Challenges in Accessing and Delivering Maternal and Child Health Services during the COVID-19 Pandemic: A Cross-Sectional Rapid Survey from Six States of India.

BACKGROUND/OBJECTIVES: Globally, the COVID-19 pandemic and its prevention and control policies have impacted maternal and child health (MCH) services. This study documents the challenges faced by patients in accessing MCH services, and the experiences of health care providers in delivering those services during the COVID-19 outbreak, explicitly focusing on the lockdown period in India. METHODS: A cross-sectional study (rapid survey) was conducted in 18 districts from 6 states of India during March to June, 2020. The sample size included 540 MCH patients, 18 gynaecologists, 18 paediatricians, 18 district immunisation officers and 108 frontline health workers. Bivariate analysis and multivariable analysis were used to assess the association between sociodemographic characteristics, and challenges faced by the patients. RESULTS: More than one-third of patients (n = 212; 39%) reported that accessing MCH services was a challenge during the lockdown period, with major challenges being transportation-related difficulties (n = 99; 46%) unavailability of hospital-based services (n = 54; 23%) and interrupted outreach health services (n = 39; 18.4%). The supply-side challenges mainly included lack of infrastructural preparedness for outbreak situations, and a shortage of human resources. CONCLUSIONS/RECOMMENDATIONS: A holistic approach is required that focuses on both preparedness and response to the outbreak, as well reassignment and reinforcement of health care professionals to continue catering to and maintaining essential MCH services during the pandemic.

Factors associated with intended use of a maternity waiting home in Southern Ethiopia: a community-based cross-sectional study.

BACKGROUND: Although Ethiopia is scaling up Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, women's use of MWHs varies markedly between facilities. To maximize MWH utilization, it is essential that policymakers are aware of supportive and inhibitory factors. This study had the objective to describe factors and perceived barriers associated with potential utilization of an MWH among recently delivered and pregnant women in Southern Ethiopia. METHODS: A community-based cross-sectional study was conducted between March and November 2014 among 428 recently delivered and pregnant women in the Eastern Gurage Zone, Southern Ethiopia, where an MWH was established for high-risk pregnant women to await onset of labour. The structured questionnaire contained questions regarding possible determinants and barriers. Logistic regression with 95% Confidence Intervals (CI) was used to examine association of selected variables with potential MWH use. RESULTS: While only thirty women (7.0%) had heard of MWHs prior to the study, 236 (55.1%), after being explained the concept, indicated that they intended to stay at such a structure in the future. The most important factors associated with intended MWH use in the bivariate analysis were a woman's education (secondary school or higher vs. no schooling: odds ratio [OR] 6.3 [95% CI 3.46 to 11.37]), her husband's education (secondary school or higher vs. no schooling: OR 5.4 [95% CI 3.21 to 9.06]) and envisioning relatively few barriers to MWH use (OR 0.32 [95% CI 0.25 to 0.39]). After adjusting for possible confounders, potential users had more frequently suffered complications in previous childbirths (adjusted odds ratio [aOR] 4.0 [95% CI 1.13 to 13.99]) and envisioned fewer barriers to MWH use (aOR 0.3 [95% CI 0.23 to 0.38]). Barriers to utilization included being away from the household (aOR 18.1 [95% CI 5.62 to 58.46]) and having children in the household cared for by the community during a woman's absence (aOR 9.3 [95% CI 2.67 to 32.65]). CONCLUSIONS: Most respondents had no knowledge about MWHs. Having had complications during past births and envisioning few barriers were factors found to be positively associated with intended MWH use. Unless community awareness of preventive maternity care increases and barriers for women to stay at MWHs are overcome, these facilities will continue to be underutilized, especially among marginalized women.

Emergency obstetric care provision in Southern Ethiopia: a facility-based survey.

