Assessment of anxiety and depression, and coping mechanisms during COVID-19 lockdown among pregnant women.

Background: COVID-19 lockdown was associated with disruption of daily life, economy, essential health services including maternal health service, and psychological reflexes such as panic, sleep disorders, fear, anxiety, and depression. Aim: To assess the perception of pregnant women on the COVID-19 pandemic lockdown and the prevalence of common mental health disorders (CMHD) among pregnant women. Methods: A cross-sectional study was conducted among 380 pregnant women at the University College Hospital (UCH) Ibadan; participants were enrolled using a simple random sampling technique. Data was collected using pretested interviewer-administered questionnaire. Information obtained - sociodemographic and obstetric characteristics, perception and reaction to the COVID-19 pandemic and lockdown, effect on ANC, coping mechanisms, and presence of CMHD (anxiety and depression) were measured using Hospital Anxiety and Depression Scale (HADS). Data were analysed using STATA 16.0 Software. Descriptive and bivariate statistics were performed. The level of significance was p-value < 0.05. Results: The mean age was 32 ± 4.78 years, most respondents were <35 years (75%), married (97.1%), had a higher education (89%) and multiparous (70%). About 43.9% were worried that COVID-19 would affect pregnancy care, 42.9% reported it affected care and 81.6% were not worried it would affect the delivery care. Among respondents, 96.6% were able to cope with the effects of the pandemic and 96.8% enjoyed good social support. Respondents did not have CMHD (88.16%), 7.9% had CMHD (4.74% had depression and 3.16% had anxiety) and 3.95% had co-morbid depression and anxiety. On multinomial regression analysis, relative to anxiety or depression only, respondents with combined depression and anxiety had higher odds of having no delivery plan and thought COVID-19 may affect their delivery. Conclusion: Only a few women reported anxiety and depression symptoms during the lockdown and those with anxiety or combined symptoms of anxiety and depression had no birth plan and believed that COVID-19 would affect their delivery.

Nigeria, a high burden state of obstetric fistula: a contextual analysis of key drivers.

Obstetric fistula (OF) remain a source of public health concern and one of the most devastating maternal morbidities afflicting about two million women, mostly in developing countries. It is still prevalent in Nigeria due to the existence of socio-cultural beliefs/practices, socio-economic state and poor health facilities. The country's estimated annual 40,000 pregnancy-related deaths account for about 14% of the global maternal mortality, placing it among the top 10 most dangerous countries in the world for a woman to give birth. However, maternal morbidities including OF account for 20 to 30 times the number of maternal mortalities. This review substantiates why OF is yet to be eliminated in Nigeria as one of the countries with the largest burden of obstetric fistula. There is need for coordinated response to prevent and eliminate this morbidity via political commitment, implementation of evidence-based policy and execution of prevention programs.

Economic status, a salient motivator for medicalisation of FGM in sub-Saharan Africa: Myth or reality from 13 national demographic health surveys.

Female Genital Mutilation or Cutting (FGM) and its medicalisation remain a challenge in sub-Sahara African (SSA). Early identification of at-risk women might help in instituting focused counselling against FGM medicalisation. We hypothesised that the risk of medicalised FGM by girls/women is associated with socioeconomic status (SES) their household belongs. We used 2010-2019 Demographic and Health surveys data from 13 countries in SSA. We analysed information on 214,707 women (Level 1) nested within 7299 neighbourhoods (Level 2) from the 13 countries (Level 3). We fitted 5 multivariable binomial multilevel logistic regression models using the MLWin 3.03 module in Stata. The estimation algorithms adopted was the first order marginal quasi-likelihood linearisation using the iterative generalised least squares. The odds of FGM medicalisation increased with the wealth status of the household of the woman, with 29%, 45%- and 75%-times higher odds in the middle, richer and richest household wealth quintiles, respectively than those from the poorest households (p < 0.05). The more educated a woman and the better a woman's community SES was, the higher her odds of reporting medicalisation of FGM. Rural community was associated with higher odds of medicalised FGM than urban settings. Medicalised FGM is common among women from a high socioeconomic, educational background and rural settings of SSA. We recommend a culturally sensitive policy that will discourage perpetuation of FGM, particularly by healthcare providers. Future studies should focus on identifying drivers of FGM among the high social class families in the society in SSA.

Breast Cancer Knowledge Assessment of Health Workers in Ibadan, Southwest Nigeria.

