Antenatal Detection of Paediatric Surgical Congenital Abnormalities and its Impact on Maternal Anxiety: A Multicentre Prospective Study in a Middle-Income Country

doi:10.21203/rs.3.rs-5308024/v1

Background: In middle-income countries, healthcare systems face unique challenges in ensuring timely antenatal detection of congenital abnormalities that require paediatric surgical intervention. Early detection can significantly improve outcomes, yet resource constraints often limit access to diagnostic technologies. This study evaluates the antenatal detection rate of congenital abnormalities referred to paediatric surgical services in three Malaysian tertiary centres and examines its effect on maternal anxiety.

Methods: A prospective observational study was conducted at Hospital Raja Permaisuri Bainun (HRPB), Hospital Sultanah Aminah (HSA), and University of Malaya Medical Centre (UMMC) over a 8 month period. Data were collected from mothers of neonates born with congenital abnormalities, and the Spielberg State-Trait Anxiety Inventory (STAI) was used to assess maternal anxiety.

Results: A total of 58 patients were recruited. The overall antenatal detection rate for congenital abnormalities was 43.1%, comparable to high-income countries despite resource limitations. Antenatal counselling by paediatric surgeons was rare (6.9%) and showed no significant reduction in maternal anxiety (p = 0.374).

Conclusion: The antenatal detection rates at the three Malaysian centres align with those in more developed nations, underscoring the potential of middle-income healthcare systems to deliver high-quality prenatal care. However, improving access to diagnostic technologies and involving paediatric surgical teams in antenatal counselling could further enhance care.

congenital abnormalities

antenatal detection

maternal anxiety

middle-income country

paediatric surgery

Congenital abnormalities requiring surgical intervention place a significant emotional, financial, and logistical burden on healthcare systems, particularly in middle-income countries.[1, 2] These abnormalities account for a large proportion of neonatal mortality and morbidity, with many requiring urgent surgical correction soon after birth.[3] Early antenatal detection is crucial for preparing both healthcare teams and families for the necessary interventions. While high-income countries have well-established systems for antenatal screening and counselling, middle-income countries like Malaysia face several barriers to implementing and optimizing these services.[4]

In middle-income countries, there is often a disparity in healthcare infrastructure between urban and rural areas. Urban centres are more likely to have advanced diagnostic equipment, highly trained specialists, and tertiary care hospitals capable of handling complex congenital anomalies. However, rural areas may lack access to these resources, resulting in delayed or missed diagnoses. This disparity poses significant challenges in providing equitable healthcare across the country.[4]

Malaysia, a rapidly developing middle-income country, has made significant strides in improving its healthcare system, yet challenges remain.[5] The country’s healthcare system is primarily public, with services heavily subsidized by the government, making healthcare accessible to a large portion of the population. However, there are still limitations, especially in ensuring equitable access to advanced antenatal diagnostic tools such as high-resolution ultrasonography and foetal anomaly scans.[6]

This study aims to evaluate the antenatal detection rate of congenital abnormalities referred to paediatric surgical services in three tertiary hospitals across Malaysia. It also explores the relationship between antenatal counselling and maternal anxiety, a critical aspect of managing congenital abnormalities that has not been thoroughly studied in middle-income settings. By examining detection rates and the effectiveness of antenatal counselling, this study seeks to identify areas for improvement in Malaysia’s paediatric surgical services and provide insights relevant to other middle-income countries.

Study Design and Setting

This study was designed as a multicentre, prospective observational study, conducted over eight months. The three tertiary centres chosen for this study—University of Malaya Medical Centre (UMMC) in Kuala Lumpur, Hospital Sultanah Aminah (HSA) in Johor Bahru, and Hospital Raja Permaisuri Bainun (HRPB) in Ipoh—represent major referral centres with paediatric surgical units serving a broad population across urban and rural regions. These centres reflect a typical middle-income healthcare system that includes a mixture of well-resourced urban hospitals and more resource-constrained regional centres.

Participants

Mothers of neonates diagnosed with congenital abnormalities were recruited for the study if their neonates met specific inclusion criteria. These criteria included a wide range of surgical congenital abnormalities such as thoracic (congenital diaphragmatic hernia, congenital pulmonary airway malformation), abdominal (omphalocele, gastroschisis), gastrointestinal (bowel atresia, anorectal malformation), and urological (posterior urethral valve, congenital hydronephrosis) anomalies. Neonates born during the study period and referred to paediatric surgery were included if their mothers consented to participate.

