Robson classification of caesarean births: implications for reducing caesarean section rate in a private tertiary hospital in Nigeria.

BACKGROUND: Caesarean section (CS) is a potentially lifesaving obstetric procedure. However, there are concerns about the rising CS rate in many countries of the world including Nigeria. The Ten-Group Robson classification system is presently recommended as an effective monitoring tool for comparing CS rates and identifying target groups for intervention aimed at reducing the rates. The aim of this study was to evaluate the cesarean section rate and the groups with the highest risk of CS at the obstetric unit of Babcock University Teaching Hospital (BUTH), using the Robson classification system. METHODS: A cross-sectional study involving 447 women who gave birth at the obstetric unit of BUTH between August 2020 and February 2022. Relevant information was retrieved from the delivery records of the study participants. Data were analyzed using the IBM-SPSS Statistics for Windows version 23.0 (IBM Corp., Armonk, NY, USA). RESULTS: The overall CS rate was 51.2%. Multiparous women with previous CS, single, cephalic, term (group 5); nulliparous women, single cephalic, term, with induced labour or pre-labour CS (group 2); women with preterm single cephalic, term (group 10); and single cephalic term multiparous women in spontaneous labour (group 3) were the largest contributors to CS rate accounting for 34.5%, 14.0%, 12.6%, and 10.0% respectively. The commonest indication for CS was previous CS (87; 38.0%), followed by poor progress in labour (24; 10.5%). CONCLUSIONS: The CS rate in BUTH is high and Robson groups 5, 2 10 and 3 were the major contributors to this high rate. Interventions directed at reducing the first CS by improving management of spontaneous and induced labours; and strengthening clinical practice around encouraging vaginal birth after CS will have the most significant effect on reducing CS rate.

The ability and safety of community-based health workers to safely initiate lifesaving therapies for pre-eclampsia in Ogun State, Nigeria: An analysis of 260 community treatments with MgSO4 and/or methyldopa.

OBJECTIVES: To evaluate community-based health workers' ability to identify cases of hypertension in pregnancy, safely deliver methyldopa and magnesium sulphate and make referrals when appropriate. STUDY DESIGN: This was part of Nigeria Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494). Community-based Health Workers (CHW) recruited pregnant women from five Local Government Areas (clusters) and used mobile health aid for clinical assessment of pre-eclampsia. MAIN OUTCOME MEASURES: The primary outcome was the number of adverse events that occurred after the administration of magnesium sulphate and/or methyldopa to pregnant women by CHWs. FINDINGS: Of 8790 women receiving mobile health-guided care, community-based health workers in Nigeria provided 309 women with hypertension (4.2% of delivered women), and safely administered 142 doses of intramuscular magnesium sulphate. Community Heath Extension Workers (CHEWs) and nurses gave fifty-two and sixty-seven doses of intramuscular magnesium sulphate respectively, twenty-three doses were given by other health care workers (midwives, community health officers, health assistants). The high rate of administration by nurses can be explained by turf protection as well as their seniority within the health system. Also, CHEWs and nurses gave 124 doses of oral methyldopa and 126 urgent referrals were completed. There were no complications related to administration of treatment or referral. INTERPRETATION: These findings demonstrate the ability of community-based health workers to safely administer methyldopa and intramuscular magnesium sulphate. The use of task-sharing, therefore, could drastically reduce the three delays (triage, transport and treatment) associated with high maternal mortality and morbidity in rural communities in low- and middle-income countries.

A Single-Blind, Parallel Design RCT to Assess the Effectiveness of SMS Reminders in Improving ART Adherence Among Adolescents Living with HIV (STARTA Trial).

