SOURCES AND CAUSES OF MATERNAL DEATHS AMONG OBSTETRIC REFERRALS TO FORTPORTAL REGIONAL REFERRAL HOSPITAL , .

BY

LOGOSE JOAN

BMS/0075/133/DU

A RESEARCH PROPOSAL SUBMITTED TO THE FACULTY OF CLINICAL

MEDICINE AND DENTISTRY FOR THE AWARD OF A BACHELORS IN MEDICINE

AND SUGERY AT INTERNATIONAL UNIVERSITY

MARCH, 2019

TABLE OF CONTENTS

TABLE OF CONTENTS ...... i

DECLARATION ...... iv

APPROVAL ...... v

DEDICATION ...... vi

LIST OF ABBREVIATIONS AND ACRONYMS ...... vi

OPERATIONAL DEFINITIONS ...... vii

CHAPTER ONE ...... 1

1.0 Introduction ...... 1

1.1 Background ...... 1

1.2 Problem Statement ...... 4

1.3 Objectives of the study...... 4

1.3.1 Broad objective ...... 4

1.3.2 Specific objectives ...... 5

1.4 Research Questions ...... 5

1.6 Scope of the study ...... 6

1.6.1 Geographical scope ...... 6

1.6.2 Content scope ...... 6

1.6.3 Time scope ...... 6

CHAPTER TWO: LITERATURE REVIEW ...... 8

Introduction ...... 8

CHAPTER THREE: RESEARCH MOTHODOLOGY ...... 12

3.0 Introduction ...... 13

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3.1 Study design ...... 13

3.2 Study population ...... 13

3.2.1 Inclusion criteria ...... 13

3.2.2 Exclusion criteria ...... 13

3.3 Sample size determination ...... 13

3.4 Sampling technique ...... 13

3.5 Data collection method ...... 13

3.6 Tools of data collection ...... 13

3.7 Data collection procedure ...... 14

3.8 Quality control ...... 14

3.9 Data analysis ...... 14

3.9.1 Validity of the instruments ...... 14

3.9.2 Reliability of the instruments ...... 14

3.10 Ethical consideration ...... 15

CHAPTER FOUR: DATA PRESENTATION AND INTERPRETATION ...... 16

4.0. Introduction ...... 16

4.1. Biodata ...... 16

4.2. Sources of obstetric referrals to Regional Referral Hospital...... 18

4.3. Causes of maternal deaths among obstetric referrals to Fortportal Regional Referral

Hospital ...... 21

4.4. Means of transport from the referral source to FPRRH ...... 23

CHAPTER FIVE: DISCUSSION OF RESULTS, CONCLUSION AND RECOMMENDATION

...... 26

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5.0. Introduction ...... 26

5.1. Discussion of results ...... 26

5.1.1. Sources of obstetric referrals to FPRRH ...... 26

5.1.2. Causes of maternal deaths among obstetric referrals to FPRRH ...... 26

5.2. Conclusion ...... 27

5.3. Recommendations ...... 27

5.3.1. To healthcare unit ...... 27

5.3.2. To the district ...... 28

5.3.3. To the Ministry of Health ...... 28

REFERENCES ...... 29

APPENDICES ...... 31

APPENDIX I: CHECKLIST ...... 31

APPENDIX II: ESTIMATED BUDGET ...... 33

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DECLARATION

I, Logose Joan, do hereby declare that this research proposal is the product of my own efforts and to the best of my knowledge has never been presented to any institution for any award or qualification whatsoever.

Wherever the works of other people have been included, due acknowledgement to this has been made in accordance with the appropriate referencing and citations.

The findings and the analysis that will result from this research project will be my original information.

Researcher: Logose Joan

Signature ……………………………………………...

Date: ………………………………………………...….

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APPROVAL

This is to certify that this research proposal has been prepared under my supervision and has never been presented anywhere for any other purpose and is now ready for submission to the Faculty of

Clinical Medicine and Dentistry of Kampala International University for further consideration.

Supervisor: Dr. Ddamulira Adam

Signed………………………………………………….

Date: ……………………………………………….……

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DEDICATION

I dedicate this research to the Almighty God who has seen me through this course, to my parents

Mr. Walega John and Mrs. Walega Philo Rose who have been so patient with me and have sacrificed so much to see me through these past six years, my dear friend Mr. Philemon Kiyombo who has continuously encouraged me and put a smile on my face when the going got tough and finally to everyone else who has played a role in this journey and training of becoming a doctor.

I am so grateful for all your efforts and sacrifice. Thank you so much and may God bless and abundantly reward all of you in Jesus’ name, Amen.

