A twenty-five year review of maternal mortality in Barbados: 1970-1994

Maternal mortality is a sensitive indicator of the health status of a country, reflecting not only the quality of obstetric care, but of all services which contribute to the well-being of women of reproductive age. All maternal deaths taking place in Barbados in the twenty-five year period 1970-1994 were ascertained and the causes of death documented. The overall maternal mortality rate was 86 deaths per 100,000 live births, and unexpectedly high level of mortality. The major causes of deaths were sepsis, complications due to ectopic gestation and abortion, haemorrhagic complications and hypertensive disorders of pregnancy. Improvements in the provision of services resulted in no deaths due to sepsis being documented after 1985, nor were there any deaths attributed to complications of abortion or ectopic gestation after 1989. We note a reduction in the annual mortality rate over the last decade of the period reviewed, albeit significantly less than expected given the level of improvement in health care services. In particular, the maternal mortality rate due to hypertensive disease of pregnancy had remained unchanged. Further research is therefore necessary to elucidate factors which affect the access of patients to health care services, as well as their utilisation of such services. Furthermore, research aimed at evaluating the actual services available to pregnant women might also be appropriate, in order to allow the formulation of strategies aimed at reducing the maternal mortality rate further.(AU)

Detection and identification of human papilloma viruses present in cervico-vaginal lavages by PCR and direct sequence analysis of the PCR product - abstract

Human papilloma virus (HPV) DNA was detected in cercico-vaginal lavages from two groups of women by PCR with the CPI/1IG consenus primer pair. The first group comprised 40 women from a colposcopy clinic with cervical cytology/histology indicative of HPV infection; these were matched with a control group of 45 women who had no history of cervical HPV infection. HPV DNA was detected in 21 (52 percent) of samples from women suspected of HPV and in 21 (47 percent) of those with no history of HPV infection. Direct sequence analysis of the purified PCR product revealed a range of HPV types within the two groups. HPV type 18 was identified in four of the 21 PCR positive women for te Colposcopy Clinic and in one woman in the control group. Type 16 was found in two women only, both the Colposcopy Clinic. Mainly low or intermediate-risk HPV types were identified in the control group. The study revealed that there is a moderately high prevalence of a variety of types of HPA DNA in women with no cytological or histological evidence of HPV infection. (AU)

The Barbados low-dose aspirin in pregnancy (BLASP): a population based trial in a developing country with excess pre eclampsia and perinatal mortality

A large randomised controlled double blind trial (RCT), BLASP was set up in Barbados' one main maternity centre (QEH). Almost all women at 12-32 weeks attending for antenatal booking were eligible in the period July 1992-1994. After consent, entry details were recorded on a computer with random allocation to either a slow-release 75 mg aspirin (A) or a placebo (P). Intention-to-treat analysis, based on the 3,643 randomized pregnant women (1,819 allocated aspirin and 1,824 a placebo), is viewed in context of all other randomised control trials (RCTs). Entry date balanced in A and P for gestational age of 20.2 weeks, average maternal age 24 years, more than half aged 20-29 years and 44 percent primigravidae. Previous obstetric complications were lower than expected at 5 percent. Family histories of diabetes mellitus and hypertension were high (> 33 percent). Compliance was moderate with 36 percent taking allocated tablets for more than 95 percent of the time, but a third for less than 80 percent. There were no serious side effects, and in particular no bleeding. PE rates were low at 2.2 percent in A and 2.5 percent in P, a 13.3 percent odds reduction with wide 95 percent CI showing no significant effect. A tendency in all predefined categories (PE + PIH, etc.) for fewer cases in A (n=203, 11.2 percent) than in P (n=231, 12.7 percent) is not confirmed in an overview of all trials. Antenatal hospital admissions occurred in 34 percent of A and 33 percent of P. There was no difference in very low-birth-weight (<1500 g) but rates were 7 percent in A and 8.3 percent in P for birthweight between 1,500 and 2,499 g. Mean pregnancy duration was virtually identical at 38.7 (SD 3.6) weeks. Stillbirths and neonatal death rates were 2.3 percent and 2 percent, and Caesarean Sections 13.6 and 13.8 percent, in A and P, respectively. It is concluded that in this large RCT conducted in the Caribbean (BLASP), there were no meaningful differences between those allocated aspirin or placebo but event rates were low, perhaps due to the "healthier recruit" effect. In the context of all other published randomised trials, these results confirm that aspirin has little effect on the prevention of PE or PIH or other specified outcomes but is entirely safe (AU)

