Outcomes and quality of care for women and their babies after caesarean section in Nigeria

OBJECTIVE

To describe the outcomes and quality of care for women and their babies after caesarean section (CS) in Nigerian referral-level hospitals.

DESIGN

Secondary analysis of a nationwide cross-sectional study.

SETTING

Fifty-four referral-level hospitals.

POPULATION

All women giving birth in the participating facilities between 1 September 2019 and 31 August 2020.

METHODS

Data for the women were extracted, including sociodemographic data, clinical information, mode of birth, and maternal and perinatal outcomes. A conceptual hierarchical framework was employed to explore the sociodemographic and clinical factors associated with maternal and perinatal death in women who had an emergency CS.

MAIN OUTCOME MEASURES

Overall CS rate, outcomes for women who had CS, and factors associated with maternal and perinatal mortality.

RESULTS

The overall CS rate was 33.3% (22 838/68 640). The majority of CS deliveries were emergency cases (62.8%) and 8.1% of CS deliveries had complications after delivery, which were more common after an emergency CS. There were 179 (0.8%) maternal deaths in women who had a CS and 29.6% resulted from complications of hypertensive disorders of pregnancy. The overall maternal mortality rate in women who delivered by CS was 778 per 100 000 live births, whereas the perinatal mortality at birth was 51 per 1000 live births. Factors associated with maternal mortality in women who had an emergency CS were being <20 or >35 years of age, having a lower level of education and being referred from another facility or informal setting.

CONCLUSIONS

One-third of births were delivered via CS (mostly emergency), with almost one in ten women experiencing a complication after a CS. To improve outcomes, hospitals should invest in care and remove obstacles to accessible quality CS services.

Antibody response to Covid-19 vaccine (AstraZeneca) amongst Healthcare Workers in a Tertiary Hospital in Nigeria

BACKGROUND

With no known cure, accelerated development of vaccines became pertinent to contain the COVID-19 pandemic.

OBJECTIVES

To assess the IgG antibody response to the viral spike protein and determinants of developing IgG antibodies after vaccination with two doses of the AstraZeneca vaccine.

METHODS

This was a prospective cohort study amongst healthcare workers. Serum samples were obtained before vaccination and at 4 and 12 weeks after the first and second doses of the vaccine respectively. Qualitatively testing for the presence of IgG antibodies to the viral spike protein was conducted using the Vidas SARS-CoV-2 IgG and IgM analyser while IgG antibodies were quantitatively assessed by antibody titre estimation using a stepwise two-fold serial dilution method.

RESULTS

A total of 155 subjects between the ages of 25 to 64 years were studied. 85 (54.8%) had positive anti-spike IgG antibodies before vaccination. Out of the remaining 70 subjects, 87.3% and subsequently 96.2% developed IgG antibodies to the viral spike protein 4 and 8 weeks after the first and second doses of the vaccine respectively. The AstraZeneca vaccine was found to stimulate antibody response more than natural infection. Prior positive IgG antibodies from natural infection was found to boost antibody response to vaccination. The antibody titre levels rose with vaccination but waned overtime after the second dose of the vaccine.

CONCLUSION

The AstraZeneca COVID-19 vaccine elicits an immunogenic IgG antibody response that is augmented by prior infection but however declines a few weeks after the second dose of the vaccine.

CONTEXTE

En l'absence de remède connu, le développement accéléré de vaccins est devenu pertinent pour contenir la pandémie de COVID-19.

OBJECTIFS

Évaluer la réponse des anticorps IgG à la protéine de pointe virale après vaccination avec deux doses du vaccin AstraZeneca.

MÉTHODES

Il s'agissait d'une étude de cohorte prospective parmi les travailleurs de la santé. Des échantillons de sérum ont été obtenus avant la vaccination et à 4 et 12 semaines après la premier et la deuxième doses du vaccin respectivement. Des tests qualitatifs pour la présence d'anticorps IgG dirigés contre la protéine de pointe virale ont été effectués à l'aide de l'analyseur Vidas SARS-CoV-2 IgG et IgM, tandis que les anticorps IgG ont été évalués quantitativement par estimation du titre d'anticorps à l'aide d'une méthode de dilution en série en deux étapes.

RÉSULTATS

Au total, 155 sujets âgés de 25 à 64 ans ont été étudiés. 85 (54,8 %) avaient des anticorps IgG anti-pic positifs avant la vaccination. Sur les 70 sujets restants, 87,3 % puis 96,2 % ont développé des anticorps IgG contre la protéine de pointe virale 4 et 8 semaines après la première et la deuxième doses du vaccin respectivement. Le vaccin AstraZeneca s'est avéré stimuler la réponse anticorps plus que l'infection naturelle. Des anticorps IgG antérieurement positifs d’une infection naturelle ont été trouvés pour stimuler la réponse des anticorps à la vaccination. Les niveaux de titre d'anticorps ont augmenté avec la vaccination mais ont cependant diminué avec le temps après la deuxième dose du vaccin.

