Perinatal practices in two rural districts of Zimbabwe: a community perspective

OBJECTIVE: To describe perinatal practices from a community perspective and identify factors associated with perinatal death. DESIGN: Cross sectional community based survey. SETTING: Murewa and Madziwa rural areas, Zimbabwe. SUBJECTS: Women aged 15 to 50 years who had been pregnant within the 24 months preceding the survey. MAIN OUTCOME MEASURES: Where delivered, where preferred to deliver, model of delivery, use of herbs in labour, duration of labour, assistant at delivery, time of delivery, condition of baby at birth, resuscitation methods, birth weight, initiation of breast feeding, illness in the first week and outcome of pregnancy. RESULTS: 644 women were interviewed; 581/644 stated where they would have liked to deliver and 505/644 stated where they actually delivered their last baby. The majority 369/581 (62.4%) preferred to delivery at a government hospital and 240/505 (47.5%) actually delivered at a government hospital. Of the home deliveries only 27/581 (4.6%) preferred to deliver at home and yet 123/505 (24.4%) actually delivered at home. Primary care clinics were less preferred 151/581 (25.5%) as a place for delivery and 89/505 (17.6%) actually delivered there. Labour lasting more than 12 hours occurred in 20.4% of deliveries. Nurses were the commonest attendants at delivery 309/508 (60.4%) and morbidity following delivery was noted in 72/495 (14.5%). Resuscitation was carried out in 61/72 infants. Beating/shaking 36/61 (58.0%) and pouring cold water over the baby 11/61 (18.0%) were the commonest methods of resuscitation. Being delivered by a doctor compared to a nurse and being in Murewa district were statistically significant risk factors for mortality with Odds Ratio (OR) 5.21 (95% CI 2.86 to 9.51) and 3.90 (95% CI 1.51 to 10.09) respectively. The odds of dying when delivered by breech extraction were high, but not statistically significant OR 3.73 (95% CI 0.92 to 13.97) when compared to being delivered by vertex delivery. Labour more than 12 hours, use of herbs in pregnancy and time of delivery were not significantly associated with mortality with OR (95% CI) of 1.02 (0.40 to 2.19), 0.92 (0.00 to 4.38), 1.05 (0.56 to 1.97) respectively. On logistic regression analysis only being delivered in Murewa district remained significant. CONCLUSION: The utilisation of primary health care centres for delivery was unexpectedly low and home deliveries were unacceptably high. Increased mortality when delivered by a doctor and high early neonatal morbidity suggest poor monitoring and delayed intervention in labour. Infant morbidity following delivery was high and methods for neonatal resuscitation inappropriate. There is a need for more studies looking into health worker skills particularly in the areas of partogram use and neonatal resuscitation in these districts.     

The causes of perinatal mortality in Bulawayo, Zimbabwe.

The causes of all perinatal deaths at Mpilo Maternity Hospital were investigated over a 12-month period, during which there were a total of 466 stillbirths and 379 neonatal deaths, with a perinatal mortality rate of 36.0/1000 births in Bulawayo, Zimbabwe. The causes of death were in order of importance; congenital syphilis (20.5 pc), birth asphyxia (18.8 pc), unexplained stillbirths (11.8 pc), hyaline membrane disease (11.5 pc) neonatal septicaemia (10.8 pc), congenital malformations (7.7 pc), pregnancy induced hypertension (5.4 pc), placental abruption (4.9 pc), congenital infection (2.2 pc) and other causes (6.4 pc). Eleven pc of mothers booking in antenatal clinics had positive syphilis serology. Most were successfully treated. But over 400 mothers with early syphilis escaped treatment usually because they booked late or failed to book at all at antenatal clinics (74 pc) and occasionally because they had false negative results or were infected after early booking (27 pc). They delivered 101 stillbirths, most of whom died prematurely before labour and often had abdominal distension. There were 72 neonatal deaths, most of whom were preterm babies with respiratory distress and often hepatosplenomegaly. One half of the deaths from asphyxia were caused by prolonged obstructed labour and one quarter by prolapsed cord, stuck head in breech delivery and retained second twin. The incidence of both early and late onset neonatal septicaemia was very high with Group B Streptococci, Kliebsiella and Staphylococcus aureus the predominant pathogens. Improved antenatal, intrapartum and neonatal care could substantially reduce the perinatal mortality rate by preventing congenital syphilis and birth asphyxia and by treating hyaline membrane disease and neonatal septicaemia.     

Situation analysis for cervical cancer diagnosis and treatment in Zimbabwe

OBJECTIVE: To establish factors influencing early diagnosis and treatment of cervical cancer in Zimbabwean women. DESIGN: A cross sectional study. SETTING: A random selection of 29 primary health care facilities, 11 district/provincial and four tertiary hospitals in Zimbabwe. RESULTS: All the institutions at primary health care, district, provincial and tertiary levels had the basic infrastructure to perform exfoliative cytology screening (Pap. smear). An average of only nine pap. smears per month were performed at primary health clinics and at district/provincial and tertiary levels seven and 23 Pap. smears per week were done respectively. Infrequent supplies of consumable materials and lack of policy guidelines were the most common reasons for not screening women. Surgical treatment for cervical cancer was offered in all tertiary hospitals but only 22% of provincial hospital had facilities to perform hysterectomy. CONCLUSION AND RECOMMENDATIONS: There is an urgent need to improve screening for cervical pre-cancer in Zimbabwean women with emphasis to provide adequate treatment facilities especially at district and provincial Hospitals. A national policy guideline should be drawn to address specific ages and frequency of screening for cervical cancer.     

Risk factors for neonatal mortality: Harare Central Hospital Neonatal Unit--Zimbabwe

OBJECTIVE: To assess risk factors for neonatal mortality in a tertiary level neonatal unit. DESIGN: Case control analysis of routine neonatal data for 1998. SETTING: Harare Central Hospital Neonatal Unit. SUBJECTS: All neonates delivered at Harare Maternity Hospital and admitted to the neonatal unit for care between January and December 1998. MAIN OUTCOME MEASURE: Neonatal mortality in hospital. RESULTS: A total of 5,305 neonatal admissions were studied of which 19.3% died in hospital. The median age at death was two days (Q1 = 1, Q3 = 3) and the median age at hospital discharge was 3 days (Q1 = 1, Q3 = 6). Risk factors for mortality were un-booked mother odds ratio (OR) 2.36 (95% CI = 1.98 to 2.81), breech delivery OR: 1.76 (95% CI = 1.39 to 2.22), low birth weight OR: 4.67 (95% CI = 3.92 to 5.57), prematurity OR: 2.36 (95% CI = 2.09 to 2.66), congenital malformations OR: 2.80 (95% CI = 1.72 to 4.53) and birth asphyxia OR: 1.79 (95% CI = 1.51-2.12). Being admitted for respiratory distress was associated with better survival OR: 0.22 (95% CI = 0.17 to 0.28). Having a Caesarian section was also protective OR: 0.60 (95% CI = 0.47 to 0.76). Mother's age, parity, time of delivery and sex were not significantly associated with mortality odds ratios (95% CI) of 1.07 (0.86 to 1.34), 0.94 (0.78 to 1.13), 1.10 (0.93 to 1.30) and 0.89 (0.78 to 1.03) respectively. On regression analysis birth weight greater than 2,500 g, being un booked and breech delivery were predictive of mortality with OR (95% CI) of 0.99 (0.99 to 0.99), 1.31 (1.12 to 1.61) and 1.15 (1.04 to 1.28) respectively. CONCLUSION: Low birth weight is the highest risk factor for mortality in this tertiary level hospital. Strategies targeted at low birth weight infants such as antenatal corticosteroid use, improved intrapartum care, appropriate antibiotic use, improved efficiency and access to neonatal intensive care will have the most impact on neonatal mortality.     

Risk factors for gonococcal and chlamydial cervical infection in pregnant and non-pregnant women in Zimbabwe

