Peripartum cardiac failure

Bull. Org. mond. Sante 1974, 51, 203-208 Bull. Wid Hith Org. Peripartum cardiac failure An explanation for the observed geographic distribution in Nigeria * N. McD. DAVIDSON,1 LORNA TREV1TT,2 & E. H. 0. PARRY3 Peripartum cardiac failure (PPCF) is common in Zaria, in northern Nigeria, but has not been described elsewhere in Nigeria except in Ibadan. The geographic origin of a series of 224 patients with PPCF was studied in Zaria, and a survey of the syndrome as seen in hospitals and by physicians in the northern states of Nigeria was carried out; information was also gathered from medical and nursing students from various tribal groups in the same area. It was found that PPCF is only common in the areas of Hausa majority, mostly around Zaria and Malumfashi, where the postpartum practices of taking hot baths, lying on a hot bed, and taking large amounts of kanwa (a lake-salt rich in sodium) are pursued with great vigour. These customs may impose a critical load on a vulnerable myocardium, and it seems that tribe and tradition could well explain the high incidence of PPCF around Zaria. The syndrome of peripartum cardiac failure (PPCF) has been described intermittently in the American Negro since the 1930s and in south and west Africa more recently, but it is very rarely seen in other racial groups except in the Koreans (3, 4). The essential feature is cardiac failure of unknown cause, occurring in relation to childbirth, usually in the first 2 months postpartum. We have found that PPCF is extremely common in Zaria, in northern Nigeria, where we have studied 224 patients admitted to Ahmadu Bello University Hospital, Zaria, over 3 years. During our study we found that patients, students and nurses from other parts of Nigeria had often never heard of the illness in their home areas, whereas those from around Zaria recognized it. This prompted us to investigate the geographic distribu- tion of the syndrome in Nigeria, particularly around Zaria and in the northern states. In trying to explain our findings, we have compared the observed vari- ations in incidence with the different traditional postpartum customs. GEOGRAPHIC BACKGROUND Zaria is an ancient walled city of about 200 000 inhabitants, in the flat northern Nigeria savanna, * From the Department of Medicine, Ahmadu Bello University, Zaria, Nigeria. Senior Lecturer in Medicine. 'Research Sociologist (V.S.O.). Professor of Medicine. at an altitude of 700 m above sea level. It lies about 110 north of the Equator, at the southern limit of the area of the Hausa-Fulani majority (hereafter referred to as " Hausa " for convenience). Apart from about 1100 mm of rainfall from May to September, there is no rain for about 6 months of the year. Temperatures may reach 40°C in April and May, when the midday relative humidity rises to about 70%. To the south, rainfall and minimum temperatures increase progressively; maximum tem- peratures are lower, however, and so the range is narrower. To the north, the country becomes increas- ingly dry and hot. The vegetation of Zaria is typical of the northern Guinea savanna where the staple is guinea-corn (Sorghum spp.), which is harvested from October to December. About 80 km farther north, there is a transition to the Sudan savanna where millet (Pennisetum spp.) begins to take the place of guinea- corn. About 150 km south of Zaria, the northern Guinea zone begins to change to the southern where more maize is grown and yam becomes more plenti- ful. Farther to the south, there is derived savanna and then forest, which reaches the coast. Ibadan, the only other centre in Nigeria from where PPCF has been reported, lies in the northern part of the forest zone (1). PATIENTS AND METHODS A consecutive series of 224 patients with PPCF, comprising all those seen at the Ahmadu Bello Uni- 3255 - 203 - N. MCD. DAVIDSON ET AL. versity Hospital over the 3 years 1969-72, was studied. PPCF was defined as cardiac failure dating from pregnancy or the first 6 months postpartum and seen within 6 months of the first symptom, for which no known cause of heart disease could be found. Patients with anaemia and hypertension, which was