U. Onwudiegwu

The effect of a depressed economy on the utilisation of maternal health services: the Nigerian experience II

This study follows an earlier one on the effect of the depressed Nigerian economy on the utilisation of maternal health services. Since then, there has been an observed and continued deterioration in maternal health service utilisation. The present study compares service utilisation within three time periods: pre-Structural Adjustment Programme (SAP) period of 1980-84; 1985-89 and 1990-94, revealing a continued decline in antenatal bookings, obstetric admissions and hospital deliveries with figures well below the pre-SAP levels. Maternal and perinatal morbidity have maintained a disproportionate upward trend. Specifically, perinatal mortality, obstructed labour and anaemia increased by two-, three- and six-fold respectively in the decade between the pre-SAP period and 1990-94 time period. Maternal mortality ratio of 9.3 per 1000 births is a 1.5 increase over pre-SAP level. The findings indicate a continuation over unsafe reproductive life among Nigerian women with bleak prospects into the 21st century and call for urgent change in government policy.

Emergency obstetric admissions: late referrals, misdiagnoses and consequences

This is a prospective study that examined the nature of emergency obstetric admissions in a Nigerian university hospital in association with such factors as late referrals and misdiagnoses and their contribution to maternal and perinatal morbidity/mortality. The study comprised 144 consecutive emergency obstetric admissions to the hospital over a 6·5-month period. An incidence of 13·6% emergency admissions was recorded. Despite the proximity of the hospital to the parturients, most of them laboured in substandard facilities within the community. Referrals to the university hospital were made only after prolonged delay and onset of complications. Obstetric haemorrhage (24·6%) was the most common cause for referral followed by labour disorders (19%) and hypertensive disorders (8·4%). Thirteen maternal deaths occurred, giving a maternal mortality ratio of 6·2%, while perinatal mortality rate was 461 per 1000 births. Twelve of the maternal deaths were in women living within 5 km of the hospital. There was a caesarean section rate of 50·9%, a 4·8% incidence of diagnostic laparotomy, a 9% incidence of emergency hysterectomy and 44% of emergency blood transfusions. Misdiagnoses of clinical conditions were made by the referring centres in 68% of cases, which contributed to the high maternal morbidity and mortality. Patient attitude was the main cause of non-use of teaching hospital facilities (fear of operation in 32% of cases, dissuasive advice from friends in 27·4% and negative staff attitude in 7%). A need for and type of programme that will promote increased utilisation of modern maternal health services in the community are discussed.

Ureteric injuries associated with gynecologic surgery

We conducted a review of eight ureteric injuries associated with major gynecologic surgery in seven patients over an 11‐year period. Our low incidence of 0.36% is comparable with other reports. Diagnosis was made either intra‐operatively or postoperatively. Immediate ureteric repair is advocated for all injuries discovered intra‐operatively. Attention to preventive measures both before and during gynecological operations will reduce the incidence of ureteric injuries.

Decision -- caesarean delivery interval in a Nigerian university hospital: implications for maternal morbidity and mortality.

This is a 5-month prospective study to determine the decision emergency caesarean delivery interval in a Nigerian tertiary hospital, the factors responsible for the delays and the consequent maternal and perinatal complications. One hundred and thirty-four emergency caesarean deliveries were analysed and the main indications were failure to progress/ prolonged labour (35.4%), previous caesarean-section/failed trial of scar (27.9%), cephalopelvic disproportion (26.8%), fetal distress (19.5%), pre-eclampsia/eclampsia (15.3%) and obstructed labour/ruptured uterus (14.7%). The mean decision-caesarean delivery interval was 4.4 +/- 4.2 (SD) hours (range 0.5-26 hours), median 3.2 hours and mode 2 hours. Bottlenecks within the maternity unit were responsible for delays in 31.7% of cases. Unavailability of paediatrician (19.6%), non-availability of anaesthetic coverage (13.6%), unreadiness of the operation theatre (11.9%) and seeking second opinion (6.4%) were other major causes of delay. There were 15 perinatal deaths, five of whom were directly linked to the delays i.e. a perinatal mortality rate of 3.7%. Four maternal deaths were directly attributable to delay, a maternal mortality rate of 3%. Other direct consequences of the delays were severe haemorrhage (10.3%), uterine rupture (2.3%) and disseminated intravascular coagulopathy (1.5%). Suggestions on how to minimise delays in emergency services and overall improvement in quality assurance control are discussed.

