Background
Preterm prelabor rupture of membranes (PPROM) remains a significant contributor to preterm birth globally, complicating approximately 2 to 3% of pregnancies and accounting for a substantial proportion of neonatal morbidity and mortality (Goldenberg et al., 2008). The condition is clinically important because it sits at the intersection of two competing risks prematurity and infection. Neonates are vulnerable to respiratory distress syndrome, sepsis, and intraventricular hemorrhage, while mothers face risks of chorioamnionitis and sepsis (Mercer, 2003; Romero et al., 2014). Although the biological mechanisms of PPROM are well described, outcomes are not uniform across settings and are strongly shaped by the capacity of the health system to manage both prematurity and infection.
In high-income settings, management of PPROM is guided by structured protocols and supported by neonatal intensive care, laboratory diagnostics, and timely access to medications. Expectant management prior to 34 weeks’ gestation is widely recommended in the absence of maternal and fetal compromise, with the aim of prolonging pregnancy and improving neonatal outcomes (ACOG, 2020; Thomson & the Royal College of Obstetricians and Gynaecologists, 2019). However, even within these settings, the optimal approach in late preterm PPROM (34 to 36 + 6 weeks), remains debated, as studies have demonstrated reduced maternal infection with early delivery but increased neonatal morbidity (Morris et al., 2016). These findings highlight that the balance between infection and prematurity is not static but shifts across gestational age.
Studies from sub-Saharan Africa suggest that outcomes following PPROM are strongly influenced by gestational age at delivery and the capacity for infection surveillance, with considerable variability reported across settings, particularly in relation to infection rates and neonatal survival (Fernandes et al., 2012; Mwimba et al., 2022). However, these findings remain heterogeneous and are largely derived from retrospective or single center cohorts, limiting generalizability. In Zimbabwe, there is a notable absence of prospective data evaluating the outcomes of expectant versus immediate management of PPROM across a broad gestational window. As a result, clinical practice is often informed by evidence generated in high resource settings, despite clear contextual differences. This gap limits the ability to define locally appropriate management thresholds. The present study therefore aimed to evaluate maternal and early neonatal outcomes following expectant versus immediate management of PPROM between 28 and 36 + 6 weeks gestation in a Zimbabwean tertiary hospital.
Methods
Study design and setting
This study was conducted as a prospective observational cohort study at Sally Mugabe central hospital, a tertiary referral center in Harare, Zimbabwe. The hospital serves predominantly urban and peri-urban population and functions as a major public sector referral facility for obstetric and neonatal care. The study was carried out over a 12-month period from March 2025 to March 2026
Study population, size and sampling techniques
The study population comprised pregnant women presenting with confirmed PPROM between 28 + 0 and 36 + 6 weeks gestation.
The sample size was calculated using the StatCalc function of Epi Info version 7 (Centers for Disease and Prevention, Atlanta, USA). A minimum sample size of 100 participants was estimated to allow for calculation of outcome proportions with a 95% confidence level and a margin of error of 5%, assuming a conservative expected frequency of 50% in the absence of precise local estimates.
A consecutive sampling approach was employed, whereby all eligible women presenting during the study period were recruited and followed prospectively until delivery and through the early neonatal period up to day 7 of life.
Eligibility criteria
Inclusion criteria were singleton pregnancies with confirmed diagnosis of PPROM within the specified gestational age range, and provision of informed consent.
Exclusion criteria included multiple gestations, known major fetal anomaly incompatible with life, maternal contraindications to expectant management including severe antepartum hemorrhage and maternal instability and incomplete clinical records precluding outcome assessment.
Exposure classification
Participants were classified into two groups based on clinical management:
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Expectant management: inpatient monitoring with delayed delivery after 24 hours of admission
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Immediate management: planned delivery within 24 hours of admission
Management decisions were made by the attending obstetric team based on clinical assessment and institutional practice. Allocation to management group was not influenced by study participation.
