The impact of regional origin on the incidence of gestational diabetes mellitus in a multiethnic European cohort

Introduction

Women with migration background present specific challenges related to risk stratification and care of gestational diabetes mellitus (GDM). Therefore, this study aims to investigate the role of ethnic origin on the risk of developing GDM in a multiethnic European cohort.

Methods

Pregnant women were included at a median gestational age of 12.9 weeks and assigned to the geographical regions of origin: Caucasian Europe (n = 731), Middle East and North Africa countries (MENA, n = 195), Asia (n = 127) and Sub-Saharan Africa (SSA, n = 48). At the time of recruitment maternal characteristics, glucometabolic parameters and dietary habits were assessed. An oral glucose tolerance test was performed in mid-gestation for GDM diagnosis.

Results

Mothers with Caucasian ancestry were older and had higher blood pressure and an adverse lipoprotein profile as compared to non-Caucasian mothers, whereas non-Caucasian women (especially those from MENA countries) had a higher BMI and were more insulin resistant. Moreover, we found distinct dietary habits. Non-Caucasian mothers, especially those from MENA and Asian countries, had increased incidence of GDM as compared to the Caucasian population (OR 1.87, 95%CI 1.40 to 2.52, p < 0.001). Early gestational fasting glucose and insulin sensitivity were consistent risk factors across different ethnic populations, however, pregestational BMI was of particular importance in Asian mothers.

Discussion

Prevalence of GDM was higher among women from MENA and Asian countries, who already showed adverse glucometabolic profiles at early gestation. Fasting glucose and early gestational insulin resistance (as well as higher BMI in women from Asia) were identified as important risk factors in Caucasian and non-Caucasian patients.

"Mothers get really exhausted!" The lived experience of pregnancy in extreme heat: Qualitative findings from Kilifi, Kenya

Heat exposure in pregnancy is associated with a range of adverse health and wellbeing outcomes, yet research on the lived experience of pregnancy in high temperatures is lacking. We conducted qualitative research in 2021 in two communities in rural Kilifi County, Kenya, a tropical savannah area currently experiencing severe drought. Pregnant and postpartum women, their male spouses and mothers-in-law, community health volunteers, and local health and environment stakeholders were interviewed or participated in focus group discussions. Pregnant women described symptoms that are classically regarded as heat exhaustion, including dizziness, fatigue, dehydration, insomnia, and irritability. They interpreted heat-related tachycardia as signalling hypertension and reported observing more miscarriages and preterm births in the heat. Pregnancy is conceptualised locally as a 'normal' state of being, and women continue to perform physically demanding household chores in the heat, even when pregnant. Women reported little support from family members to reduce their workload at this time, reflecting their relative lack of autonomy within the household, but also potentially the 'normalisation' of heat in these communities. Climate change risk reduction strategies for pregnant women in low-resource settings need to be cognisant of local household gender dynamics that constrain women's capacity to avoid heat exposures.

Stool Xpert MTB/RIF as a possible diagnostic alternative to sputum in Africa: a systematic review and meta-analysis

Introduction

Worldwide, COVID-19 pandemic lead to a large fall in the number of newly reported TB cases. In sub-Saharan Africa, microbiological diagnosis of TB is generally based on smear microscopy and Xpert MTB/RIF on sputum samples, but good quality sputum samples are often difficult to obtain, leading clinicians to rely on more invasive procedures for diagnosis. Aim of this study was to investigate pooled sensitivity and specificity of Xpert MTB/RIF on stool samples compared to respiratory microbiological reference standards in African countries.

Methods

Four investigators independently searched PubMed, SCOPUS, and Web of Science until 12th October 2022, then screened titles and abstracts of all potentially eligible articles. The authors applied the eligibility criteria, considered the full texts. All the studies reported the data regarding true positive (TP), true negative (TN), false positive (FP) and false negative (FN). Risk of bias and applicability concerns were assessed with the Quadas-2 tool.

Results

overall, among 130 papers initially screened, we evaluated 47 works, finally including 13 papers for a total of 2,352 participants, mainly children. The mean percentage of females was 49.6%, whilst the mean percentage of patients reporting HIV was 27.7%. Pooled sensitivity for Xpert MTB/RIF assay for detecting pulmonary tuberculosis was 68.2% (95%CI: 61.1-74.7%) even if characterized by a high heterogeneity (I2=53.7%). Specificity was almost 100% (99%, 95%CI: 97-100%; I2 = 45.7%). When divided for reference standard, in the six studies using sputum and nasogastric aspirate the accuracy was optimal (AUC = 0.99, SE = 0.02), whilst in the studies using only sputum for tuberculosis detection the AUC was 0.85 (with a SE = 0.16). The most common source of bias was exclusion of enrolled patients in the analysis.

