IGBINEDION UNIVERSITY, OKADA

INAUGURAL LECTURE SERIES

'Ben-oni, son of my sorrow': Personal perspectives on the challenges of maternal

morbidity and mortality.

Jacob Aghomon UnuigbeMBBS (Ibadan), FWACS, FICS, FRCOGProfessor of Obstetrics and Gynaecology,

College of Health SciencesIgbinedion University

OKADA

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Preamble

INTRODUCTION

I feel inspired to commence this address with an important Biblical reference:

Rachel was about to die, but with her last breath she named the baby Ben-oni, which means 'son of my sorrow'. The baby's father, however, called him Benjamin, which means 'son of my right hand'. Genesis 35:18

The concept of 'Sorrow' here depicts misery, mourning, sadness, hopelessness, weakness, danger, defeat, destruction, and death. This concept represents maternal morbidity and mortality. On the other hand, 'Right Hand' represents cheerfulness, celebration, happiness, hope, strength, safety, victory, survival, and life, all accompaniments of safe motherhood.

The word Perspective is chosen here as it derives from the Latin word perspicere, to inspect carefully, from per- (intensive) and specere (to behold). The Collins World English Dictionary has many meanings for perspective, two of which are considered relevant here: a way of regarding situations, facts, etc and judging their relative importance; the proper or accurate point of view or the ability to see it objectively.

Medical studies

It is by God's grace and divine intervention that my late father wisely removed me, a 'spoilt over-indulged' nine year-old last child, from my doting late mother and from my hometown, Erah in Owan East LGA, to live with my eldest brother, then unmarried, at the University College Ibadan (UCI). The experience of seeing medical students shuttling between their halls of residence and the preclinical departments in UCI, and the admirable debonair carriage of Drs Adenle and Boyd, staff medical officers of the UCI Jaja Staff Health Centre, all so close to my school, Abadina primary school in UCI, influenced and inspired me as I proceeded to Holy Trinity Grammar School, HTGS, Sabongidda-Ora in 1961. While at school in Ora, I resolved to return and join these mentors viewed as 'medical heroes' as soon as I could. My efforts with prayers were amply rewarded for, after HTGS in

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1965, I returned to the University of Ibadan (UI) in September 1966, this time, as a medical student.

I join the numerous students of Midwestern State of Nigeria origin of the Nigerian civil war generation in paying special tribute to the then Military Governor, Brigadier S. O. Ogbemudia, and his then Commissioner for Education, Chief Edwin Clark, for the generous across-the-board bursary awards to all students of Midwestern State origin in 1967. This measure paved the way to the future main source of staff development in the University of Benin. Specifically, the first set of house officers recruited to the new University of Benin Teaching Hospital, UBTH, an unbelievable total of 19 house officers in 1972, were almost without exception beneficiaries of these bursary awards. I was one of these fortunate house officers. It may interest us to note that I was the house surgeon on duty in the emergency room on that memorable day in May 1973, when the then Nigerian First lady, Mrs. Victoria Gowon, formally opened the University of Benin Teaching Hospital.

Recruitment into Obstetrics and Gynaecology Specialty

The mentor that I found in the person of late Professor Tiramiyu Belo Osagie, B.Sc, MD, FRCOG, CON, the pioneer rector of the UBTH/pioneer Dean and later first Provost of the College of Medicine, University of Benin, channeled my decision to specialize in the Obstetrics and Gynaecology specialty. Not only was my internship in this specialty conducted with utmost vibrant enthusiasm under my mentor, he actually simply decided that his professional son and protégé had no choice but to continue residency training in his department after my house job.

The next three years at the UBTH as a resident in Obstetrics and Gynaecology under tutelage of amiable and competent teachers, Professors L. N. Ajabor, A. U. Oronsaye, F. M. Diejomaoh, Drs M. Asuen and S.E. Okojie, saw me through the gruesome rigours of Obstetric and Gynaecological practice in the developing world. It was during these preliminary years of my life as a trainee obstetrician that a seed was sown within me; the seed that germinated over years into appreciation of all elements of the perils of motherhood and the travails and odyssey that lock within.

By the conclusion of my residency training in the United Kingdom followed by assumption of consultant status back in the UBTH, the appreciation of human suffering entailed in motherhood had taken a substantial dominion over my professional and academic life. This is in effect what this inaugural address is all

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about: my personal perspectives on maternal morbidity and mortality, with my professional and academic contributions in maternal care, over a period spanning over 40 years.

CLINICAL AND RESEARCH ACTIVITIES ON MATERNAL MORBIDITY AND MORTALITY,

1980-2013

Overview of Maternal Morbidity and Mortality

By the mid 80s, an estimated 585,000 Maternal deaths occurred globally annually, i.e., one maternal death per minute 1. In 1996, WHO and UNICEF 2 revised the estimates and showed that the scale of the problem was even greater, that closer to 600,000 maternal deaths occurred each year. Of these, a total of <4,000 Maternal deaths (<1%) occur in Developed countries which accounted for 13% of the world’s births. Death Ratios are highest in Africa, (notably sub-Saharan), Asia and Latin America.

Table 1: OVERVIEW OF MATERNAL MORTALITY

1. About 585,000 Maternal deaths annually

2. <4,000 Maternal deaths (<1%) occur in Developed Countries which account for 13% of the world’s births.

