Bio

Curriculum vitae

Professor Qureshi is the current Head of Department of Obstetrics and Gynaecology. She has interests in safe motherhood, management of pregnancy complications and postpartum bleeding.

PreviewAttachmentSize
prof_qureshi_cv_updated.pdf952.11 KB

Publications


Submitted

Qureshi, ZP.  Submitted.  Case Records and Commentaries.

2017

Motomura, K, Ganchimeg T, Nagata C, Ota E, Vogel JP, Betran AP, Torloni MR, Jayaratne K, Jwa SC, Mittal S, Recidoro ZD, Matsumoto K, Fujieda M, Nafiou I, Yunis K, QURESHI ZAHIDA, Souza JP, Mori R.  2017.  Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health. Scientific Reports. 7 AbstractWebsite

Caesarean section (CS) is increasing globally, and women with prior CS are at higher risk of uterine rupture in subsequent pregnancies. However, little is known about the incidence, risk factors, and outcomes of uterine rupture in women with prior CS, especially in developing countries. To investigate this, we conducted a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health, which included data on delivery from 359 facilities in 29 countries. The incidence of uterine rupture among women with at least one prior CS was 0.5% (170/37,366), ranging from 0.2% in high-Human Development Index (HDI) countries to 1.0% in low-HDI countries. Factors significantly associated with uterine rupture included giving birth in medium- or low-HDI countries (adjusted odds ratio [AOR] 2.0 and 3.88, respectively), lower maternal educational level (≤6 years) (AOR 1.71), spontaneous onset of labour (AOR 1.62), and gestational age at birth <37 weeks (AOR 3.52). Women with uterine rupture had significantly higher risk of maternal death (AOR 4.45) and perinatal death (AOR 33.34). Women with prior CS, especially in resource-limited settings, are facing higher risk of uterine rupture and subsequent adverse outcomes. Further studies are needed for prevention/management strategies in these settings.

Use of caesarean section (CS) deliveries has been steadily increasing, from 6.7% in 1990 to 19.1% in 2014 globally1,2. Consequently, the number of deliveries by mothers with prior CS is also on the rise1.

Women with prior CS are at higher risk of uterine rupture. The reported incidence of uterine rupture among women with prior CS ranged from 0.22% to 0.5% in some developed countries3,4,5,6. The risk factors for uterine rupture in women with a history of CS include prior classical incision, labour induction or argumentation, macrosomia, increasing maternal age, post-term delivery, short maternal stature, no prior vaginal delivery, and prior periviable CS4,7,8,9,10,11. Uterine rupture poses considerable risk of adverse maternal and perinatal outcomes. The prevalence of maternal and perinatal complications, such as severe post-hemorrhagic anemia, major puerperal infection, bladder injury, hysterectomy, and perinatal mortality, are significantly higher in women with uterine rupture than women without uterine rupture4,10,12,13.

A World Health Organization (WHO) systematic review to determine the prevalence of uterine rupture worldwide identified uterine rupture as a serious obstetric complication being more prevalent and with more serious consequences in developing countries than in developed countries14. In developing countries, uterine rupture has been reportedly associated with obstructed labour, grand multiparity, injudicious obstetric interventions/manipulations, lack of antenatal care, unbooked status, poor access to emergency obstetric care, and low socioeconomic status rather than prior CS15,16,17,18. However, uterine rupture after prior CS is becoming more common as the availability of CS increases in these settings18. According to a literature review on uterine rupture in developing countries, the proportion of women with prior CS or uterine scar among women who had uterine rupture was up to 64%18. A study in India reported that the incidence of uterine rupture among women with prior CS was 1.69%19. Nevertheless, there are few studies about the incidence, risk factors, and outcomes of uterine rupture among women with prior CS from these settings.

Typically, uterine rupture occurs suddenly and requires immediate critical emergency care for mothers, fetuses, or neonates. The strategies for prevention and management, as well as the quality of affordable care for women at risk of or experiencing uterine rupture, are likely to vary across settings depending on their diagnostic capacity, availability of obstetric interventions, and human and facility resources. Therefore, the findings in developed countries may not be generalizable to low-resource countries and settings. The aim of this analysis was to describe the incidence, risk factors, and maternal and perinatal outcomes of uterine rupture among women with prior CS using data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which was conducted in facilities in 29 countries worldwide from 2010 to 2011.

Shakur, H, Roberts I, Fawole B, Chaudhri R, El-Sheikh M, desina Akintan, QURESHI ZAHIDA, Kidanto H, Vwalika B, Abdulkadir A, Etuk S, Noor S, Asonganyi E, Alfirevic Z, Beaumont D, Ronsmans C, Arulkumaran S.  2017.  Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. AbstractWebsite

Summary
Background
Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of
tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration
of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.
Methods
In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a
clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries.
We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual
care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of
tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box
containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those
assessing outcomes were masked to allocation. We originally planned to enrol 15
000 women with a composite primary
endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became
apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although
tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore
increased the sample size from 15
000 to 20
000 women in order to estimate the effect of tranexamic acid on the risk of
death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with
ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.
Findings
Between March, 2010, and April, 2016, 20
060
women were enrolled and randomly assigned to receive
tranexamic acid (n=10
051) or placebo (n=10
009), of whom 10
036 and 9985, respectively, were included in the analysis.
Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10
036 patients
vs
191
[1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given
treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group
vs
127 [1·7%] in the placebo group,
RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy
was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group
vs
351 [3·5%] in the placebo
group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy
was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group
vs
546 [5·5%]
in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did
not differ significantly in the tranexamic acid versus placebo group.
Interpretation
Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no
adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as
possible after bleeding onset.
Funding
London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and
Bill & Melinda Gates Foundation.

