Survival of cervical cancer patients at Moi teaching and Referral Hospital, Eldoret in western Kenya.

BACKGROUND: Cervical cancer is a major health burden and the second most common cancer after breast cancer among women in Kenya. Worldwide cervical cancer constitutes 3.1% of all cancer cases. Mortality rates are greatest among the low-income countries because of lack of awareness, screening and early-detection programs and adequate treatment facilities. The main aim was to estimate survival and determine survival predictors of women with cervical cancer and limited resources in western Kenya. METHODS: Retrospective charts review of women diagnosed with cervical cancer and follow-up for two years from the date of the histologic diagnosis. The outcome of interest was death or survival at two years. Kaplan Meier estimates of survival, log-rank test and Cox proportional hazards regression were used in the survival analysis. RESULTS: One hundred and sixty-two (162) participants were included in the review. The median duration was 0.8 (interquartile range (IQR) 0.3, 1.6) years. The mean age at diagnosis was 50.6 years (SD12.5). The mean parity was 5.9 (SD 2.6). Fifty percent (50%) did not have health insurance. Twenty six percent (26%) used hormonal contraceptives, 25.9% were HIV positive and 70% of them were on anti-retroviral treatment. The participants were followed up for 152.6 person years. Of the 162 women in the study, 70 (43.2%) died giving an overall incidence rate (IR) of 45.9 deaths per 100 person years of follow up. The hazard ratios were better for the patients who survived (0.44 vs 0.88, p-value < 0.001), those who had medical insurance (0.70 vs 0.48, p-value = 0.007) and those with early stage at diagnosis (0.88 vs 0.39, p-value < 0.001). Participants who were diagnosed at late stage of the disease according to the International Federation of Gynecology and Obstetrics staging for cervical cancer (FIGO stage 2B-4B) had more than eight times increased hazard of death compared to those who were diagnosed at early stage (1-2A): Hazard Ratio: 8.01 (95% CI 3.65, 17.57). Similarly, those who underwent surgical management had 84% reduced hazard of mortality compared to those who were referred for other modes of care: HR: 0.16 (95% CI: 0.07, 0.38). CONCLUSION: Majority of the participants were diagnosed late after presenting with symptoms. The 1 and 2-year survival probability after diagnosis of cervical cancer was 57% AND 45% respectively. It is imperative that women present early since surgery gives better prognosis or better still screening of all women prioritized.

Sexual harassment before and during the COVID-19 pandemic among adolescent girls and young women (AGYW) in Nairobi, Kenya: a cross-sectional study.

OBJECTIVES: Sexual harassment among adolescent girls and young women (AGYW) is a prevalent and understudied form of gender-based violence (GBV) with negative impacts on health and well-being. The COVID-19 pandemic raised global concern about GBV within homes; less is known about how it affected GBV in public spaces. METHODS: Present analyses use cross-sectional data from a cohort of adolescents and young adults residing in Nairobi, Kenya, restricted to female participants. Data were collected August-October 2020 via phone after implementation of COVID-19 restrictions. Prevalence of past-year sexual harassment and harassment relative to COVID-19 restrictions were calculated for overall sample, and by individual, household, and pandemic-related factors. Multivariate negative binomial regression models examine correlates of (1) past-year sexual harassment and (2) increases in sexual harassment relative to COVID-19 restrictions. RESULTS: Overall, 18.1% of AGYW experienced past-year sexual harassment at the 2020 survey. Among this group, 14.6% experienced sexual harassment pre-COVID-19 only, 18.8% after only and 66.6% at both time points. Among the latter group, 34.9% reported more occurrences following COVID-19 restrictions, 20.5% reported less occurrences and 44.7% reported no change in occurrence. Overall, 42.0% of AGYW experienced an increase in sexual harassment while 58.0% experienced no increase since COVID-19. In adjusted models, past-year sexual harassment was associated with higher educational attainment (adjusted risk ratio, aRR 2.11; 95% CI 1.27 to 3.52) and inability to meet basic financial needs (aRR 1.67; 95% CI 1.05 to 2.66). Increased sexual harassment since COVID-19 was associated with having full control to leave the home (aRR 1.69; 95% CI 1.00 to 2.90). CONCLUSIONS: Sexual harassment among AGYW in Nairobi, Kenya was prevalent before and during COVID-19 restrictions. Safety in public spaces remains a highly gendered issue that impacts women's safety and ability to participate in public life. Prevention and support services to address sexual harassment remain an important element in ensuring safe, sustainable public spaces.

