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The maternal deaths occurring in the Kilimanjaro Christian Medical Center (KCMC), which serves as a supraregional reference hospital for the 5 regions of Northern and Central Tanzania, are reviewed for the 1971-1977 period and avoidable factors are discussed. All deaths occurring within the hospital during pregnancy or the first 6 weeks of the puerperium were included in this survey. Postmortem examination was performed in 35% of the cases. In the remaining cases the diagnosis was made on clinical grounds. During the period under review, there were 10 deaths among 83 cases, a mortality of 12%. The major cause of rupture was obstructed labor associated with a contracted pelvis or abnormal lie. 25% of the patients had had a previous cesarean section scar give way. 2 other deaths were attributed to anesthetic accidents and 1 was probably due to pulmonary embolism. The primary cause of death in the 7 remaining cases was hemorrhage (4) and sepsis (3). If deaths from ruptured uterus are to be avoided, early diagnosis is essential. 1044 cases of moderate and severe EPH gestosis (preeclampsia) were treated in KCMC during the period under review together with 54 cases of eclampsia. There were 5 deaths among the patients with eclampsia, a mortality of 9%. In addition to the 11 sepsis deaths there were 3 others included among the cases of ruptured uterus. There were 4 cases of septic abortion and 3 of those admitted to criminal interference. Preexisting anemia was a complicating factor in 5 cases, all of whom died within 15 minutes of arrival. There were 4 deaths among 251 cases of ruptured ectopic pregnancy. There were 10 deaths associated with cesarean section among 1271 sections peformed during the period under review. Deaths from associated diseases included the following: enterocolitis (12 deaths); renal and hypertensive disease (4 deaths); cardiac disease (2 deaths); anemia (2 deaths); malaria (2 deaths); tuberculous meningitis (2 deaths); and miscellaneous associated conditions (11 deaths).
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PMID:Maternal deaths in the Kilimanjaro region of Tanzania. 47 24

The examination of early perinatal mortality (between 28 weeks gestation and 1 week after birth) was conducted in the Machakos District Hospital in Kenya over a 4-month period. The hospital provides full gynecological and obstetric services and family planning. Out of 2171 deliveries recorded that early perinatal mortality rate (EPMR) was 53/1000 (114 losses). The maternal mortality rate was 2.7/1000 due to 3 ruptured uteri, 1 postpartum hemorrhage, 1 case of cerebral malaria, and 1 care of anesthetic complications. In the analysis of factors associated with EPMR, the findings showed that there was a statistically significant difference between married and single/separated status with regard to EPMR. Although not statistically significant, EPMR was lowest at a parity of 2. Maternal educational level and socioeconomic status had a statistically significant impact on EPMR. 70% of the mothers were in the low socioeconomic group, which had the highest rates of mortality. 5% of the birthing mothers did not receive prenatal care and contributed 22% of the perinatal mortality. There was also an unexpected number of perinatal deaths for mothers who had received prenatal car at a sub-district hospital. There was a very low EPMR (34/1000) for mothers without any complications, which constituted 81.4% of pregnancies. The highest EPMR of 315/1000 was found among those mothers with "threatened abortion." Malpresentation accounted for an EPMR of 242/1000, and prepartum hemorrhage, for an EPMR of 210/1000. 1.1% of mothers had a urinary tract infection, .1% had cardiac disease, and .1% had diabetes, but these complications were not associated with EPMR. 17% were premature births; 10% were births after 42 weeks. Mortality was highest among babies of less tan 28 weeks gestation. Among the 82% with the uncomplicated labor the EPMR was 10/1000. The 6% with prolonged labor had an EPMR of 177/1000. The highest EPMR was found among women with a ruptured uterus an cord collapse. The birth weight groups of 3000 to 3494 had the lowest EPMR. The recommendations pertained to improvements in the health care system.
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PMID:Factors influencing early perinatal mortality in a rural district hospital. 164 26

