STDS in women attending family planning clinics: a case study in Addis Ababa.

For cultural reasons modern contraception has been slow to gain acceptance in Ethiopia. Knowledge about contraception and abortion is still limited in many family and community settings in which it is socially disapproved. By 1990 only 4% of Ethiopian females aged 15-49 used contraception. Little is known of sexually transmitted disease (STD) prevalence in family planning (FP) attenders in Africa in general and Ethiopia in particular, even though attenders of family planning clinics (FPCs) are appropriate target groups for epidemiological studies and control programmes. A study of 2111 women of whom 542 (25.7%) attended FPCs in Addis Ababa showed utilisation rates to be highest in women who were: Tigre (33%) or Amhara (31%), aged 20-34 years (30%), age 16 or older at first marriage/coitus (28%:38% in those first married after 25 years); who had a monthly family income of 10 Ethiopian Birr (EB) or more (33%:36% for those with income 100-500 EB), three or more children (37%), more than five lifetime husbands/sexual partners (39%); or were bargirls (73%) or prostitutes (43%). The seroprevalence rates for all STDs, higher in FPC attenders compared with other women, were syphilis (TPHA) 39%, Neisseria gonorrhoeae 66%, genital chlamydia 64%, HSV-2 41%, HBV 40% and Haemophilus ducreyi 20%. Only 4% of FPC attenders had no serological evidence of STD: 64% were seropositive for 3 or more different STD. Clinical evidence of pelvic inflammatory disease (PID) was also more common in the FPC attenders (54%), 37% having evidence of salpingitis. The FPC provides a favourable setting for screening women likely to have high seroprevalence of STD, who for lack of symptoms will not attend either an STD clinic nor a hospital for routine check up. We recommend that measures be taken to adequately screen, treat and educate FPC attenders, their partners, and as appropriate and when possible their clients, in an attempt to control STDs and ultimately HIV in the community. Social, economic and cultural factors in the occurrence of STDs, prostitution, family planning and modern contraception coverage in Ethiopia are identified and deficiencies of current programmes briefly discussed with the objective of targeting services more effectively.

Chlamydial infection in a population of Ethiopian women attending obstetric, gynaecological and mother and child health clinics.

The prevalence of chlamydial infection was assessed in 1,846 Ethiopian women attending clinics in Addis Ababa. Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGVI-3), and C. pneumoniae (CPn), in a micro-immunofluorescence (micro-IF) test. Three levels of chlamydial infection were established. Sera with: 1) antibodies to CTA-C, CTD-K, LGV 1-3 and CPn singly or in combination, are considered as evidence of overall exposure to chlamydial species (OEC); 2) antibodies to CTD-K and LGV 1-3 are considered as evidence of exposure to genital chlamydial pathogens (GENCI); 3) IgM titre > or = 1/8, or Ig G titre > or = 1/64 to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn is considered as being evidence of active genital chlamydial infection (AGCI). OEC was found in 84 pc, GENCI in 60 pc and AGCI in 42 pc. Infection was highest in family planning and lowest in antenatal clinic attenders. OEC increased progressively with age while GENCI and AGCI peaked at ages 35 to 49. Chlamydial infection was highest in those married and sexually active < 13 years of age (OEC 88 pc, GENCI 69 pc, AGCI 49 pc); the lowest income groups (OEC 85 pc, GENCI 65 pc, AGCI 45 pc); those with more than five sexual partners (OEC 92 pc, GENCI 78 pc and AGCI 65 pc); with highest prevalence in bargirls (OEC 97 pc, GENCI 84 pc, AGCI 75 pc). Fifty pc had clinical evidence of past or present infection in the urethra, salpinges or bartholin glands (USB). OEC, GENCI and AGCI were associated with PID. The association of seropositivity with USB was remarkably similar for both gonorrhoea and chlamydial infection: we recommend adoption of a treatment regimen effective for both infections. The micro-IF test is a useful epidemiological tool for identifying the of antibodies to chlamydial pathogens. Use of antigen pools CTA-C, CTD-K LGVI-3 and CPn enables a distinction to be made between genital and non-genital infections. The problem of symptomatic and asymptomatic chlamydial disease needs to be addressed urgently.

