Conscientious objection and reproductive health service delivery in sub-Saharan Africa.

Lack of access to quality reproductive health services is the main contributor to the high maternal mortality and morbidity in sub-Saharan Africa (SSA). This is partly due to a shortage of qualified and experienced health care providers. However conscientious objection amongst the available few is a hitherto undocumented potential factor influencing access to health care in SSA. Provision of certain reproductive health services goes counter to some individual's religious and moral beliefs and practices. Health providers sometimes refuse to participate in or provide such services to clients/patients on moral and/or religious grounds. While the rights to do so are protected by the principles of freedom of religion, among other documents, their refusal exposes clients/patients to the risk of reproductive health morbidity as well as mortality. Such providers are required to refer the clients/patients to other equally qualified and experienced providers who do not hold similar conscientious objection. Access to high quality and evidence-based reproductive health services by all in need is critical to attaining MDG5. In addressing factors contributing to delay in attaining MDG5 in SSA it is instructive to consider the role of conscientious objection in influencing access to quality reproductive health care services and strategies to address it.

FEMALE SEXUAL DYSFUNTION AND GYNAECOLOGICAL PRACTICE: REPORT OF SIX CASES.

Sexuality is a complex phenomenon, yet an essential part of a healthy life, influenced by biological, psychological and socio-economic factors. Current re-conceptualisation of women's sexual response acknowledges that they have many reasons for engaging in sex beyond sexual desire. Women are increasingly becoming aware of their sexuality and demand sexual fulfilment more than ever before and when that is not realised there may be personal distress. Female sexual dysfunction is prevalent in all populations and cultures globally. However, very few women seek medical help due to belief that the problem is not serious, challenges with access to or affordability of care and lack of awareness of available treatments. It's also infrequently diagnosed, due to lack of awareness among health care providers. Case scenarios on female sexual dysfunction managed by the author are presented with the aim of raising awareness among health professionals. Possible strategies to address the problems are proposed.

Informed consent for clinical trials: a review.

OBJECTIVE: To identify and highlight challenges related to informed consent process for clinical trials in sub-Saharan Africa. DATA SOURCES: Published original research findings and reviews in the English literature, together with anecdotal information from our current professional experiences with clinical trials. DESIGN: Review of peer-reviewed articles. DATA EXTRACTION: Online searches were done and requests for reprints from corresponding authors and institutional subscription. DATA SYNTHESIS: Information categorised accordingly. RESULTS: Informed consent for clinical trials conducted in sub-Saharan Africa (SSA) is not always "truly informed" or "truly voluntary". Guidelines for obtaining informed consent are often difficult to implement because of low literacy levels, socio-economic and cultural factors. The local ethics committees, whose role is critical in informed consent, are weak, ill-equipped or non-existent in some countries. Many participants may have incomplete understanding of the various aspects of the clinical trials due to language barriers, the way information is disclosed or terms used for informed consent documents. In some settings, clinical trials are the only access to health care services for the local population. Further, participants may enroll with perceived notion of cure of their conditions, for monetary or material benefits. CONCLUSIONS: There is need for national guidelines on clinical research including ethics review, compensation of subjects, requirements for research investigators, facilities and ethics committees as well as budgetary allocation. These guidelines must not only address specific and unique local circumstances but also meet minimum international clinical research standards. Local bioethics and research capacity should be developed and strengthened with research sponsors contributing towards this. Local research is needed on the validity and reliability of informed consent for clinical trials and factors influencing that in different socio-cultural settings in SSA.

Therapeutic misconception and clinical trials in sub-Saharan Africa: a review.

OBJECTIVES: To identify possible existence of therapeutic misconception and its effects on clinical trials in sub-Saharan Africa. DATA SOURCE: Original research findings and reviews published in the English literature and author's professional experience with clinical trials in some East, Central and West African countries. DESIGN: Review of peer-reviewed articles. DATA EXTRACTION: Online searches and requests for reprints from corresponding authors and institutional subscription. DATA SYNTHESIS: Information categorised accordingly. RESULTS: Therapeutic misconception, defined as a conflation by research subjects of research goals and those of routine health care is considered widely prevalent globally. The subjects misunderstand the disclosures during consenting process and enroll hoping to derive personal benefits from the study. Though no study has looked at therapeutic misconception specifically in sub-Saharan Africa, available evidence suggests that it is prevalent. Therapeutic misconception is incompatible with informed voluntary consent. It may affect participation in clinical trials, subjects' safety and well-being and possibly the research findings. CONCLUSIONS: There is need for studies to identify the prevalence and effects of therapeutic misconception in the region. Researchers in sub-Saharan Africa should be aware of its existence, thus design trials in which it will not have significant effects and strengthen the consent process to reduce it.

