Antenatal cardiotocography: experience in a Nigerian tertiary hospital.

OBJECTIVES: To compare selected perinatal characteristics between infants of mothers with reactive and non-reactive antenatal cardiotocography (non-stress test) results. PATIENTS AND METHODS: The medical records of all women who delivered within one week of a non-stress test were retrieved. The indication, test result, gestational age at delivery, Apgar score at 5 minutes, perinatal complications and neonatal ward admission were documented. RESULTS: One hundred and twelve women met study criteria among whom 51 tests were reactive and 61 were non-reactive. Post-datism, intra-uterine growth restriction, hypertensive disorders of pregnancy, and premature rupture of membranes were the commonest indications for the test. Post-datism was more commonly associated with a non-reactive test result. Women with non-reactive tests were almost twice as likely to be delivered by emergency Caesarean section, compared with women with reactive tests; although the test result did not significantly influence the mode of delivery. A non-reactive test was significantly associated with a higher perinatal mortality (p = 0.04). Although the reactive test was associated with a three-fold reduction in the incidence of low Apgar scores compared with the non-reactive test, this difference was not statistically significant (p = 0.18). A non-reactive test was significantly associated with small for gestational age infants (p = 0.01). CONCLUSIONS: Non-reactive non-stress test may be associated with higher perinatal mortality. When appropriately utilised, the test is a valuable tool for early detection of foetal compromise. Antenatal cardiotocography has a place in obstetric practice in low-resource settings for improving perinatal care.

Evaluation of criteria-based clinical audit in improving quality of obstetric care in a developing country hospital.

Study evaluated criteria-based clinical audit in measuring and improving quality of obstetric care for five life-threatening obstetric complications: obstetric haemorrhage, eclampsia, genital tract infections, obstructed labor and uterine rupture. Clinical management of 65 patients was audited using a 'before (Phase I) and after (Phase II)' audit cycle design using standard criteria. Following Phase I, areas in need of improvement were identified; mechanisms for improving quality of care were identified and implemented. Overall care of the complications improved significantly in obstetric haemorrhage (61 to 81%, p = 0.000), eclampsia (54.3 to 90%, p = 0.00), obstructed labour (81.7 to 93.5%, p < 0.001) and genital tract sepsis (66 to 85.2%, p < 0.01). Clinical monitoring, drug use, and urgent attention by senior medial staff also improved significantly after intervention. Criteria-based clinical audit is feasible and acceptable for improving management of life-threatening obstetric complications. Its application is recommended in health institutions in developing countries.

Evaluation of criteria-based clinical audit in improving quality of obstetric care in a developing country hospital

Study evaluated criteria­based clinical audit in measuring and improving quality of obstetric care for five life-threatening obstetric complications: obstetric haemorrhage, eclampsia, genital tract infections, obstructed labor and uterine rupture. Clinical management of 65 patients was audited using a 'before (Phase I) and after (Phase II)' audit cycle design using standard criteria. Following Phase I, areas in need of improvement were identified; mechanisms for improving quality of care were identified and implemented. Overall care of the complications improved significantly in obstetric haemorrhage (61 to 81%, p = 0.000), eclampsia (54.3 to 90%, p=0.00), obstructed labour (81.7 to 93.5%, p<0.001) and genital tract sepsis (66 to 85.2%, p < 0.01). Clinical monitoring, drug use, and urgent attention by senior medial staff also improved significantly after intervention. Criteria-based clinical audit is feasible and acceptable for improving management of life-threatening obstetric complications. Its application is recommended in health institutions in developing countries (Afr J Reprod Health 2008; 12[3]:59-70)

A criteria-based audit of the management of severe pre-eclampsia in Kampala, Uganda.

OBJECTIVE: To improve the quality of clinical care for women with severe pre-eclampsia. METHODS: A criteria-based audit was conducted in a large government hospital in Uganda. Management practices were evaluated against standards developed by an expert panel by retrospectively evaluating 43 case files. Results of the audit were presented, and recommendations developed and implemented. A re-audit was conducted 6 months later. RESULTS: The initial audit showed that most standards were rarely achieved. Reasons were discussed. Guidelines were produced, additional supplies were purchased following a fundraising effort, labor ward procedures were streamlined, and staffing was increased. In the re-audit there were significant improvements in diagnosis, monitoring, and treatment. CONCLUSION: Criteria-based audit can improve the quality of maternity care in countries with limited resources.

