University of Khartoum

Faculty of Medicine
Postgraduate Medical Studies Board

Analysis of Maternal Mortality at Omdurman

Maternity Hospital

By
Abdel Magid Mohamed Ahmed
M.B.B.S (University of Gezira)

A thesis submitted in partial fulfillment for the requirements of the

Degree of clinical M.D. in Obstetrics and Gynaecology
March 2003

Supervisor
Professor Abdel Salam Gerais
FRCOG

CONTENTS
Page
Dedication

Acknowledgment

ii

Abbreviations

iii

English abstract

iv

Arabic abstract

Chapter 1:

o Introduction

o Literature Review

o Justification

22

o Objectives

23

Chapter 2:
o Materials & Methods
Chapter 3:

24
25
26

o Results

27

o Figures

30

o Tables

33

Chapter 4:

35

o Discussion

36

o Conclusion

44

o Recommendations

45

o References

46

DEDICATION

To my mother

ACKNOWLEDGEMENT
I wish to express my thanks to professor (A/Salam Gerais), the
consultant Obstetrician and Gynaecologist in the faculty of Medicine
university of Khartoum who supervised this research.
My sincere thanks are due to my wife Omima Ahmed Abdullah for
helping me in using computer.
My thanks are also extended to my niece Haifa Alarabi and my
nephew Ahmed Salih for exploring internet, and typing this research.

ii

Abbreviations
ALT: Alanine Aminotransferase.
CBRHP: The Community-Based Reproductive Health Project.
CI: Confidence Interval.
HELLP syndrome: Haemolysis, Elevated liver Enzymes, low Platelets.
HIV: Human Immunodeficiency Virus.
MMR: Maternal Mortality Rate.
MOH: Ministry Of Health.
N = : (Number equal).
n = : (Number equal).
NGO: Non Governmental Organization.
OR: Odds Ratio.
PPH: Postpartum Haemorrhage.
SMS: Safe Motherhood Survey.
TBAs: Traditional Birth Attendants.
VHWs: Village Health Workers.

iii

English abstract
Objective: Study of maternal deaths to find out the causes and factors
leading to maternal mortality.
Methods: A descriptive analysis of maternal deaths at Omdurman
maternity hospital during, the one year period between 1/8/2001 to
31/7/2002 was conducted.
Results: The total number of deaths was 30 cases out of 14500 deliveries
and the corrected maternal mortality rate is 206 per 100,000 births. The
most important factor leading to maternal death is absence of antenatal
care.
Death among unbooked ladies compared to booked ladies was much
higher.
The correlation between booking status as general and maternal death
was statistically highly significant.
Of all causes of maternal death hypertension in pregnancy was the
leading cause of death, causing 14 deaths (46.66% of all deaths).
Again booking was studied in hypertensive ladies and its correlation with
maternal death was significant.
The second cause of death was shared between haemorrhage and hepatic
coma, both causing 4 deaths which is 13.33% of all deaths. This to be
followed by sepsis which has caused 3 deaths (10%), both pulmonary
embolism and portal hypertension caused 2 deaths (6.66%), and finally
malaria which has caused one death (3.33%)
Conclusion
At the level of primary prevention it is recommended that, provision of
effective free antenatal care with qualified staff to all pregnant women all
over the country and a special plan dedicated to hypertensive disorders
with pregnancy.
Health education about importance of antenatal care and risks of its
omission should be delivered to community and specially women.
At the level of secondary prevention it is suggested that, improvement of
hospital facilities and provision of trained medical and paramedical staff.

iv

Arabic abstract

:
.
:
2001/8/1
.2002/7/31
:
30 14.500 206
100.000 . .

.
14
) %46.66 (
.
4 % 13.33
. 3 %10
.
%6.66
%3.33 .
:


.
.

.

Chapter 1

Introduction
Literature review
Justification
Objectives

INTRODUCTION
Death of a mother is a sad event in the part of her family and the caring
health team.
There may be tremendous adverse social, psychological and economical
impact inflicted upon the family when the mother dies. Approximately
90% of maternal deaths (more than 0.5 million each year) occur in
developing countries. (1) The meticulous study of the previous
successful experiences in reducing maternal mortality, well help to set up
plans for dealing with the problem. There are many preventable &
avoidable factors which if elucidated, and plans set up to deal with them,
a satisfactory reduction in maternal deaths will be achieved. In Sudan the
major causes of maternal mortality are more or less the same like other
developing nations. There are many preventable & avoidable factors at
primary, secondary and tertiary levels.

Literature Review
Definitions:
Maternal death
Death of a women while pregnant, or within 42 days of termination of
pregnancy, from any cause related to or aggravated by, pregnancy or its
management, but not from accidental or incidental causes.
Direct maternal deaths are defined as deaths resulting from obstetric
complications of the pregnant state (pregnancy, labour and puerperium),
from interventions, omissions, incorrect treatment or from a chain of
events resulting from any of the above.
Indirect maternal deaths are defined as deaths resulting from previous
existing disease, or disease that developed during pregnancy and which
was not due to direct obstetric causes, but which was aggravated by
physiologic effects of pregnancy.
Late maternal deaths are deaths occurring between 42 days and one
year after abortion, miscarriage or delivery that are due to direct or
indirect causes.
Fortuitous deaths are deaths from unrelated causes that happen to occur
in pregnancy or the puerperium.

Maternal mortality rate (MMR)

This generally defined as the number of deaths from obstetric causes per
100,000 maternities. Maternities are the number of mothers delivered of
registerable live births, at any gestation, or stillbirths of 24 weeks or later.
(2)

Safe motherhood survey 1999 in Sudan (SMS)

The Arabic edition of this survey was published at October 2002. In this
survey, the maternal mortality rate was 519 per 100,000 live births and
the risk of death due to motherhood was 3.3%. Comparing these figures
to the demographic survey done in 1989 (where maternal mortality rate
was 537 per 100,000 live births and risk of death due to motherhood was
3.7%), there was slight improvement. In the national capital Khartoum,
maternal mortality rate was 559 per 100,000 live births compared to 524
and 319 per 100,000 live births in Darfur and northern regions
respectively, the latest showed the lowest rate over all the Sudan. (3)
Although most deaths occurred around labour and delivery, the level of
care by trained personnel was better during antenatal period rather than
around labour and delivery. Care during antenatal period was mostly
conducted by doctors or health visitors, but unfortunately care around

labour and delivery was conducted mostly by village midwife or

traditional birth attendants. This may be due to social reasons or poverty.
(4)
A study of the maternal deaths that occurred at Kassala new hospital in
eastern Sudan was conducted by Mohamed A. A. and his colleagues. In
this study there were 34 maternal deaths (the hospital maternal mortality
rate was found to be 2119 per 100,000 live births). 19 cases (55.9%) were
directly due to obstetrical causes. 15 (44.1%) involved none obstetrical
complications. Puerperal sepsis was found to be the leading obstetrical
cause of death, responsible for 31.6% of obstetrical causes and 17.6% of
all maternal deaths. Complications of malaria were the most important
none obstetrical cause, responsible for 46.7% of none obstetrical
mortality and 20.6% of over all maternal deaths. The most important
contributing factors were delay in seeking care (in 88.2% of cases),
failure in the referral system (85.4% of cases), and failure to receive
optimum care in index hospital (11.8% of cases). They concluded that
maternal mortality rate was very high, with malaria the major none
obstetrical cause. Other factors included delay in seeking care, lack of
appropriate emergency facilities and referral procedures in the rural
hospitals. Poverty in this region plays a major role in under utilization of
the available services. (5)
Dafallah SE and his colleagues conducted a study at the Medani Teaching
Hospital, Medani City, Sudan which included 877 women died during the
period 1985-1999. Out of the total number of deliveries in that period (N
= 44,605), 877 women died with a rate of 1,966 per 100,000 total births.
This rate showed a decline each year, being 2,661 per 100,000 total births
during the period 1985-1989. The mortality rate during 1990-1994 was
2,021 per 100,000 total births and 1,363 per 100,000 total births during
the last period of 1995-1999. Sepsis was the cause of death in almost one
third of cases, while malaria accounted for 37.2%. The number of
preventable deaths had decreased steadily. They concluded that the study
highlighted the existence of a serious and preventable obstetrical
problem. Sepsis, malaria, haemorrhage and hypertensive disorders are the
main contributory factors. Poor antenatal care, poor intranatal care, and
poor provision of health services add more to the problem. They also
concluded that conduction of research into the problem of malaria,
sterilization, anaesthesia, vascular accidents, and indication for caesarean
section together with social and medical improvements will definitely
reduce the maternal morbidity and mortality. (6)

