Sanitary Evacuations at the Maternity Unit of the Social Hygiene Institute (IHS) in Dakar in 2020 ()
1. Introduction
In Senegal, the maternal mortality ratio is estimated at 315 deaths per 100,000 live births in 2015. This ratio decreased by approximately 40% between 1990 and 2015 in Senegal. However, efforts are still needed for the Sustainable Development Goals, particularly in terms of the availability of emergency obstetric and neonatal care centres. This would allow a better organization of the Referral/Evacuation system. Indeed, in our developing countries, parturients encounter many difficulties when they have to be evacuated to a Maternity Hospital adapted to their level of risk. They make a real obstacle course before finding a reception structure. This observation led us to carry out this study whose objectives are to determine the frequency of evacuations, to specify the epidemiological and clinical characteristics of the evacuees, to evaluate the data of the evacuation, the care and the maternal-fetal prognosis.
2. Patients and Methods
Type of study
This was a descriptive and analytical retrospective study on obstetrical evacuations at the level of the Gynecology-Obstetrics Department of the Hospital Institute of Social Hygiene (IHS) in Dakar over the period from January 1 to December 31, 2020.
Patient selection criteria
We included all patients evacuated to the IHS in Dakar during the study period and whose records were usable.
Data collection and analysis
Data collection was made from patient files and birth, abortion and hospitalization registers. The data were analyzed by the EPI info version 3.5 software. The parameters studied were the socio-demographic characteristics of the patients, the gynecological and obstetrical history, the characteristics of the evacuation (reasons for evacuation, means of transport, number of transit structures), management and prognosis.
3. Results
3.1. Frequency
During the study period, we collected 1156 evacuees out of a total of 3507.
Patients treated in the Service, i.e. a frequency of 33%.
3.2. Socio-Demographic and Clinical Characteristics of Patients
The average age of the patients was 27.07 years with extremes of 14 and 46 years.
Patients aged between 20 and 29 were the most represented (51.73%). The average parity was 1.6 with extremes of 0 and 10 pares. The nulliparous (46.37%) were the majority. The majority of evacuated patients (99.6%) resided in the Dakar region, including 58% in the suburbs and 42% in the city center. Pregnancy was most often at term (63.54%) (Figure 1). The majority of patients (83%) were in labor.
3.3. Prenatal Follow-Up
The patients received had performed an average of 3 prenatal consultations with extremes ranging from 0 to 9 CPN. The majority of pregnant women were followed by a midwife (98.46%), most often in a health center (60.6%) or a health post (34.9%).
3.4. Evacuation Data
Reasons for evacuation
The reasons for evacuations were dominated by dystocia (21.54%) followed by premature rupture of membranes (17.21%) and premature deliveries (16.35%) (Table 1).
Level of the original structure
Patients came to us most often from health centers (55.05%) or hospitals (29.09%) (Figure 2).
The evacuation decision-making time was specified in 92 patients (8.21%) with average of 11.4 minutes and extremes of 0 and 259. On admission, only 176 patients (15.2%) were provided with an evacuation sheet. The service provider who provided evacuation was most often a midwife (96.6%). Patients transited on average through two health structures (extremes ranging from 0 to 7 structures) before reaching the reception structure. The evacuation was most often done with a private vehicle on the patient’s own means (91.96%). Only 87 patients (7.53%) were evacuated by an ambulance (Figure 3).
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Figure 1. Distribution of patients according to gestational age.
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Figure 2. Distribution of patients according to the structures of origin.
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Table 1. Distribution of patients according to reasons for evacuation.
Support data in the reception structure
In our study, the fate of the evacuees was as follows:
- 842 cases of vaginal delivery or hospitalization of a pathological pregnancy (72.79%),
- 275 emergency cesareans (23.83%),
- 6 planned caesareans (0.5%),
- 23 cases of laparotomy for GEU or uterine rupture (1.99%),
- 9 cases of medical treatment of an abortion with misoprostol (0.8%),
- and a valve examination in a single patient (0.08%) (Table 2).
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Figure 3. Distribution of patients according to the means of transport used for medical evacuation.
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Table 2. Distribution according to the future of patients evacuated (N = 74).
Prognostic data
Maternal prognosis
The average length of hospitalization was 2.3 days with extremes of 0 and 40 days. The majority of patients (99.4%) had evolved favorably and five patients (0.48%) were transferred to another department for more appropriate care. We recorded one maternal death (0.09%) related to late puerperal infection.
Fetal prognosis
In our study, we recorded 74 perinatal deaths and 1041 live births, i.e. a stillbirth rate of 71.1‰ live births. The causes of death were dominated by prematurity (24.7%) followed by pregnancy-induced hypertension or preeclampsia (21%) and perinatal asphyxia (19.8%) (Table 3).
