Tropical Medicine and International Health volume 18 no 6 pp 712724 june 2013

doi:10.1111/tmi.12100

Systematic Review

Prevalence of placenta praevia by world region: a systematic review and meta-analysis

ronique Filippi Jenny A. Cresswell, Carine Ronsmans, Clara Calvert and Ve
London School of Hygiene & Tropical Medicine, London, UK

Abstract

objectives (i) To estimate the prevalence burden of placenta praevia in each world region, and (ii) to investigate potential sources of heterogeneity. methods Systematic review of the literature and random-effects meta-analysis. Potential sources of heterogeneity were investigated using meta-regression. results The overall prevalence of placenta praevia was 5.2 per 1000 pregnancies (95% CI: 4.5 5.9). However, there was evidence of regional variation (P = 0.0001); prevalence was highest among Asian studies (12.2 per 1000 pregnancies; 95% CI: 9.515.2) and lower among studies from Europe (3.6 per 1000 pregnancies; 95% CI: 2.84.6), North America (2.9 per 1000 pregnancies; 95% CI: 2.33.5) and Sub-Saharan Africa (2.7 per 1000 pregnancies; 95% CI: 0.311.0). The prevalence of major placenta praevia was 4.3 per 1000 pregnancies (95% CI: 3.35.4). conclusion The prevalence of placenta praevia is low at around 5 per 1000 pregnancies. There is some evidence suggestive of regional variation in its prevalence, but it is not possible to determine from existing data whether this is due to true ethnic differences or other unknown factor(s). keywords placenta praevia, antepartum haemorrhage, systematic review, meta-analysis, maternal health, reproductive health

Introduction Placenta praevia is a potentially severe obstetric complication where the placenta lies within the lower segment of the uterus, presenting an obstruction to the cervix and thus to delivery. Risk factors for placenta praevia include those that increase the likelihood of uterine scar tissue (including higher parity, prior caesarean delivery or prior abortion) or multiple gestations (Ananth et al. 1997; Faiz & Ananth 2003; Gurol-Urganci et al. 2011). A previous systematic review by Faiz and Ananth (2003) of studies published between 1966 and 2000 calculated the prevalence of placenta praevia to be 4.0 per 1000 pregnancies; both the search strategy and evidence synthesis of this review emphasised North American literature. Our study, conducted as part of a larger project aiming to quantify the global burden of maternal haemorrhage (Calvert et al. 2012), updates these results and puts particular emphasis on capturing and including studies originating outside of the USA and high-income countries. Placenta praevia can result in life-threatening maternal complications such as haemorrhage and shock and in adverse infant outcomes such as prematurity, stillbirth and 712

neonatal death (Crane et al. 1999, 2000; Bahar et al. 2009). National hospital surveillance data from the USA demonstrate a case-fatality rate of 17.3 deaths per 100 000 White women with placenta praevia and 40.7 deaths per 100 000 among Black women (Tucker et al. 2007). The case-fatality rate in low-income settings is likely to be considerably higher due to reduced antenatal screening and lack of quality emergency obstetric care. The primary objective of this paper was to estimate the prevalence of placenta praevia in each world region; the secondary objective was to investigate potential sources of heterogeneity.

Methods Data sources & search strategy This review was part of a larger study investigating the prevalence of maternal haemorrhage and the causes of haemorrhage (Calvert et al. 2012). The databases EMBASE, Medline, Popline, CAB Abstracts, African Index Medicus, Eastern Mediterranean Region Index Medicus, Latin American and Caribbean Center on Health Sciences Information, and Western Pacic Region Index Medicus

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Tropical Medicine and International Health J. A. Cresswell et al. Placenta praevia by world region

