Bacterial pathogens and their antimicrobial susceptibility in Kumasi, Ghana

Between January, 1994 and June, 1996 a survey of bacterial isolates from clinical specimens and their antimicrobial susceptibility was performed at the Komfo Anokye Teaching Hospital, Microbiology Department, Kumasi, Ghana. A total of 11,380 bacterial isolates were cultured from eight different specimens. The sites of origin were wounds 32.2%, urine 28.1%, ear, nose and throat 3.6%, sputum 2.5% and aspirates 2.5%. Gram-negative bacteria accounted for 7955 (69.9%) isolates, the main species were Escherichia coli 47.1%, Pseudomonas spp. 16.8%, Proteus spp 14.6%, Klebsiella spp 10.2%, Neisseria gonorrhoeae 4.2%, Gram-positive bacteria contributed 3425 ((30.1%) of isolates, with Staphylococcus aureus 54.6% being the most predominant followed by Coagulase negative Staphylococcus 18.1%, Streptococcus pneumoniae 13.7% and Beta-haemolytic streptococci 4.1%. Escherichia coli showed 88% and 82% resistance to ampicillin and cotrimoxazole respectively with 78% being susceptible to gentamicin. Cefuroxime resistance in Gram-negative bacilli was 5%. As much as 30.6% and 21.7% of Streptococcus pneumoniae isolates were resistant to Penicillin and chloramphenicol respectively. Ten per cent of Staphylococcus aureus strains were susceptible to penicillin and 18% were resistant to flucloxacillin.     

Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world

Prolonged obstructed labor may produce injuries to multiple organ systems. The best known, and most common, of these injuries is obstetric fistula formation. When obstructed labor is unrelieved, the presenting fetal part is impacted against the soft tissues of the pelvis and a widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula formation. Unlike the postsurgical vesicovaginal fistula, however, which is usually the result of focal trauma to otherwise healthy tissues, the obstetric fistula is the result of a "field injury" to a broad area. The field injury that is produced by prolonged obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply on the "hole" between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and foot-drop. In addition to their physical injuries, women who have experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities, separation from their families, worsening poverty, malnutrition, and almost unendurable suffering. Isolated almost exclusively to the developing world, particularly Africa, this problem has not received the international attention that it deserves, from either a medical or a social standpoint.     

Promotion of neovascularization around hollow fiber bioartificial organs using biologically active substances

Hypertension is common in West Africa and likely to become more common as urbanisation increases. There are at present few facilities for the detection and management of hypertension so the influence it has on overall morbidity and mortality in the population is not clear. The objectives of the study were to assess: (a) renal disease and blood pressure related admissions and deaths among acute medical admissions to Komfo Anokye Teaching Hospital, Kumasi, during an 8-month period; and (b) the burden of renal disease among out-patient hypertensives at the same hospital. Ward admission books were examined in the four acute medical wards to ascertain admission diagnosis and cause of death (two 4-month periods in 1995 and 1996). Clinical assessment (blood pressure, plasma creatinine, proteinuria) was also made of 448 consecutive out-patient hypertensives seen between March 1995 and April 1996. Five hundred and ninety-three (17.9%) of 3317 acute medical admissions were ascribable to a cardiovascular cause (hypertension, heart failure, stroke); 171 (28.8%) of these died. One hundred and sixty-six (5.0%) had renal disease of whom 45 (27.1%) died, usually of end-stage renal disease. Among the 448 hypertensive out-patients, 30.2% (110 out of 365) had a plasma creatinine >140 micromol/l (48 > or = 400 micromol/l) and 25.5% (96 out of 376) had proteinuria. Eighty-nine of the 448 had a diastolic blood pressure > or =115 mm Hg; in this group 38 (42.7%) had a plasma creatinine of >140 micromol/l (and 18 or 20.2% > or =400 micromol/l). In conclusion, cardiovascular and renal disease are important contributors to morbidity and mortality among acute medical admissions to a large city hospital in Ghana. Among out-patient hypertensives renal disease is an important complication, especially in those with the more severe hypertension.     

