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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 4  |  Page : 171-175

Preventing pregnancy among women with chronic illnesses: A study of the roles of non-gynecologists practicing in Zaria, Nigeria


Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Submission22-Sep-2019
Date of Acceptance12-Nov-2019
Date of Web Publication10-Feb-2020

Correspondence Address:
Dr. Afolabi K Koledade
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_29_19

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  Abstract 


Background: Women all over the world suffer from chronic illnesses such as hypertensive diseases, cardiac diseases, diabetes mellitus, mental illnesses, cancers, and HIV/AIDS. Unprotected sex in the presence of preserved fertility could lead to unplanned pregnancies that could pose additional challenges to the ongoing chronic morbidities especially in low-resource settings. We assess the knowledge of non-gynecologists on contraceptive requirements for women with chronic and debilitating illnesses and how these requirements are met within their practice.
Patients and Method: A cross-sectional descriptive study using a structured pretested and self-administered questionnaire, administered to non-gynecologists physicians providing care to chronically ill patients in Zaria, northern Nigeria. Data were collected, cleaned, and analyzed using IBM SPSS v19.0.
Results: The response rate was 71% (85). Most respondents (88.2%) practice in the teaching hospital and 77.8% (66) had at most 10 years of medical practice. The majority (92.9%) manage women of the reproductive age group (WRAG) with debilitating illnesses. Up to 95.3% (84) agreed that pregnancy affects the management of chronic or debilitating diseases, and 91.8% agreed that these women can benefit from modern contraceptive methods to delay or prevent pregnancies. 74.1% had diagnosed pregnancy among women they managed for chronic or debilitating diseases. Sixty six (76.6%) referred their patients to a contraceptive provider while 9.4% offered them contraception. Up to 51.8% are willing to be trained as counselors in contraception to improve their practice.
Conclusions: Training on counseling, especially in the form of Continuous Medical Education can help improve the capacity of non-gynecologists to offer contraceptive services in the context of chronic disorders among WRAG.

Keywords: Chronic illnesses, contraceptive, counseling, pregnancy


How to cite this article:
Koledade AK, Adaji SE, Madugu NH. Preventing pregnancy among women with chronic illnesses: A study of the roles of non-gynecologists practicing in Zaria, Nigeria. Arch Int Surg 2018;8:171-5

How to cite this URL:
Koledade AK, Adaji SE, Madugu NH. Preventing pregnancy among women with chronic illnesses: A study of the roles of non-gynecologists practicing in Zaria, Nigeria. Arch Int Surg [serial online] 2018 [cited 2020 Feb 25];8:171-5. Available from: http://www.archintsurg.org/text.asp?2018/8/4/171/278025




  Introduction Top


Women all over the world suffer from chronic illnesses, some of which are debilitating. Examples are hypertensive diseases, cardiac diseases, diabetes mellitus, mental illnesses, cancers, and HIV/AIDS. Most of these illnesses are not curable but treatable and are associated with improved survival and quality of life. Unprotected sex in the presence of preserved fertility could lead to pregnancies that are unplanned or unintended.[1] These pregnancies could pose additional challenges in women already struggling with ongoing chronic morbidities, especially in low-resource settings.[2]

A common medical condition that could predate pregnancy is hypertension. This condition is found among 1–6% of young women and up to 50% of them may become pregnant even when they desire to limit their families.[3],[4] Treatment is with antihypertensive and lifestyle modification, all of which aim to decrease cardiovascular risk. A clinician must not only be aware of a woman's method of contraception but also the potential of an antihypertensive agent to cause birth defects following inadvertent exposure in early pregnancy. It is also worthy to note that not all contraceptive methods are safe in hypertensive women.

