Professional Documents
Culture Documents
Faculty of Medicine
Postgraduate Medical Studies Board
By
Abdel Magid Mohamed Ahmed
M.B.B.S (University of Gezira)
Supervisor
Professor Abdel Salam Gerais
FRCOG
CONTENTS
Page
Dedication
Acknowledgment
ii
Abbreviations
iii
English abstract
iv
Arabic abstract
Chapter 1:
o Introduction
o Literature Review
o Justification
22
o Objectives
23
Chapter 2:
o Materials & Methods
Chapter 3:
24
25
26
o Results
27
o Figures
30
o Tables
33
Chapter 4:
35
o Discussion
36
o Conclusion
44
o Recommendations
45
o References
46
DEDICATION
To my mother
ACKNOWLEDGEMENT
I wish to express my thanks to professor (A/Salam Gerais), the
consultant Obstetrician and Gynaecologist in the faculty of Medicine
university of Khartoum who supervised this research.
My sincere thanks are due to my wife Omima Ahmed Abdullah for
helping me in using computer.
My thanks are also extended to my niece Haifa Alarabi and my
nephew Ahmed Salih for exploring internet, and typing this research.
ii
Abbreviations
ALT: Alanine Aminotransferase.
CBRHP: The Community-Based Reproductive Health Project.
CI: Confidence Interval.
HELLP syndrome: Haemolysis, Elevated liver Enzymes, low Platelets.
HIV: Human Immunodeficiency Virus.
MMR: Maternal Mortality Rate.
MOH: Ministry Of Health.
N = : (Number equal).
n = : (Number equal).
NGO: Non Governmental Organization.
OR: Odds Ratio.
PPH: Postpartum Haemorrhage.
SMS: Safe Motherhood Survey.
TBAs: Traditional Birth Attendants.
VHWs: Village Health Workers.
iii
English abstract
Objective: Study of maternal deaths to find out the causes and factors
leading to maternal mortality.
Methods: A descriptive analysis of maternal deaths at Omdurman
maternity hospital during, the one year period between 1/8/2001 to
31/7/2002 was conducted.
Results: The total number of deaths was 30 cases out of 14500 deliveries
and the corrected maternal mortality rate is 206 per 100,000 births. The
most important factor leading to maternal death is absence of antenatal
care.
Death among unbooked ladies compared to booked ladies was much
higher.
The correlation between booking status as general and maternal death
was statistically highly significant.
Of all causes of maternal death hypertension in pregnancy was the
leading cause of death, causing 14 deaths (46.66% of all deaths).
Again booking was studied in hypertensive ladies and its correlation with
maternal death was significant.
The second cause of death was shared between haemorrhage and hepatic
coma, both causing 4 deaths which is 13.33% of all deaths. This to be
followed by sepsis which has caused 3 deaths (10%), both pulmonary
embolism and portal hypertension caused 2 deaths (6.66%), and finally
malaria which has caused one death (3.33%)
Conclusion
At the level of primary prevention it is recommended that, provision of
effective free antenatal care with qualified staff to all pregnant women all
over the country and a special plan dedicated to hypertensive disorders
with pregnancy.
Health education about importance of antenatal care and risks of its
omission should be delivered to community and specially women.
At the level of secondary prevention it is suggested that, improvement of
hospital facilities and provision of trained medical and paramedical staff.
iv
Arabic abstract
:
.
:
2001/8/1
.2002/7/31
:
30 14.500 206
100.000 . .
.
14
) %46.66 (
.
4 % 13.33
. 3 %10
.
%6.66
%3.33 .
:
.
.
.
Chapter 1
Introduction
Literature review
Justification
Objectives
INTRODUCTION
Death of a mother is a sad event in the part of her family and the caring
health team.
There may be tremendous adverse social, psychological and economical
impact inflicted upon the family when the mother dies. Approximately
90% of maternal deaths (more than 0.5 million each year) occur in
developing countries. (1) The meticulous study of the previous
successful experiences in reducing maternal mortality, well help to set up
plans for dealing with the problem. There are many preventable &
avoidable factors which if elucidated, and plans set up to deal with them,
a satisfactory reduction in maternal deaths will be achieved. In Sudan the
major causes of maternal mortality are more or less the same like other
developing nations. There are many preventable & avoidable factors at
primary, secondary and tertiary levels.
Literature Review
Definitions:
Maternal death
Death of a women while pregnant, or within 42 days of termination of
pregnancy, from any cause related to or aggravated by, pregnancy or its
management, but not from accidental or incidental causes.
Direct maternal deaths are defined as deaths resulting from obstetric
complications of the pregnant state (pregnancy, labour and puerperium),
from interventions, omissions, incorrect treatment or from a chain of
events resulting from any of the above.
