All patients that had developed a lesion had at least 1 of the follow-ing risk factors: delivery by cesarean, use of regional or general anesthe-sia, primary postpartum hemorrhage greater than 500 mL, or use of apressure dressing. Most patients had more than 1 risk factor (Table 2).These risk factors mirror the established risk factors for skin break-down: prolonged periods of immobility, contact with moisture (lochia,amniotic fluid, surgical wash), and hypoalbuminemia (serum albuminlevels will be lowered after sudden volume depletion [3]).

Local practices were changed in response to these findings. A pres-sure sore checklist was introduced in the delivery suite and operatingtheatre. This included a tick box system to ensure pressure areas wereroutinely assessed and documented if felt to be “at risk.” Patients hadthe checklist completed before discharge to the postnatal ward. Themethod in which the abdomen was prepared for cesarean delivery waschanged from a 50-mL chlorhexidine wash applied with sterile swabsand poured liberally over the abdomen to the ChloraPrep (Carefusion,San Diego, USA) system (chlorhexidine gluconate/isopropyl alcohol).The latter system uses a small volume of antiseptic applied with awand directly over the incision site and allowed to dry before draping.This method ensures that the wash does not soak the sheets underlyingthe patient. The routine use of pressure dressings was discontinued. Theresults of the audit were discussed at multidisciplinary clinical risk man-agement meetings to improve staff awareness of the risk factors. Thesemeasures ensured that both the incidence and severity of the skin lesionswere significantly reduced during the second audit period from October

14, 2010 toMay 31, 2011 (Pb0.01 calculated using the Fisher exact test).The incidence dropped to 8 (0.14%) cases out of 5582 women deliveredin the second audit period, representing an 80% relative risk reduction.One patient had a grade I lesion. Seven patients developed a grade II le-sion. There were no grade III or grade IV lesions (Table 3).

The incidence of pressure sores in obstetric patients will continue torise in parallel with the upward trend in cesarean delivery. In anincreasingly litigious environment every aspect of intrapartum caremust be examined to minimize risk exposure. This audit demonstratesthat small changes in practice can impact significantly on the qualityof patient care and reduce peripartum morbidity. It also underpins theimportance and effectiveness of clinical audit.

Conflict of interest

The authors have no conflicts of interest to declare.

References

[1] Newton H, Butcher M. Investigating the risk of pressure damage during childbirth.Br J Nurs 2000;9(6 Suppl.):S20-2 [S24, S26].

[2] Malone C. Pressure sores in the labour ward. RCM Midwives J 2000;3(1):20-3.[3] Baskett PJ. ABC of major trauma. Management of hypovolaemic shock. BMJ

1990;300(6737):1453-7.

0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijgo.2012.10.012

Table 3Incidence and severity of skin lesions before and after audit period.

Audit period No. of women delivered No. of skin lesions reported Incidence of skin lesions, % Grade I Grade II Grade III Grade IV

1 (May 1, 2010 to October 13, 2010) 3894 28 0.71 0 25 3 02 (October 14, 2010 to May 31, 2011) 5582 8 0.14 1 7 0 0

Placenta previa at University Hospital, Yaoundé, Cameroon

Pierre Marie Tebeu a,b,⁎, Gisele Kengne Fosso a,b, Robinson Enow Mbu a, Inoussa Nsangou c,Luc Kouam a, Joseph Nelson Fomulu a

a Department of Gynecology and Obstetrics, University Hospital, Yaoundé, Cameroonb Ligue d'Initiative et de Recherche Active pour la Santé et l'Education de la Femme (LIRASEF), Cameroonc Department of Pediatrics, University Hospital, Yaoundé, Cameroon

a r t i c l e i n f o

Article history:Received 31 August 2012Received in revised form 4 October 2012Accepted 21 November 2012

Keywords:CameroonPlacenta PreviaRisk factorsYaoundé

⁎ Corresponding author at: Department of Obstetrics and Gynecology, Faculty ofMedicine and Biomedical Sciences, University Hospital, Yaoundé, Cameroon. Tel.: +23777 67 55 33.

E-mail address: pmtebeu@yahoo.fr (P.M. Tebeu).

In placenta previa, the placenta is wholly or partially inserted onthe lower uterine segment and the condition complicates 0.4%–1.5%of deliveries [1,2]. It is characterized by spontaneous, painless, mildvaginal bleeding without signs of labor. The case fatality rate hasbeen reported as up to 9 per 1000 cases and the perinatal mortalityrate as up to 21.3% [1,3].