2016

J, H, Z Q.  2016.  Preventing deaths due to haemorrhage. . Best Practice & Research Clinical Obstetrics & Gynaecology Elsevier. 36:68-32.Website
Z, Q, A M.  2016.  Development of Basic Obstetric Theater Facility in a Low-resource Setting.. Gynecologic and Obstetric Surgery Challenges and Management Options.
M, W, H A-A, G C, YS C, A C, B F, S G, GJ H, P L, K M, TM N, Z Q, JP S, AM G.  2016.  Room temperature stable carbetocin for the prevention of postpartum haemorrhage during the third stage of labour in women delivering vaginally. Study protocol for a randomized controlled trial. 17(1) Abstract

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in low-income countries and contributes to nearly a quarter of maternal deaths globally. The current available interventions for prevention of postpartum haemorrhage, oxytocin and carbetocin, are limited by their need for refrigeration to maintain potency, as the ability to maintain a cold chain across the drug distribution and storage network is inconsistent, thus restricting their use in countries with the highest burden of maternal mortality. We describe a randomized, double-blind noninferiority trial comparing a newly developed room temperature stable formulation of carbetocin to the standard intervention (oxytocin) for the prevention of PPH after vaginal birth.
METHODS/DESIGN:
Approximately 30,000 women delivering vaginally will be recruited across 22 centres in 10 countries. The primary objectives are to evaluate the non-inferiority of room temperature stable carbetocin (100 μg intramuscular) versus oxytocin (10 IU intramuscular) in the prevention of PPH and severe PPH after vaginal birth. The primary endpoints are blood loss ≥500 mL or the use of additional uterotonics (composite endpoint required by drug regulatory authorities) and blood loss ≥1,000 mL (WHO requirement). Non-inferiority will be assessed using a two-sided 95 % confidence interval for the relative risk of the above endpoints for room temperature stable carbetocin versus oxytocin. The upper limit of the two-sided 95 % confidence interval for the relative risk for the composite endpoint of blood loss ≥500 mL or the use of additional uterotonics, and for the endpoint of blood loss ≥1,000 mL, will be compared to a non-inferiority margin of 1.16 and 1.23, respectively. If the upper limit is below the corresponding mar in, non-inferiority will have been demonstrated. The safety analysis will include all wom n receiving treatment. Safety and tolerability will be assessed by a review of adverse events, by conducting inferential testing with significance levels for between-group comparisons.
DISCUSSION:
If the results of the study show that room temperature stable carbetocin is a safe and effective alternative to oxytocin, this could have a substantial impact on the prevention of postpartum haemorrhage and maternal survival worldwide.
TRIAL REGISTRATION:
ACTRN12614000870651 (14 August 2014).

Santana, DS, Cecatti JG, Surita FG, Silveira C, Costa ML, Souza JP, Mazhar SB, Jayaratne K, QURESHI ZAHIDA, Sousa MH, Vogel JP.  2016.  Pregnancy and Severe Maternal Outcomes: The World Health Organization Multicountry Survey on Maternal and Newborn Health.. Obstetrics & Gynecology. 127(4):631-641. Abstractpregnancy_and_severe_maternal_outcomes.pdf

OBJECTIVE: To evaluate maternal complications (potentially life-threatening conditions, maternal near miss, and maternal death) that are mutually exclusive and severe maternal outcomes (maternal near miss or maternal death) associated with twin pregnancies.
METHODS: We performed a secondary analysis of a cross-sectional World Health Organization Multicountry Survey, which was implemented in 29 countries. Data from 4,756 twin deliveries were compared with 308,111 singleton deliveries. Factors associated with maternal morbidity and twin pregnancies were reported with adjusted prevalence ratio (95% confidence interval).
RESULTS: Potentially life-threatening conditions, maternal near miss, severe maternal outcomes, and maternal deaths were 2.14 (1.99–2.30), 3.03 (2.39–3.85), 3.19 (2.58–3.94), and 3.97 (2.47–6.38) times higher, respectively, among twin pregnancies. Maternal age older than 20 years, having a partner, multiparity, and elective cesarean delivery were associated with twin pregnancies. Postpartum hemorrhage and chronic hypertension were more frequently associated with severe maternal outcomes among twin pregnancies. Conditions indicating organ dysfunction (maternal near miss) were twofold to fivefold higher for twins. Poisson multiple regression analysis identified several factors independently associated with a severe maternal outcome, but not twin pregnancies.
CONCLUSION: Twin pregnancy is associated with greater severe maternal morbidity and a higher rate of maternal death than singleton pregnancy.

2015

Vogel, JP, Betrán AP, Vindevoghel N, Souza JP, M. R. Torloni ZJ, Tuncalp O, Mori R, Morisaki N, Ortiz-Panozo E, Hernandez B, Pérez-Cuevas R, Qureshi Z, Gülmezoglu AM, Temmerman M.  2015.  Use of the Robson classification to assess caesarean section trends in 21 countries. A secondary analysis of two WHO multicountry surveys Lancet Glob Health, 2015.. Abstract

Background
Rates of caesarean section surgery are rising worldwide, but the determinants of this increase, especially in low-income and middle-income countries, are controversial. In this study, we aimed to analyse the contribution of specific obstetric populations to changes in caesarean section rates, by using the Robson classification in two WHO multicountry surveys of deliveries in health-care facilities. The Robson system classifies all deliveries into one of ten groups on the basis of five parameters: obstetric history, onset of labour, fetal lie, number of neonates, and gestational age.
Methods
We studied deliveries in 287 facilities in 21 countries that were included in both the WHO Global Survey of Maternal and Perinatal Health (WHOGS; 2004–08) and the WHO Multi-Country Survey of Maternal and Newborn Health (WHOMCS; 2010–11). We used the data from these surveys to establish the average annual percentage change (AAPC) in caesarean section rates per country. Countries were stratified according to Human Development Index (HDI) group (very high/high, medium, or low) and the Robson criteria were applied to both datasets. We report the relative size of each Robson group, the caesarean section rate in each Robson group, and the absolute and relative contributions made by each to the overall caesarean section rate.
Findings
The caesarean section rate increased overall between the two surveys (from 26·4% in the WHOGS to 31·2% in the WHOMCS, p=0·003) and in all countries except Japan. Use of obstetric interventions (induction, prelabour caesarean section, and overall caesarean section) increased over time. Caesarean section rates increased across most Robson groups in all HDI categories. Use of induction and prelabour caesarean section increased in very high/high and low HDI countries, and the caesarean section rate after induction in multiparous women increased significantly across all HDI groups. The proportion of women who had previously had a caesarean section increased in moderate and low HDI countries, as did the caesarean section rate in these women.
Interpretation
Use of the Robson criteria allows standardised comparisons of data across countries and timepoints and identifies the subpopulations driving changes in caesarean section rates. Women who have previously had a caesarean section are an increasingly important determinant of overall caesarean section rates in countries with a moderate or low HDI. Strategies to reduce the frequency of the procedure should include avoidance of medically unnecessary primary caesarean section. Improved case selection for induction and prelabour caesarean section could also reduce caesarean section rates.
Funding
None.

