Comparative Effectiveness of Teaching Obstetrics and Gynaecological Procedural Skills on Patients versus Models: A randomized trial.

OBJECTIVE: To compare the effectiveness of learning procedural skills on patients versus mannequins and models. METHODS: Seventy four interns from two consecutive batches at the Department of Obstetrics and Gynaecolgy Unit-I at Jinnah Postgraduate Medical Center Karachi participated in the study between April and September 2014. Five basic skills; taking a cervical (Pap) smear, intrauterine contraceptive device insertion, manual vacuum aspiration, making/ suturing an episiotomy and active management of the third stage of labour were identified. Interns were randomly allocated to two training groups (Group-1 and 2 of thirty eight and thirty six trainees respectively), with Group-I received training on the five procedural skills on models and mannequins for four weeks while Group-II trained on patients initially. After an evaluation at four weeks the groups crossed over with a final evaluation at eight weeks. The evaluation was through identical objective structured assessment of technical skills on models and mannequins for both groups with standard checklists. RESULTS: There was no significant difference in skills between the two groups at the four weeks assessment. However at the end of training, Group-1 trainees performed significantly better than Group 2 with higher overall tests scores (86.7 ± 2.7 versus 80.4 ± 4.8, p< 0.001). This difference was more marked in skills of intrauterine contraceptive device insertion, making and suturing an episiotomy and active management of third stage of labour. CONCLUSION: Our findings suggest that simulations using models and mannequins for developing procedural skills can be readily incorporated in training programs with potential benefits for teaching infrequently performed or more difficult procedures. Our data suggest potential benefits of initiation of trainings on simulations and mannequins followed by human subject exposure.

Awareness about human papillomavirus as a cause of cervical cancer and its prevention in the undergraduate female students of Karachi.

OBJECTIVE: To determine the rate of acceptance of human papillomavirus vaccine for prevention of cervical cancer, and to identify causes of its low acceptance and means of encouraging its uptake. METHODS: This cross-sectional study was conducted at five different universities of Karachi, from July to December 2011, and comprised female undergraduate students. The participants, aged between 17-26 years, were in their first four years of undergraduate studies, and were selected from five universities. The distributed questionnaire included queries related to demographic information, knowledge and attitude about sexually transmitted diseases, cervical cancer, human papillomavirus and its vaccine. SPSS 20 was used for data analysis. RESULTS: Of the 1,277 participants, 1,038(81.3%) filled in the questionnaires correctly. Of them, the awareness level regarding sexually transmitted diseases, cervical cancer, human papillomavirus, and human papillomavirus as a cause of cervical cancer was 863(83.1%), 483(51.3%), 244(23.5%), and 138(13.3%), respectively. Moreover, 200(19.3%) participants were aware of the vaccine and 13(1.3%) had had themselves vaccinated. CONCLUSIONS: Few respondents were aware of all the three topics, i.e. sexually transmitted diseases, cervical cancer and human papillomavirus. .

A risk prediction model for the assessment and triage of women with hypertensive disorders of pregnancy in low-resourced settings: the miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) multi-country prospective cohort study.

BACKGROUND: Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications. METHODS AND FINDINGS: From 1 July 2008 to 31 March 2012, in five LMICs, data were collected prospectively on 2,081 women with any hypertensive disorder of pregnancy admitted to a participating centre. Candidate predictors collected within 24 hours of admission were entered into a step-wise backward elimination logistic regression model to predict a composite adverse maternal outcome within 48 hours of admission. Model internal validation was accomplished by bootstrapping and external validation was completed using data from 1,300 women in the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) dataset. Predictive performance was assessed for calibration, discrimination, and stratification capacity. The final miniPIERS model included: parity (nulliparous versus multiparous); gestational age on admission; headache/visual disturbances; chest pain/dyspnoea; vaginal bleeding with abdominal pain; systolic blood pressure; and dipstick proteinuria. The miniPIERS model was well-calibrated and had an area under the receiver operating characteristic curve (AUC ROC) of 0.768 (95% CI 0.735-0.801) with an average optimism of 0.037. External validation AUC ROC was 0.713 (95% CI 0.658-0.768). A predicted probability ≥25% to define a positive test classified women with 85.5% accuracy. Limitations of this study include the composite outcome and the broad inclusion criteria of any hypertensive disorder of pregnancy. This broad approach was used to optimize model generalizability. CONCLUSIONS: The miniPIERS model shows reasonable ability to identify women at increased risk of adverse maternal outcomes associated with the hypertensive disorders of pregnancy. It could be used in LMICs to identify women who would benefit most from interventions such as magnesium sulphate, antihypertensives, or transportation to a higher level of care.

Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities.

Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We undertook an in-depth analysis of Pakistan's progress towards MDGs 4 and 5 and the principal determinants of health in relation to reproductive, maternal, newborn, and child health and nutrition. We reviewed progress in relation to new and existing public sector programmes and the challenges posed by devolution in Pakistan. Notwithstanding the urgent need to tackle social determinants such as girls' education, empowerment, and nutrition in Pakistan, we assessed the effect of systematically increasing coverage of various evidence-based interventions on populations at risk (by residence or poverty indices). We specifically focused on scaling up interventions using delivery platforms to reach poor and rural populations through community-based strategies. Our model indicates that with successful implementation of these strategies, 58% of an estimated 367,900 deaths (15,900 maternal, 169,000 newborn, 183,000 child deaths) and 49% of an estimated 180,000 stillbirths could be prevented in 2015.

Conducting a diabetes mellitus prevention trial in women with GDM in Pakistan: a feasibility study.

BACKGROUND: Women with gestational diabetes mellitus (GDM) are at a greater risk of developing type 2 diabetes mellitus (T2DM) than women without GDM. Despite this elevated risk, few trials on the prevention of T2DM among South Asian women with GDM have been reported. Therefore, this study aimed to assess the feasibility of conducting a diabetes prevention program on women with a history of GDM to inform the development of a contextually relevant definitive trial. METHODS: Using a randomized controlled trial, women with GDM (n = 180) who delivered at the study hospitals (one public and one private teaching hospital, Karachi) with fasting blood glucose levels < 120 mg/dl at 6 weeks postpartum were randomized to the intervention (n = 88) or control arms (n = 92). Women in the intervention group received individualized home-based educational sessions from trained community health workers at 0, 1, 3, 6, and 9 months. In addition, they received short text messages, prerecorded messages, and printed educational material (calendars and pamphlets) for reinforcement. The intervention was centered on equipping women with knowledge, skills, and confidence to eat a healthy diet rich in fruits, vegetables, and low-fat dairy products and perform regular physical activity based on walking and household chores to reduce weight (up to 5% of their initial body weight). Women in the control arm received standard care. The feasibility outcomes of the study included screening, recruitment, and retention rates and in-depth interviews at 6 months post-intervention to explore women's experiences with the intervention. Descriptive analysis and thematic analysis were performed. RESULTS: Of the 324 women screened during the antenatal care visits and after delivery, 255 (78.7%) were contactable 6 weeks postpartum, and 180 (70.6%) were eligible and randomized to intervention (n = 88) and control (n = 92) groups. Loss to follow-up in the intervention and control arms was 22.7% (n = 20/88) and 18.5% (n = 17/92), respectively. Women expressed satisfaction with home-based counseling and follow-up visits, text message reminders, and printed material in the form of a calendar through our qualitative interviews. CONCLUSIONS: Home-based lifestyle modification intervention augmented with text messages and printed material is feasible. However, to evaluate the intervention's effectiveness, a larger trial is warranted to assess its long-term impact on diabetes prevention. TRIAL REGISTRATION: ISRCTN, ISRCTN11387113 . Registered 5 December 2017-retrospectively registered.

Emergency obstetric hysterectomy.

OBJECTIVE: To assess the frequency of obstetric hysterectomy, its indications and associated maternal and perinatal morbidity and mortality. METHODS: The retrospective observational analytical study was conducted at the Department of Obstetrics and Gynaecology, Unit-I, Jinnah Postgraduate Medical Centre, Karachi from January 2003 to December 2009. Records of all patients who had underone hysterectomy at the study centre during the study period were explored for age, parity, booking status indication and the type of operation performed. Maternal and foetal morbidity and mortality were also recorded. SPSS 13.0 was used for statistical analysis. RESULTS: Against the total 44,612 deliveries during the period, 121 hysterectomies were performed for obstetric indications. The frequency of the procedure, as such, was 1 in 368 (0.27%) deliveries. The major indications were ruptured uterus in 57 (47.1%), and severe postpartum haemorrhage due to atony of uterus in 35 (28.9%). Other indications included severe haemorrhage due to placental abnormalities in 14 (11.6%); placenta previa in 3 (2.5%); abruptio placenta in 4 (3.3%); and severe infection following vaginal delivery in 3 (2.5%). Infection was the commonest complication seen in 14 (11.6%) patients. There were 11 (9.0%) maternal deaths and 65 (53.7%) perinatal deaths. CONCLUSION: Emergency obstetric hysterectomy remains a necessary tool for consultant obstetricians. Acting at the optimal time with clear judgment, and professional surgical technique can reduce morbidity and mortality in such cases.

