Investigating maternal mortality in a public teaching hospital, abakaliki, ebonyi state, Nigeria

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

INTRODUCTION

Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.

METHODS

Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.

RESULTS

This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.

DISCUSSION

Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

A randomised controlled trial of tranexamic acid versus misoprostol in reducing blood loss during caesarean section

OBJECTIVE

To determine the efficacy of intravenous tranexamic acid versus rectal misoprostol in decreasing intraoperative blood loss during caesarean section (C/S).

DESIGN AND SETTING

Randomised controlled study involving pregnant women undergoing C/S at Alex Ekwueme Federal University Teaching Hospital, Abakaliki in Nigeria.

PARTICIPANTS AND INTERVENTIONS

Five hundred and fourteen women undergoing elective C/S were assigned randomly (257 patients per group) to receive either pre-operative 1000 µg rectal misoprostol or 1000mg intravenous tranexamic acid after spinal anaesthesia. Data from 248 patients were analysed in the misoprostol group, while data from 250 patients were analysed in the tranexamic acid group. Sixteen patients were excluded from analysis; nine had incompletely filled proforma, while seven were lost to follow-up.

MAIN OUTCOME

Intraoperative blood loss.

RESULTS

The mean intraoperative blood loss was not significantly different between the misoprostol group and the tranexamic acid group (547 ± 183.75ml vs. 551.66 ± 21.74ml, P = 0.157). The mean difference in pack cell volume (PCV) changes was not significant between the groups (2.41±0.95% vs. 2.36±0.56%, P = 0.474). The side effects profile was similar for both groups except for shivering, which was statistically higher among the misoprostol group (RR = 0.70; 95%CI 0.40 - 0.91, P = 0.028).

CONCLUSION

Intravenous tranexamic acid was comparable to rectal misoprostol in the reduction of blood loss during C/S. Tranexamic acid could act as a good alternative to misoprostol for prophylaxis for blood loss during elective C/S.

FUNDING

None declared.

Tranexamic acid for reducing blood loss following vaginal delivery: a double-blind randomized controlled trial

BACKGROUND

Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality worldwide. Tranexamic acid (TXA) is a useful drug for prevention of PPH and merits evaluation in Nigeria, where PPH is the leading cause of maternal death (25%) and severe maternal morbidity. This study evaluates the efficacy of TXA in reducing blood loss following vaginal delivery.

METHODS

This was a double-blind randomized placebo-controlled study on the efficacy and safety of intravenous TXA in reducing blood loss in women undergoing vaginal delivery in a tertiary hospital. Data analysis was conducted with IBM SPSS software (version 20, Chicago II, USA). P-value < 0.05 was considered statistically significant.

RESULTS

The mean estimated blood loss was lower in TXA compared with the placebo group. (174.87 ± 119.83 ml versus 341.07 ± 67.97 ml respectively; P < 0.0001). PPH (blood loss > 500 ml) was 5.13% in the study arm compared to the control arm 7.14%- risk ratio (RR) 0.71; 95% CI: 0.38-1.79, p = 0.5956]. Additional uterotonics was required more in the control group compared to the treatment group 14(16.67%) versus 3(3.85%), p-value= 0.007. There were no major complications noticed in the treatment group.

CONCLUSION

This study demonstrated that intravenous administration of TXA reduced blood loss following vaginal delivery. It also reduced the need for additional uterotonics. However, blood loss greater than 500 was not significantly reduced.

TRIAL REGISTRATION

This trial was registered retrospectively. Pan African Clinical Trial Registry: PACTR202010828881019 on 12/10/2020.

