Length of stay and determinants of early discharge after facility-based childbirth in Cameroon: analysis of the 2018 Demographic and Health Survey.

BACKGROUND: A minimum length of stay following facility birth is a prerequisite for women and newborns to receive the recommended monitoring and package of postnatal care. The first postnatal care guidelines in Cameroon were issued in 1998 but adherence to minimum length of stay has not been assessed thus far. The objective of this study was to estimate the average length of stay and identify determinants of early discharge after facility birth. METHODS: We analyzed the Cameroon 2018 Demographic and Health Survey. We included 4,567 women who had a live birth in a heath facility between 2013 and 2018. We calculated their median length of stay in hours by mode of birth and the proportion discharged early (length of stay < 24 h after vaginal birth or < 5 days after caesarean section). We assessed the association between sociodemographic, context-related, facility-related, obstetric and need-related factors and early discharge using bivariate and multivariable logistic regression. RESULTS: The median length of stay (inter quartile range) was 36 (9-84) hours after vaginal birth (n = 4,290) and 252 (132-300) hours after caesarean section (n = 277). We found that 28.8% of all women who gave birth in health facilities were discharged too early (29.7% of women with vaginal birth and 15.1% after a caesarean section). Factors which significantly predicted early discharge in multivariable regression were: maternal age < 20 years (compared to 20-29 years, aOR: 1.44; 95%CI 1.13-1.82), unemployment (aOR: 0.78; 95%CI: 0.63-0.96), non-Christian religions (aOR: 1.65; 95CI: 1.21-2.24), and region of residence-Northern zone aOR:9.95 (95%CI:6.53-15.17) and Forest zone aOR:2.51 (95%CI:1.79-3.53) compared to the country's capital cities (Douala or Yaounde). None of the obstetric characteristics was associated with early discharge. CONCLUSIONS: More than 1 in 4 women who gave birth in facilities in Cameroon were discharged too early; this mostly affected women following vaginal birth. The reasons leading to lack of adherence to postnatal care guidelines should be better understood and addressed to reduce preventable complications and provide better support to women and newborns during this critical period.

Use of WhatsApp®, for distance teaching during COVID-19 pandemic: Experience and perception from a sub-Saharan African setting.

BACKGROUND: In the midst of the COVID-19 pandemic, to palliate to the lockdown and cover academic programs, the faculty of medicine and pharmaceutical sciences (FMPS) of the university of Dschang (UDs) in Cameroon has implemented e-learning using WhatsApp®. AIM: Describe the opinion of students and lecturers after its implementation of e-learning at the FMPS of UDs. METHODS: We designed a uniform teaching scheme using WhatsApp® during the university lockdown. Students and members of the teaching staff of the FMPS of UDs were enrolled after receiving clear information on the study implementation. At the end of the online-teaching period of two and a half months, we surveyed our students and teaching staff. Sociodemographic characteristics and opinions about e-learning were collected using a standard questionnaire. RESULTS: We enrolled 229 students and 40 lecturers of the FMPS. Students reported a decremented quality of internet connection (p < 0.001, p-homogeneity < 0.001) despite an increased expenditure related to internet use. Electronic devices were broadly used before the implementation of mobile learning. The use of course materials was significantly more challenging among students because of the size/format of lecture notes and internet connection/cost (all p < 0.05). Perception of discipline compared to classroom-based lessons was not significantly different among students compared to lecturers (all p > 0.05). While lecturers were mainly more comfortable conveying the contents of their lectures, students tended to be less prone to actively participate. The motivation and satisfaction of the latter group toward e-learning were modest compared to classroom-based lectures while their feedback about the organization was positive. CONCLUSIONS: E-learning using WhatsApp® could be an effective alternative to conventional classroom-based lessons in the context of COVID-19 pandemic. The use of a blended-learning program including classroom-based sessions could help improve its limitations.

Outcome of deliveries among adolescent girls at the Yaoundé central hospital.

