Acceptability of human immunodeficiency virus testing in patients with invasive cervical cancer in Kenya.

Invasive cervical cancer (ICC) is common in areas where human immunodeficiency virus (HIV) is also prevalent. Currently, HIV seroprevalence as well as acceptability of HIV testing in ICC patients in Kenya is unknown. The objective of this study was to determine the acceptability of HIV testing among patients with ICC. Women with histologically verified ICC at Kenyatta National Hospital participated in the study. A structured questionnaire was administered to patients who gave informed consent. HIV pre- and posttesting counseling was done. Blood was tested for HIV using enzyme-linked immunosorbent assay. Overall, 11% of ICC patients were HIV seropositive. The acceptance rate of HIV testing was 99%; yet, 5% of the patients did not want to know their HIV results. Patients less than 35 years old were two times more likely to refuse the result of the HIV test (odds ratio [OR] 2.2). Patients who did not want to know their HIV results were three times more likely to be HIV seropositive (OR 3.1). Eighty four percent of the patients were unaware of their HIV seropositive status. The HIV-1 seroprevalence in ICC patients was comparable to the overall seroprevalence in Kenya. ICC patients were interested in HIV testing following pretest counseling. Offering routine HIV testing is recommended in ICC patients.

Improving technologies to reduce abortion-related morbidity and mortality.

This article reviews the technologies used to diagnose pregnancy and manage abortion in developing countries. The author discusses methods of diagnosing pregnancy--including physical examination, laboratory and home testing, and ultrasound--as well as methods for performing safe abortions. Due to manual vacuum aspiration (MVA) advances, vacuum aspiration has become safer and more feasible in low-resource settings. The discussion of medical abortion includes the advantages and limitations of mifepristone, misoprostol-only regimens, methotrexate, and other methods. The author stresses the importance of post-abortion care and post-abortion contraception and, in the conclusion, identifies six areas in which technology can reduce abortion-related morbidity and mortality: pregnancy prevention, early diagnosis of pregnancy, accurate assessment of gestation, standardization and supply of MVA technology, and simple and affordable regimens for medical abortion.

Knowledge and practice about cervical cancer and Pap smear testing among patients at Kenyatta National Hospital, Nairobi, Kenya.

Invasive cervical cancer (ICC) is the leading cause of cancer-related death among women in developing countries. Population-based cytologic screening and early treatment does reduce morbidity and mortality associated with cervical cancer. Some of the factors related to the success of such a program include awareness about cervical cancer and its screening. The objective of this study was to assess knowledge and practice about cervical cancer and Pap smear testing among cervical cancer and noncancer patients using a structured questionnaire to obtain information. Fifty-one percent of the respondents were aware of cervical cancer while 32% knew about Pap smear testing. There were no significant differences in knowledge between cervical cancer and noncancer patients. Health care providers were the principal source of information about Pap testing (82%). Only 22% of all patients had had a Pap smear test in the past. Patients aware of cervical cancer were more likely to have had a Pap smear test in the past. The level of knowledge is low among ICC and noncancer patients. There is need to increase the level of knowledge and awareness about ICC and screening among Kenyan women to increase uptake of the currently available hospital screening facilities.

HIV and cervical cancer in Kenya.

OBJECTIVES: To determine the effect of the HIV epidemic on invasive cervical cancer in Kenya. METHODS: Of the 3902 women who were diagnosed with reproductive tract malignancies at Kenyatta National Hospital (KNH) from 1989 to 1998, 85% had invasive cervical cancer. Age at presentation and severity of cervical cancer were studied for a 9-year period when national HIV prevalence went from 5% to 5-10%, to 10-15%. RESULTS: There was no significant change in either age at presentation or severity of cervical cancer. Of the 118 (5%) women who were tested for HIV, 36 (31%) were seropositive. These women were 5 years younger at presentation than HIV-negative women. CONCLUSIONS: A two- to three-fold increase in HIV prevalence in Kenya did not seem to have a proportional effect on the incidence of cervical cancer. Yet, HIV-positive women who presented with cervical cancer were significantly younger than HIV-negative women.

FIGO society survey: acceptance and use of new ethical guidelines regarding induced abortion for non-medical reasons.

