Babatunde Ahonsi

Population Council, New York City, New York, United States

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Publications (23)58.89 Total impact

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    ABSTRACT: A total of 385 drug users (9% females and 91% males) with mean age of 30 years were interviewed. • More than 94% injected drugs in the last 12 months. • Mean age of drug use debut was 15.4 years, while mean duration of drugs use was 15 years. • Types of drugs injected included heroine (30%), cocaine (24%), amphetamine (8%), crack (10.4%), and pentazocine (39.2%) (Figure 1). • Over 80% of heroin users and 72.3% of cocaine users, had unprotected sex with a casual partner in the last 6 months. • About 28% of drug users experienced one form of STIs in the last 6 months. • Logistic regression analysis showed that amphetamine users were 11 times more likely to have a STI (Adjusted OR = 11.52, 95%CI = 4.27–31.10) followed by heroin users (Adjusted OR = 4.99, 95% CI=2.46– 10.13), and pentazocine users (Adjusted OR = 2.86, 95% CI=1.41–5.81) (Table 1). • Furthermore, clients who ever married were 7 times more likely to report STIs (Adjusted OR = 7.05, 95% CI = 2.08–23.86) (Table 1).
    HIV Research for Prevention, Capetown, South Africa; 10/2014
  • AIDS research and human retroviruses. 10/2014; 30 Suppl 1:A114.
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    AIDS research and human retroviruses. 10/2014; 30 Suppl 1:A277-8.
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    ABSTRACT: Face-to-face (FTF) interviews are the most frequently used means of obtaining information on sexual and drug injecting behaviours from men who have sex with men (MSM) and men who inject drugs (MWID). However, accurate information on these behaviours may be difficult to elicit because of sociocultural hostility towards these populations and the criminalization associated with these behaviours. Audio computer assisted self-interview (ACASI) is an interviewing technique that may mitigate social desirability bias in this context. This study evaluated differences in the reporting of HIV-related risky behaviours by MSM and MWID using ACASI and FTF interviews. Between August and September 2010, 712 MSM and 328 MWID in Nigeria were randomized to either ACASI or FTF interview for completion of a behavioural survey that included questions on sensitive sexual and injecting risk behaviours. Data were analyzed separately for MSM and MWID. Logistic regression was run for each behaviour as a dependent variable to determine differences in reporting methods. MSM interviewed via ACASI reported significantly higher risky behaviours with both women (multiple female sexual partners 51% vs. 43%, p = 0.04; had unprotected anal sex with women 72% vs. 57%, p = 0.05) and men (multiple male sex partners 70% vs. 54%, p≤0.001) than through FTF. Additionally, they were more likely to self-identify as homosexual (AOR: 3.3, 95%CI:2.4-4.6) and report drug use in the past 12 months (AOR:40.0, 95%CI: 9.6-166.0). MWID interviewed with ACASI were more likely to report needle sharing (AOR:3.3, 95%CI:1.2-8.9) and re-use (AOR:2.2, 95%CI:1.2-3.9) in the past month and prior HIV testing (AOR:1.6, 95%CI 1.02-2.5). The feasibility of using ACASI in studies and clinics targeting key populations in Nigeria must be explored to increase the likelihood of obtaining more accurate data on high risk behaviours to inform improved risk reduction strategies that reduce HIV transmission.
