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

Introduction: Life-threatening complications in pregnancy rarely achieves public health prominence in the same way as maternal mortality partly because they represent a wide spectrum of conditions. The improved level of care in many high-income countries has significantly reduced morbidity and risk of death from these conditions. However in low-income countries, such as Uganda, weak and poorly resourced health systems, socio -cultural factors and the threat by HIV/AIDS combine to increase the risk of morbidity and death. The rationale for the studies was the need to identify ways to promote health actions that can reduce maternal morbidity from life-threatening pregnancy complications.

Aim: This thesis explores the role of HIV/AIDS in post abortion endometritis-myometritis (PAEM) and postpartum endometritis-myometritis (PPEM). It also examines audit of a subset of women with lifethreatening pregnancy complications called "near miss cases"; monitoring of treatment of lifethreatening pregnancy complications and socio cultural barriers to access care in Uganda.

Methods: A case-control design was used over a 12-month period to study the risk of HIV infection in women with and without PAEM and PPEM in one hospital in Kampala, Uganda (papers 1&2). Then a subset of women (229) with life-threatening pregnancy complications called "near miss cases" were audited with respect to seeking care, access to services and quality of care in 4 referral hospitals, over a 21 months period (Paper 3). A cross sectional survey of all basic EmOC and comprehensive EmOC (district hospital) facilities in Kiboga district was carried out over a two year period to document treatment of women with lifethreatening pregnancy complications. Met need for treatment of these cases was derived, in relation to the population of the district (Paper 4). Seventeen FGD were conducted with adult men and women and with adolescent boys and girls in three study districts, on adolescence, their roles and responsibilities, pre-marital sexual relations, HIV/AIDS, pregnancy and abortion. Content analysis was used to describe the findings (Paper 5).

Results: HIV infection was not found to correlate with the risk for PAEM, HIV-1 seroprevalence 17 (32.7%) among women with PAEM and 38 (36.5%) among women without post-abortion infection; but this was double the seroprevalence among antenatal clients in the same hospital, 14.6% in 1997. HIV-1 seroprevalence was significantly higher among women with postpartum endometritismyometritis (PPEM) than controls, 26 (42.3%) and 26 (21.3%) respectively (p=0.002) OR 2.74 (95%Cl 1.34- 5.65). Over a two-year period, there was a ten-fold increase in "met need" for treatment of women with life-threatening pregnancy complications from 4% to 47%. Births in health facilities increased from 17% to 24%. Met need for cesarean sections increased from 1.3% to 2.3% and case fatality rite for women with life-threatening complications decreased from 9.4% to 1.85%. A major finding was the gender inequality in income generation, leading to different social and sexual strategies between adolescent boys and girls. Customary requirements for boys to offer gifts or pay bridal wealth in marriage and the local government taxation act, which selectively taxes boys but not girls of the same age, serve to entrench the subordinate roles of girls predisposing them to high-risk sexual behavior. Lack of empathy and support from parents and the community for an unmarried pregnant girl often leaves her without other options than to resort to unsafe abortion.

Conclusions: The prevalence of HIV-1 among women with and without PAEM was higher than in antenatal mothers, but HIV was not a risk factor for PAEM. HIV-1 was found to be a risk factor for PPEM, these findings further complicating management of these life-threatening complications of pregnancy. Women who were treated for life-threatening pregnancy complications survived in spite of substandard care identified in more than half the cases. However audit of near miss cases might offer a non-threatening stimulus for improving quality of obstetric care. More than a ten-fold increase in treatment of life-threatening pregnancy complications was achieved over a two year period, and this might offer an important way of monitoring programmes for reduction of maternal mortality. Engendering local government taxation act and customary marriage requirements might reduce entrenching gender stereotypes among adolescents. There is need to involve parents, teachers and adolescents in dialogue on an enabling environment for safe transition from childhood to adulthood.

List of scientific papers

I. Okong P, Biryahwaho B, Bergstrom S (2002). "Post-abortion endometritis-myometritis and HIV infection. " Int J STD AIDS 13(11): 729-32
https://pubmed.ncbi.nlm.nih.gov/12437891

II. Okong P, Biryahwaho B, Bergstrom S (2004). "Intrauterine infection after delivery: a marker of HIV-1 seropositivity among puerperal women in Uganda?" Int J STD AIDS 15(10): 669-72
https://pubmed.ncbi.nlm.nih.gov/15479503

III. Okong P, Byamugisha J, Mirembe F, Byaruhanga R, Bergstrom S (2004). "Audit of severe maternal morbidity in Uganda - implications for quality of obstetric care." Acta Obstetricia et Gynecologica Scandinavica (Accepted)

IV. Lalonde AB, Okong P, Mugasa A, Perron L (2003). "The FIGO Save the Mothers Initiative: the Uganda-Canada collaboration. " Int J Gynaecol Obstet 80(2): 204-12
https://pubmed.ncbi.nlm.nih.gov/12566200

V. Okong P, Kyomuhendo-Bantebya G, Johansson A (2004). "Not a child not an adult. Gender and generational perspectives on adolescent period in Uganda: implications for girls sexual and reproductive health." (Submitted)