Strategies to reduce maternal mortality in Central African Republic

Le Problème  Mortalité maternelle est un grave problème de santé publique en RCA avec un taux de 1355 décès pour 100.000 naissances vivantes.  Quatre principales difficultés sont à la base de ce problème : o Difficultés liées à l'accès aux soins o Difficultés liées à l'insuffisance et à la répartition inégale du personnel de santé o Difficultés liées à la prise en charge des urgences obstétricales et au système de référence o Difficultés liées à l'utilisation des services de santé  La réduction de la mortalité maternelle peut utiliser un certain nombre de stratégies efficaces et réalisables en Centrafrique. Cependant, le manque d'un guide clair et explicite limite la mise en oeuvre et la coordination de ces stratégies. Les Options Politiques Trois options politiques complémentaires ont été définies dans l'objectif de réduire la mortalité maternelle en Centrafrique:  Renforcement des capacités nationales en matière de la santé de la reproduction : o Renforcement des ressources humaines dans le domaine des soins obstétricaux d'urgence o Relèvement de plateau technique  Renforcement de la prise en charge des urgences obstétricales : o Prévention des grossesses non désirées o Prise en charge des urgences obstétricales o Sécurisation des produits de la santé de la reproduction o Audit des décès maternels  Mobilisation des différentes ressources en faveur de la lutte contre la mortalité maternelle : o Développement des systèmes de financement alternatif aux soins o Amélioration du niveau des connaissances des communautés sur les urgences obstétricales et les avortements à risque o Promotion de l'alphabétisation fonctionnelle des femmes o Amélioration des connaissances des décideurs sur les urgences obstétricales et les avortements à risque Stratégies de mise en oeuvre La combinaison des stratégies de mise en oeuvre est effective pour les trois (3) options choisies pour la réduction de la mortalité maternelle dont :  Le renforcement des ressources humaines par des formations de courte durée destinées aux agents itinérants ainsi qu'aux matrones.  Le développement des mesures incitatives pour amener les cadres à travailler dans les provinces  L'incitation du gouvernement à augmenter le nombre des formations sanitaires  La sensibilisation de la communauté pour la mise en place des mutuelles d'assurance  L'intensification d'un partenariat technique et financier avec les partenaires au développement

[Cervical dysplasia in women with human immunodeficiency virus (HIV) in areas of high prevalence of infection]. / Dysplasies cervicales chez les femmes séropositives pour le VIH en zone de forte prévalence de l'infection.

OBJECTIVES: To determine the prevalence of cervical squamous intraepithelial lesions among HIV-positive women, compared to that of HIV-negative women and identify the different types of lesions in both groups. PATIENTS AND METHODS: Cross-sectional study conducted in 16 months in two facilities and the service of pathological anatomy of Bangui. The sample consisted of 250 HIV-positive women matched to 250 HIV-negative women. The parameters studied were the HIV status, the result of cervical smear screening, the rates of CD4 and the data of the interview. RESULTS: The smears were inflammatory in 54.4% of HIV-negative and 46.4% of HIV-positive. Epidermoid intraepithelial lesions of the cervix were more frequent among HIV-positive women than among HIV-negative women with respectively 34.8% and 16.4% (P<0.0001). The low-grade lesions were more common regardless of HIV status of patients. The median age of onset of the LEI was lower among HIV-positive whatever the grade of the lesion. Koïlocytosis was found in 27.2% of HIV-positive women against 9.2% among HIV-negative (P<0.001). DISCUSSION AND CONCLUSION: The prevention of infection by HIV and HPV and the monitoring of precancerous lesions would allow to prevent their evolution towards invasive cancer.

[How far do clandestine abortion providers go in Africa?]. / Jusqu'où vont les auteurs d'interruption clandestine de grossesse en milieu Africain ?

A 28-year-old, gravida 2, para 2 was admitted to undergo abortion in the third quarter. The procedure consisting of mechanical induction of labor using plastic catheters was performed by a male nurse. The day after placement of the catheters the patient began labor and gave uneventful birth to female infant weighing 2900 grams. The procedure undertaken to destroy the fetus led to the birth of a normal healthy child. Mechanical induction after full-term pregnancy (rarely performed in our areas) is unwarranted if pregnancy is ongoing. Due to his ignorance of the late stage of pregnancy and of the potential consequences of the procedure, the male nurse had exposed the patient to risk of severe trauma. Although the outcome was favorable for the patient, action must be taken to control intermediate level health care workers whose practices can endanger the population.