OBJECTIVE: To identify demographic, behavioural and clinical characteristics of symptomatic and asymptomatic women with gonococcal and/or chlamydial cervicitis a study was conducted among women attending antenatal clinics and primary care clinics in Harare, Zimbabwe. DESIGN: Cross sectional study. SETTING: Primary care clinics and antenatal clinics in Harare. SUBJECTS: 467 women with vaginal discharge and 1,189 asymptomatic pregnant women. MAIN OUTCOME MEASURES: Behavioural and clinical correlates of gonococcal and chlamydial cervical infection. RESULTS: The mean age of symptomatic women was 26.11 +/- 6.84 years (range: 15 to 52 years) and that of asymptomatic pregnant women was 24.67 +/- 5.43 years (range: 15 to 45 years). Gonococcal and/or chlamydial cervical infection was found in 69 of 1,189 (5.8%) pregnant women and in 77 of 467 (16.5%) non-pregnant women. Logistic regression analysis identified the following predictors of gonococcal or chlamydial infection in women with vaginal discharge: being separated from the partner for a month or more (p = 0.002), having had sex with a new partner in the last three months (p = 0.002), current use of condoms (p = 0.011), and the finding on examination of a purulent vaginal discharge (p = 0.004). Amongst these women an increasing educational level was inversely associated with cervical infection (p = 0.007). Amongst asymptomatic pregnant women the following were identified as predictors of cervical infection: the patient admitting to having a vaginal discharge on direct questioning (p = 0.004), and the finding of a purulent vaginal discharge on examination (p = 0.001). CONCLUSIONS: Amongst symptomatic and asymptomatic women certain behavioural factors and some clinical findings are associated with cervical gonococcal or chlamydial infection. Women with multiple partners and with partners who are currently using condoms with them and those women with a purulent vaginal discharge are likely to be infected. The age and marital status of subjects was not associated with cervical infection. These findings are useful in providing appropriate care for women with overt or minimal symptoms.     

Kangaroo care for well low birth weight infants at Harare Central Hospital Maternity Unit--Zimbabwe

OBJECTIVE: To describe the experience in a newly established Kangaroo Care Unit (KCU) at a tertiary level hospital and to identify factors associated with poor outcome in this unit. DESIGN: Cross sectional study. SETTING: Kangaroo Care Unit at Harare Central Hospital, Zimbabwe. SUBJECTS: Mothers admitted to the KCU and their well preterm infants. MAIN OUTCOME MEASURES: Discharge home or referral back to the Neonatal Unit (NNU) for conventional care. RESULTS: 613 mother infant pairs were studied from May 1994 to December 1996. The median age for all mothers was 23 years (Q1 = 15, Q3 = 26). Fifty four percent of the infants were female. Median age at admission to KCU was 12 days (Q1 = 1, Q3 = 25). Seventy two percent of infants were discharged home from the KCU. The rest (28%) were referred back to NNU for conventional care. The odds of being referred back to the NNU were significantly higher if the infant was male OR = 1.82 (95% CI: 1.25 to 2.66); if the birth weight was < 1 500 gms OR = 1.52 (95% CI: 1.04 to 2.22); if the admission weight to the KCU was < 1500 grams OR = 2.16 (95% CI: 1.42 to 3.29) or if the age on admission to KCU was 14 days or more OR = 2.15 (95% CI: 1.44 to 3.29). These factors remained significant after adjusting for confounding. Mother's age, parity, booking status or whether admission was during the cold months or not had no significant bearing on the outcome in this unit. Reasons for referral back to NNU included apnoea (27%); respiratory distress (27%); aspiration pneumonia (18%); neonatal jaundice (8%); poor feeding (7%); ill mother (5%); sepsis (4%) and diarrhoea (3%). On multivariate analysis birth weight was the strongest predictor for being referred back to the NNU OR = 10.753 (95% CI: 6.026-19.186). CONCLUSION: Establishment of a KCU at a tertiary level hospital is feasible. Kangaroo care for well preterm infants is suitable for most mothers and their preterm infants. Infants were more likely to be referred back for conventional care if they were male, very low birth weight and if the age at admission was greater than two weeks. Further studies are needed to determine the long term survival of these infants.     

Comparison of wheelchair accessibility of public buildings pre and post the International Year of Disabled Persons (IYDP) in Harare, Zimbabwe: a case study

OBJECTIVE: To compare the accessibility to wheelchair users of public buildings built pre and post the International Year of the Disabled Persons (1981) in Harare central business district in Zimbabwe. DESIGN: A case study. SETTING: Harare central business district. SUBJECTS: 20 public buildings with at least two floors open to all users in the central business district of Harare, Zimbabwe. MAIN OUTCOME MEASURES: Wheelchair accessibility of public buildings. RESULTS: There were no significant differences in the median percentage compliance of parking areas (p = 0.546), ramps (p = 0.155) and toilets (p = 0.648) between the buildings built before the International Year of the Disabled Persons (IYDP) and those built after the IYDP. The overall median compliance of parking areas, ramps and toilets was 14% (Q1 = 14, Q3 = 21), 54% (Q1 = 43, Q3 = 62) and 45% (Q1 = 31.5, Q3 = 70), respectively. However, there was some evidence (p = 0.067) to suggest that compliance of entrances was better IYDP [median = 100% (Q1 = 90, Q3 = 100)] than pre IYDP [median = 80% (Q1 = 70, Q3 = 100)]. Meanwhile there was a significant difference in the median percentage compliance of elevators (p = 0.014) between pre[median = 90% (Q1 = 80, Q3 = 90)] and post [median = 100% (Q1 = 100, Q3 = 100)] IYDP. CONCLUSION: Overall compliance was poor. It is recommended that people with disabilities and the experts in the area of physical ability management be consulted and involved in the design and construction of these buildings.     

