Care for women in Sub-Saharan Africa Joseph Vyankandondera
Selected indicators about African region ( source: the African Health Observatory)
Year
Afr ican r egion
Global
Population size (in thousands)
2008
804,865
6,737,480
Life expectancy at birth (years)
2008
53
68
1990
51
64
Adult mortality rate 2008 (probability of 1990 dying between 15 and 60 years per 1000 population)
392
180
371
210
Gross national income per capita (PPP int. $)
2008
2,279
10,290
2000
1,506
6,940
Shortage of personnel: 25%of world pathologies for 1,3%of global workforce
World burden but mostly african one: Example of neglected disease • Nearly 500,000 women: diagnosed with invasive cervical cancer every year. • 275,000 women die every year. 80%to 85%of deaths occur in developing countries. • Most cervical cancer in developing countries occurs in women who take care of children, provide income for families, and work in their communities. • Poor women in industrialized countries have a higher incidence of cervical cancer than their wealthier neighbors.
Incidence and mortality with in cervical cancer cases
Continuum of Care for Cervical Cancer Prevention and Control
15 years
Vaccination
Source: WHO 2006
30 years
Screening and treatment 7
45 years
Cancer treatment
Child health
Child health
• Bedankt
Maternal health
Rwanda
Clinical presentations and management of complicated unsafe abortion in Kigali Teaching Hospital: case series Review of 60 cases between 2005-2009
Joseph Vyankandondera
Definition According to WHO, abortion is a loss of the foetus before it is viable: <
24 weeks. Spontaneous (Miscarriage) or induced (Safe / unsafe) If induced: procedure to stop the intrauterine life of the foetus. Medical indication - or Criminal Medical abortion : safe Criminal: unsafe terminating a pregnancy (an unwanted) either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.
Abortion laws Worldwide
Objectives To gather epidemiological data of illegal abortion
among Rwandan women To describe the damage caused by the practice of
criminal abortion To report the management of the consequences of
criminal abortion and prognosis
Patients and methods The study was prospective Carried out in KUTH, Dept of Obs-Gyn Period: Sept 2005 up to Aug 2009 Standardized questionnaire was used Patients: referred or self referred for complicated
illegal abortion
Patients and methods Inclusion criteria: Patients admitted for abortion related symptoms and confirmed by history as assessed by the clinical staff Criminal abortion confirmed medical staff morning meeting Patient herself or “accompagnateurs” after counselors/ nurses discussions
Age of the patients Age
n
%
15-19
21
35.0
20-24
29
48.3
25-29
4
6.7
30 and above
6
10.0
Total
60
100
Mean age:21years.The majority of the patients are between 20-24 years followed by teenagers. More than 80% are below 25 years.
Profession of the patients Profession
n
%
House girls
16
26.7
School girl
32
53.3
Students
10
16.7
Employed
2
3.3
Total
60
100
More than a half of the patients (53.3%) were school girls followed by house girls (26.7%).
Marital status of the patients Marital status
n
%
Single
57
95
Married
1
1.7
Prostitute
2
2.3
Total
60
100
The vast majority (95%) of the patients were single.
Parity & Gestity Parity
Gestity Total
Total
0
1
>1
1
51
0
0
51
>1
0
8
1
9
51
8
1
60
85% were at their first pregnancy.
Initiation, initiator &Clinical presentations Place of initiation (n=60)
N
%
Health facility
18
30.0
Home
27
45.0
Not revealed
15
25.0
Professional
26
43.3
Non professional
34
56.7
Hemorrhagic shock
15
25.0
Septic shock
15
25.0
Anemia
22
36.7
Evident peritonitis
8
13.3
Initiator of TOP (n=60
Clinical features on admission
Reason for TOP Reason
n
%
Young age
15
25.0
Academic pursuit
13
21.7
Poverty
19
31.7
Unpreparedness
4
6.6
Emotional context
9
15.0
Total
60
100
Main reason : inappropriate time of pregnancy, others linked to Poverty
Treatment modalities used Treatment
(N=60)
%
Medical
19
31.7
Surgical
41
68.3
Surgical treatment (n=41) Curettage
21
48.8
Exp Laparotomy 20 51.2 Surgical management was commonly used and mainly (20/41= 51.2%) underwent explorative laparotomy.
Surgical management findings (n=41) Findings of the explorative laparotomy (n=21) Generalized peritonitis
16
72.6%
Localized peritonitis
5
27.45
Yes
12
57.1%
No
9
42.9%
Hysterectomy (n=21)
72.6% of generalized peritonitis were found and 12/21 (57.1%) underwent total hysterectomy (11/12 were primigravida).
