From Essential obstetric and newborn care › Chapter 1: Diagnosing and monitoring pregnancy · Médecins Sans Frontières, Current online edition, 2026
MSF guidance on identifying pregnancies requiring higher-level monitoring and arranging appropriate delivery settings.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Midwives, obstetricians, general practitioners providing antenatal care
- Evidence
- Expert consensus based on MSF field experience
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This section from MSF’s Essential Obstetric and Newborn Care guideline defines complicated pregnancy as any pregnancy where mother or infant faces increased risk due to obstetric or medical pathology or history. It categorises risk factors into three groups: those requiring higher-level monitoring during pregnancy, those requiring special precautions for delivery, and those requiring both.
The guideline stratifies delivery location based on risk. Certain conditions require delivery in Basic Emergency Obstetric and Newborn Care (BEmONC) facilities, including primiparity, grand multiparity (5 or more deliveries), height less than 1.50 m, and history of haemorrhage or instrumental delivery. More complex situations require Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facilities, particularly those routinely requiring caesarean section (history of uterine rupture, more than two caesarean births, transverse lie) or at high risk of emergency intervention.
Conditions requiring both closer monitoring and CEmONC delivery include pre-eclampsia/eclampsia, significant bleeding, severe anaemia (with transfusion available in third trimester), multiple pregnancy, and preterm rupture of membranes. The guideline emphasises that all BEmONC facilities must have effective referral systems to CEmONC facilities.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Height less than 1.50 m requires delivery in a BEmONC facility due to risk of foeto-pelvic disproportion
- Grand multiparity (5 deliveries or more) requires BEmONC delivery due to risks of uterine atony, related haemorrhage, and uterine rupture
- History of uterine rupture, more than two caesarean births, or vertical (classical) caesarean incision routinely require CEmONC facility delivery
- Transverse lie routinely requires caesarean section and CEmONC delivery
- Severe anaemia during third trimester requires transfusion availability at delivery
- Multiple pregnancy requires CEmONC delivery due to risks of obstructed labour, preterm delivery, hypertension, diabetes, growth restriction and postpartum haemorrhage
- All BEmONC facilities must have an effective system for referring patients to a CEmONC facility
- Pre-eclampsia and eclampsia require both closer monitoring during pregnancy and CEmONC delivery due to risks of coagulopathy, maternal death, abruptio placentae, and intrauterine foetal death
Risk stratification for delivery location in complicated pregnancy
Table extracted from the guideline
| Condition/History | Delivery Location | Primary Risk |
|---|---|---|
| Height < 1.50 m | BEmONC | Foeto-pelvic disproportion |
| Primiparity | BEmONC | Obstructed labour |
| Grand multiparity (≥5 deliveries) | BEmONC | Uterine atony, haemorrhage, rupture |
| History of haemorrhage | BEmONC | Recurrence, maternal death |
| History of uterine rupture | CEmONC | Requires caesarean section |
| History of >2 caesarean births | CEmONC | Requires caesarean section |
| Transverse lie | CEmONC | Requires caesarean section |
| Breech presentation (esp. primipara) | CEmONC | May require caesarean/complex manoeuvres |
| Pre-eclampsia/eclampsia | CEmONC | Eclampsia, coagulopathy, maternal death |
| Severe anaemia | CEmONC | Prematurity, vulnerability to haemorrhage |
| Multiple pregnancy | CEmONC | Obstructed labour, preterm delivery, haemorrhage |
| Preterm rupture of membranes | CEmONC | Infection, preterm delivery |
Source: Médecins Sans Frontières, Monitoring complicated pregnancies — MSF Essential obstetric and newborn care. Reproduced in summary form.
From the guideline
Verbatim
“it is essential that all BEmONC facilities have an effective system for referring patients to a CEmONC facility”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I recognise this MSF guidance addresses a critical gap in our maternal health system. Georgia has made significant progress in institutional delivery rates (exceeding 99%), but maternal mortality remains a concern, particularly in rural regions where risk stratification and timely referral are inconsistent. The specific thresholds—height less than 1.50 metres, grand multiparity of 5 or more deliveries, and the clear distinction between conditions requiring basic versus comprehensive emergency obstetric care—provide actionable criteria that should be integrated into our antenatal protocols. The primary implementation challenge for Georgia will be ensuring that rural maternity homes and district hospitals not only identify high-risk pregnancies using these criteria but also have functioning ambulance services and referral agreements with regional perinatal centres equipped for caesarean section and blood transfusion, particularly in mountainous areas where transport times can exceed two hours.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is directly applicable to Georgia’s three-tier maternity care system, which includes rural maternity homes, district hospitals with basic obstetric care, and regional/national centres with comprehensive capabilities. Georgian maternity services would need to ensure clear referral pathways between levels, particularly from basic to comprehensive facilities. The specific thresholds (height <1.50 m, grand multiparity ≥5 deliveries) should be incorporated into antenatal risk assessment protocols. Georgia's ongoing efforts to reduce maternal mortality (currently around 25 per 100,000 live births) would benefit from systematic application of these risk stratification criteria, ensuring high-risk pregnancies are identified early and delivered in appropriately equipped facilities with surgical and transfusion capabilities.
Questions this guideline answers
Quick answers
What defines grand multiparity and why does it require special delivery arrangements?
Grand multiparity is defined as 5 deliveries or more. It requires delivery in a BEmONC facility due to increased risks of uterine atony, uterine atony-related haemorrhage, and uterine rupture during delivery.
When should a woman with previous caesarean section deliver in a CEmONC versus BEmONC facility?
Women with a history of vertical (classical) caesarean incision or more than two caesarean births routinely require CEmONC delivery. Those with a single previous low segment transverse incision require CEmONC due to high risk of emergency caesarean need, though caesarean is not routine.
Why does maternal height matter for delivery planning?
Height less than 1.50 m indicates increased risk of foeto-pelvic disproportion (baby too large for pelvis), requiring delivery in a BEmONC facility where interventions for obstructed labour are available.
What conditions require both closer monitoring during pregnancy and CEmONC delivery?
Pre-eclampsia/eclampsia, bleeding during pregnancy, severe anaemia (requiring transfusion availability in third trimester), multiple pregnancy, preterm rupture of membranes, and history of abruptio placentae or severe pre-eclampsia all require both enhanced antenatal monitoring and CEmONC facility delivery.
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- Issuer
- Médecins Sans Frontières
- Guideline
- Essential obstetric and newborn care
- Chapter
- Chapter 1: Diagnosing and monitoring pregnancy
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- Section 1.3 of MSF Essential obstetric and newborn care guideline
- Audience
- Midwives, obstetricians, general practitioners providing antenatal care
- Evidence
- Expert consensus based on MSF field experience
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Monitoring complicated pregnancies. In: Essential obstetric and newborn care [Internet]. Paris: MSF; 2026 [cited 2026 Oct 14]. Chapter 1, Section 1.3. Available from: https://medicalguidelines.msf.org/GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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