[Maternal morbidity and qualification of health-care workers: comparison between two different populations in Senegal]. / Morbidité maternelle et qualification du personnel de santé: comparaison de deux populations différentes au Sénégal.

OBJECTIVE: High fertility rates and high maternal mortality ratios have led most cooperation agencies to place high priority on health of women and children. The objective of this study was to compare maternal morbidity and mortality tin two populations with widely contrasting availability of health care in order to test the hypothesis that differences in maternal outcome mainly result from the qualification of health carers. METHODS: This population-based study included a cohort of pregnant women which was part of a multicenter study of maternal morbidity in six countries in West Africa (MOMA). We compared health outcome in two different populations of Senegal (Saint-Louis and Kaolack).3,777 pregnant women were follow through pregnancy, delivery and pureperium. Maternal morbidity was assessed from the women's recall at each visit of the investigator and from obstetric complications diagnosed by the birth attendant within health facilities. RESULTS: Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centers, most often assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities were principally referred to the regional hospital and were generally assisted by midwives (874 and 151 maternal deaths per 100,000 live births respectively, p<0.01). Diagnosed maternal morbidity, however, was higher in Saint-Louis than in the Kaolack area, especially for births in health facilities (9.50 and 4.84 episodes of obstetric complications per 100 lie births respectively, p<0.01). Univariate and multivariate analyses showed that diagnosed morbidity was mainly associated with degree of training of the health attendant in facility deliveries and that antenatal care had no effect. DISCUSSION: Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to a lower case-fatality rate. This could explain the differences in maternal outcome between two urban centers with contrasting health care availability. CONCLUSION: These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labor.

[Indications and prognosis of cesarean sections at the Dakar University Hospital Center]. / Indications et pronostic de l'opération césarienne au CHU de Dakar.

From 1st January 1992 to 30 June 1994, 8489 delivered at the Dakar University Hospital. Among them, there were 953 cesarean sections, i.e. 11.2%. Epidemiological analysis revealed that mean parity was 2 for a mean age of 26 years. 22% of the women had a clinically perceptible pelvic problem. The indications for cesarean section were divided into 3 groups: mandatory operations (feto-pelvic disproportion, haemorrhagic placenta praevia, dystocia): 41.4%; prudent operations (long-awaited infant, fetal suffering, breech presentation, cicatricial uterus): 50%; and necessary operations (maternal disease, especially hypertension): 8.6%. There was a high postoperative mortality (1.4%) and major morbidity, especially infection (10%). Neonatal prognosis was also poor with a 14% early neonatal mortality. These findings reflect the major problems facing obstetricians in Senegal and Subsaharian Africa. Improved prognosis necessarily will involve better organization of our health systems allowing easier access to life-saving cesarean section for our rural populations.

[Epidemiological surveillance and obstetrical dystocias surgery in Senegal]. / Surveillance épidémiologique et couverture chirurgicale des dystocies obstétricales au Sénégal.

Maternal morbidity and mortality remain major problems of public health in developing countries. Having long been neglected, maternal health is now being included among the priorities of a large number of countries. The rate of maternal mortality in Senegal is 850 per 100,000 live births, among the highest in the world. The main causes of maternal mortality in Africa are obstructed labour and uterine rupture, hypertensive disorders of pregnancy, puerperal infection and haemorrhage. An epidemiological survey of obstetric disorders was initiated in 1992 in Senegal to characterise the requirements for surgical coverage during pregnancy and delivery. In 1992, the national rate of caesarean section was low (0.66% of estimated births). However, rates differed greatly between regions, and between rural and urban areas. The indications for caesarean section were classified into three groups, each corresponding to a different public health issue. The rate of maternal mortality associated with surgery was high: 4.7%, of which 29% during surgery and 71% post op. Perinatal prognosis was also poor, with a mortality rate of approximately 30%. There are only 18 reference obstetrics units functioning, and they give a very uneven coverage of the country. These finding have led to new guidelines to improve the quality and cover of maternal care over the coming years.

