EFFECTIVENESS AND SAFETY OF 2-HOURLY 20 MCG ORAL MISOPROSTOL SOLUTION COMPARED TO STANDARD INTRAVENOUS OXYTOCIN IN LABOUR INDUCTION DUE TO PRE-LABOUR RUPTURE OF MEMBRANES AT TERM: A RANDOMISED CLINICAL TRIAL AT KENYATTA NATIONAL HOSPITAL.

BACKGROUND: Pre-labour rupture of membranes (PROM) at term is a common event whose management varies from centre to centre. The practice at the Kenyatta National Hospital (KNH) for patients with PROM at term is to initiate delivery of the patient soon on admission with intravenous oxytocin, if there are no contraindications to vaginal delivery. However, in PROM at term, if the cervix is not ripe, vaginal administration of prostaglandin pessaries for cervical ripening is not possible when there is active draining of liquor, thus use of intravenous oxytocin may take a very long time or fail all together. Oral misoprostol at low doses has been found to be a safe and effective agent for labour induction in numerous studies carried out in the developed world, where there are better resources for monitoring of labour. None of the studies has been carried out in Kenya, a limited resource country. Therefore, there is a need to determine the effectiveness and safety of oral misoprostol solution at the KNH, a limited resource set up. OBJECTIVE: To determine the effectiveness and safety of 2-hourly 20 mcg oral misoprostol solution compared to the standard intravenous oxytocin in labour induction in mothers with pre-labour rupture of membranes at term at the Kenyatta National Hospital. DESIGN: An unblinded randomised clinical trial. SETTING: Kenyatta National Hospital Labour Ward Unit. PARTICIPANTS: Eighty three pregnant women with pre-labour rupture of membranes at term without an indication for Caeserian section were consented and randomised for labour induction with either oral misoprostol at a dose of 20mcg 2-hourly up to a maximum of 4-doses, or with intravenous oxytocin according to the WHO protocol. MAIN OUTCOME MEASURES: Induction to delivery interval; maternal complications and early neonatal outcomes. RESULTS: The overall induction success rates in the misoprostol arm was 81% versus 83% in the oxytocin arm (P = 0.447). The mean induction to vaginal delivery interval in the misoprostol arm was 8.4 hours as compared to 9.45 hours in the oxytocin arm (P = 0.116). The induction to active labour interval was similar in the two study arms. The mean induction to active labour in the misoprostol arm was 4.02 hours as versus 4.51 hours in the oxytocin arm (P = 0.223 ). Two women who had failed induction with misoprostol were augmented with oxytocin and delivered vaginally. The Caesarean section rates were 19% in the misoprostol arm and 17% in the oxytocin arm (P = 0.447), which was not statistically significant. The maternal outcomes were similar in the two study arms. Four women had tachysystole in the misoprostol arm, compared to three in the oxytocin arm (P = 0.253). In the misoprostol arm two women had hypertonus compared to three in the oxytocin arm (P = 0.322).There was one case of hyperstimulation in the misoprostol arm and two in in the oxytocin arm. There were no differences in the foetal/neonatal outcomes. No baby had an Apgar score of less than seven at one or five minutes. No baby was admitted to the New Born Unit in either of the two arms. There was no case of a still birth in either of the study arms. There was no significant difference in the passage of meconium between the two arms, 39% in the misoprostol arm and 35.7% in the oxytocin arm (P = 0.755). The passage of meconium did not impact on the neonatal outcomes. CONCLUSION: Oral misoprostol solution 20mcg 2-hourly is as safe and effective as the standard intravenous oxytocin for labour induction in women presenting with prelabour rupture of membranes at term at the Kenyatta National Hospital.

Multifoetal pregnancies at a maternity hospital in Nairobi.

