Morbidity and mortality in booked women who deliver ...

Acta Tropica 75 (2000) 309 – 313 www.elsevier.com/locate/actatropica

Morbidity and mortality in booked women who deliver outside orthodox health facilities in Calabar, Nigeria S.J. Etuk *, I.H. Itam, E.E.J. Asuquo Department of Obstetrics and Gynaecology, College of Medical Sciences, Uni6ersity of Calabar, PMB 1115 Calabar, Nigeria Received 19 August 1999; received in revised form 16 December 1999; accepted 20 December 1999

Abstract Women who booked for antenatal care at the University of Calabar Teaching Hospital (UCTH), Calabar, but delivered outside orthodox health facilities were studied. The aims were to determine the pattern of maternal morbidity and mortality in them and to compare this with the pattern in women who booked and delivered at UCTH. One hundred and eighteen of the defaulters traced (35.1%) had complications compared with 34 (10.1%) of the control. Only 32.2% of these defaulters with complications presented in orthodox health facilities for treatment. The major complications in the study group were: perineal tear (19.0%); primary postpartum haemorrhage (12.5%); and puerperal sepsis (5.4%). These were significantly higher in the study group than in the controls (PB 0.001). Maternal mortality ratio of 6.0 per 1000 live births was recorded in the study group, but there was no death in the control. Health education and public enlightenment campaigns emphasising universal antenatal care along with delivery in orthodox health facilities are strongly advocated. © 2000 Published by Elsevier Science B.V. All rights reserved. Keywords: Morbidity and mortality pattern; Booked women; Delivery outside orthodox health facilities

1. Introduction Maternal morbidity and mortality rates in the developing world are still widely different from what occurs in the industrialised countries (Harrison, 1989; Garenne et al., 1997). Of the 585 000 women who die each year during childbirth, over 98% are from the developing world (Mahler, 1987; Etuk and Asuquo, 1997; Olaniran et al., 1997). Again, for each woman that dies, ten to 15 others suffer different forms of serious morbidity (Mahler, 1987; Workshop Secretariat, 1997). * Corresponding author.

One of the known ways of preventing maternal morbidity and mortality is by offering universal antenatal care (Mahler, 1987; Harrison, 1989). The positive influence of antenatal care is usually noticeable irrespective of other maternal characteristics such as differences in maternal age and parity (Harrison, 1988). This favourable outcome of antenatal care seems to be the result of enlightenment from health education which patients obtain during the antenatal care (Harrison, 1988; Megafu, 1988). This enables them to appreciate the advantages of delivery in health facilities where emergency obstetric care is readily available. Many authors have clearly shown that a rise

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S.J. Etuk et al. / Acta Tropica 75 (2000) 309–313

in hospital delivery rate usually leads to a fall in the maternal morbidity and mortality rates in any community (Harrison, 1983; Cardosa, 1986; Ekwempu, 1988). Recently, it has been reported that many of the booked women at the University of Calabar Teaching Hospital (UCTH) antenatal clinic deliver outside orthodox health facilities (Etuk, 1997). High hospital bill, ‘fear of spiritual attack by wicked people and prophetic warning in church’, and lack of transport facilities were given as major reasons why these booked women delivered outside orthodox health facilities (Etuk, 1997). Some of these women delivered under the supervision of untrained Traditional Birth Attendants (TBAs) while others delivered in churches where emergency obstetric care is scarcely available and no provision for referral to hospital in case of any complications. It has been shown that women who have had apparently normal antenatal period do develop complications in labour and puerperium and some of them die (Lennox, 1984; Alauddin, 1986; Kimball et al., 1988). The morbidity and mortality patterns in these women who booked but delivered outside orthodox health facilities in our community have not yet been studied. This work is designed to meet this need. It is hoped that the findings will help determine whether it would be reasonable to emphasize universal antenatal care and delivery in health facilities or encourage universal antenatal care without emphasis on place of delivery in this community and similar communities within and outside Nigeria.

