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. 2025 Jan 20;24(1):19.
doi: 10.1186/s12939-025-02379-5.

Mixed vulnerabilities: the biological risk of high parity is aggravated by emergency referral in Benin, Malawi, Tanzania and Uganda

Manuela Straneo  1   2   3 , Lenka Beňová  4   5 , Thomas van den Akker  6   7 , Muzdalifat S Abeid  8 , Elizabeth Ayebare  9 , Jean-Paul Dossou  10 , Greta Handing  11 , Bianca Kandeya  12 , Andrea B Pembe  13 , Claudia Hanson  14   5
Affiliations

Mixed vulnerabilities: the biological risk of high parity is aggravated by emergency referral in Benin, Malawi, Tanzania and Uganda

Manuela Straneo et al. Int J Equity Health. .

Abstract

Identification of interacting vulnerabilities is essential to reduce maternal and perinatal mortality in sub-Saharan Africa (SSA). High parity (≥ 5 previous births) is an underemphasized biological vulnerability linked to poverty and affecting a sizeable proportion of SSA births. Despite increased risk, high parity women rarely use hospitals for childbirth. We assessed whether emergency referral during childbirth was associated with adverse events in high parity women in hospitals in Benin, Malawi, Tanzania and Uganda. We used e-registry data collected in 16 hospitals included in the Action Leveraging Evidence to Reduce perinatal morbidity and morTality (ALERT) trial. Main outcomes were severe maternal outcomes and in-facility peripartum death (fresh stillbirth or very early neonatal death). Main exposure was parity; emergency (in-labour) referral was included as effect modifier with potential confounders. We used multivariable logistic regression including parity/referral interaction and post-regression margins analysis. Among 80,663 births, 4,742 (5.9%) were to high parity women. One third reached hospital following emergency referral. Severe maternal outcomes and peripartum mortality were over 2.5-fold higher in high parity women with emergency referral compared to the lowest risk group. To avert these adverse events, emergency referral must be avoided by ensuring high parity women give birth in hospitals. Trial registration Pan African Clinical Trial Registry ( www.pactr.org ): PACTR202006793783148. Registered on 17th June 2020.

Keywords: Childbirth; Emergency referral; Fresh stillbirths; High parity; Hospitals; Intrapartum care; Maternal health; Perinatal health; Sub-Saharan Africa; Very early neonatal mortality; Vulnerability.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Ethical approval for ALERT was obtained from institutional review boards in Benin, Malawi, Tanzania, Uganda, Sweden, and Belgium, as follows: 1. Sweden: Etikprövningsmyndigheten— (Dnr 2020–01587). 2. Benin: Comité National d’Ethique pour la Recherche en Santé, Cotonou, Bénin—(N∘44 du 21/12/2020). 3. Malawi: College of Medicine Research and Ethics Committee (COMREC)—(COMREC P.04/20/3038). 4. Tanzania: Muhimbili University of Health and Allied Sciences (MUHAS), Senate Research and Publication Committee, Tanzania (MUHAS-REC-04–2020-118); the Aga Khan University Ethical Review Committee, Tanzania (AKU/2019/044/fb); and National Human Research Ethics Committee (NatHREC), Tanzania (NIMR/HQ/R.8a/Vol.IX/3493). 5. Uganda: Makerere University School of Public Health Research and Ethics committee (Protocol 808) and Uganda National Council for Science and Technology— (HS1324ES). 6. Belgium: The Institutional Review Board at the Institute of Tropical Medicine Antwerp and the Ethics Committee at the University Hospital Antwerp, Belgium—(ITG 1375/20.B3002020000116). Ethics approval from all countries exempted the study from informed individual consent from women, as data would be de-identified before incorporation into the e-registry. All study procedures were in accordance with national ethical standards on human experimentation and with the Helsinki Declaration. Consent for publication: Not applicable. Competing interests: TvdA is part of the editorial board of BMC Pregnancy and Childbirth. There are no other competing interests.

Figures

Fig. 1
Fig. 1
A: Estimated probability, with 95% CI, of a severe maternal outcome among women giving birth, and B: Estimated probability, with 95% CI, of peripartum death among infants born, by combination of woman’s parity and referral status, in hospitals in Benin, Malawi, Tanzania, Uganda, using post-estimation margins analysis
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