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Annettee Nakimuli (Obstetrician; Lecturer and PhD student in the Department of Obstetrics and Gynaecology, Makerere University)Maternal Mortality in Africa: Experiences of a Ugandan Obstetrician
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What are the causes of
maternal mortality in Africa?
Experiences of a Ugandan
ObstetricianAnnettee Nakimuli,
Obstetrician & gynaecologist,
Lecturer and PhD Student,
Makerere University(Uganda)
Preamble
• I have worked at Mulago Hospital for a
decade
• It is the National referral Hospital and
also the teaching hospital for Makerere
University
• It is the biggest hospital in the country
• Conducts close to 32,000 deliveries a
year
Map of Uganda
Selected health indicators for Uganda
1991-2011
Indicator YEAR
1991 1995 2002 2007 2011
Contraceptive Prevalence Rate 5 14.9 22.8 23.7 30
Total Fertility Rate 7.1 6.9 6.9 6.7 6.2
Unmet need for FP (%) 54 29 35 41
Maternal MR(100,000 live
births)
527 506 505 435 310
Adolescent pregnancy (%) 44 43 32 25
Infant MR (/1000) 122 81 85 76 54
HIV prevalence rate 30 15 6.1 6.4 7.3
Supervised deliveries (%) 38 38 38 41 57
Mulago Hospital
A typical day on the labour ward
• The team on duty consists of 5 doctors
• Duty starts at 8:00 am
• Followed by a round in the labour ward
that usually lasts 4 hours
• At the round clinical progress is
reviewed & prioritization of patients is
done
The work load on the ward
• 80-100 deliveries conducted daily
• This is over 3 times the bed capacity
• On average 20 caesarian sections
performed daily
• Generally 4 maternal deaths occur in a
week
Maternal mortality trends at Mulago
Hospital
Causes of maternal death at Mulago Hospital in Jan-Mar 2012
haemorrhage29%
pre-eclampsia14%
sepsis11%
abortion8%
others direct6%
indirect26%
unknown6%
Physical & psychological challenges of fistula
10
Challenges faced • Women present too late
• Patient congestion leading to “floor cases”
• Shortage of midwives
• Shortage of anaesthetists
• Inadequate supply of blood for transfusion
• Heavy loads of mothers in the antenatal clinics
• Inadequate intensive care facilities
• Shortage of basic supplies like suture materials, surgical gloves
• Poor staff remuneration
Records keeping
Floor cases on the ward
Why they come late• Await permission from spouses and close
social networks
• As a sign of strength
• Fear of caesarean delivery
• Use of local herbs
• Start with the traditional birth attendants
• Delay in referral
• Transport problems
• Failure to recognize danger signs of pregnancy
• Attitude of health workers
Male involvement is great sometimes
Effects of high maternal mortality
on the service providers
• Emotionally draining
• Poor and slow emergency response
• Lack of motivation to work
• “Blame game tactics”
• Worsening service delivery
• Mothers staying away or delaying to come
• Increasing maternal mortality!
Pre-eclampsia research• I am doing doctoral studies on the
immuno-genetics of pre-eclampsia
• I was inspired because pre-eclampsia is
common at Mulago
• Linked up with Prof Ashley Moffett
• Over 250 pre-eclamptics and 500 normal
controls recruited
• Genotyping performed at the University of
Cambridge
• Data analysis is underway
Preliminary research findings• A combination of immune genes in the
mother and fetus increase risk of pre-
eclampsia
• This combination is similar to that seen in
Caucasians
• Is more common in Africans
• A bit more from Ashley Moffett
Obstetricians & gynaecologists of Mulago Hospital
THANK YOUASANTE SANA
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