{"_asset":{"@search.score":6.948129,"Name":"Pregnancy and neonatal outcomes in Eastern Democratic Republic of the Congo: a systematic review","AlternateTitleCommaDelimited":"","Id":"9055","AssetLocationUri":null,"Abstract":"

BACKGROUND

Conflict is known to impact maternal and neonatal health in Eastern Democratic Republic of the Congo (DRC), an area of longstanding insecurity. We conducted a systematic review on pregnancy and neonatal outcomes in this region to provide a comprehensive overview of maternal and neonatal outcomes over a 20-year period.

METHODS

We systematically searched databases, such as Medline, EMBASE, Global Health, ClinicalTrials.gov and the Cochrane Library, along with grey literature, for articles published between 2001 and 2021. These articles provided quantitative data on selected pregnancy and neonatal outcomes in the provinces of Ituri, Maniema and North and South Kivu, Eastern DRC. We conducted a descriptive analysis, combining results from different data sources and comparing incidence of outcomes in North Kivu with those in other provinces in Eastern DRC.

RESULTS

A total of 1,065 abstracts from peer-reviewed publications and 196 articles from the grey literature were screened, resulting in the inclusion of 14 scientific articles in the review. The most frequently reported pregnancy complications were caesarean sections (11.6%–48.3% of deliveries) and miscarriage (1.2%–30.0% of deliveries). The most common neonatal outcomes were low birth weight (3.8%–21.9% of live births), preterm birth (0.9%–74.0%) and neonatal death (0.2%–43.3%).

CONCLUSION

Our review provides data on pregnancy and neonatal outcomes in Eastern DRC, which will be valuable for future studies. Despite the area's ongoing armed conflict, the percentages of complications we noted in Eastern DRC are comparable with those observed in other countries in the region.

","PublicationOrPresentationDate":"2024-12-05T00:00:00Z","LastModifiedDate":"2025-01-24T00:51:54.857Z","IsDeleted":false,"DigitalObjectIdentifier":"10.3389/fgwh.2024.1412403","ContentTypeName":"Research","ParentContentTypeName":"Journal Article","JournalName":"Frontiers in Global Women's Health","ContentType":"Journal Article > Research","AvailabilityTypeId":1,"AvailabilityType":"Full Text","JournalIssue":null,"JournalVolume":"5","JournalPages":"1412403","JournalAbbreviation":"Front Glob Womens Health","Conference":null,"ConferenceStartDate":null,"ConferenceEndDate":null,"content":"\nTYPE Systematic Review\nPUBLISHED 05 December 2024| DOI 10.3389/fgwh.2024.1412403\nEDITED BY\n\nTabassum Firoz,\n\nYale New Haven Health System, United States\n\nREVIEWED BY\n\nPamela Schuetze,\n\nBuffalo State College, United States\n\nDieudonne Mpunga,\n\nKinshasa School of Public Health, Democratic\n\nRepublic of Congo\n\n*CORRESPONDENCE\n\nKambale Kasonia\n\nkambale.kasonia@lshtm.ac.uk\n\n†These authors have contributed equally to\n\nthis work and share first authorship\n\nRECEIVED 04 April 2024\n\nACCEPTED 05 November 2024\n\nPUBLISHED 05 December 2024\n\nCITATION\n\nKasonia K, Brindle H, Manno D, Edwards T,\n\nGardais S, Mambula G, Mossoko Z, Choi EM,\n\nConnor NE, Mukadi P, Grais RF, Keshinro B,\n\nRoberts CH, Kavunga-Membo H, Bausch DG,\n\nMuyembe J-J and Watson-Jones D (2024)\n\nPregnancy and neonatal outcomes in Eastern\n\nDemocratic Republic of the Congo: a\n\nsystematic review.\n\nFront. Glob. Womens Health 5:1412403.\n\ndoi: 10.3389/fgwh.2024.1412403\n\nCOPYRIGHT\n\n© 2024 Kasonia, Brindle, Manno, Edwards,\nGardais, Mambula, Mossoko, Choi, Connor,\nMukadi, Grais, Keshinro, Roberts, Kavunga-\nMembo, Bausch, Muyembe and Watson-\nJones. This is an open-access article\ndistributed under the terms of the Creative\nCommons Attribution License (CC BY). The\nuse, distribution or reproduction in other\nforums is permitted, provided the original\nauthor(s) and the copyright owner(s) are\ncredited and that the original publication in\nthis journal is cited, in accordance with\naccepted academic practice. No use,\ndistribution or reproduction is permitted\nwhich does not comply with these terms.\nFrontiers in Global Women’s Health\nPregnancy and neonatal\noutcomes in Eastern Democratic\nRepublic of the Congo:\na systematic review\nKambale Kasonia1*†, Hannah Brindle1†, Daniela Manno1,\nTansy Edwards2,3, Soazic Gardais4, Grace Mambula4,\nZephirin Mossoko5, Edward M. Choi1, Nicholas E. Connor1,\nPierre Mukadi5, Rebecca F. Grais4, Babajide Keshinro6,\nChrissy H. Roberts1, Hugo Kavunga-Membo5, Daniel G. Bausch7,8,\nJean-Jacques Muyembe5 and Deborah Watson-Jones1,9†\n\n1Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene\nand Tropical Medicine, London, United Kingdom, 2MRC International Statistics and Epidemiology Group,\nFaculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London,\nUnited Kingdom, 3School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan,\n4Research Department, Epicentre, Paris, France, 5Institut National de Recherche Biomédicale, Kinshasa,\nDemocratic Republic of the Congo, 6Janssen Vaccines and Prevention B.V., Leiden, Netherlands,\n7Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene &\nTropical Medicine, London, United Kingdom, 8FIND, Geneva, Switzerland, 9Mwanza Intervention Trials\nUnit, National Institute for Medical Research, Mwanza, Tanzania\nBackground: Conflict is known to impact maternal and neonatal health in\nEastern Democratic Republic of the Congo (DRC), an area of longstanding\ninsecurity. We conducted a systematic review on pregnancy and neonatal\noutcomes in this region to provide a comprehensive overview of maternal and\nneonatal outcomes over a 20-year period.\nMethods: We systematically searched databases, such as Medline, EMBASE, Global\nHealth, ClinicalTrials.gov and the Cochrane Library, along with grey literature, for\narticles published between 2001 and 2021. These articles provided quantitative\ndata on selected pregnancy and neonatal outcomes in the provinces of Ituri,\nManiema and North and South Kivu, Eastern DRC. We conducted a descriptive\nanalysis, combining results from different data sources and comparing incidence\nof outcomes in North Kivu with those in other provinces in Eastern DRC.\nResults: A total of 1,065 abstracts from peer-reviewed publications and 196 articles\nfrom the grey literature were screened, resulting in the inclusion of 14 scientific\narticles in the review. The most frequently reported pregnancy complications were\ncaesarean sections (11.6%–48.3% of deliveries) and miscarriage (1.2%–30.0% of\ndeliveries). The most common neonatal outcomes were low birth weight (3.8%–\n21.9% of live births), preterm birth (0.9%–74.0%) and neonatal death (0.2%–43.3%).\nConclusion: Our review provides data on pregnancy and neonatal outcomes in\nEastern DRC, which will be valuable for future studies. Despite the area’s\nongoing armed conflict, the percentages of complications we noted in Eastern\nDRC are comparable with those observed in other countries in the region.\n\nSystematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/\ndisplay_record.php?RecordID=262553, PROSPERO (CRD42021262553).