Data collection
Data were collected using a structured dated abstraction tool developed by the study. Information was obtained from patient interviews at admission clinical records and neonatal follow-up documentation. Participants were enrolled at admission and followed prospectively until delivery for maternal outcomes and up to day 7 of life for neonatal outcomes. Data collected included demographic characteristics of sharing history clinical presentation management interventions and maternal and neonatal outcomes.
Outcome measures
The primary outcome was neonatal deterioration, defined as a composite of neonatal intensive care admissions, suspected neonatal sepsis or respiratory compromise within the first seven days of life.
Secondary outcomes included NICU admission, length of stay in NICU, birth weight, and maternal outcomes, including suspected chorioamnionitis and antepartum hemorrhage.
Data management and statistical analysis
Data were initially entered into Microsoft Excel and checked for completeness and consistency. Cleaning procedures include range checks and verification against source documents. The data set was then exported to STATA version 19 for analysis.
Continuous variables were summarized using means and medians with interquartile range depending on distribution. Category of variables were presented as frequencies and percentages.
Comparisons between expectant and immediate management groups were performed using Chi squares and Fisher exact test for categorical variables, and Student T-test and Mann Whitney U for continuous variables.
Multivariable logistic regression analysis was conducted to identify factors independently associated with outcomes. Variables with P < 0.20 in bivariate analysis were considered for inclusion in the multivariable model. Statistical significance was set at P < 0.05.
Ethical considerations and ethical approval were obtained from the Joint Research Ethics Committee and the Sally Mugabe central hospital Ethics Committee. Written informed consent was obtained from all participants prior to enrollment.
Participant confidentiality was maintained using unique study identifiers, and all the data was stored securely with access restricted to the research team.
Results
A total of 108 women with preterm prelabor rupture of membranes (PPROM) were included in the analysis, of whom 64 (59.3%) were managed expectantly and 44 (40.7%) underwent immediate delivery. The baseline demographic and clinical characteristics were generally comparable between the two groups. The median maternal age was similar between women managed expectantly (22 years [IQR, 19–26]) and those who underwent immediate delivery (23.3 years [IQR, 18.5–27]; P = 0.895). Likewise, the proportion of married women was comparable between the expectant management and immediate delivery groups (92.2% vs. 86.4%, respectively; P = 0.621), as were the proportions of women in formal employment (17.2% vs. 6.8%, respectively; P = 0.209), nulliparous women (51.6% vs. 47.7%, respectively; P = 0.600), and women with a history of previous preterm birth (21.9% vs. 22.7%, respectively; P = 0.705). However, women managed expectantly were more likely to have attained secondary education (93.8% vs. 84.1%, respectively; P = 0.004), to have attended antenatal care (87.5% vs. 70.5%, respectively; P = 0.028), and to have had a greater median number of antenatal care visits (2 [IQR, 1–4] vs. 1 [IQR, 0–3], respectively; P = 0.024)
Gestational age at admission was similar between groups. However, women in the immediate delivery group were more likely to present in advanced labor and with greater cervical dilatation at admission. Fetal heart rate abnormalities were also more frequently documented in this group.
Gestational age at delivery was significantly higher among women managed expectantly. There was no statistically significant difference in signs of infection and admission between groups (Table 1)
Women in the expectant management group were significantly more likely to receive prophylactic antibiotics and antenatal corticosteroids. The median latency period in this group was 72 hours (Table 2).
Maternal outcomes were comparable between groups with no statistically significant differences observed in mode of delivery, suspected chorioamnionitis, or antepartum hemorrhage.