Maternal mortality at the Queen Elizabeth Central Teaching Hospital, Blantyre, Malawi.

BACKGROUND: Maternal mortality in Malawi continues to increase despite the global SMI and national safe motherhood programme's efforts to reduce it. OBJECTIVES: To identify the social, demographic and reproductive profiles of women suffering a maternal death, the main immediate causes and the operational factors. DESIGN: A retrospective descriptive survey. SETTING: The Gogo-Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi, from January 1, 1999 to December 31, 2000. SUBJECTS: All women who suffered a maternal death in the unit. RESULTS: There were a total of 204 maternal deaths and 19,859 live births, giving a Maternal mortality ratio (MMR) of 1027.2/100,000 live births. Their ages ranged from 16 to 40 years. Adolescents comprised 20.6%, while the majority, (56.4%), were aged 15 - 24 years. Almost half of the group, (43.4%), were para 1 and less, with a range of 0 to 12. The top five causes of death were puerperal sepsis, (29.4%); postabortal complications, (23.5%); other infectious conditions, (20.1%); obstetric haemorrhage, (10.6%), and eclampsia, (6.4%). Some of the identified operational factors included delay in accessing and receiving emergency obstetric care, poor quality services, HIV infection/ AIDS and unsafe induced abortion following unwanted pregnancy. CONCLUSION AND RECOMMENDATIONS: Most of the causes and operational factors for maternal deaths are easily avoidable. The country needs to make more commitment and investments necessary to mitigate these deaths.

Fournier's gangrene complicating vasectomy.

Quality of care of services provided to family planning clients is a source of major concern in reproductive health care, especially in resource-poor settings. It may be measured in terms of safety of the method or service provided and may be influenced by the knowledge, skills and experience of the service providers, the environment in which the services are provided and the care thereafter. As a result of various efforts by the government and other stake-holders there have been tremendous developments in the family planning programme in Malawi in the past ten or so years. The contraceptive prevalence rate (CPR) more than doubled between 1992 and 2000. Secondly there has been expansion of facilities providing contraceptive services and the method mix such as introduction of voluntary surgical contraception (VSC) for both females and males. The increased demand for contraceptive services has outstripped the available services and as a result led to lapses in the quality of care. These have resulted in some apparently healthy individuals either dying in the course of or following service provision or suffering serious morbidities. This paper presents two cases of Fournier's gangrene following vasectomy in previously healthy male adults in Malawi. It discusses their diverse management and results thereof, and explores the potential impact on the programme in Malawi, in the context of adverse publicity on contraceptives. The possible operational factors for the complications are explored and preventive strategies proposed to ensure sustenance of the already registered gains in fertility control in Malawi.

Reproductive awareness behaviour and profiles of adolescent post abortion patients in Blantyre, Malawi.

BACKGROUND: Adolescent sexuality and its sequelae are now acknowledged as major public health, social and economic problems in Malawi, for which appropriate programmes and services are being designed and implemented. OBJECTIVES: To identify the profiles of adolescent post abortion patients, their reproductive and contraceptive knowledge and factors related to the index pregnancy. SETTING: Queen Elizabeth Central Hospital, Blantyre, Malawi. DESIGN: Cross-sectional, descriptive study. METHODS: All adolescents treated for incomplete abortion, January to December 1997 were eligible. Data was collected by means of interviewer-administered questionnaire, one for each, during reproductive health education and/or post abortion contraceptive counselling and service provision. This was subsequently analysed using EPI-INFO 6.0 data analysis packages. RESULTS: Of the 465 adolescents treated during this period, 446 (95.9%) were enrolled in the study. Their mean age was 17.5 years (SD 1.3), that at menarche and sexual debut 14.3 years (SD 1.4) and 15.7 years (SD 1.75) respectively. The unmarried adolescents formed 43.9%, while students comprised 38.6% of the total. Their level and accuracy of knowledge on reproductive biology was poor. While their contraceptive knowledge was high, its use was very low, 70.9% vs 9.5% respectively. The number of sexual partners one had had ranged from 1 to 10 with a median of 1. The index pregnancy was reportedly unwanted by 45.1%. The young (< 16 years), more educated, single and students were more likely to have unwanted pregnancy. CONCLUSIONS: Sexual activity starts early in Malawi, with poor contraception, thus predisposing to unwanted pregnancy. Lack of appropriate reproductive awareness appears to be partly responsible for that. These need to be addressed through the national reproductive health programmes and services.

Socio-demographic characteristics of adolescent post-abortion patients in Blantyre, Malawi.

BACKGROUND: Unsafe sex, unwanted pregnancy and unsafe abortion are some of the emerging adolescent reproductive health challenges in Malawi. OBJECTIVES: To study socio-demographic characteristics of adolescent post-abortion patients and that of their male partners, with the aim of better understanding the determinants of adolescent fertility in Malawi, thus facilitating design of appropriate intervention strategies. DESIGN: A descriptive, cross-sectional study. SETTING: The Queen Elizabeth Central Hospital, Blantyre, Malawi. SUBJECTS: A total of 446 out of 465 eligible adolescents managed for incomplete abortion during the study period were enrolled from January 1st to December 31st 1997. RESULTS. Their mean age was 17.5 years (SD +/- 1.3), while that of their male partners was 22.4 years (SD +/- 3.4). The unmarried adolescents comprised 43.9% and students 38.6%. About 30.0% had attained secondary school level of education. The mean age at sexual debut was 15.7 years (SD +/- 1.75), about a year after that at menarche (14.3 years, (SD +/- 1.4)). The mean number of sexual partners they had had was 1.5 (SD +/- 0.86), the highest being 10. The index pregnancy was reportedly unwanted in 45. 1% of the total. The rate was higher among the young, single and students. They were also less likely to have informed their partners about the pregnancy or the abortion (p = 0.0001). About 52.8% of the female students were involved with fellow male students. Of the married adolescents, 4.4% reported having had extramarital affairs. CONCLUSION: There is need to design appropriate programmes to promote safe sex and reduce unwanted pregnancy and unsafe abortion with its potential sequelae among adolescents in Malawi.

Post-abortion contraceptive acceptability in Blantyre, Malawi.

BACKGROUND: Unsafe abortion remains one of the major reproductive and public health challenges globally, but more so in developing countries. Lack of or poor contraception has been shown to be one of predisposing factors. OBJECTIVE: To determine contraceptive acceptance amongst post-abortion patients in Blantyre, Malawi. DESIGN: A cross-sectional pilot study. SETTING: The study was conducted in the gynaecological ward of the Queen Elizabeth Central Hospital, Blantyre, Malawi, the University Teaching Hospital. RESULTS: A total of 464 patients were studied. Their mean age and parity were 24 (SD 6.1) and 1.5 (SD 1.9) respectively. The single comprised 20.3% and students 16.4%. The index pregnancy was reportedly unwanted by 45.3% and 17.2% said they had unsafe abortion. Of these 373 (80.4%) accepted contraception. There was no relationship between acceptance and one's age (p = 0.28), marital status (p = 0.59); or parity (p = 0.5). The most commonly chosen methods were oral pills (45.3%), DMPA (21.8%) and male condoms (20.7%). The young (<25 years old), single, more educated, and women of low parity, preferred relatively less reliable contraceptives. CONCLUSION: The results of this study indicate that with proper planning postabortion contraception is acceptable in Malawi. It will provide an additional contraceptive service opportunity, thus increasing the currently low National CPR, and reduce repeat unwanted pregnancy, unsafe abortion, with all its potential sequel. We therefore recommend its integration into emergency post-abortion care.

Socio-demographic characteristics of family planning clients and their possible influence on contraception in Malawi.

In a survey of family planning clients at the central Teaching Hospital, Blantyre, between July 1 and December 31, 1993, to determine their social, biological and reproductive profiles, contraceptive awareness and previous use, 766 new clients were recruited and interviewed by means of partially structured questionnaire. Their mean age was 27 years, with a range of 15-43 years. Adolescents formed 10.1% and those above 35 years of age were 17.1%. 91.3% were married. While 12.6% had no formal education, 29.7% had secondary school education and higher. Their mean parity and living children were 3.6 and 3.1 respectively. The mean desired fertility was 4.5. 93.3% of all clients had live births in their last pregnancies. Contraceptive awareness was quite high, about 98.0%. However, only 30.9% had ever-used contraceptives before then. When these are looked at against a background of the corresponding situations in the country, it appears that the individuals seeking, accepting and using contraceptives in Malawi, are better off in the various aspects of life, thus suggesting their possible influence on contraceptive use. There is need to review the national family planning programme, address the contraceptive needs of adolescents and women aged above 35 years, improve formal female education, change the prevailing socio-cultural and traditional beliefs and practices which affect women adversely, thus empowering them over affairs of their health.