There is a poor provision of family planning and prepregnancy advice for women with cardiac diseases.[5] Few cardiologists have practical knowledge of the interactions between complex heart disease, pregnancy, and contraception. Some women with the cardiac risk associated with pregnancy have been advised to undergo termination when the pregnancy could have been prevented in the first place. However, for each contraceptive method, the contraceptive efficacy and cardiovascular risks should be considered. Likewise, for each cardiac condition, the choice of contraceptive method depends on the cardiac risks associated with the method, the level of contraceptive efficacy required, and on the patient choice.[6] Advice from a multidisciplinary team of family planning clinicians, cardiologists, and obstetricians with appropriate specialist skills should equip women with the understanding to make their own decisions about planned future pregnancies or to adjust to the possibility of not having a pregnancy.[6]

About one in every 1000 pregnancies does coincide with cancer. Cancer most commonly diagnosed during pregnancy is breast cancer, followed by cervical cancer, then lymphoma and thyroid cancer. Less common are leukemia and melanoma.[7],[8] However, there are also those that become pregnant after the development of cancer. Often, these women are advised to terminate their pregnancies, depending on the stage of their cancer and their medical health. This also brings with it the sociocultural and religious challenges in addition to possible complications of abortion.

Hospital-based studies show a high level of contraception awareness as well as contraception prevalence of up to 81% among HIV positive women of reproductive age group (WRAG).[9],[10],[11] This is not surprising as most hospitals have various intervention programs including prevention of mother to child transmission which lay emphasis on contraception including dual protection. The values may be a lot less in the community especially among people who do not know their status and most likely would not be opportune to benefit from the various hospital-based intervention.

Pregnancy coexisting with chronic morbidity also pose challenges to health services as it could impose additional costs on services. Despite the fact that many women and health providers continue to contend with the consequences of pregnancy on women, their families, and health services, little information is available on the scale of the problem and how best to prevent such pregnancies or delay them in non-gynecologic settings until the patients' condition improves enough to cope with additional burden of such pregnancies. To prevent such pregnancies, there is a need for the health personnel to offer their patients some form of contraceptive services or pathway to contraceptive use.[3],[4],[12],[13]

This study is intended to assess the knowledge, attitude, and practice of non-gynecologists who manage such patients on pregnancy prevention. The study is a necessary initial step to generate baseline information that could be used to improve the capacity to address contraceptive needs in the context of chronic morbidity.


  Patients and Method Top


This is a cross-sectional descriptive study. The study population consists of non-gynecology health care providers working in settings where the care is offered to chronically ill patients within the Zaria metropolis. Participants were randomly selected at the Ahmadu Bello University Teaching Hospital, Hajia Gambo Sawaba General Hospital, and some private hospitals all in Zaria, northern Nigeria and entered into the study following consent. A structured questionnaire was developed, piloted, and self-administered. Data were collected by trained data collectors, entered into SPSS statistical software (IBM SPSS version 19.0 Armonk NY: IBM Corp.), cleaned, and analyzed.


  Results Top


Out of 120 questionnaires that were served, only 85 (70.8%) were filled and returned. The majority (75 [88.2%]) of the respondents were males. Distribution of the respondents by ethnicity revealed Hausa 13 (15.3%), Ibo 10 (11.3%), Yoruba 22 (25.9%) while the minority tribes mostly from the north constituted the majority of 40 (47.1%). It was found that 54 (63.5%) were of the Christian faith while 31 (36.5%) were of Islam. 75 (88.2%) of the respondents' practice in the teaching hospital [Figure 1]. Fifty-one (60%) of the respondents had their age range between 31 and 40 years and 63 (74.1%) had at most 10 years of medical practice experience [Figure 2], [Figure 3]. The spread of specialization includes surgery, internal medicine, laboratory medicine, maxillofacial surgery, psychiatry, and ophthalmology among others. 79 (92.9%) manage WRAG with debilitating illnesses. Up to 48 (56.5%) manage such cases daily while 17 (20%) get to manage them once weekly. The study showed that 81 (95.3%) of the respondents agree that pregnancy affects the management of the chronic or debilitating diseases and 78 (91.8%) agree that these women can benefit from modern family planning methods to delay or prevent pregnancies. Sixty-three (74.1%) confessed that their patient had gotten pregnant while they were being managed for chronic or debilitating diseases.
Figure 1: Place of practice