PIP: In Addis Ababa, Ethiopia, purified chlamydial antigens were used in a micro-immunofluorescence (micro-I) test to detect type-specific antibodies against various chlamydial species in blood samples from 1846 women attending family planning, prenatal, and postnatal clinics. The antigens were for Chlamydia trachomatis A-C (CTA-C), Chlamydia trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV 1-3), and C. pneumonia (CPn). The researchers considered sera with antibodies to CTA-C, CTD-K, LGV 1-3, and CPn independently or in combination as evidence of overall exposure to chlamydial species (OEC) and those to CTD-K and LGV 1-3 as evidence of exposure to genital chlamydial pathogens (GENCI). They considered sera with IgM titre of 1/8 or more, or IgG titre of 1/64 or more to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn as evidence of active genital chlamydial infection (AGCI). 84% were categorized as OEC. 60% were categorized as GENCI. 42% were categorized as AGCI. The prevalence of chlamydial infection was greatest in family planning clients and lowest in pregnant women (OECD: 88% vs. 78%, p = 0.004; GENCI: 63% vs. 54%, p 0.02; and AGCI: 46% vs. 31%) (p 0.01). The geometric mean of the titre was also highest in family planning clients and lowest in pregnant women (85% vs. 58%). The most significant factor for chlamydial infection was being married and having first coitus before age 13 (OEC: 88% vs. 75% for first coitus at 18 years; p 0.001). Other risk factors included low income (p 0.005), more than 5 sexual partners (p 0.01), bar-girl occupation (p 0.001), and Amhara and Oromo ethnic groups (p 0.001). 50% of all women had clinical evidence of past or present infection in the urethra, fallopian tubes, and/or bartholin glands. Women with pelvic inflammatory disease (PID) were more likely to have chlamydial infection than those with no infection in the urethra, fallopian tubes, or bartholin glands (OEC: 95% vs.83%; GENCI: 86% vs. 58%; AGCI: 72% vs. 38%) (p 0.001). PID was also associated with gonorrhea.

Teenage obstetric and gynaecological problems in an African city.

OBJECTIVE: To measure the prevalence of sexually transmitted diseases (STD), pelvic inflammatory disease (PID), cervical cancer, pregnancy and use of contraception in teenagers, and to determine socioeconomic factors associated with these conditions to aid planners of medical services and promotion of sexual health. SUBJECTS: 181 Ethiopian teenagers and 1,845 women aged 20 to 45 years for comparison. SETTING: Gynaecological outpatient department, antenatal, postnatal and family planning clinics, in two teaching hospitals and a mother and child heath centre in Addis Ababa, Ethiopia. METHODS: Results of serologic tests for STD, clinical evidence of PID, and cervical cytology were analysed against socio-economic factors. RESULTS: In teenagers early age at first marriage/coitus, more common in those of rural origin, was associated with poverty, a greater number of lifetime sexual partners, and prostitution: 40 pc were first sexually active before the menarche. Prevalence of seropositivity to specific STD pathogens was; Treponema pallidum (TPHA) 21 pc, Neisseria gonorrhoeae (gonococcal antibody test: GAT) 40 pc, genital chlamydiae 51 pc, hepatitis B virus 36 pc, herpes simplex virus (HSV-2) 32 pc, and Haemophilus ducreyi 16 pc: 92 pc of teenagers were seropositive to one or more STD's. STD seroprevalence was higher in those with more than one sexual partner, those sexually active by age 15 (very high in those sexually active by age 12), those involved in prostitution and those attending the family planning clinic. Forty three pc had clinical evidence of PID; one married at age 10 had invasive cervical cancer by age 18; 40 pc of teenagers were pregnant compared with 25 pc of those aged 20 to 45; 21 pc attended for family planning; of regular FPC attenders 81 pc were GAT seropositive. CONCLUSION: Despite legislation early age of sexual debut is common, STD and PID are widely prevalent, the pregnancy rate in adolescents is high and contributes to the national population growth rate. Action is required at family, medical and governmental level to encourage cultural acceptance that marriage and sexual activity should not occur before the age of 16 years, with education appropriate to culture to prevent STD. Similar studies are recommended in other countries to establish a baseline for informed strategy regarding prevention of STD and health education.