Satisfaction with Delivery Services Offered under the Free Maternal Healthcare Policy in Kenyan Public Health Facilities.

Background: Patients' satisfaction is an individual's positive assessment regarding a distinct dimension of healthcare and the perception about the quality of services offered in that health facility. Patients who are not satisfied with healthcare services in a certain health facility will bypass the facility and are unlikely to seek treatment in that facility. Objective: To determine satisfaction level of mothers with the free maternal services in selected Kenyan public health facilities after the implementation of the free maternal healthcare policy. Methods: Data was collected through a quantitative exit survey questionnaire. The respondents were mothers who had delivered in the health facilities and were waiting to leave the health facilities after discharge. The sample included 2,216 mothers in 77 public health facilities across 14 counties in Kenya under tier 3 and tier 4 categories. The number of respondents to be interviewed was proportionately arrived at based on each health facility's bed capacity. Results: The study established a satisfaction rate of 54.5% among the beneficiaries of the free maternal healthcare services in the country. Mothers benefiting from the free delivery services were satisfied with communication by the healthcare workers, staff availability in the delivery rooms, availability of staff in the wards, and drug and supplies availability (>56%) but unsatisfied with consultation time, cleanliness, and privacy in the wards (<56%). High education levels and lengthy stay in healthcare facilities were negatively associated with the satisfaction with the free delivery services (P < 0.05). Conclusion: There is a high satisfaction with the free maternal healthcare services in Kenya. However, the implementation of the free maternal healthcare policy was associated with low privacy, poor hygiene, and low consultation time in the health facilities. Therefore there is need to address these service gaps so as to attract more mothers to deliver in public health facilities.

The effect of Kenya's free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities.

BACKGROUND: Kenya abolished delivery fees in all public health facilities through a presidential directive effective on June 1, 2013 with an aim of promoting health facility delivery service utilization and reducing pregnancy-related mortality in the country. This paper aims to provide a brief overview of this policy's effect on health facility delivery service utilization and maternal mortality ratio and neonatal mortality rate in Kenyan public health facilities. METHODS: A time series analysis was conducted on health facility delivery services utilization, maternal and neonatal mortality 2 years before and after the policy intervention in 77 health facilities across 14 counties in Kenya. RESULTS: A statistically significant increase in the number of facility-based deliveries was identified with no significant changes in the ratio of maternal mortality and the rate of neonatal mortality. CONCLUSION: The findings suggest that cost is a deterrent to health facility delivery service utilization in Kenya and thus free delivery services are an important strategy to promote utilization of health facility delivery services; however, there is a need to simultaneously address other factors that contribute to pregnancy-related and neonatal deaths.

Gender differences in treatment outcomes among 15-49 year olds with smear-positive pulmonary tuberculosis in Kenya.

OBJECTIVE: To determine gender differences in treatment outcomes among 15-49 year olds with smear-positive pulmonary tuberculosis (PTB) and factors associated with poor outcomes in Kenya. DESIGN: Retrospective descriptive cohort. RESULTS: Of 16 056 subjects analysed, 38% were female and 62% male. Females had a higher risk of poor treatment outcome than males (12% vs. 10%, P < 0.001; adjusted OR 1.29, 95%CI 1.16-1.44, P < 0.001). In the first multivariate model, restricting the analysis to human immunodeficiency virus (HIV) positive patients and adjusting for risk factors and clustering, females had a non-significantly lower risk of poor outcome (OR 0.99, 95%CI 0.86-1.13, P = 0.844). In the model restricted to HIV-negative patients, a non-significantly lower risk was found (OR 0.89, 95%CI 0.73-1.09, P = 0.267). In the second model, restricting analysis to patients on antiretroviral therapy (ART) and adjusting for risk factors and clustering, females had a non-significantly lower risk of poor PTB treatment outcomes (OR 0.98, 95%CI 0.84-1.14, P = 0.792). In the model restricted to HIV-positive patients not on ART, a non-significantly higher risk was found (OR 1.15, 95%CI 0.79-1.67, P = 0.461). CONCLUSION: Females of reproductive age are likely to have poorer treatment outcomes than males. Among females, not commencing ART during anti-tuberculosis treatment seemed to be associated with poor outcomes.

Antenatal care and pregnancy outcomes in a safe motherhood health voucher system in rural Kenya, 2007-2013.

