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.

Pattern of placenta histopathology in low birth weight babies seen in a tertiary health centre in South-Western Nigeria.

BACKGROUND: Pre-term delivery is usually associated with low birth weight and is a known obstectrics problem in our setting. Few Histopathologists are interested in placental pathology, and this is particularly so because consent is often difficult to get from the relatives making few specimens available for study in our environment. OBJECTIVE: Our objective was to evaluate the placental histopathology in low birth weight infants (LBW, birth weight < 2500 g) and to determine if placental histopathological findings are associated with low birth weight and preterm deliveries. METHODS: The placenta of thirty-eight consecutive cases of LBW deliveries at the Obafemi Awolowo University Teaching Hospital, Wesley Guild Hospital, (lesa were histologically examined. RESULTS: A total of thirty-eight LBW placentas were examined. The Male: Female ratio was 1.8:1. The maternal age range 19 - 38 years (mean age = 28.7 yrs +/- 5.37SD). The parity ranged from 0 to 5. The birth weight ranged 0.75 - 2.4kg (mean 1.84kg +/- 0.39SD). The gestational age at delivery range was 25 - 38 weeks (mean 32.85 weeks +/- 3.7SD). Histological examination of the placentae showed that 17 cases (44.7%) had evidence of placenta malaria (PM), 17 cases (44.7%) had chorioamnionitis (CA), 9 cases (23.7%) had villitis, 2 cases (5.3%) had vasculitis and 4 cases (10.5%) had no abnormality. Four sets of twins (8 cases) were among the 38 cases seen. A case of abruptio placenta was delivered by caesarean section, with histological diagnosis of active- chronic malaria. Out of the cases with CA11 (64.7%) had mild CA, 4 (23.6%) moderate while 2 (11.8) had severe infection. Placenta malaria co-infection was also found in 7 (41%) of the CA. Nine (23:7%) had villitis, only 2 cases had umbilical cord vasculitis. Of the cases with PM, 10 (58.8) had active-chronic infection while 7 (41.2%) had evidence of past infection. CONCLUSION: The main placenta findings histologically in LBW babies include chorioamnionitis and placenta malaria infection. These are known contributory factors to preterm labour. Improved maternity care, health education of pregnant women to reduce ascending infection and use of intermittent preventive treatment for malaria in pregnancy will go a long way in improving outcome of pregnancy.

Perinatal autopsies in a tertiary health facility in Southwestern Nigeria: a retrospective evaluation of 14 consecutive cases.

BACKGROUND: Perinatal autopsy remains a valuable tool in perinatal medicine. It provides an insight into the genetic implications of subsequent pregnancies and also helps reduce parental events such as maternal illness or maternal use of medications. The practice is not popularly acceptable in our environment for socio-cultural reasons. The scarcity of pathologists who are interested in this aspect of pathology is also an issue. No wonder, the literature is scanty on the cases of perinatal autopsy reported in our environment. MATERIAL AND METHODS: This was a retrospective review of patients' medical and autopsy records to measure the perinatal autopsy rate at a tertiary health institution and identify the trends over the last 12 months (January 1, 2010 and December 31, 2010). This study also aim examining any discordance between antemortem diagnoses and postmortem diagnoses. RESULTS: Of 263 perinatal deaths, autopsies were requested and performed in 14 of the cases representing a perinatal autopsy rate of 5.3%. New information was obtained in 64.3% of the cases. The birth weights of the infants ranged from 500g to 3600g with their gestational ages ranged from 22 weeks to 41 weeks. CONCLUSIONS: This study is a preliminary report that serves principally to provide base line data for the ongoing study.

HELLP syndrome: the experience at Ile-Ife, Nigeria.

