ASSESSMENT OF THE RISK APPROACH IN THE REDUCTION OF MATERNAL MORTALITY IN NORTH-CENTRAL NIGERIA

Abstract

Introduction

Risk screening during antenatal care has been traditionally believed to be impactful in maternal and newborn mortality reduction. Relative risk of death is commonly used as a guide for clinical practice. To inform good decision-making in planning maternal mortality reduction programs, the number of maternal deaths as well as the relative risk should be considered. The objective of this study was to predict the risk of death using the age distribution, parity and booking status of women who had maternal deaths in the four facilities during the 6 months study period.

Methods

This was a 6 month prospective, cross sectional study of maternal deaths from 1^st January, 2011 to 30^th June, 2011 using the emergency obstetric care register in four health facilities in Makurdi North-central Nigeria.

Results

Women aged 20-34 years accounted for 82% of deliveries and contributed 74% of maternal deaths. Primigravidae and grand multigravidae made up 569 (41%) of all deliveries but contributed 58% of all maternal deaths. Most (53%) maternal deaths occurred in booked women.

This is contrary to conventional knowledge where primigravidae, grand multipara, women who are unbooked, less than 20 years, 35 years and above, were expected to have high risk of maternal mortality.

Conclusion

This study shows that most maternal deaths occurred in the standard low risk women. Therefore age, parity and booking status do not predict maternal mortality accurately in this environment. All pregnant women should therefore be viewed as being at risk of maternal death all through pregnancy, delivery and puerperium.

Introduction

There are several interventions to reduce maternal mortality. They include: traditional birth attendants, antenatal care, family planning, skilled birth attendants at childbirth, emergency obstetric care etc. Maternal and newborn mortality have been used as a measure of the quality of antenatal services. Risk screening during antenatal care has been traditionally believed to be impactful in maternal and newborn mortality reduction. One of the primary goals of antenatal care is to identify those women with raised risks for problems during pregnancy or delivery, in order to ensure that precautionary measures are instituted where possible or more intensive medical care is available should it be needed. The definition of maternal risk is the probability of dying or being seriously injured during pregnancy. Safe motherhood programs have included risk assessment in antenatal care to identify women who could develop complications and then to refer women at high risk to a tertiary care institution. The concept of maternal risk as a tool for service delivery design is based on the following: certain groups of women have a higher likelihood of maternal death than other women; health workers can identify these women; and if they locate these women, health workers can prevent deaths.1 In the past, women were screened to determine who was at high risk of developing complications. Criteria, referred to as the “four toos” was used to screen women for this purpose. These include women who were: too young (less than 15 years); too old (greater than 35 years); too often (birth interval shorter than 24 months); and/or too many (greater than five pregnancies). In many countries, 50 to 60 percent of pregnancies are considered “high risk” using these screening parameters2.

In the developing world, where most women deliver outside formal health care facilities and emergency transport is often difficult or impossible to obtain, the ability to identify those women who are at high risk of delivery complications and who ought, therefore, to deliver at a hospital would be very valuable. Such referrals could greatly reduce the present high levels of maternal mortality and morbidity, if women followed the recommendations and if effective hospital care were then provided. Despite all the attention paid to identifying "high risk" women during pregnancy, there are no published studies linking risk factor identification with reduced maternal or perinatal morbidity or mortality. There are many reasons for the paucity of data on this complex inter-relationship, including lack of conceptual clarity among clinicians working in this area, multifactorial outcomes and aetiologies, logistical difficulties in implementing needed research, and ethical dilemmas. Unlike other types of epidemiological research, which look at risk factors as a means of untangling aetiologies, obstetric risk factors are often used as a screening device to assist in patient management. In this situation, a risk factor is noteworthy if it is an effective predictor of the outcome of interest, even if it is only indirectly related to the outcome and cannot by itself be changed or prevented. Risk factor identification is often focused on secondary rather than primary prevention, since many maternal complications can be treated but not prevented from occurring. Research into obstetric risk factors has not been a high priority in industrialized countries, since most women have ready access to prompt and competent medical care there and poor maternal outcomes are relatively rare. Maternal risk factors have been studied primarily for their value in predicting or preventing unfavourable perinatal outcomes. 3,,5,6,7 The role that pregnancy care, as distinct from delivery care, has played in the dramatic decline in maternal mortality in the developed world is not clear. The effectiveness of the formal risk-approach strategy to the reduction of maternal mortality and morbidity has not been systematically examined in trials. There is a need to confirm or refute their supposed benefits. Basic and epidemiological research on antenatal care in developing countries is not an academic luxury but essential in planning effective health services to reduce maternal and newborn mortality and morbidity.8,9

The Federal Ministry of Health in Nigeria, in an effort to achieve the 4^th and 5^th Millennium development goals designated The Federal Medical Centre Makurdi, Benue State as an Emergency Obstetric and Neonatal Care training centre since 2003. Several cadres of doctors ranging from Youth Corps Doctors to consultant obstetricians and paediatricians have been trained on emergency Obstetric and neonatal care in the institution. The hospital has partnered with the Federal Ministry of Health, UNICEF, World Bank, Health System Development project, WHO, Partnership for transforming health systems etc to achieve this objective. The objective of the training is to build the capacity of the doctors on the management of women with obstetric complications with particular emphasis on their attitude, knowledge, skills and audit / judgement/decision making capacity. Four facilities had been used for the training, they include, The Federal Medical Centre Makurdi, Benue Women Hospital Makurdi, Family Support Clinic Makurdi and the Bishop Murray Medical Centre Makurdi. The audit is facilitated by the prospective documentation of delivery statistics, obstetric complications and maternal mortality from these facilities in the emergency obstetric care register. The objective of this study was to predict the risk of death using the age distribution, parity and booking status of women who had maternal deaths in the four facilities during the 6 months study period.

Reports

Methodology

This is a 6 month prospective, cross sectional study of maternal deaths from 1^st January, 2011 to 30^th June, 2011 at the Obstetric services of The Federal Medical Centre Makurdi, Benue Women Hospital Makurdi, Family Support Clinic Makurdi and the Bishop Murray Medical Centre Makurdi after obtaining their Ethical Board approvals.

Results

The average gestational age at presentation was 39weeks 3 days with a range of 35 weeks one day to 44 weeks 6 days.

Table 1: Maternal Mortality by Age

Age	Number of deliveries	Number of Maternal deaths	Maternal Mortality ratio*	% of deliveries	% of Maternal deaths	Relative Risk of maternal death
<2020-2425-2930-3435-3940 and aboveMissing	1043274772861172462	144631-	9521,2238392,0982,5644,167-	723342082	5212132165	0.70.90.61.51.93.1
Total	1,397	19	1,360

*Maternal deaths per 100,000 deliveries.

The relative risk for women aged 20-34 years (low risk pregnancy) was 0.9

Table 2: Maternal Mortality by Parity and Booking Status

Parity	Number of deliveries	% of deliveries	Number of Maternal deaths	% of Maternal deaths	Relative Risk of maternal death
1	370	26	4	21	0.8
2-4	828	59	8	42	0.7
5- Above	199	14	7	37	2.6
Total	1397	100	19	100
Booking Status
Booked	1000	72	10	53	0.7
Unbooked	397	28	9	47	1.7
Total	1397	100	19	100

Conclusions

This study shows that most maternal deaths occurred in the standard low risk women. Therefore age, parity and booking status do not predict maternal mortality accurately in this environment. All pregnant women should therefore be viewed as being at risk of maternal death all through pregnancy, delivery and puerperium.

Discussion

The main finding of this study was that all pregnant women were at risk of maternal mortality irrespective of their risk categorization. Sociodemographic risk factors are poor predictors of direct maternal mortality because a good number of pregnant women without these risk factors accounted for a high proportion of deaths in this study. We found that even though majority of women that died were aged 20-34 years or booked, these women were not at risk since their relative risks were less than 1. Based on the finding of this study, primigravidity was not a risk factor for maternal mortality. During the 6 months study period, there were 1,397 deliveries and 19 maternal deaths giving a maternal mortality ratio of 1,360/100,000 total deliveries. Out of these deaths 18 (95%) were due to direct obstetric complications while one was an indirect death due to HIV infection. Primigravidae and grand multigravidae made up 569 (41%) but accounted for 58% of the deaths with a relative risk of 0.8 and 2.6 respectively. This implies that primigravida is not a risk factor for maternal death. Though the relative risk in booked women was 0.7, they accounted for most of the deaths (53%). The unbooked women had a relative risk of 1.7 but constituted 28.42% of all the deliveries indicating that they had a risk of death. Women aged 20-34years accounted for 81.6% of deliveries and contributed (73.63%) of direct maternal deaths.Though most deaths occur in this age range the relative risk was 0.9%.

Significance of the findings

This finding shows that, contrary to the expectations in routine obstetric practice, majority of maternal deaths occur in the low risk group. This finding is in agreement with findings from other studies8,10,11. Several studies have been done on maternal mortality and on the assessment of risk factors for maternal deaths12,13,14,15,16,17,18,19,20,21. These have revealed that age, parity, education of mothers, obstetric factors, unavailability of health facilities and trained health personnel, and socio-economic factors, are associated with an increased risk of maternal death. There was less agreement on the cut-off points of these factors. Most of the previous studies did not consider the absolute numbers of maternal deaths in the low risk group. Prerequisites for risk systems to work like a reliable rating system, effective teaching and application of the system, a reasonable cost, and adequate referral and / or treatment were lacking in previous studies.

Implications of the findings

This study shows that; age, parity and booking status were not reliable predictors of maternal deaths. Using screening of these risk factors in pregnant women to identify those at high risk of death will neglect the low-risk women when, in fact, most complications and deaths occurred in this group. Using the booking status to prevent obstetric complications is ineffective as most of the women that died were booked.

The limitation of this study was that it was not a randomized controlled trial of pregnant women to identify those who develop obstetric complications or maternal mortality. Further research need to be conducted to develop better screening parameters and to understand the role of social risk factors in maternal mortality.

The unanswered question in this study is how to develop a comprehensive screening method that would accurately identify pregnant women who would develop major complications or die during pregnancy, childbirth or puerperium.