Incidence and risk factors for herpes simplex virus type 2 seroconversion among pregnant women in Uganda: A prospective study.

INTRODUCTION: Herpes simplex virus type 2 (HSV-2) acquired during pregnancy is associated with adverse outcomes such as perinatal HSV-2 transmission. HSV-2 seroconversion occurs within four weeks of HSV-2 acquisition. There was neither documented incidence nor risk factors for HSV-2 seroconversion during pregnancy in Uganda. The objective of this study was to determine the incidence and risk factors for HSV-2 seroconversion among pregnant women in Mulago Hospital, Uganda. METHODOLOGY: A prospective study of 200 consenting HSV-2-negative women between 26 and 28 weeks of gestation was done between November 2013 and October 2014. HSV-2 serostatus was determined using HerpeSelect HSV-2 enzyme-linked immunosorbent assay (ELISA). Interviewer-administered questionnaires were used to collect socio-demographic characteristics and sexual history. Human immunodeficiency virus (HIV) serostatus was obtained from antenatal records. A total of 191 women completed follow-up and repeat HSV-2 serology by 38 weeks. Negative binomial regression analysis was used to estimate risk ratios for risk factors for HSV-2 seroconversion. RESULTS: Of 191 women, 15 (7.9%) seroconverted during pregnancy. Having multiple sexual partners, being in polygamous unions, and having HIV-positive serostatus were found to be risk factors for HSV-2 seroconversion. CONCLUSIONS: The incidence of HSV-2 seroconversion during pregnancy in Uganda was high. Multiple sexual partners, polygamy, and HIV-positive serostatus were risk factors for HSV-2 seroconversion during pregnancy. Strengthening health education on the avoidance of multiple sexual partners during pregnancy is paramount in prevention of HSV-2 seroconversion.

Genital infections and risk of premature rupture of membranes in Mulago Hospital, Uganda: a case control study.

BACKGROUND: Inflammatory mediators that weaken and cause membrane rupture are released during the course of genital infections among pregnant women. We set out to determine the association of common genital infections (Trichomonas vaginalis, syphilis, Neisseria gonorrhea, Chlamydia trachomatis, Group B Streptococcus, Bacterial vaginosis, Herpes Simplex Virus Type 2 and candidiasis) and premature rupture of membranes in Mulago hospital, Uganda. METHODS: We conducted an unmatched case-control study among women who were in the third trimester of pregnancy at New Mulago hospital, Uganda. The cases had PROM and the controls had intact membranes during latent phase of labour in the labour ward. We used interviewer-administered questionnaires to collect data on socio-demographic characteristics, obstetric and medical history. Laboratory tests were conducted to identify T. vaginalis, syphilis, N. gonorrhea, C. trachomatis, Group B Streptococcus, Bacterial vaginosis, Herpes Simplex Virus Type 2 (HSV-2) and candidiasis. Logistic regression models were used to estimate the odds ratios (OR) and 95% CI of the association between genital infections and PROM. RESULTS: There was an association between PROM and abnormal vaginal discharge (OR = 2.02, 95% CI 1.10-3.70 and AOR = 2.30, 95% CI 1.18-4.47), presence of candidiasis (OR = 0.27, 95% CI 0.14-0.52 and AOR = 0.22, 95% CI 0.10-0.46) and T. vaginalis (OR = 2.98, 95% CI 1.18-7.56 and AOR = 4.22, 95% CI 1.51-11.80). However, there was no association between PROM and presence of C. trachomatis (OR = 2.05, 95% CI 0.37-11.49) and HSV-2 serostatus (OR = 1.15, 95% CI 0.63-2.09). Few or no patients with Bacterial vaginosis, Neisseria gonorrhoea, Group B streptococcus or syphilis were identified among the cases and controls. Co-infection of Trichomoniasis and candidiasis was not associated with PROM (AOR = 1.34, 95% CI 0.16-11.10). Co infection with T. vaginalis and C. trachomatis was associated with PROM (OR = 3.09, 95% CI 1.21-7.84 and AOR = 4.22, 95% CI 1.51-11.83). CONCLUSION: Trichomonas vaginalis alone, T. vaginalis with C. trachomatis co-infection and abnormal per vaginal discharge were found as risk factors for PROM. There was no association of HSV-2 serostatus, syphilis, N. gonorrhea, C. trachomatis, Group B Streptococcus and Bacterial vaginosis with PROM. Candidiasis seemed to have a protective effect on PROM.