Decision-making and involvement of women with previous C-section in choosing their mode of delivery.

OBJECTIVE: To determine the attitude and factors leading to decision regarding the mode of delivery in women with previous experience of C-section. METHODS: The cross-sectional study was conducted at Maternity Unit of Jinnah Postgraduate Medical Centre, Karachi, from January to August 2008, and involved 150 women with one previous C-section without any recurrent cause. All women had a parity of two or more. Women with more than one caesarean section and women who lost contact were excluded. The women were recruited from antenatal clinic and were briefed by medical professionals before the questionnaire was filled out. SPSS version 10 and Chi square test were used for statistical analysis. RESULTS: Of the total 29 (19.3%) preferred a repeat caesarean section, and 121 (80.7%) opted for the trial of scar. No significant difference was seen in the mode of delivery when the decision was taken by women alone or when it was taken jointly by doctors and women. When the decision was taken by doctors, there was significant difference in the mode of deliveries. The patients expressed satisfaction towards the information received. Previous associated factors, like negative birth experience, had an influence on decision-making regarding the mode of delivery. CONCLUSION: Decision by women is extremely important regarding their mode of delivery and should be respected. Psychological support during pregnancy may provide an alternative to caesarean section for women with previous negative experience.

Exploring terminology for puerperal sepsis and its symptoms in urban Karachi, Pakistan to improve communication, care-seeking, and illness recognition.

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols.

Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect.

BACKGROUND: Our objective was to estimate the effect of various childbirth care packages on neonatal mortality due to intrapartum-related events ("birth asphyxia") in term babies for use in the Lives Saved Tool (LiST). METHODS: We conducted a systematic literature review to identify studies or reviews of childbirth care packages as defined by United Nations norms (basic and comprehensive emergency obstetric care, skilled care at birth). We also reviewed Traditional Birth Attendant (TBA) training. Data were abstracted into standard tables and quality assessed by adapted GRADE criteria. For interventions with low quality evidence, but strong GRADE recommendation for implementation, an expert Delphi consensus process was conducted to estimate cause-specific mortality effects. RESULTS: We identified evidence for the effect on perinatal/neonatal mortality of emergency obstetric care packages: 9 studies (8 observational, 1 quasi-experimental), and for skilled childbirth care: 10 studies (8 observational, 2 quasi-experimental). Studies were of low quality, but the GRADE recommendation for implementation is strong. Our Delphi process included 21 experts representing all WHO regions and achieved consensus on the reduction of intrapartum-related neonatal deaths by comprehensive emergency obstetric care (85%), basic emergency obstetric care (40%), and skilled birth care (25%). For TBA training we identified 2 meta-analyses and 9 studies reporting mortality effects (3 cRCT, 1 quasi-experimental, 5 observational). There was substantial between-study heterogeneity and the overall quality of evidence was low. Because the GRADE recommendation for TBA training is conditional on the context and region, the effect was not estimated through a Delphi or included in the LiST tool. CONCLUSION: Evidence quality is rated low, partly because of challenges in undertaking RCTs for obstetric interventions, which are considered standard of care. Additional challenges for evidence interpretation include varying definitions of obstetric packages and inconsistent measurement of mortality outcomes. Thus, the LiST effect estimates for skilled birth and emergency obstetric care were based on expert opinion. Using LiST modelling, universal coverage of comprehensive obstetric care could avert 591,000 intrapartum-related neonatal deaths each year. Investment in childbirth care packages should be a priority and accompanied by implementation research and further evaluation of intervention impact and cost. FUNDING: This work was supported by the Bill and Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.

Alma-Ata: Rebirth and Revision 6 Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make?

Several recent reviews of maternal, newborn, and child health (MNCH) and mortality have emphasised that a large range of interventions are available with the potential to reduce deaths and disability. The emphasis within MNCH varies, with skilled care at facility levels recommended for saving maternal lives and scale-up of community and household care for improving newborn and child survival. Systematic review of new evidence on potentially useful interventions and delivery strategies identifies 37 key promotional, preventive, and treatment interventions and strategies for delivery in primary health care. Some are especially suitable for delivery through community support groups and health workers, whereas others can only be delivered by linking community-based strategies with functional first-level referral facilities. Case studies of MNCH indicators in Pakistan and Uganda show how primary health-care interventions can be used effectively. Inclusion of evidence-based interventions in MNCH programmes in primary health care at pragmatic coverage in these two countries could prevent 20-30% of all maternal deaths (up to 32% with capability for caesarean section at first-level facilities), 20-21% of newborn deaths, and 29-40% of all postneonatal deaths in children aged less than 5 years. Strengthening MNCH at the primary health-care level should be a priority for countries to reach their Millennium Development Goal targets for reducing maternal and child mortality.

Maternal health and survival in Pakistan: issues and options.

Although its measurement may be difficult, the maternal mortality ratio (MMR) is a key indicator of maternal health globally. In Pakistan each year over five million women become pregnant, and of these 700,000 (15% of all pregnant women) are likely to experience some obstetrical and medical complications. An estimated 30,000 women die each year from pregnancy-related causes, and the most recent estimates indicate that the MMR is 276 per 100,000 births annually. In this review, we describe the status of maternal health and survival in Pakistan and place it in its wider context of key determinants. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women's empowerment. Undernutrition for girls, early marriage, and high fertility rates coupled with unmet needs for contraception are important determinants of maternal ill health in Pakistan. Our review also examines factors influencing the under-utilization of maternal health services among Pakistani women, such as the lack of availability of skilled care providers and poor quality services. Notwithstanding these observations, there are evidence-based interventions available that, if implemented at scale, could make important contributions towards reducing the burden of maternal mortality in Pakistan.

A comparative evaluation of multiple micronutrient and iron-folic acid supplementation during pregnancy in Pakistan: impact on pregnancy outcomes.

BACKGROUND: Maternal micronutrient deficiencies are widespread in Pakistan and are potentially associated with maternal undernutrition and intrauterine growth retardation. Intervention strategies largely consist of administration of iron-folic acid supplements during pregnancy. OBJECTIVE: We evaluated the acceptability of multiple micronutrient supplementation and its potential benefits on pregnancy outcomes and maternal micronutrient status in a cohort of pregnant women in rural and urban Sindh through a cluster-randomized design. METHODS: We randomly assigned 2378 pregnant women to receive either iron-folic acid or multiple micronutrient supplements. The supplements were administered fortnightly by community health workers who performed home visits to assess tolerance and observe the mothers. RESULTS: The women in both groups consumed about 75% of the supplements provided, and few reported adverse effects such as vomiting, abdominal pain, etc. There was a small (70 g) but significant increase in birthweight among infants of mothers receiving multiple micronutrients as compared with infants of mothers receiving iron-folic acid supplements (2.95 +/- 0.6 vs. 2.88 +/- 0.5 kg, p = .01). This translated into a 10% reduction (p < 0.17) in the proportion of low-birthweight infants among infants of mothers receiving multiple micronutrients. Although stillbirth rates were comparable in the two groups, the early neonatal mortality rate in the group receiving multiple micronutrients was higher, although not significantly, than that in the group receiving iron-folic acid (43.2 vs. 23.5 deaths per 1000 live births; RR = 1.64; 95% CI, 0.94 to 2.87). Comparable reductions in anemia (hemoglobin < 11 g/dL) were observed, although the proportion with low iron stores (assessed by serum ferritin) was lower in the iron-folic acid group in the postnatal period. Although the proportion of women with subclinical vitamin A deficiency after supplementation did not differ between the two groups, the iron-folic acid group had a higher proportion with lower serum zinc levels in the immediate postpartum period. CONCLUSIONS: These data suggest that multiple micronutrient supplements are well tolerated during pregnancy, but the effect on birthweight is modest. The observed effect on early neonatal mortality suggests the need for further studies and careful assessment of the intervention in health system settings.

Loading dose of magnesium sulphate versus standard regime for prophylaxis of pre-eclampsia.

