Disease burden due to pre-eclampsia/eclampsia and the Ethiopian health system's response

Pre-referral management of preeclampsia with severity features in a low-income country-characteristics and challenges in a Sub-Saharan setting: a mixed method study

BACKGROUND

Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting.

OBJECTIVE

To determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features.

STUDY DESIGN

We conducted a mixed method study on the pre-referral management of pregnant women complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who are complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20-30 minutes of semistructured, qualitative, face-to-face, in-depth interviews with 14 health professionals. Quantitative data were analyzed using SPSS (version 23), and simple descriptive statistics were employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data.

RESULTS

A total of 261 pregnant women who had preeclampsia with severity features were included in the study, and 14 care providers were interviewed about existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3 mm Hg and 100.3 mm Hg, respectively. The total perinatal mortality was 6.5% (17/261). Three of 261 mothers (1.1%) were complicated by intracranial hemorrhage, and other 1.1% (3/261) of other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulfate before referral. Similarly, antihypertensive medication was given only to 35 of 261 patients (13.4%) pre-referral. Eight of 261 mothers convulsed (3.1%) during referral. Two of 261 mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Similarly, another 2 of 261 (0.8%) women developed disseminated intravascular coagulation by the time of arrival from the referring health institution. On the basis of qualitative data analysis, 3 overarching themes were recognized: (1) challenges related to patient and family resistance, (2) Challenges related to healthcare providers' knowledge, skill, and confidence, and (3) health system-related challenges. Low use of magnesium sulfate and antihypertensive drugs, patient misperceptions regarding reasons for referral, providers' lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institutions, and nonexistence of uniform preeclampsia pre-referral and referral management protocols among the referring institutions were the identified gaps.

CONCLUSION

We found a significant gap in pre-referral management for patients with preeclampsia with severity features. Preeclampsia management policy reforms should include the introduction of adequate patient counseling platforms, increasing community awareness creation, providing in-service training on pre-referral management of preeclampsia for health personnel, ensuring constant availability of anticonvulsant and antihypertensive drugs and uniform implementation of preeclampsia pre-referral management protocols across health institutions.

Perinatal outcomes and their determinants among women with eclampsia and severe preeclampsia in selected tertiary hospitals, Eastern Ethiopia

BACKGROUND

Neonatal complications and deaths are still increasing worldwide. Therefore, this study aimed to assess perinatal outcomes and their determinants among women with eclampsia and severe preeclampsia admitted to selected tertiary hospitals Eastern Ethiopia.

METHODS

The prospective observational study was conducted among 245 foetal born to women with eclampsia and severe preeclampsia admitted to selected Hospitals. Data were collected from patients' charts and maternal interviews using questionnaires and telephone follow-ups from April 01 to September 30, 2022. Then, Cox regression were used to determine the predictors of perinatal clinical outcomes by SPSS (version 21.0®). Hazard ratios with a two-sided P-value < 0.05 were considered statistically significant.

RESULT

Of 245 deliveries, perinatal mortality was 26.1 % and about 57.4 % of newborns developed neonatal complications. Fifth-minute Apgar score (AHR: 10.3; 95 % C.I: 3.8-28.1; P: 0.0001) was statistically a determinant to perinatal mortality whereas maternal parity (AHR: 1.7; 95 % CI: 1.0-2.86; P: 0.05), maternal diagnosis (AHR: 2.1; 95 % C.I:1.17-3.66; P: 0.012), maternal complications (AHR: 1.96; 95 % C.I: 1.13-3.41; P: 0.018) and fifth-minute Apgar score (AHR: 2.0; 95 % C.I: 1.29-3.19; P: 0.002) were found to be determinants for neonatal complications.

CONCLUSION

Despite the inclusion of magnesium sulphate into the national drug list of Ethiopia to reduce maternal and perinatal morbidity and mortality, the perinatal condition remained a severe concern and worse among patients with eclampsia. Interventions to reduce the incidence of eclampsia, better antenatal care, early recognition, prompt treatment of severe preeclampsia, and enhanced neonatal care have to be initiated for patients.

Clinical features and outcomes of patients with preeclampsia and eclampsia at Gondar University hospital, Amhara, Ethiopia 2021

Objective

The aim of this study was to investigate the clinical features, and treatment outcome of women with preeclampsia and eclampsia at Gondar University Comprehensive Specialized Hospital in Amhara, Northern Ethiopia, in 2021.

Methods

An institutional-based retrospective chart review was conducted at Gondar University Specialized Hospital from March to June 2021. The study participants were chosen using a simple, systematic random sampling method. A pretested check list was used to collect data from medical records. The collected data was coded, entered into Epi-data version 4.6, and exported to SPSS version 26 for descriptive and inferential analysis. A Fisher's exact test was used to determine statistically significant factors at a p-value of < 0.05.

Results

Of the 311 study participants, more than half (53 %) of mothers have illiterate, nearly half (49.8 %) had preeclampsia with severe features. Eclampsia accounted for 18.6 % of females in the study setting. For various reasons, more than half of the mothers required immediate intervention to terminate the pregnancy via cesarean section. Unfavorable maternal outcomes were present in more than 25 % of cases; the observed unfavorable maternal outcomes were aspiration pneumonia (10.6 %), hemolytic elevated liver function test and low platelet count syndrome (8.7 %), and maternal death (0.6 %). The severity of the disease, mode of delivery, aspartate transaminase, gravidity, gestational age, and antenatal care were all statistically significant predictors of pregnancy outcome.

Conclusion

The prevalence of unfavorable maternal and perinatal outcomes of preeclampsia and eclampsia is considerable in the study area. To prevent these perinatal and postnatal effects, maternal outcomes of pregnancy, antenatal care services, emergency obstetrics, and new born care should be expanded and strengthened.

A mathematical model of vascular and hemodynamics changes in early and late forms of preeclampsia

Preeclampsia-eclampsia syndrome is a leading cause of maternal mortality. The precise etiology of preeclampsia is still not well-defined and different forms exist, including early and late forms or preeclampsia, which may arise via distinctly different mechanisms. Low-dose aspirin administered at the end of the first trimester in women identified as high risk has been shown to reduce the incidence of early, but not late, preeclampsia; however, current risk factors show only fair predictive capability. There is a pressing need to develop accurate descriptions for the different forms of preeclampsia. This paper presents 1D fluid, solid, growth, and remodeling models for pregnancies complicated with early and late forms of preeclampsia. Simulations affirm a broad set of literature results that early forms of preeclampsia are characterized by elevated uterine artery pulsatility index (UA-PI) and total peripheral resistance (TPR) and lower cardiac output (CO), with modestly increased mean arterial blood pressure (MAP) in the first half of pregnancy, with elevation of TPR and MAP beginning at 20 weeks. Conversely, late forms of preeclampsia are characterized by only slightly elevated UA-PI and normal pre-term TPR, and slightly elevated MAP and CO throughout pregnancy, with increased TPR and MAP beginning after 34 weeks. Results suggest that preexisting arterial stiffness may be elevated in women that develop both early forms and late forms of preeclampsia; however, data that verify these results are lacking in the literature. Pulse wave velocity increases in early- and late-preeclampsia, coincident with increases in blood pressure; however, these increases are mainly due to the strain-stiffening response of larger arteries, rather than arterial remodeling-derived changes in material properties. These simulations affirm that early forms of preeclampsia may be associated with abnormal placentation, whereas late forms may be more closely associated with preexisting maternal cardiovascular factors; simulations also highlight several critical gaps in available data.

International Academy of Perinatal Medicine (IAPM) guidelines for screening, prediction, prevention and management of pre-eclampsia to reduce maternal mortality in developing countries

Approximately 800 women die from pregnancy or childbirth-related complications around the world every day, 99% of which occur in developing countries. In majority of cases deaths are related to pre-eclampsia and eclampsia. The purpose of new adjusted and simplified IAPM guidelines is specifically lowering maternal mortality by decreasing preventable deaths in developing countries (particularly in remote rural areas) by using rather cheap medicines used to control chronic and gestational hypertension, prevent pre-eclampsia in high-risk pregnancies and treat severe pre-eclampsia and eclampsia. IAPM guidelines should be implemented and evaluated in each developing country respecting specific problems, needs and resources. It is of essential importance to: 1. Identify specific high-risk pregnancies, 2. Commence timely appropriate ASA and calcium supplementation, 3. Organize basic antenatal care and adequate referral of pregnancies with early onset of pre-eclampsia to the appropriate institutions and ensure induction of labour in well-equipped delivery facility for women with near-term and term pre-eclampsia 4. Ensure magnesium sulphate availability to prevent severe pre-eclampsia and eclampsia-related maternal deaths, and 5. Identify specific barriers for implementation of these guidelines and correct them accordingly. Only by systematic implementations of these guidelines, we may have a chance to decrease the mortality of pre-eclampsia an its complications as a killer number one of mothers in developing countries.

