Two decades of minilaparotomy female sterilisation at the university of benin teaching hospital.

OBJECTIVE: To evaluate female sterilisation through minilaparotomy approach in University of Benin Teaching Hospital over a 20-year period. STUDY DESIGN, SETTING AND SUBJECTS: This was a retrospective study in which the case notes of 156 clients who accepted permanent method of contraception out of 14771 acceptors of family planning methods in the University of Benin Teaching Hospital between January 1985 and December 2004 were retrieved and analyzed for socio-demographic characteristics of the clients, timing, technique, type of anaesthesia used and the complications associated with the procedure. RESULTS: The incidence of female sterilisation was 1%, mean age and parity were 36.9 +/- 3.6years and 6.4 +/- 1.6 respectively. 80.8% had interval sterilisation and the tubal occlusion was mainly by Pomeroy's technique. Local anaesthesia under heavy sedation was used in 85.9% of the clients. Surgical complications occurred in 3.24% and were uterine perforation, bladder and intestinal injuries and bleeding from the fallopian tube and the mesosalpinx. 3.85% had wound infection and 1.94% anaesthetic complications. Effectiveness was 100% and there was no mortality. CONCLUSION: Our institution would need to scale up counseling of clients for permanent method of contraception to improve on the poor acceptability. Careful surgical techniques with local anaesthesia alone or with light sedation and adherence to infection prevention practices would reduce the incidence of surgical, anaesthetic complications and wound sepsis that would ensure client satisfaction.

Vaginal birth after one previous caesarean section in a tertiary institution in Nigeria.

Vaginal birth after one previous lower segment caesarean section represents one of the most significant and challenging issues in obstetric practice. A 5-year retrospective study was carried out at the University of Benin Teaching Hospital between January 1999 and December 2003, to determine the incidence, the maternal and fetal outcome following vaginal delivery after one previous caesarean section with a view to evaluating its safety and efficacy. There were 5234 deliveries, with 395 cases of one previous caesarean section, giving an incidence of 7.5%. The incidences of emergency caesarean section, elective caesarean section and spontaneous vaginal delivery following trial of vaginal delivery were 34.7%, 9.4% and 48.1%, respectively. During the study period there were 1317 cases of caesarean section, giving an incidence of 25.2% caesarean section rate. The incidence of one previous section among all caesarean section births was 30%. The major morbidity following vaginal delivery was uterine rupture with an incidence of 1.5% and hysterectomy of 0.8%. Three of the uterine ruptures occurred before admission because the patients laboured at home. One maternal death occurred as a result of uterine rupture and postpartum haemorrhage, giving a maternal mortality ratio of 19/100,000 and a case fatality rate of 0.3%. The corrected perinatal mortality rate was 15.2/1000, mainly from obstructed labour, abruptio placenta and fetal distress. Both maternal and fetal mortalities from vaginal birth after one previous section were significantly less than the respective overall maternal and fetal mortality from the institution. The 1-minute apgar score of babies delivered by elective section was significantly (P < 0.001) higher than the apgar score of babies delivered by emergency section and vaginally. There was only one patient with wound dehiscence at elective section without associated perinatal death. Vaginal delivery following caesarean section is relatively safe. However, women in developing countries will continue to require counselling to counter the myths of aversion to operative delivery even at the expense of losing their lives. Our hospitals should have adequate monitoring equipment for high-risk pregnancies so that patients and their babies can be assured of survival.

Abortion-related morbidity and mortality in Benin City, Nigeria: 1973-1985.

In a 13-year review of maternal deaths at the University of Benin Teaching Hospital, Benin City, abortion was one of the three major causes of death, accounting for 37 (22.4%) out of the 165 deaths. Induced abortion was responsible for 34 (91.9%) of these deaths. The usual victim is the teenage, inexperienced school girl who has no ready access to contraceptive practice. Death was mainly due to sepsis (including tetanus), hemorrhage and trauma to vital organs, complications directly attributable to faulty techniques by unskilled abortion providers, a by-product of the present restrictive abortion laws. Total overhaul of maternal child health services and the family health education system, as well as integration of planned parenthood at primary health care level into the health care delivery system, are suggested. Contraceptive practice should be made available to all categories of women at risk, and the cost subsidised by governmental and institutional bodies. Where unwanted pregnancies occur, the authors advocate termination in appropriate health institutions where lethal and sometimes fatal complications are unlikely to occur. In effect, from the results of this study and a review of studies on abortion deaths in Nigeria and other developing countries, it is obvious that a revision of abortion laws as they operate, notably in the African continent, is overdue.

PIP: In a 13-year review of maternal deaths at the University of Benin Teaching Hospital, Benin City, abortion was one of the 3 major causes of death, accounting for 37 (22.4%) out of the 165 deaths. Induced abortion was responsible for 34 (91.9%) of these deaths. The usual victim is the teenage, inexperienced school girl who has no ready access to contraceptive practice. Death was mainly due to sepsis (including tetanus), hemorrhage and trauma to vital organs, complications directly attributable to faulty techniques by unskilled abortion providers, a by-product of the present restrictive abortion laws. Total overhaul of maternal child health services and the family health education system, are suggested. Contraceptive practice should be made available to all categories of women at risk, and the cost subsidized by governmental and institutional bodies. Where unwanted pregnancies occur, the authors advocate termination in appropriate health institutions where lethal and sometimes fatal complications are unlikely to occur. In effect, from the results of this study and a review of studies on abortion deaths in Nigeria and other developing countries, it is obvious that a revision of abortion laws as they operate, notably in the African continent, is overdue.

Maternal mortality at the University of Benin Teaching Hospital Benin City, Nigeria.

PIP: A study of 165 maternal deaths at the University of Benin Teaching Hospital, Benin City over a 13-year period (from April 1, 1973 to December 31, 1985) is presented. All patients' case files were recovered from the central records library and each case file was carefully analyzed. With a total delivery of 29,324, the maternal mortality rate, inclusive of death from abortion, was 563/100,000 deliveries. There was a general increase in maternal mortality rate with age and this became alarming from 35 years. There was an equally high mortality rate among teenagers, mainly accounted for by illegally induced abortion. Indeed, abortion accounted for 72% of teenage mortality. A statistically significant association between maternal deaths and parity (p, 0.001) was observed. The most important causes of death were hemorrhage with a total of 26 out of 42 deaths, sepsis, and abortion. Other important causes were hypertensive disorders such as eclampsia, liver and respiratory disease, anemia, trophoblastic diseases, caesarean sections, and acute renal failure. Additional causes of maternal deaths include tetanus, sickle-cell disease, anesthetic death, drug reactions, pulmonary embolism, acute pyogenic meningitis, typhoid disease, urinary bladder tumor, acute lymphoblastic leukemia, and carcinoma of the breast thyroid. Factors identified with these deaths included such health services factors as deficient medical treatment of obstetric complications, lack of adequate personnel at primary and secondary health care levels, lack of access to maternal health services, and consequently, lack of prenatal care. Extreme reproductive age, grandmultiparity, and unwanted pregnancies, especially among teenagers, also contributed to maternal deaths. Overhaul of the maternal health care services at national level to include organization of such programs as provision of adequate blood transfusion facilities, prompt treatment of infections, early referrals of patients at risk to secondary and tertiary health centers, intensified family planning programs, and liberalization of abortion laws are recommended in order to reduce the unacceptably high maternal mortality.^ieng

Preventable factors in abortion-related maternal mortality in Africa: focus on abortion deaths in Benin City, Nigeria.