OBJECTIVES: To assess the provision of basic emergency obstetric and newborn care (BEmONC), knowledge of high-risk pregnancies and referral capacity at health centres in Southern Ethiopia. DESIGN: A facility-based survey, using an abbreviated version of the Averting Maternal Death and Disability needs assessment tool for emergency obstetric and newborn care. Modules included infrastructure, staffing, number of deliveries, maternal and perinatal mortality, BEmONC signal functions, referral capacity and knowledge of risk factors in pregnancy. SETTING: Primary healthcare centres providing delivery services in the Eastern Gurage Zone, a predominantly rural area in Southern Ethiopia. PARTICIPANTS: All 20 health centres in the study area were selected for the assessment. One was excluded, as no delivery services had been provided in the 12 months prior to the study. RESULTS: Three out of 19 health centres met the government's staffing norm. In the 12 months prior to the survey, 10 004 ([Formula: see text]) deliveries were attended to at the health centres, but none had provided all seven BEmONC signal functions in the three months prior to the survey ([Formula: see text]). Eight maternal and 32 perinatal deaths occurred. Most health centres had performed administration of parenteral uterotonics (17/89.5%), manual removal of placenta (17/89.5%) and neonatal resuscitation (17/89.5%), while few had performed assisted vaginal delivery (3/15.8%) or administration of parenteral anticonvulsants (1/5.3%). Reasons mentioned for non-performance were lack of patients with appropriate indications, lack of training and supply problems. Health workers mentioned on average 3.9±1.4 of 11 risk factors for adverse pregnancy outcomes. Five ambulances were available in the zone. CONCLUSION: BEmONC provision is not guaranteed to women giving birth in health centres in Southern Ethiopia. Since the government aims to increase facility deliveries, investments in capacity at health centres are urgently needed.

Maternity waiting homes in Ethiopia--three decades experience.

BACKGROUND: Access to comprehensive emergency obstetric care is limited in Ethiopia. Maternity waiting homes are part of the strategies utilized to improve access to hard to reach rural populations. Despite long years of existence of this service in Ethiopia, the practice has not been adequately assessed so far. OBJECTIVES: Describe the current status of maternity waiting home services in Ethiopia METHODS: All facilities in Ethiopia that have a maternity waiting home were identified from FMOH data as well as personal contacts with focal persons at Regional Health Bureaus in the nine regions and UNICEF regional offices. A standardized data collection tool for facility assessment was developed by the quality referral team, Health Section, UNICEF. Data collection included site visits and documentation of infrastructural related issues through a facility checklist. Service related issues were also collected from log books and other documents as well as through interview with relevant staff Focus group discussions were held with all MWHs attendants who were found admitted at the time of the review at Attat, Wolisso and Gidole hospital maternity waiting homes on major thematic areas identified by the review team regarding MWH care RESULTS: The practice of maternity waiting homes in Ethiopia spans more than three decades. Nine facilities located in five Regional States had maternity waiting home services. All except one were located in hospitals. Admission capacity ranged from 4 up to 44 mothers at a time. Seven of the maternity waiting homes required the clients to cater for their own food, firewood and clothing supply providing only kitchen space and few kitchen utensils. Clients came from as far as 400 kms away to obtain services. Medical care and documentation of services were not standardized Duration of stay varied from 3-90 days. Monthly admission rates varied from 0-84 mothers at different institutions. Major indications for admission were previous caesarean section 34%; previous fistula repair 12%; multiple pregnancy 12% and malpresentations 8% Indications for admission were not standardized and not medically clear in some instances. There were indirect evidences that the service improved maternal health outcome while caesarean sections rates were much higher among clients' admitted to maternity waiting homes compared to non-users. CONCLUSIONS: Provided that maternity waiting home service is standardized and institutionalized it can be one approach to improving access to comprehensive emergency obstetric care for rural mothers in Ethiopia who are challenged by distance to access services. RECOMMENDATIONS: There is a need to standardize indications for admission to maternity waiting homes as well as formalize the semi-institutionalized care being provided at these facilities at present. Benefits towards better maternal and neonatal outcome as well as cost effectiveness of care should be documented through further analytic studies.

Current and future role of voluntary surgical contraception in increasing access to and utilization of family planning services in Africa.