PURPOSE: The study evaluated the feasibility, acceptability, and efficacy of interactive and tailored short message reminders on antiretroviral therapy adherence among adolescents (15-19 years) living with HIV in southwest Nigeria. METHODS: The study was a single-blind, parallel-design (ratio 1:1), and multicenter RCT of 209 medication-non-adherent adolescents living with HIV at HIV clinics in two states in southwest Nigeria. The research assessed ART adherence using the visual analog scale, viral suppression, pill count, and ACTG scores; the feasibility of the intervention by the SMS delivery and response (overall and individual) rates; and acceptability using self-report, willingness to continue receiving the intervention, and desire for its scale-up. RESULTS: A total of 17,690 text messages were sent while 10,119 (57.2%) got delivered to the participants. Out of 9,216 responses that were received from the study participants, 8,781 (95.3%) indicated acceptability of the intervention. The end-of-study log10 of viral load values between control and intervention groups had a mean difference of 0.66 (95% CI 0.26-1.06) and p-value of .001. Also, the unadjusted odds ratio of undetected viral load (≤20 copies/ml) was 1.356 (1.039-1.771) with a p-value of .002. However, the intervention had no effect on subjective measures of antiretroviral therapy adherence. CONCLUSIONS: The use of interactive and tailored short message reminders to enhance antiretroviral therapy adherence among adolescents has good potential. It seems feasible, highly acceptable, and possibly leads to improved viral load count. It is likely that the associated antiretroviral therapy adherence enhances viral suppression and, therefore, improves outcomes in adolescent HIV.

Influence of Perception of Family Support and Functioning on Adolescent High-Risk Sexual Behavior.

Adolescents often engage in high-risk behaviors which often have lifelong consequences. It is unclear whether an association exists between adolescents' perception of family support and family functioning and sexual risk behavior. We conducted a cross-sectional study of 702 adolescent students (aged 15-19 years) of a university in Nigeria and assessed high-risk sexual behavior (HRSB) and their judgment of family functioning and support. We used multivariable logistic regression analyses to evaluate the relationship between HRSB and the perception of family support and functioning. We found that 114 (16.2%, 95% CI: 13.69-19.16) of the adolescents engaged in HRSB. A higher proportion of boys (22.7%, 95% CI: 17.79-28.47) than girls (12.93, 95% CI: 10.17-16.31) engaged in HRSB (P = 0.001). The prevalence of intimate partner violence in our study was 8% (95% CI: 6.19-10.29). Participants with lower perception scores were more likely to be engaged in HRSB (aOR: 0.920, 95% CI: 0.878-0.965). Likewise, the perception of family functioning was inversely related to HRSB among the participants (aOR: 0.884, 95% CI: 0.813-0.962). There is an association between adolescents' perception of family support and functioning and HRSB. This association may provide a link in the complex interaction between the role of the family and adolescent sexuality. Programs and interventions for preventing HRSB and promoting risk-reducing autonomous decision-making among adolescents should include context- and setting-specific interventions that improve family support and functioning, and those that target in dysfunctional family settings.

Labor Analgesia in South West Nigeria: Methods and Self-reported Effectiveness.

Context: Labor exposes many women to severe pain. Effective labor pain management is one of the prerequisites for a satisfying labor experience. Aim: The aim of this study was to assess the labor pain management practices and patients' assessment of adequacy of pain relief in two tertiary hospitals in South West Nigeria. Materials and Methods: This was a cross-sectional study involving 132 pregnant women who had a noninstrumental vaginal delivery at the obstetric units of Babcock University Teaching Hospital and Olabisi Onabanjo University Teaching Hospital, between December 2017 and May 2018. A structured questionnaire was administered to women within 24 h of delivery to record details of labor and delivery, the form of labor analgesia administered and respondents' perceived effectiveness of the analgesia. Data were analyzed using the IBM-SPSS statistics for Windows version 21.0 (IBM, Armonk, New York). Results: Sixty-six (50%) women rated labor pain to be severe. Thirty-eight women (28.8%) did not receive any pain relief during labor. Nonpharmacological pain management practices such as back massage, breathing exercises, and companionship were administered to 45(34.1%), 79(59.8%), and 45(34.1%) women, respectively. Nine women (6.8%) received intramuscular pentazocine (30 mg) for labor analgesia. There was a statistically significant association between use of back massage and severe labor pain perception (χ 2 = 4.080; P = 0.043). Self-reported effectiveness was highest among users of back massage (82.2%) and companionship (77.8%). Conclusions: There is a large unmet need for labor analgesia in South West Nigeria. Nonpharmacological pain management practices were the most frequently used methods, and most patients experienced reduction in severity of pain. There is need for improvements in obstetric analgesia services in our maternity units.

