Implementation of the Revised National Malaria Control Guidelines: Compliance and Challenges in Public Health Facilities in a Southern Nigerian State.

Background: There has been a concerted effort to reduce malaria burden and bring malaria related mortality to zero. The objectives of this survey were to assess the level of adherence to the current revised malaria control guidelines in the public health facilities in Cross River State of Nigeria and to identify the challenges as well as suggest ways for improvement in treatment outcomes. Methods: This was a mixed observational and qualitative survey conducted in 32 public health facilities from 21st to 25th June 2022. Treatment records on malaria were assessed for adherence to the National guidelines. In-depth interviews were conducted with 36 key informants and 4 purposefully selected stakeholders to identify the successes and challenges. Quantitative data were summarized and presented in simple proportions and percentages while qualitative information was recorded, the transcripts thematically coded, analyzed and presented using NVivo 11 software. Results: The survey revealed that vector control program was poorly implemented across the state. For case management, presumptive treatment was frequently practiced especially at secondary health facilities for uncomplicated malaria. More than 60% of uncomplicated malaria were being treated with parenteral artemether instead of oral artemisinin combination therapy (ACTs) as recommended. Severe malaria were not treated with Intravenous (IV) Artesunate as first line drug in about 40% of the secondary health facilities. Key successes were noted in malaria management in pregnancy. Major challenges identified include: stock out of commodities, shortage of clinical man power, and low trust in parasitological diagnosis. Conclusion: The survey showed that adherence to the key recommendations in various categories of malaria control among health care providers in the public health facilities was below expectation. Malaria preventive treatment in pregnancy with SP fared better perhaps because of its inclusion in ANC packages.

A Comparative Evaluation of the Effects of N95 and Surgical Facemasks on Pregnant Women Performing Moderate-Intensity Exercise: A Prospective Randomized Study.

Background and objective A facemask is often indicated for the control of the spread of airborne pathogens. At the peak of the COVID-19 pandemic, there was mass enforcement of mask use across the globe. Pregnant women were not excluded. While several studies have been conducted to evaluate and compare the efficacy of various mask types, data on their effects on pregnant women during exercise are scarce. The objective of this study was to evaluate and compare the effects of N95 and surgical facemasks on the cardiopulmonary functions of pregnant women during moderate-intensity exercise. Methods A prospective randomized study was conducted among 104 healthy women with advanced singleton pregnancies performing moderate-intensity exercise wearing either surgical or N95 masks during routine antenatal care. Their respiratory rates were counted, and arterial oxygen saturation (SPO2) and radial pulses (heart rates) were recorded with a mobile digital pulse oximeter at baseline and after 30 minutes of exercise. The mean values were calculated. Data analysis was done using Statistical Product and Service Solutions (SPSS, version 25; IBM SPSS Statistics for Windows, Armonk, NY). An independent t-test was used to compare the mean SPO2 and radial pulse between the two groups. Chi-square was used to examine differences in categorical variables. The level of significance was set at 0.05. Results Their demographic profiles and measured baseline parameters were comparable. Following a 30-minute exercise, the N95 mask group had lower mean SPO2 compared to the surgical mask group (95.5% versus 97.0%; P=0.028, 95%CI; -2.607 to 0.15). Further, the N95 group recorded a higher mean heart rate than the surgical mask group ((97.23 b/m versus 95.02b/m, respectively, mean difference (MD)=2.212, P=0.021, 95%Cl: 1.249-3.672). The mean respiratory rates were also higher among women in the N95 mask group (32.1 c/m versus 29.08 c/m, MD=3.018, 95%CI: 1.392-4.662, P=0.001). Conclusion The study, comparing the relative effects of the surgical and N95 facemask on the cardiorespiratory functions of exercising pregnant women, findings suggest that surgical facemasks may be better tolerated in advanced pregnancy when performing routine antenatal aerobic exercise in comparison with N95 masks.

Effectiveness of Combined Preoperative Sublingual Misoprostol and Intravenous Tranexamic Acid on Intraoperative Blood Loss During Elective Caesarean Section: A Randomised, Blinded, Placebo-Controlled Trial.