Between 1 January and 31 December, 2006, 34 consecutive cases of severe pre-eclampsia (12), imminent eclampsia (10) and eclampsia (12) who were admitted at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife in the south-western part of Nigeria, were investigated for the development of HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome in a prospective study. The ages of the women ranged from 18 to 38 years, parity 0-5 and the estimated gestational age from 18-41 weeks at presentation. A total of 26 (76.5%) of the patients were unbooked, six (17.6%) of the 34 cases developed HELLP syndrome. Four (33%) of the 12 eclamptics developed HELLP syndrome, while only one (10%) of the cases of imminent eclampsia and 1 (8.3%) of severe pre-eclamptic cases developed the syndrome. Using the Mississippi Triple class system, none of the HELLP syndrome cases belonged to Class I; 4 were categorised in Class II while 2 were in Class III. All of the four eclamptic cases with HELLP syndrome died giving a 100% fatality rate while none of the imminent eclamptic and severe pre-eclamptic patients with the syndrome died. Furthermore, there were six (15.8%) perinatal deaths among the 38 infants delivered by the 34 mothers with severe pre-eclampsia/eclampsia. Our data suggest that the development of HELLP syndrome is more likely in eclamptic patients and when it occurs in them, it is highly fatal. Most of the cases in this study were unbooked. Substandard care may have contributed to the progression of the disease state and consequently, to maternal mortality. It is imperative to draw up an action plan for the identification of the risk factors for the development of pre-eclampsia/eclampsia at peripheral hospitals and maternity centres and for prompt referral of such cases afterwards. Efforts should also be geared towards the minimising of treatment delay in all phases, so as to minimise both perinatal and maternal morbidity and mortality.

A prospective randomized clinical trial of urethral catheter removal following elective cesarean delivery.

OBJECTIVE: To compare immediate and 24-hour postoperative removal of urethral catheters for elective cesarean delivery. METHOD: A prospective randomized trial of 200 women admitted for elective cesarean delivery where the urethral catheter was removed 24 hours postoperatively or immediately after the procedure. Urine samples were collected preoperatively and 72 hours postoperatively for microscopy, culture, and sensitivity (MCS). Outcome measures included preoperative and 72-hour postoperative urine MCS, postoperative morbidities, and length of hospital stay. RESULTS: There were no significant differences in postoperative urinary retention (P=0.986), dysuria (P=0.188), urgency (P=0.134), fever (P=1.000), 72-hour postoperative urine MCS (P=0.489), and length of hospital stay (P=0.879) between the 2 groups. There was a non-significant lower incidence of positive urine culture 72 hours postoperatively for women in the immediate removal group compared with those who were catheterized for 24 hours (8.1% vs 11.2%; P=0.489). CONCLUSION: Immediate postoperative removal of a urethral catheter after elective cesarean delivery may be associated with a lower risk of urinary infection.

Rate of increase in oxytocin dose on the outcome of labor induction.

OBJECTIVE: To compare the efficacy and safety of arithmetic and geometric increases in oxytocin infusion dosage during induction of labor. METHODS: A total of 120 pregnant women requiring induction of labor at term were randomly assigned to receive oxytocin at dosages increasing arithmetically or geometrically. Maternal demographics, labor delivery data, and newborn outcomes were compared. The setting was the maternity unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. RESULTS: The mean maximum rates of oxytocin delivery needed to achieve adequate uterine contractions were similar in the 2 groups (24.66+/-8.34 mU/min vs. 26.38+/-8.77 mU/min, P=0.24). Labor duration was significantly shorter in the geometric progression group (496.33+/-54.77 min vs. 421.34+/-63.91 min, P<0.001). There were no differences in the rates of cesarean sections, vaginal deliveries, or uterine hyperstimulation, or in neonatal outcomes. CONCLUSION: A geometric rise in the rate of oxytocin infusion delivery reduced the duration of labor without affecting the rates of cesarean sections and uterine hyperstimulation, or newborn outcomes.

Sociodemographic characteristics of anaemic gravidae at booking: a preliminary study at Llesha, Western Nigeria.

