AAMJ, Vol.7, N. 3, September, 2009 ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ COMPARATIVE STUDY OF THE INCIDENCE MATERNAL MORTALITY AND MORBIDITY AMONG PREGNANT WOMEN IN EL SHATBY UNIVERSITY HOSPITAL VERSUS El Beltagy NS, Saad el Deen S, Kharboush IF and Ahmed N.

Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Egypt. ---------------------------------------------------------------------------------------------SUMMARY Objectives: This study was conducted to compare between public and insurance hospitals in Alexandria as regard the maternal mortality causes, demographic characters, and the incidence of maternal morbidity among pregnant women delivered in both types of hospitals. Materials and Methods: The study was conduct on pregnant women delivered in El Shatby Maternity University Hospital that represent a public hospital and Gamal Abed El Naser Insurance Hospital for 6 months from 1/1/2009 to 30/6/2009. Results: Out of 6237 pregnant women delivered in El Shatby Hospital (public university hospital) during the study period, maternal mortality and morbidity constituted 32.6% of deliveries. Maternal mortality rate was 0.2% but the maternal mortality ratio was 212 per 100 000 living birth. Out of 812 women delivered in Gamal insurance hospital, combined maternal morbidity rate and maternal mortality rate was (19.4%), maternal mortality rate was (0.1%). The maternal mortality ratio was 125 per 100 000 living birth. There were high statistical significant differences between both hospitals as regarding morbidity. However, there were no statistical significant differences between them regarding mortality. Maternal morbidity in the age group of 20 -35 years represented (82%) in El Shatby University Hospital compared to (81%) of those pregnant women delivered in Gamal Abd El Naser Insurance Hospital. According to the mode of deliveries, cesarean section signified the highest percentage in both hospitals. In both hospitals, the most common cause of maternal morbidity was pre eclapmsia/ eclapmsia. Postpartum hemorrhage was the most common cause of maternal mortality in both hospitals. Conclusion: To decrease maternal mortality in Egypt there is a need to develop the antenatal care system in both public and insurance hospitals. Abbreviation: HELLP: Haemolysis, Elevated Liver Enzymes, Low Platelets

El Beltagy NS et al,. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ INTRODUCTION Maternal Mortality Ratio (MMR) is the number of maternal deaths per 100,000 live births. The MMR is used as a measure of the quality of a health care system. Further, it is well recognized that maternal mortality numbers are often significantly underreported (1) in 2005, the WHO produced a report with maternal mortality in Egypt is 84/100,000 live birth. (2) The major causes of maternal death are obstetrical hemorrhage, ectopic pregnancy, puerperal sepsis, amniotic fluid embolism, and complications of unsafe abortions. Additionally, bacterial infection, variants of gestational hypertension including pre-eclampsia and HELLP syndrome, Lesser known causes of maternal death include renal failure, cardiac failure, and persistent hyperemesis gravidarum(2) Forty-five percent of postpartum deaths occur within 24 hours. Over 90% of maternal deaths occur in developing countries.(2) High rates of maternal deaths occur in the same countries that have high rates of infant mortality reflecting generally poor nutrition and medical care.(3) Cases of near miss are those in which women has a potentially fatal complication during pregnancy, delivery or during the purperium. Once severe maternal morbidity precedes maternal death, the systematic identification and the study of near miss cases may present further understanding of the determinants of maternal mortality and who survive mainly by chance or by good hospital care. (4, 5) The purpose of this study is to compare the incidence, causes and clinical characteristics of maternal mortality and morbidity among pregnant women in El-Shatby University Hospital versus Gamal Abd El-Naser Insurance Hospital. METHODS A descriptive prospective study approach of all pregnant women delivered in EL Shatby Maternity University Hospital and Gamal Abd El Naser Hospital for 6 months from 1/1/2009 to 30/6/2009. Maternal morbidity and mortality data was collected from delivered women, doctors and mortality and morbidity sheet. Collected data included: 1. Demographic factors: such as name, age, residence 2. Past obstetric history: such as parity, abortion, mode of last deliveries and past history of any medical condition 3. Present pregnancy data: such as date, diseases like pre-eclampsia, Gestational diabetes and gestational age