3. Death Ratios are highest in Africa, (notably Sub-Saharan), Asia and Latin America.

4. The Life-Time Risk (LTR) of dying from Pregnancy-related causes in Developing Countries is often greater than 1 in 60. In developed countries, the LTR is often less than 1 in 2000.

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Table 2: DEFINITIONS

1. MATERNAL MORBIDITY Specifically refers to serious illnesses complicating pregnancy, delivery and the puerperium.

2. MATERNAL MORTALITY Death of a woman during pregnancy, delivery and up to 42 days after pregnancy termination.

3. MATERNAL MORTALITY RATIO The number of maternal deaths divided by the number of live births. Usually expressed as per 100,000 MMRatio = No. Mat. Deaths X 100,000 No. Live births

4. MATERNAL MORTALITY RATE The number of Maternal deaths divided by the number of women of reproductive age. MMRate = No. Maternal deaths x 100,000 No. Women of Repr. Age

5. MATERNITIES Numbers of mothers delivered of both live births and stillbirths (Total births). U.K. MMR are expressed per 100,000 maternities.

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Table 3a: WHO ESTIMATES OF MATERNAL MORTALITY, WORLDWIDE.

Region Live births(millions)

1983 - 1988

Maternal deaths(thousands)

1983 - 1988

Maternal mortality ratio (per 100, 000

live births)1983 - 1988

World 128.3 137.6 500 509 390 370

Developing Countries

110.1 120.3 494 505 450 420

Developed Countries

18.2 17.3 6 4 30 26

Africa 23.4 26.7 150 169 640 630

Asia 73.9 81.2 308 310 420 380

Latin America 12.6 12.2 34 25 270 200

Northern America

4.0 4.0 1 1 12 12

Europe 6.6 6.4 2 1 27 23

Oceania 0.2 0.2 2 1 - -

USSR 5.2 5.2 3 3 50 45

TABLE 3b: LEADING CAUSES OF MATERNAL DEATHS (GLOBAL)

1. Hemorrhage

2. Puerperal sepsis

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3. Obstructed labor

4. Abortion complications (Botched, usually illicit abortions)

5. Hypertensive diseases

Table 4: Maternal mortality in the UK, 1997-2008 (*per 100,000 maternities)

Triennium 1997-99 200-02 2003-2005 2006-8

Type/Causes Number (*Rate)

Direct 1.Thromboembolism2.PIH3.Haemorrhage4.Amniotic Fluid embolism5.Deaths in early pregnancy6.Genital Tract Sepsis7.Other direct total 8.Anaesthetic

106(5.0) 106(5.3) 132 (6.24) 107 (4.67)

Indirect (Cardiac, Psychiatric, Malignancies, others)

136(6.4) 155(7.8) 163 (7.71) 154 (6.72)

Coincidental 29(1.4) 36(1.8) 55 (2.60) 50 (2.18)

Late 49 82 33

Total 346 432 344

Ref: Centre for Maternal And Child Enquiries (CMACE). Saving mothers’ lives: Confidential Enquiries into Maternal Deaths in the UK, 2006-2008. BJOG, March 2011; 118(Suppl.1): 1-205

The Life-Time Risk (LTR) of dying from pregnancy-related causes in Developing Countries is often greater than 1 in 30, in some cases up to 1 in 12. In developed countries, the LTR is often less than 1 in 4,000. This makes pregnancy-related complications among the greatest killers of women of reproductive age in developing countries 3, (Tables 1, 2a, 2b, 3a, 3b, Fig 1, Table 4). Of all the health data monitored by the WHO, maternal mortality demonstrates the greatest disparity between rich and poor nations.

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Preliminary Research at the UBTH 1980-1986

This gloomy state of affairs dwelt on my mind as I returned to Benin City in 1980 to assume duty as a young specialist/consultant at the UBTH and an academic staff with University of Benin. The next six years saw me through heart-breaking clinical experience and investigative clinical obstetric research that exposed me to the serious challenges of unsafe motherhood in our community. For starters, a major review of 165 maternal deaths suffered by mothers in the UBTH spanning its first 13 years of existence from 1973-1985 was conducted 4, 5. While the recognized global main causes of maternal death were evident in these studies, viz obstetric haemorrhage, obstructed labour, illicit abortion, hypertensive crisis, and puerperal genital sepsis (Table 5), some unusual causes of death are worth mention.

Table 5: Leading causes of maternal deaths in Benin City, Nigeria

CAUSES NUMBER

*Haemorrhage 42

Abortion 37

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Sepsis Puerperal sepsis

Tetanus (postabortal - 6) (puerperal - 1)

32

Hypertensive disorders 16

Liver Disease 14

Anaemia in Pregnancy 11

Trophoblastic diseases 9

Acute renal failure 7

Respiratory diseases 6

Caesarean section 23

Puerperal hysterectomy 2

Total deaths (MMR) 165 (563/100,000 maternities)

Ref. Unuigbe JA et.al. Maternal mortality at the UBTH Benin City, Nigeria, 1973-1985. Trop J Obstet Gynaecol, 1988; 1(1): 13-18

One such bizarre experience was a parturient mother with obstructed labour I encountered in my first year as a consultant. At laparotomy, a fungating, partly necrotic urinary bladder tumour was found to be the cause of obstructed labour. The poor woman succumbed to this serious pathology that proved histologically to be a rhabdomyosarcoma of the urinary bladder (Fig 2) 6, an extremely rare malignant tumour that

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would pick on the bladder at this most inauspicious moment of this woman’s life! Her baby was stillborn.