Fat distribution and glucose metabolism in pregnancy: an anthropometric study of Barbadian women

Two hundred and fifty women were studied to evaluate the effects of maternal growth on glucose and insulin metabolism during the pregnancy. Participants were recruited from the antenatal clinic at the Queen Elizabeth Hospital, Barbados, if they booked by 16 weeks' gestation. Anthropometric indices, including skinfold thickness, weight, height and hip circumference, were measured at recruitment, and participants subjected to a 75-gm oral glucose tolerance test (WHO criteria) at 18 weeks' gestation. Fasting blood samples were collected for plasma lipids, venous plasma glucose (VPG), serum insulin, c-peptide and glycosylated haemoglobin. Samples were taken at 1 and 2 hours post glucose load for VGP (fasting: p=0.003; 1 hour: p=0.008; 2 hour: p=0.026) and fasting insulin levels (p=0.02). High mean hip circumference at booking was associated with raised VPG (fasting:p=0.07; 1 hour: p=0.04; 2hour: p=0.16) and fasting serum insulin (p<0.001). Fat distribution, rather than global obesity per se, may be an important factor influencing glucose and insulin metabolism during pregnancy (AU)

Genital tract infections in sexually active women in Barbados

Ninety-eight women attending three different clinics were prospectively studied for the presence of genital tract infections, including Chlamydia trachomatis. Of these 98 women, 35 were presenting to a polyclinic with symptoms of genital tract infection, 55 were attending an antenatal clinic for their first visit, and 8 referred to a colposcopy clinic because of an abnormal Papanicolaou smear were included. Gonorrhoea was detected in one patient, syphilis in two, and Trichomonas vaginalis in six. Candida albicans and Chlamydia trachomatis were each detected in 18 patients, while the most common condition was bacterial vaginosis, detected in 35 patients. The prevalence of these infections was lowest in patients referred for colposcopy and highest in the women attending the antenatal clinic, Chlamydia trachomatis was the most common sexually-transmitted pathogen detected in this population. These data emphasise the need for an aggressive approach to the diagnosis and treatment of chlamydial infection in females

Genital tract infections in sexually active women in Barbados

Ninety-eight women attending three different clinics were prospectively studied for the presence of genital tract infections, including Chlamydia trachomatis. Of these 98 women, 35 were presenting to a polyclinic with symptoms of genital tract infection, 55 were attending an antenatal clinic for their first visit, and 8 referred to a colposcopy clinic because of an abnormal Papanicolaou smear were included. Gonorrhoea was detected in one patient, syphilis in two, and Trichomonas vaginalis in six. Candida albicans and Chlamydia trachomatis were each detected in 18 patients, while the most common condition was bacterial vaginosis, detected in 35 patients. The prevalence of these infections was lowest in patients referred for colposcopy and highest in the women attending the antenatal clinic, Chlamydia trachomatis was the most common sexually-transmitted pathogen detected in this population. These data emphasise the need for an aggressive approach to the diagnosis and treatment of chlamydial infection in females (AU)

Running large clinical trials in the Caribbean on major public health problems: examples through low-dose aspirin studies in pregnancy in Barbados and Jamaica - abstract

Advances in the management of individual patients and public health require evidence that the balance of benefit versus risk, and the cost of intervention are in favour of intervention. Since clinical 'common sense' is unreliable and unscientific, it is an inadequate guide. The only reliable way to show effectiveness is to carry out a randomised trial of adequate power and sample size to detect differences in outcome. The methodology is rigorous but simple, and is applied in the study of pregnancy-induced hypertension (PIH) and pre-eclampsia (PE) as major sources of morbidity and mortality in the Caribbean. Two double-blind randomised placebo-controlled trials are being conducted in Barbados and in Jamaica to test the hypothesis that low-dose aspirin (75/60 mg), taken once daily to term, can reduce the rates of perinatal mortality and proteinuric PE by 30 percent. Other endpoints include birth weight, pregnancy duration, number of admissions and highest blood pressures. Due to a high PIH prevalence in Barbados, all pregnant women over 12 weeks' gestation (except those with allergy or bleeding) are invited to partiacipate. Over 90 percent of the 4000 births a year in Barbados occur at the Queen Elizabeth Hospital, and the planned sample size of some 7000 births will require 3 years to collect. In Jamaica, all primiparae in high-risk antenatal clinics in Kingston and St. Andrew are eligible. Two full-time research midwives and a pharmacist run BLASP by entering data onto a dedicated clinic computer which generates randomised blinded aspirin/placebo pack numbers. One further form is completed after delivery. A monitoring group examines the data for safety independently of the steering group. By the end of November, 1993, 2358 women had consented to enter the study in Barbados, and 1691 had delivered with 112 cases of PE, 65 of PIH, 52 with growth delay and 31 perinatal deaths (19/1000). In Jamaica, 5700 women have been entered with 4414 deliveries; there are 34 cases of eclampsia (7.7/1000). If the trials show treatment to be effective, substantial reduction in the costs of antenatal and neonatal care can be expected. On the other hand compliance may be too poor in the long term to justify public health use (AU)