OBJECTIVE: FIGO's Ethical guidelines regarding induced abortion for non-medical reasons offer guidance concerning women's right to safe abortion services and the medical community's attendant responsibilities. Ipas surveyed FIGO constituent societies to determine their agreement with the Guidelines' recommendations and their readiness to use them to improve and expand services. METHOD: Ten months after the Guidelines publication in IJGO, a ten-item questionnaire was mailed to 283 Officers of the 101 FIGO societies, with follow-up prompts to non-respondents. RESULTS: Officers of 59 societies responded, divided evenly between those in countries whose laws permit induced abortion on non-medical grounds and those in countries prohibiting it. In 'permitting' countries all responding societies supported the recommendations, and 85% said they should adopt them or had already done so. Two-thirds in 'prohibiting' countries supported the recommendations, but less than half believed their FIGO society, or their government, should adopt them. However, 20% in the 'prohibiting' countries had adopted or formally considered the recommendations and 23% had already brought them to the attention of their governments. CONCLUSION: The FIGO constituent societies showed overall strong support for the recommendations, but efforts need to be made to encourage those in 'prohibiting' countries to promote implementation of the recommendations.

Maternal mortality in Kenya: the state of health facilities in a rural district.

BACKGROUND: This study was formulated from the premise that the known causes of maternal mortality, namely haemorrhage, sepsis, obstructed labour and abortion belie the more fundamental development problems that influence it, such as the state of local medical services, quality of care and the facilities' ability to respond to reproductive health emergencies. OBJECTIVE: To document some of the underlying problems and how they were found to influence maternal mortality in Kenya, with specific reference to a rural district. DESIGN: The researchers used the Prevention of Maternal Mortality Network (PMMN) methodology/study design to assess the current state of health facilities, their level of function, and factors influencing their utilisation. Both qualitative and quantitative methods of data collection tools were used. SETTING: Siaya District in the western region of Kenya. Data were collected from thirty facilities, which provide obstetric care in the district. PARTICIPANTS: Data were collected by nurse/midwives, nursing school tutors and social scientists with experience in qualitative research methods. Respondents included health service providers and managers at the 30 health facilities. Qualitative data were obtained through focus group discussions with health facility staff as well as community members. RESULTS: All the thirty facilities studied, were grossly wanting in terms of staffing, equipment, essential drugs and supplies. Both quality of care and record keeping were well below acceptable standards. CONCLUSIONS: The study findings are a sad but a fair reflection of our situation not only in Kenya but also in sub-Saharan Africa ten years after the declaration of the Safe Motherhood Initiative (SMI). The results indicate a predictable, widening gap in basic service provision that must be urgently bridged as a prerequisite to any serious and meaningful approaches to reducing maternal mortality in Africa.

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.

Induced abortion in Kenya: its determinants and associated factors.

In a study involving 1077 women who were admitted and treated for incomplete abortion and its related problems at eight hospitals (seven district and one mission hospitals) in six of the eight provinces of Kenya, between October 1988 and March 1989, 169 (15.7%) had illegally induced unsafe abortion, based on their own history and clinical findings. The illegally induced unsafe abortions were common among both rural and urban dwellers, and women from almost all social and economic strata were involved. However, they were more common among the youth (< 25 year olds), school girls, those with high formal education, in formal employment, and not currently married. Majority (90.4%), of the induced group said their pregnancies were unwanted, as compared to only 29.1% of the non-induced (p < 0.05). The main determining factor for termination of pregnancy amongst these women appeared to be the fact that it was unwanted and/or unplanned, either because of inappropriate timing, the type of man responsible, the relationship itself and the social and economic implications thereof. This is contributed to by poor contraceptive use inspite of very good awareness, and/or desire to use. There is urgent need to integrate abortion care and related services into the overall reproductive health care and as a part of the broader safe motherhood initiative in Kenya. In addition it is necessary to revise the legal provisions on abortion so as to make them more relevant. Appropriate management of adolescent fertility, should be undertaken with the aim of reducing the extent of illegally induced unsafe abortion with attendant sequealae.

PIP: As part of a larger survey of the epidemiology of unsafe abortion in Kenya, 1007 women admitted to 8 hospitals in 6 of Kenya's 8 provinces during October 1988-March 1989 for incomplete abortion or its complications were interviewed. 169 of these women (15.7%) were considered to have undergone induced abortion (115 women who admitted to interfering with their pregnancy and 57 women who had clear physical evidence of an attempt at pregnancy termination). The induced abortion rate ranged from 0.9% at the Malindi coastal district hospital to 36.4% at the only mission hospital (Chogoria) in the study. Although adolescents (10-19 years old) comprised 15.2% of the total study group, 29.6% of induced abortion patients were in this age group. 22.9% of the total study group, compared with 70.4% of the induced group, were unmarried. There was a steady increase in the proportion of women with induced abortion with increasing educational level, from 4.7% of those with no formal education to 26.3% among those with a college or university education. Induced abortion patients were significantly more likely than those in the broader group to be students (14.8%) or employed in the formal sector (13%). Contraceptive prevalence at the time of conception of the index pregnancy was 12.1% in the broader group and 23.1% in the induced abortion group. 37.8% of induced abortion patients, compared with 50.2% of non-induced women, reported to the hospital within 24 hours of initial symptoms of abortion. Finally, complications were more prevalent in the induced abortion group and included sepsis (34.3%), anemia (17.8%), genital injury (16.6%), and hemorrhage (12.4%). The one death in the induced abortion group was attributable to severe septicemia. The 15.7% induced abortion rate identified in this study is considered to be an underreport, as suggested by the finding that 38.6% of the total study group stated their pregnancy was unwanted.

Socio-economic client characteristics and consequences of abortion in Nairobi.

In Nairobi, 281 women presenting with alleged miscarriage were subdivided in the following subgroups, 91 spontaneous abortions (group 1), 152 suspected induced abortions (group 2) and 38 admittedly induced abortions (group 3). In the statistical analysis women in group 1 were compared with women from groups 2 and 3 combined (here referred to as group 4). Group 4 differed significantly from group 1 in the following respects: they were younger (p = 0.03) although they had previously born more babies (p = 0.008), lived more often together with their parents (p = 0.024), were less often married (p = 0.000012), worked more often as housewives (p = 0.00079), and lived in bigger households (p = 0.000015). No significant differences were encountered regarding religious beliefs. Group 4 women were more informed about contraceptives than group 1 (p = 0.04), particularly regarding injectables (p = 0.000096) and oral contraceptives (p = 0.0013) but also intra uterine devices (p = 0.024). Almost 90% of group 4 women indicated post abortion contraceptive interest, while only 1/3 of group 1 women did so. Group 3 women needed extensive parenteral treatment with a total hospital treatment cost amounting to 300 times that of group 1. The total cost of intravenous infusions was almost 10 times as high in group 3 as in group 1. The total number of days in hospital was significantly higher in group 4 than in group 1 (p = 0.0098).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of recurrent cervical cancer: the place of ultra-radical surgery.

Although mortality from cervical cancer has decreased substantially the incidence of recurrent disease, at 35-50%, remains unaltered. Many more young patients are seen with recurrent cervical cancer today. This paper reviews this problem--its diagnosis and available modes of treatment. The place of re-irradiation, chemotherapy and ultra-radical surgery are discussed and their limitations highlighted. Better patient selection and individualised treatment planning are emphasised. Newer, more objective prognostic indicators based on molecular understanding of cancer cells are mentioned as hopeful means through which patient selection and treatment could be improved in the future. In the developing world where persistent or recurrent disease is more common, the situation is unlikely to improve soon.

Induced abortion in sub-Saharan Africa.

Unsafe abortions and their complications are a major cause of maternal mortality. Hospital based studies from most African countries confirm that up to 50% of maternal deaths are due to abortion. This paper reviews problem of induced abortion in sub-Saharan Africa. Issues of prevalence and prevention are addressed while acknowledging the need to review the legal regimes operating in these countries.

PIP: There is confirmation from hospital-based studies that unsafe abortion and complications have been the cause of up to 50% of maternal deaths in sub Saharan Africa. In this article, estimates of induced abortion are discussed as well as abortion law and abortion services from an African perspective. Future prospects for resolving the abortion issues are hampered by fear and restrictions. Recommended strategies for decreasing he undesirable outcomes of botched abortions were 1) improvement in the availability of good health care including drugs and referrals, 2) improvement in accessibility of contraceptive services and involvement of males in decision making, 3) introduction of appropriate and simple technology for performing safe abortions, 4) increases in access to affordable abortion services, and 5) active education and involvement of local women's groups regarding fertility reproduction and abortion. The development of an effective abortion program is dependent on a reliable health service infrastructure, which includes lamps, examination tables, and sterilization equipment. The WHO has recommended vacuum aspiration for uterine evacuation and induction of abortion or treatment of complications at the first referral level. The current availability of this equipment is limited. Also recommended is the training of medical and nonmedical personnel in the use of Karman's syringe and cannula. Consideration should be given to provision of abortion services at local health centers and dispensaries rather than in big hospitals. Constructive dialogue with lawmakers is also important for easing restrictions. Abortion must be a part of reproductive health agendas. The extent of unwanted pregnancy is apparent from news articles about abandoned newborns in schools, or deaths of honor students in rural areas who learned in class about health for all, but were unable to experience it in real terms.

Manual vacuum aspiration saves lives.

PIP: In Kenya, where abortion remains illegal except in cases where the mother's life is in danger, incomplete illegal abortion accounts for over 25% of all hospital admissions. In Kenyatta National Hospital's 100-bed acute gynecology ward, 90% of admissions in 1985-87 were for incomplete abortion and an average of 40 women/day underwent dilatation and curettage under general anesthesia, with a waiting time of 12-14 hours. To remedy overcrowding and a bed occupancy rate of 300%, the hospital introduced manual vacuum aspiration on an experimental basis in 1987. In 1988, after a 6-month study, the hospital began using vacuum aspiration in all 1st-trimester abortions; in addition, all medical students received training in the procedure, ward nurses received training in equipment care and patient counseling, and postabortion contraception counseling were introduced. After the 1st year, 5000 incomplete abortions had been treated at Kenyatta National Hospital with vacuum aspiration. In 1989-91, the procedure was introduced to 18 district hospitals in Kenya and 3 mission hospitals; plans to expand the service to 20 or more district hospitals by 1994 are being developed. In the more than 20,000 vacuum aspiration abortions performed in Kenya to date, there have been no deaths or major complications. Patient satisfaction has been high and gynecology wards now have available beds. However, the conservation and lack of commitment of many health care workers to this life-saving procedure remain problematic.^ieng

A comparison of the costs of manual vacuum aspiration (MVA) and evacuation and curettage (E and C) in the treatment of early incomplete abortions in Kenya.

PIP: Limited access to safe abortion is a leading cause of maternal mortality and morbidity in the developing world. Hospitals are often overwhelmed by the large number of women presenting for treatment of the complications of previous unsafe abortions. In many settings, the number of incomplete or septic abortions comprises more than half of all gynecological admissions. In the absence of measures to reduce the incidence of unsafe abortions, hospitals treat these female patients with complications in the most efficient and effective manner allowed by limited available resources. In most developing countries, Evacuation and Curettage (E&C) is the standard approach to treating cases of incomplete abortion. Requiring a physician, operating theater, and often general anesthesia, E&C is usually performed in the hospital setting. Patients may have to wait several days for treatment, a period during which complications such as hemorrhage and sepsis may develop. In the developed world, however, Manual Vacuum Aspiration (MVA) is the standard treatment for uterine evacuation. MVA usually requires neither anesthesia, anesthetist, operating theater, nor an overnight stay, and it may be performed by a wide range of trained medical personnel including physician's assistants, nurse practitioners, and nurse midwives who may work in rural health clinics with no operating room facilities. This paper documents the magnitude of differences in cost between MVA and E&C in the treatment of early incomplete abortions in the following four hospitals in Kenya: Kenyatta National Hospital in Nairobi, Kisii District Hospital, Eldoret District Hospital, and Machakos District Hospital. Data were collected over the period March-June 1991 and consider costs comprehensively in terms of staff time, in-patient or hotel costs, and drugs and equipment. Analysis found MVA to be the most appropriate and cost-effective way of managing incomplete abortion. Effort should therefore be made to extend the availability of MVA to all district hospitals and to effect changes in patient management which can maximize the benefits of MVA and the use of available resources.^ieng