PIP: A survey of 181 Ethiopian females ages 14-19 years recruited from health facilities in Addis Ababa revealed a high incidence of obstetric and gynecologic problems. All subjects completed a questionnaire administered by a female health worker and underwent a gynecologic examination and serologic tests. 49% of subjects were married and 18% were divorced; 11% were prostitutes. Age at first intercourse was under 12 years in 18%, 13-15 years in 38%, and 16 years or above in 44%; 40% were sexually active before menarche. 92% of adolescents had at least one sexually transmitted disease (STD), predominantly gonorrhea (40%), genital chlamydia (51%), hepatitis B (36%), herpes simplex virus (32%), and syphilis (21%), and 43% had clinical signs of pelvic inflammatory disease (PID). 53% had had at least one pregnancy. The earlier the age at first intercourse, the more likely it was that the adolescent would have multiple sexual partners and several STDs; adolescents in this category were also more likely to be from poor families from rural areas. Only 21% were attending a family planning clinic for annual check-ups; 14% of these females were using contraception. Although only 8% were infertile at the time of assessment, 23% had clinical evidence of salpingitis--a risk factor for future infertility. Given the long-term health risks (e.g., infertility, cervical cancer, and gonorrhea-related infant morbidity) associated with the patterns observed among these adolescents, it is recommended that STD education receive higher priority and that the Ethiopian Government consider greater enforcement of the law prohibiting sexual intercourse and marriage before the age of 16 years.

Seroepidemiological studies of Haemophilus ducreyi infection in Ethiopian women.

BACKGROUND AND OBJECTIVES: To measure prevalence of anti-Haemophilus ducreyi antibodies in sera from Ethiopian female attendees, and to determine significant socioeconomic associations. STUDY DESIGN: A modified ELISA immunoassay was used to test sera of 1,831 Ethiopian women attending gynecological, obstetric, and family planning clinics in Addis Ababa. RESULTS: Overall seropositivity was 19.4%. Prevalence rates for seropositivity for antibodies to H. ducreyi were significantly associated with ethnic group and religion, older age (> or = 50 years: 28%), early age at first coitus (< 13 years: 28%) and first coitus before the menarche (25%), being divorced (27%) or a prostitute (24%), longer duration of marriage (> 20 years: 27%) and sexual life (> 20 years: 24%), number of lifetime sexual partners (2 to 5 partners: 27%) and self-reported history of both syphilis and gonorrhea (31%). Of these factors, the two most significant were first coitus before the menarche (P < 0.0001) and not being still married to the first husband/sexual partner (P < 0.001). Differences in seropositivity according to ethnic group and religion may be explained by the number of women within each group who had only one lifetime sexual partner. Women with serological evidence of exposure to another sexually transmitted disease (STD) had a greater risk of exposure to H. ducreyi. The odds ratio for H. ducreyi seropositivity in women with syphilis or gonorrhea was 3.6, for women with genital chlamydial infection, 2.3, and for those with HBV or HSV-2, 1.4 and 1.3 respectively. CONCLUSIONS: This study illustrates the usefulness of the modified ELISA immunoassay for measuring exposure to H. ducreyi, and the usefulness of H. ducreyi as a marker for cumulative sexual exposure. Further studies on the association of HIV transmission and H. ducreyi in Ethiopia are now indicated.

PIP: Genital ulcerated disease (GUD), which includes chancroid, has been identified as a risk factor for HIV transmission. This study reports the prevalence of anti-Hemophilus ducreyi (chancroid) antibodies in 1831 Ethiopian women and looks at the behavioral and social factors which might affect the incidence and potential spread of chancroid. Patient data regarding ethnic and socioeconomic aspects were collected from detailed questionnaires. Blood collection was performed under medical surveillance. Complete gynecological examinations were performed. Papanicolaou stained smears were used as the basis of the cytological data. Serological studies utilized an enzyme immunoassay (EIA) test for STD detection. Statistical tests used included the Chi-square test, the multivariate analysis technique, and the Cochran-Mantel-Haenszel General Association Statistic Test. Antibodies to H. ducreyi were found in 335 women (19.4%). Prevalence of H. ducreyi was significantly associated with Amhara or Tigre ethnic heritage; older age; first coitus before beginning menstruation; history of STDs; divorced status; being a prostitute; longer duration of married and sexual life; and younger age at first coitus. Logistic regression demonstrated that 3 factors were significant when associated with H. ducreyi seropositivity. First coitus before beginning menstruation was highly significant (OR 1.95; 95% CI, 1.49-2.57; P 0.0001). Not being still married to the first husband was also significant (OR 1.68; 95% CI, 1.23-2.30; P 0.001). Being of the Ethiopian Orthodox religion was significant (OR 2.11; 95% CI, 1.21-3.68; P 0.005). Prevalence in women with 2-5 lifetime husbands was higher than in women with only 1 husband.

A socioeconomic, clinical and serological study in an African city of prostitutes and women still married to their first husband.

The aim of this paper was to compare women involved in prostitution with a group of women still married to their first husband and reporting having had only one sexual partner, in order to ascertain what factors if any contributed to women going into prostitution or staying still married to their first husband, their only sexual partner, and thereafter to compare clinical and serological aspects of the gynaecological conditions of the women in these two groups. The role of prostitutes in transmission of sexually transmitted diseases (STD) is widely recognised. Socioeconomic factors determining whether a woman will drift into prostitution or have a stable first marriage are largely unknown as are prevalence rates of STD, pelvic inflammatory disease (PID) and cervical cancer in these women. A socioeconomic, clinical and serologic study is reported for 2111 Ethiopian women attending teaching hospitals and maternal and child health clinics in Addis Ababa, analysing basic demographic data of three groups of women: (i) 278 engaged in prostitution, (ii) 730 still married to their one and only sexual partner, and (iii) 1103 single, widowed, divorced or married to their second or subsequent partner. Thereafter groups (i) and (ii) were compared and contrasted with regard to further socioeconomic, clinical and serological associations. The most significant socioeconomic associations for women in prostitution were low income (95% had < 50 Ethiopian birr [< U.S. $25] per month), ethnic group, and the timing of first coitus in relation to the menarche (81% were first married by age 15), in that order. Women still married to their first sexual partner had higher income, higher age at first marriage and longer duration of marriage. Sero-prevalence rates of STD in prostitutes were high: gonorrhoea 88%, genital chlamydiae 78%, syphilis (TPHA) 62%, HSV2 and HBV 46%, and chancroid 19%: 67% had PID and 2.9% cervical cancer. In comparison, rates for women married to their first and only sexual partner were: gonorrhoea 40%, genital chlamydiae 54%, syphilis (TPHA) 19%, HSV2 33%, HBV 35%, chancroid 13%, PID 47% and cervical cancer 1%. While the very high prevalence of STD in women involved in prostitution is not so unexpected, the high rate of STD in women still married to their first and only sexual partner is indicative of male promiscuity. Control of prostitution and diseases spread by it, together with education of both men and women is a national priority.

Is cervical cancer in Ethiopian women the result of a sexually transmitted disease?

Cervical cancer is the most prevalent cancer of women in Ethiopia and sexually transmitted diseases are highly prevalent in the country. In order to establish a possible cause and effect relationship between sexually transmitted diseases and cervical cancer, likely etiological socio-economic factors for these two conditions have been analysed. While residence, income, age at first coitus, age, number of sexual partners, marital status/profession and duration of sexual life affect both conditions, there is a significant difference between the most important factors in the etiology of the separate conditions. Serological testing shows a high prevalence of gonorrhea, which was used as a marker of STD. Women with gonococcal antibodies had evidence of increased exposure to other STD; there was no such correlation for cervical cancer. Our results indicate that STD per se is unlikely to be a primary cause of CC in Ethiopia. It appears probable that the etiology of CC in Ethiopia is multifactorial. Early exposure of the immature cervical epithelium to STD, the trauma of repeated childbirth, and multiple sexual partners in women whose defence factors are impaired by chronic malnutrition, add up to a major medico-socio-economic factor. The evidence presented here suggests that CC in Ethiopia is not so much the result of a sexually transmitted disease, but a sociosexual disease.

Seroepidemiological and socioeconomic studies of genital chlamydial infection in Ethiopian women.

