Disclosure, Contraceptive Practices, Reproductive Desires and Outcomes of Abortion, at Mbarara Regional Referral Hospital

Background: Globally, abortion mortality accounts for at least 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing mortality and morbidity from abortion constitutes an important part of safe motherhood initiatives. Methods: This was a cross sectional study. The study period was from August to December 2015. Women with missed abortion and threatened abortion were excluded. The outcome variables included treatment outcomes, contraceptive practices, reproductive desires and disclosure. Results: There were a total of 40 respondents. Prevalence of knowledge of contraceptives was 87.5%, though 95% lacked knowledge of ECs.  The ended pregnancy was unintended in majority of respondents (62.5%). Half of the abortions 50% were induced. Of the eight induced abortions (62.5%) were done by health workers, (25%) by a traditional healer, and 12.5% by a relative. The methods used to induce the abortion included medical methods (25%) =5, surgical (60%) n=12, mechanical local (5%) n=1, herbal (10%) n=2.  Complications of abortion occurred in 20%. Women who had intended pregnancy were more willing to get more children as compared to women who had had unintended pregnancy, 60 % and 54 % respectively. More complications occurred among induced abortions as compared to spontaneous abortion37.5% and 9.7% respectively. Eight women (20%) volunteered to have induced abortion. Conclusion: There is low knowledge of ECs among women undergoing PAC at MRRH with majority having unintended pregnancy. Half of the abortions are induced. Providers of abortion include health workers, a traditional healer, and a relative. The methods used included medical method, mechanical local and, herbal   Complications of abortion occurred in 20%. , and these included septic abortion, perforated viscera and anaemia. Women who had intended pregnancy were more willing to get more children as compared to women who had had unintended pregnancy. More complications occurred among induced abortions as compared to spontaneous abortion. Voluntary disclosure was in 40% of all women who had induced abortion. Recommendations: There is need for expansion of contraceptive services in order to reduce the burden of unintended pregnancies. Emergency contraception should be made more available. All abortions should regard and managed as induced abortion as the rate of voluntary disclosure is low (40%). Keywords: Contraceptive, Practice, Desires, Abortion

Factors Associated with Short Births Intervals among Women Delivering at Mbarara Hospital

Background; Birth interval is the time between two consecutive births. World Health Organization recommends a minimum birth to pregnancy interval of 24months after live birth and 6months after abortion. Short birth interval is associated with adverse perinatal and maternal outcomes. Few studies have described factors associated with birth intervals. Knowing these factors will enable stake holders and care providers to modify practice to address them thus improving neonatal infant and maternal health.Methods: This was a case-control study. We enrolled 56cases and 162 controls that consented to the study and interviewed them. Statistical analysis was done using SPSS statistical software, version 20 (SPSS, Chicago, IL, USA). Cross tabulations was conducted to obtain descriptive statistics. Bivariable and multivariable logistic regression models were used to test the association.Results: The age of participants ranged from 17 to 42years, the modal birth interval as 36months. Age below 30years P=0.015 (OR 2.3 CI 1.17-4.67), low education level P= 0.005, lack of contraceptive use P=0.000 and lack of contraceptive P=0.000. A previous good fetal birth outcome and having live child was protective P=0.000, P=0.000 respectively.Conclusion and recommendation: Contraceptive knowledge and use programs targeting mothers below 30years should be strengthened especially in the postnatal period. Universal secondary school education program should be strengthened. Programs to improve neonatal and child survival should be strengthened as they directly affect child spacing thereby indirectly affecting maternal health. Keywords: Birth interval, Deliver

Resources and Costs for Initiation and Sustainability of a Secondary Cervical Cancer Prevention Clinic at Mbarara Regional Referral Hospital, Uganda