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were searched using thesaurus and free-text terms to identify literature published from 1 January 1990 onwards. The initial search strategy identied studies published up until 2009; the search was later updated in April 2012. The search strategy included thesaurus and free-text terms relating to haemorrhage, placenta praevia and bleeding. A particular effort was made to identify literature from low-income settings by searching the WHO regional databases. The reference lists of eligible studies were hand searched to identify further publications. The full search strategy is available upon request. Inclusion criteria Studies were eligible for inclusion if they reported the number of cases of placenta praevia, along with a suitable denominator for the total number of deliveries or births in the population, and the median year of the study was 1990 onwards. To capture population-representative data, facility-based studies were excluded if local or national (if local data unavailable) skilled birth attendance was <95%. Studies that reported the total number of caesarean deliveries as the denominator were excluded. Case reports and publications that did not report original data were excluded; all other study types were eligible. Studies with a sample size of fewer than 30 deliveries were excluded. No language restrictions were imposed. Where cases were potentially reported in multiple publications due to overlap in the study site and dates, the publication covering the longest time period was selected. Statistical analysis Placenta praevia exists in different grades, according to the precise location of the placenta and the degree of overlap with the cervical os Oppenheimer and Farine (2009). Due to inconsistencies in the severity of placenta praevia across the different studies, the results are presented in two groups: (1) studies representing all cases of placenta praevia (marginal, partial or complete coverage of the os) and (2) studies representing major placenta praevia (partial and complete coverage of the os) only. Meta-analysis was conducted using the DerSimonian Laird random-effects model (Viechtbauer 2010). Proportions were transformed prior to meta-analysis using the FreemanTukey double arcsine transformation for variance stabilisation (Freeman & Tukey 1950; Rucker et al. 2009). Pooled proportions were subsequently back-transformed to the original scale (Miller 1978). Meta-regression was used to investigate potential sources of heterogeneity. Geographic region, World Bank income, study setting, time at which diagnosis was con-

rmed and denominator denition were hypothesised a priori to potentially contribute towards between-study heterogeneity. Analyses were carried out using R 2.12.2 and Stata 12.0. Results Our initial search identied 13 205 potentially relevant studies (Figure 1). A total of 58 articles met the review inclusion criteria; 10 of these were duplicate publications reporting on the same location and time period, leaving 48 unique studies included in our review (41 of which report on all cases of placenta praevia and 22 of which report the number of major praevia cases). Studies are described in Appendix S1. Studies were identied from Asia (n = 9), Australasia (n = 3), Europe (n = 15), Latin America (n = 3), North Africa/Middle East (n = 6), North America (n = 10) and Sub-Saharan Africa (n = 2). Most studies originated from high-income settings (n = 36). Overall, the pooled prevalence of all cases of placenta praevia was 5.2 cases per 1000 pregnancies (95% CI: 4.55.9) (Table 1). Prevalence was highest among Asian studies (12.2 per 1000) and lower among studies from Europe (3.6 per 1000), North America (2.9 per 1000) and Sub-Saharan Africa (2.7 per 1000). The pooled prevalence of major placenta praevia was 4.3 cases per 1000 pregnancies (95% CI: 3.35.4). A very high level (>97%) of heterogeneity was observed for all and major cases, which remained even after stratication by study characteristic (Table 1). In the meta-regression (Table 2), the only study characteristic with a signicant effect on prevalence of all cases of placenta praevia was geographic region (P = 0.0001). Although region could explain around half of the between-study variance, there was still a very high level of residual heterogeneity after accounting for region (98.5%). Discussion Our results show that the prevalence of placenta praevia was around 5.2 cases per 1000 pregnancies (95% CI: 4.55.9); the prevalence of major placenta praevia was 4.3 cases per 1000 pregnancies (95% CI: 3.35.4). Heterogeneity was very high, even after stratication on study characteristics. Geographic region was the only study characteristic with a signicant inuence on prevalence. Prevalence was highest among Asian studies (12.2 per 1000) and lower among studies from Europe (3.6 per 1000), North America (2.9 per 1000) and Sub-Saharan Africa (2.7 per 713

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Tropical Medicine and International Health J. A. Cresswell et al. Placenta praevia by world region

