Building a national framework for multicentre research and clinical trials: experience from the Nigeria Implementation Science Alliance.

There is limited capacity and infrastructure in sub-Saharan Africa to conduct clinical trials for the identification of efficient and effective new prevention, diagnostic and treatment modalities to address the disproportionate burden of disease. This paper reports on the process to establish locally driven infrastructure for multicentre research and trials in Nigeria known as the Nigeria Implementation Science Alliance Model Innovation and Research Centres (NISA-MIRCs). We used a participatory approach to establish a research network of 21 high-volume health facilities selected from all 6 geopolitical zones in Nigeria capable of conducting clinical trials, implementation research using effectiveness-implementation hybrid designs and health system research. The NISA-MIRCs have a cumulative potential to recruit 60 000 women living with HIV and an age-matched cohort of HIV-uninfected women. We conducted a needs assessment, convened several stakeholder outreaches and engagement sessions, and established a governance structure. Additionally, we selected and trained a core research team, developed criteria for site selection, assessed site readiness for research and obtained ethical approval from a single national institutional review board. We used the Exploration, Preparation, Implementation, Sustainment framework to guide our reporting of the process in the development of this network. The NISA-MIRCs will provide a nationally representative infrastructure to initiate new studies, support collaborative research, inform policy decisions and thereby fill a significant research infrastructure gap in Africa's most populous country.

"It might be a statistic to me, but every death matters.": An assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries.

BACKGROUND: Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016-2017, the US Agency for International Development's Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. METHODS: A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0-30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 ('evidence of MPDSR practice'). RESULTS: The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75-27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. CONCLUSION: This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.

"I think this is the only challenge the stigma" Stakeholder perceptions about barriers to Antenatal care (ANC) and Prevention of mother-to-child transmission (PMTCT) uptake in Kano state, Nigeria.

BACKGROUND: Despite the progress made so far in reducing mother-to-child transmission (MTCT), Nigeria still contributes significantly to the global burden of new pediatric HIV infections. The elimination target for MTCT has not been reached and the decline in new infections among all Global Plan countries from 2009 to 2015 was lowest in Nigeria. This qualitative study explores the barriers to uptake of prevention of mother-to-child transmission (PMTCT) intervention in Kano, the second most populous state in Nigeria. METHODS: Key informant interviews (KIIs) were conducted among twelve stakeholders who were purposively selected based on their knowledge and involvement in PMTCT program activities in the state. The KII guide explored the status and challenges of PMTCT uptake in Kano state. Qualitative data analysis was managed using NVIVO 11 software and themes were analyzed using thematic analysis. RESULTS: We found that the key barriers to uptake of PMTCT identified by stakeholders cut across the domains of the socio-ecological model. These include-fear of stigma associated with being seen accessing HIV related services, low male partner involvement, socio-cultural beliefs about the dangers of hospital-based delivery, poor attitude of health workers, distance/cost to facilities, issues with availability of HIV test kits and poor organization of health services. CONCLUSION: The implementation of effective PMTCT programs would require innovative strategies that leverage improvement of Antenatal care (ANC) uptake as an entry point for PMTCT. In addition, sustaining engagement in care requires creating a supportive stigma-free environment in the community as well as spousal support to ensure women can navigate the socio-cultural barriers that limit access to health services.

Cesarean Section and Maternal-fetal Mortality Rates in Nigeria: An Ecological Lens into the Last Decade.