BACKGROUND: Voluntary surgical contraception is the most widely utilized method of contraception in the world. High effectiveness, low complication rates and reduced cost in the long term make them the ideal contraceptive choice to diverse group of clients including clients from low resource settings. OBJECTIVE: To assess the current status of utilization and effectiveness of voluntary surgical contraception in Africa and suggest possible future roles in contraceptive method choice. METHODS: A review of available literature on voluntary surgical contraception and synthesis of information under relevant headings. RESULTS: Despite very high total fertility rates in most countries of Africa, surgical contraceptives still contribute to a very small proportion ofcontraceptive method choice in the continent. Client profile and acceptability studies indicate a large unmet need for permanent contraception in the continent. Lack of information, misconceptions and weak health systems (particularly surgical care) are the major impediments to increasing availability of surgical contraception. Lack of knowledge and low levels of motivation among health care providers may also be significant barriers to access. CONCLUSIONS: Ihcreasing availability of information on the safety and effectiveness of these methods to both health care providers and the general population can increase demand and acceptability. Delegating service provision to appropriately trained non-physician providers at primary care settings can assist in increasing accessibility of these important family planning methods.

Disease burden due to pre-eclampsia/eclampsia and the Ethiopian health system's response.

OBJECTIVE: To assess the maternal disease burden due to pre-eclampsia/eclampsia in Ethiopia and the national health system's readiness to respond to the needs of women with pre-eclampsia/eclampsia. METHODS: The national emergency obstetric and newborn care (EmONC) assessment entailed collecting information from 112 hospitals and 685 health centers in Ethiopia, focusing on their infrastructure, the services they provided, human resources, equipment and supplies, case load, and mortality due to pre-eclampsia/eclampsia. RESULTS: Pre-eclampsia/eclampsia complicated 1.2% of all institutional deliveries. Given the low institutional delivery rate and an expected incidence of 2%-8% of all deliveries, this implies that only a small fraction (3.8%) of all women with pre-eclampsia/eclampsia received care at health facilities. 11% of all maternal deaths and 16% of direct maternal deaths were due to this obstetric complication. The cause-specific case fatality rate was high (3.6%). Availability of urine test strips, anticonvulsants, antihypertensives, and actual service provision to treat these diseases was limited, especially at health centers. CONCLUSION: The salutary effects of the national EmONC assessment were immediate, as evidenced by how quickly the release of the Ethiopian report led to important national efforts to improve maternal and newborn health. Expansion of health services should be augmented with periodic assessments of logistics and quality-related issues to assure functioning facilities for women accessing obstetric services.

Audit of obstetrician-gynecologists in Ethiopia, 1950's-2007--implications for specialty level reproductive health care provision.

BACKGROUND: Health human resource audits are important to assess the adequacy of available health manpower; monitor changing trends and assist in formulating relevant human resource policies and strategies. Such audits are scarce in the African setting including Ethiopia. OBJECTIVE: This audit of obstetrician-gynecologists in Ethiopia of the last half century was conducted with the objective of providing a baseline audit on this important medical specialty of relevance to maternal and neonatal health. METHODS: Information was obtained from Ministry of Health (MOH) reports; Ethiopian society of Obstetricians and Gynecologists (ESOG) membership information; Addis Ababa University graduate program office and personal contact with gynecologists. Data was collected as to place and year of training; nationality; mortality; current service location and profile; ever public service; ever service and duration of service in the regions outside Addis Ababa. RESULTS: A total of 236 obstetrician-gynecologists have served in Ethiopia since the late 1950's till 2007. 181 (76.7%) were graduates of the Addis Ababa University graduate program, while the rest were foreign trained. 55 (23.3%) were foreign nationals. It was learned that 8 (4.4%) of the AAU graduates have passed away. 30 (16.6%) of the AAU graduates have emigrated to other countries. The USA is the commonest destination of émigrés. 176 gynecologists were present in Ethiopia in 2007; 98 (55.7%) of whom were serving in the public sector. Annual emigration fraction has markedly decreased in recent years; while the trend clearly indicated that progressively more and more gynecologists were serving in the regions. Production of gynecologists in the last thirty years is very small; it is the most significant reason for the small numbers; rather than emigration. CONCLUSIONS: There is a need to increase training of obstetricians and gynecologists by opening more graduate schools in the universities across the country. Mortality should be one of the parameters included in health manpower audits in addition to emigration. There is a need to reconsider the current service profile of specialists.

Maternal mortality studies in Ethiopia--magnitude, causes and trends.

BACKGROUND: Reduction of maternal mortality is a global public health priority. Periodic maternal mortality studies are required to monitor changing trends. Both direct and indirect methods of maternal mortality measurement are used in different settings. OBJECTIVES: To study the geographic coverage, study base, type, maternal mortality ratio level and proportion of different causes of maternal deaths identified by maternal mortality studies conducted in Ethiopia. METHODS: Electronic databases search coupled with search in local journals of health as well as interview with relevant university departments for unpublished literatures on maternal mortality studies was conducted. Structured questionnaire was used to extract relevant data which was analyzed using SPSS 13 statistical package. RESULTS: Twelve maternal mortality studies were identified from 1980 to 2008. Eight were hospital based and four community based studies. Only two were based on a national sample. Maternal mortality ratios ranged from 567 to 2600 per hundred thousand live births. Hospital studies had nearly double ratios compared to community studies. Maternal mortality ratios from hospitals outside Addis were nearly double or more compared to Addis hospital ratios. Abortion complications, ruptured uterus, puerperal sepsis, postpartum hemorrhage and preeclampsia/ eclampsia were the five major causes of maternal mortality. The only study conducted since 2000 has shown a marked reduction in abortion related mortality; compared to findings of earlier studies. CONCLUSION: Only four of the country's nine regions were covered by the hospital studies. The large pastoralist community has not been adequately addressed by any of the studies. There is a need to conduct national health facility based studies to gather representative data on the proportion of different causes of maternal deaths and their predisposing factors. Inclusion of verbal autopsy techniques to demographic and health surveys and the decennial census can increase the power of these studies to define maternal mortality in more detail. In general, there is a paucity of information on maternal mortality.

Clinical estimation of fetal weight in low resource settings: comparison of Johnson's formula and the palpation method.

BACKGROUND: Estimation of fetal weight is important for antenatal and intrapartum clinical decision-making. Sonographic estimates may not always be available in low resource settings. In such instances it is essential to study the reliability of clinical estimation of fetal weight in assisting decision-making. OBJECTIVES: Estimate the accuracy of the Johnson's formula and the palpation methods of fetal weight estimation and their correlation. SETTINGS: Maternity units of three teaching hospitals (Tikur Anbessa, Gandhi Memorial and Saint Paul's) in Addis Ababa, Ethiopia. SUBJECTS AND METHODS: Three hundred and twenty mothers were included in the study at the three hospitals from May 1 to September 30, 2004. Fetal weight was estimated for each mother using both methods prior to delivery. Accuracy of estimation was determined by the percentage error, absolute percentage error and the proportion of estimates within 10% of the actual birth weight. Statistical analysis was performed using the student's t test, paired t test, comparison of correlated variances using the modified F test, Wilcoxon sign test and the X2 test. RESULTS: Actual birth weight was 3152 +/- 494 grams; ranging from 1600-5250. The mean of all error terms of EFW (estimated fetal weight) with palpation method were significantly smaller than those of Johnson's method and rate of estimates within 10% of actual birth weight was significantly higher for the palpation method (65%, versus 38%). For birth weights less than 2500 grams both methods overestimated the birth weight; the mean error of the palpation method was significantly smaller than those of the Johnson's method. In the 2500-3999 birth weight range, only the palpation method had no systematic error, whereas the Johnson's method systematically overestimated the birth weight. The mean errors of the palpation method were significantly smaller and a rate of birth weight +/- 10% significantly higher than those of the Johnson's method (68% versus 40%). In the larger weight (>4000 gms), the Johnson's method had less systematic error compared to the palpation method (mean percent error = -0.9 + 11.3. p =0.42), although the small sample size in this group precludes a firm conclusion of the issue in this category. CONCLUSIONS: Estimation of fetal weight by the Palpation method appears to be more accurate than the Johnson's method. In the lower and average birth weight range the palpation method is the more accurate of the two, while in the higher weight category the Johnson's method appears to be more accurate.

Health research in Ethiopia--past, present and suggestions on the way forward.

