Effect of diagnosis and treatment of inoperable cervical cancer on quality of life among women receiving radiotherapy at Kenyatta National Hospital.

BACKGROUND: Cancer of the uterine cervix is the most common female cancer in Kenya. Despite being preventable, it is often diagnosed when it is already late. For this reason, only palliative therapy is provided. Hence, it is expected that their daily routines and that of their caregivers are severely disrupted. OBJECTIVES: To determine the extent to which diagnosis and treatment of inoperable cervical carcinoma affects quality of life (QOL). DESIGN: Cross-sectional descriptive study. Setting Radiotherapy Department at the Kenyatta National Hospital. SUBJECTS: Women undergoing radiotherapy for inoperable cervical cancer. RESULTS: There is high prevalence of profound disruptions in nearly all domains of QOL. In the social domain, between 33% and 44% had the perception that family members and friends had withdrawn social support. Reduction in various economic facets was reported by 47.4%-52.6%, with 44.7% reporting a fall in the overall living standards. There were significant changes in the sexual domain, as a result in which 28.3% reported marital discordance. In the personality domain, decreased self-esteem and self-projection in life occurred in 30.9% and 36.2% respectively. On functional outcomes (EORTC QLQ-C30), only 32%-41% reported not being affected in the various facets of emotional function. Physical functions were affected in 19%-79%, role functions in 69%-75%; symptoms in 49%-80%; cognitive functions in 46%-56%; social functions in 63%-71% and financial aspects by 63%. On global QOL, 53% and 47% respectively reported high level disruption in overall physical health and overall QOL. CONCLUSION: Severe deterioration of QOL occurs as a result of diagnosis of inoperable cervical cancer and subsequent therapies. For this reason there is need to establish severe disease and end-of-life research and management services that would ensure better coping with cancer for patients and for home-based caregivers.

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.

Induced abortion in Kenya: its determinants and associated factors.

In a study involving 1077 women who were admitted and treated for incomplete abortion and its related problems at eight hospitals (seven district and one mission hospitals) in six of the eight provinces of Kenya, between October 1988 and March 1989, 169 (15.7%) had illegally induced unsafe abortion, based on their own history and clinical findings. The illegally induced unsafe abortions were common among both rural and urban dwellers, and women from almost all social and economic strata were involved. However, they were more common among the youth (< 25 year olds), school girls, those with high formal education, in formal employment, and not currently married. Majority (90.4%), of the induced group said their pregnancies were unwanted, as compared to only 29.1% of the non-induced (p < 0.05). The main determining factor for termination of pregnancy amongst these women appeared to be the fact that it was unwanted and/or unplanned, either because of inappropriate timing, the type of man responsible, the relationship itself and the social and economic implications thereof. This is contributed to by poor contraceptive use inspite of very good awareness, and/or desire to use. There is urgent need to integrate abortion care and related services into the overall reproductive health care and as a part of the broader safe motherhood initiative in Kenya. In addition it is necessary to revise the legal provisions on abortion so as to make them more relevant. Appropriate management of adolescent fertility, should be undertaken with the aim of reducing the extent of illegally induced unsafe abortion with attendant sequealae.

PIP: As part of a larger survey of the epidemiology of unsafe abortion in Kenya, 1007 women admitted to 8 hospitals in 6 of Kenya's 8 provinces during October 1988-March 1989 for incomplete abortion or its complications were interviewed. 169 of these women (15.7%) were considered to have undergone induced abortion (115 women who admitted to interfering with their pregnancy and 57 women who had clear physical evidence of an attempt at pregnancy termination). The induced abortion rate ranged from 0.9% at the Malindi coastal district hospital to 36.4% at the only mission hospital (Chogoria) in the study. Although adolescents (10-19 years old) comprised 15.2% of the total study group, 29.6% of induced abortion patients were in this age group. 22.9% of the total study group, compared with 70.4% of the induced group, were unmarried. There was a steady increase in the proportion of women with induced abortion with increasing educational level, from 4.7% of those with no formal education to 26.3% among those with a college or university education. Induced abortion patients were significantly more likely than those in the broader group to be students (14.8%) or employed in the formal sector (13%). Contraceptive prevalence at the time of conception of the index pregnancy was 12.1% in the broader group and 23.1% in the induced abortion group. 37.8% of induced abortion patients, compared with 50.2% of non-induced women, reported to the hospital within 24 hours of initial symptoms of abortion. Finally, complications were more prevalent in the induced abortion group and included sepsis (34.3%), anemia (17.8%), genital injury (16.6%), and hemorrhage (12.4%). The one death in the induced abortion group was attributable to severe septicemia. The 15.7% induced abortion rate identified in this study is considered to be an underreport, as suggested by the finding that 38.6% of the total study group stated their pregnancy was unwanted.

A survey of the knowledge, attitude and practice of induced abortion among nurses in Kisii district, Kenya.

PIP: A cross-sectional study was carried out in Kisii District in the western part of Kenya between April 1 and April 28, 1991, with the objectives of ascertaining the attitude of nurses towards induced abortion, patients, and their involvement in abortion. Data were collected using a structured, self-administered questionnaire. All nurses present at the various institutions were recruited. A total of 218 nurses were recruited into the study. 75-83% were married, female nurses younger than 40, and therefore in the reproductive age group. 134 (61.5%) nurses were Protestant and 51% worked in the government district hospital. The nurses displayed a deficient knowledge of all aspects of induced abortion. Among clinically safe methods only intraamniotic saline instillation and dilation and curettage were mentioned by 4% and 11%, respectively. This deficiency in knowledge may be explained by the fact that most nurses work in the government hospitals, where induced abortion is not a routine procedure. Only 26-28% of the nurses thought it was safe to induce abortion at 1 and 2 months of gestation. 31-43% either did not know or were uncertain. Abortion is illegal in Kenya except when the life of the mother is in danger. Most nurses seemed to favor the law. A previous study in Nairobi revealed that only 38% of the nurses favored abortion on demand under a liberalized abortion law. 24 (11%) of nurses admitted to have induced abortion before. Their knowledge of induced abortion needs to be improved in order to prevent an increase in mortality and morbidity associated with improperly performed abortions.^ieng

Past reproductive and sexual characteristics of women with tubal infertility at Kenyatta National Hospital.