    PLoS ONE 01/2014; 9(1):e81981. · 3.53 Impact Factor
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    ABSTRACT: Distribution of Cost and Determinants of Effectiveness in Provision of HIV Testing and Counselling (HTC) for Male MARPs in Nigeria. Background HIV testing and counselling (HTC) remains the gateway to HIV prevention interventions and as countries scale-up towards universal access, priority backed with resource allocation should be given to aspects of HCT programmes that ensure value for money especially in resource poor settings. We evaluated the distribution of cost and determinants of effectiveness in the provision of HCT for male most-at-risk-population (MMARPs) (men who have sex with men (MSM) and men who inject drugs (MWID) in Nigeria. Methods MSM and MWID were provided with HTC through the Men’s Health Network, Nigeria (MHNN), an HIV prevention intervention between July 2009 and July 2012. Financial costs of providing HCT were estimated from a health provider perspective and classified as capital (rent, furniture, equipment) or recurrent (personnel, stationery, supplies, meetings, monitoring, etc) costs. Effectiveness was measured as the number of clients who tested positive to HIV. Exploratory analyses were conducted to test for the assumption of normal distribution. Variables with skewed distribution were logarithmized to the base of 10. Multiple linear regression analysis was conducted to determine the best linear combination of cost components for reaching HIV positive male MARPs. The dependent variable was the number of male MARPs that tested positive to HIV during the period, while the independent variables were the following cost components: (1) Personnel; (2) Workshops and Meetings; (3) Utilities; (4) Advocacy; (5) Supplies; (6) Promotional materials and incentives; (7) Training; and Monitoring & Evaluation [M&E]. Results: A total of $295,126.23 was spent in providing HTC for 31,609 MMARPs among whom 2,510 tested positive to HIV. More than half (54.1%) was spent on personnel; 14% on workshops and meetings, 11.4% on utilities and 9.2% on M&E. The multiple linear regression analysis generated a model that significantly predicted the number of HIV positive male MARPs reached, F (2, 24) =7.60, p< 0.01 and explained about 34% of the variance in the number of HIV positive male MARPs reached. The model retained the cost (Log10) of promotional materials and the cost (Log10) of M&E but only the cost (log10) of M&E significantly contributed to the prediction (β=0.49, p=0.016). Thus, for every unit increase in the cost (Log10) of M&E, there was a significant 2.4 times increase in the number (Log10) of male MARPs who tested positive to HIV during the period. Conclusion Although personnel cost is over half of the total average cost of the program, it was not significant in increasing the number of Male MARPS who tested positive to HIV contrary to M&E which as a component is rather small. Our study therefore shows that marginal increase in spending on M&E can significantly contribute to program effectiveness especially among male MARPS, who in our context are a hidden population. Designing interventions targeting male MARPS with this in mind could be useful in informing efficient resource allocation to program components that will reduce wastes and ensure achievement of desired results, especially in similar resource poor settings. Further research is required to determine how M&E directly affects program effectiveness.
    17th International Conference on AIDS and Sexually Transmitted Infections in Africa, Cape Town, South Africa; 12/2013
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    ABSTRACT: Estimating the size of populations most affected by HIV such as men who have sex with men (MSM) though crucial for structuring responses to the epidemic presents significant challenges, especially in a developing society. Using capture-recapture methodology, the size of MSM-SW in Nigeria was estimated in three major cities (Lagos, Kano and Port Harcourt) between July and December 2009. Following interviews with key informants, locations and times when MSM-SW were available to male clients were mapped and designated as "hotspots". Counts were conducted on two consecutive weekends. Population estimates were computed using a standardized Lincoln formula. Fifty-six hotspots were identified in Kano, 38 in Lagos and 42 in Port Harcourt. On a given weekend night, Port Harcourt had the largest estimated population of MSM sex workers, 723 (95% CI: 594-892) followed by Lagos state with 620 (95%CI: 517-724) and Kano state with 353 (95%CI: 332-373). This study documents a large population of MSM-SW in 3 Nigerian cities where higher HIV prevalence among MSM compared to the general population has been documented. Research and programming are needed to better understand and address the health vulnerabilities that MSM-SW and their clients face.
    African Journal of Reproductive Health 12/2013; 17(4 Spec No):83-9.
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    ABSTRACT: There is little research on injecting drug use in Nigeria. We investigated the prevalence of HIV, hepatitis B and C, and sexually transmitted infections (STIs) among male injection drug users (IDUs) in Lagos. Male IDUs (N 328) were recruited through respondent-driven sampling. Participants completed an interview about their sexual and injecting risk behaviours and were tested for hepatitis B surface antigen (HBV), hepatitis C antibody (HCV), HIV and syphilis, as well as genital chlamydia and gonorrhoea infections. Three-quarters of IDUs (74) reported injecting drugs in the past one month although most did not share needles (92) and the majority obtained sterile needles from pharmacists (87). Estimated HBV, HCV, HIV, syphilis, gonorrhoea and chlamydia prevalences were 7.8, 7.7, 0.9, 1.9, 0.0, and 3.7, respectively. The burden of HIV is presently low among IDUs in Lagos. Changes in accessibility to sterile needles at pharmacists would likely have a deleterious effect on IDUs' health. HBV vaccination and HCV prevention programmes for IDUs are urgently needed.
