Search

Objective: To audit intrapartum fetal and early neonatal deaths of infants weighing >or=2000 g in a regional hospital in western Tanzania.Methods: The 3-delays methodology was applied to a cohort of perinatal deaths from July 2002 to July 2004.Results: The overall perinatal mortality rate in the hospital was 38 per 1000 live births, and in just over half of these cases the birth weight was >or=2000 g. The leading clinicopathologic causes of death were birth asphyxia (19.0%), prolonged or obstructed labor (18.5%), antepartum hemorrhage (11.5%), and uterine rupture (9.0%). First delays occurred in 19.0% of the cases, second delays occurred in 21.5%, and third delays occurred in 72.5%.Conclusion: For women who delivered in this hospital, most of the substandard care occurred after admission to the health facility. The improvement of institutional health care may have a significant impact on the decision to attend health institutions and, thereby, reduce first delays. [ABSTRACT FROM AUTHOR]

A study in 2000–2001 of causes of death of women of reproductive age (15–49) in the West Bank, Palestinian Occupied Territories, found that 154 of the 411 deceased women aged 15–49 with known marital status were single. Death notification forms for reported deaths were analysed and verbal autopsies carried out, where possible, with relatives of the deceased women. We found important differences in the age at death and causes of death among the single and married women, which can be attributed to the disadvantaged social status of single women in Palestinian society, exacerbated by the current unstable political situation. 41% of the deceased single women were under 25 years of age at death compared to 8% of the married women. The proportion of violent deaths and suicides among the single women was almost twice as high as among the married women, mainly in those below age 25. The single women were also more likely to die from medical conditions which indicated that they faced barriers to accessing health care. The fieldwork was conducted at the height of the Intifada and the Israeli military response, with heavy restrictions on mobility, limiting the possibility of probing deeper into the circumstances surrounding sensitive deaths. More research into the socio-cultural context of single women in Palestine society is needed as a basis for intervention. En 2000-2001, une étude des causes de mortalité des femmes en âge de procréer (15-49) dans la Rive occidentale (Territoires palestiniens occupés) a révélé que 154 des 411 femmes décédées dans cette tranche d'âge et l'état civil était connu étaient célibataires. Nous avons analysé les formulaires de déclaration des décès et procédé à des autopsies verbales, si possible avec des parents de la morte. D'importantes différences apparaissaient dans l'âge au moment du décès et les causes de décès chez les femmes célibataires et mariées, pouvant être attribuées au statut social défavorisé des femmes célibataires dans la société palestinienne, exacerbé par l'instabilité de la situation politique. Au moment du décès, 41% des femmes célibataires avaient moins de 25 ans contre 8% des femmes mariées. La proportion de morts violentes et de suicides chez les femmes célibataires était près de deux fois plus élevée que chez les femmes mariées, principalement chez les moins de 25 ans. Les célibataires couraient aussi davantage de risque de succomber à des affections médicales, ce qui est révélateur des obstacles qui entravent leur accès aux soins de santé. Le travail sur le terrain a été mené au plus fort de l'intifada et de la réponse militaire israélienne, ce qui a nettement restreint la mobilité et la possibilité d'étudier plus profondément les circonstances entourant les décès sensibles. Davantage de recherches sur le contexte socioculturel des femmes célibataires dans la société palestinienne sont nécessaires comme base des interventions. En un estudio de las causas de muertes de mujeres en edad reproductiva (15–49) en Cisjordania, Territorios Palestinos Ocupados, realizado en 2000–2001, se encontró que 154 de las 411 mujeres fallecidas, de 15 a 49 años de edad, con estado civil conocido eran solteras. Se analizaron los formularios de notificación de defunción de las muertes y, donde fue posible, se realizaron autopsias verbales con los familiares de las difuntas. Se encontraron importantes diferencias en la edad al morir y las causas de muerte entre las mujeres solteras y casadas, lo cual puede atribuirse a la condición social desfavorecida de las solteras en la sociedad palestina, exacerbada por la situación política inestable actual. El 41% de las mujeres solteras fallecidas eran menores de 25 años de edad al morir, comparado con el 8% de las casadas. La proporción de muertes violentas y suicidios entre las solteras fue casi el doble que entre las casadas, principalmente en aquéllas menores de 25 años. Las mujeres solteras también eran más propensas a morir de problemas médicos, lo cual indica que afrontaban barreras para acceder a la atención médica. El trabajo en el campo fue realizado en plena Intifada y respuesta militar israelí, con marcadas restricciones sobre la movilidad, lo cual limitó la posibilidad de indagar más sobre las circunstancias en torno a las muertes sensibles. Para tener una base de intervención, es necesario realizar más investigaciones sobre el contexto sociocultural de las mujeres solteras en Palestina. [ABSTRACT FROM AUTHOR]