Experience with intravaginal misoprostol in the management of intra-uterine fetal death.

This collaborative study between the departments of Obstetrics and Gynaecology of the University College Hospital, Ibadan and Federal Medical Centre, Abeokuta assessed the value of intravaginal misoprostol in the management of intra-uterine fetal death. Fifty-six women at gestational ages between 17 weeks and term admitted for intra-uterine death with no contraindications to misoprostol received 400mcg of misoprostol administered intravaginally 12-hourly, until the establishment of effective uterine contractions. The mean gestational age was 27.9 weeks+/-7.1(SD) and the mean Bishop score was 2.7+/-2.4(SD). The mean duration of onset of contractions was 5.0 hours+/-8.4 (SD); the mean induction-delivery interval was 17.5 hours+/-6.3(SD). Ninety three percent of the women had expelled within 48 hours. Successful induction was achieved in all women. Prophylactic vacuum aspiration was performed (lower gestation only) in 19.6% of cases. Fever, nausea and vomiting were the commonest side effects (7.1%). Neither gestational age nor the cervical score significantly affected the insertion-contraction or induction-delivery intervals. Intra-vaginal Misoprostol at the dosage administered is safe, effective and reduces staff workload.

Introducing criteria based audit into Ugandan maternity units.

PROBLEM: Maternal mortality in Uganda has remained unchanged at 500/100 000 over the past 10 years despite concerted efforts to improve the standard of maternity care. It is especially difficult to improve standards in rural areas, where there is little money for improvements. Furthermore, staff may be isolated, poorly paid, disempowered, lacking in morale, and have few skills to bring about change. DESIGN: Training programme to introduce criteria based audit into rural Uganda. SETTING: Makerere University Medical School, Mulago Hospital (large government teaching hospital in Kampala), and Mpigi District (rural area with 10 small health centres around a district hospital). STRATEGIES FOR CHANGE: Didactic teaching about criteria based audit followed by practical work in own units, with ongoing support and follow up workshops. EFFECTS OF CHANGE: Improvements were seen in many standards of care. Staff showed universal enthusiasm for the training; many staff produced simple, cost-free improvements in their standard of care. LESSONS LEARNT: Teaching of criteria based audit to those providing health care in developing countries can produce low cost improvements in the standards of care. Because the method is simple and can be used to provide improvements even without new funding, it has the potential to produce sustainable and cost effective changes in the standard of health care. Follow up is needed to prevent a waning of enthusiasm with time.

Vaginal bleeding patterns in Nigerian users of nomegestrol acetate subdermal contraceptive implant.

A 12 months longitudinal study was carried out in 214 consecutive Nigerian women using Nomegestrol acetate subdermal contraceptive implant (Uniplant) for the first time to establish the rates of different vaginal bleeding patterns according to WHO bleeding/spotting classification, and to assess their relationship with Uniplant discontinuation. The results showed an initial rise in the number of women experiencing altered vaginal bleeding which continued to fall towards the 12th month of use (57.01% vs 26.17%). Similarly, a significant increase in mean menstrual cycle length occurred in the first trimester of use and this disappeared by the third trimester. The mean numbers of bleeding/spotting days and bleeding/spotting free intervals increased significantly from first trimester to the fourth trimester. No change was noted in the mean number of bleeding/spotting episodes through, out the follow up period. The total discontinuation rate was 15.42%. Discontinuation on account of altered vaginal bleeding pattern was 3.27%. One accidental pregnancy occurred during follow up (Pearl index = 0.52). No significant change in haemoglobin levels was noted in the women. It was concluded that changes in menstrual patterns in Uniplant users occur mostly in the first six months of use and are unlikely to have any deleterious effects on the general health of the users.

Evaluation of the Nigerian population policy--myth or reality?

