Quality of life and associated factors among infertile women attending infertility clinic at Mnazi Mmoja Hospital, Zanzibar.

BACKGROUND: Worldwide, it is estimated at least 50 million couples are affected by infertility with the prevalence of infertility being 16% in Tanzania. Psychological impact of infertility in patients negatively affects women's Quality of Life (QoL) defined as a person`s perception of where they are in life in terms of culture and value in the emotional, mind-body, relational, social, environment and tolerability of treatment aspects. Poor Quality of Life is related to increased treatment discontinuation. The aim of this study was to determine the Quality of Life and associated factors among infertile women attending infertility clinic at Mnazi Mmoja Hospital, Zanzibar. METHODS: A hospital based cross-sectional study was conducted among 340 infertile women attending infertility clinic at Mnazi Mmoja Hospital, Zanzibar. Data was collected using FertiQoL tool. The factors associated with Quality of Life using FertiQoL tool in infertile women were estimated in a multivariable linear regression model at 95% confidence interval and 5% level of significance. RESULTS: Quality of life of infertile women at Mnazi Mmoja infertility clinic was 70.6 ± 10.0 on a scale of 0 to 100. It increased significantly with increase in educational level (p = 0.009). Women with female individual causes on average had 5.07 (B=- 5.07, 95%CI: -7.78, -2.35) and women with individual and respective male partner causes of infertility had on average 4.95 (B= -4.95, 95% CI: -7.77, -2.12) respective decrease in the FertiQoL scores compared to those who had their male partner with problems as reason for infertility. There was an average 4.50 (B=-4.50, 95% CI: 2.30, 6.70) decrease in quality of life in women with secondary infertility compared to women with primary infertility. Every month increase in duration of infertility led to an average of 0.04 (B=-2.57, 95%CI: -0.07, -0.01) decrease in FertiQoL scores. CONCLUSION: The overall quality of life in this population was positively associated with level of education but negatively affected with reason for infertility, type of infertility and duration of infertility.

Quality of life among cervical cancer patients following completion of chemoradiotherapy at Ocean Road Cancer Institute (ORCI) in Tanzania.

OBJECTIVE: Effective cancer treatment involves aggressive chemo-radiotherapy protocols that alter survivors' quality of life (QOL). This has recently aroused the attention not only to focus on clinical care but rather to be holistic and client-centered, looking beyond morbidity and mortality. The study assessed the QOL and associated factors among patients with cervical cancer (CC) after the completion of chemoradiotherapy. METHODS: A cross-sectional analytical study was conducted at Ocean Road Cancer Institute (ORCI) from September to November 2020. A total of 323 CC patients were interviewed with a structured questionnaire of QOL, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and its cervical cancer module (EORTC QLQ-CX24). The QOL domains, socio-demographic and clinical variables were analyzed with Mann-Whitney and Kruskal-Wallis on SPSS version 23, and a P < 0.05 was considered significant. RESULTS: More than half (54.8%) of the CC patients had a good overall QOL. Overall, QOL was affected by education (P = 0.019), smoking (0.044), sexual partner (P = 0.000), treatment modality (P = 0.018), and time since completion of treatment (P = 0.021). Patients who underwent external beam radiation suffered from significant side effect symptoms (P < 0.05) while those who underwent combined external beam radiation and brachytherapy had higher functioning in most domains (P < 0.05). CONCLUSIONS: A significant improvement in QOL was observed after chemoradiotherapy and was affected by socio-demographic and clinical variables. Thus, calls for individualized care in addressing these distressing symptoms.

Intermittent fetal heart rate monitoring using a fetoscope or hand held Doppler in rural Tanzania: a randomized controlled trial.