Neonates born to women managed expectantly were less likely to require neonatal intensive care unit (NICU) admission than those in the immediate delivery group (50.0% vs. 81.8%, respectively; P = 0.001). Among infants admitted to the NICU, the median duration of stay was also shorter in the expectant management group (1 day [IQR, 0–7] vs. 6 days [IQR, 1–7], respectively; P = 0.001). Mean birth weight was significantly higher among neonates in the expectant management group than in the immediate delivery group (2181.64 ± 771.64 g vs. 1532.79 ± 441.13 g, respectively; P < 0.001). Neonates in the expectant management group also had lower rates of suspected neonatal sepsis (37.5% vs. 61.4%, respectively; P = 0.015) and respiratory distress syndrome (51.6% vs. 79.6%, respectively; P = 0.003). There was no significant difference between groups in the incidence of necrotizing enterocolitis (3.1% vs. 4.6%, respectively; P = 1.000). Although neonatal deaths occurred only in the immediate delivery group (0.0% vs. 6.8%), this difference did not reach statistical significance (P = 0.065).
On univariable analysis, several clinical and treatment related factors were associated with management strategy. However, in multivariable logistic regression, only cervical dilatation, antibiotic administration, and corticosteroid use remained independently associated. Neonatal outcomes were not independently associated after adjustment (Table 3).
Discussion
This prospective cohort study found that expectant management of preterm prelabor rupture of membranes (PPROM) between 28 and 36 + 6 weeks’ gestation was associated with more favorable short-term neonatal outcomes, without a corresponding increase in clinically apparent maternal infectious morbidity. These findings suggest, in this setting, gestational prolongation under careful clinical monitoring may be associated with more favorable neonatal outcomes without substantially increasing clinically apparent maternal infectious morbidity.
The more favorable neonatal outcomes observed in the expectant management group are likely related to the later gestational age at delivery achieved in these women. The approximately three-week difference in gestational age at delivery between groups is clinically meaningful, as even modest increases in gestational maturity within the late preterm period are associated with substantial reductions in respiratory morbidity and need for intensive care (Engle et al., 2007; Reddy et al., 2009; Wang et al., 2004). The observed differences between management groups are therefore consistent with the established relationship between advancing gestational age and improved neonatal outcomes.
These findings are broadly consistent with existing evidence, although important contextual differences should be considered. The PPROMT trial demonstrated that immediate delivery in late preterm PPROM reduced maternal infection but was associated with increased neonatal respiratory morbidity and NICU admission (Morris et al., 2016). Although conducted in high-resource settings, the overall pattern observed was similar to that seen in this cohort. However, the greater differences in neonatal outcomes observed in this study may reflect the impact of limited neonatal care capacity in resource- constrained settings, where the consequences of prematurity are more pronounced. Observational studies from sub-Saharan Africa similarly report neonatal outcomes in PPROM are closely linked to gestational age at delivery and health system capacity, although findings remain heterogeneous (Mwimba et al., 2022; Okeke et al., 2014).
An important finding was that, after adjustment for potential confounders cervical dilatation, prophylactic antibiotic administration and corticosteroid administration remained independently associated with management strategy, whereas neonatal variables such as NICU admission, duration of NICU stay and birth weight did not. This suggests that the choice of expectant or immediate management was influenced primarily by clinical presentation and treatment-related factors rather than neonatal outcomes themselves. Women with less advanced cervical dilatation were more likely to be managed expectantly, reflecting established clinical practice in which the absence of active labor creates an opportunity for conservative management (Mercer, 2003). Similarly, the strong association between expectant management and receipt of corticosteroids and antibiotics reflects adherence to evidence from PPROM protocols, where these interventions are used to enhance fetal maturity, prolong pregnancy and reduce infectious morbidity (Kenyon et al., 2001; Roberts et al., 2017) . The loss of significance of neonatal variables after adjustments suggest that differences observed in an adjusted analysis may have been influenced by these clinical and treatment factors. This finding supports the view that neonatal outcomes in PPROM are closely linked to gestational age at delivery and optimization of perinatal care, a relationship that has been consistently demonstrated in both randomized trials and observational studies (Morris et al., 2016; Romero et al., 2014).