SETTING: A rural private health facility, Ruby Medical Centre (RMC), participating in a safe motherhood health voucher system for poor women in Kiambu County, Kenya. OBJECTIVES: Between 2007 and 2013, to determine 1) the number of women who delivered at the RMC, their characteristics and pregnancy-related outcomes, and 2) the number of women who received an incomplete antenatal care (ANC) package and associated factors. DESIGN: Retrospective cross-sectional study using routine programme data. RESULTS: During the study period, 2635 women delivered at the RMC: 50% were aged 16-24 years, 60% transferred in from other facilities and 59% started ANC in the third trimester of pregnancy. Of the 2635 women, 1793 (68%) received an incomplete ANC package: 347 (13%) missed essential blood tests, 312 (12%) missed the tetanus toxoid immunisation and 1672 (65%) had fewer than four visits. Presenting late and starting ANC elsewhere were associated with an incomplete package. One pregnancy-related mortality occurred; the stillbirth rate was 10 per 1000 births. CONCLUSION: This first assessment of the health voucher system in rural Kenya showed problems in ANC quality. Despite favourable pregnancy-related outcomes, increased efforts should be made to ensure earlier presentation of pregnant women, comprehensive ANC, and more consistent and accurate monitoring of reproductive indicators and interventions.

Contexte : Une structure de santé privée rurale, le Ruby Medical Centre (RMC), participant à un système de bons de traitement de Maternité sans risques destiné à des femmes pauvres du conté de Kiambu au Kenya.Objectifs : Entre 2007 et 2013, déterminer 1) le nombre de femmes qui ont accouché au RMC, leurs caractéristiques et le devenir de leur grossesse, et 2) le nombre ne bénéficiant que d'un paquet de soins anténataux (ANC) incomplets et les facteurs associés.Schéma : Etude rétrospective transversale basée sur les données recueillies en routine dans les programmes.Résultats : Au cours de la période d'étude, 2635 femmes ont accouché au RMC : 50% étaient âgées de 16 à 24 ans, 60% avaient été transférées d'autres structures et 59% avaient débuté les ANC au cours du 3e trimestre. De ces 2635 femmes, 1793 (68%) avaient un paquet d'ANC incomplet : 347 (13%) ont manqué les principaux tests sanguins, 312 (12%) n'ont pas eu de vaccination anti-tétanique et 1672 (65%) ont eu moins de quatre consultations. Un démarrage tardif et des ANC débutés ailleurs étaient associés à un paquet d'ANC incomplet. Un décès lié à la grossesse est survenu et le taux de mortinatalité a été de 10/1000 naissances.Conclusion : Cette première évaluation du système de bons de traitement dans les zones rurales du Kenya a mis en évidence des problèmes de qualité des ANC. En dépit de l'évolution favorable des grossesses, il est nécessaire d'accroitre les efforts pour faire venir les femmes enceintes plus tôt, offrir des ANC complets et un suivi plus cohérent et précis des indicateurs et des interventions de santé reproductive.

Marco de referencia: El Ruby Medical Centre (RMC) es un centro de atención de salud privado en zona rural, que participa en el sistema de cupones por una maternidad sin riesgo en el condado de Kiambu, en Kenia.Objetivos: Determinar entre el 2007 y el 2013: 1) la cantidad de mujeres cuyo parto se atendió en el RMC, las características de las mujeres y los desenlaces relacionados con el embarazo; y 2) el número de mujeres que recibieron una atención prenatal (ANC) incompleta y los factores asociados con esta situación.Métodos: Fue este un estudio transversal retrospectivo a partir de los datos del programa corriente.Resultados: Durante el período del estudio, se atendió el parto de 2635 mujeres en el RMC, el 50% de las cuales tenía entre 16 y 24 años de edad, el 60% acudió como remisión de otros centros de atención y el 59% había comenzado la ANC durante el tercer trimestre del embarazo. De las 2635 mujeres, 1793 recibieron una ANC incompleta (68%) a saber: en 347 no se practicaron los principales exámenes sanguíneos (13%); 312 no recibieron la vacuna con el toxoide antitetánico (12%); y 1672 acudieron a menos de cuatro citas de control (65%). Los factores asociados con una ANC incompleta fueron una presentación tardía al programa y el inicio de la ANC en un centro diferente. Se presentó un caso de mortalidad relacionada con el embarazo y la tasa de mortinatalidad fue de 10 por 1000 nacimientos.Conclusión: El presente estudio es la primera evaluación del sistema de cupones por una maternidad sin riesgo en la zona rural de Kenia y puso en evidencia problemas en materia de calidad de la ANC. Pese a los desenlaces favorables del embarazo, se precisan iniciativas que fomenten una presentación más temprana de las embarazadas al programa, la ANC integral, y una vigilancia más regular y exacta de los indicadores y las intervenciones en materia de salud reproductiva.