Conclusions

Our study confirms that, in Africa, stool Xpert MTB/RIF may be a useful rule-in test for children above and below 5 years of age under evaluation for pulmonary tuberculosis. Sensitivity increased substantially when using both sputum and nasogastric aspirate as reference samples.

Prevalence of gestational diabetes mellitus in women with a family history of type 2 diabetes in first- and second-degree relatives

AIMS

A family history of type 2 diabetes mellitus (T2DM) markedly increases an individual's lifetime risk of developing the disease. For gestational diabetes (GDM), this risk factor is less well characterized. This study aimed to investigate the relationship between family history of T2DM in first- and second-degree relatives in women with GDM and the differences in metabolic characteristics at early gestation.

METHODS

This prospective cohort study included 1129 pregnant women. A broad risk evaluation was performed before 16 + 0 weeks of gestation, including a detailed family history of the different types of diabetes and a laboratory examination of glucometabolic parameters. Participants were followed up until delivery and GDM assessed according to the latest diagnosis criteria.

RESULTS

We showed that pregnant women with first- (FHD1, 26.6%, OR 1.91, 95%CI 1.16 to 3.16, p = 0.005), second- (FHD2, 26.3%, OR 1.88, 95%CI 1.16 to 3.05, p = 0.005) or both first- and second-degree relatives with T2DM (FHD1 + D2, 33.3%, OR 2.64, 95%CI 1.41 to 4.94, p < 0.001) had a markedly increased risk of GDM compared to those with negative family history (FHN) (n = 100, 15.9%). The association was strongest if both parents were affected (OR 4.69, 95%CI 1.33 to 16.55, p = 0.009). Women with FHD1 and FHD1 + D2 had adverse glucometabolic profiles already in early pregnancy.

CONCLUSIONS

Family history of T2DM is an important risk factor for GDM, also by applying the current diagnostic criteria. Furthermore, we showed that the degree of kinship plays an essential role in quantifying the risk already at early pregnancy.

Extramedullary haematopoiesis presenting as an adnexal mass in a patient with β-thalassaemia

Solid masses of the ovaries raise the suspicion of malignancy or metastasis and require histological diagnosis. Extramedullary haematopoesis (EMH) is a rare histological finding of a mass of the adnexa. The sonographic pattern of EMH has rarely been described in the literature. Transvaginal biopsy of EMH has not been reported in the literature. We present a case of adnexal EMH in a patient affected with β-thalassaemia, and we performed a narrative review. Only in our case, the sonographic pattern was described, and a transvaginal ultrasound-guided core biopsy was used. Assessing patients’ medical history and correlating it to the findings of diagnostic imaging is of paramount importance when evaluating patients with adnexal masses. The correct interpretation of sonographic images can avoid unnecessarily invasive procedures. A transvaginal biopsy could be a safe, easy and well-tolerated method to gain definite histological diagnosis in cases where a primary ovarian malignancy is not suspected.

The Interplay between Host Defense, Infection, and Clinical Status in Septic Patients: A Narrative Review

Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Despite significant morbidity and mortality throughout the world, its pathogenesis and mechanisms are not clearly understood. In this narrative review, we aimed to summarize the recent developments in our understanding of the hallmarks of sepsis pathogenesis (immune and adaptive immune response, the complement system, the endothelial disfunction, and autophagy) and highlight novel laboratory diagnostic approaches. Clinical management is also discussed with pivotal consideration for antimicrobic therapy management in particular settings, such as intensive care unit, altered renal function, obesity, and burn patients.

Central obesity, smoking habit, and hypertension are associated with lower antibody titres in response to COVID-19 mRNA vaccine

AIMS

To explore variables associated with the serological response following COVID-19 mRNA vaccine.

METHODS

Eighty-six healthcare workers adhering to the vaccination campaign against COVID-19 were enrolled in January-February 2021. All subjects underwent two COVID-19 mRNA vaccine inoculations (Pfizer/BioNTech) separated by 3 weeks. Blood samples were collected before the 1st and 1-4 weeks after the second inoculation. Clinical history, demographics, and vaccine side effects were recorded. Baseline anthropometric parameters were measured, and body composition was performed through dual-energy-X-ray absorptiometry.