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Figure 2: Age range of respondents (years)

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Figure 3: Years of medical practice

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Sixty respondents (70.6%) have counseled such women for contraception. However, 74 (87%) refer these women to a gynecologist or a family planning provider for contraception, 8 (9.4%) offer them contraception, while 3 (3.5%) do nothing. Up to 76 (89.4%) of the respondents agree that counseling on contraception improves the quality of care offered by female patients with chronic debilitating illness within the reproductive age group. Seventy-three (85.9%) would consider contraception as a part of the management of these women; however, 43 (50.6%) do not have counseling skills. Up to 44 (51.8%) are willing to be trained as counselors in contraception to improve their practice. However, after counseling, 71 (83.5%) would rather refer the patient to a gynecologist while about 6 (7.1%) would institute the contraception method themselves.


  Discussion Top


It is not surprising that the majority of the respondents practice in the teaching hospital which serves as a referral center for specialist care and also postgraduate medical training. Hence the management of WRAG with debilitating illnesses constitutes a major part of their consultation.

Almost all the respondents are of the opinion that pregnancy adversely affects the management of chronic and debilitating diseases and that modern contraceptive methods are helpful in preventing these, and therefore, improve the quality of care given. This opinion cuts across the influence of ethnicity, culture, or religious beliefs. However, the unmet need among their patients was still as high as 74.1% despite counseling and referral to gynecologist or family planning providers for contraception. This suggests that either the counseling is either deficient or the patient is not motivated enough to present for family planning services. Up to 51% confessed to not having counseling skills.

It is noteworthy that almost all non-gynecologists 79 (92.9%) respondents irrespective of their specialties or interest manage women in the reproductive age group with one form of debilitating illness or the other and 48 (56.5%) do this daily. Despite the high knowledge of the possibility of pregnancy while managing these patients with the accompanying complexity it brings and even the experience of having to co-manage such debilitating illness with pregnancy in 63 (74.1%) of the respondents, 60 (70.6%) have ever given such contraceptive counseling but most 74 (87%) would rather refer patients to gynecologists or contraceptive providers for contraception. It appears the patients do not make it to the gynecologists after the counseling hence the high unmet need amongst them. This may be due to suboptimal counseling as up to 44 (51.8%) are willing to be trained as counselors in contraception, suggesting most of them never had formal training for the counseling they have been offering. Also to increase uptake amongst these groups of women integrated management where their primary caregiver is properly trained in contraception counseling may go a long way in reducing the non-compliance with referral to gynecologists for contraceptive services.

Trained counselors are likely to use the right techniques and skills to get better results.[14] This would lead to optimal uptake of appropriate contraceptive methods among clients either directly from primary healthcare giver managing the chronic illness or from the gynecologists and other contraceptive providers when the patients are referred.

For example, a skilled and well-trained contraception counselor would ensure a woman diagnosed with cancer should not be encouraged to opt for combined oral contraceptive pills which contains estrogen that may further increase the risk of venous thromboembolism. Patients with breast cancer would do well with a highly effective, long-acting reversible nonhormonal method such as the copper T380A while levonorgestrel may be preferred for patients on tamoxifen as it decreases endometrial proliferation.[15],[16] Likewise, nonhormonal contraceptive methods are beneficial for patients with cardiac diseases. Barrier methods additionally protect against sexually transmitted infections but overall nonhormonal IUD, as well as tubal ligation, are also invaluable for these patients.[17],[18] 73 (85.9%) of the respondents see the importance of contraception and would consider it as part of the management of these women. Here lies the opportunity to include contraceptive counseling when managing WRAG in the various curricula or at least in the form of continuous medical education.


  Recommendations Top


Training of non-gynecologist medical practitioners who manage patients with the chronic and debilitating disease in contraceptive counseling would help reduce unmet needs amongst these patients and, therefore, improve the quality of care given. This can be achieved by incorporating contraceptive counseling into continuous medical education for non-gynecologists or making reproductive health counselors available at various non-gynecological clinics where chronic debilitating illnesses are being managed to identify and give appropriate counseling to WRAG. This would particularly help reduce the rate of loss or noncompliance to referral as counseling is done on the spot at the place of primary health caregiver as a one-stop comprehensive care.

