Low levels of serum calcidiol in an African population compared to a North European population.

OBJECTIVE: To compare vitamin D status in an African population living at 10 degrees N with a Norwegian population living at 60 degrees N. DESIGN: Serum samples from 30 healthy young Ethiopians and 31 full term pregnant women from Addis Ababa were collected in September, and from 24 healthy Norwegians in March and 23 pregnant women from Oslo in February to June. METHODS: Serum (s) levels of calcidiol and intact parathyroid hormone (iPTH) were measured. RESULTS: The median values for s-calcidiol were significantly lower in Ethiopians compared with Norwegians (young Ethiopians 23.5nmol/l vs young Norwegians 81nmol/l, P<0.001; pregnant Ethiopians 25nmol/l vs pregnant Norwegians 36nmol/l, P<0.05) while those for s-iPTH were significantly higher (young Ethiopians 5.7pmol/l vs young Norwegians 2.4pmol/l, P<0.001; pregnant Ethiopians 4.8pmol/l vs pregnant Norwegians 2.8pmol/l, P<0.02). CONCLUSION: In spite of abundant availability of ultraviolet radiation, the population from Addis Ababa had a high rate of biochemical vitamin D deficiency compared with the Norwegian group.

The FIGO Save the Mothers Initiative: the Ethiopia-Sweden collaboration.

The overall goal of the FIGO Save the Mothers Fund was to establish basic and comprehensive emergency obstetric care (EmOC) with the specific objectives of increasing the availability and utilization of quality obstetric care as measured by the UN indicators. As a result of this commitment by FIGO, the Ethiopian Society of Obstetricians and Gynecologists (ESOG) launched the Save the Mothers Project (SMP) in West Showa Zone (WSZ), Ethiopia in 1998 to implement and test a demonstration project and evaluate the feasibility and impact of the intervention. The overall objectives matched FIGO's-reducing maternal deaths by promoting the availability, access and utilization of EmOC services for women with complications of pregnancy and childbirth. The intervention package included capacity building as a major activity, and physicians and other service providers from Ambo Hospital, Shenen and Ijaji Health Centers were trained in EmOC. This was intended to combat the high staff turnover in the area. Equipment, materials and supplies were also provided to the demonstration sites to enable them provide basic and comprehensive EmOC services. The interventions, begun in 1999, led to improvements in availability, utilization and met need, which suggests that such an approach may eventually lead to the reduction of maternal deaths. The cesarean section rate for Ambo Hospital increased from 3.7% in 1998 to 17.3% in 2001--an almost six-fold increase. At Ambo Hospital both the total number of deliveries and cases admitted with obstetric complications have increased from baseline. Patients with obstructed labor comprise 39% of all obstetric patients making it the leading cause of hospitalization. Obstetric hemorrhage comes next with 24% of all admissions. The case fatality rate (CFR) (for direct maternal deaths) decreased from 7.2% at baseline, to 4.6% in 2001--showing a definite trend of improvement. Currently, there is 24-h EmOC service at Ambo Hospital where an obstetrician and general medical practitioners with EmOC training are responsible for the service. Shenen and Ijaji health Centers are upgraded in terms of training of staff members, provision of equipment and supplies, and regular supervision so that the community in these areas has access to basic EmOC services. To replicate similar activities, in a setting like ours, EmOC projects have to be low cost to attract decision-makers. The SMP used almost US dollars 100,000 over 3 years to ensure availability of EmOC services for women in WSZ. A favorable political climate such as maintenance of relative peace, and flexibility in adapting to local conditions also contributed to the success of the SMP.

Neonatal congenital hypothyroidism screening in Addis Ababa, Ethiopia.

OBJECTIVES: To determine the prevalence of congenital hypothyroidism, establish reference levels for thyroid stimulating hormone (TSH), and determine the cut-off points of TSH level for neonatal screening in congenital hypothyroidism. DESIGN: A cross-sectional study. SETTING: Ghandhi Memorial, Zewditu, Tikur Anbessa and St Paulo's referral hospitals in Addis Ababa, Ethiopia, from July 1996 to January 1997. SUBJECTS: Four thousand two hundred and six consecutive newborns. MAIN OUTCOME MEASURES: TSH and T4 values using standard TSH level estimation approach. RESULTS: The overall mean TSH value was 9.6 mIU/l with standard deviation of 7.8 mIU/l. Transient hypothyroidism occurred in 3.6% of the neonates. No true case of congenital hypothyroidism was identified. The mean(SD) sampling time was 12.8(6.7) hours and the recall rate 4.8%. Most neonates (98.6%) were screened at or less than 24 hours of age. Twins had lower mean TSH value of 7.9(SD=6.4) mIU/l than single neonates with 9.6(SD=7.8) mIU/l, while females had significantly lower mean TSH value of 9.4(SD=7.9) mIU/l than males of 9.8(SD=7.6) mIU/l. The mean TSH level decreased significantly as sampling time increases, the mean TSH level for neonates older than 24 hours is significantly lower than the mean TSH level for those with 24 hours old or less. No significant difference was found in the mean TSH levels in relation to maternal age, parity and gestational age. No significant correlation was found between TSH value and birth weight (r=0.02), height (r=0.03), and head circumference (r=0.02) of the neonates. The most appropriate TSH level cut-off point was found to be at 29.4 mIU/l. The reference range (the range between 2.5th and 97.5th percentiles) for serum thyrotrophin value was higher in the age range of 6 to 12 hours and then declined. CONCLUSION: This pilot study has highlighted important findings, however larger studies should be conducted to assess the magnitude and associated factors of congenital hypothyroidism because congenital hypothyroidism represents one of the most common preventable causes of mental retardation.

Induction of abortion by condom-Foley catheter method in pregnant women with intra-uterine foetal death.

To induce abortion in women with intra-uterine foetal death (IUFD), during a two-year period (August 1990 to October 1992), at Yekatit 12 Hospital, Addis Abeba, Ethiopia, condom-Foley catheter method (CFCM) with oxytocin, and oxytocin infusion alone were compared. All 25 pregnant women randomly assigned to the CFCM aborted within 24 hr, a 100% success rate with an induction-abortion time interval of 14.6 hr (p < 0.001), whereas among 20 patients who were treated with oxytocin infusion alone, induction failed in all. Repeated induction in the second group resulted in a marked delay of abortion; these patients were crossed over to either combined medical and surgical induction or to the CFCM depending on their cervical status. The rapid cervical dilatation and safe abortion in pregnant women with IUFD make the CFCM a superior procedure to induction of abortion with oxytocin infusion alone. In places where there is no experience with the use of prostaglandins and the agent, which may have undesirable side-effects, is unavailable, the CFCM is a simple cost-effective technique which could be used safely.

PIP: In the Department of Obstetrics and Gynecology, Yekatit 12 Hospital, Addis Ababa, Ethiopia, during August 1990-October 1992, pregnant women at 20-28 weeks of gestation who presented with intra-uterine fetal death (IUFD) were enrolled in a comparative study after giving verbal consent. Patients were randomly assigned to two groups. In the first group, abortion was induced in the conventional method by oxytocin infusion alone. In the second group, in addition to oxytocin infusion, the condom-Foley catheter method (CFCM) was employed. All 25 patients with the CFCM aborted within 24 hours, yielding an induction abortion time interval (IATI) of 14.60 +or- 5.27 hours. In contrast, induction failed twice among the 20 patients getting oxytocin infusion alone, and 5 patients were submitted to combined medical and surgical induction (CMSI) (IATI of 59.4 +or- 8.7 hours), as they had an appropriate cervix, and they expelled the fetus within 48 hours. Among the remaining 15 patients induction failure occurred for the third time, and 8 of them had developed an appropriate cervix (Bishop scone = 4-6), but the other 7 patients did not show any cervical change. Those with the appropriate cervix were submitted to CMSI, and those whose cervical state was unchanged were transferred to the CFCM. Both groups aborted within 72 hours; the respective IATIs were 93.5 +or- 12.0 hours and 86.7 +or- 4.8 hours. In 48.9% of the patients, the cause of the IUFD was preeclampsia/eclampsia (2 patients had eclampsia). One patient was positive for syphilis and another was diabetic, both received treatment before admission. There was no abnormal bleeding or any signs of infection. Blunt curettage was performed in 37.8% of patients between 20 and 26 weeks of gestation after the expulsion of the fetus in the oxytocin group. 53.3% of the patients in the CFCM group also received this treatment.

Reproductive health: conceptual and operationalization challenges.

This review article is a teaching material for those who are engaged in reproductive health (RH) service delivery, managers, policy makers, professionals and the RH community. It also aims at addressing the RH concept and indicates some of the operationalization modalities, challenges and attempts to promote the realization of RH and population programmes in the country. It has been shown time and again that even five years after the International Conference on Population and Development (ICPD), policy makers, administrators and service providers still lack an understanding of not only the integrated approach of RH services, but the concept of RH also. In addition, the majority poorly perceives the RH rights notion. It is imperative that issues like understanding of the integrated approach of RH services, ensuring the adequacy of the information or choices offered to women and emphasis on the quality of care offered to clients have to be addressed urgently and adequately. The conceptualization and operationalization of RH will require full understanding of the health, population and women policies, legal and institutional implications of these concepts and the actions needed to convert them into reality. In order to achieve better results, commitment not only of relevant governmental agencies but also by non-governmental organizations (NGOs) and the RH community is a prerequisite. This includes allocation of adequate resources and proper interpretation of the RH concept in the Ethiopian context.

Breech delivery and foetal outcome: a review of 291 cases.

In a three year period (September 1989 to August 1992), among 7,170 consecutive deliveries at Yekatit 12 Hospital, Addis Abeba, Ethiopia, there were 291 singleton breech deliveries with a 4% incidence rate at a gestational age of 28 weeks and above. In 28% and 57% of the infants, weight was below 2,500 grams and Apgar score was less than 7 in the first minute, respectively. The gross perinatal mortality rate for breech delivery in the first 24 hours was 330 per 1,000 deliveries, which was significantly higher than for the total number of deliveries (70 per 1,000; p < 0.001). However, the perinatal mortality rate was 1,000 per 1,000 deliveries for foetuses of less than 1,500 grams, 635 for foetuses between 1,500-2,500 grams, and 156 for foetuses of greater than 2,500 gm. In general, foetuses with low birth weight showed a high mortality rate (p < 0.001). There was also a two-fold increase in perinatal death in patients without antenatal care (p < 0.001). In order to reduce this unacceptably high perinatal mortality, emphasis must be given to appropriate training of physicians and midwives in the management of breech deliveries along with provisions of efficient prenatal care to improve birth weight. In addition, as most of the neonatal problems are preventable, measures need to be taken to establish neonatal units equipped with basic resuscitation materials and manpower.

PIP: An obstetrician-gynecologist retrospectively reviewed the delivery records of 291 singleton breech presentations (BP) that occurred during September 1989-August 1992 at Yekatit 12 Hospital in Addis Ababa, Ethiopia, to examine birth outcomes. The singleton breech delivery rate was 4%. 57% of the BP infants had a one-minute Apgar score of less than 7. These infants comprised the majority of perinatal deaths. Perinatal death was more common among the low birth weight BP infants than those weighing 2500 g (707 vs. 156/1000; p 0.001). The perinatal mortality rate (PMR) increased as the birth weight decreased (2500 g, 156; 1500-2500 g, 635; and 1500 g, 1000). Mothers of BP infants who did not receive prenatal care were more likely to experience perinatal loss than those who received prenatal care (427 vs. 216; p 0.0001). 70% of perinatal deaths among those not receiving prenatal care occurred to infants weighing no more than 2500 g. 4.8% of cesarean sections had BP as an indication for cesarean section without maternal death. Since the hospital is a big referral hospital, many women came to the hospital in established and prolonged labor, which contributed to fetal death. The lack of a neonatal unit equipped with basic resuscitation equipment and health personnel further exacerbated the chances of infant survival. Establishment of such a unit and appropriate training of physicians and midwives in the management of breech deliveries will likely contribute to better fetal outcomes.

Caesarean section and foetal outcome at Yekatit 12 Hospital, Addis Abeba, Ethiopia, 1987-1992.

This retrospective study was carried out to examine indications for Caesarean section (CS), foetal outcome and postoperative complications and to recommend ways of reducing maternal and neonatal deaths. In a five year period (September 1987 to August 1992), among 11,657 consecutive deliveries at Yekatit 12 Hospital, Addis Abeba, Ethiopia, there were 645 CSs, an overall CS rate of 5.5%. During this study, the indications for CS were cephalopelvic disproportion (31.2%), foetal distress (21.4%), previous CS (17.5%), placenta praevia (6.6%), cord prolapse (4.2%) and others (19.1%). There were 99 perinatal deaths, a gross perinatal mortality rate of 153.5 per 1,000 live births, which was a significantly higher rate than the total rate for all deliveries (67.5 per 1,000 live births, p < 0.01). There were seven maternal deaths (case fatality rate of 1.1%). The very high perinatal mortality in this study calls for a better and more effective antenatal service to improve foetal and maternal survival. This could be achieved by strengthening the referral system for pregnant women with obstructed and prolonged labour.

Prolonged paresis in a primigravida during and after caesarean section.

A primigravida, who had a Caesarean section because of cervical dystocia and relative cephalo-pelvic disproportion, in Nov. 1988 in Yekatit 12 Hospital, Addis Ababa, remained relaxed and without spontaneous respiration for about four hours after the completion of the operation, requiring assisted respiration. This condition is the result of a decreased plasma cholinesterase (PCE) activity which is responsible for the breaking down of succinylcholine used in general anaesthesia as a muscle relaxant. Although the incidence of PCE deficiency in our population is not known, it should be remembered that such a complication may be seen in hospitals where operations are carried out using succinylcholine as a muscle relaxant.

Rubber ring clamping of the umbilical cord: a randomized trial.

A randomized trial to compare two methods of umbilical cord tying in neonates, immediately after birth, was undertaken from February to April 1997 in the Department of Obstetrics & Gynaecology, Zewditu Memorial Hospital, Addis Ababa, Ethiopia. In less than 3 months, we investigated 300 neonates, of whom 150 infants were randomly assigned to the traditional ligation of the umbilical cord (using a piece of thread) and the rest to a rubber ring clamping method. Among the former group, 13.3% (20/150) of the neonates bled from their umbilical cords which necessitated re-tying, whereas in the later group, there was no sign of haemorrhage or infection within 12 h of clamping. We suggest that the rubber ring method described is a superior procedure and can easily replace the traditional, cumbersome and time-consuming umbilical cord ligation.