Geographical accessibility to functional emergency obstetric care facilities in urban Nigeria using closer-to-reality travel time estimates: a population-based spatial analysis

BACKGROUND

Better accessibility for emergency obstetric care facilities can substantially reduce maternal and perinatal deaths. However, pregnant women and girls living in urban settings face additional complex challenges travelling to facilities. We aimed to assess the geographical accessibility of the three nearest functional public and private comprehensive emergency obstetric care facilities in the 15 largest Nigerian cities via a novel approach that uses closer-to-reality travel time estimates than traditional model-based approaches.

METHODS

In this population-based spatial analysis, we mapped city boundaries, verified and geocoded functional comprehensive emergency obstetric care facilities, and mapped the population distribution for girls and women aged 15-49 years (ie, of childbearing age). We used the Google Maps Platform's internal Directions Application Programming Interface to derive driving times to public and private facilities. Median travel time and the percentage of women aged 15-49 years able to reach care were summarised for eight traffic scenarios (peak and non-peak hours on weekdays and weekends) by city and within city under different travel time thresholds (≤15 min, ≤30 min, ≤60 min).

FINDINGS

As of 2022, there were 11·5 million girls and women aged 15-49 years living in the 15 studied cities, and we identified the location and functionality of 2020 comprehensive emergency obstetric care facilities. City-level median travel time to the nearest comprehensive emergency obstetric care facility ranged from 18 min in Maiduguri to 46 min in Kaduna. Median travel time varied by location within a city. The between-ward IQR of median travel time to the nearest public comprehensive emergency obstetric care varied from the narrowest in Maiduguri (10 min) to the widest in Benin City (41 min). Informal settlements and peripheral areas tended to be worse off compared to the inner city. The percentages of girls and women aged 15-49 years within 60 min of their nearest public comprehensive emergency obstetric care ranged from 83% in Aba to 100% in Maiduguri, while the percentage within 30 min ranged from 33% in Aba to over 95% in Ilorin and Maiduguri. During peak traffic times, the median number of public comprehensive emergency obstetric care facilities reachable by women aged 15-49 years under 30 min was zero in eight (53%) of 15 cities.

INTERPRETATION

Better access to comprehensive emergency obstetric care is needed in Nigerian cities and solutions need to be tailored to context. The innovative approach used in this study provides more context-specific, finer, and policy-relevant evidence to support targeted efforts aimed at improving comprehensive emergency obstetric care geographical accessibility in urban Africa.

FUNDING

Google.

Socio-spatial equity analysis of relative wealth index and emergency obstetric care accessibility in urban Nigeria

BACKGROUND

Better geographical accessibility to comprehensive emergency obstetric care (CEmOC) facilities can significantly improve pregnancy outcomes. However, with other factors, such as affordability critical for care access, it is important to explore accessibility across groups. We assessed CEmOC geographical accessibility by wealth status in the 15 most-populated Nigerian cities.

METHODS

We mapped city boundaries, verified and geocoded functional CEmOC facilities, and assembled population distribution for women of childbearing age and Meta's Relative Wealth Index (RWI). We used the Google Maps Platform's internal Directions Application Programming Interface to obtain driving times to public and private facilities. City-level median travel time (MTT) and number of CEmOC facilities reachable within 60 min were summarised for peak and non-peak hours per wealth quintile. The correlation between RWI and MTT to the nearest public CEmOC was calculated.

RESULTS

We show that MTT to the nearest public CEmOC facility is lowest in the wealthiest 20% in all cities, with the largest difference in MTT between the wealthiest 20% and least wealthy 20% seen in Onitsha (26 vs 81 min) and the smallest in Warri (20 vs 30 min). Similarly, the average number of public CEmOC facilities reachable within 60 min varies (11 among the wealthiest 20% and six among the least wealthy in Kano). In five cities, zero facilities are reachable under 60 min for the least wealthy 20%. Those who live in the suburbs particularly have poor accessibility to CEmOC facilities.

CONCLUSIONS

Our findings show that the least wealthy mostly have poor accessibility to care. Interventions addressing CEmOC geographical accessibility targeting poor people are needed to address inequities in urban settings.

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 geospatial database of close-to-reality travel times to obstetric emergency care in 15 Nigerian conurbations

Travel time estimation accounting for on-the-ground realities between the location where a need for emergency obstetric care (EmOC) arises and the health facility capable of providing EmOC is essential for improving pregnancy outcomes. Current understanding of travel time to care is inadequate in many urban areas of Africa, where short distances obscure long travel times and travel times can vary by time of day and road conditions. Here, we describe a database of travel times to comprehensive EmOC facilities in the 15 most populated extended urban areas of Nigeria. The travel times from cells of approximately 0.6 × 0.6 km to facilities were derived from Google Maps Platform's internal Directions Application Programming Interface, which incorporates traffic considerations to provide closer-to-reality travel time estimates. Computations were done to the first, second and third nearest public or private facilities. Travel time for eight traffic scenarios (including peak and non-peak periods) and number of facilities within specific time thresholds were estimated. The database offers a plethora of opportunities for research and planning towards improving EmOC accessibility.

A continuous quality improvement strategy to strengthen screening practices and facilitate the routine use of intravenous iron for treating anaemia in pregnant and postpartum women in Nigeria: a study protocol

BACKGROUND

Pregnancy-related anaemia is a public health challenge across Africa. Over 50% of pregnant women in Africa get diagnosed with this condition, and up to 75% of these are caused by iron deficiency. The condition is a significant contributor to the high maternal deaths across the continent and, in particular, Nigeria, which accounts for about 34% of global maternal deaths. Whereas oral iron is the mainstay treatment for pregnancy-related anaemia in Nigeria, this treatment is not very effective given the slow absorption of the medication, and its gastrointestinal adverse effects which lead to poor compliance by women. Intravenous iron is an alternative therapy which can rapidly replenish iron stores, but fears of anaphylactic reactions, as well as several misconceptions, have inhibited its routine use. Newer and safer intravenous iron formulations, such as ferric carboxymaltose, present an opportunity to overcome some concerns relating to adherence. Routine use of this formulation will, however, require addressing misconceptions and systemic barriers to adoption in the continuum of care of obstetric women from screening to treatment. This study aims to test the options to strengthen routine screening for anaemia during and immediately after pregnancy, as well as evaluate and improve conditions necessary to deliver ferric carboxymaltose to pregnant and postpartum women with moderate to severe anaemia.

