Maternal near-miss and death among women with rupture of the gravid uterus: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden of maternal near-miss and death due to rupture of the gravid uterus, the indicators of quality of care, and avoidable factors associated with care deficiencies for ruptured uterus in Nigerian tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: Cases of severe maternal outcome [SMO: maternal near-miss (MNM) or maternal death (MD)] following uterine rupture were prospectively identified over 1 year. MAIN OUTCOME MEASURES: Incidence of SMO, indicators of quality of care, and avoidable factors associated with deficiencies in care. RESULTS: There were 91 724 live births and 3285 women with SMO during the study period. SMO due to uterine rupture occurred in 392 women: 305 MNM and 87 MD. Uterine rupture accounted for 11.9, 13.3, and 8.7% of all SMO, MNM, and MD, respectively. SMO, MNM, and intra-hospital maternal mortality ratios due to uterine rupture were 4.3/1000 live births, 3.3/1000 live births, and 94.8/100 000 live births, respectively. Mortality index (% of MD/SMO) was 22.2%, and MNM:MD ratio was 3.5. Avoidable factors contributing to deaths were related to patient-orientated problems, especially late hospital presentation and lack of insurance to cover life-saving interventions. Medical personnel problems contributed to care deficiencies in one-third of women who died. CONCLUSION: Uterine rupture significantly contributes to SMO in Nigerian tertiary hospitals. Strategies to improve maternal survival should address avoidable institutional factors and include community-based interventions to encourage skilled attendance at birth and early referral of complications. TWEETABLE ABSTRACT: Uterine rupture remains an important cause of maternal death in Nigerian tertiary hospitals.

HORMONAL PARAMETERS AND SEMEN MICROBIOLOGICAL PATTERN OF INFERTILE MALES: A COMPARATIVE CROSS-SECTIONAL STUDY IN BENIN CITY, SOUTH SOUTH NIGERIA.

BACKGROUND: In many Nigerian studies, male factors were responsible for up to 50 to 70% of infertility. AIM: To evaluate the contribution of endocrinopathy and bacteriospermia to male infertility in Benin. STUDY DESIGN: A comparative cross-sectional study. SETTING: Department of Obstetrics and Gynecology of Central Hospital, Benin City. METHODOLOGY: Male partners of 355 couples who presented with infertility over 8 months were studied. The data collected included socio-demographics, clinical features, hormonal assays, semen analysis, and semen culture. These were analyzed using Statistical Package for Social Sciences version 21.0, employing both univariate and bivariate analyses, and multivariate logistic regression to identify independent determinants of abnormal semen analysis. RESULTS: The mean age of the subjects was 34.98±4.67 years and mean duration of infertility was 4.5±2.17 years. A total of 59.7% patients were of low socioeconomic status. The participants had at least a primary school education, and 81.7% dwelt in the urban areas of the state. Secondary infertility was the commonest (82.3%); while 56.6% of the subjects were overweight and 14.9% obese. 66.5% of participants had abnormal semen parameters. Oligospermia was the commonest (22.8%) abnormality. The commonest hormonal disorders were abnormality of luteinizing hormone (79.1%) and follicle stimulating hormones (26.8%). There was positive semen culture in 162(43.6%) of participants, of which 135(83.3%) had abnormal semen analysis (p=0.000). Men with positive semen culture had more than four-fold odds of having abnormal semen analysis (OR=4.554; 95%CI=2.761-7.513). CONCLUSION: This study has shown that male endocrinopathy and bacteriospermia contributed significantly to male infertility in our environment.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country.

OBJECTIVE: To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals. DESIGN: Nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth and puerperal complications. METHODS: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS: Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care. CONCLUSIONS: Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care. TWEETABLE ABSTRACT: Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Maternal and fetal Acid-base chemistry: a major determinant of perinatal outcome.

