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Maternal Death Review in Gezira State, Sudan (2013)

Dr. Mohammed Hassan Abdel Gadr

MBBS 2004 (Kassala University)

A thesis submitted in partial fulfillment for the requirements of MD Degree in

Obstetrics and Gynaecology

Department of Obstetrics & Gynaecology

Faculty of Medicine - Gezira University

September 2016

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صدق اهلل العظيم

سورة البقرة

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Dedication

TO

My Family, my Wife and My Kids

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List of CONTENTS

List of contents…………………………………………….………………………..I

Abbreviations……………………………………………………………………...II

tables…………………….………………..……………………...........……..…. III

Acknowledgement…………………………….………………...…………...IV

Abstract………………………………………………………………….…….......V

Arabic Abstract………………………………………………………….…….......VI

CHAPTER ONE

Introduction ………………………………………….………………….….……...1

Justification…………………………………..……………………………….….....3

Literature Review……………………………..………………………..…….….....4

Objectives…………………………………..……………………………….….....22

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CHAPTER TWO

Methodology……………………………………………………………………....23

CHAPTER THREE

Results………………………………………………………………………….....27

CHAPTER FOUR

Discussion……………………………………………………………………...40

Conclusion….…….……………….……………….……………….……….…43

Recommendations. ……….……………………….…………………….…44

References……………………………………………………………….………..45

Appendix (Quationare)..................................................….......48

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ABBREVIATIONS

Acquired Immunodeficiency Syndrome AIDS

Antepartum Haemorrhage APH

Caesarean section C/S

Central Venous Pressure CVP

Disseminated Intravascular Coagulopathy DIC

Emergency Obstetrical Care EMOC

Health visitor H/V

Human Chorionic Gonadotrophin HcG

Haemolysis + Elevated Liver Enzymes +Low platelets HELLP

Midwife M/W

Maternal death MD

Maternal Mortality Ratio MMR

Postpartum Haemorrhage PPH

Statistical Package For Social Sciences SPSS

Vaginal Birth After c/s VBAC

World Health Organization WHO

Systematic maternal death review committee SMDRC

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LIST OF TABLES

28 Table:1 Distribution of MD according to place of death at Gezira

state (January2013_Decmber2013).

29 Table:2 Distribution of MD according to age at Gezira state

(January2013_Decmber2013).

30 Table:3 Distribution of MD according to cause of death at Gezira

state (January2013_Decmber2013).

31 Table:4 Distribution of MD according to hospital stayed before

death at Gezira state (January2013_Decmber2013).

32 Table:5 Distribution of MD according to route of admission at

Gezira state (January2013_Decmber2013).

33 Table:6 Distribution of MD according to parity at Gezira state

(January2013_Decmber2013).

34 Table:7 Distribution of MD according to GA in weeks at Gezira

state (January2013_Decmber2013).

35 Table:8 Distribution of MD according to follow up during current

pregnancy at Gezira state(January2013_Decmber2013).

36 Table:9 Distribution of MD according to ANC provider at Gezira

state(January2013_Decmber2013).

37 Table:10 Distribution of MD according to mode of delivery at

Gezira state(January2013_Decmber2013).

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38 Table:11 Distribution of MD according to outcome at Gezira

state(January2013_Decmber2013).

39 Table:12 Distribution of MD according to areas of delay at Gezira

state (January2013_Decmber2013).

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Acknowledgement

I am really sad to write condolence instead of acknowledgement.

The evening of December 28th of 2015 was a very sad to me when my two

supervisors; Dr. Adel Rahim Haggaz and Dr. Magid Ibrahim Ahmed were lost in a

traffic road accident while they were coming back from a Nobel mission in

Algadarif university participating in final class examination of the medical student.

That made sad all in the country .

I ask Allah to bless them and rest them including our brothers Dr.Osman Eltyeb ,

Dr, Mahir Gailani and the driver Rabiea Mosa, who were in the same accident.

My thanks extended to Sister Fatima Ahmed Abdalla , the focal person in

maternal deaths registration, for her help in collecting data and registering the

deaths.

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Maternal Death Review in Gezira State, Sudan (2013)

ABSTRACT

This is a prospective hospital and community-based survey study conducted in

Gezira State _Sudan during the period from January2013_Decmber2013.

Objectives of the study were to estimate maternal mortality at Gezira State, to

identify the causes of maternal deaths, and the risk factors. The data consisted of

all deaths occurred in Gezira State during the period of the study. They were 90

deaths, the number of live birth 96426. Data was analyzed , and maternal mortality

ratio was 93.3 per 100.000 live births .Causes of maternal death obstetrical

hemorrhage(26.7%),jaundice(18.9%),sepsis(12.2%),eclampsia(8.9%),anemia(2.2%),

rupture uterus (6.7%),malaria(3.3%), abortion(2.2%), anesthesia(2.2%), pulmonary

embolism (1.1%), others(15.6%). The significant risk factors were lack of ante natal

care, lack of family planning, previous caesarean section, anemia, education of the

mother and the husband. We recommend to continue in maternal deaths review

at hospital and community level. Also health education for mothers and upgrade of

the rural hospitals.

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(3102تقصي وفيات االمهات بالجزيرة )

ملخص األطروحة

انسدا في في اليت انجزيزة في في يعذل فياث األياث االسخباقيت أجزيج ذ انذراست

ذل فياث األياث يعحساب حيث كا انذف األساسي نهذراست يايز اني ديسبز انفخزة ي

99قذ كا عذد انفياث . عايم االخخغار األسباب انخي أدث إنى فياث األياث يعزفت

199,999يعذل فياث األياث في كم حان الدة. 96466 عذد انالداث انحيت فاة

%, 18.9% ,انيزقا 66.7أى األسباب فياث األياث كاج انزف 93.3 يند حي

%.6.6%, فقز انذو 6.7%, افجار انزحى8.9%, فزط ضغظ انذو يع انحم16.6ى انذو حس

% ي انفياث حذثج في ياعق حجذ با خذياث 91.1انخذياث انصحيت يخفزة بذنيم أ

% ي حاالث انفياث حزجع نعذو انخابعت 55.6 اسخغالنا كا ضعيفا بذنيم ا صحيت نك

أى انعايم انخي حؤثز عهى حياة األو أثاء ي أحضح ي ذ انذراست أ أثاء فخزة انحم.

صي باناصهت , فقز انذو. , انباعذة بي انالداث فخزة انحم انالدة ي ع انالدة

انسخشفياث انزيفيت شز انعي حأيم، يع بزايج حقصي فياث االياث اننذا

.االياث انصحي بي

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CHAPTER ONE

Introduction

Maternal Mortality definition

According to the World Health Organization (WHO) (1)

"A maternal death is defined as the death of a woman while pregnant or within 42 days of

termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause

related to or aggravated by the pregnancy or its management but not from accidental or

incidental cause.[2]

Maternal death, or maternal mortality, also "obstetrical death" is the death of a woman during or

shortly after a pregnancy. In 2010, researchers from the University of Washington and the

University of Queensland in Brisbane, Australia, estimated global maternal mortality in 2008 of

which less than 1% occurred in the developed world.[1] However, most of these deaths have

been medically preventable for decades, as treatments to avoid such deaths have been well-

known since the 1950s. (1)

Generally there is a distinction between a direct maternal death that is the result of a

complication of the pregnancy, delivery, or their management, and an indirect maternal death

that is a pregnancy-related death in a patient with a preexisting or newly developed health

problem. Other fatalities during but unrelated to a pregnancy are termed accidental, incidental, or

non obstetrical maternal deaths. ,[3]

Maternal mortality is a sentinel event to assess the quality of a health care system.

However, a number of issues need to be recognized. First of all, the WHO definition is one of

many; other definitions may also include accidental and incidental causes. Cases with "incidental

causes" include deaths secondary to violence against women that may be related to the

pregnancy and be affected by the socioeconomic and cultural environment. Also, it has been

reported that about 10% of maternal deaths may occur late, that is after 42 days after a

termination or delivery,[3] thus, some definitions extend the time period of observation to one

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year after the end of the gestation. Further, it is well recognized that maternal mortality numbers

are often significantly underreported.[4]

Reducing the maternal mortality by three quarters between 1990 and 2015 is a specific

part of Goal 5 -Improving Maternal Health- of the eight Millennium Development Goals; its

progress is monitored at mdgmonitor.org [5]

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JUSTIFICATION

Maternal Mortality Review Is a qualitative investigation of the causes and circumstances

surrounding maternal death in health facility or community, it could be a part of safe motherhood

need assessment or stand alone activity also could be used to initiate a system to strengthen

institutionalize maternal death reporting and analysis and safe motherhood or a mixture of two

approach. It has two main purposes: To activate intervention which reduced these avoidable

factors and prevent further maternal death and to raise the awareness among professionals and

community about risk factors could have been prevented.

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LITRATURE REVIEW:

Of all the experiences of the human condition, child birth represents the most important one. The

spectrum of maternal experiences of childbirth extends from exhilarated, fulfilled and enriched

mothers, to those women who are permanently crippled physically or emotionally and even, still

all too commonly, those who pay for the experience with their lives (6).

Maternal death is defined as “ the death of women while pregnant or within 42 days from

termination of pregnancy irrespective of duration and site of pregnancy from any cause related

to or aggravated by the pregnancy or it is management but not from accidental or incidental

cause” (6).

Pregnancy is not a disease and pregnancy related mortality is almost always preventable. Yet

more than half a million women die annually worldwide, due to pregnancy related

complications. About 90-95% of these come from developing countries. Maternal Mortality

Ratio (MMR) in developing countries ranges from 300 to 1000 in contrast with 2.9 in the

industrialized world. This is the only Public Health Statistic with such a huge difference. There

are a number of causes behind this problem, major being illiteracy, lack of health education, lack

of Trained Birth Attendants (TBAs), lack of transport facilities and lack of Health Care Services.

Major Clinical causes include Haemorrhage, Hypertensive disorders/Eclampsia, and Puerperal

sepsis. Literature review has shown that a number of deaths occur even after reaching and

seeking maternity care services either at Primary; Secondary and Tertiary level (7).