Fetomaternal Outcomes and Associated Factors among Mothers with Hypertensive Disorders of Pregnancy in Suhul Hospital, Northwest Tigray, Ethiopia

Background

Hypertensive disorder of pregnancy is the leading cause of maternal and perinatal morbidity and mortality worldwide and the second cause of maternal mortality in Ethiopia. The current study is aimed at assessing fetal-maternal outcomes and associated factors among mothers with hypertensive disorders of pregnancy complication at Suhul General Hospital, Northwest Tigray, Ethiopia, 2019. Methods:A hospital-based cross-sectional study was conducted from Oct. 1^st, 2019, to Nov. 30, 2019, at Suhul General Hospital women's chart assisted from July 1^st, 2014, to June 31^st, 2019. Charts were reviewed consecutively during five years, and data were collected using data abstraction format after ethical clearance was assured from the Institutional Review Board of Mekelle University College of Health Sciences. Data were entered into Epi-data 3.5.3 and exported to SPSS 22 for analysis. Bivariable and multivariable analyses were done to ascertain fetomaternal outcome predictors. Independent variables with p value < 0.2 for both perinatal and maternal on the bivariable analysis were entered in multivariable logistic regression analysis and the level of significance set at p value < 0.05.

Results

Out of 497 women, 328 (66%) of them were from rural districts, the mean age of the women was 25.94 ± 6.46, and 252 (50.7%) were para-one. The study revealed that 252 (50.3%) newborns of hypertensive mothers ended up with at least low Apgar score 204 (23.1%), low birth weight 183 (20.7%), preterm gestation 183 (20.7%), intensive care unit admissions 90 (10.2%), and 95% CI (46.1% -54.9%), and 267 (53.7%) study mothers also developed maternal complication at 95% (49.3-58.1). Being a teenager (AOR = 1.815: 95%CI = 1.057 − 3.117), antepartum-onset hypertensive disorders of pregnancy (AOR = 7.928: 95%CI = 2.967 − 21.183), intrapartum-onset hypertensive disorders of pregnancy (AOR = 4.693: 95%CI = 1.633 − 13.488), and low hemoglobin level (AOR = 1.704: 95%CI = 1.169 − 2.484) were maternal complication predictors; rural residence (AOR = 1.567: 95%CI = 1.100 − 2.429), antepartum-onset hypertensive disorders of pregnancy (AOR = 3.594: 95%, CI = 1.334 − 9.685), and intrapartum-onset hypertensive disorders of pregnancy (AOR = 3.856: 95%CI = 1.309 − 11.357) were predictors of perinatal complications.

Conclusions

Hypertensive disorder during pregnancy leads to poor fetomaternal outcomes. Teenage age and hemoglobin levels were predictors of maternal complication. A rural resident was the predictor of poor perinatal outcome. The onset of hypertensive disorders of pregnancy was both maternal and perinatal complication predictors. Quality antenatal care services and good maternal and childcare accompanied by skilled healthcare providers are essential for early detection and management of hypertensive disorder of pregnancy.

Evaluation of serum uric acid and liver function tests among pregnant women with and without preeclampsia at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Background

Pre-eclampsia can be described as new-onset hypertension (blood pressure ≥140/90 mmHg) together with proteinuria (24-hr urinary protein ≥ 0.3 g) or any indication of end-organ damage after 20 weeks of gestation. Liver and kidney dysfunction, thrombocytopenia, pulmonary edema, and neurologic dysfunction are common manifestations of end-organ damage due to pre-eclampsia. Pre-eclampsia is the most common cause of liver and kidney dysfunction due to hypoxia and endothelial dysfunction. Hyperuricemia indicates kidney dysfunction and is considered a predictor of the severity of preeclampsia. Therefore, the objective of this study is to evaluate the utility of the levels of serum uric acid and liver function tests [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)] as biomarkers of preeclampsia-related organ damage.

Methods and materials

An institutional-based comparative cross-sectional study design was conducted, and a total of 102 subjects (51 patients with preeclampsia and 51 normotensive pregnant women) were recruited. The parameters measured were levels of serum uric acid and liver function tests.

Results and discussion

There were statistically significant differences in the mean serum uric acid, ALT, and AST levels between preeclamptic pregnant women and normotensive pregnant women (p<0.05). There were no statistically significant differences in the mean total and direct bilirubin levels. There was also a significant difference in mean serum uric acid, alanine transaminase, and aspartate transaminase levels across different gestational age categories.

Conclusion

Our study revealed that serum uric acid, ALT, and AST levels were higher in pre-eclamptic pregnant women compared to those of normotensive pregnant women, and the differences were statistically significant. As such, serum uric acid and liver function tests may be considered biomarkers of pre-eclampsia-related end-organ damage.

Health Care Readiness in Management of Preeclampsia/Eclampsia in Ethiopia: Evidence from National Facility-Based Survey

Background

Early case detection, treatment, and timely referral for better services can significantly reduce the negative outcomes of preeclampsia and eclampsia. However, evidence on health facilities' readiness to provide such services and the associated challenges is limited in Ethiopia. Therefore, this study aimed to assess the readiness of Ethiopian health care facilities to manage preeclampsia and eclampsia.

Methods

This study used the 2016 Ethiopia national emergency management of obstetrics and newborn care (EmONC) survey. This survey was a national cross-sectional census of health facilities that provided delivery services. Data on facility infrastructure, equipment and supplies were collected through a facility checklist, and interview health provider experiences. Cross tabulation, summarisation and chi square tests by facility type, location, and management authority were conducted.

Results

There were 3804 health facilities included in the survey across all regions of Ethiopia. The majority of facilities (92%) were public/government managed with only 1% of available hospitals located in rural areas. Poor availability of dipsticks for proteinuria tests (55.3%), caesarean sections (7.9%), and ambulance services (18.4%) were reported across health facilities with high variations in terms of facility type, location, and type of managing authority. Diazepam was a widely available anticonvulsant compared with magnesium sulfate (MgSO₄), with more available in private for-profit facilities compared with public facilities. Nearly one third of health care providers were not trained to administer MgSO₄ intravenously. The result indicated that the chi-square test was statistically significant at P < 0.001.

Conclusions and Recommendations

There were notable gaps in readiness of facilities in detection and management of preeclampsia/eclampsia that increase maternal and perinatal mortality in Ethiopia. Therefore, availability of essential supplies, medications, and referrals are required. In addition, refresher training to healthcare providers on screening, diagnosis and management of preeclampsia/eclampsia and continuous supervision should be provided.

Effect of anesthesia choice on hemodynamic stability and fetomaternal outcome of the preeclamptic patient undergoing cesarean section

Background

The main aim of this study is to compare hemodynamic stability and feto-maternal outcome between general and spinal anesthesia in pre-eclampsia patients undergoing C/S.

Methods

A prospective cohort study was used with a calculated sample size of 266. Comparison of numerical variables between study groups was done using unpaired student t-test and Manny Whitney U test for symmetric and asymmetric data respectively. A P-value <0.05 considered significant.

Result

There is a comparable distribution of socio-demographic, obstetric variables, and baseline hemodynamic variables between groups. The change in a hemodynamic variable from baseline and during the first 24 h was also comparable between groups. The numbers of ICU admission were comparable between groups (8.03% vs. 10.41%, p = 0.549) in spinal and general anesthesia groups respectively. With regards to hospital stay patients in general anesthesia groups had longer hospital stay 5.92 days compared to 4.67 days in the spinal anesthesia group, with a statistically significant difference,(p = 0.024). The Spinal anesthesia group showed lower maternal mortality 2.6% compared to 14.8% in the general anesthesia group during the first 48th hour (p = 0.027). At the first 48 h only 7.14% of neonates in the spinal anesthesia group, and 16.6% o in the general anesthesia group had reported dead (p = 0.315).

Conclusion

Spinal anesthesia (SA) was alternative to general anesthesia regarding hemodynamic stability. Regarding maternal outcome, SA overall shows a better maternal outcome during the first 48 h. The numbers of ICU admission were comparable between groups. The SA group showed lower maternal mortality at the 48th hr.

•

Preeclampsia is a multisystem disorder characterized by new onset of hypertension.

•

Anesthetic management of pre-eclampsia patients remains a challenge.

•

Spinal anesthesia is alternative to general anesthesia for hemodynamic stability.

•

Spinal anesthesia group showed lower maternal mortality at the 48th hour.

Audit of Clinical Care for Women with Preeclampsia or Eclampsia and Perinatal Outcome in Ethiopia: Second National EmONC Survey

Background

Preeclampsia and eclampsia contribute to maternal and perinatal morbidity and mortality, especially in developing countries. However, the evidence on clinical practice in the management of preeclampsia/eclampsia and perinatal outcomes is limited. Therefore, the aim of this study was to assess clinical care and perinatal outcomes for women with preeclampsia/eclampsia admitted to health facilities in Ethiopia.

Methods

This study used the 2016 Emergency Obstetric and Newborn Care survey, which included 3804 health facilities. The last two cases of women with preeclampsia/eclampsia who were admitted for birth in each participating health facility were selected and their medical records were reviewed. Descriptive analyses by health facility type, location and management authority were conducted. A chi-squared test was used to test for differences.