Tetanus was found to be responsible for a significant number of maternal deaths 7, notably among women that succumbed to complications of illicit abortions. I believe our efforts at the UBTH, by the publication and advocacy that followed this review, contributed to revision of anti-tetanus prophylaxis that now operates in obstetric practice in respect of routine antenatal care as well as management of illicit septic abortion.

For every maternal death we encountered, many mothers survived but with crippling physical disabilities as well as mental trauma. A number of women escaped death from postpartum haemorrhage but with a major involuntary sacrifice; a caesarean or early puerperal hysterectomy. An unusual postabortal morbidity encountered in 1984 was a 13-year old school girl admitted into the emergency room of the UBTH in profound shock with severe vaginal bleeding immediately following attempted instrumental termination of an unwanted pregnancy at 17-weeks' gestation in a private clinic 8. This girl sustained multiple perforating injuries to both the anterior wall of the uterus (at the isthmus) and the urinary bladder base that resulted in both utero-vesical and vesico-vaginal fistulae (Fig. 3)

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At laparotomy; there was copious blood with clots and urine in the peritoneal cavity. The uterine and bladder injuries were successfully repaired after evacuation of retained uterine products of conception, and blood with urine from the peritoneal cavity. She went home healthy eight days after admission. One can only imagine the challenging life-long mental scar this girl has had to contend with.

Apart from the risk of maternal deaths, the 2005 WHO World Health Report 3

provided chilling revelations on the plight of survivors: 20 million women each year will experience maternal disability, which can range from fever and depression to severe complications such as obstetric fistula and uterine prolapse. Research indicates that the health of newborns is closely linked with health of their mothers. Surviving children of a deceased mother are three to ten times more likely to die within two years.

The HIV/AIDS pandemic takes an increasing toll of women and children especially in sub-Saharan Africa 9. By 2004, some 49 million people lived with

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HIV, of whom 2.2 million were children under 15 years of age and 18 million were women. HIV/AIDS has thus led to significant increases in mortality in many countries, notably in sub-Saharan Africa. Across the world, around 2.2 million women with HIV infection give birth each year. HIV infection in pregnancy increases the risk of complications of pregnancy and childbirth, including vertical transmission of HIV infection to neonates. Poverty, illiteracy, and risk-taking behaviours account for much of the epidemic. It is important that obstetricians, midwives and nurses understand the extent of the problem.

These published clinical experiences and many others from the University of Benin Obstetrics and Gynaecology Department joined many other national institutional publications in clamoring for national as well as international recognition of maternal mortality as a major challenge to humanity, notably in developing countries.

The Safe Motherhood Initiative 1987-2012

The Safe Motherhood initiative was launched in 1987 in Nairobi, Kenya with robust attendance by dignitaries, including Professor Olikoye Ransome Kuti of blessed memory, the then Nigerian Health Minister. The launching was at the instance of international agencies and governments to raise global awareness about the impact of maternal mortality and morbidity, and find solutions. It was co-sponsored by seven agencies, UNFPA, UNDP, UNICEF, WHO, IPPF, the Population Council and the World Bank. The main agenda was to address this scourge of wastage of maternal human lives, and the Initiative's goal was to reduce maternal mortality by half by the year 2000.

Beginning in the 1990s, the United Nations sponsored a series of international conferences to develop a framework for achieving progress on population, health, and development. Safe motherhood, including maternal mortality reduction has been consistently identified as a key development goal at all of these global conferences: the Children’s Summit in New York (1989); the International Conference on Population and Development (ICPD) in Cairo, Egypt (1994); the Fourth World Conference on Women in Benjing, China (1995); the Safe Motherhood Tenth Anniversary technical consultative meeting in Colombo, Sri Lanka (1997); the Millennium Development Goals UN Millennium General Assembly in New York (2000); and the United Nations Human Rights Council summit in New York (2010).

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Building on the agreements and commitments at the series of world conferences held in the 1990s, the Millennium Development Goal 5 called for an improvement on maternal health and a reduction in maternal mortality by 75 percent by 2015 from 1990 levels. The recognition of maternal health as one of the eight MDGs (Table 6) firmly identifies it as central to poverty reduction and overall development efforts. Its inclusion has increased international attention to maternal mortality.

Table 6: UNITED NATIONS MILLENIUM DEVELOPMENT GOALSMILLENIUM DEVELOPMENT DECLARATION (2000)

Goal 1. Eradicate extreme poverty and hunger

Goal 2. Achieve universal primary education

Goal 3. Promote gender equality and empower women

*Goal 4. Reduce child mortality

*Goal 5. Improve maternal health

*Goal 6. Combat HIV/AIDS, malaria, and other diseases

Goal 7. Ensure environmental sustainability

Goal 8. Develop a Global Partnership for Development

*Three MDGs (4, 5, and 6) relate directly to Maternal and Perinatal health

A summary of the Ten Safe Motherhood Action Messages articulated over the years needs to be presented. They highlight the most critical interventions for reducing maternal mortality and morbidity and the range of barriers (economic, legal, social, and cultural) that women face in accessing high-quality maternal health care 10.