Neonates had non-surgical congenital abnormalities or where the mother had pre-existing mental health conditions (such as anxiety or depression) that could independently affect the maternal anxiety scores, were excluded. Additionally, families where the mother was not the primary caregiver or unable to provide consent (e.g., due to illness or other incapacity) were also excluded. Only mothers were included in this study because they are typically the primary caregivers in the early neonatal period, especially in the context of a middle-income country like Malaysia, where mothers often bear the primary responsibility for neonatal care.

Data Collection

Data were collected from antenatal records, postnatal medical files, and by administering structured questionnaires. The primary outcome measured was the antenatal detection rate of congenital abnormalities. The timing of the diagnosis—antenatal or postnatal—was noted, along with details of any antenatal counselling provided.

To evaluate the psychological impact on mothers, the Spielberg State-Trait Anxiety Inventory (STAI) was used. The STAI consists of two scales: the Y-1 form measures state anxiety, reflecting how respondents feel “at the moment,” while the Y-2 form measures trait anxiety, indicating baseline anxiety levels. Mothers were asked to complete the STAI within the first week postpartum.

Variables and Definitions

Antenatal Detection Rate: The proportion of neonates whose congenital abnormalities were diagnosed during pregnancy via routine antenatal care.
Maternal Anxiety: Measured using the STAI, with higher scores indicating greater anxiety. STAI scores are categorized into low, moderate, and severe anxiety based on standardized thresholds.
Antenatal Counselling: Defined as consultations provided to expectant mothers by paediatric surgeons, paediatricians, or obstetricians regarding the congenital abnormality diagnosed antenatally.
Surgical Condition: Defined as a congenital abnormality that requires surgical intervention by a general paediatric surgical team during the neonatal period or early infancy. This includes conditions that involve thoracic (e.g., congenital diaphragmatic hernia), abdominal (e.g., omphalocele, gastroschisis), gastrointestinal (e.g., bowel atresia, anorectal malformation), and urological (e.g., posterior urethral valve, congenital hydronephrosis) anomalies, all of which necessitate corrective surgery for optimal outcomes.

Statistical Analysis

Data were analysed using descriptive statistics to summarize demographic and clinical variables. Mann-Whitney U tests was used to compare maternal anxiety between groups based on antenatal versus postnatal diagnosis. A two-way ANOVA was employed to assess whether antenatal consultations with paediatric surgeons had a significant effect on anxiety scores. A p-value of ≤ 0.05 was considered statistically significant.

A power calculation was not performed for this study due to the observational and exploratory nature of the research, as well as the relatively limited pool of eligible participants during the study period. The sample size was determined based on the availability of cases at the participating centres. This study was intended to provide preliminary insights into antenatal detection rates and maternal anxiety, which will inform future, larger-scale studies with appropriate sample size calculations.

Demographics and Clinical Characteristics

A total of 58 neonates with congenital abnormalities were included in the study, with a male predominance (69.0%). The mean birth weight was 2.5 kg, and the average gestational age at birth was 37.2 weeks. Most participants (96.6%) were Malaysian citizens, and the majority (65.5%) came from low-income households (B40, Bottom 40% income group). Table 1 presents a detailed summary of patient demographics.

Table 1

Demographic Characteristics of Patients and Mothers
Characteristic	Frequency (%)	Mean (SD)
Gender
Male	40 (69.0%)
Female	18 (31.0%)
Birth Weight (kg)		2.5 (0.49)
Gestational Age at Birth (weeks)		37.2 (2.06)
Ethnicity
Malay	42 (72.4%)
Chinese	10 (17.2%)
Indian	4 (6.9%)
Indigenous populations of Borneo	2 (3.4%)
Nationality
Malaysian	56 (96.6%)
Foreigner	2 (3.4%)
Place of Birth
UMMC	12 (19.7%)
HSA	22 (37.9%)
HRPB	24 (41.4%)
Antenatal Detection Rate
Antenatally diagnosed	25 (43.1%)
Postnatally diagnosed	33 (56.9%)
Mode of Delivery
Spontaneous Vaginal Delivery	19 (32.8%)
Instrument Assisted Delivery	2 (3.4%)
Emergency LSCS	25 (43.1%)
Elective LSCS	12 (20.7%)
Mother’s Occupation
Housewife	38 (65.5%)
Working Full-Time	20 (34.5%)

Antenatal Detection Rates

The overall antenatal detection rate across the three centres was 43.1%, with significant differences between the centres. UMMC, located in a well-resourced urban setting, reported the highest detection rate at 66.7%, while HSA, a regional hospital serving a more rural population, had a detection rate of 31.8%. HRPB, another regional centre, had an intermediate detection rate of 41.7% (Table 2).

Table 2

Antenatal Detection Rate by Centre
Centre	Antenatal Detection Rate (%)
UMMC	66.7%
HSA	31.8%
HRPB	41.7%

The detection rate also varied based on the type of congenital abnormality. Gastroschisis and omphalocele were detected antenatally in all cases (100%), while conditions such as tracheo-oesophageal fistula (22.2%) and anorectal malformations (15.4%) had much lower detection rates (Table 3).

Table 3

Antenatal Detection Rates by Type of Abnormality
Congenital Abnormality	No. of Cases	Cases Detection Antenatally, n (%)
Congenital Diaphragmatic Hernia (CDH)	8	4 (50%)
Congenital Pulmonary Airway Malformation (CPAM)	5	4 (80%)
Tracheo-oesophageal Fistula (TOF)	9	2 (22.2%)
Pure Oesophageal Atresia (OA)	4	2 (25%)
Omphalocele	1	1 (100%)
Gastroschisis	1	1 (100%)
Small Bowel Atresia	17	9 (52.9%)
Anorectal Malformation (ARM)	13	2 (15.4%)
Congenital Hydronephrosis	3	3 (100%)
Sacrococcygeal Teratoma (SCT)	2	1 (50.0%)

Antenatal Counselling and Maternal Anxiety

Out of 58 mothers, only 6.9% received antenatal counselling from a paediatric surgeon, indicating a limited role for paediatric surgical teams in the antenatal management of congenital abnormalities. Most antenatal counselling was provided by obstetricians (70%), with paediatricians contributing in 15% of cases (Table 4).

Table 4

Providers of Antenatal Counselling for Mothers
Counselling Provider	Frequency (%)
Obstetric & Gynaecologist (Public Service)	14 (70.0%)
Obstetric & Gynaecologist (Private Practice)	4 (20.0%)
Paediatrician (Public Service)	5 (25.0%)
Paediatric Surgical Team (Public Service)	3 (15.0%)
Paediatrician (Private Practice)	1 (5.0%)

The STAI scores revealed that maternal anxiety levels were high across all groups. Mothers whose babies were diagnosed antenatally did not show significantly lower anxiety levels compared to those diagnosed postnatally (p = 0.653) (Table 5). Additionally, the number of antenatal consultations with paediatric surgeons did not result in a significant reduction in anxiety (p = 0.374) (Table 6).

Table 5

Mean STAI Scores Based on Timing of Diagnosis
Timing of Diagnosis	STAI Y1 (State Anxiety) (Mean, SD)	STAI Y2 (Trait Anxiety) (Mean, SD)	p-value
Antenatally (n = 25)	52.7 (11.01)	41.8 (8.21)	0.653
Postnatally (n = 33)	53.9 (10.13)	42.2 (7.38)	0.653

Table 6

Mean STAI Scores Based on Counselling by Paediatric Surgery
Counseling Provider	STAI Y1 (Mean, SD)	STAI Y2 (Mean, SD)	p-value
No consultation by paediatric surgical team (n = 54)	52.7 (11.01)	41.8 (8.21)	0.374
Counselled by paediatric surgical team (n = 4)	53.9 (12.3)	43.0 (9.5)	0.374

Challenges in Antenatal Detection

The antenatal detection rate of 43.1% observed in this study is comparable to high-income countries, despite the resource constraints typical of a middle-income country.[7] This finding underscores the success of Malaysia’s public healthcare system in providing accessible antenatal care across different regions. However, the significant variation in detection rates between the three centres reflects ongoing disparities in healthcare access and resource availability. Urban centres like UMMC benefit from better diagnostic equipment, including higher-resolution ultrasound machines and a greater concentration of foetal medicine specialists. In contrast, hospitals like HSA and HRPB, which serve larger rural populations, often lack such resources, leading to lower detection rates for complex internal anomalies such as anorectal malformations and tracheo-oesophageal fistulas.

