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This issue gives abstracts of articles covering a wide range of blood pressure and related problems, particularly studies done in Sub-Saharan Africa, some of which have yielded some interesting res ts.. One study says that as long as Africa remains impoverished, a major rise in coronary heart disease is unlikely, having concluded that CHD is common in urban centres while nearly absent in rura areas on account of risk factors such as low physical activity, smoking in males and obesity in women, high cholesterol levels, among other. Some intervention programmes have been tried in various countries with varying degrees of success.
Hypertension is the major public health problem in most African countries. However, the availability of basic and reliable data on cardiovascular problems in Africans is limited, thus hindering the resentation of a comprehensive review of the subject and underscoring the importance of cardiovascular research in Africa today.
Hypertension is the commonest cardiovascular disease in Africans occurring in more than 15% of the adult population in some studies. It occurs in the lower as much as in the higher socio-economi groups. Recent studies have confirmed earlier findings that essential hypertension in Africans is characterised by volume loading, low plasma renin activity, high salt taste threshold, high nary sodium and low potassium excretion and high plasma aldosterone. The commonest complication of hypertension in Africans is congestive cardiac failure followed by cerebrovascular accidents. Coronary heart disease is rare. Even in the absence of overt heart failure and compounding factors like obesity, alcoholism, cigarette smoking, diabetes mellitus and myocarditis, evidence of abno al left ventricular morphology and function is often present in newly diagnosed patients with moderate or severe hypertension. Response to monotherapy with beta-blockers or ACE inhibitors is usu ly poor but is good with thiazide diuretics or calcium channel blockers. The diuretics are an essential component of a two or three drug regime containing other classes of antihypertensive dru . Cost of drugs is the most important determinant of compliance with drug treatment and consequently the likelihood of progression of the diseases to more severe forms in long term follow-up.
Salako LA. Hypertension in Africa and effectiveness of its management with various classes of antihypertensive drugs and in different socio-economic and cultural environments.
Review Clinical & Experimental Hypertension. 15(6):997-1004, 1993 Nov.
Management of hypertension at primary health care level
OBJECTIVE.
To outline rational and cost-effective comprehensive management of hypertension by health care professionals in a primary care setting.OUTCOMES.
Control of hypertension with a target blood pressure (BP) of systolic 140 - 159 mmHg, diastolic 90 - 94 mmHg, with minimal or no drug side-effects. Reduce BP in the elderly and those ith severe hypertension gradually. Stricter BP control is required for patients with end-organ damage, coexisting risk factors, diabetes mellitus. Extensive data including many randomised cont lled trials showed the benefit of controlling hypertension. This evidence is reported in: Opie L. H. and Steyn K., Rationale for the hypertension guidelines for primary care in South Africa, S Afr Med J 1995; 85: 1325-1338.VALUES.
To treat as many of the untreated hypertensive patients as possible, using rational and cost-effective care. Cost-effectiveness and access to therapy are major issues.BENEFITS AND COSTS:
Reduction in stroke, cardiac failure, renal failure and coronary artery disease. The major precautions and contraindications to each antihypertensive drug recommended are listed. The financial costs of the drugs are considered.RECOMMENDATIONS:
Correct BP measurement procedure. identification of blood pressure levels for appropriate management. Evaluation of other cardiova ular risk factors and their influence on when to treat hypertension. Lifestyle modification and patient education for all patients. Drug therapy: first line--low-dose diuretics; second lineerpine or beta-blockers or ACE inhibitors or calcium channel blockers; third line--hydralazine or prazosin or another second-line drug. Drug treatment and referral or specific cases (pregnancy, diabetes mellitus, severe hypertension).VALIDATION:
Developed by the Hypertension Society of Southern Africa Executive Committee and co-opted persons during 1995, with added input from HSAA mem rs at the National Congress. Endorsed by the Medical Association of South Africa.
Guidelines for the management of hypertension at primary health care level Association of South Africa and the Medical Research Council.
South African Medical Journal. 85(12 Pt 2):1321-5, 1995 Dec.
Ethnicity & cardiovascular disease
A long term study of diversity between two ethnic groups was developed in Evans County, Georgia. The findings are predicated on the genotypic-phenotypic interactions, with the multitude of envonmental factors. The genetic-environmental interaction ultimately determines the individual's state of health or disease. For example, coronary heart disease prevalence and incidence rates e extremely low for blacks in Africa and four times lower than whites in rural South Georgia in the 1960s.Excessive hypertension and diabetes mellitus, and greater cerebrovascular disease in black men, is now well known. Blood pressure levels studied in rural Africa were normal and did not rise with age, whereas blacks, conversely, demonstrated twice as much hypertension in South Georgia as whites and demonstrated an inverse relation between education and blood pressure (ie, the lower the education the higher the blood pressure). Cultural adaptation has accelerated hypertensive disease and strokes in blacks, while there remains a excess of atherosclerotic coronary heart disease in white men. Secular trends suggest that coronary heart disease is decreasing among white men but may be increasing in black men. Studies of hnicity and biracial populations provide important cardiovascular disease associations with clinical risk factor studies.
Hames CG. Greenlund KJ. Ethnicity and cardiovascular disease: The Evans County heart study [ published erratum appears in Am J Med Sci 1996 Jun;311(6):295]
American Journal of the Medical Sciences. 311(3):130-4, 1996 Mar.
Lifestyle, education, and prevalence of hypertension in populations of African origin
Lifestyle Incongruity has been shown to be associated with elevated blood pressure in various developing societies. We sought to test this model for an international collaborative study of hypertension in populations of African origin. Data were available for 4770 men and women, aged 25-74, from Africa, the Caribbean, and the United States. T main effects of lifestyle score (LSS) and education on hypertension prevalence were explored, as well as interactions predicted by the Lifestyle Incongruity model. Significant interactions were observed, but only the U.S. men conformed to the pattern predicted. For this group, adjusted ORs for LSS were 4.45 among low-education and 0.71 among high-education subgroups (risk OR = 0.03-0.84 95% CI). The Lifestyle Incongruity model therefore received limited support. The model was designed to describe processes in societies experiencing modernization and opportunities in lifestyle differentiation, conditions that may not have been met in some sites.
Kaufman J.S. Tracy J.A. Durazo-Arvizu R.A. Cooper R.S. Lifestyle, education and prevalence of hypertension in populations of African origin. Results from the International Collaborative Study on Hypertension in Black Americans.
Annals of Epidemiology. 7(1)\;22-7, 1997 Jan.