METHODS

This study will be conducted in a cluster of six health facilities in Lagos State, Nigeria. The study will employ continuous quality improvement through the Diagnose-Intervene-Verify-Adjust framework and Tanahashi's model for health system evaluation to identify and improve systemic bottlenecks to the adoption and implementation of the intervention. Participatory Action Research will be employed to engage health system actors, health services users, and other stakeholders to facilitate change. Evaluation will be guided by the consolidated framework for implementation research and the normalisation process theory.

DISCUSSION

We expect the study to evolve transferable knowledge on barriers and facilitators to the routine use of intravenous iron that will inform scale-up across Nigeria, as well as the adoption of the intervention and strategies in other countries across Africa.

Effects of a mHealth voice messaging intervention on antenatal care utilisation at primary care level in Lagos, Nigeria: a cluster randomised trial

Background

Nigeria has one of the lowest antenatal care (ANC) utilization rates compared to other low- and middle-income nations. In order to ensure a positive pregnant experience, the World Health Organization recommends at least eight ANC visits during pregnancy. This study intends to examine the impact of a mobile phone-based voice message intervention on ANC use in Lagos, Nigeria.

Methods

In this cluster-randomized experiment, primary healthcare centres were divided into five intervention and five control groups using multistage simple random sampling. The intervention consisted of a weekly voice message transmitted through mobile phone from the time of recruitment in the first trimester until two weeks postpartum. Attending at least eight ANC visits before birth was the primary outcome. STATA v17.0 was used to conduct descriptive and bivariate analyses as well as multivariate linear models to calculate crude risk ratios.

Results

458 women participated. All intervention group women (269 women, or 58.7% of the sample) received the text message. These ladies were mostly married, Christian, had several children, and had completed high school. Women who received the intervention were more likely to attend eight ANC visits.

Conclusion

A voice message-based intervention can boost ANC utilization, according to the conclusion. This contributes to the existing body of information about the influence of mHealth treatments on maternal health outcomes and serves as a useful tool for ensuring that no woman is left behind.

Intravenous versus oral iron for iron deficiency anaemia in pregnant Nigerian women (IVON): study protocol for a randomised hybrid effectiveness-implementation trial

Background

Anaemia in pregnancy is highly prevalent in African countries. High-dose oral iron is the current recommended treatment for pregnancy-related iron deficiency anaemia (IDA) in Nigeria and other African countries. This oral regimen is often poorly tolerated and has several side effects. Parenteral iron preparations are now available for the treatment of IDA in pregnancy but not widely used in Africa.

The IVON trial is investigating the comparative effectiveness and safety of intravenous ferric carboxymaltose versus oral ferrous sulphate standard-of-care for pregnancy-related IDA in Nigeria. We will also measure the implementation outcomes of acceptability, feasibility, fidelity, and cost-effectiveness for intravenous ferric carboxymaltose.

Methods

This is an open-label randomised controlled trial with a hybrid type 1 effectiveness-implementation design, conducted at 10 health facilities in Kano (Northern) and Lagos (Southern) states in Nigeria. A total of 1056 pregnant women at 20–32 weeks’ gestational age with moderate or severe anaemia (Hb < 10g/dl) will be randomised 1:1 into two groups. The interventional treatment is one 1000-mg dose of intravenous ferric carboxymaltose at enrolment; the control treatment is thrice daily oral ferrous sulphate (195 mg elemental iron daily), from enrolment till 6 weeks postpartum.

Primary outcome measures are (1) the prevalence of maternal anaemia at 36 weeks and (2) infant preterm birth (<37 weeks’ gestation) and will be analysed by intention-to-treat. Maternal full blood count and iron panel will be assayed at 4 weeks post-enrolment, 36 weeks’ gestation, delivery, and 6 weeks postpartum. Implementation outcomes of acceptability, feasibility, fidelity, and cost will be assessed with structured questionnaires, key informant interviews, and focus group discussions.

Discussion

The IVON trial could provide both effectiveness and implementation evidence to guide policy for integration and uptake of intravenous iron for treating anaemia in pregnancy in Nigeria and similar resource-limited, high-burden settings. If found effective, further studies exploring different intravenous iron doses are planned.

Trial registration

ISRCTN registry ISRCTN63484804. Registered on 10 December 2020

Clinicaltrials.govNCT04976179. Registered on 26 July 2021

The current protocol version is version 2.1 (080/080/2021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06690-2.

Leveraging big data for improving the estimation of close to reality travel time to obstetric emergency services in urban low- and middle-income settings

Maternal and perinatal mortality remain huge challenges globally, particularly in low- and middle-income countries (LMICs) where >98% of these deaths occur. Emergency obstetric care (EmOC) provided by skilled health personnel is an evidence-based package of interventions effective in reducing these deaths associated with pregnancy and childbirth. Until recently, pregnant women residing in urban areas have been considered to have good access to care, including EmOC. However, emerging evidence shows that due to rapid urbanization, this so called “urban advantage” is shrinking and in some LMIC settings, it is almost non-existent. This poses a complex challenge for structuring an effective health service delivery system, which tend to have poor spatial planning especially in LMIC settings. To optimize access to EmOC and ultimately reduce preventable maternal deaths within the context of urbanization, it is imperative to accurately locate areas and population groups that are geographically marginalized. Underpinning such assessments is accurately estimating travel time to health facilities that provide EmOC. In this perspective, we discuss strengths and weaknesses of approaches commonly used to estimate travel times to EmOC in LMICs, broadly grouped as reported and modeled approaches, while contextualizing our discussion in urban areas. We then introduce the novel OnTIME project, which seeks to address some of the key limitations in these commonly used approaches by leveraging big data. The perspective concludes with a discussion on anticipated outcomes and potential policy applications of the OnTIME project.

