Friday Okonofua

Unsafe abortion: the preventable pandemic

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving womens health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves womens health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

A Global Perspective on Genetic Variation at the ADH Genes Reveals Unusual Patterns of Linkage Disequilibrium and Diversity

Variants of different Class I alcohol dehydrogenase (ADH) genes have been shown to be associated with an effect that is protective against alcoholism. Previous work from our laboratory has shown that the two sites showing the association are in linkage disequilibrium and has identified the ADH1B Arg47His site as causative, with the ADH1C Ile349Val site showing association only because of the disequilibrium. Here, we describe an initial study of the nature of linkage disequilibrium and genetic variation, in population samples from different regions of the world, in a larger segment of the ADH cluster (including the three Class I ADH genes and ADH7). Linkage disequilibrium across approximately 40 kb of the Class I ADH cluster is moderate to strong in all population samples that we studied. We observed nominally significant pairwise linkage disequilibrium, in some populations, between the ADH7 site and some Class I ADH sites, at moderate values and at a molecular distance as great as 100 kb. Our data indicate (1) that most ADH-alcoholism association studies have failed to consider many sites in the ADH cluster that may harbor etiologically significant alleles and (2) that the relevance of the various ADH sites will be population dependent. Some individual sites in the Class I ADH cluster show Fst values that are among the highest seen among several dozen unlinked sites that were studied in the same subset of populations. The high Fst values can be attributed to the discrepant frequencies of specific alleles in eastern Asia relative to those in other regions of the world. These alleles are part of a single haplotype that exists at high (>65%) frequency only in the eastern-Asian samples. It seems unlikely that this haplotype, which is rare or unobserved in other populations, reached such high frequency because of random genetic drift alone.

Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross-sectional study

BackgroundLate presentation of patients at advanced stages when little or no benefit can be derived from any form of therapy is the hallmark of breast cancer in Nigerian women. Recent global cancer statistics indicate rising global incidence of breast cancer and the increase is occurring at a faster rate in populations of the developing countries that hitherto enjoyed low incidence of the disease. Worried by this prevailing situation and with recent data suggesting that health behavior may be influenced by level of awareness about breast cancer, a cross-sectional study was designed to assess the knowledge, attitude and practices of community-dwelling women in Nigeria towards breast cancer.MethodsOne thousand community-dwelling women from a semi-urban neighborhood in Nigeria were recruited for the study in January and February 2000 using interviewer-administered questionnaires designed to elicit sociodemographic information and knowledge, attitude and practices of these women towards breast cancer. Data analysis was carried out using Statistical Analysis Software (SAS) version 8.2.ResultsStudy participants had poor knowledge of breast cancer. Mean knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer presents commonly as a painless breast lump. Practice of breast self examination (BSE) was low; only 432 participants (43.2%) admitted to carrying out the procedure in the past year. Only 91 study participants (9.1%) had clinical breast examination (CBE) in the past year. Women with higher level of education (X2 = 80.66, p < 0.0001) and those employed in professional jobs (X2 = 47.11, p < 0.0001) were significantly more knowledgeable about breast cancer. Participants with higher level of education were 3.6 times more likely to practice BSE (Odds ratio [OR] = 3.56, 95% Confidence interval [CI] 2.58–4.92).ConclusionThe results of this study suggest that community-dwelling women in Nigeria have poor knowledge of breast cancer and minority practice BSE and CBE. In addition, education appears to be the major determinant of level of knowledge and health behavior among the study participants. We recommend the establishment and sustenance of institutional framework and policy guidelines that will enhance adequate and urgent dissemination of information about breast cancer to all women in Nigeria.

Haplotypes and linkage disequilibrium at the phenylalanine hydroxylase locus, PAH, in a global representation of populations.

Because defects in the phenylalanine hydroxylase gene (PAH) cause phenylketonuria (PKU), PAH was studied for normal polymorphisms and linkage disequilibrium soon after the gene was cloned. Studies in the 1980s concentrated on European populations in which PKU was common and showed that haplotype-frequency variation exists between some regions of the world. In European populations, linkage disequilibrium generally was found not to exist between RFLPs at opposite ends of the gene but was found to exist among the RFLPs clustered at each end. We have now undertaken the first global survey of normal variation and disequilibrium across the PAH gene. Four well-mapped single-nucleotide polymorphisms (SNPs) spanning approximately 75 kb, two near each end of the gene, were selected to allow linkage disequilibrium across most of the gene to be examined. These SNPs were studied as PCR-RFLP markers in samples of, on average, 50 individuals for each of 29 populations, including, for the first time, multiple populations from Africa and from the Americas. All four sites are polymorphic in all 29 populations. Although all but 5 of the 16 possible haplotypes reach frequencies >5% somewhere in the world, no haplotype was seen in all populations. Overall linkage disequilibrium is highly significant in all populations, but disequilibrium between the opposite ends is significant only in Native American populations and in one African population. This study demonstrates that the physical extent of linkage disequilibrium can differ substantially among populations from different regions of the world, because of both ancient genetic drift in the ancestor common to a large regional group of modern populations and recent genetic drift affecting individual populations.

Why Nigerian adolescents seek abortion rather than contraception: evidence from focus-group discussions.

Nigerian adolescents generally have low levels of contraceptive use but their reliance on unsafe abortion is high and results in many abortion-related complications. To determine why it is important to investigate adolescents perceptions concerning the risks of contraceptive use versus those of induced abortion. Data were collected through focus-group discussions held with adolescents of diverse educational and socioeconomic backgrounds. All were asked what they knew about abortion and contraception and each method of contraception was discussed in detail. In particular youths were asked about contraceptive availability perceived advantages of method use side effects and young peoples reasons for using or not using contraceptives. Fear of future infertility was an overriding factor in adolescents decisions to rely on induced abortion rather than contraception. Many focus-group participants perceived the adverse effects of modern contraceptives on fertility to be continuous and prolonged while they saw abortion as an immediate solution to an unplanned pregnancy -- and therefore one that would have a limited negative impact on future fertility. This appears to be the major reason why adolescents prefer to seek induced abortion rather than practice effective contraception. The need to educate adolescents about the mechanism of action of contraceptive agents and about their side effects in relation to unsafe abortion is paramount if contraceptive use is to be improved among Nigerian adolescents. (authors)

The evolution and population genetics of the ALDH2 locus: random genetic drift, selection, and low levels of recombination

The catalytic deficiency of human aldehyde dehydrogenase 2 (ALDH2) is caused by a nucleotide substitution (G1510A; Glu487Lys) in exon 12 of the ALDH2 locus. This SNP, and four non‐coding SNPs, including one in the promoter, span 40 kb of ALDH2; these and one downstream STRP have been tested in 37 worldwide populations. Only four major SNP‐defined haplotypes account for almost all chromosomes in all populations. A fifth haplotype harbours the functional variant and is only found in East Asians. Though the SNPs showed virtually no historic recombination, LD values are quite variable because of varying haplotype frequencies, demonstrating that LD is a statistical abstraction and not a fundamental aspect of the genome, and is not a function solely of recombination. Among populations, different sets of tagging SNPs, sometimes not overlapping, can be required to identify the common haplotypes. Thus, solely because haplotype frequencies vary, there is no common minimum set of tagging SNPs globally applicable. The Fst values of the promoter region SNP and the functional SNP were about two S.D. above the mean for a reference distribution of 117 autosomal biallelic markers. These high Fst values may indicate selection has operated at these or very tightly linked sites.

Perceptions of Sexual Behavior and Knowledge About Sexually Transmitted Diseases Among Adolescents in Benin City, Nigeria

This single-sex focus group discussion study conducted among young people aged 15-20 attending secondary schools in Benin City explored adolescents perception knowledge and experience regarding the acquisition symptoms prevention and treatment of sexually transmitted diseases (STDs). Findings revealed that the participants perceived that sexual activity are common among their peers. Although physical attraction is the main reason for romantic relationships which might include sex the desire for material or financial gain is the primary motivation for having sexual relationships. The young people had some knowledge about STDs especially HIV and AIDS but many believed infections were inevitable. The participants generally agreed that most adolescents with symptoms of STD seek care from traditional healers; they were unlikely to seek treatment from doctors because of high cost slow service negative provider attitudes toward young people and a perceived lack of confidentiality. However the participants considered media campaigns as the best way to educate young people about the disease and condom use. Program implications designed to increase safer sex and treatment-seeking behavior among the sexually active adolescents are presented.