Contexte: Le travail expose de nombreuses femmes à des douleurs intenses. Une gestion efficace de la douleur du travail est l'une des conditions préalables à une expérience de travail satisfaisante. Objectif: Évaluer les pratiques de gestion de la douleur du travail et l'évaluation par les patientes de l'adéquation du soulagement de la douleur dans deux hôpitaux tertiaires du sud-ouest du Nigéria. Méthodologie: Il s'agissait d'une étude transversale portant sur 132 femmes enceintes qui ont eu un accouchement vaginal non instrumental dans les unités d'obstétrique de l'hôpital universitaire de Babcock et de l'hôpital universitaire d'Olabisi Onabanjo, entre décembre 2017 et mai 2018. Un questionnaire structuré a été administré aux femmes dans les 24 heures suivant l'accouchement pour enregistrer les détails du travail et de l'accouchement, la forme d'analgésie du travail administrée et l'efficacité perçue de l'analgésie par les répondantes. Les données ont été analysées à l'aide des statistiques IBM-SPSS pour Windows version 21.0 (IBM Corp., Armonk, NY, USA). Résultats: Soixante-six (50%) femmes ont évalué la douleur du travail comme étant sévère. Trente-huit femmes (28,8%) n'ont reçu aucun soulagement de la douleur pendant le travail. Des pratiques de gestion de la douleur non pharmacologiques telles que le massage du dos, les exercices de respiration et la compagnie ont été administrées à 45 (34,1%), 79 (59,8%) et 45 (34,1%) femmes respectivement. Neuf (9) femmes (6,8%) ont reçu de la pentazocine intramusculaire (30 mg) pour l'analgésie du travail. Il y avait une association statistiquement significative entre l'utilisation du massage du dos et la perception d'une douleur intense au travail (χ2 =4.080; P = 0.043). L'efficacité autodéclarée était la plus élevée parmi les utilisateurs de massage du dos (82,2%) et de compagnie (77,8%). Conclusions: Il existe un grand besoin non satisfait d'analgésie du travail dans le sud-ouest du Nigeria. Les pratiques de gestion de la douleur non pharmacologiques étaient les méthodes les plus fréquemment utilisées et la plupart des patients ont connu une réduction de la sévérité de la douleur. Il est nécessaire d'améliorer les services d'analgésie obstétricale dans nos maternités.

A process evaluation plan for assessing a complex community-based maternal health intervention in Ogun State, Nigeria.

BACKGROUND: Despite increased investment in community-level maternal health interventions, process evaluations of such interventions are uncommon, and can be instrumental in understanding mediating factors leading to outcomes. In Nigeria, where an unacceptably number of maternal deaths occur (maternal mortality ratio of 814/100,000 livebirths), the Community Level Interventions for Pre-eclampsia (CLIP) study (NCT01911494) aimed to reduce maternal and neonatal mortality and morbidity with a complex intervention of five interrelated components. Building from previous frameworks, we illustrate a methodology to evaluate implementation processes of the complex CLIP intervention, assess mechanisms of impact and identify emerging unintended causal pathways. METHODS: The study was conducted from 2013-2016 in five Local Government Areas in Ogun State, Nigeria. A six-step approach was developed to evaluate key constructs of context (external factors related to intervention), implementation (fidelity, dose, reach, and adaption) and mechanisms of impact (unintended outcomes and mediating pathways). The steps are: 1) describing the intervention by a logic model, 2) defining acceptable delivery, 3) formulating questions, 4) determining methodology, 5) planning resources in context, lastly, step 6) finalising the plan in consideration with relevant stakeholders. RESULTS: Quantitative data were collected from 32,785 antenatal and postnatal visits at the primary health care level, from 66 community engagement sessions, training assessments of community health workers, and standard health facility questionnaires. Forty-three focus group discussions, 38 in-depth interviews, and 23 structured observations were conducted to capture qualitative data. A total of 103 community engagement reports and 182 suspected pre-eclampsia case reports were purposively collected. Timing of data collection was staggered to understand feedback mechanisms that may have resulted from the delivery of the intervention. Data will be analysed using R and NVivo. Diffusions of innovations and realist evaluation theories will underpin analysis of the interaction between context, mechanisms and outcomes. CONCLUSION: This comprehensive approach can serve as a guide for researchers and policy makers to plan the evaluation of similar complex health interventions in resource-constrained settings, and to aid in measuring 'effectiveness' of interventions and not just 'efficacy'. TRIAL REGISTRATION: This research is a part of the Community Level Interventions for Pre-eclampsia Study, NCT01911494. The trial is registered in Clinicaltrials.gov, the URL is https://clinicaltrials.gov/ct2/show/NCT01911494 The trial was registered on June 28, 2013 and the first participant was enrolled for intervention on March 1, 2014.