Levels of maternal mortality and morbidity tell us about the risk attributable to pregnancy and

childbirth as well as the performance of health systems in terms of access to health care and the

quality of care provided. However, accurate assessment of these indicators has been problematic.

The World Health Organization (WHO) has developed estimates of maternal mortality, anaemia

during pregnancy, low birth weight and unsafe abortion at national, regional and global levels

using modeling techniques. The lack of good quality data for many countries and different

methodologies used to estimate levels of mortality complicate monitoring of the trends and

comparisons between countries. Although considerable amounts of facility-based data on

maternal morbidity are generated, these may not reflect the actual health status of women in the

whole community or area. Population-based data on the status of women's health are more useful

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and needed, yet scarce. Even when available, the challenge remains as to how to compile and

summarize the data and thus map the burden of reproductive ill-health. A logical approach is to

extend the concept of systematic reviews from randomized controlled trials to observational data.

For more than a decade, systematic reviews of randomized controlled trials (RCTs) have been

used increasingly to evaluate the effectiveness of various health care interventions (8).

The Cochrane Library as of 2004 includes more than 3000 systematic reviews. Considerable

experience of methodological issues such as literature search, critical appraisal of identified

studies and methods for summarizing data has been gained and tools have been developed for the

reviews and meta-analysis of RCTs. However, systematic reviews of observational studies are

rather rare and the relevant experience is limited. Most of the work in this area relates to

questions for which RCTs are difficult, impossible or unethical to conduct (e.g. testing

aetiological hypothesis, less common adverse effects in drugs). Methodological issues with

regard to inclusion of studies with different designs, population and setting characteristics, and

statistical methods to combine the data are evolving and need to be improved. With these

considerations, we are conducting a systematic review of prevalence/incidence of maternal

mortality and morbidities from 1997 to 2002. The primary objective is to contribute to mapping

the global burden of reproductive ill-health. The review will provide a comprehensive,

standardized and reliable tabulation of available data on the incidence/prevalence of maternal

morbidity and mortality, and case-fatality rates for maternal morbid conditions (9).

Maternal mortality is a sentinel event to assess the quality of health care system however, a

number of issue need to be recognized first of all the WHO definition is one of many other

definition may also include accidental and incidental causes .Cases with incidental causes

include deaths secondary to violence against women that may be related to the pregnancy and be

affected by socioeconomic and cultural environment. Also it has been reported that 10% of

maternal death occur late , that is after 42 days of termination of pregnancy ,thus some

definition extend for one year. The majority of maternal deaths occurring in the world

occurs in the developing countries 99% .

Global attention began to focus more seriously on maternal mortality when in 1985; Rosenfield

and Maine (1985) published a thought-provoking article in the Lancet. In this classic article titled

'Maternal Mortality - a neglected tragedy - where is the M in MCH?', Rosenfield and Maine

alerted the world to the fact that many developing countries were neglecting this important

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problem and that existing programs were unlikely to reduce the high maternal mortality rates in

the developing world. Another significant contribution to the crusade against maternal mortality

was the WHO (1986) publication, 'Maternal Mortality: helping women off the road to

death.'(10).

All these led to the Safe Motherhood Conference in Nairobi, Kenya in 1987. Speakers at this

conference presented global statistics on death and complications resulting from pregnancy.

They also showed that in sub-Saharan African, the lifetime risk that a woman would die in

childbirth is 1 in 21 and that this is 400 times higher than the lifetime risk for her counterpart in

Western Europe or North America. The conference concluded with strong recommendations

about maternal health and that was when the Safe Motherhood Initiative was born (10).

The reduction of maternal mortality by half the 1990 levels by the year 2000 was a goal common

to several of such conferences including in particular, the 1990 World Summit for Children, the

1994 Cairo International Conference on Population and Development and the 1995 Fourth World

Conference on Women. At the Millennium Summit in September, 2000, the largest gathering of

world leaders in history adopted the United Nations (UN) Millennium Declaration, committing

their nations to a new global partnership aimed at eradicating extreme poverty and hunger,

achieving universal primary education, promoting gender equality and empowerment of women,

reducing child mortality, improving maternal health, combating HIV/AIDS, malaria and other

diseases and ensuring environmental sustainability. These targets were all given a deadline of

2015 and have since been known and referred to as the Millennium Development Goals (MDGs)

(11).

Globally, 529,000 women die each year from pregnancy-related complications, of which about

90% occur in developing countries, the worst affected being West Africa, including Ghana (UN

Millennium Project, 2006). In Africa 1 out of 16 women stand the risk of dying through

pregnancy and childbirth. The risk of maternal deaths is highest in Africa, where countries

struggle to provide health services for large number of its populations.

The World Health Organization (WHO) states that worldwide 1500 women die each day, or one

a minute, in pregnancy or due to childbirth related complications. It is estimated that over half of

these deaths are in sub-Saharan Africa, with maternal mortality ratio of 910 deaths per 100,000

live births (WHO, 2006). Maternal haemorrhage, obstructed labour, postpartum sepsis,

eclampsia, unsafe abortion and anaemia are among the leading causes of death among pregnant

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women in developing countries. These complications of pregnancy contribute significantly to the

high levels of maternal and neonatal mortality in Sub-Saharan Africa (12).

Measures of maternal mortality:

Maternal Mortality Ratio: the number of maternal deaths per 100,000 live births

calculated in a year, it represents the risk associated with each pregnancy, i.e. the time period of

observation to one year after the end gestation.

Maternal Mortality Rate: the number of maternal deaths per year per 100,000 females in

the reproductive age group (15 – 49 years),it take into account not only the obstetric risk , but

also the frequency with which women are exposed to that risk .

Lifetime Risk: the number of maternal deaths in the reproductive period divided by the

number of women entering the reproductive period ,it measure women’s risk of becoming

pregnant as well as the risk of dying while pregnant.

The difference in maternal mortality between rich (mortality risk 1 in4000-10 ,000) and poor

countries (mortality risk 1 in 15-50) is one highest public health. A total of 99% of all maternal

deaths occur in developing countries ,where 85% of population lives .More than half of these

deaths occur in sub-Saharan Africa and one third in South Asia .The maternal mortality ratio in

developing countries is 450 maternal deaths per 100 000 live birth versus 9 in developed

countries .Fourteen countries have maternal mortality ratio of at least 1000 per 100 000 live birth

, except Afghanistan all are sub-Saharan Africa : Angola ,Burundi ,Cameron ,Chad the

Democratic republic of the Congo, Guinea-Bissau, Liberia ,Malawi ,Niger ,Nigeria ,Rwanda

,Sierra Leone and Somalia . It is estimated that about 500,000 mothers die annually in the

world or 1600 maternal death per day or about one maternal death per minute, of these it is

estimated that 100,000-200,000 are related to poorly performed or illegal abortion (13).

Maternal Mortality Review: Is a qualitative investigation of the causes and be a part of

safe motherhood need assessment or stand alone activity.

It could be used to initiate a system to strengthen institutionalize maternal death reporting and

analysis and safe motherhood or a mixture of two approach It has two main purposes first one to

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activate intervention which reduce these avoidable factors and prevent further maternal

death.seond raise the awareness among professionals and community about risk factors this

could have been prevented .

Underlining principles are,Confidentially,Every maternal death should be reviewed,Information

must be freely.MMR/MDR should not be a fault finding exercise and therefore punitive action

should not be the result.WHO state four levels to safe mother hood.family planning,ANC.Clean

safe delivery.

Reducing the maternal mortality by 75% between 1995-2015 is specific part of goal (13).

Maternal death is directly affected by maternal health status no one knows exactly how many

women die each year as a result of becoming pregnant. Most of those who die are poor, live in

remote areas and their deaths are recorded little importance. In the part of the world when

maternal mortality is highest, deaths are rarely recorded and even if they are, the cause of death

is usually not given. Fortunately, in recent year there have been a growing number of good

community surveys which shed some lights on the problem in places where very little was

known before. By definition death of mother in the reproductive age while she pregnant or intra

partum or forty days postpartum not due accidental or incidental cause, maternal health status is

a necessary precondition for maternal death. The health status of women is determined by

developing obstetric complication during pregnancy, delivery or post partum period including

hemorrhage, eclampsia, retained placenta, prolonged labour, sepsis operative deliveries, rupture

of the uterus. A women’s personal health status prior to and during pregnancy can have an

important influence on her chances of developing and surviving a complication. The leading

preexisting health conditions (obstetric problems) that are exacerbated by pregnancy and

delivery account for approximately one-quarter of maternal deaths in developing countries are

malaria, jaundice, anemia, urinary tract infection vaginal bleeding, diabetes and renal disease.

Other exogenous variables that affect maternal health status include the prevalence of harmful

traditional practice such as FGM, early marriage and food taboos among the societies in the third

world countries (14).

Notwithstanding, intermediate variables play a very important role in the working mechanism

and efficacy of both the endogenous and exogenous variables. Regarding the socioeconomic

status, many studies have proved the high influence of maternal health status is by age, parity,

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residence (rural-urban), education (illiterate, primary, secondary) occupation, income, exposure

to media, and social and legal autonomy in the society. For services to be effective, women have

to use them. The use of prenatal care (to diagnose either preexisting health problems or to detect

certain complications), the use of care during and after labour (treat complications that may

arise) and the use of family planning for either delaying or spacing birth are particularly

important for the health of both mother and child (14).

Maternal Care:

Maternal care is essential for both the mother and the child health. The risk of maternal mortality

and morbidity as well as neonatal death can be reduced substantially through proper prenatal

care, such as regular antenatal check-ups during pregnancy and delivery under safe and hygienic

condition. The importance of maternal health services in reducing maternal and infant morbidity

and mortality has received significant recognition in the past decade. Studies demonstrating the

high levels of maternal mortality in developing countries, identifying causes of maternal death

have repeatedly emphasized the need for prenatal care and availability of trained personnel to

attend women during labour and delivery. Mother death caries profound consequences not only

for her family, especially her surviving children, but also for her community and country. In

addition, because a women dies during her most productive years, her death has a strong social

and economic impact, her family and community lose a productive worker and primary care

giver.