[Student sexual behavior at the University of Bangui in the Central African Republic]. / Comportement sexuel des etudiants de l'Université de Bangui (Centrafrique).

Encouraging responsible sexual behavior has become an important issue in recent years mainly due to the worldwide human immunodeficiency virus (HIV) epidemic and to the high number of unwanted pregnancies that often end in high-risk abortions. Young people and in particular students in higher education are high-risk groups for both unwanted pregnancy and HIV. The purpose of this report is to describe the findings of a month-long survey conducted among students at the University of Bangui (UB) in 1998-1999. Individual students were asked to give immediate responses to semi-open questions. The Chi test was used to assess correlation between a number of variables. A total of 422 UB students including 218 males (51.7%) and 204 females (483%) were included in the survey. Mean age was 24.9 years for females and 26.1 years for males. Over half of the students of both sexes reported having their first sexual relation between the ages of 15 and 19 years. Males were more satisfied by their first experience than females. The percent of married students (male or female) was 5.9%. Most students (62.1%) had at least 2 sex partners and 58.3% had at least one child. The preferred contraceptive method was condom use for males and the Ogino technique for females. The percent of female students expressing fear of HIV infection was 27.4%. The results of this study show that information and education campaigns are needed to encourage UB students to practice sexual behavior to avoid both unwanted pregnancies and sexually transmitted diseases such as HIV infection.

[Analysis of abortions at a community maternity hospital in Bangui]. / Analyse des avortements à la maternité de l'Hôpital communautaire de Bangui.

Abortion, i.e., early termination of pregnancy, has few complications when it occurs spontaneously. However self-inflicted abortion (SIA) often leads to more or less serious complications. In view of the increasing number of abortion cases in our department, we undertook this yearlong transversal study to evaluate the incidence of SIA in the department, determine the demographic characteristics of the women that practiced SIA, and identify the complications of SIA. Only ongoing or incomplete abortions were studied. Amenorrhea not related to pregnancy or associated with ectopic pregnancy was excluded from study. Clinical and demographic data were noted on forms specially designed by the research team. Data analysis yielded the following findings. Abortion accounted for 719 of the 5292 hospitalizations (13.6%) in gynecology unit, including 43.4% of SIA. Mean patient age was 24.7 years (range, 13 to 39). Spontaneous abortion was more likely to be observed in married women than in students who usually presented SIA. Wanted pregnancy was more likely to be reported by married women than by single woman who posed the problem of unwanted pregnancy. Students had more SIA. The main reasons for practicing SIA were financial (61.5%). The most common methods used for SIA were drug combinations (39.1%) and mechanical tools (26.0%). All severe complications such as infection and death were observed in women who practiced SIA. The high incidence of SIA in the department was especially disturbing due to the young age of the women involved and the severity of the complications. More action is needed to spread information on contraceptive methods in schools and universities to avoid unintended pregnancies that drive young people to practice SIA.

Analyse des avortements a la maternite de l'hopital communautaire de Bangui

Abortion; i.e.; early termination of pregnancy; has few complications when it occurs spontaneously. However self-inflicted abortion (SIA) often leads to more or less serious complications. In view of the increasing number of abortion cases in our department; we undertook this ye a rlong transversal study to eva l u ate the incidence of SIA in the department; d e t e rmine the demographic characteristics of the women that practiced SIA; and identify the complications of SIA. Only ongoing or incomplete abortions were studied. Amenorrhea not related to pregnancy or associated with ectopic pregnancy was excluded from study. Clinical and demographic data were noted on forms specially designed by the research team. Data analysis yielded the following findings. Abortion accounted for 719 of the 5292 hospitalizations (13.6) in gynecology unit; including 43.4of SIA. Mean patient age was 24.7 ye a rs (ra n ge; 13 to 39). Spontaneous ab o rtion was more like ly to be observed in married women than in students who usually presented SIA. Wanted preg n a n cy was more like ly to be rep o rted by married women than by single woman who posed the problem of unwanted pregnancy. Students had more SIA. The main reasons for practicing SIA were financial (61.5). The most common methods used for SIA were drug combinations (39.1) and mechanicaltools (26.0). All seve re complications such as infection and death we re observed in women who practiced SIA. The high incidence of SIA in the department was especially disturbing due to the young age of the women involved and the severity of the complications. More action is needed to spread info rm ation on contracep t ive methods in schools and unive rsities to avoid unintendedpregnancies that drive young people to practice SIA