Indirect maternal deaths are defined as deaths resulting from previous
existing disease, or disease that developed during pregnancy and which
was not due to direct obstetric causes, but which was aggravated by
physiologic effects of pregnancy.
Late maternal deaths are deaths occurring between 42 days and one
year after abortion, miscarriage or delivery that are due to direct or
indirect causes.
Fortuitous deaths are deaths from unrelated causes that happen to occur
in pregnancy or the puerperium.
these factors and to intervene promptly both during antenatal care and
immediately after delivery. The evidence-based approach is a way of
reaching this solution. Antenatal care is a concept that extends from prepregnancy to postpartum, leading to effective emergency care for
unpredictable and predictable complications during pregnancy and
childbirth. Worldwide policies are not always applicable to each country.
There is still a need for prospective randomized trials to clarify this
concept and the relevant policies. (1)
A 13-year hospital based study done about Trends in maternal mortality
in rural Ghana by Geelhoed DW and his colleageus. In the study 229
maternal deaths were analyzed. The overall maternal mortality rate of
1077/100,000 live births did not change significantly during the study
period. However, the relative contributions of sepsis, haemorrhage,
obstructed labour, anaemia, sickle cell disease and pre-eclampsia
diminished, while abortion complications increased significantly. They
concluded that, the Safe Motherhood Initiative in the study area has
contributed to the reduction of maternal mortality due to causes against
which interventions were directed. Abortion complications as cause of
maternal mortality need to be included in interventions and research. (14)
Okonta PI and his colleagues performed a study to explore the causes of
and risk factors for maternal deaths in a rural Nigerian referral hospital. It
was a 10-year (1990-9) review of all maternal deaths at Mater
Misericordiae Hospital. A total of 104 deaths occurred out of 13,391
deliveries (MMR 777/100,000). Haemorrhage, sepsis and Hypertensive
diseases in pregnancy were the leading causes of death. Age below 15,
Nulliparity, Grandmultiparity, low socio-economic class, lack of formal
education and being unbooked were also significant risk factors. Delay in
accessing health facility was also an identified contributing factor. They
suggested Public enlightenment to encourage utilisation of antenatal
facilities, prompt referral of complicated cases and adequate equipping of
the referral hospital. (15)
Ezechi UO conducted a prospective study that examined the nature of
emergency obstetric admissions in a Nigerian university hospital in
association with such factors as late referrals and misdiagnoses and their
contribution to maternal and perinatal morbidity/mortality. The study
comprised 144 consecutive emergency obstetric admissions to the
hospital over a 6.5-month period. An incidence of 13.6% emergency
admissions was recorded. Despite the proximity of the hospital to the
parturients, most of them laboured in substandard facilities within the
8
the NGOs could also have contributed. Maternal mortality in the NGO
areas was lower in 2000-02 than the most recent estimate for Bangladesh.
Further reduction is likely to depend on improved access to qualified
community midwives and essential obstetric care at government referral
facilities. (20)
Fernando D and his colleagues addressed the national strategies which led
to reducing maternal deaths and disability in Sri Lanka. They considered
the declining trend in the maternal mortality rate (MMR) from the 1930s
to the late 1990s has resulted from several strategies implemented within
and outside the health sector. Expansion of both field-based and
institutional services through the past decades contributed to improved
geographical access and provision of 'free' services improved economic
access. These led to increased use of antenatal and natal services provided
by trained midwives and other personnel followed by improvements in
the availability of specialized care and emergency obstetric care.
Integration of family planning and other inputs to the maternal health
programme has yielded positive results. The role of the private sector is
limited to provision of a component of antenatal services. The
organization for service provision and an information system made
significant contributions towards improvement. The commitment of the
health sector to provide services free of charge supported by non-health
inputs, especially female education, has enabled Sri Lanka to make gains
in maternal health. (21)
Hofmeyr GJ. conducted a study to identify, from the best available
evidence, underutilized and promising technologies that may reduce
maternal mortality from obstructed labour. The results showed that
obstructed labour causes approximately 8% of maternal deaths, and
indirectly contributes to a greater percentage. Proven or widely accepted
technologies that help reduce mortality from obstructed labour include
contraception, external cephalic version, the partogram, augmentation of
labour, selective amniotomy, selective episiotomy, vacuum extraction,
caesarean section, symphysiotomy, and destructive procedures for nonviable fetuses. Technologies of uncertain usefulness include maternal
height and shoe size, vaginal cleansing, upright posture for delivery and
vaginal lubrication. Unuseful technologies include pelvimetry, estimating
fetal weight, early labour induction, routine amniotomy and
augmentation, routine episiotomy, and starvation during labour. It was
concluded that access to well established technologies, particularly safe
caesarean section, can reduce maternal mortality in resource-poor
countries. (22)
11
Hussein J and Fortney JA. reviewed the current medical literature about,
Puerperal sepsis and maternal mortality to see what role can new
technologies play?
