A ten-year review of maternal mortality rates in the University College Hospital, Ibadan, Nigeria

Clinical Screening May be a Cost-Effective Way to Screen for Severe Anaemia

Clinical screening for pallor is one of the most common methods of screening for anaemia. Health workers examine the face, inner lower eyelids or conjunctiva, palms, nail beds, and other body parts for paleness or pallor that may be a sign of anaemia. MotherCare found 17 studies that evaluated the sensitivity and specificity of using pallor to identify individuals with anaemia. the focus was to review the sensitivity of pallor screening to detect individuals with severe anaemia and to make recommendations to improve the sensitivity of screening for pallor. the studies confirmed that sensitivities increased as the haemoglobin level decreased.

Maternal mortality at Nnamdi Azikiwe University Teaching Hospital, Southeast Nigeria: a 10-year review (2003-2012)

Background

Maternal mortality is high the world over, especially in sub-Saharan Africa, including Nigeria. Nigeria has consistently demonstrated one of the most abysmally poor reproductive health indices in the world, maternal mortality inclusive. This is a sad reminder that, unless things are better organized, Southeast Nigeria, which Nnamdi Azikiwe University Teaching Hospital (NAUTH) represents, may not join other parts of the world in attaining Millennium Development Goal 5 to improve maternal health in 2015.

Objectives

This study was conducted to assess NAUTH’S progress in achieving a 75% reduction in the maternal mortality ratio (MMR) and to identify the major causes of maternal mortality.

Materials and methods

This was a 10-year retrospective study, conducted between January 1, 2003 and December 31, 2012 at Nnamdi Azikiwe University Teaching Hospital, Nnewi, Southeast Nigeria.

Results

During the study period, there were 8,022 live births and 103 maternal deaths, giving an MMR of 1,284/100,000 live births. The MMR was 1,709 in 2003, reducing to 1,115 in 2012. This is to say that there was a 24.86% reduction over 10 years, hence, in 15 years, the reduction should be 37%. This extrapolated reduction over 15 years is about 38% less than the target of 75% reduction. The major direct causes of maternal mortality in this study were: pre-eclampsia/eclampsia (27%), hemorrhage (22%), and sepsis (12%). The indirect causes were: anemia, anesthesia, and HIV encephalopathy. Most of the maternal deaths occurred in unbooked patients (98%) and within the first 48 hours of admission (76%).

Conclusion

MMRs in NAUTH are still very high and the rate of reduction is very slow. At this rate, it will take this health facility 30 years, instead of 15 years, to achieve a 75% reduction in maternal mortality.

Pregnancy following eclampsia: a longitudinal study at korle-bu teaching hospital

SUMMARY OBJECTIVE

To find out the reproductive performance of patients in the immediate pregnancy following an eclampsia.

DESIGN

Longitudinal survey.

SETTING

Obstetrics Unit of Department of Obstetrics and Gynaecology in a teaching hospital.

SUBJECTS AND METHODS

Three hundred and ninety seven women whose previous pregnancies were complicated by eclampsia were followed up based on a schedule of antenatal care from 14-16 weeks gestation till delivery. The occurrence of hypertensive complications, timing of delivery, fetal outcome and birth weight were noted.

RESULTS

There were no cases of recurrent eclampsia and no maternal death. Pregnancy-induced hypertension and pre-eclampia recurred in 15.8% of the women. These recurrencies were more significant among those who had changed their male partners (p = 0.0005). The caesarean section rate was 65.9%. The mean ponderal indices in those who developed hypertensive complications were significantly lower than the normotensives (P<0.03 However, the overall perinatal mortality rate of 23.3 per 1000 deliveries was lower than the 62.8 per 1000 in the general obstetric population.

CONCLUSION

Previous episode of eclampsia does not necessarily affect perinatal and maternal outcome adversely in subsequent pregnancy, provided adequate antenatal surveillance and timely delivery are offered to the patients.

Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries

The World Health Organization estimates that 58% of pregnant women in developing countries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron in a supplement form, maternal anemia prevalence has not declined significantly where large-scale programs have been evaluated. During the period 1991-98, the MotherCare Project and its partners conducted qualitative research to determine the major barriers and facilitators of iron supplementation programs for pregnant women in eight developing countries. Research results were used to develop pilot program strategies and interventions to reduce maternal anemia. Across-region results were examined and some differences were found but the similarity in the way women view anemia and react to taking iron tablets was more striking than differences encountered by region, country or ethnic group. While women frequently recognize symptoms of anemia, they do not know the clinical term for anemia. Half of women in all countries consider these symptoms to be a priority health concern that requires action and half do not. Those women who visit prenatal health services are often familiar with iron supplements, but commonly do not know why they are prescribed. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. During iron supplementation trials in five of the countries, only about one-tenth of the women stopped taking the tablets due to side effects. The major barrier to effective supplementation programs is inadequate supply. Additional barriers include inadequate counseling and distribution of iron tablets, difficult access and poor utilization of prenatal health care services, beliefs against consuming medications during pregnancy, and in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. Facilitators include women's recognition of improved physical well being with the alleviation of symptoms of anemia, particularly fatigue, a better appetite, increased appreciation of benefits for the fetus, and subsequent increased demand for prevention and treatment of iron deficiency and anemia.

Eclampsia: 134 consecutive cases

OBJECTIVE

A retrospective analysis of all cases of eclampsia (134) at Korle Bu Teaching Hospital, Accra, Ghana, in 1991, was undertaken to determine future directions in prevention and management.

METHODS

One hundred and thirty-four consecutive cases of eclampsia were reviewed to assess possible risk factors, associated medical impact, and the usefulness of prenatal care.

RESULTS

Risk factors for the development of eclampsia include: young age, delivery in the rainy season, nulliparity, multiple pregnancy, prolonged labor, and lack of prenatal care. Eclampsia is associated with high maternal and perinatal mortality.

CONCLUSIONS

Future emphasis on prenatal clinics, and earlier detection and management of pre-eclampsia should lessen the incidence of this severe obstetric emergency.

Maternal mortality due to hemorrhage in Ghana

OBJECTIVE

This hospital-based review of maternal mortality due to hemorrhage in Kumasi, Ghana was undertaken to determine the factors related to and influencing cases of fatal maternal hemorrhage.

METHOD

The review was based on inpatient case notes, labor ward delivery notes, and operative records at the Maternity Block of the Komfo Anokye Teaching Hospital, Kumasi. The diagnoses were based on International Classification of Diseases (ICD) 9th and 10th editions. It covered the period 1981 to 1989.

RESULT

It was observed that maternal hemorrhage accounted for over 40% of all obstetric complications admitted and also 27% of all maternal deaths in the period under review. However, the case fatality rate for maternal hemorrhage decreased from 1.34% in 1981 to 0.7% in 1989. The cesarean section rate increased from 6.7% in 1981 to 9.1% in 1989. The maternal mortality rate over the period was 1140 per 100,000 births.

CONCLUSION

Based on this review and other related research, the following interventions have been planned for implementation in order to improve the situation: improving staff-patient relationship through training in interpersonal skills; ensuring 24-h availability of drugs, supplies and blood; establishment of a resuscitation unit at the casualty department so that first aid can be provided to patients with obstetric emergencies before transfer to the wards; establishment of a maternity care monitoring system to continually improve the quality of care; introduction of confidential enquiry into all maternal deaths in order to reduce their incidence. A monitoring and evaluation plan has been developed to assess regularly progress on implementation. Although, maternal deaths are due to multifactorial causes, it is hoped that these interventions, if successfully implemented, will contribute significantly towards the reduction of maternal deaths due to institutional factors, especially direct obstetric causes like maternal hemorrhage.

Church-based obstetric care in a Yoruba community, Nigeria

The analysis of data from available delivery registers in a Yoruba community, Nigeria suggests that about a half of recorded births between 1983 and 1990 were delivered in 'faith clinics' and not in a maternity centre. This paper reports on the mode of operation of these faith clinics in the town. It was observed that the faith clinics were under the control of mission-trained midwives all of whom claimed divine call as the reason for taking up the job. The midwives also listed prayer, fasting and guidance from the Holy Spirit as their main tools of trade. They offered no medicine to their clients and would not recommend any other treatment for them. Pregnant women that come for prenatal care are required to attend weekly prayer meetings for expectant mothers, take weekly baths in a particular river and maintain inward and outward cleanliness in their behaviour. The reasons for the relative success of these midwives in the town are discussed using a combination of economic, symbolic interactionist and pragmatic approaches. Recommendations on how best to tap their resourcefulness for a more effective health services delivery in the area include making them educators on and communicators of modern preventive health.

Mortality in acute gynecology: a developing country perspective

Over a 20-month period 109 deaths were recorded in the Acute Gynecology Ward, Kenyatta National Hospital, Nairobi; a rate of 5 deaths per month. Forty-one percent of the deaths were directly attributable to pregnancy and 46% were due to malignancy (mainly cervical carcinoma). Of the dead, 12.4% were teenagers and 63% below 35 years in age. They were generally of low parity. A tragic picture is presented of death of young women in their prime from almost entirely preventable causes. The need for improved maternal care, including family planning and cytological screening for cervical carcinoma is discussed and emphasized.

