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Qureshi ZP. Case Records and Commentaries.; Submitted.
2020
Collaborators TWHOACTIONT. "Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries." New England Medical Journal. 2020;382(17). AbstractWebsite

Abstract

Background: The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain.

Methods: We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale.

Results: A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P=0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P=0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events.

Conclusions: Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection.

Brizuela V, Bonet M, Romero CLT, Abalos E, Baguiya A, Fawole B, Knight M, Lumbiganon P, Minkauskienė M, Nabhan A, Osman NB, Qureshi ZP, Souza JP. "Early evaluation of the ‘STOP SEPSIS!’ WHO Global Maternal Sepsis Awareness Campaign implemented for healthcare providers in 46 low, middle and high-income countries." British Medical Journal . 2020;10(5). AbstractWebsite

Objective To evaluate changes in awareness of maternal sepsis among healthcare providers resulting from the WHO Global Maternal Sepsis Study (GLOSS) awareness campaign.

Design Independent sample precampaign/postcampaign through online and paper-based surveys available for over 30 days before campaign roll-out (pre) and after study data collection (post). Descriptive statistics were used for campaign recognition and exposure, and odds ratio (OR) and percentage change were calculated for differences in awareness, adjusting for confounders using multivariate logistic regression.

Setting and participants Healthcare providers from 398 participating facilities in 46 low, middle and high-income countries.

Intervention An awareness campaign to accompany GLOSS launched 3 weeks prior to data collection and lasting the entire study period (28 November 2017 to 15 January 2018) and beyond.

Main outcome measures Campaign recognition and exposure, and changes in awareness.

Results A total of 2188 surveys were analysed: 1155 at baseline and 1033 at postcampaign. Most survey respondents found the campaign materials helpful (94%), that they helped increase awareness (90%) and that they helped motivate to act differently (88%). There were significant changes with regard to: not having heard of maternal sepsis (−63.4% change, pre-OR/post-OR 0.35, 95% CI 0.18 to 0.68) and perception of confidence in making the right decisions with regard to maternal sepsis identification and management (7.3% change, pre-OR/post-OR 1.44, 95% CI 1.01 to 2.06).

Conclusions Awareness raising campaigns can contribute to an increase in having heard of maternal sepsis and an increase in provider perception of confidence in making correct decisions. Offering the information to make accurate and timely decisions while promoting environments that enable self-confidence and support could improve maternal sepsis identification and management.

Mitchell EJ, Qureshi ZP, Were F, Daniels J, Gwako G, Osoti A, Opira J, Bradshaw L, Oliver M, Pallotti P, Ojha S. "Feasibility of using an Early Warning Score for preterm or low birthweight infants in a low-resource setting: results of a mixed-methods study at a national referral hospital in Kenya." BMJ Open. 2020;10(10). AbstractWebsite

Abstract

Introduction: Fifteen million babies are born prematurely, before 37 weeks gestational age, globally. More than 80% of these are in sub-Saharan Africa and Asia. 35% of all deaths in the first month of life are due to prematurity and the neonatal mortality rate is eight times higher in low-income and middle-income countries (LMICs) than in Europe. Early Warning Scores (EWS) are a way of recording vital signs using standardised charts to easily identify adverse clinical signs and escalate care appropriately. A range of EWS have been developed for neonates, though none in LMICs. This paper reports the findings of early work to examine if the use of EWS is feasible in LMICs.

Methods: We conducted an observational study to understand current practices for monitoring of preterm infants at a large national referral hospital in Nairobi, Kenya. Using hospital records, data were collected over an 8-week period in 2019 on all live born infants born at <37 weeks and/or <2500 g (n=294, 255 mothers) in the first week of life. Using a chart adopted from the EWS developed by the British Association of Perinatal Medicine, we plotted infants' vital signs. In addition, we held group discussions with stakeholders in Kenya to examine opinions on use of EWS.

Results: Recording of vital signs was variable; only 63% of infants had at least one temperature recorded and 53% had at least one heart rate and respiratory rate recorded. Stakeholders liked the traffic-light system and simplicity of the chart, though recognised challenges, such as staffing levels and ability to print in colour, to its adoption.

Conclusion: EWS may standardise documentation and identify infants who are at higher risk of an adverse outcome. However, human and non-human resource issues would need to be explored further before development of an EWS for LMICs.

Bonet M, Brizuela V, Abalos E, Cuesta C, Baguiya A, Group TWHOGMSS(GLOSS) R. "Frequency and management of maternal infection in health facilities in 52 countries: Results of the WHO Global Maternal Sepsis Study (GLOSS), a one-week inception cohort." Lancet Global Health. . 2020;8(5):661-671. AbstractWebsite

Background
Maternal infections are an important cause of maternal mortality and severe maternal morbidity. We report the main findings of the WHO Global Maternal Sepsis Study, which aimed to assess the frequency of maternal infections in health facilities, according to maternal characteristics and outcomes, and coverage of core practices for early identification and management.
Methods
We did a facility-based, prospective, 1-week inception cohort study in 713 health facilities providing obstetric, midwifery, or abortion care, or where women could be admitted because of complications of pregnancy, childbirth, post-partum, or post-abortion, in 52 low-income and middle-income countries (LMICs) and high-income countries (HICs). We obtained data from hospital records for all pregnant or recently pregnant women hospitalised with suspected or confirmed infection. We calculated ratios of infection and infection-related severe maternal outcomes (ie, death or near-miss) per 1000 livebirths and the proportion of intrahospital fatalities across country income groups, as well as the distribution of demographic, obstetric, clinical characteristics and outcomes, and coverage of a set of core practices for identification and management across infection severity groups.
Findings
Between Nov 28, 2017, and Dec 4, 2017, of 2965 women assessed for eligibility, 2850 pregnant or recently pregnant women with suspected or confirmed infection were included. 70·4 (95% CI 67·7–73·1) hospitalised women per 1000 livebirths had a maternal infection, and 10·9 (9·8–12·0) women per 1000 livebirths presented with infection-related (underlying or contributing cause) severe maternal outcomes. Highest ratios were observed in LMICs and the lowest in HICs. The proportion of intrahospital fatalities was 6·8% among women with severe maternal outcomes, with the highest proportion in low-income countries. Infection-related maternal deaths represented more than half of the intrahospital deaths. Around two-thirds (63·9%, n=1821) of the women had a complete set of vital signs recorded, or received antimicrobials the day of suspicion or diagnosis of the infection (70·2%, n=1875), without marked differences across severity groups.
Interpretation
The frequency of maternal infections requiring management in health facilities is high. Our results suggest that contribution of direct (obstetric) and indirect (non-obstetric) infections to overall maternal deaths is greater than previously thought. Improvement of early identification is urgently needed, as well as prompt management of women with infections in health facilities by implementing effective evidence-based practices.

Mitchell EJ, Benjamin S, Ononge S, Ditai J, QURESHI ZAHIDA, Masood SN, Whitham D, Godolphin PJ, Duley L. "Identifying women giving birth preterm and care at the time of birth: a prospective audit of births at six hospitals in India, Kenya, Pakistan and Uganda." BMC Pregnancy Childbirth . 2020;20(439). AbstractWebsite

Background
Globally, 15 million infants are born preterm each year, and 1 million die due to complications of prematurity. Over 60% of preterm births occur in Sub-Saharan Africa and south Asia. Care at birth for premature infants may be critical for survival and long term outcome. We conducted a prospective audit to assess whether women giving birth preterm could be identified, and to describe cord clamping and neonatal care at hospitals in Africa and south Asia.

