The burden of severe maternal outcomes and indicators of quality of maternal care in Nigerian hospitals: a secondary analysis comparing two large facility-based surveys.

OBJECTIVE: To compare severe maternal outcomes (SMOs) from two multi-centre surveys in Nigerian hospitals, and to evaluate how the SMO burden affects quality of secondary and tertiary hospital care. DESIGN: Two facility-based surveys of women experiencing SMO (maternal near-miss or maternal deaths). SETTING: Sixteen secondary and five tertiary facilities in Nigeria [WHO Multi-Country Survey on Maternal and Newborn Health (WHOMCS)] and 42 public tertiary facilities in Nigeria (Nigeria Near-Miss and Maternal Death Survey). POPULATION: 371 women in WHOMCS-Nigeria and 2449 women in Nigeria Near-Miss and Maternal Death Survey who experienced SMO. METHODS: Secondary analysis and comparison of SMO data from two surveys, stratified by facility level. MAIN OUTCOME MEASURES: Maternal mortality ratio (MMR) per 100 000 livebirths (LB), maternal near-miss (MNM) ratio per 1000 LB, SMO ratio per 1000 LB and mortality index (deaths/SMO). RESULTS: Maternal mortality ratio and mortality indices were highest in tertiary facilities of the WHOMCS-Nigeria (706 per 100 000; 26.7%) and the Nigeria Near-Miss and Maternal Death Survey (1088 per 100 000; 40.8%), and lower in secondary facilities of the WHOMCS-Nigeria (593 per 100 000; 17.9%). The MNM ratio and SMO ratio were highest in secondary WHOMCS-Nigeria facilities (27.2 per 1000 LB; 33.1 per 1000 LB). CONCLUSIONS: Tertiary-level facilities in Nigeria experience unacceptably high maternal mortality rates, but secondary-level facilities had a proportionately higher burden of severe maternal outcomes. Common conditions with a high mortality index (postpartum haemorrhage, eclampsia, and infectious morbidities) should be prioritised for action. Surveillance using SMO indicators can guide quality improvement efforts and assess changes over time. TWEETABLE ABSTRACT: 2820 Nigerian women with severe maternal outcomes: high mortality in tertiary level hospitals, higher burden in secondary level.

Maternal near-miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden and health service events surrounding severe maternal outcomes (SMO) related to life-threatening postpartum haemorrhage (PPH) in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: All cases of SMO [maternal near miss (MNM) or maternal death (MD)] due to PPH were prospectively identified using WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence of SMO, health service events, case fatality rate (CFR) and mortality index (MI: % of death/SMO). RESULTS: Postpartum haemorrhage occurred in 2087 (2.2%) of the 94 835 deliveries recorded during the study period. A total of 354 (0.3%) women had an SMO (103 MD; 251 MNM). It was the most frequent obstetric haemorrhagic complication across hospitals. PPH had the highest maternal mortality ratio (112/100 000 live births) and the recorded MI (29.1%) and CFR (4.9%) were second only to that of ruptured uterus. About 83% of women with SMO were admitted in a critical condition with over 50% being referred. MD was more likely when PPH led to neurological (80.8%), renal (73.5%) or respiratory (58.7%) organ dysfunction. Although the timing of life-saving interventions was not statistically different between the cases of MD and MNM, close to one-quarter of women who died received critical intervention at least 4 hours after diagnosis of life-threatening PPH. CONCLUSIONS: Postpartum haemorrhage was a significant contributor to obstetric haemorrhage and SMO in Nigerian hospitals. Emergency obstetric services should be enhanced at the lower levels of healthcare delivery to reduce avoidable deaths from PPH. FUNDING: The original research that generated the data for this secondary analysis, and the publication of this secondary analysis, was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization. We have no other funding issue to declare for our study. TWEETABLE ABSTRACT: One hundred and three maternal deaths and 251 near-misses resulted from PPH in 42 Nigerian tertiary facilities in 1 year.

Microalbuminuria, Other Markers of Nephropathy and Biochemical Derangementsin Type 2 Diabetes Mellitus: Relationships and Determinants.

