A criteria-based audit of the management of severe pre-eclampsia in Kampala, Uganda.

OBJECTIVE: To improve the quality of clinical care for women with severe pre-eclampsia. METHODS: A criteria-based audit was conducted in a large government hospital in Uganda. Management practices were evaluated against standards developed by an expert panel by retrospectively evaluating 43 case files. Results of the audit were presented, and recommendations developed and implemented. A re-audit was conducted 6 months later. RESULTS: The initial audit showed that most standards were rarely achieved. Reasons were discussed. Guidelines were produced, additional supplies were purchased following a fundraising effort, labor ward procedures were streamlined, and staffing was increased. In the re-audit there were significant improvements in diagnosis, monitoring, and treatment. CONCLUSION: Criteria-based audit can improve the quality of maternity care in countries with limited resources.

Introducing criteria based audit into Ugandan maternity units.

PROBLEM: Maternal mortality in Uganda has remained unchanged at 500/100 000 over the past 10 years despite concerted efforts to improve the standard of maternity care. It is especially difficult to improve standards in rural areas, where there is little money for improvements. Furthermore, staff may be isolated, poorly paid, disempowered, lacking in morale, and have few skills to bring about change. DESIGN: Training programme to introduce criteria based audit into rural Uganda. SETTING: Makerere University Medical School, Mulago Hospital (large government teaching hospital in Kampala), and Mpigi District (rural area with 10 small health centres around a district hospital). STRATEGIES FOR CHANGE: Didactic teaching about criteria based audit followed by practical work in own units, with ongoing support and follow up workshops. EFFECTS OF CHANGE: Improvements were seen in many standards of care. Staff showed universal enthusiasm for the training; many staff produced simple, cost-free improvements in their standard of care. LESSONS LEARNT: Teaching of criteria based audit to those providing health care in developing countries can produce low cost improvements in the standards of care. Because the method is simple and can be used to provide improvements even without new funding, it has the potential to produce sustainable and cost effective changes in the standard of health care. Follow up is needed to prevent a waning of enthusiasm with time.

Vulnerability and risk factors for sexually transmitted infections and HIV among adolescents in Kampala, Uganda.

Three hundred and six sexually experienced adolescents participated in a study on sexually transmitted infection (STI) prevalence and associated risk factors. The prevalence of Neisseria gonorrhoea (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV) and syphilis was 4.5%, 9%, 8% and 4% for females and 4.7%, 5.7%, 0% and 2.8% for males. HIV-seropositivity was found in 15.2% of females and 5.8% of males. Structured face-to-face interviews were used to obtain information about social background, sexual experience and genital symptoms. Four focus-group discussions were used in order to validate the interview data. Females were more likely to be infected by the four treatable STIs and HIV, despite risky behavior being more common among males. Unemployment, little formal education, the presence of bacterial STIs and post-coital bleeding or a bad smell from the vagina was highly associated with the risk for HIV in females. The higher prevalence of STIs, including HIV, among adolescent girls cannot be explained by sexual behavior only, as boys reported more risk behavior and were still less affected by STIs. Biological and social factors are definitely of importance.

A situation analysis of induced abortions in Uganda.

PIP: Although abortion in Uganda is illegal and permitted only to save the life of the mother, both spontaneous and induced abortion remains a major health problem in the country. Over the years, abortion has contributed largely to a high maternal mortality and morbidity rate (550/100,000 live births). A study conducted in 3 hospitals in Kampala recorded 3132 cases of induced abortion in 13 months; 420 were certainly induced abortions, 28 of which resulted in maternal death. In spite of the high fertility rate, contraceptive prevalence remains low in the country, resulting in high rates of teenage pregnancy. Generally single, young, and low-parity women, most often secondary school and university students, account for the bulk of all induced abortions. Most common reasons for termination of pregnancy include a desire to continue education and parental fear. The leading complications resulting from induced abortions were sepsis, hemorrhage, and genital tract trauma.^ieng

Time course of the changes in uterine vascular permeability associated with the development of the decidual cell reaction in ovariectomized steroid-treated rats.

Uterine vascular permeability and tissue blood volume during the development of the oil-induced decidual cell reaction (DCR) in ovariectomized steroid-treated rats were assessed by measuring the extravascular accumulation of 125I-labelled human serum albumin and the tissue content of 51Cr-labelled red cells 30 min after intravenous administration. Within 15 min of oil instillation into one uterine horn, the vascular permeability of the horn was significantly elevated. Permeability rose to a sharp peak (10 times control levels) 9 h after oil instillation, but dropped to 5 times control values by 12 h and continued a steady decline over the next 7 days. Although a marked increase in uterine weight was associated with the development of the DCR, there was no significant change in blood volume/g tissue until 4 days after oil instillation.

Intraluminally injected oil induces changes in vascular permeability in the 'sensitized' and 'non-sensitized' uterus of the mouse.

After suitable sensitization of ovariectomized mice with progesterone and oestradiol, the intrauterine instillation of oil produces a massive decidual cell reaction. Vascular permeability, as reflected by the extra-vascular accumulation of 125I-labelled human serum albumin, increased after oil instillation and was maintained at 2-3 times control values for at least the next 3 days. Although oil instillation did not produce a decidual response in females treated with progesterone alone, an increase in vascular permeability (about 2 times control levels) still occurred. This response peaked 8 h after oil instillation and was not maintained. These results indicate that the progesterone-dominated uterus which has not been sensitized with oestradiol cannot be viewed as completely unresponsive to the stimulus of oil and demonstrate that a marked increase in vascular permeability is not itself sufficient to induce decidualization of progesterone-dominated uterine stromal cells. The uterine extravascular accumulation of 125I-labelled albumin was increased both in association with tribromoethanol anaesthesia and after oestradiol treatment of progesterone-primed animals. In pregnant mice, the appearance of Pontamine Sky Blue spots provided an earlier indication of implantation than did determination of total uterine extravascular 125I-labelled albumin accumulation.