Ensuring financial access to emergency obstetric care: three years of experience with Obstetric Risk Insurance in Nouakchott, Mauritania.

INTRODUCTION: The high cost of emergency obstetric care (EmOC) is a catastrophic health expenditure for households, causing delay in seeking and providing care in poor countries. METHODS: In Nouakchott, the Ministry of Health instituted Obstetric Risk Insurance to allow obstetric risk sharing among all pregnant women on a voluntary basis. The fixed premium (US$21.60) entitles women to an obstetric package including EmOC and hospital care as well as post-natal care. The poorest are enrolled at no charge, addressing the problem of equity. RESULTS: 95% of pregnant women in the catchment area (48.3% of the city's deliveries) enrolled. Utilization rates increased over the 3-year period of implementation causing quality of care to decline. Basic and comprehensive EmOC are now provided 24/7. The program has generated US$382,320 in revenues, more than twice as much as current user fees. All recurrent costs other than salaries are covered. CONCLUSION: This innovative sustainable financing scheme guarantees access to obstetric care to all women at an affordable cost.

[Training midwives in developing countries in obstetric ultrasonography: goals and application]. / La formation des sages-femmes en échographie obstétricale dans les pays en développement: pourquoi et comment?

Obstetric ultrasonography is one of the most important advances in antenatal and obstetric emergency care. As part of the program designed to reduce maternal and perinatal mortality, it can provide real patient benefit and should become a standard procedure in developing countries. The midwife is the ideal health worker to practice first level obstetric ultrasonography. Appropriate material can be procured and of specific training can be organized at a moderate cost. Several difficulties are encountered, but there is a solution for each. The concept of the training program is particularly important.

[Uterine rupture of pregnant uterus: study of a continuous series of 63 cases at the referral maternity of Niamey (Niger)]. / Rupture utérine sur utérus gravide: étude d'une série continue de 63 cas à la maternité de référence de Niamey (Niger).

Uterine rupture contributes significantly to high maternal mortality rates in developing countries. We conducted a prospective study of 63 cases of uterine rupture during pregnancy in the Gazobi Hospital in Niamey, Niger between November 1977 to December 1998. The incidence in the maternity department was 2.3%. Most of the patients were transported from inland areas. Mean age was 29 years, and mean parity was 5.7. More than half of patients (53%) presented uterine scar defects. Two thirds of patients had undergone no prenatal care. Analysis of iatrogenic etiologic factors demonstrated strong correlation with use of oxytocin, forceps delivery and fundal pressure. In 75% of cases, diagnosis of uterine rupture was made before delivery. The main symptom was hemorrhage. Surgical treatment consisted of hysterorraphy in 79% of the cases. Maternal mortality was 4.7% and perinatal mortality was 76%. Discussion focuses on the frequency of uterine rupture in developing countries, etiologic factors, diagnostic modalities, and therapeutic guidelines. Several simple preventive measures are proposed to reduce the incidence of uterine rupture in developing countries.

Maternal mortality in West Africa. Rates, causes and substandard care from a prospective survey.

BACKGROUND: According to estimates of maternal mortality rates from WHO/UNICEF, the West African rates appear to be among the world's highest. The precision of these estimates from general mortality models is far from ideal and no information on the distribution of causes of death is provided. The principal objective of our study is to describe the maternal mortality, estimation of the rates and distribution of obstetric causes, from a population based survey of pregnant women carried out in West Africa. We also present the main characteristics of the deaths that occurred, including avoidable aspects. METHODS: The survey included all the pregnant women living in seven defined areas, from December 1994 through June 1996, depending on the area. Twenty thousand three hundred and twenty-six pregnant women (94.3% of all those identified) agreed to participate and 19,545 were followed throughout the second trimester of pregnancy, delivery and the puerperium. Physicians from the survey team made special enquiries about all maternal deaths. But the deaths occurring during the first months of pregnancy could not be estimated. A subcommittee analyzed all the deaths, assigned the underlying cause and discussed the avoidable aspects of the death. RESULTS: Sixty-six deaths were reported. Fifty-five (three late) were deaths due to obstetric causes; six were fortuitous deaths, and no cause could be defined for five. As a mean and for pregnancy after week 25, the maternal mortality rate was estimated at 311 (95% CI 234-404) per 100,000 live births and 852 (95% CI 456-1457) in rural areas. Hemorrhages accounted for 29% of obstetric deaths, uterine rupture 13%, eclampsia and infectious diseases 11% each. Seventy-four percent of the direct obstetric causes were considered avoidable. CONCLUSION: Confidential enquiries into maternal deaths in West Africa are not just a concern of the others. They are urgently requested to promote the improvement of health services.

[The delivery record: a help to make the right decision]. / La dossier d'accouchement: une aide à la décision.

The delivery record is a key document for risk assessment and proper decision making at the right time during delivery. If it is exhaustive or badly presented, health workers see it as an administrative constraint, not as a help. The authors recall some principles regarding its form and contents. Its different parts are reviewed: administrative data, medical history, antenatal care, admission clinical examination, partograph, delivery, newborn, recent post-partum and exit examinations. An example of a delivery record used in Nouakchott is presented.

[Dystocia by excess volume of the fetal abdomen: a case of giant polycystic kidney]. / Dystocie par excès de volume de l'abdomen foetal: un cas de polykystose rénale géante.

We describe a case of dystocia by excess of fetal abdominal part related to giant polycystic renal disease. We list the fetal malformations leading to dystocia and discuss the choice between embryotomy and cesarean section, particularly in countries were no prenatal diagnosis can be made.

[Common obstetric practices in Niger]. / A propos de quelques pratiques obstétricales populaires au Niger.

The aim of this study was to describe common practices and representations concerning pregnancy, childbirth and postnatal care in Niger. We interviewed everyone involved in antenatal care and delivery in 12 villages. We describe here common practices for diagnosis of pregnancy, antenatal care, normal and problem deliveries and postnatal care. Our findings raise questions about maternal health policies in developing countries, which do not always fully take into account the requirements of the population.

[Ultrasonographic fetal biometry charts in Niger]. / Courbes de biométrie échographique foetale au Niger.

Ultrasound scanning to confirm fetal growth is an essential part of prenatal screening and depends on comparison with biometric reference charts. Charts for ultrasound scanning in Niger were established at the Poudriere Hospital in Niamey between 1994 and 1997. A total of 5,197 measurements were made on 736 fetuses to obtain 50 values for biparietal diameter, transverse abdominal diameter, and femoral length between the 14th and 41st weeks from the last menses. Each parameter was presented with dispersion and compared with similar findings from other series to establish reference charts for the population of Niger. Transverse abdominal fetal diameter in Niger appeared to be below normal. These charts establish a local reference at a given time but will require revision in the future.

[Impact of the introduction of a partogram on maternal and perinatal mortality. Study performed in a maternity clinic in Niameny, Niger]. / Impact de l'introduction du partogramme sur la mortalité maternelle et périnatale. Etude faite dans une maternité à Niameny, Niger.

Maternal mortality remains one of the major problems in public health today especially in developing countries where maternal mortality is estimated to be between 500 and 1000 deaths for 100,000 live births. In 1987, the safe motherhood initiative was launched with the objective of reducing maternal mortality by 50% within ten years. One of the methods introduced to reduce the high incidence of maternal and neonatal mortality in developing countries, is the partogram, a visual means used in evaluating a normal delivery. It acts as an early warning system, allowing for the early detection of abnormal evolution in labour as well for the mother as for the foetus. This instrument was introduced in all the maternity wards in Niger in 1990 by the Ministry of Public Health. A study was conducted in one of the maternities of the capital to ascertain the effectiveness of this new instrument to both the mother during labor and the newborn child. 1299 women in labor, primi-and multiparous, participated in the study. Two groups were formed: one consisted of women that delivered prior to the introduction of the partogram, the second group was comprised of women who delivered after its introduction. The results of this study have shown that the introduction of the partogram: reduces the amount of time that a women is in labor, improves the follow-up care the pregnant woman receives, results in a more timely decision made by the health official, and consequently, a prompt referral to a specialised center. The authors estimate that, if used correctly, the introduction of this instrument can have along with other appropriate measures, a considerable impact in the reduction of maternal and neonatal mortality.

[Preventable maternal mortality in an urban area in Niamey (Niger)]. / Mortalité maternelle évitable en milieu urbain à Niamey (Niger).

Maternal mortality is a particularly serious public health problem in Niger. A number of studies suggest that the average rate is 650 to 700 maternal deaths for every 100,000 live births. However, in rural areas, the figure is probably nearer 1,300 and in urban areas 450. We report an analysis of 25 maternal deaths in hospitals or medical centers among patients living in the urban community of Niamey. For nine of these cases, no accurate diagnosis was established, and for twelve others, the death could probably have been avoided. Although this study was not quantitative, it suggests that risk factors for maternal mortality include multiparity, and being a single or primiparous mother. The absence of diagnosis for nine cases was due to the insufficient clinical detail in the medical files (which were scarcely usable), the rarity of paraclinical investigations for economic and organizational reasons, and the absence of post-mortem examination. The avoidable factors leading to death in twelve cases were: negligence on the part of the health service, inappropriate therapy, lack of blood transfusion, lack of vigilance by the patient, absence of medical care for abortion, erroneous diagnosis and transport problems. The patients' relatives appeared to be relatively resigned to the deaths for religious reasons. Further studies are required to understand prevalent attitudes. Numerous studies have concluded that many maternal deaths are often avoidable, both in developing and industrialized countries. This study in Niamey identified various deficiencies and dysfunctions of the system which allow this situation to continue. We propose seven recommendations which could help reduce the incidence of maternal deaths in Niamey.

[Preliminary study of the risk factors in premature delivery in the Rivas region (Nicaragua)]. / Etude préliminaire des facteurs de risque d'accouchement prématuré dans la région de Rivas (Nicaragua).

It is always interesting to know what goes on elsewhere and this study from Nicaragua shows how uneasy it is compare regions between one another. A rate of 17% of premature infants appears considerable but when 2 out of 5 premature infants weigh more than 2,500 grams in a country where accuracy of the period records is, at the very least, questionable, the rate is reduced to 10%. Women under 19 years represent 20% of the population and 24% of the delivering women and the rate of premature births is 34%. There also if we only consider women between 20 and 39 years, the rate is markedly lower than the gross rate.