"Near-miss" obstetric events and maternal deaths in Sagamu, Nigeria: a retrospective study

AIM: To determine the frequency of near-miss (severe acute maternal morbidity) and the nature of near-miss events, and comparatively analysed near-miss morbidities and maternal deaths among pregnant women managed over a 3-year period in a Nigerian tertiary centre. METHODS: Retrospective facility-based review of cases of near-miss and maternal death which occurred between 1 January 2002 and 31 December 2004. Near-miss case definition was based on validated disease-specific criteria, comprising of five diagnostic categories: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. The near-miss morbidities were compared with maternal deaths with respect to demographic features and disease profiles. Mortality indices were determined for various disease processes to appreciate the standard of care provided for life-threatening obstetric conditions. The maternal death to near-miss ratios for the three years were compared to assess the trend in the quality of obstetric care. RESULTS: There were 1501 deliveries, 211 near-miss cases and 44 maternal deaths. The total near-miss events were 242 with a decreasing trend from 2002 to 2004. Demographic features of cases of near-miss and maternal death were comparable. Besides infectious morbidity, the categories of complications responsible for near-misses and maternal deaths followed the same order of decreasing frequency. Hypertensive disorders in pregnancy and haemorrhage were responsible for 61.1% of near-miss cases and 50.0% of maternal deaths. More women died after developing severe morbidity due to uterine rupture and infection, with mortality indices of 37.5% and 28.6%, respectively. Early pregnancy complications and antepartum haemorrhage had the lowest mortality indices. Majority of the cases of near-miss (82.5%) and maternal death (88.6%) were unbooked for antenatal care and delivery in this hospital. Maternal mortality ratio for the period was 2931.4 per 100,000 deliveries. The overall maternal death to near-miss ratio was 1: 4.8 and this remained relatively constant over the 3-year period. CONCLUSION: The quality of care received by critically ill obstetric patients in this centre is suboptimal with no evident changes between 2002 and 2004. Reduction of the present maternal mortality ratio may best be achieved by developing evidence-based protocols and improving the resources for managing severe morbidities due to hypertension and haemorrhage especially in critically ill unbooked patients. Tertiary care hospitals in Nigeria could also benefit from evaluation of their standard of obstetric care by including near-miss investigations in their maternal death enquiries

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

Background Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival. Methods We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (USMR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index. Findings Global U5MR decreased from 71.2 deaths per 1000 livebirths (95% uncertainty interval WI] 68.3-74-0) in 2000 to 37.1 (33.2-41.7) in 2019 while global NMR correspondingly declined more slowly from 28.0 deaths per 1000 live births (26.8-29-5) in 2000 to 17.9 (16.3-19-8) in 2019. In 2019,136 (67%) of 204 countries had a USMR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030,154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9.65 million (95% UI 9.05-10.30) in 2000 and 5.05 million (4.27-6.02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3.76 million 95% UI 3.53-4.021) in 2000 to 48% (2.42 million; 2.06-2.86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0.80 (95% UI 0.71-0.86) deaths per 1000 livebirths and U5MR to 1.44 (95% UI 1-27-1.58) deaths per 1000 livebirths, and in 2019, there were as many as 1.87 million (95% UI 1-35-2.58; 37% 95% UI 32-43]) of 5.05 million more deaths of children younger than 5 years than the survival potential frontier. Interpretation Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve USMR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd

Outcome of Pregnancy and Labour in the Nullipara

Context: Nulliparous women are reportedly at a higher risk of developing complications of pregnancy and delivery than multipara. There is a need to document the outcome of their pregnancy in order to improve the quality of care they receive. Objectives: To find out problems associated with pregnancy and labour in the nullipara compared to their multiparous counterparts. Subjects and Methods: The delivery records of 528 nulliparous women and 2980 multipara delivering singleton babies at Ogun State University Teaching Hospital, Sagamu from January 1988 to December, 1990 were retrieved and data about the socio-demographic and clinical characteristics of the patients were extracted for analysis. Results: The mean age of the nullipara and the multipara were 21.2 (SD 3.5) years and 27.4 (SD 5.7) years respectively, a statistically significant difference (p < 0.001). The multiparae had a mean parity of 3.3 (SD 2.0). The nulliparae were significantly shorter (159.0cm; SD 6.1) than the multipara (160.7 cm; SD 1.3). The nullipara were more likely to have anaemia, preeclampsia, preterm births, prolonged second stage of labour, vacuum extraction and to give birth to lighter babies than the multipara (2.9 kg; SD 0.5) vs (3.1kg; SD 0.5). The multipara were at a higher risk of developing urinary tract infection in pregnancy, ante- and post- partum haemorrhage, fetal distress, retained placenta and perinatal mortality. Conclusion: Both the nullipara and multipara are exposed to a variety of complications in pregnancy, which require prompt and adequate attention in order to forestall perinatal and maternal morbidity and mortality. Key Words: Pregnancy, Parturient, Parity, Outcome. [Trop J Obstet Gynaecol, 2003, 20: 56-58

Isolated Giant Vulval Neurofibroma: A Case Report

A case of isolated giant vulval neurofibroma in a 34 year old para 1 lady is reported. She presented with a large vulval swelling involving labia majora, minora and the clitoris preventing her from having sexual intercourse. She had vulval biopsy sent for histopathological examination and it was diagnosed as “chronically inflammed neurofibroma of the vulval”. Because of the large size, simple vulvectomy was performed and she recovered well postoperatively. Literature on vulval neurofibroma regarding the presentation and management was revieved. Key Words: Vulva Neurofibroma, Vulvectomy [ Trop J Obstet Gynaecol, 2004;21:190-192

Prevalence of Obesity and its primary comorbidities among patients attending the dietetics out-patient clinic in a tertiary health institution in southwestern Nigeria

Objective: The study assessed the prevalence of obesity and its co-morbidities among patients attending the dietetics outpatient clinic of the hospital.Methods: The prevalence of obesity and its co-morbidities were assessed in this retrospective study from the available in the outpatient clinic of the Dietetics Department in University College Hospital Ibadan, Oyo State. Age, gender, occupation, religion, height, weight, diagnosed diseases were extracted from the record of individuals who presented at the clinic over 72 months. Data obtained was analyzed using the Statistical Package for Social Sciences (SPSS) version 20.Result: A total of 3248 patients’ records were assessed. Of these, 1174 (36.15%) patients met the criteria for obesity according to their recorded BMI; 614(52.3%) had obesity class I (BMI 30–34.9), 343(29.2%) had obesity class II (BMI 35–39.9) and 217(18.5%) had obesity class III (BMI ≥40). Obesity was significantly higher amongst females than males (p&lt;0.05). The most prevalent single co-morbidity was diabetes 22.3%, while the most prevalent double co-morbidity was hypertension/diabetes 22.9%.Conclusion: The prevalence of obesity amongst patients was significant. Diabetes and hypertension were the most dominant co-morbidity. Interventions should be developed to combat the increasing prevalence of the diseases and these should involve educating the public and clinical management of the diseases upon identification

Uterine Rupture: a Major Contributor to Obstetric Morbidity in Sagamu

Background: The incidence of uterine rupture is high in most developing countries and it is a leading cause of maternal mortality and morbidity. Objectives:To determine the incidence, aetiology and the associated morbidity and mortality in cases of ruptured uterus presenting at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. Materials and Methods: A review of all the case notes of patients that were managed for uterine rupture over a 7-year period was conducted. The records were analysed for the patients' mode of presentation, possible predisposing factors, type of uterine rupture, and the associated morbidity and mortality. Results: The incidence of rupture during the period was 1 in 67 deliveries or 14.9 per 1000 deliveries. The mean age [SD] was 30.1 [1.8] and the mean parity was 3.3 [0.93]. Majority (88.5%) of the patients were unbooked. Oxytocin administration was the identified aetiological factor in 41 (67.2%) of the patients. Majority (73.8%) presented with clinical signs of shock. At operation, 56 (91.8%) were found to have complete uterine rupture, with a predominance of anterior wall rupture (83.6%). Uterine repair with or without bilateral tubal ligation was the usual surgical treatment offered while wound sepsis, with or without generalized septicaemia, was the commonest morbidity found. Maternal mortality was 14.8%. Conclusion: Uterine rupture continues to be a major cause of maternal morbidity and mortality in Sagamu and efforts should be geared towards reducing the number of women affected by this problem. Key Words: Uterus Rupture, Genital Injury, Haemorrhage, Shock [Trop J Obstet Gynaecol, 2003, 20: 137-140

Maternal Deaths from Induced Abortions

Context: Unsafe abortion has grave implications for the life of a woman and her future reproductive career. Efforts to find the reasons underlying how a woman gets to the point of having an unsafe abortion, and means of preventing and minimising complications arising thereby are highly desirable. Objective: To find the extent to which unsafe abortion contributes to maternal mortality in our environment. Study Design, Setting and Subjects: A descriptive study of patients who were admitted for complications arising from induced abortions between January 1988 and December 2000 at Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria with the data being obtained from case records. Results: A total of 103 patients presented with complications arising from induced abortions. Twenty-one (20.4%) of these patients died as a result of complications arising thereby. During the same period, there were 71 deaths in the gynaecological ward. Thus, deaths from induced abortion accounted for 29.6% of all gynaecological deaths. There were 105 maternal deaths in the hospital during the period. Hence, induced abortions were responsible for 20% of all maternal deaths. The patients had various complications including 15 (71.4%) with septicaemia, 10 (47.6%) with anaemia, 7 (33.3%) each with jaundice and peritonitis. Conclusion: Abortion-related maternal death is still a major contributor to maternal mortality in this environment. Women empowerment, easy access to good quality and cheap family planning methods and post abortion care and rationalisation of abortion law may help to halt this stream of deaths from unsafe abortions. Key Words: Pregnancy, Unsafe Abortion, Maternal Mortality [Trop J Obstet Gynaecol, 2003, 20: 101-104

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health : all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

Background Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival. Methods We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (USMR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index. Findings Global U5MR decreased from 71.2 deaths per 1000 livebirths (95% uncertainty interval WI] 68.3-74-0) in 2000 to 37.1 (33.2-41.7) in 2019 while global NMR correspondingly declined more slowly from 28.0 deaths per 1000 live births (26.8-29-5) in 2000 to 17.9 (16.3-19-8) in 2019. In 2019,136 (67%) of 204 countries had a USMR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030,154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9.65 million (95% UI 9.05-10.30) in 2000 and 5.05 million (4.27-6.02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3.76 million [95% UI 3.53-4.021) in 2000 to 48% (2.42 million; 2.06-2.86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0.80 (95% UI 0.71-0.86) deaths per 1000 livebirths and U5MR to 1.44 (95% UI 1-27-1.58) deaths per 1000 livebirths, and in 2019, there were as many as 1.87 million (95% UI 1-35-2.58; 37% [95% UI 32-43]) of 5.05 million more deaths of children younger than 5 years than the survival potential frontier. Interpretation Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve USMR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.Peer reviewe