4. Discussion
1) Epidemiology
In our study, the frequency of evacuees was 33% and most of them came from health centers (55.05%) or hospitals (29.09%). This proves that our structure is a
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Table 3. Distribution of patients according to causes of perinatal death (N = 74).
reference center in Dakar where serious pathologies of pregnancy and childbirth are taken care of. The average age of the patients (27.07 years) does not differ from those recorded in the literature. Indeed, Sylla in Saint Louis [1] and Maiga [2] in Mali found an average age of 26.83 and 26.17 years respectively. In our pronatalist societies, with early marriage, the age of parturients is relatively low, unlike in industrialized countries where marriage is often late and the age at first childbirth high. In our series, nulliparas were the majority (46.37%). Belinga [3] in Cameroon reported 40.5% of nulliparas. This predominance of nulliparas among evacuees is explained by the complications of pregnancy and childbirth, which are more frequent among them, justifying the need to carry out prenatal monitoring and childbirth in a surgical maternity unit. Indeed, the reasons for evacuations were dominated by dystocia (21.54%), followed by premature rupture of membranes (17.21%) and premature delivery (16.35%).
2) Clinical data
Nearly two thirds of the patients evacuated (63.54%) were pregnant. We recorded 29.68% of preterm deliveries and 6.77% of term overruns. These results are similar to the data found by Ciss [4] with 62.5% full-term pregnancies. The significant frequency of premature births recorded in our series is explained by the presence of a Neonatology Service in our structure, often justifying in utero transfers to the IHS for severe maternal or fetal pathologies.
3) Evacuation data
The reasons for evacuation were mainly dominated by dynamic and/or mechanical dystocia (21.54%) and premature rupture of the membranes (17.21%). Sylla [1] made the same observation with a predominance of dystocia (29.76%). Diallo [5] had found a higher frequency of bleeding. These situations, which often require a cesarean delivery or an artificial induction of labor, justify the evacuation of parturients and pregnant women to Maternities like ours where the technical platform is adapted to the level of risk. In our study, 15.22% of evacuations were made with a liaison form. This rate is lower than those found by Diarra [6] and Coulibaly [7] , which were 19.09% and 29% respectively. This document is very important because it guides the staff of the reception center and thus makes it possible to reduce the waiting times. Before being admitted to the Service, 21.83% of patients had gone through a structure and 3.69% of them through at least 3 health structures. This shows the major shortcomings in our referral-recourse system, which does not always obey the architecture of the health pyramid but rather the availability of hospital beds. We have indeed received 29.09% of patients from hospitals of the same level as ours or of a higher level. Transportation was most often done by a private vehicle (91.96%) at the patient’s own expense. This is due to the fact that in our hospitals there is most often only one ambulance for the different services. As the latter is often occupied, evacuations are done by taxi or private car, thus exposing the fetus and its mother to major risks of complications. Thiam [8] and Sylla [1] had made the same observation with respectively 29.3% and 41.28% of patients transported by means of a personal vehicle or a taxi.
4) Support at admission
In our series, the caesarean section rate among evacuees was 24.3%. This result is comparable to that found by Diallo [5] with 25.7% caesareans. This relatively high caesarean section rate among evacuees could be explained by the seriousness of the clinical situations which often justifies a caesarean delivery to save the life of the mother and the newborn, in particular dystocia. The WHO recommends a caesarean section rate of between 5% and 15% of deliveries [9] .
5) Maternal prognosis
In Senegal, maternal deaths often occur among evacuated women whose prenatal monitoring data and history are unknown. Several factors are incriminated, in particular the delay in the decision to evacuate, the poor evacuation conditions and the long delays in diagnosis and care in the reception structure. These are major obstacles to reducing maternal mortality in Senegal and in developing countries [1] . In our series, we recorded one maternal death (0.09%) which was largely inferior to the results found in the studies of Diallo [5] , Sylla [1] and Cissé [10] which were respectively 1%, 1.03% and 8.80% of maternal deaths. This low rate of maternal deaths that we have observed is due to the quality of the management of obstetric emergencies which is provided in our structure 24 hours a day, 7 days a week by qualified personnel. Other reasons are mentioned, in particular the availability of an intensive care unit for rapid and diligent management of serious cases.
6) Fetal prognosis
We recorded a stillbirth rate of 71.1‰ live births, far lower than that found in Thiam’s study [8] , which was 180‰ live births. These deaths were most often due to prematurity (24.7%), pregnancy-induced hypertension or preeclampsia (21%) and perinatal asphyxia (19.8%). These results are consistent with literature data. In fact, prematurity is the leading cause of neonatal death in our developing countries. Also, vascular-renal syndromes and their complications due to the risk of intrauterine growth retardation and induced prematurity expose the new to death.
5. Conclusion
Obstetrical evacuations are frequent at the maternity ward of the Institute of Social Hygiene in Dakar. Despite the often difficult evacuation conditions and the severe pathologies, the maternal and perinatal prognosis is relatively favorable.