RESULTS

Higher waist circumference was associated with lower antibody (Ab) titres (R = -0.324, p = 0.004); smokers had lower levels compared to non-smokers [1099 (1350) vs. 1921 (1375), p = 0.007], as well as hypertensive versus normotensive [650 ± 1192 vs. 1911 (1364), p = 0.001] and dyslipideamic compared to those with normal serum lipids [534 (972) vs 1872 (1406), p = 0.005]. Multivariate analysis showed that higher waist circumference, smoking, hypertension, and longer time elapsed since second vaccine inoculation were associated with lower Ab titres, independent of BMI, age. and gender.

CONCLUSIONS

Central obesity, hypertension, and smoking are associated with lower Ab titres following COVID-19 vaccination. Although it is currently impossible to determine whether lower SARS-CoV-2 Abs lead to higher likelihood of developing COVID-19, it is well-established that neutralizing antibodies correlate with protection against several viruses including SARS-CoV-2. Our findings, therefore, call for a vigilant approach, as subjects with central obesity, hypertension, and smoking could benefit from earlier vaccine boosters or different vaccine schedules.

Clinical Characteristics and Outcome of Patients with Suspected COVID-19 in Emergency Department (RESILIENCY Study II)

Objectives: COVID-19 may show no peculiar signs and symptoms that may differentiate it from other infective or non-infective etiologies; thus, early recognition and prompt management are crucial to improve survival. The aim of this study was to describe clinical, laboratory, and radiological characteristics and outcomes of hospitalized COVID-19 patients compared to those with other infective or non-infective etiologies. Methods: We performed a prospective study from March 2020 to February 2021. All patients hospitalized for suspected or confirmed COVID-19 were prospectively recruited. All patients were evaluated according to a predefined protocol for diagnosis of suspected SARS-CoV-2 infection. The primary endpoint was evaluation of clinical, laboratory, and radiological characteristics associated or not with COVID-19 etiology at time of hospitalization in an emergency department. Results: A total of 1036 patients were included in the study: 717 (69%) patients with confirmed COVID-19 and 319 (31%) without COVID-19, hospitalized for other causes. The main causes of hospitalization among non-COVID-19 patients were acute heart failure (44%) and bacterial pneumonia (45.8%). Overall, 30-day mortality was 9% among the COVID-19 group and 35% in the non-COVID-19 group. Multivariate analysis showed variables (fever > 3 days, dry cough, acute dyspnea, lymphocytes < 1000 × 10³/µL, and ferritin > 250 ng/mL) independently associated with COVID-19 etiology. A decision tree was elaborated to early detect COVID-19 patients in the emergency department. Finally, Kaplan–Meier curves on 30-day survival in COVID-19 patients during the first wave (March–May 2020, n = 289 patients) and the second wave (October–February 2021, n = 428 patients) showed differences between the two study periods (p = 0.021). Conclusions: Patients with confirmed diagnosis of COVID-19 may show peculiar characteristics at time of hospitalization that could help physicians to distinguish from other infective or non-infective etiologies. Finally, a different 30-day mortality rate was observed during different periods of the pandemic.

Anaplastic astrocytoma during pregnancy: the importance of an effective multidisciplinary approach

A 34-year-old pregnant woman at 28 gestational weeks was diagnosed with a brain tumor after experiencing a generalised seizure. After completion of antenatal fetal lung maturation, she underwent an osteoplastic craniotomy parietal on the left side and a microsurgical partial tumor resection under general anaesthesia. With a histology of a diffuse astrocytoma and the postoperative stable amount of residual tumor on follow-up imaging, the pregnancy proceeded until 37 gestational weeks. A healthy baby boy was delivered by elective caesarean section. An awake craniotomy for removal of the residual tumor was planned two weeks later, followed by adjuvant treatment (combined radio-/chemotherapy). A multidisciplinary approach, combined with appropriate timing and a transparent and empathic communication, was able to create the most effective tailored management and optimise maternal and neonatal outcomes.

Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco

BACKGROUND

Across the Africa region and beyond, the last decade has seen many countries introducing policies aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso, Mali and Morocco.

METHODS

The study uses a comparative case study design with mixed methods, including realist evaluation components. This article presents results across 14 different data collection tools, used in 4-6 research sites in each of the four study countries over 2011-13. The methods included: document review; interviews with key informants; analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff; interviews with patients and observation of care processes.