Methods
This prospective audit of livebirths was conducted at six hospitals in Uganda, Kenya, India and Pakistan. Births were considered preterm if between 28+ 0 and 33+ 6 weeks gestation and/or the birthweight was 1.00 to 1.99 kg. A pre-specified audit plan was agreed with each hospital. Livebirths before 28 weeks gestation with birthweight less than 1.0 kg were excluded. Data were collected on estimated and actual gestation and birthweight, cord clamping, and neonatal care.

Results
Of 4149 women who gave birth during the audit, data were available for 3687 (90%). As 107 were multiple births, 3781 livebirths were included, of which 257 (7%) were preterm. Antenatal assessment correctly identified 148 infants as ‘preterm’ and 3429 as ‘term’, giving a positive predictive value of 72% and negative predictive value of 97%. For term births, cord clamping was usually later at the two Ugandan hospitals, median time to clamping 50 and 76 s, compared with 23 at Kenyatta (Kenya), 7 at CMC (India) and 12 at FBH/LNH (Pakistan). At the latter two, timing was similar between term and preterm births, and between vaginal and Caesarean births. For all the hospitals, the cord was clamped quickly at Caesarean births, with Mbale (Uganda) having the highest median time to clamping (15 s ‘term’, 19 ‘preterm’). For preterm infants temperature on admission to the neonatal unit was below 35.5 °C for 50%, and 59 (23%) died before hospital discharge.

Conclusions
Antenatal identification of preterm birth was good. Timing of cord clamping varied between hospitals, although at each there was no difference between ‘term’ and ‘preterm’ births. For premature infants hypothermia was common, and mortality before hospital discharge was high.

2019
Ismail LW, ZP Q, SB O. "The acceptability of HIV testing among women receiving post abortion care." South Sudan Medical Journal. 2019;12(3):101-105. AbstractWebsite

Introduction: In South Sudan few women have heard about the HIV. The prevalence of HIV infection in the country is 2.6%. Post abortion care (PAC) accounts for over 50% of all gynaecological admissions at the Juba Teaching Hospital (JTH). HIV testing is not routinely offered as part of PAC services.

Objective: To determine factors associated with acceptability of HIV testing among women receiving PAC at JTH.

Methods: This was a cross-sectional study, conducted at the Gynaecological Unit of JTH. Three hundred and forty patients were interviewed using a structured questionnaire.

Results: The mean age of the participants was 24.7 years with 50.5% aged <25years, 31.5% were employed, and 31.8% had no formal education. Acceptability of HIV testing was 70.9% and the prevalence of HIV was 2.7%. The most common reason for not accepting, was the belief, based on previous results, that they were HIV negative. Patients aged ≥25 years and those with primary and secondary education were twice as likely to accept HIV testing than those <25 years and those with no formal education, respectively. Employment status, religion and marital status were not statistically associated with acceptability of HIV testing. Patients previously tested for HIV were more likely to accept testing.

Conclusion: Routine HIV testing should be integrated into PAC services with efforts to increase awareness of HIV and importance of testing

Key words: HIV, abortion, post-abortion care, South Sudan

Odhiambo SA, ZP Q, PM N, Kosgei RJ, AB K, Ayieko P, PK K, A O, Odawa FX, GN G, MK K, O K, O O. "Born Too Soon: Provide Corticosteriods at the earliest opportunity even if dose is not completed." Journal of Obstetrics and Gynaecology of East & Central Africa. 2019;30(2):62-63.Website
Odhiambo SA, ZP Q, PM N, Kosgei RJ, AB K, Ayieko P, PK K, A O, Odawa FX, GN G, MK K, O K, O O. "Early Neonatal Outcomes among Mothers receiving variable doeses of Dexamethasone for Preterm Premature Rupture of Membranes at Kenyatta National Hospital: A restrospective Cohort Study ." Journal of Obstetrics and Gynaecology of East & Central Africa. 2019;30(2):54-61.Website
P G, H S, D M, L L, E B, T MD, L O, V W, C W, Z Q, E O, A G, R M. "Effectiveness of an Electronic Partogram: A Mixed-Method, Quasi- experimental Study." Global Health: Science and Practice. 2019;7(4):521-539. AbstractWebsite

Background: Timely identification and management of intrapartum complications could significantly reduce maternal deaths, intrapartum stillbirths, and newborn deaths due to hypoxia. The World Health Organization (WHO) identifies monitoring of labor using the paper partograph as a high-priority intervention for identifying abnormities in labor and fetal well-being. This article describes a mixed-method, quasi-experimental study to assess the effectiveness of an Android tablet-based electronic, labor clinical decision-support application (ePartogram) in limited-resource settings.

Methods: The study, conducted in Kenya from October 2016 to May 2017, allocated 12 hospitals and health centers to an intervention (ePartogram) or comparison (paper partograph) group. Skilled birth attendants (SBAs) in both groups received a 2-day refresher training in labor management and partograph use. The intervention group received an additional 1-day orientation on use and care of the Android-based ePartogram app. All outcomes except one compare post-ePartogram intervention versus paper partograph controls. The exception is outcome of early perinatal mortality pre- and post-ePartogram introduction in intervention sites compared to control sites. We used log binomial regression to analyze the primary outcome of the study, suboptimal fetal outcomes. We also analyzed for secondary outcomes (SBAs performing recommended actions), and conducted in-depth interviews with facility in-charges and SBAs to ascertain acceptability and adoptability of the ePartogram.

Results: We compared data from 842 clients in active labor using ePartograms with data from 1,042 clients monitored using a paper partograph. SBAs using ePartograms were more likely than those using paper partographs to take action to maintain normal labor, such as ambulation, feeding, and fluid intake, and to address abnormal measurements of fetal well-being (14.7% versus 5.3%, adjusted relative risk=4.00, 95% confidence interval [CI]=1.95–8.19). Use of the ePartogram was associated with a 56% (95% CI=27%–73%) lower likelihood of suboptimal fetal outcomes than the paper partograph. Users of the ePartogram were more likely to be compliant with routine labor observations. SBAs stated that the technology was easy to use but raised concerns about its use at high-volume sites. Further research is needed to evaluate costs and benefit and to incorporate recent WHO guidance on labor management.

Conclusion: ePartogram use was associated with improvements in adherence to recommendations for routine labor care and a reduction in adverse fetal outcomes, with providers reporting adoptability without undue effort. Continued development of the ePartogram, including incorporating new clinical rules from the 2018 WHO recommendations on intrapartum care, will improve labor monitoring and quality care at all health system levels.

P G, H S, D M, L L, E B, T MD, L O, V W, C W, Z Q, E O, A G, R M. "Effectiveness of an Electronic Partogram: A Mixed-Method, Quasi- experimental Study." Global Health: Science and Practice. 2019;7(4):521-539. AbstractWebsite

Background: Timely identification and management of intrapartum complications could significantly reduce maternal deaths, intrapartum stillbirths, and newborn deaths due to hypoxia. The World Health Organization (WHO) identifies monitoring of labor using the paper partograph as a high-priority intervention for identifying abnormities in labor and fetal well-being. This article describes a mixed-method, quasi-experimental study to assess the effectiveness of an Android tablet-based electronic, labor clinical decision-support application (ePartogram) in limited-resource settings.

Methods: The study, conducted in Kenya from October 2016 to May 2017, allocated 12 hospitals and health centers to an intervention (ePartogram) or comparison (paper partograph) group. Skilled birth attendants (SBAs) in both groups received a 2-day refresher training in labor management and partograph use. The intervention group received an additional 1-day orientation on use and care of the Android-based ePartogram app. All outcomes except one compare post-ePartogram intervention versus paper partograph controls. The exception is outcome of early perinatal mortality pre- and post-ePartogram introduction in intervention sites compared to control sites. We used log binomial regression to analyze the primary outcome of the study, suboptimal fetal outcomes. We also analyzed for secondary outcomes (SBAs performing recommended actions), and conducted in-depth interviews with facility in-charges and SBAs to ascertain acceptability and adoptability of the ePartogram.