Osoti, A, Gwako GN, Liyayi B, Qureshi ZP.  2015.  Distinguishing Intrauterine Fetal Demise versus Abdominal Pregnancy in Low Resource Settings. East African Medical Journal. 92(1) Abstractdistinguishing_intrauterine_fetal_demise_versus_abdominal_pregnancy_in_low_resource_settings.pdf

Diagnosis of abdominal pregnancy always poses a clinical dilemma. Transvaginal ultrasound is the ideal radiological procedure in locating these pregnancies. However in resource limited setting, abdominal and pelvic ultrasounds can be the only available yet unreliable modalities for distinguishing intrauterine versus abdominal pregnancies. We present a case of a 36 year old para 4+0 gravida 5 who presented with fetal demise at 16 weeks of gestation. Multiple abdominal and pelvic ultrasounds showed intra uterine fetal demise for which she underwent induction. The definitive diagnosis of abdominal pregnancy was established using transcervical Foleys catheter aided abdominal-pelvic ultrasound which showed an empty uterus and a gestational sac, placenta and a 16-week fetus with no cardiac activity in the right adnexa/iliac region.

Okusanya, BO, Oladapo OT, Long Q, Lumbiganon P, Carroli G, Qureshi Z, Duley L, Souza JP, Gulmezoglu AM.  2015.  Clinical pharmacokinetic properties of magnesium sulphate in women with preeclampsia and eclampsia. A systematic Review 2015. Abstractclinical_pharmacokinetic_properties_of_magnesium_sulphate_in_women_with_pre.pdf

Background
The pharmacokinetic basis of magnesium sulphate (MgSO4) dosing regimens for eclampsia prophylaxis and treatment is not clearly established.
Objectives
To review available data on clinical pharmacokinetic properties of MgSO4 when used for women with pre-eclampsia and/or eclampsia.
Search strategy
MEDLINE, EMBASE, CINAHL, POPLINE, Global Health Library and reference lists of eligible studies.
Selection criteria
All study types investigating pharmacokinetic properties of MgSO4 in women with preeclampsia and/or eclampsia.
Data collection and analysis
Two authors extracted data on basic pharmacokinetic parameters reflecting the different aspects of absorption, bioavailability, distribution and excretion of MgSO4 according to identified dosing regimens.
Main results
Twenty-eight studies investigating pharmacokinetic properties of 17 MgSO4 regimens met our inclusion criteria. Most women (91.5%) in the studies had pre-eclampsia. Baseline serum magnesium concentrations were consistently <1 mmol/l across studies. Intravenous loading dose between 4 and 6 g was associated with a doubling of this baseline concentration half an hour after injection. Maintenance infusion of 1 g/hour consistently produced concentrations well below 2 mmol/l, whereas maintenance infusion at 2 g/hour and the Pritchard intramuscular regimen had higher but inconsistent probability of producing concentrations between 2 and 3 mmol/l. Volume of distribution of magnesium varied (13.65–49.00 l) but the plasma clearance was fairly similar (4.28–5.00 l/hour) across populations.
Conclusion
The profiles of Zuspan and Pritchard regimens indicate that the minimum effective serum magnesium concentration for eclampsia prophylaxis is lower than the generally accepted level. Exposure–response studies to identify effective alternative dosing regimens should target concentrations achievable by these standard regimens.

2014

Souza, JP, Widmer M, Gülmezoglu AM, Lawrie TA, Adejuyigbe EA, Carroli G, Crowther C, Currie SM, Dowswell T, Hofmeyr J, Lavender T, Lawn J, Mader S, Martinez FE, Mugerwa K, QURESHI ZAHIDA, Silvestre MA, Soltani H, Torloni MR, Tsigas EZ, Vowles Z, Ouedraogo L, Serruya S, Al-Raiby J, Awin N, Obara H, Mathai M, Bahl R, Martines J, Ganatra B, Phillips SJ, Johnson BR, Vogel JP, Oladapo OT, Temmerman M.  2014.  Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exercise., 2014. Reproductive health. 11:61. Abstract

Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required.

Vogel, JP, Souza JP, Gülmezoglu MA, Mori R, Lumbiganon P, QURESHI ZAHIDA, Carroli G, Laopaiboon M, Fawole B, Ganchimeg T, Zhang J, Torloni MR, Bohren M, Temmerman M.  2014.  Use of antenatal corticosteroids and tocolytic drugs in preterm births in 29 countries: an analysis of the WHO Multicountry Survey on Maternal and Newborn Health., 2014 Nov 22. Lancet. 384(9957):1869-77. Abstract

Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. We analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries.

2013

Souza, JP, Gülmezoglu AM, Vogel J, Carroli G, Lumbiganon P, QURESHI ZAHIDA, Costa MJ, Fawole B, Mugerwa Y, Nafiou I, Neves I, Wolomby-Molondo J-J, Bang HT, Cheang K, Chuyun K, Jayaratne K, Jayathilaka CA, Mazhar SB, Mori R, Mustafa ML, Pathak LR, Perera D, Rathavy T, Recidoro Z, Roy M, Ruyan P, Shrestha N, Taneepanichsku S, Tien NV, Ganchimeg T, Wehbe M, Yadamsuren B, Yan W, Yunis K, Bataglia V, Cecatti JG, Hernandez-Prado B, Nardin JM, Narváez A, Ortiz-Panozo E, Pérez-Cuevas R, Valladares E, Zavaleta N, Armson A, Crowther C, Hogue C, Lindmark G, Mittal S, Pattinson R, Stanton ME, Campodonico L, Cuesta C, Giordano D, Intarut N, Laopaiboon M, Bahl R, Martines J, Mathai M, Merialdi M, Say L.  2013.  Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study., 2013 May 18. Lancet. 381(9879):1747-55. Abstract

We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities.

