Survival of cervical cancer patients at Moi teaching and Referral Hospital, Eldoret in western Kenya.

BACKGROUND: Cervical cancer is a major health burden and the second most common cancer after breast cancer among women in Kenya. Worldwide cervical cancer constitutes 3.1% of all cancer cases. Mortality rates are greatest among the low-income countries because of lack of awareness, screening and early-detection programs and adequate treatment facilities. The main aim was to estimate survival and determine survival predictors of women with cervical cancer and limited resources in western Kenya. METHODS: Retrospective charts review of women diagnosed with cervical cancer and follow-up for two years from the date of the histologic diagnosis. The outcome of interest was death or survival at two years. Kaplan Meier estimates of survival, log-rank test and Cox proportional hazards regression were used in the survival analysis. RESULTS: One hundred and sixty-two (162) participants were included in the review. The median duration was 0.8 (interquartile range (IQR) 0.3, 1.6) years. The mean age at diagnosis was 50.6 years (SD12.5). The mean parity was 5.9 (SD 2.6). Fifty percent (50%) did not have health insurance. Twenty six percent (26%) used hormonal contraceptives, 25.9% were HIV positive and 70% of them were on anti-retroviral treatment. The participants were followed up for 152.6 person years. Of the 162 women in the study, 70 (43.2%) died giving an overall incidence rate (IR) of 45.9 deaths per 100 person years of follow up. The hazard ratios were better for the patients who survived (0.44 vs 0.88, p-value < 0.001), those who had medical insurance (0.70 vs 0.48, p-value = 0.007) and those with early stage at diagnosis (0.88 vs 0.39, p-value < 0.001). Participants who were diagnosed at late stage of the disease according to the International Federation of Gynecology and Obstetrics staging for cervical cancer (FIGO stage 2B-4B) had more than eight times increased hazard of death compared to those who were diagnosed at early stage (1-2A): Hazard Ratio: 8.01 (95% CI 3.65, 17.57). Similarly, those who underwent surgical management had 84% reduced hazard of mortality compared to those who were referred for other modes of care: HR: 0.16 (95% CI: 0.07, 0.38). CONCLUSION: Majority of the participants were diagnosed late after presenting with symptoms. The 1 and 2-year survival probability after diagnosis of cervical cancer was 57% AND 45% respectively. It is imperative that women present early since surgery gives better prognosis or better still screening of all women prioritized.

Routine third-trimester ultrasound for the detection of small-for-gestational age in low-risk pregnancies (ROTTUS study): randomized controlled trial.

OBJECTIVE: To compare the proportion of small-for-gestational-age (SGA) infants detected by routine third-trimester ultrasound vs those detected by selective ultrasound based on serial symphysis-fundus height (SFH) measurements (standard care) in low-risk pregnancy. METHODS: This was an open-label randomized controlled trial conducted at a hospital in Kenya between May 2018 and February 2020. Low-risk pregnant women were randomly allocated (ratio of 1:1) to routine ultrasound for fetal growth assessment between 36 + 0 and 37 + 6 weeks' gestation (intervention group) or to standard care, which involved a selective growth scan on clinical suspicion of fetal growth abnormality based on serial SFH measurements (control group). During ultrasound examination, fetal growth was assessed by measurement of the abdominal circumference (AC), and AC < 10th centile was used to diagnose a SGA fetus. The main prespecified outcomes were the detection of neonatal SGA, defined as birth weight < 10th centile, and of severe neonatal SGA, defined as birth weight < 3rd centile. The predictive performance of routine third-trimester ultrasound and selective ultrasound based on serial SFH measurements was determined using receiver-operating-characteristics (ROC)-curve analysis. RESULTS: Of 566 women assessed for eligibility, 508 (89.8%) were randomized, of whom 253 were allocated to the intervention group and 255 to the control group. Thirty-six babies in the intervention group and 26 in the control group had a birth weight < 10th centile. The detection rate of SGA infants by routine third-trimester ultrasound vs that by standard care was 52.8% (19/36) vs 7.7% (2/26) (P < 0.001) and the specificity was 95.5% (191/200) and 97.9% (191/195), respectively (P = 0.08). The detection rate of severe SGA was 66.7% (12/18) by routine ultrasound vs 8.3% (1/12) by selective ultrasound based on SFH measurements (P < 0.001), with specificities of 91.7% (200/218) and 98.1% (205/209), respectively (P = 0.006). The area under the ROC curve of routine third-trimester ultrasound in prediction of SGA was significantly greater than that of selective ultrasound based on SFH measurements (0.92 (95% CI, 0.87-0.96) vs 0.68 (95% CI, 0.58-0.77); P < 0.001). CONCLUSIONS: In low-risk pregnancy, routine ultrasound performed between 36 + 0 and 37 + 6 weeks is superior to selective ultrasound based on serial SFH measurements for the detection of true SGA, with high specificity. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Determinants of preconception care among pregnant women in an urban and a rural health facility in Kenya: a qualitative study.