Effects of pregnancy on cardiac structure and function in women with sickle cell anemia: a longitudinal comparative study

BACKGROUND

Sickle cell anemia is the commonest hemoglobinopathy in pregnant Nigerian women, and cardiac manifestations are a significant feature of the disease especially in pregnancy. Pregnant women with sickle cell anemia are at high risk of morbidity and mortality and cardiac dysfunction in them increases this risk and may compromise their post-partum health.

OBJECTIVE

To evaluate the cardiac size and function in women with sickle cell anemia (HbSS) during late pregnancy and postpartum.

METHODOLOGY

This was a longitudinal comparative study in which 40 women, consisting of 20 pregnant HBSS and 20 pregnant HBAA women controls, were recruited. Echocardiography was performed in the third trimester of pregnancy and 6 weeks postpartum.

RESULTS

There was a decrease in the mean left atrial diameter (p < .001), left ventricular diameter in diastole (p = .041), and left ventricular mass (p = .004) of HBSS women in the postpartum period compared to their antepartum state. In contrast, there was no significant difference in most cardiac dimensions of pregnant vs postpartum HBAA women. There was no significant change in cardiac function in the pregnant vs postpartum states in both study groups. There were significant differences in cardiac size but not function when comparing HBSS and HBAA women in pregnancy and postpartum.

CONCLUSION

Changes in cardiac size of sickle cell women in pregnancy does not appear to affect cardiac function during pregnancy and in the puerperium, suggesting that the increased size may purely be a response to their chronic anemic state. Studies following women up for longer periods including those with co-morbidities are recommended.

Challenges in access and satisfaction with reproductive, maternal, newborn and child health services in Nigeria during the COVID-19 pandemic: A cross-sectional survey

BACKGROUND

The presence of COVID-19 has led to the disruption of health systems globally, including essential reproductive, maternal, newborn and child health (RMNCH) services. This study aimed to assess the challenges faced by women who used RMNCH services in Nigeria's epicentre, their satisfaction with care received during the COVID-19 pandemic and the factors associated with their satisfaction.

METHODS

This cross-sectional survey was conducted in Lagos, southwest Nigeria among 1,241 women of reproductive age who had just received RMNCH services at one of twenty-two health facilities across the primary, secondary and tertiary tiers of health care. The respondents were selected via multi-stage sampling and face to face exit interviews were conducted by trained interviewers. Client satisfaction was assessed across four sub-scales: health care delivery, health facility, interpersonal aspects of care and access to services. Bivariate and multivariate analyses were used to assess the relationship between personal characteristics and client satisfaction.

RESULTS

About 43.51% of respondents had at least one challenge in accessing RMNCH services since the COVID-19 outbreak. Close to a third (31.91%) could not access service because they could not leave their houses during the lockdown and 18.13% could not access service because there was no transportation. The mean clients' satisfaction score among the respondents was 43.25 (SD: 6.28) out of a possible score of 57. Satisfaction scores for the interpersonal aspects of care were statistically significantly lower in the PHCs and general hospitals compared to teaching hospitals. Being over 30 years of age was significantly associated with an increased clients' satisfaction score (ß = 1.80, 95%CI: 1.10-2.50).

CONCLUSION

The COVID-19 lockdown posed challenges to accessing RMNCH services for a significant proportion of women surveyed. Although overall satisfaction with care was fairly high, there is a need to provide tailored COVID-19 sensitive inter-personal care to clients at all levels of care.

Feasibility and acceptability of early infant screening for sickle cell disease in Lagos, Nigeria-A pilot study

In Nigeria, about 150000 babies are born annually with sickle cell disease (SCD), and this figure has been estimated to increase by 100% by the year 2050 without effective and sustainable control strategies. Despite the high prevalence, newborn screening for SCD which allows for early prophylactic treatment, education of parents/guardians and comprehensive management is not yet available. This study explored a strategy for screening in early infancy during the first and second immunization visits, determined the prevalence, feasibility and acceptability of early infant screening for SCD and the evaluation of the HemoTypeSC diagnostic test as compared to the high-performance liquid chromatography (HPLC) gold standard. A cross-sectional study was conducted in two selected primary health care centres in Somolu local government area (LGA) in Lagos, Nigeria. Two hundred and ninety-one mother-infant pairs who presented for the first or second immunization visit were consecutively enrolled in the study following written informed consent. The haemoglobin genotype of mother-infant pairs was determined using the HemoTypeSC rapid test kit. Confirmation of the infants’ Hb genotype was done with HPLC. Data were analysed with SPSS version 22. Validity and Predictive value of HemotypeSC rapid screening test were also calculated. Infant screening for SCD was acceptable to 86% of mothers presenting to the immunization clinics. The prevalence of SCD among the infant cohort was 0.8%. The infants diagnosed with SCD were immediately enrolled in the paediatric SCD clinic for disease-specific care. The HemoTypeSC test had 100% sensitivity and specificity for sickle cell disease in early infancy compared to HPLC. This study affirms that it is feasible and acceptable for mothers to implement a SCD screening intervention program in early infancy in Lagos State. The study also demonstrates the utility of the HemotypeSC rapid testing for ease and reduced cost of screening infants for SCD.

Good clinical practice advice for the management of pregnant women with suspected or confirmed COVID-19 in Nigeria

The impact on healthcare services in settings with under-resourced health systems, such as Nigeria, is likely to be substantial in the coming months due to the COVID-19 pandemic, and maternity services still need to be prioritized as an essential core health service. The healthcare system should ensure the provision of safe and quality care to women during pregnancy, labor, and childbirth, and at the same time, maternity care providers including obstetricians and midwives must be protected and prioritized to continue providing care to childbearing women and their babies during the pandemic. This practical guideline was developed for the management of pregnant women with suspected or confirmed COVID-19 in Nigeria and other low-resource countries.

