Trends and Factors for Adverse Pregnancy Outcomes of Low-Risk Pregnancy from a Midwife Obstetric Unit in South Africa, 2018–2022

The trend of birth outcomes was recorded in a small number of research from rural South Africa. Using the most recent delivery data from 2018 to 2022, this study aims to measure trends and risk factors for context-specific demographic, obstetric, and antenatal care (ANC) for stillbirth and early neonatal deaths (ENND) of pregnant women who gave singleton births. All pregnant women who gave birth to singletons at Kwadabeka CHC (KCHC) between January 2018 and December 2022 were the focus of a retrospective cohort research. Of the total 4116 women, 60 (1.5%) delivered stillbirths and 4080 had live births. Of them, 36 were ENND, resulting in 8.8 per 1000 live births. Variables that were found to increase are ANC utilization rates from 95.4% in 2018 to a higher rate of 96.4% in 2022 (p < 0.05), who received ANC at KCHC 41.4% in 2018 to 69.6% in 2022 (p < 0.001). Variables that had a declining trend are BBA falling from 5.7% in 2018 to 3.8% in 2022 (p = 0.021) and neonatal PCR positive fell from 4.3% to 2.5 %, respectively (p = 0.001). Women having no ANC care had a higher OR = 33.18 (95% CI:3.6-301.0, p = 0.002), and ANC visits between 1–3 had an OR of 9.6 (95% CI;1.2-75.0, p = 0.03) for ENND. Variables having higher OR for stillbirths are women who had ANC at other PHC facilities (OR = 1.91, 95% CI 1.91-3.32, p = 0.02), women who never had ANC (OR = 11.7, 95% CI:2.9-45.9, p < 0.001) and ANC visits between 1–3 (OR = 4.1, 95% CI:1.38-12.1, p = 0.01). Variables that had lower OR for stillbirths are Pregnant women aged between 30–34 years (OR = 0.15, 95% CI:0.04-0.57, p = 0.005), women without HIV infection (OR = 0.56, 95% CI:0.31-0.89, p = 0.008), without syphilis infection (OR = 0.29, 95% CI:0.09-0.92) and those women had no BBA (OR = 0.16, 95% CI:0.08-0.34, p < 0.001). There were no trends for ENND and stillbirth. However, there were decreasing trends in BBA and PCR positivity rates. There were increasing trends for having ANC and having ANC at KCHC. Having no ANC or lower numbers of ANC visits were the strong risk factors for ENNDs and stillbirths. The other risk factors for stillbirths were maternal age, ANC at other PHC clinics, BBA, HIV, and syphilis infections. We suggest continuing to strengthen and promote early ANC attendance and increasing the number of ANC visits. Further studies are encouraged to identify the quality of ANC and the delivery practices that have been implemented.

Introduction

According to the global Sustainable Development Goals (SDGs), maternal and child health is a top priority in low- and middle-income nations, including South Africa (SA), since it represents the overall standard of living in a community [1], [2]. Approximately 99% of maternal deaths worldwide are thought to have occurred in developing nations in 2015, with sub-Saharan Africa accounting for 66% of these deaths [3]. Unfortunately, a significant portion of pregnancies have unfavourable pregnancy outcomes; not all of these pregnancies end in live births. Abortions, miscarriages, stillbirths, perinatal and neonatal fatalities, and maternal deaths are among the major unfavourable pregnancy outcomes [4]–[6]. Approximately 73 million of the 210 million pregnancies that occur worldwide terminate in abortion or stillbirth [7]. Perinatal deaths were responsible for around 7% of the world’s illness burden, more than the combined burden of malaria and diseases that can be prevented by vaccination, according to World Bank data [8]. These unfavourable pregnancy outcomes are a serious public health issue that affects both industrialized and developing nations [9]. Reaching SDG 3 targets, which seek to drastically lower maternal and newborn mortality by 2030, depends on ensuring healthy pregnancies and favourable pregnancy outcomes [10], [11]. Aspiration 1, goals 1 and 3 of the African Union’s (AU) 2063 agenda declare that all Africans desire to lead healthy lives and identifying and addressing the variables linked to unfavourable pregnancy outcomes is essential to achieving this goal. The United Nations Inter Agency Group for Child Mortality (UN-IAGCM) seeks to make sure that every nation is on track to meet the “Every Newborn Action Plan” (ENAP), which aims to reduce stillbirths as well as neonatal, child, and maternal mortality from preventable causes, even though the SDG 3 targets do not include foetal deaths or stillbirths [12]–[14].

Despite significant efforts and investments being made in maternal and infant health, a global analysis of stillbirth trends found stagnation in the annual global estimates of stillbirths [13]. According to a study on patterns and variables linked to unfavourable pregnancy outcomes (abortion and stillbirths) in Uganda, the number of stillbirths increased between 1996 and 2013. Because abortion is criminalized and has cultural overtones, such findings are common in African contexts [7]. As far as we are aware, no research has been done on the patterns of unfavourable pregnancy outcomes in South Africa, and little is known about these patterns at the community level. In the literature, factors linked to unfavourable pregnancy outcomes have been examined and recorded. Significant correlations between specific sociodemographic, economic, cultural, environmental, and maternal factors were discovered by earlier researchers [4], [15]. Because the studies were context-specific, the findings differed; even within the same geographic areas, these characteristics are known to be distributed differently among populations [16]. Therefore, it is crucial to avoid assuming that patterns and contributing variables to unfavourable pregnancy outcomes seen in earlier research are the same as those that could be seen in South Africa. Furthermore, the majority of this research is conducted in hospitals with low hospital service usage rates and rely on faulty data from medical records [9], [7]. From 2013 to 2017, the number of reported negative pregnancy outcomes (stillbirths, low birth weight) decreased overall [17]. Maternal and newborn fatalities have decreased in South Africa (SA) due to greatly better HIV treatment initiation, higher syphilis testing during ANC in Ethiopia, and improved labour partograph completion in India [18]–[20]. Stillbirths and maternal and neonatal mortality have decreased in South Africa [21]–[23]. Up to 50% of neonatal fatalities were avoidable, despite the fact that the rate dropped from 12 deaths per 1000 live births in 2012 to 10.7 deaths in 2018 [1], [22], [24].