INTRODUCTION: The objective of this study was to evaluate the effect of preoperative administration of sublingual misoprostol and intravenous tranexamic acid (TXA) on intraoperative blood loss during elective caesarean sections. METHODS: This was a double-blinded, randomised, placebo-controlled study involving 116 women scheduled for elective caesarean sections. The treatment arm, group 1 (n=58), received 1000 mg of intravenous tranexamic acid 10-15 minutes before skin incision and 600 mcg of sublingual misoprostol after sub-arachnoid anaesthesia and before skin incision. Group 2 (n=58) received placebos; both groups had oxytocin injections at the delivery of the placenta. The data were analyzed using IBM® Statistical Package for the Social Sciences (SPSS) version 24 (IBM Corp., Armonk, NY). RESULTS: The primary outcome was the intraoperative blood loss and the difference between preoperative and postoperative hematocrit values in both groups. The mean intraoperative blood loss was significantly lower in the study group than in the control group (308.552 ± 42.991 mL versus 736.414 ± 171.889 mL, p<0.001). The differences between the preoperative and post-operative hematocrit values were also significantly lower in the study group than in the control group (2.212% ± 0.805% versus 5.660% ± 2.496%, p<0.001). CONCLUSION: Preoperative administration of 1000 mg of intravenous tranexamic acid and 600 mcg of sublingual misoprostol significantly reduced blood loss related to elective caesarean delivery.

Infant-Feeding Practices Among Women Living With Human Immunodeficiency Virus (HIV) in a Southern Nigerian Region: A Mixed Comparative Study.

Background and objective  Infant survival depends on proper nutrition. Breastfeeding enhances infant health and offers some benefits to the mother as well. However, in the setting of the HIV pandemic, it is important to assess the benefits and the risk for each individual in choosing a feeding option. The purpose of this research was to determine the infant-feeding practices among women living with HIV/AIDS (WLWHA) and compare them with the general population of women. Methods A mixed comparative survey was conducted among 246 HIV-positive mothers nursing infants of at least one year of age. An equal number of matched HIV-negative women from the same locality were selected as controls. Quantitative data were analyzed using IBM SPSS Statistics version 23 (IBM Corp., Armonk, NY) while qualitative findings were presented in a thematic approach. Results The prevalence of exclusive breastfeeding (EBF) among WLWHA was 73.6% compared to 55.2% in the controls [p=0.002; chi-square (X2)=5.264]. Only 6.5% of WLWHA practiced exclusive replacement feeding (ERF). Vaginal birth was associated with increased odds for early initiation of breastfeeding [p=0.001; odds ratio (OR): 3.135; 95% confidence interval (CI): 2.130 to 4.616]. Also, urban dwellers commenced breastfeeding earlier than women residing in rural communities (p=0.002; OR: 5.58; 95% CI: 3.85 to 8.07). Based on in-depth interviews, cultural influences and non-disclosure of HIV status to family members promoted mixed feeding. Concomitant intake of anti-tuberculosis drugs was a major reason for adopting ERF in some women. Conclusion There was a high prevalence of EBF among WLWHA. Counseling on infant feeding is an effective component of the Prevention of Mother-to-Child Transmission (PMTCT) programs. Cultural beliefs and fear of stigmatization are major challenges to infant nutrition in sero-exposed babies.

The Influence of Threatened Miscarriage on Pregnancy Outcomes: A Retrospective Cohort Study in a Nigerian Tertiary Hospital.

BACKGROUND: Pregnancies complicated by threatened miscarriage (TM) may be associated with adverse pregnancy outcomes. The objective of this study was to compare the differences in pregnancy outcomes between the women who experienced TM and asymptomatic controls. METHODS: This was a 10-year retrospective review. Case records of 117 women who were managed for TM from January 1, 2010, to December 31, 2019, were retrieved and studied. The control group was developed from an equal number of asymptomatic clients matched for age, parity, and BMI who were receiving antenatal care (ANC) during the same period. Data on demography, clinical and ultrasound findings, treatment, and pregnancy outcomes were retrieved and analyzed. RESULTS: Spontaneous abortion rate of 13.7% was recorded among the study group compared with 3.4% in the control (P-value [p] = 0.005, odds ratio [OR]: 4.475; 95% confidence interval [CI]: 1.445 - 13.827). Women with TM had higher odds for placenta previa (p = 0.049, OR: 4.77, 95% CI: 2.19 - 23.04), premature rupture of membranes (PROM) (p = 0.028, OR: 1.918, 95% CI: 1.419 - 2.592), postpartum hemorrhage (PPH) (p = 0.001, OR: 2.66, 95% CI: 20.8 - 8.94), and preterm birth (OR: 2.5, 95% CI: 1.75 - 3.65). They were also more likely to undergo cesarean section (p = 0.020, OR: 1.70, 95% CI: 1.053 - 2.964). There was no statistically significant difference in their infants' mean birth weight (3.113 ± 0.585kg for the TM group and 3.285± 0.536kg for the control, P=0.074). Other maternal and perinatal complications were similar. Admission for bed rest significantly improved fetal survival. Women who were not admitted for bed rest had higher odds of pregnancy loss (OR: 3.443, 95% CI: 1.701-7.99). Other treatment plans did not significantly contribute to a positive outcome. CONCLUSION: Threatened miscarriage is a significant threat to fetal survival and may increase the risk for operative delivery. Bed rest improves the live birth rate.

Establishing event-based surveillance system in Nigeria: a complementary information generating platform for improved public health performance, 2016.

Introduction: event-based surveillance (EBS) is a surveillance method involving systematic and prompt data collection on incidents of public health importance, and complements the current indicator-based surveillance system and the Integrated Disease Surveillance and Response System (IDSR). It also promotes a rapid assessment and response to public health emergencies in Nigeria, although there is a lack of information regarding the status of EBS among Public Health Stakeholders in Nigeria; hence our study aimed to assess the awareness, availability, and utility of EBS among Nigerian public health stakeholders. Methods: we conducted a cross-sectional study to assess the awareness, availability, functionality, and utilization of EBS in the 36 States in Nigeria, plus the Federal Capital Territory (FCT). We interviewed 53 stakeholders in disease surveillance and response using a self-administered, semi-structured questionnaire to obtain responses on the awareness of the event-based surveillance system, availability, and functionality. We also assessed the common structures used to report health-related events and the availability of minimum requirements for an event-based surveillance system. We performed descriptive statistics for the data obtained. Results: the majority of respondents were males and 37.7% were disease surveillance and notification officers (DSNOs). Awareness of EBS was poor with about half, 49% of the respondents reported hearing of EBS, but only 17% described it correctly. The overall level of availability of the EBS reporting structure was inadequate, 28.2% and poorly utilised in the States. Conclusion: the awareness, availability, and utilization of event-based surveillance systems are low in Nigeria. The government should improve the feasibility and utility of EBS in the States to enhance early disease detection and response.

Diabetes in pregnancy and risk of near-miss, maternal mortality and foetal outcomes in the USA: a retrospective cross-sectional analysis.

BACKGROUND: The prevalence of diabetes in pregnant women has increased in the USA over recent decades. The primary aim of this study was to assess the association between diabetes in pregnancy and maternal near-miss incident, maternal mortality and selected adverse foetal outcomes. METHODS: We conducted a retrospective, cross-sectional analysis among pregnancy-related hospitalizations in USA between 2002 and 2014. We examined the association between DM and GDM as exposures and maternal in-hospital mortality, maternal cardiac arrest, early onset of delivery, poor foetal growth and stillbirth as the outcome variables. RESULTS: Among the 57.3 million pregnant women in the study population, the prevalence of GDM and DM was 5.4 and 1.3%, respectively. We found that pregnant women with DM were three times more likely to experience cardiac arrest (OR = 3.21; 95% CI = 2.57-4.01) and in-hospital maternal death (OR = 3.05; 95% CI = 2.45-3.79), as compared to those without DM. Among pregnant women with GDM and DM, the risk for early onset of delivery was higher, compared to women without GDM or DM. CONCLUSION: A diagnosis of diabetes prior to pregnancy contributes significantly to the risk of maternal cardiac arrest, maternal mortality and adverse foetal outcomes.

Predictors and Utilization of Health Institution Services for Childbirth among Mothers in a Southern Nigerian City.

BACKGROUND: Poor maternal health indices, including high maternal mortality, are among Nigeria's major public health problems. Most of these deaths can be prevented by timely access and utilization of maternity healthcare services by women. Aim/Objective. This study seeks to identify factors affecting the utilization of health facilities for the delivery of babies among mothers in Calabar, Cross River State, Nigeria. Methodology. The study was a community-based cross-sectional study. A structured questionnaire was administered to 422 women of reproductive age residents in the study area who had given birth at least once within the last five years prior to the survey using a multistage random sampling technique. Data generated were entered, coded, and analyzed using Statistical Packages for Social Sciences (SPSS version 22.0), and results were presented in tables and charts. Chi-squared tests and multiple logistic regression were used for the identification of variables associated with health facility-based delivery. RESULT: The mean age of respondents was 27.3 years (SD = 8.4). Fifty-two percent of the respondents utilized the health facility for delivery, 89.6% attended at least one antenatal clinic (ANC), and 18.9% completed at least 3 ANC sessions. There was a statistically significant association between health facility delivery and marital status (P=0.007), education (P=0.042), and family size (P=0.002). Older women (OR = 0.7, CI = 0.169-3.714), Christians (OR = 1.9, CI = 0.093-41.1), divorcees (OR = 3.7, CI = 0.00-0.00), and respondents who registered early (first trimester) for ANC (OR = 4.9, CI = 0.78-31.48) were found to be higher users of delivery services at the health facility. CONCLUSION: Community health intervention focusing on improving the knowledge and awareness of the significance of utilizing available delivery services at the healthcare facility should be developed and implemented.

A feasibility hybrid II randomised controlled trial of volunteer 'Health Champions' supporting people with serious mental illness manage their physical health: study protocol.

BACKGROUND: People with serious mental illnesses (SMI) such as schizophrenia often also have physical health illnesses and interventions are needed to address the resultant multimorbidity and reduced life expectancy. Research has shown that volunteers can support people with SMI. This protocol describes a feasibility randomised controlled trial (RCT) of a novel intervention involving volunteer 'Health Champions' supporting people with SMI to manage and improve their physical health. METHODS: This is a feasibility hybrid II randomised effectiveness-implementation controlled trial. The intervention involves training volunteers to be 'Health Champions' to support individual people with SMI using mental health services. This face-to-face or remote support will take place weekly and last for up to 9 months following initial introduction. This study will recruit 120 participants to compare Health Champions to treatment as usual for people with SMI using secondary community mental health services in South London, UK. We will measure the clinical and cost effectiveness including quality of life. We will measure the implementation outcomes of acceptability, feasibility, appropriateness, fidelity, barriers and enablers, unintended consequences, adoption and sustainability. DISCUSSION: There is a need for interventions to support people with SMI with their physical health. If this feasibility trial is successful, a definitive trial will follow to fully evaluate the clinical, cost and implementation effectiveness of Health Champions supporting people with SMI. TRIAL REGISTRATION: ClinicalTrials.gov, registration no: NCT04124744 .

Erratum to "Severe Life-Threatening Pregnancy Complications, "Near Miss" and Maternal Mortality in a Tertiary Hospital in Southern Nigeria: A Retrospective Study".

[This corrects the article DOI: 10.1155/2020/3697637.].

Severe Life-Threatening Pregnancy Complications, "Near Miss" and Maternal Mortality in a Tertiary Hospital in Southern Nigeria: A Retrospective Study.

BACKGROUND: Investigating severe life-threatening pregnancy complications that women encounter and the maternal morbidities (near miss) may help to evaluate the quality of care in health facility and recommend ways to improve maternal and infant survival especially in low-income countries. The aim of this review was to identify, classify, and determine the frequency and nature of maternal near miss events and the maternal and perinatal outcomes. METHODS: A retrospective facility-based review of cases of near miss and maternal mortality occurring between 1st January 2012 and 31st December 2016 at the University of Calabar Teaching Hospital was conducted. Near miss case definition was based on the WHO disease specific criteria. The main outcomes included the maternal mortality ratio (MMR), maternal near miss ratio (MNMR), mortality index, maternal morbidities, and perinatal outcome. RESULTS: There were 10,111 pregnancy-related admissions, 790 life-threatening pregnancy complications that resulted in 99 maternal deaths, and 691 near miss cases. The maternal mortality ratio was 979 maternal deaths per 100,000 live births, and the maternal near miss ratio was 6,834 per 100,000 maternities. The MMR to MNMR ratio was 1 : 8. Sepsis and severe anaemia had high case-specific mortality indices of 0.4 and 0.53, respectively. The perinatal outcome was poor compared to that of uncomplicated pregnancies: perinatal mortality rate (PMR) 266 per 1000 live births (OR 7.74); neonatal intensive care (NIC) admissions 11.6 percent (OR 1.83); and low birth weight (LBW) (<2.5 kg) 12.19 percent (OR 1.89). CONCLUSION: Antenatal care and early recognition of danger signs in pregnancy as well as prompt referral and early institution of essential obstetrics care are important for maternal and infant survival.

