Management of Obstetric Emergencies in a Tertiary Hospital in Cameroon: A Milestone for End of Preventable Maternal Deaths

Background: Maternal mortality was insufficiently reduced in Cameroon in 2015 despite the adoption of Millennium development goals. To tackle the situation and meet the sustainable Millennium goals target of 140/100,000 live births by 2030, the Government adopted the strategies of building reference hospitals where high quality obstetric care, timely and optimal management of obstetric emergencies will be offered. The objective of this study was to describe the patterns of obstetric emergencies in Douala Gynaeco-obstetric and Paediatric Hospital, evaluate the outcomes of their management and the contribution to maternal mortality. Patients and Methods: 418 patients with obstetric


Introduction
Reducing maternal mortality by the year 2015 was one of the most challenging millennium goals pledged by the United Nations' members in 2000. The target was to reduce by 75% the high maternal mortality ratios of the 1990's by the year 2015 [1] [2]. There has been a period of escalation of maternal mortality in low and middle income countries (LMIC) and especially in sub-Saharan Africa where the majority of the world maternal death was recorded [1] [3] [4] [5]. The evaluation of the achievement of the goal showed a global reduction of 44% worldwide but with a lot of disparities in the efforts of countries [2] [6] [7]. In a new publication of WHO, entitled Ending preventable maternal mortality (EPMM), new target at country level was established at a maternal mortality rate (MMR) not more than 140/100,000 live births [8]. In Cameroon MMR has almost doubled from 430/100,000 live births in 1998 to 782 in 2011 [3] [5] [9]. To respond to this situation, the Cameroon government has adopted amongst other strategies the one of constructing tertiary hospitals with high technology equipment, skilled health workers and other facilities with the missions of offering high quality obstetric care (state of the art obstetric care). These hospitals are expected to offer evidence based reproductive health care to women to minimise maternal deaths. Tebeu et al. in a study conducted in a tertiary hospital in Cameroon, in 2010, reported an MMR of 287.5%/100,000 live births as compared to 782 at National level [9]. Amongst the strategies proven efficient to reduce maternal and perinatal deaths are management of obstetric and neonatal emergencies, the antenatal care, skilled birth attendants, and good health care delivery system. Appropriate and timely management of obstetric emergencies in hospital (reducing the third delay) has been proven as an efficient strategy to reduce maternal and neonatal mortality by many authors [8] [10]. In a study conducted in Nigeria, Lamina Mustafa et al. [11] found that obstetric emergencies constitute 18.5% of deliveries and represented 70.6% of causes of maternal death. Di-rect obstetric causes of MM in Cameroon include post partum haemorrhage (29.2%), unsafe abortions (25%), ectopic pregnancy (12.5%), hypertensive diseases in pregnancy (8.3%) and indirect causes include malaria (8.2%) and cardiac diseases in 4.2% [9]. Studies designed to determine the case fatality of individual causes of maternal and perinatal death are scarce in Cameroon. The objective of this study was to describe the patterns of obstetric emergencies in HGOPED, the outcome of management and the contribution of each of these to maternal death.

Study Site
DGOPH is a tertiary Hospital created in 2013 and inaugurated in 2015, mainly dedicated to mother and child care. The three missions of this institution comprise of 1) providing high standard and quality care to targeted patients, 2) contributing to Medical training and 3) healthcare related research. The infrastructure and equipment are of high quality; human resources include 9 obstetrician and Gynaecologists, 5 Paediatricians, 3 intensive care workers, radiologists, surgeons, qualified midwives, nurses and many other categories of workers involved in management of emergencies. The laboratory service host one of the most functional blood bank units of the country where blood products like whole blood, frozen plasma, packed cells, platelets are always available.
In this study, an obstetrical emergency was any life-threatening medical condition during pregnancy, labour or post partum. The scope included direct obstetrical causes and acute complications of some indirect causes like malaria, cardiac diseases, and sickle cell anaemia.