The MamaMiso study of self-administered misoprostol to prevent bleeding after childbirth in rural Uganda: a community-based, placebo-controlled randomised trial.

BACKGROUND: 600 mcg of oral misoprostol reduces the incidence of postpartum haemorrhage (PPH), but in previous research this medication has been administered by health workers. It is unclear whether it is also safe and effective when self-administered by women. METHODS: This placebo-controlled, double-blind randomised trial enrolled consenting women of at least 34 weeks gestation, recruited over a 2-month period in Mbale District, Eastern Uganda. Participants had their haemoglobin measured antenatally and were given either 600 mcg misoprostol or placebo to take home and use immediately after birth in the event of delivery at home. The primary clinical outcome was the incidence of fall in haemoglobin of over 20% in home births followed-up within 5 days. RESULTS: 748 women were randomised to either misoprostol (374) or placebo (374). Of those enrolled, 57% delivered at a health facility and 43% delivered at home. 82% of all medicine packs were retrieved at postnatal follow-up and 97% of women delivering at home reported self-administration of the medicine. Two women in the misoprostol group took the study medication antenatally without adverse effects. There was no significant difference between the study groups in the drop of maternal haemoglobin by >20% (misoprostol 9.4% vs placebo 7.5%, risk ratio 1.11, 95% confidence interval 0.717 to 1.719). There was significantly more fever and shivering in the misoprostol group, but women found the medication highly acceptable. CONCLUSIONS: This study has shown that antenatally distributed, self-administered misoprostol can be appropriately taken by study participants. The rarity of the primary outcome means that a very large sample size would be required to demonstrate clinical effectiveness. TRIAL REGISTRATION: This study was registered with the ISRCTN Register (ISRCTN70408620).

Vaccines against human papillomavirus in low and middle income countries: a review of safety, immunogenicity and efficacy.

Currently, there is limited data on the immunogenicity and efficacy of human papillomavirus vaccines in Low and Middle income countries (LMIC). The review aims to summarize the current status from published HPV vaccine safety, immunogenicity and efficacy studies in low and middle income countries (LMIC). Electronic databases (PubMed/MEDLINE and HINARI) were searched for peer reviewed English language articles on HPV vaccination in LMIC that have so far been published from 1st January 2006 up to 30th January 2015. Eligible studies were included if they had used the bivalent (bHPV) or quadrivalent HPV (qHPV) vaccines in a LMIC and investigated safety, immunogenicity and/or efficacy. The main findings were extracted and summarized. A total of fourteen HPV vaccine studies assessing safety, Immunogenicity and efficacy of the bivalent or quadrivalent vaccines in LMIC were included. There are only ten published clinical trials where a LMIC has participated. There was no published study so far that assessed efficacy of the HPV vaccines in Sub-Saharan Africa. From these studies, vaccine induced immune response was comparable to that from results of HICs for all age groups. Studies assessing HPV vaccine efficacy of the bivalent or quadrivalent vaccine within LMIC were largely missing. Only three studies were found where a LMIC was part of a multi center clinical trial. In all the studies, there were no vaccine related serious adverse events. The findings from the only study that investigated less than three doses of the bivalent HPV-16/18 vaccine suggest that even with less than three doses, antibody levels were still comparable with older women where efficacy has been proven. The few studies from LMIC in this review had comparable safety, Immunogenicity and efficacy profiles like in HIC. Overall, the LMIC of Africa where immune compromising/modulating situations are prevalent, there is need for long term immunogenicity as well as surveillance studies for long term clinical effectiveness after two and three dose regimens.

The levels of anti-HPV16/18 and anti-HPV31/33/35/45/52/58 antibodies among AS04-adjuvanted HPV16/18 vaccinated and non-vaccinated Ugandan girls aged 10-16 years.

