Time Interval between Onset of Symptoms of Severe Preeclampsia to Delivery: Effect on Pregnancy Outcomes at Mbarara Regional Referral Hospital, South Western Uganda

Background: Hypertensive disorders of pregnancy (HDP) account for nearly 18% of all maternal deaths worldwide. Preeclampsia is a leading cause of direct maternal mortality worldwide, and the second in Uganda contributing about 9.1% of total maternal death. Expectant management of severe pre-eclampsia at 30–34 weeks is associated with good perinatal outcome and risk reduction for the motherMethods: This was a retrospective cohort study done by reviewing maternal medical records from September 2009 to September 2011 and all mothers who had delivered at Mbarara Hospital with a diagnosis of severe pre-eclampsia (SPE) during study period were included in the study. Results: Primigravida accounted for about 42.6% of the cases of severe pre-eclampsia studied and majority (66.7%) of the women were aged between 20-30 years. The overall good fetal outcome rate in this study was 47.5% and 68.3% of the women studied were more than 28 weeks of amenorrhoea and 31.2% had still births. The most common symptom was headache (47%) and over 35% of these women presented for delivery more than 72hours from onset of symptoms. Delivery between 0-18 hours was protective OR 0.43, CI=0.29-0.52), p-value 0.013Conclusions: The complication rate associated with severe preeclampsia is high and worsens with longer duration of symptoms before delivery. Delivery within 18 hours of onset of symptoms is associated with good fetal outcomes and this stresses the importance of early presentation for care by the mothers and timely decision making by the clinicians.

Association between Labour Outcomes and Level of Healthcare System at Which Initial Delivery Assessment is done before Referral in South Western Uganda

Background: In 2013, an estimated 289,000 women died due to complications in pregnancy and childbirth, (WHO 2014). In the same year, almost 1 million newborns died on the day they were born (UNICEF, 2014).Access to appropriate maternity care including prompt referrals for emergency obstetric care (EmOC) services and skilled birth attendance could significantly reduce both perinatal and maternal mortality and/or morbidity (C. Ronsmans et al., 2006, A. Paxton et al 2005).Objective: To determine the association between labour outcomes and the level of healthcare system at which delivery is first attempted before referral to Mbarara hospital (MRRH).Methods: Retrospective review of 644 records was done over a period of five months for referrals that delivered at MRRH. The data was analyzed using SPSS and cross tabulations were done and frequencies, percentages and Pearson Chi-square statistics obtained. Bivariate and multivariate logistic regression models were used to test association. Significance level was set at p value < or = 0.05.Results: First attempt of delivery from a hospital was protective against poor fetal and maternal outcomes OR= 0.43 [0.27-0.69, 95%CI] p<0.001, and OR= 0.49, [0.27-0.92, 95%CI],p=0.024  respectively. A distance of more than 5km from the health facility was associated with poor maternal outcomes OR= 2.38, [1.16-4.86, 95%CI] p=0.015 and urban residence was protective against poor fetal outcomes OR= 0.29, [0.18-0.46,95%CI], p<0.001.Conclusion/Recommendations: Initial labour assessment and management in lower health facilities is associated with poor delivery outcomes. Lower health facilities should be support supervised and mentored as pertains management of mothers in labour. Keywords: Referral, delivery, outcomes, attempt

Factors associated with poor delivery outcomes among women delivering by breech in South Western Uganda: Unmatched case control study

Background: It is globally observed that breech delivery through vaginal route is associated with more adverse neonatal outcomes compared to caesarian section including low 5 minute Apgar score and perinatal mortality increased. The ideal mode of delivery in breech presentation remains an area of intense controversy worldwide coupled with paucity of studies to high light factors associated with poor outcomes among breech deliveries. Objective: This study set out to determine the neonatal delivery outcomes in women delivering by breech at Mbarara University teaching hospital, South Western Uganda and factors associated with poor neonatal outcomes among breech deliveries. Methods: This was an unmatched case control study of 208 breech births between January to December 2014. Relevant socio-demographic and obstetrical variables were abstracted from patients’ records. The data was analyzed using SPSS and cross tabulations were done and frequencies, percentages and Pearson Chi-square statistics obtained. Bivariate and multivariate logistic regression models were used to test association. Significance level was set at p value < or = 0.05 Results: Among the 206 deliveries that were analyzed, 120 babies delivered by caesarean section (C/S) and 86 by assisted vaginal breech delivery. In the C/S group, 4 (3.3%) were fresh still births (FSB) and 116 (96.7%) were live births while in the assisted vaginal breech group, 25 (29.1%) were FSB and 61 (70.1%) were live births. Babies born by C/S had better Apgar scores at 5 minutes with 5 (4.1%) of babies born through C/S scored 0-6 while 115 (95.8%) scored between 7-10 whereas 31 (36%) of babies born by assisted vaginal breech delivery scored between 0-6 while 55 (64%) scored between 7-10. The factors associated with low Apgar scores at five minutes and fresh still births were vaginal mode of delivery, birth weight of less than 3 kilograms and multi-parity. Conclusion: Safe caesarian section and birth weight >2.5kg is associated with better perinatal outcome among breech deliveries Keywords: Breech delivery, mode of delivery, birth weight, Apgar score, perinatal outcome

