Community health insurance as a catalyst for uptake of family planning and reproductive health services: the Obio Cottage Hospital experience.

Health service delivery in the Niger Delta region of Nigeria has suffered many setbacks. Community participation may help break the barriers limiting access to health services, especially those associated with family planning and reproductive health services. This is a two-year review of family planning and reproductive health services records offered by the Obio Cottage Hospital from the onset of the Community Insurance Scheme (2010-12). Since the inception of the Community Insurance Scheme, there has been an increase in the uptake of family planning methods of more than 50%; 1,274 women in 2011 vs 3,140 in 2012. An increase in number of women seeking reproductive health services was also observed. The Community Health Insurance Scheme (CHIS) at the Obio Cottage Hospital provides evidence for expansion, as seen in the improvement in patronage for family planning and reproductive health services.

Pre-induction cervical ripening: transcervical foley catheter versus intravaginal misoprostol.

The object of this study was to compare the effectiveness of the intravaginal Misoprostol and transcervical Foley catheters as pre-induction cervical ripening agents, to estimate the proportion of patients achieving vaginal delivery and to compare the complications of labour and foetal outcome between the two groups. The study was a prospective, randomised study of pregnant women, with singleton pregnancies who presented for antenatal care and delivery at the University College Hospital (UCH), Ibadan, Nigeria. Ninety-nine patients were invited to participate and ninety-six (96) agreed. No patient withdrew from the study. The patients were assigned by means of computer-generated random numbers to receive transcervical Foley catheters (Size 16F, with 30 ml balloon capacity) or 50 microg intravaginal Misoprostol (Cytotec tablet, Searle & Co., Chicago). Fifty (50) patients received intravaginal Misoprostol and Forty-six (46) received Transcervical Foley catheters. The proportions of nulliparous, primiparous and multiparous patients were 52, 20 and 28% in the misoprostol group and 43.5, 26.1 and 30.4%, respectively, in the Foley catheter group. The time to achieve a favourable cervical status was significantly shorter in the Misoprostol group, with 98.0% of the subjects attaining Bishop score > or = 6 within 6-12 hours of insertion of the study agent, in contrast to 69.0% of the subjects in the Foley catheters group (P<0.001). Thirteen (26.6%) and three (6.5%) patients in the Misoprostol and Foley catheters groups, respectively, went into labour while undergoing cervical ripening and all had uneventful vaginal deliveries (P<0.05). The induction-delivery interval did not differ significantly between the groups. The incidence of caesarean delivery was 6.0% in the Misoprostol group compared with 2.2% in the Foley catheter group (P=0.62). Instrumental vaginal delivery rates were similar in both groups. Overall, the mode of delivery did not differ significantly between the groups. The number of neonates with 1-minute Apgar score <7 did not differ significantly in both groups and no neonate had 5-minute Apgar score <7. Meconium stained liquor was noticed in 5 (Misoprostol) vs 2 (Foley catheters) patients in labour. None of the neonates had any features suggestive of meconium aspiration. Labour complications were mainly precipitate labour {2 (Misoprostol) vs 1 (Foley catheters) } and 1 patient with transient tachysystole (> or =6 contractions in 10 minutes for two consecutive 10-minute periods) in the Misoprostol group. Hyperstimulation was not noticed in any of the patients in either arm of the study groups. Intravaginal Misoprostol is as effective a pre-induction cervical ripening agent as transcervical Foley catheters, with added advantages of shorter duration of cervical ripening, reduced oxytocin requirement for induction of labour and greater acceptability to patients. The incidence of caesarean sections, other labour complications and the foetal outcome were similar with both methods.

Comparison of changes in pre-induction cervical factors' scores following ripening with transcervical foley catheter and intravaginal misoprostol.

The study compares the changes in the cervical factors in pre-induction cervical ripening with both transcervical Foley catheter and Intravaginal Misoprostol. This was a randomised prospective study of pregnant women, with singleton gestations who presented for antenatal care and delivery at a tertiary health institution in the South-western Nigeria between 1st March 2003 and 31st March 2004. One hundred and two (102) patients received 50microg intravaginal Misoprostol and Ninety-six (96) received size 16F Transcervical Foley catheters. Both groups were similar at the baseline. Misoprostol group showed greater improvement in the final cervical length score, with 38.4% and 58.6% scoring 2 and 3 respectively, in contrast with the Foley catheter group where 77.7% had final score of 1, with only 16% scoring 2 and none scored 3 (P = 0.00). Ninety-one percent of the patients in the misoprostol group achieved the maximum cervical consistency score of 2, contrasting with the 31.9% in the Foley Catheter group (P = 0.00). 64.9% of the patients in the Foley catheter group did not achieve appreciable change in cervical consistency. Our findings indicate that intravaginal misoprostol was more effective in improving the scores of cervical length and consistency, while transcervical Foley catheter was better at improving the cervical os dilatation score at pre-induction cervical ripening. The clinical implication is that, patients for pre-induction cervical ripening can be selected for either of these ripening agents based on which cervical factors require improvement in scores

Awareness of cervical cancer, Papanicolaou's smear and its utilisation among female undergraduates in Ibadan.

A survey was conducted among 421 undergraduates of the University of Ibadan using self-administered questionnaires probing into their risk factors for neoplastic cervical lesions, awareness of cervical cancer, Papanicolaou's smear and its utilisation. The percentage of sexually active respondents was 81.5%. Sexual exposure before the age of 20 years occurred in 51.7%. The mean age at sexual debut was 18.8 years while the modal age was 18 years. Fifty seven per cent had multiple sexual partners, but only 38.1% used condoms. Seventy one per cent were aware of cervical cancer, while only 33.5% were aware of Papanicolaou's smear. Awareness was found to be more among medical students and the married ones. On the other hand, only 8.3% of them had ever done a Papanicolaou's smear. There is a need to increase awareness and incorporate cervical screening into the pre-existing university health services. Also, logistic barriers to cervical screening need to be removed.

Sexuality, contraceptive choice and AIDS awareness among Nigerian undergraduates.

A survey of 2388 Nigerian undergraduates revealed that 87% were sexually active and 66% had more than one sexual partner, while 17.5% have had clandestine abortions. All respondents were quite knowledgeable about HIV/AIDS but few sexually active ones took precautions to prevent HIV transmission. Majority (87.5%) were knowledgeable about contraception and approved of its use, but only 34.2% were current users of contraceptives. About 58% of these cited pharmacy shops as their source of contraceptives. The attitudes of the students were below expectation. Specially designated centres for the provision of appropriate contraceptive services to students by trained personnel are needed in the institutions in order to tackle their reproductive health problems.

Three decades of acquired gynaetresia in Ibadan: clinical presentation and management.

A retrospective analysis of acquired gynaetresia (Vaginal Stenosis) managed at the University College Hospital Ibadan, Nigeria between 1967 and 1996 was conducted in terms of clinical presentation and management. The prevalence rate was 7/1000. The peak age incidence was 20-30 years. Chemical vaginitis resulting from insertion of caustic vaginal pessaries for various reasons was the major cause of acquired gynaetresia. Dyspareunia/apyreunia and vaginal stenosis/occlusion were the most common symptoms and clinical findings respectively. The various surgical treatment of acquired gynaetresia included one stage vaginoplasty, McIndole-Read's two stage vaginplasty, separation of labial agglutination, Williams's operation, and simple dilatation of the vagina. Successful correction was recorded in 68% of the patients while 28% had residual partial stenosis, 4% had complete stenosis and 6% were lost to follow-up. It was concluded that acquired gynaetresia is preventable. Efforts should be made by authorities to address this issue and create designated centres in the country for the management of these cases and training of junior gynaecologists.

The psychosocial burden of caring for some Nigerian women with breast cancer and cervical cancer.

In Nigeria, the rising incidence of cancer and the paucity of institutional facilities and specialist man-power implies that the burden of care rests largely on relatives. We assessed the severity of indices of psycho-social and economic burden among relatives of women with breast and cervical cancer; and its relationship with patients' psychosocial distress. Using a burden questionnaire, relatives of 73 women with cancer (41 cervical and 32 breast, mean age of caregivers 35.6 years) were interviewed, in out-patient clinics. While the caregivers admitted high frequency of all indices of 'objective' burden, emotional ties at home and social relationships in the neighbourhood seemed intact, indicating tolerance and lack of social stigma. The financial burden was more problematic than the effect of caring on family routines; and these two factors significantly predicted global rating of burden. The severity of patient's worries and psychopathological symptoms were not significantly correlated with care-giver global rating of burden. The tolerance shown by this group of relatives implies that they have strong potentials for playing useful roles in community care of patients.

Hyperprolactinaemia as a cause of male infertility in Ibadan.

