Maternal near-miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden and health service events surrounding severe maternal outcomes (SMO) related to life-threatening postpartum haemorrhage (PPH) in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: All cases of SMO [maternal near miss (MNM) or maternal death (MD)] due to PPH were prospectively identified using WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence of SMO, health service events, case fatality rate (CFR) and mortality index (MI: % of death/SMO). RESULTS: Postpartum haemorrhage occurred in 2087 (2.2%) of the 94 835 deliveries recorded during the study period. A total of 354 (0.3%) women had an SMO (103 MD; 251 MNM). It was the most frequent obstetric haemorrhagic complication across hospitals. PPH had the highest maternal mortality ratio (112/100 000 live births) and the recorded MI (29.1%) and CFR (4.9%) were second only to that of ruptured uterus. About 83% of women with SMO were admitted in a critical condition with over 50% being referred. MD was more likely when PPH led to neurological (80.8%), renal (73.5%) or respiratory (58.7%) organ dysfunction. Although the timing of life-saving interventions was not statistically different between the cases of MD and MNM, close to one-quarter of women who died received critical intervention at least 4 hours after diagnosis of life-threatening PPH. CONCLUSIONS: Postpartum haemorrhage was a significant contributor to obstetric haemorrhage and SMO in Nigerian hospitals. Emergency obstetric services should be enhanced at the lower levels of healthcare delivery to reduce avoidable deaths from PPH. FUNDING: The original research that generated the data for this secondary analysis, and the publication of this secondary analysis, was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization. We have no other funding issue to declare for our study. TWEETABLE ABSTRACT: One hundred and three maternal deaths and 251 near-misses resulted from PPH in 42 Nigerian tertiary facilities in 1 year.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country.

OBJECTIVE: To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals. DESIGN: Nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth and puerperal complications. METHODS: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS: Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care. CONCLUSIONS: Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care. TWEETABLE ABSTRACT: Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Community health workers' knowledge and practice in relation to pre-eclampsia in Ogun State, Nigeria: an essential bridge to maternal survival.

BACKGROUND: Pre-eclampsia is a leading cause of maternal and fetal morbidity and mortality worldwide. Early detection and treatment have been instrumental in reducing case fatality in high-income countries. To achieve this in a low-income country, like Nigeria, community health workers who man primary health centres must have adequate knowledge and skills to identify and provide emergency care for women with pre-eclampsia. This study aimed to determine community health workers' knowledge and practice in the identification and treatment of pre-eclampsia, as they are essential providers of maternal care services in Nigeria. METHODS: This study was part of a multi-country evaluation of community treatment of pre-eclampsia. Qualitative data were obtained from four Local Government Areas of Ogun State, in south western Nigeria by focus group discussions (N = 15) and in-depth interviews (N = 19). Participants included a variety of community-based health care providers - traditional birth attendants, community health extension workers, nurses and midwives, chief nursing officers, medical officers - and health administrators. Data were transcribed and validated with field notes and analysed with NVivo 10.0. RESULTS: Community-based health care providers proved to be aware that pre-eclampsia was due to the development of hypertension and proteinuria in pregnant women. They had a good understanding of the features of the condition and were capable of identifying women at risk, initiating care, and referring women with this condition. However, some were not comfortable managing the condition because of the limitation in their 'Standing Order'; these guidelines do not explicitly authorize community health extension workers to treat pre-eclampsia in the community. CONCLUSION: Community-based health care providers were capable of identifying and initiating appropriate care for women with pre-eclampsia. These competencies combined with training and equipment availability could improve maternal health in the rural areas. There is a need for regular training and retraining to enable successful task-sharing with these cadres. TRIAL REGISTRATION: NCT01911494 .

Recurrent pregnancy loss and antiphospholipid syndrome: an overlooked association.

Antiphospholipid Syndrome (APS), a thrombophilic condition, is being increasingly recognised as an important cause of recurrent pregnancy loss, preeclampsia and possible infertility. It could occur as a primary condition or it may be secondary to connective tissue diseases, infections or malignancies. Though recurrent pregnancy loss is a common feature ofAPS, there are other presentations attributable to thrombosis. The mechanism of thrombosis is still not completely understood but there are various suggested mechanisms. Presence of anti-cardiolipin antibodies (aCL) and lupus anticoagulant (LAC) are diagnostic. Management is variously with heparin, aspirin and warfarin, although other treatment modalities are being deployed. A high index of suspicion is needed for this otherwise treatable condition. Management is ideally best done by an obstetrician and a rheumatologist.

