 2011, the maternal mortality rate in the booked population was 266/100000 births and 1818/100000 births in the unbooked population. In 2010 therefore, an unbooked mother was 5 times more likely to die from childbirth and 6 times more likely to die in 2011. This is a setback for the battle against maternal mortality.
Caesarean section rate was almost more than double in the unbooked population with almost half of the unbooked mothers undergoing emergency caesarean section (See results above). The rate of vacuum delivery in the unbooked population was also very high. In 2010, of the 55 cases of vacuum delivery, 39 were in the booked population while 16 were in the unbooked population. The rate of vacuum delivery was 1.49% in the booked population and 5.42% in the unbooked population. Therefore, an unbooked woman was 4 times more likely to have a vacuum delivery than in the booked patient in 2010.  In 2011, of the 85 cases of vacuum delivery, 62 were in the booked population while 23 were in the unbooked population. The rate of vacuum delivery was 1.84% in the booked population and 5.97% in the unbooked population. Therefore, an unbooked mother was 3 times more likely to undergo vacuum delivery than a booked mother in 2011.
The parameters used in assessing perinatal outcome included perinatal asphyxia and still birth (macerated still births and fresh still births). It was difficult to track cases of early neonatal deaths in the 1st 7 days of life because some may have been discharged and may now present at the special care baby unit or outside the hospital.
Perinatal morbidity and mortality was also on the very high side in the unbooked population. Ekwempu C.C. in a retrospective study in 1988 showed clearly that proper antenatal care was associated with a three- fold reduction in perinatal loss and virtual elimination of fetal loss from stillbirth.[15]
Perinatal morbidity as reflected by perinatal asphyxia was also noted to be much higher in the unbooked pregnancies. Seventy seven (25.58%) neonates of unbooked mothers in 2010 and 85 (21.04%) neonates of unbooked mothers in 2011 were asphyxiated (See Table V&VI).
In the booked population only 3.6% (95) of neonates were asphyxiated in 2010 while only 2.28% (77) of neonates were asphyxiated in 2011.
Therefore, the neonate of an unbooked mother was 7 times more likely to be asphyxiated in 2010 and 9 times more likely to be asphyxiated in 2011. Perinatal asphyxia is a cankerworm that will continue to torment the baby and the family for the rest of their lives. Hypoxic ischaemic encephalopathy may leave some of these neonates with neurological deficiencies and with growth and mental retardation. A long follow-up will be required to find out how these babies fare.
The perinatal mortality rate in 2010 was 261/1000 births in the unbooked population and 63/1000 births in the booked population. In 2011, the perinatal mortality rate was 309/1000 births for the unbooked and 17/1000 births for the booked population. This is a lot more than the report by Madike et al, of 44/1000births among the unbooked population in Velden hospital in Limpopo South Africa.[16, 17]
The neonate of an unbooked mother was 4 times more likely to die during labour in 2010 and 18 times more likely to die in 2011. The contrast here is that stillbirth rate was reduced in the booked population in 2011 but was increasing in the unbooked population.
There was a paucity of patients in July 2010. This was due to an industrial action that affected clinical activities in the hospital.
In conclusion, it is overwhelmingly clear that booking and indeed early booking is one of the measures that will impact positively on perinatal and maternal morbidity and mortality in our society. The health personnel, the churches/mosques, the school and the government must come together to ensure that the issue of booking can be made acceptable to the women and their husbands. Further awareness must be created on the importance of antenatal care in maternal and child health. Antenatal care should also be made accessible, available and affordable to all women.

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