A sixteen year survey of maternal mortality associated with eclampsia in Ilorin, Nigeria

An analysis was made of 94 maternal deaths following eclampsia, occurring over a 16-year period. Maternal deaths were high in the very young, primigravida and in elderly women of higher parity. The overall maternal mortality over the years appears the same; while mortality associated with eclampsia seems dependent on time. Factors attributed to high maternal death rate from eclampsia are examined and recommendations made as to their prevention.

Maternal mortality inquiry in a rural community of north India

Community inquiry on maternal mortality was conducted in a rural area of North India. Maternal deaths were identified by multiple informants and investigated by doctors. Amongst 257 deaths registered in women in the 15-44 year age group, 55(21.4%) were maternal deaths. Maternal mortality ratio was 230 per 100,000 live births. Major causes were antepartum and postpartum hemorrhage (18.2%), puerperal sepsis (16.4%), severe anemia (16.4%), abortion (9.1%) and obstructed labor (7.3%). This rapid, simple and low cost method is recommended for application in areas where vital registration system is unsatisfactory.

A 15-year study of illegally induced abortion mortality at Ilorin, Nigeria

Fifty-three women died from complications of illegally induced abortion over a 15-year period. Seventeen (32.2%) of them were under 20 years of age, while 28 (52.8%) were nulliparous. The abortion rate was 210/100,000 with an abortion mortality rate of 0.9/100,00 women. Also the abortion ratio was 73.4/1000 live-births while the abortion mortality ratio was 4.20/1000 abortions. Sepsis and hemorrhage were the two commonest avoidable causes of death, and preventable measures were discussed.

Maternal mortality in Hong Kong 1961-1985

The maternal mortality rate in Hong Kong fell from 0.45/1000 total births in 1961 to 0.05/1000 total births in 1985. During the period between 1961 and 1985 there were a total of 438 maternal deaths and 2,193,012 births. Of the 438 deaths 150 (34%) were due to haemorrhage during pregnancy and childbirth (ICD 640, 641, 666), 89 (20%) were due to pre-eclampsia (ICD 642, 643) and 60 (13.7%) were due to ectopic pregnancy (ICD 633). Comparison of maternal deaths by cause between the periods 1961-1965 and 1981-1985 showed an 86% reduction in deaths due to haemorrhage and pre-eclampsia and a 72% reduction in deaths due to ectopic pregnancy. Pulmonary embolism was not a major cause of maternal mortality.

Maternal mortality in Anambra State of Nigeria

The maternal mortality rate (MMR) in 10 hospitals scattered all over Anambra State in a 5-year period was studied. The hospitals covered urban, semi-urban and rural areas. The MMR varied from 1.8 to 13 per thousand with a mean of 4.97 per thousand. The causes of and various factors influencing this high mortality rate are examined as well as the avoidable factors. Suggestions are made for its reduction based on accurate data collection, improved health facilities, improved socio-economic status and basic education.

Abortion-related morbidity and mortality in Benin City, Nigeria: 1973-1985

In a 13-year review of maternal deaths at the University of Benin Teaching Hospital, Benin City, abortion was one of the three major causes of death, accounting for 37 (22.4%) out of the 165 deaths. Induced abortion was responsible for 34 (91.9%) of these deaths. The usual victim is the teenage, inexperienced school girl who has no ready access to contraceptive practice. Death was mainly due to sepsis (including tetanus), hemorrhage and trauma to vital organs, complications directly attributable to faulty techniques by unskilled abortion providers, a by-product of the present restrictive abortion laws. Total overhaul of maternal child health services and the family health education system, as well as integration of planned parenthood at primary health care level into the health care delivery system, are suggested. Contraceptive practice should be made available to all categories of women at risk, and the cost subsidised by governmental and institutional bodies. Where unwanted pregnancies occur, the authors advocate termination in appropriate health institutions where lethal and sometimes fatal complications are unlikely to occur. In effect, from the results of this study and a review of studies on abortion deaths in Nigeria and other developing countries, it is obvious that a revision of abortion laws as they operate, notably in the African continent, is overdue.

