Trends in utilization of obstetric care at Wesley Guild Hospital, Ilesa, Nigeria. Effects of a depressed economy.

Perinatal mortality rate (PNMR) at Wesley Guild Hospital (WGH), Ilesa, Nigeria, over a ten-year period was retrospectively analysed. The main objective was to determine the trends in the utilization of obstetric care and PNMR in the face of current economic difficulties in Nigeria and to make suggestions for improvement. The average PNMR over the period was 57.8/1000 births. There was a sharp rise in PNMR in 1985 to a peak of 110/1000 in 1987 (p < 0.0001). This was associated with a decline in utilization of maternity services, probably as a result of the introduction of fees for maternity services late in 1984 and increase in economic hardship in Nigeria. Actions are needed to improve enhanced access to obstetric care for the poor. These actions include: improvement in the economic conditions of the people, emphasis on primary health care (PHC) and early referral of high-risk pregnant women to tertiary units.

PIP: During 1981-1990, there were 12,925 deliveries and 68,668 mothers received prenatal care at Wesley Guild Hospital in Ilesa, Nigeria. Physicians retrospectively analyzed data on these deliveries to determine trends in the perinatal mortality rate under harsh economic conditions. Rising economic hardship in Nigeria forced the hospital to introduce fees in late 1984, after which, the number of mothers receiving prenatal care and the resultant number of deliveries at the hospital declined significantly (p 0.001). In fact, the percentage of deliveries where the mothers did not receive prenatal care increased as the total number of deliveries decreased (p 0.001). The fees and the concurrent economic hardship decreased the purchasing power of the people, thus more and more mothers could not afford to pay for prenatal care and delivery in the hospital. During the study period, there were 747 perinatal deaths for a perinatal mortality rate of 57.8/1000 total births. The rate increased from 38.7 after introduction of fees and peaked at 110.5 in 1987. Leading obstetric complications were antepartum hemorrhage, prolonged obstetric labor, preeclampsia, cord prolapse, retained second twin, severe anemia, and maternal and fetal distress. The distribution of stillbirths, early neonatal deaths, and major obstetric complications was unequal during the study period. Stillbirths accounted for more than 75% of perinatal deaths. Factors related to stillbirth included prolonged obstructed labor, antepartum hemorrhage, multiple pregnancy, and eclampsia. The two leading causes of early neonatal death were preterm delivery (low birth weight 2500 g) (62.2%) and birth asphyxia (27.7%). More than 75% of these deaths occurred within the first 48 hours of life. More than 50% of the preterm infants weighed less than 1500 g at birth. These findings reflect the adverse effect of economic hardship and of the introduction of fees on perinatal health at Wesley Guild Hospital.

Maternal tetanus toxoid coverage during pregnancy in Ile-Ife, Nigeria.

A cluster survey on maternal tetanus toxoid (TT) coverage was carried out in the Ile-Ife Central Local Government Area. Out of the 896 mothers of babies 0-12 months old who were interviewed, 668 (74.6%) claimed they received TT during pregnancy, this was confirmed in 37 (4.1%) and in only 25 (2.8%) of these cases could the babies be said to have been protected from neonatal tetanus (NNT) at birth. About 35% of the babies were delivered at home/churches where most babies with NNT are usually born.

The obstetric performance of sickle cell disease patients and homozygous hemoglobin C disease patients in Ile-Ife, Nigeria.

In a 9-year period (1980-1988), 46 delivered hemoglobinopathy patients were studied. There was a high incidence of complications during pregnancy. The perinatal and maternal mortalities were 13.4% and 9.2% respectively. The complications could be minimized by adequate supervision in pregnancy, labor and puerperium.

Biosocial factors affecting menarche in a mixed Nigerian population.

A prospective study of school girls in a mixed Nigerian population revealed that the mean menarcheal age was 13.98 +/- 1.30 years. The mean menarcheal age was influenced by the social class of the parents, being higher in the lower social class, there were considerable variations in the biologic measurements (height, weight and body mass index) among girls who attained menarche.