CONTROVERSY ABOUT EMBRYOGENESIS AND ORGANISATION OF HUMAN FEMALE URETHRA: A REVIEW.

OBJECTIVE: To assess current knowledge on development and associated structures. DATA SOURCES: Current scientific publications in the pubmed data base on the development of human female urethra were reviewed. The embryology of human female urethra and its associated structures is presented. STUDY SELECTION: The following search words: urethra development, female urethra development, and male urethra development were used. DATA EXTRACTION: The first 100 publications from urethra development search and thereafter 100 publications excluding those in the first search were reviewed to determine whether they described development of female urethra. DATA SYNTHESIS: There are limited studies describing the formation of female urethra. Unlike male urethra, female urethra does not undergo masculinisation meaning there is no formation of clitoral urethra. Like the male urethra, there are female urethra associated glands whose presence and functions remain speculative. Female urethra associated structures including Skene's glands also referred to as female prostate, corpus spongiosum of female urethra and what has been described as the G-Spot may all be congenital malformations considering that they are not uniformly present. CONCLUSIONS: Female urethra development differs from that of males though there are some similarities. Studies to elucidate the development of female urethra are needed to clarify some of the misconceptions and to provide embryological explanation of gross and histological features of female urethra.

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya.

OBJECTIVES: 1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ≥2 weeks' duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya. DESIGN: Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya. RESULTS: Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26-35) and 26 years (IQR 24-31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/µl (IQR 244-530) for HIV-infected women. One non-HIV-infected patient was sputum-positive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants. CONCLUSION: This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya.

CD4 T-LYMPHOCYTE SUBSETS IN WOMEN WITH INVASIVE CERVICAL CANCER IN KENYA.

OBJECTIVE: Invasive cervical cancer (ICC) and HIV are common in sub-Sahara Africa. Both ICC and HIV are immunosuppressive, and are associated with decreased CD4 and CD8 profiles. In a group of women with ICC starting radiotherapy, we determined their CD4 profiles. DESIGN: A cross-sectional study. SETTINGS: Kenyatta National Hospital, Nairobi, Kenya, radiotherapy unit. SUBJECTS: Women with invasive cervical cancer (344) seeking radiotherapy treatment for the first time between January 2000 and March 2003, had blood samples analyzed for CD4 and CD8 cell counts by flow cytometry. Haemoglobin, white cell count, lymphocyte and platelet counts were determined using coulter machine. All patients had received pre- and post HIV counseling. RESULTS: The mean age was 49+13 years. About 13.1% of the women with ICC were HIV positive. Overall, mean and median CD4 cell count was 829+355 cells/mm and 792 cells/mm3. Among HIV+ patients, mean and median CD4 cell counts were 451+288 cells/mm and 405 cells/mm respectively. The mean CD4 cell count for the HIV+ womenwas 886+329 cells/mm3 with median of 833 cells/mm3, range 147-2065 cells/mm3. Only nine (20%) of the 45 HIV+ women had CD4 cell count of 0-200. HIV+ women had lower CD4 percentage and cell count and higher CD8 percentage and cell count as compared to HIV negative women, p < 0.001. HIV infection was significantly and independently associated with high proportion of women who had CD4 cell count of less than 200 cells/mm3 or less than 350 cells/mm3, p < 0.0001. CONCLUSIONS: Women with ICC and concurrent HIV infection have decreased CD4 cell subset. These results suggest HIV infection may be associated with more severe CD4 depletion in women with ICC.

Structural changes in umbilical vessels in pregnancy induced hypertension.

