A population-based estimation of maternal mortality in Lagos State, Nigeria using the indirect sisterhood method

BACKGROUND

Pregnancy and delivery deaths represent a risk to women, particularly those living in low- and middle-income countries (LMICs). This population-based survey was conducted to provide estimates of the maternal mortality ratio (MMR) in Lagos Nigeria.

METHODS

A community-based, cross-sectional study was conducted in mapped Wards and Enumeration Areas (EA) of all Local Government Areas (LGAs) in Lagos, among 9,986 women of reproductive age (15-49 years) from April to August 2022 using a 2-stage cluster sampling technique. A semi-structured, pre-tested questionnaire adapted from nationally representative surveys was administered using REDCap by trained field assistants for data collection on socio-demographics, reproductive health, fertility, and maternal mortality. Data were analysed using SPSS and MMR was estimated using the indirect sisterhood method. Ethical approval was obtained from the Lagos State University Teaching Hospital Health Research and Ethics Committee.

RESULTS

Most of the respondents (28.7%) were aged 25-29 years. Out of 546 deceased sisters reported, 120 (22%) died from maternal causes. Sisters of the deceased aged 20-24 reported almost half of the deaths (46.7%) as due to maternal causes, while those aged 45-49 reported the highest number of deceased sisters who died from other causes (90.2%). The total fertility rate (TFR) was calculated as 3.807, the Lifetime Risk (LTR) of maternal death was 0.0196 or 1-in-51, and the MMR was 430 per 100,000 [95% CI: 360-510].

CONCLUSION

Our findings show that the maternal mortality rate for Lagos remains unacceptable and has not changed significantly over time in actual terms. There is need to develop and intensify community-based intervention strategies, programs for private hospitals, monitor MMR trends, identify and contextually address barriers at all levels of maternal care.

Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries

BACKGROUND

The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain.

METHODS

We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale.

RESULTS

A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P = 0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P = 0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events.

CONCLUSIONS

Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000476336; Clinical Trials Registry-India number, CTRI/2017/04/008326.).

A prospective study of severity of complications associated with use of misoprostol and other abortion methods in South West Nigeria

OBJECTIVES

To assess the severity of complications following misoprostol used to induce abortion compared with other methods among women admitted for postabortion complications.

METHODS

A cross-sectional study of women who presented with complications of induced abortion at nine secondary and tertiary hospitals in South West Nigeria between April 1, 2013 and May 31, 2014. Face-to-face interviews were conducted and information on the current admission was extracted from patient records. Associations between abortion method used and severity of abortion complications were evaluated using χ² and Fisher exact tests.

RESULTS

Of 522 women included in the study, 177 reported an induced abortion: 41 women (23.2%) had used misoprostol at the first attempt to induce abortion, whereas 79 (44.6%) women had undergone surgical abortion. Occurrence of fever (P=0.06), bleeding (P=0.3), and lower abdominal pain (P=0.32) was not significantly different between the misoprostol and surgical abortion/other methods groups. Severe complications were rare with misoprostol, but more common among women in the surgical abortion/other methods group. Maternal mortality occurred only among women in the surgical abortion/other methods group.

CONCLUSION

Use of misoprostol for induced abortion was associated with fewer complications and no maternal mortality compared with surgical abortion/other methods.

Narratives of women presenting with abortion complications in Southwestern Nigeria: A qualitative study

Unsafe abortion continues to impact negatively on women’s health in countries with restrictive abortion laws. It remains one of the leading causes of maternal mortality and morbidity. Paradoxically, modern contraceptive prevalence remains low and the unmet need for contraception continues to mirror unwanted pregnancy rates in many countries within sub-Saharan Africa. This qualitative study assessed women’s knowledge; their expectation and experiences of the methods employed for abortion; and their health care-seeking decisions following a complicated abortion. Women who presented with abortion complications were purposively sampled from seven health facilities in south-west Nigeria. In-depth interviews were conducted by social scientists with the aid of a semi-structured interview guide. Coding schemes were developed and content analysis was performed with WEFTQDA software. Thirty-one women were interviewed. Misoprostol was used by 16 women; 15 women used other methods. About one-fifth of respondents were aged ≤ 20 years; almost one-third were students. Common reasons for terminating a pregnancy were: “too young/still in school/training”; “has enough number of children”; “last baby too young” and “still breastfeeding”. Women had little knowledge about methods used. Friends, nurses or pharmacists were the commonest sources of information. Awareness about use of misoprostol for abortion among women was high. Women used misoprostol to initiate an abortion and were often disappointed if misoprostol did not complete the abortion process. Given its clandestine manner, women were financially exploited by the abortion providers and only presented to hospitals for post-abortion care as a last resort. Women’s narratives of their abortion experience highlight the difficulties and risks women encounter to safeguard and protect their sexual and reproductive health. To reduce unsafe abortion therefore, urgent and synergized efforts are required to promote prompt access to family planning and post-abortion care services.