presumed to be acute, were not excluded, because the significance of these factors was uncer- tain. A full clinical analysis of PPCF is being prepared. One of us (L.T.), who was familiar with these patients in Zaria, visited hospitals in parts of North Western, North Central, Kano, and North Eastern States. There she scrutinized hospital records, ques- tioned physicians, and talked to midwives, nursing sisters, and women from the local tribal groups, to gather information about the incidence of the syndrome in the area and the customs of the local women. Questionnaires were also sent to physicians in these states, and in Benue-Plateau and Kwara States in an attempt to obtain prospective infor- mation. Medical and nursing students were questioned about their knowledge of an illness marked by swell- ing, after childbirth, in their home areas, and they were encouraged to forage for information among the local women when they went home on holiday. This method was considered useful because the students were knowledgeable and motivated investi- gators who could get good local data. Additional information about traditional practices during the puerperium in our area was gathered in a sociological study of 313 married Hausa women in a ward of old Zaria (6). RESULTS PPCFpatients in Zaria The most obvious feature was that 96% of our 224 patients were Hausa or Fulani in origin, com- pared with 70% for women admitted to the medical wards, and only 38% for those delivering in hospital. (The ratio of Hausa to Fulani was about 10: 1, which is very similar to that seen throughout the hospital. We have therefore referred to Hausa and Fulani jointly as " Hausa ".) Very few of our patients came from beyond a radius of 50-150 km of the hospital. Patients came equally from all directions up to the limits of the area; however, 58% of them lived more than 6 km away from Zaria, compared with only 37% of other female medical patients admitted. From our data it has been possible to establish in various ways that the incidence of PPCF in Zaria is about 1 % of Hausa deliveries; for instance, of 879 Hausa mothers admitted in 1970 for a delivery in our hospital, 8 later returned with PPCF. This incidence may be compared with the next highest published estimate of 0.08% by Meadows (5) in Chicago. Survey data The only other hospital where PPCF is known to be very common is the one in Malumfashi, a small town 80 km north of Zaria, where we ourselves have seen many patients. Total numbers there were smaller, but the incidence could approach that of Zaria. The syndrome is also well known in Kano, but is probably less common there than in Zaria and Malumfashi. In Sokoto, about 25 cases are seen every year, but some Zaria women living there said that swelling was less common, and less of a talking point, than in Zaria. In Katsina about 15 or 20 patients are seen annually. Both Sokoto and Katsina hospitals serve a population as large as Zaria. In Birnin Kebbi, 5 cases were seen in 1 year. In the relatively small hospital in Yelwa, 7 patients with PPCF were seen in 2 years; the local dispensers and nurses recognized the syndrome, but said that it was uncommon. Patients with PPCF are infre- quently seen in our sister teaching hospital in Kaduna. Sporadic cases have been seen in Vom and in Argungu. The syndrome was very uncommon in Maiduguri and in Mubi, one patient only being remembered at each hospital. Physicians at Bauchi and Gombe saw occasional cases, but the data were vague. The syndrome was unknown in Bida, Abuja, and Minna (in the southern part of North Western State), in Biu, Yola, Garkida, Bambur, and Numan (North Eastern State), and in Jengre, Akwanga, Mkar, and Takum (Benue-Plateau State), and among the Tiv, Idoma, Igala, Igbirra, Nupe, Gwari, Bachama, Tangale, Longuda, Higi, Bura, Tera, Margi, and Kilba peoples. It is clear from Fig. 1 how closely the distribution of the syndrome of PPCF corresponds to the area of Hausa majority. The syndrome is also occasion- ally seen in Fulani settlements in towns east of this area, as far as Cameroon. Postpartum practices in Zaria Heating. Immediately after her delivery, and con- tinuing for 40 to 120 