BACKGROUND: Pregnancy Induced Hypertension (PIH) is associated with placental morphological changes, alterations in the blood flow patterns in the umbilical vessels and adverse fetal and maternal outcome. Studies have demonstrated changes in the structure of the umbilical vessels but these have not been described across the length of the cord or correlated with the severity of disease. STUDY DESIGN: A case control study. SETTING: Kenyatta National Hospital. MATERIALS AND METHODS: Thirty six umbilical cords from newborns of women with and without PIH (18 cases, 18 controls) were obtained and studied with light microscopy. Of the cases 9 women had severe PIH and 9 had mild PIH. Means and standard deviations for the various parameters of the various groups were obtained. Student's t-test and ANOVA were used to compare means, a p value of <0.05 being significant. RESULTS: The structure of the umbilical vessels changes from the placental end to the fetal end. The umbilical vein in PIH had a greater wall thickness and a smaller luminal area than in the controls. The vein's wall-luminal ratio increased from the placental to the fetal end. Duplication of the elastic subintimal lamina (ESL) was higher in the cases. The ESL was more commonly duplicated in the fetal end. There were no structural differences between the umbilical arteries in PIH and in the controls. CONCLUSION: PIH is associated with structural changes in the umbilical vessels. These changes are more predominant in the vein than in the artery and in the vein, they are more obvious in the fetal end. The observed increase in wall-luminal ratio from the placental to the fetal end suggests that the fetal end of the umbilical vein has a more refined role in the regulation of blood flow to the fetus.

Quality of record keeping in the intrapartum period at the Provincial General Hospital, Kakamega, Kenya.

OBJECTIVE: To assess the quality of recording critical events in the intrapartum period in Kakamega Provincial General Hospital (PGHK). DESIGN: Retrospective comparative study. SETTING: Provincial General Hospital, Kakamega, the referral hospital for Western Province, Kenya. PARTICIPANTS: Two hundred women admitted at the labour ward during the six-month period between 1st September 2000 and 28th February 2001 were compared to two hundred women admitted between 1st July 2001 and 31st December 2001. INTERVENTION: The Safe Motherhood Demonstration Project (SMDP) was introduced in four districts of Western Province, Kenya, in which PGHK is located. It included on job training in Safe Motherhood which emphasised, among others, collection and utilisation of maternal health care services data. MAIN OUTCOME MEASURES: Comprehensiveness of recording of biodata, history taking and examination findings were assessed for women in labour before and during the implementation of the SMDP. The proportion of cases in labour managed by use of partograph and its appropriate use were also determined. RESULTS: Retrieval rate of patients' notes was 86.9% and 89.6% before and during SMDP respectively. Information on sociodemographic characteristics, history taking, general and obstetric examination had a near universal recording in both groups but data on alcohol consumption, smoking, menarche, previous pregnancies and contraceptive use was poorly recorded. There was a significant improvement in recording of diagnosis and plan of management during the SMDP (p = 0.037). The partograph was used in only 11% of patients before SMDP as compared to 85% during SMDP (p = 0.000). Record on foetal condition and progress of labour were significantly improved during the SMDP (p = 0.000). Records on summary of labour likewise significantly improved during the SMDP (p = 0.02). CONCLUSION: The quality of record keeping in the intrapartum period at the PGHK greatly improved during the implementation of the SMDP. It would be worthwhile to assess the sustainability of quality of intrapartum records and care a year or so after the SMDP ended.

The effects of HIV-1 Tat protein on cell cycle during cervical carcinogenesis.

The role of HPV in the carcinogenesis of intraepithelial and invasive anogenital lesions is currently well established. E6 and E7 oncoproteins of high-risk HPV genotypes are known to inactivate p53 and pRb pathways. Several studies have described an increased prevalence and recurrence of both cervical HPV infection and invasive cervical cancer among HIV-1 positive women compared to HIV-1 negative cases. For these reasons, cervical cancer is considered an AIDS-defining neoplasm. Unlike other AIDS-associated neoplasms, the occurrence of cervical cancer is independent of immune suppression. HIV-1 infection in patients with high grade precancerous lesions and invasive cervical cancers results in a therapy refractory and more aggressive disease phenotype, which is not yet well understood at the molecular level. An upregulation of HPV E6 and E7 gene expressions by HIV-1 proteins such as Tat has been documented by some authors. However, the role of HIV-1 in cervical carcinomas is still unclear. It is already known that HIV-1 Tat protein is able to influence cell cycle progression. Altogether, these facts led us to investigate the effects of Tat on the expression of cell cycle regulator genes. After transfection of HeLa cells with Tat, we analyzed the expression of cell cycle regulators from these cells by IHC and Real-time PCR. A significant reduction in the expression of cell cycle inhibitors of transcription and an increase in the levels of proliferation markers were observed. These results suggest that HIV-1 may enhance cervical carcinogenesis by promoting cell cycle progression. We also found that this HIV-1 Tat-induced cell proliferation was not dependent on the E2F family of transcription factors, and therefore postulate that Sp factors may be involved.