Sera from normospermic, oligospermic and azoospermic adult Nigerians were analysed by radioimmunoassay (RIA) for prolactin (PRL) and testosterone (T). The mean +/- SEM DRL concentration (M.I.U./L) of 1275.00 +/- 157.90 in azoospermics and 1165.50 +/- 181.50 in Oligospermics are significantly higher (P < 0.001) than 727.60 +/- 42.60 in normospermics. The mean +/- SEM T concentration (nmol/L) of 29.60 +/- 18.20 in azoospermics and 56.50 +/- 15.50 in Oligospermics are significantly lower (P +/- 0.001) than 258.60 +/- 62.20 in normospermics.

Pregnancy outcome in the elderly primigravidae.

We assessed the effect of advancing maternal age ( 35 years) on the outcome of pregnancy in first births among 50 elderly primigravidae compared with a control group of 50 younger primigravidae (20-29 years) at the University College Hospital Ibadan from 1 January 1988 to 31 December 1992. Most of the elderly primigravidae were professionals and the majority of them (68%) had involuntary infertility. Frequent hospital admissions, preterm delivery, low birth weights and very high caesarean section rates were the major problems highlighted in the elderly primigravidae, while anaemia was more frequent in the younger primigravidae. Unnecessary caesarean sections on the excuse of 'precious' baby in the elderly primigravidae should be discouraged bearing in mind its medico-social implications. It is concluded that although the elderly primigravidae may have higher rates of complications of pregnancy, delivery and neonatal deaths their overall risk of referral to special care baby unit is not appreciably increased.

Laparoscopic and microbiological features of acute salpingitis in developing countries.

One hundred and twenty-four out of 198 consecutive women who underwent diagnostic lasparoscopy for clinical symptoms and signs of acute salpingitis at the University College Hospital, Ibadan, Nigeria had acute salpingitis. These were slightly younger than those without acute salpingitis, otherwise there were no differences in the sociodemographic characteristics of the two groups. Urinary and gastrointestinal symptoms, abnormal vaginal discharge, fever (> 38 degrees C) and sexually transmitted organisms were significantly more in women with acute salpingitis. Ninety-five per cent of the Neisseria gonorrhoea cultured were of the PPNG strain. Pelvic adhesions were present in 69.4% of the women with acute salpingitis. Forty-one per cent of the women had tubal occlusion. It was concluded that laparoscopy rather than clinical findings alone would determine the severity of acute salpingitis. This should be performed along with culture of genital discharges and peritoneal fluid for optimum management. The use of a single dose broad spectrum antibiotics active against both PPNG and non-PPNG strains, and chlamydial infections is advocated for treatment in developing countries.

Measurement of cell numbers by means of the endogenous enzyme hexosaminidase: applications to cell adhesion assays in endometrial and ovarian carcinoma cell lines.

Using a chromogenic substrate for the lysosomal enzyme, hexosaminidase to estimate cell numbers, a sensitive, simple, and non-radioactive procedure has been previously developed (1) in which microtiter reaction wells are directly scanned using a spectrophotometer. The applications of this method to quantitation of cell numbers and adhesion assays to coated substrates in endometrial adenocarcinoma (Ishikawa) and epithelial ovarian cancer (Ovcar) cells are discussed. The methods are safe, cheap, and easily applicable to biological researches particularly in developing countries.

Characterization of integrin expression in a well differentiated endometrial adenocarcinoma cell line (Ishikawa).

The pattern of constitutive and cycle-dependent integrins in normal endometrium has recently been established, suggesting a role for cell adhesion molecules in endometrial receptivity and implantation. Currently few, if any, models exist for the study of human endometrial integrins and their role in establishment of the receptive endometrial phenotype. The Ishikawa cell line maintains functional estrogen receptors and progesterone receptors. The progesterone receptors in these cells are inducible by priming with estradiol and down-regulated by treatment with progesterone. In the present study the pattern of integrin expression in this well differentiated endometrial cell line is compared to that in normal endometrial epithelium using immunohistochemistry and flow cytometry and is confirmed by immunoprecipitation, Western immunoblot, and PCR. Like normal endometrial epithelium, Ishikawa cells maintain constitutive expression of alpha 2 beta 1, alpha 3 beta 1, alpha 6 beta 4. PCR demonstrates the expected size fragments of each, although evidence for alternatively spliced forms of the alpha 2-subunit was noted. Progesterone treatment of estradiol-primed cells resulted in increased expression of the alpha 1 beta 1 collagen-laminin receptor and suppression of the alpha v beta 3 vitronectin receptor, two of the cycle-dependent integrins expressed by normal endometrial epithelium. These data support the use of Ishikawa cells as an excellent model to study the regulation endometrial integrins and advance our understanding of hormonally mediated events surrounding implantation.

Vaginal delivery after one caesarean section in Nigerian women.

