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Prevalence, trends, and maternal risk factors of adverse birth outcomes from a hospital-based birth defects surveillance system in Kampala, Uganda, 2015–2022

BMC Pregnancy and Childbirth volume 25, Article number: 408 (2025) Cite this article

Abstract

Background

Adverse birth outcomes (ABOs) cause significant infant morbidity and mortality in resource-limited settings. Many of the maternal risk factors associated with ABOs can be prevented. We present the prevalence, trends, and risk factors of selected ABOs from a hospital-based birth defects surveillance program in Kampala, Uganda.

Methods

We analyzed data for all mothers with singleton deliveries collected from four urban hospitals between 2015 and 2022. Prevalence of preterm birth [PTB], low birth weight [LBW], small for gestational age [SGA], and stillbirth [SB] and maternal HIV seroprevalence were calculated among 222,427 births. SB was defined as infant born without life ≥ 28 weeks of gestation, LBW as term live birth weighing < 2500 g and PTB as live birth born < 37 weeks of gestation. Time trends of ABOs by maternal HIV status and age were computed using quasi-Poisson regression model and presented graphically. Risk factor associations were estimated using robust Poisson models adjusting for infant sex, hospital of delivery, and birth year.

Results

Prevalence of PTB, LBW, SGA, and SB were 14.8%, 4.3%, 17.8%, and 3.1%, respectively. Maternal HIV seroprevalence was 7.7%. Compared to mothers aged 25–34 years, young adolescents 10–18 years was associated with PTB (adjusted risk ratio [aRR]: 1.44, 95% confidence interval (CI): 1.38–1.50); LBW (1.65,1.51–1.81); and SGA (1.18; 1.12–1.24). HIV seropositivity was associated with PTB (1.18; 1.14–1.22), LBW (1.54; 1.43–1.65), and SGA (1.28; 1.23–1.33). Compared to starting ANC in the first trimester, no antenatal care (ANC) was associated with PTB (2.44; 2.33–2.56), LBW (1.80; 1.55–2.09), SGA (1.37; 1.27–1.49), and SB (3.73; 3.32–4.15) and late attendance with LBW (1.09; 1.02–1.16), SGA (1.26; 1.22–1.30), and SB (1.09; 1.02–1.17). Our findings also indicate a rising trend in PTB among adolescent and young women aged 10–24 years, and a declining trend in LBW and SGA over time (ptrend < 0.05 for all).

Conclusions

Young maternal age, maternal HIV, and late or no ANC attendance were associated with ABO. Childbearing in the ages 25–34, preventing HIV in women, and supporting early and frequent ANC attendance are important in improving birth outcomes.

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Introduction

Adverse birth outcomes (ABOs), including preterm birth (PTB), low birth weight (LBW), small for gestational age (SGA) and stillbirths (SB), are a global public health problem. They cause significant infant morbidity and mortality with the majority occurring in resource-limited settings [1,2,3]. About 15 million infants worldwide are estimated to be born preterm annually with more than 60% occurring in Africa and Asia [4]. An analysis done in 12 countries showed that 74% of SB were preterm with 16% of them being SGA [5]. A recent study in East African countries showed a pooled PTB prevalence of 3.1 [6]. The global prevalence of low birth weight is estimated to be between 15 and 20% of all births representing over 20 million births annually [7]. There are variations in the distribution of low birth weight across regions with the highest prevalence occurring in Southern Asia (32.3%) and Sub-Saharan Africa (16.4%) [1]. In 2021, it was estimated that about 1.9 million babies were SB, equating to a global rate of 13.9 stillbirths per 1000 total births [8]. The highest estimated SB rates occur in Sub-Saharan Africa and Southern Asia with the two regions accounting for three quarters of all stillbirths. Sub-Saharan Africa has a SB rate of 21.0 per 1000 total births which was seven times higher than the lowest regional rate of 2.9 found in Europe, Northern America, Australia and New Zealand [8]. It is estimated that 32.4 million babies are born SGA in low and middle-income countries, which constitutes 27% of all live births [9].

Reducing ABOs like PTB, LBW and SB are part of the United Nations Sustainable Development Goal (SDG) targeted under goal 3.2 to end preventable deaths of children under 5 years of age [10]. The adverse birth outcomes can lead to health complications such as sensory deficits, respiratory illnesses, developmental delays, learning disabilities, increased risk of infections and neurologic diseases [11], leading to increased morbidity and mortality among under 5 years of age [12]. There is an overlap between PTB and LBW and such babies are at high risk of adverse neonatal outcomes. This combination exacerbates the risk of morbidity, mortality and lifelong consequences [13]. Studies done in Sub-Saharan Africa have shown diverse risk factors associated with ABOs including sociodemographic factors, neonatal factors, maternal characteristics, previous pregnancy outcomes and health system-related factors [14,15,16]. More work remains to better understand ABO risk factors, especially maternal characteristics during pregnancy like timing of first antenatal care (ANC), maternal age, HIV status, the understanding of this can lead to improved birth outcomes.

This study utilized the data from the birth defects surveillance project in Kampala, Uganda [17] from 2015 to 2022 to explore maternal factors associated with PTB, LBW, SGA and SB, as well as examine prevalence trends over time.

Methods

Study design and population

The analysis used data of all mothers with singleton deliveries from the birth defects surveillance system collected between 2015 and 2022 from four urban hospitals in Kampala, Uganda. The four hospitals included one public/government hospital (Kawempe National Referral Hospital) and three faith-based private not-for-profit hospitals (Mengo Hospital, Nsambya Hospital and Lubaga Hospital). The birth defects surveillance program methodology, including the inclusion and exclusion criteria, data collection process and data management, is described elsewhere [17]. Data collection started in August 2015 and paused for 6 months (March to August 2020) due to COVID-19 imposed lockdown. The mothers with multiple deliveries were excluded from analysis because studies have shown that such deliveries have a fivefold higher risk of adverse birth outcomes as compared to singleton deliveries [18, 19] and including them could lead to over estimation of prevalence. The analysis included babies with birth defects because sensitivity analysis showed no significant differences in the prevalences of ABOs before and after inclusion of birth defects (Supplemental Table 1).

Operational definitions of selected Adverse Birth Outcomes

In this analysis, the selected ABOs were PTB, LBW, SGA and SB. PTB was defined as a live delivery before 37 completed weeks of gestation. LBW was defined as a live term birth weight less than 2500 g. SB was defined as an infant born without life at 28 weeks of gestation or more [7]. SGA was defined as birth weight falling below 10th percentile for gestational age [20]. Infants with implausible values on birth weight and gestational age were excluded from the analysis.

Statistical analysis

The prevalence of ABOs among singleton deliveries and Wilson’s 95% confidence intervals (CI) were computed based on the respective ABOs definitions. Descriptive statistics such as frequency and percentages were used to summarize the data. To explore changes in the prevalences of ABOs overall and specifically for different groups of HIV status and age groups over the years 2015 to 2022, time trends of prevalences were also plotted and computed using a quasi-Poisson regression model. The Robust Poisson regression model was used to explore associations between ABOs with maternal characteristics like HIV status, maternal age, timing of first antenatal care (ANC) visit and number of ANC visits. Multicollinearity was assessed using the variance inflation factor (VIF) and variables with a score that exceeds 10 were considered collinear. The number of ANC visits was dropped from the model because it had a high VIF score and was highly correlated with timing of the first ANC. The regression models were adjusted for infant sex, year of delivery, mode of delivery and health facility of delivery. Infant sex was adjusted for because males and females can have different growth patterns. The year of delivery was adjusted to cater for temporal changes in medical practices, healthcare policies and environmental factors over time that would affect birth outcomes [21]. Accounting for the health facilities helps to account for disparities in health care access and quality given that the health facilities are a mix of private, public and referral. A p-value < 0.05 was considered statistically significant and the analysis was done using R statistical computing software (version 4.3.1) [22].