Approximately 25% of maternal and newborn fatalities and stillbirths in low- and middle-income countries (LMICs) can be avoided with better prenatal and postnatal care, making it crucial to enhance the quality of maternal and neonatal healthcare (MNH) services globally [25]. The use of maternal health care services during the prenatal period, during delivery, and after delivery increased between 1998 and 2016, according to the South Africa Demographic and Health Surveys (SADHS) conducted in 1998 and 2016. For example, the percentage of children born or delivered at health facilities increased from 83% in 1998 to 96% in 2016, and 97% of deliveries were assisted by a skilled health provider in 2016 [2]. Of all births, 68% were delivered by a nurse or midwife, and 29% were attended by a physician. For rural women, the percentage of births delivered in health facilities grew somewhat, while public sector health facilities accounted for the bulk of institutional deliveries. According to antenatal care (ANC), the percentage has slightly increased from 74% in 1998 to 76% in 2016. Furthermore, from 28% in 1998 to 47% in 2016, the percentage of women who had ANC throughout the first trimester rose [2]. Overall, the percentage of women in rural regions who attended four or more ANC visits increased from 71.3% in 1998 to 79.7% in 2016, whereas the percentage of women in urban areas decreased from 77.5% in 1998 to 73.2% in 2016. Compared to women with no education (69.3%) in 1998 and those with only a primary education (69.8%) in 2016, the percentage of women with four or more visits is significantly lower. Pregnant women who had completed school and postsecondary education were more likely to have four or more ANC visits [2]. Additionally, according to the SADHS 2016, 84% of mothers and 86% of newborns in South Africa received a postnatal checkup during the first two days following delivery. KwaZulu-Natal had the lowest percentage of mothers who obtained a timely postnatal health check (80.1%), while the Western Cape and Free State had the highest percentages (91% each). Compared to women who gave birth elsewhere, those who gave birth in a medical facility had a much higher chance of receiving a postnatal health check within the first two days following delivery [2].

South Africa (SA) has a higher incidence of Perinatal Mortality Rates (PNMR) despite national and local efforts to optimize pregnancy and its outcomes. At 63 per 1000 live births, the PNMR is high for SA and higher for KZN [26]. Nearly the majority of the estimated 2.6 million stillbirths that took place globally in 2015 in underdeveloped nations [27]. Maternal age and both communicable and non-communicable illnesses, such as syphilis, HIV, Group B streptococcus, and malaria, have been linked to stillbirths, especially in sub-Saharan Africa [27]–[29]. According to estimates, nearly three-quarters of newborn deaths occur in the first few days after birth, and nearly half of stillbirths in low-income countries occur during or around the time of delivery [30], [31]. Therefore, it is believed that the woman and her foetus or newborn are most at risk of dying during the time leading up to birth. There are significant shortcomings in maternal health program initiatives in developing nations, especially in rural areas [32]. For Black and rural populations in South Africa, access to maternal health services was a significant issue. The trend of birth outcomes was recorded in a small number of research, especially from rural KZN. Using the most recent delivery data from 2018 to 2022, the current study used a rural PHC-level approach to identify the context-specific demographic, obstetric, and ANC trends and characteristics linked to unfavourable pregnancy outcomes (stillbirth and early infant mortality) of pregnant women who gave singleton births between 2018 and 2022 was the aim of this study.

Materials and Method

Study Design, Sample Selection, and Data Collection

All pregnant women who gave birth to singletons at Kwadabeka Community Health Center (KCHC) between January 2018 and December 2022 were the focus of a retrospective cohort research. From June to December 2023, information was gathered from the labor ward’s delivery register (also known as the birth registration) for every pregnant woman. All deliveries at KCHC and babies born before arrival (BBA) are officially recorded in this registry. Obstetric data as exposure, stillbirth and early neonatal mortality as outcome variables, and minimum factors pertaining to pregnant women’s personal information were all included in the register. This study did not include women who had given birth to more than one child. Age, parity, ANC, GA at booking and at delivery, ANC location (facility), number of ANC visits, ANC booking prior to 20 weeks of GA, baby born before arrival (BBA), HIV and syphilis status, neonatal gender, targeted polymerase chain reaction (PCR) test result for live birth of HIV-infected mother, stillbirth, and early neonatal death were among the variables included in this study. Using various codes, information from the maternity record was input into the Microsoft Excel application.