Maternal mortality is examined from June 1980 to December 1986 at Mulago, Nsambyo, Old Kampala, Rubaga, and Mengo Hospitals in Kampala, Uganda. Clinical or immediate causes, direct and indirect, were recorded from case summary forms based on ICD9 definitions of obstetric complications. The nonabortion maternal mortality rate (NAMMR) was 2.65/1000 deliveries (580 deaths); the abortion-related maternal mortality rate (ARMMR) was 3.58/1000 abortions. The hospital maternal mortality rate was 2.0/1000 deliveries. 75% of maternal deaths of women of 28 weeks' gestation or more had delivered outside the hospital. NAMMR doubled between 1980-86, a statistically significant increase. ARMMR increases were almost significant. 75% were direct obstetric and 21% were indirect obstetric causes. 38% had clinical anemia, 29% had some sepsis, 18% had substantial bleeding, and 14% had obstructed labor. Other contributing conditions were pneumonia, ruptured uterus, laparotomy, evacuations and curettage, malaria, preeclampsia, sickle cell anemia, pulmonary embolism, malnutrition, tetanus, meningitis, prolonged labor, and hepatitis. At admission, 48% were in poor condition, 30% in good condition, and 22% in fair condition. 27% had sickle cell anemia, high blood pressure, multiple pregnancy, or malaria at admission. 64% were admitted within 24 hours after delivery, 67% 1-7 days after delivery, and 92% 7-42 days after delivery. Those in good condition were all admitted 7 days postdelivery. 41% of deaths were due to lack of drugs, 7% lack of fluids, 20% with theater problems, 14% with doctor-related factors, and 3% with midwife-related factors. Better information is needed on mortality before delivery, mortality in hospitals vs. outside, and mortality from abortion, and ectopic and hydatidiform molar pregnancies. An explanation given for the increase in maternal mortality is the decline in economic conditions. Abortion complications may be due to the concealment practiced. Causes are consistent with trends from the 1950s, 1960s, and 1970s in Uganda and developing countries in general. Availability and accessibility of gynecological and obstetric services needs great improvement. Training traditional birth attendants and obtaining rural ambulance services are also needed. Health workers lack creativity and imagination for developing country conditions; scarce resources are not the only problem.
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PMID:Incidence and causes of maternal mortality in five Kampala hospitals, 1980-1986. 176 15

The case notes of all patients who died over the January 1980 to December 1985 period in Tikur Anbessa Teaching Hospital, Addis Ababa, Ethiopia, as a result of conditions associated with pregnancy, labor, and puerperium were reviewed in an effort to identify the most common causes of maternal death. Postpartum autopsy seldom was possible; consequently, the cause of death was based on clinical findings only. 216 deaths occurred over the 6-year period; there were 22,404 live births in the same period, giving a maternal mortality rate (MMR) of 9.6/1000. This rate included deaths from complications following abortions. 197 of the deaths occurred in women who were not booked into Tikur Anbessa Hospital. In terms of direct causes of death, abortion, puerperal sepsis, and ruptured uterus together accounted for 75.9% of deaths. Of indirect causes, infectious hepatitis, relapsing fever, and malaria accounted for 56.8% of deaths. Of deaths due to abortion, 21/48 occurred in nulliparas, and 25 were below age 19. Of the deaths caused by ruptured uterus, 20/29 occurred in multipara, and all of those women were from rural areas. The majority of deaths from hepatitis occurred in the 30-34 years age group. In Ethiopia, the maternal mortality rate is high because of both poor or inadequate antenatal and postnatal care as well as because of poor transportation and communication systems.
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PMID:A six-year review of maternal mortality in a teaching hospital in Addis Ababa. 341 42

The training and use of trained birth attendants (TBAs) in Guinea Bissau was started in 1977 as part of the primary health care program. The majority of TBAs are illiterate, making accurate record-keeping of antenatal visits ineffective. This paper presents an antenatal card developed by the Ministry of Health and Social Affairs in use since 1982. The card was designed for several purposes: to help nurse-supervisors find and correct mistakes, to help TBAs remember what to look for during antenatal visits, and to enable them to identify at-risk pregnancies and refer them if necessary. The card requires no writing other than the initial visit, when it is suggested that a literate person assist the TBA in recording name, age, and village. Pictorial symbols are used on the rest of the card, which is retained by the patient between visits. The card is divided into 3 areas: a history (number of live children, number of dead children, number of abortions) recorded by placing the correct number of ticks in the proper column; examination (weight if possible, signs of anemia and edema indicated by a +or-, height of uterus, presence of fetal heart sounds); care (reminding TBAs to give nutritional advice, malaria prophylaxis, dispense iron tablets, determine if referral is necessary). The card needs to be field tested by nurses and midwives who will be training the TBAs, and then evaluated for its use in detecting at-risk pregnancies, making any additions or changes as necessary.
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PMID:Antenatal card for illiterate traditional birth attendants. 376 84