Hypertension intervention program
The Mamre Hypertension Project was initiated in response to studies indicating that hypertension and cardiovascular disease were prevalent in a rural community of Mamre, located in the Western Cape, South Africa. A survey was done to collect baseline information the prevalence of hypertension and other cardiovascular disease risk factors. The age-adjusted prevalence of hypertension in people aged 15 years or more was 13.9% in men and 16.3% in women. Of the hypertensive subjects, 27% were not aware of their hypertension, a further 14.4% were not on treatment, and only 16.8% had their blood pressure (BP) c trolled at under 140/90 mm Hg. There was a high prevalence of smoking, heavy alcohol use (in men), obesity (in women) and physical inactivity.The survey results will be used to assess the im of the intervention programme using a before and after design, and are being used to direct interventions. The intervention programme comprises a BP station catering primarily for people with hypertension, and a health education and promotion programme directed at the general community. The BP station screens for hypertension, monitors BP and compliance with medication in hypertensives, and encourages risk factor modification. Health promotion activities include a smoking cessation group and a weight reduction and exercise group. These are run by community volunteers with support from outside consultants. The effects of the programme will be assessed after 4-5 years.
Kaufman JS. Tracy JA. Durazo-Arvizu RA. Cooper RS. Lifestyle, education, and prevalence of hypertension in populations of African origin. Results from the International Collaborative Study on Hypertension in Blacks.
Annals of Epidemiology. 7(1):22-7, 1997 Jan.
Coronary heart disease
In Africa, coronary heart disease (CHD) is near absent in rural areas, and very uncommon in urban centres, where many Africans are in an advanced stage of transition. Among town dwellers intakes food, especially fat, have risen and intakes of fibre-containing foods have fallen. Mean serum cholesterol level is almost double that of rural populations living traditionally. Obesity in females has risen enormously. Prevalence of hypertension exceeds that in the white population. The same applies to the practice of smoking in males, but not in females. The level of physical activity has fallen generally. With these increases in risk factors we can expect urban Africans to attain the high mortality rate for CHD now experienced by Afro-Americans. Prevention by urging rever on to previous life-style behaviour is a non-starter. However, as long as Africa remains impoverished, a major rise in CHD is unlikely
Walker AR. Sareli P. Coronary heart disease: outlook for Africa.[Review] [57 refs]
Journal of the Royal Society of Medicine. 90(1):23-7, 1997 Jan.
Is the pathogenesis of hypertension different in black patients?
There is a higher prevalence of hypertension in the urban black population of South Africa and the USA in comparison to whites living in the same geographical areas. Several factors including urbanisation, socioeconomic status and acculturation contribute to the differences in the prevalence of hypertension between blacks and whites. In addition there may be a genetic element. Biochemical differences in the lipid profile of the blacks in Sub-Saharan Africa may play an Important role in the lower incidence of coronary heart disease. Blacks have an abnormal transport mechanism of sodium. There are varying responses to antihypertensive drugs in blacks compared to whites. It is probable that with a better understanding of the pathogenesis of hypertension in blacks we will be able to reduce the high prevalence, prevent complications and institute more effective treatment and control of hypertension.
Seedat YK. Is the pathogenesis of hypertension different in black patients?.[Review]
Journal of Human Hypertension. 10 Suppl.. 3:S35-7, 1996 Sep.
Hypertension & Mortality
The contribution of hypertension to adult mortality in Africa has not been well studied. Although cross-sectional surveys have provided data on the prevalence of this condition, the relative risk death associated with hypertension has not been defined. In the face of high levels of competing mortality from infectious disease among the general population, and thevirtual absence of atherosclerotic precursors, estimates of risk derived from industrialised countries may not be generalisable to this setting. We conducted a 2-year prospective study among 1344 n and women in a rural community in south-western Nigeria. The prevalence of hypertension (140/90 mm Hg) at baseline was 9.3%. In the observational phase, 3.0% of the survey participants died eac year. Among the 74 decedents, hypertension was nearly twice as common as among those who survived (14.9% vs 8.4%). In multivariate analysis the risk of death increased over 60% for a 20 mm Hg incr se in diastolic blood pressure. The population attributable risk, or the reduction in mortality that would have been observed if hypertension were not present in this community, was estimated as well. These findings document an identifiable impact of hypertension on all-cause mortality in rural Africa and demonstrate that programs to evaluate potential treatment options are needed.
Kaufman J.S. Rotimi C.N. Brieger W.R. Oladokum M.A. Kadiri S. Osotimehin B.O. Cooper R.S. The mortality risk associated with hypertension: preliminary results of a prospective study in rural Nigeria
Journal of Human Hypertension. 10(7):461-4, 1996 July
Ramipril in chronic congestive cardiac failure
In 5 separate exercise capacity trials in similar patients with chronic congestive heart failure performed in Europe, the United States, and South Africa, 627 patients were randomized to ramipri and 428 to placebo. The dose of ramipril ranged from 1.25 to 20 mg/day. Follow-up was at 12 or 24 weeks. None of the trials were designed to assess efficacy with regard to clinical outcome. To a ess in the combined experience whether there was an effect of ramipril on mortality, hospitalization, functional classification (New York Heart Association class), and exercise capacity, we led data from each trial and performed a meta-analysis. Of the patients randomized to ramipril and placebo, respectively, and based on intention to treat, 14 (2.2%) and 18 (3.8%) patients died dds ratio 0.60, 95% confidence interval 0.28 to 1.29), and 59 (9.4%) and 67 (14.3%) patients died or were hospitalized (odds ratio 0.68, 95% confidence interval 0.46 to 1.00). The New York Heart Association class improved in 29% and 25% respectively, whereas 8% and 15% deteriorated (p=0.04, based on intention to treat. In ranked comparisons based on intention to treat and with imputation of exercise time as 0 for patients who were unable to exercise because of death or who were hospitalized, exercise capacity was significantly improved by ramipril. We concluded that ramipril is likely to have an effect on mortality, morbidity and functional capacity in patients with chronic congestive heart failure similar to that of other angiotensin-converting enzyme inhibitor.
Lubsen J. Chadha DR. Yotof YT. Swedberg K. Meta-analysis of morbidity and mortality in five exercise capacity trials evaluating ramipril in chronic congestive cardiac failure
American Journal of Cardiology. 77(14):1191-6, 1996 Jun 1
Mortality risk associated with hypertension
The developing world is an economic entity arbitrarily characterised by a gross national product (GNP) of US $7910 per capita, and below. It is further categorised into low and middle-income ec omies with a GNP of US $635 as the dividing line. The bulk of low-income economies, often referred to as the Third World, are in sub-Saharan Africa, Asia and China, and are either impoverished very limited resources both human and material, or with large populations. Nigeria is affected by both situations.
