Afromedica 2012 by Federation Of African Medical Students' Associations

FAMSA SCIENTIFIC JOURNAL  VOLUME 001 ISSUE 001  MARCH 2012  ISSN 1821-8598

AN OFFICIAL JOURNAL OF THE FEDERATION OF AFRICAN MEDICAL STUDENTS ASSOCIATIONS

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Contents Editorial | Juventius Arthur (Editor in chief) …3 Afromedica Production Team …7 Message from FAMSA President | Ralph K Akyea …8 ARTICLES Pregnancy Outcomes In Patients With Sickle Cell Disease | Shittu A. A …9 Obstetric Fistula - The Forgotten Disease | Ibrahim Sufyan …16 INTERVIEW Ipas Vice president for Africa | Dr. Eunice Amissah …23 ABSTRACTS A Study On The Preferred Places Of Delivery By Pregnant Women In Rural Chongwe And How Best These Places Can Be Used To Reduce Maternal Mortality | Sichembe Wantula …28 A Study To Determine Risk Factors For Caesarean Section And The Fetal Outcomes In Postcaesarean Section Women At Korle-Bu Teaching Hospital | Caroline Hlordzi …38 Prevention Of Mother To Child Transmission Of Hiv | Clara Lubinza …40 Acceptability Of Hiv Counselling And Testing In Youth In Ablekuma, South Sub-Metropolitan Area, Accra, Ghana | Ohaeri A. O …44 Curbing Malnutrition As The Major Cause Of Child Morbidity And MORTALITY | George Mkoma

…46 Family Planning In Africa | Glory Msaky …49 The Prevalence, Associated Factors And Complications Of Home Delivery For The Past Five Years At Bungu Village In 2010 | Elisha Osati …51 A Comparative Study On Labour Outcomes In Mothers Who Have Undergone Female Genital Mutilation (Fgm), And Mothers Who Have Not, Delivering At Kapenguria District Hospital, Rift Valley Province Kenya | Mokoh Lilian Warimu …52 Safe Delivery As A Pillar Of Safe Motherhood: A Study Of Narok North District, Kenya | Sinikka Rono …53 CASE REPORTS Case Report: Intestinal Duplication With Malrotation And A Rectovestibular fistula | Nelson F, Onchonga A, Magoma G, Matheka C …55 Testicular Neoplasm Presenting With Recurrent Intestinal Obstruction: A Case Report | Cyrus Matheka, Faroj Alkizim, Dr Wambugu …57

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Editorial The theme for this edition of Afromedica is ‘Promoting Maternal and Child Health in Africa’ which is in line with the theme for FAMSA’s 27th General Assembly scheduled to take place in March 2011 in Uganda. The choice of the theme has been informed by the observed fact that Africa is still far from achieving the Millennium Development Goals 4 and 5. Many mothers are unjustly being lost in their quest to fulfil childbirth, a purely natural and important event of humanity. Many of our future leaders (children) are also being lost to PREVENTABLE and CURABLE diseases. Malaria is still reported to be the leading cause of morbidity and mortality in Africa 1 with the at risk group being mainly children and pregnant women.

Chief Editor: Juventius Arthur

The issue of Maternal and Child Health in Africa as in other developing countries remains a hard rock to quarry on discussion grounds. The mortality and morbidity figures though have been going downslope over the past few years are still intolerably high. This makes one want to ask, “What isn’t being done?” the answer to which must probably be the solution to the problem. In a typical African family, it stands without doubt that the life of the father is precious but that of the mother is more precious and that of the child even much more precious. It is therefore worrying to find that developing countries continue to lose many of their women and children to preventable causes.2, 3, 4 To consider that Malaria remains a leading cause of morbidity in many Sub-Saharan African countries and deaths from unsafe abortions continue to surf with the top five causes of maternal mortality alone speaks volumes.1,4,5 It permits the adulteration of Mahmoud Fathalla’s statement to read, ‘Women and Children are not dying because of diseases we cannot treat, they are dying because societies are yet to decide that their lives are worth saving.

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The Problem mortality since 1990. In other regions including Asia and North Africa, even greater strides have been made. However, between 1990 and 2008, the global maternal mortality ratio declined by only 2.3% per year. This is far from the annual decline of 5.5% required to achieve MDG5.6

MATERNAL HEALTH Over half a million women die each year due to complications during pregnancy and childbirth. The vast majority of these deaths are preventable4 According to the WHO, approximately 1000 women die from preventable causes

In recent years, there has been increased recognition that reducing maternal mortality is not just an issue of development, but also an issue of human rights. Preventable maternal mortality occurs where there is a failure to give effect to the rights of women to health, quality and non-discrimination.4

related to pregnancy and childbirth every day and goes further to state that 99% of all maternal deaths occur in developing countries and Sub-Saharan Africa suffers the greatest deal.6 Countries like Mozambique, Malawi and Central African Republic have Maternal Mortality ratios as high as 1100 per 100000 live births. Life time risk of maternal death is again highest in Sub-Saharan Africa (1 in 31) compared to a world risk of 1 in 140.7

As Mahmoud Fathalla puts it, “Women are not dying because of diseases we cannot treat, they are dying because societies have yet to decide that their lives are worth saving...” Maternal health is therefore closely related to the right to highest attainable standard of health and therefore warrants relentless effort and focused attention by all to help reduce the burden.

Causes of maternal death have been indirectly blamed on a 3-delay model i.e. Delay in deciding to seek appropriate medical help, Delay in reaching an appropriate facility and Delay in receiving adequate care when the facility is reached. Contributing to delay in deciding to seek appropriate medical help are reasons of cost, lack of recognition of emergencies, poor education, lack of access to information, gender inequality and not to be overlooked, Cultural beliefs. Also, contributing to delay in reaching appropriate facility are reasons of distance, transportation and infrastructure, all of which are situations most pronounced in low income countries like Africa.

CHILD HEALTH Although child health has improved overall, three of the ten most important conditions of the global burden of disease still are diseases of childhood – respiratory infections, perinatal conditions and diarrheal diseases.8 Under-5 mortality is currently estimated at 4.6 million per year. The global desire to improve child survival is enshrined in the Millennium Development Goal 4 (Reduce Child Mortality) with a key target to reduce by two-thirds, between 1990 and 2015, the under-five mortality rate. This has led to the institution of Childhood Survival Strategies which highlights an Integrated Management of Childhood Illnesses and Immunization.

In acknowledgement of the issue as a global burden, Improving maternal health is one of the eight Millennium Development Goals (MDGs) adopted at the 2000 Millennium Summit. A key target is to reduce the maternal mortality ratio (MMR) by three-quarters between 1990 and 2015. In sub-Saharan Africa, a number of countries have halved their levels of maternal 4

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Again, it’s Sub-Saharan Africa that suffers the greatest deal of Child Mortality. “Sub-Saharan Africa is the only region in the world registering an increase in the under age 5 mortality rate, which has risen in Cameroon, Central African Republic, Chad, Congo, Kenya and Zambia. Thirty-four of the world's 36 countries with child mortality rates above 100 per 1,000 births are in sub-Saharan Africa. The others are Afghanistan and Myanmar.9 Sierra Leone has the highest child mortality rate (262 in 2007). This has led the WHO region for Africa to develop a strategy to optimize child survival, growth and development, and reduce mortality among children less than five years of age.

CONCLUSION The issue of Materal and Child Health remains a huge burden in developing countries with Subsaharan Africa being the most affected. This is in spite of the many programs that have been developed, adopted and embraced by many countries in pursuit of the Millenium Development Goals 4 and 5. Though some progress have been made in reducing the burden, the facts still show that morbidity and mortality rates are high and far from targets set under the MDGs expected to be achieved by 2015. It is therefore duly due for questions to be asked not concerning what is being done but what is not being done. It is duly due for a collective decision to be taken by all so as to ensure that mothers deliver safely and children live to experience the best that life has to offer.

THE PAIR OF MATERNAL AND CHILD HEALTH A mother’s health profoundly affects the health and well-being of her children.10 When a child falls ill, it’s the mother who spends time off economic activities to ensure that the child is restored to good health.

REFERENCES 1. Bawah A A, Binka F N. How many years of life could be saved if malaria were eliminated from hyperendemic area of Northern Ghana. Am J Trop Med Hyg. 2007; 77(6):145-152

More so, Maternal and Child Health are indicators of a nation’s development. However, achieving adequate Maternal and Child Health has further been complicated by the HIV/AIDS pandemic and other preventable and curable infectious diseases like Malaria that have Children and Pregnant women as most vulnerable groups.

2. UNICEF. Children should not be dying from preventable cause [homepage on the internet]. c2012[updated 2012 Feb 9; cited 2012 Mar 18] Available from http://www.unicef.org/childsurvival/index.html 3. USAID. Two decades of progress: USAID’s child survival and maternal health program.

The USAID’s Child survival and Maternal Health program which evolved from the ‘Child survival revolution’ through ‘Child Survival Strategy’ to include Maternal Health in recognition of the strong link between the two, is aimed at combating preventable childhood illnesses while addressing issues of Maternal Health.11

4. Hunt P, Bueno de Mesquita J. Reducing Maternal Mortlity: The contribution of the right to the highest attainable standard of health. University of Essex: Human rights center. 2010 5. WHO. Maternal health [homepage on the internet]. C2012 [cited 2012 Mar 18] Available from http://www.who.int/topics/maternal_health/e n/

In developing countries like Africa where children spend a considerable period of time with parents from birth through to puberty, ensuring good health of mothers is bound to influence that of child survival as well.

6. WHO. Maternal mortality. Fact sheet [homepage on the internet]. C2010 [cited Mar 5

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18] Available from http://www.who.int/mediacentre/factsheets/fs 348/en/index.html 7. WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality:1990 to 2008 8. WHO. Child Health Research: foundation for improving child health. 2002

9. Child death rates rise in 6 African countries [homepage on the internet]. C2010 [cited Mar 18] Available from http://articles.boston.com/2010-0623/news/29287733_1_poverty-rates-childmortality-rates-extreme-poverty 10. USAID. Maternal and Child Health [homepage on the internet]. [updated 2012 Feb 8; cited 2012 Mar 18] Available from http://www.usaid.gov/our_work/global_health /mch/index.html

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The Team EDITOR IN CHIEF

Mr Juventius Arthur (University of Ghana)

Afromedica is a peer reviewed Journal of the Federation of African Medical Students Association (FAMSA). Material on these pages is copyright FAMSA Publications or reproduced with permission from other copyright owners. It may be downloaded and printed for personal reference, but not otherwise copied, altered in any way or transmitted to others (unless explicitly stated otherwise) without the written permission of FAMSA. Hypertext links to other Web locations are for the convenience of users and do not constitute any endorsement or authorisation by FAMSA.

MANAGING EDITOR Ms. Nyuma Mbewe (University of Zambia)

EDITORS Mr Umoren Blaise (University of Ibadan, Nigeria) Cyrus Matheka (University of Nairobi) Mr Emanuel Chongwe

PROOF-READERS Dr John Banin (University of Ghana) Mr Webby Phiri (University of Zambia) Mr Juventius Arthur (University of Ghana)

PRODUCTION TEAM Mr Farinu Opeoluwa (Lautech Osogbo, Nigeria) Mr Stanley Binagi (Kilimanjaro Christian Medical University College, Tanzania)

MARKETING TEAM Mr Njoku Kingsley (University of Nigeria College of Medicine, Enugu Campus) Mr Moses Ssemusu (Makerere University College of Health Sciences)

GRAPHICS EDITOR Mr Stanley Binagi (Kilimanjaro Christian Medical University College, Tanzania)

OTHER MEMBERS Ms Dorothy Abakah Ms Grace Gyimah Mr Rankeet

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Message from FAMSA President Afromedica, an annual peer-reviewed Medical Journal published by the Federation of African Medical Students’ Associations (FAMSA), serves as a forum for the publication of medical student research papers, scientific materials and medical articles themed in line with the Federation’s General Assembly and International Scientific Conference. The theme for this year’s edition is “Promoting Maternal and Child Health in Africa.” With only 3 or less years left to achieve the United Nation’s Millennium Development Goals (MDGs) for Maternal and Child Health, most African countries in the region are unlikely to meet their targets. With just a little time for achieving success, a crucial appreciation of where and why maternal and child deaths occurs and strategic prioritization of interventions, are essential to accelerate progress. This edition of Afromedica is enriched with research articles, abstracts and case reports by medical students for medical students on the aforementioned theme. FAMSA for about 10 years has been unable to publish its Afromedica. I am pleased with the unwavering commitment of the chairman of the Standing Committee for Publication (SCOPUB) and the Editorial Team to get this year’s edition published, despite the challenges. Africa is indeed grateful for their commitment to make every mother and child count. Ralph Kwame Akyea President, FAMSA

AFROMEDICA 2012 1(1) : 9 â&#x20AC;&#x201C; 15 Pregnancy outcomes in patients with sickle cell disease

ORIGINAL ARTICLE

PREGNANCY OUTCOMES IN PATIENTS WITH SICKLE CELL DISEASE Author: Shittu A.A Sickle cell disease is an inherited autosomal recessive disorder of haemoglobin structure (Sickle Cell Disorders) which result from single amino acid substitutions on the haemoglobin molecule. In the HbS, valine is substituted for glutamic acid at position 6 of the haemoglobin molecule and in HbC; lysine is substituted for glutamic acid. The disease may occur as homozygous HbSS, HbCC, or heterozygous HbSC. Of these, HbSS has been found to be the most clinically significant.1It is a part of a spectrum of diseases termed haemoglobinopathies that also include disorders which result from abnormalities in haemoglobin synthesis called the thalassemias. They are mainly seen in individuals who originate from Africa, the Middle East, the Caribbean, Mediterranean, Asia and the Far East where it is estimated that worldwide 5% of adults are carriers of haemoglobin trait; 2.9% and 2.3% for thalassemias and sickle cell diseases respectively.2 In Nigeria, about 25% of the population carries the sickle cell trait and approximately 100,000 children are born annually with a serious sickle cell disorder (WHO 1994).2

Background And Objectives:

distinguished those of HbSC and HbAA mothers. Inferentially, neonates delivered by HbSS women were both underweight and preterm, whereas those of HbSC women were preterm but not underweight, and apparently large for gestational age (LGA).8

The haemoglobinopathies are associated with significant perinatal morbidity and mortality worldwide with a greater proportion of the burden in sub-Saharan Africa. In Africa presently, the numbers of pregnant patients with haemoglobinopathies are increasing because patients now live till child-bearing age. Early experience with sickle cell disease and pregnancy was a cause for pessimism and the first report of a successful pregnancy in a woman with the disease was in 1931.3

Pregnancy Induced Hypertension is one of the most serious pregnancy complications arising among HbSS patients together with the attendant risks of preeclampsia and eclampsia. 9, 10Patients with sickle cell disease have been demonstrated to be at a significantly higher risk of developing pre-eclampsia and eclampsia when compared to their HbAA counterparts.11

A 5-year retrospective review of pregnancy outcome done in 1990 on HbSS patients managed at the University College Hospital showed the main complications during pregnancy to be anaemia, bacterial infections such as pyelonephritis and endometritis, pre-eclampsia, bone pain crisis and pseudotoxaemia. The maternal and perinatal mortality rates were 48 and 95 per 1000 respectively.4During the antenatal period, patients with haemoglobinopathiesare seen earlier, have more visits and transfers to the Intensive Care Unit. When compared to the HbSC patients however, HbSS patients are seen earlier by the haematologists and have more transfusions.5This is becauseHbSS patients have lower baseline haematocrits.6HbSS patients also have higher admission rates compared to their HbAA counterparts where most admissions occur in the first trimester.7In another study done in Ghana, neonates of HbSS mothers had a statistically lower than normal mean birth weight and gestational age, but only a shorter mean gestational age significantly

Pregnancies in patients with haemoglobinopathies are usually associated with higher caesarean section rates and poorer maternal and fetal outcomes as evidenced by higher rates of intra-uterine growth retardation, smaller gestational age at delivery, lower Apgar scores and increased maternal and fetal death rates.5,12 With a cure for sickle cell disease still elusive, preconceptional care and antenatal screening are thus very important as they ultimately minimise the perinatal morbidity and mortality associated with haemoglobinopathies in pregnancy. The high risk of fetal and maternal sequelae in these pregnancies mandate a multidisciplinary management involving the obstetrician, haematologist and a specialist nurse. This approach poses numerous challenges especially in resource poor settings like Nigeria where the rate of the disease is one of the highest. Various management strategies are not yet universally accepted or widely 9

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available e.g. prophylactic transfusion to combat the anaemia that occurs during pregnancy.13

and a total of 50 cases were studied, 35 cases in University College Hospital with 35 controls and 15 cases in Oluyoro Catholic Hospital with 15 controls.Data Analysis was done with the Statistical Package for the Social Sciences (SPSS) software version 15 and to obtain frequency tables, Chi test, T-test and multivariate analysis.

The overall objective was to analyse the perinatal outcomes in patients with sickle cell disease (HbSS and HbSC) in Oluyoro Catholic Hospital, (OCH) and University College Hospital, (UCH), Ibadan from January 1st 2006 to December 31st 2010.