Effect of age and parity on primary caesarean section rates

OBJECTIVE: To study the effect of maternal age and parity on the rates of primary caesarean section. METHOD: We reviewed all patients who delivered at the Princess Badeea Teaching Hospital between 1 January, 1995 and 26 November, 1995. RESULTS: There were 8,732 deliveries included in this study. The primary caesarean section rates in primiparous women less than 25, 25 to 34 and over 34 years of age were 6.1%, 11.1% and 22.2%, respectively. A similarly dramatic rise with advancing maternal age was seen in multiparous women with rates of 3.1%, 6.4% and 9.5%, respectively, in the three age groups. A strong association between maternal age and primary caesarean section exists (p < 0.05). Caesarean section rates in the primiparous women were higher in all age groups when compared with multiparous women (p < 0.0001). CONCLUSIONS: Increasing maternal age and parity are factors strongly associated with increased primary caesarean section rates.     

Obstetric management of 219 infants with hypoplastic left heart syndrome

OBJECTIVE: The objective of this study was to describe the obstetric parameters from 219 deliveries of infants with hypoplastic left heart syndrome. STUDY DESIGN: The Pediatric Cardiovascular Surgery Database at the University of Michigan was searched, and cases of neonates with the diagnosis of hypoplastic left heart syndrome were found. Obstetric records were then reviewed. RESULTS: One hundred sixty-one infants (74%) were delivered vaginally and 58 (26%) were delivered by the cesarean route. The mean gestational age at delivery was 38.9 weeks. Mean Apgar scores at 1 and 5 minutes were 7 and 8, respectively. Ninety percent were delivered at term and 10% were delivered before 37 weeks. The diagnosis of hypoplastic left heart syndrome was made antenatally in 82 cases (37%) and neonatally in 137 cases (63%). In the antenatal group the mean gestational age at diagnosis was 27 weeks. Karyotype analysis was performed in 32 of all cases (15%), with 8 fetuses revealing an abnormal karyotype. Seven cases were 45,X and 1 was trisomy 21. CONCLUSION: Staged reconstruction surgery has markedly improved survival for neonates born with isolated hypoplastic left heart syndrome. Our review suggests that, aside from determining the karyotype, no further obstetric interventions seem warranted. While awaiting spontaneous labor at term, the planned mode of delivery should be vaginal, with cesarean delivery performed for routine obstetric indications only.     

Susceptibility pattern of Neisseria gonorrhoeae isolated at the Komfo, Anokye Teaching Hospital, Ghana to commonly prescribed antimicrobial agents

This study which aimed to determine the susceptibility patterns of seven often prescribed antimicrobial agents for treatment of gonorrhoea in Kumasi, Ghana, over a study period of 3 years (1991 through 1993), examined a total of 1187 specimens (high vaginal, cervical and urethral). Identification of N. gonorrhoeae was by colonial morphology, oxidase test, sugar fermentation test and the Gram-stain. The Intra-lactam strip method was used to determine which Neisseria gonorrhoeae isolates were beta lactamase producers (PPNG). Of the 1115 PPNG strains encountered, 300 were selected for MIC determination against seven (penicillin, cotrimoxazole, tetracycline erythromycin, spectinomycin, norfloxacin and ceftriaxone) antimicrobial agents in current usage in Kumasi, Ghana. Based on our results it was concluded, that PPNG strains are rampant/endemic in Kumasi, Ghana and that most exhibited multiple antimicrobial resistance. This situation requires, therefore, a serious review of the current Ghana Ministry of Health gonorrhoea treatment regimen. Suggestions to this end have been made.     