Al-Suleiman s. and his colleagues conducted a twenty-year survey about

maternal mortality at the King Faisal University Hospital, Al-Khobar,
Eastern Saudi Arabia including 56,422 total births.
The maternal mortality rate was 28.4/100,000 maternities. The leading
cause of death was haemorrhage in seven (43.75%) patients, followed by
pulmonary embolism in four (25%) and general anaesthesia in two
(12.5%) mothers. The risk factors noted were maternal age 35 years and
parity 5 coupled with iron deficiency anaemia. The main avoidable
factors were failure of the patients to seek timely medical care and to
follow medical advice. More than half of the numbers of direct obstetrical
causes of death was thought to be preventable. A rapidly changing
attitude of women towards childbirth is occurring through progressively
increasing female education and community health programmes in the
region. Further reduction of maternal mortality rates in the community is
envisaged through greater patient acceptance of medical advice, family
spacing and proficient obstetric services. (7)
Maternal deaths in Kasturba Hospital, during the 10-year period from
January 1989 to December 1998 were studied by Baul MK. and
Manjusha. A total of 419 deaths were recorded among 112,133 deliveries,
with an average maternal mortality rate of 360. The year wise maternal
mortality rate showed an almost consistent decline from 468 to 190 over
the decade. Almost all the deaths (95%) occurred among unbooked
gravidas. Indirect causes claimed 62.5% lives while 33.8% were due to
direct obstetric causes and 15 (3.6%) deaths were due to coincidental
causes. Severe anaemia was the largest killer, causing 31% of total
deaths. Majority (65.6%) of deaths occurred in the postnatal period. Most
of the deaths could have been prevented by better community
participation, antenatal care, iron-folate prophylaxis and timely medical
care. (8)
An analysis of maternal mortality was conducted at Ayub Teaching
Hospital, Abbottabad by Begum S, Aziz-un-Nisa and Begum I., from
January 2000 to December 2001. In this analysis, Twenty-six maternal
deaths were recorded during study period. The major causative factors
were haemorrhage 9 (34.6%), eclampsia 8 (30%), sepsis 5 (19.2%),
anaesthetic complications 3 (11.5%) and hepatic encephalopathy 1
(3.8%). Maternal mortality ratio was 12.7/1000 live births (26/2040). The
age range was between 18-42 years. There were 16 (61.5%) patients in >
30 years age group. Most of them (69%) were grand multiparas (Parity >
5). Education, antenatal booking and socio-economic status were poor.
The distance from hospital was between 10 and 100 KM. The level of
care available at nearest health facility was estimated, 40% were attended
5

by traditional birth attendants, 33% by lady health visitors, 10% by

doctors, and in 17% no level of care was available. They concluded that
obstetrical haemorrhage and hypertensive disorders are still major causes
of maternal deaths. Most maternal deaths are preventable. The provision
of skilled care and timely management of complications can lower
maternal mortality in their setup. (9)
A study about maternal mortality between 1980 and 1996 was conducted
in Italy by Biaggi A. and his colleagues. In this study, maternal mortality
rates have decreased from 13.25 (1980) to 3.78 (1996) per 100000 live
births. Haemorrhage and hypertension have been the main causes of
maternal death, while pulmonary embolism has had a minor effect on
maternal mortality rates compared to other countries, particularly in
Europe. They concluded that Italian data appear reassuring and encourage
further investigations on detailed welfare problems. (10)
A study done at Rotunda Hospital, Dublin, Ireland, about Successful
reduction of massive postpartum haemorrhage by use of guidelines and
staff education by Rizvi F and his colleagues. They reviewed all cases of
massive primary postpartum haemorrhage greater than 1000 mL over a
six month period in 1999 to establish the incidence, identify aetiological
factors and implement change. Fifty-four cases (1.7%) were identified.
Four were classified as 'near-miss' maternal mortality. Over 60% were
delivered by caesarean section. Seventy-six percent were due to uterine
atony, 9% due to genital tract trauma and 15% were associated with
significant antepartum haemorrhage from placenta praevia or abruption.
No obvious labour or delivery risk factors were identified but deviation
from hospital guidelines was common. Following revision of the
guidelines, dissemination to staff and use of practice drills, the study was
repeated on a prospective basis over the same time period in 2002. There
was a significant reduction in the incidence of massive postpartum
haemorrhage to 0.45%, and 100% adherence to the guidelines which
resulted in a significant reduction in maternal morbidity. (11)
Thonneau PF. and his colleagues conducted an African multicentre
hospital-based study about distribution of causes of maternal mortality
during delivery and post-partum period. The results showed of a total of
10,515 women, 1495 presented a major obstetric complication with
dystocia or inappropriate management of the labour phase as the leading
cause of death. Eighty-five maternal deaths were reported, giving a global
hospital-based maternal mortality rate of 800/100,000. Hypertensive
disorders were involved in 25/85 cases (29%) and post-partum
haemorrhage in 13/85 cases (15%). Relatively few cases (14) of major
6

sepsis were reported, leading to three maternal deaths. They concluded

that, the results of this multicenter study confirm the high rates of
maternal mortality in maternity units of reference hospitals in large
African cities, and in addition to dystocia the contribution of hypertensive
disorders and post-partum haemorrhage to maternal deaths. (12)
A study about postpartum haemorrhage in developing countries (to see if
the public health community using the right tools) was conducted by Tsu
VD and his colleagues. (Programme for Appropriate Technology in
Health (PATH), Seattle, WA, USA)
Results showed that haemorrhage, primarily postpartum, accounts for
approximately 25% of maternal deaths globally. Uterotonic drugs offer
great promise for both prevention and management of postpartum
haemorrhage (PPH). Other technologies such as anti-shock garments,
umbilical vein injection of oxytocin, and simple anaemia detection
methods represent potential new opportunities to reduce PPH-related
mortality. They concluded that Clinical and operational research is
needed to answer remaining questions about misoprostol, the anti-shock
garment, and umbilical vein injection of oxytocin for retained placenta.
Efforts are needed to ensure the availability of technologies with proven
value, such as oxytocin in the prefilled injection devices. Equally
important, technologies and techniques with proven efficacy such as
active management of third-stage labour and aortic compression must be
translated into general use by disseminating the evidence for them,
incorporating them into national guidelines and training curricula, and
ensuring the availability of supportive supplies and equipment. (13)
Yayla M. conducted a study about maternal mortality in developing
countries. The study showed that of all health statistics mentioned by the
World Health Organization (WHO), maternal mortality is unique in
showing the largest discrepancy between developed and developing
countries. Approximately 90% of maternal deaths (more than 0.5 million
each year) occur in developing countries. Over the last century, almost all
countries have accepted antenatal care principles. However, insufficiency
of resources and lack of women's compliance were the main handicaps in
developing countries and compelled these countries to apply various
standard programmes. Unfortunately, these programmes are not
sufficiently effective in the prevention and treatment of maternal
mortality. Fixing the number (quantity) of antenatal visits and the static
approach affect the quality of antenatal care. Bleeding, chronic anaemia,
hypertensive disorders, obstructed labour, unsafe abortions and infections
are the main factors leading to maternal mortality. The majority of these
factors are preventable. It is important to suspect the presence of any of
7

these factors and to intervene promptly both during antenatal care and
immediately after delivery. The evidence-based approach is a way of
reaching this solution. Antenatal care is a concept that extends from prepregnancy to postpartum, leading to effective emergency care for
unpredictable and predictable complications during pregnancy and
childbirth. Worldwide policies are not always applicable to each country.
There is still a need for prospective randomized trials to clarify this
concept and the relevant policies. (1)
A 13-year hospital based study done about Trends in maternal mortality
in rural Ghana by Geelhoed DW and his colleageus. In the study 229
maternal deaths were analyzed. The overall maternal mortality rate of
1077/100,000 live births did not change significantly during the study
period. However, the relative contributions of sepsis, haemorrhage,
obstructed labour, anaemia, sickle cell disease and pre-eclampsia
diminished, while abortion complications increased significantly. They
concluded that, the Safe Motherhood Initiative in the study area has
contributed to the reduction of maternal mortality due to causes against
which interventions were directed. Abortion complications as cause of
maternal mortality need to be included in interventions and research. (14)
Okonta PI and his colleagues performed a study to explore the causes of
and risk factors for maternal deaths in a rural Nigerian referral hospital. It
was a 10-year (1990-9) review of all maternal deaths at Mater
Misericordiae Hospital. A total of 104 deaths occurred out of 13,391
deliveries (MMR 777/100,000). Haemorrhage, sepsis and Hypertensive
diseases in pregnancy were the leading causes of death. Age below 15,
Nulliparity, Grandmultiparity, low socio-economic class, lack of formal
education and being unbooked were also significant risk factors. Delay in
accessing health facility was also an identified contributing factor. They
suggested Public enlightenment to encourage utilisation of antenatal
facilities, prompt referral of complicated cases and adequate equipping of
the referral hospital. (15)
Ezechi UO conducted a prospective study that examined the nature of
emergency obstetric admissions in a Nigerian university hospital in
association with such factors as late referrals and misdiagnoses and their
contribution to maternal and perinatal morbidity/mortality. The study
comprised 144 consecutive emergency obstetric admissions to the
hospital over a 6.5-month period. An incidence of 13.6% emergency
admissions was recorded. Despite the proximity of the hospital to the
parturients, most of them laboured in substandard facilities within the
8

community. Referrals to the university hospital were made only after

prolonged delay and onset of complications. Obstetric haemorrhage
(24.6%) was the most common cause for referral followed by labour
disorders (19%) and hypertensive disorders (8.4%). Thirteen maternal
deaths occurred, giving a maternal mortality ratio of 6.2%. Twelve of the
maternal deaths were in women living within 5 km of the hospital. There
was a caesarean section rate of 50.9%, a 4.8% incidence of diagnostic
laparotomy, a 9% incidence of emergency hysterectomy and 44% of
emergency blood transfusions. Misdiagnoses of clinical conditions were
made by the referring centres in 68% of cases, which contributed to the
high maternal morbidity and mortality. Patient attitude was the main
cause of non-use of teaching hospital facilities (fear of operation in 32%
of cases, dissuasive advice from friends in 27.4% and negative staff
attitude in 7%. A need for and type of programme that will promote
increased utilisation of modern maternal health services in the community
are discussed. (16)
Bashir A. viewed the story of success of reducing maternal mortality of
the Faisalabad district in Pakistan. Maternal-child health care
interventions in this district have produced dramatic reductions in
maternal mortality and are potentially replicable in other developing
country settings. In the late-1970s, health personnel became concerned
with the high rates of maternal mortality, infant mortality, malnutrition,
fertility, and illegal abortion in the district. Since 80% of deliveries in
Pakistan are carried out by traditional birth attendants (TBAs), the author
initiated a programme of refresher courses for TBAs in the district. In the
10 years since 1978, 5500 urban and rural TBAS have participated in
these annual seminars and been provided with information on detection of
high-risk pregnancies for referral, sepsis prevention, prenatal care,
neonatal resuscitative measures, and family planning. During this same
10-year period, maternal mortality dropped from 10.1 to 1.86/1000,
largely as a result of referral of complicated cases to the district
headquarters Hospital. Another innovation was the Faisalabad flying
squad service; an emergency ambulance equipped with medicines and
trained staff that can rapidly transport women who develop complications
during delivery to the hospital. In the 1 year since programme inception
in January 1989, there have been 73 calls for the emergency service. In
1990, the year of the mother and child lectures on family planning,
maternal-child health, and the availability of the obstetric Flying Squad
were given throughout the district. The main causes of the 48 maternal
deaths in the district in 1989 (maternal mortality rate of 0.86/1000) were
insistence on home delivery and reluctance to go to the hospital. (17)