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1. Advance Safe Motherhood through Human Rights.The United Nations Human Rights Council in 2010 put preventable maternal mortality on its agenda of human rights violations. Women’s right to safe motherhood is now recognized as a human right that should be respected, protected, and implemented

2. Empower women, ensure choices.Maternal deaths are rooted in women’s powerlessness and their unequal access to employment, finances, education, basic health care, and other resources.

3. Safe Motherhood is a vital economic and social investment.All national development plans and policies should include safe motherhood programs, in recognition of the enormous cost of a woman’s death and disability to health systems, the labour force, communities, and families. Additional resources should be invested in the most cost-effective interventions.

4. Delay marriage and first birth Pregnancy and childbearing during adolescence carries considerable risks. Reproductive health information and services for adolescents need to be legally available, widely assessable, and affordable. Families and individuals need to delay marriage and first births until women and physically, emotionally, and economically prepared for motherhood.

5. Every Pregnancy faces risksDuring pregnancy, any woman can develop serious, life-threatening complications that require medical care. It is therefore essential that all pregnant women have access to high-quality obstetric care throughout their pregnancies, especially during labour and early puerperium, when most lethal emergency complications occur.

6. Ensure skilled attendance at deliveryThe single most critical intervention for safe motherhood is to ensure that a health worker with midwifery skills is present at every birth, and transportation to a health facility is available in case of an emergency. A sufficient number of health workers must be trained and provided with essential supplies and equipment, especially in poor and rural communities.

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7. Improve access to quality reproductive health servicesA large number of women in developing countries do not have access to maternal reproductive health services. Many cannot get to, or afford, high quality care. Cultural customs and beliefs can also prevent women from understanding the importance of health services, and from seeking them. In addition to legal reform and efforts to build support within communities, health systems must work to address a range of clinical, interpersonal, and logistical problems that affect the quality, sensitivity, and accessibility of the services they provide.

8. Prevent unwanted pregnancy and address unsafe abortionAn estimated 75 million unwanted pregnancies occur globally every year. Many women without access to safe services resort to unsafe abortion, which often results in death or disability. Unsafe abortion is the most neglected – and most easily preventable - cause of maternal death. These deaths can be significantly reduced by ensuring that safe motherhood programs include family planning services to prevent unwanted pregnancy, contraceptive counseling for women who have had an induced abortion, the use of appropriate technologies for women with abortion complications, and, where not against the law, safe services for pregnancy termination.

9. Measure progressGovernments around the world have pledged to reduce maternal mortality. Because maternal mortality is difficult to measure, safe motherhood partners have developed alternative means for measuring the impact and effectiveness of programs; for example, by recording the proportion of births attended by a skilled health provider. These indicators can identify weaknesses and suggest program priorities so that maternal deaths can be better prevented in future.

10. The Power of PartnershipReducing maternal mortality requires sustained, long-term commitment and the inputs of a range of partners. Governments, non-governmental organizations (including women’s groups, and family planning agencies), international assistance agencies, donors, and others should share their diverse strengths and work together to promote safe motherhood within

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countries and communities and across national borders. National plans and policies should put maternal health into its broad social and economic context, and incorporate all groups and sectors that can support safe motherhood.

The West African Prevention of Maternal Mortality Program as part of the global Safe Motherhood Initiative

In 1986, the Society of Gynaecology and Obstetrics of Nigeria hosted an international conference in Enugu to address the subject of maternal mortality. I was privileged to present our Benin experience 4, 5 at that conference. The conference deliberations were favourably received by international agencies, so much so that an agency of the Carnegie Corporation of New York, The Carnegie Agency for the Development of Human Resources in Developing Countries, under the chairmanship of a foremost past teacher and my Professor at the University of Ibadan College of Medicine, Adetokunbo Lucas, then a visiting Professor of International Health at the Harvard School of Public Health, sponsored the setting up of the West African Prevention of Maternal Mortality network. The next two years witnessed preliminary preparations and eventual launching of the PMM program.

From 1988 to 1996, researchers from the School of Public Health (Center for Population and Family Health), Columbia University, New York, led by its Dean, Professor Allan Rosenfield, with Ms Deborah Maine, Ms Angela Kamara, and Dr James Allman as coordinators/facilitators, collaborated with a network of eleven multi-disciplinary teams in West Africa to address the subject of maternal mortality in the West African sub region. This large research group was called the Prevention of Maternal Mortality (PMM) Network 11, 12. The West African teams were set up in the following institutions: Nigeria, (seven teams) - University of Benin, University of Ilorin, University of Calabar, Ahmadu Bello University, University of Port Harcourt, University of Ibadan, and University of Sokoto; Ghana, (two teams) – University of Accra, and University of Kumasi; Sierra Leone, (two teams) – University of Sierra Leone , in Freetown and in Bo.

I was privileged to lead a formidable team, the Benin PMM team that included core brilliant academics: Professor Augustine Oronsaye of blessed memory, Consultant Obstetrician and Gynaecologist and a former Chief Medical Director, UBTH, Drs Suleiman Braimah and Okolocha, two brilliant Medical Sociologists

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from the Department of Sociology, University of Benin, Dr Jasper Chiwuzie, an Associate Professor and Community Health Consultant Physician, UBTH, and a Midwifery Nursing Officer at the UBTH, Sister Patience Olumeko.

These PMM Network teams carried out operations-research projects on maternal mortality, collected a body of information on the design and evaluation of such programs, and produced analytical work that significantly influenced program design. Each research team chose as its subject for research, an important recognized cause of maternal mortality in the region. The Benin team chose Obstetric Haemorrhage, and we focused our operations-research on the 13 communities that make up Ekpoma Clan 13, 14. An important design that evolved from the PMM Program that considered situation analysis of emergency obstetric care (12), was ‘The Three Delays’ model, which analyzed the factors that prevent women from receiving essential care, and their focus on the importance of emergency care for life-threatening obstetric complications. Our experiences provided the safe motherhood community with solid evidence on the types of interventions that have the greatest impact on reducing maternal death and disability: Emergency Obstetric Care (EmOC) 15.

Experience in the Middle East 1991-2007

For circumstances beyond my control, I professionally relocated to the Kingdom of Saudi Arabia, KSA, in 1991. What I projected to be stint tenure of one year leave of absence from the University of Benin stretched to 16 years! I spent a total of four years and 12 years in Riyadh and Jizan respectively, serving in two very busy tertiary health institutions: the Prince Salman Hospital, Riyadh, as Consultant Obstetrician and Gynaecologist; and the King Fahd Central Hospital, Jizan. as consultant and Chief of Obstetrics and Gynaecology.

My professional and academic interests in maternal health care with respect to maternal morbidity and mortality remained undiminished as I settled down to obstetric and gynaecological practice. It became clear soon enough that in Saudi Arabia, the emphasis on maternal complications predominantly centred on morbidity. This was evident in the first national triennial prospective survey of maternal deaths in all hospitals in Saudi Arabia from August 1989 to June 1992 (1410-1412 Hejira) 16 that was conducted by a national team of experts hosted by the Prince Salman Hospital, Riyadh in 1992 during my first year in the hospital. The highlights of the findings are shown in tables 7 and 8. The overall national

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MMR was 17.6/100,000 live births, a ratio that was comparable to figures from developed countries.

Table 7: MMR IN SAUDI ARABIA (1410 – 1412 HEGIRA)

AREA OF RESIDENC

E

TOTALBIRTHS

DIRECT DEATHS

DIRECTOB-MMR

TOTAL DEATHS

MMR

CENTRAL PROVINCE

261,335 19 7.3 31 12.0

NORTHERN PROVINCE

86,971 14 16.0 15 17.2

SOUTHERN PROVINCE

172,165 23 13.4 36 21.0

EASTERN PROVINCE

120,612 17 14.0 27 22.4

WESTERN PROVINCE

239,140 32 13.4 46 19.3

TOTAL 880,248 105 12 155 17.6

MMR – Maternal Mortality Ratio per 100,000 births

Table 8: DIRECT CAUSES OF MATERNAL DEATHS IN SAUDI ARABIA

CAUSES NUMBER %

Hemorrhage 26 24.8

Pulmonary Embolism 18 17.0

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Hypertensive Disorders 13 12.4

Ruptured Uterus 15 14.3

Sepsis 9 8.5

Abortion and Hydatidiform Mole

12 11.4

Ectopic Pregnancy 1 1.0

Amniotic Fluid Embolism

8 7.6

Anesthesia 1 1.0

Other Direct Causes 2 2.0

All Deaths 105 100

Maternal deaths were averted by scrupulous and meticulous maternal care provided generally country-wide, at all levels (primary, secondary, and tertiary) of health care. But more important was the revised national health policy on maternity services, with priority hinged on EmOC, based on principles expressed in the PMM network activities that were already in place and further developed during my 12 years in Jizan.

I witnessed a total of six maternal deaths throughout my years of service in the KSA, one in Riyadh and five in Jizan. One of these deaths is worth mention because of its peculiarity and inevitability. The death occurred in KFCH, Jizan, with a 37 year-old grandmultipara, Para 9, who had End-Stage Renal Disease, ESRD, and was on haemodialysis. She had uremic encephalopathy and cardiomyopathy and was admitted to the hospital's intensive care unit, ICU, in the second stage of labour with an intrauterine fetal death. After I performed a forceps delivery of the baby, she had an emergency haemodialysis. She died few hours after dialysis. Interestingly, during my tenure in Jizan, the KFCH, with the largest kidney centre in the KSA, the 200-bedded Prince Sultan Kidney Centre, recorded 38 pregnancies amongst 35 women with chronic renal failure, nine of who had ESRD 17. We recorded a perinatal survival rate of 74.3% overall and 55.6% amongst women with ESRD on dialysis!