BACKGROUND: Neonatal mortality is a global challenge, with an estimated 1.3 million intrapartum stillbirths in 2015. The majority of these were found in low resource settings with limited options to intrapartum fetal heart monitoring devices. This trial compared frequency of abnormal fetal heart rate (FHR) detection and adverse perinatal outcomes (i.e. fresh stillbirths, 24-h neonatal deaths, admission to neonatal care unit) among women intermittently assessed by Doppler or fetoscope in a rural low-resource setting. METHODS: This was an open-label randomized controlled trial conducted at Haydom Lutheran Hospital from March 2013 through August 2015. Inclusion criteria were; women in labor, singleton, cephalic presentation, normal FHR on admission (120-160 beats/minute), and cervical dilatation ≤7 cm. Verbal consent was obtained. RESULTS: A total of 2684 women were recruited, 1309 in the Doppler and 1375 in the fetoscope arms, respectively. Abnormal FHR was detected in 55 (4.2%) vs 42 (3.1%). (RR = 1.38; 95%CI: 0.93, 2.04) in the Doppler and fetoscope arms, respectively. Bag mask ventilation was performed in 80 (6.1%) vs 82 (6.0%). (RR = 1.03; 95%CI: 0.76, 1.38) of neonates, and adverse perinatal outcome was comparable 32(2.4%) vs 35(2.5%). (RR = 0.9; 95%CI: 0.59, 1.54), in the Doppler and fetoscope arms, respectively. CONCLUSION: This trial failed to demonstrate a statistically significant difference in the detection of abnormal FHR between intermittently used Doppler and fetoscope and adverse perinatal outcomes. However, FHR measurements were not performed as often as recommended by international guidelines. Conducting a randomized controlled study in rural settings with limited resources is associated with major challenges. TRIAL REGISTRATION: This clinical trial was registered on April 2013 with registration number NCT01869582 .

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study.

BACKGROUND: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. METHODS: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. RESULTS: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. CONCLUSIONS: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. TRIAL REGISTRATION: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.

Decision to delivery interval, maternal and fetal outcomes in emergency caesarean sections in a tertiary teaching hospital, Dar es salaam, Tanzania.

Background: Emergency caesarean section (CS) answers the question on how soon the procedure should be performed. Maternal and fetal outcomes deteriorate when decision to delivery interval (DDI) exceeds 75 min. This study aimed at determining the DDI, Maternal and fetal outcomes in CS categories at Muhimbili National Hospital (MNH). Methodology: A descriptive cross-sectional study involving 427 emergency CS at MNH was conducted from September to November, 2017. Data was extracted and analysed using SPSS version 23.0 where frequency, means, chi-square test and DDI were calculated to determine its association with categories of CS. Results: The mean DDI for category one, two and three CS were 126.73, 133.57 and 160.08 min respectively. Only two (0.5%) and 54 (12.6%) of category one and two emergency CS met the recommended DDI of 30 and 75 min respectively. Maternal and fetal adverse outcome were increasing with increase in DDI. There was no significant association between DDI and adverse maternal outcome (OR: 1.2; 95% CI 0.49-2.83) and fetal outcome (OR: 1.7; 95% CI 0.91-3.38). Conclusion: The proportions of adverse maternal and fetal outcome were high when DDI was ≥ 75 min. Improving triage of the patients according to their urgency is crucial in reducing prolonged DDI.

Advancing primary care: Establishing family medicine specialty in Tanzania.

Family medicine has existed as a training pathway through a private university in Tanzania since 2004. As global calls have increased to embrace primary health care as a pathway to ensuring universal health coverage, so has Tanzania recently turned to explore family medicine as a specialty to improve access to comprehensive, high-quality healthcare for her entire population. This article outlines ongoing efforts to define competencies and skills of a family medicine physician in Tanzania, engage government support and open the first public university training programme for family medicine postgraduate education.

Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap.

BACKGROUND: Criteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania. OBJECTIVE: The prevalence of eclampsia in MNH is high (≈6%) with the majority of cases arriving after start of convulsions. In 2004-2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit. METHODS: A CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit. RESULTS: There was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001). CONCLUSION: CBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.