Acceptability of human immunodeficiency virus testing in patients with invasive cervical cancer in Kenya.

Invasive cervical cancer (ICC) is common in areas where human immunodeficiency virus (HIV) is also prevalent. Currently, HIV seroprevalence as well as acceptability of HIV testing in ICC patients in Kenya is unknown. The objective of this study was to determine the acceptability of HIV testing among patients with ICC. Women with histologically verified ICC at Kenyatta National Hospital participated in the study. A structured questionnaire was administered to patients who gave informed consent. HIV pre- and posttesting counseling was done. Blood was tested for HIV using enzyme-linked immunosorbent assay. Overall, 11% of ICC patients were HIV seropositive. The acceptance rate of HIV testing was 99%; yet, 5% of the patients did not want to know their HIV results. Patients less than 35 years old were two times more likely to refuse the result of the HIV test (odds ratio [OR] 2.2). Patients who did not want to know their HIV results were three times more likely to be HIV seropositive (OR 3.1). Eighty four percent of the patients were unaware of their HIV seropositive status. The HIV-1 seroprevalence in ICC patients was comparable to the overall seroprevalence in Kenya. ICC patients were interested in HIV testing following pretest counseling. Offering routine HIV testing is recommended in ICC patients.

Socio-demographic characteristics of patients admitted with gynaecological emergency conditions at the provincial general hospital, Kakamega, Kenya.

OBJECTIVE: To determine the magnitude of gynaecological emergencies and the socio demographic characteristics of patients admitted at Provincial General Hospital Kakamega (PGHK). DESIGN: Retrospective cross-sectional study. SETTING: Provincial General Hospital Kakamega, the referral hospital for Western Province, Kenya. SUBJECTS: Four hundred patients admitted at the gynaecological wards during the period 1st January 2002 to 31st December 2002. RESULTS: In this study 80% of gynaecological patients admitted at PGH Kakamega were of an emergency nature with 45% being teenagers. The mean age was 17 +/- 3 (mean +/- SD). The majority had primary level of education or below (69%), unemployed (87%) and were rural residents (71%). Patients with abortion formed about 43% of the study group while those with inflammatory disease, pelvic abscess and ectopic pregnancy formed about 24%, 10% and 8% respectively. CONCLUSION: Most gynaecological admissions in PGH Kakamega are of acute nature, with abortion being the most common diagnosis. Hence, trained staff, equipment, supplies and drugs for management of acute gynaecological conditions should be available in hospitals in Western Kenya.

Congenital syphilis in a Nairobi maternity hospital.

OBJECTIVE: To assess adverse pregnancy outcome associated with maternal syphilis and congenital syphilis rate based on FTA-ABS-19s-IgM. DESIGN: Descriptive cross-sectional study. SETTING: Pumwani Maternity Hospital (PMH), the largest maternity unit in Nairobi, Kenya. SUBJECTS: Rapid Plasma Reagin reactive women and their live born infants. MAIN OUTCOME MEASURES: Syphilis serology in pregnant women, FTA-ABS-19s-IgM in cord blood and pregnancy outcome. RESULTS: Three hundred and seventy seven out of 12,414 women (3%) were RPR+. 4.0% of RPR+ and 1.4% of RPR- women delivered a stillbirth (OR 3.0, p<0.001). 19% of RPR+ and 10% of RPR- had low birth weight deliveries (OR 2.1, p<0.001). Mothers untreated for syphilis during pregnancy had significantly more preterm births (18.5% vs 9.2%, OR 2.3, p=0.026), and more stillbirths (5.4% vs 1.0%, OR 6.3, p=0.044). Of the 200 randomly selected cord bloods of RPR+ women, 142 (72%) were TPHA+. Nine (6.3%) of the 142 TPHA+ cords were FTA-ABS-19s-IgM+. CONCLUSIONS: Stillbirth and low birth weight rates were high in RPR+ untreated pregnant women and treatment significantly improved pregnancy outcome. Based on very stringent laboratory criteria (FTA-ABS-19s-IgM), 6.3% of live born infants with TPHA+ cord blood were considered syphilis infected.

