Characteristics of health districts in Côte d'Ivoire and maternal mortality
Equipment and infrastructure
Sub-Saharan African countries have high maternal mortality ratios. To reduce maternal mortality, a district approach that favors the development of health sectors based on an operational unit has been experimented with within the health system of developing countries. In the context of the MDGs (Millennium Development Goals), this approach should have as its primary objective the reduction or optimal management of PPH, which is the leading cause of maternal mortality in Africa.
To achieve this, our health system is based on the configuration of a pyramidal organization, i.e., based on the referral and counter-referral system. The first contact health centers should be able to provide basic EmONC (emergency obstetrical and neonatal care), while the referral centers should provide complete EmONC through the availability of operating rooms. In Côte d'Ivoire, 100% of the districts had basic EmONC, which explains why all the districts had oxytocin as a uterotonic while only half of the districts (45%-56%) had their pharmacy supplied with Misoprostol. These elements in the framework of AMTSL (active management of the third stage of labor) are essential in the management of PPH. Of the 86 health districts in Côte d'Ivoire, 51 (59.30%) had complete EmONCs, i.e., 1.7 complete EmONCs per 500,000 inhabitants, and all the health districts had basic EmONCs, i.e., 4 basic EmONCs per 1,187,147 inhabitants. This is still sufficient according to WHO standards for full EmONCs and insufficient for basic EmONCs, as WHO recommends four basic EmONCs for one full EmONC per 500,000 inhabitants [7]. To varying degrees, this situation is found in most African countries. For example, a study carried out in Burkina Faso in 2004 showed that operating theatres were available in 85.5% of referral health facilities [8], whereas in Uganda [9], out of 41 hospitals and health centers, only 23 (56.10%) provided complete EmONC.
This average coverage of comprehensive EmONC in sub-Saharan African countries is one of the reasons for the high maternal mortality rate. In fact, despite the inadequacy of surgical facilities, the cesarean section rate was 19.3% in our study, which is higher than the 2% of cesarean section indications reported by the MICS 5 survey (Multiple Indicator Cluster Survey). This rate is also higher than that recommended by the WHO because according to a systematic review by the world body, increases in cesarean section rates of up to 10–15% at the population level are associated with decreases in maternal, neonatal, and infant mortality [10]. On the other hand, this increase in cesarean section rate beyond this threshold is no longer beneficial. This cesarean delivery rate of health care facilities varies considerably depending on the composition of the obstetric populations they care for, their capacity and resources, and their management protocols. For example, a 2004 study by Prual [11] showed that the cesarean section rate was excessively low in urban Africa (< 1.3%), whereas in Latin America the rate was excessively high (50% in some cities). In France, the figures were higher in 2007 with cesarean section rates ranging from 9–29.5% [12].
Moreover, it was also noted that more than half (77%) of the women in labor in these health centers came on their own while 22% were evacuated for obstetrical complications. This frequency of obstetric evacuations is lower than in Senegal where it was 31.2% in 2011 [13]. For these evacuations to be of good quality, these districts must have a significant number and quality of ambulances. However, there is an irregularity in the number of ambulances in the different districts, as almost all the health districts studied (59.30%) had at least one ambulance and 29.5% of the districts had 2 or even 3 ambulances. This delays the care of women and could explain the third delay: the delay in the evacuation of parturients. In other words, this reveals the delay in the administration of care, particularly the dysfunction of the health system, and the financial unavailability of patients. The lack of ambulances represented the dysfunction and the evaluation of maternal mortality, including 26.66% of deaths as reported by a study in Abidjan [14]. These obstetrical evacuations are an essential element of the referral and counter-referral system, and the lack of ambulances appears to be an obstacle to the evacuation of patients from a peripheral hospital to another central hospital. The consequence of this transfer dysfunction can be reduced by increasing the number and efficiency of facilities with full ERS. Since PPH is the major cause of mortality, delays in evacuation explain the precarious hemodynamic state of patients on arrival at the referral center. The establishment or existence of blood banks in these centers could contribute to the improvement of hemodynamic status and maternal mortality. However, in our study only 72% of the districts had a blood bank within the health facility between 2013 and 2015 and 80% had one between 2016 and 2017. Indeed a systematic review conducted by Bates [15] in 2008 showed that more than 25% of maternal deaths related to hemorrhage in sub-Saharan Africa were due to lack of blood. The lack of health facilities per capita, evacuation means or medical ambulances, of blood products and derivatives, and surgical technical platforms would explain in large part the high maternal mortality rates. However, other factors such as human resources also contribute to these deaths.
