In low-and middle-income countries, the disproportionate burden of high-risk pregnancy complications and mortality continues even though maternal and perinatal morbidity and mortality is improving due to increases in the coverage of facility births and antenatal care. Better and more efficient identification of women at high risk is key in the prevention of adverse consequences that were preventable, but, due to lack of specialists, diagnostic tools and referral systems many settings are limited in their ability to do so, making it paramount to adopt risk stratification tools that are simple, low-cost, and scalable in the management of triage, surveillance, and early intervention. One such practical tool is the Modified Coopland Scoring System (MCSS) that combines major maternal, obstetric, and current-pregnancy risk factors into a single risk score to classify antenatal women as low, moderate or high risk in order to institute focused care paths without relying on complex technologies.[1-5]

Available hospital- and community-based data suggest that MCSS-derived categorization is correlated with a continuum of poor maternal and neonatal outcomes, and that MCSS-oriented neonatal outcome gradient is significant also in resource-constrained settings, justifying its use as a programmatically relevant risk triage instrument in the latter. In a retrospective series with MCSS, high-risk pregnancy proportions were large and antepartum hemorrhage, miscarriages, and interventions were more likely to occur in these women, and their neonate had significantly more low birth weight (LBW) and respiratory distress, indicating a clinically significant division in the risking groups as well which can be used to plan the care. On the same note, potential use of MCSS indicates a large increase in LBW, low 5-minute Apgar, NICU admission, postpartum hemorrhage (PPH) and operative delivery in a high-risk stratum when compared to low-risk stratum, supporting its predictive performance on maternal and perinatal outcomes.[1,2,6,7]

The construct validity of MCSS conforms to the recognized epidemiology of perinatal risk in India and similar contexts: maternal age, parity, anemia, hypertensive disorders, diabetes, and other antecedents of LBW and perinatal mortality, are always implicated, and those determinants are all within or proximate to MCSS domains. Reviews of examples of systematic reviews in India note that all measurement antenatal risk score systems, such as Coopland-based systems, can predict adverse neonatal outcomes and can facilitate faster identification to provide early intervention but a study indicates there is a need to calibrate and further analyze the use of the various tools since they are heterogeneous. That LBW contributes significantly to neonatal morbidity, hypothermia, hypoglycemia, and infant death and that such instances may have life-course cardiometabolic implications, it is clinically and policy relevant to give priority to detection and prevention, especially in antenatal pathways, where programmatic efforts are being enhanced to improve ANC quality and nutrition supplementation.[3,4,8-10]

MCSS feedback: Retrospective reviews MCSS provides practical understanding of realities on the ground in terms of performance and service delivery gaps: they can quantify the burden of high-risk pregnancy in a catchment, demonstrate dose-response relationships across strata of risk, and reflect the outcome (operative delivery, PPH, LBW, Apgar scores, NICU utilization, perinatal mortality) against risk strata in ANC to plan staffing, blood bank requirements, and neonatal resuscitation capacities. Although retrospective designs are weak in forming causal inferences, and can down-sample confounders or those consequences occurring out of the facility evaluation, retrospective designs are ideal to feasibility appraisal and to narrow the risk thresholds and to formulate propositions to be tested prospectively or implemented research. Further, rational resource allocation would be facilitated by MCSS: the focus of specialist oversight, improved surveillance, and rapid referral in high-risk women (particularly pertinent in circumstances in which tertiary beds and operating theater time are limited)[1,2,4,6].

It is against this background that a retrospective analysis named as Utilizing Modified Coopland Scoring System to Identify and Predict the Outcome Of High-Risk Pregnancy aims at quantifying the allocation of antenatal risk through MCSS and testing its affiliation with maternal and neonatal outcomes in a low resource environment with the aim to influence the readiness to handle a risk-based intrapartum, hemorrhage prophylaxis, fetal growth monitoring, and neonatal preparedness. Positioning findings within the wider Indian evidence base, relating to perinatal risk factors and antenatal scoring tools, the study seeks to explain the extent to which the MCSS can be operationalized to enhance triage and better predict outcomes, and instituting a structured care pathway that can be flexed in response to local service issues.[1-4,6,8-10]

Study design and setting

This retrospective, case-record–based study was conducted in the Department of Obstetrics and Gynaecology, Mahaveer Medical College, Bhopal, Madhya Pradesh, India, a tertiary care teaching hospital.

