Maternal morbidity in Uganda : studies on life-threatening pregnancy complications in low-income settings

Introduction: Life-threatening complications in pregnancy rarely achieves
\npublic health prominence in the same way as maternal mortality partly
\nbecause they represent a wide spectrum of conditions. The improved level
\nof care in many high-income countries has significantly reduced morbidity
\nand risk of death from these conditions. However in low-income countries,
\nsuch as Uganda, weak and poorly resourced health systems, socio -cultural
\nfactors and the threat by HIV/AIDS combine to increase the risk of
\nmorbidity and death. The rationale for the studies was the need to
\nidentify ways to promote health actions that can reduce maternal
\nmorbidity from life-threatening pregnancy complications.
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\nAim: This thesis explores the role of HIV/AIDS in post abortion
\nendometritis-myometritis (PAEM) and postpartum endometritis-myometritis
\n(PPEM). It also examines audit of a subset of women with lifethreatening
\npregnancy complications called "near miss cases"; monitoring of treatment
\nof lifethreatening pregnancy complications and socio cultural barriers to
\naccess care in Uganda.
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\nMethods: A case-control design was used over a 12-month period to study
\nthe risk of HIV infection in women with and without PAEM and PPEM in one
\nhospital in Kampala, Uganda (papers 1&2). Then a subset of women (229)
\nwith life-threatening pregnancy complications called "near miss cases"
\nwere audited with respect to seeking care, access to services and quality
\nof care in 4 referral hospitals, over a 21 months period (Paper 3). A
\ncross sectional survey of all basic EmOC and comprehensive EmOC (district
\nhospital) facilities in Kiboga district was carried out over a two year
\nperiod to document treatment of women with lifethreatening pregnancy
\ncomplications. Met need for treatment of these cases was derived, in
\nrelation to the population of the district (Paper 4). Seventeen FGD were
\nconducted with adult men and women and with adolescent boys and girls in
\nthree study districts, on adolescence, their roles and responsibilities,
\npre-marital sexual relations, HIV/AIDS, pregnancy and abortion. Content
\nanalysis was used to describe the findings (Paper 5).
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\nResults: HIV infection was not found to correlate with the risk for PAEM,
\nHIV-1 seroprevalence 17 (32.7%) among women with PAEM and 38 (36.5%)
\namong women without post-abortion infection; but this was double the
\nseroprevalence among antenatal clients in the same hospital, 14.6% in
\n1997. HIV-1 seroprevalence was significantly higher among women with
\npostpartum endometritismyometritis (PPEM) than controls, 26 (42.3%) and
\n26 (21.3%) respectively (p=0.002) OR 2.74 (95%Cl 1.34- 5.65). Over a
\ntwo-year period, there was a ten-fold increase in "met need" for
\ntreatment of women with life-threatening pregnancy complications from 4%
\nto 47%. Births in health facilities increased from 17% to 24%. Met need
\nfor cesarean sections increased from 1.3% to 2.3% and case fatality rite
\nfor women with life-threatening complications decreased from 9.4% to
\n1.85%. A major finding was the gender inequality in income generation,
\nleading to different social and sexual strategies between adolescent boys
\nand girls. Customary requirements for boys to offer gifts or pay bridal
\nwealth in marriage and the local government taxation act, which
\nselectively taxes boys but not girls of the same age, serve to entrench
\nthe subordinate roles of girls predisposing them to high-risk sexual
\nbehavior. Lack of empathy and support from parents and the community for
\nan unmarried pregnant girl often leaves her without other options than to
\nresort to unsafe abortion.
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\nConclusions: The prevalence of HIV-1 among women with and without PAEM
\nwas higher than in antenatal mothers, but HIV was not a risk factor for
\nPAEM. HIV-1 was found to be a risk factor for PPEM, these findings
\nfurther complicating management of these life-threatening complications
\nof pregnancy. Women who were treated for life-threatening pregnancy
\ncomplications survived in spite of substandard care identified in more
\nthan half the cases. However audit of near miss cases might offer a
\nnon-threatening stimulus for improving quality of obstetric care. More
\nthan a ten-fold increase in treatment of life-threatening pregnancy
\ncomplications was achieved over a two year period, and this might offer
\nan important way of monitoring programmes for reduction of maternal
\nmortality. Engendering local government taxation act and customary
\nmarriage requirements might reduce entrenching gender stereotypes among
\nadolescents. There is need to involve parents, teachers and adolescents
\nin dialogue on an enabling environment for safe transition from childhood
\nto adulthood.

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