Care during Pregnancy:

Maternal care during pregnancy provides an important opportunity for discussion between a

pregnant women and health care providers about healthy behavior during pregnancy such as

adequate nutritional of recognition complications that may arise during pregnancy and the

delivery plan that will meet the needs of individual women. Antenatal care is important for

preventive care, including Tetanus Toxoid (TT) immunization and provision of iron/folic acid

tablets to prevent and treat anemia. Antenatal care is important for early diagnosis and prompt

treatment for complication of pregnancy that can arise during pregnancy such as hypertensive

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disorders, STDs, Malaria and infections. Prenatal care visit are considered most effective if the

visits are started at early pregnancy and continued at a regular intervals throughout the pregnancy

(15).

Care during Delivery:

The vast majority of women will need only basic care during labour and delivery. Cleanliness

and the presence of skilled personnel will help to ensure that normal births are clean and save

and that obstetric complications are dealt with promptly. Doctors, midwives and nurses who

attended deliveries must have the midwifery skills needed to recognize the onset of

complications, perform essential interventions, start treatment and supervise the referral of

mother and baby for the management of interventions which are beyond the care giver’s

competence or not possible on that particular facility (15) .

2.4.3 Postpartum Care:

There has generally been less attention paid to the role; and content of post partum care than to

other aspects of maternal mortality and morbidity occurs during post partum period. Early post

partum care is essential in order to diagnose and treat complications, such as puerperal

infections, secondary post partum hemorrhage and eclampsia, which are major causes of post

partum mortality. Postpartum care provides an opportunity to check on the general wellbeing of

mother and infant and to ensure that the infant is feeding well. Postpartum care has been a

relatively neglected aspect of maternity care. Less than one-third of developing countries report

national data, and level of coverage are as low as 51%. The lack of reporting of postpartum care

is an indication of the low priority placed on this aspect of care which does not feature in the

goals of major international conferences. Estimates based on the limited data available indicate

coverage of post partum care below 30%. This low level of care is disturbing since timely

interventions during the post partum period can prevent death of both mothers and newborn

infant (16).

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2.5 Family Planning Service:

Family planning programs are meeting current demand better by expanding the range of

contraceptive choices, reaching more climate in rural areas, providing empathic counseling, and

addressing the concerns of their clients. Nonetheless according to a study of 20 developing

countries in 1990, averages of 22% of all births are unwanted (17).

In developing countries the percentage of married couples using contraception has risen

substantially from less than 10% in the 1960s to 55% in 1998, and it continues to rise. Family

planning could avoid most of the estimated 78000 maternal death that result from unsafe

abortion, about 13% of 585,000 maternal deaths each year. Worldwide if all couples who do not

currently want to have a child used effective contraception, most of the estimated 416 million

induced abortions each year would not occur. And therefore, expanding and improving family

planning programs and increase use of effective contraception reduce the risk of pregnancies and

abortion. As studies have shown in many countries and at different time, abortion rates have

fallen (18).

Every pregnancy poses risks. When a woman wants to avoid pregnancy, using contraception

consistently and correctly helps protect her from exposure to the risk pregnancy and childbirth.

In developing countries complication of pregnancy and childbirth cause at least 25% of death

among women in reproductive age compared with less than 1% in developed countries. For some

women, pre-existing medical conditions make pregnancy especially risky. Such condition

include high blood pressure, valvular heart disease, heart disease with blocked arteries, diabetes,

a history of current breast cancer, malaria, sickle cell disease, anemia, tuberculosis, hepatitis, and

sexually transmitted infection. Pregnancy may aggravate these conditions which can be fatal.

Among women who do not want to have children, contraception can save lives by avoiding the

possible complication of childbirth, which can be especially risky when access to emergency

obstetric care is limited (19).

Studies have found that childbearing is safer for women between the age of 20 and 40. This

indicated that only through family planning that the teenager could avoid pregnancy and

therefore avoid complications such as obstructed labour ad eclampsia. Regarding old mothers

over 40 childbearing is very danger to their health and the risk of death is five times higher than

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among women in their 20s.In a social environment that allows women to take other roles than

motherhood, family planning empowers women by enabling them to choose the number and

timing of their births. In Sudan, fertility controls is not yet get priority in Government’s plan for

actions. Much of the emphasis of the Federal Ministry of Health (FMOH) which is also in-charge

of providing family planning services is to reduce maternal and infant mortality rate through safe

motherhood programs (20).

2.6 Causes of Maternal Death:

It’s customary to classify the causes of maternal death under three headings; direct, indirect and

coincidental. Direct causes refer to diseases of complication that occur only during pregnancy,

including abortion, ectopic pregnancy, hypertensive diseases of pregnancy, ante-partum and post

partum hemorrhage, obstructed labor and puperial sepsis. Indirect causes are diseases that may

be present before pregnancy but are aggravated by pregnancy, such as heart disease, anemia,

malaria, hepatitis, diabetes mellitus and Tuberculosis (21).

2.6.1 Hypertensive Disease of Pregnancy Pre-eclampsia & Eclampsia:

This group of disease includes pre-eclampsia and eclampsia. The characteristics of pre-eclampsia

are high blood pressure, protein in the urine and swelling of the tissues (Edema) during the

second half of pregnancy. Headaches, vomiting blurring of vision and pain in the upper abdomen

occur and the affected women may then stop producing urine. In the last and most severe stage

of this disease, convulsions develop; this is the stage referred to as eclampsia. If eclampsia is left

untreated the women rapidly becomes unconscious and dies from heart failure, kidney failure,

liver failure or brain hemorrhage. Once eclampsia develops, immediate treatment and rapid

delivery are needed. In tropical Africa the disease can develop rapidly, progressing from the

earliest physical signs right through to eclampsia within 24 hours. Pre-eclampsia, common

during first pregnancies, a woman having overweight, has diabetes mellitus or essential

hypertension, or is expecting a multiple birth, girls in the early teenage years who are pregnant

for the first time, and those over 35 years are particularly vulnerable. There is also evidence that

preeclampsia runs in families (22).

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2.6.2 Obstructed Labour and Rupture of the Uterus:

In most cases of obstructed delivery, the problem arises because the space in the bony birth canal

of the mother is either too small or too destructed by disease to permit easy passage of the head

of the baby during labour. Therefore short women are more likely to develop obstructed labour

than the taller of the same age. The relationship is the proportion of women with small pelvises

decrease steadily with increasing height. Genetic, physiological and environmental factors

including nutrition all affect the status of person. Under less favorable conditions where

environmental hygiene is poor and malnutrition and infectious disease such as Malaria, diarrhea

and measles are spread, growth in stature will be slowed causing stunting. Some of the most

extreme forms of pelvic contraction are found in societies where there is mass poverty, and

where childbearing is begin before girls are fully grown. In such areas labour is often obstructed

at the time of the birth of the first baby. The principal way to relieve the obstruction and to save

lives of both mother and baby is to perform a caesarean section. If the condition is not dealt with

in its early stages, the obstruction can last for days and may result in the death of the mother

through infection and exhaustion. Rupture of the uterus is another major complication of

obstructed labour. Extremely rare in women giving birth for the first time, it may be a common

occurrence in those who have borne several children. Once the uterus ruptures, there is severe

pain and tenderness over it, heavy bleeding and the death results from hemorrhage and shock

within 24 hours. Surgical treatment, aimed at arresting the bleeding, is always necessary if the

mother is to survive. This is achieved either by repairing the tear in the uterus or by removing the

uterus (hysterectomy). Other cause of obstructed labour include; deformity or abnormal position

of the fetus; and abnormalities of the cervix or vagina, sometimes caused by female

circumcision. However, obstructed labor is common in developing countries (23).

2.6.3 Hemorrhage: Bleeding related to late pregnancy and delivery can be

conveniently considered under two main heading; ante-partum hemorrhage, in

which vaginal bleeding occur before the child is born; and postpartum hemorrhage,

where excessive bleeding begin, after the birth of the baby.

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2.6.3.1 Ante Partum Hemorrhage:

Episodes of bleeding through the vagina during pregnancy are always abnormal. When such

bleeding occurs before the 28th week of pregnancy, it’s commonly associated with abortion of

one kind or another. Bleeding after 28th weeks of pregnancy may be due to premature separation

of the placenta, or to injury or even to disease affecting the lower genital tract. In cases where the

bleeding is associated with placental separation, the eventual outcome will depend partly on the

position of the placenta within the uterus. Placenta praevia is the other type of ante partum

hemorrhage. Here the bleeding is from the separation of a placenta whose position in the uterus

is abnormal in the lower part such a condition required rapid delivery around 38th of gestation

(19).

2.6.3.2 Postpartum Hemorrhage:

Postpartum hemorrhage refers to excessive bleeding through the birth canal after the birth of the

baby. It takes place normally due to the failure in the separation of placenta, and therefore

bleeding will not stop as long as the placenta or a part of it remains in the uterus. Other causes of

post partum hemorrhage include prolonged labour, all forms of operative vaginal delivery, the

action of anesthetic agents, and uterine tumors such as fibroids. Heavy bleeding can also result

from injuries caused during childbirth, either spontaneously or during operative delivery.

Rupture of the uterus, tears in the cervix and vagina, and injuries lower down the birth canal and

the perineum can all cause hemorrhage. Women with a multiple pregnancy and those who have

had four or more previous birth are particularly at risk of postpartum hemorrhage. The risk of

dying from hemorrhage depends on the amount and rate of blood loss on the state of the patient.

A woman with ante partum hemorrhage is estimated to have around 12 hours to live unless she

receives treatment and women with postpartum hemorrhage only 2 hours. Not surprisingly;

hemorrhage is the biggest single cause of maternal death in many reports from developing

countries (24).

2.6.4 Ectopic Pregnancy:

Ectopic pregnancy is another important cause of heavy bleeding. In this condition the

implantation of the fertilized ovum and its development which take place in the uterus, occur

28

outside it, resulting in the rupture of the fallopian tube as it can’t accommodate the growing

embryo and fetus. (Usually within the first 10 weeks of pregnancy). There is bleeding, and blood

accumulates in the abdomen producing pain, fainting and shock. The analysis of maternal death

revealed that ectopic pregnancy was responsible for 10% of such death .

2.6.5 Puerperal Sepsis:

For various reason women are particularly prone to infection of the genital tract following

delivery and abortion. Tears in the lining of genital tract, blood clots, tissue fragments and pieces

of the product of conception abound and these may become infected. The affecting germs may

enter the genital tract in various ways such as unclean hands or uses of dirty instruments.

Infection can also be conveyed from dust in the atmosphere, transference of infected organism

from anus, insertion of foreign objects into the vagina during labour such as herbs, leaves, mud

or various oil by traditional attendants. Abscesses may form within the fallopian tubes, the pelvis

and underneath the diaphragm. In severe cases, the infection can spread into the bloodstream

(septicemia) giving rise to abscesses in the brain, muscles heart and kidneys. If the infection is

not controlled, mental disorientation and coma set in and death occurs from a wide variety of

complications including shock, kidney failure, liver failure and anemia (25).

2.6.6 Death from Abortion:

Every year between 40 and 60 million women seek termination of unwanted pregnancies.

Induced abortion is the oldest and probably widely used method of fertility control. In many

parts of the world induced abortion is still illegal or severely restricted by the law; elsewhere

some governments have legalized pregnancy termination have yet to provide adequate services

to meet the demand. As a result, a large proportion of the world’s women are without access to

safe procedures carried out by professionally qualified personnel under aseptic conditions.

However, there is over helming evidence that neither restrictive law nor lack of access to

professional care stop women from seeking abortion. On the contrary, such obstacles affect only

the outcome of the procedure. The most common abortion complications are incomplete

abortion, sepsis, hemorrhage, and intra-abdominal injury. Except for intra-abdominal injury, all

complication can result from either spontaneous abortion (miscarriage) or induced abortion. Left

untreated, each can lead to death. Also, women surviving immediate abortion complications

29

often suffer life-long disability or face elevated risk of complications in future pregnancies .In

Sudan there is a little evidence available about the nature and scope of the problem of induced

abortion, although the 1991 FMOH statistics indicate that it’s indeed a problem. There is some

evidence to suggest that induced abortion is also a problem. The availability of valid and reliable

information about the underlying reasons for and consequence of spontaneous or induced

abortion would be facilitating the tailoring of services to respond to these problems (26).

2.6.7 Operative Deliveries:

Operative deliveries take several forms. In some, the manipulations needed to extract the baby

are carried out vaginally. Obstetric forceps, vacuum extraction and destruction of the fetus are

example of operative vaginal delivery. The other group of operative deliveries is abdominal,

caesarean section being the commonest. All operative deliveries carry risks to the mother and

infant. The risks arise partly from the nature of the operations, partly from other procedures that

go hand in hand with operative deliveries. Such as anesthesia and blood transfusion, and partly

from the pregnancy complication which necessitated the operation in the first place. Other

complications develop after operative delivery such as severe bleeding and infection much will

depend on the quality of care available.

2.7 Other Medical Causes of Material Death:

Embolism, sickle cell disease and complications associated with anesthesia currently contribute

little in the high death rate during pregnancy in the third world. An embolus is a plug of material

such as fat, amniotic fluid, air or blood clot that blocks a blood vessel. In pregnant women,

emboli formed from blood clot are the commonest variety. The clot starts to form in the deep

veins of the lower limbs and the pelvis, and eventually lodge in the lungs. Women over 35 years,

overweight and those who delivered by caesarean section are especially at risk.

Improvements in an anesthesia techniques and technical expertise are among the most important

reasons for the fall in maternal mortality rate in developed countries. Failure in managing the

anesthetic techniques properly leads rapidly to death from cardiac and respiratory arrest and

sometimes from gas embolism .

30

2.7.1 Anemia: Anemia is the term used to describe the condition in which there is a reduction

of the concentration of hemoglobin in the bloodstream to a level (below 110g/1 for pregnant

women).During pregnancy, growth of the fetus and of the uterus, lead to an increase in the

demand for many nutrients, especially ion and folic acid. Since most women in the third world

start pregnancy with depleted body stores of these nutrients, their extra requirement is even high

than usual. If because of dietary deficiencies, these needs are not met, the rate of formation of

hemoglobin declines and its concentration in the circulating blood falls. Malaria, sickle cells

disease, bacterial infections, and blood loss from abortion ectopic pregnancy or intestinal

parasites such as hookworms are all important causes of anemia. Behind the medical causes of

anemia, socioeconomic factors play an important role. The extent of poverty in developing

countries largely explains why serves anemia is so common and why its affect are so serious

throughout most of the developing countries. WHO estimates, three of every five pregnant

women in developing countries except in China are anemic. Anemic women are less able to

resist infection and less able to survive hemorrhage or those complication of labour and delivery.

The term sickle cell disease is used to describe a group of inherited blood diseases in which there

is an abnormality in the chemical structure of the hemoglobin. It affects the red cells and leads to

anemia. Death results associated with sickle cell disease occurs during the last four weeks of

pregnancy, labour and first week after delivery .Even normal pregnancy and childbirth put stress

on the cardiovascular system. Thus may be fatal to women with heart disease.

2.7.2 Jaundice in Pregnancy and Acute Liver Failure:

Malaria, certain blood disease and hepatitis can cause Jaundice and threaten life during

pregnancy. Viral hepatitis is a disease in which the liver is invaded and injured by certain viruses

and to which pregnant seem to be especially susceptible, there are three forms of viral hepatitis;

hepatitis A hepatitis B, and hepatitis none A, non B Viral hepatitis in its fulminating form occurs

most often in the third trimester of pregnancy. Premature labour, liver failure and severe

hemorrhage commonly complicate this form of the disease, and many infants are born too soon

to survive. The deaths of mothers result from liver failure and severe hemorrhage (27).

2.7.3 Sexual Transmitted Disease HIV/AIDS:

31

Sexually transmitted diseases should be treated before a woman becomes pregnant to avoid

complications of pregnancy such as ectopic pregnancy, spontaneous abortion, and premature

onset of labour, postpartum infection, which can cause death and infection of the infant. Better

than treatment is prevention, a mutual faithful, long term sexual relationship with one partner is

best protection. Women at risk of acquiring an STD, however, can protect themselves and their

children by insisting that their partners use condoms, and preferably by using barriers

contraceptive method themselves well. Aids –acquired immune deficiency syndrome is a new,

deadly and rapidly spreading sexual transmitted disease. Unlike most, other sexual transmitted

disease, there is no cure for AIDS. Human immunodeficiency virus (HIV) which causes AIDS is

infecting increasing numbers of young women in the prime childbearing ages. Once infected, a

pregnant woman-with or without symptoms, passes the virus to her child, before or during

delivery, in 30 to 60 percent of cases (28).

2.7.4 Reproductive Factors:

2.7.4.1 Too Close: Spacing birth or acceding pregnancy for at least 24 months is considered to

be an important factor that determines the health of mothers and children too. Spacing

pregnancies at least two years is particularly important in developing countries, where infant

mortality rate are over 10 times higher than in developed countries .

2.7.4.2 Too Young: When a woman is tow young, pregnancy – wanted or unwanted can be

dangerous for both mother and infant. Complication of childbirth and unsafe abortion are among

the main causes of death for women under age 20. Even under optimal conditions, younger

mothers, especially those under age 17 are more likely than women in their 20s to suffer

pregnancy related complications and to die in childbirth. The risk of death may be two to four

times higher, depending upon women’s health and socio-economic status .The life threatening

complications of pregnancy that women under age 20 face are the same risk that all other women

face, hemorrhage, sepsis, and pregnancy induced hypertension including preeclampsia and

eclampsia, obstructed labour caused by cephalo pelvic disproportion, complication of unsafe

abortion and iron deficiency anemia. These risks are higher for younger women not only because

of their age but also because births to younger women often are first birth, which are riskier than

the second, third or fourth birth. Socio-economic factors; including poverty malnutrition. Lack of

32

education and lack of access to prenatal care or emergency obstetrical care can further increase a

young woman’s risks of pregnancy related complications (29).

2.7.4.3 Too Old: The health risks of childbearing increase after age 39, among women age

40-44; the risk of death is five times higher than among women in their 20s. Older women may

have accumulated various health problems during their lives, such as hypertension, kidney

disease or diabetics which can cause obstetric complications. In addition, older women are more

likely to have already had five or more births which also increase the risk (30).

2.7.4.4 Too Many: The risk of maternal complication rises dramatically after a women’s fifth

birth. Regardless of a women’s age, her risk of dying when giving birth for the fourth time or

more is an estimated to be 1.5 to 3 times higher than when having the second or third birth.

Women, who have at least-four births, often develop complications during delivery. Such

women are more likely to be complicated by hemorrhage during delivery or have a rupture of the

uterus, uterine prolapsed or kidney disease.

Logistic Problems:

Place of residence, especially in developing countries, is associated with major difference, not

only in environmental sanitation, quality of having socio-economic and cultural conditions, but

also in their health status and problems. Mortality rates for instance were found to be invariably

higher in rural areas than in urban areas.

Community factors: Including environment and geography also disadvantage the poor in

relation to health. People living in underserved, rural and remote areas have less access to clean

water, safe housing and efficient transportation. Moreover, the poor are more likely to find that

health services are unavailable and inaccessible, too expensive or of relatively low quality. Often

governments allocate the highest proportion of their health budgets to urban hospitals, learning

rural residents without adequate health facilities (31).

2.8.1 Barriers to skilled attendance:

Results from the evaluation of maternal health strategies in three countries confirm that, the three

barriers to accessing skilled delivery care are, financial, physical and functional.

33

2.8.1.1 Financial barriers:

The cost of obstetric care presents important barriers to its use. All countries that have reduced

maternal death have afforded free care. Study evaluated the Government of Ghana's delivery-fee-

exemption policy instituted in 2003 to reduce financial barriers to delivery services. The fee-

exemption policy covered normal and assisted deliveries such as caesareans, and complications

that arose from deliveries, transportation, logistic and supply costs were not covered by the free

exemption.