Psychiatric morbidity in a pregnant population in Nigeria.

Psychiatric morbidity among 240 pregnant women attending an antenatal unit was assessed by a two-stage screening procedure, using the General Health Questionnaire (GHQ-30) and Present State Examination Schedule (PSE). The prevalence of psychiatric morbidity was found to be significantly associated with younger age (< 24 years), being primigravid, married for less than 1 year, having an unsupportive husband, and a previous history of induced abortion. It is suggested that more attention needs to be paid to the mental health of pregnant women in developing countries (where pregnancy rates and the risks associated with pregnancy/delivery are much higher than in the developed countries) at the primary, secondary, and tertiary levels of health care.

The application of operational research (OR) procedures to maternal mortality from puerperal sepsis in a rural community.

An operation research (OR) procedure on maternal mortality from puerperal sepsis was carried out in Irepodun Local Government Area of Kwara State of Nigeria. The study involved ten focus groups discussion (FGD) in two districts of the Local Government Area. The findings were analysed from three broad perspectives, that is, consumers' views, providers' views and community decision takers' views. In general, the analysis revealed that the community knowledge of puerperal sepsis is poor. In addition, limited access and prohibitive cost of orthodox health care services prevented the community from full utilization of the few available health care centres in the community. The study also revealed that there is urgent need to introduce three key interventions for an improved maternity care in the community. These interventions are community health education, health institutions development and community participation in provision of ancillary services such as transportation.

Psychiatric morbidity in a gynaecology clinic in Nigeria.

Psychological disorders among 233 women attending a gynaecology out-patient clinic was assessed by a two-stage screening procedure, using the GHQ-30 and the PSE. The prevalence of psychiatric disorders was found to be 35.2%. Psychiatric morbidity was significantly associated with a history of induced abortion, previous marriages, having no children, complaints of menstrual abnormalities, chronic pelvic pain and having unsupportive husbands. It is suggested that more attention needs to be paid to the psychological health of patients with gynaecological disorders (in line with the biopsychosocial model of health care). This will ensure an overall improvement in the quality of care.

PIP: Many studies in developed countries show a high frequency of psychological distress among women attending gynecology clinics. The aim of this study is to assess the prevalence of psychiatric morbidity among 239 women attending a gynecology clinic at Ilorin Maternity Hospital in Nigeria. The aim also was to test the validity of using the 30-item version of the General Health Questionnaire (GHQ-30) as a screening tool. Clinical diagnoses were recorded according to the International Classification of Diseases-Ninth Edition (ICD-9). Psychiatric morbidity was determined according to the method of Deshpande. Literate respondents used a self-administered GHQ-30 and illiterate respondents were interviewed with the GHQ-30. The psychiatric interview was conducted by a research psychiatrist. Patients were grouped into 1) patients with symptoms diagnoses according to ICD-9, 2) cases with subdiagnostic syndromes, and 3) patients without significant psychiatric symptoms. A basic demographic profile of patients is given. Obstetrics and gynecologic data reveal that 31.3% were nulliparous, 44.5% had between 1 and 4 children, and 24.5% had 5-8 children. 64.4% reported regular menses, 21.9% reported scanty menstrual flow, and 64.4% had a normal flow. 17/6% reported a history of induced abortion, and 43.4% reported previous spontaneous abortion. 23.6% had primary infertility and 28.3% had secondary infertility; infertility was the most common complaint. A score of 5 or higher on the GHQ-30 indicated a psychiatric case. 35/2% were found to suffer from definite psychiatric morbidity. An additional 6.4% had severe psychiatric symptoms. Of the psychiatric diagnoses, 34.1% were for neurotic depression, 24.4% for anxiety, 25.7% for adjustment reaction, 12.2% manic depressive psychosis (depressed type), 2.4% phobic state, and 1.2% schizophrenia. Psychiatric morbidity was found to be unrelated to age, marital status, religion, education, occupational group, or duration of marriage. Symptoms such as irregular menses, pelvic pain, ad having no children were factors significantly associated with psychiatric morbidity; this pattern is supported in the developed country literature. Policy should be directed to a preventive and biopsychosocial model of health care.

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.

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.

PIP: Determinants aside from prenatal care that are responsible for maternal death from eclampsia are analyzed in this study. During the 16-year study period (January, 1972 to December, 1987), there were 169,200 deliveries at the University of Ilorin Teaching Hospital in Nigeria. Of these, there were 651 cases of eclampsia with 94 (14.4%) maternal deaths. Total maternal deaths were 748 during the 16-year study period. 12.6% of these resulted from eclampsia. The maternal mortality rate (MMR) due to eclampsia was 0.6/1000 deliveries. Maternal deaths were high in very young primigravida and elderly women of higher parity. The overall MMR ranged between 2.4 and 7.4/1000 and the rates appear the same over the years. The MMR due to eclampsia was between 0.3 and 1.6/1000 deliveries. The rates differ from year to year. 74% were emergencies; postpartum eclampsia was recorded in 20 (21.3%) cases. Perinatal mortality was 4 times the overall crude perinatal mortality rate for the hospital. Operative delivery was performed in 35 (37.2%) of the 94 cases. Over the 16-year period, eclampsia-related maternal deaths remained high. The overall incidence of eclampsia is 3.8/1000 deliveries. Recommendations for prevention of maternal death from eclampsia include: 1) encouraging high-risk women to eat a high protein diet with unrestricted sodium intake at the normal recommended daily allowance; 2) an improvement in the knowledge, attitudes, and practices of the community and those who make policy in regards to eclampsia; 3) a national program on family health education; 4) improvement of the socioeconomic status of women; and 5) a change in national education policy in support of literacy.

The pattern of eclampsia at the University of Ilorin Teaching Hospital (U.I.T.H.) Ilorin, Nigeria.

In Ilorin, Nigeria, 788 cases of eclampsia were managed between 1968 and 1987, giving an incidence of 4.2/1000 deliveries. Five hundred thirty-five of the patients were nulliparous and 353 had received some form of antenatal care. There was no apparent change in the pattern of eclampsia over the years. The predisposing factors to developing eclampsia are examined and suggestions offered for the prevention of eclampsia in third world countries.

Maternal mortality--a twelve-year survey at the University of Ilorin Teaching Hospital (U.I.T.H.) Ilorin, Nigeria.

This paper concerns an analysis of maternal death at the University of Ilorin Teaching Hospital (U.I.T.H.) Ilorin over a 12-year period (1972-1983). There were 138,577 births and 624 deaths making a maternal mortality rate of 4.50 per 1000 births. Hemorrhage, ruptured uterus and obstructed labor were the major direct obstetric causes of death. The most important indirect causes were cerebrospinal meningitis, pulmonary infections and fulminating hepatitis. The main avoidable factors were ineffective and cumbersome blood transfusion services; poor management of the third stage of labor; large number of unbooked patients and poor delivery room structure encouraging sepsis. Suggestions are made for a more integrated type of maternity services in our hospital, health education programs for the public and particularly the expectant women and availability of an effective blood bank service within the maternity hospital premises for prompt treatment of patients requiring emergency blood transfusion. The analysis underlines the great problem of maternal mortality in the developing world.

PIP: This paper concerns an analysis of maternal death at the University of Ilorin Teaching Hospital over a 12 year period (1972-1983). There were 138,577 births and 624 deaths making a maternal mortality rate of 4.50/1000 births. Hemorrhage, ruptured uterus and obstructed labor were the major direct obstetric causes of death. The most important indirect causes were cerebrospinal meningitis, pulmonary infections and fulminating hepatitis. The main avoidable factors were ineffective and cumbersome blood transfusion services; poor management of the 3rd stage of labor; large number of unbooked patients and poor delivery room structure encouraging sepsis. Suggestions are made for a more integrated type of maternity service in this hospital, health education programs for the public and particularly the expectant woman, and availability of an effective blood bank service within the maternity hospital premises for prompt treatment of patients requiring emergency blood transfusion. The analysis underlines the great problem of maternal mortality in the developing world.

