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Continental J. Tropical Medicine 2: 1 - 6, 2008. © Wilolud Online Journals, 2008.

ANTIMICROBIAL ACTIVITY AND PHYTOCHEMICAL SCREENING OF EXTRACTS FROM THE ROOT BARK OF CARISSA EDULIS, AGAINST HUMAN / ANIMAL PATHOGENS

K. B. Abdu1 ▪ M. E. Khan2 and M. M. Rumah1

1Department of Chemistry, Bayero University, Kano, Nigeria, 2Department of Chemistry, Gombe State University, Gombe, Nigeria

ABSTRACT The aim of this paper was to confirm the folkloric claim that C. edulis treats tuberculosis. To validate this tribal claim, the phytochemicals screening was determined. The root barks were tested against some human ailments. Extracts from the root-bark of Carissa edulis were macerated with different solvents. All fractions were subjected to phytochemical screening and antimicrobial activity using the disc-diffusion method. The extracts contained alkaloids, sterols and resin. The ethanol and the pet-ether fractions were active on Staphylococcus aureus and Escherichia coli respectively, at high concentrations. This attests that Carissa edulis contains bioactive compounds of potential therapeutic and prophylactic significance and supports the claim for its treatment of bacterial and fungal infections. Further analyses could pave way for candidature as phyto-therapeutic agents against some bacterial infections. KEYWORDS: Carissa edulis, root-bark, phyto-therapeutic, Staphylococcus aureus, gram-positive, Escherichia coli

INTRODUCTION Plants serve as the basis of traditional medicine systems for thousands of years in Nigeria, India, Chin, Indonesia etc. (Hammer, 1999). In Kano, Nigeria, tuberculosis is a health challenge (FHI, 2001; Nwankwo et al., 2005; Emokpae et al., 2006) and is believed that Carissa edulis, vahl (Apocynaceae) possesses medicinal properties effective in the management of tuberculosis and other ailments. It is used traditionally for the treatment of headache, chest complaints, rheumatism, gonorrhea, syphilis, rabies and as a diuretic and cancer (Nedi et al., 2004). The medicinal flora in the tropical eco-region has a preponderance of plants that provide raw materials for addressing medical disorders and pharmaceutical requirements. Collectively, plants produce diverse arrays low molecular mass natural products also known as secondary metabolites, (Fatope, 2001). Most developing countries have adopted traditional medical practice as an integral part of their culture. Some plants contain high calcium in their cell walls which has made them suitable for the growth of mineral crystals. The presence of phosphorus in them can be exploited for synthesizing hydroxapatite, thus, utilizing the traditional bone-fracture healing in advanced techniques of new material synthesis. (Habibovic, et al., 2002) This knowledge has led to the interest by pharmaceutical companies as a resource for research and development programmes in the pursuit of discovering novel drugs. The medicinal value of these metabolites is due to the presence of chemical substances that produce definite physiological action on the human body. Some of the valuable ones include: alkaloids, glucosides, Steroids, flavonoids, terpenoids, fatty oils, resins, mucilages, tannins, gums, phosphorus and calcium for cell growth, replacement, body building (Chidambara et al., 2003). There are reports of antibiotic resistance of human pathogens, to available antibiotics (Mitsuyama et al., 1987; Gutmann et al., 1988; Mathias et al.,., 2000; Ganguly, et al., 2001; Martino et al; 2002). Biomolecules of plant origin appear as alternatives for the control of these and some human pathogens and their uses have been shown to have scientific basis, since chemical compounds found in the various species have medicinal effects. Carissa edulis (Hausa, Chizake or lemun-daji) is a crottalabe overlapping to the right, anthers not tailed, ovary syncarpus; fleshy, branches usually armed with axillary spines. Spiny shrup up to 5m high. Its leaves