Results

Out of the 3804 health-care facilities across the country, we could review a total of 959 medical records of women with preeclampsia or eclampsia. Of all cases, 90% (863) were hospitalised in public health facilities, 542 (56.6%) were admitted at health centre/clinics and 638 (66.3%) were in urban health facilities. A substantial proportion of maternal and newborn information was missing from their medical records. Of the 553 records that recorded perinatal outcomes, the proportion of perinatal mortality prior to discharge was 16.3% (95% CI: 13.4%, 19.6%). A significant perinatal death was recorded among mothers admitted to hospitals (P < 0.01), maternal age 15–24 (P < 0.04), facilities in urban areas (P < 0.01), referred cases (P < 0.007), high systolic and diastolic blood pressure (P < 0.001), unconscious and experience seizure (P < 0.001), newborn with morbidity (P < 0.001), and women who spent more hours before giving birth (P < 0.002).

Conclusions and Recommendations

High perinatal mortality in health facilities was reported and care toward mothers with preeclampsia/eclampsia was limited. Strengthening the health facility readiness to respond for management with data registration and reporting system needs to be improved for evidence-based decision-making on perinatal and maternal health.

Risk factors of preeclampsia among pregnant women admitted at labor ward of public hospitals, low income country of Ethiopia; case control study

BACKGROUND

Preeclampsia is a pregnancy-specific, multisystem disorder of unknown etiology, which characterized by new onset of high blood pressure & proteinuria after 20 weeks of gestation. Globally, it contributes 76,000 maternal deaths, 500,000 infant deaths annually, and the second common cause of maternal deaths. In Ethiopia, 19% of maternal deaths result from hypertensive disorder of Pregnancy.

OBJECTIVE

To assess the risk factors of preeclampsia among pregnant women admitted in labor ward of Public hospitals, Amhara Region Ethiopia, METHODS: A facility based unmatched case-control study design was conducted in two public hospitals of North Wollo Zone. Cases were pregnant women, who had confirmed diagnosis of preeclampsia, controls were those who had no evidence of preeclampsia, and 65 cases and 195 controls were selected by convenience and systematic random sampling techniques respectively. The collected data was interred in to in EPI INFO version 7.1, transferred, and analyzed using SPSS version 20.00 statistical software. Multivariate logistic regression was used to identify independent variables. Factors with P-value < 0.05 were taken as statistically significant of pre-eclampsia among pregnant women.

RESULT

All of the respondents of cases and controls were participated in the study. Factors associated with preeclampsia were respondents who had read and write (AOR = 3.22, 95% CI: (1.05-9.84)) and attended primary school [AOR = 7.02, 95% CI: (1.57-31.45)]. Those pregnant women, who had at least two ANC visit [AOR = 8.69, 95%CI: (1.43-52.85)] and those who had three visit [AOR = 12.59, 95%CI: (3.06-56.05)]. In addition to these, birth Interval less than 24 month [AOR = 4.09, 95% CI: (1.33-12.61)]. Birth Interval 24-35 month [AOR = 2.53, 95% CI: (1.38-11.87], respondents with family history of HPN (AOR = 5.93, 95%CI: (2.39-14.67), family history of DM [AOR = 2.15, 95%CI: (1.12-6.98)], and respondents with previous history of preeclampsia (AOR = 4.14 95%CI: (1.66-10.33) were identified significant factors of preeclampsia among pregnant women attended in labour ward.

CONCLUSION AND RECOMMENDATION

Educational status, antenatal care, lower birth interval, having family history of chronic HPN and DM, and history of preeclampsia were identified as major risk factors for occurrence of preeclampsia. Early detection of cases and intensive screening of pregnant women in every visit should be done and large-scale study will be done to identify other risk factors of preeclampsia.

Incidence and determinants of adverse outcomes among women who were managed for eclampsia in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Background

The incidence of eclampsia and its adverse maternal outcomes are very high in developing countries, particularly in Subsaharan African Countries. Identifying predictors for adverse maternal outcomes of eclampsia has paramount importance for helping health care providers to optimize their management outcomes. Therefore, this study aimed to assess the incidence of adverse maternal outcomes of eclampsia and its determinant factors.

Methods

A retrospective follow-up study design was applied. The data were extracted from patient charts using a structured, pre-tested, questionnaire. Descriptive analyses (frequencies, means, and standard deviation) were calculated, and bi-variable and multivariable logistic regression models were used to testing the association between independent variables and an outcome variable. After the data were coded and entered into Epi-Info Version 7.2 Software, the data were analyzed using STATA Version 14 Statistical Software.

Results

The magnitude of eclampsia was 5.36 per 1000 pregnancies (95% CI: 4.72, 6.10). The incidence of adverse maternal outcomes in eclamptic mothers was 53.7% (95% CI: 47.02, 60.24%). After adjusting for covariates maternal age 30–34, AOR 5.4 [95% CI = 1.02, 28.6]; age above 34, AOR 10.5 [95% CI = 1.3, 88.6]; gravidity 2–4, AOR 0.3 [95% CI = 0.1, 0.9]; 10 or more convulsions, AOR 4.6 [95% CI = 1.4, 14.9]; mild pyrexia, AOR 20.4 [95% CI = 3.7, 112.7]; moderate pyrexia, AOR 14.6 [95% CI = 1.7125.1]; platelet count below 50,000 cells/mm³, AOR 34.9 [95% CI = 3.6, 336.2]; platelet count between 50,000 and 99,000 cells/mm³, AOR 24.5 [95%CI = 5.4111.6]; and stillbirth of the current pregnancy, AOR 23.2 [95%CI = 2.1257.5] were strong predictors of adverse maternal outcomes in eclamptic mothers.

Conclusions

The incidence of adverse maternal outcomes of eclampsia was found to be high compared to similar studies discussed in this study. This study recommends early identification of patients with the risk factors (having many convulsions, high body temperature, low platelet count, patient age above 30 years, and 2–4 pregnancies), strengthening the referral system, and advocation of research on the area of adverse maternal outcomes and thereby encourage evidence-based medicine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04199-1.

Treatment Outcomes and Determinants of Eclampsia and Severe Preeclampsia Among Pregnant Women Admitted to Selected Tertiary Hospitals in Ethiopia: A Cohort Study

Background

Eclampsia contributes to 12% of all maternal deaths worldwide during pregnancy. Again, women with severe preeclampsia and eclampsia had a three to 25-fold increased risk of severe complications. Therefore, this study was aimed to determine treatment outcomes and determinants of eclampsia and severe preeclampsia among pregnant women admitted to selected tertiary hospitals.

Methods

A prospective cohort study was conducted on 217 women with eclampsia or severe preeclampsia from April 1 to October 30, 2019. Data were collected from patients' chart, questionnaire-based interviews at baseline and telephone interviews during follow-up. Then, the collected data were entered into EpiData 3.1 and exported to SPSS 21.0 for final analysis. Kaplan-Meier (log rank test) and Cox regression were employed to compare baseline survival experience and to adjust for the predictors of clinical outcomes, respectively.

Results

Of 217 women, 80.2% of them developed maternal complications, while nine (4.2%) women died. Determinant factors of maternal complications were linked with eclampsia case (AHR: 1.98; 95%CI: 1.28-3.06; P=0.002), lack of ANC follow-up (AHR: 1.75; 95%CI: 1.22-2.51; P=0.002), presence of maternal leukocytosis (AHR: 1.53; 95%CI: 1.12-2.09; P=0.008), elevated serum creatinine (AHR: 1.51; 95%CI: 1.05-2.17; P=0.02), and maternal age of 20-35 years (AHR: 0.61; 95%CI: 0.41-0.90; P=0.01).

Conclusion

Despite improved survival of women with preeclampsia/eclampsia, different complications that they experienced remained serious problems. We suggest strategies that comprise frequent ANC follow-up and check-up for women with leukocytosis and kidney impairment so as to optimally prevent and treat eclampsia and preeclampsia during pregnancy.

Knowledge and attitude of pregnant women towards preeclampsia and its associated factors in South Gondar Zone, Northwest Ethiopia: a multi-center facility-based cross-sectional study

BACKGROUND

Preeclampsia has the greatest impact on maternal mortality which complicates nearly a tenth of pregnancies worldwide. It is one of the top five maternal mortality causes and responsible for 16 % of direct maternal death in Ethiopia. Little is known about the level of knowledge and attitude towards preeclampsia in Ethiopia. This study was designed to assess the knowledge and attitude towards preeclampsia and its associated factors in South Gondar, Northwest Ethiopia.

METHODS

A multicenter facility-based cross-sectional study was implemented in four selected hospitals of South Gondar Zone among 423 pregnant women. Multistage random sampling and systematic random sampling techniques were used to select the study sites and the study participants respectively. Data were entered in EpiData version 3.1 while cleaned and analyzed by Statistical Package for Social Sciences (SPSS) version 23. Descriptive and inferential statistics were performed. Adjusted odds ratio with 95 % confidence interval were used to identify the significance of the association between the level of knowledge on preeclampsia and its predictors.

RESULTS

In this study, 118 (28.8 %), 120 (29.3 %) of the study participants had good knowledge and a positive attitude towards preeclampsia respectively. The likelihood of having good knowledge on preeclampsia was found to be low among women with no education (AOR = 0.22, 95 % CI (0.06, 0.85)), one antenatal care visit (ANC) (AOR = 0.13, 95 % CI (0.03, 0.59)). Whereas, those who booked for ANC in the first trimester (AOR = 6.59, 95 % CI (1.43, 30.33)), gave the last birth at a health facility (AOR = 2.61, 955 CI (1.03, 6.61)), and experienced a complication during previous births (AOR = 3.67, 95 % CI (1.78, 7.57)) were more likely to be knowledgeable on preeclampsia.

