Implementation of postabortion care (PAC) services in three states in eastern Sudan 2009 - 2010

Objectives: This is an observational study done in three states in eastern Sudan, Red sea, Kassala and Gadarif states. It was conducted to determine number of patients presented for PAC, their socio-demographic characteristics and medical treatment they received.Methodology: The study was carried in nine hospitals, in three states in eastern part of Sudan. Training of health care providers was done before embarking on the study together with renovation of health care centers. Patients presented for PAC, were included in the study after an informedconsent, during 2009- 2010. Data was collected by trained group of registrars in obstetrics and gynecology department.Results: The study showed that, 3762 patients were admitted for PAC services during study period, accounting for 11.9% of the total hospitals admission, 3740 enrolled in the study. Abortion cases were classified as spontaneous 3463 (92.6%), while 277 (7.4%) were induced. Evacuation was done for 3548 (94.9%), the rest were spontaneous complete abortion, received uterotonics and antibiotics. Sharp curettage was done for 3065 (86.3%), manual vacuum aspiration-MVA, for 414 (11.7%) and 69 cases (2.0%) received misoprostol. Counseling and family planning provided to 301 cases (8.0%). Pregnancy was intentional and wanted in 2647 cases (70.8%), wanted but unplanned in 553 (14.8%), and unwanted in 540 cases (14.4%).Conclusion: Miscarriage (abortion) is prevalent even within desired pregnancy. Sharp curettage is still the method of practice. Family planning is not well integrated within PAC services. Health care providers need to know, practice and maintain full package of PAC

Association of placenta praevia with repeat cesarean section in Omdurman Maternity Hospital, Sudan 2010- 2012

Background: Several risk factors for placenta praevia exist, including  previous cesarean section(C/S). This association has been investigated long time ago, however in this hospital there is no documented evidence. This study was done to assess the risk of placenta praevia based on number of previous cesarean sections.Methods: A hospital-based study, at Omdurman maternity hospital- OMH during; January 2010-December 2012. Deliveries in OMH were reviewed by trained registrars. Patients diagnosed prenatally or during delivery as  placenta praevia were included. All women operated were followed till  discharge from hospital.Results: Total number of deliveries during the study period is 94758.Of them 68415 (72.2%) delivered vaginally and 26343 (27.8%) by C/S.Of the latter 10643 (40.4%) underwent elective and 15700 (59.6%) emergency CS.448 (0.5%) were diagnosed as placenta praevia. Placenta praevia was more common in patients with scarred uterus being found a 250 out of 9853 CS (2.5%). Its frequency increased with the number of uterine scars: one scar; (1.7%), (RR = 1.45, CI= 1.12-1.88), 2-4 scars (2.8%), (RR = 2.32, CI= 1.87-2.87) & five or more scars; (12.7%), (RR = 10.54, CI= 7.34-15.13). Nineteen patients (7.6%) had adherent placenta, (RR = 42.41, CI =5.69-315.83), 68(15.2%) had history of dilatation and  curettage (D&C) or evacuation,(RR = 1.5, CI = 1.18-1.94), 37 (8.3%) had previous history of placenta praevia, (RR= 8.30, CI = 6.17- 11.19). Threematernal deaths were encountered (0.7%).Conclusion: The frequency of placenta praevia in this study increased with increasing number of previous C/S, and was associated with adverse  feto-maternal outcome. This study provides a reason to reduce primary C/S and encouraging vaginal birth after C/S (VBAC).Key words: Placenta praevia. Repeated cesarean section. Sudan

Maternal Death Review in Sudan (2010 – 2012): Achievements and Challenges

Background: Despite the worldwide commitment to improving maternal health, measuring, monitoring and comparing mortality estimates remain a challenge. Maternal death review (MDR) is a tool used to measure maternal mortality ratio (MMR) and to improve quality of obstetric care.Objectives: This study was done to assess maternal mortality and to identify underlying causes during 2010-2013.Materials and Methods: Facility and community- based maternal death review was conducted during three years in Sudan to study maternal mortality. National and states’ maternal death review committees were established. A focal person for each state, health facility and locality was nominated. Notification of maternal deaths was done by telephone, followed by review of all notified maternal deaths using a structured format. Data was analyzed using microcomputer, with SSPS, version 18.0.Results: Over three years, 2933 maternal deaths were notified, out of 1509354 Live births (LB). MMR was 194/ 100000 LB, with different variation between states. Facility maternal deaths were 2503 (85.3%) and community deaths were 430 (14.7%), reviewed formats were 2859 (97.5%). Direct obstetric deaths were 1845 (64.5%), mainly due to haemorrhage 884 (30.9%), eclampsia 383 (13.4%) and sepsis 321 (11.2%). Indirect causes were 1014 (35.5%), 363 (12.7%) due to hepatitis and 197 (6.9%) to anemia. Most of hospital deaths 1947 (77.9%); admitted late from home, 2462 (73.4%) were critically ill and 1484 (60.3%) died within 24 hours.Conclusion: Home delivery, late presentation, unavailability of blood and poor referral system, are the main factors behind maternal deaths. Maternal death review has to be integrated within the health management information system (HMIS) with strong commitment of various stakeholders.Key words: Maternal mortality, maternal death review, Sudan