Comportement sexuel des etudiants de l'universite de Bangui (Centrafrique)

Encouraging re s p o n s i ble sexual behavior has become an important issue in recent ye a rs mainly due to the world-wide human immu n o d e fi c i e n cy virus (HIV) epidemic and to the high number of unwanted pregnancies that often end in highrisk abortions. Young people and in particular students in higher education are high-risk groups for both unwanted preg nancyand HIV. The purpose of this report is to describe the findings of a month-long survey conducted among students at the University of Bangui (UB) in 1998-1999. Individual students we re asked to give immediate responses to semi-open questions. The Chitest was used to assess corre l ation between a number of vari ables. A total of 422 UB students including 218 males (51.7) and 204females (48.3) were included in the survey. Mean age was 24.9 years for females and 26.1 years for males. Over half of the students of both sexes reported having their first sexual relation between the ages of 15 and 19 years. Males were more satisfied by their fi rst ex p e rience than females. The percent of married students (male or female) was 5.9. Most students (62.1) had at least 2 sex partners and 58.3had at least one child. The preferred contraceptive method was condom use for males and the Ogino technique for females. The percent of female students expressing fear of HIV infection was 27.4. The results of this study show that information and education campaigns are needed to encourage UB students to practice sexual behavior to avoid both unwanted pregnancies and sexually transmitted diseases such as HIV infection

[Value of fetal pulmonary maturity determination with the Clements test in high risk pregnancies]. / Intérêt de l'évaluation de la maturité pulmonaire foetale par le test de clements dans les grossesses à risque èlevé.

To extract a foetus which presents chronic suffering in high risk pregnancy, the determination of pulmonary maturity leads to take the decision. Among the complementary analysis to determine the pulmonary maturity, we used of Clements test (CT) which realization is easy and the results rapid. The objectives of this paper were to evaluate the pulmonary maturity with CT, to establish correlation between CT and breathing distress syndrome at birth and to determine the validity of CT about new born vitals parameters. During a two years prospection in "Hopital Communautaire" maternity and "Complexe Pédiatrique", we have recruited 390 laboring women with high risk pregnancy who attained six months. We have leaved out the search cases of prematureness membrane rupture or tinted amniotic fluid. The fluid amniotic to be analyzed was taken with syringe and was subjected to different techniques allowing to conclude pulmonary maturity or not. Statistical tests has permitted to establish correlation between CT and new born vitals parameters. The means of laboring women age was 25 years old. In 59.3%, the women have between 1 and 3 children. The caesarians decided in 21.4% of cases were related to generally restricted pelvis with bi-scared uterus. The prematurity confinement had concerned 37.4% of new born. The CT result was positive in 61% of cases. The Apgar score under 7 had been more observed among children who had positive CT. The respiratory distress was significantly more frequent among children born by caesarian. The stillbirths rates of was more exalted with cases of negative CT. The results of this search have permitted to identify new born correlative parameters with pulmonary maturity. This one might be determined by CT, in high risk new born, the vulgarization of this test would improve their management.

[Report of a case of ovarian pregnancy observed at the Gynecolgy-Obstetrics Service in Bangui (Central African Republic)]. / A propos d'un cas de grossesse ovarienne observée dans le service de Gynécologie-Obstétrique à Bangui (Centrafrique).

The case report was the first observed in Central African Republic. The patient was a thirty years woman who comes from a small-townish for dead fetus retained. She had not point out abdominal pain or bleeding and had presented a satisfied clinical state. The investigations had confirm a dead abdominal pregnancy. During the laparotomy, it was uncovered a regular mass developed on the right annex. Those annex mass hasn't presented adherences with other abdominal organs. The ablation of the mass and the right annex had been done without difficulty. The holing of operated mass had permit to uncover a macerated dead male fetus weighted 1650 grams. The following of operation was normal The histological analysis had determined the nature of that ovarian pregnancy. Hour attention was be retain by that case who had prolonged development and almost non-existence complications.

[Uterine rupture in the maternity ward of the Bangui Community Hospital (Central Africa)]. / Les ruptures uterines à la Maternité de l'Hopital communautaire de Bangui (Centrafrique).

