Pain relief using paracervical block in patients undergoing manual vacuum aspiration of uterus.

OBJECTIVE: To evaluate pain relief using paracervical nerve block with 1% lignocaine injection in patients undergoing uterine evacuation by Manual Vacuum Aspiration (MVA) for the treatment of incomplete abortion. DESIGN: A randomized double blind clinical trial. SETTING: Marie Stopes Health Centre, Nairobi. METHODS: One hundred and forty two patients were recruited between September and October 1997. The intervention was random assignment to the study group (paracervical block with 1% lignocaine) or the placebo group (paracervical block with sterile water for injection). Intra and post operative assessment of pain was made using McGills and facial expression scales. RESULTS: The untreated group experienced significantly more pain than the treated group, especially lower abdominal pain and backache. The pain was especially marked intraoperatively, less so 30 minutes post-operatively. CONCLUSION: Based on the findings of this study, any patient going for manual vacuum aspiration for the treatment of incomplete abortion should be given Paracervical block as it is cost effective, easy to perform and with less side effects.

A fifteen-year review of female sterilization by minilaparotomy under local anesthesia in Kenya.

This paper is a comprehensive review of literature concerning the Kenyan experience with female sterilization through minilaparotomy under local anesthesia (ML/LA). A composite picture from analysis of several studies that include some 12,000 clients since 1979 reveals an average Kenyan user to be 31-34 years old (SD 4.9) with 5.9-6.8 children (SD 1.7-1.8). In up to 96% of cases, the indication for choosing sterilization is personal socio-economic considerations. The majority of clients (97%-99%) report satisfaction with their choice of sterilization at the first follow-up visit, and 96-99% state that they would recommend the method to others. The operation takes an average of 14 min (SD 4.5-5.3) "skin-to-skin" through a 2.5.2.8 cm incision (SD 0.5). A mean of 18 cm3 of 1% lignocaine is used (SD 2.7). Most clients (76.4%) have no post-operative complaints; those who do have any complaints report minor transitory problems. Similarly, most clients (96%) have moderate, little, or no peri-operative pain, but 1.9%-5% report much pain. The intra-operative and early complication rate is 0.9%. Some 3.3% of clients suffer at least one complication, some multiple, and the complication rate at 6 weeks is 4.1%, with major complications occurring in 0.7% of cases, and minor complications in 3.4%. The crude failure rate is 0.4% in the first year and 0.1% in the second year, when corrected for luteal phase pregnancies, which account for 50% of all "failures," the actual failure rate is 0.2% in the first year and 0.1% in the second year both for interval and postpartum procedures. This literature review finds outpatient ML/LA to be a relatively safe, simple, effective, and well-accepted option for most Kenyan couples seeking contraception that is intended to be permanent. Counseling, adequate client assessment, and voluntarism have been shown to be essential elements, not only for client satisfaction and avoidance of possible future regret, but also for technical ease of the operative procedure. Recommendations that derive from the Kenya experience are made.

Correlates of contraceptive failure among clients attending an antenatal clinical in Nairobi.

This paper presents a study analysing 100 cases of contraceptive failure and an equal number of controls in Nairobi. The study population included all the patients who attended the antenatal clinic at Kenyatta National Hospital, during a ten-week study period and who had conceived while on a contraceptive method. The controls were patients who were carrying a planned pregnancy. The objective of the study was to determine the sociodemographic patterns, level of counselling and attitudes of patients who presented to antenatal clinic after contraceptive failure and to formulate recommendation on how to manage these patients. User failure was more common than method failure. High parity and a high number of living children were associated with increased risk of contraceptive failure (OR 3.7 and 4.6, respectively). Other factors found to be associated with increased risk of contraceptive failure were: inadequate counselling at contraceptive initiation (OR 4.0), poor knowledge of different contraceptive methods (OR 1.9), short duration of contraceptive use (OR 3.3), and non-compliance, with 40% of the cases having been non-compliant. Thirty per cent of the patients who had contraceptive failure were unhappy about the pregnancy. This paper finds that better counselling on contraceptive use and compliance would reduce contraceptive failure and diminish the negative programme effects of failed contraception. Counselling would also enhance acceptance of the pregnancy and minimise the chances of negative psychological sequelae.

Acceptability and discontinuation of Depo-Provera, IUCD and combined pill in Kenya.

This paper reports on a prospective study conducted between June 1990 and June 1992 to determine method acceptability, user satisfaction and continuation rates for three highly effective and reversible contraceptive methods currently available in Kenya: the CuT 380A (IUCD), the injectable, Depo-Provera and the low-dose oral contraceptive pill, Microgynon. A non-randomised sample of volunteer participants was used. One thousand and seventy-six users were followed up for a period of one year or up to the time of discontinuation of the method, whichever came earlier. Analysis revealed method specific differences in users' characteristics. The OC users were younger and had fewer children than the IUCD or Depo-Provera users. The Depo-Provera users were older, and had the largest family sizes. Many OC users (almost 40%) were single, while almost three-quarters of IUCD and Depo-Provera users were married. IUCD users were also more educated compared to OC and Depo-Provera users. Survival analysis was used to calculate cumulative life table discontinuation rates by method for the 12 month period. Discontinuation rates were highest for OC users (80%) and lowest for IUCD users (20%) and intermediate for Depo-Provera users (39%). Ninety percent of OC and Depo-Provera users and 86% of IUCD users said they were satisfied with their respective methods. While OCs are among the most popular family planning methods in Kenya, they are also one of the most problematic, while IUCD has the fewest compliance problems. Service providers need to address the issue of high discontinuation rates among the young OC users.

PIP: This paper reports on a prospective study conducted between June 1990 and June 1992 to determine method acceptability, user satisfaction, and continuation rates for three highly effective and reversible contraceptive methods currently available in Kenya: the CuT 380A IUD; the injectable Depo-Provera; and the low-dose oral contraceptive Microgynon. A nonrandomized sample of volunteer participants was used. 1076 users were followed up for a period of 1 year or up to the time of discontinuation of the method, whichever came earlier. Analysis revealed method-specific differences in users' characteristics. The OC users were younger and had fewer children than the IUD or Depo-Provera users. The Depo-Provera users were older and had the largest family sizes. Many OC users (almost 40%) were single, while almost three-quarters of the IUD and Depo-Provera users were married. IUD users were also more educated compared to OC and Depo-Provera users. Survival analysis was used to calculate cumulative life table discontinuation rates by method for the 12-month period. Discontinuation rates were highest for OC users (80%), lowest for IUD users (20%), and intermediate for Depo-Provera users (39%). 90% of OC and Depo-Provera users and 86% of IUD users said they were satisfied with their respective methods. While OCs are among the most popular family planning methods in Kenya, they are also one of the most problematic, while IUDs have shown the fewest compliance problems. Service providers need to address the issue of high discontinuation rates among young OC users.

Attitudes to prenatal testing and notification for HIV infection in Nairobi, Kenya.

Four hundred antenatal clinic attendants were surveyed for their attitude to testing and notification for HIV infection test results. The participants were systematically sampled from the antenatal clinic at the Kenyatta National Hospital, Nairobi, and interviewed using a closed-ended structured questionnaire. All the attendants had heard of HIV, and only 5(1.3%) did not know how Acquired Immunodeficiency Syndrome (AIDS) presents. Fifty one percent of them had no objection to their blood being tested for HIV. In fact, 52.5% thought, wrongly, that blood was routinely tested for HIV at the hospital's antenatal clinic. More than one third (35.8%) of respondents wished their permission to be obtained before the testing and 95% wished to be informed of the test result. Acceptability of testing was 33.8%, for Named Voluntary Testing, 62.0% for Universal Testing and 1.0% for Anonymous Testing. All the women said they would want to use a method of contraception, principally tubal ligation, if found HIV seropositive and 63.7% would seek a termination of pregnancy. In this study population, acceptability and expressed willingness to know HIV test results and willingness to let a spouse/sexual partner know the result was high. This paper makes recommendations that HIV testing be made available at the ANC, together with competent pre and post-test counselling.

PIP: A survey of 400 women attending a high-risk antenatal clinic at Kenyatta National Hospital in Nairobi, Kenya, revealed high levels of willingness both to submit to human immunodeficiency virus (HIV) serodiagnosis and to authorize partner notification of a positive result. 210 women (52.5%) believed, incorrectly, that HIV screening was performed routinely at the clinic. 393 respondents (98.3%) supported voluntary or universal HIV testing of pregnant women. While 54% of these women wanted to give their consent for the test to be performed, another 44.8% did not consider permission necessary. 94.5% of respondents wanted to be notified of their test result and 97.5% indicated they would authorize the clinician to notify others of the result. The frequency distribution of categories of people women would allow to be informed of their serostatus were: spouse/sexual partner, 95.0%; health worker, 86.3%; religious leaders, 45.3%; employer, 22.8%; and insurance company, 20.0%. All respondents stated they would want to avoid pregnancy if their HIV test was positive; 57.3% would seek sexual sterilization in this case. If already pregnant at the time of learning of a positive HIV test result, 63.7% would terminate the pregnancy. Although these findings may, in part, reflect the high educational status of respondents (i.e., 70.3% had secondary and postsecondary education), they are indicative of a strong concern for limiting sexual and perinatal transmission of HIV. The introduction of voluntary prenatal HIV testing, combined with competent pre- and post-test counseling, is recommended to give seropositive women the opportunity to make informed childbearing and contraceptive decisions.

Barriers to contraceptive use in Kenya.

This study was designed to identify and to better understand the barriers to contraceptive use among Kenyan-couples. Data were collected through structured interviews and focus group discussions among couples not planning for pregnancy and not using any effective contraceptive method. The study was conducted in the Baba Dogo urban slum area of Nairobi, and Chwele, a rural sub-location in Bungoma, western Kenya. Some important barriers to contraceptive use were identified in couples wishing to space or limit further births. Those barriers included lack of agreement on contraceptive use and on reproductive intentions; husband's attitude on his role as a decision maker; perceived undesirable side effects, distribution and infant mortality; negative traditional practices and desires such as naming relatives, and preference for sons as security in old age. There were also gaps in knowledge on contraceptive methods, fears, rumours and misconceptions about specific methods and unavailability or poor quality of services in the areas studied. This paper recommends that information and educational programmes should be instituted to increase contraceptive knowledge, to emphasise the value of quality of life over traditional reproductive practices and desires, and to improve availability and quality of services.

PIP: This article presents an analysis of interviews and focus group discussions among men and women from an urban slum in Nairobi, Kenya, and the rural Chwele in Bungoma District in the Western Province of Kenya. The systematic sample survey included 594 individual interviews with currently married individuals, where the wife was aged 15-49 years and not pregnant or using contraceptives. 80% of wives and 90% of husbands had at least a primary level of education. 125 couples were from Nairobi and 172 were from Bungoma. The pill was the most widely known method. Wives were more aware of female methods, and husbands were more aware of male methods. 21-28% of persons had ever used family planning. 72% of Nairobi wives who had ever used and 22% of Bungoma wives who had ever used relied on the pill. Almost all knew that family planning services were available but did not use these services. About 33% of individuals in Nairobi and 50% in Bungoma desired no more children. Husbands desired about four or more children than wives wanted. 34-38% of husbands and 63-74% of wives desired to wait at least 2 years before the next pregnancy. About 75% of couples agreed on whether or not they wanted to have additional children, but only 30% of Nairobi couples and 41% of Bungoma couples agreed on the timing of the next birth. 64% of couples in Nairobi and only 42% of couples in Bungoma had joint knowledge of family planning. 6% of Nairobi couples and 27% of Bungoma couples had a joint lack of information on where to obtain contraception. The focus groups revealed a greater range of reasons for nonuse of contraception. Lack of couple agreement and communication were primary reasons for nonuse. Couples had more than the desired family size of 2-4 children due to desired gender balance, parent-naming, and risk of child mortality. Confidence in family planning would be enhanced by better education.

Norplant implants acceptability and user satisfaction among women in two African countries.

An analysis of 350 users of Norplant contraceptive subdermal implants from six centers in two African countries (Ghana and Nigeria) indicates that method acceptability remained high among the women who used the method for five years. Overall, 90.1% of the 155 five-year users in these countries reported having a very favorable experience and 9.9% a favorable experience with Norplant implants. Ease of use was cited by 56.1% and duration of use by 13.6% of the women as the most liked characteristics of the method at study completion after five years. Menstrual disturbance was the least liked aspect, by 41.9% of the women. On average, women who discontinued early from the study had fewer living children and were more likely to desire additional children at method adoption than those who completed five years of use; the differences were statistically significant. Differences in level of education and previous use of contraception were not found to be statistically significant between completers and non-completers. Differences in age were not significant in Nigeria, but were marginally significant in Ghana, with completers being older than non-completers. Of the clients who completed this study, 79.2% indicated a desire to continue with contraception and 43.9% planned to have a second set of implants inserted. These findings have important implications for counseling, method access and service sustainability in African countries.

Preliminary comparison of the polyurethane female condom with the latex male condom in Kenya.

This paper summarizes acceptability data published to date on the innovative female condom, and presents an additional study comparing the acceptability of the female condom and the latex male condom in a sample of low risk women attending private obstetrician/ gynaecologists' clinics in Nairobi, Kenya. Eighty-four percent of all subjects who completed interviewer-assisted questionnaires reported that they liked using the female condom, and more than two-thirds of all the women liked the female condom as much or better than the male condom. Fifty-five percent of the women would use the device in future if it were available. The least liked features were that the device was too large for easy insertion, messy to handle, and reduced sensation. Use became easier and more comfortable with experience. The most liked features were that the device made sex more enjoyable, protected against sexually transmitted diseases and pregnancy, and was under the woman's control. Male partner response was slightly less favourable, and sometimes resulted in women's noncompliance or discontinuation of use, despite the fact that such a device is supposed to empower women. This study provides preliminary data indicating that the female condom is a fairly acceptable method for some Kenyan couples, but recommends further research into safety, cost-effectiveness and hindrances to acceptability.

PIP: A survey of 48 female volunteers recruited from 3 private gynecology-obstetrics clinics in Nairobi, Kenya, revealed preliminary support for the female condom as an acceptable family planning method. In the study's first phase, women were provided with 2 male and 2 female condoms to be used in the ensuing 3 weeks. In the second phase, they were supplied with 4 more female condoms. A total of 113 female condoms were used during the 2 study phases. Overall, 84% of women expressed favorable reactions to the female condom and 55% indicated they would use this method in the future were it available. In the first phase, 39% stated they preferred the female to the male condom, while 37% liked the 2 condoms about the same; all 12 women who completed the second phase preferred the female condom, suggesting that use becomes easier and more comfortable with time. Although 55% of male partners were reported to like the female condom the same or better than the male condom, and 39% liked it less; male partner disapproval was a major factor in study discontinuation. Enhanced enjoyment of sex, protection against pregnancy and sexually transmitted diseases, and female control were the most frequently cited positive attributes of the female condom; the device's large size, messiness, and reduced sensation were its least liked characteristics. Insertion difficulties and discomfort caused by the device's outer ring were common. There were 3 incidents (2.7%) of condom breakage and 11 (10%) of condom displacement during intercourse. More research on acceptability, cost-effectiveness, and safety is required before the female condom is slated for large-scale distribution in Kenya.

Value of sedative premedication in female sterilization via minilaparotomy: a prospective study of two local anaesthesia regimen.

A prospective study of two local anaesthesia regimen for female sterilization is presented. A total of 1,077 female clients were sterilized via minilaparotomy under local anaesthesia (ML/LA) as outpatients. The clients underwent pre-operative screening and received pre-operative and continuing counselling. The first 257 of these clients were sedated with an intramuscular injection of pethidine after atropine premedication (pre-sedated group). The other clients (non-sedated group) were premedicated with atropine alone, without sedation. For the pre-sedated group, the mean volume of one percent lignocaine used was 18.3 (S.D. 2.2) ml, the mean length of surgical incision was 2.8 (S.D. 0.5) cm, and the mean duration of surgical was 15.8 (S.D. 5.3) minutes; 8.2% of these clients reported that they felt much pain. In comparison, 7.7% of the non-sedated group clients reported much pain following a mean of 17.7 ml of one percent lignocaine (S.D. 2.7) through an incision of mean length 2.5 (S.D. 0.5) cm for surgery lasting a mean of 14.5 (S.D. 4.5) minutes. Clients who were pre-medicated with pethidine were more likely to have multiple post-operative complaints, especially dizziness, faintness, headache, nausea and vomiting. This study found no significant difference in the clinical performance of female sterilization by minilaparotomy, duration of operation, length of incision, amount of local anaesthesia required or perception of pain between clients who were premedicated with intramuscular pethidine and those who were not.

PIP: A prospective study of two local anaesthesia regimens for female sterilization is presented. A total of 1077 female clients were sterilized via minilaparotomy under local anaesthesia (ML/LA) as outpatients. The clients underwent preoperative screening and received preoperative and continuing counseling. The first 257 of these clients were sedated with an intramuscular injection of pethidine after atropine premedication (presedated group). The other clients (nonsedated group) were premedicated with atropine alone, without sedation. For the presedated group, the mean volume of 1% lignocaine used was 18.3 (SD, 2.2) ml, the mean length of surgical incision was 2.8 (SD, 0.5) cm, and the mean duration of surgical procedure was 15.8 (SD, 5.3) minutes; 8.2% of these clients reported that they felt much pain. In comparison, 7.7% of the nonsedated group clients reported much pain following a mean of 17.7 ml of 1% lignocaine (SD, 2.7) through an incision of mean length 2.5 (SD, 0.5) cm for surgery lasting a mean of 14.5 (SD, 4.5) minutes. Clients who were premedicated with pethidine were more likely to have multiple postoperative complaints, especially dizziness, faintness, headache, nausea, and vomiting. This study found no significant difference in the clinical performance of female sterilization by minilaparotomy, duration of operation, length of incision, amount of local anaesthesia required, or perception of pain between clients who were premedicated with intramuscular pethidine and those who were not.

A comparative study of users of long-term contraceptive subdermal implants and female surgical contraception in Kenya.

This was a comparative study of users of Norplant contraceptive, Subdermal implants and LA Minilap, in rural, urban and peri-urban sites in Kenya during 1991-1993. Both methods are very well accepted by well counselled women seeking long-term, continuous, convenient, highly effective contraception. Norplant users had a mean age of 27.3 years, an average of 2.6 living children and 25.3 per cent were unmarried, while 32.9 percent had completed their families. This compares with 31.3 years, 6.2 living children, 0.6 percent unmarried and 100 percent completed families respectively for LA Minilap. Norplant acceptance rates have continued to rise over the few years since programme inception, and now stand at 5.4 percent of all new acceptors. LA Minilap acceptance trends shows a plateau or moderate down-turn at 21.6 percent of new acceptors. The possible reasons and implications of these observations, along with user characteristics are discussed.

Acceptability of Norplant contraceptive subdermal implants in Kenya.

Norplant contraceptive implants are a relatively new acquisition onto the Kenyan family planning scene. The method seems highly acceptable to a wide cross-section of Kenyan women in government and non-governmental organisations (NGO) clinics. One thousand, six hundred and fifty four clients were recruited into the programme of the largest family planning NGO between 1991 and 1994. Most of the acceptors were young with an average number of 2.6 living children. Half-yearly acceptance rates have been rising. There were minimal serious side effects reported, but 72.0% of the clients complained of some menstrual disruption. Site infection rates were 0.2%, the same as capsule expulsion rates and benign ovarian cyst. Continuation rates were good at 91.0% over the first year and 80.0% over the second year. Client profile and user characteristics are presented. Norplant seems to be a well accepted contraceptive method by young low-parity Kenyan women seeking long-term, continuous yet reversible contraceptive options.

Surgical contraception: the kindest cut of all?

PIP: Over 10,000 sterilizations are performed annually in Kenya, 99% of them on women. The mortality associated with female sterilization is only 1/100 that of pregnancy and childbirth, documented in the literature. Sterilization is costly in the short-term, but is cost-effective because it provides contraceptive protection for an average of 12.5 years for Kenyan couples. While 49% of Kenyan women have completed their families, only 5% choose permanent contraception. People need to be counseled that sterilization is permanent, and informed that it can be done as an outpatient with local anesthesia and a mini-laparotomy, through a 3 cm incision. Other barriers to more extensive use of sterilization are the reluctance of men to accept it, low educational status of women, and inadequate services and providers.^ieng

Minilaparotomy female sterilisation in clients with lower midline abdominal scar.

A total of 1221 female clients were sterilised via minilaparotomy under local anaesthesia as outpatients. 101 of these clients had lower midline abdominal scars, 1120 did not. The first group had slightly increased minilap incision length, duration of surgery and amount of local anaesthesia required compared to the second group but the differences were not clinically significant. The "scar group" also tended to have wider ranges for these same parameters, and there was one case of abandoned procedure. The incidence of peri-operative complications was low, and most of these were minor transitory grievances--the incidence was slightly more in the previous scar group. Minilap female sterilisation under local anaesthesia is safe and suitable even for clients with a lower midline abdominal scar, but good counselling and meticulous client selection is a prerequisite.

Twice-failed tubal ligation: a case report.

The case is presented of a twice-failed tubal ligation in a woman with six previous children. The first failure followed laparoscopic tubal occlusion by silastic falope rings, while the second failure was subsequent to tubal ligation and division via minilaparotomy. No similar reports have been reported in the East African Literature. Possible reasons for failure are discussed.

