Abubakar A. Kullima

Trends in maternal mortality in a tertiary institution in Northern Nigeria

OBJECTIVE To look at the trends in maternal mortality in our institution over 5 years. METHODS Records of 112 maternal deaths were retrospectively reviewed to determine the trends and the likely direct cause of each death over the study period. RESULTS There were a total of 112 maternal deaths, while 3931 deliveries were conducted over the 5-year period. The maternal mortality ratio (MMR) was 2849/100,000 deliveries. The highest MMR of 6234/100,000 was observed in 2003, with remarkable decline to 1837/100,000 in 2007. Eclampsia consistently remained the leading cause, accounting for 46.4% of the maternal deaths, followed by sepsis and postpartum hemorrhage (PPH) contributing 17% and 14.3%, respectively. There were no statistically significant differences in the corresponding percentages of maternal deaths between various age groups (chi2=6.68; P =0.083). Grandmultiparas accounted for a significant proportion of maternal deaths as compared to low parity, with chi2=10.43; P =0.00054. Lack of seeking antenatal care (unbooked) and illiteracy were observed to be significant determinants of maternal mortality (chi2=64.69, P =0.00000; and chi2=18.52, P =0.0000168, respectively). CONCLUSION In spite of decrease in the maternal mortality ratio over the years, it still remains high, with eclampsia persistently contributing most significantly. Community enlightenment on the need to avail of antenatal care and hospital delivery services, and improvement in the quality of skilled maternity care will, among other factors, drastically curtail these preventable causes of maternal death and reduce MMR.

A 5-year review of maternal mortality associated with eclampsia in a tertiary institution in northern Nigeria

OBJECTIVE To determine the incidence of maternal mortality associated with eclampsia and to determine how socio-demographic and clinical characteristics of the women influence the deaths. METHODOLOGY Records of 52 eclampsia-related mortalities from January 2003 to December 2007 were reviewed, retrospectively. Their social demography, mode and place of delivery, time of eclampsia, and fetal outcome were extracted for analysis. RESULTS Eclampsia accounted for 52 (46.4%) of the 112 total maternal deaths recorded within the 5-year period, with case fatality of 22.33%. Age group <20, 20-29 and above 30 all had similar case fatality rate of 22.1%, 23.8% and 26.7%, respectively. Those who were experiencing their first deliveries have the worst deaths recording 42.5% of the case fatality in that category. As expected, unbooked had a higher case fatality of 24.0% compared to 15% among book cases, while those with formal education also had more death (22.3% case fatality) as compared to 3.3% among those who had some form of formal education. Antepartum eclampsia was the cause in 50% of the death, 11 (21.2%) of the pregnancies were not delivered before their death, while 18 (34.6%) were stillbirth. CONCLUSION Eclampsia still remains the major cause of maternal mortality in this region resulting from unsupervised pregnancies and deliveries. There is need to educate and encourage the general public for antenatal care and hospital delivery.

Outcome of twin deliveries at the University of Maiduguri Teaching Hospital: a 5-year review.

OBJECTIVES The objectives of the study were to determine the outcome of twin births at the University of Maiduguri Teaching Hospital (UMTH), Maiduguri, in terms of morbidity and mortality and to recommend possible measures to curtail or reduce some of the preventable complications. MATERIALS AND METHODS This is a 5-year retrospective study, from January 2000 to December 2004, of twin births at the UMTH. RESULTS There were 196 twin deliveries in 8431 total deliveries, with a twin incidence of 2.3%. Dizygotic twins accounted for 63.4%. The increasing maternal age and positive family history of multiple pregnancies were associated with the increasing twinning rate. The main complications encountered were preterm labor, pregnancy-induced hypertension, and cord prolapse. The perinatal mortality rate of 107.5/1000 births was higher than that observed for singleton pregnancies in the same institution. Similarly, there was a higher Cesarian section rate of 24.7% compared to singletons within the same period. There were significantly higher perinatal mortality rates among the preterm (P = 0.000002) and low-birth-weight (P = 0.000004) fetuses. CONCLUSION Considering that fetal prematurity and low birth weight, sequelae to preterm labor, are the commonest causes of perinatal death in this study, efforts should be geared during the antenatal period toward the prevention of a premature birth.