CONCLUSIONS

Le vaccinAstraZeneca COVID-19 suscite une réponse immunogène en anticorps IgG qui est augmentée par une infection antérieure mais qui décline cependant quelques semaines après la deuxième dose du vaccin.

Mots clés

COVID-19, Travailleurs de la santé, Vaccination, vaccin AstraZeneca, Immunogène, Anticorps, réponse d'anticorps, Titre d'anticorps.

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.).

Comparative outcome of overhead and total body phototherapy for treatment of severe neonatal jaundice in Nigeria

Background: In Nigeria, neonatal jaundice is commonly treated by overhead phototherapy with neonates lying supine, often with effective exposure of less than one half of the body surface. Total body exposure in phototherapy has been in use for less than 2 years in Nigeria, but is available in only five neonatal centres.Aim: To compare the effectiveness of total body exposure (TBPE) with the conventional partial exposure (COPT) for treatment of hyperbilirubinaemia.Methods: Eleven datasets from 10 neonatal units across Nigeria were retrieved. They included neonates with severe hyperbilirubinaemia treated with TBPE using the Firefly® device (MTTS Asia) as a test group. The remainder of the patients, the controls, were treated with COPT. Any requirement for exchange blood transfusion (EBT) in either group was documented. Total serum bilirubin (TSB) >213.8 μmol/L (12.5 mg/dL) was treated as severe hyperbilirubinaemia. The efficiency of the intervention was determined according to the time taken for a severe case to be downgraded to mild at ≤213.8 μmol/L.Results: A total of 486 patients were studied, 343 controls and 143 cases. Mean (SD) postnatal age was 6 days (0.7) for cases and 5 (0.9) for controls, for gestational age (GA) in completed weeks was 36 (0.5) for cases and 37 (0.7) for controls and for birthweight was 2.7 kg (0.25) for cases and 2.7 (0.22) for controls. Mean (SD) pre-intervention TSB was 299.3 (35.7) μmol/L for cases and 327.3 (13.9) for controls. Severity downgrade day was Day 2 (0.4) for cases and Day 5 (1.1) for controls. Overall relative EBT rate was 6% for cases and 55% for controls (p= 0.0001), and early preterm relative EBT rate was 0% for cases and 68% for controls (p < 0.01).Conclusion: TBPE was quicker and safer for reduction of hyperbilirubinaemia and patients rarely required EBT. TBPE is recommended for rapid reduction of serum bilirubin levels and the reduction of treatment costs, morbidity and mortality in low- and middle-income countries.Abbreviations: EBT, exchange blood transfusion; TBPE, total body exposure technique; COPT, conventional partial exposure; TSB, total serum bilirubin; SB, serum bilirubin; NNJ, neonatal jaundice; SCNU, special care neonatal unit; LMIC, low- and middle-income countries; HIC, high-income countries; LED, light-emitting diode.

A new low-cost commercial bubble CPAP (bCPAP) machine compared with a traditional bCPAP device in Nigeria

Background: The bubble continuous positive airway pressure (bCPAP) technique is widely applied in neonatal respiratory support. Commercial bCPAP brands are expensive in Nigeria and this has driven Nigerian paediatricians to use potentially risky improvised devices (IbCPAP). Aim: This study aimed to design, produce and trial an appropriate low-cost bCPAP machine which is functionally effective and safe. Methods: Questionnaires were distributed to assess the need for a new bCPAP design for use in Nigeria, leading to the development of a new system (politeCPAP) which was functionally and clinically validated in three Nigerian hospitals. Six months of clinical data on the new device of sufficient comparative quality were generated from one of the hospitals and compared with control data on the IbCPAP. The hospitals (n = 3) submitted data on 71 patients on IbCPAP or politeCPAP; 14 were disqualified on the basis of the elimination criteria. The infants were classified into two birthweight categories: <1000 g (extremely low birthweight, ELBW, n = 15) and 1000 g (n = 42). Results: Six ELBW neonates on politeCPAP survived; there were no ELBW survivors in the IbCPAP group (n = 9). The IbCPAP device delivered an average 90% O2-gas ratio (FiO2) whereas the politeCPAP required only 47%. Many heavier neonates in the IbCPAP group survived (23 of 26); however, supplementary warming was required for all of them whereas none of the politeCPAP infants required warming. The politeCPAP costs around US$2000 whereas standard commercial CPAP brands in Nigeria range from US$5000 to US$18,000. High oxygen requirement and iatrogenic hypothermia were serious adverse features of IbCPAP. Conclusions: The study has narrowed the gap between relatively low-cost, risky devices (e.g. IbCPAP) and high-cost commercial machines. The politeCPAP is a feasible alternative to the IbCPAP in cost-constrained settings. Abbreviations: bCPAP: bubble continuous positive airway pressure; CPAP: continuous positive airway pressure; ELBW: extremely low birthweight; FiO₂: ratio of oxygen content in gas flow (%); IbCPAP: improvised bubble continuous positive airway pressure device; LBW: low birthweight; NNU: neonatal unit; PEEP: positive end expiratory pressure; politeCPAP: the newly developed commercial bCPAP machine; RDS: respiratory distress syndrome; SpO₂, oxygen saturation level (%).