RESULTS:

The specific objectives were to compare pregnancy, birth and puerperal events in age matched HbAA patients and patients with sickle cell disease that were managed in both facilities; to compare these characteristics and medical interventions employed in patients with haemoglobinopathies in both hospitals and to make recommendations about the management of patients with sickle cell disease in Ibadan.

The reference population (HbSS) and the control group (HbAA) were age-matched; the mean ages were 29.5 years and 29.6 years respectively; 37.8% of the subjects had post-secondary education compared to 73.3% of the control population. Only 19% of the patients booked their pregnancies in the first trimester with 47% and 34% of the subjects booking in the second and third trimesters respectively. Less than half (44%) of the subjects received Intermittent Preventive Therapy as compared to 77.8% of the controls.

MATERIALS AND METHODS This is a retrospective study. The study population comprised patients with sickle cell disease (HbSS and HbSC) seen at the Obstetric Clinics and Wards of University College and Oluyoro Catholic Hospitals from January 1st 2006 to December 2010. University College Hospital is a tertiary health facility, a teaching hospital attached to the University of Ibadan, while Oluyoro Catholic Hospital is a secondary health facility managed under the Oyo State Hospitals Management Board (OSHMB). The control population were HbAA pregnant patients seen at both hospitals within the same period.

The commonest crisis suffered during pregnancy was of the vaso-occlusive type which was more frequent in third trimester in both facilities. Patients with sickle cell disease were also found to have significantly higher rates of transfusions both before and during gestation. Patients with sickle cell disease did not differ greatly with the control in mode of delivery; 51% of controls compared to 54% of the subjects had spontaneous vaginal delivery and 48% of the controls compared to 43% of the cases had Caesarian Section. However, the rates of instrumental delivery for the subjects and controls were 4% and 1% respectively, indicating a positive association ofsickle cell disease with instrumental deliveries.In comparing the modes of deliveries in both facilities, University College Hospital, Ibadan had significantly higher rates of Caesarian sections and instrumental deliveries.

Inclusion criteria were cases of HbSS and pregnantwomen who had booked, received antenatal care and delivered in both hospitals. The preference for the booked patients was to minimise disparities in the clinical management they were exposed to in pregnancy and labour. A total population survey of such patients with haemoglobinopathies (HbSS and HbSC) was carried out

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Figure 1: Chart comparing modes of delivery in HbSS and HbAA patients

51%

CONTROL SICKLE CELL

53.7% 48.8% 42.6%

3.7%

Figure 2: Chart comparing the modes of delivery in University College Hospital and Oluyoro Catholic Hospital

UCH

80%

OLUYORO

% of Patients

56.6%

40.7%

20%

2.7%

CS: Caesarian Section, SVD: Spontaenous Vaginal Delivery 11

OLUYORO, INSTRUMENTAL DELIVERY, 0

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Pregnancy outcomes were poorer in the sickle cell group compared to the controls with higher rates of preterm and stillbirth deliveries: 13.73% versus 12.5% and 5.88% versus 2.88%respectively though rates of term deliveries were similar. Maternal complications during pregnancy ranged from anaemia and malaria to the severe ones such as pre-eclampsia and eclampsia. Malaria and anaemia were the commonest complications in both groups. Figure 3 shows the distribution of complications maternal deaths occurred significantly more in the control group, 4% compared to 0%.

CONTROL

50%

27%

30%

30% 17% 9% 4%

0% CONTROL, UTI,

4% 0%, SICKLE CELL, APH

CONTROL, PPH, 0

8.7%

0% CONTROL, Maternal Death

Figure 3: Chart showing complications and frequencies in haemoglobinopathy patients compared with controls. APH: Antepartum Haemorrhage, PPH: Postpartum Haemorrhage

Babies of patients with sickle cell disease suffered complications like Premature Rupture of Membranes (PROM) and birth asphyxia; being the commonest followed by intra-uterine growth restriction (IUGR). In

comparing deliveries that occurred in UCH and OCH, deliveries in the former had fewer rates of neonatal complications as depicted in Figure 4.

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UCH 31%

25%

18.9% 16%

16%

9% 6.1%

OLUYORO, IUGR, 0 OLUYORO, IUFD, 0

3% OLUYORO, Preterm Labour, 0

`Figure 4: Chart comparing perinatal outcomes between University College and Oluyoro Catholic Hospitals IUFD: Intra-uterine foetal death, IUGR: Intra-uterine growth restriction, LBW: Low Birth Weight, PROM: Premature Rupture of Membranes.

DISCUSSION:

Less than half of the population had access to Intermittent Preventive Therapy during pregnancy and this probably accounts for malaria being one of the most frequent maternal complications arising during pregnancy. None of the patients had hydroxyurea during the course of their pregnancy and this could also account tor anaemia which also ranked as one of the commonest maternal complications. To combat the high prevalence of anaemia in pregnant HbSS patients, some centres in countries offered prophylactic transfusions to all sickle cell patients in pregnancy. However, prophylactic transfusion did not improve obstetric outcomes compared to those pregnancies that were not.4

The finding that patients with sickle cell disease are less likely to have formal education indicates that the disease has a profound effect on their education. This may result in their having lower socioeconomic status and being unable to take appropriate treatments when confronted with health challenges. They may also be unaware of the complications that may arise in the course of their pregnancy as a result of the disease. They were also found to book their pregnancies late with only a minority (19%) booking in the first trimester. This will contribute to the poorer pregnancy outcomes seen in a developing country like Nigeria when compared to developed countries. These results also correlate with other studies done in other parts of Nigeria.14, 15

The higher incidence of operative and instrumental deliveries found in UCH compared to Oluyoro Catholic 13

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Hospital, (56.6% versus 20%) and (2.7% versus 0%) respectively may be attributed to lack of pre-requisite skills or simply the unavailability of instruments in Oluyoro Catholic Hospital. When also compared to the control population, sickle cell disease was positively associated with caesarean section delivery and induction of labour. These results are similar to the findings by Villers et al in 2008.16

2. WHO. Updated estimates of the frequency of the haemoglobin disorders in each country. Guidelines for the control of haemoglobin disorders. B Modell, 1994, WHO/HDP/HB/GL/94.

The overall difference in outcomes by both hospitals: the University College Hospital had better outcomes than the Oluyoro Catholic Hospital which can be attributed to UCH being a tertiary hospital where facilities and manpower are more available compared to Oluyoro Hospital.

4. Idris A, Omigbodun AO, Adeleye JA, Pregnancy in haemoglobin sickle cell patients at the University College Hospital. Ibadan. Int. J Obstet. 1992, June; 38(2): 83-6

3. Oteng-Ntim E., Apryll R. Chase, Jo Howard, Elizabeth N. Anionwu. Sickle cell disease in pregnancy.

5. C. Ngo, G. Kayem, A. Habibi, A. Benachi, F. Goffinet, F. Galacteros, B. Haddad. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2010; 152(2): 138-142.

CONCLUSIONS AND RECOMMENDATIONS:

6. Sun PM, Wilburn W, Raynor BD, Jamieson D. Sickle cell disease in pregnancy. Twenty years of Experience at Grady Memorial Hospital, Atlanta, Georgia. Am J Obstet Gynecol. 2001; 184(6): 112730.

It can be concluded from the study that the management of sickle cell disease remains a daunting challenge worldwide and even more so in a developing country like Nigeria.The better outcomes produced by the University College Hospital are still poor compared to those of developed countries like Saudi Arabia and the United States. 17, 18However concrete conclusions cannot be made on fetal outcome due to insufficient data on parameters like Apgar scores as they were not recorded in the patients’ files. Better management practices need to be incorporated into clinical management of pregnant patients with sickle cell disease such as pre-conceptional counselling of couples and adequate pregnancy care that includes optimal nursing care and adequate analgesia during crises.19

7. Yu CKH, Stasiowska E, Stephens A, Awogbade M , Davies A. Journal of Obstetrics and Gynaecology, August. 2009; 29(6): 512–516 8. Addai FK, Wilson JB, Quashie FJ. Comparative studies of live neonates in maternal sickle cell haemoglobinopathy in Ghana. Trop Geogr Med. 1992 Oct; 44(4):312-6. 9. Ogedengbe O K, Akinyanju O. The pattern of sickle cell disease in pregnancy in Lagos, Nigeria. West African Journal of Medicine.1993; 12: 96–100

Prenatal diagnosis and early screening of infants should be standard clinical practices. Adequate malaria prophylaxis should also be given to patients. All these will ensure that the pregnant patient with sickle cell disease is managed in the best possible way as her condition demands.

10. Smith JA, Espeland M, Bellevue R, Bonds D, Brown AK, Koshy M. Pregnancy in Sickle Cell Disease: Experience of the Cooperative Study of Sickle Cell. Obstet Gynecol. 1996; 87:199-204 11. Larrabee KD, Monga M. Women with Sickle Cell Trait are at increased risk of Pre-eclampsia. Am J Obstet Gynaecol. 1997;177(2):425

REFERENCES: 1. Ronald L. Nagel, Mary E. Fabry, Martin H. Steinberg. The paradox of haemoglobin SC disease. Blood Reviews. 2003; 17, 167–178 14

AFROMEDICA 2012 1(1) : 9 – 15 Pregnancy outcomes in patients with sickle cell disease

12. Afolabi BB, Iwuala NC, Iwuala IC, Ogedengbe OK. Morbidity and mortality in sickle cell pregnancies in Lagos, Nigeria: A case control study. Journal of Obstetrics and Gynaecology. 2009; 29(2):104-106

16. Villers MS, Jamison MG, De Castro LM, James AH. Morbidityassociated with sickle cell disease in pregnancy. Am J Obstetrics and Gynecology. 2008;199:125.e1-125.e5.

13. Howard RJ, Tuck SM, Pearson TC. Pregnancy in sickle cell disease in the UK: results of a multicentre survey of the effect of prophylactic blood transfusion on maternal and fetal outcome. Br J Obstet Gynaecol. 1995 Dec; 102(12):947-51.

17. Fathia E. Al Jama, Turki Gasem et al. Pregnancy outcome in patients with homozygous sickle cell disease in a University Hospital, Eastern Saudi Arabia.Arch Gynecol Obstet. 2009; 280:793–797

14. Odum CU, Anorlu RI, Dim SI, Oyekan TO. Pregnancy outcome in HbSS–sickle cell disease in Lagos, Nigeria. West Afr J Med. 2002; 21:19–23

18. Barfield WD, Barradas TD, Manning SE, Kotelchuck M, Shapiro-Mendoza CK. Sickle Cell Disease and Pregnancy Outcomes in Women of African Descent. Am J Prev Med. 2010;38(4S):S542–S549

15. Omo-Aghoja IO, Okonofua FE. Pregnancy outcome in women with sickle cell–a Five year review. Niger Postgrad Med J. 2007; 14:151–154

19. Montgomery KS. Caring for the Pregnant Woman with Sickle Cell Disease. The American Journal of Maternal/Child Nursing. 1996; 21(5): 224-22

Author: Shittu A.A., 2nd Year Clinical Student, College of Medicine, University College Hospital, Ibadan, Nigeria This was a Comparative Study between Oluyoro Catholic Hospital (OCH), and University College Hospital, (UCH), Ibadan, Nigeria from January 1st 2006 to December 31st2010. Project by Group A 2009 students of the Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Nigeria as a part of the Obstetrics and Gynaecology Posting. Supervised by Dr A.A. Odukogbe*, Dr F.A. Bello* and Dr O. Olayemi* *Consultant, Department of Obstetrics and Gynaecology, University College Hospital, University of Ibadan, Nigeria

AFROMEDICA 2012 1(1) : 16 – 22 Obstetric fistula – The forgotten disease

ORIGINAL ARTICLE

OBSTETRIC FISTULA - THE FORGOTTEN DISEASE Author: Ibrahim Sufyan

Obstetric fistula is a problem of the developing world that arises as a complication of prolonged obstructed labour. Unlike surgical urogenital fistulae, obstetric fistulae are larger and more complex injuries, whose ramifications are multi-systemic. The consequences of obstetric fistulae inevitably extend into the social lives of the patients and the effects are felt by the patient’s family. Unfortunately, a problem of such magnitude has not received due attention. Adequate screening to identify women with obstetric fistula, and appropriate medical care can mitigate the disease’s effects. Nevertheless, nearly 2 million women suffer from this condition and up to 100000 new cases arise each year. Typically, the condition affects young, primiparous women who have often not achieved physical maturity. Labour in such women would have been prolonged for periods exceeding 48 hours. At present, several classification systems exist. Treatment could be non-surgical in cases of small fistulae, while surgical repair is necessary for fistulae >2cm in diameter. Repair may be carried out immediately after delivery, provided no life-threatening co-morbidities exist. Alternatively, a waiting period of 3 months has been proposed prior to repair. Prevention would entail community mobilization and risk group sensitization in addition to improvement of emergency obstetric care services and their uptake. More comprehensive and authoritative epidemiological data is required, and standardization of terminology, classification, management protocols and reporting of surgical outcomes are needed.

Introduction

relatively little has been done to address the issue of incontinence arising as a result of obstetric fistula. 4 This is despite the fact that maternal morbidity due to obstetric fistula parallels maternal mortality in the developing world. Furthermore, the reason forwarded for this lack of concern is that the problem remains hidden behind geographical, political, socio-economic and cultural barriers. 1

Obstetric complications are undoubtedly as old as the process of childbearing.1 One of the most catastrophic complications of childbirth is obstetric fistula.2 Existence of this complication of childbearing has been demonstrated in mummies of ancient Egyptian times. James Marion Sims was among the first obstetricians to attempt closure of an obstetric fistula, though nearly 30 procedures were required to successfully close it. His methods still form the basis of the surgical technique used today for closure of fistulas. 3While the condition in the developed world is as a result of surgical trauma or radiotherapy, it is almost exclusively due to childbirth gone wrong in the developing world. 1

Effort however, has been made to salvage the situation. Drs. Reginald and Catherine Hamlin, in 1975, established the Addis Ababa Fistula Hospital for poor Ethiopian women upon realizing the full extent of the disease. Nearly 13 000 fistulae had been repaired by 1996, and 1 000 new fistulae were being repaired each year. 1 Similar centres have been established in many parts of Africa.

The obstetric fistula problem has been largely ignored such that the WHO has termed it as the ‘forgotten disease’. Compared to the attention childhood and old age incontinence has received in the form of multimillion dollar pharmaceutical business ventures to develop disposable napkins and incontinence sheets, 16

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Pathophysiology

Along with prolonged obstructed labour playing a pivotal role in development of obstetric fistula, the role of genital mutilation prior to labour and during labour cannot be ignored. Due to cultural practices such as clitoridectomy or in an attempt to relieve obstructed labour, a traditional birth attendant may perform a ‘symphisiotomy’ that ultimately results in formation of a vesico-vaginal fistula. 4,6.Other factors that contribute towards the formation of obstetric fistula include experiencing labour before attaining full pelvic maturity, young age, poor nutrition, skeletal deformities and a narrowed vaginal introitus due to previous genital mutilation.

The close embryonic development of the lower genital and urinary tracts, with minimal intervening connective tissue between the urinary bladder and vagina, or for that matter the rectum and the vagina predisposes all females to obstetric fistula. 5 During prolonged, obstructed labour the presenting part of the foetus impacts against the bony pelvis, with the urinary bladder and vagina interposed. Alternatively it could be the vagina and the rectum lying between the presenting part of the foetus and the bony pelvis. This impaction leads to ischaemia of the intervening tissues and subsequent necrosis. The necrotic tissue then sloughs off with a resultant ‘hole’ connecting the vagina and the bladder, or the vagina and the rectum

Ultimately however, it is interplay of these biological factors with socio-economic and cultural factors such as lack of transportation, lack of trained health personnel at grass-root level capable of identifying the problem, scarcity of health facilities or socio-cultural traditions impeding access to health care that lead to development of obstetric fistula. 5,7

1,4

However, unlike urogenital fistula arising as a result of surgical trauma, obstetric fistula is not a focal injury. Rather, it is an injury with multiple organ system consequences. The fistula itself may be larger and of variable shape. Furthermore, it is often surrounded by grossly abnormal and necrotic tissue.