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K. B. Abdu et al: Continental J. Tropical Medicine 2: 1 - 6, 2008. ovale usually acute at apex, shortly cuneate or rounded at base, 2-6cm long, and 2-5cm broad, with 3-5 pairs of lateral nerves, glabrous or pubescent. Petiole short (Festus et al; 2006). C. edulis has been used in Nigeria in forms of decoction and concoctions for the cure of cough, catarrh, diarrhea and tuberculosis (Aja afar,1982.). This paper reports the potentials of C. edulis for its anti-microbial activity. MATERIALS AND METHODS Sampling Fresh samples of the root- bark of Carissa edulis was collected in June, 2006 from a local medical practitioner at Zerewa town Rogo local Government area of Kano State Nigeria. It was identified and authenticated according to Hutchinson and Dalziel (1956). The sample was air dried in the laboratory before being powdered using pestle and mortar to a mesh size of about 60 and then stored in a dry container. Extraction Eight hundreds grams (800g) of the powdered roots of the plant was percolated with (5Lt) of distilled ethanol for two-weeks. After which it was decanted, filtered, and concentrated on rotary evaporator (R110) at 400C to obtain ethanol soluble fraction, (FE01), weight, 17.73g. (Crude). FE01 was macerated with petroleum ether and concentrated with (R110) at 400C, to obtain pet ether soluble fraction. It weighed 6.30g and was labeled (FPE01). Successive maceration and concentration with (R110) at 400C processes continued with different solvents thus, ethyl acetate, 2.9g (FEA01), Chloroform 5.1g(FC01), and acetone 2.2g (FA01), with an insoluble junk. Anti-microbial testing The disc`s were prepared using a What-man filter paper by punching and were kept in vial-bottles and sterilized in an oven at 1500C for 15minutes. Preparation of stock solution. Five different extracts (FE01), (FPE01), (FEA01), (FC01), and (FA01) were used for both analysis. Concentrations (in triplicates) were produced from each extract at 5000, 2500, 1000, and 500µg / (cm3) respectively using the dilution formula ( Almagboul, using pestle and mortar to a mesh size of about 60 and then stored in a dry container. Preparation of culture medium Four bacteria species: Staphylococcus aureus, Escherichia coli, Klibsiela. pneumonia and Streptococcus species stock cultures were collected at Murtala Mohammed Specialist Hospital Kano; These organisms were identified in the Microbiology Department of Bayero University Kano. Sensitivity test Approximately eleven grams (11.24g) of the nutrient agar were dissolved in 400cm3 of distilled water, shaken and sterilized in an autoclave in the microbiology laboratory for 15 minutes at 1210C. 20 cm3 of the mixture each was then pippetted into Petri-dishes with the help of heat in order to kill any species around and avoid contamination. The samples plates were allowed to set and later incubated aerobically at370C then turn upside down in the ovum for them to dry. Inoculation of the test organisms on nutrient agar-prepared plates were prepared as reported by Fatope et al ;( 1993) was achieved by; flaming a wire loop on a spirit lamp, cooling the wire loop (air cooling) and fetching the test organisms. Prepared disks containing the fractions at different concentrations were placed on the inoculated plates using sterilized forceps in each case (Fatope et al; 1993); the plates were then turned upside-down and incubated at 370C for 18 h.

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K. B. Abdu et al: Continental J. Tropical Medicine 2: 1 - 6, 2008. Scoring and Reading The result was taken by considering the zone of growth and inhibition of the organism by the various concentrations of the test fractions (Mackie et al; 1989).Activity and inactivity were observed in accordance with the standard and acceptable method and results tabulated as shown in Table I. Phytochemical screening All soluble fractions were subjected to phytochemical screening in accordance with the standard procedure. (Harborne 1973and 1992), Alkaloids, steroids, carbohydrates tannins, saponnins and resin tests were carried out on all the fractions. The results obtained are shown in Tables II. RESULTS AND DISCUSSION Antimicrobial efficacy of different solvent extracts of root-bark of Carissa edulis against human pathogen bacteria (Zones of inhibition in millimeters). Table I. Antimicrobial activity of the extracts from root-bark of:

Plant Fraction Microorganism E. coli K.pneumonia S. aureus S.species

Car

issa

edu

lis

Ethanol 13.50±0.10 8.32±0.16 - -

Pet- ether 19.45±0.14 17.36±0.13 21.15±0.16 6.54±0.10

Ethyl acetate 09.05±0.44 06.32±0.43 05.32±0.43 -

Chloroform 14.51±0.11 15.51±0.11 09.00±0.44 -

Acetone 02.13±0.14 05.43±0.21 05.43±0.21 -

Control Gentamicin 21.65±0.10 13.85±0.15 14.65±0.15 9.50±0.10 Table II Phytochemical analysis of root-bark of Carissa eduli: Test for: Ethanol Pet. Ether Ethyl acetate Chloroform Acetone Alkaloids. + + + + + Saponnins - - - - - Sterols + + - + + Resin + + - + + Key: Absent (-); Present (+) From the results, the ethanol extract is active only on the E. coli, distorted on the K. pneumonia and inactive on other bacteria. The pet-ether extract showed the highest activity at all concentrations with zone of inhibition of 21.15 mm on the S. aureus. This followed by the chloroform fraction at higher concentrations (>1000) with an inhibition zone of 15.51mm, though moderately active on the other microbes. This may be due to its oxidation to phosgene. The ethyl acetate and acetone fractions are active on three of the micro-organisms. S. species is inactive to all the fractions. It must have developed resistance against the extracts. Other observation is that there are morphogenetic and phenotogenical variations of