They pointed that the literature indicates that infection control protocols
and evidence-based procedures-including prophylactic antibiotics for
caesarean section or preterm rupture of membranes, and updated
antibiotic regimens-should be widely adopted. Devices such as hand rubs,
needle-disposal systems, and rapid microbiological diagnostic tests can
improve compliance and efficiency. Operational research on promising
developments like vaginal cleansing with antiseptics, vitamin A
supplementation, and prophylactic antibiotics in high-risk women is
needed. It was concluded that, sepsis management continues to depend on
good implementation of established technologies. Programme-based
approaches are required to improve uptake. (23)
Imbert P. and his colleagues conducted a prospective study about
maternal and infant prognosis of emergency caesarean section at the
Principal Hospital in Dakar, Senegal. They found that the prognosis of
emergency caesarean section is poor for both the mother and child in
developing countries. This prospective study was carried out in 370
women (mean age, 30.5 years) who underwent emergency caesarean
sections between January 1 and December 31, 1997. Fifty percent of
these women had been transferred from an outside maternity clinic.
Indications related to the mothers (75% of cases) or fetuses (25% of
cases) were divided into two groups according to degree of emergency:
absolute (n = 163) and relative (n = 207). Placental haematoma (n = 64)
and fetus-pelvis size mismatching (n = 49) were the main indications in
both groups. The technique chosen for initial anaesthesia performed by a
specialized nurse in most cases was either spinal anaesthesia if there were
no contraindications (50.8%) or general anaesthesia (49.2%). There were
5 complications including 1 that was fatal (aspiration during intubation
for general anaesthesia). The postoperative maternal morbidity rate was
low (n = 7) and outcome was favorable. A total of 7 patients (1.9%) died
due to anaesthesia-related events in 1 case and obstetrical factors in 6.
Mortality in the absolute emergency group was significantly higher for
women who were transferred from other clinics (p < 0.02). Maternal
mortality rate was correlated with the severity of obstetrical
manifestations and delay of care. Findings also showed that a wellorganized care system lowers the operative risk of emergency caesarean
section even in developing countries. (24)
Shaheen B. and his colleagues conducted a study about eclampsia as a
major cause of maternal and perinatal mortality. It was a prospective cross12
sectional observational study (from 1st Jan 2001 to 31st Mar 2002)
included all the patients admitted to the unit with eclampsia. Results
during the study period showed that 71 patients developed eclampsia
(frequency: 1.2%). Majority were unbooked (86%), primigravida (69%),
< or = 25 years of age (63%), referred from other health facilities (66.2%)
and had some delay in seeking medical help (60%). Thirty five percent of
patients developed major complications and 16.9% of them died (48% of
overall maternal mortality). Mortality was frequent in Afghani women
(OR 7.71 p value 0.002) and in women who sought medical help more
than 6 hrs after developing seizures (OR 14.6 P value 0.0004). They
concluded that, to decrease the adverse outcome associated with
eclampsia a community based approach is needed to improve community
health education, socioeconomic status and prenatal care. Delivery of
proper health care system and emergency obstetrical care facilities are
vital for prevention, early detection, proper management and hence to
save the mothers and their babies from such a dreadful disease. (25)
Ikechebelu JI and Okoli CC. conducted a review of eclampsia at the
Nnamdi Azikiwe University teaching hospital, Nnewi (January 1996December 2000). It was a retrospective study of 43 cases of eclampsia
managed at the hospital over a 5-year period, an incidence of 0.75% out
of 5750 labour ward admissions was found. Eclampsia was more
prevalent in the primigravidae (65%) and unbooked patients (83.7%) than
in the multigravidae (35%) and booked (16.3%) patients. The mean age
of the patients was 23.5 years. The majority of the eclamptic seizure
(55.8%) occurred in the antepartum period. Many unbooked patients
presented after more than two seizures. The most frequently used drugs in
the management of eclampsia in the hospital were intravenous diazepam
and hydralazine. For the 35 cases of antepartum eclampsia, 85.7% had a
caesarean section while 14.3% had an operative vaginal delivery; none
had a spontaneous vaginal delivery. There were four maternal deaths
(9.3% of the cases). Clinical causes of death in the women were
cardiopulmonary failure (three cases) and coagulation disorders (one
case). The total maternal deaths in the hospital during this period was 19
given a maternal mortality rate of 330 per 100,000 births. Eclampsia,
therefore, contributed 21.1% of the maternal deaths. The role of health
education and good antenatal, labour and early puerperal supervision is
stressed in the reduction of the incidence of eclampsia in the developing
countries. (26)
Srp B and his colleagues carried out an analysis of 31 cases of maternal
deaths, which was associating with severe preeclampsia and eclampsia in
the Czech Republic during 1978-2000, using a database of 470 maternal
13
deaths during the observed period. They considered timelines of lifethreatening events, age of mother, parity, and place of death. It was the
5th most frequent cause of maternal death. Clinical management was not
adequate in 15 cases of death (48%). Severe preeclampsia and eclampsia
were more frequent among older women and multiparae. First group
(61%) is composed of women with manifest convulsions, 25% of them
experienced convulsion after delivery, and only few cases had mild
preeclampsia antepartum. Eclampsia with convulsions leading to coma
was seen in 10 cases complicated with DIC, two cases in this group had
premature separation of placenta. The second group (39%) were cases
without convulsions. These cases were complicated with severe liver
disorders and renal failure, and 5 cases of intra-cranial haemorrhage.
