Scourge of intra-partum foetal death in Sub-Saharan Africa.

Intra-partum foetal death has been variously defined. However, a definition adopted at a technical consultation in 2006 is employed in this review. The quality of intra-partum care is a crucial factor for pregnancy outcome for both mothers and new-borns. Intra-partum stillbirth is defined as late foetal death during labour, which clinically presents as fresh stillbirth. The largest proportion of the world's stillbirths occurs in the late preterm, term and intra-partum periods. The Western Pacific region has the greatest reduction in stillbirth with a 3.8% annual decline between 1995 and 2009; however, the annual decline in the African region is less than 1%. Caesarean delivery is still uncommon, especially in rural areas: 1% of births in rural Sub-Saharan Africa and 5% in rural South Asia are by caesarean delivery; 62% of stillbirths occurred during the intra-partum period; 61.4% of stillbirths are attributable to obstetrical complications. Preventive measures aimed at reducing the incidence of intra-partum foetal death entail all measures aimed at improving quality antenatal care and preventing intra-partum asphyxia. This review discusses intra-partum foetal deaths from a Sub-Saharan African perspective. It explores the contribution of research within the region to identifying its impact on new-born health and potential cost-effective policy interventions.

Endometriosis and associated symptoms among Nigerian women.

OBJECTIVE: To determine the prevalence of endometriosis and identify associated symptoms among Nigerian women. METHODS: A cross-sectional study was conducted at a center in Ibadan, Nigeria, between October 2008 and December 2010. All women aged 18-45 years scheduled for their first diagnostic laparoscopy for gynecologic indications were enrolled. Participants completed a previously validated self-administered questionnaire. Endometriosis was diagnosed on the basis of visual evidence. RESULTS: Among 239 women analyzed, 115 (48.1%) had endometriotic lesions. Endometriosis was more common among women reporting dysmenorrhea and pelvic pain than among those not reporting these symptoms (20/28 [71.4%] vs 95/211 [45.0%]; P=0.009). Women who reported dysmenorrhea were significantly more likely to have endometriosis than were those without dysmenorrhea (90/171 [52.6%] vs 25/68 [36.8%]; P=0.027). The risk of endometriosis was not significantly increased in women with one pain symptom (odds ratio [OR]1.69; 95% confidence interval [CI] 0.67-4.27), but was significantly increased in women with two (OR 2.70; 95% CI 1.13-6.52) or three (OR 4.87; 95% CI 1.88-12.82) pain symptoms (χ(2)trend=15.5; P<0.001). In a multivariate logistic regression model, only pain other than dysmenorrhea or dyspareunia independently predicted endometriosis (P=0.017). CONCLUSION: Endometriosis is fairly common among Nigerian women. Efforts to increase the awareness of endometriosis among the public, researchers, and clinicians are needed.

The knowledge base and acceptability of prenatal diagnosis by pregnant women in Ibadan.

This cross-sectional study evaluated knowledge and acceptability of prenatal diagnosis among 500 pregnant women at the University College Hospital, Ibadan. Most participants were aged 25-34 years, self-employed, Muslim, monogamy, secondary school leavers, on income of < naira10,000.00 (US$ 67.00)/month. Attitudinal mean score was dependent on age (p = 0.006), educational attainment (p = 0.001), marital status (p = 0.025) and religion (p = 0.012). Knowledge mean score was influenced by marital status (p = 0.028). Overall, acceptance of prenatal diagnosis was high. There was a direct correlation between acceptance and educational attainment: 41.5%, 31.50%, 19%, 19% of women who agreed to have prenatal diagnosis had tertiary, secondary school, primary school and no formal education respectively. Determinants of acceptability were age, educational attainment, marital status and religion. Being married significantly affected knowledge scores, while tertiary education, being divorced, unskilled and self-employed positively influenced attitude towards prenatal diagnosis.

Attitude and practices of obstetricians and gynecologists towards involvement of physiotherapists in management of obstetric and gynecologic conditions.