Health is a fundamental prerequisite to human development. Evidence based strategies for effective health interventions emanate from a representative, ethical and rigorously conducted health research. Health research undertakings require the coordinated efforts of researchers, research funders and research users as well as the presence of detailed laws and regulations conducive for undertaking health research. Global health research partners have stressed that attempts to improve country level health research should follow the "National Health Research Systems" approach as components of the system are highly interrelated. The systems approach begins with a situation analysis of the existing national health research system. History of health research in Ethiopia spans nearly seven decades. Study of historical abstracts, websites of health research and academic institutions, review of relevant publications, site visits and interview with institution authorities was undertaken to provide an overview of past and present status of health research in Ethiopia. The researcher profile, disease and health focus, publication audit, dissemination modalities and international collaboration of research institutes are outlined. Applicable Ethiopian laws and regulations regarding health research are documented. Existing challenges to conduct of health research are outlined. The number of health researchers, research institutes and volume of research output so far is small. Detailed laws and regulations pertaining to health research are not enacted and governance of health research is not clearly articulated. There are global, regional and programmatic inequities in the national health research arena. Evolution of the health research in the country into an organized "National Health Research System" is still at an early stage. Suggestions are forwarded to augment the ongoing discussions on strengthening efforts to improve the national health research system. These include the needs for establishing a Medical Research Council; adopting or adapting laws and regulations governing health research; formulation of a national statistical and data policy; establishment of a national library; establishing research funding and financing agencies; strengthening public-private partnerships in health research; maintaining national and international commitments towards research financing; increased incentives provided to researchers thereby curbing brain drain; attracting young scientists to a career of research and increasing capital expenditure in order to establish research institutes in various parts of the country. The historic juncture offered by the second millennium celebrations should be used to review the status of health research and indicate strategies to strengthen it. A strong National Health Research System is one of the essential prerequisites to improving the health status of the nation. It is hoped that this outline of the status of health research in Ethiopia at the end of its second millennium and the proposed actions will indicate areas for future improvement.

Past reproductive performance and its correlation with perinatal mortality in the current gestation at teaching hospitals in Addis Ababa, Ethiopia.

BACKGROUND: Perinatal mortality remains a challenge in the care of pregnant women world wide, particularly, in low-resource settings. Each year, 8 million perinatal deaths occur through out the globe; 98% of them in developing countries. Data on the frequency and distribution of adverse birth outcomes and their related risk factors are important for planning maternal and child health care services in developing countries. Such information is scarce from developing settings including Ethiopia. OBJECTIVE: To determine the correlation and predictive value of past reproductive performances to the risk of perinatal death occurrence in current pregnancy among mothers who came for delivery at the three hospitals of Addis Ababa. METHODS: Hospital-based case-control study of 390 delivering women conducted at the three teaching hospitals of Addis Ababa, Ethiopia. Control subjects (n = 260) were mothers with live birth and cases (n = 130) were those who experienced perinatal death during current delivery. Information on sociodemographic, past pregnancy outcome, current pregnancy/delivery and its outcome were collected. The difference in proportion was analyzed with Pearson chi square test. The possible confounding effects between independent variables were examined with bivariate and partial correlation analysis. The predictive ability to perinatal outcome of each model as a function of these risk factors was determined. RESULTS: After adjustment for maternal age, parity, address and gestational age of index pregnancy, multivariate analysis showed the following independent variables to be associated with increased risk of perinatal deaths:--maternal illiteracy (OR = 3.0; 95% CI = 0.93 - 9.4) and birth interval < 48 months (OR = 2.3; 95% CI = 0.9 - 6.0) were marginally significant risk factors for perinatal mortality. Birth weight <2500gm (OR = 43.1; 95% CI = 12.0 - 154.6); lack of prenatal care (OR = 10.9; 95% CI = 2.3 - 51.6) and a history of past perinatal loss (OR = 10.6; 95% CI = 3.2 - 35.5) were consistently strong predictors of perinatal mortality in the current delivery. The predictive value (i.e. sensitivity and specificity) of a regression model of perinatal outcome as a function of these independent variables was 80% and 91% respectively. CONCLUSIONS: Multivariate analysis has shown the aforementioned independent variables as predictors of nearly three-fifth of perinatal mortalities in the study population. Hence, by implementing strategies directed to these risk factors, it may be possible to reduce perinatal mortality by at least 60%. Therefore, large community-based studies are recommended to validate the findings and to explain other unmeasured risk factors.

Primary fallopian tube carcinoma (PFTC) comorbidity with infertility and bilateral hydrosalpinx.

Primary fallopian tube carcinoma (PFTC) is the rarest gynecologic malignancy. We present the first documented case of this rare neoplasm in Ethiopia, in a 50 years old perimenopausal woman. The patient complained of irregular menses, on and off vaginal discharge and longstanding lower abdominal pain. She had longstanding infertility for which she did not seek medical help. The patient was subjected for laparotomy with the preoperative diagnosis of chronic pelvic inflammatory disease. Huge bilateral hydrosalpinges were found with pelvic adhesions involving the ovaries. Total hysterectomy with bilateral adnexectomy was performed following adhesiolysis. The diagnosis of low-grade papillary tubal carcinoma was made postoperatively when the specimen from total abdominal hysterectomy and bilateral salpingoopherectomy was examined histologically. The patient declined relaparatomy for proper staging or further adjuvant treatment. She was free of clinically demonstrable recurrence five months after discharge. Challenges in the detection of PFTC relating to its signs and symptoms, diagnostic difficulties, choice of treatment and factors that may influence survival are outlined It is prudent to perform histopathologic examination on all surgically excised specimens however obvious the clinical findings appear to be.

Torsion of pedunculated subserous myoma--a rare cause of acute abdomen.

Leiomyoma uteri are common benign genital neoplasia among women of late reproductive age. Most are asymptomatic. Among those having symptoms, abnormal uterine bleeding and pelvic pressure symptoms are common presenting features. Less common indications for treatment include infertility and abdominal distension. Acute onset severe abdominal pain is an unusual presenting complaint. When present, pain is usually related to complications involving the myoma including red degeneration, infection, process of expulsion of a submucous pedunculated myoma, uterine torsion, compression of myoma between the uterus and sacrum or torsion of a pedunculated subserous myoma. Standard gynecologic textbooks frequently mention torsion of pedunculated subserous myoma as one of the causes of myoma related acute abdomen. Literature search on the topic however does not yield many specific case reports of this myoma related complication or it's presenting features. The condition has not been reported from Ethiopia so far. A case of torsion of pedunculated subserous myoma presenting in early pregnancy that was managed in one of the maternity hospitals in Addis Ababa, Ethiopia is presented.

High prevalence of abnormal Pap smears among young women co-infected with HIV in rural South Africa - implications for cervical cancer screening policies in high HIV prevalence populations.

OBJECTIVE: To establish the relationship between HIV infection and cervical dysplasia in young women in rural South Africa. METHODS: This cross-sectional study was conducted at a primary health care clinic in Vulindlela, KwaZulu- Natal. Standardised questionnaires were used to collect sociodemographic and clinical presentation data from women attending family planning and other reproductive health services. Pap smears were done using standard methods. Pap smear data were linked to HIV serostatus. RESULTS: Four hundred and sixty-six women were included in the study. The median age was 24.3 years (range 15 - 55 years), and 80% were younger than 30 years. The HIV prevalence rate was 24.5% (95% confidence interval: 20.7 - 28.7%) and the prevalence of abnormal Pap smears was 16.9 - 6.4% ASCUS (atypical squamous cells of undetermined significance), 9.2% LGSIL (low-grade squamous intraepithelial lesions), and 1.3% HGSIL (high-grade squamous intraepithe lial lesions). The association between HIV seropositivity and abnormal Pap results was statistically significant (p < 0.05). CONCLUSION: There is a need for more data on cervical changes in HIV co-infected women and for review of guidelines on selective Pap smear screening in high HIV prevalence settings such as sub-Saharan Africa and where access to antiretroviral treatment remains limited.

Prevalence and clinical correlates of the hypertensive disorders of pregnancy at Tikur Anbessa Hospital, Addis Ababa, Ethiopia.