Management of covid-19: a practical guideline for maternal and newborn health care providers in Sub-Saharan Africa

COVID-19 is a pandemic that is currently ravaging the world. Infection rate is steadily increasing in Sub-Saharan Africa. Pregnant women and their infants may suffer severe illnesses due to their lower immunity. This guideline prepares and equips clinicians working in the maternal and newborn sections in the sub-region to manage COVID-19 during pregnancy and childbirth.

Towards zero mortality in sickle cell pregnancy: A prospective study comparing haemoglobin SS and AA women in Lagos, Nigeria

INTRODUCTION

Sickle cell disease in pregnancy carries increased risk of maternal and perinatal morbidity and mortality. Past studies on pregnancy complications in sickle cell disease women were limited by relatively small sample sizes, and use of retrospective and hospital discharge data.

STUDY DESIGN

This prospective case-control study compared booked pregnant Haemoglobin (Hb) SS women with AA controls from two tertiary centres in Lagos, in order to precisely identify their complication and mortality rates and identify associated factors. Eligible pregnant HbSS and HbAA women were recruited from antenatal clinics at booking and follow-up visits. Information was collected on a proforma and data was analyzed using IBM SPSS version 20.

RESULTS

We found higher complication rate in HbSS group, commonest complications being vaso-occlusive crisis (RR 1.47, 95% CI 1.22 - 1.78), pregnancy induced hypertension (RR 1.31, 95% CI 1.08 - 1.57), urinary tract infection (RR 1.32, 95% CI 1.12 - 1.57), and intrauterine growth restriction (RR 1.2, 95% CI 1.05 - 1.34). HbSS group had higher systolic and mean arterial blood pressure values in early puerperium compared to HbAA group (p = 0.014 and 0.024 respectively). No maternal death recorded in both group. Incidence of low birth weight <2.5Kg was 38% in HbSS and 4% in HbAA subjects, p = 0.001. However, overall maternal and perinatal outcomes were comparable in both groups (p = 1.000).

CONCLUSION

Although sickle cell disease poses higher obstetric risk in pregnancy, maternal and perinatal outcome can be as good as in the non-sickle cell pregnant women if adequate and prompt individualized care is given to this group of women.

Postpartum Sequelae of the Hypertensive Diseases of Pregnancy: A Pilot Study

Background

Hypertensive disorders are one of the most common medical conditions that may complicate pregnancy. Postpartum blood pressure (BP) pattern is, however, less clear in affected women and decision to discharge them is usually decided arbitrarily.

Materials and Methods

A cohort study conducted at Lagos University Teaching Hospital, Lagos, Nigeria, aimed at determining the proportion of pregnant women with pregnancy-induced hypertension (PIH) and preeclampsia (PE) whose BP remains elevated 6 weeks postdelivery and factors associated with the persistent rise. Fifteen women each with PIH and PE were studied in different phases of pregnancy and followed up until 6 weeks postdelivery. Fifteen normotensive pregnant women served as controls. BP patterns were monitored and fasting lipid levels, serum creatinine, fasting glucose profile (FGP), and FGP/insulin ratio were assayed. Data were analyzed with IBM SPSS version 20.

Results

Proportion of women with PIH or PE who had persistent hypertension at 6 weeks postpartum was 3/29 (10.3%), risk ratio of 1.1. No statistically significant association was found between mean arterial BP at 6 weeks postpartum and age, parity, gestational age at delivery, body mass index, and family history of hypertension. Serum creatinine level showed moderate correlation with persistent hypertension at 6 weeks postpartum (r = 0.441,P = 0.006), with sensitivity of 100% and specificity of 81.8% at cutoff value of 1.2 mg/dL in detecting pregnant women with hypertensive disorders who will likely remain hypertensive at 6 weeks postpartum.

Conclusion

There is a need for long-term follow-up of women with PIH/PE beyond puerperium.

Female genital mutilation/cutting in Africa

Female genital mutilation/cutting (FGM/C) is a traditional practice in which the external female genitalia is partially or totally incised or excised for a non-therapeutic reason, usually without the consent of the individual. FGM/C is common in Africa with varying prevalence in different countries, though the incidence is reducing because it is considered a human rights issue with tremendous advocacy for its elimination by mainly nongovernmental organizations. It is mainly underreported in many countries in Africa especially where it has been declared illegal. FGM/C is often performed by a nonmedical practitioner with the aim of fulfilling religious or cultural rites and sometimes for economic benefits with the resultant acute, intermediate and late complications. It is sometimes performed by medical practitioners when it is speciously believed that its medicalization reduces the complications associated with the practice. The sensitivity of FGM/C is amplified when compared to male circumcision and voluntary alterations of the female external genitalia like piercing and tattooing as similar practices. The magnitude of the physical and psychosocial consequences of FGM/C outweighs the presumed benefits of the procedures highlighting the need for improvement of the multiple preventive measures by all the stakeholders and in all the sectors.

Volume regulatory hormones and plasma volume in pregnant women with sickle cell disorder

Background:

Sickle cell disease (haemoglobin SS (HbSS)) mainly affects those of West African origin and is associated with hypervolaemia. Plasma volume rises by up to 50% in normal pregnancy but was previously found to be paradoxically contracted in late sickle cell pregnancy. The renin–angiotensin–aldosterone system is activated very early in human pregnancy to support the plasma volume expansion. We hypothesised that activation of the renin–angiotensin–aldosterone system would be blunted in pregnant women with sickle cell disease.

Materials and methods:

We measured plasma volume and concentrations of plasma renin, angiotensinogen, aldosterone and other volume-related hormones in a cross-sectional study of pregnant and non-pregnant Nigerian women with HbSS or HbAA.

Results:

Plasma volume was higher in non-pregnant HbSS than HbAA women, but had not risen by 16 weeks, unlike plasma volume in HbAA women. The concentration of plasma renin also rose significantly less by 16 weeks in HbSS; angiotensinogen and aldosterone concentrations increased.