Epidemiology Obstetric fistula is a preventable condition. Nearly 2 million women are believed to suffer from this condition, and 50 000-100 000 new cases develop each year. 2 In Ghana, West Africa, obstetric fistula is estimated to occur at the rate of about 1-2% of all deliveries.8

Some of the direct clinical consequences of obstetric fistula and the processes leading to its formation include urinary incontinence which is often difficult to manage. Ascending urinary tract infections or urethral scarring leading to urinary retention could result in renal failure. In one study, nearly 60% of the women were amenorrhoeic, most of central nervous system origin or had developed intrauterine scarring and Asherman syndrome. 6 Due to a focal breach of the vaginal skin and occasional trauma to the cervix, healing could occur by fibrosis and the ensuing gynaetresia may present as secondary infertility. There may also be trauma directly to the pelvic bones. Foot drop is another presentation often encountered. It may be due to impaction of the fetal presenting part against the sacral plexus of nerves, or injury to the peroneal nerve as a result of prolonged squatting during delivery. Appropriately, this multifaceted nature of obstetric fistula has been referred as the obstructed labour injury complex. 1

Several studies have been conducted to ascertain the roles played by age, parity, and labour circumstances in the occurrence of obstetric fistula. Studies conducted by Hilton and Ward 6, Ibrahim et al.9, Wall et al.10, Tahzib 11, Kelly and Kwast 12and Holme et al.13, have described the risk factorswhich are summarized in table 1 below.Most women who developed obstetric fistula had been in labour for over two days. Most were primiparous, though one study showed increased point prevalence in grandmultips. 1 Holme et al. showed a bimodal age peak in the incidence of obstetric fistulae 13, while a study carried out in Pakistan reported larger incidence of obstetric fistula in higher age and parity groups as compared with primiparous and younger women. 17

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Table 1 Socio-medical risk factors associated with obstetric fistula*

Author, country, Number year of cases

Obstetric causes (%)

Mean % duration primiparous of labour (days)

Place of delivery (%)

83.8

Mean/media n age at development of fistula (years) 21.0

Tahzib, Nigeria, 1443 1983 Kelly and Kwast, 209 Ethiopia, 1993

3.0

52.0

97.4

27.4

3.9

62.7

92.2

28.0

2.5

31.4

Home 64.4, hospital 6.4 Home, alone or unskilled attendant 60.8 Home 27, hospital 73

Hilton and 2484 Ward, Nigeria, 1998 Ibrahim et al., 31 Nigeria, 2000

100

60% 13-15 4,0 years, 90% <18 years 27.0 2.4

Wall et al., 932 96.5 Nigeria, 2004 Holme et al., 239 100 22.0 2.0 Zambia,2005 *Adapted and modified from Creanga and Grenadey, 2009.

Diagnosis

Home 16, hospital 84

45.8

Home 23.5, hospital 76.5 Home 9, health facility 89.1

dye test in the presence of clear urine in the vaginal fornices after an intravenous infusion of furoseminde invariably implies a ureteric fistula. 4,7

This is often definitive, given the history of prolonged labour and leakage of urine or stool, with inability to keep clean. If the patient is seen shortly after delivery, a characteristic odour due to incontinence and necrotic slough may often aid in establishment of the diagnosis. 4 Performing a vaginal examination may have to be done with the aid of anaesthesia or sedation, particularly shortly after delivery. 5 The vaginal examination is best performed with the aid of a Sims speculum, with the patient positioned in an exaggerated left lateral position. Note must be made of the location, size and shape of the fistula as well as nature and viability of tissues surrounding the fistula, the latter being essential in cases where previous repair has been attempted.

Classification Currently, many classification systems for obstetric fistulae exist. Lawson in 1972 came up with a simplified anatomical classification, 5 while Elkins adopted a similar approach in 1994. 15 Waaldijk proposed a functional classification system where closure of the urethral mechanism was considered, 16 The most recent classification for vesico-vaginal fistulae as well as recto-vaginal fistulae has been that proposed by Goh. 17 The system attempts to incorporate anatomical, functional as well as pathological aspects of obstetric fistulae. The system takes into consideration the fistula with respect to the external urethral meatus, its size and the gross pathology of the fistula and surrounding tissues in terms of fibrosis. It is

In the case of smaller fistulae, a dye test with gentian violet or methylene blue would be helpful. A negative 18

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however hoped, that with the establishment of the International Society of Obstetric Fistula Surgeons (ISOFS), some level of standardization will be achieved, not only for classification but for management protocols and reporting of outcomes. 18

4-6 weeks. If the fistula drains urine after this period, then surgical closure would be required. The reasoning is that keeping the fistula dry would create an environment supporting fistula healing. 4,7

Management

Three approaches exist: vaginal, abdominal and a combined trans-abdominal, trans-vaginal approach. The vaginal approach is favoured by gynaecologists and is advantageous in that minimal blood is lost, pain is less, complications are fewer and the duration of stay in hospital is shorter. 5 The abdominal route is frequently adopted by urologists. It is useful in repair of complex fistulae, where ureteric implantation is required and where the vagina is stenosed. 26 The combined approach is employed in situations where there may be need to apply an additional layer of tissue such as omentum to fill up dead space or introduce a new blood supply.

Surgical Approach

The first attempt to repair the fistula is often crucial. 19,20 Successful surgical outcome rates have been reported in the range of 58-90%. 13,21,22 However, several challenges are faced in accessing this form of treatment. Ultimately, surgical management is treatment of choice. Surgical outcome has been shown to have an impact on the mental wellbeing of the patient. 23 The debate currently is when to attempt repair. While older authors advocated for a 3 month interval prior to attempting repair, contemporary surgeons feel immediate surgery is of benefit as duration of social stigma is reduced. Positive outcomes have been recorded with this latter approach. 24

The success or failure of repair is dependent on the site, size, and degree of fibrosis of intervening tissue. 27 The overall health of the patient, availability of facilities, number of previous attempts and surgeon expertise are additional factors. 21 In the presence of a rectovaginal fistula, vesicovaginal fistula repair is generally less successful. 1

In the pre-operative stages, screening for comorbidities that may negatively affect outcome and treating them is important. Screening for more lifethreatening conditions such as tuberculosis, poor nutrition, schistosomiasis among others would be necessary, particularly when there is clinical evidence supporting presence of such diseases. 5 Presence of bladder stones may require postponement of surgery 14 , while physiotherapy may be required to relieve contractures that may have set in, so as to achieve adequate operating field.

Post-operatively, recovery varies with the extent of repair. Continuous bladder draining is advised at least 10 days post-operatively and sexual activity may only be resumed 3-4 months after repair. 21 Most authors recommend caesarean delivery for pregnancies after fistula repair, though successful vaginal deliveries have been documented after repair. 20

While use of prophylactic antibiotics in the preoperative stage has not been shown to be of much value in determining the outcome of the repair, it does reduce the incidence of post-surgical urinary tract infections and sepsis. 25

Complications Several post-operative complications have been described. Most of the complications arise due to the procedure itself or as residual effects of the fistula as it heals. Amenorrhoea is thought to arise due to suppression of the hypothalamus as a result of the fistula, which resolves spontaneously 24 months later if the fistula is left untreated. 6 When repaired, the woman begins menstruating within 6 months. 28

Non-surgical Management For fistulae less than 2cm in diameter, an indwelling size 18F Foley catheter may be applied and in this way, treatment attempted. The catheter is left in place for 19

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Conclusion

Anuria, bladder stones, reduced bladder capacity, stress incontinence, ureteric injury, urinary retention and urinary tract infections are possible renal complications.

Obstetric fistula is a multi-faceted problem. Given the impact it has on the affected patients, prevention and treatment are crucial public health issues. 29 Absolute prevention may be a distant goal and therefore establishment of dedicated fistula centres is important. 1 Separate fistula centres are probably better than treating fistula patients in hospitals. 4 The fistula centres require a multi-disciplinary approach towards patients and co-operation among fistula centres needs to be improved.

Gynaetresia arises as the repair site heals with vaginal stenosis being a common manifestation. Secondary infertility would then ensue. Trauma to the sacral plexus during repair could cause foot drop, while superficial wound infection in the absence of proper wound toilet is always likely.

In spite of the difficulties likely to be faced in preventing occurrence of obstetric fistulae, efforts can be made to overcome the three delays; delay in deciding to use health care, delay in reaching the health care facility and delay in receiving proper health care. Emergency obstetric care services in countries where obstetric fistula is endemic, need to be affordable, accessible and of acceptable standards. 7

Social consequences of Obstetric fistula The problems associated with obstetric fistula are not only medical. The condition has several socioeconomic consequences experienced by the patient and often extending to the family of the patient. 22 Women who develop this condition often are from the lower strata of the socio-economic scale. They are often impoverished with poor nutrition, unemployed and often illiterate. Many are from rural areas and subsist on crops grown on small scale. In addition, they are responsible for household chores and day to day running of the household.

Community mobilization and education programmes on safe motherhood practices could go a long way in preventing obstetric fistula. 30On the academic front, further discussions and studies are required on the syndromic concept pertaining to obstetric fistula and accurate epidemiological data on prevalence is needed. 1,13 Terminology, classification, treatment protocols and reporting needs to be standardized. 5,18 Training of fistula surgeons needs to be standardized too, along with their assessment.

Incontinence and foot drop will render them unable to perform daily activities. Failure to keep clean will see them being thrown out of the family household, occupying a separate shelter from the rest of the family. In multiparous women, this could entail loss of care received by the children from their mother. Exclusion from social and religious activities could be another disastrous consequence, particularly when these aspects form a vital part of the individualâ&#x20AC;&#x2122;s life.

References 1. Arrowsmith E, Hamlin CE, Wall LL. Obstructed labour injury complex: obstetric fistula formation and the multifaceted of maternal birth trauma in the developing world. Obstet Gynecol Surv 1996; 5:9. 2. United Nations Population Fund and Engender Health. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries. New York, NY: United Nations Population Fund and Engender Health, 2003. [www.unfpa.org/fistula/docs/fistula-needsassessment.pdf]. Accessed 26 Nov 2011.

Sexual intimacy is lost. One study demonstrated that 50% of the women had either been divorced or were on separation with their spouses. 13 Having lost their child during the index pregnancy may be the last opportunity to have children. This may be due to vaginal disfigurement, cervical injury, amenorrhoea or post fistula pelvic inflammatory disease. 1

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3. Sims JM. On the treatment of vesico-vaginal fistula. Am J Med Sci 1852; 23: 59-82. 4. Walley RL, Kelly J, Matthews KM, Pilkington B. Obstetric fistulae: a practical review. Rev Gynaecol Pract 2004; 4: 73-81. 5. Creanga AA, Genadey RR. Obstetric fistulas: a clinical review. Int J Gynecol Obstet 2009; 99: S40S46. 6. Hilton P, Ward A.Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years’ experience in southeast Nigeria. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9: 189-94. 7. Breen M. Care of a patient after prolonged labour with a dead baby. In: Essential O+G Guidelines And Other Protocols For District Hospitals 2008; 55. 8. Lassey AT, Ghosh TS. Vesico-vaginal fistula in Ghana. Unpublished report for the Ministry of Health of Ghana and non-governmental organizations in the case of women in Ghana, November 1993. 9. Ibrahim T, Sadiq AU, Daniel SO. Characteristics of VVF patients as seen at the specialist hospital Sokoto, Nigeria. West Afr J Med. 2000; 19: 59-63. 10. Wall LL, Karishma JA, Kirschner C, Arrowsmith SD. The obstetric vesic-vaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004; 190: 1011-19. 11. Tahzib F. Epidemiological determinants of vesicovaginal fistulas. Br J Obstet Gynaecol 1983; 90: 387-91. 12. Kelly J, Kwast BE. Epidemiologic study of vesicovaginal fistulas in Ethiopia. Int Urogynecol J. 1993; 4: 278-281. 13. Holme A, Breen M, MacArthur C. Obstetric fistulae: a study of women managed at the Monze Mission Hospital, Zambia. Br J Obstet Gynaecol 2007; 114: 1010-17. 14. Ahmad S, Nishtar A, Hafeez GA, Khan Z. Management of vesico-vaginal fistulas in women. Int J Gynecol Obstet 2005; 88(1): 71-75. 15. Elkins TE. Surgery for the obstetric vesico-vaginal fistula: a review of 100 operations in 82 patients. Am J Obstet Gynecol 1994; 170(4): 1108-1120. 16. Waaldijk K. Surgical classification of obstetric fistulas. Int J Gynecol Obstet 1995; 49(2): 161-163.

17. Goh JT. A new classification for female genital tract fistula. Aust N Z J Obstet Gynecol 2004; 44(6): 502504. 18. Elneil S, Browning A. Obstetric fistula: a new way forward. An Int J Obstet Gynaecol 2009; 116: 3032. 19. Angioli R, Penalver M, Muzii L, Mendez L, Mirhashemi R, Bellati F, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Haematol 2003; 48(3): 295-304. 20. Kelly J. Vesicovaginal fistulae. Br J Urol 1979; 51(3): 208-210. 21. Kelly J. Fistulae of obstetric origin. Midwifery 1991; 7(2): 71-73. 22. Yeakey MP, Chipeta E, Rijken Y, Taulo F, Tsui AO. Experiences with fistula repair surgery among females and families in Malawi. Glob Pub Health 2011; 6(2): 153-67. 23. Browning A, Fentahun W, Goh J. The impact of surgical treatment on mental health of women with obstetric fistula. Br J Obstet Gynaecol 2007; 114: 1439-41. 24. Waaldijk K. The immediate surgical management of fresh obstetric fistulas with catheter and/or early closure. Int J Gynecol Obstet 1994; 45(1): 1116. 25. Tomlinson AJ, Thornton JG. A randomized controlled trial of antibiotic prophylaxis for vesicovaginal fistula repair. Br J Gynaecol Obstet 1998; 105(4): 397-399. 26. Carr LK, Webster GD. Abdominal repair of vesicovaginal fistula. Urology 1996; 48(1): 10-11. 27. Rathee S, Nanda S. Vesicovagianl fistula: a 12-year study. J Indian Med Assoc 1995; 93(2): 93-94. 28. Evoh NJ, Akinla O. Reproductive performance after the repair of obstetric vesicovaginal fistulae. Ann Clin Res 1978; 10(6): 303-306. 29. Miller S, Lester F, Webster M, Cowan B. Obstetric fistula: a preventable tragedy. J Midwifery Womens Health 2005; 50:4. 30. Turan JM, Johnson K, Polan ML. Experiences of women seeking medical care for obstetric fistula in Ethiopia: implication for prevention, treatment and

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social reintegration. Glob Pub Health 2007; 2(1):

64-77.

Author: Ibrahim Sufyan Medical student University of Zambia

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Interview with Ipas’ Vice President Biography Ambassador Dr. Eunice Brookman Amissah is Ipas’ Vice President for Africa. Ipas is an International not-for-profit Organization working globally to improve Women’s health through a focus on Reproductive Health. She joined Ipas full time in 2001 from The Hague where she had been her country Ghana’s Ambassador to The Kingdom of the Netherlands. Before that she had been Minister of Health in Ghana. She pioneered in West Africa what has come to be known as Community Gynecology. She also has been a temporary consultant to the WHO on several occasions. She was elected Fellow of the West African College of Physicians in 1989 and awarded the Fellowship ad eundem of the Royal College of Obstetricians and Gynecologists, United Kingdom, in 1998 in recognition of her enormous contribution to that specialty. Dr Brookman Amissah was the first woman Vice President of the Ghana Medical Association and has been the Commonwealth Medical Association’s representative to the Advisory Committee of the Commonwealth Human Rights Initiative, CHRI, since 2002. She is also a member of the Committee on Women and Development (CWD) of the UN’s Economic Commission for Africa (ECA). In 2004 she was accorded representational status at the UN Economic Commission for Africa in Addis Ababa. She is a foundation member and Vice Chairman of the Africa Regional Reproductive Health Research and Training Network, based in Johannesburg. She now lives in Nairobi, Kenya where she heads Ipas’ Africa Alliance for Women’s Reproductive Health and Rights.

The Interview Afromedica: Hello Dr Amissah, we are happy to interact with you today. We have heard and read so much about you. 1. Afromedica: We would like you to briefly tell us about yourself. Amb. E B-A: I am an African Woman, a doctor by profession and have been a policy maker in my role as Minister of Health of Ghana in the mid 90’s, a former Ambassador of Ghana to 23

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the Kingdom of the Netherlands and now working with the international NGO, Ipas as Vice President for Africa. I am also a mother of three with two grandchildren.

2. Afromedica: During your medical training, did you always envisage yourself doing what you are doing now? Amb. E B-A: I inherited a streak for public service from my mother who was a great reformer and advocate for women and youth empowerment and so knew I wanted to work to change things but didn’t quite know from the beginning exactly what form this was going to take. I have never contested for any position but was thrown into politics early and by acclamation as the first Treasurer of the then Ghana Medical Students Association in 196465. Then as a doctor, I was the Vice –president of the Ghana Medical Association; I believe the first women to hold that position. And I was elected in my absence. I was also Chairman of the Society of Ghana Private Medical and Dental Practitioners. I also heard about my appointment as Minister on TV!

3. Afromedica: As a mother, former diplomat and politician, champion of women's rights and health, how do you combine these responsibilities and deliver effectively? Amb. E B-A: I believe the various roles have re-enforced each other. As a practicing doctor I was acutely aware of the tragedy of maternal deaths and as a minister took the lead to reform the health sector to deliver more effectively. During my sojourn in the Netherlands as Ambassador I saw how the reproductive health services including maternal health were organized to deliver an almost zero Maternal Mortality Ratio. I knew then that it was indeed possible to work to reduce the unacceptably high maternal deaths in our countries in Africa. So when I was invited by Ipas to take up the newly created position of Vice President for Africa I did not hesitate. I saw the chance to help make a difference in the lives of women by eliminating a totally and easily preventable cause of a huge portion of maternal deaths in the region.