PIP: This study examined the social, demographic, and reproductive profiles and contraceptive usage of women seeking contraceptive services at the largest public clinic in Blantyre, Malawi, during July 1 to December 31, 1993. Data were obtained from a prospective survey among 830 new family planning clients at the Queen Elizabeth Central Teaching Hospital. 69.1% of new clients were seeking contraception for the first time. The mean age of new clients was 27 years. 10.1% of new clients were aged 10-19 years, and 17.1% were aged over 35 years. Almost 30% had a secondary education or higher. 57.7% had only primary school education. 12.6% had no formal education. Better educated women had lower parity, number of living children, and desired fertility. 91.3% were married. 66.3% were housewives. 24.4% were engaged in formal employment. 88.5% of male partners were engaged in formal employment. The mean age at menarche was 15 years. The mean parity was 3.6. Nearly 60% of women aged under 24 years had a parity of 2 or higher. 65.9% had the same number of living children as their parity. 31.1% of women desired 4 children. 13.4% desired a pregnancy within 2 years of the previous pregnancy, which was a poor outcome. Women with a higher number of living children had the desire for the longest birth interval. 98.7% knew at least one family planning method. 30.9% had ever used contraceptives (oral pills and condoms). 49.0% and 42.9% of the 963 clients accepted, respectively, the oral pill and Depo Provera. There was a strong correlation between the methods known and desired, and the methods accepted.

Validation of the WHO diagnostic algorithm and development of an alternative scoring system for the management of women presenting with vaginal discharge in Malawi.

OBJECTIVE: To evaluate the performance of the WHO algorithm for the detection of cervical infection in women presenting with vaginal discharge and modify the risk assessment score for optimum effectiveness in Malawi. METHODS: 550 consecutive women presenting with non-ulcerative genitourinary complaints were interviewed and examined. Cervical infection was defined as presence of Neisseria gonorrhoeae on culture and/or Chlamydia trachomatis by EIA. Other laboratory investigations included wet mount microscopy, serology for syphilis and HIV, LED testing of cervical and vaginal secretions, and pH testing of vaginal fluid. Sensitivity, specificity, and positive predictive values (PPV) of different algorithms were determined in the analysis. RESULTS: Cervical infection was identified in 19.5% of women (17.1% gonorrhoea, 3.7% chlamydial infection). The sensitivity/specificity/PPV of the WHO risk assessment were 43%/73%/28%, respectively by history and 62%/61%/27% with the addition of speculum examination. Using Malawi results to modify the risk assessment improved the performance to 61%/68%/31% respectively by history alone, which increased to 73%/64%/33% with bimanual examination and 72%/56%/29% with speculum examination. CONCLUSION: The sensitivity of the WHO risk assessment is low for the detection of cervical infection in Malawi. Although the Malawi risk assessment performed somewhat better on history alone, this study identified external and bimanual examination variables that improved the diagnostic performance of the algorithm in settings where speculum examination is not possible. Although the PPVs of the algorithms are low, country specific risk assessments can provide a framework for management until simple, affordable diagnostic tests for the definitive diagnosis of cervical infection are available.

Sexual abuse of minors: emerging medical and social problem in Malawi.

Sexual abuse is one of the most dehumanising human offenses. There has been an increasing public concern and outcry regarding the escalating wave of sexual abuse of young girls in Malawi, in the recent past. Four young girls, aged between two and seven years who were sexually abused by adult males aged between 20 and 70 years seen and managed in the department within the past two years, are presented to illustrate the problem. Their physical injuries, varied reactions and those of their immediate families to the abuse; possible predisposing factors to the abuses; the related medical, psychosocial as well as legal management of such incidents, in the light of limited public awareness, and lack of adequately and appropriately trained personnel and facilities in Malawi are discussed. With the scare of AIDS and an increasing disintegration of the traditional family fabric, there is a high potential for an increase, not only of the prevalence of sexual abuse of minors in Malawi, but also the variety and severity of sequelae. It is therefore recommended that there is need to create public awareness about sexual abuse, train and equip the relevant personnel to appropriately manage such cases, as well as enact and enforce the relevant legal provisions, so as to curb the menace, for the well-being of the society.