A total of 120 Nigerian women at term pregnancy with one previous caesarean delivery were studied between June 1988 and May 1993. Elective caesarean section was performed in 3 (2.5%). Vaginal delivery was achieved in 101 (86.5%) of those allowed a trial of labour. Intrapartum caesarean section was done in 16 (13.7%) cases. Rupture of the uterus occurred in 3 cases (2.6%) with perinatal loss of 2 babies. There was no maternal mortality. There was no significant correlation between vaginal delivery and birth weight, gestational age or initial indication for the primary caesarean section. It is concluded that trial of labour is safe after a previous caesarean section in selected patients.

Biophysical and biochemical analysis of semen in infertile Nigerian males.

Biophysical analysis of semen was performed in fifty-eight Nigerian male partners of infertile marriages. Sperm count concentration was significantly higher (P < 0.001) in oligospermics compared to normospermics as expected. However, there was no significant difference in sperm volume or motility percentage between the normospermics and the oligospermics; of course, no sperms were seen in the azoospermics. Biochemical analyses of serum zinc, copper, magnesium, and manganese by atomic absorption spectrophotometry [8] were further correlated in fifty-two patients. There were no statistically significant differences observed in the serum levels of zinc, magnesium, and copper among the normospermics, oligospermics, and azoospermics. The normospermic infertile patients, however, exhibited higher serum manganese when compared with oligospermics and azoospermics (P < 0.001). This finding suggests a potential role for manganese in the evaluation of infertile males.

Characterization of the functional progesterone receptor in an endometrial adenocarcinoma cell line (Ishikawa): progesterone-induced expression of the alpha1 integrin.

Endometrial progesterone receptors (PR) are regulated by both estrogen (E2) and progesterone (P) and mediate the expression of specific endometrial proteins. Ishikawa cells are a well-differentiated human endometrial adenocarcinoma cell line, with both estrogen receptors (ER) and PR, regulated in a manner similar to that of normal endometrium. Immunohistochemical and biochemical analyses demonstrate that the concentration of PR is increased by E2 priming and decreased by subsequent treatment with P. Scatchard plot analysis showed a K(d) of 1 nM. On the basis of biochemical analysis, PR concentrations reached approximately 1400 fmol/mg cytosol protein in cells after treatment with E2 (10(-8) M) for 4 days. Immunoprecipitation and Western blot studies revealed the presence of both the 116 kDa and 81 kDa proteins with multiple isoforms of the high molecular weight (MW) protein. Northern blot analysis demonstrated transcriptional control of PR by steroid treatment. These studies demonstrate the coordinate regulation of all PR mRNA species. The functionality of Ishikawa PR was demonstrated by the expression of alpha1beta1 integrin in response to E2 plus P, at the level of transcription and translation. This effect was blocked by the addition of the anti-progestin, RU-486. These studies reconfirm that the Ishikawa cell line is an excellent model for the study of hormonally regulated events in the human endometrial epithelium.

Endometrial progesterone receptors and markers of uterine receptivity in the window of implantation.

OBJECTIVE: To compare the expression of endometrial P receptors (PR) levels with markers of endometrial receptivity during the window of implantation. DESIGN: Prospective, controlled study to examine endometrial PR and three cycle-specific integrins in endometrial biopsies obtained during the window of implantation. SETTING: An academic teaching hospital. PATIENTS: One hundred seventy-five endometrial biopsies from regularly cycling women with luteal phase defect (LPD; group 1; n = 80), medically treated LPD (group 2; n = 16), minimal and mild endometriosis with aberrant alpha v beta 3 expression (group 3; n = 21), fertile controls (group 4; n = 26), and infertile controls (group 5; n = 32). MAIN OUTCOME MEASURE: Immunohistochemical staining intensity of each antigen using the semi-quantitative grading system (HSCORE), compared using analysis of variance with Scheffe's correction. RESULTS: Among the five groups studied, nuclear PR expression was significantly elevated in glandular epithelial cells from tissue samples with histologic delay > or = 3 days consistent with luteal phase deficiency (LPD; group 1). Failure of PR down-regulation was associated with aberrant alpha v beta 3 integrin expression. Medical correction of LPD was associated with return of normal endometrial histology, normal integrin expression, and the loss of epithelial PR, similar to controls. The other two cycle-dependent integrin markers, alpha 1 beta 1 and alpha 4 beta 1, were not different between groups. In women with aberrant alpha v beta 3 and "in phase" endometrium, epithelial PR expression was not different from controls. CONCLUSIONS: The establishment of normal endometrial receptivity appears to be tightly associated with the down-regulation of epithelial PR. Histologic delay, consistent with LPD, is associated with a failure of PR down-regulation and the lack of normal markers of endometrial receptivity. Occult uterine receptivity defects (aberrant beta 3 expression in otherwise normal histology) are regulated differently, suggesting alternate mechanisms also exist which influence endometrial receptivity.

Luminal and glandular endometrial epithelium express integrins differentially throughout the menstrual cycle: implications for implantation, contraception, and infertility.

PROBLEM: Integrins belong to a family of cell adhesion molecules that are present on virtually all cells. The temporal and spatial expression of these important proteins on the human endometrium suggests that certain integrins may participate in the cascade of molecular events leading to successful implantation. METHODS: Using immunohistochemistry, we studied the expression of 12 different integrins in up to 600 samples of human endometrium throughout the menstrual cycle. Intensity and distribution of staining was determined using the semiquantitative HSCORE, with specific focus on the differences between glandular and luminal expression. RESULTS: We noted that the glandular and luminal epithelium undergo independent alterations in integrin expression throughout the menstrual cycle. Specifically, glandular epithelium express certain integrins only during the window of implantation, while luminal epithelium down-regulate certain integrins during this time. The expression of one integrin (the alpha v beta 3 vitronectin receptor) on both luminal and glandular epithelium coincides with the time of embryo attachment; aberrant expression of this integrin is associated with infertility. CONCLUSION: It appears that the endometrium is a unique tissue with regard to the number of integrins that undergo temporal and spatial changes during the menstrual cycle. These data may offer new directions for the development of a novel contraceptive approach targeted to the endometrium as well as a better understanding of occult causes of infertility in women.

Open comparison of artemether and mefloquine in uncomplicated Plasmodium falciparum hyperparasitaemia in children.

The efficacy of intramuscular artemether given for 5 days and a single oral dose of mefloquine, 25 mg/kg/body-weight, was evaluated in 84 children with uncomplicated Plasmodium falciparum hyperparasitaemia ( > 5% parasitized erythrocytes). Follow-up was for 14 days in the artemether group and 28 days in the mefloquine group. Artemether produced a significantly higher parasite reduction at 24 hours [mean 90.6 vs 63.3%, 95% confidence interval 10.7-43.9] and significantly shorter parasite clearance time [mean 38.4 vs 49.3 hours, 95% confidence interval 5.5-16.3] than mefloquine. Fever clearance times were similar, presumably because of the use of an antipyretic in both treatment groups. Cure rate was 98% with artemether on day 14 and 100% with mefloquine on day 28. One child in the artemether group who had recurrence of parasitaemia on day 14 responded promptly to mefloquine with clearance of parasitaemia and fever at 24 hours. Although both drugs were well tolerated, mefloquine produced more episodes of abdominal pain with or without diarrhoea and vomiting. These results suggest that both drugs are effective in uncomplicated Plasmodium falciparum hyperparasitaemia in children from an endemic area of south-west Nigeria.

Endometrial dating correlated with multiple luteal progesterone levels in confirming ovulation and luteal function in infertile Nigerian women.

Infertility is a medico social problem in Nigeria and it accounts for 40 percent of our outpatient gynaecological consultations; therefore the need to evaluate the two common presumptive methods of ovulation (serum progesterone and endometrial history) is indicated. An endometrial biopsy and three blood samples taken between M-4 and M-11 (4 and 11 days to the next menstruation) for progesterone determination in the luteal phase of the cycles of 50 infertile Nigerian women were analyzed. The methods were compared for confirmation of ovulation and evaluation of luteal functions. Total luteal phase progesterone value of 11.3 nmol/1 or greater was consistent with ovulation (secretory endometrium) in 90% of the cycles. 41 cycles yielded sufficient information to compare the two methods for evaluation of luteal function. The total progesterone value of 15 nmol/1 or greater was consistent with in-phase biopsies. Twenty eight (68.3%) of the cycles showed evidence of In-Phase (IP,) biopsies while thirteen (32.7%) showed out of phase (00P) biopsies suggestive of abnormal luteal function. The mean progesterone levels of patients with IP biopsies were significantly higher than those with 00P biopsies (P < 0.0001). Compared to studies by other workers using single midluteal progesterone assay, it seems multiple progesterone assay does not confer added advantage in confirming ovulation or in evaluation of luteal function. It is suggested that simultaneous measurements of serum progesterone levels with endometrial biopsies should be used to document ovulation and luteal function in infertile Nigerian women in view of the scarcity of ultrasonographic machines and emerging new technologies in our practice.