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PLoS One. 2018 Aug 6;13(8):e0199243. doi: 10.1371/journal.pone.0199243. eCollection 2018.

Concordance of three alternative gestational age assessments for pregnant women from four African countries: A secondary analysis of the MIPPAD trial.

Author information

Center for Public Health, Department of Epidemiology, Medical University of Vienna, Vienna, Austria.
Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Ludwig-Maximilians University, Munich, Germany.
Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria.
Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria.
Barcelona Centre for International Health Research, (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain.
Manhiça Health Research Center (CISM), Manhiça, Mozambique.
Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon.
Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany.
German Center for Infectious Diseases (DZIF), Tübingen, Germany.
Department of Parasitology, Université des Sciences de la Santé (USS), Libreville, Gabon.
Faculté des Sciences de la Santé (FSS), Université d'Aboméy Calavi, Cotonou, Benin.
Institut de Recherche pour le Développement (IRD), Paris, France.
Ministère de la Santé, Burkina Faso.
Ifakara Health Institute (IHI), Dodoma, Tanzania.
Ngounie Medical Research Centre, Fougamou, Gabon.
Université René Descartes, Paris, France.
Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and University Medical Center Hamburg-Eppendorf, Hamburg, Germany.



At times, ultrasound is not readily available in low resource countries in Africa for accurate determination of gestational age, so using alternative methods is pivotal during pregnancy. These assessments are used to aid the risk analysis for an infant and management strategies for premature delivery, if necessary. Currently, date of last menstrual period, fundal height measurements, and the New Ballard Score are commonly used in resource-limited settings. However, concordance of these measures is unknown for sub-Saharan Africa. We obtained data from an open-label randomized controlled trial, to assess the concordance of these alternative assessment methods. The purpose of our study was to determine the agreement between these alternative methods when used in sub-Saharan African populations.


A total of 4,390 pregnant women from Benin, Gabon, Mozambique and Tanzania were included in our analysis. The assessment methods compared were: 1) reported last menstrual period, 2) symphysis-fundal height measurement, and 3) the New Ballard Score. The Bland-Altman method and intraclass correlation coefficient (ICC) were used to test the degree of agreement. Survival range gestational age, used as an inclusion criterion for further analysis, was from 22 to 44 weeks.


Plots showed a lack of agreement between methods and the 95% limits of agreement too wide to be clinically useful. ICC = 0.25 indicated poor agreement. A post-hoc analysis, restricted from 32 to 42 weeks, was done to check for better agreement in this near-term population. The plots and ICC = 0.16 still confirmed poor agreement.


The alternative assessments do not result in comparable outcomes and discrepancies are far beyond the clinically acceptable range. Last menstrual period should not be used as the only estimator of gestational age. In the absence of reliable early ultrasound, symphysis-fundal height measurements may be most useful during pregnancy for fetal risk assessment and the New Ballard Score after delivery as a confirmation of these estimations and for further neonatal management. However, promotion of portable ultrasound devices is required for accurate assessment of gestational age in sub-Sahara Africa.

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