Chhabra S and Sirohi R conducted a study about, Trends in maternal

mortality due to haemorrhage over two decades in Indian rural regions.
In this study Obstetric haemorrhage continues to be a major cause of
maternal mortality. Their analysis of records of over a period of 20 years
from April 1982 to March 2002 reveals that it was a contributory cause of
maternal mortality in 19.9% of cases. The majority of deaths, (65%) had
occurred within 24 hours of admission and in 47.5% of cases there was
severe anaemia on admission, 17.5% had died due to an atonic PPH,
which was the largest category, followed by ruptured uterus (15%),
abruptio placenta (15%) and retained placenta (12.5%). Deaths due to
obstetric haemorrhage because of a ruptured uterus, retained placenta and
abortion have decreased from 22.22% between 1982 and 1987 to zero in
the last 5 years and an increase was seen in deaths due to haemorrhage
because of gestational trophoblastic neoplasia and ectopic pregnancy,
from 1.69% to 4.87%, unclassified haemorrhage 1.96% to 7.31% and
placenta praevia from zero between 1982 and 1987 to 4.87% between
1997 and 2002. (18)
Nkata M. conducted a study at Mansa General Hospital (Zambia); he
used birth records, death certificates, and operating theatre and autopsy
records to analyze maternal mortality. During the 2-year study period,
there were 3282 live births and 95 maternal deaths at this facility, for a
maternal mortality ratio of 29/1000 live births. 35% of maternal deaths
were to illiterate adolescents who relied on untrained traditional birth
attendants. 18 women (19%) died immediately after emergency
admission for delivery. The major risk factors for maternal mortality were
a labour exceeding 48 hours, age in the teens, primiparity, use of herbal
medicines, and uterine rupture. The principal causes of death were sepsis
(53%) and haemorrhage (22%). Delay on the part of traditional birth
attendants in referring women with obstructed labour and uterine rupture,
the unavailability of emergency transport, insufficient blood supplies for
transfusions, and a lack of qualified personnel at first-level health
facilities contributed to maternal mortality. (19)
Mercer A. and his colleagues studied the effectiveness of a nongovernmental organization (NGO) primary health care programme in
rural Bangladesh. It is based on data from the programme's management
information system reported by 27 partner NGOs from 1996-2002.On the
basis of a crude indicator of socio-economic status, the programme is
poverty-focused. The lower child and maternal mortality for the NGO
areas combined, compared with estimates for Bangladesh in recent years,
may at least in part be due to high coverage of reproductive and child
health services. Other development programmes implemented by many of
10

the NGOs could also have contributed. Maternal mortality in the NGO
areas was lower in 2000-02 than the most recent estimate for Bangladesh.
Further reduction is likely to depend on improved access to qualified
community midwives and essential obstetric care at government referral
facilities. (20)
Fernando D and his colleagues addressed the national strategies which led
to reducing maternal deaths and disability in Sri Lanka. They considered
the declining trend in the maternal mortality rate (MMR) from the 1930s
to the late 1990s has resulted from several strategies implemented within
and outside the health sector. Expansion of both field-based and
institutional services through the past decades contributed to improved
geographical access and provision of 'free' services improved economic
access. These led to increased use of antenatal and natal services provided
by trained midwives and other personnel followed by improvements in
the availability of specialized care and emergency obstetric care.
Integration of family planning and other inputs to the maternal health
programme has yielded positive results. The role of the private sector is
limited to provision of a component of antenatal services. The
organization for service provision and an information system made
significant contributions towards improvement. The commitment of the
health sector to provide services free of charge supported by non-health
inputs, especially female education, has enabled Sri Lanka to make gains
in maternal health. (21)
Hofmeyr GJ. conducted a study to identify, from the best available
evidence, underutilized and promising technologies that may reduce
maternal mortality from obstructed labour. The results showed that
obstructed labour causes approximately 8% of maternal deaths, and
indirectly contributes to a greater percentage. Proven or widely accepted
technologies that help reduce mortality from obstructed labour include
contraception, external cephalic version, the partogram, augmentation of
labour, selective amniotomy, selective episiotomy, vacuum extraction,
caesarean section, symphysiotomy, and destructive procedures for nonviable fetuses. Technologies of uncertain usefulness include maternal
height and shoe size, vaginal cleansing, upright posture for delivery and
vaginal lubrication. Unuseful technologies include pelvimetry, estimating
fetal weight, early labour induction, routine amniotomy and
augmentation, routine episiotomy, and starvation during labour. It was
concluded that access to well established technologies, particularly safe
caesarean section, can reduce maternal mortality in resource-poor
countries. (22)

11

Hussein J and Fortney JA. reviewed the current medical literature about,
Puerperal sepsis and maternal mortality to see what role can new
technologies play?
They pointed that the literature indicates that infection control protocols
and evidence-based procedures-including prophylactic antibiotics for
caesarean section or preterm rupture of membranes, and updated
antibiotic regimens-should be widely adopted. Devices such as hand rubs,
needle-disposal systems, and rapid microbiological diagnostic tests can
improve compliance and efficiency. Operational research on promising
developments like vaginal cleansing with antiseptics, vitamin A
supplementation, and prophylactic antibiotics in high-risk women is
needed. It was concluded that, sepsis management continues to depend on
good implementation of established technologies. Programme-based
approaches are required to improve uptake. (23)
Imbert P. and his colleagues conducted a prospective study about
maternal and infant prognosis of emergency caesarean section at the
Principal Hospital in Dakar, Senegal. They found that the prognosis of
emergency caesarean section is poor for both the mother and child in
developing countries. This prospective study was carried out in 370
women (mean age, 30.5 years) who underwent emergency caesarean
sections between January 1 and December 31, 1997. Fifty percent of
these women had been transferred from an outside maternity clinic.
Indications related to the mothers (75% of cases) or fetuses (25% of
cases) were divided into two groups according to degree of emergency:
absolute (n = 163) and relative (n = 207). Placental haematoma (n = 64)
and fetus-pelvis size mismatching (n = 49) were the main indications in
both groups. The technique chosen for initial anaesthesia performed by a
specialized nurse in most cases was either spinal anaesthesia if there were
no contraindications (50.8%) or general anaesthesia (49.2%). There were
5 complications including 1 that was fatal (aspiration during intubation
for general anaesthesia). The postoperative maternal morbidity rate was
low (n = 7) and outcome was favorable. A total of 7 patients (1.9%) died
due to anaesthesia-related events in 1 case and obstetrical factors in 6.
Mortality in the absolute emergency group was significantly higher for
women who were transferred from other clinics (p < 0.02). Maternal
mortality rate was correlated with the severity of obstetrical
manifestations and delay of care. Findings also showed that a wellorganized care system lowers the operative risk of emergency caesarean
section even in developing countries. (24)
Shaheen B. and his colleagues conducted a study about eclampsia as a
major cause of maternal and perinatal mortality. It was a prospective cross12

sectional observational study (from 1st Jan 2001 to 31st Mar 2002)
included all the patients admitted to the unit with eclampsia. Results
during the study period showed that 71 patients developed eclampsia
(frequency: 1.2%). Majority were unbooked (86%), primigravida (69%),
< or = 25 years of age (63%), referred from other health facilities (66.2%)
and had some delay in seeking medical help (60%). Thirty five percent of
patients developed major complications and 16.9% of them died (48% of
overall maternal mortality). Mortality was frequent in Afghani women
(OR 7.71 p value 0.002) and in women who sought medical help more
than 6 hrs after developing seizures (OR 14.6 P value 0.0004). They
concluded that, to decrease the adverse outcome associated with
eclampsia a community based approach is needed to improve community
health education, socioeconomic status and prenatal care. Delivery of
proper health care system and emergency obstetrical care facilities are
vital for prevention, early detection, proper management and hence to
save the mothers and their babies from such a dreadful disease. (25)
Ikechebelu JI and Okoli CC. conducted a review of eclampsia at the
Nnamdi Azikiwe University teaching hospital, Nnewi (January 1996December 2000). It was a retrospective study of 43 cases of eclampsia
managed at the hospital over a 5-year period, an incidence of 0.75% out
of 5750 labour ward admissions was found. Eclampsia was more
prevalent in the primigravidae (65%) and unbooked patients (83.7%) than
in the multigravidae (35%) and booked (16.3%) patients. The mean age
of the patients was 23.5 years. The majority of the eclamptic seizure
(55.8%) occurred in the antepartum period. Many unbooked patients
presented after more than two seizures. The most frequently used drugs in
the management of eclampsia in the hospital were intravenous diazepam
and hydralazine. For the 35 cases of antepartum eclampsia, 85.7% had a
caesarean section while 14.3% had an operative vaginal delivery; none
had a spontaneous vaginal delivery. There were four maternal deaths
(9.3% of the cases). Clinical causes of death in the women were
cardiopulmonary failure (three cases) and coagulation disorders (one
case). The total maternal deaths in the hospital during this period was 19
given a maternal mortality rate of 330 per 100,000 births. Eclampsia,
therefore, contributed 21.1% of the maternal deaths. The role of health
education and good antenatal, labour and early puerperal supervision is
stressed in the reduction of the incidence of eclampsia in the developing
countries. (26)
Srp B and his colleagues carried out an analysis of 31 cases of maternal
deaths, which was associating with severe preeclampsia and eclampsia in
the Czech Republic during 1978-2000, using a database of 470 maternal
13

