FACTORS OF OBSTETRIC

Obstetric emergencies are the leading cause of maternal and child mortality worldwide. According to WHO, about 15% of all pregnant women will develop obstetric emergencies that will require special skills to manage. A Nigerian woman has a 1 in 22 lifetime risk of dying during pregnancy, childbirth or postpartum/post-abortion whereas most other developed countries have a risk of 1 in 4900. With figures so high, there is need for prompt response to arrest the problem. A good knowledge/awareness of pregnant women on the predisposing risk factors for occurrence of obstetric emergencies better equips them with appropriate steps to take in preventing the occurrence of such. In this study, the awareness of pregnant women on the risk factors of obstetric emergencies was assessed. Just about 37% of the women knew the concept of obstetric emergencies but when asked the specific types, a good number were aware of all the types. The most popular type was postpartum hemorrhage with 43.5% knowledge. The risk factors most recognized included poor antenatal care, age, infection, drugs and alcohol. 96% of the population however did not think they were at risk of developing any obstetric emergency.


INTRODUCTION
Pregnancy is a thing of joy for most women! While most pregnancies and childbirths are uneventful and normal, about 15 % of all pregnant women will develop a potentially life threatening complication requiring skilled care/ intervention to survive (WHO).
ALL pregnancies are at risk of developing obstetric emergencies! These emergencies are much more delicate owing to the fact that at least two patients; the mother and her baby (ies) are involved. Obstetric emergencies are the leading cause of maternal and child mortality worldwide, especially in developing countries where poverty, lack of antenatal care, literacy, poor transport and equipment/ staffing make them more prevalent (Olonade et al 2019). The survival of a woman experiencing an obstetric emergency is determined by the amount of time taken to deliver care and the level and quality of care provided (WHO, 2017).

LITERATURE REVIEW
Obstetrics is the field of study which concentrates on pregnancy, childbirth and the postpartum period. An emergency is a serious, often dangerous situation which develops unexpectedly and requires immediate attention to prevent loss of life. An obstetric emergency is therefore an unexpected, potentially dangerous situation which develops during pregnancy, childbirth or shortly after the birth of a child.

i. Hypertensive conditions in pregnancy
• Pre-eclampsia: Pre-eclampsia is the presence of hypertension with a diastolic arterial pressure of ≥90mmHg and/or systolic arterial pressure of ≥140mmHg that develops after 20 weeks of gestation in association with proteinuria (≥ 0.3g in a 24 hour specimen). A global incidence rate of 4.6% was recorded for pre-eclampsia by Abalos et al, 2013 in a review involving 40 countries with 39 million women. In developing countries, the prevalence rate of pre-eclampsia ranges from 1.8% to 16.7% (Osungbade and Ige, 2011). The risk factors for development of pre-eclampsia include a previous history of pre-eclampsia, pre-existing hypertension, chronic kidney disease, insulin dependent diabetes, etc (English et al, 2015).

• Eclampsia
Eclampsia is the presence of seizures and/or coma in a woman suffering from preeclampsia/ not caused by coincidental neurologic disease. The symptoms of eclampsia may start before, during or after childbirth until the fourth week postpartum. It occurs typically during or after the 20 th week of gestation or within 48 hours postpartum (Micheal Ross, 2019). The risk factors for eclampsia include: family history of eclampsia or preeclampsia, previous eclampsia or pre-eclampsia, teen pregnancy, women >35 years, chronic hypertension, gestational diabetes, multifetal gestations, etc.
ii. Antepartum Hemorrhage • Ectopic pregnancy Ectopic pregnancy results when the fertilized ovum implants in tissues rather than the lining of the uterus, ultimately leading death of the fetus. This condition can be life threatening if it is not diagnosed and treated early enough. About 95% of ectopic pregnancies occur in the fallopian tube (Ali et al, 2019). Other sites include ovary, cervix and the abdomen.
The World Health Organisation defines postpartum hemorrhage as blood loss greater than 500 mL within 24 hours after birth, and severe primary postpartum hemorrhage as blood loss greater than 1000 mL within 24 hours after birth. It is the leading cause of maternal mortality, accounting for about 35% of all maternal deaths (Paul Ashigbie, 2013). The risk factors for postpartum hemorrhage include antepartum hemorrhage, prolonged labor, maternal obesity, augmented labor, fetal macrosomia, multifetal gestation, preeclampsia, etc. women with risk factors are more prone to postpartum hemorrhage however, 20% of postpartum hemorrhage occurs in women with no risk factors (Evensen et al, 2017). iv.
Obstetric infections • Septic abortion • Obstetric sepsis and septic shock v. Cardiorespiratory arrest in pregnancy vi.
Preterm labour and delivery