Caesarean section--an appraisal of some predictive factors in Lagos Nigeria

Background

Several maternity units in the developing world lack facilities for caesarean section and often have to transfer patients in extremis. This case controlled study aimed to appraise predictive factors for caesarean section.

Methods

One hundred and fifty two consecutive women with singleton pregnancies who had caesarean section were studied. The next parturient with normal delivery served as control. Variables such as age, parity, marital status, booking status, past obstetric history, weight, height, infant birth weight were assessed. Data obtained were analysed using SPSS 16.0 Windows package.

Results

During the study period, there were 641 deliveries with 257 of them by caesarean section (40.1%).

Logistic regression analysis showed that parity, booking status, maternal height; maternal weight, birth weight, previous caesarean section and ante-partum bleeding were significant predictive factors for caesarean section while maternal age was not.

Conclusions

These predictive factors should be considered in antenatal counseling to facilitate acceptance by at risk women and early referral.

The understanding and acceptability of assisted reproductive technology (ART) among infertile women in urban Lagos, Nigeria

This descriptive study was carried out to assess the awareness and acceptability of Assisted Reproductive Technology (ART) among infertile women in Lagos, Nigeria. Self-administered questionnaires on the knowledge of ART in the women were used. After a brief exposé on ART, questions relating to their attitude were answered. A total of 166 women were studied. Only 51.8% had any knowledge of ART and most of these had poor knowledge. A total of 137 women would embrace ART if offered but 29 would not, for reasons such as religion, fear of side-effects, failure and unaffordable costs. There is a paucity of good knowledge of ART. A significant number of the women would consider ART if offered. There is thus a need to create more awareness about the possibilities offered by ART, as well as instituting low cost ART strategies in developing world countries.

Delays in presentation and management of ovarian cancer in Lagos, Nigeria

This study highlights the extent of delays in the presentation and management of ovarian cancer at the Lagos State University Teaching Hospital. A total of 37 histologically confirmed epithelial ovarian cancer cases managed from January 2004 to December 2008 were analysed. The time interval between onset of symptoms and seeking healthcare, was 36.1 ± 40.8 weeks; between seeking healthcare and referral to tertiary hospital, was 22.7 ± 30.4 weeks; and the overall time interval from onset of symptoms to presentation for definitive care, was 52.0 ± 51.8 weeks. Private hospitals (35.1%) and herbal homes (21.6%) were the commonest facilities first visited. A total of 32 (86.5%) of the patients presented in stages III and IV. The overall compliance rate for recommended chemotherapy was 11.1%. Ovarian cancer in Lagos, Nigeria is characterised by patient-related delays in presentation, provider-related delays in referrals and poor compliance with recommended chemotherapy.

Training health workers for magnesium sulfate use reduces case fatality from eclampsia: results from a multicenter trial

OBJECTIVE

To investigate the effectiveness of an intervention aimed at improving the case management of eclampsia.

DESIGN

A multi-center intervention study.

SETTING

Six teaching hospitals in Nigeria.

SAMPLE

Clinical records of cases of eclampsia treated before and 1 year after the intervention.

METHODS

Doctors and midwives in selected hospitals were re-trained to manage eclampsia using magnesium sulfate according to the Pritchard protocol.

MAIN OUTCOME MEASURES

Eclampsia case fatality rates, maternal and perinatal mortality rates before and after the intervention.

RESULTS

A total of 219 cases of eclampsia were managed over a 12-month period. There were seven maternal deaths. The post intervention case fatality rate of 3.2% was significantly less than the pre-intervention rate of 15.1% (p < 0.001). The overall maternal and perinatal mortality ratios and rates respectively in the hospitals declined from 1199.2 to 954 per 100,000 deliveries and 141.5 to 129.8 per 1000 births, respectively (p > 0.05).