4. Afromedica: In relation to your work, what’s your typical day like in Nairobi? Amb. E B-A: I think this is going to be a long answer! The short answer is HECTIC!! As Vice president for Africa I have headed the Ipas Africa Alliance for Women’s Reproductive Health and Rights based in Nairobi. Ipas was established about forty years ago with a mission to improve Women’s Reproductive Health and rights and to reduce preventable maternal deaths from unsafe abortion. So our focus is on reducing the incidence of unwanted pregnancy though improved access to contraception and provision of safe abortion services as needed by women who have no access to Family Planning or have had 24

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contraceptive failure. It sounds simple enough but the politics around abortion is such that there is so much stigma and longstanding silence regarding the issue such that knowledge about it is limited. Also the criminalization of abortion through laws inherited from our colonial masters has been the main cause of this stigma and marginalization of a health service that women need and which saves lives. My work has been to create an enabling environment in the region for safe abortion and reproductive rights. This has meant working with regional institutions at the highest political level—African Union and its agencies to advance the needed policies which we then follow up with countries to implement. Also with the African Commission on Human and Peoples Rights whose mandate is to Promote and Protect the rights of Africans. Ipas believes, as I do, that women have a right to reproductive wellbeing. We have worked with sub-regional health agencies like the West African Health Organization-WAHO; and the East Central and Southern Africa Health Commission ECSA –HC based in Arusha Tanzania. We work with Health Professional Associations like FIGO and the various Africa regional Obstetrics and Gynaecology Societies. We also work with Midwives associations at an international and national level and are in the process of supporting the creation of a Confederation of African Midwives. I believe that with the huge burden of maternal health in Africa there is need to bring the professionals most closely associated with the issue together to learn from and re-enforce each other for success. Among others, we also work with lawyers and Parliamentarians and Women’s Rights advocates to sensitize them on the issue and for them to do advocacy in their various fields of work to move the agenda for improving the lives of African women. Another important partner for us is the Media and journalists who we sensitize and train for better reportage on the sensitive issue of abortion and to enhance knowledge about it. We also feel it is important to have youth leaders sensitized and mentored to become advocates for women’s reproductive health and rights. Working with FAMSA we feel will lead to the double advantage of having future doctors who understand the issues with unsafe abortion and will be willing to provide services in their practice and also as future leaders advocate for or make the policies that will help end the tragedy of abortion related deaths. So working from Nairobi we organize and conduct these conferences and workshops across the region and have defined activities including training and services set up currently in seven countries.

5. Afromedica: What is the vision of Ipas Africa Alliance? Amb. E B-A: Every country in Africa has at least one and many have several indications for which abortion is legal. We would like to see soon; all countries develop service guidelines and provide safe services for these legal indications. Ipas would also like to see –in the not 25

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very far future a region where women’s rights are respected, where women can make choices and especially their own reproductive choices and plan their families in and their lives order to attain their full social and economic development and potential. Most of all I would like to see an Africa where women will not have to die from unsafe abortions—a totally preventable cause of maternal mortality

6. Afromedica: What has been some of the achievements of Ipas Africa Alliance so far in contributing to the improvement of maternal health in Africa? Amb. E B-A: When I started work at Ipas ten years ago the word abortion was not one to be mentioned in polite society. It was so deeply stigmatized. Forty thousand women were dying from complications of unsafe abortions every year and nothing was being done about this. Moreover, many more thousands of women were living with long term residual effects including infertility from botched abortions. Through the work that I have described earlier with regional and country partners, the very sensitive issue of abortion has been brought to the fore in regional and national discourse and recognized in binding and non-binding agreements such as the Protocol to the African Charter on the Rights of Women in Africa and the Maputo Plan of Action for the Operationalization of the Sexual and Reproductive Health Strategy for all Africans. And we are seeing some real progress in recent years:  with expanded legal indications for abortion in Ethiopia, Kenya, and several Francophone countries;  Commitments to scale-up safe services in Ghana, South Africa, and Zambia;  And active consideration of liberalizing laws by governments in several other countries 7. Afromedica: What has been some of the challenges so far in our part of the world to the work that you do and how do you deal with these challenges? Amb. E B-A: The biggest challenge has been with bringing out an issue that had been hitherto highly stigmatized and not talked about- breaking the loud silence that surrounds abortion. And trying to change the attitude of people long socialized to believe that abortion is sinful and criminal. Trying to get people, including policy makers to look at unsafe abortion as a public health issue and access to safe abortion as a right of women as affirmed by many of our countries in international, regional and national treaties and laws. I think invoking the Africa Women’s Protocol and the Maputo Plan of Action as well as Goal 5b of the MDGs has all been extremely useful in moving us forward in the campaign to reduce abortion related deaths.

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8. Afromedica: Do you see Africa achieving MDGs 4 and 5? Amb. E B-A: Very few countries are on target to achieve the MDGs especially MDG 5. Countries like Seychelles and Mauritius have done well to move up the development index and reduce maternal mortality ratios. They still have restrictive abortion laws but there is high and effective family planning available and the women who experience unwanted pregnancies can access relatively safe abortion services. Unsafe abortions with the horrible complications as we see them in other countries are a thing of the past. With unsafe abortion contributing up to 30% of maternal deaths in some of our countries, eliminating this cause of Maternal deaths can yield great dividends in reducing Maternal Mortality Rates and at very little cost. We have highlighted this in our advocacy work.

9. Afromedica: It is said that achieving MDG 5 has a telling on achieving MDGs 1 through 4, how true is this? Amb. E B-A: I think that the opposite is rather the case. That all the other MDGs have a bearing on reducing Maternal mortality and morbidity- reduction of poverty, access to education have been shown to improve women’s pregnancy outcomes. As has women’s empowerment and absence of diseases like HIV and malaria which complicate pregnancy and are a significant cause of maternal deaths and morbidity.

10. Afromedica: Your final words for us; young ones especially women medical students across Africa? Amb. E B-A: Like Steve Jobs I will say first and foremost have a vision for what you want to be or do and hold on to your dream. It may not be easy but perseverance and determination will get you there. There is a lot of good in our world but there is also so much that can be improved. We can all work to make our corner of the world a little better in some way and we should aim at that. Whatever you do; try to be the best at it. There is no room for mediocrity. And as somebody rightly said, “-- in a race you don’t win the silver—you lose the gold!“ You have to try and win the gold. And for the women doctors I say it is possible to combine a successful career in medicine with raising a family – and to enjoy both.

AFROMEDICA 2012 1(1) : 28 – 37 Preferred places of delivery by pregnant women in Chongwe

ORIGINAL ARTICLE

A STUDY ON THE PREFERRED PLACES OF DELIVERY BY PREGNANT WOMEN IN RURAL CHONGWE AND HOW BEST THESE PLACES CAN BE USED TO REDUCE MATERNAL MORTALITY Author: Sichembe Wantula Objectives

CONCLUSIONS

General Objectives To identify the preferred places of delivery by pregnant women in rural Chongwe district, Lusaka, Zambia, and describe ways in which these preferred places of delivery could best be utilized to reduce on maternal mortality.

The importance of giving birth at a health facility should be communicated to mothers who give birth at home, during postnatal visits or clinic outreach sessions. For those that cannot manage at all costs, Traditional Birth Attendants (TBAs) should be involved in their deliveries so as to avoid complications that could lead to maternal mortality.

INTRODUCTION

Specific Objectives  To identify the preferred places of delivery by pregnant women in rural Chongwe district  To establish the reasons for these plans  To establish any arrangements made towards these plans  To establish how these preferred places of delivery could best be improved to reduce on delivery complications and maternal mortality

The World Health Organization (WHO) reports that reproductive health problems account for more than one third of the total burden of disease in women. WHO further estimates that over 500,000 women die every year from complications of pregnancy, including abortion and virtually all these deaths occur in the developing countries, which accounts for 99% of all deaths. The major causes of this maternal mortality in these developing countries include anaemia, haemorrhage, eclampsia, infections, abortions and complications of obstructed labour. These are all preventable causes. This all lies in the health care that a mother receives during pregnancy, at the time of delivery and soon after delivery as it is important for the survival and well-being of both the mother and her child.

RESULTS A total of 50 pregnant women were recruited in the study, majority of whom were between 15-24 years of age(60%) and were married (86%). 70% had gone up to primary school level of education and were able to read and write. The majority of the women walked on foot to the health facilities(66%) and took less than an hour to reach the facilities for most of them(48%). 78% of the women had made plans towards their delivery, and of these, 74.4% had made plans concerning the place of delivery. A total of 89.6% opted to deliver from a health facility while the rest opted to deliver from either their own homes (6.9%) or their parents’ homes (3.4%). Reasons for the choices were that either they trusted the place (41.4%), or the place was closest to their homes (34.5%) or they did not trust the nearest health facility (6.9%) or simply had no choice (17.2%).

However, the poor health care systems in most developing countries, especially in Sub-Saharan Africa, makes the achievement of reduction of maternal mortality quite a difficult task. These include issues of limited skilled health professionals, distances to the nearest health facilities, poor attitudes of health workers towards the expectant mothers and so on, and these have an effect on the woman’s choice of place of delivery.

AFROMEDICA 2012 1(1) : 28 â&#x20AC;&#x201C; 37 Preferred places of delivery by pregnant women in Chongwe

From the womanâ&#x20AC;&#x2122;s perspective, two key sets of factors should influence her decision on where to give birth:

2. The structure of the health system in her country, including availability of public and private providers, financing mechanisms for the demand and supply side, the supply and location of the health workforce as well as their decisions on care provision, health information available to the public, and government policies influencing private/public sector behavior as well as patient choice.

1. Her individual determinants, such as sociodemographic characteristics, economic and physical access based on household wealth and proximity to birth facilities, and actual/perceived need for health care based on risks associated with childbirth and the use of antenatal care (ANC) and other health care services.

Factors Affecting a Womanâ&#x20AC;&#x2122;s Choice of Birth Facility

STATEMENT OF PROBLEM

These choices a woman makes have an effect on the kind of care she would receive at the place she chooses to deliver from. Most women opt to deliver at home where they are assisted by relatives and friends or by TBAs. It is therefore important to determine what choice women will make and therefore be ready to meet them at the places they choose. However, the importance of giving birth at a health facility should still be communicated to mothers who give birth at home, during postnatal visits or clinic outreach sessions.

Zambia adopted the concept of Primary Health Care (PHC) to bring health services including maternity services as close to the family as possible. It is estimated that 50% of households in rural areas are within a radius of 5 km from a health facility. In spite of the closeness to a health facility, only 27.9% of live births are delivered at such health facilities, suggesting that 22.1% of the expectant women do not deliver at a health facility despite being within reach of a health facility. There is overwhelming evidence that distance to a health facility is a strong determinant of the choice 29

AFROMEDICA 2012 1(1) : 28 â&#x20AC;&#x201C; 37 Preferred places of delivery by pregnant women in Chongwe

for maternal health services, However, factors other than distance to health facility have been reported to be associated with health service utilization for childbirth such as education, maternal age , parity, economic status, cultural factors and beliefs, lack of skilled staff at primary health care level, and health worker negative attitudes towards expectant mothers. Expectant mothers, therefore tend to make decisions as where they would deliver from based on these factors and not so much on their safety. It is therefore important to identify the alternative places of delivery that these pregnant women chose so as to take the necessary health care to them.

Maternal situation in Zambia ď&#x201A;ˇ Maternal Mortality Rate: 591/100,000

Percentage of Maternal Deaths by stage of Death During Pregnancy

26% 61%

13%

During Labour After Labour

This research proposal aims to identify the preferred places of delivery by pregnant women in rural Chongwe district and describe ways in which these preferred places of delivery could best be utilized to reduce on maternal mortality.

Percentage of Postpartum Maternal Deaths by Time of Death 22%

36%

Same day 1-3 days

15%

4-7 days

STUDY JUSTIFICATION 27%

Provision of safe motherhood is of utmost importance in the reduction of maternal mortality. Zambia has one of the highest maternal mortality rate in the world at 591/100000 live births, and can be even higher in some remote areas . Safe deliveries can only be guaranteed if deliveries are conducted at a health facility by skilled staff. However, staffing of qualified staff for safe deliveries in health facilities in Zambia remains a challenge. Overall, 33% of rural health centres are staffed by unqualified health workers, and the shortage of midwives is even more critical.

7+ days

Percentage of Maternal Deaths by Place of Death 12% 47% 41%

Health Facility Home Other

The availability of delivery assistance by Traditional Birth Attendants (TBAs) has been reported to be associated with non-utilization of a health facility. In communities such as Chongwe that are poorly serviced by health facilities, TBAs will always be used. Therefore once the preferred places of deliveries by pregnant women in Chongwe is established, it would be easier to reach them at those particular places so as to provide the highest possible health care at those point through TBAs. Thus, there is need to train TBAs in safe delivery, and referral of expectant mothers to health facilities in time to get to the centres.

ď&#x201A;ˇ

47.7% of deliveries occur in health facility - 32.8% in rural areas - 83.7% in urban areas

A lot more women are dying during and after childbirth than during pregnancy, with the most percentage being after labour. This therefore means that in order to reduce this maternal mortality, care of women during and after labour should be increased. Most of these postpartum deaths occur the same day of delivery and within the first three days. Of these deaths, a greater percentage occurs outside the health facilities. With the evidence that very few women in the rural areas deliver from the health facilities, this statistics could even be much more than this.

LITERATURE REVIEW 30

AFROMEDICA 2012 1(1) : 28 – 37 Preferred places of delivery by pregnant women in Chongwe

Zambia’s Millennium Development Goal Number 5 is to improve maternal health. The target is to reduce by threequarters, between 1990 and 2015, the maternal mortality ratio.

In order to achieve this, one of the ways is to establish why pregnant women are not going to the health facilities to deliver and also ensure that women have proper access to health care and proper delivery system, whether within or outside the health facility.

Mountains, islands, rivers-poor organization 3. Delay in receiving care at the health facility due to: - Supplies, personnel - Poorly trained personnel with punitive attitude - Finances -

Why are the pregnant women not going to the health facilities to deliver? And why do they die? This is answered by the “Three Delays Model”:

This research aimed to establish the choices that women would make based on where to deliver their babies from and how best the health system can be utilized to ensure that it reaches the women wherever they choose to deliver from.

The Three Delay Model 1. Delay in decision to seek care, which is influenced by: - Lack of understanding of complications - Acceptance of maternal death - Low status of women - Socio-cultural barriers to seeking care 2. Delay in reaching care due to:

AFROMEDICA 2012 1(1) : 28 â&#x20AC;&#x201C; 37 Preferred places of delivery by pregnant women in Chongwe

RESEARCH METHODOLOGY

ETHICAL CONSIDERATION:

Study Site: This research study was carried out at various rural health centres in Chongwe district, Lusaka Province, Zambia

Permission was sought from the Sisters-in-charge or any relevant person in charge of the health centres at the various health centres in Chongwe district. Participants were also consented for them to be involved in the study. Confidentiality was kept at all costs.

Target Population: The participants of this research study were pregnant women attending Antenatal visits at the various rural health centres in Chongwe district, Lusaka, Zambia. The eligible age group was all pregnant women of reproductive age, that is, between 15 and 49 years of age. Study Design: This study was a random descriptive cross-sectional study. Sample Size: 50 pregnant women were randomly selected as they attend their initial or follow-up Antenatal visits. Sampling Technique: The participants who took part in the study were selected on the basis of a systematized random sampling technique. A register of the pregnant women attending the clinic on a particular day was be drawn up and every third woman in the register was be picked and interviewed. Data Collection Methods: A total of 50 questionnaire-based interviews were conducted. The questionnaires contained closedended and open-ended questions and was structured in a way that was both easily understandable and timeefficient for the participants. Data Analysis: The data collected was analyzed manually. A tally system was used to compile data which was then used to construct tables and plot graphs. Research Limitations: As the study was being done in rural Chongwe district, the distances among the various rural health centres was a hindrance on how many pregnant women were captured per health centre.

AFROMEDICA 2012 1(1) : 28 â&#x20AC;&#x201C; 37 Preferred places of delivery by pregnant women in Chongwe

DATA COLLECTION AND ANALYSIS

EDUCATION LEVELS

1. Age Groups AGE GROUP FREQUENCY/50

< 15 YEARS 0

15-24 YEARS 30

25-34 YEARS 17

35+

NEVER ATTENDED

PRIMARY

SECONDARY

TERTIARY

70%

3 24%

AGE GROUPS PERCENTAGES

EDUACTION LEVELS PERCENTAGES

6% 0% < 15 YEARS

6% of the women had never attended school; 70% had gone up to primary level; 24% had reached secondary level, while none of them had ever done any tertiary education. This shows that the majority of the women had only gone up primary school level.

15-24 YEARS 25-34 YEARS 35+

2. Education Level

DIVORCED/ SEPERATED

MARITAL STATUS FREQUENC Y/50

WIDOWED

3. Marital Status

There were no pregnant women less than the age of 15. The majority of the women were in the age group of 15-24 years old (60%), followed by the age group of 25-34 years old (34%). The age group of 35 years and above had 6%. This showed that the majority of pregnant women are young women between the age of 15-24 years old.

MARRIED

60%

SINGLE

34%

MARITAL STATUS PERCENTAGES

LEVEL

NEVER ATTENDED

PRIMARY

SECONDARY

TERTIARY

0% 0%

FREQUENCY/50

14%

SINGLE MARRIED WIDOWED

86%

DIVORCED/SEPER ATED

None of the women were widowed, separated or divorced. They were either single (14%) or married (86%). Thus the majority of pregnant women interviewed were married.

AFROMEDICA 2012 1(1) : 28 – 37 Preferred places of delivery by pregnant women in Chongwe

4. HOW THEY GET TO HEALTH FACILITY MEANS OF TRANSPORT ON FOOT

BUS/TAXI

BICYCLE

CARRIED/WHEEL BARROW

OTHERS

MEANS OF TRANSPORT TO HEALTH FACILITY

FREQUENCY/50 33

ON FOOT BUS/TAXI BICYCLE CARRIED/WHEELBARROW OTHER 66% 26%

The means of transport used by the pregnant women to get to the health centres were: 60% came on foot, 26% used either a bus or taxi, 4% came by bicycle, while 2% used other means of transport such as ox-carts. None of the women were carried or came by wheel barrow.

>3 HOURS 6%

VISIT NUMBER

<1 HOUR 48%

FREQUENCY/50

OTHER 0%

FOLLOWUP 64%

64% of the women came for follow-up visits, while 36% were attending initial visits. There were no other types of visits.

6. VISIT NUMBER INITIAL

INITIAL 36%

The majority of the women (48%) took less than an hour to get to the health centre, while 46% took 1-3 hours and 6% took more than 3 hours.

VISIT

5. HOW LONG IT TOOK TO GET TO HEALTH FACILITY TIME <1 1-3 >3 HOURS HOUR HOURS FREQUENCY/50 24 23 3

TIME TAKEN TO REACH HEALTH FACILITY

1-3 HOURS 46%

FOLLOWUP 32

7. MADE PLANS FOR DELIVERY MADE PLANS YES FREQUENCY/50 39

OTHER 0

NO 11

AFROMEDICA 2012 1(1) : 28 – 37 Preferred places of delivery by pregnant women in Chongwe

78% of the women had made plans towards their delivery, whereas 22% had not made any form of plans. 22%

PLAN

0% MADE PLANS FOR DELIVERY YES

FREQUENCY/39 17

BABY CLOTHES

20%

ASSISTANCE DELIVERY

78%

40%

PLACE OF DELIVERY

60%

OTHER TRANSPORT ARRANGEMENTS

8. PLANS MADE

80%

TRANSPORT MONEY

100%

PLANS MADE 94.90% 74.40% 43.60% 15.40%

10.30% TRANSPORT MONEY OTHER TRANSPORT ARRANGEMENTS

PLACE OF DELIVERY

ASSISTANCE AT DELIVERY

BABY CLOTHES

Of the 78% that made plans, 43.6% made plans towards transport money, 10.3% made other transport arrangements. 74.4% made plans of the place they would want to deliver from, 15.4% had made plans as to who would assist them at delivery. 94.9% of the women had made plans towards baby clothes.

9. PREFERRED PLACE OF DELIVERY PLACE OF DELIVERY HOME

FREQUENCY/29

PARENT’S HOME

NEAREST HEALTH FACILITY 19

ANOTHER HEALTH FACILITY 5

NEAREST HOSPITAL 2

AFROMEDICA 2012 1(1) : 28 – 37 Preferred places of delivery by pregnant women in Chongwe

LOVE TO GIVE BIRTH 65.50%

17.20% 6.90% HOME

6.90%

3.40% PARENT'S HOME

NEAREST HEALTH FACILITY

ANOTHER HEALTH FACILITY

NEAREST HOSPITAL

Of the 74.4% that had made plans towards the place of delivery, 6.9% had decided on giving birth at home, 3.4% had decided to deliver from their parents’ home. 65.5% had decided to deliver from the nearest health facility, whereas 17.2% had decided on another health facility other than the nearest. 6.9% had decided on delivering from the nearest hospital. 10. REASONS FOR CHOICE REASON IT IS NEAREST

TRUST THE PLACE

FREQUENCY/29 10

DONT TRUST THE NEAREST HEALTH FACILITY 2

MALE NURSES AT LOCAL CLINIC

NO CHOICE

REASONS FOR CHOICE 41.40% 34.50% 17.20% 6.90% 0% IT IS NEAREST

TRUST THE PLACE

DONT TRUST MALE THE NEAREST NURSES AT HEALTH LOCAL CLINIC FACILITY

NO CHOICE

The reasons for the choice of place of delivery were: 34.5% chose the place because it was the nearest, 41.4% chose the place because they trust the place. 6.9% chose the place they chose because they don’t trust the nearest health facility. 17.2% chose the place they did because they had no choice.

AFROMEDICA 2012 1(1) : 28 â&#x20AC;&#x201C; 37 Preferred places of delivery by pregnant women in Chongwe

DISCUSSION

CONCLUSIONS

A total of 50 pregnant women were recruited in the study, majority of whom were between 15-24 years of age(60%) and were married (86%). 70% had gone up to primary school level of education and were able to read and write.

The importance of giving birth at a health facility should be communicated to pregnant women who prefer to give birth at home. These can be reached when they attend antenatal, postnatal services or at mobile clinics. If they, however, cannot manage, Traditional Birth Attendants can be assigned to attend to them until they deliver, thus ensuring safe, uncomplicated deliveries. The TBAs can also look out for early signs of complications and intervene quickly and ensure that the mothers are taken to the nearest health facility in good time.

The majority of the women walked on foot to the health facilities(66%) and took less than an hour to reach the facilities for most of them(48%). 78% of the women had made plans towards their delivery, and of these, 74.4% had made plans concerning the place of delivery. A total of 89.6% opted to deliver from a health facility while the rest opted to deliver from either their own homes (6.9%) or their parentsâ&#x20AC;&#x2122; homes (3.4%). Reasons for the choices were that either they trusted the place (41.4%), or the place was closest to their homes (34.5%) or they did not trust the nearest health facility (6.9%) or simply had no choice (17.2%).

ACKNOWLEDGEMENT I am grateful to the mothers for their participation in the study. We wish also to express our appreciation to the management for Chongwe District Health Management Team, Lusaka, Zambia for the permission granted to carry out the study, and the University of Zambia, School of Medicine, Department of Community Medcine.

The women that had plans to deliver from a health facility were at a lesser risk of maternal mortality, should any complications arise. As from those who opted to deliver from home, there is an increased risk of complications due to unsafe delivery and lack of skilled birth attendants or health worker to attend to them. And in cases where labour complicates such as obstructed labour, postpartum haemorrhage, or even prolonged labour, these women would not be able to receive the needed care that could save both their lives and that of their children.

REFERENCES 1.

There was also another group of women (22%) that had not made any plans at all concerning their deliveries. These women if they remained undecided were even at greater risk due to their indecision. The importance of planning for delivery should thus be communicated to these women.

4. 5. 6.

7. 8.

From these findings, some women might never deliver from a health facility and so it is important to put up measures to reach out to these women at the places they decide to deliver from. This is in no way a substitute to health facility delivery, but as a way of preventing complications of unattended labour which could lead to both maternal and infant mortality.

Pomeroy A., Koblinsky M. & Alva S, 2010 Private Delivery Care in Developing Countries: Trends and Determinants, ICF Macro Calverton, Maryland, USA Hazemba AN, Siziya S Choice of place for childbirth: prevalence and correlates of utilization of health facilities in Chongwe district, Zambia, Medical Journal of Zambia, Volume 35 Number 2 Zambia Demographic Health Survey(ZDHS) 2007 final report Zambia Reproductive Health Policy, June 2000 Zambia MDGs 2008 Progress Report Bisika T. 2008, The Effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi, East African Journal of Public Health, Volume 5 Number 2 http://www.bioline.org.br/pdf?rh09039 http://www.mmcizambia.org/index.php?option=com_ content&view=article&id=55&Itemid=62

Author: Sichembe Wantula University Of Zambia, School Of Medicine Department Of Community Medicine

It is therefore cardinal to train more skilled traditional Birth Attendant who will identify these women in the community and pay them regular visits so as to be able to plan safe uncomplicated home deliveries. However, the point on emphasizing the importance of facility delivery to these women cannot be over-stated. 37

AFROMEDICA 2012 1(1) : 38 â&#x20AC;&#x201C; 39 A study to determine the risk factors for caesarean section

ORIGINAL ARTICLE

A STUDY TO DETERMINE RISK FACTORS FOR CAESAREAN SECTION AND THE FETAL OUTCOMES IN POSTCAESAREAN SECTION WOMEN AT KORLE-BU TEACHING HOSPITAL Author: Caroline Hlordzi

Background

demographic, anthropometric, biomedical obstetric information were collected.

Cesarean delivery (CD) refers to the delivery of a baby through surgical incisions in the abdomen and uterus. Cesarean deliveries are categorized as either primary (ie, first cesarean delivery) or repeat (ie, after a previous caesarean birth). The total cesarean delivery rate is the sum of these two components1

and

Results: Among the 110 women who had caesarean section, 56.4%(n=62) were emergency and 43.6% (n=48) were elective caesarean sections. Majority (34.5%) of the respondents were within the 30-34 year age group. According to Stewart et al. (2007), the appropriate age range to conceive without risks for undesirable outcomes is 20 â&#x20AC;&#x201C; 35 years. Under-age (below 19 years) and over-age mothers (above 35 years) were at increased risk of poor pregnancy outcomes such as pre-term, small for gestation and low birth weight babies and high neonatal mortality 5 .

There has been an escalation in caesarean section rates globally. In the Korle-Bu Teaching Hospital (KBTH), caesarean section rate has risen over the past 37years, being 10.9 % in 1973 rising to about 17-25% from 1988-19992, 3 and it has escalated to 35.6% and 36.7% in 2010 and half way through 2011 respectively. According to a survey by the WORLD Health Organisation (WHO), nearly half of all births in China are delivered by caesarean section and 31.8% in the US at the end of 2007. 4

The average maternal height in this study was 1.57 meters. The average maternal height that has been associated with good pregnancy outcomes is >1.51 meters6. Forty-three (43.7 %) percent were overweight, 33.6 % were obese and 22.7 % were of normal weight in first trimester at booking visit. Patients with high BMI (overweight and obese) who had emergency caesarean section had fetal distress and cephalopelvic disproportion (CPD) as the predominant indications. The average gestational age at delivery in this study was 37.87 weeks. An earlier study conducted in Morogoro reported a relatively average shorter gestational age7. Among the respondents, 25.5% developed pregnancy induced hypertension. From this study, pregnancy induced hypertension was strongly associated with poor APGAR scores (<5/10, <5/10), low birth weight of less than 2.5kg and stillbirths - 80% of stillbirths were born to mothers with pregnancy induced hypertension. The average birth weight of babies in this study was 3.15 kg. This birth weight was slightly higher than that which was reported by Nyaruhucha in Tanzania,20067.

Numerous prenatal factors have been associated with elective and emergency caesarean sections, some of which may be amenable to change. The caesarean section rate continues to rise in many countries with routine access to medical services yet this increase is not associated with a significant improvement in perinatal mortality or morbidity. A large number of commentaries in medical literature and media suggest that consumer demand contributes significantly to the continued rise of births by caesarean section internationally. This study however verified maternal risk factors and fetal outcomes for caesarean section deliveries in the Korle-Bu Teaching Hospital, Accra, Ghana.

Methods: A cross-sectional study of 110 post-caesarean section clients in the postnatal wards in KBTH. Quantitative data collection technique with structured questionnaires were used. Socio-economic,

AFROMEDICA 2012 1(1) : 38 – 39 A study to determine the risk factors for caesarean section

Other variables such as maternal age, parity, maternal educational level, smoking, alcohol consumption, gestational age at delivery, and body mass index(BMI) did not show significant association with fetal outcome.

Author: Caroline Hlordzi University of Ghana Medical School

Conclusion: The c-section rate during the study period was 38.1%. The common risk factors for caesarean section werefound to be high BMI and pregnancy induced hypertension. These factors were also associated with poor fetal outcome.

References 1. Vincenzo Berghella; Cesarean delivery: Preoperative issues UpToDate version 19.1. 2011 2. Ali HS, Saleem N, Agha F. Caesarean section; Surgical technique. Professional Med J. 2010;17(3): 505-511. 3. Betrán AP, Merialdi M, Lauer JA, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol 2007; 21:98. 4. The association press daily news staff writer , Wednesday January 13, 2010 5. Stewart, C.P., Katz, S.K., LeClerq, S.C., Shrestha, S.R., West, K.P. & Christian, P. (2007) Preterm delivery but not intrauterine growth retardation is associated with young maternal age among primiparae in rural Nepal. Maternal and Child Nutrition 3. 2007; 174 - 185. 6. Kirchengast, S, Hartmann, B. Short stature is associated with an increased risk of caesarean deliveries in low risk population. Acta Medica Lituanica 14).2007; 1 – 6. 7. Nyaruhucha CNM., Msuya JM, Ngowi B, Gimbi DM. Maternal weight gain in second and third trimesters and their relationship with birth weights in Morogoro Municipality, Tanzania. Tanzania Health Research Bulletin 8. 2006; 41 – 44.

AFROMEDICA 2012 1(1) : 40 – 43 Prevention of mother to child transmission of HIV

ORIGINAL ARTICLE

PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV Author: Clara Lubinza

Mother-to-child transmission (MTCT) is when an HIV-infected woman passes the virus to her baby. This can occur during pregnancy, labor and delivery, or breastfeeding. Without treatment, around 15-30 percent of babies born to HIV-infected women will become infected with HIV during pregnancy and delivery. A further 5-20 percent will become infected though breastfeed.

Abbreviations

and AIDS. Sub-Saharan Africa is the world’s most severely affected region. With only 10% of the world’s population, it shelters about two thirds of the global total number of people living with HIV and AIDS. Today, there are an estimated 33.3 million people living with HIV and AIDS with 2.7 million new infections every year worldwide[2].

PMTCT - Prevention of Mother To Child Transmission. ARV - Ant retroviral drugs. ZDV - Zidovudine SSA - Sub Saharan Africa AIDS - Acquired Immunodeficiency Syndrome HIV - Human Immunodeficiency Virus VCT - Voluntary counseling testing DOTS - Directly Observed Therapy Strategy HAART - Highly Active Anti-retro viral Therapy NRTI - Nucleoside Reverse Transcriptase Inhibitor NNRTI - Non-Nucleoside Reverse Transcriptase Inhibitor STI - Sexually Transmitted Infection.

One in 12 adults in this region is reported to be infected with HIV. Although there are now reports of declining trends in HIV incidence in a number of countries, presumably due to changes in behavior and prevention programmes, the number of people withHIV has continued to rise, due to population growth, and more recently, the life-prolonging effects of antiretroviral therapy[3].

Introduction Mother-to-child transmission (MTCT) is when an HIVinfected woman passes the virus to her baby. This can occur during pregnancy, labor and delivery, or breastfeeding. Without treatment, around 15-30 percent of babies born to HIV-infected women will become infected with HIV during pregnancy and delivery. A further 5-20 percent will become infected though breastfeed.

Since the first three AIDS cases were reported in Tanzania in 1983, the HIV epidemic has spread rapidly to all districts and communities and has affected all sectors of the society. During the year 2003 a total of 18,929 AIDS cases were reported to the National AIDS Control-Programme (NACP) from the 21 regions, bringing the cumulative total of reported cases since the epidemic broke to 176,102[2].

Methodology

In 2007 about 2 million persons were estimated to be living with HIV and AIDS, with approximately 600,000 (30%) in need of ART. Recent data based on household surveys estimate the sero-prevalence in adults aged between 15 – 49 years in Tanzania to be 7%, with a wide variation across the regions. Sexual intercourse is the main mode of transmission of infection. That is why sexually active individuals aged between 15 and 49 are most severely affected, with women being at a higher risk of being infected than men[1].

Meta-analysis of detailed literature by authors of articles published since 1980’s from various sources, including MEDLINE, EMBASE, relevant reports, bulletins and guidelines from the United Nations (UN) and World Health Organization (WHO); and observation on relationship of mother to child HIV infection using different articles and papers.

Results HIV and AIDS are a major global health problem. By the end of 2007, it was estimated that a total of 33.2 [30.6 – 36.1] million people worldwide were living with HIV 40

AFROMEDICA 2012 1(1) : 40 – 43 Prevention of mother to child transmission of HIV

Mother-To-Child Transmission Of HIV

AZT and single dose NVP. This approach is much more difficult to administer than single dose nevirapine on its own, but it is significantly more effective, and is less likely to lead to drug resistance.

Around 300,000 children in sub-Saharan Africa became infected with HIV in 2009.The vast majority of these children have been infected with HIV during pregnancy, childbirth or breastfeeding, as a result of their mother being infected with the virus.

Triple combinations The most effective PMTCT therapy involves a combination of three antiretroviral drugs taken during the later stages of pregnancy and during labor.

Without interventions, there is a 20-45% chance that an HIV-positive mother will pass the virus on to her child. If a woman is supplied with antiretroviral drugs, however, this risk can be significantly reduced. Before these measures can be taken the mother must be aware of her HIV status, so HIV screening plays a vital role in the prevention of MTCT.

HIV and safer infant feeding The protective benefit of drugs is diminished when babies continue to be exposed to HIV through breastfeeding. Mothers with HIV are advised not to breastfeed whenever the use of breast milk substitutes is acceptable, feasible, affordable, sustainable and safe. However if they live in a country where safe water is not available then the risk of life-threatening conditions from formula feeding may be higher than the risk from breastfeeding.

ROLE OF ARV’S The following are the factors considered before deciding which drugs to take and at what time; 1. Health of an HIV pregnant woman. 2. Reducing the risk of HIV transmission from mother to child. 3. The possibility of developing HIV side effect. 4. The possibility of drugs causing harm to the baby.

Efficacy of antiretroviral drugs preventing HIV infection in infants

The efficacy of ARV prophylaxis regimens can be expressed either as short-term (4–6 weeks) or longterm efficacy. Infant and young child feeding patterns and the infant mortality rate in a population influence the relationship between short-term efficacy and longterm efficacy. Short-term efficacy, as determined by infant infection status at 4–8 weeks of life, has been demonstrated for short-course prophylactic ARV regimens comprising: ZDV alone, ZDV together with 3TC, NVP alone, ZDV plus NVP and ZDV + 3TC plus NVP.

TREATMENT FOR THE MOTHER AND REDUCING RISK OF HIV TRANSMISSION TO THE BABY Women who have AIDS require a combination of antiretroviral drugs for their own health. It is a daily treatment for the rest of life. It is highly effective at preventing mother-to-child transmission (PMTCT). Their newborn babies usually get a course of treatment for the first few days or weeks of life, to lower the risk even further.

Single dose Nevirapine

In a recent trial from Malawi infants born to women who had not received any ARV prophylaxis were given either single-dose NVP or single-dose NVP plus ZDV for one week. The combination of NVP and ZDV was more efficacious than NVP alone. In contrast, a further trial in Malawi showed no benefit of adding ZDV for one week to neonatal single-dose NVP when the mother had received intrapartum NVP[2].

A single dose of nevirapine given to the mother at the onset of labor and to the baby after delivery roughly halved the rate of HIV transmission. It is the Simplest of all PMTCT drug regimes. A single dose nevirapine is relatively cheap and easy to administer. Since 2000, many thousands of babies in resource-poor countries have benefited from this simple intervention, which has been the mainstay of many PMTCT programs.

Combining Nevirapine

AZT

with

single

Availability of PMTCT services

dose

To achieve wide coverage, PMTCT programmes must be integrated into existing public health systems, with services provided by all antenatal and delivery clinics. In Southern Africa, where HIV is very widespread among pregnant women, Botswana leads the way. High quality PMTCT services are provided in

According to the World Health Organization (WHO) 2006 guidelines, the recommended course of drugs for preventing mother to child transmission (PMTCT) in resources-limited settings should be a combination of 41

AFROMEDICA 2012 1(1) : 40 â&#x20AC;&#x201C; 43 Prevention of mother to child transmission of HIV

Testing methods

all of the country's public facilities through the Maternal Child Health/Family Planning system, which serves over 95% of pregnant women. Test results from between November 2006 and February 2007 indicate that less than 4% of babies born to HIV positive mothers in Botswana were infected - a rate comparable with the USA and Western Europe.

Numerous studies have found that switching from VCT( voluntary counselling and testing) to routine testing can dramatically improve take-up of testing in PMTCT programmes. For example, at one hospital in rural Uganda, the proportion of pregnant women with documented HIV status at discharge was more than doubled from 39% to 88% after routine testing was introduced. Some programmes have introduced rapid tests which produce result in as little as twenty minutes[4].

EFFICIENCY OF PMTCT SERVICES Improving efficiency means looking at nine main issues: accessibility; clinic resources; testing methods; fear and distrust; disclosure and discrimination; drug effectiveness; treatment for mothers; feasibility of replacement feeding; and male visits to antenatal clinics.

Fear and distrust Some women refuse HIV testing because they are afraid of knowing that they have a life-threatening disease - afraid that the resulting worry and stress will quicken death: "I would like to know my status if this will prevent my baby from getting infected, but on the other hand I fear knowing that I am among the dead and I am to experience much suffering of AIDS, so I would not want to know my HIV status for fear of those deep thoughts."Polly, south-west Uganda.

Accessibility Poor women in low and middle-income countries have many responsibilities. Also many live a long way from their nearest health facility and have little access to transport. It is therefore hardly surprising that a third of the world's pregnant women don't attend antenatal clinics.

Disclosure and discrimination To increase attendance, clinics should aim to be as accessible as possible. Improvements should include providing travel services. Nevertheless, to attain high coverage, PMTCT programmes also need to reach those who deliver at home. One way to achieve this is to give a Nevirapine pill to each HIV-positive woman in advance - perhaps even at the time of diagnosis - to be kept at home and taken at the start of labor. PMTCT programmes can increase acceptance of selfadministered drugs by working with traditional birth attendants, who attend the majority of home deliveries.

Many women are concerned that, if found to be HIV positive, their diagnosis will not remain secret. HIVrelated stigma and discrimination are found in all societies and can lead to social isolation and even loss of family support. Often the greatest worry is the reaction of a male partner.

Drug effectiveness and adherence Nevirapine, given in one dose each to mother and child, is by far the easiest type of drug for PMTCT programmes to administer and is the most basic. But it only reduces the risk of transmission by around 50%, and it can encourage HIV to develop drug resistance. Longer courses of drugs - involving daily doses for several weeks - are more effective at preventing HIV transmission and less likely to cause drug resistance[2].

Clinic resources Shortages of HIV test kits, preventive drugs and other supplies can limit the efficiency of PMTCT programmes. It is therefore important to have reliable supply chains that are integrated into the systems serving maternal and child health clinics. Staff shortages and motivational issues can also be very significant, especially when it comes to counseling, which takes a long time to do well. Ultimately, the best solution is to recruit more health workers. In the shorter term, better training, greater support and motivation can improve the efficiency of existing staff.

Male visits to antenatal clinics A study from Kenya revealed that where women are supported and accompanied by their male partners, they are more likely to consistently visit antenatal clinics. Few men usually accompany their wives on visits to antenatal clinics for fear of being ridiculed by peers. However it has been shown that when male partners are involved, both partners can get tested for HIV, know their status, and therefore improve the baby's chances of a healthy survival.

AFROMEDICA 2012 1(1) : 40 – 43 Prevention of mother to child transmission of HIV

2. UNICEF “evaluation of united nations supported pilot studies on the prevention of mother to child HIV transmission.” August 2003.

RECCOMENDATIONS   

Effective prevention of mother-to-child transmission (PMTCT) requires a three-fold strategy. Preventing HIV infection among prospective parents. Avoiding unwanted pregnancies among HIV positive women. Preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labor, delivery and breastfeeding.

3. WHO; ‘Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants, in resource limited settings’ 2010. 4. WHO, Geneva 'Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Towards Universal Access', 2006.

CONCLUSION Firstly, it is crucial to prevent children from becoming infected with HIV at birth as well as later in life. Secondly, if efforts are made to prevent adults becoming infected with HIV, and to care for those already infected, then fewer children will be orphaned by AIDS in the future. A number of African countries have conducted large-scale HIV prevention initiatives in an effort to reduce the scale of their epidemics. Senegal, for example, responded early to the emergence of HIV with strong political and community leadership now has one of the lowest HIV prevalence rates in sub-Saharan Africa. However, not all African countries have had such successful HIV prevention campaigns. In South Africa, the government's failure to respond to the AIDS crisis has lead to an unprecedented number of people living with HIV. An estimated 70,000 babies are born with HIV every year, reflecting significant failures in prevention of mother-to-child transmission initiatives.

Author: CLARA LUBINZA 2nd Year Medical Student Muhimbili University Of Health And Allied Sciences (MUHAS) Address: P. O. Box 65001, Dar Es Salaam, Tanzania. Telephone Number: +255 765 541193 Email. Karungiclavery@Yahoo.Com

ACKNOWLEDGEMENT Gratitude’s to the almighty God for without his hand this work could have never come out no matter what .With due respect , thanks to Muhimbili university of health and allied sciences academic staff members for the committed work of impacting knowledge and skills regarding health , Lazaro M. Mnongya MD3-MUHAS ,Mayega Samson MD2-MUHAS and Mkoma George MD3-MUHAS,for their pioneering in compiling this work.

REFERENCES 1. All Africa “mothers’ protest at withdrawal of free formular milk. 2010, 11th March.

AFROMEDICA 2012 1(1) : 44 â&#x20AC;&#x201C; 45 Acceptability of HIV counselling and testing in youth

ORIGINAL ARTICLE

ACCEPTABILITY OF HIV COUNSELLING AND TESTING IN YOUTH IN ABLEKUMA, SOUTH SUB-METROPOLITAN AREA, ACCRA, GHANA. Author: Ohaeri AO

Background:

75% of them choosing sexual contact and unscreened blood transfusion respectively, amongst other routes, as possible modes of transmission. They also had a good knowledge of preventive measures with 90% and 81.7% selecting abstinence from sex and use of condoms respectively as common modes of prevention of HIV. The respondents also had a good knowledge of HCT services, mostly from the media, and they had a fair idea of where to get tested in hospitals and health centres. However, their attitude and acceptability of HCT was low, despite the fact that 98% of the respondents believe that HCT is important in preventing and controlling the spread of HIV. Only a third (31%) of the respondents had undergone HCT and knew their HIV status, and another third were not willing to undergo HCT, even if it was free. Factors which affected the acceptability of HCT in the youth included not being ready to take the test, fear of stigmatization, fear of psychological trauma if results are positive, fear of unreliable results and absence of a cure.

HIV was first identified in Ghana in March 1986 and has since spread slowly but steadily and poses a great problem in most parts of the world today. Currently in Ghana, although the HIV prevalence has dropped from 1.9% in 2009 to 1.5% in 2010, which is lower than that of many African countries, it is firmly established that within the whole society, sub-populations with higher prevalence and risk of transmission constitute a reservoir for sustaining the epidemic. Various preventive strategies have been employed to curb the spread of HIV infection as there is presently no cure. Abstinence, avoidance of multiple sexual partners, condom use, HIV Counseling and Testing (HCT) and treatment of HIV-infected individuals form the cornerstone of HIV prevention. This study assesses the acceptability of HCT among youth in a specific submetropolitan area in Ghana.

Aim: The aim of this study was to determine the level of acceptability of HIV Counseling and Testing, as well as identify factors influencing acceptance in the youth of the Ablekuma South Sub-Metropolitan area.

Conclusion: The knowledge level on HIV modes of transmission and prevention in youth in Ablekuma South SubMetropolitan area is high; the knowledge level of youth on HCT services is adequate. However, the level of acceptance and utilization of HCT in youth is low, thus this behaviour needs to be addressed.

Methodology: A descriptive cross-sectional quantitative study design was used in which data was collected using a pretested self-administered questionnaire. The study population was youth aged between 15 to 35 years in the Ablekuma South Sub-Metropolitan Area, with a total of 126 respondents. Information about HIV modes of transmission and prevention, knowledge of HCT services and attitudes towards HCT was elicited among respondents. The data collected was analysed and interpreted using SPSS Statistical Gradpack 17.0 and Microsoft Excel.

REFERENCES 1. Bassett IV, Giddy J, Nkera J, Wang B, Losina E, Lu Z, Freedberg KA, Walensky RP. (2007). Routine voluntary HIV testing in Durban, South Africa: the experience from an outpatient department. Journal of Acquired Immune Deficiency Syndrome, 46, 181186. 2. Abanga A J. (2007). Awareness and Acceptability of Voluntary Counselling and Testing for HIV/AIDS in the Bolgatanga Municipality, Ghana.

Results: The majority of the respondents had a good knowledge of HIV modes of transmission with 99% and 44

AFROMEDICA 2012 1(1) : 44 â&#x20AC;&#x201C; 45 Acceptability of HIV counselling and testing in youth

3. Fylkesnes K & Siziya SA. (2004). Randomized trial on acceptability of voluntary HIV counselling and testing. Tropical Medicine and International Health, 9, 566-572. 4. Genberg BL, Kawichai S, Chingono A, Sendah M, Chariyalertsak S, Konda KA, & Centanto DD. (2007). Assessing HIV/AIDS stigma and discrimination in developing countries. AIDS and Behavior, 12(5), 772780. 5. Iliyasu Z, Abubakar IS, Kabir M, & Aliyu MH. (2006). Knowledge of HIV/AIDS and attitude towards voluntary counselling and testing among adults. Journal of the National Medical Association, 98(12), 1917-1922. 6. Kilewo J, Kwesigabo G, Comoro C, Lugalla J, Mhalu F, Biberfeld G, Wall S, & Sanstrom A. (1998). Acceptability of HIV counselling with testing in a rural village in Kagera, Tanzania. AIDS Care, 10, 431-439.

Author Ohaeri A. O Department of Community Health, University of Ghana Medical School, Class of 2011

AFROMEDICA 2012 1(1) : 46 – 48 Curbing malnutrition as the major cause of child morbidity and mortality

ORIGINAL ARTICLE

CURBING MALNUTRITION AS THE MAJOR CAUSE OF CHILD MORBIDITY AND MORTALITY. Author: George F. Mkoma.

LIST OF ABBREVIATIONS             

syntheses on nutrition status of children were put in inclusion criteria and analysed.

AIDS - Acquired immunodeficiency Syndrome FAO - Food and Agriculture Organization HIV - Human immunodeficiency Virus IDPs - Internally displaced persons MDGs - Millennium Development Goals SSA - Sub Saharan Africa TB - Tuberculosis UN - United Nation UNHCR - United Nations High Commissioner for Refugees UNICEF - United Nations Children's Fund WFS - World Food Summit WHO - World Health Organization WTO - World Trade Organization

Results: The number of hungry people is estimated to be 13.6% of the world’s population, children are the most victims, and this is due to neglect of agriculture, current worldwide economic crisis and the significant increase of food prices. The major challenges to food security in Africa are an Underdeveloped Agricultural Sector, Effects of Globalization, Barriers to Market Access and Disease and Infection. There is the need for an effective food quality control system where by food is made safe and its quality is maintained during production, handling, processing and packaging. And food security interventions must be based on nutritional interventions, facilitating market access and capacity building.

Background:

Discussion:

In the developing world, an estimated 230 million (39%) children under the age of five are chronically malnourished and about 54% of deaths among children younger than 5 are associated with malnutrition.1Malnutrition is a major public health and development concern with important health and socioeconomic consequences. In Sub-Saharan Africa (SSA), the prevalence of malnutrition among the group of under-fives is estimated at 41%.2

World agriculture produces 17% more calories per person today than it did 30 years ago, despite a 70% population increase. This is enough to provide food for everyone in the world.24 The problem is that many people do not have sufficient land to grow, or income to purchase, enough food. The role of maternal nutritional knowledge in child health is essential, as their ability to rightly judge whether their children’s growth status is normal or not. Micronutrient deficiencies and causes of hunger like poverty and conflict are areas where solutions are needed so as to reduce impact of malnutrition.

Aim: To identify the factors responsible for the high prevalence of malnutrition, challenges being faced by developing countries, different programs supported by United Nations and what interventions a country and people can take in reducing the impacts of malnutrition.