Setting and Population

With more than 150,000 Black residents, KCHC serves as a PHC for the residents of Kwadebeka and Clermont. These settlements are located inside eThekweni’s (Durban) municipal limits. Located in the KZN province, the City of Durban is home to South Africa’s largest port. Seven more permanent PHC clinics in the area, run by KCHC, offer PHC service packages that additionally cover prenatal and postnatal care without delivery services. Pregnant women from those clinics use KCHC for delivery services. Based on the ideas of the District Health System, which was put into place in 1994 following the democratization of South Africa, the majority of people living in Kwadebeka and Clermont are impoverished, jobless, and primarily dependent on the public health services provided by KCHC as their first point of contact for medical care. These people have a common culture with the rural populations of the provinces of KZN and the Eastern Cape. The Midwife Obstetric Unit (MOU) at KCHC provides 24-hour maternity services and is staffed by qualified midwives. According to national guidelines, this unit’s primary responsibilities include postnatal checkups, managing labour and delivery services for low-risk women, treating common pregnancy problems, providing antenatal care for low- and intermediate-risk women, managing emergencies during antenatal and delivery services, and referring patients to the appropriate hospitals (requiring level one care to district hospitals and level two care to regional hospitals) [33]. Along with additional support workers, three midwives are assigned to perform births and provide care for women and newborns during the day (7 am to 4 pm) and two midwives during the evening (4 pm to 7 am). KCHC provides antenatal care and delivery services in accordance with the national protocol and guidelines, which have been in place since 2002 and have been updated in 2016 and 2023. Pregnancy complications that are discovered during prenatal care are referred to hospitals; therefore, they are not covered in this study.

Care During ANC and Delivery for Mothers and Neonates

Anaemia, syphilis, HIV, and rhesus (Rh) blood grouping screening tests are routinely performed throughout several ANC visits in South Africa. On the same day of the test, if there are no contraindications (such as hepatitis, tuberculosis, etc.), all pregnant women are offered voluntary HIV testing and counselling for inclusion in the universal antiretroviral treatment (ART) program (lifelong ART regardless of gestation, CD4 count, viral load (VL), or clinical stage). A fixed dosage combination (FDC) of tenofovir (TDF), lamivudine (3TC), and dolutegravir (DTG) is advised for women beginning ART for the first time. To prevent HIV transmission from mother to child, FDC with one dose of Nevirapine (NVP) is immediately administered to women who are not on ART and have just been confirmed or identified as HIV positive. Lifelong ART is started after all ART medication contraindications have been ruled out. According to established standards, both mothers and their partners receive long-acting penicillin treatment if the mother’s syphilis screening tests come back positive [33]. Additional screening for Rh incompatibility, a disorder that may develop in the infant, is necessary if the mother’s Rh blood grouping is negative and the baby’s Rh blood grouping is Rh positive. In this case, the anti-Rh Abs titre is assessed for the neonates’ postpartum Anti-D vaccination [33].

An examination and assessment are performed to diagnose or categorize any obstetric and fetal hazards when a pregnant woman presents to KCHC with labor discomfort. Women with no evident risk or impending pregnancy or delivery troubles are permitted to give birth at KCHC; those with problems are sent to a hospital via an emergency medical rescue ambulance. To track the progression of labour, a partogram—a chart that records all maternal and foetal observations, fluid intake and output, and medication—is utilized. To identify labour difficulties for both women and foetuses, alert and action lines on the partogram are utilized in conjunction with other observations (such as the mother’s temperature, blood pressure (BP), foetal heart rate, etc.). Hospitalization is recommended for maternal and newborn problems or risk factors (such as elevated maternal blood pressure, eclampsia, foetal distress, etc.) during labour that cannot be treated at the MOU. Mothers and newborns are monitored for eight hours following delivery for women who give birth at the MOU without any issues. The birth register contains the demographic and obstetric data together with any observations and examination results made during and after delivery. Uncomplicated mothers and newborns are monitored for eight hours at KCHC before being sent home following appropriate counselling regarding postpartum and neonatal care, immunizations, nursing, family planning, etc. Only vaginal deliveries are carried out at KCHC; no instruments such as vacuums or forceps are used. If a mother or newborn has any complications during the postpartum period, they are also referred to the hospital. If a referred baby dies within 7 days in the hospital, it is reported to KCHC for the mother’s postnatal care. Labor augmentation is not used in this MOU. All newborns exposed to HIV get a birth polymerase chain reaction (PCR) test in order to identify HIV infection in utero. Additionally, all newborns exposed to HIV get prophylactic nevirapine (NVP) for at least six weeks after exposure. For the first six weeks of life, all high-risk newborns who are chosen to breastfeed should take extra AZT, and for at least 12 weeks, they should have NVP. NVP should not be discontinued until four weeks after the mother stops nursing or when the VL is less than 1000 copies/ml. For six weeks, AZT and NVP should be given to all high-risk newborns who are fed just formula. According to the Maternity and Neonatal Care Guidelines, the additional neonatal procedures include injectable vitamin K, BCG, and oral polio vaccine. If a baby has been exposed to tuberculosis and will be on TB prophylaxis, the BCG vaccination should be avoided [34]. Regardless of birth weight, ART should be started for all HIV-positive neonates [33].

Definition of Terms

Either at home or while traveling to KCHC, the baby was delivered before arrival (BBA). Because the facility had cared for both the mother and the newborns, these mothers were included in our analysis. When a dead foetus weighs more than 1000 g or is born beyond 28 weeks of gestation, it is referred to as a stillbirth. However, it is separated into two groups: (a) fresh stillbirths (FSB), which occur when the foetus dies during labour, and (b) macerated stillbirths (MSB), which occur when the foetus dies before the start of labour. Both of the aforementioned criteria are classified as stillbirths and expressed as percent of all single deliveries for the purposes of this study.

A neonatal death is defined as a death during the first 28 days of life (0–27 days). The NMR is often broken down into early (0–7 days) and late (8–27 days) neonatal mortality rates. Institutional neonatal mortality relates to neonatal deaths that occur within a health institution. When a live birth death occurs at KCHC or a hospital within seven days of referral, it is referred to as an early neonatal death (ENND), expressed as numbers per 1000 live births.

A targeted PCR test is a method that gives babies of HIV-positive moms a quick and precise diagnosis of neonatal HIV infection.