    International Journal of STD & AIDS 07/2013; · 1.00 Impact Factor
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    ABSTRACT: Background: Evidence has shown that Magne-sium Sulphate (MgSo 4) is the gold standard for treating severe pre-eclampsia and eclampsia (SPE/E), and calls for its widespread use at all levels of health service delivery, including the primary care level. Objective: To determine if ad-ministering loading dose of MgSo 4 on pregnant women with severe preeclampsia and eclampsia at primary care level would improve maternal and fetal outcomes. Method: Two sets of Primary Health Care (PHC) facilities were identified; one served as experimental one and the other as control. The community health extension workers (CHEWs) and the community health officers (CHOs) at the experimental PHCs were trained to administer the loading dose of MgSo 4 for patients with SPE/E, in addition to other supportive treat-ments, before making a referral while the control PHCs did not give MgSo 4 , and neither adminis-tered diazepam as an alternative or no anti-con-vulsant at all, before making a referral to higher centers. Patients from the experimental and con-trol facilities were prospectively monitored for fetal and maternal outcomes, namely maternal and fetal deaths, and for toxic effects of MgSo 4 in the experimental arm. Results: Of the 150 pa-tients recruited, 82 (55%) were in the experimen-tal group and 68 (45%) were in the control group. 90% of the patients in the experimental group defaulted after receiving the loading dose of MgSo 4 while the remaining 10% completed the referral process. 44% of those in the control group completed the referral process. There were 3 maternal and 3 perinatal deaths, all in the control group. No adverse outcome (maternal or fetal death) or toxic effect was recorded among the recipients of MgSo 4 . Conclusion: This study suggests that lower-cadre health care profes-sionals at PHCs can administer the loading dose of MgSo 4 to SPE/E patients to improve maternal and fetal survival in critical states, without sig-nificant risk of adverse effects. However, the lack of compliance with referral processes remains a huge challenge.
    07/2013; 5:1461-1466.
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    ABSTRACT: Background HIV counseling and testing (HCT) remains the cornerstone of HIV programming and given the reduced donor funds for HIV services, it is imperative to use the most cost effective methods. We evaluated the cost-effectiveness of three HCT strategies for male most-at-risk-population (M-MARPS) in Nigeria. Methods Three HCT strategies were implemented between July 2009 and July 2012 among men who have sex with men (MSM) and injecting drug users (IDUs). The first strategy (S1) was facility based with community mobilization component using key opinion leaders (KOLs). The second strategy (S2) involved KOLs referring M-MARPS to nearby mobile HCT teams, while the third strategy (S3) involved mobile M-MARPS peers conducting HCT. Cost and output data for HCT services were retrospectively collected from financial and program records. Financial costs of providing HCT were estimated from a health provider perspective and classified as capital or recurrent costs. Variation in duration of each strategy was controlled by using the last six months of each strategy. Effectiveness was measured as the number of HIV positive clients per strategy while Incremental Cost Effective Ratio (ICER) was calculated using S1 as the base model. The strategy with the lowest ICER was considered most cost-effective. Results A total of 1,988, 14,726 and 14,895 male MARPs received HCT through the S1, S2 and S3 methods respectively with the proportion of first time testers being 88%, 84% and 90%. HIV prevalence (effectiveness) was 9%, 3%, and 13% respectively. The average cost for delivering HCT per client after controlling for variation in duration was $41 for S1, $9 for S2 and $6 for S3. ICER for S2 and S3 were 204 and 3 respectively. Conclusion Peer mediated HIV Counseling and Testing (S3) was the most cost effective method in providing HCT to M-MARPS as well as in reaching first time testers and identifying HIV positive clients. Our study highlights the feasibility of training MARPS in providing HCT services on a large-scale. Engaging members of a target community is essential in optimizing the cost and delivery of HCT to M-MARPs in Nigeria.