RESULTS

The article finds that the policies have contributed to continued increases in skilled birth attendance and caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households after the policy, suggesting that the financial protection objectives may have been met, at least in the short term, although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative effects on technical quality of care, or of unintended negative effects on untargeted services.

CONCLUSIONS

We conclude that the policies were effective in meeting financial protection goals and probably health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and equity. These include broadening the exempted package (especially for those countries which focused on caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for indigents, and paying more attention to quality of care, especially for newborns.

Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis

BACKGROUND

Obstetric fistula is a severe condition which has devastating consequences for a woman's life. The estimation of the burden of fistula at the population level has been impaired by the rarity of diagnosis and the lack of rigorous studies. This study was conducted to determine the prevalence and incidence of fistula in low and middle income countries.

METHODS

Six databases were searched, involving two separate searches: one on fistula specifically and one on broader maternal and reproductive morbidities. Studies including estimates of incidence and prevalence of fistula at the population level were included. We conducted meta-analyses of prevalence of fistula among women of reproductive age and the incidence of fistula among recently pregnant women.

RESULTS

Nineteen studies were included in this review. The pooled prevalence in population-based studies was 0.29 (95% CI 0.00, 1.07) fistula per 1000 women of reproductive age in all regions. Separated by region we found 1.57 (95% CI 1.16, 2.06) in sub Saharan Africa and South Asia, 1.60 (95% CI 1.16, 2.10) per 1000 women of reproductive age in sub Saharan Africa and 1.20 (95% CI 0.10, 3.54) per 1000 in South Asia. The pooled incidence was 0.09 (95% CI 0.01, 0.25) per 1000 recently pregnant women.

CONCLUSIONS

Our study is the most comprehensive study of the burden of fistula to date. Our findings suggest that the prevalence of fistula is lower than previously reported. The low burden of fistula should not detract from their public health importance, however, given the preventability of the condition, and the devastating consequences of fistula.

Social and ethical determinants of sexuality: gender and health

The aim of this paper is to expand concepts of gender and explore how behaviours associated with sexual identity affect health risks, as well as the right to sexual expression for sexual minorities and persons with disabilities, to promote safe sexual behaviour and reduce the incidence of sexually transmitted diseases, through the internationally sanctioned Sexual and Reproductive Health concept. During the XX century the multiple meanings of sexuality have been progressively recognized and its physical and psychological health dimension have become a reality, enshrined in United Nations (UN) documents. Countries have begun to adapt their legislations to this new reality and Conventions today guarantee equal sexual and reproductive rights to persons with disabilities, while the nature of variant sexual behaviours is being debated. Sexual and reproductive health is today an acknowledged goal for every individual and the right to equality for persons with variant behaviours and disabilities, as well as the coexistence of diverse meanings of sexuality an established fact. Healthy and safe sexual behaviour should become an important goal for all societies and cultures.

Social and ethical determinants of human sexuality: 1. The need to reproduce

Aims of this study was to review the many and diverse factors conditioning human sexual behavior; starting with the first and still most important: the need to reproduce and to analyse these factors and how they have changed over time in order to better understand the interplay between the major determinants of human sexuality. For this aim the authors made a literature review of relevant scientific papers and books, including religious websites. At the dawn of humanity, sexuality was focused on reproduction; this, however, did not exclude other important meanings in sexual relationships, since non-conceptive copulations have been a constant aspect of human behavior, becoming an almost unique feature of genus homo. In this respect, the characteristics of a female continuously accessible to her male set the stage for a trend towards monogamy and created the substrate for closed families. Anthropologists have justified conceptive sexuality because sexual activity is costly in terms of energy consumption; for this reason, in the early days, restricting sexual activity made sense for the survival of the species. Traditional ethical considerations and ancient norms by the three major monotheistic religions have favored conceptive sexuality, restricting sexual activity to sanctioned unions and insisting that the major scope of sexuality is procreation. In spite of this, among humans sexuality has always had a wider meaning to the point that for millennia, humans have tried to separate its unitive and procreative meanings. Today much has changed since reproduction can be achieved without intercourse, further separating it from sexual activity. In humans sexuality always possessed multiple meanings, first and foremost reproduction and the creation of a bond between a man and one or several women.

Erratum to "Maternal, neonatal and child health interventions and services: moving from knowledge of what works to systems that deliver" [International Health 2 (2010) 87-98]

The Publisher regrets that an error occurred in the name of the 6th listed co-author for this paper. B. Matthias was listed in the original paper instead of M. Borchert; the correct listing can be seen above.

