Int J Gynaecol Obstct 17: 290-293, 1979
Dietary Iron Intake of Pregnant Nigerian Women with Anemia O. Ogunbode, 1 1. O. Akinyele 2 and M. A. Hussain 2 Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria Department of Human Nutrition, University of Ibadan, Ibadan, Nigeria
Ogunbode 0, Akinyele 10, Hussain MA (Dept of Obstetrics and Gynaecology, University College Hospital, Ibadan, and Dept of Human Nutrition, University of Ibadan, Ibadan, Nigeria). Dietary iron intake of pregnant Nigerian women with anemia. Int J Gynaecol Obslet 17: 290-293, 1979 The daily dietary iron intake of nine pregnant Nigerian women with confirmed iron deficiency anemia was determined. The daily dietary iron intake from hospital meals served to ten other pregnant women was also assessed to serve as a control. The mean daily iron intake of the group of anemic patients on home diet was 14.6 mg (range of individual means = 8.37-25.28 mg), whereas the group of patients served hospital meals had a mean daily dietary iron intake of 36.92 mg (range of individual means = 25.09-46.47 mg). It is, therefore, clear that the etiology of iron deficiency in the patients studied was mainly dietary. Thus, our pregnant patients, many of whom are on diets similar to those of the group studied, should receive iron supplements during pregnancy.
Investigations into the etiology of the iron deficiency strongly suggest undernutrition because the main characteristic of these anemic patients is that they belong to the low socioeconomic group. Social classification was made using Fleming's parameters (3). Patients were asked five questions and scored 0, 1 or 2, with the maximum score being 10 points. T h e questions concerned the woman's education, the education of her parents, her husband's education, his occupation and their place of residence. Patients were classified as " u p p e r " socioeconomic class (score = 6-10) and low socioeconomic class (score = 0-5). No significant association was found between anemia in pregnancy and any of the endemic parasitic infections, such as malaria and hookworm (13). T h e present study was, therefore, designed to estimate the average iron intake of patients with anemia during pregnancy. T h e dietary iron intake from Nigerian foods served to pregnant women at U C H was also determined to serve as a control.
INTRODUCTION
MATERIALS A N D M E T H O D S
Until recently, the main causes of anemia in pregnancy in Ibadan were identified as red cell hemolysis due to malaria (2, 7), dietary deficiency of folates (3, 4) and hemoglobinopathies (8). As a result of these reports, the antenatal routine at the University College Hospital (UCH) in Ibadan and most maternity centers that follow U C H practices is to give a prophylactic antimalarial agent (25 mg of pyrimethamine) weekly and 5 mg of folic acid daily to pregnant women. However, in the past few years, evidence has been accumulating that iron deficiency is also present in many of our patients with pregnancy anemia, particularly in those patients with mild to moderate degrees of anemia (1215).
Dietary histories were obtained from 64 patients whose iron deficiency anemia was confirmed using absence of iron in the marrow as the diagnostic index. T h e history of foods consumed and the frequency of their consumption were compared with the quality and variety of foods served to patients at U C H . Arrangements designed to estimate the dietary iron intake presented difficulties. Only a few patients were prepared to grant permission to visit their homes and make a record of the foods they ate. There was also the problem of getting these patients to present a true sample and quantity of the foods normally eaten. As a result, many patients could not be fully investigated.
ABSTRACT
Int J Gynaecol Obslet 17
Iron intake in anemic pregnant women
Food samples were collected and the amount consumed was estimated for only nine of the anemic patients over a period of four consecutive days to determine the daily intake of iron from their habitual diet. A research assistant visited the homes of these patients and, at each visit, weighed the individual item of food before and after each meal. A note was also made of the types of food eaten. Samples of food taken were collected in polyethylene bags. Foods served to the patients at U C H were similarly weighed and samples were obtained for iron content analysis. Samples were obtained from ten such pregnancy inpatients for four days. As soon as the foods were collected, they were weighed and transported to the laboratory of the UCH's Department of Nutrition for preparation before the determination of iron. Preparation involved blending whole diets in a quartz mortar with a pestle. After thorough mixing, the individual samples were placed in clean plastic plates and dried at 80 C in an air oven to a constant weight. The dried samples were then subsampled by weighing out, in duplicate, 2 gm into clean silica crucibles and then dried to constant weight in an air oven. This was immediately followed by dry ashing in a muffle furnace at 450 C for 16 hours. The residual white ash was dissolved in 2 ml of concentrated nitric acid and the solution was diluted with deionized water after it was transferred to a 250-ml standard flask. T w o milliliters of 5% lanthanum chloride solution was added and the solution was made u p to the 250-ml mark with deionized solutions. T h e iron content of the diets was then determined with the atomic absorption spectrophotometer (Perkin-Elmer model 305B, Perkin-Elmer Corp, Norwalk, C T , USA) and the appropriate hollow cathode lamp using a wavelength of 248.3 mm. Results were read from the calibration curve and were multiplied by the appropriate dilution factor to calculate the amount of iron contained in each sample of foods examined.