LIST OF ABBREVIATIONS AND ACRONYMS

AIDS : Acquired Immuno-deficiency Syndrome

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CDC : Centers for Disease Control and prevention

FPRRH : FortPortal Regional Referral Hospital

HIV : Human Immuno-Deficiency Virus

HIV/AIDS : Human Immuno-deficiency Virus/Acquired Immuno-deficiency Syndrome

HPV : Human papillomavirus

MMRate : Maternal Mortality Rate

MMRatio : Maternal Mortality Ratio

STIs : Sexually Transmitted Infections

UNAIDS : The Joint United Nations Programme on HIV/AIDS

UNFPA : United Nations Population Fund

UNICEF : United Nations International Children’s Fund

U.S : United States

WHO : World Health Organization

OPERATIONAL DEFINITIONS

Obstetric referrals: Refers to a woman that has been referred with an obstetric condition that needs urgent interventions.

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Sources of obstetric referrals: Refers to the health units that refer obstetric cases

Maternal deaths: Refers to the death of a woman while pregnant or within 42 days of termination of a pregnancy.

Pregnancy related deaths: refers to the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.

Direct obstetric deaths: refers to those deaths resulting from obstetric complications of the pregnancy.

Indirect obstetric deaths: refers to those deaths resulting from previous existing disease or disease that developed during pregnancy and is due to the pregnancy.

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CHAPTER ONE

1.0 Introduction

This chapter covers the introduction of the study, the historical background of the study, conceptual background, theoretical background, problem Statement, and objectives of the study, research questions and significance of the study.

Every day, approximately 830 women die from preventable causes related to pregnancy and child birth. And about 99% of all maternal deaths occur in developing countries especially among women living in rural areas and among poorer communities (WHO 2019).

So as a result, many lives have been lost, not only of the mothers but also of their newly born and unborn children.

Therefore, identifying the sources and causes of maternal deaths is important as it will help to come up with interventions that could help to stop the many preventable maternal deaths.

1.1 Background

UNFPA (United Nations Population Fund) estimated that 303,000 women died of pregnancy and childbirth related causes in 2015. The global MMRatio (Maternal Mortality Ratio) has fallen from

385 deaths per 100,000 live births in 1990 to 216 deaths per 100,000 live births in 2015 and many countries have halved their maternal death rates in the last 10years (WHO, 2019).

The global report revealed that the number of women dying from causes related to pregnancy and child birth has almost halved since 1990. By 2017, the world MMRate (Maternal Mortality Rate) had declined to 44% since 1990 but still everyday 830 women die from pregnancy and childbirth related causes and yet these deaths are entirely preventable (WHO, 2019).

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As much as many countries globally have halved their maternal deaths in the past 10 years, this decline has not been reflected in low income countries especially sub-Saharan Africa where majority of these maternal deaths occur (women’s health bulletin).

Two regions, sub-Saharan Africa and south Asia account for 88% of maternal deaths worldwide with sub-Saharan Africa having the highest ratio of 546 maternal deaths per 100,000 live births or

201,000 maternal deaths per year which is two thirds (66%) maternal deaths per year worldwide

(maternal mortality UNICEF data 2017).

Maternal mortality in developing countries has been described as a silent tragedy by Barate P,

Temmerman. It is the one with the largest discrepancy between developed and developing countries of all the health statistics monitored by WHO. It is estimated that about 1,600 maternal deaths occur each day worldwide and a total of around 586,000 maternal deaths a year of which

99% of these occur in developing countries which is mostly attributed to access to quality health care during pregnancy (Investigating maternal mortality in a public teaching hospital, Abakali) .

Furthermore, maternal mortality remains a public health concern in developing countries due to the fact that the in 2015 the maternal mortality ratio in developing countries was 239 maternal deaths per 100,000 live births whereas the maternal mortality ratio in developed countries was only 12 maternal deaths per 100,000 live births in the same year. This implies that a woman in a developing country is 97 times more likely to die as a result of pregnancy and child birth related causes than a woman in a developed country. (Women’s health bulletin).

In Africa as a continent, each year 162,000 women die during pregnancy, birth or puerperium.

This is approximated to about 62% of all maternal deaths worldwide. There is a 1 in 30 risk of maternal deaths in sub-Saharan Africa against a 1 in 5,600 risk in developed countries. Obstetric risk is by far the highest in sub-Saharan Africa. In 2015, the maternal mortality ratio for sub-

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Saharan Africa was estimated to be nearly 546 maternal deaths per 100,000 live births which is

30times higher than in industrialized countries which is only 16 maternal deaths per 100,000 live births. (Fondation Sanofi espour).