Although now uncommon in developed countries, uterine rupture is among the major obstetrical emergencies dealt on a daily bases in the maternity ward of the Bangui Community Hospital in Central African Republic, which is the national reference facility. Uterine rupture is life-threatening for both the fetus and mother. In view of the relatively high rate of rupture observed in our department in previous years, this cross-sectional study was undertaken in order to determine incidence, identify predisposing factors, evaluate prognosis for the mother and newborn, and propose solutions. From January 1997 to December 1997, all deliveries by the vaginal route or cesarean section including cases involving uterine rupture were recorded. The length of time elapsed between the decision to perform cesarean section and actual performance of the procedure was determined. Risk factors associated with uterine rupture in our department were noted. The outcome of uterine rupture was evaluated in both the mother and fetus. Of a total of 5763 deliveries during the study period, 299 required cesarean section (5.9%). Uterine rupture occurred in 35 cases of the 299 women (11.7%). In 10 cases of uterine rupture, the time lapse for performance of cesarean section was at least 2 hours. The main cause of delay was the lack of funding for cesarean section. Six women died due to irreversible shock (0.1% of deliveries, 2% of cesarean sections and 17.1% of uterine ruptures). The perinatal mortality rate was 80%. In our department, uterine rupture is a common emergency causing high mortality in mothers and newborns. Most of these patients could have been saved.

[How is breast-feeding valued in the urban and semi-urban Central African milieu?]. / Quelle valueur l'allaitement maternel a-t-il en milieu urbain et semi-urbain centrafricain?

Efforts have been made for several years to promote the use of breast milk by mothers. This is important for mothers in developing countries faced with economic problems, especially for those tempted by milk substitutes. Fortunately, BF (breast feeding) is used by a majority of women in these developing countries, its practice is often influenced by an early introduction of supplements. Why this early supplementation? In order to answer this question we performed this study, a transversal survey of mothers in neonatal period in a regional town and the capital of Central Africa. The compilation of data of this seven month study, carried out in four maternities and nine SMI centers, was carried out from a pre-established questionnaire. This allowed us to obtain the following results. We interrogated 734 mothers of newborn babies aged between 14 and 45 years, including 534 in Bangui and 200 in Bossangoa. Breast feeding was chosen by 96.5% of mothers, however exclusive breast feeding was only carried out by 17% of mothers. Feeding on demand was widely spread both in Bangui (92.7%) and in Bossangoa (92%). Breast milk was the first food received at birth by 84.5% of newborn babies. At the neonatal period, water supplementation was more frequent (78.1%, including 23% at birth) than that of solid or semi-liquid food (6.2%). The value given to breast milk was just nutritional, its other virtues were not well known. Conclusion, In breast mil remains the food of choice in our country. However, its practice suffers from much ignorance. An effort should be made to heighten awareness and give milk its due worth.

Secretory anti-human immunodeficiency virus (HIV) antibodies in colostrum and breast milk are not a major determinant of the protection of early postnatal transmission of HIV.

The immune response to human immunodeficiency virus (HIV) type 1 was evaluated in breast milk from HIV-infected African mothers who had transmitted and those who had not transmitted HIV to their children through breast-feeding. The levels, specific activities against gp160 and 2 HIV-derived peptides from gp41 and gp120 (V3 loop), and inhibitory activity toward viral transcytosis in vitro of secretory IgA (S-IgA) and IgG purified from breast milk were investigated in 8 transmitting mothers and 18 nontransmitting mothers. S-IgA and IgG antibodies to gp160 and to peptides were found in all breast milk samples. The specific activities of S-IgA and IgG to gp160 and peptides were similar between transmitting and nontransmitting mothers. No difference of the capacity of S-IgA and IgG to block HIV transcytosis in vitro was found between the 2 groups. These results suggest that humoral mucosal immunity to HIV does not appear as a predominant factor for protection against viral transmission through breast milk.

[Analysis of transfers in the Gynecology and Obstetrics Department of Bangui Hospital]. / Analyse des évacuations sanitaires en gynécologie-obstétrique à Bangui, Centrafrique.

During a study carried out over twelve months in the National Reference Center for Gynecology and Obstetrics at Bangui Hospital, we recorded 1,369 cases of evacuation in a total 5,020 admissions to the department. This corresponds to a frequency of 27.3%. In 73.8% of cases, this intervention was performed for obstetric reasons. It was justified in 73.1% of cases, and 96.5% of the justified interventions were for obstetric reasons. The unjustified interventions led to a normal delivery in 97% of cases. Errors in diagnosis were detected in 16.5% of the cases. In terms of prognosis, we recorded 91 deaths in the perinatal period (96 per thousand live births) and 37 maternal deaths (of the 39 recorded in the department), accounting for 94.9% of all maternal deaths, with a mortality rate of 2.7% for women undergoing uterine evacuation. Infant mortality was higher in cases of late intervention. The most frequent causes of death of the mothers were hemorrhagia on delivery, severe infection, rupture of the uterus and the tearing of soft tissues.