Viral hepatitis as a major cause of maternal mortality in Addis Ababa, Ethiopia

Causes of maternal mortality were investigated in Addis Ababa, Ethiopia, from September 1981 to September 1983. Viral hepatitis ranked third among the leading causes of maternal mortality behind septic abortion and puerperal sepsis. There were 26 deaths from viral hepatitis during the 2-year study period for a hospital maternal mortality rate of 91.0 per 100,000 live births. Although 30% of women who died of all maternal causes received antenatal care in Addis Ababa, only 13% of women who died from viral hepatitis in our hospital study received antenatal care. Low socio-economic status (SES) has been shown to be associated with low antenatal care utilization and with an increased risk of protein malnutrition. Malnutrition is considered a predisposing factor for liver damage. Suggestions for reducing hepatitis transmission and maternal mortality through education, better hygiene, and improved sanitation are discussed.

Pregnancy termination: results of a community-based study in Lagos, Nigeria

A community survey in the Shomolu area of Lagos Nigeria showed the incidence of induced abortion to be 5.6%. Most of the abortions were carried out under medical supervision, using a combination of methods. Reasons for the abortions suggest that many were carried out on pregnancies that could have been prevented.

The demography of maternal mortality--seven Swedish parishes in the 19th century

Complications of childbirth is a leading death cause for women of reproductive ages in the developing countries today. The unique Swedish population statistics from the 19th century permit comparable historical studies. In seven Swedish parishes 170 maternal deaths were observed - 595 per 100,000 live births. Eclampsia, obstructed labor and hemorrhage were responsible for 92 deaths, and puerperal sepsis for only 15 deaths. Indirect obstetrical deaths, like pneumonia, tuberculosis, dysentery and heart diseases, accounted for 30.8% (41/133) of the specified death causes. With a time limit of 1 year instead of 42 days following delivery, maternal mortality was increased by 17%. Out of 14 married women 1 died from childbirth. Maternal deaths accounted for 40-50% of all deaths in the central ages of reproduction, leaving the motherless children with a highly increased death risk. Of the live born, 3% survived 5 years after the mothers' death. Of children aged 1-5 only 13% survived 5 years after the mothers death.

Maternal mortality--a world wide problem

Death during pregnancy and delivery is one of the leading causes of death among women in the developing countries. A review of literature, and a comparison of the decline of the maternal mortality in Sweden, concludes that maternal mortality is a sensitive socio-economic index of health in the society, but also that this death cause is one of the few that it is really possible to prevent by the impact of medical services - antenatal and delivery care.

Adolescent induced abortion in Benin City, Nigeria

Induced adolescent abortion is a major cause of maternal and gynecologic death in the University of Benin Teaching Hospital, where 244 out of 349 such cases seen from January 1, 1974 to December 31, 1979 were reviewed. Ignorance and lack of contraceptive facilities were contributory factors. To deal with this problem that has been pervasive throughout Nigeria for the past decade, the authors advocate sex education, systematic dissemination of information for planned and conscientious parenthood as well as free availability of alternative methods of contraception. Interruption of early pregnancy should be an essential component of a national family planning program.

Maternal mortality at twelve teaching hospitals in Indonesia-an epidemiologic analysis

Records on 36,062 maternity cases admitted to 12 teaching hospitals throughout Indonesia between 1977 and 1980 were analyzed. A hospital maternal mortality rate of 37.4/10,000 cases (39.0/10,000 live births) was derived that was about ten times higher than rates reported from developed countries in the early seventies. Hemorrhage, infection and toxemia accounted for 91.2% of deaths resulting from direct obstetric causes and for 86,1% of total deaths. It is postulated that if all pregnant women received adequate antenatal care, and if all women wanting no additional children were sterilized, maternal mortality would be cut in half. It is recommended that maternal health services in Indonesia be integrated into its successful family planning program.

Perinatal care by traditional healer-midwives of Nigeria

A group of 106 Yoruba traditional healers who practice midwifery were interviewed, by means of a semistructured questionnaire, regarding their knowledge of various aspects of perinatal care. The study confirmed earlier reports that these herbalists are indispensable to delivery services in Nigeria. Their procedures for assisting at births were described and the healers were found to be ignorant in such important areas as normal duration of labor, causes of various obstetric complications and functions of the placenta. It was concluded that the lacunae in their knowledge could be responsible for the high morbidity and mortality associated with their practice, and might also explain their unscientific and sometimes magico-religious approach to management of perinatal health problems. The need to provide them with appropriate training is emphasized.

Immunoglobulin levels in apparently normal and hypertensive Nigerian mothers at delivery

Immunoglobulin (Ig) levels in 68 apparently normotensive and 29 hypertensive mothers were estimated at parturition. There was a significantly higher incidence of elevated IgG levels in the hypertensive group (p less than 0.005) even though there were no differences in their mean concentrations. The mean IgA levels were not different in the two groups. IgM levels were higher in the hypertensive than in the normotensive mothers. The significance of these findings is discussed.