Preterm birth and associated factors among mothers who gave birth at public hospitals in Addis Ababa, Ethiopia : a facility based cross-sectional study

Technical Summary: Preterm Birth and Associated Factors in Addis Ababa Public Hospitals

Problem Statement
Preterm birth (PTB), defined as a live birth before 37 completed weeks of gestation, remains a critical public health challenge globally and specifically in Ethiopia. It is a leading cause of neonatal mortality and the second leading cause of under-five child mortality. In low-income settings like Ethiopia, limited access to quality antenatal care and skilled birth attendance exacerbates the issue. While PTB contributes significantly to neonatal morbidity and mortality, there is a scarcity of recent, facility-based evidence regarding its magnitude and specific determinants within public hospitals in Addis Ababa. Existing data is often outdated, limited to specific regions outside the capital, or lacks granularity on local risk factors.

Methodology
The study employed a facility-based cross-sectional design conducted between August 1 and August 30, 2024.

• Setting: Four public hospitals in Addis Ababa: Gandhi Memorial Hospital, Abebech Gobena Hospital, Menelik Comprehensive Specialized Hospital, and Zewditu Memorial Hospital.
• Population: 316 mothers who delivered during the study period. Inclusion criteria required mothers to know their Last Normal Menstrual Period (LNMP) or have an ultrasound before 14 weeks of gestation. Women with communication barriers (e.g., coma, hearing/speech impairments) were excluded.
• Sampling: A systematic random sampling technique was used. The sample size (n=316) was calculated based on the prevalence of PTB (24.9% from a previous study) and factors associated with PTB (using OpenEpi), with a 10% non-response rate added. Participants were selected at a regular interval (k≈8) based on the proportional delivery volume of each hospital.
• Data Collection: Data was gathered via structured face-to-face interviews using a pretested questionnaire adapted from WHO guidelines and medical record reviews. Variables included socio-demographics, obstetric history, medical conditions, and behavioral factors.
• Analysis: Data were analyzed using SPSS Version 25. Descriptive statistics summarized the data. Bivariable and multivariable logistic regression models were used to identify associated factors. Variables with p < 0.25 in bivariable analysis were entered into the multivariable model. Statistical significance was set at p < 0.05 with a 95% Confidence Interval (CI).

Key Results

• Magnitude of PTB: The study found that 17.7% (56 out of 316) of the mothers experienced a preterm birth (95% CI: 13.88–21.52).
• Socio-Demographic Profile: The majority of participants were aged 25–34 years (74.1%), married (90.5%), urban dwellers (75.3%), and had secondary education or higher (58.2%).
• Obstetric and Clinical Factors:
  • 20.9% of participants experienced Premature Rupture of Membranes (PROM).
  • 7.3% experienced Ante-partum Hemorrhage (APH).
  • 5.4% had Pregnancy-Induced Hypertension (PIH).
  • 3.8% reported Urinary Tract Infections (UTI).
  • 12.0% had at least one medical condition, with anemia (9.2%) and UTI (3.8%) being the most common.
• Associated Factors (Multivariable Analysis): Four independent factors were significantly associated with preterm birth:
  1. Pregnancy-Induced Hypertension (PIH): Mothers with PIH were 6.46 times more likely to have a PTB compared to those with normal blood pressure (AOR = 6.46; 95% CI: 3.12–14.17).
  2. Urinary Tract Infection (UTI): Mothers with UTI were 4.71 times more likely to have a PTB (AOR = 4.71; 95% CI: 3.08–7.82).
  3. Premature Rupture of Membranes (PROM): Mothers with PROM were 4.26 times more likely to have a PTB (AOR = 4.26; 95% CI: 1.94–6.8).
  4. Ante-partum Hemorrhage (APH): Mothers with APH were 3.23 times more likely to have a PTB (AOR = 3.23; 95% CI: 2.61–6.87).

Contributions and Significance
The paper claims to provide updated, context-specific evidence on the prevalence and determinants of preterm birth in Addis Ababa's public health sector.

• Prevalence Context: The observed prevalence (17.7%) is higher than the national pooled estimate for Ethiopia (10.48%) and several regional studies, but lower than reports from Jimma (25.9%) and Tanzania (39.1%). The authors attribute this variation to the study setting (tertiary referral hospitals with higher case complexity) compared to lower-level facilities in other studies.
• Clinical Implications: The study identifies specific, modifiable clinical conditions (PIH, UTI, PROM, APH) as major drivers of PTB in this setting. It underscores the need for targeted antenatal care interventions focusing on the early detection and management of these specific complications.
• Policy Relevance: The findings support the development of interventions to reduce neonatal morbidity and mortality by addressing these specific risk factors, aligning with Sustainable Development Goal 3 (SDG 3) regarding maternal and child health.

Limitations
The authors acknowledge several limitations:

• Self-Reporting: Conditions such as UTI, anemia, and malnutrition were partly based on self-reported symptoms rather than laboratory confirmation, potentially leading to over-reporting.
• Hypertension Classification: The study did not differentiate between specific types of hypertensive disorders (e.g., preeclampsia vs. gestational hypertension), grouping them generally as PIH.
• Scope: As a cross-sectional study, it identifies associations but cannot definitively establish causality.

Conclusion
The study concludes that preterm birth remains a significant public health problem in Addis Ababa, affecting nearly one in six women. The magnitude is driven significantly by obstetric complications, specifically PIH, UTI, PROM, and APH. The authors recommend strengthening antenatal care quality through the early identification and management of these specific conditions to improve maternal and neonatal outcomes.