Ethical and regulatory approvals

Research Advisory Committee (RAC) approval was obtained from the RAC Committee of Mahaveer Medical College, Bhopal, Madhya Pradesh, India, before study initiation.

Study period, population, and sample size

Medical records of antenatal women who received care at the institution between Jun 2022 and May 2024 were reviewed. A total of 200 antenatal women were included. Inclusion criteria were pregnant women aged 18–45 years who had attended a minimum of six antenatal check-ups at Mahaveer Medical College during the study period. Records with incomplete key variables for risk scoring or outcomes were excluded.

Data sources and variables

Data were extracted from antenatal case records and delivery registers. Information captured included:

• Socio-demographic characteristics: age, educational status.
• Obstetric history: parity and prior obstetric events.
• Medical and surgical history: chronic hypertension, heart disease, prior gynecological surgery.
• Current pregnancy details: antenatal complications, gestational age at delivery, mode of delivery, and maternal and fetal outcomes.

Risk stratification tool

Modified Coopland’s Scoring System was applied to numerically assess risk for each record, using third-trimester assessments. The tool comprised three parts:

• Part A: age and obstetric status.
• Part B: pre-existing medical or surgical conditions (e.g., chronic hypertension, heart disease, prior gynecological surgery).
• Part C: complications in the current pregnancy (e.g., antepartum bleeding, malpresentation, pre-eclampsia, gestational diabetes mellitus).

Total scores categorized women into low risk (0–3), moderate risk (4–6), and high risk (>7).

Outcomes

The primary objective was to estimate the proportion of high-risk pregnancies (HRPs) among antenatal women attending the hospital during the study period. Secondary objectives were to compare maternal and fetal outcomes across risk categories.

• Maternal outcomes: pregnancy outcome, complications during pregnancy, mode of delivery, postpartum hemorrhage (PPH), and maternal mortality.
• Fetal/neonatal outcomes: preterm birth (<37 weeks), low birth weight (LBW; <2.5 kg), intrauterine death (IUD), need for NICU admission, meconium aspiration syndrome (MAS), and congenital anomalies.

Statistical analysis

Descriptive statistics summarized baseline characteristics and risk category distribution. Categorical variables (e.g., risk group, mode of delivery, PPH, LBW, preterm birth, NICU admission) were compared using chi-square or Fisher’s exact tests as appropriate. Continuous variables were assessed for normality and summarized using means with standard deviations or medians with interquartile ranges. A two-sided P value <0.05 was considered statistically significant. Analyses were performed using standard statistical software.

TABLE 1: Distribution of study population according to the Age

                Fisher’s exact test*

Table 1 shows the vast majority of study participants belonged to the mild risk group and were of age 0 on the bilateral age score that was used in the study, at 97.4 percent, and the prevalence of individuals in the severe range was spurred by the occurrence of age score 2 in it (55.6 percent). In total 91.5 per cent of this cohort were in age category 0. The correlation of age category with the risk category was greatly strong (Fisher exact test, p<0.0001) meaning that there was a difference in age distribution among the different risk groups.

Table-2 Association between at-risk pregnancy groups and parity score

Table 2 shows there was a predominance of lower parity (score 0-1) in mild and moderate groups, yet severe risk was shooting toward higher parity: 33.3 percent of those had parity score 2 compared to 1.3 percent in mild. All in all, 67.5percent of the cohort possessed parity 0. There was a significant correlation between risk group parity score (p=0.003); in that the parity increases the occurrence of a higher parity risk.

TABLE 3: Association between at-risk pregnancy groups and maternal outcomes

Table 3 reveals operative delivery was much more common as the severity of risk increased (52.3% mild vs 86.8% moderate vs 66.7% severe; p<0.0001). Postpartum hemorrhage was infrequent on the whole (2.5%) but, in severe instances, it increased numerically (11.1%) with a borderline p-value (0.055). Such results show the increasing intervention requirements and the tendency of the increasing hemorrhagic complications with the increasing risk category.

TABLE 4: Association between at-risk pregnancy groups and neonatal outcomes

Chi-square test, Fisher’s exact test*

Table 4 shows adverse neonatal outcomes showed increment relation to the severity of the risk. There was a significant occurrence of low birth weight that increased to 66.7 percent (severe) against 25.5 percent (mild). There was also an augmentment in perinatal mortality(2.0% mild, 7.9% moderate, 22.2% severe; p=0.009). The quantitative findings were higher proportions in moderate/severe groups of preterm birth and NICU admission and were not statistically significant, and low 5-min Apgar was also very rare and not significant.