Gwako, G, Qureshi Z, Kudoyi W, Were F.  2013.  Antenatal corticosteroid use in preterm birth at Kenyatta National Hospital. J. Obst. Gynae. East Central. Afr. 25(1):3-9.
Souza, JP, Gülmezoglu AM, Vogel J, Carroli G, Lumbiganon P, QURESHI ZAHIDA.  2013.  Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet. 381(9879):1747-1755. Abstract

Summary

Background: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities.

Methods: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios.

Results: From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23 015 (7•3%) women had potentially life-threatening disorders and 3024 (1•0%) developed an SMO. 808 (26•7%) women with an SMO had post-partum haemorrhage and 784 (25•9%) had preeclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0•826 [95% CI 0•802–0•851]).

Interpretation: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of lifesaving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy.

Funding: UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

2012

Bennett, C.L; Qureshi, SNMXTZP; AO;.  2012.  Gadolinium-induced nephrogenic systemic fibrosis: the rise and fall of an iatrogenic disease.. Abstract

In 2006, nephrologists in Denmark unexpectedly identified chronic kidney disease (CKD) patients with a new syndrome, nephrogenic systemic fibrosis (NSF). Subsequently, 1603 NSF patients were reported to the Food and Drug Administration. Sixty hospitals in the USA account for 93% of these cases, and two hospitals in Denmark account for 4% of these reports. We review Denmark's identification and subsequent rapid eradication of NSF. METHODS.: NSF reports from clinicians, the Danish Medicines Agency (DMA) and gadolinium-based contrast agents (GBCAs) manufacturers were reviewed (2002-11). RESULTS.: In 1994, the DMA approved a non-ionic linear GBCA, gadodiamide (0.1 mmol/kg), for magnetic resonance imagings (MRIs), with a renal insufficiency contraindication. In 1996, 0.3 mmol/kg dosing received DMA approval. In 1998, the DMA removed renal contraindications. In 1997 and 2002, radiologists at Skejby Hospital and Herlev Hospital, respectively, began performing gadodiamide-enhanced magnetic resonance angiography scans (0.3 mmol/kg) of CKD patients. In 2005, Herlev clinicians requested assistance in evaluating etiological causes of NSF occurring among 10 CKD patients who had developed NSF. This investigation, focusing on infectious agents, was inconclusive. In 2006, Herlev clinicians reported that of 108 CKD patients who had received gadodiamide-enhanced MRI, 20 had developed probable NSF. Herlev radiologists voluntarily discontinued administering gadodiamide to all patients and no new NSF cases at Herlev Hospital developed subsequently. After meeting with Herlev radiologists, Skejby radiologists also discontinued administering gadodiamide to all patients. In 2007, the European Medicines Agency and the DMA contraindicated gadodiamide administration to CKD patients. In 2008, in response to these advisories, radiologists at the other 36 Danish hospitals discontinued administering gadodiamide to all patients, following on practices adopted at Skejby and Herlev Hospitals. In 2009, clinicians at Skejby Hospital reported that a look-back survey identified 33 CKD patients with NSF developing after undergoing GBCA-enhanced MRIs between 1999 and 2007. In 2010, an independent review, commissioned by the Minister of Health, concluded that the DMA had erred in rescinding gadodiamide's renal insufficiency contraindication in 1998 and that this error was a key factor in the development of NSF in Denmark. In 2011, three NSF cases associated with macrocyclic GBCA-associated NSF and three NSF patients with Stages 3 and 4 CKD disease from Skejby Hospital were reported. CONCLUSION.: A confluence of factors led to the development and eradication of NSF in Denmark.

Chen, B, Restaino J, Norris L, Xirasagar S, Qureshi ZP, McKoy JM, Lopez IS, Trenery A, Murday A, Kahn A, Mattison DR, Ray P, Sartor O, Bennett CL.  2012.  A tale of two citizens: a State Attorney General and a hematologist facilitate translation of research into US Food and Drug Administration actions--a SONAR report. Abstract

Pharmaceutical safety is a public health issue. In 2005, the Connecticut Attorney General (AG) raised concerns over adverse drug reactions in off-label settings, noting that thalidomide was approved to treat a rare illness, but more than 90% of its use was off label. A hematologist had reported thalidomide with doxorubicin or dexamethasone was associated with venous thromboembolism (VTE) rates of 25%. We review US Food and Drug Administration (FDA) and manufacturer responses to a citizen petition filed to address these thalidomide safety issues. Case study. The AG petitioned the FDA requesting thalidomide-related safety actions. Coincidentally, the manufacturer submitted a supplemental New Drug Approval (sNDA), requesting approval to treat multiple myeloma with thalidomide-dexamethasone. FDA safety officers reviewed the petition and the literature and noted that VTE risks with thalidomide were not appropriately addressed in the existing package insert. In the sNDA application, the manufacturer reported thalidomide-associated toxicities for multiple myeloma were primarily somnolence and neurotoxicity, and a proposed package insert did not focus on VTE risks. In October, the FDA informed the Oncology Drug Division that VTE risks with thalidomide were poorly addressed in the existing label. After reviewing this memorandum, an Oncology Drug Division reviewer informed the manufacturer that approval of the sNDA would be delayed until several thalidomide-associated VTE safety actions, including revisions of the package insert, were implemented. The manufacturer and FDA agreed on these actions, and the sNDA was approved. New approaches addressing off-label safety are needed. The conditions that facilitated the successful response to this citizen petition are uncommon.

A.M, G, P. L, S. L, M. W, H. A-A, M. F, G. C, Z. Q, JP. S.  2012.  Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet. 379(9827):1721-7. Abstract

BACKGROUND:

Active management of the third stage of labour reduces the risk of post-partum haemorrhage. We aimed to assess whether controlled cord traction can be omitted from active management of this stage without increasing the risk of severe haemorrhage.