2. Subjects and methods The booking and delivery registers of UCTH, Calabar, Nigeria, between June 1996 and May 1997 were reviewed. The names and addresses of all those with definite last menstrual period, who had exceeded their expected date of delivery by 1 month or more but had not been delivered in the hospital were selected. They were visited at home or as they brought their babies for immunization or admitted in the hospital because of maternal or

fetal complications. Those who delivered outside orthodox health facilities were interviewed. This formed the study population of this survey. For the control group, women who booked and delivered in UCTH were selected and matched for age, height, parity, marital status, educational status and social class with those of the study population. There was one control for every subject. The maternal outcomes of the study group were compared with those of the control. Calabar where this study was carried out is the capital of Cross River State in the south-eastern part of Nigeria. It has an estimated population of 218 000 (preliminary report of 1991 Nigeria Census). The inhabitants are mainly the Efiks, Quas, Ejagham, Efut, Ibibio, Annang and others — the migrant workers. They are mainly civil servants, subsistence farmers, traders and fishermen. Most people were Christians, there were very few Moslems and Pagans. Monogamous marriage is the norm and only a few families were polygamous. For the purpose of this study, the following definitions were used: Booked women: pregnant women attended at least once during the pregnancy by trained personnel (WHO, 1993). Orthodox health facilities: the modern health care centres where the care is offered by trained health attendants. Primary postpartum haemorrhage: bleeding from the genital tract within the first day of delivery which is excessive and makes the patient weak and feel faint. Puerperal sepsis: fever with offensive vaginal discharge following delivery of the baby. Prolonged labour: labour that lasts longer than sun rise to sun rise or sun set to sun set. Retained placenta: when the placenta is not delivered before full bathing of the baby. Simple proportions, rates and tables were used to analyse the results. Statistical significance was determined by Chi-square (x 2) test and McNemar Chi-square (x 2) test for matched pairs (Fleiss, 1981). This was with the help of a computer EPI/INFO-6 (Dean et al., 1994).

S.J. Etuk et al. / Acta Tropica 75 (2000) 309–313 Table 1 Incidence of complications in women in the study group compared with those in the control groupa Incidence

Study group (%), n=336

Control group (%), n= 336

Complications No complications

118 (35.1) 218 (65.0)

34 (10.1) 302 (89.9)

Total

336 (100.0)

336 (100.0)

a X =59.99; df=1; PB0.001; relative risk (RR) = 3.5 (95% confidence limits).

3. Results During the period of study, 1616 women booked for antenatal care in UCTH, Calabar, Nigeria. Eight hundred and forty-four of them delivered in the same hospital while 772 (47.8%) delivered outside. Of the 772 defaulters, 520 (67.36%) of them were traced and 336 (43.5%) of them were found to have delivered outside orthodox health facilities. Table 1 shows the incidence of complications in women in the study group compared with those in the control group. The incidence of complications in the study group was significantly higher than in the controls (PB 0.001) with a relative risk value of 3.5 (95% confidence limits). Only 38 (32.2%) of the defaulters with complications presented in orthodox health facilities for the treatment of their complications, the rest (67.8%) continued in their places of delivery. Morbidity pattern of women in the study group is shown in Table 2. Sixty-four (19.0%) of the

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defaulters had perineal tear. Primary postpartum haemorrhage occurred in 42 (12.5%), puerperal sepsis in 18 (5.4%) and prolonged labour in 14 (4.2%) of them. Table 2 also compares the maternal morbidity of women in the study group with that of women in the control group. Perineal tear stood out as the commonest complication in both the study group (19.0%) and the control group (6.5%). There was no difference in the frequency of retained placenta in both the study group and control (3.0%). A comparison of the incidence of morbidities in the study and control groups shows that the incidence of perineal tear, primary postpartum haemorrhage, puerperal sepsis, prolonged labour and postpartum eclampsia was significantly higher in the study than in the control group (PB 0.0001– PB 0.05) (Table 2). Two deaths were recorded in the study group giving a maternal mortality ratio of 6.0 per 1000 live births. No death was registered in the control group.

4. Discussion This study has shown that 35.1% of booked women who delivered outside orthodox health facilities developed complications during their delivery. This is 3.5-fold higher than the complication rate (10.1%) in the control group. That labour not supervised by trained personnel greatly increases the risk of morbidity and mortality has been reported by others (McClure Brown and Dixon, 1978; Kaunitz, 1984; Brennan, 1988). This

Table 2 Maternal morbidity pattern of women in the study group and control Morbidity

Study group (%), n =336

Control (%), n= 336

McNemar x 2

P

Perineal tear Primary postpartum haemorrhage Puerperal sepsis Prolonged labour Postpartum eclampsia Retained placenta Obstetric palsy

64 42 18 14 8 10 4

22 7 2 3 2 10 0

27.11 29.64 14.06 7.69 4.17 0.25 –

B0.001 B0.0001 B0.001 B0.001 B0.05 0.62 –

(19.0) (12.5) (5.4) (4.2) (2.4) (3.0) (1.2)

(6.5) (2.1) (0.6) (0.9) (0.6) (3.0) (0.0)

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is not surprising; indeed some practices of untrained attendants may even be a source of complications (Harrison, 1983; WHO, 1994a). Even when the complications occurred, the urge to seek emergency obstetric care in orthodox health facilities by these defaulters was low. Besides, the unorthodox delivery centres have no provision for referral of these patients. Hence, only 32.2% of the defaulters with complications presented in orthodox health facilities for treatment. Perineal tear was the commonest complication in both the study and control groups and was significantly higher in the study group than in the controls (PB0.001). This higher incidence of perineal tear in unorthodox delivery facilities may follow the avoidance of or inability to perform episiotomy or failure to control the delivery of the head in these delivery centres (Ityavyar, 1984). Delivery of the posterior shoulder of the baby, if not carefully taken, even in trained hands may result in perineal tear. The incidence of primary postpartum haemorrhage was also very significantly higher in the study group than in the controls (P B 0.0001). The gravity of this can be felt when one realizes that primary postpartum haemorrhage is one of the major causes of maternal mortality in our environment (Adetoro and Okwerekwu, 1988; Chukudebelu and Ozumba, 1988). This higher incidence of primary postpartum haemorrhage in the unorthodox delivery facilities may be due to the higher incidence of perineal tear and prolonged labour in these centres than in the orthodox delivery centres (Gilbert et al., 1987; Anate, 1993). The knowledge of risk factors to postpartum haemorrhage and active management of third stage of labour which exists in orthodox health facilities (Anate, 1993), prevents postpartum haemorrhage. The incidence of puerperal sepsis was very significantly higher in the study group than in the controls (PB0.001). This may be readily explained by the poor standard of hygiene and lack of aseptic technique which characterise the practice in unorthodox delivery facilities (Brennan, 1988). A significantly higher incidence of prolonged labour in the study group than the controls (P B

0.01) was noted in this survey. Most of the attendants in the unorthodox delivery facilities regard their profession as a gift from God and rely on their prayers for miracles (Brennan, 1988). They believe that no matter how long it takes, the miracle can still happen (WHO, 1994a). Again, lack of referral facilities may have made some contribution to this higher incidence of prolonged labour in these centres. Delivery in unorthodox facilities is unlikely to be associated with blood pressure monitoring or urine analysis (WHO, 1994b). Hence, the significantly higher incidence of postpartum eclampsia in the study group than in the controls. There was no difference in the incidence of retained placenta in both the study and control groups. Obstetric palsy was only seen in the study group. This may have to do with the incidence of prolonged obstructed labour and its management outside orthodox health facilities. Two deaths were recorded in the study group, giving a maternal mortality ratio of 6.0 per 1000 live births. There was no death in the control group. The two deaths were associated with primary postpartum haemorrhage. This supports the findings of other authors that postpartum haemorrhage is the commonest cause of maternal mortality in our environment (Adetoro and Okwerekwu, 1988; Chukudebelu and Ozumba, 1988). In unorthodox delivery centres where the standard management of this condition is non-existent, it is not surprising that many lives are lost from postpartum haemorrhage. In conclusion, the maternal morbidity and mortality pattern in booked women who deliver outside orthodox health facilities in our community is poor. It is significantly worse than the pattern in booked women who deliver under the supervision of trained attendants. Health education at booking clinics and proper public enlightenment campaigns with formation of relevant health messages emphasising that antenatal care is not an end in itself, but with delivery under supervision of trained personnel can yield favourable outcome and are strongly advocated.


Acknowledgements We wish to express our thanks to the University of Calabar, Calabar, for sponsoring this project through its Senate Research Grant. We thank the Community Health Nurses in Maternal and Child Health Unit, staff of the Isolation Wards and Sick Baby’s Unit of the University of Calabar Teaching Hospital, Calabar; staff of the Family Health Clinic, Moore Road, Calabar for their assistance during the data collection. We are also grateful to Dr E.E. Edet, for his guidance in the statistical analysis of this work and Ms Eno Etuk, for her secretarial assistance.

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