PIP: Although the magnitude of child sexual abuse (CSA) in sub-Saharan Africa remains unknown, this problem has become a focus of increasing public concern and outcry. Presented in this article are 4 of the 20 CSA cases treated at the Department of Obstetrics and Gynecology at the University of Malawi Hospital (Blantyre) in a recent 2-year period. The 4 girls, aged 2-7 years, were molested by men 20-70 years old well known to the families. Physical injuries included extensive third-degree perineal tears, lacerations of the lateral vaginal wall and vestibule, bruised labia majora, and torn hymen. In all 4 cases, the caretakers refused to report the assault to the police because of fear of social stigma and the likelihood of a hostile response on the part of authorities. Despite instructions to return to the unit for follow-up, none of the children were seen after their injuries had been treated. Thus, no information is available on long-term medical or psychological sequelae of the abuse. The guardians of 2 of the girls refused to authorize HIV testing; 1 of the 2 tested children had a positive result, but infection may have been acquired prenatally. In 2 cases, the child was living with her grandmother; in the remaining 2, both parents worked in the city and the children were in the care of a houseboy. Continued disintegration of traditional family structures is expected to contribute to increases in the prevalence of CSA in sub-Saharan Africa. Also of concern are cultural practices, such as the belief that sex with a virgin child can cure sexually transmitted diseases or bring riches, as well as a tendency for adult males to attempt to avoid HIV infection through sex with children. Prevention and management of CSA require public awareness campaigns, the design of protocols for the treatment of child victims, guidelines for the management of immediate families and assailants, health personnel training, and enforcement of appropriate legal provisions.

Antepartum and postpartum haemorrhage in primary cervical choriocarcinoma: case report.

Primary cervical choriocarcinoma is very rare. So far only about 60 authenticated cases have been reported in the English literature. Primary cervical choriocarcinoma presenting with antepartum or postpartum haemorrhage is even rarer. A case of primary cervical choriocarcinoma with an apparently normal intrauterine pregnancy, in a 36 year old Malawian African woman, presenting with antepartum haemorrhage at 28 weeks of gestation and later with secondary postpartum haemorrhage is reported. The primary cause in this case was not quite certain. Though rare, it is suggested that cervical choriocarcinoma should be considered a possible local cause of antepartum and or postpartum haemorrhage in a parous woman, in areas where gestational trophoblastic disease (GTD) is relatively commoner, such as Africa.

Induced abortion in Kenya: its determinants and associated factors.

In a study involving 1077 women who were admitted and treated for incomplete abortion and its related problems at eight hospitals (seven district and one mission hospitals) in six of the eight provinces of Kenya, between October 1988 and March 1989, 169 (15.7%) had illegally induced unsafe abortion, based on their own history and clinical findings. The illegally induced unsafe abortions were common among both rural and urban dwellers, and women from almost all social and economic strata were involved. However, they were more common among the youth (< 25 year olds), school girls, those with high formal education, in formal employment, and not currently married. Majority (90.4%), of the induced group said their pregnancies were unwanted, as compared to only 29.1% of the non-induced (p < 0.05). The main determining factor for termination of pregnancy amongst these women appeared to be the fact that it was unwanted and/or unplanned, either because of inappropriate timing, the type of man responsible, the relationship itself and the social and economic implications thereof. This is contributed to by poor contraceptive use inspite of very good awareness, and/or desire to use. There is urgent need to integrate abortion care and related services into the overall reproductive health care and as a part of the broader safe motherhood initiative in Kenya. In addition it is necessary to revise the legal provisions on abortion so as to make them more relevant. Appropriate management of adolescent fertility, should be undertaken with the aim of reducing the extent of illegally induced unsafe abortion with attendant sequealae.

PIP: As part of a larger survey of the epidemiology of unsafe abortion in Kenya, 1007 women admitted to 8 hospitals in 6 of Kenya's 8 provinces during October 1988-March 1989 for incomplete abortion or its complications were interviewed. 169 of these women (15.7%) were considered to have undergone induced abortion (115 women who admitted to interfering with their pregnancy and 57 women who had clear physical evidence of an attempt at pregnancy termination). The induced abortion rate ranged from 0.9% at the Malindi coastal district hospital to 36.4% at the only mission hospital (Chogoria) in the study. Although adolescents (10-19 years old) comprised 15.2% of the total study group, 29.6% of induced abortion patients were in this age group. 22.9% of the total study group, compared with 70.4% of the induced group, were unmarried. There was a steady increase in the proportion of women with induced abortion with increasing educational level, from 4.7% of those with no formal education to 26.3% among those with a college or university education. Induced abortion patients were significantly more likely than those in the broader group to be students (14.8%) or employed in the formal sector (13%). Contraceptive prevalence at the time of conception of the index pregnancy was 12.1% in the broader group and 23.1% in the induced abortion group. 37.8% of induced abortion patients, compared with 50.2% of non-induced women, reported to the hospital within 24 hours of initial symptoms of abortion. Finally, complications were more prevalent in the induced abortion group and included sepsis (34.3%), anemia (17.8%), genital injury (16.6%), and hemorrhage (12.4%). The one death in the induced abortion group was attributable to severe septicemia. The 15.7% induced abortion rate identified in this study is considered to be an underreport, as suggested by the finding that 38.6% of the total study group stated their pregnancy was unwanted.