BACKGROUND: Preconception care (PCC) is a form of preventive health care that is offered to women and couples before conception, with the aim of improving their health status and mitigating various risk factors that could contribute to poor maternal and child health outcomes. The levels of PCC utilization are still low globally, especially in developing countries and in rural areas. Little is known regarding PCC use in Kenya that could help in addressing this shortfall. This study aimed to qualitatively assess the determinants of PCC in urban and rural settings in Kenya. METHODS: A qualitative approach was employed to assess determinants of PCC using a semi-structured interview guide. The study was conducted from May to October 2017. Selected pregnant women seeking antenatal care (ANC) were recruited by quota sampling, at the Mother and Child Health (MCH) clinics in Aga Khan University Hospital, Nairobi (AKUH, N-urban) and Maragua Level Four Hospital (MLFH-rural). The interviews were thereafter transcribed verbatim and analyzed thematically. FINDINGS: A total of 26 women were invited, of whom 21 accepted to participate in in-depth interviews (IDIs). Saturation of themes occurred with 13 interviews (7 at AKUH and 6 at MLFH). Transcription, coding and thematic analysis of the IDIs yielded 12 themes. Eleven of these themes were identified as determinants of PCC. The twelfth theme contained suggested strategies of increasing PCC awareness and utilization, such as using the media, setting up PCC clinics and integrating PCC into other clinics. The dominant themes were awareness about PCC and attitudes towards PCC and pregnancy. The broad determinants of PCC were similar in urban and rural settings - with a few notable exceptions. For example, in the rural setting, women's level of education and a pervasive history of poor interactions with healthcare providers were major determinants of PCC. CONCLUSION: From this study we conclude that women's lack of awareness about PCC, in conjunction with attitudes towards PCC and pregnancy impact strongly on its utilization. This lack of awareness could be addressed through health education programs for both the public and for healthcare providers, as well as integrating PCC in the curricula of the later.

Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: a retrospective review of 4396 women in East and Central Africa.

OBJECTIVE: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula. DESIGN: Retrospective record review. SETTING: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia. POPULATION: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014. METHODS: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries. MAIN OUTCOME MEASURES: Mode of delivery, stillbirth. RESULTS: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514). CONCLUSIONS: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth. TWEETABLE ABSTRACT: Caesarean section is increasingly performed in African women with stillbirth treated for obstetric fistula.

Does place and attendance at birth improve early neonatal mortality? Secondary analysis of nine Demographic and Health Surveys.

OBJECTIVES: To determine the relation between place and skilled birth attendance at birth and early neonatal mortality. DESIGN: Retrospective analysis using data from Demographic and Health Surveys on obstetric complications. SETTING: Nine low and middle income countries between 2006 and 2013. POPULATION: 71 758 women aged 15-49 years. METHODS: A secondary analysis was carried out to investigate the occurrence and effect of obstetric complications on early neonatal mortality and association with place and attendance at birth. Obstetric complications studied were prolonged labour, puerperal infection and eclampsia. MAIN OUTCOME MEASURES: Association between early neonatal mortality and place and attendance at birth, unadjusted and adjusted for presence of severe obstetric complications. RESULTS: Thirty-five percent of all births were at home: 70% of these were without skilled attendamts. Obstetric complications were reported in 17 079 women: 82% of these women gave birth in health facilities. Overall, no association was observed between place of birth or attendance at birth and early neonatal mortality. When adjusted for obstetric complications, the odds of early neonatal deaths for births at home without a skilled attendant were 1.3 (95% CI 1.1-1.5) compared with 1.2 (95% CI 1.0-1.5) with a skilled attendant and births in health facilities. CONCLUSIONS: When adjusted for obstetric complications, births in health facilities were associated with reduced early neonatal mortality. However, reporting and referral bias account for at least part of the association. TWEETABLE ABSTRACT: Births in health facilities are linked with fewer early newborn deaths when adjusted for obstetric complications.

Addressing the intersection between alcohol consumption and antiretroviral treatment: needs assessment and design of interventions for primary healthcare workers, the Western Cape, South Africa.

BACKGROUND: At the points where an infectious disease and risk factors for poor health intersect, while health problems may be compounded, there is also an opportunity to provide health services. Where human immunodeficiency virus (HIV) infection and alcohol consumption intersect include infection with HIV, onward transmission of HIV, impact on HIV and acquired immunodeficiency syndrome (AIDS) disease progression, and premature death. The levels of knowledge and attitudes relating to the health and treatment outcomes of HIV and AIDS and the concurrent consumption of alcohol need to be determined. This study aimed to ascertain the knowledge, attitudes and practices of primary healthcare workers concerning the concurrent consumption of alcohol of clinic attendees who are prescribed antiretroviral drugs. An assessment of the exchange of information on the subject between clinic attendees and primary healthcare providers forms an important aspect of the research. A further objective of this study is an assessment of the level of alcohol consumption of people living with HIV and AIDS attending public health facilities in the Western Cape Province in South Africa, to which end, the study reviewed health workers' perceptions of the problem's extent. A final objective is to contribute to the development of evidence-based guidelines for AIDS patients who consume alcohol when on ARVs. The overall study purpose is to optimise antiretroviral health outcomes for all people living with HIV and AIDS, but with specific reference to the clinic attendees studied in this research. METHODS: Overall the research study utilised mixed methods. Three group-specific questionnaires were administered between September 2013 and May 2014. The resulting qualitative data presented here supplements the results of the quantitative data questionnaires for HIV and AIDS clinic attendees, which have been analysed and written up separately. This arm of the research study comprised two, separate, semi-structured sets of interviews: one face-to-face with healthcare workers at the same primary healthcare clinics from which the clinic attendees were sampled, and the other with administrators from the local government health service via email. The qualitative analysis from the primary healthcare worker interviews has been analysed using thematic content analysis. RESULTS: The key capacity gaps for nurses include the definition of different patterns and volumes of alcohol consumption, resultant health outcomes and how to answer patient questions on alcohol consumption while on antiretroviral treatment. Not only did the counsellors lack knowledge regarding alcohol abuse and its treatment, but they were also they were unclear on their role and rights in relation to their patients. Doctors highlighted the need for additional training for clinicians in diagnosing alcohol use disorders and information on the pharmacological interventions to treat alcoholism. CONCLUSION: Pertinent knowledge regarding patient alcohol consumption while taking ARVs needs to be disseminated to primary healthcare workers.

Quality of antenatal and childbirth care in northern Ghana.

The QUALMAT research project aims to improve maternal and newborn health by improving the quality of antenatal and childbirth care provided in primary healthcare facilities. Within the frame of this project, a comprehensive quality assessment took place in selected health centres in northern Ghana. The results of this assessment showed that overall quality of routine antenatal and childbirth care was satisfactory, although some critical gaps were identified. Counselling and health education practices need to be improved; laboratory investigations are often not performed; examination and monitoring of mother and newborn during childbirth are inadequate; partographs are often not used and poorly completed; and equipment to provide assisted vaginal deliveries was absent.

Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study.

OBJECTIVE: To investigate the risk of adverse pregnancy outcomes among adolescents in 29 countries. DESIGN: Secondary analysis using facility-based cross-sectional data of the World Health Organization Multicountry Survey on Maternal and Newborn Health. SETTING: Twenty-nine countries in Africa, Latin America, Asia and the Middle East. POPULATION: Women admitted for delivery in 359 health facilities during 2-4 months between 2010 and 2011. METHODS: Multilevel logistic regression models were used to estimate the association between young maternal age and adverse pregnancy outcomes. MAIN OUTCOME MEASURES: Risk of adverse pregnancy outcomes among adolescent mothers. RESULTS: A total of 124 446 mothers aged ≤24 years and their infants were analysed. Compared with mothers aged 20-24 years, adolescent mothers aged 10-19 years had higher risks of eclampsia, puerperal endometritis, systemic infections, low birthweight, preterm delivery and severe neonatal conditions. The increased risk of intra-hospital early neonatal death among infants born to adolescent mothers was reduced and statistically insignificant after adjustment for gestational age and birthweight, in addition to maternal characteristics, mode of delivery and congenital malformation. The coverage of prophylactic uterotonics, prophylactic antibiotics for caesarean section and antenatal corticosteroids for preterm delivery at 26-34 weeks was significantly lower among adolescent mothers. CONCLUSIONS: Adolescent pregnancy was associated with higher risks of adverse pregnancy outcomes. Pregnancy prevention strategies and the improvement of healthcare interventions are crucial to reduce adverse pregnancy outcomes among adolescent women in low- and middle-income countries.

Pregnancy outcomes in Benghazi, Libya, before and during the armed conflict in 2011.

Stressful life events experienced by pregnant women may lead to adverse obstetric outcomes. This study in Benghazi compared the rates of preterm, low-birth-weight and caesarean-section births at Al-Jamhouria hospital in the months before and during the armed conflict in Libya in 2011. Data were collected on all women admitted to the delivery ward during February to May 2011 (the months of the most active fighting in the city) (n = 7096), and October to December 2010 (the months immediately before the war) (n = 5935). Compared with the preceding months there was a significant rise during the conflict in the rate of deliveries involving preterm (3.6% versus 2.5%) and low-birth-weight (10.1% versus 8.5%) infants and caesarean sections (26.9% versus 25.3%). Psychosocial stress may have been a factor (among others) in an increase in negative pregnancy outcomes, and obstetric hospitals should be aware of these issues in times of war.

Quality of antenatal and childbirth care in selected rural health facilities in Burkina Faso, Ghana and Tanzania: similar finding.

OBJECTIVES: To measure pre-intervention quality of routine antenatal and childbirth care in rural districts of Burkina Faso, Ghana and Tanzania and to identify shortcomings. METHODS: In each country, we selected two adjoining rural districts. Within each district, we randomly sampled 6 primary healthcare facilities. Quality of care was assessed through health facility surveys, direct observation of antenatal and childbirth care, exit interviews and review of patient records. RESULTS: By and large, quality of antenatal and childbirth care in the six districts was satisfactory, but we did identify some critical gaps common to the study sites in all three countries. Counselling and health education practices are poor; laboratory investigations are often not performed; examination and monitoring of mother and newborn during childbirth are inadequate; partographs are not used. Equipment required to provide assisted vaginal deliveries (vacuum extractor or forceps) was absent in all surveyed facilities. CONCLUSION: Quality of care in the three study sites can be improved with the available human resources and without major investments. This improvement could reduce maternal and neonatal mortality and morbidity.

