Int J Gynecol Obstet, 1992, 37: 89-95 International Federation of Gynecology
89 and Obstetrics
Level and causes of maternal mortality Africa) B. Tourea,
P. Thonneaub,
P. Cantrelle’,
in Guinea (West
T.M. Barrya, T. Ngo-Khacd
and E. Papiernik”
‘Maternity Unit of Donka Hospital, Conakry (Guinea), hNational Institute of Health and Medical Research (INSERM), Unit 292, Paris (France), “ORSTOM. Population and Health Division, Paris (France), ““Sufe Motherhood” Programme of Operational Research, WHO, Geneva (Switzerland) and ‘Department of Gynaecology and Obstetrics, Cochin Hospital. Paris (France) (Received (Revised
April 28th, and accepted
1991) June
13th. 1991)
Abstract
In order to evaluate the level of maternal mortality at Conakry, capital of Guinea (West Africa), a descriptive epidemiological study was made of all maternal deaths occurring between July lst, 1989 and June 30th, 1990. To ensure that cases of maternal death were recorded as exhaustively as possible, we conducted this study over I year in municipal and hospital maternity units, and 3 months in the urban community. One hundred thirty-nine maternal deaths were registered, representing an annual maternal mortality rate of .559/100 000 live births. The main causes of maternal death were abortion, complications linked with hypertension, and postpartum bleeding.
Keywords: Maternal mortality;
Guinea.
Introduction
Whereas in most developed countries maternal mortality has fallen considerably over the last 30 years (to levels around 10 per 100 000 live births at present), its proportions remain tragic in developing countries, at between 400 and 1300 per 100 000 live births. According to the World Health Organization, 0020-7292/92/$05.00 0 1992 International Federation Published and Printed in Ireland
more than 500 000 women die each year during pregnancy or immediately after giving birth, and 99% of these maternal deaths occur in developing countries [ 11. Since the Safe Motherhood conferences at Nairobi (Kenya) in 1987 and Niamey (Niger) in 1989, African governments have become more aware of the vast public health problem represented by maternal mortality. In Guinea, West Africa, two studies made in the two referral hospital maternity units of the capital found particularly high levels of maternal mortality: 1247 per 100 000 live births at the Donka Hospital in 1986 [2], and 830 per 100 000 live births between 1982 and 1986 in the Maternity Unit of Ignace Deen Hospital [3]. However these results are only partial hospital indicators which do not express the level of maternal mortality in the city of Conakry as a whole. In collaboration with the Safe Motherhood Programme of WHO and the French Ministry of Cooperation and Development, an epidemiological and demographic research program was conducted to assess the scale and causes of maternal mortality in Conakry, the capital of Guinea. This paper is composed of the descriptive, epidemiological part of this programme. Its aims were to measure maternal mortality levels and to establish the main causes of the maternal deaths. Article
of Gynecology
and Obstetrics
90
Toure et al.
Methodology The geographical situation
This study took place in Conakry, capital of the Republic of Guinea, West Africa. The population of Conakry is estimated at 1 million, and the city covers an area of 25 km2. There are two referral maternity units (each with surgical facilities) in the two university hospitals, and six municipal maternity units. These six units have no surgical or obstetric facilities (such as oxytocin drip, forceps delivery, or for cesarean section, hysterectomy), and they are no more than 10 km away from one of the two referral hospital maternity units. There are also 10 maternal and child health centers, mostly incorporated in the maternity units, which provide prenatal care and family planning services. Several private maternity services also exist in Conakry, run by physicians, midwives or tradibirth attendants. tional Obstetrical intervention (delivery or cesarean section) is free of charge, but the patient pays for drugs and surgical materials. Live births
The last demographic survey was conducted in Guinea in 1954. We therefore used our feasibility study (January to June 1989) together with the current demographic survey made over the last 2 years, to estimate the proportion of deliveries taking place at maternities (85%) and at home (15%). We performed a demographic survey in tandem with our epidemiological research project. In the absence of a standard registry of births for all the maternity units of Conakry, we instituted a registry in each maternity unit (conforming to the standards of the National Health Information Department and the Ministry of Public Health and Population). Each registration included the following data: marital status, age, date of delivery, obstetric history, number of prenatal consultations, type of delivery (spontaneous, forceps, cesarean, simple/multiple, head/ breech), place of delivery (maternity Int J Gynecol Obstet 37
