STUDY QUESTION: What is the evidence pertaining to availability, effectiveness and safety of assisted reproductive technology (ART) in sub-Saharan Africa? SUMMARY ANSWER: According to overall limited and heterogeneous evidence, availability and utilization of ART are very low, clinical pregnancy rates largely compare to other regions but are accompanied by high multiple pregnancy rates, and in the near absence of data on deliveries and live births the true degree of effectiveness and safety remains to be established. WHAT IS KNOWN ALREADY: In most world regions, availability, utilization and outcomes of ART are monitored and reported by national and regional ART registries. In sub-Saharan Africa there is only one national and no regional registry to date, raising the question what other evidence exists documenting the status of ART in this region. STUDY DESIGN, SIZE, DURATION: A systematic review was conducted searching PUBMED, SCOPUS, AFRICAWIDE, WEB OF SCIENCE and CINAHL databases from January 2000 to June 2017. A total of 29 studies were included in the review. The extracted data were not suitable for meta-analysis. PARTICIPANTS/MATERIALS, SETTING, METHOD: The review was conducted according to PRISMA guidelines. All peer-reviewed manuscripts irrespective of language or study design that presented original data pertaining to availability, effectiveness and safety of ART in sub-Saharan Africa were eligible for inclusion. Selection criteria were specified prior to the search. Two authors independently reviewed studies for possible inclusion and critically appraised selected manuscripts. Data were analyzed descriptively, being unsuitable for statistical analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The search yielded 810 references of which 29 were included based on the predefined selection and eligibility criteria. Extracted data came from 23 single centre observational studies, 2 global ART reports, 2 reviews, 1 national data registry and 1 community-based study. ART services were available in 10 countries and delivered by 80 centres in 6 of these. Data pertaining to number of procedures existed from 3 countries totalling 4619 fresh non-donor aspirations in 2010. The most prominent barrier to access was cost. Clinical pregnancy rates ranged between 21.2% to 43.9% per embryo transfer but information on deliveries and live births were lacking, seriously limiting evaluation of ART effectiveness. When documented, the rate of multiple pregnancy was high with information on outcomes similarly lacking. LIMITATIONS, REASONS FOR CAUTION: The findings in this review are based on limited data from a limited number of countries, and are derived from heterogeneous studies, both in terms of study design and quality, many of which include small sample sizes. Although representing best available evidence, this requires careful interpretation regarding the degree of representativeness of the current status of ART in sub-Saharan Africa. WIDER IMPLICATIONS OF THE FINDINGS: The true extent and outcome of ART in sub-Saharan Africa could not be reliably documented as the relevant information was not available. Current efforts are underway to establish a regional ART data registry in order to report and monitor availability, effectiveness and safety of ART thus contributing to evidence-based practice and possible development strategies. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study. The authors had no competing interests. TRIAL REGISTRATION NUMBER: PROSPERO CRD42016032336

Includes abstract. / Includes bibliographical references. / Objective: To compare the analgesic efficacy of ketamine with Fentanyl/Midazolam in women requiring uterine evacuation for incomplete miscarriage as measured by the patients’ perceived pain. Study design: An efficacy trial with a naturally occurring control group who received what is currently standard practice. The study ran over two 4-week periods (25/06/2012 to 19/08/2012). Setting: Groote Schuur Hospital (a tertiary hospital) situated in Cape Town, South Africa. Population: All women between the ages of 18 and 55 years admitted to Groote Schuur Hospital for uterine evacuation following a spontaneous incomplete miscarriage or missed miscarriage that were not excluded by any of the exclusion criteria. Methods: Over a 2 month period (two 4-week periods), all patients meeting the inclusion criteria were allocated to either the control group (month 1) or the study group (month 2). Data was collected from all these evacuations during the study period at Groote Schuur Hospital.

Includes bibliographical references (leaves 36-37). / Care of the critically ill pregnant woman poses exceptional challenges in the intensive care unit and requires the skills of health care providers who have knowledge of the physiological changes of pregnancy as well as specific pregnancy-related disorders in order to achieve optimal management.

BACKGROUND Sacrospinous Fixation is a procedure for mid-compartment apical suspension in pelvic organ prolapse surgery with high success rates. The approach by traditional wide dissection has been well-documented. The literature is lacking however with regard to newer devices on the market that use less extensive dissection to perform this procedure. METHODS A randomised controlled trial was carried out comparing the Boston Scientific's Capio Slim® (control) and Bard's Fixt® (intervention) for bilateral sacrospinous fixation in women with mid-compartment prolapse requiring surgery and who met the study criteria. The primary outcome was time (in seconds) to successful bilateral suspension suture placements. Secondary outcomes examined were used to assess short-term safety and efficacy of the devices at the time of the procedure and at the six week follow-up.