The Role of Paediatric Surgeons in Antenatal Care

A notable finding of this study was the limited involvement of paediatric surgeons in antenatal counselling. While antenatal counselling is crucial for preparing parents for the birth of a child with congenital abnormalities, the majority of counselling in this study was provided by obstetricians. The low rate of consultations with paediatric surgeons (6.9%) reflects a broader issue in middle-income countries: the limited availability of specialized healthcare providers. Paediatric surgeons are often concentrated in urban tertiary centres, making it difficult for parents in rural areas to access these services. This lack of access may contribute to the high levels of maternal anxiety observed in this study.[8]

Addressing Maternal Anxiety

One of the most important aspects of antenatal care for congenital abnormalities is addressing maternal anxiety. High levels of anxiety can negatively affect maternal and neonatal outcomes, increasing the risk of postpartum depression and impacting the mother’s ability to care for her child.[9] However, this study found no significant reduction in maternal anxiety for those who received antenatal counselling compared to those who did not. This could be due to the insufficient time available for detailed counselling, especially when conducted in busy public hospitals with limited staff. Additionally, parents may not feel adequately reassured unless they receive detailed, condition-specific information from specialists.

In this context, providing more structured, multidisciplinary antenatal counselling—where both obstetricians and paediatric surgeons are involved—could better prepare parents and reduce their anxiety.[10] Further, the incorporation of telemedicine services could help bridge the gap between urban and rural healthcare services, allowing parents to access specialist consultations without the need for travel.

Resource Allocation in Middle-Income Countries

To improve antenatal detection and counselling for congenital abnormalities, middle-income countries must address the resource gaps in rural and regional hospitals. Investing in better ultrasound machines and providing training for sonographers and obstetricians in identifying complex congenital abnormalities could significantly improve detection rates.[11] Similarly, expanding the availability of paediatric surgeons in regional centres could help ensure that more parents receive comprehensive antenatal counselling.

Strengths

The study’s multicentre design offers a representative sample across varied healthcare settings in Malaysia, capturing both urban and rural contexts. Its use of validated tools like the Spielberg State-Trait Anxiety Inventory (STAI) provides robust insights into maternal anxiety. Additionally, this research fills a critical gap by addressing antenatal detection rates and counselling in a middle-income country, offering valuable data for improving prenatal care in similar contexts globally.

Limitations

The relatively small sample size limits the generalizability of the findings, particularly regarding the impact of paediatric surgical counselling on maternal anxiety. The variability in resources between study centres may have confounded results, as differences in diagnostic equipment and staff expertise were not standardized. Self-reported anxiety data may also introduce bias, as participants’ responses can be influenced by external factors at the time of survey completion.

Future Directions

Larger studies are needed to confirm these findings and explore detection rates across a broader range of settings, including smaller regional hospitals. Investigating the long-term effects of antenatal counselling on maternal mental health and neonatal outcomes would be valuable. Furthermore, integrating telemedicine for antenatal consultations in rural areas could help improve access to specialized care, reducing disparities in middle-income healthcare systems.[12]

This study demonstrates that middle-income countries like Malaysia can achieve antenatal detection rates for congenital abnormalities that are comparable to high-income countries, provided that healthcare resources are effectively allocated. However, significant disparities remain between urban and rural centres, and improvements are needed in both the availability of diagnostic equipment and access to specialist care. Enhancing antenatal counselling services, particularly through greater involvement of paediatric surgeons, is crucial for reducing maternal anxiety and improving neonatal outcomes.

As Malaysia continues to develop its healthcare infrastructure, focusing on equitable resource distribution and improving antenatal care protocols will be essential in ensuring better outcomes for children born with congenital abnormalities.

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of Interest/Competing Interests:

The authors declare that they have no conflicts of interest.

Availability of Data and Material:

The datasets generated and analysed during the current study are available from the corresponding author on request.

Ethics Approval:

This study was approved by the relevant institutional ethics committees, including the Medical Research and Ethics Committee (MREC) of the Ministry of Health Malaysia and the University of Malaya Research Ethics Committee (MREC ID: 20211234UM).

Consent to Participate:

Informed consent was obtained from all individual participants included in the study.

Consent for Publication:

Consent for publication of de-identified data was obtained from all participants.

AI Language Assistance:

The authors used Open AI ChatGPT (GPT-4) to improve the language and readability of the manuscript. The AI was not involved in generating scientific content or interpreting the results.

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No competing interests reported.

Antenatal Detection of Paediatric Surgical Congenital Abnormalities and its Impact on Maternal Anxiety: A Multicentre Prospective Study in a Middle-Income Country

Status:

Version 1

Abstract

Introduction

Materials and Methods