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K. B. Abdu et al: Continental J. Tropical Medicine 2: 1 - 6, 2008. plants harvested at the vegetative, floral budding, full flowering, fresh fruiting and mature fruiting stages (Cuneyt et al; 2007). Phytochemical screening portrays that most of the natural products tested for were present in the plant material except saponnins. This shows the generality of the components in medicinal plants. Biological actions are due to these components in complicated concert of synergistic or antagonistic activities. Mixtures of such chemicals show a broad spectrum of biological effects and pharmacological properties. To a large extent, the phonological age of the plant, percentage humidity of the harvested material, situation and time of harvest, and the method of extraction are possible sources of variation in the chemical composition, toxicity and bioactivity of the extracts (Felix, 1982). It is difficult though, to make connections between the present findings and the acclaimed efficacy of these plants on the management of tuberculosis. However studies have indicated that certain biflavonoids have inhibitory activity against Mycobacterium that causes tuberculosis (Lin et al., 2001) and other components that act in similar way as the Isoniazid, Rifampin and Pyrazinamide, antituberculosis drugs (Sadoff, 2006) towards patients utilizing the plant studied in this work. CONCLUSION These results suggest that, pet-ether and chloroform extracts of Carissa edulis probably contain active agent(s) and this provides the basis for the folkloric claim and could be a promissory candidate for drug development and validate the tribal claim, as a cure for tuberculosis and some human ailments. This assertion is confirmed, as their extracts indicate the presence of phytochemicals. It is suggested that more work be conducted that will further elucidate and characterize the active components and possible mechanism involved in the use of these plants in the ethno medical practices. RECOMMENDATION It is desirable that more effort, more research, more support, and more funding be encouraged specially in valorizing our natural patrimony as well as conducting more scientific researches on local herbs. This will ensure that the entire ethno- flora of the sanctuary be documented in a way that information about sustainable uses of plants is conserved. Our base will thus be strengthen and it will foster greater compatibility between orthodox and ethno medical claims paving the way to the discovery of “lead” compound(s) to our present day ailments. REFERENCES Aja`afar,B.I. (1982) :Northern Nigeria medicinal Plants a sources of Drugs Unpublished work; Bayero University ,Kano. Department of Chemistry. B.Sc project. Almagboul, A.Z,,Bashir,A.K. Farouk,A and Karim,A (1985): Antimicrobial Activity of certain Sudanese plants used in Folkoric medicine.screening of antibacterial activity (IV). Fitoterapia 56:33-37 Chidambara,K; Vanitha, A., Mahadeva,M., and Ravishankar, G; (2003): Antioxidant and antimicrobial activity of Cissus quandrangularis L. Journal of Medicinal Food,6 number 2. Cuneyt Cirak, Jolita Radusiere:Hypericins in Hypercum montbreti (2007),Variation among parts and phenological stages. Medicinal and Aromatic plant science and biotechnology.1: 253 – 256. Emokpae, M. A., E. E. Nwokedi and A. I. Dutse (2006) Biochemical changes in adult Nigerians with pulmonary tuberculosis in Kano-Nigeria Highland Medical Research Journal 4(1): 15-21 Fatope .M.O and Adoum .O.A. (1993), Bioactivity of some savanna plants in the brine shrimp lethality test and in-vitro anti-microbial assay. Int. J Pharmacognosy 35(5) 334-337 Fatope,M .O. (2001) Looking back and looking forward; Natural Product Science.

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K. B. Abdu et al: Continental J. Tropical Medicine 2: 1 - 6, 2008. Festus, M; Tolo; Geoffrey, M; Rukunga, Faith, W; Muli, Eliud, N.M; Njagi; Wilson Njue, Kazuko Kumon; Geoffrey M. Mungai; Charles N. Muthaura,; Joseph M. Muli; Lucia K. Keter; Esau Oishi; and Mawuli, W; Kofi-Tsekpo; (2006): Anti-viral activity of the extracts of a Kenyan medicinal plant Carissa edulis against herpes simplex virus Journal of Ethnopharmacology, 104, , 92-99. FHI: Family Health International (2001): Kano State, Nigeria. Report of the In-Depth Assessment of the HIV/AIDS Situation Institute for HIV/AIDS. 2101 Wilson Blvd., Suite 700 Arlington, VA 22201 USA. Ganguly R., Mishra P. and Sharma A. (2001). Microbes and infection. Indian J. Microbio. 41: 211–213. Gutmann L., Billot-Klein D., Williamson R., Goldstein F. W., Mounier J.,Acar F. and Collatz E. (1988). Antimicrob. Agents Chemothe. 32: 195–201.

Habibovic, P., Barrere, F., Van Blitterswijk, C. A., De Groot, K. and Layrolle, P. (2002), Biomimeitic hydroxyapatite coating on metal implants. J. Am. Ceram. Soc. 85, 517–522. Hammer, K (1999) Antimicrobial activity of essential oils and other plant extracts Journal of Applied Microbiology 86:985-990. Harborne, J. B; (1992): Phytochemical methods. Chapman and Hall publications,London. 7–8. Harborne, J. B. (1973): Phytochemical Methods: A Guide to modern techniques of Plant Analysis; Charpman and Hall, London, p. 279. Lin, Y. M., Flavin, M. T., Cassidy, C. S., Mar, A., Chen, F. C. (2001): Bioflavonoid as novel anti-tuberculosis agents. Bioorg Med Chem Lett. 20; 11(16):2101-4. Mackie, and McCartney; (1989): Practical Medicinal Microbiology 3rd edtion, Vol 2 Churchill Livingstone (Publishers), London and New York. Page 100-106 121,141,163-167,303,432-491. Martino, P. D; Gagniere, H; Berry, H; and Bret, L; (2002): Anti-microbial Agents.Microbes and Infection. 4: 613–620. Mathias, A. J., Somashekar, R. K; Sumithra, S. and Subramanya, S; (2000): Ant- microbe. Agents: Indian J. Microbio. 40: 183–190. Mitsuyama, J., Hiruma, R., Yamaguchi, A; and Sawai, T; (1987): Antimicrob.Agents: Chemothe. 31: 379–384. Nedi, T, Mekonnen, N, Urgak, K; (2004): Diuretic effect of the crude extracts of Carissa edulis in rats. J.Ethnopharmacol 95 (1):57-61, Nwankwo, E. K., A. Kwaru, A; Ofulu, and Babashani, M; (2005): Haematological Changes in Tuberculosis in Kano, Nigeria Journal of Medical Laboratory Sciences 14(2):35-39 Richard Pankhurst, (1990): An Introduction to the Medical History of Ethiopia (Trenton: Red SeaPress), p. 97 (http://en.wikipedia.org/wiki.Acacia). Sadoff, J. (2006). Advances in Tuberculosis Vaccine Strategies. Nature Reviews Microbiology. 4: 2-8

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K. B. Abdu et al: Continental J. Tropical Medicine 2: 1 - 6, 2008. Received for Publication: 12/06/2008 Accepted for Publication: 29/07/2008 Corresponding Author: M. E. Khan

Department of Chemistry, Gombe State University, Gombe, Nigeria

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Continental J. Tropical Medicine 2: 7 - 13, 2008. © Wilolud Online Journals, 2008.

