Oxytocics in developing countries.

OBJECTIVES: A prospective multicenter study of obstetric practices was conducted in three developing countries (Benin, Congo and Senegal) to analyze oxytocic use during labor. One of the objectives was to assess the possible negative effects of the treatment regimens instituted during the labor monitoring phase. METHODS: Four health districts participated in the study. All women who gave birth in one of the participating health facilities over a 6-month period in Benin and Congo, and over a 3-month period in Senegal, were recruited. The number of deliveries studied in each district varied from 457 to 1048. For each case a partogram was used to assess the progress of labor and the onset of dysfunctional labor. Information was collected on the risk factors for dysfunctional labor, stillbirths and resuscitation of the neonate. RESULTS: Each of the four collaborating centers used oxytocics preferentially to treat dysfunctional labor, but even in normal labor (i.e. with a normal partogram) oxytocics were used in 4.4-21.5% of cases. In normal labor the incidence of neonatal resuscitation was higher in cases with than in those without oxytocic use: the relative risks (R.R.) varied from 1.9 to 5.6; the odds ratios varied from 2.4 to 7.0, and both were statistically significant in the four settings. In addition the stillbirth rate was always higher, though not significantly, when oxytocics were used in normal labor (R.R. 1.2-2.2). When the data of the four centers were pooled, the global relative risk for stillbirths was 1.9, and the 95% confidence interval was 1.1-3.4. Logistic regression analysis was carried out for five confounding factors (primiparity, a previous complicated delivery, presence of meconium, ruptured membranes and educational level) to adjust the odds ratio for the risk of neonatal resuscitation when oxytocics were used in normal labor. Except in the case of Abomey in Benin, where the variable 'presence of meconium' decreased the odds ratio from 6.4 to 3.4, the adjusted odds ratios remained similar to their non-adjusted values. In cases of non-dysfunctional labor, nurses and midwives used oxytocics more often than lesser trained health personnel (R.R. 4.0 [3.2-5.1]). CONCLUSION: Our results show that an obstetric treatment which is safe when used in certain well-defined indications, may have significant negative effects when used in situations where the same technical quality of care cannot be guaranteed.

How accurate is maternal height measurement in Africa?

Maternal height is one of the risk parameters for dystocia that is often used in antenatal clinics which are organized by health centers and dispensaries in developing countries. In this paper, the results of an analysis on the reliability of height measurements in four African countries: Benin, the Congo, Senegal and Zaire are presented. Different causes appear to reduce this reliability: attraction to round numbers, assignment of some standard size, and in one situation an overrecording (probably intentional) of an at-risk woman. Different solutions are being suggested, and the importance of assessing the quality of risk factor measurement in improving the efficacy of the risk approach strategy is stressed.

Value of the alert and action lines on the partogram.

A partogram based on a World Health Organisation model has been used for many years in the peripheral maternity clinics of Pikine, Senegal, to monitor labour. We have assessed the value of the partogram and efficacy of the alert and action lines. 1022 pregnant women were monitored by partogram during 4 months. The alert line was crossed in 100 (9.8%) of these cases and the frequency of neonatal resuscitation was higher for this group (relative risk 4.0, 95% confidence interval 2.3-7.1; p less than 0.0001), as was the number of "fresh" stillbirths (5.3, 1.8-15.6; p less than 0.01) (recent death may have occurred during labour). Among the women who crossed the alert but not the action line, neonatal resuscitation was also four times more likely than for the normal labour group (4.0, 2.1-7.6; p less than 0.001), and the fresh stillbirth rate was higher but not significantly so. For women who crossed both lines, the fresh stillbirth rate was ten times higher than for women in the normal labour group (9.9, 2.8-34.7; p less than 0.001). Crossing the alert line had a sensitivity of 27%, a specificity of 93%, and a positive predictive value of 17% for neonatal resuscitation. If the action line was chosen as the decision level, the positive predictive value remained the same but the sensitivity was only 8%. Health workers intervened (eg, artificial rupture of the membranes, administration of oxytocics) in half the dystocic cases. Of the women who did not receive any such treatment 44% crossed the action line compared with only 26% of those who did receive treatment (p = 0.06). The results show the usefulness and efficacy of the partogram and underscore the value of medical intervention as soon as the alert line is crossed.

[Sexually transmitted diseases in the female population of Pikine, Senegal]. / Maladies sexuellement transmissibles dans la population féminine à Pikine, Sénégal.

