Fetal and Neonatal Outcomes in Booked vs. UnBooked Deliveries: A Systematic Review and Meta-analysis of the Global Literature

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Systematic Review

Fetal and Neonatal Outcomes in Booked vs. UnBooked Deliveries: A Systematic Review and Meta-analysis of the Global Literature

https://doi.org/10.21203/rs.3.rs-5067026/v1

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Purpose

A booked case is an indicator of antenatal care (ANC), embodying a proactive approach to pregnancy care, whereas unbooked deliveries describe scenarios in which pregnant women delay seeking ANC, which may cause adverse fetal outcomes and lead to neonatal morbidity and mortality. Despite extensive exploration of the effects of ANC on maternal and fetal health, a detailed review comparing fetal outcomes in booked versus unbooked cases was lacking. Our study aimed to quantify the effects of ANC on fetal and neonatal outcomes through a comprehensive meta-analysis of booked and unbooked cases.

Methodology

This review was registered in PROSPERO (Registration No: CRD42024526568). Two databases were systematically searched, PubMed and Google Scholar, with a time filter of 2003–2023. Quality was assessed on the basis of the Newcastle‒Ottawa scale for cohort studies and the modified version for cross-sectional studies. The main outcomes were neonatal mortality, low Apgar scores, low birth weight (LBW), macrosomia, meconium aspiration and birth asphyxia. The secondary outcomes were neurological symptoms, neonatal intensive care unit (NICU) admissions, congenital anomalies, jaundice and neonatal sepsis. A random-effects model was used to evaluate the pooled effect size of the odds ratio (OR).

Results

In total, 28 studies were included in the final review, with the majority (n = 24) originating from low to middle-income countries. For the majority of the outcomes, being booked was found to be protective on the basis of pooled ORs, i.e., neonatal mortality (OR 0.30; 95% CI 0.15–0.63, I² = 96%), low APGAR scores at 1 minute (OR 0.33; 95% CI 0.29–0.38, I² = 92% and 5 minutes (OR 0.16; 95% CI 0.08–0.32, I2 = 91%), LBW (OR 0.36; 95% CI 0.30–0.43, I2 = 46%), jaundice (OR 0.48; 95% CI 0.19–1.25, I² = 74%), MAS (OR 0.36; 95% CI 0.18–0.70, I² = 64%), neurological symptoms (OR 0.34; 95% CI 0.13–0.85, I²=20%), neonatal sepsis (OR 0.56; 95% CI 0.37–0.86, I² = 17%), asphyxia (OR 0.39; 95% CI: 0.32–0.49; I² = 0%) and however, we did not find any difference between booked and unbooked deliveries in terms of macrosomia (OR 0.99; 95% CI: 0.53–1.83, I² = 32%) and congenital anomalies (OR 0.09; 95% CI 0.35–2.29 I2 = 83%). The publication bias was minimal.

Conclusion

This meta-analysis provides substantial evidence that booked deliveries have significantly better fetal outcomes across a broad spectrum than unbooked deliveries do; therefore, interventions that improve ANC coverage need to be implemented to reduce adverse fetal outcomes.

Pediatrics

Neonatal mortality

antenatal care

booking status

fetal complications

deliveries

Antenatal care (ANC) is pivotal for maternal and fetal well-being and plays a critical role in preventing, identifying, and managing complications during pregnancy.¹ It has a profound effect on decreasing maternal and neonatal death rates.² Serving as a fundamental pillar in comprehensive maternal and fetal healthcare, ANC provides a spectrum of services to monitor and ensure the well-being of expectant mothers.³ Despite the global progress in ANC, a significant gap in access to comprehensive services persists, particularly in developing nations.³ The World Health Organization (WHO) stresses the necessity of early and regular ANC to monitor and address risks associated with maternal and child well-being.⁴ Therefore, monitoring ANC utilization in LMICs is crucial.