Conclusion: Action plans are of value. First, nutrition objectives and actions must be incorporated into national, sectoral and integrated development plans and the necessary human and financial resources must be allocated for achieving these objectives. Second, specific nutritional interventions must be developed which are directed at particular problems or groups. And third, community-

Methods: Data were collected from literature with English abstract published years between 1999-2010.Different articles and relevant reports from United Nations, FAO, UNICEF and UNHCR. The articles which presented 46

AFROMEDICA 2012 1(1) : 46 – 48 Curbing malnutrition as the major cause of child morbidity and mortality

based actions for nutritional assessment of problems and the implementation of appropriate measures need to be initiated.

malnutrition: socioeconomic determinants of anthropometric status of preschool children and their mothers in an African urban area. Public Health Nutrition 2000, 3:39-47. 12. Martorell R, Rivera J, Kaplowitz H, Pollitt E: Long-term consequences of growth retardation during early childhood. In Human growth: basic and clinical aspects. Edited by Hernandez M, Argente J. Amsterdam: Elsevier Science Publishers; 1992:143149. 13. Lavy V, Strauss J, Thomas D, de Vreyer P: Quality of health care, survival and health outcomes in Ghana. Journal of Health Economics 1996, 15:333357. 14. de Onis M, Frongillo EA, Blossner M: Is malnutrition declining? An analysis of changes in levels of child malnutrition since 1980. Bulletin of the World Health Organization 2000, 78:1222-1233. 15. UN Millennium Project. About MDGs: What they are. [ homepage on the internet]. No date [cited 2011 Dec 12]. Available from: http://www.unmillenniumproject.org/goals/ 16. UNDP. Human Development Report. 2005. 17. Nolen LB, Braveman P, Dachs JN et al. Strengthening health information systems to address health equity challenges. Bull World Health Organ. 2005, 83(8):597-603. 18. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year?" Lancet. 2003 Jun 28;361(9376):2226-34.19 19. Black RE, Allen LH, Bhutta ZA et al. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. 2008; 371(9608): 243-260 20. Jennifer Bryce, Cynthia Boschi-Pinto, Kenji Shibuya, Robert E. Black, and the WHO Child Health Epidemiology Reference Group. 2005. WHO estimates of the causes of death in children. Lancet; 365: 1147–52. 21. Cafiero, Carlo and Pietro Gennari. 2011. The FAO indicator of the prevalence of undernourishment FAO 22. Caulfield LE, de Onis M, Blössner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia,

REFERENCES 1. Assistant Scientist, Department of International Health, Johns Hopkins University, School of Public Health, 615 North Wolfe Street, Room W2041, Baltimore, MD 21205, USA (email: arice@jhsph.edu). Correspondence should be addressed to this author. 2. UNICEF. The state of the world's children 2000 [homepage on the internet]. No date [cited 2011 Dec 12]. Available from: http://www.unicef.org/sowc00/ 3. UN. Sub-Saharan Africa – the human costs of the 2015 'business-as-usual' scenario. 4. Smith LC, Obeid AEE, Jensen HH: The geography and causes of food insecurity in developing countries. Agricultural Economics 2000, 22:199-215 5. Smith LC, Haddad LJ: Explaining child malnutrition in developing countries: a cross-country analysis. International Food Policy Research Institute, Food Consumption and Nutrition Division discussion paper nr. 60; 2000. 6. Vella V, Tomkins A, Borghesi A, Migliori GB, Adriko BC, Crevatin E: Determinants of child nutrition in north-west Uganda. Bulletin of the World Health Organization 1992, 70:637-647. 7. Pelletier DL, Frongillo EA, Habicht JP: Epidemiological evidence for a potentiating effect of malnutrition on child mortality. American Journal of Public Health 1993, 83:1130-1133 8. Schroeder DG, Brown KH: Nutritional status as a predictor of child survival: summarizing the association and quantifying its global impact. Bulletin of the World Health Organization 1994, 72:569-579 9. Pelletier DL, Frongillo EA: The effects of malnutrition on child mortality in developing countries. Bulletin of the World Health Organization 1995, 73:443-448. 10. Mendez MA, Adair LS: Severity and timing of stunting in the first two years of life affect performance on cognitive tests in late childhood. Journal of Nutrition 1999, 129:1555-1562. 11. Delpeuch F, Traissac P, Martin-Pre Y, Massamba JP, Maire B: Economic crisis and 47

AFROMEDICA 2012 1(1) : 46 – 48 Curbing malnutrition as the major cause of child morbidity and mortality

malaria, and measles. American Journal of Clinical Nutrition 2004; 80: 193–98. 23. Shaohua Chen and Martin Ravallion. How have the world’s poorest fared since the early 1980s? World Bank Policy Research Working Paper 3341 Washington: World Bank; 2004. 24. Food and Agriculture Organization, International Fund for Agricultural Development, World Food Program. Reducing Poverty and Hunger, the Critical Role of Financing for Food, Agriculture, and Rural Development; 2002. 25. UNHCR. The Year in Review: A world in motion [homepage on the internet]. 2008 [cited 2011 Dec 12]. Available from: http://www.unhcr.org/4a2d0b1d2.pdf 26. Pelletier DL et al. A methodology for estimating the contribution of malnutrition to child mortality in developing countries. Journal of Nutrition, 1994, 124: 2106–2122. 27. Schroeder DG, Brown KH. Nutritional status as a predictor of child survival: summarizing the association and quantifying its global impact. Bulletin of the World Health Organization, 1994, 72: 569– 579. 28. Jamison D et al, eds. Disease control priorities in developing countries. New York, Oxford University Press; 1993. 29. Lambrechts T, Bryce J, Orinda V. Integrated management of childhood illness: a summary of first experiences. Bulletin of the World Health Organization, 1999, 77: 582–94. 30. Tulloch J. Integrated approach to child health in developing countries. Lancet, 1999, 354: 16–20. 31. InterAcademy Council. Realizing the promise and potential of African Agriculture [homepage on the internet]. c2004 [cited 2011 Dec 12]. Available from: http://www.interacademycouncil.net/24026/African Agriculture.aspx 32. Kherallah et al. Reforming Agricultural Markets in Africa. IFPRI. The Johns Hopkins University Press; 2002. 33. Hilary, J. Trade liberalization, Poverty and the WTO: Assessing the Realities.

34. In: The WTO and Developing Countries. Homi Katra and Roger Strange (eds); 2004.

Author: George F. Mkoma. Muhimbili University of Health and Allied Sciences. email: georgemkoma@yahoo.Com Phone no: +255 713 905229/ +255 753 712268

AFROMEDICA 2012 1(1) : 49 – 50 Family planning in Africa

ORIGINAL ARTICLE

FAMILY PLANNING IN AFRICA Author: Glory. A. Msacky

LIST OF ABBREVIATIONS

2000 to 2005, and of currently 2010 from SubSaharan Africa such as SDHS and TDHS.

 CPR - Contraceptive Prevalence Rate  SADHS - South Africa Demographic Health Survey  MDG`s - Millennium Development Goals  DHS - Demographic Health Survey  TNPP - Tanzanian National Population Policy  CPS - Contraceptive Prevalence Surveys  SSA - Sub Saharan Africa  FP - Family Planning  IUD - Intra-Uterine Devices

FINDINGS An analysis of fertility trends in 23 countries of Sub-Saharan Africa from 1980 to 1995 showed that in two-thirds of the countries there was evidence of fertility decline, with a particularly rapid decline in Kenya and Zimbabwe[7]. Furthermore 2010 statistics show the African total fertility rate to be standing at 4.7. These rates reflect contraceptive prevalence of these specific regions.

Background

Generally in all world regions, contraceptive use corresponds with fertility patterns.[13,14] . In regions where contraceptive use is widespread, fertility is low but in regions where contraceptive use is uncommon, fertility is high.[15,16].

Sub-Saharan Africa has the highest average fertility rate in the world. In 2009 the average number of births per woman was 5.1—more than twice as many as in South Asia (2.8) or Latin America and the Caribbean (2.2) [1]. More than 100 million women in less developed countries, or about 17 percent of all married women, would prefer to avoid a pregnancy but are not using any form of family planning.[4].

CONCLUSION The paper has shown that the high fertility pattern in Africa is among others, a result of the ineffectiveness of family planning programs.

Currently, approximately 24.8 percent of African women have unmet needs for family planning; this simply means 24.8 million women of reproductive ages who prefer to avoid or postpone childbearing are not using any method of contraception.[5] .

RECOMMENDATION The overall low rate of contraceptive prevalence and high unmet need for family planning suggests the need for African national governments and population policy makers to rethink access to contraceptives.

OBJECTIVES

REFFERENCES

 To review the current status of family planning practice in Africa.  To expore the relationship between family planning use and fertility in Africa.

1.World Bank. 2009. World Development Indicators. Washington, DC: World Bank 2.Preston-White, E., M. Zondi, G. Mavundla and H. Gumede (1990). Teenage pregnancy, whose problem?Realities and prospects for action in Kwazulu-Natal. South African Medical Journal,

METHOD Data were obtained by reviewing different literature on trends of family planning and fertility from 1980-1995 and from Tanzania Demographic Health Survey of 1990 to 1995 and

3. United Nations (UN), “Programme of Action of the International Conference on Population 49

AFROMEDICA 2012 1(1) : 49 – 50 Family planning in Africa

and Development,” accessed online at www.unfpa.org/icpd/reports&doc/icpdpoae.ht ml, on Dec. 9, 2002

13.Bertrand, J.T., E.K. Bauni, R.J. Lesthaeghe, M.R. Montgomery, O. Tambashe, and M.J. Wawer (1993): Factors Affecting Contraceptive Use in Sub-Saharan Africa. Washington D.C.: National Academy Press.

4. United States Agency for International Development. 2009. The status of Family Planning in sub-Saharan Africa Briefing Paper

14.Dodoo, F. N 2001 Fertility preferences and contraceptive use: A profitable nexus for understanding theprospects for fertility decline in Africa” workshop on prospects for fertility decline in high fertility countries.population division. Department of economic and social affairs. United Nations secretariat. 9-11 July 2001

5. Department of Economic and Social Affairs, Population Division. 2011. “Global population to pass 10 billion by 2100, UN projections indicate” United Nations. http://www.un.org/apps/news/story.asp?NewsI D=38253 Accessed 26 May 2011. 6. Aloo-Obunga, C. 2003. Country Analysis of Family Planning and HIV/AIDS: Kenya. Policy Project, Washington DC. (Johannesburg), vol. 77, No.3, pp. 11-20.

15.Williamson L.M, ParkesA. Wight D. Petticre M; Hart G. Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research. 2009. Reproductive Health. Vol 6. No 3. Page 9

7. Saxena P.C; Jurdi R. Impact of Proxitate Determinants on the recent fertility in Yemen

16. Saxena P.C; Jurdi R. Impact of Proxitate Determinants on the recent fertility in Yemen

8.Aloo-Obunga, C. 2003. Country Analysis of Family Planning and HIV/AIDS: Kenya. Policy Project, Washington DC.

17. Gribble J and Joan Haffey, Reproductive health in sub-Saharan Africa. Population Reference Bureau. 2008

9. Lucas, D. 1992. ―Fertility and Family Planning in Southern and Central Africa.‖ Studies in Family Planning 23 (3): 145–58.

18.Caldwell, J. C., and P. Caldwell. 1987. ―The Cultural Context of High Fertility in Sub-Saharan Africa.‖ Population and Development Review 13 (3): 409–37.

10. Rutenberg, N., M. Ayad, L.H. Ochoa, and M. Wilkinson (1991): Knowledge and Use of Contraception. Demographic and Health Surveys Comparative Studies No. 6, Columbia, Maryland, USA: Institute for Resource Development/Macro International Inc . 11. World Health Organisation. 2011. World Health Statistics John A. Ross and William L. Winfrey, “Unmet Need for Contraception in the Developing World and the Former Soviet Union: An Updated Estimate,” International Family Planning Perspectives 28, no. 3 (2002). 12.Dodoo, F. N 2001 Fertility preferences and contraceptive use: A profitable nexus for understanding the prospects for fertility decline in Africa” workshop on prospects for fertility decline in high fertility countries. population division. Department of economic and social affairs. United Nations secretariat. 9-11 July 2001.

19. Caldwell, J. C., and P. Caldwell. 2002. ―Africa: The New Family Planning Frontier.‖ Studies in Family Planning 33 (1): 76–86 20. Population Reports. 2003. The Reproductive Revolution Continues. Series M. Number 17 Page 8; Gribble J and Haffey,J . 2008. Reproductive health in sub-Saharan Africa. Population Reference Bureau.

Author: Glory. A. Msacky Muhimbili University Of Health And Alliened Science, Tanzania email: glorymsacky@gmail.com Phone no: 0718494657

AFROMEDICA 2012 1(1) : 51 The prevalence, associated factors and complications of home delivery

ORIGINAL ARTICLE

THE PREVALENCE, ASSOCIATED FACTORS AND COMPLICATIONS OF HOME DELIVERY FOR THE PAST FIVE YEARS AT BUNGU VILLAGE IN 2010 Author: Elisha O. Osati

Childbirth in Tanzania is influenced by various factors that can affect place of birth and itâ&#x20AC;&#x2122;s outcomes. These factors range from the public health system to individual, social, and community characteristics. It is insisted that women should deliver at hospital so as to reduce the maternal and infant morbidity and mortality.

Materials and Methodology:

number of home delivery. A large number of home deliveries are assisted by untrained personnel with small number of them assisted by medical personnel.

One hundred and sixty-six women who gave birth within past five years were included in this study. The information collected using Swahili structured questionnaire on which the direct questions were asked by the interviewer and the questionnaire filled based on the response from interviewee. Data were analyzed using a computer program EPI-INFO 2006. Chi-square was used to assess the level of statistical significance.

Recommendation: There is a need to increase efforts by the Government and Non-government organization on antenatal care, and the following should be considered: 1. Multisectoral approach: More people should be educated through implementation of attaining the primary universal education as one of the millennium development goals. Also topics about pregnancy and its complication should be included in the syllabus of primary, secondary and proceeding levels of education.

Results: Out of 166 households, 20 had home delivery which makes it 12%. Among the population interviewed, the prevalence of home delivery is high in the age group of 25-34 years of which 18.6% had home delivery. Among the households which were headed by women, 13.8% of them had home delivery as compared to 7% which were headed by men. 60% of all home deliveries were assisted by untrained personnel as compared to 25% who were assisted by traditional birth attendants leaving only 15% which were assisted by Medical personnel.

2. The pregnant women should be continually educated on the importance of attending antenatal clinic and preparedness for delivery. 3. Reproductive Health education should be provided to both women and men to increase their awareness about the disadvantages of unintended pregnancy which is one of the factors contributing to more households headed by women hence increase the chances of home delivery.

Conclusion: A good number of households have at least a good knowledge about delivery and the complication associated with it. Households which are headed by women are more likely to have high prevalence of home delivery as compared to those headed by men. Increasing level of education also reduces the

4. The Government should increase the numbers of trained health personnel in safe delivery to serve at the community level

AFROMEDICA 2012 1(1) : 52 Comparative study on labour outcomes on mothers who have undergone FGM

ORIGINAL ARTICLE

A COMPARATIVE STUDY ON LABOUR OUTCOMES IN MOTHERS WHO HAVE UNDERGONE FEMALE GENITAL MUTILATION (FGM), AND MOTHERS WHO HAVE NOT, DELIVERING AT KAPENGURIA DISTRICT HOSPITAL, RIFT VALLEY PROVINCE KENYA. Author: MOKOH Lillian Wairimu _______________________________________________________________________

Introduction:

had undergone FGM. Infants with an Apgar score between 8-10 were 68% and 85%, 4-7 were 28.3% and 13.3% and 0-3 were 3.3%and 1.7% among FGM and non FGM mothers respectively. Mothers who have undergone FGM are more likely to have perineal tears and extensive episiotomies and are prone to getting postpartum haemorrhage.25% of the mothers with FGM scars delivered through Caesarean section while only 10% of the non FGM delivered through it, but there was no direct relationship between presence of an FGM scar and Caesarian section.

Female Genital Mutilation has major health effects among women and children born of mothers who undergo it. Research done shows that the highest maternal and infant mortality rates are in FGMpracticing regions. Among the Pokot community in Kenya Female Genital Mutilation is widely practiced and serves as one of the hindrances towards our countryâ&#x20AC;&#x2122;s efforts of attaining the Millennium Development Goals (MDGs) as described in Kenyaâ&#x20AC;&#x2122;s vision 2030.

Broad Objective:

Conclusions:

To compare the maternal and foetal outcomes amongst mothers who have undergone Female Genital Mutilation compared to those who have not.

Female Genital Mutilation puts the women who undergo it at risk of various obstetric complications and their infants are more predisposed to a lower Apgar scores. Thus Female Genital Mutilation is a practice that contributes greatly to maternal and child mortality. If the practice continues, it will be difficult to foster gender equality and prevent child and maternal mortality.

Methodology: A cross-sectional study was carried out where labour outcome of 60 mothers who had undergone FGM was compared to 60 mothers who had not undergone FGM. Technique used to collect data was purposive. Data was collected by use of Data sheets, analysed using chi squares and odds ratio in Statistical Package for the Social Sciences (SPSS) and presented in charts, tables and graphs.

Results: There was no relationship between the maternal age and parity and the presence or absence of FGM scar thus the two had no effect on the study outcome. Majority of the women whose second stage of labour lasted more than 10 minutes are those who

AFROMEDICA 2012 1(1) : 53 - 54 Safe delivery as a pillar of safe motherhood

ORIGINAL ARTICLE

SAFE DELIVERY AS A PILLAR OF SAFE MOTHERHOOD: A STUDY OF NAROK NORTH DISTRICT, KENYA Author: Sinikka Rono _____________________________________________________________________________________________

Introduction:

of births, hospital deliveries were at 46.8%, home deliveries at 45.9% and the remaining 7.3% had their deliveries on the way to hospital. Out of the home deliveries, 16.7% were assisted by TBAs, 13.3% by a neighbor, 11.7% by a relative, 3.3% by a skilled birth attendant and 5% without any assistance. The factors that led to these home deliveries were long distances to health facilities, inaccessibility to health facilities due to poor infrastructure, readily available TBAs and sudden onset of labor.

This is a study done during COBES V, which is one of the courses designed in the MBchB curriculum of Moi University School of Medicine undertaken in the fifth year of study. The initials stand for Community Based Education and Service. The students are attached to a District Hospital for six weeks, between the months of May and June, 2011. This study was based on obstetric care which involves safe delivery as one of the eight pillars of safe motherhood that is geared towards reducing maternal mortality so as to achieve the fifth millennium development goals that focuses on improving maternal health.

Discussion: Despite the increasing availability of formal obstetric care in Kenya, the majority of births in areas of the country still occur at home assisted by unskilled traditional birth attendants (TBAs). However, they did acknowledge that ANC attendance was very important. In addition to this acknowledgement, they added that that they had not failed to attend ANC clinic for all their pregnancies.

Objective: To determine the factors affecting safe deliveries in Narok North District in Kenya.

Methodology: This was a cross sectional, descriptive study. The study area was Narok North District Hospital, in Narok North District, one of the rural districts in Kenya. Purposive sampling technique was used in which a sample size of 60 women was selected. Data collected was from the ANC and maternity records and also by interviewing pregnant women by use of an interviewer administered questionnaires. Data collected was entered, summarized, analyzed and presented in graphs and charts.

Conclusion: The women are not unaware of the capacity of the hospital to make child delivery safer, and there is little evidence that they reject outright the utilization of obstetric services from the hospital. The women also acknowledged the superiority of the hospital as a delivery site, especially during obstetric emergencies or when anticipating difficult childbirths. However, even with this knowledge, there were factors that led them to choose home delivery over hospital delivery.

Data Findings: The results brought out clearly that there was a difference in the total number of women who attended ANC and those who had hospital deliveries in the period between May 2010 and May 2011. These figures were 53.2% and 46.8% respectively. Out of the 60 women interviewed, 80% had attended ANC for all their deliveries. Out of the total number

Recommendations: There is the need to improve the level of awareness on importance of obstetric care as a pillar of safe motherhood and to improve on the infrastructure in

AFROMEDICA 2012 1(1) : 53 - 54 Safe delivery as a pillar of safe motherhood

Narok to make it easier for the women to access health facilities.

Author: Sinikka Rono 5th Year Medical student, Moi University School of Medicine, Kenya Email: snixrono@yahoo.com

AFROMEDICA 2012 1(1) : 55 – 56 Case report: Intestinal duplication with malrotation and a rectovestibular fistula

ORIGINAL ARTICLE

CASE REPORT: INTESTINAL DUPLICATION WITH MALROTATION AND A RECTOVESTIBULAR FISTULA Authors: Nelson F, Onchongà A, Magoma G, Matheka C

Intestinal duplications are a rare anomaly with few cases reported in English literature. They present as either tubular or spherical structures and sometimes with other associated congenital anomalies. A case of intestinal duplication associated with malrotation of the gut and a recto-vestibular fistula is presented with the relevant literature review. Objectives Broad Objective To report a case of intestinal duplication associated with malrotation of the gut and rectovestibular fistula.

Patient specific data A 2 week old female was presented at Kenyatta National Hospital, a referral institution in Kenya, by her mother who complained of meconium that was appearing per vagina. The baby had been born at home at term and had been on BF without problems. The patient underwent examination under anesthesia and a diagnosis of Anorectal Malformation with Recto Vestibular Fistula was made. Examination revealed that the patient had a malrotation of the gut with the appendix and the caecum in the left iliac fossa. Gut duplication from the mid jejunum was also diagnosed with a patent inactive anus and a fistula to the posterior wall of the vagina. Each of the two lumens had its own mesentery, blood supply with a loose adhesion band between them. A transverse divided colostomy and a fistulogram was performed. The patient is in the ward waiting for a posterior saggittal ano-rectoplasty (PSARP).

Specific Objectives  To present the patient specific data  To highlight the management of patients with intestinal duplication  To review relevant literature on intestinal duplication and malrotation Introduction Intestinal duplications are a rare anomaly (1) occurring in 1 in 4000 births (2). They present as either tubular or spherical structures that are attached to the mesenteric side of the lumen (3). Based on the location, 75% have been reported to be abdominal, 20% intrathoracic and 5% thoracoabdominal. Morphologically, 75% are cystic while 25% are tubular (4). Tubular duplications, true duplications, are much rare with less than 75 cases reported in English literature and they mainly involve the hindgut (2). Colonic duplication can present as an isolated anomaly or in combination with multiple congenital anomalies. Such associated anomalies include vertebral body anomalies, genitourinary tract abnormalities (5, 6), cardiac anomalies and situs inversus (7).

Diagnosis and treatment In cases of isolated colonic duplication, the diagnosis is invariably delayed until symptoms alert clinicians and prompt diagnostic evaluation. However in instances where associated congenital anomalies are present, the duplication is usually detected perinatally, either as part of a multisystem evaluation, or due to the existence of a fistulous communication with the genito-urinary tract leading to aberrant faecal drainage. Genitourinary anomalies are common since the urinary bladder, colon and urethra develop from the distal hindgut enlage (2). Fistulas with the 55

AFROMEDICA 2012 1(1) : 55 – 56 Case report: Intestinal duplication with malrotation and a rectovestibular fistula

genitourinary system commonly connect to the posterior urethra in males and the vagina in females (2) as in this case.

Treatment of small cystic or short tubular duplication involves segmental resection along with adjacent intestine. A long tubular duplication cannot be excised as it will lead to short bowel syndrome. In these cases mucosal stripping through a series of multiple incisions is recommended. The surgeon must consider the common blood supply shared between the duplication and the native bowel avoiding unattent sacrifice of normal bowel (7). Associated anomalies, location, and size of the duplication also influence the surgical treatment. Small and medium duplications should be resected with a small segment of bowel followed by primary anastomoses. Simple excision or enucleation of an enteric cyst is possible in some cases.

tract duplication. Ann Surg. 1989; 209: 167 – 174 Ravitch MM. Hindgut duplication—doubling of colon and genital urinary tracts. Ann Surg 1953; 137:588–601. Yousefzadeh DK, Blekers GH, Jackson Jr JH, Benton C. Tubular colonic duplication—review of 1876–1981 literature. Pediatr Radiol. 1983; 13(2):65–71. Stringer MD, Spitz L, Abel R, et al. Management of alimentary tract duplication in children. Br J Surg. 1995; 82(1):74-78. Macpherson RI: Gastrointestinal tract duplications: Clinical, pathologic, etiologic, and radiologic considerations. Radiographics. 1993;13:1063-1080.

Authors: Nelson F, Onchongà A, Magoma G, Matheka C School of Medicine, University of Nairobi, Kenya. All correspondence to: Matheka C. E-mail: mcw102005@yahoo.co.uk

In extensive or giant duplications, there are 2 main options: the surgical removal of both the lesion and the involved organ or a partial resection of the lesion with stripping of the residual mucosa (8). In extensive tubular duplication, the stripping of the mucosal lining (to remove any possible ectopic epithelium) followed by a latero-lateral anastomosis is recommended; this avoids an extensive bowel resection and is a good option in large duodenum duplications that otherwise would be treated by a pancreatoduodenectomy. REFERENCES 1. Pinter AB, Schubert W, Szemledy F, Gobel P, Schafer J, Kustos G. Alimentary tract duplications in infants and children. Eur J Pediatr Surg. 1992; 2(1):8-12. 2. Payne CE, Deshon GE, Kroll JD, Sumfest J. Colonic duplication: an unusual cause of Enterovesical fistula. UROLOGY. 1995; 46:726728, 3. Chaudhary S, Raju U, Harjai M, Gupta M. Intestinal Duplication Cyst. MJAF.I 2006; 62 : 87-88 4. Holcomb G, Gheissari A, O’Neill J, Shorter N, Bishop H. Surgical management of alimentary

AFROMEDICA 2012 1(1) : 57 â&#x20AC;&#x201C; 60 Testicular neoplasm presenting with recurrent intestinal obstruction: A case report

ORIGINAL ARTICLE

TESTICULAR NEOPLASM PRESENTING WITH RECURRENT INTESTINAL OBSTRUCTION: A CASE REPORT. Authors: Cyrus Matheka, Faraj Alkizim and Dr. Wambugu

Gastrointestinal tract metastases may present with complications including gastrointestinal haemorrhage, intestinal obstruction and rarely ulceration of the bowel mucosa. Testicular neoplasms metastasizing to the gastrointestinal rarely involve the upper gastrointestinal tract.

Case presentation:

reported only in few patients (1). As cancer patients live longer with improved therapy, physicians are more likely to encounter such rare phenomena. We hereby present a case report of recurrent intestinal obstruction in a male patient diagnosed with germ cell carcinoma. The aim of this article is to define current knowledge on this phenomenon, with emphasis on its presentation, clinical characteristics and investigations and to increase the awareness of the clinician treating cancer patients or gastroenterologists of such possibilities.

We describe an unusual case of recurrent gastrointestinal obstruction as the presenting manifestation of metastatic testicular neoplasm in a 13 year-old male without cryptorchidism.

Conclusion: Testicular neoplasm diagnosis should be considered when recurrent intestinal obstruction is identified in a young male.

Introduction Presentation of small bowel obstruction amongst oncological patients is common (1). This has serious implications with associated diagnostic as well as therapeutic dilemmas (1). The condition is most commonly caused by peritoneal carcinomatosis and post-irradiation adhesions or postoperative adhesions. Other causes have been reported including, Linitis plastica caused by metastatic lobular carcinoma of the breast (2), disseminated breast cancer (3), metastatic malignant melanoma (4) and small bowel intussusceptions due to metastatic malignant melanoma (5). Others include intestinal metastasis causing intussusceptions in patients treated for osteosarcoma, rectal obstruction after transanal resection of the prostate to for prostate cancer, and rectal adenocarcinoma. Jejunal intussusceptions with gastrointestinal bleeding caused by metastatic testicular germ cell cancer have also been reported. However, obstruction caused by secondary neoplasms i.e metastases from other organs to the bowel wall is

Case presentation A 13 year old male patient was referred to Kenyatta National Hospital, a major referral tertiary hospital, complaining of post-prandial vomiting, constipation, and epigastric pain. The vomiting was non-projectile, non-bloody and non-faeculent. This followed admission in a peripheral health facility where a diagnosis of intestinal obstruction had been made and explorative laparotomy performed. Extensive lymphadenopathy of the small gut mesentery was noted intraoperatively. Excisional biopsies of the nodes were taken for histopathological examination. The results revealed replacement of lymph nodes by medium to large germ cells. On presentation at our institution, the patient was conscious, alert, oriented, but lethargic and in severe pain. Other than the intestinal obstruction, he had no significant past medical history. On physical examination, the vital signs were normal. There was no 57

AFROMEDICA 2012 1(1) : 57 â&#x20AC;&#x201C; 60 Testicular neoplasm presenting with recurrent intestinal obstruction: A case report

jaundice, pallor, or cyanosis. The cardiovascular, respiratory and neurological systems were noted to be normal. On abdominal examination, there was obvious abdominal distension with tenderness. Bowel sounds were increased. Random Blood Sugar measured at the casualty was 5.7mmol/l. The patient was put on Penicillin, Gentamicin, Flagyl, Diclofenac and Buscopan. Paracentesis tested negative for ascites. An abdominal x-ray showed multiple air-fluid levels, while abdominal ultra-sound showed a large lobulated mass at the left epigastric and left lumbar region.

Histochemistry

Figure C

Immunohistochemistry studies reported the following: AE1/AE3 (negative), LCA (negative), Vimentin (positive), CD30 (positive), CD20 (negative), SIOD (negative), CD3 (negative) and CD117 (negative). Other tumor markers were not assayed.

Figures A, B and C. Ultrasound images showing the location of the abdominal mass and its relation to other organs.

Blood work up A blood diagnostic work up revealed: White blood count, 14.5 x 10e9/l; Neutrophils, 10.6 x 10e9/l (73.7%) with band forms; Lymphocytes, 1.63 x 10e9/l (11.3%); Monocytes, 1.93 x 10e9/l (13.3%) , Eosinophils, 0.068 x 10e9/l (0.473%); Basophils , 0.182 x 10e9/l (1.26 %) , Red blood cells, 4.36 x 10e12/l; Haemoglobin, 10.9g/dl; Haematocrit, 36.1%; MCV, 82.7fl; MCH, 27.4 pg , MCHC, 30.2g/dl , RDW, 15.3%; Platelets., 790 x10e9/l. The electrolytes were: Na121.5 mmol/l, K-3.6 mmol, Creatinine-3.6Âľmol/l and Urea-3.8 mmol/l.

Figure A

A diagnosis of intestinal obstruction was made secondary to metastatic testicular embryonal carcinoma. A differential diagnosis of a poorly differentiated mesenteric lymph node malignancy was also entertained. The patient passed on before chemotherapy could be initiated.

Discussion The patient did not have undescended testes. Cryptorchidism carries a higher potential for malignant transformation than the normally descended intrascrotal testes (6). Involvement of the gastrointestinal tract by metastatic germ cell neoplasms is very rare; with only 5% of metastastic testicular germ cell tumours involving the bowel (7). Seminomas are least likely to involve the

Figure B

AFROMEDICA 2012 1(1) : 57 – 60 Testicular neoplasm presenting with recurrent intestinal obstruction: A case report

Authors' contributions

gastrointestinal tract (8). In a series of autopsy study with GIT involvement, the main cancers were embryonal, teratoma and choriocarcinoma (9). Whereas the small bowel is the most common GI site of involvement, the duodenum is rarely involved. The involvement of the duodenum by metastatic testicular neoplasms has been attributed to the position of its second, third and fourth segments in the retroperitoneum where the lymphatic drainage of the testis is located (8). Unfortunately, our patient succumbed before chemotherapy or

Cyrus and Faraj were responsible for the literature review and composition of this manuscript. Dr. Wambugu was actively involved in care of the patient and revision of the final manuscript.

References 1. Efraim I., Hanoch K., Eli M., Baruch B. Small bowel obstruction caused by secondary tumours. Surgical Oncology 2006; 15:29–32. 2. 2. Cormier W.J., Gaffey T.A., Welch J.M., et al. Linitis plastica caused by metastatic lobular carcinoma of the breast. Mayo Clinic Proceedings 1980; 55:747–53.

radiotherapy could be initiated. This patient was not a good candidate for surgical management. This is because he had developed post-surgical adhesions after the explorative laparotomy. It has been noted that although other cancers such as melanoma, kidney, and stomach are much more common than germ cell tumour and more often metastasize to the small bowel, this diagnosis should be considered when recurrent small bowel mass with recurrent obstruction is identified in a young male (10).

3. Clavien P.A., Laffer U., Torhos J., et al. Gastrointestinal metastases as first clinical manifestation of the dissemination of a breast cancer. European Journal of Surgical Oncology 1990; 16:121–6. 4. Bender G.N., Maglinte D.D., McLarney J.H., et al. Malignant melanoma: patterns of metastasis to the small bowel, reliability of imaging studies, and clinical relevance. American Journal of Gastroenterology 2001; 96:2392–400.

Conclusion Although modern chemotherapeutic regimens have high success rates in the treatment of metastatic germ cell carcinomas, some authors have proposed that patients with intestinal metastasis belong to a high-risk group. Early intervention with surgical resection of the involved segment of bowel is necessary when GI complications are encountered. This group of patients with intermediate or high risk traditionally receive four cycles of bleomycin, etoposide, and cisplatin (BEP) with a known 30% to 40% failure of achieving a durable response (11). Unfortunately, our patient passed on before this could be initiated.

5. Gatsoulis N., Roukounakis N., Kafetzis I., et al. Small bowel intussusception due to metastatic malignant melanoma. A case report. Technical Coloproctology 2004; 8:141–3. 6. Adnan A.M., Hisham A.M., and Ossama I.N. Seminoma of an undescended testes presenting as incomplete large bowel obstruction. Med. Sci. 1994; 4:71-77. 7. Ranko Miocinovic and Ronney Abaza. Testicular Seminoma presenting with duodenal perforation: a case Report. Journal of Medical Case Reports 2008, 2:294

Consent It was impossible to obtain written informed consent from the patient since they are a minor and are since decease and the next of kin were untraceable. We believe this case report contains a worthwhile clinical lesson which could not be as effectively made in any other way. We do not expect objection from the next of kin for the publication since the patient remains anonymous.

8. Sweetenham J.W., Whitehouse J.M., Williams C.J., Mead G.M. Involvement of the gastrointestinal tract by metastases from germ cell tumours of the testis. Cancer 1988; 61:2566-2570.

AFROMEDICA 2012 1(1) : 57 â&#x20AC;&#x201C; 60 Testicular neoplasm presenting with recurrent intestinal obstruction: A case report

9. Chait M., Kurtz R.C., Hajdu S.I. Gastrointestinal tract metastases in patients with germ cell tumor of the testis. Dig Dis 1978; 23:925-928. 10. Miller T.T., Mendelson D.S., Wu L.T., Halton K.P. Seminoma of the testes presenting as an ulcerating mass of the duodenum. Clin Imaging 1992; 16:201-203. 11. Carver B.S., Sheinfeld J. Germ cell tumours of the testis. Ann Surg Oncol 2005; 12:871-880.

Authors: Cyrus Matheka, Faraj Alkizim and Dr. Wambugu School of medicine-University of Nairobi Department of Surgery-University of Nairobi, Kenyatta National Hospital Address: University of Nairobi, Department of Surgery P.O Box 30197-00100, Nairobi-Kenya. Corresponding author: Dr. Wambugu. Email: wambugudr@yahoo.com, phone: +254722530687

FAMSA THE FEDERATION OF AFRICAN MEDICAL STUDENTS ASSOCIATIONS

TEAM 2011/2012