Community Malaria Knowledge, Experiences, Perceived Roles, and Acceptability of Community-Directed Distribution of Intermittent Preventive Therapy for Pregnancy in Rural Southeast Nigeria.

BACKGROUND: The community plays key roles in protecting pregnant women in rural areas from malaria. This study assessed malaria experiences, knowledge, perceived roles in malaria prevention in pregnancy, and acceptability of community-directed distribution of intermittent preventive therapy (IPTp) for malaria in pregnancy in rural Southeast Nigeria. METHODS: This study presents part of the baseline findings of a before-and-after study. Data was collected from 817 community members in Ebonyi State using interviewer-administered questionnaires and focus group discussions (FGDs). Data were analyzed using SPSS version 20 and thematic analysis. RESULTS: The majority of the respondents were females (73.8%) with a mean age of 36.08 ± 15.4. Most respondents (65.2%) had Insecticide-Treated Net (ITN) and fever in the past year (67.1%). Malaria (88.6%) was identified as the major health condition in the community. Majority (74.1%) knew infected mosquito bites as the cause of malaria while 61.1% and 71.5% were definitely sure that pregnant women and children were at risk for malaria. Sleeping under ITN (54.3%), clean environment (39.7%), and herbal medications (26.8%) were the main ways of malaria prevention cited. Only 18.4% of the participants rated their knowledge of IPTp as adequate, and only 9.3% knew the common drug names used for IPTp. The major perceived roles in malaria prevention in pregnancy were referral of pregnant women to the health facility, encouragement of household ITN use, and sustaining malaria-related projects. The majority of the participants (60.6%) strongly agreed that community-directed distribution of IPTp-SP will improve the prevention of malaria in pregnancy. Most (77.2%) considered community-directed distribution of IPTp acceptable, and 74.4% of the pregnant respondents preferred community to facility administration of IPTp. CONCLUSIONS: Malaria was recognized as a prevalent disease, but there was inadequate knowledge of malaria prevention in pregnancy notably intermittent preventive therapy. There was positive perception of roles in malaria prevention in pregnancy and high acceptability of community-directed distribution of IPTp. Community-level malaria control programs should utilize a whole-of-community approach to optimally engage and educate the community on malaria prevention in pregnancy as well as explore community distribution approach for IPTp.

Drotaverine to shorten the duration of labour in primigravidas: a randomised, double-blind, placebo-controlled trial.

Background: Drotaverine, a spasmolytic, has been found to have potential to achieve a reduction in the duration of labour and prevent prolonged labour. Objective: To compare the effects of intravenous drotaverine hydrochloride with placebo for shortening the duration of active phase of labour in primigravidas. Methods: A double-blind, placebo-controlled randomized trial of 246 primigravidas in active phase of labour at term was conducted. They were randomly (1:1 ratio) administered intravenous 2 ml (40mg) of drotaverine hydrochloride or 2 ml of Vitamin B complex as placebo. The primary outcome measure was the duration of active phase of labour. The secondary outcome measures were cervical dilatation rate, oxytocin augmentation rate, incidence of prolonged labour, labour pain scores, mode of delivery, maternal and neonatal outcomes. Results: The mean duration of active phase of labour (hour) was significantly lower in the drotaverine group compared to the control (drotaverine; 6.22 ± 2.41 vs placebo; 8.33 ± 3.56; p <0.001). Also, the cervical dilatation rate (cm/hr) was significantly faster in the drotaverine arm (drotaverine; 1.68 ± 1.02 versus placebo; 1.06 ± 0.53, p <0.001). There was a significantly higher probability of faster delivery among women who were given drotaverine (log-rank test, p < 0.001). The oxytocin augmentation rate, incidence of prolonged labour, labour pain scores, mode of delivery, maternal and neonatal outcomes were not significantly different among the groups. Conclusions: Drotaverine hydrochloride is effective in shortening the duration of active phase of labour without adverse maternal and neonatal outcomes. However, more evidence is needed to explore its role in active phase of labour among primigravid women. Trial registration number: PACTR201810902005232.

Disrespectful Maternity Care and Abuse During Childbirth: Exploring Perceptions and Experiences of Women Delivered at a Tertiary Hospital in Abakaliki, Nigeria.

Background: An important but little understood component of poor care that women receive during antenatal care and childbirth is disrespect and abuse perpetuated by health workers. Fear of experiencing disrespect and abuse has a negative influence on women's decision to seek care at health facility during pregnancy, labour and delivery. The objective of this study is to determine the prevalence, pattern and predictors of disrespect and abuse during labour and delivery. Methodology: This is a questionnaire-based cross-sectional study conducted from February 1, 2019, to July 31, 2019 among postnatal women delivered at Alex Ekwueme Federal University Teaching Hospital, Abakaliki. Data were analyzed using SPSS version 22. Results: The prevalence of disrespectful maternity care and abuse was 47.6%. The forms of disrespect and abuse experienced by the participants were detention in the health facility (40.2%), physical abuse (34.1%), non-dignified care (37.2%), non-consented care (20.1%), abandonment of care (18.9%), non-confidential care (25%) and discriminatory care (15.2%). Lack of companionship during delivery (AOR: 7.01, 95%CI: 1.27-4.49; p = 0.007), unbooked status (AOR: 2.37, 95%Cl: 0.31 - 0.92; p = 0.01) and rural residence (AOR = 4.52 95% CI: 2.33-8.75, P<0.0001) were factors associated with disrespect and abuse during childbirth. Conclusion: Disrespectful maternity care and abuse during childbirth among women seeking maternity care is still prevalent (47.6%) in our hospital. Educating health workers on the importance of respectful maternity care would ensure acceptable, quality and dignified care for all women seeking maternity care in our facility.

Prevalence and predictors of depression, anxiety, and stress symptoms among pregnant women during COVID-19-related lockdown in Abakaliki, Nigeria.

Background: Several studies have been published on the topic of COVID-19 and pregnancy over recent months. However, few studies have evaluated the impact of this pandemic on maternal mental health, particularly in low-resource settings. Aim: To determine the prevalence and predictors of COVID-19-related depression, anxiety and stress symptoms among pregnant women. Methods: This was a cross-sectional study that involved 456 pregnant women attending prenatal care at Abakaliki, Nigeria, during the COVID-19 lockdown. These patients were screened for psychological morbidities using the Depression Anxiety and Stress Scale-21 (DASS-21). Results: Severe and extremely severe depression were reported in 7.2% (n=33) and 6.4% (n=29) of participants, respectively. Analysis also revealed that 3.3% (n=15) and 7.7% (n=35) of women had severe and extremely severe anxiety, respectively. In total, 23% (n=105) of the participating women had severe stress while 16.7% (n=76) reported extremely severe stress. Multiparity (2-4) and occupation, such as trading and farming, were predictors of depression whereas grand-multiparity, urban residence, and trading, were identified as predictors of anxiety and stress. Conclusion: Symptoms of depression, anxiety and stress were relatively common among pregnant women during the COVID-19 lockdown in Abakaliki, Nigeria. There is a clear need to integrate screening for depression, anxiety and stress, in existing antenatal care programs so as to identify and prevent long-term adverse psychological outcomes related to the COVID-19 pandemic.

Spontaneous Ruptured Bilateral Tubal Ectopic Pregnancy Following Natural Conception: A Rare Case Report.