A "booked case" serves as the cornerstone of comprehensive ANC, embodying a proactive and systematic approach to pregnancy care. Pregnant women actively engage by registering early and initiating a continuum of care involving regular check-ups, diagnostic tests, and educational sessions.⁵ Scheduled checkups during pregnancy, a vital component of ANC, monitor the health of both mothers and fetuses, allowing healthcare professionals to track pregnancy progression, identify deviations, and detect complications early.⁶ Early diagnosis of conditions, such as gestational diabetes or hypertensive disorders, enables proactive management, reducing risks and optimizing outcomes.⁷ Educational sessions in booked cases empower expectant mothers with essential knowledge, including nutrition, lifestyle, and postpartum care, facilitating informed choices for a healthy pregnancy.⁸ On the other hand, "unbooked deliveries" describe scenarios where pregnant women either delay seeking ANC or initiate care late in their pregnancies, posing a significant and concerning risk for adverse fetal outcomes.⁹ Unfavourable foetal outcomes, including low birth weight (LBW), stillbirth, and premature birth, are prominent causes of neonatal morbidity and mortality.¹⁰ Delayed initiation of ANC in nonbooked deliveries is a risk factor for adverse fetal outcomes, such as intrauterine growth restriction (IUGR), birth before term (37 weeks), LBW, congenital anomalies, and an elevated risk of stillbirth. ^11–15 The absence of regular check-ups and interventions during pregnancy exacerbates these risks in unbooked delivery.

Despite extensive exploration of the impact of ANC on maternal and fetal health, there is currently a gap in dedicated systematic reviews comparing fetal outcomes in booked versus unbooked cases. This study aims to address this gap by analysing the available evidence. Given that neonatal disorders remain the 5th leading cause of mortality worldwide¹⁶, the significance of a systematic review is to emphasize the importance of booked pregnancies and ANC in preventing adverse fetal outcomes. This study has the potential to guide future interventions.

We registered this review in PROSPERO (Registration No. CRD42024526568). The guidelines outlined by the PRISMA guidelines were thoroughly followed throughout the study.

Data Sources

A thorough search of the literature was performed via the PubMed and Google Scholar databases. We used the following search terms: (booked delivery OR scheduled delivery OR planned birth) AND (unbooked delivery OR unscheduled delivery OR nonarranged delivery) AND (fetal outcome OR pregnancy outcome OR fetal complications OR still birth OR birth asphyxia). The search was restricted to the publication period within the range of 2000–2024. Details of the search strategy are provided in supplementary file 1 (Appendix D).

Eligibility criteria

The eligibility criteria for study inclusion were primary research articles written in English that focused on both primary and multigravida pregnant women of reproductive age (WRA), irrespective of the mode of delivery, as the population was included to ensure a comprehensive analysis. The intervention was then the status of being booked for delivery. The comparison was with women who were not booked for delivery, and the outcomes were fetal or neonatal complications, specifically mortality, low Apgar scores, LBW, macrosomia, meconium aspiration, neurological disorders, congenital defects, sepsis, jaundice, neonatal intensive care unit (ICU) admission and birth asphyxia.

The exclusion criteria were studies that were case reports, case series, or review articles and did not report outcomes with respect to booking status.

Screening and study selection

Two independent investigators (NLS and UH) checked the titles and abstracts of all studies for eligibility, and discrepancies were solved by either discussion or consultation with a third party (NK or JM). Citations were also checked in review articles. When an abstract favoured that the article may fulfil the inclusion criteria, its full text was reviewed. Rayyan software was used for screening.¹⁷

Data Extraction and Analysis

The data were extracted via a predefined Microsoft Excel grid. Extraction was also performed by two independent researchers (FM and RZ). The full text of each article was thoroughly reviewed for extraction, and any disagreements were discussed with senior members of the team (JM and NK).

Assessment of the Quality of the Included Studies

The quality of the included articles was evaluated via the Newcastle‒Ottawa scale for both cohort and cross-sectional studies.¹⁸ Two independent reviewers (AA and UH) assessed the quality, and a third person (JM and AN) later resolved the discrepancies. The quality assessment is described in detail in supplementary file 1 (Appendix A).

