ورقة علمية / Research Paper

Background: Pregnancy-related complications are a major public health challenge worldwide, particularly in low- and lower-middle-income countries. Sub-Saharan Africa carries the highest burden, with maternal mortality ratios exceeding the global average by more than twofold. Sudan has historically faced high maternal mortality, and the armed conflict that began in April 2023 has further strained the health system. Reports indicate that many health facilities in conflict-affected areas, including Northern State, have closed or are functioning at reduced capacity, severely limiting access to essential maternal healthcare. Socioeconomic factors such as low income, limited education, rural residence, and lack of health insurance are known to increase the risk of pregnancy complications. Obstetric history, including previous cesarean sections, miscarriages, preterm births, and chronic illnesses, also contributes to adverse maternal outcomes. Infection during pregnancy is particularly concerning as a strong predictor of complications. Currently, there is a knowledge gap regarding the prevalence and determinants of midtrimester pregnancy complications in Northern State, as pre-conflict data no longer reflect the current reality. Understanding these factors is critical to guide interventions, strengthen antenatal care, and improve maternal outcomes in this conflict-affected region. Objectives Primary Objective: • To determine the maternal and socioeconomic determinants of mid-trimester pregnancy complications among women attending health facilities in Northern State, Sudan. Secondary Objectives: 1. To estimate the prevalence of mid-trimester pregnancy complications in Northern State. 2. To assess the association between socioeconomic factors (income, education, residence, health insurance) and pregnancy complications. 3. To evaluate obstetric and medical risk factors, including previous cesarean section, gravidity, parity, chronic illness, and infections, for mid-trimester complications. Methods Study Design and Setting This will be a cross-sectional analytical study conducted in Northern State, Sudan. Data will be collected from both primary and referral health facilities in urban and rural areas of the state. Study Population The study population will include pregnant women in their second trimester presenting to participating health facilities. Inclusion Criteria: 1. Sudanese women 2. Gestational age between 13 and 27 weeks (confirmed by last menstrual period or ultrasound) 3. Complete medical follow-up card 4. Ability to provide informed consent Exclusion Criteria: • Critically unstable women unable to participate after stabilization • Incomplete medical follow-up card Sampling Technique • Facility Selection: Purposive sampling of functional health facilities due to conflict-related closures. • Participant Recruitment: Consecutive sampling of all eligible women presenting to selected facilities until the sample size is reached. Data Collection Instrument A structured interviewer-administered questionnaire, validated through expert review and pilot testing, will be used. Sections include: 1. Socio-demographic characteristics: age, residence, education, income, health insurance, marital status 2. Obstetric and medical history: gravidity, parity, prior cesarean sections, miscarriages, chronic illnesses, infections 3. Clinical presentation and management 4. Outcome variables: presence or absence of pregnancy-related complications Operational Definitions • Pregnancy-related complications: Clinically diagnosed maternal complications such as infection, hemorrhage, miscarriage-related complications, preterm labor, or sepsis. • Infection during pregnancy: Diagnosis confirmed by attending physician or laboratory, or symptoms consistent with urinary tract infection, malaria, dengue, or other infectious conditions. Data Management and Analysis • Data will be collected using Google Forms and analyzed with Jamovi (version 2.3.8).

All participants will be provided with clear information about the study, including its purpose, procedures, potential risks and benefits, and their rights as participants. They will be informed that participation is entirely voluntary and that they can withdraw at any time without affecting their access to healthcare services. Informed consent will be obtained verbally or in writing depending on their literacy level.

• Evidence-based planning: Provides up-to-date, locally relevant data on maternal complications in Northern State, especially in a conflict-affected context. • Policy guidance: Helps health authorities and NGOs design targeted interventions, resource allocation, and maternal health programs. • Maternal health improvement: Identifies high-risk populations, enabling policymakers to prioritize preventive care and early intervention.