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SOURCE:
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The main feature article has been contributed by Dr. Yusuf Ahmed, Head of Obstetrics & Gynaecology Department of the School of Medicine, University of Zambia, one of the Zambian contributors to the Monograph on Complications of Unsafe Abortion in Africa, a publication of the Commonwealth Regional Health Community Secretariat.
In Zambia, the maternal mortality ratio is estimated at 730 per 100,000 live births while fertility stands at just above 6 children per woman. High fertility and a variety of social, cultural and economic factors contribute a great deal to maternal mortality rates. A Zimbabwean study found that all situations associated with diminished or absent social support, i.e. being single, divorced, widowed, one of several wives, cohabiting or self-supporting carried an increased risk for maternal mortality, especially in the rural areas.
In Guinea Bissau, traditional and spiritual concepts surrounding pregnancy and childbirth were found to be preventing appropriate nutrition, antenatal and delivery care, underscoring the need to develop appropriate health education programmes to overcome prevailing prejudices towards the modern health sector, and the need to encourage integration of traditional practitioners into the existing primary health care system.
Health information systems should be strengthened so that there can be adequate provision of acurate information on pregnancy related morbidity and maternal mortality. Abortion still continues to take the cake', with up to 50% maternal deaths in Africa arising from complications of abortion.
Anaemia & Pregnancy
Our intentions were to determine the incidence of the association of anemia and pregnancy, to evaluate maternal and fetal prognosis and to offer some recommendations regarding national health care policies. This prospective study lasting 30 months included all cases of anemia and pregnancy detected by
clinical and laboratory examinations. Thus 13,191women were enrolled in the study but only 1408 cases of anemia and pregnancy (10.67%). Primipara and grand multipara were particularly at risk. Severe forms of anemia and pregnancy were encountered often (51.71%). Maternal and fetal prognoses were very poor. Maternal mortality was 852/100,000, accounting for 65% of the maternal mortality of the department.
The stillborn rate was 50 per thousand. This is a serious health problem which needs to be dealt with by a national health education programme.
Diallo MS. Diallo TS. Diallo FB. Diallo Y. Camara AY.
Onivogui G. Keita N. Diawo SA.
"Anaemia & Pregnancy" Revue Francaise de Gynecologie et d Obstetrique 90(3):138-41,1995 Mar.
Anaemia & HIV in pregnant women:
Maternal mortality has recently received attention as a neglected public health problem in many developing countries where mortality rates are estimated to be
8-200 times those in developed countries. Most maternal mortality estimates in sub-Saharan Africa have used retrospective methods because of the lack of large population-based studies. The Mangochi Malaria Research Project, a trial of antimalarial chemoprophylaxis in pregnant women, provided an opportunity to examine prospectively mortality among the study women. Among 4,053 monitored pregnant
women, 27 women were known to have died during pregnancy, labor, delivery and the one-year follow-up period. Three women died during the antenatal period and 12 died within six weeks of delivery for an estimated maternal mortality rate of 370 per 100,000
pregnant women; this rate was consistent with rates reported from retrospective surveys in Malawi. Twelve women died between three and 10 months after delivery, and the mortality rate in this non-maternal period was estimated to be 341 per 100,000. Mortality rates in the maternal and nonmaternal periods were surprisingly similar. Human immunodeficiency virus type-1 (HIV-1) infection and anemia were strongly
associated with death in the nonmaternal period. Mortality among infants of mothers who died was 3.7 times higher than the rate of death among infants born to mothers who survived. This study highlights that for rural Malawian women, pregnancy and delivery are risky periods, that the death of the mother adversely affects the survival of her children, and that HIV and anemia are important contributors to nonmaternal
mortality in reproductive-age women. Strategies to reduce mortality among women of child-bearing age in sub-Saharan Africa must focus on decreasing the complications of pregnancy and delivery, and address important preventable causes of death, such as anemia and HIV infection.
McDermott JM. Slutsker L. Steketee RW. Wirima JJ. Breman JG.
Heymann DL. "Anaemia & HIV in pregnant women: rural Malawi" American Journal of Tropical Medicine & Hygiene 55(1Suppl):66-70, 1996.
Aids & maternal mortality
AIDS is the leading cause of death amongst adults in Zimbabwe and the major contributor to rising rates of infant, child and maternal mortality. About 9% of the
population are HIV-positive and the number of orphans due to AIDS is projected to reach 600,000 by the year 2000. Around 90% of HIV transmission in Zimbabwe
happens through heterosexual intercourse.
O'Donoghue J. "Zimbabwe's AIDS programme for schools"
Promotion et Education 3(2):7-12, 45, 1996 Jun.
Haemorrhage, infection & hypertensive disease
OBJECTIVE: Determination of the maternal mortality ratio and the main causes of maternal death.
SETTING: Pelonomi Hospital, a tertiary care and referral hospital in Bloemfontein, South Africa.
METHODS: Review of prospectively completed structured questionnaires on all maternal deaths from 1986 to 1992.
RESULTS: The maternal mortality ratio at our institution was 171 per 100 000 live births. Haemorrhage (25%), infection (24%) and hypertensive disease (18%) were the most important causes of death. Seventy-one per cent were direct obstetric deaths and 23% indirect; in the remaining 6%, the cause was uncertain. Of all deaths, 35% were considered preventable.
CONCLUSIONS: The maternal mortality ratio has decreased since our previous report for the period 1980-1985, and haemorrhage has replaced infection as
the leading cause of death.
Spies CA. Bam RH. Cronje HS. Schoon MG. Wiid M. Niemand
I. "Haemorrhage, infection and hypertensive disease"
South African Medical Journal 85(8):753-5, 1995 Aug.
Acute renal failure in pregnancy:
This study compares our experiences of the incidence and etiology of acute renal failure in pregnancy (ARF-P) in patients requiring hemodialysis, a decade
after a previous publication from our institution. A retrospective analysis of the hospital records of 42 patients with a diagnosis of ARF-P during a 3-year period from 1990 to 1992 was undertaken [16% of the total number of acute renal failure (ARF) patients
needing hemodialysis]. The incidence of ARF-P (expressed relative to all cases of acute renal failure requiring hemodialysis) decreased from 24.6% (1978) to 16% (1992: p = 0.03). Preeclampsia-eclampsia (PE:E) replaced septic abortion as the principal cause of ARF-P. In those patients with PE:E, thrombocytopenia (platelet count < 150 x 10(9)/L) occurred in all, while 33% developed the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). Ingestion of herbal toxins was noted mostly in patients with septic abortion. Maternal mortality was 5% and was due to multiorgan failure complicating septic abortion. The perinatal mortality of 55%
occurred in women with early gestation, thrombocytopenia, and high serum creatinine levels.
Acute renal failure in pregnancy continues to present a challenge in South Africa, a developing country. There were significantly more obstetric than gynecological
causes in 1992 (p = 0.0003). This could be attributed to the steady decline in septic abortion since 1978. The main contributor to obstetric-related causes was PE:E.
Greater emphasis should therefore be placed on detecting hypertension at antenatal visits.
Randeree IG. Czarnocki A. Moodley J. Seedat YK. Naiker IP.
"Acute renal failure in pregnancy" Renal Failure 17(2):147-53, 1995 Mar.
Mortality associated with multiple gestation:
BACKGROUND. Multiple gestation is associated with increased maternal, perinatal, and infant mortality. The prevalence of multiple gestation varies widely with the
highest rates reported among populations in Africa. There have been few population-based studies of the impact of multiple gestation on pregnancy outcomes in
sub-Saharan Africa.