Ethical Considerations

UMgungundlovu Health Ethics Review Board has given ethical permission (Reference no. UHERB 015/2020). Permission was sought from the KZN Provincial Health Research Committee and the management of KCHC. Since the study used a registered review, no informed consent was required. Therefore, no patient name was required to present the results.

Data Analysis

For analysis, data from the Microsoft Excel application was imported into SPSS v24.0.1 (SPSS Inc., Chicago, IL, USA). Descriptive summary measures, which are represented as percentages for categorical variables and means with standard deviations (SD) for continuous variables, were used to summarize the patient’s baseline demographic and pregnancy outcome characteristics. The data was divided into discrete groups to analyse the major variables. The parity of pregnant women was divided into 0 (Nil), 1–2, 3–4, 4–5, and 6 or above; their ages were divided into five groups: under 20 years old (teenage), 20–24, 25–29, 30–34, and 35 years and above. The ANC location was classified as KDC and other medical institutions; ANC booking status was further documented as either Yes or No, and ANC initiation timing with gestational age (GA) was classified as booking prior to 20 weeks (Yes/No). ANC visits were divided into five categories: zero, one to three, four to six, seven to nine, and more than nine visits. Neonates’ gender was categorized as either male or female, and their HIV and syphilis status was displayed as either positive or negative. The results of the targeted birth PCR test were reported as either positive or negative and expressed in percentages of live births of HIV-positive women. In bivariate analysis, such as cross-table analysis, the dependent (exposure) and outcome variables (ENND = yes/no and stillbirth = yes/no) were correlated by Pearson Chi-square (X²) and p values (p < 0.05). Significant prospective predictors for outcome variables were identified through the use of binary logistic regression with significant exposure variables. The results of regression models were expressed using adjusted odds ratios (OR), matching two-sided 95% Confidence interval (95% CI) and associated p-values. If the P-value was 0.000 or less, it was reported as less than 0.001 (<0.001). P-values were reported to three decimal places.

Results

One percent (106) of the 4222 expecting mothers who were listed in the KCHC birth registry throughout the study period had multiple pregnancies and were not included in the analysis. Thus, 4116 women who gave birth at KCHC made up the study’s entire sample. Of these women, 60 (1.5%) gave birth to stillborn children, 4080 gave birth to living children, and 36 of them had ENND, for a total of 8.8 per 1000 live births (Table I). There were 163 (1.63%) women with BBA. Women ranged in age from 14 to 46 years old, with a mean age of 25.9 (SD = 5.7) years. The overall percentage of women who did not start ANC was 4.6%, and the rate decreased significantly from 5.5% in 2018 to 3.6% in 2022 (p < 0.05). The mean number of ANC visits for individuals who received ANC was six (SD = 2.8), with a minimum and maximum of one and twenty-three visits, respectively. The demographic and pregnancy outcome characteristics are displayed in Table I. There was no discernible rise or fall in the annual delivery numbers, which ranged from 794 (the lowest in 2021) to 848 (the highest in 2020 and 2022) (p > 0.05). During that time, there were no notable differences in the age groups of women. Pregnancy among elderly adults (>35 years) ranged from 7.4% to 9.2%, while the percentage of teenage pregnancies remained high, ranging from 14.3% to 15.9%.

Table I. Demographic, Obstetric, ANC Indicator and Pregnancy Outcome Trends from 2018 to 2022

Variables	2018	2019	2020	2021	2022	X2 value	P value
No of deliveries	819	807	848	794	848	0.56	0.681
Age category
<20 years	14.3%	15.1%	15.9%	14.5%	14.6%	10.41	0.844
20–24 years	29.7%	27.5%	31.5%	30.6%	30.5%
25–29 years	28.6%	29.1%	24.4%	27.5%	26.3%
30–34 years	20.0%	19.1%	19.9%	18.5%	19.6%
=>35 years	7.4%	9.2%	8.3%	8.9%	9.0%
Parity
Nil	30.9%	29.4%	31.2%	28.1%	30.2%	5.87	0.922
1–2	54.6%	57.6%	57.0%	58.0%	57.1%
3–4	13.2%	11.8%	10.6%	12.4%	11.2%
>5	1.3%	1.2%	1.2%	1.5%	1.4%
Booked for ANC
Yes	94.5%	93.7%	96.7%	95.7%	96.5%	12.62	0.013
No	5.5%	6.3%	3.3%	4.3%	3.5%
Number of ANC visit
0	7.3%	5.8%	3.8%	4.9%	4.7%	23.80	0.094
1–3	18.2%	16.5%	15.6%	16.1%	16.5%
4–6	39.9%	40.6%	39.7%	38.0%	38.3%
7–9	20.0%	23.8%	24.9%	25.9%	25.4%
> 9	14.5%	13.3%	16.0%	15.0%	15.1%
Facility of ANC
Other health facility	58.6%	53.6%	39.8%	35.5%	30.4%
At KCHC	41.4%	46.4%	59.2%	64.5%	69.6%	239.24	<0.001
ANC booking before 20 weeks gestation
No	43.7%	45.3%	43.8%	47.9%	47.8%
Yes	56.3%	54.7%	56.2%	52.1%	52.2%	5.47	0.242
Syphilis status of mothers at birth
Negative	97.9%	97.6%	98.5%	98.1%	98.0%
Positive	2.1%	2.4%	1.5%	1.9%	2.0%	1.53	0.820
HIV status of mothers at birth
Negative	56.2%	58.0%	61.0%	61.6%	61.7%	8.34	0.080
Positive	43.8%	42.0%	39.0%	38.4%	38.3%
Gender of the neonates
Female	47.7%	49.7%	48.3%	47.5%	49.5%	1.33	0.855
Male	52.3%	50.3%	51.7%	52.5%	50.5%
Live birth
No	2.0%	1.4%	1.4%	1.3%	1.7%	1.66	0.797
Yes	98.0%	98.6%	98.6%	98.7%	98.3%
BBA
No	94.3%	93.6%	96.5%	95.6%	96.2%	11.56	0.021
Yes	5.7%	6.4%	3.5%	4.4%	3.8%
Targeted birth PCR test results of live births of HIV-positive mothers
Negative	95.7%	91.1%	95.5%	95.3%	97.5%	17.85	0.001
Positive	4.3%	8.9%	4.5%	4.7%	2.5%
Stillbirth
No	98.0%	98.6%	98.8%	98.7%	98.5%	2.16	0.706
Yes	2.0%	1.4%	1.2%	1.3%	1.5%
Early neonatal death per 1000 live births
Yes	3.6	8.7	14.3	10.2	7.1	5.73	0.220