Female circumcision and obstetric complications

Objectives: To examine whether complications at delivery are associated with female circumcision. Method: One thousand eight hundred and fifty‐one women seeking family planning or antenatal care in three south‐west Nigerian hospitals were interviewed and had a medical exam. The prevalence of complications at delivery for uncircumcised women and circumcised women with type 1 (partial or total removal of the clitoris) or type 2 (partial or total removal of the clitoris and part or all of the labia minora) were determined. Associations between self‐reported complications at delivery and clinic‐reported type of circumcision were analyzed using bivariate and multivariate logistic regression. Result: Forty‐five percent were circumcised; 71% had type 1 and 24% had type 2. Circumcised women had significantly higher risks of tearing and stillbirths when all pregnancies were analyzed. Conclusion: Circumcised women experienced more obstetric complications, while there was no significant difference between women with type 1 and type 2.

COMT haplotypes suggest P2 promoter region relevance for schizophrenia

A recent study found, in a large sample of Ashkenazi Jews, a highly significant association between schizophrenia and a particular haplotype of three polymorphic sites in the catechol-O-methyl transferase, COMT, gene: an IVS 1 SNP (dbSNP rs737865), the exon 4 functional SNP (Val158Met, dbSNP rs165688), and a downstream SNP (dbSNP rs165599). Subsequently, this haplotype was shown to be associated with lower levels of COMT cDNA derived from normal cortical brain tissue, most likely due to cis-acting element(s). As a first step toward evaluating whether this haplotype may be relevant to schizophrenia in populations other than Ashkenazi Jews, we have studied this haplotype in 38 populations representing all major regions of the world. Adding to our previous data on four polymorphic sites in the COMT gene, including the Val158Met polymorphism, we have typed the IVS 1 rs737865 and 3′ rs615599 sites and also included a novel IVS 1 indel polymorphism, yielding seven-site haplotype frequencies for normal individuals in the 38 globally distributed populations, including a sample of Ashkenazi Jews. We report that the schizophrenia-associated haplotype is significantly heterogeneous in populations worldwide. The three-site, schizophrenia-associated haplotype frequencies range from 0% in South America to 37.1% in Southwest Asia, despite the fact that schizophrenia occurs at roughly equal frequency around the world. Assuming that the published associations found between the exon 4 Val158Met SNP and schizophrenia are due to linkage disequilibrium, these new haplotype data support the hypothesis of a relevant cis variant linked to the rs737865 site, possibly just upstream in the P2 promoter driving transcription of the predominant form of COMT in the brain. The previously described HindIII restriction site polymorphism, located within the P2 promoter, varies within all populations and may provide essential information in future studies of schizophrenia.