METHODS:

We did a multicentre, non-inferiority, randomised controlled trial in 16 hospitals and two primary health-care centres in Argentina, Egypt, India, Kenya, the Philippines, South Africa, Thailand, and Uganda. Women expecting to deliver singleton babies vaginally (ie, not planned caesarean section) were randomly assigned (in a 1:1 ratio) with a centrally generated allocation sequence, stratified by country, to placental delivery with gravity and maternal effort (simplified package) or controlled cord traction applied immediately after uterine contraction and cord clamping (full package). After randomisation, allocation could not be concealed from investigators, participants, or assessors. Oxytocin 10 IU was administered immediately after birth with cord clamping after 1-3 min. Uterine massage was done after placental delivery according to local policy. The primary (non-inferiority) outcome was blood loss of 1000 mL or more (severe haemorrhage). The non-inferiority margin for the risk ratio was 1·3. Analysis was by modified intention-to-treat, excluding women who had emergency caesarean sections. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN 12608000434392.

FINDINGS:

Between June 1, 2009, and Oct 30, 2010, 12,227 women were randomly assigned to the simplified package group and 12,163 to the full package group. After exclusion of women who had emergency caesarean sections, 11,861 were in the simplified package group and 11,820 were in the full package group. The primary outcome of blood loss of 1000 mL or more had a risk ratio of 1·09 (95% CI 0·91-1·31) and the upper 95% CI limit crossed the pre-stated non-inferiority margin. One case of uterine inversion occurred in the full package group. Other adverse events were haemorrhage-related.

INTERPRETATION:

Although the hypothesis of non-inferiority was not met, omission of controlled cord traction has very little effect on the risk of severe haemorrhage. Scaling up of haemorrhage prevention programmes for non-hospital settings can safely focus on use of oxytocin.

FUNDING:
United States Agency for International Development and UN Development Programme/UN Population Fund/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research

2011

Qureshi, ZP, Sartor O, Xirasagar S, Liu Y, Bennett CL.  2011.  Pharmaceutical fraud and abuse in the United States, 1996-2010.
P.K., T, Z. Q, G. N.  2011.  Estimation of blood loss after vaginal delivery. J. Obst. Gynae. East Central. Afr.. 23(2):55-60. Abstract

Background: Thirty to thirty nine percent of maternal mortality is attributed to excess bleeding after childbirth. Amount of blood loss after childbirth is generally estimated visually though it is known that such estimates are grossly inaccurate. Locally, no studies had been done to assess the performance of visual estimation and direct measurement methods of estimating blood loss after delivery. This study aimed at estimating the amount of blood loss after childbirth using three different quantitative methods (visual estimation, direct measurement and laboratory determination). The study also aimed at establishing the incidence of Postpartum Hemorrhage (PPH) in a setting where Active Management of Third Stage of Labor (AMSTL) is practiced.

Objectives: To determine the amount of blood loss and the prevalence of PPH after vaginal delivery.

Design: Analytic cross-sectional study.

Setting: Pumwani Maternity Hospital (PMH) in Nairobi, Kenya.

Subjects and methods: One hundred thirty four pregnant women delivering vaginally at PMH were recruited and studied. Sampled pregnant women were interviewed using a structured data collection form, pre- and post delivery venous blood samples were taken for determination of hematocrit and blood loss after delivery estimated visually by the primary clinician conducting the delivery and directly measured by the researchers.

Main outcome measures: Visually estimated blood loss, directly measured blood loss and pre-and post-delivery hematocrit values.

Results: The mean age of the study population was 24.7 ± 4.8 years. The mean visually estimated, directly measured and laboratory determined blood loss was 121.1 ml, 300.2 ml and 257.0 ml respectively. Prevalence of PPH (blood loss ≥ 500 ml) by visual estimation was zero percent and 13.4% (95% Cl 5.3 - 21.5) and 11.2% (95% Cl 4.0 - 18.8) by direct measurement and laboratory determination respectively. Visual estimation consistently underreported the most significant risk factor for PPH was performance of an episiotomy.

Conclusion: Visual estimation is not sensitive and grossly underestimates the amount of blood loss after delivery, magnitude of underestimation increases with increasing amount of blood loss. Direct measurement of blood loss is both highly sensitive and specific in the detection of PPH.

N., W, H. T, Z. Q.  2011.  Prevalence of cervical cytology abnormalities among women attending antenatal clinic at Kenyatta National Hospital. J. Obst. Gynae. East Central. Afr.. 23(2):37-41. Abstract

Background: Cancer of the cervix is among the leading causes of cancer related deaths among women in Kenya. Cervical cytology screening programs have been shown to significantly reduce mortality and morbidity associated with cancer of the cervix. Since 90% of pregnant women attend antenatal clinic at least once, the antenatal period offers an opportunity for cervical cytology screening. The local prevalence of abnormal cervical cytology has not been documented.

Objective: To determine the prevalence of cervical cytology abnormalities among women attending antenatal clinic at Kenyatta National Hospital.

Methods: This was a cross-sectional descriptive study, carried out among pregnant women on their first antenatal visit between February and August 2008. A papanicolaou smear was taken for each consenting participant. Obstetric and gynaecology profiles of the participants were obtained with a structured questionnaire.

Results: A total of 171 participants were recruited. Only 10.5% had had previous screening for abnormal cervical cytology. One hundred and sixty pap smears were satisfactory for evaluation while five (2.9%) were unsatisfactory. The prevalence of squamous intra-epithelial lesions was 5.8% (3.5% LSIL, 2.3% HSIL). Thirty one percent were inflammatory, 1.2% had trichomonas vaginalis, 7% had bacterial vaginosis (diagnosed by the presence of clue cells) and 10.5% had Candid spp. Forty nine percent of the pap smears were reported normal. HIV positive status and abnormal vaginal discharge were significantly associated with the presence of any pap smear abnormality (p value <0.05).

