Barriers and facilitators to hepatitis B birth dose vaccination: Perspectives from healthcare providers and pregnant women accessing antenatal care in Nigeria.

Nigeria is estimated to have the largest number of children worldwide, living with chronic hepatitis B virus (HBV) infection, the leading cause of liver cancer. Up to 90% of children infected at birth develop chronic HBV infection. A birth dose of the hepatitis B vaccine (HepB-BD) followed by at least two additional vaccine doses is recommended for prevention. This study assessed barriers and facilitators of HepB-BD administration and uptake, using structured interviews with healthcare providers and pregnant women in Adamawa and Enugu States, Nigeria. The Consolidated Framework for Implementation Sciences Research (CFIR) guided data collection and analysis. We interviewed 87 key informants (40 healthcare providers and 47 pregnant women) and created a codebook for data analysis. Codes were developed by reviewing the literature and reading a subsample of queries line-by-line. The overarching themes identified as barriers among healthcare providers were: the lack of hepatitis B knowledge, limited availability of HepB-BD to vaccination days only, misconceptions about HepB-BD vaccination, challenges in health facility staffing capacity, costs associated with vaccine transportation, and concerns related to vaccine wastage. Facilitators of timely HepB-BD vaccination included: vaccine availability, storage, and hospital births occurring during immunization days. Overarching themes identified as barriers among pregnant women were lack of hepatitis B knowledge, limited understanding of HepB-BD importance, and limited access to vaccines for births occurring outside of a health facility. Facilitators were high vaccine acceptance and willingness for their infants to receive HepB-BD if recommended by providers. Findings indicate the need for enhanced HepB-BD vaccination training for HCWs, educating pregnant women on HBV and the importance of timely HepB-BD, updating policies to enable HepB-BD administration within 24 hours of birth, expanding HepB-BD availability in public and private hospital maternity wards for all facility births, and outreach activities to reach home births.

An appraisal of the implementation of the national school feeding programme and its effect on enrolment and attendance in public primary schools in Southeast, Nigeria: perception of heads of schools.

INTRODUCTION: The National Home Grown School Feeding Programme (NHGSFP) was re-launched in Nigeria in 2016, eleven years after it was first introduced in the country, with Enugu as one of the beneficiary States. The objectives of the programme are to improve the health of school children and aid in the realization of Universal Basic Education (UBE) goals. This study explored the opinions of heads of public primary schools on the implementation and policy benefits of NHGSFP in Enugu, southeast Nigeria. METHODS: This was a cross-sectional study conducted among 24 headmasters and headmistresses purposively selected from public primary schools in the Enugu metropolis. Qualitative data were collected through the use of a pretested Key Informant Interview (KII) guide, and analyzed using a thematic approach. RESULTS: All the participants were aware of the NHGSFP, which involved the provision of one mid-day meal per child per school day to the pupils, and all their schools were part of the programme. Most of the participants complained about the nutritional quality and quantity of the school meals which they felt were poor. None of the schools had a kitchen within the school premises, and all the participants admitted that deworming was not regularly carried out, as part of the programme. Most of the participants believed that the objectives of the feeding programme, including, reduced hunger among learners, increased school enrolment, attendance and enhanced participatory learning, were being met. CONCLUSION: Although the NHGSFP was implemented in every school in Enugu metropolis, Enugu State, Nigeria, regular deworming of pupils was not carried out, and there were concerns about certain aspects of the implementation, such as inadequate funding and poor quality of school meals. Thus, there is a need for the introduction of deworming and more allocation of funds to the programme to improve the quantity and nutritional quality of school meals.

Physician emigration from Nigeria and the associated factors: the implications to safeguarding the Nigeria health system.

