Female genital mutilation (FGM) management during pregnancy, childbirth and the postpartum period.

Female genital mutilation (FGM) is a traditional practice with serious health consequences to women that is still practiced in 28 countries with approximately 2 million girls exposed to the practice annually. The complications of FGM cause suffering to the woman all her life. Pregnancy, childbirth and the postpartum period are particularly important as there is increased risk of mortality and morbidity from FGM complications. Although the overall strategy should be to eliminate the practice completely, the healthcare providers and policy makers in the meantime should not only be aware but also well trained in the management of FGM complications to decrease the risk of mortality and serious morbidity.

Factors associated with high risk of perinatal and neonatal mortality: an interim report on a prospective community-based study in rural Sudan.

In a community-based prospective study, 6275 deliveries resulting in 6084 livebirths, 150 stillbirths (SB) and 167 neonatal deaths (NND) were monitored over a period of 3 years. The risk of an unfavourable outcome (SB or NND) in multiple pregnancies was more than ninefold that of singletons. Teenage mothers and those over 34 years of age ran nearly twice the risk of having an unfavourable outcome of pregnancy compared with mothers aged 20-29 years. First pregnancy and grand-multiparity (greater than eight previous pregnancies) carried a similar risk of an unfavourable outcome compared with mothers with 1-4 previous pregnancies. The most serious risk factor was the adverse outcome of the previous pregnancy. Compared with mothers whose last outcome had resulted in a livebirth surviving at least 30 days, mothers with a previous SB had seven times the risk (adjusted for age and parity) of SB and more than twice the risk of NND in the current pregnancy. Maternal illiteracy was associated with significantly higher risk of NND, and this rate decreased with increasing years of education. Frequency of antenatal visits had a marginally significant effect on the SB rate. Socioeconomic factors, diet and iron supplementation during pregnancy did not seem to affect the outcome.

PIP: Between March 1985 and April 1988 in a rural community in Sudan, a prospective study was conducted to determine the factors linked to perinatal and neonatal mortality. There were 6275 pregnancies and 6150 singleton births, 124 pairs of twins, and 1 set of triplets. The multiple pregnancy rate was 19.9/1000 deliveries. Pregnancy outcomes included 6084 live births surviving more than 30 days, 150 fetal deaths, 124 early neonatal deaths, and 43 late neonatal deaths. When the researcher controlled for age and parity, multiple pregnancies carried a higher risk of still birth, perinatal mortality, and neonatal mortality than did singleton pregnancies (relative risk [RR] = 6.1, 8.9, and 12.3, respectively; p 0.0001). Poor pregnancy outcome was 1.8 times more likely for teenage mothers than for 20-29 year old mothers (p 0.0003). First pregnancy and grandmultiparity ( 8 previous pregnancies) were associated with a higher risk of perinatal mortality when compared to mothers of parity 1-4 (RR = 1.9 [p 0.001] and 1.8 [p 0.01], respectively). A poor outcome of last pregnancy was the most important risk factor for neonatal death of current pregnancy (X2 = 55 when adjusted for multiple pregnancies and 36.5 when adjusted for age, parity, and multiple pregnancies; p 0.0001). The risk was highest when the last pregnancy outcome was stillbirth (RR = 6.9; p 0.001). Mothers with a previous stillbirth faced a 2.4-fold increased risk of neonatal death for the current pregnancy (p 0.001). Perinatal mortality rates fell as the number of years of full-time maternal education increased (p = 0.02 for the trend). Education mainly had an effect on reducing neonatal deaths (X2 for trend = 5.3 [p 0.05] vs. 1.8 for perinatal deaths and 1.1 for stillbirths). The frequency of prenatal visits had only a limited significant effect of reducing stillbirths (p = 0.05) and no effect of reducing perinatal and neonatal deaths. Household income, diet, and iron supplementation during pregnancy did not affect pregnancy outcome.

The role of the village midwife in detection of high risk pregnancies and newborns.

The preliminary findings of a prospective study of perinatal, neonatal and maternal mortality carried out in a rural community of Sudan are reported. Out of 6275 deliveries monitored over a period of 3 years, 150 stillbirths, 167 neonatal deaths and 27 maternal deaths were observed. An intervention program to upgrade the skills of the village midwives started in the middle of the second year. There was a 25% reduction in the risk of unfavorable outcome of pregnancy (i.e. stillbirth and neonatal death) in the third year relative to the first 2 years. Peer review of the 40 village midwives who took part in the study revealed their tremendous potentials in mobilization of mothers as well as participation in primary health care. Their role in detection of high risk pregnancies and newborns cannot be overemphasized.

Infertility in Africa.

PIP: Infertility is of particular concern in Africa because of the extent of the problem and the social stigma attached to it. The highest prevalence of infertility in Africa occurs south of the Sahara, but 5-8% of couples are estimated to experience infertility at some point in their reproductive lives (50-80 million people worldwide). The average infertility in Africa is 10.1% of couples, with a high of 32% in some countries, and certain tribes have high infertility rates. While primary infertility is higher in other regions of the world, secondary infertility is more common in Africa, and secondary infertility rates are very complicated to determine. The World Health Organization Task Force on the Diagnosis and Treatment of Infertility instituted a standardized approach to studies of infertility which was adopted in 33 countries. Between 1978 and 1982, a pilot study of this approach examined 8504 couples and found that less than 50% of male and female infertile partners were primarily infertile, and 66% did achieve a pregnancy within the union. The cause of infertility was not determined for 35% of the women and 50% of the infertile men in the sample. Infertility was accounted for by endocrine factors (usually menstrual or ovulatory disturbances) in 35% of infertile cases and tubal factors (such as unilateral or bilateral tubal occlusion, pelvic adhesion, and other abnormalities) in 32%. About 66% of African women experienced tubal factors compared to about 33% worldwide. About 9% of women reported a history of sexually transmitted disease (STD), and 8% reported abortion complications. 46% of men in sub-Saharan Africa reported a history of STDs. About 24% of women with primary infertility and 40% of women with secondary infertility had no previous history of pelvic inflammatory disease or STDs and had tubal disease. African infections are common due to inadequate health services, improper use of antibiotics, and penicillin-resistant strains of gonorrhea. Public health programs should be implemented to prevent infection-related infertility.^ieng

Population policy in the Sudan.

PIP: Preliminary results from Sudan's 1983 census point to an annual national population growth rate of 2.8%. Population size was expected to increase from 20.6 million in 1983, to 25 million by 1987. Such ongoing, rapid increase stymies national socioeconomic development, and is accordingly not in the best interest of developing countries. Only recently, however, has the government seriously worked to adopt a policy to control national population growth. Inadequate demographic data, lack of awareness of the problem, poor understanding of development goals, and the influence of pronatalist political leaders formerly combined to delay policy development. The 3rd National Population Conference in Khartoum, October, 1988, however, marked the occasion of the Prime Minister to announce steps for a 4-year government plan integrating policy for the control of rapid population growth. Sudan's population policy will aim to redistribute population through the settling of nomads, and retaining or attracting population to rural areas. The National Population Committee has been coordinating key issues with public and private sectors since the 1988 Conference. Demographic factors, population problems, evolution of population policy, goals, strategy, policy content, policy implementation, and overall conclusions are presented and discussed in detail in the text.^ieng

Maternal and child health and family planning services in the Sudan.

PIP: Given the high rates of infant and maternal mortalty, the prevalence of infectious diseases, poor nutritional status among women and children, and numerous endemic diseases such as malaria and bilharzia, maternal-child health serivces have been given a high priority in the Sudan. In reality, however, this area has not received adequate attention within the primary health care system in terms of management, service provision, and training. Major obstacles to effective maternal-child health services include: 1) the lack of involvement of community health workers, the main providers of other primary health care services in the Sudan, in the area; 2) the clinical orientation of physicians, which mitigates against attention to the promotive and preventive components of health care; 3) a lack of standardization of medical records or data collection routines, which hinders program monitoring; and 4) the failure to integrate related national programs such as immunization into a comprehensive maternal-child health program. In addition, there are administrative and organizational obstacles, such as the lack of institutionalization of maternal-child health services within the Ministry of Health, inadequate managerial capabilities, an absence of guidelines for service delivery at the regional and provincial levels, delays in the procurement of equipment and supplies, a widely dispersed population, and transportation difficulties. Family planning, too, is supposed to be the responsibility of all primary health care workers in the Sudan. However, current training programs for physicians, nurses, village midwives, and community health workers do not prepare them to fulfill this role. Development of an official population policy in the Sudan is recommended to ameliorate some of these problems.^ieng

A crossover pill study among Sudanese women.

A crossover study from a standard-dose to a low-dose oral contraceptive was conducted in the Sudan. Reported side effects were very few, with a headache the most frequently reported. Switching to the other pill did not affect the rate of any side effects.

Etiologic factors in pelvic inflammatory disease in Sudanese women.

Pelvic inflammatory disease constitutes a major gynecologic problem in the Sudan as in most African countries. This article reviews studies of three important causes of PID involving Sudanese women. Women who attended the gynecologic clinic of Khartoum Hospital with a complaint of vaginal discharge were tested for gonococcal infection to evaluate this potential etiology; only 1.4% of these women had gonorrhea. Since septic abortions also result in PID, we studied 2,447 women admitted to Khartoum hospitals in 1976; only 0.4% of these women had had septic abortions. Female circumcision, which is widely practiced in the Sudan, is the subject of an ongoing epidemiologic study. The clinical impression is that this harmful tradition is an important cause of PID among Sudanese women.

Hospital counseling in Khartoum: a study of factors affecting contraceptive acceptance after abortion.

This study examines the impact of contraceptive counseling on 3 263 women hospitalized in Khartoum for treatment of incomplete abortion. The analysis which focused on education and parity/child desire, revealed that the counseling program produced contraceptive acceptance among 47.0% of those followed up. In spite of the counseling efforts, half of the women in this study did not accept contraception following the abortion-regardless of education or parity/child desire. It is difficult to determine why 50% of those who had recently undergone an incomplete abortion were willing to put themselves at risk again. Apparently, future efforts to increase the impact of counseling programs must also examine patients' motivation to accept (or not to accept) contraception.

Contraceptive practice after women have undergone "spontaneous" abortion in Indonesia and Sudan.

Studies of hospitalized "spontaneous" abortion patients in two Muslim countries (Indonesia and Sudan) revealed the need for contraception in this group of married women and indicated the potential role of maternity hospitals in providing them with contraceptive counseling. It could not be determined which of the abortions were induced outside the hospital and which were truly spontaneous. Of the 893 women treated at the Djakarta Hospital, 15.3% used contraceptives during the month of conception of the index abortion, compared to 10.0% of the 2 759 patients in Khartoum. After hospitalization for completion of the abortion, the rates of contraceptive use increased by more than one third in both cities. The highest rates of increase in contraceptive use after abortion were noted among poorly educated women, women with large families, and women with abortions diagnosed as septic. Among the nonseptic patients at all hospitals, those experiencing complications associated with the abortion reported a slightly higher rate of postabortion contraceptive use. In hospitals where contraceptive counseling was provided, there was a proportional increase in postabortion use of contraceptives by the study population.