Current Situation Of Maternal Mortality (death)

Current situation of Maternal Mortality (Death) in the University of Port Harcourt Teaching Hospital, Port Harcourt in 15 years (1989 – 2003). A Summary. By: Dr. S A UZOIGWE. Department of Obstetrics and Gynaecology. University of Port Harcourt Teaching Hospital. Oct 14, 2008

Dr S A Uzoigwe

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Definition: Maternal mortality (death): The death of a woman while pregnant or within 42 days of termination of a pregnancy from any cause related to or aggravated by the pregnancy or its management but not from incidental or accidental cause (WHO: 10th revision, International classification of disease, injuries and causes of death and adopted by International Federation of Gynaecology and Obstetrics, FIGO) Death of a woman while pregnant or within 42 days of termination of pregnancy. Death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the cause. Oct 14, 2008

Dr S A Uzoigwe

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In practice, the period may be extended, for example, in England and Wales, the duration of the puerperium in this context is extended to 12 months, while American Medical Association Committee on Maternal and Child Care uses a 90-day limit.

Oct 14, 2008

Dr S A Uzoigwe

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Importance of maternal deaths: It is one of the key indices of the state of health of a nation. It is the basic indicator of quality of health care in any society and attitude towards women. It is the measure of human development that is internationally comparable. The death of a mother has a devastating effect on the whole family. 90% of babies born in the present pregnancy, when the woman dies suffer intra-uterine fetal death or neonatal death or die within 1 year. More than 9 out of 10 do not survive their 5th birth day. The mother’s death increases the chances of death of the other children 2-4 times, due to absence of care and support. A ripple effect bears on perinatal and infant mortality and morbidity by reducing maternal mortality. Oct 14, 2008 4 Dr S A Uzoigwe

Unit of measurement Maternal mortality ratio (MMR): Annual number of maternal deaths per 100,000 live births. No. of maternal deaths in a year X P No. of deliveries in the same year Where P = 100,000 10,000 1,000

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Dr S A Uzoigwe

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Live births: The birth of a live born infant that weighs 500g or more. In the absence of unknown weight, an estimated duration of 20 weeks or more, calculated from the first day of the last menstrual period. The information contained here was extracted from the publications made in the first 12 years from 1989 – 1998, then 1999 and year 2000. The information from the last 3 years was obtained from the annual report. The records are fairly accurate since death is an event that does not hide and diagnosis is 100% correct. Oct 14, 2008

Dr S A Uzoigwe

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When it comes to the causes of death, the classification becomes difficult, since two or more causes may operate to kill a patient. However, I opted for a principal cause when such a situation arises. For instance, if a patient with eclampsia developed sepsis on admission and dies, the cause of death was attributed to eclampsia and sepsis was considered secondary.

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Dr S A Uzoigwe

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Total deaths for booked and unbooked mothers in a period of 15 years (1989 – 2003), including deliveries. Year

Deaths Booked

Deliveries

Unbooked

Total

Booked

Unbooked

Total

1989

9

18

27

1985

218

2203

1990

2

19

21

1761

178

1939

1991

5

18

23

1619

184

1803

1992

8

19

27

2145

267

2412

1993

3

42

45

1500

242

1742

1994

1

21

22

1068

116

1184

1995

2

38

40

1373

141

1514

1996

3

25

28

792

88

880

1997

3

58

61

1550

197

1747

1998

8

35

43

1898

348

2246

1999

5

40

45

1472

173

1645

2000

2

16

18

1562

247

1809

2001

3

25

28

1544

217

1761

2002

3

24

27

1978

313

2291

2003

6

35

41

2539

289

2828

Total

66

449

515

24,786

3,218

28,004

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Fig I: Total deaths for booked and unbooked mothers in a period of 15 years (1989 – 2003). 70 60 50 40 30 20 10 0 1985

1990 Booked

Oct 14, 2008

1995 Unbooked Dr S A Uzoigwe

2000

2005

Total 9

Fig II: Total deliveries for booked and unbooked mothers in a period of 15 years (1989 – 2003). 3000 2500 2000 1500 1000 500 0 1985

1990

1995

Deliveries Booked

2000

2005

Deliveries Unbooked

Deliveries Total Oct 14, 2008

Dr S A Uzoigwe

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Table II: Maternal Mortality Ratio (MMR) / 100,000 deliveries. Year

Booked

Unbooked

Hospital Total

1989

454.4

8256.9

1225.6

1990

113.6

10674.2

1083.0

1991

308.8

9782.2

1257.7

1992

373.0

7116.1

1119.4

1993

200.0

17355.4

2583.2

1994

93.6

18103.4

1858.1

1995

145.7

26950.4

2642.0

1996

378.5

1136.4

3181.8

1997

193.5

29441.6

3491.7

1998

421.5

10557.5

1914.5

1999

339.7

23121.4

2735.6

2000

128.0

6477.7

995.0

2001

194.0

11520.7

1590.0

2002

151.6

7667.7

1178.0

2003

236

12110.7

1449.0

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Fig III: Maternal Mortality Ratio (MMR) / 100,000 deliveries. 35000 30000 25000 Booked

20000

Unbooked

15000

hospital total

10000 5000

Oct 14, 2008

Dr S A Uzoigwe

20 03

20 01

19 99

19 97

19 95

19 93

19 91

19 89

0

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Table III: MMR / 100,000 live births in some developed and developing countries U.K.

54 (1952) 10 (from 1986) 5 – 6 from direct Obst causes

South Africa 150 (1998) 92.6 in African women Srilanka

80 (1975 – 1980)

Cuba

36 (1990)

Scandinavian countries (Sweden,

4.3

Norway, Finland, Denmark)

Nigeria

1000 – 1500 (before 1999) ? 704 (1999 = FOS/UNICEF)

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Dr S A Uzoigwe

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Table IV:MMR / 100,000 deliveries and the risk of dying (1989 – 2003) in the University of Port Harcourt Teaching Hospital (15 years) Booked

Unbooked

Hospital Total

MMR

266.0

13,953.0

1839.0

Risk of dying

1:375

1:7

1:54

Chance of dying (1:250 in 1847 in Britain) Oct 14, 2008

Dr S A Uzoigwe

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Table V: Major Obstetric causes of death in 12 years (1989 – 1998), 1999, 2000. 1989 – 1998 (%)

1999 (%)

2000 (%)

74 (21.9)

16 (35.6)

4 (22.2)

37 (10.9)

13 (28.9)

3 (16.6)

44 (13.0)

-

1 (5.5)

labour Abortion related

44 (13.0)

2 (4.4)

-

Sepsis

33 (9.7)

6 (13.3)

4 (22.2)

Ruptured uterus

35 (10.3)

-

1 (5.5)

Severe Pre-eclampsia /eclampsia Obstetric haemorrhage Obstructed

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Fig IV: Major Obstetric causes of death in 12 years (1989 – 1998), 1999, 2000.

percentage

40 35

severe preeclampsia/eclampsia

30

Obstetric haemorrhage

25

Obstructed labour

20 15

Abortion related

10

Sepsis

5 Ruptured uterus

0 1989-1998 Oct 14, 2008

1999

2000 Dr S A Uzoigwe

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Table VI: Major obstetric causes of death in the last 3 years (2001 – 2003) 2001 (%)

2002 (%)

2003 (%)

6 (21.4)

8 (29.6)

11 (26.8)

/eclampsia Obstetric haemorrhage

5 (17.9)

3 (11.1)

7 (17.1)

Sepsis

5 (17.9)

4 (14.8)

8 (19.5)

Obstructed labour

-

3 (11.1)

1 (2.4)

Ruptured uterus

-

1 (3.7)

3 (7.3)

Abortion related

4 (14.2)

4 (14.8)

3 (7.3)

HIV / AIDS

-

1 (3.7)

3 (7.3)

Severe pre-eclampsia

Other causes are pulmonary embolism, sequestration crises, hepatic failure, jaundice in pregnancy, anaesthesia, anaemia, ruptured ectopic pregnancy, congestive cardiac failure, acute renal failure, blood transfusion reaction, diabetic coma, broncho-pneumonia, abdominal massage and others. Oct 14, 2008

Dr S A Uzoigwe

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Table VI: Major obstetric causes of death in the last 3 years (2001 – 2003) 35

severe preeclampsia/eclampsia

30

Obstetric haemorrhage

Percentage

25

sepsis

20 Obstructed labour

15 10

Ruptured uterus

5

Abortion related

0 2001 Oct 14, 2008

2002

2003 Dr S A Uzoigwe

HIV/AIDS 18

Observation: That this is a hospital based information in a tertiary institution in Rivers State. It does not represent maternal death in Rivers State or Nigeria. That the maternal death as seen is astronomically high and unacceptable. That most of the deaths occurred among the unbooked emergencies. That there is still a high risk of dying as a booked patient in the UPTH. That the pattern of maternal death is uncharacteristic and unpredictable. That there is no tendency of maternal mortality ratio coming down. Oct 14, 2008

Dr S A Uzoigwe

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That the commonest cause of death is severe pre-eclampsia / eclampsia (22.6%) published work with a MMR of 430.1 between 1989 – 1998. That we are seeing less of obstructed labour as a major cause of death. That the revolving fund introduced in 1997 appears not to have had any effect on overall maternal death but may have contributed to the prompt treatment of patients who presented with obstructed labour. It also provided blood transfusion and antibiotics.

Oct 14, 2008

Dr S A Uzoigwe

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Solution: Not easy, Complex. No simple pathway, multidimensional. That the beginning is auditing as we are currently doing in the department. This should go beyond this hospital. Contribution from BMH could be married with ours. Population (community) auditing of maternal death in Port Harcourt and Rivers State will be ideal. This will give us a good insight into the magnitude of the problem. Antenatal care remains the pillar for reduction of maternal mortality. Therefore, user fee should be removed. Should be made available for every pregnant woman.

Oct 14, 2008

Dr S A Uzoigwe

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The social, economic, religious and cultural condition that created the unbooked mothers are the remote (root) causes of these deaths. They operate when the female child was born, continues in pregnancy, delivery and pueperium. This is for the policy makers. Illiteracy and extreme poverty must be tackled. Magnesium sulphate is considered a cheap and essential drug (WHO). Should be made available to treat severe pre-eclampsia / eclampsia. Organisation of health services and proper referral system. Intervention measures to reduce maternal death should be the next target of our research. Oct 14, 2008

Dr S A Uzoigwe

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Conclusion: This tragedy will remain with us for a long time to come as the reduction of maternal death is not only clinical but political. It appears that the biblical curse of Eve “In sorrow thou shalt bring forth children” is being fulfilled unfortunately in our days.

Oct 14, 2008

Dr S A Uzoigwe

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