Human resources
For the animation of health centers, the quality, a sufficient number of health care personnel, and compliance with procedures remain important for the achievement of SDG 3. In Côte d'Ivoire, the doctor/population ratio varied from 1 per 12,887 in 2013 to 1 per 9648 in 2017. According to the 2015 annual health status report [16], these figures show that Cote d'Ivoire has reached the WHO standard of 1 physician per 10,000 population. Gynecological doctors represented 35.50% of all doctors. However, there is a disparity by the district at the national level. Considering the WHO standards, 80% of these health regions were below the WHO standards [16]. This dysfunction is also observed in the distribution of specialist physicians, which necessitated the use of 20.5% of general practitioners as gynecologists in some districts. Paradoxically, our series did not show a significant decrease in the number of deaths between the districts that had GPs and those that had gynecologists, which would indicate that in addition to the weakness of the figures to show a difference, the significant impact of the first and second delays could explain this observation. Indeed, the patients were evacuated (22.42%) in precarious conditions associated with the absence of blood products in the blood banks (79.60%) which could explain the fatal outcome. In Abidjan, Tonneau [17] reported that half of the deaths occurred within 6 hours of admission, indicating a critical condition on arrival.
Regarding paramedical staff, the ratio of midwives in our series according to women of childbearing age was 1 per 10,000 women from 2013 to 2017. Our figures are not superimposable with those of RASS 2015 (1 midwife per 3,000 women of childbearing age) [16]. However, this must be put into perspective because of a selection bias, as the ratios calculated in our study were based on a sample of practitioners from areas with an operating room only, thus excluding a good proportion of midwives. This exclusion at the base is likely to qualify the comparison and explain our low ratio because Cote d'Ivoire has reached the norms (1 midwife for 3000 women of childbearing age) [16]. However, the failure of health care personnel to respect norms and procedures can increase the number of maternal deaths. Indeed, a multicenter study conducted by the WHO in 2008 showed that 11 to 47% of maternal deaths in the countries studied (Colombia, India, Tanzania, and Vietnam) were due to faulty or inadequate intervention by medical personnel [18].
Reproductive health coverage
Women respond to this public health offer with its infrastructure and health personnel with an average attendance rate (38–46%). The various health facilities in our study received a total of 693,415 clients, which represents an average of 138,683 clients per year, or a frequency of 7 women per day. A study of the supply of prenatal consultations within the framework of free care at the Yopougon University Hospital (reference structure) in 2016 showed that the average number of visits to the gynecologist had increased from 8 to 12 women [14]. CPN1 coverage (prenatal coverage 1) represented in our study on average 41.79% of consultations. These figures are lower than those observed in Guinea (48%) and Burkina Faso (53%). Higher rates were observed in Senegal (60%). However, the lowest rates of prenatal consultations are found in Mali and Niger, respectively 13% and 20% [19]. These low attendance rates could be related to the difficulty of geographical access, the social and cultural environment, and the lower perception by rural women of the usefulness of the services offered by the health structures. The maternal mortality reduction strategy advocates for adequate prenatal care coverage. Indeed, good access to obstetrical care requires good prenatal care coverage. This lack of prenatal coverage is seen in several sub-Saharan countries, with rates varying from one country to another. Lower rates are found in Niger (5%) and Mauritania (17%). Efforts have been made by some countries to improve prenatal coverage figures; for example, the rate rose from 49–59% in five years (2006–2013) in Mali. The figures are almost similar in Nigeria (53%) and Senegal (63%) [19]. In Benin, the figures are much higher and antenatal coverage increased from 74% in 2001 to 81% in 2012 [20]. Our study shows that from 2013 to 2017 we noted a rate of assisted deliveries in the health districts of about 57.20%, these figures are close to the national rate of assisted deliveries in Côte d'Ivoire which is 54.65% [21]. This relatively high rate of assisted deliveries does not explain the high mortality rate. However, scientific evidence has shown that the increase in deliveries in health facilities has not been accompanied by the expected reduction in maternal mortality. This finding suggests that while service utilization increased, the quality of care in health facilities did not necessarily improve [22]. Many authors have shown that poor quality of care plays a major role in maternal mortality [23]. As the increase in hospital attendance does not reduce the high mortality rate, efforts should be made to improve the management of assisted deliveries.
