Institutionen för folkhälsovetenskap / Department of Public Health Sciences
Abstract
Introduction: Life-threatening complications in pregnancy rarely achieves
public health prominence in the same way as maternal mortality partly
because they represent a wide spectrum of conditions. The improved level
of care in many high-income countries has significantly reduced morbidity
and risk of death from these conditions. However in low-income countries,
such as Uganda, weak and poorly resourced health systems, socio -cultural
factors and the threat by HIV/AIDS combine to increase the risk of
morbidity and death. The rationale for the studies was the need to
identify ways to promote health actions that can reduce maternal
morbidity from life-threatening pregnancy complications.
Aim: This thesis explores the role of HIV/AIDS in post abortion
endometritis-myometritis (PAEM) and postpartum endometritis-myometritis
(PPEM). It also examines audit of a subset of women with lifethreatening
pregnancy complications called "near miss cases"; monitoring of treatment
of lifethreatening pregnancy complications and socio cultural barriers to
access care in Uganda.
Methods: A case-control design was used over a 12-month period to study
the risk of HIV infection in women with and without PAEM and PPEM in one
hospital in Kampala, Uganda (papers 1&2). Then a subset of women (229)
with life-threatening pregnancy complications called "near miss cases"
were audited with respect to seeking care, access to services and quality
of care in 4 referral hospitals, over a 21 months period (Paper 3). A
cross sectional survey of all basic EmOC and comprehensive EmOC (district
hospital) facilities in Kiboga district was carried out over a two year
period to document treatment of women with lifethreatening pregnancy
complications. Met need for treatment of these cases was derived, in
relation to the population of the district (Paper 4). Seventeen FGD were
conducted with adult men and women and with adolescent boys and girls in
three study districts, on adolescence, their roles and responsibilities,
pre-marital sexual relations, HIV/AIDS, pregnancy and abortion. Content
analysis was used to describe the findings (Paper 5).
Results: HIV infection was not found to correlate with the risk for PAEM,
HIV-1 seroprevalence 17 (32.7%) among women with PAEM and 38 (36.5%)
among women without post-abortion infection; but this was double the
seroprevalence among antenatal clients in the same hospital, 14.6% in
1997. HIV-1 seroprevalence was significantly higher among women with
postpartum endometritismyometritis (PPEM) than controls, 26 (42.3%) and
26 (21.3%) respectively (p=0.002) OR 2.74 (95%Cl 1.34- 5.65). Over a
two-year period, there was a ten-fold increase in "met need" for
treatment of women with life-threatening pregnancy complications from 4%
to 47%. Births in health facilities increased from 17% to 24%. Met need
for cesarean sections increased from 1.3% to 2.3% and case fatality rite
for women with life-threatening complications decreased from 9.4% to
1.85%. A major finding was the gender inequality in income generation,
leading to different social and sexual strategies between adolescent boys
and girls. Customary requirements for boys to offer gifts or pay bridal
wealth in marriage and the local government taxation act, which
selectively taxes boys but not girls of the same age, serve to entrench
the subordinate roles of girls predisposing them to high-risk sexual
behavior. Lack of empathy and support from parents and the community for
an unmarried pregnant girl often leaves her without other options than to
resort to unsafe abortion.
Conclusions: The prevalence of HIV-1 among women with and without PAEM
was higher than in antenatal mothers, but HIV was not a risk factor for
PAEM. HIV-1 was found to be a risk factor for PPEM, these findings
further complicating management of these life-threatening complications
of pregnancy. Women who were treated for life-threatening pregnancy
complications survived in spite of substandard care identified in more
than half the cases. However audit of near miss cases might offer a
non-threatening stimulus for improving quality of obstetric care. More
than a ten-fold increase in treatment of life-threatening pregnancy
complications was achieved over a two year period, and this might offer
an important way of monitoring programmes for reduction of maternal
mortality. Engendering local government taxation act and customary
marriage requirements might reduce entrenching gender stereotypes among
adolescents. There is need to involve parents, teachers and adolescents
in dialogue on an enabling environment for safe transition from childhood
to adulthood