Past reproductive and sexual characteristics of patients with tubal sterility (cases) and currently fertile women (control group) were studied. The ages at first coitus and the number of sexual partners were significantly more (p less than 0.01) in the cases than in the controls. Most cases (56.0%) had only primary school education whereas most of the controls (68.7%) had secondary school education. Nearly 70% of the cases had had the first sexual intercourse by 16 years compared with about 40% in the controls. Pre-menarcheal sexual intercourse occurred in 1/4 of the cases compared with less than 1/10 in the controls (p less than 0.001). Of those with secondary infertility; 33.3% had had the first pregnancy by the age of 16 years compared with 12.0% in the controls (p less than 0.001); and in 83.3% of the cases, the first pregnancy was not by the current husband compared with 26.0% in the controls (p less than 0.001). In addition, the cases had more abortions before marriage (p less than 0.001), more induced abortions (p less than 0.001) and had medically diagnosed sexually transmitted diseases more often (p less than 0.01). It is concluded that the reproductive and sexual events that occur during the teen-age determine the future prospects of fertility. Intensification of educational programs by the government and all relevant organisations, with emphasis on the relationship between sexual behaviour during adolescence and future reproductive problems, is strongly recommended.

The effect of low-oestrogen combined pill, progestogen-only pill and medroxyprogesterone acetate on oral glucose tolerance test.

The effect of a low-oestrogen combined pill, progestogen-only pill and medroxyprogesterone acetate on oral glucose tolerance test was studied in 29, 30 and 9 indigenous Kenyan women respectively. Glucose tolerance test was performed before treatment was started and then after 1,3 and 6 months in microgynon users. The mean areas under the glucose curves were also significantly elevated. Significant increase in blood glucose values were noted only at 30 minutes after 6 months of use of the progestogen-only oral contraceptive but the mean blood glucose values were higher than in the control after 1,3 and 6 months of use. However, the mean values of the areas under the glucose curves were significantly elevated after 1,3, and 6 months of use. Medroxyprogesterone acetate users showed significantly lower fasting blood glucose values at 60 and 90 minutes after 1 month of use, after which the blood glucose values returned to the pre-treatment values. The mean values of the glucose curve areas showed no significant change. It is concluded that both microgynon and minipill cause relative impairment of glucose tolerance test as early as after 1 month of use. Medroxyprogesterone acetate does not impair oral glucose tolerance for at least the first 6 months of use. The implications of these findings are discussed.

PIP: Researchers followed 68 women who attended the Family Welfare Clinic at the Kenyatta National Hospital in Nairobi, Kenya to determine if the low estrogen combined oral contraceptive (OC) Microgynon, a progestogen only OC, and Depo-Provera induce changes in the oral glucose test. These women did not take any steroidal contraceptives before entry into the study. Blood glucose levels were significantly higher after 60, 90 and 120 minutes than the control levels for women taking Microgynon. In addition, the mean areas under the glucose curves were substantially elevated after 1, 3, and 6 months above the control (p.002, .005, and .01 respectively). The only significant change in blood glucose levels in women taking the progestogen only OC occurred at 30 minutes after 6 months. Yet the mean areas under the curve were significantly higher than the control after ,1 2, and 3 months (p.005, .05 and .002 respectively). As for Depo-Provera, significantly lowered blood glucose levels only occurred after 1 month at 30, 50, and 90 minutes although no significant changes occurred after 1, 3, and 6 months in the mean areas under the glucose curves. Metabolic change occurred earlier and more often in Microgynon users than progestogen only OC users. This could be due to the progestogen levonorgestrel which has been shown to interrupt glucose metabolism. These changes could possible adversely effect women who are predisposed to developing diabetes, since 1 woman did develop a diabetic curve after 1 month of using Microgynon. Nevertheless no pattern towards abnormal glucose tolerance existed. Standard deviations of areas under the curves indicated that the number of women who develop glucose intolerance may increase with duration of use.

Birth interval and pregnancy outcome.

PIP: 615 Kenyan women who had experienced 2407 pregnancies and 1792 birth intervals were interviewed who had delivered at the Kenyatta National Hospital during the months of June and July, 1985. Birth intervals that were 25-36 months long were associated with the most favorable pregnancy outcome. Poor pregnancy outcome was followed by very short birth intervals with more than 75% of the birth intervals being 24 months long or less. When no contraceptives were used 58% of the birth intervals were 24 months long or less compared with only 25.5% when contraceptives were used. Breastfeeding alone is not very effective in prolonging the birth interval since 33.4% of women resumed regular menstruation by 4-6 months when they are still breastfeeding. Only 31% of married women were abstinent by 3 months postpartum and therefore in this group of women abstinence played no role in prolonging the birth interval. It is apparent that the use of effective modern contraceptive methods, good obstetrics and neonatal care and adequate breastfeeding are the key measures that can ensure the optimum birth interval and hence the most favorable pregnancy outcome.^ieng