CONCLUSIONS

No formal education and not attending four ANC visits were associated with poor knowledge of preeclampsia. While participants who visited health facilities during the first trimester, who gave birth at health facilities, and those who experienced a complication in previous births were more likely to be knowledgeable on preeclampsia. Improving the numbers of ANC visits and encouraging facility delivery are important measures to improve women's knowledge on preeclampsia. Health education regarding preeclampsia risk factors, symptoms, and complications shall be emphasized.

Incidence and Predictors of Pre-Eclampsia Among Pregnant Women Attending Antenatal Care at Debre Markos Referral Hospital, North West Ethiopia: Prospective Cohort Study

Background

Pre-eclampsia is a pregnancy-induced hypertension that occurs after 20 weeks of gestation. It is the leading cause of maternal and perinatal morbidity and mortality globally, but it is higher in developing countries. In Ethiopia, conducting research on the incidence and predictors of pre-eclampsia is crucial due to the paucity of information.

Methods

A prospective cohort study was undertaken using 242 pregnant women between November 1, 2018 and March 30, 2019 at Debre Markos Referral Hospital. All eligible women who fulfilled the inclusion criteria were included in this study. Data were entered into the epic-data Version 4.2 and analyzed using the STATA Version 14.0 software. The Cox-proportional hazard regression model was fitted and Cox-Snell residual test was used to assess the goodness of fit. Pre-eclampsia free survival time was estimated using the Kaplan–Meier survival curve. Both bivariable and multivariable Cox-proportional hazard regression models were fitted to identify predictors of pre-eclampsia.

Results

The overall incidence rate of pre-eclampsia was 3.35 per 100 person-years. Having a pre-existing history of diabetes mellitus [AHR=2.7 (95% CI=1.43–8.81)], having a history of multiple pregnancy [AHR=3.4 (95% CI=2.8–6.9)] and being ≥35 years old age [AHR=2.5 (95% CI=1.42–3.54)] were the significant predictors of pre-eclampsia.

Conclusion

The incidence of pre-eclampsia was high in this study. Having (pre-existing diabetes and multiple pregnancy) and being ≥35 years old age were the significant predictors of pre-eclampsia. Inspiring pregnant women’s health-seeking behavior should provide a chance to diagnose pre-eclampsia early to prevent the medical complication of pre-eclampsia.

Integrating Calcium Into Antenatal Iron-Folic Acid Supplementation in Ethiopia: Women's Experiences, Perceptions of Acceptability, and Strategies to Support Calcium Supplement Adherence

Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.

Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia: A systematic review and meta-analysis

INTRODUCTION

Hypertensive disorder of pregnancy is the second commonest causes of maternal death globally. Different public health studies were conducted on hypertensive disorder of pregnancy which presented inconsistent result. Therefore, this systematic review and meta-analysis was commenced to summarize the findings conducted in several parts of the country and to generate the nationwide representative data on the prevalence and risk factors of hypertensive disorder of pregnancy in Ethiopia.

METHODS AND MATERIALS

Electronic databases such as PubMed, Scopus, Google Scholar, Hinari, and African Journals Online were searched for studies published in English up to March, 2020. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument and Newcastle-Ottawa Scale were used for data extraction and quality assessment of the included studies. The meta- regression analysis was computed at 95% CI to present the pooled prevalence and risk factors of hypertensive disorder of pregnancy.

RESULTS

Thirty four studies were included in this systematic review and meta-analysis. The pooled prevalence of hypertensive disorder of pregnancy and preeclampsia in Ethiopia were 6.82% (95% CI (5.90, 7.74)) and 4.74% (95% CI (3.99, 5.49)) respectively. Maternal age ≥35 years (Adjusted Odds Ratio (AOR): 2.91 (95% CI: 1.60, 5.26)), twin pregnancy (AOR: 3.04 (95% CI: 1.89, 4.87)), previous history of preeclampsia (AOR: 5.36 (95% CI: 3.37, 8.53)), family history of hypertension (AOR: 4.01 (95% CI: 2.65, 6.07)), family history of diabetes mellitus (AOR: 3.07 (95% CI: 1.66, 7.70)), body mass index ≥25 (AOR: 3.92 (95% CI: 1.82, 8.42)), alcohol consumption (AOR: 1.77 (95% CI: 1.11, 2.83)), urinary tract infection (AOR: 4.57 (95% CI: 3.47, 6.02)), lack of nutritional counseling during antenatal period (AOR: 4.87 (95% CI: 3.36, 7.06)), lack of fruits (AOR: 3.49 (95% CI: 2.29, 5.30)), and vegetables consumption (AOR: 2.94 (95% CI: 2.01, 4.31)) were the risk factors of hypertensive disorder of pregnancy in Ethiopia.

CONCLUSIONS

The pooled prevalence of hypertensive disorder of pregnancy is relatively higher compared with the previous reports. Maternal age ≥35 years, twin pregnancy, previous history of preeclampsia, family history of hypertension, family history of diabetes mellitus, body mass index ≥25, alcohol consumption, urinary tract infection, lack of fruits and vegetables during pregnancy were risk factors of hypertensive disorder of pregnancy. The governments and stakeholders should work to strengthen the antenatal care practice to include the possible risk factors of hypertensive disorders of pregnancy.

Perceptions of midwives on the quality of emergency obstetric care at hospitals in Ethiopia: A qualitative explanatory study

BACKGROUND

In Ethiopia, maternal mortality remains an important public health concern. High maternal mortality is attributed in part to the poor quality of obstetric care. This study was designed to investigate perceptions of midwives about the quality of emergency obstetric care provided at hospitals in the Harari region of Ethiopia.

METHODS

An explanatory qualitative study was conducted from December 2018 to February 2019 at public and private hospitals in the Harari region, Ethiopia. The data were obtained through in-depth interviews with 12 midwives working in maternity units. The interviewers took notes and audio-recorded the respondents' descriptions. Braun and Clarke's thematic analysis method was employed to analyse the data using Nvivo 12 qualitative data analysis software.

RESULTS

Poorly designed infrastructure, including a scarcity of beds, rooms and ambulances challenged the provision of quality obstetric services. Midwives working at hospitals were inadequate in number and training opportunities were scarce. Language barriers affected effective communication between patients and caregivers. Frequent disruptions to medical supplies resulted in the provision of suboptimal obstetric care as it created an inability to provide appropriate medications. A lack of treatment protocols, poor supportive supervision, and poor staff motivation impaired the provision of quality obstetric care at hospitals, although disparities were observed among hospitals in this regard.

CONCLUSIONS

Several interdependent factors limited the quality of emergency obstetric care at hospitals in the region. Quality improvement initiatives and equitable resource distribution for hospitals need to be enhanced while the existing health infrastructure, resources and service delivery management need to be strengthened.

Feto-maternal outcomes of hypertensive disorders of pregnancy in Yekatit-12 Teaching Hospital, Addis Ababa: a retrospective study

BACKGROUND

In resource poor countries, hypertensive disorders of pregnancy are common and form one of the deadly triads, along with hemorrhage and infection, which contribute greatly to maternal and fetal jeopardy.

METHODS

The aim of this study was to assess the prevalence of hypertensive disorders of pregnancy, and determine the effects of hypertensive disorders of pregnancy on the feto-maternal outcomes. It was a descriptive, cross-sectional, retrospective study on randomly selected 615 women who attended delivery at Yekatit-12 Teaching Hospital from 1st of July 2017 -1st of Jan 2018. Data was analyzed using SPSS version 20 software. Descriptive statistics were used to calculate rates. Chi-square statistics were used to estimate the associations among selected predictor variables. A p-value < 0.05 was taken as statistically significant.

RESULTS

Out of the 615 study population, the prevalence of hypertensive disorders of pregnancy was found to be 25.4%, of which the majority (52.5%) was severe pre-eclampsia. Eclampsia accounted for 2.6%, and superimposed pre-eclampsia was 2.6%. The rate of severe pre-eclampsia with HELLP syndrome was 7.1% of all mothers with the hypertensive disorders. The majority of mothers with hypertensive disorders (59.6%) had age range of 25-34 years. About 46% of mothers required interventions to terminate the pregnancy either by cesarean section (42.3%) or instrumental deliveries (3.7%) due to conditions related to Hypertensive disorders. The rate of preterm, low birth weight, and low Apgar at 1st and 5thminutes accounted for 29.5, 24.4, 22.4 and 16.7% of neonates born to mothers with hypertensive disorders, respectively. Over 10.9% of neonates required resuscitation and 11.5% NICU referral. The rate of still birth was 3.8%.

CONCLUSION

The prevalence of hypertensive disorders of pregnancy is high in the study area and complicates maternal and fetal outcomes of the pregnancy. To deter its detrimental effects both on fetal and maternal outcomes of pregnancy, antenatal surveillance should be expanded to enable early detection, stringent follow-up and timely intervention in severely affected pregnancies.

Maternal and perinatal outcome of preeclampsia without severe feature among pregnant women managed at a tertiary referral hospital in urban Ethiopia

BACKGROUND

Preeclampsia refers to the new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman. Pregnant women with preeclampsia are at an increased risk of adverse maternal, fetal and neonatal complications. The objective of the study is, therefore, to determine the maternal and perinatal outcome of preeclampsia without severity feature among women managed at a tertiary referral hospital in urban Ethiopia.