Maternity Care in Developing Countries

This 422-paged book first published in 2001, is the most recent book that provides essential information on maternity care for clinicians working in developing countries. As the editors reveal in its preface, the book is a radical revision of an earlier book entitled Obstetrics and Gynaecology in the Tropics and Developing Countries , edited by J. B. Lawson and D. B. Stewart first published by Edward Arnold in 1967 and which remained in print until 1991. Those familiar with this book popularly called “Lawson and Stewart” in many medical schools in Africa, will agree that for several years it served as an important reference for clinicians, undergraduate and post-graduate medical students and midwives in many developing countries. Thus, it was with great anticipation that practitioners in developing countries awaited this new revised version, as it was expected to similarly lead the way on present-day thinking and practices regarding maternity care within the context of developing countries. I last met the late Professor J B Lawson at a workshop on reproductive health in developing countries in Uppsala, Sweden in the summer of 1996, and it was with great enthusiasm that he informed me that he and his team were working on revising his highly popular book. Although he did not live long enough to complete the editing of the book, it was delightful that he left the work in the hands of a highly competent team. Professor Kelsey Harrison is well known worldwide for his highly successful study that described the situation of obstetric care in Zaria, northern Nigeria 1 . There was evidence that he used the results of this study as well as his long years of experience working and teaching in Nigeria, to bear on editing the book. Professor Staffan Bergstrom, a Swedish obstetrician and gynaecologist, and public health expert at the KarolinskaInstitutet, Stockholm, Sweden has worked extensively in many parts of East Africa, especially Mozambique and Tanzania. Staffan Bergstrom is highly competent to write on maternity care in developing countries, as he has worked and written exclusively on various issues relating to the improvement of maternity care in developing countries. Thus, the personalities involved in editing this book is impressive and convinces me personally that yet again we are having a book from this stable that would stay in the mind of clinicians, teachers and students in developing countries for many years to come. The book itself was very finely finished in paperback format and with gloss pages, appropriately illustrated and well formatted in color in relevant parts. There are 26 chapters in the book, written by 22 different authors, all of who are highly experienced and known worldwide for their contributions in promoting maternal health in developing countries. For example, Professor Mahmoud Fathalla wrote an excellent piece on family planning; Alan Fleming wrote the chapters on blood transfusion facilities and HIV/AIDS along with other authors; while Robert Fraser wrote the chapter on abortion. However, Kelsey Harrison and Staffan Bergstrom wrote nearly a half of the chapters. Throughout the book the authors used a uniquely distinctive, simple but forceful language in conveying the essential messages, an approach, which makes it easy and very appealing to read. An important question that would immediately be asked about the book is: “what is new that makes it different from the earlier book written by Lawson and Stewart”? Several of the old chapters have been improved upon, to bring in new information and new knowledge. However, the most significant modification was the removal of the chapter on obstetric fistulae. Obstetric fistula in the older version of the book was described extensively, and contained sufficient information for lone operators working on the field. In this new book, obstetric fistula was discussed only as part of the chapter on o bstructed labour and its sequelae , written by Chris Hudson. I suspect this to be due to the need to focus exclusively on preventive obstetrics in great detail with a heavy slant towards high maternal and perinatal mortality reduction, while laying less emphasis on core gynaecology. However, as an important cause of obstetrics morbidity in developing countries, the editors may wish to consider including more in-depth discussion of obstetric fistulae in a later edition of the book. New approaches to maternity care in developing countries have been highlighted in the book. The chapter on “difficult labour” by Chris Lennox most fittingly discussed the use of partograph for the prevention of prolonged labour in developing countries. Although the WHO identified partography as an important tool for preventing obstructed labour in developing countries in the 1980s, very little work has been done in popularizing the use of the method. No doubt, this basic description in this important textbook will increase the knowledge of clinicians and midwives about partography and their use of the method. Also, the chapter on quality and audit of maternity care by Bergstrom, and that by Kwast and Bergstrom on the training of professionals for safer motherhood are excellent pieces of work that focus on important issues relevant for optimizing maternity care in developing countries. New chapters have also been added on HIV/AIDS, childlessness and unsafe abortion, to give emphasis to the continuing importance of these problems in many developing countries. In my view, the most important issue related to maternity care in developing countries today is the prevention of the high rate of maternal mortality in these countries. Many conventional textbooks in maternity care often fail to address this problem adequately, at least not from the perspective of developing countries. One of the strongest points in favour of this new book is the clarity with which it elucidated the problem of maternal mortality in developing countries. In the opening chapter by Kelsey Harrison and Staffan Bergstrom, they described the problem of maternal mortality very vividly, especially its tenuous association with poverty, deprivation and poor organization of services. They proffer a number of solutions, the most important of which are basic education for all, improvement of the social economies of developing countries, and the training of professionals to manage obstetric complications. These recommendations address the core issues and should form the basis for policymakers and practitioners aiming to solve the problem of maternal mortality in developing countries. Overall, this book is a masterpiece, which makes important contributions to the understanding and practice of maternity care in developing countries in modern times. The book would be useful to anyone interested in maternity care and the reduction of maternal mortality in the developing world. I recommend it very highly to policymakers, undergraduate and postgraduate medical students, practicing obstetricians and gynaecologists, midwives and advocates in reproductive health. However, the publishers should make strenuous efforts to ensure affordable pricing of the book and make it available it for sale locally in developing countries.