Despite concerns that expectant management following PPROM may increase the risk of maternal infection, this study did not demonstrate a significant difference in clinically apparent maternal infectious morbidity between the expectant and immediate management groups. Rates of suspected chorioamnionitis were low in both groups, suggesting that carefully selected women may be managed expectantly without a substantial increase in overt maternal infection. Similar findings have been reported in studies where expectant management was accompanied by antibiotic administration and close clinical surveillance (Mercer, 2003; Mwimba et al., 2022). However, these findings should be interpreted cautiously. Infection in PPROM exists along a spectrum ranging from subclinical intrauterine inflammation to overt chorioamnionitis, and reliance on clinical criteria alone may underestimate the true burden of disease (Higgins et al., 2016). The absence of routine laboratory markers or placental histopathology in this study may therefore have limited detection of subclinical infection.
These findings have important implications for PPROM in low-resource settings. In many sub-Saharan African health systems, clinical decision-making requires balancing the competing risks of prematurity and infection within the constraints of limited neonatal intensive care, restricted access to diagnostic investigations and variable availability of essential medication (Mwimba et al., 2022; Romero et al., 2014). While the observed differences in neonatal outcomes should be interpreted in the context of gestational age at delivery and exposure to evidence-based interventions, the findings suggest that expectant management can be implemented in carefully selected women without a substantial increase in clinically apparent maternal infectious morbidity. Importantly, this study provides prospective data from Zimbabwe, where evidence to guide PPROM management remains limited, and contributes context-specific evidence that may inform clinical practice in similar resource-constraint settings.
This study has several strengths. Its prospective design enabled systematic data collection and temporal assessment of maternal and neonatal outcomes within a real-world setting. However, several limitations should be acknowledged. Management allocation was not randomized, introducing the possibility of confounding by indication, as women undergoing immediate delivery were more likely to present with advanced labor or other clinical concerns. The relatively modest sample size may have limited statistical power to detect differences in less frequent outcomes. In addition, maternal infection was assessed primarily using clinical criteria without routine laboratory confirmation, raising the possibility of under-recognition of subclinical infection. Finally, neonatal follow-up was limited to the first seven days of life and therefore does not provide information on longer-term neonatal morbidity and developmental outcomes. Future research should include larger multicenter studies and extended neonatal follow-up. Where feasible, randomized controlled trials would provide stronger evidence regarding optimal management strategies for PPROM in low-resource settings.
In this Zimbabwean cohort, expectant management of PPROM between 28 and 36+6 weeks’ gestation was associated with more favorable short-term neonatal outcomes without a significant increase in clinically apparent maternal infectious morbidity. The observed differences in neonatal outcomes may reflect later gestational age at delivery and greater exposure to evidence-based interventions, including antenatal corticosteroids and prophylactic antibiotics. These findings contribute context-specific evidence to inform the management of PPROM in low-resource settings. Further, multicenter studies with longer neonatal follow-up and, where feasible, randomized controlled trials are needed to strengthen the evidence base for PPROM management approaches in similar settings.
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Sally Mugabe Central Hospital Ethics Committee and the Joint Research Ethics Committee prior to commencement of the study (JREC/332/2025; approved on 22 May 2025). Eligible women presenting with suspected preterm prelabour rupture of membranes between 28+ 0 and 36+6 weeks’ gestation at Sally Mugabe Central Hospital during the study period were identified consecutively by the clinical team and invited to participate. Written informed consent was obtained from all participants prior to enrolment. Participant confidentiality was maintained through the use of unique identifiers, and all study data were stored securely with access restricted to the research team.
Availability of data and materials
The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request
Competing interests
The author declare that they have no competing interest.
Funding
This research received no external funding.
Authors’ contributions
Belinda Mutibura conceptualized the study, collected data, performed data analysis, and drafted the manuscript.
Professor Malede Birara contributed to supervision, and critical revision of the manuscript.
Dr Rumbidzai Makoni contributed to manuscript review.
Acknowledgements
The author would like to acknowledge the staff of staff of Sally Mugabe Central Hospital for their support during data collection, and all participants who took part in this study.