Sociocultural factors influencing decision-making related to fertility among the Kanuri tribe of north-eastern Nigeria

ABSTRACT Background The Kanuri tribe is found in the Lake Chad basin. However, the majority of the tribe lives in Borno State, Nigeria. Before this study was undertaken, factors related to fertility decisions among the tribe were not known. Objectives This study is aimed at describing and documenting the sociocultural factors affecting decisions related to fertility among the Kanuri tribe. Method The study applied the qualitative research method. In-depth interviews and focus-group discussions were used as data collection methods. Analysis was done manually. Results Children among the Kanuri were highly valued and desired irrespective of their gender. The ideal family size, according to most of the respondents, was 16 children. Kanuri men are polygamous and can marry up to four wives in order to form large families. However, it is an abomination among Kanuri women to fall pregnant in quick succession; a phenomenon they termed konkomi. Other reasons for child-spacing were related to child welfare and maternal well-being. Methods for child-spacing included prolonged breastfeeding (Nganji yaye), ornaments in various forms and shapes, spiritual invocations and dried herbs (Nganji Yandeye). Few Kanuri women practiced modern methods of family planning. Conclusion Trends in fertility among the Kanuri tribe need to be monitored regularly and appropriate measures be taken to introduce and promote modern family planning and child health services to ensure a healthier family life.

Epidemiology of vesico-vaginal fistula : No longer a calamity of teenagers

Vesico-vaginal fistula (VVF), an abnormal communication between the vagina and the urinary bladder, leads to continuous leakage of urine that is not just a severe medical problem but a great social embarrassment to the patient. It is the commonest fistula encountered as a consequence of poor or lack of appropriate obstetric interventions (Kelly 2004). Beyond their medical problems, VVF patients have unpleasant experiences in the community. These are often associated with serious psychosocial consequences and unaffordable economic burdens on the patients. Such women face a triad of embarrassment from continuous leakage of urine, bereavement from losing her child and the loss of her husband due to the social stigma of the condition. It is one of the most dehumanising conditions that afflicts women (Ekewempu 1988; Inimgba et al. 1999; Waaldijk and Armayau 1993). It is also usually associated with other morbidities such as foot drop, ammenorrhoea and gynaetresia. A total of 88 cases of VVF managed from January 1995 to December 2004 in the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria were analysed. Data pertaining to age, parity, literacy level, possible aetiologic factors and outcome in terms of cure were collected. VVF constituted 1.4%, of the total gynaecological admissions and 8.0% of the major gynaecological surgeries performed during the period. Illiteracy was a major problem – 68% were uneducated. Table I shows that majority (76.2%) were over 20 years, with a peak-age specific prevalence rate of 33.8% at the 20– 24 years age group. Teenagers only accounted for 23.8%. Most patients sustained the VVF during their first childbirth (51.3%), by the second delivery 78.8% were involved and 2 (2.5%) occurred after the fifth delivery. All the teenagers had only one delivery, while all the grandmultipara were 40 years and above. A total of 72 (90%) of them had no supervised antenatal care and had their deliveries at home under untrained traditional birth attendants (TBAs). The only eight patients that were delivered in the hospital all had laboured at home before later recourse to the hospital. Prolonged obstructed labour was the leading cause with 68 (85%) patients, while instrumental vaginal delivery was identified as a cause in eight (10%). Gishiri cut and cervical cancer each accounting for two (2.5%) patients. Some 60 patients had successful repair and were discharged in good condition, while 18 were unsuccessful at both first and second attempts (Table II). VVF in developed countries are gynaecological in origin; they are almost exclusively obstetric fistulas in developing countries. Obstetric fistulas accounted for 97% and 98% of fistulas in previous studies reported from Ethiopia and Nigeria, respectively (Kelly et al. 1992; Waaldjik et al 1993), compared with 5% from England (Kelly 2004). This reflects the poor obstetrics care in the developing countries. This is the consequence of a high prevalence of poorly managed prolonged obstructed labour (Waaldijk and Armayau 1993), the leading cause of obstetric VVF in this study. Early marriage with subsequent teenage pregnancy is a common finding among VVF patients, but accounted for only 23.8% of cases in this study, showing a shift of preponderance from teenagers to older women who would have already attained their optimum pelvic size. Other factors such as socio-cultural practices and religion that limit the woman’s access to appropriate healthcare may therefore become more important in developing VVF. In traditional African society, the husband’s consent is paramount before the women can access any type of healthcare and home deliveries under the supervision of traditional birth attendants, who are often untrained is common, as seen in this study. In addition, virtually all VVF patients are afflicted by a crunch of economic incapability due to their poor and uneducated background, into which they also marry and continue in the vicious circle of ignorance and poverty. Hence, they do not and cannot afford to access good obstetric services. Childhood malnutrition might have prevented adequate pelvic development, resulting in short statured women with small pelves, even after they have achieved their maximum growth potential. Those with the potential for large family sizes and increased birth weight, would invariably give rise to the disease even among older patients, thus shifting the epidemiology towards older women and no longer the hitherto reported teenager.

