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A PROSPECTIVESTUDY OF EARLYPUERPERAL MORBIDITY IN KUMASI.

GHANA

BY CISYLVIADEGANU$-AMORIN

A thesissuhai t te d to theSchoo l of Gradu ate studiesin partial ful filil entof the

re qu i r eme nt sforthede gre eof Ka s t er of Sci ence

Di vi s ionof co_uni t yMed i c ine Facultyof Medi c ine Memo ri al unive rsi ty of NeWf oundland

1992

st.John's Newfou n dlan d

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ABSTRACT

The objectives or this study were to; (1) describe the incidences and determinants of early puerperal morbidities in women in Kumasi; and (2 ) provide information for use in improvingthe postpa rtumhealthcare of thesewomen.

A cohort of 472 women from home, who had vaginal deliveries at the KomEa Anakye hospital in Kumasi, Ghana, were recruited and followed up during theirearly puerperalperiod.

Morbidity was assessed through interview, physical examination and haemoglobin investigation. An overall 81% follow-up rate was obtained. Forty-eight percentof subjects scheduled for fallow-upfailed to attend the special clinic and had to be tracedtotheir homes.

The SUbjects were mostly from low socioeconomic levels.

Their mean age and parity was 25.4 years and 2.8 dejfve r Loa respectively. While three-quarters of them (78.4%) had at least one identifiablepregnancy or labour risk factor (nearly 40% were anaemic at labour) they had relatively uneventful deliveries.

Nine out of everyten womenseen postpartum reported at least one heal thcomplaint. The most frequent symptoms were fever(28%), abdomina l pai n(64%), perinealsoreness(3U)and

i l

dysuria(26 %).Nearly 60% of the study women sel f- trea tedwith potent medica tions ra ng ing from analgesicsto antibiotics.

On assessment, 66.6% of the wone n discharged home routinelyafter delivery, were found tohave at le a s t one puerpera lhealthcomplicati onrequiringme d i c al attention.In 46%of sUbjectsmorbiditywasse ve r e enough to warrantmedical attentio nwithin72 hours or less.The incidences of puerperal uppe r and lowe r genitaltract infection in the study sample were180 and 151per 1000 de l i ve r i e s res p e c t ively. Postpartum anaemia occurred in 35.1% of women. The inc i dences of postpartumhype r t e ns ion, acute urinary tract infection, and mastit iswer-e88.2, 52 . 2 and 13.1 per 1000 respectivel y .

The findings in this study suggest that high rates of puerperal compli cations occur in women in Kumasi who are discharged homein a"s a t i s f a c t o r y"healthconditionwithina few hours after delivery . Postpartum health care services sho u l d address this need. I t is recommended tha t: (1) a routine earlypostpartum clini c be or gani s e d for all women dischargedhomewithinhours afterdelivery ;(2) womenreceive healtheduc ati onabout thehazardsof self-medication,and (J) further at t e ntio n be paid to identify i ngthe determinantsof the specifi cmorbidities.

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ACKNOWLEDGEMENTS

I ack no wledgethehe l p oftwo very efficient la d i e s ,Ms' Catheri ne Nor t eyand Gladys Anko mall, indata coirect rcnfo r th i s at.udy , My tha n k s also gotothe doctors and nurses of the depar tme n t of Obste tr icsandGynaecol ogy , Komf a AnokyeTeach- ingHospita l andth e Mate rn a l and ChildHealthCare Centre in Kuma si, Ghana.They contributedin many ways to the success ful outcome of th e enudy, inspiteof the inconveniencesit caused them.

ToProfessorHu t t on lIddy and st affof theDepartment of

Communi ty Me d i cine, Sc hoolof Medical sciences,University of Science andTechno log y(UST), I expressmy sincerethanks. Tho transport an d log istic support th e y provided ensu red the success fu l ou t co me of theseudy, I also thank Mr Akuayi,UST Hospital, for taking time to analyze th e numerous blood eenpiee coll ec ted intheeeuey •

Thisstu d y wcul.d not have be e n poss ible wi th o ut generous donatio ns of labora to r y supplies and drugs from Becton- Dicke n s on, St.Jo hn' s , Cana da,andUNICEF, Ghana. I amind e ed grate f u l to thetwoorga n isations.

Ver y sp e c i althan k s go to my supervisors, Doctors Robin Mo or e-Orr , Lynn Mc Inty r e,JorgeSe govia and Derek Matthewfor th eirenco urage men t , sup po rtand use fu l sugg estionswhic hnot

iv

onl y gre at l yenri ch e dthe su bsta nceof thisdocum e nt,but also enric hedmyexperi e nces ofgr aduate study.

I thank Iloll staff at th e Divison of CommunityMedicine.

Theirkind ne s s and suppo rtdurin g the time r hav e be en wi t h themhas seen me throu gh. Man y ot her individuals have in vario us ways alsocontri b uted to the successful outcome of this study. They cannot al l be men tioned he re. r however extendtothe m all my si ncere than ks .

err», through the Kumasi/Da lhousieProject funded mein thisgra d uate programandga ve me the opportu nityto enhance my educatio nand tocarryout thisres earc h. I thank them fo r thischa nce.

Lastly, but not the lea st, I extend my tha nks to the women of Kumasiwhopart i c i pate din thi s study. It isthe y who made the st udya success and who ha v e contr i bute dto a future ofhop e for mo t h ersinGha n a.

Page ABSTRACT. • ..•.• •. ••••.•••. • ••. •••• • .•.•. i i lI.CKNOWLEDGEMENTS.••. •••• ••. . ••.••.• •.... iv LIST OFTABLES . ... . .... ... .. . .. .. .. viii LI ST OF FIGURES.• • •.• ••••• .. .• .•... • .••. CHAPTER 1 INTRODUCTION •.•••• •.• . ... ..•. CHAPTER 2 BACKGROUND INFORMATION•.•..••.

2.1 The country and study area... 6 2..2.The study cente r... ... . ... . 11 2.3 Matc.mal health in Ghana... 14 CHAPTER J LI TERATURE REVIEW... . 18 J.1 Puerperal mortality.. .. ...•• • •.• 21 3. 2The puerperal morbidities .... ... 27 3.2.1Infectious morbidities .. .. . . 27 3.2..2. Non-infectiousmorbidities. . 52 CHAPTER 4 METHODS•.••..•• • • •..••••.•• ••.

4.1 Studydesign... ..•. •.••• .•• •.. . 79 4.2 Study objectives..••.•.• . ••.• •. . . 79 4.3 Planni ng &the considerations. ... 80 4.4 Study subjects... .. ... 81 4.5Enh a n cing participation. . ... . .... 83 4.6 Baselineda t a... ... . 84 4.7Follow-upassessment... 85 4.8 Operat ionaldefinitions..••.• . .• . 89 4.9 Non-attendingsubjects...•• • . •.•• 91 4.10 Laboratory investigations... .. 93 4. 11 Data management&ana l y s i s.... . . 94 CHAPTER 5THE RESULTS... . .. . .. .. .... .. .. 100 5.1 Ba s e l i ne characteristics... 102 5.2 Follow-up&morbidity....••.••.. . 118

!i.3 Incidenceof morbidity... ... . 146

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5.4 De t e r mi nan t s of morbidity. .. ... .. 155

5.5 He a l th complai nts&:::l i nic... . 168

5.6 other study dat<1'.. . . . ... ... 170

CHAPTER6 DISCUSSION&RECOMMENDATIONS.. 173

6. 1Thediscussion .... ... ...• 173

6.2 The liml tations.. . .. . .. .. . . ... 207

6.3Conc lusions&recommendations... . 215

REFERENCES... . ... ... ... ... 218

APPENDICES.. ... ... .. .... . . .. ... 239

A: Mapof Ghana &study area... 239

B:Study iden titycard... ... 240

c: st udyForm A. .... ... . ... ... 241

0: Study Form B... ... ... . 24 3 E: Definitionofterms... . . . .. ... 248

F: Results of multivariateregression analysis ; paramete r estimates... 252

G: Resul tsof multivaria te re g r e s s i on an"lysis ; Correlatio nnatrices... . . 253 1-1: Determinants of UGTI;Results of univariateanalysis 254 I: Predictorsof UGTI; The Correlz.tionmatrices .•.... •. .. 255

J: Determinantsof po stp ar t u llI anaemia; Resultsofun i v ar iat e ana lysis.... 25 6 K: Thepr e dic t o r s of postpar t umanaemi a Thecorrela tionmatrices. ... .. 25 7 L: Determinantsof Postpartum hyperten. Resu l tsof univariateanal ys is 258 M:Thepredictorsofpos t p a rt um hyperten ;Th e correlation matrices•.•.•.. . ... 259

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LIST OF TAB LES

Table 1.1. The ett n i<::groups of study participants.

Table1.2. The educational levelsof study partic ipants. Table 1.3. Theoccu pa t i o n s of study participan ts Table 1.4. Antenat;:l,lcare: Gestati on at onset and qualit y

of care.