BACKGROUND: Adolescent pregnancies are a growing public health problem in Cameroon. We sought to study the outcome of such pregnancies, in order to inform public health action. METHODS: A cross-sectional analysis of 5997 deliveries which compared the outcome of deliveries in adolescent (10-19 years old) pregnant women registered at the Yaoundé Central Hospital between 2008 and 2010 to that of their non-adolescent adult (≥ 20 years old) counterparts. Variables used for comparison included socio-demographic and obstetric characteristics of parturients, referral status, and maternal and fetal outcomes. Predictors of maternal and of perinatal mortality were determined through binomial logistic modeling. RESULTS: Adolescent deliveries represented 9.3% (560) of all pregnancies registered. Adolescent pregnancies had significantly higher rates of both gestational duration extremes: preterm as well as post-term deliveries (29.3% versus 24.5%, p = 0.041 OR 1.28 95% CI 1.01-1.62 and 4.9 versus 2.4%, p = 0.014 OR 2.11 95% CI 1.46-3.87 respectively). Both groups did not differ significantly with respect to mean blood loss, rates of cesarean or instrumental deliveries. Adolescent deliveries however required significantly twice as many episiotomies (OR 2.15 95% CI 1.59-2.90). The likelihood of perineal tears in the adolescent group was significantly higher than that in the adult group on assuming episiotomies done would have been tears if they had not been carried out (OR 1.45 95% CI 1.16-1.82). Adolescent parturients had a higher likelihood of apparent fetal death at birth as well as perinatal fetal death after resuscitation efforts (AOR 1.75 95% CI 1.25-2.47 and AOR 1.69 95% CI 1.17-2.45 respectively).Comparisons of pregnancy outcomes between early (10-14 years), middle (15-17 years) and late adolescence (18-19 years) found no significant differences. Predictors of maternal death included having been referred, having had ≥5 deliveries and preterm deliveries. These were also predictors of perinatal death, as well as being a single mother, primiparous, and multiple gestations. CONCLUSIONS: Adolescent pregnancies in Cameroon compared to those in adults are associated with poorer outcomes. There is need for adolescent-specific services to prevent teenage pregnancies as well as interventions to prevent and manage the above mentioned predictors of in-facility maternal and perinatal mortality.

Training, Supervision, and Competence Assessment of Cameroonian Health Care Providers Using HPV Self-Sampling, Triage by Visual Inspection, and Treatment by Thermal Ablation in a Single Visit.

Background: Developing human resource capacity and efficient deployment of skilled personnel are essential for cervical cancer screening program implementation in resource-limited countries. Our aim was to provide a context-specific training framework, supervision, and effectiveness evaluation of health care providers in a cervical cancer screening program. Methods: A 5-year cervical cancer screening program was implemented in Dschang, West Cameroon. Women were invited to perform human papillomavirus self-sampling (Self-HPV), followed by triage using visual inspection with acetic acid (VIA) and thermal ablation if needed. Health care providers were trained in four key learning phases to perform counseling, screening, and treatment process in a single visit. Training included (i) a 3-day basic course, (ii) 3-day advanced practical training, (iii) 2 weeks of supervision, and (iv) bi-monthly supervision by a mentor. The diagnostic performance of health care providers was compared between two time periods, period I (September 2018 to April 2019) and period II (May 2019 to January 2020), for an overall 17-month study period. Results: Fourteen health care providers were recruited for the training course and 12 of them completed the training objectives. Follow-up and evaluations were conducted for three health care providers working in the screening unit at Dschang District Hospital. During the study period, 1,609 women performed Self-HPV, among which 759 were screened during period I and 850 during period II. HPV positivity was 18.2 and 17.1%, and VIA positivity was 45.7 and 71.0% in period I and II, respectively. VIA sensitivity was 60.0% (95% confidence interval [CI] 26.2-87.8) and 80.8% (95% CI 60.6-93.4) in period I and II, respectively (p = 0.390). VIA specificity decreased between period I (57.4, 95% CI 48.1-66.3) and II (30.8, 95% CI 22.6-40.0) (p < 0.001). Health care providers demonstrated substantial agreement with their mentor in their diagnoses during both periods (period I: Cohen's kappa coefficient [k] = 0.73, 95% CI 0.62-0.85, and period II: k = 0.62 0.47-0.76; p = 0.0549). Discussion: Training, supervision, and a focus on effectiveness in cervical cancer screening are interventions that contribute to improving frontline provider competencies and maintaining a high quality of health care service delivery.

Pitfalls in Diagnosing Heterotopic Pregnancy in Sub-Saharan Africa: A Case Report at the Yaounde University Teaching Hospital (Cameroon).

Heterotopic pregnancy (HP) is a dizygotic twin pregnancy in which one gestational sac is intrauterine and the other is extrauterine. The prevalence of HP is unknown in Cameroon where the diagnosis is difficult and usually fortuitous like in other resource-poor settings. We herein depict pitfalls and delays in the diagnosis and management of a ruptured heterotopic pregnancy at the Yaounde University Teaching Hospital. After a wrong diagnosis and inadequate treatment, our patient presented at our emergency unit with severe pelvic pain and clinical signs of hemoperitoneum with shock. She underwent a total left salpingectomy through laparotomy. She had a complete spontaneous abortion five days after the surgery. Given that sonography is not routinely available in emergency departments in resource-poor settings, it may be relevant for practitioners to always bear HP in mind when facing ruptured ectopic pregnancies.

Poor knowledge of COVID-19 and unfavourable perception of the response to the pandemic by healthcare workers at the Bafoussam Regional Hospital (West Region-Cameroon).

INTRODUCTION: WHO warned against a dramatic impact of COVID-19 in Africa unless adequate response strategies are implemented. Whatever the strategy, the role of health staff is pivotal. Objective: Assess knowledge and perception of the response to COVID-19 among health staff. METHODS: we used a convenience non probabilistic sample to conduct a survey with a self-administered questionnaire from April 14 - 29, 2020 at the Bafoussam Regional Hospital (BRH). All the staff was invited to participate. Analyses were done with Microsoft Excel 2010 and Epi-Info version 7.1.5.2. RESULTS: response rate was 76.1% (464/610). Mean age (SD) was 35.0 (8.9) years. Sex ratio (M/F) was 101/356. Nursing/midwifery staff (56.8%) and in-patients units (49.94%) were predominant. Origin and transmission of SARS-CoV-2 were poorly known while knowledge of clinical signs and the role of laboratory tests were good. For 53.2% of respondents all therapeutic regimens are supportive and only 31.6% trusted state-recommended drugs. For 169 of respondents (36.9%), herbal remedies prevent/cure COVID-19. Seventy percent (70%) felt they were not knowledgeable enough to handle COVID-19 cases. Eighty-five point six percent (85.6%) thought the BRH had insufficient resources to fight COVID-19 and 55.6% were dissatisfied with its response (weaknesses: medicines/technologies (74.5%), service delivery (28.1%), staff (10.9%)). Sixty-eight percent (68%) reported insufficient protection on duty. Seventy-six point five percent (76.5%) reported a drop in non-COVID-19 services. Eighty-five point five (85.5%) percent said they complied with community preventive measures. For 44% of respondents, regulations on COVID-19 corpses should be made more culture-sensitive. Fifty one point two percent (51.2%) of respondents were against vaccine trial in their community. CONCLUSION: knowledge was poor and perception of the response to COVID-19 was unfavourable.

Seroprevalences and Correlates of Hepatitis B and C Among Cameroonian Pregnant Women.

BACKGROUND AND RATIONALE: Viral hepatitis B (VHB) and viral hepatitis C (VHC) are major public health issues in resource-poor countries where vertical transmission remains high. AIM: To assess prevalences and correlates of VHB and VHC among women attending antenatal clinic. METHODS: A cross-sectional study at the Yaounde Central Hospital from January 1 to June 30, 2016. We included 360 pregnant women who were screened for hepatitis B virus surface antigen (HbsAg) and VHCAb by rapid diagnostic test (DiaSpot Diagnostics, USA) followed by confirmation of positive results by a reference laboratory. Odds ratios (95% confidence interval [CI]) were used to measure associations between variables. Statistical significance was set for P-value <.05. RESULTS: Mean age was 27.9 ± 5.6 years. The prevalences of HbsAg and VHCAb were 9.4% (n = 34) and 1.7% (n = 6), respectively. Multiplicity of sex partners was significantly associated with HbsAg positivity (adjusted odds ratio [aOR]: 11.6; 95% CI: 5.1-26.7; P < .001) while none of the studied factors was associated with VHCAb. CONCLUSION: The high prevalence of hepatitis B among pregnant women supports systematic screening and free vaccination of pregnant women and women of childbearing age.

Term Abdominal Pregnancy Revealed by Amnioperitoneum in Rural Area.

Abdominal pregnancy (AP) accounts for 1% of ectopic implantations. In sub-Saharan Africa, the high prevalence of sexually transmitted infections explains the increasing frequency of this pathology. In Cameroon it rose from 1/10000 deliveries (1995) to 3.3/10000 (2015). Authors herein report a case of a viable abdominal pregnancy discovered at term during emergency laparotomy for suspected uterine rupture. The 24-year-old G2P0 patient was HIV-positive, under antiretrovirals, though AP exceptionally occurs in HIV patients. She did only two antenatal consultations: her main complaint was abdominal pain but five echographies concluded to normal intrauterine pregnancy. Findings at laparotomy were as follows: amnioperitoneum, a live female baby weighing 3.4 kilogrammes without deformities and a placenta deeply inserted on the uterine fundus. Removal of the placenta triggered massive bleeding (2400 milliliters) with shock managed with a tourniquet on the lower uterine segment and fluid resuscitation. Outcome was favourable for the mother and child. Prevention of vertical transmission of HIV was successful with antiretroviral therapy.

