Emergency obstetric referrals to Mulago hospital: Sources, immediate maternal and fetal outcomes

Abstract

Within 72hrs after admis: Maternal and Child mortality, as largely avoidable causes of death are an important focus of international development, thus millennium development goals (MDGs) 4 and 5. The Uganda maternal mortality ratio (MMR) of 438 per 100,000 live births and infant mortality rate (IMR) of 54 per 1,000 live births are still high and far from the MDG targets. Emergency obstetric referrals contribute significantly to maternal and neonatal mortality. Mulago Hospital receives a large number of obstetric referrals, but, to date, little is documented about them. There is need to determine the sources, referral circumstances, socio-demographic and reproductive characteristics as well as immediate maternal and fetal outcomes of emergency obstetric referrals to Mulago Hospital in order to make evidence based decisions on how to improve the outcomes of these referrals as one way of improving maternal health and reducing child mortality. Objectives: The aim of the study was to determine the sources, immediate maternal and fetal outcomes of emergency obstetric referrals to Mulago Hospital. Methods: This was a descriptive cross sectional study with a follow up component conducted in lower Mulago Hospital, wards 5B Postnatal and 5C labour ward from 1st August to 30th September 2014. A total of 302 eligible mothers who had been admitted as emergency obstetric referrals were recruited after undergoing the required appropriate emergency interventions. Data was obtained using an interviewer administered questionnaire, and additional information on interventions and outcomes was obtained from their clinical records. Data was entered into Epidata version 3.1 and exported into STATA version 1.2 for analysis. Results: There were 261(86.4%) institutional referrals while 41(13.6%) were self referrals, 31 of whom came directly from home. The majority (55.6%) of the referrals were from within Kampala, followed by 32.5% from Wakiso district. Of the 261 institutional referrals, 19(6.3%) were from private general clinics , 29(9.6%) from private midwife clinics , 56(18.5%) from hospitals while 64(21.2%) came from health centre (HC) IVs and 103(34.1%) came from HC IIIs. Of the 56 referrals from hospitals,24 (42.9%) were from Naguru Hospital, while the majority of those from health centre IVs and IIIs were from Kisenyi HC IV (37.5%) and Kawaala HC III (26.2%) respectively. The majority (52.6%) of the referrals were delivered by emergency caesarean section while 33.7% had spontaneous vertex delivery followed by 9.6% who had emergency laparotomy and 2.4% had assisted vaginal deliveries. Out of the 29 ruptured uteri, 17 occurred after admission while awaiting interventions. Of the 302 mothers, 12(4.0%) died, 88(29.1%) were near misses while 202(66.9%) were alive and stable within 72hrs after admission. The MMR was 4,878 per 100,000 live births. Of the 300 babies delivered, 68(22.5%) had birth asphyxia with Apgar scores less than seven at five minutes while 46(15.3%) of the babies were admitted to the neonatal special care unit (SCU) for various reasons, and 54(18%) were still births. sion, the majority (66.9%) of the babies were alive and well while 38(12.6%) were still unwell and in special care unit, and 6(2.4%) of those born alive had died (early neonatal death). The perinatal mortality was 23%. The perinatal mortality rate was 259 per 1000 live births. Conclusion: The majority of the referrals were institutional referrals from within Kampala district, and from units like Naguru Hospital, and Kisenyi HC IV which should be able to provide the comprehensive emergency obstetric care that was needed by most of these referrals. The immediate maternal and fetal outcomes of the referrals were poor compared to the general obstetric population at Mulago Hospital in the same year. The likely reasons for the poor outcomes among these referrals were third delay (long decision to intervention interval) contributed to by congestion created by the many referrals, deficiencies in the referral mechanisms with inadequate support provided to patients during the referral process which were compounded by poor quality ANC, low socioeconomic status of the mothers, and low male partner involvement.