Of all the human development indicators, maternal and infant mortality rates reflect the widest disparities between industrialized and developing countries  .
Indeed, every minute in the world, 380 women start a pregnancy, 110 suffer from a complication and one dies from a complication related to pregnancy or to childbirth   .
Regarding this maternal mortality the followings have been described:
- direct causes, such as bleeding, infection or high blood pressure and its complications;
- indirect causes such as malaria, anemia or HIV infection (human immunodeficiency virus);
- contributing factors such as delays in making the decision to go to hospital for consultation, delays in admission to the appropriate health facility, and delays in access to patient management   .
In sub-Saharan Africa, the situation is worrying because the risk of death is 1/13 compared to 1/4100 in industrialized countries  . In Guinea, this mortality was estimated at 679 per 100,000 live births in 2015  .
Among the determinants of this mortality, obstetric referrals, which account for more than 20% of pregnancy-related morbidity cases, hold an important place  .
In the study conducted by Baldé I S et al. at Ignace Deen National Hospital, intrapartum obstetric transfers accounted for 7.05% of admissions in one year  .
The referral system allows populations to have access to health care that is not likely to be provided at the local level and to manage certain complications that occur in emergency situations. Medical evacuation means a transfer made in an emergency context. This is the case for emergency obstetric and neonatal care  .
The objectives of this study were to:
- Describe the socio-demographic aspects of transferred parturient women;
- Identify the means of transport used by the transferred women in the Donka maternity ward of the University Hospital of Conakry;
- Describe the difficulties met;
- Assess maternal and fetal prognosis.
2. Patients and Method
The study was carried out at the maternity ward of the Donka National Hospital of the Conakry University Hospital, a level III Maternity Hospital (which is the top). This was a cross-cutting descriptive prospective study that ran from February 1 to July 31, 2018, i.e. a six-month period. The study population consisted of all transferred patients.
Only patients transferred for obstetrical reasons were included in this study.
We excluded postpartum transferred patients from this study. We have exhaustively identified all cases of transfers to the maternity ward. Data were collected as soon as the patients arrived. The supports used were the survey form, the obstetrical file and the obstetrical evacuation form. For each patient, we studied the socio-demographic and clinical characteristics, the means of transport used, the difficulties encountered and the maternal-fetal prognosis.
Data entry, processing and analysis were carried out using Word, Excel and Epi info version 7 software.
The informed consent of patients had been obtained.
We had obtained the prior approval of the national ethics committee.
The absence of liaison sheets making it impossible to clarify the success of events before the evacuation was the main difficulty and limitation of this study.
3.1. Frequency of Obstetric Transfers
During the study period we recorded 452 obstetric evacuations out of a total of 3276 obstetric admissions, i.e. a frequency of 13.79%.
3.2. Socio-Demographic Features
The average age of the patients was 25.7 years, with extremes of 15 and 44 years.
The 15 - 24 age group was the most affected, with 246 patients i.e. 54.4%.
3.2.2. Marital Status
The number of patients with a marital life was 420, i.e. 92.92%.
There were 286 housewives i.e. 64.27%. Students represented 17.30%, dressmakers 14.61% and civil servants 3.82%.
3.2.4. Educational Level
The number of out-of-school patients was 245 i.e. 54.2%. Patients who completed primary education were 95 i.e. 21%, those who completed secondary education were 75 patients i.e. 16.6% and patients who had completed higher education were 37 i.e. 8.2%.
3.2.5. Gesture and Parity
Primigravida were the most represented with 156 i.e. 34.5%, followed by paucigravida with 183 i.e. 40.5%. Multi-gestures with a total number of 113 represented 25%. The average parity was 5.8 with extremes of 1 and 11 deliveries.
3.2.6. Places Patients Came from
We recorded 150 patients who came from health centers in Conakry city (32.2%) and 140 were from municipality medical centers in Conakry city (31%). These were patients transferred from private clinics in the city of Conakry in 96 cases i.e. 21.2%. In 66 cases i.e. 14.6%, they were transferred from delivery houses.
3.3. Evacuation Data
3.3.1. Distance Travelled
Table 1 represents the distribution of transferred parturient women by distance travelled.
The average distance covered was 16 km with extremes of 3 and 50 km. More than half of our patients travelled more than 20 km. Those who came from less than 10 km represented only 6.64% of the evacuated parturient women.
3.3.2. Means of Transport and Organization of the Transfer
Transportation to the referral maternity clinic was not medicalized in 94% of cases and was provided by public transport or personal vehicles. Only 6% of our patients were transferred by ambulance.
The venous route was not taken in 96% of cases.
The mother was not accompanied by a health worker in 98% of cases.
