Delivery rate in Benin City, Nigeria: are there seasonal variations?

OBJECTIVE: To determine if there are monthly variations in the rate of deliveries in Benin City, Nigeria. MATERIALS AND METHODS: A retrospective descriptive study carried out in the three major obstetric centers in Benin City, Nigeria. We extracted the total number of deliveries from the hospitals' records for over a five-year period and analyzed the figures for monthly variation in delivery rates. This was repeated for a standardized 30-day month and the findings noted. RESULTS: There were 28,686 deliveries during the study period with an average monthly delivery of 2,390. The monthly distribution showed a sinusoidal pattern with peak delivery rates in April-May and October and lowest rates in July-August and December. The months of April, May, and October had delivery rates that were significantly higher than the monthly average delivery rate, while the converse was true for July, August, and December at the 99% confidence interval. CONCLUSIONS: There exists a significant monthly variation in delivery rates in Benin City. This finding will prove valuable in health system planning and in the interpretation of seasonal variations in other reproductive parameters.

Non-consensual sex in Benin.

OBJECTIVE: The objective of the study is to investigate the prevalence and risk factors of non-consensual sex/rape in Benin. MATERIALS AND METHODS: We surveyed 580 females in the University Community of Benin, 414 questionnaires were sufficiently completed for analysis. RESULTS: Seventy-six (18.4%) respondents reported that they had been victims of non-consensual sex (NCS), 36 in their current relationship. The unmarried single respondents had the lowest mean age at NCS experience of 18 years, while the divorced victims had the highest mean age of 32.5 ( P = 0.000). There was a major exposure peak age at 19 years with a smaller peak at 25. The majority of sex offenders were their present partners and next the husbands (22.2%). The father was the perpetrator on one (2.78%) occasion, while armed robbers raped two of the victims. Eighteen of the seventy-six respondents made a formal report. Cumulatively, 95.4% of the respondents felt it was futile reporting, four (5.3%) felt it was not all a bad experience. The risk of being infected with the HIV/AIDS virus was the worst fear. Ninety-five of four hundred and fourteen respondents want the public and parents to be educated, 64 would like the penal code to be tougher and better implemented, while 64 (14.0%) crave for a dress code for the University community. CONCLUSIONS: The self-reported incidence of NCS is high, majority were not formally reported as most of the sex offenders were the (ex)partners of the victims. There was a major exposure peak age at 19 with a smaller peak at 25 years. There was a condoned sense of futility and frustration in reporting.

Aspects of psychosocial problems of patients with vesico-vaginal fistula.

Our objective was to evaluate psychosocial problems among patients presenting with vesico-vaginal fistula (VVF), and their close relatives. All patients presenting with VVF and their spouses or attendant close relatives were administered a structured questionnaire followed by an in-depth interview. A total of 20 patients and 10 attendant relatives were interviewed. The average age of patients was 24.7 years, range 16-38 years. A total of 11 patients (55%) had their first marriage between the ages of 15-20 years, with one nulliparous, unmarried patient, who acquired VVF following infertility treatment with herbs. Of the interviewed respondents, 19 affirmed that prolonged labour was the cause of VVF, while four patients developed VVF sequel to unsupervised vaginal birth after a previous caesarean section. Reported medical problems were dermatitis (20%), foul smell of urine (15%), recurrent UTI (10%), infertility (5%), amenorrhoea (5%), in that order. Socially, 45% felt ostracised and 50% were economically impoverished by job loss. The divorce rate was 25%, with one case of remarriage and childbirth with an unrepaired VVF. Some 56.6% respondents suggested hospital delivery was a preventive measure, while 33.3% felt avoidance of premarital sex and early marriage would prevent VVF. VVF is still a major social and reproductive health problem and most patients and relatives understand the place of difficult childbirth in VVF formation. The need to empower patients to timely access standard maternity and emergency obstetric care is recommended.

Relationship between visually estimated blood loss at delivery and postpartum change in haematocrit.

This study was to assess blood loss using visual estimation and change in postpartum haematocrit value following vaginal delivery, and to study any relationship that may exist. A total of 152 parturients who had had vaginal delivery were studied. Blood loss at delivery was visually estimated. An intrapartum haematocrit with a 48 h postpartum haematocrit were evaluated. Data were analysed with SPSS 15 statistical package. The average visual estimation of blood loss (VEBL) was 217 +/- 197 ml with a I degrees PPH rate of 6.6%. Some 93 (61.2%) mothers had a blood loss of < or = 200 ml. There was no statistical significant difference in the average VEBL within the age or parity groups of the mothers (p values, 0.234 and 0.87). The average postpartum haematocrit change was -0.74 +/- 3.99, while 46.7% of the parturients had a decline in haematocrit value. The range of haematocrit change for parturients with VEBL > or = 500 ml was -12 to -4. Regression analysis showed a negative correlation between VEBL and change in haematocrit values from positive to negative. Pearson's correlation coefficient -0.549, p < 0.00. It was concluded that postpartum haematocrit has a significant negative non-linear correlation with VEBL. In the absence of primary postpartum haemorrhage, majority of women have either the same or an increased haematocrit following vaginal delivery. Consequently, routine haematocrit estimation in parturients with visual estimated blood loss of <500 ml barely confers any cost benefit.

