Cervixsuspicious of

cancer

Appearance notsuggestive of

cancer (e.g.polyp,cervicitis, warts,

ectropion)

Normal

Fast trackcolposcopy(2 weeks)

Routine referral to a Colposcopy Clinic

Investigations : swabs + colposcopy +b

cervical smear if indicated

Treatinfection

If persistent PCB(6-8 weeks)

PCB

History includingsexual history,contraceptive

history and LMP

Speculum and pelvic examination

Swabs for sexually transmitted infection

Cervical smear should not be performedunless it is duea

Fig. 1. Proposed pathway for clinical assessment of women (all age groups)with postcoital bleeding (PCB). Adapted from the Clinical Practice Guidance by the UKAdvisory Committee forCervical Screening [2]. a As part of theUKNational Cervical Screening Programme,women aged 25–50 years are offered 3-yearly screening, followed by 5-yearly screening upuntil the ageof 65. The sensitivity is reported to be 84%. This program uses liquid-based cytology [4]. b Postmenopausal women should additionally have an ultrasound scan of the pelvis to assess theendometrial cavity.

0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijgo.2012.07.017

Hospital work shifts and days of occurrence of maternal deaths in 6 hospitals in theUpper West Region of Ghana

Kofi Issah ⁎, Alexis Nang-Beifubah, Rosina Yenli, Ambrose Naawah, Clifford Veng, Prosper TangGhana Health Service, Upper West Region, Ghana

a r t i c l e i n f o

Article history:Received 18 June 2012Received in revised form 1 August 2012Accepted 13 September 2012

Keywords:Day of weekGhanaHospital work shiftsMaternal death auditsMaternal mortality

⁎ Corresponding author at: Ghana Health Service, Upper West Region, P.O. Box 298Wa, Ghana. Tel.: +233 242210335, +233 392022204; fax: +233 392022471.

E-mail address: akofiissah@yahoo.com (K. Issah).

Many interventions have been put in place in low-resource coun-tries to reduce the high rates of maternal mortality. One of the effec-tive tools used to improve service delivery and therefore reducedeaths is the maternal death audit [1].

In the conduct of these audits, the managerial and technicalfactors contributing to deaths are identified and recommenda-tions made to health managers to help reduce the effects ofthese factors. The “3 delays” model [2] has identified these factorsas being associated with decision making at householdlevel, reaching a health facility, and receiving care at the healthfacility. The interplay of several factors at each stage of delay con-tributes to determine the outcomes of obstetric and neonatalemergencies.

It is the delay in receiving care at the facility that hospital man-agers can reduce when recommendations of audit committees arepromptly implemented. The ability to reduce the delays in provisionof adequate care in hospitals might also depend on the availability

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of skilled personnel, availability of equipment, drugs, and other sup-plies as well as the use of protocols within a functional quality assur-ance system.

The Upper West Region has the worst maternal health indica-tors in Ghana and to reverse this trend the Regional Health Servicehas conducted audits for 99 maternal deaths since 2009. The au-dits have become routine for the past 3 years and their qualityhas moved beyond diagnosing the cause of death to finding link-ages between the deaths, day of the week, and hospital worksshifts.

The present study was a retrospective study on maternal deathsoccurring over a 3-year period (January 1, 2009 to December 31,2011) in 6 hospitals in the Upper West Region that serve a populationof approximately 700 000 inhabitants. In 2011, these hospitalsrecorded 9554 prenatal attendances, about 11 000 deliveries, and806 cesarean deliveries.

The availability of doctors, midwives, and essential services weredocumented according to the hospital work shifts on each day of theweek. The 99 deaths were reviewed and reclassified into 11 catego-ries to reflect the most common direct and indirect causes of mater-nal deaths; when the deaths occurred was also documented. Datawere analyzed using SPSS version 16.0 (IBM, Armonk, NY, USA). In-formed consent was not needed therefore permission for the con-duct of the study was obtained from the Regional Director ofHealth Services.

All activities in the hospitals are organized in 3 shifts: morning(8 AM – 2 PM), afternoon (2 PM – 8 PM), and night (8 PM – 8 AM).One day is designated for routine obstetric and gynecologicalprocedures.

