Estimation of gestational age in pregnancy in Africa, a scoping review

ESTIMATION OF THE GESTATIONAL AGE IN PREGNANCY IN AFRICA. A SCOPING REVIEW PROTOCOL AUTHORS Winile Dorentce Cele1, Pretty Mbeje PhD1, Euphamia Mbali Mhlongo PhD1, Geldine Chironda PhD2 AUTHOR AFFILIATIONS 1.College of Health Sciences, School of Nursing and Public Health, Howard College Campus, University of KwaZulu-Natal, Durban 4041, South Africa Email: winiledcele@gmail.com; Mbejep@ukzn.ac.za; mhlongoem@ukzn.ac.za 2. Seed Global Health, St John of God University, Area 10 Plot 185, Off Zomba Street, Bua Road, P.O.Box 30111, Lilongwe 3, Malawi Email: gchikanya@seedglobalhealth.org INTRODUCTION Pregnancy is described as the period in which a foetus develops inside a woman's uterus, it is calculated from the first day of the last normal menstrual period (LNMP) until delivery. Usually, normal pregnancy lasts about 38 to 42 weeks. In developing countries adolescent pregnancy is reported to be increasing at a higher rate. According to the research conducted on adolescent pregnancy, Africa is the leading continent with high prevalence of adolescents between the age of 10-19 (Maharaj, 2022). This is caused by its higher proportion of youth. East Africa has the highest prevalence of adolescent pregnancy whereas Northern Africa has the lowest (Kassa et al., 2018). Adolescent pregnancy may be associated with lack of parental education regarding sexual and reproductive health, low level of education especially in rural areas, getting marriage at a younger age and religious beliefs (Kassa et al., 2018; Maharaj, 2022) Fetal growth monitoring is an important practice during antenatal care. It is monitored through estimation of gestational age which is done at first antenatal visit and throughout pregnancy. Gestational age is defined as the length of pregnancy calculated from the first day of the last menstrual period. (Lu & Lu, 2008). However, this estimation may be inaccurate if a woman is unsure of her dates. According to Winningham (2019) normal pregnancy ranges from 38 to 42 weeks. When the delivery occurs at the gestational age of less than 38 weeks it is considered prematurity (Winningham, 2019). Accurate estimation of gestational age determines the antenatal outcomes by identifying maternal risks such as intrauterine growth retardation (IUGR), multiple pregnancy, polyhydramnios, oligohydramnios and postdate pregnancy (Lu & Lu, 2008). If the maternal risks are not identified, this may lead to mismanagement. Gestational age is also used to determine when to repeat screening tests (Hb, HIV and RPR throughout pregnancy (Naidu & Fredlund, 2023). It also assists in making clinical decisions and timing of administration of corticosteroids for foetal lung maturation in case of suspected preterm labour (Naidu & Fredlund, 2023) . According to basic antenatal care (BANC), Hb is repeated at 30 and 38 weeks, HIV is repeated at every visit if negative and RPR is repeated at 34 weeks. According to BANC antenatal care (ANC) is defined as the care rendered to a woman during pregnancy which aims at identifying problems that can affect her and the foetus. It is essential because it reduces maternal morbidity and mortality since the pregnant women are receiving skilled services (Dickson et al., 2022). This was concluded by (Dickson et al., 2022) when reporting the findings of a study conducted in sub-Saharan Africa about the utilization of skilled services. Gestational age is estimated during antenatal visit which should be at least 8 visits throughout pregnancy (BANC.) Gestational age is done at different levels of healthcare which may differ among African countries. ANC, including estimation of gestational age may be provided at different levels of care. Primary health care (PHC) clinic is the first step in the provision of antenatal care. PHC caters for pregnant women who need basic antenatal care. When a woman needs further investigations and management, she is referred to the community health centre (CHC). The second step is community health care centre (CHC) which provides a 24 hours’ maternity services. Uncomplicated deliveries are conducted at CHCs. Third step is District hospital where antenatal care is rendered by the nurses and doctors. The patients are referrals from PHCs and CHCs. Level 2 care is provided by the specialists to high risk maternal cases. Level 3 care is provided by specialists in the provincial tertiary hospitals. These hospitals consist of generalists who specialize in other services. At Level 4, Central hospitals provide highly specialized care and have highly specialized units to cater for women referred by the provincial tertiary hospitals care (Communications, 2014). Nxiweni et al. (2022) conducted a study in South Africa which concurs that antenatal care is provided by the health care professionals who are the doctors (18%) , the midwives (70%), traditional birth attendants (2%) and no clinic cases make 10%. Statistics showed that Western cape has the highest percentage of women utilizing ANC services. Several studies were conducted to estimate gestational age in Africa (Malaba et al., 2018; Unger et al., 2019; Yovo et al., 2022). They conducted cohort studies in Sub Saharan countries and in South Africa. They looked at different methods of estimating gestational age which are: ultrasound, last normal menstrual period and ultrasound. Findings revealed that there was poor to moderate correlation between ultrasound and other methods. However, there are no previous reviews that were conducted on estimation of gestational age conducted in Africa. Aim of the review To map and synthesize the evidence on estimation of the gestational age in pregnancy in Africa. This review will identify the types of methods used to estimate gestational age. It will clarify the key concepts related to gestational age and will also determine the research methodology adopted and results of research that was conducted on gestational age (Unger et al., 2019). This review will identify the gaps and make recommendations for further systematic reviews (Munn et al., 2018). Scoping review questions a) What are the publication characteristics of evidence conducted to estimate the gestational age in pregnancy in Africa? (Year, country, design, setting, population, sample, sample size) b) What type of pregnancy identified from the evidence (single, twin, triple pregnancy)? c) What are the different methods used to estimate gestational age in pregnancy in Africa? d) What gaps in methods used to estimate gestational age in single pregnancy in Africa? METHODOLOGY A scoping review protocol will be developed according to the Joanna Briggs Institute (JBI) Manual (Peters et al., 2022). Protocols provide the reviewers with the direction on how to conduct and report the scoping review results. Protocols also specify the inclusion and exclusion criteria, databases and the search strategy that will be adopted (Peters et al., 2022). The reviewer will register the scoping review to avoid unintended duplication of reviews. When conducting a scoping review, the researcher will follow the steps as described in the (JBI) manual. These steps differ from those that are used when conducting the traditional systematic reviews because the scoping review addresses the broader goal as opposed to the systematic review (Peters et al., 2022). Eligibility criteria When developing search terms, inclusion, and exclusion criteria, the researcher will apply the Population, Concepts, Context (PCC) framework as indicated in the table below. Table 1 PCC: Search terms and eligibility criteria Variable Description Inclusion criteria Exclusion criteria Population A pregnant woman is a woman attending antenatal care clinic with a singleton or multiple pregnancy) Pregnant women, pregnant mothers or expecting mothers, antenatal patients Non pregnant women Concept Gestational age is defined as the length of pregnancy calculated from the first day of the last menstrual period. Estimation of gestational age, gestational aging, foetal growth monitoring, symphysis fundal height measurement Studies conducted on embryonic gestational age Context Africa is the second largest contingent on the earth Africa*, OR African countries* OR developing countries*, OR low resource countries*, OR low- and middle-income countries*, sub-Saharan Africa, southern Africa, East Africa, Central Africa, West Africa, North Africa, Community health care centres, primary health care centres and district hospitals, tertiary and central hospitals Studies not conducted in Africa. Type of article English articles conducted between 2013 and 2023, ether peer or non-peer reviewed Quantitative article, qualitative article, review articles, mixed method articles, documents, guidelines, Search words The following search word combination of PCC, separated by Boolean operations and truncations will be used (see Figure 1 below) Figure 1: Search