BACKGROUND: The role of physiotherapists in obstetrics and gynecology is pivotal. However, utilization of their capabilities depends on the cooperation of other health professionals in discharging their services to patients, who are the focus of the team. This study was designed to assess the attitude of obstetricians and gynecologists in south-western Nigeria towards involving physiotherapists in the management of patients with obstetric and gynecologic conditions. METHODS: This was a descriptive survey of obstetricians and gynecologists from seven hospitals in south-western Nigeria. Sixty-seven participants, including 41 senior registrars and 26 consultants, participated in the study. More consultants (73.1%) than senior registrars (46.3%) had a good knowledge of the role of physiotherapists in obstetric and gynecological practice. All participants had general knowledge of the role of physiotherapists in obstetrics and gynecology, but a limited knowledge of specific conditions amenable to treatment by physiotherapists. More senior registrars had a better attitude (73.2%) than consultants (53.8%) towards involvement of physiotherapists in their practice, and 94.0% of the obstetricians and gynecologists utilized the services of physiotherapists, with referral of patients (56.7%) mainly to physiotherapists working in general/state hospitals. CONCLUSION: There is a need for better interaction and communication between physiotherapists and obstetricians and gynecologists, which could be achieved through clinical meetings, seminars, and workshops.

Misoprostol as first-line treatment for incomplete abortion at a secondary-level health facility in Nigeria.

OBJECTIVE: To determine the feasibility of introducing misoprostol as first-line treatment for incomplete abortion at a secondary-level health facility. METHODS: An open-label prospective study was conducted in a secondary-level health facility in Nigeria. Eligible women diagnosed with incomplete abortion received 400-µg sublingual misoprostol as first-line treatment. Nurse-midwives took the lead in diagnosis, counseling, treatment, and assessment of final outcome. The primary outcome was the proportion of women who completed the abortion process. RESULTS: Complete evacuation was achieved in 83 of 90 (92.2%) eligible women. The most common adverse effects were abdominal pain/cramps (58 [64.4%]), heavy bleeding (21 [23.3%]), spotting (15 [16.7%]), and fever/chills (11 [12.2%]). More than 90% of women reported that the procedure was satisfactory, that pain and adverse effects were tolerable, and that bleeding was acceptable. Eighty-four (93.3%) and 86 (95.6%) women, respectively, would use the method in the future and recommend it to friends. CONCLUSION: Misoprostol is an effective, safe, and acceptable method for treating incomplete abortion. It can be successfully used as first-line treatment by nurse-midwives. Success rates over 90% are consistent with findings from previous studies in which drug administration was controlled solely by physicians.

Determinants of perinatal mortality in Nigeria.

OBJECTIVE: To determine risk factors for perinatal mortality among hospital-based deliveries in Nigeria. METHODS: The WHO Global Maternal and Perinatal Health Survey was implemented in Nigeria as a first step in establishing a global system for monitoring maternal and perinatal health. Twenty-one health facilities with more than 1000 deliveries annually were selected by a stratified multistage cluster sampling strategy. Information was recorded on all women who delivered and their neonates within a 3-month period. RESULTS: Overall, there were 9208 deliveries, comprising 8526 live births, 369 fresh stillbirths, 282 macerated stillbirths, 70 early neonatal deaths, and 721 perinatal deaths. The stillbirth and perinatal mortality rates were, respectively, 71 and 78 per 1000 deliveries; the early neonatal death rate was 8 per 1000 live births. Approximately 10% of all newborns weighed less than 2500 g, and 12.3% were born at less than 37 weeks of gestation. Predictors of perinatal mortality were mother's age, lack of prenatal care, unbooked status, prematurity, and birth asphyxia. CONCLUSION: The perinatal mortality rate remains unacceptably high in Nigeria. Fresh stillbirth accounted for most perinatal deaths. Interventions to improve the utilization and quality of prenatal care, in addition to the quality of intrapartum care, would considerably reduce perinatal death.

A double-blind, randomized, placebo-controlled trial of misoprostol and routine uterotonics for the prevention of postpartum hemorrhage.

OBJECTIVE: To assess the effects of 400-µg sublingual misoprostol plus routine uterotonics on postpartum hemorrhage. METHODS: A double-blind, placebo-controlled, randomized study was performed. After delivery of the child, eligible women received routine uterotonics and were randomly allocated to receive 400-µg misoprostol or placebo sublingually. The primary outcome measure was blood loss of at least 500 mL within 1 hour of taking the trial tablets. RESULTS: In total, 672 women received misoprostol and 673 received placebo. The baseline data were similar for both groups. Misoprostol plus routine uterotonics reduced postpartum blood loss, but the effect was not significant for blood loss of at least 500 mL (relative risk [RR] 0.96; 95% confidence interval [CI], 0.63-1.45) or blood loss of at least 1000 mL (RR 0.50; 95% CI, 0.15-1.66). Misoprostol also reduced the need for non-routine oxytocin, manual removal of the placenta, and hysterectomy, but these differences were not significant either. Misoprostol was associated with pyrexia and moderate/severe shivering. There was no death in either group. CONCLUSION: Misoprostol plus routine uterotonics resulted in modest reductions of blood loss in the third stage of labor, but the effects did not reach statistical significance. Larger studies are recommended.