Ectopic pregnancy complicates 0.25%-2% of all pregnancies and is one of the most common causes of first-trimester maternal mortality in developing countries due to late diagnosis. Spontaneous ruptured bilateral tubal ectopic pregnancies are extremely rare, with very limited data on its occurrence in the literature. In a spontaneous conception, the preoperative diagnosis is difficult to make but an important one to consider at surgery for presumed unilateral tubal ectopic pregnancy because missing the diagnosis can lead to mortality. We report a case of a 38-year-old multipara with a history of amenorrhea of 8 weeks and 2 days and complaints of vaginal spotting of 4-day duration and sudden onset of abdominal pain of 4 h before presentation. On admission, a preoperative diagnosis of ruptured left tubal ectopic pregnancy was made following ultrasound findings of left adnexal mass and hemoperitoneum. However, both fallopian tubes were found to harbor ectopic gestational sac with bleeding rents on the tubal walls at surgery. She subsequently had exploratory laparotomy and bilateral salpingectomy with good outcome. In low-resource settings, ectopic pregnancy is associated with poor maternal outcome due to late presentation. Diagnosis of ruptured bilateral tubal ectopic pregnancy is difficult before surgery. Therefore, examination of both tubes at laparotomy for ectopic pregnancy should be routine and mandatory to avoid missing the diagnosis.

Determinants, reasons for choice and willingness to recommend birthing facility among mothers in public and private health facilities in Ebonyi, Nigeria.

INTRODUCTION: facility-based births remain low in Nigeria despite the enormous benefits on maternal and neonatal health. We compared the determinants, reasons for choice and willingness to recommend public and private birthing facilities among mothers in Ebonyi, Nigeria. METHODS: this was a cross-sectional survey among 620 women whose childbirth occurred in public (teaching) and private-for-profit mission hospitals in Ebonyi, Nigeria. Semi-structured, interviewer-administered questionnaires were used for data collection. RESULTS: the mean age of the respondents was 29.86±4.4. Most had post-secondary education (71.0%), more than 4 antenatal visits (83.4%) and vaginal births (77.7%). Respondents with high economic status [adjusted odds ratio (aOR) 2.88; Confidence Interval (CI) 1.98-4.18], post-secondary education (aOR 1.73; CI 1.13-2.64) and urban residence (aOR 3.51; CI 2.19-5.61) were more likely to utilize public birthing facilities. In the private hospital, religion (78.4%) was the commonest reason for utilization while poor quality of services (61.9%) was the major cause of dissatisfaction. In the public hospital, the main reason for patronage was insurance enrolment (73.2%) while negative provider attitude (66.7%) led to dissatisfaction. In both facilities, majority (92%) were willing to recommend their birth facility to others. CONCLUSION: regardless of facility type, respondents were willing to recommend or reuse the health facility for subsequent obstetric care. Religion and insurance enrolment were the major reasons for choosing the private and public hospital respectively. Residence, educational and income status influenced birthing facility type used. We recommend improved quality of services in private hospitals and provision of insurance with improved provider attitude in public health facilities.

Is the Training, Knowledge, and Perception of Maternal Health Providers Adequate for the Provision of Respectful Maternity Care? Policy Implications for Practice in a Nigerian Tertiary Hospital.

Background: Health providers play pivotal roles in achieving respectful maternity care (RMC). This study assessed the training, knowledge, and perception of respectful maternity care among maternal health providers in a Nigerian tertiary hospital. Methodology: This was across-sectional study conducted among 156 maternal health providers in Ebonyi Nigeria. Self-administered questionnaires were used for data collection. Results: The respondents had a mean age of 31.97±6. 8years. Females constituted 35.9% of the respondents while 25.6% were midwives. Less than half had received undergraduate (48.7%) and postgraduate (42.3%) training on RMC. The majority were aware (72.4%) and had good knowledge (78.8%) of respectful maternity care. Medical books (33.3%) was the major source of information on RMC. Most respondents (90.4%) desired more education on RMC. Over four-fifths (82.1%) had a positive perception of RMC. Only 27.6% of respondents agreed that mistreatment during childbirth was a common phenomenon in their clinical practice context. About three-fourths (76.6%) did not agree that mistreatment during childbirth was harmful to maternal health. Undergraduate training on RMC (AOR=0.33, 95% CI=0.13-0.81), postgraduate training on RMC (AOR=0.30, 95% CI=0.11-0.82) and higher monthly income (AOR=0.20 95% CI=0.05-0.88) were predictors of awareness of RMC. Knowledge of RMC was a predictor of perception about RMC (AOR=0.29, 95% CI=0.11-0.71). Conclusion: There was good awareness, knowledge and perception of RMC predicted by training exposures and income status However, gaps existed in the perception of the occurrence and consequences of mistreatment during childbirth. We recommend the inclusion of RMC training in both undergraduate and postgraduate medical training curricula.

Multi-stakeholder Perspectives on the Maternal, Provider, Institutional, Community, and Policy Drivers of Disrespectful Maternity Care in South-East Nigeria.

PURPOSE: Understanding the contextualized perspectives of stakeholders involved in maternal health care is critical to promoting respectful maternity care. This study explored maternal, provider, institutional, community, and policy level drivers of disrespectful maternity care in Southeast Nigeria. This study also identified multi-stakeholder perspectives on solutions to implementing respectful maternity care in health facilities. MATERIALS AND METHODS: This was a mixed-methods cross-sectional study conducted in two urban cities of Ebonyi State, South-eastern Nigeria. Data were collected using semi-structured questionnaires, focus group discussions, and key informant interviews with mothers, providers, senior facility obstetric decision-makers, ministry of health policymaker, and community members. Quantitative data and qualitative data were analysed using SPSS version 20 and manual thematic analysis, respectively. RESULTS: Maternal level drivers were poor antenatal clinic attendance, uncooperative clients, non-provision of birthing materials, and low awareness of rights. Provider factors included work overload/stress, training gaps, desire for good obstetric outcome, under-remuneration and under-appreciation. Institutional drivers were poor work environments including poorly designed wards for privacy, stressful hospital protocols, and non-provision of work equipment. Community-level drivers were poor female autonomy, empowerment, and normalization of disrespect and abuse during childbirth. The absence of targeted policies and the high cost of maternal health services were identified as policy-related drivers. CONCLUSION: A variety of multi-level drivers of disrespectful maternity care were identified. A diverse and inclusive multi-stakeholder approach should underline efforts to mitigate disrespectful maternity care and promote respectful, equitable, and quality maternal health care.

Efficacy of nifedipine versus hydralazine in the management of severe hypertension in pregnancy: A randomised controlled trial.

BACKGROUND: Despite the availability of effective antihypertensive drugs, the quality of evidence regarding the best antihypertensive agent for the treatment of hypertensive emergencies in pregnancy is still poor. AIM: The aim of this study was to compare the efficacy and side effects of oral nifedipine and intravenous hydralazine for control of blood pressure (BP) in severe hypertension in pregnancy. MATERIALS AND METHODS: An open-label, parallel, randomised, controlled trial of 78 pregnant women (≥28 weeks' gestation) with severe hypertension was conducted. Severe hypertension was defined as systolic BP of 160 mmHg or above and/or diastolic BP of 110 mmHg or above. They were randomly (1:1 ratio) administered oral nifedipine 20 mg or intravenous hydralazine 10 mg every 30 min up to 5 doses or until the target BP of 140-150 mmHg systolic and 90-100 mmHg diastolic was achieved. Intravenous labetalol was given if the primary treatment failed. The primary outcome measure was the number of doses needed to achieve targeted BP. The secondary outcome measures were the time needed to achieve desired BP, maternal adverse effects and perinatal outcome. RESULTS: The sociodemographic characteristics did not differ between the two study groups. The average number of dosages (nifedipine; 1.4 ± 0.6 vs. hydralazine; 1.7 ± 0.5, P = 0.008) needed to control the BP was lower in the nifedipine arm. Time (min) taken to control the BP was similar between the groups (hydralazine; 43.7 ± 19.7 vs. nifedipine; 51.2 ± 18.9, P = 0.113). Adverse maternal and perinatal effects did not differ in the study groups. CONCLUSION: Oral nifedipine and intravenous hydralazine showed comparable efficacy in the BP control in the severe hypertensive disorders of pregnancy without significant difference in adverse maternal and perinatal outcomes. However, further studies are required to explore the role of these drugs in BP control during hypertensive emergencies in pregnancy. CLINICALTRIALS.GOV: (Identification number: NCT04435210).