Hirsutism Caused by Pregnancy Luteoma in a Low-Resource Setting: A Case Report and Literature Review.

BACKGROUND: Pregnancy luteomas are rare, benign, ovarian neoplasms resulting from increased androgenic activity during pregnancy. Often, they occur asymptomatically and are only diagnosed incidentally during imaging or surgery: cesarean section or postpartum tubal ligation. Most common symptoms associated with pregnancy luteoma include acne, deepening of voice, hirsutism, and clitoromegaly. Most pregnancy luteomas regress spontaneously postpartum. Thus, the management of pregnancy luteomas depends on the clinical situation. CASE: We report a case of 28-year-old gravida 2, para 1 who presented at 39 + 1 weeks of gestation with prolonged labor and delivered by emergency cesarean. Intraoperatively, a huge left ovarian mass was identified and resected, and tissue was sent for histopathology and a diagnosis of pregnancy luteoma was made after the pathological report. CONCLUSION: The present report emphasizes that pregnancy luteoma is a benign neoplasm and imprudent surgical intervention should be reserved. Proper imaging techniques, preferably MRI or ultrasonography that visualize the size of the ovary and reproductive hormonal profiles, would suffice for the diagnosis and management of pregnancy luteoma.

Intrapartum fetal heart rate monitoring using a handheld Doppler versus Pinard stethoscope: a randomized controlled study in Dar es Salaam.

BACKGROUND: Fetal stethoscopes are mainly used for intermittent monitoring of fetal heart rate (FHR) during labor in low-income countries, where perinatal mortality is still high. Handheld Dopplers are rarely available and are dependent on batteries or electricity. The objective was to compare the Pinard stethoscope versus a new wind-up handheld Doppler in the detection of abnormal FHR. MATERIALS AND METHODS: We conducted a randomized controlled study at Muhimbili National Hospital, Tanzania, from April 2013 to September 2015. Women with gestational age ≥37 weeks, cephalic presentation, normal FHR on admission, and cervical dilatation <7 cm were included. Primary outcome was abnormal FHR detection (<120 or >160 beats/min). Secondary endpoints were time to delivery, mode of delivery, and perinatal outcomes. χ2, Fisher's exact test, Mann-Whitney test, and logistic regression were conducted. Unadjusted and adjusted odds ratios were calculated with respective 95% confidence interval. RESULTS: In total, 2,844 eligible women were assigned to FHR monitoring with Pinard (n=1,423) or Doppler (n=1,421). Abnormal FHRs were more often detected in the Doppler (6.0%) versus the Pinard (3.9%) arm (adjusted odds ratio =1.59, 95% confidence interval: 1.13-2.26, p=0.008). Median (interquartile range) time from abnormal FHR detection to delivery was comparable between Doppler and Pinard, ie, 80 (60,161) and 89 (52,165) minutes, respectively, as was the incidence of cesarean delivery (12.0% versus 12.2%). The incidence of adverse perinatal outcomes (fresh stillbirths, 24-hour neonatal admissions, and deaths) was similar overall; however, among newborns with abnormal FHR delivered vaginally, adverse outcomes were less incident in Doppler (7 of 43 births, 16.3%) than in the Pinard arm (10 of 23 births, 43.5%), p=0.021. CONCLUSION: Intermittent FHR monitoring using Doppler was associated with an increased detection of abnormal FHR compared to Pinard in a low-risk population. Time intervals from abnormal FHR detection to delivery were longer than recommended in both arms. Perinatal outcomes were better among vaginally delivered newborns with detected abnormal FHR in the Doppler arm.

Large neurofibroma of the labia majora: A case report.