\n\nKEYWORDS\n\npregnancy, neonatal, outcomes, eastern, DRC, conflict\n01 frontiersin.org\n\nhttp://crossmark.crossref.org/dialog/?doi=10.3389/fgwh.2024.1412403&domain=pdf&date_stamp=2020-03-12\nmailto:kambale.kasonia@lshtm.ac.uk\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttp://creativecommons.org/licenses/by/4.0/\nhttp://creativecommons.org/licenses/by/4.0/\nhttps://www.frontiersin.org/articles/10.3389/fgwh.2024.1412403/full\nhttps://www.frontiersin.org/articles/10.3389/fgwh.2024.1412403/full\nhttps://www.frontiersin.org/articles/10.3389/fgwh.2024.1412403/full\nhttps://www.frontiersin.org/articles/10.3389/fgwh.2024.1412403/full\nhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=262553\nhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=262553\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n1 Introduction\n\nArmed conflict has been shown globally to negatively impact\n\nmaternal and child health often through indirect means such as\n\nreduced vaccination coverage or limited access to healthcare,\n\nincluding antenatal care and skilled birth attendants (1–4). The\n\nEastern Democratic Republic of the Congo (DRC) has a long\n\nhistory of conflict, with wars from 1996 to 2003 followed by\n\ncontinued insecurity due to the presence of numerous armed\n\nrebel groups and non-state actors (5), some of which operate in\n\nthe areas next to Goma (6). As a result, humanitarian\n\norganisations have been present in Eastern DRC for many years\n\n(5), with many providing maternal and child healthcare (7–14).\n\nThis influx of aid, potentially led to claims that the health system\n\nin Eastern DRC was the best in the country (15), suggesting a\n\nmore complex situation compared to the typically negative\n\nimpact of conflict on maternal and child health reported in other\n\ncountries. In 2016, Lindskog found no association between\n\nneonatal mortality and conflict in Eastern DRC (16), Kandala\n\net al. (2014) reported that the under-five mortality rate in DRC\n\nwas lowest in North Kivu (17) and Guo et al.(2021) observed\n\nthat the adjusted coverage of antenatal care and skilled birth\n\nattendance increased in North Kivu and South Kivu (18).\n\nAdditionally, due to the high prevalence of gender-based and\n\nsexual violence in the region and the subsequent occurrence of\n\ngynaecological fistulas, many obstetric services have been\n\nimplemented to address these complications (19–21). These\n\nservices may indirectly benefit maternal and child health.\n\nAlthough previous studies have provided data on these\n\noutcomes in this conflict-affected area, a comprehensive review\n\nof the literature will be helpful to determine what rates of\n\nadverse maternal and neonatal outcomes have been documented\n\nto allow monitoring of trends over time as the conflict continues.\n2 Materials and methods\n\n2.1 Scientific articles\n\n2.1.1 Search strategy\nOne researcher (HB) extracted abstracts from Medline,\n\nEMBASE, Global Health, ClinicalTrials.gov (clinicaltrials.gov)\n\nand the Cochrane Library (cochranelibrary.com) databases on 27\n\nMay 2021 for scientific articles using the search terms and limits\n\nprovided in Supplementary Material S1. Duplicate abstracts\n\nwere removed.\n\nOne reviewer (HB) searched the English-language grey literature\n\non 5 July 2021, and a second reviewer (KK) searched the French-\n\nlanguage grey literature on 7 July 2021. Searches were performed\n\nusing the Google search engine, the websites for the DRC\n\nDemographic Health Survey Program (DHS) (dhsprogram.com),\n\nthe ReliefWeb (reliefweb.int), the MedRxiv website (medrxiv.org),\n\nthe bioRxiv (biorxiv.org) website, and the websites of non-\n\ngovernmental organisations (NGOs) working in the region,\n\nincluding the United Nations International Emergency Children’s\nFrontiers in Global Women’s Health 02\nFund (UNICEF; unicef.org), Médecins Sans Frontières (MSF;\n\nmsf.org), and the United States Agency for International\n\nDevelopment (USAID; usaid.gov) using the search terms provided\n\nin Supplementary Material S2.\n2.1.2 Screening\nAt least two reviewers (including KK, HB, SG, GM, ZM, DM)\n\nindependently screened abstracts from the database search, or full\n\narticles from the grey literature search.\n\nScientific articles or grey literature were included if they\n\nreported pregnancy outcomes such as miscarriage, pre-eclampsia,\n\neclampsia, gestational diabetes, hyperemesis gravidarum, maternal\n\nanaemia, intrauterine growth restriction (IUGR), placenta\n\npraevia, maternal death, stillbirth, birth outcomes in caesarean\n\nsection and reasons for caesarean section, preterm rupture of\n\nmembranes, post-partum haemorrhage or maternal death, or\n\nneonatal outcomes, such as preterm birth, low birth weight,\n\nneonatal death, congenital anomalies, Apgar score, small for\n\ngestational age or prolonged hospitalisation; were in English or\n\nFrench; conducted in Eastern DRC (i.e., Ituri, North Kivu, South\n\nKivu or Maniema provinces); were published between 2001 and\n\n2021; were observational or interventional studies; and for grey\n\nliterature, were published by either the DRC government\n\n(including DHS surveys) or by ReliefWeb, UNICEF, MSF or\n\nUSAID. Case series, case studies, scientific articles and grey\n\nliterature which only included qualitative results were excluded.\n\nWe used a checklist (Supplementary Material S3) to screen the\n\nabstracts and articles. Each reviewer gave a final recommendation\n\nas “include”, “exclude” or “unsure”. In the event of discordant\n\nviews, a third independent reviewer was added and, if they agreed\n\nwith one of the preceding two reviewers, that was considered the\n\nfinal decision. If there was no concordant decision (e.g., “include”-\n\n“exclude”- “unsure”), a fourth reviewer was added, with the final\n\ndecision based on the majority recommendation.\n\nIf both initial reviewers classified an abstract as “unsure”, the\n\nfull text was screened. For studies identified on ClinicalTrials.gov\n\nfor which the classification was “unsure” or “include”, a single\n\nreviewer screened any linked publications from that study. To\n\nensure that we did not miss any publication, we screened\n\nreference lists from each of the articles included in the review\n\nbased on the title. Those articles that had not been screened were\n\nadded to the full screening process.\n\nFor peer-reviewed scientific articles, we identified a total of\n\n1,065 relevant abstracts, including 242 from Medline, 387 from\n\nEMBASE, 187 from Global Health, 231 from Cochrane and 18\n\nfrom ClinicalTrials.gov. We removed 382 duplicate records,\n\nleaving 683 abstracts to be screened. Of these, 20 articles were\n\neligible for data extraction. For grey literature, we identified 196\n\narticles and reports, including 63 via a Google search, 22 from\n\nthe DHS, 28 from the MSF website, 25 from the ReliefWeb\n\nwebsite, six from the UNICEF website and 46 from the\n\nMedRxiv/BioRxiv preprint websites. We also identified six\n\nrecords for screening from references in publications assessed for\n\neligibility. This process resulted in 23 eligible grey literature\n\narticles for data extraction (Figure 1).\nfrontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nFIGURE 1\n\nPRISMA flow diagram of article selection. * Referred to as ‘articles’. † For ClinicalTrials.gov, this refers to the study details published online. ** Previously\nscreened references were excluded. ‡ For ClinicalTrials.gov, this refers to the number of trials. We used PRISMA flow diagram template available from\nhttps://www.prisma-statement.org/prisma-2020-flow-diagram.\n\nKasonia et al. 10.3389/fgwh.2024.1412403\nOf the total of 43 articles which were eligible from the database\n\nsearch and from the grey literature search, 29 were excluded\n\nbecause numerators and/or denominators were absent (n = 10),\n\nthe articles did not include data or outcomes relevant to our\n\nreview (n = 8), there were no data from Eastern DRC (n = 6), the\n\narticles were case series (n = 2), the studies were conducted\n\noutside the defined geographical area for our review (n = 2) or\n\nthe article was a duplicate (n = 1) (Figure 1 and Supplementary\n\nMaterial S4). In total, 14 publications were included in this\n\nsystematic review, comprising ten from the database search and\n\nfour from the grey literature search.\n2.1.3 Data extraction and quality assessment\nWe obtained the full text of all scientific articles to be\n\nincluded in the review and at least two independent reviewers\n\n(including HB, DM, KK, and ZM) extracted data using a form\n\ncreated for that purpose (Supplementary Material S5), while\n\nchecking for consistency between reviewers. Scientific articles\n\nthat were not open access were obtained from the London\n\nSchool of Hygiene and Tropical Medicine (LSHTM) library or\n\nthrough direct contacts with the author. Data from reports (for\n\nexample, those published from the DHS) and articles (for\n\nexample, those published by NGOs) were extracted by a single\n\nreviewer. We assessed the validity of scientific articles using the\n\nNational Institutes of Health National Heart, Lung and Blood\nFrontiers in Global Women’s Health 03\nInstitute Study Quality Assessment Tools for observational\n\ncohorts and cross-sectional studies (22). At least two reviewers\n\nindependently scored the articles, with the inclusion of a third or\n\na fourth reviewer in the event of discordant results. Each\n\nreviewer provided an overall assessment of “good”, “fair” or\n\n“poor” based on the quality of the publication, with the majority\n\ngrade presented.\n\nA summary table of the 14 final articles identified for analysis,\n\nincluding the pregnancy and neonatal outcomes provided, whether\n\nthese were included in our analysis according to the inclusion\n\ncriteria, and the final grades from the quality assessment are\n\ngiven in Table 1. Figure 2 shows the geographic distribution of\n\nthe study sites in these articles, created using R statistical\n\nsoftware (37) with the GPS coordinates of these sites obtained\n\nfrom Google and the Shapefile (baseline) from Humanitarian\n\nData Exchange (38).\n2.2 Study registration and ethics\n\nWe registered the systematic review with PROSPERO\n\n(CRD42021262553) on 12 July 2021 (39). We made two\n\namendments to the protocol following initial registration: (1) a\n\nchange of the criteria used for the quality assessment and (2) a\n\ncorrection to the search criteria. Ethical approval was not\n\nrequired for this review.\nfrontiersin.org\n\nhttps://www.prisma-statement.org/prisma-2020-flow-diagram\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nTABLE 1 Summary and quality assessment of scientific articles included in the analysis.\n\nNumber\n(reference)\n\nFirst author,\nyear\n\nRegion Study design and\nsetting\n\nStudy population Outcomes Included\nin our\nanalysis\n\nQuality\n\n1 (23) Ahuka, 2006 Irumu, Ituri Retrospective cross-sectional\nstudy, Centre Médical\nEvangélique, a 250-bed referral\nhospital in Nyankunde, Ituri\nsubregion, Oriental Province.\nThe 30-bed maternity unit\nserved as the referral hospital for\nhigh-risk pregnancies in Ituri.\n\n8,824 babies delivered alive at\nthe maternity unit from January\n1993 to August 2001\n\nCongenital\nanomalies\n\nYes Fair\n\n2 (24) Bahizire, 2018 Miti-\nMurhesa,\nSouth Kivu\n\nProspective cohort study nested\nwithin a study evaluating the\neffectiveness of intermittent\npreventive treatment with\nSulfadoxine-Pyrimethamine\nduring pregnancy (IPTp-SP)\nconducted in health facilities of\nLwiro, Miti-Murhesa Health\nzone, South Kivu Province.\n\n478 pregnant women (residents\nof Miti-Murhesa Health Zone)\nrecruited during their second\ntrimester (12 to 24 weeks)\nbetween November 2010 and\nJuly 2011 at their first antenatal\nvisit at Lwiro (n = 370) and\nMurhesa health facilities (n =\n108).\n355 single full-term live neonates\n\nLow birth weight No Good\n\nMiscarriage Yes\n\nMaternal\nanaemia\n\nNo\n\nMaternal death No\n\nPreterm birth No\n\nStillbirth Yes\n\n3 (25) Benfield, 2015 Goma,\nNorth Kivu\n\nRetrospective cross-sectional\nstudy to examine risk factors for\nfistula development, conducted\nin HEAL Africa Hospital, Goma,\nNorth Kivu Province. This\ntertiary hospital is owned and\nmanaged by HEAL Africa, an\nNGO. and a specific fistula care\nprogramme\n\n187 women from Eastern DRC\nwho underwent fistula surgery\nbetween 1 April 2009 and 1\nMarch 2012 and who were asked\nabout previous caesarean\nsections (North Kivu n = 121,\nSouth Kivu n = 18, Maniema n =\n48), Women from other\nprovinces not included in review.\n\nCaesarean\nsection\n\nYes Fair\n\nNeonatal death Yes\n\nStillbirth Yes\n\n4 (26) Gulimwentuga,\n2016\n\nBukavu,\nSouth Kivu\n\nRetrospective cohort study,\nDepartment of Surgery, Hôpital\nProvincial Général de Référence\nde Bukavu (HPGRB). This is a\ntertiary hospital in Bukavu,\nSouth Kivu.\n\n30 neonates aged 1–30 days who\nwere hospitalised at HPGRB\nfrom January 2010 to December\n2013 for a surgical emergency\n(whether operated on or not).\n\nCongenital\nanomalies\n\nYes Poor\n\nNeonatal death Yes\n\nPreterm birth No\n\n5 (27) Kambale, 2016 Bukavu,\nSouth Kivu\n\nCross-sectional study conducted\nin the neonatology ward,\nDepartment of Paediatrics,\nHPGRB, South Kivu.\n\n1,638 neonates aged 0–28 days\nwith complete medical records\nhospitalised from January 2009\nto December 2013.\n\nApgar score Yes Fair\n\nCongenital\nanomalies\n\nYes\n\nLow birth weight Yes\n\nNeonatal death Yes\n\nPreterm birth Yes\n\nProlonged\nhospitalisation\n\nNo\n\n6 (28) Kingwenge, 2019 Kindu,\nManiema\n\nCross-sectional study conducted\nin l’Hôpital Général de Référence\nde Kindu (HGRK), town of\nKindu, Maniema Province.\n\n1230 neonates admitted to the\nHGRK Neonatology Unit\nbetween 2017 and 2018.\n\nPreterm birth Yes Fair\n\nLow birth weight Yes\n\nNeonatal death Yes\n\nProlonged\nhospitalisation\n\nNo\n\n7 (29) Maroyi, 2020 South Kivu Cross-sectional study conducted\nin maternity wards of five\ntertiary care hospitals in South\nKivu (Ifendula and Kalonge rural\nhospitals; Nyantende and Rau\nsuburban hospitals and Panzi\nurban hospital).\n\n422 women who delivered\n(vaginally or via planned or\nemergency caesarean section)\nwith a history of two or more\nprevious caesarean sections at\none of the five tertiary care\nhospitals in South Kivu.\n\nCaesarean\nsection,\n\nYes Good\n\nReasons for\ncaesarean\nsection\n\nYes\n\n8 (30) Mbusa-Kambale,\n2018\n\nBukavu,\nSouth Kivu\n\nProspective cohort study with\nenrolment at the Neonatology\nUnit, Reference Provincial\nGeneral Hospital of Bukavu\n(HPGRB) over a period of six\nmonths.\n\n200 mother-child pairs (100\ninfants randomly selected from\n183 low birth weight infants w\n(<2,500 g) and 100 infants\nrandomly selected from 413\ninfants born at full-term with\nbirth weight of �2,500 g Pair\nenrolled between January 2016\nand December 2016.\n\nIntrauterine\ngrowth\nrestriction\n\nYes Good\n\nPreterm birth Yes\n\nProlonged\nhospitalisation\n\nNo\n\n(Continued)\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n\nFrontiers in Global Women’s Health 04 frontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nTABLE 1 Continued\n\nNumber\n(reference)\n\nFirst author,\nyear\n\nRegion Study design and\nsetting\n\nStudy population Outcomes Included\nin our\nanalysis\n\nQuality\n\n9 (31) Michel, 2019 Goma,\nNorth Kivu\n\nCross-sectional study in four\nreferral hospitals in Goma, North\nKivu (Virunga Hospital,\nBethesda Hospital, Charité\nMaternelle Hospital and Goma\nProvincial Referral Hospital)\n\n736 women who delivered by\ncaesarean section between 1\nNovember 2013 and 1 January\n2016 at one of the four hospitals.