Uterine Rupture with Evisceration of Intestines through the Vagina during Labour.

Uterine rupture is a life threatening obstetric emergency and is associated with high maternal and perinatal mortality. There are some risk factors associated with uterine rupture which may include: prolonged obstructed labour, previous scarred uterus, grand-multiparity, macrosomic baby, abnormal lie, instrumental delivery, induction of labour, oxytocin stimulation and excessive uterine manipulation. Its modes of presentation have been widely reported. Here, we present a case with an unusual mode of presentation where about two-third of the small intestines protruded through the vagina following some manipulations by an unskilled birth attendant. This highlights the fact that when uterine rupture is suspected, the cord-like structure protruding per vaginum may not always be umbilical cord.

Trend and Causes of Maternal Mortality in a Nigerian Tertiary Hospital: A 5-year Retrospective Study (2010-2014) at the University of Calabar Teaching Hospital, Calabar, Nigeria.

BACKGROUND: Maternal mortality ratios (MMR) are still unacceptably high in many low-income countries especially in sub-Saharan Africa. MMR had been reported to have improved from an initial 3,026 per 100,000 live births in 1999 to 941 in 2009, at the University of Calabar Teaching Hospital (UCTH), Calabar, a tertiary health facility in Nigeria. Post-partum haemorrhage and hypertensive diseases of pregnancy have been the common causes of maternal deaths in the facility. AIM: This study was aimed at determining the trend in maternal mortality in the same facility, following institution of some facility-based intervention measures. METHODOLOGY: A retrospective study design was utilised with extraction and review of medical records of pregnancy-related deaths in UCTH, Calabar, from January 2010 to December 2014. The beginning of the review period coincided with the period the "Woman Intervention Trial" was set up to reduce maternal mortality in the facility. This trial consists of the use of Tranexamic acid for prevention of post-partum haemorrhage, as well as more proactive attendance to parturition. RESULTS: There were 13,605 live births and sixty-one (61) pregnancy-related deaths in UCTH during the study period. This yielded a facility Maternal Mortality Ratio of 448 per 100,000 live births. In the previous 11-year period of review, there was sustained the decline in MMR by 72.9% in the initial four years (from 793 in 2010 to 215 in 2013), with the onset of resurgence to 366 in the last year (2014). Mean age at maternal death was 27 ± 6.5 years, with most subjects (45, 73.8%) being within 20-34 years age group. Forty-eight (78.7%) were married, 26 (42.6%) were unemployed, and 33 (55.7%) had at least secondary level of education. Septic abortion (13, 21.3%) and hypertensive diseases of pregnancy (10, 16.4%) were the leading causes of death. Over three quarters (47, 77.0%) had not received care from any health facility. Most deaths (46, 75.5%) occurred between 24 and 97 hours of admission. CONCLUSION: Compared with previous trends, there has been a significant improvement in maternal mortality ratio in the study setting. There is also a significant change in the leading cause of maternal deaths, with septic abortion and hypertensive disease of pregnancy now replacing post-partum haemorrhage and puerperal sepsis that was previously reported. This success may be attributable to the institution of the Woman trial intervention which is still ongoing in other parts of the world. There is, however, need to sustain effort at a further reduction in MMR towards the attainment of set sustainable development goals (SDGs), through improvement in the provision of maternal health services in low-income countries.

Antenatal Deworming and Materno-Perinatal Outcomes in Calabar, Nigeria.