BACKGROUND: Microalbuminuria is an early indicator of Diabetic nephropathy and cerebrovascular disease. OBJECTIVE: To evaluate relationships between microalbuminuria and other predictors of morbidity and mortality in type 2 DM. METHODS: Fifty type 2 diabetic subjects were recruited each for three groups separated by disease durations. Thirty non-diabetic subjects were recruited to control each group. Urine albumin-to-creatinine ratio (ACR) was estimated. Fasting plasma glucose (FPG), serum creatinine, urea, total cholesterol (TC), triglycerides (TG), high-and low density lipoprotein (HDL, LDL) were measured. RESULTS: The diabetics with longest disease duration of >10 years were the oldest (65.86±1.71), had highest systolic BP (147.12±3.39mmHg) and least BMI (27.20±0.71Kg/m2); they had poorest lipid control (TC:5.54±0.26mmol/L), though with the least TG (0.97±0.09mmol/L); they also had the most severe microalbuminuria (33.63±8.03g/L) and ACR (65.85±10.38mg/gm). Patients with diabetes of 5-10 years had the poorest glycaemic control:FPG-7.82±0.47mmol/L; HbA1c-13.09±0.74%). Significant negative correlations exist between microalbuminuria, HBA1c(r=-2.28, p=0.028) and serum creatinine(r=-2.11, p=0.042) in patients with 5-10 years disease; a positive correlation between the ACR and TC(r=1.00,p<0.01) in those with >10 years disease. In multivariate analysis, independent predictors of microalbuminuria were disease duration (OR 2.2, p< 0.001); HBA1c (OR 7.3, p=0.02); LDL/HDL ratio (OR 13.4, p< 0.001). CONCLUSION: The severity and progression of albuminuria are associated with longer duration of diabetes and poor glycaemic control. Significant relationships exist between ACR and HBA1c, TC, HDL-C, TG, creatinine. Disease duration, ethnicity, HBA1c, TC, TG, HDL-C and LDL/HDL ratio are independent predictors of albuminuria. FUNDING: None declared.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country.

OBJECTIVE: To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals. DESIGN: Nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth and puerperal complications. METHODS: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS: Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care. CONCLUSIONS: Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care. TWEETABLE ABSTRACT: Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Blood pressure indices and disease severity in patients with sickle cell anaemia.

Background: Individuals with sickle cell anaemia (SCA) have lower systemic blood pressures compared to individuals with haemoglobin Hb AA phenotype. Objective: Seventy-nine (79) individuals with SCA (subjects) in steady state and 50 age-matched individuals with Hb AA (controls) were prospectively studied. Height, blood pressure (BP), weight, creatinine clearance (by 24-hour urine collection), full blood count (FBC) and reticulocyte count were obtained from all subjects and controls. Body mass index (BMI), corrected reticulocyte count, mean arterial pressure (MAP) and pulse pressure (PP) were calculated using standard protocols.The frequency of vaso-occlusive crises in the last one year and number of blood transfusions in the last two years were obtained from subjects. Data was analyzed using descriptive and inferential statistics and p ≤0.05 was used to define the level of statistical significance. Methodology: Seventy-nine (79) individuals with SCA (subjects) in steady state and 50 age-matched individuals with Hb AA (controls) were prospectively studied. Height, blood pressure (BP), weight, creatinine clearance (by 24-hour urine collection), full blood count (FBC) and reticulocyte count were obtained from all subjects and controls. Body mass index (BMI), corrected reticulocyte count, mean arterial pressure (MAP) and pulse pressure (PP) were calculated using standard protocols.The frequency of vaso-occlusive crises in the last one year and number of blood transfusions in the last two years were obtained from subjects. Data was analyzed using descriptive and inferential statistics and p ≤0.05 was used to define the level of statistical significance. Results: The systolic (105.52±11.75mmHg and 113.20±7.94mmHg respectively; P = 0.01), diastolic (62.59±9.33mmHg and 75.40±5.70mmHg respectively; P=0.03) and mean arterial pressures (76.90±8.81mmHg and 88.00±5.51mmHg respectively; P =0.04) were significantly lower in subjects when compared with controls. ; pulse pressure (PP) was however significantly higher in subjects than controls (42.92±10.91mmHg and 37.80±7.43mmHg respectively (P = 0.03). In female subjects, the white cell count was negatively correlated with systolic BP (r = -0.39;P = 0.01) and PP (r = -0.33; P = 0.03). Conclusion: Lower systolic and pulse pressures may predict worsening disease severity in individuals with sickle cell anaemia.