Conclusions:

The lower plasma renin concentration at 16 weeks with HbSS could be either primary or secondary to vasoconstriction related to inadequate vasodilator activity. The contracted plasma volume might then stimulate aldosterone synthesis by non-angiotensin II dependent stimulation. Studies of vasodilators such as nitric oxide, vasodilator eicosanoids or the PlGF/VEGF/sFlT-1 axis in pregnant HbSS and HbAA women will test this hypothesis.

Utility of a single mid-trimester measurement of plasminogen activator Type 1 and fibronectin to predict preeclampsia in pregnancy

BACKGROUND

Preeclampsia (PE) is the second most common cause of maternal death after obstetric hemorrhage in Africa, a resource-limited region. This study was designed to examine the potential usefulness of a single screening plasma plasminogen activator inhibitor-1 (PAI-1) and fibronectin (FN) level for the prediction of PE in pregnant women.

MATERIALS AND METHODS

In a cohort of 180 pregnant women who were normotensive at baseline, venous blood samples were obtained before 20 weeks of gestation for the assay of plasma levels of PAI-1 and FN levels measured by enzyme-linked immunoassay technique. Twenty nonpregnant normotensive women were also evaluated as a control group. Outcomes of gestation were evaluated and correlated with the plasma levels of PAI and FN measured at mid-trimester. Mean plasma values of PAI-1 and FN were also compared between the different outcome groups.

RESULTS

Plasma PAI-1 level was significantly higher in the pregnant women (8.68 ± 0.56 ng/ml) than in nonpregnant controls (5.55 ± 0.32 ng/ml) (P = 0.01). However, plasma FN did not show any significant difference in pregnant women (2.60 ± 0.37 μg/ml) and nonpregnant controls (2.60 ± 0.23 μg/ml) (P = 0.9). Mid-trimester mean plasma PAI-1 level measured in women who developed PE (7.08 ± 5.49 ng/ml, n = 12) and gestational hypertension (GH) (9.78 ± 6.2 ng/ml, n = 13) was not significantly different in comparison to normotensive pregnant women (8.78 ± 5.63 ng/ml, n = 153) (P = 0.75). Likewise, the mean FN level in women who developed PE was also not significantly different from nonpreeclamptics; however, the FN level in the pregnant women who developed GH was significantly different from women who remained normotensive throughout pregnancy (P = 0.02).

CONCLUSION

Single mid-trimester assessment of PAI-1 and FN levels in maternal plasma was not found to be useful in predicting PE as an outcome of pregnancy in the study population.

Bacterial Vaginosis and Pregnancy Outcome in Lagos, Nigeria

Background.  Bacterial vaginosis (BV) is a complex clinical syndrome characterized by alterations in the normal vaginal flora and a malodorous discharge when symptomatic. In pregnancy, BV has been associated with adverse outcomes such as miscarriage, premature rupture of membranes, preterm birth, and low birth weight. This study was conducted to determine the prevalence and associations of BV and pregnancy outcomes among pregnant women in Lagos University Teaching Hospital (LUTH). Methods.  We conducted a prospective observational study with high vaginal swabs obtained from consecutive newly registered antenatal women between 14 and 36 weeks gestation. The women were monitored until delivery, and their pregnancy outcome and demographic data were obtained using an interviewer-administered questionnaire. Results.  Bacterial vaginosis was diagnosed by Nugent score in 64 of 246 women, giving a prevalence rate of 26%. Bacterial vaginosis was significantly associated with preterm delivery (risk ratio [RR], 2.68; 95% confidence interval [CI], 1.44-4.98), low birth weight (RR, 3.20; 95% CI, 1.29-7.94), and premature rupture of membranes (RR, 6.75; 95% CI, 3.11-14.67). The association between BV and miscarriage (<28 weeks gestation) and neonatal admission for various morbidities was not statistically significant. Conclusions.  The prevalence rate of BV among pregnant women in LUTH is high and is significantly associated with adverse pregnancy outcome. Routine screening and treatment of women preconceptually may enable interventions to prevent these adverse outcomes.

Intramuscular versus intravenous anti-D for preventing Rhesus alloimmunization during pregnancy

BACKGROUND

Antibodies to the red cell Rhesus D (RhD) antigen can be produced during pregnancy in a RhD-negative mother carrying a RhD-positive fetus, in particular following feto-maternal haemorrhage at birth or following any procedure that may cause feto-maternal haemorrhage. While the first baby is usually not harmed, these antibodies may cause haemolytic disease of the fetus/newborn (HDFN) in subsequent RhD-positive babies. RhD incompatibility is a major cause of HDFN.To reduce the risk of HDFN, anti-D is given to RhD-negative mothers at 28 or 30 weeks of pregnancy and within 72 hours of potential maternal exposure to fetal red cells. Anit-D is currently available in both intramuscular (IM) and intravenous (IV) preparations.

OBJECTIVES

To compare the efficacy and effectiveness of IM versus IV anti-D IgG in preventing RhD alloimmunization in RhD-negative pregnant women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2012).

SELECTION CRITERIA

Randomized controlled trials, quasi-randomized trials and cluster-randomized trials comparing IM and IV anti-D for preventing RhD alloimmunization in RhD-negative pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors extracted data. Data were checked for consistency by both authors.

MAIN RESULTS

Two studies involving 447 (with sample sizes 14 and 432) RhD negative women were included. The studies compared IM and IV administration of anti-D prophylaxis. In both studies the women received a 1500 IU (300 microgram) dose of Rhophylac during week 28 of gestation. There was no incidence of RhD alloimmunization in either of the studies, as the sample size was insufficient for meaningful comparison of this uncommon outcome. One of the studies found that the mean anti-D IgG concentrations after IV and IM administration differed up to seven days (36.1 (2.6) ng/mL IV; 19.8 (8.7) ng/mL IM on day seven). However, from two to three weeks post-administration, the concentrations were similar for both routes of administration. None of the women involved in the studies developed antibodies against the RhD antigen.

AUTHORS' CONCLUSIONS

It appears that IM and IV administration of anti-D are equally effective. The number of included studies and the number of participants are not enough to assess whether there are any differences. Anti-D can be administered by IM or IV injection. The choice of IM or IV route of administration will depend on the available preparations, the dose to be administered and also on the patients' preferences. This review found insufficient information upon which to guide practice due to the limited number of included studies, small sample sizes and methodological limitations.

Regional versus general anaesthesia for caesarean section

BACKGROUND

Regional anaesthesia (RA) and general anaesthesia (GA) are commonly used for caesarean section (CS) and both have advantages and disadvantages. It is important to clarify what type of anaesthesia is more efficacious.

OBJECTIVES

To compare the effects of RA with those of GA on the outcomes of CS.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011). We updated the search on 20 August 2012 and added the results to the awaiting classification section of the review.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials evaluating the use of RA and GA in women who had CS for any indication. Cluster-randomised trials and trials using a cross-over design are not included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy.

MAIN RESULTS

Twenty-two out of 29 included studies (1793 women) contributed data to this review.The included studies did not report some our primary outcomes: maternal death, incidence of maternal postoperative wound infection, maternal postoperative other infection such as endometritis and urinary tract infection, neonatal death.Compared to women who had GA, women who had either epidural anaesthesia or spinal anaesthesia were found to have a significantly lower difference between pre and postoperative haematocrit. For epidural, the mean difference (MD) was 1.70% and 95% confidence interval (CI) 0.47 to 2.93 (one trial, 231 women) and for spinal anaesthesia, the MD was 3.10% and 95% CI 1.73 to 4.47 (one trial, 209 women). Compared with GA, women having either an epidural anaesthesia or spinal anaesthesia had a lower estimated maternal blood loss (epidural versus GA: standardised mean difference (SMD) -0.32 mL; 95% CI -0.56 to -0.07; two trials, 256 women; spinal versus GA anaesthesia: SMD -0.59 mL; 95% CI -0.83 to 0.35; two trials, 279 women). There was evidence of a significant difference in terms of satisfaction with anaesthetic technique -  compared with the epidural or spinal group, more women in the GA group stated they would use the same technique again if they needed CS for a subsequent pregnancy (epidural versus GA: risk ratio (RR) 0.80; 95% CI 0.65 to 0.98; one trial, 223 women; spinal versus GA anaesthesia: RR 0.80; 95% CI 0.65 to 0.99; one trial, 221 women).No significant difference was seen in terms of neonatal Apgar scores of six or less and of four or less at five minutes and the need for neonatal resuscitation with oxygen.

AUTHORS' CONCLUSIONS

There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.

Mannitol and other osmotic diuretics as adjuncts for treating cerebral malaria

BACKGROUND

Cerebral oedema occurs with cerebral malaria, and some clinicians think osmotic diuretics, such as mannitol or urea, may improve outcomes.

OBJECTIVES

To compare mannitol or urea to placebo or no diuretic for treating children or adults with cerebral malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (Issue 4, 2010), CENTRAL (The Cochrane Library Issue 12, 2010), MEDLINE (1966 to November 2010), EMBASE (1974 to November 2010), LILACS (1982 to November 2010), and the reference lists of articles. We contacted relevant organizations and researchers.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials comparing mannitol or urea to placebo or no treatment in children and adults with cerebral malaria. Primary outcomes were death, life-threatenining sequelae and major neurological sequelae at six months.

DATA COLLECTION AND ANALYSIS

Two authors applied the inclusion criteria, assessed risk of bias, and extracted data independently.

MAIN RESULTS

One trial met the inclusion criteria, comparing mannitol 20% to saline placebo in 156 Ugandan children. Allocation was concealed. No difference in mortality, time to regain consciousness, or neurological sequelae were detected.

AUTHORS' CONCLUSIONS

There are insufficient data to know what the effects of osmotic diuretics are in children with cerebral malaria. Larger, multicentre trials are needed.

Adenosine deaminase activity in subjects with normal pregnancy, pregnancy induced hypertension and pre-eclampsia

BACKGROUND

Both pregnancy and adenosine deaminase (ADA) are associated with depressed cellular mediated immunity. There is little information on ADA activity in pregnant Africans.

OBJECTIVE

To determine the serum levels of adenosine deaminase (ADA) in normal pregnancy and pregnancy complicated by hypertension in Nigerian women.

METHODS

One hundred and twenty-five pregnant women comprising 35 normal non-pregnant women, 35 normal pregnant women, 35 pregnant women with pregnancy induced hypertension and 20 patients with pre-eclampsia were recruited for the study. Serum adenosine deaminase enzyme (ADA) activity was measured by the Giusti and Galanti spectrophotometric method in all study subjects.

RESULTS

The mean serum ADA level in the non-pregnant women was higher than that in the normal pregnant women (23.21 +/- 6.3 v 14.69 +/- 3.2, p<0.001). Amongst the pregnant women, mean serum ADA in the hypertensive and pre-eclamptic women was significantly higher than that in the normal pregnant group (p<0.001).

CONCLUSION

These findings indicate a probable decrease in cellular immunity in normal pregnancy and an enhanced cell mediated immunity in pre-eclampsia.

Fasting plasma glucose levels in normal pregnant Nigerians

A study was undertaken to determine a reference value for fasting plasma glucose in a group of apparently normal pregnant Nigerian women. Three hundred and twenty women were tested; 260 pregnant and 60 non-pregnant. There were 60, 100 and 100 subjects in the first, second and third trimesters, respectively. Fasting plasma glucose was measured in each of the women using the glucose oxidase method. The mean fasting plasma glucose level was 4.64 +/- 0.79 mmol/l in the control group and 3.72 +/- 0.58, 3.78 +/- 0.81 and 3.81 +/- 0.85 mmol/l in the first, second and third trimesters of pregnancy, respectively. Mean fasting plasma glucose+2 standard deviations (SD) of all the pregnant women was 5.3 mmol/l, which is much lower than the World Health Organisation value for the diagnosis of diabetes mellitus.