PIP: Senegal's maternal mortality rate of about 850/100,000 is one of the highest in the world. A program of epidemiologic surveillance of obstetrical pathology and surgery was established in 1992 in Senegal's 18 obstetric services. The monitoring program targets extrauterine pregnancy; cesarean delivery; hysterectomy for rupture, infections, or hemorrhage; forceps or vacuum extraction delivery; and embryotomy. The National Office of Maternal-Child Health and Family Planning periodically calculates intervention rates based on standardized reports from the centers. Indications for cesarean were classified into three groups: obligatory, referring to conditions such as fetopelvic disproportion in which the delivery could not otherwise proceed; prudent, for cases such as scarred uteri or breech presentation in which cesarean is not indispensable but may provide a better prognosis for the mother or child; and necessity, in which dynamic dystocia, hypertension, or other usually preventable maternal condition has not been adequately treated and threatens to lead to emergency cesarean to save the mother's life. During 1992, around 3220 women underwent obstetrical surgery. 75% of the interventions were cesareans, 10% were forceps deliveries, 9% were extrauterine pregnancies, 3% were hysterectomies, 1% were embryotomies, and 2% were other. The average maternal age for all interventions and for cesareans was 26 years, 7 months. 18.2% of interventions were in women under 20. 36% were primiparas, 25% had 2-3 children, 16% had 4-5, and 23% had 6 or more. Average parity was 3.5. 67% of forceps or vacuum extraction deliveries were in primiparas, while 64% of hysterectomies for infection or hemorrhage and 40% for rupture were in grand multiparas. The principal study objective was to determine surgical coverage of obstetric pathology for the country and its regions. In 1992, 0.66% of deliveries in Senegal were cesareans, with rates ranging from 1.24% in Dakar to 0.24% in Tambacounda. 50% of the cesareans were for obligatory indications, 28% were for indications of prudence, and 22% were for indications of necessity. The proportion for different categories of indications differed greatly in different regions. The maternal mortality rate for all indications was 4.7%, representing over 150 deaths. 29% of deaths occurred during the intervention and 71% in the postoperative period. The maternal mortality rate was 0.8% for extrauterine pregnancy, 1.9% for forceps deliveries, 4.4% for cesareans, 29.3% for hysterectomies for rupture, and 32.0% for hysterectomies for infection or hemorrhage. The perinatal mortality rate for all indications except extrauterine pregnancy was nearly 30%. A goal of 3% of deliveries by cesarean has been established for Senegal to ensure that all situations defined as obligatory will be treated by cesarean. Steps must be taken to improve the accessibility and quality of obstetrical surgery throughout the country.

[Epidemiology of bone fluorosis of hydrotelluric origin]. / Epidémiologie de la fluorose osseuse d'origine hydrotellurique.

Although endemic fluorosis occurs in many countries, epidemiological studies have been limited by funding problems, a lack of awareness of the public health impact of the disease, and the absence of inexpensive defluoridation methods. The effects of fluorides on human bone are reviewed and the methodological problems raised by epidemiological studies of endemic skeletal fluorosis are discussed.

Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey).

OBJECTIVE: To compare maternal morbidity and mortality in two urban populations with contrasting availability of health care, and to test the hypothesis that differences in maternal outcome result mainly from the management of delivery in health facilities. DESIGN: A population-based study of a cohort of pregnant women which was part of a multicentre study of maternal morbidity in six countries of western Africa (MOMA). SETTING: Two different urban areas of Senegal (Saint-Louis and Kaolack). POPULATION: 3,777 pregnant women who were followed up throughout pregnancy, delivery and puerperium. MAIN OUTCOME MEASURES: Maternal morbidity and mortality: morbidity was assessed from women's recall at each visit by the investigator and from obstetric complications diagnosed by the birth attendant within health facilities. RESULTS: Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centres, usually assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities went principally to the regional hospital and were usually assisted by midwives (874 and 151 maternal deaths per 100,000 live births, respectively, P < 0 x 01). Maternal morbidity, however, was higher in Saint-Louis than in Kaolack area, especially for births in health facilities (9 x 50 and 4 x 84 episodes of obstetric complications per 100 live births, respectively, P < 0 x 01). Univariate and multivariate analyses showed that morbidity was mainly associated with the training of the birth attendant in facility deliveries and that antenatal care had no effect. CONCLUSION: Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to low fatality rates. This could explain differences in maternal outcome between two urban centres with contrasting health care availability. These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labour.