BACKGROUND: Data on Human Papilloma virus (HPV) vaccine immune response in sub-Saharan Africa is still sparse yet such knowledge is critical for optimal implementation and monitoring of HPV vaccines. Our primary objective was to evaluate levels of anti-HPV-16/18 antibodies and six other 'high risk' HPV (hrHPV) types among the vaccinated and unvaccinated Ugandan girls. METHODS: We conducted a cross sectional study among AS04-adjuvanted HPV-16/18 vaccinated and unvaccinated school girls aged 10-16 years in Western Uganda using purposive sampling. The vaccinated girls were at 18 months post vaccination. After consenting and assenting, data was collected using interviewer administered questionnaires for demographics and sexual history. Blood was drawn from which serum samples were analysed by the multiplex HPV serology technology to determine anti-HPV antibody levels to HPV-16/18 and six other hrHPV types (31, 33, 35, 45, 52 and 58). The antibody levels were expressed as Median Fluorescent Intensity (MFI). A total of 207 vaccinated [mean age 13.1 years (SD 1.5); range 10-16 years] and 197 unvaccinated girls [mean age 13.6 years (SD 1.3); range 10-16 years] participated in the study. Sexual activity was self reported among 14/207 (6.8%) vaccinated and 5/197 (2.5%) unvaccinated girls. The MFI levels for HPV-16 and HPV-18 were 15 and 20 times higher respectively in the vaccinated girls than in the unvaccinated girls. HPV-16 mean MFI level was 4691(SD 1812; 95% CI: 4438-4958) among the vaccinated compared to 218 (SD 685; 95% CI: 190-252) among the unvaccinated girls. For HPV-18 the mean MFI level was 1615 (SD 1326; 95% CI: 1470-1776) among the vaccinated compared to MFI 103 (SD 506; 95% CI: 88 -121) among unvaccinated girls. In addition antibody levels to non vaccine hrHPV types (31, 33, 35, 45, 52 and 58) were all significantly higher in the vaccinated group than in the unvaccinated group (p<0.01). CONCLUSION: The AS04-Adjuvanted HPV-16/18 vaccinated girls showed a higher level of antibodies to HPV-16/18 and other non-vaccine hrHPV types compared to the unvaccinated girls. This may translate into protection against HPV-16/18 and other hrHPV types.

Nevirapine-based antiretroviral therapy does not reduce oral contraceptive effectiveness.

OBJECTIVE: To evaluate the effect of nevirapine-containing antiretroviral therapy (ART) on combined oral contraceptive (COC) effectiveness. DESIGN: Nonrandomized prospective clinical trial. METHODS: We enrolled HIV-infected women aged 18-35 years in South Africa and Uganda who had regular menses, were sexually active, and had no medical contraindications to COC use. We enrolled 196 women taking nevirapine-containing ART and 206 women not yet eligible for ART as a control group. We treated all participants with low-dose COCs. Our main outcomes were ovulation and pregnancy rates. We estimated ovulation in the first two cycles using weekly serum progesterone and tested for pregnancy monthly for 24 weeks. RESULTS: The median age of participants was 29 and their median CD4 cell count was 486. In the ART group, 43 of 168 (26%) ovulated in cycle 1, 30 of 163 (18%) in cycle 2, and 18 of 163 (11%) in both cycles. In the non-ART group, 26 of 168 (16%) ovulated in cycle 1, 31 of 165 (19%) in cycle 2, and 20 of 165 (12%) in both cycles. We found no significant difference in ovulation rates between groups: unadjusted odds ratio 1.36 (95% confidence interval 0.85-2.18). Pregnancy rates also did not differ: 10.0 per 100-women-years in the ART group and 10.1 per 100-women-years in the non-ART group. Self-reported COC adherence, condom use, vaginal bleeding, and adverse events were similar. Five serious adverse events were reported, all in the non-ART group. CONCLUSION: ART use did not affect risk of ovulation or pregnancy in women taking COCs, suggesting that nevirapine-containing ART does not interfere with COC contraceptive effectiveness.

Prevalence, incidence and risk factors for anogenital warts in Sub Saharan Africa: a systematic review and meta analysis.

INTRODUCTION: The quadrivalent HPV vaccine is highly effective in primary prevention of anogenital warts (AGWs). However, there is lack of systematic review in the literature of the epidemiology of AGWs in Sub Saharan Africa (SSA). OBJECTIVE: To review the prevalence, incidence and risk factors for AGWs in SSA prior to the introduction of HPV vaccination programs. METHODS: PubMed/MEDLINE, Africa Index Medicus and HINARI websites were searched for peer reviewed English language published medical literature on AGWs from January 1, 1984 to June 30, 2012. Relevant additional references cited in published papers were also evaluated for inclusion. For inclusion, the article had to meet the following criteria (1) original studies with estimated prevalence and/or incidence rates among men and/or women (2) detailed description of the study population (3) clinical or self-reported diagnosis of AGWs (4) HPV genotyping of histologically confirmed AGWs. The final analysis included 40 studies. Data across different studies were synthesized using descriptive statistics for various subgroups of females and males by geographical area. A meta - analysis of relative risk was conducted for studies that had data reported by HIV status. RESULTS: The prevalence rates of clinical AGWs among sex workers and women with sexually transmitted diseases (STDs) or at high risk of sexually transmitted infection (STIs) range from 3.3% - 10.7% in East, 2.4% - 14.0% in Central and South, and 3.5% - 10.5% in West African regions. Among pregnant women, the prevalence rates range from 0.4% - 3.0% in East, 0.2% - 7.3% in Central and South and 2.9% in West African regions. Among men, the prevalence rates range from 3.5% - 4.5% in East, 4.8% - 6.0% in Central and South and 4.1% to 7.0% in West African regions. In all regions, the prevalence rates were significantly higher among HIV+ than HIV- women with an overall summary relative risk of 1.62 (95% CI: 143-1.82).The incidence rates range from 1.1 - 2.7 per 100 person-years among women and 1.4 per 100 person years among men. Incidence rate was higher among HIV+ (3.0 per 100 person years) and uncircumcised men (1.7 per 100 person-years) than circumcised men (1.3 per 100 person-years).HIV positivity was a risk factor for AGWs among both men and women. Other risk factors in women include presence of abnormal cervical cytology, co-infection with HPV 52, concurrent bacteria vaginoses and genital ulceration. Among men, other risk factors include cigarette smoking and lack of circumcision. CONCLUSIONS: AGWs are common among selected populations particularly HIV infected men and women. However, there is need for population-based studies that will guide policies on effective prevention, treatment and control of AGWs.

Universal routine HPV vaccination for young girls in Uganda: a review of opportunities and potential obstacles.

This article reviews the existing realities in Uganda to identify opportunities and potential obstacles of providing universal routine HPV vaccination to young adolescent girls. Cervical cancer is a public health priority in Uganda where it contributes to about 50-60% of all female malignancies. It is associated with a dismal 5-year relative survival of approximately 20%. With adequate financial resources, primary prevention through vaccination is feasible using existing education and health infrastructure. Cost-effectiveness studies show that at a cost of US$2 per dose, the current vaccines would be cost effective. With optimal (≥70%) coverage of the target population, the lifetime risk of cervical cancer could be reduced by >50%. Uganda fulfils 4 out of the 5 criteria set by the WHO for the introduction of routine HPV vaccination to young adolescent girls. The existing political commitment, community support for immunization and the favorable laws and policy environment all provide an opportunity that should not be missed to introduce this much needed vaccine to the young adolescent girls. However, sustainable financing by the government without external assistances remains a major obstacle. Also, the existing health delivery systems would require strengthening to cope with the delivery of HPV vaccine to a population that is normally not targeted for routine vaccination. Given the high incidence of cervical cancer and in the absence of a national screening program, universal HPV vaccination of Ugandan adolescent girls is critical for cervical cancer prevention.

Epidemiology of HPV genotypes in Uganda and the role of the current preventive vaccines: A systematic review.