OBJECTIVE: To review some of the aspects of multiple pregnancies. DESIGN: A retrospective review of multiple pregnancy deliveries. SETTING: Pumwani Maternity Hospital- Nairobi Kenya, between 1st January and 31st December 2006. SUBJECTS: Three hundred and twenty eight mothers with twins and two sets of triplet deliveries. RESULTS: The total annual deliveries were 15,642. The twinning rate was one in 48 deliveries and the triplet rate was one in 7,821 deliveries. Most of the mothers were of low parity and in the lower age group. Majority had no previous history of twins and were married. The sex differences in both the first and second twins were as of the normal population with males being delivered more than females. Most of the twins were delivered alive through spontaneous vertex delivery (SVD). Majority of first twins had no complications while in second twins the majority had more complications. Most of the deliveries had no obvious congenital malformations. Most of the twins were of low birth weight and were of the same sex (monozygotic). The most common complications in both first and second twins were prematurity and asphyxia. The majority of the twins were diagnosed during the prenatal period and the most common method of diagnosis was by ultrasonography. The majority of the mothers had no complications. The most common maternal complications being preeclampia (PET) and anaemia. CONCLUSION: Most of the mothers with multiple pregnancies were of low parity and in the lower age group. Diagnosis was mainly done by ultrasonography therefore emphasis should be done to improve clinical diagnosis especially in resource constrained facilities. A more detailed study should be undertaken especially the events in the pre-pregnancy and during the antenatal period. The present study assumes that same sex twins are the same as monozygotic twins. A more detailed study on the types of placentation would be useful. As PET, anaemia, prematurity and asphyxia are the most common maternal and neonatal complications medical workers need to be made aware of the appropriate management of the conditions. These babies will need long-term follow-up.

Quality of record keeping in the intrapartum period at the Provincial General Hospital, Kakamega, Kenya.

OBJECTIVE: To assess the quality of recording critical events in the intrapartum period in Kakamega Provincial General Hospital (PGHK). DESIGN: Retrospective comparative study. SETTING: Provincial General Hospital, Kakamega, the referral hospital for Western Province, Kenya. PARTICIPANTS: Two hundred women admitted at the labour ward during the six-month period between 1st September 2000 and 28th February 2001 were compared to two hundred women admitted between 1st July 2001 and 31st December 2001. INTERVENTION: The Safe Motherhood Demonstration Project (SMDP) was introduced in four districts of Western Province, Kenya, in which PGHK is located. It included on job training in Safe Motherhood which emphasised, among others, collection and utilisation of maternal health care services data. MAIN OUTCOME MEASURES: Comprehensiveness of recording of biodata, history taking and examination findings were assessed for women in labour before and during the implementation of the SMDP. The proportion of cases in labour managed by use of partograph and its appropriate use were also determined. RESULTS: Retrieval rate of patients' notes was 86.9% and 89.6% before and during SMDP respectively. Information on sociodemographic characteristics, history taking, general and obstetric examination had a near universal recording in both groups but data on alcohol consumption, smoking, menarche, previous pregnancies and contraceptive use was poorly recorded. There was a significant improvement in recording of diagnosis and plan of management during the SMDP (p = 0.037). The partograph was used in only 11% of patients before SMDP as compared to 85% during SMDP (p = 0.000). Record on foetal condition and progress of labour were significantly improved during the SMDP (p = 0.000). Records on summary of labour likewise significantly improved during the SMDP (p = 0.02). CONCLUSION: The quality of record keeping in the intrapartum period at the PGHK greatly improved during the implementation of the SMDP. It would be worthwhile to assess the sustainability of quality of intrapartum records and care a year or so after the SMDP ended.

Socio-demographic characteristics of patients admitted with gynaecological emergency conditions at the provincial general hospital, Kakamega, Kenya.

OBJECTIVE: To determine the magnitude of gynaecological emergencies and the socio demographic characteristics of patients admitted at Provincial General Hospital Kakamega (PGHK). DESIGN: Retrospective cross-sectional study. SETTING: Provincial General Hospital Kakamega, the referral hospital for Western Province, Kenya. SUBJECTS: Four hundred patients admitted at the gynaecological wards during the period 1st January 2002 to 31st December 2002. RESULTS: In this study 80% of gynaecological patients admitted at PGH Kakamega were of an emergency nature with 45% being teenagers. The mean age was 17 +/- 3 (mean +/- SD). The majority had primary level of education or below (69%), unemployed (87%) and were rural residents (71%). Patients with abortion formed about 43% of the study group while those with inflammatory disease, pelvic abscess and ectopic pregnancy formed about 24%, 10% and 8% respectively. CONCLUSION: Most gynaecological admissions in PGH Kakamega are of acute nature, with abortion being the most common diagnosis. Hence, trained staff, equipment, supplies and drugs for management of acute gynaecological conditions should be available in hospitals in Western Kenya.

Knowledge, attitudes, and practices regarding emergency contraception among nurses and nursing students in two hospitals in Nairobi, Kenya.