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Original search on haemorrhage & causes of haemorrhage to 31st December 2009 MEDLINE, Embase, Popline LILIACS, CAB, EMRIM, AIM, WPRIM n = 13 205 Excluded at title/abstract screen n = 12 182 Full text not available n = 136 Full text obtained n = 887 Did not contain any information related to placenta praevia n = 785 Contained potentially relevant information on placenta praevia n = 102 Exclusions: Skilled birth attendance <95% = 17 Outcome data unsuitable = 13 Denominator unsuitable = 11 No denominator = 9 Dates out of range = 5 No original data = 1 Data duplicated in other publication n = 10 Met inclusion criteria n = 36

Update of search strategy 1st April 2012 MEDLINE, Embase, Popline LILIACS, CAB, EMRIM, AIM, WPRIM n = 5121 Excluded at title/abstract screen n = 5053

Full text obtained n = 68

Exclusions: Skilled birth attendance <95% = 10 Outcome data unsuitable = 19 Denominator unsuitable = 7 No denominator = 7 Dates out of range = 2 No original data = 2 Data duplicated in other publication n=9 Met inclusion criteria n = 12

Inclusion in meta-analysis n = 48 Contained data on all placenta praevia cases (marginal, partial and total):41 Contained data on major placenta praevia cases (partial and total):22

Figure 1 Search strategy ow diagram.

1000). This could plausibly be due to true geographic or ethnic differences between populations; several previous studies have found the prevalence of placenta praevia to vary between different ethnic groups (Sheiner et al. 2001; Ananth et al. 2003), including increased prevalence among Asian women relative to White women (Shen et al. 2005). Any biological mechanism for this association is poorly understood; however, ethnic differences in prematurity rates or pelvic structure are possible explanations. It has been observed that normal gestational length is shorter among Black and Asian women than among White European women (Patel et al. 2004). However, it is also possible that the apparent importance of the geographic region variable is a marker for other (unknown) causes of heterogeneity between the studies. The majority of studies identied in this review did not report the distance between the placental edge and the cervical os; 714

subtle differences in national diagnostic protocols or conventions may account in part for the observed regional differences. This study has investigated the prevalence of placenta praevia in more diverse geographic locations than previously. However, there are a number of limitations. Despite our best efforts, we retrieved a relatively small number of studies from low- and middle-income countries. This partially reects an imbalance in where studies on placenta praevia are conducted; however, this was also partially due to our a priori decision to only include facility-based studies where skilled birth attendance was >95%. We acknowledge that doing so has meant that we have very few studies from some regions, such as SubSaharan Africa, and that consequently our estimates cannot be interpreted as representative of the entire region. Nevertheless, we believe that our strategy was preferable

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Table 1 Random-effects meta-analysis of pooled prevalence of placenta praevia, stratied by covariates Pooled prevalence per 1000 pregnancies No. of Studies k n Prevalence (95% CI) Variation due to Study Heterogeneity (I2)

Characteristic

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6 3 13 50 582 1 461 928 9.5 3.6 (4.8, 15.7) (2.8, 4.6)

378 856

12.2

(9.5, 15.2)

97.7% 95.0% 98.1%

Tropical Medicine and International Health

3 6 8 19 688 426 99 544 6.4 2.9

40 058

5.1

(2.5, 8.7) (5.6, 7.3) (2.3, 3.5)