East Africa has been singled out in particular to be leading the highest maternal deaths which is

18% in Africa due to unsafe abortions (All East African) according to documents presented by experts in reproductive health to the Pan African Parliament Convening in Midrand. Across

Eastern Africa, women are still dying unnecessarily in the most basic and natural act of giving life.

According to UNICEF, UNFPA and World Bank estimates in 2010, about 58,000 lost their lives during pregnancy and childbirth accounting for a fifth of such maternal deaths worldwide. In

Eastern and Southern Africa between 1990 and 2010 the maternal mortality had fallen from 740 maternal deaths per 100,000 live births to 410 maternal deaths per 100,000 live births however the pace of progress is far too slow (All East African).

In Uganda women are dying at an alarming rate due to pregnancy and birth related causes. About

1 woman of every 49 will die of maternal complications related to pregnancy or delivery. Uganda’s

MMRatio has consistently been one of the highest in the world with 440 maternal deaths per

100,000 live births according to Uganda Demographic and Health Survey 2005/2006 which has declined from 527 maternal deaths per 100,000 live births estimated in 1990. This translates to about 6000 women dying every year due to pregnancy related causes.

Women in rural Uganda face multiple barriers accessing critical routine and lifesaving maternal healthcare which are basically; delay in deciding to seek healthcare, delay in reaching healthcare due to transport or lack of infrastructure and delay in receiving adequate and appropriate healthcare for example due to lack of skilled attendants (Maternal Health – SOUL Foundation).

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1.2 Problem Statement

The Uganda Maternal Mortality ratio is 343 maternal deaths per 100,000 live births (UNICEF data

2019). Maternal and child morbidity account for the highest disease burden in Uganda (Roadmap for accelerating the reduction of maternal and neonatal mortality and morbidity). The leading causes of maternal deaths in Uganda are hemorrhage, eclampsia unsafe abortions and infections.

All these causes are largely preventable and with appropriate medical care they wouldn’t occur

(Maternal Health – SOUL Foundation).

According to Ministry of Health report about Maternal deaths on Monday May 13th 2019,

Fortportal Regional Referral Hospital has been registering the highest number of maternal deaths among all regional referral hospitals in the country, Uganda which is 62 and 53 maternal deaths in calendar years 2016 and 2017 respectively and in 2018 by the end of June 27 mothers had died already. This means that every week since January 2016 to date, a mother has been dying at this hospital due to pregnancy and related causes (Ministry of Health report, 2019).

FPRRH receives many referrals from various health centers including refugee camps some of which are located far from the hospital. Therefore it calls for further investigations to identify the sources and causes of maternal deaths among the obstetric referrals.

1.3 Objectives of the study

1.3.1 Broad objective

To assess the sources and causes of maternal deaths among obstetric referrals to Fortportal

Regional Referral Hospital.

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1.3.2 Specific objectives

1. To identify sources of obstetric referrals to FortPortal Regional Referral Hospital.

2. To establish the causes of maternal deaths among obstetric referrals to FortPortal Regional

Referral Hospital.

1.4 Research Questions

1. What are the sources of obstetric referrals to FPRRH?

2. What are the causes of maternal deaths among obstetric referrals to FPRRH?

1.5 Justification of the study.

This research study will attempt and fill the research gap that exists concerning obstetric maternal deaths.

It will provide data about the causes of maternal mortality and their sources in FPRRH. This data will not only inform decisions and planning by the concerned authorities in FPRRH, but also higher up in the ministry, government and global health bodies.

A feedback will be given to the lower health centers that refer obstetric patients to FPRRH

The respondents will also benefit from early detection and management of the causes of maternal deaths and thus decreasing mortality among referred patients.

The research findings will also act as a reference upon which other researchers can base their studies and it will also facilitate to decrease the burden on women’s disease where maternal deaths and disabilities are the leading contributors with an estimation of about 275,000 women dying every year in child birth and due to pregnancy worldwide (WHO, Maternal deaths).

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1.6 Scope of the study

1.6.1 Geographical scope

The study will be carried out in FortPortal Regional Referral Hospital. FortPortal Regional

Referral Hospital is located in FortPortal town, Kabarole district in western Uganda along

Mugurusi Road. It is the referral hospital for the districts , , Kabarole,

Kamwengye, and .

1.6.2 Content scope

The study will be carried out on the sources and causes of maternal deaths among obstetric referrals to FPRRH. The sub themes will be include the sources of these referrals and the causes of maternal deaths.

1.6.3 Time scope

The study will take a period of 6months and this includes designing a proposal, collecting data, presentation of data, analysis of data and final preparation and submission of the research report.

1.7 Conceptual framework

1.7.1 The independent variables

The independent variables are the causes and sources of maternal death among the obstetric referrals

1.7.2 The dependent variables

The dependent variables are the direct obstetric causes healthcare unit factors and personal influences.

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Figure 1. Conceptual framework for the sources and causes of maternal deaths among obstetric referrals

Healthcare unit factors

Interventions before Direct obstetric causes referral Personal influence

Nature and severity of the Cadre and expertise of Age, parity and marital disease referral officer status

Gravidity and parity Mode of transport Financial status

Complications following Availability of necessary Knowledge delivery resources for patient care Cultural norms and practices

Maternal deaths among obstetric referrals

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CHAPTER TWO: LITERATURE REVIEW

Introduction

This chapter will deal with the literature that was written about maternal deaths, their causes and sources. Therefore the available literature is worth reviewing for better understanding and analytical process of this study. The chapter further covers the themes and sub themes of the literature reviewed about the sources and causes of maternal deaths among obstetric referrals.

Obstetric referrals especially to FortPortal regional referral hospital are majorly from the neighboring lower heath centers and general hospitals in the neighboring districts which include

Kasese, Bundibugyo, Kabarole, Kamwengye, Ntoroko and Kyenjojo (WHO, 2019).

Others come in from various private medical centers.

Causes of maternal deaths are multilayered and have origins in many intertwined factors starting with the social status and position of women greatly affected by the economic resources and infrastructure of the country, and immediately dependent on the accessibility and availability of skills, materials and facilities for family planning. But medical causes play the major role in maternal deaths. The medical causes of maternal deaths are classified under three categories; the direct, indirect and coincidental causes.

The direct obstetric medical causes of maternal deaths including anemia account for 80% of all maternal deaths in developing countries (C.Abouzhar Maternal mortality Global handbook). It refers to those diseases or complications which occur only during pregnancy. They include;

Obstetric hemorrhages. This refers to any form of bleeding while pregnant or within 28days after termination of pregnancy. Antepartum hemorrhage (APH) refers to bleeding before childbirth.

When it occurs less than 28weeks of gestation, causes are usually due to abortion or due to ectopic pregnancy. After 28weeks of gestation, the cause is usually due to separation of the placenta from

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the uterus caused by placenta praevia or abruptio placenta.

Postpartum hemorrhage (PPH) is excessive bleeding and loss of blood after childbirth. A skilled health care provider can stop the bleeding. But, if a healthcare provider with the proper knowledge and skills is not available, a mother can die from losing too much blood. PPH is responsible for approximately 27 percent of all maternal deaths (Murray Maternal mortality rates, causes and prevention).

Another direct medical cause of maternal deaths is preeclampsia and eclampsia. This refers to raised maternal blood pressures and presence of proteins in the urine. The exact causes are unknown. Good prenatal care and testing usually picks up issues such as high blood pressure and protein in the urine. With good medical care, doctors can treat and monitor pre-eclampsia. But, without care, it can become dangerous and lead to death. Hypertensive disorders are responsible for 14 percent of pregnancy-related deaths.

Puerperal sepsis or infection is yet another direct medical cause of maternal death. Women can get an infection from unsafe abortion, an unsanitary delivery, or a very long labor. The most common cause is failure to observe aseptic technique during childbirth and presence of underling infection.

A lack of understanding and information on personal hygiene and how to care for the body after childbirth can also put a mom at risk for infection. About 11 percent of maternal deaths are the result of an infection. It’s the most common complication in unsafe abortions.

Termination of Pregnancy. Unsafe abortions are the leading causes of death among women who have an unintended pregnancy. It is the reason that approximately 68,000 women die each year.

Termination of pregnancy accounts for 8 percent of the maternal deaths.

Obstructed labor refers to failure of progress of labor characterized by arrest of descent of fetal head and cervical dilatation. It’s commonly caused by disproportion between the fetal head and

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the space in the bony birth canal of maternal pelvis which may be due to stunting or malnutrition of the mother, a disease condition distorting the pelvis or poor position of the baby or when the baby is too big.

Approximately 10 percent of women die from other direct pregnancy-related issues (D. Murray maternal mortality rates, causes and prevention). Conditions such as hypertensive disorders of pregnancy, uterine rupture, and ectopic pregnancy which can lead to complications and death without the proper care and management.

An indirect cause of death in pregnant women is from a condition that is not directly related to the pregnancy but develops or gets worse during pregnancy or may have been present before the pregnancy. Pregnancy can affect health problems such as HIV and heart disease. Conditions such as diabetes and anemia can develop or get worse. Other indirect causes include essential hypertension, hemoglobinopathies and anemia. These issues account for approximately 28 percent of maternal deaths (D. Murray maternal mortality rates, causes and prevention).