Abstract: In this study, we present a simple and easy-to-use extraction method that is based on a hollow-fiber microporous membrane liquid–liquid extraction (HF-MMLLE), as an extraction technique, followed by gas chromatography–mass spectrometry (GC–MS) to determine a group of brominated flame retardants (BFRs), polybrominated diphenyl ethers (PBDEs), at trace levels in aqueous samples. The hollow-fiber membrane (HF) filled with organic solvent was immersed into the aqueous sample, spiked with the analytes at ngl−1 level, and stirred for 60min. The proposed method could attain enrichment factors (E e) up to 5200 times, after optimising parameters, such as organic solvent, stirring speed and extraction time, that affect the extraction. The HF-MMLLE–GC–MS method was successfully applied to the extraction of PBDEs from tap, river and leachate water samples with spike recoveries ranging from 85% to 110%. The method validation with reagent and leachate water samples provided good linearity, detection limits of 1.1ngl−1 or lower, both in reagent and leachate water, as well as satisfactory precision in terms of repeatability and reproducibility with values of % relative standard deviation (%RSD) lower than 8.6 and 16.9, respectively. [Copyright &y& Elsevier]

Background: There is a need to assess the cost-benefit of different models of antibiotic administration for the prevention of post cesarean infection, particularly in resource-scarce settings.Design: Randomized, nonblinded comparative study of a single combined preoperative dose of gentamicin and metronidazole vs. a post cesarean scheme for infection prophylaxis.Methods: Pregnant women (n = 288) with indication for emergency cesarean section were randomly allotted to two groups. Group 1 (n = 143) received the single, combined dose of prophylactic antibiotics and group 2 (n = 145) received, over 7 days, the postoperative standard scheme of antibiotics followed in the department. Both groups were followed up during 7 days for detection of signs of wound infection, endometritis, peritonitis and urinary tract infection.Main Outcome Measures: Prevalence of postoperative infection, mean hospital stay and costs of antibiotics used.Results: Women completing the study (n = 241) were distributed into group 1 (n = 116) and group 2 (n = 125). No significant difference was found neither in the prevalence of postoperative infection nor in the mean hospital stay. No death occurred. The cost of the single dose of prophylactic antibiotics was less than one-tenth of the cost of the standard postoperative scheme.Conclusion: In our setting, the administration of a single dose of 160 mg of gentamicin in combination with 500 mg of metronidazole before emergency cesarean section for prevention of infection is clinically equivalent to existing conventional week-long postoperative therapy, but at approximately one-tenth of the cost. [ABSTRACT FROM AUTHOR]

Background: With a new symphysis-fundus height (SFH) growth chart, based on Mozambican women with ultrasound-dated singleton pregnancies, the aim was to examine the possibility to enhance sensitivity of predicting small for gestational age (SGA) newborns by attempts to adjust the chart for parity and for mid-upper-arm circumference (MUAC).Methods: Two antenatal clinics were chosen in the suburban area of Maputo City. A cohort of 904 consecutively recruited antenatal clients was followed until birth. Gestational age was determined by ultrasound at enrolment. The growth of the SFH was measured every 2-3 weeks. Women with multiple pregnancy or with gestational age >21 weeks at enrolment were excluded. Attempts were made to adjust SFH measurements for parity and MUAC by developing a mathematical model to increase sensitivity of the SFH method to predict a foetus being SGA.Results: Parous women had on average 0.5-1 cm higher SFH readings than nulliparous women. Women with a body mass index (BMI) <19 and women with BMI >27 had approximately 1 cm lower and 1 cm higher readings, respectively, compared with women of normal BMI. There was a significant correlation between BMI and MUAC (r = 0.621; P < 0.001). The usefulness of SFH measurements to predict SGA newborns was analysed. The sensitivity was 49%, the specificity was 66%, the positive predictive value was 14% and the negative predictive value, 93%. By using the correlation between BMI and MUAC we tried to find a simple and useful method to improve the sensitivity of SFH to detect SGA foetuses. By reducing the SFH measurement by 1 cm for women with MUAC >29 and by 1 cm for multiparous women the sensitivity raised to 65% at the expense of reducing the specificity to 51%. Using a linear function of BMI, MUAC and parity to adjust the SFH measurement for each individual woman, it was possible to get a sensitivity of 70% with a corresponding specificity of 56%.Conclusion: By using BMI, MUAC and parity, it might be possible to improve the sensitivity of the SFH growth chart in predicting newborn being SGA but mostly at the expense of specificity. [ABSTRACT FROM AUTHOR]

