Changing trends in maternal mortality in a developing country.

OBJECTIVE: To have a 5-year review of the maternal mortality ratio in the largest centrally located Mission hospital in Benin City where a large proportion of women deliver yearly.
METHOD: This was a 5-year (January 1, 1996 through December 31, 2000) review of the causes of maternal mortality at the Saint Philomena Catholic Hospital, Benin City. The case notes of those that suffered maternal mortality were retrieved and thoroughly perused. Information on all cases of maternal mortality were extracted from the patients' case-notes; the labour ward Registers; the antenatal, postnatal, the female ward and the theatre registers. The midwifery/nurses' reports were also examined. The duplicate copies of the death certificates were examined and the necessary information was also extracted. The total deliveries for the period were extracted from the delivery registers.
RESULTS: There were 7055 women who gave birth during the 5-year period. There were 32 maternal deaths; Maternal Mortality Ratio (MMR) of 454/ 100,000 live births. Unbooked emergencies accounted for 68.7% of all deaths, and were more than doubled the booked women. The MMR increased progressively from 325 in 1996 to peak at 765 in 1999 (P < 0.0001) with an insignificant drop in 1998 (P > 0.06). It was lowest in 2000 (241) (P < 0.0001). Paradoxically, as the number of deliveries decreased progressively from 1530 in 1996 to 1247 in 2000, the MMR increased progressively from 327 in 1996 to 675 in 1999. There were no postmortem examinations and no coroner's inquests. More than 76% of the women spent 48 hours or less from time of admission to death and majority of them were of low parity. Nulliparity was 37.5%. The mean parity was one. Young women 20-39 years old accounted for 81.3% with 9.4% teenage deaths due to illegally induced abortions. Eclampsia (34.4%), hemorrhage (25.0%), Infections (18.8%) and abortions 12.5%) were the four leading causes of death. Puerperal deaths were 56.3%. Five short case scenarios were presented to highlight the tortuous pathway the women passed to end in maternal mortality.
CONCLUSION: The MMR ratio was still unacceptably high. The causative factors were largely preventable. The puerperium was the most dangerous period. Women empowerment, free or highly subsidized universal antenatal care services, and provision of adequate emergency obstetric services with effective contraceptive backup is suggested. Re-orientation of care givers and community leaders to enhance awareness and early recognition of the danger signs and risk factors associated with pre-eclampsia and eclampsia with prompt and adequate management or referral is emphasized.