Changing trends in maternal mortality in a developing country.

OBJECTIVE: To have a 5-year review of the maternal mortality ratio in the largest centrally located Mission hospital in Benin City where a large proportion of women deliver yearly. METHOD: This was a 5-year (January 1, 1996 through December 31, 2000) review of the causes of maternal mortality at the Saint Philomena Catholic Hospital, Benin City. The case notes of those that suffered maternal mortality were retrieved and thoroughly perused. Information on all cases of maternal mortality were extracted from the patients' case-notes; the labour ward Registers; the antenatal, postnatal, the female ward and the theatre registers. The midwifery/nurses' reports were also examined. The duplicate copies of the death certificates were examined and the necessary information was also extracted. The total deliveries for the period were extracted from the delivery registers. RESULTS: There were 7055 women who gave birth during the 5-year period. There were 32 maternal deaths; Maternal Mortality Ratio (MMR) of 454/ 100,000 live births. Unbooked emergencies accounted for 68.7% of all deaths, and were more than doubled the booked women. The MMR increased progressively from 325 in 1996 to peak at 765 in 1999 (P < 0.0001) with an insignificant drop in 1998 (P > 0.06). It was lowest in 2000 (241) (P < 0.0001). Paradoxically, as the number of deliveries decreased progressively from 1530 in 1996 to 1247 in 2000, the MMR increased progressively from 327 in 1996 to 675 in 1999. There were no postmortem examinations and no coroner's inquests. More than 76% of the women spent 48 hours or less from time of admission to death and majority of them were of low parity. Nulliparity was 37.5%. The mean parity was one. Young women 20-39 years old accounted for 81.3% with 9.4% teenage deaths due to illegally induced abortions. Eclampsia (34.4%), hemorrhage (25.0%), Infections (18.8%) and abortions 12.5%) were the four leading causes of death. Puerperal deaths were 56.3%. Five short case scenarios were presented to highlight the tortuous pathway the women passed to end in maternal mortality. CONCLUSION: The MMR ratio was still unacceptably high. The causative factors were largely preventable. The puerperium was the most dangerous period. Women empowerment, free or highly subsidized universal antenatal care services, and provision of adequate emergency obstetric services with effective contraceptive backup is suggested. Re-orientation of care givers and community leaders to enhance awareness and early recognition of the danger signs and risk factors associated with pre-eclampsia and eclampsia with prompt and adequate management or referral is emphasized.

Towards Reducing Cancer Death: an Exploratory Study of Physicians Knowledge on Cancer Basic Facts

Objective: To explore the knowledge of basic facts on common female cancers amongst Physicians in active practice. Materials and Methods: A descriptive study among 160 doctors working in a Nigerian Teaching Hospital. Results: Majority of the physicians surveyed (86.2) were in full time academic practice with 13.8in combined academic and private practice. The experience (years in practice) of the Physicians varied from 1-22 years; with a majority (57.9) in category A (1-5 years ); while 40.3were in category D (15 years). A large proportion of the Physicians had poor knowledge on basic cancer facts with regards to the prevalence (47.2); mortality rate (54.1); available screening tests (65.4); and association between HPV and cancers of the anogenital region (56.6). The type of practice did not significantly influence Physicians knowledge on basic cancer facts (P values 0.05) More Physicians in full academic practice had good kowledge about human papilloma virus compared to those in combined practice (23.3vs. 5; fulltime academics vs. combine practice). There was no significantdifference in the knowledge of the Physicians on the prevalence; available screening tests and mortality rate of the cancers based on their experience (P values 0.05) Conclusion: Physicians in active practice have poor knowledge of basic cancer facts irrespective of their number of years in practice. These portend serious setback for health education; policy formulation on prevention and reduction of Cancer related morbidity and mortality

Labour management: an appraisal of the role of false labour and latent phase on the delivery mode.

Achieving normal vaginal delivery requires an orderly transition from early labour to an established active labour. We analysed retrospectively the outcome of labour and the delivery mode based on the diagnosis of labour from the first examination of 3,130 parturients. A total of 1,847 (59.1%) delivered mothers had the first vaginal examination performed by the senior house officer (SHO). The majority (74.4%) of the mothers presented in established labour (cervical dilatation > or =4 cm), 25.6% in early labour, while 11.3% in latent phase. Patients who presented in established labour had a statistically significant higher spontaneous vertex delivery (SVD) rate (Pearson chi2 = 29.74, p = 0.000). A total of 62 parturients (17.5%) who presented in the latent phase and 204 (29.1%) in early labour had an unfavourable delivery mode; 46 had a caesarean section. There was a significant correlation between delivery mode and prolonged latent phase (Pearson correlation coefficient R = -0.066, p = 0.000). Linear regression analysis showed that the total number of VEs was the most significant predictor of the delivery mode of SVD (Regression beta-coefficient = 0.278, t = 10.37, p = 0.000). Early admissions in labour and a prolonged (abnormal) latent phase are significant predictors of difficult mode of delivery (poor labour outcome). We suggest that the first vaginal examination should be undertaken by the most experienced medical personal present at admission.

An appraisal of the level of awareness and utilization of the Pap smear as a cervical cancer screening test among female health workers in a tertiary health institution.

Papanicolaou (Pap) smear test is considered the best approach to reduce cervical cancer incidence worldwide. We surveyed 195 female health workers with structured questionnaires to identify factors that could influence the awareness and utilization of the Pap smear as a cervical cancer screening test. More than 65% of the respondents were aware of the disease, cervical cancer, and approximately 64% were aware of the Pap smear test. Seven three (39.7%) of the respondents had their sexual debut (coitarche) before the age of 20 years, while 109 (59.9%) have had multiple sexual partners. The modal number of sexual partners was 3, range 0-8. Pap smear awareness level significantly varied among the categories of the female health workers (P < 0.001). A minority of 14.1% have had a Pap test. There was a significant variation in utilization of Pap test across the various categories of the health workers (Pearson Chi-square 14.67, P < 0.05), and a significant correlation between Pap smear awareness and utilization (P < 0.001). The majority, 89%, believed that they were not at risk of developing cervical cancer. The self-reported utilization of Pap test among health workers was low. While there was a positive correlation between Pap test awareness and utilization, screening uptake was very poor due to a combination of inappropriate beliefs, misapprehension, and deficient knowledge. There is an urgent need for an aggressive awareness campaign and the provision of a screening program nationally.

Cancer of the ovary at the University of Benin Teaching Hospital: a 10-year review, 1992-2001.

Forty-nine patients managed for primary ovarian cancer between January 1992 and December 2001 were analyzed, to appraise the incidence, clinical presentation and management. Data of relevance to the socio- demographic profile, clinical presentation, histopathological types, treatment modality and outcome of management were extracted from patients' case notes. A total of 412 patients with gynaecological malignancies, including 49 (11.9%) ovarian cancer were admitted in the gynaecological wards in the study period. The peak age of incidence was between 51- 60. mean 58 years. Social classes I and II were in the majority, 21.7% and 32.6% respectively. Late presentation, with stage III (76.2% of the patients) is the modal stage at presentation. The majority (73.8%) of the tumours were of epithelial origin. Gastrointestinal symptoms (86.9%) were the most common clinical features at presentation. The majority of patients (91.3%) had surgery (cytoreductive) as first line treatment, while 36/42 patients had adjuvant chemotherapy. Intraoperative haemorrhage (11.9%) was the most common complication. 2.4% of the patients died intraoperatively Primary ovarian carcinomas in Benin are predominantly epithelial in origin. It is the second most frequent gynaecological malignancy. Patients present late. mortality is high and unsatisfactory despite multimodal therapy. Public enlightenment to increase awareness and introduction of screening program for early detection is advocated.

Care for the terminally ill: a review of deaths in the gynaecological wards of a tertiary institution, 1986-2000.