The National Population Policy (NPP) was promulgated to improve the living standards and quality of life of Nigerians by reducing the persistently high level of fertility and population growth, and achieving an even rural-urban development. The aim of this study was to review Nigeria's demographic patterns in the last decade against the 1995 and AD 2000 benchmarks stipulated in the NPP. The results revealed that the total fertility rate fell significantly to 6.2 in the earlier half of the decade but is still far from the targeted figure of 4.0. The infant mortality rate had risen in the past five years, and although the crude death rate declined by 21.49% in 1995, it has remained stagnant since then. There has been no appreciable decline in the rate of natural increase which was expected to fall by 31.03% in AD 2000. The current contraceptive prevalence rate of 11.0% is a far cry from the targeted 80% set in the population policy. In general, the situation that influenced the decision to promulgate the NPP in 1988 has not improved much: the national decline in fertility is not appreciable neither is the increase in welfare significant. The key issues in the reproductive health sectors include the limited availability and poor quality of services, which lead to high maternal and infant mortality rates, inadequate adolescent outreach, and limited use of contraceptives. This evaluation of the policy's targets and objectives in the light of the 1995 and AD 2000 benchmarks reveals that the NPP has failed due to an underestimation of the huge financial resources required for implementation, lack of political will, poor and uncoordinated organisation, 'gender-divide' and the prolonged political instability in the country.

Factors determining the choice of contraceptive methods at the Family Planning Clinic, University College Hospital, Ibadan, Nigeria.

In a study of 2000 women volunteers seeking contraceptive services at the Family Planning Clinic (FPC), University College Hospital, Ibadan, Nigeria, 66.2 per cent chose the intrauterine device (IUD) making it the most common method of contraception. Factors influencing choice of contraceptive methods were advice from friends and family members, intended duration of use and information from the media. Ignorance, fear and unfounded cultural beliefs were factors responsible for the delay in seeking contraceptive advice. The mass media was an important source of information for most of the women. We conclude that the IUD is the contraceptive of choice in our clinic because of the highly selective nature of our clients. In order to provide a service with a broader clientele, we suggest the incorporation of other priority reproductive health services such as cervical and breast cancer screening, prevention and treatment of reproductive tract infections and sexually transmitted diseases including HIV/AIDS.

PIP: Studies conducted in Nigeria consistently find that, while oral contraceptives (OCs) are the most popular fertility control method on a national level, the IUD is the method most frequently selected by women who obtain contraception from a family planning center. The possibility that this phenomenon reflects family planning provider bias in favor of the IUD was investigated in a survey of 2000 women seeking contraceptive services at the Family Planning Clinic of University College Hospital in Ibadan, Nigeria, in 1986-90. The mean age of acceptors was 31.5 years; mean parity was 4.4. 63.2% of these women sought contraception to delay or postpone pregnancy. Clients were offered a choice of the standard range of barrier and hormonal methods as well as sterilization. The four most frequently selected methods were IUDs (66.2%), OCs (10.4%), injectables (7.9%), and sterilization (5.8%). IUDs were a popular choice among women who had not obtained their husbands' support for attending the center. Only 9.1% of IUD acceptors did so on the advice of family planning center staff. Information from the mass media (television and radio) and friends were most influential. Although this finding would seem to refute the hypothesis that the preponderance of IUD users at family planning centers reflects provider bias, an indirect association may be operating. Most material on contraception in the mass media is provided by family planning workers and many family planning center clients who are satisfied IUD users refer their friends to the clinic.

Performances of copper T 380A and multiload copper 375/250 intrauterine contraceptive devices in a comparative clinical trial.

An evaluation of the performances of copper T 380A (TCU 380A) and multiload copper 375/250 (MLCU 375/250) intrauterine contraceptive devices (IUCDS) was carried out at University College Hospital, Ibadan, Nigeria (UCH) in a clinical comparative trial. The IUCDS showed similar low vent rates at one year of continuous use. The difference in cumulative net probabilities for termination due to pelvic inflammatory disease was weakly significant at the sixth month of follow up with MLCU 250 having the highest rate. (TCU 380A-0%; MLCU 375-0%; MLCU 250-3.1%; X2 = 6.0; P < 0.05). This significant difference disappeared by the twelfth month of continuous use. Likewise, the difference in cumulative net probabilities for overall termination was significant at six months and insignificant at twelve months of follow up. The continuation rate after one year were 86%, 92% and 87% respectively for TCU 380A, MLCU 375 and MLCU 250. These rates were higher than 80% and 51% quoted for the previously available Lippes loop in the same environment [1,2]. It was therefore concluded that the three IUCDS are comparable in performances in the first year of use and could be used at our family planning clinic or any other clinic in a similar setting.

PIP: Between April 1988 and June 1991, health workers in Nigeria followed 300 women aged 20-40 who had had a copper releasing IUD inserted during menstruation at the family planning clinic of the University College Hospital in Ibadan. The double blind clinical trial compared the effectiveness and side effects of three copper releasing IUDs: Copper T380A, Multiload 375, and Multiload 250. 75.7% had used no contraception before admission to the study. Pelvic inflammatory disease (PID) occurred more often in the MLCU 250 group than the other two groups. Only two women were hospitalized for PID. These two women used the TCU 380A or MLCU 250. Many IUD users experienced abdominal pain during menstruation and TCU 380A users had the highest rate (27% vs. 21-24%). Heavy bleeding during menstruation was more common in TCU 380A and MLCU 375 users (5% and 4%, respectively, vs. 2%). Pelvic pain/cramps were present in 1-3% of women, but did not contribute to removal. The only case of uterine perforation was in a user of the TCU 380A. None of the MLCU 375 users experienced IUD expulsion, while two TCU 380A users experienced total expulsion and two and one MLCU 250 users experienced total and partial expulsion, respectively. PID was related to IUD removal at 6 months (3.1% vs. 0; p 0.05). The pregnancy rate at 6 months was 1.1% for the TCU 380A group and 0 for the other groups. At 12 months, it was 1.1% for the TCU 380A group and the MLCU 375 group and 0 for MLCU 250. The net 6-month IUD cumulative termination rate was highest in the TCU 380A group (11.1% vs. 3-7%; p 0.05). These differences were no longer significant at 12 months. The net 6- and 12-month IUD continuation rate was 97% and 92% for MLCU 375 compared to 88.9% for TCU 380A and 93% for MLCU 250 and 85.8% for TCU 380A and 87% for MLCU 250, respectively. These findings suggest that these three IUD devices could be used in the hospital's family planning clinic.

Comparative study on the efficacy, acceptability, and side effects of a contraceptive pill administered by the oral and the vaginal route: an international multicenter clinical trial.

The objective of this multicenter randomized clinical trial was to compare the efficacy, acceptability, and occurrence of side effects associated with the oral versus vaginal route of administration of contraceptive pills. Eight hundred nineteen healthy, parous women of reproductive age were recruited at family planning clinics and research centers, members of the South to South Cooperation in Reproductive Health, in seven countries of the developing world. These women were randomly assigned to use either oral or vaginal administration of the same contraceptive pill, which contained 250 micrograms levonorgestrel and 50 micrograms ethinyl estradiol. No statistically significant differences were found in discontinuation rates between the two groups after 1 year. Involuntary pregnancy rates after 1 year were not statistically significantly different between the two groups. The vaginal route of administration appears to be as acceptable and efficacious as the oral route.

PIP: The objective of this multicenter randomized clinical trail was to compare the efficacy, acceptability, and occurrence of side effects associated with the oral versus vaginal route of administration of contraceptive pills. This study started in June, 1987, and data collection extended up to April, 1992, at family planning clinics and research centers, members of the South to South Cooperation in Reproductive Health, in seven countries of the developing world. The 819 subjects were from 17 to 39 years of age, had already had at least one pregnancy, had had regular menstrual cycles for 3 months before, were exposed to the risk of pregnancy, and were not using any other method of contraception. 424 were randomly assigned to use the pills orally (which contained 250 mcg levonorgestrel and 50 mcg ethinyl estradiol), whereas 395 inserted the pills vaginally. 625 subjects completed at least 6 months of use, 326 used the pills orally and 299 used the pills vaginally. 385 subjects completed 1 year of pills use, 201 in the oral group and 184 in the vaginal group. The 1-year discontinuation rate per 100 subjects per year for the oral group was 34.71 +or- 2.42, while it was 36.35 +or- 2.53 for the vaginal group. This difference was not statistically significant. The only single reason of statistically significant difference for discontinuation was "desire for pregnancy" (p = 0.444). Paired value analysis of subjects completing 12 months of study showed that women in the oral group had a statistically significant increase in weight, from a mean of 55.8 kg at admission to a mean of 56.9 kg at 6 months (p 0.05) and 57.3 kg at 1 year (p = 0.05). The mean weight of the vaginal group increased from 56.52 kg to 57.22 kg (p = 0.036) at 12 months. Significantly more complaints of vaginal discharge were recorded in women using the pills by the vaginal route (p = 0.001). However, only one subject discontinued the pills because of vaginal discharge.

Norplant use by women with sickle cell disease.

OBJECTIVE: To assess the safety of Norplant contraceptive implant use by women with mild-moderate homozygous sickle cell disease (HbSS). METHOD: Prospective observation of women pre- and post-insertion of Norplant, with each woman serving as her own control. PARTICIPANTS: 25 women 18-40 years of age who attended a hospital sickle cell clinic; post-insertion data were available for 23 women. OUTCOME MEASURES: Changes in hematologic parameters including PCV, MCV, reticulocytes, ISCs, HbF and bilirubin; changes in biochemical parameters including HDL cholesterol, aspartate transaminase, alkaline phosphate, serum creatinine and serum albumin. RESULT: With a mean follow-up of 12.4 months (range 1-29 months), there were no clinically or statistically significant group or individual changes in the hematologic or biochemical parameters after Norplant insertion. CONCLUSION: Norplant appears to be a safe and appropriate contraceptive for women with mild-moderate HbSS disease.

Insecticide poisoning in pregnancy. A case report.

A 25-year-old multigravida drank an organochlorine insecticide in an attempt to commit suicide at 16 weeks of pregnancy. This resulted in the death of twin fetuses and vaginal bleeding. The pregnancy was terminated using gemeprost, syntocinon and later surgical evacuation of the uterus. She developed respiratory arrest after the fetuses were aborted and also after surgical evacuation. On both occasions, she was intubated and mechanically ventilated. We believe that organochlorine insecticides may be fetocidal. In addition, surges in blood levels may occur during termination of pregnancy, delivery or evacuation of retained products of conception.

Carbohydrate metabolism before and after Norplant removal.

Changes in carbohydrate metabolism, measured by oral glucose tolerance test, were studied in Norplant users before and after removal. The mean area under the glucose curve rose from 24.7 min mmol/L before Norplant insertion to 35.1 min mmol/L before removal and decreased to 26.1 min mmol/L four weeks after Norplant removal. The areas before insertion and after removal were not statistically different (95% confidence interval -3.3 to 0.56, P = 0.16). The mean areas under the insulin curves before insertion (53.14 min uU/L) and after removal (59.46 min uU/L), however, were significantly different (95% confidence interval -7.64 to -5.0, P less than 0.0001). We conclude that changes in carbohydrate metabolism induced by Norplant are reversible once the implants are removed. While the changes in glucose induced by Norplant returned to pre-insertion levels within 4 weeks after removal, insulin changes were slower to return to pre-insertion values.

PIP: Physicians at the University College Hospital in Ibadan, Nigeria recruited 24 26-39 year old women who had use Norplant for 18-30 months between January 1986-July 1988 into a study to determine changes in carbohydrate metabolism before and after removal of Norplant. None of the women had diabetes mellitus. The women underwent a glucose tolerance test (GTT) before insertion, just before removal, and 30 days after removal. The mean area under the GTT curve increased from 24.7 min mmol/L before insertion to 35.1 min mmol/L before removal and decreased to 26.1 min mmol/L 30 days after removal (p.0001). Yet there was no statistical difference between the mean areas under the GTT curve before insertion and those after removal. Thus glucose levels returned to preinsertion levels shortly after removal. There were significant differences in the mean areas under the insulin curves between before insertion and after removal, however (5314 min uU/L vs. 59.46 min uU/L; p.0001). Thus insulin levels 30 days after removal did not return to preinsertion levels as rapidly as did glucose levels. These results suggest that carbohydrate metabolic changes may be significant in women with diabetes mellitus. Therefore physicians should monitor blood glucose levels in diabetics. The changes in carbohydrate metabolism caused by Norplant return to almost normal when it is removed.

The effect of continuous subdermal levonorgestrel (Norplant) on carbohydrate metabolism.

Blood glucose and plasma insulin levels during an oral glucose tolerance test were measured in 20 women using continuous subdermal levonorgestrel (Norplant) for contraception over a 12-month period. Changes in carbohydrate metabolism occurred as early as 1 month but were most marked after 6 months. After 1 month the area under the glucose and insulin curves increased by 12.3% and 37.7%, respectively. This increase was more marked by 6 months, but by 12 months it was significantly less marked. Although changes in the blood glucose and plasma insulin levels at different times during the oral glucose tolerance test occurred, they were all within normal limits for normal women. The peak blood glucose and insulin levels after insertion of the implant occurred 60 minutes after the glucose load, as opposed to 30 minutes before insertion. Apart from this, there was a significant delay in the return of these levels to fasting values. We conclude that this product, like any other progesterone-containing contraceptive, alters carbohydrate metabolism, but these alterations are not clinically significant in normal women. It is, however, possible that in potential cases of diabetes it may predispose to frank diabetes.

Changes in carbohydrate metabolism during 30 months on Norplant.

During a 30-month period, changes in carbohydrate metabolism (measured by oral glucose tolerance test) were studied in 20 Norplant acceptors. Changes were first observed one month after Norplant insertion and peaked between 12-18 months. The area under the glucose curve rose by 12.3% and 40.5% one and 12 months post insertion, respectively. At 18, 24 and 30 months the rise was, respectively, 41.9%, 40% and 38.6%. Although the changes under the insulin curves were similar, the increase at one month was doubled (25.7%). Only fasting insulin values showed very slight and insignificant changes during the 30-month period. All the changes were, however, within the normal limits for healthy women. We conclude that although Norplant induces changes in carbohydrate metabolism, these changes remain within normal limits, peak at 12 months and either remain the same or decrease with time.

The prevalence of Gardnerella vaginalis, Trichomonas vaginalis and Candida albicans in the cytology clinic at Ibadan, Nigeria.

In a study of 2224 adult women from the cytology clinic of the University College Hospital, Ibadan, Nigeria, the prevalence of 'specific vaginal infection' (i.e. Gardnerella vaginalis, Trichomonas vaginalis and Candida albicans) was 14.5%. For individual organisms, the rates were 9.76% for G. vaginalis, 2.52% for T. vaginalis and 2.20% for C. albicans. About half of the patients were asymptomatic while others were referred from other clinics with vaginal discharge, cervical erosion, post-coital bleeding, intermenstrual bleeding and various other symptoms and signs. The infections were almost uniformly distributed in all age groups studied. Increasing promiscuity either as a result of increased mobility of husbands (due to economic depression) or increased use of contraception by older women was thought to be responsible for the persistence of these infections in those aged 45 years and above. In addition, Gardnerella vaginalis, Trichomonas vaginalis and Candida albicans infections can also be easily diagnosed from cervical cytology, by identification either of the organism or of characteristic cytological cellular changes.