From 28 October 1991 to 30 December 1992, in Jima Hospital, a teaching hospital serving a predominantly rural population in southwestern Ethiopia, there were 841 deliveries and 573 abortions with 22 maternal deaths, a maternal mortality rate of 26 per thousand live births. Direct obstetric causes accounted for 19 of the 22 deaths. The non-obstetric causes were one case each of intestinal obstruction, cerebral malaria and pneumonia. The most frequent causes of death were illegal abortion in nine, ruptured uterus in six and post partum haemorrhage (PPH) in three. Half of the deaths occurred within 24 hours of admission. The causes of maternal death are analyzed and possible preventive measures are suggested.
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PMID:Analysis of maternal deaths in Jima Hospital southwestern Ethiopia. 803 78

According to the World Health Organization, between 1980 and 1985 the total fertility rate was 2.0 in the wealthy countries and 4.1 in the less developed countries. The highest rate was found in Kenya with 8.1. The risk of maternal mortality in connection with pregnancy and childbirth was 1/10,000 in Northern Europe, but 1/21 in Africa. Every year about 500,000 women die because of complications before, during, or after delivery. The maternal mortality rate (30/100,000 live births in Europe) is still 500-800/100,000 in the developing countries, although Tanzania has succeeded in cutting its rate from 450/100,000 to 170/100,000. The main causes of maternal mortality are: 1) unrecognized obstructed labor, 2) postpartum bleeding that could be managed by massaging the uterus, administration of oxytocin or by the manual removal of the placenta, 3) postpartum infections that could be treated by timely administration of antibiotics, 4) preeclampsia that could be detected and treated, and 5) abortion complications requiring effective treatment. Among indirect causes of death is anemia: 66% of pregnant women in developing countries are anemic, compared to 14% in industrialized countries. So far the cause of the reduction of partial immunity against malaria parasites in primiparas has not been explained. A significant percentage of deaths (11-47%) can be traced to unqualified and negligent personnel, especially in the slums and rural areas. Only 52% of deliveries are attended by well-trained health personnel, although in 10% of pregnancies complications arise. Young age is another factor: in 1989 in Tanzania the first pregnancy occurred on the average at age 17.6 years compared to 27 years in England. In the beginning of the 1990s there were an estimated 3 million HIV-infected women, therefore maternal mortality as a consequence of AIDS is going to increase. In high prevalence areas the population growth rate will decline from 3% to 2.4%. Traditional birth attendants could be trained and used effectively to reduce maternal mortality by 3-11% as part of a functioning referral system.
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PMID:[Obstetrics in the Third World]. 811 19

This program evaluation pertains to a program initiated in 1990 for training of 18 traditional birth attendants (TBAs) from Fulani or Rimaibe villages in the department of Sebba in northern Burkina Faso. All were illiterate and most were another ethnic minority. Training was directed to performing safe birth procedures and the detection of high risk pregnancies. Techniques were taught for massaging the uterus in order to induce contractions, putting the baby to the breast immediately after delivery, and referral. Methods involved group discussions, practical demonstrations, and role playing. Pictorial cards were used for recording pregnancy information. TBAs received simple maternity kits. An ambulance was made available for emergency referral to the regional hospital. The area is served by two clinics and one medical center. Program evaluation occurred in 1992. Interviews were conducted among 17 TBAs, health service statistics were collected, and a health survey was conducted in the department (296 women of childbearing age from 21 villages). 397 deliveries occurred in the five years preceding the survey. 92% of deliveries were at either of the two clinics or at the Sebba medical center. 12% delivered without assistance. 39% had the assistance of a friend or relative. 24% had assistance from an older neighbor. 19% had assistance from untrained TBAs. 7% had health personnel assistance. TBAs were found to have retained most of the childbirth information, and 11 could correctly identify signs of high risk pregnancy. 14 correctly described hygienic practices. All 17 recognized chloroquine as an anti-malaria drug, and 12 knew the proper dosage of 3 tablets per week. Knowledge of postpartum hemorrhage was weak. The trained TBAs were seldom used in the two year period. Seven villages regularly used their services. Three correctly attended 35-50% of all births in their villages. 13 TBAs made a total of 36 referrals. Program success was not related to training activities or cultural obstacles. The entire health delivery system at the clinic level, the referral system, and health staff training rather than grass roots changes, were suggested improvements. Candidates for training should be selected more appropriately.
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PMID:Training birth attendants in the Sahel. 853 51