A 20 year retrospective study of rape pattern in Ebonyi State, South-East Nigeria

This paper investigates patterns of rape in Ebonyi state, South-East Nigeria. This was a retrospective study in which data on rape over a twenty year period (January 1999 to December 2018) were obtained from the records of the Criminal Investigation Department, Nigerian Police Force, State Headquarters, Abakaliki and the Ebonyi State Ministry of Justice, Abakaliki. The data was analysed with the Statistical Package for Social Sciences version 20 software (SPSS Inc, Chicago, IL, USA). The Chi square test and Students’ t-test test were used to analyze the categorical and continuous variables respectively. A multinomial Logistics Regression (MLR) and Pearson correlation Coefficient were used to determine the influence of the socio-demographic characteristics of the victims and perpetrators on rape of the victims. A P-value of less than 0.05 was considered statistically significant. This study showed an association between recreational drug use by the perpetrators and rape of the victims. There was a nexus among types of perpetrators, site of committed crime and social habits of the perpetrators with rape of the victims. Victims in urban residential areas were more likely to be raped based on the types of the perpetrators, site of the crime committed and social habits of the perpetrators than the victims in rural areas. Victims who were <18 years were more likely to be raped by neighbors (P = 0.01). Out of 8,286 perpetrators charged to court, it was only 2.9% of them that were convicted. Measures to stop recreational drug use will be useful in stemming the tide of increasing rape cases in the state. The relevant sections of Nigerian law on rape need to be altered to broaden its scope and help punish the perpetrators in order to serve as deterrents to others. Education and empowerment of females will help reduce rape and its associated stigma thereby enhancing the perseverance of the victims to the logical conclusion of the case.

Individual, health facility and wider health system factors contributing to maternal deaths in Africa: A scoping review

The number of women dying during pregnancy and after childbirth remains unacceptably high, with African countries showing the slowest decline. The leading causes of maternal deaths in Africa are preventable direct obstetric causes such as haemorrhage, infection, hypertension, unsafe abortion, and obstructed labour. There is an information gap on factors contributing to maternal deaths in Africa. Our objective was to identify these contributing factors and assess the frequency of their reporting in published literature. We followed the Arksey and O'Malley methodological framework for scoping reviews. We searched six electronic bibliographic databases: MEDLINE, SCOPUS, African Index Medicus, African Journals Online (AJOL), French humanities and social sciences databases, and Web of Science. We included articles published between 1987 and 2021 without language restriction. Our conceptual framework was informed by a combination of the socio-ecological model, the three delays conceptual framework for analysing the determinants of maternal mortality and the signal functions of emergency obstetric care. We included 104 articles from 27 African countries. The most frequently reported contributory factors by level were: (1) Individual-level: Delay in deciding to seek help and in recognition of danger signs (37.5% of articles), (2) Health facility-level: Suboptimal service delivery relating to triage, monitoring, and referral (80.8% of articles) and (3) Wider health system-level: Transport to and between health facilities (84.6% of articles). Our findings indicate that health facility-level factors were the most frequently reported contributing factors to maternal deaths in Africa. There is a lack of data from some African countries, especially those countries with armed conflict currently or in the recent past. Information gaps exist in the following areas: Statistical significance of each contributing factor and whether contributing factors alone adequately explain the variations in maternal mortality ratios (MMR) seen between countries and at sub-national levels.

Effectiveness of preoperative tranexamic acid in reducing blood loss during caesarean section at Aminu Kano Teaching Hospital, Kano: a randomized controlled trial

Introduction

bleeding during and after caesarean section is one of the contributors to maternal mortality and morbidity. Tranexamic acid can be given before surgery to significantly reduce the amount of blood loss during caesarean section. The objective was to evaluate the effectiveness of preoperative tranexamic acid in reducing blood loss during caesarean section at Aminu Kano Teaching Hospital, Kano.

Methods

this was a randomized double blind placebo controlled study that was carried out among 244 women who were to have emergency caesarean section between December 2017 and June 2018 and were randomly assigned to the study group or control group. Women in the study group received lg (10mls) of tranexamic acid intravenously while women in the control group received 10ml of normal saline. Oxytocin was administered in the two groups according to protocol. Measurement of blood loss was done immediately after surgery. Postoperative drop in haemoglobin and haematocrit were also determined. Statistical analysis was done using SPSS Version 22.