deaths during the observed period. They considered timelines of lifethreatening events, age of mother, parity, and place of death. It was the
5th most frequent cause of maternal death. Clinical management was not
adequate in 15 cases of death (48%). Severe preeclampsia and eclampsia
were more frequent among older women and multiparae. First group
(61%) is composed of women with manifest convulsions, 25% of them
experienced convulsion after delivery, and only few cases had mild
preeclampsia antepartum. Eclampsia with convulsions leading to coma
was seen in 10 cases complicated with DIC, two cases in this group had
premature separation of placenta. The second group (39%) were cases
without convulsions. These cases were complicated with severe liver
disorders and renal failure, and 5 cases of intra-cranial haemorrhage.
Several cases had combination of symptoms. DIC was present in 6 cases.
In both groups there were 5 cases with haemorrhagic skin symptoms,
thrombopenia, symptoms of DIC and liver and renal failure, which would
fall into HELLP syndrome according to current classification. Most of
women died during the postpartum period (87%) mostly after emergency
operative deliveries. The fact that no women died during pregnancy
indicates the effort to perform life-saving operative delivery. Forty two
percent of women were term. Especially at the beginning of observed
period they noticed tendency to prolong gestation in order to save the
baby. The operative deliveries accounted for 71%; the majority of them
were caesarean sections. More than 50% of cases were operated in coma.
This considered to indicate major mistakes and failures in organization of
care, primary prevention, diagnosis, and consequent care. It was
concluded that positive results in area of maternal deaths in association
with severe preeclampsia and eclampsia during last 10 years are due to
improved diagnostic and therapeutic measures, because obstetricians
currently terminate pregnancies early than before while symptoms of
preeclampsia get worse. They focus on early recognition of symptoms of
coagulopathy in combination with symptoms of preeclampsia, especially
on early detection and treatment of HELLP syndrome. (27)
Duley L and Henderson-Smart D. reviewed the literature to assess the
effects of magnesium sulphate compared with diazepam when used for
the care of women with eclampsia. They reviewed five trials involving
1236 women. Most of these trials were of good quality. Magnesium
sulphate was associated with a substantial reduction in the recurrence of
convulsions, when compared to diazepam (relative risk 0.45, 95%
confidence interval 0.35 to 0.58). Maternal mortality was also reduced,
although this difference was borderline for statistical significance
(relative risk 0.60, 95% CI 0.36-1.00). They concluded that Magnesium

14

sulphate appears to be substantially more effective than diazepam for

treatment of eclampsia. (28)
Taguchi N. and his colleagues studied the Influence of socio-economic
background and antenatal care programmes on maternal mortality in
Surabaya, Indonesia. Their objective was to determine the risk factors,
such as socio-economic background, quality of antenatal care and
availability of family planning, responsible for high maternal mortality in
Surabaya, Indonesia. The study used a case-control design, comparing 59
maternal deaths and 177 women survivors in the referral hospital, from
1996 to 1999. Results showed that the risk factors for maternal mortality
were, living outside of Surabaya [odds ratio (OR) = 11.7, 95% confidence
interval (CI) = 5.0-29.2], unemployment (OR = 4.4, 95% CI = 1.7-13.8),
unavailability of toilet facilities (OR = 2.9, 95% CI = 1.0-7.7), <4
antenatal visits (OR = 2.5, 95% CI = 1.1-5.5) and initial visit to antenatal
care facilities after the fourth month of pregnancy (OR = 3.0, 95% CI =
1.3-7.0). There was no significant association between maternal mortality
and the availability of family planning. They concluded that, Low socioeconomic background and the availability of antenatal care have a
significant influence on maternal mortality in Surabaya, Indonesia. (29)
Tomta K. and his colleagues studied maternal deaths due to anaesthetics in
the Lome (Togo) University Hospital. It was a six-month prospective study
(from January to June 2002) in the anaesthesiology/intensive care unit of
the obstetrics and gynaecology department. A case report file was
completed for each patient, and all anaesthetics administered in the
obstetrical department (labour and delivery room) were recorded and
considered. Results showed that, Anaesthetics were administered to 318
women during caesarean delivery (306) and uterine scar repair (12).
General anaesthesia was induced in 95.9% of the women and spinal block
used for 4.1%. Emergency situations accounted for 89.6% of these
surgical procedures. Twelve deaths occurred, for a mortality rate among
surgical patients of 3.8%. The principal causes of death were respiratory
complications of anaesthesia and of pregnancy-related toxemia and the
unavailability of hypertonic solutions and blood products. The results of
this survey showed that anaesthetics play a role in maternal mortality in
Togo. Good practice guidelines adapted to this setting must therefore be
developed. (30)
Ahluwalia IB. and his colleagues evaluated a community-based approach
to safe motherhood in northwestern Tanzania. They present an evaluation
of the community capacity building and empowerment initiative,
undertaken by the community-based reproductive health project
15

(CBRHP), designed to address high maternal morbidity and mortality.

The utilized qualitative data from group interviews and programme data
from CBRHP were used to assess progress in development and use of
community level transport systems and support for the village health
workers (VHWs). Results showed that, project activities increased
community participation in maternal health. An increase was seen in
knowledge of danger signs, birth planning, timely referrals, and transport
of pregnant women to hospitals, as well as in support and retention of
VHWs. More women with obstetrical problems are using the communitybased transport system to get to hospitals. They concluded that
community participation and support for VHW activities and the
transport systems have led to better care for pregnant women and
sustained links between the communities and health facilities, which may
reduce maternal morbidity and mortality. (31)
Fenton PM and his colleagues conducted a prospective study about, early
maternal and perinatal mortality due to Caesarean section in Malawi. It
was a prospective observational study of 8070 caesarean sections
performed between January 1998 and June 2000 and associated
complications. It included 23 district and two central hospitals in Malawi.
45 anaesthetists from hospitals that carried out caesarean sections
participated in the study. Main outcome measures: Associations between
maternal or perinatal deaths in the first 72 hours and various quantifiable
risk factors. Questionnaires were returned for 5236 caesarean sections in
district hospitals and 2834 in central hospitals; 7622 (94%) were
emergencies, 5110 (63%) were because of obstructed labour.
Preoperative haemorrhagic shock was present in 610 women (7.6%),
anaemia in 503 (6.2%), and ruptured uterus in 333 (4.1%). Eighty five
women died (1.05%), 68 of whom died postoperatively on the wards.
Higher maternal mortality was associated with ruptured uterus (adjusted
odds ratio 2.3, 95% confidence interval 1.3 to 4.0), little anaesthetic
training (2.9, 1.6 to 5.1), general as opposed to spinal anaesthesia (6.6,
2.3 to 18.7), and blood loss requiring transfusion of >or= 2 units (21.0,
11.7 to 37.7). They concluded that, in sub-Saharan Africa high maternal
mortality at caesarean section is associated with major preoperative
complications that are unusual in developed countries. Improved training
in anaesthetics, wider use of spinal anaesthesia, and improved
surveillance and resuscitation in postoperative wards might reduce
mortality. (32)
Mbonye AK., conducted a study to assess the magnitude of maternal
deaths in health units in Uganda, and the risk factors associated with such
deaths. A retrospective study of maternal deaths in 20 hospitals and 54
16

randomly selected health centers was conducted in 12 randomly selected

districts of Uganda. The reference period for documenting maternal
deaths was September 1992 to September 1993. Data on maternal deaths
and associated risk factors was obtained from admission and patient case
notes. A total of 418 maternal deaths and 75,000 live births were
recorded, giving a maternal mortality rate of 557 per 100,000 live births.
Three hundred and sixty (86.1%) mothers died within one hour of
admission. The risk factors identified were inadequate antibiotic supply,
intravenous drug fluids and blood for transfusion in health units; non-use
of family planning, use of traditional medicine; mothers aged 15-19 and
30-50 years. Others included those who had a history of two or more
abortions and stillbirths; parity of five and above; and living within a
distance of more than 10 km to the nearest health unit. They concluded
that the focus on risk factors for maternal deaths have policy implications.
(33)
Shulman CE and Dorman EK. published a paper about importance of
malaria in pregnancy and role of its prevention. They considered malaria
in pregnancy as a major cause of severe maternal anaemia contributing to
maternal mortality. The clinical features of Plasmodium falciparum
malaria in pregnancy depend to a large extent on the immune status of the
woman, which in turn is determined by her previous exposure to malaria.
In pregnant women with little or no pre-existing immunity, such as
women from non-endemic areas or travellers to malarious areas, infection
is associated with high risks of severe disease with maternal and perinatal
mortality. Women are at particular risk of cerebral malaria,
hypoglycaemia, pulmonary oedema and severe haemolytic anaemia.
Adults who are long-term residents of areas of moderate or high malaria
transmission, including large parts of sub-Saharan Africa, usually have a
high level of immunity to malaria. Infection is frequently asymptomatic
and severe disease is uncommon. During pregnancy this immunity to
malaria is altered. Infection is still frequently asymptomatic, so may go
unsuspected and undetected, but is associated with placental
parasitization. Malaria in pregnancy is a common cause of severe
maternal anaemia, this complication being more common in
primigravidae than multigravidae. Preventative strategies include regular
chemoprophylaxis, intermittent preventative treatment with antimalarials
and insecticide-treated bednets. (34)
Anya SE. noted an increase in maternal mortality risk during peak
malaria transmission in endemic countries. The purpose of his study was
to evaluate changes in risk and causes of maternal death in relation to the
malaria season at the main referral hospital in The Gambia. During the
17

