The relationship between antenatal risk characteristics, place of delivery and adverse delivery outcome in rural Malawi

Objective. To describe and compare the frequency of antenatally identified maternal 'risk' characteristics, place of delivery and occurrence of delivery complications. Methods. A prospective cohort study of 780 pregnant women completing antenatal followup at a rural health center in Malawi. Results. Three-quarters of the subjects had at least one commonly accepted risk characteristic. Only 30% of these women, and 22% of those with no risk characteristics, delivered in a modern health facility. Four women died, 127 experienced other delivery complications and there were 52 perinatal deaths. The 'at-risk' classification had over 80% sensitivity but less than 30% specificity to predict delivery complications or perinatal deaths. The positive predictive values were as low as 20% for delivery complications and 7% for perinatal mortality. Most individual 'risk' characteristics were not associated with adverse delivery outcomes, even when adjusted for the place of delivery. Conclusions. Antenatal risk identification failed to promote safe deliveries because of a poor predictive value of the 'risk' variables and the failure of the identified 'at-risk' individuals to deliver in modern health facilities.