[Voluntary pregnancy termination over the first trimester. A five-year observation]

AIM

The law for legalising abortion was approved by the Italian Government in May 1978. In regulating legal abortion this law identifies two different scenarios: one where legal abortion is performed within 90 days of gestational age, and the second where it can be performed beyond this term but within 120 days: ''when pregnancy or delivery can cause a severe damage to the woman's life, in case of severe pathologies, as fetal relevant anomalies or malformations which can cause a severe damage to the woman's physical or psychological health''. Since during the last years an increase of requests for voluntary pregnancy termination (VPT) over 90 days of gestational age has been observed in Italy, it was decided to carry out a retrospective study on the reasons for requesting such an operation.

METHODS

All interventions for VPT over 90 days of gestational age performed in the Department of Obstetrics and Gynecology in the University of Rome ''La Sapienza'' between January 2003 and December 2007 have been re-assessed, analysing age of women, obstetric anamnesis, reasons for VPT request, gestational age, mode of intervention, complications due to intervention and days of inpatient admission.

RESULTS

During five years 255 women demanded to terminate a pregnancy over the first trimester. In all cases requested have been authorized following a psychological consult assessing a severe damage on psychological health by the Clinical Psychology Service of ''La Sapienza'' University, that in all cases was subsequent to a diagnosis of fetal anomalies, ascertained by a genetic test and/or ultrasound scan. Anomalies were genetic in 112 of cases (43.2%) and morphological, both single and multiple, in 143 of cases (56.8%). In most of the cases (65%) these anomalies have been assessed by ultrasound scan, while in 35% by cariotype analysis.

CONCLUSION

After the legalisation in 1978, cases of abortion have constantly increased. More detailed data would be helpful to better understand and face this event.

[Intrauterine death: experience at a tertiary centre of Italy]

AIM

In order to analyse causes of stillbirths, we collected all the cases observed from January 1993 to December 2006 at the Department of Gynecological Sciences, Perinatology and Child Care, University ''La Sapienza'', Rome, Italy.

METHODS

For each case, age of the patient, parity, country of origin, gestational age at the moment of stillbirth, clinical condition before pregnancy, pathologies occurred during pregnancy, possible therapies and autopsy of the fetus, have been collected. To evaluate and classify the obtained data, both the NICE (Neonatal and Intrauterine Death Classification according to Etiology) and the ReCoDe (Relevant Condition at Death) classifications have been utilised; the first one being more suitable than the second for our case series.

RESULTS

Results showed that among 25892 labours, 186 were intrauterine deaths (7.2%). In 1999 we noticed a decrease in the number of labours of approx. 30%, due to a reduction in the number of inpatients available spaces. The number of stillbirths presented a slithering line until 2001, while after then a marked decrease has been observed.

CONCLUSION

A high percentage of stillbirths had to be classified as ''unknown causes'' (26.9%). Additional prospective research, in order to achieve a better classification, is needed. All the new cases, should be classified using the most appropriate parameter, drawing attention to all the possible issues, and centralizing the data acquired.

Seasonal patterns and preterm birth: a systematic review of the literature and an analysis in a London-based cohort

OBJECTIVE

The objectives of this study included a systematic review of the countries in which a seasonal pattern of preterm birth has been reported and an analysis on the seasonal variability of preterm birth in a London-based cohort.

DESIGN

Cross-sectional study.

SETTING

Eighteen maternity units in a London health region from 1988 to 2000.

POPULATION

The study population comprised 482,765, live singleton births born after 24 weeks of gestation and weighing more than 200 g.

METHODS

Systematic review and secondary analysis of seasonality over 13 years of births from the St Mary's Maternity Information System (SMMIS).

MAIN OUTCOME MEASURE

Annual patterns of preterm birth and a comparison of risk by seasons.

RESULTS

Three studies from developing countries and three from developed countries reported a seasonal pattern of preterm birth. One study from the USA reported no seasonal pattern of preterm birth. No British studies were located. Rates of preterm birth in developed countries were highest twice a year (once in winter and again in summer). In London (SMMIS data set), however, preterm births peaked only once a year, in winter. Babies born in winter were 10% more likely to be preterm compared with those born in spring (OR 1.10, 95% CI 1.07-1.14).

CONCLUSION

Establishing a seasonal pattern of birth can have important implications for the delivery of healthcare services. Most studies from both developed and developing countries support the existence of preterm birth seasonality. This study has shown that the seasonality of preterm births in this London-based cohort differs from other developed countries that have previously reported a seasonal pattern of preterm birth.