Antenatal care patterns and factors associated with perinatal outcome in two rural districts in Zimbabwe

OBJECTIVE: To study antenatal care (ANC) patterns, to identify factors associated with poor perinatal outcome and quality of ANC. DESIGN: Cross sectional community based survey. SETTING: Murewa and Madziwa rural Districts. SUBJECTS: 644 women aged between 15 to 50 years who had been pregnant in the immediate 24 months preceding the survey. MAIN OUTCOME MEASURES: Perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of ANC. RESULTS: A total of 644 women were interviewed. Overall perinatal mortality was 115 per 1,000 births. 511/644 (79.3%) visited a health centre for ANC. The woman herself (41.8%) as well as husbands (41.8%) were commonly the decision makers regarding starting ANC. Only 298/510 (58.4%) of women used primary health care facilities for ANC. 211/629 (35.1%) of women lived more than 5 kms from the health care centre. 153/629 (24.3%) were not able to pay for ANC. Only 110/509 (21.6%) started ANC in the first trimester. 307/495 (62.0%) made five or less ANC visits. Pregnancy related morbidity was high 209/644 (32.5%) and use of traditional herbs was common 158/644 (24.%). There were significant differences between districts as far as perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of care all having p values of 0.001 or less. On further analysis using logistic regression, having problems with pregnancy and vaginal bleeding were significant predictors of poor perinatal outcome with odds ratio (95% CI) of 2.8 (1.4 to 5.9) and 3.0 (1.1 to 8.6) respectively. Quality of ANC was rated as sub-optimal. CONCLUSION: Majority of rural women attended clinics for ANC. Perinatal mortality rate and pregnancy related morbidity were high. Vaginal bleeding was the strongest predictor for mortality. There is need to improve quality of antenatal care as this was found to be suboptimal. More objective oriented antenatal care visits and waiting mother's shelters form part of the solutions. Further studies are called for.     

阜阳市2008～2010年孕产妇死亡分析及建议

目的分析阜阳市2008～2010年孕产妇死亡状况及其影响因素,为有关部门制定孕产妇保健策略提供科学依据。方法根据阜阳市妇幼保健机构上报孕产妇死亡资料,对孕产妇死亡调查结果进行分析。结果阜阳市2008年孕产妇死亡率为31.6/10万,2009年为26.7/10万,2010年为27.9/10万,影响孕产妇死亡的主要原因为直接产科原因,前三位死因分别为产科出血、妊娠期高血压疾病和肺栓塞,只有59.5%的人接受过产前检查,分娩地点在乡镇卫生院的比例高,占38.1%,死亡地点在县区级以上医院比例高,占50%。结论 2008～2010年孕产妇死亡率呈波动下降,加大宣传力度、加强孕产期保健服务及管理、强化乡镇级卫生院产科质量建设和专业技能培训能进一步有效地降低孕产妇死亡率。     

深圳市龙岗地区流动人口与常住人口妊娠妇女合并症、并发症对比研究

目的:探讨深圳龙岗地区流动人口与常住妊娠妇女合并症、并发症的差异。方法:已收集流动人口孕产妇病例资料336例,按病例对照研究的要求,以1:2的比例随机抽取同期672例常住人口的同类病例行病例对照研究。结果:与本地常住人口相比较,本地区流动人口妊娠妇女的居住条件、生活环境、工作环境、经济收入较差,文化素质较低,卫生保健意识淡薄,她们的孕期保健措施不到位,其妊娠合并症、并发症(如贫血、胎膜早破、妊娠期高血压、前置胎盘、胎盘早剥、产后出血等)均高于常住人口;而围产儿健康状况较差。结论:流动人口的孕期保健工作需要加强。     

Feasibility of collaborative care treatment of opioid use disorders with buprenorphine during pregnancy

Background: Medication-assisted treatment with buprenorphine or methadone is recommended for pregnant patients with opioid use disorders (OUDs) to minimize adverse maternal and neonatal outcomes. Collaborative care approaches have been successfully utilized with office-based opioid treatment with buprenorphine in primary care settings, but research is significantly limited in the obstetric setting. Our aim with this study is to demonstrate the feasibility of a collaborative care model for pregnant patients with opioid use disorder. Methods: This is a case series of 16 pregnancies in 14 women initiated on office-based opioid treatment with buprenorphine in a perinatal mental health service embedded in 2 obstetric clinics. Patients are treated by a psychiatrist alongside their prenatal care provider and followed for up to 6 months postpartum and referred to ongoing substance abuse treatment to a community prescriber. Results: The average age of the patients was 30.3 years, and an average gestational age of 23.6 weeks at the time of referral. Treatment continued until delivery in 15 (93.8%) pregnancies, with an average duration of treatment of 14.5 weeks. The majority (60%) had a cesarean delivery. Twelve (80%) infants were admitted to the Neonatal Intensive Care Unit (NICU) for monitoring or treatment of neonatal abstinence syndrome, 14 (87.5%) patients continued or resumed treatment with buprenorphine postpartum at the time of discharge from our program, and 13 (81.3%) were referred to a community prescriber. Conclusions: A collaborative care approach to buprenorphine treatment is feasible during pregnancy. Further research is needed to improve the treatment of OUD during pregnancy.     

成都市龙泉驿区妊娠期糖尿病的发生率及高危因素调查

目的调研龙泉驿区妊娠期糖尿病(gestational diabetes mellitus,GDM)的发生率及高危因素。方法回顾性分析2013年01月—06月在笔者所在院建卡分娩的孕妇GDM的发生率,同时将其作为试验组(n=49),选取同期的健康孕妇作为对照组(n=39)。比较两组孕妇的基本情况及可能的病因学因素。结果该地区GDM的发生率为8.48%。糖尿病家族史、不良产科史、甘油三酯血症、高龄、多产、孕前体重指数高是该地区GDM的高危因素。结论应对GDM高危人群做好早预防、早诊断、早管理。     

Intrapartum foetal heart rate monitoring--continuous electronic versus intermittent Doppler--a randomised controlled trial.

OBJECTIVE--To compare different methods of intrapartum foetal heart rate monitoring in high risk pregnancies in detecting foetal heart rate abnormalities, need for operative delivery for foetal distress, and neonatal mortality and short term neonatal morbidity. DESIGN--A prospective randomised controlled trial. SETTING--Women in labour at a referral maternity hospital. PATIENTS--Women who were 37 weeks or more pregnant with singleton cephalic presentation and normal foetal heart rate prior to entry into the study. INTERVENTION--Women were randomly allocated using sealed opaque envelopes to either continuous electronic foetal heart rate monitoring or intermittent monitoring using hand held doppler foetal heart rate detector. OUTCOME MEASURES--These include abnormal foetal heart rate patterns, need for operative delivery for foetal distress, neonatal mortality, Apgar scores, admission to NNU, neonatal seizures, and hypoxic encephalopathy. RESULTS--Randomisation achieved good comparability between the two groups. Abnormal FHR patterns were more frequent in the electronic group (54 pc versus 32 pc). Caesarean section rate was not significantly different in the two groups (28 pc versus 24 pc) although slightly higher compared to overall for the unit (18pc). Foetal outcome was also comparable between the two groups. CONCLUSIONS--Asphyxia can be detected with a hand held doppler just as reliably as by the use of electronic monitors and their use should be further evaluated and promoted in obstetric units caring for high risk pregnancies in developing countries with scarce resources.     

新生儿窒息的原因和复苏术的分析

目的 了解新生儿窒息的原因,探讨其抢救措施,掌握抢救的要点,总结抢救的经验.方法 搜集本院129例新生儿窒息的临床资料,分析造成新生儿窒息的原因,并提出最佳的复苏措施.结果 导致新生儿窒息的主要原因是胎儿宫内窘迫、脐带因素和羊水过少,其次是胎位和产程异常.本组129例患儿中,抢救成功率93.80%,其中治愈121例,致残3例,死亡5例.结论 新生儿窒息的发生与多种产科因素及分娩方式密切相关;加强围产期保健和产程监护,正确处理产程,提高助产和复苏技术,选择适当的分娩方式,是降低新生儿窒息率的有效措施.