Coincidental medical causes maternal deaths are fortuitous in nature and include road traffic accidents during pregnancy that eventually lead to maternal deaths.

And behind these medical causes of maternal deaths are logistic causes which include failures in the healthcare system, lack of transport and many others. And behind these are the social, cultural and political factors which together determine the status of women, their health, fertility and health seeking behavior.

The healthcare system especially the referral sources and the referral destinations play an important role in the maternal deaths among obstetric referrals. The WHO health system building blocks offer a starting point to classify health system determinants of maternal deaths which include the following: quality of services delivered at the health centers and also the referral system; number,

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distribution, and training of the different healthcare providers required, including midwives and obstetrician-gynecologists; the completeness and responsiveness of the health information system; the ease of access to essential medications required such as magnesium sulphate, misoprostol and oxytocin, and the supplies necessary for blood transfusions; the leadership and financing of the different health centers which is a particular relevant issue in several Sub-Saharan African countries, which have ended users’ fees; the governance, including the capacity of authorities at various levels of the health system to put policies and a management system in place so that women’s health can improve.

However, among all these, the equitable distribution of staff and the adequacy of blood supplies appear to be problematic in most settings in the lower health centers (V.Filippi and others, Levels and causes of maternal morbidity and mortality 2013).

Most women especially from rural areas have others influences that are closely intertwined with the direct obstetric causes of maternal deaths. These include lack of finances, poor or no education, extremities of age, the parity especially the first pregnancies and more than three deliveries, etc.

Money is often required to move from the area of referral to the referral unit and also for any other emergency procedures that maybe have to be carried out such as an emergency caesarian section.

Lack of finances leads to major delays in seeking care which can result into catastrophic events.

This is more common is single pregnant women who often lack support from their partners but also occurs among those with supportive partners with poor or no income source(V.Filippi and others, Levels and causes of maternal morbidity and mortality 2013).

Women of reproductive age range below twenty and above thirty five have a higher risk of complications due to pregnancy and child birth and hence maternal deaths however the largest numbers of maternal deaths might be in the middle group because this is when most births occur.

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With most deaths 50percent and 70 percent occurring between ages of 20-35 years (Wendy

Graham and Pauline Airey, measuring maternal mortality 1987).

The first pregnancy and more than three to five pregnancies have a higher risk of complications and death because women in their first pregnancy have a longer duration of labor whereas those with higher parity and gravidity are more like to get postpartum hemorrhage (Wendy Graham and

Pauline Airey, measuring maternal mortality 1987). Most of these women are from rural areas and have received poor or no education and do not know where to obtain effective obstetric services or even to request for them, let alone the ability to afford these services.

CHAPTER THREE: RESEARCH MOTHODOLOGY

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3.0 Introduction

This chapter describes the study area focusing on population structure and many other aspects including study design, sample size determination, sampling method, selection criteria, data

Collection, data analysis, data presentation, data quality control, study limitation and Ethical consideration.

3.1 Study design

The study will use a descriptive research design and will also employ a retrospective approach to address the problem under investigation.

3.2 Study population

3.2.1 Inclusion criteria

All obstetric patients that died while pregnant, after delivery or termination of pregnancy and were presented as referrals.

3.2.2 Exclusion criteria

All mothers who arrived while dead or died in transit.

3.3 Sample size determination

Periodic prevalence.

3.4 Sampling technique

All obstetric referral cases that resulted into maternal deaths.

3.5 Data collection method

Observation method.

3.6 Tools of data collection

Indirect observation method will be employed using a checklist.

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3.7 Data collection procedure

I will seek permission from chief hospital administrator as the administrative head of the hospital so as to go through the patient medical records. After receiving the response, I analyze the medical records. Following the comments from the supervisor, a final report will be compiled and submitted for examination for the award of a Bachelor of Medicine and Surgery at Kampala

International University.

3.8 Quality control

I will ensure quality control through induction and training of research assistants.

3.9 Data analysis

Data will be exported to SPSS version 17. Using double entry, the data will be checked for consistency and accuracy. Observations will be given points and tallied then recorded to obtain means then presented in graphs, charts and tables.

This will include both validity and reliability of the collection data instruments as below;

3.9.1 Validity of the instruments

The quality of the instruments will be determined by the supervision of the researcher and he or she will be expected to further determine the extent to which the methods will be meaningful, and of good quality.