BACKGROUND OR OBJECTIVES: Despite the global decline in maternal mortality within the last decade, women continue to die excessively from pregnancy-related complicationsin developing countries. We assessed the trends in maternal mortality, fetal mortality and cesarean section (C-Section) rates within 25 selected Nigerian hospitals over the last decade. METHODS: Basic obstetric data on all deliveries were routinely collected by midwives using the maternity record book developed for the project in all the participating hospitals. Trends of C-Section Rates (CSR), Maternal Mortality Rates (MMR), Fetal Mortality Rates (FMR) and Spontaneous Vaginal Delivery rates (SVD) were calculated using joinpoint regression models. RESULTS: The annual average percent change in CSR was 12.2%, which was statistically significant, indicating a rise in CSR over the decade of the study. There was a noticeable fall in MMR from a zenith of about 1,868 per 100,000 at baseline down to 1,315/100,000 by the end of the study period, representing a relative drop in MMR of about 30%. An average annual drop of 3.8% in FMR and 1.5% drop in SVD over time were noted over the course of the study period. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: We observed an overall CSR of 10.4% and a significant rise in CSR over the 9-year period (2008-2016) of about 108% across hospital facilities in Nigeria. Despite the decrease in MMR, it was still high compared to the global average of 546 maternal deaths per 100 000 livebirths. The FMR was also high compared with the global average. The MMR found in this study clearly indicates that Nigeria is far behind in making progress toward achieving the Sustainable Development Goal 3 (SGD 3) which aims to reduce the global MMR to less than 70 per 100 000 live births by 2030.

Intraoperative insertion of intrauterine contraceptive device at cesarean section: A survey on the experiences of trainee and practicing obstetricians

Background: Intrauterine contraceptive device (IUCD) placement during cesarean section has been shown to be a safe and effective method of contraception with very low complication and disuse following insertion. Its practice can be of immense benefit, especially in developing countries like Nigeria where high unmet needs for contraception and increasing cesarean section rates are prevalent. Objective: The objective of this study is to evaluate the practice of obstetricians and trainees on counseling and insertion of IUCD during cesarean section. Materials and Methods: A questionnaire­based cross­sectional study was conducted among obstetricians and trainees at the 49th Annual Scientific Conference of the Society of Gynecology and Obstetrics of Nigeria held in November 2015. The data were analyzed using the SPSS version 20. Results: Of 150 respondents, 134 returned completed questionnaires, giving a response rate of 89.3%, 130 of these were adjudged to be correctly filled and were analyzed. Majority of the respondents, 97 (74.6%), were consultants. The mean age of the respondents was 42.01 years ± 7.00. About 95% (125) of the respondents admitted performing cesarean sections, but only 13 (10%) had ever inserted IUCD during cesarean operations. Counseling for the procedure was also low, as only 35 (26.9%) of the respondents had ever counseled the clients toward IUCD placement at cesarean section. Conclusion: For counseling and practice of insertion of IUCD at cesarean section is very low among Nigerian obstetricians, revealing a major barrier to clients' access to this effective and safe method of contraception. Advocacy, education, and training of this category of health­care providers are necessary for improved contraceptive access to cesarean section clients

The Benefits of a Guideline on Safe Termination of Pregnancy for Legal Indications: An Illustrative Case Report of a Hydranencephaly.

After years of the worsening burden of unsafe abortion and attendant morbidities and mortalities in Nigeria, a National Guideline on the Safe termination of pregnancy for legal indications was enunciated. This report presents and discusses an illustrative case of a hydranencephaly that benefited from it. A 43-year old multipara was informed during routine ultrasonography at booking for antenatal care, at 16 weeks of gestation, of a major defect in her baby and advised to meet her physician. Following a repeat high- resolution ultrasonography and discussions between the Obstetricians, Neurosurgeon, and Ultrasonologist, the woman was counseled on the diagnosis. At her insistence and provision of written consent, medical abortion with Mifepristone and Misoprostol was successfully instituted.

Women's experience with group prenatal care in a rural community in northern Nigeria.

OBJECTIVE: To assess women's experience of group prenatal care in a rural Nigerian community. METHODS: In an observational study, consenting pregnant women were enrolled in a group prenatal care program based on the CenteringPregnancy model from July 1, 2010, to June 30, 2011, in Tsibiri, Nigeria. Women were interviewed before joining the group and postnatally. A predesigned pro forma was used to assess group behavior during sessions. Descriptive and inferential statistics were applied to data. RESULTS: In total, 161 women enrolled, and 54 of 72 scheduled prenatal sessions took place. The average number of visits was three per woman, with good group interaction and cohesion. Mothers who could mention at least five out of eight danger signs of pregnancy increased from 1.4% (2) to 13.3% (14) (P<0.001, 95% CI 4.28-19.52), while mean knowledge score for danger signs increased from 31% to 47.8% (P<0.001, 95% CI 0.86-2.16). Commitment to birth preparedness plans was impressive. The mothers enjoyed the group sessions and shared the lessons they learned with others. CONCLUSION: Group prenatal care was feasible and acceptable to women in the present study setting. Comparative trials would be helpful to demonstrate the benefits of the tested model in low-income settings.

The effects of centering pregnancy on maternal and fetal outcomes in northern Nigeria; a prospective cohort analysis.

BACKGROUND: Maternal and infant mortality remains high in Nigeria primarily due to low use of skilled birth attendants. Huge disparities exist between southern and northen Nigeria on use of skilled birth attendants with south significantly higher than the north. We assessed the effect of centering pregnancy group (CPG) antenatal care on the uptake of antenatal care (ANC), facility delivery and immunization rates for infants in Kano state. METHODS: Between December 2012 and May 2014, pregnant women with similar sociodemographics and obstetric history were enrolled into intervention (CPG) and control groups and followed up prospectively. Chi-square tests were conducted to compare the differences between the intervention and the control groups with respect to background characteristics and intervention outcomes. Logistic regression was used to measure the associations between CPG and uptake of services for mother-baby pairs in care. RESULTS: A total of 517 (260 in the control group and 257 in the CPG) pregnant women enrolled and participated in the study. Thirty-six percent of women in the control group attended ANC at least once in 2nd and 3nd trimester compared to 49% of respondents in the CPG (p < 0.01). Health facility delivery was higher among CPG (13% vs. 8%; p < 0.01). When controlled for age, number of previous pregnancies, number of term deliveries, number of children alive and occupation of respondent or their spouses, respondents who participated in the CPGs compared to those who did not, were more likely to attend at least one antenatal care (ANC) session in the third trimester [adjusted risk ratio (ARR):1.52; 95% CI:1.36-1.69], more likely to immunize their babies at six weeks [ARR: 2.23; 95% CI: 1.16-4.29] and fourteen weeks [ARR: 3.46; 95% CI: 1.19-10.01] and more likely to use health services [ARR: 1.50; 95% CI: 1.06-2.13]. CONCLUSION: Centering or group pregnancy showed a positive effect on the use of antenatal services, facility delivery and postnatal services and thus is a promising intervention to increase uptake of maternal health care services in northern Nigeria. The low facility delivery remains a cause for alarm and requires further investigation to improve facility delivery in northern Nigeria.

Experiences of 6 years quality assurance in obstetrics in Nigeria - a critical review of results and obstacles.

OBJECTIVE: The objective of this study was to monitor the maternal mortality ratio (MMR) in 19 general hospitals after introducing quality assurance in four states in Nigeria. METHODS: Data collection with a structured maternity record book started in 2008 in ten rural hospitals in Kano and Kaduna State. In 2011, five hospitals from Federal Capital Territory Abuja were added, whilst in 2013 four hospitals were added from Ondo State. The routine data collection was conducted by experienced midwives and supervised by obstetricians from each of the states. However, the data from all four states were collated centrally at Aminu Kano Teaching Hospital for analysis. RESULTS: From 2008 to 2013, 121,808 deliveries were evaluated; MMR fell from 1380 to 360/100,000 in Kaduna State, whilst for Kano State there was a gradual reduction of MMR from 2100/100,000 in 2008 to 1070/100,000 in 2011, and then it increased to 2150/100,000 in 2013. Ondo state had the lowest MMR of 180/100,000 in 2013 followed by Abuja with 240/100,000. The median cesarean section rate was 8.19%, (range 0.97-22.53%), eclampsia/preeclampsia was 4.43% (range 0-56.55%), and postpartum hemorrhage was 3.36% (range 0.81-11.4%). CONCLUSIONS: Quality assurance in rural hospitals generates the awareness necessary to improve maternal health and lead to reduction of MMR.

Community-level distribution of misoprostol to prevent postpartum hemorrhage at home births in northern Nigeria.

In Nigeria, most deaths due to postpartum hemorrhage (PPH) occur in the absence of skilled birth attendants. A study using community mobilization and the training of community drug keepers to increase access to misoprostol for PPH prevention was conducted in five communities around Zaria in Kaduna State, Nigeria. Community-oriented resource persons (CORPs) and traditional birth attendants (TBAs) recruited and counseled pregnant women on bleeding after delivery, the importance of delivery at a health facility, and the role of misoprostol. Drug keepers stored and dispensed misoprostol during a woman's third trimester of pregnancy. TBAs and CORPs enrolled 1,875 women from January through December 2009. These results are based on 1,577 completed postpartum interviews. Almost all women delivered at home (95%) and skilled attendance at delivery was low (7%). The availability of misoprostol protected 83% of women who delivered at home against PPH who otherwise would not have been protected. Policymakers working in similar contexts should consider utilizing commuity-level distribution models to reach women with this life-saving intervention.

Acceptability and feasibility of medical abortion with mifepristone and misoprostol in Nigeria.

OBJECTIVE: To examine the acceptability and feasibility of medical abortion in Nigeria. METHODS: In total, 250 women who were eligible for legal pregnancy termination with a gestational age of up to 63 days since last menstrual period were enrolled in Benin City and Zaria between May 2005 and October 2006. Participants received 200 mg of oral mifepristone in the clinic and then took 400 µg of oral misoprostol 2 days later-choosing to either return to the clinic or take it at home. Women returned 2 weeks later for an assessment of abortion status. RESULTS: The vast majority (96.3%) of women had successful complete abortions. Ultrasound was used to determine outcome in less than one-third (28.9%) of participants. Most women (83.2%) took the misoprostol at home. Almost all (96.2%) participants were satisfied or very satisfied with the abortion method. CONCLUSION: The introduction of medical abortion with mifepristone and misoprostol could greatly expand current method options and improve the quality of reproductive health care in Nigeria and other settings in which access to legal abortion services is limited.

Community-based intervention is necessary for the control of HIV in North-Central Nigeria.

OBJECTIVES: To determine factors associated with the observed high prevalence of HIV in North-Central Nigeria. METHODS: In a cross-sectional multisite study conducted in 2007, behavioral, medical, and demographic data were obtained from pregnant women (N = 1011) who were tested for the presence of antibody against HIV-1 and HIV-2. RESULTS: The overall prevalence of HIV-1 in the 1011 women included in the study was 10.3% (95% confidence interval (CI) 8.4-12.2). In the multivariate analysis, HIV-1 seropositivity was significantly associated with women from the Makurdi (odds ratio (OR) 31.3, 95% CI 3.8-255.7) and Minna (OR 15.4, 95% CI 1.7-135.1) sites in comparison with Panyam site. The presence of tuberculosis (OR 10.7, 95% CI 2.4-48.3) was also significantly associated with HIV-1 seropositive status. Factors associated with HIV-1 also differed between sites. The presence of antibody against HIV-2 was not observed. CONCLUSIONS: The high HIV-1 prevalence observed in this study corroborates previous observations in North-Central Nigeria. Disparity in the prevalence across communities was also seen. This is the only detailed socio-epidemiological and behavioral study that has explored potential factors associated with HIV-1 in North-Central Nigeria, and it revealed that differences in risk factors explain the disparity in prevalence across communities.

Community mobilization to reduce postpartum hemorrhage in home births in northern Nigeria.

The purpose of this study is to demonstrate the importance of community mobilization in the uptake of a health intervention, namely, community-based distribution of misoprostol to prevent postpartum hemorrhage. Community mobilization to increase access to misoprostol for postpartum hemorrhage prevention was implemented in northwestern Nigeria in 2009. Theories of community participation and the current near-epidemic maternal mortality conditions underpin an approach using modest levels of community involvement. The study was undertaken in five communities around Zaria, Nigeria. Community leaders and selected community members participated in a series of dialogs. Additionally, community education, information and dramas sessions were held. Twenty nine community oriented resource persons (CORPs), 27 drug keepers and 41 traditional birth attendants (TBAs) were involved in the intervention. Postpartum interviews were used to assess the impact of community mobilization efforts and to track use of misoprostol. Multiple logistic regression was used to examine the association between correct use and receiving information regarding misoprostol from TBAs or CORPs. A total of 1875 women were enrolled in the study in 2009. Most women delivered at home (95%) and skilled attendance at delivery was low (7%). Community mobilization efforts reached most women with information about postpartum hemorrhage and misoprostol (88%), resulting in high comprehension of intervention messages. Women identified TBAs and CORPs as the single most important source of information about misoprostol 41% and 31% of the time, respectively. Availability of misoprostol at the community level gave 79% of enrolled women some protection against postpartum hemorrhage which they otherwise would not have had. Although high level community participation in health care interventions is the ideal, this study suggests that even in circumstances where only modest levels of participation can realistically be achieved, community mobilization can have a significant impact on the successful distribution and uptake of a potentially life-saving health intervention, in turn helping promote policy change.

