Pakistani obstetricians' recognition of and attitude towards domestic violence screening.

OBJECTIVE: Our study assesses Pakistani obstetricians knowledge of the prevalence of domestic violence in clinical practice and attitudes towards instituting screening protocols during routine antenatal care. METHODS: One hundred obstetricians, all Karachi residents, were randomly drawn from a stratified sampling list taken from membership lists. A structured questionnaire assessing prevalence, attitudes, and beliefs on training and domestic violence screening protocols was administered. RESULTS: Nearly 70% of obstetricians reported that more than 30% of Pakistani women are victims of domestic abuse. Sixty-two obstetricians specified that they had identified a physically abused woman within the past year. Almost half of the respondents were favorably inclined to screen patients. Professional, personal and patient-related barriers were identified as the main hurdles preventing instituting screening. CONCLUSIONS: The desire for instituting routine screening despite the recognition of major hurdles by Pakistani obstetricians should propel reproductive health stakeholders to raise awareness about appropriately modifying standard antenatal care protocols.

Maternal mortality in Pakistan--compilation of available data.

OBJECTIVE: To compile available information - both hospital and community based--on the maternal mortality ratios (MMRs) and the causes of maternal deaths in Pakistan METHODS: Data was collected from articles published in Medical Journals, in Proceedings of Conferences and of Workshops as well as from Newsletters of the National Committee for Maternal Health (NCMH). The data was then tabulated in order of the year of publication. RESULTS: The MMRs reported from hospitals vary between 17 in a private tertiary hospital to 2,736 in a government tertiary hospital. In the community the range is from 160 in Sindh to 673 in Khuzdar. Data for different periods of time from three tertiary public hospitals, two in the south and one in the north of Pakistan, show no decrease in MMRs. The trend remains the same. In the hospitals over 80% of the deaths are due to direct causes. The most common cause of death is hemorrhage, followed by eclampsia and sepsis. The causes of death in the community are also the same though the proportions vary. Direct causes account for 78.1% of deaths, hemorrhage being the most common followed by sepsis, eclampsia, rupture of the uterus, and abortions. CONCLUSIONS: Available data shows that the Maternal Mortality Ratios in Pakistan continue to remain high despite attention paid to maternal health. To address the unacceptable state of maternal health, a policy change with a more comprehensive and integrated approach to maternal health services is needed. Strategies need to be developed which are short term, medium term and long term. This includes competency based training, deployment and supervision of a cadre of skilled attendants for delivery at the community level. In addition upgrading of health care systems especially availability of emergency obstetric care is urgently required.

Ectopic pregnancies: a three year study.

OBJECTIVE: To analyze the risk factors and assess the results of management with respect to maternal morbidity and mortality of ectopic pregnancy during the last three years. SETTING: Ziauddin Medical University Hospital, North Nazimabad campus (ZMUH), Karachi. RESULTS: Forty-three patients were admitted with ectopic pregnancy at ZMUH from 1st January 1997 to 31st December 1999. Frequency of ectopic pregnancy was 1.3% of total 3252 pregnancies. Risk factors were found in 33% of cases. There was one case of heterotopic pregnancy. Surgical treatment was performed in 36 cases. Two patients were given intramuscular methotrexate and one un-ruptured ectopic resolved after expectant management. CONCLUSION: Conservative management was an option but surgical treatment was done more often because of late referrals. Screening of high risk cases, early diagnosis and early intervention would reduce the morbidity in ectopic pregnancies.

Maternal sociocultural status: a novel assessment of risk for the birth of small for gestational age, low birth weight infants.