METHODS. Data from a 1987-1990 prospective study of the effect of malaria chemoprophylaxis among pregnant women on birthweight and mortality of their
infants in a rural area of Malawi were used to estimate the prevalence of multiple gestation and to quantify the risk of mortality associated with multiple gestation
compared with single gestation.
RESULTS. There were 88 (2.2%) multiple gestations among 4049 women. Mortality was high; only 38% of mothers were known to have all their infants survive to 1 year,
compared with 74% in singleton gestations. The increased mortality associated with multiple gestation was due to two factors: a higher frequency of low birthweight and a fourfold increase in perinatal mortality among the infants with birthweights > or =
2500 g and among infants with unknown birthweight. We estimated that multiple gestation contributes to 5.5% of the perinatal, 1.2% of the postperinatal, and
11.5% of the maternal deaths in this population.
CONCLUSION. Multiple gestation in Malawi contributed to increased perinatal and maternal mortality, but did not increase the risk of mortality after the perinatal period.
McDermott JM. Steketee R. Wirima J. "Maternal mortality associated with multiple gestation in Malawi" International Journal of Epidemiology 24(2):413-9, 1995 Apr.
Perinatal and maternal mortality associated with retained second twins:
OBJECTIVES: The aim of this study of retained second twins admitted to Korle-Bu Hospital between 1988 and 1993 was to identify the factors contributing
to the mode of delivery, perinatal and maternal mortalities, and draw up recommendations to improve outcome.
METHODS: The study consisted of a review of record cards, outpatient admission and discharge books, delivery books, and inpatient case notes of women admitted with retained second twins of 28 weeks' or more gestation during the study period.
RESULTS: Of the 65 cases fully reviewed, 33 (approximately 50%) were delivered by cesarean section due mainly to abnormal lie with or without shoulder impaction. The rest were assisted deliveries, mainly vertex deliveries or breech extractions. The
perinatal mortality of the retained second twins was 38.5% compared with 12.3% for the first twins. Although in general the longer the interdelivery interval, the greater the second twin perinatal mortality risk, no clear direct correlation could be established.
There was one perioperative maternal mortality due to anaphylactic reaction to intramuscular morphine injection.
CONCLUSION: Irrespective of the antenatal course and early labor findings, twin delivery should be undertaken in a unit equipped for cesarean section and
assisted delivery. The unacceptably high perinatal mortality of retained second twins could thus be significantly reduced.
Lassey AT. Ghosh TS. "Perinatal and Maternal Mortality associated with retained second twins" International Journal of Gynaecology & Obstetrics 48(3):277-81, 1995
Abortion & Maternal Mortality:
Unsafe abortions and their complications are a major cause of maternal mortality. Hospital based studies from most African countries confirm that up to 50% of
maternal deaths are due to abortion. This paper reviews problem of induced abortion in sub-Saharan Africa. Issues of prevalence and prevention are addressed
while acknowledging the need to review the legal regimes operating in these countries. [References: 51]
Rogo KO. "Abortion & maternal mortality"
East African Medical Journal 70(6):386-95, 1993 Jun.
Anthropological Factors in MMR:
A Mexican study of life histories of women who died from maternal causes identified a lack of value attached to the care of the pregnant woman as one of the main
constraints to the prevention of maternal mortality. The immediate family members and women who died had considered pregnancy as a "natural" event. Maternal complications were not perceived as meriting appropriate medical attention. This negative scenario combined with rivalry between providers of traditional and modern medical care, led to a passivity which ultimately prevented appropriate maternal care.
These social and cultural values, which reinforce the lack of attention given to pregnant women call for educational efforts on the part of community leaders and health service providers to change the perceptions of pregnancy and childbirth as a completely "natural" event which needs little health care attention. The conflict between traditional birth attendants and the medical profession needs to be addressed by the
respective authorities and educational solutions must be identified to rectify the existing lack of knowledge amongst TBA's. The question of developing a frame-work for collaboration between the traditional and the modern sector of health care will need to be addressed in the future.
Elu MC. "Mexico: maternal deaths, fertyility patterns, and social cost-- an
anthropological study" World Health Statistics Quarterly - Rapport Trimestriel de Statistiques Sanitaires Mondiales 48(1):47-9, 1995.
Traditional and spiritual concepts surrounding pregnancy & childbirth:
The study examined the range of traditional and spiritual concepts surrounding pregnancy and childbirth in Guinea Bissau. Most of these beliefs and
practices prevent appropriate nutrition, antenatal, and delivery care. Knowledge of danger signs and risk factors is virtually absent. When illness becomes manifest the women tend to consult competing sectors of traditional and modern medicine, but no referral or cooperation exists between them. The perceived curative orientation of antenatal service results in their underutilization. The study findings reinforce the need
to develop appropriate health education programmes to overcome prevailing prejudices towards the modern health sector and covering a wide range of health
education topics, including danger signs in pregnancy and the accompanying antenatal and delivery care. The integration of traditional practitioners into the existing primary health care system should be encouraged. The modern sector would benefit from the upgrading of personnel, equipment, and drugs as well as the development of integrated maternal and child health and family planning services. Continuous education should help nurses and midwives to become more responsive to the special needs of pregnant women and to provide family planning education. Outside the health sector, school health education should include sex education in order to avoid unwanted, early pregnancies. Finally the health information system should be improved to provide accurate information on pregnancy related morbidity and maternal mortality.
Oosterbaan MM. da Costa MV. "Traditional and spiritual concepts surrounding pregnancy and childbirth - Guinea Bissau" World Health Statistics Quarterly 48(1):39-43, 1995.
MMR & attitudes:
Maternal mortality and morbidity estimates in Nigeria continue to be dramatically high largely because maternal services, especially in rural areas, are often deficient and inappropriate to women's situations. The Safe Motherhood Project in Zone A examined thepregnancy-related knowledge, attitudes, and practices of community members, and women's use of community maternal health services. Focus-group discussions and interviews confirmed a number of recent findings by other studies; they also documented extensive hostility between the two most commonly used health-care providers: traditional birth attendants and midwives. The hostility resulted in rumors,
deliberate attempts to discourage women from seeking higher levels of care, and refusals to accept referrals or treat patients, which were found to be serious
constraints to good maternal care in the targeted rural area.
Okafor CB. Rizzuto RR. "MMR & attitudes in rural Nigeria"
Studies in Family Planning 25(6 Pt 1):353-61, 1994 Nov-Dec.
Risk factors in maternal mortality:
A community-based incidence case-referent study was undertaken in a rural and an urban setting in Zimbabwe in order to define risk factors associated with maternal
deaths at family, community, primary and referral health care levels. Referent subjects were drawn from place or area of delivery for each consecutive maternal death. Using a multiple source confidential reporting network for all maternal deaths, the maternal mortality rate for the rural setting was 168/100,000 live births and that for the urban setting was 85/100,000 live births. A model for interacting factors contributing to
maternal mortality was designed. Haemorrhage and abortion sepsis were the major direct causes while malaria was the leading indirect cause in the rural setting. In the urban setting, eclampsia, abortion and puerperal sepsis were the leading causes of maternal deaths. It was found that all situations associated with diminished, or absent social support, that is, being single (Odds Ratio = 4.7, 95% CI = 2.2-9.8) divorced,
widowed, one of several wives, cohabiting, or self-supporting carried an increased risk for maternalmortality, especially in the rural area. Income and level of education for index and referent subjects were comparable, probably because of the limited part of the population under study that belonged to a more affluent class. Distribution of cases and referents by religious-affiliation was also comparable. Age > 35 years and parity > 6 were significant risk factors for maternal mortality in the rural setting, whereas bad
reproductive history with reported stillbirth or abortion constituted a high risk both in the city and in the rural areas (Odds Ratios 4-6).