For ten patients out of 452 (2.21%), the health care provider had informed the Hospital prior to the transfer. Communication was made by telephone in 100% of cases.
More than half of our patients 249 (55.1%) had stayed more than 24 hours in their first medical facility. The evacuation time between the evacuation decision and the arrival at the Donka maternity ward of CHU CONAKRY was at least 2 hours for 58.5% of the transferred patients.
3.3.3. Management before Medical Transfer
Only 20 patients out of 452 (4.42%) had a venous approach. The solute used was: isotonic glucose serum in 6 cases (30%), Ringer Lactate in 9 cases (45%), isotonic salt serum in 5 cases (25%). It was noted that no patients received macromolecules or blood transfusion prior to their transfer.
Table 1. Distribution of transferred parturient women by distance travelled.
3.4. Reasons for Medical Transfer
Hemorrhages were the most frequent reason for evacuation (21.6%) followed by acute fetal suffering (18.4%).
3.5. Prenatal Consultation (PNC)
More than a quarter of our patients (26.8%) had more than 4 prenatal consultations (PNC), the average number of ANCs was 2 with extremes of 0 and 9.
3.6. Time Limit for Management at Admission
Management was carried out on average within 30 minutes after admission with extremes of 15 and 190 minutes. The average length of stay was 3.6 days with extremes of 1 and 28 days.
3.7. Pregnancy Term on Admission
The majority of transferred pregnant women (94%) had a full-term pregnancy whose age range varied from 37 to 42 SA, 4% had a pregnancy ranging from 22 to 36 SA and only 2% had a pregnancy between 42 SA and over.
3.8. The Diagnosis at Admission Is Shown in Table 2
Mode of Delivery of Patients
Caesarean section involved 359 patients, i.e. rate of 79.4%, and 93 patients delivered vaginally, 20.6%.
3.9. Maternal Prognosis
Retro placental hematoma was the most common complication and involved 115 patients i.e. 25.4% followed by placenta previa with 66 patients i.e. 14.6%, uterine rupture 64 patients i.e. 14.1%, and eclampsia 54 patients i.e. 11.9%. Bleeding accounted for 54.1%;
We recorded 8 maternal deaths, for a lethality rate of 1.77%.
3.10. Fetal Prognoses
Per partum fetal death was the most frequently encountered fetal complication:
Table 2. Distribution according to diagnosis at admission.
133 cases i.e. 29.4% and hypotrophy involved 25 newborns i.e. 5.6%. Normal newborns accounted for 59.7%.
3.11. The Counter-Reference
The counter-reference was not performed in 442 patients i.e. 97.79% and only 10 patients received a counter-reference i.e. 2.21%. The means used were a letter given to the patient and a telephone number to the referring provider.
Our frequency of 13.8% is significantly lower than the data reported by Ouattara A in Burkina Fasso (43%)  and Cissé in Senegal (46.7%)  . However, Diarra Nama in Côte d’Ivoire  and Coulibaly  in Mali had 10.4% and 7.9% respectively.
4.2. Socio-Demographic Aspects
The average age of the patients was 25.7 years with extremes of 15 and 44 years. The 15 - 24 age group was the most affected (54.4%). Ouattara A et al.  reported an average age of 26.11 years with extremes of 13 and 49 years
Thiam O et al. reported an average age of 26.6 years  with extremes of 15 and 47 years, the 20 - 24 age group being the most affected. Tchaou et al. reported an average age of 26.7 ± 6.2 years with extremes of 15 and 45 years  .
With regard to marital status, our data are close to those of Ouattara and Diarra Nama, who reported 89.8% and 95.5% of married women respectively   .
With regard to the profession, our result is close to that reported by Tchaou B A et al. in Benin, who found 40.4% of housewives  . Ouattara A et al. reported 74.4% in Burkina Fasso  .
Regarding the level of education our result is different from that found by Sepou A et al. in Bangui who reported that 56.1% of women had a primary educational level  . This indicates the high level of illiteracy in our country  .
The average gestiture was 2.86 with extremes of 1 and 12. Thiam et al. reported an average gestiture of 3.8  . Primigrae were the most affected in our series (34.5%) and this trend was confirmed by Diarra Nama et al. who reported 27.7% among primigravida  For Tchaou B A et al. the average gestiture was 3.21 ± 2.16  .
The average parity was 1.54 with extremes of 1 and 11, nulliparous and primiparous women were concerned in our series with 32.5% and 23.2% respectively. Thiam O et al. reported an average parity of 2.7  . For Tchaou B A et al. the average parity was 2.00 ± 2.13  .
For patients place of origin our result is close to that reported by Ouattara A et al. who found that 96% of their patients were evacuated from the city of Ouagadougou and only 4% were from the neighbouring provinces of the city  .
With regard to evacuation data, the average distance covered was 16 km with extremes of 3 and 50 km. Serious maternal and fetal complications and deaths were observed in the majority of cases among patients received after having covered a distance of more than 20 km. This result corroborates the SEPOU data  . Transportation to the referral maternity clinic was not medicalized in 94% of cases and only 6% of our patients were evacuated by an ambulance. Thiam et al. reported in their study that evacuation was provided by ambulance in 69.2%, by personal transportmeans in 28.9% and public transport in 1.5%  . 26.1% of evacuations in the Central African Republic are provided by ambulance  .
Only twenty of our patients out of 452 (4.42%) had a venous approach. In the study conducted by Thiam et al. 61% of evacuated patients received a venous approach  .
These data show that a lot of effort must be made by medical authorities to equip health centers with ambulances. Thus, to improve the quality of health coverage in urban areas, the creation of functional surgical blocks, the training and the provision of refresher courses for health personnel appear to be a priority.
4.3. Clinical Aspect
Hemorrhages were the most frequent reason for obstetric evacuation 54.2%. For Thiam O et al. the motives were dominated by dystocias 37.3%  . Sepou et al. reported maternal exhaustion as the main reason for transfer  . For Diarra Nama et al., dystocias were the main reason for transfer  .
The average time to provide medical management in our case was 30 minutes. This average delay was 28.8 minutes in the Thiam et al. cases with extremes of 10 and 180 minutes  .
About the pregnancy term at admission, the majority of our patients were evacuated at full pregnancy. For Tchaou B A et al. the average gestational age was 33.3 ± 9.3 SA (amenorrhea week) with extremes of 6 and 43 SA  .
4.4. Diagnosis at Admission
Retroplacental hematoma was the most common diagnosis encountered. For Diarra Nama et al., the main diagnosis at admission was dominated by dystocia  . However, in most cases the reason for transfer did not match the diagnosis at admission. This could be explained by the low professional level of agents providing initial medical management. This fact has been noted by some authors   .
4.5. Prenatal Consultation
The frequency of prenatal follow-up in our case is lower than those reported by Touré in Côte d’Ivoire and Diallo in Senegal, who found less than 3 PNCs in 78.1% and 74.4% respectively   .
Akpadza et al. in Togo reported that the frequency of obstetric evacuations tends to decrease as the number of PNCs increases  .
4.6. Mode of Delivery
The cesarean section rate was 79.4% in our case. It was 33.2% for Thiam O et al., 48% for Cissé et al. in Senegal and 18.5% for Soltani in Tunisia    . Our high rate would be explained by the severity of complications at admission (hemorrhage, acute fetal suffering).
4.7. Maternal Prognosis
Maternal complications were dominated by third trimester hemorrhages with a total of 245 cases i.e. More than half 64.1%, which is followed by eclampsia 54 cases i.e. 11.9%. Tchaou A B et al. reported 32.1% dystocia, 21.7% hemorrhagic emergencies and 16.4% hypertensive emergencies  .
Our maternal lethality is lower than those reported by Thiam O, Ouattara A and Sepou A who found 2%, 3.9% and 6.9% respectively    . The difference between our figures and those of these authors in the work context could be explained by the positive impact of the subsidy granted to emergency obstetric care by government authorities.
4.8. Fetal Prognosis
Fetal complications were dominated by per partum fetal deaths 133 cases i.e. 29.4% which is followed by growth retardation 25 cases i.e. 5.6% and prematurity 24 cases i.e. 5.3%. Ouattara A et al. reported a frequency of 18.85% of neonatal deaths  .
Diallo F.B et al. found in their study that the incidence of stillbirths among children born to evacuated mothers is six times higher than among those who were not transferred  .
Dolo A had observed that the risk of mortinatality was four times higher in evacuated patients than in referred patients and twice as high as in self-referred patients  .
4.9. The Second-Reference
The counter-referral was performed in only 2.21% of our patients.
For Thiam O et al. this rate was 97.3% and the means used were a letter given to the patient and a telephone number to the referring provider: a letter was used in 76.8% and the telephone in 15.6% of patients  .
Delays in evacuations, the poor organization of the referral/evacuation system, the poor quality of our transport infrastructure, the use of unsuitable vehicles, the unavailability of certain emergency medicines and the under-equipment at reception facilities are real time bombs in terms of maternal mortality.
The training of peripheral health personnel on the recognition of risk factors, the education of women on the risks faced by them and their children, the improvement of logistical means of evacuation, the creation of an emergency obstetric medical reception unit in urban areas, the creation of functional surgical relay centers, the implementation of an effective information, monitoring and communication system would undoubtedly reduce the importance of this scourge, which delays and alienates efforts to achieve the objectives of a sustainable development.