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My tenure in the KSA was full of encounters with extremely morbid conditions that could have resulted in mortality but for the emergency preparedness that

prevailed in the care of mothers. An unforgettable case treated in Riyadh was a woman 18, Para 1+0 with a previous caesarean section delivery, who presented in my antenatal booking clinic with six weeks' amenorrhea, positive pregnancy test, and vague lower abdominal discomfort. An immediate pelvic ultrasound revealed an empty uterine cavity with bilateral adnexal swellings. An immediate laparotomy confirmed intact bilateral tubal ectopic pregnancy; a right fimbrial and a left ampullary ectopic gestation. Conservative surgery consisting of expression (milking out) of the right tubal contents through the fimbrial ostium and a left salpingotomy was performed. Histopathology on the evacuated specimens confirmed the diagnosis of bilateral tubal ectopic pregnancies (Figs. 4 and 5).

Hysterosalpingogram performed six weeks following surgery confirmed patency of both fallopian tubes with prompt peritoneal spill of the medium into the peritoneal cavity. This conservative tubal surgical treatment was rewarded a year later when this lady returned to have a normal delivery at term under my care.

In KFCH, Jizan, the infrastructural designs that were in operation in the KSA health sector, notably in emergency

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obstetric care, were much in evidence. For, in the very busy obstetric unit of well over six thousand deliveries annually (an average of 15-20 deliveries daily), there were inevitably many serious morbid obstetric cases, some of them near-misses. We cared for many women presenting with the HELLP syndrome complicating severe preeclampsia and eclampsia, 12 of whom we reported on 19. There was no mortality despite the grave morbidity.

I reported on a woman, Para 2, who had a cervical ectopic pregnancy that clinically presented as a missed abortion 20. At evacuation of retained products of conception, she had torrential intra-operative vaginal bleeding from the disturbed, hitherto undiagnosed, cervical pregnancy. Her survival was decided by a timely conduct of an emergency hysterectomy with transfusion of six units of blood and three units of fresh frozen plasma. Histopathology of the specimens confirmed cervical implantation of the placenta, uterine leiomyomata with blood clots in the uterine cavity, and a left ovary with multiple follicular cysts.

Another gravely ill patient, a Para 5 woman, was admitted seven hours post partum, after a normal term delivery in a peripheral hospital, in profound shock with unrecordable diastolic blood pressure, a full abdomen with marked rebound tenderness 21. A ruptured uterus was suspected and immediate laparotomy was performed after active resuscitation. At laparotomy, the pelvic genital organs were found to be normal. There was extensive gangrene of the colon extending from the caecum down to the recto-sigmoid junction and haemorrhagic clots covering the colon and mesocolon. All veins in the affected area were thrombosed. She underwent subtotal colectomy and ileo-sigmoidostomy. She recovered and was discharged 13 days post surgery. Subsequent histopathology on the resected bowel confirmed mesenteric venous thrombosis, an unusual and very rare complication encountered in obstetric practice.

My final near-fatal case 22 concerned a 30 year-old nullipara with a history of seven years infertility that required assisted reproductive technique, In Vitrio Fertilization, to achieve pregnancy. She was admitted in obstructed labour and had an emergency caesarean section and was delivered of a live female infant. After closure of the caesarean section uterine wound, the back of the uterus was inspected. What was initially suspected to be a posterior uterine rupture turned out to be an extensive rent of the upper posterior vaginal wall, primary colporrhexis, (Fig. 6), an exceedingly rare lethal obstetric complication with less than 10 reported cases in the English literature.

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The injury consisted of an extensive posterior semi-circular rent affecting the upper vaginal wall at the level of the posterior and both lateral fornices causing an almost complete avulsion (detachment) of the uterus with the cervix. She had considerable blood loss (about 1000 mls). The rent was repaired after peritoneal toileting and the patient went home healthy, with her uterus intact, three weeks post partum.

The relative success with maternity care in the KSA as noted above hinged on the emergency care combat-readiness that prevailed in health institutions, notably with EmOC. Under my command in the obstetrics and gynaecology department, KFCH, Jizan, protocols were designed to address morbid obstetric conditions such as obstructed labour, major obstetric haemorrhage, severe preeclampsia and eclampsia, shoulder dystocia, retained placenta, and ectopic pregnancy. These protocols were drafted, discussed at departmental seminars, and adopted for use by the department. They were regularly updated.

I developed special interest in severe preeclampsia and eclampsia and obstetric hypertensive crisis (SP-EOHC) because of the high prevalence of the condition and success achieved with management of the extremely morbid cases encountered in Jizan region. The protocol developed followed research conducted on team approach to critical care of affected women, use of Magnesium Sulphate to arrest convulsions, control of malignant hypertension with Labetalol, obstetric treatment, and supportive treatment of mothers. Our success with this protocol was immense and constituted the subject of my subsequent lectures delivered at seminars in

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Jizan, Riyadh, and Bisha in the KSA 23, 24, and at the UBTH while I was on vacation in Nigeria in January 2006, when the protocol emphasizing the use of Magnesium Sulphate to replace Valium was introduced to the obstetric unit.

Current Clinical Research Engagement: 2007-Date

A lot of attention has hitherto been drawn to a not-so-focused and rather amorphous conglomeration of factors in maternal deaths and the SFI's varied action strategies. These wide range activities circulate around the three main pivots identified in the PMM network's 'Three Delays' model. The SFI includes so many activities (family planning, antenatal care, safe delivery, basic maternal care, primary health care, equity for women, women's education, etc) that there arises the need to focus on activities that actually have more immediate direct impact on maternal survival. While all these activities are worthy and important goals, the PMM network report 1, 25 identifies EmOC, perhaps with the exception of family planning, as the only one that can substantially reduce maternal deaths. My experience in the KSA attests to the validity of this PMM principle.