CONCLUSION

An intervention to build the capacity of care-providers to use an evidence-based protocol for the treatment of eclampsia in Nigeria was successful in reducing associated case fatality rate. The increased and widespread use of such an intervention in maternity units might contribute to the reduction of maternal mortality in low-income countries.

Ruptured uterus and bowel injury from manual removal of placenta: a case report

BACKGROUND

Retained placenta is a significant cause of maternal mortality and morbidity throughout the developing world. 'Though, intestinal injury may arise as a complication of induced abortion following instrumentation through the genital tract, the involvement of the large bowel in complicated manual removal of placenta is a very rare occurrence

CASE REPORT

We present the case of a 28 year-old Para 3+0, 3 alive woman who had attempted manual removal of placenta in a basic emergency obstetric care facility that resulted in lower uterine segment rupture with evisceration of bowels through the laceration outside the introitus. She subsequently had right hemi- colectomy with ileo-transverse anastomosis and repair of uterine rupture with bilateral tubal ligation.

CONCLUSION

This case highlights the risk of exposing parturients to inexperienced attendants at delivery and emphasises the need for intensification of manpower training to attain the 5th MDG enunciated by the United Nations.

Evaluation of blood reservation and use for caesarean sections in a tertiary maternity unit in south western Nigeria

BACKGROUND

Haemorrhage from obstetric causes is the most common cause of maternal mortality in the developing world. Prevention of mortality from haemorrhage will necessarily involve prompt blood transfusions among other life saving measures. There are however limited stocks of fresh or stored blood in many health care facilities in Sub Saharan Africa. Caesarean section has been identified as a common indication for blood transfusion in obstetrics practice and its performance is often delayed by non availability of blood in our centre. An evaluation of blood reservation and use at caesarean sections in a tertiary maternity unit in Lagos, south western Nigeria should therefore assist in formulating the most rational blood transfusion policies.

METHODS

Case records of 327 patients who had elective and emergency caesarian sections at the Lagos State University Teaching Hospital between 1st October and 31st December 2007 were reviewed. Data pertaining to age, parity, booking status, type and indication for Caesarean section, pre- and post-operative packed cell volume, blood loss at surgery, units of blood reserved in the blood bank, unit(s) of blood transfused and duration of hospital stay was extracted and the data analysed.

RESULTS

There were 1056 deliveries out of which 327 (31%) were by Caesarean section. During the study period, a total of 654 units of blood were reserved in the blood bank and subsequently made available in theatre. Out of this number, only 89 (13.6%) were transfused to 41 patients. Amongst those transfused, twenty-six (54%) were booked and 31 (75.6%) had primary caesarian section. About 81% of those transfused had emergency caesarean section. The most common indication for surgery among those transfused were placenta praevia (9 patients with 21 units of blood) and cephalo-pelvic disproportion (8 patients with 13 units).

CONCLUSION

Even though a large number of units of blood was reserved and made available in the theatre at the time of operation, majority of the patients operated did not need blood transfusion. Provision of a mini- blood bank within the obstetric unit and careful patient categorization will ensure timely availability of blood for surgery without necessarily tying down stock in the central blood bank.

Active management of third stage of labor: evidence versus practice

OBJECTIVE

To determine the correct use of active management of third stage of labor (AMTSL) (using the full complement of existing standard definitions) and compare the outcomes of third stage of labor in women who received AMTSL (according to these definitions) with those who did not.

DESIGN

Observational, cross-sectional survey.

SETTING

Seven tertiary centers in southwest Nigeria.

POPULATION

Women undergoing non-instrumental vaginal deliveries.

METHODS

Prospective direct observations of childbirth procedures. AMTSL was defined according to Cochrane review, ICM/FIGO (International Confederation of Midwives/International Federation of Gynecology and Obstetrics), and WHO (World Health Organization) recommendations. Main outcome measures. Use of AMTSL and its components and outcome of third stage of labor.

RESULTS

There was a high rate of compliance with most of the individual components of AMTSL. The use of AMTSL varied widely with the definition applied and tended to decrease with increasing strictness of the criteria (Cochrane review: 88.9%; ICM/FIGO: 42%; WHO: 1.8%). The frequencies of adverse labor outcomes were generally low (postpartum hemorrhage (PPH): 4.9%; severe PPH: 0.8%; retained placenta: 1.9%; uterine inversion: 0.0%). Frequencies of PPH, postpartum anemia, and mean blood loss among women who received AMTSL according to the Cochrane review definition were significantly lower than for those who did not (p < 0.05). There was no significant difference between any of the outcomes for women who received AMTSL according to the ICM/FIGO definition and those who did not.

CONCLUSIONS

The survey reveals substantial definition-dependent variation in the providers' adherence to recommended AMTSL practices. The clinical implications of the current practice in this population suggest the need for randomized comparison of various AMTSL packages to determine their comparative effectiveness in the prevention of PPH.

Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial

OBJECTIVE

To assess the effect of psychosocial support on labour outcomes.

METHODOLOGY

A randomised control trial conducted at the University College Hospital Ibadan, Nigeria, from November 2006 to 30 March 2007. Women with anticipated vaginal delivery were recruited and randomised at the antenatal clinic. The experimental group had companionship in addition to routine care throughout labour until two hours after delivery, while the controls had only routine care. The primary outcome measure was caesarean section rate. Others included duration of active phase, pain score, time of breast-feeding initiation and description of labour experience. Multivariable analyses were used to adjust for potential confounders. The level of statistical significance was set at 5%.

RESULTS

Of the 632 recruited, 585 were eventually studied: 293 and 292 were in experimental and control groups, respectively. Husbands constituted about two-thirds of the companions. Women in the control group were about five times more likely to deliver by caesarean section (95% confidence interval (CI) 1.98-12.05), had significantly longer duration of active phase (P < 0.001), higher pain scores (P = 0.011) and longer interval between delivery and initiation of breast-feeding (P < 0.001). However, those in experimental group had a more satisfying labour experience (odds ratio 3.3 95% CI 2.15-5.04).

CONCLUSION

Women with companionship had better labour outcomes compared to those without. It is desirable to adopt this practice in our health-care settings as an alternative strategy to provide comparable quality services to would-be mothers in labour.

Pattern of genital tract abnormalities on hysterosalpingography in infertile patients in ikeja, Nigeria

Structural abnormalities of the female genital tract, whether congenital or acquired could result in infertility or reproductive failure. This study retrospectively analysed the structural abnormalities found in patients who had hysterosalpingography in the Lagos State University Teaching Hospital (LASUTH), Ikeja. A descriptive analysis of structural abnormality of the uterine cavity, fallopian tube and the cervical canal in two hundred and fifty patients, who were referred from the gynaecology clinic to the Radiology Department of LASUTH, from January to December 2005, is presented. The commonest abnormality seen was tubal blockage (56.8%) whether unilateral or bilateral. Filling defects (16%) were seen within or outside the uterus, causing irregularity of its wall. These could be due to fibroids, endometrial polyps or fibrous tissue causing adhesions. Cervical canal (19.8%) abnormalities were also noted. Only two cases of congenital anomalies were seen. We found that hysterosalpingography is a relatively cheap and easy mode of diagnosing structural anomalies of the genital tract such as fibroids and tubal pathologies.

Sexual behaviour of in-school adolescents in Ibadan, South-West Nigeria

This study was a crossectional survey conducted among 716 senior secondary school adolescents in Ibadan from March to August 2005. The result of 695 that was analyzed revealed that the mean age of 15 +/- 2.6years. 28.3% of the respondents had previous sexual exposure with higher proportions being male (p = 0.00043). Majorities' first sexual exposure was unplanned. Family settings and educational level do not have significant influence on the previous sexual exposure. The methods of sexual activity were mainly through vagina route while some had also practiced oral and anal sex. Most of those that are sexually exposed had more than one partner. About half of the respondents learn about sex from their friends while others through their parents and media. We conclude that in-school adolescents practiced unsafe sexual activity and they are therefore predisposed to STI/HIV and other reproductive health risks.

Uterine artery ligation for management of uterine fibroids

OBJECTIVE

To determine the efficacy of uterine artery ligation by the vaginal route for the management of symptomatic uterine fibroids. A pilot study had suggested that the procedure was effective.

METHODS

After bilateral uterine artery ligation, ultrasonic measurements of uterine and fibroid volumes were determined at 6 and 12 months in 21 women (age, 31-49 years) with symptomatic fibroids. The severity of symptoms was assessed preoperatively and postoperatively.

RESULTS

Mean uterine and fibroid volumes were significantly reduced at 6 and 12 months. A consistent pattern of decreased duration of menstrual blood flow was recorded. All participants who completed follow-up expressed satisfaction with treatment outcome.

CONCLUSION

The procedure was found to be a safe, inexpensive, and effective therapeutic option for the treatment of symptomatic uterine fibroids.