The prevalence of some sexually transmitted disease is determined in 250 gynaecology patients and in 200 pregnant women seen in primary health centers in Pikine, Senegal. The main reason for consultation at gynaecology is infertility. Gonorrhoea and Chlamydia trachomatis infection are present respectively in 1.5% and 7% of pregnant women and in 4.4% and 7.6% of gynaecology patients. Human papillomavirus infection, determined by DNA extraction and hybridization technique, is seen in 4% of obstetric and in 1.2% of gynecology patients. Cytological anomalies is found in 5.5% of pregnant women and in 4.8% of gynecology patients.

[Neisseria gonorrhoea in Pikine (Senegal): survey of antibiotic sensitivity]. / Neisseria gonorrhoea à Pikine (Sénégal): surveillance de la sensibilité aux antibiotiques.

The antimicrobial sensitivity of 96 strains of Neisseria gonorrhoeae, isolated in 1987-88 in Pikine, Senegal was determined. Twenty four percent of isolates produced beta-lactamase (PPNG). Among the beta-lactamase negative strains, 27% showed a decreased sensitivity to penicillin (MIC 0.125-0.25 mg/l) and 3% were resistant (MIC greater than or equal to 0.5 mg/l). Seventeen percent of isolates showed a decreased sensitivity to thiamphenicol (MIC 1-4 mg/l) and 7% were moderately resistant to tetracycline (MIC 2-4 mg/l). All isolates were sensitive to spectinomycin and sensitive to moderately sensitive to kanamycin. During an earlier survey performed in 1981, chromosomal resistance to tetracycline was not seen and only 4% of strains were beta-lactamase positive. These results suggest a decreasing antimicrobial sensitivity of N. gonorrhoeae in Pikine. Spectinomycin can be used as a first choice antimicrobial and thiamphenicol may be recommended as a valuable alternative treatment of gonorrhoea in Pikine, Senegal.

Induced abortion in maternal and child health centres in a general family planning programme in Cap Bon, Tunisia.

PIP: A study was conducted in the maternal and child health centers in 2 small towns in the Cap Bon peninsula (northeast Tunisia) in an attempt to determine the incidence of induced abortions. The birth rate in this area was 38.8/1000 in 1973 and 23.8/1000 in 1977. The family planning program and the liberalization of the abortion law might have contributed to the birth rate decline. A total of 502 induced abortions were performed over the September 1976 to December 1978 period. Each woman desiring an abortion was examined by the midwife for pregnancy confirmation. Any woman with a pregnancy of more than 2 1/2 months was referred to the nearby regional hospital. The abortion was performed by the gynecologist using vacuum aspiration under local anesthesia. Immediately after aspiration, an IUD is inserted or the oral contraceptive is given and its use explained. Each woman is kept under observation for 1-2 hours. Seven characteristics of the abortion patients were analyzed: age; number of living children and parity; age of last living child at time of conception; breastfeeding; domicle; use of contraception prior to induced abortion; and contraception in immediate postabortion period. 89% of the women were aged 20-39 years; 43% were under 30 years old. 40% had 1-3 living children and 58% had more than 3 children. Women aged under 30 had a mean of 2.49 living children and a mean parity of 2.78; for those over 30 the corresponding figures were 5.23 and 6.44. 60% had a child under 2 years old; 28% had their last living child aged 2-5 years; and 12% had a school age child. Of 463 women, 154 were breastfeeding at the time of conception. 71% of the women lived in the town where the center is located, and 29% came from the rural neighboring areas. A small number of women became pregnant due to the failure of their contraceptive method (IUD and technically failed tubal ligation). 1/3 of 492 women had used a contraceptive method since their last delivery, but most had stopped it after a time or had used it erratically. 3/4 accepted the IUD as an immediate postabortion method; 21.3% accepted oral contraception, and 2.6% accepted tubal ligation. The following factors have improved the acceptance of contraception and induced abortion by the women: there is no need for husband's consent or for approval of a medical panel; contraception and abortion are free of charge; decentralization of family planning and abortion; and the requirement of only a short stay for postintervention observation.^ieng

Excessive carbohydrate intake in pregnancy and neonatal obesity: study in Cap Bon, Tunisia.

A high incidence (over 20%) of obesity was found in 250 neonates living in a rural area of Tunisia, by using weight and ponderal index per gestational age as the nutritional index. Maternal diabetes was probably excluded. Two surveys on nutritional habits--one on the general population and the other on pregnant women--showed a tendency to consume a high carbohydrate and low protein diet. The effect of a badly balanced maternal diet on the fetus is discussed.