Background: Postpartum maternal morbidity is becoming a major public health concern worldwide due to impact of modern development in feto-maternal medicine and maternal care. Major acute and long term maternal morbidities which may occur during obstetric management affect the life and reproductive career of women. Objective: To assess the trends, risk factors and pattern of postpartum maternal morbidity in Ikot Ekpene a local community in southern Nigeria. Materials and Methods: This was a 4-year prospective cross sectional observational study carried out in the maternity section of General Hospital Ikot Ekpene, Akwa Ibom State, Nigeria between 2008 and 2011. Parturients managed in the hospital for postpartum morbidity were recruited for the study. Relevant information was obtained from structured questionnaire administered to the patients and those extracted from other medical records in the course of managing the patients. This was analysed using the SPSS computer statistical package. Result: A total of 5760 women delivered during the period, of which 296 (5.1%) were treated for postpartum morbidity. Most of the patients (46.9%) were between 31 and 40 years old and 68.8% were of low educational background. Half of the deliveries with morbidity were conducted by unskilled attendants. The most common maternal morbidity encountered included primary postpartum haemorrhage (22.2%), genital sepsis (16.1%), and hypertensive disorders (12.8%). Anaemia (12.8%) and malaria (11.1%) were the commonest non obstetrics causes of morbidity. It was relatively more common with delivery attended by untrained personnel. There was significant reduction in morbidity in the last 2 years of this study. Conclusion: The incidence of postpartum morbidity in the Ikot Ekpene is still high with a downward trend over the years. Obstetric haemorrhage, hypertensive disorders, anaemia and genital tract sepsis were the common causes and were commoner with delivery attended by unskilled personnel. It is hoped that supervision of deliveries by skilled medical attendants, improvement in general health and educational level will reduce postpartum morbidity in this rural community.
The post partum period is very important but most neglected during obstetric care [
Even though The World Health Organisation defines the postpartum period or purperium as beginning after the delivery of the placenta and continuing until 6 weeks (42 days) after the birth of infant, maternal morbidity generally refers to complications that arise during pregnancy, delivery or the postpartum period [1,4-6]. However, many of the postpartum complications that lead to maternal morbidity and mortality arise during labour, delivery and in the first 1 - 2 weeks following delivery [6-8].
The incidence of postpartum maternal morbidity is difficult to estimate due to lack of standard definitions and measuring criteria as well as poor data management system [1,6,9,10]. Generally, the burden of this problem is high in most resource constraints countries. In developing countries, pregnancy and complications from childbirth account for 18% of the disease among females [2,11]. Out of the 585,000 women who die each year during childbirth, over 98% are from the developing world. Again, for each woman that dies, 10 - 15 others suffer different forms of serious morbidity [5,6]. About 40% of the pregnant women in Nigeria experience pregnancy-related health problems during or after pregnancy and childbirth with an estimated 15% suffering from serious or long term complications [4,6,12]. Major acute obstetric morbidities like haemorrhage, sepsis, genital tract injuries, wound infections and long term morbidities such as uterine prolapsed, urinary incontinence, dysparunia and infertility are well documented [1,4,13- 16]. In recent times the rising incidences of none pregnancy related morbidity such as anaemia, malaria, hypertension and chronic chest infections have been reported in developing countries with major impact on maternal health and wellbeing [6,17,18]. While in developed countries of the world, the incidences of these common morbidities are reducing, severe acute maternal morbidly (SAMM) or “near miss” condition is becoming prevalent [10,17,19, 20]. The latter is related to effective obstetric care resulting in reduction in mortality and many patients now end up with severe morbidity.
Good antenatal care and skilled attendants at delivery have long been identified as major factors at reducing maternal injuries, morbidity and mortality [4,6,21]. Many national and international programs/agencies have been put in place to emphasize their importance with variable results. Currently, many policies and programs are being put in place by governments in most developing countries with emphasise on postpartum care to expand the scope of previous practices to create more impact at reducing the maternal mortality and morbidity [8,20,21]. In line with this consideration, the government of Akwa Ibom State in the Niger Delta Region of Nigeria has upgraded General Hospital Ikot Ekpene, a secondary heath care facility to offer specialist care to the people of the rural community. It is therefore, necessary to assess the impacts of these programs on postpartum maternal morbidity over the period in the hospital.