Knowledge and practice about cervical cancer and Pap smear testing among patients at Kenyatta National Hospital, Nairobi, Kenya.

Invasive cervical cancer (ICC) is the leading cause of cancer-related death among women in developing countries. Population-based cytologic screening and early treatment does reduce morbidity and mortality associated with cervical cancer. Some of the factors related to the success of such a program include awareness about cervical cancer and its screening. The objective of this study was to assess knowledge and practice about cervical cancer and Pap smear testing among cervical cancer and noncancer patients using a structured questionnaire to obtain information. Fifty-one percent of the respondents were aware of cervical cancer while 32% knew about Pap smear testing. There were no significant differences in knowledge between cervical cancer and noncancer patients. Health care providers were the principal source of information about Pap testing (82%). Only 22% of all patients had had a Pap smear test in the past. Patients aware of cervical cancer were more likely to have had a Pap smear test in the past. The level of knowledge is low among ICC and noncancer patients. There is need to increase the level of knowledge and awareness about ICC and screening among Kenyan women to increase uptake of the currently available hospital screening facilities.

HIV and cervical cancer in Kenya.

OBJECTIVES: To determine the effect of the HIV epidemic on invasive cervical cancer in Kenya. METHODS: Of the 3902 women who were diagnosed with reproductive tract malignancies at Kenyatta National Hospital (KNH) from 1989 to 1998, 85% had invasive cervical cancer. Age at presentation and severity of cervical cancer were studied for a 9-year period when national HIV prevalence went from 5% to 5-10%, to 10-15%. RESULTS: There was no significant change in either age at presentation or severity of cervical cancer. Of the 118 (5%) women who were tested for HIV, 36 (31%) were seropositive. These women were 5 years younger at presentation than HIV-negative women. CONCLUSIONS: A two- to three-fold increase in HIV prevalence in Kenya did not seem to have a proportional effect on the incidence of cervical cancer. Yet, HIV-positive women who presented with cervical cancer were significantly younger than HIV-negative women.

Rate of caesarean section as a process indicator of safe-motherhood programmes: the case of Kenya.

The study assessed the value of currently-available data on the rates of caesarean section as an indicator of safe-motherhood programmes. Data, collected through the routine health information system of the Ministry of Health, Kenya, were used for analyzing the available process indicators. The methodology of this study illustrates both usefulness and limitations of readily-available healthcare information. The rate of hospital-based caesarean section was 6.3% of all births (range 0.3-37%), whereas the rate of population-based caesarean section was 0.95% (range 0.1%-4%). The rate of population-based caesarean section indicates a significant unmet need for obstetric care in the rural areas and may be a useful tool for monitoring progress on safe-motherhood initiatives in poor settings. Rates of population-based caesarean section are low in Kenya, especially in the rural areas. The rate of caesarean section may be a valuable process indicator for identifying the gaps in obstetric care and may be used for advocating improvements for healthcare to the relevant authorities.

Effect of a syphilis control programme on pregnancy outcome in Nairobi, Kenya.

OBJECTIVES: To assess the impact of a syphilis control programme of pregnant women on pregnancy outcome in Kenya. METHOD: Women who came to deliver to Pumwani Maternity Hospital (PMH) between April 1997 and March 1998 were tested for syphilis. Reactive rapid plasma reagin (RPR) tests were titrated and confirmed with treponema haemagglutination test (TPHA). Equal numbers of RPR and TPHA negative women were enrolled. Antenatal syphilis screening and treatment history were examined from the antenatal cards. RESULTS: Of 22,466 women giving birth, 12,414 (55%) were tested for syphilis. Out of these, 377 (3%) were RPR reactive of whom 296 were confirmed by TPHA. Syphilis sero-reactive women had a more risky sexual behaviour and coexistent HIV antibody positivity; 26% were HIV seropositive compared with 11% among syphilis negative mothers. The incidence of adverse obstetric outcome defined as low birth weight and stillbirth, was 9.5%. Syphilis seropositive women had a higher risk for adverse obstetric outcome (OR 4.1, 95% CI 2.4-7.2). Antenatal treatment of RPR reactive women significantly improved pregnancy outcome but the risk of adverse outcome remained 2.5-fold higher than the risk observed in uninfected mothers. CONCLUSIONS: These data confirm the adverse effect of syphilis on pregnancy outcome. This study also shows the efficacy of antenatal testing and prompt treatment of RPR reactive mothers on pregnancy outcome.