AAMJ, Vol.7, N. 3, September, 2009 ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ 4. Present delivery data as: mode of delivery, surgical interference, admission to intensive car unit or eclampsia unit and blood transfusion 5. Medical records: to determine their adequacy as a source of information for maternal mortality and morbidity Statistical Methodology: Data was collected and coded then entered into IBM compatible computer, using SPSS (Statistical Package of the Social Sciences). version 13 for windows. Entered data was checked for accuracy then for normality, using Kolmogrov- Smimov& Sharpiro-Wilk tests and some were proved not to be normally distributed. Qualitative variables were expressed as numbers and percentage while quantitative variables were expressed as mean and standard deviation. The Following Statistical Tests Were Used: 1. Independent samples t-test was used as a parametric test of significance for comparison between two sample means, after performing the Leven’s test for equality of variance. 2. McNemar’s Chi-square (X2) test was used for paired comparison of dichotomous variables. 3. Fisher’s exact test was used A 5% level is chosen as a level of significance in all statistical significance tests used. RESULTS This Study was conducted on all pregnant women delivered in EL Shatby Maternity University Hospital and Gamal Abed El Naser Hospital for 6 months from 1/1/2009 to 30/6/2009. The number of deliveries in EL Shatby Hospital during the study period was 6237, number of maternal morbidity was 2021 represent (32.4%), maternal mortality was 13 represent (0.2%) and maternal mortality ratio was 212 per 100 000 living birth. The number of deliveries in Gamal Abed EL Naser Hospital was 812, the number of maternal morbidity and mortality was 157 represent (19.3%), and number of maternal mortality was one case represent (0.1%) and maternal mortality ratio was 125 per100 000 living birth. There were highly statistical significant differences between El Shatby Hospital and Gamal Abed EL Naser Hospital as regarding morbidity (p=0.001), but there were no statistical significant differences between them regarding mortality (p=0.508) (table 1).

El Beltagy NS et al,. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ Table II shows the clinical findings at admission included mean maternal age of 27.37±6.10 in El Shatby Hospital and 30.85± 5.0 in Gamal Hospital. The age group from 20 -35 years represents (82%) in El Shatby and represents (81%) in Gamal hospital. Women from rural area represents (53.3%) in El Shatby Hospital, and (5%) in Gamal Abed El Naser Hospital. There was a statistical significant difference between them (p=0.001). Women who received antenatal care in El Shatby hospital represent (89.1) and in Gamal Abd El Naser represent (98.7%). There was a statistical significant difference between them (p=0.001). According to the mode of deliveries, cesarean section represents the highest percentage in both hospitals. The incidence of morbidity among the cases delivered normally was (19.1%) in El Shatby hospital and (23.6%) in Gamal while the incidence of morbidity among cases delivered by caesarian section was (47.9%) in El Shatby hospital and (18.2%) in Gamal Abd El Naser hospital. In both hospitals the most common cause of maternal morbidity was pre eclapmsia/ eclapmsia. The second cause was postpartum hemorrhage but it was the most common cause of maternal mortality. Table III shows the incidence of maternal morbidity in both hospitals. There were statistical significant differences in all diagnosis except deep vein thrombosis, rupture uterus, hysterectomy, injury of bladder and injury to ureter. Table IV shows demographic characters of maternal mortality in El Shatby Hospital, the age group (20 to 35) represents the highest percent (84.6%). Patients from urban area represent highest percent (61.5%) compared to women from rural area (38.5%). The highest percent of parity was from 1 to 2 represent (53.8%) with mean parity was 0.75±0.754. Gestational age between 37-40 weeks represent the highest percent (69.2%), Patients who have done three or more anti natal visits represent (92.3%). As regard Gamal Abd El Naser Hospital there was only one case of maternal mortality: 33 years old, from urban area, parity 2, and gestational age 38w with more than three anti natal visits. Figure I show causes of maternal mortality in El Shatby hospital, post partum hemorrhage represents the highest percent (77%), disseminating intravascular coagulopathy represents (38.5%), HELLP syndrome represents (30.8%), cerebral hemorrhage represents (7.7%) and pulmonary embolism represents (7.7%). As regard Gamal Abed El Naser hospital, there was only one case of maternal mortality from post partum hemorrhage with disseminating intra vascular coagulopathy.