Degrees of kidney disease in nigerian adults with sickle-cell disease.

OBJECTIVE: To study degrees of chronic kidney disease (CKD) using creatinine clearance in adult Nigerian patients with sickle-cell disease (SCD). METHODS: One hundred SCD patients, made up of 79 HbSS (homozygous haemoglobin S) patients and 21 HbSC (heterozygous haemoglobins S and C) patients, were investigated prospectively, along with 50 normal controls. Their sociodemographic data, weight and drug history were documented. Each participant underwent dipstick urinalysis, and creatinine clearance was calculated following a 24-hour urine collection and serum creatinine measurement. They were categorized into stages of CKD based on the creatinine clearance. RESULTS: Of the 79 HbSS patients, 14 (18%), 28 (35%), 33 (42%) and 4 (5%) had stage 1, 2, 3 and 4 CKD, respectively. In the HbSC group, 3 (14%), 9 (43%) and 9 (43%) patients had stage 1, 2 and 3 CKD, respectively. Proteinuria was noted in 16 (20%) HbSS patients but not in any of the HbSC patients. Of the subjects aged ≤24 years (n = 49), 9 (18%), 18 (37%), 21 (43%) and 1 (2%) had stage 1, 2, 3 and 4 CKD, respectively. Of those aged >24 years (n = 51), 8 (16%), 19 (37%), 21 (41%) and 3 (6%) had stage 1, 2, 3 and 4 CKD, respectively. None of the subjects had stage 5 CKD. CONCLUSION: In this study, the adult subjects with SCD had various degrees of CKD. Adequate follow-up and active intervention are advocated to delay the onset of end-stage nephropathy.

The pattern and challenges of infertility management in Lagos, Nigeria.

BACKGROUND: Infertility remains a threat to successful reproduction by couples desirous of pregnancy. OBJECTIVE: To determine the pattern of infertility cases amongst infertile couples seeking care in Lagos University Teaching Hospital as well as challenges in their management. METHODS: A review of the management of couples referred for infertility to the gynaecological outpatient clinic of the Lagos University Teaching Hospital (LUTH), Nigeria from 1(st) January 2005 to 31(st) December 2006. RESULTS: The incidence of infertility was found to be 26.8% of the gynaecological consultations with a mean duration of infertility of 4.3 ± 3.4 years. The mean age of the women was 33.8 ± 5.2 years and 66.1% were nulliparous. Secondary infertility accounted for 80% of cases. Male factors only was the cause in 11.1%, female factor only in 37.8%, both male and female factors in 40% while no cause was identifiable in 11.1%. There was no association between tubal occlusion and a history of induced abortion in this study (p >0.05). There was a high rate of discontinuation of care by their large numbers lost to follow up. CONCLUSION: Infertility is still a public health problem in Lagos, Nigeria.

Predictors of maternal mortality in institutional deliveries in Nigeria.

BACKGROUND: Maternal mortality in poor countries reflects the under-development in these societies. Global recognition of the burden of maternal mortality and the urgency for a reversal of the trend underpin the Millenium Development Goals (MDGs). OBJECTIVE: To determine risk factors for maternal mortality in institutional births in Nigeria. METHOD: Twenty one health facilities in three states were selected using stratified multi-stage cluster sampling strategy. Information on all delivered mothers and their newborn infants within a three-month period was culled from medical records. RESULTS: A total of 9 208 deliveries were recorded. About one-fifth (20.5%) of women had no antenatal care while 79.5% had at least one antenatal visit during pregnancy. Four-fifths (80.5%) of all deliveries were normal deliveries. Elective and emergency caesarean section rates were 3.1% and 11.5% respectively. There were 79 maternal deaths and 8 526 live births, giving a maternal mortality ratio of 927 maternal deaths per 100 000 live births. No antenatal care, parity, level of education, and mode of delivery were significantly associated with maternal mortality. Low maternal education, high parity, emergency caesarean delivery, and high risk patients risk independently predicted maternal mortality. CONCLUSION: Meeting goal five of the MDGs remains a major challenge in Nigeria. Multi-sectoral approaches and focused political will are needed to revert the high maternal mortality.