In a 13-year review of maternal deaths of the University of Benin Teaching Hospital, Benin City, abortion was one of the 3 major causes of death, accounting for 37 (22.4) out of 165 deaths. Induced abortion was responsible for 34 (91.9%) of these deaths. The usual victim is the teenage and inexperienced school girl who has no ready access to contraceptive practice. Death was mainly due to sepsis, (including tetanus) hemorrhage, and trauma to vital organs, complication directly attributable to faulty techniques by unskilled abortion providers, by- product of the present restrictive abortion laws. Total overhaul of maternal child health services and family health education system, as well as integration of planned parenthood at primary health care level into the health care delivery system, are suggested. Contraceptive practice should be made available to all categories of women at risk and the cost subsidized by governmental and institutional bodies. Where unwanted pregnancies occur, the authors advocate termination in appropriate health institutions where lethal and sometimes fatal complications are unlikely to occur. In effect, from the results of this study and review of studies on abortion deaths in Nigeria and other developing countries, it is obvious that a revision of abortion laws as they operate, notable, in the African continent, is overdue.

Bone marrow status of anaemic pregnant women on supplemental iron and folic acid in a Nigerian community.

The bone marrow status of 31 consecutive pregnant women who had been on supplemental oral iron and folic acid since early pregnancy at the University of Benin Teaching Hospital was assessed later in pregnancy to test the efficacy of oral iron and folic acid in preventing iron deficiency and/or megaloblastic anaemia in our community. Only those pregnant patients with haemoglobin genotype AA or AS took part in the study. Nobody was excluded except those with CC or SC. 96.77% (30 out of 31 patients) had iron deficiency with no stainable iron in the bone marrow. 35.4% (11 out of 31 patients) had megaloblastic changes in the bone marrow. 32.2% (10 out of 31 patients) had a combined iron deficiency and megaloblastic anaemia while only one out of 31 patients (3.23%) had megaloblastic anaemia without concurrent iron deficiency. 60.4% (20 out of 31 patients) had iron deficiency alone without concomitant megaloblastic changes in marrow. The bone marrow in all the patients were normal in other respects except with regards to iron-deficiency and/or megaloblastic status. The significance of this high incidence of iron-deficiency and/or megaloblastic anaemia in patients already on routine pre-natal drugs is discussed.

The challenges of vaginal atresia and stenosis: Nigerian experience.

From July 1973 to December 1980, 6942 patients were admitted to the Gynaecology unit of the University of Benin Teaching Hospital, Benin City, Nigeria. Fifty-nine patients presented with gynatresia (vaginal atresia and stenosis), an incidence of 8.5 1000. The most common causes of this condition were caustic vaginitis, secondary to local herb pessary insertion, and circumcision. The resulting vaginal adhesions were effectively treated surgically by simple adhesiolysis . There was a low incidence of congenital gynatresia . As the large proportion of cases of acquired gynatresia were preventable, improvement in health education should further reduce incidence of this condition in our community.

Attitudes toward abortion and contraception among Nigerian secondary school girls.

A study of the attitudes of school girls in Benin City, Nigeria, toward abortion and contraception was carried out in three of the city's postprimary schools, using a uniform multiple-choice questionnaire. The findings show that although a significant proportion of the school girls had resorted to abortion to solve their problem of unwanted pregnancy, liberalized abortion law was only favored by a minority (approx. 30%). Also, although this indicated a high rate of sexual activity, their knowledge and practice of contraception and contraceptive methods is deficient and prejudiced. The latter findings may be responsible for the high rate of abortion among school girls in Nigeria.

PIP: This study investigated the attitudes toward abortion and contraception among 530 girls in 3 secondary schools in Benin City, Nigeria. 21.1% of the study population had 1st sexual intercourse before age 15 years and 55.1% before age 16. 160 respondents (30.2%) reported an illegally induced abortion, 81.2% of whom were ages 15-19 years and unmarried. Still in school was the reason for pregnancy termination cited by 106 (66.2%). 30% who reported an abortion (cases) and 27% of those who had never had an abortion (controls) indicated support for liberalized abortion law. 5% of cases and 15% of controls asserted that abortion was wrong under any circumstances, whereas the remaining 55% cases and 58% controls felt abortion was justified on medical grounds. 86% who had undergone abortion and 60% of controls were opposed to contraception because it is harmful to health and detrimental to future fertility. 3% of cases and 24% of controls supported contraceptive use. Among the study population as a whole, 44% had never used any form of contraception, 30% had used the condom, and 6% had used oral contraception. The high rate of sexual activity among Nigerian school girls is not matched by effective contraceptive practice. Sex education is recommended to overcome the deficient and inaccurate knowledge of contraception found in this population.

Pregnancy among schoolgirls in Nigeria.

A study was made of 127 cases of schoolgirls with pregnancy-related problems who were admitted into three of the major hospitals in Benin City, Nigeria, over a 10-month period. The findings suggest that schoolgirl pregnancy in Benin City is found chiefly among teenage girls during the early years of secondary school. Lack of experience in family life and knowledge about contraceptive methods, coupled with poor parental control, are the major factors that put the young adolescent at risk of unwanted pregnancy. School drop-out and complications of illegally induced abortion are the most frequent and worst consequences of schoolgirl pregnancies. The provision of formal education on family life and effective and easily accessible family planning methods for the adolescent population are suggested as a means to reduce the rate of schoolgirl pregnancy.

PIP: A study was made of 127 schoolgirls with pregnancy-related problems who were admitted into 3 of the major hospitals in Benin City, Nigeria over a 10-month period. The findings suggest that schoolgirl pregnancy in Benin City is found chiefly among teenage girls during their early years in secondary school. Lack of experience in family life and knowledge of contraceptive methods, coupled with poor parental control, are the major factors which place the young adolescent at risk for unwanted pregnancy. School dropout and complications of illegally induced abortion are the most frequent and worst consequences of schoolgirl pregnancy. The provision for formal education on family life and effective and easily accessible family planning methods for the adolescent population are suggested as a means to reduce the rate of schoolgirl pregnancy.

Adolescent induced abortion in Benin City, Nigeria.

Induced adolescent abortion is a major cause of maternal and gynecologic death in the University of Benin Teaching Hospital, where 244 out of 349 such cases seen from January 1, 1974 to December 31, 1979 were reviewed. Ignorance and lack of contraceptive facilities were contributory factors. To deal with this problem that has been pervasive throughout Nigeria for the past decade, the authors advocate sex education, systematic dissemination of information for planned and conscientious parenthood as well as free availability of alternative methods of contraception. Interruption of early pregnancy should be an essential component of a national family planning program.

PIP: Records of adolescent girls in Nigeria admitted to the gynecologic ward of the University of Benin Teaching Hospital from 1974-79 show that abortion accounted for 28% of gynecologic admissions in Nigeria. In a review of 244 cases, 60.8% of the patients were adolescent girls and 53.7% of them had septic abortions. 37.5% of the authors' patients already had 1-3 induced abortions or live births at the time of admission and yet had no knowledge of contraception. Only 16.8% were attended by physicians, 9.8% were self induced. The most common complications were hemorrhage, sepsis, cervical laceration, and hypovolemic shock. The main causes of severe morbidity and mortality were uterine and bowel perforation, peritonitis, and endotoxic shock. Several studies indicate that unsuccessful illegal induced abortion is one of the main causes of death among unmarried Nigerian girls of school age, who are ignorant of and lack access to contraception. 2.8% of illegal abortions in this series resulted in death compared to 11% in 1963-67 in Lagos. 62.5% of abortion-related deaths occurred in adolescent girls and 20% of all female adolescent deaths in the entire hospital. Morbidity and mortality associated with adolescent induced abortion are extraordinarily high in Nigeria compared with the U.K., Denmark, and Sweden. The Federal Government of Nigeria is urged to liberalize the abortion law and to provide basic sex education and family planning for adolescent boys and girls in order to discourage criminal abortion and its attendant complications.

Incidence of ectopic pregnancy in Benin City, Nigeria.

A study of 100 consecutive cases of ectopic pregnancy managed over a 21-month period in the University Department of Obstetrics and Gynaecology is reported. The results show that this is a common gynaecological emergency in the community. Although pelvic inflammatory disease appears to be an important aetiological factor, a significant proportion showed no evidence of previous pelvic sepsis. The usual surgical treatment of cases in our unit is, where possible, total salpingectomy rather than salpingo-oophorectomy.