2.8.1.2 Physical Barriers:

To improve maternal health it is also important to removed physical barriers to care such as

difficulties of traveling by distance. Evidence from Indonesia showed that fewer maternal deaths

occurred in villages where three or more trained residents, midwives provided services compared

with villages with no trained midwives, or where trained midwives were shared with other

villages.

2.8.1.3 The Functional Barrier: A well-functioning health care system is one in which

all the obstetric needs of a pregnant or delivering woman are met. Including referral for

emergency care. The World Health Organization (WHO) defines a functioning system as one

with available, skilled, supervised and motivated health personnel working in facilities with

appropriate equipments, drugs, communication and transportation to offer round-the-clock

services.

The Skilled Care Initiative (SCI) program was introduced in Burkina Faso to improve maternal

health and reduce maternal mortality. The SCI tried to address health worker shortages, improve

provider performance and the quality of care, upgrade health facilities, and strengthen health

management system. SCI also put in place a radio-call system to facilitate referrals for

complication. In general, the poor are disadvantaged in all of the determinants of health. They

are more vulnerable to ill-health and disease because of a lack of financial resources, limited

knowledge of health matters and limited use of health services.

34

2.9 Maternal Mortality in Sudan:

Data on maternal mortality in Sudan are scare, although it has been suggested that maternal

mortality is relatively high (SDHS report, 1990). Studies indicate that only 10% of women in

Sudan practice family planning. About 93% of them know at least one method of family

planning and 70% know of modern methods. About 40% of pregnant women do not receive any

prenatal care by trained health personal and 80% of child deliveries take place at home. The

MMR is estimated as 660per 100,000live births (1998 CBS estimate). While the ratio in rural

areas is much higher (UNFPA, 1999).Sudan faces significant challenges given the size of the

country and the protracted civil strife. The current war represents an immediate challenge for the

southern provinces. Operationally, the main challenge is in securing funding to maintain and

expand maternal and neonatal services (32).

The sustainability of maternal and newborn services in the light of these many complex

challenges across all development sectors is an important consideration for international partners

and the government of Sudan. Women of reproductive age (15-49) represent around 20% of the

total population and despite the early start of organized midwifery services in 1980s, estimate of

maternal mortality require concerted effort at the local, national and the international level to

improve the situation. Causes of maternal mortality in Sudan are the same, as those in other part

of the world. Interventions proven to reduce maternal mortality should be used. In order to

reduce maternal and neonatal mortality the creation of a health referral system will be needed.

These services to improve coverage and quality of services at the community level and will

provide early intervention for obstetrical emergencies (WHO, UNICEF 1996) (33).

35

OBJECTIVES:

General objectives:

To review maternal death in Gezira state in 2013

Specific objectives:

To identify the causes of maternal death in Gezira state.

To identify the risk factors of maternal death in Gezira state.

To determine maternal mortality ratio in Gezira state (2013).

36

CHAPTER TWO

Methodology

Study design and duration

This study is a cross-sectional, descriptive hospital and community based study, conducted in 12

months in the duration between the first January 2013 to 31 of December 2013

Area of study

Its carried out in Gezira state hospital an community . Gezira state is 26000 Sq.Ki , populated

by 4,255,173 . it contains seven localities include Wad Madani al kubra , AL- hassahsa , AL-

managel, Umalghura ,South of Gezira , East of Gezira and Al kamleen .

It contains about 70 hospital which include central and rural hospitals . It has 311 health

centre of which 200 regarded as maternal and childhood care centers .It contains 23 blood bank

and 6 dialysis centers

These hospitals and health's centers provide services to the hole population of the Gezira , in

addition to refrred patient from others state of Sudan .

At least one hospital on each locality is regarded as central hospital, and all hospitals

services cover the relevant branches of medicine ( obstetric an gynecology , surgery, medicine

.pediatric, radiology ophthalmology, laboratory and blood banks ), apart from Wad madani

which is specialist obstetrical an gynecological hospital .

Services in obstetric an gynecology are covered by consultant , registrar and house officers in

some hospitals, medical officers in others ,in addition to midwifes and sisters

37

At least in each hospital there is labor ward, antenatal ward, postnatal word, eclampsic room,

gynecological ward, septic room, major and minor theater and blood bank .

access and availability of superfesion is variable a among these centers.

Study population and inclusion criteria:

The method chosen aimed to tracing each death among women of reproductive age (15-49

years). The definition of maternal death used was that of WHO/FIGO (a death of any women

during pregnancy or within 42 days after termination of pregnancy irrespective of duration and

location of pregnancy and due tp any cause related to or aggravated by the pregnancy or its

management but not accidental or incidental causes).

Variables:

The variables studies are place of death , cause of death, age group, hospital stayed before death,

route of admission, hospital stayed before death, GA in weeks, follow up during current

pregnancy, ANC, mode of delivery, outcome, time of admission, avoidable, unavoidable areas of

death and postmortum )

Data collection:

It was a team work achieved by collaboration between all health care providers

(house-officers, medical officers and distributed to the medical directors to allow reporting,

auditing and utilization of information for research.

The issue to report immediately ant death by fulfilling the information sheet

(questionnaire) of national maternal death review form.

The connection was thought the direct visits to make sure that no death had been

missed and to revise the doctors who confirmed the death for immediate reporting

38

Data analysis:

The data analyzed by computer using Statistical Package for Social Sciences (SPSS) and

the results presented in tables . Maternal mortality ratio with the number of the live births as

denominators was used.

Challenges and limitation:

In some situation the cause of death necessitated autopsy, but unfortunately this had

been done in only one case who represented medico legal case.

Very limited information's had been collected from the brought dead cases a 2 cases.

Ethics:

An ethical clearance was obtained from the Ministry of Health general managers and

medical directors to conduct the research .

Verbal justification, how important the research was delivered to the co-patients and

relatives of the dead mothers in very brief and simple words .

Methods of data collections:

1. MDRC at Gezira State had been established .

2. A focal person in Gezira State is nominated for MDR .

3. A focal person is nominated for every hospital in Gezira State .

4. A focal person is nominated for every locality .

5. Every MD is notified daily to state focal person then notified to central office .

6. Every MD in hospital is reviewed by focal person in hospital with the help investigator .

7. Every MD in community is reviewed by the investigator with help of SMDRC .

8. Every month SMDRC meet, discusses MD, generate recommendation for investigator .

9. All MD review format should be send weekly to central office .

10. Every month meeting of investigator with all H/V, M/W, to collect life birth, community

and hospital (separately) .

39

Maternal death surveillance and discussion

Surveillance for maternal death has been done at level of the hospital. All cases of maternal

deaths were discussed with more details in the discharge clinic held regularly in Wad Medani

Teaching Hospital.

Discharge clinic is an academic activity regularly done every Thursday since 1970 , when

established and continue till present, with participation of units and doctors.

40

CHAPTER THREE

Results

In this study 90 deaths were reported out of 96426 live births equillivent to MMR 93.3

/100000 live birth 82 patient (91.1%) died al hospital while 8 deaths (8.9%) died at home

considering the cause of death 24 cases (26.7%) due to obstetrical hemorrhage , 17 cases (18.9%)

died due to jaundice , 11 cases (12.2%) due to sepsis ,8 cases (8.9%) due to eclampsia , 6 cases

(6.7%) died due to ruptured uterus , 2 cases (2.2%) due to anemia and related conditions , 3

cases (3.3%) died due to malaria , 2 cases abortion (2.2%) , anesthesia 2 cases (2.2%),

pulmonary embolism 1 cases (1.1%) and others 11 cases (15.6%) .

According to the age group 50 cases (55.5%) ranging between 21-30 year 30 cases

(33.3%) died within the first 24 hours of admission ,while 2 cases (2.2%) died at home and

brought died considering the rout or admission 50 cases (55.6%) brought as emergency to the

hospital , while 20 cases (22.2%) where referred from rural hospitals or health centers multipara

(2-4) represent 41cases (45.6%) while primigravidae represent 20 cases (22.2%) and

grandmultipara 29 cases (32.2%) .

Most of cases has no ANC 50 cases represent (55.6%) , 15 cases were not delivered

(16.7%) most of cases 59 cases (65.6%) were brought critically ill , 21 cases brought stable ,

while 2 cases brought dead at home .

The majority of cases 58 (64.4%) where delayed at home , while delay in receiving

treatment ay hospital were just 2 cases (2.2%) .

41

Table1: Distribution of MD according to place of death at Gezira state

(January2013_Decmber2013)

Percentage Frequency Place of death

91.1% 82 Hospital

8.9% 8 Community

100% 90 Total

42

Table 2: Distribution of maternal death according to age at Gezira state

(January2013_Decmber2013).

Percentage Frequency Cause of maternal death

16.7% 15 15_20

55.5% 50 21_30

27.8% 25 31_40

100% 90 Total

43

Table 3: Distribution of maternal death according to cause of death at Gezira

(January2013_Decmber2013)

Percentage Frequency Cause of maternal death

26.7% 24 Obstetric hemorrhage

18.9% 17 Jaundice

12.2% 11 Sepsis

8.9% 8 Eclampsia

6.7% 6 Ruptured uterus

2.2% 2 Anemia related condition

3.3% 3 Malaria

2.2% 2 Abortion

2.2% 2 Anathesia

1.1% 1 PE

15.6% 14 Others( specify)

100% 90 Total

44

Table 4 Distribution of MD According to hospital stayed before death at Gezira

state (January2013_Decmber2013)

Percentage Frequency Time

33.3% 30 24hours <=

55.6% 50 24hours >

2.2% 2 Died at home

&brought dead

8.9% 8 Community death

100% 90 Total

45

Table 5 Distribution of MD according to route of admission at Gezira state

(January2013_Decmber2013)

Percentage Frequency Rout of admission

55.6% 50 Emergency admission from

home

22.2% 20 Referred admission

2.2 % 2 Died at home &brought dead

11.1% 10 Elective admission

7.8% 8 Community death not

admitted

100% 90 Total

46

Table 6: Distribution of MD according to parity at Gezira state

(January2013_Decmber2013)

Percentage Frequency Parity

22.2% 20 Primagravida

45.6% 41 Multipra (2-4)

32.2% 29 Grand multipra (5)

100% 90 Total

47

Table 7: b Distribution of MD according to Gestational age in weeks at Gezira

state (January2013_Decmber2013).