CD4 T-LYMPHOCYTE SUBSETS IN WOMEN WITH INVASIVE CERVICAL CANCER IN KENYA.

OBJECTIVE: Invasive cervical cancer (ICC) and HIV are common in sub-Sahara Africa. Both ICC and HIV are immunosuppressive, and are associated with decreased CD4 and CD8 profiles. In a group of women with ICC starting radiotherapy, we determined their CD4 profiles. DESIGN: A cross-sectional study. SETTINGS: Kenyatta National Hospital, Nairobi, Kenya, radiotherapy unit. SUBJECTS: Women with invasive cervical cancer (344) seeking radiotherapy treatment for the first time between January 2000 and March 2003, had blood samples analyzed for CD4 and CD8 cell counts by flow cytometry. Haemoglobin, white cell count, lymphocyte and platelet counts were determined using coulter machine. All patients had received pre- and post HIV counseling. RESULTS: The mean age was 49+13 years. About 13.1% of the women with ICC were HIV positive. Overall, mean and median CD4 cell count was 829+355 cells/mm and 792 cells/mm3. Among HIV+ patients, mean and median CD4 cell counts were 451+288 cells/mm and 405 cells/mm respectively. The mean CD4 cell count for the HIV+ womenwas 886+329 cells/mm3 with median of 833 cells/mm3, range 147-2065 cells/mm3. Only nine (20%) of the 45 HIV+ women had CD4 cell count of 0-200. HIV+ women had lower CD4 percentage and cell count and higher CD8 percentage and cell count as compared to HIV negative women, p < 0.001. HIV infection was significantly and independently associated with high proportion of women who had CD4 cell count of less than 200 cells/mm3 or less than 350 cells/mm3, p < 0.0001. CONCLUSIONS: Women with ICC and concurrent HIV infection have decreased CD4 cell subset. These results suggest HIV infection may be associated with more severe CD4 depletion in women with ICC.

Terminations of pregnancy in the European Union.

OBJECTIVE: To study the current legislation and trends in terminations of pregnancy in the European Union (EU). DESIGN: Data were collected on legislation and statistics for terminations of pregnancy. SETTING: Population-based statistics from the EU member states. POPULATION: Women in reproductive age in the 27 EU member states. METHODS: Information on legislation was collected for all 27 EU member states. Statistical information until 2008 was compiled from international (n = 24) and national sources (n = 17). Statistical data were not available for Austria, Cyprus and Luxembourg. MAIN OUTCOMES MEASURES: Terminations of pregnancy per 1000 women aged 15-49 years. RESULTS: Ireland, Malta and Poland have restrictive legislation. Luxembourg permits termination of pregnancy on physical and mental health indications; Cyprus, Finland, and the UK further include socio-economic indications. In all other EU member states termination of pregnancy can be performed in early pregnancy on a women's request. In general, the rates of termination of pregnancy have declined in recent years. In total, 10.3 terminations were reported per 1000 women aged 15-49 years in the EU in 2008. The rate was 12.3/1000 for countries requiring a legal indication for termination, and 11.0/1000 for countries allowing termination on request. Northern Europe (10.9/1000) and Central and Eastern Europe (10.8/1000) had higher rates than Southern Europe (8.9/1000). Northern Europe, however, had substantially higher rates of termination of pregnancy among teenagers. CONCLUSION: A more consistent and coherent reporting of terminations of pregnancy is needed in the EU. The large variation of termination rates between countries suggests that termination of pregnancy rates may be reduced in some countries without restricting women's access to termination. Sexual education and provision of access to reliable and affordable contraception are essential to achieve low rates of termination of pregnancy.

Pregnancy outcome of Moroccan and Turkish women in Belgium.

