Bilateral tubal ligation in a rural hospital in the Niger Delta, Nigeria.

BACKGROUND AND OBJECTIVE: To document bilateral tubal ligation (BTL) rates and highlight the need to improve on the rates. MATERIALS AND METHODS: A retrospective review of BTLs done in a five-year period from January 2000 to December 2004 constituted the study group. RESULTS: There were a total of 103 BTLs, 58 were Caesarean BTLs, six were cases of BTL with repair of uterine rupture and 39 had BTL from mini-laparotomy. There were 937 Caesarean sections and 2,356 deliveries during the study period. BTL therefore constituted 0.044% of the total deliveries. The majority (51.7%) were above 35 years of age and grandmultiparity constituted 60.4% of BTL cases. The majority was in the low social Class 4 and 5 (41.3%). Grandmultiparity was the most common indication (60.4%). Previous Caesarean sections were more in the highest social class with a mean of 2.9 ± 1.21 while ruptured uterus had the lowest. Unbooked cases of BTL constituted 62.1% of BTL. CONCLUSIONS: Bilateral tubal ligation rate was low in this study with grandmultiparity being the commonest indication, the majority of patients were elderly parturient and largely unbooked. Social class was highest among those with previous Caesarean section.

Perception of intimate pelvic examination by gynaecological clinic attendees in rural Southeast Nigeria.

CONTEXT: Intimate gynaecological examinations are part of the necessary retinue in gynaecological consultation and management. OBJECTIVE: To evaluate women's perception of digital and speculum vaginal examinations in rural Southeast Nigeria. METHODS: This was a prospective descriptive study. Gynaecologic clinic attendees in a Mission hospital in rural Nigeria were interviewed using a pre-tested questionnaire over a 3-year period. RESULTS: Four hundred and eighty-six women with a mean age of 35.2 ± 8.1 years were interviewed. They presented mainly for infertility (36.8%), menstrual abnormalities (31.1%) and early pregnancy complications (10.7%). Over a quarter of the women felt embarrassed at vaginal examination and 37.2% found it a bit painful or felt discomfort. In spite of the discomfort, 73.7% believed vaginal examination was necessary and over 95% indicated readiness to undergo such examination in future if necessary. CONCLUSION: Performing intimate gynaecological examination should be a carefully planned procedure with patient's consent, and performed conscientiously taking patient's feelings and emotions into consideration, to engender confidence.

Vasectomy: a survey of attitudes, counseling patterns and acceptance among Nigerian resident gynaecologists.

OBJECTIVES: Previous Nigerian studies show widespread ignorance and low acceptance of vasectomy among the male population. The objectives of this study were to determine the level of knowledge of, attitudes to, counselling pattern and acceptance of vasectomy among Nigerian Resident Gynaecologists. DESIGN: A cross-sectional questionnaire based survey. METHOD: Resident Doctors attending a national update course in obstetrics and gynaecology. RESULTS: Most of the doctors had good knowledge of Vasectomy. More than four-fifth of the doctors were convinced that the average Nigerian male will not accept vasectomy when indicated while more than three-fifth consider BTL a more appropriate option for permanent contraception in our setting. Forty one point three percent of the doctors will opt for vasectomy or urge their husbands to. Reasons for opposition to vasectomy were socio-cultural (21.3%), religious (13.1%) and psychological (41.0%), 24.6% had no specific reasons. While 89.4% of the doctors counselled often for BTL only 5.8% did for vasectomy. CONCLUSION: The Doctors showed good knowledge of vasectomy but most were poorly disposed towards use of vasectomy. The findings suggest a need for effective national training programmes targeted at resident doctors to enhance their knowledge of vasectomy as well as break barriers to personal use of, and counselling for vasectomy.

Ruptured uterus: the unabating obstetric catastrophe in South eastern Nigeria.