OBJECTIVE: To determine the efficacy of single dose of magnesium sulphate versus the standard Pritchard regime in the management of pre-eclampsia. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Jinnah Postgraduate Medical Centre, Karachi, from January 2004 to January 2006. METHODOLOGY: All women with severe pre-eclampsia and impending eclampsia were included in the study. Patients with pregnancy induced hypertension and mild to moderate pre-eclampsia were excluded. From the 100 women included in the study, after matching for age, parity and gestational age, 50 were given only bolus dose of magnesium sulphate and 50 were given the standard regime. They were observed for one week for the number of convulsions. Fisher's exact test and Chi-square test were used to analyze results. RESULTS: There was no significant difference in the two groups in term of occurrence of seizures, one patient developed fit with Pritchard regimen. The rate of caesarean section was lower in group A, 12% versus 30% in group B (p=0.05). There was no significant difference in perinatal outcome in either group (82% live births in group A versus 72% amongst group B (p=0.2). Few side effects like vomiting, dizziness and irritation at the site of injection were observed when standard treatment was used. Single dose treatment was also found to be cost-effective costing Pak Rs. 45 (US $ 0.56) as compared to Pak Rs. 195 (US $ 2.4) in control group. No maternal death was observed in either group. CONCLUSION: Having the equal effectiveness, ease of monitoring and cost-effectiveness, single loading dose of magnesium sulphate is preferable over the standard regime in the management of pre-eclampsia as a prophylactic measure for prevention of seizure.

Role of partogram in preventing prolonged labour.

OBJECTIVE: To determine the effect of partogram on the frequency of prolonged labour, augmented labour, operative deliveries and whether appropriate interventions based on the partogram will reduce maternal and perinatal complications. METHOD: A case controlled, prospective and interventional study on 1000 women in labour was carried out in the obstetric unit of Jinnah Post graduate medical center, Karachi, from 1st July to 30th December, 2002. Five hundred women were studied before and after the introduction of partogram. Duration of labour, mode of delivery, number of cases augmented and neonatal outcome were noted RESULTS: Labour was shorter than 12 hours in 80.8% primigravida, 18.4% had labour shorter than 24 hours and only 0.8% had labour longer than 24 hours. After introduction of partogram 91.6% delivered within 12 hours and rest (8.4%) delivered within 24 hours. Normal vaginal delivery was had in 88%, 5.6% had operative vaginal delivery and 6.4% had caesarean section. Introduction of partogram showed significant impact on duration of labour (p < 0.001) as well as on mode of delivery (p < 0.01). In multigravidae 94.4% delivered within 12 hours and rest 5.6% delivered within 24 hours when partogram was used while 88.4% delivered within 12 hours and the rest 11.6%) within 24 hours before the use of partogram. Partogram showed significant reduction in duration of labour (p < 0.01). Results also showed significant reduction in number of augmented labour (p < 0.001) and vaginal examinations (p < 0.001). CONCLUSION: By using partogram, frequency of prolonged and augmented labour, postpartum haemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality was reduced.

An audit and trends of perinatal mortality at the Jinnah Postgraduate Medical Centre, Karachi.

OBJECTIVE: To prospectively review the extent and determinants of perinatal mortality (PNM), at a large Government referral teaching hospital in Karachi and to compare the rate with previous data. METHODS: One year study from 1st January to 31st December 2001 was carried out in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi. A prospective review of all stillbirths from 28 weeks of pregnancy and neonatal deaths within first seven days of life in the hospital either in the obstetric ward or in the neonatal nursery was done. The details of each mother and newborn delivered were recorded on standardized proforma. Aberdeen (Obstetric) classification of perinatal deaths was applied in the survey for classification of perinatal causes. RESULTS: During the one year period from 1st January to 31st December, 2001, there were 7743 deliveries and 753 perinatal deaths. Five hundred and sixty nine were still born and 184 died within 7-days of birth. The perinatal mortality rate (PNMR) was 97.2/1000 total births and still birth rate 73.4/1000 total births. The leading cause of stillbirth was hypertensive disease of mother in 180 (24%). This included Pregnancy Induced Hypertension (PIH) 106 (14%) and eclampsia 74 (10%). The next common cause was mechanical, accounted for 161 (21.4%). Antepartum haemorrhage (APH) was responsible for 151 (20%) perinatal deaths and low birth weight (LBW) was identified in 108 (14.4%). Congenital malformation caused deaths in 47 (6.2%), maternal medical disorders as jaundice, anaemia and diabetes in 24 (3.2%) and neonatal infections as Respiratory Distress Syndrome (RDS), probable pneumonia, bleeding disorders and septicaemia caused deaths in 35 (4.8%). CONCLUSION: Perinatal deaths are largely the result of poor maternal health, low socio-economic status, lack of health awareness and inadequate care during antepartum, intrapartum and postpartum period. Perinatal mortality rate has largely remained unchanged over the last 40 years at the premier referral and teaching institution of Karachi, due to higher patient influx and referral rate.