A cross-sectional descriptive study on knowledge, attitudes, and practice about emergency contraception (EC) was conducted among nurses and nursing students using a self-administered questionnaire. One-hundred-sixty-seven qualified nurses and 63 nursing students completed the questionnaire. Over 95% listed at least one regular contraceptive method but only 2.6% spontaneously listed EC as a contraceptive method, whereas 48% of the respondents had heard of EC. Significantly more nursing students than qualified nurses were familiar with EC. Knowledge about the types of EC, applications, and side effects was poor and 49% of the respondents considered EC as an abortifacient. Of those familiar with EC, 77% approved its use for rape victims and 21% for adolescents and schoolgirls. Only 3.5% of all respondents had personally used EC in the past, 23% of those familiar with EC intend to use it in the future, whereas 53% intend to provide or promote it. The view that EC was abortifacient negatively influenced the decision to use or provide EC in the future. The present findings suggest that the level of knowledge of EC is poor and more information is needed. These findings indicate the potential to popularize emergency contraception in Kenya among nurses and nursing students.

PIP: A descriptive research study on knowledge, attitudes and practices with regard to emergency contraception (EC) was conducted using a questionnaire among 167 nurses and 63 nursing students in Nairobi, Kenya. Results revealed that 95% recorded at least one regular contraceptive method. About 48% of the respondents had heard about EC, but only 2.6% had used it. More nursing students than qualified nurses were aware of EC. There was poor knowledge about the types, applications and side effects of EC. Some 49% of the subjects regarded EC as an abortifacient. About 77% of those knowledgeable about EC approved its use for rape victims and 21% for adolescents and schoolgirls. Only about 3.5% had personally used it. Some 23% of those aware of EC intended to use it in the future. About 53% planned to provide or promote it. The perception that EC is abortifacient affected the decision whether to use or provide it. The data imply that there is potential for effective promotion of EC among nurses and nursing students in Kenya.

Abortion: behaviour of adolescents in two districts in Kenya.

BACKGROUND: In Kenya the reported high rates of unwanted pregnancies (more than 90%), among adolescents have subsequently resulted in unsafely induced abortions with the associated high morbidity and mortality rates. OBJECTIVE: To evaluate the adolescents' behaviour regarding induced abortion. DESIGN: A cross-sectional, prospective study done from July 1995 to June 1996. SETTING: Schools and health facilities in Kiambu and Nairobi districts in Kenya. PARTICIPANTS: Interviews were conducted among adolescents aged 10-19 years in schools at the two districts and selected using a multi-stage random sampling procedure, as well as adolescent girls at two hospitals and two clinics in the immediate post-abortion period. MAIN OUTCOME MEASURES: The number of adolescents health programmes, aimed at reducing the dangers of unsafely induced abortion, which are designed and subsequently implemented. DATA COLLECTION: Demographic and health data, as well as data on behaviour regarding induced abortion were collected using a self-administered questionnaire. RESULTS: The study sample comprised 1820 adolescents. These were 1048 school girls (SG), 580 school boys (SB) and 192 post-abortion (PA). Many adolescents were aware of abortion dangers, with the awareness being significantly lower among the SB whose girlfriends (GF) had aborted than those whose GF had not (p < 0.01). The practice of abortion was reported among 3.4% SG, 9.3% SBs' GF and 100% PA. Direct and indirect costs of abortion were heavy on the girls. Knowledge of the abortion dangers had no influence on the choice of the abortionist. Abortion encounter positively influenced approval by the adolescents, of abortion for pregnant school girls (p < 0.01). CONCLUSION: Despite the costs and awareness of abortion dangers by adolescents, they will take risks.

Abortion: knowledge and perceptions of adolescents in two districts in Kenya.

BACKGROUND: Pregnancy among adolescents is unplanned in many instances. Although some pregnant adolescents carry the pregnancy to term, abortion, in many instances unsafely induced, is a commonly sought solution in Kenya. OBJECTIVE: To determine adolescents' perceptions of induced abortion. DESIGN: A cross-sectional descriptive study carried out between July 1995 and June 1996. SETTING: An urban and a rural district in Kenya. PARTICIPANTS: Adolescents aged 10-19 years in schools in Nairobi and Kiambu districts, and a group of immediate post-abortion adolescent girls in some health facilities in Nairobi. MAIN OUTCOME MEASURES: The number of health programmes formulated and put into use, which are adolescent-friendly and providing information, education and communication on abortion issues. DATA COLLECTION: One thousand eight hundred and twenty adolescents were subjected to a self-administered questionnaire that collected demographic and health data as well as perceptions of induced abortion. Focus group discussions on perceptions of abortion were held with 12 groups of adolescents in schools and the information obtained recorded on paper and in a tape-recorder. RESULTS: One thousand nine hundred and fifty two adolescents, comprising of 1048 school girls (SG), 580 boys (SB), 192 post-abortion girls (PA) and 132 adolescents in the focus group discussions, formed the study sample. More than 90% were aware of induced abortion (IA). Knowledge of IA correlated positively with level of education (P < 0.01). Seventy one per cent of SG, 84% of PA and 40% of SB were aware of abortion-related complications, the most common being infections, death and infertility. Eighty three per cent of PA felt that complications were preventable by seeking care from a qualified doctor compared to one quarter each for the SB and SG. 56% PA, 69% SB and 72% SG felt that abortions were preventable. However, less than 40% proposed abstinence as a primary strategy. The most important source of information on abortion was the media followed by friends and teachers. CONCLUSION: Adolescents are aware of abortion and the related complications, but there is more variability in their knowledge and preventive measures.