AAMJ, Vol.7, N. 3, September, 2009 ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ Table (I): Maternal Mortality and Morbidity Of Study Population In EL Shatby Maternity University Hospital And Gamal Abd El Naser Hospital During The Study Period Shatby H Total No of deliveries Total No of morbidity Percent from total no of deliveries Total No of mortality Percent from total no of deliveries Total No of living birth Maternal mortality ratio

Gamal H

Total

Significance

6237 2021

812 157

7049 2178

32.4%

19.3%

30.9%

13

1

14

0.2%

0.1%

0.19

6133

803

6937

212

125

X2= 57.47

P= 0.000*

FET

P=0.508

FET

P =0.505

Maternal mortality ratio: number of mortality per 100000 living birth FET = Fisher exact test. Table (II) Demographic Characteristics of Patients of Maternal Mortality and Morbidity Delivered In El-Shatby Maternity University Hospital and Gamal Abd EL Naser Hospital Shatby H n=2034 No. % Age 35 Rang Mean ± SD Urban Rural > 3 Anti natal visits < 3 Anti natal visits

Gamal H n=158 No. % 0 128 30 20-45

0 81 19

Total n= 2192 No. %

149 1667 218 17-47 27.37± 6.101 949

7.3 82 10.7

149 1795 248

46.7

150

95

1099

50.3

1085

53.3

8

5

1093

49.9

1813

89.1

156

98.7

1969

89.8

221

10.9

2

1.3

223

10.2

Significance

6.8 81.9 11.3

30.855.00

t=8.25

P=0.001 *

X2= 13.6

P=0.000*

X2=14.78

P=0.000*

El Beltagy NS et al,. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ Table (III): Incidence of Maternal Morbidity in El-Shatby Maternity University Hospital and Gamal Abd EL Naser Hospital

Diagnosis #

Shatby H

Gamal H

Total

n=2034

n=158

n=2192

Significance

No

%

No

%

No

%

Pre-eclampsia/ eclampsia

1064

17.1

61

7.5

1125

16

X2=48.12

P=0.000*

Post partum hemorrhage

492

7.8

36

4.4

528

7.5

X2=12.38

P=0.000*

Obstructed labor

289

4.6

21

2.5

310

4.4

X2=7.16

P=0.007*

Gestational diabetes

288

4.6

16

1.9

304

4.3

X2=12.20

P=0.000*

Heart diseases

166

2.6

9

1.1

175

2.5

X2=7.16

P=0.007*

Anti partum hemorrhage

155

2.4

8

1

163

2.3

X2=7.16

P=0.007*

Anti partum fits

108

1.7

1

0.1

109

1.5

X2=12.21

P=0.000*

Post partum fits

94

1.5

0

0

94

1.3

X2=12.40

P=0.000*

Deep vein thrombosis

72

1.1

6

0.7

78

1.1

X2=1.13

P=0.287

Disseminating intravascular coagulopathy

48

0.7

1

0.1

49

0.7

X2=4.35

P=0.037*

HELLP syndrome

39

0.6

1

0.1

40

0.6

FET

P=0.046*

Diabetic ketoacidosis

36

0.5

0

0

36

0.5

FET

P=0.012*

Rupture uterus

24

0.34

2

0.2

26

0.4

FET

P=0.410

Hysterectomy

12

0.19

1

0.1

13

0.2

FET

P=0.548

Injury of bladder

5

0.08

0

0

5

0.1

FET

P=0.542

injury to ureter

1

0.02

0

0

1

0.01

FET

P=0.884

FET = Fisher exact test.

