Introduction of postabortion contraception, prioritizing long-acting reversible contraceptives, in the principal maternity hospital of Gabon.

A prospective, descriptive, analytic study was conducted at the Centre Hospitalier de Libreville in Gabon between February and September 2013 to evaluate acceptance of long-acting reversible contraceptives (LARC) and depot-medroxyprogesterone acetate (DMPA) following abortion. Women received counseling on the combined oral pill, DMPA, copper intrauterine devices (IUDs), and implants. The association between sociodemographic and clinical characteristics, knowledge of contraceptives, and acceptance was analyzed. Of the 383 women admitted with abortion complications, 206 (53.7%) knew of no systemic contraceptives. The best-known method was the oral pill (42.0%). Only 14 women (3.6%) knew of a LARC method (IUD or implants) and only 2 (0.5%) said the injectable was their best-known method. Over 90% accepted a modern contraceptive method after abortion. Two-thirds (66.8%) chose the pill, 14.6% DMPA, and 9.3% a LARC method. Only 9.1% of the women refused to initiate use of any method.

The contribution of research results to dramatic improvements in post-abortion care: Centre Hospitalier de Libreville, Gabon.

In 2009, we published an article in RHM showing a large delay in provision of emergency obstetric care to women who died from unsafe abortion complications at the Centre Hospitalier de Libreville. The paper raised awareness among hospital and government authorities of a serious delay in timely treatment, and they supported the recommendation of the hospital's Maternal Mortality Committee to greatly reduce the delay and also improve the care of women with abortion complications. Training in manual vacuum aspiration (MVA) for uterine evacuation was introduced, for use by midwives as well as obstetrician-gynaecologists, with local anaesthesia. The mean delay in providing care to women with abortion complications in the 2008 findings was compared to data from the five months from 1 November 2011 through 31 March 2012. In 2008, all incomplete abortions were treated by physicians with dilatation & evacuation (D&C) or electric vacuum aspiration (EVA) with general anaesthesia. In 2011-12, two-thirds of women were treated with manual vacuum aspiration with local anaesthesia instead, one half of them by midwives. The mean delay between presentation and treatment was 18.0 hours in 2008 and 1.8 hours in 2011-12. The mean delay did not differ between women treated with MVA or D&C/EVA, nor if treated by midwives or physicians.

Delay in the provision of adequate care to women who died from abortion-related complications in the principal maternity hospital of Gabon.

Deaths resulting from unsafe induced abortions represent a major component of maternal mortality in countries with restrictive abortion laws. Delays in obtaining care for maternal complications constitute a known determinant of a woman's risk of death. However, data on the role of delays in providing care at health care facilities are sparse. The association between the cause of maternal death (abortion versus post-partum haemorrhage or eclampsia) and the time interval between admission to hospital and the initiation of treatment were evaluated among women who died at the Maternité du Centre Hospitalier de Libreville, Gabon, between 1 January 2005 and 31 December 2007. The women's characteristics and the time between diagnosis of the condition that led to death and the initiation of treatment were compared for each cause of death. After controlling for selected variables, the mean time between admission and treatment was 1.2 hours (95% CI: 0.0-5.6) in the case of women who died from post-partum haemorrhage or eclampsia and 23.7 hours (95% CI: 21.1-26.3) in the case of women who died of abortion-related complications. In conclusion, delay in initiating care was far greater in cases of women with complications of unsafe abortion compared to other pregnancy-related complications. Such delays may constitute an important determinant of the risk of death in women with abortion-related complications.

[Maternal mortality in Libreville, Gabon: assessment and challenges]. / Mortalité maternelle à Libreville (Gabon): état des lieux et défis à relever en 2006.

OBJECTIVE: To analyze the course over time of the rates and causes of maternal mortality in Libreville, Gabon. MATERIAL AND METHODS: This prospective descriptive study covers the 6-year period from January 1, 2001, to December 31, 2006. It was performed at the Libreville Hospital Center (LCH) maternity ward, the leading obstetrical care facility in the country. A maternal mortality registry began recording deaths on January 1, 2001. All maternal deaths are listed there, and a department meeting focusing on the death is organized after each. In this study, we analysed the epidemiologic characteristics, circumstances and cause of each death. RESULTS: In all, 136 women died. Their mean age was 25 +/- 5 years with a range of 16 to 41 years. Mean parity was 4 +/- 3, and ranged from 1 to 7. Most of the women were not employed (86%), but had at least some secondary schooling (88%). There were 126 cases (93%) of intrapartum deaths. They occurred more often at night (72% versus 28% during the day) and during the week (77% versus 23% on weekends). The maternal mortality rate was cut in half between 2000 and 2006 (p<0.005), dropping from 444 to 248 per 100 000 live births. Hemorrhages and eclampsia were the two principal causes of mortality. CONCLUSION: Faster access to care and improvement in the quality of emergency obstetrical care are essential conditions for reducing maternal mortality.

[Audit of the severe obstetrical morbidity (near miss) in Gabon]. / Audit de la morbidité obstétricale grave (near miss) au Gabon.

