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Tinatin Manjavidze,1 Charlotta Rylander,1 Finn Egil Skjeldestad,1 Nata Kazakhashvili,2 Erik Eik Anda1 1Department of Community Medicine, Faculty of Health Sciences, University of Tromsø – The Arctic University of Norway, Tromsø 9037, Norway; 2Department of Public Health, Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, GeorgiaCorrespondence: Tinatin Manjavidze 35a Guramishvili Ave, Tbilisi 0178, GeorgiaTel +995 598292936Email tinatin.manjavidze@uit.noIntroduction: The majority of pregnant women in Georgia attend the free-of-charge, national antenatal care (ANC) programme, but over 5% of pregnancies in the country are unattended. Moreover, Georgia has one of the highest perinatal mortality (PM) rates in Europe (11.7/1000 births).Purpose: To assess the association between unattended pregnancies and the risk of PM.Methods: Data were extracted from the Georgian Birth Registry (GBR) and the national vital registration system. All mothers who had singleton births and delivered in medical facilities in Georgia in 2017– 2018 were included in the study and categorised into attended pregnancies (at least one ANC visit during pregnancy) and unattended pregnancies (no ANC visits during pregnancy). After exclusions, the study sample included 101,663 women and their newborns, of which 1186 were either stillborn or died within 7 days. Logistic regression analysis was used to assess the effect of unattended pregnancies on PM.Results: During the study period, the PM rate was 12.9/1000 births. In total, 5.6% of women had unattended pregnancies. The odds of PM among women with unattended pregnancies were more than double those among women with attended pregnancies (odds ratio=2.21, [95% confidence interval: 1.81– 2.70]). Multiparous women with higher education and who resided/delivered outside of Tbilisi were significantly less likely to experience PM.Conclusion: The risk of PM doubled among women with unattended pregnancies. Six percent of PM cases were attributable to unattended pregnancies. Targeting women with previous unattended pregnancies will likely reduce the PM rate in Georgia.Keywords: stillbirth, early neonatal mortality, antenatal care, birth registry

Background: Despite recent achievements, perinatal mortality (PM) rates remain high worldwide, especially in low-income countries (>30 per 1000 births). PM is defined as the death of a fetus/livebirth between 22 completed weeks of gestation and the first 7 days of life. Simple, non-invasive interventions could reduce PM rates, since most deaths are caused by preventable conditions. Adequate antenatal care (ANC) is one of the steps towards better pregnancy outcomes. Georgia has one of the highest PM rates in Europe, but they also have high ANC coverage. We aimed to understand the causes of PM and the impact of ANC on PM in the Republic of Georgia. Methods: The Georgian Birth Registry was the main source of data, and the Vital Registration System was used as a supplementary source for data validation. Mothers who delivered in 2017-2019 and their newborn were included in the analysis. We used the Wigglesworth classification to categorise causes of death, and the adequacy of prenatal care utilisation index to analyse ANC. We assessed potential confounders by directed acyclic graphs and detected associations between exposures and outcomes by logistic regression analyses. Results: The majority of stillbirths in Georgia were reported as unexplained (80%) and antepartum (85%), and preterm birth complications and congenital malformations were the most common causes of early neonatal death (END). The stillbirth to END ratio was 2.1, and newborn who died during first day of life represented 30% of the total number of ENDs. Unattended pregnancies (no ANC attendance) comprised 5.6% of all pregnancies in our study and carried more than two times higher odds of PM compared to attended pregnancies. Sixty-two percent of women did not receive adequate care during the study period. Women in the inadequate care group had the highest odds of PM when using the adequate care group as a reference; women who received intermediate care had the lowest odds of PM. Conclusion: Initially, our study revealed potential misclassification between stillbirths and ENDs. We suspect that asphyxiated newborn who died shortly after birth might be classified as antepartum stillbirths. Adequate ANC has the potential to reduce PM and should be used as a tool for improving newborn health outcomes. Further, some women without any particular medical need may receive more than the recommended number of ANC visits. Increasing the number of ANC visits from four to eight did not seem to improve PM rates. Therefore, it is not sufficient to look only at the number of ANC visits; the quality should also be monitored.

The WHO currently considers maternal anemia global public health concern, and one of the most common complications during pregnancy. Symptoms range from weakness and fatigue, to serious cardiac complications. Maternal anemia also poses a risk to the infant, as it can increase the likelihood of preterm birth and low birth weight babies, among additional concerns. Past research is primarily focused on low and middle-income countries. Georgia is an upper-middle income country located at the intersection of Europe and Asia, and a country that has experienced rapid social and economic growth in the last two decades. Presently, there is no national study regarding the prevalence of maternal anemia in Georgia. The objective of this thesis is to establish the prevalence of maternal anemia in Georgia, and to determine the associated factors of its presence. This cross-sectional study consisted of women who delivered in Georgia in 2019, using data from the Georgian Birth Registry. This included all women who had serum hemoglobin measured at least once during their pregnancy, with a final population of n=35,677. Anemia was categorized according to WHO guidelines into mild, moderate, and severe, and compared with several associated factors using descriptive statistics. The relationship between the associated factors and the presence of maternal anemia was analyzed using logistic regression. This study identified a 42% prevalence of maternal anemia in Georgia. Among anemic mothers, 61% were mildly anemic, 36% moderately anemic, and 3% severely anemic. Significant associated factors of anemia presence included 1 previous birth (OR 1.19 [1.14-1.26]), and 2 or more previous births (1.23 [1.16-1.31]), as well as underweight BMI (OR 1.12 [1.03-1.21]). Higher education (OR 0.85 [0.81-0.89]) and maternal age greater than 25 (OR 0.9 [0.85-0.94]) or maternal age greater than 35 (OR 0.89 [0.82-0.96]) were associated with lower presence of anemia. This study identified that maternal anemia is a serious maternal health concern in Georgia. Several associated factors of maternal anemia presence were identified. The findings of this study may be beneficial for policy workers and healthcare providers interested in preventing and treating maternal anemia within Georgia.