METHODS

A hospital-based prospective observational study was conducted to evaluate the maternal and perinatal outcome of pregnant women who were on expectant management with the diagnosis of preeclampsia without severe feature at a referral hospital in urban Ethiopia from August 2018 to January 2019.

RESULTS

There were a total of 5400 deliveries during the study period, among which 164 (3%) women were diagnosed with preeclampsia without severe features. Fifty-one (31.1%) patients with preeclampsia without severe features presented at a gestational age between 28 to 33 weeks plus six days, while 113 (68.9%) presented at a gestational age between 34 weeks to 36 weeks. Fifty-two (31.7%) women had maternal complication of which, 32 (19.5%) progressed to preeclampsia with severe feature Those patients with early onset of preeclampsia without severe feature were 5.22 and 25.9 times more likely to develop maternal and perinatal complication respectively compared to late-onset after 34 weeks with P-value of <0.0001, (95% CI 2.01-13.6) and <0.0001(95% CI 5.75-115.6) respectively.

CONCLUSION

In a setting where home-based self-care is poor expectant outpatient management of preeclampsia without severe features with a once per week visit is not adequate. It's associated with an increased risk of maternal and perinatal morbidity and mortality. Our findings call for special consideration and close surveillance of those women with early-onset diseases.

Awareness of pregnancy induced hypertension among pregnant women in Tigray Regional State, Ethiopia

Introduction

Pregnancy-induced hypertension is among the leading cause of maternal mortality in Tigray regional state, Ethiopia. However, there was no study in this study area about awareness of pregnancy induced hypertension among pregnant women. Therefore, the aim of this study was to assess awareness of pregnancy induced hypertension among pregnant women.

Methods

A cross-sectional study design was conducted on a total of 798 pregnant women attending antenatal care in general hospitals of Tigray Regional State. Data were collected from February to November 30, 2018. Binary logistic regression analysis was used to determine factors associated with poor awareness and p-values < 0.05 was considered as statistically significant.

Results

A total of 792 pregnant women were included in this study with a response rate of 99.2%. In this study, 41.8% of pregnant women were having poor awareness of pregnancy-induced hypertension. Primigravida, women with no formal education, women with the lowest wealth status and occupation of a housewife were significantly associated with poor awareness. Additionally, there was a significant difference in the mean score of awareness of pregnancy-induced hypertension between normotensive women and women with pregnancy-induced hypertension (Mean score difference (95% CI) = 1.90(1.35, 2.45), t = 6.75, df = 790, p < 0.001)).

Conclusion

A high proportion of pregnant women had poor awareness on pregnancy-induced hypertension. Health care providers should improve awareness of pregnant women about pregnancy-induced hypertension in antenatal care clinics and at a community level with a special focus of awareness on primigravida women, women with no formal education, women with lowest wealth status and housewives.

Cohabitation duration, obstetric, behavioral and nutritional factors predict preeclampsia among nulliparous women in West Amhara Zones of Ethiopia: Age matched case control study

BACKGROUND

Preeclampsia is a major cause of maternal and perinatal mortality in developing countries. Identifying its risk factors is essential for early diagnosis and management. However, there has been a paucity of information on predictors of preeclampsia among nulliparous women in a resource limited setting. This study bridges the gap in this regard by examining the association of cohabitation duration, obstetric, behavioral and nutrition factors with preeclampsia among nulliparous women in West Amhara Zones of Ethiopia.

METHODS

Age matched case-control study design was employed among 110 preeclamptic and 220 non-preeclamptic women who came for delivery services at Felege Hiwot, Addis Alem, and Debre Tabor hospitals. Double population proportion formula with an assumption of 95% confidence interval, 80% power and a 2:1 control to case ratio was used to calculate sample size. Epi data 3.1 and SPSS 20 were used for data entry and analysis, respectively. Magnitudes of cohabitation duration, obstetric, behavioral and nutritional factors among nulliparous women with preeclampsia and their controls were calculated and the differences were tested with a Chi-square test. Conditional bivariable and multivariable logistic regression analysis were fitted to identify predictors of preeclampsia. Odds ratio along with their 95% confidence interval were used to identify the strength, direction and significance of association. Ethical clearance was secured from the research ethics committee of the School of Public Health in Addis Ababa University.

RESULTS

A total of 107 cases and 214 controls completed the interview giving a response rate of 97.27% for both cases and controls. Short cohabitation duration (AOR = 2.13, 95% CI (1.10, 4.1)), unplanned pregnancy (AOR = 2.35, 95% CI (1.01, 5.52)), and high body weight (AOR = 2.00, 95% CI (1.10, 3.63)) were found to be significant risk factors for preeclampsia. Whereas, antenatal advice about nutrition (AOR = 0.52, 95% CI (0.29, 0.96)), vegetable intake (AOR = 0.42, 95% CI (0.22, 0.82)) and fruit intake during pregnancy (AOR = 0.45, 95% CI (0.24, 0.87)) were protective factors for preeclampsia.

CONCLUSION

Special attention should be given to nulliparous women with short cohabitation duration, unplanned pregnancy, and high body weight to minimize the effect of preeclampsia. Nutritional counseling shall be stressed during antenatal care follow ups.

Prevalence of hypertensive disorders of pregnancy and pregnancy outcomes in Sub-Saharan Africa: A systematic review and meta-analysis

Hypertensive disorders of pregnancy are one of the leading causes of poor pregnancy outcomes and are associated with increased rates of maternal mortality, preterm birth, small for gestational age newborns, stillbirth, and neonatal death. The overall and type-specific prevalence of hypertensive disorders of pregnancy and associated pregnancy outcomes are unknown in Sub-Saharan Africa. Therefore, this review aimed to identify the prevalence of hypertensive disorders of pregnancy and associated pregnancy outcomes in Sub-Saharan Africa. A systematic review and meta-analysis were conducted on observational facility-based studies irrespective of publication status, sample size, language, and follow-up duration from 19 countries between the years 2000 and 2018 in Sub-Saharan Africa. A review of studies using PubMed, EMBASE, African Index Medicus, and African Journals Online was completed with independent extraction of studies by review authors using the predefined inclusion criteria. Quality and risk of bias of individual studies were assessed using the Joanna Briggs Institute Checklist. Random effects model was used to estimate the pooled prevalence of hypertensive disorders of pregnancy and type-specific hypertensive disorders of pregnancy. A pooled adjusted odds ratio with 95% confidence interval for each study was calculated using comprehensive meta-analysis version 2 software to estimate the association of hypertensive disorders of pregnancy and its outcomes. The existence of heterogeneity was assessed using I2 and its corresponding P value. We assessed the presence of publication bias using the Egger's test. Subgroup analysis was performed to assess the potential effect of variables, and a sensitivity analysis was conducted to assess any undue influence from studies. The analysis included 70 studies. The pooled prevalence of hypertensive disorders of pregnancy (all types combined), chronic hypertension, gestational hypertension, preeclampsia, and eclampsia were 8% (95% confidence interval = [5, 10]), 0.9% (95% confidence interval = [0.4, 1.8]), 4.1% (95% confidence interval = [2.4, 7]), 4.1% (95% confidence interval = [3.2, 5.1]), and 1.5% (95% confidence interval = [1, 2]), respectively. Compared with normotensive pregnant or postpartum women, women with hypertensive disorders of pregnancy were associated with increased risk of maternal mortality, odds ratio = 17 (95% confidence interval = [9.6, 28.8]); cesarean section, odds ratio = 3.1 (95% confidence interval = [1.7, 5.6]); perinatal mortality, odds ratio = 8.2 (95% confidence interval = [2.8, 24]); low birth weight, odds ratio = 3.2 (95% confidence interval = [2, 5]); and preterm delivery, odds ratio = 7.8 (95% confidence interval = [2.5, 25.3]) according to this analysis. The pooled prevalence of hypertensive disorders of pregnancy was high in Sub-Saharan Africa compared to those reported from other regions. Pregnant or postpartum women with hypertensive disorders of pregnancy have increased risk of maternal mortality, cesarean section, preterm delivery, perinatal mortality, and low birth weight newborn. Therefore, creating awareness of the risks of hypertensive disorders of pregnancy is essential. Pregnant women with hypertensive disorders need due attention to manage appropriately and more importantly to have favorable outcomes in this population.

Incidence of maternal near miss among women in labour admitted to hospitals in Ethiopia

OBJECTIVES

To assess the incidence of maternal near miss and contributing factors among hospitals in Ethiopia. The study also assessed the ability of hospitals to provide signal functions of emergency obstetric care and its regional distribution.

DESIGN

A national dataset accessed from the Ethiopian Public Health Institute were analysed to assess the incidence of maternal near miss and mortality index among women admitted to hospitals with obstetric complications.

SETTING

Maternal health indicators including obstetric complications, maternal deaths and births conducted at all hospitals available in Ethiopia were included.

MEASUREMENTS

The maternal near miss incidence ratio, which is the number of near miss cases per 1,000 live births, and the mortality index were presented descriptively. Chi-squared test at p value ≤ 0.05 was used to assess the presence of significant regional differences of the provision of signal functions of emergency obstetric care.

