Annettee Nakimuli (Obstetrician; Lecturer and PhD student in the Department of Obstetrics and Gynaecology, Makerere University) Maternal Mortality in Africa: Experiences of a Ugandan Obstetrician

1. What are the causes of
maternal mortality in Africa?
Experiences of a Ugandan
Obstetrician
Annettee Nakimuli,
Obstetrician & gynaecologist,
Lecturer and PhD Student,
Makerere University(Uganda)

2. 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

3. Map of Uganda

4. 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 527 506 505 435 310
births)
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

5. Mulago Hospital

6. 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

7. 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

8. Maternal mortality trends at Mulago
Hospital

9. Causes of maternal death at Mulago
Hospital in Jan-Mar 2012
unknown
6%
haemorrhage
indirect
29%
26%
pre-eclampsia
14%
others direct
abortion
6%
8% sepsis
11%

10. Physical & psychological challenges of fistula
10

11. 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

12. Records keeping

13. Floor cases on the ward

15. 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

16. Male involvement is great sometimes

17. 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!

18. 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

19. 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

20. Obstetricians & gynaecologists of Mulago Hospital

21. THANK YOU
ASANTE SANA