Analysis of Maternal Mortality in Obstetrics and Anesthesia Resuscitation in 15 Years at Chu Point “G” about 389 Cases Bamako/Mali

Objective: Analyze the maternal mortality in the two departments of CHU Point “G” in Bamako, because of high maternal mortality rate in our country. Material and Methods: This was an analytical cross-sectional study on maternal deaths from February 19, 2005 to November 19, 2019 for patients admitted in both departments and who died during the pregnancy-puerperal period at CHU Point “G”. All the patients who died outside this pregnancy-puerperal period were not retained. The data were entered and analyzed using SPSS 12.0 software. The statistical test used was that of Chi2, the statistical significance threshold was fixed at 5%. Results: During our study, we recorded 389 maternal deaths out of 16,033 admissions in 15 years and 18,060 live births during the same period making a maternal mortality ratio of 2153.931 and a frequency of 2.426. At the end of our study, we noted that the frequency of maternal deaths was higher in 2014: 12.9% (50/389). The maternal death predominantly affected women aged of 20 - 24 with a frequency of 22.4% (87/389). The multiparity (166/389 making 42.7%), illiteracy (341/389 making 87.7%), the poor evacuation conditions (non-medicalized transport): 263/389 making 67.6%; the evacuation without any evacuation sheet: 259/389 making 66.6%), poor CPN (Prenatal consultation) quality (undone CPN: 191/389 making 49.1%) and the poor monitoring of delivery works (no use of partograph in 343/389 making 88.2%) were the factors favoring maternal deaths. The main causes of maternal deaths were direct in 231/389 making 59.4% with hemorrhage in first line: 21.1% (82/389), infection (61/389 cases making 15.68%), dystocia: 50 cases making 12.85% and high blood pressure and complications (38/389 making 9.76%); indirect in 158/389 cases making 40.6% (Figures 1-3). The majority of women 65.8% (256/389) of our patients died in the gynecology and obstetrics department; in the Resuscitation department 73/389 making 18.8%; in the operating room 43/389 making 11.1% and the deaths that were observed on arrivals represented 17/389 making 4.4%. In our study, 10.3% (40/389) of our patients died in the antepartum, 57.1% (222/389) in perpartum, and 32.6% (127/389) in the postpartum (Figure 4). The need not covered in blood transfusion represented 91.5% the cases either 356/389. Conclusion: The frequency of maternal deaths is very high in our country. Reducing the rate of maternal deaths requires improving the SONU (cares obstetrical and neonatal emergency).


Introduction
The death of a woman in the pregnancy-puerperal period is still experienced as a tragedy. Expecting a child, giving him birth and hugging him are the wishes of every woman. Pregnancy if it is well carried out, leads to a live birth, and constitutes for women a criterion of social valorization. However, for thousands of women, giving birth is not the cause of exhilarationas it should be, but rather a suffering whose outcome can be fatal. The death of a woman is a terrible loss, despite the silence, not only for the family but also for the community and the whole nation [1].
The level of maternal mortality has become an indicator of the performance of the health care system because the visible part of the interventions that prevent maternal death is completely managed by the health services. However, we must look beyond and consider that the maternal death is the result of a chain of dysfunctions and lack of resources, which depend on the factors situated outside the health care system [2]. At the dawn of the new millennium, in the world which is experiencing an unprecedented economic growth and technological progress, there is still an alarming number of women who die during the pregnancy, deliveries and its outcomes [3]. In 2015, 303,000 women died during the pregnancy-puerperal period, approximately 830 women died every day from preventable causes related to pregnancy and deliveries. The maternal mortality ratio in developing countries in 2015 was 239 per 100,000 births, compared to 12 per 100,000 in developed countries; 99% of all the maternal deaths occur in developing countries, more than half of them in South Sahara Africa. It is the region in which the maternal mortality ratio is the highest representing 542 per 100,000.
[4] In Mali, several efforts have been made in the fight against the maternal mortality: The report of mortality linked to pregnancies has decreased between 2001 and 2018 from 582 per 100,000 live births to 373 per 100,000 live births in 2018 [5] [6] [7] [8].
The Sustainable Development Goal (SDG) 5 between 2016 and 2030 is to bring the global maternal mortality rate below 70 per 100,000 live births [3] [4]. Despite that some progresses have been made, the maternal mortality rate remains high in our country, hence this work is to contribute to a decline in the rate of maternal mortality with the objective of analyzing the contributing factors and the causes of maternal mortality in the two departments at CHU Point "G".

Patients and Methods
This was a cross-sectional analytical study on maternal deaths from February 19, 2005 to November 19, 2019 in the gynecology, obstetrics and anesthesia-resuscitation departments of CHU Point "G". The population we studied consisted of all the pregnant women we received and cared for during the study period. Were retained in our study, all the patients admitted in the gynecology and obstetrics department and who died either in the gynecology and obstetrics department or in the anesthesia and resuscitation department during the pregnancy-puerperal period. We excluded all the living women and those who died outside the pregnancy-puerperal period. The variables we studied were the frequency, age, marital status, occupation, antecedents, prenatal consultation (CPN), the parameters of evacuation, the factors favoring maternal death, the causes of maternal death with as of information collecting sources: an individual survey form, obstetrics admission registers, operation reports, obstetric records/files. The data were entered and analyzed using SPSS 12.0 software. The statistical test used was that of Chi-square, the threshold of statistical significance was set at 5%.

Results
From February 19, 2005 to November 19, 2019, we recorded 389 maternal deaths out of 16,033 admissions and 18,060 live births making a maternal mortality ratio of 2153.931 and a frequency of 2.426. The ratio of the maternal mortality in these 15 years was higher in 2007 with 5413.105 (38 maternal deaths and 702 live births). The highest frequency of maternal deaths was recorded in 2014 presenting 12.9%.
The 20 -24 age group was the most frequent in our sample: 22.4% (87/389) and there was a relationship between the age group and the period of death and the duration of stay in the service with Khi 2 respectively: 11.32; P < 0.05 and Khi 2 : 25; P < 0.05 [9] ( Table 1). The housewives represented 87.4% (340/389) of our sample. They were uneducated in 87.7% (341/389) and were married in 93.3% (363/389) ( Table 2). We found a relationship between marital status and the period of death with Chi-square: 10.16 and P < 0.05. The spouses were mainly farmers with 28.3% (110/389) and uneducated in 64.8% (252/389). In our study, Open Journal of Obstetrics and Gynecology  (World Health Organization) and the midwives were the authors in 32.4% (127/389) of the cases. In our study, we have found a relationship between the prenatal consultation and the death service with Chi-square: 13.27; P < 0.00. There was also a relationship between the quality of prenatal consultation and the causes of maternal death with Chi-square: 16.64; P < 0.05. The partographs were used for monitoring delivery only in 11.8% (46/389) of the cases, and there was a relationship between the use of partographs during the delivery works and the period, causes, and service of maternal death with Chi-square respectively: 49.97; P < 0.001; Chi-square: 42.41; P < 0.001 and Chi-square: 8 (Figures 1-3). In 65.6% (255/389) of the cases the patients were cared for within 24 hours and there is a relationship between the care times and the maternal death service with Chi-square: 10.08; P: 0.03. The blood transfusion needs were not satisfied in 91.5% (356/389) of the cases. In our study, 10.3% (40/389) of our patients died in the antepartum, 57.1% (222/389) perpartum, and 32.6% (127/389) in the postpartum (Figure 4). The majority of women (65.8% (256/389) of our patients died in the gynecology department and obstetrics. The patients died within 2 hours after admission in 99.5% (387/389).

Discussion
During our study we were confronted with many difficulties between other incomplete files, badly informed, badly archived, registers and lost files.     702 live births). In developing regions, the maternal mortality rate is 450 maternal deaths per 100,000 live births, compared to 9 in developed regions [10] [11]. The highest frequency of maternal deaths was recorded in 2014, 12.9% in our study.
2) The sociodemographic factors: In our study, the 20 -24 age group was the most frequent in our sample: 22.4% making 87/389 patients, but all the age groups were represented. There was a relationship between the age group and the period of death and the duration of stay in the service with Khi 2 respectively: 11.32; P < 0.05 and Khi 2 : 25; P < 0.05 (Table 1). Koudjou T. andcoll found that the age group 20 -24 was the majority presenting 41.09% [12]. Boubacar B. and all in Senegal found that the age group 16 -20 years was the most represented. These figures show that young and very old women are at greater risk of maternal death, so early and late childbearing negatively influences maternal mortality [13]. A study conducted in Nigeria showed that the maternal mortality rate was 7 times higher among women aged of 15 years old than those aged from 20 to 24 [14]. A study carried out in hospitals in Tunisia found that the maternal mortality rate was 33.72 per 100,000 live births and that primiparity, multiparity, unfavorable socio-economic conditions, risky pregnancies and poor follow-up of pregnancy are the risk factors for maternal mortality [15]. In our study, the ethnic group which constituted the majority was Bambara with a frequency of 48.8% which is the majority ethnic in Mali ( and 81.60% respectively [18]. According to Caldwell [19] educated mothers, more than those who are not, tend to use modern health services for both prevention and curative cares in case of illness. T and all found that 89.04% of the patients were evacuated [12]. Boubacar B. and all found that 60% of the women came from rural areas and 40% from urban areas. This also shows that in rural areas the problem was very important because the factors linked to customs, traditions and delays are more serious [13]. The patients were evacuated in 66.6% of the cases without any evacuation sheets and 67.7% of the cases without any medicalized means of evacuation (Ambulances) in our study. We found a relationship between the means of transport and the period, the service of death with respectively Khi 2 : 11.98, P: 0.01 and Khi 2 : 06, P: 0.01 (Table 3). The itinerary from home to CHU-Point G without passing by CHU GT (Gabriel TOURE) constituted the majority making 27.5% of the cases in our sample and we found a strong correlation between the distance and the period of death and the death service with  [23].

4) Support
In 65.6% of the cases in our study, the patients were care for within 24 hours and there is a relationship between the care times and the maternal death service with Chi-square: 10.08; P: 0.03. Moussa A. and all showed that 71.1% of the patients were cared for/treated before 24 hours [21]. The majority, 65.8% (256/389) Open Journal of Obstetrics and Gynecology of our patients died in the gynecology and obstetrics department; In the study led by Moussa A. and all 76.7% of patients died in the gynecology department [21]. The patients died within 2 hours after admission in 99.5% of the cases according to our study. In our study, 10.3% of our patients died in the antepartum, 57.1% in perpartum, and 32.6% in the postpartum. Moussa A. and all found 27.3% of deaths in the antepartum, 8% in the perpartum and 64.7% in the postpartum [21]. The study in Tunisia has shown that all deaths have occurred after delivery, 60% in the immediate postpartum [22]. The blood transfusion needs were not met in 91.5% of the cases.

Conclusion
The maternal mortality remains high in our services and constitutes a major public health problem. It reflects the dysfunction of our health system, namely the problem of qualified personnel, the technical platform of health structures, and the dysfunction of our referral/evacuation system. Reducing the maternal death rate requires improving the SONU.