Investigation of risk factors for severe maternal morbidity and progression to mortality: a case control and follow up study in Mulago Hospital Complex Uganda

Maternal morbidity is physical ill health related to pregnancy and childbirth or any maternal complication during pregnancy, labour and puerperium. Severe maternal morbidity is a life-threatening obstetric complication. The importance of severe maternal morbidity is that it precedes maternal mortality and is therefore critical in the understanding of the factors that influence maternal mortality. The overall aim of the study was to investigate risk factors associated with severe maternal morbidity and progression to maternal mortality in Mulago hospital, Kampala, Uganda. The study had two stages: Stage 1 was an unmatched case-control study of severe maternal morbidity and Stage 2 was a follow-up of all cases from Stage 1 to discharge or death. A total of 499 cases of severe maternal morbidity and 500 controls (women with normal deliveries and no severe maternal morbidity) were studied. Both the cases and controls were interviewed to obtain information on socio demographic factors, previous obstetric outcomes and present obstetric performance. Information on obstetric management was extracted from clinical notes. All cases and controls were tested for HIV, syphilis and haemoglobin level. A total of 39 of the 499 severe maternal morbidity cases died. The causes of SMM were severe pre eclampsia (25%), severe dystocia (31%) Post partum haemorrhage (19%), ante partum haemorrhage (14%) puerperal sepsis (5%) and medical diseases (6%). The main risk factors for severe maternal morbidity were low socio economic class, long distance from home to Mulago hospital, having specific medical conditions, having to request permission to attend health unit, having a long interval since the last birth, HIV positive status and poor quality of care during antenatal and delivery. Further details, plus separate analyses of specific causes of SMM (eclampsia, post partum haemorrhage, severe dystocia and ante partum haemorrhage) are presented. Determinants of progression to maternal death included low socio economic class, factors associated with management of labour, and HIV/AIDS. The main conclusion from this work is that improvements in the social and economic status of women, the level of HIV in the community, and the quality of care offered 2 during pregnancy will reduce the burden of severe maternal morbidity and mortality in Kampala, Uganda. It is likely that these results can be generalised to other areas of sub-Saharan Africa and usefully integrated into Safe-Motherhood Programs there.