COMPARATIVE STUDY ON PHYSICOCHEMICAL VARIATION OF MICROSTYLIS WALLICHII: A

DRUG USED IN AYURVEDA

Alok Sharma1, R.K. Tiwari2, L.K. Tyagi3, Modhak R. Sharma4 and Kruna Shankar2 1JSS College Phytopharmacy and Phytomedicine, JSS College of Pharmacy, Ooty, India.

2Drug Standardisation Research Unit, Central Institute 474/6, Sitapur Road, Lucknow, India 3Formulation and Development Section, Ranbaxy Laboratories, Gurgaon, Haryana, India.

3Department of Pharmacy, National Institute of Medical Science, Shobha Nagar, Jaipur. India 4College of Pharmaceutical Sciences, Manipal, Karnataka, India

ABSTRACT

The present study is intended primarily to confirm harmonization with respect to quality of the drug. In the lack of proper production and supply system and the increasing demands of herbal drug are the major factors promoting the practices of adulteration and substitution. Therefore, the standardization of the herbal drugs is essential for assuring the therapeutic efficacy of the herbal drugs. The comparative studies were carried out to evaluate the pharmacognostical as well as physico-chemical standards of Microstylis wallichii with emphasis on TLC fingerprinting of the drug for chemical identification. Samples were procured from two diverse vicinities to determine the quality variations varied with the place of collections. The physiological and non-physiological contaminations were also reported.

KEYWORDS- Microstylis wallichii, Physico-chemical studies, Standardization, TLC studies, Ash-value, Herbal drugs

INTRODUCTION Microstylis wallichii Lindl is a Rasayana and belongs to the “Ashtverga.’. It constitutes a group of eight drugs, which form an important constituent of a number of Ayurvedic preparations with the help of which wonderful cures have been claimed, but these drugs have not been properly identified even today. These drugs are known in Sanskrit as Jiwak, Rishbhak (Microstylis wallichii Lindl), Mahameda, Meda, Kakoli, Kharkakoli, Ridhi and Bridhi (Chunekar, 1982). Extremely vague descriptions about these are available in the Ayurvedic literature and it has so far not been possible to ascertain what particular botanical plants actually these are. The result is that all sorts of plants are currently being used as “Ashtaverg” (Chopra et al., 1956). Microstylis wallichii Lindl. var. bilbo (Lindl) Hook (family: Orchidaceae) has also been reported by another vernacular name Malaxis accuminata D. Don (Rastogi and Mehrotra, 1993). Morphological and histological characters of the drug have been reported (Bhatnagar and Shant, 1966). The extensive literature survey of the plant revealed that the no research work dealing with the isolation and characterization of phytochemicals and their pharmacological activities of Microstylis wallichii Lindl has been carried out so far. However, one sterol namely β-sitosterol and an alcohol identified as cetyl alcohol, two sugars namely glucose and rhamnose and five basic compounds one of them being cholin were reported from the Microstylis wallichii Lindl (Bhatnagar et al., 1970). Limonene, eugenon, citronellal, 1,8- cineole, piperitone and p-cymene were reported to occur in Malaxis accuminata by thin layer chromatographic separation (Gupta et al., 1978). In this study we aimed to provide more information and scientific validation of the Microstylis wallichii Lindl for the acclaimed medicinal use and to determine the quality of the drug varied with the place of collection from two diverse vicinity.

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Alok Sharma et al: Continental J. Tropical Medicine 2: 7 - 13, 2008. MATERIALS AND METHODS The tubers of Microstylis wallichii Lindl were supplied by Regional Research Institute, Tarikhet (Ranikhet), Uttranchal and also purchased from herbal drug supplier, Lucknow U.P (Table 1). Microtome section were taken, stained and mounted following the usual plant micro-techniques (Kay., 1938 ; Johnsen., 1940) and representative diagram were sketched through Lucida camera. For study of isolated cells and tissues, small pieces of tubers were macerated with schult’s fluid, washed and mounted in glycerin. Physio-chemical test were carried out adopting, standard procedure (Trease and Evan., 1983 ; Kokate et al., 2001).

