Non-obstetric causes of severe maternal complications: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To evaluate the burden, causes and outcomes of severe non-obstetric maternal complications in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary health facilities. POPULATION: Women admitted with complications during pregnancy, childbirth or puerperium. METHODS: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) due to non-obstetric causes were prospectively identified over a 1-year period. Maternal near-miss was defined using organ-system dysfunction (WHO), clinical, or management-based criteria. MAIN OUTCOME MEASURES: Causes and contributions of non-obstetric complications to SMO; fetal and neonatal outcomes; health service events associated with non-obstetric complications; and mortality index (% of maternal death/SMO). RESULTS: Of 100 107 women admitted with complications, 9401 (9.4%) were for non-obstetric causes; and 4.0% (375/9401) suffered severe non-obstetric complications. Of the 375 cases of severe non-obstetric complications, 48.8% (183/375) were near-misses and 51.2% (192/375) were maternal deaths. Severe anaemia unrelated to haemorrhage contributed 61.2% of near-misses and 32.8% of maternal deaths. The highest mortality indices were observed for cancer (91.7%), hepatic diseases (81.8%) and HIV/AIDS/HIV wasting syndrome (80.4%). Fatality was significantly high with extremes of age and no formal education. Regarding organ dysfunctions, neurological (77.1%) and cardiovascular (75.0%) dysfunctions had the highest mortality indices. Perinatal mortality was 65.9%. Time from diagnosis of severe non-obstetric complications to review by senior medical personnel, and to definitive intervention was <30 minutes in 30.2% and 29.8% of women with SMO, respectively. However, over 240 minutes elapsed between diagnosis and definitive intervention in more than one-third of women with SMO. CONCLUSION: Non-obstetric complications are associated with poorer pregnancy outcomes and deserve attention similar to that accorded obstetric complications. FUNDING: The original research that generated the data for this secondary analysis and the publication of this secondary analysis were funded by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO). TWEETABLE ABSTRACT: Non-obstetric causes are important contributors to maternal deaths and life-threatening morbidities in Nigerian hospitals.

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.

Predictors of maternal mortality in institutional deliveries in Nigeria.

BACKGROUND: Maternal mortality in poor countries reflects the under-development in these societies. Global recognition of the burden of maternal mortality and the urgency for a reversal of the trend underpin the Millenium Development Goals (MDGs). OBJECTIVE: To determine risk factors for maternal mortality in institutional births in Nigeria. METHOD: Twenty one health facilities in three states were selected using stratified multi-stage cluster sampling strategy. Information on all delivered mothers and their newborn infants within a three-month period was culled from medical records. RESULTS: A total of 9 208 deliveries were recorded. About one-fifth (20.5%) of women had no antenatal care while 79.5% had at least one antenatal visit during pregnancy. Four-fifths (80.5%) of all deliveries were normal deliveries. Elective and emergency caesarean section rates were 3.1% and 11.5% respectively. There were 79 maternal deaths and 8 526 live births, giving a maternal mortality ratio of 927 maternal deaths per 100 000 live births. No antenatal care, parity, level of education, and mode of delivery were significantly associated with maternal mortality. Low maternal education, high parity, emergency caesarean delivery, and high risk patients risk independently predicted maternal mortality. CONCLUSION: Meeting goal five of the MDGs remains a major challenge in Nigeria. Multi-sectoral approaches and focused political will are needed to revert the high maternal mortality.

Epidemiological characteristics of carcinoma of the cervix in the Federal capital Territory of Nigeria.

OBJECTIVES: To study the epidemiological characteristics of cancer of the cervix in the Nigerian Federal Capital Territory (FCT), and also to serve as baseline information for future monitoring of on-going screening for pre-malignant cervical lesions. METHODOLOGY: Retrospective study of all confirmed cases of cancer of cervix managed at the National Hospital, Abuja (NHA) from its inception in 1999 to 2003. The case records of the patients were retrieved from diagnosis, treatment and follow up. RESULTS: Over the 5 year study period, 117 cases of cancer in women were managed in the hospital. Thirty-six (30.8%) were Cancer of the cervix. The mean age of the patients was 52.4 years, STD 1.18. Twenty-five (69.4 %) were grandmultiparous. The age at first confinement ranged from 12 to 19 (mean 15) years. Six (15%) admitted to multiple sexual partners. A common presenting complain was bleeding through the vagina 28(51.9%), 27(50%) were anaemic and 21 (38.9%) were cachetic. Late stage cancers were 31(86%), and 34 (88.9%) were squamous cell carcinoma. Radiotherapy was offered to 21(58.3%). Five (13.9%) were confirmed dead but 16 (44.4%) were lost to follow up. CONCLUSION: Cancer of the cervix present late in the FCT and the burden is heavy. The mortality is such that ongoing screening for pre-malignant lesions of the service in the FCT should be encouraged and widened.

Decision - delivery interval and perinatal outcome in emergency caesarean sections.

Recent studies have cast doubt on the recommended 30-min decision--delivery interval (DDI) in emergency caesarean sections. The practicability, justification, anticipated beneficial effect on neonatal outcome and its medico-legal implications have been questioned. We set out to determine (1) the DDI for emergency caesarean sections in two Nigerian tertiary care centres (2) the effect of DDI on perinatal outcome (particularly if the DDI is longer than the internationally recommended 30 min) and (3) the factors causing delays in intervention if any. This was a prospective observational study of consecutive cases of emergency caesarean sections performed at the two centres over an 8-month period. The main outcome measures were: indication for the caesarean, the decision-baby delivery interval, 1-min and 5-min Apgar scores, newborn admission to special care, perinatal death and reasons for any delay in decision - delivery interval beyond 30 min. The data were analysed with descriptive and inferential statistics and regression equations at the 95% confidence level. A total of 224 emergency caesarean sections were performed in the two institutions within the period of study. None of the caesarean sections was done within the recommended 30-min interval. Despite this, there was no significant correlation between the DDI and perinatal outcome. The major causes of delays in DDI were anaesthetic delays in both centres and difficulty in sourcing essential materials in one of the centres. The recommended 30-min DDI in emergency caesarean section is not currently feasible in Nigeria. Although the 30-min interval should remain the gold standard, DDI up to 3 hours may not be incompatible with good perinatal outcome as shown in this study. As in other studies, anaesthetic delay is the major cause of delay in carrying out emergency caesarean sections. Finally, since prolonged DDI may not be the cause of an adverse perinatal outcome in the majority of cases, litigation on these grounds may be unjustified.

Should routine ultrasonography in pregnancy be mandatory?

A review of the first 500 obstetric ultrasound scans performed at the National Hospital, Abuja between September 1999 and February 2000 was carried out. Five hundred pregnant women aged 18-41 years, mean age of 30 +/- 3.41 years; who had obstetric scans were studied. 287 (57.4%) had routine scans while 213 (42.6%) had specific obstetric reasons for scanning. The former served as the control group. Of the total, positive findings were seen in 180 cases (36%). 71.8% of those with specific indications for scanning had positive findings of clinical significance, while only 9.4% of the control group had incidental findings of clinical significance. Positive findings on ultrasound were significantly greater in the group with specific reasons for scanning, P < 0.001. We suggest that ultrasound examination in pregnant women should be performed based on established medical indications, elucidated clinically.

Maternal mortality at the University of Nigeria Teaching Hospital, Enugu, before and after Kenya.

A comparative retrospective analysis of maternal deaths at the University of Nigeria Teaching Hospital, Enugu, Nigeria, was carried out for two ten-year periods--1976-1985 and 1991-2000--in order to evaluate the effect of Safe Motherhood Initiative on maternal mortality in the hospital. Variables for the two periods were compared by means of the t-test at 95% confidence level. Maternal mortality ratio was significantly higher in Period II than in Period I (1406 versus 270 per 100,000, p = 0.00). The leading causes of maternal death were uterine rupture for Period I and septicaemia for Period II. Although from the first to the second ten-year period there was a significant decrease in the number of midwives, physicians and nurse anaesthetists, there was more than a proportionate decrease in the number of deliveries. There was also increase in the incidence of anaemia due to diminished standards of living and in the mean decision-intervention interval (1.5 +/- 0.5 versus 5.8 +/- 1.2 hours; p = 0.000) as a result of worker dissatisfaction and changes in hospital policies. We conclude that since the launching of the Safe Motherhood Initiative, MMR at the University of Nigeria Teaching Hospital, Enugu, Nigeria, has increased five-fold as a result of institutional delays and a deterioration in the living standards of Nigerians, both consequences of a depressed economy. To halt this trend, we recommend that the living standard of all Nigerians should be improved. Furthermore, healthcare personnel should be motivated through enhanced salaries and provision of working materials including efficient mobile telephone services.