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

Prevalence of and Factors Associated with Vulva Intraepithelial Neoplasia (VIN) among HIV Positive Women at Mbarara Regional Referral Hospital, Uganda

Background: Vulva intraepithelial neoplasia (VIN) is a noninvasive potential precursor of squamous cell carcinoma of the vulva. VIN is more prevalent in HIV-positive than HIV-negative women and if not identified and treated early, there is a high risk of progression to invasive cancer. Despite a large number of HIV-positive women getting care from Immunesuppression (ISS) clinic at Mbarara Regional Referral Hospital (MRRH), the local burden of VIN remains unknown in this group. Objective: To determine the prevalence and factors associated with vulva intraepithelial neoplasia (VIN) among HIV-positive women attending HIV care clinic at Mbarara Regional Referral Hospital (MRRH). Methods: This cross sectional study consisted of 225 HIV-positive women who attended the HIV care clinic at MRRH in a period of three months. Simple random sampling was used in the recruitment of study participants until the sample size was achieved. All participants underwent vulvoscopy. Any lesion detected was biopsied. Demographic and medical data were collected. The dependent variable was histologically confirmed VIN. Logistic regression analysis to assess association of factors with VIN was done. Results were presented in charts, graphs and tables.  Results: Two hundred and twenty five HIV-positive women were enrolled. Their median age was 33 years.  14 (6.22%) had VIN; of these, 9 had VIN-1, 4 had VIN-2 and 1 had VIN-3. All the study participants with VIN had Human papilloma virus (HPV) infection and were on antiretroviral therapy (ART). The symptoms of VIN included vulvar itching (43%), vulvar burning sensation (29%), and superficial dyspareunia (14%). Age, multiple sexual partners, age of sexual debut, menarche and genital warts were not significantly associated with VIN Conclusion: The prevalence of VIN among HIV-positive women attending HIV care clinic at MRRH is low. All participants with VIN had the following in common, HPV infection; vulva itching, vulva burning sensation and superficial dyspareunia. Recommendations: Since all cases of VIN had HPV infection we recommend that HPV vaccination should be included in HIV care to prevent VIN and consequently vulva cancer. We also recommend that all women with vulva itching, vulva burning and superficial dyspareunia should be screened for VIN. Key words: Vulva Intraepithelial Neoplasia (VIN), Human Immunodeficiency Virus (HIV

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

Frequency of HIV status disclosure, associated factors and outcomes among HIV positive pregnant women at Mbarara Regional Referral Hospital, southwestern Uganda

Introduction: positive HIV results disclosure plays a significant role in the successful prevention and care of HIV infected patients. It provides significant social and health benefits to the individual and the community. Non-disclosure is one of the contextual factors driving the HIV epidemic in Uganda. Study objectives: to determine the frequency of HIV disclosure, associated factors and disclosure outcomes among HIV positive pregnant women at Mbarara Hospital, southwestern Uganda. Methods: a cross-sectional study using quantitative and qualitative methods among a group of HIV positive pregnant women attending antenatal clinic was done and consecutive sampling conducted. Results: the total participant recruitment was 103, of which 88 (85.4%) had disclosed their serostatus with 57% disclosure to their partners. About 80% had disclosed within less than 2 months of testing HIV positive. Reasons for disclosure included their partners having disclosed to them (27.3%), caring partners (27.3%) and encouragement by health workers (25.0%). Following disclosure, 74%) were comforted and 6.8% were verbally abused. Reasons for non-disclosure were fear of abandonment (33.3%), being beaten (33.3%) and loss of financial and emotional support (13.3%). The factors associated with disclosure were age 26-35 years (OR 3.9, 95% CI 1.03-15.16), primary education (OR 3.53, 95%CI 1.10-11.307) and urban dwelling (OR 4.22, 95% CI 1.27-14.01). Conclusion: participants disclosed mainly to their partners and were comforted and many of them were encouraged by the health workers. There is need to optimize disclosure merits to enable increased participation in treatment and support programs

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

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

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

Cervical Cancer at Mbarara Regional Referral Hospital: Magnitude, Trends, Stages at Presentation, Impact of Acetic Acid Screening and the Need for Radiotherapy Services

Background: Globally, cervical cancer the fourth most common cause of cancer death accountable for approximately 266,000 deaths of women, with sub-Saharan Africa and East Africa having the highest burden. In Uganda about 2,275 new cervical cancer deaths occur annually. The main objective of the study was to describe the magnitude, trends, clinical stage on presentation and show the importance of cervical cancer prevention and radiotherapy services at Mbarara Regional Referral Hospital. Methods: This was a descriptive cross-sectional study. In the first phase of the study, leading cancers at Mbarara Regional Referral Hospital were determined.  In the second phase of the study, the burden of cervical cancer on the gynecological ward was determined. In the third part of the study the trends of cervical cancer over a ten year period was determined. In the fourth phase of the study the effects of acetic acid screening on the trends of cervical cancer was determined. Results: With a proportion of 25.2%, cervical cancer is the single leading cancer in the hospital. Cervical cancer contributes 10.1% of all diseases on the gynecological ward and 73.9% of all gynecological cancers.  The frequency of cervical cancer more than doubled between 2006 and 2014) with 60.3% of presenting with late stage. The number of cases of early cervical cancer detected had shown a small but steady increase since 2009. There was a decline in clinic cervical cancer incidence rate from 3.2% in 2009, 0.9% in 2013. Conclusion: Cervical cancer is the leading cancer and also the leading gynecological cancer at Mbarara Regional Referral Hospital. Women with cervical cancer are diagnosed late. Screening increases the rate of early detection. Acetic acid screening is effective in reversing the trends of cervical cancer. Expanding cervical cancer preventive services is capable of reducing the burden of cervical. Recommendations: There is need for expansion of HPV vaccination. There is need for expansion of acetic acid cervical cancer screening in southwestern Uganda. There is need for making radiotherapy services more accessible in developing countries. Keywords: Cervical Cancer, Magnitude, Trends, Stages, Impact, Acetic Acid, Screening, Radiotherapy

Comparison of non-magnetic and magnetic beads multiplex assay for assessment of Plasmodium falciparum antibodies

Background New reagents have emerged allowing researchers to assess a growing number of vaccine-associated immune parameters. Multiplex immunoassay(s) are emerging as efficient high-throughput assays in malaria serology. Currently, commercial vendors market several bead reagents for cytometric bead assays (CBA) but relative performances are not well published. We have compared two types of bead-based multiplex assays to measure relative antibody levels to malarial antigens. Methods Assays for the measurement of antibodies to five Plasmodium falciparum vaccine candidates using non-magnetic and magnetic fluorescent microspheres were compared for their performances with a Bio-Plex200 instrument. Mean fluorescence intensity (MFI) was determined from individuals from western Kenya and compared to known positive and negative control plasma samples. Results P. falciparum recombinant antigens were successfully coupled to both non-magnetic and magnetic beads in multiplex assays. MFIs between the two bead types were comparable for all antigens tested. Bead recovery was superior with magnetic beads for all antigens. MFI values of stored non-magnetic coupled beads did not differ from freshly coupled beads, though they showed higher levels of bead aggregation. Discussion Magnetic and non-magnetic beads performed similarly in P. falciparum antibody assays. Magnetic beads were more expensive, but had higher bead recovery, were more convenient to use, and provided rapid and easy protocol manipulation. Magnetic beads are a suitable alternative to non-magnetic beads in malarial antibody serology

Association between Duration of Second Stage of Labour and Perinatal Outcomes among Mothers admitted in Labour at Mbarara Regional Referral Hospital, Uganda

About four million babies die in the first 4 weeks of life annually. Most of the neonatal deaths occur in the first week mainly on the first day after delivery. The objective of our study was to determine the factors associated with poor perinatal   outcomes among low risk mothers admitted in labour at Mbarara Regional Referral Hospital (MRRH). This was a retrospective cohort study of mothers on the postnatal ward of MRRH. The total number of respondents was 140. The duration of second stage was ≤30 minutes in 70.0% of the women.  The number of women with poor feotal outcome was 27(19.3%). The poor outcomes included, birth asphyxia, fresh still birth and early neonatal death. The odds of having a good feotal delivery outcome was inversely proportional to time, with best results registered when delivery occurred within 30minutes OR, 4.9, 95% CI (1.8-13.1), weakening towards duration of ≥60 minutes with OR, 17.7, 95% CI (5.3-52.5). A second stage of labour lasting more than 60 minutes is associated with poor neonatal outcomes.For best perinatal outcomes we recommend if the second stage exceeds 60 minutes, labour should be re-assed and action should be taken to avoid further delay. To avoid poor neonatal outcomes, a second stage of labour lasting more than 60minutes requires continuous feotal monitoring