word combination View Results (249,316View Details Searching in selected Search engines and electronic data bases During the initial search, two databases PubMed and EBSCOhost will be searched, and titles and abstracts will be screened from the retrieved articles. To refine the search terms, key words and Mesh terms will be discussed with the review team (Peters et.al, 2020). In step two search will be done from Google, google scholar, CINHAL, Sabinet, AJOL, Web of Science, Science Direct, Professional organisations like the WHO, UNICEF, Nursing and Midwifery Organisation. Grey literature will also be searched in the form of dissertations and theses. In step three the searching of the reference list of the articles included will be done. The key authors of the reviews and primary studies will be contacted should the additional information be required (Peters et al., 2022). The review team, with the help of the subject librarian will apply the eligibility criteria to screen the articles. Relevant studies obtained from the search will be imported to the endnote version 20.5. Rayyan software will also be used for the documentation and management of the results (Peters et al., 2022) Process of source selection During the first phase of source selection the review team will remove the duplicates and then will independently screen the titles and abstracts of papers that have been searched. About 15 articles will be piloted and screened by three reviewers who will be functioning independently with Blind On. The agreement level for the piloted articles will be greater than 75 %. Studies which do not meet the inclusion criteria will be excluded (Arksey & O'Malley, 2005).Secondly the inclusion and exclusion criteria will be applied to screen the full text of the papers. PCC framework recommended by the JBI will be adopted when selecting the studies. If new terms, concepts, and sites of evidence are revealed during the review process, searches will be modified (Peters et al., 2022). The number of articles searched will be presented in Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews PRISMA-ScR) checklist. The aim of the PRISMA-ScR is to help readers to understand the relevant items to be reported for scoping reviews (Tricco et al., 2018). Data extraction A draft charting table will be developed and used to extract data using the PCC variables. To answer the review questions, the information in table 2 will be included as listed in JBI manual (Peters et al., 2022). Table 3: Draft charting table for the symphysis fundal height measurement in Africa Author/year/ Country Country Research design Population; type of pregnancy Sample; Sampling setting Methods used to estimate gestational age - The reviewers will pilot the charting template on two or three articles to ensure that the required data is added. - The reviewers would ascertain if the data extracted is consistent with the review questions and the inclusion criteria, they will also familiarize themselves with the form. - During data extraction process, the reviewers will revise and modify charting of data. - Three reviewers will double check the data independently, and the fourth reviewer will be involved to ensure that the consensus is reached. They will focus on the following data: Author(s), year of publication, country of origin (where the study was published or conducted), aims/purpose of the study, study population if applicable, method ology/methods, intervention, type or duration and key findings that relate to the scoping review question/s (Peters et al., 2022) - If there is additional or missing information required, the reviewers will contact the key authors. COLLATING, SUMMARIZING, AND REPORTING RESULTS Figures and tables will be used to chart and present the extracted data. The results will be analysed using a descriptive and narrative analysis. During the narrative analysis, the emerging themes will be identified and interpreted. The reviewers will summarize the findings and report how they will be published. The methodologies used, population and the identified gaps will also be reported, including the methods used to estimate gestational age. Dissemination of data will be done through presentation of results at local conference, and they will be submitted to a relevant journal for publication. DISCUSSION This scoping review will evaluate the evidence of the methods used to estimate the gestational age and to monitor foetal growth. The