Our aim was to construct a new symphysis-fundus height (SFH) growth chart, based on Mozambican women with ultrasound-dated singleton pregnancy, who represent the largest obstetric cohort in a developing country followed for this purpose. Two antenatal clinics were chosen in the suburban area of Maputo City. A cohort of 904 consecutively recruited antenatal clients was followed until delivery. The growth of the SFH was measured every second to third week. Gestational age was determined by ultrasound at enrolment. Women with multiple pregnancy or with gestational age > 21 weeks at enrolment were excluded. The average number of antenatal SFH measurements per woman was 7.8 (SD 2.4). The drop out rate was 9.6%. Mean birthweight was 2909 g. Pre-term deliveries occurred in 15% and low birthweight deliveries (< 2500 g) in 16%. Using proper longitudinal methods, we constructed an FH growth chart and compared it with various previously published SFH charts, which showed the Mozambican chart to be 0-3 cm below the others. Nulliparous women were 0.5 cm below multiparous women. We did not find any difference in the SFH growth charts between women with or without overt morbidity. Women with a body mass index (BMI) < 19 and women with a BMI > 27 had approximately 1 cm lower and 1 cm higher readings, respectively, than women with normal BMI. The Mozambican SFH growth chart is an example of an elaborated growth chart for a well-defined population in a low-income country. It constitutes the basis for further studies to predict the small-for-gestational age newborn from anthropometrical data obtained by use of appropriate technology. [ABSTRACT FROM AUTHOR]

Background: Third trimester fetal death is a common problem in Mozambique, occurring in approximately 5% of parturient women.Objective: To elucidate the magnitude of the gestational diabetes mellitus problem, and to estimate its prevalence in a group of women with unexplained late fetal deaths and in women with live fetuses (referents).Methods: An incident case-referent study of 109 pregnant Mozambican women with fetal deaths and 110 women delivering liveborns, regarding fasting B-glucose, oral glucose tolerance test and glycosylated hemoglobin.Result: The difference in gestational diabetes mellitus prevalence in the two groups is not significant. The prevalence of gestational diabetes mellitus was high in both groups: 11% and 7%, respectively. [ABSTRACT FROM AUTHOR]

Background. The purpose of this study was to evaluate the association between third trimester unexplained prelabor fetal deaths and various socio-economic, demographic and obstetric factors in Lithuania. Methods. A case–referent study on 58 women with third trimester fetal death and 116 women with live fetus at term was carried out. Inclusion criteria for women in the first group (cases) were: prelabor fetal death of unknown etiology, singleton pregnancy >26 weeks of gestation and intact fetal membranes. For each case two referent women were recruited, admitted during the same period in active phase of labor at term (>37 weeks of gestation) with intact fetal membranes and fetus alive. Data were obtained by interview, anthropometry and by reviewing the medical records. Several potential socio-economic, demographic and obstetrical risk factors for unexplained fetal death were investigated. Results. Univariate analyses determined several factors that were associated with fetal death of unknown etiology: low educational level, single marital status, low income, etc. After secondary logistic regression analysis only three independent variables remained significantly associated with otherwise unexplained stillbirth: small for gestational age fetus (OR 29.6; 95% CI 6.2–141.6), low income (OR 7.4; 95% CI 3.1–17.6), and maternal white blood cell count more than 16,000/mm3 (OR 5.4; 95% CI 1.4–21.6). Body mass index, smoking, occupation of women and other evaluated parameters were not confirmed to be significant risk factors. Conclusion. Small for gestational age fetus, low income and elevated maternal white blood cell count are factors significantly associated with late prelabor fetal death in Lithuania. [ABSTRACT FROM AUTHOR]

Objective. To investigate the risk for anal sphincter tears (AST) in infibulated women. Design. Population-based cohort study. Setting. Nationwide study in Sweden. Population. The study population included 250 491 primiparous women with a vaginal singleton birth at 37-41 completed gestational weeks during 1999-2008. We only included women born in Sweden and in Africa. The African women were categorized into three groups; a Somalia group, n = 929, where over 95% are infibulated; the Eritrea-Ethiopia-Sudan group, n = 955, where the majority are infibulated, compared with other African countries, n = 1035, where few individuals are infibulated but had otherwise similar anthropometric characteristics. These women were compared with 247 572 Swedish-born women. Methods. Register study with data from the National Medical Birth Registry. Main outcome measures. AST in non-instrumental and instrumental vaginal delivery. Results. Compared with Swedish-born women, women from Somalia had the highest odds ratio for AST in all vaginal deliveries: 2.72 (95%CI 2.08-3.54), followed by women from Eritrea-Ethiopia-Sudan 1.80 (1.41-2.32) and other African countries 1.23 (0.89-1.53) after adjustment for major risk factors. Mediolateral episiotomy was associated with a reduced risk of AST in instrumental deliveries. Conclusion. Delivering African women from countries where infibulation is common carries an increased risk of AST compared with Swedish-born women, despite delivering in a highly technical quality healthcare setting. AST can cause anal incontinence and it is important to investigate risk factors for this and try to improve clinical routines during delivery to reduce the incidence of this complication. [ABSTRACT FROM AUTHOR]

An estimated 60% of all adolescent pregnancies in low-income countries are unintended. The present study was carried out at the university hospital in Lusaka, Zambia over a four-month period in 2005. The aim was to explore experiences of pregnancy loss and to ascertain the girl's contraceptive knowledge and use and their partner's involvement in the pregnancy/abortion. Eighty-seven girls aged 13-19 years admitted to hospital for incomplete abortions were interviewed. Of these girls, 53 (61%) had had a spontaneous abortion and 34 (39%) had undergone an unsafe induced abortion. Significantly more girls with an unsafe induced abortion were single, students, had completed more years in school and were in less stable relationships. Girls' overall contraceptive knowledge and use was low and most pregnancies were unplanned. Partners played a decisive role in terminating pregnancy through unsafe induced abortion. Traditional healers, girls themselves and health professionals were the main abortion providers. Young women's health risks due to unprotected sex and lack of contraceptive services should urgently be addressed. The existence of the abortion law and access to emergency contraception should be better publicized in Zambia. [ABSTRACT FROM AUTHOR]

Abstract: The determination of acidic pharmaceuticals, such as non-steroidal anti-inflammatory drugs NSAIDs and clofibric acid (metabolite of clofibrate), at low ngL−1 levels in wastewater requires highly selective and sensitive analytical procedures. The removal of matrix components during sample preparation results in significant benefits towards reducing the matrix effects during LC–MS analysis. Therefore this work describes a simple method to enrich and clean up NSAIDs and clofibric acid from sewage water using molecularly imprinted solid-phase extraction (MISPE). Final analysis was performed by liquid chromatography–tandem mass spectrometry. The performance of this method has been evaluated in fortified tap and sewage water in terms of recovery, precision, linearity, and method quantification limit. Recovery for all compounds ranged in all matrices between 84 and 116% with intra-day R.S.D. values below 11.5%. Matrix effect evaluation demonstrated that even complex sample matrixes, such as pond or sewage water did not showed significant ion suppression/enhancement compared to tap water. The performance of the method was further emphasized by the study of pond water, which receives treated water from a sewage treatment plant in south Sweden. Raw sewage and treated water were also tested. In those samples, all acidic pharmaceuticals were detected in concentration above method quantification limits ranging from 5.1 to 5153.0ngL−1. [Copyright &y& Elsevier]

Postpartum hemorrhage (PPH) is the single most common cause of maternal death in the world, and oxytocin is known to be effective for its prevention and treatment. The use of syringes can be problematic in areas affected by HIV. The aim of this study was to introduce Uniject™ (a new disposable device for administration of 10 IU oxytocin) as part of active management of the third stage of labor (AMTL) and try to reduce PPH.A prospective, comparative study was performed between March 1998 and May 2000 in Luanda. Seven hundred and eighty-two parturient women with physiological management were compared to 814 with AMTL. Postpartum lost blood was collected using a plastic sheet during labor and a bucket placed under a cholera bed for 2 h postpartum. Student'st-test andχ2 test were used.PPH was reduced from 40·4 to 8·2% and severe PPH (≥1000 ml) from 7·5 to 1% in the AMTL group (P < 0·001).Uniject™ was well tolerated and offers an alternative for oxytocin administration. AMTL should be implemented also in resource-poor settings as a routine management to reduce PPH. [ABSTRACT FROM AUTHOR]

Indigenous Fijians and the descendants of Asian Indians constitute the two major ethnic groups in Fiji. There are differences between the two groups in perinatal outcomes. To study fetal growth patterns in the two ethnic groups and to ascertain the influence, if any, of ethnicity on fetal growth. A longitudinal study was carried out on women with sure dates, regular cycles, no known risk factor complicating pregnancy and having their first antenatal examination before 20 weeks. Symphysis-fundal height, biparietal diameter, abdominal circumference and femur length were measured by the same observer at recruitment and at follow-up visits until delivery. Infant measurements were recorded soon after birth. Indian babies were on average 795 g lighter, had 5.5 days shorter mean length of gestation and slower growth of biparietal diameter and abdominal circumference when compared to Fijian babies. Ethnicity of the mother was significantly associated with the difference in growth even after adjusting for other factors known to influence fetal growth. Given the ethnic differences in fetal growth and maturation, it would be appropriate to use ethnicity-specific standards for perinatal care in Fiji. [ABSTRACT FROM AUTHOR]

