Maternal and Fetal Outcomes of Meconium-Stained Amniotic Fluid at KCMC Teaching Zonal Referral Hospital: A Prospective Cohort Study

Maternal and Fetal Outcomes of Meconium-Stained Amniotic Fluid at KCMC Teaching Zonal Referral Hospital: A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Maternal and Fetal Outcomes of Meconium-Stained Amniotic Fluid at KCMC Teaching Zonal Referral Hospital: A Prospective Cohort Study Subiraga Mwaihabi², Raziya Gaffur², Kelvin Musa¹², Elizabeth Msoka³, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8379542/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Aims Meconium-stained amniotic fluid (MSAF) remains a significant obstetric concern due to its association with adverse maternal and neonatal outcomes. However, the absence of standardized management guidelines contributes to clinical uncertainty regarding appropriate interventions, such as operative delivery particularly in low-resource settings like Tanzania. This study aimed to determine the maternal and fetal outcomes associated with different grades of MSAF. Methods The prospective cohort of 362 term pregnant women with singleton pregnancies were conducted between September 2024 to February 2025 at KCMC hospital. Maternal and neonatal outcomes were compared between women with and without MSAF, and Poisson regression models with robust standard errors estimated crude and adjusted risk ratios (aRRs), controlling for key confounders. Results Among 362 women (median age: 31 years, IQR: 27–35), 29.3% experienced MSAF. Women with MSAF had significantly higher risks of cesarean delivery (aRR 5.8; 95% CI 3.6–9.1), postpartum hemorrhage (aRR 9.8; 95% CI 4.1–23.2), and puerperal sepsis (aRR 2.1; 95% CI 1.1–4.1). Neonates exposed to MSAF had significant increased risks of NICU admission (aRR 3.2; 95% CI 1.9–5.3), respiratory distress (aRR 2.4; 95% CI 1.2–4.8), and meconium aspiration syndrome (aRR 7.6; 95% CI 2.9–19.9), with risks increasing progressively across MSAF grades. Conclusion MSAF, particularly in its thicker grades, is associated with substantially increased risks of adverse maternal and neonatal outcomes. Strengthening intrapartum monitoring, timely intervention, and provider training is critical to mitigate these risks. Findings underscore the need for context-specific guidelines to enhance outcomes in resource-limited settings. Meconium-stained amniotic fluid pregnancy outcomes maternal health neonatal outcomes provider perceptions Figures Figure 1 Figure 2 Background Meconium-stained amniotic fluid (MSAF) it is characterized by the presence of the meconium (first stool) in the amniotic fluid (1,2). Its remain the major obstetrics concern due its association with adverse fetal and martenal outcome. The presence of meconium-stained amniotic fluid (MSAF) can arise from the normal physiological maturation and activity of the fetal digestive system, but it may also indicate that the fetus is experiencing hypoxic stress.(3) Globally about 8–38% of all pregnancies experience MSAF with the highee reported in Low and Middle Income Countries (LMICs). Meconium is usually expelled within the first 24 to 48 hours following birth(1,4) .However, it can also be passed during labor due several factors such as obstructed labor, advanced maternal age, smoking, oligohydramnios, anemia, prolonged labor, the use of uterotonic agents, and hypertensive disorders during pregnancy(5–7). In lower resource setting it usually considered as a sign of fetal distress(8). The risk and severity of complications are influenced by several factors, including the thickness or grade of meconium, the duration of labor, and the timeliness of obstetric management (9). Despite its clinical relevance, there remains a lack of consensus and standardized protocols on the optimal management of MSAF, particularly in resource-limited settings. In Tanzania, MSAF continues to be an important contributor to maternal and perinatal morbidity and mortality (10). However, local data on the burden and outcomes of MSAF are scarce, and evidence-based guidance for clinical decision-making remains limited. Kilimanjaro Christian Medical Centre (KCMC) Teaching Zonal Referral Hospital, a major tertiary and teaching institution in northern Tanzania, manages a high volume of deliveries, offering an ideal setting to explore the clinical implications of MSAF. This study aims to determine the maternal and fetal outcomes associated with meconium-stained amniotic fluid among laboring women at KCMC Teaching Zonal Referral Hospital. Findings from this study will provide valuable insights into the relationship between MSAF severity and clinical outcomes, inform local practice guidelines, and contribute to efforts to reduce preventable maternal and neonatal complications in similar low-resource settings. Methodology Study Design and Setting: A prospective cohort study was conducted over a six-month period, from September 2024 to February 2025, to determine the proportion and pregnancy outcomes associated with meconium-stained amniotic fluid (MSAF) among women delivering at Kilimanjaro Christian Medical Centre (KCMC), a tertiary referral hospital located in Moshi, Northern Tanzania. KCMC serves as a zonal referral center for over 15 million people across Northern Tanzania and provides advanced obstetric and neonatal care. The Department of Obstetrics and Gynecology , where the study was based, includes a busy labor ward managing both routine and high-risk deliveries. The prospective cohort design allowed for the establishment of a temporal relationship between MSAF exposure (at any grade) and pregnancy outcomes, as well as direct measurement of the incidence of specific pregnancy outcomes associated with MSAF exposure. Study population The study included all term pregnant women admitted for delivery at KCMC during the study period. Eligible participants were women with a gestational age of ≥37 weeks, singleton pregnancies, cephalic presentation, and ruptured fetal membranes who were diagnosed with meconium-stained amniotic fluid (MSAF) during labor or delivery. Women with multiple gestations, preterm deliveries (<37 weeks), known congenital fetal malformations, or those who declined to participate were excluded from the study. Sample size and sampling technique The sample size was determined using the two-proportion Z-test formula, based on the difference in the rate of meconium aspiration syndrome (MAS) among fetuses with meconium-stained liquor versus those with clear amniotic fluid, reported as 7.58% and 0.68%, respectively (11). The formula used was: Where: , , , , , and . Using a significance level (α) of 0.05 and a power (1–β) of 80%, the calculated sample size was 362 pregnant women, accounting for possible non-response. This total comprised women diagnosed with MSAF (exposed group) and those with clear amniotic fluid (comparison group). A consecutive sampling technique was employed. All eligible pregnant women presenting to the labor ward at KCMC during the study period (September 2024 to February 2025) were recruited prospectively until the desired sample size of 362 was attained. Eligibility was assessed using the study inclusion and exclusion criteria, ensuring that all term singleton pregnancies with ruptured membranes were considered. This approach minimized selection bias by including every eligible participant in sequence.. Study Variables and key Concepts Variables of interest were adopted and modified from previous study (12). and included participants’ socio-demographic characteristics, maternal outcomes, and fetal or neonatal outcomes. The primary exposure variable was meconium-stained amniotic fluid (MSAF), diagnosed visually during labor or delivery. MSAF was graded according to its color and consistency into three categories: Grade 1 (light or thin meconium), Grade 2 (moderate meconium), and Grade 3 (thick or heavy meconium). For analytical purposes, MSAF was defined both as a binary variable, indicating its presence or absence, and as an ordinal variable reflecting its severity by grade. Maternal outcomes included postpartum hemorrhage (PPH), puerperal sepsis, and mode of delivery. Postpartum hemorrhage was defined as an estimated blood loss of ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, or any bleeding that resulted in a ≥10% reduction in hemoglobin, required blood transfusion, or caused hemodynamic instability necessitating uterotonics or surgical intervention. Puerperal sepsis was defined in accordance with the World Health Organization (WHO) criteria and required the presence of clinical signs of genital tract infection such as fever (≥38°C), uterine tenderness, and foul-smelling lochia, along with systemic manifestations such as tachycardia or organ dysfunction, after exclusion of other potential infection sources such as urinary or respiratory tract infections. Mode of delivery was categorized as spontaneous vaginal delivery (SVD), instrumental vaginal delivery, or cesarean section (CS). Spontaneous vaginal delivery referred to natural childbirth without surgical or instrumental assistance, whereas instrumental vaginal delivery involved the use of tools such as vacuum extractors or forceps due to indications like fetal distress, prolonged second stage of labor, or maternal exhaustion. Cesarean section referred to the surgical extraction of the fetus through abdominal and uterine incisions and was further classified as elective when planned before labor or emergency when performed in response to intrapartum complications such as fetal distress or cephalopelvic disproportion. All information on delivery mode was extracted from labor ward records and operative notes to ensure accuracy. Fetal and neonatal outcomes included neonatal intensive care unit (NICU) admission, neonatal sepsis, respiratory distress, meconium aspiration syndrome (MAS), birth asphyxia, and neonatal death. Neonatal sepsis was defined based on WHO criteria, requiring at least two clinical signs such as fever (≥38°C), hypothermia (≤36°C), poor feeding, lethargy, respiratory difficulty, or convulsions, accompanied by at least one abnormal laboratory finding such as elevated C-reactive protein (CRP), abnormal white blood cell count (WBC >20,000/mm³ or <5,000/mm³), or positive blood culture. Birth asphyxia was identified following WHO and American Academy of Pediatrics definitions as failure to establish effective breathing at birth, indicated by an Apgar score below 7 at one or five minutes and requiring resuscitation beyond tactile stimulation, such as bag-mask ventilation or chest compressions. Fetal heart rate (FHR) anomalies were assessed during labor through