RESULTS

In 2015, 78,195 women were admitted to hospitals with both the direct (68,002) and indirect (10,193) causes of maternal mortality. Of women who experienced the direct causes, 435 died which means there were 67,567 maternal near miss cases. In the same year, 323,824 live births were reported in hospitals, making the crude maternal near miss incidence ratio of 20.8% (9.1-38.8%) and mortality index of 0.64% (435/68,002) for the direct causes of maternal mortality. A significant regional variation was observed with regard to incidence of maternal near miss, mortality index and the provision of signal functions of emergency obstetric care. Administration of parenteral antibiotics was the most frequently practiced signal function of emergency obstetric care while blood transfusion was the least provided signal function.

CONCLUSIONS

In Ethiopian hospitals, the incidence of maternal near miss was unacceptably high. A significant regional variation was detected with regard to maternal near miss incidence ratio, mortality index and the provision of signal functions of emergency obstetric care. The Ethiopian government needs to work on equitable resource distribution and quality improvement initiatives in order to close the detected regional variations.

IMPLICATIONS FOR PRACTICE

The Ethiopian government needs to practice evidence-based maternal health strategies, including capacity building of the regional hospitals in order to improve the distribution of resources and quality of maternal health.

Prevalence and associated factors of pre-eclampsia among pregnant women attending anti-natal care at Mettu Karl referal hospital, Ethiopia: cross-sectional study

Background

Preeclampsia is leading causes of maternal and perinatal morbidity and mortality worldwide and it is a hypertensive disorder which usually occurs after 20 weeks of gestation. In Ethiopia, according to Ethiopian National Emergency Obstetric and Newborn Care about 10% of all maternal mortality (direct and indirect) were due to preeclampsia. Despite this condition has adverse effects on the maternal and child health, its prevalence is still significant especially in developing countries including Ethiopia.

Objectives

The aim of the study is to assess the prevalence and associated factors of preeclampsia among pregnant women attending antenatal care at Mettu Karl referral hospital.

Method

The study was conducted at Mettu Karl referral hospital using institutional based cross sectional study design among women whose age was greater or equal to eighteen from March to April 2018. Data were collected from 129 participants by face to face interview technique using structured and pretested questionnaire. Logistic regression analysis was used to identify the factors associated with preeclampsia development.

Result

A total of 129 participants were enrolled in the study with the mean age of 25.87 [SD ± 4.757]. Prevalence of preeclampsia among the current pregnant women who attend ANC in Mettu Karl Hospital were 16 (12.4%) with 95% CI (7, 18). Predictor variables like respondents age (AOR = .009, 95% CI = [.000, .317]), current multiple pregnancy (AOR = .071, 95% CI = [.007, .773]) and history of diabetes mellitus (AOR = .058, 95% CI = [.007–.465]) were significantly associated with the current preeclampsia.

Conclusion

The finding of this study showed that a considerable proportion of women had preeclampsia. Health seeking behavior towards pregnant women’s should be encouraged for both urban and rural residents, which provide a chance to diagnose preeclampsia as early as possible and to prevent the coming complication towards preeclampsia.

Point of care ultrasound: does the presence of ascites in severe pre-eclampsia correlate with poor maternal and neonatal outcome?

OBJECTIVE

Ascites in severe pre-eclampsia may impact foetal and maternal outcomes. The objective was to determine the prevalence of ascites in women with severe pre-eclampsia by point of care (POC) ultrasound and to determine whether it correlates with higher perinatal risks.

METHODS

Prospective cohort study of patients admitted with severe pre-eclampsia at 2 teaching hospitals in Kigali, Rwanda. Serial POC ultrasound was performed to document ascites. Patients were stratified by the presence of ascites in perinatal period. Maternal demographics and complications were recorded and compared between groups.

RESULTS

There were 112 patients with severe pre-eclampsia, and ascites was found in 53.5% (76.7% antepartum, and 23.3% postpartum). Antepartum ascites correlated with an earlier delivery (32.2 ± 0.51 vs. 33.8 ± 0.47 weeks, P = 0.022) as well as lower birthweight (1587.3 ± 77.03 vs. 2011.6 ± 103.5 g, P = 0.002). Antepartum ascites was associated with higher stillbirth rates (P = 0.034) and NICU admission (87.2% vs. 68%, P = 0.034). Maternal hospital stay was increased in the ascites group (P < 0.0001).

CONCLUSIONS

Ascites is common in severe pre-eclampsia in Rwanda and maybe a prognosticator for poor outcomes. A larger sample is necessary to determine whether ascites is independently associated with maternal morbidity and mortality and whether documenting its presence aids in the management of the foetus and mother.

Perinatal outcomes of severe preeclampsia/eclampsia and associated factors among mothers admitted in Amhara Region referral hospitals, North West Ethiopia, 2018

Objective

This study was aimed to assess perinatal outcomes of severe preeclampsia/eclampsia and associated factors among mothers admitted in Amhara Region referral hospitals, North West Ethiopia, 2018.

Results

This study revealed that the overall prevalence of unfavorable perinatal outcome from the severe preeclamptic/eclamptic mothers was 46.5%. It shows that the finding of unfavorable perinatal outcome was high which needs an obligation to put our recommendation as improvement of health care set ups for preventions as well as interventions of such problems. Variables which were positively associated with unfavorable perinatal outcomes were: maternal educational status (AOR = 6.6, 95% CI 1.32, 10.03), parity (AOR = 8.3, 95% CI 6.27, 27.02), gestational age in weeks (AOR = 9.6, 95% CI 2, 18.65) and time of drug given for the mother (AOR = 3.8, 95% CI 1.81, 8.07).

Comparing the Effect of Spinal and General Anaesthesia for Pre-Eclamptic Mothers Who Underwent Caesarean Delivery in A Tertiary, Addis Ababa, Ethiopia

Background

Opinions are controversial regarding the use of general and spinal anesthesia in pre-eclamptic mothers undergoing Caesarean section. Some studies recommended avoiding spinal anesthesia in pre-eclamptic patients because of concern for sudden severe hypotension, while other studies support the use of spinal anesthesia as first choice reasoning less post-operative morbidity and mortality. This study aims to compare maternal outcome among pre-eclamptic women undergone caesarian delivery under general and spinal anesthesia.

Methods and Patients

A retrospective comparative cross-sectional study was conducted to compare maternal outcome. All pre-eclamptic mothers who underwent Caesarian section in Black Lion Specialized Hospital from October 2014 to October 2016 were included in the study. Data entry and analysis were conducted using SPSS version 20. Student's T-test was used to compare the outcome in both groups and p value < 0.05 was set as cut off point for statistical significance.

Results

A total of 170 client documents were reviewed. The mean age of the study subjects was 28.18 ± 4.66 years, with median age 28 years (IQR: 25–30). Our study shows that both general and spinal anesthesia have no difference in terms of maternal survival status, days of hospital stay, post-operative admission to ICU, and post-operative complications. However, this study found a statistically significant higher post-operative blood pressure and pulse rate among general anesthesia groups compared with spinal anesthesia group.

Conclusion

Spinal anesthesia is safer than general anesthesia in terms of stable vital signs among pre-eclamptic women undergoing Cesarean section.

Risk factors for hypertensive disorders of pregnancy among mothers in Tigray region, Ethiopia: matched case-control study

BACKGROUND

Hypertensive disorders of pregnancy are a global public health concern both in developed and developing countries. However, evidences regarding the risk factors of hypertensive disorders of pregnancy are limited particularly in Ethiopia. The aim of the study was to assess risk factors associated with hypertensive disorders of pregnancy among mothers in public hospitals of Tigray.

METHODS

The study was conducted in seven public hospitals of Tigray region, Ethiopia from June 2017 to November 2017. A facility based matched case-control study was employed to select 110 cases and 220 controls who were pregnant women. Cases and controls were matched by parity status. A case was a mother diagnosed to have hypertensive disorders of pregnancy by an obstetrician in the antenatal period while a control was a mother who did not have a diagnosis of hypertensive disorders of pregnancy. Data were collected by face to face interview technique using a pretested questionnaire and a checklist. Conditional logistic regression analysis was used to identify the independent predictor variables. Adjusted matched odds ratio with its corresponding 95% confidence interval was used and significance was claimed at P-value less than 0.05. Overall findings were presented in texts and tables.

RESULTS

Rural residents were at greater odds of suffering from hypertensive disorders (OR = 3.7, 95% CI; 1.9, 7.1). Similarly, mothers who consume less amount of fruits in their diet had 5 times higher odds of developing hypertensive disorders than those who consume fruits regularly (OR = 5.1, 95% CI; 2.4, 11.15). Overweight (BMI > 25 Kg/m2) mothers were also at risk of developing hypertensive disorders of pregnancy as compared with the normal and underweight mothers (AOR = 5.5 95% CI; 1.12, 27.6). The risk of developing hypertensive disorders of pregnancy was 5.4 times higher among diabetic mothers.

CONCLUSION

Rural residence, less fruit consumption, multiple pregnancy, presence of gestational diabetes mellitus and pre-pregnancy overweight were identified as independent risk factors in this study. It is recommended that health care givers may use these factors as a screening tool for the prediction, early diagnoses as well as timely interventions of hypertensive disorders of pregnancy.