[Prenatal care in a semiurban area of Central African Republic: frequency, influential factors, maternal and neonatal prognosis]. / Les consultations prénatales en zone semi-urbaine Centrafricaine: fréquence, facteurs influençants, pronostic maternel et néonatal.

This 9-month longitudinal study was carried out in a cohort of 287 women hospitalized for various obstetrical reasons in Bouar, the third largest city in Central Africa. A total of 225 of these women gave birth to 229 children. The purpose of study was to evaluate attendance at prenatal examinations, risk factors for obstetrical morbidity, and maternal and neonatal prognosis. Results showed an overall absence rate at scheduled examinations of 38 p. 100. Only 8.4 p. 100 of women enrolled for prenatal care complied fully with the examination schedule. The factors associated poor attendance were age older than 19 years, distance greater than 5 kilometers between the woman's home and care facility, and illiteracy. The incidence of complicated pregnancy was significantly higher in refractory women. Reported complications included eclampsia, extrauterine pregnancy, and death of the mother. A total of 43.5 p. 100 of home deliveries involved women that did not attend prenatal care clinics. A total of 23.1 p. 100 of newborns without prenatal care presented complications requiring intensive neonatal care with an Apgar score below 7. Overall the perinatal death rate was 12.7 p. 100 (n = 29). The stillbirth rate was 10.1 p. 100 (n = 16). The findings of this study demonstrate the favorable impact of prenatal care on pregnancy outcome for both mother and child. Prenatal care should be made available to all pregnant women.

Compartmentalization of the IgG immune response to HIV-1 in breast milk.

OBJECTIVE: To evaluate the IgG immune response to HIV-1 in colostrum. METHODS: Paired serum and colostrum were collected from 16 asymptomatic HIV-1-infected women. IgG to gp160 and to four peptides (gp41 immunodominant DI domain, gp41/Id; EDLKWA epitope of DIII domain, gp41/K; gp120 C-terminus, gp120/Ct; V3 loop, gp120/V3) were evaluated in all samples. Functional activity of purified IgG was assessed for the ability to block transcytosis of cell-associated HIV-1 through a tight monolayer of endometrial epithelial cell line HEC1. RESULTS: IgG antibody to gp160 and to the four env-encoded synthetic peptides were detected in all specimens. The mean specific activity of IgG to gp41/K was 4.2 fold higher in colostrum than in paired serum. In contrast, mean specific activities of IgG to gp160 and gp41/Id were twofold higher in serum than in paired colostrum. Mean specific activities of IgG to gp120/V3 and to gp120/Ct were similar in systemic and milk compartments. Functional activity of IgG was evaluated in six paired serum and colostrum: in two women, serum IgG was 3.0 and 7.6 fold more efficient in blocking transcytosis than colostrum IgG; in one patient, colostrum IgG exhibited a 28 fold higher inhibitory capacity than serum IgG; in the remaining patients, serum and colostrum IgG demonstrated similar inhibitory activities against transcytosis of HIV. CONCLUSION: These features are consistent with a compartmentalization of the humoral IgG immune response to HIV within the mammary gland. Some HIV-1 antigens are able to induce a strong humoral mucosal immune response which may be of relevance for the design of a mucosal vaccine against HIV-1.

[Giant anovulvar condyloma acuminata revealing hiv-1 seropositivity in a Centrafrican patient]. / Condylome acuminé anovulvaire géant révélant une séropositivité VIH-1 chez une centrafricaine.

As a general rule, genital condylomas present as localized lesions and large masses of warts are observed only during pregnancy. In this report we describe a giant anogenital condyloma in a non-pregnant 18-year-old Centrafrican woman. Soft papillomas completely covered the anterior and posterior perineum and obstructed the vagina. Clinical findings were suggestive of vulvar Buschke and Loewenstein tumor. The extent of the lesions and a history of unprotected relations with several sex partners raised suspicion of HIV infection which was subsequently confirmed. The CD4+ lymphocyte count was 540/min3. Surgical removal led to complete cure after healing of the surgical wound. Histological findings showed that the lesions were benign and ruled out malignant vulvar tumor. This case documents the link between florid genital condylomas and HIV infection with no change in immune status.