cardiotocography (CTG) or intermittent auscultation using a fetoscope or Doppler device. Anomalies were classified as tachycardia (FHR >160 bpm for more than 10 minutes), bradycardia (FHR <110 bpm for more than 10 minutes), or decelerations, which were further categorized as early (Type I), variable (Type II), or late (Type III) based on timing and morphology. Neonatal respiratory distress was defined by the presence of at least two clinical signs—tachypnea (respiratory rate >60 breaths per minute), grunting, nasal flaring, chest retractions, or central cyanosis—occurring within the first 24 hours of life. The severity was categorized as mild when observation alone was sufficient or moderate to severe when oxygen therapy or NICU admission was required. Diagnoses were confirmed through neonatal clinical assessments and documented in medical charts and nursing notes. Meconium aspiration syndrome (MAS) was diagnosed clinically in neonates born through meconium-stained amniotic fluid who developed respiratory distress within the first few hours of life, especially those requiring resuscitation at birth. Diagnostic features included respiratory distress characterized by tachypnea, grunting, nasal flaring, retractions, and cyanosis; the presence of meconium below the vocal cords on suctioning; and chest radiographic findings typical of MAS. The diagnosis was distinguished from other causes of neonatal respiratory distress based on its association with MSAF and the early onset of symptoms. Neonatal admission was defined as any transfer of a newborn to the neonatal unit for observation, monitoring, or treatment within the first 28 days of life. Common indications for admission included respiratory distress, birth asphyxia, neonatal sepsis, MAS, prematurity, or low birth weight. Admission details such as timing, duration of stay, and clinical indications were obtained from NICU registers and medical records. Sociodemographic and obstetric characteristics, including maternal age, parity, gravidity, gestational age at delivery, timing of membrane rupture, presence of fetal heart rate anomalies, and medical comorbidities, were considered potential confounding variables and were included as independent variables in the analysis Data management and analysis plan Data were carefully checked for completeness and consistency throughout the data collection period. Double data entry was performed using EpiData to minimize entry errors. The cleaned dataset was exported to Stata version 18 for analysis. Descriptive statistics such as frequencies, percentages, means, and standard deviations summarized sociodemographic and clinical characteristics as well as maternal and fetal outcomes. The proportion of meconium-stained amniotic fluid (MSAF) was calculated as the proportion of all deliveries during the study period. Bivariate analyses used chi-square or Fisher’s exact tests to examine associations between MSAF and selected outcomes. To assess the risk of adverse maternal outcomes associated with MSAF, Poisson regression models with robust standard errors were applied to estimate crude and adjusted risk ratios (cRR and aRR). Covariates including maternal age, parity, gestational age at delivery, and hypertensive disorders were included in adjusted models to control for confounding. Model diagnostics showed no evidence of poor fit or over dispersion, confirming the suitability of the Poisson regression approach. Statistical significance was set at p < 0.05 or 95%CI for risk ratios (RR) that does not contain null value 1. Ethics approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Board (IRB) of KCMU College (Reference No. NO.PG 159/2024). Permission to conduct the study was also granted by the Kilimanjaro Christian Medical Centre (KCMC) hospital administration. Written informed consent was obtained from all individual participants included in the study prior to any study-related procedures. Results Participants Enrollment Flowchart A total of 655 term pregnant women were admitted to the labor ward for delivery during the study period. Of these, 293 women were excluded due to [(breech presentation, fresh or macerated stillbirth, antepartum hemorrhage, congenital malformations, prolonged rupture of membranes >18 hours and chorioamnionitis). The remaining 362 women were recruited for the study, all of whom were included in the final analysis (Figure 1). Socio-demographic characteristics of the participants Among 362 participants, majority were aged 26-35 years (n=210, 58.0%) with 60 (28.6%) experiencing MSAF. The majority were married/cohabiting (n=339, 93.6%) where 97 (28.6%) had MSAF, while single participants (n=23, 6.4%) had a higher proportion (n=9, 39.1%). Most participants had college/university education (n=289, 79.8%) with 85 (29.4%) having MSAF. Urban residents comprised 91.2% (n=330) with 91 (27.6%) experiencing MSAF, while rural residents (n=32, 8.8%) had a notably higher proportion (n=15, 46.9%), (Table 1). Clinical and Obstetric Characteristics by Meconium-Stained Amniotic Fluid Among the 362 participants, primigravida women constituted 128 (35.4%) with 41 (32.0%) experiencing MSAF, while multigravida and grand multigravida women accounted for 78 (21.6%) and 156 (43.1%), with MSAF rates of 27 (34.6%) and 38 (24.4%), respectively. Regarding parity, most were primipara 219 (60.5%), with 70 (32.0%) affected by MSAF. Notably, half of those with membrane rupture before labor had MSAF 35 (50.7%) compared to 71 (24.2%) during labor. Fetal heart rate anomalies were present in 53 (14.6%) of participants, with a markedly higher MSAF prevalence 31 (58.5%) compared to those without anomalies 75 (24.3%). Hypertension disorders and history of postpartum hemorrhage were less common 35 (9.7%) and 25 (6.9%), respectively, and showed comparable MSAF proportions 9 (25.7%) and 8 (32.0%). Diabetes mellitus was rare 4 (1.1%) but showed a 50% (2) MSAF occurrence, (Table 2). Incidence of Meconium-Stained Amniotic Fluid and its grades The overall incidence of meconium-stained amniotic fluid (MSAF) was 29.3% (n=106, 95% CI: 24.6-34.3) among the 362 women studied. Of these, Grade 2 MSAF was the most frequent, observed in 47.2% (n=50) of cases, followed by Grade 3 MSAF in 38.7% (n=41), and Grade 1 MSAF in 14.2% (n=15). Clear amniotic fluid (CAF) was noted in 70.7% (n=256) of participants, (Figure 2). Maternal outcomes frequency and proportions by MSAF status and grades As presented in Table 3, women with meconium-stained amniotic fluid (MSAF) experienced substantially higher rates of adverse maternal outcomes compared to those with clear amniotic fluid (CAF). The overall cesarean section (CS) rate was markedly increased in the MSAF group (42.5%, n=45) relative to CAF (7.0%, n=18). This trend intensified with increasing MSAF severity, rising from 26.7% (n=4) in Grade 1 to 38.0% (n=19) in Grade 2 and peaking at 53.7% (n=22) in Grade 3. Similarly, the proportion of puerperal sepsis was higher among women with MSAF (15.1%, n=16) than CAF (6.6%, n=17), with a slight increase across MSAF grades (Grade 1: 13.3%, Grade 2: 14.0%, Grade 3: 17.1%). Notably, postpartum hemorrhage (PPH) occurred nearly ten times more often in women with MSAF (23.6%, n=25) than in those with CAF (2.3%, n=6), with increasing proportions observed across Grades 1 (13.3%), 2 (26.0%), and 3 (24.4%). Risk of Adverse Maternal Outcomes Associated with MSAF As it is shown in Table 4, MSAF has been observed increased risk of several adverse maternal outcomes associated with MSAF. Women with MSAF had a significantly higher risk of cesarean section (CS) delivery compared to those with clear amniotic fluid (CAF), with nearly a six-fold increase observed in both unadjusted (cRR: 6.0; 95% CI: 3.7-9.9) and adjusted models (aRR: 6.3; 95% CI: 3.9-10.1). The risk of CS delivery increased progressively with MSAF severity, showing adjusted risk ratios of 3.2 (95% CI: 1.5-6.8) for Grade 1, 5.7 (95% CI: 3.3-9.9) for Grade 2, and 9.1 (95% CI: 5.2-16.0) for Grade 3, indicating a clear dose-response relationship between MSAF grade and the likelihood of operative delivery. Women with MSAF were also at greater risk of developing puerperal sepsis, with unadjusted (cRR: 2.3; 95% CI: 1.2-4.3) and adjusted analyses (aRR: 2.2; 95% CI: 1.2-4.3) confirming a strong association. The risk increased with MSAF severity, with adjusted risk ratios of 1.8 (95% CI: 0.4-7.8) for Grade 1, 2.0 (95% CI: 0.9-4.8) for Grade 2, and 2.6 (95% CI: 1.2-5.8) for Grade 3, suggesting a trend of higher infection risk in more severe meconium cases. Women with MSAF had a markedly higher risk of postpartum hemorrhage (PPH) in both unadjusted and adjusted models (cRR: 10.1; 95% CI: 4.2-23.9 and aRR: 9.8; 95% CI: 4.1-23.2). The risk increased progressively with MSAF severity, with adjusted risk ratios of 5.7 (95% CI: 1.3-25.7) for Grade 1, 10.2 (95% CI: 4.0-25.7) for Grade 2, and 11.2 (95% CI: 4.2-30.0) for Grade 3, compared to women with clear amniotic flui Adverse Fetal outcomes frequency and proportions by MSAF status and grades As illustrated in Table 5 , adverse fetal outcomes were more frequent in cases of meconium-stained amniotic fluid (MSAF), with a progressive increase across MSAF grades. NICU admissions occurred in 7.8% (20/256) of neonates with clear amniotic fluid (CAF) and rose to 20.0% (3/15) in Grade 1, 24.0% (12/50) in Grade 2, and 36.6% (15/41) in Grade 3 MSAF. Similarly, neonatal infections were reported in 10.2% (26/256) of CAF cases, increasing to 20.0% (3/15) in Grade 1, 28.0% (14/50) in Grade 2, and 34.1% (14/41) in Grade 3. Respiratory distress affected 7.8% (20/256) of neonates in CAF and increased to 6.7% (1/15) in Grade 1, 12.0% (6/50) in Grade 2, and 14.6% (6/41) in Grade 3 MSAF. Neonatal asphyxia was observed in 7.4% (19/256) of CAF cases and rose to 13.3% (2/15), 16.0% (8/50), and 17.1% (7/41) in Grades 1, 2, and 3, respectively. Meconium aspiration syndrome (MAS) was not observed in CAF but was present in 13.3% (2/15) of Grade 1, 10.0% (5/50) of Grade 2, and 19.5% (8/41) of Grade 3. Neonatal deaths, though relatively rare, were more frequent in MSAF grades, occurring in 1.2% (3/256) of CAF, 6.7% (1/15) of Grade 1, 4.0% (2/50) of Grade 2, and 7.3% (3/41) of Grade 3 (Table 5). Risk of Adverse Fetal Outcomes Associated with MSAF MSAF was associated with a significantly increased risk of NICU admission (cRR: 3.6; 95% CI: 2.2-6.1) and after adjustment (aRR: 3.8; 95% CI: 2.3-6.3). By grade, Grade 1 showed a non-significant increased risk (cRR: 2.6; 95% CI: 0.9-7.7; aRR: 2.6; 95% CI: 0.8-7.9), while Grades 2 (cRR: 3.1; 95% CI: 1.6-5.9; aRR: 3.3; 95% CI: 1.7-6.4) and 3 (cRR: 4.7; 95% CI: 