Applying international guidelines for calcium supplementation to prevent pre-eclampsia: simulation of recommended dosages suggests risk of excess intake in Ethiopia

OBJECTIVE

To simulate impact of Ca supplementation on estimated total Ca intakes among women in a population with low dietary Ca intakes, using WHO recommendations: 1·5-2·0 g elemental Ca/d during pregnancy to prevent pre-eclampsia.

DESIGN

Single cross-sectional 24 h dietary recall data were adjusted using IMAPP software to simulate proportions of women who would meet or exceed the Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL) assuming full or partial adherence to WHO guidelines.

SETTING

Nationally and regionally representative data, Ethiopia's 'lean' season 2011.

SUBJECTS

Women 15-45 years (n 7908, of whom 492 pregnant).

RESULTS

National mean usual Ca intake was 501 (sd 244) mg/d. Approximately 89, 91 and 96 % of all women, pregnant women and 15-18 years, respectively, had dietary Ca intakes below the EAR. Simulating 100 % adherence to 1·0, 1·5 and 2·0 g/d estimated nearly all women (>99 %) would meet the EAR, regardless of dosage. Nationally, supplementation with 1·5 and 2·0 g/d would result in intake exceeding the UL in 3·7 and 43·2 % of women, respectively, while at 1·0 g/d those exceeding the UL would be <1 % (0·74 %) except in one region (4·95 %).

CONCLUSIONS

Most Ethiopian women consume insufficient Ca, increasing risk of pre-eclampsia. Providing Ca supplements of 1·5-2·0 g/d could result in high proportions of women exceeding the UL, while universal consumption of 1·0 g/d would meet requirements with minimal risk of excess. Appropriately tested screening tools could identify and reduce risk to high Ca consumers. Research on minimum effective Ca supplementation to prevent pre-eclampsia is also needed to determine whether lower doses could be recommended.

Prevalence of hypertensive disorders of pregnancy in Ethiopia: a systemic review and meta-analysis

BACKGROUND

Although hypertensive disorders of pregnancy are the leading cause of poor perinatal outcomes in Ethiopia, there is no study that shows the national prevalence. Therefore, the aim of this study was to estimate the national pooled prevalence of hypertensive disorders of pregnancy from studies conducted in different parts of the country.

METHODS

Databases; MEDLINE, PubMed, HINARI, EMBASE, Google Scholar and African Journals Online were searched by using different search terms on HDP and Ethiopia. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument was used for critical appraisal of studies. The analysis was done using STATA 14 software. The Cochran Q test and I2 test statistics were used to test heterogeneity of studies. Egger's test was used to show the publication bias. The pooled prevalence of HDP and the odds ratio (OR) with 95% confidence interval was presented using forest plots.

RESULT

Seventeen studies were included in this review, with a total of 258,602 pregnant women. The overall pooled prevalence of hypertensive disorders of pregnancy in Ethiopia was 6.07% (95% CI: 4.83%, 7.31%). The Subgroup analysis by region and year of study showed a higher prevalence of hypertensive disorders of pregnancy in Southern Nations, Nationalities, and Peoples' Region, 10.13% (95% CI = (8.5, 12.43)), and reduction in the rate of HDP from 1990's to 2010's, 8.54% reducing to 5.71% respectively. The pooled prevalence of pregnancy-induced hypertension (PIH) and preeclampsia/eclampsia alone were 6.29 and 5.47 respectively. Pregnant women ≥ 35 years old are more likely to develop hypertensive disorders of pregnancy, OR = 1.64 (95% CI = (1.18, 2.28)). No statistically significant difference was observed between HDP and younger maternal age (less than 20 years old); OR = 2.92 (95% CI = (0.88, 9.70)). There was no association between hypertensive disorders of pregnancy and number of pregnancy, OR = 1.37 (95% CI = 0.78, 2.41)).

CONCLUSIONS

The prevalence of hypertensive disorders of pregnancy is high in Ethiopia. The problem is more common among older pregnant women (> 35 years old). Government and other stakeholders should give due attention to an early screening of hypertension during pregnancy.

A one year review of eclampsia in an Ethiopian Tertiary Care Center (Saint Paul's Hospital Millennium Medical College, SPHMMC)

Eclampsia remains one of the five major causes of maternal mortality in developing countries. Advances in diagnosis and management have led to a significant reduction in maternal mortality and morbidity from this disease in developed countries. In developing countries the incidence of maternal death attributed to eclampsia remains high and, in Ethiopia, maternal mortality from this complication has instead risen over the last decade. The purpose of this study was to review the incidence of eclampsia at the largest feto-maternal center in the country over 1 year in an attempt to determine what quality improvement measures are needed and could realistically be implemented within the system to decrease this complication. There were a total of 104 eclamptic patients during the study period. The hospital incidence of eclampsia was 82/10,000 deliveries excluding those arriving to the hospital in the postpartum period (28 cases). There were eight maternal deaths making the case fatality rate one in 13 cases. The median convulsion to arrival time, referral to arrival time and magnesium sulphate administration time were found to be 3, 2 and 3 h, respectively. The probability of multiple seizures (≥3 episodes) was increased significantly with the prolongation of these time variables. Occurrence of multiple seizures was in turn significantly associated with adverse maternal outcomes (ICU admission, morbidities and mortalities). As expected, there was a high incidence of eclampsia and eclampsia related maternal death in the hospital. We recommend a thorough assessment of the referral system, upgrading and capacity building of more health facilities, organizing trainings and drills in health facilities; and availing magnesium sulphate in all health centers among others.

Prodromal symptoms, health care seeking in response to symptoms and associated factors in eclamptic patients

BACKGROUND

Eclampsia is one of the leading causes of maternal death worldwide. Maternal catastrophe is made worse in developing countries by the high incidence coupled with delayed presentation of patients and health facility constraints in effective management of eclampsia and its complications.

METHODS

A prospective study of all 93 eclamptic women admitted to a general hospital in Somali regional state, Ethiopia was conducted between May 1, 2014 and April 30, 2015 using a structured questionnaire which included socio-demographic data, antenatal visit status, distance of nearest maternal health facility, timing of convulsions, questions related to symptoms preceding seizures; health care seeking for the symptoms and time interval from prodromal symptoms to the diagnosis of eclampsia. Descriptive statistics and multivariable logistic regression analyses were conducted. Statistical tests were done at a level of significance of P < 0.05.

RESULTS

There were 93 cases of eclampsia among 3500 deliveries with an incidence of 2.7%. The timing of Eclampsia was antepartum in 57 (61.3%); intrapartum in 26 (28.0%) and postpartum in 10 (10.7%). Most (63%) were not having any antenatal care (ANC) follow up. Precedent symptoms were reported in 73 (79.0%) of the mothers with severe head ache in 70 (75.0%); visual disturbance in 44 (47%) and epigastric pain in 17 (18.0%). The frequency of symptoms was not influenced by the timing of eclampsia and degree of hypertension and prodromal symptoms were reported in 80% of the patients with severe hypertension. The mean duration of prodromal symptoms before patients were diagnosed with eclampsia was 5.5 days. Only 19/73 (26.0%) of the patients with prodromal symptoms visited a health facility for their complaints prior to developing eclampsia. The diagnosis of hypertensive disorder of pregnancy was made in 8 (42.0%) of these patients. Independent predictors of failure to seek health care in response to preceding symptoms were: rural residence (p-value < 0.001) and distance of maternal health facility of > 5km (p-value < 0.01).

CONCLUSIONS

Precedent symptoms were reported in most women. But many patients present late in response to these warning signs of eclampsia. Improving awareness of prodromal symptoms of eclampsia and timely health care seeking; providing ANC advises on danger signs of eclampsia in the socio-cultural context of the community; ensuring access to ANC services for rural mothers, and administration of anticonvulsants for all women with prodromal symptoms are recommended.

Trends of preeclampsia/eclampsia and maternal and neonatal outcomes among women delivering in addis ababa selected government hospitals, Ethiopia: a retrospective cross-sectional study

INTRODUCTION

The burden of preeclampsia has been a major concern worldwide, particularly in developing countries such as Ethiopia. Preeclampsia is associated with substantial maternal complications, both acute and long-term. The aim of this research was to determine the magnitude and trends of preeclampsia/ eclampsia, maternal complications, and neonatal complications among women delivering babies at selected government hospitals in Ethiopia.

METHODS

Data were collected retrospectively by reviewing the five-year medical records for 2009 to 2013, using data abstraction tools, to identify mothers with preeclampsia/eclampsia. A total of 1,809 cases were reviewed for general characteristics of the mother, delivery details, and any complications. Descriptive analyses were employed. In addition, extended Mantel Haenszel chi square for linear trend was used to check for significance of the trends.