Several cases had combination of symptoms. DIC was present in 6 cases.
In both groups there were 5 cases with haemorrhagic skin symptoms,
thrombopenia, symptoms of DIC and liver and renal failure, which would
fall into HELLP syndrome according to current classification. Most of
women died during the postpartum period (87%) mostly after emergency
operative deliveries. The fact that no women died during pregnancy
indicates the effort to perform life-saving operative delivery. Forty two
percent of women were term. Especially at the beginning of observed
period they noticed tendency to prolong gestation in order to save the
baby. The operative deliveries accounted for 71%; the majority of them
were caesarean sections. More than 50% of cases were operated in coma.
This considered to indicate major mistakes and failures in organization of
care, primary prevention, diagnosis, and consequent care. It was
concluded that positive results in area of maternal deaths in association
with severe preeclampsia and eclampsia during last 10 years are due to
improved diagnostic and therapeutic measures, because obstetricians
currently terminate pregnancies early than before while symptoms of
preeclampsia get worse. They focus on early recognition of symptoms of
coagulopathy in combination with symptoms of preeclampsia, especially
on early detection and treatment of HELLP syndrome. (27)
Duley L and Henderson-Smart D. reviewed the literature to assess the
effects of magnesium sulphate compared with diazepam when used for
the care of women with eclampsia. They reviewed five trials involving
1236 women. Most of these trials were of good quality. Magnesium
sulphate was associated with a substantial reduction in the recurrence of
convulsions, when compared to diazepam (relative risk 0.45, 95%
confidence interval 0.35 to 0.58). Maternal mortality was also reduced,
although this difference was borderline for statistical significance
(relative risk 0.60, 95% CI 0.36-1.00). They concluded that Magnesium
14
malaria season, there was a 168% increase in the maternal mortality ratio
(MMR), a three-fold increase in the proportion of deaths due to anaemia,
and an eight-fold increase in the anaemia MMR. Apart from a 5.4-fold
increase in eclampsia, there was no significant change in the contribution
of other causes of death. It is estimated that malaria may account for up to
93 maternal deaths per 100,000 live births. (35)
Etard JF and his colleagues conducted a study about: Seasonal variation
in direct obstetric mortality in rural Senegal: role of malaria?
They explore a possible link between malaria and maternal death in a
rural area of Senegal by assessing the seasonal pattern of maternal
mortality by cause and examining whether this pattern coincides with the
malaria season. Overall mortality in women 15-49 years of age did not
differ by season, while maternal and direct obstetric deaths were
significantly more frequent during the rainy/malaria season than during
the rest of the year, even after adjusting for place of delivery. (36)
Mirghani OA and his colleagues conducted a prospective case-control
study about Viral hepatitis among 50 pregnant women and 31
nonpregnant women (age 15-40 years), admitted to Wad Medani
Teaching Hospital, Sudan, during the period January 1987-January 1990.
The mean serum bilirubin level was higher in the control group and the
difference was statistically significant (p = 0.0084). Significantly more
cases came from rural settings (76%) compared with control patients
(48%) (p 0.01). The criteria for admission were the presence of symptoms
and signs of hepatitis and bilirubin in the urine. Almost all patients
admitted to the study had viral hepatitis caused by type A virus, type B
virus, or non-A, non-B viruses, however, a very small number of diseases
of patients could be attributed to rare viruses like EB or cytomegalovirus.