2.6-8.4; aRR: 4.7; 95% CI: 2.6-8.3) had significantly increased risks, showing a dose-response pattern. MSAF showed a significant crude association with neonatal infection (cRR: 2.9; 95% CI: 1.8-4.6), but this was not significant after adjustment (aRR: 1.3; 95% CI: 0.6-2.5). Similarly, none of the MSAF grades had significant adjusted risks: Grade 1 (cRR: 1.9; 95% CI: 0.7-5.8; aRR: 0.9; 95% CI: 0.1-6.5), Grade 2 (cRR: 2.8; 95% CI: 1.6-4.9; aRR: 1.1; 95% CI: 0.5-2.6), and Grade 3 (cRR: 3.4; 95% CI: 1.9-5.9; aRR: 1.9; 95% CI: 0.7-4.7). No significant association was found for respiratory distress with overall MSAF (cRR: 1.6; 95% CI: 0.8-3.0; aRR: 1.3; 95% CI: 0.6-2.5), nor for any MSAF grade: Grade 1 (cRR: 0.9; 95% CI: 0.1-5.9; aRR: 0.9; 95% CI: 0.1-6.5), Grade 2 (cRR: 1.5; 95% CI: 0.7-3.6; aRR: 0.9; 95% CI: 0.4-2.2), Grade 3 (cRR: 1.9; 95% CI: 0.8-4.4; aRR: 1.8; 95% CI: 0.7-4.7). MSAF was significantly associated with neonatal death (cRR: 4.8; 95% CI: 1.2-19.0), but adjusted risk was not estimable due to data sperse. Grade-specific risks were significant only for Grade 3 after adjustment (cRR: 6.2; 95% CI: 1.3-30.0; aRR: 3.8; 95% CI: 1.1-12.7), while Grades 1 and 2 were not significant. MSAF was associated with significantly increased risks of neonatal asphyxia in both crude (cRR: 2.5; 95% CI: 1.2-4.0) and adjusted (aRR: 2.1; 95% CI: 1.1-4.6) analyses. For MSAF grades, Grade 1 showed no significant risk (cRR: 1.8; 95% CI: 0.5-7.0; aRR: 1.6; 95% CI: 0.4-6.4), while Grade 2 (cRR: 2.1; 95% CI: 1.0-4.7; aRR: 2.2; 95% CI: 1.1-4.6) and Grade 3 (cRR: 2.3; 95% CI: 1.0-5.1; aRR: 2.3; 95% CI: 1.0-5.0) showed statistically significant increased risk (Table 6). Discussion This study revealed that nearly one-third of women delivering at KCMC had meconium-stained amniotic fluid, highlighting a substantial burden of this condition in the population. Maternal outcomes showed that MSAF significantly increased the likelihood of cesarean delivery, postpartum hemorrhage, and puerperal infections. Fetal outcomes were similarly affected, with MSAF linked to a range of adverse events including fetal distress, neonatal intensive care admissions, respiratory complications, and lower Apgar scores, reflecting the considerable threat to newborn wellbeing associated with meconium exposure. The severity of these adverse outcomes was directly related to the grade of meconium-staining, revealing a clear dose-response relationship. Thicker grades of meconium (Grade 2 and Grade 3) were associated with increased higher risks of cesarean section, puerperal sepsis, fetal heart rate abnormalities, neonatal infections, respiratory distress, and neonatal asphyxia compared to thinner or Grade 1 meconium. T he incidence of meconium-stained amniotic fluid The current study identified meconium-stained amniotic fluid (MSAF) as a common occurrence at KCMC, affecting nearly one-third of deliveries, with moderate and thick grades predominating. This finding is consistent with reports from other sub-Saharan African hospitals, such as Korle Bu Teaching Hospital in Ghana and Bugando Medical Centre in Tanzania, where prevalence ranges around one-fifth of deliveries (13,14). Similar proportion rates and the predominance of thick meconium have also been reported in Cameroon, underscoring that MSAF remains a significant intrapartum concern in resource-limited settings (15). These patterns emphasize the urgent need for strengthening intrapartum monitoring and timely clinical interventions to prevent adverse neonatal outcomes such as aspiration syndrome and birth asphyxia. However, the observed proportion exceeds figures reported in some other low- and middle-income countries, such as Iran, where a lower prevalence (approximately 12%) of MSAF was found (16). This discrepancy may reflect differences in healthcare infrastructure, antenatal care quality, and referral system effectiveness. Inadequate fetal surveillance, delayed identification of fetal distress, and late referrals are challenges frequently reported in similar settings and likely contribute to higher rates and severity of MSAF. Variations in clinical guidelines, provider training, and resource availability may also influence detection and management, resulting in divergent outcomes. T he maternal outcomes associated with different grades of meconium-stained amniotic fluid In this study, identified a significantly increased risk of cesarean delivery associated meconium-stained amniotic fluid (MSAF), with the severity of these outcomes increasing alongside the grade of meconium staining. Women presenting with moderate to thick meconium (Grades 2 and 3) experienced significantly higher risks of cesarean section. This finding is consistent with previous literature, which indicates that thick meconium often prompts clinical decisions favoring operative delivery to reduce potential neonatal complications such as meconium aspiration syndrome. For instance, (4) reported higher cesarean section rates among women presenting with grade III MSAF in a tertiary hospital in China. Similarly,(11) found operative deliveries to be markedly more common in the presence of MSAF, with women experiencing nearly fivefold increased risk compared to those with clear amniotic fluid. These trends likely reflect a clinical response to perceived fetal distress, emphasizing the role of cesarean section as a critical intervention to improve perinatal outcomes in the context of MSAF. Moreover, this study revealed a significant association between MSAF and puerperal sepsis, particularly with higher grades of meconium staining. The correlation between thicker meconium and increased postpartum infection rates may be attributed to prolonged rupture of membranes and labor complications commonly observed in MSAF cases, which enhance susceptibility to ascending infections. Supporting this, (11) documented a markedly increased risk of puerperal sepsis among Ethiopian women with MSAF, with nearly one-fifth of affected mothers developing sepsis compared to significantly lower rates in women with clear amniotic fluid. Additionally, (17) reported an increased risk of postoperative surgical site infections following cesarean deliveries complicated by MSAF, further highlighting the infectious morbidity associated with this condition. This study found that women with meconium-stained amniotic fluid (MSAF) were at markedly increased risk of postpartum hemorrhage (PPH), with the risk rising progressively across meconium grades. This dose-response pattern suggests that thicker meconium may reflect underlying obstetric complications such as prolonged labor, intrauterine inflammation, or uterine atony that predispose to PPH. Our findings align with(18) who reported higher rates of severe and massive PPH among women with MSAF, attributing this to prolonged labor and increased operative deliveries (18). Similarly, (19) observed a higher PPH proportion in MSAF cases, though they found no difference for severe PPH, highlighting possible variations in obstetric practices and case severity. Unlike these studies, our analysis differentiated MSAF grades, revealing a stronger association with higher grades, underscoring the clinical importance of grading in risk stratification. The fetal outcomes associated with different grades of meconium-stained amniotic fluid This study identified a strong association between higher grades of meconium-stained amniotic fluid (MSAF) and increased proportion of fetal heart rate abnormalities, consistent with evidence from other settings.(3) similarly reported that moderate and thick meconium (grades 2 and 3) were independently linked to increased fetal distress markers, including abnormal heart rate patterns, which often necessitate prompt obstetric intervention. These findings underline the critical need for continuous and rigorous fetal monitoring during labor when MSAF is detected, to enable timely decision-making and potentially reduce adverse perinatal outcomes. However, unlike some studies that reported universal fetal heart rate monitoring standards, resource constraints in many low-resource settings may limit optimal surveillance, indicating a clear area for health systems strengthening and operational research. Respiratory complications, particularly meconium aspiration syndrome (MAS), were markedly more common in cases with thick meconium. This aligns with (20) who reported high NICU admission rates due to respiratory distress in neonates exposed to thick MSAF. The Italian study by (3)also found a dose-response relationship, with grades 2 and 3 MSAF significantly increasing risks of MAS, transient tachypnea, and acute respiratory distress syndrome. Conversely, some regional studies have shown variability in respiratory complication rates, possibly due to differences in neonatal care availability and early intervention protocols. Clinically, these findings emphasize the necessity of preparing neonatal resuscitation teams and ensuring access to respiratory support facilities, especially in tertiary centers managing high-risk deliveries. Neonatal infection risk was similarly increased with increased MSAF severity in this study, reflecting a pattern also documented in prior research (3). Thick meconium can serve as a medium for bacterial growth, predisposing neonates to sepsis. While our findings correspond with those from higher-income settings, some low-resource environments report under diagnosis or underreporting of neonatal infections due to limited diagnostic capacity. This disparity highlights a critical research gap and the need for improved infection screening and management protocols for neonates born through MSAF-complicated labor, alongside strengthening microbiological laboratory capacity. It was also found that, a higher proportion of neonatal asphyxia among infants exposed to moderate and thick meconium, reflected in lower Apgar scores and increased need for resuscitation. Similar observations were made in studies from Ethiopia and Nigeria (21,22), reinforcing the prognostic significance of meconium thickness for neonatal outcomes. However, the degree of resuscitation and NICU admission varied across studies, likely influenced by differences in clinical practice guidelines and resource availability. These findings support prioritizing training in neonatal resuscitation and enhancing NICU capacity to mitigate the consequences of birth asphyxia linked to MSAF Conclusion This study demonstrates that meconium-stained amniotic fluid, particularly moderate and thick grades, is significantly associated with adverse maternal and neonatal outcomes, including increased cesarean section rates, puerperal sepsis, low