Ta b l e 1.5 . Pregnancy and labour risk factors in study participants.

Table 1.6. La bo u r and it s complicat ions instu d y parti c ipants.

Ta b l t.!2.1. Reaso ns for ad mi s sio n in the24 hos p i t ali sed patients.

Table 2.2. Reason s given by no n-a t t e nde r s for not attend ing the morbid!ty clinic.

Table 2. 3. p-vetues obtainedonunivariate co mp aris o noC baseline character.isticsof the dif fere ntqroup u of study SUbjects as regards clini cat.t. enocnc e and follow-upoutcome .

Table 2.4. Medicati onsused by SUbjects for self -treatment.

Table 2. 5. The characteristicsof lochiaas reported by study SUbjectsatIrrtervj.ev,

Table 2.6. Other he a l t hco mp l a i nt s re p o r t e d by par t icipant s at inte rvie w.

'l'able2.7. The distributionof body temp eraturesof subjects at examination.

Table2.8. Abdominal findings on clinical examination. Table2.9. Lo c h i a findings at clinical examination.

Table2.10 Other pathological findings in thirty-one subjects.

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Ta b le 2.1 1 Diag nos esin tre a tedan d/o r re f e r r e d study euej ec es .

Table 3.1. The cla s sif i c at i on ofmorbidityinstudy sUbjectsby degre e of seve r ity .

Table3.2. Summary tab le of the incidence and preva lence rate s of spe cificpo s tpar t um he a lth compl.icatio ns notedinthis st udy. Table 4.1. Pred icto rsof up p e r genit altra c t infec tlO:ll

Res u l t s of mul tiva ri a t e logi s t.i.e regression anal ysis.

'reore4.2 . Pr edictorsof postpartum anaem ia: Results of a multiva r iatelogistic regressionanal ys is.

Tabl e4.3. Predicto rsof pos t pa rtumhypertension:Re sul t s of mu ltiplereg ression ana l y s is of 8 basel ine var Lab.tes•

Table 6.1. The Ind LcetiIons for emerge n c y caesarean section in subjectswho came from ho me to deliver.

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LISTOF FIGURES

Figure 1.1 Flow chart of suu:iectrecruitment and follow- up.

Figure 1.2. Age distribution of study SUbjects.

Figure 1.3. parity distributionof SUbjects.

Figure 1.4. Antenatal care.

Figure 1.5. The distribution of pre-deliveryhaemoglobin levels in studysubjects.

Fi g u r e 2.1. How SUbjects ranked their health postpartum. Figur'O! 2.2. The occurrenceoffeve r and its management in

SUbjectsdischarged home.

Figure 2.3 . The day of feveronset reported by SUbjects.

Figure2.4 . Occurrence of lower abdominal pain and its management in sUbj ect;s•

Figure 2.5. The distribution of postpartumhaemoq Lob Ln leve.\s in study subjects.

Figure2.6. Changesin haemog lobin re v e r af t e r delivery.

Figure3.1. Postpart'Jrn heal thstatus of subjects successfullyfol lowed-Up.

Figure 5.1. The associationsbetween health cumplaints of study sUbjects andattendance to the post.pa rt.um clinic.

CHAPTER1 INT RODU CTI ON

Asmo r e in formatio non the high mat erna l death ra t e s in thedevelopi ngworld ha s become av aila b le , worl datt entionhas beendrawntothe neg l ecte dtrage dyof mate r na lill-he a l t h and deathin th e s e disadv a ntagedcoun tries (1 ] . It is estimated tha t half u mi ll i on women die fr om pregn a n cy-re l ated causes eachyear world wide; 99%of the s e occurinthe dev elopi ng cou ntr iesat' Af ri c a , Asia and South America (1). In Africa, th e cu rre ntl y es t i mate d mate r nal deathra teis 6.4pe r 10 00 , as compa redwit h rate s of lessthan0.1pe r 1000inEuropeand Nort hAmerica[2, 3 , 4 ] . Infa ct acme studieshav e even recorded ratesof 20 per10 0 0 in some partsofth e Africa n co n t i n e n t [5].In today'sworld , the s ehorrif i c mate r na l dea t h ratesare remin iscent of rates in pre- n t ne eeeen ce nt u r yEu r o pe [6,7], and child bear ing rightl y desc ribed by some as still a dange ro us qarabje fo r the seunfortunatewo me n (8 ] .

Deaths are jus t the tip of the ice berg of maternal suffering. It is es t i ma ted tha t, fo r every woma n who dies another 10 to 15mor e suffe r se vere hea lth cons e qu e nc es from their preg nancies [9]. InAfrica an est imated two to thre e millionwome nare belie ved tobedisabl e d or incapacitated to var yi ngde grees by pa st;pregna ncies [1]. Some ofthe s e women describedas the liv i n g dead, onl yconti n ue to live at th e

fringes of health and silently bear bitter social and pc e-eoncf consequences.

The actual extent of the problem of maternalill-health in Africa is sti l lnot known however, because data <Ire lacking from many par-ts ofth e conti nent. The majority of the data available describethe direct causes ofmortality, eapec Ie Lf y peri-partumdeaths and morbidity during pregnancy.Data on the health of the women who have apparently "s uc c e s s f u ll y "

survived labourare scanty.

The few studies that hav e looked at the puerperium in Africa have shown the significant contributiondeaths in the puerperium make to the overall high mortality rates 1n tt.e region [5,10]. These mortality findings suggest too that significant morbidity occurs in the pu e r pe r i um on the continent. The findingsof some hospital-basedstudies which indicate that postpartum complicat ions such as infection, anaemia, haemorrhage and vesico-vaginalfistulae account for a not i c e a b l e proportion of admissions and deaths in gynaecological wards, furthersupport this view [8,11].

Since th e time of semmelwies, the role that unhygienic labour managementplays in contributing to maternal morbidity and mortality has been well known 1 this situation re ma i ns common inmanypartsof Africa [12J.Of note too, isthe fact that in some African societies, the puerperium is characterisedby traditional cultural practices that could

impair mater nalhealth[13]. The already existingburdens of ende micinf ect i ousdiseasesand malnutritionwhich plague the health of these womenfurt h.er add to theseodds. When all the above h.a zards are conside r ed , high rates of puerperal morbidity ca nbeexpected in the region.

The lack ofac c u r a t e dataonpuerperal healthsta t us of African women however,ha s createddifficultiesin jUdgingthe extent and severi ty ofpuerper a l morbidi ty , and has impaired the planning of health mea sures to deal with the pro blem . Postnatal car e onth e continent is generally de f ic ient and appe a r s tobe laggingbehindother aspectsof obstetric ca re (14). If maternal li ve s are to be sav ed, this aspect of mat ernalhealth needsto be moreclose lyexamined.

The majority of deliveries inAf ric a,particula rl y in the rura l areas, still occur at home and data onth e s e lilrouP of womenare veryhard toobta i n. In urban Afr ican commun ities howe ve r there is a rapidly increasing trend for wome n to deliver at health centers [15J . Despite this chan ge , inform ationon the puerperalhealthof even these"fortunate"

woman is still not forthcoming, as postpartum mon itoring remains inadequate.

In Ghana, the great demands on the very few urban obs't etr Lc facilities, haveresultedinwomenbeingdischarged homefrom most centers withina few hours of delivery.Reports indicatethat thissituationprevailsin many ot herdevelop-

in9 countrie s [6,16 ] . Th e pre sent postna ta lhealthcar esystem in the Ghana , is that inh er ite d wit h th e int r o duc tio n of western medic ine ,wh e r ewome n areseen at theend of thoirsix weekpuerperal peri od. InEurope,whe rethis pr a ct i c e evol ved , womon are kep tin hos p i ta l forse veraldays after deliveryand therefore any earl y pu e r pe r a l comp j Lc a t Lons are quickly ide ntifi e dand deal t withbereredischarge.

In Gha na ,wome nmanage th ei r puerperium intheirownwa ys with only the occasiona l war nings issued bythc dischargi ng hospita lmidwivesto guidethe m.The experienceDfthisauthor and othersisth at , once home , these voneninfluencedby their pe ers , fr eque nt l y resort tic tradi tional puerperal care practicesuse d bywomenwho delive rat hone (9,13} .ND other postnat a l moni tDri ng occurs , and if the women do not report with cc mp j.Lc a 't .Ion stoa he alt h facility , thentheir heal t h stat us during the critical period of the puerperium is unk no wn.

At SlX weekspostpa rtu m,th ey may reporttoth e specially organisedmatern a l and child post - natal clinics , a combined clinicwherethei r inf a nts also re c e i v e their first vaccin- at ion s andgrowt hmonitor ing . The expe r i e nceof this au t h o r, is however-that the maternalcomponent;ot:theclinicis often neg lectedin favo ur of childhealt h.Thisfact isev en evident in the way mot hers refe rto this clinic, as "Weighing".