Background: Each year approximately 450,000 new cases of invasive cervical carcinoma are diagnosed worldwide. The cervical cancer incidence rate is highest in countries that have little or no cytologic cervical cancer screening. There are many barriers to establishing cervical cancer screening programs in resource-poor settings. The main objective was to determine the cost of setting up and sustaining secondary cervical cancer prevention services in Uganda. Methods: In order to evaluate the use of alternative screening methods in a resource-poor setting, we instituted a study at the colposcopy and cervical pathology clinic at Mbarara Regional Referral Hospital in Uganda. Previously unscreened women ages 25years and above were screened using a combination of conventional cytology and direct visual inspection (DVI). The outcomes included costs of clinic set up, training costs, cost of equipments, salaries and supplies. Screening strategies were distinguished by the number of clinical visits, the use of 1 or 2 screening tests and screening frequency. Screening tests included DVI and cytology. Results: The screening started in April 2009 through aid of an American non government organization known as Program for Appropriate Technology in Health (PATH) which provided the initial funding for equipment and clinic set-up. Out of 4659 women screened in 2013, 73.2% were below 50 years, 17.7% were 50 years and above. Majority of women (55.0%) come from Mbarara district, 71.3% were from rural areas outside Mbarara Municipality. The prevalence of HIV was 19.0%. Cervical intraepithelial neoplasia comprised (4.8%), 225cases, while cervical cancer comprised (2.7%) 125cases, 94.2% were treated with Cryotherapy, 5.3% were treated by LEEP and one total abdominal hysterectomy. The cost of reusable requirements for setting up a cervical cancer screening clinic was Ugshs 11,730,000.00. The cost of screening a population of 4659 in 2013 was 54, 302, 200.00, the cost of screening one woman using acetic acid was Ugshs 152.00, and Pap smear per woman is Ugshs 55,000.00, while the cost of screening one woman using lugol’s iodine was Ugsh 4,000.00(the cost of reusable speculums, gloves,cotton and gauze is not included on individual patients).  The cost of cin treatment of a population of 3569 women was Ugshs 9,800,000.00 plus 2280.00USD. Cryotherapy per woman was Ugshs 46,226.00.(the cost of  gloves, cotton, guaze and reusable equipment such as speculums is not included). When using two  stationary clinic nurses the cost in salaries and training will be Ugshs 23,204,000.00, however if using outreach model the cost in allowances and training will be 85,450,000.00. When using a group of 20 volunteers for the outreach model the cost in allowances and training will be Ugshs 33,050,000.00.(USD = Ugshs 4000.00). (The cost of gloves, cotton swabs and gauze is not included). Conclusion: Cytologic screening is several times more costly than direct visual inspection (DVI). Visual inspection screening of the cervical and treatment with Cryotherapy can be used as a cost effective alternative method to cytologic examination for control of cervical cancer in low resource areas. Using existing staff and integration of screening services into existing services into annual hospital budget helps in sustainability of donor initiated cervical cancer screening programs. Recommendations: Cervical cancer screening programs in low resource areas should adopt direct visual inspection using 3-5% acetic acid as the main screening method and “see and treat” approach for treatment of positive lesions. For program sustainability cervical cancer screening services should be integrated into the main hospital programs and annual budget. Existing personnel and infrastructure should be used for cost effectiveness and sustainability. Keywords: Resources, Initiation, Sustainability, Cervical Cancer, Preventio

Knowledge and Perceptions of Severe Pre-Eclampsia among Postnatal Women at Mbarara Regional Referral Hospital

Background: Preeclampsia is associated with acute and long-term morbidities. Knowledge of obstetric danger signs and birth preparedness are important strategies at enhancing utilization of skilled care in low income countries. It is generally believed that in light of a looming disaster, those who promote and regulate health and safety need to understand how people think about and respond to risk. We undertook this study because we wanted to know how women in Mbarara perceive vulnerability or risk of death due to severe preeclampsia and how their perceptions influence their response. Methods: This was a cross sectional study that recruited mothers on the postnatal ward. These women were expected to have gained knowledge about pregnancy danger signs during their antenatal period. Women were classified to have either high knowledge perceptions or low knowledge perceptions based on their perceived knowledge of symptoms, complications, right decision and perceived dangers. Knowledge about the above areas of assessment was analyzed and classified as high and low knowledge perceptions. Results: Eighty three percent (83.0%) did not know any symptom of severe preeclampsia, 99.1% knew less than three symptoms of severe preeclampsia, and 36.6% did not know any complication of severe preeclampsia. Conclusion: The knowledge concerning pre eclampsia and its symptoms are still low among women at Mbarara Regional Referral Hospital. Many post natal mothers have misconceptions about severe pre eclampsia and its symptoms. “When I get headache i eat some food or drink water” --- it is a sign of hunger or dehydration’’ are some of the responses we received from the respondents. Recommendations: There is need for the antenatal care service providers to emphasize to the mothers about danger symptoms and signs in pregnancy. Health education during antenatal clinics should be given in a language and methods easily understood by women

Antiretroviral treatment Long-Term (ALT) cohort: a prospective cohort of 10 years of ART-experienced patients in Uganda.

