Capacity of Non-Tertiary Kenyan Health Facilities Selected for Decentralised Dental Training

Objective: To determine the capacity of six non-tertiary Kenyan hospitals enrolled as sites for decentralised dental education.Design: A descriptive cross-sectional study. Setting: The Dental departments of six non-tertiary Kenyan health facilities.Main outcome measures: Capacity of the hospitals to be used as sites for decentralised dental education.Results: Five out of the six facilities had capacity for final year undergraduate students to gain learning experiences in more than 60% of the clinical disciplines studied. All the selected facilities had challenges of lack of specialists; broken down dental equipment and inadequate materials. Conclusion: Although the six hospitals faced various challenges in maintenance of equipment; availability of dental materials and specialist staff; five out of the six facilities had the capacity for dental student learning in more than 60% of the clinical disciplines studied

HIV infection and sexual partnerships and behaviour among adolescent girls in Nairobi, Kenya.

Early sexual partnerships place young women in sub-Saharan Africa at high risk for HIV. Few studies have examined both individual- and partnership-level characteristics of sexual relationships among adolescent girls. A cross-sectional survey of sexual history and partnerships was conducted among 761 adolescent girls aged 15-19 years in Nairobi, Kenya. Rapid HIV testing was conducted and correlates of HIV infection were determined using multivariate logistic regression. The HIV prevalence was 7% and seropositive adolescents had a younger age at sexual debut (P < 0.01), more sexual partners in 12 months (P = 0.03), and were more likely to report transactional or non-consensual sex (P < 0.01). Girls who reported not knowing their partner's HIV status were 14 times as likely to be HIV-seropositive than girls who knew their partner's status (adjusted odds ratio: 14.2 [1.8, 109.3]). Public health messages to promote HIV testing and disclosure within partnerships could reduce sexual risk behaviours and HIV transmission among adolescents.

REMINDER SYSTEMS FOR SELF UTERINE MASSAGE IN THE PREVENTION OF POSTPARTUM BLOOD LOSS.

BACKGROUND: Uterine massage may significantly reduce post partum blood loss and could be patient-driven. OBJECTIVE: To assess the effectiveness of an alarm reminder system for self uterine massage in the prevention of post partum blood loss. DESIGN: A random controlled trial. SETTING: Meru District Hospital, Kenya. SUBJECTS: One hundred and twenty seven (127) women were randomly assigned to a 15 minute alarm reminder system (71) and non-alarm (56) control arm during the fourth stage of labour. RESULTS: Uterine massage compliance was better in the alarm group compared to the non-alarm group (Average massage of seven and two in two hours respectively P-value <0.0001), however the difference in blood loss was not significant 45.6 ml (95% CI 43-46) vs 47.1 ml (95% CI 43-52)ml p-value 0.892. CONCLUSION: Uterine massage compliance is remarkably increased by the use of an alarm reminder.

Mode of delivery decisions among HIV-infected mothers at an urban maternity hospital in Kenya.

OBJECTIVES: To quantify the use of elective Caesarean section (ECS) for prevention of mother-to-child transmission of HIV (PMTCT) at an urban Kenyan maternity hospital, to describe mode of delivery decision making among HIV positive women, and to understand patient knowledge and attitudes regarding ECS for PMTCT. DESIGN: Descriptive cross-sectional study. SETTING: Pumwani Maternity Hospital, Nairobi, Kenya. SUBJECTS: Two hundred and fifty postpartum HIV-infected women. MAIN OUTCOME MEASURES: ECS delivery rate, correlates of mode of delivery decisions and ECS for PMTCT knowledge and attitudes RESULTS: The rate of delivery by ECS for PMTCT was 4.0% (10/250), though 13.6% (34/250) planned this mode of delivery. Patient education regarding ECS for PMTCT was limited, and 64% (160/250) of participants had never heard of ECS. Planning ECS for PMTCT was positively correlated with attending clinic at PMH (OR=9.12, 95% CI: 2.94-28.28, p<0.001), knowledge of ECS (OR=27.22, 95% CI: 5.04-148.20, p<0.001) and having a history of abdominal surgery (OR=30.96, 95% CI: 6.32-205.02, p<0.001). Delivering by ECS was associated with planning this mode of delivery (OR=19.52, 95% CI: 3.69-103.23, p<0.001). Planning but not delivering by ECS was mostly due to labour before scheduled ECS (55.6%, 15/27) or poor patient understanding of the intervention (29.6%,8/27). After education on ECS for PMTCT, 48.0% (120/250) of participants would consider elective Caesarean section if offered, though cost represented a significant barrier to acceptability. CONCLUSIONS: Knowledge and utilisation of ECS for PMTCT are limited and varied in this patient population. ECS may be an acceptable mode of delivery for some Kenyan women, especially if the burden of cost is removed. A clear policy on ECS counselling and utilisation is urgently needed to ensure consistent and appropriate use of this PMTCT intervention in Kenya.

HIV testing men in the antenatal setting: understanding male non-disclosure.

Prevention of infant HIV is a powerful incentive for maternal HIV diagnosis and an opportunity to increase male HIV testing and disclosure of HIV status within couples. We examined male HIV disclosure in couples who attended a Nairobi antenatal clinic (ANC), had individual HIV testing, and were counselled to disclose to their partner. At two-week follow-up, men and women independently reported HIV disclosure. Of 2104 women, 1993 requested partner attendance; 313 male partners came, of whom 183 chose individual HIV testing. Of 106 couples who followed up, 93% of both partners reported disclosure by women versus 71% by men (P < 0.0001); 27% of men reported disclosure while their female partner reported not knowing partner HIV status. In these couples, male ANC HIV testing did not result in shared knowledge of HIV status. Couple counselling models that incorporate disclosure may yield greater HIV prevention benefits than offering individual partner HIV testing services at ANC.

