Nationwide maternal mortality in Surinam.

OBJECTIVE: To assess the magnitude, causes and associated factors of maternal mortality in Surinam. METHODS: Nationwide confidential enquiry. Maternal deaths were identified using various methods and sources for the period 1991-1993. All cases were examined by a maternal mortality expert committee for substandard care analysis. RESULTS: The national maternal mortality ratio was 226 per 100,000 live births, which is six times higher than the official maternal mortality ratio of 38 for the preceding three year period. The main causes of death were haemorrhage (30%) and pre-eclampsia (20%). In 95% of analysed cases, substandard care factors which had contributed to the deaths were present at one or more levels of maternity care. CONCLUSIONS: Maternal mortality was found to be several times higher than had been officially reported for Surinam during the previous three decades. Improvement of maternity care services in Surinam is needed, and has to be addressed at all levels, from the community, health centre and hospital to the highest level of organisation.

PIP: This study assessed the extent, causes, and factors associated with maternal mortality (MM) during 1991-93 in Surinam. Data were obtained from a national mortality survey and verified with the doctors who signed death certificates. A single underlying cause was assigned to each death. Findings indicate that the national MM ratio was 226/100,000 live births (64 maternal deaths), which was 6 times higher than the official figures for the same period. 76.6% were due to direct maternal causes; 23.4% to indirect maternal causes. The main causes of death were hemorrhage (29.7%), pre-eclampsia (20.3%), complications from cesarean section (7.8%), sepsis from genital tract infections (6.3%), and other (7.8%). 87.5% died in the densely populated coastal area, 12.5% died inland, 82.8% died in a hospital, 3.1% died in health centers, and 14.1% at home. 71.7% had vaginal deliveries; 28.3% were delivered by cesarean section. Among 59 maternal deaths, 22% had no prenatal care, 45.8% had their first prenatal visit in the second half of the pregnancy, and 32.2% began prenatal care before the 20th week of gestation. 61.9% had uneventful obstetric histories. 12.7% had health risk factors. 95.2% of cases involved substandard care practices by the woman and her family, obstetricians, hospital care, and/or the organization of health care. Deaths from hemorrhage were mostly due to late blood transfusion. Deaths from eclampsia were due to late transport to the hospital.

Human papillomavirus in malignant cervical lesions in Surinam, a high-risk country, compared to the Netherlands, a low-risk country.

In various countries epidemiologic studies show an association between human papillomavirus (HPV) and cancer of the uterine cervix. We determined the presence of HPV and the distribution of the different HPV genotypes in cervical carcinomas from Surinam, a high-incidence country. The results were compared to the Netherlands where the incidence is five times lower. One hundred thirty cervical carcinomas from patients in Surinam were randomly selected and compared to an unselected group of 128 cervical carcinomas from caucasoid Dutch patients. Presence of HPV and distribution of HPV genotypes was determined in DNA extracted from paraffin-embedded specimens by polymerase chain reaction and sequence analysis. HPV DNA was detected in 82% of the Surinamese cervical cancer patients and in 87% of the Dutch patients. Thirteen different HPV genotypes were detected in the Surinamese group, and nine different HPV genotypes were detected in the Dutch group. Among the HPV-positive samples, HPV 16 was present in 68% in the Netherlands compared to only 49% in Surinam, where less common genotypes such as HPV 35, 45, and 58 were more prevalent. The results show a strong association between HPV and cervical cancer in both groups. However, the observed significant variation in distribution of the genotypes in the two populations with a large difference in cervical carcinoma incidence is important to the general understanding of the etiology of cervical cancer and to the development of HPV vaccination strategies.

Reproductive age mortality survey to study under-reporting of maternal mortality in Surinam.

OBJECTIVES: A nationwide confidential enquiry into maternal deaths was carried out in Surinam during the years 1991-1993. Preliminary analysis showed a maternal mortality ratio (MMR) of 240 per 100000 live births, which was almost four times higher than the official MMR for the preceding decade. The question arose whether maternal deaths had been under-reported for the years 1981-1990. For these 10 years official statistics revealed 65 maternal deaths. METHODS: For the period 1981-1990 a retrospective reproductive age mortality survey was carried out in five urban hospitals covering 78% of all deliveries in Surinam. RESULTS: In these hospitals 1216 women of age 10-49 years died. Due to disorganized filing 439 medical records (36%) could not be traced. By reviewing 64% of the records, 85 maternal deaths were identified (70 direct and 15 indirect). CONCLUSION: Although only 64% of medical records could be reviewed, the number of maternal deaths identified in five hospitals (85) was 1.3 times higher than the officially reported number for the whole country (65). Maternal mortality was found therefore to be under-reported in Surinam for the period 1981-1990.

PIP: This study investigates the reliability of the maternal mortality ratio reported officially by hospitals in Surinam during 1981-90. A survey on retrospective reproductive age mortality was carried out in five urban hospitals in Surinam. Within the study period, the total number of live births in 5 hospitals was 82,512. In these hospitals, 85 cases of maternal death were identified, which is 1.3 times higher than the 65 cases of maternal death officially reported to the Ministry of Health. But this hospital ratio does not reflect the national ratio because of the following reasons: 1) the number of maternal death occurring outside the hospitals remains unknown; 2) only 64% of the records of women dying during the reproductive age in urban hospitals were studied. Thus under-reporting of maternal mortality in the Surinam national register for the period 1981-90 is likely to reflect a worse scenario than the officially reported number of cases. This study indicates that there is a need to improve the quality of registration of maternal deaths in Surinam.

Cervical carcinoma in Surinam. Incidence and staging of cervical carcinoma between 1989 and 1994.

BACKGROUND: Epidemiologic data show a high incidence of cervical cancer throughout the world and a high mortality, particularly in developing countries. The aim of this study was to describe the incidence and stages of cervical carcinoma in Surinam. Results were compared with data from The Netherlands (used as representative of western European countries) because of a medical and patient exchange program. METHODS: Data for Surinamese patients analyzed in this study were based on the files from the Department of Pathology at the University of Surinam from 1989 through 1994. Cumulative and incidence rates standardized to the World Standard Population were calculated and compared with rates in other South American countries and in The Netherlands. Age distribution and stage of disease (according to the International Federation of Gynecology and Obstetrics) among Surinamese and Dutch women were compared. Furthermore, differences in incidence rates among the multiple ethnicities of the Surinamese population were evaluated. RESULTS: Age standardized incidence rates for Surinam and The Netherlands were 26.7 and 6.2 per 100,000 women, respectively. The cumulative rate up to age 74 years was 2.9 in Surinam versus 0.6 in The Netherlands. Incidence in Surinam rose sharply with age. More than 40% of the Surinamese women presented with Stage IIB disease or higher compared with 12% in The Netherlands. In Surinam, low stage of disease was highest in the youngest group (48%), whereas only 18% of women 65 years or older presented with Stage I disease. Incidence rates in Surinam varied by ethnic group. Amerindians and Javanese were more likely to develop cervical cancer than were other ethnicities. CONCLUSIONS: Cervical carcinoma in Surinam was characterized by high incidence rates and relatively advanced stage of disease at presentation. Moreover, incidence was not equally distributed among the different ethnic groups. This may reflect a greater exposure to risk factors and differential access to diagnostic and treatment services.