BACKGROUND: There is yet no formula to predict the expected date of death, however this information may be invaluable to the terminally ill, care givers, friends and family members to write the will, arrange for end-of-life care, settle disputes, and to make plans for burial ceremonies. OBJECTIVE: The study is an audit of all deaths in the gynaecological wards to determine the causes of death and highlight the care option for the terminally ill patient. STUDY METHODS: The admission ward registers and the duplicate copies of issued death certificates between 1986-2000 were studied. Details of the individual patients diagnosis and at death or discharge were collected and crosschecked with the patient's casenote. The collected data was subjected to statistical analysis using appropriate computer software. RESULTS: A total of 10,485 admissions were recorded in the study period. There were 89 (0.85%) deaths and 27(0.26%) discharges against medical advice. The yearly rate of death varied between 0.36% and 1.66% admissions. Patients' discharging themselves from the gynaecological wards against medical advice started in 1992, and was at a maximum (2.0%%) in 1996. Carcinoma of the cervix (30.3%) was the most frequent cause of death next was ovarian cancer (29.2%). Death following complications from criminal abortions (11.2%) was fourth while deaths subsequent to operation for uterine fibroids and ectopic pregnancies were 2.2% each. Patients dying from complication of abortion were the youngest (22.6 years +/- 9.13), while patients dying from endometrial carcinoma were the oldest (64.75 years +/- 9.84). The mean age of patients dying from advance gynacological malignancies was 44.13 years +/- 17.07, which is significantly higher than the mean age of patients dying from complications of abortion, P<0.00015 (Student's T-Test, two tail, type 2). CONCLUSION: Advanced malignancies of the cervix, ovary and chorion carcinoma are the major causes of gynaecological deaths. Next, are deaths resulting from the complication of criminal abortion. Patients' discharge against medical advice as option of care needs further investigation.

A raised mid-trimester mean arterial blood pressure: is it predictive of pregnancy induced hypertension in nigerian pregnant women?

Pregnancy-induced hypertension/pre-eclampsia and its sequelae eclampsia are major causes of maternal and perinatal morbidity and mortality in Nigeria. A retrospective review of 1200 deliveries in women who booked for antenatal care before the 20th week of gestation was done in a tertiary hospital. This was aimed at determining if a raised mid-trimester mean arterial blood pressure was predictive of subsequent development of pregnancy-induced hypertension/pre-eclampsia in Nigerian women, and if it is, to assess its sensitivity, specificity, positive predictive value and negative predictive value. There was a statistically significant higher incidence of Pregnancy-induced hypertension/pre-eclampsia in women with an elevated mid-trimester mean arterial blood pressure (P< 0.0001,OR=3.7). The sensitivity of the screening test was 22.9% , specificity 92.5% , positive predictive value 25.0% and negative predictive value 91.7% . The relative risk of developing Pregnancy-induced hypertension in women with elevated mid-trimester mean arterial blood pressure was 3 times that of those with a normal mid-trimester blood pressure. It is concluded that the test shows a high specificity and negative predictive value and allows apportioning of relative risks of developing the disease among booked antenatal patients. The calculation of the mid-trimester mean arterial blood pressure should become a routine part of antenatal care in Nigerian women.

Obstetric hysterectomy: fifteen years' experience in a Nigerian tertiary centre.

The aim of this study was to determine the incidence, indications, associations and complications of obstetric hysterectomy in our centre with a view to suggesting ways of improving outcome. This is a descriptive study of patients who had obstetric hysterectomy in the University of Benin Teaching Hospital from January 1986 to December 2000. Data obtained from hospital records were analysed using appropriate computer statistical software for graphs and chi(2) test. In the period under study there were 20 344 deliveries. There were 46 obstetric hysterectomies, resulting in an incidence of 0.226%. Incidence increased with increasing maternal age from 0.10% at 20 years to 0.706% at 40 years and above. Incidence also increased with parity from 0.028% at para 0 to 1.298% for grandmultiparous women. The indications for the procedure were ruptured uterus 14/40 (35.0%), atonic postpartum haemorrhage 13/40 (32.5%) and placenta praevia 9/40 (22.5%); 12/40 (30.0%) of patients had previous caesarean sections. Subtotal hysterectomy had been undertaken in 43.5% of cases. There was a maternal mortality rate of 12.5%. Mortality was associated with torrential continuing haemorrhage and septicaemia. Urinary tract injury occurred in 7.50% of patients. Injury to the urinary tract was associated with previous caesarean section and total hysterectomy. Obstetric hysterectomy can have grave consequences. Availability of blood products, intensive monitors and limitation of family size is advised.

Surgical management of early stages of cervical cancer: the value of internal iliac artery ligation.