Statistical analysis

The studies included in the meta-analysis were those with complete extractable data. The extracted data were imported into RevMan (version 5.4). Forest plots in which the odds ratio (OR) was used as the effect size were generated via a random effects model.

To assess heterogeneity, I² values were calculated, and values above 75% were considered high heterogeneity. Sensitivity analysis was subsequently conducted to assess the robustness of the results in accordance with the guidelines of the Cochrane Handbook of Systematic Reviews.¹⁹ The evaluation of publication bias was conducted through the use of a funnel plot, accompanied by Egger's regression test, employing the "metafor" and "meta" packages in R Studio.

Initially, 2,050 records were identified from databases, with 107 from PubMed and 1,940 from Google Scholar, along with 3 additional studies from reviews and citations. Before screening, 99 duplicate records and 3 non-English records were removed, leaving 1,948 records for screening. Of these, 1,906 records were excluded during the screening phase. A total of 42 reports were subsequently sought for retrieval, but 1 report was not retrieved. Of the 41 reports assessed for eligibility, 13 were excluded: 10 for not reporting fetal outcomes and 3 for not classifying outcomes as booked and unbooked. The final number of articles selected for the systematic review was 28. The descriptive information is presented in Table 1. There were 17 cross-sectional studies among the included publications, followed by 5 articles utilizing a cohort study design, 4 case‒control studies and 1 prospective observational survey.

Table 1

Features of the studies included
Author	Year	Journal Name	Study Design	Country	Total Sample Size	Unbooked Sample Size	Booked Sample Size	Quality Assessment
Oguejiofor C et al ²⁰	2023	Journal of Gynecology Obstetrics and Mother Health	Cross-Sectional	Nigeria	434	152	282	Satisfactory
Okojie OH et al ²¹	2022	Journal of Community Medicine and Primary Health Care	Cross-Sectional	Nigeria	390	130	260	Satisfactory
Anikwe C et al ²²	2022	African Health Sciences	Cross-Sectional	Nigeria	214	156	58	Satisfactory
Ghafoor M et al ²³	2022	Pakistan Journal Of Health Sciences	Cross-Sectional	Pakistan	380	190	190	Good
Adenaya OR et al ²⁴	2022	Obstetric Outcome between Booked and Unbooked Mothers	Cross-Sectional	Nigeria	2232	235	1997	Satisfactory
Almarri S et al ²⁵	2022	Cureus	Cross Sectional	Saudi Arabia	186	57	129	Good
Rathod D et al ²⁶	2021	National Journal of Integrated Research in Medicine	Prospective cohort	India	1500	500	1000	Satisfactory
Sule Odu et al ²⁷	2020	West African Journal of Nigeria	Cross-Sectional	Nigeria	1664	627	1037	Satisfactory
Bangera R et al ²⁸	2020	International Archives of Integrated Medicine	Cross Sectional	India	2518	854	1664	Satisfactory
Setia S et al ²⁹	2020	international journal of clinical obstetrics and gynecology	Prospective observational	India	400	200	200	Satisfactory
Onyema M et al ³⁰	2019	Open Journal of Obstetrics and Gynecology,	Case Control	Nigeria	623	219	404	Satisfactory
Zaki N et al ³¹	2019	J Soc Obstet Gynaecol Pak	Cross-Sectional	Pakistan	235	121	114	Satisfactory
Hijazi A et al ³²	2019	The internet Journal of Gynecology and Obstetrics.	Retrospective Cohort	Saudi Arabia	400	200	200	Satisfactory
Bulsara N et al ³³	2019	Indian Journal of Obstetrics and Gynecology	Prospective cohort	India	1000	500	500	Good
Bibi N et al ³⁴	2016	Pakistan Journal of Medical & Health Sciences	Cross-Sectional	Pakistan	544	272	272	Satisfactory
Pettit K et al ³⁵	2017	The Journal Of Maternal-Fetal & Neonatal Medicine	Retrospective cohort	USA	124	41	83	Satisfactory
Takai I et al ³⁶	2016	Archives of International Surgery	Cross-Sectional	Nigeria	147	25	122	Good
Chourasia S et al ³⁷	2016	International Journal of Reproduction, Contraception, Obstetrics and Gynecology	Case Control	India	800	400	400	Satisfactory
Abisowo O et al ³⁸	2016	Open Journal of Obstetrics and Gynecology	Cross Sectional	Nigeria	123	74	49	Satisfactory
Kalim D et al ³⁹	2015	Khyber Medical University Journal	Cross Sectional	Pakistan	2000	840	1160	Satisfactory
Ekpenyong M et al ⁴⁰	2011	Global education	Retrospective cohort	Nigeria	362	32	330	Good
Iklaki et al ⁴¹	2011	ISRN Obstetrics and Gynecology	Case Control	Nigeria	644	245	399	Satisfactory
Tucker A et al ⁴²	2010	Archives of Gynecology and Obstetrics	Retrospective cohort	UK	273	91	182	Satisfactory
Chigbu B et al ⁴³	2009	East African Medical Journal	Cross-Sectional	Nigeria	3734	634	3100	Satisfactory
George I et al ⁴⁴	2009	International journal of Biomedical science	Cross-Sectional	Nigeria	88	80	8	Satisfactory
Owolabi A T et al ⁴⁵	2008	Singapore Medicine	Cross-Sectional	Nigeria	1154	240	654	Good
Okonta P et al ⁴⁶	2007	Nigerian Journal of Medicine	Cross Sectional	Nigeria	19	13	6	Satisfactory
Fasubaa O et al ⁴⁷	2003	Tropical Journal of Obstetrics and Gynecology	Case Control	Nigeria	96	30	66	Satisfactory

