Int J Gynecol
O&et.
International
Federation
1991, 36: 195-201 of Gynecology
I95 and Obstetrics
The risk approach Yaounde experience
for reducing
B.T. Nasahaq* R.J. Leke”, A.S. Doh”, J. Kamdom O.M. Njikamb
maternal
Mayo”,
mortality:
J. Fomulua
the
and
“Department of Obstetrics and Gynaecology. University Centre for Health Sciences or Centre Universitaire des Science de Iu SantC (CUSS), University of Yaounde. Yaounde (Cameroon) and h WHO Centre.fi,r Research in Human Reproduction (Received (Revised
March
l6th,
1990)
and accepted December
19th. 1990)
Abstract A review of the strategy of the risk approach to maternal care in the obstetrics and gynecology services of CUSS over a 12-year period has been reported. By combining antepartum, intrapartum, and postpartum family planning components and by a rational of personnel and restricted deployment resources, the maternal mortality ratio was decreased by up to 60% in one unit and maintained at O-O.84 per 1000 in the other unit. The package is proposed as a prototype for Africa and the developing world.
deaths per thousand births are highest in Africa and are similar only to what was obtained in some countries of Europe in the 16th to the 18th centuries [4]. While ideas are many [3], little concrete work has been done to putting a stop to the staggering loss of maternal lives in Africa. This is mandatory because the deaths involve young women whose efforts sustain their families and contribute to the development of their communities. We report here our experience in Yaounde with the high risk approach to care of the mother as a strategy for reducing maternal deaths. Population of study
Keywords: Risk approach; ty; Political commitment.
Maternal mortali-
Introduction
Even though the standard of reporting is low and in most cases only fragmentary, several reports attest to the alarmingly high rates of maternal deaths in Africa [6,10,14]. Indeed, of all developing countries maternal *Present address: Regional in Family Health,
WHO,
Centre
Kigali,
for Training
and Research
B.P. 1324, Republic
of Rwan-
da.
Clinical and Clinical Research
0020-7292/91/$03.50 0
1991 International
This study was undertaken in Yaounde, the capital of the Republic of Cameroon and the seat of the only medical school in the country. The estimated population of Yaounde for 1985 was 525 000 with birth rate of 43/1000, or an estimated 22 575 deliveries per year. This population is served by the University Staff of two teaching referral hospitals, the Central Maternity (CM) from 1972 and the University Hospital Centre (UHC) from 1982. In addition there are 18 private maternity units in the city which deal principally with normal deliveries while complicated cases are referred mainly to CM. Referrals to CM were
Federation
Published and Printed in Ireland
of Gynecology
and Obstetrics
196
Nash et al.
mainly from within Yaounde with only about 10% coming from outside the city, both booked and unbooked. Unfortunately, statistics on the number of births assisted in the 18 private units are inaccurate and incomplete. Consequently our estimate of the number of deliveries has been based on the birth rate and total population of Yaounde, estimates of the Ministry of Plan and Regional Development. The UHC accepts booked cases only, over 80% of whom are high risk mothers. The two populations of women delivering in the CM and UHC are comparable by age groups, and parity but biased by socioeconomic status since at the time of the study, delivery was free only at the CM. However, several studies of weight gain during pregnancy and birthweights have revealed satisfactory nutritional status in both groups [ 111. It is estimated that about 85% or more of the total deliveries of the city of Yaounde take place in these units based on the observation that no complications of home deliveries have been received at the CM during the last 12 years. It is known that some traditional healers do work on inducing abortion because complications of such practice are frequently encountered in the same maternity. It should be assumed that few if any delivery is assisted by these healers at home. Moreover it is common for women who do not have time or easy transportation to reach hospital at the time of delivery, to report at the maternity after birth. Approximately 10-l 5% of all deliveries registered at CM annually were delivered before arrival. All mothers received for delivery at the CM had received antenatal care either at the adjacent MCH center or the CM itself or elsewhere. The MCH center sees approximately 20 000 antenatal cases a year of which 40% are new cases. A team of ten midwives run four antenatal clinics a week referring problem cases to the CM. Each mother is seen on average six times. Clinic conditions are tight for space, and minimal laboratory equipment for simple tests like hematocrit or urinary proteins, are nonfunctioning most of the Inr J Gynecol
Ohsrer 36
time. The workload on the midwives is crushing, and the waiting time for the patients exhaustively long. Methodology
A series of epidemiological studies were undertaken between 1973 and 1978 to establish the characteristics of women dying in our maternity services as previously described [ 121. Screening and referral guidelines are provided for the detection of patients at risk both during pregnancy and labor, while clinical skills in family planning are regularly updated. A regular rotation of staff through the major sections of the service, outpatients (antenatal, postnatal and family planning), labor ward and lying-in combined obstetrics and gynecology, ensures updating of clinical skills and the effective ad hoc deployment of staff from one section to the other as and when indicated by emergency increased workload in one of the sections or attrition of personnel. The results of these studies provided the course content for in-service training of all categories of personnel on the detection and management of high risk pregnancy. The objectives of the training were (1) To provide information on the causes of maternal mortality in the Central Maternity; (2) To develop skills in the detection of high risk factors associated with maternal mortality; (3) To acquire skills in the use of the partogram in the management of labor; (4) To acquire skills in the selection of mothers for contraception; (5) To acquire skills in the insertion of intrauterine contraceptive devices; (6) To acquire skills in the establishment and maintenance of service records. Family planning services were established in the CM in 1975, and in the UHC in 1982. In both institutions the services are run by midwives. Specialist obstetricians and gynecologists are involved with the selection of high risk pregnant mothers and thereafter routine care is provided by the midwives,
Risk upprouch
IO muternul
mortulit)
191
while back-up specialist support is available on a regular basis. Mothers in labor are monitored using the partogram as previously described [2]. Active management of the third stage by controlled cord traction has been routine practice since 1975. Specialist coverage of the labor ward is provided for 24 h including weekends and public holidays. Both our labor wards are unsophisticated. In both, our equipment is pinard stethoscopes, the partogram, blood pressure machines, blood bank and operating theatre blocks. Results Prevalence of high risk factors
I
The prevalence of risk factors have been shown to be 27.5% in the pregnant population studied both in urban [12] and rural [8] Yaounde. These include grand multiparity, teenage single mother, complicated past obstetric history, pre-eclampsia, previous or present medical complications etc.
Fig. 2. Relationship in each clinical group between normal spontaneous deliveries and deliveries requiring medical or surgical interference.
Relation between risk factor and pregnancy outcome
As previously published [ 121, 27.5% of the risk population cause about 67% of complications in labor and the pueperum. The value of the partogramme in the management of labor
Fig. I. The alert and action lines on the cervigograph showing the clinical subgroups. Group I : patients who delivered before the labor curve reached the alert line. Group 2: patients whose cervicograph crossed the alert line but who were delivered before it reached the action line. Group vicograph crossed the action line.
3: patients
whose cer-
Two-thirds of morbidity and mortality and 72% of deliveries with medical or surgical interventions occurred in group 3 where the labor curve was allowed to cross the action line (Figs. 1 and 2). This emphasizes the value of the action line in the management of labor [2]. However, since the presence of a risk factor may not always mean that the unwanted outcome will occur and vice versa, these results should be interpreted with caution. For this reason we do not determine the sensitivity or the specificity of our risk instrument which will be unnecessarily complicated for the levels of our midwifery personnel. We therefore rely heavily on clinical judgment for decision making. Clinical
and Clinical
Research
198
Nash et al
Maternal
mortality
trends I978-
I987
Maternal mortality in the central Hospital has maintained a significant downward trend over the period of study coming down from 200 to 60 per 1000 live births. In the UHC death has been almost completely eliminated. Causes of maternal mortality
The direct causes maternal mortality were: hemorrhage, 43.30%; pueperal sepsis, 16.70%. Indirect causes were: medical complications, 8.30%; 15.8%; pre-eclampsia/eclampsia, uterine rupture, 10.0%; others, 15.8%. Discussion Our studies have shown that about 28% of the pregnant population in Yaounde are high risk and cause approximately 67% of maternal morbidity and mortality [12]. By focusing on this high risk group it has been possible to reduce maternal mortality by 60% in the CM [7], and to maintain it at O-O.84 per 1000 live births in the UHC over the past 7 years. The latter compares very favorably with hospital maternal mortality ratios in developed countries and encouragingly better than results from most African countries [3-5,13,14]. In practice, the high risk approach reserves available resources and expertise for high risk cases while relegating the care of healthy pregnant mothers to less qualified staff. Secondly, screening for high risk factors was not limited to the antenatal period but continued during labor. In a previous unpublished report of 37 maternal deaths, we found inadequate care of hospitalized mothers in labor to be responsible for 54% of the deaths. In that report, we also estimated a 2% risk of death in the population studied. The use of our partogram with its alert (attention) line and action (interference) line provides an accurate and reliable guideline for the students, midwives and physicians in the prediction of early abnormalities, relating to both mother and fetus, requiring immediate management [2]. Since in most cases transfer to a secondary or tertiary center is called for, the real place of the parInt J Gynecol Ohstet 36
togram is in the rural areas. It has been successfully introduced in some rural maternities in Yaounde [8] and work towards expansion to other areas is ongoing. As mentioned earlier, the major difference in the two hospital populations was socioeconomic status since all patients admitted into the UHC are selected by their capacity to pay in addition to qualifying as a high risk mother. However, the nutritional status of both groups were comparable. Studies showed that weight gain during pregnancy was the same [l 11. Mean birthweights from both maternities are similar. The difference in the results obtained from the two maternities can therefore not be attributable to population differences but obstetric and logistic factors. By strict application of the risk approach, maternal mortality was reduced by 60% in 10 years in the CM and maintained at O-O.84 per 1000 live births in the UHC. The difference between these two institutions is organizational and logistic. The CM, has a heavy workload, conducting an average of 30-50 deliveries daily, both normal and abnormal and often lacking basic life saving drugs and materials while the UHC has a reasonable workload limited predominantly to the high risk group. However, for the risk approach to succeed, strong leadership is a sine qua non to ensure discipline, clear definition of individual and group roles, establishment of management protocols and to foster the team spirit. Maternal mortality pregnancy
and abortion
and ectopic
In a retrospective study in the CM (1973-1976) which did not include abortion and ectopic pregnancy, the maternal mortality ratio was 1.47 per 1000 live births. When these were included in a prospective study (1977) the maternal mortality ratio increased from 1.47 to 2.01. More recently no abortion death was recorded in the services reported by Leke [7]. On the other hand, studies reported from some developing countries [ 131and developed countries where preventable factors like
hemorrhage and sepsis have been reduced to a minimum, abortion deaths have assumed priority place. Therefore, in Yaounde, as indeed in some other developing countries, complications of delivery are far more important causes of death than abortions or ectopic pregnancy. Healthy women and safe childbirth Our adoption of the risk approach as a strategy for reducing maternal mortality is based on the thesis that pregnancy is not a disease. Evidence from our units [l 11, and from Nigeria [4], show that booked healthy women and the booked women with complications had by far the safest childbirth. Because of the serious shortage of doctors and specialists we use our midwives and midwife-assistants more extensively in the provision of care to healthy pregnant mothers; the more experienced midwives, doctors and specialists concentrate on risk patients. We believe that this model can be adapted with advantage in most African settings. Aspects of hospital management in relation to maternal mortality - Organization of the service. The main problem with most of our maternity units in Cameroon and indeed in Africa is lack of discipline and organization and good management. The notion of risk exists but the services are not organized to deal with these risk women as a group. For example, basic maternity audit is not undertaken annually. Even when it is, it is not given a high priority. The general complaint is lack of facilities and material, yet a strong case for obtaining necessary materials cannot be made without data. Regular maternal mortality conferences should be a springboard for data collection. Utilization of available services. Available services in Yaounde, especially the public services are overstretched. The MCH Centre in Yaounde sees a minimum of 20 000 pregnant mothers per annum with each mother making an average of six visits during pregnancy. One
would have expected that problems encountered by these mothers such as absence of laboratory facilities necessitating their referral to another laboratory, as well as waiting for long hours to be seen, would discourage clinic attendance. But this has not been the case. Annual maternity statistics show increasing utilization of about 10% of births each year. Indeed 15% of women are registered annually in the Central Maternity who deliver on their way to the hospital. What is required therefore is the construction of satellite maternities to cater for normal deliveries. By so doing the tertiary units will be decongested to cater for problem cases. Communication and maternal mortality. Whereas major fatal complications like postpartum hemorrhage and ruptured uterus have been completely eliminated from booked cases in the CM, these complications are still recorded among late transfers from rural communities and even from within the city itself. The most effective means of intra-city and even inter-city communication exists only for the military. Ambulance services are not efficiently organized in any of the institutions. Communication by road is not only difficult or impossible at certain times of the year but is often left to the family who are often without the means. Yet the relationship between the time interval from development of complication in labor to the provision of appropriate treatment is inversely related to maternal survival. Maternal mortality and family planning. Government permission to start this service in the maternity was given at a time when official policy was against family planning. The Annual Report of the Maternity Service (unpublished) then made a strong case for reducing parity and spacing births as a strategy for reducing maternal deaths, and this was granted. Concomitant with the decrease in maternal deaths has been an increase of over 40% acceptors and a decrease of high parity in our clinic population [9] (unpublished data). The profile of women seeking contraception has changed considerably over the reporClinical
and Clinical
Resmrclr
200
Nash et al.
ting period. Between 1975 and 1977, of the women seeking contraception, 70% were married and 66% were grandmultiparas, whereas by 1985 these figures had decreased to 51% and 36%, respectively [9]. Indeed the largest group of acceptors in 1985 were women of parity one to three, i.e. 36% as against 6% in 1975. It has not been possible to evaluate in more precise terms the impact of family planning on maternal mortality. The trends reported here show decreasing high risk groups in the maternity population. We have however not demonstrated a concomitant reduction in the total number of births. In a study of induced abortion in the central maternity in 1976 nearly 60% of patients were unmarried at a time when only 20% were contracepting. As of 1985 the proportion of single women seeking contraception had risen to 36%. Thus this can be seen to reflect a reduction in the number of unwanted pregnancies, even if not quantified in this study. Reducing maternal mortality: a political decision. In spite of the criminal level of
deaths of mothers in Africa, one is left with the impression that this is accepted as an act of God. Unlike the practice in Europe at the turn of the century and which still continues today, there is no confidential enquiry into the causes of maternal death. This should exist in all maternity units under the direct control of the appropriate Ministry. But it will be useful only if the principle of No name, no blame is adopted and if it looks at social causes. The full impact of the risk approach can be felt nationally only if there is the political will and commitment to do so, in keeping with the spirit of Mexico 1984 at the United Nations International conference on Population. For Cameroon, political commitment has been demonstrated in several ways, for example by the permission to extend the risk approach to all institutions in the country and by the formation of the Cameroon National Association for Family Welfare, with responInt J Gynecol Obsret 36
sibilities for family planning among other activities. The risk approach has already been tested, with very encouraging results, in six rural communities in the Centre Province [8]. For all Africa, and indeed the developing world, a serious rethinking of the policy for allocating available resources is mandatory. This should mean relating expenditure on defense, education and health to the basic needs of Health for All by the Year 2000. In order of priority this should be education, health and finally defense. One of the weaknesses of this paper is that the relative risk of the different factors have not been calculated nor have these factors been individually quantitatively evaluated for their impact on mortality. Work in this area is ongoing in the same maternity units. Conclusion A model of the risk approach developed by our group has been shown to be effective in reducing maternal mortality in two hospital institutions. It is proposed for adoption by other centers with similar problems. References Dobbie BM: An attempt to estimate the true rate of maternal mortality in sixteenth to eighteenth centuries. Medical History 26: 79, 1982. Drouin P, Nasah BT, Nkounawa, F: The value of the partogramme in the management of labour. Obstet Gynecol 53: 6, 1979. WHO/FHE/86.4, World Health Organization, Geneva, 1986. Harrison KA: A review of maternal mortality in Nigeria with particular reference to the situation in Zaria, Northern Nigeria, 19761979. Interregional Meeting on Prevention of Maternal Mortality, WHO, Geneva, 1985, unpublished. Lamb WH, Foord FA, Lamb CMB, Whitehead RG: Changes in maternal and child mortality rate in three isolated Gambian villages over 10 years. Lancet 1984. Editorial: Maternal Health in Subharan Africa, Lancet i: 1987. Leke RJ: Outcome of pregnancy and delivery at the Central Maternity, Central Hospital, Yaounde. Ann Univ Sci Sante 4: 322, 1987. Leke RJ, Nasah BT, Mtango FDF: Introduction of high
Risk upprouch to muirrnol
risk pregnancy care in rural Cameroon: health service research approach. J Obstet Gynecol East Central Afr 7: 7, 1988. 9 Lienou P: Evolution du Planning familial a Yaounde, Service de Gynkcologie (l975--l985), Projet de these pour I’obtention du diplome de Docteur en Mtdecine, Centre Universitaire des Sciences de la Sante. Universite de Yaounde, 1987 (unpublished). IO Mahler H: The safe motherhood initiative: a call to action. Lancet i: 1987. I I Nasah BT, Drouin P: Care of Mother in the Tropics, pp 33-35. Publishing and Production Centre for Teaching and Research, Yaounde, 1982.. I2 Nasah BT, Drouin P: Care of Mother in the Tropics, pp 10-14. Publishing and Production Centre for Teaching and Research, Yaounde, 1982.
I3
I4
mortulit)
201
Wanjala Samson et al: Mortality due to abortion at Kenyatta National Hospital, 19761983. Abortion: Medical Progress and Social Implications, Ciba Foundation Symposium 115. Pitman, London. WHO: Maternal mortality: helping women off road to death. WHO Chroniclevol 40: 175, 1986.
Address for reprints: B.T. Nash B.P. 1324 WHO Kigali Rwanda
Clinical
and Clinical
Research
O&et.
International
Federation
1991, 36: 195-201 of Gynecology
I95 and Obstetrics
The risk approach Yaounde experience
for reducing
B.T. Nasahaq* R.J. Leke”, A.S. Doh”, J. Kamdom O.M. Njikamb
maternal
Mayo”,
mortality:
J. Fomulua
the
and
“Department of Obstetrics and Gynaecology. University Centre for Health Sciences or Centre Universitaire des Science de Iu SantC (CUSS), University of Yaounde. Yaounde (Cameroon) and h WHO Centre.fi,r Research in Human Reproduction (Received (Revised
March
l6th,
1990)
and accepted December
19th. 1990)
Abstract A review of the strategy of the risk approach to maternal care in the obstetrics and gynecology services of CUSS over a 12-year period has been reported. By combining antepartum, intrapartum, and postpartum family planning components and by a rational of personnel and restricted deployment resources, the maternal mortality ratio was decreased by up to 60% in one unit and maintained at O-O.84 per 1000 in the other unit. The package is proposed as a prototype for Africa and the developing world.
deaths per thousand births are highest in Africa and are similar only to what was obtained in some countries of Europe in the 16th to the 18th centuries [4]. While ideas are many [3], little concrete work has been done to putting a stop to the staggering loss of maternal lives in Africa. This is mandatory because the deaths involve young women whose efforts sustain their families and contribute to the development of their communities. We report here our experience in Yaounde with the high risk approach to care of the mother as a strategy for reducing maternal deaths. Population of study
Keywords: Risk approach; ty; Political commitment.
Maternal mortali-
Introduction
Even though the standard of reporting is low and in most cases only fragmentary, several reports attest to the alarmingly high rates of maternal deaths in Africa [6,10,14]. Indeed, of all developing countries maternal *Present address: Regional in Family Health,
WHO,
Centre
Kigali,
for Training
and Research
B.P. 1324, Republic
of Rwan-
da.
Clinical and Clinical Research
0020-7292/91/$03.50 0
1991 International
This study was undertaken in Yaounde, the capital of the Republic of Cameroon and the seat of the only medical school in the country. The estimated population of Yaounde for 1985 was 525 000 with birth rate of 43/1000, or an estimated 22 575 deliveries per year. This population is served by the University Staff of two teaching referral hospitals, the Central Maternity (CM) from 1972 and the University Hospital Centre (UHC) from 1982. In addition there are 18 private maternity units in the city which deal principally with normal deliveries while complicated cases are referred mainly to CM. Referrals to CM were
Federation
Published and Printed in Ireland
of Gynecology
and Obstetrics
196
Nash et al.
mainly from within Yaounde with only about 10% coming from outside the city, both booked and unbooked. Unfortunately, statistics on the number of births assisted in the 18 private units are inaccurate and incomplete. Consequently our estimate of the number of deliveries has been based on the birth rate and total population of Yaounde, estimates of the Ministry of Plan and Regional Development. The UHC accepts booked cases only, over 80% of whom are high risk mothers. The two populations of women delivering in the CM and UHC are comparable by age groups, and parity but biased by socioeconomic status since at the time of the study, delivery was free only at the CM. However, several studies of weight gain during pregnancy and birthweights have revealed satisfactory nutritional status in both groups [ 111. It is estimated that about 85% or more of the total deliveries of the city of Yaounde take place in these units based on the observation that no complications of home deliveries have been received at the CM during the last 12 years. It is known that some traditional healers do work on inducing abortion because complications of such practice are frequently encountered in the same maternity. It should be assumed that few if any delivery is assisted by these healers at home. Moreover it is common for women who do not have time or easy transportation to reach hospital at the time of delivery, to report at the maternity after birth. Approximately 10-l 5% of all deliveries registered at CM annually were delivered before arrival. All mothers received for delivery at the CM had received antenatal care either at the adjacent MCH center or the CM itself or elsewhere. The MCH center sees approximately 20 000 antenatal cases a year of which 40% are new cases. A team of ten midwives run four antenatal clinics a week referring problem cases to the CM. Each mother is seen on average six times. Clinic conditions are tight for space, and minimal laboratory equipment for simple tests like hematocrit or urinary proteins, are nonfunctioning most of the Inr J Gynecol
Ohsrer 36
time. The workload on the midwives is crushing, and the waiting time for the patients exhaustively long. Methodology
A series of epidemiological studies were undertaken between 1973 and 1978 to establish the characteristics of women dying in our maternity services as previously described [ 121. Screening and referral guidelines are provided for the detection of patients at risk both during pregnancy and labor, while clinical skills in family planning are regularly updated. A regular rotation of staff through the major sections of the service, outpatients (antenatal, postnatal and family planning), labor ward and lying-in combined obstetrics and gynecology, ensures updating of clinical skills and the effective ad hoc deployment of staff from one section to the other as and when indicated by emergency increased workload in one of the sections or attrition of personnel. The results of these studies provided the course content for in-service training of all categories of personnel on the detection and management of high risk pregnancy. The objectives of the training were (1) To provide information on the causes of maternal mortality in the Central Maternity; (2) To develop skills in the detection of high risk factors associated with maternal mortality; (3) To acquire skills in the use of the partogram in the management of labor; (4) To acquire skills in the selection of mothers for contraception; (5) To acquire skills in the insertion of intrauterine contraceptive devices; (6) To acquire skills in the establishment and maintenance of service records. Family planning services were established in the CM in 1975, and in the UHC in 1982. In both institutions the services are run by midwives. Specialist obstetricians and gynecologists are involved with the selection of high risk pregnant mothers and thereafter routine care is provided by the midwives,
Risk upprouch
IO muternul
mortulit)
191
while back-up specialist support is available on a regular basis. Mothers in labor are monitored using the partogram as previously described [2]. Active management of the third stage by controlled cord traction has been routine practice since 1975. Specialist coverage of the labor ward is provided for 24 h including weekends and public holidays. Both our labor wards are unsophisticated. In both, our equipment is pinard stethoscopes, the partogram, blood pressure machines, blood bank and operating theatre blocks. Results Prevalence of high risk factors
I
The prevalence of risk factors have been shown to be 27.5% in the pregnant population studied both in urban [12] and rural [8] Yaounde. These include grand multiparity, teenage single mother, complicated past obstetric history, pre-eclampsia, previous or present medical complications etc.
Fig. 2. Relationship in each clinical group between normal spontaneous deliveries and deliveries requiring medical or surgical interference.
Relation between risk factor and pregnancy outcome
As previously published [ 121, 27.5% of the risk population cause about 67% of complications in labor and the pueperum. The value of the partogramme in the management of labor
Fig. I. The alert and action lines on the cervigograph showing the clinical subgroups. Group I : patients who delivered before the labor curve reached the alert line. Group 2: patients whose cervicograph crossed the alert line but who were delivered before it reached the action line. Group vicograph crossed the action line.
3: patients
whose cer-
Two-thirds of morbidity and mortality and 72% of deliveries with medical or surgical interventions occurred in group 3 where the labor curve was allowed to cross the action line (Figs. 1 and 2). This emphasizes the value of the action line in the management of labor [2]. However, since the presence of a risk factor may not always mean that the unwanted outcome will occur and vice versa, these results should be interpreted with caution. For this reason we do not determine the sensitivity or the specificity of our risk instrument which will be unnecessarily complicated for the levels of our midwifery personnel. We therefore rely heavily on clinical judgment for decision making. Clinical
and Clinical
Research
198
Nash et al
Maternal
mortality
trends I978-
I987
Maternal mortality in the central Hospital has maintained a significant downward trend over the period of study coming down from 200 to 60 per 1000 live births. In the UHC death has been almost completely eliminated. Causes of maternal mortality
The direct causes maternal mortality were: hemorrhage, 43.30%; pueperal sepsis, 16.70%. Indirect causes were: medical complications, 8.30%; 15.8%; pre-eclampsia/eclampsia, uterine rupture, 10.0%; others, 15.8%. Discussion Our studies have shown that about 28% of the pregnant population in Yaounde are high risk and cause approximately 67% of maternal morbidity and mortality [12]. By focusing on this high risk group it has been possible to reduce maternal mortality by 60% in the CM [7], and to maintain it at O-O.84 per 1000 live births in the UHC over the past 7 years. The latter compares very favorably with hospital maternal mortality ratios in developed countries and encouragingly better than results from most African countries [3-5,13,14]. In practice, the high risk approach reserves available resources and expertise for high risk cases while relegating the care of healthy pregnant mothers to less qualified staff. Secondly, screening for high risk factors was not limited to the antenatal period but continued during labor. In a previous unpublished report of 37 maternal deaths, we found inadequate care of hospitalized mothers in labor to be responsible for 54% of the deaths. In that report, we also estimated a 2% risk of death in the population studied. The use of our partogram with its alert (attention) line and action (interference) line provides an accurate and reliable guideline for the students, midwives and physicians in the prediction of early abnormalities, relating to both mother and fetus, requiring immediate management [2]. Since in most cases transfer to a secondary or tertiary center is called for, the real place of the parInt J Gynecol Ohstet 36
togram is in the rural areas. It has been successfully introduced in some rural maternities in Yaounde [8] and work towards expansion to other areas is ongoing. As mentioned earlier, the major difference in the two hospital populations was socioeconomic status since all patients admitted into the UHC are selected by their capacity to pay in addition to qualifying as a high risk mother. However, the nutritional status of both groups were comparable. Studies showed that weight gain during pregnancy was the same [l 11. Mean birthweights from both maternities are similar. The difference in the results obtained from the two maternities can therefore not be attributable to population differences but obstetric and logistic factors. By strict application of the risk approach, maternal mortality was reduced by 60% in 10 years in the CM and maintained at O-O.84 per 1000 live births in the UHC. The difference between these two institutions is organizational and logistic. The CM, has a heavy workload, conducting an average of 30-50 deliveries daily, both normal and abnormal and often lacking basic life saving drugs and materials while the UHC has a reasonable workload limited predominantly to the high risk group. However, for the risk approach to succeed, strong leadership is a sine qua non to ensure discipline, clear definition of individual and group roles, establishment of management protocols and to foster the team spirit. Maternal mortality pregnancy
and abortion
and ectopic
In a retrospective study in the CM (1973-1976) which did not include abortion and ectopic pregnancy, the maternal mortality ratio was 1.47 per 1000 live births. When these were included in a prospective study (1977) the maternal mortality ratio increased from 1.47 to 2.01. More recently no abortion death was recorded in the services reported by Leke [7]. On the other hand, studies reported from some developing countries [ 131and developed countries where preventable factors like
hemorrhage and sepsis have been reduced to a minimum, abortion deaths have assumed priority place. Therefore, in Yaounde, as indeed in some other developing countries, complications of delivery are far more important causes of death than abortions or ectopic pregnancy. Healthy women and safe childbirth Our adoption of the risk approach as a strategy for reducing maternal mortality is based on the thesis that pregnancy is not a disease. Evidence from our units [l 11, and from Nigeria [4], show that booked healthy women and the booked women with complications had by far the safest childbirth. Because of the serious shortage of doctors and specialists we use our midwives and midwife-assistants more extensively in the provision of care to healthy pregnant mothers; the more experienced midwives, doctors and specialists concentrate on risk patients. We believe that this model can be adapted with advantage in most African settings. Aspects of hospital management in relation to maternal mortality - Organization of the service. The main problem with most of our maternity units in Cameroon and indeed in Africa is lack of discipline and organization and good management. The notion of risk exists but the services are not organized to deal with these risk women as a group. For example, basic maternity audit is not undertaken annually. Even when it is, it is not given a high priority. The general complaint is lack of facilities and material, yet a strong case for obtaining necessary materials cannot be made without data. Regular maternal mortality conferences should be a springboard for data collection. Utilization of available services. Available services in Yaounde, especially the public services are overstretched. The MCH Centre in Yaounde sees a minimum of 20 000 pregnant mothers per annum with each mother making an average of six visits during pregnancy. One
would have expected that problems encountered by these mothers such as absence of laboratory facilities necessitating their referral to another laboratory, as well as waiting for long hours to be seen, would discourage clinic attendance. But this has not been the case. Annual maternity statistics show increasing utilization of about 10% of births each year. Indeed 15% of women are registered annually in the Central Maternity who deliver on their way to the hospital. What is required therefore is the construction of satellite maternities to cater for normal deliveries. By so doing the tertiary units will be decongested to cater for problem cases. Communication and maternal mortality. Whereas major fatal complications like postpartum hemorrhage and ruptured uterus have been completely eliminated from booked cases in the CM, these complications are still recorded among late transfers from rural communities and even from within the city itself. The most effective means of intra-city and even inter-city communication exists only for the military. Ambulance services are not efficiently organized in any of the institutions. Communication by road is not only difficult or impossible at certain times of the year but is often left to the family who are often without the means. Yet the relationship between the time interval from development of complication in labor to the provision of appropriate treatment is inversely related to maternal survival. Maternal mortality and family planning. Government permission to start this service in the maternity was given at a time when official policy was against family planning. The Annual Report of the Maternity Service (unpublished) then made a strong case for reducing parity and spacing births as a strategy for reducing maternal deaths, and this was granted. Concomitant with the decrease in maternal deaths has been an increase of over 40% acceptors and a decrease of high parity in our clinic population [9] (unpublished data). The profile of women seeking contraception has changed considerably over the reporClinical
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ting period. Between 1975 and 1977, of the women seeking contraception, 70% were married and 66% were grandmultiparas, whereas by 1985 these figures had decreased to 51% and 36%, respectively [9]. Indeed the largest group of acceptors in 1985 were women of parity one to three, i.e. 36% as against 6% in 1975. It has not been possible to evaluate in more precise terms the impact of family planning on maternal mortality. The trends reported here show decreasing high risk groups in the maternity population. We have however not demonstrated a concomitant reduction in the total number of births. In a study of induced abortion in the central maternity in 1976 nearly 60% of patients were unmarried at a time when only 20% were contracepting. As of 1985 the proportion of single women seeking contraception had risen to 36%. Thus this can be seen to reflect a reduction in the number of unwanted pregnancies, even if not quantified in this study. Reducing maternal mortality: a political decision. In spite of the criminal level of
deaths of mothers in Africa, one is left with the impression that this is accepted as an act of God. Unlike the practice in Europe at the turn of the century and which still continues today, there is no confidential enquiry into the causes of maternal death. This should exist in all maternity units under the direct control of the appropriate Ministry. But it will be useful only if the principle of No name, no blame is adopted and if it looks at social causes. The full impact of the risk approach can be felt nationally only if there is the political will and commitment to do so, in keeping with the spirit of Mexico 1984 at the United Nations International conference on Population. For Cameroon, political commitment has been demonstrated in several ways, for example by the permission to extend the risk approach to all institutions in the country and by the formation of the Cameroon National Association for Family Welfare, with responInt J Gynecol Obsret 36
sibilities for family planning among other activities. The risk approach has already been tested, with very encouraging results, in six rural communities in the Centre Province [8]. For all Africa, and indeed the developing world, a serious rethinking of the policy for allocating available resources is mandatory. This should mean relating expenditure on defense, education and health to the basic needs of Health for All by the Year 2000. In order of priority this should be education, health and finally defense. One of the weaknesses of this paper is that the relative risk of the different factors have not been calculated nor have these factors been individually quantitatively evaluated for their impact on mortality. Work in this area is ongoing in the same maternity units. Conclusion A model of the risk approach developed by our group has been shown to be effective in reducing maternal mortality in two hospital institutions. It is proposed for adoption by other centers with similar problems. References Dobbie BM: An attempt to estimate the true rate of maternal mortality in sixteenth to eighteenth centuries. Medical History 26: 79, 1982. Drouin P, Nasah BT, Nkounawa, F: The value of the partogramme in the management of labour. Obstet Gynecol 53: 6, 1979. WHO/FHE/86.4, World Health Organization, Geneva, 1986. Harrison KA: A review of maternal mortality in Nigeria with particular reference to the situation in Zaria, Northern Nigeria, 19761979. Interregional Meeting on Prevention of Maternal Mortality, WHO, Geneva, 1985, unpublished. Lamb WH, Foord FA, Lamb CMB, Whitehead RG: Changes in maternal and child mortality rate in three isolated Gambian villages over 10 years. Lancet 1984. Editorial: Maternal Health in Subharan Africa, Lancet i: 1987. Leke RJ: Outcome of pregnancy and delivery at the Central Maternity, Central Hospital, Yaounde. Ann Univ Sci Sante 4: 322, 1987. Leke RJ, Nasah BT, Mtango FDF: Introduction of high
Risk upprouch to muirrnol
risk pregnancy care in rural Cameroon: health service research approach. J Obstet Gynecol East Central Afr 7: 7, 1988. 9 Lienou P: Evolution du Planning familial a Yaounde, Service de Gynkcologie (l975--l985), Projet de these pour I’obtention du diplome de Docteur en Mtdecine, Centre Universitaire des Sciences de la Sante. Universite de Yaounde, 1987 (unpublished). IO Mahler H: The safe motherhood initiative: a call to action. Lancet i: 1987. I I Nasah BT, Drouin P: Care of Mother in the Tropics, pp 33-35. Publishing and Production Centre for Teaching and Research, Yaounde, 1982.. I2 Nasah BT, Drouin P: Care of Mother in the Tropics, pp 10-14. Publishing and Production Centre for Teaching and Research, Yaounde, 1982.
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Wanjala Samson et al: Mortality due to abortion at Kenyatta National Hospital, 19761983. Abortion: Medical Progress and Social Implications, Ciba Foundation Symposium 115. Pitman, London. WHO: Maternal mortality: helping women off road to death. WHO Chroniclevol 40: 175, 1986.
Address for reprints: B.T. Nash B.P. 1324 WHO Kigali Rwanda
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