Determinants of Choice of Facility-Based Delivery among Mothers in Kwara State, Nigeria.

BACKGROUND: Nigeria has the highest number of maternal deaths in the world, which is a major public health problem. One of the major contributory factors is high prevalence of unskilled birth attendance from low facility delivery. However, the reasons for and against facility delivery are complex and not fully understood. OBJECTIVE: The objective of this study was to identify the facilitators and barriers to facility based deliveries (FBD) among mothers in Kwara state, Nigeria. METHODS: The study was carried out among 495 mothers that delivered in the five years prior to the study in three selected communities from the three senatorial districts of Kwara state using mixed methods. The study design consisted of a cross-sectional study with mixed data collection involving qualitative and quantitative methods. Multistage sampling technique was employed. Primary outcome measures were place of delivery, reasons for and against FBD. RESULTS: Of the 495 respondents that had their last delivery during the study period, 410 respondents delivered in the hospital (83%). Common reasons for hospital delivery were ease and convenience (87.1%), safe delivery (73.6%) and faith in healthcare providers (22.4%). The common barriers to FBD included high cost of hospital delivery (85.9%), sudden birth (58.8%) and distance (18.8%). Other important barriers were availability of cheaper alternatives (traditional birth attendants and community health extension workers practising at home), unavailability of community health insurance and lack of family support. Parity, level of education of respondents and husband had significant influence on choice of delivery (p<0.05). CONCLUSION: These findings provided a good insight into the reasons for and against facility delivery among Kwara women, which can assist policy makers and program interventions that can improve facility deliveries and ultimately improve skilled birth attendance, reduce maternal and newborn morbidity and mortality.

CONTEXTE: Le Nigeria compte le plus grand nombre de décès maternels au monde, ce qui constitue un problème majeur de santé publique. L'un des principaux facteurs contributifs est la forte prévalence de l'assistance à l'accouchement non qualifiée due à un accouchement dans des établissements de faible qualité. Cependant, les raisons pour et contre la prestation en établissement sont complexes et ne sont pas entièrement comprises. OBJECTIF: L'objectif de cette étude était d'identifier les facilitateurs et les obstacles aux accouchements en établissement (FBD) chez les mères de l'État de Kwara, au Nigeria. METHODES: L'étude a été menée auprès de 495 mères qui ont accouché au cours des cinq dernières années précédant l'étude dans trois communautés sélectionnées des trois districts sénatoriaux de l'État de Kwara en utilisant des méthodes mixtes. La conception de l'étude consistait en un entretien avec des informateurs clés et une étude transversale avec une collecte de données mixte impliquant des méthodes qualitatives et quantitatives. La technique d'échantillonnage à plusieurs degrés a été employée. Les principaux critères de jugement étaient le lieu d'accouchement, les raisons pour et contre le FBD. RESULTATS: Parmi les 495 répondantes qui ont eu leur dernier accouchement au cours de la période d'étude, 410 répondantes ont accouché à l'hôpital (83 %). Les raisons courantes de l'accouchement à l'hôpital étaient la facilité et la commodité (87,1 %), la sécurité de l'accouchement (73,6 %) et la confiance dans les prestataires de soins de santé (22,4 %). Les obstacles courants à la FBD comprenaient le coût élevé de l'accouchement à l'hôpital (85,9 %), l'accouchement soudain (58,8 %) et la distance (18,8 %). D'autres obstacles importants étaient la disponibilité d'alternatives moins chères (accoucheuses traditionnelles et agents de vulgarisation de la santé communautaire exerçant à domicile), l'absence d'assurance maladie communautaire et le manque de soutien familial. La parité, le niveau d'éducation des répondants et le mari ont une influence significative sur le choix de l'accouchement (p<0,05). CONCLUSION: Ces résultats ont fourni un bon aperçu des raisons pour et contre l'accouchement en établissement chez les femmes Kwara, ce qui peut aider les décideurs politiques et les interventions de programme qui peuvent améliorer les accouchements en établissement et, en fin de compte, améliorer l'assistance qualifiée à l'accouchement, réduire la morbidité et la mortalité maternelles et néonatales. Mots clés: Prestation en établissement; Facilitateurs; Barrières; État de Kwara; Nigeria.

South African women's perspectives on self-sampling for cervical cancer screening: A mixed-methods study.

BACKGROUND: Self-sampling as a method of screening for cervical cancer and its precursors is an attractive option for low-resource settings. However, to allow successful integration of self-sampling into national screening programmes, it is necessary to understand women's perceptions and beliefs surrounding this method of sampling the cervix. OBJECTIVES: To explore women's attitudes to self-collection of samples for cervical screening in a low-resource setting in South Africa (SA). METHODS: Mixed methods were used to meet the study objectives. We recruited women aged 30 - 65 years into a study in Cape Town, SA, to participate in a cross-sectional survey. All women collected a vaginal self-sample, and underwent visual inspection with acetic acid, colposcopy, and collection of cervical samples and appropriate histology specimens by a doctor. Women had a quantitative questionnaire-based exit interview. A subset of these women participated in focus group discussions (FGDs). RESULTS: A total of 822 women answered the exit survey questionnaire and 41 women participated in the FGDs. Most women from the survey had a positive perception of self-sampling, with 93.6% of the women reporting not feeling embarrassed and 89.4% reporting experiencing no discomfort at all when taking a self-sample. This was corroborated by the FGD participants, who found self-sampling easier, more comfortable and less embarrassing than clinician sampling. However, many women (64.7%) felt more confident when the sample was taken by a clinician, despite having a positive attitude towards self-sampling. In most cases this was because they thought that the clinician would take a better sample, as explained by the FGD participants. Although 93.9% of the women were willing to collect a self-sample, the women in the FGDs expressed a preference for doing so at the health facility rather than at home. There were many reasons for this, including the cost of returning to the clinic with the sample. CONCLUSIONS: Attitudes regarding self-sample collection were positive in this study population. Participants were willing to perform self-sampling, but expressed concerns regarding the quality of the specimen and the financial implications of returning to the clinic with it. Pilot implementation studies will be useful before this method of sampling is adopted and integrated into screening programmes.

Role of Risk-Based Approach in the Prevention of Vertical Transmission of Neonatal Sepsis.

AIMS AND OBJECTIVES: Vertical transmission of infections remains a common cause of neonatal morbidity and mortality worldwide. We studied the risk-based approach in preventing the vertical transmission of neonatal sepsis. PATIENTS AND METHODS: A prospective case control study of 154 pregnant women with risk factors for vertical transmission of infections (subjects) and 154 pregnant women without the risk factors (control) at University of Ilorin Teaching Hospital, Ilorin from 1st July to 31st December, 2010. After counseling and consent taking, all participants had active management of labour and all subjects had parenteral intrapartum antibiotic prophylaxis with Ampicillin. There was postnatal evaluation of all babies for signs of neonatal sepsis followed by blood culture and treatment of culture positive babies. The outcome measures were signs and symptoms of neonatal sepsis, neonatal positive blood culture and maternal postpartum morbidity. RESULTS: Neonatal sepsis occurred in 16 babies (subjects=11, control=5); three babies had Early Onset Group B Streptococcal Disease (EOGBSD) (subjects=2, control=1; P=0.501) while 13 had non Group B Streptococcal (GBS) infections (subjects=9, control=4; P=0.113); onset of signs and symptoms was < 24hrs in all cases, incidence of EOGBSD were 12.9/1000 (subjects) and 6.5/1000 (controls). Subjects whose babies had sepsis had multiple risk factors; one dose of antibiotics and antibiotics to delivery interval < 2hours. There was no sepsis in babies of mothers who had adequate antibiotic prophylaxis. There was no maternal or neonatal death but 17.5% of subjects had maternal postpartum morbidities. CONCLUSION: The risk-based approach is a practicable alternative in preventing vertical transmission of neonatal sepsis if antibiotic prophylaxis is adequate before delivery.

Coagulation profile in severe pre-eclampsia and eclampsia in Ilorin, Nigeria: implications for anaesthetic management in operative obstetrics.

BACKGROUND: Severe preeclampsia and eclampsia are associated with coagulopathy which may be a contraindication to central neural axial blockade for caesarean section. Many investigations of bleeding tendencies are not done in our environment because of logistic reasons and emergency presentations of these patients.The study was designed to determine the coagulation profile of severe preeclamptic and eclamptic women in labour and possibly arrive at affordable and readily available investigation(s) that can be used in excluding bleeding tendencies in these patients. STUDY DESIGN: In a prospective study, 50 severely preeclamptic/eclamptic patients in labour and, 50 parturients with normal pregnancies, and, in labour were recruited. Full blood count including platelet count, prothrombin time (PT) using the International Normalized Ratio (INR) and partial thromboplastin time with kaolin (PTTK) were done in all the patients. RESULTS: Mean platelet count was significantly lower in study patients than in controls, 158.1 × 10(9)/l versus 216.9 × 10(9)/l, p = 0.0001. Mean INR and PTTK were within the reference values for the reagents used but mean INR was significantly greater in cases than in controls, 1.06 ± 0.01 versus 0.92 ± 0.01 (p = 0.001) while PTTK was also significantly longer in cases than in controls, 38.4 ± 0.21 versus 34.3 ± 0.44 seconds (p = 0.002). CONCLUSION: As platelet count can be readily obtained and it is affordable in our environment, it can be used in assessing bleeding tendencies in these patients for their effective management.

Missed Diagnosed Bicornuate Unicollis Uterus Presenting As Acute Abdomen.

Uterus bicornuate unicollis is one of the various congenital abnormalities of the female genital tract caused by partial fusion of the mullerian ducts on both sides. A case of acute abdomen resulting from missed diagnosed bicornuate unicollis uterus in a 42-year infertile women was presented. The ultrasonographic diagnosis of twisted complex left adnexial cyst was made prior to exploratory laparotomy. However, findings at laparotomy revealed a non-communicating bicornuate unicollis uterus with damaged right tube (hyrosalpinx) and normal ovaries and left tube. A blind-ended rudimentary left sided uterine horn was excised with the ovary spared and the right sided hydrosalpinx disconnected using chromic 1. Patient was however counselled for in vitro fertilization.

Ectopic pregnancy in Ilorin, Nigeria: a four year review.

AIMS AND OBJECTIVES: This is to study the incidence, predisposing factors, clinical presentation and management of ectopic pregnancy that presented over a four year period. PATIENTS, MATERIALS AND METHODS: This is a retrospective study of 98 ectopic pregnancies managed at the gynaecological unit of University of Ilorin Teaching Hospital, Ilorin from 1st January 2004 to 31st December 2007. Information was obtained from the case notes, theatre and labour ward registers. RESULTS: A total of 10,054 deliveries were recorded while 1,430 gynaecological patients were admitted. Ninety eight patients had ectopic gestation accounting for 1% of all deliveries and 6.9% of all gynaecological admissions. The peak age group was 25-29 years (33%); 70 (74.5%) were married and 16 (17%) were students mostly undergraduates. Previous pelvic inflammatory disease 78 (83%), previous pelvic surgery 7 (7.4%) and previous history of ectopic pregnancy 2 (2.1%) were the most common risk factors in the patients. Lower abdominal pain 90 (95.7%), missed period 82 (87.2%), dizziness/fainting attack 57( 60.6%) and vaginal bleeding 50 (53.2%) were the predominant symptoms at presentation. There were 2 (2.1%) bilateral ampullary tubal ectopic with one unruptured ec- topic which was treated with linear salpingostomy. Only one (1.1%) case of heterotrophic pregnancy. Open abdominal surgery was the treatment employed in all the patients. No Mortality was recorded. CONCLUSION: The incidence of ectopic pregnancy can be reduced by putting in place measures to reduce induced abortion and pelvic inflammatory disease. In addition, early presentation, prompt diagnosis and efficient blood transfusion services will decrease the morbidity and mortality associated with ectopic pregnancy.

Repeat caesarean delivery as a risk factor for abnormal blood loss, blood transfusion and perinatal mortality.

We reviewed 450 cases of caesarean delivery (January-December 2009) at the University of Ilorin Teaching Hospital in Nigeria. We analysed the association between caesarean delivery status (primary or previous) and the following outcomes: abnormal blood-loss, blood transfusion and perinatal mortality. Although significant differences were observed between primary and previous caesarean delivery groups in regards to maternal age, urgency of the caesarean delivery, booking status, and cadre of birth attendant staff, no association was noted between caesarean delivery status and any of the three outcomes. Further analyses identified parity as an important predictor for blood transfusion and abnormal blood loss. In addition, we found a dose?response relationship between parity and abnormal blood loss (< 0.05). Also, mothers with an emergency caesarean delivery of the index pregnancy were more than twice as likely to have a blood transfusion as compared with those with an elective caesarean delivery.