Advanced maternal age is consistently linked to higher rates of operative delivery, particularly cesarean section, with effects differing by parity—stronger in nulliparas for intrapartum/operative interventions and present prelabor among multiparas, aligning with the observed gradient in operative delivery across severity categories in the study.[11]Several studies report advanced maternal age associated with adverse perinatal outcomes (e.g., LBW, perinatal mortality), though findings vary by adjustment for comorbidities and care context; this supports interpreting age as a contributor within multifactorial risk stratification rather than a uniform independent driver across all outcomes.[11-13]Parity contributes to hemorrhage risk and interacts with age and mode of delivery; modeling and observational data identify parity along with age and mode as important predictors of PPH risk, consistent with the study’s observation that higher parity clustered in the severe-risk group and that hemorrhage trends rose with severity.[14-16]

Operative delivery increases with maternal risk factors such as advanced age, mirroring the study’s severity-linked escalation in operative deliveries and need for intrapartum readiness.[11]Severe PPH risk is elevated with intrapartum cesarean compared with prelabor cesarean, and influenced by factors such as general anesthesia, multiple pregnancy, low predelivery hemoglobin, hypertensive disorders, and high birthweight—converging with the study’s rationale for targeted PPH prophylaxis in higher-risk strata and optimization of anemia/comorbidity management.[14-17]

Low birth weight is robustly associated with unfavorable perinatal outcomes, and maternal risk factors (including anemia) increase risks of LBW, preterm birth, and perinatal mortality—supporting the study’s finding that LBW and perinatal mortality climb with maternal risk severity and the recommendation to optimize modifiable contributors (nutrition, anemia correction).[18-20]

The graded increase in perinatal mortality across risk categories is directionally consistent with literature linking higher-risk maternal profiles and LBW to mortality; although some cohorts find no independent age effect after adjustment, most agree fetal vulnerability rises with compounded maternal risk load.[11,12,18,19] Low 5-minute Apgar scores strongly correlate with neonatal mortality at population level, even as statistical significance may vary in smaller samples—supporting the study’s interpretation that nonsignificant trends in Apgar and NICU admissions could reflect power limitations and warrant enhanced surveillance.[21-23]

Systematic reviews of antenatal risk scoring systems show that composite risk tools predict outcomes such as neonatal death, stillbirth, preterm birth, LBW, low Apgar, and NICU admission—corroborating the study’s conclusion that structured risk stratification anticipates operative needs and identifies dyads at risk for LBW and perinatal loss.[24] While advanced maternal age frequently increases operative delivery, its independent association with perinatal outcomes is context-dependent; cohorts with differing comorbidity burdens and care access show variable perinatal effects after adjustment, underscoring the study’s call to adjust for confounders like hypertensive disorders and diabetes.[11,12] Postpartum hemorrhage was uncommon but trended higher in severe-risk categories in the study; external data emphasize that PPH risk is strongly modulated by delivery mode (especially intrapartum cesarean), anesthesia type, anemia status, and hypertensive disease—supporting protocolized prophylaxis and active third-stage management in higher-risk groups.[14-17] The study’s nonsignificant rises in preterm birth, low Apgar, and NICU admissions are consistent with literature showing directionally adverse trends that sometimes fail to reach significance in single-center or underpowered samples, yet carry clinical importance warranting preparedness and surveillance.[21-24]

This retrospective review from a tertiary center in Bhopal demonstrates that the Modified Coopland’s Scoring System (MCSS) reliably stratifies antenatal risk and correlates with a graded rise in adverse outcomes. Higher risk categories showed substantially greater operative delivery rates and a trend toward increased postpartum hemorrhage, indicating the need for enhanced intrapartum preparedness and hemorrhage prophylaxis. Neonatal outcomes deteriorated with severity, with significantly higher low birth weight and perinatal mortality in severe-risk pregnancies, while preterm birth, low 5-minute Apgar, and NICU admissions trended higher but were not statistically significant, suggesting limited power. Age and parity were strongly associated with escalating risk, highlighting key demographic contributors in this setting. Overall, integrating MCSS into routine antenatal care can guide targeted surveillance, resource allocation, and multidisciplinary planning for moderate-to-severe risk pregnancies. Future work should adjust for confounders and assess structured risk-based care pathways to reduce low birth weight and perinatal loss.

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