To identify women having unsafe abortions and elucidate whether an acceptable follow-up rate among these women can be retrieved. One thousand three hundred and fifty-seven women attended Temeke Municipal Hospital, Dar es Salaam with an abortion-related diagnosis. Women having unsafe abortions were identified by an empathetic dialogue, offered a contraceptive service and asked to return for follow-up. Three different ways of achieving follow-up information were tested. In phase 1, a combination of hospital-based and home-based interviews was utilized, in phase 2, an additional 1-month control visit was added to the protocol, and in phase 3, the contraceptive counseling and service was provided by technically well-skilled counselors. Seven hundred and eighty-eight women were identified as having had unsafe abortions and 491 women as spontaneous abortions. Women having unsafe abortions were younger, more often single and of higher parity than women having spontaneous abortions. The follow-up rate achieved varied from 47%−72%, being lowest in phase 1 and highest in phase 3. The two most common reasons for loss to follow-up were the interviewer's inability to locate the respondent's house either because of an unspecific or a remote address (58%) and migration (29%). If hospital-based and confidential home-based interviews are used combined and if the women having unsafe abortions are counseled by technically well-skilled counselors, it is possible to achieve a reasonable follow-up rate among women having unsafe abortions. [ABSTRACT FROM AUTHOR]

Background. The objectives were to test the hypothesis that certain strains of microorganisms are present in fetal blood in a significant proportion of parturient women suffering unexplained third trimester fetal death, and to examine the correlation between fetal bacteremia and histologic chorioamnionitis and vasculitis. Methods. A case-referent study was carried out on 58 pregnant women with fetal death of unknown etiology (cases) and 116 pregnant women at term (referents) with live fetuses. Cultures from maternal endocervix, amniotic fluid, placental homogenate, external ear and blood of newborns were performed in both groups. Histological examination of placentas and fetal membranes was carried out in order to identify chorioamnionitis and chorionic vasculitis. Results. Intrauterine fetal bacteremia was observed in 36% of cases and in 0% of referents (p=0.001). Escherichia coli was the most common strain, isolated in 21% of fetal blood samples in cases. Extensive histologic chorioamnionitis was observed in 50% of cases with the presence of Escherichia coli in blood of stillborns. Chorionic vasculitis was found in 67% of such cases. Positive significant correlations between isolation of the Escherichia coli from maternal endocervix, amniotic fluid, placenta, fetal ear and blood in stillborns and histological chorioamnionitis and chorionic vasculitis were observed. Conclusions. Escherichia coli bacteremia was detected in a significant proportion of stillborns suffering a third trimester prelabor death. Fetal bacteremia significantly correlated with histologic signs of inflammation in placenta and membranes. Ascending subclinical intrauterine infection may play an important role in the etiology of otherwise unexplained late prelabor fetal death. [ABSTRACT FROM AUTHOR]

Objectives. This study estimated the proportion of incomplete abortions that are induced in hospital-based settings in Tanzania. Methods. A cross-sectional questionnaire study was conducted in 2 phases at 3 hospitals in Tanzania. Phase 1 included 302 patients with a diagnosis of incomplete abortion, and phase 2 included 823 such patients. Results. In phase 1, in which cases were classified by clinical criteria and information from the patient, 3.9% to 16.1% of the cases were classified as induced abortion. In phase 2, in which the structured interview was changed to an empathetic dialogue and previously used clinical criteria were omitted, 30.9% to 60.0% of the cases were classified as induced abortion. Conclusions. An empathetic dialogue improves the quality of data collected among women with induced abortion. (Am d Public Health. 2000; 90:1141-1144) [ABSTRACT FROM AUTHOR]

Illegal abortion is known to be a major contributor to maternal mortality. The objective of the study was firstly to identify women with illegally induced abortion, (IA) and to compare them with women admitted with a spontaneous abortion (SA) or receiving antenatal care (AC), and secondly to describe the circumstances which characterized the abortion. The population of this cross-sectional questionnaire study comprised patients from Temeke District Hospital, Dar es Salaam, Tanzania. After an in-depth confidential interview, 603 women with incomplete abortion were divided into two groups: 362 women with IA and 241 with SA. They were compared with 307 AC women. IA women were significantly younger, more often better educated, unmarried, nulliparous and students than AC women. Regarding civil-status, educational level, proportion of nullipara and proportion of students, SA patients were similar to AC women. These results lend support to the assumption that the in-depth confidential interview made it possible to distinguish IA women from SA women. [ABSTRACT FROM AUTHOR]

