Determinants of obstructed labour and associated outcomes in 54 referral hospitals in Nigeria

OBJECTIVE

To estimate the prevalence of obstructed labour, associated risk factors and outcomes across a network of referral hospitals in Nigeria.

DESIGN

Retrospective observational study.

SETTING

A total of 54 referral-level hospitals across the six geopolitical regions of Nigeria.

POPULATION

Pregnant women who were diagnosed with obstructed labour during childbirth and subsequently underwent an emergency caesarean section between 1 September 2019 and 31 August 2020.

METHODS

Secondary analysis of routine maternity care data sets. Random-effects multivariable logistic regression was used to ascertain the factors associated with obstructed labour.

MAIN OUTCOME MEASURES

Risk factors for obstructed labour and related postpartum complications, including intrapartum stillbirth, maternal death, uterine rupture, postpartum haemorrhage and sepsis.

RESULTS

Obstructed labour was diagnosed in 1186 (1.7%) women. Among these women, 31 (2.6%) cases resulted in maternal death and 199 (16.8%) cases resulted in postpartum complications. Women under 20 years of age (OR 2.03, 95% CI 1.50-2.75), who lacked formal education (OR 1.88, 95% CI 1.55-2.30), were unemployed (OR 1.94, 95% CI 1.57-2.41), were nulliparous (OR 2.11, 95% CI 1.83-2.43), did not receive antenatal care (OR 3.34, 95% CI 2.53-4.41) or received antenatal care in an informal healthcare setting (OR 8.18, 95% CI 4.41-15.14) were more likely to experience obstructed labour. Ineffective referral systems were identified as a major contributor to maternal death.

CONCLUSIONS

Modifiable factors contributing to the prevalence of obstructed labour and associated adverse outcomes in Nigeria can be addressed through targeted policies and clinical interventions.

Quality and outcomes of maternal and perinatal care for 76,563 pregnancies reported in a nationwide network of Nigerian referral-level hospitals

BACKGROUND

The WHO in collaboration with the Nigeria Federal Ministry of Health, established a nationwide electronic data platform across referral-level hospitals. We report the burden of maternal, foetal and neonatal complications and quality and outcomes of care during the first year.

METHODS

Data were analysed from 76,563 women who were admitted for delivery or on account of complications within 42 days of delivery or termination of pregnancy from September 2019 to August 2020 across the 54 hospitals included in the Maternal and Perinatal Database for Quality, Equity and Dignity programme.

FINDINGS

Participating hospitals reported 69,055 live births, 4,498 stillbirths and 1,090 early neonatal deaths. 44,614 women (58·3%) had at least one pregnancy complication, out of which 6,618 women (8·6%) met our criteria for potentially life-threatening complications, and 940 women (1·2%) died. Leading causes of maternal death were eclampsia (n = 187,20·6%), postpartum haemorrhage (PPH) (n = 103,11·4%), and sepsis (n = 99,10·8%). Antepartum hypoxia (n = 1455,31·1%) and acute intrapartum events (n = 913,19·6%) were the leading causes of perinatal death. Predictors of maternal and perinatal death were similar: low maternal education, lack of antenatal care, referral from other facility, previous caesarean section, latent-phase labour admission, operative vaginal birth, non-use of a labour monitoring tool, no labour companion, and non-use of uterotonic for PPH prevention.

INTERPRETATION

This nationwide programme for routine data aggregation shows that maternal and perinatal mortality reduction strategies in Nigeria require a multisectoral approach. Several lives could be saved in the short term by addressing key predictors of death, including gaps in the coverage of internationally recommended interventions such as companionship in labour and use of labour monitoring tool.

FUNDING

This work was funded by MSD for Mothers; and UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO).

Implementation and evaluation of obstetric early warning systems in tertiary care hospitals in Nigeria

Obstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers about the implementation of an obstetric EWS and assess its effectiveness as an alternative clinical monitoring method compared to standard practice. This mixed-method study included obstetric admissions (n = 2400) to inpatient wards between 01/08/2018 and 31/03/2019 at three Nigerian tertiary hospitals (1 intervention and two control). Outcomes assessed were the efficiency of monitoring and recording vital signs using the patient monitoring index and speed of post-EWS trigger specialist review. These were evaluated through a review of case notes before and four months after EWS was introduced. Qualitative data was collected to explore healthcare workers' views on EWS' acceptability and usability. EWS was correctly used in 51% (n = 307) of the women in the intervention site. Of these women, 58.6% (n = 180) were predicted to have an increased risk of deterioration, and 38.9% (n = 70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites. Health workers reported that the EWS helped them cope with work demands while making it easier to detect and manage deteriorating patients. Nurses and doctors reported that the EWS was easy to use and that scores consistently correlated with the clinical picture of patients. Identified challenges included rotation of clinical staff, low staffing numbers and reduced availability of monitoring equipment. The implementation of EWS improved the frequency of patient monitoring, but a larger study will be required to explore the effect on health outcomes. The EWS is a feasible and acceptable tool in low-resource settings with implementation modifications. Trial registration: ISRCTN, ISRCTN15568048. Registration date; 9/09/2020- Retrospectively registered, http://www.isrctn.com/ISRCTN15568048.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country

OBJECTIVE

To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.

DESIGN

Nationwide cross-sectional study.

SETTING

Forty-two tertiary hospitals.

POPULATION

Women admitted for pregnancy, childbirth and puerperal complications.

METHODS

All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.

MAIN OUTCOME MEASURES

Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).

RESULTS

Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.

CONCLUSIONS

Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.

TWEETABLE ABSTRACT

Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Indications and outcome of abdominal myomectomy in University of Maiduguri Teaching Hospital: Review of ten year

BACKGROUND

Abdominal myomectomy is a common modality of treatment for large and symptomatic uterine fibroid in women who wish to retain their fertility. Though frequently performed the procedure may still be associated with complications.

MATERIALS AND METHODS

A retrospective review of all patients who had abdominal myomectomy from January 1999 to December 2008 at the University of Maiduguri Teaching Hospital. Information on the Sociodemographic characteristics, indication for the myomectomy, uterine size, pre and post operative packed cell volume (PCV), intraoperative findings, cadre of surgeon, duration of hospital stay and complications were obtained.

RESULTS

The rate of abdominal myomectomy was 3.34%. Majority of the patients (79.8%) aged 30-49 years, and most (58.9%) were nulliparas. Abdominal mass (63.7%), menorrhagia (57.7%), and subfertility 55.2% were the leading indications for abdominal myomectomy. Complications were seen in 10.9% of the cases, 55.5 % of which were wound infections. Clinical and intra operative factors associated with complications included menorrhagia (P=0.003), estimated blood loss (EBL) ≥500mls (P=0.005) and post operative PCV of <30% (P=0.081).

CONCLUSION

Complication rate after myomectomy was low with menorrhagia and EBL ≥ 500 mls being significantly associated with development of complication.

Emergency obstetrics care in a Nigerian tertiary hospital: a 20 year review of umblical cord prolapse

CONTEXT

Umbilical cord prolapse is an obstetric emergency associated with high perinatal morbidity and mortality unless prompt delivery by the fastest and safest route is carried out.

OBJECTIVES

To determine the incidence of umbilical cord prolapse, predisposing factors, and fetal outcome.

STUDY DESIGN, SETTING AND SUBJECTS

A 20 year retrospective study of all women who presented with umbilical cord prolapse at University of Maiduguri Teaching Hospital, Maiduguri, North-Eastern Nigeria.

RESULTS

During the study period there were 27,753 deliveries and 75 women had cord prolapse, giving the incidence of 1 in 370 deliveries (0.27%). Significantly more patients with non vertex presentation, twins and preterm delivery had cord prolapse. The highest occurrence was in those with unengaged presenting part (65.2%), spontaneous rupture of membrances (62.1%) and grandmultiparous women (57.6%). Caeserean section was carried out in 50% of cases, with mean decision-delivery interval of 77.1 +/- 21.7 minutes and 28/33 (84.9%) of babies delivered within 60 minute had normal Apgar scores. The Knee-chest position was most commonly used method of alleviating cord compression while arrangement for caesarean section was being made. The perinatal mortality was 27.3%.

CONCLUSION

umbilical cord prolapse is a brisk obstetric emergency with high perinatal morbidity and mortality unless prompt delivery is undertaken. Better communication and prompt response to emergency by the theatre team to reduce the decision-delivery interval would improve the perinatal outcome.

Knowledge, attitude and practice of ante-natal attendees toward prevention of mother to child transmission (PMTCT) of HIV infection in a tertiary health facility, Northeast-Nigeria

OBJECTIVE

Knowledge, attitude and practice of pregnant women toward prevention of mother to child transmission of HIV infection have not been evaluated in any tertiary health facility in the Northeast region of Nigeria.

METHODS

A structured questionnaire was used to obtain data from 172 women that consecutively attended the antenatal clinic of University of Maiduguri Teaching Hospital to determine their level of knowledge, practice and attitude toward HIV/AIDS issues with respect to PMTCT.

RESULTS

The survey revealed a high level of knowledge on modes of transmission, risks behaviours and prevention of HIV and other sexually transmitted infections among the pregnant women. However, the use of breast milk substitute (BMS) by HIV positive nursing mothers and use of condom during sexual intercourse did not receive very encouraging responses from 42 (24.4%) and 58 (33.7%) of the women respectively. Those that do not encourage use of BMS indicated spouse dislike as a major reason and the fact that the community places higher premium on breastfeeding than BMS. Majority of those that discouraged condom use 28 (48.3%), said the practice was against their religions beliefs while a few believes withdrawal before ejaculation and use of antibiotics after sex can equally prevent HIV infection. Majority of the respondents, 106 (61.6%) admit their willingness to support their spouses that tested positive for HIV.

CONCLUSION

The pregnant women accepted PMTCT as a veritable means of preventing infants from HIV infection as well as an opportunity to know ones HIV status through voluntary testing. Majority implored greater involvement of their male partners and other significant family members during PMTCT counselling sessions to guard against ejection, stigma and discrimination if tested HIV positive. Staff training, awareness creation and community mobilization were identified as key to success of PMTCT programmes and fight against stigma and discrimination.

Sex and reproduction among HIV-infected people in Maiduguri, Nigeria

For HIV-infected people, prevention of transmission of the virus to their spouses and other sexual partners can only be achieved through abstinence and safer sex practices using condoms. New drugs and technologies are now available that can prevent vertical transmission of the virus. A total of 262 people living with HIV/AIDS (PLWHA) were interviewed to explore their sexual and reproductive desires and practices. About 75.6% of them were sexually active and 62.2% never used condoms. Although only 26.3% had no living child, the majority of these (71.4%) wanted to have children. Their knowledge of mother-to-child transmission of HIV and how to prevent it was good. PLWHA engage in unprotected sexual intercourse with the desire to have more children. It is expected that more paediatric HIV infections will be seen in the future in a poor-resource setting like ours.

The value of highly active antiretroviral therapy in the prevention of mother-to-child transmission of HIV

Over 90% of the children infected with HIV globally were as a result of mother-to-child transmission. With a high prevalence of HIV among women of reproductive age and a high fertility rate in Nigeria, the prevention of mother-to-child transmission of HIV is an important strategy to curb the menace of HIV. This paper examines the value of highly active antiretroviral treatment in the prevention of mother-to-child transmission of HIV. Pregnant women attending the antenatal clinic of the University of Maiduguri Teaching Hospital were offered voluntary counselling and testing for HIV. Seropositive women who fulfilled the criteria for administration of antiretroviral drugs were offered a triple combination of nevirapine, stavudine and lamivudine in pregnancy. Women who did not fulfil the criteria were offered single dose nevirapine in labour. The newborn of all HIV-positive women were offered nevirapine suspension within 72 h of delivery. Overall transmission rate for women who had combination treatment was 9.1% which was lowered to zero level among those that had elective caesarean section and infant formula in addition to the drugs. Those who had single dose nevirapine in labour had a transmission rate of 33.3%. It is recommended that the single dose nevirapine be abandoned in favour of combination treatment.