malaria season, there was a 168% increase in the maternal mortality ratio
(MMR), a three-fold increase in the proportion of deaths due to anaemia,
and an eight-fold increase in the anaemia MMR. Apart from a 5.4-fold
increase in eclampsia, there was no significant change in the contribution
of other causes of death. It is estimated that malaria may account for up to
93 maternal deaths per 100,000 live births. (35)
Etard JF and his colleagues conducted a study about: Seasonal variation
in direct obstetric mortality in rural Senegal: role of malaria?
They explore a possible link between malaria and maternal death in a
rural area of Senegal by assessing the seasonal pattern of maternal
mortality by cause and examining whether this pattern coincides with the
malaria season. Overall mortality in women 15-49 years of age did not
differ by season, while maternal and direct obstetric deaths were
significantly more frequent during the rainy/malaria season than during
the rest of the year, even after adjusting for place of delivery. (36)
Mirghani OA and his colleagues conducted a prospective case-control
study about Viral hepatitis among 50 pregnant women and 31
nonpregnant women (age 15-40 years), admitted to Wad Medani
Teaching Hospital, Sudan, during the period January 1987-January 1990.
The mean serum bilirubin level was higher in the control group and the
difference was statistically significant (p = 0.0084). Significantly more
cases came from rural settings (76%) compared with control patients
(48%) (p 0.01). The criteria for admission were the presence of symptoms
and signs of hepatitis and bilirubin in the urine. Almost all patients
admitted to the study had viral hepatitis caused by type A virus, type B
virus, or non-A, non-B viruses, however, a very small number of diseases
of patients could be attributed to rare viruses like EB or cytomegalovirus.
No specific medication was given and patients were managed by bed rest
and parenteral multivitamins (Parentrovit). All patients were kept in the
hospital until they became asymptomatic and serum bilirubin dropped to
less than 2 mg/100 ml. All cases and controls were followed up for 6
weeks. All the control patients were discharged after recovery and none
of them died or developed recurrence of disease. Out of the 50 pregnant
women, 7 died (14%). the rest recovered and none of them developed
recurrence of disease during the follow-up period. The difference
between the 2 groups was statistically significant (p = 0.04). The
estimated relative risk of death in viral hepatitis with pregnancy was 9.93.
Among 5 deaths that occurred after delivery during the 3rd trimester, one
was at term and the baby was normal; 4 were preterm deliveries. Out of

18

the 50 pregnant women, one died before delivery and one delivered at
home. (37)
Strand RT and his colleagues conducted a study about Infectious
aetiology of jaundice among pregnant women in Angola.
The
contribution of viral hepatitis, human immunodeficiency virus (HIV)
infection and malaria to jaundice among pregnant women in Luanda,
Angola, was studied. 20 pregnant women with jaundice (cases) were
identified in 2 large maternity hospitals and compared with 40 pregnant
women without jaundice (controls). Among the cases 6 patients died,
whereas no death occurred in the control group (p < 0.001). Of the cases
40% had anti-hepatitis E virus antibodies compared with 13% of the
controls (p = 0.02). Plasmodium falciparum parasitaemia occurred in
47.5% and 5% of cases and controls, respectively (p < 0.001). There was
no difference in the prevalence of antibodies against hepatitis C or HIV
among cases and controls. The carriership of hepatitis B surface antigen
was 10% in both groups. They concluded that jaundice during pregnancy
is often associated with maternal mortality in Luanda, women suffering
from jaundice during pregnancy have an extremely high case fatality rate,
and P. falciparum and hepatitis E are associated with jaundice in the
setting studied. (38)
Wong HY and his colleagues conducted a study about, abnormal liver
function tests in the symptomatic pregnant patient: the local experience in
Singapore. In this study they found that, the causes of abnormal liver
function tests in pregnancy are varied and may or may not be pregnancyrelated. Often, the diagnosis can be difficult. This study looked at the
causes of deranged liver function tests in obstetric patients with
significant symptoms and signs. Data from 50 cases of abnormal liver
function tests in pregnant patients, who presented from 1998 to 2001,
were analysed. Their presenting symptoms included persistent vomiting
(48%), pruritis (14%), jaundice (26%), upper abdominal discomfort
(24%) and hypertension (46%). Results showed that Pregnancy-related
causes accounted for 84% of the abnormal liver function tests. Abnormal
liver function tests occurred more frequently in the first (34%) and third
(58%) trimesters than in the second trimester (8%). Hyperemesis
gravidarum (94%) and partial haemolysis, elevated liver enzymes and
low platelets (HELLP) syndrome (31%) were the commonest causes in
the first and third trimesters respectively. Hepatitis B flare resulted in 2
maternal deaths. Seven patients with pre-eclamptic toxaemia, acute fatty
liver of pregnancy or partial/complete HELLP syndrome had their liver
function tests measured sequentially before and after delivery. All of
them showed rapid improvement postpartum with their alanine
19

aminotransferase (ALT) dropping 50% within 3 days. It was concluded

that, the majority of patients with abnormal liver function tests had a
cause related to pregnancy, and pregnancy-related causes in the third
trimester improved rapidly postpartum. Hepatitis B flare was a significant
non-obstetric cause leading to maternal mortality. This diagnosis must
therefore be considered in ethnic groups where the incidence of chronic
hepatitis B infection is high, especially in chronic hepatitis B carriers with
suspected pregnancy-related disease who deteriorate postpartum. (39)
Aisien AO and his colleagues conducted a retrospective analysis of cases
of caesarean section performed in Jos University Teaching Hospital
(Nigeria) between January 1994 and December 1998. There were 11,571
deliveries with 2083 caesarean sections done giving an incidence of 18%.
62.2% of the patients who had caesarean section were booked for
antenatal care and delivered in the hospital, while 37.8% were unbooked
seen as emergency. 90% of the operations were done as an emergency
while only 10% was electively performed. There was a high caesarean
section rate in all the age groups as well as the various parity
distributions. The maternal mortality rate was 624.1/100,000 due mainly
to haemorrhage, eclampsia and sepsis and there was one anaesthetic death
amongst the booked patients. The clinical causes of maternal deaths were
ante-partum haemorrhage and obstructed labour. (40)
Kavatkar AN and his colleagues carried out an autopsy study of maternal
deaths to obtain an insight into the underlying disorder or pathologies in
different organs or systems, and to attempt clinicopathologic correlation
in maternal deaths. It was a retrospective study of 95 maternal autopsies
done from 1993 to 2000 in Sassoon General Hospital, Pune, India. The
cause of death was arrived, after reviewing clinical details, available
investigations, morphological findings, and clinicopathologic correlation.
Ninety-five (45.02%) out of 211 maternal deaths were autopsied. Out of
95, there were 47 (49.5%) direct obstetric deaths, and 33 (34.7%) indirect
obstetric deaths. Fifteen (15.8%) deaths were unrelated to pregnancy, 14
of which were due to infections. They concluded that, hypertensive
disorders associated with pregnancy (24.2%) and anaemia (14.7%) were
most common. In the hypertensive group, important findings were
disseminated intravascular coagulation, haemorrhages in different organs
and thromboemboli. Two cases were HIV seropositive. The autopsy
helped to elucidate factors contributing to death and pathology in
different organ systems. (41)
Mousa HA and Alfirevic Z. carried out a study about, treatment for
primary postpartum haemorrhage. The main results were about one trial,
20

comparing rectally administered misoprostol versus syntometrine

combined with an oxytocin infusion, met the eligibility criteria and was
included in the review. It was not large enough to evaluate the effects of
rectal misoprostol on maternal mortality, serious maternal morbidity or
hysterectomy rates in women with primary postpartum haemorrhage.
Compared with a combination of intramuscular syntometrine injection
and oxytocin infusion, rectal misoprostol administration showed a
statistically significant reduction in the number of women who continued
to bleed after the intervention and those who required medical cointerventions to control the bleeding (6% versus 34%) (relative risk 0.18,
95% confidence interval 0.04 to 0.67). However, there was no significant
difference between the two groups regarding surgical interventions to
control intractable haemorrhage including hysterectomy, internal iliac
artery ligation and/or uterine packing. So they concluded that, rectal
misoprostol in a dose of 800 micrograms could be a useful 'first line' drug
for the treatment of primary postpartum haemorrhage. Further
randomized controlled trials are required to identify the best drug
combinations, route, and dose for the treatment of postpartum
haemorrhage. (42)

21

JUSTIFICATION
Since the maternal mortality rate is still very high in most of the
developing world including Sudan, maternal mortality studies are
required to identify causes and risk factors.
There are general causes which are more or less similar in different
communities, but there may be certain causes or factors peculiar to a
specific community or region.
This may be a reflection of certain endemic disease(s) associated with
maternal death, a trend or a behavior specific to that community.
So, maternal mortality studies will continue to be useful, as the
communities' pattern of diseases is changeable even over longer or
variable periods of time.

22

OBJECTIVES
1. To identify the causes and risk factors of maternal deaths in the Sudan.
2. To find out preventable and avoidable elements in the scene of events
leading to maternal death.
3. To set up definitive practical and applicable plans to reduce maternal
mortality.

23

Chapter 2
Material and methods

24

MATERIALS & METHODS

Cases:
This is a descriptive study which was conducted during the period
from 1/8/2001 to 31/7/2002 at Omdurman Maternity Hospital (Sudan).
All maternal deaths during this one year period were included in the
study.
The materials were collected from hospital records and maternal deaths
reports which were available in most instances.

Methods:
Sampling method is not applicable, as all births were included
during the study period.
The total numbers of births (live & still) were collected. Booking status,
parity and social class were reported.
Maternal deaths, its aetiology, factors, and circumstances around it were
noted.
The pattern of diseases and complications leading to maternal death were
studied.
Every case of maternal death was studied in details its history, booking
status, clinical examinations, investigations and death report were
studied. The results were calculated manually.
Some of the major factors and causes leading to maternal deaths were
cross tabulated and tests of significance employed by using the computer.
It was selectively chosen due to its impact and /or the feasibility of
solutions.
The literature was reviewed, to find out recent studies about maternal
mortality in developing and developed world.

25

Chapter 3

Results
Figures
Tables

26

Results
The total number of deliveries (life and stillbirths) was 14,500 during the
period from 1/8/2001 to 31/7/2002. The number of booked patients
among whole deliveries was 9584 (66.1%) compared to 4916 (33.9%) in
the unbooked group. All vaginal deliveries (instrumental and non
instrumental) were 11631 which is 80.21% and deliveries by caesarean
deliveries were 2869, giving a caesarean section rate of 19.79%. Non
instrumental vaginal deliveries were 11228 (77.43% of total births).
Instrumental deliveries were 403 (2.77% of total births) of which forceps
deliveries were 325 (2.24% of total births) and deliveries by ventouse
were 78 which is 0.53% of total births (Figure 1). Forceps deliveries
comprise 80.65% of all instrumental deliveries and ventouse deliveries
were 19.35% of all instrumental deliveries. Of all deliveries there were
4325 primparous patients (29.82%), 8270 multiparous patients (57.03%)
and 1905 grand multiparous patients (13.14%).
Total maternal deaths during the study period were 30 deaths, with the
leading cause of death being pregnancy induced hypertension (14 deaths
which is 46.66% of all deaths). This to be followed by, hepatic coma and
haemorrhage, with 4 deaths for each of them (which is 13.33% of all
deaths). Sepsis caused 3 deaths (which is 10% of all deaths). Both Portal
hypertension and pulmonary embolism caused 2 deaths for each of which
are 6.66% of all deaths, and chloroquine resistant malaria caused one
death which is 3.33% all deaths (Figure 2).
No anaethestic deaths were reported during the study period.
Data was cross tabulated by computer. The correlation between booking
status in all births and maternal mortality was highly significant (Table 1)
(p value = 0.0000000). The correlation between parity and maternal death

27

(Table 2) was not significant (P value = 0.692060). The correlation

between maternal death and mode of delivery was found to be significant
(P value = 0.036278) (Table 3). The correlation of maternal death and
state of booking in cases of hypertensive disorders was significant (P
value = o.oo14027) (Table 4).
Unbooked cases among deaths were 26 cases (86.66%) and booked cases
were 4 only (13.33%). Deaths among booked patients as whole were
0.42/1000 compared to 5.29 per 1000 in unbooked cases, which is more
than 12 fold in the later group (Figure 3). There were 14 deaths among
primiparous patients (46.66% of all deaths), 11 deaths (36.67% of all
deaths) among multiparous women and 5 deaths (16.67% of all deaths)
among grandmultiparous patients. Out of 4325 primiparous patients 14
patients died with a ratio of 3.24 per 1000, the corresponding figures for
multiparous and grand multiparous are 1.33 and 2.62 per 1000
respectively.
There were 11 deaths following caesarean section (36.66 % of total
deaths and 0.38% of all caesarean sections).There were 18 deaths
following non instrumental vaginal deliveries which are 60% 0f total
deaths but only about 0.16% of the non instrumental vaginal deliveries.
There was one death following forceps delivery which is 3.33% of total
deaths and 0.31% of whole forceps deliveries. There were no deaths
following vetouse deliveries.
Concerning income 13 cases of all deaths (43.33%) were of average or
high income, socio-economic group and the rest (56.66%) were of low
income.(income was sorted out by the job of the husband, class of
admission and the residence area)
Deaths following medical causes were 10 deaths which are 33.33% of
total deaths and the rest where due to obstetric causes (66.67% of total
deaths). Direct deaths were 18 deaths (60% of total deaths) and indirect
28

deaths were 12 (40% of total deaths). There were 3 deaths following

home deliveries which are 10% of the total deaths. There was only one
death in an undelivered patient (3.33%).
Of the leading cause of death (i.e. pregnancy induced hypertension) there
were 6 primigravid patients (42.86% of the deaths due to pregnancy
induced hypertension), and all of them were unbooked. There were also 8
multigravid patients who died as a result of pregnancy induced
hypertension (57.14% of deaths due to hypertension), with only one of
them was booked case. The total number of hypertensive disorders is 480
cases, 253 cases of them were booked (52.71%) and 227 cases were
unbooked (47.29%).

29

Figures

Figure 1: Mode of delivery in Percentage

90
80
70

60

Non-Instrumental Vaginal Delivery

50

Caesaren Section

40

Forceps Delivery
Ventouse Delivery

30
20
10
0
Mode of Delivery

30

Figure 2:Causes of Maternal Deaths (%)

Hypertensive Disorders
Hepatic Coma
Haemorrhage
Sepsis
Portal Hypertension
Pulmonary Embolism
Chloroquine Resistant Malaria

31

Figure 3:Deaths per 1000 in Booked & Unbooked Patients

6
5
Deaths
Per 4
1000
Booked

Unbooked

2
1
0
Booking Status

32

Tables
Table 1 Correlation between maternal death and booking status in all
births.
Deaths
Booking Status

No

Yes

Ratio Per 1000

Booked

9580

0.42

Unbooked

4890

26

5.29

Chi- 37.35
P-Value 0.0000000
Comment, highly significant p value

Table 2 Correlation between parity and maternal death.

Death
Mortality
Parity

Yes

No

Total

Primipara

14

4311

4325

Multipara

11

8259

8270

Grandmultipara

1900

1905

Total

30

14470

14500

Chi square = 5.33

P value =0.692060
Comment, p value (not significant)

33

Table 3 Correlation between mode of delivery and maternal morality

Maternal .Mortality

Yes

No

Total

Vaginal Delivery

19

11612

11631

Caesarean section

11

2858

2869

Total

30

14470

14500

Mode of Delivery

Chi Square = 4.38

P value = 0.0362748 Comment, P value (significant)

Table 4 Correlation between Maternal Mortality and the state of booking

in cases of hypertensive disorders.
Maternal Mortality

Yes

No

Total

Booked

252

253

Unbooked

13

214

227

Total

14

466

480

Booking Status

Chi Square = 10.20

P value = 0.0014027
Comment, P value (significant).

34

Chapter 4

Discussion
Conclusion
Recommendations
References

35

Discussion

The major causes of maternal deaths are more or less repetitive in this
study compared to other studies done in Sudan and are also have many
similarities to other developing countries. Compared to Mohamed A. A.
and his colleagues study at Kassala new hospital (5), maternal mortality
rate was 10 fold lower in our study (2119 vs. 206 per 100,000 births).
Where in our study hypertensive disorders of pregnancy were the major
killers, in Mohamed A. A. and his colleagues study complication of
malaria was the leading cause of maternal deaths accounting for 20.6% of
all deaths vs. 3.3% in our study. When comparing sepsis in our study to
Mohamed A. A., and the study done at the Medani Teaching Hospital by
Dafallah SE and his colleagues (7), we will find that it comprises 17.6%
in Mohamed A. A., study, 10% in our study and about 33.3% in Dafallah
and his colleagues study. In all situations significant reduction of deaths
can be achieved by strict antisepetic measures and use of prophylactic
antibiotics. In both Dafallah and his colleagues study and Mohamed A. A.
and his colleagues study malaria was the leading cause of death reflecting
the high endmicity of the disease in their areas. Primary prevention by
insecticides, insecticides impregnated mosquito nets, and prophylactic
antimalarial drugs in pregnancy are effective measures to reduce maternal
deaths due to this disease.
Still there are major killers common to advanced countries and
developing countries like pregnancy induced hypertension and deaths
associated with haemorrhage but of course the rates are very much lower
in the developed world.
The cornerstone for plans to reduce maternal deaths to the minimum
possible rate is to study the risk factors leading to maternal mortality.
36

