Nifedipine for tocolysis

Publisher PDFNon peer reviewe

Respectful care in labour

Provision of respectful care in labour requires awareness of the special circumstances of childbirth as a natural process. The need for woman centred humanistic care runs alongside the duty to provide access to clinical interventions as required, recognising the limitations of risk assessment. Avoidance of over medicalisation and inappropriate interventions contributes to respectful care, as does leadership to develop and sustain good working relationships among staff, so that women experience care provided by staff who are functioning at their best. Institutionalising respectful care provision alongside evidence based clinical practice represents the goal of ‘mother-baby friendly birthing facilities’ as advocated by FIGO.PostprintNon peer reviewe

Access to antenatal blood pressure measurement in Malawi

Aim To identify service side factors associated with access to antenatal blood pressure measurement at health facilities in Malawi. Methods Secondary data analysis of 1499 observations of antenatal consultations undertaken in the Service Provision Assessment survey 2013-14, a census of all formal health facilities in the country. Results Differentials in access to antenatal blood pressure measurements by client age or educational status and provider gender or in-service training did not reach statistical significance although clinically important effects cannot be excluded. There was substantial variation among districts, ranging from 14% to 100% of observed consultations. Facilities in the Central and Southern regions had lower odds of providing blood pressure measurement relative to the Northern region (OR 0.17, 95% CI 0.03 to 0.30 and 0.11, 95% 0.04 to 0.31 respectively). Facilities affiliated to the Christian Health Association of Malawi and facilities under private management had higher odds of provision relative to government facilities (OR 3.24, 95% CI 1.71 to 6.11 and 5.77, 95% CI 1.87 to 17.79 respectively). Where observed consultations included taking the client’s weight and measuring the symphysis-fundus height, the odds of blood pressure measurement were significantly increased (OR 6.4, 95% CI 3.32 to 12.34 and 1.71, 95% CI 1.01 to 2.88 respectively). Conclusion An indicator for effective coverage, the proportion of antenatal visits that included blood pressure measurement, recorded in health passports examined at the time of admission for delivery, should be tested for incorporation into the District Health Information System to enable tracking of quality improvement in antenatal care. Further research is needed to elucidate the reasons for the variations identified here

Evidence on Populations and Programs to Support Contraceptive Service Design, with special reference to Adolescents in Sub Saharan Africa : Tsogolo Langa Desk review

The government of Malawi has committed to improving the Sexual and Reproductive Health Rights and Family Planning (SRHR/FP) across the country, including for adolescents. However, challenges to contraceptive uptake and access to FP services prevail. To address the modest fall in age-specific fertility seen among adolescents in Malawi in recent years with its related adverse social and health consequences, all available relevant evidence that could inform programming is needed. This desk review focused on two main objectives with a specific focus on adolescents: 1. Evidence on factors that underlie reproductive health decision making and specifically contraceptive use amongst adolescents including vulnerable sub-groups such as young people with disabilities in Sub Saharan Africa 2. Review of scientific papers and programme reports that contain analytical findings about contraceptive service delivery An electronic search was undertaken using a formal search strategy. Working papers and reports that may contain relevant studies from Tsogolo Langa partners were also sought. In response to objective 1, the literature review identified 388 potentially related sources of which 29 were found to be informative. The review identified evidence falling into three key thematic areas: cultural belief systems including prevalent gender norms, lack of confidentiality and shame, and influencers of contraceptive use. To address the second objective, 2,341 potential sources were identified from the search. An initial review of titles and abstracts resulted in 241 sources retained, and of these 38 were reviewed in detail. Main findings • There are a number of powerful disincentives for adolescents in Malawi to access and use contraceptives, including cultural beliefs that prevail about fertility, masculinity and misconceptions about fertility linked to contraceptive use, alongside issues related to confidentiality and shame regarding accessing services. These are compounded by influencers, including parents, partners and peers, and traditional initiation practices. Furthermore, providers’ unwillingness to provide contraceptive services to unmarried adolescents also hinder the contraceptive uptake by this age-group. As such, the Malawian context for adolescents accessing SRHR/FP demands further research. • In terms of effective platforms from which to engage adolescents, there were a number of key findings to consider. A lesson from peer education and schoolbased intervention studies is that only modest impact can be expected when educational strategies do not include access to services. Post abortion care is an important setting for providing contraception to adolescents. In addition, according to published evidence, in Malawi the use of Health Surveillance Assistants to drive community-based provision may not be an ideal approach. • Through the desk review, specific knowledge gaps were identified and should be considered for examination. - The SRHR/FP experience of adolescents living with disabilities and those of boys and young men; interventions targeting adolescents with disabilities. - Lower use of emergency contraception (EC) in Malawi than other countries resulting in preventable unintended pregnancy. - Concentration of information about EC pertains to urban/educated adolescents with little to no information on rural populations. - As national policy for Pre Exposure Prophylaxis for HIV prevention (PrEP) extends to AGYW, strategies for integration with other SRHR/FP services is a key priority. Conclusion To drive effective evidence based SRH programming that addresses the needs of adolescents (male and female), exploration of their wider needs for health services, including optimal access points and the mix of services is needed. Social networks need to be explored as channels for accessing information about services and spreading correct understanding about non contraceptive benefits of method use, to dispel misconceptions and myths. A special focus on LARC is needed so that longer acting methods can be made fully accessible to adolescents, in parallel with ready access to EC

