The M of MCH

The ways in which better prenatal, intrapartum and postpartum care of mothers in Papua New Guinea could decrease perinatal mortality are discussed. Papua New Guinea has a fairly well developed system of rural health care, with teams visiting villages monthly. Emphasis on immunization and acute treatment of children, however, often consumes workers' time so that pregnant women are neglected. Tabulations of perinatal mortality in the Port Moresby General Hospital suggest that 14 to 49% of these deaths could have been prevented. 90% of babies born in the Central Province and National Capital District were delivered in this hospital. There were 132 stillbirths at the hospital in 1985, of which 10 were considered preventable. Prematurity is a common cause of neonatal mortality at the hospital, while infection, often associated with difficult labor, is more common in the rural highlands. There are 3 essential components of good antenatal care: selection of high-risk women for institutional delivery, prophylaxis for anemia, malaria and tetanus, and management of obstetric problems. Often good nutrition, rest from hard physical labor and cleanliness will make a significant impact. Cephalopelvic disproportion frequently complicates delivery, therefore sending all small primigravidae for institutional delivery would be ideal. The most important element of postpartum care is establishment of lactation. In Papua New Guinea, cultural mores regarding sexual abstinence after pregnancy are breaking down, necessitating the introduction of modern family planning.     

Perinatal mortality at the Port Moresby General Hospital and St. Therese's Maternity Hospital 1972

A study was made of the 67 still-births and the 58 neonatal deaths that occurred among the 3,516 viable infants (birth weight 1,000 g. or more) that were born to public patients of the obstetric units of Port Moresby General Hospital and St. Therese's Maternity Hospital during the year 1972. The combined stillbirth and neonatal mortality rate was 35.5 per 1,000 births. The adverse effects of lack of antenatal care, delivery outside hospital, high parity, maternal anaemia, mulitple pregnancy, and low birth weight are demonstrated. Low birth weight (1,000 to 2,200 g.) of unknown cause accounted for 24.0 per cent of the deaths. In 16,8 per cent of cases the birth weight was more than 2,200 g. and the cause of death was unknown. Birth trauma accounted for 19.2 per cent of the deaths, congenital malformation for 11.2 per cent, antepartum haemorrhage for 11.2 per cent, toxaemia for 10.4 per cent, and maternal disease for 3.2 per cent. There were miscellaneous causes in 4.0 per cent of cases. Approximately 75 per cent of the deaths were considered to be the result of unfavourable factors in the mother's environment. Approximately 14 per cent were primarily the result of obstetric complications and might have been avoided by a higher standard of obstetric care. Improving the standard of obstetric care that is presently available in Port Moresby would probably reduce the perinatal mortality rate by not more than 5 per 1,000.     

Maternal mortality in a subdivisional hospital of eastern Himalayan region.

This study was conducted in a subdivisional hospital of eastern Himalayan region among 5,273 pregnant women over a period of 8 years. There were 29 deaths, the maternal mortality rate was 55 per 10,000. Septic abortion was encountered in 4 among them. Direct obstetric cause was responsible in 72.41% of cases and indirect cause in 27.59% cases. Sepsis, both puerperal and postabortal resulted in 24.14% followed by postpartum haemorrhage in 20.69%. Two of these cases were associated with inversion of the uterus. Preeclampsia caused 10.34% and eclampsia 6.9% of the deaths. Among the indirect causes severe anaemia and pulmonary tuberculosis accounted for 10.34% and 6.9% respectively. Infective hepatitis was the cause in 6.9% cases. Only 17% of the cases were booked and the rest were unbooked. Majority of the cases (62.07%) belonged to the age group of 20-30 years. Primigravida constituted 41.38% of the cases.     

Maternal mortality at Queen Elizabeth Central Hospital, 1989 to 1990

An obstetrician examined records of all maternal deaths that occurred in the Chatinkha Maternity Wing of Queen Elizabeth Central Hospital in Blantyre, Malawi, during 1989-1990. None of the deaths were caused by conditions unrelated to pregnancy. In 1989 there were 78 maternal deaths out of 14,272 live births (a maternal mortality ratio of 546/100,000 live births). In 1990 there were 73 maternal deaths out of 14,281 live births (a maternal mortality ratio of 511/100,000 live births). In each year, 37 women died directly from complications of pregnancy, delivery, or their management. In 1989, the leading cause of maternal death was postabortal sepsis (15 cases), followed by obstructed labor (8 cases) and puerperal sepsis (6 cases). In 1990, the leading causes were puerperal sepsis (13 cases) and postabortal sepsis (10 cases). The number of HIV-seropositive women among direct maternal deaths was 8 for both years. In 1990, the cesarean section rate was 6.5%. Women who had undergone a cesarean section faced a risk of puerperal sepsis-related death 8.5 times greater than that of women who had delivered vaginally. The 1990 mortality rate among induced abortion cases may have been as high as 8%. There were 41 and 36 indirect maternal deaths in 1989 and 1990, respectively. The leading causes of indirect maternal death were fever (8 cases) and bacterial meningitis (5 cases). The cause could not be determined in 15 cases. By 1990, the leading causes of indirect maternal death were bacterial meningitis (8 cases) and AIDS (6 cases). 5 of the 8 bacterial meningitis cases tested positive for HIV. The 4 patients with tuberculosis and 3 patients with septicemia were HIV positive. 41% and 56% of maternal deaths in 1989 and 1990, respectively, were avoidable. When one excluded uncertain avoidable factors, 21% and 45% of maternal deaths could not be avoided. The leading avoidable factors were deficient hospital care (18 cases), patient's delay (12 cases), and illegal abortion (10 cases) in 1989; they were patient's delay (10 cases) and illegal abortion (8 cases) in 1990.     

Maternal mortality at Sagamu, Nigeria--a ten year review (1988 - 1997)

A review of maternal deaths at the Ogun State University Teaching Hospital, Sagamu, Nigeria over a 10 year period is presented. During the period, there were 92 maternal deaths, those from abortion and ectopic pregnancy inclusive. The total deliveries were 5423 giving a maternal mortality ratio of 1700 per 100,000. Ruptured uterus was the most common cause followed by eclampsia, postpartum haemorrhage and complications of abortion in that order. Unbooked patients constituted about one third of the total (29. 1 %). Primipara and grandmultipara were the most at risk of maternal death and the risk of dying following operative delivery was six times that of vaginal delivery. Easy access to affordable antenatal care, good blood transfusion services, more widespread use of contraceptives and training of traditional birth attendants would help reduce the risk of maternal death.     

Mortality at the medical wards of a university teaching hospital in Papua New Guinea: a study of 1242 admissions

The records of all patients who died in the medical wards of the University Teaching Hospital in Papua New Guinea during a 6-month period between 1st January and 1st July 1984 were reviewed. Deaths were classified as early or late and subclassified as preventable, treatable, untreatable or undetermined. There were 120 deaths among 1242 adult patients admitted to the medical wards during the period under study (overall case fatality rate 10%). 35 patients died within 24 hours after admission (early death), 2 of preventable, 7 of treatable, 8 of untreatable and 18 of undetermined causes. Of patients who stayed alive in the hospital for more than one day, 5 died of preventable, 28 of treatable, 23 of untreatable and 29 of undetermined causes. Autopsy was performed on 3 patients (2.5%). Age of the deceased patients ranged from 13 to 67 years (median: 37). Male to female ratio was 1.86. The length of hospital stay ranged from 1 to 77 days (median: 4). Infectious diseases were found to be the major cause of death with pneumonia and tuberculosis leading the list. The emergency procedures, laboratory facilities and autopsy rate need to be improved to reduce the number of deaths from undetermined and preventable causes in Papua New Guinea.     

Maternal mortality in Papua New Guinea 1976-1983

In April 1970 a Maternal Mortality Register (MMR) was started in Papua New Guinea to record in more detail deaths occurring both at home and in health care facilities. This paper reports 628 maternal deaths for which death certificates were registered and 385 deaths reported to the Maternal Mortality Register (MMR) for the January 1, 1976-December 31, 1983 period. A total of 895 maternal deaths were reported between January 1, 1976 and December 31, 1983. The annual average was 111, but the average number of deaths reported to the MMR was only 48. This represents a marked decrease in the reporting rate from previous reports. The number of deaths reaching the Death Registry (DR) was fairly consistent for the period, and the percentage of hospital and health center deaths registered was high (78-96%). Yet, the number of deaths being notified to the MMR was erratic and considerably less complete (18-55%). Notably, the percentage of deaths notified to both the MMR and the DR has been very low throughout the period (2-22%). It seems that many health workers feel that notification to 1 registry is sufficient. With the marked decline in reporting maternal deaths to the MMR it is more difficult than previously to calculate the maternal mortality rate for Papua New Guinea. A table presents the maternal mortality figures previously reported from the registry. According to Bell (1983) the rate was 1.6/1000 births in urban areas, 10/1000 in rural areas, and 9/1000 overall. The authors of this report think that the rate varies from approximately 2/1000 for urban areas, to 20/1000 in areas without accessible health services. It is probably about 8/1000 overall. According to this estimate, 1/10 of the maternal deaths were reported for the period under review. A table shows the causes of 895 maternal deaths, and another table groups the deaths according to whether they were reported to the MMR or the DR. For 22 of the village deaths and 6 of the institutional deaths it was not possible to determine the cause of death from the information provided. Relatively few deaths from trophoblastic disease, ectopic pregnancy, and abortion were notified to the MMR because of their less obvious "maternal" nature. The causes of death were as follows: puerperal sepsis -- 195 deaths recorded by the DR and 76 by the MMR; postpartum hemorrhage -- 130 recorded by the DR and 102 by the MMR; associated medical and surgical complications -- 140 deaths, which accounted for 26% of the deaths notified to the MMR and only 10% of locatable deaths in the DR; prolonged or obstructed labor (45 deaths) and ruptured uterus (38 deaths), with the MMR showing that primigravidas accounted for 45% of the deaths from prolonged and obstructed labor and grandmultiparas accounted for 60% of the deaths from ruptured uterus; abortion, 38 deaths; antepartum hemorrhage, 36 deaths; eclampsia, 30 deaths; trophoblastic disease, 25 deaths; pulmonary embolus, 25 deaths; actopic pregnancy, 20 deaths; 14 operative and anasthetic deaths; 10 miscellaneous causes of death; and 39 deaths associated with caesarean section.     

Maternal mortality in a district hospital in West Bengal

To ascertain the causes of high maternal mortality in West Bengal, the author examined maternal mortality between 1964-68. It was intended that measures to improve the situation in rural areas could be suggested. Women in labor often arrive at the hospital very late and few antenatal care facilities are available in rural areas. High risk cases often are delivered at home, a situation which often results in fetal complications. Maternal deaths have declined, but not dramatically. Of the 24,265 deliveries at the Burdwan district hospital, there were 333 maternal deaths for an incidence of 13.7/1000, along with another 42 cases where death was due to pregnancy-associated causes. In contrast, the maternal mortality rate in a district hospital in Calcutta was 4/1000 in 1968. Eclampsia accounted for 42.34% (141) of maternal deaths making it the major cause of death. In Calcutta this cause of death is receding gradually but in the districts it still accounts for a heavy loss of life (an incidence of 1 in 38). Adequate antenatal care would reduce this high mortality. 2 factors which have contributed to the high mortality are the hours lost in transporting a patient from a rural area and inadequate hospital staff. Postpartum hemorrhage and/or retained placenta was responsible for 39 deaths and none of the cases admitted from outside had received antenatal care. A shortage of blood was also a contributory factor. Severe anemia was responsible for 34 deaths and abortions resulted in another 29 deaths (16 because of severe sepsis; 13 due to hemorrhage or shock). An emergency service would help reduce the number of deaths but at present such a service does not even exist in the urban areas. Ruptured uterus resulted in 29 deaths and obstructed labor in 27 deaths. Placenta previa brought about 14 deaths and the remaining 20 deaths were due to such causes as accidental hemorrhage (10), hydatidiform mole (4), puerperal sepsis (3), ectopic pregnancy (2), and uterine inversion (1). Timely admission would have helped most of these cases. In summation, the preventive measures which would help to lower maternal mortality are: 1) mass education about the need for antenatal care, 2) provision of good obstetrical service, 3) provision of quick transport, 4) adequate staffing of hospitals, 5) refresher courses for medical personnel, and 6) 24 hour blood transfusion service.     

Maternal health services and maternal mortality in Papua New Guinea

Surveys of maternal mortality rates in rural areas of Papua New Guinea over the past thirty years report 2-18 deaths per 1000 live births. The national maternal mortality register commenced in 1970 and reports rates of 2-7/1000 deaths for urban areas and 7-20/1000 deaths for rural areas. However, less than a quarter of maternal deaths are believed to be reported to the register: most of the unreported deaths are unsupervised confinements. Nevertheless obstetrical causes now account for 20% of total admissions to hospital and health centres in Papua New Guinea, and are the commonest causes of admission. The great majority of obstetrical admissions come from urban and periurban areas. Most rural women continue to confine at home where only a small fraction of maternal deaths are reported. It is as yet unclear whether modern health services have made any impact on rural maternal mortality rates. A plea is made for more complete reporting of maternal deaths to the national register of both supervised and unsupervised confinements.     

Antenatal care in Goroka: issues and perceptions

The high maternal mortality rate in Papua New Guinea indicates an urgent need for action. One area for examination is antenatal care. From April 2002 to August 2002 a qualitative study was undertaken in order to identify perceptions, beliefs, barriers and strengths relevant to the utilization of antenatal care by women in the urban, periurban and rural communities of Goroka, Papua New Guinea. Interview data about antenatal care utilization were collected from 20 pregnant or parous women and 4 antenatal health care workers and relevant statistics were reviewed. This information was analyzed in order to identify the constraints faced by the users of antenatal care and health care workers providing such services and to make recommendations aimed to improve the utilization and delivery of antenatal care in Goroka. Multiple encouragers and barriers to using antenatal care were identified within the three categories of physical barriers/encouragers, cultural issues and health care system characteristics. The attitude of health care workers and their perceived ill-mannered treatment of women was one of the most significant concerns raised by the women. Nevertheless, all of the women expressed overall satisfaction with the care given. All of the health care workers stated that antenatal care is very important for the health of both the baby and the mother and expressed a desire to improve the level of care. The major constraints faced were staff shortages, limited supplies and broken equipment. There were four key areas of strength: the broad level of coverage, the high regularity of attendance, the women's commitment to antenatal care and the willingness of health care workers to overcome resource difficulties in the provision of care. Recommendations to improve the delivery of antenatal care services and their utilization by women addressed the situation of women and the interactions between women and health care providers, and proposed innovations in the health care system.     

Maternal death in Papua New Guinea, 1984-1986

The life-time risk of maternal death in the developing world is about 500 times that for women in developed countries. This disparity is wider than for any other public health statistic. The causes of 304 maternal deaths occurring in the period 1984-1986 are reported; this most likely represents only 10% of the total occurring in Papua New Guinea. The maternal mortality rate is estimated at 7/1000 for the period. Figures for Simbu Province are given in more detail than are available for other parts of Papua New Guinea.     

A serological survey of rickettsial infections in the Gazelle Peninsula, East New Britain and a review of the literature

Of the various rickettsial diseases, only scrub typhus has been well documented in Papua New Guinea. A review of the historical literature confirms this. A serological survey was conducted on 113 antenatal patients presenting to a district hospital in Kokopo, East New Britain. Results suggested that a spotted fever rickettsial infection is common in this area with a seroprevalence of about 17% in young women. There was no evidence of scrub typhus or murine (endemic) typhus in the population sampled. Clinical implications of these findings are discussed.     

Aboriginal and non-aboriginal perinatal deaths in Darwin: a comparative view.

OBJECTIVE: To compare perinatal deaths in Aborigines and non-Aborigines, and to identify the differences between the two groups in order to plan better prevention and bring about a reduction in perinatal deaths. DESIGN: A retrospective review of the records of 198 consecutive perinatal deaths (96 Aboriginal and 102 non-Aboriginal) in infants delivered in the maternity unit between 1984 and 1989. SETTING: Royal Darwin Hospital Maternity Unit. MAIN OUTCOME MEASURES: Stillbirth rate, neonatal death rate, perinatal mortality rate; classifying perinatal deaths by cause and birthweight. MAIN RESULTS: The Aboriginal perinatal mortality rate was 40.9 per 1000, three times that of the non-Aboriginal rate (13.4 per 1000). The stillbirth rate in Aborigines was 18.7 per 1000, 2.5 times that in non-Aborigines (7.2 per 1000). The Aboriginal neonatal mortality rate was 22.5 per 1000, 3.5 times the non-Aboriginal rate (6.2 per 1000). There was no significant difference in the distribution of Aboriginal and non-Aboriginal perinatal deaths when classified by cause, with the exception of pre-eclampsia. Aboriginal women appeared to be 2.5 times more likely than non-Aboriginal women (P = 0.002) to have pre-eclampsia causing perinatal death. Prematurity and the unexplained categories were the major causes of perinatal death in both Aboriginal and non-Aboriginal infants. MAIN CONCLUSION: The suboptimal perinatal outcome in Aborigines highlights the importance of antenatal care for Aboriginal mothers, and indirectly reflects the need for improving their standard of living.     

Vitamin D deficiency in veiled or dark-skinned pregnant women

OBJECTIVES: To determine the vitamin D status of veiled or dark-skinned pregnant women, because of their known increased risk of vitamin D deficiency. DESIGN: An audit of vitamin D status. SETTING: An antenatal clinic in a major metropolitan teaching hospital, Melbourne, Victoria. PARTICIPANTS: Pregnant women attending the clinic who agreed to be screened. MAIN OUTCOME MEASURES: Serum 25-hydroxyvitamin D3 (25OHD3) level at first visit to the antenatal clinic. RESULTS: Of 94 women, 82 were screened. Sixty-six women (80%) had 25OHD3 values below the test reference range (22.5-93.8 nmol/L). CONCLUSIONS: Our findings are a cause for concern, because vitamin D deficient women are at risk of bone disease and their children at risk of neonatal hypocalcaemia and rickets.     

Hepatitis B surface antigen, e antigen and HBV DNA in healthy antenatal patients attending Goroka Hospital and their relationship to tattooing practices

The prevalence of hepatitis B surface antigen (HBsAg) in women attending the antenatal clinic at Goroka Hospital was 14%. 32% of those positive for HBsAg also had hepatitis B e antigen (HBeAg), indicative of an infectious state. The mean HBV DNA level in HBeAg-positive women was 1800 pg/ml. These results suggest that vertical transmission of hepatitis B virus may be of importance in Papua New Guinea. Tattooing is common in this population: 91% of women in the study had tattoos. Methods employed in tattooing are a potential health risk but in a community which is now exposed to hepatitis B virus early in life tattooing practices are not important in the transmission of hepatitis B infection.     

Antenatal care of low risk obstetric patients by midwives. A randomised controlled trial.

OBJECTIVES: To assess the practicality, acceptability to patients and salary costs of the antenatal care of low risk obstetric patients by midwives. DESIGN: A randomised controlled trial. SETTING: The antenatal clinic at Westmead Hospital, a teaching hospital of the University of Sydney in western Sydney. PATIENTS: From January 1989 until November 1990, 89 women booking for full antenatal care at Westmead Hospital and classified as low risk were randomly allocated to one of two groups. Group 1 (43 patients) had their antenatal care provided by registered midwives. Group 2 (46 patients) had their antenatal care provided by an obstetrician (either Visiting Medical Officer or Staff Specialist) in a routine hospital antenatal clinic. INTERVENTIONS: Patients in the midwives' clinic were seen by an obstetrician at their first visit to the antenatal clinic and again at 30 weeks and at 40 weeks. MAIN OUTCOME MEASURES: These were the salary costs of each clinic and the patients' levels of satisfaction. Maternal and neonatal indicators, delivery details and analgesic requirements were also considered. These indicators were planned before data collection commenced. RESULTS: The major differences found were a 28% to 68% salary cost saving and that patients cared for by midwives showed appreciation of the continuity of care and information given at the midwives' clinic. CONCLUSIONS: The care of low risk obstetric patients by midwives in a midwives' clinic showed salary cost savings and high patient acceptance.     

同仁县2003-2007年孕产妇死亡评审结果分析

目的分析同仁县孕产妇死亡和死因变化规律,以便提出干预措施,切实降低孕产妇死亡率。方法严格按照世界卫生组织推荐的十二格表评审法、《孕产妇死亡评审标准》全国进行评审和分析。结果通过评审,明确了同仁县孕产妇死亡的原因依次为:第1位胎盘滞留占37.5%;第2位产褥感染25%;第3位羊水栓塞、葡萄胎,内科合并症12.5%。结论大部分孕产妇死亡为可避免死亡(75%),通过评审分析孕产妇死亡原因,提出有针对性的干预措施,提高我县妇幼保健工作质量。