PURPOSE: Little information is available on patients on antiretroviral treatment (ART) after a long-term period from sub-Saharan Africa, with the longest follow-up and related outcomes being after 10 years on ART. At the Infectious Diseases Institute (IDI) (Kampala, Uganda), we set up a cohort of patients already on ART for 10 years at the time of enrolment, who will be followed up for additional 10 years. PARTICIPANTS: A prospective observational cohort of 1000 adult patients previously on ART for 10 years was enrolled between May 2014 and September 2015. Patients were eligible for enrolment if they were in their consecutive 10th year of ART regardless of the combination of drugs for both first- and second-line ART. Data were collected at enrolment and all annual study visits. Follow-up visits are scheduled once a year for 10 years. Biological samples (packed cells, plasma and serum) are stored at enrolment and follow-up visits. FINDINGS TO DATE: Out of 1000 patients enrolled, 345 (34.5%) originate from a pre-existing research cohort at IDI, while 655 (65.5%) were enrolled from the routine clinic. Overall, 81% of the patients were on first line at the time of the enrolment in the ART long-term cohort, with the more frequent regimen being zidovudine plus lamivudine plus nevirapine (44% of the cohort), followed by zidovudine plus lamivudine plus efavirenz (22%) and tenofovir plus lamivudine or emtricitabine plus efavirenz (10%). At cohort enrolment, viral suppression was defined as HIV-RNA <400 copies/mL was 95.8%. FUTURE PLANS: Through collaboration with other institutions, we are planning several substudies, including the evaluation of the risk for cardiovascular diseases, the assessment of bone mineral density, screening for liver cirrhosis using fibroscan technology and investigation of drug-drug interactions between ART and common drugs used for non-communicable diseases

Distribution of Pregnancy Complications by Gestational Age at Mbarara Regional Referral Hospital, Southwestern Uganda

Background: During pregnancy; both the woman and her developing foetus face various health risks. Pregnancy complications can range from mild discomfort, to severe, sometimes life threatening illnesses. Our objective was to determine the pregnancy complications and the associated gestation ages at Mbarara regional referral hospital. Methods: It was a cross sectional study. The Primary outcome was any pregnancy complications. The sample size was 1016. Pearson Chi-square was used to determine association between categorical variables.  Odds ratio was used to determine statistical significance. Results: The complications included abortion 6.2%, preterm labour 6.0%, and preeclampsia, premature rupture labour, preterm premature rupture of membranes, urinary tract infections 2.4%, malaria, intrauterine feotal death 1.5%, antepartum haemorrhage 1.5% and anaemia. The complications started rising from 29 weeks to 36 weeks and started declining thereafter but rose again after 42 weeks. Majority of complications occurred between 29 and 36 weeks. At bivariate analysis the following were found to be significantly associated with complications in pregnancy, age 35 years and above (OR 2.247(1.376-3.670), 95% CI), being single was negatively associated with absence of pregnancy complications(OR 0.435(0.219-0.863,95% CI), a gestational age bracket of 29-36 was negatively associated with absence of pregnancy complications (OR 0.169(0.123-0.233,95% CI), Conclusion: Though pregnancy complications can occur at any gestational age, there are three peaks at which complications are most common, early pregnancy between 5-16 weeks, 29–36 weeks and after 44weeks of gestation. Pregnancy complication drastically dropped towards term i.e. from 37-42 weeks and an increasing trend thereafter. A maternal age of 35 years and above, being single and a gestational age bracket of 29-36 are associated with pregnancy complications. Recommendations: Pregnant women who are 35 years and above and those who are single need to be monitored as high risk pregnancies. Investigations should be carried out for all women between 29-36 weeks when they come for antenatal care to rule out the potential risks. Pregnancies beyond 42 weeks should be induced. First antenatal care attendance should be as early as five weeks and efforts should be made to encourage preconception care in our setting since complications of pregnancy are high in the first few weeks of gestation

