PERCEPTIONS AND PRACTICES OF VAGINAL BIRTH AFTER CAESAREAN SECTION AMONG PRIVATELY PRACTICING OBSTETRICIANS IN KENYA

Objective: To determine perceptions, preferences and practices of vaginal birth after Caesarean.Design: Cross-sectional descriptive study.Setting: Private clinics of obstetricians in five major towns of Kenya.Subjects: Obstetricians in private practice.Main outcome measures: Practice and experiences in trial of labour (TOL); need for, and application of, selection criteria in TOL; perceptions on outcomes of TOL and patient preference; perception on trends of vaginal birth after Caesarean (VBAC) and need for policy on TOL.Results: Nearly all respondents (98.4%) believed in the need for, and application of, selection criteria for allowing TOL. However, only 23% believed in routine screening with radiological pelvimetry, while 63.2% believed in routine foetal weight estimation. All obstetricians (100%) have ever managed TOL in private practice, and 74% had managed at least one case in the last six months. Despite lack of tangible selection criteria,83.1% think that most women prefer TOL while 95.1% discourage it if perceived as inappropriate. Failure rate of TOL was perceived to be more than 50% by 35.2% of the respondents. A majority of the respondents (about 75%) would prefer TOL on themselves or their spouses. Those who perceived that there was a falling trend of VBAC were 58%, citing increased demand by mothers (45.7%), obstetricians’ convenience (40.0%) and fear of litigation (26.8%) as the reasons for this observation. A fluid policyof “TOL whenever it is deemed as appropriate” was preferred by 88.7%.Conclusion: The perception of obstetricians is that desire for VBAC predominates over elective repeat Caesarean. However, consensus on appropriate selection criteria is lacking, which leaves the obstetrician in a management dilemma. Hence, there is need to study outcomes of both ERC and TOL in order to come out with objective policy guidelines on management of one previous Caesarean in pregnancy

PREGNANCY OUTCOMES IN MOTHERS WITH ADVANCED HUMAN IMMUNODEFICIENCY VIRUS DISEASE

Objective: To determine the impact of HIV disease on immediate maternal and foetaloutcomes at the Kenyatta National Hospital, Nairobi, KenyaDesign: Prospective cohort study.Setting: Kenyatta National Hospital, Nairobi, Kenya, between September 2004 andApril 2005.Subjects: Sixty eight mothers with advanced HIV disease (WHO clinical stage 3 and4) and 68 HIV negative pregnant mothers.Results: Mothers with advanced HIV disease were more likely to be anaemic (55% vs.16% p<0.001), to have sexually transmitted diseases (56% vs. 15%, p=0.004), to havechorioamnionitis (14.8% vs. 2%, p=0.004), to develop preterm premature rupture ofmembranes (31 % vs. 9%, p<0.001), to have puerperal pyrexia (16% vs. 2%, p=0.032)an to die (5% vs. 0.5%, p=0.028) compared to HIV negative mothers. The meangestational age at deliver was lower in mothers with advanced HIV disease comparedto the seronegative counterparts (73% vs. 32%, delivery<37 weeks, p<0.00l). Infants ofmothers with advanced HIV disease compared to infants of seronegative mothers weremore likely to be low birth weight infants (58% vs. 21%, p<0.00l), stillborn (4% vs.2%, p=0.308) and to have low Apgar scores (28% vs. 12%, Apgar score < 4 at 5 minutesp=0.02). Perinatal sepsis and perinatal deaths were more common in infants born tomothers with advanced HIV disease compared to infants born to HIV negative mothers(8 vs. 3, p=0.003 and 14 vs. 5, p=0.025 respectively). External congenital anomalies weresimilar in the two groups (5.9% vs. 5.9%).Conclusion: Pregnancies complicated by advanced HIV disease are more likely to haveadverse outcomes, both maternal and foetal. Advanced HIV disease is associated withincreased risk of both maternal and fetal mortality. HIV infected mothers should becounselled on the increased pregnancy risks associated with advanced disease

BODY DYSMORPHIC DISORDER: CASE REPORT

SUMMARYThe desire for self-mutilation in the absence of any discernible psychopathology is relativelyrare. Self-mutilation is most commonly a manifestation of an underlying psychopathology suchas depression, schizophrenia, personality disorder, transexuality, body dysmorphic disorder andfactitious disorder. In this article, a case in which a 29-year-old single Kenyan lady of Africanorigin demanded a surgical operation to modify and reduce the size of her external genitalia ispresented. Although female genital mutilation is still widespread in the country, this case is ofinterest in that the woman did not seek the usual circumcision but sought to specifi cally reducethe size of her labia minora so that she could feel like a normal woman. The unique challengesin her management are discussed. Possible aetiological factors in patients who demand surgicalremoval or modifi cation of parts of their bodies without an obvious cause is discussed

MODE OF DELIVERY DECISIONS AMONG HIV -INFECTED MOTHERS AT AN URBAN MATERNITY HOSPITAL IN KENYA

Objectives: To quantify the use of elective Caesarean section (ECS) for prevention of mother-to-child transmission of HIV (PMTCT) at an urban Kenyan maternity hospital, to describe mode of delivery decision making among HIV positive women, and to understand patient knowledge and attitudes regarding ECS for PMTCT.Design: Descriptive cross-sectional study.Setting: Pumwani Maternity Hospital, Nairobi, Kenya.Subjects: Two hundred and fifty postpartum HIV-infected women.Main outcome measures: ECS delivery rate, correlates of mode of delivery decisions and ECS for PMTCT knowledge and attitudesResults: The rate of delivery by ECS for PMTCT was 4.0% (10/250), though 13.6% (34/250) planned this mode of delivery. Patient education regarding ECS for PMTCT was limited, and 64% (160/250) of participants had never heard of ECS. Planning ECS for PMTCT was positively correlated with attending clinic at PMH (OR=9.12, 95% CI: 2.94-28.28, p<0.001), knowledge of ECS (OR=27.22, 95% CI: 5.04-148.20, p<0.001)and having a history of abdominal surgery (OR=30.96, 95% CI: 6.32-205.02, p<0.001).Delivering by ECS was associated with planning this mode of delivery (OR=19.52, 95% CI: 3.69-103.23, p<0.001). Planning but not delivering by ECS was mostly due to labourbefore scheduled ECS (55.6%, 15/27) or poor patient understanding of the intervention (29.6%,8/27). After education on ECS for PMTCT, 48.0% (120/250) of participants would consider elective Caesarean section if offered, though cost represented a significant barrier to acceptability.Conclusions: Knowledge and utilisation of ECS for PMTCT are limited and varied in this patient population. ECS may be an acceptable mode of delivery for some Kenyan women, especially if the burden of cost is removed. A clear policy on ECS counselling and utilisation is urgently needed to ensure consistent and appropriate use of thisPMTCT intervention in Kenya

Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017

Background: Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of “leaving no one behind”, it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990–2017, projected indicators to 2030, and analysed global attainment. Methods: We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0–100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator. Findings: The global median health-related SDG index in 2017 was 59·4 (IQR 35·4–67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6–14·0) to a high of 84·9 (83·1–86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030. Interpretation: The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains—curative interventions in the case of NCDs—towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions—or inaction—today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030. Funding: Bill & Melinda Gates Foundation. © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens