Maternal near-miss and death associated with abortive pregnancy outcome: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the prevalence of life-threatening complications related to pregnancies with abortive outcome and the associated health service events and performance in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy-related complications. METHODS: All cases of severe maternal outcomes (SMO: maternal near-miss or death) due to abortive pregnancy complications (defined as spontaneous or induced abortion, and ectopic pregnancy) were prospectively identified over 1 year using uniform identification criteria. MAIN OUTCOME MEASURES: Prevalence of SMO, mortality index (% maternal death/SMO), case fatality rate, time until death after admission, and health service performance. RESULTS: Of 5779 women admitted with abortive pregnancy complications, 444 (7.9%) experienced an SMO: 366 maternal near-misses and 78 maternal deaths. Intra-hospital maternal mortality ratio from complicated abortive pregnancy outcome was 85/100 000 live births. Case fatality rate was worst for abortion-related infections (19.1%). A quarter of maternal deaths occurred on the same day of admission; however, the peak time of occurrence of death was 3-7 days of admission. Women experiencing cardiovascular, renal or coagulation organ dysfunction were less likely to survive. Higher level of maternal education and closer residence to a health facility improved chance of maternal survival. CONCLUSIONS: Abortive outcome remains a major contributor to SMO in Nigeria. Although early hospital presentation by women is critical to surviving abortive pregnancy complications, improved, appropriate, and timely management is essential to enhance maternal survival. TWEETABLE ABSTRACT: 78 maternal deaths and 366 near-misses occurred from abortions and ectopic pregnancies in 42 Nigerian referral hospitals in 1 year.

Cigarette smoking and perception of its advertisement among antenatal clinic attendees in referral health facilities in Enugu, Nigeria.

BACKGROUND: The most predominant form of tobacco use is cigarette smoking, and it poses serious threats to maternal and child health. The magnitude of cigarette smoking in pregnancy in our environment is not well-known. The study aimed to determine the prevalence of cigarette smoking among pregnant women in Enugu, Nigeria as well as their exposures and perceptions of cigarette smoking advertisement. MATERIALS AND METHODS: Questionnaires were administered to a cross-section of pregnant women randomly selected from three hospitals in Enugu, South-East Nigeria, from May 2, 2012 to June 12, 2012. Analysis was both descriptive and inferential at 95% confidence levels. RESULTS: The prevalence of tobacco smoking in pregnancy was 4.5% (9/200). Over 90% of respondents admitted that cigarette smoking could harm both mother and unborn baby. In all, 79.5% (159/200) of respondents had seen or heard of advertisement for cigarette smoking as against 82.5% (165/200) that had seen or heard of antismoking advertisement (P = 0.444, odds ratio = 1.2 [95% confidence intervals: 0.74, 2.00]). CONCLUSIONS: The prevalence of cigarette smoking in pregnancy in Enugu, Nigeria was low, and there was high exposure to both pro-and anti-smoking advertisement. The awareness of harmful health effect of smoking was high but, that of the specific diseases associated with smoking in pregnancy was limited. Hence, antenatal classes and antismoking advertisement should be scaled-up to include maternal and peri-natal diseases/conditions associated with cigarette smoking.

Current approaches for assessment and treatment of women with early miscarriage or ectopic pregnancy in Nigeria: a case for dedicated early pregnancy services.

CONTEXT: It has been suggested that women with early miscarriage or ectopic pregnancy are best cared for in dedicated units which offer rapid and definitive ultrasonographic and biochemical assessment at the initial review of the patient. AIMS: To describe the current protocols for the assessment and treatment of women with early miscarriage or ectopic pregnancy as reported by Nigerian Gynecologists, and determine if dedicated early pregnancy services such as Early Pregnancy Assessment Units could be introduced to improve care. SETTINGS AND DESIGN: A cross-sectional survey of Nigerian Gynecologists attending the 46 th Annual Scientific Conference of the Society of Gynaecology and Obstetrics of Nigeria. MATERIALS AND METHODS: This was a questionnaire-based study. STATISTICAL ANALYSIS: Data analysis was by descriptive statistics using Statistical Package for the Social Sciences software, version 17.0 for Windows (IBM Corporation, Armonk, NY, USA). RESULTS: A total of 232 gynecologists working in 52 different secondary and tertiary health facilities participated in the survey. The mean age of the respondents was 42.6 ± 9.1 years (range 28-70 years). The proportion of gynecologists reporting that women with early miscarriage or ectopic pregnancy were first managed within the hospital general emergency room was 92%. The mean reported interval between arrival in hospital and first ultrasound scan was 4.9 ± 1.4 hours (range ½-8 hours). Transvaginal scan was stated as the routine initial imaging investigation by only 17.2% of respondents. Approximately 94.8% of respondents felt that dedicated early pregnancy services were feasible and should be introduced to improve the care of women with early miscarriage and ectopic pregnancy. CONCLUSIONS: Reported protocols for managing early miscarriage or ectopic pregnancy in many health facilities in Nigeria appear to engender unnecessary delays and avoidable costs, and dedicated early pregnancy services could be both useful and feasible in addressing these shortcomings in the way women with such conditions are currently managed.

Risks associated with subsequent pregnancy after one caesarean section: A prospective cohort study in a Nigerian obstetric population.

CONTEXT: Aversion for cesarean delivery is common in our practice and risks associated with caesarean section may contribute to this phenomenon. OBJECTIVE: The objective of this study was to estimate the risks associated with subsequent pregnancies in women with one previous cesarean section in a low resource setting. SETTING AND DESIGN: A prospective cohort study carried out at two major tertiary maternity centers in Enugu. MATERIALS AND METHODS: Maternal and perinatal outcomes were compared between women with one previous caesarean and women who had only previous vaginal deliveries. STATISTICAL ANALYSIS USED: Analysis was performed with SPSS statistical software version 17.0 for windows (IBM Incorporated, Armonk, NY, USA) using descriptive and inferential statistics at 95% of the confidence level confidence. RESULTS: A total of 870 women were studied. These were divided into 435 cases and 435 controls. The absolute risk of cesarean section in a subsequent pregnancy in women with one previous cesarean was 75.8% (95% confidence interval [CI]: 72.0, 80.0). Cesarean section was significantly commoner in women with one previous cesarean compared with those who had previous vaginal delivery (Relative risk [RR] =3.78; 95% CI: 1.8, 6.2). Placenta praevia (RR = 5.0; 95% CI: 2.6, 7.2.), labor dystocia (RR = 6.4, 95% CI: 3.2, 11.2) intrapartum hemorrhage (RR = 5.0, 95% CI: 2.1, 9.3) primary postpartum hemorrhage (RR = 5.0, 95% CI: 1.5, 4.3.), blood transfusion (RR = 6.0, 95% CI: 3.4, 10.6) and Newborn special care admission (RR = 2.5; 95% CI: 1.1, 4.9) were significantly more common in women with one previous cesarean compared with those with previous vaginal deliveries. The absolute risk of failed trial of vaginal birth after a cesarean was 45% (95% CI: 38.5, 51.5). CONCLUSION: Women who have one previous C-section face a markedly increased risk of repeat caesarean sections and feto-maternal complications in subsequent pregnancies. There is a need for doctors in Nigeria to be mindful of these risks while offering primary cesarean section in this low resource setting.

Reducing maternal deaths in a low resource setting in Nigeria.

OBJECTIVE: To assess the impact of the adoption of evidence based guidelines on maternal mortality reduction at Enugu State University Teaching Hospital, Nigeria. MATERIALS AND METHODS: A retrospective review of all maternal deaths between 1 st January, 2005 and 31 st December, 2010 was carried out. Evidence based management guidelines for eclampsia and post-partum hemorrhage were adopted. These interventions strategy were carried out from 1 st January, 2008-31 st December, 2010 and the result compared with that before the interventions (2005-2007). MAIN OUTCOME MEASURE: Maternal mortality ratio (MMR) and case fatality rates. RESULTS: There were 9150 live births and 59 maternal deaths during the study period, giving an MMR of 645/100 000 live births. Pregnant women who had no antenatal care had almost 10 times higher MMR. There was 43.5% reduction in the MMR with the interventions (488 vs. 864/100 000 live births P = 0.039, odds ratio = 1.77). There was also significant reduction in case fatality rate for both eclampsia (15.8% vs. 2.7%; P = 0.024, odds ratio = 5.84 and Post partum hemorrhage (PPH) (13.6% vs. 2.5% P value = 0.023, odds ratio = 5.5. Obstetric hemorrhage was the most common cause of death (23.73%), followed by the eclampsia. CONCLUSION: Administration of evidence based intervention is possible in low resource settings and could contribute to a significant reduction in the maternal deaths.