#more than one allowed

AAMJ, Vol.7, N. 3, September, 2009 ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ Table (IV): Demographic Character of Maternal Mortality among Pregnant Women Delivered in El-Shatby Maternity Hospital El-Shatby H n=13 No. % Age 35 Rang Mean ± SD

1 11 1 19-35 27.54±5.285

7.7 84.6 7.7

8 5

61.5 38.5

Parity 0 1-2 3-4 5 OR more Rang Mean ± SD

6 7 0 0 0-2 0.75±0.754

46.2 53.8 0 0

Gestational age 40 Rang Mean ± SD

4 9 0 27-40 36.58±3.528

30.8 69.2 0

12 1

92.3 7.7

Urban Rural

> 3 Anti natal visits < 3 Anti natal visits

El Beltagy NS et al,. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ Shatby H Gamal H 120 100

%

80 60 40 20 0 y m ge ra LP ar m a n tr u g e ni t h y E E m e o s rrh g a t H ro m o li p a rh a o l n t i p d u s r n a t lo P em b em h Po mo in g u sy l m ra he is c o a b D r e er la u C sc a v

Figure (1): Causes of Deaths in El-Shatby Maternity University Hospital and Gamal Abd EL Naser Hospital DISCUSSION Maternal death is tragedy, affecting children, families and communities. Each year, millions of children are left motherless and an estimated one million young children die as result of maternal deaths. According to the WHO report 2005 mortality ratio in Egypt was 84/100,000 live birth. (6) James, et al., (2008) summarized that, overall maternal mortality ratio (MMR) per 100,000 live birth is 13 in industrialized countries, 440 in developing countries and 890 in the least developed countries. (7) Iao et al., (2005), found that, maternal mortality ratio in Nigeria is one of the highest in the world. They revealed that, in the maternity unit of Jos University Teaching Hospital, the maternal mortality ratio (MMR) was 740/100,000 total deliveries. The major cause of death was haemorrhage (34.6%). (8)

AAMJ, Vol.7, N. 3, September, 2009 ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ Our results revealed that, maternal mortality ratio in Shatby Hospital was 212/100,000 which is a high ratio because Shatby hospital is a referral hospital , while in Gamal Abd El-Naser Hospital MMR was 125/100,000. In this study, post partum hemorrhage was 7.8%, 4.4% in Shatby and Gamal Abd El Naser Hospitals respectively, while eclampsia was 17.1% and 7.5 % for the two studied hospitals respectively. Anti-partum hemorrhage was 2.4% and 1% in the two studied hospitals respectively. Gandhi, (2004) in South African, found the commonest obstetric diagnoses were eclampsia (39%) and obstetric hemorrhage (32%). (9) Similarly, Patricia et al. (1999) found that, hemorrhage was 3.1% in general hospitals in Netherland. (10) Also, Savita, et al. (2005) in India, found that post partum hemorrhage was 27.84%. 3% were anti-partum hemorrhage (11). Jun et al. (2006) in USA represented that the incidence of eclampsia was 5.9% and superimposed pre-eclampsia remained unchanged during the 10 years period. Women with pre-eclampsia and eclampsia had a 3 to 25 fold increased risk of severe complications, such as disseminated intravascular coagulation, pulmonary edema. (12) As regard HELLP syndrome we found that, maternal death were 10.3% (4/39), while Ahmed et al. (2007) revealed that, maternal deaths were 6.2% (1/16) due to HELLP syndrome. (13) Our data showed that, 77% of maternal mortality was due to postpartum hemorrhage, and 7.7% due to pulmonary embolism. Elizabeth, 2001, found that, embolism present (19.6%) followed by hemorrhage (17.2%). (14) Christine, (2008) in New South Wales in Australia, found that 33.2% with morbidity from the total number of deliveries. (15) While in our study, 32.4% cases with morbidity from the total number of deliveries for both university and insurance hospitals. In conclusion, in both hospitals the most common cause of maternal morbidity was pre eclapmsia/ eclapmsia. The second cause was postpartum hemorrhage. Maternal mortality ratio in El Shatby hospital was 212 per 100000 living birth while in Gamal Abd el Naser Hospital it was 125 per 100000. The most common cause of maternal mortality was postpartum haemorrhage. To decrease maternal mortality in Egypt there is a need to develop the antenatal care system in both public and insurance hospitals.