Association between Contraceptive Awareness and Use, and Teenage Pregnancy among Prime Gravidas Delivering at Mbarara Hospital Regional Referral, Uganda

Introduction: The promotion of family planning, so that women can avoid unwanted pregnancy, is central to the World Health Organisation work on improving maternal health. This requires that women have access to safe and effective methods of fertility control. It is estimated that 90% of abortion-related and 20% of pregnancy-related morbidity and mortality, along with 32% of maternal deaths, could be prevented by use of effective contraception. In sub-Saharan Africa, it is estimated that 14 million unintended pregnancies occur every year, with almost half occurring among women aged 15–24 years. The objective of this study was to determine the impact of contraceptive awareness and use on teenage pregnancy among primigravidas at Mbarara Regional Referral Hospital, Southwestern Uganda. Methods: The study was conducted on postnatal ward at Mbarara Regional Referral Hospital between October and December 2015 using case control design by consecutively sampling 100 primiparas who delivered during the study period at gestation age ≥28 WOA Results: The total number of respondents was 100 where by 30 mothers were below 20 years and 70 above 20 years. The age range was 15- 35 years and the most frequent age was 20 years.  Majority of teenage mothers were either married or cohabiting (85%), unemployed (57%), never used contraceptive (93%), lacked knowledge of long term contraception (71%) and emergency contraception (84%). Lack of Knowledge of contraceptives, long term contraception and Emergency contraception was found to be strongly associated with likelihood of teenage pregnancy [OR (95%CI) and p values: 7.992(2.533- 25.222) <0.0001, 6.838(1.891-24.730) 0.001, 0.105(0.013-0.837) 0.012] respectively. Other factors associated with teenage pregnancy included rural residence [OR (95%CI) 2.382 (1.022-5.556) p value 0.043], Education Below secondary level [OR (95%CI): 5.167(2.116-12.617) p value<0.0001] and being unemployed [OR (95%CI): 9.374(2.595-33.859) p value <0.000]. Conclusion: Majority of teenage mothers delivering at Mbarara Regional Referral Hospital lack knowledge about contraception, long term contraceptives and emergency contraception. This knowledge gap is associated with low use of contraception and hence of teenage pregnancy. Key Words: teenage mothers, Contraception, Knowledge, Primigravida

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

Prevalence, Outcome and Associated Factors among Adolescents Delivering at Mbarara Regional Referral Hospital

Globally, almost one in five women aged 20 to 24 (19 %) had a live birth by their 18th birthday. Adolescent pregnancies and deliveries are universally recognized to be associated with many complications. Although many studies have been done on adolescent mothers globally, not much has been documented on the prevalence, outcomes and associated factors especially in Uganda. This study aimed at finding out the prevalence of adolescent deliveries, delivery outcomes and potential factors influencing these outcomes among adolescent mothers at Mbarara Regional Referral Hospital (MRRH), in Southwestern Uganda. We conducted a cross sectional study at MRRH between June and October 2015. We consecutively sampled 786 adolescent mothers within 24 hours postpartum and obtained their characteristics and delivery outcomes. The prevalence of adolescent deliveries at MRRH was 23.4% of all deliveries. Majority of the participants were aged 18-19 years (median 18.5years, standard deviation 0.87).  Majority had only attained primary education and almost all (90.5%) were married. Most had an average of 3 antenatal care visits, delivered by spontaneous vaginal delivery (59.4%). Caesarian section rate was 39.4% with the main indication of contracted pelvis (45.8%).  Majority had good fetal outcome (80.7%) while 50.2% of mothers had poor outcome. The main obstetric complication was perineal tears (32.6%) followed by prolonged labour (23%). Being referred and delivery by vacuum delivery remained significantly associated with poor outcomes while episiotomy and delivery by Caeserian section were protective. The prevalence of adolescent deliveries at MRRH is high with most of adolescent mothers having poor sociodemographic characteristics. Commonest poor maternal outcome was perineal tears followed by prolonged labour. Fetal outcomes were good. Being referred and delivery by vacuum delivery were associated with poor outcomes while episiotomy and delivery by Caeserian section were associated with good fetal outcome. Keywords: adolescent delivery, delivery outcome, maternal outcome, fetal outcome, associated factor

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

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

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