WRAG with the chronic and debilitating disease can be co-managed with the gynecologist who would address their reproductive health needs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McEvoy JP, Hatcher A, Appelbaum PS, Abernethy V. Chronic Schizophrenic women's attitudes toward sex, pregnancy, birth control, and childrearing. Hosp Community Psychiatry 1983;34:536-9.  Back to cited text no. 1
    
2.
Muhuhu P. Family planning: An integral part of mental health care. J Famil Health Train 1982;1:7-9.  Back to cited text no. 2
    
3.
Magee LA. Treating hypertension in women of child-bearing age and during pregnancy. Drug Saf 2001;24:457-74.  Back to cited text no. 3
    
4.
Rachael James P, Nelson-Piercy C. Management of hypertension before, during and after pregnancy. Heart2004;90;1499-504.  Back to cited text no. 4
    
5.
Leonard H, O'Sullivan JJ, Hunter S. Family planning requirements in the adult congenital heart disease clinic. Heart 1996;76:60-2.  Back to cited text no. 5
    
6.
Thorne S, MacGregor A, Nelson-Piercy C. Risk of contraception and pregnancy in heart disease. Heart2006;92:1520-5.  Back to cited text no. 6
    
7.
Saeed Z., Shafi M. Cancer in Pregnancy. Elsevier Obstetrics, Gynaecology and Reproductive Medicine 2011;21:7:183-9.  Back to cited text no. 7
    
8.
Breast Cancer Treatment and Pregnancy. (PDQ). Health Professional Version. U.S. National Institute s of Health. Available from: www.cancer.gov.  Back to cited text no. 8
    
9.
Ogbe AE, Mutihir JT. Pattern of contraception among HIV positive women in Jos University teaching hospital. Niger J Med 2012;21:11-5.  Back to cited text no. 9
    
10.
Ezugwu EC, Nkwo PO, Agu PU, Ugwu EO, Asogwa AO. Contraceptive use among HIV-positive women in Enugu, Southeast Nigeria. Int J Gynaecol Obstet 2014;126:14-7.  Back to cited text no. 10
    
11.
Enyindah CE, Enaohwo BO. Contraceptive prevalence and pattern among HIV positive women in Port Harcout, South-South Nigeria. Int J Reprod Contracept 2012;23:186-92.  Back to cited text no. 11
    
12.
Skouby SO, Melsted-Pedersen L, Petersen KR Contraception for women with diabetes: An update. Baillieres Clin Obstet Gynaecol. 1991;5:493-503.  Back to cited text no. 12
    
13.
Holing EV, Beyer CS, Brown ZA, Connnell FA. Why don't women with diabetes plan their pregnancies? Diabetes Care 1998;21:889-95.  Back to cited text no. 13
    
14.
Zapata LB, Pazol K, Dehlendorf C, Curtis KM, Malcom NM, Rosmarin RB, et al. Contraceptive counseling in clinical settings: An updated systematic review. Am J Prev Med 2018;55:677-90.  Back to cited text no. 14
    
15.
Mody SK, Panelle DM, Hulugalle A, Su HI, Gorman JR. Contraceptive concerns, utilization and counseling needs of women with a history of breast cancer: A qualitative study. Int J Womens Health 2017;9:507-12.  Back to cited text no. 15
    
16.
Society of Family Planning Clinical Guidelines: Cancer and contraception. Contraception 2012;86:191-8.  Back to cited text no. 16
    
17.
Roos-Hesselink JW, Cornette J, Sliwa K, Pieper PG, Veldtman GR, Johnson MR. contraception and cardiovascular disease. Eur Heart J 2015;36:1728-34.  Back to cited text no. 17
    
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Jakes AD, Coad F, Nelson-Piercy C. A review of contraceptive methods for women with cardiac disease. Obstet Gynaecol 2018;20:21-9.  Back to cited text no. 18
    


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