Determinants of Choice of Facility-Based Delivery among Mothers in Kwara State, Nigeria.

BACKGROUND: Nigeria has the highest number of maternal deaths in the world, which is a major public health problem. One of the major contributory factors is high prevalence of unskilled birth attendance from low facility delivery. However, the reasons for and against facility delivery are complex and not fully understood. OBJECTIVE: The objective of this study was to identify the facilitators and barriers to facility based deliveries (FBD) among mothers in Kwara state, Nigeria. METHODS: The study was carried out among 495 mothers that delivered in the five years prior to the study in three selected communities from the three senatorial districts of Kwara state using mixed methods. The study design consisted of a cross-sectional study with mixed data collection involving qualitative and quantitative methods. Multistage sampling technique was employed. Primary outcome measures were place of delivery, reasons for and against FBD. RESULTS: Of the 495 respondents that had their last delivery during the study period, 410 respondents delivered in the hospital (83%). Common reasons for hospital delivery were ease and convenience (87.1%), safe delivery (73.6%) and faith in healthcare providers (22.4%). The common barriers to FBD included high cost of hospital delivery (85.9%), sudden birth (58.8%) and distance (18.8%). Other important barriers were availability of cheaper alternatives (traditional birth attendants and community health extension workers practising at home), unavailability of community health insurance and lack of family support. Parity, level of education of respondents and husband had significant influence on choice of delivery (p<0.05). CONCLUSION: These findings provided a good insight into the reasons for and against facility delivery among Kwara women, which can assist policy makers and program interventions that can improve facility deliveries and ultimately improve skilled birth attendance, reduce maternal and newborn morbidity and mortality.

CONTEXTE: Le Nigeria compte le plus grand nombre de décès maternels au monde, ce qui constitue un problème majeur de santé publique. L'un des principaux facteurs contributifs est la forte prévalence de l'assistance à l'accouchement non qualifiée due à un accouchement dans des établissements de faible qualité. Cependant, les raisons pour et contre la prestation en établissement sont complexes et ne sont pas entièrement comprises. OBJECTIF: L'objectif de cette étude était d'identifier les facilitateurs et les obstacles aux accouchements en établissement (FBD) chez les mères de l'État de Kwara, au Nigeria. METHODES: L'étude a été menée auprès de 495 mères qui ont accouché au cours des cinq dernières années précédant l'étude dans trois communautés sélectionnées des trois districts sénatoriaux de l'État de Kwara en utilisant des méthodes mixtes. La conception de l'étude consistait en un entretien avec des informateurs clés et une étude transversale avec une collecte de données mixte impliquant des méthodes qualitatives et quantitatives. La technique d'échantillonnage à plusieurs degrés a été employée. Les principaux critères de jugement étaient le lieu d'accouchement, les raisons pour et contre le FBD. RESULTATS: Parmi les 495 répondantes qui ont eu leur dernier accouchement au cours de la période d'étude, 410 répondantes ont accouché à l'hôpital (83 %). Les raisons courantes de l'accouchement à l'hôpital étaient la facilité et la commodité (87,1 %), la sécurité de l'accouchement (73,6 %) et la confiance dans les prestataires de soins de santé (22,4 %). Les obstacles courants à la FBD comprenaient le coût élevé de l'accouchement à l'hôpital (85,9 %), l'accouchement soudain (58,8 %) et la distance (18,8 %). D'autres obstacles importants étaient la disponibilité d'alternatives moins chères (accoucheuses traditionnelles et agents de vulgarisation de la santé communautaire exerçant à domicile), l'absence d'assurance maladie communautaire et le manque de soutien familial. La parité, le niveau d'éducation des répondants et le mari ont une influence significative sur le choix de l'accouchement (p<0,05). CONCLUSION: Ces résultats ont fourni un bon aperçu des raisons pour et contre l'accouchement en établissement chez les femmes Kwara, ce qui peut aider les décideurs politiques et les interventions de programme qui peuvent améliorer les accouchements en établissement et, en fin de compte, améliorer l'assistance qualifiée à l'accouchement, réduire la morbidité et la mortalité maternelles et néonatales. Mots clés: Prestation en établissement; Facilitateurs; Barrières; État de Kwara; Nigeria.

Early age thermal manipulation on the performance and physiological response of broiler chickens under hot humid tropical climate.

Initial brooding temperature is critical for post-hatch growth of broiler chickens. A study was conducted to investigate the early age thermal manipulation (EATM) on the performance and physiological responses broiler chickens under hot humid tropical climate. A total of 260 unsexed day-old Arbor-acre broiler chicks were assigned to five thermal treatments of brooding temperature regimens having 4 replicates of thirteen birds each. The heat treatments were: initial brooding temperature of 35 °C for the first 2 days, and then decreased subsequently, gradually to 22 °C at 21 d of age (CT), initial temperature of 35 °C, sustained for the first 4 days and then decreased gradually (conventionally) (FD), initial temperature of 35 °C for the first 7 days (SD), the birds in CT, but the brooding temperature was raised to 35 °C again for another 3 days from day 7 (SD3), initial brooding temperature of 35 °C for the first 10 days (TD). Data were collected on daily feed intake and weekly body weights. Blood samples were collected from 8 birds per treatment weekly for the determination of plasma uric acid, triglycerides, triiodothyronine (T3) and creatinine kinase. Data obtained were laid out in a Completely Randomized Design (CRD). Results showed that the final weights of the birds in FD were higher (P < 0.05) than those of the other treatments at the finisher phase. Feed intake of the birds in FD was higher than those of SD3 and TD. FCR of broiler chickens in CT, SD, SD3 and TD was higher than that of FD. The rectal temperature, plasma MDA and blood glucose of the thermally challenged birds in FD was generally better (P < 0.05) than those of the other treatments. It was concluded that EATM can be used to improve performance and also protect broiler chickens from acute heat stress at market age.

Grandmultiparity: evaluating obstetric and neonatal outcomes after eliminating confounders.

AIMS AND OBJECTIVES: The objective was to evaluate obstetric and neonatal outcomes in booked grandmultiparas (para e"5) and compare with outcome in age and social status matched booked multiparas (para 2-4) after eliminating confounders. PATIENTS AND METHODS: A cohort study with grandmultiparas (subjects) and age and social status matched multiparas as controls. All participants were counseled and an informed consent obtained at the antenatal clinic. Maternal demography and history were taken; they were subsequently monitored during pregnancy, labour and immediate puerperium. The main outcome measures were obstetric and neonatal outcomes among subjects and controls. RESULTS: The incidence of grandmultiparity was 4.1%. During antenatal period, grandmultiparas had statistically significantly higher occurrence of late antenatal booking (P=0.0202), anaemia (P=0.0024) and past history of poor perinatal outcome (P=0.0124). Grandmultiparas had statistically significant occurrence of preterm delivery (P=0.0389) and higher but not statistically significant mean duration of labour (P=0.3532), intrapartum complications (P=0.2014) and postpartum haemorrhage (P=0.2126). Neonates of grandmultiparas had statistically significant low first minute Apgar scores (P=0.0011) with higher but not statistically significant occurrence of low birth weight (P=0.1613) and neonatal intensive care admission (P=0.7202). The perinatal mortality rates were 136 and 75 per 1 000 deliveries for grandmultiparas and multiparas. There were no maternal deaths during the study period. CONCLUSION: After controlling for age and social class, booked grandmultiparas had poorer obstetric and neonatal outcome compared to booked multiparas but these were majorly statistically insignificant due to effect of modern antenatal care.

Pattern of gynaecological malignancies at the University of Ilorin Teaching Hospital, Ilorin, Nigeria.

Gynaecological malignancies contribute to the global burden of diseases and are of public health interest. The objective of this study was to determine the pattern of distribution of gynaecological malignancies seen between 1 January 2002 and 31 December 2006, at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. It was a retrospective descriptive study. A total of 166 cases of gynaecological malignancies were encountered, cervical cancer was the most common (59.6%). This was followed by ovarian cancer (21.1%), trophoblastic tumour (7.8%) and corpus uteri cancer (6.0%). Others included cancer of the vulva (3.6%) and cancer of the vagina (1.8%). Squamous cell carcinoma accounted for 96.0% of cervical cancers. Epithelial tumours represented 60.0% of ovarian cancers, and serous cyst adenocarcinoma was the most common histological variety. All the vulval and vaginal cancers were of squamous cell type. In conclusion, genital malignancies are common and cervical cancer remains the leading gynaecological malignancy in this centre.

Vesicovaginal fistula: a review of nigerian experience.

BACKGROUND: Vesicovaginal fistula is a preventable calamity, which has been an age-long menace in developing countries. OBJECTIVE: To review the causes, complications, and outcome of Vesicovaginal fistula in Nigeria. METHODS: Studies on Vesicovaginal fistula were searched on the internet. Information was obtained on PubMed(medline), WHO website, Bioline International, African Journal of Line, Google scholar, Yahoo, Medscape and e Medicine. RESULTS: Many Nigerian women are living with Vesicovaginal fistula. The annual obstetric fistula incidence is estimated at 2.11 per 1000 births. It is more prevalent in northern Nigeria that southern Nigeria. Obstetric fistula accounts for 84.1%-100% of the Vesicovaginal fistula and prolonged obstructed labour is consistently the most common cause (65.9%-96.5%) in all the series. Other common causes include caesarean section, advanced cervical cancer, uterine rupture, and Gishiri cut. The identified predisposing factors were early marriage and pregnancy, which were rampant in northern Nigeria, while unskilled birth attendance and late presentation to the health facilities was common nationwide. Among the significant contributory factors to high rate of unskilled birth attendance and were poverty, illiteracy, ignorance, restriction of women's movement, non-permission from husband and transportation. All but one Nigerian studies revealed that primiparous women were the most vulnerable group. Pregnancy outcome was dismal in most cases related to delivery with still birth rate of 87%-91.7%. Stigmatization, divorce and social exclusion were common complications. Overall fistula repair success rate was between 75% and 92% in a few centres that offer such services. CONCLUSION: Vesicovaginal fistula is prevalent in Nigeria and obstetric factors are mostly implicated. It is a public health issue of concern.

Maternal mortality in a Nigerian teaching hospital - a continuing tragedy.

The aim of this review is to determine the maternal mortality ratio (MMR) in a Nigerian tertiary health institution (University of Ilorin Teaching Hospital, Ilorin, Nigeria). The review was done through a retrospective analysis of maternal mortality records. The MMR for the 6-year period (1997-2002) was 825 per 100,000 live births. The common causes of maternal mortality included severe pre-eclampsia/eclampsia, 30 (27.8%); haemorrhage, 22 (20.4%) and complications of unsafe abortion 16 (14.8%). Grandmultiparous and patients aged 40 years and above were at the highest risk. This hospital-based MMR is very high and when compared with previous reports showed a 150% increase. Most of the maternal deaths are, however, preventable. Increased efforts at educating women, improvement of the socioeconomic conditions of the populace and strong political commitment in making emergency obstetric care available in rural and district hospitals are some of the measures that need to be adopted to reduce this avoidable tragedy.

Obstetric urogenital fistula: the Ilorin experience, Nigeria.

A study of thirty-four cases of obstetric urogenital fistula managed over a ten-year period (1st January, 1989 to 31st December, 1998) at the University of Ilorin Teaching Hospital is reported. The incidence of obstetric urogenital fistula is 1.1 per 1000 births. The condition is associated with illiteracy and poorly supervised delivery. The peak incidence is in 15-19 years age group and primipara accounting for 26.5% and 50% respectively. Prolonged obstructed labour was the most common aetiological factor in 28 (82.4%) of cases. Juxta-cervical region was the most common site of obstetric urogenital fistula. Eight (23.5%) patients were separated/divorced from their husbands. Obstetric urogenital fistula can be prevented by improving socio-economic condition of the populace, educating the populace to utilize health facilities and advice against teenage pregnancy. Labour should be supervised by trained health personnel and difficult labour referred early to appropriate health care facility.

Cancer of the cervix in Ilorin, Nigeria.

OBJECTIVE: The purpose of this study is to review our experience with carcinoma of the cervix in Ilorin, Nigeria. METHOD: From 1st January 1990 to 31st December 1999, a total of 169 cases of invasive cervical cancer wereseen at the Department of Obstetrics and Gynaecology of the University of Ilorin Teaching Hospital, Ilorin, Nigeria. RESULTS: Carcinoma of the cervix accounted for 63.1 % of histologically confirmed gynaecological cancers. Most of the patients were married 147 (98.7 %) and of low socio-economic status 132 (88.6%). One hundred and three (89.1 %) patients were in the age bracket 40-69 years with highest frequency in 40-49 years age group. The disease is associated with high parity with grandmultiparous patients constituting 119 (79.9 %) of the cases. Irregular vaginal bleeding 109 (73.2 %), vaginal discharge 58 (38.9%) and postcoital bleeding 31(20.5%) were the common symptoms. Nineteen (12.8%) patients reported at the hospital within one month of onset of symptoms. About three quarter ofthe patients had advanced disease and stage III disease was the most common stage 75 (50.4 %). CONCLUSION: This study has shown a high incidence of carcinoma ofcervix at the University of Ilorin Teaching Hospital.

Uterine fibroids: a ten-year clinical review in Ilorin, Nigeria.