Work Organization and Management of Obstetrical Emergencies (OE) at DGOPH
The work organization in the department of Obstetrics and Gynaecology is divided into two shifts for medical physicians, residents in Obstetrics and Gynaecology: the daily routine activities and the call duties. Besides routine duties, the service is covered every day by a team comprised of the above mentioned workers' categories, supervised by a consultant obstetrician and gynaecologist who work in close collaboration with the team of midwives, nurses and other paramedical staff. The hospital has elaborated guidelines for the standardized management of the most frequent OE and gynaecological emergencies. Thought not exhaustive, these guidelines are qualitatively and quantitatively updated on regular basis.

Study Design
We carried out a two phases cross sectional study with the retrospective phase consisting of review of service delivery records of cases of obstetrical emergencies from August 2015 to December 2017. In the prospective phase same infor-mation was recorded to refine the analysis from January 2018 to December 2019.

Inclusion Criteria
All cases of obstetrical emergencies received and managed during the period of study were included.

Exclusion Criteria
Those with incomplete data in the files (retrospective phase) or who died less than two hours after admission in our maternity (prospective phase) were excluded. We also excluded all patients who refused to participate in the study.

Variables Collected and Analyzed
We compiled the following information from patients' files or directly from patients or relatives in the prospective phase and entered in a pre-tested data collection sheet: 1) Socio-demographic data such as age, level of education and profession; 2) obstetric information: parity, gestational age and 3) therapeutic information: patient managed in this hospital or referred, diagnosis or type of obstetric emergency, management according to hospital guidelines or no, obstetrician present at arrival or not, maternal outcome (successful with no admission in intensive care unit (ICU), admission in ICU, death, referred to other health facilities). Case fatality was determined for each type of obstetric emergency and in case of death, factors involved were analysed (existence of protocol of management, timing of management, availability of carers, and availability of blood products) to evaluate the use of evidence-based and standard health care procedures.
Data analysis was done using SPSS version 23 software.

Ethical Considerations
We obtained clearance from the hospital institutional review board and the General Manager granted administrative authorization.

Results
The results were similar for the retrospective and the prospective phases and are analysed conjointly.

Socio-Demographic Characteristics of Study Population
Out of the 2634 deliveries recorded during the study period, 418 (15.86%) presented as obstetrical emergencies.

Primary Site of Patients' Management
Forty per cent of patients with obstetric emergencies (167) were referred from other health facilities while 251(60%) started management in the study site.  Table 2 highlights the patterns of obstetric emergencies recorded during the study period. Hypertensive diseases in pregnancy (HDP) mostly Preeclampsia/eclampsia (PEE) constituted the most frequently encountered 86/418 (20.57%) followed by ectopic pregnancy, 58 (13.87%).

Maternal Outcome after Management
Out the 418 patients, 412 (98.56%) were managed successfully with only 19.61% admitted in ICU. Six (6) maternal deaths were recorded giving a case fatality of 6/418 (1.4%) of obstetric emergencies and an MMR of 228/100,000 live births. The causes of death are summarized on Table 3.
Of the 418 patients, 336 (80.38%) were managed without admission in ICU. It must be noted that some of the patients who needed intensive care were managed in the routine wards because of limited places and equipment in ICU. Open Journal of Obstetrics and Gynecology Three diseases namely post partum haemorrhage (PPH), sickle cell anaemia (SCA), and preeclampsia/eclampsia (PEE) dominated the causes of maternal death with equal proportion of 2 (33.33%) each. The case fatality for PPH was 2/32 (6.25%), 2/4 (50%) for SCA and 2/86 (2.32%) for PEE.

