Acceptability of IV iron treatment for iron deficiency anaemia in pregnancy in Nigeria: a qualitative study with pregnant women, domestic decision-makers, and health care providers

BACKGROUND

Anaemia in pregnancy causes a significant burden of maternal morbidity and mortality in sub-Saharan Africa, with prevalence ranging from 25 to 45% in Nigeria. The main treatment, daily oral iron, is associated with suboptimal adherence and effectiveness. Among pregnant women with iron deficiency, which is a leading cause of anaemia (IDA), intravenous (IV) iron is an alternative treatment in moderate or severe cases. This qualitative study explored the acceptability of IV iron in the states of Kano and Lagos in Nigeria.

METHODS

We purposively sampled various stakeholders, including pregnant women, domestic decision-makers, and healthcare providers (HCPs) during the pre-intervention phase of a hybrid clinical trial (IVON trial) in 10 healthcare facilities across three levels of the health system. Semi-structured topic guides guided 12 focus group discussions (140 participants) and 29 key informant interviews. We used the theoretical framework of acceptability to conduct qualitative content analysis.

RESULTS

We identified three main themes and eight sub-themes that reflected the prospective acceptability of IV iron therapy. Generally, all stakeholders had a positive affective attitude towards IV iron based on its comparative advantages to oral iron. The HCPs noted the effectiveness of IV iron in its ability to evoke an immediate response and capacity to reduce anaemia-related complications. It was perceived as a suitable alternative to blood transfusion for specific individuals based on ethicality. However, to pregnant women and the HCPs, IV iron could present a higher opportunity cost than oral iron for the users and providers as it necessitates additional time to receive and administer it. To all stakeholder groups, leveraging the existing infrastructure to facilitate IV iron treatment will stimulate coherence and self-efficacy while strengthening the existing trust between pregnant women and HCPs can avert misconceptions. Finally, even though high out-of-pocket costs might make IV iron out of reach for poor women, the HCPs felt it can potentially prevent higher treatment fees from complications of IDA.

CONCLUSIONS

IV iron has a potential to become the preferred treatment for iron-deficiency anaemia in pregnancy in Nigeria if proven effective. HCP training, optimisation of information and clinical care delivery during antenatal visits, uninterrupted supply of IV iron, and subsidies to offset higher costs need to be considered to improve its acceptability. Trial registration ISRCTN registry ISRCT N6348 4804. Registered on 10 December 2020 Clinicaltrials.gov NCT04976179. Registered on 26 July 2021.

Prevalence of and risk factors for iron deficiency among pregnant women with moderate or severe anaemia in Nigeria: a cross-sectional study

BACKGROUND

Anaemia during pregnancy causes adverse outcomes to the woman and the foetus, including anaemic heart failure, prematurity, and intrauterine growth restriction. Iron deficiency anaemia (IDA) is the leading cause of anaemia and oral iron supplementation during pregnancy is widely recommended. However, little focus is directed to dietary intake. This study estimates the contribution of IDA among pregnant women and examines its risk factors (including dietary) in those with moderate or severe IDA in Lagos and Kano states, Nigeria.

METHODS

In this cross-sectional study, 11,582 women were screened for anaemia at 20-32 weeks gestation. The 872 who had moderate or severe anaemia (haemoglobin concentration < 10 g/dL) were included in this study. Iron deficiency was defined as serum ferritin level < 30 ng/mL. We described the sociodemographic and obstetric characteristics of the sample and their self-report of consumption of common food items. We conducted bivariate and multivariable logistic regression analysis to identify risk factors associated with IDA.

RESULTS

Iron deficiency was observed among 41% (95%CI: 38 - 45) of women with moderate or severe anaemia and the prevalence increased with gestational age. The odds for IDA reduces from aOR: 0.36 (95%CI: 0.13 - 0.98) among pregnant women who consume green leafy vegetables every 2-3 weeks, to 0.26 (95%CI: 0.09 - 0.73) among daily consumers, compared to those who do not eat it. Daily consumption of edible kaolin clay was associated with increased odds of having IDA compared to non-consumption, aOR 9.13 (95%CI: 3.27 - 25.48). Consumption of soybeans three to four times a week was associated with higher odds of IDA compared to non-consumption, aOR: 1.78 (95%CI: 1.12 - 2.82).