Ash-value, solubility (cold percolation and graded extraction) in the various solvents such as petroleum ether, alcohol (95%) and water values, screening of thin layer chromatography, effect of different chemical reagents and florescence analysis under ultra-violet radiation which are considered to be immense help in detection of adulterants were also carried out (Chase and Pratt., 1949 ; API, 1999 ; PSAF, 1987 ; Winton and Winton., 2001). Qualitative for identification of phyto-constiuents like alkaloids, steroids terpenoids, phenols, tannins, saponins and flavinoids etc, were also carried out (Kokate et al., 2001). TLC Analysis Various extracts of Microstylis wallichii Lindl were subjected to TLC on silica gel-G (manually coated on glass plate in laboratory). Various combinations of the solvents of different polarity were adjusted to found out the suitable TLC pattern of the drug. The resolution pattern was detected in iodine-chambers and Lieberman-reagent. They are summarized in Table 7. RESULTS Description of Tubers The tubers were 3-6 cm long, 0.5-1.0 cm thick and have a fibrous root, which arises from the base. Odour was characteristic with no taste; surface was smooth and brown, yellowish in colour. They were covered externally with white papery membrane. Organoleptic identification of Microstylis wallichii Lindl. have been summarized in Table 2. Powder Description Microscopic examination of the powder showed calcium oxalate crystals of various shapes and sizes, parenchymatous cells single or in groups containing yellowish brown pigments. Fibres, vessels and trachoids were single or in groups. No fungus had developed during storage. Transverse section. of Microstylis wallichii Lindl was circular in outline. Epidermal cells were barrel shaped having cuticle in outline. Below epidermis, large ground tissue consisting of parenchymatous cells. Parenchymatous cells towards epidermis were smaller in size while towards center they were bigger. Parenchymatous cells had sufficient inter-cellular spaces. Vascular bundles were scattered in ground tissue. Phloem was encircled by xylem. Numerous mucilage canals were present in ground tissue. Vascular elements showed scalariform and spiral thickening (Figure 1). DISCUSSION The powder of the drug Microstylis wallichii Lindl was non-hygroscopic in nature. The qualitative analysis of both the samples (Tarikhet and market) was showed that the most of the major plant metabolites are common, except for alkaloids and flavonoides, which were negative in the market sample (Table 3). The difference in foaming index of both the samples of Microstylis wallichii Lindl (Tarikhet<1000 and Market 333) indicate that the foaming ability of the drug decoction is governed by the nutrient and chemical nature of the soil from which the drug is collected (Table 4). Comparative lower value of swelling index (Tarikhet 1.92, Market 1.12) reveals that the Tarikhet sample of Microstylis wallichii Lindl having appreciably more amounts of mucilage, pectin and hemicellulose compared to the market sample (Table 4). The comparison of total ash value suggests that the total physiological and non-physiological ash is higher in Tarikhet sample compared to the market sample (Table 4). But the non-physiological ash (acid insoluble

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Alok Sharma et al: Continental J. Tropical Medicine 2: 7 - 13, 2008. value), clearly indicate that the market sample is contaminated with silica or siliceous matters. The chemical assay of Microstylis wallichii Lindl is yet to be instituted. The variation in extractable matter in various solvents is suggestive of the fact that the formation of bioactive principles of medicinal plants is influenced by number of intrinsic and extrinsic factors, leading to strange qualitative and quantitative changes making such plants totally unfit for prescribed purpose even of same species. This is highlighting the importance of chemical mapping of the drug species. Behavior of drug powder in different reagents was observed under ordinary light and UV radiation (254 and 366nm) (Tables 5&6). None of reagent shows the diagnostic colour reaction under either ordinary or UV radiation. The TLC patterns were recorded and the results are tabulated (Table-7). Following the instruction of Indian Herbal Pharmacopoeia (IHP, 1999) TLC pattern of purified methanol fraction (the coloring matter was removed with the help of activated charcoal) was obtained. The preliminary TLC studies revealed that the solvent system was ideal and gave the well-resolved spot of the fractions. The chemical mapping of various extracts of Microstylis wallichii Lindl was carried out by means of thin layer chromatography. Thus the quality of the wild crafted drug Microstylis wallichii Lindl varied with the place of collection. However, this conclusion required further experimental elaboration. Therefore, more useful work for purification, isolation and characterization on bioactive compound of Microstylis wallichii Lindl are required. ACKNOWLEDGEMENT The authors are thankful to the Dr. G. S. Lavekar, Director, Central council for research in Ayurveda and Siddha (CCRAS), New Delhi for financial assistance and constant encouragement. The help rendered by C.N. Singh is greatly appreciated. REFERENCES API (Ayurvedic Pharmacopoeia of India). (1999), Ministry of Health and Family Welfare, Govt of India, New Delhi. 1(2), 70-79. Bhatnagar J.K., Handa S.S. and Duggal S.C. (1970), Chemical investigation on Microstylis wallichii., Planta Medica., 20, 157-161. Bhatnagar J.K. and Shant S.S. (1966), Jiwak its botanical source and pharmacognostic character In: Proceeding Indian Pharmaceutical Congress, Bombay, India. 339. Chase C.R. and Pratt F.J. (1949), Fluorescence of powered vegetable drugs with particular reference to development of a system of identification. J.Am.Pharm.Assoc., 38, 324 -333. Chopra I.C., Handa K.L. and Sobti S.N. (1956), Need for the cultivation of vegetable drugs used in Ayurvedic and Unani Medicine, Ind. J. of Pharm., 18, 364-377. Chunekar K.C. (1982), Bhavaprakasa Nighantu. Chaukhambha Bharti Academy, Varanasi, India., 498 - 490. Gupta R., Agarwal M. and Baslas R.K. (1978), Chromatographic seperation and identification of various constituents of essential oil from the bulb of M. accuminata, Indian Perfume., 22 (4), 287-288. IHP (Indian Herbal Pharmacopoeia). (1999), IDMA, Mumbai and RRL Jammu, 1, 1-17 & 64-72. Johnsen D.A. (1940), Plant Micro-Technique. Mc-Graw Hill Book Co. Inc. New York., 182-203. Kay A.L. (1938), Microscopically Studies on Drugs., Balliere Tindall and Cox, London., 18. Kokate C.K., Purohit A.P. and Gokhle, S.B. (2001), Pharmacognosy, Nirali Prakashan, Pune, India., 1-18.

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Alok Sharma et al: Continental J. Tropical Medicine 2: 7 - 13, 2008. PSAF (Pharmacopoeial Standards for Ayurvedic Formulations). (1987), Central Council for Research in Ayurveda and Siddhha, Ministry of Health and Family Welfare, Govt of India, New Delhi. Rastogi R.P. and Mehrotra B.N. (1993), Compendium of Indian Medicinal Plants, 3, 425. Trease G.E. and Evan W.C. (1983), Pharmacognosy, ed 12, English Language Book Society , Balliere, Tindall, 309-315 & 706-708. Winton A.L. and Winton K.B. (2001), Techniques of Food Analysis, Agrobios, India, 110-112.

Table 1: The topographical details of collection of Microstylis wallichii Lindl.

Place of collection Supplied by CRI, Tarikhet (Uttaranchal)

Market Sample*

Time of collection NP - Location NP - Climate Subtropical region, Hill area. -

Rainfall average 50-70 cm (Annual) - NP- Not provided by the genuine drug supply unit. * No information regarding the origin of sample. Table 2: Organoleptic identification of Microstylis wallichii Lindl.

Parameters Observations

Tarikhet sample Market Sample

Botanical

Sensory Evaluation Visual macroscopy Touch Odour Taste Colour

Curved Rough Characteristic Light sweet Green to brown

Curved Rough Characteristic Tasteless Yellowish to brown

Foreign Organic Matter No adulterants have been found No adulterants have been found

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Alok Sharma et al: Continental J. Tropical Medicine 2: 7 - 13, 2008. Table 3: Qualitative analysis of plant metabolites (primary and secondary both) of Microstylis wallichii Lindl.

S. No Phytochemicals Microstylis wallichii Lindl (Tarikhet sample)

Microstylis wallichii Lindl (Market sample)

1. Alkaloid +ve -ve

2. Carbohydrate +ve +ve

3. Flavonoid +ve -ve

4. Protein -ve -ve

5. Resin +ve +ve

6. Saponin +ve +ve

7. Starch +ve +ve

8. Steroids +ve +ve

9. Tannin +ve +ve

10. Triterpenoids -ve -ve

Table 4: Physico-chemical Parameters of Microstylis wallichii Lindl. S. N0. Parameters Observations

Tarikhet sample Market Sample

1. Physicochemical

Ash Values (% w/w)

a) Total Ash Value b) Acid Insoluble Ash c) Water Soluble Ash

6.25 ± 0.50 3.00 ± 0.03 4.00 ± 0.43

4.80 ± 0.39 3.75 ± 0.04 4.00 ± 0.43

Extractive values (% w/w)

Cold percolation method PE (40-60°) EtOH (95%) H2O

4.66±0.3 4.80±0.3 6.25±0.5

9.50 ± 0.4 4.66 ± 0.8 18.3 ± 1.2

2.

Soxhlet graded extraction method PE (40-60°) EtOH (95%) H2O Moisture content (Tarikhet sample fresh; Market sample -air dried) Volatile Oils (%v/w) Pharmacological Swelling Index Foaming Index

6.25 ± 0.4 4.75 ± 0.4 11.25 ± 0.9 36.49 ± 1.18 (% w/w) By Hot air Oven method 35.12 ± 0.98 (%v/w) By Azeotropic method 0.54 ± 0.28 1.92 ± 0.14 more than 1000

8.00±0.5 5.00±0.7 10.00±0.9 6.65± 0.50 (% w/w) By Hot air Oven method 7.02 ± 0.42 (%v/w) By Azeotropic method ND 1.72±0.20 333

Values presented are mean of triplicate (Mean ± S. d.), ND-: Not detected

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Alok Sharma et al: Continental J. Tropical Medicine 2: 7 - 13, 2008. Table 5: Behavior of Microstylis wallichii Lindl (Tarikhet ) powder with different reagents observed under ordinary light and UV-radiation.

S.NO. Interaction of Microstylis wallichii Lindl (Tarikhet Sample) powder with different reagent

Colour produced under ordinary light Colour produced under

UV-radiation

Short (254nm) wavelength

Long (366nm) wavelength

1. Drug (P) as such Grey Blue Violet 2. P + Nitrocellulose in amyl acetate Brown Pink Green

3. P+1N.NaOH in water Light Brown Violet Light Green 4. P+1N.NaOH+ Nitrocellulose in

amyl acetate Dark Brown Brown Dark Green

5. P+1N.HCL+Nitrocellulose in amyl acetate

Brown Dark Brown Brown

6. P+1N.NaOH in Methanol Grey Red Green 7. P+50%KOH Brown Pink Brown 8. P+1N.HCL Light Brown Violet Dark Brown 9. P+50%H2SO4 Brown Brown Pink 10. P+50%HNO3 Violet Dark Brown Brown 11. P+Conc.HNO3 Brick Red Brown Light Brown 12. P+ Acetic acid Grey Light grey Violet 13. P+Conc. H2SO4 Light Brown Dark red Brown 14. P+ Iodine water Brown Brown Dark Brown

Table 6: Behaviour of Microstylis wallichii Lindl (Market sample) powder of pseudobulb with different reagents observed under ordinary light and UV-radiation.

