The burden of caesarean section refusal in a developing country setting.

OBJECTIVE: To investigate the prevalence, aetiology and outcomes of caesarean section refusal in pregnant women. DESIGN: A prospective controlled study. SETTING: University of Nigeria Teaching Hospital and Aghaeze Hospital, Enugu, Nigeria. POPULATION: A total of 62 Nigerian women who declined elective caesarean section. METHOD: Interviewer-administered questionnaires at the time of caesarean section refusal and postdelivery. The delivery outcomes of the subjects were compared with that of a matched control group of women who accepted caesarean section. MAIN OUTCOME MEASURES: Prevalence, maternal reasons for caesarean section refusal and the resultant maternal and perinatal mortality. RESULTS: The prevalence of caesarean section refusal was 11.6% of all caesarean deliveries. Maternal reasons for refusing caesarean section include fear of death, economic reasons, desire to experience vaginal delivery and inadequate counselling. Outcomes were significantly worse among women who refused elective caesarean section than in the controls with a maternal mortality of 15% (versus 2%, P = 0.008) and a perinatal mortality of 34% (versus 5%, P < 0.001). CONCLUSION: There is a high prevalence of caesarean section refusal in south-eastern Nigeria. Women declining caesareans have very poor maternal and perinatal outcomes and need extra support.

Cesarean section on request in a developing country.

OBJECTIVE: To assess the prevalence of cesarean sections (CSs) and women's reasons for requesting the procedure in a developing country. METHOD: Pregnant women scheduled for elective CS were interviewed to determine whether the procedure was requested by them or suggested by a physician. The women who personally requested a CS filled out questionnaires before surgery and at the postnatal visit 6 weeks later, and their answers were analyzed. RESULTS: The prevalence of CS on request was 4.4%. Previous infertility and advanced maternal age at first pregnancy were the most common reasons for requesting a CS, but most women said they would prefer a vaginal delivery in subsequent pregnancies. CONCLUSION: The women who requested a CS in this study did so for reasons different from those put forth by women in developed countries. The view that a CS is the surest way toward a live birth was the critical factor underlying their choice.

Juxtacervical vesicovaginal fistulae: outcome by route of repair.

Vesicovaginal fistula is a major public health problem in Nigeria with diverse medical, psychological and social consequences for the patient. This study compared the outcome of vaginal vs abdominal repair of juxtacervical vesicovaginal fistulae. It was a retrospective review undertaken at the University of Nigeria Teaching Hospital, Aghaeze Hospital and Mbanefo Hospital, all in Enugu, Nigeria, from 1 January 1992 to 31 December 2004. The outcome measures were primary repair success rate, blood transfusion, postoperative urinary tract infection rate and duration of hospital stay. Abdominal repair of juxtacervical vesicovaginal fistula was associated with a significantly higher need for blood transfusion when compared with vaginal repair. Both routes of repair had similar primary repair success rates, postoperative urinary tract infection rates and duration of hospital stay. It was concluded that the route of repair of juxtacervical vesicovaginal fistula should be determined by accessibility of the fistula and whenever possible, the vaginal route should be preferred.

Influence of formal maternal education on the use of maternity services in Enugu, Nigeria.

Although some previous studies have suggested formal maternal education as the most potent tool for reducing the mortality ratio in Nigeria, other studies found that the depressed Nigerian economy since 1986 has marginalised the benefits of education with the result that educated women stopped making use of existing health facilities because they could not afford the cost of health services. This study was carried out to determine the current influence of formal maternal education and other factors on the choice of place of delivery by pregnant women in Enugu, south-eastern Nigeria. It was a pre-tested interviewer-administered questionnaire study of women who delivered within 3 months before the date of data collection in the study area. In an increasing order of level of care, the outcome variable (place where the last delivery took place) was categorised into seven, with home deliveries representing the lowest category and private hospitals run by specialist obstetricians as the highest category. These were further sub-categorised into non-institutional deliveries and institutional deliveries. Maternal educational level was the main predictor variable. Other predictor variables were sociodemographic factors. Data analysis was by means of descriptive and inferential statistics including means, frequencies and chi2-tests at the 95% confidence (CI) level. Out of a total of 1,450 women to whom the questionnaires were administered, 1,095 women responded (a response rate of 75.5%). A total of 579 (52.9%) of the respondents delivered outside health institutions, while the remaining 516 (47.1%) delivered within health institutions. Regarding the educational levels of the respondents, 301 (27.5%) had no formal education; 410 (37.4%) had primary education; 148 (13.5%) secondary education and 236 (21.5%) post-secondary education. There was a significant positive correlation between the educational levels of the respondents and their husbands (r=0.86, p=0.000). With respect to occupational categories of the respondents, 88 (8.0%) of them belonged to occupational class I, 158 (14.4%) to occupational class II, 107 (9.8%) to occupational class III, 14 (1.3%) to occupational class IV and 728 to occupational class V. There was a significant positive correlation between the respondents' and their husbands' occupational levels (r=0.89, p=0.000). There were statistically significant associations between choice of institutional or non-institutional deliveries and respondents' educational level as well as place of residence (urban/rural), religion, tribe, marital status, occupational level, husband's occupational and educational levels, age and parity (p

Cervico-vaginal fistula from induced abortions causing subsequent spontaneous midtrimester abortions in Nigerians: case report.