unit/home), sex and weight of child, result of Apgar test, and status of mother and child (living, stillborn, dead). It was also necessary to distinguish women residing in Conakry from those who came from the provinces around the capital in order to give birth; this was ascertained systematically by asking the woman or her family where she usually lived. In each maternity unit the Guinean staff were taught how to complete the birth registers and encode the obstetric data on a Toshiba T- 1000 portable microcomputer with Questor software [4]. In view of the expected average number of births (about 30 000), over the 12 months of the study we recorded data on one birth in ten (chosen at random) on computer for each of the eight maternity units. Maternal deaths
The Ninth Revision of the International Classification of diseases [5] defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”. In order to find all the maternal deaths that occurred in Conakry, we conducted two parallel surveys, one in medical centers (municipal maternity units, hospital maternity units and other hospital departments), the other in the urban community at places of worship and cemeteries. Deaths in medical facilities. Firstly, we performed a feasibility study (January to April 1989) and ran an information campaign over several weeks for staff in all the maternity units, so that all maternal deaths between July lst, 1989 and June 30th, 1990 would be registered. We enlisted the help of the administration, mortuary and other departments (resuscitation, surgery, general medicine, infectious diseases) in the two teaching hospitals to ensure the inclusion of maternal deaths that did
Maternal mortality in Guinea
not occur in gynecology and obstetrics units. For this reason, all women who died between the ages of 15 and 45 were listed and their medical records were checked to verify whether or not they counted as maternal deaths. We formed and trained a Guinean obstetric team to make enquiries in the dead woman’s family home when there was insufficient information in the medical records. This was a mobile team (with motor transport), whose members spoke all the local dialects. A standard questionnaire (validated during the preparatory phase) was used to register all information on maternal deaths, irrespective of where or how the death occurred. This the following questionnaire included variables: age, marital status, type of dwelling, occupation and level of education of the woman and her husband (or father of child), income of head of household, number of pregnancies, parity, date of last pregnancy, previous obstetric complications, previous cesarean, course of pregnancy (prenatal consultations) and abnormalities (hemorrhage, anemia, fever, edema, pains, albumin, parasites, icterus, eclampsia, hospitalization), outcome of pregnancy (ectopic, abortion, premature or term delivery), circumstances of delivery (place, spontaneous, forceps, single or twin delivery, professional qualification of birth attendant, total duration of labor, time spent in hospital), obstetric complications in the course of labor (mechanical dystocia, fever, hemorrhage caused by placenta previa or abruptio placentae, infection, vomiting, eclampsia, rupture of the uterus), type of delivery (normal, hemorrhagic), cesarean intervention (duration, complications in the course of intervention); date of death, place of death (maternity unit, at home, in transit), medical cause of death (i.e. diagnostic conclusions of the Guinean obstetric team), time elapsed between admission and death. In the event of abortion: number of weeks of amenorrhea, type (spontaneous, induced) of abortion and presence of any complication or additional surgical intervention. Deaths in the community. With the col-
9I
laboration of the Imams, the local Muslim religious authorities, and with the city’s cemetery caretakers, we set up a survey in the urban community for 3 months (April to June 1990) to record deaths that occurred at home and were not registered in the hospital. Every Imam and cemetery caretaker was asked to keep a record of each woman who died between the ages of 15 and 49, and for whom he had had to perform religious ceremonies or arrange burial. The following information was noted: age, address, date and place of death, cause of death and, in the event of maternal death, the moment of death (pregnancy, delivery, abortion). Supervision
of research/processing
of data
The Guinean obstetric team coordinated and managed all phases of the research with the help of WHO consultants. All the questionnaires were checked by the Guinean research team, then sent for processing to Unit no. 292 (Public Health, Epidemiology, Human Reproduction) of INSERM (the French National Institute for Health and Medical Research), in Paris. The statistical analyses involved descriptive analysis and tests comparing percentage (chi square) and average (t-test) (SPSS and SAS software). Results
Level of maternal mortality
Between July lst, 1989 and June 30th, 1990, 144 maternal death questionnaires were registered at health institutions (two referral maternity units, six municipal maternity units, private medical and paramedical surgeries, and other hospital departments). Twenty-one women not resident in Conakry were excluded, giving a figure of 123 registered maternal deaths (10.8 per month). Ninety percent of these occurred in the two referral maternity units (57% in Donka and 33% in Ignace Deen), 7% in five of the six municipal maternity units and 3% at home (and were then taken to hospital for registry of death). Article
92
Toure et al.