Mbizvo MT. Fawcus S. Lindmark G. Nystrom L. "Risk factors in maternal mortality"
Social Science & Medicine 36(9):1197-205, 1993 May.
Reducing maternal and perinatal mortality:
The purpose of this article is two-fold: (i) to lay out conceptual frameworks for programming in the fields of maternal and neonatal health for the reduction of
maternal and peri/neonatal mortality; (ii) to describe selected MotherCare demonstration projects in the first 5 years between 1989 and 1993 in Bolivia, Guatemala, Indonesia and Nigeria. In Inquisivi, Bolivia, Save the Children/Bolivia, worked with 50 women's groups in remote rural villages in the Andean mountains.
Through a participatory research process, the 'autodiagnosis', actions identified by women's groups included among others: provision of family planning through a local non-governmental organization (NGO), training of community birth attendants, income
generating projects. In Quetzaltenango, Guatemala, access was improved through training of traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery/neonatal complications, while quality of care in health facilities was improved through modifying health professionals' attitude towards TBAs and clients, and implementation of management protocols. In Indonesia, the University of Padjadjaran addressed issues of referral and emergency obstetric care in the West-Java subdistrict of Tanjunsari. Birthing homes with radios were established in ten of the 27 villages in the district, where trained nurse/midwives provided maternity care
on a regular basis. In Nigeria professional midwives were trained in interpersonal communication and lifesaving obstetric skills, while referral hospitals were
refurbished and equipped. While reduction in maternal mortality after such a short implementation period is difficult to demonstrate, all projects showed improvements in referral and in reduction in perinatal mortality.
Kwast BE. "Reducing maternal & perinatal mortality" European Journal of Obstetrics, Gynecology, & Reproductive Biology 69(1):47-53, 1996 Oct.
Management of snake and spider bite in pregnancy:
The fact that venomous snakebites during pregnancy result in a high fetal wastage and that both venomoussnake and spider bites may cause maternal mortality,
makes this an important, albeit uncommonly encountered, entity in obstetrics. Perhaps the most difficult aspect of dealing with this clinical situation is that care must be rendered simultaneously to two patients with a complex interrelationship. The object is
to optimize maternal care and increase the chances of successful pregnancy. Adherence to the tenet that what is best for the mother is best for the fetus will probably
produce the most satisfactory outcome.
Pantanowitz L. Guidozzi F. "Management of snake and spider bites in pregnancy"
Obstetrical & Gynecological Survey 51(10):615-20, 1996 Oct.
Treatment of Eclampsia:
Eclampsia is a leading cause of maternal mortality. The prevention of seizure activity in pre-eclampsia and recurrent seizures in eclamptic patients is an essential
aspect of management. Many drugs with anticonvulsant properties have been used to treat patients with pre-eclampsia and eclampsia. Magnesium sulfate is a significantly better drug than either diazepam or phenytoin for preventing recurrent seizures in
eclamptic patients. Magnesium sulfate has diverse cardiovascular and neurological effects and also alters calcium metabolism. Although the drug crosses the placenta and may affect the fetus, these effects are clinically small and fetal morbidity has been shown to be reduced in randomised studies comparing magnesium sulfate to either phenytoin or benzodiazepines. Dosage regimens of magnesium sulfate are empirical. Because adverse effects of this agent are related to toxicity, the establishment of
greater efficacy by using higher dosage regimens needs to be tested against a greater risk of adverse effects. The most serious toxicity related to magnesium sulfate
use is magnesium sulfate use is neuromuscular blockade that may result in respiratory arrest. Magnesium sulfate is now the drug choice for treating eclamptic patients. However, further studies are required to establish the role of this agent as a prophylactic agent in the prevention of eclampsia.
Anthony J. Johanson RB. Duley L. "Magnesium sulphate in the treatment of Eclampsia" Drug Safety 15(3):188-99, 1996 Sep.
Treatment of eclampsia:
OBJECTIVE: To evaluate the effectiveness of magnesium sulphate in the treatment of eclampsia and pre-eclampsia by a systematic quantitative overview of controlled clinical trials.
DESIGN: Online searching of the MEDLINE database between 1966 and 1995, and
scanning of the bibliography of known primary studies and review articles on the use of magnesium sulphate in eclampsia and pre-eclampsia. Study-selection, study quality assessment and data extraction were performed independently by two reviewers under masked conditions. Where possible outcome data from trials were pooled and summarised using the Mantel-Haenszel method.
PARTICIPANTS: One thousand seven hundred and forty-three women with eclampsia and 2390 with pre-eclampsia included in nine randomised trials that evaluated the effects of magnesium sulphate.
MAIN OUTCOME: Seizure activity and maternal death.
RESULTS: In eclampsia, recurrence of seizures was less common with magnesium sulphate therapy compared with phenytoin (odds ratio [OR] 0.27, 95%
CI 0.17-0.45, P = 0.00) and diazepam (OR 0.41, 95% CI 0.30-0.57, P = 0.00). As indicated by the point estimate, there was a trend towards a reduction in maternal mortality with magnesium sulphate in eclampsia (OR 0.51, 95% CI 0.24-1.07, P = 0.10
versus phenytoin; OR 0.78, 95% CI 0.41-1.45, P = 0.52 versus diazepam). When used for seizure prophylaxis in pre-eclampsia, magnesium sulphate was found to be more effective than phenytoin (OR 0.15, 95% CI 0.03-0.72, P = 0.01).
CONCLUSION: Magnesium sulphate is a superior drug in preventing the recurrence of seizures in eclampsia and in seizure prophylaxis in pre-eclampsia.
Chien PF. Khan KS. Arnott N. "Magnesium sulphate in the treatment of Eclampsia"
British Journal of Obstetrics & Gynaecology 103(11):1085-91, 1996 Nov.
Measles and pregnancy:
Measles is a highly infectious disease. In Mexico, nevertheless the postvaccine era, continue being an endemic disease. It has been described that measles increase the maternal mortality, because pregnant women have a more severe clinical course of the
disease; measles also has negative repercussion on pregnancy, increasing the frequency of premature labor. We report two pregnant women complicated with measles, both of them had a clinical course of the disease and they didn't have obstetric or neonatal complications.
Villagrana-Zesati R. Figueroa-Damian R. Santamaria-Corona H.
Ortiz Ibarra FJ. "Measles and pregnancy" Ginecologia y Obstetricia de Mexico 64:459-62, 1996 Oct.
Caesarian section:
OBJECTIVE: Our purpose was to examine the pregnancy and neonatal outcomes at a perinatal center with a consistent cesarean section rate approximately half the national average. STUDY DESIGN: Ten years of vaginal delivery and cesarean section rates (1983 to 1992) and 5 years of mortality and morbidity outcomes (1988 to 1992) were compared with national health statistics and national health objectives.
RESULTS: The cesarean section rate during the 10-year period ranged from 10% to 15%, with an average of 12.5%. The cesarean section rate for the 5 years during which
maternal and neonatal outcome data were obtained was 11.3%. The forceps and vacuum extraction rates during that time were consistently less than 5%. The
nurse-midwifery service delivered approximately 36% of all babies during this period. In an examination of maternal mortality, we discovered only one death during the 5-year interval. The rate of maternal admission to the intensive care unit after delivery was
0.2%. The percent of women who received blood transfusions was 1%. The average length of stay for both vaginal and cesarean section deliveries declined steadily across the whole interval and was 2.5 days for a vaginal delivery and 5.5 days for a cesarean section. An examination of neonatal morbidity and mortality revealed an admission rate to the intensive care unit of less than 6%. The distribution of Apgar scores
indicated less than 4% of neonates had scores < or = 3 at 1 minute; 0.5% had scores < or = 3 at 5 minutes. The neonatal death rate was 614 per 100,000 births, and
fetal mortality was 729 per 100,000 births from 1988 to 1992.
CONCLUSIONS: The lowest safe cesarean sectionrate is not known; it will undoubtedly vary with location and patient mix. We believe that we have been
able to establish a rate of cesarean section one half of the national average with good maternal and fetal outcomes. This has been accomplished through a vigorous prenatal care program, excellent perinatal and infertility services, a vigorous program of vaginal
birth after cesarean section, and a competent nurse-midwifery service.
Rooney BL. Thompson JE. Schauberger CW. Pearse CA. "Caesarian section"
Journal of Perinatology 16(3 Pt 1):215-9, 1996 May-Jun.
Pregnancy with epilepsy:
OBJECTIVES: To study the course of epilepsy in pregnancy and to assess the perinatal outcome.
METHODS: A retrospective analysis of 219 pregnant patients with epilepsy. The type of epilepsy, drug therapy and seizure frequency were documented. The perinatal outcome of 157 pregnancies with epilepsy was analyzed and compared with that of 471 normal gravidas of similar age and parity.
RESULTS: Generalized seizures occurred in 203 patients, partial seizures in 13 patients and complex partial seizures in three patients. One hundred fifty-two patients (69.41%) were on monotherapy. Carbamazepine was the most common drug (56.58%) used. Ninety-five patients (43.38%) had seizures in the current pregnancy, five of whom had status epilepticus. There was no maternal mortality in status epilepticus. There was no difference in perinatal outcome between the study and control groups. The incidence of congenital malformations was higher in the control group (5/476, 1.05%) than in the study group (1/160, 0.63%). The incidence of
low-birth-weight babies was higher in the study group in patients with gestational seizures.
CONCLUSION: The course of pregnancy and perinatal outcome was not altered by epilepsy. There was no increase in the incidence of congenital malformations with the use of monotherapy.
Sawhney H. Vasishta K. Suri V. Khunnu B. Goel P. Sawhney IM. "Pregnancy with epilepsy" International Journal of Gynaecology & Obstetrics 54(1):17-22, 1996 Jul.
Ectopic pregnancy:
Ectopic pregnancy is an increasingly common and
potentially catastrophic condition in which the patient often presents to the ED with abdominal pain or vaginal bleeding. Recent developments in the laboratory (sensitive beta hCG assays, progesterone assays), in ultrasonography (transvaginal probes,
Doppler ultrasonography), and in the combination of modalities (discriminatory zone of beta hCG for ultrasonographic evidence of IUP) have allowed the earlier diagnosis of ectopic pregnancy, with the potential for a reduction in maternal mortality and
morbidity. Understanding the strengths and limitations of the variety of diagnostic modalities available will allow the clinician to formulate a rational strategy for
the early diagnosis of ectopic pregnancy. Numerous algorithms have been developed. All begin with high clinical suspicion for women of reproductive age with abdominal/pelvic pain or vaginal bleeding. Pregnancy testing with a sensitive beta hCG qualitative test is next. For stable patients found to be pregnant, sonography generally follows (often first transabdominally then transvaginally). Unstable patients require immediate resuscitation and gynecology consultation; invasive diagnostic methods
may supplant laboratory studies and sonography. Unclear cases may necessitate the use of quantitative beta hCG (discriminatory zone), other pregnancy hormones (progesterone), invasive procedures (laparoscopy, culdocentesis, D&C), or observation
(serial beta hCGs). A suggested algorithm incorporating these elements is shown (Fig. 1).
Brennan DF. "Ectopic pregnancy: diagnostic procedures and imaging"
Academic Emergency Medicine 2(12):1090-7, 1995 Dec.
Maternal mortality estimates remain a sensitive indicator of provision of and uptake of health services. It offers a litmus test of the status of women, their access to health care and the adequacy of the health care system in responding to their needs. It not only tells us about the risks of pregnancy and childbirth, but also for what it implies about women's health in general and, by extension, their social and economic status.
Magnitude of the problem:
The World Health Organisation estimates that of the over 585 000 maternal deaths that occur worldwide each year, 99% are in the developing world (WHO, 1987; WHO, 1991a, WHO, 1996). Maternal mortality ratios (defined as maternal deaths per 1000 000 livebirths) are highest in Africa, with figures of up to and over 1000 per 100 000 livebirths reported in several rural areas; ratios of over 5000 per 1000 000 livebirths have been reported in some cities (WHO, 1991a; WHO 1991b).
The risk of dying as a result of a given pregnancy in the richer and developed countries is at least 100 fold smaller than in the poorer countries in Africa and Asia. Maternal mortality ratios in Western and Northern Europe are about 10 per 1000 000 livebirths or lower (but up to 30 per 1000 000 livebirths in parts of Eastern Europe). Ratios in Japan, Canada and USA in line with those of Western Europe. Coupled with low fertility this means that only between 4000 to 5000 maternal deaths a year (1% of total worldwide) occur in the developed world and that a woman living in a developed country may have only as little as a 1 in 4000 risk of dying from pregnancy-related causes (WHO 1988, WHO 1991a, WHO, 1996).
Overall in Sub-Saharan Africa, high maternal mortality ratios are compound by high fertility - an average of 8 livebirths per woman and possibly 10 pregnancies per woman is not uncommon. The risk during pregnancy are higher in Eastern, Central and Western than they are in Southern and Northern Africa. The total fertility rate for a women in Zambia currently stands at just over 6 (meaning a woman would have up to births in her lifetime) (1996 Zambia Demographic and health Survey). The same 1996 survey also estimated the maternal mortality ratio at 730 per 100 000 livebirths. Accordingly a woman's risk of dying from pregnancy-related causes is almost 1 per 20 pregnancies, and some areas much areas much less.
Causes and determinants of maternal mortality:
In developing countries, not only are causes of maternal mortality different to those in developed countries, but so are the factors leading to them. There are numerous contributing factors in developing countries which have been elucidated by many studies. A summary of factors have been collated by Thaddeus and Maine (1990) from research worldwide, predominantly in developing countries. They outline factors falling under the following categories:
Maternal Mortality and Determinants of health seeking behavior:
The high level of maternal mortality in developing countries, and in Africa in particular, stems from a complex array of factors. In addition to the inadequacy of health services there may be social, cultural, economic and logistic problems, coupled with very high fertility. By and large such women, having been neglected as children and married when adolescent, may be poor, illiterate, underfed, overworked, subjected to harmful traditional practices, usually lack adequate family planning and maternal health services and cannot get their views heard where they matter.
As Thaddeus and Maine in their 1990 document put it: the process of obtaining medical care for women with obstetric complications begins with the recognition of danger signs. Access to such information and understanding of the gravity of symptoms, such as bleeding or prolonged labour, help a woman and her family to seek timely treatment. Even when women and their families recognize danger signals, and understand fully well that a woman with obstetric complications needs to receive medical care, they are also aware of another fact: namely, that there is not much the medical facility can do for her when there is no trained doctor or nurse-midewife, when blood shortages are regular and when they know equipment is frequently broken. People do not bother to seek care when they know that they probably will not be cured, that they are even likely to die in the hospital. Unfortunately, and despite the efforts of many dedicated and hardworking health providers, those is the state of affairs in many facilities in the developing world. Under such circumstances, there is validity in people's decision not to use the health facilities available to them'.
The published literature shows that health-care-seeking behavior I strongly influenced by the characteristics of the illness as perceived by individuals. To begin with, prospective health-care users must recognise that an abnormal condition exists. The perceived severity and the perceived etiology of the disorder then shape the decision to seek care.