The percentage of expectant mothers who did not schedule an ANC appointment declined from 5.6% in 2018 to 2.4% (−3.2%) in 2022 (p = 0.013). Likewise, there was a discernible downward trend in the BBA rates, which dropped from 5.7% in 2018 to 3.8% in 2022 (p = 0.021). It revealed a markedly rising trend among women who gave birth at KCHC, rising from 41.4% in 2018 to 69.6% in 2022 (p < 0.001). However, between 2018 and 2022, the proportion of ANC received at other healthcare facilities decreased from 55.3% to 29.7% (−25.6%). Likewise, the findings of the neonatal PCR test revealed a dramatic decline from 4.3% in 2018 to 2.5% in 2022 (p = 0.001). However, early neonatal and stillbirth rates did not show any trends or significant changes in rates over the study period as p > 0.05.

The gender of the neonate (male-to-female ratios), the prevalence of HIV (ranging from 43.8% in 2018 to 38.3% in 2022), the rates of syphilis positivity (ranging from 1.5% to 2.4%), and the overall syphilis rate of 2.0% for the five-year study period did not exhibit any significant changes or trends (p values > 0.05) (Tables I and II).

Table II. Cross Table Analysis of Dependent or Exposure with Outcome (ENND & Stillbirth) Variables

Variables	Actual sample percent n (%)	Early neonatal death n (Per 1000 live births)	X2 values	P values	Stillbirth frequency (n) and (%)	X2-values	P values
Age distribution (in years) (n = 4116)
<20 years (Teenage)	613 (14.9)	6 (1.47)	0.54	0.970	12 (2.0)	11.16	0.025
20–24 years	1234 (30.0)	12 (2.94)			21 (3.5)
25–29 years	1117 (27.1)	8 (1.96)			15 (2.50)
30–34 years	800 (19.4)	7 (1.71)			3 (0.5)
>35 years	352 (8.6)	3 (0.73)			9 (1.5)
Parity (n = 4111)
0 (Nil)	1233 (30.0)	12 (2.94)	0.85	0.836	21 (3.5)	1.53	0.675
1–2	2337 (56.8)	19 (4.65)			33 (5.5)
3–4	486 (11.8)	5 (1.22)			6 (1.0)
4–5	55 (1.3)	0 (0)			0 (0.0)
Place of ANC (n = 3968)
Other health facility	1637 (41.3)	14 (3.43)	36.38	<0.001	31 (57.4)	5.89	0.012
At KCHC	2331 (58.7)	22 (6.39)			23 (42.6)
Booked for ANC (n = 4116)
Yes	3928 (95.4)	33 (8.08)	56.27	<0.001	52 (8.6)	10.73	<0.001
No	188 (4.6)	3 (0.73)			8 (1.3)
Booking before 20 weeks gestation (n = 3973)
Yes	2157 (54.3)	11 (2.69)	5.57	0.018	24 (44.4)	2.13	0.144
No	1816 (45.7)	25 (6.12)			30 (55.6)
No of ANC visits (n = 4112)
Nil	218 (5.3)	12 (2.94)	69.17	<0.001	11(18.3)	37.72	<0.001
1–3	682 (16.6)	11 (2.69)			20 (33.3)
4–6	1616 (39.3)	11 (2.69)			18 (30.0)
7–9	988 (24.0)	1 (0.24)			7 (11.7)
>9	608 (14.8)	1 (0.24)			4 (6.7)
BBA (n = 4114)
		0.05	0.57		63.47	<0.001
Yes	60 (1.5)			2 (0.49)			44 (73.3)
No	4054 (98.5)			34 (8.33)			16 (26.7)
HIV Status of mothers (n = 4116)
Positive	1659 (40.3)	17 (4.16)	0.72	0.395	32 (53.3)	4.29	0.038
Negative	2457 (59.7)	19 (4.65)			28 (46.7)
Gender of the neonates (n = 4116)
Male	2103 (51.1)	21 (5.14)	1.38	0.239	35 (58.3)	2.32	0.127
Female	2013 (48.9)	15 (3.65)			25 (41.7)
Targeted birth PCR test result (n = 1659 for ENDD)
Positive	76 (4.6)	2 (0.12)	2.58	0.108	1 (0.03)	0.11	0.734
Negative	1583 (95.4)	13 (0.78)			29 (1.15)
Syphilis status of mothers
Positive	81 (2.0)	1 (2.8)	0.12	0.725	4 (0.67)	6.96	0.008
Negative	4034 (98.0)	35 (97.2)			56 (9.3)

With a total of 1.5% for the study period, the stillbirth rates over the years showed no trend but instead ranged between 1.2% and 2% without any significance (p > 0.05). Likewise, the ENND rates ranged from 3.6 to 14.3 per 1000 live births, but the difference was not statistically significant (p = 0.22), totalling 8.8 per 1000 live births (Tables I and II).