Active management of prolonged pregnancy

OBJECTIVES: We assessed perinatal morbidity and mortality of prolonged pregnancies (> or = 294 days) compared with those of term gestations. We also evaluated the impact of induction of labor compared with spontaneous onset of labor. STUDY DESIGN: This observational study included consecutive cases treated at Chicago Lying-In Hospital from July 1980 to December 1984. Complications, presence of meconium, indications for cesarean section, mode of delivery, perinatal morbidity (and mortality), meconium aspiration, and duration of labor were compared with those in the total hospital population, in infants weighing > or = 2500 gm, and within prolonged gestation groups; spontaneous onset and induced ("active management") labors were also compared. The chi 2 analysis was used. RESULTS: Of 12,930 deliveries there were 707 prolonged gestations (5.5%) and 10,698 with infants > or = 2500 gm. Among the prolonged gestations 67% were in multiparous women and 33% in primiparous women. Labor started spontaneously in 62%, and 38% underwent induction; the overall cesarean section rate was 17% with similar indications in both spontaneous onset and induction groups. Meconium was present in 34%; it was present in 23% of inductions, which is fewer (p < 0.01) than among those with spontaneous onset of labor (40%). Also there were fewer depressed neonates at 5 minutes (p = 0.03) among inductions. Meconium aspiration was seen in 24, with nine deaths. The perinatal mortality was 14 per 1000 (corrected 12.7/1000), significantly more than in the general population. Among those with spontaneous onset of labor it was 20.5 per 1000; there were no deaths among inductions. Postpartum maternal morbidity was 16% among cesarean sections and 4% among vaginal deliveries. CONCLUSIONS: Prolonged gestation has a high perinatal morbidity and mortality rate. All perinatal deaths were observed among patients whose labor started spontaneously. "Active management" (induction at 42 weeks) did increase the primary cesarean section rate compared with that of the general obstetric population; it did not do so among prolonged gestations and prevented perinatal deaths in this group. From this experience an active approach seems justified.     

Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria

Northern Nigeria has a maternal mortality ratio greater than 1,000 maternal deaths per 100,000 live births. Serious maternal morbidity (for example, vesico-vaginal fistula) is also common. Among the most important factors contributing to this tragic situation are: an Islamic culture that undervalues women; a perceived social need for women's reproductive capacities to be under strict male control; the practice of purdah (wife seclusion), which restricts women's access to medical care; almost universal female illiteracy; marriage at an early age and pregnancy often occurring before maternal pelvic growth is complete; a high rate of obstructed labor; directly harmful traditional medical beliefs and practices; inadequate facilities to deal with obstetric emergencies; a deteriorating economy; and a political culture marked by rampant corruption and inefficiency. The convergence of all of these factors has resulted in one of the worst records of female reproductive health existing anywhere in the world.     

Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development

BACKGROUND: Whereas organized trauma care systems have decreased trauma mortality in the United States, trauma system design has not been well addressed in developing nations. We sought to determine areas in greatest need of improvement in the trauma systems of developing nations. METHODS: We compared outcome of all seriously injured (Injury Severity Score > or = 9 or dead), nontransferred, adults managed over 1 year in three cities in nations at different economic levels: (1) Kumasi, Ghana: low income, gross national product (GNP) per capita of $310, no emergency medical service (EMS); (2) Monterrey, Mexico: middle income, GNP $3,900, basic EMS; and (3) Seattle, Washington: high income, GNP $25,000, advanced EMS. Each city had one main trauma hospital, from which hospital data were obtained. Annual budgets (in US$) per bed for these hospitals were as follows: Kumasi, $4,100; Monterrey, $68,000; and Seattle, $606,000. Data on prehospital deaths were obtained from vital statistics registries in Monterrey and Seattle, and by an epidemiologic survey in Kumasi. RESULTS: Mean age (34 years) and injury mechanisms (79% blunt) were similar in all locations. Mortality declined with increased economic level: Kumasi (63% of all seriously injured persons died), Monterrey (55%), and Seattle (35%). This decline was primarily due to decreases in prehospital deaths. In Kumasi, 51% of all seriously injured persons died in the field; in Monterrey, 40%; and in Seattle, 21%. Mean prehospital time declined progressively: Kumasi (102 +/- 126 minutes) > Monterrey (73 +/- 38 minutes) > Seattle (31 +/- 10 minutes). Percent of trauma patients dying in the emergency room was higher for Monterrey (11%) than for either Kumasi (3%) or Seattle (6%). CONCLUSIONS: The majority of deaths occur in the prehospital setting, indicating the importance of injury prevention in nations at all economic levels. Additional efforts for trauma care improvement in both low-income and middle-income developing nations should focus on prehospital and emergency room care. Improved emergency room care is especially important in middle-income nations which have already established a basic EMS.     