Among the studies included in this analysis, 24 were conducted in low- and middle-income countries, whereas only 4 were conducted in high-income countries. The majority of these articles were authored by researchers from Nigeria (n = 15), followed by 5 from India, 4 from Pakistan, 2 from the Kingdom of Saudi Arabia (KSA), and 1 each from the United States of America (USA) and the United Kingdom (UK).

Outcomes

The main outcomes were neonatal mortality, followed by low Apgar scores, birth weight, macrosomia, meconium aspiration, neurological disorders, sepsis, jaundice, birth asphyxia, congenital defects, and admission to the NICU.

Mortality

We used data from eighteen studies to determine the prevalence of death. All types of mortality, including still births, intrauterine death and neonatal mortality, were combined. Among the 13030 booked patients, 947 (7.26%) died. Conversely, among the 6386 unbooked patients, 846 died (13.2%). Forest plot analysis revealed highly significant results (p < 0.00001), with an OR of 0.30 (95% CI: 0.15–0.63, I² = 96%), indicating higher mortality rates among unbooked patients. The variation between the research articles was high (I² = 96%).

Low APGAR scores

At 60 seconds

Data from twelve studies were used to estimate low 60-second APGAR scores. Booked cases had lower odds of having low 1-minute APGAR scores. (OR 0.33, 95% CI 0.29–0.38; I² = 92%). The studies showed a high degree of variability.

At 5 minutes

Similarly, the data from 6 studies reported low 5-minute APGAR scores. Figure 3 shows that in a total of 6503 booked cases, 318 neonates had low APGAR scores compared with 1738 unbooked women, and 521 delivered neonates had low 5-minute APGAR scores. Therefore, booked patients demonstrated lower odds of having low 5-minute APGAR scores (OR 0.16, 95% CI 0.08–0.32; I2 = 91%).

Low birth weight

Data from 9 studies were compiled to estimate LBW. Compared with booking cases, booking cases presented lower odds of LBW (OR 0.36, 95% CI 0.30–0.43; I² = 46%).

Macrosomia

Data from 3 studies were used to estimate macrosomia. The forest plot analysis yielded a nonsignificant result (p = 0.23), with an OR of 0.99 (95% CI: 0.53–1.83, I² = 32%), indicating comparable occurrence rates of macrosomia between the two groups.

Meconium aspiration syndrome

Meconium aspiration syndrome (MAS) was assessed as an outcome via data from 5 studies. Among the 1950 booked patients, 99 (5.08%) had meconium aspiration syndrome, whereas 175 out of 1320 (13.26%) unbooked patients had the syndrome. Compared with unbooked cases, booked cases presented significantly lower odds (OR 0.36, 95% CI 0.18–0.70; I² = 64%).

Asphyxia

Data from 5 studies were utilized to estimate the prevalence of asphyxia. Among the 1941 booked patients, 139 (7.16%) had asphyxia, whereas 235 out of 1386 (16.9%) unbooked patients had asphyxia. The forest plot analysis yielded a statistically significant result, with an OR of 0.39 (95% CI: 0.32–0.49), indicating a lower occurrence of asphyxia among booked patients than among unbooked patients.

Secondary Outcomes

The secondary outcomes are neurological symptoms, NICU admissions, congenital anomalies, jaundice and neonatal sepsis. (See supplementary file 1: Appendix B)

Sensitivity analysis

The sensitivity analysis revealed that there was no substantial difference in the effect sizes; therefore, our analysis can be considered robust (see supplementary file 1: Appendix C).

Publication Bias

The funnel plot shows that the studies are distributed on both sides, and Egger’s test also reveals a p value > 0.05. Therefore, the chance of publication bias is less likely. (See supplementary file 1: Appendix E)

Fetal complications are still a major challenge despite efforts to increase the survival of newborns. The findings of this research may have important impacts on decision makers and government officials related to mothers’ and children’s health. The data mainly originated from low socioeconomic countries and were obtained through a systematic review and meta-analysis. Hence, it is a better representative of that population and should be interpreted cautiously. In most cases, being booked was found to have a protective effect, as indicated by the pooled odds ratios (ORs). Specifically, for neonatal mortality, the OR was 0.30 (95% CI 0.15–0.63, I² = 96%), and for low APGAR scores at 1 minute and 5 minutes, the ORs were 0.33 (95% CI 0.29–0.38, I² = 92%) and 0.16 (95% CI 0.08–0.32, I² = 91%), respectively. Other outcomes with protective effects included neonates with LBW (OR 0.36; 95% CI 0.30–0.43, I² = 46%), jaundice (OR 0.48; 95% CI 0.19–1.25, I² = 74%), MAS (OR 0.36; 95% CI 0.18–0.70, I² = 64%), neurological symptoms (OR 0.34; 95% CI 0.13–0.85, I² = 20%), sepsis (OR 0.56; 95% CI 0.37–0.86, I² = 17%), asphyxia (OR 0.39; 95% CI 0.32–0.49; I² = 0%) and NICU admission (OR 0.75; 95% CI 0.65–0.86, I² = 97%). Nevertheless, we did not find a significant difference between booked and unbooked deliveries for few outcomes, including macrosomia (OR 0.99; 95% CI 0.53–1.83, I² = 32%) or congenital anomalies (OR 0.09; 95% CI 0.35–2.29, I² = 83%). These findings emphasize the importance of regular prenatal care, as booked patients generally experience fewer complications.

Our findings are consistent with those of another meta-analysis performed by Wondemagegn AT et al., who explored the impact of ANC monitoring on newborn outcomes; however, we assessed booking status.² Another recent analysis of national representative surveys of 43 LMICs revealed that the risk factors leading to neonatal mortality were being male, having a low or high birth weight, being born to less educated mothers, being delivered at home, having born after a short birth interval and not having routine ANC. Interestingly, they also reported that countries with high fertility rates and low literacy rates are more susceptible to this complication.⁴⁸

Target 3.2 of the sustainable development goals (SDG) is focused on ending neonatal mortality. Compared to the past two decades, neonatal mortality has declined. However, the progress has been slow, and approximately 60 countries still lag behind.⁴⁹ Therefore, to achieve this goal, few countries, such as Paraguay, Egypt, Ethiopia and South Africa, have proposed a draft decision toward SGD progress.⁵⁰ Such decisions need to be taken up by more African and South Asian countries as highlighted in our study. The World Health Organization has launched a monitoring framework for ANC targeted for better feto-maternal outcomes. However, at the implementation level, there is considerable variability.⁵¹

Tackling stillbirths and neonatal mortality necessitates interventions that span from preconception planning to the postpartum period, involving all levels of the health system, including family and community, outreach services, and clinical or facility-based care.⁵² Another study revealed that the decline in neonatal mortality was largely due to better infection control in newborns, particularly for those with sepsis and pneumonia. They also conducted qualitative interviews, which highlighted that prioritizing neonatal health in community planning, developing a national strategy, training health workers, establishing neonatal intensive care units, and partnering with local leaders and women’s groups to promote facility births and clean practices were key factors.⁵³ In our study, we also noted similar complications in most of the included studies.

ANC visits offer valuable information on postnatal care, newborn care, breastfeeding, recognition of potential issues, and appropriate action.⁵⁴ Despite the crucial role of ANC visits, there are still barriers, and most studies have pointed to women's negative opinions and perceptions of health care, the cost of services, financial problems, long waiting periods for care, and poor transport as deterrents to prenatal care.⁵⁵ These obstacles prevent women from seeking follow-up, likely leading to fetal complications.

To the best of our knowledge, this study is the first to produce thorough evidence on the effect of booking status on neonatal outcomes via the use of a robust methodology utilizing the global literature, addressing a major gap in the literature, and to conduct sensitivity analysis via different methods. However, there are a few limitations, as most of the articles used are from developing countries; therefore, interpretation needs to be done with caution. Additionally, there might be some chance of underreporting of outcomes in the included studies. Finally, we could assess only the immediate outcomes; therefore, long-term outcomes related to maternal and child health need to be explored in future studies.

There is consistent evidence that booked deliveries are associated with favourable outcomes across a wide range of fetal outcomes compared with unbooked deliveries; therefore, interventions that increase ANC coverage among pregnant women need to be implemented to reduce these adverse fetal outcomes.

Javeria Mansoor

Uffaira Hafeez

Noor Ullah Khan

Ahtisham Ali

Rooja Zubair

NLS

N.L. Swathi

Abdullah Nadeem

Faareah Mansoor

Competing Interests

The authors have no relevant financial or nonfinancial interests to disclose.

Source of Funding

The authors declare that no funding was received at any stage of this research.

Ethics approval

This review utilized data from publicly available resources with prior ethical consent given for them and thus does not require ethical approval. References to all the articles utilized in this study have been provided in the text.

Author contributions

Javeria Mansoor had the idea and conceptualized the topic. All authors contributed to the literature search and data curation, with Uffaira Hafeez, Noor Ullah Khan, Ahtisham Ali, and Rooja Zubair handling the cleaning of data and analysis and N.L. Swathi, Abdullah Nadeem, and Faareah Mansoor focusing more on the writing aspect of the article. All the authors take collective responsibility for the contents of the article and consent to its publication.

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The authors declare no competing interests.

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Fetal and Neonatal Outcomes in Booked vs. UnBooked Deliveries: A Systematic Review and Meta-analysis of the Global Literature

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Abstract

Purpose

Methodology

Results

Conclusion

Figures

Introduction

Methodology

Data Sources

Eligibility criteria

Screening and study selection

Data Extraction and Analysis

Assessment of the Quality of the Included Studies

Statistical analysis

Results

Outcomes

Mortality

Low APGAR scores

At 60 seconds

At 5 minutes

Low birth weight

Macrosomia

Meconium aspiration syndrome

Asphyxia

Secondary Outcomes

Sensitivity analysis

Publication Bias

Discussion

Conclusion

Abbreviations

Declarations

Competing Interests

Source of Funding

Ethics approval

Author contributions

References

Additional Declarations

Supplementary Files

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