Except for the Regional Hospital, the other 5 hospitals have only 1permanent medical officer with skills in obstetric and gynecologicalprocedures and a total of 65 midwives. There is no more than an aver-age of 6 midwives on duty during the morning shift in the labor/ma-ternity wards of any of the 6 hospitals and not more than 3midwives on duty during the afternoon shifts and only 1 during thenight shifts.

Blood bank, theatre, and pharmacy services are open fully andstaffed during the morning shift. These 3 service delivery areas aremanned by skeleton staff during the night and the personnel have tobe called from their homes to open the facilities and provide servicesto emergency cases.

Data on 93 deaths were analyzed and, out of these, 48 (51.6%)were due to direct causes, 41 (44.1%) were due to indirect causes,and 4 (4.3%) had no cause of death stated. Table 1 shows the occur-rence of maternal deaths according to the length of hospital stay. Thehighest number of deaths (n=46, 49.1%) occurred within 24 hoursafter admission, 22 of which took place during the night shift. Withinthe same 24-hour period, 9 out of 15 deaths due to sepsis, 8 out of 11deaths due to postpartum hemorrhage (PPH), and 5 out of 11 deathsdue to anemia occurred. Table 2 illustrates the causes of maternaldeath and linkages with hospital work shifts. The highest numberof deaths (n=39) occurred on the night shift. It is also during thenight shift that 7 out of 11 deaths due to anemia and 5 out of 11deaths due to PPH took place.

The occurrence of 46 deaths within 24 hours after admission clear-ly highlights that emergency response systems, proper use of antibi-otics, and prompt provision of blood transfusions are not adequateon any given day of the week. Secondly, the inadequacy of the emer-gency response systems are more pronounced during the night shiftas nearly half of PPH patients (5 out of 11) and over 60% (7 out of11) of anemia patients died during this period. Wednesday was theday of the week on which the highest number of deaths occurred(n=19, 20.4%), while the weekend days of Saturday and Sundayrecorded 10 deaths each.

Although the numbers of maternal deaths involved are inadequatefor a more precise scientific analysis, the conduct of this study meansthat hospitals in low-resource settings are beginning to unravel other“hidden” managerial and administrative factors contributing to ma-ternal deaths.

This study has gone further in documenting the causes of deathsand their occurrence based on day of the week and the hospitalwork shift. In comparison, other studies have sought to document

Table 1Maternal deaths by length of hospital stay.

Cause of death Length of stay

b24 h 24–72 h 72 h −7 d >7 d Total

APH 0 1 0 0 1PPH 8 1 1 1 11Obstructed labor 3 1 0 0 4Sepsis 9 0 5 1 15Abortion 4 2 1 0 7PIH 1 1 0 2 4Eclampsia 3 1 2 0 6Malaria 1 0 1 2 4Anemia 5 1 4 1 11Other 10 6 8 2 26Cause of death unknown 2 1 1 0 4Total 46 15 23 9 93

Abbreviations: APH, antepartum hemorrhage; PPH, postpartum hemorrhage; PIH,pregnancy induced hypertension.

Table 2Occurrence of maternal deaths by work shift.

Cause of death Shift time Time of deathunknown

Total

8 AM – 2 PM 2 PM – 8 PM 8 PM – 8 AM

APH 0 0 1 0 1PPH 5 1 5 0 11Obstructed labor 0 2 2 0 4Sepsis 3 7 4 1 15Abortion 2 3 2 0 7PIH 2 0 1 1 4Eclampsia 0 2 4 0 6Malaria 1 1 1 1 4Anemia 1 2 7 1 11Other 6 8 10 2 26Cause of death unknown 0 2 2 0 4Total 20 28 39 6 93

Abbreviations: APH, antepartum hemorrhage; PPH, postpartum hemorrhage; PIH, pregnancy induced hypertension.

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the season of delivery during the year (wet or dry season) [3] andday of the week (weekdays or weekends) [4] that maternal deathsoccurred.

Although it is difficult to draw definite conclusions on the link-ages between the hospital shifts and the maternal deaths, the lownumbers of doctors and midwives available on any given day ofthe week might be an area to be reviewed by hospital managers.There is however the need for further qualitative research todraw these linkages and implement recommendations to avert ma-ternal deaths.

Conflict of interest

None declared.

References

[1] Pearson L, deBernis L, Shoo R. Maternal death review in Africa. Int J Gynecol Obstet2009;106(1):89-94.