Results: We compared data from 842 clients in active labor using ePartograms with data from 1,042 clients monitored using a paper partograph. SBAs using ePartograms were more likely than those using paper partographs to take action to maintain normal labor, such as ambulation, feeding, and fluid intake, and to address abnormal measurements of fetal well-being (14.7% versus 5.3%, adjusted relative risk=4.00, 95% confidence interval [CI]=1.95–8.19). Use of the ePartogram was associated with a 56% (95% CI=27%–73%) lower likelihood of suboptimal fetal outcomes than the paper partograph. Users of the ePartogram were more likely to be compliant with routine labor observations. SBAs stated that the technology was easy to use but raised concerns about its use at high-volume sites. Further research is needed to evaluate costs and benefit and to incorporate recent WHO guidance on labor management.

Conclusion: ePartogram use was associated with improvements in adherence to recommendations for routine labor care and a reduction in adverse fetal outcomes, with providers reporting adoptability without undue effort. Continued development of the ePartogram, including incorporating new clinical rules from the 2018 WHO recommendations on intrapartum care, will improve labor monitoring and quality care at all health system levels.

Kivai JM, KAYIMA JK, Were AO, Qureshi Z. "Foetal outcome in women with Pregnacy related Acute Kidney Injury in a referral facilty in Kenya ." IOSR Journal of Dental and Medical Sciences. 2019;18(11):52-56.Website
Kivai JM, KAYIMA JK, Were AO, Qureshi Z. "Impact of Pregnancy Related Acute Kidney Injury on foetalsurvival: a single Centre Experience in Kenya." IOSR Journal of Dental and Medical Sciences. 2019;18(7):13-17.Website
M W, G P, GJ H, G C, A C, I G, S G, AM G, S LL, P L, K M. "Maternal characteristics and causes associated with refractory postpartum haemorrhage after vaginal birth: a secondary analysis of the WHO CHAMPION trial data." BJOG: An International Journal of Obstetrics & Gynaecology.. 2019;127(5):628-634. AbstractWebsite

Objective: To assess the maternal characteristics and causes associated with refractory postpartum haemorrhage (PPH).

Design: Secondary analysis of the WHO CHAMPION trial data.

Setting: Twenty-three hospitals in ten countries.

Population: Women from the CHAMPION trial who received uterotonics as first-line treatment of PPH.

Methods: We assessed the association between sociodemographic, pregnancy and childbirth factors and refractory PPH, and compared the causes of PPH between women with refractory PPH and women responsive to first-line PPH treatment.

Main outcome measures: Maternal characteristics; causes of PPH.

Results: Women with labour induced or augmented with uterotonics (adjusted odds ratio [aOR] 1.35; 95% CI 1.07-1.72), with episiotomy or tears requiring suturing (aOR 1.82; 95% CI 1.34-2.48) and who had babies with birthweights ≥3500 g (aOR 1.33; 95% CI 1.04-1.69) showed significantly higher odds of refractory PPH compared with the reference categories in the multivariate analysis adjusted by centre and trial arm. While atony was the sole PPH cause in 53.2% (116/218) of the women in the responsive PPH group, it accounted for only 31.5% (45/143) of the causes in the refractory PPH group. Conversely, tears were the sole cause in 12.8% (28/218) and 28% (40/143) of the responsive PPH and refractory PPH groups, respectively. Placental problems were the sole cause in 11 and 5.6% in the responsive and refractory PPH groups, respectively.

Conclusion: Women with refractory PPH showed a different pattern of maternal characteristics and PPH causes compared with those with first-line treatment responsive PPH.

Thanh BY, P L, Pattanittum P, Laopaiboon M, JP V, Oladapo OT, Pileggi-Castro C, Mori R, Jayaratne K, Z Q, J S. "Mode of delivery and pregnancy outcomes in preterm birth: a secondary analysis of the WHO Global and Multi-country Surveys." Scientific reports. 2019;9(15556):1-8. AbstractWebsite

Many studies have been conducted to examine whether Caesarean Section (CS) or vaginal birth (VB) was optimal for better maternal and neonatal outcomes in preterm births. However, findings remain unclear. Therefore, this secondary analysis of World Health Organization Global Survey (GS) and Multi-country Survey (MCS) databases was conducted to investigate outcomes of preterm birth by mode of delivery. Our sample were women with singleton neonates (15,471 of 237 facilities from 21 countries in GS; and 15,053 of 239 facilities from 21 countries in MCS) delivered between 22 and <37 weeks of gestation. We assessed association between mode of delivery and pregnancy outcomes in singleton preterm births by multilevel logistic regression adjusted for hierarchical data. The prevalences of women with preterm birth delivered by CS were 31.0% and 36.7% in GS and MCS, respectively. Compared with VB, CS was associated with significantly increased odds of maternal intensive care unit admission, maternal near miss, and neonatal intensive care unit admission but significantly decreased odds of fresh stillbirth, and perinatal death. However, since the information on justification for mode of delivery (MOD) were not available, our results of the potential benefits and harms of CS should be carefully considered when deciding MOD in preterm births.

Subject terms: Epidemiology, Outcomes research

Obimbo MM, Y Z, MT MM, CR C, Z Q, J O’ech, JA O’o, SJ F. "Placental Structure in Preterm Birth Among HIV-Positive Versus HIV-Negative Women in Kenya." Journal of Acquired Immune Deficiency Syndromes. 2019;80(1):94-102. AbstractWebsite

Background: Preterm birth (PTB) is a major cause of infant morbidity and mortality in developing countries. Recent data suggest that in addition to Human Immunodeficiency Virus (HIV) infection, use of antiretroviral therapy (ART) increases the risk of PTB. As the mechanisms remain unexplored, we conducted this study to determine whether HIV and ART were associated with placental changes that could contribute to PTB.

Setting: We collected and evaluated placentas from 38 HIV-positive women on ART and 43 HIV-negative women who had preterm deliveries in Nairobi, Kenya.

Methods: Anatomical features of the placentas were examined at gross and microscopic levels. Cases were matched for gestational age and compared by the investigators who were blinded to maternal HIV serostatus.

Results: Among preterm placentas, HIV infection was significantly associated with thrombosis (P = 0.001), infarction (P = 0.032), anomalies in cord insertion (P = 0.02), gross evidence of membrane infection (P = 0.043), and reduced placental thickness (P = 0.010). Overall, preterm placentas in both groups were associated with immature villi, syncytial knotting, villitis, and deciduitis. Features of HIV-positive versus HIV-negative placentas included significant fibrinoid deposition with villus degeneration, syncytiotrophoblast delamination, red blood cell adhesion, hypervascularity, and reduction in both surface area and perimeter of the terminal villi.

Conclusions: These results imply that HIV infection and/or ART are associated with morphological changes in preterm placentas that contribute to delivery before 37 weeks. Hypervascularity suggests that the observed pathologies may be attributable, in part, to hypoxia. Further research to explore potential mechanisms will help elucidate the pathways that are involved perhaps pointing to interventions for decreasing the risk of prematurity among HIV-positive women.

D P, ZP Q, K L, MK K, GN G, Odawa FX, A O, O K, PK K, Kosgei RJ, AB K, PM N, O O. "Policy Brief - Increasing Caesarean Section rates among low risk women after introduction of free maternity services in a Kenyan National Referral Hospital." Journal of Obstetrics and Gynaecology of East & Central Africa. 2019;30(2):52-53.Website
Osoti AO, JP V, Oladapo OT, ZP Q, AM G. "Tranexamic acid for treatment of postpartum haemorrhage." Obstetrics, Gynaecology & Reproductive Medicine. 2019;29(5):146-147. AbstractWebsite

Postpartum haemorrhage remains the leading cause of maternal mortality globally. Mortality and severe morbidity due to postpartum haemorrhage is highest in lower-resource settings. Tranexamic acid is an anti-fibrinolytic drug that has been in use in humans for nearly five decades. It is a structural analogue of lysine that binds irreversibly to plasminogen, thereby inhibiting the binding of plasmin to fibrin. This in turn inhibits fibrinolysis, thus stabilizing blood clots. Tranexamic acid has been shown to improve outcomes in trauma-related bleeding. New research has shown that early use of tranexamic acid (within 3 hours of birth), in addition to standard care, safely reduces deaths due to bleeding in women with clinically diagnosed postpartum haemorrhage, regardless of the mode of birth.

Keywords: anti-fibrinolysis,maternal mortality,postpartum haemorrhage,tranexamic acid

D P, ZP Q, K L, MK K, GN G, Odawa FX, A O, O K, PK K, Kosgei RJ, AB K, PM N, O O. "Use of the Robson Classification to compare Caesarean Section patterns at the Kenyatta National Hospital after and before free Maternity Services in Kenya." Journal of Obstetrics and Gynaecology of East & Central Africa. 2019;30(2):46-51.Website
Collaborators WHOACTIONT. "The World Health Organization ACTION-I (Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns) ." TRIALS. 2019;20(1):507. AbstractWebsite

Background
Antenatal corticosteroids (ACS) have long been regarded as a cornerstone intervention in mitigating the adverse effects of a preterm birth. However, the safety and efficacy of ACS in hospitals in low-resource countries has not been established in an efficacy trial despite their widespread use. Findings of a large cluster-randomized trial in six low- and middle-income countries showed that efforts to scale up ACS use in low-resource settings can lead to harm. There is equipoise regarding the benefits and harms of ACS use in hospitals in low-resource countries. This randomized controlled trial aims to determine whether ACS are safe and efficacious when given to women at risk of imminent birth in the early preterm period, in hospitals in low-resource countries.

Methods/design
The trial design is a parallel, two-arm, double-blind, individually randomized, placebo-controlled trial of ACS (dexamethasone) for women at risk of imminent preterm birth. The trial will recruit 6018 women in participating hospitals across five low-resource countries (Bangladesh, India, Kenya, Nigeria and Pakistan). The primary objectives are to compare the efficacy of dexamethasone with placebo on survival of the baby and maternal infectious morbidity. The primary outcomes are: 1) neonatal death (to 28 completed days of life); 2) any baby death (any stillbirth postrandomization or neonatal death); and 3) a composite outcome to assess possible maternal bacterial infections. The trial will recruit eligible, consenting pregnant women from 26 weeks 0 days to 33 weeks 6 days gestation with confirmed live fetuses, in whom birth is planned or expected within 48 h. The intervention comprises a regimen of intramuscular dexamethasone sodium phosphate. The comparison is an identical placebo regimen (normal saline). A total of 6018 women will be recruited to detect a reduction of 15% or more in neonatal deaths in a two-sided 5% significance test with 90% power (including 10% loss to follow-up).

Discussion
Findings of this trial will guide clinicians, programme managers and policymakers on the safety and efficacy of ACS in hospitals in low-resource countries. The trial findings will inform updating of the World Health Organization’s global recommendations on ACS use.

2018
Widmer M, Piaggio G, Nguyen TM, Osoti A, Owa OO, Misra S, Coomarasamy A, Abdel-Aleem H, Mallapur AA, Qureshi Z, Lumbiganon P. "Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth." New England Journal of Medicine. 2018;379(8):743-752. AbstractWebsite

Background: Postpartum hemorrhage is the most common cause of maternal death. Oxytocin is the standard therapy for the prevention of postpartum hemorrhage, but it requires cold storage, which is not available in many countries. In a large trial, we compared a novel formulation of heat-stable carbetocin with oxytocin.

Methods: We enrolled women across 23 sites in 10 countries in a randomized, double-blind, noninferiority trial comparing intramuscular injections of heat-stable carbetocin (at a dose of 100 μg) with oxytocin (at a dose of 10 IU) administered immediately after vaginal birth. Both drugs were kept in cold storage (2 to 8°C) to maintain double-blinding. There were two primary outcomes: the proportion of women with blood loss of at least 500 ml or the use of additional uterotonic agents, and the proportion of women with blood loss of at least 1000 ml. The noninferiority margins for the relative risks of these outcomes were 1.16 and 1.23, respectively.

Results: A total of 29,645 women underwent randomization. The frequency of blood loss of at least 500 ml or the use of additional uterotonic agents was 14.5% in the carbetocin group and 14.4% in the oxytocin group (relative risk, 1.01; 95% confidence interval [CI], 0.95 to 1.06), a finding that was consistent with noninferiority. The frequency of blood loss of at least 1000 ml was 1.51% in the carbetocin group and 1.45% in the oxytocin group (relative risk, 1.04; 95% CI, 0.87 to 1.25), with the confidence interval crossing the margin of noninferiority. The use of additional uterotonic agents, interventions to stop bleeding, and adverse effects did not differ significantly between the two groups.

Conclusions: Heat-stable carbetocin was noninferior to oxytocin for the prevention of blood loss of at least 500 ml or the use of additional uterotonic agents. Noninferiority was not shown for the outcome of blood loss of at least 1000 ml; low event rates for this outcome reduced the power of the trial. (Funded by Merck Sharpe & Dohme; CHAMPION Australian New Zealand Clinical Trials Registry number, ACTRN12614000870651 ; EudraCT number, 2014-004445-26 ; and Clinical Trials Registry-India number, CTRI/2016/05/006969 .).

Group WHOODR. "Odon device for instrumental vaginal deliveries: results of a medical device pilot clinical study ." Reproductive Health . 2018;15(45). AbstractWebsite

Background
A prolonged and complicated second stage of labour is associated with serious perinatal complications. The Odon device is an innovation intended to perform instrumental vaginal delivery presently under development. We present an evaluation of the feasibility and safety of delivery with early prototypes of this device from an early terminated clinical study.

Methods
Hospital-based, multi-phased, open-label, pilot clinical study with no control group in tertiary hospitals in Argentina and South Africa. Multiparous and nulliparous women, with uncomplicated singleton pregnancies, were enrolled during the third trimester of pregnancy. Delivery with Odon device was attempted under non-emergency conditions during the second stage of labour. The feasibility outcome was delivery with the Odon device defined as successful expulsion of the fetal head after one-time application of the device.

Results
Of the 49 women enrolled, the Odon device was inserted successfully in 46 (93%), and successful Odon device delivery as defined above was achieved in 35 (71%) women. Vaginal, first and second degree perineal tears occurred in 29 (59%) women. Four women had cervical tears. No third or fourth degree perineal tears were observed. All neonates were born alive and vigorous. No adverse maternal or infant outcomes were observed at 6-weeks follow-up for all dyads, and at 1 year for the first 30 dyads.

Conclusions
Delivery using the Odon device is feasible. Observed genital tears could be due to the device or the process of delivery and assessment bias. Evaluating the effectiveness and safety of the further developed prototype of the BD Odon Device™ will require a randomized-controlled trial.

Santana DS, Silveira C, Costa ML, Souza RT, Surita FG, Souza JP, Mazhar SB, Jayaratne K, QURESHI ZAHIDA, Sousa MH, Vogel JP, Cecatti JG. "Perinatal outcomes in twin pregnancies complicated by maternal morbidity:evidence from the WHO Multicountry Survey on Maternal and Newborn Health." BMC Pregnancy and Childbirth . 2018;18(449). AbstractWebsite

Background: Twin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes, especially for the second twin. In addition, the maternal complications (potentially life-threatening conditions-PLTC, maternal near miss-MNM, and maternal mortality-MM) are directly related to twin pregnancy and independently associated with adverse perinatal outcome. The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth.

Methods: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), a cross-sectional study implemented in 29 countries. Data from 8568 twin deliveries were compared with 308,127 singleton deliveries. The occurrence of adverse perinatal outcomes and maternal complications were assessed. Factors independently associated with adverse perinatal outcomes were reported with adjusted PR (Prevalence Ratio) and 95%CI.

Results: The occurrence of severe maternal morbidity and maternal death was significantly higher among twin compared to singleton pregnancies in all regions. Twin deliveries were associated with higher rates of preterm delivery (37.1%), Apgar scores less than 7 at 5th minute (7.8 and 10.1% respectively for first and second twins), low birth weight (53.2% for the first and 61.1% for the second twin), stillbirth (3.6% for the first and 5.7% for the second twin), early neonatal death (3.5% for the first and 5.2% for the second twin), admission to NICU (23.6% for the first and 29.3% for the second twin) and any adverse perinatal outcomes (67% for the first twin and 72.3% for the second). Outcomes were consistently worse for the second twin across all outcomes. Poisson multiple regression analysis identified several factors independently associated with an adverse perinatal outcome, including both maternal complications and twin pregnancy.

Conclusion: Twin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.

Keywords: Maternal morbidity; Perinatal outcome; Twin pregnancy.

PUlei AN, Shatry NA, Sura MK, Njoroge MW, Kibii DK, Mwaniki DK, Teko HP, Maranga O, Ogutu O, Vogel JP, Qureshi Z. "Updating of a clinical protocol for the prevention and management of postpartum haemorrhage at Kenyatta National Hospital, Nairobi, Kenya." East African Medical Journal. 2018;95(2). AbstractWebsite

Background: Postpartum haemorrhage (PPH) affects 6% of births and accounts for almost 30% of maternal deaths. The use of clinical protocols for preventing and treating PPH is recommended by WHO. Protocols should be evidence-based, regularly updated, widely available and routinely adhered to.
Broad Objective: To update the Kenyatta National Hospital (KNH) PPH prevention and management protocol based on latest recommendations, and ensure its dissemination and use by providers.
Materials and Methods: A literature search identified selected PPH-related guidelines which were assessed using the AGREE-II tool for guideline quality. A matrix was created to compare recommendations across guidelines. Recommendations included in the KNH protocol were based on agreement across guidelines, guideline quality, publication year, and contextual factors in our setting. To aid implementation, an updated KNH protocol document, a clinical algorithm and a PPH management checklist were developed. These were reviewed and accepted as best practice by KNH and University of Nairobi.
Results: Six PPH-related guidelines were used (WHO, FIGO, RCOG, ACOG, FOGSI, and the Kenya National Guidelines for Quality Obstetrics and Perinatal care). The KNH protocol covers PPH prevention, including: active management of third stage, oxytocin after vaginal or caesarean delivery, other drugs for prevention (when oxytocin is not available), controlled cord traction and delayed cord clamping. It also covers PPH management (supportive and definitive measures).
Conclusion: An updated PPH prevention and management protocol for KNH was developed. Implementation and adherence will help standardize PPH-related care and improve health outcomes for women.

Muhula S, Opanga Y, Kuyo M, Qureshi Z, Memiah P, M N. "Use of performance dashboards in health care project management: a case of an international health development organization in Kenya." Africa Health Agenda International Journal. 2018;1(3). AbstractWebsite

In this paper we document the use of dashboards in health care project management in an international health non-governmental organization. All projects at the organization monitor output performance on specific indicators against set targets and report these as project outputs performance report every month. In addition, projects prepare quality improvement report, compliance report and financial report. The four reports are then used to generate the monthly integrated performance monitoring and management dashboard which is shared with all staff and used by project managers and programme directors to review projects performance in the 4 parameters of measure and then used to provide appropriate technical support. We conducted a client satisfaction survey among staff to assess their levels of satisfaction with the dashboard and it came out that staff consider the dashboard as a “must have” monthly project management tool as it results in timely measurement of projects’ financial performance, programmatic performance, quality of service performance and compliance performance at a glance without the need to go through detailed reports. Programme directors and project managers use the dashboard to quickly identify hotspots, detect outliers in indicators of measure in a project and use this to deeply analyse possible causes of poor performance in projects for targeted technical assistance.

2017
Vogel JP, Oladapo OT, Pileggi-Castro C, Adejuyigbe EA, Althabe F, Ariff S, Ayede AI, Baqui AH, Costello A, Chikamata DM, Crowther C, Fawole B, Gibbons L, Jobe AH, Kapasa ML, Kinuthia J, Kriplani A, Kuti O, Neilson J, Patterson J, Piaggio G, Qureshi R, Qureshi Z, Sankar MJ, Stringer JSA, Temmerman M, Yunis K, Bahl R, Gülmezoglu AM. "Antenatal corticosteroids for women at risk of imminent preterm birth in low-resource countries: the case for equipoise and the need for efficacy trials." British Medical Journal Global Health. 2017;2(3). AbstractWebsite

The scientific basis for antenatal corticosteroids (ACS) for women at risk of preterm birth has rapidly changed in recent years. Two landmark trials-the Antenatal Corticosteroid Trial and the Antenatal Late Preterm Steroids Trial-have challenged the long-held assumptions on the comparative health benefits and harms regarding the use of ACS for preterm birth across all levels of care and contexts, including resource-limited settings. Researchers, clinicians, programme managers, policymakers and donors working in low-income and middle-income countries now face challenging questions of whether, where and how ACS can be used to optimise outcomes for both women and preterm newborns. In this article, we briefly present an appraisal of the current evidence around ACS, how these findings informed WHO's current recommendations on ACS use, and the knowledge gaps that have emerged in the light of new trial evidence. Critical considerations in the generalisability of the available evidence demonstrate that a true state of clinical equipoise exists for this treatment option in low-resource settings. An expert group convened by WHO concluded that there is a clear need for more efficacy trials of ACS in these settings to inform clinical practice.

Keywords: antenatal corticosteroids; neonatal mortality; preterm birth.

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. "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. 2017. 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.

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. "Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health." Scientific Reports. 2017;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.

M B, N PV, J RM, A C, D L, JP S, A.M G. "Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation ." Reproductive Health . 2017;14(67). AbstractWebsite

Background
There is a need for a clear and actionable definition of maternal sepsis, in order to better assess the burden of this condition, trigger timely and effective treatment and allow comparisons across facilities and countries. The objective of this study was to review maternal sepsis definitions and identification criteria and to report on the results of an expert consultation to develop a new international definition of maternal sepsis.

Methods
All original and review articles and WHO documents, as well as clinical guidelines providing definitions and/or identification criteria of maternal sepsis were included. A multidisciplinary international panel of experts was surveyed through an online consultation in March-April 2016 on their opinion on the existing sepsis definitions, including new definition of sepsis proposed for the adult population (2016 Third International Consensus Definitions for Sepsis and Septic Shock) and importance of different criteria for identification of maternal sepsis. The definition was agreed using an iterative process in an expert face-to-face consensus development meeting convened by WHO and Jhpiego.

Results
Standardizing the definition of maternal sepsis and aligning it with the current understanding of sepsis in the adult population was considered a mandatory step to improve the assessment of the burden of maternal sepsis by the expert panel. The literature review and expert consultation resulted in a new WHO consensus definition “Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, child-birth, post-abortion, or post-partum period”. Plans are in progress to validate the new WHO definition of maternal sepsis in a large international population.

Conclusion
The operationalization of the new maternal sepsis definition requires generation of a set of practical criteria to identify women with sepsis. These criteria should enable clinicians to focus on the timely initiation of actionable elements of care (administration of antimicrobials and fluids, support of vital organ functions, and referral) and improve maternal outcomes.

2016
Z Q, A M. "Development of Basic Obstetric Theater Facility in a Low-resource Setting.". In: Gynecologic and Obstetric Surgery Challenges and Management Options.; 2016.
Santana DS, Cecatti JG, Surita FG, Silveira C, Costa ML, Souza JP, Mazhar SB, Jayaratne K, QURESHI ZAHIDA, Sousa MH, Vogel JP. "Pregnancy and Severe Maternal Outcomes: The World Health Organization Multicountry Survey on Maternal and Newborn Health." Obstetrics & Gynecology. 2016;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.

J H, Z Q. "Preventing deaths due to haemorrhage. ." Best Practice & Research Clinical Obstetrics & Gynaecology Elsevier. 2016;36:68-32.Website
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. "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. 2016;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).

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

Osoti A, Gwako GN, Liyayi B, Qureshi ZP. "Distinguishing Intrauterine Fetal Demise versus Abdominal Pregnancy in Low Resource Settings." East African Medical Journal. 2015;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.

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. "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.. 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.

2014
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. "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." Lancet. 2014;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.

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. "Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exercise." Reprod Health. 2014;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.

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. "Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study." Lancet. 2013;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. "Antenatal corticosteroid use in preterm birth at Kenyatta National Hospital." J. Obst. Gynae. East Central. Afr. 2013;25(1):3-9 .
Souza JP, Gülmezoglu AM, Vogel J, Carroli G, Lumbiganon P, QURESHI ZAHIDA. "Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study." Lancet. 2013;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
A.M G, P. L, S. L, M. W, H. A-A, M. F, G. C, Z. Q, JP. S. "Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial." Lancet. 2012;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

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

2011
K. W, S. M, J.W. M, Z. Q, J. B, P. V. "Depression among women with obstetric fistula in Kenya." Int J Gynaecol Obstet. 2011;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

P.K. T, Z. Q, G. N. "Estimation of blood loss after vaginal delivery." J. Obst. Gynae. East Central. Afr.. 2011;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.

Qureshi ZP, Sartor O, Xirasagar S, Liu Y, Bennett CL. "Pharmaceutical fraud and abuse in the United States, 1996-2010.". 2011.
N. W, H. T, Z. Q. "Prevalence of cervical cytology abnormalities among women attending antenatal clinic at Kenyatta National Hospital." J. Obst. Gynae. East Central. Afr.. 2011;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. "The World Health Organization multicountry survey on maternal and newborn health: study protocol." BMC Health Serv Res. 2011;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.

2010
Z. Q. "Editorial Maternal Health." J. Obst. Gynae. East Central. Afr . 2010;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.

Jaldesa GW, Qureshi ZP, Kigondu CS. "Psychosexual problems associated with Female Genital Mutilation (FGM)." J. Obst. Gynae. East Central. Afr. . 2010;22(1):1-6.
Z.P. Q, C. S-K, S.M. M. "Rapid assessment of partograph utilization in selected maternity units in Kenya." East Afr Med J. 2010;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
AM G, M W, M M, Z Q, G P. "Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial." Reprod Health. 2009;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. N, A. A, Z.P. Q, C.S. K. "Gestational thyrotoxicosis associated with emesis in early pregnancy." East Afr Med J. 2009;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.

Ndungu JR, Amayo A, Qureshi ZP, Kigondu CS. "Gestational Thyrotoxicosis associated with Emesis in early Pregnancy." East. Afr. Med. J. 2009;86(2):55-58.
J.R DRNDUNGU, A DRAMAYO, Z.P DRQURESHI, C PROFSEKKADE-KIGONDU. "Gestational thyrotoxicosis associated with emesis in early pregnancy." E.A.M.J. 2009;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. Q, J. K. "Birth preparedness among antenatal clients." East Afr Med J. 2008;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.

S.M M, J. K, Z. Q. "Contraceptive use among HIV infected women attending Comprehensive Care Centre." East Afr Med J. 2008;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.P. Q, J. K. "Emergency preparedness among antenatal clients at Kenyatta National Hospital." J. Obst. Gynae. East Central. Afr.. 2008;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. "Obstetrical emergencies in relation to millennium development goals." East Afr Med J. 2008;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.

2006
J. S, N. N, Z. Q, M. N. "Does assessment of signs and symptoms add to the predictive value of an algorithm to rule out pregnancy?" J Fam Plann Reprod Health Care. 2006;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.

2005
ZAHIDA DRQURESHI. "Editorial Safe motherhood in Africa: Achievable Goal or a Dream?" East Afr Med J. . 2005;82(1):1. AbstractWebsite

Safe motherhood refers to a woman's ability to have a safe and healthy pregnancy and delivery. The goal of safe motherhood is to ensure that every woman has access to a full range of high-quality affordable sexual and reproductive health services especially maternal care and treatment of obstetric emergencies to reduce deaths and disabilities

Wasike C, Ndavi M, Kigondu CS, Wanjala SM, Qureshi ZP. "Motivation for Reacceptance of Intradermal Implants –Norplant on Removal after using for Five Years." J. Obst. Gynae. East Central. Afr. . 2005;18(1):31-45 .
2002
Z.P. Q. "Current management of hypertensive disease in pregnancy." East Afr Med J. 2002;79(4):169-71. Abstract

Hypertensive disorders occur in 6-8% of all pregnancies with the incidence varying with geographic location. Studies conducted at Kenyatta National Hospital have noted a prevalence of 5.4% of hypertensive disease and 0.56% for eclampsia. Pregnant mothers with hypertension are predisposed towards the development of potentially lethal complications, notably abruption placentae, disseminated vascular coagulation, cerebral haemorrhage, hepatic failure and acute renal failure. The baby many have intra-uterine growth retardation, suffer the consequences of being born to early, or die in utero. Causes of hypertensive disease especially pre-eclampia remain unknown.

PARVEEN DRQURESHIZAHIDA. "Stanback J, Qureshi Z, Sekkade-Kigondu C. Advance Provision of Oral Contraceptives to Family Planning Clients in Kenya 1: East Afr Med J. 2002 May;79(5):257-8.". In: East Afr Med J. 2002 May;79(5):257-8. Far East Journal of Theoretical Statistics; 2002. Abstract

OBJECTIVE: In sub-Saharan Africa, many family planning programmes do not encourage advance provision of oral contraceptives to clients who must wait until menses to initiate pill use. Since some resistance to advance provision of pills is due to provider fears that the practice may be harmful, we conducted a study in Kenya in 1997 to compare pill-taking outcomes between 20 "advance provision" clients and 280 "standard" clients. DESIGN: Prospective observational study. SETTING: Six family planning clinics in Central and Western Kenya. SUBJECTS: Women presenting as new clients at MOH family planning clinics. INTERVENTIONS: Researchers used prospective tracking to compare indicators of pill-taking success between non-menstruating clients given pills to carry home for later use and menstruating clients who began pill use immediately. MAIN OUTCOME MEASURES: Pill-taking outcomes such as side effects, compliance, knowledge, satisfaction, and a continuation proxy. RESULTS: Among clients returning for re-supply, those receiving advance provision of pills did no worse than, and often had superior outcomes to, their counterparts who started taking pills immediately after the clinic visit. CONCLUSIONS: Advance provision of pills, already practiced worldwide, is safe and feasible. Explicit mention should be made of advance provision of pills in national family planning guidance documents and training curricula in Kenya and throughout sub-Saharan Africa.

1999
J. S, Z. Q, C S-K, B. G, T N. "Checklist for ruling out pregnancy among family-planning clients in primary care." Lancet. 1999;354(9178):566. Abstract

Abstract

Where pregnancy tests are unavailable, health providers, fearing possible harm to fetuses, often deny contraception to nonmenstruating clients. In Kenya, a trial of a simple checklist to exclude pregnancy showed a good negative predictive value, which could improve access to service and reduce unwanted pregnancies and their sequelae.