    IAS 2013, Malaysia; 07/2013
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    ABSTRACT: Background Some studies have shown that greater perceived vulnerability to HIV is associated with less involvement in risk taking. We evaluated prevalence and correlates of HIV risk perception among men who have sex with men (MSM) in Nigeria. Methods A cross sectional study using respondent driven sampling (RDS) was conducted in six Nigerian states in 2010. MSM underwent interviewer-administered surveys. HIV risk perception was assessed as a binary outcome with "0/1" assigned to those whose response was "no risk"/"yes, feel at risk" respectively. Weighted HIV risk perception and sexual risk behaviors were calculated using an RDS analytic tool. Logistic regression was used to determine correlates of HIV risk perception, stratified by state. Results The total number of MSM ranged from 217 in Abuja to 314 in Cross River state. Median age ranged from 22 years in Cross River state to 26 years in Kano. Less than two-fifths had comprehensive knowledge of HIV. Median age of sexual debut was <18 years except for Kano and Oyo states. HIV risk perception ranged from 10% in Cross River state to 58% in Kaduna state and was 38%, 44%, 19% and 20% in Kano, Lagos, Abuja and Oyo states respectively. HIV risk perception was significantly higher among those who had ever had an HIV test compared to those that had never had an HIV test in Cross River (14% vs.4.1%;p=0.002), FCT (28%vs.14%;p=0.023), Kano (63% vs.11%;p<0.001), Lagos (58% vs.28%;p ≤0.001) and Oyo states (36% vs.13%;p ≤0.001). Factors associated with HIV risk perception include purchasing sex (AOR:3.1, 95% CI:1.00-9.38) and no exposure to peer educator (AOR:0.2, 95% CI:0.04-0.61) in Cross River; no comprehensive knowledge of HIV (AOR:0.22, 95% CI:0.1-0.7) and receptive anal partners (AOR:8.9, 95% CI:2.1-37.8) in Abuja; attaining at least secondary level education in Kano (AOR:4.5, 95% CI:1.8-11.5); no comprehensive HIV knowledge (AOR:2.6, 95% CI:1.0-6.7) in Lagos and selling sex (AOR:4.7, 95% CI:1.4-16.2) in Oyo state. Conclusion This study shows that HIV risk perception and comprehensive HIV knowledge are very low among MSM in Nigeria. Heterogeneity in associated factors suggests that targeted interventions are needed to increase HIV risk perception in the different states. The role of HCT in increasing risk perception needs further evaluation.
    IAS 2013, Malaysia; 07/2013
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    ABSTRACT: Objective: Injecting drug use is now recognized as a significant risk factor for HIV in sub- Saharan Africa. We evaluated prevalence and correlates of HIV among young (18-24 years) injecting drug users (IDUs) in Nigeria. Methods: A cross sectional study using respondent driven sampling (RDS) was conducted in five Nigerian states in 2010. Current IDUs underwent interviewer-administered surveys and HIV tests. Logistic regression was used to determine correlates of HIV infection, stratified by state. Results: Total numbers of IDUs ranged from 43 in Oyo to 84 in Cross River state (CR). Median duration of injecting drug ranged from 2 months in Federal Capital Territory (FCT) to 24 months in Kano. HIV prevalence was highest in Kano (4.8%) and was 2.4% Kaduna, Oyo 4.7%, FCT 2.5% and CR 3.6%. Prevalence of all injecting risk behaviors was highest in FCT, ranging from 22% to 79% for use of prefilled syringe and sharing of needles, respectively. Over 80% of respondents were sexually active but consistent condom use was less than 50% with girlfriends and less than 70% during casual sex. Injecting risk behaviors were not associated with HIV in all states surveyed Conclusions: Median duration of injecting drugs was 24 months suggesting that majority of the respondents were relatively new injectors. HIV prevalence, though low, was higher than national estimates (4.1%) in Kano and Kaduna. Efforts must be geared towards preventing the initiation of drug use and managing new initiators . Additionally, HIV prevention intervention must focus on both injecting and sexual risk behaviors among youth. Further research is needed to understand the HIV transmission dynamics among young IDUs.
