Reducing maternal deaths in a low resource setting in Nigeria

Objective: To assess the impact of the adoption of evidence based guidelines on maternal mortality reduction at Enugu State University Teaching Hospital, Nigeria.Materials and Methods: A retrospective review of all maternal deaths between 1st January, 2005 and 31st December, 2010 was carried out. Evidence based management guidelines for eclampsia and post‑partum hemorrhage were adopted. These interventions strategy were carried out from 1st January, 2008‑31st December, 2010 and the result compared with that before the interventions (2005‑2007). Main outcome measure: Maternal mortality ratio (MMR) and case fatality rates.Results: There were 9150 live births and 59 maternal deaths during the study period, giving an MMR of 645/100 000 live births. Pregnant women who had no antenatal care had almost 10 times higher MMR. There was 43.5% reduction in the MMR with the interventions (488 vs. 864/100 000 live births P = 0.039, odds ratio = 1.77). There was also significant reduction in case fatality rate for both eclampsia (15.8% vs. 2.7%; P = 0.024, odds ratio = 5.84 and Post partum hemorrhage (PPH) (13.6% vs. 2.5% P value = 0.023, odds ratio = 5.5. Obstetric hemorrhage was the most common cause of death (23.73%), followed by the eclampsia.Conclusion: Administration of evidence based intervention is possible in low resource settings and could contribute to a significant reduction in the maternal deaths.Key words: Eclampsia, guidelines, hemorrhage, low resource settings, maternal death, Nigeri

Maternal mortality in a Transitional Hospital in Enugu, South East Nigeria

Nigeria has one of the highest maternal mortality ratios in the world. The study was to determine the trend of maternal mortality ratio in the hospital as it transits from a General through a Specialist to a Teaching hospital. It was a retrospective review of maternal deaths at Enugu State University Teaching Hospital Parklane, over its 5 year transition period (January 2004 to December 2008). There were 7146 live births and 60 maternal deaths giving an overall maternal mortality ratio (MMR) of 840/100,000 livebirths. The MMR rose from 411 to 1137/100 000 live births as a specialist hospital, with a decline to 625/100 000 as a Teaching hospital. Pre-eclampsia/eclampsia was the leading cause (29.63%) of maternal death. MMR was highest as a Specialist hospital due to limited manpower and inadequate facilities to properly manage the rising number of referred obstetric emergencies. Adequate preparations should be made before upgrading a hospital, to enable it cope with the challenges of managing referred obstetric emergencies (Afr J Reprod Health 2009; 13[4]:67-72)

Debating elective single embryo transfer after in vitro fertilization: a plea for a context sensitive approach

The number of embryos transferred after in vitro fertilization (IVF) have been a topic of debate for over a decade now. Due to the risk associated with multiple pregnancy, there has been a global effort at reducing the multiple pregnancy rates to a minimum while maintaining an acceptable level of successful IVF pregnancy rate. Elective single embryo transfer (eSET) is advocated in most European countries. In Belgium and Sweden, eSET is mandatory for couples with a good prognosis. However, despite clinical recommendations and policy statements, patients in clinical practice frequently do request for the transfer of multiple embryos in order to have twins. Such requests conflict with policy guidelines and create an ethical dilemma for physicians: Should the physician do as the couple requests, and there with respect the autonomy of patients, or adhere to medical policy that takes the health of the mother and children at heart? This article provides an exploration of the arguments found in the literature that plays a role in the discussion on this topic and eventually argues that what a physician should do depends on the specificities of the context in which patients and physicians are implicated. These contextual issues can be taken into account in a shared decision‑making procedure, which allows reflections and the responsibilities of both patients and physicians to be attended in decision about assisted reproduction.Keywords: Autonomy, Embryo transfer, In vitro fertilization, Multiple pregnancy, Values and cultur

Conducting defect with atrial septal aneurysm in a preterm neonate: A case report from resource limited setting

Conducting defect (CD) co-existing with interatrial septal anomaly (ISA) like Atrial Septal Aneurysm (ASA) is a rare congenital heart disease presenting with bradyarrhythmia in-utero due to defects in the heart electrical conducting system. We report a case of a preterm female ‘CC’ (GA=35weeks) low birth weight (2.4kg) neonate with CD and associated ASA. CC’s mother presented with poor foetal movements and bradyarrhythmia and had an emergency caesarian section at 35weeks with Apgar score of 3, 5. She was managed for perinatal Asphyxia. This report highlights the fact that ASA resolved at around the first year of life but the associated heart electrical conducting system defects persisted. The report also emphasizes the challenges of managing a rare neonatal cardiac condition in a resource limited setting and the importance of thorough foetal biophysical profile and early interventional delivery when it is necessary.Keywords: Conducting defect; neonatal; Atrial Septal Aneurysm

Maternal death and obstetric care audits in Nigeria: A systematic review of barriers and enabling factors in the provision of emergency care.