Drug resistance pattern of HIV type 1 isolates sampled in 2007 from therapy-naive pregnant women in North-Central Nigeria.

In Nigeria, the country with the second largest number of HIV-1-infected people globally, antiretroviral therapy rollout is now widespread with an increasing number of individuals and communities benefitting. However, the drug resistance profile of patients initiating or failing on antiretroviral therapy is not well characterized. Here we studied the molecular variability of the protease and reverse transcriptase region of isolates from therapy-naive pregnant women in North-Central Nigeria (one of the geopolitical zones with the highest prevalence of HIV in Nigeria) to identify baseline mutations with potential drug resistance implications. We observed the predominance of CRF02_AG and subtype G in the North-Central Nigerian epidemic and the presence of both primary and secondary drug resistance mutations. Contrary to observation from other geopolitical zones, a decreased frequency of reverse transcriptase mutations/polymorphisms was observed, thus suggesting regional differences in level of transmitted drug resistance that require more study.

Obstetric quality assurance to reduce maternal and fetal mortality in Kano and Kaduna State hospitals in Nigeria.

OBJECTIVE: To achieve Millennium Development Goals 4 and 5 in Nigeria, a quality assurance project in obstetrics in 10 hospitals in northern Nigeria was established to improve maternal and fetal outcome. METHODS: The project commenced in January 2008 with assessment and improvement of the structure of the 10 hospitals. Continuous maternal and fetal data collection and analysis were conducted from 2008 to 2009 by means of a maternity record book and structured monthly summary form. The quality of hospital infrastructure and equipment was also assessed. RESULTS: The mean maternal mortality ratio (MMR) was reduced from 1790 per 100000 births in the first half of 2008 to 940 per 100000 births in the second half of 2009. The average fetal mortality ratio (FMR) decreased slightly from 84.9 to 83.5 per 1000 births. There was an inversely proportional relationship between the total number of deliveries in a hospital and MMR and FMR. There was a close correlation between the MMR and the equipment status and hygiene conditions of the hospitals. CONCLUSION: Continuous monitoring of quality assurance in maternity units raised the awareness of the quality of obstetric performance and improved the quality of care provided, thereby improving MMR.

Genetic characteristics, coreceptor usage potential and evolution of Nigerian HIV-1 subtype G and CRF02_AG isolates.

HIV-1 CRF02_AG and subtype G (HIV-1G) account for most HIV infections in Nigeria, but their evolutionary trends have not been well documented. To better elucidate the dynamics of the epidemic in Nigeria we characterised the gag and env genes of North-Central Nigerian HIV-1 isolates from pregnant women. Of 28 samples sequenced in both genes, the predominant clades were CRF02_AG (39%) and HIV-1G (32%). Higher predicted proportion of CXCR4-tropic (X4) HIV-1G isolates was noted compared to CRF02_AG (p = 0.007, Fisher's exact test). Phylogenetic and Bayesian analysis conducted on our sequences and all the dated available Nigerian sequences on the Los Alamos data base showed that CRF02_AG and HIV-1G entered into Nigeria through multiple entries, with presence of HIV-1G dating back to early 1980s. This study underlines the genetic complexity of the HIV-1 epidemic in Nigeria, possible subtype-specific differences in co-receptor usage, and the evolutionary trends of the predominant HIV-1 strains in Nigeria, which may have implications for the design of biomedical interventions and better understanding of the epidemic.

Cisplatin chemotherapy for haemostasis in bleeding cervical cancer: experience from a resource-poor setting.

BACKGROUND: Cervical cancer is the commonest cancer in northern Nigeria. There are only two radiotherapy centers in the north and four centres in the south, each with only one megavoltage machine for a population of over 140 million. The number of patients requiring radiotherapy for various malignancies is beyond the available facilities and expertise leading to long waiting time and disease progression with its attendant sequelae. This is the basis of using other orthodox treatment modalities as first line. PATIENTS AND METHODS: Between January 2006 and December 2007, 116 patients with histologically confirmed cervical cancer with vaginal bleeding as the predominant symptom were treated. Patients presenting with torrential haemorrhage were excluded from this study as they constitute oncologic emergencies. Patients were interviewed with a structured pro forma on a 3-weekly basis during chemotherapy schedules to assess and evaluate per vaginal bleeding and discharge. Dose of chemotherapy was 70 mg/m² every 3 weeks. Results were analysed using Epi Info soft ware Version 3.4.1; 2007 Edition. RESULTS: The median age was 49 years (27-80 yrs). 62 patients were having per vagina bleeding for more than 6 months before commencement of chemotherapy (range 1-60 months). 49 patients had blood transfusion before chemotherapy, average of 2.7 pints of blood transfused per patient. 84 had at least FIGO stage IIIA disease. Squamous cell carcinoma is the commonest histology type followed by adenocarcinoma with 95 and 16 patients respectively. 81 patients had complete cessation of per vagina bleeding with 69 having complete cessation on or before 4th course of chemotherapy (9th week) and complete cessation of per vagina discharges was seen in 52 patients. 115 patients had a performance status KPS of below 80 prior to chemotherapy, and after completing 6 cycles, 100 patients had KPS of 80 and above. CONCLUSION: In resource-poor setting, Cisplatin based chemotherapy can be used by medical, gynaecological oncologists and general practitioners to control vaginal bleeding and improve the quality of life of patients pending radiotherapy. For optimal treatment with chemoradiotherapy, government and non-governmental agencies must do all it takes to remedy the problems of shortage of resources.

Suffering in silence: pregnant women's experience of urinary incontinence in Zaria, Nigeria.

OBJECTIVE: To determine the prevalence and severity of urinary incontinence during pregnancy in Zaria, Nigeria. STUDY DESIGN: This was a descriptive, cross-sectional study in which 204 apparently healthy pregnant women attending routine antenatal care (ANC) at the Ahmadu Bello University (ABU) Teaching Hospital in Zaria, Nigeria were screened for urinary incontinence using the International Consultation on Incontinence Questionnaire on Urinary Incontinence (ICIQ-UI Short Form) UK English Version. Nurses working in the antenatal clinic were trained on how to help respondents (most of whom were not literate) to respond to the questions. Uni- and bivariate analysis was performed on the data using SPSS version 15 for Windows. RESULTS: The prevalence rate of all types of urinary incontinence during pregnancy was 21.1% in the study population. Stress urinary incontinence was the most common type accounting for 60.5%. The majority of the expectant mothers (74.4%) reported leaking no more than once a week; in 90% of them the volume was small in amount. The modal ICIQ score for urinary incontinence was 3 for the study population. The majority (83.4%) of the incontinent women felt their symptom did not interfere with their daily routines. CONCLUSIONS: About one-fifth of pregnant women in this setting experienced urinary incontinence which they did not report to their primary care providers. Awareness needs to be created for antenatal clients and providers on how to recognize symptoms and manage them. The ICIQ questionnaire has simplified this process.

Weight changes in clients on hormonal contraceptives in Zaria, Nigeria.

Misconceptions exist in Nigeria about the effects of hormonal contraceptives on weight, which may have negative effects on contraceptive use. Data from case notes of clients attending the reproductive health centre at the Ahmadu Bello University Teaching Hospital, Zaria, between 1993 and 1995, were analysed to determine the effects of hormonal contraceptives on body weight, comparing them to clients using intrauterine contraceptive devices. Weight changes were not significantly different in clients using hormonal contraceptives and those using intrauterine contraceptive devices. This information will be beneficial in contraceptive counselling for clients in this environment and provide a baseline for further research.