Vibeke Rasch

Cigarette, alcohol, and caffeine consumption: risk factors for spontaneous abortion

Objective. To study the association between cigarette, alcohol, and caffeine consumption and the occurrence of spontaneous abortion.

Expanding Comprehensive Postabortion Care to Primary Health Facilities in Geita District, Tanzania

Background Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa. Methodology/Principal Findings Seventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HWs had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children. Conclusion/Significance Health workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.

Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial

BackgroundApplying mobile phones in healthcare is increasingly prioritized to strengthen healthcare systems. Antenatal care has the potential to reduce maternal morbidity and improve newborns’ survival but this benefit may not be realized in sub-Saharan Africa where the attendance and quality of care is declining. We evaluated the association between a mobile phone intervention and antenatal care in a resource-limited setting. We aimed to assess antenatal care in a comprehensive way taking into consideration utilisation of antenatal care as well as content and timing of interventions during pregnancy.MethodsThis study was an open label pragmatic cluster-randomised controlled trial with primary healthcare facilities in Zanzibar as the unit of randomisation. 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary healthcare facilities were included at their first antenatal care visit and followed until 42 days after delivery. 24 primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text-message and voucher component. Primary outcome measure was four or more antenatal care visits during pregnancy. Secondary outcome measures were tetanus vaccination, preventive treatment for malaria, gestational age at last antenatal care visit, and antepartum referral.ResultsThe mobile phone intervention was associated with an increase in antenatal care attendance. In the intervention group 44% of the women received four or more antenatal care visits versus 31% in the control group (OR, 2.39; 95% CI, 1.03-5.55). There was a trend towards improved timing and quality of antenatal care services across all secondary outcome measures although not statistically significant.ConclusionsThe wired mothers’ mobile phone intervention significantly increased the proportion of women receiving the recommended four antenatal care visits during pregnancy and there was a trend towards improved quality of care with more women receiving preventive health services, more women attending antenatal care late in pregnancy and more women with antepartum complications identified and referred. Mobile phone applications may contribute towards improved maternal and newborn health and should be considered by policy makers in resource-limited settings.Trial registrationClinicalTrials.gov, NCT01821222.

Reproductive tract infections in women seeking abortion in Vietnam

BackgroundWomen requesting abortion are at increased risk of developing RTI complications. However, RTI control in many resource-poor countries including Vietnam have been faced with logistical and methodological problems due to lack of standardized definitions of RTIs, lack of well-validated diagnostic criteria, lack of accurate laboratory tests, and lack of diagnostic equipment and skills. This article investigates the prevalence of RTIs among Vietnamese abortion-seeking women, to evaluate the available diagnostic techniques, and to assess antibiotic resistance among aetiological agents of RTI.MethodThe study was conducted in Phu-San hospital (PSH) from December 2003 through April 2004 among 748 abortion clients. A structured questionnaire was used to collect data on socio-economic and reproductive characteristics. Specimens were collected for laboratory analyses of chlamydia, gonorrhoea, trichomoniasis, vaginal candidiasis (VC), bacterial vaginosis (BV) and syphilis. To assess the validity of the obtained results, the study was repeated among 100 women and the duplicate samples were analysed at PSH and Copenhagen University Hospital (CUH).ResultsIn all 54% of the women were diagnosed as having an RTI, including 3.3% with sexually transmitted infections. Endogenous infections were most prevalent (VC 34% and BV 12%) followed by chlamydia (1.3%) and trichomoniasis (0.7%). The sensitivity of culture for VC and BV was 30% and 88%, respectively, when tests in PSH were measured against tests in CUH. Antibiotic resistance was common among bacterial isolates.ConclusionRTIs are common among women seeking abortion. The presence of RTIs is associated with an increased risk of developing iatrogenic infections, routine administration of prophylactic antibiotic to all women undergoing abortion should be considered. However, the choice of routine prophylactic antibiotics should be based on relevant surveillance data of antibiotic resistance. Moreover, since the accuracy of diagnosis is doubtful and to address the problem of under-diagnosed and treated RTIs new investment in diagnostic facilities with simple performed microscopy or improved rapid tests should also be taken into consideration.

Unsafe abortion and postabortion care-An overview

Forty per cent of the worlds women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a womans life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub‐Saharan Africa where unsafe abortion occurs at rates of 18–39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short‐ and long‐term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance womens access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.

Human papillomavirus prevalence and type distribution in 3603 HIV-positive and HIV-negative women in the general population of Tanzania: the PROTECT study.