OBJECTIVE: To examine "near-miss" cases to identify the weak points of our department. MATERIAL AND METHODS: This prospective study took place at the Libreville Hospital Maternity Center for six months, from 1 June to 31 December 2006. It included all pregnant women with a severe obstetrical complication (uterine haemorrhage with signs of shock, eclampsia, severe infection) or whose condition required a major intervention to prevent death. The quality of these patients' management was studied from their arrival in the department to their discharge. RESULTS: The prevalence of near-misses was of 3.15%, that is, 137 cases among 4350 deliveries. Ruptured ectopic pregnancies, haemorrhage following clandestine elective abortions, and post-partum haemorrhages (third stage of delivery) were the three primary causes for near misses. Almost 40% of these women waited more than 45 minutes before seeing any qualified personnel. Once the patient was seen, clinical examinations were impossible for 22% because of the lack of the appropriate material. The average time to surgery was 5 hours and 15 minutes. The lack of sterilized surgical linens was one of the major causes of delay in surgical management. CONCLUSION: The number of patients seeking care in our department, relative to the staff resources, makes it difficult to optimise the quality of emergency obstetric care.

[Nonpalpable breast lesions: correlation of the BI-RADS classification and histologic findings]. / Corrélation radio-histologique des lésions mammaires infracliniques à partir de la classification BI-RADS (étude gabonaise).

UNLABELLED: Diagnosis of nonpalpable breast lesions too often requires a breast biopsy or tumorectomy. OBJECTIVE: To validate the American College of Radiology (ACR) classification and lexicon using a standardized description to improve the uniformity of management of abnormal mammographic lesions and reduce the number of unnecessary tumorectomies. MATERIAL AND METHODS: This prospective study was conducted in Libreville Hospital Center over a 4-year period and compared the histologic results of 150 nonpalpable masses identified by mammography and their ACR classification to assess the correlation between the radiographic and histologic findings. RESULTS: There were 90 cases (60%) of ACR2 lesions, 28 cases (18%) of ACR3, 6 cases (4%) of ACR4 and 26 cases (17%) of ACR5 lesions. Histologic results showed that 3% of the ACR2 lesions were malignant, 11% of the ACR3, 67% of the ACR4 and 92% of the ACR5 lesions. CONCLUSION: The correlations showed that the ACR classification was highly reliable for ACR2 and ACR5 lesions and makes it possible to optimize their treatment. ACR3 and ACR4 lesions must be watched carefully.

[Risk factors for eclampsia in Libreville (Gabon): a case-control study]. / Facteurs de risque de l'éclampsie à Libreville (Gabon): étude cas-témoins.

OBJECTIVES: To determine the current prevalence of eclampsia in our department, identify its risk factors and assess the prognosis of mother and child. MATERIAL AND METHODS: This retrospective case-control study took place from January 1, 2004, through December 31, 2005, in the gynecology-obstetrics and intensive care departments of the Libreville Hospital Center. Every case of eclampsia was compared with three control patients. We collected social, demographic and clinical variables and compared them between the two groups. Univariate analysis was conducted with Epi Info 6.0. The odds ratio (OR) and 95% confidence intervals (95% CI) were calculated for each variable and compared with the Chi 2 test (significance defined as a p value less than 0.05). RESULTS: The prevalence of eclampsia was 0.5%. The principal risk factors were: mother aged younger than 19 years (OR=3.38; CI= 1.77-6.47), nulliparity (2.21; 1.22-4.02) and one or no prenatal consultations (19.23; 6.45-61.40). Severe high blood pressure (>160/110 mmHg) was found in 52% of cases. There were 14 maternal deaths (21%) in the case group and none among the controls. CONCLUSION: Improvement in the quality and quantity of prenatal care should help reduce the incidence of eclampsia.

[Emergency obstetrical hysterectomy: about 58 cases at Libreville Hospital Centre]. / L'hystérectomie obstétricale d'urgence. A propos de 58 cas au Centre hospitalier de Libreville.

OBJECTIVE: To evaluate the incidence, indications and prognosis of this surgery in our daily practice in order to suggest preventive action. PATIENTS AND METHOD: This is a retrospective study over a period of 10 years, from January 1, 1992 to December 31, 2001. Using patient's documents, parameters have been analysed as followed: age, parity, antecedent of uterine surgery, indications, surgery technique, foeto-maternal prognosis. RESULTS: The frequency of this intervention is 0.07%. The average age of patients was 31 years and the average parity was 6. The indications were: 44 cases of haemorrage (76%) and 14 cases of post-abortum infection (24%). Sub-total hysterectomy was performed on all the patients. We have observed 14 cases of maternal death (24%) and 24 cases of foetal death (57%). CONCLUSION: The frequency of this surgery is weak in our daily practice, compared with other Black African countries. But foeto-maternal prognosis is severe. A better sensibilisation of the population on prenatal consultations benefits and the setting up of a real national strategy of obstetrical emergency care constitute a means to prevent this type of surgery.