Objective: To elucidate whether there is an association between pregnancy-related back and pelvic pain and changes in bone density.Methods: In this prospective cohort study, bone density was measured in the distal and ultra-distal forearm at 12 and 35 weeks of pregnancy and at 5 months post partum. The location and degree of any back or pelvic pain was registered. The patients were classified into four subgroups on the basis of presence or absence of disabling pain in late pregnancy and presence or absence of pain at 5 months' follow-up. Forty-nine women participated.Results: Bone density decreases during pregnancy and lactation. Trabecular bone is mainly lost during pregnancy and cortical bone during lactation. No association between back or pelvic pain during pregnancy and bone loss was found. Between 35 weeks of pregnancy and 5 months post partum, bone loss in all the women was estimated as 1.1% of cortical bone (p < 0.001) and 0.6% of trabecular bone (n.s.). During the same period five women with mild pain during pregnancy and pain at follow-up lost 3.9% of cortical bone (p=0.043) and 5.3% of trabecular bone (p=0.043). Although this bone loss was significant compared to the other subgroups, the small study size does not permit general conclusions to be drawn from this finding.Conclusion: The results indicate that bone density decreases during pregnancy and lactation. The decrease in bone density was not associated with back or pelvic pain during pregnancy. It remains unclear whether bone loss is associated with back and pelvic pain during lactation. [ABSTRACT FROM AUTHOR]

The objectives of this study were to identify decision makers for FGM and determine whether medicalization takes place in Sierra Leone. Structured interviews were conducted with 310 randomly selected girls between 10 and 20 years in Bombali and Port Loko Districts in Northern Sierra Leone. The average age of the girls in this sample was 14 years, 61% had undergone FGM at an average age of 7.7 years (range 1-18). Generally, decisions to perform FGM were made by women, but father was mentioned as the one who decided by 28% of the respondents. The traditional excisors (Soweis) performed 80% of all operations, health professionals 13%, and traditional birth attendants 6%. Men may play a more important role in the decision making process in relation to FGM than previously known. Authorities and health professionals' associations need to consider how to prevent further medicalization of the practice.

The Extracting Syringe (ESy), a novel membrane-based sample preparation technique directly coupled as an autosampler to gas chromatography, has been employed for the analysis of organochlorine pesticides (OCPs) in raw leachate water. The ESy has also been applied for extraction of OCPs from contaminated soil samples and its performance has been compared to liquid-solid extraction (LSE) and accelerated solvent extraction (ASE). Extraction of 3-mL leachate sample at the optimised conditions resulted in enrichment factors from 32 (Endrin aldehyde) to 242 (Endrin) and detection limits from 1 to 20 ng/L. The inter-day and intra-day repeatability (% RSD) at 100 and 500 ng/L were <6% and <24%, respectively. The relative recovery at 100 and 500 ng/L ranged from 68% (Aldrin) to 116% (Endrin aldehyde); except Heptachlor that showed 51 and 60%, respectively. The ESy extraction of the slurry-made soil samples revealed occurrence of Endosulfan I (18.2 microg/g soil), 4,4'-DDE (2.6 ng/g soil), Endosulfan II (8.7 microg/g soil) and Endosulfan sulfate (1.1 microg/g soil); showing good agreement with LSE results. The total ESy consumption of organic solvents was 4.2 mL from which only 0.6 mL n-undecane was used during the extraction step (7 microL for the extraction per se), while in the LSE and ASE, it was 420 and 18.1 mL, respectively. The ESy extraction time (0.5 h) was comparable to the ASE time (0.6 h); and the time required for the LSE was 3.75 h. To sum up, the ESy has shown its competency to LSE and ASE technologies, demonstrating its applicability for environmental analysis of organic pollutants, towards green techniques for green environment.

The aim of this study was to observe and analyse midwifery care routines related to asphyxia and hypothermia during the perinatal period and to investigate the effect of an in-service education program. A direct non-participant pre- and post-intervention observation study of midwifery a performance during childbirth was conducted at a labour ward in Maputo. The observed groups consisted of 702 and 616 midwifery-attended deliveries. Examination was also conducted of the partographs (702 vs. 616). The quality of midwifery care related to prevention and early detection of asphyxia and hypothermia was found to be inadequate and the intervention had no significant effect upon the midwives' performances. This could be attributed to the quality of the intervention itself or to failure of implementing managerial decisions such as transfer of partograph documentation from obstetricians to midwives. Change in professional performance does not automatically follow awareness of evidence-based midwifery practices, but requires behavioural change, which may be more difficult to achieve.