The great bulk of deaths are due to failure of establishing effective system
of primary prevention, and deaths at hospital level are mostly associated
with risk factors outside the hospital.
Since our study is done in a maternity hospital early pregnancy deaths are
not present because these cases are seen in Omdurman teaching hospital
but due to its importance as a cause of maternal mortality, it will be
included in this discussion.
In our series 86.66% of the deaths were among unbooked patients
compared to 95% in Baul MK. and Manjusha., study (9). As we can see in
table 1 page 33, the correlation between booking status and maternal
death is statistically highly significant. This was further studied in the
leading cause of death in our study i.e. hypertensive disorders where
about 92.86% deaths due to pregnancy induced hypertension (46.66% of
all deaths in our study)

were among unbooked ladies, and again

correlation was statistically significant ( see table 4 page 34). Also it was
the leading cause of death in the African multicenter study by Thonneau
PF. and his colleagues, comprising 29% of all deaths (13). Unfortunately
it is symptomless disease and is really a dreadful disease unless every
pregnant lady has access to antenatal care. Though it cannot be prevented
its spectrums of complications can be highly ameliorated if it is
discovered early and patient referred to hospital.
Should these ladies have had regular antenatal care the outcome would
have been much different and many lives would have been saved.
Measuring the blood pressure and testing the urine for albumin to
discover this common problem early before life threatening spectrums of
complications exist should be a primary health care priority within the
context of antenatal care. Awareness of the community and female
population of the seriousness of this problem is of paramount importance

37

in order to increase their attendance to antenatal clinics. Likewise

politicians and health planners should be enlightened.
So at the level of primary prevention comprehensive antenatal care is the
best remedy to this problem and many other problems leading to maternal
death. It is cheap and effective, and needs trained midwifes who refer the
ladies at the proper time and according to policies and protocols under
supervision of senior obstetricians.
In order to have successful outcome involving community leaders should
be considered. The community members should know that hypertensive
disorders in pregnancy are dangerous problems and its complications can
be prevented through early discovery by antenatal care.
At the secondary levels of health care (i.e. hospitals) doctors, nurses,
midwifes and any other concerned personnel should be will trained about
the management of PIH.
There should be no hesitation in termination of pregnancy if there is
danger to mother life at any gestational age. There should be clear
protocols about assessment and monitoring of patients and use of
anticonvulsants especially Magnesium sulphate in the management as the
later has proved to be effective as prophylactic against new fit and
reducing maternal mortality. It has been proved to be substantially more
effective than diazepam for treatment of eclampsia by Duley L and
Henderson-Smart D. (30)
At the tertiary health levels at the national capital or states capitals
hospitals, ideally there should be intensive care units but these
promotions should be after insuring implementation of primary care
services. In the event that primary health care is effective and widespread
to pregnant and birthing women, the burden inflicted upon higher health
levels will be much reduced.

38

Both Hepatic coma and haemorrhage caused 13.33% of whole deaths and
they shared the second place among causes of maternal mortality.
Hepatic coma is most likely due to infective hepatitis of viral origin as
demonstrated by Mirghani OA and his colleagues (38). Again increased
community awareness and avoiding contact with jaundiced patients or
patients with general ill health, anorexia and abdominal symptoms should
be simply conveyed to community. Ladies should understand that
jaundice in pregnancy is a serious condition. Environmental sanitation
and safe disposal of faecal mater is of paramount importance. The use of
disposable needles and safe discarding of sharp objects is the mainstay in
preventing hepatitis B and C infections. Vaccination against hepatitis B
virus in children and school girls should be studied concerning its impact
in reducing hepatitis in pregnancy.
Concerning haemorrhage primary prevention is also very important plus
measures to be taken at hospital levels. At the primary level
comprehensive antenatal care will help to detect high risk pregnancies
and give advice about hospital deliveries like all primigravid patients
whom

obstetrical

performance

have

not

been

tested

before,

grandmultiparous with their known spectrums of complications including

atonic post-partum haemorrhage and ruptured uterus etc., and also
patients with past obstetric history of placenta praevia or past history of
post-partum haemorrhage. Early referral in all cases of bleeding during
any gestational age is vital and all pregnant ladies and all community
members concerned should be educated about reporting to health
personnel in event of bleeding during pregnancy at any gestational age.
At hospital level prompt actions by the most senior staff is important.
hereby I like to stress the importance of continuous availability of Onegative blood for ready use where the compatible blood is not available
and also awareness of doctors about coagulopathy and importance of the
39

use of fresh blood and fresh frozen plasma under certain circumstances
like massive blood loss , massive transfusions, placental abruption and
patients with suspected and known coagulopathy. Involvement of senior
staff is vital and their prompt response is crucial in saving patients. As it
has been demonstrated by Tsu VD and his colleagues(14), active
management of the third stage of labour is of proven efficacy in reducing
PPH. They also pointed that uterotonic drugs offer great promise for both
prevention and management of postpartum haemorrhage (PPH). Other
technologies such as anti-shock garments, umbilical vein injection of
oxytocin, and simple anaemia detection methods represent potential new
opportunities to reduce PPH-related mortality. They also pointed that
more research is needed about the role misoprostol.
Concerning deaths associated with bleeding in early pregnancy every
staff should be aware of the possibility of pregnancy and its spectrum of
complications in any lady in reproductive age with complaints of
bleeding and /or abdominal pain specially if there is menstrual delay.
Ectopic pregnancy is amenable to misdiagnosis. In case of doubt sensitive
pregnancy tests and ultrasound (preferably by endovaginal route) should
be requested. Once pregnancy is confirmed by these tests, coupled with
history, examination and any other relevant tests correct diagnosis and
management can be done. Again effective resuscitation should have the
priority. The role of ultrasound scan in the diagnosis of causes of early
pregnancy bleeding and causes of

antepartum bleeding is not

questionable but there still certain limitations and precautions:

(1) Facilities for ultrasound are not available in many hospitals and
health institutes in Sudan.
(2) The results should be taken with caution as experience of
ultrsonographer is very crucial in order to utilize it for diagnosis
and management.
40

(3) In the event that ultrasound scan result is negative this does not
exclude ectopic pregnancy but sensitive pregnancy beta HCG
should be done and ideally before the scan.
But despite all this limitation ultrasound is very useful and in my opinion
should be offered if possible at least twice to pregnant ladies one with
booking in the first trimester to confirm gestational age and confirm
intrauterine pregnancy. The second scan can be done in the third trimester
to exclude placenta praevia.
There were 3 deaths due to sepsis ( 10% of total deaths ) in 2 of them
there were clear predisposing factors, in the first following prolonged
rupture of membranes for more than 5 days at home and the other was
following caesarean section due to failure to progress. The third case
followed elective caesarean section which is the only death following an
elective caesarean section in all deaths during the period of the study.
In first case delivery was by vaginal route in hospital and patient received
injectable antibiotics but it was late after chorio-amnionitis have already
developed. As it was discussed above and concluded by Hussein J and
Fortney JA. (25), that infection control protocols and evidence-based
procedures-including prophylactic antibiotics for caesarean section or
preterm rupture of membranes, and updated antibiotic regimens-should
be widely adopted.
Two deaths were associated with pulmonary embolism which is 6.66% of
all deaths during the period and also there were two deaths due to portal
hypertension.
Pulmonary embolism continue to be a significant cause of death and to
reduce it, we have to know the risk factors and to give prophylactic
measures accordingly.
High risk cases should receive prophylactic heparin or warfarin as
indicated plus other measures and precautions. High index of suspicion is
41

needed specially where investigation are not mostly available in Sudan.

In the event investigation available and can be done, venography,
Doppler ultrasound of the lower limbs, and perfusion ventilation lung
scans should be done according to clinical situation which dedicate which
one or more of them needed.
The two deaths associated with portal hypertension reflect impact of
endemic disease (i.e. Bilharziasis) on maternal death, again primary
prevention is the answer to the question of how to eliminate or to reduce
this cause?, and the same applies to the last case of our series due to
chloroquine resistant malaria(one case=3.33%) as highlighted above.
Out of 4325 primiparous ladies delivered during the period of the study
14 died with a ratio of 3.24 per 1000, the corresponding figures for grand
multiparous was 2.62 per 1000 and for multiprous (from 2 to 4 previous
deliveries) was 1.33 per 1000. This demonstrates that primigravid
patients were the most vulnerable group, followed by grand multiparous
patients and multiparous patients are the least affected group. Although
the risk was not statistically significant (see table 2 page 33), this may be
due to the fact that the patients are being managed in the hospital. So at
the level of primary prevention ladies should understand the importance
of antenatal care and especially primigravid and grandmultiparous where
both of them should have close monitoring as high risk groups who also
should have planned hospital delivery.
Concerning mode of delivery vaginal deliveries were 77.43%, caesarean
sections about 19.78% and instrumental deliveries were 2.77%. The
highest death percentage was among ladies delivered by caesarean
section which is o.38% of all caesarean sections, corresponding figures
for forceps deliveries and vaginal deliveries were 0.31% and 0.16%
respectively. So deaths associated with non instrumental vaginal
deliveries were more than two times less than deliveries by caesarean
42

sections and near to half that of forceps deliveries. As we can see in table
3 page 34, by correlating mode of delivery to maternal death, the
association was statistically significant in the sense that caesarean section
is more risky than vaginal delivery. So measures to reduce incidence of
caesarean section are useful in reducing maternal mortality.
76.67% of all ladies who died were of the low income group, which is
associated with illiteracy and both are major risk factors for maternal
mortality. There were 3 deaths following home deliveries (10% of all
deaths) which are usually conducted by less trained personnel under poor
standards.
There were no deaths associated with anaethesia though regional
anaethesia is rarely conducted at this hospital.

43

Conclusion
The main factors in maternal mortality are lack of antenatal care, literacy,
difficult transport, poverty, and finally poor facilities at hospital levels.
In our study more than 80% of deaths were among unbooked ladies.
The most common cause of death was hypertensive disorders and almost
all the patients were unbooked and came in late stage to a hospital devoid
of intensive care facility which is the only hope in serious cases of this
category.
More importantly for these cases and most of the others is provision of
comprehensive primary health care system all over our country.
To increase the compliance of our pregnant ladies, antenatal care should be
free service as poverty is widespread all over the country. Health
education with participation of people, women, and community leaders is
mandatory.
To minimize complications at hospital levels promotion of emergency
units, training of the staff and provision of easy access to contact senior
staff is recommended. Till the major projects of economic, health, and
education are implemented all high risk ladies should be advised to be near
to hospitals with specialist units especially in their last month and those
with very high risk and leaving far should be admitted to hospital at
relevant gestational age.
Every lady and her husband should understand the plan of her pregnancy
and delivery in a simple way.

44

RECOMMENDATIONS
1. Provision of comprehensive antenatal care, within the context of
primary health care and exemption of pregnant ladies from user
fees.
2. Training plans for the staff at primary, secondary and tertiary
levels with special emphasis on leading causes of maternal
mortality like hypertensive disorders and postpartum
haemorrhage.
3. Supervision of all deliveries by trained staff.
4. Training and endorsement of traditional birth attendants, village
midwifes, trained midwifes and doctors about strategies for
reducing maternal mortality and importance of timely referral,
with community participation and involvement of community
leaders.
5. Health education for women about importance of antenatal care.
6. Rehabilitation of hospitals with special emphasis on blood bank
services, management of critically ill mothers, staff training and
timely involvement of senior staff.
7. Auditing and researches about maternal mortality and near miss
cases in order to set up evidence based protocols for reducing
maternal mortality.

45

REFERENCES
1- Yayla MJ. Maternal mortality in developing countries. Perinat Med
2003; 31: 386-91
2- Campell S, Lees C. Maternal and perinatal mortality. In: Campell S,
Lees C, editors. Obstetrics by Ten Teachers. 17th ed. London: Arnold;
2000. p. 20.
3- UNFPA&Ministery of Health (Sudan). Safe Motherhood Survey
(SMS), National Report 1999. The ministry; 2002.
4- UNFPA&Ministery of Health (Sudan). Safe Motherhood Survey
(SMS), National Report 1999. The ministry; 2002.
5- Mohamed A, Abdelrahiem S, Elnour M. Maternal deaths at Kassala
new hospital (Eastern Sudan). J of Arab Board of Medical specializations
2002; 4(pt 2): 31-4E
6- Dafallah SE, El-Agib FH, Bushra GO. Maternal mortality in a teaching
hospital in Sudan. Saudi Med J 2003; 24: 369-72.
7- Al-Suleiman S, Al-Sibai M, Al-Jama F, El-Yahia A, Rahman J,
Rahman M. Maternal mortality: a twenty-year survey at the King Faisal
University Hospital, Al-Khobar, Eastern Saudi Arabia. J Obstet Gynaecol
2004; 24: 259-263.
8- Baul MK, Manjusha. Maternal mortality,a ten year study. J Indian Med
Assoc 2004; 102: 18-9, 25.
9- Begum S, Aziz N, Begum I. Analysis of maternal mortality in a
tertiary care hospital to determine causes and preventable factors. J Ayub
Med Coll Abbottabad 2003; 15: 49-52.
10- Biaggi A, Paradisi G, Ferrazzani S, Carolis SD, Lucchese A, Caruso
A. Maternal mortality in Italy, 1980-1996. Eur J Obstet Gynecol Reprod
Biol 2004; 114: 144-9.

46

11- Rizvi F, Mackey R, Barrett T, McKenna P, Geary M. Successful

reduction of massive postpartum haemorrhage by use of guidelines and
staff education. BJOG 2004; 111: 495-8.
12- Thonneau PF, Matsudai T, Alihonou E, De Souza J, Faye O,
Moreau JC, et al. Distribution of causes of maternal mortality during
delivery and post-partum in an African multicentre hospital-based study.
Eur J Obstet Gynecol Reprod Biol 2004; 114: 150-4.
13- Tsu VD, Langer A, Aldrich T. Postpartum haemorrhage in
developing countries: is the public health community using the right
tools?. Int J Gynaecol Obstet 2004; 85: 42-51.
14- Geelhoed DW, Visser LE, Asare K, Schagen JH, van Roosmalen J.
Trends in maternal mortality: a 13-year hospital-based study in rural
Ghana. Eur J Obstet Gynecol Reprod Biol 2003; 107: 135-9.
15- Okonta PI, Okali UK, Otoide VO, Twomey D J. Exploring the causes
of and risk factors for maternal deaths in a rural Nigerian referral
hospital. Obstet Gynaecol 2002; 22: 626-9.
16- Ezechi UO. Emergency obstetric admissions: late referrals,
misdiagnoses and consequences. J Obstet Gynaecol 2001; 21: 570-575.
17- Bashir A. Maternal mortality in Pakistan. A success story of the
Faisalabad district. IPPF Med Bull 1991; 25: 1-3.
18- Chhabra S, Sirohi R. Trends in maternal mortality due to
haemorrhage: two decades of Indian rural observations. J Obstet
Gynaecol 2004; 24: 40-3.
19- Nkata M. Maternal deaths in Zambia. Afr Health 1998; 21: 2.
20- Mercer A, Khan MH, Daulatuzzaman M, Reid J. Effectiveness of an
NGO primary health care programme in rural Bangladesh: evidence from
the management information system. Health Policy Plan 2004; 19: 18798.

47

21- Fernando D, Jayatilleka A, Karunaratna V. Pregnancy--reducing

maternal deaths and disability in Sri Lanka: national strategies. Br Med
Bull 2003; 67: 85-98.
22- Hofmeyr GJ. Obstructed labour: using better technologies to reduce
mortality. Int J Gynaecol Obstet 2004; 85: 62-72.
23- Hussein J, Fortney JA. Puerperal sepsis and maternal mortality: what
role can new technologies play?. Int J Gynaecol Obstet 2004; 85: 52-61.
24- Imbert P, Berger F, Diallo NS, Cellier C, Goumbala M, Ka AS, et al.
Maternal and infant prognosis of emergency caesarean section:
prospective study of the Principal Hospital in Dakar, Senegal. Med Trop
(Mars) 2003; 63: 351-7
25- Shaheen B, Hassan L, Obaid M. Eclampsia, a major cause of
maternal and perinatal mortality: a prospective analysis at a tertiary care
hospital of Peshawar. J Pak Med Assoc 2003; 53: 346-50.
26- Ikechebelu JI, Okoli CC. Review of eclampsia at the Nnamdi
Azikiwe University teaching hospital, Nnewi (January 1996-December
2000). J Obstet Gynaecol 2002; 22: 287-90.
27- Srp B, Velebil P, Kvasnicka J. Fatal complications in pre-eclampsia
and eclampsia. Ceska Gynekol 2002; 67: 365-71.
28- Duley L, Henderson-Smart D. Magnesium sulphate versus diazepam
for eclampsia. Cochrane Database Syst Rev 2003;(4): Available from:
http://www.pubmed.com
29- Taguchi N., Kawabata M, Maekawa M, Maruo T, Aditiawarman,
Dewata L. Influence of socio-economic background and antenatal care
programmes on maternal mortality in Surabaya, Indonesia. Trop Med Int
Health 2003; 8: 847-52.
30- Tomta K, Maman FO, Agbetra N, Baeta S, Ahouangbevi S, Chobli
M. Maternal deaths and anaesthetics in the Lome (Togo) University
Hospital. Sante 2003; 13: 77-80.
48

31- Ahluwalia IB, Schmid T, Kouletio M, Kanenda O. An evaluation of a

community-based approach to safe motherhood in northwestern
Tanzania. Int J Gynaecol Obstet 2003; 82: 231-40.
32- Fenton PM, Whitty CJ, Reynolds F. Caesarean section in Malawi:
prospective study of early maternal and perinatal mortality. BMJ 2003;
327: 587.
33- Mbonye AK. Risk factors associated with maternal deaths in health
units in Uganda. Afr J Reprod Health 2001; 5: 47-53.
34- Shulman CE, Dorman EK. Importance and prevention of malaria in
pregnancy. Trans R Soc Trop Med Hyg 2003; 97: 30
35- Anya SE. Seasonal variation in the risk and causes of maternal death
in the Gambia: malaria appears to be an important factor. Am J Trop Med
Hyg 2004; 70: 510-3.
36- Etard JF, Kodio B, Ronsmans C. Seasonal variation in direct obstetric
mortality in rural Senegal: role of malaria?. Am J Trop Med Hyg 2003;
68: 503-4.
37- Mirghani OA, Saeed OK, Basama FM. Viral hepatitis in pregnancy.
East Afr Med J 1992; 69: 445-9
38- Strand RT, Franque-Ranque M, Bergstrom S, Weiland O. Infectious
aetiology of jaundice among pregnant women in Angola. Scand J Infect
Dis 2003; 35: 401-3.
39- Wong HY, Tan JY, Lim CC. Abnormal liver function tests in the
symptomatic pregnant patient: the local experience in Singapore. Ann
Acad Med Singapore 2004; 33: 204-8.
40- Aisien AO, Lawson JO, Adebayo AA. A five year appraisal of
caesarean section in a northern Nigeria university teaching hospital. Niger
Postgrad Med J 2002; 9: 146-50.
41- Kavatkar AN, Sahasrabudhe NS, Jadhav MV, Deshmukh SD.
Autopsy study of maternal deaths. Int J Gynaecol Obstet 2003; 81: 1-8.
49

42- Mousa HA, Alfirevic Z. Treatment for primary postpartum

haemorrhage. Cochrane Database Syst Rev 2003;(1): Available from:
http://www.pubmed.com

50