Plasma total and ultrafiltrable calcium in normal pregnancy, hypertension in pregnancy and pre-eclampsia

OBJECTIVE

To measure the ultrafiltrable and total plasma calcium in normal pregnancy and pregnancies complicated with hypertension and pre-eclampsia.

PATIENTS AND METHODS

Total and ultrafiltrable calcium concentrations were measured in maternal plasma from non-pregnant (35), normal pregnant (35), Pregnancy induced hypertension (35) and pre-eclamptic (20) women. Plasma total calcium level was measured by the o'cresolphthalein method. Ultrafiltrate of plasma was obtained using the Amicon MPS-1 micro-partition device.

RESULTS

There was no significant difference in the plasma total calcium level between the non- pregnant group and the pregnant group (normal, hypertensive and pre-eclamptic). However there was a significant reduction in the ultrafiltrable (protein free and complexed) calcium level in the pregnant group compared to the non-pregnant group (1.15mmol/L +/- 0.23 Vs 1.25mmol/L +/- 0.13) p<0.05.

CONCLUSION

Measurement of the ultrafiltrable calcium in addition to total calcium assay may be more useful in assessing calcium status in normal and complicated pregnancies.

Urgency of surgery and presence of maternal disease influence the choice of anaesthesia for Caesarean section at LUTH

AIMS AND OBJECTIVES

Worldwide, Caesarean sections are commonly done under regional anaesthesia which offers numerous advantages over general anesthesia. However there are still indications for the use of general anaesthesia in obstetric practice. This includes emergent Caesarean sections. This study sought to determine the factors that inform the decision on the choice of anaesthesia for Caesarean section in a tertiary institution in Nigeria.

PATIENTS AND METHODS

All patients scheduled for elective and emergency caesarean sections between January and December 2002 were prospectively studied. Study variables included age of mother, gestational age and parity. Urgency of surgery, indication for surgery, maternal pre-existing disease and the choice of anaesthetic technique were documented. Neonatal weight was recorded and outcome was assessed by Apgar score at 1 and 5 minutes, the presence of respiratory difficulties and the need for admission into the Neonatal unit.

RESULTS

One hundred and ninety-six patients were studied. Elective surgery was performed for 17.3%, while 47.4% and 28.6% had urgent and emergency Caesarean sections respectively. Urgency of surgery was not documented in 6.7% of cases. Previous caesarean section was the commonest indication for elective procedures (47%), foetal distress for emergency (62.5%) and previous caesarean section in labour for urgent procedures (30.1%). General anaesthesia was employed in 33.2% of patients while regional anaesthesia was used in 66.8%. Fifty per cent of emergency cases had general anaesthesia. Regional anaesthesia was used in 72% of urgent and 85.3% of elective procedures. The commonest regional technique was spinal anaesthesia (60.7%). Nineteen per cent of our patients had a co-existing medical problem, and 73% of these received a spinal anaesthetic. More neonates delivered under general anaesthesia had respiratory difficulties at birth (p=0.002) and more were admitted to the Neonatal unit (p=0.031).

CONCLUSION

The choice of anaesthesia depends on the urgency of surgery and the medical condition of the mother. General anaesthesia was more likely to be administered for bleeding emergencies and foetal distress. Spinal anaesthesia was preferred for elective and urgent cases or when maternal disease existed.

Regional versus general anaesthesia for caesarean section

BACKGROUND

Regional and general anaesthesia (GA) are commonly used for caesarean section (CS) and both have advantages and disadvantages. It is important to clarify what type of anaesthesia is more efficacious.

OBJECTIVES

To compare the effects of regional anaesthesia (RA) with those of GA on the outcomes of CS.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 1), MEDLINE (1966 to December 2005), and EMBASE (1980 to December 2005).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials evaluating the use of RA and GA in women who had CS for any indication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion, data extraction and trial quality.

MAIN RESULTS

Sixteen studies (1586 women) were included in this review. Women who had either epidural anaesthesia or spinal anaesthesia were found to have a significantly lower difference between pre and postoperative haematocrit (weighted mean difference (WMD) 1.70, 95% confidence interval (CI) 0.47 to 2.93, one trial, 231 women) and (WMD 3.10, 95% CI 1.73 to 4.47, one trial, 209 women). Compared to GA, women having either an epidural anaesthesia or spinal had a lower estimated maternal blood loss (WMD -126.98 millilitres, 95% CI -225.06 to -28.90, two trials, 256 women) and (WMD -84.79 millilitres, 95% CI -126.96 to -42.63, two trials, 279 women). More women preferred to have GA for subsequent procedures when compared with epidural (odds ratio (OR) 0.56, 95% CI 0.32 to 0.96, one trial, 223 women) or spinal (OR 0.44, 95% CI 0.24 to 0.81, 221 women). The incidence of nausea was also less for this group of women compared with epidural (OR 3.17, 95% CI 1.64 to 6.14, three trials, 286 women) or spinal (OR 23.22, 95% CI 8.69 to 62.03, 209 women). No significant difference was seen in terms of neonatal Apgar scores of six or less and of four or less at one and five minutes and need for neonatal resuscitation with oxygen.

AUTHORS' CONCLUSIONS

There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.

Accreditation of undergraduate medical training programs: practices in nine developing countries as compared with the United States

CONTEXT AND OBJECTIVES

Undergraduate medical training program accreditation is practiced in many countries, but information from developing countries is sparse. We compared medical training program accreditation systems in nine developing countries, and compared these with accreditation practices in the United States of America (USA).

METHODS

Medical program accreditation practices in nine developing countries were systematically analyzed using all available published documents. Findings were compared to USA accreditation practices.