BACKGROUND: Ruptured uterus is an obstetric catastrophe and results in significant maternal and perinatal morbidity and mortality in Nigeria. METHODS: To review the incidence and management of ruptured uterus over the 8-year period (2000-2004 and 2007-2009) and analysis of records of cases of ruptured uterus during the period under review in a descriptive study. RESULTS: The incidence of uterine rupture is 1 in 81 deliveries with a contribution of 13.8% to maternal mortality in Ebonyi State University Teaching Hospital, Nigeria. There was high fetal wastage as 99 (97.1%) of the babies died. The highest incidence of ruptured uterus was found in the para 2-4 group. Teenagers constituted 4 (3.96%) of the cases. Majority of the rupture, 69 (65.4%) occurred anteriorly. Fifty-seven (56.4%) had only repair of the rupture done. The greatest complication was septicemia, which occurred in 32 (31.7%) of the patients. CONCLUSION: The incidence of uterine rupture is very high in our center. It is one of the highest causes of maternal and perinatal morbidity and mortality. There should be a multi-pronged effort aimed at improving the utilization of medical services by the populace and the health institutions offering efficient obstetric emergency care.

Reasons given by pregnant women for late initiation of antenatal care in the niger delta, Nigeria.

BACKGROUND: Many studies show that the vast majority of Nigerian women register for antenatal care late and that the determinants may differ from those found in developed countries. OBJECTIVE: To determine the reasons for late booking among women presenting at the antenatal clinic of a major tertiary hospital in the Niger Delta, Nigeria DESIGN: A cross sectional questionnaire based survey. SETTING: A large tertiary hospital in the Niger delta, Nigeria PARTICIPANTS: Pregnant women registering for antenatal care after 14 weeks gestation. RESULTS: The majority of respondents were aged 20-39 years (97.1%), quarters were primigravidae and 25 % of the women belonged to the upper socioeconomic class. Seventy three point six percent booked in the second trimester and 26.4% in the third trimester. Of the women who had given birth before, 80% had booked late in at least one previous pregnancy. More than three-fifth of the women (65.6%) booked late due to ignorance or misconceptions of the purpose of, and right time to commence antenatal care. CONCLUSION: The findings of this study suggest that most women book late because of a belief that there are no advantages in booking for antenatal care in the first three months of pregnancy. This seems to be because antenatal care is viewed primarily as curative rather than preventive in the study population. Research is needed to determine the best approaches for health education programmes to correct the misconceptions about antenatal care.

High caesarean section rate: a ten year experience in a tertiary hospital in the Niger Delta, Nigeria.

BACKGROUND: Caesarean section rate is rising worldwide and Nigeria is no exception. METHODS: This was a descriptive study. The data from case notes, antenatal and theatre records of patients who had caesarean delivery over a ten year period in the Baptist medical center, Eku were extracted and analysed. RESULTS: The total delivery for the period under study was 5,153 and the total number of caesarean deliveries was 1,777 giving a caesarean section rate of 34.5%. There was no definite trend in the yearly caesarean section rates. Majority of the cases were aged 25-29 (32%). Grandmultipara constituted 26.4% of the patients while 70.1% of cases presented at a gestational age range of 37-42 weeks. Majority of the patients (59.5%) where unbooked for antenatal care. Dystocia (27.1%) was the commonest indication for caesarean section. Emergency abdominal delivery constituted 63.3% of cases while the common complications included wound breakdown, anaemia and endometritis. There were a total of 25 maternal deaths giving a case fatality rate of 1.4%. The leading causes of deaths were haemorrhage (36%), infections (24%), severe preeclampsia/eclampsia (24%), cardiac arrest (12%) and anaesthesia related complication (4%). CONCLUSION: This study found a very high caesarean section rate with majority of cases presenting as unbooked emergency cases. High caesarean section rate in this region was due to increase in primary caesarean delivery for dystocia, elective repeat caesarean deliveries and caesarean deliveries for preeclampsia/eclampsia. Future studies should be extended to rural areas and be targeted at determining whole population Caesarean section rates.

Small bowel obstruction following perforation of the uterus at induced abortion.

