[Practice and complications of spinal anesthesia in African tropical countries]. / Pratique et complications de la rachianesthésie en milieu tropical africain.

OBJECTIVE: To evaluate the risk of the practice of spinal anaesthesia (SA) in African tropics. STUDY DESIGN: Prospective study in multiple centres over a two years period. PERSONS: Twenty-one anaesthesiologists and anaesthetist nurses covering ten African countries. METHODS: Two anonymous questionnaires; the first, filled in each anaesthetic problem occurred, to define the type of incident or accident, and its circumstances; the second was designed to define the position occupied, to quantify the global anaesthetic activity, the number of SA, and to value the number of complications or deaths linked to SA. RESULTS: Six anaesthesiologists and one anaesthetist nurse replied to the study, covering six sites in five different countries (Senegal, Chad, Central African Republic, Niger and Madagascar). On the 18,432 anaesthetic acts collected, 2,703 (14.7%) were SA. In the well-equipped centres, general anaesthesia was predominant with a frequency of over 75%. However in the not so well equipped centres or those which supplies were more problematical, SA technique was used with a frequency varying from 48.9 to 68.7%. Forty incidents and accidents were reported (1.5%), five led to the death of the patient (0.2%). Among the seven cardiac arrests (0.3%), four were fatal (0.1%). Eight of the ten accidents and all of the deaths occurred in the least equipped centres. Eight of ten accidents happened during emergency caesarean sections. All cardiac arrests were preceded by a severe hypovolemia. For the four deaths after cardiac arrest, an anaesthetist nurse with isobaric bupivacaine 0.5% carried out SA. CONCLUSIONS: This study showed that the practice of SA in African tropics was performing in different practice conditions and people qualification than they were in France. The frequency of cardiac arrests and deaths was respectively five and 20 times more important, in those conditions. The first conclusion that can be drawn from this study is that it is questionable to use SA for emergency Caesarean section under hypovolemic condition. The second is the necessity for specific training on the local anaesthesia for anaesthetist nurses but also training to choose the anaesthesia best adapted to the surgery, the condition of the patient and the means available.

[Constraints faced by hospitalized maternity patients in Niamey (Niger)]. / Les contraintes des malades hospitalisées à la maternité de référence à Niamey (Niger).

A cross-sectional survey was conducted in the main maternity hospital in Niamey (Maternité Poudrière) in July 1995 to evaluate the domestic and financial pressures faced by the patients. One-hundred-and-five women were included in this exhaustive survey which analyzed the socio-demographic characteristics of the patients' households, the reasons for their hospitalization, the organization of their daily life while in hospital, and the costs involved (type of costs, the amounts, and who paid which cost). Fifty-seven women lived in Niamey, and forty-eight in a rural area. The socio-demographic characteristics of the survey population were in agreement with the characteristics of Niger's census in 1988. Analysis of the patients' incomes showed that they were highly dependent on their husbands. Fifty-eight received surgical treatment, and forty-seven received medical treatment. The costs of hospitalization included the standard fee, traveling expenses, and the costs of drugs and surgery. On average, 72% of the hospitalization costs were paid by the husbands, and 15% by close members of the family. The contribution by extended family members and friends was very small. Only 40.5% of the total amounts exceeding 25,000 FCFA were wholly paid. Niger has a policy of recovering medical costs. Our survey shows the difficulties of attempting to reconcile the operation of health centers with access to specialist care.

[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.