Very small changes in pH may significantly affect the function of various fetal organ systems, such as the central nervous system, and the cardiovascular system with associated fetal distress and poor Apgar score. Review of existing data on maternal-fetal acid-base balance in pregnancy highlight the factors that are associated with derangements of the acid-base status and the impact of the derangements on fetal outcome. Extensive search of electronic databases and manual search of journals for relevant literature on maternal and fetal acid chemistry, clinical studies and case studies were undertaken. There is a substantial reduction in the partial pressure of carbon dioxide (pCO2) in pregnancy. Adequate buffering prevents significant changes in maternal arterial pH. Normal fetal metabolism results in the production of acids which are buffered to maintain extracellular pH within a critical range. Fetal hypoxia can occur when maternal oxygenation is compromised, maternal perfusion of the placenta is reduced, or delivery of oxygenated blood from the placenta to the fetus is impeded. When adequate fetal oxygenation does not occur, metabolisms proceed along with an anaerobic pathway with production of organic acids, such as lactic acid. Accumulation of lactic acid can deplete the buffer system and result in metabolic acidosis with associated low fetal pH, fetal distress and poor Apgar score. There is a significant reduction in pCO2 in pregnancy. This change, however, does not result in a corresponding significant reduction in maternal arterial pH, because of adequate buffering. Very small changes in pH may cause significant derangement in fetal function and outcome.

Maternal and Fetal Acid-Base Chemistry: A Major Determinant of Perinatal Outcome

Very small changes in pH may significantly affect the function of various fetal organ systems; such as the central nervous system; and the cardiovascular system with associated fetal distress and poor Apgar score. Review of existing data on maternal-fetal acid-base balance in pregnancy highlight the factors that are associated with derangements of the acid-base status and the impact of the derangements on fetal outcome. Extensive search of electronic databases and manual search of journals for relevant literature on maternal and fetal acid chemistry; clinical studies and case studies were undertaken. There is a substantial reduction in the partial pressure of carbon dioxide (pCO2) in pregnancy. Adequate buffering prevents significant changes in maternal arterial pH. Normal fetal metabolism results in the production of acids which are buffered to maintain extracellular pH within a critical range. Fetal hypoxia can occur when maternal oxygenation is compromised; maternal perfusion of the placenta is reduced; or delivery of oxygenated blood from the placenta to the fetus is impeded. When adequate fetal oxygenation does not occur; metabolisms proceed along with an anaerobic pathway with production of organic acids; such as lactic acid. Accumulation of lactic acid can deplete the buffer system and result in metabolic acidosis with associated low fetal pH; fetal distress and poor Apgar score. There is a significant reduction in pCO2 in pregnancy. This change; however; does not result in a corresponding significant reduction in maternal arterial pH; because of adequate buffering. Very small changes in pH may cause significant derangement in fetal function and outcome

Association of anti-Chlamydia antibodies with ectopic pregnancy in Benin city, Nigeria: a case-control study.

BACKGROUND: Ectopic pregnancy remains a major public health problem especially in many developing countries where it is a significant contributor to pregnancy related morbidity and mortality. OBJECTIVE: To determine the association between prior Chlamydia trachomatis infection and the risk of ectopic pregnancy. METHODS: A case-control study from two tertiary health care facilities in Benin City, Nigeria. Ninety eight women with ectopic pregnancy (cases) and another 98 women with uncomplicated intrauterine pregnancy (controls) matched for age, were interviewed using a semi-structured questionnaire and evaluated for serological evidence of prior Chlamydia trachomatis infection. RESULTS: The antibody titres in cases (48%) were significantly higher than in controls (16.3%) (p<0.001). However, the association between Chlamydia antibodies and ectopic pregnancy was attenuated when the effects of indicators of previous pelvic infections, socio-demographic characteristics, contraceptive and sexual history were controlled for. Primary level of education (OR = 6.32; CI, 2.31 - 17.3), three or more lifetime sexual partners (OR = 5.71; CI, 2.39 - 13.65) and prior history of vaginal discharge (OR = 5.00; CI, 2.03 - 12.3) were more likely to be associated with ectopic pregnancy than with the presence of antibodies to Chlamydia trachomatis (OR = 2.82; 95% CI, 1.33 - 5.95). The Population Attributable Risk was 30.9%. CONCLUSION: Chlamydial infections play only a limited role in the pathogenesis of ectopic pregnancy.

