April 2007 - Volume 1, Issue 2

TOWARD MAKING PREGANCY SAFER

	Dr. Thamer Kadum Yousif Al Hilfy MBChB/DCM/FICMS JMHPE/MsC/Member/medical education Director Health For All Center (NGO) / Iraq-Baghdad Assistant Professor / Alkindy College of Medicine/Baghdad
	Tel. +96417721963 +9647703459903 Mobile. +9647901734108 E-mail: thamer_sindibaad@yahoo.com thamer_center2005@yahoo.com

ABSTRACT Background: This study was carried out in an attempt to demonstrate the epidemiology of safe pregnancy outcome in Iraq. Safe pregnancy is defined as the period encompassing pregnancy, childbirth and the postpartum, which is experienced without complications for both the mother and the fetus/baby. Methodology: The current work represents an observational longitudinal study, which included (2080) cases of all pregnant women who terminated their pregnancy by delivery, abortion or ectopic pregnancy, or within (42) days after termination of pregnancy, who attended gynecological, obstetrical wards, outpatient clinic and the reproductive health center (family planning clinic) in Tikrit Teaching hospital for the period between the first of November to the end of April (2006). A direct interview was done with every woman; special questionnaire and a physical examination was conducted only for women and their babies included in our study, and investigations done when needed. Results: It had been found that of the total (2080) women, (1060, 51%) had a safe pregnancy outcome for both mother and her fetus/newborn, and (1020, 49%) had unsafe outcomes either for mother or her fetus/newborn. The total sample was also classified into four groups according to safety of mothers and babies, to make results more accurate. These groups included safe pregnancy outcome for both mother and her fetus/newborn, unsafe outcome for both, safe mother outcome and unsafe fetus/newborn outcome, and unsafe mothers with safe fetus/newborn outcome. The total number of each group of previous groups of mothers and fetuses/newborns, differed from table to table, or figure to another according to their relationship with other variables. The study also determined the rate of perinatal, and maternal mortality, and its causes. The results showed that, there were many maternal related factors affecting pregnancy outcome that included adolescent mothers, uneducated (not able to read and write) women, grandmultiparas, and women who had broken marital relations (mostly separated) associated with unsafe pregnancy outcome. Rural residence had been associated with unsafe pregnancy outcomes. The study found that, consanguineous marriage (second degree relative) was associated with unsafe pregnancy outcomes. Fetal related factors had an effect on pregnancy safety. Single fetus pregnancy, normal newborn birth weight (2500-4000) gm was associated more with safe pregnancy outcome. Good antenatal care of mothers was associated with safe pregnancy outcome, particularly in those women who attended both private doctor's clinic and primary health care center. Women who received tetanus toxoid immunization completely, and who spaced their pregnancies more than two years apart, had safer pregnancy outcomes. The women who completed (37-42) weeks of gestation, with hospital delivery, beside intrapartum regular fetal heart monitoring, and labor within normal duration had been associated with safe pregnancy outcomes. Rh incompatibility problems between mother and fetus/newborn, bad obstetrical history, positive medical and gynecological and obstetrical surgical problems of mothers had been associated with maternal and fetal/newborn complications. Conclusion and Recommendations: We concluded from this study that, maternal complications are more frequent in the ante partum period, while fetal complications happened more in the post partum period. Regarding the perinatal morbidity and mortality, predisposing factors had been related mostly to maternal causes. About maternal deaths, the study found that most of deaths occurred in the first 42 postpartum days due to direct causes related to pregnancy. The critical issue of maternal mortality encourages us to compare our results with other corresponding studies in the world, and then ratios and the major causes of maternal mortality were determined. We recommended improvement of maternal health, and neonatal health. This could be achieved by serious cooperation between community (general population), health institutions and their staff.

INTRODUCTION

Every year about (210) million become pregnant in the world (1). Every minute of every day, somewhere in the world and most often in a developing country, a woman dies from complications related to pregnancy or childbirth. That is (515,000) women, at the minimum, die every year. Nearly all maternal deaths (99%) occur in the developing world (2).

For every woman who dies, 30 to 50 women suffer injury, infection, or disease. Pregnancy related complications are among the leading causes of death and disability for women aged 15-49 in developing countries. When a mother dies, children lose their primary caregiver, communities are denied her paid and unpaid labor, and countries forego her contributions to economic and social development. A woman's death is more than personal tragedy; it represents an enormous cost to her nation, her community, and her family. Any social and economic investment that has been made in her life is lost. Her family loses her love, her nurturing, and her productivity inside and outside the home (2).

In developing countries, women's risk of dying, from pregnancy related disorders is on average about 250 times greater than women in most developed countries(1).

In the world more than 70% of maternal deaths are caused by just five conditions: bleeding after delivery - 25% of deaths, infection after delivery - 15%, unsafe abortion - 13%, hypertensive disorders - 12%, obstructed labor - 8%. In addition, about 20% of maternal deaths are due to diseases that are aggravated by pregnancy such as cardiovascular diseases, chronic anemia, gynecological infections, pyelonephritis, chronic renal diseases, malaria, fistulas, uterine prolapse, chronic pelvic pain, and depression also affect large numbers of women (1).

More than a decade of research has shown that small and affordable measures can significantly reduce the health risks that women face when they become pregnant. Most maternal deaths could be prevented if women had access to appropriate health care during pregnancy, childbirth, and immediately afterwards (2).

In Iraq health statistics, the population of Iraq during 2002 was estimated to be 5,565,000 with an urban: rural ratio of 67:33 .The childbearing age women (6.064.000). The health indicators for Iraq are as follows: Maternal mortality ratio is 294/100,000 live births. The percentage of pregnancies at risk is 37.8%. The total fertility rate for Iraqi women is 6% and contraceptive use is 32%. The estimated lifetime risk of maternal death of women in Iraq is 1 in 57. The literacy rate for Iraqi women is 74%. The proportion of maternal deaths taking place during the puerperium is 49%. The main causes of maternal deaths are bleeding (46.4%), followed by acute pulmonary embolism (11.9%), hypertension (8.3%), abortion complications (5.7%), sudden death and irreversible shock (2.3% each), sepsis and obstructed labor (1.1%) (3).

In Salah Al-Deen governorate about 292,000 women are at reproductive age, and the maternal mortality ratio in the governorate is about 29 per 100,000 live births. The most common causes of maternal death were hypertensive disorders, hemorrhage, and midwives' interference (4).

Many of the causes of maternal deaths and disabilities also jeopardize the survival and health of newborn infants (1). Every year in the world nearly 4 million newborn babies die during the first month of life, an additional 4 million are stillborn (2), and millions more are disabled because of inadequately managed pregnancies and deliveries, and because of women's poor health and poor nutritional status. Neonatal infection accounts for 33% of deaths in newborn babies; asphyxia and trauma at birth account for 28%, premature delivery and low birth weight account for 24%, and congenital anomalies around 10% (1), while about 40%-80% of cases of newborn death were due to low birth weight (2).

Newborn health and survival are closely linked to the health of the mother before and during pregnancy, as well as during labor, childbirth, and the postpartum period. Key interventions or improving mother and newborn health include ensuring that all women receive effective, affordable, accessible, and acceptable maternity care (2).

In Iraq, health statistics record that neonatal mortality rate is 67/1000 live births, and the prevalence of low birth weight is 23.1% (3).

In Salah Al-Deen governorate the prenatal mortality ratio was 257 per 100 000 live births(4).
In Tikrit General Teaching Hospital, the statistical records were incorrect and not accurate because of insufficient records supplied by the health office. Regarding 2005, recorded maternal mortality number was only 3, while the perinatal mortality is not recorded and neonatal death is recorded as infant mortality (5). AIM

The aim of this study is to contribute to achieving of safe pregnancy outcomes among Iraqi childbearing women. OBJECTIVES

The study is conducted to:

1. Identify effective practices that could improve maternal and neonatal health.
   
2. To recognize the extent and major determinants of maternal mortality and morbidity.
   
3. To assess the effect of abortion, delivery site, duration of labor and maternal RH on mothers safety.
   
4. To estimate fetal monitoring during pregnancy and labor.
   
5. To describe causes of maternal death.
   

Design of the study:
The current work represents an observational longitudinal study, which was conducted from 1st November 2005 to April 2006, and within regular working hours. The study design suited the purpose of this research, and is feasible both from financial as well as technical points of view.

Socio-Demographic characteristics:
The study was conducted in Tikrit General Teaching Hospital, which represents one of the biggest centers located in the center of Tikrit city, which serves a large proportion of the community from different sectors of Salah Al Deen.

Salah Al-Deen Governorate has an estimated population of 1,162,490 persons; Tikrit city represents 159,721 of the population. About 292,000 females or 20% of Salah Al-Deen population, are females at reproduction age (15-49 years old).

The study groups:
Sampling population: Our sample included all females who attended Tikrit General Teaching Hospital for delivery (pre term, term or post term), abortion, ectopic, or attending for contraceptive advice, check up, or for treatment of any complications, within 42 days of termination of pregnancy, and who attended from the first of November 2005 to the end of April 2006. This includes 2080 pregnant women. Those females were followed in the gynecological and obstetrical wards, outpatient clinic of gynecology and obstetrics, and family planning clinic.
The total sample was classified into four groups which includes the following:

Safe mother and fetus outcome (newborn), unsafe outcome for both mother and fetus, safe mother outcome with unsafe outcome regarding fetus/newborn and the last group is safe fetal/newborn outcome with unsafe outcome regarding the pregnant women. This classification was introduced for the sake of more accurate results.

Our results were compared with three major studies dealing with same concerns. A meta analytic approach was used to study some common variables mainly the maternal mortality ratio (women who died within 42 days postpartum due to direct and indirect causes related to pregnancy).

The total sample size chosen is considered to be suitable in this design study for showing the expected degree of differences regarding different variables. It is known that the sample size had an inverse relationship with alpha error.

As regards the power of the study it is acceptable to use 0.8(80%), as this will guarantee, as we believe that B error will have a limited effect at this level (accepting the null hypothesis when it is false) .

Pilot study and preset:
The real benefit of a pilot study in this research is its usefulness as a pretest measure, done on small scale, to identify any area of ambiguity or weakness related to the research design and tools, besides the acceptability of the community and subjects of the study sample to the research. A small scale pilot study was carried out on a sample of 30 cases and included women pregnant, delivered, and aborted. This pilot study was run for 3 weeks before the study was launched. The consent of those participating in the study was also tested to ensure the clarity of the language and to give an indirect idea about the acceptability of the sampling population.

We did look for any possibility of error and tried to correct it from the beginning as part of quality control measures. Thus quality checks will be set at each state of data collection.
Another seminar was made in the Community Medicine Department in Tikrit College of Medicine, in the presence of the chairman of the department and postgraduate students of the college.
Discussion was made, and comments, notes and suggestions were given by the audience, which were very worthy, and helped much in conducting the final study in a more perfect and practical way.

Development of Questionnaire and Data Collection:
The questionnaire was developed to collect all the data relevant to socio-economic class, and all variables listed below using structured interviewing and simple questionnaire. The interviewing here has the advantages of both the questionnaire and the observation. The response of the study sample was high and was suitable even for illiterates. The possibility of a skewing effect is not high since the required data are not critical to the interviewee, and ethical issues relating to the questions were considered. All questions were to be part of the interview. Issues of confidentiality were foremost and checking on data entry is done on a regular basis.

Age:
It included five age groups (<16, 16-25, 26-35, 36-45, >45) years old.
Occupation.
Marital status.
Residency.
Rh of both parents and baby, which is very important when the mother is Rh negative and the father is Rh positive.
Degree of consanguinity between parents.

Points related to ANC at antenatal period of women include:
Parity: (Zero), (1-4), (=5) babies delivered after 24th weeks of gestation.
Gravida.
Abortion.
Last menstrual period to determine gestational age, and expected delivery date.
ANC was performed with adequate visits or not, and where (private, PHCC, or both).
Immunization: Tetanus toxoid if received by pregnant women completed, or not.
Risky mothers determined with level of risk and its causes.
Any complication during this period.
Termination of pregnancy, abortion and its type, ectopic pregnancy, or stillbirth at which gestational age, causes, and complications.
Intra-partum period
Labor: Full term, preterm, post term.
Site of delivery: Hospital, home.
Duration of labor.
Type of fetal monitoring in the intrapartum period.
Type of delivery: Spontaneous vaginal delivery, normal vaginal delivery with induction, C/S, or instrumental.
Complication during this period (mother, baby).
Number of babies, gender and weight of baby.
Postpartum complications (early, late).

Subjects and Methods
Past obstetrical history:
Number of previous pregnancies.
Outcome of previous pregnancies.
Type of delivery.
Effect of ANC and PNC.
Spacing: It calculated average birth spacing among all pregnancies. Birth spacing less than 2 years, or more than 2 years.
Contraception use and type .
Drug history for:
Preconception preventive drugs.
Specific diseases.
Regarding pregnancy.
Medical history: Cardiovascular diseases, diabetes mellitus, blood diseases, renal diseases and others.
Surgical history: Pelvic (gynecological, obstetrical, or non gynecological), and others.
Social history: Smoking, alcohol, illicit drugs.
Family history: Chronic diseases, multiple pregnancy, hereditary diseases, congenital anomalies.