Caesarean section and subsequent fertility in sub-Saharan Africa

OBJECTIVE

To determine the impact of caesarean section on fertility among women in sub-Saharan Africa.

DESIGN

Analysis of standardised cross-sectional surveys (Demographic and Health Surveys).

SETTING

Twenty-two countries in sub-Saharan Africa, 1993-2003.

SAMPLE

A total of 35 398 women of childbearing age (15-49 years).

METHODS

Time to subsequent pregnancy was compared by mode of delivery using Cox proportional hazards regression models.

MAIN OUTCOME MEASURES

Natural fertility rates subsequent to delivery by caesarean section compared with natural fertility rates subsequent to vaginal delivery.

RESULTS

The natural fertility rate subsequent to delivery by caesarean section was 17% lower than the natural fertility rate subsequent to vaginal delivery (hazard ratio = 0.83, 95% CI 0.73-0.96, P < 0.01; controlling for age, parity, level of education, urban/rural residence and young age at first intercourse). Caesarean section was also associated with prior fertility and desire for further children: among multiparous women, an interval > or =3 versus <3 years between the index birth and the previous birth was associated with higher odds of caesarean section at the index birth (OR = 1.4, 95% CI 1.1-1.7, P= 0.005); among all women, the odds of desiring further children were lower among women who had previously delivered by caesarean section (OR = 0.67, 95% CI 0.54-0.84, P < 0.001). Caesarean section did not appear to increase the risk of a subsequent pregnancy ending in miscarriage, abortion or stillbirth.

CONCLUSIONS

Among women in sub-Saharan Africa, caesarean section is associated with lower subsequent natural fertility. Although this reflects findings from developed countries, the roles of pathological and psychological factors may be quite different because a much higher proportion of caesarean sections in sub-Saharan Africa are emergency procedures for maternal indication.

Unprecedented reversible coupling of alkynyl and phosphide ligands on a dinuclear platinum framework

The reductive coupling of the bridging phosphide and the adjacent [sigma]-alkynyl moieties in [Pt2(mu-P(t)Bu2){mu,eta1:eta2-C(Ph)CH2}(C[triple bond]C-Ph)(CO)(P(t)Bu2H)(Br)] is promoted by bromide abstraction and is reversed by adding N(n)Bu4Br.

Responsiveness to life-threatening obstetric emergencies in two hospitals in Abidjan, Cote d'Ivoire

OBJECTIVES

To document the frequency of severe obstetric illness, and the intervals between admission or decision and life-saving surgery and the factors contributing to delays, which were reported during case reviews in two hospitals in Abidjan, Côte d'Ivoire.

METHODS

The study was conducted in the teaching hospital in Cocody (CHUC) and the district hospital in Abobo (FSAS) in 2000-01. All severe obstetric cases were inventoried over a period of 1 year, and a subset of cases selected for in-depth review. For the 23 audited cases requiring emergency surgery, the interval between admission/decision and surgery was determined and reasons for the delays examined.

FINDINGS

The yearly incidence of severe obstetric morbidity was 224.5 and 11.8 per 1000 live births in the CHUC and FSAS respectively. In CHUC, the decision-to-delivery time was extremely long (median 4.8 h) and this was largely determined by the time needed to obtain a complete surgical kit (median 2.8 h), either because the family had to pay for it in advance or because the kit lacked some essential components, which had to be bought separately. In FSAS, the decision-to-delivery time was much shorter (median 1.0 h).

CONCLUSION

The interval between decision and emergency obstetric surgery substantially exceeded the 30 min generally advocated in industrialized countries. The reasons for the long delays were multiple and complex, but the main factors governing them were the huge case load of severe cases and the absence of any clear policy towards ensuring prompt and adequate treatment for life-threatening emergencies. In-depth reviews of cases of severe obstetric morbidity focusing in particular on the timing of emergency treatment could increase the responsiveness of the health system and providers to the needs of women requiring emergency obstetric care.

