Eclampsia at Ga-Rankuwa Hospital.

OBJECTIVES: To study the epidemiology of eclampsia and the maternal and fetal outcome of the disease. DESIGN: Observational study. SETTING: Ga-Rankuwa Hospital, a tertiary institution. SUBJECTS: Patients admitted with the diagnosis of eclampsia from 1 January 1994 to 31 December 1995. OUTCOME MEASURES: Age, parity, booking status, fits, blood pressure, gestational age, mode of delivery, fetal outcome, maternal complications and outcome. RESULTS: Out of 18145 women delivered, 66 had eclampsia (3.6/1000). Of the 36 maternal deaths in the same period, 14 (38.9%) were caused by eclampsia. The case fatality rate was 21.2%. Maternal mortality was significantly higher in the unbooked population, women aged 30 years and above, and those with multiple fits. The mean (SD) maternal age was 22.3 (6.8) years and fits occurred in the presence of high diastolic blood pressure (mean 113.7 +/- 15.6 mmHg). The majority of fits (90.1%) occurred at home and in 70.3% of patients, this happened before 37 weeks (mean gestational age 33.2 (3.9) weeks). In 77.3%, eclampsia was antepartum while it occurred postpartum in 4.5% of cases. The caesarean section rate of 66.7% is justified. The perinatal mortality rate was 47.7% and maternal complications were varied and severe. It is disturbing that health care providers failed to act on warning signs in 14 (46.7%) of the 30 booked patients that were evident long before they developed fits. CONCLUSION: Eclampsia is a problem and is responsible for a significant proportion of maternal deaths. The epidemiological factors responsible are identified and some recommendations are made. Patient and physician education, together with improved socio-economic conditions, are likely to improve the situation.

Sexual behaviour, contraceptive practice and reproductive health among school adolescents in rural Transkei.

OBJECTIVES: To determine the patterns of sexual maturation, sexual behaviour, contraceptive practice and reproductive health among Transkeian adolescents. DESIGN: Cross-sectional descriptive study, using self administered questionnaires. SETTING: Twenty-six schools in 22 rural districts of the Transkei region of the Eastern Cape. SUBJECTS: Standard 5, 6 and 7 pupils of both sexes. OUTCOME MEASURES: Demographic and social characteristics, maturational and sexual behavioural milestones, and the prevalence of contraceptive use, pregnancies and sexually transmitted diseases (STDs). RESULTS: Data from 1,072 girls and 903 boys were analysed. The mean ages (+/-SD) of the girls and boys were 15.29 +/- 1.89 and 16.25 +/- 2.05 years, respectively. Menarche and semenarche occurred at 13.90 +/- 1.23 and 15.12 +/- 1.58 years in girls and boys, respectively. Overall, 76% of the girls and 90.1% of the boys in this survey were already sexually experienced. The age of initiation of sexual activity was positively correlated with the age of first dating and the age of menarche and semenarche. The boys initiated sexual activity at an earlier age (13.43 v. 14.86 years, P = 0.0000), had sexual intercourse more regularly (61.6% v. 42.3%, P = 0.0000) and more frequently, and had more lifetime sexual partners (mean of 3.27 v. 1.35, P = 0.0000) than the girls did. Nearly twice as many sexually experienced boys as girls had a history of STD (48% v. 25%, P = 0.0000) and, of these, 19.1% of the boys and 6.5% of the girls had a history of genital ulcer disease. The prevalence of whether contraceptives had ever been used was only 23% among sexually experienced girls and, of these, only 19.4% used condoms. Surprisingly, 62.1% of the sexually experienced boys had used condoms, and of these nearly one-third enjoyed using them. The prevalence of adolescent schoolgirl pregnancy was 31.3%. CONCLUSIONS: Sexual maturation occurs at an earlier age than previously among rural Transkeian adolescents. This is associated with early initiation and a high level of sexual activity, low contraceptive usage, and a high rate of adolescent pregnancy and STDs, which therefore expose adolescents to a high risk of HIV infection.

Adolescent sexual behaviour, knowledge and attitudes to sexuality among school girls in Transkei, South Africa.

Teenagers make up a quarter of all mothers in Transkei, South Africa, and well over 75% of them are unmarried. Such a high rate of teenage pregnancy is indicative of a high level of unprotected adolescent sexual activity. We examined sexual behaviour, knowledge and attitudes to sexuality among adolescent school girls in Transkei, using a self-administered questionnaire, in order to establish the incidence of sexual activity, and associated risk factors. Of the 1072 respondents, 74.6% were already sexually experienced, and 21.0% were not. The majority of sexually experienced girls (SEGs) and sexually inexperienced girls (SIGs) were living with both their parents. There were no religious differences between the two groups of girls. The age of SEGs at first coitus correlated positively with the age of menarche, and the age at the first date, suggesting that sexual maturation and onset of dating were possible risk factors for initiation of sexual activity. Contraceptive use was low, and a third of SEGs had been pregnant at least once. The knowledge of reproductive biology among both groups of girls was generally poor, although SEGs were significantly more knowledgeable than SIGs. The majority of girls in both groups did not approve of premarital sex, and adolescent pregnancy. They also did not approve of the idea of introducing sex education in schools, or the provision of contraceptives by schools. Nearly a third of the respondents in both groups did not wish to get married in future. In conclusion, there is a high level of unprotected sexual activity among school girls in Transkei. The risk factors for this include early sexual maturation, early onset of dating, and poor knowledge of reproductive biology and contraceptives.

PIP: In Transkei, South Africa, 25% of births are to teenagers, 75% of whom are unmarried. To investigate the factors associated with adolescent sexual activity and facilitate the design of preventive programs, a self-administered questionnaire was provided to 1025 females from 21 secondary schools. 800 (74.6%) were already sexually active; 18.7% had initiated coitus before menarche. Only 182 (23.5%) of these teens had ever used a modern method of contraception and 241 reported at least 1 pregnancy. Among sexually active teens, mean ages at menarche, first date, and first coitus were 13.91, 14.47, and 14.86 years, respectively. Major reasons cited for initiating coitus included forced by partner (28.4%), peer pressure (20.0%), carried away by passion (15.1%), to prove normality (11.7%), and to prove love of boyfriend (10.1%). The reasons provided by sexually inexperienced girls for delaying intercourse included religious values (25.4%), fear of pregnancy (23.8%), wish to wait for marriage (20.0%), fear of acquired immunodeficiency syndrome (AIDS) (15.6%), not emotionally ready (8.6%), and fear of sexually transmitted diseases and AIDS (6.4%). Knowledge of reproduction was low, with only 19% able to identify the fertile phase of the menstrual cycle. The majority of experienced (64.0%) and inexperienced (73.5%) girls disapproved of premarital sex while still in school; only 27.6% and 11.4%, respectively, supported the inclusion of sex education in the school curriculum. Overall, these findings indicate that early sexual maturation, early onset of dating, and poor knowledge of reproductive biology and contraception represent risk factors for unprotected sexual activity in this population and suggest a need for school-based family life education introduced before girls initiate sexual activity.

Clinical presentation of ectopic pregnancy in Transkei, South Africa.

Due to advances in diagnostic techniques, it has become possible to identify and manage ectopic pregnancies before they cause clinical symptoms in many developed countries. However, the situation appears not to be the same in developing countries. We carried out a cross-sectional study at Umtata General Hospital, which serves an underprivileged black South African population in order to document the incidence, risk factors, clinical presentation and complications of ectopic pregnancy. We found the incidence of ectopic pregnancy was 11 per 1000 reported pregnancies, and the mortality rate was 2.0%. Of 148 consecutive cases of ectopic pregnancy, 62.2% were in shock and two thirds were severely anaemic on arrival. About 71% of the cases had tubal rupture and 25% were chronic leaking ectopics. Only four intact unruptured ectopics were found in spite of the availability of modern diagnostic techniques such as ultrasonography and sensitive pregnancy tests. About 86% of the cases had evidence of previous pelvic infection, thus making pelvic inflammatory disease (PID) the most important risk factor for ectopic pregnancy. We conclude that most ectopic pregnancies in Transkei are associated with previous pelvic infection, and still present as acute emergencies. Preventive measures should aim at controlling sexually transmitted diseases and PID.

Surgical waiting lists I: Definition, desired characteristics and uses.

In the first of this two-part series, the authors define waiting lists, review the waiting list situation in Canada, discuss factors affecting such lists, outline their desired characteristics and describe the analysis and use of waiting list data. The manner in which lists are compiled results in significant differences which makes the meaning of waiting lists difficult to determine. From the literature reviewed and interviews with various health service executives, the authors show that waiting lists, as compiled today, are not a valid and reliable measure of the extent of unmet demands for hospital care. In Part II, which will be published in the next issue of FORUM, the authors will present the results of an exploratory survey done to determine how waiting lists and times are presently being compiled and used in secondary and tertiary hospitals. These findings will be summarized and compared to the desired characteristics and uses of a waiting list as presented in Part I.