Anion gap as a prognostic tool for risk stratification in critically ill patients – a systematic review and meta-analysis

Background Lactate concentration is a robust predictor of mortality but in many low resource settings facilities for its analysis are not available. Anion gap (AG), calculated from clinical chemistry results, is a marker of metabolic acidosis and may be more easily obtained in such settings. In this systematic review and meta-analysis we investigated whether the AG predicts mortality in adult patients admitted to critical care settings. Methods We searched Medline, Embase, Web of Science, Scopus, The Cochrane Library and regional electronic databases from inception until May 2016. Studies conducted in any clinical setting that related AG to in-hospital mortality, in-intensive care unit mortality, 31-day mortality or comparable outcome measures were eligible for inclusion. Methodological quality of included studies was assessed using the Quality in Prognostic Studies tool. Descriptive meta-analysis was performed and the I2 test was used to quantify heterogeneity. Subgroup analysis was undertaken to identify potential sources of heterogeneity between studies. Results Nineteen studies reporting findings in 12,497 patients were included. Overall, quality of studies was poor and most studies were rated as being at moderate or high risk of attrition bias and confounding. There was substantial diversity between studies with regards to clinical setting, age and mortality rates of patient cohorts. High statistical heterogeneity was found in the meta-analyses of area under the ROC curve (I2=99%) and mean difference (I2=97%) for the observed AG. Three studies reported good discriminatory power of the AG to predict mortality and were responsible for a large proportion of statistical heterogeneity. The remaining 16 studies reported poor to moderate ability of the AG to predict mortality. Subgroup analysis suggested that intravenous fluids affect the ability of the AG to predict mortality. Conclusion Based on the limited quality of available evidence, a single AG measurement cannot be recommended for risk stratification in critically ill patients. The probable influence of intravenous fluids on AG levels renders the AG an impractical tool in clinical practice. Future research should focus on increasing the availability of lactate monitoring in low resource settings.Publisher PDFPeer reviewe

A systematic review and diagnostic test accuracy meta-analysis of the validity of anion gap as a screening tool for hyperlactatemia

Objective This systematic review and meta-analysis seeks to determine the validity of the anion gap to screen for hyperlactatemia in critically ill patients. We have previously shown that the anion gap does not predict 31-day and in-hospital mortality in critically ill patients. The present review aims to add confirmatory evidence to identify whether the anion gap is a suitable tool for risk stratification in low-resource countries. Results Nine studies reporting on 4504 samples from 2111 patients were included. The anion gap failed to detect hyperlactatemia defined as lactate above 2.5 mmol/l but showed good discriminatory ability for the detection of severe hyperlactatemia defined as lactate over 4 mmol/l. At the 2.5 mmol/l threshold, the anion gap had high specificity but low sensitivity for the detection of hyperlactatemia. A meta-analysis of correlation coefficients yielded high statistical heterogeneity. Therefore, in keeping with our previous findings, the use of the anion gap for risk stratification as an alternative to lactate cannot be recommended. However, the strength of the evidence we have synthesised is adversely affected by the small number of studies included, inconsistency of effect measures and positivity thresholds reported, and selection bias within individual studies. PROSPERO Registration Number: CRD42015016470 (registered on the 4th February 2015)

Preventing deaths from complications of labour and delivery

The process of labour and delivery remains an unnecessary and preventable cause of death for women and babies around the world. Although rates of maternal and perinatal death are declining, there are large disparities between rich and poor countries, and sub-Saharan Africa has not seen the scale of declines shown elsewhere. In many areas, maternity services remain sparse and under-equipped, with insufficient and poorly trained staff. Priorities for reducing the mortality burden are provision of safe caesarean section, prevention of sepsis, and appropriate care of women in labour in line with current best practices, appropriately and affordably delivered. A concern is that large-scale recourse to caesarean delivery has its own dangers and may present new dominant causes for maternal mortality. An area of current neglect is newborn care. However, innovative training methods and appropriate technologies offer opportunities for affordable and effective newborn resuscitation and follow-up management in low-income settings.PostprintPeer reviewe

Prostate-specific Antigen as a Risk Factor for Skeletal Metastasis in Native Ethnic African Men with Prostate Cancer: A Case-control Study