94.4% 57.8% 99.5%

J. A. Cresswell et al. Placenta praevia by world region

All cases of placenta praevia (marginal, partial or complete) GBD Region Asia (Hendricks et al. 1999; Yamada et al. 2005; Fujii et al. 2010; Huang et al. 2011; Jang et al. 2011; Matsuda et al. 2011) Australasia (Olive et al. 2006; Lain et al. 2008; McCormack et al. 2008) Europe (Taipale et al. 1998; DSouza 2000; Vettraino et al. 2001; Grgic et al. 2004; Love et al. 2004; Romundstad et al. 2006; Tuzovic 2006; Papinniemi et al. 2007; Tata et al. 2007; Milosevic et al. 2009; Vazquez Rodriguez et al. 2010; Daskalakis et al. 2011; Rosenberg et al. 2011) Latin America & the Caribbean Cabrera (Hern andez et al. 1999; Faneite et al. 2001; Rivas et al. 2001) North Africa/Middle East (Ismail 2001; Bhat et al. 2004; Bahar et al. 2009; Celik Acioglu et al. 2010; Davood et al. 2010; Alshami et al. 2011) North America (Ananth et al. 2001; Francois et al. 2003; Koroukian 2004; Shen et al. 2005; Predanic et al. 2007; Yang et al. 2009; Aliyu et al. 2011a,b; Eichelberger et al. 2011) Sub-Saharan Africa (Prual et al. 2000; Buambo-Bamanga et al. 2004) 2 30 40 560 21 559 572 2.7 5.2 (0.3, 11.0) (4.4, 6.0) 99.2% 99.6%

World Bank Classication

149 822

5.8

(3.5, 8.8)

97.8%

High income (Taipale et al. 1998; Hendricks et al. 1999; DSouza 2000; Ananth et al. 2001; Vettraino et al. 2001; Francois et al. 2003; Bhat et al. 2004; Koroukian 2004; Love et al. 2004; Shen et al. 2005; Yamada et al. 2005; Olive et al. 2006; Tuzovic 2006; Romundstad et al. 2006; Papinniemi et al. 2007; Predanic et al. 2007; Tata et al. 2007; McCormack et al. 2008; Bahar et al. 2009; Yang et al. 2009; Bragg et al. 2010; Fujii et al. 2010; Vazquez Rodriguez et al. 2010; Aliyu et al. 2011a,b; Alshami et al. 2011; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011; Matsuda et al. 2011; Rosenberg et al. 2011) Upper-middle income (Cabrera Hern andez et al. 1999; Faneite et al. 2001; Ismail 2001; Rivas et al. 2001; Grgic et al. 2004; Milosevic et al. 2009; Celik Acioglu et al. 2010; Davood et al. 2010; Huang et al. 2011) Low and Lower-middle income (Prual et al. 2000; Buambo-Bamanga et al. 2004) 2

40 560

2.7

(0.3, 11.0)

99.2%

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715

716
Pooled prevalence per 1000 pregnancies No. of Studies k n 21 590 322 5.5 (4.7, 6.3) 99.6% Prevalence (95% CI) 31 Variation due to Study Heterogeneity (I2) J. A. Cresswell et al. Placenta praevia by world region 10 159 622 4.2 (2.7, 6.2) 96.5% 28 547 893 5.2 (4.3, 6.2) 95.9% 13 21 202 060 5.0 (3.9, 6.3) 99.8%

Table 1 (continued)

Characteristic

Tropical Medicine and International Health

Language of Publication

English (Taipale et al. 1998; Hendricks et al. 1999; DSouza 2000; Ananth et al. 2001; Ismail 2001; Francois et al. 2003; Bhat et al. 2004; Koroukian 2004; Love et al. 2004; Shen et al. 2005; Yamada et al. 2005; Olive et al. 2006; Romundstad et al. 2006; Tuzovic 2006; Tata et al. 2007; Papinniemi et al. 2007; Predanic et al. 2007; McCormack et al. 2008; Bahar et al. 2009; Yang et al. 2009; Bragg et al. 2010; Davood et al. 2010; Fujii et al. 2010; Aliyu et al. 2011a,b; Alshami et al. 2011; Daskalakis et al. 2011; Eichelberger et al. 2011; Huang et al. 2011; Jang et al. 2011; Matsuda et al. 2011; Rosenberg et al. 2011) Non-English (Cabrera Hern andez et al. 1999; Prual et al. 2000; Faneite et al. 2001; Rivas et al. 2001; Vettraino et al. 2001; Buambo-Bamanga et al. 2004; Grgic et al. 2004; Milosevic et al. 2009; Celik Acioglu et al. 2010; Vazquez Rodriguez et al. 2010)

Study Setting

ndez et al. 1999; Facility-based (Taipale et al. 1998; Cabrera Herna Hendricks et al. 1999; DSouza 2000; Faneite et al. 2001; Ismail 2001; Rivas et al. 2001; Vettraino et al. 2001; Francois et al. 2003; Bhat et al. 2004; Buambo-Bamanga et al. 2004; Grgic et al. 2004; Love et al. 2004; Yamada et al. 2005; Olive et al. 2006; Tuzovic 2006; Papinniemi et al. 2007; Predanic et al. 2007; McCormack et al. 2008; Bahar et al. 2009; Milosevic et al. 2009; Celik Acioglu et al. 2010; Davood et al. 2010; Vazquez Rodriguez et al. 2010; Alshami et al. 2011; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011) Population-based (Prual et al. 2000; Ananth et al. 2001; Koroukian 2004; Shen et al. 2005; Romundstad et al. 2006; Tata et al. 2007; Yang et al. 2009; Bragg et al. 2010; Fujii et al. 2010; Aliyu et al. 2011a,b; Huang et al. 2011; Matsuda et al. 2011; Rosenberg et al. 2011)

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Table 1 (continued) Pooled prevalence per 1000 pregnancies No. of Studies k n 1 617 940 4.4 (3.2, 5.7) Prevalence (95% CI) 13 98.9%

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Characteristic

Variation due to Study Heterogeneity (I2)

Tropical Medicine and International Health

Conrmation of Placenta Praevia Diagnosis 11 626 884 6.1 (3.7, 9.1)

J. A. Cresswell et al. Placenta praevia by world region

99.4%

ndez et al. 1999; Conrmed at delivery (Taipale et al. 1998; Cabrera Herna Hendricks et al. 1999; DSouza 2000; Ananth et al. 2001; Rivas et al. 2001; Francois et al. 2003; Buambo-Bamanga et al. 2004; Olive et al. 2006; Romundstad et al. 2006; Papinniemi et al. 2007; Bahar et al. 2009) Present at last ultrasound prior to delivery (Faneite et al. 2001; Ismail 2001; Bhat et al. 2004; Love et al. 2004; Yamada et al. 2005; Tuzovic 2006; Predanic et al. 2007; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011; Matsuda et al. 2011; Rosenberg et al. 2011) Not reported (Prual et al. 2000; Vettraino et al. 2001; Grgic et al. 2004; Koroukian 2004; Shen et al. 2005; Tata et al. 2007; McCormack et al. 2008; Milosevic et al. 2009; Yang et al. 2009; Bragg et al. 2010; Celik Acioglu et al. 2010; Davood et al. 2010; Fujii et al. 2010; Vazquez Rodriguez et al. 2010; Aliyu et al. 2011a,b; Alshami et al. 2011; Huang et al. 2011) 17 19 505 130 5.2 (4.3, 6.2) 21 1 749 648 4.6 (3.6, 5.7)

99.5%

Denition of denominator

98.5%

1 16

21 234 2 607 980

17.5 5.8

(15.8, 19.4) (4.0, 8.0)

99.7%

ndez et al. 1999; Prual et al. 2000; All deliveries (Cabrera Herna Faneite et al. 2001; Ismail 2001; Rivas et al. 2001; Vettraino et al. 2001; Francois et al. 2003; Bhat et al. 2004; Buambo-Bamanga et al. 2004; Grgic et al. 2004; Love et al. 2004; Shen et al. 2005; Yamada et al. 2005; Olive et al. 2006; Tuzovic 2006; Tata et al. 2007; Milosevic et al. 2009; Bragg et al. 2010; Celik Acioglu et al. 2010; Davood et al. 2010; Rosenberg et al. 2011) All Live Births (Huang et al. 2011) All singleton deliveries (Taipale et al. 1998; Hendricks et al. 1999; DSouza 2000; Romundstad et al. 2006; Papinniemi et al. 2007; Predanic et al. 2007; McCormack et al. 2008; Bahar et al. 2009; Fujii et al. 2010; Vazquez Rodriguez et al. 2010; Aliyu et al. 2011a,b; Alshami et al. 2011; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011; Matsuda et al. 2011) All Singleton Live Births (Ananth et al. 2001; Koroukian 2004; Yang et al. 2009) 3

17 371 092

3.5

(2.4, 4.8)

99.6%

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717

718
Pooled prevalence per 1000 pregnancies No. of Studies k n 5.2 (4.5, 5.9) 99.5% Prevalence (95% CI) 21 749 954 Variation due to Study Heterogeneity (I2) 5 0 7 3 2 4 1 16 463 284 20 234 5.3 4.3 51 494 166 458 4.1 3.0 40 058 3.3 (1.3, 6.1) (3.6, 4.7) (1.5, 5.0) (4.4, 6.4) (3.3, 5.4) 127 485 3.2 (1.9, 4.8) 164 559 8.0 (6.0, 10.3) 95.6% 94.9% 93.8% 0.0% 97.1% 96.3% J. A. Cresswell et al. Placenta praevia by world region 5 1 16 86 770 20 234 473 560 4.1 5.3 4.5 (1.1, 8.7) (4.4, 6.4) (3.3, 6.0) 98.6% 97.7% 6 96 728 3.6 (2.2, 5.4) 94.2%

Table 1 (continued)

Characteristic

Tropical Medicine and International Health

Overall

41

Major placenta praevia (partial or complete) GBD Region Asia (Hendricks et al. 1999; Hung et al. 2007; Sumigama et al. 2007; Hasegawa et al. 2009; Jang et al. 2011) Australasia Europe (Taipale et al. 1998; DSouza 2000; Becker et al. 2001; Grgic et al. 2004; Love et al. 2004; Guariglia et al. 2006; Daskalakis et al. 2011) Latin America & the Caribbean Cabrera (Hern andez et al. 1999; Faneite et al. 2001; Rivas et al. 2001) North Africa/Middle East (Bhat et al. 2004; Bahar et al. 2009) North America (Crane et al. 2000; Cleary-Goldman et al. 2005; Predanic et al. 2007; Eichelberger et al. 2011) Sub-Saharan Africa (Buambo-Bamanga et al. 2004)

World bank classication

High income (Taipale et al. 1998; Hendricks et al. 1999; Crane et al. 2000; DSouza 2000; Becker et al. 2001; Bhat et al. 2004; Love et al. 2004; Cleary-Goldman et al. 2005; Guariglia et al. 2006; Predanic et al. 2007; Sumigama et al. 2007; Bahar et al. 2009; Hasegawa et al. 2009; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011) Upper-middle income (Cabrera Hern andez et al. 1999; Faneite et al. 2001; Rivas et al. 2001; Grgic et al. 2004; Hung et al. 2007) Low and Lower-middle income (Buambo-Bamanga et al. 2004)

Language of Publication

English (Taipale et al. 1998; Hendricks et al. 1999; Crane et al. 2000; DSouza 2000; Becker et al. 2001; Bhat et al. 2004; Love et al. 2004; Cleary-Goldman et al. 2005; Hung et al. 2007; Predanic et al. 2007; Sumigama et al. 2007; Bahar et al. 2009; Hasegawa et al. 2009; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011) Non-English (Cabrera Hern andez et al. 1999; Faneite et al. 2001; Rivas et al. 2001; Buambo-Bamanga et al. 2004; Grgic et al. 2004; Guariglia et al. 2006)

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Table 1 (continued) Pooled prevalence per 1000 pregnancies No. of Studies k n 476 292 4.3 (3.3, 5.5) 97.1% Prevalence (95% CI) 21 Variation due to Study Heterogeneity (I2)

Characteristic

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Study Setting

Tropical Medicine and International Health

ndez et al. 1999; Facility-based (Taipale et al. 1998; Cabrera Herna Hendricks et al. 1999; DSouza 2000; Becker et al. 2001; Faneite et al. 2001; Rivas et al. 2001; Bhat et al. 2004; Buambo-Bamanga et al. 2004; Grgic et al. 2004; Love et al. 2004; Cleary-Goldman et al. 2005; Guariglia et al. 2006; Hung et al. 2007; Predanic et al. 2007; Sumigama et al. 2007; Bahar et al. 2009; Hasegawa et al. 2009; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011) Population-based (Crane et al. 2000) 1 13 366 688 4.5 93 996 3.2 (2.9, 3.6) (3.2, 6.0)

J. A. Cresswell et al. Placenta praevia by world region

Conrmation of Placenta Praevia Diagnosis 8 194 590 4.4

97.4%

ndez et al. 1999; Conrmed at delivery (Taipale et al. 1998; Cabrera Herna Hendricks et al. 1999; Crane et al. 2000; DSouza 2000; Becker et al. 2001; Rivas et al. 2001; Buambo-Bamanga et al. 2004; Cleary-Goldman et al. 2005; Guariglia et al. 2006; Bahar et al. 2009) Present at last ultrasound prior to delivery (Faneite et al. 2001; Bhat et al. 2004; Love et al. 2004; Predanic et al. 2007; Sumigama et al. 2007; Hasegawa et al. 2009; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011) Not reported (Grgic et al. 2004; Hung et al. 2007) 1 12 9 010 322 601 1.3 4.1

(2.6, 6.4)

97.2%

(0.7, 2.2) (3.0, 5.3)

95.8%

Denition of denominator

ndez et al. 1999; Crane et al. 2000; All deliveries (Cabrera Herna Becker et al. 2001; Faneite et al. 2001; Rivas et al. 2001; Bhat et al. 2004; Buambo-Bamanga et al. 2004; Grgic et al. 2004; Love et al. 2004; Guariglia et al. 2006; Sumigama et al. 2007; Hasegawa et al. 2009) All live births All singleton deliveries (Taipale et al. 1998; Hendricks et al. 1999; DSouza 2000; Cleary-Goldman et al. 2005; Hung et al. 2007; Predanic et al. 2007; Bahar et al. 2009; Daskalakis et al. 2011; Eichelberger et al. 2011; Jang et al. 2011) All Singleton Live Births 0 10 0

247 687

4.6

(2.8, 6.7)

98.1%

570 288 4.3

(3.3, 5.4)

97.2%

Overall

22

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719

Table 2 Meta-regression Residual variation due to study heterogeneity (Residual I2)

720
OR [95% condence interval] Test for covariate with Knapp-Hartung modication Proportion of between-study variance explained (Adjusted R2) [0.361.68] [0.170.49] [0.190.90] [0.301.03] [0.130.42] [0.080.46] [0.641.99] [0.141.33] [0.451.34] [0.511.39] [0.742.56] [0.631.93] [0.9618.49] [0.782.08] [0.342.00] F = 0.89; P = 0.3522 F = 0.49; P = 0.4889 F = 0.56; P = 0.5754 F = 1.70; P = 0.1846 F = 1.32; P = 0.2786 J. A. Cresswell et al. Placenta praevia by world region 1.00 0.78 0.29 0.42 0.55 0.24 0.19 1.00 1.13 0.44 1.00 0.77 1.00 0.84 1.00 1.38 1.11 1.00 4.22 1.28 0.82 F = 6.96; P = 0.0001 50.4% 98.5% [0.210.75] [0.180.90] [0.211.31] [0.170.75] [0.212.18] [0.441.81] [0.335.19] [0.431.53] F = 2.64; P = 0.0533 30.9% 95.3% 1.00 0.39 0.40 0.53 0.36 0.67 1.00 0.89 1.31 1.00 0.81 F = 0.16; P = 0.8548 F = 0.48; P = 0.4959