Since returning to Benin City in 2007, my clinical research activities have focused on the PMM network's principle that emphasizes the health provider component of health care, Comprehensive Emergency Obstetric Care, CEmOC. Specifically, my interest has focused on SP-EOHC, building on my experience in the KSA and updating the SP-EOHC protocol as I returned to Nigeria.

In 2008, Nigeria (with 50,000 maternal deaths) was second only to India (with 63,000 maternal deaths) out of a global total of 358,000 maternal deaths 26 Latest Figures in 2012 show a decreasing global trend with an annual total of 287,000 deaths in 2010 from a total of 543,000 deaths in 1990. Nigeria does not appear to benefit from this global approach to the desired Millennium Development Goal (MDG) of an annual 250,000 maternal deaths by 2015. Indeed indications are that Nigeria’s contribution to global maternal deaths has increased from previous level of about 10% to current level of 17%! (Nigeria has about 2% of global population). Sadly, the condition SP-EOHC contributes an increasing prominent quota to these uncontrolled deaths. Recent studies on maternal mortality in Nigeria indicate that SP-EOHC is now the leading cause of maternal deaths, especially in the northern parts of the country 27, 28. It follows that efforts should be made to address the challenges posed by SP-EOHC in Nigeria following the example of a recent

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American College of Obstetricians and Gynecologists (ACOG) task force set up to address the subject of hypertension in pregnancy in the United States of America 29

.

Addressing Severe Preeclampsia and Eclampsia and Obstetric Hypertensive Crisis in Nigeria

Success with CEmOC, especially with respect to SP-EOHC, is very much tied to team approach that relies on active timely full participation of all team members. Specifically, emphasis is now tilted in the direction of meticulous team approach to maternity care with the concept of what I consider a 24-hour health institutional combat readiness (24H-HICR). The ACOG identifies the continued development of the Obstetric-Gynecologic Hospitalist (Labourist) Model as one potential approach to achieving increased professional and patient satisfaction while maintaining safe and effective care across delivery settings 30. The Royal College of Obstetricians and Gynaecologists (RCOG) in collaboration with the National Health Service (NHS) has adopted a policy of increased senior medical (consultant) staff participation in emergency obstetric care with specific injunction on 'increased consultant presence in delivery suites'. The team approach to CEmOC described above constitutes the main focus for the SP-EOHC protocol developed in Benin City with effect from 2008. My experience with the protocol for the management of SP-EOHC developed in Gizan, described earlier, has been brought to Benin City. The team includes all categories of top echelon of staff; medical, anaesthesiology, nursing, laboratory medicine staff, and hospital administrative staff.

The protocol developed, updated, and adopted in Jizan consisted of preferred drug use of a combination of intravenous Magnesium Sulphate, MGSO4 and intravenous Labetalol (Trandate) for arresting eclamptic convulsions and bringing down dangerously elevated blood pressure (BP) respectively. This combination of drugs worked quickly, effectively, and satisfactorily. Back home in Benin City, Labetalol was not available in the quantitative and economic dimension required for use in obstetric hypertensive crisis. Eventually, Labetalol in the form of Labet was introduced into the country as Labet50 (50 mg ampoule) and Labet200 (200mg tablet),manufactured by Popular Pharmaceuticals Ltd, Dhaka, Bangladesh, and distributed in Nigeria by Generix Global Ltd, Benin City.

After the National Agency for Food and Drug Administration and Control, NAFDAC, trials, approval, and certification of Labet, we carried out a six months’

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trial on a protocol consisting of the combined use of Labet/MGSO4 medication on women with SP-EOHC in the three obstetric departments of Igbinedion University Teaching Hospital, Okada, the central Hospital, and Stella Obasanjo Hospital for Women and Children, Benin City. The results of the trial, presented at the RCOG International Conference 31 in Athens, Greece, in September 2011 were found satisfactory and comparable to outcomes on the use of Trandate/MGSO4 in Jizan.

After this trial a Protocol for the management of Severe Preeclampsia, Eclampsia, and Obstetric Hypertensive Crisis that includes the combined use of MGSO4 and Labet has been developed and is now made available for adoption in delivery rooms. Furthermore the summary of the protocol has been designed into a card that can be double-folded to fit into the breast pocket. This brochure-card serves as a readily available guideline for use by medical officers in emergency rooms as well as those working in remote secondary-level maternity centres for effective EmOC in respect of SP-EOHC.

I have given a number of guest lectures on the care of mothers with SP-EOHC at seminars and conferences in Nigeria over the past three years; the UBTH, Benin City, Irrua Specialist Teaching Hospital, University of Abuja Teaching Hospital, Lagos University Teaching Hospital, and a plenary lecture at the 2012 Annual Congress of the Society of Obstetrics and Gynaecology of Nigeria held at Abakaliki, in November 2012. I am happy to report progress made judging by the favourable response on the adoption of this protocol (with modification when deemed necessary) by colleagues from many health institutions in the country

CONCLUSION AND RECOMMENDATIONS

As a conclusive remark, I crave your indulgence to allow me reiterate the following four major propositions on safe motherhood that I hold dear to my heart and should be taken seriously by all of us as we depart from this lecture:

1. Safe Motherhood as Human RightAt the United Nations Millennium Summit in the year 2000, representatives of 189 countries, including Nigeria, together with 23 International Organizations, committed themselves to eight MDGs, with the aim of reducing poverty and promoting human development. Improving maternal health is one (# 5) of these eight goals adopted. In 2010, the United Nations Human Rights Council put preventable maternal mortality on its agenda of human rights violations.