Results

the average intra operative blood loss was 414.0 ml in the study group and 773.8 ml in the control group (t = - 16.18, p ≤ 0.01). Average postoperative haemoglobin was 10.1 g/dl in the study group and 9.5 g/dl in the control group (t = 4.99, p ≤ 0.01). Average postoperative haematocrit was 31.5% in the study group and 29.9% in the control group (t = 4.70, p ≤ 0.01).

Conclusion

there was a significant reduction in the blood loss when preoperative tranexamic acid was given to patients who were to undergo emergency caesarean section.

Preoperative vaginal cleansing with chlorhexidine solution in preventing post-cesarean section infections in a low resource setting: A randomized controlled trial

INTRODUCTION

Infection is one of the most common causes of maternal morbidities and mortality and has been reported to be responsible for about 15% of maternal deaths. Any woman is at risk of infection during childbirth, but women undergoing cesarean section are at higher risk. Improvement in surgical procedures with asepsis and the use of antibiotics have helped reduce postoperative infectious morbidities. However, ascending infection from the lower to the upper genital tract is a common but often neglected source of infection. Cleaning the vagina with chlorhexidine antiseptic solution before cesarean section can be a cheap and affordable source of infection control. This study is aimed at evaluating the efficacy of preoperative vaginal cleansing using 1.0% chlorhexidine in the reduction of post-cesarean section infectious morbidities.

MATERIAL AND METHODS

This prospective randomized control trial was conducted among 322 pregnant women who underwent an emergency cesarean section at Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AE-FUTHA). The women were randomized into two groups. The interventional group received vaginal cleansing with three standard gauzes soaked in 30 mL 1.0% chlorhexidine gluconate solution preoperatively in addition to surgical skin cleaning with chlorhexidine-alcohol. The women in the control group only had surgical skin cleaning with chlorhexidine-alcohol. All the women received pre- and postoperative antibiotics. The primary outcomes were endometritis and wound infections.

RESULTS

Infectious morbidity was significantly reduced from 36.8% in the control group to 12.0% in the intervention group (P = .001). Endometritis occurred significantly less frequently in the intervention group than the control group (respectively 6.6% compared with 27.6%: relative risk [RR] 0.29, 95% confidence interval [CI] 0.16-0.53; P < .05). Foul-smelling vaginal discharge was significantly more common in the control group than in the intervention group (11.8% vs 1.3%, respectively) but the CI was wide (RR 8.5, 95% CI 1.30-64.55; P < .001). Fever and wound infection were more common in the control group (5.9% vs 3.3% and 9.2% vs 5.3%) but the difference was not significant. The hospital stay was significantly shorter among the intervention group (5.54 ± 1.04 days compared with 6.01 ± 1.55 days, P < 0.05). The most common microbial isolate implicated in endocervical colonization was Staphylococcus aureus followed by Klebsiella species.

CONCLUSIONS

Vaginal cleansing with 1.0% chlorhexidine gluconate solution before emergency cesarean section appears to be effective in reducing rates of post-cesarean section infectious morbidity in the study area. We recommend its use among women undergoing cesarean section to help reduce the contribution of infections to a poor obstetrics outcome.

Correlates of patients' satisfaction with antenatal care services in a tertiary hospital in Abakaliki, Ebonyi State, Nigeria

Introduction

antenatal care is a specialized pattern of care organized for pregnant women to improve their chances of a safe delivery. Assessment of patients' perception of healthcare services is one of the ways of measuring the quality of healthcare as satisfied patients are likely to come back for the services they need and to recommend the services to others.

Methods

this is a cross-sectional study. Two hundred and eighty-four booked antenatal attendees were randomly selected at the antenatal clinic of Federal Teaching Hospital, Abakaliki in November 2016 and interviewed using semi-structured questionnaire. Items in the questionnaire included sociodemographic and obstetric variables, assessment of amenities, total time spent, services and level of satisfaction. Data obtained were analyzed using Epi info TM 7.1.3.10 and presented with a simple percentage and chi-square. Main outcome measure: satisfaction with antenatal care.