Active management of third stage of labor: evidence versus practice.

OBJECTIVE: To determine the correct use of active management of third stage of labor (AMTSL) (using the full complement of existing standard definitions) and compare the outcomes of third stage of labor in women who received AMTSL (according to these definitions) with those who did not. DESIGN: Observational, cross-sectional survey. SETTING: Seven tertiary centers in southwest Nigeria. POPULATION: Women undergoing non-instrumental vaginal deliveries. METHODS: Prospective direct observations of childbirth procedures. AMTSL was defined according to Cochrane review, ICM/FIGO (International Confederation of Midwives/International Federation of Gynecology and Obstetrics), and WHO (World Health Organization) recommendations. Main outcome measures. Use of AMTSL and its components and outcome of third stage of labor. RESULTS: There was a high rate of compliance with most of the individual components of AMTSL. The use of AMTSL varied widely with the definition applied and tended to decrease with increasing strictness of the criteria (Cochrane review: 88.9%; ICM/FIGO: 42%; WHO: 1.8%). The frequencies of adverse labor outcomes were generally low (postpartum hemorrhage (PPH): 4.9%; severe PPH: 0.8%; retained placenta: 1.9%; uterine inversion: 0.0%). Frequencies of PPH, postpartum anemia, and mean blood loss among women who received AMTSL according to the Cochrane review definition were significantly lower than for those who did not (p < 0.05). There was no significant difference between any of the outcomes for women who received AMTSL according to the ICM/FIGO definition and those who did not. CONCLUSIONS: The survey reveals substantial definition-dependent variation in the providers' adherence to recommended AMTSL practices. The clinical implications of the current practice in this population suggest the need for randomized comparison of various AMTSL packages to determine their comparative effectiveness in the prevention of PPH.

National data system on near miss and maternal death: shifting from maternal risk to public health impact in Nigeria.

BACKGROUND: The lack of reliable and up-to-date statistics on maternal deaths and disabilities remains a major challenge to the implementation of Nigeria's Road Map to Accelerate the Millennium Development Goal related to Maternal Health (MDG-5). There are currently no functioning national data sources on maternal deaths and disabilities that could serve as reference points for programme managers, health advocates and policy makers. While awaiting the success of efforts targeted at overcoming the barriers facing establishment of population-based data systems, referral institutions in Nigeria can contribute their quota in the quest towards MDG-5 by providing good quality and reliable information on maternal deaths and disabilities on a continuous basis. This project represents the first opportunity to initiate a scientifically sound and reliable quantitative system of data gathering on maternal health profile in Nigeria. OBJECTIVE: The primary objective is to create a national data system on maternal near miss (MNM) and maternal mortality in Nigerian public tertiary institutions. This system will conduct periodically, both regionally and at country level, a review of the magnitude of MNM and maternal deaths, nature of events responsible for MNM and maternal deaths, indices for the quality of care for direct obstetric complications and the health service events surrounding these complications, in an attempt to collectively define and monitor the standard of comprehensive emergency obstetric care in the country. METHODS: This will be a nationwide cohort study of all women who experience MNM and those who die from pregnancy, childbirth and puerperal complications using uniform criteria among women admitted in tertiary healthcare facilities in the six geopolitical zones in Nigeria. This will be accomplished by establishing a network of all public tertiary obstetric referral institutions that will prospectively collect specific information on potentially fatal maternal complications. For every woman enrolled, the health service events (care pathways) within the facility will be evaluated to identify areas of substandard care/avoidable factors through clinical audit by the local research team. A summary estimate of the frequencies of MNM and maternal deaths will be determined at intervals and indicators of quality of care (case fatality rate, both total and cause-specific and mortality index) will be evaluated at facility, regional and country levels. MANAGEMENT: Overall project management will be from the Centre for Research in Reproductive Health (CRRH), Sagamu, Nigeria. There will be at least two meetings and site visits for efficient coordination of the project by regional coordinators and central coordinating staff. Data will be transferred electronically by hospital and regional coordinators and managed at the Data Management Unit of CRRH, Sagamu, Nigeria. EXPECTED OUTCOMES: The outcome of the study would provide useful information to the health practitioners, policy-makers and international partners on the strengths and weaknesses of the infrastructures provided for comprehensive emergency obstetric care in Nigeria. The successful implementation of this project will pave way for the long-awaited Confidential Enquiries into Maternal Deaths that would guide the formulation and or revision of obstetric policies and practices in Nigeria. Lessons learnt from the establishment of this data system can also be used to set up similar structures at lower levels of healthcare delivery in Nigeria.