Impact of Female Genital Mutilation on second stage of labour in Primigravida at Omdurman Maternity Hospital, Sudan 2010

Objective: To find out the impact of female genital mutilation (FGM) on the second stage of labour at Omdurman Maternity Hospital (OMH).Methodology: A descriptive cross-sectional study, for primigravidae delivered vaginally in 2010. After an informed consent circumcised women, were included as study group and uncircumcised ladies as control group. Data was collected by trained registrars using a structured questionnaire to collect frequency of postpartum haemorrhage (PPH), perineal tear, birth asphyxia, neonatal death and hospital stay.Results: A total of 1961 primigravidae, delivered in 2010 at OMH, 629(32.1%) were circumcised and 1332(67.9%) were uncircumcised. There was no significant difference in the mode of delivery and episiotomy.Conclusion: FGM places women at a greater risk during childbirth, endangering their health and their babies compared to uncircumcised.Key words: Female Genital Mutilation, second stage of labor, Sudan

Malaria risk factors in north-east Tanzania

BACKGROUND: Understanding the factors which determine a household's or individual's risk of malaria infection is important for targeting control interventions at all intensities of transmission. Malaria ecology in Tanzania appears to have reduced over recent years. This study investigated potential risk factors and clustering in face of changing infection dynamics. METHODS: Household survey data were collected in villages of rural Muheza district. Children aged between six months and thirteen years were tested for presence of malaria parasites using microscopy. A multivariable logistic regression model was constructed to identify significant risk factors for children. Geographical information systems combined with global positioning data and spatial scan statistic analysis were used to identify clusters of malaria. RESULTS: Using an insecticide-treated mosquito net of any type proved to be highly protective against malaria (OR 0.75, 95% CI 0.59-0.96). Children aged five to thirteen years were at higher risk of having malaria than those aged under five years (OR 1.71, 95% CI 1.01-2.91). The odds of malaria were less for females when compared to males (OR 0.62, 95% CI 0.39-0.98). Two spatial clusters of significantly increased malaria risk were identified in two out of five villages. CONCLUSIONS: This study provides evidence that recent declines in malaria transmission and prevalence may shift the age groups at risk of malaria infection to older children. Risk factor analysis provides support for universal coverage and targeting of long-lasting insecticide-treated nets (LLINs) to all age groups. Clustering of cases indicates heterogeneity of risk. Improved targeting of LLINs or additional supplementary control interventions to high risk clusters may improve outcomes and efficiency as malaria transmission continues to fall under intensified control

Estimating Individual Exposure to Malaria Using Local Prevalence of Malaria Infection in the Field

BACKGROUND: Heterogeneity in malaria exposure complicates survival analyses of vaccine efficacy trials and confounds the association between immune correlates of protection and malaria infection in longitudinal studies. Analysis may be facilitated by taking into account the variability in individual exposure levels, but it is unclear how exposure can be estimated at an individual level. METHOD AND FINDINGS: We studied three cohorts (Chonyi, Junju and Ngerenya) in Kilifi District, Kenya to assess measures of malaria exposure. Prospective data were available on malaria episodes, geospatial coordinates, proximity to infected and uninfected individuals and residence in predefined malaria hotspots for 2,425 individuals. Antibody levels to the malaria antigens AMA1 and MSP1(142) were available for 291 children from Junju. We calculated distance-weighted local prevalence of malaria infection within 1 km radius as a marker of individual's malaria exposure. We used multivariable modified Poisson regression model to assess the discriminatory power of these markers for malaria infection (i.e. asymptomatic parasitaemia or clinical malaria). The area under the receiver operating characteristic (ROC) curve was used to assess the discriminatory power of the models. Local malaria prevalence within 1 km radius and AMA1 and MSP1(142) antibodies levels were independently associated with malaria infection. Weighted local malaria prevalence had an area under ROC curve of 0.72 (95%CI: 0.66-0.73), 0.71 (95%CI: 0.69-0.73) and 0.82 (95%CI: 0.80-0.83) among cohorts in Chonyi, Junju and Ngerenya respectively. In a small subset of children from Junju, a model incorporating weighted local malaria prevalence with AMA1 and MSP1(142) antibody levels provided an AUC of 0.83 (95%CI: 0.79-0.88). CONCLUSION: We have proposed an approach to estimating the intensity of an individual's malaria exposure in the field. The weighted local malaria prevalence can be used as individual marker of malaria exposure in malaria vaccine trials and longitudinal studies of natural immunity to malaria

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone