Cesarean section on request in a developing country

OBJECTIVE

To assess the prevalence of cesarean sections (CSs) and women's reasons for requesting the procedure in a developing country.

METHOD

Pregnant women scheduled for elective CS were interviewed to determine whether the procedure was requested by them or suggested by a physician. The women who personally requested a CS filled out questionnaires before surgery and at the postnatal visit 6 weeks later, and their answers were analyzed.

RESULTS

The prevalence of CS on request was 4.4%. Previous infertility and advanced maternal age at first pregnancy were the most common reasons for requesting a CS, but most women said they would prefer a vaginal delivery in subsequent pregnancies.

CONCLUSION

The women who requested a CS in this study did so for reasons different from those put forth by women in developed countries. The view that a CS is the surest way toward a live birth was the critical factor underlying their choice.

Contents and readability of currently used surgical/procedure informed consent forms in Nigerian tertiary health institutions

BACKGROUND

Surgical informed consent forms should have evidence that their use will enhance a shared decision-making which is the fundamental objective of informed consent in clinical practice. In the absence of any guideline in Nigeria on the content and language of informed consent forms, we sort to examine the surgical and procedure consent forms used by Federal tertiary health institutions in Nigeria, to know whether they fulfill the basic elements of informed consent.

MATERIALS AND METHODS

The surgical and procedure informed consent forms of 33 tertiary health institutions in Nigeria were assessed for their readability and contents. Adequacy of their content was evaluated based on provision for 28 content items identified as necessary information to be provided in a good consent form. The potential of the forms to be comprehended were assessed with Flesch readability formula.

RESULTS

The contents of majority of the forms were scant. None of the forms made provision for documentation of the patient's permission for blood transfusion, tissue disposal, awareness of the risks of not undergoing the prescribed treatment, and the risk of anesthesia. Risk disclosures were only mentioned in specific terms in 11.4% of the forms. Less than 10% of the forms made provisions for an interpreter, signature of anesthetists, alternative to the procedure to be mentioned, and answering of the patient's questions. The Flesch reading ease scores of the forms ranged from 34.1 (Difficult) to 67.5 (Standard), with a mean score of 55.2 (Fairly difficult level). Field evaluation of the forms show that they shall be partly understood by 13- to 15-year-old patients with basic education but are best understood by literate adult patients.

CONCLUSION

The content of majority of the informed consent forms used in Nigerian tertiary health institutions are poor and their readability scores are not better than those used in developed parts of the world. Health Institutions in Nigeria should revise their informed consent forms to improve their contents and do a usability trial on the sample forms before deployment in order to ensure that they are comprehensible for their patient population.

Induction of labor on request in a resource-poor setting

OBJECTIVE

To determine the prevalence of and reasons for induction of labor on maternal request in a setting where aversion to induction of labor is the norm.

METHOD

Women undergoing induction of labor on maternal request at three maternity centers in Enugu, Nigeria were interviewed by means of pre-tested self-administered questionnaires. The outcomes of labor in these women were also compared with those of a control group consisting of women who had induction of labor for medical reasons.

RESULTS

The prevalence of induction of labor on maternal request was 7.4%. Maternal convenience was the commonest reason for request induction. The outcomes of labor were similar between the subjects and their controls.

CONCLUSION

Nigerian women are beginning to request induction of labor without medical indications and have comparable outcomes with those who have medical indications. There is need for appropriate regulatory guidelines.

Evaluation of content and cost of traditional eye medication in a resource-poor country - Implications for eye care practice and policy

Background

Cataract, glaucoma, and conjunctivitis are common causes of ocular morbidity in Nigeria. A major obstacle in reducing the burden of ocular morbidity in rural areas is access to eye care services. Up to 80% of the population in developing countries use traditional medications for their primary healthcare needs because they are accessible, available, and affordable. The aim of this study is to evaluate the content and cost of commercialized traditional medications used in the treatment of common eye conditions in Nigeria.

Patients and Methods

All the registered traditional healers (THs) at an International Trade Fair in Enugu who treated eye problems were identified. Data on their location and scope of their practice were collected by the researchers. Proxy patients consulted THs in the trade fair with simulated cataract, glaucoma, and bacterial conjunctivitis, and treatment was sought. Medication for the treatment of the simulated disorders was paid for and procured. The mode of administration and the cost of the drugs were recorded by proxy patients. Each medication was labeled with a code and sent to the laboratories of the National Agency for Drug Administration and Control for analysis. Data were entered into a database on Microsoft Access and transferred to STATA V12.1 (StataCorp) for analysis.

Results

Cataract was treated by 87.5% of all the traditional eye healers interviewed. A total of 32 samples were collected and analyzed. These comprised mainly oral (53.1%) and topical traditional medications (43.8%). The pH of the topical samples ranged from 3.5 to 10, while the mean microbiological load per topical solution was 3.3 × 10⁴ cfu/mL ± 0.96. The cost of treatment of cataract ranged from 4 to 70 USD.

Conclusion

The content of the majority of the samples of traditional eye medications in this study had high extremes of pH and/or had a high microbial content. The practice of THs should be regulated.

Beliefs, perceptions, and views of pregnant women about cesarean section and reproductive decision-making in a specialist health facility in Enugu, Southeast Nigeria

Context

Through the process of socialization, women and men are conditioned to behave and play different roles in society. While the African culture "rewards" women who have vaginal birth despite the cost to their health, the burden of reproductive decision-making is placed on the menfolk. However, these seem to be changing.

Aims

Our aim was to assess the beliefs and perceptions of pregnant women about cesarean section (CS), including their views regarding decision-making on the mode of delivery, in Enugu, Southeast Nigeria.

Settings and Design:

A cross-sectional descriptive study.

Subjects and Methods

A structured questionnaire was administered to 200 pregnant women, following an oral informed consent.

Statistical Analysis Used

: Statistical Package for the Social Sciences version 17 with descriptive statistics of frequencies and percentages.

Results

All the respondents believe that CS is done for the safety of the mother/baby. Thirteen percent reject the procedure for themselves no matter the circumstance. Joint decision-making was the view of two-thirds of the women. Majority of them will accept CS if their husbands consent. Younger women were of the view that husbands decide on the delivery mode (P = 0.019).

Conclusions

Culture remains an impediment to CS uptake. Most women preferred joint decision-making on the mode of delivery.

A mixed-methods study of the drivers of stunting reduction among children under five in Nigeria, 2008-2018

BACKGROUND

Although stunting reduction at the national level in Nigeria has been modest in recent decades, especially considering the country's rapid economic growth, there is much subnational variation.

OBJECTIVES

The objective of this study was to identify the factors associated with declining stunting prevalence in those states in Nigeria where the most progress was made between 2008 and 2018.

METHODS

This mixed-methods study included quantitative analysis of household survey data using regression-based Oaxaca-Blinder decomposition analysis to identify factors associated with a change in mean height-for-age z-score (HAZ) over time; deductive thematic analysis of qualitative data collected through key informant interviews and focus group discussions; and policy and program review.

RESULTS

Improvement in child linear growth over the past decade is evident in exemplar states in both the north and south of Nigeria, driven largely by the same factors. Our modeling predicted 66% of the observed +0.25 increase in mean HAZ over time in exemplar states, with nearly 60% of the predicted increase associated with improvements in non-health sector factors: parental education (43%), household wealth (8%), and household sanitation (3%). Malaria prevention was associated with an additional 29% of the predicted HAZ change. Qualitative participants highlighted insecurity, poverty, and lower education levels in some parts of the country as barriers to improving child health and nutritional status, along with insufficient human resources for health despite an increase in the number of healthcare facilities in the country. Participants identified a range of policies and programs across multiple sectors as having likely contributed to the decline in stunting prevalence.

CONCLUSIONS

A multisectoral approach to stunting reduction in Nigeria appears to have been key, with progress having been driven by both the health sector and, especially, non-health sector action.

Experiences of female clients in the assisted reproductive technology process in Nigeria

Background

Though assisted reproductive technology (ART) has been a source of hope for many infertile couples, it is known to be associated with physical, social, psychological, and ethical challenges in different settings.

Objective

The study objective was to explore the experiences of female clients who accessed services in ART clinics in Nigeria.

Methods

An exploratory qualitative design, using snowballing technique was employed. It involved in-depth interviews of eight women who had gone through the assisted conception process, using an interview guide. Data collection was from November 2019 to January 2020. Results: The age range of the participants was 30 - 52 years with a mean of 41.88 years. Majority of the clients presented at advanced age to their ART providers because of lack of funds and ignorance. Other challenges were suboptimal risk disclosure, high cost of services, feelings of shame and stigmatization during and after the process.

Conclusion

Cost of ART remain unaffordable to most Nigerians hence the need for government subsidization and in-corporation of ART services into the National Health Insurance Scheme. Additionally, lack of adequate information disclosure, shared decision-making and gendered suffering are areas of great concern among the study participants. A national regulatory guideline will ensure uniform international standard of care.

Attitude of Nigerian obstetrician-gynecologists toward gamete donation

Background

Assisted Reproductive Technology (ART) as a treatment for infertility has come to stay in Nigeria. However, currently there is no national regulation of the practice even though the Association for Fertility and Reproductive Health has recently produced a guideline for practice by its members. Though there is an international trend toward more information giving to donors/clients/child in gamete donation, opinions and attitudes depend on cultural and societal values.

Aim

To investigate the attitude of Nigerian obstetrician/gynecologists toward gamete donation.

Subjects and Methods

This is a cross-sectional descriptive study in which a structured questionnaire was administered to 110 obstetrician-gynecologists following an oral informed consent. Data analysis was done using SPSS v. 20 by descriptive statistics of frequency and percentage, with Pearson Chi-square test for association between demographic variables and responses.

Results

The age range of respondents was 31-68 years with a mean of 44.5 +/-8.9 SD. Majority (85.5%) were males and 72 (65.5%) were <50 years of age. Seventy-five (68.2%) and sixty-six (60%) respondents were in support of anonymous and non-anonymous gamete donation, respectively. More than two-thirds of participants rejected giving off-springs donor information either in child or adulthood. Forty respondents (36.4%) rejected that parents be honest with the child about his/her genetic origin, whilst sixty-two (56.4%) and forty-three (38%) gynecologists were of the view that sperm and oocyte donors should not be compensated, respectively.

Conclusion

There is a greater support for anonymous than non-anonymous gamete donation among Nigerian obstetrician/gynecologists, and they also have a negative attitude to disclosure of donor-information to off-springs from gamete donation. They were more likely to support compensation for oocyte than sperm donors. Legal protection of donors and recipients through a national regulation will provide greater openness among all stakeholders.

Perception of Key Ethical Issues in Assisted Reproductive Technology (ART) by Providers and Clients in Nigeria

PURPOSE

In the past decade, developments in the field of Assisted Reproductive Technology (ART) have intensified the hopes and the desires of infertile people to overcome infertility, resulting in an increasing demand for such services worldwide. However, as developments in ART have evolved rapidly, so have ethical, social, and political controversies surrounding many aspects arisen. It is known that societal ethics is dependent on the values and culture of a given group. We sought to explore how practitioners and clients in Nigeria perceive some Key ethical issues surrounding ART.

MATERIALS AND METHODS

This was an explorative descriptive study involving in-depth interview of three ART providers and eight female ART clients, all domiciled in Southeastern Nigeria. Sampling was by purposive and snowballing techniques for providers and clients, respectively. Ethical approval was obtained from University of Ibadan/University College Hospital and University of Nigeria Teaching Hospital Research Ethics Committees. Responses were grouped into themes for ease of discussion.

RESULTS

Providers and clients were in support of sex selection for family balancing, and multiple embryo transfers. They also perceive that the health of the woman should be the factor considered and not biological age for service provision. However, views differed on marital status as an access factor. Participants were in support of legally binding regulations to guide practice.

CONCLUSION

A culturally sensitive national regulation is recommended to guide practice in this vital area of reproduction.

Gamete donation-A review of ethical and legal issues

Sperm and oocytes are building blocks in assisted reproduction. Sperm and ovum donation permit separation of the biological act of producing a child from the psychological process of nurturing and raising the child. However, the art of obtaining and use of these gametes are fraught with ethical and legal challenges. Relevant aspects concerning anonymity, genetic screening, consanguinity, informed consent and risk disclosure, compensation for donors, and child welfare are discussed. Though the issue of anonymity remains controversial, the importance of the welfare of the offspring has come to the fore as a result of the debate. Calls for more rigorous genetic testing for donated gametes to avoid genetic disease transmission, though supported by the principle of beneficence, has to be balanced by its possible deleterious effects on the donors and their relatives especially if findings reveal a serious genetic risk that has no medical treatment as yet. Reimbursement for direct and indirect costs, as well as fair compensation for time lost, inconveniences and risks suffered during treatment is recommended for oocyte donors. The risk of consanguinity remains a problem across the world even though the different guidelines limiting the number of pregnancies by a single gamete may be helpful, if enforceable. It is important that egg donors be clearly made to understand in simple language during the informed consent process of the yet unknown health risks involved so that the consent can be truly voluntary. This will protect donors from the backlash of the doctrine of "Volenti Non Fit Injuria". It is also suggested that specific legislation with regards to gamete donation, parenthood, and ART should be passed in countries where these are absent, to avoid controversies that may arise due to current gaps in the law.