Includes bibliographical references / Background: A near miss occurs when a pregnant woman experiences a severe life threatening complication during pregnancy or up to 42 days after the end of the pregnancy and survives. The near miss rate is defined as the number of near misses per 1000 live births. In 2011, World Health Organization (WHO) produced a useful tool for identifying near misses according to composite criteria which include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. The ratio of maternal near miss cases to maternal deaths and the mortality index both reflect the quality of care provided in a maternity service Maternal deaths have been audited in the Metro West maternity service for many years but there has been no routine monitoring or evaluation of maternal near misses. Aim of study: The study aim was to perform a near miss audit in Metro West, specifically (a) measuring the near miss rate, the maternal mortality ratio and the mortality index, (b) performing an in-depth investigation of the associated demographic, clinical and health system factors of the near miss cases, and (c) providing input into the development of an on -going system of auditing near misses cases in Metro West. Methods: A retrospective observational study conducted over 6 months between mid- March 2014 to mid -September 2014. This service includes 9 level one maternity facilities which refer all complicated maternal cases to two secondary hospitals, New Somerset (NSH) and Mowbray Maternity (MMH); or to the tertiary hospital, Groote Schuur Maternity Center (GSH). All cases of near miss managed at the three hospitals were identified weekly by the author with the assistance of onsite health providers. These cases included near misses that occurred at level one facilities and were referred on to one or more of the three hospitals. Strict criteria were used to ascertain a case as a near miss according to the WHO near miss definitions. The folders of all the near misses were reviewed and relevant data entered into a data collection form which was adapted from the WHO near miss data form. In addition, these identified folders were reviewed by two senior obstetric specialists to confirm adherence to the WHO inclusion criteria for near miss classification, and also to determine avoidable factors in the management of the near miss cases. Maternal deaths occurring during the same time period of the Near Miss audit were identified from monthly mortality meetings and the ongoing maternal mortality audit system in Metro West. Results: 112 near miss cases and 13 maternal deaths were identified, giving a total of 125 women with severe maternal outcomes. There were a total of 19,222 live births in Metro West facilities. The Maternal mortality ratio (M MR) was 67.6 per 100,000 live births and the maternal near miss rate was 5.83 per 1000 live births. The maternal near miss to death ratio was 8.6:1 and the mortality index was 10.4% Hypertension, obstetric hemorrhage and pregnancy related sepsis were the major causes of the near miss cases accounting for 50(44.6%), 38(33.9%), and 13 (11.6%) of near misses respectively. These three conditions all had low mortality indices; 1.9%, 1.9% and 0 for hypertension, pregnancy related sepsis and hemorrhage respectively. Less common conditions were, medical /surgical conditions, non-pregnancy related infections and acute collapse, accounting for 7 (6.3%), 2 (1.8%), and 2 (1.8%) of near misses respectively. Although these numbers were small, these three conditions accounted for more maternal deaths with mortality indices of 66.7 %, 33.3% and 33.3% for non- pregnancy related infections, medical /surgical conditions, and acute collapse respectively. There were 25 (22.3%) of the near miss cases who were HIV positive. The majority of near misses 99(88.4%) had antenatal care. Analysis of avoidable factors showed that, the most common problems were lack of antenatal clinic attendance (11.6%) and inter-facility transport problems (6.3%). For health provider related avoidable factors, the highest number of avoidable factors were identified at level 2 (38.2%), followed by level one (25.9%) and level 3 (7.1%). The most common factors were problem recognition, monitoring and substandard care Discussion and Conclusions: The near miss rates and maternal mortality ratio in Metro West were lower than for some other developing countries, but higher than rates in high income countries. The mortality index was low for direct obstetric conditions such as hypertensive disorders, obstetric hemorrhage and pregnancy related sepsis, reflecting good quality of care and referral mechanisms for these conditions. The mortality indices for non-pregnancy related infections, medical/surgical conditions and acute collapse were much higher and, suggest that medical problems may need more focused attention. Ongoing near miss audit would be valuable for Metro West but would require identification and monitoring systems to be institutionalized.

No description available.

Includes bibliographical references / This study aims to address the lack of data on the link between BMI and infertility in the South African population by describing the prevalence of male overweight and obesity in a group of men undergoing infertility investigation, as well as assessing any semen analysis abnormalities in these groups. It also aims to describe how well men can predict their BMI category and determine whether weight loss would be an acceptable part of infertility management in overweight or obese male partners. Beliefs surrounding healthy weight and fertility will also be addressed.