The role of ultrasonography in in-vitro fertilization and embryo transfer (IVF-ET).

BACKGROUND: Although ultrasonography was introduced into Obstetrics and Gynaecology by a British Gynaecologist over five decades ago, the requirements for formal training in its use by gynecologists in Nigeria is just beginning to catch on, despite its indispensible role in various aspects of our clinical practice. OBJECTIVE: To describe the role of ultrasonography in in-vitro fertilization and the indispensability of the instrument to reproductive medicine. METHOD: A review of literature written in English language on the use and application ofultrasonography. in in-vitro fertilization was done. The review covered articles published between 1980-2012. RESULTS: Ultrasound is the most versatile method for pre-treatment assessment in IVF being the dominant instrument for assessing ovarian reserve, pelvic pathologies and for assessing the uterine cavity. The ability of ultrasonography to measure endometrial thickness in addition to detecting uterine masses gives it an edge over laparoscopy/hysteroscopy as a diagnostic procedure in uterine cavity assessment, although hysteroscopy has the advantage of therapeutic potential. Similarly, ultrasonography is superior to biochemical methods for follicular monitoring because of its ability to demonstrate the number and sizes of follicles, and guide preparations for oocyte retrieval. The relative ease of ultrasound guided oocyte retrieval; its less technical demands and the possibility of conducting the procedure under local anaesthesia have made ultrasound guided oocyte retrieval more popular across the world. Randomized controlled trials show that ultrasound-guided transfer techniques have better outcomes than the clinical touch technique in terms of on-going pregnancies and Clinical pregnancies. Ultrasonography is now the key instrument for diagnosing and monitoring pregnancy following embryo transfer, biochemical methods being complimentary. CONCLUSION: Ultrasonography is now the single most important instrument in in-vitro fertilization .programmes and gynaecologists with interest in reproductive medicine need necessarily to obtain a formal training in its use.

Perception and care-seekling behaviour for post partum morbidity among mothers in Enugu south east, Nigeria.

BACKGROUND: Postpartum Care is necessary to monitor and ensure return to normal of some physiological changes that occurred during pregnancy and delivery, and any abnormalities detected should be treated. The aim of this study is to describe the perception of and care seeking behaviour for maternal morbidity following childbirth among mothers in Enugu, Nigeria and determine if they depend on the socio-demographic characteristics ofmothers. METHODS: A cross-sectional survey of women who had recent deliveries was done. Quantitative and qualitative methods of data collection were used. Data analysis was by descriptive and inferential statistics at 95% level of confidence and manual content analysis. RESULTS: Three hundred and seventy-one respondents who had, at least, one self-reported morbidity following childbirth were studied. Only approximately 43.1% perceived their symptoms as abnormal and 39.5% sought medical attention for their symptoms. Inaccurate perception was influenced by the severity of symptoms as well as cultural beliefs on what constitutes abnormal symptoms following childbirth. Correct perception of morbidity was dependent on maternal age (p = 0.002) and educational status (p = 0.004) whereas positive care seeking behaviour was dependent on area of residence (p = 0.03). A greater proportion of mothers aged 30 years or below had accurate perception compared to older mothers (p = 0.02). A greater proportion of rural dwellers sought medical attention for their symptoms compared to urban dwellers. CONCLUSION: Inaccurate perception of, and poor care seeking behaviour for postpartum morbidity were common among a sample of women with recent deliveries in Enugu due largely to cultural beliefs about morbidity following childbirth. Correct perception and positive care seeking behaviour were not enhanced by older age, greater educational attainment of mothers or residence in urban areas.

Obstetric outcome following free maternal care at Enugu State University Teaching Hospital (ESUTH), Parklane, Enugu, South-eastern Nigeria.

This study aims to determine the impact of free maternal care on the utilisation of the available delivery services and to evaluate the obstetric outcome. All deliveries at ESUTH, Parklane within the 4 months of free maternal care from 1 September to 31( )December 2008 were studied and compared with deliveries that took place 4 months before and after the free services. The results were analysed using Epi-info statistical software version 3:2:2. There was an 88% rise in the number of deliveries with the introduction of free maternal services and a 30% drop within 4 months of its termination. The maternal mortality ratio (MMR) dropped slightly, but morbidity increased significantly, as well as stillbirth rate (77/1,000 births), especially intrapartum stillbirth. Cost barrier limits women's access to healthcare in developing countries and must be addressed if we aim to achieve Millennium Development Goals (MDGs) 4 and 5.

Maternal mortality in a transitional hospital in Enugu, south east Nigeria.

Nigeria has one of the highest maternal mortality ratios in the world. The study was to determine the trend of maternal mortality ratio in the hospital as it transits from a General through a Specialist to a Teaching hospital. It was a retrospective review of maternal deaths at Enugu State University Teaching Hospital Parklane, over its 5 year transition period (January 2004 to December 2008). There were 7146 live births and 60 maternal deaths giving an overall maternal mortality ratio (MMR) of 840/100,000 livebirths. The MMR rose from 411 to 1137/100,000 live births as a specialist hospital, with a decline to 625/100,000 as a Teaching hospital. Pre-eclampsia/eclampsia was the leading cause (29.63%) of maternal death. MMR was highest as a Specialist hospital due to limited manpower and inadequate facilities to properly manage the rising number of referred obstetric emergencies. Adequate preparations should be made before upgrading a hospital, to enable it cope with the challenges of managing referred obstetric emergencies

Risk factors for hepatitis B infection during pregnancy in a Nigerian obstetric population.

We aimed to assess the risk factors for hepatitis B infection among pregnant women in Enugu, southeast Nigeria. This was a prospective case-control study of risk factors for hepatitis B surface antigen positivity among pregnant women seen in two tertiary health institutions in Enugu, southeast Nigeria. It was carried out over an 8-month period, January - August 2005. Of the 1,499 pregnant women attending the antenatal clinic, 4.6% (n = 69) were seropositive for hepatitis B surface antigen. A total of 35 (50.7%) HBsAg positive women and 71 negative controls were interviewed. The risk factors for HBsAg were present in 71% (n = 25) of the positive cases, while only 27% (n = 19) of the negative cases had risk factors. The significant risk factors for HBsAg positivity were higher mean parity, higher number of sexual partners since sexual debut, polygamy and previous positive history of sexually transmitted diseases (STD) (p < 0.05). The two groups did not differ with respect to presence of tattoo or scarification marks, positive history of jaundice or contact with a jaundiced patient, previous blood transfusion or contact with blood products, intravenous drug abuse or sharing personal instruments (p > 0.05). Screening pregnant women for hepatitis B infection on the basis of presence of risk factors may not effective. Universal antenatal screening for HBsAg, health education aimed at reducing risk factors and immunisation of all newborn and those at risk of hepatitis B is advocated.

Gynaecologic mortality in Enugu, Nigeria.

A retrospective review of 79 deaths in 2033 gynaecologic admissions at a referral centre showed that the leading causes of mortality were cervical cancer, choriocarcinoma, septic abortion and ovarian cancer, in that order. The results suggest a need for an organized cancer programme to limit morbidity and mortality from malignant disease of the female genital tract.

Five-year experience with depot medroxy progesterone acetate injectable contraception.

BACKGROUND: The objective of this article is to describe the characteristics and experiences of clients who used depot medroxy progesterone acetate for contraception. METHODS: A retrospective review of family planning records of clients who used depo-provera between 1992 and 1996 at the family planning clinic of University of Nigerian Teaching Hospital, Enugu. RESULTS: The mean age of clients was 32.7 +/- 5.2 years. Over 71% of clients had five or more children. Clients with no education (78.7%) or primary education (75.1%) were more likely to be grand-multiparous compared to women with at least secondary education (49.6%). Among clients with 1-4 living children, 81.3% used depo-provera for child spacing. Among those with 5-8 living children, 48.8% used it for child spacing. Menstrual abnormalities were the main complications but the commonest reason given for discontinuation was "husband's wish". The continuation rate at 36 months was 82.7%. CONCLUSION: Depot medroxy progesterone acetate is an acceptable and effective method of contraception. The involvement of men in family planning programmes cannot be over-emphasised as they significantly influence the decision of women regarding contraceptive use.