[2] Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med1994;38(8):1091-110.

[3] Olopade FE, Lawoyin TO. Maternal mortality in a Nigerian Hospital. Afr J BiomedRes 2008;11:267-73.

[4] Ministry of Health/Ghana Health Service. National Assessment for EmergencyObstetric and Newborn Care. Accra: Government of Ghana; 2011.

0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijgo.2012.08.007

Emergency obstetric hysterectomy at University Hospital, Yaoundé, Cameroon

Pierre Marie Tebeu a,b,⁎, Patrick Esame Ndive c, William Takang Ako a, Paul Theodore Tjek Biyaga a,Joseph Nelson Fomulu a, Anderson Sama Doh a

a Department of Gynecology and Obstetrics, University Hospital, Yaoundé, Cameroonb Ligue d'Initiative et de Recherche Active pour la Santé et l'Education de la Femme, Yaoundé, Cameroonc Garoua Regional Hospital, Garoua, Cameroon

a r t i c l e i n f o

Article history:Received 13 June 2012Received in revised form 27 July 2012Accepted 11 September 2012

Keywords:CameroonEmergency obstetric hysterectomyIndicationsObstetric surgeryRisk factors

⁎ Corresponding author at: Department of Gynecology and Obstetrics, Faculty ofMedicine and Biomedical Sciences, University Hospital, Yaoundé, Cameroon. Tel.: +23777 67 55 33.

E-mail address: pmtebeu@yahoo.fr (P.M. Tebeu).

Emergency obstetric hysterectomy (EOH) is a high-risk operationwith a case fatality rate of up to 29.8% [1]. The present paper reportsa cross-sectional analytic study that was conducted from January 1,1998, to December 31, 2008, at the University Centre Hospital inYaoundé, Cameroon, following approval from the National EthicalCommittee. The aim of the studywas to investigate the EOHprocedureat University Hospital and its indications, risk factors, andcomplications.

All women who underwent EOH during the study period wereincluded. For each case of EOH, 3 controls were also included. Thesewere the next 3 consecutive women who delivered after each EOHcase butwhodid not undergo EOH, as registered in the delivery room re-cords. A total of 25 cases of EOH were identified. Of these, 5 were

excluded owing to missing files. Therefore, 20 cases of EOH were com-pared with 60 controls. Data on sociodemographic characteristics, pastobstetric history, maternal and newborn status were retrospectivelyreviewed. Data were analyzed using Epi info 3.5.1 (CDC, Atlanta, GA,USA). An odds ratio (OR) with a 95% confidence interval (CI) was usedto determine the risk of undergoing EOH. Pb0.05was considered statis-tically significant.

During the study period there were 20 039 deliveries and 25 EOHsperformed, for a prevalence rate of 1.25 per 1000 deliveries. Ageof the EOH patients ranged from 18–44 years and 80% were aged30 years or older (Table 1).

Indications for EOH were uterine rupture 7 (35%), uterine atony5 (25%), placenta accreta 3 (15%), disseminated intravascular coagu-lation 3 (15%), and placenta previa 2 (10%).

More women over the age of 35 years underwent EOH (40% vs6.6%; OR 9.33, 95% CI, 2.07–45.27; P=0.001) and were multiparous(75% vs 5%; OR 57.0, 95% CI, 10.27–381.52; Pb0.001) compared withthe control group (Table 2).

Among the EOH patients, 95% had a subtotal hysterectomy, whichis similar to the 80% reported in Nigeria [1]. There was 1 (4%) deathamong the 25 EOH cases in the present study, which was lowerthan that reported in Nigeria [1].

The prevalence rate of 1.25 per 1000 deliveries observed in thepresent study is similar to other reports, among which rates rangefrom 0.17–5.4 per 1000 deliveries [1–4]. The highest rates of2.5–5.4 per 1000 deliveries were reported in Asia and Africa andthe lowest of 0.17–1.9 per 1000 deliveries were reported in NorthAmerica, Central Europe, and the Middle East [1–4]. In Nigeria,71% of EOH patients were at least 30 years old, which is similarto the present study [1]. In Nigeria, indications included uterinerupture (35%), placenta accreta (15%), placenta previa (10%), anddisseminated intravascular coagulation (15%) [5]. In most

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