Pregnancy and childbirth are ubiquitous events. Although acknowledged as potentially risky, pregnancy, labour and delivery are commonly considered natural and normal work for women. In other words, they are often not seen as illness for which medical expenses are justified and a hospital room booked. Furthermore, just as pregnancy is considered a normal event, death during labour and delivery may sometimes be considered a normal' event or inevitable.' Such fatalistic views can be lead to the perception that the condition is not amenable to treatment, and can thus act as effective barriers to a timely decision to seek care.
Mention should be made of situation in which a health problem is recognised, but care not sought because of the fear of social or legal sanctions. Unsafe induced abortion often remain unreported, therefore untreated, because of ostracism and fear of sociolegal sanctions. Certainly in the case of unwanted pregnancy, the condition and the need for care are both recognized. However, fear, shame and desperation can act as powerful barriers and lead to disastrous consequences as women seek illicit and unsafe abortion, attempt to self-abort, and in extreme cases commit suicide (Kwast et al., 1984; Mhango et al, 1986).
Maternal deaths-avoidable or unavoidable:
In addition to identifying the diagnosis in cases of maternal death, some hospital-based studies determine whether or not the deaths are avoidable. They generally find that while a number of maternal deaths are unavoidable, many more are either entirely or probably preventable. For example in an institution based study of maternal mortality at the University Teaching Hospital (UTH) in Lusaka, Hickey and Kasonde (1977) state that the most worrying finding was that an avoidable hospital factor was present in 52 percent of cases.' Hospital factors identified included poor intrapartum assessment, failure to correct anaemia, missed diagnosis of ruptured ectopic pregnancy and unavailability of the anaesthetist. The investigators argue that all these factors could be reduced or eliminated.'
A later study conducted at Lusaka s UTH estimated that 85% of maternal deaths between 1982 and 1983 were avoidable (Mhango et al, 1986). In this study as in Hickey and Kasone's study of 1977 , half of the deaths were judged to be due to inadequate or inappropriate medical management' of the patient. As Hickey and kasonde had stated in 1977: The seriousness of the patients' condition was... not fully appreciated'. Mhango et al (1986) identified health-care provider and institutional deficiencies, including a lack of trained obstricians, as major health-care problems associated with maternal mortality.
Even if facilities are staffed with competent providers, shortages of drugs and supplies can hamper the timely provision of care. A lack of equipment and supplies plagues health facilities in most regions of the developing world. There is little question that this situation is due in part t the very real issue of limited resources. However these barriers can still be mitigated by adequate management and organization of the available resources.
Maternal mortality in Zambia:
Figures of maternal mortality ratio in Zambia have been sketchy. They range from a few hundred
to over 1000 per 100 000 libebirths. WHO had estimated that the 1990 maternal motality ratio
for Zambia as a whole was around 940 per 100 000 livebirths. In a different methodology, the
1996 Demographic and Health Survey puts the figure at 730 per 100 000 livebirths. These figures
relate to different methods of estimation but put forward a very important message - that maternal
mortality is high in Zambia.
Zambian studies onmaternal mortality: causes and determinants:
In a case referent study (i.e. comprising factors associated with maternal deaths against pregnant
women who do not die) conducted in three centres in Zambia in 1990 (CRHCS, 1994) the
summary of factors outlined earlier (Thaddeus and Maine, 1990) were all relevant. Namely delays
in the decision to seek medical care, delays in getting to a health facility, and delays in the
provision of adequate care at the health centre all featured to some extent.
Le Bacq and Rietsma (1997) studied maternal mortality in Kasama and Kaputa Districts and also Kasama General Hospital over the period 1991 t 1995 using the Sisterhood method and analysis of records. They reported high levels of maternal mortality in Kaputa District mainly attributable to remoteness. In consequence the authors highlight that in remoter areas of Zambia a substantial reduction in maternal mortality could be achieved by improving access to a referral hospital. Further reductions could then be achieved through improvement in services at the hosptial level.
Kanyama et al (1996) in a report of focus group discussions on maternal mortality in Kaputa District (Northern Province) in 1995 wrote of a maternal mortality ratio exceeding 1500 per 100 000 livebirths. As reported in the discussions, most maternal deaths were attributed to blood loss, obstructed labour and traditional causes'. Very few of the women who died appeared to have been assisted by trained health personnel. These findings have led to a number of interventions planned by the district within their Safe Motherhood programme.
High maternal mortality rations were found in Western Province (e.g. Mongu, Sesheke, Kalabo and Senanga). In Mongu, once again, haemorrhage was a common cause of maternal death. In addition, other causes quoted included sepsis, malaria and obstructed labour. In a report from Western Province on Unplanned Pregnancy Causes and Effects, Koster-Oyekan (1995) reports on the disproportionate number of school girls who die from complications of unsafe abortion and recommends an intensive awareness campaign and also access to affordable abortion services in hospital.
UTH Studies on Maternal Mortality:
Studies at UTH over the years have reported on istitutional figures of maternal mortality. It is
unclear how representative these are of the whole city or the country. Often cases may not be
identified as maternal mortality (e.g. in the puerperium when patients are referred to wards other
than in maternity units). Lusaka has a maternity service with urba clinics staffed by midwives who
refer on any cases to UTH. Review of causes of maternal mortality over the years have yielded
useful information on changing trends in causes and also points to suggestions for interventions.
The table below summarises causes of maternal mortality as reported over the years at UTH.
| 1974-76 | 1974-76 | 1982-83 | 1982-83 | 1989 | 1989 | 1996 | 1996 | |
|---|---|---|---|---|---|---|---|---|
| Diagnosis | # | % | # | % | # | % | # | % |
| Abortion | 7 | 13 | 14 | 23 | 24 | 24 | 7 | 7 |
| Toxaemia | 20 | 37 | 12 | 20 | 12 | 12 | 10 | 9 |
| Haemorrhage | 13 | 24 | 10 | 17 | 10 | 10 | 16 | 15 |
| Puerperal sepsis | 8 | 15 | 9 | 15 | 15 | 15 | 8 | 7 |
| AIDS | 0 | 0 | 0 | 0 | 8 | 8 | ? | ? |
| Malaria | 0 | 0 | 0 | 0 | 13 | 13 | 32 | 30 |
| Meningitis | 0 | 0 | 0 | 0 | 3 | 3 | 3 | 3 |
| Other | 6 | 11 | 15 | 25 | 16 | 15 | 31 | 25 |
| Total | 54 | 100 | 60 | 100 | 101 | 100 | 100 | 100 |
*these 31 include 18 cases of tuberculosis and chronic chest infection that could have been attributed to HIV. A further number had a diagnosis of Aids. Toxaemia refers to pre-eclampsia and eclampsia.
(References: 1.Grech, 1978; 2.Mhango et al, 1986; 3.Cerne and Odeback, 1991; 4.Ahmed Y, Department of Obstetrics and Gynaecology, UTH, unpublished, 1997).
Haemorrhage was the leading cause of direct obstetric deaths at UTH in 1996 (often due to unavailability of blood), followed by pre-eclampsia/eclampsia. Deaths due to pre-eclampsia/eclampsia have decreased. Abortion (complications of miscarriage or unsafe termination of pregancy) accounted for a significant percentage of all maternal mortalities since 1982-3. This is not so based on the 1996 figures. Availability of termination of pregnancy and also extensive use of manual vacuum aspiration to treat miscarriage could have contributed to the dcline . Obstructed labour and its complications leading to maternal death did not feature in this series - perhaps reflecting the use of partogramme and the established referral system that exists in Lusaka.
