"In vast areas of the world, in South East Asia, in Burma, in India, 'in parts of Central America, South America and Africa 50 million women will bring forth their children this year in sorrow, as in ancient Biblical times, and exposed to grave dangers. In consequence, today as ever in the past, uncounted hundreds of thousands of young mothers annually suffer childbirth injuries; injuries which reduce them to the ultimate state of human wretchedness. Consider these young women. Belonging generally to the age group 15-23 years, and thus at the very beginning of their reproductive lives, they are more to be pitied even than the blind, for the blind can sometimes work and marry. Their desolation descends below that of the lepers, who though scarred, crippled and shunned, may still marry and find useful work to do. The blind, the crippled and the lepers, with lesions obvious to the eye and therefore appealing to the heart, are all remembered and cared for by great charitable bodies, national and international. Constantly in pain, incontinent of urine or faeces, bearing a heavy burden of sadness in discovering their child stillborn, ashamed of a rank personal offensiveness, abandoned therefore by their husbands, outcasts of society, unemployable except in the fields, they live, they exist, without friends and without hope. Because their injuries are pudendal, affecting those parts of the body which must be hidden from view and which a woman may not in modesty easily speak, they endure their injuries in silent shame. No charitable organization becomes aware of them. Their misery is utter, lonely, and complete."

The obstetric vesicovaginal fistula in the developing world.

BACKGROUND: Obstructed labor is one of the common preventable causes of maternal and perinatal morbidity and mortality in developing countries. Africa has the highest maternal mortality in the world, estimated at an average of about 1,000 deaths per 100,000 live births. This study was conducted to assess the incidence, causes and outcome of obstructed labor in Jimma University Specialized Hospital. METHODS: Hospital-based, cross-sectional study was conducted on all mothers who were admitted and delivered in the labor ward of Jimma University Specialized Hospital from November 1, 2008 to April 30, 2009. Data was collected using structured questionnaire and checklist, and then analyzed using SPSS for windows version 16.0. 
RESULTS: The incidence of obstructed labor was 12.2%. Out of these 61.5% did not have antenatal care follow-up. Most of the cases, accounting for 145(81.0%), 160 (89.4%) and 170 (93.9%) were referred from health centers, visited the hospital after at least 12 hours of labor and came from a distance of more than 10 kilometers, respectively. The causes of obstructed labor were cephalo-pelvic disproportion in 121(67.6%) and malpresentation in 50 (27.9%) of the cases. The commonest maternal complications observed were uterine rupture in 55 (45.1%) and sepsis in 48 (39.3%) of the cases with complications. Forty-five point eight percent of fetuses were born alive and all had low first minute APGAR score. CONCLUSION: The incidence of obstructed labor was high with high rate of complications. The antenatal care follow-up practice was also found to be low. Improved antenatal care coverage, good referral system, and availing comprehensive obstetric care in nearby health institution are recommended to prevent obstructed labor and its complications.

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Incidence, Causes and Outcome of Obstructed Labor in Jimma University Specialized Hospital

Obstructed labour is still a major cause of maternal morbidity and mortality and of adverse outcome for newborns in low-income countries. The aim of this study was to investigate the role of individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda. A review was performed on 12,463 obstetric records for the year 2006 from six hospitals located in south-western Uganda and 11,180 women records were analysed. Multivariate logistic regression analyses were applied to control for probable confounders. Prevalence of obstructed labour for the six hospitals was 10.5% and the main causes were cephalopelvic disproportion (63.3%), malpresentation or malposition (36.4%) and hydrocephalus (0.3%). The risk of obstructed labour was statistically significantly associated with being resident of a particular district [Isingiro] (AOR 1.39, 95% CI: 1.04-1.86), with nulliparous status (AOR 1.47, 95% CI: 1.22-1.78), having delivered once before (AOR 1.57, 95% CI: 1.30-1.91) and age group 15-19 years (AOR 1.21, 95% CI: 1.02-1.45). The risk for perinatal death as an adverse outcome was statistically significantly associated with districts other than five comprising the study area (AOR 2.85, 95% CI: 1.60-5.08) and grand multiparous status (AOR 1.89, 95% CI: 1.11-3.22). Women who lacked paid employment were at increased risk of obstructed labour. Perinatal mortality rate was 142/1000 total births in women with obstructed labour compared to 65/1000 total births in women without the condition. The odds of having maternal complications in women with obstructed labour were 8 times those without the condition. The case fatality rate for obstructed labour was 1.2%. Individual socio-demographic and health system factors are strongly associated with obstructed labour and its adverse outcome in south-western Uganda. Our study provides baseline information which may be used by policy makers and implementers to improve implementation of safe motherhood programmes.