Kaufman JS. Rotimi CN. Brieger WR. Oladokum MA. Kadiri S. Osotimehin BO. Cooper RS. The mortality risk associated with hypertension: preliminary results of a prospective study in rural Nigeria.
Journal of Human Hypertension. 10(7):461-4, 1996 July
Monitoring cardiovascular disease in Zimbabwe
The relative and absolute importance of cardiovascular disease (CVD) in countries of sub-Saharan Africa is assumed to be increasing, but information on morbidity, mortality and prevalence of risk actors is scant. This paper reviews available information on CAD in Zimbabwe; in particular, which type of CAD is important, which segments of the population are affected, which risk factors are levant and at what levels they are present. Based on the findings, options for monitoring CAD rates and risk factors in Zimbabwe are discussed. For the purpose of identifying risk groups and nitoring secular trends, CAD morbidity data derived from the National Health Information System are insufficient in terms of completeness, accuracy and precision of diagnosis. Use of vital registration data are available for Harare, where persons aged 45 to 64 years experience a relatively high mortality from hypertensive sequelae and a low mortality from ischaemic heart disease. This finding, however, cannot be generalised.Clinical studies confirm a high prevalence of hypertension; it is presently the most important risk factor for CAD. Smoking rates, however, appear to be increasing. Little is known about CAD rates and levels of risk factors in poor and rural population strata and in ethnic minorities. Options to improve monitoring of CAD morbidity and risk factor levels include establishing community registries of stroke and repeatedly examining representative population samples. Nation wide vital registration would be desirable to monitor CAD mortality but appears not to be feasible at present; maintaining a sample registration system would be prohibitively expensive.
Resume O Monitoring cardiovascular disease in Zimbabwe: a review of needs and options. [Review] [23 refs]
Central African Journal of Medicine. 42(4):120-4, 1996 April
The Nigerian hypertension programme
The determinants of hypertension in West Africa have not been well defined. The authors sampled 598 participants aged 45 years or more from a recent population-based survey in southwest Nigeria (1 rural men and women, 205 urban poor men and women, and 203 retired railway workmen). The estimated mean age was 61 (10) years. Mean pressures were low relative to westernized societies: systemic blood pressure = 124 (24) mmHg, diastolic blood pressure = 72 (13) mmHg. Both men and women were remarkably lean: body mass index = 21.3 (3.6) and 23.0 (5.2) kg/me, respectively. Hypertension evalence increased across the gradient from rural farmers to urban poor to railway workers: 14, 25, and 29 percent, respectively, had a blood pressure of 140/90 mmHg or greater, and 3, 11, and 14 ercent, respectively, had a blood pressure of 160/95 mmHg or greater (p for trend < 0.01 for both cut points). On the basis of a 24-hour urine sample, daily electrolyte excretion was 110 (57) m of sodium and 46 (24) mEq of potassium. Mean sodium:potassium ratio was 2.6 (1.0) and was higher among the urban residents (p < 0.01) and correlated with systolic and diastolic pressures (r = .16-0.18, p < 0.01).These findings provide quantitative estimates of the impact of known hypertension risk factors in West Africa and demonstrate the basis for increased prevalence with urbaniza on and associated economic and dietary change. These results also provide support for recommendations for prevention in West Africa and provide a benchmark against which to compare populations i he African diaspora.
Akinkugbe, O. O. The Nigerian hypertension programme.
Journal of Human Hypertension. 10 Suppl. 1:S43-6, 1996 Feb.
Is low birth weight a risk factor for adult hypertension?
Recently, a number of studies have found an association between low birth weight and fetal growth retardation, with the risk of elevated blood pressure and hypertension in adulthood. This paper re ews this literature with particular reference to Africa. There appears to be an inverse relationship between birth weight and blood pressure; this has been observed in adults and children.In adolescents and infants, however, the findings have been inconsistent. In Africa, although this apparent association may be obscured by undiagnosed and unreported hypertension, differential birth weight mortality and lower levels of longevity and obesity, it may provide a partial explanation for the rapidly increasing prevalence of hypertension on the continent.
Woelk GB. Is low birth weight a risk factor for adult hypertension? A literature review with particular reference to Africa.[Review] [53 ref]
South African Medical Journal. 85(12 Pt 2):1348-9, 1352-3, 1995 Dec.
Determinants of hypertension in West Africa
OBJECTIVE:
To describe the characteristics and renal function of hypertensive patients at their first hospital admission in Sub-Saharan Africa.DESIGN: Retrospective study of all hypertensive patients.
SETTING:
Department of Cardiology and Internal Medicine of Yalgado Ouedraogo National Hospital in Burkina Faso, a country in Sub-Saharan Africa.PATIENTS:
Three hundred and seventeen consecutive hypertensive patients (systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 90 mmHg, or both, or patients receiving antihypertensive treatment) referred between 1 November 1988 and 1 October 1990. RESULTS: The hypertensive patients accounted for 36.5% of admissions and included 198 males and 119 females (mean +/- SD age 49 +/- 14 years). Two-thirds of the patients belonged to the poorer socio-economic groups. Hospital admission was necessary because of the symptoms and complications of hypertension: 43% had diastolic blood pressure > 130 mmHg, 73.5% had at least e target organ affected and 38.2% had renal involvement in the form of chronic renal failure or as proteinuria > 1.5 g/24 h. Patients with renal involvement were younger and had blood pressure t t responded less well to acute treatment. One-fifth of the patients died during their hospital stay, and most of these had impaired renal function.
Kaufman JS. Owoaje EE. James SA. Rotimi CN. Cooper RS. Determinants of hypertension in West Africa: contribution of anthropometric and dietary factors to urban-rural and socioeconomic gradients.