Serum copper, zinc and magnesium in maternal and cord blood at delivery.

Serum concentrations of copper, zinc and magnesium were determined in maternal and cord blood at delivery in term pregnancies among healthy Nigeria women. Maternal serum copper concentration was significantly higher than cord serum concentration. There were no significant differences in maternal and cord serum levels of zinc and magnesium.

Ureteric injuries associated with gynecologic surgery.

We conducted a review of eight ureteric injuries associated with major gynecologic surgery in seven patients over an 11-year period. Our low incidence of 0.36% is comparable with other reports. Diagnosis was made either intra-operatively or postoperatively. Immediate ureteric repair is advocated for all injuries discovered intra-operatively. Attention to preventive measures both before and during gynecological operations will reduce the incidence of ureteric injuries.

Bilateral tubal and twin pregnancies in Ile-Ife, Nigeria.

Three cases of unilateral tubal twin pregnancies and four cases of simultaneous bilateral tubal pregnancy recorded in a Nigerian University Teaching Hospital were reviewed. The incidences were 1 in 68 and 1 in 51 ectopic pregnancies respectively. High twinning rates within the environment and tubal damage from pelvic infections were considered as possible etiologic factors.

Abortion-related deaths in Ile-Ife, Nigeria: a 12-year review.

Cases of death due to abortions at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, between January 1977 and September 1988 were reviewed. Abortion accounted for 12.5% of the maternal deaths and the majority (88.9%) were from illegal abortions. The majority (92.6%) of the patients were of low educational status. Both married women and single girls were involved. Instrumentation was employed in 81.5% of the abortions and unqualified personnel were involved in 74.1% of cases of such intervention. Seventeen (63%) of the pregnancies were terminated within the first trimester. Most (96.3%) of the patients were admitted in poor clinical state and 51.8% of them died within 48 h of admission. Sepsis was the commonest cause of death.

PIP: Deaths due to abortions at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria between January 1977-September 1988 were reviewed. Abortion accounted for 12.5% of the maternal deaths and the majority (88.9%) were from illegal abortions. The majority (92.6%) of the patients had secondary school education and below, and both married and single women were included. Instrumentation was employed in 81.5% of the abortions and unqualified personnel were involved in 74.1% of the cases where intervention occurred. 17 (63%) of the pregnancies were terminated within the 1st trimester. Most (96.3%) of the patients were admitted in poor clinical state and 51.8% of them died within 48 hours of admission. Sepsis was the most common cause of death. (author's modified)

Ectopic pregnancy in a defined Nigerian population.

All cases of ectopic pregnancy in the Ile-Ife teaching hospital between 1977 and 1987 were reviewed. The incidence per 1000 births was 4.76, and this condition accounted for 2.75% of all gynecological admissions. The associated mortality was low (0.5%). An increasing incidence was observed during the study period, as was an increasing proportion of nulliparous patients. Tubal damage from pelvic infections might account for the trends.

Neonatal tetanus in babies of women immunized with tetanus toxoid during pregnancy.

In a study of 52 cases of neonatal tetanus admitted to Wesley Guild Hospital, Ilesha, it was found that 17 (33%) of the babies were delivered to mothers who had received adequate tetanus toxoid immunization during pregnancy. The 17 babies were compared with the remaining 35 babies whose mothers had not received tetanus prophylaxis. The case fatality rates in these two groups were 12.5% and 60% respectively (P less than 0.01). This report shows that neonatal tetanus can occur in babies of mothers who were immunized with tetanus toxoid during pregnancy. Maternal immunity may, however, improve the prognosis in such infants.

Rupture of the gravid uterus in Ile-Ife, Nigeria.