Prevalence of chlamydia trachomatis infection in pregnant women in Barbados - abstract

Fifty-six pregnant women were investigated for the presence of genital tract infections during their first visit to the antenatal clinic. Their mean age was 23 years (range 17-39) and the mean gestational age was 31.6 weeks. Delivery occurred at a mean of 38.4 weeks and the mean birth weight of the infants was 2892g. Syphilis and gonorrhoea were not detected in this study. Candidiasis and bacterial vaginosis were each detected in 27 per cent of the women studied and Trichomonas vaginalis was found in 4.7 per cent. Infection with Chlamydia trachomatis was detected in 23 per cent of women by antigen EIA on endocervical swabs. Serology demonstrated anti-chlamydial antibodies in 75 per cent (IgG) and 23 per cent (IgA) of women. Women with positive EIA tests were treated with erythromycin. These data emphasize the need for an aggressive approach to the diagnosis and treatment of chlamydial infection. We suggest that C. trachomatis EIA should be adopted as part of the routine antenatal screening process (AU)

Maternal mortality in the English-speaking Caribbean

A review of maternal mortality in Caribbean countries shows that there is still a high incidence of deaths in women related to pregnancy. The main causes of death appear to be related to hypertensive disease in pregnancy. The deficiencies of the recording system and the need for a confidential enquiry proceedure in each country is stressed (AU)

Maternal mortality in the English-speaking Caribbean

A review of maternal mortality in Caribbean countries shows that there is still a high incidences of death in women related to pregnancy. The main causes of death appear to be related to hypertensive disease in pregnancy. The deficiencies of the recording system and the need for a confidential enquiry procedure in each country is stressed. (Summary)

Chlamydia serology in women with ectopic pregnancy in Barbados - abstract

A study on antichlamydial antibodies in women with ectopic pregnancy was carried out at the Queen Elizabeth Hospital, Barbados, between January and June 1991. The incidence of ectopic pregnancy at QEH during this period was 26.5/1,000. It has been shown that there is a close association between ectopic pregnancy and pelvic inflammatory disease (PID). Since chlamydia trachomatis is related to PID, the prevalence of antichlamydial IgG and IgA in the 35 women who had ectopic pregnancy was assessed. This was compared with the prevalence of antichlamydial antibodies in 76 women attending antenatal clinic. Eighty-two per cent of women with ectopic pregnancy showed serological evidence of previous exposure to chlamydia trachomatis. Two women with ectopic pregnancy had had a previous history of acute PID. The prevalence of IgG antichlamydial antibodies in women with ectopic pregnancy was significantly higher than in the control group (X2ý 11.7 with Yates correction). This indicates that both groups had previous exposure to chlamydia trachomatis, but there was evidence of recent reinfection in the women with ectopic pregnancy (AU)

A review of 292 patients with tubal ectopic pregnancy (1984-1988) - abstract

All case notes at the Queen Elizabeth Hospital from January 1, 1984 to December 31, 1988 were reviewed to identify all cases of tubal ectopic pregnancy and to determine trends and review management of this condition. All diagnoses were confirmed histologically. The age range was 15 to 42 years and the rate of tubal ectopic pregnancy was highest in the age groups 35-39 years (33.2/1,000) pregnancies and 30-34 years (26.0/1,000 pregnancies). Fifty-nine patients (20 per cent) had previous pelvic inflammatory disease, 64 (22 per cent) had o 1 previous abortion, and 22 (7.5 per cent) had a previous tubal pregnancy. Rupture of the tubal pregnancy occurred in 227 (78 per cent) patients and the commonest surgical procedure was salpingectomy (61 per cent). There were no deaths in this series (AU)