American Journal of Epidemiology. 143(12):1203-18, 1996 Jun 15
Blood pressure tracking from child to adulthood: a review
This paper reviews blood pressure tracking from childhood through adolescence, to adulthood. Blood pressure tracking correlations in childhood and adolescence vary from 0.2-0.6. Systolic blood ssure tracks better than diastolic pressure. There does not appear to be a gender difference, except that girls mature earlier than boys and so reach their adult blood pressure sooner. Tracking ould be improved by increasing the number of observations per time period, thus reducing intrasubject variability. Various models, which do not assume linearity, have been developed to improve ediction. However, more studies with longer follow up periods need to be carried out to assess the importance of tracking as a screening tool. There is need also, for further studies in Africa, of the epidemiology of hypertension appears to be different in this setting. From the available data though, large scale screening programmes for children and adolescents are of little merit at this time. [References: 27]
Whelk G. Blood pressure tracking from child to adulthood: a review.[Review] [27 refs]
Central African Journal of Medicine. 40(6):163-9, 1994 June
Hypertensive disease and renal risk factors in black Africa
The goal of this paper has been to summarize the existing data on the epidemiology of hypertension in Africa and to provide the basis for designating important known risk factors. We hope that this document will serve as the basis for a comprehensive evaluation of the disease burden from hypertension on the continent and the potential for prevention to reduce the health risk from this condition. Given the difficulty in maintaining long-term drug therapy in the African setting, and the increasing scientific basis for primary prevention, the time has clearly come to organize community campaigns to control the causal risk factors for hypertension.
Laville M. Lengani A. Serme D. Fauvel JP. Ouandaogo BJ. Zech P. Epidemiological profile of hypertensive disease and renal risk factors in black Africa.
Journal of Hypertension. 12(7):839-43; discussion 845, 1994 July
Hypertension in Africa: prevalence rates and causal risk factors
Cardiovascular disorders currently receive little or no attention in most African countries. Projections based on recent studies suggest that the management of these disorders will represent a major challenge for the over-extended and shrinking health budgets of these poor nations in the very near future. Given the prevalence of such common cardiovascular conditions as hypertension, which in some cases can be 25% or higher, treatment is beyond the budgetary possibilities of any of these countries. Other conditions--including infections involving the heart and related structures, rheumatic fever and its complications, cardiomyopathies, and congenital heart disease--are also common, taken together, and recent trends suggest that ischemic heart disease may be less uncommon than was previously thought. Health planners and policy makers must be educated on the crucial role of health research in general, and cardiovascular research in particular, as a basis for formulating a rational health care policy and making managerial decisions. The needs for training and funding, and especially the leadership required to develop and sustain research activity, will require a multidisciplinary, multidirectional, collaborative approach at national and international levels, as well as firm local commitment. As is the case for most other important health problems, cardiovascular disorders are rapidly becoming a global issue and should be recognized as such.
Kaufman J. Barkey N. Hypertension in Africa: an overview of prevalence rates and causal risk factors.[Review] [154 refs]
Ethnicity & Disease. 3 Suppl:S83-101, 1993.
Cardiovascular research in Africa today
We studied residents of urban and rural areas of Ghana from 1972 through 1987 to evaluate the health burden of cardiovascular diseases, especially high blood pressure, in these African communities. Among urban adults, the prevalence of hypertension was 8% to 13%, compared to only 4.5% among rural adults. Overall, rates were higher among men than among women. However, the rate of hypertension was the same for men and women over 40 years old. The prevalence of hypertension was 29% for persons aged 35 and older, compared to 3.9% for persons under 35 years of age. Of the 24% of the study participants who were aware of their hypertension status, only a third were undergoing treatment, and only half of those were receiving adequate treatment. The determinants of hypertension include age, family history, body mass index, parity, and alcohol use. On a continent where over 80% of the health budget is spent on communicable diseases such as malaria, this study represents one of the few early attempts to understand the magnitude of the health burden of noncommunicable diseases in Africa.
Muna WF. The importance of cardiovascular research in Africa today.
Ethnicity & Disease. 3 Suppl:S8-12, 1993.
Community-based high blood pressure programs in Sub-Saharan Africa
The availability of basic and reliable data on cardiovascular problems in Africans is limited and this hinders the presentation of a comprehensive review of the subject. Nevertheless, there is a strong suggestion that the spectrum and pattern of cardiovascular disorders in Africa is rapidly becoming indistinguishable from that observed in developed countries. The classic risk factors appear to be on the rise and smoking may attain levels equal to or exceeding those in many developed countries. Infectious and inflammatory cardiovascular conditions may still be the most common, although limitations in the technology available for accurate diagnosis make this difficult to verify. Rheumatic fever and rheumatic heart disease remain common, and the potential for educational and other preventive strategies is being realized in many countries. Hypertension at frequencies exceeding 5-10% in most rural areas and 12% in most urban areas, together with complications such as stroke, heart failure and renal failure, are leading causes of morbidity and mortality.Hypertension is the major public health problem in most African countries. The cardiomyopathies are a common problem, and the limited availability of specific diagnostic procedures is matched by limited therapeutic options for most Africans. The prevalence of atherosclerosis and coronary artery disease and its complications, such as myocardial infarction and other degenerative disorders, remains low, but the situation is rapidly changing, especially in urban areas where appropriate diagnostic capabilities exist. It is thought that changes or modifications in lifestyle, risk-prone behaviour, diet, cultural attitudes and certain other consequences of rapid urbanization and demographic tendencies largely explain the observed trends.
Pobee JO. Community-based high blood pressure programs in sub-Saharan Africa.
Ethnicity & Disease. 3 Suppl:S38-45, 1993
Cardiovascular disorders in Africa
Hypertension is the commonest cardiovascular disease in Africans occurring in more than 15% of the adult population in some studies. It occurs in the lower as much as in the higher socio-economic groups. Recent studies have confirmed earlier findings that essential hypertension in Africans is characterised by volume loading, low plasma renin activity, high salt taste threshold, high urinary sodium and low potassium excretion and high plasma aldosterone.The commonest complication of hypertension in Africans is congestive cardiac failure followed by cerebrovascular accidents. Coronary heart disease is rare. Even in the absence of overt heart failure and compounding factors like obesity, alcoholism, cigarette smoking, diabetes mellitus and myocarditis, evidence of abnormal left ventricular morphology and function is often present in newly diagnosed patients with moderate or severe hypertension. Response to monotherapy with beta-blockers or ACE inhibitors is usually poor but is good with thiazide diuretics or calcium channel blockers. The diuretics are an essential component of a two or three drug regime containing other classes of antihypertensive drugs. Cost of drugs is the most important determinant of compliance with drug treatment and consequently the likelihood of progression of the diseases to more severe forms in long term follow-up.
Muna WF. Cardiovascular disorders in Africa. [Review] [74 refs]
World Health Statistics Quarterly - Rapport Trimestrial de Statistiques Sanitaires Mondiales. 46(2):125-33, 1993
Management of hypertension in Africa
We report clinical data and autopsy renal histology in 78 patients who died from chronic renal failure in Ghana. There were 78 patients, 54 male and 24 female, and the majority were aged between 20 and 50 years. The major causes of chronic renal failure were hypertensive renal damage (38 patients) and chronic glomerulonephritis (33 patients). The most common glomerular lesion leading to end-stage renal failure was a focal segmental sclerosing glomerulonephritis. It is possible that some of these segmental sclerosing glomerular lesions were secondary to glomerular hyperfiltration caused by reduced renal mass from hypertension-induced glomerular ischaemia. A public health programme leading to better awareness of the importance of detecting hypertension and having this treated could be a major contribution to reducing by at least half the number of deaths from renal failure reported here.
Salako LA. Hypertension in Africa and effectiveness of its management with various classes of antihypertensive drugs and in different socio-economic and cultural environments.[Review]
Clinical & Experimental Hypertension. 15(6):997-1004, 1993 Nov.
Epidemiology of cardiovascular diseases
At the beginning of this century, high blood pressure was virtually non-existent among the indigenous Kenyans. This phenomenon of normotension continued until the Second World War following which the Kenyan African began to exhibit progressive rise in blood pressure which was age-related. Similar changes were observed in Uganda at the same time. From about 25 years ago, high blood pressure became established in Kenya and the neighbouring countries, in particular Uganda. These trends have been observed in West Africa notably Ghana, Nigeria, Cote d'Ivoire and also in Cameroon and Zaire in the Central African region. Consumption of sodium salt and alcohol, psychological stress, obesity, physical inactivity and other dietary factors are thought to play important aetiologic role in the genesis of primary hypertension in the susceptible individuals. Low blood pressure communities still exist scattered all over the world, where blood pressure does not seem to rise with age. In Africa these have been observed in Kenya, Nigeria, Zaire and Kalahari Desert. They also exist in Pacific island, Australia, South America and elsewhere. Rural-urban migration coupled with acculturation and modernization trends have some relationship with the development of high blood pressure as observed in Kenyan and Ghanian epidemiologic studies.
Lore W. Epidemiology of cardiovascular diseases in Africa with special reference to Kenya: an overview.
East African Medical Journal. 70(6):357-61, 1993 Jun.
Hypertension during pregnancy in Africa and infants' health. A cohort study in an urban setting
The objective of the study was to assess the prevalence of unclassified hypertension during pregnancy and its consequences on infant's health in an African urban setting: Pikine, a suburb of Dakar, Senegal. A cross-sectional study of a random sample of pregnant women and a prospective study, from the inclusion to seven days after delivery, were performed. 886 women attending the prenatal centers were included in the cross-sectional study. 471 pregnant women were included in the follow-up study. The prevalence of DBP > or = 120 mmHg was 0.7%; 5.7% of the women had DBP > or = 95 mmHg. Longitudinal data were available for 425 deliveries. Two spontaneous abortions, 25 stillbirths, and 12 deaths during the early neonatal period were recorded. Among babies living at birth, the percentage of LBW (> or = 2500 g) was 8.5%. The percentages of adverse outcome of pregnancy (death and/or low birth weight) was associated with mothers' diastolic BP: < 85 mmHg: 13%; 85 to 89: 16%; 90 to 94: 9%; DBP > or = 95: 32%, (p < 0.01). Using 95 mmHg as a cut point, the relative risk of adverse outcome associated with a DBP > or = 95 mmHg was 2.5 (CI 95%: 1.4-4.3). This risk was significantly increased among women who reported difficult living conditions. Eight percent of the adverse outcomes of pregnancy, 10% of the low birth weights and 8% of the perinatal mortality were found to be associated with DBP > or 95 mmHg.
Lang T. Delarocque E. Astagneau P. de Schampfeleire I. Jeannee E. Salem G. Hypertension during pregnancy in Africa and infants' health. A cohort study in an urban setting.
Journal of Perinatal Medicine. 21(1):13-24, 1993.
Literature:
Aim:
To determine the importance of congestive Cardiac Failure
CCF as a cause for medical admissions into the medical
wards.
Objectives:
Methodology:
Prospective study:
1st October 1996 to 31st March, 1997. Three hundred and twelve (312) patients of CCF were seen in this period. We used McKee et al, Classification of CCF.
Majors:
Motivation:
Number of CCF patients seemed to go up. No epidemiological or aetiological survey at UTH.
Criticism:
Results:
Size problem: Total CCF - 312 in the six months period
study
Total Admissions 13.742 in the six months
period of study.
Therefore CCF as % 312
X 100 = 2.2
13.742
Average admission/Month =2.290 per month (mean)
Therefore CCF per month=2.2
X 2290 = 50 admission per
month
1000
NOTE: Each ward has 40 beds and they therefore CCF
patients occupy a full ward per month.
MALE: FEMALE ratio
70 : 242 at admission (six months)
= 1:3
MORTALITY RATES:
Phase V (Admission Ward) Mortality Rates:
| Male | E01 | E11 | E21 | Total |
|---|---|---|---|---|
| Oct 96 | 2 | 3 | 5 | 10 |
| Nov 96 | 6 | 1 | 4 | 11 |
| Dec 96 | 6 | 4 | 4 | 14 |
| Jan 97 | 5 | 8 | 7 | 20 |
| Feb 97 | 3 | 8 | 1 | 14 |
| Mar 97 | 3 | 4 | 4 | 11 |
| Male | E02 | E12 | E22 | Total |
|---|---|---|---|---|
| Oct 96 | 8 | 16 | 15 | 39 |
| Nov 96 | 7 | 19 | 10 | 27 |
| Dec 96 | 8 | 21 | 19 | 48 |
| Jan 97 | 8 | 11 | 20 | 39 |
| Feb 97 | 11 | 14 | 14 | 39 |
| Mar 97 | 15 | 14 | 25 | 54 |
Discussion:
The study has revealed that the incidence of congestive
cardiac failure in the internal medicine wards is 2.2%;
meaning that we see an average 50 patients per month with
congestive cardiac failure. The male to female ratio is 1:3
at admission. The case mortality rate is 14.7% (women
12.3; men 22.8%). This showed that males had a higher
mortality than women. Total males admitted was 70 while
females were 242. The males came in rarely but when they
did, they came in with worse disease than females. By age
distribution, 50% of male patients where below 35 years of
age and 50% were above 35 years. By the Zambian
definition, everyone below 35 years of age is considered a
youth while those above are elderly.
In females 25% were below 35 years of age (youth) and 75% were above 35 years of age. A further break down of the females admitted for congestive heart failure was studied and it was seen that of the total of 242 females admitted: -25% were below 35 years of age -13% were between 35 - 45 years of age-62% were above 435 years of age. Therefore the majority of the female population with CCF was elderly (over 45 years)Mortality at admission The case fatality at admission (that is those who died while in the admission wards before being taken to the medical wards) were) Males and females = 4.8% (with males = 12.8% / females 2.9% b) Comparative mortality ratio of Males: females 12.8 : 209 = 4.4:1
The comparative analysis of male to female admission per month revealed that in each month: the female admission were far more than the male admissions The average length of stay (model) was 2 days. The female patients stayed for a shorter time than the male patients. One of the male patients stayed for 35 days.
Among the causes it was found that about 52% of female patients had valvular heart diseases. The leading cause of congestive heart failure in males was hypertension. It was not possible to give figures of how much the other causes contributed. Suffice to say, other causes in both sexes were cardiomyopathies; atrial fibrillations, anaemia, myocardial infarction. Congestive cardiac failure was more common in females than males. This is very different from other parts of the world where the reverse is true.(7) However this agrees with the studies done in Portugal and also the Hong Kong studies which revealed that the prevalence of congestive heart failure is more in females.(8) It was seen from this study that in females, the incidence of congestive heart failure increased with age. However in males this was not so. The males were fewer at admission but they carried a worse prognosis and stayed longer in the Hospital.
Conclusion:
Recommendations:
Schoolchildren especially those living in disadvantaged areas may have as many as 4 to 6 upper respiratory tract infections during a year. These respiratory tract infections may include a runny nose, cough, cold, flu and sore throat. Most sore throats are caused by viruses but sometimes they are caused by a bacteria, called streptococcus. A streptococcal (or strep' as it is commonly called) sore throat is a frequent illness among school-age children and is easily transmitted where housing and school conditions are poor and crowded.
When does a child have a strep' sore throat? A child may feel well and suddenly within a few hours, the child gets a very sore throat and a high fever (over 38 C). The back of the child's neck become enlarged, tender and painful. There usually is no runny nose or coughing.
You must go to the health dispensary or clinic. The nurse or health worker will look into your mouth and give you medicine.
The child must be taken to the health post, dispensary or centre for treatment as soon as possible. The attending health worker will examine the child. The child will be treated with an injection of benzathine penicillin. This treatment prevents the child from acquiring rheumatic fever. It will also prevent the child from spreading the illness to others at home and at school.
If a strep' sore throat is not treated properly, the child may get rheumatic fever sometime during the next 2 weeks. This time the fever will be accompanied by painful and swollen joints (pain and swelling in the wrists, elbows knees and ankles). The swollen joints will feel hot. Sometimes the pain will move from one joint to another. For example, one day there will be swelling and pain in the wrists, the next day there may be swelling and pain in the ankles, the next day in the knees and so on.
You must go the health dispensary or centre immediately. The health worker will give you medicine. A child with rheumatic fever must be treated immediately. The child must be taken to the health post, dispensary or centre and examined. The child will be treated with an injection of benzathine penicillin and aspirin. Recuperation from rheumatic fever takes a long time. The child will need bed rest for one month or more. It is important that the child is well-fed during the recuperation period.
A child who gets rheumatic fever can get rheumatic fever again. Another attack of rheumatic fever must be prevented because it can lead to serious heart damage. To avoid another attack of rheumatic fever the child must receive preventive treatment once every month until he or she is 18 years old or older. Each and every month the child will need to get an injection of benzathine penicillin from a health worker.
This kind of fever can hurt your heart and make you feel very tired when you do a lot of exercise. If the child does not receive the preventive monthly medical treatment, he or she can acquire rheumatic heart disease which is a very serious illness because it can cause severe heart damage. Every time a child has an attack of rheumatic fever, the heart may get more and more damaged. A person whose heart is damaged by rheumatic heart disease can have shortness of breath, weakness and an irregular heart beat especially after strenuous physical activity or exercise. The person may also have a heart murmur. The conditions associated with rheumatic heart disease can get worse over time and the afflicted person may become physically disabled for life and may even die prematurely. Copyright: UNESCO, WHO, ISFC
Despite difficulties in obtaining some of the information, the primary data collected for this study from hospitals in Malawi, Uganda and Zambia confirm the literature review findings. At the urban tertiary care centers, large numbers of women present for treatment of incomplete abortion and other complications of spontaneous or (poorly-performed) induced abortions. Annual logbook estimates of the number of cases of abortion complications at the major teaching hospital in each of the three countries were approximately 2300 in Malawi, 700 in Uganda and 3200 in Zambia. In addition, the contribution of abortion patients to overall gynaecological admissions is significant: in the two hospitals surveyed in the capital city of Uganda, for example, abortion cases (as estimated by providers interviewed) accounted for 53% and 64% of annual gynaecological admissions.
At the regional and district levels, the absolute number of cases is lower-for example, nine cases per month were recorded in a rural Ugandan district hospital and 69 were documented per month in a provincial facility in Zambia. Consequently, at these more peripheral levels, the relative contribution of abortion complications to the total gynaecological caseload may provide a better indication of the magnitude of the problem. To illustrate, at one Malawi district hospital, an estimated 300 patients are treated for complications of abortion each year. This figure represents approximately 70% of the total annual gynaecological cases admitted to that facility.
Abortion patient DBO rates are another indicator of the demand for treatment services. In the Ugandan hospitals surveyed for this monograph, abortion patients occupied between 2% and 49% of available beds (Although shared beds and/or patients lying on ward floors were observed frequently). The overall DBO rate for abortion patients at the major Zambian hospital in this study was calculated at 386% because only two beds were available for abortion cases and the daily turnover of patients was quite high. And this figure does not quantify the inconvenience and discomfort experienced by women waiting on benches because the two beds were occupied. At the major teaching hospital in Malawi, over one quarter of available beds in the gynaecology ward were filled with abortion patients during the study observation period.
What is evident from both of the monograph data sources is the treatment or women with abortion complications constitutes a significant part of the total gynaecological services offered by health care facilities in SSA countries. What these data do not tell us is the magnitude of abortion complications at the population level, specifically, the number of women who do not seek care in public facilities because: 1) they have only minor complications, 2) the cannot or choose not to seek care in such facilities, 3) their complications have been attended to through other channels (e.g., private practitioners), or 4) they die before receiving medical treatment. The fact that about a third of the abortion patients interviewed for the study in the various facilities knew of a relative or friend who had died or become very ill from complications of abortion suggests that the problem in the community is larger than hospital-based studies have been able to document.