Bowel resection and anastomosis Bowel resection and anastomosis (n=21) Yes
4
19.0
No
17
81.0
4 patients were found to have serious bowels injury
that resulted in Resection and anastomosis. 1 colostomy was performed
Prognosis and hospital stay Healed/ Improved
n 57
% 95
Died 5 5.0 Overall mortality of 5% was recorded Many, however went home with definitive sterility (12/60) and aesthetic sequelae of laparotomy in addition to risks of further intestinal obstruction.
Conclusion Primigravida, unmarried and adolescents are the most affected
population Anaemia, haemorrhage, septic shock were the commonest signs Outcome: Fatal in 5%, absolute sterility in 20%: hysterectomy Other after-effects?
Unsafe abortion had no link with the qualification of the initiator Or the place of the procedure,
What is the contribution of rape?
Difficulties measuring the problem • Underreporting • Fear of stigma • Fear of being cast out by family • Family member is perpetrator • Difficult to access a care facility • Dysfunction of the justice system • Desire to solve the problem within the family
How prevalent? • Studies show 10-69%of women report assault by intimate partner at some time in their lives • From a U.S. study only 35.6%of women injured during their most recent rape received medical treatment. • Sub-saharan Africa: assault by partner 13-45%of women • No estimate in MOH report from 2008 for Rwanda • Anecdotal reports: CHUB 4/ day to referral hospital cachement area: 300,000?= 106 reported rapes/ day for 8,000,000 people this equates to 39,000 rapes per year
For decision makers • Thanks
Ignorance of Patients/ Accountability or competence of Health workers
Chronic abdominal pain wrongly treated as pelvic infection: Extended Endometr iosis
Burundian woman: has been bleeding for > 3 years receiving vitamines and seek leaves: Polyps
and has been treated by antibiotics for at least one year: vaginal metastasis of chor iocar cino ma
How this can be accepted (breastfeeding woman): was suggested to have mastectomy although it was an abcess
Infertility: Neglected Foreign bodies (bornes removed by hysterotomy)
National University of Rwanda in Southern Province
NUR FACMED
National University of Rwanda
Faculty of Medicine
2010 undergraduate students Year
Female
Male
Total
1
19
61
80
2
18
66
84
3
22
111
133
4
18
70
88
5
13
53
66
6
13
44
57
total
103
405
508
National University of Rwanda
Faculty of Medicine
2009 Postgraduate students Int.M O&G Paed Surg
Anes Fam
Tot
7-2f
10
10-4f 9
5
48-6f
Yr 3
3 -1f
2
1
8
2
16-1f
Yr 4
6
8
9
3
2
28
Tot
13-3f 20
20-4f 20
9
Yr 1
7
Yr 2
National University of Rwanda
Faculty of Medicine
7
92-7f
2009 Postgraduate students Int.M O&G Paed Surg
Anes Fam
Tot
7-2f
10
10-4f 9
5
48-6f
Yr 3
3 -1f
2
1
8
2
16-1f
Yr 4
6
8
9
3
2
28
Tot
13-3f 20
20-4f 20
9
Yr 1
7
Yr 2
National University of Rwanda
Faculty of Medicine
7
92-7f
POSTGRADUATE ISSUES
Lack of qualified academic staff inadequate clinical supervision training abroad Rotations at other specialist sites
National University of Rwanda
Faculty of Medicine
Health strengthening strategy: Teaching and mentoring
Post graduate teaching
High laparoscopy unmet need Worldwide More than 70 % women seek care – chronic pelvic pain, – infertility or – genital bleeding.
More than 80 % of gynecological operations can be done by laparoscopy or hysteroscopy In Rwanda
–There are (were)only three places and only in Kigali –Need for new centre
Non invasive surgery: added value to the hospital and the community •Reducing the hospital stay(one day clinic is possible) •Reducing/preventing the post operative infection •Allowing accurate diagnosis ( endometriosis, peritoneal tuberculosis, ovarian or liver cancer) •Reinforcing the service package and enhancing the academic role of the site. •Etc
Practical training in Butare (teaching hospial)
One day later
Ectopic pregnancies are not always fatal: Abdominal pregnancy born at 32 weeks
: “ If you plan for a year, plant a seed. If for 10 years, plant a tree. If for 100 years teach the people” Confucius
Bedankt