A cross-sectional study was performed at the University Hospital,Yaoundé, Cameroon between January 1, 2004, and December 31,2008, following approval granted by the National Ethical Committee.The aim of the study was to evaluate the risk factors andmaternal andperinatal outcomes of pregnancies complicated by placenta previa.Participants were identified from the delivery room registers. Acomparison group was established by selecting the two consecutivepatients without placenta previa who delivered after each case ofplacenta previa.

286 BRIEF COMMUNICATIONS

Epi Info version 3.5.1 (CDC, Atlanta, GA, USA) was used for dataanalysis. Odds ratios were used for comparisons between the groupsand Pb0.05 was considered statistically significant.

A total of 11 197 deliveries were registered over the study period,including 126 (1.1%) cases of placenta previa. The control groupcomprised 252 women. A total of 14 patients from the placentaprevia group and 12 from the comparison group were excludedowing to missing data, leaving 112 cases of placenta previa and 240controls.

The prevalence rate of 1.1% was similar to other studies in whichprevalence was reported to range between 0.4% and 3% [1,2]. Ana-tomically, placenta previa was classified as lateral (27.7%), marginal(22.3%), partial (19.6%), and complete (30.4%).

Patients with placenta previa were more likely to be housewives(50.9% vs 32.1%) and have a history of cesarean delivery (5.4% vs2.1%) (Table 1). A greater proportion of patients with placenta previahad had at least 6 previous pregnancies (9.8% vs 5.0%; OR 2.09; 95% CI,1.16–3.7; P=0.0128).

More womenwith placenta previa were multiparous with at least4 deliveries (26.8% vs 14.6%; OR 2.14; 95% CI, 1.1–3.8; P=0.0067).However, after adjusting for potential confounders (occupation andnumber of pregnancies), multiparity was no longer significant anddid not appear as an independent risk factor for placenta previa(OR 1.88; 95% CI, 0.6–5.9; P=0.2279). This observation suggests apossible association between grand multiparty and housewifestatus.

Histories of patients with placenta previa revealed many cases offirst trimester bleeding (16.0% vs 0.4%; Pb0.001), which is similar toa report from Israel [2]. Patients with placenta previa were more like-ly to deliver before 37 weeks (36.6% vs 8.3%; OR 6.3; 95% CI, 3.3–12.0;Pb0.001) and cesarean delivery was the preferred mode of delivery(91.1% vs 1.3%; Pb0.001).

Patients with placenta previa were more likely to have a historyof previous cesarean delivery (5.4% vs 2.1%; OR 2.7; 95% CI,0.7–10.7; P=0.169), which is consistent with a study that found a1.5-fold increased risk among women with previous cesareandelivery [4].

Blood transfusion was common practice for patients with placentaprevia compared with controls (18.8% vs 1.3%; OR 12.9; 95% CI,3.5–56.6; Pb0.001). The main complication associated with thecondition was anemia (79.4% vs 10.5%; OR 11.6; 95% CI, 5.8–23.3;Pb0.001). The present findings are consistent with those from astudy that reported a 2-fold increased risk of postpartum hemor-rhage, a 5-fold increased risk of blood transfusion, and a 40-fold in-creased risk of obstetric hysterectomy [1].

There was 1 maternal death, leading to a case fatality rate of7.9 per 1000. A greater proportion of neonates born to women withplacenta previa had 1-minute Apgar scores of 1–6 (25.9% vs 10.4%;OR 3.0; 95% CI, 1.6–5.6; Pb0.001). More of these children hada birth weight of less than 2500 g (25% vs 6.3%; OR 4.7; 95%CI, 2.3–9.9; Pb0.001). The low birth weight is in agreement withthe 36.6% premature delivery rate observed among patients with pla-centa previa. Perinatal mortality was higher in the placenta previagroup compared with the control group (13.5% vs 5.9%; OR 2.5; 95%CI, 1.09–5.7, P=0.0449).

The findings of the present study highlight the need to improvehealth promotion and emergency obstetric and neonatal care in thissetting.

Conflict of interest

The authors have no conflicts of interest to declare.

References

[1] Onwere C, Gurol-Urganci I, Cromwell DA, Mahmood TA, Templeton A, van derMeulen JH. Maternal morbidity associated with placenta praevia among womenwho had elective caesarean section. Eur J Obstet Gynecol Reprod Biol 2011;159(1):62-6.