The following independent factors had significant differences in neonatal death rates with regard to place of ANC, booked for ANC, booking ANC before 20 weeks of GA, and number of ANC visits, according to Table II with cross-table analysis. Logistic regression analysis was used to determine the risk factors or predictors for ENND and stillbirth because the independent variables—such as the pregnant mother’s age, the ANC’s location, the number of ANC visits, BBA, HIV, and syphilis status—had significantly different rates of stillbirths.

In our situation, the only predictor of ENND was the frequency of ANC visits, as Table III demonstrated. ANC visits between 1–3 had an OR of 9.6 (95% CI:1.2-75.0, p = 0.03) compared to >9 visits, while women without ANC had a greater OR = 33.18 (95% CI:3.6-301.0, p = 002).

Table III. Logistic Regression Output for Early Neonatal Deaths

Exposure variables	Sig.	Adjusted OR	95% C.I. for OR
			Lower	Upper
Number of ANC visits	<0.001
0 (nil)	0.002	33.18	3.65	301.00
1–3	0.030	9.65	1.24	75.01
4–6	0.182	4.03	0.52	31.33
7– 9	0.715	0.05	0.03	9.55
Constant	<0.001

The chances of stillbirth were nearly doubled for pregnant women who received ANC at other PHC institutions, according to Table IV (OR = 1.91, 95% CI 1.91-3.32, p = 0.02). An OR of 11.7 (95% CI:2.9-45.9, p < 0.001) indicated that women who had never had ANC were 11.7 times more likely to have stillbirths, while those who had ANC visits between 1–3 had an OR of 4.1 (95% CI:1.38-12.1, p = 0.01), indicating that they were 4 times as likely to have stillbirths. The age of expectant mothers was a predictor of stillbirths. With a decreased OR of 0.15 (95% CI:0.04-0.57, p = 0.005), women aged 30–34 are 89% less likely to experience stillbirths. The odds of stillbirth were 64% lower for women without HIV infection, with an OR of 0.56 (95% CI:0.31-0.89, p = 0.008), and the chances of stillbirths were decreased for those with a negative syphilis status (OR = 0.29, 95% CI:0.09-0.92). The risks of stillbirth were also reduced for those women without BBAs (OR = 0.16, 95% CI:0.08-0.34, p < 0.001).

Table IV. Final Stage of Logistic Regression Output for Stillbirths

Variables	P values	OR	95% CI. for OR
			Lower	Upper
Place of ANC	0.04
ANC at other health facilities	0.02	1.91	1.10	3.32
Age coded	0.03
Teenage	0.67	1.22	0.46	3.23
20–24 years	0.66	0.82	0.34	1.98
25–29 years	0.36	0.66	0.27	1.60
30–34 years	0.006	0.11	0.02	0.54
HIV status	<0.001
HIV Negative	0.008	0.56	0.31	0.89
Syphilis status	0.001
Syphilis negative	0.037	0.29	0.09	0.92
BBA	<001
No BBA	<0.001	0.16	0.08	0.34
Number of ANC visits	0.000
ANC visit (0 or nil)	<0.001	11.70	2.98	45.94
ANC visits (1–3)	0.01	4.10	1.38	12.12
ANC visits (4–6)	0.34	1.68	0.56	5.02
ANC visits (7–9)	0.82	1.10	0.32	3.78
Constant	<0.001	0.011

Discussion

Only pregnant women who gave birth at KCHC between 2018 and 2022 were included in this study. Since most deliveries under public health facilities are thought to take place at KCHC, these statistics included a lot of delivery information from the Kwadabeka and Clermont populations. However, only pregnant women who gave birth at KCHC were included in this study. Five years was thought to be a suitable time frame for gathering sufficient data for comparison and trend measurement. Given that most deliveries under the purview of public health institutions are thought to take place at KCHC, this data represented a significant amount of delivery data from the Kwadabeka and Clermont populations. In SA, 97% of expectant mothers are known to attend ANC at least once, and 96% give birth in a medical facility with a trained birth attendant [2]. However, due to the facility-based study, it was unknown what percentage of pregnant women in our area gave birth at public and private healthcare facilities. One could anticipate a higher rate of use of these services by the target population because maternity healthcare is free for users in South African public health facilities, the socioeconomic status of the catchment population is low, the KCHC is located nearby, and strategies are in place to encourage pregnant women to use public health facilities for maternity care, including deliveries. Information bias resulted from the retrospective review of birth registrations, which further restricted the availability of study variables. For example, the birth registry did not include cultural customs and socioeconomic data of expectant mothers, which are known risk factors for stillbirths and neonatal mortality [4], [5].

Annual Deliveries

Over the course of five years, from 2018 to 2022, 4226 women gave birth to singletons, live births, and stillbirths at KCHC MOU. There was no discernible rise or fall in the number of deliveries from the base year of 794 (2018) to the higher number of 848 in 2020 and 2022 (p > 0.05). These figures are consistent with previous reports [17]. In South Africa, however, an average of 564 deliveries from CHCs are reported annually [35]. The number of pregnant women admitted to labour and delivery centres who receive care at a MOU is significantly higher than these yearly delivery numbers. These differences pertain to women who were referred to the hospital at the time of admission; difficulties linked to the labour process for either the mother or the foetus are not included. According to earlier reports, almost 60% of pregnant women in South Africa are referred to hospitals from PHC facilities during ANC, delivery, and the postpartum period [33]. Prior studies on hospital referrals from KZN and Gauteng provinces’ MOUs at the time of labour ward admission in South Africa showed that the percentages were 25% (2011) and 38.3% (2014), respectively [36], [37]. Referral rates that occurred during the ANC period due to pregnancy complications, such as pregnancy-induced hypertension, antepartum haemorrhages, and acute and chronic medical conditions like diabetes, essential hypertension, chronic asthma, etc., were not included or known to us, which is why these lower rates exist. All deliveries at KCHC from women who received ANC there have been on the rise (41% in 2018 to 70% in 2022, p < 0.05). That is, fewer pregnant women were receiving ANC at other PHC clinics within the catchment area. The adoption of the revised national guidelines on the criteria of hospital referral from PHC may be the cause of the trend since more women were referred from PHC clinics to hospitals during ANC for pregnancy problems [33].