Management Processing Time
As shown in Table 4, the minimal processing time was 10 minutes and the maximum 1140. The shorted mean processing time was recorded for abortions and the longest for sickle cell anaemia.  [14]. All the cases of maternal death were due to obstetric emergencies with 66.66% (n = 4) due to direct causes and 33.33% (n = 2) to indirect causes. It is well established that obstetric emergencies constitute the major causes of maternal deaths in LMIC.  Post partum haemorrhage (PPH) represented one of the most frequent causes of maternal death in our study (7.65%). Two out 32 patients who presented with PPH died, making a case fatality of 6.25%. Case fatality of PPH reported in LMIC varies widely (1.3% to 27.3%) with countries and levels of care and also when evidence-based interventions are implemented or not [15]- [20].
Ezugwu EC et al. reported that case fatality of PPH without evidence-based health intervention will be as high as 13.6% as compared to 2.5% when timely and standardized management is applied [16]. Determinants of death related to post partum haemorrhage include women's characteristics, pre-delivery maternal anaemia, lack of blood products, unskilled birth attendants, inadequate or no antenatal care, transfer from other health facilities, delays in management in the hospital amongst others [15] [18] [19] [20]. All the cases of maternal death recorded in our study were referred from other health facilities with critical conditions which warranted admission in intensive care unit. The role of poor referral system has been demonstrated by other authors in Cameroon like Belinga Etienne et al. [21] who quoted that 70% -90% of maternal deaths are due to referred cases according to Perrin in Benin.
Hypertensive diseases in pregnancy (HDP) (mostly preeclampsia/eclampsia) constituted 33.33% of maternal deaths (MD). According to WHO, HDP is one of the four main causes of maternal death (WHO report 2019) and Lale Say et al.
reporting a global maternal death causes according to WHO review found these to represent 11.6% to 21% causes of MD [10]. In studies conducted in tertiary hospitals in Cameroon, Tebeu [23]. Me-koya D. Mengistu, TilatumRuma and coll. reported no death in a retrospective study enrolling 156 cases of HDP in Addis Ababa. We attribute our relative good performance to many factors including: 1) The existence of management protocols in the service to which almost all carers are strictly bound; 2) The availability of skilled workers (obstetricians, midwife, and reanimators) when needed; 3) The availability of drugs (antihypertensive drugs, magnesium sulphate); 4) The Presence of an ICU where critical cases needing special attention are admitted though with insufficient beds and resuscitation equipment. In fact, our protocol of management recommends, in accordance with the state of the art in developed countries that all cases of severe preeclampsia and eclampsia be admitted in ICU and hospitals with obstetric units should have an obstetric ICU [24] but we could not achieve this objective because of the aforementioned reasons. This is a shortcoming in the management of emergencies in general and HDP in particular.

5)
Concerning the timing of management, the mean proceeding time was 61.53 ± 85.49 (see Table 4) with extremes of 15 minutes to 3 hours. American college of Obstetricians and Gynecologists (ACOG) recommends that expeditious management of confirmed severe HDP should be initiated within 30 -60 minutes [25]. Our proceeding time did not always fall within this timeline and delays of up to 3 hours were observed due to several factors including frequent stoke outs of emergency drugs, lack of financial means (payment was made out of patients pockets!) and at time absence of one or many members of the multidisciplinary therapeutic team.  Tanza-nia [30]. This high mortality can be explained by the reduced number of cases, the fact that patients were all referred in critical conditions but also can delineate the suboptimal performance of our ICU which is not specialized in such diseases.
The other diseases were successfully managed with some mild adverse maternal outcomes but no maternal death. Contrary to other studies carried in Cameroon and other sub-Saharan countries which displayed an important contri-bution of abortions (up to 25%) and sepsis, Ectopic pregnancy to maternal death, we recorded no death for these conditions. Although we attribute the relative good performance to the limited number of our sample size, the role of enough qualified staff, the relatively good plateau technique, the availability of management guidelines appear to be contributing factors.

Conclusion
Obstetric emergencies were high in the DGOPH, representing 15.4% of all live births. The management of these emergencies resulted in a relatively low rate of adverse maternal outcomes and only 6/418 deaths were recorded making a case fatality of 1.43%. Of the causes of maternal death, the case fatality of PPH and HDP was comparable to the high performance hospitals in LMIC. Determinants of this performance include the plateau technique, the quality of personnel, the existence of treatment guidelines and an ICU. These findings suggest that the strategy of building reference hospital where "state of the art obstetric care" can be implemented is an important milestone in the attainment of the sustainable millennium goals.