CONCLUSION

About 4 in 10 women with moderate or severe anaemia during pregnancy had IDA. Our study provides evidence for the protective effect of green leafy vegetables against IDA while self-reported consumption of edible kaolin clay and soybeans appeared to increase the odds of having IDA during pregnancy. Health education on diet during pregnancy needs to be strengthened since this could potentially increase awareness and change behaviours that could reduce IDA among pregnant women with moderate or severe anaemia in Nigeria and other countries.

Obstetric referrals, complications and health outcomes in maternity wards of large hospitals during the COVID-19 pandemic: a mixed methods study of six hospitals in Guinea, Nigeria, Uganda and Tanzania

OBJECTIVES

The COVID-19 pandemic affected provision and use of maternal health services. This study describes changes in obstetric complications, referrals, stillbirths and maternal deaths during the first year of the pandemic and elucidates pathways to these changes.

DESIGN

Prospective observational mixed-methods study, combining monthly routine data (March 2019-February 2021) and qualitative data from prospective semi-structured interviews. Data were analysed separately, triangulated during synthesis and presented along three country-specific pandemic periods: first wave, slow period and second wave.

SETTING

Six referral maternities in four sub-Saharan African countries: Guinea, Nigeria, Tanzania and Uganda.

PARTICIPANTS

22 skilled health personnel (SHP) working in the maternity wards of various cadres and seniority levels.

RESULTS

Percentages of obstetric complications were constant in four of the six hospitals. The percentage of obstetric referrals received was stable in Guinea and increased at various times in other hospitals. SHP reported unpredictability in the number of referrals due to changing referral networks. All six hospitals registered a slight increase in stillbirths during the study period, the highest increase (by 30%-40%) was observed in Uganda. Four hospitals registered increases in facility maternal mortality ratio; the highest increase was in Guinea (by 158%), which had a relatively mild COVID-19 epidemic. These increases were not due to mortality among women with COVID-19. The main pathways leading to these trends were delayed care utilisation and disruptions in accessing care, including sub-optimal referral linkages and health service closures.

CONCLUSIONS

Maternal and perinatal survival was negatively affected in referral hospitals in sub-Saharan Africa during COVID-19. Routine data systems in referral hospitals must be fully used as they hold potential in informing adaptations of maternal care services. If combined with information on women's and care providers' needs, this can contribute to ensuring continuation of essential care provision during emergency.

Achieving a robust mentoring and research capacity program in a LMIC - the BRAINS faculty development model

BACKGROUND

A research and training program (RTP) was carried out to build the capacity of faculty and improve the culture of research in the College of Medicine, University of Lagos (CMUL), Nigeria.

METHODS

Realist-guided mixed methods evaluation of the BRAINS project was carried out using secondary data generated during the 5-years (2015 - 2020) of project implementation. Capacity building workshops and mentored research activities targeted at faculty in the CMUL were conducted. Overall, 1,418 participants attended the workshops in batches. Among the participants, forty-five faculty received grants and were mentored by senior professionals (local & international) to conduct research. Data were extracted from all project-related documents including coursework biodata, workshop evaluation forms, quarterly project reports, and end- of-project reports, submitted by the mentees, minutes of meetings, and the proposal submitted for funding. It was in the form of continuous variables and prose (sentences & stories). Quantitative data were analysed with IBM SPSS statistics version 20. Mean knowledge score and mean difference was calculated, paired t-test was carried out using p < 0.05 to determine statistical significance. The prose was thematically analysed to generate themes and narratives. Both were subsequently combined for interpretation and used to refine the initial programme theory into an evidence-informed theory.

RESULTS

Twelve courses were deployed, and 1,418 participants (47.8% males and 52.2% females) from medical, nursing, and allied medical departments were trained. Eighty participants were trained in Responsible Conduct of Research and eighty-one on Manuscript Writing over three years. A comparison of the pre/post-test knowledge scores showed a positive mean difference. Thematic analysis of workshop data produced three thematic domains representing effectiveness and gains namely: cognitive, reward, and behavioural. 45 trainees were awarded grants and mentored, and analysis of mentee's data generated 4 themes: Achieving a robust mentoring program; Benefits of the mentoring program; Resilience in research; Improving the mentoring program.

CONCLUSION

By contributing to the body of knowledge available on RTPs, this evaluation identified key components that contributed to the success of the project and developed a model for achieving a robust training and mentoring program which can be replicated in other LMICs.

Serum concentrations of IL-16 and its genetic polymorphism rs4778889 affect the susceptibility and severity of endometriosis in Nigerian women

BACKGROUND

Endometriosis is the presence of active ectopic endometrial glands and stroma at other sites outside the uterine cavity. It is a common cause of chronic pelvic pain which is sometimes debilitating, and inflammation is one of the known triggers of endometriosis. Interleukins 6 and 16 (IL-6 and IL-16) are proinflammatory cytokines which play essential roles in inflammatory diseases. We therefore investigated the relationship between genetic polymorphisms of interleukins 6 and 16, and the development of endometriosis in Nigerian women.

METHOD

One hundred and thirty (130) consenting women were consecutively enrolled, sixty-five (65) of whom had endometriosis and 65 age-matched women as reference group, surgically confirmed as not having endometriosis. Spectrophotometric determination of serum concentrations of Interleukins 6 and 16 was carried out and the genotyping of IL-6 (rs1800795) and IL-16 (rs4778889, rs11556218, rs4072111) genes were performed using TaqMan assays.

RESULTS

Serum IL-16 concentration was significantly higher in women with severe chronic pelvic pain compared to those with mild pain (p = 0.023). The C allele of rs4778889 was associated with endometriosis (OR: 1.80, 95% CI: 1.08 - 3.02, p = 0.024).

CONCLUSION

Serum IL-16 and IL-16 rs4778889 may be important markers for endometriosis in Nigerian, and by extension, African women. Multicentre African studies would clarify this.

Use of exchange blood transfusion in the management of severe COVID-19 infection in pregnancy: experience from Lagos, Nigeria

Coronavirus disease 2019 (COVID-19) presents with symptoms that may be mild or severe. The individual with the severe form of the disease usually presents with a constellation of respiratory symptoms typical of acute respiratory distress syndrome. In this report, we present our experience of the successful management of an oxygen-dependent pregnant woman with severe COVID-19 infection who had 2 sessions of partial exchange blood transfusion. We discussed the principles that informed this intervention and the need to adopt this novel approach in the care of severe COVID-19 infection.

Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study

Introduction

Prompt access to emergency obstetrical care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetrical emergencies in Lagos State, Nigeria.

Methods

We conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1 November 2018 and 30 October 2019, we extracted socio-demographic, travel and obstetrical data. The extracted travel data were exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death.

Findings

Of 4181 pregnant women with obstetrical emergencies, 182 (4.4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10 km directly from home, and 61.9% arrived at the hospital ≤30 mins. The median distance and travel time to EmOC was 7.6 km (IQR 3.4–18.0) and 26 mins (IQR 12–50). For all women, travelling 10–15 km (2.53, 95% CI 1.27 to 5.03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10–15 km in the non-referred group (2.48, 95% CI 1.18 to 5.23) and for travel ≥120 min (7.05, 95% CI 1.10 to 45.32). For those referred, odds became statistically significant at 25–35 km (21.40, 95% CI 1.24 to 36.72) and for journeys requiring travel time from as little as 10–29 min (184.23, 95% CI 5.14 to 608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3.60, 95% CI 1.59 to 8.18) or rural (2.51, 95% CI 1.01 to 6.29) areas.

Conclusion

Our evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030.

A mixed-methods study of maternal health care utilisation in six referral hospitals in four sub-Saharan African countries before and during the COVID-19 pandemic

INTRODUCTION

In sub-Saharan Africa, referral hospitals are important sources of key maternal health services, especially during a crisis such as the COVID-19 pandemic. This study prospectively assessed the effect of the COVID-19 pandemic on maternal health service utilisation in six large referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the pandemic.

METHODS

Mixed-methods design combining three data sources: (1) quantitative data based on routine antenatal, childbirth and postnatal care data collected March 2019-February 2021, (2) qualitative data from recurring rounds of semi-structured interviews conducted July 2020-February 2021 with 22 maternity skilled heath personnel exploring their perceptions of service utilisation and (3) timeline data of COVID-19 epidemiology, global, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on the timeline analysis and triangulated when reporting.

RESULTS

Three periods including a first wave, slow period and second wave were identified. Maternal health service utilisation was lower during the pandemic compared with the prepandemic year in all but one selected referral hospital. During the pandemic, service utilisation was particularly lower during the waves and higher or stable during the slow period. Fear of being infected in hospitals, lack of transportation, and even when available, high cost of transportation and service closures were key reasons affecting utilisation during the waves. However, community perception that the pandemic was over or insinuation by Government of the same appeared to stabilise use of referral hospitals for childbirth.

CONCLUSION

Utilisation of maternal health services across the continuum of care varied through the different periods and across countries. In crisis situations such as COVID-19, restrictions and service closures need to be implemented with consideration given to alternative options for women to access and use services. Information on measures put in place for safe hospital use should be communicated to women.

'We are not going to shut down, because we cannot postpone pregnancy': a mixed-methods study of the provision of maternal healthcare in six referral maternity wards in four sub-Saharan African countries during the COVID-19 pandemic

INTRODUCTION

Referral hospitals in sub-Saharan Africa are located in crowded urban areas, which were often epicentres of the COVID-19 pandemic. This paper prospectively assesses how maternal healthcare was provided in six referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the COVID-19 pandemic.

METHODS

Mixed-methods design using three data sources: (1) qualitative data from repeated rounds of semi-structured interviews conducted between July 2020 and February 2021 with 22 maternity skilled heath personnel (SHP) on perceptions of care provision; (2) quantitative monthly routine data on caesarean section and labour induction from March 2019 to February 2021; and (3) timeline data of COVID-19 epidemiology, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on timeline analysis, and triangulated during reporting.

RESULTS

We identified three periods: first wave, slow period and second wave. The first wave was challenging for SHP given little knowledge about COVID-19, lack of infection prevention and control training, and difficulties reaching workplace. Challenges that persisted beyond the first wave were shortage of personal protective equipment and no rapid testing for women suspected with COVID-19. We noted no change in the proportion of caesarean sections during the pandemic, and a small increase in the proportion of labour inductions. All hospitals arranged isolation areas for women suspected/confirmed with COVID-19 and three hospitals provided care to women with suspected/confirmed COVID-19. Breastfeeding was not discouraged and newborns were not separated from mothers confirmed with COVID-19. Care provision was maintained through dedication of SHP, support from hospital management and remote communication between SHP.

CONCLUSION

Routine maternal care provision was maintained in referral hospitals, despite first wave challenges. Referral hospitals and SHP contributed to guideline development for pregnant women suspected/confirmed with COVID-19. Maternity SHP, women and pregnancy must always be included in priority setting when responding to health system shocks, including outbreaks.

Ovarian reserve in nigerian women with sickle cell anaemia: a cross- sectional study

INTRODUCTION

Sickle cell disease is the most common monogenetic disorder worldwide. There have been reports of endocrine dysfunction and gonadal failure among affected individuals, especially in males. The findings on ovarian reserve and failure in women with sickle anaemia have been inconsistent.

AIM AND OBJECTIVE

The aim of this study was to determine and compare the ovarian reserve of Nigerian women with and without sickle cell anaemia attending a University Teaching Hospital.

STUDY DESIGN

This cross-sectional study was carried out at the Adult Sickle Cell Clinic and the Community Health Clinic of the Lagos University Teaching Hospital.

METHODOLOGY

A total of 166 participants who met the selection criteria, were recruited for the study. The study population consisted of two groups of women matched for age: 83 women with HbSS and 83 women with HbAA. The haemoglobin phenotype of each participant was determined on alkaline electrophoresis (pH 8.4) before analysis. Serum Anti-Mullerian Hormone (AMH) was determined using Enzyme-linked immunosorbent assay (ELISA) method (Calbiotech Inc. USA, Catalog no AM448T).

RESULTS

The mean ± SD of serum AMH level in women with HbSS was 3.64 ± 0.65 ng/mL and was lower than that of women with HbAA 7.35 ±1.19 ng/mL (p < 0.001). Serum AMH negatively correlated with age in both study groups (HbAA and HbSS). Also, a significant negative correlation was found between serum AMH and BMI in women with HbAA.

CONCLUSION

The study showed diminished ovarian reserve in women with HbSS when compared to age-matched women with HbAA.

Genetic polymorphisms of Vascular Endothelial Growth Factor (VEGF) associated with endometriosis in Nigerian women

OBJECTIVE

To determine if genetic polymorphism of VEGF is associated with the development of endometriosis in Nigerian women.

STUDY DESIGN

Case control study of 100 women (50 healthy controls and 50 with endometriosis). Serum VEGF concentration of participants were determined using enzyme-linked immunosorbent assay (ELISA) technique. Genomic DNAs were isolated from peripheral blood samples and quantified by nanodrop spectrophotometer one. Single nucleotide polymorphisms genotyping was carried out by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP).

RESULTS

Mean age of participants was 32.96 ± 6.91 years for control and 32.04 ± 7.56 years for cases. VEGF levels in case and control groups were not statistically different (82.68 pg/ml [69.11-121.11 pg/ml] vs. 82.81 pg/ml [72.90-113.82 pg/ml] respectively; p = 0.967). All four genotypes examined were in Hardy-Weinberg equilibrium. Minor allele frequency of - 460T > C, - 1154G > A, + 936C > T and + 2578C > A were 24%, 8%, 6% and 10% in the control and 19%, 9%, 5% and 14% in endometriosis patients. However, allele and genotype distributions of - 460T > C, - 1154G > A, + 936C > T and + 2578C > A VEGF polymorphisms in endometriosis patients and control were not significantly different (p > 0.05).

CONCLUSION

Our preliminary findings revealed no association between endometriosis and - 460T > C, - 1154G > A, + 936C > T and + 2578C > A of VEGF genes among Nigerian women.

An assessment of geographical access and factors influencing travel time to emergency obstetric care in the urban state of Lagos, Nigeria

Previous efforts to estimate the travel time to comprehensive emergency obstetric care (CEmOC) in low- and middle-income countries (LMICs) have either been based on spatial models or self-reported travel time, both with known inaccuracies. The study objectives were to estimate more realistic travel times for pregnant women in emergency situations using Google Maps, determine system-level factors that influence travel time and use these estimates to assess CEmOC geographical accessibility and coverage in Lagos state, Nigeria. Data on demographics, obstetric history and travel to CEmOC facilities of pregnant women with an obstetric emergency, who presented between 1st November 2018 and 31st December 2019 at a public CEmOC facility were collected from hospital records. Estimated travel times were individually extracted from Google Maps for the period of the day of travel. Bivariate and multivariate analyses were used to test associations between travel and health system-related factors with reaching the facility >60 minutes. Mean travel times were compared and geographical coverage mapped to identify ‘hotspots’ of predominantly >60 minutes travel to facilities. For the 4005 pregnant women with traceable journeys, travel time ranges were 2–240 minutes (without referral) and 7–320 minutes (with referral). Total travel time was within the 60 and 120 minute benchmark for 80 and 96% of women, respectively. The period of the day of travel and having been referred were significantly associated with travelling >60 minutes. Many pregnant women living in the central cities and remote towns typically travelled to CEmOC facilities around them. We identified four hotspots from which pregnant women travelled >60 minutes to facilities. Mean travel time and distance to reach tertiary referral hospitals were significantly higher than the secondary facilities. Our findings suggest that actions taken to address gaps need to be contextualized. Our approach provides a useful guide for stakeholders seeking to comprehensively explore geographical inequities in CEmOC access within urban/peri-urban LMIC settings.

Low-dose aspirin for preventing intrauterine growth restriction and pre-eclampsia in sickle cell pregnancy (PIPSICKLE): a randomised controlled trial (study protocol)

INTRODUCTION

Pregnancy in sickle cell disease is fraught with many complications including pre-eclampsia (PE) and intrauterine growth restriction (IUGR). Previously, we found an abnormality in prostacyclin-thromboxane ratio in sickle cell pregnant women, a situation that is also found in non-sickle pregnancies with PE and unexplained IUGR. Low-dose aspirin (LDA) has been shown to reduce the incidence of PE and IUGR in high-risk women by reducing the vasoconstrictor thromboxane while sparing prostacyclin, in effect 'correcting' the ratio. It has been found to be safe for use in pregnancy but has not been tested in sickle cell pregnancy. We hypothesise that LDA will reduce the incidence of IUGR and PE in pregnant haemoglobin SS (HbSS) and haemoglobin SC (HbSC) women.

METHODS AND ANALYSIS

This is a multisite, double blind, randomised controlled trial, comparing a daily dose of 100 mg aspirin to placebo, from 12 to 16 weeks' gestation until 36 weeks, in Lagos state, Nigeria. Four hundred and seventy-six eligible pregnant HbSS and HbSC women will be recruited consecutively, randomly assigned to either group and followed from recruitment until delivery. The primary outcome will be the incidence of birth weight below 10th centile for gestational age on INTERGROWTH 21 birth weight charts, or incidence of miscarriage or perinatal death. Secondary outcomes will include PE, maternal death, preterm delivery, perinatal death, number of crises, need for blood transfusion and complications such as infections and placental abruption. Analysis will be by intention to treat and the main treatment effects will be quantified by relative risk with 95% CI, at a 5% significance level.

ETHICAL APPROVAL

Ethical approval has been granted by the Health Research and Ethics committees of the recruiting hospitals and the National Health Research and Ethics Committee. Study findings will be presented at conferences and published appropriately.

TRAIL REGISTRATION NUMBER

PACTR202001787519553; Pre-results.

Reproductive Maternal and Newborn Health Providers' Assessment of Facility Preparedness and Its Determinants during the COVID-19 Pandemic in Lagos, Nigeria

The global COVID-19 pandemic is predicted to compromise the achievement of global reproductive, maternal, and newborn health (RMNH) targets. The objective of this study was to determine the health facility (HF) preparedness for RMNH service delivery during the outbreak from the perspective of RMNH providers and to determine what factors significantly predict this. An anonymous cross-sectional online survey of RMNH providers was conducted from to July 1–21, 2020 in Lagos State, Nigeria. We conducted a descriptive and ordinal regression analysis, with RMNH worker perception of HF preparedness for RMNH service delivery during the outbreak as the dependent variable. In all, 256 RMNH workers participated, 35.2% reported that RMNH services were unavailable at some time since March 2020, 87.1% felt work-related burnout, 97.7% were concerned about the availability of personal protective equipment (PPE) and related guidelines, and only 11.7% were satisfied with the preparedness of their HFs. Our final model was a statistically significant predictor of RMNH worker perception of HF preparedness explaining 54.7% of the variation observed. The most significant contribution to the model was communication by HF management (likelihood ratio chi-square [LRCS]: 87.94, P < 0.001) and the availability of PPE and COVID-19 guidelines (LRCS: 15.43, P < 0.001). A one-unit increase in the level of concern about the availability of PPE and COVID-19 guidelines would increase the odds of observing a higher category of satisfaction with HF COVID-19 preparedness. Adequate support of RMNH providers, particularly provision of PPE and guidelines, and appropriate communications about COVID-19 should be prioritized as part of HF preparedness.

A double-edged sword-telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers

INTRODUCTION

The COVID-19 pandemic has led to a rapid implementation of telemedicine for the provision of maternal and newborn healthcare. The objective of this study was to document the experiences with providing telemedicine for maternal and newborn healthcare during the pandemic among healthcare professionals globally.

METHODS

The second round of a global online survey of maternal and newborn health professionals was conducted, disseminated in 11 languages. Data were collected between 5 July and 10 September 2020. The questionnaire included questions regarding background, preparedness and response to COVID-19, and experiences with providing telemedicine. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregated by country income level.

RESULTS

Responses from 1060 maternal and newborn health professionals were analysed. Telemedicine was used by 58% of health professionals and two-fifths of them reported not receiving guidelines on the provision of telemedicine. Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline and online psychosocial counselling. Challenges reported lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients. Telemedicine was considered as an important alternative to in-person consultations. However, health providers emphasised the lower quality of care and risk of increasing the already existing inequalities in access to healthcare.

CONCLUSIONS

Telemedicine has been applied globally to address disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. More research regarding the effectiveness, efficacy and quality of telemedicine for maternal healthcare in different contexts is needed before considering long-term adaptations in provision of care away from face-to-face interactions. Clear guidelines for care provision and approaches to minimising socioeconomic and technological inequalities in access to care are urgently needed.

Utilization cost of maternity services for childbirth among pregnant women with coronavirus disease 2019 in Nigeria's epicenter

OBJECTIVE

To estimate utilization costs of spontaneous vaginal delivery (SVD) and cesarean delivery (CD) for pregnant women with coronavirus disease 2019 (COVID-19) at the largest teaching hospital in Lagos, the pandemic's epicenter in Nigeria.

METHODS

We collected facility-based and household costs of all nine pregnant women with COVID-19 managed at the hospital. We compared their mean facility-based costs with those paid by pregnant women pre-COVID-19, identifying cost-drivers. We also estimated what would have been paid without subsidies, testing assumptions with a sensitivity analysis.

RESULTS

Total utilization costs ranged from US $494 for SVD with mild COVID-19 to US $4553 for emergency CD with severe COVID-19. Though 32%-66% of facility-based cost were subsidized, costs of SVD and CD during the pandemic have doubled and tripled, respectively, compared with those paid pre-COVID-19. Of the facility-based costs, cost of personal protective equipment was the major cost-driver (50%). Oxygen was the major driver for women with severe COVID-19 (48%). Excluding treatment costs for COVID-19, mean facility-based costs were US $228 (SVD) and US $948 (CD).

CONCLUSION

Despite cost exemptions and donations, utilization costs remain prohibitive. Regulation of personal protective equipment and medical oxygen supply chains and expansion of advocacy for health insurance enrollments are needed in order to minimize catastrophic health expenditure.

Reaching health facilities in situations of emergency: qualitative study capturing experiences of pregnant women in Africa's largest megacity

Background

The consequences of delays in travel of pregnant women to reach facilities in emergency situations are well documented in literature. However, their decision-making and actual experiences of travel to health facilities when requiring emergency obstetric care (EmOC) remains a ‘black box’ of many unknowns to the health system, more so in megacities of low- and middle-income countries which are fraught with wide inequalities.

Methods

This in-depth study on travel of pregnant women in Africa’s largest megacity, Lagos, is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Following familiarisation, coding, and searching for patterns, the data was analysed for emerging themes.

Results

Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choices vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time was between 5 and 240 min in daytime and 5–40 min at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had a personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women.

Conclusion

If the goal, to leave no one behind, remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved. Advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored.

A preprogram appraisal of factors influencing research productivity among faculty at college of medicine, University of Lagos

Background

A defining feature of any university is its dedication to scholarly activities, leading to the generation of knowledge and ideas Research productivity is a measure of achievement of a scholar. The number of research publications in peer-reviewed journals is an important criterion for assessing productivity and prestige in the academia.

Aims and Objectives

This cross-sectional descriptive study assessed the level of research productivity (RP) among junior faculty at the College of Medicine, University of Lagos, and investigated factors affecting their research output prior to the implementation of a 5-year training grant funded by the National Institutes of Health.

Methods

Seventy junior faculty members attended a pre-program training, and the self-reported number of peer-reviewed publications (PRPs) was used as an indicator. Intrinsic and extrinsic factors influencing RP among the attendees were assessed and ranked.

Results

The majority (42/70, 60%) of the respondents had <10 PRPs. The median (interquartile range) number of PRPs was 7 (3-18). A desire for the development of their personal skills, contribution to society, and personal research interests topped the list of intrinsic factors influencing RP. Work flexibility, research autonomy, and scholarly pursuits were the bottom three. A desire for promotion, respect from peers, and increased social standing were the top three extrinsic factors, while monetary incentives, employment opportunities, and the need to attend conferences were the lowest three. The top barriers to RP were lack of resources and lack of mentoring. Perceived older age, lack of time, and motivation were the lowest three barriers. Older age and professional cadre were associated with increased RP (P < 0.05).

Conclusion

Among the participants, research output appears to be motivated primarily by a desire for personal development,promotion, and respect from peers. Lack of access to resources was the main barrier to increased RP. These factors may need to be considered when developing programs designed to promote RP.