Results

the mean age of the respondents was 28.2 ± 4.2 years, majority 130 (45.8%) were within the 25-29 age bracket. Most had tertiary education (146, 51.4%) and less than 10% are grand multipara. In general, 89.4% of the respondents were satisfied with the quality of antenatal care services. Majority of the respondents 170 (59.9%) were unsatisfied with the water supply while 128 (45.1%) were unsatisfied with cervical cancer prevention discussion during the health talk. The mean total time spent in the antenatal clinic was 4.1 hours ± 1.2 hours (range 2-7 hours). Being married and multiparous significantly affected satisfaction with the quality of antenatal care services as represented by P-value of 0.015 and 0.005 respectively.

Conclusion

majority of pregnant women were satisfied with the care they received. Health providers should, however, improve the state of sanitary facilities and ensure the provision of adequate information on cervical cancer screening during health talks.

Birth Preparedness and Complication Readiness among Pregnant Women in a Secondary Health Facility in Abakaliki, Ebonyi State, Nigeria

Background

Birth preparedness and complication readiness (BP/CR) concept is based on the premise that preparing for birth and being ready for complications reduce all three phases of delay to a bad obstetric outcome.

Objectives

To determine the knowledge of BP/CR with its determinants and BP/CR index among pregnant women in Abakaliki, southeast Nigeria.

Methods

A cross-sectional survey was done between 1^st March 2019 and 31^st July 2019 among 450 randomly selected antenatal attendees at Mile Four Hospital, Abakaliki, Nigeria. The data were obtained using a pretested interviewer-administered structured questionnaire adapted from the maternal and neonatal health program handbook of the Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO). The data obtained were analyzed using percentages, chi-square, and odds ratios. The level of significance is at P value < 0.05.

Results

The birth preparedness and complication readiness index was 41.9%. Only 44.9% and 36.9% of the study population had adequate knowledge of birth preparedness (BP) and complication readiness (CR), respectively. Upper social class, lower educational level, urban residence, and less than 30 years of age were associated with increased odds of respondents having adequate knowledge of BP and CR (P > 0.05). However, only booking in the 1^st or 2^nd trimester was a significant determinant of the respondent's adequate knowledge of BP (AOR = 0.63, 95% CI 0.40-0.98) and CR (AOR = 0.62, 95% CI 0.39-0.97). Identification of transport and saving of money was the commonest birth plan while the commonest danger sign known to the participants was bleeding.

Conclusion

This study revealed that knowledge of BP/CR is suboptimal. The determinant of this knowledge is antenatal booking. It is recommended that women should have adequate antenatal care education to improve their knowledge of BP/CR. This will help to increase the low BP/CR index seen in our study.

"I am alive; my baby is alive": Understanding reasons for satisfaction and dissatisfaction with maternal health care services in the context of user fee removal policy in Nigeria

Background

The main policy thrust in many sub-Saharan Africa countries’ aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood.

Methods

This study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011–2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis.

Results

The overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers’ attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care.

Conclusion

The findings establish a high level of beneficiaries’ satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers.

Pattern and Outcome of Obstetric Admissions into the Intensive Care Unit of a Southeast Nigerian Hospital

Background and Aims:

Although pregnancy and labor are considered physiological processes, the potential for catastrophic complications is constant and may develop rapidly. There is growing evidence that admission of high-risk patients into the Intensive Care Unit (ICU) is associated with a reduction in maternal mortality. This study was aimed at reviewing all obstetric patients admitted into the ICU.

Materials and Methods:

This was a retrospective study of all obstetric patients who were admitted into the ICU between January 1, 2012, and December 31, 2013.

Results:

There were 89 obstetric patients admitted and managed at the ICU out of 5176 deliveries, thereby accounting for 1 admission in 58 deliveries. Majority of the patients were between 26 and 30 years, primiparous, and unbooked. The indications for ICU admission in this study were ruptured uterus (36.0%), eclampsia (22.5%), obstetric hemorrhage (19.1%), septicemia (10.1%), severe preeclampsia (6.7%), and obstructed labor (6.7%). The maternal and perinatal mortality was 13.5% and 47.2%, respectively. Maternal unbooked status was significantly associated with maternal mortality (P < 0.05).