Tropical Medicine and International Health

Study characteristic

All cases of placenta praevia (marginal, partial or complete) GBD Region Asia Australasia Europe Latin America & the Caribbean North Africa/Middle East North America Sub-Saharan Africa World Bank High income Classication Upper-middle income Low and Lower-middle income Language of English Publication Non-English Study Setting Facility-based Population-based Conrmation Conrmed at delivery of Placenta Present at last ultrasound prior to delivery Praevia Diagnosis Not reported Denition of All deliveries Denominator All live births All singleton deliveries All singleton live births Major placenta praevia (partial or complete) GBD Region Asia Europe Latin America & the Caribbean North Africa/Middle East North America Sub-Saharan Africa World Bank High income Classication Upper-middle income Low and Lower-middle income Language of English Publication Non-English

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Conrmed at delivery Present at last ultrasound prior to delivery Not reported All deliveries All singleton deliveries

to any alternative to enhance the validity of our estimates. The true prevalence of placenta praevia is likely to lie somewhere between that estimated by the facility-based and population-based designs. Facility-based studies may overestimate prevalence because of referral patterns. Conversely, estimates from population-based studies may underestimate the prevalence of placenta praevia due to the increased potential for missing cases. Populationbased studies are more likely to lack detailed information on the grade of the placenta praevia, and clinical diagnosis procedures and many population-based studies restrict the denominator to live births, which excludes cases of placenta praevia accompanied by stillbirth. Placenta praevia is a rare condition and may have been subject to differential under-reporting depending on local antenatal routines, which are difcult to ascertain at the aggregate level. For example, one Sub-Saharan study Prual et al. 2000 reported a substantially lower prevalence (0.59 cases per 1000 pregnancies) than other studies in this review. This study predominantly identied cases of placenta praevia that were accompanied by a maternal haemorrhage, and likely missed those with less serious outcomes, which would be identied in well-resourced settings where women may have multiple ultrasounds during pregnancy. We observed very high levels of heterogeneity in this review. Most of the studies included in this review had large sample sizes that produced very precise estimates. Because within-study variance was very small compared to between-study variance, high I2 values were observed. Statistically signicant differences between study estimates were not necessarily clinically signicant. In conclusion, the prevalence of placenta praevia is low, but remains a serious obstetric complication with a high case-fatality rate. There is some evidence to suggest regional variation in the prevalence of placenta praevia, although it is not possible to determine from studies such as this whether this is due to true population differences or some unknown factor. Acknowledgements This project was funded by a grant from the Bill and Melinda Gates Foundation to the US Fund for UNICEF to support the Child Health Epidemiology Reference Group (PI: Robert E Black). The authors acknowledge the valuable contributions of Alma Adler, Sara Thomas and Karen Wagner to the project. The authors would like to thank Fernanda Boueri, Kathryn Church, Xing Lin Feng, Sylvia Marinova, Ana Montoya, Yusuke Shimakawa and Katerini Storeng for their help translating articles. 721

Test for covariate with Knapp-Hartung modication

Proportion of between-study variance explained (Adjusted R2) F = 1.43; P = 0.2630 [0.541.69] [0.081.31]

Residual variation due to study heterogeneity (Residual I2)

Table 2 (continued)

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Conrmation of Placenta Praevia Diagnosis Denition of Denominator

Study characteristic

1.00 0.96 0.32 1.00 1.09

OR

[0.621.92]

[95% condence interval]

F = 0.10; P = 0.7557

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Supporting Information Additional Supporting Information may be found in the online version of this article: Appendix S1. Description of eligible studies.

Corresponding Author Jenny A. Cresswell, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, UK. E-mail: jenny.cresswell@lshtm.ac.uk

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