RESULTS T h e dietary histories from completed questionnaires were very different between the two groups of patients studied. T h e nine patients with iron deficiency anemia lived mainly on gari, a carbohydrate, and usually had two meals a day. Their protein consumption was very low. T h e stew was recooked over a period of 3-4 days. T o avoid frequent cooking, these patients bought foods from
291
stalls to supplement their homemade meals. Protein, when taken, represented 5%-10% of the total food consumption. O n the other hand, the hospital patients were served three main meals daily that contained a variety of carbohydrates and foods rich in animal proteins. Hospital patients consumed about 3.5 kg of food daily compared with a 2.5-kg daily intake at home by the anemic women examined. T h e mean of the daily dietary iron intakes of all ten patients on the hospital diet was 36.92 mg (range of individual means = 25.09-46.47 mg). Except for three patients in the anemic group with daily iron intakes of 21.62 mg, 23.72 mg and 25.28 mg, the rest of the patients had daily iron intakes of less than 15 mg. T h e mean of the daily iron intakes of the nine patients in this group was 14.6 mg (range of individual means = 8.37-25.28 mg). Tables I and II show the individual
Table I. Dietary iron intake of nine pregnant patients with iron deficiency anemia on home diets. Range of Daily Iron Intake Mean Patient (mg) (mg) ~ i 7.80-12.12 9^63 2 8.50-15.00 11.37 3 6.50-12.00 9.07 4 18.50-29.06 21.62 5 6.50-11.40 9.06 6 10.40-15.50 13.35 7 16.50-26.40 23.72 8 7.20-10.50 8.37 9 24.06-26.51 25.28 Mean Range
14.60 8.37-25.28
Table II. Dietary iron intake of ten pregnant patients on hospitals diets. Range of Daily Patient
Iron Intake (mg)
Mean (mg)
1 2 3 4 5 6 7 8 9 10
34.50-45.11 30.79-51.52 33.07-47.41 22.51-29.72 36.06-43.90 32.20-36.30 37.70-53.84 41.83-53.85 27.76-48.69 25.23-42.99
36.24 33.88 36.90 25.09 39.74 34.26 46.47 43.89 37.20 35.50
Mean Range
25.09-46.47
36.92
Int J Gynaecol Obstet 17
292
Ogunbode et al
daily iron intakes of the groups of patients on the home and hospital diets, respectively.
DISCUSSION Lawson (9) thought that anemia was more common in pregnancy in the tropics because of dietary deficiencies of iron and folic acid; however, he did not give the daily consumption of these blood-forming substances. Iron deficiency had, all along, been considered to be relatively unimportant in Nigeria because of the richness of iron in our foods. We have confirmed the report of Gilles (6) that foods of the people of Western Nigeria are rich in iron. T h e present study has shown a possible average daily intake of 36.92 m g of iron in patients having an adequate daily diet rich in animal proteins. However, the majority of patients in the low socioeconomic group, the class most likely to have inadequate and unbalanced meals, had a mean daily iron intake of 14.6 m g during pregnancy. Results of several studies in Nigeria reported a daily iron intake of 20-50 mg in various parts of the country (1, 5, 6, 11). T h e daily iron intake of pregnant women in two villages of Oyo State, where the present study was conducted, was found to be 15.3 mg and 24.7 mg, respectively (15). T h e iron content of our foods is much higher than that reported for the United Kingdom by the National Food Survey Committee (10). In that report, a family with an expectant mother had an average of 17.9 mg of iron per person per day. What is clear from our study is that the average Nigerian cannot at present afford an adequate and balanced diet. Besides, the patients with an average iron intake of 14.6 mg were by no means the poorest in the community. They probably represented the low middle class. In addition, the foreknowledge of the tests to be carried out may have influenced the type, quality and quantity of foods presented as their "normal meals." In spite of this factor, which would tend to increase their real dietary intake, 44% of them had a daily intake of less than 10 mg of iron in their diet. Any individual's food intake is strongly determined by economic sufficiency. T h e restricted intake of food can be further aggravated by tribal taboos, pregnancy, anorexia and ignorance of the need to consume an adequately balanced and nutritious diet during pregnancy. All these factors combine to affect the development and exacerbation of the anemic state. T h e three patients who had
IntJ Gynaecol Obstet 17
tolerable daily dietary iron intakes of 21-25 mg but were anemic probably had a combination of causes for their anemias, including folic acid deficiency, malarial infection and, most probably, malabsorption. In our environment, iron supplements during pregnancy seem to be necessary because the vast majority of the people cannot afford the hospitaltype meals which could provide sufficient amounts of iron to meet the woman's increased requirements during pregnancy.
