Even when West African women have easy access to a maternity ward and essential obstetric care, many develop life-threatening complications of pregnancy, and the fatality rate associated with some complications can be quite high.1 In a study conducted in cities and towns in six countries, 3-9 women of every 100 giving birth developed a severe complication that was directly related to the pregnancy. Roughly one-third of those with sepsis or uterine rupture, and about one-fifth of those with eclampsia, died.
The study examined the incidence of pregnancy-related morbidity in the capital cities of Burkina Faso, Côte d'Ivoire, Mali, Mauritania and Niger, and in two small towns and a major city in Senegal. Maternity wards with midwives and doctors on staff were accessible in each study area; all of the cities also afforded easy access to hospitals where women could be seen for obstetric complications. Pregnant women were identified between December 1994 and June 1996, and were asked to participate in four survey interviews: one each at enrollment, at 32-36 weeks' gestation (as measured by weeks since their last menstrual period), at delivery and 60 days later. Although some of the home visits included physical examinations, researchers explained to the women that these examinations were only for purposes of the study, and they encouraged participants to get regular medical care.
In all, 20,326 women (virtually all pregnant women in the study areas) participated. On average, they were 27 weeks pregnant and 26 years old when they enrolled; three in 10 women were in the age-groups generally considered at risk for obstetric complications (i.e., younger than 20 and 35 or older). Most were married, and about half were literate. Excluding the current pregnancy, participants had been pregnant an average of 2.7 times.
By 36 weeks' gestation, the women had had, on average, 2.2 prenatal consultations; 7% had received no prenatal care. The majority of participants (81%) gave birth at a health center; of these, 72% were assisted by midwives, 21% by trained traditional birth attendants, 3% by doctors, and the rest by untrained attendants or family members. Among women who delivered at home, only 5% were attended by midwives or doctors, and 24% were assisted by trained traditional birth attendants.
Some 1,215 women experienced severe obstetric complications, such as hemorrhage requiring a blood transfusion or hospitalization, dystocia (mainly obstructed or prolonged labor, but also uterine perforation), hypertensive disorders (eclampsia, preeclampsia and hypertension leading to hospitalization or death) and sepsis. The resulting severe maternal morbidity ratio was 6.2 life-threatening conditions per 100 live births; this ratio ranged from 3.0 per 100 in Mali to 9.1 per 100 in the Senegalese city included in the study. Socioeconomic variations did not explain differences among sites.
The most common life-threatening pregnancy complication was hemorrhage, which accounted for 46% of severe complications; more than half of hemorrhages occurred during the postpartum period. Dystocia was the second most frequent severe complication, representing 31% of severe maternal morbidity. Hypertensive disorders accounted for 10% of life-threatening complications; sepsis, for 1%; and a variety of other causes, for 12%.
Forty-one women--or one woman for every 32 severe complications--died of these conditions. Case fatality rates ranged widely by type of complication. Thirty-three percent of women who developed sepsis, 30% of those who had a ruptured uterus and 18% of those with eclampsia died. By contrast, the proportion among those who had a hemorrhage or another type of complication was 3%. Hemorrhage accounted for the largest number of deaths (17), and other complications accounted for 4-7 deaths each.
According to the researchers, the findings that many women delivering in health facilities are not attended by doctors or midwives and that certain complications carry high risks of death suggest a "significant malfunctioning of public health services" and "an unsatisfactory quality of maternal health care" in these six countries. By clarifying maternal health needs and identifying conditions that often lead to obstetric deaths, the investigators hope to have contributed to a better understanding of severe maternal morbidity and thus to efforts to reduce maternal and perinatal mortality in West Africa.--D. Hollander
1. Prual A et al., Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates, Bulletin of the World Health Organization, 2000, 78(5):593-599.