Evaluation of patients' satisfaction after laparoscopic surgery in a tertiary hospital in Cameroon (Africa).

INTRODUCTION: Access to laparoscopy is low in Cameroon where customers' satisfaction has not been reported so far. We assessed patients' satisfaction with the process of care during laparoscopic surgery in a new tertiary hospital. METHODS: A questionnaire was addressed to consenting patients (guardians for patients under 18) with complete medical records who underwent laparoscopy at the Douala Gynaeco-Obstetric and Paediatric Hospital (Cameroon) from November 1, 2015 to July 31, 2016. The following modified Likert's scale was used to assess satisfaction: very weak: 0-2.5; weak 2.6-5; good: 5.1-7.5; very good: 7.6-10. Only descriptive statistics were used. RESULTS: Response rate was 90% (45/50). Of the 45 respondents, 39 (86.7%) were female, 14(31.1%) were referred and 39 (86.7%) paid by direct cash deposit. Mean age was 36.8±11.9 years. Laparoscopies were carried out in emergency for 3 (6.7%) patients. Digestive abnormalities indicated 13 (28.9%) laparoscopies while gynaecologic diseases accounted for 32 (71.1%) cases. Perception of the overall care process was good with a mean satisfaction score of 6.8 ± 1.4. Scores in categories were: 0% (Very weak); 13.3% (weak); 57.8% (good) and 28.9% (very good). Specifically mean satisfaction scores were: 7.8 ± 1.0 with doctors' care; 7.1 ± 1.3 with hospital administration; 7.0 ± 1.2 with nursing and 4.7 ± 1.4 with the costs. Main complaints were: long waiting time (73.3%), constraining geographical access (66.7%) and expensiveness (48.9%). CONCLUSION: Patients were globally satisfied with the process of care but financial and geographical barriers should be addressed.

Associations of body mass index and gestational weight gain with term pregnancy outcomes in urban Cameroon: a retrospective cohort study in a tertiary hospital.

BACKGROUND: Obesity is a rising public health issue worldwide. Guidelines regarding maternal body mass index (BMI) and gestational weight gain (GWG) are missing in Cameroon where maternal mortality rate remains very high. We hypothesized that obesity and inappropriate GWG are associated with poor pregnancy outcomes. We aimed at assessing associations of BMI and GWG with pregnancy outcomes. METHODS: This was a retrospective cohort study at the Yaoundé Central Hospital. We included women with term singleton deliveries in the post-partum ward. The World Health Organisation classification of BMI and the United States Institute Of Medicine (IOM) categories of GWG were used to stratify participants. Poor maternal outcome was defined by the occurence of caesarean section, preeclampsia or obstetrical haemorrhage. Poor perinatal outcome was defined by the occurence of perinatal death, admission in intensive care unit, low birth weight, macrosomia or fifth minute Apgar score <7. Multiple logistic regressions were used to calculate unadjusted and adjusted Odds Ratios (uOR, aOR) for poor maternal outcome (PMO) and for poor perinatal outcome (PPO) in each category of BMI and GWG. Adjustment was done for age, scarred uterus, sickle cell disease, malaria, human immunodeficiency virus (HIV) infection, parity and smoking. RESULTS: Of the 462 participants, 17 (4 %) were underweight (BMI < 18.5), 228 (49 %) had normal pre-pregnancy BMI, 152 (33 %) were overweight (25 ≤ BMI < 30) and 65 (14 %) were obese (BMI ≥ 30). Following the IOM recommendations, GWG was normal for 186 (40 %) participants, less than recommended for 131 (28 %) and above the recommended norms for 145 (32 %). GWG above the IOM recommendation was significantly associated with PMO (aOR: 1.7, 95 % CI 1.1-2.8). GWG less than the IOM recommended values, overweight and obesity were not significantly associated with poor pregnancy outcomes. CONCLUSION: While waiting for local recommendations for GWG, the IOM recommendations can be used for Cameroonian women as far as maternal outcome is concerned. Unlike in studies in different ethnic and racial groups, abnormal BMI was not associated with poor pregnancy outcomes in our cohort of Cameroonian women.

Viable abdominal pregnancy: a case report in Yaoundé (Cameroon).

We herein report a case of abdominal pregnancy managed in Yaounde (Cameroon). The 33 year old G5P2022 woman was referred to our setting for management of an abdominal pregnancy of 34 weeks diagnosed during the first routine obstetrical ultrasonography done two days earlier. This ultrasonography revealed a live foetus within intestinal loops with a severe oligoamnios. After two days of lung maturation, laparotomy was carried out and the live male baby weighed 2 600 grammes. The placenta was left on its implantation sites: omentun, uterine fundus and intestinal loops. The mother did well post-operatively and the resorption of the placenta took 11 months. The newborn presented compression deformities and died three days later of respiratory distress. This case illustrates that intra-abdominal fetuses can reach viability. Though rare, abdominal pregnancy remains a threat to mothers. Practitioners should therefore know the traps in its management.

Spontaneous second-trimester ruptured pregnancy of rudimentary horn: a case report in Yaounde, Cameroon.

Rudimentary uterine horn pregnancy is rare and, to our knowledge, has not been previously reported in Cameroon. We herein report the case of a 22 year old second gravida referred for acute abdominal pain at 17 weeks of gestation. Physical examination revealed hemoperitoneum with hypovolemic shock. After resuscitation, an emergency exploratory laparotomy was done and we found hemoperitoneum of 3,500 milliliters, a bicornuate uterus with a ruptured right rudimentary communicating horn containing a non viable foetus. There were no other abnormalities. We performed an excision of the rudimentary horn with ipsilateral salpingectomy. Post-operative course was uneventful and the woman was discharged seven days later. This case emphasizes the importance of good antenatal care to avoid complications.

Ruptured heterotopic pregnancy in a natural conception cycle: a case report at the Yaounde central Hospital (Cameroon).

Heterotopic pregnancy is very rare under natural circumstances. We report the case of a 28 year old Gravida2 Para1001 woman at 9 weeks of pregnancy who consulted in emergency for acute pelvic pain following metrorrhagia. Physical exam revealed hemoperitoneum without shock. An emergency ultrasonography revealed two gestational sacs, one intra-uterine and the other extra-uterine. Laparotomy was done and the findings were: a ruptured right tubal pregnancy with 1,300 milliliters of hemoperitoneum, type B left utero-adnexal adhesions and an increased uterus consistent with a 9 weeks pregnancy. Right total salpingectomy was done and the patient did well postoperatively. That intrauterine pregnancy evolved normally under progesterone supply and the woman delivered a termed live female baby weighing 3.1 kilogrammes. In our context where ultrasound is not always available, practitioners carrying out salpingectomy for ruptured ectopic pregnancies should bear in mind the plausibleness of heterotopic pregnancy in order to properly handle the uterus.

Ovarian pregnancy: a case report in a resource-poor setting.

Ovarian pregnancy is very rare and to our knowledge, no case has been reported in Cameroon. We herein report a case at the Yaounde Central Hospital. It is the case of a 29 years old woman who consulted in emergency for left pelvic pain at 9 weeks of pregnancy. The level of beta human chorionic gonadotropin was 96702 milli-international Units/ milliliter and ultrasound revealed an intra-ovarian gestational sac, an empty uterus and no peritoneal effusion. In the absence of facilities for laparoscopy, an emergency laparotomy was done. We found the non ruptured mass inside the left ovary. The left fallopian tube, the uterus and the right adnexae were normal. We did a successful ovarian dissection and resection of gestational sac. Trophoblastic tissue was found at pathology. Similar symptoms should draw attention of practitioners on the plausibility of ovarian pregnancy.

A case of abdominal textiloma following gynecologic surgery at the Yaounde Central Hospital, Cameroon.

Textiloma is the inadvertent retention of a textile foreign body on the surgical site. It is a rare complication of surgery but which carries severe consequences for both patients and surgeons in terms of morbi-mortality and medico-legal procedures respectively. We herein report the case of an abdominal textiloma in a 42 year old woman who underwent a total abdominal hysterectomy for symptomatic leiomyomas. We also depict the errors that led to this mishap in a tertiary hospital in Yaounde (Cameroon). The textiloma was recognized six weeks after the causative surgery and removed by laparotomy without further complications.

Carcinosarcoma of the corpus uteri (Malignant Müllerian Mixed Tumor): a case report in Yaoundé (Cameroon).

Carcinosarcoma of the uterus is a rare tumor representing 2-4% of uterine malignancies. Its prognosis is poor with a 5 years survival rate of 10-30%. We report a first documented case of carcinosarcoma occurring in a 62 years old woman who presented with postmenopausal vaginal bleeding for one year. The preoperative biopsy of endometrium revealed a leiomyosarcoma. Total body Computerized Tomography (CT) Scan revealed a mass limited to the uterus without other abnormalities. We carried out a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Post operative histology of the specimen found a carcinosarcoma. The patient underwent a course of radiotherapy and a total body CT Scan done eight months later revealed no signs of recurrence or metastasis. Clinicopathological aspects, treatment options and prognosis of this aggressive neoplasm are reviewed. We recommend practitioners to be aware of this lesion for an early diagnosis and appropriate treatment.