Antenatal determinants of oro-facial clefts in Southern Nigeria.

OBJECTIVES: Cleft lip with or without cleft palate, is the most common serious congenital anomaly that affects the orofacial regions. The management and care of the cleft patient constitutes a substantial proportion of the workload of the Nigerian maxillofacial surgeon and allied specialties. Yet, there are no specific programmes targeted at this group. We believe that the findings of this study is capable of identifying useful interventions for designing programs that will lead to a reduction in the burden of orofacial cleft in Nigeria. METHODS: It was a transverse cross-sectional study that was undertaken at the Maxillofacial Units of the University of Benin Teaching Hospital and the Central Hospital, Benin City respectively. The prevalence and antenatal determinants of cleft lip and palate were determined. RESULTS: Cleft lip and palate were often encountered in clinical practice in Benin City with a prevalence of 1.35%. The results showed that orofacial clefts were commoner in females and that the combined unilateral cleft lip and palate was the commonest entity encountered amongst the cases. The following risk factors were associated with the risk of development of cleft lip and palate: Paternal age >40 years, maternal age >35 years, genetic/family history, low socio-economic status, alcohol consumption and indulgence in the intake of herbal medications in pregnancy. CONCLUSION: Public health education programmes and advocacy activities geared towards raising awareness of the identified risk factors for the development of cleft lip and or cleft palate would go a long way to obviate the occurrence and reduce the burden.

The story of abortion: issues, controversies and a case for the review of the Nigerian national abortion laws.

Abortion continues to be a major public health issue that evokes social, political, legal, cultural and religious sentiments and debates in all societies. This is particularly so in countries with restrictive abortion laws. It is one of the leading causes of maternal mortality and morbidity. Despite variations in the legal status of abortions in favor of restrictiveness in developing countries compared with developed countries, overall rates are quite higher in the developing countries. This review article therefore, examines the historical perspectives of induced abortion as well as the issues and controversies associated with induced abortion. Also, a review of the Nigeria national abortion law is made. We believe that this is capable of identifying useful interventions for designing programs that will lead to a reduction in the burden of unsafe abortion in developing countries.

Factors Associated with the Knowledge; Perceptions and Practice of Pap Smear Screening for Cervical Cancer in Southern Nigeria

Background: Cervical cancer persists as a major reproductive health challenge in Nigeria with most cases presenting at advanced stage. Methods: This was an analytical cross-sectional survey of the factors associated with the knowledge; perceptions and practice of Pap smear screening amongst 238 women attending antenatal clinic at Central Hospital; Benin City; South-south Nigeria. Results: The median age of the respondents was 30 years (range = 18-49 years). The median parity was 1 (range = 0-5). Most of the respondents (49.2) had tertiary level of education closely followed by secondary level of education (42.2). Forty-five percent of the respondents were aware of cervical cancer and 22.3were aware of Pap smear screening. The sources were largely from the health personnel (32.1); journals/textbooks (26.4) and electronic media (26.4). Only 2.7of the respondents had ever had Pap smear screening done. The major determinants of utilization of Pap smear screening were knowledge of the test; non-availability of service delivery points; lack of spousal consent; fear that the test will detect cervical cancer and cost; with level of education strongly correlated with awareness of Pap smear screening. Awareness was shown on multiple logistic regression analysis as the only strong predictive factor for the practice of Pap smear screening. Conclusion :The knowledge and practice of Pap smear screening was poor; but the perception of the respondents was favorably excellent. We recommend reproductive health education programmes and advocacy activities; strengthening the existing opportunistic screening and establishing national guidelines for routine Pap smear screening

Coitally Related Traumatic Injury of the Female Genital Tract in a Nigerian Urban Setting: A-5 year review.

BACKGROUND: Available evidence suggests that most female lower genital tract injuries are primarily of coital origin and may result in death where prompt diagnosis and treatment is not obtained. Yet there is paucity of recent reports on this clinical entity from our setting. METHODS: This was a retrospective study of the service delivery records of patients with coital trauma seen at the University of Benin Teaching Hospital over 5 years. RESULTS: The incidence of coital trauma was 0.7% of the total gynaecological patients (3,300) seen within the study period. Majority (52.2%) of the patients were nulliparous. A significant proportion (73.9%) of the patients were single and 82.2% had primary or no formal education. Coital laceration occurred in sexual intercourse with boyfriends in 39.1% of patients and casual sex partners in 30.4% of cases. Non-consensual sex was reported in 47.8% of the patients and 39.1% had consensual sex. Sex was pre-marital in 65.2% of the cases. Inadequate or lack of foreplay was a significant predisposing circumstance to coital trauma (56.5%). Pain was a presenting symptom in 60.9% of cases, and same proportion of patients had laceration > 4cm. CONCLUSION: The incidence of coitally associated trauma was low. Nulliparity, low levels of education, non-consensual and premarital sex with little or no foreplay were strongly correlated with the risk of coital trauma. Severe forms of intra-peritoneal complications were not documented in this series. Management strategies were quite adequate.

Factors associated with the knowledge, practice and perceptions of contraception in rural southern Nigeria.

BACKGROUND: Significant proportion of maternal deaths in Nigeria is due to complications of unsafe abortions, and these abortions are responses to unwanted pregnancies that could have been prevented by effective contraceptive programming. Despite intense programmatic efforts by the Nigerian government and various non-governmental agencies to reverse the trend, there has been little evidence to suggest a systematic improvement in these indicators. METHODOLOGY: A household random survey of 1,528 women aged between 15-49 years was undertaken at Amukpe community in Nigeria, to determine their knowledge, practice and perceptions of contraception. RESULTS: The results showed that 86.2% of the respondents had secondary or less level of education and 19.2% of the respondents were single parents. The level of contraceptive awareness was high (92.3%) and 88% of the respondents became aware of contraception in the last 14 years. Friends/relatives (40.6%), followed by nurses (31.7%) and then doctors (17.3%) were the common sources of contraceptive awareness. The most widely known contraceptive methods were injectables, condoms, POP and OCP. The specific knowledge of emergency contraception was poor. The factors associated with low contraceptive usage were poor level of training and ineffective conveyance of relevant information to clients by health personnel, low literacy levels, extremes of reproductive age and extremes of parity. Others were fear of side effects, lack of knowledge, and lack of spousal consent. CONCLUSION: Contraceptive usage remain poor despite high level of awareness. Effective educational and counseling interventions are likely to improve providers' and consumers' knowledge and subsequent uptake of contraceptive usage.

Perceptions and attitudes of a rural community to abortion in the Niger-delta region of Nigeria.

OBJECTIVE: To determine the perceptions and beliefs relating to unwanted pregnancy, family planning and abortion, and identify issues that can be leveraged to initiate positive attitudes towards family planning and abortion in the area. MATERIALS AND METHODS: Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted in Amukpe, Delta State, Nigeria. A highly motivated and well-trained team versed in the local language and culture conducted the FGDs and IDIs. RESULTS: There was unanimity that unwanted pregnancies was quite common amongst women of reproductive age group and constitute a significant problem in the community. Abortion, particularly in the hands of quacks was a major option to handling an unwanted pregnancy. Almost all agreed that their culture and religion abhors abortion, yet widely practiced because of the odium associated with an unwanted pregnancy in the community. The knowledge of the Nigeria National abortion law even amongst the health workers and teachers was generally poor. The participants agreed that there were problems and complications (often severe) including death associated with abortion in the community. It was largely agreed that contraceptive knowledge and usage was poor. The reasons adduced for this include lack of knowledge, lack of spousal consent, socio-cultural taboos and misconceptions, as well as economic reasons. It was suggested that imbibing positive family values by parents in their wards and government leveraging the socio-economic status of the community will go a long way to stemming the tide. CONCLUSION: Unwanted pregnancy, unsafe abortion and abortion complications are reported to be common amongst women of reproductive age group in Amukpe community, whilst contraceptive awareness and usage is poor.

