ObjectiveTo investigate the burden and causes of life‐threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.DesignNationwide cross‐sectional study.SettingForty‐two tertiary hospitals.PopulationWomen admitted for pregnancy, childbirth and puerperal complications.MethodsAll cases of severe maternal outcome (SMO: maternal near‐miss or maternal death) were prospectively identified using the WHO criteria over a 1‐year period.Main outcome measuresIncidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).ResultsParticipating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near‐misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre‐eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life‐threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21–215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non‐availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.ConclusionsImproving the chances of maternal survival would not only require timely application of life‐saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.Tweetable abstractOf 998 maternal deaths and 1451 near‐misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

BACKGROUND: Vesicovaginal fistula is a preventable calamity, which has been an age-long menace in developing countries. OBJECTIVE: To review the causes, complications, and outcome of vesicovaginal fistula in Nigeria. METHODS: Studies on vesicovaginal fistula were searched on the internet. Information was obtained on Pubmed (medline), WHO website, Bioline Innternational, African Journal on Line, Google scholar, Yahoo, Medscape and e Medicine. RESULTS: Many Nigerian women are living with vesicovaginal fistula. The annual obstetric fistula incidence is estimated at 2.11 per 1000 births. It is more prevalent in northern Nigeria than southern Nigeria. Obstetric fistula accounts for 84.1%-100% of the vesicovaginal fistula and prolonged obstructed labour is consistently the most common cause (65.9%-96.5%) in all the series. Other common causes include caesarean section, advanced cervical cancer, uterine rupture, and Gishiri cut. The identified predisposing factors were early marriage and pregnancy, which were rampant in northern Nigeria, while unskilled birth attendance and late presentation to the health facilities was common nationwide. Among the significant contributory factors to high rate of unskilled birth attendance were poverty, illiteracy, ignorance, restriction of women's movement, non-permission from husband, and transportation. All but one Nigerian studies revealed that primiparous women were the most vulnerable group. Pregnancy outcome was dismal in most cases related to delivery with still birth rate of 87%-91.7%. Stigmatization, divorce and social exclusion were common complications. Overall fistula repair success rate was between 75% and 92% in a few centres that offer such services. CONCLUSION: Vesicovaginal fistula is prevalent in Nigeria and obstetric factors are mostly implicated. It is a public health issue of concern.

Objective To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.Design Nationwide cross-sectional study.Setting Forty-two tertiary hospitals.Population Women admitted for pregnancy, childbirth and puerperal complications.Methods All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.Main outcome measures Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).Results Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were preeclampsia/eclampsia (23.4%) and postpartum haemorrhage †The members of Nigeria Near-miss and Maternal Death Surveillance Network are in Appendix 1.

A retrospective analysis of 348 cases of primary postpartum haemorrhage (PPH) that occurred at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between 1 January 1993 and 31 December 1996 was carried out. The incidence of PPH was 4.5%. Booking status of the patients had no relation with occurrence of PPH in this study (P>0.05). The risk of PPH in advanced maternal age (over 35 years) and grandmultiparity (para 5 and over) was twofold higher than low maternal age (<25 years) and low parity (para 0-1), P<0.05, respectively. The incidence of PPH was higher in deliveries conducted by midwives than doctors (P<0.05). Anaemic patients (PCV< or =30%) were more at risk than non-anaemic patients (P<0.05). Uterine atony, 183 (53.8%) was the most common cause of PPH and a combination of uterotonic agents and uterine massage were effective in controlling PPH in 171 (49.1%) of the cases. Seven (2.0%) patients required hysterectomy. One-third of the patients had a blood transfusion. To reduce the incidence of PPH, we recommend that doctors should supervise the delivery of parturients at risk of PPH and advocate health education against high parity.

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