S.NO. Interaction of Microstylis wallichii Lindl (Market Sample) powder with different reagent

Colour produced under ordinary light

Colour produced under

UV-radiation

Short (254nm) wavelength

Long (366nm) wavelength

1. Drug (P) as such Grey Blue Violet 2. P+ Nitrocellulose in amyl acetate Brown Pink Green 3. P+1N.NaOH in water Light Brown Violet Light Green 4. P+1N.NaOH+ Nitrocellulose in

amyl acetate Dark Brown Brown Dark Green

5. P+1N.HCL+Nitrocellulose in amyl acetate

Brown Dark Brown Brown

6. P+1N.NaOH in Methanol Grey Red Green 7. P+50%KOH Brown Pink brown 8. 9. 10.

P+1N.HCL P+50%H2SO4 P+50%HNO3

Light brown Brown Violet

Violet Brown Dark Brown

Dark Brown Pink

Brown 11. P+Conc. H2SO4

Brick Red Brown Light Brown

12. P+ Acetic acid Yellow Grey Light yellow 13. P+Conc. H2SO4 Light Brown Dark red Brown 14. P+ Iodine water Brown Brown Dark brown

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Alok Sharma et al: Continental J. Tropical Medicine 2: 7 - 13, 2008.

Table 7: Thin Layer Chromatographic pattern of extract of Microstylis wallichii Lindl (pseudobulb) of Tarikhet and Market samples.

S.N0. Stationary Phase Solvent System Loading Extract Visualisation/ Detection

Rf Value (Rf x 100)

1. Silica gel-G Toluene:EtOAc:MeOH:AcOH (20:4:1:2drop)

MeOH (graded) Market

I2 35.7, 57.1, 71.4, 85.7

2. Silica gel-G Toluene:C2H5O C2H5

(3:1) MeOH (Cold) Market

I2 64.2, 75.0, 86.4

3. Silica gel-G C6H6:Toluene:MeOH:AcOH(15:5:5:2drops)

MeOH (graded) Market

I2 33.3, 44.4, 53.3, 56.0

4. Silica gel-G Hexane:Acetone:MeOH(2:2:1)

MeOH (graded) Tarikhet

LB 23.0, 40.0, 55.0, 69.0

5. Silica gel-G MeOH: CHCl3:Hexane (1:1:4)

MeOH (Cold) Tarikhet

LB 10.7, 25.0, 42.0, 75.0, 67.2, 72.6, 82.0, 85.0

Silica gel-G ……..do….. MeOH (graded) Tarikhet

…do.. 17.0, 35.7, 46.0, 57.0, 71.0

6. Silica gel-G PE: C6H6 (1:2) PE (Cold) Market

LB 22.0, 33.0, 48.0, 62.0

Silica gel-G ……..do……. PE (graded) Market

LB 33.0, 37.0, 77.0, 81.4

7. Silica gel-G Heptane:n-butanol: MeOH(3:2:1)

MeOH (graded)Market

I2 15.3, 30.7, 53.0, 53.8,, 76.9

Silica gel-G …….do……. (Tarikhet Sample)

..do… 15.3, 30.7, 53.8, 73.7

8. Silica gel-G Hexane:Acetone:AcOH (20:10:2drop)

MeOH (graded)Market

I2 26.6, 36.6, 66.6

Silica gel-G …….do……. (Tarikhet Sample)

..do… 13.3, 20.0, 33.8, 54.7

9. Silica gel-G Heptane:EtOH(2:1) PE (graded)Market

I2 37.5, 50.0, 62.5, 66.6, 90.0

Silica gel-G …….do……. (Tarikhet Sample)

..do… 37.5, 41.6, 50.0, 62.5, 90.0

10. Silica gel-G Hexane: CHCl3: MeOH(4:1:1)

PE (graded) Market

I2 57.6, 73.0, 84.6, 96.0

Silica gel-G …….do……. (Tarikhet Sample)

..do… 57.6, 76.0, 84.6, 96.0

MeOH-: Methanol, EtOH-:Ethanol, PE-:Petroleum ether, CHCl3-:Chloroform , C6H6-:Benzene, EtOAc-:Ethyl acetate, C2H5OC2H5-:Diethyl ether

Received for Publication: 12/06/2008 Accepted for Publication: 29/07/2008 Corresponding Author: Alok Sharma JSS College Phytopharmacy and Phytomedicine, JSS College of Pharmacy, Ooty, India. Email: alokaloksharma@rediffmail.com

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Continental J. Tropical Medicine 2: 14 - 25, 2008. © Wilolud Online Journals, 2008. REDUCING HIGH MATERNAL MORTALITY IN DEVELOPING COUNTRIES: PROPOSITION FOR

ADOPTION OF UNCONVENTIONAL APPROACHES

OFILI Mary Isioma1, IRINOYE Omolola2, AKINTOMIDE Anthony3, ONYESOM, Innocent4, ADEYEMI Adebanjo Babalola5.