Acknowledgements We would like to thank Yutaka Osakabe for co-ordinating the retrieval of full text articles. The John D. and Catherine T. MacArthur Foundation supported this study, grant number 12-100074-000-INPPeer reviewedPublisher PD

Maternal and child health interventions in Nigeria: a systematic review of published studies from 1990 to 2014

BACKGROUND: Poor maternal and child health indicators have been reported in Nigeria since the 1990s. Many interventions have been instituted to reverse the trend and ensure that Nigeria is on track to achieve the Millennium Development Goals. This systematic review aims at describing and indirectly measuring the effect of the Maternal, Newborn, and Child Health (MNCH) interventions implemented in Nigeria from 1990 to 2014. METHODS: PubMed and ISI Web of Knowledge were searched from 1990 to April 2014 whereas POPLINE® was searched until 16 February 2015 to identify reports of interventions targeting Maternal, Newborn, and Child Health in Nigeria. Narrative and graphical synthesis was done by integrating the results of extracted studies with trends of maternal mortality ratio (MMR) and under five mortality (U5MR) derived from a joint point regression analysis using Nigeria Demographic and Health Survey data (1990-2013). This was supplemented by document analysis of policies, guidelines and strategies of the Federal Ministry of Health developed for Nigeria during the same period. RESULTS: We identified 66 eligible studies from 2,662 studies. Three interventions were deployed nationwide and the remainder at the regional level. Multiple study designs were employed in the enrolled studies: pre- and post-intervention or quasi-experimental (n = 40; 61%); clinical trials (n = 6;9%); cohort study or longitudinal evaluation (n = 3;5%); process/output/outcome evaluation (n = 17;26%). The national MMR shows a consistent reduction (Annual Percentage Change (APC) = -3.10%, 95% CI: -5.20 to -1.00 %) with marked decrease in the slope observed in the period with a cluster of published studies (2004-2014). Fifteen intervention studies specifically targeting under-five children were published during the 24 years of observation. A statistically insignificant downward trend in the U5MR was observed (APC = -1.25%, 95% CI: -4.70 to 2.40%) coinciding with publication of most of the studies and development of MNCH policies. CONCLUSIONS: The development of MNCH policies, implementation and publication of interventions corresponds with the downward trend of maternal and child mortality in Nigeria. This systematic review has also shown that more MNCH intervention research and publications of findings is required to generate local and relevant evidence

Challenges associated with the management of gynecological cancers in a tertiary hospital in South East Nigeria

Chukwuemeka Anthony Iyoke,1 George Onyemaechi Ugwu,1 Euzebus Chinonye Ezugwu,1 Frank Okechukwu Ezugwu,2 Osaheni Lucky Lawani,3 Azubuike Kanayo Onyebuchi3 1Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, 2Department of Obstetrics and Gynaecology, Enugu State University Teaching Hospital, Park Lane, Enugu, 3Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria Background: There are reports of increasing incidence of gynecological cancers in developing countries and this trend increases the need for more attention to gynecological cancer care in these countries. Objective: The purpose of this study was to describe the presentation and treatment of gynecological cancers and identify barriers to successful gynecological cancer treatment in a tertiary hospital in South East Nigeria. Methods: This study was a retrospective longitudinal analysis of the presentation and treatment of histologically diagnosed primary gynecological cancers from 2000 to 2010. Analysis was by descriptive and inferential statistics at the 95% level of confidence using Statistical Package for the Social Sciences version 17 software. Results: Records of 200 gynecological cancers managed during the study period were analyzed. Over 94% of cervical cancers presented in advanced stages of the disease and received palliative/symptomatic treatment. Only 1.9% of cervical cancer patients had radical surgical intervention, and postoperative mortality from these radical surgeries was 100%. Approximately 76% of patients with ovarian cancer had debulking surgery as the mainstay of treatment followed by adjuvant chemotherapy. Postoperative mortality from ovarian cancer surgery was 63%. Cutting edge cytotoxic drugs were not used as chemotherapy for ovarian and chorionic cancers. Compliance with chemotherapy was poor, with over 70% of ovarian cancer patients failing to complete the prescribed courses of chemotherapy. Most patients with endometrial and vulval cancers had only surgical treatment, as compliance with follow-up for adjuvant chemotherapy or radiotherapy was poor. Functional radiotherapy facilities were not available at the center during the study period, thereby necessitating external referrals to centers hundreds of kilometers away. Conclusion: Late presentation of cases, noncompliance with treatment regimens, lack of use of cutting edge cytotoxic drugs, the poor outcome of radical surgeries, and lack of a functional radiotherapy facility combined to create a very difficult gynecological cancer care environment at the study center. Keywords: gynecological cancer, management challenges, cancer surgery, chemotherap