BACKGROUND: Limited data are available on the distribution of human papillomavirus (HPV) genotypes in the general population and in invasive cervical cancer (ICC) in Uganda. Yet, with the advent of preventive HPV vaccines that target HPV 16 and 18 responsible for causing about 70% of ICC cases in the world, such information is crucial to predict how vaccination and HPV-based screening will influence prevention of ICC. METHODS: To review the distribution of HPV infection and prevalent genotypes, electronic databases (e.g. PubMed/MEDLINE and HINARI) were searched for peer reviewed English articles on HPV infection up to November 30, 2010. Eligible studies were selected according to the following criteria: DNA-confirmed cervical or male genital HPV prevalence and genotypes, HPV incidence estimates and HPV seroprevalence among participants. RESULTS: Twenty studies were included in the review. Among HIV negative adult women, the prevalence of HR-HPV infections ranged from 10.2% -40.0% compared to 37.0% -100.0% among HIV positive women. Among HIV positive young women aged below 25 years, the prevalence of HR-HPV genotypes ranged from 41.6% -75.0% compared to 23.7% -67.1% among HIV negative women. Multiple infections with non vaccine HR-HPV genotypes were frequent in both HIV positive and HIV negative women. The main risk factors for prevalent HPV infections were age, lifetime number of sexual partners and HIV infection. Incident infections with HR-HPV genotypes were more frequent among adult HIV positive than HIV negative women estimated at 17.3 and 7.0 per 100 person-years, respectively. Similarly, incident HR-HPV among young women aged below 25 years were more frequent among HIV positive (40.0 per 100 person-years) than HIV negative women (20.3 per 100 person-years) women. The main risk factor for incident infection was HIV infection. HPV 16 and 18 were the most common genotypes in ICC with HPV 16/18 contributing up to 73.5% of cases with single infections.Among uncircumcised adult HIV positive males, HR-HPV prevalence ranged from 55.3% -76.6% compared to 38.6% -47.6% in HIV negative males. Incident and multiple HR-HPV infections were frequent in HIV positive males. Being uncircumcised was the main risk factor for both prevalent and incident HPV infection. CONCLUSION: Infections with HR-HPV genotypes were very common particularly among HIV positive individuals and young women irrespective of HIV status. Given the high prevalence of HIV infection, HPV-associated conditions represent a major public health burden in Uganda. However, although the most common HPV genotypes in ICC cases in Uganda were those targeted by current preventive vaccines, there were a large number of individuals infected with other HR-HPV genotypes. Technology allowing, these other HR-HPV types should be considered in the development of the next generation of vaccines.

STI-prevalence and differences in social background and sexual behavior among urban and rural young women in Uganda.

BACKGROUND: Adolescents in Uganda carry a heavy burden of reproductive health problems. Different environment creates different problems. OBJECTIVES: To study the prevalence of STI and to compare social and behavioral risk factors for Neisseria gonorrhoea (NG) and Chlamydia trachomatis (CT) among sexually experienced young women in one urban and one rural area in Uganda. METHODS: Consenting, sexually experienced women, below 20 years, visiting two different youth clinics were asked about social background, genital symptoms and sexual experiences. Vaginal samples were taken for NG and CT and analyzed by PCR. RESULTS: The prevalence of NG and/or CT was 20 (6.8%) in the urban and 23 (7.8%) in the rural study site, a non-significant difference. The rural women were often in marital union, 25.3% compared to 12.2% of the urban women (OR 2.4, 95% CI 1.6-3.8) and had experienced more pregnancies and had more children. Their partners were often more than 10 years older. More urban women (42.2%) knew their HIV status compared to rural women (16.2%), OR 2.1 (1.6-2.7), reported more condom use and more sexual partners. CONCLUSIONS: Marital status and few sexual partners does not appear to protect young rural women from sexually transmitted infections (STIs), implying that male sexual behavior may have an important impact on women's risk to be infected.

A randomized clinical trial of two emergency contraceptive pill regimens in a Ugandan population.

BACKGROUND: Recent trials on emergency contraception (EC) have indicated that levonorgestrel (LNG) used alone has fewer side-effects and is more efficacious than the Yuzpe regimen (high dose combined oral contraceptive pills). However, the experienced side-effects and acceptability may vary between different groups or societies. OBJECTIVE: The primary objective of this study was to determine side-effects and acceptability of two emergency contraceptive pill (ECP) regimens among users in Kampala, Uganda. STUDY DESIGN: Randomized clinical trial. METHODS: A total of 337 women were enrolled in a double blind randomized clinical trial. Women requesting ECPs within 72 hours after unprotected sexual intercourse received either LNG or the Yuzpe regimen. The women returned for follow-up after three days and a follow-up interview was performed after one year. RESULTS: Levonorgestrel had significantly fewer side-effects than the Yuzpe regimen (p < 0.001). There was a significant association between having worries about the method and experiencing side-effects (p < 0.001). Most women (81%) were prime users of EC. The majority would recommend ECP to other clients. CONCLUSIONS: Levonorgestrel is a superior option to the Yuzpe regimen and should be promoted as the recommended ECP. Having worries about ECP may influence experience of the side-effects. Correct information is critical in promotion of ECP use.

Association between HSV-2 and HIV serostatus in pregnant women of known HIV serostatus attending Mulago hospital antenatal clinic, Kampala, Uganda.

BACKGROUND: Studies show that STIs such as HSV-2 increase the probability of HIV-1 acquisition and enhance transmission by increasing susceptibility and infectiousness respectively. The objective of this study was to compare the proportion of HSV-2 in HIV-positive and HIV-negative pregnant mothers attending the antenatal clinic in Mulago Teaching Hospital in Kampala, Uganda. METHODS: This case control study included 50 pregnant women who were HIV positive and 200 controls of pregnant women who were HIV negative and were aware of their serostatus. Data was collected in two parts: the first part involved a pretested interviewer-administered semi-structured questionnaire for socio-demographic characteristics, sexual and behavioral history. The second part consisted of a serological test using an ELISA assay specific for IgG against viral glycoprotein G, specific to HSV-2. RESULTS: The proportion of HSV-2 was 86% (43/50) among the HIV-positive cases and 62% (125/200) among the HIV-negative controls. The odds of being HSV-2 seropositive was 3.7 times higher (95% CI was 1.58 - 8.61) in HIV-positive cases than in the HIV negative controls. The odds of HSV-2 was significantly increased to 5.32 (95 CI was 1.92 - 14.73) among cases when adjustment was done for age, education, marital status, religion, age at first sexual experience, lifetime partners, type of earning, and whether the mother involved the partner in seeking treatment for sexually transmitted diseases. CONCLUSION: The proportion of HSV-2 was higher in HIV-positive cases than in the HIV negative controls.

Faced with a double-edged risk: Ugandan university students' perception of the emergency contraceptive pill in Uganda.

Whereas in high-income countries potential users of Emergency Contraception (EC) have information and access to emergency contraceptive pills (ECPs), it has remained secretive in low-income countries like Uganda. Although several studies have been conducted in relation to EC, few have addressed users' perceptions. The objective of our study was to explore perceptions of EC by university students in Kampala, Uganda. Seven focus group discussions and four key informant interviews were conducted at Makerere University, Kampala. The transcribed data was analyzed for content and recurrent themes. Participants expressed ambivalence about ECPs. The method was generally recommended but only to the "right people", in this context being those aged eighteen years and more. There were reservations surrounding provision of ECPs like similarity with abortion and fear of side effects. Users' and potential-users' perceptions are crucial in the accessibility and utilization of ECPs.

Lack of effectiveness of cellulose sulfate gel for the prevention of vaginal HIV transmission.

BACKGROUND: Women make up more than 50% of adults living with human immunodeficiency virus (HIV) infection or the acquired immunodeficiency syndrome (AIDS) in sub-Saharan Africa. Thus, female-initiated HIV prevention methods are urgently needed. METHODS: We performed a randomized, double-blind, placebo-controlled trial of cellulose sulfate, an HIV-entry inhibitor formulated as a vaginal gel, involving women at high risk for HIV infection at three African and two Indian sites. The primary end point was newly acquired infection with HIV type 1 or 2. The secondary end point was newly acquired gonococcal or chlamydial infection. The primary analysis was based on a log-rank test of no difference in the distribution of time to HIV infection, stratified according to site. RESULTS: A total of 1398 women were enrolled and randomly assigned to receive cellulose sulfate gel (706 participants) or placebo (692 participants) and had follow-up HIV test data. There were 41 newly acquired HIV infections, 25 in the cellulose sulfate group and 16 in the placebo group, with an estimated hazard ratio of infection for the cellulose sulfate group of 1.61 (P=0.13). This result, which is not significant, is in contrast to the interim finding that led to the trial being stopped prematurely (hazard ratio, 2.02 [corrected]; P=0.05 [corrected]) and the suggestive result of a preplanned secondary (adherence-based) analysis (hazard ratio, 2.02; P=0.05). No significant effect of cellulose sulfate as compared with placebo was found on the risk of gonorrheal infection (hazard ratio, 1.10; 95% confidence interval [CI], 0.74 to 1.62) or chlamydial infection (hazard ratio, 0.71; 95% CI, 0.47 to 1.08). CONCLUSIONS: Cellulose sulfate did not prevent HIV infection and may have increased the risk of HIV acquisition. (ClinicalTrials.gov number, NCT00153777; and Current Controlled Trials number, ISRCTN95638385.)

Knowledge, attitudes and prescribing pattern of emergency contraceptives by health care workers in Kampala, Uganda.

BACKGROUND: Health care workers (HCWs) play an important role in making emergency contraceptives (ECs) available to clients. They can influence accessibility positively through counselling, prescribing or advocating the use of ECs. However, in some settings, HCWs have been blamed for unfavourable attitudes and lack of accurate information. Objective. To assess the knowledge, attitudes and prescribing pattern of EC by HCWs in Kampala district, Uganda. METHODS: The total number of health units at different levels of health care delivery in Kampala (894) was obtained. Probability proportional to size (PPS) technique of sampling was applied. Some 247 HCWs completed a self-administered questionnaire on their knowledge about EC, including methods, mechanism of action, prescription of EC, sources of information, attitudes towards EC, and if and how it should be made available. RESULTS: Of the HCWs, 80% had knowledge of ECs. However, 1 in every 4 was not sure about the time limit within which EC is effective. A total of 50% of the participants had obtained information from a physician (26.4%) or from a training school (24%). The Yuzpe regimen was the most commonly mentioned and prescribed method of EC. The HCWs attitudes to EC were generally positive, and it was suggested that the community should be informed and sensitised about EC. There was a significant difference between having had a family planning educational update or not in the last year and knowledge of EC (p=0.005). CONCLUSION: Most HCWs were aware of EC, but some lacked important knowledge on its use or available methods. RECOMMENDATION: HCWs should have regular (annual) in-service training in reproductive health issues, such as counselling on EC. This will enable them to keep up to date with the current evidence-based recommendations in the field of contraceptive technology.

Escaping the triple trap: coping strategies of pregnant adolescent survivors of domestic violence in Mulago hospital, Uganda.

OBJECTIVE: Why domestic violence survivors develop adverse outcomes following domestic violence during pregnancy is unclear, but may depend on how survivors cope with the stress of violence. The objective was to describe strategies pregnant adolescents employ in coping with domestic violence. METHODS: This was a qualitative study involving 16 in-depth interviews with adolescent domestic violence survivors who attended the antenatal clinic in Mulago hospital, Kampala, Uganda, from January to May 2004. Theoretical sampling, necessitated by the emergent theory from sequential data collection and analysis, further provided diversity of experiences from adolescents of different ages, parity, pregnancy duration, and socioeconomic status until saturation was reached. Data were analyzed using grounded theory. FINDINGS: Survivors described varied experiences of physical, sexual, and psychological violence. Coping strategies employed were analyzed as: Minimizing damage - decreasing impact and severity of violence, withdrawal - physical or social withdrawal, seeking help and retaliation (fighting back). Coping strategies were influenced by adolescence and pregnancy, and are explained in relation to theories of coping with stress. CONCLUSIONS: Coping strategies adopted by pregnant adolescent survivors range from problem-focused approaches to emotion-focused approaches. Coping strategies are influenced markedly by adolescence and pregnancy.

Domestic violence during pregnancy and risk of low birthweight and maternal complications: a prospective cohort study at Mulago Hospital, Uganda.

OBJECTIVES: To investigate whether domestic violence during pregnancy is a risk factor for antepartum hospitalization or low birthweight (LBW) delivery. METHODS: A prospective cohort study was conducted in Mulago hospital, Kampala, Uganda, among 612 women recruited in the second pregnancy trimester and followed up to delivery, from May 2004 through July 2005. The exposure (physical, sexual or psychological violence during pregnancy) was assessed using the Abuse Assessment Screen. The relative and attributable risks of LBW and antepartum hospitalization were estimated using multivariate logistic regression analysis. RESULTS: The 169 women [27.7% 95% CI (24.3-31.5%)] who reported domestic violence during pregnancy did not differ significantly from the unexposed regarding sociodemographic characteristics, but differed significantly (P < 0.05) regarding domicile variables (had less household decision-making power, more resided in extended families and more had unplanned pregnancy). They delivered babies with a mean birthweight 2647.5 +/- 604 g, on average 186 g [(95% CI 76-296); P = 0.001] lower than those unexposed. After adjusting for age, parity, number of living children, pregnancy planning, domicile and number of years in marriage, the relative risk (RR) of LBW delivery among women exposed to domestic violence was 3.78 (95% CI 2.86-5.00). Such women had a 37% higher risk of obstetric complications (such as hypertension, premature rupture of membranes and anaemia) that necessitated antepartum hospitalization [RR 1.37 (95% CI 1.01-1.84)]. CONCLUSION: In this pregnancy cohort, domestic violence during pregnancy was a risk factor for LBW delivery and antepartum hospitalization.