No specific medication was given and patients were managed by bed rest
and parenteral multivitamins (Parentrovit). All patients were kept in the
hospital until they became asymptomatic and serum bilirubin dropped to
less than 2 mg/100 ml. All cases and controls were followed up for 6
weeks. All the control patients were discharged after recovery and none
of them died or developed recurrence of disease. Out of the 50 pregnant
women, 7 died (14%). the rest recovered and none of them developed
recurrence of disease during the follow-up period. The difference
between the 2 groups was statistically significant (p = 0.04). The
estimated relative risk of death in viral hepatitis with pregnancy was 9.93.
Among 5 deaths that occurred after delivery during the 3rd trimester, one
was at term and the baby was normal; 4 were preterm deliveries. Out of
18
the 50 pregnant women, one died before delivery and one delivered at
home. (37)
Strand RT and his colleagues conducted a study about Infectious
aetiology of jaundice among pregnant women in Angola.
The
contribution of viral hepatitis, human immunodeficiency virus (HIV)
infection and malaria to jaundice among pregnant women in Luanda,
Angola, was studied. 20 pregnant women with jaundice (cases) were
identified in 2 large maternity hospitals and compared with 40 pregnant
women without jaundice (controls). Among the cases 6 patients died,
whereas no death occurred in the control group (p < 0.001). Of the cases
40% had anti-hepatitis E virus antibodies compared with 13% of the
controls (p = 0.02). Plasmodium falciparum parasitaemia occurred in
47.5% and 5% of cases and controls, respectively (p < 0.001). There was
no difference in the prevalence of antibodies against hepatitis C or HIV
among cases and controls. The carriership of hepatitis B surface antigen
was 10% in both groups. They concluded that jaundice during pregnancy
is often associated with maternal mortality in Luanda, women suffering
from jaundice during pregnancy have an extremely high case fatality rate,
and P. falciparum and hepatitis E are associated with jaundice in the
setting studied. (38)
Wong HY and his colleagues conducted a study about, abnormal liver
function tests in the symptomatic pregnant patient: the local experience in
Singapore. In this study they found that, the causes of abnormal liver
function tests in pregnancy are varied and may or may not be pregnancyrelated. Often, the diagnosis can be difficult. This study looked at the
causes of deranged liver function tests in obstetric patients with
significant symptoms and signs. Data from 50 cases of abnormal liver
function tests in pregnant patients, who presented from 1998 to 2001,
were analysed. Their presenting symptoms included persistent vomiting
(48%), pruritis (14%), jaundice (26%), upper abdominal discomfort
(24%) and hypertension (46%). Results showed that Pregnancy-related
causes accounted for 84% of the abnormal liver function tests. Abnormal
liver function tests occurred more frequently in the first (34%) and third
(58%) trimesters than in the second trimester (8%). Hyperemesis
gravidarum (94%) and partial haemolysis, elevated liver enzymes and
low platelets (HELLP) syndrome (31%) were the commonest causes in
the first and third trimesters respectively. Hepatitis B flare resulted in 2
maternal deaths. Seven patients with pre-eclamptic toxaemia, acute fatty
liver of pregnancy or partial/complete HELLP syndrome had their liver
function tests measured sequentially before and after delivery. All of
them showed rapid improvement postpartum with their alanine
19
21
JUSTIFICATION
Since the maternal mortality rate is still very high in most of the
developing world including Sudan, maternal mortality studies are
required to identify causes and risk factors.
There are general causes which are more or less similar in different
communities, but there may be certain causes or factors peculiar to a
specific community or region.
This may be a reflection of certain endemic disease(s) associated with
maternal death, a trend or a behavior specific to that community.
So, maternal mortality studies will continue to be useful, as the
communities' pattern of diseases is changeable even over longer or
variable periods of time.
22
OBJECTIVES
1. To identify the causes and risk factors of maternal deaths in the Sudan.
2. To find out preventable and avoidable elements in the scene of events
leading to maternal death.
3. To set up definitive practical and applicable plans to reduce maternal
mortality.
23
Chapter 2
Material and methods
24
Methods:
Sampling method is not applicable, as all births were included
during the study period.
The total numbers of births (live & still) were collected. Booking status,
parity and social class were reported.
Maternal deaths, its aetiology, factors, and circumstances around it were
noted.
The pattern of diseases and complications leading to maternal death were
studied.
Every case of maternal death was studied in details its history, booking
status, clinical examinations, investigations and death report were
studied. The results were calculated manually.
Some of the major factors and causes leading to maternal deaths were
cross tabulated and tests of significance employed by using the computer.
It was selectively chosen due to its impact and /or the feasibility of
solutions.
The literature was reviewed, to find out recent studies about maternal
mortality in developing and developed world.