PIP: A case of 2 failed tubal ligations in a para 6 Kenyan woman is described. She had an interval laparoscopic sterilization with silastic rings after delivery of her 6th child at age 38. After 3 menstrual periods she became pregnant. She decided to be sterilized again after delivery of her 7th child, a 3.5 kg male. Because of moderate obesity, a minilaparotomy with intravenous anesthesia was performed. The right fallopian tube was only partially occluded with a silastic ring, but the left tub was properly occluded. A Pomeroy tubal ligation was done, excising 2 cm of each tube, and ligating with No. 1 catgut. The woman experienced 2 more menses, and conceived again. She was delivered of a term female, and submitted to a hysterosalpingogram, which showed a tubal-peritoneal fistula on the right. The woman expressed fatalism about future childbearing, and eventually refused to return for contraceptive care or another sterilization.

Safety issues in voluntary female surgical contraception: peri-operative complications.

PIP: Worldwide, voluntary surgical contraception (VSC) is among the most widely employed of family planning methods. Relatively few vasectomies have been reported in Kenya over the last decade, with VSC in the country referring almost exclusively to female sterilization. Several papers have surfaced on the acceptance and sociodemographic aspects of female sterilization in Kenya, but there is still a need for more research into safety issues and the quality assurance of female VSC. The authors therefore prospectively followed 1999 women undergoing VSC in Thika, Kenya, for intraoperative and early post-operative complications. Interview, physical examination, and peri-operative data were collected between January 1985 and November 1988. 1498 of the clients underwent tubal ligation by minilaparotomy under local anesthesia, 201 under general anesthesia, and 28 by laparoscopy, while 302 underwent tubal ligation concurrently with laparotomy for other surgical problems. There was a 30.2% overall complication rate for all cases, but 8.1% for minilaparotomy cases alone. 98.7% were minor complications, with small wound hematoma and wound sepsis being the most common manifestations. There was no early mortality directly attributable to VSC. The authors stress that VSC is a simple and relatively safe method of family planning which should be considered by couples who have achieved their desired family size.^ieng

Early and medium-term morbidity of minilaparatomy female sterilisation in Kenya.

A total of 1,521 clients undergoing voluntary surgical contraception via Minilaparatomy under local anaesthesia (L.A. Minilap) were prospectively followed up for early and medium-term morbidity. The commonest complaint was some degree of abdominal pain at 24.2%. Eight percent of these [corrected] reported that the operative pain was severe, but 92.0% reported minimal or moderate pain. The overall complication at 6 weeks was 4.1%, 17.5% of these were major and 82.5% minor, i.e. the rate for major complications was 0.7% and 3.4% for minor complications. There were no deaths. Female VSC via Minilaparatomy under L.A. is a relatively comfortable and easy procedure in well selected and counselled clients and carries minimal, usually non-recurrent morbidity.

PIP: Kenya over the past two decades has had one of the highest growth rates in the world. 49% of married women aged 19-49 years, however, have completed their family size and do not wish to bear additional children. Under such conditions, one would expect to see significant demand for female voluntary surgical contraception (VSC) in existing parenthood and family planning programs. Many cultural, socioeconomic, and religious barriers, however, exist to its widespread adoption. Program delivery and safety issues are also of concern. The authors therefore investigated the safety of minilaparotomy female sterilization under local anesthesia in the simple, basic outpatient facilities of the Family Planning Association of Kenya, Thika Clinic. The clinic is a simple facility without anesthetic machine, major surgical equipment or drugs other than analgesics, lignocaine, and emergency drugs. All 1521 female clients undergoing VSC via minilaparotomy under local anesthesia between January 1986 and November 1991 were followed prospectively to assess the level of early and medium-term morbidity they experienced. The women were aged 19-50 years of mean age 33.9, 86.9% were currently married, and the mean parity was 6.8. 24.2% complained of abdominal pain, the most common complaint. 1.9% of all the women reported severe operative pain. There was a 4.1% overall complication rate at six weeks; 17.5% of these complications were major and 82.5% minor. There was therefore a 0.7% overall major complication rate and a 3.4% minor complication rate. There were no deaths. The authors conclude on the basis of these findings that female VSC via minilaparotomy under local anesthesia is a relatively comfortable and easy procedure in well-selected and counselled clients which carries minimal, usually non-recurrent morbidity.

Experience with MacDonald's cervical cerclage in a rural setting.

Eighty-two patients with cervical incompetence were managed with MacDonald's cervical cerclage, bed rest, tocolytics and sedatives. 78 of the patients were followed upto termination of pregnancy and their pregnancy data recorded. 69.5% delivered at term. 78.1% were discharged from hospital with live babies. The incidence of operative delivery was encountered. MacDonald's cervical cerclage has a high success rate in a rural setting, well comparable to that in urban settings and prolonged in-patient treatment is not always necessary.