Reducing maternal mortality in Mozambique: challenges, failures, successes and lessons learned.

The aim of this paper is to describe different approaches to make emergency obstetric care (EmOC) accessible to women in Mozambique. The definitions of basic (BEmOC) and comprehensive EmOC (CEmOC), proposed by the UN agencies, were adopted by FIGO and by the Mozambican Ministry of Health as a general strategy to reduce maternal mortality. Four projects are presented: (1) José Macamo and (2) Mavalane Hospitals in Maputo city, (3) Manhiça District in Maputo Province and (4) Sofala Province. José Macamo was staffed by physicians 24 h a day; other hospitals by non-physicians trained in surgical and anesthesiology techniques, as well as nurse-midwives. José Macamo Hospital provided CEmOC to the city of Maputo and the southern area of Maputo Province. In 2001, this hospital attended 32% of deliveries and 38% of cesarean sections in the city, up from 14 and 2.5%, respectively, in 1998. The Mavalane Hospital failed to provide CEmOC; however, the number of deliveries per year almost doubled. The Manhiça hospital carried out 31% of the District's C-sections in 2001, up from 9% in 1998. In Sofala Province, one additional CEmOC and four BEmOCs were installed and case fatality rates decreased. In conclusion, the strategy for ensuring provision of EmOC is feasible even in countries with minimal resources and a scarcity of physicians, such as Mozambique.

Low birthweight and post partum endometritis-myometritis.

BACKGROUND: The study aims at confirming or rejecting the hypothesis of an association between birthweight and post partum uterine infection. METHODS: A case-referent study was performed on 51 puerperal women with clinical signs of endometritis-myometritis. To each case an otherwise healthy puerperal woman was recruited and matched for age, parity and days after delivery. RESULTS: The proportion of women having had newborns with birthweight < 2500 g was 20/49 among cases and 2/50 among referents (odds ratio 16.6; 95% CI 3.5-152.3). Preterm births were registered in 15/50 cases and 2/49 referents (odds ratio 10.1; 95% CI 2.1-94.5). The average gestational age at delivery was approximately 2 weeks shorter among cases than among referents (37.5 versus 39.5 weeks). CONCLUSIONS: Low birth weight was ten times more prevalent among women with puerperal infection than among healthy puerperal women. The findings indicate that giving birth to a low birth weight baby is strongly associated with ensuing puerperal infection, possibly by a subclinical antenatal intrauterine infection, predisposing to both adverse fetal and maternal outcomes of pregnancy.

A case-control study on post-caesarean endometritis-myometritis in Mozambique.

Post-caesarean endometritis-myometritis (PCEM) was diagnosed in 49 Mozambican women. They were compared with 47 control women without signs of PCEM after caesarean section. The patients and controls were matched for age, parity and days post partum. Features of the socio-economic background and of past and current obstetric history were registered. Endocervical, intracavitary and blood cultures were carried out. Screening for syphilis seropositivity and HIV-1 and HIV-2 antibodies was performed. Socio-economic and obstetric background factors were similarly distributed in cases and referents, though previous caesarean section was less frequent among cases than among referents (OR 0.12). Moderate high-risk factors in existing antenatal card tended to be more frequent among cases than among referents (OR 3.29). Microbiological findings indicated more anaerobes in the vagina, in the endocervix and in the uterine cavity, though the differences only approached significance. It is concluded that women with PCEM in the setting studied expose few characteristic background features discriminating them from women with uneventful post-caesarean outcome. Further research efforts should be directed towards case-control studies with focus upon surgical factors and on a more comprehensive microbiology and serology approach.

PIP: A case control study included 49 women diagnosed with post-cesarean endometritis-myometritis (PCEM) and 47 controls who had also undergone a cesarean section but had no PCEM. Controls were matched with cases by age, parity, and days postpartum. All cases and controls delivered at Maputo Central Hospital in Mozambique. The study aimed to define potential background PCEM risk factors of socioeconomic and obstetric origin and serological and microbiological correlates. Health workers took blood samples, endocervical swabs, and intracavitary cultures from all cases and controls. They administered intraoperative prophylactic antibiotics to all cases and controls. Cases were more likely to live in a household of at least 6 persons (odds ratio [OR] = 4.44). Other socioeconomic factors studied were not significantly different between the 2 groups. Number of live births, stillbirths, abortions, and previous low birth weight deliveries were similar among both cases and controls. Cases were significantly less likely to have undergone a previous cesarean section than controls (OR = 0.12). Anaerobic bacteria were isolated more often from cases than controls in vaginal, endocervical, and intrauterine cultures (OR = 1.65, 1.95, and 1.77, respectively). Yet, the observed cultures were not significantly different between the 2 groups. Syphilis seropositivity and Chlamydia trachomatis rates were similar in cases and controls. These findings did not reveal any easily recognizable background risk factors for PCEM or any etiologic agent for PCEM. Additional case control studies are needed to focus on surgical factors. They also need to take on a more comprehensive microbiology and serology approach.

Risk factors in puerperal endometritis-myometritis. An incident case-referent study.

Postpartum endometritis-myometritis (PPEM) was identified in 51 women after vaginal delivery, who were compared with 51 healthy referent parturients, matched for age, parity and days postpartum. Socio-economic background data, past and current obstetric history and clinical data from recent delivery were analyzed. Endocervical and intracavitary cultures and blood cultures were performed and serological analyses of syphilis and HIV antibodies were carried out. No socio-economic factor studied discriminated significantly between cases and referents. Previous stillbirth (OR 9.44) and previous low-birthweight delivery (OR 3.90) occurred significantly more often among cases. In recently past pregnancy preterm delivery (OR 10.07), low birthweight (OR 16.55) and serious neonatal morbidity (OR 14.27) were significantly more common among cases. Cases and referents differed also significantly in body mass index < 22.5 (OR 3.41), left mid-upper-arm circumference < 25 cm (OR 2.66), haemoglobin < 100 g/l (OR 3.12) and high-risk classification in antenatal care (OR 11.95). Bacterial intracavitary cultures tended to be positive and have anaerobes more frequently in cases than in referents. It is concluded that women with PPEM in the setting studied belong to a group at risk also regarding adverse fetal outcome, both in recently past and in previous pregnancies.

Puerperal measurement of the symphysis-fundus distance.

Three groups of puerperal women were compared. The first group comprised 51 women with clinically evident endometritis-myometritis. This group was compared to 51 referents (group 2), matched for age, parity and days after delivery. Group 3 comprised 69 randomly selected, healthy puerperal women coming for postnatal check-up of their newborns. Groups 1 and 2 were compared regarding symphysis-fundus (SF) distance. It was found that puerperal women with clinical signs of endometritis-myometritis and healthy, matched referents (groups 1 and 2) did not differ in uterine size as measured by the SF distance. The uterine involution can be followed by simple anthropometry by assessment of the SF distance over the puerperal period. It is concluded that the allegedly swollen and enlarged uterus in puerpera with endometritis-myometritis post partum does not differ in fundal height from the uterus of healthy, normal puerpera.