Pregnancy outcomes in mothers with advanced human immunodeficiency virus disease.

OBJECTIVE: To determine the impact of HIV disease on immediate maternal and foetal outcomes at the Kenyatta National Hospital, Nairobi, Kenya. DESIGN: Prospective cohort study. SETTING: Kenyatta National Hospital, Nairobi, Kenya, between September 2004 and April 2005. SUBJECTS: Sixty eight mothers with advanced HIV disease (WHO clinical stage 3 and 4) and 68 HIV negative pregnant mothers. RESULTS: Mothers with advanced HIV disease were more likely to be anaemic (55% vs. 16% p < 0.001), to have sexually transmitted diseases (56% vs. 15%, p = 0.004), to have chorioamnionitis (14.8% vs. 2%, p = 0.004), to develop preterm premature rupture of membranes (31% vs. 9%, p < 0.001), to have puerperal pyrexia (16% vs. 2%, p = 0.032) an to die (5% vs. 0.5%, p = 0.028) compared to HIV negative mothers. The mean gestational age at deliver was lower in mothers with advanced HIV disease compared to the seronegative counterparts (73% vs. 32%, delivery <37 weeks, p < 0.001). Infants of mothers with advanced HIV disease compared to infants of seronegative mothers were more likely to be low birth weight infants (58% vs. 21%, p < 0.001), stillborn (4% vs. 2%, p = 0.308) and to have low Apgar scores (28% vs. 12%, Apgar score < 4 at 5 minutes p = 0.02). Perinatal sepsis and perinatal deaths were more common in infants born to mothers with advanced HIV disease compared to infants born to HIV negative mothers (8 vs. 3, p = 0.003 and 14 vs. 5, p = 0.025 respectively). External congenital anomalies were similar in the two groups (5.9% vs. 5.9%). CONCLUSION: Pregnancies complicated by advanced HIV disease are more likely to have adverse outcomes, both maternal and foetal. Advanced HIV disease is associated with increased risk of both maternal and fetal mortality. HIV infected mothers should be counselled on the increased pregnancy risks associated with advanced disease.

Body dysmorphic disorder: case report.

The desire for self-mutilation in the absence of any discernible psychopathology is relatively rare. Self-mutilation is most commonly a manifestation of an underlying psychopathology such as depression, schizophrenia, personality disorder, transexuality, body dysmorphic disorder and factitious disorder. In this article, a case in which a 29-year-old single Kenyan lady of African origin demanded a surgical operation to modify and reduce the size of her external genitalia is presented. Although female genital mutilation is still widespread in the country, this case is of interest in that the woman did not seek the usual circumcision but sought to specifically reduce the size of her labia minora so that she could feel like a normal woman. The unique challenges in her management are discussed. Possible aetiological factors in patients who demand surgical removal or modification of parts of their bodies without an obvious cause is discussed.

Perceptions and practices of vaginal birth after Caesarean section among privately practicing obstetricians in Kenya.

OBJECTIVE: To determine perceptions, preferences and practices of vaginal birth after Caesarean. DESIGN: Cross-sectional descriptive study. SETTING: Private clinics of obstetricians in five major towns of Kenya. SUBJECTS: Obstetricians in private practice. MAIN OUTCOME MEASURES: Practice and experiences in trial of labour (TOL); need for, and application of, selection criteria in TOL; perceptions on outcomes of TOL and patient preference; perception on trends of vaginal birth after Caesarean (VBAC) and need for policy on TOL. RESULTS: Nearly all respondents (98.4%) believed in the need for, and application of, selection criteria for allowing TOL. However, only 23% believed in routine screening with radiological pelvimetry, while 63.2% believed in routine foetal weight estimation. All obstetricians (100%) have ever managed TOL in private practice, and 74% had managed at least one case in the last six months. Despite lack of tangible selection criteria, 83.1% think that most women prefer TOL while 95.1% discourage it if perceived as inappropriate. Failure rate of TOL was perceived to be more than 50% by 35.2% of the respondents. A majority of the respondents (about 75%) would prefer TOL on themselves or their spouses. Those who perceived that there was a falling trend of VBAC were 58%, citing increased demand by mothers (45.7%), obstetricians' convenience (40.0%) and fear of litigation (26.8%) as the reasons for this observation. A fluid policy of "TOL whenever it is deemed as appropriate" was preferred by 88.7%. CONCLUSION: The perception of obstetricians is that desire for VBAC predominates over elective repeat Caesarean. However, consensus on appropriate selection criteria is lacking, which leaves the obstetrician in a management dilemma. Hence, there is need to study outcomes of both ERC and TOL in order to come out with objective policy guidelines on management of one previous Caesarean in pregnancy.

Effect of chronic trypanosomiasis on immunization against East Coast fever.

Two experiments were carried out in which uninfected cattle, or cattle chronically infected with Trypanosoma congolense, were immunized by the infection and treatment method against East Coast fever (ECF; Theileria parva infection). Chronic trypanosomiasis did not prevent cattle mounting an effective immunological response to ECF immunization and resisting subsequent lethal challenge. There appeared to be no difference in the level or quality of immunity between uninfected cattle and trypanosome-infected cattle. Thus, T. congolense infection on its own does not appear to provide a constraint to ECF immunization in the field.