Results

The analysis included 222,427 mothers with singleton deliveries from the four urban hospitals in Kampala, over the period of 8 years from 2015 to 2022. The median age of mothers was 26 (interquartile range: 22.0–30.0) years, with 50.3% (n = 111,884) aged 25 years to 34 years (Table 1). The maternal HIV seroprevalence over the period was 7.7% (Table 1) and decreased from 11.0% in 2015 to 6.4% in 2022 (ptrend=0.001; Fig. 1). Most women, 97% (n = 216,669), attended at least one ANC visit, with 1.8% (n = 3,962) attending at least 8 ANC visits recommended by WHO (Table 1). 46% (n = 102,271) of the mothers started attending the first ANC in the third trimester and only 19.0% (n = 42,229) started in the WHO recommended first trimester (Table 1).

Table 1 Maternal and infant characteristics among Singleton deliveries, Kampala, Uganda, 2015–2022
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Fig. 1
figure 1

Trends of maternal HIV seroprevalence among singleton deliveries, Kampala, Uganda 2015–2022

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The timing of the first ANC was associated with PTB, SB, LBW and SGA (Table 2). The mothers who did not attend ANC were: 3.7 times more likely to have a SB delivery (Adjusted Risk Ratio (ARR) = 3.73, 95% CI: 3.33–4.17), 1.8 times more likely to have LBW delivery (ARR = 1.80, 95% CI: 1.55–2.09), 2.4 times more likely to have a PTB (ARR = 2.44, 95% CI: 2.33–2.56), and about 1.4 times more likely to have a delivery with SGA (ARR = 1.37, 95% CI:1.27–1.49) as compared to the mothers who started ANC in the first trimester. Also, those that started ANC late, in the third trimester, were slightly more likely to have SB delivery (ARR = 1.09, 95% CI: 1.02–1.17), LBW delivery (ARR = 1.09, 95% CI: 1.03–1.16) and SGA (ARR = 1.26, 95% CI: 1.22–1.30) as compared to mothers who started ANC in the first trimester.

Table 2 Multivariable regression model of adverse birth outcomes among Singleton deliveries, Kampala, Uganda, 2015–2022
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Maternal age was significantly associated with LBW, PTB and SGA (Table 2). As compared to the mothers in the age group 25–34 years, younger adolescent mothers 10–18 years were more likely to have an infant with a LBW (ARR = 1.65, 95% CI: 1.51–1.81), PTB (ARR = 1.44, 95% CI: 1.38–1.50) and SGA (ARR = 1.18, 95% CI: 1.12–1.24). Similarly, the young adults 19–24 years were more likely to have an infant with a LBW (ARR = 1.19, 95% CI: 1.13–1.26), PTB (ARR = 1.13, 95% CI: 1.10–1.16) and SGA (ARR = 1.12, 95% CI: 1.09–1.15). Also, mothers aged 35 years or older were more likely to a have a infant with LBW (ARR = 1.13, 95% CI: 1.04–1.23) and PTB (ARR = 1.09, 95% CI: 1.05–1.13) as compared to mothers aged 25–34 years.

HIV seropositivity was associated with an increased risk for LBW, PTB and SGA (Table 2). The risk of LBW delivery was 54% higher in mothers living with HIV as compared to those mothers not living with HIV (ARR = 1.54, 95% CI: 1.43–1.65). The risk of PTB (ARR = 1.18, 95% CI: 1.14–1.22) and SGA (ARR = 1.28, 95% CI: 1.23–1.33) was higher in mothers living with HIV as compared to those not living with HIV.

Parity was associated with the risk of LBW and SGA (Table 2). Nulliparity and low multiparity were associated with higher risk of LBW and SGA. The mothers with nulliparity were 38% more likely to have an infant with LBW (ARR = 1.38, 95% CI: 1.26–1.51) as compared to mothers with a grand parity greater or equal to 4. The nulliparous women (P0) and low multiparous (P1-3) women were associated with less risk of SB and PTB as compared to the grand multiparous women (P ≥ 4) (Table 2).