Table 1Classification of patients according to their characteristics.a

Characteristics Placenta previa Total (n=352)

Yes(n=112)

No(n=240)

OccupationHousewife 57 (50.9) 77 (32.1) 134 (38.1)Trader/civil servant 16 (14.3) 32 (13.3) 48 (13.6)Student 13 (11.6) 63 (26.2) 76 (21.6)Non-civil servant salaries 21 (18.7) 56 (23.3) 77 (21.9)Not specified 5 (4.5) 12 (5.0) 17 (4.8)

Age, y 29.1±6.3 27.4±5.710–19 3 (2.7) 14 (5.8) 17 (4.8)20–34 84 (75.0) 188 (78.3) 272 (77.3)35–46 23 (20.5) 30 (12.5) 53 (15.1)Not specified 2 (1.8) 8 (3.3) 10 (2.8)

Marital statusSingle 37 (33.0) 110 (45.8) 147 (41.8)Ever married 66 (58.9) 118 (49.1) 184 (52.3)Not specified 9 (8.0) 12 (5.0) 21 (6.0)

Parity at admission0 19 (17.0) 87 (36.3) 106 (30.1)1 29 (25.9) 55 (22.9) 84 (23.9)2–3 34 (30.3) 61 (25.4) 95 (27.0)4–5 19 (17.0) 23 (9.6) 42 (11.9)6–12 11 (9.8) 12 (5.0) 23 (6.5)Not specified 0 (0.0) 2 (0.8) 2 (0.6)

History of placenta previaNo 94 (83.9) 219 (91.2) 313 (88.9)Yes 2 (1.8) 0 (0.0) 2 (0.6)Non specified 16 (14.3) 21 (8.8) 37 (10.5)

History of myomectomyNo 100 (89.3) 217 (90.4) 317 (90.0)Yes 1 (0.9) 1 (0.4) 2 (0.6)Not specified 11 (9.8) 22 (9.2) 33 (9.4)

History of cesarean deliveryNo 94 (83.9) 216 (90.0) 310 (88.1)Yes 6 (5.4) 5 (2.1) 11 (3.1)Not specified 12 (10.7) 19 (7.9) 31 (8.8)

History of abortionNo 60 (53.6) 130 (54.2) 190 (54.0)Yes 46 (41.1) 99 (41.2) 145 (41.2)Not specified 6 (5.4) 11 (4.6) 17 (4.8)

Gestational age at delivery, wk28–34 18 (16.1) 7 (2.9) 25 (7.1)34–37 23 (20.5) 13 (5.4) 36 (10.2)37–41 56 (50.0) 172 (71.7) 228 (64.8)41–43 7 (6.3) 36 (15.0) 43 (12.2)43–45 1 (0.9) 4 (1.7) 5 (1.4)Not specified 7 (6.3) 8 (3.3) 15 (4.3)

Mode of deliveryCesarean 102 (91.1) 3 (1.3) 105 (29.8)Non-instrumental vaginal delivery 9 (8.0) 234 (97.5) 243 (69.0)Instrumental vaginal delivery 1 (0.9) 3 (1.3) 4 (1.1)

Blood transfusionNo 76 (67.9) 141 (58.8) 217 (61.6)Yes 21 (18.8) 3 (1.3) 24 (6.8)Not specified 15 (13.4) 96 (40.0) 111 (31.5)

Apgar score at first minute0 13 (11.6) 11 (4.6) 24 (6.8)1–6 29 (25.9) 25 (10.4) 54 (15.3)7–10 62 (55.4) 198 (82.5) 260 (73.9)Not specified 8 (7.1) 6 (2.5) 14 (4.0)

Birth weight, g500–1999 9 (8.0) 5 (2.1) 14 (4.0)2000–2499 19 (17.0) 10 (4.2) 29 (8.2)2500–3999 71 (63.4) 203 (84.6) 274 (77.8)4000–5000 2 (1.8) 13 (5.4) 15 (4.3)Not specified 11 (9.8) 9 (3.8) 20 (5.7)

a Values are given as number (percentage) or mean±SD.

287BRIEF COMMUNICATIONS

[2] Rosenberg T, Pariente G, Sergienko R, Wiznitzer A, Sheiner E. Critical analysis ofrisk factors and outcome of placenta previa. Arch Gynecol Obstet 2011;284(1):47-51.

[3] N'guessan K, Kouakou F, Loué V, Angoi V, Abauleth Y, Boni S. Placenta praevia:maternal and featal prognosis inUniversity Hospital of Cocody (Abidjan-Cote d'Ivoire).Mali Med 2009;24(2):57-9.

[4] Gurol-Urganci I, Cromwell DA, Edozien LC, Smith GC, Onwere C, Mahmood TA,et al. Risk of placenta previa in second birth after first birth cesarean section: apopulation-based study and meta-analysis. BMC Pregnancy Childbirth 2011;11:95.