Dipole source localization by means of maximum likelihood estimation I. Theory and simulations

The obstetric histories of 26 women with myotonic dystrophy (DM), who had a total of 67 gestations, were reviewed retrospectively comparing gestations with affected (DM-fetuses) and unaffected fetuses (UA-fetuses). Second, the influence of gestation on the disease course and the personal attitude towards family planning in DM was assessed. Miscarriages and terminations occurred in 11 pregnancies. Of the 56 infants carried to term, 29 had or most likely had inherited the gene for DM from their affected mothers at the time of investigation; 18 (61%) in this series were affected by the congenital form of DM. Perinatal loss rate was 11% and associated with congenital DM. The rate of obstetric complications was significantly increased in all women. However, preterm labor was a major problem in gestations with DM-fetuses (55 vs. 20%), as was polyhydramnios (21% vs. none). While forceps deliveries or vacuum extractions were required in 21% of deliveries with DM-fetuses and only 5% of UA-fetuses, the frequency of Cesarean sections was similar in both groups (24 and 25%). Obstetric problems were inversely correlated with age at onset of maternal DM, while no effect of age at delivery or birth order on gestational outcome was seen. DNA analysis confirmed the diagnosis in 19 patients by the presence of enlarged CTG repeats (EcoRI-expansions) on chromosome 19. Of the 17 patients whose CTG repeat length was known, 59% were classified as E2 (corresponding to 500-1000 repeats), 24% as E1 (<500 repeats), while larger expansions (E3; 1000-1500 repeats, or E4; >1500 repeats) were seen in three patients (17%). Obstetric complications or congenitally affected children occurred in all maternal phenotypes and CTG repeat classes. Eight (31%) patients experienced a worsening of symptoms that was temporary, weight related in three cases, and persistent in five. With the exception of three patients, most new mothers were able to care for their families. To conclude, pregnant women with DM need constant obstetric monitoring and should be advised to deliver in centres with perinatal facilities.     

Enterocutaneous fistula in cancer patients: etiology, management, outcome, and impact on further treatment

Enterocutaneous fistulae that develop in patients with cancer represent a difficult management situation, which is often complicated by prior treatment including surgery, radiation therapy, and chemotherapy. A fistula may in turn delay potentially beneficial treatment of the underlying malignancy. To provide a better understanding of this problem, we reviewed the National Institutes of Health experience with enterocutaneous fistulae in adult patients with cancer. The medical records of patients with cancer who developed a fistula from the gastrointestinal tract during the period 1980 through 1994 were reviewed. Etiology, management, outcome, and impact on further treatment were assessed. Twenty-five patients with gastrointestinal fistulae were identified. The most common primary tumor site was the colon/rectum in males and the ovary in women. The majority of patients had metastatic disease at diagnosis and a history of prior therapy and presented with anorexia and weight loss. The fistula was usually single, most commonly developed from the jejunum/ileum (13 patients) or colon/rectum (6 patients), and occurred postoperatively after procedures on the small bowel (10 patients) or colon (8 patients). Malnutrition and sepsis developed in 60 per cent of patients. Thirty-day mortality was 16 per cent and correlated with prior radiation therapy, location and output from the fistula, and hypoalbuminemia. An enterocutaneous fistula negatively impacted on the provision of further therapy for the majority of patients (63%). Enterocutaneous fistula in the patient with cancer occurs most frequently in the setting of extensive prior therapy and is associated with prolonged morbidity. Identification of high-risk patients and early management of fistulas once they develop may prevent delays in subsequent cancer therapy and decrease morbidity.     

The repair of vesicovaginal fistulae by means of omental slings and grafts

The treatment of 19 consecutive cases of vesicovaginal fistulae, 16 of which were caused by obstructed labour, is described. The fistulae were treated with omental grafts and slings and the results and advantages of this method are discussed.     