BACKGROUND: Adequate Human Resources for Health is indispensable to achieving Universal Health Coverage and physicians play a leading role. Nigeria with low physician-population ratio, is experiencing massive exodus of physicians. This study investigated emigration intention of physicians, the factors influencing it and discussed the implications to guide policy formulation and reforms, curtail the trend and safeguard the country's health system. METHODS: Through cross-sectional survey, 913 physicians from 37 States were interviewed with semi-structured questionnaire using Google form shared via WhatsApp and Telegram forums of Nigeria Medical Association. Data were analysed with IBM-SPSS version-25 and charts were created with Microsoft-Excel. Chi-square and multiple regression tests were done with p-value set at 0.05. RESULTS: The mean age of respondents is 37.6 ± 7.9 years; majority of them are males (63.2%), married (75.5%) with postgraduate qualifications (54.1%) and working in public health facilities (85.4%). Whereas 13% and 19.3% are, respectively, satisfied with their work and willing to continue practice in Nigeria, 43.9% want to emigrate and 36.8% are undecided about future location of their practice. The commonest reasons for emigration are poor remuneration (91.3%), rising insecurity (79.8%) and inadequate diagnostic facilities (61.8%). Physicians working in public health facilities are 2.5 times less satisfied than their counterparts in non-public sector (AOR = 0.4; 95% CI = 0.3-0.8). Physicians in their thirties, forties and fifties are 3.5 (95% CI = 1.5-8.0), 5.5 (95% CI = 2.1-14.5) and 13.8 (95% CI = 3.9-49.3) times, respectively, more willing to retain practice in Nigeria than those younger and those satisfied with their work are 4.7 (AOR = 4.7, 95% CI = 2.9-7.4) times more willing to practice in Nigeria than those not satisfied. CONCLUSION: Majority of Nigerian physicians want to emigrate for professional practice and top among the push factors are poor remuneration, rising insecurity and inadequate diagnostic facilities. The observed trend portends danger to the country's health system due to the foreseeable negative consequences of physician deficit to the system. We recommend upward review of physician remuneration, a root cause analysis of insecurity to determine workable preventive measures and increased funding of the health sector to improve the diagnostic infrastructure, retain physicians and save the health system from imminent collapse.

Nanovesicle Formulation Enhances Anti-inflammatory Property and Safe Use of Piroxicam.

BACKGROUND: Enhanced utilization of certain drugs may be possible through the development of alternative delivery forms. It has been observed that NSAIDs have adverse gastrointestinal tract effects such as irritation and ulceration during anti-inflammatory therapy. This challenge may be overcome through nano topical formulations. OBJECTIVE: This study aimed to explore the potentials of a transdermal nanovesicular formulation for safe and enhanced delivery of piroxicam (PRX), a poorly water-soluble NSAID. METHODS: Preformulation studies were conducted using DSC and FTIR. Ethosomal nanovesicular carrier (ENVC) was prepared by thin-film deposition technique using Phospholipon® 90 H (P90H) and ethanol and then converted into gel form. The formulation was characterized using a commercial PRX gel as control. Permeation studies were conducted using rat skin and Franz diffusion cell. Samples were assayed spectrophotometrically, and the obtained data was analyzed by ANOVA using GraphPad Prism software. RESULTS: The preformulation studies showed compatibility between PRX and P90H. Spherical vesicles of mean size 343.1 ± 5.9 nm, and polydispersity index 0.510 were produced, which remained stable for over 2 years. The optimized formulation (PE30) exhibited pseudoplastic flow, indicating good consistency. The rate of permeation increased with time in the following order: PE30 > Commercial, with significant difference (p< 0.05). It also showed higher inhibition of inflammation (71.92 ± 9.67%) than the reference (64.12 ± 7.92%). CONCLUSION: ENVC gel of PRX was formulated. It showed potentials for enhanced transdermal delivery and anti-inflammatory activity relative to the reference. This may be further developed as a safe alternative to the oral form.

A Comparison of the Characteristics of Maternal Near-Misses and Maternal Deaths in Enugu, Southeast Nigeria: A 3-Year Prospective Study.

BACKGROUND: Maternal near-misses, also known as severe acute maternal morbidity, have become globally recognized as an appropriate indicator of obstetric care. Women experiencing maternal near-misses are more in number than maternal deaths, and can provide more specific and detailed evidence, as the patient herself can be a leading source of useful information. OBJECTIVE: To determine the frequency of maternal near-misses and maternal deaths in the University of Nigeria Teaching Hospital in Ituku-Ozalla, Enugu, document the primary determinant factor that caused these, and compare cases of maternal near-miss and maternal deaths. METHODS: This was a 3-year prospective study of all women admitted for delivery or within 42 days of delivery or termination of pregnancy at the hospital. Data were collected prospectively in consecutive patients in a pro forma manner and entered into SPSS version 17 for Windows. RESULTS: There was a total of 2,236 deliveries, of which 88 had severe maternal outcomes. Of the latter, 60 were maternal near-misses, while 28 suffered maternal death. The maternal near-miss:mortality ratio was found to be 2.14. The maternal mortality ratio here was 1,252 per 100,000. All the 88 women that had severe maternal outcomes lived at least 5 km from the hospital. The leading organ-system dysfunction in this study was cardiovascular, manifesting as shock and cardiac arrest, and respiratory, manifesting as gasping and cyanosis. Leading complications were severe hemorrhage, anemia, and hypertensive disorders. The pattern of complications was similar in both near-misses and maternal deaths, but cases of hypertensive disorders and exploratory laparotomy as an intervention for those with organ dysfunction were noted to be higher in near-miss cases, and differences were statistically significant. CONCLUSION: It was concluded that despite numerous similarities in the characteristics of patients who had had maternal near-misses or died, our study points out that those who succumb to death are often <40 years of age, poorly educated, unemployed, usually present as unbooked emergencies from a distance >5 km and suffer maternal death within 24 hours of presentation.