ACKNOWLEDGMENT T h e authors would like to acknowledge the assistance of the nursing staff of the Inalende Maternity Centre from which many of the patients studied were drawn. They are also grateful to the nursing staff of Ward W4, including the hospital maids who assisted with the collection of food samples. Finally, thanks are due to Mrs Sumbo Adelaja for her secretarial services.
REFERENCES 1. Collis W R F , Dema I, Omololu A: O n lhe ecology of child nutrition and health in Nigerian villages: dietary and medical surveys. T r o p Geogr Med 14:201, 1962. 2. Fleming AF: Iron status of anaemic pregnant Nigerians. J Obstet Gynaecol Br C o m m o n w 76.1013, 1969. 3. Fleming AF: A study of anaemia in pregnancy in Ibadan, Western Nigeria, with special reference to folic acid deficiency, thesis. University of I b a d a n , I b a d a n , Nigeria. 4. Fleming AF, Hendrickse J P de V, Allan M C : T h e prevention of megaloblastic anaemia. J Obstet Gynaecol Br Commonw 75:425, 1969. 5. Food and Nutrition Summaries for Countries of the African Region, Vol 2. Madagascar-Zambia, p 11. A F R / N U T / 177. World H e a l t h Organization, Regional Office for Africa, Brazzaville, Congo. 6. Gilles H M : Hookworm infection and anaemia. T r o p Doct 5:51, 1975. 7. Gilles H M , Lawson J B , Sibelas M, Voiler A, Allan M : Malaria, anaemia in pregnancy. Am T r o p Med Parasitol 61-245, 1969. 8. Hendrickse J P de V, Watson-Williams J : T h e influence of haemoglobinopathies on reproduction. Am J Obstet Gynecol 94:739, 1966. 9. Lawson J B : Severe anaemia in pregnancy. T r o p Med Doct /:77, 1971. 10. National Food Survey Committee: National Food Survey: Domestic Consumption and Expenditure, 1961. Her Majesty's Stationery Office, London, 1963. 11. Nutrition Survey of Nigeria, 1965. Nutrition Section, Office of International Research, National Institutes of Health, Bethesda, M D , 1968. 12. O g u n b o d e O , Oluboyede O A : Iron deficiency anaemia in
Iron intake in anemic pregnant women
Nigerian pregnant women. Int J Gynaecol Obstet ¡4:315, 1976. 13. O g u n b o d e O , Oluboyede O A , Ayeni O: T h e treatment of iron deficiency anaemia with a new intramuscular iron preparation (Ferastral). Scand J Haematol (Suppl] 52:364, 1977. 14. O g u n b o d e O , Oluboyede O A , Ayeni O, Esan G J F : Diagnosis of iron deficiency anaemia a m o n g Nigerian pregnant women by serum iron/T.I.B.C. determination. Int J Gynaecol Obstet / ¿'246, 1976. 15. Oluboyede O A , O g u n b o d e O: Iron deficiency anaemia in
293
a rural area in Nigeria: evaluation of diagnosis and treatment with Imferon. Int J Gynaecol Obstet 14:529, 1976.
Address for reprints: O. Ogunbode Dept of Obstetrics and Gynaecology University College Hospital Ibadan Nigeria
Int J Gynaecol Obstet 17
Dietary Iron Intake of Pregnant Nigerian Women with Anemia O. Ogunbode, 1 1. O. Akinyele 2 and M. A. Hussain 2 Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria Department of Human Nutrition, University of Ibadan, Ibadan, Nigeria
Ogunbode 0, Akinyele 10, Hussain MA (Dept of Obstetrics and Gynaecology, University College Hospital, Ibadan, and Dept of Human Nutrition, University of Ibadan, Ibadan, Nigeria). Dietary iron intake of pregnant Nigerian women with anemia. Int J Gynaecol Obslet 17: 290-293, 1979 The daily dietary iron intake of nine pregnant Nigerian women with confirmed iron deficiency anemia was determined. The daily dietary iron intake from hospital meals served to ten other pregnant women was also assessed to serve as a control. The mean daily iron intake of the group of anemic patients on home diet was 14.6 mg (range of individual means = 8.37-25.28 mg), whereas the group of patients served hospital meals had a mean daily dietary iron intake of 36.92 mg (range of individual means = 25.09-46.47 mg). It is, therefore, clear that the etiology of iron deficiency in the patients studied was mainly dietary. Thus, our pregnant patients, many of whom are on diets similar to those of the group studied, should receive iron supplements during pregnancy.
Investigations into the etiology of the iron deficiency strongly suggest undernutrition because the main characteristic of these anemic patients is that they belong to the low socioeconomic group. Social classification was made using Fleming's parameters (3). Patients were asked five questions and scored 0, 1 or 2, with the maximum score being 10 points. T h e questions concerned the woman's education, the education of her parents, her husband's education, his occupation and their place of residence. Patients were classified as " u p p e r " socioeconomic class (score = 6-10) and low socioeconomic class (score = 0-5). No significant association was found between anemia in pregnancy and any of the endemic parasitic infections, such as malaria and hookworm (13). T h e present study was, therefore, designed to estimate the average iron intake of patients with anemia during pregnancy. T h e dietary iron intake from Nigerian foods served to pregnant women at U C H was also determined to serve as a control.
INTRODUCTION
MATERIALS A N D M E T H O D S
Until recently, the main causes of anemia in pregnancy in Ibadan were identified as red cell hemolysis due to malaria (2, 7), dietary deficiency of folates (3, 4) and hemoglobinopathies (8). As a result of these reports, the antenatal routine at the University College Hospital (UCH) in Ibadan and most maternity centers that follow U C H practices is to give a prophylactic antimalarial agent (25 mg of pyrimethamine) weekly and 5 mg of folic acid daily to pregnant women. However, in the past few years, evidence has been accumulating that iron deficiency is also present in many of our patients with pregnancy anemia, particularly in those patients with mild to moderate degrees of anemia (1215).
Dietary histories were obtained from 64 patients whose iron deficiency anemia was confirmed using absence of iron in the marrow as the diagnostic index. T h e history of foods consumed and the frequency of their consumption were compared with the quality and variety of foods served to patients at U C H . Arrangements designed to estimate the dietary iron intake presented difficulties. Only a few patients were prepared to grant permission to visit their homes and make a record of the foods they ate. There was also the problem of getting these patients to present a true sample and quantity of the foods normally eaten. As a result, many patients could not be fully investigated.
ABSTRACT
Int J Gynaecol Obslet 17
Iron intake in anemic pregnant women
Food samples were collected and the amount consumed was estimated for only nine of the anemic patients over a period of four consecutive days to determine the daily intake of iron from their habitual diet. A research assistant visited the homes of these patients and, at each visit, weighed the individual item of food before and after each meal. A note was also made of the types of food eaten. Samples of food taken were collected in polyethylene bags. Foods served to the patients at U C H were similarly weighed and samples were obtained for iron content analysis. Samples were obtained from ten such pregnancy inpatients for four days. As soon as the foods were collected, they were weighed and transported to the laboratory of the UCH's Department of Nutrition for preparation before the determination of iron. Preparation involved blending whole diets in a quartz mortar with a pestle. After thorough mixing, the individual samples were placed in clean plastic plates and dried at 80 C in an air oven to a constant weight. The dried samples were then subsampled by weighing out, in duplicate, 2 gm into clean silica crucibles and then dried to constant weight in an air oven. This was immediately followed by dry ashing in a muffle furnace at 450 C for 16 hours. The residual white ash was dissolved in 2 ml of concentrated nitric acid and the solution was diluted with deionized water after it was transferred to a 250-ml standard flask. T w o milliliters of 5% lanthanum chloride solution was added and the solution was made u p to the 250-ml mark with deionized solutions. T h e iron content of the diets was then determined with the atomic absorption spectrophotometer (Perkin-Elmer model 305B, Perkin-Elmer Corp, Norwalk, C T , USA) and the appropriate hollow cathode lamp using a wavelength of 248.3 mm. Results were read from the calibration curve and were multiplied by the appropriate dilution factor to calculate the amount of iron contained in each sample of foods examined.