Nigerian male sexual activity during pregnancy.

OBJECTIVES: To determine the prevalence of extra-marital sexual affairs as well as other aspects of male sexual behavior during pregnancy in Nigeria. METHODS: A questionnaire survey of the husbands of consecutive women who delivered in three tertiary care centers in south-eastern Nigeria within an 8-week period. The data were analyzed by means of simple percentages and descriptive and inferential statistics, using t-tests, chi-square tests and regression equations at the 95% confidence level. RESULTS: 279 (88.3%) of the 316 eligible husbands responded to the questionnaire. A total of 78 (28.0%) of the respondents engaged in extra-marital sexual relationships during pregnancy. Of the respondents, 36.6% and 32.3% experienced a decrease in achievement of erection and orgasm, respectively. While libido decreased in 41.9%, coital frequency declined in 72.4% of the respondents. On univariate analysis, respondent's age > or = 40 years, duration of marriage > or = 5 years, having an extra-marital sexual partner and beliefs that coitus during pregnancy should be less frequent or can cause miscarriage were significant predictors of reduced coital frequency while a belief that coitus enhances fetal well-being was a significant predictor of increased coital frequency during pregnancy (P<0.05 for each variable). On multivariate logistic regression, three factors were statistically significant predictors of reduced coital frequency - age > or = 40 years (OR=2.3; 95% C.I., 1.9-2.3) and beliefs that coitus during pregnancy can cause miscarriage (OR=1.9; 95% C.I., 1.5-2.3) and should be less frequent (OR=1.9; 95% C.I., 1.8-2.5). CONCLUSIONS: Personal beliefs significantly affect sexual relationships between Nigerian husbands and their pregnant wives, making approximately one-third of husbands engage in extra-marital relationships as a way to satisfy their unmet sexual need during pregnancy. There is a need to educate husbands and their pregnant wives on sexual matters during pregnancy.

The knowledge, attitude and practice of child adoption among infertile Nigerian women.

To determine the knowledge, attitude and practice of child adoption among infertile Nigerian women we undertook a questionnaire survey of 279 consecutive infertile women seen in three tertiary care centres in South Eastern Nigeria within a 9-month period. The data were analysed by means of simple percentages and descriptive and inferential statistics, using t-tests, chi-square tests and regression equations at the 95% confidence level. Two hundred and sixty-four questionnaires were analysed. Although 228 (86.4%) of the respondents were aware of child adoption, only 72 (27.3%) knew its correct meaning. Fifty-seven (21.6%) women knew how to adopt a baby while the rest did not; 183 (69.3%) respondents expressed their unwillingness to adopt a baby while the remaining 81 (30.7%) were willing. Twelve (14.8%) of these 81 respondents (or 4.5% of all respondents) had either adopted or made an effort to adopt a child at the time of the study. The major reasons given by the 183 respondents unwilling to adopt a child were: adoption not a solution to their infertility (84 respondents); adoption psychologically unacceptable (78 respondents); fear of unknown parental background (75 respondents) and abnormal behaviour in the child (75 respondents). Univariate analysis showed six factors significantly associated with a favourable attitude to child adoption: a correct knowledge of the meaning of adoption (P=0.00007), duration of infertility >5 years (P=0.0002), previous orthodox specialist treatment (P=0.0002), tubal infertility (P=0.002), no living child (P=0.02) and maternal age >35 years (P=0.03). In a multiple logistic regression involving these six factors, with attitude to adoption as the dependent variable, two factors were associated significantly with a favourable attitude to adoption: correct knowledge of the meaning of adoption (OR=1.9, P=0.04) and previous orthodox specialist treatment (OR=2.9, P=0.05). Although the majority of infertile Nigerian women have heard of child adoption, only a minority knew its real meaning, its legality and the process it entails. Approximately one-third of them were disposed favourably to adoption as a treatment option for their infertility. The Nigerian experience was compared and contrasted with the experiences of other countries. Factors associated with a favourable attitude to adoption were presented and discussed. In the presence of such factors, especially when the probability of cure of infertility is small, child adoption as a treatment option should be offered early so that willing couples can initiate the processes.