ManyAfricancountries likeGhana,are takingmeasuresto reducethe unnecessa ry tollof mate rnal ill-heal t hand death.

To achieve their aims, however, they require accurate and detailedinf o r ma t i o nonthema t erna l healthsituationin each specificarea. Thisprospect ivecohort atrudywascarriedout primarilyto descri be the pue r pera l heal th status of womenin Rumasi, to identifythe predomi nant ca us e s of il l -hea lth, and to provide informat i on forus ein impr ov ing postna talhealth care. If we believe however thattheseurban womenhavebetter access tohea l t h and obstetriccare than their counte rpa r tsin the rura l area, then the findings may be of benefit in estimating the extent of puerp eral morbidity in the less fortunate rura l group , and cou ldassist health care providers tota ke necessar ymeasuresto allev iate the sUfferingof all mothers inGha na.

The socioeconomicproble msandheal thsystem inadequacies described in th i s paper areals o simi larto thos e found in manyother urban communi ties ofthede ve l op ingwo rl d , and the results of this stud ycould well app ly to the m, and be of relevance.To quo t e Dr.Ha l f danMa hle r , the former di r e c t or of tho World Health organisation:

"Ifwe are ef f e ctive l ytoappl yexistingkncwI edq e in a wide rangeof dif fe rentcon ditio ns,muchfur the rresearch is es se nt i al. In ea c h countryIs ctrcuneeencee the preventablecausesof maternal deaths mus t be clarified and the pot entialfor improveme ntinthat country 'sown context mustbe identified " [9].

CHAPTER 2

BACKGROUND INFORMATION

2•1.: THE COUNTRYANDSTUDY AREA

GHANA: Thecou nt r y, is located on the westcoast of Afr i c a , between latitudes4.25to11 . 11 degreesnorth of the equa t or and longitud e s1.14east to 3.03degre e s we st. Itha s atotal area of 23 8, 5 3 9 squ are ki lometres. A.former colony of the Br i tish Empire, i t was called Th e Gold co a s t; in i ts pro- independen cedays (APP ENDI X A)•

Ecologicall y the country isdiv i d e d into 3 mainzones namely : th e co a sta l aav an ne h, the cl osed forest, and the nor t h e r n sav an na h .Thecl im a t e istrop i c al, withtempera t u re s ra ngi ng betwee n25-3 0 C most oftheye ar.Th e r earetwoma jor seasons of theyea r , the rainy and the dry. The amount of rainfall general lydecreasesas one mo ves fromsou t h to no r t h.

Theto tal populationLs presentlyestima t ed tobe about 14.6million with an annual growth ra t e of 2.6t (17}. More than sotof the tot alpopulationlives inthe south ernhalfof the country.LikeotherpopUlationsofthe developingwor ld, GhanaIs popuLatiLon is characterised by it s youch EuLnensr child r e n aged0- 15 years comprise47\ofthe totalpo pUlat i o n;

women of childbearing age comprise about 20% (17 ) . Other he a l t hand demographicindicatorsareasfollows [17 -2 0 1:

Sex ratio (M/F ) (1989) 0. 9 8 Rural tourban population {t).•... 69.3 1 population densityper sq.km. . .. . . •...52

GNP per capita (us $)(1990) 461

Percentageliterate (age>9yrs )1990 male 61 female 51 Lifeexpectancyat birth•...•..average 56 years male 53 year s female 57 years

Crude birth rat e 42 pe r 100 0

Cr ude deathrate 11 per 10 0 0

To ta l ferti l ityrate ... . .. . •. . . .. ..•. .... 6.4 Infantmortality rate(1988)..90/1000 live births Ma ter n a l mortality rate .•.5-10/1 00 0 livebirths Physi cianpopulation ra t i o(198 8 ) •. . ••• 1:15,130 Popu,acces sto heal thservi ces (t)...Urban92 Rural45 Total 60

Ethni c gr oups: Although there are more than 90 minor ethnic gr oups in Ghana, the population can be classifi ed into two majo r la ng ua g e groups . TheKwa in the south comprising mostly of Akans (44%), Ewes (13%), and Ga-Adangbe (8%). The Cur in the no r t h comprisingof the Mole-Dagbani(16t) ,Grushl( 2%), and Gruma(4%) [19].

Twotraditional sys temsof inh e ritanceareprac ti s ed by the tribes intheco u nt r y, matriline ",l and patriline al. The forme r is practisedentirelyby theAk a ns , Whilst the latter is practisedby all the other eth nicgroups.

Religion: 'rtu- e e types of religious practices exist inth e country, Chri s tia n i ty 50%, Traditional 22%, and Islam 14%

(1 9 ].

oc c;; pati on : Farming is the si ng lemost imp o r.t a n t occupation for the majori tyof Ghanaians;over 61% e rc invol vedinsmall scale fa r mi ng [20].

Admini strati v e st r u c t u re: The country is divided into 10 adminis t ra tiveregionsandeach regionis furtherdividedinto distric ts. In all there ar e 110 districts presently. In coexiste nce within this modern structure however are also tradit ional ad mi n i s t rat i v e areas of "c hi e f doms" whichplay important admini s t r a t i ve rolesat the community le ve l (19].

J\,SH1I.NTI REGI ON: This re g i on whichis cent ra llylocated inthe co untry , has an area of 24,390 sq.kmand a pop ulatio nof about 2.4million (a bout17% of nationa lpopu lation)with an ann ual

growt hrateof 2.5%[21].It is divided into 18 administrat ive districts, including Kumasi district, the lo c a t i o n of tl;ll

present study .Geographicallythe region fa l l s predominan tly inth e tropical deciduousforest zonewit h a maxi mummonthly rain fall level of 310 millilitresin June.

It is inhabited mostly by the Ashanti, who form the largest ethnicgroupvithinthe Akan linguistic group, anda fe w othermigranttribes. The Ashanti areape op l ewith arich cuI ture and histo ry , and are notedfortheir legend aryGolden Stoo l. Ruled by a powerfulki ng,the Asanteh ene, theAshant i in the past conquered manyne i g h bou r ing groups and createda po we r f u l kingdom.

Like other Akans, they have a matrilinear system of inheritance.This systemof inheri tanceappears to grantwomen more political and economic rights than does the patri l ineal systempractised bythe other tribes [19 ].

In Ashanti cul t ure, life 's experiences are taken ve ry seriously.Eventslike death, ill -healthand infe rtili tyare viewed with suspicion. Pregnancy , labour and the puerper ium are co nsid e r e d spec ial milestone s and are markedbysp e c i fic norms and practicesaimed at protectingthehealth ofmo t h er an d child. For in s t a nc e, to mark a successful outcome of pregnancy, th e woman is expected to dress up in "wh LtiLsh"

garmentsand richje welle r y whenever she goes out.

10 Agriculture, trading, mining,and timber logging are the major industries in the region, and together with social service relatedjobs,are the major forms of employment.The region is considered one of the richest in the country in terms of na turalresources.

Other socie-demographic and health indicators are follows [19,21,22):

Populationdensity per sq. km. 86

Urban to rural proportion 32: 68

Infa nt mortalityrate 70 per 1000

Maternal mortality ra t e <Iper1000

Total fertility rate 5.9

Physician popuLation ratio (1987 ) 1:18,291

RUMASI DISTRICT: Thi s is a major urban trading center, co n s i sting mostlyof J(umas! city, tihe reglonal capital, and the second larg e s t city in the country. with a total population of 553,414 (1989), it has abouta quarter of the region 's total popul atio n; 81.1% of whom residein the urban sector[21,22].Beingan importanttrading canter the district also has a high ru r a l-urba n pop u l a ti on drift with about 200,000 peo p l e moving in and out ofthe districteach day. Some of its health and socia-demographic indictors are as follows [21,22]:

Sex ratio (M as a%of F) Crude birthra t e cruda death rate Infa ntmortalityrate Maternalmortalityrate

94.9 52.0per1000 15.4per10 0 0 60per1000 5.6per 1000

11

Reported sup erviseddelive ries1989(t) 82.9

The distric t is relativelywell-endowedwithhealthfacilities When compared to otherdistricts in the country and health service is accessibleto over 95% of residents.

2. 2: THESTUDY CENT RE

The Komfa Anokye Teachi ng Hospi ta l (KATH)and its ancilla ry publichealth division,the Materna l andChild HealthCen tre (MCHC)we r echosenas the cent r es for thestudy.

The J:omt"o Anoltye TeaChing Hospital: is th e second la rg e s t hospital inthe country,and it serves as a regiona l hospital as well as the teaching hosp ita l forthe country's second medical school. Being a maj or referr al center, it has a catc hment area far be yo nd reg iona l boundaries and serves virtually all of the northernhalf of the country. Al t hou g h

12 plan ned as a 500 bed ho s p i t a l , it us ually has a patient oc c u pan c y wellover a 1000 , resulting in manypatients lying on the floor, overcrowdingand chron i c sho r t ag e sof personnel and supplies.A government-owned institution, it is opento the genel'a1 public. 'i'he subsid i zed ra t es charged make it accessibleto the general public.