Attitude of Nigerian women to contraceptive use by men

Summary This study was aimed at finding the attitude of Nigerian women to contraceptive use by their male partners. A total of 417 women received the questionnaire; 71% of these were sexually active and 34.8% were not aware of any male contraceptive method. Only 1.7% reported regular use of condoms by their spouses, however this was significantly higher if the women were better educated. Most of the women had a positive attitude to contraceptive use by their spouses, as 54% (225/417) of them showed preference to male dependant contraceptives in their relationship. However, only 32.3% (135/417) of the women had ever-requested their spouse to use a condom and in just 18.5% (25/135) was such a request regularly complied with. Significantly more Muslim women prefer their partners to use a contraceptive rather than themselves (p = 0.001), but the condom usage by their spouses is significantly lower than their Christian counterparts (p = 0.000). There is a need to offer counselling on male contraceptives to both genders so that they can make an informed choice, especially with the dual protection offered by the use of condoms.

The benefit of myomectomy in women aged 40 years and above: Experience in an urban teaching hospital in Nigeria

Background: Abdominal myomectomy remains the mainstay of surgical management of uterine fibroids in our environment. However, its benefit in women aged 40 years and above remains debatable. Materials and Methods: An 11-year prospective study was conducted involving 98 women, aged 40 years and above, who had abdominal myomectomy for the treatment of uterine fibroid at the University of Maiduguri Teaching Hospital, Maiduguri. They were followed up regularly for 1–6 years to detect conception, resolution of symptoms and obstetrics performance. Data were analyzed using SPSS version 13. Results: The mean age of the patients was 42.6±2.9 years and 77 (78.6%) of them were nulliparous. Lower abdominal swelling was the commonest clinical presentation and the mean uterine size was 18.6±8.5 weeks. Infertility with uterine fibroids was the indication for myomectomy in majority of the cases [48 (48.9%)], while pregnancy complications accounted for 11.2% (11) of the cases Fertility restoration was 10.4% among the infertile patients. There was complete resolution of symptoms in 35.9% of those who required symptomatic relief, and term pregnancies were recorded in 72.7% of patients with pregnancy complications. Conclusion: Myomectomy is the recommended treatment of uterine fibroids in women aged 40 years and above with infertility and who wish to become pregnant. If there is no need for further fertility preservation, hysterectomy should be offered.