Percentage Frequency Gestational age in weeks

17.8% 16 28weeks <

6.7% 6 28-36weeks

13.3% 12 37weeks >

62.2% 56 Peurperium

100% 90 Total

48

Table 8: Distribution of MD according to follow up during current pregnancy at

Gezira state (January2013_Decmber2013).

Percentage Frequency Follow up during current

pregnancy

55.6% 50 No ANC

6.7% 6 Regular ANC

37.7% 34 Irregular ANC

%100 90 Total

49

Table9 Distribution of MD according to ANC provider at Gezira state

(January2013_Decmber2013).

Percentage Frequency ANC provider

55.6% 50 No ANC

33.3% 30 Consultant

4.4% 4 Registrar ,medical officer

6.7% 6 Midwive, health visitor

100% 90 Total

50

Table 10 Distribution of MD according to mode of delivery at Gezira state

(January2013_Decmber2013).

Percentage Frequency Mode of delivery

16.7% 15 Not delivered

23.3% 21 Delivered at home

31.1% 28 Emergency C\S

22.2% 20 Vaginal delivery at hospital

6.7% 6 Elective C\S

100% 90 Total

51

Table 11 Distribution of MD according to outcome at Gezira state

(January2013_Decmber2013)

Percentage Frequency Out come

55.6% 50 Alive & well

16.7% 15 Not delivered

16.7% 15 Fresh stillbirth

3.3% 3 PND(including pre

term)

4.4% 4 Macerated stillbirth

3.3% 3 Miscarriage

100% 90 Total

52

Table 12 Distribution of MD according to areas at Gezira state

(January2013_Decmber2013)

Percentage Frequency Areas of delay

64.4% 58 Delay at home

25.6% 23 No delay

7.8% 7 Delay reaching

hospital

2.2% 2 Delay in receiving

treatment at hospital

100% 90 Total

53

CHAPTER FOUR

Discussion:

This study was done in Geira State where an important initiative was introduced by the

University of Gezira in order to reduce maternal and neonatal mortality rate. An integrated

approach at all levels of healthcare delivery system. This initiative has led to a remarkable

reduction in the maternal mortality ratio (MMR) and in the neonatal mortality ratio (NMR) in

Gezira state. The effort has recorded great achievements in Gezira, lowering the MMR from 469

per 100,000 live births in 2005 to 57 in 2014, and the NMR from 43 per 1,000 live births in 2005

to 11.3 per 1,000 in 2014.

Maternal mortality is a challenge facing health, governmental and social workers and it represent

a tragedy for the society , particularly the developing world where most of the deaths occur .

Maternal mortality ratio is difficult to assess with accuracy because of poor registration in

hospitals and many deliveries still conducted at home, However hospitals based study remains

main access for evaluating maternal mortality ratio, causes of deaths and risk factors for these

deaths.

In this study 90 deaths out of 69469 live births had been reported and MMR was found

6939/100000 live birth there is reduction in MMR compared with the previous study in 2012

130/100000 but still more high than target . improvement might be due to patient's awareness,

improved health services in hospitals , coverage of the obstetrical units by senior personal and

researches. Haemorrhage considered the most common direct cause of death 26.7% and post

partum hemorrhage was the common cause of obstetrical hemorrhage which necessitates the

intra partum and postpartum care, this result is similar to those reported for many developing

countries because they share same circumstances, culture , health services and facilities,

according to WHO analysis haemorrhage constitutes 33,9% of maternal deaths in Africa and

30.8% in Asia(34).

In this study, jaundice is the second cause of maternal death 17/90 (18.9%) is higher compared

to a previous study (14.6%) and the most common cause of death was hepatic failure. In this

study, they were 11 cases of sepsis (12.2%) in previous study were (14%) , in comparison with

54

study 1996 in Madani hospital which were (32%) and this most likely due to improvement of

infection prevention system and advanced new generation of antibiotics (34).

In this study, eclampsia represent (8.9%) 8/90 of cases compared with previous study(9.9%) this

due to use of MgSO4, more ANC for hypertensive disorder patient. In this study, ruptured

uterus were 6/90 (6.7%) which reduced from previous study in 2013(7.9%)which raised

awareness about health education and good management of high risk patient especially VBAC,

In this study, malaria represent 3/90 cases (3.3%), and since Gezira state is known to be an

endemic area of malaria there was improvement from 2013(6.2%) by following the management

protocol of WHO and national protocol for malaria in Sudan and intensive health education (35).

In this study, the majority of cases 50 cases (55.6%) where brought as emergency admission

from home and they gave birth at home and transferred to hospital when their lives threatened,

while the elective admission where 10 case (11.1%) and the referral admission were 20 cases

(22.2%) and patient died at home and brought dead were 2 case (2.2%) .This can be prevented by

adequate referral system, improving emergency obstetric care in primary health facilities and

good transport system.

In this study, the multipart (2-4) 41 cases (45.6%) they present the majority of cases ,while the

primigravidae where 20 cases (22.2%) the grand multipara where 29 cases (32.2%) and this can

be explained by the fact that almost all primigravidae prefer to delivered at hospitals while the

multipara tend to try home delivery because they thing that they had Experienced vaginal

delivery and no need for hospital delivery, so this also can be prevented by good health

education and increase the community awareness of complications of home delivery and for high

risk patient specifically.

In this study, women who died and had no ANC represent the majority of cases 50 (55.6%) ,

while 6 cases (6.7%) where had regular ANC (minimum 4 visits ) and . 34 cases (37.7%) where

had irregular ANC , so lacking of awareness and poverty and illiteracy might be the cause.

regarding the mood of delivery In this study, undelivered cases 13 (16.7%) delivered at home

21 (23.3%) ,emergency c/s 28 (31.1%) , elective c/s 6 cases (6.7%)

so the home delivery and emergency c/s revealed their complications and still the hospital and

elective c/s the best of all.

55

Regarding the condition of the patient at the time of admission , the critically ill patient

represent the majority of patient 59 cases (65.6%), the stable cases were 11 (12.2%), while the

dead patient at home and brought dead 2 (2.2 %), this reflect the delay in referral system , poor

health education ,poverty and no ANC, , which in most of time cannot be saved ( late

presentation ).The delay at home represent 58 cases (64.4%) , delay in reaching hospital 7 cases

(7.8%), no delay 23 cases (25.6%) and delay in receiving treatment at hospital 2 cases (2.2%).

56

CONCLUSION:

1. Maternal mortality is still high in this state and the direct causes of women death are the

same as described for developing world.

2. Obstetric haemorrage was the leading cause of direct maternal mortality (26.7%) .

Postpartum haemorrhage was the common cause of obstetric haemorrhage and

predominantly it was due to uterine atony ,which could be effectively reduced by active

management of third stage of labour.

3. Late presentation, poor intrapartum care and obstacles with blood transfusion were the

main risk factors beyond death in haemorrhagic group.

57

RECOMMENDATIONS:

1. Support the Gezira Initiative for safe motherhood and childhood for more reduction in

MMR

2. Proper training for all medical stafe (registrar, medical officer, house officer” midwife,

sisters) .

3. Continuous and regular training with update protocols for management of obstetrical

emergencies.

4. Optimal emergency obstetrical care and establishment of Emergency Obstetrical Care

(EmOC) Unit

5. Availability of the drug of emergency free in all health service area

6. Heath education to pregnant women.

7. Encourage regular ANC.

8. ANC should be available free of charge for all pregnant ladies at community level.

58

References:-

1. Hogan MC et al. Maternal mortality for 181 countries, 1980-2008: A systematic

analysis of progress towards Millennium development Goal 5. The Lancet 2010; 375

(9726): 1609–1623.

2. CAHR, Maternal Mortality in Central Asia, Central Asia Health Review. 2008,7:12

3. Koonin, Lisa M, Hani K, Atrash, Roger W. Rochat, Jack C Smith. Maternal Mortality

Surveillance, United States, 1980–1985. 1988;37 (5):19–29.

4. Deneux Tharaux, Berg C, Bouvier Colle MH, et al. Underreporting of Pregnancy-

Related Mortality in the United States and Europe. Obstet Gynecol 2005;106 (4): 684–

692.

5. Monitor of Goal 5 of the Millennium Development Goals, International statistical

classification of diseases and related health problem. 2008,1:2

6. Cunningham FG, Gant NF, Leveno KJ, Gilstrap III LC, Hauth JC Wenstrom KD .

Debate: Vaginal Breech Delivery.Obstetrics & Gynecology2002; 99(6):1115–1116

7. Jafary SN. Maternal Mortality in Pakistan: An overview. Maternal and Prenatal Health

1991: 21-31.

8. Villar J, Betrn AP, Gülmezoglu AM, Say L: WHO leads global effort on systematic

reviews3 International Journal of Epidemiology2003,32:164-165.

9. Dickersin K: Systematic reviews in epidemiology: why are we so far behind?

International Journal of Epidemiology 2002, 31:6-12.

10. AbouZahr, C.J.M. Murray, A. Lopez, G Maternal mortality overview. World Health

Organization,2009,87.42:962

11. Butler, A King. Phylogenetic comparative analysis: A modelling approach for adaptive

evolution. American Naturalist. 2004, 164:683-695.

12. Kenj S, aA.Lopes. Maternal mortality in 2005: Estimates developed by WHO,

UNICEF, UNFPA and The World Bank.2007. 370 , 9599, : 1653–1663

13. G.Tog. Systemic review, the cause of maternal mortility WHO 2007.26(3):18-20

14. TF Baskett, CM O'Connell. Severe obstetric maternal morbidity: A15-year population-

based study 2005;25(1) : 7-9.