3.9.2 Reliability of the instruments

The reliability of the instruments will be that the instruments used will give the same results repeatedly. The data collected will ascertain if the instruments will measure what is supposed to be measured in the findings.

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3.10 Ethical consideration

The research project is subjected to approval by Kampala International University institution review board and then clearance shall be obtained.

Permission will be got from the authority of FortPortal Regional Referral Hospital.

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CHAPTER FOUR: DATA PRESENTATION AND INTERPRETATION

4.0. Introduction

This chapter presents the study findings in tables and figures and interpretation of the findings.

4.1. Biodata

Table 1: Demographic characteristics

Variables Frequency (n=48) Percentage (%)

Age (years) <19 9 18.8 19-24 11 22.9 25-29 13 27.0 30-34 8 16.7 ≥35 7 14.6 Total 48 100 Occupation Peasant 26 54.2 Teacher 5 10.4 Businesswoman 4 8.3 Student 4 8.3 Housewife 1 1 Information unavailable 8 16.7 Total 48 100 Religion Catholic 17 35.4 Anglican 17 35.4 Pentecostal 4 8.3

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Muslim 4 8.3 Seventh day Adventists 1 2.1 Information unavailable 5 10.4 Total 48 100 Marital status Married 26 54.2 Single 13 27.0 Information unavailable 9 18.8 Total 48 100 Parity PG 18 37.5 Multiparty 21 43.7 Grand multiparty 4 18.8 Total 48 100

From the 48 case files that were reviewed, majority of the referred mothers that died, 13 and 11

(27.0% and 22.9%) were in the age groups 25-29 and 19-24 years old respectively, most of them

26 (54.2%) were peasants and others were teachers, students and businesswomen, almost three quarters 34 (70.8%) were Catholics and Anglicans, the others were Muslim 4(8.3%), Pentecostals

4 (8.3%) and 1 Seventh Day Adventist (2.1%) however 5 (10.4%) of the mothers didn’t have information pertaining their religion. Majority of the mothers 26(54.2%) were married, 13(27.0%) were single and almost a quarter of them 9(18.8%) didn’t have information concerning their marital status. Almost half of the mothers that died 21(43.7%) were multiparas, about a third

18(37.5%) of them were prim gravidas and only 4(18.8%) were grand multiparas.

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4.2. Sources of obstetric referrals to Fort portal Regional Referral Hospital.

Table 2

Source Frequency (n=48) Percentage (%)

Kasese district 12 25.0

Kibiito health center iv 6 50.0

Rwimi health center iii 3 25.0

Rwesande health center iv 1 8.3

St Paul health center iv 1 8.3

Kitswamba health center iii 1 8.3

Kyenjojo district 10 20.8

Kyenjojo district hospital 6 60.0

Kyarusozi health center iv 2 20.0

Nkuraba health center iii 1 10.0

Katooke health center iii 1 10.0

Kyegegwa district 7 14.6

Bujubuli health center iv 3 42.9

Kyaka health center ii 2 28.6

Kyegegwa health center iv 2 28.6

Kabarole district 7 14.6

Kijura health center iii 2 28.6

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Bukuuku health center iv 2 28.6

Kibatsi health center iii 1 14.3

Kaswa health center iii 1 14.3

Kagote health center iii 1 14.3

Ntoroko district 3 6.3

Karugusu health center iv 2 66.7

Stella Maris health center iii 1 33.3

Kamwengye district 2 4.2

Rukungu health center iv 2 100

Bundibugyo district 1 2.1

Kasitu health center iv 1 100

Information unavailable 6 12.5

Total 48 100

Among the 48 of referred mothers that died, a quarter 12(25.0%) were from followed by Kyenjonjo, 10(20.8%) while Bundibugyo 1(2.1%), Kamwengye 2(4.2%) and Ntoroko

3(6.3%) districts had the least referred number of mothers who died. Kyegegwa and Kabarole districts had 7(14.6%) and 7(14.6%) referred mothers who died respectively. Among the referred mothers from Kasese district that died of the 12, half of them 6(50%) were from Health

Center III, a quarter of them were from health center iii and the other health centers each

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referred 1 patient which is 8.3% of all those referred from Kasese district as shown in the table above.

A total of 10 mothers had been referred from Kyenjojo district and 6 of these (60%) were from

Kyenjojo district hospital, only 2(20%) were from Nkuraba health center iii and all the other health centers only referred 1(10%) as shown in the table above.

Kyegegwa and Kabarole districts both referred 7 mothers each, Bujubuli health center iv in

Kyegegwa referred the most mothers 4(42.9%) of those from whereas the highest number of referred mothers from Kabarole district were from health center iv and

Kibatsi health center iii whereby each referred 2(28.6%) mothers.

