Effects of multifaceted interventions to prevent and manage primary postpartum haemorrhage in referral hospitals: a quasi-experimental study in Nigeria.

INTRODUCTION: Primary postpartum haemorrhage (PPH) is the leading cause of Nigeria's high maternal mortality rate. This study investigated the effectiveness of a set of multifaceted interventions to manage and reduce PPH in selected secondary referral health facilities in Nigeria. METHODS: This is a quasi-experimental study using an interrupted time-series design to assess a set of multifaceted interventions that address factors identified by stakeholders as associated with PPH. Interventions were implemented at two regional general hospitals, with a general hospital in the same region as the control. Intervention participants were women during antepartum and clinical and administrative staff. Cases of PPH were determined in women at delivery. The outcomes measured were the incidence of primary PPH and related deaths during the study period. Analyses included a comparative description of characteristics of the women, trend of time-series data at intervention and control hospitals, and multivariable analysis of factors associated with PPH occurrence. RESULTS: Monthly numbers of primary PPH were collected at participating hospitals over 21 months for 18 181 women. Intervention hospitals represent 54% vs 46% in control hospitals. Time-series analyses show a significant downward trend in intervention hospitals. The overall incidence of primary PPH was lower in the intervention hospitals than in the control hospitals. Multilevel regression adjusted for hospital-level effect showed a 68% reduction in odds of PPH cases at intervention compared with control hospitals. There were 12 PPH-related maternal deaths in one of the control hospitals, with no deaths in the intervention hospitals. CONCLUSION: We conclude that multiple interventions that address identified challenges in the prevention of primary PPH can potentially effectively reduce reported primary PPH in Nigerian referral hospitals. This approach is relevant for scaling the development of policies and programmes to prevent primary PPH and maternal mortality in Nigeria.

Does introduction of user fees affect the utilization of cervical cancer screening services in Nigeria?

BACKGROUND: Screening for cervical cancer improves outcome. This comes at an economic price which some may not be able to afford. OBJECTIVE: To evaluate the influence of user fees on the utilization of cervical cancer screening services in Port Harcourt. MATERIALS AND METHODS: A cross sectional study of clients presenting for cervical cancer screening. Data on the number, socio-demographic characteristics, distance from screening center following 1 month of free cancer screening and 7 months of user fee introduction, was collated and analyzed using SPSS version 20 statistical software. Results are presented in percentages, tables and charts with test of significance set at P < 0.05. RESULTS: Of the 167 women who presented for cervical cancer screening during the study period, the mean age was 42.08 ± 8.9 years and range was 20-70 years. The average parity of patients was 2.83 ± 2.24. Clients' utilization of cervical cancer screening facilities was negatively affected by the introduction of user fees P < 0.001). There is no association between the distance of patients' home from the hospital and the utilization of facility (X2 = 0.24, P = 0.887). There was sustained decrease in number of clients with the introduction of fees. CONCLUSION: The introduction of user fees had a negative impact on the utilization of cervical cancer screening facilities. Eradicating user fee and improving the socioeconomic status of patients may improve the utilization of screening services.

Women's perceptions of reasons for maternal deaths: Implications for policies and programs for preventing maternal deaths in low-income countries.

We investigated perceptions of the causes of maternal mortality by women attending referral hospitals in Nigeria. Focus group discussions were conducted with various categories of women. Our results showed that women were aware of the medical causes of mortality, although a few listed divine reasons. Delays in reaching hospitals or after women arrive in hospitals featured prominently as lead causes mentioned by women. Listening to women as end-users is an important approach to identify points of remediation in the provision of maternal health care. This should be taken into cognizance when policymakers or international agencies plan the prevention of maternal deaths in developing countries.

Perceptions of women on workloads in health facilities and its effect on maternal health care: A multi-site qualitative study in Nigeria.

OBJECTIVE: of the study was to explore women's perception of maternal health care providers' workload and its effects on the delivery of maternal healthcare in secondary and tertiary hospitals in Nigeria. RESEARCH DESIGN, SETTING, PARTICIPANTS: five focus groups discussions (FGDs) were conducted with women in each of eight secondary and tertiary hospitals in 8 States in four geo-political zones of the country. In all, 40 FGDs were held with women attending antenatal and post-natal clinics in the hospitals. We elicited information on women's perceptions of workloads of maternal health providers and the effects of the workloads on maternity care. The discussions were audio-taped and transcribed while thematic analysis was carried out using Atlas.ti computer software. FINDINGS: the majority of the participants submitted that the health providers are burdened with heavy workloads in the provision of maternal health care. Examples of heavy workload cited included complaints from health providers, evidence of stress and strain in care provision by providers and the sheer numbers of patients that are left unattended to in health facilities. Poor quality care, insufficient time to carry out necessary investigations on patients, and prolonged waiting time experienced by women in accessing care featured as consequences of heavy workload, with the secondary result that women are reluctant to seek care in the health facilities because of the belief that they would spend a long time in receiving care. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: we conclude that women are concerned about heavy workloads experienced by healthcare providers and may partly account for the low utilization of referral health facilities for maternal health care in Nigeria. Efforts to address this problem should include purposeful human resource policy development, the development of incentives for health providers, and the proper re-organization of the health system.

Implementing the new WHO antenatal care model: voices from end users in a rural Nigerian community.

CONTEXT: The recommended WHO antenatal focused visits with reduced number of visits and tests is yet to be implemented in many communities in rural Nigeria. AIM: This paper evaluated the attitude of antenatal clients in a rural mission hospital to the new antenatal model. STUDY DESIGN: Focus group discussions were carried out bi-weekly for 12 weeks with consenting booked antenatal clients. The topic guide was developed following interactions with prenatal clients at a referral tertiary center. RESULTS: One hundred and forty-four clients were interviewed. Prior to discussion, none had heard of the new antenatal care model. More than half of them will prefer the traditional policy with multiple visits to the new model. The traditional visit was said to be more reassuring and provides the clients time away from their routine chores/occupations and afford them the opportunity to interact with other expectant mothers and get acquainted with the health care providers. CONCLUSION: To realize the goals of the new WHO recommended antenatal model in rural Nigeria, mass enlightenment and education must precede its gradual and cautious introduction.

HELLP syndrome: a report of two cases.

BACKGROUND: HELLP Syndrome is a major disorder of the second half of pregnancy that is associated with high risk of maternal and neonatal morbidity and mortality. HELLP is an acronym for Haemolysis, Elevated Liver enzyme levels and Low Platelet Count. As an obstetric complication, it is frequently misdiagnosed at the initial presentation. The purpose of this report is to bring to focus this life threatening disorder that could occur in the second half of pregnancy. METHODS/RESULT: Two cases of HELLP Syndrome are reported. Their conditions were diagnosed and managed accordingly. The first case was delivered by caesarean section while the second case had a vaginal delivery following induction of labour. They fully recovered from the illness and were discharged home from hospital. CONCLUSION: HELLP Syndrome, being an uncommon major disorder of the second half of pregnancy, early diagnosis is critical to avert a high morbidity and mortality, which have been reported to be as high as 25%.

Marjolin's ulcer: report of 4 cases.

BACKGROUND: Marjolin's ulcer is a rare and often aggressive cutaneous malignancy that arises in a previously traumatized or chronically inflamed skin particularly after burns. The aim of the study is to highlight the surgical importance of this ulcer and to emphasize the necessity of closely monitoring unstable scars of chronic wounds especially post burns wounds. METHOD: A report of four cases of Marjolin's ulcer seen over a fifteen-year period at the University of Port Harcourt Teaching Hospital is presented with a review of the literature. RESULTS: Four cases were seen over a period of fifteen years. There were two females and two males aged 23, 65, 46, 19 years respectively. They all sustained injuries over 20 years prior to being seen at the surgical clinic and presented with ulcers that had features of malignancy. The two females had their ulcers excised and grafted, and were discharged from the hospital tumour free. The two males presented to the hospital very late with malignant ulcers, which could not be resected and they took their own discharge from the hospital. CONCLUSION: Marjolin's ulcer is uncommon in this environment but with the increasing incidence of petrochemical burns due to the oil industry in the environment, incidence of Marjolin's ulcer might increase.