Neonatal outcomes associated with maternal recto-vaginal colonization with extended-spectrum β-lactamase producing Enterobacteriaceae in Nigeria: a prospective, cross-sectional study

OBJECTIVES

The objective of this study was to assess the prevalence of maternal recto-vaginal extended-spectrum β-lactamase producing Enterobacteriacea (ESBL-E) colonization, identify risk factors for maternal and neonatal ESBL-E colonization, and subsequent impact on neonatal mortality.

METHODS

A prospective, cross-sectional study was conducted at the University of Abuja Teaching Hospital from April 2016 to May 2017. Maternal-neonatal pairs were screened for ESBL-E exposure at time of delivery. Neonatal mortality was assessed at 28 days.

RESULTS

A total of 1161 singleton deliveries were evaluated. In total, 9.7% (113/1161) of mothers and 4.3% (50/1161) of infants had ESBL-E-positive cultures at delivery. Maternal antibiotic exposure was associated with ESBL-E recto-vaginal colonization (18.6% (21/113) vs. 8.4% (88/1048), p < 0.001)). Maternal ESBL-E colonization (adjusted odds ratio (AOR) 14.85; 95% CI 7.83-28.15) and vaginal delivery (AOR 6.35; 95% CI 2.63-17.1) were identified as a risk factor for positive ESBL-E neonatal surface cultures. Neonatal positive ESBL-E surface cultures were a risk factor for neonatal mortality (stillbirths included, AOR 4.84; 95% CI 1.44-16.31). The finding that maternal ESBL-E recto-vaginal colonization appeared protective in regards to neonatal mortality (AOR 0.22; 95% CI .06-0.75) requires further evaluation.

CONCLUSIONS

Maternal ESBL-E recto-vaginal colonization is an independent risk factor for neonatal ESBL-E colonization and neonates with positive ESBL-E surface cultures were identified as having increased risk of neonatal mortality.

Status of Retinoids and Carotenoids and Associations with Clinical Outcomes in Maternal-Infant Pairs in Nigeria

Vitamin A is an essential nutrient in pregnancy, and other carotenoids have been independently associated with maternal-infant outcomes. The objective of this study was to quantify the status of vitamin A and carotenoids in Nigerian maternal-infant pairs at delivery, compare these to a cohort from a developed nation, and determine the impact on clinical outcomes. Maternal and cord blood samples were collected in 99 Nigerian mother-infant pairs. Concentrations of lutein + zeaxanthin, β-cryptoxanthin, lycopene, α- and β-carotenes, and retinol were measured using HPLC. Descriptive statistics were calculated and Spearman coefficients were used to assess correlations between maternal and cord measurements; Mann-Whitney tests were used to compare median plasma values between dichotomous variables. Linear regression models were used to adjust for relevant confounders. A p < 0.05 was considered statistically significant. Thirty-five percent of mothers had plasma retinol concentrations ≤0.70 µmol/L; 82% of infants had plasma retinol concentrations ≤0.70 µmol/L at delivery. Maternal and infant concentrations of vitamin A compounds were highly correlated and were associated with newborn growth and Apgar scores. Despite plasma concentrations of pro-vitamin A carotenoids higher than those reported in other populations, pregnant Nigerian women have a high prevalence of vitamin A deficiency. As vitamin A related compounds are modifiable by diet, future research determining the clinical impact of these compounds is warranted.

Salmonella Bacteremia Among Children in Central and Northwest Nigeria, 2008-2015

BACKGROUND

Etiologic agents of childhood bacteremia remain poorly defined in Nigeria. The absence of such data promotes indiscriminate use of antibiotics and delays implementation of appropriate preventive strategies.