Of the three mothers from , 2(66.7%) were from Karugusu health center IV and only 1(33.3%) from Stella Maris Health Center III.

All the 2 mothers from Kamwengye district were from Rukungu health center iv whereas the only mother referred from was from Kasitu health center iv and out of the 48 mothers that died, 6(12.5%) of them didn’t have any record about the exact source of referral.

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4.3. Causes of maternal deaths among obstetric referrals to Fortportal Regional Referral

Hospital

Figure 1

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41.7% 20

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10 18.8% 18.8%

5 8.3% 6.3% 2.1% 2.1% 2.1%

0

Majority of the referred mothers 20 (41.7%) died due to postpartum hemorrhage followed by puerperal sepsis and uterine rupture where each claimed 9(18.8%) of the mothers. 4(8.3%) died due to antepartum hemorrhage and 3(6.3%) died due to eclampsia.

One mother (2.1%) died in each of the cases of cryptococal meningitis, hepatic encephalopathy and intestinal obstruction as shown in the table above.

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Table 3 Direct and indirect causes of maternal deaths

Causes of maternal deaths among obstetric referrals Percentage (%)

Anemia secondary to postpartum 41.7 hemorrhage Direct obstetric causes Puerperal sepsis 18.8

Shock secondary to uterine rupture 18.8

Anemia secondary to antepartum 8.3 hemorrhage Hypertensives disorders in pregnancy 6.3

Cryptococal meningitis 2.1

Indirect causes Hepatic encephalopathy 2.1

Intestinal obstruction 2.1

According to the study that was carried out, 93.7% of the causes of maternal deaths among the obstetric referrals were direct obstetric causes and only 6.3% were indirect causes.

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4.4. Means of transport from the referral source to FPRRH

Figure 2 Means of transport to FPRRH

MEANS OF TRANSPORT

22.9%

58.3% 18.8%

PUBLIC MEANS AMBULANCE INFORMATION UNAVAILABLE

Among the 48 mothers that died, majority of them 28(58,3%) used public means; motorcycles and taxis to move from the area of referral to FPRRH and only 9(18.8%) were able to afford to use the ambulance whereas the other 11(22.9%), no information was attained concerning the transport means to FPRRH as shown in the figure above.

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Table 4 interventions on arrival to FPRRH

Interventions Frequency Percentage (%) (n=48)

Emergency Caesarian section 27 56.3

Emergency Caesarian section plus Subtotal abdominal 1 2.1 hysterectomy

Explatory laparotomy 3 6.3

Emergency Caesarian section plus Explatory 2 4.2 laparotomy

Explatory laparotomy plus subtotal abdominal 4 8.3 hysterectomy

Blood transfusion 8 16.7

Cardiopulmonary Resuscitation 2 4.2

Manual vacuum aspiration 1 2.1

Total 48 100

Concerning the interventions performed on admission to FPRRH, more than half 27(58.3%) underwent an emergency Caesarian section and 8(16.7%) were transfused with blood and the least interventions done were emergency Caesarian section with a subtotal abdominal hysterectomy and manual vacuum aspiration each 1(2.1%) mother of those that died and had been referred.

Except for the mode of delivery among the mothers that had delivered, there were no other interventions indicated in the patients’ records before referral.

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Table 5 Time interval between arrival to FPRRH and death Time interval Frequency Percentage (%) (n=48)

≤24 hours 28 58.3

1-6 days 15 31.3

≥7 5 10.4 days

Total 48 100

Of the 48 mothers, more than half 28(58.3%) died within 24hours of admission, almost a third

15(31.3%) died between 1 to 6 days of admission and 5(10.4%) died after 7 days or more after admission.

Of the 48 mothers that died; 7(14.6%) were referred by a doctor, 10(20.8%) were referred by a clinical officer, 18(37.5%) were referred by a midwife and 13(27.1%) did not have any information concerning the referring officer.

Thirty seven (77.1%) of the mothers had information concerning antenatal care attendance.

Eighteen (37.5%) of the mothers were referred after delivery of which 12(66.7%) of these had delivered by Spontaneous Vertex Delivery and the other 6(33.3%) had delivered by Caesarian

Section. However, details concerning place of delivery, neonatal condition and time of delivery were not indicated on the death notification report. The other 30 mothers delivered at FPRRH by

Caesarian Section.

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CHAPTER FIVE: DISCUSSION OF RESULTS, CONCLUSION AND

RECOMMENDATION

5.0. Introduction

This chapter discusses the results that were obtained from the data that was collected from the maternal death records of FortPortal Regional Referral Hospital.

5.1. Discussion of results

In this study, the total number of maternal deaths that occurred among obstetric referrals over a period of 1 year (April 2018 to March 2019) was 48 women.

5.1.1. Sources of obstetric referrals to FPRRH

Obstetric referrals especially to FortPortal regional referral hospital are majorly from the neighboring lower heath centers and general hospitals in the neighboring districts which include

Kasese, Bundibugyo, Kabarole, Kamwengye, Ntoroko and Kyenjojo. Others come in from various private medical centers.

According to the study that was carried out among the 48 of referred mothers that died, a quarter

12(25.0%) were from Kasese district followed by Kyenjonjo, 10(20.8%) while Bundibugyo

1(2.1%), Kamwengye 2(4.2%) and Ntoroko 3(6.3%) districts had the least referred number of mothers who died. Kyegegwa and Kabarole districts had 7(14.6%) and 7(14.6%) referred mothers who died respectively which is contrally to the hospital records which indicate that most obstetric referral cases are from Kamwengye district, followed by Kyenjonjo and then Kasese district.

5.1.2. Causes of maternal deaths among obstetric referrals to FPRRH

According to the study that was carried out, 93.7% of the causes of maternal deaths among the obstetric referrals were direct obstetric causes and only 6.3% were indirect causes. However,

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according to C.Abouzhar Maternal mortality Global handbook, the direct causes of obstetric deaths account for 80% of the maternal deaths.

Majority of the maternal deaths, 41.7% were due to postpartum hemorrhage. This is almost twice the 27% figure that was seen for the percentage contribution of postpartum hemorrhage to maternal deaths in the study on maternal mortality rates, causes and prevention (Murray Maternal mortality rates, causes and prevention).

Majority of the maternal deaths among the obstetric referrals occurred in the 25-29 age group and among the multipara group which is consistent with the hospital records.

And behind these medical causes of maternal deaths are logistic causes which include failures in the healthcare system, lack of transport and many others. And behind these are the social, cultural and political factors which together determine the status of women, their health, fertility and health seeking behavior however some of these parameters could not be assessed due to inadequate information the patient records.

5.2. Conclusion

Obstetric hemorrhages are the leading cause of maternal deaths among obstetric referrals accounting for 50% of the deaths.

Most of the patients were referred from peripheral health centers of the neighboring districts to

FortPortal Regional Referral Hospital. According to the study, Kasese district referred the majority

(25%) of the mothers that died.

5.3. Recommendations

5.3.1. To healthcare unit

To give feedback to the respective healthcare units about the outcome of their referred obstetric cases.

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The referral health units should improve on documentations concerning referrals.

5.3.2. To the district

Notification of the respective districts of the health centers about the maternal deaths.

The barriers to emergency obstetric care such as blood transfusion and means of transportation should be eliminated.

The district should organize for and conduct awareness campaigns in different regions of the country targeting all women in order to increase their obstetric knowledge especially to do with age, gravidity-parity status, the associated risk factors and where to seek adequate obstetric care.

Mass media, which is an effective, means of communication in particular radios should be utilized during these campaigns so that awareness messages can reach a wider audience.

5.3.3. To the Ministry of Health

Health units should be well equipped with resources that enable them to handle obstetric

emergencies.

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REFERENCES

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Adler, A. J., V. Filippi, S. L. Thomas, and C. Ronsmans. 2012. Quantifying the global burden of morbidity due to unsafe abortion: magnitude in hospital-based studies and methodological issues.

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Bang, R.A., A. T. Bang, M. H. Reddy, M. D. Deshmukh, S. B. Baitule, and V. Filippi. 2004.

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Murray. D. 2003. Maternal mortality rates, causes and prevention.

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APPENDICES

APPENDIX I: CHECKLIST

Section A: Biodata 1 2 3 4 5 Age Tribe Religion Address Parity Occupation Marital status

Section B: Sources of obstetric referrals 1 2 3 4 5 Referral unit District Cadre of referral officer Reason for referral Date and time of referral Date and time of arrival Duration to arrival Means of transport used

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Section C: Cause of maternal death 1 2 3 4 5 Date and time of admission Date and time of death Time interval from admission to death Interventions on admission Cause of death Outcome of pregnancy Mode of delivery Place of delivery ANC attendance

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APPENDIX II: ESTIMATED BUDGET ACTIVITY QUANTITY AMOUNT PER TOTAL AMOUNT

QUANTTY ( UG SHS)

Typing and printing 70 1500 105000

Collection of 50000 information

Transport 100000

Communication 10000

Laborer’s wages 30000 miscellaneous 50000

Total 345000

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