Active management of third stage of labour: a survey of providers' knowledge in southwest Nigeria.

BACKGROUND: The disparity between current evidence and practice on active management of third stage of labour (AMTSL) demands assessment of providers' knowledge on the subject. OBJECTIVE: To assess the level and determinant(s) of accurate knowledge of obstetric providers regarding AMTSL. METHODS: Questionnaire-based survey of 361 labour and delivery professionals in public tertiary obstetric centres in southwest Nigeria. RESULTS: Female nurses at different cadres accounted for most of the respondents. Majority (90.6%) of the respondents reported being aware of AMTSL as an obstetric intervention and 49.7% were aware of FIGO/ICM recommendation on AMTSL. Out of 13 potential third stage interventions, 102 respondents (28.3%) correctly and exclusively identified the components of AMTSL as defined by FIGO/ICM. Many procedures reserved for treatment of complicated third stage of labour such as manual placental removal (37.7%), blood transfusion (20.2%), bimanual uterine compression (24.7%) and uterine artery ligation (13.9%) were also selected as AMTSL components. Multivariate logistic regression analysis indicated that being in administrative position (adjusted OR: 2.68; CI 1.19-6.02) and frequent compared to rare or no consultation of books, journal and internet sources for information (adjusted OR: 2.58; CI 1.21-5.52) increased the odds of having accurate knowledge of AMTSL while being a nurse/midwife (adjusted OR: 0.15; CI 0.05-0.39), matron (adjusted OR: 0.25; CI 0.08-0.79) or intern (adjusted OR: 0.07; CI 0.01-0.29) compared to postgraduate resident doctors reduced the odds of having accurate knowledge of AMTSL. CONCLUSION: AMTSL was a familiar but poorly understood intervention among obstetric care providers in this region. Improvement in healthcare quality and practitioners' adherence to recommended guidelines on AMTSL urgently requires educational interventions that target those who provide routine delivery care and organisation of the health care delivery system in such a way that enables providers to act on acquired knowledge.

Clients' perceptions of the quality of antenatal care.

OBJECTIVES: To assess perceptions of pregnant women about quality of antenatal care. METHODS: Descriptive cross-sectional study in a developing country setting. Three-hundred-ninety-five previously booked pregnant women randomly selected from private and public health facilities at the 3 levels of care were interviewed using a 52-stem interviewer-administered, semistructured questionnaire. The questionnaire sought information about bio data, health information and services, interpersonal communications, amenities and constellation of services. RESULTS: Mean gestational age at booking was 18.5 +/- 6.3 weeks. Only 25.8% of respondents booked in the first trimester. Mean number of antenatal visits was 4.0 +/- 2.4. Mean time spent during clinic visits was 3.9 +/- 1.4 hours. Waiting time was rated as appropriate by most women (67.1%). Women with high education and in upper socioeconomic class tended to rate the waiting time as too long. Counseling for HIV was the predominant health education subject. More than half (53.9%) of respondents did not receive information about cervical cancer. About 10% of patients did not receive information about danger signs during pregnancy, breast self-examination, family planning and prevention of sexually transmitted infections. Clinic amenities and constellation of services were rated highly. Most women (96.5%) were satisfied with the care received, would use the same facility in future pregnancies and would recommend it to friends. CONCLUSIONS: The majority of pregnant women were satisfied with the care they received. However, frequent antenatal visits and long waiting times are the norm of our antenatal service. Measures for improving elements of quality of antenatal care are imperative.

Misoprostol for induction of labour: a survey of attitude and practice in southwestern Nigeria.