Apgar scores, respiratory distress, and neonatal intensive care admissions.These insights underscore the critical need for evidence-based clinical guidelines, improved intrapartum monitoring, and strengthened referral systems to optimize outcomes in resource-limited settings. Recommendations Based on the study findings, the following recommendations are proposed to improve the management of meconium-stained amniotic fluid (MSAF) and related maternal and neonatal outcomes. There is a need need to develop and implement standardized, evidence-based protocols for the management of MSAF, with particular emphasis on risk stratification according to meconium grade. Strengthening intrapartum monitoring systems is critical and should include ensuring access to reliable fetal heart rate monitoring technologies, such as cardiotocography and handheld Dopplers. Furthermore, fostering inter-professional collaboration through structured communication tools, joint decision-making checklists, and regular multidisciplinary team training could enhance consistency and timeliness in clinical responses. Interventional studies are needed to evaluate strategies aimed at reducing unnecessary operative deliveries while maintaining neonatal safety. Policy initiatives should also integrate antenatal education on MSAF into routine maternal health services, equipping expectant mothers with accurate information to alleviate fear, promote informed decision-making, and encourage timely care-seeking behavior. Declarations Consent for publication Not applicable. Source of funding None Conflict of Interest Declaration The authors have no conflicts of interest to declare. Human Ethics and Consent to Participate declarations Not aplicable Data Availability The datasets generated and analyzed during the current study are not publicly available due to patient privacy considerations but are availablefrom the corresponding author ( [email protected] ) on reasonable request. Contributorship Statement Dr. Subilaga led the conception of the study, developed the study design, coordinated data collection, conducted the primary data analysis, and drafted the initial manuscript. Dr. Bariki Mchome provided overall supervision of the study, offered methodological guidance, and critically reviewed the manuscript for important intellectual content. Kelvin Musa, Elizabeth Msoka, Raziya Gaffur, Pendo Mlay, Glory Mangi, Caroline Wanjara, Rachel Pesha, and Fortunatha Nzota contributed to data collection, data verification, and manuscript review. Prof. Joseph Mlay and Prof. Olola Oneko provided expert oversight, contributed to study interpretation, and reviewed the manuscript for scientific accuracy and clarity. All authors read and approved the final manuscript. References Gallo DM, Romero R, Bosco M, Gotsch F, Jaiman S, Jung E, et al. Meconium-stained amniotic fluid. Vol. 228, American Journal of Obstetrics and Gynecology. Elsevier Inc.; 2023. p. S1158–78. Sayad E, Silva-Carmona M. Meconium Aspiration. Neonatal Emergencies: A Practical Guide for Resuscitation, Transport and Critical Care of Newborn Infants. 2023 Apr;269–79. Dani C, Ciarcià M, Barone V, Di Tommaso M, Mecacci F, Pasquini L, et al. Neonatal Outcomes of Term Infants Born with Meconium-Stained Amniotic Fluid. Children. 2023 May 1;10(5). Zhu X, Huang S, Tang Y, Wu Z, Sun Y, Ren H, et al. Once We Find Grade III Meconium Stained Amniotic Fluid, Must We Act as Early as Possible? Int J Womens Health. 2023;15:7–23. Abate E, Alamirew K, Admassu E, Derbie A. Prevalence and Factors Associated with Meconium-Stained Amniotic Fluid in a Tertiary Hospital, Northwest Ethiopia: A Cross-Sectional Study. Obstet Gynecol Int. 2021;2021. David AN, Njokanma OF, Iroha E. Incidence of and factors associated with meconium staining of the amniotic fluid in a Nigerian University Teaching Hospital. J Obstet Gynaecol (Lahore). 2006 Aug;26(6):518–20. Ahanya SN, Lakshmanan J, Morgan BLG, Ross MG. Meconium passage in utero: Mechanisms, consequences, and management. Obstet Gynecol Surv. 2005 Jan;60(1):45–56. Olicker AL, Raffay TM, Ryan RM. Neonatal Respiratory Distress Secondary to Meconium Aspiration Syndrome. Children. 2021 Mar;8(3):246. Msisiri LS, Kibusi SM, Kimaro FD. Risk Factors for Birth Asphyxia in Hospital-Delivered Newborns in Dodoma, Tanzania: A Case-Control Study. SAGE Open Nurs. 2024 Jan 1;10. Sabra S Masoud, Matilda Ngarina, Furaha August, Kamilya A Omar BT, Olirk. USE OF TRADITIONAL MEDICINE DURING LABOR AND ITS ASSOSCIATION WITH PREGNANCY OUTCOMES AMONG WOMEN DELIVERING AT MNAZI MMOJA HOSPITAL, ZANZIBAR. 2023; Addisu D, Mekie M. Adverse Maternal and Perinatal Outcomes of Meconium-Stained Amniotic Fluid in Term Labor at Hospitals in South Gondar Zone, Northwest Ethiopia: A Prospective Cohort Study. Biomed Res Int. 2023;2023(1). Dohbit JS, Mah EM, Essiben F, Nzene EM, Meka EUN, Foumane P, et al. Maternal and Fetal Outcomes Following Labour at Term in Singleton Pregnancies with Meconium-Stained Amniotic Fluid: A Prospective Cohort Study. Open Journal of Obstetrics and Gynecology. 2018;08(09):790–802. Amoah E, Asah-Opoku K, Osman K. The Global Health Network Collections • The Global Health Network Conference Proceedings 2022 Incidence of meconium stained amniotic uid among deliveries at the Korle Bu Teaching Hospital. The Global Health Network License: Creative Commons Attribution 4. 2022. Kamuli S, Kaiza I, Kihunrwa A, Chibwe E, Mabega N. Prevalence of Meconium Stained Amniotic Fluid and Predictors for Poor Fetal Outcomes Among Women Delivering at Bugando Medical Centre Mwanza Tanzania. European Journal of Preventive Medicine. 2024;12(4):94–102. Mesumbe EN, Nana PN, Nouetchognou JS, Sama J, Mah E, Eko FE, et al. Perinatal Outcome in Term Pregnancies with Meconium Stained Amniotic Fluid in Two Referral Hospitals of Yaoundé- Cameroon. Biomed J Sci Tech Res. 2018;2(2):2533–7. Shekari M, Jahromi MS, Ranjbar A, Mehrnoush V, Darsareh F, Roozbeh N. The incidence and risk factors of meconium amniotic fluid in singleton pregnancies: an experience of a tertiary hospital in Iran. BMC Pregnancy Childbirth. 2022 Dec 1;22(1). Ma’ayeh M, Snyder A, Oliver EA, Gee SE, Rood KM. Meconium-stained amniotic fluid and the risk of postcesarean surgical site infection. Journal of Maternal-Fetal and Neonatal Medicine. 2021;34(9):1361–7. Bouchè C, Wiesenfeld U, Ronfani L, Simeone R, Bogatti P, Skerk K, et al. Meconium-stained amniotic fluid: A risk factor for postpartum hemorrhage. Ther Clin Risk Manag. 2018;14:1671–5. Fang ZJ, Liu HF, Zhang YL, Yu L, Yan JY. Relation of meconium-stained amniotic fluid and postpartum hemorrhage: a retrospective cohort study. Eur Rev Med Pharmacol Sci. 2020;24(20):10352–8. Subramani U, Akshay Patil D, Kumar P. A Prospective Study on Perinatal Outcome in Meconium Stained Amniotic Fluid. Int J Life Sci Biotechnol Pharma Res. 2023;12(1):649. Amenu Sori D, Belete A. Meconium Stained Amniotic Fluid: Factors affecting Maternal and Perinatal Outcomes at Jimma University Specialized Teaching Hospital, South West Ethiopia. Gynecology & Obstetrics. 2016;6(8). Laima DrCH, Yayaha DrUR, El-Nafaty AU. Meconium stained amniotic fluid in labour: A comparative study of maternal and foetal outcomes in a tertiary hospital, north-east Nigeria. International Journal of Clinical Obstetrics and Gynaecology. 2020 Mar 1;4(2):140–3. Tables Table 1 to 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files TablesDrsubiraga.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 19 Jan, 2026 Reviewers invited by journal 08 Jan, 2026 Editor invited by journal 18 Dec, 2025 Editor assigned by journal 17 Dec, 2025 Submission checks completed at journal 17 Dec, 2025 First submitted to journal 16 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":26854,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1Subiraga1.png","url":"https://assets-eu.researchsquare.com/files/rs-8379542/v1/97875e572f607e3a73db2437.png"},{"id":100126696,"identity":"39a06dd1-1deb-4c48-9633-73e9b6423044","added_by":"auto","created_at":"2026-01-13 09:25:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46950,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1Subiraga2.png","url":"https://assets-eu.researchsquare.com/files/rs-8379542/v1/30c7dd42a450e4cfc10ccc0e.png"},{"id":100405656,"identity":"4d1abf81-f10d-446f-a6ed-50fbceec3390","added_by":"auto","created_at":"2026-01-16 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Study","fulltext":[{"header":"Background","content":"\u003cp\u003eMeconium-stained amniotic fluid (MSAF) it is characterized by the presence of the meconium (first stool) in the amniotic fluid (1,2). Its remain the major obstetrics concern due its association with adverse fetal and martenal outcome. The presence of meconium-stained amniotic fluid (MSAF) can arise from the normal physiological maturation and activity of the fetal digestive system, but it may also indicate that the fetus is experiencing hypoxic stress.(3)\u003c/p\u003e \u003cp\u003eGlobally about 8\u0026ndash;38% of all pregnancies experience MSAF with the highee reported in Low and Middle Income Countries (LMICs). Meconium is usually expelled within the first 24 to 48 hours following birth(1,4) .However, it can also be passed during labor due several factors such as obstructed labor, advanced maternal age, smoking, oligohydramnios, anemia, prolonged labor, the use of uterotonic agents, and hypertensive disorders during pregnancy(5\u0026ndash;7). In lower resource setting it usually considered as a sign of fetal distress(8).\u003c/p\u003e \u003cp\u003eThe risk and severity of complications are influenced by several factors, including the thickness or grade of meconium, the duration of labor, and the timeliness of obstetric management (9). Despite its clinical relevance, there remains a lack of consensus and standardized protocols on the optimal management of MSAF, particularly in resource-limited settings.\u003c/p\u003e \u003cp\u003eIn Tanzania, MSAF continues to be an important contributor to maternal and perinatal morbidity and mortality (10). However, local data on the burden and outcomes of MSAF are scarce, and evidence-based guidance for clinical decision-making remains limited. Kilimanjaro Christian Medical Centre (KCMC) Teaching Zonal Referral Hospital, a major tertiary and teaching institution in northern Tanzania, manages a high volume of deliveries, offering an ideal setting to explore the clinical implications of MSAF.