RESULTS

The five year average proportion of preeclampsia/eclampsia was 4.2% (95%CI 4.02%, 4.4%). The proportion of women with preeclampsia was 2.2% in 2009 and increased to 5.58% in 2013 (p<0.001), which was a 154% increase. Of the 1,809 mothers with preeclampsia/eclampsia, 36% (95%CI 33.85%, 38.28%) experienced at least one maternal complication; there was an increase of 26.5% (p<0.01) over the five year period. The main complications were HELLP (variant of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count) syndrome, 257 (39.5%); aspiration pneumonia, 114 (17.5%); pulmonary edema, 114 (17.5%); and abruption placentae, 100 (15.3%). At least one neonatal complication occurred in 66.4% (95%CI 64.24%, 68.59%) of deliveries during the five-year study. A decreasing trend in neonatal complications was observed from 2009 (76%) to 2013 (66%), which showed a percentage change over time of negative 13.2%. The most common neonatal complications were stillbirths, which accounted for 363 (30.2%); prematurity, with 395 (32.8%); respiratory distress syndrome, with 456 (37.9%); and low birth weight, with 363 (30.2%).

CONCLUSION

There was an increasing trend of preeclampsia/eclampsia and maternal complications over a five year period in selected maternity governmental hospitals. In contrast, neonatal complications experienced a significant decrease over the five-year period. It is essential to raise awareness among mothers in the community regarding early signs and symptoms of preeclampsia/eclampsia and to design a better tracking system for antenatal care programs.

Assessment of prevalence of preeclampsia from Dilla region of Ethiopia

Background

Preeclampsia is a multi-organ system disorder that occurs after the 20th week of gestation in pregnancy and is characterized by hypertension and proteinuria. In Africa more than 270,000 women die from maternal deaths, worldwide approximately 76,000 women and 500,000 babies die yearly due to preeclampsia. It affects about 8–10 % of all pregnancies. Studies have shown that up to 77 % women affected with preeclampsia lack knowledge about preeclampsia, and therefore cannot take preventative measures. The aim of study is to evaluate the outcomes and quality of care given to preeclamptic patients treated in Dilla University Referral Hospital.

Methods

The study is a retrospective, hospital based study. One hundred and seventy two records of women were retained for final study out of 7702 patients from January 2009 to December 2012.

Results

The incidence rate of preeclampsia in Dilla University Referral Hospital was found to be 2.23 %. The common mean ages found to be affected for preeclampsia were 19.2, 22.5 and 27.8 and 31.5 with a trend towards increasing severity with younger age population.

Conclusion

A guideline on the management and prevention of preeclampsia needs to be produced for Ehiopia.

Preeclampsia and associated factors among pregnant women attending antenatal care in Dessie referral hospital, Northeast Ethiopia: a hospital-based study

Background

Preeclampsia is one of the leading causes of maternal mortality in Ethiopia. It has been increasing and linked to multiple factors, making prevention of the disease a continuous challenge. Yet few studies have been conducted in Ethiopia. This study aimed to assess the prevalence and factors associated with preeclampsia among pregnant women attending antenatal care in Dessie referral hospital, Northeast Ethiopia.

Methods

A hospital-based cross-sectional study was conducted in Dessie referral hospital between August and September 2013. All pregnant women who had antenatal visit at Dessie referral hospital were included for the study. A total of 490 pregnant women were enrolled in the study. Pretested and structured questionnaire via face-to-face interview technique was used for data collection. The data were entered in to EPI info version 3.5.3 statistical software and exported to SPSS version 20 statistical package for further analysis. Descriptive statistics were used to explore the data in relation to relevant variables. Binary logistic regression analysis was employed. Odds ratio with 95% confidence intervals (CI) was computed to identify factors associated with Preeclampsia.

Results

The prevalence of preeclampsia among pregnant women in Dessie referral hospital was found to be 8.4%. Women having family history of hypertension [Adjusted Odds Ratio (AOR) = 7.19 (95% CI 3.24–15.2)], chronic hypertension [AOR = 4.3 (95% CI 1.33–13.9)], age ≥35 years [AOR = 4.5 (95% CI 1.56–12.8)], family history of diabetes mellitus [AOR = 2.4 (95% CI 1.09–5.6)] and being unmarried [AOR = 3.03 (95% CI 1.12 – 8.2)] were found to be associated with preeclampsia.

Conclusions

The prevalence of preeclampsia in this hospital was lower that other studies. Having personal or family history of hypertension, older age, and family history of diabetic mellitus were factors associated with preeclampsia. Encouraging pregnant women to have health seeking behavior during pregnancy would provide a chance to diagnose preeclampsia as early as possible.

Maternal mortality predictors in women with hypertensive disorders of pregnancy: a retrospective cohort study

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are multisystem disorders unique to human pregnancy. They are becoming the leading causes of maternal mortality worldwide, with the majority of deaths occurring in low income countries. However, little is known about the predictors of maternal mortality in women with HDP.

METHODS

A retrospective cohort study was conducted between 2008 and 2013 in three university teaching hospitals among 1015 women admitted with a diagnosis of HDP. Statistically significant associations were assessed by the hazard ratio (HR) with 95% confidence using the Cox proportional hazards model and by the Log Rank test using the Kaplan-Meier survival analyses.

RESULTS

There were 51(5%) maternal deaths and the majority died after they developed eclampsia. The median delay in arrival among the deaths was longer than the survivors. The multivariate survival analyses showed an increased risk of maternal mortality among women with eclampsia (HR=8.4), no antenatal care (HR=2.3), being grand multiparous (HR=2.8), having low diastolic blood pressure (HR=4.5), high creatinine level (HR=9.9), use of diazepam as anticonvulsant (HR=2.7) and untreated with antihypertensive drug (HR=4.2).

CONCLUSIONS

The case fatality rate of HDP was among the highest in the world and a delay in initiation of treatment because of delay in health care-seeking contributed to the majority of maternal deaths.

Prevention and management of severe pre-eclampsia/eclampsia in Afghanistan

Background

An evidence-based strategy exists to reduce maternal morbidity and mortality associated with severe pre-eclampsia/eclampsia (PE/E), but it may be difficult to implement in low-resource settings. This study examines whether facilities that provide emergency obstetric and newborn care (EmONC) in Afghanistan have the capacity to manage severe PE/E cases.

Methods

A further analysis was conducted of the 2009–10 Afghanistan EmONC Needs Assessment. Assessors observed equipment and supplies available, and services provided at 78 of the 127 facilities offering comprehensive EmONC services and interviewed 224 providers. The providers also completed a written case scenario on severe PE/E. Descriptive statistics were used to summarize facility and provider characteristics. Student t-test, one-way ANOVA, and chi-square tests were performed to determine whether there were significant differences between facility types, doctors and midwives, and trained and untrained providers.

Results

The median number of severe PE/E cases in the past year was just 5 (range 0–42) at comprehensive health centers (CHCs) and district hospitals, compared with 44 (range 0–130) at provincial hospitals and 108 (range 32–540) at regional and specialized hospitals (p < 0.001). Most facilities had the drugs and supplies needed to treat severe PE/E, including the preferred anticonvulsant, magnesium sulfate (MgSO₄). One-third of the smallest facilities and half of larger facilities reported administering a second-line drug, diazepam, in some cases. In the case scenario, 96% of doctors and 89% of midwives recognized that MgSO₄ should be used to manage severe PE/E, but 42% of doctors and 58% of midwives also thought diazepam had a role to play. Providers who were trained on the use of MgSO₄ scored significantly higher than untrained providers on six of 20 items in the case scenario. Providers at larger facilities significantly outscored those at smaller facilities on five items. There was a significant difference between doctors and midwives on only one item: continued use of anti-hypertensives after convulsions are controlled.

Conclusions

Drugs and supplies needed to treat severe PE/E are widely available at EmONC facilities in Afghanistan, but providers lack knowledge in some areas, especially concerning the use of MgSO₄ and diazepam. Providers who have specialized training or work at larger facilities are better at managing cases of severe PE/E. The findings suggest a need to clarify service delivery guidelines, offer refresher training, and reinforce best practices with supervision and reinforcement.

A national review of cesarean delivery in Ethiopia

OBJECTIVE

To describe Ethiopian national population-based and institutional cesarean delivery rates by sector, and to describe indications for cesarean delivery, fetal and maternal outcomes, and aspects of quality of care.

METHODS

The data source was the national baseline assessment of emergency obstetric and newborn care--a cross-sectional, facility-based survey of 797 facilities. Two instruments were used to collect the data for the present paper: a retrospective record review of 267 cesarean deliveries based on the last 3 performed in each facility; and a 12-month summary of each facility's statistics on vaginal and abdominal deliveries.

RESULTS

The national population-based cesarean delivery rate was 0.6%, with regional rates varying from 0.2% to 9%. The overall institutional rate was 18%, which varied between 46% in the private for- profit sector and 15% in the public sector. Maternal indications accounted for 66% of the cesareans reviewed, and fetal indications for 34%. Three-quarters of the cesareans were recorded as emergencies, but only 12% of these had their labor monitored with a partograph. The interval between decision and delivery was within 30 minutes for 36% of the women, 31-60 minutes for 23%, and more than 5 hours for 19%. Antibiotics were given in 94% of the reviewed cases; nevertheless, 12% of the cases reported wound infection. There were 2 maternal deaths and 14% of the newborns were stillbirths or died shortly after birth.

CONCLUSION

The study showed little progress in the proportion of all births delivered by cesarean and a high rate of cesarean among women attended in the private sector--indicating a need to monitor the appropriateness of obstetric care in all sectors and to increase access in rural areas. Clinical management protocols for obstetric and newborn care are needed, and audits of cesareans should be performed at all institutions, especially in the private sector. The importance of improving record keeping is crucial for informed local decision-making.