A report of three cases of cervico-vaginal fistula (CVF) from induced abortions causing subsequent spontaneous mid-trimester abortions and a literature review is presented. Restrictive abortion laws, low contraceptive usage and increased sexual activity consequent upon adverse socio-economic conditions have led to an increase in the prevalence of illegal abortions in Nigeria over the previous two decades. CVF appears to be an emerging complication of such abortions. Cervical cerclage is preferred to trachelorrhaphy in the management of such cases. However, where vaginally performed cerclage does not succeed, the abdominal route should be used as a last resort. After a previous induced abortion, clinicians managing the subsequent pregnancy need to search carefully for cervico-vaginal fistula, which may compromise that particular pregnancy. Appropriate contraceptive use and safe abortions using modern methods in cases of contraceptive failure will prevent such horrendous complications of induced abortions in Nigeria and other developing countries.

Nigerian male sexual activity during pregnancy.

OBJECTIVES: To determine the prevalence of extra-marital sexual affairs as well as other aspects of male sexual behavior during pregnancy in Nigeria. METHODS: A questionnaire survey of the husbands of consecutive women who delivered in three tertiary care centers in south-eastern Nigeria within an 8-week period. The data were analyzed by means of simple percentages and descriptive and inferential statistics, using t-tests, chi-square tests and regression equations at the 95% confidence level. RESULTS: 279 (88.3%) of the 316 eligible husbands responded to the questionnaire. A total of 78 (28.0%) of the respondents engaged in extra-marital sexual relationships during pregnancy. Of the respondents, 36.6% and 32.3% experienced a decrease in achievement of erection and orgasm, respectively. While libido decreased in 41.9%, coital frequency declined in 72.4% of the respondents. On univariate analysis, respondent's age > or = 40 years, duration of marriage > or = 5 years, having an extra-marital sexual partner and beliefs that coitus during pregnancy should be less frequent or can cause miscarriage were significant predictors of reduced coital frequency while a belief that coitus enhances fetal well-being was a significant predictor of increased coital frequency during pregnancy (P<0.05 for each variable). On multivariate logistic regression, three factors were statistically significant predictors of reduced coital frequency - age > or = 40 years (OR=2.3; 95% C.I., 1.9-2.3) and beliefs that coitus during pregnancy can cause miscarriage (OR=1.9; 95% C.I., 1.5-2.3) and should be less frequent (OR=1.9; 95% C.I., 1.8-2.5). CONCLUSIONS: Personal beliefs significantly affect sexual relationships between Nigerian husbands and their pregnant wives, making approximately one-third of husbands engage in extra-marital relationships as a way to satisfy their unmet sexual need during pregnancy. There is a need to educate husbands and their pregnant wives on sexual matters during pregnancy.

Conservative management of early-onset pre-eclampsia and fetomaternal outcome in Nigerians.

The aim of this study was to determine the effect of conservative management of pre-eclampsia with onset in the second trimester on fetomaternal outcome. This was a prospective study of 749 consecutive cases of pre-eclampsia seen over a 5-year period in a tertiary care centre in Enugu, Eastern Nigeria. One hundred and seventy-five (23.4%) of the 749 cases started at less than 30 weeks' gestational age. These early-onset cases formed the study group, while the remaining 574 with onset at 30 weeks' gestation or later (the late-onset cases) served as controls. The two groups were compared for some fetomaternal outcome variables at the 95% confidence level. Ninety-one (52%) of the early-onset group had pure pre-eclampsia while the remaining 84 were thought to have pre-eclampsia superimposed on chronic hypertension. The mean gain in gestational age in the early-onset group was 8.8 +/- 1.5 (range: 0-19) weeks. Compared to the late-onset group, the early-onset group had a twofold increase in maternal mortality ratio and a significantly increased incidence of renal failure and HELLP syndrome. The perinatal mortality rate increased fourfold in the early-onset compared to the late-onset group due principally to prematurity and intrauterine growth restriction. The perinatal mortality rate was, however, comparable to results from similar Caucasian studies. It was concluded that there has been an increased incidence of early-onset pre-eclampsia in Nigerian women. Although conservative management of such cases may improve fetal results, it is associated with increased maternal mortality and morbidity because of institutional delays and non-availability of magnesium sulphate at the time of the study. Minimising institutional delays, providing magnesium sulphate and improving neonatal services will enhance maternal and fetal results in early-onset pre-eclampsia in Nigeria and are recommended.