Three consecutive ipsilateral tubal pregnancies in a nulliparous African woman: the role of conservative treatment.

A very rare case of three consecutive ipsilateral tubal pregnancies, in a 31 year old nulliparous Malawian woman is presented. The three pregnancies occurred over a four year period between 1989 and 1993, and were treated at three different hospitals in Malawi and Britain. The first two were treated conservatively by "milking" the ectopic out in Malawi and Britain respectively while the third was treated by partial salpingectomy in Malawi. All three were confirmed clinically, ultrasonographically, at surgery and histopathologically. The rarity of such a condition, the role and value of conservative treatment of tubal pregnancy in Africa, especially in the light of the probable aetiological and/or predisposing factors are discussed.

Utilisation of family planning services at the teaching hospital in Blantyre, Malawi.

In the whole of 1993, there were a total of 1533 new clients who attended the family planning clinic at the Queen Elizabeth Central Teaching Hospital in Blantyre, Malawi. They formed 23.0% of the total client-visits for the year. 305 women had surgical contraception (bilateral tubal ligation) for various reasons, but mainly on request for family limitation. The ages of the new clients ranged from 15 to 49 years. Adolescents (< 20 years old) formed only 9.0%, while those aged > 35 years formed 22.0%. Their parity ranged from 0 to 11, with 58.0% of them being para 1 to 4. The grandmultiparae (para > 5) formed 31.0%. The oral pill was the most favoured method (42.0%), followed by depo-provera (31.0%) and sterilisation (21.0%). Though the majority of the clients who chose the oral pill were aged less than 30 years, about 6.0% were aged > 35 years. Likewise about 15.0% of those who took oral pills were para > 5, i.e. grandmultiparae. These are women who should have either stopped producing a long time back or been counselled to have tubal ligation rather than these temporary methods, when seen in the clinic then. Amongst all the client-visits for the year, oral pill and depo-provera were the two most popular methods, 42.0% and 41.0%, respectively. The ratio, between the clients who discontinued the method they were on and the new clients was 1:6.8, and that of drop-out/new clients was 1:2.4, which are quite high. The rate of absenteeism was also high at 29.0% of the total client-visits.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: A study was conducted of patterns of family planning use during 1993 at the Queen Elizabeth Central Teaching Hospital in Blantyre, Malawi. There were 6803 family planning visits, which comprised 23% of all visits. 305 women underwent tubal ligation during 1993, yet only 319 were counseled on tubal ligation. 22% of women undergoing tubal ligation underwent interval sterilization. There were 1533 new clients and only about 1282 of them had been counseled at the family planning clinic. 1461 clients returned for their first visit that year. There were 3445 subsequent visits that year, and 138 clients came back to the clinic after an absence of more than one year from the time they were scheduled to return. 226 clients discontinued the method they were using, 23% of whom changed to another method. 53% of discontinuers were using the IUD. The major reason for discontinuation was to conceive again (48.2%). The women were 15-49 years old. 9% were less than 20 years old. Women 35 and over comprised 22% of the population. 58% of all clients had 1-4 children. Women with more than 5 children comprised 31%. The leading family planning methods were oral contraceptives (OCs) (42%), Depo-Provera (31%), and sterilization (21%). OCs and Depo-Provera were responsible for most family planning visits during 1993 (42% and 41%, respectively). About 94% of OC users were younger than 35. Around 15% of OC users had more than 5 children. Family planning providers should have advised sterilization to the high parity users of temporary methods. For every 2.4 new clients there was 1 drop out from the clinic. For every 6.8 new clients there was 1 who discontinued the method she was using. 8% of clients conceived while using a family planning method. 77% of them were using OCs. The absenteeism rate was 29%. Some key findings of this study were inadequate counseling or missing opportunities to address family planning.

Incomplete abortion at the teaching hospital, Blantyre, Malawi.