Eleven maternal deaths were recorded in the 3-month community survey of Imams and cemetery caretakers (an average of 3.7 per month, i.e., 44 maternal deaths per annum). Our final estimate from these two surveys is that 167 Conakry resident women (123 + 44) died during pregnancy within 42 days of giving birth. Using the birth registers in the eight maternity units, we arrived at a total estimate of 33 000 live births by women normally resident in Conakry over the 12 months of the study. The level of maternal mortality for the city of Conakry was found to be 559 per 100 000 live births. Sociodemographic features
The women who died had an average age of 24.8 years (SD = 6.6); 93% of them were under 35 and 25% under 20. Eighty-three percent of the deceased women were married, 15’/0single and 2% divorced. Ninety-three percent had lived in the traditional house with a shared yard, 4% in a detached house and 3% in a clay dwelling. Sixty percent were housewives, 3% serving staff, 5% students, 4”/0office workers and 21% had no occupation. In 38% of cases the spouses were laborers or serving staff, 17% office workers, 11% managers, 12% soldiers, 12% street peddlers and 8O/owere unemployed. Twenty-nine percent of the women who died and 53% of their spouses had had primary education (3% of women and 7% of men had been to university). In 60% of cases the family income was under 50 000 Guinean francs (the average earning of a secretary) while 10% of the families earned more than 100 000 Guinean francs, Number of pregnancies, tween pregnancies
parity, interval be-
The women who died had an average of 2.1 children (k2.3). In 40% of cases it was the first pregnancy, while 30% had already been pregnant more than four times. Of the 59/123 women who had already given birth, 14 (24%) had last been pregnant (interval between pregnancies) less than 2 years previously. Twenty-four percent of the women who had Int J Gynecol Obstet 37
already been pregnant had presented complications during their previous pregnancy (dystocia, hypertension, hemorrhage). Eight percent of the women who died had a history of cesarean section. Course and outcome of pregnancy
On average the women who died had had three prenatal consultations ( * 2.8); 26% had had no consultations, but 37% between had between 4 and 12. Midwives or nurses were consulted in 83’/ of cases and physicians in 17% of cases. Eleven percent of the women had had their prenatal consultation in one of the two referral maternity units of the hospitals, 89% in maternal and child health centers or in private practice. Seventy-four percent of the women had had medical treatment during pregnancy, and 27% had consulted a healer. The time elapsed between the last prenatal consultation and the moment of delivery was less than or equal to 1 week in 26% of cases. Seventy percent of the women who died had presented one symptom in the course of pregnancy (Table 1). Of the 123 maternal deaths registered in health facilities, 94 (76%) were term pregnancies, 19 (15’/0) abortions, 9 (7%) premature deliveries, and 2 (2%) ectopic pregnancies. Of the 11 maternal deaths registered in the community, 5 were term pregnancies and 6 were abortions. Obstetric labor exceeded 7 h in 80%, 38% between 7 and 15 h, 29% between 16 and 24 h and 13% lasted more than 1 day (Table 1 shows the obstetric
Table I. Symptoms and pathologies presented who died during pregnancy and labor. During
pregnancy
Fever Hemorrhage Albuminuria Edema Pains
During 61 17 31 36 89
by the women
labor
Mechanical dystocia Infection Hemorrhage (placenta Eclampic crises Abruptio placentae Rupture of the uterus
previa)
28 32 4 6 II 9
Maternal mortality in Guinea
complications observed in the first part of delivery). The time between admission to the maternity unit and onset of labor was less than half a day in 74% of cases, 1 day in 11% of cases, 2 days in 6% and over 2 days in 9% of cases. Forty-seven cesarean sections were performed (38% of the whole term deliveries). Surgical operating time was less than 60 min in 58% of cases, 60-90 min in 37% of cases and over 90 min in 5% of cases; 21% of the cesareans had no complication, 79% had complications such as hemorrhage or surgical complications. Delivery was considered abnormal in 24% of all the whole pregnancies but represented 54% of the term pregnancies. Cause of maternal deaths (Table 2) Twenty-two maternal deaths were associated with hypertension, and 21 were related to complications that arose at delivery while 19 deaths occurred after abortion and 2 after ectopic pregnancy. In 11 women the cause of death was related to operative or postoperative hemorrhagic complications. Of the 19 cases of abortion, 3 (20%) were spontaneous and 13 (80°> induced; 13 of the
Table 2. Main causes of maternal mortality in maternity units and in the community.
Abortion Ectopic pregnancy Hypertensive disease (eclampsia, abrupt0 placentae) Sepsis Rupture of the uterus Placenta previa Postpartum bleeding Obstetric hemorrhage Other causes (amniotic embolism, anemia, anesthetic shock) No cause identified
Maternity units (‘Vu)
Community (‘Vu)
19 (17) 2 (2) 22 (20)
6/11 (54)
13 (12) 3 (3) 3 (3) 21 (19 ) 11 (IO) 8 (7)
II (10)
4111 (36)
93
19 women (87%) had had amenorrhea for 12 weeks or more. In the postabortion complications, sepsis was most common (71%), followed by perforation of the uterus (7%) and icterus (7 “A). In two-thirds of cases of abortion registered in health facilities (66%), the patients had taken abortifacient medicinal plants. Of the 11 maternal deaths registered in the community enquiry in Conakry, 6 were induced abortions and 5 were postpartum bleeding. We have calculated the time elapsed between arrival of the woman in one of the two main hospital maternity units and the moment of maternal death. This period was less than 6 h in one-third of cases, between 6 and 48 h in another third, and over 2 days for the last third. In one-third of cases of maternal death, the Guinean obstetricians had mentioned short supply of surgical equipment (lack of resuscitation products, shortage of blood products or antibiotics). Discussion
Statistical coverage of maternal deaths As several authors have noted [6,7] the bias arising from nonregistration of certain maternal deaths is one of the main difficulties with the validity of this type of research. In order to address this problem, we consulted first of all the data available in medical facilities: referral maternity units, municipal maternity units and other hospital departments (internal medicine, surgery, resuscitation). We also held regular meetings and information sessions throughout the year of the study with all the obstetric, medical and paramedical staff. Nevertheless, the main problem concerning exhaustiveness is nonnotification of some maternal deaths, and the complete lack of contact between some Guinean women and the obstetric care system. The community survey conducted with the help of religious leaders (Imams) and cemetery caretakers confirmed this hypothesis, Adele
94
Toure et al.