Prevalence of postpartum hemorrhage
PPH is a major cause of MM worldwide with an incidence of 2–11% [1]. Its prevalence in hospital series in sub-Saharan Africa is very high. In our study, we recorded 20,796 cases of PPH for 540,508 deliveries, i.e. a proportion of 4%. The frequency of PPH varied in our study between 106 and 107 cases per 1000 live births between 2013–2014. We found a drop of about 75% in 2015 which stabilized between 33.1–37.63 PPH per 1000 live births from 2015-to 2017. This drop could be explained by an increase in the number of physicians between 2015 and 2017 in the management of obstetric emergencies which would have significantly reduced the number of PPH. According to the WHO, 70,000 women die from PPH each year [24]. A prospective study on risk factors related to MM conducted in several West African countries including Côte D'Ivoire showed a frequency of 1.7 PPH per 100 pregnant women [19]. Our figures are higher than those observed in Benin (2.3 cases per 100 deliveries). In addition, lower figures were observed in three studies in India, Burkina Faso, and Nigeria respectively 1.3, 0.8, and 2.9%. Of all the causes of PPH, delivery hemorrhage is the most frequent. In our study, it represented 65.39% of PPH. We noted 13599 cases of hemorrhage of the delivery for 540508 deliveries or a proportion of 2.5% from 2013 to 2017. However, several studies have shown that the distribution of emergency care is insufficient in Sub-Saharan Africa, particularly about delivery hemorrhage [25, 26]. The management of a delivery hemorrhage is medical and surgical. Medical treatment was carried out in 100% of patients as recommended by health guidelines and standards. Surgical management can be conservative or radical; uterine artery ligation, which is the conservative surgical management, was very rarely performed in our series (1.88%). On the other hand, radical surgery, i.e. hemostasis hysterectomy, was performed in 98.11% of cases.
Prevalence of hemostasis hysterectomy.
Hemostasis hysterectomy is generally considered the last resort for the management of PPH. The percentage of hemostasis hysterectomy within a country also varies from center to center, depending on the technical platform and protocols for the management of PPH. The high frequency of hemostasis hysterectomy in Côte d'Ivoire, as in developing countries, is related to the poor management of the third stage of labor. The late diagnosis of PPH in a patient with hemodynamic instability combined with the absence of blood products obliges the obstetrician to perform radical surgical management. According to the literature, a higher level of obstetric care is associated with a lower incidence of hysterectomy. It is therefore an indicator of the quality of care and the health care system.
Lethality of PPH
To reduce maternal mortality by 75%, a survey was carried out in 6 sub-Saharan African countries (MOMA survey). It showed in 2004 that the case fatality rate was 2.8% [27]. This rate is lower than that of our study which is 5.52%. This lethality related to PPH could explain the share of PPH in MM, which oscillated between 600 and 900 deaths per 100,000 births from 2013 to 2017 with a peak frequency in 2014 of 846.78 deaths per 100,000 births. A similar trend was observed in Burundi with 866 deaths per 100,000 live births [28]. Our results are in line with the observations of Hogan et al [29]. According to their work, the maternal mortality ratio in sub-Saharan African countries was above 280 deaths per 100,000 live births in 2008. These ratios observed in sub-Saharan Africa are well above those observed in the West. Indeed, according to Saucedo et al, the maternal mortality rate is 10.3 per 100,000 births in France [30]. The solutions are known, but their implementation in the health systems of developing countries represents a major challenge in terms of both the availability of resources and organization.