BACKGROUND: Studies have shown that administration of anthelmintic drugs in pregnancy can reduce the incidence of maternal anaemia; however, data on other maternal and perinatal outcomes are limited. AIM: This study was therefore conducted to evaluate the direct impact of mass deworming on delivery and perinatal outcome. MATERIAL AND METHODS: A total of 560 healthy pregnant women in their second trimester were randomised to receive a single dose of oral mebendazole (500 mg) and placebo. Each participant received the standard dose of iron supplement and malaria prophylaxis. They were followed up to delivery and immediate postpartum period to document the possible impact on maternal and perinatal outcomes. RESULTS: The prevalence of anaemia at term, 37 weeks gestation and above, among the treatment arm was 12.6% compared with 29.9% in the placebo arm (p < 0.001). Caesarean section rates was higher in the treated group and the placebo (p = 0.047). There were no statistically significant differences in incidences of postpartum haemorrhage (p = 0.119), Puerperal, pyrexia (p = 0.943), low birth weight (p = 0.556) asphyxia (p = 0.706) and perinatal death (p = 0.621). CONCLUSION: Presumptive deworming during the antenatal period can significantly reduce the incidence of peripartum anaemia. However, more studies may be needed to prove any positive perinatal outcome.

Factors Influencing Antenatal Haematinics Prescription Behaviour of Physicians in Calabar, Nigeria.

BACKGROUND: Routine iron and folic acid supplementation in pregnancy have been proved to be effective in reducing the prevalence and morbidities of anaemia. However, there is limited data regarding the prescription habits of physician obstetric care givers. AIM: This study set to investigate the attitudes and factors which influence the practice among physicians in University of Calabar Teaching Hospital (UCTH). MATERIAL AND METHODS: A questionnaire based cross-sectional survey was conducted among randomly recruited physician offering antenatal services between August and September 2015. Systemic sampling was used to select 70 doctors in the departmental duty roster. Data were presented in percentages and proportion. Chi-square test was used to test the association between variables. Statistical significance was set at p < 0.05. RESULTS: The response rate was 100%. The mean age of the respondents was 30.26 ± 6.67 years. All the respondents routinely prescribed haematinics to pregnant women but 34.3% of them did not prescribe to apparently healthy clients in their first trimester. Only 30% and 11.4% of them prescribed it in the postnatal and preconception periods respectively. Brands that contained iron, folate and vitamins as a single capsule were mostly favoured, and information about brands of drugs was mostly provided by the pharmaceutical sales representatives. Younger doctors were more likely to offer haematinics with nutritional counselling compared to older respondents. However, there was no significant relationship between haematinics prescription and sex (p = 0.3560), Age (p = 0.839), current professional status (p = 0.783), and client complaint of side effect of medication (p = 0.23). Oral medication was mostly utilised. CONCLUSION: Effort to effectively control anaemia in pregnancy should involve re-orientation of physician obstetric care providers especially about prenatal and postnatal medication and counselling.

HIV infection in pregnancy: maternal and perinatal outcomes in a tertiary care hospital in Calabar, Nigeria.

BACKGROUND: Human immunodeficiency virus (HIV) infection is likely to have untoward effects on pregnancy and its outcome. This study assessed the impact of maternal HIV infection on pregnancy outcomes in a tertiary centre in Calabar, Nigeria. METHODS: This retrospective study analysed delivery records of 258 HIV-positive and 257 HIV-negative women for pregnancy and delivery complications. Maternal and fetal outcomes of HIV-positive pregnancies were compared with those of HIV-negative controls. RESULTS: Adverse pregnancy outcomes significantly associated with HIV status were: anaemia: 33 (8.1%) vs. 8 (3.1%) in controls; puerperal sepsis: 18 (7%) vs. 2 (0.8%); and low birth weight: 56 (21.7%) vs. 37 (14.4%). Caesarean delivery was higher among HIV-positive women than controls: 96 (37.2%) vs. 58 (22.6%). Preterm births were higher in those HIV cohorts who did not receive antiretroviral therapy (ART): 13 (16.9%) vs. 7 (3.9%). CONCLUSION: HIV-positive status increased adverse birth outcome of pregnancy. ART appeared to reduce the risk of preterm births in HIV-positive cohorts.