A total of 444 women treated for incomplete abortion using the manual vacuum aspiration technique, at the Queen Elizabeth Central Teaching Hospital, Blantyre, between 10th January and 9th April, 1994, were interviewed by means of partially structured questionnaire, to determine among other things, their socio-demographic profiles, contraceptive behaviour, as well as associated complications. These formed 56.0% of all abortion cases seen in the department during the study period. All abortion formed 68.0% of all the gynaecological admissions, and an abortion delivery ratio of 1:4. The ages of the patients ranged from 15 to 44 years with a mean of 24.4 years. Adolescents formed 21.2% of the total, while those aged 35 years and above formed 8.4%. Only 15.8% of the total were single. Their parities ranged from 0 to 12 with a mean of 2, while number of living children ranged from 0 to 9 with a mean of 1.7. 16.9% of them had had previous abortions, with the highest number of abortion being 6 and a mean of 1.6. 79.9% of the total group were housewives, and 10.6% students. Of their male partners (i.e. people responsible for the index pregnancy), only 4.2% were students and 25.0% of the school girls were involved with fellow school boys. Majority of the rest (56.3%) were involved with more mature self-sustaining males. The gestational ages ranged from 6 weeks to 20 weeks with a mean of 15 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Knowledge of sexually transmitted diseases, HIV infection and AIDS among sexually active adolescents in Nairobi, Kenya and its relationship to their sexual behaviour and contraception.

A total of 675 male and female adolescents, aged 10 to 19 years, who were attending the adolescent antenatal clinic at the Kenyatta National Hospital and the Special STD and Skin Disease Clinic in Nairobi, between April 1, 1991 and July 31, 1991, were interviewed by means of partially structured questionnaire, to determine their level of awareness on sexually transmitted diseases, HIV infection, AIDS and contraception with its relationship to their sexual behaviour and contraceptive practice. Adolescents formed 27.6% of people attending the STD and Skin diseases clinic, of whom 52.9% were females and 41.2% were males. Majority of them were not in any formal employment. A few were students in schools in the city. 70.4% of the total group mentioned gonorrhoea as a sexually transmitted disease, as compared to only 54.3% who mentioned AIDS as a sexually transmitted disease. They only mentioned three diseases, namely gonorrhoea, syphilis, and AIDS (HIV infection). Majority of them had started coitus very early. They were involved with many and different partners, some of whom belonged to the high risk groups for HIV infection as well as STD's. As a reflection of their low awareness on AIDS, most of these sexually active adolescents had not changed their sexual behaviour, nor were they using any protective measure against STD's or HIV infection. The implications of these findings are discussed and possible remedial measures suggested.

PIP: The authors interviewed 675 male and female adolescents aged 14-19 years of mean age 18.2 attending the adolescent antenatal clinic of Kenyatta National Hospital and the Special STD and Skin Disease Clinic in Nairobi between April 1, 1991 and July 31, 1991. The interviews were conducted to determine participants level of awareness on sexually transmitted diseases (STD), HIV infection, AIDS, and contraception relating to their sexual and contraception behaviors. The adolescents comprised 27.6% of clinic attendees; 52.9% were male, 56.5% of males and 77.8% of females were not formally employed and some were students. Respondents mentioned being aware of only three STDs in the following proportions: 70.4% gonorrhea, 56.5% syphilis, and 54.3% AIDS. 76.6% cited print and electronic media as their main sources of information on such subjects. Although the youngest reported age at first coitus was 8 years, the mean age for first intercourse among males and females were, respectively, 15.1 and 16.0 years. 22.6% and 8.3% respectively, of males and females had experienced sexual intercourse by age 14. 93.3% had been sexually active during the preceding 12 months, with 42.4% of these youths reporting having had sex with two or more partners during the period. 37.3% had had sexual intercourse with strangers, bar attendants, and prostitutes, although males were more likely to be involved with such individuals. 75.9% had not used any form of contraception. Communication and education on the risks of unprotected sexual activity are urgently needed in this sexually active population of youths which thus far remains largely ignorant about StDs and contraception.

The value of ultrasonography in the diagnosis of ectopic pregnancy at the Kenyatta National Hospital, Nairobi.

Over a six-month-period, from 1st March 1988 to 30th September 1988, 127 patients suspected of having ectopic gestation at the Kenyatta National Hospital (KNH) were referred for sonographic examination, of whom 100 (78.7%) had enough data for a final diagnosis. During sonography, ectopic pregnancy was diagnosed in 31 (31%) patients, out of whom 15 (48.4%) were confirmed to have ectopic gestation at laparotomy. Of the 69 who were thought to have other gynaecological disorders at sonographic examination, 2 (2.9%) were later found to have other ectopic gestation at surgery. Of the 17 patients who had ectopic gestation finally, extrauterine gestational sac with a demonstrable foetal pole were observed in only 6 (35.3%) cases, thus allowing a confident diagnosis of ectopic pregnancy by sonography. An empty, bulky uterus, demonstrable adnexal mass, pseudo-gestational sac and fluid in the culde-sac, together improved the sonographic positive predictive value to 67.0%. This study has shown that sonography can be used in the diagnosis of ectopic pregnancy at the KNH. However, in order to improve its reliability, further studies are recommended involving a combination of pregnancy test and sonography.