Thehos pita l has a verybusy ob ste tr i c and qynaecoLoqy departmen t that handles about 65\ of all in s t i t u tio na l deliveries in th e di stri c t. On the, av erage ab o ut 98 00 deliveries occur each year at the hospit a l, with a C:etily averageof about 25deliveries .The labour wardwhichhandl e s all thesedeliveri e s , ha d atth e time of the stUdy only ten flrst stage beds, five sec o nd st a ge / de live ry beds , and six imme d i a t e postpartumbeds. It is the r eforenot uncommon to havepatientssha ring beds onmost days.The reare two other lying-inwards, ea chwith about36 bedswhichca te r topos t- ca e s a r e a n eect.Icn patients and otherpue r p e ra l admi ss i on s.

Theseare almostalwaysfullyoccupied .Becauseof thelac kof sp a c e,patients delivered normally ared l acha rqe dhomewit h i n 24 hoursof delivery if no severehe a lthco mp lica t i o ns occu r at labour .

There are no restrictionswh a t s oever as to whode l i v e rs inthe hospitaland prior cookfog isnot needed. It hasbeen ob s e rved thatmany women come to the hosp ital in the late stages of labour and thereforefrequently spendle s s than24

13 hours in the ho s p i tll;l. No r mal deliveries are doneby nurse mid wi ves; docto rs are called in only for the complicated labours. The caes area nsec tion rate inthehospita l is about 12\, and the average maternal mortality rateat th ehos pita l is8.7 per 10 0 0 [22].

Th o Mate r nalandCh i l dHealth centre : Thisis a special uni t set up to deal with the spec ial publ Lc health aspects of materna l and ch ildhe alt h care. The uni toffers ante-natal, post-natal and familyplan nin g services butha s no delivery uni t. Child health pr og ramme s at the unit include growth monito ring, nutrit.Lcne L rehabilitatio n and immun iz a t i o n services.

The unit is open to the general public, and like the hospitalis alsoheavilYsubsidizedby government.Postna tal c1 lnics ar e organized twice weekly for women in theirsixth postpartum we e k . The clinic, li k e others in the country, offersacombinedhealthcare service in whichinfantgrowth moni t oringand immuni sationare alsobegan. SinceKomfo Ano k ye Hospita l do e s not offer any special po s t nata l clinics the majority of person sde l i ve r ingat thehos p i t al reporttothis unit for this postna ta l visi t. Info rmationabout the po st - na t alatt endancerates , andthe morbidit ies presentedtothis unit are notavailabletothis aut horat this time.

14 2.3 : MATERNA LHEALTH

Ghanaia nsociety, like many other Afr i ca n societies,are strongly pr o-na t a list i c . Marriag e and childbearing are consideredth e essential vocationfor women andtherefore many women marry and child-bear ear ly. One na t i on a l study. for example,observed thatby ages 15-19 years, 17% of women were alreadymarried, and by 25 years less than5%had never been married [17]. Child-bearing, in most Ln s 't ances , immediately follows mar riage. Amotherofmanychildren is ....eti-c e e pe c e e e , while the infertile woman is stigmatized.Fertility rates in the country have therefore been hi g h ; the averageGhan a i a n WOman tod a y expects to deliver 6.4 children during he r re pr od uc t i v e ye ars (23).

There ha s been a trend for fewer children in recent times. The fert i l ityrateha s decreased from the rate of 6.9 observed in 195 5 - 60 (23). The proportion of pregnant women withfou r or morechildrenrepo rting to antenatal clinics has also dropped from 64\ in 1987 to 40\ in19 9 0 [24] .

For Ghanaianwomen, the Lncreasedexposu r e to pregnancy fromthis highfertilityincreasesthei rrisks forpre gn an c y - related compl icatio ns, particularl y since th G majority of women fac e a viciouscycleofpoverty, ig no r a nc e and disease.

The maternal morta l i ty rate in the country ishi g h , and has si nce the mid 197 0' sbeenes tima ted to be 5-10 pe r 1000 live

15 births (1 9 ) . Although no community -based studies have been carried out to validate this figu re, it is considered re a l i s tic andis st il l the acceptedrateincurre ntuse . Two studies atho s p i t al s in the Great e r Accra region, reported maternal mortalityrate sof 10.8and 7.9per 10 0 0 in 1953-67 and 1986-89 respective ly [25,26]. Ma t e r nal mortality rates (per10 0 0live births) in1990 report e d from the westernand Upper East regions of the country were 6.0 and 5.6 resp ectively {27 , 28 J .

The immediate causes of maternal deathar e due mostlyto peri-pa r tumrela tedcomplicationsof haemorrhage,septicaemia and eclampsia whic h account for 42% of all deaths [19]. Indirectcausessuch as anae mia . infections like hepatitis, and othe r cardia-respiratoryconditions, ac c oun t for anothe r 32% of deaths (19].

Ma t erna l morbidity figures, however, are le s s readily available. The ev idence sugg ests that poor he al t hin the s e is of te n combina tion of pr e gn a nc y- r e l ated complications, povert y and the sanita t ion - rela ted diseases wh i c h also affectth egeneral popul at.Lcn(19]. Commonprob lems du r i ng preg nancyincludeana emia, infections such asmalari a , he pa t i ti s, hookworm, etc .(19 ). In 1990 for exa mpl e , 71%:of wo men visitingan ante na ta l cli nic for the fir st ti me were fou nd tohave hae moglob i n le vel s be low10.0 gm/ dl [24 ) . In the Asha nti re g ion, in 1987 , about a third of pregnant women

rs presented at clinics wit h a febrile condition , 12\ with diar r hoealdisease,and 19 \ withi!I.re s p i r a t o ry infec t ion(29). In f ormationon puerperiumill-heal thin Ghana is lacking ; this probably reflects the littl e atten tion paid to the prob l em.

TheGhanaia n gover nment is committed to improv ing the healthof its mothe r s andeffo r tsarecontinua llybeingmade to fac ilitate and improv e pregna ncy care and also pr-c e o t;e smal l e r famil y sizes.Progressis beingmedcrpresentre ports ind i c a t e tha t in 19 90 nati ona ll y, 65.5\: of pre g na nt women util ize davail ab leantenatalservice,anincrease fro m56\ in 1987 [24). The average nUmbe r of visits per woman, however, ha s re ma i ne d low; only2.1in 1990[24) .

National statistics indicate that supe rv i s e d delivery rates are still generally ve ry low, al t ho ug h they have increas e d from 19\ in 1987to 42\ in 1990 [24 J. Supervised deliverycoverageis usuallyhigher inurba n than rural areas;

for exa mpl e 82.9\ in the Kumasi dist ric t

r

respe c tively. It is of con c ern presently that many of the womenwho see k ante- na t a l ca r e fromtr a ined perso nnel du r i ng their pregnancy sti l l pr e f e r to deliver the i rbabies in their homes. Att endance at the si x weekpo stnatal cli n i c, tho ugh poor, isbe t ter than the supervised delivery rates, and ha s stabili sed aro un d40- !:I ot ove r the pa s t two ye a r s [24].

17 Itis obvi ousfroID.the aboveinforma t i o n that the goal of ad equ a t eca re for all moth e r s inGha n a is tar fromach i e v ed. ReducIngmat e r nalmorta lit y and morbid ity . isst i l l animmense ta s k which requi res all pos siblehelp in developing nee de d clin i c al and pUblic heal t h strateg ies.

CHAPTER 3

A REVIEW OFTHE LIT ERAT URE

The puerperalperiod, wh i c h has been ar b i t r a r il y defi ned th e fi r s t 42 days (sixweeks) postpartullIis th e periOd during whichmost ofth e phys iologicchanges which occurred dur ingpr eg nancy revert totheir pre-pregna ncystatus.

Fo r many women, this pe r iod is oftenunevent f ul ,but for others th epe r i od cenbecome very compli cated, severe 111- heal th or even de a t h can occur. Events that occur during pregnancy , and particularly at the timeot la bour, haveall been observed to ha ve important effects on the pue r pe r a 1 healthstatu s .During theentireprocessofch i l d-beari ng,the puerperal periodcouldprobablybeid en t ifi e d assecond tothe peri-p artuJII periodinte n s of health risks .

Disease proces ses. which commonly complicate the puerpe riumincludethefollowing :in f e c t ions,particu larl yof the gen ital tract, urinary tract and breast. haemorrhage:

intra-v a s c ula rthr ombos i sIand ana emia.Infact fe v e r due to inf e ctiv e complicat ions in the pue r pe r i um was suc han omi no us sig n in thepa stthat it ear-ne d the name "Ch il d birt hrevee'' (or puerperal fever), andbec ameanimportlllntclin icalsign of puer p e ra l ill - health (30).

rs The need for adequate puerperal care became obvious during the 18 and 19 t h centuries when outbreaks of "Ch i l d birth (puerperal) fever" with its resulting high fatality rates occurred in lying-inbirthing units in Europe[7].Today however, in these same countries.this andmost other threats to puerperal health have been virtually eliminated or significantly controlledby advances in science and medicine (7]. An important contributing factor too, ha s been the improved standards of li v i n g in these developed countries which assures women better nutritiona l and health status to cope with the extra demandsof childbeari ng.

