title: Risk factors for reported obstetric complications and near misses in rural northwest Bangladesh: analysis from a prospective cohort study.
abstract: BACKGROUND
  In rural Bangladesh, more than 75% of all births occur at home in the absence of skilled birth attendants. Population-based data are lacking on the burden and risk factors for obstetric complications in settings with low rates of institutional delivery. We sought to describe the prevalence of reported complications and to analyze risk factors for obstetric complications and near misses, using data from a representative, rural setting of Bangladesh.
  
  
  METHODS
  This study utilized existing data on 42,214 pregnant women enrolled in a micronutrient supplementation cohort trial between 2007 and 2011 in rural northwest Bangladesh. Based on self-report of complications, women were categorized as having obstetric complications, near misses, or non-complicated pregnancies using definitions modified from the World Health Organization. Multivariable multinomial regression was used to analyze the association of biological, socioeconomic, and psychosocial variables with obstetric complications or near misses.
  
  
  RESULTS
  Of enrolled women, 25% (n = 10,380) were classified as having at least one obstetric complication, 2% (n = 1,004) with reported near misses, and 73% (n = 30,830) with non-complicated pregnancies. Twelve percent (n = 5,232) reported hemorrhage and 8% (n = 3,259) reported sepsis. Of the 27,241 women with live births or stillbirths, 11% (n = 2,950) reported obstructed labor and 1% (n = 328) reported eclampsia. Biological risk factors including women's age less than 18 years (Relative Risk Ratio [RRR] 1.26 95%CI:1.14-1.39) and greater than 35 years (RRR 1.23 95%CI:1.09-1.38), history of stillbirth or miscarriage (RRR 1.15 95%CI:1.07-1.22), and nulliparity (RRR 1.16 95%CI:1.02-1.29) significantly increased the risk of obstetric complications. Neither partner wanting the pregnancy increased the risk of obstetric complications (RRR 1.33 95%CI:1.20-1.46). Mid-upper arm circumference <21.5 cm increased the risk of hemorrhage and sepsis.
  
  
  CONCLUSIONS
  These analyses indicate a high burden of obstetric morbidity. Maternal age, nulliparity, a history of miscarriage or stillbirth, and lack of pregnancy wantedness were associated with increased risk of obstetric complications. Policies to address early marriage, unmet need for contraception, and maternal undernutrition may help mitigate this morbidity burden in rural Bangladesh.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. ssikder@jhsph.edu.
authors.forename: Shegufta S
authors.initials: SS
authors.lastname: Sikder
authors.forename: Alain B
authors.initials: AB
authors.lastname: Labrique
authors.forename: Abu A
authors.initials: AA
authors.lastname: Shamim
authors.forename: Hasmot
authors.initials: H
authors.lastname: Ali
authors.forename: Sucheta
authors.initials: S
authors.lastname: Mehra
authors.forename: Lee
authors.initials: L
authors.lastname: Wu
authors.forename: Saijuddin
authors.initials: S
authors.lastname: Shaikh
authors.forename: Keith P
authors.initials: KP
authors.lastname: West
authors.forename: Parul
authors.initials: P
authors.lastname: Christian
mesh_terms: D000293:Adolescent; D000328:Adult; D001459:Bangladesh; D016009:Chi-Square Distribution; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006700:Home Childbirth / Q000009:adverse effects* / Q000706:statistics & numerical data; D006801:Humans; D007194:India; D007231:Infant, Newborn; D016015:Logistic Models; D008428:Maternal Mortality / Q000639:trends*; D015999:Multivariate Analysis; D007744:Obstetric Labor Complications / Q000175:diagnosis / Q000453:epidemiology*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis / Q000453:epidemiology; D011256:Pregnancy Outcome; D011446:Prospective Studies; D012307:Risk Factors; D012424:Rural Population; D012959:Socioeconomic Factors; D055815:Young Adult