15. Bhatia J.C,. Levels and causes of maternal mortality. in South journal. 1998.6,11:84-91

59

16. B.Salanavo., Studies in Family Planning India ,2008 .65,11:121-125.

17. Bouvier – Colle et al,. Obstetric Patient treated in intensive care units and maternal

mortality. European Journal of obstetric and Gynecology and Reproductive

Biology1996 43;127-135.

18. Brass W. Screening procedures for detecting errors in Maternity history data WFS

Technical Paper 1978;818: 33.

19. Brockerhaff, et .al, . The poverty of cities in developing world. population control paper

New York. Population Council,1994;39 )9(:1303–1314

20. Chen, N.P. Valente and H. Zlotnik, Migration. return and small enterprise development

Recent trend in Urbanization, 2010, 3: 59–88.

21. Cicred. Policy Paper (Urban Population, Development and Environment Dynamics

Paris . 2008,25(.2):107-117

22. Cook C.T, York, medical model.. The effect of skilled health attendants on Reducing

maternal deaths in developing countries; Eval Program ,2002.166:14

23. N.jock,. Maternal and child dietary system, papers submitted in workshop, 1984: 6.

24. R.Jon.Family care international, The challenge of survival; Safe Motherhood in

SAPCC Region, Family care International and the World Bank1991.84;3.

25. . G.kong. International Classification of diseases and related health . International

family planning perspective 1997, 10(2):65-67

26. Koblinsky, M.A., O. Campbell, . Timyan and J. Gay. "Mother and More: A Broader

Perspective on Women's Health. Oxford.2003,15(4);221-222

27. Morge Koblinsky et al, . Organizing delivery care, WHO. 1999,17:45

28. . Timyan and J. Gay.. Mother-baby Package: Implementing safe Motherhood in

countries1994,34:88-90

29. . Timyan and J. Gay.Population J. Gay.Reference ,. Delivering Safe

Motherhood.2007,34(3): 1875.

30. . Timyan and J. Gay.Population . Improving the health of the mother.2004, 23: 1875.

31. Shenc.Williamson, Soc.S.,Med.Maternal Mortality, Women's Status, and Economic

dependency in less developed countries: 2009,18:11 .

32. D.son. Reviewing maternal Deaths and Complication to Make pregnancy safer.

2004,3:77.

60

33. R,foj instance mortality rates at the Dublin Maternity Hospital 2009,3 1784–1849

34. Ahamed Khalafalla Alhaj Maternal mortality review in Gezira state 2012 result :31-38

(Non Publish)

35. Ibnkhtab Abuzaid Maternal mortality review in Gezira state 2011 by result: 33-40 (Non

Publish)

61

Appendix (questionnaire)

Republic of Sudan

Federal Ministry of Health

Maternal & Child Reproductive Health Programme

National Maternal Death Review Office

NMDR (General form- to be filled in for every maternal death)

Section One:

1- Date:…../……/……..

2- State: ………………………… Locality: …………

3- Patient name:……….……………………………….

4- Age: ……………………………………………….

5- Place of Death:

a) Home

b) Hospital (Hospital name)…………………………..

6- Date of admission:……/…… / …….

7- Time of admission ……………

8- Date of death: ..…. /….. / ………..

9- Time of death:……..……

10- Time stayed in hospital before death in hours: ………………

11- Route of Admission:

a) Elective Admission

62

b) Emergency Admission from Home

c) Referred Emergency Admission

12- Parity:

a) Primigravida

b) Multipara (2-4)

c) Grandmultipara (5 or more)

13- Gestational age in weeks:

a) < 28 weeks

b) 28-36 weeks

c) 37 or more

d) peurperium

14- Follow up during current pregnancy:

a) No ANC

b) Irregular ANC (< 4)

c) Regular ANC (minimum 4) visits

15- ANC provider:

a) Consultant

b) Registrar

c) Medical Officer

d) Health Visitor

e) Midwife

f) No ANC

16- Status of Delivery:

63

a) Not delivered.

b) Delivered at Home

c) Vaginal Delivery in Hospital

d) Instrumental vaginal delivery

e) Elective C/S

f) Emergency C/S

17- Pregnancy Outcome:

a) Not Delivered

b) Miscarriage

c) Alive and well

d) FSB

e) MSB

f) PND (Including Preterm)

18- Presentation at the time of Admission:

a) In labour

b) Bleeding

c) Convulsions

d) Fever

e) Jaundice

f) Others (specify……………..)

19- Condition at the time of admission:

a) Brought Dead

b) Cretically ill

c) Stable

20- Cause of Maternal Death:

a) Obstetric Haemorrhage ( Fill Form A Section two)

b) Eclampsia (HT disorder) ( Fill Form B Section two)

64

c) Sepsis ( Obestructed labour….) ( Fill Form C Section two)

d) Anesthesia

e) Ruptured uterus( Obest. Lab....)

f) Abortion ( Haemorrhage, Sepsis) ( Fill Form D Section two)

g) Malaria ( Fill Form E Section two)

h) Jaundice ( Fill Form F Section two)

i) Anemia related conditions

j) Others(specify…………….)

21- Health Care Provider Attending Maternal Death:

a) Specialist

b) Registrar

c) Medical Officer

d) House Officer

e) Anesthesist

f) Midwife

g) Others ( relative, alone, etc)

22- Areas of Delay:

a) No Delay

b) Delay at home

c) Delay in reaching hospital

d) Delay in receiving treatment at hospital

65

23- Postmortum:

a) Not Requested

b) Not done, refused by relatives

c) Not done, relatives refused to sign consent

d) Done after consent

Remarks:

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………….....................................................................................................................

24- Notifier:……………………………………….. Tel:......................

25- Reviewer ………………………………………. Tel:......................

66

Republic of Sudan

Federal Ministry of Health

Maternal & Child Reproductive Health Programme

National Maternal Death Review Office

National Maternal Death Review Form

Section Two

Form A: (MD from Obestetric Haemorrhage)

1- Type of Obstetric Haemorrhage:

a) PPH- Post Partum Haemorrhage

b) APH- Anti Partum Haemorrhage

c) Miscarriage

d) Others( specify………………..)

2- Cause of PPH:

a) Uterine atonía

b) Birth canal injuries

c) Ruptured uterus

d) Retained placenta

e) Blood disorders

3- Management Received in Hospital

a) Seen and managed by specialist

b) Seen by specialist & managed by junipor

c) Not seen by specialist managed by junior

d) Received blood ( number of units……..)

e) Not received blood or substitute

f) Received oxytocin or (uterotonic)

g) Not received any uterotonic

67

h) Laparotomy or hystrectomy

68

4- Delay in Management at Hospital:

a) No specialist available or accessable

b) No uterotonic available

c) No blood available

d) Theater not ready or occupied

e) No Anesthesist

f) No ICU

5- Active Management of Third stage of Labour (AMTL) for at risk:

a) Delivered at home

b) AMTL is not used routainly for at risk

c) No protocol for AMTL

d) No drugs available

e) blood was not prepared

6- Delay in Receiving Blood:

a) No blood substitute ( expanders) available

b) No donors

c) No available testing reagents

d) No Bags or sets

e) No blood Bank

69

Republic of Sudan

Federal Ministry of Health

Maternal & Child Reproductive Health Programme

National Maternal Death Review Office

National Maternal Death Review Form

Section Two

Form B: (MD from Eclampsia)

1- Onset of Convulsion Related to Delivery:

a) Ante Partum.

b) Intra Partum.

c) Post Partum.

2- Place of Onset of First Fit:

a) Started at Home

b) Started on the way to Hospital

c) Started in Hospital

3- Interval from First Fit to Death:

a) < 2 Hours

b) 2-6 Hours

c) 7-24 Hours

d) > 24 Hours

4- Interval from First Fit in Hospital to Death:

a) < 2 Hours

b) 2-6 Hours

c) 7-24 Hours

d) > 24 Hours

5- Total Number of Fits Before Death:

a) 1-4 fits

b) 5-10 fits

70

c) >10 fits

6- Cause of Maternal Death from Eclampsia:

a) Airway obstruction

b) Heamorrhage (PPH. APH. DIC. HELLP)

c) Acute renal failure

d) Acute pulmonary edema

e) CVA

f) Others( specify……………………..)

7- Management Received in Hospital:

a) Seen and managed by specialist

b) Seen by specialist & managed by junior

c) Not seen by specialist managed by junior

d) Received Anti convulsant ( specify………………..)

e) Not received Anti convulsant

f) Received anti hypertensive ( specify……………..)

g) Not received any treatment

8- Delay in Management at Hospital:

a) No specialist available or accessable

b) No mgso4 available

c) No Protocol for mgso4 use

d) mgso4 is not used for treatment In this Hospital

e) Theater not ready or occupied

h) No Anesthesist

f) No ICU

71

Republic of Sudan

Federal Ministry of Health

Maternal & Child Reproductive Health Programme

National Maternal Death Review Office

National Maternal Death Review Form

Section Two

Form C: (MD from Sepsis)

1-Mode of delivery:

a) Vaginal delivery at home

b) Instrumented Vaginal delivery in hospital

c) Elective C/S

d) Emergency C/S

e) Incomplete (Septic) Abortion

2- Duration of first stage of labour

a) < 12 hours

b) 12-24 hours

c) >24 hours

d) Miscarraige

3- Duration of second stage of labour

a) < 1 hour

b) 1-2 hours

c) > 2 hours

d) Miscarraige

72

4- Onset of symptoms after delivery:

a) 1st

24 hours after delivery

b) 2-3 days

c) >= 4 days at home

d) >= 4 days in hospital

Presentation on Admission:

a) Infected wound ( episiotomy or decurcumcision)

b) Infected wound (C/S or Lap)

c) Pelvic Peritonitis

d) Septicemic shock

e) Incomplete (septic ) abortion

5- Patient’s condition on discharge after delivery:

a) not delivered in hospital

b) Asymptomatic with prophylactic antibiotics

c) Asymptomatic without prophylactic antibiotics

d) With symptoms of infection & on antibiotics

6- Treatment recieved after admission:

a) Dressing & antibiotics

b) Antibiotics & conservative treatement

c) Antibiotic, secondery sutures and or exploration

7- Cause of death from sepsis:

a) Septicaemia

b) Accute renal failure ( ARF)

c) Liver failure

d) Secondary heamorhage

8- Intervention taken after admission

73

a) Swap for culture and sensetivity( C/S)

b) Swap for culture and sensetivity( C/S) from labour ward

c) Swap for culture and sensetivity( C/S) from theater

d) Swap for culture and sensetivity( C/S) from hospital staff

74

Republic of Sudan

Federal Ministry of Health

Maternal & Child Reproductive Health Programme

National Maternal Death Review Office

National Maternal Death Review Form

Section Two

Form D: (MD from Abortion)