"Pregnancy and Landry Gullian Barre syndrome".

Landry Gullian Barre Syndrome is rare in pregnancy. The case described occurred in a 30 year old woman at a gestational age of 33 weeks. This is probably the 30th case described in the Literature. Unlike in some previous reports remarkable improvement occurred with caesarean section.

Cervico-isthmic twin pregnancy carried to 37 weeks.

The management of twin pregnancy located in the cervico-isthmic region of the uterus in a primigravida has been described. Cesarean section performed at 37 weeks resulted in live female and male infants weighing 2.5 kg and 2.2 kg, respectively. Complications were primary and secondary hemorrhage and post partum morbidity.

260 cases of juxta cervical fistula.

A review of 260 juxta cervical fistulae over a 10 year period revealed that the fistula was more common in grandmultiparous women with brim disproportion. High rectovaginal fistula was a more likely complication than vaginal stenosis. Proximity of the ureteric orifices to the fistulae may lead to post-operative anuria even when adequate care has been taken. Successful repair was achieved in 85% of the patients.

Quintuplet pregnancy. [case report]

A 32 year-old nigerian woman who was admitted with premature rupture of the fetal membranes in the thirty-fifth week of her quintuplet pregnancy is presented. Management is discussed

The diagnosis of ectopic pregnancy by real-time ultrasonography.

The value of ultrasonography in the diagnosis of ectopic gestation was jointly investigated at UNTH and Hansa Clinics. One hundred and two doubtful ectopic pregnancies had ultrasonic evaluation after initial clinical work up. 52 (76.5%) patients out of 68 who had ectopic pregnancy were diagnosed at the first scan. There were 16 (23.5%) false negatives. Twenty-eight (82.4%) patients out of 34 patients who never had ectopic pregnancy were cleared at the first scan. There were 6 (17.6%) false positives who had laparotomy performed. Fetal pulsations were seen as early as 6 weeks in 11.8% of the ectopic pregnancies. This sign was considered diagnostic. Ultrasound was found promising in the confirmatory diagnosis of ectopic pregnancy especially when a strong suspicion was established by history clinical examination and pregnancy test.

The increasing incidence and declining mortality of ruptured uterus in Enugu.

A 10-year review of ruptured uterus at the University of Nigeria Teaching Hospital disclosed an incidence of 1 in 500 deliveries. The average incidence for booked patients alone was 1 in 1271 deliveries. The maternal and perinatal mortalities were 17% and 91% respectively, while the contributions of ruptured uterus to the overall hospital maternal and perinatal mortalities for the period under review were 4.1 and 2.6% respectively. In 1978, the average incidence of ruptured uterus in all patients delivered at the hospital increased from 1 in 787 in the 1st 5 years to 1 in 330 in the 2nd 5 years, while the maternal mortality from ruptured uterus decreased from 27% in the 1st 1/2 to 10% in the 2nd 1.2 of the study. The decline in maternal mortality in this environment is due to better availability of stored blood and management which included subtotal hysterectomy in many cases.

Two-stage repair of giant vesico-vaginal fistula.

A review of 840 bladder fistulae over 10 years revealed that 64 (7.6%) were giant vesico-vaginal fistulae. Association with vaginal stenosis and recto-vaginal fistulae were 23.4% and 4.6%, respectively. The results of direct one-stage repair were poor at 35% for the first attempt while the two-stage repair achieved 80% success at the first attempt. Advantages of the two-stage repair include change in the direction of repair for maximum protection of the terminal ureters and also the possibility of change in patient positioning and approach to the repair of the fistula after the first stage.

Maternity care monitoring: the case of the unbooked patient.

PIP: The results of an investigation of 333 unbooked maternal patients at the University of Nigeria Teaching Hospital Enugu are reviewed. Most of the patients were referred by maternity homes. 37% of emergency admissions were cephalo-pelvic disproportion involving obstructed labor and ruptured uteri. Although only 13% lacked antenatal care, the care received by the majority of patients may not have been adequate. 48.9% of the deliveries were laparotomy followed by normal (25.5%), breech (7.8%), vacuum (4.8%), and forceps (1.5%). The maternal mortality rate was determined to be 45/1000. Causes of death include cephalo-pelvic disproportion and complication, retained placenta and postpartum hemorrhage, antepartum hemorrhage, severe anemia, and perforated duodenal ulcer. The perinatal death rate for unbooked patients was 360/1000. Emphasis must be placed on proper antenatal care. Antenatal care and its importance can be implemented through general education, health education, improved health status, improved transport facilities and communication, improved antenatal care services and facilities, and improved health care. Maternal health care delivery should of 3 different degrees. Primary care should involve maternity homes and primary health care centers staffed by trained midwives supervised by obstetricians. Secondary care should involve hospitals directed by obstetricians and capable of emergency services. Tertiary care should be available in university teaching hospitals promoting health care worker training and research.^ieng