\u003c/p\u003e \u003cp\u003eThis study aims to determine the maternal and fetal outcomes associated with meconium-stained amniotic fluid among laboring women at KCMC Teaching Zonal Referral Hospital. Findings from this study will provide valuable insights into the relationship between MSAF severity and clinical outcomes, inform local practice guidelines, and contribute to efforts to reduce preventable maternal and neonatal complications in similar low-resource settings.\u003c/p\u003e"},{"header":"Methodology","content":"\u003ch2\u003eStudy Design and Setting:\u003c/h2\u003e\n\u003cp\u003eA prospective cohort study was conducted over a six-month period, from September 2024 to February 2025, to determine the proportion and pregnancy outcomes associated with meconium-stained amniotic fluid (MSAF) among women delivering at Kilimanjaro Christian Medical Centre (KCMC), a tertiary referral hospital located in Moshi, Northern Tanzania. KCMC serves as a zonal referral center for over 15 million people across Northern Tanzania and provides advanced obstetric and neonatal care.\u0026nbsp;The Department of Obstetrics and Gynecology , where the study was based, includes a busy labor ward managing both routine and high-risk deliveries.\u0026nbsp;The prospective cohort design allowed for the establishment of a temporal relationship between MSAF exposure (at any grade) and pregnancy outcomes, as well as direct measurement of the incidence of specific pregnancy outcomes associated with MSAF exposure.\u003c/p\u003e\n\u003ch2 id=\"_Toc202916953\"\u003eStudy population\u003c/h2\u003e\n\u003cp\u003eThe study included all term pregnant women admitted for delivery at KCMC during the study period. Eligible participants were women with a gestational age of \u0026ge;37 weeks, singleton pregnancies, cephalic presentation, and ruptured fetal membranes who were diagnosed with meconium-stained amniotic fluid (MSAF) during labor or delivery. Women with multiple gestations, preterm deliveries (\u0026lt;37 weeks), known congenital fetal malformations, or those who declined to participate were excluded from the study.\u003c/p\u003e\n\u003ch2 id=\"_Toc202916959\"\u003eSample size\u0026nbsp;and sampling technique\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe sample size was determined using the two-proportion Z-test formula, based on the difference in the rate of meconium aspiration syndrome (MAS) among fetuses with meconium-stained liquor versus those with clear amniotic fluid, reported as 7.58% and 0.68%, respectively (11). The formula used was:\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img1768228017.png\" style=\"width: 310px;\"\u003e\u003c/p\u003e\n\u003cp\u003eWhere:\u003cbr\u003e\u003cimg width=\"84\" height=\"22\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img1768227967.png\" alt=\"image\"\u003e, \u003cimg width=\"84\" height=\"22\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img176822796732.png\" alt=\"image\"\u003e, \u003cimg width=\"84\" height=\"22\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img176822796716.png\" alt=\"image\"\u003e, \u003cimg width=\"83\" height=\"22\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img176822796782.png\" alt=\"image\"\u003e, \u003cimg width=\"95\" height=\"24\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img176822796718.png\" alt=\"image\"\u003e, and \u003cimg width=\"83\" height=\"24\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img176822796754.png\" alt=\"image\"\u003e.\u0026nbsp;Using a significance level (\u0026alpha;) of 0.05 and a power (1\u0026ndash;\u0026beta;) of 80%, the calculated sample size was 362 pregnant women, accounting for possible non-response. This total comprised women diagnosed with MSAF (exposed group) and those with clear amniotic fluid (comparison group).\u003c/p\u003e\n\u003cp\u003eA consecutive sampling technique was employed. All eligible pregnant women presenting to the labor ward at KCMC during the study period (September 2024 to February 2025) were recruited prospectively until the desired sample size of 362 was attained. Eligibility was assessed using the study inclusion and exclusion criteria, ensuring that all term singleton pregnancies with ruptured membranes were considered. This approach minimized selection bias by including every eligible participant in sequence..\u003c/p\u003e\n\u003ch3 id=\"_Toc202916971\"\u003eStudy Variables and key Concepts\u003c/h3\u003e\n\u003cp\u003eVariables of interest were adopted and modified from previous study (12).\u0026nbsp; \u0026nbsp;and included participants\u0026rsquo; socio-demographic characteristics, maternal outcomes, and fetal or neonatal outcomes. The primary exposure variable was meconium-stained amniotic fluid (MSAF), diagnosed visually during labor or delivery. MSAF was graded according to its color and consistency into three categories: Grade 1 (light or thin meconium), Grade 2 (moderate meconium), and Grade 3 (thick or heavy meconium). For analytical purposes, MSAF was defined both as a binary variable, indicating its presence or absence, and as an ordinal variable reflecting its severity by grade.\u003c/p\u003e\n\u003cp\u003eMaternal outcomes included postpartum hemorrhage (PPH), puerperal sepsis, and mode of delivery. Postpartum hemorrhage was defined as an estimated blood loss of \u0026ge;500 mL after vaginal delivery or \u0026ge;1000 mL after cesarean section, or any bleeding that resulted in a \u0026ge;10% reduction in hemoglobin, required blood transfusion, or caused hemodynamic instability necessitating uterotonics or surgical intervention. Puerperal sepsis was defined in accordance with the World Health Organization (WHO) criteria and required the presence of clinical signs of genital tract infection such as fever (\u0026ge;38\u0026deg;C), uterine tenderness, and foul-smelling lochia, along with systemic manifestations such as tachycardia or organ dysfunction, after exclusion of other potential infection sources such as urinary or respiratory tract infections. Mode of delivery was categorized as spontaneous vaginal delivery (SVD), instrumental vaginal delivery, or cesarean section (CS). Spontaneous vaginal delivery referred to natural childbirth without surgical or instrumental assistance, whereas instrumental vaginal delivery involved the use of tools such as vacuum extractors or forceps due to indications like fetal distress, prolonged second stage of labor, or maternal exhaustion. Cesarean section referred to the surgical extraction of the fetus through abdominal and uterine incisions and was further classified as elective when planned before labor or emergency when performed in response to intrapartum complications such as fetal distress or cephalopelvic disproportion. All information on delivery mode was extracted from labor ward records and operative notes to ensure accuracy.\u003c/p\u003e\n\u003cp\u003eFetal and neonatal outcomes included neonatal intensive care unit (NICU) admission, neonatal sepsis, respiratory distress, meconium aspiration syndrome (MAS), birth asphyxia, and neonatal death. Neonatal sepsis was defined based on WHO criteria, requiring at least two clinical signs such as fever (\u0026ge;38\u0026deg;C), hypothermia (\u0026le;36\u0026deg;C), poor feeding, lethargy, respiratory difficulty, or convulsions, accompanied by at least one abnormal laboratory finding such as elevated C-reactive protein (CRP), abnormal white blood cell count (WBC \u0026gt;20,000/mm\u0026sup3; or \u0026lt;5,000/mm\u0026sup3;), or positive blood culture. Birth asphyxia was identified following WHO and American Academy of Pediatrics definitions as failure to establish effective breathing at birth, indicated by an Apgar score below 7 at one or five minutes and requiring resuscitation beyond tactile stimulation, such as bag-mask ventilation or chest compressions.\u003c/p\u003e\n\u003cp\u003eFetal heart rate (FHR) anomalies were assessed during labor through cardiotocography (CTG) or intermittent auscultation using a fetoscope or Doppler device. Anomalies were classified as tachycardia (FHR \u0026gt;160 bpm for more than 10 minutes), bradycardia (FHR \u0026lt;110 bpm for more than 10 minutes), or decelerations, which were further categorized as early (Type I), variable (Type II), or late (Type III) based on timing and morphology. Neonatal respiratory distress was defined by the presence of at least two clinical signs\u0026mdash;tachypnea (respiratory rate \u0026gt;60 breaths per minute), grunting, nasal flaring, chest retractions, or central cyanosis\u0026mdash;occurring within the first 24 hours of life. The severity was categorized as mild when observation alone was sufficient or moderate to severe when oxygen therapy or NICU admission was required. Diagnoses were confirmed through neonatal clinical assessments and documented in medical charts and nursing notes.\u003c/p\u003e\n\u003cp\u003eMeconium aspiration syndrome (MAS) was diagnosed clinically in neonates born through meconium-stained amniotic fluid who developed respiratory distress within the first few hours of life, especially those requiring resuscitation at birth. Diagnostic features included respiratory distress characterized by tachypnea, grunting, nasal flaring, retractions, and cyanosis; the presence of meconium below the vocal cords on suctioning; and chest radiographic findings typical of MAS. The diagnosis was distinguished from other causes of neonatal respiratory distress based on its association with MSAF and the early onset of symptoms. Neonatal admission was defined as any transfer of a newborn to the neonatal unit for observation, monitoring, or treatment within the first 28 days of life. Common indications for admission included respiratory distress, birth asphyxia, neonatal sepsis, MAS, prematurity, or low birth weight. Admission details such as timing, duration of stay, and clinical indications were obtained from NICU registers and medical records.\u003c/p\u003e\n\u003cp\u003eSociodemographic and obstetric characteristics, including maternal age, parity, gravidity, gestational age at delivery, timing of membrane rupture, presence of fetal heart rate anomalies, and medical comorbidities, were considered potential confounding variables and were included as independent variables in the analysis\u003c/p\u003e\n\u003ch2 id=\"_Toc202916974\"\u003eData management and analysis plan\u003c/h2\u003e\n\u003cp\u003eData were carefully checked for completeness and consistency throughout the data collection period. Double data entry was performed using EpiData to minimize entry errors. The cleaned dataset was exported to Stata version 18 for analysis. Descriptive statistics such as frequencies, percentages, means, and standard deviations summarized sociodemographic and clinical characteristics as well as maternal and fetal outcomes.