registering 11 maternal deaths in 3 months (3.7 per month). If we extrapolate this monthly rate to a year, the number of maternal deaths not registered in a simple hospital survey is 44, or a quarter of all maternal deaths in Conakry. We decided to limit the duration of the community survey to 3 months, since the approach is very time-consuming (involving frequent visits to cemeteries and to the Imams) and presents ethical difficulty (inquiries in the neighborhood, then questioning of the family of the dead woman). This is why we were able to obtain only general information, with no recording of sociodemographic features, obstetric history and the course of pregnancy. We believe that thanks to this combination of methods, few of the maternal deaths occurring in the city of Conakry escaped the attention of the research Guinean team, although it is better to regard the estimate of 559 per 100 000 as a minimum level.
women at consultations, referral and specialist treatment of women identified as suffering from hypertension), especially as two out of three Conakry resident women who died had had at least one prenatal consultation [ Ill. Postpartum bleeding accounts for a significant proportion of maternal deaths: 4/11 (36%) in the community and 21/123 (17%) in hospital maternities. Of these 21 women, 2/3 had been referred from municipal maternity, and 90% died within 6 h of admission. Management of this last phase of childbirth, with special training of midwives and traditional birth attendants, should help to reduce this percentage drastically [ 121. No cause of maternal death is mentioned for 11 women. This statistic, though still too high, is yet encouraging since it shows the increasing tendency of Guinean obstetric teams to analyze all cases of maternal death systematically [ 131.
Causes of maternal death
Conclusion
Our results confirm the importance of abortion in maternal deaths, already highlighted by several authors [8,9]. The figures found were 19/123 (15%) in hospital and municipal maternity units, and over half (6 out of 11) of the maternal deaths reported in the community. The very strict legislation regarding voluntary termination of pregnancy and certain cultural practices undoubtedly lead many women to practise abortion in secret and in conditions that put their lives at risk [lo]. In spite of probable underreporting of cases of abortion, this study shows that for Conakry resident women under the age of 30 and pregnant for the first time, clandestine abortion is probably one of the main causes of death related to pregnancy. Hypertension and its consequences (eclampsia, abruptio placentae) account for 18% of all maternal deaths. This is an obstetric complication with relatively simple diagnosis and treatment in most cases (screening for previous hypertension and systematic checking of the blood pressure of all pregnant Int J Gynecol Obstet 37
The immediate conclusion of this study is that the level of maternal death in the Guinean capital is still high [14]. Our approach, covering both hospital and municipal maternity units and the community, confirms the importance of seeking out all cases of maternal death, in order to ensure the validity of the numbers registered. The results of this study will constitute a reference value for West African countries, and lead to further analytical epidemiological studies of maternal risk factors (a case-control study parallel to this descriptive study is under way in Conakry). Acknowledgments This research project was carried out with the technical support of the “Safe Motherhood” unit of the World Health Organization; it was financed by the French Ministry of Cooperation and Development, and by the World Health Organization. We
Maternal
are grateful to all obstetrical, medical and paramedical personnel in Conakry, and especially to members of SOGGO (The Guinean Society of Gynaecology and Obstetrics) as well as to B. Ferry (WHO, Geneva), Dr. B. Ducot, Dr. L. Meyer, Professor A. Spira and P. Rosinel (INSERM, Paris) and all those who have collaborated in this research project.
tality inquiry in a rural community Gynecol Obstet 29: 313. 1989.
of North
India. Int J
95
Royston E, Lopez D: On the assessment of maternal mortality. Rapp Trimest Statist Sanit Mond 40: 214. 1987.
8
El Kady AA, Saleh S, Gadalla S, Fortney J. Bayoumi H: Obstetric deaths in Menoutia Governorate, Egypt. Br J Obstet Gynaecol 96: 9, 1989. Aggarwal VP, Mati JKG: Review of abortions at Kenyat-
9
I2
ta National Hospital, Nairobi. East Afr Med J 57: 1980. Chatterjee TK: Socioeconomic and demographic characteristics of induced abortion cases. Int J Gynecol Obstet 23: 149. 1985. Lopez-Llera M, de la Luz Espinosa M, Arratia S: Eclampsia and placental abruption: basic patterns, management and morbidity. Int J Gynecol Obstet 27: 335, 1988. Fernandez H, Djanhan Y, Papiernik E: Mortalitt
13
maternelle par hemorragie dans les pays en voie de dtveloppement. Quelle politique proposer? J Gynecol Obstet Biol Reprod 17: 687, 1988. Cook R: The role of confidential enquiries in the reduc-
IO
II
Boerma JT: Levels of maternal mortality in developing countries. Stud Fam Plann 18: 213, 1987.
World Health Organization: International Classification of Diseases. Injuries and Death, 9th edn. WHO. Geneva. 1979). Kumar R, Sharma AK, Barik S, Kumar V: Maternal mor-
in Guinea
7
References
Keita N. Hijazy Y. Diallo MS: Etude de la mortalite maternelle au CHU de Donka (Conakry, Guinee). J Gynecol Obstet Biol Reprod (Paris) 18: 849. 1989. Diallo MS, Sidibe M and Keita: La mortalite maternelle; a propos de 212 observations en 7 ans (1980-1986) a la materniti lgnace Deen de Conakry (Guinee). Rev Fr Gynecol Obstet 84: 419, 1989. Ferry B, Cantrelle P: Les experiences nouvelles en matiere de collecte integree de donnees sur micro-ordinateurs portables. International Population ConferenceiCongres International de la Population, New Delhi. 1989. UIESP Vol. 2. pp 47-62.
mortality
I4
tion of maternal mortality and alternatives to this approach. Int J Gynecol Obstet 30: 41, 1989. Boerma T: The magnitude of the maternal mortality problem in sub-Saharan Africa. Sot Sci Med 24: 551. 1987.
Address for reprints: P. Thonneau INSERM, Unit 292 Hbpital de Bic&re 78 rue du GCdral Leclerc 94275 Le Kremlin Biche France
Article
89 and Obstetrics
Level and causes of maternal mortality Africa) B. Tourea,
P. Thonneaub,
P. Cantrelle’,
in Guinea (West
T.M. Barrya, T. Ngo-Khacd
and E. Papiernik”
‘Maternity Unit of Donka Hospital, Conakry (Guinea), hNational Institute of Health and Medical Research (INSERM), Unit 292, Paris (France), “ORSTOM. Population and Health Division, Paris (France), ““Sufe Motherhood” Programme of Operational Research, WHO, Geneva (Switzerland) and ‘Department of Gynaecology and Obstetrics, Cochin Hospital. Paris (France) (Received (Revised
April 28th, and accepted
1991) June
13th. 1991)
Abstract
In order to evaluate the level of maternal mortality at Conakry, capital of Guinea (West Africa), a descriptive epidemiological study was made of all maternal deaths occurring between July lst, 1989 and June 30th, 1990. To ensure that cases of maternal death were recorded as exhaustively as possible, we conducted this study over I year in municipal and hospital maternity units, and 3 months in the urban community. One hundred thirty-nine maternal deaths were registered, representing an annual maternal mortality rate of .559/100 000 live births. The main causes of maternal death were abortion, complications linked with hypertension, and postpartum bleeding.
Keywords: Maternal mortality;
Guinea.
Introduction
Whereas in most developed countries maternal mortality has fallen considerably over the last 30 years (to levels around 10 per 100 000 live births at present), its proportions remain tragic in developing countries, at between 400 and 1300 per 100 000 live births. According to the World Health Organization, 0020-7292/92/$05.00 0 1992 International Federation Published and Printed in Ireland
more than 500 000 women die each year during pregnancy or immediately after giving birth, and 99% of these maternal deaths occur in developing countries [ 11. Since the Safe Motherhood conferences at Nairobi (Kenya) in 1987 and Niamey (Niger) in 1989, African governments have become more aware of the vast public health problem represented by maternal mortality. In Guinea, West Africa, two studies made in the two referral hospital maternity units of the capital found particularly high levels of maternal mortality: 1247 per 100 000 live births at the Donka Hospital in 1986 [2], and 830 per 100 000 live births between 1982 and 1986 in the Maternity Unit of Ignace Deen Hospital [3]. However these results are only partial hospital indicators which do not express the level of maternal mortality in the city of Conakry as a whole. In collaboration with the Safe Motherhood Programme of WHO and the French Ministry of Cooperation and Development, an epidemiological and demographic research program was conducted to assess the scale and causes of maternal mortality in Conakry, the capital of Guinea. This paper is composed of the descriptive, epidemiological part of this programme. Its aims were to measure maternal mortality levels and to establish the main causes of the maternal deaths. Article
of Gynecology
and Obstetrics
90
Toure et al.
Methodology The geographical situation
This study took place in Conakry, capital of the Republic of Guinea, West Africa. The population of Conakry is estimated at 1 million, and the city covers an area of 25 km2. There are two referral maternity units (each with surgical facilities) in the two university hospitals, and six municipal maternity units. These six units have no surgical or obstetric facilities (such as oxytocin drip, forceps delivery, or for cesarean section, hysterectomy), and they are no more than 10 km away from one of the two referral hospital maternity units. There are also 10 maternal and child health centers, mostly incorporated in the maternity units, which provide prenatal care and family planning services. Several private maternity services also exist in Conakry, run by physicians, midwives or tradibirth attendants. tional Obstetrical intervention (delivery or cesarean section) is free of charge, but the patient pays for drugs and surgical materials. Live births
The last demographic survey was conducted in Guinea in 1954. We therefore used our feasibility study (January to June 1989) together with the current demographic survey made over the last 2 years, to estimate the proportion of deliveries taking place at maternities (85%) and at home (15%). We performed a demographic survey in tandem with our epidemiological research project. In the absence of a standard registry of births for all the maternity units of Conakry, we instituted a registry in each maternity unit (conforming to the standards of the National Health Information Department and the Ministry of Public Health and Population). Each registration included the following data: marital status, age, date of delivery, obstetric history, number of prenatal consultations, type of delivery (spontaneous, forceps, cesarean, simple/multiple, head/ breech), place of delivery (maternity Int J Gynecol Obstet 37
unit/home), sex and weight of child, result of Apgar test, and status of mother and child (living, stillborn, dead). It was also necessary to distinguish women residing in Conakry from those who came from the provinces around the capital in order to give birth; this was ascertained systematically by asking the woman or her family where she usually lived. In each maternity unit the Guinean staff were taught how to complete the birth registers and encode the obstetric data on a Toshiba T- 1000 portable microcomputer with Questor software [4]. In view of the expected average number of births (about 30 000), over the 12 months of the study we recorded data on one birth in ten (chosen at random) on computer for each of the eight maternity units. Maternal deaths
The Ninth Revision of the International Classification of diseases [5] defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”. In order to find all the maternal deaths that occurred in Conakry, we conducted two parallel surveys, one in medical centers (municipal maternity units, hospital maternity units and other hospital departments), the other in the urban community at places of worship and cemeteries. Deaths in medical facilities. Firstly, we performed a feasibility study (January to April 1989) and ran an information campaign over several weeks for staff in all the maternity units, so that all maternal deaths between July lst, 1989 and June 30th, 1990 would be registered. We enlisted the help of the administration, mortuary and other departments (resuscitation, surgery, general medicine, infectious diseases) in the two teaching hospitals to ensure the inclusion of maternal deaths that did
Maternal mortality in Guinea
not occur in gynecology and obstetrics units. For this reason, all women who died between the ages of 15 and 45 were listed and their medical records were checked to verify whether or not they counted as maternal deaths. We formed and trained a Guinean obstetric team to make enquiries in the dead woman’s family home when there was insufficient information in the medical records. This was a mobile team (with motor transport), whose members spoke all the local dialects. A standard questionnaire (validated during the preparatory phase) was used to register all information on maternal deaths, irrespective of where or how the death occurred. This the following questionnaire included variables: age, marital status, type of dwelling, occupation and level of education of the woman and her husband (or father of child), income of head of household, number of pregnancies, parity, date of last pregnancy, previous obstetric complications, previous cesarean, course of pregnancy (prenatal consultations) and abnormalities (hemorrhage, anemia, fever, edema, pains, albumin, parasites, icterus, eclampsia, hospitalization), outcome of pregnancy (ectopic, abortion, premature or term delivery), circumstances of delivery (place, spontaneous, forceps, single or twin delivery, professional qualification of birth attendant, total duration of labor, time spent in hospital), obstetric complications in the course of labor (mechanical dystocia, fever, hemorrhage caused by placenta previa or abruptio placentae, infection, vomiting, eclampsia, rupture of the uterus), type of delivery (normal, hemorrhagic), cesarean intervention (duration, complications in the course of intervention); date of death, place of death (maternity unit, at home, in transit), medical cause of death (i.e. diagnostic conclusions of the Guinean obstetric team), time elapsed between admission and death. In the event of abortion: number of weeks of amenorrhea, type (spontaneous, induced) of abortion and presence of any complication or additional surgical intervention. Deaths in the community. With the col-
9I
laboration of the Imams, the local Muslim religious authorities, and with the city’s cemetery caretakers, we set up a survey in the urban community for 3 months (April to June 1990) to record deaths that occurred at home and were not registered in the hospital. Every Imam and cemetery caretaker was asked to keep a record of each woman who died between the ages of 15 and 49, and for whom he had had to perform religious ceremonies or arrange burial. The following information was noted: age, address, date and place of death, cause of death and, in the event of maternal death, the moment of death (pregnancy, delivery, abortion). Supervision
of research/processing
of data
The Guinean obstetric team coordinated and managed all phases of the research with the help of WHO consultants. All the questionnaires were checked by the Guinean research team, then sent for processing to Unit no. 292 (Public Health, Epidemiology, Human Reproduction) of INSERM (the French National Institute for Health and Medical Research), in Paris. The statistical analyses involved descriptive analysis and tests comparing percentage (chi square) and average (t-test) (SPSS and SAS software). Results
Level of maternal mortality
Between July lst, 1989 and June 30th, 1990, 144 maternal death questionnaires were registered at health institutions (two referral maternity units, six municipal maternity units, private medical and paramedical surgeries, and other hospital departments). Twenty-one women not resident in Conakry were excluded, giving a figure of 123 registered maternal deaths (10.8 per month). Ninety percent of these occurred in the two referral maternity units (57% in Donka and 33% in Ignace Deen), 7% in five of the six municipal maternity units and 3% at home (and were then taken to hospital for registry of death). Article
92
Toure et al.
Eleven maternal deaths were recorded in the 3-month community survey of Imams and cemetery caretakers (an average of 3.7 per month, i.e., 44 maternal deaths per annum). Our final estimate from these two surveys is that 167 Conakry resident women (123 + 44) died during pregnancy within 42 days of giving birth. Using the birth registers in the eight maternity units, we arrived at a total estimate of 33 000 live births by women normally resident in Conakry over the 12 months of the study. The level of maternal mortality for the city of Conakry was found to be 559 per 100 000 live births. Sociodemographic features
The women who died had an average age of 24.8 years (SD = 6.6); 93% of them were under 35 and 25% under 20. Eighty-three percent of the deceased women were married, 15’/0single and 2% divorced. Ninety-three percent had lived in the traditional house with a shared yard, 4% in a detached house and 3% in a clay dwelling. Sixty percent were housewives, 3% serving staff, 5% students, 4”/0office workers and 21% had no occupation. In 38% of cases the spouses were laborers or serving staff, 17% office workers, 11% managers, 12% soldiers, 12% street peddlers and 8O/owere unemployed. Twenty-nine percent of the women who died and 53% of their spouses had had primary education (3% of women and 7% of men had been to university). In 60% of cases the family income was under 50 000 Guinean francs (the average earning of a secretary) while 10% of the families earned more than 100 000 Guinean francs, Number of pregnancies, tween pregnancies
parity, interval be-
The women who died had an average of 2.1 children (k2.3). In 40% of cases it was the first pregnancy, while 30% had already been pregnant more than four times. Of the 59/123 women who had already given birth, 14 (24%) had last been pregnant (interval between pregnancies) less than 2 years previously. Twenty-four percent of the women who had Int J Gynecol Obstet 37
already been pregnant had presented complications during their previous pregnancy (dystocia, hypertension, hemorrhage). Eight percent of the women who died had a history of cesarean section. Course and outcome of pregnancy
On average the women who died had had three prenatal consultations ( * 2.8); 26% had had no consultations, but 37% between had between 4 and 12. Midwives or nurses were consulted in 83’/ of cases and physicians in 17% of cases. Eleven percent of the women had had their prenatal consultation in one of the two referral maternity units of the hospitals, 89% in maternal and child health centers or in private practice. Seventy-four percent of the women had had medical treatment during pregnancy, and 27% had consulted a healer. The time elapsed between the last prenatal consultation and the moment of delivery was less than or equal to 1 week in 26% of cases. Seventy percent of the women who died had presented one symptom in the course of pregnancy (Table 1). Of the 123 maternal deaths registered in health facilities, 94 (76%) were term pregnancies, 19 (15’/0) abortions, 9 (7%) premature deliveries, and 2 (2%) ectopic pregnancies. Of the 11 maternal deaths registered in the community, 5 were term pregnancies and 6 were abortions. Obstetric labor exceeded 7 h in 80%, 38% between 7 and 15 h, 29% between 16 and 24 h and 13% lasted more than 1 day (Table 1 shows the obstetric
Table I. Symptoms and pathologies presented who died during pregnancy and labor. During
pregnancy
Fever Hemorrhage Albuminuria Edema Pains
During 61 17 31 36 89
by the women
labor
Mechanical dystocia Infection Hemorrhage (placenta Eclampic crises Abruptio placentae Rupture of the uterus
previa)
28 32 4 6 II 9
Maternal mortality in Guinea
complications observed in the first part of delivery). The time between admission to the maternity unit and onset of labor was less than half a day in 74% of cases, 1 day in 11% of cases, 2 days in 6% and over 2 days in 9% of cases. Forty-seven cesarean sections were performed (38% of the whole term deliveries). Surgical operating time was less than 60 min in 58% of cases, 60-90 min in 37% of cases and over 90 min in 5% of cases; 21% of the cesareans had no complication, 79% had complications such as hemorrhage or surgical complications. Delivery was considered abnormal in 24% of all the whole pregnancies but represented 54% of the term pregnancies. Cause of maternal deaths (Table 2) Twenty-two maternal deaths were associated with hypertension, and 21 were related to complications that arose at delivery while 19 deaths occurred after abortion and 2 after ectopic pregnancy. In 11 women the cause of death was related to operative or postoperative hemorrhagic complications. Of the 19 cases of abortion, 3 (20%) were spontaneous and 13 (80°> induced; 13 of the
Table 2. Main causes of maternal mortality in maternity units and in the community.
Abortion Ectopic pregnancy Hypertensive disease (eclampsia, abrupt0 placentae) Sepsis Rupture of the uterus Placenta previa Postpartum bleeding Obstetric hemorrhage Other causes (amniotic embolism, anemia, anesthetic shock) No cause identified
Maternity units (‘Vu)
Community (‘Vu)
19 (17) 2 (2) 22 (20)
6/11 (54)
13 (12) 3 (3) 3 (3) 21 (19 ) 11 (IO) 8 (7)
II (10)
4111 (36)
93
19 women (87%) had had amenorrhea for 12 weeks or more. In the postabortion complications, sepsis was most common (71%), followed by perforation of the uterus (7%) and icterus (7 “A). In two-thirds of cases of abortion registered in health facilities (66%), the patients had taken abortifacient medicinal plants. Of the 11 maternal deaths registered in the community enquiry in Conakry, 6 were induced abortions and 5 were postpartum bleeding. We have calculated the time elapsed between arrival of the woman in one of the two main hospital maternity units and the moment of maternal death. This period was less than 6 h in one-third of cases, between 6 and 48 h in another third, and over 2 days for the last third. In one-third of cases of maternal death, the Guinean obstetricians had mentioned short supply of surgical equipment (lack of resuscitation products, shortage of blood products or antibiotics). Discussion
Statistical coverage of maternal deaths As several authors have noted [6,7] the bias arising from nonregistration of certain maternal deaths is one of the main difficulties with the validity of this type of research. In order to address this problem, we consulted first of all the data available in medical facilities: referral maternity units, municipal maternity units and other hospital departments (internal medicine, surgery, resuscitation). We also held regular meetings and information sessions throughout the year of the study with all the obstetric, medical and paramedical staff. Nevertheless, the main problem concerning exhaustiveness is nonnotification of some maternal deaths, and the complete lack of contact between some Guinean women and the obstetric care system. The community survey conducted with the help of religious leaders (Imams) and cemetery caretakers confirmed this hypothesis, Adele
94
Toure et al.
registering 11 maternal deaths in 3 months (3.7 per month). If we extrapolate this monthly rate to a year, the number of maternal deaths not registered in a simple hospital survey is 44, or a quarter of all maternal deaths in Conakry. We decided to limit the duration of the community survey to 3 months, since the approach is very time-consuming (involving frequent visits to cemeteries and to the Imams) and presents ethical difficulty (inquiries in the neighborhood, then questioning of the family of the dead woman). This is why we were able to obtain only general information, with no recording of sociodemographic features, obstetric history and the course of pregnancy. We believe that thanks to this combination of methods, few of the maternal deaths occurring in the city of Conakry escaped the attention of the research Guinean team, although it is better to regard the estimate of 559 per 100 000 as a minimum level.
women at consultations, referral and specialist treatment of women identified as suffering from hypertension), especially as two out of three Conakry resident women who died had had at least one prenatal consultation [ Ill. Postpartum bleeding accounts for a significant proportion of maternal deaths: 4/11 (36%) in the community and 21/123 (17%) in hospital maternities. Of these 21 women, 2/3 had been referred from municipal maternity, and 90% died within 6 h of admission. Management of this last phase of childbirth, with special training of midwives and traditional birth attendants, should help to reduce this percentage drastically [ 121. No cause of maternal death is mentioned for 11 women. This statistic, though still too high, is yet encouraging since it shows the increasing tendency of Guinean obstetric teams to analyze all cases of maternal death systematically [ 131.
Causes of maternal death
Conclusion
Our results confirm the importance of abortion in maternal deaths, already highlighted by several authors [8,9]. The figures found were 19/123 (15%) in hospital and municipal maternity units, and over half (6 out of 11) of the maternal deaths reported in the community. The very strict legislation regarding voluntary termination of pregnancy and certain cultural practices undoubtedly lead many women to practise abortion in secret and in conditions that put their lives at risk [lo]. In spite of probable underreporting of cases of abortion, this study shows that for Conakry resident women under the age of 30 and pregnant for the first time, clandestine abortion is probably one of the main causes of death related to pregnancy. Hypertension and its consequences (eclampsia, abruptio placentae) account for 18% of all maternal deaths. This is an obstetric complication with relatively simple diagnosis and treatment in most cases (screening for previous hypertension and systematic checking of the blood pressure of all pregnant Int J Gynecol Obstet 37
The immediate conclusion of this study is that the level of maternal death in the Guinean capital is still high [14]. Our approach, covering both hospital and municipal maternity units and the community, confirms the importance of seeking out all cases of maternal death, in order to ensure the validity of the numbers registered. The results of this study will constitute a reference value for West African countries, and lead to further analytical epidemiological studies of maternal risk factors (a case-control study parallel to this descriptive study is under way in Conakry). Acknowledgments This research project was carried out with the technical support of the “Safe Motherhood” unit of the World Health Organization; it was financed by the French Ministry of Cooperation and Development, and by the World Health Organization. We
Maternal
are grateful to all obstetrical, medical and paramedical personnel in Conakry, and especially to members of SOGGO (The Guinean Society of Gynaecology and Obstetrics) as well as to B. Ferry (WHO, Geneva), Dr. B. Ducot, Dr. L. Meyer, Professor A. Spira and P. Rosinel (INSERM, Paris) and all those who have collaborated in this research project.
tality inquiry in a rural community Gynecol Obstet 29: 313. 1989.
of North
India. Int J
95
Royston E, Lopez D: On the assessment of maternal mortality. Rapp Trimest Statist Sanit Mond 40: 214. 1987.
8
El Kady AA, Saleh S, Gadalla S, Fortney J. Bayoumi H: Obstetric deaths in Menoutia Governorate, Egypt. Br J Obstet Gynaecol 96: 9, 1989. Aggarwal VP, Mati JKG: Review of abortions at Kenyat-
9
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ta National Hospital, Nairobi. East Afr Med J 57: 1980. Chatterjee TK: Socioeconomic and demographic characteristics of induced abortion cases. Int J Gynecol Obstet 23: 149. 1985. Lopez-Llera M, de la Luz Espinosa M, Arratia S: Eclampsia and placental abruption: basic patterns, management and morbidity. Int J Gynecol Obstet 27: 335, 1988. Fernandez H, Djanhan Y, Papiernik E: Mortalitt
13
maternelle par hemorragie dans les pays en voie de dtveloppement. Quelle politique proposer? J Gynecol Obstet Biol Reprod 17: 687, 1988. Cook R: The role of confidential enquiries in the reduc-
IO
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World Health Organization: International Classification of Diseases. Injuries and Death, 9th edn. WHO. Geneva. 1979). Kumar R, Sharma AK, Barik S, Kumar V: Maternal mor-
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