OBJECTIVE: To measure the prevalence of chlamydial genital infection in Ethiopian women attending gynaecological, obstetric and family planning clinics; to identify the epidemiological, social and economic factors affecting the prevalence of infection in a country where routine laboratory culture and serological tests for chlamydial species are unavailable; to determine the risk factors for genital chlamydial infection in those with serological evidence of other sexually transmitted diseases. SUBJECTS: 1846 Ethiopian women, outpatient attenders at two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia. SETTING: Gynaecological outpatient department, antenatal, postnatal and family planning clinics. METHODS: Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV1-3), and C. pneumoniae (CPn)), in a micro-immunofluorescence test. The genital chlamydia seropositivity was analysed against patient's age, clinic attended, ethnic group, religion, origin of residence, age at first marriage and first coitus, income, number of sexual partners, duration of sexual activity, marital status/profession, obstetric and contraceptive history, and seropositivity for other sexually transmitted diseases. RESULTS: Overall exposure to chlamydia species was found in 84%, genital chlamydial infection in 62%, and titres suggestive of recent or present genital infection in 42% of those studied. Genital chlamydial infection was highest (64%) in family planning and lowest (54%) in antenatal clinic attenders. Exposure to genital chlamydia species was influenced by ethnic group and religion. Those married and sexually active under 13 years of age had greater exposure (69%) to genital chlamydial infection than those first sexually active aged over 18 (46%). Prevalence of infection was highest in those with more than five sexual partners (78%) and in bargirls (84%). The lowest income groups had a higher prevalence (65%) of genital chlamydial infection than the wealthiest (48%). Multivariate analysis showed the most important factors to be age at first coitus, religion, prostitution and present age of the woman in that order. Risk for genital chlamydial infection was increased in those with seropositivity for syphilis, gonorrhoea, HSV-2 but not HBV infection. CONCLUSION/APPLICATION: Chlamydial genital infections are highly prevalent in both symptomatic and asymptomatic Ethiopian women. The high prevalence of infection reported reflects a complexity of socioeconomic factors: very early age at first marriage and first coitus, instability of first marriage, subsequent divorce and remarriage or drift into prostitution, all of which are influenced by ethnic group, religion and poverty--together with transmission from an infected group of prostitutes by promiscuous males to their wives, lack of diagnostic facilities and inadequate treatment of both symptomatic and asymptomatic men and women. The problem of chlamydial disease in Ethiopia needs to be addressed urgently in the context of control of STD.

A study of cervical cancer in Ethiopian women.

In common with many African countries, Ethiopia has a very limited cytological service, smears are only taken in a hospital or clinic setting and until very recently most had to be sent abroad for analysis. We describe the results of a clinical and cytological investigation of 2111 women attending hospitals and clinics in Addis Ababa: 33 invasive or microinvasive cancers and 10 dysplasias (CIN) were detected. The prevalence of invasive cervical cancer in that population was 15.6/1000. Risk factors were shown to be age over 35 (especially over 50), parity over six (especially more than 10), very low income or subsistence economy, particularly in those from the rural areas, and prostitution. Less significant factors, possibly related to age, were sexual activity of more than 20 years and first coitus before the age of 15; and more than five sexual partners. Most (66%) of women with invasive cancer were at stage 3 or 4.

Seroepidemiological study of gonorrhoea in Ethiopian women. 1. Prevalence and clinical significance.

OBJECTIVE: To measure the prevalence of gonorrhoea in Ethiopian women attending gynaecologic, obstetric and family planning clinics: to determine the reliability of patient self history of sexually transmitted disease (STD); to correlate the serological diagnosis of gonorrhoea with clinical evidence of pelvic infection in order to define a reliable clinical diagnosis of gonorrhoea in a country where pelvic inflammatory disease is very common but where routine laboratory culture and serological tests for gonorrhoea are unavailable. SUBJECTS: 1851 Ethiopian women: 50% symptomatic, 50% asymptomatic. SETTING: Gynaecological outpatient department, antenatal, postnatal and family planning clinics (Ethiopian Family Guidance Association (EFGA)), in two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia. METHODS: The indirect haemagglutination test with gonococcal pilus antigen as an epidemiological tool was used in a cross-section study to screen 1851 sera for evidence of past or current gonococcal infection. The gonococcal antibody test (GAT) seropositivity was correlated with patient's history of STD, age, clinic attended and the clinical evidence of infection in "gonococcal target organs" urethra, salpinges or Bartholin glands. RESULTS: Fifty nine per cent of the study group were seropositive for the gonococcal antibody test, 22% with titres greater than or equal to 1/320, indicative of current, recent or recurrent infection. Seropositivity indicating past or present gonococcal infection was highest in those who gave a history of having had treated syphilis (85%), in women aged 40-49 (72%), and family planning attenders (EFGA) (66%) of whom 31% had titres greater than or equal to 1/320. Fifty per cent had clinical evidence of past or present infection in the urethra, salpinges or Bartholin glands. Gonococcal antibodies were present in 54% of women with no evidence of clinical infection, compared with 91% of those with pyosalpinx and 86% of those with triple infection of urethra, salpinges and Bartholin glands. CONCLUSION: The high prevalence of gonococcal antibodies in Ethiopian women, especially in asymptomatic clinic attenders must be of concern for all health workers especially those in gynaecology and obstetrics and the related disciplines of family planning and neonatal paediatrics. While seropositivity was highest in those giving a past history of syphilis, the patient's history of STD was unreliable, as of those who denied having any history of STD, fifty per cent were GAT seropositive. Despite a high correlation between GAT seropositivity with pyosalpinx and clinical evidence of infection in urethra, salpinges and bartholin glands, gonococcal antibodies were present in 54% of women with no clinical evidence of infection. Thus we were unable to define a diagnostic clinical picture of gonorrhoea in Ethiopian women.

Seroepidemiological study of gonorrhoea in Ethiopian women. 2. Socioeconomic picture.

OBJECTIVES: To determine aetiological factors associated with the prevalence of gonorrhoea in Ethiopian women to enable subsequent formulation of intervention policies. SUBJECTS: 1851 Ethiopian women: 50% symptomatic, 50% asymptomatic. SETTING: Gynaecological outpatient departments, antenatal, postnatal and family planning clinics (Ethiopian Family Guidance Association (EFGA)), in two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia. METHODS: Using the indirect haemagglutination test with gonococcal pilus antigen, sera were tested for the presence of gonococcal antibodies indicating past or present infection. The socioeconomic facts were analysed against gonococcal seropositivity of these women. RESULTS: Gonococcal infection was associated with very early age at first marriage and first coitus, more than one sexual partner and marital status/profession. The highest prevalence and titres were found in bargirls (100%) prostitutes (89%) and sellers of local beer (85%). The lowest prevalence and titres were found in the highest income group, those married over the age of 18 years, those with only one husband or sexual partner, and those with a sexual life of less than 5 years duration. CONCLUSIONS: National measures which could contribute to reduction and control of gonorrhoea include effective raising of the age of first marriage and first coitus, as has already been defined by law; the education of all girls up to fifth grade or equivalent; the provision of financial support to prevent widows and divorcees from drifting into prostitution; regular health checks and treatment of prostitutes; and education of men. While gonorrhoea per se is a major public health problem, our findings must have serious implications in the wider context of possible transmission of HIV through the community.

Determinants of perinatal deaths: a five-year retrospective survey at Tikur Anbessa Teaching Hospital.

PIP: A 5-year retrospective hospital series on perinatal mortality at Ethiopia's Tikur Anbessa Teaching Hospital has been made. The total number of singleton deliveries was 18,675 of which 907 were stillbirths and 400 were early neonatal deaths. Unsuccessful outcomes of pregnancy were observed clearly among unbooked patients when compared with booked patients. The annual perinatal mortality rates (per 1000 total births) during the years 1981 to 1985 in unbooked patients were 91.1, 68.8, 102.5, 99.7 and 65.5 and for the booked patients 50.4, 69.8, 40.0, 45.8 and 42.8 respectively. The difference between the unbooked and booked patients was statistically significant. Weight specific perinatal mortality revealed that the birthweight groups 1,000-1,499 and 1,500- 1,999 grams showed the highest perinatal deaths. Thus, low birthweight is considered to be the most important factor in perinatal deaths in our 5-year survey. Lack of antenatal care and prematurity were found to be the most important factors determining perinatal deaths. Possible solutions to the problems and prospective studies recommended include the assessment of demographic factors in order to make community-based studies.^ieng