Caesarean Section in African Setting: Current Situation, Problematic and Qualitative Approaches at Laquintinie Hospital (Douala, Cameroon)

Background: Quality control of care aims to reduce or eliminate unnecessary care and to improve the quality of those who are useful both in their indication and in their implementation. Objective: We conducted this study to assess the rate of caesarean section, the rate of irrelevant indications, materno-foetal morbidity and mortality, biases in the management in order to suggest corrective approaches. Methods: It was a cross-sectional study conducted in the gynaeco-obstetrics department of the Laquintinie Hospital of Douala over a period of 4 months from January 1 to April 30, 2017. We included all pregnant women who had a caesarean section and who gave consent to our study as well as new-borns from these caesareans. We excluded caesarean deliveries from other health structures and referred to Laquintinie Hospital due to morbid operative follow-up. The variables collected were grouped under 3 main headings: socio-demographic data, clinical data and post-operative follow-up. Results: A total of 281 caesarean sections were performed out of a total of 967 deliveries;a caesarean section rate of 29.06% in 4 months. After data mining, 250 caesarean sections were included in the study because 31 cases of caesarean deliveries were unusable. Referred pregnancies accounted for 46.8% of the total population and the most common reason for referral was stationary labour (23% of cases). All caesareans were performed by the gynaeco-obstetricians. Women who had caesarean deliveries were informed by the operator of the surgical procedure in 28.4% of cases and 27.6% were notified of the indication for surgery. The operative kit was present in 98% of cases. The operating room was available in 93% of cases. Caesareans were performed mostly in an emergency context (91.2%) with a median turnaround time of 214 minutes (3 h 56 mins). Mechanical dystocia was the major indication in our series (21.2%) and 29 indications were irrelevant (11.6%). Intraoperative complications occurred in 3.2% of cases. Overall maternal mortality (per- and post-operative) was 0.8% (2 cases). We recorded 15 neonatal deaths out of which 8 were still births. Regarding the postoperative period, 78% of the operated patients did not have a good immediate postoperative monitoring. The post-operative protocol was not respected in 17% of cases. Postoperative complications occurred in 21.6% of patients with first cause being infections (10.8% with 5.6% being parietal suppurations). Conclusion: The frequency of Caesarean sections at Laquintinie Hospital is above the World Health Organization’s recommendations of 5% - 15%. There is a very big delay in the execution time of emergency caesareans, far above the international standards despite the quasi-availability of operating kits and the operating theatre. The state of the premises reveals a sub-workforce creating work overload and therefore a demotivation of the staff leading to insufficient communication between the operator and operated, a lack of postoperative follow-up and significant neonatal morbidity and mortality. Hence the need to initiate a staff satisfaction survey.

Epidemiological Profile of Pediatric Vital Emergencies at Laquintinie Hospital of Douala, Cameroon

Introduction: In the absence of health coverage in resource limited-settings, life-saving pediatric emergencies remain a challenge. The objective of our study was to describe the epidemiological profile of life-threatening pediatric emergencies at Laquintinie Hospital in Douala (HLD). Methods: A cross-sectional study was carried out for a period of 3 months, from March to May 2017 in the pediatric emergency unit of HLD enrolling all children presenting a life-threatening emergency on admission. Local emergency kits and an internal deferred cost recovery voucher or “green voucher” were used to facilitate access to care for children on admission. The socio-demographic, clinical, therapeutic and evolutionary characteristics were collected and analyzed using SPSS software version 20.0. Results: A total of 135 children were enrolled and the sex ratio was 1.54. The mean age was 3.8 years ± 4.05 and 80.7% of the children were under 5 years old. The majority of children (82.9%) admitted to the emergency room came from peripheral health structures. The hospital prevalence of life-saving emergencies was 42.4%. The mean time to consultation after the onset of symptoms was 5.9 days and 66.0% of admissions were made during the 3 p.m. to 8 a.m. time slot. More than 4/5 of emergencies were neurological, respiratory and cardio-circulatory emergencies representing 35.6% and 18.5% respectively. Severe malaria accounted 31.9% of the etiologies, bronchopneumopathies and meningo-encephalitis were involved in 18.5% and 17.8% of cases respectively. Patients were managed within 30 minutes of admission in 75.6% of cases and 52.6% of them received a “green voucher”. The average length of stay in the emergency room was 6 days. The death rate from life-threatening emergencies was 17.8% and represented 61.5% of total deaths recorded in pediatric emergencies. Conclusion: The profile of life-threatening emergencies at the HLD was that of a child under 5 years old, coming from a peripheral health facility and presenting a neurological emergency.