The purpose of the study was to explore the encounters with the health care system in Sweden of women from Somalia, Eritrea, and Sudan who have been genitally cut. A qualitative study was performed through interviews with 22 women originally from Somalia, Sudan, and Eritrea who were living in Sweden. The women experienced being different and vulnerable, suffering from being abandoned and mutilated, and they felt exposed in the encounter with the Swedish health care personnel and tried to adapt to a new cultural context. The results of this study indicate a need for more individualized, culturally adjusted care and support and a need for systematic education about female genital cutting for Swedish health care workers.

Prophylactic treatment against postpartum haemorrhage is a widely investigated area and injection of Oxytocics has been considered as the best choice. The occurrence of postpartum pain and discomfort was studied in a population of birthing women in an overcrowded labour ward in Angola where the oxytocin-filled device Uniject was used. This study indicates that birthing women's perceived postpartum pain increases with parity and during breastfeeding, but does not confirm that injection of oxytocin increases pain and discomfort. This is an important finding, since it might facilitate the introduction of a management practice, likely to reduce haemorrhage-related maternal morbidity and mortality after delivery in underprivileged populations. The birthing women were, by and large, satisfied with the care and treatment provided, but the encounters with midwives seem to vary in quality. Further investigation is needed to elucidate parturient women's experience of postpartum pain and their perceptions of the quality of care and treatment.

To explore paediatric complications of female genital mutilation (FGM), 255 consecutive girls aged 4-9 years presenting to an emergency ward in Sudan were included in this clinical study. Full examination, including inspection of genitalia, was performed. Dipsticks for nitrite and leucocytes were used to diagnose suspected urinary tract infection (UTI). Girls with a form of FGM narrowing vulva had significantly more UTI than others, and among girls below the age of seven there was a significant association between FGM and UTI. Only 8% of girls diagnosed as having UTI reported urogenital symptoms. In spite of the fact that 73% of the girls subjected to FGM were reported to have been bedridden for one week or more after the operation, only 10% stated immediate complications. We conclude that FGM contributes significantly to morbidity among girls, a large share of which does not come to medical attention.

Background: In theory, infections that arise after female genital mutilation (FGM) in childhood might ascend to the internal genitalia, causing inflammation and scarring and subsequent tubal-factor infertility. Our aim was to investigate this possible association between FGM and primary infertility., Methods: We did a hospital-based case-control study in Khartoum, Sudan, to which we enrolled women (n=99) with primary infertility not caused by hormonal or iatrogenic factors (previous abdominal surgery), or the result of male-factor infertility. These women underwent diagnostic laparoscopy. Our controls were primigravidae women (n=180) recruited from antenatal care. We used exact conditional logistic regression, stratifying for age and controlling for socioeconomic status, level of education, gonorrhoea, and chlamydia, to compare these groups with respect to FGM., Findings: Of the 99 infertile women examined, 48 had adnexal pathology indicative of previous inflammation. After controlling for covariates, these women had a significantly higher risk than controls of having undergone the most extensive form of FGM, involving the labia majora (odds ratio 4.69, 95% CI 1.49-19.7). Among women with primary infertility, both those with tubal pathology and those with normal laparoscopy findings were at a higher risk than controls of extensive FGM, both with borderline significance (p=0.054 and p=0.055, respectively). The anatomical extent of FGM, rather than whether or not the vulva had been sutured or closed, was associated with primary infertility., Interpretation: Our findings indicate a positive association between the anatomical extent of FGM and primary infertility. Laparoscopic postinflammatory adnexal changes are not the only explanation for this association, since cases without such pathology were also affected. The association between FGM and primary infertility is highly relevant for preventive work against this ancient practice.

There are contradicting opinions whether female genital cutting (FGC) takes place in Sweden. The results from several studies indicate, however, that FGC is practiced on girls residing in Sweden. Almost no research has been done on girls on how they are affected by FGC. Thus there is no scientifically based knowledge on signs and symptoms in girls related to the practice, which can lead to cases passing unnoticed. Many health professionals feel they have poor knowledge about FGC. It is important to teach about FGC at medical and nursing schools and to make guidelines based on paediatric aspects of FGC.