0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijgo.2012.10.013

Prevalence of and factors affecting female genital mutilation among schoolgirlsin Eastern Sudan

Abdel Aziem A. Ali a,⁎, Amira Okud a, Abdalla A. Mohammed a, Mutaz A. Abdelhadi b

a Department of Obstetrics and Gynecology, Faculty of Medicine, Kassala University, Kassala, Sudanb Ministry of Health, Kassala State, Sudan

a r t i c l e i n f o

Article history:Received 8 August 2012Received in revised form 28 September 2012Accepted 13 November 2012

Keywords:AdolescentsFemale genital mutilationHuman rightsSudan

Female genital mutilation (FGM) is a violation of human and childrights and is outlawed in many countries [1]. Sudan has a very highprevalence of FGM, ranging between 87% and 100%) [2]. In Sudan,girls typically undergo the practice between the age of 6 and 12 yearsand the cutting is always performed by midwives.

A cross-sectional schools survey was conducted to investigate theprevalence rate of FGM and associated factors among schoolgirls inKassala, Eastern Sudan, between May and June 2012. Eight schoolswere randomly selected and 972 girls were enrolled, none of whomrefused to participate in the study. The study received ethical clearancefrom the Research Board at theMinistry of Health Kassala State, EasternSudan. Sociodemographic data, including presence of a circumcisedsister and presence of a living grandmother were gathered. Univariateand multivariate analyses were performed. FGM was the dependentvariable and sociodemographic characteristics were independent vari-ables. Pb0.05 was considered significant.

The mean age of the 972 participants was 14±4.6 years (range,9–16 years). Of the 972 girls, 810 had been circumcised, for a preva-lence rate of FGM of 83.3%. Hadandawa, Biniamir, and other tribescomprised 15.0% (146/972), 40.4% (393/972), and 44.5% (433/972)of the study participants, respectively. The mean age at cutting ofthe circumcised girls was 6.1±1.0 years (range, 4–8 years).

Using logistic regression, while residence, parents' occupation,and ethnicity were not associated with FGM (P>0.05), mother's

education less than secondary level (OR 1.5; 95% CI,1.0–2.2; P=0.02), father's education less than secondary level (OR 2.3; 95% CI,1.5–3.4, Pb0.01), presence of a circumcised sister (OR 4.3; 95% CI,3.1–5.9, Pb0.01), and presence of a living grandmother (OR 7.1; 95%CI, 4.6–10.8; Pb0.01) were associated with FGM (Table 1).

Despite being unable to categorize FGM by type, the present dataindicate that there is no decline in the practice in Sudan. FGM ishighly prevalent and still persists in Eastern Sudan. The prevalenceof FGM (83.3%) is higher than in other African countries that sharea similar cultural environment with Sudan (50.3% in neighboringEgypt and ranging between 23.3% and 45.2% in Nigeria), but is inagreement with reports from other African and Asian countries; forexample Eritrea, Djibouti, Mali, and Somalia, where the prevalencerate is more than 90% [3]. The government of Sudan is not takinga strong stand against female genital cutting and society acceptscircumcision as necessary and natural, and adopts this rationale forits existence [4].

In the present study, FGM among schoolgirls is strongly associatedwith parental education. Many studies have shown that the educa-tional status of women has a decisive influence on the practice ofFGM [5]. Likewise, a husband's education in many African countries,including the present study, is strongly associated with reproductivehealth services [5]. The level of illiteracy is high in Sudan and therewill be no success in reducing FGM without consideration of parental

⁎ Corresponding author at: P.O. Box 496, Department of Obstetrics and Gynecology,Faculty of Medicine, Kassala University, Kassala, Sudan. Tel.: +249 912163820;fax: +249 411823501.

E-mail address: abuzianab73@yahoo.com (A.A.A. Ali).

Table 1Factors affecting female genital mutilation in Eastern Sudan using univariate andmultivariate analyses.

Variable Univariate analyses Multivariate analyses

OR 95% CI P value OR 95% CI P value

Rural residence 0.7 0.5–1.0 0.1 1.0 0.7–1.6 0.7Ethnicity, Hadandawa tribe 1.0 0.8–1.3 0.8 1.0 0.7–1.3 0.8Mother's education, less thansecondary

1.5 1.0–2.1 0.01 1.5 1.0–2.2 0.02

Father's education, less thansecondary

1.7 1.2–2.5 0.001 2.3 1.5–3.4 b0.01

Mother's occupation, housewife 0.6 0.3–1.0 0.05 0.8 0.5–1.5 0.6Father's occupation, non-skilledworker

1.1 0.8–1.7 0.3 0.7 0.5–1.1 0.2

Presence of circumcised sister 3.0 2.3–3.9 0.00 4.3 3.1–5.9 b0.01Living grandmother 4.7 3.3–6.7 0.00 7.1 4.6–10.8 b0.01

Abbreviations: OR, odds ratio; CI, confidence interval.

288 BRIEF COMMUNICATIONS