In the poor countries of Africa,Asia and South America, despite all the achievements in science and medicine of the 20th century, the materna l health situation appears to be similar to thatof"ye s t e r da y ' s" Europe [6,7]. The true extent of the problem, however, is not yet xncvn, because these count r i escontinueto surrex severe shortageof informationon all aspects of maternal ill-health and death. Progress is slowlybeing made, however, and since the early 1960's, data on maternal he al t h have accumulatedand drawn the world 's atte ntio ntothe tragedy fa c e d by woman in poor nations {ll. Althoughthe s e studies remain few and oftenli mi t e d in scope, they provide some insight intothe extentof maternal 111- health.The morbidity and mortality rates frequently

20 r'~p o rt ed are usually 15-20 ti me s gr e a t e r than th o s e in developed nat i on s [IJ.

Availabl ematerna l hea l th da tafrom Afr i c a andother poor coun tries are predomi nantly mortality data with fa r less informa tionexistingOn morbidity.Whe nwe conside rpuerperal morb idity,thisinformatio nis evenscantier.Thisfi ndi ng is not surp rising. In po or nati on s, de a t h is muc h cheaper and easierto countth an ill- hea lth, wh i chrequ i re smore exp ensive and intensi v e research methods. Since maternal deaths, however,include all deaths occurring during pregnancy, labour and the puerperium, and death is usually the resultof very significant morbidity, these morta lity data also provide essential clues to the extent of puerpe ralmorbidity.

Inreviewing puerpera lmorbidityin the developingworld, th i s paperwi ll examine init s first pa r t the reported rates and causesof deat hsin the puerperium . Th e second partwill reviewthe prevalenceof specif ic puerperal morbidities and theirdet ermina nts, and will reflect also on some reported tradi tional postpar t u m practiceswith severe puerperalhealth consequences.

21 3' 1. PUERPERJl.L HORTJr.LJTY 'IN'rUE THIRD WORLD

Available mortality reports show that most maternal deaths in the worl d's poo r nationsoccur soon after delivery or later on in the puerp eriumand are oftenthe result of complications arising from the time ofla bo u r [8,14J•

In Menoufia, Egypt for example, from1981- 1 9 8 3 , 56' of the 383 recorded maternal deaths occurredinth e postpartum period, as compared to 12% dur ing pre g n a n c y and 29% during la b ou r (10J• As is often the case in most developing countries, and also notedin thisEgyptian study, the majority of deliveries had occurredat home.Fifty- threepercentof the reported deathsalsooccurred at home and 62.6%of deaths were relatedtodire c t obstetric complications suchasha e mo r r h a ge , infection and hype r tens i ve disorders.

Ma ny other mor t a lity studiesfrom the African conti nent li s t pos t pa rtum complications such as sepsis, haemorrhage, anaemia and hyp e r t e n s i on as among the major causes of death [8,31-34]. InHarare , Zimbabwe , in1983pue r p e r al sepsiswas noted tobe the number one cause of deathaccounting for 23.5\

of all mate r na l deaths at the Harare hospital, and was followed closely by haemorrhage wi t h 21.6% (32]. Ano the r exte nsi ve st ud yof 737 maternal deaths also in the Southern Afr ican re g i o n from 198 0 to 198 2 by Boes, noted postpartum sepsis to be the thirdmajorcaus e of death accounting for 19%, wit h haemor r ha ge and hype rtensive di s orders account ing

22 for)0% and 20% respective l y (33].Ofnote, also isthe fact tha t of the 140 sepsis deat hs recorded in th a t study, over thre e - quar t ers fol l owed de l i v e r y . whil e approximately on e- quarter were associa t ed with abortions (33}.Fift y-onedeaths frompuerpe r al sepsis, ha d been as s o c i ate d wi th ceasarean sections, 15 with prolonged la bou r , 11 followed an uncomp licated hospita l delivery, and 12 had been afterhome delivery(33].

The pictu r eisnot very dif ferent in the otherparts of Afric a. Ina large pr o s p e c t i v e community-basedstudyinKe nya, East Af rica, of the 2,223 pregnantwomen who delivered the on lymaternaldea t hthat occurred was in the puerperium, and ina woman wh o ha d been discharged home after an uneventful hospital delivery[35]. Anothe r study, alsoinKenya, which reviewed mortality in gyna e c o l ogic al patie nts admitted to hospit al, repor t ed tha t po stpar t u m complicatio ns such as puerpera l sepsis and eclampsia account ed for a major pro po r ti onof pregna ncy-rela tedgy naecological de at hs [11J.In ne i gh bouringuganda ,puerperalcomp lica tions al s owere second onlyto immed iate labou r co mplicat ions as causes of death [36]•

Whenwe consider mo rtality data fromWes t Africa, the find ingsare similar. Inapro s pe ctive community-basedstudy in Gambia in 19 82 / 8 3 of th e 15 maternal deaths tha t ha d occu rred among the 672 women studied, four deaths oc c u r r e d

23 between 4 to 42 days of the puerperium and one in the eight postpartumweek [5). All thesepue r p e r a l deathshad oc c urred at horne ev e n thoughtwo sUbjectshad had hospitaldeli ve ries . The ca us e s of the sedeaths included anaemic cardiac failure, sep sis, eclampsia. hepatic coma and tuberculosis (5]_

Hae morrhage, whi-:::h was noted as the major cause of maternal death in thisstudy, accounted for 331 of alldeaths, all of whichoccurredwithintwelvehoursfollowingdeliver y(5).I f thi s numberdied fromsevere haemorrh age ,a question israi sed as to how many more womenhad survived postpartumhaemorrhage with resUlting anaemia.

The largestUdyby Kelsey Harrison in Zaria, Nigeria , of 22,774consecut ivebirthsfrom1976-1 979perhapsthrowsmore light on the puerperal health situation in poor sUb-Saharan communi ti es (8l. Anoverall maternal mortality rate of 10.5 per 1000 vas recorded in the e tiudy, As in the otherpa r t s of the co nt i ne nt , postpartum comp l i c a t i on s such as sepsis, anaemia and hypertensivedisorders were the major causes of death in the etiudy [8). Puerperalmorbidities noted in the study wer-e as follo"'s:puerperal hypertension (1812). anae mi a (1217) , genital and wound sepsis (1 058 ) , obstetric fi s t ula e (79 ), psychosis(40), acute genital prolapse(26),tetanus (5) and meningitis (6). Even more troublingwas the finding that the patients frequentlyhad combinationsof these complica- tions which further re d uc e dcha nc e s of survival.

24 The Za r i a st ud y(a},also revea ledthe la rg e nu mbers of emerge ncy admissions fo r sev ere lIfe-thre ate n i ng pue r pe ra l complicat i o ns. Of the 1638wome n...ho we r e ur g e nt l y admitted after hav i ng delivered at home , if only cases with late postpartum complications ar e consi dered ; 557 wamen were admitt edwithanaemiaofwhom 27 (4.8%) died;244 wi t h genital sepsis of whom 21 (9.4%) died; admissions for septicaemia totall e d 15 of wh o m 10 (66.7%:) died; andtho s e admittedwith secondarypostpartum haemorrhagetotalled 47 and one (2.1%) death occurred. If we rememb er , ho weve r , that the above numbe r s included onlythefewin d i v i d u a l s severely ill enough towa rra nt hospita l admi ssionand not themany more treated as out-patientsor wh odid not evenseek tr e atme nt , we may then begi n to appreciatethe extentof puerpera l morbidity on the cont ine nt.

Th eZar iastudyraJ,did no t ind i c ate the overall rate of puerpe ral re-ad mi s s i on s followi ng discharge after unevent f u l hospi ta ldelivery.Ma t ern al mortality ra t e s among

"book ed" cas e s wa s obse r ved to be a lo we r 3.7per 1000 than the ove r a ll 10.5 per 10 0 0 re cor d ed . Of th e 19 dea ths that occu r red among "booked" hospita l deli v e red patie nts, two however, had been patients dischar.ged home wi t hin 24 ho u r s after uneve ntfu llabour,andwhowere re a dmi t t e d10 days la t e r wit hsever epostpa rtum hype r t ens i on an dpneumonia [8].