Patient Characteristics:
Women seeking care for abortion complications
represent all women of reproductive age (i.e., married
and single, young and old, low and high parity). The
published literature indicates that young, often
unmarried women make up a large percentage of
abortion patients treated in hospitals. And, in
hospital settings, young women are often over
represented among cases with serious complications
such as septicaemia (hence, also among abortion-related deaths). The
high prevalence of young,
unmarried women, in part, reflects the fact that many
facility-based studies are conducted in urban
teaching hospitals where single women, some still in
school, are likely to seek treatment for abortion
complications. As the data collected for this study
suggest, this is less the case in more rural locations
where the women marry and begin their families at
younger ages.
The providers surveyed in the three countries reported that women seek abortions from private physicians, traditional healers and friends, or they self induce. Providers' views on the reasons women seek abortion are consistent with the published literature: unmarried; inconvenient timing of the pregnancy; financial constraints; and too many children or children spaced too closely. In Uganda, providers commented that pregnancy resulting from an extra-marital relationship or identification of HIV-positive status also may be reasons why women seek abortion.
Most of the women interviewed in the three countries were not using a contraceptive method at the time of pregnancy. A number indicated, however, that their pregnancy was initially desired-a response that suggests these patients may have experienced a spontaneous abortion or that for some reason they changed their mind and decided to terminate their pregnancy. The health concerns about contraception expressed by women interviewed for the study (e.g., that contraception use might lead to infertility) were consistent with the findings from the literature. Lack of FP information and access to services were mentioned as the main reasons for non-use of contraception in SSA. This finding is somewhat inconsistent with surveys which show that FP knowledge levels are fairly high in many SSA communities. What specifically constitutes "lack of information," however, is not clearly defined . Does this mean lack of knowledge of where to obtain methods, or lack of confidence in which method is the best/most appropriate for use given particular situations and reproductive goals? These issues have important implications for counseling and communication strategies and warrant further in-depth exploration.
Clinical Issues:
The clinical literature from SSA, while often reporting
findings from small, non-controlled studies, provides
a body of evidence about the negative out-comes of
poorly performed abortions. For example,
septicaemia and hemorrhage, often associated with
poorly-performed procedures, are cited as the two
most common causes of abortion-related deaths in
both the published and grey literature. In the three
study countries, hemorrhage and localized infection
were noted as the two most common problems, with
sepsis cited as another important complication.
As presented in the summary for this topical issue, the length of hospital stay for women with intestinal injuries from unsafe abortions can be high (over 30 days in one Nigerian study). In a study of 650 South African women with abortion-related sepsis, they remained in the hospital an average of 2 weeks compared to 1 to 2 days for non-septic abortion patients. These numbers are particularly distressing when compared to statistics on induced abortions performed by skilled providers working under hygienic conditions for which the complication rates are low particularly in the early states of pregnancy.
The South African article on prostaglandin use highlights the negative impact of stringent administrative requirements for legal abortion. These requirements often mean that women are not able to obtain an abortion until later in their pregnancy, when the risk of complications is greater. Almost one third of legal abortions performed in the study hospital were for women in the second trimester, due in part to the strict regulations for obtaining a legal abortion: the consent of two doctors and the performance of the procedure by a third.
Pain control practices related to treatment of incomplete abortion appear to fall at one of two ends of the continuum: one extreme is standard administration of heavy sedation or other pain control measures that increase the risk of complications, lengthen patients' recovery times and increase costs; the other extreme involves no individual assessment of the woman's clinical need for pain control and no provision of pain control medication.
The clinical literature on MVA for treating incomplete abortion in the first trimester documents the safety and effectiveness of this evacuation technique. Additionally, positive findings on the use of MVA on an outpatient basis, and the resulting reductions in patient stay and associated hospital costs, warrant increased use of this technique.
Despite recommendations from previously conducted clinical studies, data from the three countries document that the use of MVA remains primarily confined to the urban teaching hospitals. MVA is used at the tertiary and provincial hospitals in Zambia but not at the two district hospitals surveyed. More than half of the evacuations performed with MVA at the major Malawian hospital while SC is utilised in the remaining facilities. Data about the evacuation technique used were limited in Uganda but SC is used at the district hospital surveyed. Obstacles that limit the use of more appropriate evacuation techniques need to be identified and strategies t overcome them need to be developed.
Cost Issues:
Most of the published literature on the cost of treating
abortion complications focuses on the ALOS in the
hospital. Patients treated for complications of
induced abortion generally have longer stays than
spontaneous abortion cases. Furthermore, as noted
above, women with major complications such as
septicaemia (often as a result of poorly performed,
unsafe abortions) have especially long stays. These
data are supported by the grey literature which
indicates stays as high as high as 3 weeks for septic
abortion patients. One published study analysed
differences in the cost of treating incomplete abortion
patients with MVA versus SC in Kenya; patient ALOS
was one of the major factors affecting the cost of
treatment. The average cost of treatment with MVA
was reported to be 66% less in one district hospital
and 23% less in another.
Information gathered in Malawi, Uganda and Zambia for the monograph confirms that, in many sites, abortion patients remain for extended periods of time in hospital. Ugandan women at the provincial hospital usually remain about 4 days. The shortest lengths of stay were recorded at the tertiary level in Uganda and Zambia, about one half day in each country. For facilities like the Lusaka hospital, reduced stays for abortion patients, numbering over 3000 per year, can mean substantial cost savings to already overburdened hospital budgets.
Budgets for gynaecological services were unavailable in all monograph study hospitals and thus administrators were not able to provide exact figures on the cost of treating abortion patients. Rough estimates, developed based on data from a variety of other sources, indicated that the cost of treating one incomplete abortion patient (with no major complications) in Malawi at the time of data collection was approximately US $3.00. In contrast, the Malawian government has an annual per capita budget of US $2.55 for full health coverage. Women presenting with conditions such as septicaemia and hemorrhage inevitably require more medications, more attention from staff and even longer recuperation in the hospital, and hence treatment costs for these patients are likely to be even higher.
Clearly, health care systems in SSA are currently expending relatively large amounts of scarce resources including personnel time, medications, bed space, utilities and meals on patients suffering from abortion complications. Given the magnitude of resources spend to provide care for abortion patients, it is essential to ensure that expenditures result in the most cost-effective, high quality services. Investigations for the Kenyan cost study suggest several mechanisms to achieve this objective including: 1) using MVA to treat first trimester incomplete abortion patients, 2) performing uterine evacuation procedures in outpatient settings instead of in operating theaters, and 3) decentralizing abortion treatment to low level health care facilities to reduce costs and increase access.