Family planning practice among Nigerian student midwives.

An analysis of the various contraceptive methods practiced by a total of 462 student midwives from the Northern and Southern parts of Nigeria over a 3-years period is presented. The differences in age distribution, the type of contraceptive agents used, the reasons for using them, and the side effects in the two groups are statistically significant. The need to provide acceptable contraceptive advice to the rural communities by the midwives is discussed.

PIP: An analysis of the various contraceptive methods practiced by a total of 462 student midwives from the Northern and Southern parts of Nigeria over a 3-year period is presented. The differences in age distribution, the type of contraceptive agents used, the reasons for using them, and the side effects in the 2 groups are statistically significant. In order for the midwives to provide acceptable contraceptive advice to the rural communities they need a positive attitude toward contraception, a more involved role in family planning policy, program planning and implementation, special training in family planning practice, and to be equipped to train various community health workers on how to distribute different types of family planning techniques in all the rural areas, especially outside of the hospital setting. This survey showed that there is a high level of awareness of contraception among the Nigerian midwives studied. It also suggests that Nigerian student midwives practice family planning although many probably use less effective methods. Respondents were mostly single and young and a majority were only 3-4 years post-secondary school. The condom was highly favored, but its use requires a high degree of responsibility and self-control. 27.9% practiced the rhythm method, and 16.2% used oral contraceptives, a relatively low proportion. IUD users were few in number. Incidence of side effects for all methods was low. The midwives are in a unique position, by their practice in rural communities, to preach awareness of contraception in order to reduce the high fertility and population rate in developing countries.

The implications of childbearing in postpubertal girls in Sokoto, Nigeria.

A retrospective analysis of 337 young postpubertal delivered mothers was compared with other parturient women in Sokoto University Teaching Hospital (S.U.T.H.) during a 1-year period. In this analysis, late booking was identified as the most important factor that directly affects the perinatal outcome in young postpubertal pregnant mothers. The problems of postpubertal pregnancy were highlighted in order to motivate individuals towards family planning.

PIP: This investigation was to evaluated the characteristics and the outcome of pregnancy in young postpubertal girls and in other women of childbearing age. A retrospective analysis of 337 young postpubertal delivered mothers was compared with other parturient women in Sokoto University Teaching Hospital, Nigeria, during a 1-year period. Late booking was identified as the most important factor that directly affects the perinatal outcome in young postpubertal pregnant mothers. The problems of postpubertal pregnancy were highlighted in order to motivate individuals towards family planning. The striking features of the young postpubertal mothers in this study as in other reports were relatively low level of education, low socioeconomic status, and social and psychological immaturity. This analysis revealed a relatively low birth weight and low parity in the young adolescent mothers; this agrees with other studies. The high incidence of maternal and fetal complications contradicts some other reports that indicate that adolescent obstetrics present no greater challenge than obstetrics in general. Anemia and prematurity were common in the young mothers. The cesarean section rate was high and the main indication was cephalopelvic disproportion, with the greatest risk for women under 16, due to bone immaturity. For most developing countries of the world, especially where there is inadequate medical care, pregnancy and delivery in young postpubertal girls appear unsafe and must be discouraged through appropriate reproductive health care in the community.

Socio-biological factors influencing infertility in a rural Nigerian community.

An assessment of factors influencing infertility in a rural Nigerian community revealed a prevalence rate of 12.9% primary infertility. Secondary infertility among the subjects was 54.1%. Age, education and religion of respondents had statistically significant influence on infertility (P less than 0.05) but not income (P greater than 0.05). The correlation between age of respondents and infertility was statistically significant (P less than 0.05). Primary health care efforts aimed at implementing maternal and child health care should explore the traditional customs on infertility in rural areas of developing countries.

Sonographic assessment of the incompetent cervix in pregnancy.

Ultrasonography (US) was done in 40 women with a history of recurrent midtrimester abortion. The results were compared with those of a control group who consisted of 53 women with no previous history of abortion and had had at least one full term pregnancy with normal vaginal delivery. Mean internal cervical os diameters of 16.0 mm and 22.5 mm at 10 and 27 weeks gestation respectively were recorded in the cervical incompetent patients while mean values of 7.7 mm and 14.5 mm at 13 and 28 weeks gestation were observed in the normal control subjects. Full analysis of covariance showed statistically significant difference in the internal os diameter between the control group and the cervical incompetence cases (t90 = 9.33, P less than 0.001).

Characteristics of maternal deaths following cesarean section in a developing country.

A retrospective analysis was made of 27 maternal deaths after cesarean section occurring over a 5-year period. Sepsis was the single most important cause of maternal death (81.5%). The commonest indications for the cesarean sections were obstructed labor (59.3%) and cord prolapse (18.5%). The causes of maternal deaths were classified as avoidable and recommendations were made for their prevention.

PIP: A retrospective analysis of 27 maternal deaths associated with cesarean section and occurring at Nigeria's University of Ilorin Teaching Hospital in 1982-86 was performed. The cesarean section rate for the 48,974 deliveries that took place at the hospital during the study period was 4.1%. The death rate was 18.1/1000 cesarean sections compared with 1.89/1000 vaginal deliveries. Maternal sepsis was responsible for 22 (82%) of the cesarean section-associated maternal deaths; the remaining deaths were attributed to hemorrhage (1 primary and 3 secondary) and eclampsia (1 case). Obstructed labor was the single most important indicator for cesarean section (67%) and the most significant predisposing factor to maternal sepsis (63%). Most deaths from sepsis occurred on the 2nd-4th postoperative days. The skill of the surgeon was not a significant factor in maternal deaths. The most common antibiotic used to combat sepsis was a combination of ampicillin and gentamicin--a regimen that does not cover anaerobic organisms. Some patients did not receive antibiotics until the 3rd postoperative day because they were not on stock in the hospital pharmacy. Administrative difficulties, most notably inadequate laboratory backing and funding, also played some role in the high maternal death rate in this series.

Value of ultrasonic placental localization in pregnancy after caesarean section.

Ninety-four women who had undergone previous lower segment caesarean section (CS) were evaluated in the third trimester of pregnancy using ultrasound for localization of the placenta. Results obtained showed that posterior upper uterine segment placental implantation occurred with the highest frequency of 36.2pc followed by anterior upper uterine segment and fundal implantations which each had a frequency of 19.1pc. For anterior lower segment implantation the frequency was 18.1pc while placenta praevia occurred with frequency of 5.3pc. Altogether, anterior uterine wall placental implantation occurred with combined frequency of 37.2pc and justifies routine ultrasonic placentography in pregnant women with previous CS who are being considered for surgical procedures like amniocentesis or another CS.

Primary post-partum haemorrhage at a university hospital in Nigeria.

Two hundred and four cases of primary postpartum haemorrhage were compared with the same number of normal post-partum mothers, during a period of two years at a University Hospital in Ilorin, Nigeria. Majority of the women (71%) who suffered from primary post-partum haemorrhage were in the age group 15 to 29 years, and there was no difference in the age distribution between the study and the control groups. Primary post-partum haemorrhage occurred more in the primipara and grand-multipara compared with the control and the differences is statistically significant. Atony of the uterus was the commonest cause of post-partum haemorrhage and this was attributed to mismanagement of labour. Many of the women with post-partum haemorrhage had vaginal delivery but the difference in the mode of delivery between the study and the control groups was statistically significant. Anaemia and hypovolaemic shock were the two commonest avoidable complications and the preventable measures and the need for further investigations of cases of primary post-partum haemorrhage are highlighted.

Multiple exposure photographic (MEP) technique: an objective assessment of sperm motility in infertility management.

Multiple exposure photography (MEP), an objective technique, was used in determining the percentage of motile sperms in the semen samples from 41 males being investigated for infertility. This technique was compared with the conventional subjective ordinary microscopy method of spermatozoal motility assessment. A satisfactory correlation was observed in percentage sperm motility assessment using the two methods but the MEP estimation was more consistent and reliable. The value of this technique of sperm motility study in the developing world is discussed.