\u003c/p\u003e\n\u003cp\u003eThe proportion of meconium-stained amniotic fluid (MSAF) was calculated as the proportion of all deliveries during the study period. Bivariate analyses used chi-square or Fisher\u0026rsquo;s exact tests to examine associations between MSAF and selected outcomes.\u003c/p\u003e\n\u003cp\u003eTo assess the risk of adverse maternal outcomes associated with MSAF, Poisson regression models with robust standard errors were applied to estimate crude and adjusted risk ratios (cRR and aRR). Covariates including maternal age, parity, gestational age at delivery, and hypertensive disorders were included in adjusted models to control for confounding. Model diagnostics showed no evidence of poor fit or over dispersion, confirming the suitability of the Poisson regression approach. Statistical significance was set at p \u0026lt; 0.05 or 95%CI for risk ratios (RR) that does not contain null value 1.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003cbr\u003e Ethical approval for this study was obtained from the Institutional Review Board (IRB) of KCMU College (Reference No. NO.PG 159/2024). Permission to conduct the study was also granted by the Kilimanjaro Christian Medical Centre (KCMC) hospital administration. Written informed consent was obtained from all individual participants included in the study prior to any study-related procedures.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eParticipants Enrollment Flowchart\u003c/h2\u003e\n\u003cp\u003eA total of 655 term pregnant women were admitted to the labor ward for delivery during the study period. Of these, 293 women were excluded due to [(breech presentation, fresh or macerated stillbirth, antepartum hemorrhage, congenital malformations, prolonged rupture of membranes \u0026gt;18 hours and chorioamnionitis). The remaining 362 women were recruited for the study, all of whom were included in the final analysis (Figure 1).\u003c/p\u003e\n\u003ch2 id=\"_Toc202916980\"\u003eSocio-demographic characteristics of the participants\u003c/h2\u003e\n\u003cp\u003eAmong 362 participants, majority were aged 26-35 years (n=210, 58.0%) with 60 (28.6%) experiencing MSAF. The majority were married/cohabiting (n=339, 93.6%) where 97 (28.6%) had MSAF, while single participants (n=23, 6.4%) had a higher proportion (n=9, 39.1%). Most participants had college/university education (n=289, 79.8%) with 85 (29.4%) having MSAF. Urban residents comprised 91.2% (n=330) with 91 (27.6%) experiencing MSAF, while rural residents (n=32, 8.8%) had a notably higher proportion (n=15, 46.9%), (Table 1).\u003c/p\u003e\n\u003ch2 id=\"_Toc202916981\"\u003eClinical and Obstetric Characteristics by Meconium-Stained Amniotic Fluid\u003c/h2\u003e\n\u003cp\u003eAmong the 362 participants, primigravida women constituted 128 (35.4%) with 41 (32.0%) experiencing MSAF, while multigravida and grand multigravida women accounted for 78 (21.6%) and 156 (43.1%), with MSAF rates of 27 (34.6%) and 38 (24.4%), respectively. Regarding parity, most were primipara 219 (60.5%), with 70 (32.0%) affected by MSAF. Notably, half of those with membrane rupture before labor had MSAF 35 (50.7%) compared to 71 (24.2%) during labor. Fetal heart rate anomalies were present in 53 (14.6%) of participants, with a markedly higher MSAF prevalence 31 (58.5%) compared to those without anomalies 75 (24.3%). Hypertension disorders and history of postpartum hemorrhage were less common 35 (9.7%) and 25 (6.9%), respectively, and showed comparable MSAF proportions 9 (25.7%) and 8 (32.0%). Diabetes mellitus was rare 4 (1.1%) but showed a 50% (2) MSAF occurrence, (Table 2).\u003c/p\u003e\n\u003ch2 id=\"_Toc202916982\"\u003eIncidence of Meconium-Stained Amniotic Fluid and its grades\u003c/h2\u003e\n\u003cp\u003eThe overall incidence of meconium-stained amniotic fluid (MSAF) was 29.3% (n=106, 95% CI: 24.6-34.3)\u0026nbsp;among the 362 women studied. Of these, Grade 2 MSAF was the most frequent, observed in 47.2% (n=50) of cases, followed by Grade 3 MSAF in 38.7% (n=41), and Grade 1 MSAF in 14.2% (n=15). Clear amniotic fluid (CAF) was noted in 70.7% (n=256) of participants, (Figure 2).\u003c/p\u003e\n\u003ch3 id=\"_Toc202916984\"\u003eMaternal outcomes frequency and proportions by MSAF status and grades\u003c/h3\u003e\n\u003cp\u003eAs presented in Table 3, women with meconium-stained amniotic fluid (MSAF) experienced substantially higher rates of adverse maternal outcomes compared to those with clear amniotic fluid (CAF). The overall cesarean section (CS) rate was markedly increased in the MSAF group (42.5%, n=45) relative to CAF (7.0%, n=18). This trend intensified with increasing MSAF severity, rising from 26.7% (n=4) in Grade 1 to 38.0% (n=19) in Grade 2 and peaking at 53.7% (n=22) in Grade 3. Similarly, the proportion of puerperal sepsis was higher among women with MSAF (15.1%, n=16) than CAF (6.6%, n=17), with a slight increase across MSAF grades (Grade 1: 13.3%, Grade 2: 14.0%, Grade 3: 17.1%). Notably, postpartum hemorrhage (PPH) occurred nearly ten times more often in women with MSAF (23.6%, n=25) than in those with CAF (2.3%, n=6), with increasing proportions observed across Grades 1 (13.3%), 2 (26.0%), and 3 (24.4%).\u003c/p\u003e\n\u003ch2 id=\"_Toc202916985\"\u003eRisk of Adverse Maternal Outcomes Associated with MSAF\u003c/h2\u003e\n\u003cp\u003eAs it is shown in Table 4, MSAF has been observed increased risk of several adverse maternal outcomes associated with MSAF. Women with MSAF had a significantly higher risk of cesarean section (CS) delivery compared to those with clear amniotic fluid (CAF), with nearly a six-fold increase observed in both unadjusted (cRR: 6.0; 95% CI: 3.7-9.9) and adjusted models (aRR: 6.3; 95% CI: 3.9-10.1). The risk of CS delivery increased progressively with MSAF severity, showing adjusted risk ratios of 3.2 (95% CI: 1.5-6.8) for Grade 1, 5.7 (95% CI: 3.3-9.9) for Grade 2, and 9.1 (95% CI: 5.2-16.0) for Grade 3, indicating a clear dose-response relationship between MSAF grade and the likelihood of operative delivery.\u003c/p\u003e\n\u003cp\u003eWomen with MSAF were also at greater risk of developing puerperal sepsis, with unadjusted (cRR: 2.3; 95% CI: 1.2-4.3) and adjusted analyses (aRR: 2.2; 95% CI: 1.2-4.3) confirming a strong association. The risk increased with MSAF severity, with adjusted risk ratios of 1.8 (95% CI: 0.4-7.8) for Grade 1, 2.0 (95% CI: 0.9-4.8) for Grade 2, and 2.6 (95% CI: 1.2-5.8) for Grade 3, suggesting a trend of higher infection risk in more severe meconium cases.\u003c/p\u003e\n\u003cp\u003eWomen with MSAF had a markedly higher risk of postpartum hemorrhage (PPH) in both unadjusted and adjusted models (cRR: 10.1; 95% CI: 4.2-23.9 and aRR: 9.8; 95% CI: 4.1-23.2). The risk increased progressively with MSAF severity, with adjusted risk ratios of 5.7 (95% CI: 1.3-25.7) for Grade 1, 10.2 (95% CI: 4.0-25.7) for Grade 2, and 11.2 (95% CI: 4.2-30.0) for Grade 3, compared to women with clear amniotic flui\u003c/p\u003e\n\u003ch3 id=\"_Toc202916987\"\u003eAdverse Fetal outcomes frequency and proportions by MSAF status and grades\u003c/h3\u003e\n\u003cp\u003eAs illustrated in Table 5 , adverse fetal outcomes were more frequent in cases of meconium-stained amniotic fluid (MSAF), with a progressive increase across MSAF grades. NICU admissions occurred in 7.8% (20/256) of neonates with clear amniotic fluid (CAF) and rose to 20.0% (3/15) in Grade 1, 24.0% (12/50) in Grade 2, and 36.6% (15/41) in Grade 3 MSAF. Similarly, neonatal infections were reported in 10.2% (26/256) of CAF cases, increasing to 20.0% (3/15) in Grade 1, 28.0% (14/50) in Grade 2, and 34.1% (14/41) in Grade 3. Respiratory distress affected 7.8% (20/256) of neonates in CAF and increased to 6.7% (1/15) in Grade 1, 12.0% (6/50) in Grade 2, and 14.6% (6/41) in Grade 3 MSAF. Neonatal asphyxia was observed in 7.4% (19/256) of CAF cases and rose to 13.3% (2/15), 16.0% (8/50), and 17.1% (7/41) in Grades 1, 2, and 3, respectively. Meconium aspiration syndrome (MAS) was not observed in CAF but was present in 13.3% (2/15) of Grade 1, 10.0% (5/50) of Grade 2, and 19.5% (8/41) of Grade 3. Neonatal deaths, though relatively rare, were more frequent in MSAF grades, occurring in 1.2% (3/256) of CAF, 6.7% (1/15) of Grade 1, 4.0% (2/50) of Grade 2, and 7.3% (3/41) of Grade 3 (Table 5).\u003c/p\u003e\n\u003ch3 id=\"_Toc202916988\"\u003eRisk of Adverse Fetal Outcomes Associated with MSAF\u003c/h3\u003e\n\u003cp\u003eMSAF was associated with a significantly increased risk of NICU admission (cRR: 3.6; 95% CI: 2.2-6.1) and after adjustment (aRR: 3.8; 95% CI: 2.3-6.3). By grade, Grade 1 showed a non-significant increased risk (cRR: 2.6; 95% CI: 0.9-7.7; aRR: 2.6; 95% CI: 0.8-7.9), while Grades 2 (cRR: 3.1; 95% CI: 1.6-5.9; aRR: 3.3; 95% CI: 1.7-6.4) and 3 (cRR: 4.7; 95% CI: 2.6-8.4; aRR: 4.7; 95% CI: 2.6-8.3) had significantly increased risks, showing a dose-response pattern.\u003c/p\u003e\n\u003cp\u003eMSAF showed a significant crude association with neonatal infection (cRR: 2.9; 95% CI: 1.8-4.6), but this was not significant after adjustment (aRR: 1.3; 95% CI: 0.6-2.5). Similarly, none of the MSAF grades had significant adjusted risks: Grade 1 (cRR: 1.9; 95% CI: 0.7-5.8; aRR: 0.9; 95% CI: 0.1-6.5), Grade 2 (cRR: 2.8; 95% CI: 1.6-4.9; aRR: 1.1; 95% CI: 0.5-2.6), and Grade 3 (cRR: 3.4; 95% CI: 1.9-5.9; aRR: 1.9; 95% CI: 0.7-4.7).\u003c/p\u003e\n\u003cp\u003eNo significant association was found for respiratory distress with overall MSAF (cRR: 1.6; 95% CI: 0.8-3.0; aRR: 1.3; 95% CI: 0.6-2.5), nor for any MSAF grade: Grade 1 (cRR: 0.9; 95% CI: 0.1-5.9; aRR: 0.9; 95% CI: 0.1-6.5), Grade 2 (cRR: 1.5; 95% CI: 0.7-3.6; aRR: 0.9; 95% CI: 0.4-2.2), Grade 3 (cRR: 1.9; 95% CI: 0.8-4.4; aRR: 1.8; 95% CI: 0.7-4.7).\u003c/p\u003e\n\u003cp\u003eMSAF was significantly associated with neonatal death (cRR: 4.8; 95% CI: 1.2-19.0), but adjusted risk was not estimable due to data sperse. Grade-specific risks were significant only for Grade 3 after adjustment (cRR: 6.2; 95% CI: 1.3-30.0; aRR: 3.8; 95% CI: 1.1-12.7), while Grades 1 and 2 were not significant.\u003c/p\u003e\n\u003cp\u003eMSAF was associated with significantly increased risks of neonatal asphyxia in both crude (cRR: 2.5; 95% CI: 1.2-4.0) and adjusted (aRR: 2.1; 95% CI: 1.1-4.6) analyses. For MSAF grades, Grade 1 showed no significant risk (cRR: 1.8; 95% CI: 0.5-7.0; aRR: 1.6; 95% CI: 0.4-6.4), while Grade 2 (cRR: 2.1; 95% CI: 1.0-4.7; aRR: 2.2; 95% CI: 1.1-4.6) and Grade 3 (cRR: 2.3; 95% CI: 1.0-5.1; aRR: 2.3; 95% CI: 1.0-5.0) showed statistically significant increased risk (Table 6).