PIP: Between October 1, 1986-April 30, 1989, laboratory staff at the University College Hospital in Ibadan, Nigeria tested the cervical smears of 2224 women (20 years old). 50.3% of the women underwent a smear for routine reasons and 49.7% did due to indications such as cervical erosion, cervicitis, vaginal discharge, postcoital bleeding, and intermenstrual bleeding. 14.5% of the smears revealed specific vaginal infections. Overall prevalence for Gardnerella vaginalis was 9.76%, 2.52% for Trichomonas vaginalis, and 2.2% for Candida albicans. The staff detected G. vaginalis in 63.4% of the 322 women who had a vaginal infection. 17.4% had syphilis and 15.2% candidiasis. 30.44 year old women comprised the largest group of women (46.8%) with these sexually transmitted diseases (STDs). Yet there was a sizable percentage of women 45 years old with an STD (22.1%), especially the uneducated women. This could be due to the economic necessity of husbands leaving wives to find work and who consequently have several sexual partners. It may also be a result of increased contraceptive use among older women which fosters multiple sexual relationships. 43.13% of women with a vaginal infection had a discharge. 24.51% of all women who presented with vaginal discharge tested positive for G. vaginalis while only 8.86% of the asymptomatic controls did. All women with abnormal smears other than those with cervical intraepithelial neoplasia were treated with oral metronidazole and vaginal clotrimazole. Only 8.9% of the women still had abnormal smears after 3 months. In conclusion, the researchers believed that cervical cytology, both identification of the organism or of characteristics cellular changes, can easily diagnose these 3 STDs.

Cervical cancer screening at Ibadan.

Over a period of 44 months, 3171 smears were performed at the University College Hospital (UCH). Ibadan, Cytology Clinic. Of these, 44.2% were in asymptomatic women. Fifty-five point three percent were normal; 15.6% of the smears were reported as non-specific inflammatory changes while 20.1% were due to specific infections. Varying degrees of cervical intra-epithelial neoplasia (CIN) were diagnosed in 8.4% of the smears. The abdominal smears were treated with chemotherapy, cryocautery, diathermy, cone biopsy and hysterectomy. A simplified management plan for a patient with an abnormal smear based on our experience is also presented.

Family planning in traditional markets in Nigeria.

Operations research on the Ibadan Market-Based Distribution Project in Nigeria investigated the feasibility of a contraceptive distribution system using traders in the traditional markets to sell pills, condoms, and foaming tablets. Two hundred and thirty-five female and male traders were trained and supplied with contraceptives, malaria treatments, and oral rehydration salts to sell at low prices in 39 markets. This article presents findings from qualitative and quantitative research conducted in 1985-89 to determine if the sale of contraceptives in the marketplace is acceptable to participating traders and shoppers and to identify trader and market characteristics associated with sales volume. Sales of contraceptives totaled 18,286 pill cycles, 11,818 packages of four condoms, and 4,429 packages of four foaming tablets. The average monthly sale for each participating trader was 5.3 units. Adaptations of this model are being tested in other Nigerian cities and in Accra, Ghana.

A comparative study of three oral contraceptives in Ibadan: Norinyl 1/35, Lo-Ovral and Noriday 1/50.

A study of three combined oral contraceptives, Norinyl 1/35, Lo-Ovral and Noriday 1/50, was conducted at the University of Ibadan Teaching Hospital, Ibadan, Nigeria, to determine if there were differences in continuation rates and reasons for discontinuation. This report includes analysis of 150 women, all of whom were interval patients, randomly allocated to one of the above oral contraceptives between May 1984 and February 1985. Follow-up visits were scheduled at 1, 4 and 8 months after admission. Significantly more women in the Norinyl 1/35 group (P less than 0.05) reported intermenstrual bleeding, as well as an increase in the occurrence of intermenstrual bleeding compared to women in the Lo-Ovral group. There were no other differences between the groups for side-effects. The continuation rates at 8 months were 90.8% for the Norinyl 1/35 group, 94.4% for the Lo-Ovral group and 87.1% for the Noriday 1/50 group. The corresponding rates for those lost to follow-up were 26.0, 40.8 and 17.7. The rate for total discontinuations (all discontinuations including women lost to follow-up) was 34.0% for the Norinyl 1/35 group, 44.9% for the Lo-Ovral group and 29.4% for the Noriday 1/50 group. There was a significant difference in lost to follow-up rates between the Lo-Ovral group and the Noriday 1/50 group (P less than 0.05). There were no other significant differences between the groups for life table rates (P greater than 0.05). There were no pregnancies reported during the study period.