RISK FACTORS FOR OBSTETRIC EMERGENCIES
− Age: Adolescents who make up 13% of all pregnancies have an increased incidence of preeclampsia, preterm labor and anemia. This is usually due to neglect of prenatal care, smoking and alcohol and higher rates of STDs. Women >35 experience increased pre-eclampsia, gestational diabetes, dysfunctional labor, still birth, low birth weight, abruption placenta and placenta previa (Blomberg et al, 2014). This is also because women in this age group are more likely to have pre-existing conditions like diabetes and hypertension. Babies born of women older than 35 years are also at a higher risk of fetal chromosomal abnormalities.
− Poor antenatal care: About 69% of pregnant women in Africa have at least one antenatal visit (WHO). At least four visits are however required to achieve the full life-saving potential of antenatal care (Lincetto et al,). The essential interventions of antenatal care include; identification and management of obstetric complications like pre-eclampsia and identification and management of infections like HIV, Syphilis and other STDs. Failure to attend antenatal or insufficient attendances places the pregnant mother at a high risk of developing obstetric emergencies and a higher chance of obstetric emergencies developed to result in fatal consequences.
− Physical and social characteristics Pregnant women who are underweight (BMI <19.8 kg/m 2 ) before pregnancy are predisposed to having underweight neonates (<2.5kg). Overweight and obese women are at high risk of pre-eclampsia, gestational diabetes, fetal macrosomia, miscarriage and congenital malformations when the eventually get pregnant. Shorter women (< 152cm) are more likely to have a small pelvis which can lead to dystocia. They are also more prone to preterm labour (Artal-Mittelmark, 2019)

− Previous history of OE:
A previous preterm delivery due to preterm labour of a neonate weighing less than 1.5kg poses a 50% risk preterm delivery in the next pregnancy (Artal-Mittelmark, 2019). Women with previous preterm delivery should be monitored every 2 weeks after 20 weeks of pregnancy. A previous stillbirth also increases the risk of fetal death in subsequent pregnancies. The degree to which the risk increases depends on the cause of the previous stillbirth.
− Exposure to teratogens: Infections (like herpes simplex, viral hepatitis, Syphilis, etc) and drugs/substances (including alcohol, tobacco, cocaine and some prescription medicines like antidepressants) are the common teratogens that pregnant women are often exposed to during pregnancy.

STATEMENT OF THE PROBLEM
About 15 % of all pregnant women will develop life threatening obstetric emergencies that will require special skills to manage (WHO). The key to managing all emergencies is early detection of these disorders during pregnancy which prevents severe morbidity and mortality through prompt management (Chahabra S, 2017). Nigeria alone accounts for nearly 20% of all global maternal deaths with an estimated 600, 000 maternal deaths between 2005 and 2015 (WHO). As at 2015, the maternal mortality ratio for Nigeria was estimated to be 800 deaths per 100, 000 live births compared to a total 1700 in 46 most developed countries (WHO). The World Health Organization also posits that a Nigerian woman has a 1 in 22 lifetime risk of dying during pregnancy, childbirth or postpartum/post-abortion while in most other developed countries the risk is 1 in 4900. These figures are alarmingly high, requiring that adequate measures be put in place to arrest the situation. An awareness/knowledge of pregnant women on the risk factors that predispose them to developing these emergencies will ensure that they report to the hospital early enough for prompt attention to be administered. This will ultimately lead to reduced maternal and child mortality as nearly half of maternal deaths are preventable (Artal-Mittelmark, 2019). This study will assess the level of awareness of pregnant women on the risks that predispose them to obstetric emergencies which often lead to death.

AIMS AND OBJECTIVES
The aim of the study is to establish the level of awareness of pregnant women on the risk factors that could predispose them to developing Obstetric emergencies. The objectives include: i. To assess the knowledge of pregnant women about obstetric emergencies. ii. To assess their knowledge on the risk factors of obstetric emergencies iii. To assess their attitude towards the occurrence of obstetric emergencies iv.
To assess the level of preventive measures followed by pregnant women to avoid obstetric emergencies.

STUDY SETTING
The study area for the research was the Antenatal clinic of Federal Medical Centre, Makurdi, a tertiary health institution in Benue State.

STUDY DESIGN
This study was a hospital based cross sectional study in which pregnant women registered with the antenatal clinic of the hospital were the respondents. It assessed their level of knowledge on obstetric emergencies, the risks factors for developing obstetric emergencies as well as their attitude towards the occurrence of obstetric emergencies.