OBJECTIVE: To compare perinatal outcome in women from Turkish and Moroccan descent versus autochthonous women in Belgium. METHODS: Retrospective cohort study, data from an existing database, coupled with sociodemographic data from birth certificates. RESULTS: There were more teenage pregnancies in the Moroccan and Turkish group, Moroccan women delivered more frequently after age 40 but Turkish women less frequently. In Moroccan and Turkish women the level of education was lower, they had less hypertension, fewer pregnancies after artificial reproductive technology and preterm deliveries, more diabetes and more grand multiparity. Moroccan women demonstrated more HIV infection. Planned cesarean section was less frequent in the Moroccan and Turkish group, and there was no difference for secondary cesarean section. Belgian women had more induction of labor, instrumental vaginal delivery and epidural anesthesia. There were more babies with low birth weight in both the Moroccan and Turkish group. Moroccan woman had more babies with a birth weight above 4500 g. Total perinatal death rate was higher for Moroccan women while there was no difference between Belgian and Turkish babies. CONCLUSION: Moroccan women demonstrated higher rates of HIV infection and perinatal mortality, while in both Turkish and Moroccon women diabetes was higher and hypertension less frequent. Belgian women underwent more interventions during pregnancy.

'Mama and papa nothing': living with infertility among an urban population in Kigali, Rwanda.

BACKGROUND: Not being able to procreate has severe social and economic repercussions in resource-poor countries. The purpose of this research was to explore the consequences of female and/or male factor infertility for men and women in Rwanda. METHODS: Both quantitative and qualitative methods were used. Couples presenting with female and/or male factor infertility problems at the infertility clinic of the Kigali University Teaching Hospital (n = 312), and fertile controls who recently delivered (n = 312), were surveyed about domestic violence, current and past relationships and sexual functioning. In addition, five focus group discussions were held with a subsample of survey participants, who were either patients diagnosed with female- or male-factor fertility or their partners. RESULTS: Domestic violence, union dissolutions and sexual dysfunction were reported more frequently in the survey by infertile than fertile couples. The psycho-social consequences suffered by infertile couples in Rwanda are severe and similar to those reported in other resource-poor countries. Although women carry the largest burden of suffering, the negative repercussions of infertility for men, especially at the level of the community, are considerable. Whether the infertility was caused by a female factor or male factor was an important determinant for the type of psycho-social consequences suffered. CONCLUSIONS: In Rwanda, as in other resource-poor countries, infertility causes severe suffering. There is an urgent need to recognize infertility as a serious reproductive health problem and to put infertility care on the public health agenda.

Sexual violence, HSV-2 and HIV are important predictors for infertility in Rwanda.

BACKGROUND: In order to formulate cost-effective health interventions aimed at preventing infertility it is necessary to identify modifiable risk factors for infertility in sub-Saharan Africa. This case-control study examined potential predictors and their population attributable fraction (PAF%) for various infertility types including lifestyle factors, sexual behaviour and reproductive tract infections (RTIs). METHODS: Sexually active women aged 21-45 year presenting with infertility problems at the infertility clinic of the Kigali University Teaching Hospital (n = 312), and fertile controls who recently delivered (n = 283) were surveyed together with their male partners. Participants were interviewed about socio-demographic characteristics, sexual behaviours and lifestyle factors, and were tested for HIV and RTIs. RESULTS: Variables significantly associated with tubal infertility were history of sexual violence [adjusted odds ratio (AOR) 2.41; 95% CI 1.36-4.25]; positive HIV (AOR 2.41; 95% CI 1.36-4.25), herpes simplex virus type 2 (HSV-2; AOR 1.67; 95% CI 1.03-2.71) and Chlamydia trachomatis serology (AOR 1.78; 95% CI 0.99-3.21), and current bacterial vaginosis by Amsel criteria (AOR 1.97; 95% CI 1.12-3.47). Among men, male factor infertility was associated with positive HIV (AOR 2.43; 95% CI 1.31-5.23) and HSV-2 serology (AOR 1.71; 95% CI 1.02-2.87) and current urologic abnormalities (AOR 2.38; 95% CI 1.01-5.31). Positive HSV-2 serostatus carried the greatest PAF% (26%) for tubal infertility, followed by positive HIV serostatus (20%) and history of sexual violence (17%). CONCLUSIONS: Although temporal relationships are difficult to ascertain, history of sexual violence, HSV-2 infection and HIV infection are important predictors of infertility in Rwanda.

