Maternal death review in Sudan [2010 - 2012]: achievements and challenges

Despite the worldwide commitment to improving maternal health, measuring, monitoring and comparing mortality estimates remain a challenge. Maternal death review [MDR] is a tool used to measure maternal mortality ratio [MMR] and to improve quality of obstetric care. This study was done to assess maternal mortality and to identify underlying causes during 2010-2013. Facility and community- based maternal death review was conducted during three years in Sudan to study maternal mortality. National and states' maternal death review committees were established. A focal person for each state, health facility and locality was nominated. Notification of maternal deaths was done by telephone, followed by review of all notified maternal deaths using a structured format. Data was analyzed using microcomputer, with SSPS, version 18.0. Over three years, 2933 maternal deaths were notified, out of 1509354 Live births [LB]. MMR was 194/ 100000 LB, with different variation between states. Facility maternal deaths were 2503 [85.3%] and community deaths were 430 [14.7%], reviewed formats were 2859 [97.5%]. Direct obstetric deaths were 1845 [64.5%], mainly due to haemorrhage 884 [30.9%], eclampsia 383 [13.4%] and sepsis 321 [11.2%]. Indirect causes were 1014 [35.5%], 363 [12.7%] due to hepatitis and 197 [6.9%] to anemia. Most of hospital deaths 1947 [77.9%]; admitted late from home, 2462 [73.4%] were critically ill and 1484 [60.3%] died within 24 hours. Home delivery, late presentation, unavailability of blood and poor referral system, are the main factors behind maternal deaths. Maternal death review has to be integrated within the health management information system [HMIS] with strong commitment of various stakeholders

Association of placenta praevia with repeat cesarean section in Omdurman Maternity Hospital, Sudan 2010- 2012

Several risk factors for placenta praevia exist, including previous cesarean section [C/S]. This association has been investigated long time ago, however in this hospital there is no documented evidence. This study was done to assess the risk of placenta praevia based on number of previous cesarean sections. A hospital-based study, at Omdurman maternity hospital- OMH during; January 2010- December 2012. Deliveries in OMH were reviewed by trained registrars. Patients diagnosed prenatally or during delivery as placenta praevia were included. All women operated were followed till discharge from hospital. Total number of deliveries during the study period is 94758.Of them 68415 [72.2%] delivered vaginally and 26343 [27.8%] by C/S.Of the latter 10643 [40.4%] underwent elective and 15700 [59.6%] emergency CS.448 [0.5%] were diagnosed as placenta praevia. Placenta praevia was more common in patients with scarred uterus being found a 250 out of 9853 CS [2.5%]. Its frequency increased with the number of uterine scars: one scar; [1.7%], [RR = 1.45, CI= 1.12- 1.88], 2-4 scars [2.8%], [RR = 2.32, CI= 1.87-2.87] and five or more scars; [12.7%], [RR = 10.54, CI= 7.34-15.13]. Nineteen patients [7.6%] had adherent placenta, [RR = 42.41, CI =5.69-315.83], 68[15.2%] had history of dilatation and curettage [D and C] or evacuation,[RR = 1.5, CI = 1.18- 1.94], 37 [8.3%] had previous history of placenta praevia, [RR= 8.30, CI = 6.17- 11.19]. Three maternal deaths were encountered [0.7%]. The frequency of placenta praevia in this study increased with increasing number of previous C/S, and was associated with adverse feto-maternal outcome. This study provides a reason to reduce primary C/S and encouraging vaginal birth after C/S [VBAC]

Assessment of discharge after 24 hours following elective caesarean section in Omdurman Maternity Hospital, Sudan, 2010

To assess patient satisfaction and morbidity associated with 24 hours hospital stay after elective caesarean section. A descriptive study done in Omdurman maternity hospital [OMH] in 2010. All women admitted for elective C/S were counselled for discharge after 24 hours from C/S. Those with medical or obstetrical problems necessitating admission for longer time were excluded. Women who refused to be discharged were included as control after an informed consent. All women were operated on by trained registrars or consultants under similar conditions and were followed till discharge from hospital. The total number of deliveries in OMH during 2010 was 28975. Out of them 21022[72.6%] had spontaneous vaginal delivery and 7953 [27.4%] delivered by caesarean section. Elective C/S comprised 3204[11.1%] while emergency C/S 4749[16.4%]. The study included 1439.716[49.8%] as study group and 723[50.2%] as control. Readmission was needed for 41[2.8%], 15[1.1%] from study group and 26[1.8%] from control group. The reason in 24[1,7%] was wound infection, 5[0.3%] DVT, two with endometritis and eight [0.6%] due to non- pregnancy related infection. Although, there is slight increase in rate of readmission due to wound infection and DVT in control group, there is no significant statistical difference between the two groups. However there is significant statistical difference in the rate of satisfaction between the two groups. In the study group, 613[85.6%] ladies were satisfied with the short hospital stay compared to 269[37.2%] in the control group who were satisfied with longer hospital stay after elective C/S [P = 0.0001]. Short hospital stay after elective C/S was associated with more patients' satisfaction, without increase in maternal mortality or morbidity, compared to control

Implementation of postabortion care [PAC] services in three states in eastern Sudan 2009-2010

This is an observational study done in three states in eastern Sudan, Red sea, Kassala and Gadarif states. It was conducted to determine number of patients presented for PAC, their socio-demographic characteristics and medical treatment they received. The study was carried in nine hospitals, in three states in eastern part of Sudan. Training of health care providers was done before embarking on the study together with renovation of health care centers. Patients presented for PAC, were included in the study after an informed consent, during 2009-2010. Data was collected by trained group of registrars in obstetrics and gynecology department. The study showed that, 3762 patients were admitted for PAC services during study period, accounting for 11.9% of the total hospitals admission, 3740 enrolled in the study. Abortion cases were classified as spontaneous 3463 [92.6%], while 277 [7.4%] were induced. Evacuation was done for 3548 [94.9%], the rest were spontaneous complete abortion, received uterotonics and antibiotics. Sharp curettage was done for 3065 [86.3%], manual vacuum aspiration-MVA, for 414 [11.7%] and 69 cases [2.0%] received misoprostol. Counseling and family planning provided to 301 cases [8.0%]. Pregnancy was intentional and wanted in 2647 cases [70.8%], wanted but unplanned in 553 [14.8%], and unwanted in 540 cases [14.4%]. Miscarriage [abortion] is prevalent even within desired pregnancy. Sharp curettage is still the method of practice. Family planning is not well integrated within PAC services. Health care providers need to know, practice and maintain full package of PAC

Implementation of informed consent in obstetrics and gynecology operations in Khartoum- Sudan 2009

This is a descriptive, cross-sectional study, done in Khartoum state to assess patients and providers' knowledge and practice on informed consent in obstetrics and gynecology operations during year 2009. After an informed consent from patients and hospital directorate, data was collected by interview of both patients and health care providers at department of obstetrics and gynecology in all Khartoum state hospitals, during the period from first of January to 31st of December 2009. In this study, 544 patients and 393 health care providers were included. Informed consent is known to be important to 355 [90.3%] of health care providers, its contents are wholly or partially known to 263 [66.9%]. It was taken for surgical operation by 298 [75.8%] of providers, it was written in 279/ 298 [93.6%] and verbal in 19 /298 [06.4%]. Written consent was signed by the husband, the patient herself or her relatives. Lack of time and language are the main reasons for, not taking an informed consent. Although informed consent is relatively implemented; its requirements were notproperly fulfilled. Not taking an informed consent is influenced by multifactorial barriers including lack of time, language and lack of experience. Pre and in-service training on informed consent and communication skills, with detailed format of informed consent will improve the situation

Study of unmet need for family planning in Dar Assalam, Sudan 2001

In this descriptive study, the main objective was to determine the magnitude of unmet need for family planning among women of child-bearing age [15-49 years] in Dar Assalam. Using a detailed questionnaire, we studied 530 ever-married women selected randomly through a multistage sampling technique. Current use of contraception was 21.3%. Using the Westoff model, unmet need was 30.7%. Contraceptive pills were the most commonly used method, 92%. Knowledge on contraception was 61.3% for a single method and 23.4% > or = 2 methods. Knowledge was obtained mainly from relatives, 48.6%