PIP: To study cases of ruptured gravid uterus in Ile-Ife, Nigeria, medical records were examined. From January 1979 to December 1986, the records indicated 30,511 deliveries and 120 cases of ruptured uterus; the incidence rate was 0.4%. 112 patient records were studied. Findings included a mean patient age of 28.5 for 4.0 years, parity of 3-4 children (42%), 74% unbooked cases, and 29 booked cases. 41% of the booked cases had previous cesarean sections. 88% of the patients' labor started at home. Spontaneous uterine rupture occurred in 75% of the cases; 58% had complications of feto-pelvic disproportion and grand multiparity (30%). 15% of booked and unbooked patients had previous cesarean sections. Additional findings include iatrogenic rupture in 10% of the cases, involvement of lower uterine segment in 82%, lacerated urinary bladder (14%). Surgical procedures employed included uterine repair (50%), subtotal hysterectomy (25%), and total hysterectomy (24%). Patients receiving total hysterectomy had a mortality rate of 4% compared to 21% of all other groups. The most common maternal complications included maternal death (17%), prolonged hospital stay (58%), wound sepsis (32%), genital tract sepsis (26%), and septicemia (10%). The primary causes of death were septicemia and hemorrhagic shock. Booked patients had low mortality rates (10%) compared to unbooked patients (19%). The perinatal mortality rate was 94%. It is suggested that adequate, affordable antenatal and delivery care could decrease the complications involved with uterine rupture.^ieng

Gravid uterus in an anterior abdominal wall hernia of a Nigerian woman.

A case of a gravid uterus in an incisional hernia in the anterior abdominal wall of a 27-year-old Nigerian woman is presented. The patient developed an ulceration of the anterior abdominal wall necessitating prolonged hospitalization. She was delivered by emergency lower segment cesarean section at 35 weeks gestational age because of premature labor. The patient unfortunately died from primary postpartum hemorrhage.

Improved survival rate in neonatal tetanus among babies of immunised mothers

Fifty-two neonates admitted for tetanus into our neonatal unit at Wesley Guild Hospital; Ilesa over a thirty-month period were analysed in relation to maternal immunisation with tetanus toxoid during pregnancy. Seventeen (32.7) of the babies were delivered to mothers who had tetanus toxoid immunisation during pregnancy. The male to female ratio; mean age and weight of babies in the two groups were similar. Six mothers took discharge of their babies against medical advice. Twenty (43.5) of the remaining 46 babies died. The fatality rates in the 16 infants of mothers who had tetanus toxoid and 30 infants of mothers who did not have tetanus toxoid during pregnancy were 12.5and 60respectively (P0.01). This report thus shows that neonatal tetanus can occur in babies of mothers immunised with tetanus toxoid during pregnancy but that maternal immunity probably improved the prognosis of neonatal tetanus in such infants

Congenital absence of an ovary in a Nigerian woman.

A case of unilateral absence of the left ovary in a 45-year-old grand multiparous Nigerian woman is reported. Congenital absence of a gonad is extremely rare and it indicates a genetic or chromosomal error in the formation of the urogenital ridge.

Tetanus in pregnancy in a Nigerian woman--a case report.

PIP: Tetanus infection complicating pregnancy is strongly associated with maternal mortality and perinatal morbidity. This is a case report of a 31-year-old woman who was admitted to the intensive care unit of Obafemi Awolowo hospital in Nigeria. She presented with a 1-day history of stiff neck, backache, inability to open her mouth widely, and spasms of the facial, back and limb muscles. A physical examination revealed an acutely ill patient with trismus, and a septic ulcer on her upper thigh. A diagnosis of tetanus during pregnancy was made. The patient was given diazepam 20mg and antitetanus serum (20,000 units). This was followed by 0.5ml of tetanus toxoid intramuscular. The wound was cleaned and 50ml of pus was evacuated. The patient developed fever and the pregnancy was terminated with a premature stillbirth male fetus. The risk of tetanus related to pregnancy would be greatly reduced in the event of world wide immunization against tetanus of all females during childhood, pregnancy, postpartum immunization of unbooked patients, and proper wound care in pregnant women.^ieng