FINDINGS

Accreditation systems with explicitly defined criteria, standards and procedures exist in all nine countries studied: Argentina, India, Kenya, Malaysia, Mongolia, Nigeria, Pakistan, Philippines and South Africa. Introduction of accreditation processes is relatively recent, starting in 1957 in India to 2001 in Malaysia. Accrediting agencies were set up in these countries predominantly by their respective governments as a result of legislation and acts of Parliament, involving Ministries of Education and Health. As in the USA, accreditation: (1) serves as a quality assurance mechanism promoting professional and public confidence in the quality of medical education, (2) assists medical schools in attaining desired standards, and (3) ensures that graduates' performance complies with national norms. All nine countries follow similar accreditation procedures. Where mandatory accreditation is practiced, non-compliant institutions may be placed on probation, student enrollment suspended or accreditation withdrawn.

CONCLUSION

Accreditation systems in several developing countries are similar to those in the developed world. Data suggest the trend towards instituting quality assurance mechanisms in medical education is spreading to some developing countries, although generalization to other areas of the world is difficult to ascertain.

Spontaneous heterotropic pregnancy in sickle cell disease with survival of the abdominal pregnancy

A case is presented of a spontaneously conceived heterotopic pregnancy in a 38-year-old Haemoglobin SS woman, with intrauterine foetal demise and survival of the extra-uterine pregnancy, which was an abdominal pregnancy. The diagnosis was not made until delivery. This report should create the awareness of the possibility of abdominal or heterotopic pregnancy in spontaneous cycles, particularly in patients with recurrent severe anaemia in pregnancy, whether or not they have haemoglobinopathies.

Intravaginal misoprostol versus Foley catheter for cervical ripening and induction of labor

OBJECTIVE

To compare the efficacy and safety of 100 microg of intravaginal misoprostol with intracervical Foley catheter for cervical ripening and induction of labor.

METHOD

One hundred women being induced in the Lagos University Teaching Hospital, Nigeria, were randomized to receive a single 100 microg dose of misoprostol intravaginally or intracervical insertion of Foley catheter. Data analyses were by the Student's t-test and chi-square test.

RESULT

Misoprostol was more effective in terms of induction to delivery interval (11.84+/-5.43 versus 20.03+/-4.68 h, P<0.05), change in Bishop score, and number delivered within 24 h, in patients with a one-time successful induction. Uterine hyperactivity and rupture were more frequent in the misoprostol group.

CONCLUSION

A single 100 microg dose of intravaginal misoprostol is more efficacious than intracervical insertion of Foley catheter for cervical ripening and induction of labor. Further studies using lower doses are needed to determine the safest dose.

Intramuscular arteether for treating severe malaria

BACKGROUND

Quinine and artemisinin drugs are used in severe malaria, but quinine resistance is increasing. Arteether is a recently developed artemisinin derivative that is oil soluble, has a long elimination half life, and is more stable than other derivatives.

OBJECTIVES

To compare intramuscular arteether with other antimalarial drugs to treat severe malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (August 2004), CENTRAL (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to August 2004), EMBASE (1980 to August 2004), U.S. National Library of Medicine (NLM) Gateway (1953 to 1965), Web Science Citation (1981 to August 2004), LILACS (August 2004), Google search engine (August 2004), conference proceedings, and reference lists. We also contacted researchers, organizations, and pharmaceutical companies to help identify trials.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials of intramuscular arteether in adults and children with severe malaria.

DATA COLLECTION AND ANALYSIS

We independently assessed the methodological quality of the trials and extracted data, and analysed data using Review Manager 4.2.

MAIN RESULTS

Two small trials (n = 194) met the inclusion criteria. Both trials compared arteether with quinine in children with cerebral malaria and reported on similar outcomes. There was no statistically significant difference in the number of deaths (relative risk 0.75, 95% confidence interval 0.43 to 1.30; n = 194, 2 trials), neurological complications (relative risk 1.18, 95% confidence interval 0.31 to 4.46; n = 58, 1 trial), or other outcomes including time to regain consciousness, parasite clearance time, and fever clearance time. The meta-analyses lack statistical power to detect important differences.

REVIEWERS' CONCLUSIONS

More trials with a larger number of participants are needed before a firm conclusion about the efficacy and safety of arteether can be reached.

Mannitol and other osmotic diuretics as adjuncts for treating cerebral malaria

BACKGROUND

The main treatment for cerebral malaria is parenteral antimalarials. Mannitol and urea are used as adjunct therapy for cerebral malaria, but the World Health Organization does not recommend them.

OBJECTIVES

To compare mannitol or urea to placebo or no treatment for treating children and adults with cerebral malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (June 2004), CENTRAL (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to June 2004), EMBASE (1974 to June 2004), LILACS (1982 to June 2004), and reference lists of articles. We contacted relevant organizations and researchers.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing mannitol or urea to placebo or no treatment in children and adults with cerebral malaria.

DATA COLLECTION AND ANALYSIS

No trials met the inclusion criteria.

MAIN RESULTS

No trials met the inclusion criteria.

REVIEWERS' CONCLUSIONS

We identified no randomized or quasi-randomized controlled trials to support or refute the use of mannitol or urea as adjuncts for treating cerebral malaria in clinical practice. This is likely to require a multicentre trial.

Spinal and general anaesthesia for emergency caesarean section: effects on neonatal Apgar score and maternal haematocrit

This is a prospective comparative study to determine the effect of the type of anaesthesia used for emergency Caesarean section on neonatal and maternal outcome. The patients were recruited into the study after being given either general or spinal anaesthesia. Neonatal outcome was assessed using Apgar scores and need for respiratory assistance at birth. Maternal outcome was assessed using the difference between pre- and post-operative packed cell volumes (PCV), need for blood transfusion and estimated blood loss. The groups were matched for pre-existing risk factors. Apgar scores at 1 and 5 minutes were found to be significantly lower for the general anaesthesia group (GA) than the spinal anaesthesia group (SA) and need for respiratory assistance was greater for the GA group. Difference between pre- and post-operative PCV and need for blood transfusion were also significantly greater in the GA group. This study confirms that the current practice of spinal anaesthesia for Caesarean section in the Lagos University Teaching Hospital is a good one, but further studies need to be done to assess other outcome variables.