Conclusion and recommendations: The rate of previous screening for abnormal cervical cytology was low at 10.5%, while the prevalence of abnormal cervical cytology was high at 5.8%. Positive HIV sero-status and presence of abnormal vaginal discharge were noted to increase the risk of cervical smear abnormalities. This emphasizes the need for antenatal cervical cytology screening programs especially among HIV seropositive women and women with abnormal vaginal discharge.

J.P., S, A.M. G, G. C, P. L, Z. Q.  2011.  The World Health Organization multicountry survey on maternal and newborn health: study protocol. BMC Health Serv Res. 11:286-303. Abstract

Background: Effective interventions to reduce mortality and morbidity in maternal and newborn health already exist. Information about quality and performance of care and the use of critical interventions are useful for shaping improvements in health care and strengthening the contribution of health systems towards the Millennium Development Goals 4 and 5. The near-miss concept and the criterion-based clinical audit are proposed as useful approaches for obtaining such information in maternal and newborn health care. This paper presents the methods of the World Health Organization Multicountry Study in Maternal and Newborn Health. The main objectives of this study are to determine the prevalence of maternal near-miss cases in a
worldwide network of health facilities, evaluate the quality of care using the maternal near-miss concept and the criterion-based clinical audit, and develop the near-miss concept in neonatal health.

Methods/Design: This is a large cross-sectional study being implemented in a worldwide network of health facilities. A total of 370 health facilities from 29 countries will take part in this study and produce nearly 275,000 observations. All women giving birth, all maternal near-miss cases regardless of the gestational age and delivery status and all maternal deaths during the study period comprise the study population. In each health facility, medical records of all eligible women will be reviewed during a data collection period that
ranges from two to three months according to the annual number of deliveries.

Discussion: Implementing the systematic identification of near-miss cases, mapping the use of critical evidence-based interventions and analysing the corresponding indicators are just the initial steps for using the maternal nearmiss concept as a tool to improve maternal and newborn health. The findings of projects using approaches similar to those described in this manuscript will be a good starter for a more comprehensive dialogue with governments, professionals and civil societies, health systems or facilities for promoting best practices, improving quality of care and achieving better health for mothers and children.

K., W, S. M, J.W. M, Z. Q, J. B, P. V.  2011.  Depression among women with obstetric fistula in Kenya. Int J Gynaecol Obstet. 115(1):31-3. Abstract

OBJECTIVE:
To establish the prevalence of depression and describe associated factors among fistula patients attending an obstetric fistula surgical camp in Kenya.

METHODS:
A cross-sectional study was conducted focusing on obstetric fistula patients attending a national fistula camp held in August 2008 at Kenyatta National Hospital, Nairobi, Kenya. A structured questionnaire was used to obtain sociodemographic data and medical histories for all consenting patients before surgery. Depression measures were obtained using the Patient Health Questionnaire-9.

RESULTS:
Of the 70 women interviewed, 2 (2.9%) and 12 (17.1%) reported a history of psychiatric illness and suicidal ideations, respectively. Depression was present in 51 (72.9%) patients, with 18 (25.7%) meeting criteria for severe depression. Depression was significantly associated with women older than 20 years of age (P=0.01), unemployment (P=0.03), lack of social support following fistula (P=0.04), and living with fistula for over 3 months (P=0.01).

CONCLUSION:
Women with obstetric fistula are predisposed to high levels of depression. A holistic management approach, including mental health care and family support, is recommended

2010

Jaldesa, GW, Qureshi ZP, Kigondu CS.  2010.  Psychosexual problems associated with Female Genital Mutilation (FGM). J. Obst. Gynae. East Central. Afr. . 22(1):1-6.
Z., Q.  2010.  Editorial Maternal Health. J. Obst. Gynae. East Central. Afr . 22(2):i-iii. Abstract

As we approach 2015 the time for achieving the MDG’s let us take stock of the progress made towards MDG 5 whose targets and indicators are as listed:-
Goal 5: improve maternal health
• Target 5A: reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
o Indicator 5.1: maternal mortality ratio
o Indicator 5.2: proportion of births attended by skilled health personnel
• Target 5B: achieve, by 2015, universal access to reproductive health
o Indicator 5.3: contraceptive prevalence rate
o Indicator 5.4: adolescent birth rate
o Indicator 5.5: antenatal care coverage (at least one visit and at least four visits) one visit
o Indicator 5.6: unmet need for family planning.
Most of the statistics for the above indicators have not changed much between the KDHS of 2003 and 2008/9. The maternal mortality has increased from 414 in 203 to 488 in 2008 and the target of reduction three quarters from 1990 to 2015 seems more of a dream considering we need a figure of 170 by 2015.

Z.P., Q, C. S-K, S.M. M.  2010.  Rapid assessment of partograph utilization in selected maternity units in Kenya. East Afr Med J. 87(6):235-41. Abstract

BACKGROUND:
Prolonged labour causes maternal and perinatal morbidity and mortality. Its sequela include obstructed labour, uterine rupture, maternal exhaustion, postpartum haemorrhage, puerperal sepsis, obstetric fistula, stillbirths, birth asphyxia and neonatal sepsis. These complications can be reduced by using the partograph to assess the progress of labour. The Ministry of Health, Kenya has adopted this tool for labour management in the country and the standardised partograph is recommended for use in all delivery units.

OBJECTIVE:
To determine the utilisation of the partograph in the management of labour in selected health facilities in Kenya.

DESIGN:
A descriptive cross sectional study.

SETTING:
Nine health facilities -ranging from a tertiary hospital to health centre, including public private and faith based facilities in four provinces in Kenya.

RESULTS:
All facilities apart from Pumwani Maternity Hospital and one health centre were using the partograph. The correct use was low, the knowledge on the use of the tool was average and there was minimal formal training being provided. Staff shortage was listed as the most common cause of not using the tool. Contractions were recorded 30-80%, foetal heart rate 53-90% and cervical dilatation 70-97%. Documentation of state of the liquor, moulding and descent as well as maternal parameters such as pulse, and blood pressure and urinalysis were minimally recorded. Supplies for monitoring labour such as fetoscopes and blood pressure machines were in short supply and sometimes not functional. Overall, the poor usage was contributed to staff shortages, lack of knowledge especially on interpretation of findings, negative attitudes, conflict between providers as to their roles in filling the partograph, and senior staff themselves not acting as role models with regards to the use, advocacy and implementation of the partograph.

CONCLUSION:
The partograph was available in most units. However, accurate recording of parameters to monitor the foetus, the mother and progress of labour as recommended was mostly not done. Shortage of staff, lack of knowledge, lack of team work, lack of supplies and negative attitude among healthcare providers were some of the obstacles noted to hamper partograph use.

2009

Ndungu, JR, Amayo A, Qureshi ZP, Kigondu CS.  2009.  Gestational Thyrotoxicosis associated with Emesis in early Pregnancy. East. Afr. Med. J. 86(2):55–58.
J.R., N, A. A, Z.P. Q, C.S. K.  2009.  Gestational thyrotoxicosis associated with emesis in early pregnancy. East Afr Med J. 86(2):55-8. Abstract

OBJECTIVES:
To determine the thyroid profile and the prevalence of gestational thyrotoxicosis among women with emesis during early pregnancy.

DESIGN:
A descriptive cross-sectional study.

SETTING:
Kenyatta National Hospital acute gynaecology ward and the ante-natal clinic.

SUBJECTS:
Seventy two women presenting with emesis up to 16 weeks gestation.

MAIN OUTCOME MEASURES:
The levels of FT3, FT4, TSH and beta-hCG during the first 16 weeks of gestation. Correlation between the thyroid hormones and beta-hCG as well as the severity of vomiting was also done.

RESULTS:
The point prevalence of gestational thyrotoxicosis was 8.3%. There was a significant positive correlation between beta-hCG levels and FT3 and FT4 (P-values < 0.05), and a significant negative correlation between beta-hCG and TSH (P < 0.05). Correlation between the severity of vomiting and the thyroid hormones as well as beta-hCG was not statistically significant. Patients' age ranged from 14-38 years (median 26). Majority of the women studied were at a gestation of 8 to 11 weeks (38.9%). Most patients (84.7%) had one to five episodes of vomiting per day. Peak beta-hCG was at 12-15 weeks gestation.

CONCLUSIONS:
Thyrotoxicosis does occur among women with emesis in pregnancy in this set-up. Screening for it may be beneficial to such women and also those with high serum beta-hCG levels above the median for the gestational age.

AM, G, M W, M M, Z Q, G P.  2009.  Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial. Reprod Health. 6(2) Abstract

BACKGROUND:
The third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60-70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care.

OBJECTIVE:
The primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package.

METHODS:
A hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period.

MANAGEMENT:
Overall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field. EXPECTED OUTCOMES: The main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field.

TRIAL REGISTRATION:
ACTRN12608000434392

J.R, DRNDUNGU, A DRAMAYO, Z.P DRQURESHI, C PROFSEKKADE-KIGONDU.  2009.  Gestational thyrotoxicosis associated with emesis in early pregnancy.. E.A.M.J. 86(2):55-58. Abstract

OBJECTIVES:
To determine the thyroid profile and the prevalence of gestational thyrotoxicosis among women with emesis during early pregnancy.
DESIGN:
A descriptive cross-sectional study.
SETTING:
Kenyatta National Hospital acute gynaecology ward and the ante-natal clinic.
SUBJECTS:
Seventy two women presenting with emesis up to 16 weeks gestation.
MAIN OUTCOME MEASURES:
The levels of FT3, FT4, TSH and beta-hCG during the first 16 weeks of gestation. Correlation between the thyroid hormones and beta-hCG as well as the severity of vomiting was also done.
RESULTS:
The point prevalence of gestational thyrotoxicosis was 8.3%. There was a significant positive correlation between beta-hCG levels and FT3 and FT4 (P-values < 0.05), and a significant negative correlation between beta-hCG and TSH (P < 0.05). Correlation between the severity of vomiting and the thyroid hormones as well as beta-hCG was not statistically significant. Patients' age ranged from 14-38 years (median 26). Majority of the women studied were at a gestation of 8 to 11 weeks (38.9%). Most patients (84.7%) had one to five episodes of vomiting per day. Peak beta-hCG was at 12-15 weeks gestation.
CONCLUSIONS:
Thyrotoxicosis does occur among women with emesis in pregnancy in this set-up. Screening for it may be beneficial to such women and also those with high serum beta-hCG levels above the median for the gestational age.

2008

S.M., M, Z.P. Q, J. K.  2008.  Emergency preparedness among antenatal clients at Kenyatta National Hospital. J. Obst. Gynae. East Central. Afr.. 20(1):4–12. Abstract

Background
All women are at risk of complications during pregnancy and delivery. Most complications cannot be predicted and therefore all pregnant women should be prepared to respond appropriately when complications arise. Such advance preparations can help prevent life threatening delays in recognizing and responding to complications.
According to Kenya Demographic Health Survey (KDHS) 2003, majority of women (60%) still deliver at home where skilled care is not available and if a complication arise it may be disastrous.
Emphasis on emergency preparedness during antenatal care is a cost effective intervention, which can thus reduce maternal deaths and morbidity by avoiding delays at decision making and transport to health facilities in the event of obstetric emergencies.

Objective: To evaluate emergency preparedness among antenatal care clients at Kenyatta National Hospital.

Methods: This was a descriptive cross-sectional study done at the antenatal care clinic at Kenyatta National Hospital. A total of 394 women attending antenatal care at Kenyatta National hospital were interviewed using a pre-tested questionnaire between May 2006 and August 2006. Clients who were above 32 weeks gestation and had attended the clinic more than twice were recruited. Systematic sampling was used to select the study participants with every third client being interviewed.

Results: The mean age of the respondents was 28.4 years with a range of 18-42 years. All the respondents had formal education, 91.7% were married and 41.1% were employed. Over 60% of the respondents were informed by health workers about danger signs in pregnancy. A third of the respondents knew at least one danger sign in pregnancy while only 6.9% knew of three or more danger signs. Only 62.9% of the respondents had funds set aside for emergency purposes. 10.9& of the respondents did not have a clear plan of what to do incase of an obstetric emergency. Level of education positively influenced knowledge of danger signs.

Conclusion
Education and counseling on danger signs was not provided to all clients. Respondents’ knowledge of danger signs in pregnancy was low. Most respondents did not have plans for emergencies.

Z., Q.  2008.  Obstetrical emergencies in relation to millennium development goals. East Afr Med J. 85(2):53-5. Abstract

At the turn of this century, 189 countries endorsed the Millennium Declaration and signed up to meeting eight goals. "These eight commitments are simple but powerful objectives that every man and woman can easily understand and support. They are also different from other bold pledges that became broken promises over the past 50 years: first, because they have unprecedented political support; second, because they are measurable and time-bond, with most of this agenda meant to be attained by the year 2015; and third - and most important - because they are achievable." Koffi Annan.

Children are the future of society and their mothers the guardians of that future: Childbirth is a very special life changing event - a joyful experience when all goes well but it can also be a difficult period bringing with it new problems as well as the potential for suffering. When obstetric emergencies occur, if not dealt with immediately they can cause severe morbidity or mortality for the mother or baby or both.

S.M, M, J. K, Z. Q.  2008.  Contraceptive use among HIV infected women attending Comprehensive Care Centre. East Afr Med J. 85(4):171-7. Abstract

OBJECTIVE:
To determine contraceptive use among HIV infected women attending Comprehensive Care Centre at Kenyatta National Hospital.

DESIGN:
Hospital based cross-sectional descriptive study.

SETTING:
Comprehensive Care Centre (CCC), Kenyatta National Hospital.

SUBJECTS:
The study group was non-pregnant HIV positive women on follow up at the CCC. A total of 94 HIV infected women were interviewed between May 2006 and August 2006 through a pretested interviewer administered questionnaire. Consecutive women willing to participate in the study were interviewed.

MAIN OUTCOME MEASURES:
Current contraceptive use, contraceptive methods, source of contraception, reproductive intention and unmet need of family planning.

RESULTS:
The mean age of the respondents was 34 years, 47.9% were married, all had formal education and 74.6% were employed. Eighty six percent of the respondents did not have reproduction intentions in the next two years; however, only 44.2% of the respondents were using contraception. Condoms were the most popular (81.5%) contraceptive method. Female condom was used by 10.5% of the respondents. Norplant was the only long-term contraceptive method and was used by only 2.6%. Dual method of contraception was practiced by 13.5% of the respondents. Majority of the respondents obtained contraceptives from private sector (42.9%) with less than 10% getting them from CCC. The unmet need for family planning among the study group was 30%. Marital status and regular sexual partner were significantly associated with contraceptive use.

CONCLUSION:
Although majority of respondents did not have reproduction intentions in the next two years, use of contraception was low with only 44% being on a method. Use of long-term contraceptive methods was low among respondents. Majority of the respondents obtained contraceptives away from CCC. The unmet need for family planning was high at 30%.

S.M, M, Z. Q, J. K.  2008.  Birth preparedness among antenatal clients. East Afr Med J. 85(6):275-83. Abstract

OBJECTIVE:
To evaluate birth preparedness and complication readiness among antenatal care clients.

DESIGN:
A descriptive cross- sectional study.

SETTING:
Antenatal care clinic at Kenyatta National Hospital, Nairobi, Kenya.

SUBJECTS:
Three hundred and ninety four women attending antenatal care at Kenyatta National hospital were interviewed using a pre-tested questionnaire between May 2006 and August 2006. Clients who were above 32 weeks gestation and had attended the clinic more than twice were recruited. Systematic sampling was used to select the study participants with every third client being interviewed.

MAIN OUTCOME MEASURES:
Health education on birth preparedness, knowledge of danger signs, preparations for delivery and emergencies.

RESULTS:
Over 60% of the respondents were counselled by health workers on various elements of birth preparedness. Eighty seven point three per cent of the respondents were aware of their expected date of delivery, 84.3% had set aside funds for transport to hospital during labour while 62.9% had funds for emergencies. Sixty seven per cent of the respondents knew at least one danger sign in pregnancy while only 6.9% knew of three or more danger signs. One hundred and nine per cent of the respondents did not have a clear plan of what to do in case of an obstetric emergency. Level of education positively influenced birth preparedness.

CONCLUSIONS:
Education and counselling on different aspects of birth preparedness was not provided to all clients. Respondents knowledge of danger signs in pregnancy was low. Many respondents did not know about birth preparedness and had no plans for emergencies.

2006

J., S, N. N, Z. Q, M. N.  2006.  Does assessment of signs and symptoms add to the predictive value of an algorithm to rule out pregnancy? J Fam Plann Reprod Health Care. 32(1):27-9. Abstract

BACKGROUND:
A World Health Organization-endorsed algorithm, widely published in international guidance documents and distributed in the form of a 'pregnancy checklist', has become a popular tool for ruling out pregnancy among family planning clients in developing countries. The algorithm consists of six criteria excluding pregnancy, all conditional upon a seventh 'master criterion' relating to signs or symptoms of pregnancy. Few data exist on the specificity to pregnancy among family planning clients of long-accepted signs and symptoms of pregnancy. The aim of the present study was to assess whether reported signs and symptoms of pregnancy add to the predictive value of an algorithm to rule out pregnancy.

METHODS:
Data from a previous observational study were used to assess the performance of the algorithm with and without the 'signs and symptoms' criterion. The study group comprised 1852 new, non-menstruating family planning clients from seven clinics in Kenya.

RESULTS:
Signs and symptoms of pregnancy were rare (1.5%) as was pregnancy (1%). Signs and symptoms were more common (18.2%) among the 22 clients who tested positive for pregnancy than among the 1830 clients (1.3%) who tested negative, but did not add significantly to the predictive value of the algorithm. Most women with signs or symptoms were not pregnant and would have been unnecessarily denied a contraceptive method using the current criteria.

CONCLUSIONS:
The 'signs and symptoms' criterion did not substantially improve the ability of the algorithm to exclude pregnant clients, but several reasons (including use of the algorithm for intrauterine device clients) render it unlikely that the algorithm will be changed.

UoN Websites Search