Objective: to explore Sudanese midwives' motives for and perceptions and experiences of re-infibulation after birth and to elucidate its context and determinants., Design: triangulation of methods, using observational techniques and open-ended interviews., Setting and Participants: two government hospitals in Khartoum/Omdurman, Sudan, for the observations and in-depth interviews with 17 midwives., Findings: midwives are among the major stakeholders in the performance of primary female genital cutting (FGC) as well as re-infibulation. Focusing on re-infibulation after birth, midwives were trying to satisfy differing, and sometimes contradictory, perspectives. The practice of re-infibulation (El Adel) represented a considerable source of income for the midwives. The midwives integrated the practice of re-infibulation into a greater whole of doing well for the woman, through an endeavour to increase her value by helping her to maintain her marriage as well as striving for beautification and completion. They were also trying to meet socio-cultural requests, dealing with pressure from the family while balancing on the edge of the law., Key Conclusions and Implications for Practice: the findings confirm that midwives are important stakeholders in perpetuating re-infibulation, and indicate that the motives are more complex than being only economic. The constant balancing between demands from others puts the midwives in a difficult position. Midwives' potential role to influence views in the preventative work against FGC and re-infibulation should be acknowledged in further abolition efforts.

The circumstances of 94 deaths among females aged 15-49 years in Cape Verde were investigated to assess their access to effective care. Persons associated with the deceased women were interviewed (verbal autopsy) to explore contributing causes of death, perceived illnesses and treatment efforts. The certainty of diagnosis and avoidability of the fatal outcome were assessed by a panel ofexperts. A model of health care accessibility is elaborated to identity restricting (delay) factors. Deliberate avoidance of modern medical care and reliance on traditional medicine were major delay factors, while unawareness of the severity of symptoms and affordability limits were minor delay factors in this population. A detailed sorting of cases by health care level is used to identify the effectiveness of diagnosing, referral and care provided. Since a high proportion of avoidable deaths occurred in hospital, the quality of care may have been sub-optimal.

Only partially understood host defense mechanisms operate against infections affecting maternal and fetal morbidity. Subclinical ascending infections through the lower female genital tract are predominant worldwide. Important micronutrient deficiencies may prevail in low-income countries where these infections are much more common than in high-income countries. Important morbidities related to poor perinatal outcome both for the mother and for the fetus and newborn comprise preterm birth, prelabor rupture of membranes, placental abruption (predelivery detachment of the placenta), postpartum sepsis and maternal anemia. In the fetus, sepsis and intrauterine growth retardation are suspected to be consequences of ascending maternal infections. In the newborn, septicemia and respiratory disorders as well as some neurological disorders seem to be consequences of such ascending genital infections in the pregnant woman. It is concluded that much more attention should be given to efforts to elucidate the host defense mechanisms and antimicrobial barriers from the vagina through the cervix, fetal membranes and amniotic fluid including the early fetal immunocompetence in the second and the third trimester of pregnancy.

Maternal mortality is an important indicator used to assess the level of development of a country and particularly the coverage of health services. In Africa where the maternal mortality ratios are about 100 times higher than those of developed countries the situation is even worse due to problems of underregistration. In Mozambique the figures officially used are derived from the data of some hospitals in the main cities. This leaves out the 60% of pregnant women who do not attend health facilities. It was against this background that the present study was designed to be a prospective community-based study carried out in the central region of Mozambique involving a population of 207,369 inhabitants. The study covered a 12-month period, from 01/08/96 to 31/07/97 and found 214 deaths among women in reproductive age (15-49 yr) of whom 40 were classified as maternal deaths. Gross underregistration was revealed, as the health institutions failed by 86% in recording maternal deaths, the same happening with other official sources, like the Civil Register and the Funeral Services registering only 9% of the maternal deaths. This kind of study is however complex and labour intensive and a practical way of monitoring has to be found; for the region where the study took place close collaboration with private cemeteries appears to be a way to be further explored.

Objective: To review pregnancy-related deaths due to injuries, to identify the characteristics of these women and to compare the magnitude of injury-related maternal deaths to that of other causes of maternal death., Design: A retrospective study was performed during a five-year period (1991-1995), covering deaths from injuries, including suicide, homicide and accidents in Maputo, Mozambique., Setting: Department of Forensic Medicine at the Maputo Central Hospital, Mozambique., Population: The pregnant or recently pregnant (post-abortion and postpartum) population of Maputo city, the national capital of Mozambique. Twenty-seven cases of pregnancy-related deaths caused by injuries were identified., Main Outcome Measures: Proportion of deaths due to homicide, suicide, and accidents in pregnant women or within 42 days after termination of pregnancy., Results: Ten cases were due to alleged homicide, nine to alleged suicide and six to alleged accident. Fifty-nine percent (16/27) of women suffering an injury-related maternal death were younger than 25 years of age. Eighty-five percent of pregnancies were less than 28 weeks of gestational age. The magnitude of the problem of violence-related maternal deaths compares with the magnitude of pregnancy-induced hypertension as the fourth cause of maternal death at Maputo Central Hospital., Conclusion: The contribution of violence-related deaths tomaternal mortality is significant and must not be neglected.