BACKGROUND: Anaemia in pregnancy is a significant cause of direct and indirect morbidity and mortality to both the pregnant mother and her fetus. The prevalence however remains undetermined in many parts of Africa. The study aims at determining the prevalence of anaemia and sociodemographic characteristics of anaemic pregnant women in a Nigerian tertiary obstetric care centre. METHODS: A cross-sectional study involving all pregnant women that registered for ante-natal care between 1st January 2001 and 30th of June 2001 in Wesley Guild Hospital Unit of Obafemi Awolowo University Teaching Hospitals Complex, Ile-lfe. RESULTS: Prevalence of anaemia among the pregnant women during the period of study was 62.2%. Two percent of the women had severe anaemia. Parity and gestational age at booking significantly influenced the prevalence of anaemia. CONCLUSION: Prevalence of anaemia among pregnant women in developing world is still unacceptably high, and it calls for improvement in standard of living for our pregnant women.

Keynote address at the Fifth Congress of the International Association for Adolescent Health.

PIP: This Nigerian Ministry of Health speech reiterates the importance of focusing on the problems of youth and adolescents which was 1st identified in 1989 at a World Health Assembly. Every stage of the life cycle is important because mental, physical, psychological, and social scars are carried into the future. It is important to make the transition to adulthood as smooth as possible. Of the 30% (1.5 billion) of the World's population that are adolescents 10-24 years old, 80% live in developing countries. 50% of the world population is 25 years. In the preparation for adulthood, age-old customs, culture, and tradition have ensured the stability and survival of societies, but great changes have taken place due to colonialism, modern education, urban migration, rapid travel an communication, tourism, and trade. There is weakening of traditional marriage. Foreign cultural influence has armed youths to challenge community cultural norms and parental authority to direct their development. There is social tension, disruption, an instability. Adults as role models have sometimes failed to represent integrity and honesty. There is a need for sensitive support and guidance from adults. Peer pressure operates for both good or ill. Some will react to this stress to conform in unhealthy ways. The health care system may not fill adolescent needs because they are too old for the pediatrician and too young for the physician. Girls are particularly vulnerable to the problems of premarital pregnancy, induced abortion, out-of-wedlock births, and sexually transmitted diseases. The pressure is to grow up fast, particularly in polygamous societies where the woman has security only in her children. Opportunities for dialogue degenerate into sessions of being "talked at" and forced compliance. Unemployment is very high which can lead to loss of self-esteem, psychological stress, and hopelessness and sometimes street fighting, thuggery, drug pushing, and armed robbery. Attempts worldwide are made to guide youth. These interventions need the support of nongovernmental organizations and active participation of youths. Accurate and accessible sex information and the maturation process is needed particularly in cultures where sex is taboo. Research is needed on family structure and function. The health sector must clearly define its role in preserving youth and actively prevent the "immense mental and social morbidity" of adolescents according to the principles of relevance, acceptability, and participation. The energy of youth should be harnessed constructive activity and community development. The time to act as trailblazers is now.^ieng

Exchange transfusion using G-6-PG deficient or Hgb-AS blood in icteric neonates.

The sickle cell trait (Hgb-AS) and G-6-PD deficiency are two genetic defects which increase the hemolytic susceptibility of erythrocytes. As these two traits are common in Nigeria, blood transfusions with such defective cells are frequently given. In this study, the immediate and long-term effects of using either normal blood or blood with either or these defects for exchange transfusions in 115 neonates have been examined. Infants transfused with G-6-PD deficient blood were compared with those transfused with G-6-PD normal blood. Similarly, neonates transfused with Hgb-AS blood were compared with those who received Hgb-AA blood. There was no statistically significant difference in post-exchange serum bilirubin levels (followed for one week), hemoglobin, hematocrit, and reticulocyte counts (followed for three months). It was concluded that under normal circumstances, the use of G-6-PD deficient blood or Hgb-AS blood does not increase the risk of exchange transfusion in infants with hyperbilirubinemia.

Perinatal transmission of hepatitis B virus infection in Ile-Ife, South Western, Nigeria.