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Individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda

Obstetric fistula, a devastating complication of prolonged obstructed labor, was once common in the Western world but now occurs almost exclusively in resource-poor countries. Although much has been written about the surgical repair of obstetric fistulas, prevention of fistulas has garnered comparatively little attention. Because obstetric fistulas result from obstructed labor (one of the common causes of maternal death in impoverished countries), this study assesses the obstetric fistula problem using a framework originally developed to analyze the determinants of maternal mortality. The framework identifies and explicates three sets of determinants of obstetric fistulas: the general socioeconomic milieu in which such injuries occur (the status of women, their families, and their communities); intermediate factors (health, reproductive status, and use of health care resources); and the acute clinical factors that determine the ultimate outcome of any particular case of obstructed labor. Interventions most likely to work rapidly in fistula prevention are those that have a direct impact on acute clinical situations, but these interventions will only be effective when general socioeconomic and cultural conditions promote an enabling environment for health care delivery and use. Sustained efforts that impact all three levels of determining factors will be necessary to eradicate obstetric fistula.

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A framework for analyzing the determinants of obstetric fistula formation.

Background: Puerperal sepsis is one of the leading causes of preventable maternal morbidity and mortality. It is still ranked as 3 rd major cause of maternal deaths in our country. The objective of this study was to evaluate morbidity and mortality from puerperal sepsis and to identify its risk factors. Methods: This observational study was carried out in Ayub Teaching Hospital over a period of three years. All patients admitted with diagnosis of puerperal sepsis secondary to genital tract infection were evaluated with thorough details of history and examination to determine their demographic details, obstetrical profiles, presenting features, state of infectious morbidity, need for intervention and mortality related to puerperal sepsis. Results: Puerperal sepsis was 1.7% of all obstetrical admissions and 34.4% of postnatal complications. It was seen common among young patients of 15–25 years age, 61 (66.3%), of lower parity, 58 (63.00%), low socioeconomic status, 60 (65.20%), uneducated patients, 72 (78.20% ) , home deliveries, 68 (73.90%), prolong labour, 54 (58.60), prolong rupture of membranes from 48–72 hours, 68 (73.8%) and deliveries conducted by untrained birth attendants, 57 (60.5%). Puerperal sepsis morbidity was mostly foul smelling discharge, 23 (25%), retained product of conception, 41 (44.5%), peritonitis, 8 (8.60%), septicaemia, 4 (4.3%), pelvic abscess, 10 (10.80%), endotoxic shock, 4 (4.30%), disseminated intravascular coagulation, 2 (2.1%). Sepsis related mortality was 6/42 (14.2%). Conclusion: Puerperal sepsis is an important public health problem contributing to maternal morbidity and mortality. Majority of predisposing factors are preventable. Optimal antiseptic measures and careful monitoring are needed throughout the process of labour. Keywords: Puerperal sepsis, Maternal mortality, Rupture of membranes, Obstructed labour, Traditional birth attendant, TBA, disseminated intravascular coagulation, DIC

Puerperal sepsis - still a major threat for parturient.

Over a five year period (1985-1989) 527 cases of obstructed labour were recorded while 11,299 deliveries were conducted giving an incidence of 4.7%. The majority of the patients (59%) were primigravidae. The incidence of obstructed labour was much higher for the unbooked patients (33%) than for the booked patients (1.7%). Cephalopelvic disproportion was the greatest cause of obstructed labour (67%), while Caesarean section was the main method of delivery (85%). The leading complications of obstructed labour were puerperal sepsis (57%), post partum haemorrhage (15%), uterine rupture (14%), and genital tract laceration (14%). A maternal mortality rate of 32 per 1000 and a perinatal mortality rate of 294 per 1000 were recorded. Education of primary health providers and traditional birth attendants on the dangers of obstructed labour and the need for early referral is suggested to reduce the incidence of this condition. Governmental assistance is also required to improve existing health facilities so that antenatal and delivery services will be affordable to all pregnant women in the society.

Herbert Uchegbu

Papers

Incidence and management of obstructed labour in eastern Nigeria.