ANC Indicators

There were no notable variations in the trend of maternal age groups during the study period, and the rates were comparable to those reported in prior reports from Durban, South Africa [38]. For instance, the majority of women fall into the 20–34 years age range, which is consistent with the statistics mentioned above. Nonetheless, the rate of adolescent pregnancies over time was marginally higher (14.9%) than the rates of 9.5% and 11.5% from Tanzania and Durban, KZN, and SA [17], [38], [39]. Prior to 20 weeks of GA, the ANC booking rate was 53.4 percent, which was higher than the national average of 47% but lower than the 70% national target that was met in 2019 [1], [2], [40]. More work is required to educate the community on early ANC initiation. Additionally, the study population was represented by the pregnant women’s mean age with SD of 25.9 (5.6) years, which was comparable to other Durban studies’ mean age of 26.1 (5.9) years [41].

From 94.5% in 2018 to 96.5% in 2022 (p < 0.05), the ANC attendance rate (at least one ANC visit) of pregnant women at KCHC increased by 2% (with a mean of 95.4%) (Tables I and II), which is somewhat higher than 94% of the national rate (2016) [2]. Our study’s average of 6 ANC visits (SD = 2.8) is comparable to another study’s finding of 5.8 from a follow-up study in South Africa [41], [40]. Despite the improved ANC attendance rate, the majority of pregnant women in South Africa (79.5%) only went to four or fewer ANC visits in 2022 [40]. This is concerning because, as our study and previous research findings have shown, the quantity of ANC visits is recognized to be a risk factor for maternal and perinatal morbidities and mortality [2], [42]. Additionally, our study’s period (GA) of ANC beginning during the first trimester is 54% higher than the 47% national average recorded in 2016 [2]. Higher socioeconomic status and educational attainment are linked to higher numbers of ANC visits in South Africa [2]. The World Health Organization (WHO) developed a new guideline after finding evidence of an increased risk of perinatal fatalities linked to four or fewer ANC visits. [43] Prioritizing person-centered care and well-being along with preventing maternal and perinatal mortality and morbidity, WHO published its full guidelines on ANC visits of eight or more visits for a pleasant pregnancy experience in November 2016 [44], [45]. In response to these suggestions, the South African Health Ministry changed its four-visit basic antenatal care model in April 2017 to conform to the new WHO guidelines. These changes included adjusting the number of ANC contacts (8 visits), the content of each contact (such as clinical inquiry for intimate partner violence and respectful care), and the fundamental skills required for antenatal care. In order to improve the quality of antenatal care by providing evidence-based interventions across a minimum of eight ANC visits, especially an increased number of contacts during the third trimester (32–38 weeks of gestation), many more strategies are therefore needed to increase the number of ANC visits with the updated package of care, called Basic Antenatal Care Plus. By improving prenatal care, results, and women’s experiences, the package hopes to enhance screening and detection of pregnancy-related issues and, eventually, the quality of antenatal care [46].

HIV prevalence did not show any trend over that time, although it did decrease from 43.8% in 2018 to 38.3%, which was not statistically significant (p > 0.05). In 2022, the highest recorded total HIV prevalence in South Africa’s KwaZulu-Natal Province was 37.2% (95% CI: 35.8–38.5), which is comparable to our findings [39]. The birth PCR test results for infants of HIV-positive mothers significantly decreased with time, from 4.3% to 2.5% (p < 0.05) (Table I). The increased (99%) uptake of antiretroviral treatment (ART) and prevention from mother-to-child transmission of HIV (PMTCT) programs may be linked to this decrease in the risk of neonatal HIV infection (transmission of HIV from mother to child) [40]. The PMTCT program reported a decrease in infant PCR positivity rate at ten weeks of age from 4.3% in 2015/16 to 0.68% in 2019/20, indicating that maternal HIV testing and access to ART have significantly reduced maternal deaths from non-pregnancy-related infections and new HIV infections in children [40]. The percentage of PCR-positive newborns in our study was higher at 2.0%. HIV-positive pregnant women continue to have concerns about the ART and PMTCT programs. Therefore, it is crucial to track the maternal VL level and the ART initiation period throughout pregnancy [2]. The syphilis positivity rate (varied between 1.5% to 2.4%) and the overall rate of 2.0% (for 5 years) is lower than the national rate of 2.6%, with the highest of 4.4% for KZN [40]. It is still imperative to expedite the roll-out of the dual HIV/syphilis and single syphilis tests for pregnant women, their partners, individuals presenting to STI services, and other priority populations to identify and treat individuals with active syphilis (as it is preventable and treatable) to bring down the incidence and prevalence.