Maternal mortality in Barbados (1970-1989) - abstract

The purpose of this retrospective study was to discern trends in maternal mortality in Barbados over the period 1970-1989 and to identify the major causes of, and risk factors contributing to pregnancy-related deaths. Maternal deaths were identified from the death register and labour ward records of the Queen Elizabeth Hospital, by reviewing all death certificates kept at the Ministry of Health and by discussions with relevant doctors, nurses and record officers. The definition of maternal death used in calculating maternal mortality rates was that of the International Classification of Diseases, Injuries and Deaths (ICD9). There were 104 maternal deaths of which 92 (88 per cent) occurred during pregnancy or within 42 days of termination (ICD9 definition). Twelve deaths occurred in women who died after 42 days but within 1 year of termination of pregnancy. In patients who died when gestation was < 28 weeks (38 or 37 per cent of all deaths), 79 per cent died from ectopic pregnancy or septic abortion. Hypertensive disease, post-partum haemorrhage and puerperal sepsis were the most frequent causes of death in those dying after 28 weeks gestation. Deaths most commonly occurred between ages 21 and 25. There was a four-fold decline in deaths from ectopic pregnancy and abortion, a 71 per cent decline in deaths from puerperal sepsis and a 45 per cent decline in those due to hypertensive diseases. The average annual maternal mortality rate for the period 1970-1989 was 90.76/100,000 live births, and has declined gradually over the 20-year period (AU)

Outcome of diabetic pregnancy in Barbados: 1980-1982 - abstract

This prospective study of 76 cases was undertaken to determine the incidence of complications in the newborn of diabetic mothers; to analyse factors in the mother which may be associated with these, as well as to identify features common in the pre-diabetic phase. Of these 76 cases, 11 (14.5 percent) were primigravida and 65 (85.5 percent) multiparae; 8(10.5 percent)were teenage pregnancies; 55 (72.4 percent) were gestational diabetes and 21 (27.6 percent) overt; 41 (53.9 percent) were controlled on diet alone while 35 (46.1 percent) required medication. Complications associated with pregnancy included pre-eclampsia 3/76 (3.9 percent), hydramnios 1/76 (1.3 percent). The incidence of diabetes was 0.3 percent of total pregnancies in 1980 and 1981, but increased to 1.14 percent in 1982. Delivery was at term in 70 (92 percent) and preterm in 6 (7.9 percent). Caesarean section was performed in 18 (23.7 percent) and 58 (76.3 percent) were delivered by the vaginal route. Thirty-nine (51.3 percent) were large for gestational age (LGP), 34(44.7 percent) adequate (AGA), and 3(4 percent) small for gestational age. Commonest complications seen were jaundice 48(63.2 percent); hypoglycaemia 30 (39.5 percent); jitteriness in 20(26.3 percent), and polycythaemia in 13 (17 percent). Both infection and perinatal asphyxia occurred, each in 8 accounted for only1/76 (1.3 percent). There was 1 stillbirth in 1982 giving a perinatal mortality of 2 percent or 8 percent of the total mortality. Factors identified as significant were positive family history of diabetes 37 (48.7 percent); obesity 35 (46.1 percent); previous large babies 34(44.7 percent) and an obstetric history of stillbirth or spintaneous abortion or neonatal death 22 (28.9 percent). We conclude that the above factors should alert one to the possible eexistenc of the pre-diabetic phase in the pregnant woman. All babies born to diabetic mothers should bo obseved closely during the first 48 hours. Monitoring of blood sugar levels and early recognition and treatment of complications will decrease the high morbidity (AU)

An evaluation of paracervical block anaesthesia for use in minor gynaecological surgery

Of the 195 cases investigated, paracervical block anaesthesia was found to be effective for cervical dilatation and curettage, evacuation of retained products, termination of pregnancy, biopsy and cauterization of cervix, polypectomy and removal of embedded intra-uterine device. In one case mentioned, the anaesthesia wore of after 20 minutes, making it necessary to anesthetise the patient to carry out the procedure. There were no complications and no contra-indications were found in the use of this method. From the above, it is concluded that paracervical block anaesthesia for minor gynaecological survey is simple, safe and effective. (AU)