\n\nMiscarriage Yes Fair\n\nPlacenta praevia Yes\n\nMaternal death Yes\n\nStillbirth Yes\n\ncaesarean\nsection\n\nYes\n\nReasons for\ncaesarean\nsection\n\nYes\n\nLow birth weight Yes\n\nNeonatal death Yes\n\nApgar score Yes\n\n10 (32) Milabyo\nKyamusugulwa\net al., 2006\n\nKama and\nKipaka,\nManiema\n\nCross-sectional study, maternity\nwards of 2 rural health facilities:\nKama Referral Health Centre\nand Kipaka General Referral\nHospital Maniema Province.\n\n938 livebirths born between\nNovember 2003 and October\n2004\n\nLow birth weight\n(<2,500 g)\n\nYes Good\n\n11 (33) Mizerero, 2021 North Kivu Cross-sectional study in\nmaternal and neonatal health\ndepartments of 42 public health\nfacilities including referral\nhospitals, referral health centres\nand health centres in Goma (n =\n11), Karisimbi (n = 14) and\nRutshuru (n = 17) Health Zones,\nNorth Kivu.\n\n44,042 births in 2016\n\nMiscarriage Yes Fair\n\nPre-eclampsia Yes\n\nMaternal death Yes\n\ncaesarean\nsection\n\nYes\n\nPost-partum\nhaemorrhage\n\nNo\n\nNeonatal death Yes\n\n12 (34) Mugisho, 2002 Rutshuru,\nNorth Kivu\n\nCross-sectional study, maternity\nward, Rutshuru Referral\nHospital, North Kivu.\n\n13,042 women who delivered at\nRutshuru Referral Hospital\nbetween 1980 and 1998.\nRefugees were excluded.\n\nCaesarean\nsection\n\nYes Fair\n\nMaternal deaths Yes\n\n13 (35) Mulinganya, 2020 South Kivu Cross-sectional study in 30\nsecondary health facilities (11\ngovernment-owned, 14 faith-\nbased and 5 private) in eight\nhealth zones South Kivu\n\n5,520 women who delivered by\ncaesarean section in any of the\n30 health facilities in 2018.\n\nMiscarriage Yes Good\n\nCaesarean\nsection\n\nYes\n\nReasons for\ncaesarean\nsection\n\nNo\n\nPreterm birth Yes\n\nLow birth weight Yes\n\n14 (36) Richard, 2020 Goma,\nNorth Kivu\n\nCase-control study conducted in\nseven hospitals (undefined) in\nGoma, North Kivu to examine\nthe association between vitamin\nD status and risk of pre-\neclampsia\n\nCases: 95 pregnant women\ndiagnosed or followed up for\npre-eclampsia.\nControls: 95 women attending\nantenatal clinic visits in the same\nfacility as a case who had normal\npregnancies and no chronic/\ndebilitating conditions.\n\nMiscarriage Yes Good\n\nPre-eclampsia Yes\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n2.3 Analysis\n\nPregnancy and neonatal outcomes in North Kivu and other\n\nprovinces were analysed descriptively using the statistical\n\nsoftware, R (37). We calculated the percentage and\n\ncorresponding 95% confidence intervals (CI) of each of the\n\noutcomes based on numerators and denominators provided\n\nwithin each scientific article (Supplementary Material S6) using\n\nthe R function “prop.test” and presented these using the R\n\npackage “ggplot2” (40). Non-standard denominators were\nFrontiers in Global Women’s Health 05\nreferred to as those which included a subset of the total number\n\nof deliveries or pregnant women.\n3 Results\n\n3.1 Pregnancy outcomes\n\nPregnancy outcomes were obtained from nine scientific articles\n\nincluding six cross- sectional studies two case-control studies and\nfrontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nFIGURE 2\n\nGeographic distribution of the study sites in the included scientific articles. The areas shaded blue in (A) are the provinces included in the review. The\ncoloured dots in (B) represent the GPS coordinates of the scientific articles. The map was created using R software. Coordinates for the research sites\nof the different publications came from Google. The shapefile (base layer) for making the map came from Humanitarian Data Exchange. https://data.\nhumdata.org/dataset/cod-ab-cod.\n\nKasonia et al. 10.3389/fgwh.2024.1412403\none prospective cohort study (24) (Table 1). Of the scientific\n\narticles, the quality was judged to be good in five (24, 30, 36)\n\nand fair in four (25, 31, 33, 34) (Table 1).\n\n3.1.1 Caesarean sections\nThe percentage of caesarean sections was obtained from six\n\nfacility-based cross-sectional studies (25, 29, 31, 33–35), of which\n\ntwo used a non-standard denominator (Table 1 and Figure 3). In\n\nNorth Kivu, of the scientific articles for which the denominator\n\nwas deliveries in health facilities, the percentage of reported\n\ncaesarean sections ranged from 11.7% (95%CI 11.4%–12.0%, n =\n\n5134/44,042) (33) to 16.2% (95%CI 15.2%–17.4%, n = 736/4,530)\n\n(31). In the study which included only women who underwent\n\nfistula surgery, the percentage of women who had a caesarean\n\nsection before the surgery was 44.9% (95%CI 37.5%–52.5%,\n\nn = 79/176) (25).\n\nOutside North Kivu, the percentage of caesarean sections\n\namong all hospital deliveries was 18.6% (95%CI 18.2%–19.1%,\n\nn = 5,520/29,600) (35) and among those with a history of\n\nprevious caesarean section, the percentage of pregnant women\nFrontiers in Global Women’s Health 06\nexperiencing another caesarean section was 94.3% (95%CI\n\n91.5%–96.2%, n = 398/422) (29) (Figure 3). In North Kivu, the\n\nmost likely indication for a caesarean section was a ’scarred\n\nuterus’ (21.8%, 95%CI 18.8%–25.1%, n = 148/680) (31) whereas\n\nin South Kivu it was “abnormality of the pelvis” (55.1%, 95%CI\n\n48.8%–61.2%, n = 141/256) (29) (Figure 4).\n\n3.1.2 Maternal deaths\nData on the percentages of maternal deaths in North Kivu were\n\navailable from three studies (one prospective cohort study and two\n\ncross-sectional studies) conducted in hospitals or referral facilities\n\n(31, 33, 34), all of which used non-standard denominators\n\n(Table 1 and Figure 3). Mugisho et al., 2002 reported that 1.9%\n\n(95%CI 1.6%–2.1%, n = 243/13,042) of all deliveries (excluding\n\nmothers who were refugees) ended in maternal deaths in\n\nRutshuru hospital over an 18-year period (1980–1998). In a\n\nseparate study conducted in 42 public health facilities in a single\n\nyear (2016), among women who had an obstetric complication,\n\n5.1% died (95%CI 3.5%–7.4%, n = 28/545) and in another cross-\n\nsectional study conducted in four referral hospitals in Goma,\nfrontiersin.org\n\nhttps://data.humdata.org/dataset/cod-ab-cod.\nhttps://data.humdata.org/dataset/cod-ab-cod.\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nFIGURE 3\n\nPercentage of pregnancy outcomes reported by each scientific article. The position of squares represents the percentage of subjects with each\noutcome and bars the 95% confidence interval (95%CI). The size of the squares is weighted accorded to the size of the denominator (provided in\nsupplementary material 6). Red squares represent scientific articles conducted in North Kivu and blue squares conducted outside North Kivu. The\nasterisk (*) indicates scientific articles for which the denominator is non-standard. Placenta praevia in the study by Michel (2019) is given as the\npost-operative diagnosis only.\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n\nFrontiers in Global Women’s Health 07 frontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nFIGURE 4\n\nThe position of squares represents the percentage of subjects with each outcome and bars the 95% confidence interval (95%CI). The size of the\nsquares is weighted according to the size of the denominator (provided in supplementary material 6). Red squares represent scientific articles\nconducted in North Kivu and blue squares, conducted outside North Kivu. The indications in the scientific article by Michel (2019) are those\nprovided as the post-operative diagnoses only.