Prevalence and Factors Associated With Genital Chlamydial Infections among Women Attending the Gynaecology Clinic At Mbarara Regional Referral Hospital

Background: Chlamydia trachomatis is responsible for the most common bacterial sexually transmitted bacterial infection. The largest burden is in low income countries. These organisms are not screened for in Mbarara, and information about the burden of disease is no available. This study aimed at establishing the prevalence and factors associated with genital Chlamydia infection among women of reproductive age attending the gynecology clinic at Mbarara Regional Referral Hospital. Methods: In a cross-sectional study done at Mbarara Regional Referral Hospital, 324 women aged 15-49years were consented and interviewed. Data on socio-demographics, maternal medical conditions, obstetric and gynaecological factors and endocervical swabs were collected consecutively from November 2015 to January 2016 from women attending gynaecology clinic at Mbarara Regional Referral Hospital. Samples were analysed using a using CTK biotech Chlamydia kit, which is a rapid immunoassay test for the detection of genital chlamydial antigen in urogenital samples. Results were analysed using STATA 13, Logistic regression models were used to estimate level of significance, the odds ratios (OR) and 95 % CI of the association between the factors and genital infections. Significance was set at a p value of &lt;0.05. Results: Of the 324 samples collected,86 were positive for C. trachomatis antigen giving a prevalence rate of 26.5%. Of all the associated factors examined, only type of residence was significantly associated with C. trachomatis infection (p= 0.0413) with those living in peri-urban areas at greater risk of infection ( aOR 2.4  95%CI (1.22-4.82). Other social demographic ,medical obstetric and gynecological factors were not associated with C. trachomatis infection. No symptom or clinical sign was significant for the infection. Conclusion and recommendation: The prevalence of genital C. trachomatis infection among women attending gynecology clinic is high. Genital Chlamydia infection has no predictive signs and symptoms in our setting. Screening of women in reproductive age should be encouraged. Keywords; Genital Chlamydia trachomatis, endocervical swabs, gynaecology clinic.

Comparison of different cardiovascular risk tools used in HIV patient cohorts in sub-Saharan Africa; do we need to include laboratory tests?

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of death globally, representing 31% of all global deaths. HIV and long term anti-retroviral therapy (ART) are risk factors for development of CVD in populations of people living with HIV (PLHIV). CVD risk assessment tools are currently being applied to SSA populations, but there are questions about accuracy as well as implementation challenges of these tools in lower resource setting populations. We aimed to assess the level of agreement between the various cardiovascular screening tools (Data collection on Adverse effects of anti-HIV Drugs (D:A:D), Framingham risk score, WHO risk score and The Atherosclerotic Cardiovascular Disease Score) when applied to an HIV ART experienced population in Sub-Saharan Africa. METHODS: This study was undertaken in an Anti-Retroviral Long Term (ALT) Cohort of 1000 PLHIV in care who have been on ART for at least 10 years in urban Uganda. A systematic review was undertaken to find the most frequently used screening tools from SSA PLHIV populations; these were applied to the ALT cohort. Levels of agreement between the resulting scores (those including lipids and non-lipids based, as well as HIV-specific and non-HIV specific) as applied to our cohort were compared. Prevalence Bias Adjusted Kappa was used to evaluate agreement between tools. RESULTS: Overall, PLHIV in ALT cohort had a median score of 1.1-1.4% risk of a CVD event over 5 years and 1.7-2.5% risk of a CVD event over 10 years. There was no statistical difference in the risk scores obtained for this population when comparing the different tools, including comparisons of those with lipids and non-lipids, and HIV specific vs non-HIV specific. CONCLUSION: The various tools yielded similar results, but those not including lipids are more feasible to apply in our setting. Long-term cohorts of PLHIV in SSA should in future provide longitudinal data to evaluate existing CVD risk prediction tools for these populations. Inclusion of HIV and ART history factors to existing scoring systems may improve accuracy without adding the expense and technical difficulty of lipid testing

Factors Associated With Adverse Perinatal Outcomes Among Women Referred In Labour to Mbarara Regional Referral Hospital.

