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.

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 .

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.

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.

Complement and immunoglobulin levels in Ilorin Nigeria, and environ.

The levels of complement components C3 and C4 were determined in EDTA (ethylene-diamine-tetra-acetic acid) plasma of 106 apparently healthy people aged 11-50 years, and in 23 paired maternal and cord plasma in Ilorin. The immunoglobulins G,A and M concentrations of these paired samples were also assayed. Furthermore, serum IgG, IgA and IgM levels were quantitated in 501 apparently healthy residents of Ilorin (1-84 years old, n = 313) and its suburban community, Shao (11-80 years old, n = 188). Generally, there were no significant sex-related differences in C3 and C4 values, but these values increased steadily with age. C3 and C4 levels in cord plasma were high, representing 73% and 88% of adult levels respectively. Maternal levels of these complement components were higher (P < 0.02) than values obtained in non-pregnant females of comparable age. Immunoglobulin G values obtained for maternal and cord samples compare well with figures reported previously from other centres in Nigeria. Only 1 of 23 IgA and 2 of 23 IgM samples showed detectable values of these immunoglobulins in cord blood. The mean concentrations of immunoglobulins obtained were similar for IgG and lower for IgA and IgM in Ilorin, but higher for IgG and lower for IgA and IgM in Shao, when compared with data reported from Enugu and Zaria--both in Nigeria. Shao showed significantly higher mean level of IgG but similar levels of IgA and IgM to values obtained in Ilorin. Generally, IgG and IgA concentrations rose gradually up to age group 31-40 and 41-50 years respectively; and then declined. (ABSTRACT TRUNCATED AT 250 WORDS)

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.

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.

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.

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).

Birthweight and sociobiological factors in Ilorin, Nigeria.

Social and biological factors influencing birthweight of 3053 Ilorin babies were studied. The mean birth weights were 2.998 kg +/- 0.133 (SD) for males and 2.932 kg +/- 0.154 (SD) for females. Multiple regression analysis showed that maternal weight, height, age, education and ethnicity, and child's sex, significantly affected birthweight of infants. Some quadratic and interaction terms also contributed significantly to the prediction of birthweight. The strategies to control the incidence of low birth weight are discussed.

PIP: This study fills in the gap in data for Nigeria on distribution and correlates of birth weight among ethnic groups in the northern region, principally in Ilorin, the capital city of Kwara State. Data were taken from 50% of the records of normal live births from University Hospital during 1986, and may not represent those rural births delivered by traditional birth attendants. The population constitutes 80% of all city hospitals births and those referred for complications. Data included birth weight in metric units, maternal weight, age, height, parity, occupation, ethnic group, and education. Incidence of low birth weight was 18.2% (males) and 20.8% (females) and did not differ significantly by weight and sex. The mean birthweight 2.998 kg for males and 2.932 kg for females is slightly lower than those reported for southwestern Nigeria infants (3.162 kg for males and 3.015 kg for females in Ibidan). This is also lower that the mean birthweights of 3.145 kg recorded in southeastern Nigeria. The Ilorin babies, however, are considerably above northern Nigeria figures in southern Zaria (2.235 kg for males and 2.170 kg for females. Ilorin figures are similar to other equatorial Africa; i.e., rural Cameroon of 3.119 kg, Tanzania of 3.009 kg or 2.850 kg. British and American babies are higher at 3.415 kg and 3.400 respectively. The sex ratio was M:F 1.05:1. For male births, there is tendency for birthweight to rise with maternal height. There is a consistent rise in birthweight with maternal weight, and maternal education; there were significant differences by maternal occupation but not ethnicity. 68% of the variance was accounted for in the multiple regression by maternal weight, age education, height and ethnicity, and child's sex; this confirms the results of other investigators. The introduction of quadratic terms such as maternal weight and age improved the equation. Other variables such as length of gestation, maternal smoking improvement in the nutrition of pregnant women, sex education in school, and encouragement to defer marriage along with nutritional education for teenagers and reproductive age women. These measures may enhance the birthweight and hence survivability of children.

Socio-cultural factors in adolescent septic illicit abortions in Ilorin, Nigeria.

One hundred and ninety-two adolescents (aged 12-18 years) with septic illicit abortions were interviewed to assess socio-cultural factors associated with illegally induced septic abortions at Ilorin, Nigeria. They were mostly unmarried schoolgirls who were ignorant of contraception. Inadequate parental supervision contributed largely to unplanned pregnancies, while poor economic state of these patients influenced the occurrence of illegal septic abortions. Wide-spread availability of an acceptable family-life education, with improved socio-economic state of the adolescents would most probably reduce the socio-cultural factors favouring illicit septic induced abortions in this community.

PIP: In 1987-1989, researchers interviewed 192 adolescents admitted to University of Ilorin Teaching Hospital (UITH) in Nigeria for septic illegal abortions to determine the sociocultural factors of septic illegal abortions among adolescents and the effects of these abortions on the population. The 2 major complications resulting in the patients being admitted to UITH were hemorrhage (42.2%) and septicemia (30.7%). The abortion rate at UITH stood at 94.6/1000 deliveries representing an increase. Adolescents made up 74.4% of all induced abortions which accounted for 60.3% of all gynecological admissions. Most patients (72.5%) were between 15-19 years old. Just 12.5% lived with both parents--an example of the break down of the family which traditionally prepared children for integration into adult society. 81.3% had a primary education, but only around 30% of parents had a primary education. School officials expelled 50% of the patients thereby making expulsion from school the leading social consequence of adolescent septic illegal abortion. Indeed neither the education system nor the family were prepared to teach family life education to prevent these unwanted pregnancies. In Nigeria, since abortion is considered immoral, the adolescents had little choice but to seek a clandestine abortion. Moreover, many adolescents were poor so they opted for free abortion services which were often provided by charlatans. A shift from a rural society to an urban society also contributed to an increase in abortions. The government must emphasize maternal and child health services, especially liberalization of abortion. Further, it must make family planning education and services available to adolescents. In addition, the mass media should be exploited to spread information about the adverse consequences of adolescent illegal abortions.

The prevalence of infertility in a rural Nigerian community.

The prevalence of infertility in a rural Nigerian community is determined by a systematic random sampling of the population. The overall prevalent rate was 30.3%, giving indices of 9.2% for primary infertility and 21.1% for secondary infertility. Primary infertility is rare after the age of 30 years and acquired causes of infertility are responsible for the high prevalence rate. Genital infections (post-abortal and puerperal) are major contributory factors to the high rate of infertility. Liberal abortion laws, improved socio-economic status and elimination of harmful socio-cultural beliefs and practices would reduce the problem of infertility to the barest minimum in the developing countries.

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.

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.

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.

Maternal mortality from infection at a university hospital in Nigeria.

This study analyzed 89 cases of maternal death following infections. The overall maternal mortality rate in infection was 5.9%. The maternal death rate is significantly related to parity but higher age group mothers survived better. Septicaemic shock and cardiopulmonary arrest were the major terminal causes of maternal death. The risk factors for the high maternal death following infections were examined and preventive measures recommended.

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.

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.

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.