    Harm Reduction, Lithuania; 06/2013
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    ABSTRACT: Background: Alcohol has been associated with risky sexual behavior. Comprehensive data on the impact of alcohol on risky behaviors among female sex workers in Nigeria is lacking. We estimated frequency of alcohol use and risk behaviors among female sex workers in Nigeria. Methods: Data on female sex workers were collected from Integrated Biological and Behavioral Surveillance (IBBSS) in 9 cities in Nigeria in 2010 and evaluated in a cross sectional analysis. Chi square tests of comparison for differences between categorical variables and logistic regression analyses were conducted. Results: Of total of 4,394 FSWs surveyed, 49% were less than 25 years, 8% were currently married and 42% had at least primary level education. Prevalence of alcohol use was 77% with daily use of alcohol at 27%. HIV prevalence was 25% and alcohol use was higher among HIV negative FSWs (27% vs. 24%;p≤0.01). Daily use of alcohol was highest (35%) among those who never used a condom with their boyfriends compared to those who used condoms occasionally (28%) and those who used every time (25%), p≤0.001, however for consistent condom use with clients, daily use of alcohol was highest among those who used a condom every time (29%) compared to occasional condom use (25%) and those who never use a condom (14%; p ≤ 0.01). Daily alcohol consumption was significantly associated with consistent condom use with clients (AOR:1.5, 95%CI:1.15-1.90;p=0.002) and inconsistent condom use condom use with boyfriends. Conclusion: Daily alcohol use among FSWs is moderate, however its association with inconsistent condom use with boyfriends suggests an urgent need for HIV prevention programs addressing alcohol use both to mitigate the transmission of HIV within FSWs and the general population and also the medical complications of heavy alcohol use. Further research is needed to evaluate drug use and risk behaviors in Nigeria.
    Harm Reduction 2013, Lithuania; 06/2013
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    ABSTRACT: BACKGROUND:: This study provides population-based estimates of HIV prevalence and factors associated with HIV infection among MSM in three large cities in Nigeria. We aimed to increase the knowledge base of the evolving HIV epidemic among MSM, highlight risk factors that may fuel the epidemic, and inform future HIV prevention packages. METHODS:: A total of 712 MSM, aged 18 and older, living in Abuja, Ibadan and Lagos were recruited using respondent-driven sampling. Participants completed a behavioral questionnaire and tested for HIV. Population-based estimates were obtained using RDSAT software. Factors associated with HIV infection were ascertained using multiple logistic regression, adjusting for RDSAT individualized weights. RESULTS:: A high proportion of MSM reported high-risk behaviors, including unprotected anal sex with men (30-50%), unprotected vaginal sex with women (40%), bisexual behavior (30-45%) and never been tested for HIV (40-55%). The population-based estimates of HIV among MSM in the 3 cities were 34.9%, 11.3% and 15.2%, respectively. In Abuja, HIV was significantly associated with unprotected sex and transactional sex. In Ibadan, HIV was significantly associated with unprotected sex and self-identified bisexual. In Lagos, HIV was significantly associated with older age. CONCLUSION:: HIV prevalence among MSM in the three cities was 4 to 10 times higher than the general population prevalence and was behaviorally linked. In response to a complex set of risks and disadvantages that put African MSM at a greater risk of HIV infection, future interventions targeting MSM should focus on a comprehensive approach that combines behavioral, biomedical and structural interventions.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 02/2013; · 4.65 Impact Factor
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    ABSTRACT: This study assessed the level of internalized homophobia and associated factors among men who have sex with men (MSM) in Nigeria. Using respondent driven sampling, MSM were recruited in Lagos and Ibadan between July and September, 2006. Internalized homophobia was assessed as a negative composite score using an 11-item scale. A total of 1,125 MSM were interviewed. About 44.4% self-identified as homosexual or gay while 55% regarded themselves as bisexual. About a third of the respondents reported internalized homophobia. With homosexual/gay men as reference, respondents who self-identified as bisexual were two times more likely [AOR 2.1; 95 CI: 1.6 - 2.9, p < 0.001] to report internalized homophobia. Those who were HIV positive were also twice as likely to report internalized homophobia compared to those who were HIV negative [AOR 1.8; 95% CI: 1.2 - 2.7, p = 0.004]. As internalized homophobia impedes acceptance of HIV prevention programming, identifying MSM who experience internalized homophobia is integral to the success of HIV prevention programming in Nigeria.
    African Journal of Reproductive Health 12/2012; 16(4):21-8.