Prostate cancer is the most common noncutaneous cancer in males. Men of African origin are at a significantly higher risk as reflected in the higher incidence and mortality rates in this racial group. Metastases incidence increases parallel to serum levels of prostate-specific antigen (PSA), contributing significantly to morbidity and mortality. Staging of the disease involves bone scans, which are sensitive in detecting skeletal metastases. Suggestions that these scans may be omitted in some situations in patients with low prostate specific antigen levels have drawn attention to the matter. In this case-control study, using radiology and pathology records, a registry of prostate cancer patients recorded as being of dark-skinned ethnicity was obtained. Images were presented to image reviewers blinded to the PSA level, to determine the presence of skeletal metastases. The risk factor for the outcome of interest (skeletal metastases) was PSA level above 20 ng/mL. The reliability of image reporting was also assessed. Of the 122 patients, skeletal metastases were present in 50 (41%) while these were absent in 72 (59%). The prevalence of metastases among the high PSA group was 55.9% [95% confidence interval (CI) 44.1–67.7%] and among the normal/low PSA group was 22.2% (95% CI 11.1–33.3%). The odds ratio (OR) for skeletal metastases in the exposed (high PSA) group was 4.4 (95% CI, 2.01–9.78.) Intraobserver agreement on image interpretation was 88.5% with a Kappa statistic of 0.76. A relatively higher prevalence of skeletal metastasis is seen in regional dark-skinned African males with prostate cancer at both low and high prostate specific antigen levels. Bone scanning in this population should therefore, be considered even at PSA levels below 20 ng/mL

Perspectives on the practice of vaginal birth after caesarean section in East Africa

Background: The increasing Caesarean section rates being observed in most facilities will ultimately result in a larger proportion of women with previous scar. Choices need to be made by both the patient and the health worker between attempted vaginal birth after Caesarean section (VBAC) and Elective Repeat Caesarean section (ERCS). Both practices are associated with perinatal risks and benefits that call for certain objectivity and prudence in decision making especially where resources are scarce. Objective: To determine perceptions on the practice of vaginal birth after Caesarean section among maternity service providers in East Africa. Design: A semi-qualitative cross sectional survey using self-administered questionnaires. Setting: The study was undertaken among delegates attending a regional obstetrics and gynaecology conference in Mombasa, Kenya. Subject: Sixty-three consenting delegates were interviewed Results: A majority (69.8%) of the respondents were consultants and midwives working in government facilities. Fifty-eight out of the 63 respondents offered VBAC in their institutions despite acknowledging sub-optimal antenatal preparation. The main concerns identified were; deficiencies in healthcare delivery systems, inadequate human resources, lack of unit guidelines, inappropriate maternal education and inappropriate foetal monitoring tools. Conclusion: The practice of vaginal birth after Caesarean section was perceived to be sub-optimal with many existing deficiencies that need urgent action to ensure the safety of mothers and newborns. We therefore recommend that unless these concerns raised by maternity providers are addressed then the practice of VBAC in the region should not be encouraged

Intravenous tranexamic acid as an adjunct haemostat to ornipressin during open myomectomy. A randomized double blind placebo controlled trial

Background: Myomectomy is a surgical technique used for removal of uterine fibroids and historically hysterectomy has represented the mainstay of treatment. The options of conservative surgical approaches mainly aim at retention of fertility but have to be balanced against potential risks such as haemorrhage; blood loss at myomectomy still remains troublesome with use of various pharmacologic agents yielding inconclusive results. This trial aimed to explore the benefit of combining ornipressin and tranexamic acid during open myomectomy. Study design: A randomized double blind placebo controlled trial. Methods: Women who satisfied eligibility criteria were enrolled into the study and randomized into one of two groups. The experimental group received 1 g of tranexamic acid diluted to 50 ml of saline administered at 100 ml per hour at cutting time (knife to skin). The control group received placebo diluted to 50 ml of saline administered at 100 ml per hour at cutting time. Both groups had five international units ornipressin diluted in 60 ml of saline administered during surgery. The primary outcome (blood loss) was assessed by determining the weight difference of dry and soaked swabs using a digital weighing scale by converting this to volume (ml). Operating time was noted from the time of uterine incision to the time of uterine closure. The need for transfusion was determined by anaesthetists’ assessment of acceptable blood loss and clinical assessment of vital signs. Post-operative stay was calculated from the time of extubation to 8 am on the day of discharge. Results: A total of thirty-four patients were randomized to two groups; 17 received ornipressin only and 17 received tranexamic acid and ornipressin. There was no difference in blood loss between the groups with a median blood loss in the ornipressin (n = 17) and ornipressin plus tranexamic acid arms of 398 ml (IQR: 251–630) ml and 251 ml (IQR: 158–501) ml respectively P = 0.361. Conclusions: Ornipressin administered along with tranexamic acid is not beneficial for blood loss reduction at open myomectomy. In settings such as ours where myomata are prevalent and severe anaemia rampant, blood donation and judicious use of scarce blood resources is key. Efforts to optimize preoperative haemoglobin levels and blood auto-donation seem the most promising options in pre-operative preparation prior to myomectomy. Clinical Trials Registration Number: PACTR20120300036916