Assessment and removal of pelvic lymph nodes is an essential component of radical surgery for gynaecological cancer. However, control of pelvic haemorrhage presents a challenge to the gynaecologist. This study was designed to determine the value of routine bilateral internal iliac artery ligation (BIIAL) in the management of patients with early states of cervical cancer treated at the University Teaching Hospital (Benin). The data sheets of 32 patients who had a radical hysterectomy for Stages 1-2a carcinoma of the cervix (cases) and 128 patients (controls) who had had either total abdominal hysterectomy or other gynaecological pelvic surgery for benign conditions, between January 1992-2000, were analysed. Information extracted for analysis included socio-biological data, blood loss, complications at surgery and postoperative events. BIIAL was performed as a routine part of the procedure to control pelvic haemorrhage. The mean age of patients was 43.5 years +/- 9.4, with a range of 25-65. The mean parity was 6.64 +/- 2.11, range 2-11; 14/32(43.7%) and 11/32 (34.38%) of the patients had Stages IIA and Ib diseases. The mean pre- and postoperative PCV was 32% and 31%, respectively (cases). There was no significant difference in the pre- and postoperative PCV of the two groups. The estimated blood loss at surgery (cases) had a range of 300-850 mL, with a mean of 465 mL +/- 150.85. The mean blood loss of the controls (surgery without BIIAL) was 856 mL +/- 393.3, with a range of 300-2,500 mL. The difference was statistically significant P<0.0006, Student's two-tailed type 2, t-test). Eight patients (25.0%) had no blood transfusion, 19/32 and 5/32 patients (59.4% and 15.6%) had 2 and 3 units of blood transfused. No patient who had BIIAL required 4 units of blood transfusion. One patient (3.13%) had a laceration of the internal iliac vein; there was no operative mortality. The average hospital stay was 12 days. Ligature of the internal iliac artery seems to reduce operative blood loss when used as a prophylactic routine procedure at radical hysterectomy. This is of value to the surgeon in the developing world where there are inadequate blood transfusion and chemoradiation services. A randomized controlled trial is suggested.

Routine use of the gravidogram and foetal growth chart in Benin: is there need to customise the gravidogram?

The Objective of the study is to investigate foetal growth curve amongst the women attending the antenatal clinic of the UBTH and determine if the gravidogram needs to be customised for use in our community. Five hundred and sixty booked antenatal patients with certain last menstrual period dates were recruited for a prospective non-randomised longitudinal study. Serial measurement of the symphysis-fundus at each antenatal clinic visit was taken using a non-stretch tape measure in centimetre. The data collected was analysed for the mean longitudinal growth curve, and for the construction of a centile gravidogram (10th, 50th, 90th percentile) using a computer programmed ready-to use chart. The mothers average height and body mass index was 1.64m +/- 0.06 and 25.9+/-4.24. The mean birth weight was 3.13kg +/- 0.49. The male infants were 46.3% of the total and were slightly heavier (weight boys vs. girls, 3.15 vs. 3.11kg, P=0.467), not fetal growth curve is comparable and draws a parallel with international standard gravidogram, except that our babies grow all through pregnancy. The foetal growth pattern in Benin is comparable to international standard pattern. However, because of infant birth weight and maternal biosocial differences there is need to costomise the gravidogram to identify all at risk babies in the community.

Ectopic pregnancy revisited in Benin City, Nigeria: analysis of 152 cases.

BACKGROUND: Ectopic pregnancy is still a major health problem among women of childbearing age in our community. The majority of the patients with ectopic pregnancy are nulliparous in their mid twenties, with previous induced abortion(s) and or pelvic inflammatory disease. It remains a major challenge to the reproductive performance of women worldwide. OBJECTIVE: The study is an analysis of the clinical profile of patients presenting with ectopic pregnancy, to investigate the current status of the incidence, predisposing risk factors and the management options available in Benin. MATERIALS AND METHODS: One hundred and fifty two cases of ectopic pregnancies managed at the University of Benin Teaching Hospital (UBTH) between January 1994 and December 1998 were analyzed. Clinical and socio-biological information were retrieved from patients' case notes, and supplemented by information from the operating theatre and ward registers. RESULTS: The incidence of ectopic pregnancy during this study period was 1. 68% of total births and 6.74% of and gynecologic admissions. Nulliparous patients were 49.3%, while the peak age of incidence was 20-25 years. 95/152 (62.5%) of the patients had previous induced abortion(s), while pelvic adhesions were noted in 62/152 (40.85 approximately %). 67.8% of the patients were not using any method of contraception, while 13.8% and 9.2% were using lUD and barrier methods, respectively. Abdominal pain, 2 degrees amenorrhoea and irregular vaginal bleeding (83.6%, 77.5% and 73.7%, respectively) were the most frequent presenting complaints. 75/152 of the patients (49.3%) were in a state of shock, and 80.3% had ruptured tubal pregnancy at presentation. All patients had laparotomy, 54.6% and 34.9% had right and left salpingectomy, respectively. 831/52 of the patients (54.6%) had autotransfusion during surgery. CONCLUSION: In Benin, the majority of the patients with ectopic pregnancy are nulliparous in their mid twenties, with history of previous induced abortion(s) and or pelvic inflammatory disease. Management option is limited to laparotomy and salpingectomy.