days, the new mother takes 204 PERIPARTUM CARDIAC FAILURE 0 100 200 300 400 km ,, Fig. 1. The geographic distribution of PPCF within Nigeria; the stippled area represents the area of Hausa majority. two scalding hot baths each day to keep out the " cold ", using a bundle of leaves to splash about 30 litres of very hot water on her body. Tempera- tures of 82°C have been measured immediately before the bathing was started, and superficial burns are common. A young primipara may well have to be forced to take her baths until she herself has accepted their importance. After taking the bath, the mother remains in a well-heated room, with a fire or glowing embers underneath a specially con- structed dried mud bed, which retains the heat for several hours. Food is taken well cooked and highly peppered and all water is boiled before it is drunk. All these measures are an attempt to prevent cold (sanyi) from entering the body. Among Hausa women, cold is thought to be a common cause of illness, and especially puerperal diseases, including swelling. Similar ideas about cold and the need to roast the patient prevail in Malaysia (7). Potash. A special gruel or pap is prepared from guinea-corn or millet with potash (kanwa) and pep- pers and is taken regularly as a medicine to increase the quantity and quality of breast milk. Potash is a misnomer for a dried lake-salt, or natron, which is largely hydrated sodium carbonate; it has a high sodium content but very little potassium, and is also taken as a medicine for all sorts of minor com- plaints (2). In the puerperium it is taken in much larger quantities regularly for 40 days or more; the total amount varies greatly from woman to woman, but is up to about 30 g per day. Observance of practices. Only 1% of Hausa PPCF patients did not take postpartum baths, 3% 205 N. MCD. DAVIDSON ET AL. 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CU U, s 0) C) .r_ U oCU 0. 0 C ._ n LL. S 0) 0 C 0- D. (0 -C 0. .0 40) 10 .0 CU I- co 0 0 CO 0 ~ IL C.'C a. C4 00 LU U.2 LL EC 0- C . co 0*_ o C] 3. PERIPARTUM CARDIAC FAILURE did not lie on hot beds, and 6% took no kanwa at all. This was often because they were already too ill, but some took none because they did not want to. Postpartum practices beyond Zaria Table 1 shows that the customs of lying on a mud bed heated by a fire underneath, or heating the room by a fire, and eating large quantities of kanwa are not only largely confined to the Hausa, but are also far more intensively practised in the area around Zaria than farther north. In many other areas, however, the woman's room is heated by embers; in all areas the taking of hot baths by splashing hot water on the body is common but only around Zaria is the water very hot. North of Malumfashi (and even in Malumfashi town itself, but not in the local countryside), and beyond a radius of roughly 60 km from Zaria in other directions, the Hausa customs are practised less vigorously and for shorter periods than in Zaria. Women from Katsina say that Zaria women are more assiduous in observing the customs than they are, and will even describe devotees as behaving "like Zaria women ". DISCUSSION Although the methods used in this study were varied, with different observers and informants, and although the accuracy of diagnosis of some of the physicians could be questioned because few were familiar with the syndrome, all our evidence points to the fact that PPCF is commonest, and only popularly recognized, in Zaria and in Malumfashi in the southern part of the area of Hausa majority. Knowledge of the syndrome extends to the limits of this area, but the illness seems to be less common the farther one travels from Zaria, just as the tradi- tional Hausa customs of the puerperium are observed less vigorously as the distance from Zaria increases. The syndrome is not known in the adjacent areas, either among the women or in the hospitals, and only about 5 cases per year are seen among Yoruba women at University College Hospital in Ibadan, where the syndrome has been well studied in patients coming from a large area of intake (1). The primary association of PPCF with the Hausa area of Nigeria becomes even more