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study revealed that nearly one-third of women delivering at KCMC had meconium-stained amniotic fluid, highlighting a substantial burden of this condition in the population. Maternal outcomes showed that MSAF significantly increased the likelihood of cesarean delivery, postpartum hemorrhage, and puerperal infections. Fetal outcomes were similarly affected, with MSAF linked to a range of adverse events including fetal distress, neonatal intensive care admissions, respiratory complications, and lower Apgar scores, reflecting the considerable threat to newborn wellbeing associated with meconium exposure. The severity of these adverse outcomes was directly related to the grade of meconium-staining, revealing a clear dose-response relationship. Thicker grades of meconium (Grade 2 and Grade 3) were associated with increased higher risks of cesarean section, puerperal sepsis, fetal heart rate abnormalities, neonatal infections, respiratory distress, and neonatal asphyxia compared to thinner or Grade 1 meconium.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003cstrong\u003ehe\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eincidence\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of meconium-stained amniotic fluid\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study identified meconium-stained amniotic fluid (MSAF) as a common occurrence at KCMC, affecting nearly one-third of deliveries, with moderate and thick grades predominating. This finding is consistent with reports from other sub-Saharan African hospitals, such as Korle Bu Teaching Hospital in Ghana and Bugando Medical Centre in Tanzania, where prevalence ranges around one-fifth of deliveries (13,14). Similar proportion rates and the predominance of thick meconium have also been reported in Cameroon, underscoring that MSAF remains a significant intrapartum concern in resource-limited settings\u0026nbsp;(15). These patterns emphasize the urgent need for strengthening intrapartum monitoring and timely clinical interventions to prevent adverse neonatal outcomes such as aspiration syndrome and birth asphyxia.\u003c/p\u003e\n\u003cp\u003eHowever, the observed proportion exceeds figures reported in some other low- and middle-income countries, such as Iran, where a lower prevalence (approximately 12%) of MSAF was found (16). This discrepancy may reflect differences in healthcare infrastructure, antenatal care quality, and referral system effectiveness. Inadequate fetal surveillance, delayed identification of fetal distress, and late referrals are challenges frequently reported in similar settings and likely contribute to higher rates and severity of MSAF. Variations in clinical guidelines, provider training, and resource availability may also influence detection and management, resulting in divergent outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003cstrong\u003ehe maternal outcomes associated with different grades of meconium-stained amniotic fluid\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, identified a significantly increased risk of cesarean delivery associated meconium-stained amniotic fluid (MSAF), with the severity of these outcomes increasing alongside the grade of meconium staining. Women presenting with moderate to thick meconium (Grades 2 and 3) experienced significantly higher risks of cesarean section. This finding is consistent with previous literature, which indicates that thick meconium often prompts clinical decisions favoring operative delivery to reduce potential neonatal complications such as meconium aspiration syndrome. For instance, (4) reported higher cesarean section rates among women presenting with grade III MSAF in a tertiary hospital in China. Similarly,(11) found operative deliveries to be markedly more common in the presence of MSAF, with women experiencing nearly fivefold increased risk compared to those with clear amniotic fluid. These trends likely reflect a clinical response to perceived fetal distress, emphasizing the role of cesarean section as a critical intervention to improve perinatal outcomes in the context of MSAF.\u003c/p\u003e\n\u003cp\u003eMoreover, this study revealed a significant association between MSAF and puerperal sepsis, particularly with higher grades of meconium staining. The correlation between thicker meconium and increased postpartum infection rates may be attributed to prolonged rupture of membranes and labor complications commonly observed in MSAF cases, which enhance susceptibility to ascending infections. Supporting this, (11) documented a markedly increased risk of puerperal sepsis among Ethiopian women with MSAF, with nearly one-fifth of affected mothers developing sepsis compared to significantly lower rates in women with clear amniotic fluid. Additionally, (17) reported an increased risk of postoperative surgical site infections following cesarean deliveries complicated by MSAF, further highlighting the infectious morbidity associated with this condition.\u003c/p\u003e\n\u003cp\u003eThis study found that women with meconium-stained amniotic fluid (MSAF) were at markedly increased risk of postpartum hemorrhage (PPH), with the risk rising progressively across meconium grades. This dose-response pattern suggests that thicker meconium may reflect underlying obstetric complications such as prolonged labor, intrauterine inflammation, or uterine atony that predispose to PPH. Our findings align with(18) who reported higher rates of severe and massive PPH among women with MSAF, attributing this to prolonged labor and increased operative deliveries (18). Similarly, (19) observed a higher PPH proportion in MSAF cases, though they found no difference for severe PPH, highlighting possible variations in obstetric practices and case severity. Unlike these studies, our analysis differentiated MSAF grades, revealing a stronger association with higher grades, underscoring the clinical importance of grading in risk stratification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe fetal outcomes associated with different grades of meconium-stained amniotic fluid\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study identified a strong association between higher grades of meconium-stained amniotic fluid (MSAF) and increased proportion of fetal heart rate abnormalities, consistent with evidence from other settings.(3) similarly reported that moderate and thick meconium (grades 2 and 3) were independently linked to increased fetal distress markers, including abnormal heart rate patterns, which often necessitate prompt obstetric intervention. These findings underline the critical need for continuous and rigorous fetal monitoring during labor when MSAF is detected, to enable timely decision-making and potentially reduce adverse perinatal outcomes. However, unlike some studies that reported universal fetal heart rate monitoring standards, resource constraints in many low-resource settings may limit optimal surveillance, indicating a clear area for health systems strengthening and operational research.\u003c/p\u003e\n\u003cp\u003eRespiratory complications, particularly meconium aspiration syndrome (MAS), were markedly more common in cases with thick meconium. This aligns with (20) who reported high NICU admission rates due to respiratory distress in neonates exposed to thick MSAF. The Italian study by (3)also found a dose-response relationship, with grades 2 and 3 MSAF significantly increasing risks of MAS, transient tachypnea, and acute respiratory distress syndrome. Conversely, some regional studies have shown variability in respiratory complication rates, possibly due to differences in neonatal care availability and early intervention protocols. Clinically, these findings emphasize the necessity of preparing neonatal resuscitation teams and ensuring access to respiratory support facilities, especially in tertiary centers managing high-risk deliveries.\u003c/p\u003e\n\u003cp\u003eNeonatal infection risk was similarly increased with increased MSAF severity in this study, reflecting a pattern also documented in prior research (3). Thick meconium can serve as a medium for bacterial growth, predisposing neonates to sepsis. While our findings correspond with those from higher-income settings, some low-resource environments report under diagnosis or underreporting of neonatal infections due to limited diagnostic capacity. This disparity highlights a critical research gap and the need for improved infection screening and management protocols for neonates born through MSAF-complicated labor, alongside strengthening microbiological laboratory capacity.\u003c/p\u003e\n\u003cp\u003eIt was also found that, a higher proportion of neonatal asphyxia among infants exposed to moderate and thick meconium, reflected in lower Apgar scores and increased need for resuscitation. Similar observations were made in studies from Ethiopia and Nigeria (21,22), reinforcing the prognostic significance of meconium thickness for neonatal outcomes. However, the degree of resuscitation and NICU admission varied across studies, likely influenced by differences in clinical practice guidelines and resource availability. These findings support prioritizing training in neonatal resuscitation and enhancing NICU capacity to mitigate the consequences of birth asphyxia linked to MSAF\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that meconium-stained amniotic fluid, particularly moderate and thick grades, is significantly associated with adverse maternal and neonatal outcomes, including increased cesarean section rates, puerperal sepsis, low Apgar scores, respiratory distress, and neonatal intensive care admissions.These insights underscore the critical need for evidence-based clinical guidelines, improved intrapartum monitoring, and strengthened referral systems to optimize outcomes in resource-limited settings.\u003c/p\u003e\n\u003ch2 id=\"_Toc202916998\"\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eBased on the study findings, the following recommendations are proposed to improve the management of meconium-stained amniotic fluid (MSAF) and related maternal and neonatal outcomes.\u003c/p\u003e\n\u003cp\u003eThere is a need need to develop and implement standardized, evidence-based protocols for the management of MSAF, with particular emphasis on risk stratification according to meconium grade. Strengthening intrapartum monitoring systems is critical and should include ensuring access to reliable fetal heart rate monitoring technologies, such as cardiotocography and handheld Dopplers. Furthermore, fostering inter-professional collaboration through structured communication tools, joint decision-making checklists, and regular multidisciplinary team training could enhance consistency and timeliness in clinical responses.