PIP:
This report presents Kenya's checklist (consisting of six simple questions) for ruling out pregnancy among family planning clients; the questions are intended to improve access to service and reduce unwanted pregnancies and their sequelae. The checklist includes questions on most recent birth, duration and frequency of breast-feeding, duration since last menstrual period, duration since last abortion or miscarriage, abstinence from sexual relations, and current contraceptive practices. The checklist was administered and followed by dipstick pregnancy tests at seven family planning clinics in order to test its validity. The checklist ruled out pregnancy for 88% of women. The checklist¿s high negative predictive value (99%) should be regarded as the relevant statistic. Widespread use of this checklist could lessen restriction to contraceptives in many countries.

J S, T N, J G, Z Q. "Menstruation Requirements as a Barrier to Contraceptive Access in Kenya E.A.M.J. 76 ( 3 ): 124, 1999." E.A.M.J. . 1999;76(3):124-126. AbstractWebsite

Abstract
BACKGROUND: In many countries, non-menstruating women are routinely denied contraceptive services even when pregnancy can easily be ruled out.

OBJECTIVE: To determine whether menstruation requirements in Kenya constitute a barrier to access for potential family planning clients.

DESIGN: Prospective and retrospective observational study.

SETTING: Nine family planning clinics in western Kenya.
SUBJECTS: Women presenting as new clients at Ministry of Health family planning clinics.

INTERVENTIONS: Researchers used prospective tracking and retrospective record reviews to compare the menstrual status of women presenting for family planning services with that of women who received methods in family planning clinics.

MAIN OUTCOME MEASURES: Dichotomous outcomes (menstruating versus non-menstruating women).
RESULTS:
During the eight-week period that tally sheets were used in the one hospital and eight health centres, 45% of the 760 women presenting for services as new clients were not menstruating (clinic range = 19%-70%). In contrast, information from clinic registers and client records in the same nine clinics showed that the (weighted) proportion of registered new clients who were menstruating was 85% (n = 102). We estimated that 78% of non-menstruating women (35% of all potential new clients) were sent away without services.

CONCLUSION: For most women turned away, it is likely that pregnancy could be ruled out easily with a history and an examination. Menstruation as a pre-condition for provision of contraception wastes valuable resources and denies women their right to contraception.

1998
GW DRJALDESA, ZP DRQURESHI, SMH DRWANJALA, C PROFSEKKADE-KIGONDU. "Factors Enhancing the Practice of Female Genital Mutilation among the Kenyan Somalis. Journal of Obstetrics and Gynecology of East and Central Africa 14 (2), 110, 1998." Journal of Obstetrics and Gynecology of East and Central Africa 14 (2), 110, 1998. 1998;14(2):110-114. AbstractWebsite

This is a descriptive cross sectional study. A structured questionnaire was used to interview 300 respondents who had infibulation as a form of female genital circumcision.The interviews were conducted at Garissa General Hosptial Gynaecology out-patient clinic. The objective of this study was to establish the factors that enhance the practice of female circumcision.
Female circumcision was performed between 3 to 14 years of age with the peak age of 7 years. In 83% of the respondents the event was arranged by the mother of the respondents. The three leading reasons why the practice was carried out in the community were, religious demand(66.3%), prevention of enlargement of clitoris(51%), and protection of virginity (48.3%).
In conclusion FGM is a harmful traditional practice that is traditionally justified but has no medical support.

PARVEEN DRQURESHIZAHIDA. "Jaldesa GW, Wanjala SMH, Qureshi Z P, Sekkade-Kigondu C. Maternal Morbidity and Mortality at Garissa Provincial Hospital, 3 year retrospective Survey. Journal of Obstetrics and Gynecology of East and Central Africa 14 ( 2 ), 68, 1998.". In: Journal of Obstetrics and Gynecology of East and Central Africa 14 ( 2 ), 68, 1998. Far East Journal of Theoretical Statistics; 1998. Abstract

OBJECTIVE: In sub-Saharan Africa, many family planning programmes do not encourage advance provision of oral contraceptives to clients who must wait until menses to initiate pill use. Since some resistance to advance provision of pills is due to provider fears that the practice may be harmful, we conducted a study in Kenya in 1997 to compare pill-taking outcomes between 20 "advance provision" clients and 280 "standard" clients. DESIGN: Prospective observational study. SETTING: Six family planning clinics in Central and Western Kenya. SUBJECTS: Women presenting as new clients at MOH family planning clinics. INTERVENTIONS: Researchers used prospective tracking to compare indicators of pill-taking success between non-menstruating clients given pills to carry home for later use and menstruating clients who began pill use immediately. MAIN OUTCOME MEASURES: Pill-taking outcomes such as side effects, compliance, knowledge, satisfaction, and a continuation proxy. RESULTS: Among clients returning for re-supply, those receiving advance provision of pills did no worse than, and often had superior outcomes to, their counterparts who started taking pills immediately after the clinic visit. CONCLUSIONS: Advance provision of pills, already practiced worldwide, is safe and feasible. Explicit mention should be made of advance provision of pills in national family planning guidance documents and training curricula in Kenya and throughout sub-Saharan Africa.

PARVEEN DRQURESHIZAHIDA. "Qureshi Z P, Raassen T J I P. Vesico-vaginal fistulae occurring after total abdominal Hysterectomy. Journal of Obstetrics and Gynecology of East and Central Africa 14 (2), 115,1998.". In: Journal of Obstetrics and Gynecology of East and Central Africa 14 (2), 115,1998. Far East Journal of Theoretical Statistics; 1998. Abstract

OBJECTIVE: In sub-Saharan Africa, many family planning programmes do not encourage advance provision of oral contraceptives to clients who must wait until menses to initiate pill use. Since some resistance to advance provision of pills is due to provider fears that the practice may be harmful, we conducted a study in Kenya in 1997 to compare pill-taking outcomes between 20 "advance provision" clients and 280 "standard" clients. DESIGN: Prospective observational study. SETTING: Six family planning clinics in Central and Western Kenya. SUBJECTS: Women presenting as new clients at MOH family planning clinics. INTERVENTIONS: Researchers used prospective tracking to compare indicators of pill-taking success between non-menstruating clients given pills to carry home for later use and menstruating clients who began pill use immediately. MAIN OUTCOME MEASURES: Pill-taking outcomes such as side effects, compliance, knowledge, satisfaction, and a continuation proxy. RESULTS: Among clients returning for re-supply, those receiving advance provision of pills did no worse than, and often had superior outcomes to, their counterparts who started taking pills immediately after the clinic visit. CONCLUSIONS: Advance provision of pills, already practiced worldwide, is safe and feasible. Explicit mention should be made of advance provision of pills in national family planning guidance documents and training curricula in Kenya and throughout sub-Saharan Africa.

PARVEEN DRQURESHIZAHIDA. "Qureshi Z P, Raassen TJIP. Obstetric Fistula Repair Programme of the Department of Obstetrics and Gynaecology of the University of Nairobi. Proceedings of the 1st Meeting of the East, Central and Southern Africa Association of Obstetrical and Gynaecologic.". In: Uganda 1997 Published 1998. Far East Journal of Theoretical Statistics; 1998. Abstract

OBJECTIVE: In sub-Saharan Africa, many family planning programmes do not encourage advance provision of oral contraceptives to clients who must wait until menses to initiate pill use. Since some resistance to advance provision of pills is due to provider fears that the practice may be harmful, we conducted a study in Kenya in 1997 to compare pill-taking outcomes between 20 "advance provision" clients and 280 "standard" clients. DESIGN: Prospective observational study. SETTING: Six family planning clinics in Central and Western Kenya. SUBJECTS: Women presenting as new clients at MOH family planning clinics. INTERVENTIONS: Researchers used prospective tracking to compare indicators of pill-taking success between non-menstruating clients given pills to carry home for later use and menstruating clients who began pill use immediately. MAIN OUTCOME MEASURES: Pill-taking outcomes such as side effects, compliance, knowledge, satisfaction, and a continuation proxy. RESULTS: Among clients returning for re-supply, those receiving advance provision of pills did no worse than, and often had superior outcomes to, their counterparts who started taking pills immediately after the clinic visit. CONCLUSIONS: Advance provision of pills, already practiced worldwide, is safe and feasible. Explicit mention should be made of advance provision of pills in national family planning guidance documents and training curricula in Kenya and throughout sub-Saharan Africa.

1996
QURESHI ZAHIDA, KIGONDU-SEKADDE C. "Sekkade -Kigondu C, Qureshi Z P, Karanja JG, Jaldesa GW, Kaihura DMM Abstracts of Research in Gynaecology and Family Planning by Department of Obstetrics and Gynaecology 1971 - 1995. Published 1996.". 1996. AbstractWebsite

PIP: In November and December, 1993, a self-administered questionnaire was distributed to men in the town of Machakos and to nonmedical hospital workers of Machakos General Hospital. The purpose of the study was to assess their knowledge about and attitude towards vasectomy. The majority of men were in the age group of 30-44 years and were married; the hospital group was more educated. The town men perceived the pill to be the best contraceptive method for women in contrast to the hospital group who gave more importance to bilateral tubal ligation. The hospital group also perceived vasectomy as the best method for men. Overall, 53.2% men were aware of the correct procedure of vasectomy, but only 24% had correct knowledge of how the procedure affects masculinity. The knowledge of the procedure among hospital workers was not very different from that of the town group. Recommendations were made to increase information and education to all groups of people through various media. author's modified

PARVEEN DRQURESHIZAHIDA, OTIENO DRODAWAFRANCISXAVIER. "Qureshi Z P, Solomon MM Three case reports on Abdominal Pregnancy seen at Machakos General Hospital. Journal of Obstetrics and Gynaecology of East and Central Africa 12 (1): 12, 1996.". In: Journal of Obstetrics and Gynaecology of East and Central Africa 12 (1): 12, 1996. Far East Journal of Theoretical Statistics; 1996. Abstract
OBJECTIVE: In sub-Saharan Africa, many family planning programmes do not encourage advance provision of oral contraceptives to clients who must wait until menses to initiate pill use. Since some resistance to advance provision of pills is due to provider fears that the practice may be harmful, we conducted a study in Kenya in 1997 to compare pill-taking outcomes between 20 "advance provision" clients and 280 "standard" clients. DESIGN: Prospective observational study. SETTING: Six family planning clinics in Central and Western Kenya. SUBJECTS: Women presenting as new clients at MOH family planning clinics. INTERVENTIONS: Researchers used prospective tracking to compare indicators of pill-taking success between non-menstruating clients given pills to carry home for later use and menstruating clients who began pill use immediately. MAIN OUTCOME MEASURES: Pill-taking outcomes such as side effects, compliance, knowledge, satisfaction, and a continuation proxy. RESULTS: Among clients returning for re-supply, those receiving advance provision of pills did no worse than, and often had superior outcomes to, their counterparts who started taking pills immediately after the clinic visit. CONCLUSIONS: Advance provision of pills, already practiced worldwide, is safe and feasible. Explicit mention should be made of advance provision of pills in national family planning guidance documents and training curricula in Kenya and throughout sub-Saharan Africa.
PARVEEN DRQURESHIZAHIDA, OTIENO DRODAWAFRANCISXAVIER. "Sekkade -Kigondu C, Qureshi Z P, Karanja JG, Jaldesa GW, Kaihura DMM Abstracts of Research in Reproductive Health by Department of Obstetrics and Gynaecology 1971 - 1995. Published 1996.". In: Reproductive Health by Department of Obstetrics and Gynaecology 1971 - 1995. Published 1996. Far East Journal of Theoretical Statistics; 1996. Abstract
OBJECTIVE: In sub-Saharan Africa, many family planning programmes do not encourage advance provision of oral contraceptives to clients who must wait until menses to initiate pill use. Since some resistance to advance provision of pills is due to provider fears that the practice may be harmful, we conducted a study in Kenya in 1997 to compare pill-taking outcomes between 20 "advance provision" clients and 280 "standard" clients. DESIGN: Prospective observational study. SETTING: Six family planning clinics in Central and Western Kenya. SUBJECTS: Women presenting as new clients at MOH family planning clinics. INTERVENTIONS: Researchers used prospective tracking to compare indicators of pill-taking success between non-menstruating clients given pills to carry home for later use and menstruating clients who began pill use immediately. MAIN OUTCOME MEASURES: Pill-taking outcomes such as side effects, compliance, knowledge, satisfaction, and a continuation proxy. RESULTS: Among clients returning for re-supply, those receiving advance provision of pills did no worse than, and often had superior outcomes to, their counterparts who started taking pills immediately after the clinic visit. CONCLUSIONS: Advance provision of pills, already practiced worldwide, is safe and feasible. Explicit mention should be made of advance provision of pills in national family planning guidance documents and training curricula in Kenya and throughout sub-Saharan Africa.
1995
PARVEEN DRQURESHIZAHIDA, OTIENO DRODAWAFRANCISXAVIER. "Qureshi Z P, Solomon M M. A Survey on the knowledge and attitudes of men in Machakos town towards Vasectomy. Journal of Obstetrics and Gynaecology of East and Central Africa 11 (1): 10, 1995.". In: Journal of Obstetrics and Gynaecology of East and Central Africa 11 (1): 10, 1995. Far East Journal of Theoretical Statistics; 1995. Abstract

PIP: In November and December, 1993, a self-administered questionnaire was distributed to men in the town of Machakos and to nonmedical hospital workers of Machakos General Hospital. The purpose of the study was to assess their knowledge about and attitude towards vasectomy. The majority of men were in the age group of 30-44 years and were married; the hospital group was more educated. The town men perceived the pill to be the best contraceptive method for women in contrast to the hospital group who gave more importance to bilateral tubal ligation. The hospital group also perceived vasectomy as the best method for men. Overall, 53.2% men were aware of the correct procedure of vasectomy, but only 24% had correct knowledge of how the procedure affects masculinity. The knowledge of the procedure among hospital workers was not very different from that of the town group. Recommendations were made to increase information and education to all groups of people through various media. author's modified

1991
ZAHIDA DRQURESHI, C S-K. "A Survey determine the knowledge attitude and practice of Family Planning among the Nursing Staff of Kenyatta National Hospital. Journal of Obstetrics and Gynaecology of East and Central Africa ." Journal of Obstetrics and Gynaecology of East and Central Africa 9 (1): 49, 1991. 1991;9(1):41-45. AbstractWebsite

PIP: In November and December, 1993, a self-administered questionnaire was distributed to men in the town of Machakos and to nonmedical hospital workers of Machakos General Hospital. The purpose of the study was to assess their knowledge about and attitude towards vasectomy. The majority of men were in the age group of 30-44 years and were married; the hospital group was more educated. The town men perceived the pill to be the best contraceptive method for women in contrast to the hospital group who gave more importance to bilateral tubal ligation. The hospital group also perceived vasectomy as the best method for men. Overall, 53.2% men were aware of the correct procedure of vasectomy, but only 24% had correct knowledge of how the procedure affects masculinity. The knowledge of the procedure among hospital workers was not very different from that of the town group. Recommendations were made to increase information and education to all groups of people through various media. author's modified

1989

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