OBJECTIVE: To compare the efficacy and safety of misoprostol (Cytotec) with prostaglandin E2 (prandin gel) in cervical ripening and induction of labour at term. STUDY DESIGN: Two independent studies were performed. The first was to evaluate misoprostol as a cervical ripening agent when compared to prandin gel and the second to compare their ability to induce labour. Two hundred and forty patients requiring cervical ripening prior to induction of labour were recruited to the cervical ripening arm of the trial. Patients were randomly assigned to receive either 100 μg of misoprostol (half a 200 μg tablet) in the posterior fornix or 1mg prandin gel similarly inserted. A Bishop's score of the cervix was performed prior to drug insertion and repeated by the same clinician 24 hours thereafter if labour or delivery had not ensued. If labour commenced it were managed according to standard labour ward protocols. Three hundred and forty patients who required induction of labour for maternal or fetal reasons at term were recruited to the induction of labour arm of the trial. Half were randomly allocated to receive 100 μg misoprostol (half a 200 μg tablet) in the posterior fornix and half, 1mg prandin gel in the posterior fornix. If after 4 hours the labour had not ensued or the cervix remained too unfavourable for amniotomy, then a second dose of the drug was used. Labour and delivery was managed according to standard labour ward protocols. RESULTS: In the cervical ripening trial, data was analysed on 113 patients in the misoprostol arm and 116 in the prandin arm. The demographic characteristics were similar in both groups. Significantly more patients delivered within the 24-hour ripening period with misoprostol (88 (77.9%)) than with prandin gel (47 (40.5%)) (P < 0.001). In those patients delivered within 24 hours, the induction of labour to delivery interval was similar at, 9 hours 30 minutes (SD = 5h30) for misoprostol and 10 hours 51 minutes (SD = 5h09), with prandin gel. Significantly more patients in the prandin gel arm required oxytocin augmentation (25.5% versus 12.5% with misoprostol) but the caesarean section rate (13.6% with misoprostol and 12.7% with prandin gel) and analgesic usage were similar. Maternal side effects were similar in the two groups but tachysystole was significantly more common at 12.4% with misoprostol and 1.7% with prandin gel (P<0.01). In those patients undelivered at 24 hours, there was a significant improvement in the number of patients with a Bishop's score of > 4 with both drugs. Neonatal outcomes, including Apgar score and admission to the neonatal intensive care unit were not significantly different. In the induction of labour arm of the trial the demographic characteristics of both groups were similar. The use of misoprostol resulted in a significantly higher number of patients delivering within 12 hours of drug insertion than with prandin gel (136 (80%) with misoprostol versus 91 (66,9%) with prandin gel, P < 0.001). There was also a significantly shorter insertion to delivery interval with misoprostol (9hr13 (SD = 5hr 53)) than with prandin gel (12hr18 (SD = 6h22)), (P < 0.001). Thirty nine patients in the misoprostol group required a second dose of the drug versus 55 patients in the prandin gel group (P<0.05). Although the caesarean section rate was similar with the two drugs (30.6% with misoprostol and 34.1 % with prandin gel) significantly more patients had a caesarean section for fetal distress in the misoprostol group (21.8% vs 10.6%) (P < 0.05). Neonatal outcome, as assessed by Apgar score and admission to the neonatal intensive care unit, was however not different with either drug. Four patients had abruptio placentae in the misoprostol group and the incidence of tachysystole was significantly higher at 28.2% vs 15.3% with prandin gel (P< 0.01). Oxytocin was used for labour augmentation in 52.9% of patients with prandin gel and 27% with misoprostol (P < 0.05). Analgesic usage and other maternal side effects were similar with both drugs. CONCLUSION: Misoprostol is an effective cervical ripening and induction of labour agent when compared to prandin gel. However, it results in a higher incidence of tachysystole, caesarean section for fetal distress and abruption placentae and cannot yet be recommended for general use until the concern over adverse fetal and maternal outcome is addressed in larger trials.

PCOS is the commonest endocrinopathy occurring in women of reproductive age. This study aimed at comparing the presentation of adolescents to that of women ≥ 35 years presenting to the gynaecological endocrine clinic with a diagnosis of PCOS. This was a descriptive cohort study. Since 1996 all women with PCOS have their clinical, metabolic and endocrine data entered into a database. We compared the initial presentation of adolescents and women aged 35 and above.

Includes abstract. / Includes bibliographical references (leaves 48-53). / Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors.