Obstetric medicine in sub-Saharan Africa

Significant differences exist in pregnancy outcomes between high- and low-income countries. Pregnant women in England are more likely to die from medical problems in pregnancy,¹ while women in Uganda suffer from ‘direct’ causes such as post-partum bleeding and ruptured uterus.² One may surmise therefore that Obstetric Medicine specialists are best suited to the high-income setting, but a ward round on the maternal high dependency unit in Kampala, Uganda, tells a different story:

The first woman we see is gasping. She is 20-weeks pregnant and admitted having suffered a seizure, and is being treated with magnesium for eclampsia. The team considered cerebral malaria and meningitis, but no-one felt confident to perform a lumbar puncture (LP). The hospital laboratory has not been able to process serum samples for some months now so no blood investigations are back; she dies a few minutes later, and the cause of death recorded as eclampsia. Discussion with the family suggests a primary diagnosis of hyperemesis gravidarum.

The next lady was found confused by a landing spot near the lake. There is a vague history of an induced abortion some days ago. She has a fever and is being treated for puerperal sepsis, though the abdominal exam seems unremarkable. She has petechiae on her arms despite a normal platelet count and I raise her shoulders off the bed by lifting her head, so severe is the meningism. We revise the diagnosis to meningococcal meningitis and she is transferred to the medical hospital, one hour across town, a process that took three days due to logistical and financial issues. The LP suggested a subarachnoid bleed, a diagnosis many days too late.

Next, a woman 4-days postpartum who is hypoxic and being treated for pneumonia. She has sickle cell disease – a heaving precordium, tricuspid murmur and hepatomegaly suggest severe pulmonary hypertension. Despite the risks she has survived her sixth pregnancy, though her condition is now deteriorating. No-one ever talked to her about contraception, and she died some days later.

A woman attends postpartum but cannot give a history; she is aphasic and has a dense right hemiparesis. She is in heart failure and her swollen legs have ulcerated. Little can be established by listening to her galloping heart, and no ECG or echocardiography are available. Discussion with the mother reveals a history of palpitations and breathlessness, and an echo two weeks later reveals a tight mitral stenosis. Anticoagulation in pregnancy was never discussed, and she is discharged in a wheelchair. She quietly says thank you, with typical pseudobulbar dysphonia.

Another case of pre-eclampsia we are told – high blood pressure and proteinuria at 26-weeks – call a spade a spade! I carry my own glucometer as there is not currently one in the women’s hospital. The woman has diabetes, and is now frankly nephrotic. We discuss insulin therapy on a ward with no glucometer, and make up a regimen that would make my diabetologist colleagues wince. Her kidney function is very poor and we discuss the risks of continuing the pregnancy.

Then there is the postpartum woman with probable pulmonary embolus. A single dose of enoxaparin costs about a weeks’ average wage, so prophylaxis is not used in women undergoing caesarean section. We avoid a scan, initiate warfarin, and she is discharged 10 days later with a smile on her face. Another woman is deteriorating 3 days after losing her baby, due to pre-eclampsia again we are told. Her large thyroid goitre is buzzing with vascularity, and a diagnosis of Grave’s disease seems more likely. A woman in end-stage renal failure after a severe post-partum haemorrhage 6 weeks ago somehow survived a serum sodium of 108 mmol/l, a result not acted upon. The obstetric team admit not being comfortable with hypertonic saline. She cannot afford dialysis so we discuss potassium and bicarbonate and diuretics; we explain to the young woman’s mother that her daughter is unlikely to survive.

This is clearly an amalgamation of various ward rounds, but each day reveals several women suffering medical conditions related to their pregnancy. The final common pathway is a woman with a complex physiological derangement being attended to by a team of obstetricians with little knowledge of the evidence needed to make a correct diagnosis and offer appropriate care. The death or near-miss will more than likely be filed as a ‘direct’ obstetric complication, missing the complex interplay of medicine and obstetrics, and the focus on improving emergency surgical care will continue.³

The last two decades have seen obstetric physicians successfully carve out their niche within the health systems of high-income countries (HICs).^4,5 Since sub-speciality training in maternal–fetal medicine and a working relationship with physicians was already at least reasonably established, the typical obstetric physician is likely to hold an academic post in a tertiary or quaternary centre. They may spend their time interpreting specialised tests, addressing pregnancy in the context of rare disease and bringing together other medical specialists to deliver best-practice multi-disciplinary care^6–8 – a luxury afforded only by the wealthiest of health systems. The last place you would expect to find an obstetric physician is the tropics of sub-Saharan Africa, but I would argue no place is better. Nowhere is the need greater, the pathology denser, and may such gains be made from simple interventions.

As reported in this issue, pregnant women are suffering a huge array of general medical conditions, in departments with no maternal–fetal medicine sub-speciality training and little attention from medical departments.⁹ The practice of obstetric medicine is very different to that in HICs. An obstetric physician in Uganda must make clinical decisions in the absence of laboratory and imaging data. Glucometer strips and urine dipsticks are often out of stock. A CT scan is often of poor quality and rarely affordable. We therefore rely on the very basics of medicine; the minutiae of the history, a thorough examination, intuition, skills that have been lost in the modern well-resourced hospital. Work has begun in Kampala with joint lectures from physicians and obstetricians, plans for sub-speciality training in maternal–fetal medicine and a tentative plan to employ two in-house physicians, as the obstetrics department moves to a new specialised women’s hospital. They would clearly benefit from the support of our international community, and we look forward to the development of a manual of obstetric medicine adapted to the low-resource setting.

A literature base regarding deficiencies in obstetric medical care in Africa is emerging.¹⁰ Wium et al. in this issue describe the situation in South Africa, including the importance of data collection and the development of training programmes.¹¹ While we hope that changes in the balance of world trade, political stability and the avoidance of conflict will improve overall health outcomes in these areas, these medical interventions and training are essential to move towards more equitable maternal care.