METHODS

We established diagnostic laboratories for bacteremia surveillance at regional sites in central and northwest Nigeria. Acutely ill children aged <5 years with clinically suspected bacteremia were evaluated at rural and urban clinical facilities in the Federal Capital Territory, central region and in Kano, northwest Nigeria. Blood was cultured using the automated Bactec incubator system.

RESULTS

Between September 2008 and April 2015, we screened 10,133 children. Clinically significant bacteremia was detected in 609 of 4051 (15%) in the northwest and 457 of 6082 (7.5%) in the central region. Across both regions, Salmonella species account for 24%-59.8% of bacteremias and are the commonest cause of childhood bacteremia, with a predominance of Salmonella enterica serovar Typhi. The prevalence of resistance to ampicillin, chloramphenicol, and cotrimoxazole was 38.11%, with regional differences in susceptibility to different antibiotics but high prevalence of resistance to readily available oral antibiotics.

CONCLUSIONS

Salmonella Typhi is the leading cause of childhood bacteremia in central Nigeria. Expanded surveillance is planned to define the dynamics of transmission. The high prevalence of multidrug-resistant strains calls for improvement in environmental sanitation in the long term and vaccination in the short term.

Neonatal hyperthermia and thermal stress in low- and middle-income countries: a hidden cause of death in extremely low-birthweight neonates

BACKGROUND

Over 70% of neonatal deaths in Nigeria occur within the first 7 days of life and, despite the millennium development goals, there has been no significant reduction of this figure.

OBJECTIVE

To investigate how rapid changes of temperature outside the physiologically allowable range in extremely low-birthweight infants are associated with increased mortality.

METHODS

Ninety-eight neonatal cases in three Nigerian tertiary-care hospitals were retrospectively recruited; on the basis of birthweight  < 1500 g, this number was reduced to 41 for a two-stage analysis. In the first stage, 34 cases recruited over 24 months were analysed. In the second stage, seven cases recruited over 6 months were analysed; these were neonates managed with a new temperature control technique (the 'handy approach') to enable comparison of outcomes. The mean (SD) birthweight of the infants analysed was 991 g (251), and 28 of them were of extremely low-birthweight (ELBW) [mean (SD) 846 g (128)]. A lifetime temperature plot with a clearly visible reference zone was developed, from which all thermal stresses and their duration associated with mortality were identified and defined on the basis of their characteristics. Methods of quantifying the magnitude and duration of these thermal stresses were devised to enable definition of critical values. This was then applied to calculate a measure of the various thermal stresses which may have contributed to neonatal death.

RESULTS

Hypothermic events were very common in all the infants in the study period, but were not significantly associated with mortality. However, hyperthermic events occurred in 35% of the infants and were more likely to be associated with mortality. Most neonates with prolonged hypothermia culminating in rapid hyperthermia survived. However, all ELBW neonates who experienced prolonged hyperthermia culminating in rapid hypothermia died within 8 hours of the event. There was greater ELBW survival (6/6) in the second stage using the 'handy approach' than in the first stage (2/22).

CONCLUSION

Hyperthermia is a high-risk event in ELBW infants and methods of cooling a high and prolonged temperature must be reviewed.

A Four-Year Retrospective Review of Very Low Birth Weight Babies Seen at the University of Abuja Teaching Hospital, Abuja, Nigeria

AIMS AND OBJECTIVES

To review the outcome of very low birthweight infants admitted into the Special Care Baby Unit (SCBU) of University of Abuja Teaching Hospital (UATH), Gwagwalada, Abuja, Nigeria.

METHODS

A retrospective review of medical records of very low birthweight (VLBW) babies seen at the SCBU of UATH over a 4-year period from April 2006 to March 2010, was undertaken. Data were obtained from patients' folders and analyzed.

RESULTS

Overall survival was 60.8%. Survival of infants with birth weight below 1000 grams was 26.8% compared to 66.4% for those between 1000 and 1499 grams. The main determinants of survival were birth weight (p< 0.0001) and gestational age (p = 0.0106). Other predictors of outcome were development of features of respiratory distress syndrome within hours of delivery, recurrent apnoea, drainage of liquor of more than 18 hours before delivery, hyperkalaemia, lack of antenatal care and being born-before-arrival (outborn).

CONCLUSIONS

Survival rate is low compared to values from other communities in developing countries but better than values from many centres in Nigeria. Timely and effective management of apnoea, respiratory distress syndrome and prevention of extremely low birthweight (ELBW) deliveries through adequate antenatal care are required to improve on the current survival rate.