\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n\nFrontiers in Global Women’s Health 08 frontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n0.1% (95%CI 0%–1.0%, n = 1/676) of women who had a caesarean\n\nsection died (31).\n\n3.1.3 Miscarriage\nData on the percentage of pregnancies that ended in a\n\nmiscarriage were obtained from three cross-sectional studies (two\n\nconducted in North Kivu and one in South Kivu) and one case-\n\ncontrol study (in North Kivu) (31, 33, 35, 36), all of which used\n\nnon-standard denominators (Table 1 and Figure 3). Of the studies\n\nconducted in North Kivu, the percentage of women who\n\nexperienced a miscarriage ranged from 7.3% (95%CI 5.4%–9.9%, n\n\n= 40/545) among those with obstetric complications (33) to 13.8%\n\n(95%CI 11.3–16.8%) in the past medical history of those who had\n\na caesarean section (31) to 30% (95%CI 23.7%–37.1%, n = 57/190)\n\nof those recruited into a case-control study in which half of the\n\nparticipants had pre-eclampsia (36). In South Kivu, one cross-\n\nsectional study reported a percentage of miscarriage of 16.9% (95%\n\nCI 15.7%–18.2%, n = 578/3,420) among pregnant women who had\n\na caesarean section in a previous pregnancy (35) (Figure 3).\n\n3.1.4 Preterm births\nThe percentage of maternal deliveries resulting in preterm births\n\nwas obtained from five scientific articles conducted outside North\n\nKivu, including three cross-sectional studies, one case-control study\n\n(30), and one retrospective cohort study (26), all of which used\n\nnon-standard denominators (Table 1 and Figure 3). The lowest\n\npercentage of preterm births was reported in the cross-sectional\n\nstudy conducted in 30 secondary health facilities in South Kivu, at\n\n5.1% (95%CI 4.4%–6.0%, n = 168/3,272) among women who\n\ndelivered by caesarean section (35). The other studies all included\n\neither hospitalised infants or those with low birth weight with the\n\npercentage of preterm births ranging from 14.6% (95%CI 12.7%–\n\n16.7%) to 74% (95%CI 64.1%–82%) (28, 30) (Figure 3).\n\n3.1.5 Pre-eclampsia and eclampsia\nOf the scientific articles, the percentage of participants with\n\npre-eclampsia was obtained from two studies conducted in North\n\nKivu including the cross-sectional study conducted in 42 health\n\nfacilities (33) and a case control study conducted in Goma (36),\n\nboth of which used non-standard denominators (Table 1 and\n\nFigure 3). In the former, pre-eclampsia was diagnosed in 17.4%\n\n(95%CI 14.4%–20.9%, n = 95/545) of women with obstetric\n\ncomplications. In the latter, among the cases (who were\n\ndiagnosed with or followed up for, pre-eclampsia) and controls\n\n(women attending antenatal care with normal pregnancies and\n\nno chronic/debilitating conditions), 11.1% (95%CI 7.1%–16.6%,\n\nn = 21/190) had a history of previous pre-eclampsia (36).\n\n3.1.6 Other outcomes\nThe percentages of women experiencing IUGR, maternal\n\nanaemia, stillbirth, and placenta praevia were obtained from four\n\nscientific articles including cross-sectional studies (25, 31), and\n\ntwo prospective cohort studies. None of these outcomes included\n\nscientific articles from both North and South Kivu.\n\nIn North Kivu, the percentage of stillbirth was obtained from\n\ntwo cross-sectional studies (25, 31), both of which used non-\nFrontiers in Global Women’s Health 09\nstandard denominators (Table 1 and Figure 3). Among women\n\nwho had caesarean section in four referral hospitals in Goma, the\n\npercentage who had a stillbirth was 4.4% (95%CI 3.1%–6.4%,\n\nn = 30/676) (31). In a study among the women who underwent\n\nfistula surgery, 74.0% (95%CI 66.7%–80.2%, n = 128/183)\n\nreported a stillbirth in their past medical history (25). The\n\npercentage of women with placenta praevia was obtained from\n\none cross-sectional study in Goma, North Kivu where 7.4% (95%\n\nCI 5.6%–9.7%, n = 51/690) of those who had a caesarean section\n\nwere diagnosed postoperatively (31).\n\nThe percentage of neonates who had IUGR was 16.5% (95%CI\n\n11.8%–22.5%, n = 33/200) in a prospective cohort study in South\n\nKivu whom half of the neonates had a birth weight of less than\n\n2,500 g. In South Kivu, a prospective cohort of pregnant women\n\nrecruited at their first antenatal visit reported maternal anaemia\n\nin 32.1% (95%CI 27.8%–36.7%, n = 141/439) (24) (Figure 3).\n3.2 Neonatal outcomes\n\nEleven publications reported neonatal outcomes, including\n\neight cross-sectional studies (23, 25, 27, 28, 31–33, 35), one\n\nprospective cohort study (24), one retrospective cohort study\n\n(26), and one case-control study (30). Of these, the quality was\n\njudged to be good in four (24, 30, 32, 35), fair in six (23, 25, 27,\n\n28, 31, 33), and poor in one (26) (Table 1).\n\n3.2.1 Neonatal deaths\nThe percentages of neonates who died were obtained from five\n\ncross-sectional studies (25, 27, 28, 31, 33) and one retrospective\n\ncohort study (26), all of which only one (Mizerero et al., 2021)\n\nused a standard denominator (number of births) (Table 1 and\n\nFigure 5). In this study, conducted in 42 public health facilities\n\nin North Kivu, the percentage of very early (period undefined)\n\nneonatal deaths and intrapartum deaths among all births in\n\nthose facilities was 1.5% (95%CI 1.4%–1.6%, n = 532/35,283)\n\n(33). In North Kivu, the percentage of neonates who died within\n\n24 h and were born to women who had caesarean sections in\n\nfour hospitals in Goma was 0.4% (95%CI 0.1%–1.4%, n = 3/676)\n\n(31) and 1.2% (95%CI 0.2%–4.6%, n = 2/173) of babies born to\n\nwomen prior to fistula surgery at a hospital in Goma died in less\n\nthan a week after birth. In Maniema, 15.0% (95%CI 13.0%–\n\n17.1%, n = 184/1,230) of high risk infants admitted to the\n\nneonatal unit died (28) and in Bukavu, South Kivu, 43.3% (95%\n\nCI 26.0%–62.3%, n = 13/30) of infants aged 1–30 days admitted\n\nto a surgical emergency died (26).\n\nAn abnormal Apgar score was recorded in two scientific\n\narticles (27, 31), both of which used a non-standard denominator\n\n(Table 1 and Figure 5). In North Kivu, in a cross-sectional study\n\nof neonates born to women who had a caesarean section in four\n\nreferral hospitals in Goma, an Apgar score of less than seven at\n\n10 min was recorded in 4.6% (95%CI 3.2%–6.5%, n = 31/677)\n\n(31). In South Kivu, a cross-sectional study conducted in the\n\nneonatology ward of the provincial referral hospital of Bukavu\n\nreported an abnormal Apgar score, including moderate asphyxia\n\nor state of apparent death, in 45.0% (95%CI 42.6%–47.4%,\nfrontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nFIGURE 5\n\nProportion of neonatal outcomes for each scientific article. The position of squares represents the percentage of subjects with each outcome and the\nbars, the 95% confidence intervals (95%CI). The size of the squares is weighted accorded to the size of the denominator (provided in supplementary\nmaterial 6). Red squares represent scientific articles conducted in North Kivu and blue squares, conducted outside North Kivu. The asterisk (*) indicates\nthe scientific articles for which the denominator is non-standard. The abnormal Apgar score in Kambale (2016) is defined as “moderate asphyxia or\nstate of apparent death” and in Michel (2019) as <7 at 10 min.\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n\nFrontiers in Global Women’s Health 10 frontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nKasonia et al. 10.3389/fgwh.2024.1412403\nn = 737/1,638) of hospitalised neonates (27) (Figure 5 and\n\nSupplementary Material S6).