AIM: To determine the perinatal transmission risk of hepatitis B virus (HBV) and the maternal characteristics influencing it. METHOD: During routine antenatal screening, women who tested positive for hepatitis B surface antigen (HBsAg) were identified and followed through pregnancy. Maternal and cord blood samples were obtained at delivery. The sera of each mother-baby pair were analyzed for HBsAg, HBeAg, HBeAb, HBsAb and HBcAb using an immunochromatographic 5-in-1 panel kit. Quantitative HBV-DNA was assessed using polymerase chain reaction technique. Intrauterine infection was defined when neonatal blood test positive for HBsAg positivity and/or HBV-DNA. Confidence level was set at 95% (p < 0.05). RESULTS: Of the 716 pregnant women screened 73 (10.2%) were HBsAg-positive. Fifty of these HBsAg-positive women completed the study. Intrauterine infections were detected in 36 (72%) newborns; of them only twelve (24%) had positive HBsAg whereas all of them (n = 36) neonates had detectable HBV-DNA (>100 copies/ml). High maternal HBV-DNA titre was associated with increased neonatal HBV-DNA titre (p = 0.001). Parity, maternal age, and mode of delivery showed no association with perinatal transmission. CONCLUSION: The risk of perinatal HBV transmission in this study was high. Perinatal transmission was associated with high maternal viremia. Appropriate prophylaxis for HBsAg-positive mothers and their newborns is advocated.

Oral misoprostol versus intramuscular oxytocin in the active management of the third stage of labour.

INTRODUCTION: Although the third stage of labour is usually uneventful, several significant complications may be encountered that may lead to maternal morbidity and mortality, especially primary postpartum haemorrhage. The objective of this study was to compare 400 ug oral misoprostol with 10 IU intramuscular oxytocin in the active management of the third stage of labour. METHODS: This was a prospective randomised controlled clinical trial in which 200 parturients at term who had vaginal delivery were randomly assigned into two groups: oral misoprostol and intramuscular oxytocin, after the delivery of the baby and the clamping of the umbilical cord. The primary outcome was the incidence of primary postpartum haemorrhage. Secondary outcomes included a drop in haemoglobin concentration 48 hours after delivery, the need for extra oxytocics, duration of the third stage of labour and side effects of the oxytocics. These results were subjected to statistical analysis using chi-square test or student's t-test. RESULTS: No occurrence of primary postpartum haemorrhage or significant difference in the drop in haemoglobin concentration levels was reported after delivery (p-value is 0.49), and no significant differences were observed in other secondary outcome measures with the exception of nausea, which occurred solely in the misoprostol group (4 percent, p-value is 0.04). CONCLUSION: Oral misoprostol appeared to be as effective and as safe as intramuscular oxytocin in the active management of the third stage of labour.

Comparison of ceftriaxone versus triple drug regimen in the prevention of cesarean section infectious morbidities.

OBJECTIVE: To compare the effectiveness of single dose ceftriaxone versus multiple doses of ampiclox, gentamicin, and metronidazole to prevent infectious morbidity at elective cesarean section. METHODS: This was a randomized clinical trial involving 200 pregnant women who had an elective cesarean section for various reasons during the study period. Outcome measures included endometritis, urinary tract infections, febrile morbidities, wound infections, duration of hospital stay, and cost of antibiotic therapy. Data were managed using SPSS. RESULTS: There was no statistically significant difference in the mean duration of hospital stay between the two groups, but a significant statistical difference was found in the mean cost of antibiotic treatment ($15 for the combination and $9 for ceftriaxone; p = 0.000), with the group of patients taking a single dose of ceftriaxone (ROPHEX) having a lower mean cost of treatment than those taking a combination of ampiclox, gentamicin, and metronidazole. The study groups did not differ significantly in the incidence of endometritis (14% versus 15%), urinary tract infection (11% versus 15%), wound infections (7% versus 8%), febrile morbidity (7% versus 6%), and peritonitis (0% versus 0%). CONCLUSION: Single dose ceftriaxone was as effective as a combination of ampiclox, gentamicin, and metronidazole in preventing post-elective cesarean section complications.

Maternal complications and perinatal outcomes in booked and unbooked Nigerian mothers.