Caesarean delivery of first prediagnosed COVID-19 pregnancy in Nigeria

The COVID-19 pandemic is currently causing widespread infection and deaths around the world. Since the identification of the first case in Nigeria in February 2020, the number of confirmed cases has risen to over 9,800. Although pregnant women are not necessarily more susceptible to infection by the virus, changes to their immune system in pregnancy may be associated with more severe symptoms. Adverse maternal and perinatal outcomes have been reported among pregnant women with COVID-19 infection. However, literature is scarce on the peripartum management and pregnancy outcome of a pregnant woman with COVID-19 in sub-Saharan Africa. We report the first successful and uncomplicated caesarean delivery of a pregnant woman with COVID-19 infection in Nigeria.

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.

Evaluation of Umbilical Artery Doppler Indices in Pregnant Women With Sickle Cell Anemia Disease at a Nigerian Tertiary Hospital

Pregnant patients with sickle cell anemia (HbSS) are at risk of adverse outcomes to the mother and the fetus due to unique pathophysiologic changes. The purpose of this study was to determine the umbilical artery (UA) Doppler indices at 26 weeks gestational age (GA) in HbSS women with uncomplicated pregnancies and compare with the obstetric outcome. In this cohort study, 60 HbSS and 60 normal hemoglobin (HbAA) women with uncomplicated pregnancies were recruited from the antenatal clinic and prospectively followed to delivery. UA velocimetry, fetal biometry, maternal hematocrit, and parity were assessed at 26 weeks. Fetomaternal outcomes were also documented. UA Doppler indices and estimated fetal weights were comparable to those of HbAA control subjects at 26 weeks GA. There was a statistically significant increase in adverse obstetric outcomes in HbSS patients. There was no correlation between maternal hematocrit and artery indices. Further research is required to determine cutoff values and optimal timing for sonography in HbSS patients.

Prostacyclin, thromboxane and glomerular filtration rate are abnormal in sickle cell pregnancy

Background

Pregnancy increases the risk of morbidity and mortality in sickle cell disease. We previously showed pregnant women with sickle cell disease to have a relatively low plasma renin concentration in late pregnancy, associated with a lack of the expected plasma volume expansion. We hypothesized this to be due to increased systemic vascular resistance through an imbalance between the vasodilator prostacyclin and vasoconstrictor thromboxane, associated with decreased glomerular filtration rate (GFR).

Objective

To compare estimated prostacyclin, thromboxane and GFR in non-pregnant and pregnant women with hemoglobin SS (HbSS) and AA (HbAA).

Study design

Four groups of 20 normotensive, nulliparous women were studied in Lagos, Nigeria: pregnant HbSS or HbAA women at 36–40 weeks gestation; non-pregnant HbSS and HbAA controls. We measured stable metabolites of prostacyclin and thromboxane A₂ by enzyme-linked immunosorbent assay; GFR using the Cockcroft-Gault equation. Data analysis was by independent (Student’s) t-test or Mann-Whitney U test for comparisons between any two groups of continuous variables, univariate ANOVA for multiple groups and Pearson’s correlation coefficient for degree of association between variables.

Results

HbSS women had lower serum 6-keto-PGF1α concentrations than HbAA, whether pregnant or non-pregnant (P<0.001; P<0.004 respectively). Conversely, pregnant HbSS women had higher serum TxB2 (P<0.001); non-pregnant HbSS women had non-significantly higher TxB2 concentrations. The 6-keto-PGF1α:TxB2 ratio was markedly increased (pro-vasodilatory) in HbAA pregnancy (P<0.001) but reduced in HbSS pregnancy (P = 0.037). GFRs (mL/min) were higher in non-pregnant HbSS than HbAA (P<0.008) but only marginally raised in HbSS women in late pregnancy (P = 0.019) while markedly raised in HbAA pregnancy (P<0.001).

Conclusion

The lower ratio of prostacyclin-thromboxane metabolites in HbSS pregnancy may indicate endothelial damage and an increased tendency to vasoconstriction and clotting. If confirmed by subsequent longitudinal studies, interventions to increase prostacyclin and reduce thromboxane, such as low dose aspirin, may be potentially useful in their management.

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.

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.

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.