Costs of near-miss obstetric complications for women and their families in Benin and Ghana

This paper estimates the total cost to women and their families associated with a spontaneous vaginal delivery and five types of 'near-miss' obstetric complication in Benin and Ghana, and assesses affordability in relation to household cash expenditure. A retrospective evaluation of costs was carried out among 121 mothers in three hospitals in Ghana. A prospective evaluation of costs was undertaken among 420 pregnant women in two hospitals in Benin. Information was collected on the cost of travel to the facilities and of direct medical and non-medical costs incurred during their stay in hospital. In Benin, costs ranged from an average of 15 US dollars for a spontaneous delivery to 256 US dollars for a near-miss complication caused by dystocia. In Ghana, average costs ranged from 18 US dollars for a spontaneous vaginal delivery to 115 US dollars for a near-miss complication caused by haemorrhage. Medical costs accounted for the largest share of total costs, mainly drugs and medical supplies in Ghana and costs of the delivery and any surgical intervention in Benin. Payments associated with a spontaneous vaginal delivery amounted to at least 2% of annual household cash expenditure in both countries. In the case of severe obstetric complications, costs incurred reached a high of 34% of annual household cash expenditure in Benin. The economic burden of hospital-based delivery care in Ghana and Benin is likely to deter or delay women's use of health services. Should a woman develop severe obstetric complications while in labour, the relatively high costs of hospital care could have a potentially catastrophic impact on the household budget.

Giving birth in maternity hospitals in Benin: testimonies of women

In Benin, a Francophone country in West Africa, maternity mortality has been estimated at between 473 and 990 deaths per 100,000 live births. Yet 92 per cent of women gave birth in either a public or private health centre, and almost all of them received antenatal care. This paper reports on an exploratory, qualitative study in 1995, among 19 women aged 20-40 who had recently given birth in a referral hospital, of their experiences of antenatal and emergency obstetric care, as part of a larger study on measuring the prevalence of severe maternal morbidity in the community. Thirteen of the women had had obstetric complications and 11 had had a caesarean section. Pregnancy was described as a period of great vulnerability, and feelings of insecurity and fear of death were omnipresent in the women's accounts. Their primary motivation for seeking antenatal care was the appearance of symptoms or events they perceived as abnormal. Although a minority were lucky enough to have a kind midwife, many complained about not being able to ask questions or get any explanations, being mistreated and humiliated by health personnel and described the anguish they felt in the face of medical procedures they did not understand, especially caesarean section, which they were told were necessary to save their lives. Access to emergency obstetric care is a priority in the battle against maternal mortality, but it cannot be at the expense of improvements in the quality of the interaction between women and health personnel. The inclusion of women's voices in the objectives of safe motherhood programmes is necessary to better serve women's needs.

[Obstetric catastrophes barely just avoided: near misses in Moroccan hospitals]

A consensus definition of obstetric catastrophes barely only just avoided, called near miss cases in the recent scientific literature, has been elaborated during an international seminar held in Morocco. A near miss case was defined as "any pregnant or recently delivered - or aborted - woman, whose immediate survival is threatened and who survives by chance or because of the hospital care received". This definition was then operationalised using severity criteria combining clinical signs and types of intervention clear enough to easily screen near miss cases in hospital files. These criteria were then used to identify the near misses that occurred in 1998 in two public Moroccan hospitals (Tetouan and Sidi Kacem). A total of 81 cases of severe maternal complications (76 near misses and 5 deaths) were collected, a frequency of 11.9% among hospital admissions for delivery or pregnancy complications. The interest and limitations of such a near miss case definition are discussed. It seems that the criteria applied were operational in the Moroccan context. They are specific, i.e. they permitted to identify true cases of mother's life threatening complications. Finally, they generated a sufficiently great number of cases and a range of situations large enough to hold monthly audits and to identify sub-standard care.

Women's reports of severe (near-miss) obstetric complications in Benin

This study examines the validity of a survey instrument on near-miss obstetric complications. Three groups of women--with severe complications, with mild complications, and with a normal delivery--were identified retrospectively in three hospitals in South Benin and interviewed at home. The concept of "near-miss" was used to identify women with severe episodes of morbidity. The questionnaire was able to detect, with some accuracy, eclamptic fits, abnormal bleeding in the third trimester for a recall period of at least three to four years, and all episodes of bleeding independent of timing within a period of two years. Questions concerning dystocia and infections of the genital tract generated disappointing results except when information on treatment was included. Overall, better results were achieved for antepartum and acute events. Severity made a positive difference only in the case of eclampsia, with an increase in sensitivity. The implications of the results for using women's recall of obstetric complications in surveys are discussed.