Quantification of interstitial lung abnormalities with chest radiography: comparison of radiographic index and fractal dimension

OBJECTIVE: To evaluate the role of computed tomographic abscessograms (CTABs, consisting of injection of contrast medium through a drainage catheter followed by computed tomographic examination) in the management of patients referred for percutaneous abscess drainage (PAD). PATIENTS AND METHODS: Over 50 months, 169 patients with 203 abscesses underwent PAD, and 432 CTABs were performed. CTAB was assessed for its ability to influence treatment decisions, detect fistulae and visualize the septic process. RESULTS: CTABs allowed the detection of fistulous communications in 32% (65/203) of abscesses. In 60 of the 65 patients with fistulae (92%), the specific etiology of the abscess cavity was established through analysis of CTABs. The presence of a pathologic fistula prolonged the catheter drainage time (20.5 v. 11.9 days, p < 0.0001), and the success rate was lower if the drainage catheter was removed before the fistula was closed (90% v. 72%). CTAB images influenced catheter-manipulation decisions for 23 of the 169 patients (14%). CONCLUSION: CTABs provide important information about the underlying pathologic process while allowing detection of fistulae and ultimately influencing interventional treatment for PAD.     

Patterns of various modes of delivery in relation to presence of different risk factors in term pregnant mothers--a case-control study

A case-control study, was carried out, which aimed to determine whether a relation exists between risk factors present in mother and the mode of delivery i.e., outcome. Cases were those mothers who had one or more risk factors present during pregnancy (namely, short stature, malpresentation, antepartum haemorrhage, pre-eclamptic toxaemia/eclampsia, anaemia-haemoglobin less than 10 g/dl, twins, bad obstetric history, prolonged pregnancy, history of previous caesarean section and instrumental delivery, pregnancy associated with general diseases, prolonged difficult labour and RH-iso-immunisation). Controls were those mothers who did not have any of the above mentioned risk factors. Total of 250 cases and 250 controls were taken. Results showed that surgical and instrumental deliveries were strongly associated with presence of risk factors (odd's ratio: 5.94; attributable risks: 72%). Out of risk factors among cases, most common indication of caesarean section, was previous caesarean section followed by malpresentation, prolonged difficult labour and short statured mothers in descending order.     

Centralization in obstetrics: pros and cons

Possible advantages and disadvantages of a general centralization of German obstetric facilities are analysed in the study. The need for centralization of risk cases, especially premature births (regionalization) is pointed out. Centralization appears appropriate, since every fifth maternity unit in Germany (19.78%) has 300 or fewer deliveries per year. This one fifth of perinatal clinics accounts for 6.3% of all deliveries (N = 49450). There are appreciable differences between the old and new federal states (Bundesl?nder): in the recently acceded federal states, 48.7% of all perinatal clinics have deliveries of 300 and less per year. This group of perinatal clinics accounts for 29% of all deliveries in the new federal states. We have carried out a survey of the mother's attitude to centralization: out of 416 patients in the Detmold women's hospital whose mean age was 29.0 +/- 4.2 years, 90.4% were not in favor of general centralization of obstetrics. 43% were also against a centralization of risk cases (regionalization). 75% of the women surveyed objected to centralized obstetrics because of the 'possible absence of the family', the 'possible absence of students and trainees' (44.9%), the 'unfamiliarity with staff and premises' (41.8%) and 'fear of anonymity' (44.5%). The majority of all women (84.1%) did not want to have a drive more than 20 km to an obstetrics center. Fear of 'delivery in a taxi'(78.6%), the 'fear that the husband will come too late to the delivery' (65.4%) and that the 'overall course of the delivery might not be adequate for reasons of time'. The presence of a pediatrics department in conjunction with the perinatal clinic was rated very positively (93%). It is concluded from the data and further juridical considerations that centralization of risk cases (regionalization) is indispensable in the near future and that somewhat more further into the future decentralization should be carried out by closing obstetrics departments with substantially less than 350 deliveries per year. Attention is drawn to some consequences of such a structural reform which will probably have to be initiated by the German Association of Gynecologists and Obstetricians.     

Brachial plexus paralysis: its incidence, predisposing factors and outcome

METHODS: We have studies, retrospectively, the risk factors, incidence and outcome of obstetric palsy in all infants delivered between January 1990 and December 1994 at the Obstetric and Gynecological Department and afferent to the Neonatological Division of the University of Messina. Twenty-eight of the 5556 live born full term infants (5/1000) were at birth diagnosed as having a brachial plexus paresis. Of these eight (1.6/1000) had persistent palsy. RESULTS: In about 40-50% of the infants with brachial plexus palsy the obstetric history was characterized by high birthweight, shoulder dystocia, and parity 1. The infants who recovered totally did so during the first 12 months of life. All infants had upper brachial plexus, or Erb's palsy, which is more favorable than entire brachial plexus palsy. At follow-up (15 months-5 years), all infants with persistent palsy were afflicted by varying degrees of arm function compromise. CONCLUSIONS: We stress that, in several cases, obstetric brachial plexus palsy results in life-long handicap, and that prevention, early diagnosis and therapy need to be the goals of the obstetrical and pediatric management.     

Prolonged and postmature pregnancy terminated in non-hospital institutions

Out of 4023 deliveries, the authors came across 291 prolonged ones, of which 39 were postmature deliveries. They followed the issue of these pregnancies in the conditions of non-hospital health care. The mortality rate of postmature deliveries was 10.2%. It is recommended that all prolonged and postmature pregnancies are referred to larger hospital-type maternity wards where more help can be offered to the pregnant woman and where the actual state of the fetoplacental unit can be properly followed. However, in cases when prolonged and postmature pregnancies are to be terminated in a non-hospital institution because of the women's refusal to go a larger maternity ward, it is proposed in present conditions to use as a diagnositc means also amnioscopy in addition to cytohormonal analysis.     

Characterizing flow distributions in AV fistulae for haemodialysis access

BACKGROUND: The arteriovenous fistula is the most widely used means of enabling vascular access for chronic haemodialysis. When interest in vascular access was at its height, in the 1970s, a substantial amount of work was carried out on the physiology of arteriovenous fistulae and on the relationship between fistula flow and patency. One omission in the catalogue of studies was research into the distribution of flow in the fistula and the effects on surgical outcome. METHOD: To address this issue, 30 patients with end-to-side radiocephalic fistulae were studied. Flow measurements were made intraoperatively, and at various intervals postoperatively using colour-flow ultrasonography. RESULTS: In 22 cases, the development of the fistula was monitored at regular intervals for periods of up to 27 months. In seven of the 30 fistulae, flow in the distal artery was antegrade, while in the remaining 23, distal artery flow was retrograde. The proportion of fistula flow supplied by the proximal and distal arteries varied considerably. CONCLUSION: Despite the wide range of flow distributions in the fistulae studied, flow distribution did not appear to affect fistula maturation or long-term function.     

Forearm free skin flap transplantation: a report of 56 cases. 1981

Primary arteriovenous fistulae remain the gold standard for hemodialysis access. The radiocephalic or Brescia-Cimino fistula is the autologous fistula of choice, with a primary success rate of nearly 93% and a 1-year patency rate of up to 82%. Alternative arteriovenous fistulae include the snuff box fistula and a brachiobasilic fistula with a 1-year patency rate of up to 90%. Complications include thrombosis, infection, arterial steal syndrome, venous hypertension, aneurysms, and congestive heart failure. Despite these complications, arteriovenous fistulae provide good long-term hemodialysis access.     

Obstetric outcome in 100 women with severe anxiety over childbirth

BACKGROUND: Extreme fear of delivery with request of cesarean section is a problem. The obstetric outcome in women given psychological and obstetric support is described. METHODS: Women, consecutively referred to the Psychosomatic outpatient clinic because of fear of delivery (n = 100), were compared to a matched reference group (n = 100). RESULTS: The women in the study group had higher frequency of psychic problems than the references. The majority, 68 of the women (68%) initially requested cesarean section (CS). After individualized psychological and obstetrical support, 38 of these women agreed to vaginal delivery (38%) and 30 had an elective CS (30%). In the end another 13 (13%) women had a CS for obstetric or mixed reasons. Complication rate was low and similar in the groups. The 57 women who eventually had a vaginal delivery (57%) showed an obstetric outcome similar to the reference group. They had a higher frequency of induction of labor (p = 0.02). and of epidural and pudendal blocks for pain relief (p = 0.002 and 0.05 respectively). They had shorter labor time (p = 0.05). The cost of the psychological therapy was well compensated for by the savings due to the reduction in the number of CS. CONCLUSIONS: Psychosomatic support for women with severe fear of delivery resulted in a 50% reduction of CS for psychosocial indications and vaginal deliveries similar to a reference group. The cost of psychosomatic support was less than savings due to fewer cesarean sections.