It is noteworthy that malaria contributes so significantly to indirect causes of maternal mortality at UTH. These deaths occur to women who are younger and of less parity. This is in keeping with nulliparas (who are generally young) being more susceptible to malaria. However deaths due to malaria are not confined to the young or nulliparas. Malaria is perennial in Lusaka, but there appear to be more cases in the rainy season.
There is concern that many pregnant women who may be dying after a chronic illness, TB or chronic chest infections may infact have AIDS. In view of rising numbers of HIV positive antenatal women it is to be expected that more maternal deaths will be attributed to AIDS.
Whereas access to health facilities may be less of a problem in Lusaka compared to many of the other outlying rural areas of Zambia, the causes of maternal mortality and their strategies point to ensuring quality antenatal, intrapartum and postnatal care. The problem of malaria needs to be urgently addressed.
What can be done?
It is recognised that maternal mortality in Zambia is unacceptably high. The determinants of maternal mortality indicate that causes are often multifactorial. There appears to be a rural - urban differential pointing access to health services. Even in urban areas the high maternal mortality illustrations that other factors play a part - the recognition on the part of the patient of the patient of danger signs, access to health facilities and the preparedness of health facilities to deal with maternal problems.
It is difficult to prescribe specific interventions that would help in reducing the high level of maternal mortality. The community and women in particular have to be sensitised on the recognition of danger signs in pregnancy and be able to seek care. Improving access to health facilities particularly in rural areas remians an important intersectoral problem. Improving skills of health providers should be an on-going exercise. Lastly there will always be a need for more resources to be made available to help in provision of health services.
References:
New Mulago Hospital (NMH) is a government, tertiary level hospital as well as the teaching hospital for Makerere University. It has a total capacity of 1000 beds with a gynaecological capacity of approximately 90 beds. Some 17,000 births occur in this facility every year. This hospital, together with Nsambya and two smaller hospitals, serves the population of Kampala plus an additional 500 000 persons from adjacent districts (and referrals from districts and referrals from distant centres). Nsambya is a private missionary referral centre for the population of Kampala. It is a 450-bed facility with approximately 8500 deliveries annually and 2000 gynaecology admissions. It is a teaching hospital for junior residents (medical interns) as well as for nurses and midwives.
Jinja Hospital is a government provincial hospital with training facilities for junior residents and an affiliated nurse/midwifery training school. It has approximately 400 beds and between 10,000 and 1,500 gynaecological admissions per year. It serves a population of about 600,000 people in the immediate and surrounding area. Masaka Hospital is a government district referral hospital which provides nurse/midwifery training. It has a 21-bed gynaecology capacity and average about 50000 deliveries annually.
In all four hospitals, logbooks in the emergency, casualty, gynaecology and maternity wards were consulted to locate the study data, as well as patient hospital notes. In terms of completeness of the data, however, not all patients admitted to the wards were registered for a number of reasons (including the sensitive nature of their condition). In general, the researchers found that collecting the logbook information was very time consuming as often the records were lost or could not be located. In addition, in order to obtain the desired cost-related information, more than one interview with a hospital administrator usually was necessary. Even then the administrator frequently was not able to answer the questions and thus the interviewer had to consult staff from the accounts and the records departments to complete the questionnaire.
At each hospital, a minimum of three medical personnel were interviewed (i.e., a nurse, resident and supervisor) for a total or 17 in the four facilities. An important finding was that a substantial number of nurses approached by the research team (up to 30%) declined to be interviewed as it was unclear to them what benefit this would bring. Thus, the data presented fro this section are biased in this regard. This was not a problem with the physicians interviewed. In two facilities in Kampala-the tertiary centre and the private referral hospital-a minimum of four abortion patients were interviewed on the wards during the observation period. Due to a smaller abortion client load in the other two facilities, often fewer than four abortion patients were interviewed per day. Thus, the goal of interviewing 20 patients over the 5-day observation period could not be meet in those hospitals. Most patients and all providers/administrators could speak and understand English and therefore this was the language used for most interviews.
Results -- Magnitude of the Problem: Logbook
In three of the four hospitals, the data collectors reviewed almost 300 cases for this study, covering from 4 months of logbook admissions (in the case of NHM and Nsambya hospitals) to 1 year (Jinja). In the district hospital (Masaka), slightly more than 100 cases logged for the previous year were reviewed. the logbooks were current in all four hospitals. In none of the hospitals, however, were the logbook entries complete for patients.
The number of incomplete abortion cases per year (calculated or estimated from the logbook data) ranged from a low of 150 (the district hospital-Masaka) to a high of 3600 (the tertiary referral hospital NMH). The average monthly number of cases for the four hospitals ranged from 9 to 25 (mean = 47,5; median = 43). The percent of gynaecological cases that were incomplete abortion patients ranged from 28% to a high of 64% (NHM). The average age of the abortion patients in all four hospitals was similar, ranging from 23 to 28 years (overall mean/median = 25). In all hospitals but one Masaka, where the average parity was one), abortion patients had an average parity of two.
Overall, approximately equal percentage of cases were 12 weeks gestation or less versus 13 weeks gestation or more. These percentages varied among the hospitals, however, with as higher proportion of cases 13 weeks gestation or more since LMP being recorded for NHM and the reverse being recorded for Nsambya (the missionary referral hospital). In the one hospital reporting treatment modalities for incomplete abortion (Masaka), all abortion patients 12 weeks gestation or less were treated with sharp curettage and none treated with vacuum aspiration.
Abortion case fatality rates (as recorded in the logbooks for the period reviewed) were around 1% for jinja; 0,003% for Nsambya; 2% for Masaka: and 2,4% for NMH. The ALOS for incomplete abortion patients ranged from a low of 0,55 days (in the tertiary referral hospital) to 4 days (Jinja). The case fatality rate was highest (2,4%) in NMH which can be explained, in part, by the fact that it is tertiary level referral hospital. Statistics describing the magnitude of the problem in these four institutions are summarised in Table 9.
| NMH | Jinja | Nsambya | Masaka | Overall | Mean | |
|---|---|---|---|---|---|---|
| # of months of data reviewed | 4 | 12 | 4 | 11 | na | na |
| # of incomplete abortions recorded for the months reviewed* | 251 | 294 | 287 | 114 | na | na |
| Mean # of incomplete abortions per month | 63 | 25 | 72 | 10 | 42.5 | 44 |
| # of incomplete abortions per year** | 756 | 300 | 864 | 120 | 510 | 528 |
| % of incomplete abortions<12 weeks*** | 37.5 | 40.5 | 48.4 | 31.6 | 39.5 | 39 |
| % of incomplete abortions>13 weeks*** | 57.4 | 42.9 | 8.7 | 28.9 | 34.5 | 35.9 |
| Mean patient age | 26 | 28 | 24 | 23 | 25.3 | 25 |
| mean patient parity | 2 | 2 | 2.1 | 1.75 | 2 | 2 |
| mean uterine size | 14 | 12 | 6 | 7 | 9.75 | 2 |
| # of abortion deaths recorded for months reviewed | 6 | 2 | 1 | 2 | 2.75 | 2 |
| facility abortion case fatality rate (%) | 2.4 | .7 | .3 | 1.8 | 1.3 | 1.25 |
NA=Not Applicable
NR=Not recorded
*Investigators were requested to review approximately 300 cases or one year of data, whichever
required less reviewing.
**Calculated from mean number of incomplete abortions per month multiplied by 12 months.
***Percentage do not add up to 100% due to missing data
Ward Observation:
In all four hospitals, abortion patients recuperate in the gynaecological ward; in two hospitals, they also are admitted into the (gynaecological) casualty ward. The average DBO rate observed during the observation period for abortion patients in the casualty ward was 21% in one hospital (Nsambya) and 49% in another (NMH). For the gynaecological ward, the rate for all four hospitals ranged from 2% (Nsambya) to 17% (Jinja) (mean/median=9%). Fatality rates varied by ward in which the patient was registered.
Interview with the Head of the Maternal Mortality Review Committee (MMRC):
Interview with the Head of the MMRC (or senior provider) yield estimates of the number of incomplete abortion patients seen in each hospital annually. These estimates ranged from a low of 150 (Masaka) to high of 3600 (NHM) (mean+1438; median = 1000). These numbers are close to those calculated by the research team for each hospital from the logbook data. In terms of the types of complications typically seen, all four hospital respondents cited localised infection, septicaemia and hemorrhage. The respondent from NHM also cited uterine perforation and cervical injury.
Estimates of how long incomplete abortion patients remain in the hospital for treatment and recuperation ranged from 12 to 48 hours (mean = 27,5 hours; median = 25 hours). For some facilities, the estimate provided by the MMRC was low compared to the ALOS calculated by the research team for the study period (e.g., for Jinja Hospital the documented ALOS was 4 days).
The estimated number of hospital deaths due to complications of abortion each year ranged from two to ten. These estimates also are close to those calculated from the logbooks from each hospital which suggests that those interviewed are aware of the magnitude of the problem in their facilities. Respondents described patients who die of abortion complications as being in their early 20s and single (three respondents) or married (NHM). A mortality review committee exists in three of the four hospital (not in the district facility) although written procedures and post-mortem exams are not standardised or routinely carried out in any facility surveyed.
Cost:
Budgets do not exists for gynaecology or abortion treatment services in any of the four hospital. Therefore, the amounts listed in Table 10 represent estimates extrapolated from a number of different sources. The estimated cost of treating incomplete abortion cases was lowest in the rural facility and highest in the tertiary centre. Despite the fact that the hospital administrator(s) had difficulties quantifying the cost of treating abortion complications in their facilities, they all agreed that this service constitutes a major cost to the hospital.
| NMH | Jinja | Nsambya | Masaka | |
|---|---|---|---|---|
| # of gynaecological cases/year | 5600 | 1051 | 1850 | 450 |
| # of incomplete abortions cases/year | 3600 | 300 | 975 | 130 |
| % of incomplete abortion cases (of gyn. patients) | 64.3 | 28.5 | 52.7 | 28.9 |
| gynaecological budget/year (US$) | $248,812 | $137,755 | $275,510 | $38,775 |
| mean cost of daily patient stay (US$) | $20.40 | $5.60 | $2.00 | $2.80 |
| ALOS (days) | 0.55 | 4.02 | 1.67 | 0.78 |
| total estimated cost of treating incomplete abortion patients/year (US$)* | $40,392 | $6,754 | $3,257 | $284 |
| total estimated cost of treating incomplete abortion patients/year (US$)** | $8,482 | $6,754 | $2,886 | $262 |
*based on verbal estimates provided by hospital administrators of the number of incomplete abortions
**based on calculated estimate (P) of the number of incomplete abortions per year (table 9)
Provider Profile:
Table 11 shows the number of providers interviewed for the study in each Ugandan hospital. Of the 17 providers interviewed, seven (41,2%) were nurses, four (23,5%) were medical officers/interns and three 17,6%) were Chiefs of the Department of Obs/Gynae. The majority (82,4%) of all respondents noted that the primary postabortion care providers in the facility is the medical officer. There was an almost equal number of female and male provider respondents (52,9%) and 47,1%, respectively) and just over half (58,8%) of the providers were married.
| NMH | Jinja | Nsambya | Masaka | Total | |
|---|---|---|---|---|---|
| Number of providers interviewed (% of total) | 5 (29.4%) | 4 (23.5%) | 59 (29.4%) | 31 (17.6%) | 99 (100%) |
Provider Role:
Almost everyone (94,1%) interviewed indicated that their role in caring for abortion patients is to provide medical/clinical treatment; over three fourths (76,5%) noted that they also have a r ole counseling patients about the treatment. In only two hospitals (NMH and Masaka did) any providers also say that they provide some FP counseling (2 out of 5 providers interviewed or 40% in the former; 2 out of 3 or 66,7% in the latter facility). This suggests that some linkage between abortion and FP services exists in these two facilities.
Client Profile:
The providers had similar impressions of what constitutes a "typical" incomplete abortion patient, i.e., young, age 17 to 24 (mean response = 20 years), either single or married (52,9% said, 41,2% said married), unemployed and often still in school. Half of the providers were of the opinion that doctors perform the initial abortion procedure. None of the providers suggested traditional healers or midwives as the abortion provider.
Complications/ALOS:
Hemorrhage was the most common presenting complications noted by providers in all
hospitals. Table 12 shows the types of complications cited as occurring the most frequently among abortion patients. Providers' estimates of the amount of time that incomplete abortion patients remain hospitalised ranged between 12 and 35 hours (mean/median=24 hours). These figures are close to those estimated by the head of the MMRC interviewed and those calculated from patient discharge information for the study. Opinions regarding whether most women in the community suffering from abortion complications end up going to the hospital for treatment were split, with 41,2% of the providers saying they do and 47,1% saying they do not. Interestingly, the large majority (76,5%) of respondents did not think that maternal deaths from complications of abortion is a major problem in their community. Only in NMH (tertiary centre) did a majority (60%) of the providers interviewed perceive abortion to be a major problem in the area. This finding is notable especially given that the hospital administrators all agreed that the cost of treating abortion complications constitutes a major cost to these four hospitals.
| Hemorrhage | Localised infection | Septicaemia | Uterine Perforation | Cervical injury | |
|---|---|---|---|---|---|
| Complication Percent of Providers Citing (n=17) | 88.2% | 58.8% | 47.1% | 41.2% | 35.3% |
Contraceptive Use Among Patients:
There was consensus among all providers interviewed that the majority of women treated for incomplete abortion were using a method of FP at the time they became pregnant. Their opinions regarding reasons for non-use included: health concerns, partner disapproval, lack of access and lack of information about FP services/methods (Table 13).
| Lack of FP information | Partner disapproval | Lack of access | Health concerns | Method inconvenience | Infrequent sexual relations | Cost | Reason Percent of Providers Citing (n=17) | 88.2% | 58.8% | 47.1% | 41.2% | 35.3% | 17.6% | 11.8% |
|---|
Provision of FP Information/Services:
An overwhelming majority (88,2%) of the providers interviewed stated that incomplete
abortion patients should receive FP information while they are still in the hospital (40% of the providers in the missionary facility responded that this depends on the individual's
situation). Fewer, 70,6%, though that patients are interested in getting this type of
information while hospitalised (23,5% overall were of the opinion that this depends on the situation). Only 35,3%, however, noted that FP information is currently offered routinely to incomplete abortion patients int heir facility. In NMH, three out of five providers stated that patients are routinely provided with this information. In the other three hospitals, the majority of providers stated that patients do not receive FP information.
The providers were divided on their views about making FP methods available in hospital post-procedure. Approximately 67% indicated that they were supportive of this (none were supportive int he missionary facility). Only 12%, however, (one provider each from NMH an Jinja) said that contraceptives are, in fact, currently provided to patients before they are discharged.
Abortion Laws
:
According to World Abortion Policies 1994 (Annex 16), abortion is legally permitted in
Uganda to save the woman's life and to preserve physical health Table 14 as shows the conditions under which the providers interviewed believe abortion is legal int heir country. In all but the missionary hospital (Nsambya), the providers were in agreement that the current law is too restrictive. Similarly, everywhere but in the missionary facility, most (64,7%) providers believed that women will make decisions about pregnancy termination and providers will perform abortion services regardless of the statutes of the law.
| Save a woman's life | Foetal deformity | Woman's mental health | Incest | |
|---|---|---|---|---|
| Condition Percent of Providers Citing (n=17) | 88.2% | 58.5% | 35.3% | 11.8% |
Access to Abortion Services:
Reasons Women Seek an Abortion:
The majority of providers in all four hospitals agreed that the primary reasons women seek abortion are that they have too many children or their children are too close in age or that they lack financial resources. the fourth most important reason cited was not being married (Table 15). In Masaka, one of the areas in Uganda hardest hit with acquired immune deficiency syndrome (AIDS), HIV infection also was cited as a reason for terminating the pregnancy.
| Too many children | Luck of financial resources | Children too close in age | Un- married | Foetal deformity | Timing of pregnancy | Women's health | Rape/ Incest | Mental Health | |
|---|---|---|---|---|---|---|---|---|---|
| Reason Percent of Providers Citing (n=17) | 76.5% | 76.5% | 58.5% | 52.9% | 29.4% | 23.5% | 17.6% | 11.8% | 11.8% |
Access to Abortion Services:
The providers' view were varied in regard to ease of access to abortion services and
treatment for incomplete abortion. About 70% thought that it was either somewhat or very difficult to get abortion in Uganda. Sixty percent, however, felt that it was either very or somewhat easy for women in the hospital's catchment area to obtain medical treatment for complications of an abortion; all of the respondents in NMH and Masaka responded that access to treatment was easy. Two reasons cited for the difficulty in access to abortion were the prohibitive law and cost. All providers at the missionary hospital stated that access to FP was somewhat or very difficult, while the majority (67-100%) of providers at the other hospitals responded that access was somewhat or very easy.
Patient Perspective - Patient Profile:
A total of 77 patients were interviewed during the study period (Table 16). The age range of these patients was from 16 to 39 years (mean=24; median=23). Of interest is the difference in age distribution of patients from urban versus more rural areas. overall, 36.8% of the patients interviewed were aged 20 or younger (i.e, adolescents), and the youngest patient interviewed was 16 years old. The mean age if the adolescents was 18.6 years (median=19). Many (63,6%) women interviewed said they were married (as high as 80% in formation recorded int he patient files did not differ much from that provided by the patient during the interview. This suggests that the information is accurate although the women could have provided incorrect information on both accounts. Overall, parity levels ranged from nulliparous to ten. The mean number of living children ranged from two in NMH and Nsambya to four in Jinja (overall mean/median=2).
| NMH | Jinja | Nsambya | Masaka | Total | |
|---|---|---|---|---|---|
| Number of patients interviewed (% of total) | 30 (39%) | 17 (22.1%) | 20 (26%) | 10 (12.9%) | 77(100%) |
Contraceptive Use Among Patients:
In terms of prior contraceptive use, 35,1% of the patients interviewed said they had
previously used a method of FP (of these, 66,7% had used OCs; 34.6% had used condoms; and 7.7% had used injectable). The proportion who had ever used a FP method was similar(30%-40%) in all hospitals except for the district facility where only 20% of the women had ever used contraceptive method before. Almost 20% of the women said they had become pregnant sometime in the past while using a contraceptive method. Of these women 22,2% were using OCs, 22,2% were using condoms ans 11,1% were using injectable when they become pregnant Among the four hospitals, the highest proportion (3 out of 7 or 43%) of women reporting a pregnancy while using a FP method (not necessarily a modern method) were from jinja. Seven out of 75(9,3%) indicated that they were using contraception at the time of the most recent pregnancy. Of these women, 25% were using OCs, 12,5% were using condoms and 62,5% were using some non-modern method of FP.
Reasons Patients Sought Treatment:
The medical reason(s) for which patients said they came to the hospital for treatment are listed in Table 17. The major problems cited by patients was vaginal bleeding(85,7%). Overall, 55,2% indicated that their symptom(s) had persisted for 1 day or less before they sought treatment at the hospital; 25% said their symptoms(s) had persisted 3 or more days; and, for 19,7%, the time between onset of the problem and hospitalisation was 2 days. Women interviewed from the rural area tended to have longer intervals between onset of symptoms and presentation to the hospital. this is evidence by the finding that 50% of the women interviewed in Masaka-the district hospital-presented 3 days or more after onset of symptoms compared to a low of 6,9% for NMH. The reason for the long interval between onset of symptoms and seeking treatment among this group may relate to real or perceived access to services, the woman's perception of risk of morbidity/mortality, and/or her ability to take time out to attend to her own health needs.
| Vaginal | Obdominal | Fever | |
|---|---|---|---|
| Percent of Patients Citing (n=77) | 85 (7%) | 46 (8%) | 23 (4%) |
Transportation:
The women interviewed used both private (46,8%) and public (33,8%) transportation to
access the facilities. In the district area, where public transport is scare, private means had to used by all the women. Interestingly, the majority (82,9%) of the women interviewed expressed the opinion that it was either very or somewhat easy for them to get to the facility. For over 70% of all patients survey, it took them between 15 minutes and 1 hour to reach the hospital. for 80,3%, it took them less than 2 hours to get to the hospital. This finding substantiates the contention that populations identified in hospital-based studies are those with relatively easy access to facilities where abortion complications can be treated (and represent those who are well enough and decide to make the trip).
Waiting Period:
Sixty-two percent said that, once at the hospital, they had waited tow hours or less to see a doctor. the majority (65,8%) indicated that the amount of time they had waited was "acceptable" to them.
Procedure Experience:
Pain was experienced by the majority 74,6%) of patients interviewed one third (32,8%)
indicated that the pain was severe (in Nsambya, no patients reported severe pain).
Approximately three quarters of the women interviewed in each centre except Masaka had not received any information about how to take care of themselves at home. In contrast, at the district facility, up to almost 70% had received this advice. Overall, less than halt (41,6%) of the patients remember someone explaining to them what their treatment would involve. The proportion saying they received no explanation was highest (76,7% in NMH (tertiary centre) and lowest in the missionary and district hospital (30% in each facility).
Provision of FP Information/Services:
The overwhelming majority (83%) of patients said that no one had talked to them about FP services during their hospital stay. In only 36% of the case was the woman told where she could go in the community to obtain a FP method. In every hospital except Nsambya (missionary hospital), the number who were told and who were not told was almost equal. At Nsambya, 95% of the women interviewed said they were not given any FP information. Overall, 75% indicated that they would have liked to have had information and a FP method offered to them. The majority (75%) thought that other women in the community being treated for the same problem would like to both receive FP information and have FP methods made available to them while still in the hospital. (The majority of the other responses were "don't know" for all hospitals). These findings are particularly important in light of the fact that the majority of patients had never used a method of FP prior to the most recent (index) pregnancy.
Personal Treatment at Hospital:
Patient opinions regarding their interactions with provider(s) varied. Almost all from
Nsambya and Masaka said that the hospital staff had been very considerate. Only half in the other two hospital responded that the staff was very considerate. Overall, 70.7% said that they were satisfied with the services they had received. An overwhelming majority, 93,2%, said they would encourage any friend or relative who had the same problem to be treated at that facility.
Yours faithfully, J.L M.
Editor's Note: We would like to hear from other community health workers what their information needs are in their environment. Thank you Mr. Mutoya for appreciating the Digest and we hope that you circulated the copy among your colleagues. Some literature will be posted to you.
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Last updated September 19, 1997