\n\n3.2.2 Low birth weight\nThe percentage of low birth weight (LBW) babies was obtained\n\nfrom five cross-sectional studies (27, 28, 31, 32, 35), and one\n\nprospective cohort study (24), of which four used a non-standard\n\ndenominator (Table 1 and Figure 5). In North Kivu, in a cross-\n\nsection study conducted in Goma, 7.7% (95%CI 5.7%–10.2%,\n\nn = 46/599) of babies born to mothers who had a caesarean\n\nsection had LBW (31). In South Kivu, the percentage of LBW\n\nbabies was 6.5% (95%CI 4.2%–9.7%, n = 23/355) of neonates\n\nborn to women who attended an antenatal clinic in their second\n\ntrimester in South Kivu (24). In Maniema, LBW infants were\n\nfound in 22.0% (95%CI 19.4%–24.8%, n = 206/938) of live births\n\nin a maternity wards of two rural referral hospitals (32).\n\n3.2.3 Congenital anomalies\nThe percentage of infants with congenital anomalies was\n\nobtained from two cross-sectional studies, both conducted outside\n\nNorth Kivu (23, 27) of which one used a non-standard\n\ndenominator (Table 1 and Figure 5). In Ituri, 0.4% (95%CI 0.3%–\n\n0.6%, n = 36/8,824) of all live deliveries in a referral hospital from\n\n1993 to 2001 had a congenital anomaly, with the most commonly\n\nreported being clubbed foot (n = 9/8,824, 1 per 1,000 births),\n\ncongenital hydrocephalus (n = 8/8,824, 0.9 per 1,000 births) and\n\nspina bifida (n = 6/8,824, 0.6 per 1,000 births) (23). In South Kivu,\n\nin the neonatology ward of Bukavu Tertiary Care Hospital, 8.1%\n\n(95%CI 6.9%–9.6%, n = 133/1,638) of neonates were reported to\n\nhave a congenital anomaly (non-specified) (27).\n4 Discussion\n\nDespite the heterogeneity and varying quality of data collection\n\nmethods in the studies included in the review, the findings suggest\n\nthat this part of sub-saharan Africa has experienced a burden of\n\nadverse maternal, birth and neonatal outcomes that is comparable to\n\nthe neighbouring African countries including those not currently\n\nexperiencing armed conflict. This is further described below.\n4.1 Pregnancy outcomes\n\nOur review reported caesarean section rates ranging from 12 to\n\n16% of all deliveries in the scientific articles analysed (31, 34, 35).\n\nHowever, evidence suggests that increasing caesarean sections rates\n\nbeyond 10% does not confer additional benefits (41). Furthermore,\n\nin many resource-constrained settings, a significant proportion of\n\nmaternal and newborn fatalities are directly related to caesarean\n\nsections performed under suboptimal conditions (42). In areas of\n\nconflict, a decline in caesarean section rates might be expected as\n\nwomen have less access to healthcare. However, the presence of\n\nhumanitarian actors in these areas, particularly during protracted\n\nconflict, may actually increase the rates of caesarean sections,\n\nespecially if these services are subsided (35). This could explain\nFrontiers in Global Women’s Health 11\nwhy the caesarean section rate in Eastern DRC is higher than the\n\nDRC national average of 5.1% reported between 2008 and 2014\n\n(43). In neighbouring Uganda, while the overall population rate\n\nof caesarean sections was 5.9% in 2016, the rate among live\n\nbirths in health facilities was 11% (44), which is more\n\ncomparable to the rates observed in our review of Eastern DRC.\n\nSimilarly, in neighbouring Rwanda, the population-based\n\ncaesarean section rate was 15.6% in 2019–2020, closely aligning\n\nwith the rates observed in our review (45). However, both\n\nUganda and Rwanda have very different socio-political and\n\neconomic environments compared to Eastern DRC, with no\n\nactive conflict and a much lower presence of humanitarian\n\nactors. Neighbouring Burundi, which is economically poorer and\n\nmore fragile in terms of security than Uganda and Rwanda (46)\n\nis more similar to Eastern DRC. In Burundi, the estimates of\n\ncaesarean section rates among all live births in 2016 varied from\n\n7.1% to 15.3% depending on geographical location, wealth and\n\neducation status of the women (46).\n\nPelvic anomalies were cited as the most common indication for\n\ncaesarean sections in five tertiary care hospitals in South Kivu (29),\n\nand were the second most common indication in four referral\n\nhospitals in Goma (31). Cephalopelvic disproportion, which can\n\nresult in obstructed labour, was the most frequently cited\n\nindication for caesarean sections in a multi-centre study in sub-\n\nSaharan Africa (47). A ’scarred uterus’, often found in women\n\nwho have had a previous caesarean section, was the most\n\ncommon indication in one of the studies in Goma (31). This\n\nfinding aligns with other publications both within and outside\n\nsub-Saharan Africa, where a previous caesarean section is often\n\nthe most common indication for repeat procedures (48–53).\n\nRegarding maternal mortality, the study by Mugisho et al.\n\n(2002) conducted in Rutshuru used a denominator that closely\n\napproximates the general population (women delivering in the\n\nmaternity ward of the referral hospital, excluding refugees) (34).\n\nSince the data were from 1988 to 1998, comparing these figures\n\nwith more recent data is challenging. The study reported a\n\nmaternal mortality rate of 1.9% (34), which isnoticeably higher\n\nthan the latest national estimate of 693 per 100, 000 live births\n\n(0.6%) in 2015 (54). However, this figure aligns more closely\n\nwith the 1,188 deaths per 100, 000 live births (1.2%) reported in\n\nthe DRC between 2012 and 2016 in a multi-country prospective\n\ncohort study (55), 1,300 per 100,000 live births (1.3%) in\n\nManiema in 2020 (56) and 1,099 per 100,000 live births (1.1%)\n\nin Morogoro, Tanzania, in 1995 (57). The maternal mortality\n\nrate in the 2020 Maniema study (1.3%) was comparable to rates\n\nreported in other conflict affected regions, such as Central\n\nAfrican Republic (835 per 100, 000 live births, 0.8%) in 2020\n\n(58) and South Sudan (789 per 100, 000 live births, 0.8%) in\n\n2015 (59). Despite using a non-standard denominator, the\n\nmaternal mortality rate of 0.1% reported by Michel et al. (2019)\n\nin Goma among women who had a caesarean section (31) was\n\nmuch lower than the national estimate.\n\nThe heterogeneity of the denominators used in the scientific\n\nreviews for estimating miscarriage rates makes it challenging to\n\ndetermine the true magnitude of miscarriages in Eastern DRC.\n\nConsequently, estimates of miscarriages ranged from 7.3% to\nfrontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nKasonia et al. 10.3389/fgwh.2024.1412403\n30%. These figures are notably higher than the 2.5% incidence of\n\nmiscarriage reported in a longitudinal study conducted in\n\nTanzania, where 2.5% of 157 women attending antenatal clinics\n\nfrom their second trimester to term experienced a miscarriage\n\nbetween September 2008 and April 2009 (60).\n\nSimilarly, the variation in denominators used to estimate\n\npreterm birth rates in the scientific articles included in our review\n\nresulted in a wide range of estimates from 5.1% to 74%. These\n\nestimates do not align with rates reported in a population-based\n\nstudy conducted from 2014 to 2018 which found preterm birth\n\nrates of 18.3% in the DRC, 12.4% in Zambia and 9.8% in Kenya\n\n(61), as well as the 19.4% found in rural Uganda from 2014 to\n\n2016 (62) and the 20.2% found in Nairobi, Kenya (63). However,\n\nthe lower end of our estimates is more consistent with the 5.3%\n\nincidence from the Demographic and Health Surveys (DHS) from\n\n2006 to 2018 across 36 Sub-Saharan African countries (64) and\n\nthe 5% found in post-conflict northern Uganda from 2017 to 2019\n\n(65). It is well recognised that preterm birth rates can vary\n\nbetween and within countries, often without a clear identification\n\nof the underlying causes of these disparities (66).\n4.2 Neonatal outcomes\n\nIn the only scientific article which included a standard\n\ndenominator in our review, the percentage of neonatal deaths\n\namong all live births of 2% (33), which is consistent with the\n\nnational average of 3% (67). The neonatal death rate of1.5%\n\nreported by Mizerero et al.(2021) aligns with rates observed in\n\nstudies from the region including Eastern Uganda in 2013 (3.0%\n\nto 3.6%) (68), Tanzania (2.4% in 2009 to 8.1% in 1985) (57),\n\nKenya in 2018 (1.9%) (69), and Ethiopia from 2008 to 2013\n\n(2.7%) (70). This is noteworthy given that neonatal mortality is\n\ngenerally higher in countries experiencing armed conflict and\n\nwar (1). Similar to the findings on caesarean section rates, the\n\nlongstanding presence of humanitarian actors in Eastern DRC\n\nmay explain these relatively lower neonatal mortality rates.\n\nThe estimates for LBW in our review included two scientific\n\narticles with a standard denominator (all neonates), ranging from\n\n6% to 22% (24, 32). The study by Bahizire et al.(2018), which\n\nreported a prevalence of 6.5% (24),, was more comparable with\n\nthe national incidence of 10% in 2014 (67), the South Kivu\n\nincidence of 11% in 2013–2014 (71), and the 7.3% incidence in\n\npost-conflict northern Uganda from 2017 to 2019 (65). However,\n\nthe lower estimates in Bahizire et al.(2018) compared to those\n\nreported by Milabyo Kyamusugulwa et al.(2006) could be\n\nattributed to the inclusion of only full-term neonates in the\n\nformer study (24, 32). It is worth noting that global LBW rates\n\nhave decreased over time (72). Despite evidence linking armed\n\nconflicts with higher LBW rates (73), our estimates, except for\n\nthe study by Milabyo Kyamusughulwa et al. (2006), were inline\n\nor slightly lower than thise reported in DHS data from other\n\nsub-Saharan countries not experiencing insecurity, including\n\nGhana (10.2%), Malawi (12.2%), and Senegal (15.7%) (74).\n\nAhuka et al.(2006) reported a 1% incidence of congenital\n\nanomalies among all live births between 1993 and 2001 at a\nFrontiers in Global Women’s Health 12\nsingle hospital in Ituri (23). This is lower than the pooled\n\nprevalence of birth defects, which was 20.4 per 1,000 births (95%\n\nCI 17.0–23.7) from 25 studies in nine countries in sub-Saharan\n\nAfrica (75). However, in resource-limited like Ituri, it is possible\n\nthat some cases went undetected.\n4.3 Study limitations\n\nThe heterogeneity in the proportion of pregnant women and\n\ntheir infants experiencing adverse outcomes is likely largely due\n\nto differences in study design, particularly the selection of the\n\nstudy populations. As a result, we did not provide pooled\n\nestimates for any of the outcomes. This heterogeneity also\n\nprevented us from conducting statistical analyses to compare the\n\nincidence of outcomes between North Kivu and other provinces.\n5 Conclusion\n\nThis systematic review provides a comprehensive overview of\n\npregnancy and neonatal outcomes over the past twenty years in\n\nEastern DRC, highlighting the significant burden of adverse\n\noutcomes experienced by pregnant women and their infants.\n\nDespite the ongoing conflict, we found that pregnancy and neonatal\n\noutcomes in Eastern DRC are comparable to those in other\n\ncountries in the region that are not currently experiencing armed\n\nconflict. Further studies aimed at understanding this resilience of the\n\nDRC health system in this war- affected area will be of great benefit.\nScope statement\n\nThis review examines research articles published between 2001\n\nand 2021 across four provinces in eastern Democratic Republic of\n\nthe Congo (DRC). It was originally initiated to support an Ebola\n\nvaccine trial conducted in Goma from 2019 to 2022, which included\n\npregnant women. In the absence of a control arm, it was necessary\n\nto gather population-level data on the incidence of maternal and\n\nneonatal outcomes to contextualize the trial’s safety data and\n\npotentially inform future studies. Given that eastern DRC has\n\nexperienced prolonged armed conflict, obtaining unbiased estimates\n\nof pregnancy and neonatal outcomes has been challenging,\n\nreinforcing the need for a systematic review. Our review provides a\n\ncomprehensive overview of pregnancy and neonatal outcomes over\n\nthe past two decades, utilizing a range of studies. It highlights the\n\nsubstantial burden of adverse outcomes experienced by pregnant\n\nwomen and their babies; interestingly, these outcomes are\n\ncomparable to those in neighboring countries not affected by conflict.\nData availability statement\n\nThe original contributions presented in the study are included\n\nin the article/Supplementary Material, further inquiries can be\n\ndirected to the corresponding author.\nfrontiersin.org\n\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\nKasonia et al. 10.3389/fgwh.2024.1412403\nAuthor contributions\n\nKK: Conceptualization, Data curation, Formal Analysis,\n\nInvestigation, Methodology, Project administration, Supervision,\n\nValidation, Writing – original draft, Writing – review & editing.\n\nHB: Conceptualization, Data curation, Formal Analysis,\n\nInvestigation, Methodology, Writing – original draft, Writing –\n\nreview & editing. DM: Conceptualization, Data curation, Formal\n\nAnalysis, Investigation, Methodology, Writing – original draft,\n\nWriting – review & editing. TE: Visualization,\n\nConceptualization, Data curation, Formal Analysis, Investigation,\n\nMethodology, Writing – original draft, Writing – review &\n\nediting. SG: Conceptualization, Data curation, Formal Analysis,\n\nInvestigation, Methodology, Writing – original draft, Writing –\n\nreview & editing. GM: Conceptualization, Data curation, Formal\n\nAnalysis, Investigation, Methodology, Writing – original draft,\n\nWriting – review & editing. ZM: Conceptualization, Data\n\ncuration, Formal Analysis, Investigation, Methodology, Writing\n\n– original draft, Writing – review & editing. EC: Writing –\n\noriginal draft, Writing – review & editing, Conceptualization,\n\nData curation, Formal Analysis, Methodology. NC:\n\nConceptualization, Methodology, Supervision, Writing – original\n\ndraft, Writing – review & editing. PM: Conceptualization,\n\nMethodology, Supervision, Writing – original draft, Writing –\n\nreview & editing. RG: Conceptualization, Funding acquisition,\n\nMethodology, Project administration, Resources, Supervision,\n\nValidation, Writing – original draft, Writing – review & editing.\n\nBK: Conceptualization, Funding acquisition, Methodology,\n\nProject administration, Resources, Supervision, Validation,\n\nWriting – original draft, Writing – review & editing. CR:\n\nConceptualization, Formal Analysis, Funding acquisition,\n\nMethodology, Project administration, Resources, Software,\n\nSupervision, Validation, Writing – original draft, Writing –\n\nreview & editing. HK-M: Conceptualization, Funding\n\nacquisition, Investigation, Methodology, Project administration,\n\nResources, Supervision, Validation, Writing – original draft,\n\nWriting – review & editing. DB: Conceptualization, Formal\n\nAnalysis, Funding acquisition, Methodology, Project\n\nadministration, Resources, Supervision, Validation, Writing –\n\noriginal draft, Writing – review & editing. J-JM:\n\nConceptualization, Funding acquisition, Methodology, Project\n\nadministration, Resources, Supervision, Validation, Writing –\n\noriginal draft, Writing – review & editing. DW-J:\n\nConceptualization, Funding acquisition, Methodology, Project\n\nadministration, Resources, Supervision, Validation, Writing –\n\noriginal draft, Writing – review & editing.\nFrontiers in Global Women’s Health 13\nFunding\n\nThe author(s) declare financial support was received for the\n\nresearch, authorship, and/or publication of this article. This review\n\nwas supported through funds from the Coalition for Epidemic\n\nPreparedness Innovations (CEPI) [FELS1903] and the Paul\n\nG. Allen Family Foundation. This review was also supported by\n\nthe Department for International Development (DFID) and\n\nWellcome [220506/Z/20/Z] and by the European Union’s Horizon\n\n2020 research and innovation programme under grant agreement\n\nNo 857935. This publication reflects only the authors’ view, and\n\nthe European Commission is not responsible for any use that may\n\nbe made of the information it contains. The funders had no role\n\nin study design, data collection and analysis, decision to publish, or\n\npreparation of the manuscript. HB and ChR were funded by the\n\nDepartment of Health and Social Care using UK Aid Funding as\n\npart of the UK Vaccine Network and is managed by the National\n\nInstitute for Health and Care Research. The views expressed in this\n\npublication are those of the author(s) and not necessarily those of\n\nthe Department of Health and Social Care.\nConflict of interest\n\nThe authors declare that the research was conducted in the\n\nabsence of any commercial or financial relationships that could\n\nbe construed as a potential conflict of interest.\n\nRG and CR declare that they were editorial board member of\n\nFrontiers, at the time of submission. This had no impact on the\n\npeer review process and the final decision.\nPublisher’s note\n\nAll claims expressed in this article are solely those of the authors\n\nand do not necessarily represent those of their affiliated organizations,\n\nor those of the publisher, the editors and the reviewers. Any product\n\nthat may be evaluated in this article, or claim that may be made\n\nby its manufacturer, is not guaranteed or endorsed by the publisher.\nSupplementary material\n\nThe Supplementary Material for this article can be found\n\nonline at: https://www.frontiersin.org/articles/10.3389/fgwh.2024.\n\n1412403/full#supplementary-material\nReferences\n1. Jawad M, Hone T, Vamos EP, Cetorelli V, Millett C. Implications of armed conflict\nfor maternal and child health: a regression analysis of data from 181 countries for 2000–\n2019. PLoS Med. (2021) 18:e1003810. doi: 10.1371/journal.pmed.1003810\n\n2. Namasivayam A, Arcos González P, Castro Delgado R, Chi PC. The effect of armed\nconflict on the utilization of maternal health services in Uganda: a population-based\nstudy. PLoS Curr. (2017) 9:ecurrents.dis.557b987d6519d8c7c96f2006ed3c271a. doi: 10.\n1371/currents.dis.557b987d6519d8c7c96f2006ed3c271a\n3. Mirzazada S, Padhani ZA, Jabeen S, Fatima M, Rizvi A, Ansari U, et al. 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(2020) 36:19. doi: 10.11604/pamj.2020.36.\n19.19411\nfrontiersin.org\n\nhttps://doi.org/10.1002/ijgo.13506\nhttps://doi.org/10.1111/aogs.13816\nhttps://doi.org/10.1186/s12884-019-2558-2\nhttps://doi.org/10.18203/2320-1770.ijrcog20193047\nhttps://data.unicef.org/wp-content/uploads/cp/maternal-newborn-health/country%20profile_COD.pdf\nhttps://data.unicef.org/wp-content/uploads/cp/maternal-newborn-health/country%20profile_COD.pdf\nhttps://doi.org/10.1016/S2214-109X(18)30385-1\nhttps://doi.org/10.1186/s12884-022-04783-z\nhttps://doi.org/10.1016/j.ijgo.2015.04.021\nhttps://apps.who.int/gho/data/node.goe.ki-CAF?lang=en\nhttps://apps.who.int/gho/data/node.goe.ki-CAF?lang=en\nhttps://doi.org/10.4314/thrb.v12i4.51795\nhttps://doi.org/10.4314/thrb.v12i4.51795\nhttps://doi.org/10.1186/s12978-020-01029-z\nhttps://doi.org/10.1371/journal.pone.0235626\nhttps://doi.org/10.4236/ojog.2017.79099\nhttps://doi.org/10.1186/s12884-021-04233-2\nhttps://doi.org/10.1186/s12884-021-04233-2\nhttps://doi.org/10.3390/ijerph191912072\nhttps://doi.org/10.1002/ijgo.13195\nhttps://reliefweb.int/report/democratic-republic-congo/democratic-republic-congo-profile-preterm-and-low-birth-weight\nhttps://reliefweb.int/report/democratic-republic-congo/democratic-republic-congo-profile-preterm-and-low-birth-weight\nhttps://doi.org/10.1186/s12978-016-0119-y\nhttps://doi.org/10.2147/JMDH.S260058\nhttps://doi.org/10.2147/JMDH.S260058\nhttps://doi.org/10.1186/s40748-016-0035-8\nhttps://reliefweb.int/report/democratic-republic-congo/deuxi-me-enqu-te-d-mographique-et-de-sant-eds-rdc-ii-2013-2014\nhttps://reliefweb.int/report/democratic-republic-congo/deuxi-me-enqu-te-d-mographique-et-de-sant-eds-rdc-ii-2013-2014\nhttps://doi.org/10.1016/S2214-109X(18)30565-5\nhttps://doi.org/10.1016/S2214-109X(18)30565-5\nhttps://doi.org/10.1136/bmjgh-2017-000377\nhttps://doi.org/10.1136/bmjgh-2017-000377\nhttps://doi.org/10.1136/bmjopen-2017-020410\nhttps://doi.org/10.1136/bmjopen-2017-020410\nhttps://doi.org/10.11604/pamj.2020.36.19.19411\nhttps://doi.org/10.11604/pamj.2020.36.19.19411\nhttps://doi.org/10.3389/fgwh.2024.1412403\nhttps://www.frontiersin.org/journals/global-womens-health\nhttps://www.frontiersin.org/\n\n\tPregnancy and neonatal outcomes in Eastern Democratic Republic of the Congo: a systematic review\n\tIntroduction\n\tMaterials and methods\n\tScientific articles\n\tSearch strategy\n\tScreening\n\tData extraction and quality assessment\n\n\tStudy registration and ethics\n\tAnalysis\n\n\tResults\n\tPregnancy outcomes\n\tCaesarean sections\n\tMaternal deaths\n\tMiscarriage\n\tPreterm births\n\tPre-eclampsia and eclampsia\n\tOther outcomes\n\n\tNeonatal outcomes\n\tNeonatal deaths\n\tLow birth weight\n\tCongenital anomalies\n\n\n\tDiscussion\n\tPregnancy outcomes\n\tNeonatal outcomes\n\tStudy limitations\n\n\tConclusion\n\tScope statement\n\tData availability statement\n\tAuthor contributions\n\tFunding\n\tConflict of interest\n\tPublisher's note\n\tSupplementary material\n\tReferences\n\n\n","UrlSlug":null,"collections":[],"countries":[{"Name":"Democratic Republic of Congo","Id":52}],"asset_languages":[{"AlternateTitle":null,"language":[{"Id":1,"Name":"English"}],"contentTranslation":[],"contentLocation":[]}],"creators":[{"Name":"Grais RF","Id":17196,"ac":[{"Order":10}]},{"Name":"Edwards T","Id":19407,"ac":[{"Order":3}]},{"Name":"Bausch DG","Id":26236,"ac":[{"Order":14}]},{"Name":"Brindle H","Id":30363,"ac":[{"Order":1}]},{"Name":"Roberts CH","Id":30374,"ac":[{"Order":12}]},{"Name":"Choi EM","Id":30824,"ac":[{"Order":7}]},{"Name":"Watson-Jones D","Id":30825,"ac":[{"Order":16}]},{"Name":"Kavunga-Membo H","Id":30826,"ac":[{"Order":13}]},{"Name":"Mambula G","Id":33064,"ac":[{"Order":5}]},{"Name":"Keshinro B","Id":34778,"ac":[{"Order":11}]},{"Name":"Manno D","Id":34786,"ac":[{"Order":2}]},{"Name":"Mossoko Z","Id":34789,"ac":[{"Order":6}]},{"Name":"Mukadi P","Id":34793,"ac":[{"Order":9}]},{"Name":"Kasonia K","Id":34807,"ac":[{"Order":0}]},{"Name":"Connor NE","Id":34827,"ac":[{"Order":8}]},{"Name":"Gardais S","Id":35796,"ac":[{"Order":4}]},{"Name":"Muyembe JJ","Id":35797,"ac":[{"Order":15}]}],"keywords":[{"Name":"women's health","Id":4},{"Name":"pediatrics","Id":20},{"Name":"neonatal health","Id":61}]}}

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Pregnancy and neonatal outcomes in Eastern Democratic Republic of the Congo: a systematic review