BACKGROUND: Unsafe abortion is an important contributor to maternal morbidity and mortality. OBJECTIVE: To present a case of small bowel obstruction following perforation of the uterus at induced abortion. METHODS: A 36-year-old woman, presented at a private hospital, with abdominal pain and weight loss. She had full clinical assessment and laboratory investigations which indicated small bowel obstruction following perforation of the uterus at induced abortion, and was commenced on treatment. RESULTS: She was para 5+0. Her main complaints were abdominal and weight loss following induced abortion of a 12- week pregnancy, four months prior to presentation. At presentation the tools (ultrasound scan, plain abdominal radiograph and barium enema) used for diagnoses only suggested some form of intestinal obstruction and were unremarkable. Correct diagnoses indicating small bowel obstruction was only made at laparotomy. An exploratory laparotomy, adhesiolysis, small bowel resection, end to end anastomosis and bowel decompression was done after bowel preparation. CONCLUSION: Laparotomy has an enviable place in bowel injuries secondary to uterine perforation especially when there is a diagnostic dilemma. Nigerian female population requires continuous health education on widespread and effective use of contraception. Physicians need training and retraining on abortion techniques and management of abortion complications.

Awareness and perception of maternal mortality among women in a semi-urban community in the Niger Delta of Nigeria.

BACKGROUND: Maternal mortality rates are very high in Nigeria. Increased level of awareness and perception will reduce maternal mortality rates. OBJECTIVE: The study was aimed at assessing the awareness and perception of maternal mortality among women in the reproductive age group at Ogunu community in Warri South Local Government Area of Delta State. METHODOLOGY: This was a descriptive cross-sectional study that was carried out in Ogunu town in Delta State. A simple random sampling technique was used to select 400 women, who gave consent to be enrolled in the study. They were assisted in filling a semi-structured questionnaire containing questions on awareness and perception of maternal mortality among women in the community. Information generated was recorded on a data collection sheet designed for the study. The coded data were fed into the computer using the SPSS program to determine the mean values and frequencies. RESULTS: A total of 400 questionnaires were distributed; of these, 349 were completely filled and returned. The mean age of the study subjects was 31.6 +/- 7.7 years. Among these subjects, 54.7% were married, while 32.7%, 28.7% and 26.5% had tertiary, secondary and primary education, respectively. The study revealed that 96.3% of the subjects felt that death can occur from pregnancy-related problems, while 69.1% were aware of maternal mortality. Majority of the subjects agreed that one or more forms of delay could be responsible for their death. This study shows that a good proportion of subjects was aware of maternal mortality and also had a good perception of it. CONCLUSION: Efforts should be directed towards educating women about the risk of delivering in homes of traditional birth attendants, maternity homes and health centers, and the concept of early referral of women to the hospital should be reinforced. Providing information to women on prevention of maternal mortality and community participation and mobilization will help prevent maternal mortality to some extent in Nigeria.

Twinning rate in a rural mission tertiary hospital in the Niger delta, Nigeria.

Twin pregnancy is associated with an increased risk of pre-term deliveries, perinatal morbidity, mortality and maternal complications, especially in developing countries. A descriptive study of all women who had twin pregnancies in a rural mission tertiary hospital over a 7-year period was undertaken. There were a total of 3,351 deliveries and 99 cases of twin deliveries during the study period giving an incidence of 29.5/1,000 or one in 33.8 deliveries. Some 60% of the twins were delivered by caesarean section, while 36.4% had vaginal delivery. A total of 4% had vacuum delivery and a combination of vacuum and caesarean delivery. Twinning rate increased with increasing age and parity. The majority of the patients were unbooked (65.7%). The study could not detect any differences in the birth weights of twin 1 compared to twin 2. There were more females (52%) than males (48%). Low birth weight babies constituted 57.1% of twins. There were 26 perinatal deaths giving rise to a perinatal mortality rate of 131/1,000 and there was no difference in the perinatal mortality rate in the unbooked (131/1,000) and the booked (132/1,000). ). Booking status had no significant effect on perinatal mortality of twins and singletons, p value = 0.65. Singletons had significantly more caesarean section and vaginal delivery than twins, p value < 0.0001. Prematurity was the chief cause of perinatal death (65.4%). The most common mode of presentation was cephalic/cephalic (58.6%), followed by cephalic/breech (29.2%), breech/cephalic (7.1%) and breech/breech (5.1%). There was no maternal death.

Exploring the pattern of complications of induced abortion in a rural mission tertiary hospital in the Niger Delta, Nigeria.

