Inequalities in maternal health and pregnancy outcome among Nigerian women migrated to Italy

Among migrant women, unfavourable health conditions and adverse obstetric events are observed more often than in native-born parturients. This observational retrospective study evaluated selected pregnancy outcomes in a Nigerian population giving birth at the University Hospital of Verona. Compared to national controls, being Nigerian was associated with preterm birth (aOR 1.6, 95% CI 1.1-2.2) and Cesarean section (aOR 2.2, 95% CI 1.5-2.7). No differences were found in rates of instrumental delivery and the immigrant group had half the risk of genital tears (aOR 0.6, 95% CI 1.1-2.2) with a higher likelihood of undamaged genitals (aOR 1.5, 95% CI 1.3-2.1). Perinatal indicators of neonatal distress were increased among Nigerians, namely a low Apgar score (aOR 2.6, 95% CI 1.4-4.9), NICU admission (aOR 1.7, 95% CI 1.1-2.8), and stillbirth (aOR 4.0, 95% CI 1.3-12.8). In conclusion, sub-Saharan African women of Nigerian origin appeared more vulnerable and exposed to several adverse pregnancy outcomes. These disparities call for the improvement of obstetric care in this immigrant group. Parmis les femmes migrantes, des conditions de santé défavorables et des événements obstétricaux indésirables sont observés plus souvent que chez les parturientes natives. Cette étude rétrospective observationnelle a analysé certaines issues de la grossesse sélectionnées dans une population nigériane accouchant à l'Hôpital Universitaire de Vérone. Par rapport aux témoins nationaux, le fait d'être nigérian était associé à la prématurité (aOR 1.6, 95% CI 1.1-2.2) et à la césarienne (aOR 2.2, 95% CI 1.5-2.7). Aucune différence n'a été trouvée dans les taux d'accouchements instrumentaux et le groupe d'immigrants avait la moitié du risque de déchirures génitales (aOR 0.6, 95% CI 1.1-2.2) avec une probabilité plus élevée d'organes génitaux intacts (aOR 1.5, 95% CI 1.3-2.1). Les indicateurs périnatals de détresse néonatale ont été trouvés augmenté chez les nigérians, à savoir un faible score d'Apgar (aOR 2.6, 95% CI 1.4-4.9), l’admission en soins intensifs néonatals (aOR 1.7, 95% CI 1.1-2.8) et la mortinatalité (aOR 4.0, 95% CI 1.3-12.8). En conclusion, les femmes africaines subsahariennes d'origine nigériane semblaient plus vulnérables et exposées à plusieurs issues défavorables de la grossesse. Ces disparités appellent l'amélioration des soins obstétricaux dans ce groupe d'immigré

An Autopsy Study of Maternal Mortality in Mozambique: The Contribution of Infectious Diseases

Clara Menendez and colleagues analyze 139 complete autopsies following maternal deaths in Maputo, Mozambique and find a predominance of infectious and preventable causes

An autopsy study of maternal mortality in Mozambique: the contribution of infectious diseases

Background Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios. Methods and Findings We conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. HIV detection was done by virologic and serologic tests, and malaria was diagnosed by histological and parasitological examination. During 26 mo there were 179 maternal deaths, of which 139 (77.6%) had a complete autopsy and formed the basis of this analysis. Of those with test results, 65 women (52.8%) were HIV-positive. Obstetric complications accounted for 38.2% of deaths; haemorrhage was the most frequent cause (16.6%). Nonobstetric conditions accounted for 56.1% of deaths; HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis were the most common causes (12.9%, 12.2%, 10.1% and 7.2% respectively). Mycobacterial infection was found in 12 (8.6%) maternal deaths. Conclusions In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for HIV/AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement

Maternal outcome of pregnancy in Mozambique with special reference to abortion-related morbidity and mortality

In the capital city of one of the least developed countries, and using a hospital-based approach: The general aim was to characterise women who have undergone illegally and legally induced abortions, and to show the magnitude of both maternal mortality and abortion-related severe morbidity in adolescents and non-adolescents, in order to call the attention of decision-makers and health planners to this hazardous reality. Methods: In the Department of Gynaecology and Obstetrics of the Hospital Central do Maputo, 103 women undergoing induced legal abortion (LA), 103 women with confirmed, recent illegal abortion (IA), and 100 antenatal clinic (AC) attendees were compared, in order to find characteristic features regarding level of education, habitation, household, employment and religious belief. Reproductive characteristics were also compared. Prevalence of sexually transmitted diseases (STDs) among LA and IA women was also studied. Outcome measures comprised treatment cost ill hospital and individual cost for the woman and post-abortion health consequences. During the five-year period 1989-1993, all maternal deaths among deaths of women 10-45 years were analysed. Information was recovered from medical records, antenatal cards and autopsy records, if available. All the admission books during 1990-1999 from the gynaecology emergency ward were reviewed in order to retrieve all data on women who had sought care for incomplete abortion. For those cases of severe morbidity that were submitted to surgery tile registration books of the operating theatre were reviewed. Individual records of the deceased women were also examined. Results: Women with IA, in relation to women with LA, differed significantly in the following respects: they were younger. more often single, had lower income and education and belonged to the lower social stratum. They were less often Catholics. More often, their first sexual intercourse and their first pregnancy occurred below 20 years of age and they ]lad less knowledge of contraceptives. AC women were found to be similar to LA women in several respects but the pattern was not consistent throughout. Three maternal deaths occurred, all in the IA group. The most frequent illegal abortionist was a health worker. The hospital cost was significantly higher for IA than for LA women- The opposite was found regarding individual costs. The prevalence of syphilis, gonorrhoea and chlamydial infection was high and similar in both IA and LA groups. The MMR among adolescents was higher than among non-adolescents and the most prevalent causes of death in adolescents were malaria (27%) and pregnancyinduced hypertension/eclampsia (21%). Out of 148 women with severe complications of induced abortion 38 died shortly after admission and 110 women were submitted to surgical intervention, due to peritonitis. Out of these 110 as many as 55 (50%) had associated uterine perforation. Twenty-three (21%) died after surgery. Haemorrhage and sepsis were the most common complications. Conclusion: IA women in Maputo belong to a poor segment of the population and safe abortion is more expensive for the individual woman than an unsafe, illegal one. They are at a disadvantage regarding early, unprotected sexual intercourse with first pregnancy at a young age and with almost no experience of safe abortion. The tragic complications of unsafe abortion, particularly the adolescent maternal deaths, should be addressed. Access to contraceptives and to safe legal abortion, should be improved. Urgent interventions are needed to reduce the high prevalence of STDs and consequently their adverse consequences

Advantages of Peritoneal Closure at the Time of Cesarean Section

Hemorrhage during pregnancy is a major cause of severe maternal morbidity and mortality in high as well as in low resource settings. In particular during Cesarean section (CS), intraoperative and post-operative bleeding may become lifethreatening emergency. Consequently, any strategy to reduce severe blood loss deserves consideration and eventual implementation. We would like to call attention upon the controversy over closure or non-closure of the parietal peritoneum during the CS surgical procedure, an issue currently being debated among obstetricians

Reproductive characteristics and post-abortion health consequences in women undergoing illegal and legal abortion in Maputo

In the Maputo Central Hospital 103 women undergoing induced legal abortion (LA), 103 women with confirmed, recent illegal abortion (IA), and 100 randomly recruited antenatal clinic (AC) attenders were compared in order to find characteristic features regarding obstetric history, reproductive performance and contraceptive knowledge, attitude and practice. Women with IA were younger, had almost never undergone LA, had more often their first sexual intercourse and their first pregnancy below 20 years of age, had less knowledge of contraceptives and more often had never used contraceptives, had fewer previous spontaneous abortions and fewer previous stillbirths than LA women. There were three maternal deaths, all in the IA group. The most frequent illegal abortionist was a health worker (38%). It is concluded that, in this first comparative African study on IA and LA regarding reproductive profile and post-abortion health consequences, the former are at a disadvantage regarding early unprotected sexual intercourse with first pregnancy at a young age and with almost no experience of safe, legal abortion.illegal abortion legal abortion Mozambique

Maternal near miss and maternal deaths in Mozambique: a cross-sectional, region-wide study of 635 consecutive cases assisted in health facilities of Maputo province

Background: Life-threatening events during pregnancy are currently used as a measure to assess quality of obstetric care. The aim of this study is to assess prevalence of near miss cases and maternal deaths, to elucidate the causes and to analyze avoidable factors based upon the three-delays approach in southern Mozambique. Methods: Near miss cases comprised five categories: eclampsia, severe hemorrhage, severe sepsis, uterine rupture and severe malaria. Pregnant women surviving the event were interviewed during a 5-month period within five health facilities offering comprehensive emergency obstetric care in Maputo City and Province. Family members gave additional information and were interviewed in case of the patient's death. Results: Out of 27,916 live births, 564 near miss cases and 71 maternal deaths were identified, giving a total maternal near miss ratio of 20/1,000 live births and maternal mortality ratio of 254/100,000 live births, respectively. Near miss fatality rate was 11.2%. Among near miss cases hemorrhage accounted for the most common event (58.0%), followed by eclampsia (35.5%); HIV seroprevalence was 22.3%. Inappropriate attendance in antenatal care services (21.1%), late or wrong diagnosis (12.6%), inadequate management immediately after delivery (9.6%), no monitoring of blood pressure and other vital signs (9.2%) were the most prevalent factors contributing to the severe morbidity under study. Third delay was identified in 69.7% of the interviews. In more than one fourth of near miss cases treatment was not started immediately. Lack of blood derivates and unavailable operating room were reported in 42.0% and 35.0%, respectively. Conclusions: Near miss cases were frequent and related to delays in reaching and receiving adequate care. First and third type of delay contributed significantly to the number of maternal near miss cases and deaths. Maternal health policies need to be concerned not only with averting the loss of life, but also with ameliorating care of severe maternal complications at all levels including primary care. Sexual and reproductive health services for adolescents should be prioritized to prevent adverse outcomes

Clinico-Pathological discrepancies in the Diagnosis of Causes of Maternal Death in Sub-Saharan Africa: Retrospective Analysis

Background Maternal mortality is a major public-health problem in developing countries. Extreme differences in maternal mortality rates between developed and developing countries indicate that most of these deaths are preventable. Most information on the causes of maternal death in these areas is based on clinical records and verbal autopsies. Clinical diagnostic errors may play a significant role in this problem and might also have major implications for the evaluation of current estimations of causes of maternal death. Methods and Findings A retrospective analysis of clinico-pathologic correlation was carried out, using necropsy as the gold standard for diagnosis. All maternal autopsies (n ¼ 139) during the period from October 2002 to December 2004 at the Maputo Central Hospital, Mozambique were included and major diagnostic discrepancies were analyzed (i.e., those involving the cause of death). Major diagnostic errors were detected in 56 (40.3%) maternal deaths. A high rate of false negative diagnoses was observed for infectious diseases, which showed sensitivities under 50%: HIV/AIDS-related conditions (33.3%), pyogenic bronchopneumonia (35.3%), pyogenic meningitis (40.0%), and puerperal septicemia (50.0%). Eclampsia, was the main source of false positive diagnoses, showing a low predictive positive value (42.9%). Conclusions Clinico-pathological discrepancies may have a significant impact on maternal mortality in sub-Saharan Africa and question the validity of reports based on clinical data or verbal autopsies. Increasing clinical awareness of the impact of obstetric and nonobstetric infections with their inclusion in the differential diagnosis, together with a thorough evaluation of cases clinically thought to be eclampsia, could have a significant impact on the reduction of maternal mortality

Prevalence of the Major Diagnostic Errors by Pathology at Autopsy

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