reviewers will be looking at the methods that are used in Africa to estimate the gestational age. This review will identify gaps in the methods used to estimate gestational age and make relevant recommendations. The report will emphasize the importance of estimating gestational age since the findings can assist in the triaging of women at risk. The findings from this scoping review will be useful in the development of curriculum for the student midwives (both theory and clinical) and will also inform the stakeholders when developing the policies. REFERENCES Arksey, H., & O'Malley, L. (2005). Scoping Studies: Towards a Methodological Framework. International Journal of Social Research Methodology: Theory & Practice, 8, 19-32. doi.org Communications, K. H. C. (2014). Referral system: levels of health care. Dickson, K. S., Okyere, J., Ahinkorah, B. O., Seidu, A.-A., Salihu, T., Bediako, V., Owusu, B. A., Budu, E., Agbemavi, W., Edjah, J. O., & Darteh, E. K. M. (2022). Skilled antenatal care services utilisation in sub-Saharan Africa: a pooled analysis of demographic and health surveys from 32 countries. BMC Pregnancy and Childbirth, 22(1), 831. doi.org Kassa, G. M., Arowojolu, A. O., Odukogbe, A. A., & Yalew, A. W. (2018). Prevalence and determinants of adolescent pregnancy in Africa: a systematic review and Meta-analysis. Reproductive Health, 15(1), 195. doi.org Lu, M. C., & Lu, J. S. (2008). Encyclopaedia of infant and Early childhood Development. Maharaj, N. R. (2022). Adolescent pregnancy in sub-Saharan Africa – a cause for concern Front. Reprod. Health 4:984303. doi: 10.3389/frph.2022.984303 2. Malaba, T. R., Newell, M. L., Madlala, H., Perez, A., Gray, C., & Myer, L. (2018). Methods of gestational age assessment influence the observed association between antiretroviral therapy exposure, preterm delivery, and small-for-gestational age infants: a prospective study in Cape Town, South Africa. Ann Epidemiol, 28(12), 893-900. doi.org Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 18(1), 143. doi.org Naidu, K., & Fredlund, K. L. (2023). Gestational Age Assessment. In StatPearls. StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC. Nxiweni, P. Z., Oladimeji, K. E., Nanjoh, M., Banda, L., Anyiam, F. E., Hyera, F. L. M., Apalata, T. R., Mbokazi, J. A., & Oladimeji, O. (2022). Factors Influencing the Utilization of Antenatal Services among Women of Childbearing Age in South Africa. Women, 2(3), 285-303. mdpi.com Peters, M., Godfrey, C., McInerney, P., Khalil, H., Larsen, P., Marnie, C., Pollock, D., Tricco, A., & Munn, Z. (2022). Best practice guidance and reporting items for the development of scoping review protocols. JBI evidence synthesis, Publish Ahead of Print. doi.org Tricco, A. C., Lillie, E., Zarin, W., O'Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., . . . Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med, 169(7), 467-473. doi.org Unger, H., Thriemer, K., Ley, B., Tinto, H., Traoré, M., Valea, I., Tagbor, H., Antwi, G., Gbekor, P., Nambozi, M., Kabuya, J.-B. B., Mulenga, M., Mwapasa, V., Chapotera, G., Madanitsa, M., Rulisa, S., de Crop, M., Claeys, Y., Ravinetto, R., & D’Alessandro, U. (2019). The assessment of gestational age: a comparison of different methods from a malaria pregnancy cohort in sub-Saharan Africa. BMC Pregnancy and Childbirth, 19(1), 12. doi.org Winningham, A. L. (2019). Gestational age. Encyclopedia Britannica. britannica.com. Yovo, E., Accrombessi, M., Agbota, G., Hocquette, A., Atade, W., Ladikpo, O. T., Mehoba, M., Degbe, A., Mombo-Ngoma, G., Massougbodji, A., Jackson, N., Fievet, N., Heude, B., Zeitlin, J., & Briand, V. (2022). Assessing fetal growth in Africa: Application of the international WHO and INTERGROWTH-21st standards in a Beninese pregnancy cohort. PLOS ONE, 17(1), e0262760. doi.org Appendix 1 Table 2. Sample of search conducted in August 2023 from EBSCOhost database. Pregnant women OR pregnant mothers OR expecting mothers OR antenatal patients AND Estimation of gestational age OR gestational aging OR fetal growth monitoring OR symphysis fundal height measurement AND Africa*, OR African countries* OR developing countries*, OR low resource countries*, OR low- and middle-income countries* OR sub-Saharan Africa OR southern Africa OR East Africa OR Central Africa OR West Africa OR North Africa Limiters - Full Text; Published Date: 20130101-20230831 Expanders - Apply equivalent subjects Search modes - Boolean/Phrase View Results (249,316) View Details