1Department of Nursing Science, Delta State University, Abraka, 2Department of Nursing Science,

Obafemi Awolowo University, Ile-Ife, Nigeria, 3Department of Medicine Obafemi Awolowo University, Ile-Ife, Nigeria, 4Department of Medical Biochemistry, Delta State University, Abraka 5Department of

Obstetrics and Gynaecology, Obafemi Awolowo University, Ile-Ife, Nigeria.

ABSTRACT Pregnancy and child birth are events that occur in the lives of women who are otherwise healthy only that they are fulfilling biological functions for the survival of the human species. Child birth is a physiological phenomenon, not a disease, yet women die in pregnancy and child birth. Of all the health statistics monitored by the World Health Organization, maternal mortality is the one with the largest discrepancy between developed and developing countries. In areas where the problem is greatest, most deaths go unregistered hence, the tendency to underestimate the gravity of the situation. The global objective following the launching of the safe motherhood initiative in Nairobi, Kenya in 1987 to reduce maternal mortality by 50% by the year 2000 has not been actualized. The death of a woman in the prime of her life from a pregnancy related cause that could have been either prevented or treated with simple existing technologies is an unmitigated tragedy. Much could be done to lower this appalling waste of life through these unconventional approaches. The experience in Zaire is a dramatic demonstration of what is possible if one does not follow conventional approaches when they are simply impossible. This report attempts to review the causes of maternal mortality and the impact of conventional approaches to its management. The ameliorating roles of unconventional approaches to the management of maternal mortality is also examined and proposed for adoption. KEYWORDS: Maternal mortality, Developing Countries, Safe motherhood, Childbirth, Pregnancy

INTRODUCTION Death is real and inevitable. It occurs at any prime in life even in mothers especially during the period of parturition. Maternal mortality is among the leading causes, if not the leading cause of death among women of reproductive age in most of the developing world (WHO, 1991). Child birth is a physiological phenomenon, not a disease yet, World Health Organization (WHO, 1991) estimates that half a million women die in pregnancy and child birth each year in developing countries. In the western countries like England, child bearing has largely ceased to be the “death – trap” which it was known to be before the universal recognition and wide acceptance of the benefits of ante-natal care and hospital delivery. However, in the developing countries like Nigeria, where pregnancy is welcomed with a childish glee, its probable outcome is regarded with uncertainty and apprehension and its termination often ending in catastrophe because of poor access and inability to maximally benefit from ante-natal care and hospital delivery. Of all the health statistics monitored by the World Health Organization, maternal mortality is the one with the largest discrepancy between developed and developing countries. While infant mortality, for example,

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008. is almost seven times higher in developing countries, maternal mortality is on the average 18 times higher (WHO, 1996). In areas where the problem is greatest, most maternal deaths go unregistered. There has therefore, been a tendency to underestimate the gravity of the situation. In developed countries, the maternal mortality ratio averages around 27 maternal deaths per 100,000 live births; in developing countries, the ratio is nearly 20 times higher, at 480 per 100,000 live births, and may be as high as 1,000 per 100,000 live births in some regions (WHO, 1996).

1600

1500

1400 1200 1000

1000

800 800

600

400

200 1987-1990 1992-1995 1997-2000

Fig 1.Maternal Mortality Ratio in Nigeria (1987-2000) Source: WHO/UNICEF, 2001

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008. In parallel to this, for every maternal death in developing countries, as many as 20 to 40 or more women sustain serious, debilitating injuries (WHO, 1996). In Nigeria, maternal mortality estimates, ranged from about 35,000 in 1987 to between 40 to 50,000 in 2000 (WHO/ UNICEF, 2001). Actual figures per 100,000 live births have been provided (Fig.1). Similarly, increasing age is associated with a steep rise in maternal mortality with the lowest seen among the very young (under 18) and the highest in older women (over 35) most particularly among high parity women with 4 or more children (Rosenfield and Maine, 1992). On 11th February, 1987, the first international Safe Motherhood Conference took place in Nairobi, Kenya, and the goal of a 50% reduction in the 1990 levels of maternal mortality by the year 2000 was formulated giving maternal mortality a high priority. The global objective following the launching of the safe motherhood initiative in Nairobi, Kenya in 1987 to reduce maternal mortality by 50% by the year 2000 may not have been realized. Instead, every year, higher figures of maternal mortality ratios up from half a million deaths to between 600,000 and one million deaths are being reported and as always, about 99% of these in developing countries (Abou-Zohr, 1997, WHO, 1996). Not least is the fact that maternal mortality in Sub-Saharan Africa is rising than falling as it has done in all other regions of the developing world particularly in the rural areas, where most people live and where modern medical services and personnel generally are not available (Rosenfield and Maine, 1992). Despite the safe motherhood initiative, a hard evidence demonstrates that much of the good work done have failed to come to fruition hence Rosenfield and Maine, (1997) were justified to ask the question “where is the M in Maternal and Child Health” emphasizing the lack of attention to the persistent high maternal morbidity and mortality rates. CAUSES OF MATERNAL MORTALITY IN DEVELOPING COUNTRIES The medical causes of maternal death are remarkably similar throughout the world and the general factors responsible for such death have continued to escalate especially in developing countries, including ours. Some of these contributing factors include the near collapse of supportive socio-economic and political structures leading to increased poverty, ignorance, suffering and non-availability or breakdown of health services (Onwudiegwu, 2000). Five major common causes of deaths during pregnancy have been identified: a. Direct and indirect obstetric causes. b. