Causes of maternal death at Natalspruit Hospital, Johannesburg, South Africa.

BACKGROUND: Despite increased resources to reduce maternal deaths, South Africa (SA) has an unacceptably high maternal mortality rate (MMR). OBJECTIVES: To determine the causes of maternal deaths at Natalspruit Hospital, Johannesburg, SA. METHODS: A 2-year retrospective audit of case records was done All maternal deaths from January 2013 to December 2014 were included. RESULTS: There were 20 676 live births and 79 deaths, with a MMR of 382.08/100 000. Forty-four women (56%) were HIV-positive, 14 (21%) died of obstetric haemorrhage and 12 (15%) had hypertensive disorders of pregnancy. Thirty women (38%) had not attended an antenatal clinic. More women died between 16h00 and 08h00 than between 08h00 and 16h00. Most women (88%) had at least one avoidable factor. CONCLUSIONS: Natalspruit Hospital has a high MMR. The majority of deaths were HIV-related. There was a high number of women who were unbooked. Most deaths occurred after normal working hours.

Induced abortion.

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa.

BACKGROUND: Septic incomplete miscarriages remain a cause of maternal deaths in South Africa. There was an initial decline in mortality when a strict protocol based approach and the Choice of Termination of Pregnancy Act in South Africa were implemented in this country. However, a recent unpublished audit at the Pretoria Academic Complex (Kalafong and Steve Biko Academic Hospitals) suggested that maternal mortality due to this condition is increasing. The objective of this investigation is to do a retrospective audit with the purpose of identifying the reasons for the deteriorating mortality index attributed to septic incomplete miscarriage at Steve Biko Academic Hospital. METHODS: A retrospective audit was performed on all patients who presented to Steve Biko Academic Hospital with a septic incomplete miscarriage from 1(st) January 2008 to 31(st) December 2010. Data regarding patient demographics, initial presentation, resuscitation and disease severity was collected from the "maternal near-miss"/SAMM database and the patient's medical record. The shock index was calculated for each patient retrospectively. RESULTS: There were 38 SAMM and 9 maternal deaths during the study period. In the SAMM group 86.8% and in the maternal death group 77.8% had 2 intravenous lines for resuscitation. There was no significant improvement in the mean blood pressure following resuscitation in the SAMM group (p 0.67), nor in the maternal death group (p 0.883). The shock index before resuscitation was similar in the two groups but improved significantly following resuscitation in the SAMM group (p 0.002). Only 31.6% in the SAMM group and 11.1% in the maternal death group had a complete clinical examination, including a speculum examination of the cervix on admission. No antibiotics were administered to 21.1% in the SAMM group and to 33.3% in the maternal death group. CONCLUSION: The strict protocol management for patients with septic incomplete miscarriage was not adhered to. Physicians should be trained to recognise and react to the seriously ill patient. The use of the shock index in the identification and management of the critically ill pregnant patient needs to be investigated.

Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan.

OBJECTIVE: To study the mortality and morbidity of unsafe abortion in a University Teaching Hospital. METHODS: A cross-sectional, descriptive study was conducted in Department of Obstetrics and Gynaecology, Unit III, Dow Medical College and Civil Hospital Karachi from January 2005 to December 2009. Data regarding the sociodemographic characteristics, reasons and methods of abortion, nature of provider, complications and treatment were collected for 43 women, who were admitted with complications of unsafe abortion, and an analysis was done. RESULTS: The frequency of unsafe abortion was 1.35% and the case fatality rate was 34.9%. Most of the women belonged to a very poor socioeconomic group (22/43; 51.2%) and were illiterate (27/43; 62.8%). Unsafe abortion followed an induced abortion in 29 women and other miscarriages in 14 women. The majority of women who had an induced abortion were married (19/29, 65.5%). A completed family was the main reason for induced abortion (14/29; 48.2%) followed by being unmarried (8/29, 27.5%) and domestic violence in 5/29 cases (17.2%). Instruments were the commonest method used for unsafe abortion (26/43; 68.4%).The most frequent complication was septicaemia (34; 79%) followed by uterine perforation with or without bowel perforation (13, 30.2%) and haemorrhage (9; 20.9%). Majority of induced abortions were performed by untrained providers (22/26; 84.6%) compared to only 3/14 cases (21.4%) of other miscarriages (p = 0.0001). CONCLUSION: The high maternal mortality and morbidity of unsafe abortion in our study highlights the need for improving contraceptive and safe abortion services in Pakistan.

The impact of age on the epidemiology of incomplete abortions in South Africa after legislative change.

OBJECTIVE: In 1996 termination of pregnancy was legalised in South Africa. This article examines the impact of age on the epidemiology of incomplete abortion after legislative change. It draws comparison with the findings of a similar study undertaken in 1994. DESIGN: Multicentre, prospective, descriptive study. SETTING: Forty-seven public hospitals in all nine provinces. SAMPLE: A stratified random sample of all hospitals treating gynaecological emergencies was drawn. All women of gestation under 22 weeks who presented with incomplete abortion during three weeks of data collection in 2000 were included. METHODS: A data capture sheet completed by a clinician from the case notes. MAIN OUTCOME MEASURES: Demographic characteristics and clinical findings on admission by age of women. RESULTS: Overall, there was a significant increase in the proportion of cases with no signs of infection on admission (from 79.5% to 90.1%) and a significant decrease in evidence of interference on evacuation (4.5% to 0.6%) between 1994 and 2000. Substantial age differentials were seen. Women over 30 were significantly less likely than those 21-30 years or under 21 to be low severity (65.5% vs 75.2% vs 76.4%, P= 0.0087) and more likely to have offensive products (16.3% vs 6.0% vs 6.4%, P= 0.01) than the younger women. CONCLUSIONS: Legalisation of abortion had an immediate positive impact on morbidity, especially in younger women. This is an important change as teenagers had the highest morbidity in 1994. The trend is supported by evidence from the 1999-2001 Confidential Enquiry into Maternal Deaths, which further suggested that abortion mortality dropped by more than 90% since 1994.

Incidencia de aborto incompleto antes y después de instaurado un programa de procreación responsable / Incidence of incomplete abortion before and after established a responsible procreation program

Objetivo: evaluar la posible disminución de abortos incompletos por efecto de un programa de procreación responsable PR. Material y Métodos: el diseño del estudio fue observacional descriptivo. Fue estudiado el comportamiento del aborto incompleto durante 20 años consecutivos a través del índice L/P (número total de legrados por abortos incompletos/número total de partos, anuales para ambos), y se correlacionó con la inexistencia de un programa de PR como ocurrió en el primer decenio del estudio 1977-1986 y con la presencia del mencionado programa en el decenio siguiente 1987-1996. Resultados: observamos una significativa disminución del índice L/P en el decenio 1987-1996 respecto del decenio 1977-1986, (11.08 por ciento-7.55 por ciento diferencia entre proporciones : p<0.000001), esta disminución mostró una tendencia exponencial sin estacionalidad (test de Mann-Witney, p<0.001). El número de beneficiarias del programa PR tuvo un crecimiento lineal de 337 en el primer año hasta 8954 al final del decenio. En el decenio donde actuó el programa de PR, se observó que el índice L/P fue descendido de 10.0 por ciento hasta estabilizarse en un 7.5 por ciento, a medida que se incrementaba el número de beneficiarias del programa. El riesgo de aborto para la población expuesta, atribuible a la no existencia del programa de PR fue de 34.6 por ciento [Odds ratio=1.53 (I.C. 95 por ciento: 1.47-1.59)] y para la población general del 7.1 por ciento. Consideramos que el comportamiento del aborto provocado, estaría reflejado en la evolución del índice L/P analizado. Conclusión: el desarrollo de un programa de Procreación Responsable estuvo asociado con una disminución de la incidencia de aborto incompleto.

Incidencia de aborto incompleto antes y después de instaurado un programa de procreación responsable / Incidence of incomplete abortion before and after established a responsible procreation program

Objetivo: evaluar la posible disminución de abortos incompletos por efecto de un programa de procreación responsable PR. Material y Métodos: el diseño del estudio fue observacional descriptivo. Fue estudiado el comportamiento del aborto incompleto durante 20 años consecutivos a través del índice L/P (número total de legrados por abortos incompletos/número total de partos, anuales para ambos), y se correlacionó con la inexistencia de un programa de PR como ocurrió en el primer decenio del estudio 1977-1986 y con la presencia del mencionado programa en el decenio siguiente 1987-1996. Resultados: observamos una significativa disminución del índice L/P en el decenio 1987-1996 respecto del decenio 1977-1986, (11.08 por ciento-7.55 por ciento diferencia entre proporciones : p<0.000001), esta disminución mostró una tendencia exponencial sin estacionalidad (test de Mann-Witney, p<0.001). El número de beneficiarias del programa PR tuvo un crecimiento lineal de 337 en el primer año hasta 8954 al final del decenio. En el decenio donde actuó el programa de PR, se observó que el índice L/P fue descendido de 10.0 por ciento hasta estabilizarse en un 7.5 por ciento, a medida que se incrementaba el número de beneficiarias del programa. El riesgo de aborto para la población expuesta, atribuible a la no existencia del programa de PR fue de 34.6 por ciento [Odds ratio=1.53 (I.C. 95 por ciento: 1.47-1.59)] y para la población general del 7.1 por ciento. Consideramos que el comportamiento del aborto provocado, estaría reflejado en la evolución del índice L/P analizado. Conclusión: el desarrollo de un programa de Procreación Responsable estuvo asociado con una disminución de la incidencia de aborto incompleto. (AU)

The epidemiology of incomplete abortion in South Africa. National Incomplete Abortion Reference Group.