Examination:
Clinical assessment for every woman who was at ante-partum, intra-partum, and post-partum period, and her neonates.
Blood pressure.
Abdominal examination (fundal level at ante-partum, and post-partum periods).
Mother weight and height.
Fetal heart rate monitoring.
Weight of baby.
APGAR score of baby at first 5 minutes.
Per vaginal examination.

Statistical analysis:
Our study is a cross sectional study, and we will describe the characteristics of the sample choosing the methods of analysis depending on the type of data, whether qualitative or quantitative.

Most of our results are of a qualitative nature and so using chi square to test any significance, will be of benefit.

Several descriptions to explore our analysis were used and were not restricted to table presentation, whether percentages or frequency distribution but also including graphic presentation as a `Bar chart' as we are dealing here with qualitative data.

The data collected on 2080 women were included in the study to assess the association of many risk factors with safe outcome (for the mother and the baby).

So conventional statistical techniques were applied to the data in the study of distribution by frequency percentage, tables, and graph presentations. Considering the level of significance for this study is 0.05 for the sake of minimizing alpha error (rejecting the null hypothesis when it is true).

Statistical analysis was done using the new version of Minitab package/2006.
RESULTS

The total sample studied in this research was 2080 women who were pregnant then terminated their pregnancy, or within 42 days of termination, and attended the hospital. In general regarding the outcome including the mothers and babies 1060, (51%) were classified as safe pregnancy outcome, and 1020, (49%) as unsafe pregnancy outcome. The number of safe mothers was 1257, and unsafe mothers 823, but after exclusion of abortion and ectopic pregnancy the number of safe mothers became 1180 and unsafe mothers 780. The number of safe babies was 1680, and unsafe babies 400, but after exclusion of abortion (118) and ectopic pregnancy (2) the remaining unsafe babies were 280. Both mothers and babies were safe (1060), both unsafe (160), safe mothers and unsafe babies (120), unsafe mothers and safe babies (620), the number of twins (80) babies, except for abortion and ectopic pregnancy.

Regarding the maternal age the study showed that, those who had safe pregnancy outcome were aged 16-25 years, and their number was 518 (56.4%), and those who had unsafe pregnancy outcomes where at the age <16 and their number 40 (95.2 %). Table (1)The study demonstrated the association between maternal educational level and outcome in that 728 (76%) of safe pregnancy outcomes were of literate women, while regarding the unsafe pregnancy outcome 790 (70.4%) were illiterate women. Table (1)

Regarding the relationship between parity and pregnancy outcomes, the study showed that, 523 (56.4%) of safe pregnancies were in (1-4) of the parity group. While 166 (62.9%) of unsafe pregnancy outcomes were in (=5) parity group. Table (1) The study showed that 1054 (54.1%) of safe outcomes were in married women, but most of the unsafe outcomes were in separated women and their number was 76 (96.2%). Table (1)

Regarding the fetal and maternal safety in relation to number of fetuses, total fetuses were 2040 after exclusion of abortion and ectopic, and inclusion of twins. Among single fetuses pregnancy, 1068 (54.5%) had a safe outcome. But among multiple fetuses pregnancy, 13 (16.2%) had safe pregnancy outcomes. Table (2)

Regarding the gender, the total (2040) and the study showed that, equal effect of both male and female gender on safety of pregnancy outcome, 540 (53%) of males and 541 (53%) of females had a safe pregnancy outcome. Table (2)

Regarding weight of babies, the study demonstrated 3 (100%) of babies with extreme low birth weight [<1000] gm had unsafe pregnancy outcomes. While 74 (100%) of babies with very low birth weight [<1500] gm had unsafe pregnancy outcomes. 134 (100%) with low birth weight [<2500] gm, also had unsafe pregnancy outcomes. But 1080 (61.3%) of normal birth weight [2500-4000] gm had safe pregnancy outcomes, while 1 (1.5%) of macrosomic babies with weight [>4000] had safe pregnancy outcomes.

Regarding residency distribution, the study showed that, 674 (65.7%) of safe outcomes were living in urban areas, while 386 (36.6%) of safe outcomes lived in rural areas. Figure (1)

Regarding the degree of parental consanguinity, the study showed that, 104 (8.5%) of non-related couples had unsafe pregnancy outcomes, while 126 (45.7%) in second degree relative couples had unsafe pregnancy outcomes. Figure (2)

The study showed that, 939 (68.9%) of safe pregnancy outcomes had good antenatal care (=5visits), while 13 (12.6%) of safe outcomes had no antenatal care at all. Table (3)

After referring to ANC visit and its type, the study demonstrated the relation between antenatal care site and pregnancy outcome. After exclusion of women with no ANC, the total was 1977, 314 (66.8%) of safe outcomes attended both private, and primary health care centers, while the lowest, 185 (33.3%) of safe outcomes were in those who attended the primary health care center only. Table (4)

The study showed that most (422 - 86.5%) of mothers who completed immunization had safe mother and baby outcomes, while 138 (18.6%) of mothers who did not receive immunization had safe pregnancy outcomes. Table (5)

Regarding the relationship between birth spacing and safe pregnancy outcomes, of the total number of women (2080), the total of both unsafe mother and baby outcomes was (160)+(41) of unsafe mothers from abortion +(2) ectopic pregnancies (total) =203], when safe mother and unsafe baby the total was [120 + (77 safe mothers from abortion) =197]. The study showed that, spacing period (>2) years 720 (64.6%) had both mothers and babies safe, while 68 (6.1%) had unsafe mother and fetus. And regarding the spacing period (<2) years 368 (38.1%) had unsafe mothers and safe babies, while only 123 (12.7%) had safe mothers and unsafe babies. Table (6)

Regarding the risky women the study showed that the total risky mothers were (1400), while 125 (89.3%) of severe risk level had unsafe pregnancy outcomes, and 310 (43.4%) of high risk level had safe pregnancy outcomes.

The study showed that in 118 cases of abortion, there was a comparison between the type of abortion and mother health. Most 24 (92.3 %) of threatened abortion had safe mother outcomes, while the lowest, 1 (10%) of septic abortions had safe mother outcomes. But most 9 (90%) of septic abortion had unsafe mother outcomes, while lowest zero (0%) of inevitable abortions had unsafe mother outcomes. Table (7)

Among the total delivered mothers (1960), the study showed that, 969 (56.2%) of full term pregnancies had safe mother and fetus/baby, while 35 (40.7%) of preterm deliveries had safe mothers and unsafe fetuses/babies outcome. And 80 (53%) of post term delivery had safe pregnancy outcomes for both. Figure (3)

The study showed that from a total 1960 delivered women, after exclusion of abortion and ectopic pregnancy cases, 1017 (55.8%) of hospital delivery, had safe pregnancy outcomes regarding both mothers and fetus/baby, while 43 (62.3%) of those who had home delivery by a registered midwife, had safe outcomes for both, while 5 (100%) of home deliveries when not aided at all, were both mothers and babies having unsafe outcomes. Table (8)

Regarding the relationship between mode of delivery and pregnancy outcome, the total was 2040 after inclusion of twins and the study showed that, 461 (53.5%) of thosedelivered by spontaneous vaginal delivery had complications. Also 289 (61.8%) of induced vaginal delivery had complications, while in cesarean section, from 179 mergency cesarians 145 (81%) hadcomplicated delivery, but from 330 of elective C/S 30 (9.1%) were complicated. Table (9)

After exclusion of 330 elective cesareans, and 45 of emergency C/S, total women who had true labor were (1585). The study showed that, those who had normal duration of labour with safe outcomes were higher in primigravida 377 (79.9%), in comparison with multigravida 433 (73%). But in safe pregnancy outcomes with prolonged labor 91 (39.6%) were primigravida, while 40 (13.8%) were multigravida. Table (10)

The total number of women who received intra-partum fetal monitoring was 1360 after exclusion of home delivery (138), and (462) without monitoring, the study showed that, 844 (79.1%) with regular fetal heart monitoring had safe babies, while only 223 (20.9%) had complications. Furthermore, partogram was used in 273 (93.2%) with safe fetal outcomes but only 20 (6.8%) were associated with complications. Table (11) Regarding the problem of Rh incompatibility of mother and after exclusion of abortion and ectopic pregnancy cases, the total was 1960. Then the study showed that, most 1480 (89.2%) of Rh positive mothers and babies hadsafe pregnancy outcomes, while the highest 83 (51.6%) of Rh negative mothers and Rh positive babies had unsafe pregnancy outcomes. Table (12)

Regarding the effect of medical, and surgical history of mother, and family history of both parents on outcomes: In regard to medical illnesses, 51 (38.6%) of acute illnesses were associated with unsafe mother and fetus/baby outcomes, while 165 (42%) of chronic illnesses were associated with unsafe mother and fetus/babies.

Regardingsurgical history: the highest incidence 240 (59.6%) of gynecological and obstetrical operations was found in unsafe mothers and safe fetus/baby, while the highest incidence 86 (52.1%) of non gynecological operations was found in both safe outcomes for mother, and fetus/baby.

Regarding family history: the highest incidence 43 (58.9%) of family history of inherited disorders was found in safe mother and unsafe Fetus/baby outcomes, while the highest incidence 190 (78.2%) of family history of multiple pregnancies was found in both safe mother and fetus/baby, and the highest incidence 648 (59%) of family history of medical diseases was found in both safe mother and fetus/baby. Table (15)

Regarding the drug history, the study showed that, women using preconception preventive drugs with harmless effects 60 (84.5%) had both safe outcomes, while 7 (100%) of women using harmful drugs had safe mothers and unsafe babies outcomes. Regarding ante partum drugs, tonics 948 (64.9%) had both safe pregnancy outcomes; while regarding the drugs used for specific diseases for women 305 (59%) both had safe outcomes. Finally regarding intrapartum drugs which include antihypertensive drugs 43 (26.4%) had both unsafe outcomes, while using anti-convulsant drugs the study showed that 17 (56.7%) had unsafe outcomes for both, and oxytocic drugs 182 (70.3%) both showed safe outcomes. Table (16)

Furthermore the study showed the effect of risk factors on maternal and fetal/baby health. We determined the top10 factors that affect feto-maternal safety in order from highest to lowest. The study showed that 1099 (22.2%) of risk factors had family history of medical diseases, then 426 (8.6%) hadprevious C/S, then 345 (7%) had toxemia or hypertension in previous pregnancies, then anemia (<10 g/l) 338 (6.8%), then 318 (6.4%) were hypertensive women in the present pregnancy. Then 300 (6.1%) child weight (<5Ib, >9Ib), followed by risk of history of (=2) abortion or history of infertility or postpartum hemorrhage 292 (5.9%), then bleeding (>20, <20) weeks of present gestation 288 (5.8%), then 264 (5.3%) due to parity (>5), and lastly I.U.G.R. 168 (3.4%). Table (16)

Regarding the causes of perinatal mortality the study shows that of 120 perinatal mortalities, the highest 72 (60%) were due to maternal causes, while the lowest 12 (10%) were due to fetal causes (multiple pregnancy).

The study showed that total maternal deaths was 11 women. Of thesethe highest number was due to direct causes in the first (42) days which was 5 (45.4%) women. The lowest number was 1 (9.1%) due to direct and indirect causes in the period between (42) days to first year postpartum for each. Table (13)

The study showed that the total number of mothers who complained of complications was 1150. The highest incidence of maternal complications 369 (32.1%) were in the ante-partum (third trimester) period, while the lowest 3 (0.3%) were in the post-partum (after 42 days-1 year). The total number of fetuses who had complications was 446. The highest incidence of fetal complications 150 (33.6%) were in the intra-partum period, while the lowest, zero (0%) were in the post-partum (after 42 days of termination). Table (14)

The study determined the major causes of maternal mortality which were 2 (28.6%) for each of hypertensive disorders, and hemorrhagic problems of pregnancy. Maternal mortality ratio was 161 per 100,000 live births in Tikrit General Teaching Hospital. Table (17) DISCUSSION

Making pregnancy safer for both mothers and fetuses/babies is important because for every woman who dies, 30 to 50 women suffer injury, infection, or disease. Pregnancy related complications are among the leading causes of death, and disability for women age 15-49 in developing countries. In addition, newborn health and survival are closely linked to the health of the mother before pregnancy, during pregnancy, during labor, and in the postpartum period (125).

The study showed that the predominant childbearing age group was from 16-25 years, while Mahoney R. observed that the predominant childbearing age group was from 25-34 years (126). Also our study showed that age <16, >45 years was associated with unsafe pregnancy outcomes. This agrees with Wasunna A., and Mohammed K. who observed that adolescent mothers were more likely to have increased morbidity, and adverse outcomes particularly low birth weight problems of newborns <2500 grams (127), but this rejected by Kirchengast S., and Hartman B. who observed that adolescent mothers showed no increased incidence of low birth weight problems (128).

Also Kirchengast S., and Hartman B. and Donoso E., and Villarroe L. observed that the women older than 40 years had a higher rate of cesarean section, maternal death, late fetal death, and neonatal death. This is interpreted as an increase in the mother's age is associated with an increase in mother and newborn body dimensions(128,129).

Regarding the maternal educational level, the results showed an association between uneducated mothers (illiterate) and unsafe pregnancy outcomes. This agreed with Wasunna A., and Mohammed K. in Nairobi, the study observed women who had less formal education, and who were unemployed had obstetrical risks for poor pregnancy outcomes (127).

The results showed an association between the parity group of =5 and unsafe pregnancy outcome. This was in agreement with Olatunji A.O., and Sule-odue A.O. in Nigeria, and Williams K.P. and Wilson S. that the primiparous and the grandmultiparous women had a high risk of poor pregnancy outcome particularly small for gestational age, HELLP syndrome, operative delivery, and maternal death (130,131).

Marital state showed an association between broken marital states, especially separated women and poor pregnancy outcomes.

Conditions in Iraq, and in Tikrit city particularly, mean that pregnant women suffer from stressful events, either psychological, economical, or social effects. Additionallythere are large numbers of their husbands in American Prisons that affect negatively on pregnancy outcomes. This agrees with data from Perren S., Von-Wyl A., et al, (US Conferences of Mayors), and (National Coalition for the Homelessness -NCH-). Homeless women who are pregnant usually with inadequate prenatal care, limited access to general health care, poor nutrition and inadequate housing leads to poor birth outcomes (132,133.134). The complications of homelessness include an increased incidence of low birth weight newborn, and a higher rate of infant mortality, in addition to risk of many illnesses that could negatively affect their pregnancies, or substance abuse (134).

Considering the number of fetuses, and intra-partum and post-partum complications, the results found that the mother and fetal/baby complications associated with multiple gestation, but safe pregnancy outcome associated with singleton pregnancy. This agrees with Senat M.V., et al who also determined the most common complications associated with multiple pregnancy which includes maternal anemia due to increased demand of multiple gestation, hypertension, polyhydramnios or may be due to increased renal perfusion, premature rupture of membranes, incompetent cervix, intrauterine growth restriction, and other rare complications as conjoined (Siamese) twins, and other labor complications which include preterm labor, uterine dysfunction, abnormal fetal presentation, instrumental or cesarean birth and post-partum hemorrhage (135) . But Jacquelyn Y., Martens G., et al found that the perinatal mortality was significantly lower in twins because of early fetal death, and not early neonatal mortality (136). Francois K., Johnson J.M., and Harries C. observed that the occurrence and complications of placenta previa do not differ between singleton and multiple pregnancy (137).

Regarding gender of babies the results showed no differences between both males and females with safety of pregnancy outcome. Neville F., Moore G. astated that newborn gender may provide insight into patient and family expectation and may indicate certain genetic risk factors, also fetal and neonatal complications (11).

The results found that all babies who had extreme low birth weight (<1000) grams, and very low birth weight (<1500) grams usually were unsafe babies, but in very low birth weight babies <2500 grams, the highest number had unsafe fetus/baby outcomes., This agrees with Lynch A., McDuffie R., et al (138). The results show that normal weight of babies 2500-4000 grams) had safe fetus/baby and mother, and the predominant weight (86.3%) was normal birth weight (2500-4000 grams). This agrees with Misic Z., Krezo S., et al who observed that the predominant newborn weight (93.5%) was 2500-3000 grams (139). Macrosomic babies (>4000) grams had unsafe fetus/newborn and mother outcomes. This agrees with Boulet S.L., Alexander G.R., et al (140).

Considering area of residence, whether rural or urban, there was an association between rural areas and unsafe pregnancy outcomes, and urban areas with safe pregnancy outcomes. These results interpreted as, that the rural area has limited health services. In addition there are recent circumstances of night curfews, and sometimes even during the day, as well as insufficient fuel and high prices may prevent pregnant women from reaching the central hospital in Tikrit city. This made pregnant women experience traditional birthing practices such as home delivery by unregistered midwives, or unaided delivery, due to delay in arrival to hospital. This result agreed with Kyomuhendo G.B. in Uganda, and Safdar S., Ahmed S.T. in Pakistan who observed tharpoor pregnancy outcome was more common in rural areas (141,142).

The results also showed that there is an association between the parental consanguinity and fetal/baby outcomes in that unrelated parents had safe fetal/baby outcomes, but second degree relative parents had unsafe fetus/baby outcomes according to our study results. This agrees with Sogaard M., Vedsted-Jakobsen A. who found that consanguineous couples have a higher risk of having children with congenital malformations (143). But our results disagree with Saad F.A., Jauniaux E. in Qatar, and Al-Bustan S.A., El-Zawahri M.M., Ghunaim I. et al who didn't find any relationship between consanguineous marriage and poor fetal outcome (144,145).

Our study shows a positive relationship between prolonged spacing of >2 years as average spacing between pregnancies and good fetal/baby and maternal health, but too close pregnancies are associated with poor pregnancy outcomes. These findings agreed with the result found by (Anonymous) that the couples who space their birth (3-5) years apart increase their children's chance of survival, and mothers are more likely to survive (146).

Also our study agreed with King J.C. who found that women with early or closely spaced pregnancies have increased risk of fetal-maternal morbidity and mortality due to maternal nutrient depletion (125). Other studies done by Rachel A., and Royce, and Agudelo A.C., et al showed that close pregnancies, less than 18 months, had poor pregnancy outcomes. This result was due to maternal nutritional depletion, while the same study showed no statistically significant differences in risk between women with pregnancy interval 18-24 months, and those with intervals of 24-59 months. Regarding intervals longer than 59 months, it is observed that there are more maternal and fetal/baby problems, due tothat the woman's physiologic reproductive capacity decline and thus becoming similar to those of primigravida women. (19,147)

Considering abortion, the results showed that the abortion rate was 5.7% from the total sample (2080). Safe mother outcomes in cases of abortion were more than unsafe mothers. These results were due to increased maternal health education about the consequent complications of unsafe abortion, and availability of medical services such as medical staff, specialist doctors in obstetrics, trained sub staff, and ultrasonography. Finer L.B., Henshaw S.K. found abortion rate in (2000), in United State was (5%) (148). Our study did not determine the causes of abortion accurately, even maternal or fetal factors, because that needs some investigations which are not available in our hospital or even in Salah Al- Deen governorate, or it may be expensive and need a long time, but the results determined the risk factors of unsafe pregnancy outcome and abortion is part of it. There are different studies about risk factors of abortion, Talukder S.I., and Haque A. and Qublan H.S., Jumaian N., et al observed variation in the frequency of abortion found to be highest in the hot seasons, rural areas, old age women, and high parity (149,150).
Diejomaoh M.F., Al-Azemi M., et al in Kuwait determined the main etiological factors of recurrent pregnancy loss were uterine anomaly, chromosome anomaly, polycystic ovarian syndrome, infections, and other miscellaneous factors. Positive phospholipids antibodies are a most frequently associated cause of recurrent pregnancy loss in Kuwait (151).

Considering antenatal care 65.5% of the sample had good antenatal care, and 29.5% had poor antenatal care, and 5% had no care at all. There was an association between good antenatal care and safe mother and fetus/baby outcomes because frequent visits and checking can determine the risky groups, and follow up during pregnancy can determine the appropriate mode of delivery; while there are increased complications in women who had poor antenatal care. This is documented by Chang J., Elam-Evans L.D., et al in the United States, and Olatunji A.O., and Sule-Odu A.O. in Nigeria who observed that unbooked patients were associated with poor pregnancy outcomes and even pregnancy related death (152,130).

Regarding the antenatal care site, whether private clinics or primary health care centers or both, our study showed that the women who attended both private doctor's clinics and primary health care centers were associated with better pregnancy outcomes. This disagrees with Harvey S., Rach D., et al in Canada who observed the significantly higher satisfaction of the women with care provided by the midwives together with better clinical outcomes, than doctors' care (153).
Immunization with tetanus toxoid for pregnant women: There is a known schedule used in Iraq which includes four doses. The first dose is given in the first 6 weeks of pregnancy which gives no protection, the second dose is given 4-6 weeks later which gives protection for 3 years. The third dose is given 6 months later which gives protection for the next 5 years, and the fourth dose is given one year later which gives protection through the reproductive life. The result showed that, there were positive associations between those women who completed their tetanus toxoid immunization and good pregnancy outcomes. This result, is documented by Nasheit N.A. in Iraq, - that the tetanus toxoid played a role in decreasing perinatal mortality in Iraq (154).

Considering risk factors of mothers which determined the level of risk according to special risk scoring system, the previous results demonstrated in the discussion covered most of the risk factors and their effects, inregards to the maternal weight affecting pregnancy outcomes, most of the women with extreme weight had complications according to our results, that agree with Neggers Y., and Goldenberg R.L. and Edmonds D.K. (155, 28). Regarding maternal height, most of the women shorter than 150 cm were associated with mother and fetal/baby complications, but it may be due to the contribution of other risk factors. Edmonds D.K. observed that except in extreme cases (such as kyphoscoliosis or rickets) short stature has only a weak association with pelvic contraction, and is not usually an indication for extra care (28).

Regarding the duration of pregnancy, the baby delivered either preterm (before 37 completed weeks of gestation), or term at period 37-42 completed weeks of gestation, or post term (after 42) completed weeks of gestation) in our study, showed that there are variations in the mother and fetus/baby complications that depend on the cause of preterm, and post term delivery, type of management of labor, and neonatal care facilities which are insufficient in Tikrit Teaching General Hospital. All of these factors decided the fate of pregnancy. The study showed that full term, and post term delivery associated with better outcome than preterm delivery.

Regarding preterm delivery, our results agree with Garland S.M., Ni-Chuileannain F. et al who observed that premature or preterm delivery increased fetal susceptibility to cerebral palsy and neonatal sepsis that increases mortality, particularly extreme prematurity (156).

Ananth C.V., Smulian J.C., and Vintzileos A.M. in United States showed that the effect of placenta previa and neonatal mortality rate is according to duration of pregnancy. The risk of death from placenta previa was lower among preterm babies and higher in women without placenta previa, while mortality rates for term births were higher among babies born to women with placenta previa than among babies born to women without placenta previa (157).

Regarding the post term delivery Treger M., Hallak M., et al had a study that showed that the main problems associated with post term pregnancy are stage I, II, meconium stained amniotic fluid, macrosomia, and cesarean section were significantly higher with increasing gestational age and to decrease these problem, labor induction should be indicated at appropriate gestational age (158). This was opposite to our study results.

Regarding the duration of labor, maximum duration in multipara is 14 hours, and in primipara is 20 hours from commencement of true labor (10). The results showed that prolonged labor is associated with increased labor omplications for both primiparous and multiparous women and their babies. This result agrees with Maghoma J., and Buchmann E.J. (159).

The results showed that the hospital delivery rate is more than the home delivery rate. This may be due to the type of study which was a hospital based study, and women who have home delivery usually to not attend the hospital, unlesssevere complicationsoccur. In addition, recent conditions that include difficulty in transport from home to hospital due to fuel deficiency and night curfews, that make women prefer to attend the nearest PHCC or private doctor's clinic, and home delivery than coming to hospital. This agrees with Kaufman J., and Jing F. in China who observed that hospital delivery had more safe pregnancy outcomes (160).But Janssen P.A., et al in British Columbia disagreed with our result when they observed that planned home birth was not associated with an increase in mothers' and fetuses/babies' complications. They interpreted their results as due to labor managed by well trained midwives (161).Conversely our results showed that where labor was managed by registered midwives, it ewith better outcomes than non registered midwives. This disagrees with the result of Goldman N., and Glei D.A. in Guatemala who observed similar results between trained and untrained midwives (162).
Considering mode of delivery and feto-maternal complications at intra-partum and post-partum periods, the results showed that labor induction was associated with mothers, and fetuses/babies complications more than complications from spontaneous vaginal delivery. This disagrees with Shanchez-Ramos L., and Hsieh E. who observed that labor induction provided the surveillance for maternal and fetal safety (163).

Regarding instrument delivery, the results showed that forceps delivery had safe outcomes higher than unsafe outcomes, but vacuum delivery was not in use due to instrumental defect. Ben-Aissia N., Gara M.., et al observed that the major indication of forceps use was fetal suffering, and the maternal and fetal prognosis depended on accurate indication of the use of forceps (164). Shihadeh A. and Al-Najdawi W. observed that maternal birth canal and genital tract lacerations were significantly more common in forceps delivery and there was significantly increased morbidity in infants delivered by vacuum extraction (caput, jaundice, cephal hematoma), and serious neonatal morbidity was rare for both groups (165). Considering cesarean section, the results showed that emergency cesarean section was associated with higher rate of mothers and fetuses/babies complications than elective. This result agreed with Bergholt T., Stenderup J.K., et al in Denmark (166).

The objective of intra-partum fetal heart monitoring is to prevent fetal asphyxia, and fetal death during labor. The results showed that regular fetal heart monitoring ended with good fetal/baby outcome because the clinician can manage labor according to fetal monitoring results This agreed with Freeman R.K., Williams K.P., and Galerneau F., and Carbonne B., Gougeal V., and Fekih K.M. (167,168,169).

The use of partogram was limited in Tikrit Teaching General Hospital because of insufficient or unavailable papers of partogram that need economicsolutions. Our results showed that the use of partogram in labor ended with safe mothers and fetuses/babies, this agreed with Pattinson R.C., Howarth G.R., et al who found that the partogram played an important role in labor outcomes (170).

Regarding the Rh of mothers and babies, a large number (84.7%) of mothers were Rh positive. These results compared with Weiner C.P. who found that approximately 85% of white Americans, 92%-93% of African Americans, and 99% of the Asian population are Rh positive (171). The mother with Rh negative, and baby Rh positive had unsafe fetal/baby outcomes, either due to the problem of incompatibility or other problems, Rh incompatibility happened when the mother was previously sensitized, but iso-immunization can be prevented if the mother receives Anti-D in the first (72) hours post termination of each pregnancy according to our results. (American College of Obstetricians and Gynecology) observed the highest risk of Rh incompatibility if mothers were previously sensitized (172).

The results showed a high rate of maternal complications in the antenatal period, particularly at third trimester. This agrees with Chakraorty N., Islam M.A., et al in Bangladesh who observed a high rate of complications in the antenatal period (173).This large number of complications interpreted that, the women recall the problems because of the seriousness of these problems, or the same women had multiple problems in the antenatal period. These problems include ante-partum hemorrhage, premature rupture of membrane, or leakingfluid, threatened preterm labor and its causes, gestational hypertension and other problems.

The results showed the highest rate of fetus/baby complications occurred in the post-partum period. This disagrees with Buchmann E.J., and Pattenson R.S. who observed the highest frequency of fetal complications in the intra-partum period, especially birth asphyxia (174).
Regarding maternal use of drugs taken in preconception, ante-partum, and intra-partum periods, and fetomaternal.

Outcomes: The results showed that the preconceptional drugs with harmless effects were associated with safe pregnancy outcomes, such as using of folic acid in the prevention of birth defects and neural tube defects. This agrees with French M.R., Barr S.I., and Levy Milne R. and Barash J.H., and Weinstein L.C. (175,176).

Regarding ante-partum drugs, the results showed that tonics used during pregnancy were associated with safe mother and fetus/baby outcomes. \-his result agrees with Correa A., Botto L., et al (177).

Other drugs used in the ante-partum period to treat specific diseases such as anti- hypertensive drugs, depends on the type of drugs used and theirside effects. This agreed with Duley L., and Henderson-Smart D.J. (178).

Other drugs used in the ante-partum period were corticosteroids to decrease respiratory distress syndrome. It is given in three doses as 12 mg for three consecutive days to induce fetal lung maturation in threatened preterm labor to decrease perinatal morbidity and mortality. The results showed the positive role of corticosteroid, but Cran J., Armson A., et al observed that a single course of corticosteroids reduces perinatal mortality, respiratory distress syndrome, and intra-ventricular hemorrhage, while repeated courses of corticosteroids decrease respiratory distress syndrome, but increase rates of neonatal and maternal
infection, fetal, neonatal, and maternal adrenal suppression, decreased fetal or neonatal somatic and brain growth and increased perinatal mortality (179).

Regarding drugs used in the intra-partum period, the results showed that the hypertensive women who needed intra-partum antihypertensive drugs had high blood pressure during labor, and this hypertension did not respond to usual ante-partum antihypertensive drugs, or women had no antenatal care of diagnosed hypertension; therefore doctors try other drugs to save mothers and fetuses/babies life if possible, and according to our results both maternal and fetal/baby outcomes are affected negatively in this group of pregnant women.

Also the results showed that the women exposed to oxytocic drugs in the intra-partum period are associated with safe pregnancy outcomes. This result agrees with Pattinson R.C., Howarth G.R., et al (170).

Regardinganticonvulsant drugs: (Valium, Phenobarbital, and sometimes general anesthesia) used during labor, and they were given when convulsion occurs due to hypertensive disorders that are associated with unsafe mothers and fetuses/ babies. But Alberta by Foong S.C., and Pollard J.K. observed that use of seizure prophylaxis for all women with gestational hypertension from time of diagnosis through to (24) hours postpartum, may have been able to prevent as many as 53% of eclamptic episodes (180).

Many factors such as maternal history of medical diseases (acute and chronic infectious diseases, hypertension, diabetes mellitus, anemia, cardiovascular diseases, renal diseases, epilepsy, psychological illnesses, and others), maternal gynecological and obstetrical surgery (ovarian, tubal surgery, uterine fibroid, cesarean section, cervical, and others), and family history of inherited disorders (bleeding disorders, chromosomal abnormality, congenital anomalies, and others) all affect negatively on pregnancy outcomes. Most common medical diseases of mothers that affect fate of pregnancy wereanemia, particularly severe anemia were associated with increased mother and newborn morbidity. This agrees with Malhorta M., Sharma J.B., et al in a tropical African setting (181). The other common disease was eclampsia which was a major cause of maternal and fetus/baby morbidity and mortality. This agrees with Beye M.D., Diaouf E., et al (182). Other disease was diabetes mellitus and epilepsy, which are closely linked to an increased risk of fetal malformation, and this agree with Steel et al (183).
The high rate of perinatal mortality in our study is mainly related to maternal causes. This agreed with Aisien A.O., Lawson J.O., et al in Nigeria (184). The perinatal mortality rate related to fetal causes, agrees with Kinzler W.L., Ananth C.V., et al who found that small size ofgestational age, if exposed to labor stress, increases the risk of early neonatal death (185). According to our results obstetrical complications had the least effect on perinatal mortality. This was interpreted that most fetuses at risk of labor complications were planned for appropriate management or due to contribution of maternal and fetal causes. This agrees with Bari W., et al) who observed that perinatal death associated with obstetrical complications as assisted delivery (186),but Sheiner E. et al) who disagree with our study, observed that obstetrical problems had independent associations with perinatal mortality (187).

The study results showed the high rate of maternal mortality due to direct causes during pregnancy, and in the (first 42 days) post partum. The common causes were hypertensive disorders, postpartum hemorrhage, and thromboembolic problems. These results are explained as, early death at first 42 days may be at labor or after a short time when the mother is still in hospital, and is recorded as pregnancy related death. But the lower rate of maternal mortality was in the period (after 42days - 1year) of pregnancy termination. Berg C.J., et al in the United States showed that the pregnancy related mortality ratio increased, probably because of improved identification of pregnancy related death, and common causes were embolism, hemorrhage, and other medical conditions (188).

Meta-analysis provides an opportunity to examine consistency of the results across studies, in relation to quality of studies, and we can provide a plot of results with only the best studies included and then with successive inclusion of varying levels of quality, of the studies(115).
Our study showed that the common maternal mortality causes were hypertensive disorders, and hemorrhagic complications of pregnancy, in addition to embolism, sepsis, and cerebrovascular accidents which were less frequent than the first two causes.

Maternal mortality ratio and causes of our study compared with other studies: Gaym A), Sloan N.L., Langer A., Hernandez B., Romero M., and Winikoff B., and Berg C., Chang J., Callaghan W.M., and Whitehead S.J. agreed with our results that hemorrhage problems of pregnancy, hypertensive disorders of pregnancy, and sepsis were mutual leading causes of maternal mortality(188,189,190) . But Berg C.J., Chang J., Callaghan W.M., and Whitehead S.J. agreed with our results that embolism and cerebrovascular accidents form the leading causes of maternal mortality (188). CONCLUSIONS AND RECOMMENDATIONS

6.1. Conclusions:
6.1.1. Safe fetus/baby and mother outcomes in relation to maternal factors were found in married women, parity group of (1-4), pregnancy spacing >2 years, good antenatal care, mothers who attended both private clinics and primary health care centers, low risk level, women received tonics during pregnancy, and those who received tetanus immunization.

6.1.2. During labor, complications decreased with hospital site of delivery, normal duration of labor for both primiparous and multiparous women, and elective cesarean section and forceps delivery were associated with no complications.

6.1.3. Safe fetus/baby and mother, in relation to fetal factors associated with full term babies with normal birth weight, Rh +ve for both mother and baby, regular fetal heart monitoring during labor, and single fetuses pregnancy.

6.1.4. Male and female gender of baby had nearly equal effect on safety of mothers and fetuses/babies.

6.1.5. Maternal and fetal/baby complications mostly associated with maternal age group <16, >45 years, illiterate mothers, rural living mothers, and these complications mostly happened in ante partum period during recent pregnancy.

6.1.6. Perinatal mortality is most common due to maternal causes.

6.1.7. Maternal mortality is most common in the first (42) postpartum days due to direct causes.

6.1.8. Most common risk factors were family history of medical diseases, previous cesarean section, low birth weight babies, ante partum hemorrhage, and toxemia in that order.

6.1.9. Maternal mortality happened due to hypertensive disorders, and hemorrhagic problems of pregnancy.

6.2. Recommendations:
6.2.1. Improve maternal health by:
a. Clean and safe delivery by skilled attendant at birth of all mothers.
b. Community awareness of maternal health needs.
c. Improvement of health status of women.
d. Improve health professional performance.
e. Integrate referral hospital services into the existing primary health care services.
f. Develop appropriate strategic polices for referral hospital including antenatal, postnatal, family planning, and emergency obstetric care.
g. Reporting system for domestic and other violence against women.
h. Community awareness of family planning and advantage of child spacing.
i. Laws and legislation for midwifery.
j. Continuing pre services and in services health education.
k. Strengthening monitoring system for maternal mortality.

6.2.2. Improve neonatal health by:
a. Quality care of the newborn babies by introduction of modern/new technologies and, skilled staff.
b. Action oriented newborn death surveillance system.
c. Introducing early detection and management of hereditary diseases.
d. Introduce genetic counseling services.

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P value less than 0.001D.f= 8

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Figure (1): Relation of Residency with mother, and fetus/newborn outcome.

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Table (4):  Effect of ANC site on the mother and on the fetus/newborn outcome.

Site of ANC	Outcome
	Safe		Unsafe		Total
	No.	%	No.	%	No.	%
Private	548	57.6	403	42.4	951	48.1
PHCC	185	33.3	371	66.7	556	28.1
Both	314	66.8	156	33.2	470	23.8
Subjects	1047	53	930	47	1977	100
Chi square=89.8 Degree of freedom=2

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Figure (3): Risky women levels and outcome of the mother, and the fetus/newborn

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Table (5): Effect of maternal immunization with tetanus toxoid on the mother and the fetus/newborn outcome.

Immunization	Outcome
	Safe		Unsafe		Total
	No.	%	No.	%	No.	%
*Received
-Complete	422	86.5	66	13.5	488	23.5
-Partial	500	58.7	352	41.3	852	41
*Not received	138	18.6	602	81.4	740	35.5
Subjects	1060	51	1020	49	2080	100
Chi square= 576 Degree of freedom= 2

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Table (6): Effect of birth spacing (average spacing period among all pregnancies) on the mother and the fetal/newborn outcome.

Complications	Period of spacing
	<2years		>2years		Subjects
	No.	%	No.	%	No.	%
Both  safe	340	35.2	720	64.6	1060	51
Both unsafe	135	14	68	6.1	230	9.7
SmUb	123	12.7	74	6.7	197	9.5
UmSb	368	38.1	252	22.6	620	29.8
Total	966	46.4	1114	53.6	2080	100
Chi square= 182.5 Degree of freedom= 3

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Figure (4): Duration of pregnancy and outcome of the mother, and the fetus/newborn.

SmUb=Safe mother and unsafe baby. UmSb=Unsafe mother and safe baby.

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Appendix II -   High Risk Evaluation Form(15)
*Reproductive history
Age:   <16 years            16-35             >35	4.0>1
	4.0>0
	4.0>2
Parity:t;5	4.0>1
	4.0>0
	4.0>2
Two or more abortion or history of infertility	4.0>1
Postpartum bleeding or manual removal of placenta.	4.0>1
4.0>2
	Column Total
*Medical or surgical associated condition
Previous gynecological surgery.	4.0>1
Chronic renal diseases`	4.0>1
Gestational diabetes A.	4.0>1
Class B or greater diabetes.	4.0>3
Cardiac diseases.	4.0>3
Other significant medical disorder (1-3) according to severity.	4.0>1-3
Column Total
*Present pregnancy
Bleeding:   <20 week                     >20 week	4.0>1
	4.0>3
Anemia (<10 g/l)	4.0>1
Postmaturity.	4.0>1
Hypertension.	4.0>2
PROM.	4.0>2
Polyhydramnios.	4.0>2
I.U.G.R.	4.0>3
Multiple pregnancy.	4.0>3
Breech or malpresentation.	4.0>3
Rh-isoimmunization.	4.0>3
Column Total

*Total Score  (summation of 3 columns).

   -Low risk                  0-2

   -High risk                 3-6

   -Sever risk                7 or more