25
Chapter 3
Results
Figures
Tables
26
Results
The total number of deliveries (life and stillbirths) was 14,500 during the
period from 1/8/2001 to 31/7/2002. The number of booked patients
among whole deliveries was 9584 (66.1%) compared to 4916 (33.9%) in
the unbooked group. All vaginal deliveries (instrumental and non
instrumental) were 11631 which is 80.21% and deliveries by caesarean
deliveries were 2869, giving a caesarean section rate of 19.79%. Non
instrumental vaginal deliveries were 11228 (77.43% of total births).
Instrumental deliveries were 403 (2.77% of total births) of which forceps
deliveries were 325 (2.24% of total births) and deliveries by ventouse
were 78 which is 0.53% of total births (Figure 1). Forceps deliveries
comprise 80.65% of all instrumental deliveries and ventouse deliveries
were 19.35% of all instrumental deliveries. Of all deliveries there were
4325 primparous patients (29.82%), 8270 multiparous patients (57.03%)
and 1905 grand multiparous patients (13.14%).
Total maternal deaths during the study period were 30 deaths, with the
leading cause of death being pregnancy induced hypertension (14 deaths
which is 46.66% of all deaths). This to be followed by, hepatic coma and
haemorrhage, with 4 deaths for each of them (which is 13.33% of all
deaths). Sepsis caused 3 deaths (which is 10% of all deaths). Both Portal
hypertension and pulmonary embolism caused 2 deaths for each of which
are 6.66% of all deaths, and chloroquine resistant malaria caused one
death which is 3.33% all deaths (Figure 2).
No anaethestic deaths were reported during the study period.
Data was cross tabulated by computer. The correlation between booking
status in all births and maternal mortality was highly significant (Table 1)
(p value = 0.0000000). The correlation between parity and maternal death
27
29
Figures
60
50
Caesaren Section
40
Forceps Delivery
Ventouse Delivery
30
20
10
0
Mode of Delivery
30
Hypertensive Disorders
Hepatic Coma
Haemorrhage
Sepsis
Portal Hypertension
Pulmonary Embolism
Chloroquine Resistant Malaria
31
Unbooked
2
1
0
Booking Status
32
Tables
Table 1 Correlation between maternal death and booking status in all
births.
Deaths
Booking Status
No
Yes
Booked
9580
0.42
Unbooked
4890
26
5.29
Chi- 37.35
P-Value 0.0000000
Comment, highly significant p value
Yes
No
Total
Primipara
14
4311
4325
Multipara
11
8259
8270
Grandmultipara
1900
1905
Total
30
14470
14500
33
Yes
No
Total
Vaginal Delivery
19
11612
11631
Caesarean section
11
2858
2869
Total
30
14470
14500
Mode of Delivery
Yes
No
Total
Booked
252
253
Unbooked
13
214
227
Total
14
466
480
Booking Status
34
Chapter 4
Discussion
Conclusion
Recommendations
References
35
Discussion
The major causes of maternal deaths are more or less repetitive in this
study compared to other studies done in Sudan and are also have many
similarities to other developing countries. Compared to Mohamed A. A.
and his colleagues study at Kassala new hospital (5), maternal mortality
rate was 10 fold lower in our study (2119 vs. 206 per 100,000 births).
Where in our study hypertensive disorders of pregnancy were the major
killers, in Mohamed A. A. and his colleagues study complication of
malaria was the leading cause of maternal deaths accounting for 20.6% of
all deaths vs. 3.3% in our study. When comparing sepsis in our study to
Mohamed A. A., and the study done at the Medani Teaching Hospital by
Dafallah SE and his colleagues (7), we will find that it comprises 17.6%
in Mohamed A. A., study, 10% in our study and about 33.3% in Dafallah
and his colleagues study. In all situations significant reduction of deaths
can be achieved by strict antisepetic measures and use of prophylactic
antibiotics. In both Dafallah and his colleagues study and Mohamed A. A.
and his colleagues study malaria was the leading cause of death reflecting
the high endmicity of the disease in their areas. Primary prevention by
insecticides, insecticides impregnated mosquito nets, and prophylactic
antimalarial drugs in pregnancy are effective measures to reduce maternal
deaths due to this disease.
Still there are major killers common to advanced countries and
developing countries like pregnancy induced hypertension and deaths
associated with haemorrhage but of course the rates are very much lower
in the developed world.
The cornerstone for plans to reduce maternal deaths to the minimum
possible rate is to study the risk factors leading to maternal mortality.
36
The great bulk of deaths are due to failure of establishing effective system
of primary prevention, and deaths at hospital level are mostly associated
with risk factors outside the hospital.
Since our study is done in a maternity hospital early pregnancy deaths are
not present because these cases are seen in Omdurman teaching hospital
but due to its importance as a cause of maternal mortality, it will be
included in this discussion.
In our series 86.66% of the deaths were among unbooked patients
compared to 95% in Baul MK. and Manjusha., study (9). As we can see in
table 1 page 33, the correlation between booking status and maternal
death is statistically highly significant. This was further studied in the
leading cause of death in our study i.e. hypertensive disorders where
about 92.86% deaths due to pregnancy induced hypertension (46.66% of
all deaths in our study)
correlation was statistically significant ( see table 4 page 34). Also it was
the leading cause of death in the African multicenter study by Thonneau
PF. and his colleagues, comprising 29% of all deaths (13). Unfortunately
it is symptomless disease and is really a dreadful disease unless every
pregnant lady has access to antenatal care. Though it cannot be prevented
its spectrums of complications can be highly ameliorated if it is
discovered early and patient referred to hospital.
Should these ladies have had regular antenatal care the outcome would
have been much different and many lives would have been saved.
Measuring the blood pressure and testing the urine for albumin to
discover this common problem early before life threatening spectrums of
complications exist should be a primary health care priority within the
context of antenatal care. Awareness of the community and female
population of the seriousness of this problem is of paramount importance
37
38
Both Hepatic coma and haemorrhage caused 13.33% of whole deaths and
they shared the second place among causes of maternal mortality.
Hepatic coma is most likely due to infective hepatitis of viral origin as
demonstrated by Mirghani OA and his colleagues (38). Again increased
community awareness and avoiding contact with jaundiced patients or
patients with general ill health, anorexia and abdominal symptoms should
be simply conveyed to community. Ladies should understand that
jaundice in pregnancy is a serious condition. Environmental sanitation
and safe disposal of faecal mater is of paramount importance. The use of
disposable needles and safe discarding of sharp objects is the mainstay in
preventing hepatitis B and C infections. Vaccination against hepatitis B
virus in children and school girls should be studied concerning its impact
in reducing hepatitis in pregnancy.
Concerning haemorrhage primary prevention is also very important plus
measures to be taken at hospital levels. At the primary level
comprehensive antenatal care will help to detect high risk pregnancies
and give advice about hospital deliveries like all primigravid patients
whom
obstetrical
performance
have
not
been
tested
before,
use of fresh blood and fresh frozen plasma under certain circumstances
like massive blood loss , massive transfusions, placental abruption and
patients with suspected and known coagulopathy. Involvement of senior
staff is vital and their prompt response is crucial in saving patients. As it
has been demonstrated by Tsu VD and his colleagues(14), active
management of the third stage of labour is of proven efficacy in reducing
PPH. They also pointed that uterotonic drugs offer great promise for both
prevention and management of postpartum haemorrhage (PPH). Other
technologies such as anti-shock garments, umbilical vein injection of
oxytocin, and simple anaemia detection methods represent potential new
opportunities to reduce PPH-related mortality. They also pointed that
more research is needed about the role misoprostol.
Concerning deaths associated with bleeding in early pregnancy every
staff should be aware of the possibility of pregnancy and its spectrum of
complications in any lady in reproductive age with complaints of
bleeding and /or abdominal pain specially if there is menstrual delay.
Ectopic pregnancy is amenable to misdiagnosis. In case of doubt sensitive
pregnancy tests and ultrasound (preferably by endovaginal route) should
be requested. Once pregnancy is confirmed by these tests, coupled with
history, examination and any other relevant tests correct diagnosis and
management can be done. Again effective resuscitation should have the
priority. The role of ultrasound scan in the diagnosis of causes of early
pregnancy bleeding and causes of
(3) In the event that ultrasound scan result is negative this does not
exclude ectopic pregnancy but sensitive pregnancy beta HCG
should be done and ideally before the scan.
But despite all this limitation ultrasound is very useful and in my opinion
should be offered if possible at least twice to pregnant ladies one with
booking in the first trimester to confirm gestational age and confirm
intrauterine pregnancy. The second scan can be done in the third trimester
to exclude placenta praevia.
There were 3 deaths due to sepsis ( 10% of total deaths ) in 2 of them
there were clear predisposing factors, in the first following prolonged
rupture of membranes for more than 5 days at home and the other was
following caesarean section due to failure to progress. The third case
followed elective caesarean section which is the only death following an
elective caesarean section in all deaths during the period of the study.
In first case delivery was by vaginal route in hospital and patient received
injectable antibiotics but it was late after chorio-amnionitis have already
developed. As it was discussed above and concluded by Hussein J and
Fortney JA. (25), that infection control protocols and evidence-based
procedures-including prophylactic antibiotics for caesarean section or
preterm rupture of membranes, and updated antibiotic regimens-should
be widely adopted.
Two deaths were associated with pulmonary embolism which is 6.66% of
all deaths during the period and also there were two deaths due to portal
hypertension.
Pulmonary embolism continue to be a significant cause of death and to
reduce it, we have to know the risk factors and to give prophylactic
measures accordingly.
High risk cases should receive prophylactic heparin or warfarin as
indicated plus other measures and precautions. High index of suspicion is
41
sections and near to half that of forceps deliveries. As we can see in table
3 page 34, by correlating mode of delivery to maternal death, the
association was statistically significant in the sense that caesarean section
is more risky than vaginal delivery. So measures to reduce incidence of
caesarean section are useful in reducing maternal mortality.
76.67% of all ladies who died were of the low income group, which is
associated with illiteracy and both are major risk factors for maternal
mortality. There were 3 deaths following home deliveries (10% of all
deaths) which are usually conducted by less trained personnel under poor
standards.
There were no deaths associated with anaethesia though regional
anaethesia is rarely conducted at this hospital.
43
Conclusion
The main factors in maternal mortality are lack of antenatal care, literacy,
difficult transport, poverty, and finally poor facilities at hospital levels.
In our study more than 80% of deaths were among unbooked ladies.
The most common cause of death was hypertensive disorders and almost
all the patients were unbooked and came in late stage to a hospital devoid
of intensive care facility which is the only hope in serious cases of this
category.
More importantly for these cases and most of the others is provision of
comprehensive primary health care system all over our country.
To increase the compliance of our pregnant ladies, antenatal care should be
free service as poverty is widespread all over the country. Health
education with participation of people, women, and community leaders is
mandatory.
To minimize complications at hospital levels promotion of emergency
units, training of the staff and provision of easy access to contact senior
staff is recommended. Till the major projects of economic, health, and
education are implemented all high risk ladies should be advised to be near
to hospitals with specialist units especially in their last month and those
with very high risk and leaving far should be admitted to hospital at
relevant gestational age.
Every lady and her husband should understand the plan of her pregnancy
and delivery in a simple way.
44
RECOMMENDATIONS
1. Provision of comprehensive antenatal care, within the context of
primary health care and exemption of pregnant ladies from user
fees.
2. Training plans for the staff at primary, secondary and tertiary
levels with special emphasis on leading causes of maternal
mortality like hypertensive disorders and postpartum
haemorrhage.
3. Supervision of all deliveries by trained staff.
4. Training and endorsement of traditional birth attendants, village
midwifes, trained midwifes and doctors about strategies for
reducing maternal mortality and importance of timely referral,
with community participation and involvement of community
leaders.
5. Health education for women about importance of antenatal care.
6. Rehabilitation of hospitals with special emphasis on blood bank
services, management of critically ill mothers, staff training and
timely involvement of senior staff.
7. Auditing and researches about maternal mortality and near miss
cases in order to set up evidence based protocols for reducing
maternal mortality.
45
REFERENCES
1- Yayla MJ. Maternal mortality in developing countries. Perinat Med
2003; 31: 386-91
2- Campell S, Lees C. Maternal and perinatal mortality. In: Campell S,
Lees C, editors. Obstetrics by Ten Teachers. 17th ed. London: Arnold;
2000. p. 20.
3- UNFPA&Ministery of Health (Sudan). Safe Motherhood Survey
(SMS), National Report 1999. The ministry; 2002.
4- UNFPA&Ministery of Health (Sudan). Safe Motherhood Survey
(SMS), National Report 1999. The ministry; 2002.
5- Mohamed A, Abdelrahiem S, Elnour M. Maternal deaths at Kassala
new hospital (Eastern Sudan). J of Arab Board of Medical specializations
2002; 4(pt 2): 31-4E
6- Dafallah SE, El-Agib FH, Bushra GO. Maternal mortality in a teaching
hospital in Sudan. Saudi Med J 2003; 24: 369-72.
7- Al-Suleiman S, Al-Sibai M, Al-Jama F, El-Yahia A, Rahman J,
Rahman M. Maternal mortality: a twenty-year survey at the King Faisal
University Hospital, Al-Khobar, Eastern Saudi Arabia. J Obstet Gynaecol
2004; 24: 259-263.
8- Baul MK, Manjusha. Maternal mortality,a ten year study. J Indian Med
Assoc 2004; 102: 18-9, 25.
9- Begum S, Aziz N, Begum I. Analysis of maternal mortality in a
tertiary care hospital to determine causes and preventable factors. J Ayub
Med Coll Abbottabad 2003; 15: 49-52.
10- Biaggi A, Paradisi G, Ferrazzani S, Carolis SD, Lucchese A, Caruso
A. Maternal mortality in Italy, 1980-1996. Eur J Obstet Gynecol Reprod
Biol 2004; 114: 144-9.
46
47
50