Review of nutrition guidelines relevant for adolescents in low- and middle-income countries.

The economic and social well-being of any country will one day depend on its current adolescent population. To provide a good foundation for healthy adolescent development, healthy diet, along with physical activity and adequate nutrients, is necessary. Therefore, addressing the nutrition needs of adolescents could be an important step toward breaking the vicious cycle of intergenerational malnutrition, chronic diseases, and poverty. These problems could be addressed with timely recognition and appropriately delivered interventions. Our aim here is to review the existing guidelines on various aspects of nutrition interventions for adolescents and young women. We review all of the major existing guidelines on adolescent nutrition. We were able to find 18 guideline bodies that covered some form of nutritional advice in guidelines that targeted adolescents. Although the guidelines that focus specifically on this age group are limited in scope, we also extrapolated recommendations from guidelines focused on adults, women of reproductive age, and pregnant women, which were based on evidence that included populations of adolescent girls. We were able to extract and synthesize specific directives for nutrition in adolescents, macro- and micronutrient supplementation, exercise, obesity, and nutrition during preconception, pregnancy, and the postconception period.

Sociocultural determinants of induced abortion.

OBJECTIVE: To determine the frequency of induced abortion and identify the role of sociocultural factors contributing to termination of pregnancy and associated morbidity and mortality in hospital setting. DESIGN: Prospective observational study. PLACE AND DURATION OF STUDY: The study was conducted in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi from January 1999 to June 2001. SUBJECTS AND METHODS: The patients who were admitted for induced abortion were interviewed in privacy. On condition of anonymity they were asked about the age, parity, family setup and relationships, with particular emphasis on sociocultural reasons and factors contributing to induction of abortion. Details of status of abortionist and methods used for termination of pregnancy, the resulting complications and their severity were recorded. RESULTS: Out of total admissions, 57(2.35%) gave history of induced abortion. All women belonged to low socioeconomic class and 59.6% of them were illiterate. Forty-three (75.5%) of these women had never practiced contraception. Twenty-four (42%) were grandmultiparae and did not want more children. In 29 women (50.9%) the decision for abortion had been supported by the husband. In 25 women (43.8%) abortion was carried out by Daiyan (traditional midwives). Serious complications like uterine perforation with or without bowel injury were encountered in 25 (43.8%) of these women. During the study period illegally induced abortion accounted for 6 (10.5%) maternal deaths. CONCLUSION: Prevalence of poverty, illiteracy, grand multiparity and non-practice of contraception are strong determinants of induced abortion.

Female surgical sterilization at a tertiary care hospital in Karachi.

BACKGROUND: Tubal ligation for sterilization is one of the common methods of contraception practiced by women in developing countries like Pakistan. This study was undertaken to study characteristics of couples undergoing surgical sterilization, and to identify ways of improving utililization of contraceptive services. MATERIAL AND METHODS: Details of 1148 women who underwent tubal ligation at the reproductive health center Jinnah Postgraduate Medical Center Karachi from January to December 2002 were recorded on a special proforma. The woman's age, duration of marriage, number of living children and the couple's educational status were recorded. Contraceptive use and duration, and associated medical conditions were documented. Data was entered in SPSS, frequency tables, means and standard deviations were obtained and comparative evaluation undertaken using non parametric methods, as indicated. RESULTS: Out of the 4210 initial clients, 1163 (27.62%) underwent surgical sterilization. This included 1148 (98.69%) tubal ligations and 15 (1.31%) vasectomies. Of these, 608 (52.96%) were carried out in the immediate puerperium. The mean age of women was 33.1+/-3.55 years, they had been married for 14.84+/-4.22 years and 44.34% had already had 6 or more children. CONCLUSION: Tubal ligation performed after careful selection and counseling, by experienced personnel under local anaesthesia is a safe procedure with very few complications. However older women with no history of contraception, who have already had 6 or more children, seem to avail it. Promotion of temporary contraceptives for birth spacing among younger couples is more likely to improve maternal and newborn health in addition to limiting the family size.