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  • Title: [Epidemiological surveillance and obstetrical dystocias surgery in Senegal].
    Author: Bouillin D, Fournier G, Gueye A, Diadhiou F, Cissé CT.
    Journal: Sante; 1994; 4(6):399-406. PubMed ID: 7850191.
    Abstract:
    Maternal morbidity and mortality remain major problems of public health in developing countries. Having long been neglected, maternal health is now being included among the priorities of a large number of countries. The rate of maternal mortality in Senegal is 850 per 100,000 live births, among the highest in the world. The main causes of maternal mortality in Africa are obstructed labour and uterine rupture, hypertensive disorders of pregnancy, puerperal infection and haemorrhage. An epidemiological survey of obstetric disorders was initiated in 1992 in Senegal to characterise the requirements for surgical coverage during pregnancy and delivery. In 1992, the national rate of caesarean section was low (0.66% of estimated births). However, rates differed greatly between regions, and between rural and urban areas. The indications for caesarean section were classified into three groups, each corresponding to a different public health issue. The rate of maternal mortality associated with surgery was high: 4.7%, of which 29% during surgery and 71% post op. Perinatal prognosis was also poor, with a mortality rate of approximately 30%. There are only 18 reference obstetrics units functioning, and they give a very uneven coverage of the country. These finding have led to new guidelines to improve the quality and cover of maternal care over the coming years. Senegal's maternal mortality rate of about 850/100,000 is one of the highest in the world. A program of epidemiologic surveillance of obstetrical pathology and surgery was established in 1992 in Senegal's 18 obstetric services. The monitoring program targets extrauterine pregnancy; cesarean delivery; hysterectomy for rupture, infections, or hemorrhage; forceps or vacuum extraction delivery; and embryotomy. The National Office of Maternal-Child Health and Family Planning periodically calculates intervention rates based on standardized reports from the centers. Indications for cesarean were classified into three groups: obligatory, referring to conditions such as fetopelvic disproportion in which the delivery could not otherwise proceed; prudent, for cases such as scarred uteri or breech presentation in which cesarean is not indispensable but may provide a better prognosis for the mother or child; and necessity, in which dynamic dystocia, hypertension, or other usually preventable maternal condition has not been adequately treated and threatens to lead to emergency cesarean to save the mother's life. During 1992, around 3220 women underwent obstetrical surgery. 75% of the interventions were cesareans, 10% were forceps deliveries, 9% were extrauterine pregnancies, 3% were hysterectomies, 1% were embryotomies, and 2% were other. The average maternal age for all interventions and for cesareans was 26 years, 7 months. 18.2% of interventions were in women under 20. 36% were primiparas, 25% had 2-3 children, 16% had 4-5, and 23% had 6 or more. Average parity was 3.5. 67% of forceps or vacuum extraction deliveries were in primiparas, while 64% of hysterectomies for infection or hemorrhage and 40% for rupture were in grand multiparas. The principal study objective was to determine surgical coverage of obstetric pathology for the country and its regions. In 1992, 0.66% of deliveries in Senegal were cesareans, with rates ranging from 1.24% in Dakar to 0.24% in Tambacounda. 50% of the cesareans were for obligatory indications, 28% were for indications of prudence, and 22% were for indications of necessity. The proportion for different categories of indications differed greatly in different regions. The maternal mortality rate for all indications was 4.7%, representing over 150 deaths. 29% of deaths occurred during the intervention and 71% in the postoperative period. The maternal mortality rate was 0.8% for extrauterine pregnancy, 1.9% for forceps deliveries, 4.4% for cesareans, 29.3% for hysterectomies for rupture, and 32.0% for hysterectomies for infection or hemorrhage. The perinatal mortality rate for all indications except extrauterine pregnancy was nearly 30%. A goal of 3% of deliveries by cesarean has been established for Senegal to ensure that all situations defined as obligatory will be treated by cesarean. Steps must be taken to improve the accessibility and quality of obstetrical surgery throughout the country.
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