PIP: A detailed prospective study of cases of ectopic pregnancy in Benin City was undertaken at the University of Benin Teaching Hospital (UBTH) establish the incidence and clinical pattern of presentation and to appraise the method of surgical management used. This study included the 1st 100 cases of ectopic pregnancy admitted between April 1978 and December 1979. The following details were analyzed in all cases: biological and social data such as age, reproductive status, and marital status; clinical presentation on admission; findings at laparotomy and type of surgical treatment; and morbidity and mortality. During the period under study, there were 4318 deliveries in the maternity unit (live births and stillbirths), giving an incidence of 1 ectopic pregnancy for every 43 births (2.31%). The corresponding figure obtained for the unit in an earlier study for the 1973-76 period was 1 in 58. 92 of the patients were married, 5 divorced, and 3 single. The series cut across the social strata of the Nigerian community, although most of the women were full time housewives who participated in petty trading to supplement the husband's income. 10% were pregnant for the 1st time, whereas 81% had had 1 or more previous deliveries, including abortion in some cases. Only 3% of the patients had had a previous ectopic pregnancy. The frequency of a positive past history of induced abortion among the cases of ectopic pregnancy was 22%. Among the patients of similar reproductive status who were admitted into the gynecological ward during the same period for other conditions, and who had never had ectopic pregnancy, the corresponding figure was 8.4%. Pain, often very severe, was the most prominent symptom presented by all 92 patients who were fit to give a history on admission. Vaginal bleeding of various types was present in 51% of cases. Symptoms of gastrointestinal disturbance occurred in 33%. The most reliable and common findings on physical examination were abdominal tenderness with or without "rebound tenderness" and "cervical excitation pain." Both signs were present in 92% of the patients. 63% of the patients showed gross evidence of previous pelvic inflammatory disease (PID) at laparotomy. Salpingectomy was the treatment of choice in 90% of the cases. Results of treatment appear satisfactory as there was no maternal death.

The outcome of pregnancies subsequent to induced and spontaneous abortion.

A study was made of 8982 women who were admitted for delivery over a four-year period to the University of Benin Teaching Hospital, Benin City, Nigeria. Of the 5682 women who had had more than one pregnancy, 14.5% admitted a history of one or more abortions (spontaneous or induced). Of the whole series, 8.8% admitted having had one or more induced abortions. Patients with prior abortions were compared with selected controls, and maternal characteristics were standardized between the two groups. Undesirable outcomes of subsequent pregnancy, such as low birth weight, premature delivery, stillbirth, neonatal death, miscarriage or congenital malformation, did not seem to increase in patients with histories of abortions.

Reproductive performance among patients with tubal ectopic pregnancy.

PIP: Researchers studied 68 cases of tubal ectopic pregnancy that occurred at the university hospital in Benin city, Nigeria from February 1973- January 1976. Medical records existed for only 53 cases. The ratio of ectopic pregnancy to deliveries stood at 1:58 (incidence: 1.7%). Excluding maternity cases, these 68 cases represented 6.5% of all gynecological and adult female admissions. 1 of 40 abdominal surgeries performed at this hospital was due to a tubal ectopic pregnancy. Therefore it represents a significant condition in Nigeria. 90% of the women were 40 years old. 68% of the cases already had between 2-5 children. Average parity stood at 2.6. Only 9.4% of the women were nulliparous. Spontaneous abortions occurred in 26.48% of the women. Further, the investigators observed that the lower the parity the higher the incidence of spontaneous abortion. For example, the abortion rate for women with no children and those with 1 stood at 100% and 73.9% respectively while for women with 5 and 5 children it stood at 11.76% and 10.8% respectively. 58% of the cases had experienced a previous pelvic infection. Since there was an association between a high abortion rate and tubal ectopic pregnancy, the researchers also pointed out a possible common etiological factor causing both spontaneous abortions and tubal ectopic pregnancies. therefore a woman who may be likely to experience an early spontaneous abortion may be just as likely to have a tubal ectopic pregnancy and vice versa. Health practitioners should consider any pregnant woman who has had a tubal pregnancy to be at risk of a spontaneous abortion or early labor.^ieng