OBJECTIVES: We assessed the significance of material sociocultural status within the family as a risk factor for low birth weight-small for gestational age (LBW-SGA) births using a novel scoring system and also isolated related medical risk factors. METHODS: A prospective matched pairs case control study of 396 LBW-SGA infants (cases) and 396 term, appropriate for gestational age infants (controls) was set up. RESULTS: Low maternal sociocultural status (p = 0.02) was significantly associated with LBW-SGA births as were nonregistration for antenatal care (p = 0.001), maternal weight at delivery < 50 kg (p < 0.0001), antepartum hemorrhage/preeclampsia (p < 0.01), primigravidity and previous small baby (p <0001). Other risk factors included birth interval < 24 m (p < 0.001) and poor maternal or paternal education (p < 0.05). Conditional logistic regression identified maternal weight at delivery < 50 kg (OR 4.8, 95% C.I. 3.0-7.6), lack of antenatal care (OR 2.0, 95% C.I. 1.4-2.9), antepartum hemorrhage/preeclampsia (OR 4.3, 95% C.I. 1.7-10.8) and previous small baby (OR 4.3, 95% C.I. 2.1-8.9) as independent risk factors. CONCLUSIONS: Low sociocultural status of the mother within the family is significantly associated with having a LBW-SGA baby. Further studies are warranted to study this risk factor.

Obstetrics hysterectomy--five years experience at Jinnah Postgraduate Medical Centre, Karachi.

During the five years period (1st January 1988 to 31st December 1992), 106 hysterectomies were performed for obstetric indications in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre (JPMC), Karachi. The frequency was 1 in 331 deliveries (total 35,172 deliveries). In all except one hysterectomy was performed as a life saving measure. The major indications were ruptured uterus in 61 (58%) cases and severe postpartum haemorrhage due to uterine atony in 18 (17%). Other indications included haemorrhage due to placenta praevia in 11 (10%), placenta accreta 7 (7%) and abruptio placentae 5 (5%), severe infection 2 (2%) and broad ligament haematoma following caesarean section 1 (1%). There were 10 (9%) maternal deaths all due to severity of the conditions necessitating hysterectomy. Obstetric hysterectomy can save many lives but requires proper judgement and skill. Senior resident staff in obstetric units in the developing countries should be trained for it.

Social and cultural factors leading to mothers being brought dead to hospital.

In a 12-year period (1981-1992) 150 pregnant or recently delivered women were dead when they reached the hospital. Relevant history with emphasis on the events of the previous 24 h and the reasons for delay in reaching the hospital were obtained from the relatives accompanying the patient. The probable cause of death was determined on the basis of history only; no autopsies were done. The causes of delay were economic (54), sociocultural factors (51) and inadequate maternal services (31). In 14 cases the reasons for delay could not be established. The medical problems were either preventable or treatable if managed in time. A combination of economic, social and cultural factors played a more significant role in these deaths than medical causes.

Carriage of beta haemolytic streptococci (BHS) in pregnant women and acquisition by neonates.

Beta Haemolytic Streptococci(BHS) carriage rate in pregnant women during labour and its acquisition by their newborns just after birth was investigated in 60 mother baby pairs. The carriage rate of group B Streptococci (GBS) was 11.6%, acquisition rate by newborns of carrier and non-carrier mothers was 85.7% and 1.8% respectively. A total of 28.5% newborns were carrying GBS on all the skin sites and were heavily colonized and therefore, at higher risk of developing early onset of Streptococcal infections. Penicillin G and Ampicillin were most effective antibiotics against GBS.

Anaemia in pregnancy--its cause in the underprivileged class of Karachi.

A prospective study of the frequency and type of anaemia amongst poor urban parturients of Karachi was done. It was performed at 2 large teaching hospitals over the time span January to September, 1990. Out of 318 women studied, 104 (32.7%) were anaemic (Hb levels < 10gm/dl). The type of anaemia was assessed. Iron deficiency predominated and was seen amongst 63.5% of the anaemic population. There was an even distribution of other kinds of anaemia amongst the remainder of the population.

Frequency of Chlamydia trachomatis in pregnant women.

Frequency of chlamydia trachomatis infection was investigated in eighty-five pregnant women by direct immunofluorescence (IF) and iodine staining methods. The overall frequency of true positive by both methods was 8.2%. Direct immunofluorescence method alone detected chlamydia infection in 16.5% women with 50% sensitivity and 93% specificity and by iodine method in 14.1% women with 58.3% sensitivity and 90.4% specificity. This shows that as compared to IF iodine method is more sensitive and less expensive and easier to perform. The frequency of chlamydia trachomatis infection in our study population appears to be age dependent with younger patients being more likely to be infected than the older patients.