Median age at menopause in a rural population of western Kenya.

This was a cross sectional descriptive study to discuss the median age of menopause in a rural area of Western Kenya. The broad objective of the study was to describe the demographic and biophysical characteristics of the study population and determine the age of menopause. A review of the current and medieval records shows average age of menopause has remained relatively constant at 50 years in contrast to the receeding age of menarche. A total of 1078 women aged between 40-60 years were interviewed. The majority (98.8%) were from one ethnic group, the Luhya. Of the 1078 women, 880 (81.4%) were married and 198 (18.6%) were single. The average number of children per woman was 7.74. Most of the women (75.1%) had attained primary school education. Their husbands were unskilled workers in 30.1% of the cases. The mean weight and height of the women was 60.74 kg and 161.1 cm respectively. Using methods of probit analysis, the median and modal age of menopause was found to be 48.28 years in this group of western Kenya women. If generalised for the whole country, these results suggest that an average Kenyan woman lives for over ten years beyond menopause. It is recommended that more attention should be given to the special health problems of postmenopausal population.

PIP: This study describes the demographic and biophysical characteristics of rural menopausal women in Western Kenya. Menopause occurs as the gradual unresponsiveness of the human ovary to gonadotropins, premature ovarian failure at under 40 years, and menopause following surgical procedures of the uterus and ovaries. A 3-phase process starts with low serum estradiol and progesterone, followed by a rise in follicle stimulating hormone, and a rise in luteinizing hormone. Clinical symptoms include vasomotor ones, genitourinary ones, osteoporosis and increased incidence of bone fractures, increased incidence of thromboembolic and ischemic heart disease, and psychological symptoms of anxiety, depression, and memory loss. The age of menopause varies with socioeconomic conditions, race, parity, height, weight, skinfold thickness, lifestyle, and education. Data were obtained for this study from a sample of 1078 women from 7 sublocations in Vihiga division, Kenya. Women were aged 40-60 years. The most populous ethnic group was the Luhya. 81.6% were married, 15.6% were widowed, and 0.7% were divorced. 4 women had never been married. 75.1% had a primary school education; 18.6% had not received any formal education. 30.1% had husbands who were unskilled workers, 28.8% had husbands who were farmers, and 20.6% had husbands who were skilled workers. 1.3% had no children, and 1 woman had 17 children. The average number of children was 7.74. 9 of the nulliparous women were menopausal. The mean height was 161.1 cm. The median age at menopause was 48.28 years. Almost all women were menopausal by 55 years. The total fertility period averaged 35 years. Female life expectancy was 59 years.

Hormonal patterns during the menstrual cycles in healthy black Kenyan women.

PIP: 17 regularly mentruating young black Kenyan women were studied during a mentrual cylcle for their reproductive hormonal patterns. The serum concentrations of Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH) and Prolactin (PRL) were determined by World Health Organization Matched Reagent Programme Radioimmunoassay (WHO-MR-RIA). A biphasic basal body temperature (BBT) record was also noted. The hormonal patterns showed a mid-cycle LH surge and rise in plasma progesterone beginning with the LH peak and lasting a maximum of 6-8 days after the LH peak. Cycle lengths ranged from 25-32 days with a mean of 28 plus or minus 2 days. The follicular phase ranged from 10-17 days, and the luteal phase lasted from 13-15 days. When the mean LH and FSH concentrations and the mean BBT curve were synchronized on the day of the mid-cycle LH peak, the temperature elevation occured about 48 days after the LH peak. Along with the LH, the FSH showed a mid-cycle peak. The results of this study are consistent with those already documented for Caucasian, Asian and African females^ieng