HIV Sero-Prevalence among Pregnant Women in A Resource Constrained Setting, South East Nigeria

INTRODUCTION: HIV infection and AIDS is a public health problem worldwide, particularly affecting the populace in resource constrained settings like in sub-Saharan Africa. Women of reproductive age are most affected and infected with the disease.METHODOLOGY: A descriptive study of pregnant women presenting for the first time at the obstetrics booking clinic of ESUTTH, Parklane from 1st April, st2009 to 31 March, 2010. Socio-demographic characteristics, sexual behavior, pregnancy history and STI related symptoms were obtained using already prepared proforma. HIV Screening test was conducted in a serial two step approach using Determine HIV test kits and Stat- Pak HIV kits after obtaining an informed consent. Discordant results were subjected to Western blot for confirmation. Data were entered and analyzed using Epi-info statistical software. P Value <0.05 were assessed as statistically significant at 95% confidence interval.RESULT: A total of 1306 women were recruited, 66 women were HIV positive, giving a prevalence rate of 5.1%. Their mean age was 28.79 ± 5.06 years. Majority of them were married (9%).The mean gestational age at booking was 26.2 ± 6.8 weeks. Alcohol intake, history of 3 or more sexual partner in the last 5 years, abnormal vaginal discharge in the last 12 months, history of genital ulcer in last 12 month, had a statistically significant association with prevalence of HIV infection (p value<0.005)CONCLUSION: HIV infection prevalence rate in among antenatal attendants in Enugu is still high. A multi-sectoral approach is required for effective prevention and control of the disease to ensure achievement of Millennium development Goals 5&6KEY WORDS: HIV in Pregnancy, booking visit, low resource setting, Nigeri

Large Vulvar Lipoma Following Episiotomy - A Case Report

Vulvar lipomas are rare and few cases have been reported in the world literature. We document a case of large soft vulvar mass following episiotomy in a 23-year-old primipara. The mass was excised and histologic examination confirmed lipoma.KEYWORDS: vulvar, tumour, lipoma

Effect of treatment with single total-dose intravenous iron versus daily oral iron(III)-hydroxide polymaltose on moderate puerperal iron-deficiency anemia

Chukwuemeka Anthony Iyoke,1 Fausta Chioma Emegoakor,1 Euzebus Chinonye Ezugwu,1 Lucky Osaheni Lawani,2 Leonard Ogbonna Ajah,1 Jude Anazoeze Madu,3 Hyginus Uzo Ezegwui,1 Frank Okechukwu Ezugwu4 1Department of Obstetrics and Gynaecology, University of Nigeria, Enugu Campus, 2Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, 3Department of Haematology, University of Nigeria, Nsukka, 4Department of Obstetrics and Gynaecology, College of Medicine, Enugu State University, Enugu, Nigeria Background: Iron-deficiency anemia is the most common nutritional cause of anemia in pregnancy and is often responsible for puerperal anemia. Puerperal anemia can impair postpartum maternal and neonatal well-being. Objective: To determine the effect of treatment of moderate puerperal iron-deficiency anemia using a single intravenous total-dose iron dextran versus daily single dose oral iron(III)-hydroxide polymaltose. Methodology: A randomized controlled study in which postpartum women with moderate iron-deficiency anemia were randomized into treatment with either a single total-dose intravenous iron dextran or with daily single doses of oral iron(III)-hydroxide polymaltose tablets for 6 weeks. Effects on hemoglobin concentration using either method were compared at 6 weeks postpartum. Analysis was per protocol using SPSS version 17 for windows. P-values ≤0.05 were considered significant. Results: Two hundred eighty-four women were recruited for the study: 142 women received single total dose intravenous infusion of iron dextran while 142 received daily oral iron(III)-hydroxide polymaltose tablets. Approximately 84.0% (237/282) completed the study and were analyzed including 81% (115/142) of those randomized to injectable iron therapy compared to 85.9% (122/142) of those randomized to oral treatment. The proportions of women who had attained hemoglobin concentration of at least 10 g/dL by the 6 weeks postpartum visit did not differ significantly between cases and controls (95.7% vs 94.3%; P=0.73). Similarly, the mean increases in hemoglobin following either therapeutic route were comparable (1.03±0.56 g/dL for intravenous iron and 0.97±0.46 g/dL for the oral group; P=0.42). Conclusion: Single total-dose intravenous iron for treatment of puerperal iron-deficiency anemia was as effective as daily single doses of ferric iron tablets. For puerperal patients with iron-deficiency anemia in whom compliance with and tolerability of oral iron are not certain, a single total-dose intravenous iron can be safely offered. Keywords: effect, intravenous, iron, puerperal, anemi