\u003c/p\u003e\n\u003cp\u003eInterventional studies are needed to evaluate strategies aimed at reducing unnecessary operative deliveries while maintaining neonatal safety. Policy initiatives should also integrate antenatal education on MSAF into routine maternal health services, equipping expectant mothers with accurate information to alleviate fear, promote informed decision-making, and encourage timely care-seeking behavior.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Declaration\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot aplicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to patient privacy considerations but are availablefrom the corresponding author ([email protected]) on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eContributorship Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Subilaga led the conception of the study, developed the study design, coordinated data collection, conducted the primary data analysis, and drafted the initial manuscript. Dr. Bariki Mchome provided overall supervision of the study, offered methodological guidance, and critically reviewed the manuscript for important intellectual content.\u003c/p\u003e\n\u003cp\u003eKelvin Musa, Elizabeth Msoka, Raziya Gaffur, Pendo Mlay, Glory Mangi, Caroline Wanjara, Rachel Pesha, and Fortunatha Nzota contributed to data collection, data verification, and manuscript review. Prof. Joseph Mlay and Prof. Olola Oneko provided expert oversight, contributed to study interpretation, and reviewed the manuscript for scientific accuracy and clarity.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGallo DM, Romero R, Bosco M, Gotsch F, Jaiman S, Jung E, et al. Meconium-stained amniotic fluid. Vol. 228, American Journal of Obstetrics and Gynecology. Elsevier Inc.; 2023. p. S1158\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSayad E, Silva-Carmona M. Meconium Aspiration. Neonatal Emergencies: A Practical Guide for Resuscitation, Transport and Critical Care of Newborn Infants. 2023 Apr;269\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDani C, Ciarci\u0026agrave; M, Barone V, Di Tommaso M, Mecacci F, Pasquini L, et al. Neonatal Outcomes of Term Infants Born with Meconium-Stained Amniotic Fluid. Children. 2023 May 1;10(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu X, Huang S, Tang Y, Wu Z, Sun Y, Ren H, et al. Once We Find Grade III Meconium Stained Amniotic Fluid, Must We Act as Early as Possible? Int J Womens Health. 2023;15:7\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbate E, Alamirew K, Admassu E, Derbie A. Prevalence and Factors Associated with Meconium-Stained Amniotic Fluid in a Tertiary Hospital, Northwest Ethiopia: A Cross-Sectional Study. Obstet Gynecol Int. 2021;2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavid AN, Njokanma OF, Iroha E. Incidence of and factors associated with meconium staining of the amniotic fluid in a Nigerian University Teaching Hospital. J Obstet Gynaecol (Lahore). 2006 Aug;26(6):518\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhanya SN, Lakshmanan J, Morgan BLG, Ross MG. Meconium passage in utero: Mechanisms, consequences, and management. Obstet Gynecol Surv. 2005 Jan;60(1):45\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlicker AL, Raffay TM, Ryan RM. Neonatal Respiratory Distress Secondary to Meconium Aspiration Syndrome. Children. 2021 Mar;8(3):246.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMsisiri LS, Kibusi SM, Kimaro FD. Risk Factors for Birth Asphyxia in Hospital-Delivered Newborns in Dodoma, Tanzania: A Case-Control Study. SAGE Open Nurs. 2024 Jan 1;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabra S Masoud, Matilda Ngarina, Furaha August, Kamilya A Omar BT, Olirk. USE OF TRADITIONAL MEDICINE DURING LABOR AND ITS ASSOSCIATION WITH PREGNANCY OUTCOMES AMONG WOMEN DELIVERING AT MNAZI MMOJA HOSPITAL, ZANZIBAR. 2023;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddisu D, Mekie M. Adverse Maternal and Perinatal Outcomes of Meconium-Stained Amniotic Fluid in Term Labor at Hospitals in South Gondar Zone, Northwest Ethiopia: A Prospective Cohort Study. Biomed Res Int. 2023;2023(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDohbit JS, Mah EM, Essiben F, Nzene EM, Meka EUN, Foumane P, et al. Maternal and Fetal Outcomes Following Labour at Term in Singleton Pregnancies with Meconium-Stained Amniotic Fluid: A Prospective Cohort Study. Open Journal of Obstetrics and Gynecology. 2018;08(09):790\u0026ndash;802.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmoah E, Asah-Opoku K, Osman K. The Global Health Network Collections \u0026bull; The Global Health Network Conference Proceedings 2022 Incidence of meconium stained amniotic uid among deliveries at the Korle Bu Teaching Hospital. The Global Health Network License: Creative Commons Attribution 4. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamuli S, Kaiza I, Kihunrwa A, Chibwe E, Mabega N. Prevalence of Meconium Stained Amniotic Fluid and Predictors for Poor Fetal Outcomes Among Women Delivering at Bugando Medical Centre Mwanza Tanzania. European Journal of Preventive Medicine. 2024;12(4):94\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMesumbe EN, Nana PN, Nouetchognou JS, Sama J, Mah E, Eko FE, et al. Perinatal Outcome in Term Pregnancies with Meconium Stained Amniotic Fluid in Two Referral Hospitals of Yaound\u0026eacute;- Cameroon. Biomed J Sci Tech Res. 2018;2(2):2533\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShekari M, Jahromi MS, Ranjbar A, Mehrnoush V, Darsareh F, Roozbeh N. The incidence and risk factors of meconium amniotic fluid in singleton pregnancies: an experience of a tertiary hospital in Iran. BMC Pregnancy Childbirth. 2022 Dec 1;22(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa\u0026rsquo;ayeh M, Snyder A, Oliver EA, Gee SE, Rood KM. Meconium-stained amniotic fluid and the risk of postcesarean surgical site infection. Journal of Maternal-Fetal and Neonatal Medicine. 2021;34(9):1361\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouch\u0026egrave; C, Wiesenfeld U, Ronfani L, Simeone R, Bogatti P, Skerk K, et al. Meconium-stained amniotic fluid: A risk factor for postpartum hemorrhage. Ther Clin Risk Manag. 2018;14:1671\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang ZJ, Liu HF, Zhang YL, Yu L, Yan JY. Relation of meconium-stained amniotic fluid and postpartum hemorrhage: a retrospective cohort study. Eur Rev Med Pharmacol Sci. 2020;24(20):10352\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubramani U, Akshay Patil D, Kumar P. A Prospective Study on Perinatal Outcome in Meconium Stained Amniotic Fluid. Int J Life Sci Biotechnol Pharma Res. 2023;12(1):649.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmenu Sori D, Belete A. Meconium Stained Amniotic Fluid: Factors affecting Maternal and Perinatal Outcomes at Jimma University Specialized Teaching Hospital, South West Ethiopia. Gynecology \u0026amp; Obstetrics. 2016;6(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaima DrCH, Yayaha DrUR, El-Nafaty AU. Meconium stained amniotic fluid in labour: A comparative study of maternal and foetal outcomes in a tertiary hospital, north-east Nigeria. International Journal of Clinical Obstetrics and Gynaecology. 2020 Mar 1;4(2):140\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Meconium-stained amniotic fluid, pregnancy outcomes, maternal health, neonatal outcomes, provider perceptions","lastPublishedDoi":"10.21203/rs.3.rs-8379542/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8379542/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eMeconium-stained amniotic fluid (MSAF) remains a significant obstetric concern due to its association with adverse maternal and neonatal outcomes. However, the absence of standardized management guidelines contributes to clinical uncertainty regarding appropriate interventions, such as operative delivery particularly in low-resource settings like Tanzania. This study aimed to determine the maternal and fetal outcomes associated with different grades of MSAF.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe prospective cohort of 362 term pregnant women with singleton pregnancies were conducted between September 2024 to February 2025 at KCMC hospital. Maternal and neonatal outcomes were compared between women with and without MSAF, and Poisson regression models with robust standard errors estimated crude and adjusted risk ratios (aRRs), controlling for key confounders.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 362 women (median age: 31 years, IQR: 27\u0026ndash;35), 29.3% experienced MSAF. Women with MSAF had significantly higher risks of cesarean delivery (aRR 5.8; 95% CI 3.6\u0026ndash;9.1), postpartum hemorrhage (aRR 9.8; 95% CI 4.1\u0026ndash;23.2), and puerperal sepsis (aRR 2.1; 95% CI 1.1\u0026ndash;4.1). Neonates exposed to MSAF had significant increased risks of NICU admission (aRR 3.2; 95% CI 1.9\u0026ndash;5.3), respiratory distress (aRR 2.4; 95% CI 1.2\u0026ndash;4.8), and meconium aspiration syndrome (aRR 7.6; 95% CI 2.9\u0026ndash;19.9), with risks increasing progressively across MSAF grades.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMSAF, particularly in its thicker grades, is associated with substantially increased risks of adverse maternal and neonatal outcomes. Strengthening intrapartum monitoring, timely intervention, and provider training is critical to mitigate these risks. Findings underscore the need for context-specific guidelines to enhance outcomes in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Maternal and Fetal Outcomes of Meconium-Stained Amniotic Fluid at KCMC Teaching Zonal Referral Hospital: A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 09:25:36","doi":"10.21203/rs.3.rs-8379542/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"180782239574554747786517031721481165199","date":"2026-01-19T06:14:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-08T12:31:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-18T09:54:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-18T01:33:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-18T01:33:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-12-16T19:59:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d4c98148-591e-4944-b994-07d446e3c5a4","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-13T09:25:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 09:25:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8379542","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8379542","identity":"rs-8379542","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}