RESULTS T h e dietary histories from completed questionnaires were very different between the two groups of patients studied. T h e nine patients with iron deficiency anemia lived mainly on gari, a carbohydrate, and usually had two meals a day. Their protein consumption was very low. T h e stew was recooked over a period of 3-4 days. T o avoid frequent cooking, these patients bought foods from
291
stalls to supplement their homemade meals. Protein, when taken, represented 5%-10% of the total food consumption. O n the other hand, the hospital patients were served three main meals daily that contained a variety of carbohydrates and foods rich in animal proteins. Hospital patients consumed about 3.5 kg of food daily compared with a 2.5-kg daily intake at home by the anemic women examined. T h e mean of the daily dietary iron intakes of all ten patients on the hospital diet was 36.92 mg (range of individual means = 25.09-46.47 mg). Except for three patients in the anemic group with daily iron intakes of 21.62 mg, 23.72 mg and 25.28 mg, the rest of the patients had daily iron intakes of less than 15 mg. T h e mean of the daily iron intakes of the nine patients in this group was 14.6 mg (range of individual means = 8.37-25.28 mg). Tables I and II show the individual
Table I. Dietary iron intake of nine pregnant patients with iron deficiency anemia on home diets. Range of Daily Iron Intake Mean Patient (mg) (mg) ~ i 7.80-12.12 9^63 2 8.50-15.00 11.37 3 6.50-12.00 9.07 4 18.50-29.06 21.62 5 6.50-11.40 9.06 6 10.40-15.50 13.35 7 16.50-26.40 23.72 8 7.20-10.50 8.37 9 24.06-26.51 25.28 Mean Range
14.60 8.37-25.28
Table II. Dietary iron intake of ten pregnant patients on hospitals diets. Range of Daily Patient
Iron Intake (mg)
Mean (mg)
1 2 3 4 5 6 7 8 9 10
34.50-45.11 30.79-51.52 33.07-47.41 22.51-29.72 36.06-43.90 32.20-36.30 37.70-53.84 41.83-53.85 27.76-48.69 25.23-42.99
36.24 33.88 36.90 25.09 39.74 34.26 46.47 43.89 37.20 35.50
Mean Range
25.09-46.47
36.92
Int J Gynaecol Obstet 17
292
Ogunbode et al
daily iron intakes of the groups of patients on the home and hospital diets, respectively.
DISCUSSION Lawson (9) thought that anemia was more common in pregnancy in the tropics because of dietary deficiencies of iron and folic acid; however, he did not give the daily consumption of these blood-forming substances. Iron deficiency had, all along, been considered to be relatively unimportant in Nigeria because of the richness of iron in our foods. We have confirmed the report of Gilles (6) that foods of the people of Western Nigeria are rich in iron. T h e present study has shown a possible average daily intake of 36.92 m g of iron in patients having an adequate daily diet rich in animal proteins. However, the majority of patients in the low socioeconomic group, the class most likely to have inadequate and unbalanced meals, had a mean daily iron intake of 14.6 m g during pregnancy. Results of several studies in Nigeria reported a daily iron intake of 20-50 mg in various parts of the country (1, 5, 6, 11). T h e daily iron intake of pregnant women in two villages of Oyo State, where the present study was conducted, was found to be 15.3 mg and 24.7 mg, respectively (15). T h e iron content of our foods is much higher than that reported for the United Kingdom by the National Food Survey Committee (10). In that report, a family with an expectant mother had an average of 17.9 mg of iron per person per day. What is clear from our study is that the average Nigerian cannot at present afford an adequate and balanced diet. Besides, the patients with an average iron intake of 14.6 mg were by no means the poorest in the community. They probably represented the low middle class. In addition, the foreknowledge of the tests to be carried out may have influenced the type, quality and quantity of foods presented as their "normal meals." In spite of this factor, which would tend to increase their real dietary intake, 44% of them had a daily intake of less than 10 mg of iron in their diet. Any individual's food intake is strongly determined by economic sufficiency. T h e restricted intake of food can be further aggravated by tribal taboos, pregnancy, anorexia and ignorance of the need to consume an adequately balanced and nutritious diet during pregnancy. All these factors combine to affect the development and exacerbation of the anemic state. T h e three patients who had
IntJ Gynaecol Obstet 17
tolerable daily dietary iron intakes of 21-25 mg but were anemic probably had a combination of causes for their anemias, including folic acid deficiency, malarial infection and, most probably, malabsorption. In our environment, iron supplements during pregnancy seem to be necessary because the vast majority of the people cannot afford the hospitaltype meals which could provide sufficient amounts of iron to meet the woman's increased requirements during pregnancy.
ACKNOWLEDGMENT T h e authors would like to acknowledge the assistance of the nursing staff of the Inalende Maternity Centre from which many of the patients studied were drawn. They are also grateful to the nursing staff of Ward W4, including the hospital maids who assisted with the collection of food samples. Finally, thanks are due to Mrs Sumbo Adelaja for her secretarial services.
REFERENCES 1. Collis W R F , Dema I, Omololu A: O n lhe ecology of child nutrition and health in Nigerian villages: dietary and medical surveys. T r o p Geogr Med 14:201, 1962. 2. Fleming AF: Iron status of anaemic pregnant Nigerians. J Obstet Gynaecol Br C o m m o n w 76.1013, 1969. 3. Fleming AF: A study of anaemia in pregnancy in Ibadan, Western Nigeria, with special reference to folic acid deficiency, thesis. University of I b a d a n , I b a d a n , Nigeria. 4. Fleming AF, Hendrickse J P de V, Allan M C : T h e prevention of megaloblastic anaemia. J Obstet Gynaecol Br Commonw 75:425, 1969. 5. Food and Nutrition Summaries for Countries of the African Region, Vol 2. Madagascar-Zambia, p 11. A F R / N U T / 177. World H e a l t h Organization, Regional Office for Africa, Brazzaville, Congo. 6. Gilles H M : Hookworm infection and anaemia. T r o p Doct 5:51, 1975. 7. Gilles H M , Lawson J B , Sibelas M, Voiler A, Allan M : Malaria, anaemia in pregnancy. Am T r o p Med Parasitol 61-245, 1969. 8. Hendrickse J P de V, Watson-Williams J : T h e influence of haemoglobinopathies on reproduction. Am J Obstet Gynecol 94:739, 1966. 9. Lawson J B : Severe anaemia in pregnancy. T r o p Med Doct /:77, 1971. 10. National Food Survey Committee: National Food Survey: Domestic Consumption and Expenditure, 1961. Her Majesty's Stationery Office, London, 1963. 11. Nutrition Survey of Nigeria, 1965. Nutrition Section, Office of International Research, National Institutes of Health, Bethesda, M D , 1968. 12. O g u n b o d e O , Oluboyede O A : Iron deficiency anaemia in
Iron intake in anemic pregnant women
Nigerian pregnant women. Int J Gynaecol Obstet ¡4:315, 1976. 13. O g u n b o d e O , Oluboyede O A , Ayeni O: T h e treatment of iron deficiency anaemia with a new intramuscular iron preparation (Ferastral). Scand J Haematol (Suppl] 52:364, 1977. 14. O g u n b o d e O , Oluboyede O A , Ayeni O, Esan G J F : Diagnosis of iron deficiency anaemia a m o n g Nigerian pregnant women by serum iron/T.I.B.C. determination. Int J Gynaecol Obstet / ¿'246, 1976. 15. Oluboyede O A , O g u n b o d e O: Iron deficiency anaemia in
293
a rural area in Nigeria: evaluation of diagnosis and treatment with Imferon. Int J Gynaecol Obstet 14:529, 1976.
Address for reprints: O. Ogunbode Dept of Obstetrics and Gynaecology University College Hospital Ibadan Nigeria
Int J Gynaecol Obstet 17