1- Estimated GA

a) < 12 weeks

b) 13-20 weeks

c) > 20 weeks

2- Presentation at time of admission:

a) Brought dead.

b) Shocked with severe haemorrhage

c) Severe bleeding , but stable

d) Symptoms & signs of pentonitis

e) Symptoms & signs of infection

f) Explusion of tissue products

g) Trauma or FB at cérvix

3- Management Received in Hospital:

a) Seen and managed by specialist

b) Seen by specialist & managed by junior

c) Not seen by specialist managed by junior

d) Received blood ( number of units………..)

e) Not received blood

f) Received Ergometrine or uterotonics

g) received antibiotics

h) evacuation

i) laporatomy

j) not received any form of treatment

75

4- Delay in Management at Hospital:

a) No specialist available

b) No blood available

c) No uterotonics available

d) no antibiotics available

e) no Anesthetist

f) No ICU

5- Delay in Receiving Blood:

a) No blood substitute ( expanders) available

b) No donanors

c) No available testing reagents

d) No Bags or sets

e) No blood Bank

6- Type of evacuation:

a) Not evacuated

b) MVA

c) Sharp currettage

d) Medical ( misoprostol)

7- Cause of death from abortion:

a) Bleeding

b) Septicaemia( infection)

c) Others ( specify………………….)

8- Type of pregnancy:

a) Wanted ( intentional)

b) Unplanned

c) Unwanted

76

Republic of Sudan

Federal Ministry of Health

Maternal & Child Reproductive Health Programme

National Maternal Death Review Office

National Maternal Death Review Form

Section Two

Form F: (MD from Hepatitis)

1- Condition on Admission

a- Fever

b- Jaundice

c- Anemia

d- Coma

e- Bleeding

f- Palple Tender liver

2- Cause of Jaundice:

a- V. Hepatitis A.

b- V. Hepatitis B.

c- V. Hepatitis C.

d- V. Hepatitis E

e- Obstrutine

f- Haemlytic

g- HELLP

h- Unknown ( 3333333333333333333333333333)

i-

77

Management received in hospital:

a- Conc. glucose

b- Vitamins

c- Antibiotics (Specify…………………….)

d- Blood transfusión

e- Seen by physian

f- Managed in ICU

g- Other Antihepatic failure(specify………)

3- Investigations Done:

a- Hb.

b- Bf. For malaria

c- Ultra sound

d- Platelets Count

e- LFT.

f- RFT.

g- Serology (Hbs,Ag,etc)

h- Screening for HIV.

4- Cause of death:

a- Hepatic failure.

b- Bleeding

c- Hepato renal shut down

d- Other ( Specify…………………)

6- Delay in management

a- No delay_ Terminal presentation

b- No physian available or accessable

c- No ICU

d- No access to multidiplinary approach

e-No supportive treatment

78

تسى اهلل انشح انشحيى

خهىسيح انسىدا انذيقشاطيح

واليح اندضيشج –وصاسج انظحح

اإلداسج انؼايح نهشػايح انظحيح األونيح

إداسج انظحح اإلداتيح

ض وفياخ األيهاخ تانسرشفي )سشي(اسراسج ذق

ذؼشيف وفاج األو :

أساتيغ تؼذ انىالدج أو اإلخهاع و ذشم أسثاب انثاششج و انغيش 6وفاخ األو يقظذ تها : وفاج األو إثاء انحم وأثاء انىالدج وفي خالل

(2002يثاششج )طذوق األيى انرحذج نهسكا , ذحذيث انىفياخ , يىيىسك

واليح اندضيشج يغ –االسراسج تىاسطح انطثية و ذال يثاششج تؼذ انىفاج وذسهى إني إداسج انظحح اإلداتيح وصاسج انظحح ذال هز

انرقشيش انشهشي .

-يؼهىياخ ػايح : ( أ)

:33333333333333333333333333333333333333333333333333اسى انحهيح -1

......................اسم المستشفي :333333333333333333333333 -2

اسى انرقظي :................................................ -3

ذاسيخ انرقظي :................................................. -4

طثية ػىيي -2: أخظائي ساء و ذىنيذ 1وظيفح انرقظي : -5

انرىقيغ :...................................... خرى انسرشفي -6

يؼهىياخ ػ انرىفيح : ( ب)

اسى انشيضح ستاػي :................................................................ -7

................انؼش تانسىاخ :..................................................... -8

انسك :.................................................................................. -9

يسرىي انرؼهيى تانسىاخ :......................................................... -10

...............................................انهح :................................ -11

انحانح االخراػي : -12

يطهقح -د اسيهح -ج يرضوخح -ب غيش يرضوخح -أ

79

انقثيهح :.......................................................................... -13

يذج انضواج تانسىاخ :.......................................................... -14

ػذد يشاخ انحم :............................................................. -15

ػذد انىالداخ :................................................................. -16

ػذد يشاخ اإلخهاع : ..................................................... -17

ػش انحم انحاني تاألسثىع :............................................. -18

)ج( يؼهىياخ ػ انضواج

..ػش انضوج تانسىاخ :..................................................... -19

يسرىي ذؼهيى انضوج تانسىاخ :............................................. -20

يهح انضوج :.................................................................. -21

يرىسط انذخم / انشهش ...................................................... -22

)د( انخذياخ انظحيح تطقح انسك

هم ذىخذ يؤسسح طحيح تانطقح ) يطقح سك انشيضح ( -23

ال ؼى

ارا كاد اإلخاتح ؼى ىع انؤسسح : -24

ػيادج خاطح يسرشفي ذخظض يسرشفي سيفي يشكض طحي وحذج طحيح أساسيح

يسرشفي تانكيهىيرشاخ :.................................................................... انسافح ي اقشب -25

)هـ( يؼهىياخ ػ انحم انحاني :

ال هم كاد انشيضح ذراتغ اثاء انحم انحاني ؼى -26

ػذد صياساخ انراتؼح اثاء انحم :-27

اكثش 4 3-1 )ال ذراتغ ( طفش

80

ار كاد اإلخاتح تؼى ي انزي كا يقىو تانراتؼح : -28

اخظائي طثية ػىيي انضائشج يساػذج صائشج يساػذ طثي قاتهح

اي كاد ذرى يراتؼح انحم :-29

ػيادج خاطح و. ذخظظي و. يفي يشكض طحي انقشيح/ انحي

في انحم انحاني هم كاد ذؼاي ي : -30

ضف صالني في انثىل ضغط انذو اسذفاع

حم ذؤاو وضغ غيش طثيؼي فقش انذو

يالسيا ايشاع قهة يشقا

تههاسسيا سكش في انذو ستى

اخشي قيظشيح ساتقح

ال ؼى هم انرىفيح يطؼح ضذ انراذىط -31

:........................................................ارا كاد اإلخاتح ؼى ػذد اندشػاخ -32

)و( انىالدج

ذاسيخ وصي حضىس انقاتهح تانضل : -33

انسح انشهش انيىو انساػح

81

ذاسيخ وصي وطىل انسرشفي : -34

انسح انشهش انيىو انساػح

ي قاو تانرحىيم : -35

طثية يساػذ طثي طحيحصائشج قاتهح قشيح

-انرذخالخ انري ذد قثم انرحىيم )تانضل ( : -36

أدويح دستاخ

والدج ذؤأو قض ػدا

اخشي حذد

انحانح انؼايح نهشيضح ػذ دخىل انسرشفي : -37

يرىفيح حانح حشخح يسرقشج

ذشخيض انشيضح ػذ دخىل انسرشفي : -38

:....................................................يذج انحم -1

انرشخيض :..................................................... -2

ذاسيخ وصي انىفاج -39

انسح انشهش انيىو انساػح

ال ؼى هم ذد انىالدج قثم انىفاج : -40

82

كاد االخاتح تؼى ىع انىالدجارا -41

اخشي اسرخشاج ذهشيى يحدى قيظشيح خفد طثيؼيح

صي انىالدج تانساػاخ : -42

انشحهح انثانثح )انخالص( انشحهح انثايح )االقزاف ( انشحهح االوني )االذساع(

ي انزي قاو تؼهيح انرىنيذ : -43

أخظائي ائة أخظائي طثية ػىيي طثية ايرياص انضائشج يساػذج صائشج قاتهح قشيح

انرذخالخ انري ذد تؼذ دخىل انشيضح نهسرشفي : -44

اسركشاف ذفشيغ

قم دو إصانح سحى

إصانح يشيح أدويح

قيظشيح خفد/ يحدى

اسرخشاج ذهشيى

أخشي حذد

أػال :ي انزي قاو تانرذخالخ في انسؤال -45

أخظائي ائة أخظائي طثية ػىيي طثية ايرياص انضائشج يساػذج صائشج قاتهح قشيح

83

إرا أخشيد ػهيح ي انزي أخشا انؼهيح : -46

أخظائي ائة أخظائي طثية ػىيي طثية ايرياص

في حانح انرخذيش ىع انثح : -47

ػاو اسرشاقي ػاو وسيذي )كرالس( ظفي يىضؼي

ي انزي قاو تؼهيح انرخذيش : -48

أخظائي انرخذيش طثية يحضش ػهيح في ذخذيش

)ص( انىفاج :

-سثة انىفاج : -49

انسثة انثاشش :...................................................... -1

:...................................................انسثة انغيش يثاشش -2

سشد تئيداص نهىفاج )يالحظاخ و إضافاخ( : -3

...........................................................................................................................................................................................

...........................................................................................................................................................................................

...........................................................................................................................................................................................

...........................................................................................................................................................................................

................................

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