A one-year longitudinal study was conducted at Tikur Anbessa central referral Hospital to assess the prevalence of hypertensive disorders of pregnancy (HDP), to see the socio-demographic and clinical parameters and pregnancy outcome of pregnancies afflicted by these complications. Out of 3424 deliveries conducted during the study period, 183 (5.3%) mothers were found to have one form of hypertensive disorders of pregnancy, 85.2% were cases of pregnancy induced hypertension (PIH),the majority (78.2%) were severe pre eclampsia and eclampsia; the remaining 14.8% had pregnancy aggravated hypertension (PAH) or chronic hypertension. Preterm delivery rate was 48.6% for all cases of HDP. Intervention rate was high with 44.3% induction of labor and 44.3% caesarian section, which is much higher than the over all intervention rate in the hospital's obstetric population during the studied period. Prenatal mortality rate (PNMR), case fatality rate (CFR) and intra uterine growth restriction (IUGR) were 300/1000 deliveries, 27/1000 deliveries and 41.6% respectively in mothers with HDP. Severe hypertension, high urine protein and high uric acid level were found to be associated with higher CFR, and poor prenatal outcome. The study provides base line data on HDP in a hospital obstetric population in Ethiopia. Important peculiar findings in this study were a very high rate of severe disease, PNMR and CFR compared to other institutional studies. There is a need to conduct nation wide multi center study on HDP in order to have national base line data on this important pregnancy complication.

Post term pregnancy at teaching hospitals in Addis Ababa, Ethiopia.

OBJECTIVE: To Determine pregnancy outcome between term and post term deliveries and to assess the proportion of post maturity syndrome among neonates in the two groups. DESIGN: Cross-sectional comparative study of pregnancy outcome among term and post term mothers. SETTING: Two teaching hospitals in Addis Ababa, Ethiopia. SUBJECTS: 376 post-term mothers compared to 376 term mothers. MAIN OUTCOME MEASURES: Fetal distress, caesarean section rates, neonatal intensive care unit admission, perinatal mortality, congenital anomalies, low birth weight, Apgar scores, macrosomia and third stage complications. RESULTS: The proportion of mothers delivering post term at the study sites was 8.8%, which agrees with most series in which diagnosis of post term was based on LNMP. There were 99 (26.3%) fetal distress in the post term group compared to 50 (11.2%) among term deliveries (P<0.001). The caesarean rate for the post term mothers was 89 (23.7%) compared to term mothers of 47(12.5%) (P<0.001). Neonatal intensive care unit admission rate for post term mothers was 25(6.7%) compared with 1(2.9%) term mothers (P<0.05). No significant differences in the rates of perinatal mortality, congenital anomalies, low birth weight, macrosomia, CPD or third stage complications were observed between the two groups, though most were relatively frequent in post terms. CONCLUSION: Due to lack of antenatal care and late referral, the diagnosis of post terms is based on LNMP alone in most cases. Fetal distress, perinatal asphyxia and consequent caesarean delivery rate is much higher than other series. Health education on early initiation of antenatal care as well as timely referral from peripheral units is urgently needed. Based on the findings of our study we recommend that in all pregnant women (individualization is possible) with 42 completed weeks of gestation, the pregnancy should be terminated be it through vaginal or abdominal route for a better fetal outcome.

Microbicides-emerging essential pillars of comprehensive HIV/AIDS prevention.

A quarter century old and still going strong, the HIV/AIDS pandemic is already the deadliest and longest lasting plague in mankind's recorded history. Reportedly among the weakest of the viruses, HIV's survival instincts have relied on extreme adaptability at the molecular and virologic levels on its part. In addition, it has preyed on certain prevalent weaknesses on the part of its host (human society) - extreme poverty; gender bias; lack of education and high prevalence of STIs- to prolong its lethal grip on humanity for as long as possible. This astounding adaptability is evident by the tremendous geographic, gender, mode of transmission and age shifts it has displayed over its now respectably long history. From localized epidemics in localities in the developed world at its onset, it has gravitated and now firmly entrenched itself selecting Sub-Saharan Africa as the epicenter of its global scourge. From a disease of men having sex with men (MSMs) at its inception, it has undergone a gender shift with a definite and alarming "feminization'" or as Kofi Annan put it, has the "Face of a woman". From a demonstrable prevalence, concentrating in adults, it has chillingly shifted to being an infection that affects predominantly younger age groups and adolescents. And from its early homosexual and injection drug use transmission modes it has shifted to a predominantly heterosexual transmission for the majority of new infections. Behavioral modifications (health education towards safe sexual practices and VCT provision and utilization); correct and consistent use of male and female condoms; control of sexually transmitted diseases and strategies to prevent mother to child transmission (PMTCT) are effective methods of HIV/AIDS prevention. Their effectiveness has been demonstrated by their ability to contain the epidemic in countries that have successfully implemented them. Of questionable value in prevention but gaining momentum in accumulating data proving their effectiveness in HIV prevention are strategies including male circumcision; PEP (post-exposure prophylaxis); PREP (pre-exposure prophylaxis) and provision of ante-retroviral therapy to all who are in need. Experiences in prevention efforts in resource-poor settings over the last two decades have indicated that the traditional ABC model (abstinence, being faithful to one's partner and condom use) are inadequate in controlling HIV in those settings. Well-known biologic vulnerabilities in women as well as socio-economic, cultural and gender bias towards women, stand in the way of effective implementation of the available prevention strategies. It has become increasingly evident that as part of a comprehensive HIV prevention strategy, a female-controlled method of prevention is crucial for the eventual control of the epidemic in Africa. To this end, efforts to develop a "microbicide"- a topical agent that can be applied vaginally by women to protect themselves from infection; and a product that they can use without the necessary consent of their partner - have been gathering momentum over the last decade. At present, nearly sixty potential microbicides are in the development pipeline. Of these six are in the last (phase III) effectiveness trials that precede drug licensing. There is a general belief in the scientific community that an effective microbicidal agent for HIV prevention might be available in the next five to seven years. Lack of finance and ethical issues in conducting research are delaying rapid development of an effective agent. Ethiopia has been largely left out of research efforts towards microbicides development. It is essential that cognizance of this emerging HIV prevention strategy by health care professionals and the general public be developed in order to avoid undue delays in effective utilization once an effective agent becomes part of our HIV prevention arsenal.

Leiomyoma uteri in Ethiopian women: a clinical study.

A retrospective review of 588 patients with myoma surgically managed at Tikur Anbessa teaching hospital, Addis Ababa, Ethiopia, from February 1992-October 2000 is presented. The objectives of the study were to describe the sociodemographic profile, clinical parameters, indications for operation and outcome of management of myoma cases surgically managed at the hospital. Data was collected on sociodemographic, obstetric, gynecological and other relevant clinical variables from the patient's records. Mean age of patients was 35.8 (SD 7.5) years with a median parity of 1. Median uterine size was of 16 weeks pregnant uterus. Number of myomas removed at myomectomy ranged from 1-50 (Median 2). 98% of myomas were fundal and 2% cervical. 40 (6.8%) of the myomas were "delivered" myomas. The median duration of the presenting complaints reported by the patients was 1 year. Abnormal bleeding was the major presenting complaint (69.2%). In 101 (17.2%) of the patients other pelvic pathologies were identified, the majority being ovarian tumours. Three hundred sixteen (53.7%) of the patients had an additional medical condition encountered mainly anemia and hypertension. Intraoperative and postoperative complications were much higher following hysterectomy than myomectomy, but duration of operation, intraoperative blood loss and uterine size were not much different in the two operations. Reasons for the delay in presentation should be addressed by studies so that interventions leading to early presentation of patients can be sought. It is proposed that in all situations where it is feasible to do so, myomectomy should be performed in preference to hysterectomy irrespective of the need for future fertility.

Thoracopagus conjoint twins presenting as shoulder dystocia: a case report.

A thirty-eight year old, gravida seven, para six mother presented to the outpatient department of Saint Paul's General Specialized hospital on September 11, 2003 after attempted delivery of the shoulder failed at Meta Robi health center. Referral note indicated that she presented at the health center in the second stage of labor, which was delayed for more than two hours. Ventouse delivery was effected at the health center following which the shoulder could not be delivered and mother was referred to Addis for further management of the shoulder dystocia. Upon presentation to the hospital further delivery of the fetus was difficult and an ultrasound exam showed a twin pregnancy. A caesarean delivery was effected with the possibility of conjoined twinning. Stillborn 5100 grams thoracopagus twins were delivered with intraoperative decapitation of the head of the vaginally delivered twin. Mother was discharged after seven days in good condition. Literature on the diagnosis and management of conjoint twinning is reviewed and the rare situation in which a conjoined twin might be a differential diagnosis of shoulder dystocia is noted.