A decade of hysterectomy in a tertiary hospital in urban Niger-Delta region of Nigeria.

BACKGROUND: Hysterectomy is a very common gynaecological procedure which has a significant place in optimizing the reproductive health outcomes of women. OBJECTIVES: To document the indications, the type of hysterectomy commonly performed, the difficulties encountered and complications of the procedure at the Central Hospital, Benin City. MATERIALS AND METHODS: This was a retrospective review of the service delivery records of patients that had hysterectomy in the gynaecological unit between January, 1994 and December, 2003. RESULTS: There were 1216 major gynaecological operations during the study period. Of these, 131 (10.8%) hysterectomies were done. Total abdominal hysterectomy accounted for 80.4% of the procedures performed and most were done by consultants (94.4%). The mean age of the patients was 45.7 years with a median of 46 years and they were commonly grandmultiparous (71.0%). The commonest indication for the procedure was symptomatic uterine fibroid (62.3%) followed by urogenital prolapse (13.1%). The crude morbidity rate was 30.3% and the mortality rate was 1.6%. CONCLUSION: Hysterectomy in this centre is a fairly safe procedure. There is paucity of skills for vaginal and radical procedures. Training is advocated with a view to reducing the presently high morbidity rate as well as achieving our aim of optimizing the reproductive health outcomes of our women.

A case-control study of risk factors for male infertility in Nigeria.

AIM: To evaluate the association between selected potential socio-demographic and behavioral risk factors and infertility in Nigerian men. METHODS: There were two groups in this study. One group consisted of 150 men with proven male infertility, and the other consisted of 150 fertile men with normal semen parameters. Both were matched for age, place of residence and key socio-demographic variables. They were compared for sexual history, past medical and surgical history, past exposures to sexually transmitted infections and treatment, past and current use of drugs as well as smoking and alcohol intake history. RESULTS: Infertile men were significantly more likely than fertile men to report having experienced penile discharge, painful micturition and genital ulcers, less likely to seek treatment for these symptoms and more likely to seek treatment with informal sector providers. Multivariate analysis showed that male infertility was significantly associated with bacteria in semen cultures, self-reporting of previous use of traditional medications and moderate to heavy alcohol intake, but not with smoking and occupational types. CONCLUSION: INFERTILITY is associated with various proxies of sexually transmitted infections (STIs) and poor healthcare-seeking behavior for STIs in Nigerian men.

Experience with misoprostol in the management of missed abortion in the second trimester.

The aim of this study was to determine the effectiveness and safety of misoprostol (cytotec, Searle) used during labour in women with missed abortion in the second trimester of pregnancy. Labour was induced in 42 women with missed abortion at the Women's Health and Action Research Centre, Benin City, Nigeria with intermittent vaginal administration of 100 microg tablets of misoprostol every 6 h. All women achieved successful vaginal delivery with five women requiring post-delivery uterine evacuation. The gestational ages of the women at the time of induction ranged between 13-24 weeks with a median of 17 weeks. The median dose of misoprostol resulting in successful delivery was 1,100 microgand ranged between 300 microg to 3,100 microg. Side-effects were minimal with five patients experiencing shivering, two women experiencing fever, while three vomited during the period of the induction. These results confirm the efficacy and safety of misoprostol for induction of labour in second trimester missed abortion in Nigerian women. We conclude that misoprostol is effective in the management of missed abortion in the second trimester in Nigeria.