A retrospective study to determine the incidence, clinical presentation and management of uterine fibromyoma at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. Five hundred and sixty-nine consecutive cases of histologically confirmed uterine fibroid over a ten-year period were reviewed. Uterine fibromyoma constituted 13.4% of gynaecological admission and was responsible for 26.2% of major gynaecological surgery. Majority of the patients (78.4%) were aged between 30 and 44 years and 60.8% were of low parity (0-2). The common presentations were menstrual disorders (64.3%), infertility (56.2%) and lower abdominal swelling (35.5%). Hypertension was present in 26.5% and 42% were obese. Pelvic adhesion was noted in 58.9% of patients. Total abdominal hysterectomy was the surgical procedure in 52% of cases. Pyrexia (32.5%), Anaemia (29.3%), Prolonged hospital stay (24.1%) and Wound infection (20.2%) were the common postoperative morbidities. Fibromyoma at the University of Ilorin Teaching Hospital follows a pattern similar to other parts of the world. It is responsible for a number of gynaecological complaints. Surgery still remains the main mode of treatment.

The role of ultrasound in obstetrics.

Ultrasound contributes immensely to obstetrics and its application and use is now widespread. The clinical applications and uses of ultrasound include confirmation of pregnancy and multiple gestation, estimation of gestational age, localisation of placenta and monitoring of foetal wellbeing. The others are evaluation of caesarean section scar integrity and post partum haemorrhage. Ultrasound is also useful in prenatal diagnosis and foetal therapy. The major limitation of ultrasound is the fact that it is not useful in air/gaseous containing media. Ultrasound is safe and there is no known adverse effect for now on mother, foetus or operator at the intensity used for present obstetric examination. Overdependence and abuse of ultrasound remains a problem and it should be emphasised that ultrasound is to complement and not a substitute to clinical judgement.

Rectovaginal fistula following sexual intercourse: a case report.

Female genital fistula is an important feature of the developing countries gynecology. Most of the rectovaginal fistulae encountered in the tropics are due to obstetrics causes and genital malignancies. In developed countries, radiation injury and Crohn's disease are also common etiological factors. The index case is reported to highlight the rare situation, where a 24-year old married nullipara sustained low rectovaginal fistula following normal coitus. She was later divorced by her husband.

The bacteriology of pre-labour rupture of membranes in a Nigerian teaching hospital.

A prospective case control study that was conducted at the University of Ilorin Teaching Hospital, Ilorin, Nigeria, between 1st January and 31st December 2002. The purpose of this study was to determine the association and the pattern of bacteria/microorganisms in the aetiology of pre-labour premature rupture of membrane (PROM) in this centre. A total of 108 cases of PROM and 98 control cases that presented between 37 completed weeks' and 40 weeks' gestation were analysed. Pathogens were isolated in 48 patients, giving a recovery rate of 44.4%. The common pathogens include Gardnerella vaginalis (29.1%), Candida (23.0%) and Staphylococcus aureus (18.7%). Others were Streps. Pyogenes (16.6%), coagulase negative staphylococcus (CONS) (6.3%) and Klebsiella (6.3%). Only Candida and S. aureus were isolated in the controls. Ofloxacin and azithromycin were 100% active against all the isolated pathogens, while ampicillin was the least active. G. vaginalis was the most sensitive among the isolates while CONS and Klebsiella were the least sensitive. It is evident in this study that some pathogens were associated with PROM and that G. vaginalis was the most common organism and azithromycin was the only antibiotic with 100% sensitivity. We suggest that metronidazole should be added to azithromycin to cover for anaerobes in cases of PROM, where facilities for screening for anaerobes are not available.

Analysis of 348 consecutive cases of primary postpartum haemorrhage at a tertiary hospital in Nigeria.

A retrospective analysis of 348 cases of primary postpartum haemorrhage (PPH) that occurred at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between 1 January 1993 and 31 December 1996 was carried out. The incidence of PPH was 4.5%. Booking status of the patients had no relation with occurrence of PPH in this study (P>0.05). The risk of PPH in advanced maternal age (over 35 years) and grandmultiparity (para 5 and over) was twofold higher than low maternal age (<25 years) and low parity (para 0-1), P<0.05, respectively. The incidence of PPH was higher in deliveries conducted by midwives than doctors (P<0.05). Anaemic patients (PCV< or =30%) were more at risk than non-anaemic patients (P<0.05). Uterine atony, 183 (53.8%) was the most common cause of PPH and a combination of uterotonic agents and uterine massage were effective in controlling PPH in 171 (49.1%) of the cases. Seven (2.0%) patients required hysterectomy. One-third of the patients had a blood transfusion. To reduce the incidence of PPH, we recommend that doctors should supervise the delivery of parturients at risk of PPH and advocate health education against high parity.