Rupture of the uterus in full-term pregnancy.

Of 48,519 deliveries conducted at Jinnah Postgraduate Medical Centre (JPMC) over 7 years (January, 1986 to December, 1992), 257 were of ruptured uterus, giving a rate of one in 189 deliveries. Main cause of rupture was obstructed labour. Maternal mortality was 3.9% and foetal mortality 88% in cases admitted with uterine rupture and 17.6% in rupture occurring within the hospital (JPMA 43: 172, 1993).

Mothers brought dead: an enquiry into causes of delay.

In a 10 year period (1981-1990) 118 pregnant or recently delivered women were dead when they reached hospital. Relevant history with emphasis on the events of the previous 24 hr and the reasons for delay in reaching the hospital were obtained from the relatives accompanying the patient. The probable cause of death was determined on the basis of history only. Autopsy was not carried out on any case. The causes of delay were economic factors in 42, socio-cultural factors in 39 and inadequate maternal services in 24 cases. In 13 cases the reasons for delay could not be established. The medical problems were either preventable or treatable if managed in time. A combination of economic, social and cultural factors played a more significant role in these deaths than medical causes.

Platelets and leucocyte counts in pregnancy.

A study involving the obstetric clinic population of 3 major teaching hospitals of Karachi has been conducted to define changes in leucocyte and platelet counts as pregnancy progresses. 573 "normal" pregnant women--183 in the first trimester, 195 in the second trimester and 194 in the third trimester were included in this analysis. We have found leucocytosis to be a feature of normal pregnancy; the change is subsequent to a progressive increase in granulocytes. Platelet counts were found to decrease slightly as pregnancy progresses.

Dietary and serum calcium in pregnant women.

Dietary and serum calcium were estimated in 200 normal pregnant women between 37-41 weeks of gestation and in cord blood of their new born. Calcium intake per person per day was low, 11.8mmol/L, as compared with the daily recommended allowance of 30 mmol/L. Mean maternal serum calcium level was also low (1.9 mmol/L) and only 20% of mothers had serum calcium within normal range. Mean calcium value in cord blood was at lower limit of normal range, being 2.3 mmol/L; 38.5% of cord samples (77) were below the normal range.

Maternal morbidity in the Department of Obstetric and Gynaecology, Jinnah Postgraduate Medical Centre Karachi.

Maternal morbidity was observed in 377 obstetric cases at Jinnah Postgraduate Medical Centre (JPMC) during a period of one year. Morbidity rate was 4.4% of total deliveries. Three hundred and twenty-four (86%) mothers had no proper antenatal supervision. Infection was more common after abdominal delivery and injury to genital tract after vaginal delivery. The most serious injury was rupture of gravid uterus. Thirty-seven cases of ruptured uterus were admitted in one year and 5 cases occurred within the hospital (1 in 1225 deliveries).

Serum calcium, urea and uric acid levels in pre-eclampsia.

Serum calcium, urea and uric acid levels were determined in 100 normal pregnant women and 50 patients with pre-eclampsia. Serum calcium levels were significantly lower and urea and uric acid levels higher in pre-eclampsia. Low levels of calcium were found as early as 28 weeks and can therefore be used for early diagnosis of pre-eclampsia.

Perinatal mortality in Jinnah Postgraduate Medical Centre, Karachi.

During the one year period from 1st January to 31st December, 1989, there were 6,826 deliveries and 695 perinatal deaths, of these 553 were still-born and 142 were neonatal deaths (died within 7 days of birth). The perinatal mortality rate was 101.8 per thousand total births. The still-birth rate was 81 per thousand total births. Of the perinatal deaths, 7.9% occurred in booked and 92.1% in non-booked cases. The commonest cause of death was antepartum haemorrhage (APH), 24.2% followed by mechanical which accounted for 23.6% deaths. Abruptio placentae was the leading cause among all still-births and low-birth weight (LBW) in all neonatal deaths.