Prevalence of Chlamydophila pneumoniae antibodies in women with pre-eclampsia in Lagos, Nigeria.

ABSTRACT BACKGROUND: The precise aetiology of pre-eclampsia has remained unknown. It is still a major contributor to maternal and perinatal morbidity and mortality. OBJECTIVE: To determine the relationship between pre-eclampsia and immunoglobulin G (IgG) antibodies to Chlamydophila pneumoniae. METHODS: One hundred and eleven parturients in a tertiary hospital in Lagos, Nigeria comprising 49 women with pre-eclampsia and 62 women without pre-eclampsia were studied.Peripheral blood was obtained for Chlamydophila pneumoniae antibodies which were measured using a solid-phase enzyme-linked immunosorbent assay and maternal diastolic blood pressure, perinatal morbidity and mortality were also assessed. RESULTS: The cases (N = 49) and controls (N = 62) were evenly matched with respect to age and parity. The women with pre-eclampsia delivered at significantly lower gestational ages than those with normotensive gestations. 66.7% of all the subjects were seropositive for Chlamydophila pneumoniae antibodies. 38 out of the 49 cases (77.6%) were positive for the Chlamydophila pneumoniae antibodies compared with 36 out of the 62 controls (58.1%) [p<0.05].Higher antibody titres were found in parous women with a previous history of pre-eclampsia compared with those without a previous history (p = 0.0308).However, there was no significant association between antibody titres and pregnancy outcome (p >0.05). CONCLUSION: Results from this study suggest a link between Chlamydophila pneumoniae IgG antibodies and pre-eclampsia. Further prospective studies with larger sizes are needed to verify this association and identify therapeutic options that will effectively prevent the onset or progression of pre-eclampsia.

Outcome of term singleton breech deliveries at a University Teaching Hospital in Lagos, Nigeria.

OBJECTIVES: To determine the incidence, review the management as well as the maternal and perinatal outcome of singleton breech presentation at term at the Lagos University Teaching Hospital (LUTH). METHOD: A review of the 108 singleton term breech deliveries that took place at the Lagos University Teaching Hospital over 30 months from 1st January 2005 to 30th June 2007. RESULTS: The incidence of singleton term breech delivery was 3.4% and eighty seven per cent of the delivery was by caesarean section. Babies delivered by caesarean section were more likely to have first and fifth minute Apgar Scores greater than 7 compared to those delivered vaginally (p < 0.001). The perinatal mortality rate was more than four times higher in singleton term breech deliveries when compared to singleton term cephalic deliveries. The mean estimated blood loss following caesarean delivery was 775.5 + 441.6 ml while that following assisted breech delivery was 253.6 + 217.9 ml and this was statistically significant (p < 0.001). The mean hospital stay of mothers following caesarean birth was 6.6 + 1.8 days while it was 3.1 + 1.5 days for those that had assisted breech delivery. This was also statistically significant (p < 0.001). However all the six women with puerperal complications occurred in women that had caesarean section. CONCLUSION: Babies delivered by caesarean section had better perinatal outcome compared with assisted vaginal breech delivery. Maternal morbidity occurring in the caesarean section group was not fatal.

The acceptance rate of intrauterine contraceptive device (IUCD) amongst family planning clinic users in Lagos University Teaching Hospital (LUTH).

BACKGROUND: Intrauterine Contraceptive Device is an effective reversible long-term contraceptive method that is popular and widely used in this environment. OBJECTIVES: To determine the characteristics of women using this mode of contraception, their main reasons for acceptance, complications arising from usage and the discontinuation rate as well as reasons for discontinuing the method. METHODS: A review of case records of all the new contraceptive acceptors attending the Department of Obstetrics and Gynaecology Family Planning Clinic of the Lagos University Teaching Hospital (LUTH) from 1st January 1990 to 31st December 1994 was examined and the clients that accepted the intrauterine contraceptive device, (IUCD) during this period were identified. The records of those that opted for IUCD were thoroughly reviewed to identify the follow up events through the subsequent ten years visits to determine outcome of the contraceptive usage. RESULTS: Amongst the 2754 new contraceptive acceptors during the study period, 1602 (58.17%) clients accepted the Intrauterine Contraceptive Device (IUCD). Of these IUCD acceptors, the mean age was 31.3 +/- 5.5 years, mean parity was 3.9 +/- 2 and mean number of children alive was 3.6 +/- 1.8. Seven hundred and forty nine (46.8%) of them had previously used contraceptives and 1175 (73.3%) of them still wanted more children, thus child spacing was the main reasons for accepting this method. By 12 months, the discontinuation rate was 13.9% with the cumulative discontinuation rate of 47% as at forty-eighth month. The commonest reason for discontinuation was planning to get pregnant in 426 (26.6%) of the clients. Menstrual disorders accounted for 108 (6.7%). The mean duration of IUCD was 25.4 +/- 18.8 months with an accidental pregnancy rate of 0.3%. CONCLUSION: Intrauterine Contraceptive Device is widely accepted amongst women in the study group. Devices that reduce menstrual loss and also have long duration of action like Levonorgestrel intrauterine system (LNG-IUS) qualifies to be considered.

Screening for gestational diabetes mellitus in Nigerian pregnant women using fifty-gram oral glucose challenge test.

BACKGROUND: Gestational Diabetes Mellitus (GDM) is frequently associated with adverse pregnancy outcome if not adequately managed. Prompt identification of these women requires a programme of active screening. OBJECTIVE: To determine the predictive value of the oral 50-gram glucose challenge test (GCT) in the detection of GDM. METHODS: At 24 to 28 weeks of gestation, 134 pregnant women with risk factors for GDM (test group) and another group of 134 consecutive pregnant women without risk factors for GDM (control group) were screened with 50 grams of anhydrous glucose and venous blood obtained one hour later. A diagnostic 3-hour - 100g oral glucose tolerance test (OGTT) was done for all either within one week for those with GCT > or = 130mg/dl (7.2mmol/L) or at 30 to 32 weeks of gestation for those with GCT of less than 130mg/dll RESULTS: Of the 134 women in the test group 113 (84.3%) completed the study, as did 109 (81.3%) of the 134 women in the control group. The data from these women were analyzed. Gestational diabetes mellitus was found in 7 (6.2 %) of the test group and 5 (4.6 %) of the control group (p = 0.816), an overall prevalence of 12 (5.4 %) for the study. Among the women with newly diagnosed GDM, 58% had risk factors for glucose intolerance while 42% had no such risk factors. The sensitivity and negative predictive values were all 100% at screening values of 130mg/dl and 140mg/dl; while the specificity was 82.4% at 130mg/dl and 91% at 140mg/dl. This was however not statistically significant (p = 0.619). CONCLUSION: The plasma glucose value of 140mg/dl in the GCT should be used because of its high sensitivity and higher specificity than does the 130mg/dl screening value. GDM is unlikely to be present if the venous plasma glucose level is less than 140mg/dl, one hour after administration of 50g oral glucose load at 24 to 28 weeks gestational age.

Family limitation and fertility increase.

PIP: Researchers used data from a survey of women patients in the maternity ward during 1968-1969 and August 1978 of a hospital in Lagos, Nigeria and from the 1897 and 1926 censuses of 50 rural and urban populations in European russia to demonstrate that modernization factors that reduce mortality also increase fertility under early marital patterns. The researchers learned by examining the Nigerian data that, in a population that has recently experienced an improved standard of living just prior to the demographic transition, natural fertility rises. The pregnancy rate also increases which leads to a greater incidence of pregnancy complications. Hence more infants are born at a low birth weight and consequentially an increase in infant mortality. Yet not all populations witness this pattern. The most important find of the study was that the direction of change in fertility essentially hinges on the marital pattern current before the demographic transition begins. For example, in European Russia, 33% of the eastern provinces' rural population experienced a decline in marriages between 1897-1926 while marital fertility increased. Yet the opposite occurred among the rural marital fertility increased. Yet the opposite occurred among the rural population of the western provinces in the same period: both marital fertility and marriages fell, although the decline was stronger in fertility than in nuptiality. Presently the demographic transition theory excludes nuptiality as 1 of its consequential components. It also assumes interaction only between morality and fertility and that changes in fertility reflect changes in nuptiality. Yet evidence shows that if policy planners would include nuptiality into the theory, they could better predict the timing of sustained fertility decline. Hence population policy should be aimed at marital patterns, since affecting these more directly results in reduced fertility.^ieng

Refined fertility estimates for Nigeria.

PIP: By reanalyzing the data from the 1965-66 rural demographic survey in Nigeria this paper provides new and better estimates of fertility parameters for the various regions of Nigeria than previous estimates. The original analysis of that is criticized for excluding a large body of data from the analysis, as well as making unwarranted adjustments of estimates of fertility and crude birth rates. The 1971-73 KAP survey was also evaluated. There were doubts concerning the accuracy of the KAP survey, as under-reporting of mortality and age misreporting had occurred. The methods of analysis used in this study were called, "the c(x), 1(x) method of stable population. A model stable population can be defined by at least 2 parameters: the index of the recorded age distribution, c(x), and mortality level. A detailed presentation and rational of the present analysis is provided. The results indicate that fertility levels are rising. Factors affecting fertility are examined, such as length of lactation, postpartum abstinence and age of marriage, which is in turn affected by level of education. It is suggested that the high fertility trend in Nigeria may just be a phase identical to the 'bulge' in fertility which some European countries experienced in their demographic history.^ieng

Causes of death in Lagos: structure and change.

An analysis of the changing structure of causes of death in the city of Lagos between 1965 and 1975 was conducted. Registered deaths from the vital statistics system of the Lagos State Ministry of Health were employed. It was found that significant changes in causes of death among the population had occurred during the period. In the 1960s, diseases which killed children were more common than those which killed adults. The most significant feature of these fatal children diseases was the sharp contrast between the causes peculiar to neonates (perinatal) on the one hand and those common among post-neonates and pre-school-age children on the other. Commencing around 1970, however, children-related causes ameliorated considerably and the proportion of adults dying then became the higher. The most important cause of death during this period was accidents. The gap between male and female deaths from accidents is explained not only by different roles and behaviour of the sexes but also by men's obsession with high-risk vehicles. But this safety which women enjoyed was countered by increasing mortality from pregnancy complications, a phenomenon associated with higher gravidity in the 1970s.

The determinants of infant and child morbidity in Lagos, Nigeria.

Analysis of the structure of real morbidity among children in Lagos, Nigeria, reveals that the leading diseases were of hygienic, nutritional and perinatal origin. These diseases were highly concentrated in infancy and early childhood; in the case of the former, the concentration was greater among boys than girls. During the 1970s, a decline is noticed in the frequency of infective and parasitic diseases particularly among male infants. Simultaneously, a slightly rising trend of diseases related to birth complications and perinatal nature afflicting predominantly early infancy occurred, off-setting, to some extent, the effect of the diminishing trend in infective diseases. The rising trend of perinatal diseases should be seen in conjunction with a likely increase in gravidity of women and the resultant increase of pregnancies and birth complications, which affected the health of the mother as well as that of the child. The findings seem to suggest that although both medical and non-medical factors contributed to the change in morbidity pattern in the decade 1968-1978, the role of factors of socio-economic nature was significant. The implication is that without socio-economic epidemiology, biomedical epidemiology could make a limited contribution to the reduction of morbidity.

New estimates of fertility and child mortality in Africa, south of the Sahara.

Summary Earlier work by Page and Coale has estimated demographic indices of fertility and mortality for parts of Africa using the Sullivan modification of Brass's technique. The present paper presents modified and more accurate estimates of fertility and child mortality, not only for the sub-national units covered by Page and Coale but also for areas not covered by them. The present analysis which employs Trussell's refinement of Brass and Sullivan's techniques also includes improvements overlooked in earlier estimates. The salient finding that emerges is that while the Brass mortality technique is very powerful, his equally ingenious fertility technique is very weak and should not be relied on for estimating fertility parameters.