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