PURPOSE: Breast cancer is the most common cancer among women, and in low- to middle-income countries late-stage diagnosis contributes to significant mortality. Previous research at the University College Hospital, a tertiary hospital in Ibadan, Nigeria, on social factors contributing to late diagnosis revealed that many patients received inappropriate initial treatment. METHODS: The level of breast cancer knowledge among health practitioners at various levels of the health system was assessed. We developed a tool tailored to local needs to assess knowledge of symptoms, risk factors, treatments, and cultural beliefs. The recruitment included doctors, nurses, and pharmacists in public hospitals, physicians and pharmacists in private practice, nurses and health care workers from primary health care centers, community birth attendants, and students in a health care field from state schools. RESULTS: A total of 1,061 questionnaires were distributed, and 725 providers responded (68%). Seventy-eight percent were female, and > 90% were Yoruba, the dominant local ethnic group. The majority were Christian, and 18% were Muslim. Median knowledge score was 31 out of 56, and the differences in scores between health care worker types were statistically significant (P < .001). Nearly 60% of the participants believed breast cancer is always deadly. More than 40% of participants believed that keeping money in the bra causes breast cancer, and approximately 10% believed that breast cancer is caused by a spiritual attack. CONCLUSION: Our questionnaire revealed that, even at the tertiary care level, significant gaps in knowledge exist, and knowledge of breast cancer is unacceptably low at the level of community providers. In addition to efforts aimed at strengthening health systems, greater knowledge among community health care workers has the potential to reduce delays in diagnosis for Nigerian patients with breast cancer.

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda.

BACKGROUND: Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. METHODS: Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. RESULTS: Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. CONCLUSIONS: MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Modeling optimal cervical cancer prevention strategies in Nigeria.

BACKGROUND: This study aims to assess the most efficient combinations of vaccination and screening coverage for the prevention of cervical cancer (CC) at different levels of expenditure in Nigeria. METHODS: An optimization procedure, using a linear programming approach and requiring the use of two models (an evaluation and an optimization model), was developed. The evaluation model, a Markov model, estimated the annual number of CC cases at steady state in a population of 100,000 women for four alternative strategies: screening only; vaccination only; screening and vaccination; and no prevention. The results of the Markov model for each scenario were used as inputs to the optimization model determining the optimal proportion of the population to receive screening and/or vaccination under different scenarios. The scenarios varied by available budget, maximum screening and vaccination coverage, and overall reachable population. RESULTS: In the base-case optimization model analyses, with a coverage constraint of 20% for one lifetime screening, 95% for vaccination and a budget constraint of $1 per woman per year to minimize CC incidence, the optimal mix of prevention strategies would result in a reduction of CC incidence of 31% (3-dose vaccination available) or 46% (2-dose vaccination available) compared with CC incidence pre-vaccination. With a 3-dose vaccination schedule, the optimal combination of the different strategies across the population would be 20% screening alone, 39% vaccination alone and 41% with no prevention, while with a 2-dose vaccination schedule the optimal combination would be 71% vaccination alone, and 29% with no prevention. Sensitivity analyses indicated that the results are sensitive to the constraints included in the optimization model as well as the cervical intraepithelial neoplasia (CIN) and CC treatment cost. CONCLUSIONS: The results of the optimization model indicate that, in Nigeria, the most efficient allocation of a limited budget would be to invest in both vaccination and screening with a 3-dose vaccination schedule, and in vaccination alone before implementing a screening program with a 2-dose vaccination schedule.

Challenges and opportunities in cancer control in Africa: a perspective from the African Organisation for Research and Training in Cancer.

Sub-Saharan Africa has a disproportionate burden of disease and faces a major public-health challenge from non-communicable diseases. Although infectious diseases continue to afflict Africa, the proportion of the overall disease burden in sub-Saharan Africa attributable to cancer is rising. The region is predicted to have a greater than 85% increase in cancer burden by 2030. Approaches to minimise the burden of cancer in sub-Saharan Africa in the past few years have had little success because of low awareness of the cancer burden and a poor understanding of the potential for cancer prevention. Success will not be easy, and will need partnerships and bridges to be built across countries, economies, and professions. A strategic approach to cancer control in sub-Saharan Africa is needed to build on what works there and what is unique to the region. It should ideally be situated within strong, robust, and sustainable health-care systems that offer quality health care to all people, irrespective of their social or economic standing. However, to achieve this will need new leadership, critical thinking, investment, and understanding. We discuss the present situation in sub-Saharan Africa and propose ideas to advance cancer control in the region, including the areas of cancer awareness, advocacy, research, workforce, care, training, and funding.

Nurses in low resource settings save mothers' lives with non-pneumatic anti-shock garment.

PURPOSE: To discuss the role of nurses and nurse-midwives in preventing and treating postpartum hemorrhage (PPH) from uterine atony in developing countries and examine the role of a new device, the non-pneumatic anti-shock garment (NASG), in improving the outcomes for these patients. STUDY DESIGN AND METHODS: In this subanalysis of a larger preintervention phase/intervention phase study of 1,442 women with obstetric hemorrhage, postpartum women with hypovolemic shock (N = 578) from uterine atony (≥750 mL blood loss; systolic blood pressure <100 mmHg and/or pulse >100 beats per minute) were enrolled in two referral facilities in Egypt and four referral facilities in Nigeria. The study had two temporal phases: a preintervention phase and an NASG-intervention phase. Women with hemorrhage and shock in both phases were treated with the same evidence-based protocols for management of hypovolemic shock and hemorrhage, but women in the NASG-intervention phase also received the NASG. Relative risks (RRs) with 95% confidence intervals (CIs) were estimated for primary outcomes-measured blood loss, incidence of emergency hysterectomy, and mortality. RESULTS: Women in the NASG-intervention phase had significantly better outcomes, 50% lower blood loss, reduced rates of hysterectomy (8.9% vs. 4%), and mortality decreased from 8.5% to 2.3% (RR = 0.27, 95% CI: 0.12-0.60). CLINICAL IMPLICATIONS: In low-resource settings nurses have few resources with which to stabilize women with severe PPH. With training nurses and nurse-midwives can stabilize hemorrhaging women with the NASG, a low-technology first-aid device that shows promise for reducing blood loss, rates of hysterectomy, and mortality.

Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial.

OBJECTIVE: To assess the effect of psychosocial support on labour outcomes. METHODOLOGY: A randomised control trial conducted at the University College Hospital Ibadan, Nigeria, from November 2006 to 30 March 2007. Women with anticipated vaginal delivery were recruited and randomised at the antenatal clinic. The experimental group had companionship in addition to routine care throughout labour until two hours after delivery, while the controls had only routine care. The primary outcome measure was caesarean section rate. Others included duration of active phase, pain score, time of breast-feeding initiation and description of labour experience. Multivariable analyses were used to adjust for potential confounders. The level of statistical significance was set at 5%. RESULTS: Of the 632 recruited, 585 were eventually studied: 293 and 292 were in experimental and control groups, respectively. Husbands constituted about two-thirds of the companions. Women in the control group were about five times more likely to deliver by caesarean section (95% confidence interval (CI) 1.98-12.05), had significantly longer duration of active phase (P < 0.001), higher pain scores (P = 0.011) and longer interval between delivery and initiation of breast-feeding (P < 0.001). However, those in experimental group had a more satisfying labour experience (odds ratio 3.3 95% CI 2.15-5.04). CONCLUSION: Women with companionship had better labour outcomes compared to those without. It is desirable to adopt this practice in our health-care settings as an alternative strategy to provide comparable quality services to would-be mothers in labour.

Clients' reasons for prenatal ultrasonography in Ibadan, South West of Nigeria.

BACKGROUND: Prenatal ultrasonography has remained a universal tool but little is known especially from developing countries on clients' reasons for desiring it. Then aim was to determine the reasons why pregnant women will desire a prenatal ultrasound. METHODS: It was a cross-sectional survey of consecutive 222 women at 2 different ultrasonography facilities in Ibadan, South-west Nigeria. RESULTS: The mean age of the respondents was 30.1 +/- 4.5 years. The commonest reason for requesting for prenatal ultrasound scans was to check for fetal viability in 144 women (64.7%) of the respondents, followed by fetal gender determination in 50 women (22.6%. Other reasons were to check for number of fetuses, fetal age and placental location. Factors such as younger age, artisans profession and low level of education significantly influenced the decision to check for fetal viability on bivariate analysis but all were not significant on multivariate analysis. Concerning fetal gender determination, older age, Christianity, occupation and gravidity were significant on bivariate analysis, however, only gravidity and occupation remained significant independent predictor on logistic regression model. Women with less than 3 previous pregnancies were about 4 times more likely to request for fetal sex determination than women with more than 3 previous pregnancies, (OR 3.8 95%CI 1.52 - 9.44). The professionals were 7 times more likely than the artisans to request to find out about their fetal sex, (OR 7.0 95%CI 1.47 - 333.20). CONCLUSION: This study shows that Nigerian pregnant women desired prenatal ultrasonography mostly for fetal viability, followed by fetal gender determination. These preferences were influenced by their biosocial variables.