Conclusion:

Ruptured uterus was the most common indication for ICU admission in the center. Maternal mortality was significantly associated with unbooked status. This underscores the importance of booking for antenatal care, prompt presentation at the hospital during emergencies, skilled birth attendance, and provision of adequate facilities for the management of critical obstetric cases in this environment.

The Feto-Maternal Outcome of Preeclampsia with Severe Features and Eclampsia in Abakaliki, South-East Nigeria

INTRODUCTION

Preeclampsia with severe features and eclampsia has remained a serious challenge in tropical obstetric practice. It is a major cause of maternal and perinatal morbidity and mortality in Nigeria.

AIM

This study was aimed at determining the prevalence, the risk factors and feto-maternal outcome of preeclampsia with severe features and eclampsia in Abakaliki.

MATERIALS AND METHODS

This was a 5-year retrospective case-control study of preeclampsia with severe features and eclampsia at the Federal Teaching Hospital, Abakaliki. Case notes of preeclampsia with severe features and eclampsia between January 2008 and December, 2012 were retrieved. Similarly, the case file of next parturient that did not have any medical disease was included in the study. The cases and controls were selected at the ratio of 1:1. The data assessed were information on maternal age, parity, booking status, diagnosis, mode of delivery, complications, maternal and perinatal outcomes.

RESULTS

A total of 13,750 deliveries were recorded within the study period. The prevalence of preeclampsia with severe features and eclampsia were 136(0.99%) and 104(0.76%) respectively. Preeclampsia with severe features and eclampsia was more common among adolescents, rural dwellers, poorly educated, unemployed, unbooked and nulliparous women. It was more associated with preterm delivery, caesarean section, low birth weight babies, maternal and perinatal mortality.

CONCLUSION

Preeclampsia with severe features and eclampsia is common among the adolescents, unbooked, rural, and low socio-economic group of women in this study. It has also contributed to high maternal and perinatal morbidity and mortality. There is need for policy makers to formulate policies toward female education, women empowerment and provision of social amenities in rural areas. These policies may reverse the current ugly trend in this environment.

Maternal Mortality Ratio and Causes of Death in IRI Between 2009 and 2012

Objective: The Maternal Mortality Ratio is an important health indicator. We presented the distribution and causes of maternal mortality in Islamic Republic of Iran. Materials and methods: After provision of an electronic Registry system for date entry, a descriptive-retrospective data collection had been performed for all maternal Deaths in March 2009- March 2012. All maternal deaths and their demographic characteristic were identified by using medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-9) during pregnancy, labor, and 42 days after parturition. Results: During 3 years, there were 5094317 deliveries and 941 maternal deaths (MMR of 18.5 per 1000000 live births). We had access to pertained data of 896 cases (95.2%) for review in our study. Of 896 reported deaths, 549 were classified as direct, 302 as indirect and 45 as unknown. Hemorrhage was the most common cause of maternal mortality, followed by Preeclampsia, Eclampsia and sepsis. Among all indirect causes, cardio -vascular diseases were responsible for 10% of maternal deaths, followed by thromboembolism, HTN and renal diseases. Conclusion: Although maternal mortality ratio in IRI could be comparable with the developed countries but its pattern is following developing countries and with this study we had provided reliable data for other prospective studies.

Evaluation of Clinical Diagnosis of Fetal Distress and Perinatal Outcome in a Low Resource Nigerian Setting

INTRODUCTION

Fetal distress has been shown to contribute to the increasing caesarean section rate. There has been controversy on the usefulness of clinical diagnosis of fetal distress using only the intermittent counting of the fetal heart rate and/or passage of meconium-stained liquor.

AIM

To evaluate the clinical diagnosis of fetal distress and the perinatal outcome.

MATERIALS AND METHODS

This was a retrospective study in which the case records of the patients, who were diagnosed of fetal distress at Federal Teaching Hospital, Abakaliki, Nigeria, from January 1, 2008 to December 31, 2014, were collated. The statistical analysis was done using the Statistical Package for Social Sciences version 17 software (SPSS Inc., Chicago IL, USA).

RESULTS

Out of the 15,640 deliveries carried out within the study period, 3,761 (24.05%) deliveries were through caesarean section. A total of 326 (8.9%) of the 3,761 caesarean sections were due to fetal distress within the study period. More so, a total of 227 (70.9%) babies were born with ≥ 7 Apgar score at the 1(st) minute of delivery. The perinatal mortality rate was 31.25 per 1000 deliveries. Though birth asphyxia was recorded more on babies of mothers that had fresh meconium-stained liquor and whose decision-intervention interval was more than 30 minutes when compared with those without any of the two conditions, there was no statistical significant difference between them.

CONCLUSION

The clinical diagnosis of fetal distress is accurate in 29.1% of the cases. However, it has led to an unnecessary caesarean section in the remaining 70.9% of the parturients. In order to reduce this high trend of unnecessary caesarean sections due to clinical diagnosis of fetal distress in this environment, antepartum fetal assessment with non-stress test or biophysical profile and intrapartum use of continuous electronic fetal monitoring should be used to confirm or refute the fetal distress before any surgical intervention. Fetal blood sampling and fetal pulse oximetry should be performed in event of non- re-assuring or abnormal cardiotocography.

Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost-Effectiveness Study in Rural Nigeria

Background

While the Nigerian government has made progress towards the Millennium Development Goals, further investments are needed to achieve the targets of post-2015 Sustainable Development Goals, including Universal Health Coverage. Economic evaluations of innovative interventions can help inform investment decisions in resource-constrained settings. We aim to assess the cost and cost-effectiveness of maternal care provided within the new Kwara State Health Insurance program (KSHI) in rural Nigeria.

Methods and Findings

We used a decision analytic model to simulate a cohort of pregnant women. The primary outcome is the incremental cost effectiveness ratio (ICER) of the KSHI scenario compared to the current standard of care. Intervention cost from a healthcare provider perspective included service delivery costs and above-service level costs; these were evaluated in a participating hospital and using financial records from the managing organisations, respectively. Standard of care costs from a provider perspective were derived from the literature using an ingredient approach. We generated 95% credibility intervals around the primary outcome through probabilistic sensitivity analysis (PSA) based on a Monte Carlo simulation. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the base case separately through a scenario analysis. Finally, we assessed the sustainability and feasibility of this program’s scale up within the State’s healthcare financing structure through a budget impact analysis. The KSHI scenario results in a health benefit to patients at a higher cost compared to the base case. The mean ICER (US$46.4/disability-adjusted life year averted) is considered very cost-effective compared to a willingness-to-pay threshold of one gross domestic product per capita (Nigeria, US$ 2012, 2,730). Our conclusion was robust to uncertainty in parameters estimates (PSA: median US$49.1, 95% credible interval 21.9–152.3), during one-way sensitivity analyses, and when cost, quality, cost and utilization parameters of the base case scenario were changed. The sustainability of this program’s scale up by the State is dependent on further investments in healthcare.

Conclusions

This study provides evidence that the investment made by the KSHI program in rural Nigeria is likely to have been cost-effective; however, further healthcare investments are needed for this program to be successfully expanded within Kwara State. Policy makers should consider supporting financial initiatives to reduce maternal mortality tackling both supply and demand issues in the access to care.

Profile and microbiological isolates of asymptomatic bacteriuria among pregnant women in Abakaliki, Nigeria

Background

Detecting and treating asymptomatic bacteriuria (ASB) prevents urinary tract infection and its consequences. The cost-effectiveness of routine screening for ASB in pregnancy is controversial. In populations with high prevalence, however, it is worthwhile and justifiable.

Aim

To determine the profile, prevalence, microbiological isolates, and risk factors of ASB among booking antenatal clinic attendees in Abakaliki, Nigeria.

Materials and methods

This was a cross-sectional study involving booking antenatal clinic attendees at the Federal Teaching Hospital, Abakaliki, who met the inclusion criteria. This study occurred between January and December, 2012. The midstream urine samples of these women were subjected to microscopy, culture, and sensitivity.

Results

A total of 300 randomly selected booking antenatal clinic attendees participated in the study; 74 of them had ASB, giving a prevalence of 24.7%. With the exception of rural residence, sociodemographic and obstetric characteristics did not influence the risk of ASB among the participants in this study. Staphylococcus aureus was the commonest organism isolated. The majority of the organisms were sensitive to ofloxacin and ceftriaxone.

Conclusion

There is a high prevalence of ASB among pregnant women in Abakaliki. With the exception of rural dwelling, sociodemographic and obstetric characteristics did not significantly influence the risk of ASB among these pregnant women. Therefore, routine ASB screening of pregnant women is recommended in our environment.

Evaluation of clinical breast examination and breast ultrasonography among pregnant women in Abakaliki, Nigeria

BACKGROUND

Breast cancer in pregnancy accounts for 2%-3% of all breast cancers. The increased vascularity and lymphatic drainage from the breast during pregnancy potentiate the metastatic spread of the cancer to the regional lymph nodes. However, the increased breast density in pregnancy makes it difficult to detect breast lesions early.

AIM

To evaluate and compare the detection rate of breast lesions using clinical breast examination (CBE) and breast ultrasonography among pregnant women.

METHODOLOGY

A cross-sectional comparative study involving antenatal clinic attendees at the Federal Teaching Hospital, Abakaliki, was conducted between March 3, 2014, and December 31, 2014. CBE and breast ultrasonography were done in the participants at booking and repeated at 6 weeks postpartum. Fine-needle aspiration cytology and histology were done in women with suspicious breast lesions on CBE or breast ultrasonography or both. Data analysis was both descriptive and inferential at the 95% confidence level using the Statistical Package for the Social Sciences (SPSS) software version 17.0. Test of significance was done using chi-square test. A P-value of less than or equal to 0.05 was considered statistically significant.

RESULTS

A total of 320 pregnant women participated in the study. Of these, 267 (83.4%) were aware of breast cancer. Although more lesions were detected with breast ultrasonography than by CBE, there was no statistically significant difference between them (25 versus 17; P=0.26). The histology of the lesions revealed 21 benign lesions and 4 normal breast tissues. The sensitivity of breast ultrasonography was 95.2%, while that of CBE was 66.7%. The specificity, positive predictive value, and negative predictive value were similar between CBE and breast ultrasonography.

CONCLUSION

The detection rates of breast lesions by both CBE and breast ultrasonography were equivalent during pregnancy and 6 weeks postpartum, making CBE a convenient and very cost-effective method of detecting breast lesions in the low-risk population. However, both CBE and breast ultrasonography should be done in women with high risk of breast malignancy.

Adolescent reproductive health challenges among schoolgirls in southeast Nigeria: role of knowledge of menstrual pattern and contraceptive adherence

BACKGROUND

Reproductive health services in the form of adolescent health and contraceptive services are fundamental in the prevention of a high incidence of teenage pregnancy. The purpose of this study was to determine the age at menarche, menstrual pattern, and awareness of and use of modern contraception among secondary school girls in Abakaliki, Nigeria.

SUBJECTS AND MATERIALS

This was a cross-sectional study in which self-administered questionnaires were completed by 482 adolescent girls at two girls' secondary schools between August and September 2012.

RESULTS

The mean age at menarche was 13.13±1.37 years. The mean menstrual cycle length was 27.8±3.14 days, and the mean duration of menstrual flow was 4.8±1.14 days. Thirty-seven (7.7%) respondents were ignorant of their cycle length, while 29 (6.0%) had irregular cycles. Premenstrual syndrome and dysmenorrhea were major menstrual issues, which resulted in 69 (14.3%) and 59 (12.2%) of respondents resorting to self-medication and absenteeism from school, respectively. Mothers were the main source of their daughters' adolescent education, while friends and mass media were the main source of contraceptive information. Though there was a high level (75.7%) of awareness of contraceptive information among the girls, usage (8.9%) was poor. Only eight (18.6%) of the 43 respondents who had ever used modern contraception were adherent to modern contraceptives. Students who were more than 15 years old, attained menarche at 13 years or less, and whose families were of low socioeconomic classes were more likely to be sexually active.

CONCLUSION

The declining age at menarche, menstrual challenges, and poor reproductive health status of adolescent girls in this study have made menstrual issues and contraceptive adherence critical aspects of adolescent health care, especially when appropriate sources of reproductive health information were not fully harnessed. Therefore, there is an urgent need to establish adolescent-friendly clinics and include sexuality education in the curriculum of schools in this environment.

Declining maternal mortality in the face of persistently high HIV prevalence in a middle-income country

OBJECTIVE

To estimate maternal mortality ratio (MMR) and determine maternal death causes and trends in Greater Soweto, Johannesburg, South Africa.

DESIGN

Cross-sectional study.

SETTING

Chris Hani Baragwanath Maternity Hospital (CHBMH) in Greater Soweto.

POPULATION

Maternal deaths at CHBMH.

METHODS

Record review of maternal deaths from 1997 to 2012, using hospital death records, with denominator data from the district health information system and the hospital.

MAIN OUTCOME MEASURES

Maternal mortality ratio per 100,000 live births, and causes of death classified as in the South African confidential enquiries.

RESULTS

There were 479 deaths, with a peak MMR of 139 in 2004 and a decline to 86 in 2012. Of 332 women tested, 245 (74%) were HIV-infected. Nonpregnancy-related infection (40%) was the most frequent cause of death, followed by hypertension (16%) and obstetric haemorrhage (13%). HIV infection rates in these groups were 92%, 30% and 61%, respectively. Previous caesarean section was associated with obstetric haemorrhage death (odds ratio [OR] 3.2, 95% confidence interval [95% CI] 1.7-6.0), maternal age ≥35 years with hypertension death (OR 2.2, 95% CI 1.2-3.7) and antenatal anaemia with nonpregnancy-related infection death (OR 4.0, 95% CI 2.3-6.9), compared with other causes of death.

CONCLUSION

There is evidence of a decline in MMR since HIV treatment for pregnant women was introduced in 2004. Previous caesarean section, advanced maternal age, and anaemia were associated with death from obstetric haemorrhage, hypertensive disorders of pregnancy and nonpregnancy-related infections, respectively. MMR may be further reduced with accelerated initiation of HIV treatment during pregnancy.

Ectopic pregnancy: a life-threatening gynecological emergency

Background

Ectopic pregnancy is a life-threatening gynecological emergency, and a significant cause of maternal morbidity and mortality in Nigeria.

Objective

The aim of this work was to determine and evaluate the incidence, clinical presentation, risk factors, and management outcomes of ectopic pregnancies at Ebonyi State University Teaching Hospital (EBSUTH) in Abakaliki.

Methods

This was a retrospective, descriptive study of ectopic pregnancies managed in EBSUTH during the study period (June 1, 2002 to May 31, 2012). The medical records of the patients managed for ectopic pregnancy as well as the total birth record and gynecological admission records during the period under review were retrieved, and data were collected with the aid of data-entry forms designed for this purpose. There were 4,610 gynecological admissions and 9,828 deliveries, with 215 cases of ectopic pregnancies. A total of 205 cases were suitable for analysis after excluding cases with incomplete records. The relevant data collected were analyzed with SPSS version 15.0 for Windows.

Results

Ectopic pregnancy constituted 4.5% of all gynecological admissions, and its incidence was 2.1%. The mean age of the patients was 27 ± 2 years, 196 of 205 (95.6%) had ruptured ectopic pregnancies, and the remaining nine (4.4%) were unruptured. The commonest (166 of 205, 80.0%) clinical presentation was abdominal pain, and the commonest (105 of 205, 51.2%) identified risk factor was a previous history of induced abortion. Three deaths were recorded, giving a case-fatality rate of 1.4% (three of 205).

Conclusion

Ectopic pregnancy is a recognized cause of maternal morbidity and mortality and has remained a reproductive health challenge to Nigerian women, as well as a threat to efforts in achieving the UN’s Millennium Development Goal 5 in sub-Saharan Africa.