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    ABSTRACT: The aim of this study was to evaluate whether a new low-cost strategy for the introduction of magnesium sulphate (MgSO(4)) for preeclampsia and eclampsia in low-resource areas will result in improved maternal and perinatal outcomes. Doctors and midwives from ten hospitals in Kano, Nigeria, were trained on the use of MgSO(4). The trained health workers later conducted step-down trainings at their health facilities. MgSO(4), treatment protocol, patella hammer, and calcium gluconate were then supplied to the hospitals. Data was collected through structured data forms. The data was analyzed using SPSS software. From February 2008 to January 2009, 1,045 patients with severe preeclampsia and eclampsia were treated. The case fatality rate for severe preeclampsia and eclampsia fell from 20.9 % (95 % CI 18.7-23.2) to 2.3 % (95 % CI 1.5-3.5). The perinatal mortality rate was 12.3 % as compared to 35.3 % in a center using diazepam. Introduction of MgSO(4) in low-resource settings led to improved maternal and fetal outcomes in patients presenting with severe pre-eclampsia and eclampsia. Training of health workers on updated evidence-based interventions and providing an enabling environment for their practice are important components to the attainment of the Millenium Development Goals (MDG) in developing countries.
    Maternal and Child Health Journal 09/2012; · 2.24 Impact Factor
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    ABSTRACT: BACKGROUND:: Female sex workers (FSWs) account for about 20% of new HIV infections in Nigeria. We estimated the change in HIV prevalence and sexual risk behaviors between two consecutive rounds of integrated biological and behavioral surveillance surveys (IBBSS) and determined correlates of HIV transmission among FSWs. METHODS:: In 2007 and 2010, HIV prevalence and risk behavior data on brothel-based (BB) and non brothel-based (NBB) FSWs from the IBBSS were evaluated in 6 Nigerian states. Logistic regression was used to identify correlates of HIV infection. RESULTS:: A total of 2897 and 2963 FSWs were surveyed in 2007 and 2010, respectively. Overall HIV prevalence decreased in 2010 compared to 2007 [20% vs. 33%; p<0.001], with similar magnitude of declines among BB-FSW [23% vs. 37%; p<0.0001] and NBB-FSW [16% vs. 28%; p<0.0001]. Consistent condom use with boyfriends in the last 12 months was lower in 2010 compared to 2007 overall [23% vs. 25%; p=0.02] and among BB-FSWs [17% vs. 23%;p<0.01] while NBB-FSWs showed a marginal increase [30% vs. 27%;p=0.08]. FSWs residing in the Federal Capital Territory [AOR:1.74 (1.34 - 2.27)] and Kano state [AOR:2.07(1.59 - 2.70)] were more likely to be HIV-positive while FSWs recruited in 2010 [AOR:0.81(0.77 - 0.85)] and those who had completed secondary education [AOR:0.70(0.60 - 0.80)] were less likely to be HIV-positive. CONCLUSION:: Results suggest significant progress in reducing the burden of HIV among FSWs in Nigeria, although low condom use with boyfriends continued to be a potential bridge between FSWs and the general population. Venue-based prevention programs are needed to improve safer sex practices among BB-FSWs.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 08/2012; · 4.65 Impact Factor
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    ABSTRACT: Despite clear emphasis through the Millennium Development Goals, the problem of high maternal mortality persists especially within low and middle income countries. Various studies report remarkably high maternal mortality rates in northern Nigeria, where maternal mortality rates exceed 1,000 deaths per 100,000 live births and eclampsia contributes approximately 40% of maternal deaths. Across Nigeria, diazepam is routinely used for the management of eclampsia. Prior to February 2008, diazepam was widely used for the management of eclampsia in Kano State (within northern Nigeria) with case fatality rate being over 20%. While magnesium sulphate (MgSO4) is recognized as the most effective drug for the management of eclampsia; this study aims to compare MgSO4 therapy with diazepam therapy in terms of case fatality rates and costs. This retrospective study, including 1045 patients with eclampsia and pre-eclampsia during the years 2008 and 2009, reports a drop in case fatality rates from 20.9% (95% CI: 18.7, 23.2) to 2.3% (95% CI: 1.4, 3.2) among eclampsia patients following the MgSO4 intervention. The study observed no significant difference in the cost of using MgSO4 therapy compared to diazepam therapy. The study found a remarkable reduction in case fatality rate due to eclampsia in those who received MgSO4 therapy with minimal increase in costs when compared to diazepam therapy. Concerted efforts should be focused on properly introducing MgSO4 into emergency obstetric protocols especially within developing countries to reduce maternal mortality and also impact on health system performance.
    BMC Research Notes 08/2012; 5:421.