25

In Ghana, hospital-basedstudies on maternal mortality have also shown that most maternal deaths are the result of delivery comp li c a t i o ns which lead to puerperal complications and then death [25].The mortality rate from puerperal sepsis wa s observed to be 68.2 per 100,000live birthsin Accra tr o m 1963-1967 by Ampofo [25J. In 1986 / 8 7 at the Komfa Anokye Hospital ,Kumasi ,the maternal mortality rate recorded was 8.6 per1000 ,and haemorrhage, eclampsia, anaemia, andin f ectio n were ide nt if i e d as the four major causes of maternal death [22J.

This pattern of a compl i c a t e d orunsafe labour , in an alr eadyhealth-c omprom isedpregn antwoman,res u l t i ng indeath later in thepuerperium is characterist icnot only of Africa bu t of other poor nations .tn the world [14]. In Indonesia[37J for ex amp l e, haemorrh ag e was the number one cause of death (46\), fo ll owe d by postpartum sepsis (llt). In Bangladesh [38 ,J9], be t we e n 10-20\ of maternal deaths are related to haemorrhage and another7- 17 \ are causedby postpartum sepsis.

InInd i a thefigures for haemorrhage and postpartum sepsis are 20\and 14\ respectively [40].

In the rich countries of the world not only are maternal mortality rat e s ve r y low but the proportion of deaths resUltingfrom haemorrhage or infectionare reduced [41 ,42]. In 1987 in on ta r io, Canada, 13 deaths we r e reported in pr e g n a nt females, Df these only one, due to amniotic fluid

26 embo lis mcoul d be cla s sified as adirect obs tet r i cdeath["2]. A second deathduetoarupt ured aor ticaneurysmina pat i e nt with Mar f an' s syndrome wasclassifi ed as anindirec tobstetric dea t h. The othe r rema ining elevendea t hs were statedto be unre lated , accid e nta lor inci de nta l dea t hs and included the following: mot orveh i cle accide nts(3) ;suicide (1); intra - cerebr a l hae mor rh age s(3); and four , relatedto pr eex isti ng diseases[42].

In NewYork City,United states [41 ) , with a maternal mortalityrate of0.082per10 0 0in1980-84,the proportionof deat hs due tohaemorrhagewas 2.6%, obstetricinfection 2.2%

and tioxae mia 10.3% [41]. Th e first fo u r major causes of mort a l i tyrepor t e d,indescend i ngorderofimportancehad be en ectopicgestation, embo lis m,hyp erten s i on andcardi acarrest.

If any conclusions ar eto be drawnfromthese mortalit y findings, it 1s that thevcnen inthepoor countries of the world , unlike thei r counte rpartsin therichcountries, ar e more likely to die from the irpreg na ncies.If they do not die from haemo rrh age in the immediate peri-p a rtumperiod, the n the yfr eq uent l y di eafew dayslate rf....01llsepsisor anaemia or mos tlikely bot h.

27 3' 2 THEPUER PERA L MORBIDITIES

Si nc emortal i ty re po rts indica te tha tpue r pe r a l deat hsin developing world ar e ca used principa lly by in f ection, hyp e r t en s ivedi s o r de r s and anaemia, towhat exte nt then do morbidityfrom the s e disordersalso occur inthese countrie s?

This sectionwill examine the inci den c e and preval ence of specific puer peralcomplicationsin th edevelopi ng worl d with particu lar att e n t i o n toAf r i c a.

3: 2.1 THE INFECT I OUS MORBIDI TI ES

Puerperalinfectious mor bidi t yremains a major obstet ric complicationi.n both the deve l op ing and developed countries, and is oftenO:"l"! of thethr ee major causes ofde ath (14]. The frequently involved si tes of infect i on associated wi t h occurrence of puerpera l fe ve r includethe followi ng1 ge nita l tract (25-55%), uri nary tract (30-60% ), breas t (5-10%), and other site s (2-5%1 (43].

In the deve lope d world, th e overall incide nc e of pue r pe r al infection islow and sti ll dropping , and re c e ntl y reported rates ran ge be t we e n 1-7 %of par turients (44,45].

These lowered incide nc e rates are the result of greatly improved ob stetr i c and del ive ry practi c es, with a vir tua l elimina tio n of ris k forsepticco nt ami na tionduri ng vagina l delivery. Al t hou g h the ri s k of infe ction is hig her among euhjecba with ope ra t ivedeli verie s , most casessuffer no ve r y

serious he a l th consequences becaus e of the ava i l ab i l i t y poten t antim icrob ia l ag e ntsintheserichcount r i es[4 5].

In developing countries however, prevailing obstetr i c conditions ar e such that high rates of exposu re to infective agentsoccurbeforepregnancy(46,4 7],du ri n g and afterla b o u r [48 ]. Fac ilitiesforcontrolling an d ev en manag ing cases wh en theyoccu r are also verylimited (46]. Women in these po or commu n i tie s are not only at inc rea sed risk ofdevelop ing puer peral inf ective condi t ions but also SUf f e r fr om thei r seq uel a e [47 , 48J.

PUerperal upp e r genitaltr a ot infection:

since historica l times this type of puer pe r a l complication ha s comman d e d agrea t deal of at te ntion, an d 15 stil l the mo s t importantpuerperaldis o rderInmanycou n t. r Ies [12,45,4 9 ,5 0J . It is no wwe l l knownth a t afte rpar tu rit i o nt. he resultin gpl ace n ta bed and dec id ua are an op port une site for infection. The infecting agents could be newly intro d u ced pathogensby unhygienicla bo u r practic es or mayari s e fromthe mothers ownvag i na l t'l o r a [30, 4 9].

Inth e deve lopedworld,extensivestud ieshave been done to id e n t i f y causative agents and specific risk factors {5 1 , 52 ) ; in th e poor co u n t rie s , ac cu rat edata, on the actual inc i d e nceof thi s complication is still un a vaila bl ein most parts . The fewst udi e s don ehowever, have sh ownth atin the

29 poorcountries postpartumgenital infection is probablythe most importantca useof puerperal ill he a l th and death and frequently also leads to lo nq-te ~ reproductive mo r bid i ty (8,1 6,4 6 ,4 8 . 53)•

Reported ad miss i o n rates tor puerperal genital tract inf e c t i o n range fromone to ten percent of admiss ions to gyna ecological wards in most developing countries [46, 4 8) : co mpa r ed to the 0.03-0.10\ reported in some developed count ries [46). Puerperal ge n i tal tr a ct in fect ion ac c o unted for15 . 3 %ofall admissio nsfor pe l vic in flammatorydisease in hospita l wardsin South Africa (1972) and In d i a (1978) (46 ) . In Ethiopia, the figurewas much higher24.9\ [48 ] .

The s ehospita l admis s i on figure s. howe ver , areonly the tipof theicebe rq and refl ect th" lOiqni fi c a nt contr ibuto ry role played by puerperal genital in f e c tio n to in-patient hospital admi ss i on . In the underd ev eloped cOllllllu nit ies, the availa bility anduse of hospital facilities are l imited to on ly a few, so that thesehospitalfigure s poorlyreflect the inc i de nc eof di sea se in the gen e r a l popUlations.

A recent prospec t i ve stud y of women delivering at a hospitalinNairobi,Kenya, per hapsthr ows ali t t l e more light on the tr ue incide nce of puerpe ral ge ni t al inf e c tio n in an ur ba nAf r i c a n popUlat ion[16].Of 1013womenfoll owe d up af ter hos p i t a l di s c ha r ge the over a ll incidenc e of upper genital tract in f e c t i o n(UGTI ) was 20.3\.This incidenceiste n times

30 great e r thanthatre centl y reportedin Helsinki,Sweden[50 ). The prevalence of clinica l si g ns for genl tal infection wa s alsofound to be ex c e ed i n g lyhi g h1n the study,withuptoat least 53' of sUbjectshavingat least one sign. Th e authors report e dthat the onsetof UGTI in theirstudy populationhad oc c ur r e d almostuniversal ly by daysev e nof the puerperiu mand that its development was associated with chlamydia and gonococcal infe c t i o n , labour of greater than 12 hours dur a tion, the occurrence of oph t ha lm i a ne on atorum in the ne onate , and lastly the place of residencerIG ).

Alth oug h th~S isa "bi a s e d"hospital-based study whos e fi nd i ng s cannotbe broadlygeneralised, as the majority of delive riesin xenye and in the other developi ng countri es occurat home, it st il l p rcvLdesvery us e ful in f o rmationon What possi bly happensto thenume ro u s women di scharged ncee within a tew hours atdelivery tra mcro....de d ur b a n or even rural hospital s in poor Africancountries, and whoare not seen again. It cou l d also be a us eful in dica t o r of the possibleextent atpue rp era l UGTI in vomendel i veringat homa underles s hygieni clabour condltions .

Thisisonl y onosuchstud y howev e r,and no oth e rsimilar st ud i e s havebe e nlo c a t ed by th is auth o r.Many more studios areneeded before anymeaning fu l conc lusions canbe drawn on theaccu ra teincidencesofpuerpe r al genital sepsisinAfrica , and itsde t e rm ina nts .

J1 Because of concerns about pe lv.i..c inflamma t o ry disease (PlO) rates generally , a large nu mberof stndies have being done on sexually tr an s mi tt e d disease agentsAfrica and th e otherde veloping count r ies. These studies have freque nt ly included pregnant,partu rientandpuerperalSUbjects[4 7 , 48), and their findings have r-e v e e Iedthemuch higher risk for puerpera l geni tal sepsis fr omth e s e agents in the tropics (5 4, 5 5 ).

High ratesof gonococcaland chlamydiainfection of the re pr od uct i ve tra c t s are re po rted allover Africa (54-56]. Studiesscreening asymptomati cpregnant patientsin Cameroon, Gambia, Zambia, Senegal, Zimbabwe and Ghana have reported gonorrhoeaand chlamydiainfection ra t e s rangingfrom 2to25\

[4 7 , 5 6 - 6 0 ]. In th e otherdevelop i ng countries of Asia and South America, the reported preva lence rates are also similarly high in antenatal patients [61]. For example, gonococcal infection rates reportedinThailand, Jamaica and Chile were 12%, 11 %and 2% re s pectively (59,62,63]. These levels are far greatertha n the l.0% and 0.2% reported in ScotlandandSwitzerland re s pe c t ively [59].

A vaginal flora survey of 214 la b our patientsinHarare Zimbabwe, showed that7%ha d gonorrhoea, 13% hadchlamydia, and19%ha dtr i c homon a s(5 6J.Another survey of themicrobial flora of18 7womenad mitt e d inlab ou r in Zaria ,Ni geriafound that 63.6% of the womenhad a positive cul tu r e for at least

J2 onekn own pat h o g e n [54]_Candi d atoppedtheli s t in th atstudy with 20.9%, followed by klebsiel l a 15 %, E. coli 9.1% and Strap. faecalis 6.4%.Nogo noc oc c iwe r e foundin thestud y and chlamydia wa s r.ct; sought. Thes e Nig e r i an findings suggest that, not onlysexuallytransmittedagents are importantbut many ot he r pathoge ns coul d als opla y an impor t a nt role in causi ngpue rperal infectionsin Af r i c an Mathers.

It is evident from th e s e antenatal findingsthat in the poor countries most women enter labour with an already increased risk roc upper ge nital tract sepsis later in the puerperium.Bacteriolog ica lsurveys of asymptomatic postpartum SUbjects in some countriesalso confirm thesehighinf e c t i o n rat es (4 7, 4 8 ]. In Came r oo n (47) , for exa mp j e , 10%of 296 asymptoma t i c pos tpartum SUbjects were found to ha r bou r the gonococ c us. In Eth i opia the fi g ur e wa s 9% of 200 SUb j ec t s [48] .

It is therefore not surprising that these sexually transmi t ted pat hogens hav e been found to be impo r t a nt contributors to the occurrenc e of puerpe ra ! sepsis in these poor countries[16,64].Inthe study by P!ummeret al.[16]in Ke nya,gonococcal and chlamydia inf e c t i ons werefo und to be indepe ndentlycorrelated with increased risk for ascending ge nitalinfec tion.Amongwo me n withgonococcalinfection, 58%

of their upper gen ita! se ps i s was attributed to their infec t i on [16 ] . About 21% of symptomati c postpartum sepsis

33 patientsin the Cameroo n ha d associatedgonococcal infection (47]. In Ethiopia and Ghana the figures were 28% and 7.7%

respectively [48,65]. In Harare, Zimbabwe, of 95 puerp eral sepsis and post -abortion sepsis pa ti ents studied , gonococci wer eisolated inover 20%, chlamydiaantigen in16-2Q!1i,an dG.

vaginalis in 20% [64).

St ud i e s on inf e r t il i t y and ectopic preg nanc y in the world 's poorer nations indicate that , unlike the richer states, these problems are morethere s u l t of pelvicinfection {53,66). InAfrica, the particularlyhigh rateot: secondary infertilityhas raised que sti on s about the ro leof puerperal genital infection [53,66,67 ).In th e industrial isedcountries of Europe and No r t h America not only is the incidence of pue r pe r al UGTI far les s, as already stated, but sexually transmitted agentssuch as the gonococci appear to playfar lessimportan t roles (49]. Whe n theyoc c ur the y arequi c kl y detected and treated in the antenatalperiod, beforetheycan cause problems in the puer pe rium .

For the unfo r tunatewomen in the poor co unt riesof the world therefore, the scenariomaybe describedas follows;

the y go through pregna ncy and enter la bour with untreated

"c o l on i s e d" genitaltracts,andif la bourshoul dbe mismanaged or becomecomplicated,then risk forpue rpe ra lgeni talsepsis is even greater. Severe healthconseque ncesresultbec a u se

34 ade q uate trr e atin errc for this compl ication is oft e n dela ye d or not ob tai n e dat all.

urinarytractinflic tio n s:

Infect ions of the urinarytract ar e a re c og ni s e d common complic a t i o n of pr egnanc y and the pue r pe r i um, anda frequen t causeof pu erpe r al fever [45 , 6 8].Inth ede ve lopedwo r l d , many stud i e s hav ebe en done, wh i c h ha v e shown that about 4-7\ of womenhave asympt omaticbac teriuria during pregnancy; about 20-40% ofthes ewome n ....illdevelop symptomaticdiseaseduring pre gnancyorthe puerperium, i fno t tr e a t e d [68-72] .

Apr o s pe ct i v e stUdy of 5000 pregnantwomen in London, Engla nd, by Li ttle (1966) for examp l e, fo u nd 5.3% of them to havebacteriuriaand 25\ ofthe m todeveloppyelonephritisin preg nancyand in the puerp erium(68]. Man y otherstudieshave also re port ed similar findings, and have not e d tha t, bact e ri uria in pre g nan c y persistsinto the puerperiumandeven for longeri fnottr e ated (7 1,73].

Events however, atthetime oflab o ur,als o additionally contri but e tothede ve l o pment of bac te r i u riainth epuerperium [69 , 7 3 ].In astudyof 3554pue rperal women, whodel i v e r edct;

a hos pital in Finland from1977-7 8 , Reh u et aL, , found 5\ of the m to hav e siqnificant bacte r iuria (69 ] . Subjects wit h vagina l de liveri e s had a bacte riuriaprevale nc e of 4.5%as compa redwi th7.3\for those whoha d caesareandeliveries.The

35 study . al s o found that subjectswho had ureth ra l cat he te r - izat ionduring delivery, who ha d records of urina ry tract infection during pregnancy. and who had po s tpart u m endome tritisallhadhigherpre va l e nc e of bacte riu ria during thepuerpe riu m.[6 9 ].

SiD.ilar find i ngswe re alsore po rt edin arecent studyof 6803 pos tpartum womenin Os lo, Norway (73]. Here too , the pr ev a l e nc e of bacteriuri a was reporte d to be 8.11 whe n mid streamuri ne samples were collected, buta lower 3.710 on bladdersa mp ling . Twenty-oneperc ent oftheaffectedwomen in the Oslo st udy (13], hadcomp l a in e dot dysuria howe ve r; in th..se as ymptomaticunt r eatedcases , bacter iur i ahad persist e d forover10 weeks in 27\ of the m.

Other factors found in studies to be associated with highe r prevalence of ba c t eriu r i a in pregnancy and the puerpe rium. are low socio-eco nouic status [72.74). anaemia (75]. and sickle cell tra it (7.3-78). These predi s posing facto r s,ar eof par ticula r releva nc eto de v elop ingcou ntr i e s, where th e yare evenmore prevalent.

Mu ch lessinfo rma t ionexists ontheincide nc e of urinary tr act infect ionorba cteriuria inpregna nc yor thepuer per i um in de v e l op i n g count r i e s. Two stUdies fr omIba d an , Nigeria reported high pre valences of asymptomaticbacteriu riaof12\

[79) and9.7\ (SO}dur ingpregnanc y . Inone st Udy[7 9}, abo u t 80\of the 31 ba c t eriuricpatientsfo u ndwere mUlt ig r av idae.

36 Three of the 31 bacteriuric cases were anaemic, one of whom was due to sickle cell (SC) disease.Puerperal pyrexia, also developed in 3 of 24 bacteriuria cases who delivered and one was because of eevere genito-urlnary tract infection. This case also happened to be the subject with haemoglobinopathy (79).

Another study in Benin, Nigeria reported the incidence of acute urinary tract infection during pregnancy to be a low 0.8%, despite the previously reported high bacteriuric rates in the country [81). The authors correctly pointed out that their figure had been based only on patients admitted to hospital and was therefore likelyto be inaccurate sincema ny patients were likely to be treated as out patients (81].Other notable findings of the stUdy were that llt of the 70 cases investigated had had recurrence of the disease during pregnancy, whilst another 8.6%had recurred in the puerperium, and this occurred in spite of earliertreatment[8 1).Unlike the bacteriuria findings in the Ibadan s eudy (79), in this study [81]a significantly higher incidence of acute infection was noted in primipara as compared with multiparous women.

In Assiut, Upper Egypt, the incidence of asymptomatic bacteriuria in 830 pregnant women surveyed was 9.0% (82] . Another 1.5% of the 752 women with initially sterile urine developed bacteriuria in late pregnancy but no new cases were observed after labour in the study sample [82). A third of the

37 bacte r iur ic patientslater developedsymptoma ticdisease, a finding which is similar to that reported in the we ste r n studies (72,83].

InSout hAfrica and Uganda th e incidence of bacte r iuria in studieswere 10 . 3% and12 . 2 %re spec t i vel y [84,85] ; these figures are similartothehigh ratesalsoobtained in Nigeria andEgypt [79,80,82}.InNairobi, Kenya,7.4%of 1017 pregnant patients seen at an antenatal clinic were found to have signi ficant bacteriuria, but in only 5.5%of them was this findi ngasymptomatic [86].

Much lower rates of bacteriuria inpregnancyhavebe en reported instudies inthe af ricancount riesof Zambia, and Sudan [87,aa]. In Zambia ap proximately 4.0% of low income pregnant womenwere found tohav e asymptomat icbacte riuriaat their firstantenatalvisit{8 7 ].

In Khartoum, Sudan, the pre val en c e of aysmptomatic bact e ruiriawas 5.6% [88]. Bladder cathete rizat ionof women was us e d duringurinesamplecollect ionin Khartoum, instead ofthe routinemid-str eamuri nesampling ,andthe researchers explainedtha t , th i s methodwas usedbe c a us e they fel t thatin their circumcised femal e pop u latio n ,mid-s treamurine samples wereli kely tobe co me contami na ted as ares u l t of the gen ital de fo r mity of female circumc i s i o n. Thi s methodol ogica l differencehowever, couldhave influencedtheir findings,

l8 sinc e direct bladd er samplingha sbeenobservedto give lo we r bact e ri u ricrate s [73].

Des pi t e the s ere p ortedhigh pregnan c y bacteri u r ia rate s , litt l e at te ntio n has been paid to pue rpe r al urina ry tract in fections inAf ri ca and no stud i e sonthe conditio n havebe en foundforrevi e....inthi s presentat ion.Froll west e r nst udies, we know tha t ba cteriuria in pr e gnanc y is usua lly carried forwa rd intothe puerperium, so that puerperal ba c t e r i u ri a rate s in Africacunbe expected tobe high . The ex t ent to wh ich labou r alsocon tr i bute s toincrea s ingthisal rea d y hi gh pr ev a l enc e isnot known. Alsounkn own is the proportio nof puerperal pyr e xi a which is duetouri na r ytr a ct infection.

The pre v alenc e of pr e d i spos ingfactorstor urinarytract infectionare hi g he r in Af ricathaninthe westernworl d. In additio n to th e contribu t o ry fac t o r s noted in the western world , otherpre d i s po s i ng factors also occur in Afri ca, and manyother tropicalclimates.Twono t a b l e examplesareurinary schist o somia sis and the hemoglobin opathies Whi c h associa ted with very hi g h rates ofba c t eri a l ur ina ry tract in f e cti o n [76,89 - 91). The in cidence of acut e urinary tra c t infec t i o n , duringpregn a nc y and the puerperi umin 78sickle cell pregnancies reviewedinIb a d a nNig e ria, for examp -Lewore 36%and 19\ re spe ctively(91].

Theoccu r re nce of puerpera l uri narytra ct inf ections is as soc ia tedwi ththe pue rp era l gen ital sepsis (69) . Un t r e ated

39 urinary tact infection can aggravate other puerperal complications such as anaemia andhyperte nsion, wh i c h also frequently occur in sub-Sahara n Africa. uri nary tract inf e c t i o n in the puerperium, therefore, requires great er atte ntionin these developing countries tha n it has presently been accordedand many more st udiesare needed,

Breast infections:

The processof breast-feedingwhich follows pregnancy.

in c r e a s e s theriskfor deve lopingbreastinfections andot her breast disordersin women.In the puerperium,in f e c t i v e breast disordersrange frommino r problems such as chaffednipplesto mo r e severe conditionssuch as mastitis and uceceeees.

Puerperal breast infections have for a long time been recognisedas one of th eimport a nt infectiveccmplicationsof thepue rpe r i um (92-95],andinthe past epddemLcs of puerperal breast infectionswerereported in North America and western Europe [9 2-95 ] . In winnipeg, Canada, epidemics of breast abscesseswere reported in the la t e 1940'Swith inc i de nc e s reachingle ve l s of 10-15%of alldeliveries in1947 [95). In England , during thesamepe r-Lcd, 5 suchoutbreaks we r e also reported, wi t h infection ratesas high as 50% reported in one outbreak [93].

Apart fromthese epidemicshowe ve r, sporadicepisodes of breast infection are a well- recognised feature of the

40 puerperium{9 6 , 9 7) , Ast udy byMar s hall etal {97] inthe early 1910'5 foundthat abou t 2.5% of lactating mothers develop spor adi c mastitis, wi t h 4.6\ leading to abscesses formation. Muchhi gher mas ti tis rate s hcwever,were reported in a 1990 survey by Riordanand Ni c hol s {9B]. A third of mothersin theirsurvey reportedan episodeofmastitis during lactationand inacet;ithad occurredduring thefirst three mont hs postpartum . Athird of the cases nevercontacted a physician duri ng their mastitis episode, andha lf neverused an antibiotic [98]. Thes e findings indicate, that perhaps becausemostep i s odes of sporadicmastitis aremUd, theymay be fre quentl y under-reportedand that incidences ba s ed on hospitaldatamay be underesti mated.

The inci dence of puer peral breast abscess in the developed wor l d is fast dropp ing withthe availability of modernant ibi oticsandbetterpostpartumcareas most casesof mastitis are qui ck l y tr eated before they can progress to absc essfornation [9 7 ~ 1 0 21.ThUS,mostbr east abscesses now seen in hospitals in these countries are more likely tobe related to other chronic non-puerperal breast conditions [99 , 100 }.

Indeveloping countr iestoday theincidence of sporadic puerpera l brea s t infection is unknownandther e appears to be no repo rts of puerperal breast infection epidemics. Some hospita l -b ased studiesof benignbreastconditionsin a few

41 developing world countri es ha ve incl u d e d puerperal breast abscesses ,and give an idea of howfrequently th e cond i tion is seenat hospitals inthese countries[103-105].

In are v i e w of a 1000 cases of breast disorders seen at twohos p i t a ls inJordan ,98 casesof mastitiswerere p ort e din lactating women and 12 others presented with la cta t i n g adenomas (103). InNi g e ri a , over a 10 year period, onl y 8.6%

of 671breast cases seen and biopsiedat one hospital were pyogenic breas tabscessesassociatedwith lactation(104]. The autmcrs cautioned that their sampleincludedonlysucfectswho ha d biopsies ta k e n and because the majority of breast abscessesseen inth e hospital we r e drained without a biopsy be i ng taken , the i r reported incidencewas likely to be very muchlower thantrul y occurs[104].

Breastinfect ion howev er . wasfound to account for a much hi gh e r proportionof all breast disorders seen at a hospital in Riyadh , Saud i Arabia [105] . In a three year prospective study of 304 breast patients , postpar tum mastitisaccounted for 5J (17.5%) of cases seen; 40 (75.5%) of the mastitis pat ien tsseen ha d abscesses requi r i ng drainage (105] .

If we consider that, even intheri c h er communityof a developedcount ry, athi r d of wome nwi t h masti tisdid not seek medical atten tio n fo r their cond i tion, then in poorer countrieswherepat i entsare knowntobe less li ke l y to seek any medical help, hos p ital records will be an even poore r

42 source of information on the true extent of puerpera 1 breast infection in these countries. More broadly based studies are thereforeneeded.

The generally accepted pathoqeneslsaf puerperal breast infection is thatit starts with cracked ar sore nipples.This commonly occursafter the first few days of suckling and is associated with breaches in theprotective epidermalcovering, which facilitates the entry of pathogenic organisms into deeper breast tissue, with development of mastitis and its abscess sequelae (106). The most frequently identified causative organisms are the Staphylococci, which may arise from the mother'5 own skin flora or the Lnr e n t's naso- pharyngeal flora (94-97,107].

Sore nipples are known to occur frequently in breast- feedjng mothers especially in the first weeks of breast- feeding and withthe first child (107]. Nodata onthe actual incidence of sore or cracked nipples no r on the extent to which this contributes to mastitis have been found by this author.sporadic mastitis is often a latepuerperal disorder seen frequently after thesecondpostpartum week:most western studies indicate tha t most cases occur between thesecond and fifthpostpartum week [45,97,106,107]).Mastitis is frequently bilateral and can be recurre nt in about 12% of women in SUbsequent births (107 ].