Domestic violence as risk factor for unwanted pregnancy and induced abortion in Mulago Hospital, Kampala, Uganda.

OBJECTIVE: To compare pregnancy intention and domestic violence among women with induced and spontaneous abortion. METHOD: Case-control study in Mulago Hospital, Uganda, from September 2003 to June 2004 of 942 women seeking post-abortion care. Direct inquiry, records review and clinical examination identified 333 with induced abortion (cases) and 609 with spontaneous abortion (controls), who were compared regarding socio-demographic characteristics, contraceptive use, domicile (rural or urban, nuclear or extended families), pregnancy intention, household decision-making and domestic violence. Data was analysed with EPI-INFO and STATA, using Student t-test and analysis of variance for continuous and chi-square for categorical variables. Stratified and multivariate logistic regression analyses were used to adjust for confounding and interaction at the 95% confidence level. RESULTS: Cases significantly differed from controls as they were younger or more often single; had lower parity and education, less household decision-making and fewer living children. They were similar to controls (P > 0.05) regarding employment, spouse's age, years spent in marital relationship and domicile. Cases more frequently (P < 0.001) had mistimed, unplanned or unwanted pregnancy at conception and presentation. Cases were more likely to have a recent history of domestic violence (physical, sexual or psychological) [OR: 18.7 (95%CI: 11.2-31.0)] after adjusting for age, pregnancy intention and marital status. CONCLUSION: Domestic violence is a risk factor for unwanted pregnancy and induced abortion among women seeking post-abortion care.

Emergency contraception and fertility awareness among university students in Kampala, Uganda.

BACKGROUND: Uganda has a high maternal mortality ratio with unsafe abortions being one of the major causes. Young people are particularly vulnerable to unsafe induced abortion with its sequelae. Emergency contraception (EC) may reduce unsafe abortions if easily accessible and acceptable. OBJECTIVE: To determine knowledge about, ever use and attitudes towards EC among resident and non-resident female first year university students in Kampala. METHODS: This Cross sectional study was carried out at Makerere University from January to March 2005.Out of 5971 females admitted in the academic year 2004/2005,379 answered a self administered questionnaire. The students were approached individually and given the questionnaire if they consented. RESULTS: The mean age of the participants was 21 years. Less than half (45.1%) had ever heard about emergency contraceptive pills (ECPs). The most common sources of information about EC were friends (34%),media (24.8%) and schools (19.4%). The ever pregnancy rate was 3.4 percent and 42 percent were in a steady relationship of three or more months. The contraceptive ever-use rate was 14.5 percent. Among the users the most common methods were condoms (48.9%) and withdrawal (23.4%). Emergency contraceptive pills had been used by seven students. Forty two percent did not know the time interval within which ECPs can work and one third thought it would interrupt an ongoing pregnancy. Thirty five percent did not know when in the menstrual cycle they were likely to conceive. The majority of the students were against over the counter (OTC) availability of EC because of fear of misuse. CONCLUSIONS: Knowledge about Emergency contraception and fertility awareness is low among the female first year university students. Friends and the media are an important source of EC information. Awareness and knowledge of EC should be increased.

Introducing criteria based audit into Ugandan maternity units.

PROBLEM: Maternal mortality in Uganda has remained unchanged at 500/100 000 over the past 10 years despite concerted efforts to improve the standard of maternity care. It is especially difficult to improve standards in rural areas, where there is little money for improvements. Furthermore, staff may be isolated, poorly paid, disempowered, lacking in morale, and have few skills to bring about change. DESIGN: Training programme to introduce criteria based audit into rural Uganda. SETTING: Makerere University Medical School, Mulago Hospital (large government teaching hospital in Kampala), and Mpigi District (rural area with 10 small health centres around a district hospital). STRATEGIES FOR CHANGE: Didactic teaching about criteria based audit followed by practical work in own units, with ongoing support and follow up workshops. EFFECTS OF CHANGE: Improvements were seen in many standards of care. Staff showed universal enthusiasm for the training; many staff produced simple, cost-free improvements in their standard of care. LESSONS LEARNT: Teaching of criteria based audit to those providing health care in developing countries can produce low cost improvements in the standards of care. Because the method is simple and can be used to provide improvements even without new funding, it has the potential to produce sustainable and cost effective changes in the standard of health care. Follow up is needed to prevent a waning of enthusiasm with time.