Unsafe abortion remains a major cause of maternal morbidity and mortality in developing countries including Nigeria. We report a 10-year descriptive review of 118 consecutive cases of complicated induced abortions. At our centre, complications of induced abortion constituted 2.3% of maternal admissions, 5.6% of gynaecological admissions and 22.6% of maternal deaths. Fifty-nine percent of the women were married and the mean age was 25.6 +/- 7.9 years. Doctors performed 51.7% of the induced abortion and nurses performed 13.9%. Of the mortalities, medical doctors did 61 of the abortions in which 18 died (29.5%); traditional medical practitioners were responsible for 13 of the abortions in which two died (15.4%); of the 16 abortions performed by nurses, two died (12.5%). Sepsis was the most common cause of death (73%). There is an urgent need to improve the knowledge and utilization of modern contraception by rural women in order to prevent unwanted pregnancies. Doctors need to be continuously trained inn the basic principles of postabortion care.

A comparison of booked and unbooked patients with ruptured uterus in A referral hospital in the Niger Delta region of Nigeria.

OBJECTIVE: To document differences in characteristics and outcome between booked and unbooked patients with ruptured uterus METHODS: A 10 year retrospective comparative analysis of booked and unbooked patients with ruptured uterus at the Baptist medical center, Eku, Delta State. RESULTS: The overall incidence of ruptured uterus was 1 in 271 deliveries while the incidence among booked and unbooked patients was 1 in 556 and 1 in 140 respectively. There were a statistically significant difference in number of booked patients with formal education beyond the primary level compared with the unbooked patients (p = 0.0206; 95% CI 1.92-14.79). A higher proportion of booked patients with ruptured uterus had history of previous uterine scar. All the three maternal deaths occured in the unbooked patients. The overall case fatality rate for ruptured uterus was 23% or 1 in 4.3. CONCLUSION: Booked and unbooked patients with ruptured uterus have different characteristics and outcome. Subsequent studies on ruptured uterus should disaggregate their data according to the booking category of the patients. This will assist in making effective intervention plans that will impact both groups.

Maternal mortality in a rural referral hospital in the Niger Delta, Nigeria.

Almost two decades after the safe motherhood initiative, maternal mortality figures remain very high in Nigeria. Very few studies are available on the features of maternal mortality in rural Nigeria. The objective of this study was to determine the incidence and causes of maternal mortality in a rural referral hospital in the Niger Delta, Nigeria. An audit of 115 consecutive maternal mortalities over a 10-year period at a rural-based tertiary hospital was undertaken. There were 5,153 deliveries and 115 maternal deaths during the study period, with a maternal mortality ratio of 2,232/100,000 live births. The most common causes of maternal mortalities were puerperal sepsis, abortion complications, pre-eclampsia/eclampsia, prolonged obstructed labour, haemorrhage accounting for 33%, 22.6%, 17.4%, 13.0% and 7.8%, respectively. The percentage mortality for unbooked was 10 times that for booked patients. Unbooked status is a risk factor for maternal mortality as this was statistically significant p < 0.0001. Traditional birth attendants were involved in the initial management of at least two-fifths (38.2%) of the non-abortion mortalities while half had been managed in private hospitals and maternities. Maternal mortality will continue to increase unless appropriate steps are taken to improve the use of antenatal care, thereby reducing unbooked emergencies. Hospitals need to be equipped with facilities for emergency obstetric care. Continuous programmes that will integrate TBAs and orthodox practices should be put in place as this will reduce delays and improve referral systems.

Eclampsia: ten-years of experience in a rural tertiary hospital in the Niger delta, Nigeria.

Eclampsia is a major cause of maternal and perinatal morbidity and mortality in developing countries including Nigeria. However, most studies on eclampsia have been in urban communities. The objective of this study was to determine the incidence, pattern of clinical presentation and maternal and fetal outcomes of cases of eclampsia in a rural tertiary hospital in Nigeria. A descriptive review of all cases of eclampsia seen between 1 January 1994 and 31 December 2003 in a tertiary hospital was undertaken. The incidence of eclampsia was 1 in 43 deliveries (2.3%). Most of the women (86.2%) were unbooked for antenatal care in our centre; 58.5% were nullipara, and the onset of seizures was in the ante-partum period (68.3%). Patients presenting were mostly from the traditional birth attendants (46.3%). The time interval between the onset of convulsions and hospital admission was less than 12 h in 52% of cases. The majority of the women had premonitory symptoms (78.8%) with headache being the most frequent (78%). The major route of delivery was abdominal (66.7%). The case fatality rate was 15.4%. Most of the deaths (89.5%) were in unbooked women and the most common causes of death were acute renal failure, cardiopulmonary failure, disseminated intravascular coagulopathy and cerebrovascular accident. The perinatal mortality rate was 195 per 1000 births. This study found a high incidence of eclampsia. It is recommended that community-based health education programmes should be pursued with vigour to enhance early utilisation of modern antenatal care services in rural areas. Traditional birth attendants need to be trained and integrated into the healthcare team. Appropriate mechanisms should be put in place to improve clinic referrals. The capacity of tertiary health institutions to provide intensive care for eclamptics need to be improved with continuous training of heathcare personnel and provision of necessary equipment.

Ectopic pregnancy: an 11-year review in a tertiary centre in the Niger Delta.

Ectopic pregnancy still remains a leading cause of maternal mortality and morbidity in the first trimester of pregnancy and also a significant cause of reproductive failure in Nigeria. A descriptive review of 211 consecutive cases of ectopic gestation over an 11-year period was undertaken. Ectopic pregnancy constituted 9.5% of gynaecological admissions. In all, 86% were nulliparous and 62.6% were married. Abdominal pain and tenderness were the most consistent modes of presentation. Also, 95.3% presented as ruptured ectopic pregnancy. Induced abortion (72%) was the most common factor associated with ectopic pregnancy. Anaemia was the most common post-operative complication. In all, 21% had prior dilatation and curettage as a result of misdiagnoses. The case fatality rate was 2.5%. Ectopic pregnancy presents a major public health challenge among women of reproductive age in this region. Community-based comprehensive health education programme focusing on contraception, sex education, prevention and treatment of postabortal sepsis, pelvic inflammatory disease and puerperal sepsis are urgently needed.

Umbilical endometriosis in a 45 year old Nigerian grandmultipara.

A case of a 45 year old grandmultipara seen at our gynaecological clinic in October 2002 with a 5 month history of cyclical umbilical pain and swelling is presented. There was no prior history of abdominal or pelvic surgery. Umbilical lesion was excised and subjected to histological examination. This revealed umbilical endometriosis. Umbilical endometriosis is rare. The optimum treatment is surgical excision. It has been acknowledged that lack of awareness and facilities for diagnosis may contribute to its rarity. We recommend that gynaecologist should have an increased index of suspicion for this condition and send tissues of umbilical mass for histology.

Caring for the terminally ill: what do the doctors think?

Patients' perception of end-of-life events varies with cultural norms and values, and expectations may differ from clinicians practice and actions. In contemporary practice, conflict of ideas often results in patients discharging themselves against medical advice. Clinicians (67) that have been in medical practice for at least five years at the main tertiary hospital in Benin City were interviewed with a semi-structured questionnaire. The main outcome measured was clinicians' attitude towards caring for the terminally ill patients and physician assisted suicide (PAS). The mean age of the clinicians was 36.89 +/- 7.57, 11 females and 56 males. Twenty-six clinicians (40%) do not routinely record in the case notes details of their discussion on prognosis with their patients. Forty one (62.1%) clinicians will not support life while patients are on palliative care, while 49/66 (74.2%) will transfuse their patients with blood. Thirteen (31.7%) will not support life, and will not transfuse blood. Fifty seven (85.1%) clinicians will not support euthanasia, 8 of the 9 physicians who will support PAS are males, while 6 of the 9 clinicians that will grant patient's request for PAS are gynaecologists. All (17) clinicians in Internal Medicine specialty will not support PAS, while 51/67 (77.3%) clinicians are of the opinion that patients should be routinely informed of the prognosis of their disease. Documentation of physician-patients interactions is poor amongst clinicians. Most will not support life and physician-assisted suicide for the terminally ill patients. However, in clinical practice most will transfuse their patients on palliative care with blood and give other life support treatment; an apparent dissociation between what clinicians think and what is practised.