Objective: The aim of the Prevention of Cervical Cancer in Tanzania (PROTECT) study is to assess the prevalence of oncogenic human papillomavirus (HPV) and to determine the type distribution among women in the general population according to human immunodeficiency virus (HIV) status, in preparation for a potential HPV immunization program. Methods: We included 3603 women from the general population in urban and rural areas of Tanzania. All women underwent a gynecological examination where a Pap smear was obtained and cervical cells were collected to assess the presence of high-risk (HR) HPV DNA by hybrid capture 2 test. Genotyping was performed by the LiPaExtra method. These women were also tested for HIV. Results: The prevalence of HR HPV types was 20.1%, ranging from 14.8% in women with normal cytology to 94.2% in women with high grade squamous intraepithelial lesion (HSIL) or worse (100% in 5 cancers). In women with normal cytology or low-grade lesions, the most common type was HPV52 (3.2%), followed by HPV16 (2.1%). In contrast, HPV16 was the dominating type in HSIL or worse (32.8%). No cancers contained HPV52. The HR HPV prevalence was higher in HIV-positive women (46.7%) than in HIV-negative women (17.2%). No specific HR HPV types were significantly more common in HIV-positive women. Conclusion: The HPV type distribution is similar in HIV-positive and HIV-negative women. These results suggest that the HPV vaccines that are currently available could protect women from HPV infection independently of their HIV status.

Factors associated with and causes of perinatal mortality in northeastern Tanzania

Objective. To identify factors associated with perinatal mortality in northeastern Tanzania. Design. Prospective cohort study. Setting. Northeastern Tanzania. Population. 872 mothers and their newborns. Methods. Pregnant women were screened for factors possibly associated with perinatal mortality, including preeclampsia, small‐for‐gestational age, preterm delivery, anemia, and health‐seeking behavior. Fetal growth was monitored using ultrasound. Finally, the specific causes of the perinatal deaths were evaluated. Main outcome measure. Perinatal mortality. Results. Forty‐six deaths occurred. Key factors associated with perinatal mortality were preterm delivery (adjusted odds ratio (OR) 14.47, 95% confidence interval (CI) 3.23–64.86, p < 0.001), small‐for‐gestational age (adjusted OR 3.54, 95%CI 1.18–10.61, p = 0.02), and maternal anemia (adjusted OR 10.34, 95%CI 1.89–56.52, p = 0.007). Adherence to the antenatal care program (adjusted OR 0.027, 95%CI 0.003–0.26, p = 0.002) protected against perinatal mortality. The cause of death in 43% of cases was attributed to complications related to labor and specifically to intrapartum asphyxia (30%) and neonatal infection (13%). Among the remaining deaths, 27% (7/26) were attributed to preeclampsia and 23% (6/26) to small‐for‐gestational age. Of these, 54% (14/26) were preterm. Conclusions. Preeclampsia, small‐for‐gestational age and preterm delivery were key risk factors and causes of perinatal mortality in this area of Tanzania. Maternal anemia was also strongly associated with perinatal mortality. Furthermore, asphyxia accounted for a large proportion of the perinatal deaths. Interventions should target the prevention and handling of these conditions in order to reduce perinatal mortality.

Substandard emergency obstetric care - a confidential enquiry into maternal deaths at a regional hospital in Tanzania.

Objective  (i) To identify clinical causes of maternal deaths at a regional hospital in Tanzania and through confidential enquiry (CE) assess major substandard care and make a comparison to the findings of the internal maternal deaths audits (MDAs); (ii) to describe hospital staff reflections on causes of substandard care.

Advanced Life Support in Obstetrics (ALSO) and post‐partum hemorrhage: a prospective intervention study in Tanzania

Objective. To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and the incidences of post‐partum hemorrhage (PPH) at a regional hospital in Tanzania. Design. Prospective intervention study. Setting. A regional, referral hospital. Population. A total of 510 women delivered before and 505 after the intervention. Methods. All high‐ and mid‐level providers involved in childbirth at the hospital attended a two‐day ALSO provider course. Staff management was observed and post‐partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training. Main Outcome Measures. PPH (blood loss ≥500ml), severe PPH (blood loss ≥1000ml) and staff performance to prevent, detect and manage PPH. Results. The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 (95%CI: 0.44–0.69)], severe PPH from 9.2 to 4.3%[RR 0.47 (95%CI: 0.29–0.77)]. The active management of the third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. A significantly higher proportion of women with PPH had continuous uterine massage, oxytocin infusion and bimanual compression of the uterus after the training. Conclusions. A two‐day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short‐term effects.

Unsafe abortion in urban and rural Tanzania: method, provider and consequences

Objective  To describe unsafe abortion methods and associated health consequences in Tanzania, where induced abortion is restricted by law but common and known to account for a disproportionate share of hospital admissions.