Prevalence and trends of Adverse Birth Outcomes

The overall prevalence of LBW, PTB, SB and SGA in the years from 2015 to 2022 were 4.3%, 14.8%, 3.1% and 17.8%, respectively (Table 3). The prevalence of LBW was on a decline from 5% in 2015 to 4% in 2022 (ptrend=0.02; Fig. 2B). Also, there has been a general decline in the prevalence of SGA from 25.6% in 2015 to 14.9% in 2022 (ptrend=0.002; Fig. 2D). No significant changes in the prevalence of SB and PTB were observed (Fig. 2A and C).

Table 3 Prevalence (%) of selected adverse birth outcomes among Singleton deliveries, Kampala, Uganda 2015–2022
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Fig. 2
figure 2

Trends of adverse birth outcomes among singleton deliveries, Kampala, Uganda 2015–2022

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Trends of Adverse Birth Outcomes by maternal HIV status and age

There was an increasing time trend of SB prevalence (ptrend=0.04; Fig. 3A) and PTB prevalence (ptrend=0.001; Fig. 3C) from 2015 to 2022 among mothers living with HIV. LBW and SGA had a decreasing trend among all mothers irrespective of maternal HIV status with trends (ptrend<0.05 for all; Fig. 3B and D; Supplemental Table 2). The mothers living with HIV on ART were consistently above 95% with most mothers on ART regimen EFV + TDF/3TC and DTG + TDF/3TC (Supplemental Table 3).

Fig. 3
figure 3

Trends of adverse birth outcomes among singleton deliveries by maternal HIV status from 2015–2022 in Kampala, Uganda

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There was an increasing trend of PTB among mothers in the age group 10–24 years (ptrend = 0.001) and a decreasing trend of SGA in all age groups (ptrend<0.05 for all; Fig. 4B and D). The trend and other age specific associated p-values are presented in Supplemental Table 2.

Fig. 4
figure 4

Trends of adverse birth outcome among singleton deliveries by maternal age groups, Kampala, Uganda, 2015–2022

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Discussion

In this study we examined the prevalence, trends, and maternal risk factors for PTB, LBW, SGA and SB among singleton deliveries from a Kampala hospital-based birth defects surveillance system. The most prevalent ABOs were SGA at 17.8% (95% CI: 17.6–17.9), followed by PTB at 14.8% (95% CI:14.6–14.9), LBW at 4.3% (95% CI: 4.2–4.4), and SB at 3.1% (95% CI: 3.0–3.2) over the period 2015–2022. Our findings of ABOs being common were consistent with published reports from other studies in Uganda and the Sub-Saharan Africa [23,24,25]. For example, the pooled prevalence in a study of Tamirat et al. in Sub-Saharan Africa published in 2021 [26], the prevalence of SB fluctuated around 3% which is close to the prevalence of SB in our study, LBW at around 31% and PTB at 22% is much higher than our findings. The differences in the prevalence of LBW and PTB from our study compared to published findings could be due to the varying definitions and inclusion of only singleton deliveries in the analysis. The definition of LBW in our study considered a live term birth and weight less than 2500 g while the study of Tamirat et al. considers all babies irrespective of gestational age. Preterm birth, we considered live delivery before 37 completed weeks of gestation yet in the study of Tamirat et al., all babies below 37 weeks of gestation were considered. Our findings also indicate statistically significant declining trends in LBW and SGA and a non-significant increasing trend in PTB which are consistent with previous studies in China which were conducted between 2004 and 2020. The studies of both Zhou et al. and He et al. observed the declining trends in LBW and SGA as observed in our study. Also, the studies by Zhou et al., Deng et al., and Ma et al. observed a non-significant increasing trend of PTB [27,28,29,30]. While changes in LBW are small (only 1% over 7 years), there was approximately a 10% drop in the prevalence of SGA over the period. The declining trends could be due to improved access to care as there is evidence of increasing trend of women attending at least four ANC visits and having their first ANC visit in the first trimester [31,32,33].

In this study, the lack of ANC and late attendance of the first ANC were associated with a high risk of SB, PTB, SGA and LBW. These findings were consistent with other studies done in Uganda and Sub-Saharan Africa. Tamirat et al. and Tibaijuka et al. highlight the lack of antenatal care (ANC) and late attendance of the first ANC visit as a predictor of adverse birth outcomes. Tamirat et al. found SB, PTB, SGA and LBW were significantly associated with lack of ANC and late ANC attendance. Similarly, Tibaijuka et al. in their study at Mbarara Regional Referral Hospital found an association between inadequate and untimely ANC with preterm neonatal mortality [26, 34]. This may be related to inadequate counselling on appropriate diet and pregnancy related complications which could have been identified and managed during ANC visits, hence reducing the risk of adverse birth outcomes [35]. These findings underscore a critical role of early ANC attendance in improving birth outcomes and reducing neonatal mortality.

This study revealed that mothers who were living with HIV were associated with a higher risk of ABOs. The risk of LBW, PTB and SGA were higher for mothers living with HIV. This is consistent with other studies that have found a higher risk of adverse birth outcomes with mothers living with HIV. A meta-analysis by Xiao et al. that included a cohort studies from various regions globally including those from sub-Saharan Africa found that the risk of LBW and PTB was 73% and 63% respectively among mothers who were HIV seropositive [36]. Another study in Lesotho found that the risk of adverse birth outcomes is 2–3 times higher among mothers living with HIV compared to HIV uninfected women [37]. Our data showed an increasing trend of SB and PTB prevalence from 2015 to 2022 among mothers living with HIV. The increase in SB and PTB occurred despite the consistently high proportion of women living with HIV receiving ART (Supplemental Table 3). A scooping review of articles with 47% of them from Eastern and Southern Africa observed that the compromised immune system and placental complications due to HIV infection can result in PTB and SB [38]. Overall, LBW and SGA decreased during the period among all mothers irrespective of maternal HIV status, although the prevalence among mothers living with HIV was consistently higher than HIV uninfected mothers throughout the period. This findings are similar to a study among women of 15 years and above in Northern Tanzania [39].

This study revealed that compared to mothers aged 25–34 years, young adolescent and young adults aged 10–24 years had a slightly higher risk of LBW, PTB and SGA. Also, mothers over 35 years had a higher risk of LBW and PTB compared to the mothers in the age group 25–34 years. These findings are in line with a study which showed that teenage pregnancies were associated with high risk of LBW and PTB. Among younger mothers the reproductive system may not have fully developed hence leading to PTB and LBW. Also, older mothers are at higher risk of complications such as preclampsia, gestational diabetes, and placental issues, which can lead to PTB and SB [40, 41]. These results are also consistent with studies done in Uganda [42], Ethiopia [43] and Italy [44]. The increasing trend of PTB prevalence among adolescent and young mothers is consistent with a study done in Italy [45].

The main strength of the study was its large sample size of over 200,000 deliveries from a robust surveillance system that ensures proper documentation for all deliveries of birth outcomes, clinical observations and proper data collection through electronic data capture, and data management. The main limitation was that the data source was from an urban hospital-based surveillance system that did not include home deliveries, non-informative deliveries (deliveries that were unclear to identify birth defects and other infant characteristics), macerated stillbirths, implausible data, deliveries where family consent was not obtained for the infant examination or family leaving the health facility before the infant was examined due to cultural practices, and other hospitals that were not part of the surveillance hence limiting generalizability. Kawempe, one of the study sites, is a national referral hospital so it was more likely to have ABOs as it is likely to receive more complicated deliveries that are referred to the hospital.