Neurofibromatosis is an autosomal dominant progressive disorder with an incidence of approximately 1 in 3000 live births. Its recognized features include hyper-pigmented skin lesions (cafe-au-lait spots), neurofibromas, iris hamartomas, macrocephaly, central nervous system tumours, defects of the skull and facial bones, and vascular lesions. Involvement of the external genitalia is extremely unusual. This report describes a case of a vulva neurofibroma in a 15-years old teenage girl with no history of trauma or features of Von Recklinghausen's disease. Treatment involved total excision of the tumour under spinal anaesthesia. The diagnosis of neurofibroma was confirmed by histological examination which showed spindle shaped cells with wavy nuclei arranged in a loose myxomatous stroma. No further treatment was offered but the patient was counselled on the possibility of recurrence. She was seen one month after excision and there were no signs of recurrence.

Accuracy in diagnosis of postpartum haemorrhage using visual estimation of blood loss versus change in haematocrit in a tertiary teaching hospital in Tanzania.

Postpartum haemorrhage is the leading cause of maternal death in the developing country and yet is poorly diagnosed due to inaccurate measurement of blood loss following delivery. A study was carried out at Muhimbili National Hospital (MNH) Tanzania between October 2005 and January 2006 to determine the accuracy of visual estimation of blood loss (VEBL) in comparison to laboratory measurement of blood loss in diagnosis of primary postpartum haemorrhage (PPH). A total of 426 pregnant women who were in active phase of labour were recruited and their venous blood was drawn for estimation of haematocrit before delivery and 12 hours thereafter. Active management of third stage of labour was conducted by giving 101U of oxytocin (intramuscularly or intravenously) and this was followed by visual estimation of blood loss. The proportion of patients who developed PPH was then determined by both methods. The mean duration of third stage of labour was 8.3 minutes and mean blood loss was 164.9 ml. The prevalence of PPH was 8.9% and 16.2% by VEBL and changes in haematocrit, respectively. Change in haematocrit in diagnosis of PPH was found to be more accurate, specific with high positive predictive values compared to VEBL. The need for additional uterotonics was 5.8% and the commonest labour complications associated with PPH were second degree tear, retained placenta and EUA for continued bleeding. In conclusion, VEBL using calibrated vessel will increase accuracy where conventional method using non calibrated method is used for diagnosis of PPH. Service providers working in labour wards need to be trained on how to estimate blood loss using simulated methods so as to increase their long term memory and accuracy in diagnosis of post-partum haemorrhage, hence provision of immediate intervention.

Emergency peripartum hysterectomies at Muhimbili National Hospital, Tanzania: a review of cases from 2003 to 2007.

A retrospective review of all cases of emergency peripartum hysterectomy performed between January 1, 2003 and December 31, 2007 at Muhimbili National Hospital was done to determine the incidence, indications and complications, background characteristics, antenatal care attendance, referral status, and maternal and foetal outcomes. There were 55,152 deliveries during the study period and 165 cases of emergency peripartum hysterectomy, giving the incidence of emergency peripartum hysterectomy of 3 per 1000 deliveries. The main indication was uterine rupture (79%) followed by severe post-partum haemorrhage due to uterine atony (12.7%). The case fatality rate was 10.3% where as perinatal mortality rate was 7.7 per 1000 deliveries. The common complication identified intraoperatively was severe haemorrhage which accounted for 39.4% where as intensive care unit admissions (14.4%) and febrile morbidity (12.4%) were common after the operation. Blood was ordered in all cases but in 31 cases it was indicated that it was not available. Seventy nine patients received blood transfusion with the maximum number of units given to one patient being eight. Twenty two patients were given fresh frozen plasma (FFP), the median number of units given was two (range = 1-6). In conclusion, emergency peripartum hysterectomy is a life saving procedure and very common at MNH. The most common indication was ruptured uterus followed by severe postpartum haemorrhage. More than half of the patients underwent emergency peripartum hysterectomy were referred from other health facilities with ruptured or suspected ruptured uterus. The procedure was associated with unacceptably high maternal and perinatal morbidity and mortality.