Contraception and Abortion:
One of the most striking findings of both the
published and unpublished literature is the virtual
absence of research on postabortion FP. The need
for comprehensive postabortion care-that is,
treatment of complications in conjunction with FP and
other reproductive health services-appears self-evident. No studies
were found, however, that
examine women's reproductive intentions after
abortion, how best to offer such services, or policy
changes necessary to promote comprehensive
prostabortion services.
What little research has been done describes contraception use among women, in particular, adolescents. Overall, the literature suggests relatively low use of contraception, especially among adolescents, and widespread fear of the potential risks or side effects (real and imagined) associated with contraceptive use.
Findings from the hospitals in Malawi, Uganda and Zambia provide some insights into why studies on postabortion FP are lacking. While some of the facilities offer some FP counseling and/or methods to abortion patients, most do not. In Ugandan hospitals, for example, the vast majority of the 77 women interviewed received no FP information (although 75% said that they would have liked someone to have made FP methods and/or information available to them). Similalarly, FP information was not offered to most of the 55 Zambian patients questioned. In Malawi, where 50 patients predominantly from tertiary hospitals in the capital city were interviewed, almost all indicated that no one in the hospital had talked to them about FP, offered them a FP method or told them where they could obtain FP services once discharged.
Providers interviewed in all three countries mostly concurred with the need to offer postabortion FP services, and findings from both components of this study underscore this need. Many providers, however, expressed the need for staff training and their concern about staff shortages as issues to be considered whenever postabortion FP services are to be introduced. Testing of various models of staffing, logistics, counseling and referrals would assist service managers and policy makers in efforts to modify current programmes to include postabortion FP services.
Male Perspectives:
The degree of male "involvement' in the woman's
decision to abort appears to vary. There is an
indication that some pregnancies are terminated
because the male partner does not want a child at
that time. The literature, however, reveals that often
the male is not actively involved in decisions related
to how and where the abortion procedure is
performed except perhaps to provide financial
support. The extent to which this pattern of
communication varies between married and
unmarried couples is not clear from the available
data. In addition, how this communication (or lack
thereof) affects where women go to have their
pregnancy terminated, and how long they wait until
seeking medical assistance if there is a problem, are
not well understood.
Abortion Laws:
Numerous articles address the fact that legal abortion
is restricted to a very limited set of circumstances in
the region. Although written from a variety of
perspectives, virtually all the articles conclude that
restrictive laws negatively affect women's health,
primarily because clandestine, unsafe abortions
occur in greater numbers in such environments.
Recommendations for improving the situation include
codifying abortion laws so that they reflect health
concerns; removing administrative barriers to legal
abortion; and expanding public sector services for
abortions which are permissible under existing laws.
One article from Tunisia emphasises the positive results of liberalising laws to allow abortion at the request of the woman and the effect of this change on maternal morality (Bejaoui, 1988). The data show a reduction in maternal mortality rates, and in general, a fall in caseloads and admissions related to abortion complications. The author acknowledges that while such changes are rare in Muslim societies, the interrelationships among law, religion and policy can work toward the benefit of women's health.
Providers in hospitals in Malawi, Uganda and Zambia were interviewed about their views toward their county's laws and how the laws affect treatment services. Laws in Malawi and Uganda allow abortion only under limited circumstances while the law in Zambia permits abortion for a broad range of indications. A majority of providers in Uganda were aware of the provisions of their law regarding abortion; in the other two countries providers were less knowledgeable. Responses from Zambia indicate a lack of familiarity with the existing laws on abortion.
Most of the providers surveyed either thought that their country's abortion laws were too restrictive or appropriate as written. The majority, however, also were of the opinion that women will seek, and practitioners will perform, abortion regardless of the law.
The statistics on MR procedures at the Zambian hospitals underscore the need for legal abortion services to be more readily available in that country. The main teaching hospital in Lusaka is the only location where MR is performed on a regular basis; the published literature from this country confirms this finding. Very few MRs were reported at the provincial facility surveyed although the number of unrecorded procedures in all sites is unknown. To lower the rate of mortality and morbidity resulting from unsafely performed abortion, low-cost, safe, legal services clearly need to be more widely available and publicised in Zambia.
Quality of Service Issues:
The published literature focuses on two aspects of
quality: clinical safety and duration of patient stay.
The need to use the safest techniques available for
uterine evacuation, to appropriately manage
complications and to ensure the availability of
supplies and equipment are all touched upon as
concerns in these articles. In addition to
documenting that abortion patients often have
lengthy hospital stays, the studies also show that
improved organisation of services (e.g., evacuations
performed on an ambulatory basis with MVA) can
substantially reduce the amount of time abortion
patients must remain in the hospital. The published
and grey literature presents little or nothing about
provider-patient interactions or women's perspectives
on access to the delivery of services.
This gap in the literature stands in contrast to the primary data collected for this monograph. Both providers and women were interviewed specifically to gain insights into the quality of and access to postabortion treatment services. No consistent finding emerged from providers and patients about the quality of their interactions although many women expressed that the care they had received was good. This finding, however, could reflect a "courtesy bias. A series of questions eliciting information on indicators of quality, as perceived by users of the system, needs to be incorporated as much as possible in future studies. The most common complaints voiced by patients were long waiting times for treatment, lack of adequate pain relief, overcrowding, need for FP counseling and methods and, in the case of Zambia, where administrative requirements restrict access to safe, legal abortion services, fear of criminal prosecution. A number of providers commented on the need for more personnel to handle the patient load.
In several hospitals, women were given an explanation of the treatment they would be receiving although in most cases, no information was given prior to the procedure. Frequently, no instructions on post-procedure care at home were given either. Investigators from the three countries concluded that abortion patients remain a low priority in almost all hospitals. Evidence supporting this conclusion can be found in the form of long waits; restrictions in some centers on the number of beds available for abortion patients; and the fact that some patients are forced to sit on benches or lie on ward floors.
Many providers in the three study countries felt that women have relatively easy access to induced abortion, treatment of complications and FP services. Transportation to obtain care for complications was not identified as a key problem by most patients although women in rural areas noted this as a difficulty more than did urban women. The most common reasons stated by those interviewed for coming to a particular hospital were its proximity, afford ability and quality of care provided.
These findings summarise some of the more important quality concerns/needs of abortion patients. Addressing some of these concerns/needs requires the dedication of significant resources. Other concerns, such as providing patients with pre-and post-treated information, can markedly increase the quality of services with only minimal monetary investment.
Conclusions:
The findings from the literature and the experiences
in hospitals in Malawi, Uganda and Zambia are
essentially similar. The combined results reveal a
consistent picture across the region:
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Last updated December 29, 1997