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'Like slavery and apartheid, poverty is not natural. It is man-made and it can be overcome and eradicated by the actions of human beings. 'And overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right, the right to dignity and a decent life'. 32

Women’s right to safe motherhood is now recognized as a human right that should be respected, protected, and implemented.

2. All women must have access to high quality life-saving comprehensive emergency obstetric care if needed 33

High quality life-saving services must be available, accessible, and effective if and when needed. Blood transfusion service is crucial in this regard. In most cases it does not mean building new facilities, but a more rational allocation of available resources with more for those in more need. Enforcing this EmOC component of SMI activities, especially in sub-Saharan Africa and notably in Nigeria, should not be considered a prescription for impossibility.

The adoption of management protocols consisting of close team work that includes active timely senior obstetric staff participation in CEmOC is a major crucial determinant of maternal survival. In Nigeria this is considered most crucial with respect to SP-EOHC.

3. A lack of resources is no excuse for inaction 33

Maternal mortality levels are not simply functions of socio-economic development. Countries having the same level of low per capital income can have widely different levels of maternal mortality. The interventions that make motherhood safe are known and the resources needed are obtainable; the necessary services are neither sophisticated nor very expensive, and reducing maternal mortality is one of the most cost-effective strategies available in the area of public health.

4. Maternal Mortality, a factor of Women's PowerlessnessIn the course of the main address presented at the opening ceremony of the last World Congress of the International Federation of Gynecology and Obstetrics (FIGO) held in Rome in 2012, Professor Mahmoud Fathalla, a past President of FIGO and a founding father and midwife to the Safe Motherhood Initiative, presented the subject, 'On Safe Motherhood at 25 years: Looking Back, Moving Forward' 34, to a very attentive 8,500 strong audience of congress participants.

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After revisiting the subject of barriers to safe motherhood as part of his lecture, with a repeat presentation of his short video clip, 'Why did Mrs. X die?', first presented at the SFI launching in Nairobi in 1987 (www.whydidmrsxdie.com), he led the audience into tying maternal mortality to women's powerlessness.

This leads us to critically assess the goal of promoting gender equality and empowering women. Maternal deaths are rooted in women’s powerlessness and their unequal access to employment, finances, education, basic health care, and other resources. Mahmoud Fathalla 34 declares that the prescription women need most for their health is 'Power'. He asserts that ‘powerlessness of women is a serious health hazard, and particularly in maternal health’. He charges women to ‘fill the prescription themselves and to keep a sustainable stock of it’. With respect to the dose for that prescription, he advises women, ‘take as much as you can get. There is no risk of over-dosage, and there are no reported side effects'.

ACKNOWLEDGMENT

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3. WHO. 'Make every mother count' World Health Report 2005. Geneva: WHO, 2005.

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20. Unuigbe JA and Malik TM. Cervical pregnancy presenting as a missed abortion. Ann Saudi Med, 1997; 17(4): 462-463.

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25. WHO. Mother-Baby package: A road map for implementation in countries. WHO, Division of Family Health, 1993.

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26. Trends in Maternal Mortality 1990-2008. Estimates developed by WHO, UNICEF, UNFPA, and The World Bank. Geneva: WHO, 2010. Assessed 7 September, 2010 Website: www.who.int/en/reproductivehealth

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28. Bukar M, Kumanda V, Moruppa JY, et.al. Maternal Mortality at Federal Medical Centre, Yola, Adamawa State: A five-year review. Ann Med Health Sci Res 2013; 3: 568-71.

29. American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy. Practice Guideline WQ 244. 2013.

30. American College of Obstetricians and Gynecologists Committee opinion no. 459: The Obstetric-Gynecologic Hospitalist. Obstet Gynecol. 2010; 116: 237-239.

31. Unuigbe JA, Ebomwonyi IO, Sule Z, Agbon-Ojeme GE, Uwaifo JO, and Omorogbe SO. A protocol for the management of severe pre-eclampsia, eclampsia, and obstetric hypertensive crisis in Benin City, Nigeria, using a combination of Magnesium Sulphate and Labet (Labetalol). Proceedings of the 9th RCOG Int. scientific meeting, Athens, Greece. September 2011.

32. Nelson Mandela. Make poverty history. Speech to Trafalgar Square Crowd, February 03, 2005. An appeal directed at G7 leaders' meeting in London, February 04, 2005. Website: www.makepovertyhistory.org /docs/mandelaspeech.doc

33. Mahmoud Fathalla. 10 propositions for safe motherhood for all women. Int J Gynec Obstet 2001;72(3): 207-13.

34. Mahmoud Fathalla. On Safe Motherhood at 25 Years; Looking Back, Moving Forward. 2012. Website: www.handsonformothersandbabies.org Video clip: www.whydidmrsxdie.com

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