remarkable when compared with the practice of Hausa post- partum customs in the southern part of this area. But in what way is PPCF connected with these cus- toms? The first and most obvious explanation lies in the massive sodium loading caused by taking up to 30 g of kanwa daily (equivalent to about 450 mmol of sodium). This may well increase extracellular fluid and plasma volumes and lead to increased cardiac work. A second factor that may be impor- tant is the excessive heat load from lying on a hot bed, which further increases cardiac output and cardiac work. The sodium and heat loading may together cause cardiac failure if the myocardium is for any reason vulnerable. We therefore believe that the customs of Hausa women in Zaria are important in the pathogenesis of PPCF, although they may not be wholly responsible for the syndrome, to which the Hausa people seem to be particularly at risk. ACKNOWLEDGEMENTS This work was supported by the World Health Organ- ization (Cardiovascular Diseases unit). We are most grate- ful to Hajiya Dadasare Abdullahi Yola and Malama Adama Abdullahi without whose guidance and help the work could not have been carried out. Dr I. S. Audu kindly read the transcript and made valuable comments. RItSUMI! DtFAILLANCE CARDIAQUE AU COURS DU POST PARTUM: UNE EXPLICATION DE LA RtPARTITION GtOGRAPHIQUE DU SYNDROME AU NIGERIA Le syndrome de defaillance cardiaque au cours du post partum (DCPP) est tres frequemment rencontre a Zaria, ville du nord du Nigeria comptant 200 000 habitants appartenant pour la plupart au groupe tribal Hausa. Les auteurs ont 6tudie le cas de 224 femmes ayant presente ce syndrome au cours d'une periode de 3 ans. L'affection etant particulierement commune dans la region de Zaria, on a tente de preciser sa r6partition geo- graphique. A cet effet, on a visite des hopitaux dans les Etats du nord, interrog6 des medecins, des sages-femmes, des infirmieres et des habitants pour s'informer de l'inci- dence de la DCPP et des pratiques locales. On s'est 207 208 N. MCD. DAVIDSON ET AL. enquis aupres des etudiants en medecine et des eleves infirmieres de 1'existence de cas semblables dans leur lieu d'origine. Parmi les 224 patientes 6tudiees, 96% etaient d'origine Hausa, alors que 70% seulement des femmes hospita- lisees pour d'autres affections appartenaient a cette tribu. La DCPP n'etait connue de la population que dans le secteur du Nigeria habite par les Hausa et etait le plus fr6quemment observee dans les h6pitaux des environs de Zaria. Un tres petit nombre de patientes 6taient origi- naires d'autres secteurs ou appartenaient A d'autres groupes tribaux. Etant donn6 que les femmes Hausa observent durant le post partum certaines pratiques traditionnelles dont le r6le pourrait etre important, on a etudie la r6partition g6ographique de ces pratiques. Dans tous les Etats du nord, les jeunes meres prennent des bains chauds et la chambre oiu elles sejournent est chauff6e; & Zaria, les accouchees utilisent pour leurs ablutions quotidiennes une eau excessivement chaude (jusqu'a 82°C), pendant une periode allant de 40 a 120 jours. En outre, durant le post partum, les femmes Hausa consomment du kanwa, natron a forte teneur en sodium, la quantite ingeree pouvant atteindre 30 g par jour pendant 40 jours ou davantage. Selon les auteurs, le lien etroit entre l'incidence de la DCPP et les pratiques adoptees pendant le post partum peut s'expliquer par les effets de l'ingestion massive de sodium et de la chaleur excessive, susceptibles d'entrainer une defaillance cardiaque lorsque le myocarde est, pour l'une ou l'autre raison, vulnerable. REFERENCES 1. BROCKINGTON, I. F. Amer. J. Cardiol., 27: 650 (1971). 2. BUCHANAN, K. M. & PUGH, J. C. Land and people in Nigeria, 7th imp., London, University of London Press, 1969, p. 193. 3. BURCH, G. E. ET AL. Cardiovasc. Clin., 4 (1): 269 (1972). 4. DAVIDSON, N. McD. & PARRY, E. H. 0. Peripartum cardiac failure. In: Shaper, A. G. et al., ed. Cardio- vascular disease in the tropics. London, British Medi- cal Association, 1974. 5. MEADOWS, W. R. Circulation, 15: 903 (1957). 6. TREVITT, L. Savanna, 2: 223 (1973). 7. WILSON, C. S. Ecol. Food Nutr., 2: 267 (1973).