Trends and Risk Factors for ENND and Stillbirth

The ENND and stillbirth rates did not show any trends during the study period. The average ENND rate for the five-year study period was 8.8, with variations ranging from 3.6 to 14.3 deaths per 1000 live births, although these differences were not statistically significant (p = 0.22). In 2020, Durban Hospital follow-up research found a decreased newborn mortality rate of 7.0 per 1000 live births (within 28 days of live births), while in 2022, the ENND rate was 7 per 1000 births [41], [47]. The incidence of ENND (within 7 days of live births) in South Africa dropped from 14/1000 live births in 2014 to 12/1000 in 2019/2020, but during the COVID-19 pandemic in 2020/2021, they increased by about 3% [1], [48]. However, measures like the MomConnect program and the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA) in 2012 were credited with reducing neonatal mortality overall in South Africa [49], [50]. In order to ensure that all South Africans have healthy lives, it is critical to identify and manage variables linked to unfavorable pregnancy outcomes, such as ENND. Using mobile technology, the MomConnect strategy—which gives pregnant and postpartum women twice-weekly health information text messages and access to a helpdesk for pregnant women’s questions and feedback—and the CARMMA campaign, which involved re-engineering PHC and introducing the District Clinical Specialist Teams (DCSTs) and PHC ward-based outreach teams in 2012, produced notable improvements in maternal, perinatal, and neonatal health care (MPNH) services in South Africa [49], [50]. These tactics were put into practice at KCHC as a component of the national priority program. Our study’s ENND rate, however, took into account deaths that happened within seven days of live deliveries. As a result, there are some differences between the ENND and the overall newborn death rate. In low-income nations, it is estimated that about three-quarters of newborn deaths take place in the first few days following a live birth, often during or shortly after delivery [30], [31]. Therefore, in order to prevent maternal and neonatal deaths in South Africa, care during delivery and the postnatal period is essential.

Our analysis found that the number of ANC visits was the only risk factor. Similar to earlier research, women who did not receive ANC care had a higher OR = 33.18 (p = 002), meaning they were 33 times more likely to have ENND, and those who had ANC visits between 1–3 had an OR of 9.6 (95% CI:1.2-75.0, p = 0.03), meaning they were 9.6 times more likely to have ENND similar to previous finding [47].

Our study’s stillbirth rates throughout time ranged from 1.2% to 2.0% (p > 0.05), with a mean of 1.5% of all births. A different study indicated that 2.3% of mothers had stillbirths during the third trimester, which is lower than the 2.8% rate reported in South Africa [51], [41]. Consequently, the third trimester was found to be a critical period, with a peak in stillbirths occurring between weeks 32 and 38. A study of low-middle-income nations indicated that the total stillbirth rate was 0.7%, which was lower than the 1.5% rate we found [12]. According to recent studies, Pakistan’s stillbirth rate is 6.51%, while Argentina’s is 1.41% [52], [53]. Some of the variables that contribute to stillbirth include diabetes, high blood pressure, bacterial infections in the mother, and recreational drug use [54]. Maternal age, as well as infectious and non-communicable illnesses such as syphilis, HIV, Group B streptococcus, and malaria, have been linked to stillbirths worldwide, especially in sub-Saharan Africa [27]–[29]. Fresh stillbirths may also result from birth abnormalities or injuries involving the umbilical cord. More birth defects can now be diagnosed with greater accuracy because of the development of maternal serum testing and sonographic diagnostic techniques. PHC’s increased ANC visits in the research region were one of the factors that needed to be reduced in order to reduce stillbirths.

Significant correlations between specific sociodemographic, economic, cultural, environmental, and maternal factors were discovered by earlier researchers [4], [15]. Because the studies were context-specific, the findings differed; even within the same geographic areas, these characteristics are known to be distributed differently among populations [16]. In order to identify South African context-specific trends and factors linked to unfavorable pregnancy outcomes, such as age at delivery, the current study used a PHC-level approach and the most recent data for five years, from 2018 to 2022. Ages 30–34 years in our study had a lower OR of 0.11, meaning that these women are 89% less likely to have stillbirths than those aged 35 and above, which is comparable to other studies from Zimbabwe [55]. They discovered that the age range of 35 to 49 was linked to nearly twice as many chances of stillbirth and abortion. In contrast to pregnant women who received ANC at KCHC, the other risk factor for context-specific issues of pregnant women who received ANC at other PHC facilities nearly doubled their risk (OR = 1.91) of stillbirths. Compared to pregnant women who had nine or more ANC visits, those who had ANC visits between one and three had an OR of 4.1 (p = 0.01), meaning they were four times more likely to have stillbirths, and pregnant women who never had ANC had a greater OR of 11.7 (p < 0.001), meaning they were 11.7 times more likely to have stillbirths. Infections with syphilis and HIV were linked to stillbirths in our study. Stillbirths were 44% (OR = 0.56) and 71% (OR = 0.29) less likely in women without HIV and syphilis, respectively. Women without a BBA also had lower risks of stillbirths (OR = 0.16), meaning they were 84% less likely to experience a stillbirth. These risk factors are consistent with additional SA findings [47].

Conclusion

There were no trends for ENND and stillbirth in our study. However, there were decreasing trends in BBA and PCR positivity rates. A decreasing trend was found for KCHC deliveries and ANC at KCHC. There was only one predictor of the number of ANC visits for ENNDs (having no or lower numbers of ANC visits. Maternal age, number of ANC visits, ANC at other PHC clinics compared to KCHC, BBA, HIV, and syphilis infections were risk factors for stillbirths. There is a need to reduce negative pregnancy outcomes through integration of social issues into maternal health programs, as well as ensuring accessibility and availability of comprehensive reproductive health services that target high-risk groups. Further studies are encouraged to identify the antenatal care and delivery practices implemented; those may be associated with improving maternity service to improve delivery indicators at the facility. Continue to strengthen and promote early ANC attendance. Expedite the roll-out of the dual HIV/syphilis and single syphilis tests and treatment for pregnant women, their partners, individuals presenting to STI services, and other priority populations to identify and treat individuals with active syphilis.