Pregnancy Preferences in Females of Reproductive Age with Sickle Cell Disease at Laquintinie Hospital: A Cross-Sectional Analysis

Introduction: Females with sickle cell disease (SCD), despite having a delayed pubertal development, are subject to many worries relating to their abilities to conceive, their capacity to maintain a maternofetal-risk-free pregnancy till term and give birth to healthy children without sickle cell disease. Knowing that unplanned pregnancies are more likely to increase maternofetal morbidity and mortality, we sought out to explore the pregnancy preferences in female patients with sickle cell disease to promote healthy conception and childbirth in this vulnerable population. Methodology: We conducted a cross-sectional study involving female patients of child-bearing age with sickle cell disease followed at Laquintinie Hospital Douala or who were members of a local sickle cell association. Pregnancy preferences were determined using the Desire to Avoid Pregnancy (DAP) scale. Factors associated with pregnancy preferences were determined using multivariable linear regression model. Threshold for significance was set at p Results: Seventy-seven patients were included with a mean age of 24.71 ± 5.53 years. Forty patients (51.95%) had one sexual partner and thirteen women (32.5%) used contraceptive methods. Most patients (46.0%) responded “Strongly Agree” or “Agree” to the statement “it would be a good thing for me if I became pregnant in the next 3 months”. The mean DAP score was 1.63 ± 0.91 [1.28 ± 0.82 in those who had a sexual partner and 1.99 ± 0.86 in those who had no sexual partner]. Factors that were positively associated with DAP score were students (b = 0.32, 95% CI [0.21, 0.95], p = 0.003), monthly income ≥ 100,000 FCFA (b = 0.24, 95% CI [0.07, 0.81], p = 0.022), and not having a sexual partner (b = 0.26, 95% CI [0.11, 0.85], p = 0.012). Conclusion: Most female patients with SCD have a low desire to avoid pregnancy. This is especially true for patients who are not students, have a partner and have a low monthly income.

Etiologies of Neonatal Mortality in a Tertiary Care Hospital in a Resource-Limited Setting

Background: Neonatal mortality remains a major public health problem in low income countries. The survival within the first 28 days of life remains a challenge in such countries. Many strategies have been implemented to reduce deaths in children under five especially in sub-Saharan Africa. Laquintinie Douala Hospital benefits from some of these measures including a perinatal network and an emergency voucher. We aimed to describe the main causes of neonatal deaths at Laquintinie Douala Hospital. Methods: We carried out a cross-sectional study including files of all deceased neonates in the neonatal unit during a 24 months period from January 1st, 2017 to December 31st, 2018. Data collection included socio-demographic characteristics of the mothers and the newborns, clinical and therapeutic data and the evolution of the newborn. We used SPSS 20 software for data analysis with a p-value less than 0.05. Results: We included 270 files with an overall mortality rate of 13.1% and a sex ratio of 1.2. The main causes of death included prematurity (37.8%), neonatal infection (34.1%) and neonatal asphyxia (24.4%). The main factors associated with deaths included informal sector (OR = 5.49;95% CI 0.86 - 34.77;p = 0.07) and a primary level of education for mothers, malaria during pregnancy (OR 2.28;95% CI, 1.44 - 3.12;p = 0.0001), very preterm babies (OR 6.45;95% CI 4.68 - 8.89;p < 0.001) and resuscitation (OR 1.63; 95% CI 1.25 - 2.13;p = 0.0001). Conclusion: Neonatal mortality was lower than data in previous studies but remains high. This highlights the need for caregiver training and improvement of antenatal visits in our setting.