BACKGROUND: Although supported by research evidence, misoprostol for induction of labour remains contentious. OBJECTIVE: To assess perception and practice of obstetricians regarding use of misoprostol for labour induction. METHODOLOGY: Cross-sectional questionnaire-based survey of Senior Registrars and Consultant Obstetricians in southwestern Nigeria. RESULTS: One hundred and six questionnaires were completed (52.8% Consultants; 47.2% Senior Registrars). Most respondents (96, 90.6%) employ misoprostol for induction in both live and dead fetuses with majority having personally prescribed misoprostol for cervical ripening or induction of labour (97.2 and 79.3%, respectively). Fetal tachycardia, hyperstimulation and ruptured uterus were the commonly reported complications. Twenty-six respondents (24.5%) reported being aware of maternal death in relation to misoprostol use. Only 52.9% of the respondents have protocols guiding misoprostol use in their hospitals. More than half of respondents administer misoprostol 50 mug or higher 6 hourly. Most (92, 87.6%) believe that research evidence backs use of misoprostol for the indication; 89.5% of respondents support use of misoprostol. Most respondents (90, 86.5%) disagree with the notion that misoprostol is too dangerous for induction; only 26 respondents (25.1%) considered oxytocin a better choice for induction; 93 respondents (88.6%) agreed that, given cautious use, misoprostol is safe for induction, while 86 respondents (81.9%) considered misoprostol a cost-effective intervention for labour induction in developing countries. Though senior registrars and younger consultants tended to report side effects more frequently than older consultants, they were more likely to support misoprostol for induction of labour than older consultants. This differences were however not statistically significant (P>0.05). CONCLUSION: Misoprostol is widely utilized by obstetricians for induction of labour in southwestern Nigeria. Fetal and maternal side effects are commonly experienced. We recommend urgent adoption of evidence-based guidelines in every unit using the drug to prevent complications.

Practice of universal precautions among healthcare workers.

INTRODUCTION: Healthcare workers (HCWs) are exposed to bloodborne infections by pathogens, such as HIV, and hepatitis B and C viruses, as they perform their clinical activities in the hospital. Compliance with universal precautions has been shown to reduce the risk of exposure to blood and body fluids. This study was aimed at assessing the observance of universal precautions by HCWs in Abeokuta, Ogun State, Nigeria. SUBJECTS AND METHODS: The study was conducted in September 2003 in Abeokuta metropolis, Ogun State, Nigeria. The respondents were doctors, trained and auxiliary nurses, laboratory scientists and domestic staff. They were selected through a multistage sampling technique from public and private healthcare facilities within the metropolis. The instrument was an interviewer-administered, semistructured questionnaire that assessed the practice of recapping and disposal of used needles, use of barrier equipment, handwashing and screening of transfused blood. RESULTS: There were 433 respondents, 211 (48.7%) of which were trained nurses. About a third of all respondents always recapped used needles. Compliance with nonrecapping of used needles was highest among trained nurses and worst with doctors. Less than two-thirds of respondents (63.8%) always used personal protective equipment, and more than half of all respondents (56.5%) had never worn goggles during deliveries and at surgeries. The provision of sharps containers and screening of transfused blood by the institutions studied was uniformly high. A high percentage (94.6%) of HCWs observed handwashing after handling patients. The use of barrier equipment was variable in the institutions studied. CONCLUSION: Recapping of used needles is prevalent in the health facilities studied. Noncompliance with universal precautions place Nigerian HCWs at significant health risks. Training programs and other relevant measures should be put in place to promote the appropriate use of protective barrier equipment by HCWs at all times.

Intimate partner abuse: wife beating among civil servants in Ibadan, Nigeria.

Wife beating is one of the most common forms of violence against women by husbands or other intimate male partners. Although violence against women is pervasive, there are only few studies documenting the magnitude of the problem especially among the working class. The civil service comprises of persons from all socio-economic levels and different backgrounds. They act in advisory capacity and assist those responsible for making state policy Thus, 431 civil servants of the Oyo State government service were interviewed using a 44-item self-administered questionnaire. Results revealed that prevalence of wife beating was 31.3%. Ninety one (42.5%) men had been perpetrators, while 44 (23.5%) women had been victims. Consuming alcohol and growing up in an environment where parents fight publicly were significantly associated (p < 0.05) with men beating their wives; while being young, unmarried and a parental background of fighting was significantly associated with women being beaten (p < 0.05). Female respondents justified reasons for various types of domestic violence, including beating, more than the males (p < 0.05). Younger respondents had significantly worse attitudes (p < 0.05), while married and educated respondents had better attitude (p < 0.05). "Not wanting the children to suffer" (60.7%) and "hoping that partner will change" (28.8%) were reasons given for remaining in abusive relationships. There is an urgent need for education of the women on their rights, sensitisation of the men on gender-based violence and punishment for perpetrators. Supportive care and counselling services should also be provided for victims of violence.