El Beltagy NS et al,. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ REFERENCES 1) Deneux-Tharaux, D; Berg C, Bouvier-Colle MH, Gissler M, Harper M, Nannini A, Alexander S, Wildman K, Breart G, Buekens P. Underreporting of Pregnancy-Related Mortality in the United States and Europe. Obstet Gynecol 2005; 106: 684–692. 2) Nour NM. An Introduction to Maternal Mortality. Reviews in Ob Gyn 2008; 1: 77–81. 3) Thaddeus, S; Maine D. Too far to walk: Maternal mortality in context. Social Science & Medicine 1994; 38 (8): 1091–1110. 4) Stones W, Lim W, Al-Azzawi F, Kelly M. An investigation of maternal morbidity with identification of life-threatening 'near miss' episodes. Health Trends. 1991; 23:13–5. 5) Pattinson RC, Hall M. Near misses: a useful adjunct to maternal death inquiries. Br Med Bull. 2003; 67:231–43. Doi: 10.1093/bmb/ldg007. 6) Ronsmans C, Filippi V. Reviewing severe maternal morbidity: learning from women who survive life-threatening complications. In: Beyond the numbers. Geneva, WHO. 7) James Drife. Maternal mortality in well-resourced countries: is there still a need for confidential enquiries? Best Practice & Research Clinical Obstetrics and Gynaecology. 2008; 22: 501-515. 8) IAO Ujah, OA Aisien, JT Mutihir, DJ Vanderjagt, RH Glew and VE Uguru. Factors Contributing to Maternal Mortality in North-Central Nigeria: A Seventeen-year Review. African Journal of Reproductive Health. 1004; 9(3): 27-40. 9) Gandhi, M.N., T. Welz, C. Ronsmans Severe acute maternal morbidity in rural South Africa. International Journal of Gynecology and Obstetrics. 2004; 87: 180—187 10) Patricia N, Vanroosmalen J, Dekker G, Van Dongen P, Van Geijanlt, Graven horst JB. Under reporting of maternal mortality in Netherland. Obstet Gynaecol 1999 Jul; 19(1): 78. 11) Savita R. Maternal And Perinatal Outcome In Antepartum Hemorrhage: A Study At A Tertiary Care Referral Institute. Obstet Gynecol. 2005; 28: 5057 12) Jun Z, Susan M, Ann T. Severe Maternal Morbidity Associated with Hypertensive Disorders in Pregnancy in the United States. Afr J Reprod Health 2006; 9(3):27-40

AAMJ, Vol.7, N. 3, September, 2009 ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ 13) Ahmed F.A., Amin A., Naeem N.K. Hellp Syndrome, a Clincial Variant of Pre-Eclampsia. ANNALS 2007: 13. (2): 158-161. 14) Elizabeth F. Maternal Mortality in New Jersey. http://www.state.nj. us/ health/fhs/index.html. 15) Christine L. Roberts, MBBS, Dipobsranzcog, D Carolyn A. Cameron. Measuring Maternal Morbidity in Routinely Collected. Health Data. Medical Care. 2008; 46(8): 786-794.