OBJECTIVE: To describe the epidemiology of incomplete abortion (spontaneous miscarriage and illegally induced) in South Africa. DESIGN: Multicentre, prospective, descriptive study. SETTING: Fifty-six public hospitals in nine provinces (a stratified, random sample of all hospitals treating gynaecological emergencies). PATIENTS: All women of gestation under 22 weeks who presented with incomplete abortion during the 2-week study period. MAIN OUTCOME MEASURES: Incidence of, morbidity associated with and mortality from incomplete abortion. MAIN RESULTS: An estimated 44686 (95% CI 35633-53709) women per year were admitted to South Africa's public hospitals with incomplete abortion. An estimated 425 (95% CI 78-735) women die in public hospitals from complications of abortion. Fifteen per cent (95% CI 13-18) of patients have severe morbidity while a further 19% (95% CI 16-22) have moderate morbidity, as assessed by categories designed for the study which largely reflect infection. There were marked inter-provincial differences and inter-age group differences in trimester of presentation and proportion of patients with appreciable morbidity. CONCLUSIONS: Incomplete abortions and, in particular, unsafe abortions are an important cause of mortality and morbidity in South Africa. The methods used in this study underestimate the true incidence for reasons that are discussed. A high priority should be given to the prevention of unsafe abortion.

Complications of unsafe abortion in sub-Saharan Africa: a review.

The Commonwealth Regional Health Community Secretariat undertook a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The results of the literature review component of that study, and research gaps identified as a result of the review, are presented in this article. The literature review findings indicate a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynaecology admissions. The most common complications of unsafe abortion seen at health facilities were haemorrhage and sepsis. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay (and thus, lower resource costs) and a reduced need for a repeat evacuation. Very few articles focused exclusively on the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behaviour and abortion reported that almost all patients suffering from abortion complications had not used an effective, or any, method of contraception prior to becoming pregnant, especially among the adolescent population; studies on post-abortion contraception are virtually nonexistent. Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs that were identified include: community-based epidemiological studies; operations research on decentralization of post-abortion care and integration of treatment with post-abortion family planning services; studies on system-wide resource use for treatment of incomplete abortion; qualitative research on the role of males in the decision to terminate pregnancy and use contraception; clinical studies on pain control medications and procedures; and case studies on the provision of safe abortion services where legally allowed.

PIP: The Commonwealth Regional Health Community Secretariat conducted a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The literature review component of the study identified a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynecology admissions. Hemorrhage and sepsis were the most common complications of unsafe abortion seen at health facilities. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay and a reduced need for a repeat evacuation. Few articles focused exclusively upon the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behavior and abortion reported that almost all patients experiencing abortion complications had not used an effective, or any, method of contraception before becoming pregnant, especially among the adolescent population, while there were almost no studies on post-abortion contraception. Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs are presented.

Deaths in gynaecological wards at Groote Schuur Hospital, Cape Town, 1957 - 1977.

During the period 1957 - 1977 there were 421 deaths recorded in the gynaecological wards of Groote Schuur Hospital, Cape Town. Nearly 50% of the patients were Coloureds, 25% were Whites, and 14% were Blacks; in 14% the ethnic group was not stated. Seventy-four per cent were more than 40 years and 25% were more than 70 years of age. The causes of death in order of frequency were: malignant disease of the cervix (30%), malignant disease of the ovary (17%), incomplete abortion (15%), non-gynaecological conditions (11%), malignant disease of the corpus uteri (8%), intra-abdominal malignancy (6%), pulmonary embolism (3%), sepsis not associated with abortion (3%), malignant disease of the vulva (2%), and other conditions (5%). The six commonest causes of death varied in the three ethnic groups.

Maternal mortality. A survey of 118 maternal deaths and the avoidable factors involved.

From January 1973 to December 1975, 26 018 women were delivered at Edendale Hospital. During the same period, 4 478 patients aborted there. Maternal deaths during this period numbered 118, a mortality of 4,5/1 000 total births. Avoidable factors influencing the mortality may have been present in 28 (2387%).