INTRODUCTION: The study aimed to compare the sociodemographical characteristics, obstetrical complications and foetal outcome in delivered booked mothers and delivered unbooked mothers and to determine the correlation of maternal and perinatal outcomes. METHODS: In a prospective study over a 22-month period, outcomes of pregnancies of women booked for antenatal care were compared with that of unbooked women, who delivered in our unit at the Wesley Guild Hospital, Nigeria. RESULTS: 29 percent of the 1,154 deliveries in the study period comprised unbooked mothers. Compared with booked mothers, unbooked mothers had a higher tendency to be younger (29.3 +/- 6.08 vs. 31.12 +/- 4.80; p-value is less than 0.001), unmarried (9.2 percent vs. 1.8 percent; p-value is less than 0.01), with lower educational status (25.8 percent with postsecondary education vs. 58.7 percent; p-value is less than 0.01), lower social class (25.0 percent in upper class vs. 52.3 percent; p-value is less than 0.001) and with higher proportion of multipara (12.5 percent vs. 5.5 percent; p-value is less than 0.02), higher incidence of antepartum haemorrhage (odds-ratio [OR] 5.96, 95 percent confidence interval [CI] 2.53-14.29, p-value is less than 0.001), anaemia (OR 2.75, 95 percent CI 1.09-4.47, p-value is less than 0.001) and preeclampsia/eclampsia. Unbooked mothers were half as likely as booked mothers to deliver by spontaneous vaginal delivery (OR 0.45, 95 percent CI 0.29-0.71, p-value is less than 0.001) but were twice as likely to deliver preterm babies (OR 2.03, 95 percent CI 1.14-3.59, p-value is less than 0.009) and three times more likely to have babies with birth asphyxia. Perinatal and maternal mortalities were higher in unbooked mothers. CONCLUSIONS: The study showed a positive correlation between unbooked mothers and an increased risk of maternal and foetal adverse outcomes.

Risk factors for retained placenta in southwestern Nigeria.

INTRODUCTION: This study aimed to determine the incidence of, and identify independent risk factors to retained placenta in Ile-Ife, southwestern Nigeria. METHODS: This was a prospective case-control study involving 120 women with retained placenta after vaginal birth at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, southwestern Nigeria over a period of seven years. Two consecutive normal deliveries after each retained placenta served as controls. Following a bivariate analysis, a multivariate logistic regression model was constructed in order to define independent risk factors for retained placenta while controlling for confounding variables. RESULTS: During the study period, there were 120 cases of retained placenta, and the total number of deliveries was 6,160, making the incidence 1.9 percent. Independent risk factors associated with retained placenta include non-use of antenatal care (odds-ratio [OR] 22.71, 95 percent confidence interval [CI] 10.5-49.12, p-value is less than 0.000), previous retained placenta (OR 15.22, 95 percent CI 3.30-70.19, p-value is less than 0.000), previous caesarean section (OR 12.00, 95 percent CI 2.05-70.19, p-value is less than 0.006), maternal age 35 years or more (OR 7.10, 95 percent CI 1.5-32.40, p-values is less than 0.012), grand multiparity (OR 6.63, 95 percent CI 1.88-23.40, p-value is less than 0.003), previous dilatation and curettage (OR 4.44, 95 percent CI 1.69-11.63, p-value is less than 0.002), preterm delivery (OR 3.12, 95 percent CI 1.12-8.68, p-value is less than 0.029) and placenta weight less than 501 g (OR 2.91, 95 percent CI 1.34-6.32, p-value is less than 0.007). CONCLUSION: Women with identifiable risk factors should be targeted for the prevention of retained placenta. There is a need for the training of birth attendants in the proper conduct of delivery and third stage of labour to prevent placenta retention and postpartum haemorrhage.

Perception of labour pain among the Yoruba ethnic group in Nigeria.

In Nigeria, it is generally assumed that labour is well tolerated and pain relief is not usually considered an important part of intra-partum care. This prospective study was carried out to assess mothers' perception of labour pain and determine any factor that may influence it. During the period of study, 281 women who delivered at Wesley Guild Hospital Ilesa, Nigeria were interviewed within 2 h of delivery to assess the severity of labour pain and desire for analgesia. Perception of labour pain was assessed using a 3-point verbal rating. The majority (68.3%) of women described labour pain as severe with only 5.3% describing it as mild. More than 86% of the women would want the pain relieved. Perception of pain was not influenced by age, parity and educational level. Management of pain in labour should form an important part of intra-partum care as is the case in developed countries.