STUDY POPULATION AND SIZE
The study population comprised of pregnant women attending the antenatal clinic of Federal Medical Centre, Makurdi. Based on the Cochran formula (Singh and Masuku, 2014) for an unknown population, a total of 139 pregnant women made up the sample size. The sampling technique was a simple random one in which all pregnant women who picked 'yes' out of a ballot were included. The ballot contained just 139 yeses.

DATA COLLECTION
Data was collected through a face to face interaction with respondents using a questionnaire. The questionnaire contained the following: i. Sociodemographic profiles including age, educational qualification, marital status, first pregnancy and age at first pregnancy ii. Knowledge and perception profiles including knowledge of obstetric emergencies, experiences with obstetric emergencies, symptoms experienced, outcomes, risk factors for developing obstetric emergencies and perception on the occurrence of obstetric emergencies.

DATA ANALYSIS
Data from the questionnaires were entered into a Microsoft excel sheet before analysis. The data analysis was carried out using the Statistical Package for Social Sciences (SPSS) software. Frequency and percentage were the major descriptive statistics.

ETHICAL CONSIDERATION
Ethical approval for the study was obtained from the ethical committee of the Federal Medical Centre, Makurdi and taken to the Antenatal Clinic of the hospital before the study commenced. The confidentiality of respondent information was strictly observed as the identity and submissions of respondents were not divulged.  The table above shows that the most experienced Obstetric emergency among the population is postpartum hemorrhage with symptoms including bleeding, abdominal pain, headache, vomiting, weakness, etc. In the table above, the most know risk factors are poor antenatal care (13.5%), age (13.1%) and infection (13.1%). 96.2% of the population did not think they were at risk of developing Obstetric emergencies.

Obstetric emergencies can occur in any pregnant woman (n=115)
Frequency Percent

DISCUSSION
The best age for pregnancy with less risks of complications is between 21-30 years (Bellieni, 2016) and from the results of the study, the majority of the population fell between the 21-30 years age group, an indication that most of the respondents had less risk of developing emergencies triggered by age. The married population was slightly higher than the divorced population. Marriage is generally associated with improved pregnancy outcomes according to Barr and Marugg, 2019, as such the risk of maternal deaths is greatly reduced in women who are married. This may most likely be because in marriage, the pregnant woman can get the help needed from her spouse and when emergencies occur, there is prompt response. 72.2% of the pregnant women had had a tertiary education which places them in a better and more enlightened position to be aware of the complications that arise in pregnancy and as such be better equipped to manage them properly this is in agreement with a publication by Ketema et al, 2020 that maternal education has a positive effect on birth preparedness and complication readiness.
About half of the population had been pregnant before with the larger population having their first pregnancy between 21-30 years. Just about 4% of the population had their first pregnancy between 31-40 years. This is the age group with a high risk for the occurrence of obstetric emergencies especially pre-eclampsia, eclampsia, still births and preterm labour.
Only 37% of the pregnant women had heard about the concept of obstetric emergencies. This result was quite poor considering that the main stay for the proper management of obstetric emergencies is the early detection of the conditions (Chahabra S, 2017). More than half the population had never heard of obstetric emergencies and as such would not be equipped to properly ensure adequate management of such. When asked the specific obstetric emergencies, the most popular emergency was postpartum hemorrhage. This is in line with the publications of Halidu andSalihu, 2017 andAdelaja andTaiwo, 2011. Out of the nine risk factors for developing obstetric emergencies included in the questionnaire, the most picked risk factors were age and infection, poor antenatal care and drugs and alcohol. Knowledge of the risk factors for the occurrence of obstetric emergencies ensures that the pregnant women who are at risk take extra precautions to prevent the occurrence as well as promptly attend to the emergencies if they eventually occur.
On the perception and attitude to obstetric emergencies, 66% agreed that obstetric emergencies can occur in any pregnant women however, only 58% agreed that the emergencies could occur in them. This is an indication that a good number of pregnant women still believe obstertric emergencies to be an abstract concept occurring in a selected population. This is also in line with the 25% who would not inform a physician but hope the obstetric emergency would go away.
In comparison of the age groups and the occurrence of obstetric emergencies, the highest percentage occurred in the 21-30 (45%) age group. This could be as a result of the greater population being within that age group.

CONCLUSSION
The best age group for pregnancy is between 20-30 years and in the study population, the pregnant women belonged mostly to this age group. The effective management of obstetric emergencies starts from adequate knowledge of the emergencies, the risk factors for the development of the emergencies and knowledge of the correct actions to take in the event of such emergencies occurring. In the study however, less than half of the study population knew what obstetric emergencies were and even less were aware of the risk factors for the development of emergencies and quite a number did not even believe that such conditions could occur in them.
There is therefore a need to adequately incorporate lectures on obstetric emergencies into the antenatal care routine in order to better equip pregnant women in managing them.