Cervical cancer-a neglected health tragedy

This is a review of the problems of cervical cancer in Nigeria, typified by data from a tertiary hospital over a 9-year period. Of 146 cases of cervical cancer studied, 79% presented in advanced stages, peak age incidence was between 40 and 70 years, mean 54.5 +/- 12.4 (SD) years. Squamous cell carcinoma was predominant (97% of cases). Presentation was typical: mainly abnormal vaginal bleeding, vaginal discharge and postmenopausal bleeding. Low socioeconomic status (90%) and high parity (83%) were prominent features. Treatment and outcome were poor because of late presentation, lack of radiotherapy facilities and inadequate surgical procedures. Comparison with previous Nigerian studies reveal a continued lack of improvement over the years as regards preventative strategies and adequate treatment facilities. Suggestions on cervical cancer control measures for developing countries like Nigeria are given.

Retained placenta: a cause of reproductive morbidity in Nigeria

This study analysed the reproductive morbidity associated with 91 cases of retained placenta at the Obafemi Awolowo University Hospital in Nigeria. The incidence of retained placenta in the hospital was 1.4% of all deliveries. Over 42% of the patients were admitted in haemorrhagic shock; 56.5% were anaemic, 10.6% severely; 17% had puerperal sepsis while 67% of the women received blood transfusions. There was one maternal death (1%). Unbooked patients (74%) constituted the largest proportion of cases while inappropriate management of the third stage of labour featured in many of the patients. Retained placenta was treated with manual removal in 90% of cases. Properly supervised delivery is an important component in efforts to reduce the incidence of morbidity associated with retained placenta in Nigeria.

Changes in sexual practices and responses among ante-natal clinic attendees in a Nigerian teaching hospital

Summary A cross-sectional study was carried out among 134 antenatal clinic attendees in a Nigerian tertiary hospital to assess pregnancy-related sexual beliefs and changes in sexual frequency and response. Information was collected through a semi-structured questionnaire, and analysed by SPSS. Only 15% of women believed that religious, social or cultural reasons prevented sexual intercourse in pregnancy. Frequency of sexual intercourse decreased in pregnancy in 37.4% of the respondents, remained unaltered in 46.1% and increased in 16.5%. Age, marriage duration and gestational age were not associated with change in the pattern of coital frequency in pregnancy, but education was significantly associated. Sexual responsiveness diminished in approximately half of our respondents in terms of arousal (54.5%), orgasm (48.5%), pleasure (43.7%) and satisfaction (51.4%). The changes were not associated with pregnancy duration. We concluded that sex in pregnancy is well accepted in our environment, and health workers should promote sexual health and well-being in pregnancy.

Emergency obstetric hysterectomy in a Nigerian hospital

SummarySeventy-one cases of emergency obstetric hysterectomy were performed in 13 years in Ile-Ife, Nigeria, representing an incidence of 1 in 448 deliveries (2–2 per 1000). Rupture of the gravid uterus was the major indication, followed by uncontrollable haemorrhage. There was an associated high maternal morbidity (90 per cent), maternal mortality (11 per cent) and fetal loss (75 per cent). Relevant contributory factors were no antenatal care, increased maternal age and grand multiparity. Good antenatal care and labour supervision will reduce the rate of emergency obstetric hysterectomy and its attendant hazards.

Male contribution to infertility in a Nigerian community

SummaryAnalyses of semen samples from 346 male patients whose wives were investigated for infertility were performed over 6 years. The results showed that the gross male contribution to infertility based on sperm density was 46 per cent. Twelve per cent of the patients were azoospermic. Sperm quality was generally poor; 42-1 per cent (128 patients) had poor sperm motility and in 43-8 per cent (133 patients) there was significant abnormal sperm morphology. There was also a high incidence of necrospermia (53-3 per cent) occasioned by genital tract infections. Attention should be paid to sperm quality in the overall assessment of semen analysis and routine semen culture and sensitivity tests should be an integral part of semen analysis in infertility clinics.

Current Trends in Perinatal Mortality in Developing Countries: Nigeria as a Case Study

On November 20, 1989, the United Nations General Assembly adopted the Convention on the Rights of the Child after about a decade of deliberations between major stakeholders, including other United Nations agencies and Heads of Government of member states as well as Non-Governmental organisations (United Nations, 1989). In the World Summit for Children, which held a year later in 1990, world leaders further affirmed the need to promote earliest possible ratification and implementation of the Convention on the Rights of the Child, work for optimal growth and development in childhood, devise methods to eradicate hunger and globally attack poverty among other commitments, irrespective of race, age, colour, language, religion, socio-economic class or other considerations (United Nations, 1990).