Gender differences and factors associated with treatment-seeking behaviour for infertility in Rwanda.

BACKGROUND: This study examines perceptions of infertility causes, treatment-seeking behaviour and factors associated with seeking medical care in an urban infertile population in Rwanda, as well as the response of health providers. METHODS: Between November 2007 and May 2009 a hospital based survey was conducted among 312 women and 254 male partners in an infertile relationship. RESULTS: Infertility causes based on a medical diagnosis were mentioned by 24% of women and 17% of men. Male infertility awareness was low in both sexes with 28% of men and 10% of women reporting male-related causes. Seventy-four per cent of women and 22% of men had sought care for their infertility in the past. Seeking treatment in the formal medical sector was associated with higher income, being married and infertility duration of more than 5 years in both sexes. In women, higher education and being nulliparous and in men blaming oneself for the infertility was also associated with seeking formal medical care. Participants reported a wide array of treatments they received in the past, often including ineffective or even harmful interventions. CONCLUSION: Health authorities should invest in improving information, education and counselling on issues pertaining to causes and treatments of infertility, and in drawing up guidelines for the management of infertility at all levels of health care.

A Safe Motherhood project in Kenya: assessment of antenatal attendance, service provision and implications for PMTCT.

OBJECTIVES: To investigate uptake and provision of antenatal care (ANC) services in the Uzazi Bora project: a demonstration-intervention project for Safe Motherhood and prevention of mother-to-child transmission of HIV in Kenya. METHODS: Data were extracted from antenatal clinic, laboratory and maternity ward registers of all pregnant women attending ANC from January 2004 until September 2006 at three antenatal clinics in Mombasa and two in rural Kwale district of Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds logistic regression analyses assessed changes over time, and determinants of the frequency and timing of ANC visits, uptake of HIV testing, and provision of iron sulphate, folate and single-dose nevirapine (sd-NVP). RESULTS: About half of women in rural and urban settings (52.2% and 49.2%, respectively) attended antenatal clinics only once. Lower parity, urban setting, older age and having received iron sulphate and folate supplements during the first ANC visit were independent predictors of more frequent visits. The first ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5% and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally marked improvements were observed in the uptake of HIV testing and the provision of iron sulphate and folate. CONCLUSION: Provision of ANC services, including sd-NVP, increased markedly over time. While further improvements in quality are necessary, particular attention is needed to implement evidence-based interventions to alter ANC utilization patterns. Encouragingly, improved provision of basic essential obstetric care may increase attendance.

[Single embryo transfer]. / In Process Citation.

Thanks to assisted reproduction technology (ART) most couples with infertility can be helped today. Since the beginning of ART, however, two major problems have existed. In the first years of IVF more than one embryo was transferred in order to reach acceptable pregnancy rates, but this entails a risk of multiple pregnancy with all its morbidity and mortality due to premature birth. Also, studies comparing the outcome of children following ART with the outcome of children who were spontaneously conceived, showed that ART increased the risk of prematurity and low birth weight, even in singleton pregnancies. The transfer of just one embryo (single embryo transfer or SET) in IVF/ICSI treatment cycles appeared to be the only answer to the epidemic of multiple pregnancies. The studies which analyze the outcome of SET singletons are promising, since they suggest that a broader application of SET could have a positive influence on the outcome of pregnancies after ART as well.