Chimeric simian/human immunodeficiency virus (SHIV) consists of the env, vpu, tat, and rev genes of human immunodeficiency virus type 1 (HIV-1) on a background of simian immunodeficiency virus (SIV). We derived a SHIV that caused CD4+ cell loss and AIDS in pig-tailed macaques (S. V. Joag, Z. Li, L. Foresman, E. B. Stephens, L. J. Zhao, I. Adany, D. M. Pinson, H. M. McClure, and O. Narayan, J. Virol. 70:3189-3197, 1996) and used a cell-free stock of this virus (SHIV(KU-1)) to inoculate macaques by the intravaginal route. Macaques developed high virus burdens and severe loss of CD4+ cells within 1 month, even when inoculated with only a single animal infectious dose of the virus by the intravaginal route. The infection was characterized by a burst of virus replication that peaked during the first week following intravenous inoculation and a week later in the intravaginally inoculated animals. Intravaginally inoculated animals died within 6 months, with CD4+ counts of <30/microl in peripheral blood, anemia, weight loss, and opportunistic infections (malaria, toxoplasmosis, cryptosporidiosis, and Pneumocystis carinii pneumonia). To evaluate the kinetics of virus spread, we inoculated macaques intravaginally and euthanized them after 2, 4, 7, and 15 days postinoculation. In situ hybridization and immunocytochemistry revealed cells expressing viral RNA and protein in the vagina, uterus, and pelvic and mesenteric lymph nodes in the macaque euthanized on day 2. By day 4, virus-infected cells had disseminated to the spleen and thymus, and by day 15, global elimination of CD4+ T cells was in full progress. Kinetics of viral replication and CD4+ loss were similar in an animal inoculated with pathogenic SHIV orally. This provides a sexual-transmission model of human AIDS that can be used to study the pathogenesis of mucosal infection and to evaluate the efficacy of vaccines and drugs directed against HIV-1.
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PMID:Animal model of mucosally transmitted human immunodeficiency virus type 1 disease: intravaginal and oral deposition of simian/human immunodeficiency virus in macaques results in systemic infection, elimination of CD4+ T cells, and AIDS. 909 79

In 1993, 2,008 deliveries were recorded at the Provincial Maternity Hospital at Franceville in Gabon. The frequency of cesarean section was 3%. The perinatal mortality of children born by cesaraean section was high, 213 per thousand. The principal indications for cesarean section were the baby being too large to pass through the pelvis, bicicatricial uterus, breech presentation and toxemia during pregnancy. The maternal mortality rate was 200 per 100,000, similar to the rates of most African countries, and 75% of the women that died had undergone cesarean section. The mortality rate for cesarean section was high (4.9%), so the indications for cesarean section in underdeveloped countries are limited. Malaria was the principal reason for the hospitalization of pregnant women, because it is endemic and is a serious condition for pregnant women. The next most frequent causes of hospitalization were a high risk of premature labor and hyperemesis gravidarum, the frequency of which is high among pregnant African women, particularly those of West Africa. Toxemia in pregnancy was the fourth most important cause of hospitalization. The rate of cesarean section rupture was 2.5 per thousand. Only 20% of these cases involved a cicatricial uterus, with no maternal deaths but a fetal mortality rate of 100%. The frequency of premature birth was 4.23% and the perinatal mortality rate was 48 per thousand, with 37 stillbirths per thousand and an early neonatal mortality rate of 11 per thousand. The perinatal mortality of breech presentations was high (330 per thousand), with 13.9 delivered by cesarean section. These levels are similar to those for other African countries. Maternal health could be improved by introducing several consultations during pregnancy, improving hospital hygiene and making antibiotics more widely available. Fetal survival could be improved by preventing premature births, providing more help with delivery, decreasing the time to intervention and improving neonatal resuscitation techniques.
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PMID:[Precarious situation of obstetric practice in Gabon]. 985 7


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