Oral environment temperature changes induced by cold/hot liquid intake

The use of NiTi shape memory alloys, introduced into orthodontics because of their ability to develop light continuous forces that prove more effective than heavy intermittent forces in the teeth movement, requires the mastering of the functional properties of NiTi wires. More specifically, the recovery force acting on the teeth is a sensitive function of temperature: knowledge of oral temperature modifications is therefore required to understand the stress state modification felt during orthodontic therapy. The temperature modifications induced by cold or hot drink intake in the oral cavity were investigated by using arch wires, fixed to removable Hawley retainers, similar to those currently used in orthodontic practice, by means of six temperature sensors placed in correspondence with specific teeth. Similarly, the temperature changes were detected on a metallic frame, fixed onto the palatal zone to a Hawley retainer, where a palatal expander was placed to correct unilateral or bilateral crossbites in deciduous or in early mixed dentition. The maximum temperature change was observed in the interincisor area: The temperature modification on other teeth depends on the modality of drink intake, with the highest temperature variations being detected in the palatal zone. Hence modifications in the stress state during orthodontic therapy with NiTi wires are to be expected.

Contraceptive choice and reproductive morbidity in Istanbul

A cross-sectional survey was conducted in Istanbul to investigate the relationship between contraceptive choice and reproductive morbidity. Altogether, 918 women who had ever used any means of avoiding pregnancy were interviewed at home, and, among these, 694 parous nonpregnant women were examined by three female physicians. The women were aware of bearing a considerable burden of ill health, with 81 percent reporting at least one episode of illness in the three months prior to the interview. Current users of the intrauterine device were significantly more likely than users of other methods to report menstrual disorders, but pelvic relaxation and reproductive and urinary tract infections, whether perceived or diagnosed, were not significantly related to any of the contraceptive methods. The relatively small amount of switching between methods suggests that most users tended to stay with the same method once chosen and that health concerns played an important part only in the initial choice of the method.

Asking questions about women's reproductive health: validity and reliability of survey findings from Istanbul

In countries where population-based data on health problems are scarce, the extent of reproductive morbidity can be estimated from replies in structured interviews as a complement or as an alternative to reports from physician's examination and laboratory tests. We examined the sensitivity and specificity of detected morbidity based on these replies as compared to medical diagnoses and explored the consistency of replies when the questionnaire was administered twice, by two types of interviewers in different environments. Data were collected in a cross-sectional survey in Istanbul. The presence or absence of five morbidities, reproductive and urinary tract infections (RTI and UTI), menstrual disorders, pelvic relaxation and anaemia was determined by algorithms based on the replies, and by the physician's diagnosis. Except with anaemia, questionnaire replies were more specific than sensitive in detecting morbidity, probably partly due to many morbid conditions being accepted as normal. Sepcificity exceeded 80% for home reports of menstrual disorders (93.0%), pelvic relaxation (95.7%), RTI (abnormal discharge and pain) (81.2%) and UTI (80.7%), with the corresponding figure for anaemia at 41.7%; the best sensitivity results were for anaemia (58.3%), RTI (abnormal discharge only) (49.3%) and menstrual disorders (45.4%) with figures for pelvic relaxation and UTI reaching only 17.3 and 13.0%. Reliability between the interviews (assessed by the K coefficient), was highest at 66.1% for pelvic relaxation and lowest at 39.9% for menstrual disorders. Reliability varied between the two lay interviewers, suggesting the interviewer and the interview conditions are important. Questionnaire-based information on this type of morbidity is most useful for ascertaining perceived ill-health and only of limited use for the corresponding medically defined conditions.

Clinical algorithms for the screening of Chlamydia trachomatis in Turkish women

OBJECTIVE

To test the diagnostic validity of clinical algorithms for the detection of Chlamydia trachomatis in an urban population of married women in Turkey.

DESIGN

Cross-sectional population-based survey.

SUBJECTS

A systematic sample of 867 women who reported the use of contraceptive methods.

MAIN OUTCOME MEASURES

Sensitivity, specificity and positive predictive value of clinical algorithms for the diagnosis of C trachomatis.

RESULTS

C trachomatis was diagnosed in 4.89% of the women. The WHO algorithm for use in settings where no vaginal examination could be performed had a sensitivity of 9% and a specificity of 96%. The corresponding figures for the WHO algorithm incorporating the findings of a speculum examination were 47% and 56% respectively. Algorithms incorporating symptoms or signs other than those suggested by the WHO did not yield satisfactory standards of validity.

CONCLUSIONS

The findings of this study do not support the widespread introduction of the use of clinical decision models for screening of women for chlamydia infection in primary health care settings such as family planning or antenatal clinics. The large number of false positive results with the use of the clinical algorithms tested in this study would cause unnecessary costs to the health system and unnecessary interventions to the women treated.