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.

Coma in Mozambican gravidas: causes and perinatal outcome.

Ninety-one consecutive cases of coma were identified among gravidas at Maputo Central Hospital. The commonest causes were eclampsia (70 cases), cerebral malaria (six cases), and meningitis (five cases). Fetal mortality in eclampsia was 23 per cent and maternal mortality 10 per cent. There was a markedly higher incidence of eclampsia during the colder months.

Using decision analysis to calculate the optimum treatment for microinvasive cervical cancer.

Decision theory was used to calculate the optimum treatment of microscopic squamous cervical cancer using probabilities obtained from an exhaustive literature review and a range of plausible value estimates. This showed that if there is no vascular involvement, survival is maximised by conservative treatment if tumour invasion is less than 3 mm while treatment by radical surgery results in maximal survival rates if the tumour invasion is over 3 mm. Radical surgery also maximises survival for smaller lesions where lymph channel involvement is present, especially if a surgical mortality at the lower end of the reported range is assumed. Refinement of our analysis to include an assessment of patient values showed that these conclusions are still valid regardless of the patient's relative preference for death from surgery or death from cancer. However, the wish to preserve fertility sharply reduces the overall net benefit of surgery. Conservative treatment becomes the preferred option for all microinvasive lesions even for patients who are prepared to trade-off a small (e.g. 2%) risk of death in order to retain their fertility.

Seasonal incidence of eclampsia and its relationship to meteorological data in Mozambique.

Gestational hypertension is common in Mozambique. In a prospective study lasting 12 months every case of eclampsia in Maputo city was registered. The monthly ratio of eclampsia cases to births was calculated. With the purpose to test the hypothesis of a correlation between meteorological data and eclampsia incidence, monthly averages of temperature, humidity and atmospheric pressure were tabulated. Temperature (p less than 0.005) and atmospheric pressure (p less than 0.001) were significantly associated with the eclampsia/birth ratio. Humidity showed no significant association. We conclude that there is a statistical association between eclampsia incidence and air temperature and atmospheric pressure, respectively.

Audit of medical response to antenatal booking history.

A retrospective review of 600 obstetric case-notes, covering the years 1978 to 1984, was performed independently by two assessors. The medical response to 22 risk factors, recorded at booking by the midwife, was assessed. The medical staff recognized 69% of the risk factors recorded at booking and responded appropriately to 82% of these. The standard of care improved over the period studied. The accuracy of our conclusions was greatly enhanced by carrying out each assessment in duplicate with arbitration by a third assessor when necessary, and it is proposed that all audits of medical practice should themselves be audited in this way.

Balancing the risks of planned cesarean section and trial of vaginal delivery for the mature, selected, singleton breech presentation.

The experience of mature, singleton, vaginal breech delivery over the last decade in our hospital is reviewed. This constitutes the largest series of breech delivery reported for over twelve years. Unlike all but two previous reports, we analyze our results by management policy; elective cesarean section, trial of vaginal breech delivery and cesarean section as soon as the diagnosis of breech delivery was made on labor ('expedite' cesarean operations). Six intrapartum or neonatal deaths occurred among 613 patients selected for trial of vaginal delivery--a rate of one per cent. There were none following 217 elective or 69 expedite cesarean sections. A detailed review of the literature over the last decade confirms that trial of vaginal delivery is more dangerous to the fetus and results in about one perinatal death of a normally formed infant in 200 deliveries. Apgar scores were slightly lower following trial of vaginal delivery and there were more irritable or injured babies in this group. The last intrapartum or neonatal death occurred in 1981. However, the elective cesarean section rate has increased from 14 to 33 per cent over this time period. Similarly the rate of failed trial of vaginal breech delivery has increased from 15 to 31 per cent. The proportion of failed trials was highest where the fetus was large but clinicians were poor at estimating fetal weight. Decision theory is used to examine the maternal utility of trial of vaginal breech delivery versus elective cesarean section when the intrapartum cesarean rate rises to these levels. It is shown that, from the point of view of maternal mortality and morbidity in the current pregnancy, trial of vaginal delivery maybe the more dangerous maternal option. Thus a low threshold for cesarean section in labor leads to greater fetal safety at the mother's expense. It is nevertheless concluded that maternal attitude and the long-term effects of a uterine scar should be considered in the final decision.