Background: In 2013, 1 million newborns died on the day they were born, 2 million newborns died within the first seven days after birth, representing 73 per cent of all neonatal deaths. There are also 1.19 million intrapartum related stillbirths (Lawn et al., 2011) yet 280,000 babies die of birth asphyxia soon after birth. Poor fetal outcomes are higher among women who are referred for delivery. Objectives: The aim of the study was to determine factors associated with adverse perinatal outcomes among women referred in labour to Mbarara regional referral hospital (MRRH). Methods: We conducted an unmatched case-control study between October 2015 and February 2016 .A total of 106 cases and 212 controls were enrolled in the study. A case was a mother who delivered a baby with an adverse perinatal outcome (still birth, early neonatal death or need for admission in the neonatal ward) while a control was mother who delivered a baby with no adverse perinatal outcome. Data was collected entered in Epidata version 3.1 and analyzed using STATA Version 2012. Frequencies, percentages and Pearson Chi-square statistics obtained. Bivariate and multivariate logistic regression models were used to test association. Odds ratios with their corresponding 95% confidence intervals (CI) and p-values were recorded.  Significance level was set at p value &lt; or = 0.05. Results: Admission in second stage of labour (aOR 95% CI: 3.7 [ 1.53-9.03], p=0.0001), fetal distress (aOR 95% CI:  7.1 [ 2.92-17.45], p&lt;0.001), cord prolapse (aOR 95% CI: 7.2 [1.13-45.72], p=0.037), gestational age below 37 weeks (aOR 95% CI: 2.74 [1.25-6.00], p&lt;0.0391), preeclampsia (aOR 95% CI:13.3 [ 2.75-63.85], p=0.001), ruptured uterus (aOR 95% CI: 38.7 [4.55-329.00], p=0.001), pre-referral interventions (aOR 95% CI: 2.0 [1.12-3.73], p=0.020), and  stay at the referring facility for less than 6 hours (aOR 95% CI: 4.7 [1.33-16.48], p=0.0221) were independently associated with adverse perinatal outcomes among women referred in labour to MRRH. Socio-demographic factors were not associated with adverse perinatal outcomes. Conclusion: Admission in second stage of labour, fetal distress, gestational age less than 37 weeks, ruptured uterus, cord prolapse, pre-eclampsia, pre-referral interventions and stay at the referring health facility for less than 6 hours were independently associated with adverse perinatal outcomes among referrals in labour at MRRH. There was no association between socio-demographic factors and adverse perinatal outcomes of referrals to MRRH. Early recognition women at risk of adverse perinatal outcomes, timely referral followed by prompt and appropriate management, may reduce the adverse perinatal outcomes among women referred in labour. Keywords: Referral, Adverse perinatal outcomes, Labour

Association between Duration of Second Stage of Labour and Perinatal Outcomes among Mothers admitted in Labour at Mbarara Regional Referral Hospital, Uganda

About four million babies die in the first 4 weeks of life annually. Most of the neonatal deaths occur in the first week mainly on the first day after delivery. The objective of our study was to determine the factors associated with poor perinatal   outcomes among low risk mothers admitted in labour at Mbarara Regional Referral Hospital (MRRH). This was a retrospective cohort study of mothers on the postnatal ward of MRRH. The total number of respondents was 140. The duration of second stage was ≤30 minutes in 70.0% of the women.  The number of women with poor feotal outcome was 27(19.3%). The poor outcomes included, birth asphyxia, fresh still birth and early neonatal death. The odds of having a good feotal delivery outcome was inversely proportional to time, with best results registered when delivery occurred within 30minutes OR, 4.9, 95% CI (1.8-13.1), weakening towards duration of ≥60 minutes with OR, 17.7, 95% CI (5.3-52.5). A second stage of labour lasting more than 60 minutes is associated with poor neonatal outcomes.For best perinatal outcomes we recommend if the second stage exceeds 60 minutes, labour should be re-assed and action should be taken to avoid further delay. To avoid poor neonatal outcomes, a second stage of labour lasting more than 60minutes requires continuous feotal monitoring