Conclusion

These findings affirm that adolescent girls and young adults aged 10–24 years or those aged 35 years and above, mothers living with HIV, as well as the lack of or late ANC attendance were associated with adverse birth outcomes of PTB, SB, LBW, and SGA. Interventions for reducing adverse birth outcomes could include prevention of teenage pregnancy, support of early and adequate attendance of ANC and scale up of Elimination of Mother-to-Child Transmission (EMTCT) of HIV in Uganda.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ABOs:

Adverse birth outcomes

ANC:

Antenatal Care

ART:

Antiretroviral therapy

CDC:

Centers for Diseases Control and Prevention

COVID-19:

Coronavirus Disease

HIV:

Human immunodeficiency virus

LBW:

Low Birth Weight

PTB:

Preterm Birth

SB:

Stillbirth

SDG:

Sustainable Development Goal

SGA:

Small for Gestational Age

VIF:

Variance Inflation Factor

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Acknowledgements

We thank all the participants, birth defects surveillance staff of the Makerere University– Johns Hopkins University Research Collaboration, and the staff of Kawempe, Nsambya, Mengo and Lubaga hospitals for the participation and support in the surveillance.

Funding

This research was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) under the terms of a Cooperative Agreement numbers GH0000487 and GH002171.

Author information

Authors and Affiliations

  1. Makerere University– Johns Hopkins University Research Collaboration, Kampala, Uganda

    Ronald Kusolo, Daniel Mumpe-Mwanja, Robert Serunjogi, Joyce Namale-Matovu & Philippa Musoke

  2. Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda

    Ronald Kusolo

  3. Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA

    Augustina Delaney

  4. Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention (CDC), Kampala, Uganda

    Kenneth Mwambi & Phoebe Monalisa Namukanja-Mayambala

  5. National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA

    Jennifer L. Williams, Cara T. Mai & Yan Ping Qi

  6. Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda

    Philippa Musoke

Authors
  1. Ronald Kusolo
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  2. Daniel Mumpe-Mwanja
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  3. Robert Serunjogi
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  4. Augustina Delaney
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  5. Joyce Namale-Matovu
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  6. Kenneth Mwambi
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  7. Phoebe Monalisa Namukanja-Mayambala
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  8. Jennifer L. Williams
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  9. Cara T. Mai
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  10. Yan Ping Qi
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  11. Philippa Musoke
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Contributions

RK and PM; both took the lead in preparation and writing of the manuscript: DMM, JNM, RS, AD, KM, PMNM, JW, CM and YPQ were involved in drafting the manuscript and revising it critically for important intellectual content: RK and RS were involved in methodology, data analysis and visualization: AD, KM, PMNM, JW, CM and YPQ were involved in validation, review and editing: All authors: Approved the final manuscript version submitted.

Corresponding author

Correspondence to Ronald Kusolo.

Ethics declarations

Ethics approval and consent to participate

This study and all methods involved were performed in accordance with the ethical principles for medical research involving human subjects, stipulated within the World Medical Association (WMA) declaration of Helsinki. This study was reviewed and approved by the U.S. Centers for Disease Control and Prevention Institutional Review Board (IRB) protocol number #6606, the Joint Clinical Research Center IRB, and the Uganda National Council for Science and Technology (UNCST), following 45 C.F.R. part 46; 21 C.F.R. part 56.

Consent to participate in the surveillance was waived by both IRBs (JCRC and CDC) because the surveillance involves no more than minimal risk to the participants. However, IRB-approved written informed consent was obtained for photographs of newborns with birth defects from their mothers or legal guardians.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Kusolo, R., Mumpe-Mwanja, D., Serunjogi, R. et al. Prevalence, trends, and maternal risk factors of adverse birth outcomes from a hospital-based birth defects surveillance system in Kampala, Uganda, 2015–2022. BMC Pregnancy Childbirth 25, 408 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07550-y

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07550-y

Keywords

BMC Pregnancy and Childbirth

ISSN: 1471-2393

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