Knowledge and attitude toward interdisciplinary team working among obstetricians and gynecologists in teaching hospitals in South East Nigeria.

BACKGROUND: Interdisciplinary team working could facilitate the efficient provision and coordination of increasingly diverse health services, thereby improving the quality of patient care. The purpose of this study was to describe knowledge of interdisciplinary team working among obstetricians and gynecologists in two teaching hospitals in South East Nigeria and to determine their attitude toward an interdisciplinary collaborative approach to patient care in these institutions. METHODS: This was a questionnaire-based cross-sectional study. Data analysis involved descriptive statistics and was carried out using Statistical Package for the Social Sciences software version 17.0 for Windows. RESULTS: In total, 116 doctors participated in the study. The mean age of the respondents was 31.9±7.0 (range 22-51) years. Approximately 74% of respondents were aware of the concept of interdisciplinary team working. Approximately 15% of respondents who were aware of the concept of interdisciplinary team working had very good knowledge of it; 52% had good knowledge and 33% had poor knowledge. Twenty-nine percent of knowledgeable respondents reported ever receiving formal teaching/training on interdisciplinary team working in the course of their professional development. About 78% of those aware of team working believed that interdisciplinary teams would be useful in obstetrics and gynecology practice in Nigeria, with 89% stating that it would be very useful. Approximately 77% of those aware of team working would support establishment and implementation of interdisciplinary teams at their centers. CONCLUSION: There was a high degree of knowledge of the concept and a positive attitude toward interdisciplinary team working among obstetricians and gynecologists in the study centers. This suggests that the attitude of physicians may not be an impediment to implementation of a collaborative interdisciplinary approach to clinical care in the study centers.

Successful pregnancy following myomectomy for giant uterine fibroid in an infertile woman.

BACKGROUND: Giant uterine fibroid is a rare tumor of the uterus, usually symptomatic requiring surgical intervention. Uterine fibroid is generally common among black women. CASE PRESENTATION: In this study, a case of 31 year old nullipara was reported who presented to the Gynaecology unit of Enugu State University Teaching Hospital (ESUTH), Nigeria with a history of progressive abdominal swelling of 8 years duration, six years duration of infertility and weight loss and dyspnoea on exertion. Physical examination and transabdominal ultrasound revealed a huge abdominopelvic mass. She had myomectomy. She had a histologically confirmed giant uterine fibroid that weighed 16.8 kg. She subsequently achieved a live birth. CONCLUSION: Giant uterine fibroids are relatively rare. It poses great challenges in its management. The surgical option of management should consider the fertility preservation and aspiration of couples especially in developing countries.

Relationship between sonographic umbilical cord size and gestational age among pregnant women in Enugu, Nigeria.

BACKGROUND: Common fetal parameters for gestational age (GA) estimation have pitfalls especially in advanced pregnancy and pregnancy complicated by fetal structural anomaly. OBJECTIVE: To assess the relationship between umbilical cord size and gestational age of the fetus. SUBJECTS AND METHODS: A sonographic cross sectional study involving 300 pregnant women with GA between 14 weeks to 40 weeks was done in Enugu, Nigeria. Gestational ages were first estimated by use of Naegele's formula for GA estimation based on the date of onset of each subject's last menstrual period. Fetal parameters such as biparietal diameter, femur length, head circumference and abdominal circumference were measured and also used to estimate GA. Umbilical cord diameters were measured and used to compute the umbilical cord cross-sectional area. RESULTS: The mean umbilical cord diameter and cross-sectional area were 14.5mm ± 7.2mm and 201.6mm ± 139.5mm(2) respectively. Umbilical cord growth rate of 1.0mm/week was noted between the 14(th) and 35(th) week of pregnancy. There were significant correlations (p < 0.001) between umbilical cord size and other fetal parameters for GA estimation. CONCLUSION: Umbilical cord size had strong linear relationship with common fetal GA estimation parameters and could be used to compliment these parameters for GA estimation.

Maternal and perinatal outcomes of delivery after a previous Cesarean section in Enugu, Southeast Nigeria: a prospective observational study.

BACKGROUND: Obstetricians in developing countries appear generally reluctant to conduct vaginal delivery in women with a previous Cesarean because of lack of adequate facilities for optimal fetomaternal monitoring. OBJECTIVE: To describe delivery outcomes among women with one previous Cesarean section at a tertiary hospital in Southeast Nigeria. METHODS: This was a prospective observational study to determine maternal and perinatal outcomes of attempted vaginal birth after Cesarean sections (VBAC) following one previous Cesarean section. Analysis was done with SPSS statistical software version 17.0 for Windows using descriptive and inferential statistics at 95% level of confidence. RESULTS: Two thousand six hundred and ten women delivered in the center during the study period, of whom 395 had one previous Cesarean section. A total of 370 women with one previous Cesarean section had nonrecurrent indications, of whom 355 consenting pregnant women with one previous Cesarean section were studied. A majority of the women (320/355, 90.1%) preferred to have vaginal delivery despite the one previous Cesarean section. However, only approximately 54% (190/355) were found suitable for trial of VBAC, out of whom 50% (95/190 had successful VBAC. Ninety-five women (50.0%) had failed attempt at VBAC and were delivered by emergency Cesarean section while 35 women (9.8%) had emergency Cesarean section for other obstetric indications (apart from failed VBAC). There was no case of uterine rupture or neonatal and maternal deaths recorded in any group. Apgar scores of less than 7 in the first minute were significantly more frequent amongst women who had vaginal delivery when compared to those who had elective repeat Cesarean section (P=0.03). CONCLUSION: Most women who had one previous Cesarean delivery chose to undergo trial of VBAC, although only about half were considered suitable for VBAC. The maternal and fetal outcomes of trial of VBAC in selected women with one previous Cesarean delivery for non-recurrent indications were good. Obstetricians in this area should do more to allow VBAC in women with one previous Cesarean section for nonrecurrent indications.

Challenges associated with the management of gynecological cancers in a tertiary hospital in South East Nigeria.

BACKGROUND: There are reports of increasing incidence of gynecological cancers in developing countries and this trend increases the need for more attention to gynecological cancer care in these countries. OBJECTIVE: The purpose of this study was to describe the presentation and treatment of gynecological cancers and identify barriers to successful gynecological cancer treatment in a tertiary hospital in South East Nigeria. METHODS: This study was a retrospective longitudinal analysis of the presentation and treatment of histologically diagnosed primary gynecological cancers from 2000 to 2010. Analysis was by descriptive and inferential statistics at the 95% level of confidence using Statistical Package for the Social Sciences version 17 software. RESULTS: Records of 200 gynecological cancers managed during the study period were analyzed. Over 94% of cervical cancers presented in advanced stages of the disease and received palliative/symptomatic treatment. Only 1.9% of cervical cancer patients had radical surgical intervention, and postoperative mortality from these radical surgeries was 100%. Approximately 76% of patients with ovarian cancer had debulking surgery as the mainstay of treatment followed by adjuvant chemotherapy. Postoperative mortality from ovarian cancer surgery was 63%. Cutting edge cytotoxic drugs were not used as chemotherapy for ovarian and chorionic cancers. Compliance with chemotherapy was poor, with over 70% of ovarian cancer patients failing to complete the prescribed courses of chemotherapy. Most patients with endometrial and vulval cancers had only surgical treatment, as compliance with follow-up for adjuvant chemotherapy or radiotherapy was poor. Functional radiotherapy facilities were not available at the center during the study period, thereby necessitating external referrals to centers hundreds of kilometers away. CONCLUSION: Late presentation of cases, noncompliance with treatment regimens, lack of use of cutting edge cytotoxic drugs, the poor outcome of radical surgeries, and lack of a functional radiotherapy facility combined to create a very difficult gynecological cancer care environment at the study center.

Ethical aspects of obstetric care: expectations and experiences of patients in South East Nigeria.

BACKGROUND: Medical ethics is not given due priority in obstetric care in many developing countries, and the extent to which patients value compliance with ethical precepts is largely unexplored. OBJECTIVE: To describe the expectations and experiences of obstetric patients in South East Nigeria with respect to how medical ethics principles were adhered to during their care. METHODS: This was a cross-sectional, questionnaire-based study involving parturient women followed in three tertiary hospitals in South East Nigeria. RESULTS: A total of 1,112 women were studied. The mean age of respondents was 29.7 ± 4.1 years. Approximately 98% had at least secondary education. Ninety-six percent considered ethical aspects of care as important. On the average, over 75% of patients expected their doctors to comply with the different principles of medical ethics and specifically, more than 76% of respondents expected their doctors to comply with ethical principles related to information and consent during their antenatal and delivery care. There was a statistically significant difference between the proportions of women who expected compliance of doctors with ethical principles and those who did not (P < 0.001). Multivariate analysis showed that increasing levels of skilled occupation (odds ratio [OR] 9.35, P < 0.001), and residence in urban areas (OR 2.41, P < 0.001) increased the likelihood of patients expecting to be informed about their medical conditions and their opinions being sought. Although the self-reported experiences of patients concerning adherence to ethical principles by doctors were encouraging, experiences fell short of expectations, as the level of expectation of patients was significantly higher than the level of observed compliance for all the principles of medical ethics. CONCLUSION: The level of practice of medical ethics principles by doctors during obstetric care in South East Nigeria was encouraging but still fell short of the expectations of patients. It is recommended that curriculum-based training of doctors and medical students should be implemented, and hospital policy makers should do more to promote ethical aspects of care, by providing official written guidelines for adherence to medical ethical principles during obstetric care.

Retrospective cohort study of the effects of obesity in early pregnancy on maternal weight gain and obstetric outcomes in an obstetric population in Africa.

OBJECTIVE: The purpose of this study was to compare maternal weight gain in pregnancy and obstetric outcomes between women with obesity in early pregnancy and those with a normal body mass index (BMI) in early pregnancy. METHODS: This was a retrospective cohort study of women with obesity in early pregnancy and those with a normal BMI who were seen at three teaching hospitals in South-East Nigeria. Statistical analysis was performed using Statistical Package for the Social Sciences version 17.0 software, with descriptive and inferential statistics at the 95% level of confidence. RESULTS: The study sample consisted of 648 women (324 obese and 324 healthy-weight). The mean age of the obese women was 26.7 ± 5.1 years and that of the healthy-weight women was 26.6 ± 4.9 years. Although both excessive weight gain (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.23-0.54) and inadequate weight gain (OR 0.08, 95% CI 0.04-0.15) were less common in women with early pregnancy obesity than in healthy-weight women, a significantly higher proportion of obese women with excessive weight gain had adverse fetomaternal outcomes. Also, a significantly higher proportion of obese women had specific complications, such as premature rupture of membranes (OR 2.36, 95% CI 1.12-5.04), gestational hypertension/pre-eclampsia (OR 2.31, 95% CI 1.12-5.04), antepartum hemorrhage (OR 2.78, 95% CI 1.02-7.93), gestational diabetes (OR 4.24, 95% CI 1.62-11.74), cesarean delivery (OR 2.3, 95% CI 1.2-5.44), macrosomia (OR 4.08, 95% CI 1.06-8.41), severe birth asphyxia (OR 2.8, 95% CI 1.2-6.63), abnormal Apgar scores (OR 2.67, 95% CI 1.46-4.93), and newborn special care admissions (OR 1.18, 95% CI 1.0-3.29). CONCLUSION: Early pregnancy obesity was associated with a wide range of adverse fetomaternal outcomes, and could be a genuine risk factor for increased pregnancy-related morbidity and/or mortality in this population. Interventions to reduce prepregnancy obesity could therefore be useful in this low-resource African setting.

Baseline Renal Function among Antiretroviral Therapy-Naive, HIV-Infected Patients in South East Nigeria.

Background:Renal insufficiency has been shown to be a significant, independent risk factor for mortality among HIV-infected patients. Unfortunately, little is known about the prevalence and nature of renal impairment in African populations initiating antiretroviral treatment. This study aims to find the prevalence of abnormal renal function among antiretroviral therapy (ART)-naive, HIV-infected patients in the South Eastern geopolitical zone of Nigeria.Method:This is a cross-sectional hospital-based study, involving 300 ART-naive HIV-positive patients, seen over a 1-year period, aged from 18 years and older, presenting to the clinic for the first time.Results:A total of 300 patients were included in the study, 104 (34.7%) males and 196 (65.3%) females. The prevalence of significant renal disease was 24.3% (73 of 300), while 38.3% (115 of 300) had mild renal impairment. Using logistic regression, age, CD4 count, urea, creatinine, and hemoglobin were significantly associated with renal impairment.Conclusion:The authors observed a high prevalence of significant renal impairment among HIV-infected patients at the time of ART initiation.