Social and health reasons for lime juice vaginal douching among female sex workers in Borno State, Nigeria

ABSTRACT Background Vaginal douching with lime juice and other agents has been perceived to enhance sexual excitement through sensations of vaginal dryness, tightness or warmth, as well as prevent sexually transmitted infections and restore and tighten the vagina after delivery. Its effectiveness as a contraceptive has also been reported. However, the social and health reasons/consequences of such a practice have not been adequately documented in the communities of Borno State, Nigeria. Objectives This study aimed to determine the extent of, reasons for, and the reproductive health effects of, the use of lime juice for vaginal douching among the commercial sex workers (CSWs) in selected areas of the three senatorial regions of Borno State, Nigeria. Method This was a community-based descriptive study conducted among female CSWs in selected communities of Borno State, Nigeria. A sample of 194 CSWs were randomly selected and interviewed on their sexual history and douching practices. Results One hundred and twenty (62%) respondents admitted practicing vaginal douching with lime juice, with 85% having been CSWs for a period greater than three years. More than half douched for sexual pleasure, hygiene and contraception. Significantly more lime juice users had increased susceptibility to sexually transmitted infections (STIs) than non-users. Users had a higher prevalence of HIV infection than non-users. The Papanicouleaua (pap) smear test for cervical lesions also showed that moderate to severe dysplastic changes were more prevalent among lime-juice users. Conclusion Many CSWs in this community use lime juice for douching, for various reasons. Indications are that its use is associated with a higher prevalence of sexually transmitted diseases, including HIV infections and dysplastic cervical changes. Owing to confounding issues, such as the number of sexual partners, frequency of sexual exposure per day and the duration of exposure, it cannot, therefore, be deduced that douching with lime juice is the only reason for the higher prevalence of STIs and HIV. Nevertheless, there is an obvious need to mount extensive campaigns to educate the CSW on the possible risks of using such a practice.

Burden of Symptomatic Renal Stones in Pregnancy Managed Till Normal Delivery: A Case Report in Developing Nation

Although urolithiasis occurs in pregnancy, its management remains a great challenge in our region. It creates a diagnostic puzzle due to many differentials that can simulate the symptoms in pregnancy. This is further challenged by the limitations of the accepted imaging investigations, burden of monitoring the pregnancy and managing urolithiasis till delivery at term. We present a case of intractable flank pain due to left renal calculus in an eighteen year old primigravida which was successfully managed. Where possible, treatment of urolithiasis before conception should be our focus in addition to general preventive measures of urolithiasis.

Awareness and utilization of emergency contraception among female undergraduates in a Nigerian University.

Background: Many women are not aware of emergency contraception, which limits its use. Because increased risk of unwanted pregnancy and subsequent unsafe abortion have been well-documented, research on the knowledge and usage of emergency contraception is appropriate. Materials and Methods: The present study was a descriptive cross-sectional study conducted among 450 female undergraduate students of a University in northeast Nigeria from November to December 2014. Results: The age range of the respondents was 19-30 years, with a mean age of 21.4 ± 2.1 years. Most of them, 308 (68.4), were between the ages of 20 and 24 years. Majority of the students, 321 (71.3%), were single. Overall, 295 (65.5%) students were aware of emergency contraception, and 211 (71.5%) had utilized them. Among those who had utilized them, 174 (82.4%) were singles. The most common source of initial information about emergency contraception was health personnel, 148 (50.1%), followed by friends, 107 (36.3%). School, 11 (3.7%), and parents, 4 (1.4%), were the least utilized sources of information. Information from health personnel, news media and schools were the major influences of emergency contraceptive utilization. Levonorgestrel only pills (Postinor-2 R ) and combined pills (Yuzpe) were the most commonly utilized emergency contraception by 91 (43.1%) and 85 (40.3%) of the respondents, respectively. Conclusion: There was good level of awareness and utilization of emergency contraception among female undergraduates. However, there is a need to educate the parents, students and staff or counselors at the family clinic section of the university health clinic on its importance to improve the awareness of the students.