PIP: Between March and September 1988 at the Kenyatta National Hospital in Nairobi, Kenya, clinicians included all patients (127) referred for ultrasonography due to suspected ectopic pregnancy (age range, 18-45 years) in a study to determine whether ultrasonography can be used to accurately diagnose ectopic pregnancy. The researchers examined only the records of 100 patients who had data adequate enough to make a final diagnosis. Based on sonography, clinicians believed 31 women had an ectopic pregnancy, but laparotomy confirmed that just 15 (48.4%) of these women actually had an ectopic pregnancy. Based on sonography, they did not suspect ectopic pregnancy in the other 69 patients, but laparotomy revealed that 2 patients (2.9%) did indeed have an ectopic pregnancy. Thus, the overall ectopic pregnancy rate among the 100 women was 17%. The remaining 83 women had other gynecological conditions. 52.9% of the women with an actual ectopic pregnancy had a pseudogestational sac, which had a positive predictive value of 53% and a negative predictive value of 90%. A pseudogestational sac had a sensitivity of 53% and specificity of 90%. Just 6 ectopic pregnancy cases (35.3%) had an extrauterine gestational sac with a clear fetal pole and a fetal heart beat. An enlarged uterus was more common in women with an ectopic pregnancy than in those with other conditions (82.4% vs. 51.8%; p .05). Every ectopic pregnancy case had a complex adnexal mass compared to just 48.2% of those with other conditions (p .001). When a woman had all these conditions combined--an empty, enlarged uterus; distinct adnexal mass; a pseudogestational sac; and fluid in the cul-de-sac-sonography's positive predictive value increased to 67%. The researchers recommended additional studies using a combination of the urinary pregnancy test and sonography to improve sonography's reliability.

Pregnancy intervals: their determinants and foetal outcome at the KCMC, Moshi, Tanzania.

A total of 566 multigravidae who delivered at the Kilimanjaro Christian Medical Centre (KCMC), Moshi, between 15th May and 30th July, 1989, were interviewed to determine the pregnancy intervals, their determinants as well as foetal outcome. 62.1% of the study group had pregnancy intervals longer than 2 years. The factors which appeared to influence pregnancy interval in this study included maternal age, period of breastfeeding, postpartum amenorrhoea, postpartum coital abstinence, contraception and outcome of the preceding pregnancy. Other factors such as maternal education, occupation, marital status, pregnancy order, and religion, did not appear to have any effect on the pregnancy intervals. The pregnancy interval did not seem to affect the outcome of the index pregnancy. It is recommended that those factors with a positive impact on pregnancy interval be promoted as widely as possible in Tanzania, so as to contribute toward the control of population growth, as well as the overall maternal and child health, and national economy.

PIP: Between May 15 and July 30, 1989, in northern Tanzania, two obstetricians interviewed 566 multigravida women, 17-48 years old, who delivered at the Kilimanjaro Christian Medical Centre in Moshi to examine the determinants of birth intervals and their effect on fetal outcome. The pregnancy interval between the last and index pregnancies was greater than 2 years in 62.1% of cases. Older women tended to have a longer pregnancy interval than younger women (p .05). As the length of breast feeding increased so did the pregnancy interval. 62% of the women breast fed for more than 12 months. The greater the length of postpartum amenorrhea, the longer the pregnancy interval was. Other factors which had a positive association with pregnancy interval were postpartum sexual abstinence and contraceptive use. The most common contraceptive methods were oral contraceptives and IUD. Women who experienced an adverse preceding pregnancy outcome had a shorter pregnancy interval than those who had a positive pregnancy outcome ( 2 years, 27% for perinatal deaths vs. 70.7% for good outcome; p .05). No correlations existed between pregnancy interval and index pregnancy outcome. This was unexpected and could be explained by the fact that most of the women received prenatal care and delivered at the hospital, that husbands and families have traditionally cared well for pregnant women, or that the women were of good nutritional status. the researchers recommended that health education should stress the factors linked to long pregnancy intervals to help Tanzania reduce its high fertility rates.