High and Low-Risk Pregnancies at the First Clinic Visit Requirement of Shared Care and Special Care in Pregnancy

Abstract

Despite the fact that Sri Lanka carries the lowest maternal mortality ratio (MMR) in the South Asian region, with 33.8 maternal deaths per 100,000 live births in the year 2016, Sri Lankan maternal mortality ratio is at a static state, with over 30 MMR for the past decade. The maternal risk assessment is conducted at the first clinic visit for all pregnant women registered with the system. While this service has been in practice for a long period, there are no published data on the low and high-risk pregnancies and the burden of shared care to the system. This study was conducted as a cross-sectional analysis of an ongoing cohort of pregnant females in Anuradhapura district, the Rajarata Pregnancy Cohort Study, covering all 22 MOH areas. A total number of 3374 mothers were recruited for the study. The mean age of the sample was 27.9. 85.8%(n=2896) participants attended their first clinic visit on or before 12 weeks of period of amenorrhoea (POA). Teenagers accounted for 7.5%(n=254) and 13.3%(n=449) were at the age of 35 or more. Primigravida women accounted for 30.9% (n=1041). Considering the primigravida women also as high risk, at least a single risk factor was detected in 90.6% (n=3058) of participants. The number of participants categorized as at risk due to complicated past obstetric history was 37%(n=1247). Categorized as risk due to conditions in present pregnancy was 79.3%(n=2675). Due to other disease conditions, 9.9%(n=333) were categorised as risk pregnancies. 2%(n=68) of pregnant females were categorized as high risk due to social factors such as unmarried or widowed. Of the 2329 multigravida women, 2015(86.5%) had at least one of the risk factors listed. Among 1041 primigravida women, 732(70.3%) had risk factors. Without considering the gravidity as a risk factor, 2749(81.5%) were categorised as risk pregnancies. The observation of more than 90% of women either being a primigravida or having a risk factor at the time of first clinic visit raises several queries about the current practice. While the pregnancy is classified as “low” and “high” based on the risk profile, our comprehensive analysis shows that more than 90% of pregnancies are actually having “high risk” for complications and require special attention. Health system adaptations and policy changes may be required, focusing on risk factors that actually require shared care and those with high complication rates. Prospective evaluation of pregnancy outcomes needs to be conducted to generate evidence for this proposed practice.