The study was therefore, carried out in the hospital with the aims of assessing the trend, incidence, type of maternal morbidity and socio-demographic variable of the patients. It is hoped that the results of this study will help to create baseline data to assess maternal morbidity in future studies and identify the main factor(s) that contribute to these injuries with subsequent strategies for prevention and early treatments to avoid long term complications.
This study was conducted in the maternity section of the General Hospital Ikot Ekpene, Akwa Ibom State of Nigeria over a 4 years period (1st January 2008 and 31st December 2011).
The hospital is a secondary health facility in the senatorial district of the state upgraded to offer specialist care to the over a million people. It therefore, receives patients that present themselves directly for care or referred from other secondary facilities, private clinics and health centres across the state and beyond.
The hospital has an annual delivery rate of 1700 women and caesarean delivery rate of 30.1%.
The people of rural community are mainly farmers, house wives, petty traders and public servants. There is high fertility rate of 7.1, crude birth rate 40 per 1000 and low female literacy level.
Written approval was obtained from the ethical committee of the institution and unwritten informed consent from the women after careful and personal discussions with each of them by the authors. Patients who refused to give consent for the study were reassured of receiving standard care without bias irrespective of her decision.
The maternity section of General Hospital Ikot Ekpene Akwa Ibom State.
Cases managed for post partum morbidities in the hospital from delivery of the baby to 42 days after delivery were recruited irrespective of booking status, mode of delivery, the attendants at delivery or types of morbidity. Also included were those that delivered outside the hospital but present or referred to the hospital for treatments.
Those excluded from the study were delivery occurring before 28 weeks of gestation, patients that arrived the hospital but died before admission to the ward; those with pre-existing non obstetric morbidity before the pregnancy; those that diagnosis were not certain; Those who developed complications but later died and those who refused to give consent for the study. The latest group were assured and given standard treatment irrespective of their decision
Comprehensive medical history and physical examination were conducted on all the patients included in the study on admission in the hospital. Appropriate laboratory investigations and standard management based on the hospital policy were instituted on each the patients. Relevant information was then obtained from the patients using pretested semi structured questionnaire on admission to the ward or as soon as the clinical condition is stable; on discharge from ward and in the 6th week postnatal clinic. Information for each patient was also extracted from case records in the operation theatre, wards, laboratory and health information unit of the hospital. Information obtained included date of delivery, sociodemographic and reproductive characteristics of the patient, booking status, mode of delivery, accoucher, post delivery complications and duration of hospital stay.
The data entry and analysis were done using SPSS version 12 computer statistical package. To minimize inconsistent and wrong entries, the check option was used to program the data entry exercise for the descriptive aspect of the analysis and frequency distribution were generated for all the categorical variables.
All the patients were then managed according to the hospital protocol for the diagnosis.
For the purpose of this study the following definitions are applicable:
1) Post partum morbidity was defined as any complications occurring in the parturients from the delivery of the baby upto 6 weeks after delivery 2) Unbooked patients referred to those who did register and have antenatal care in any recognised health institutions. It also includes those who had antenatal care but attempted delivery with unskilled personnel.
3) Skilled attendants referred to those with appropriate training in government recognised institutions to supervised delivery.
4) For patients with more than one morbidity the most serious complication was recorded.
5) Severe acute maternal morbidity (SAMM) was diagnosed when one or more organ damage was diagnosed.
6) Anaemia was defined as haemoglobin concentration of less than 10 grams decilitre (g/dl).
A total of 5750 deliveries were conducted in the hospital during the 4 years period and 296 patients were managed for postpartum morbidity giving incidence of 5.1%. However records of 288 patients were satisfactory for analysis.
As shown in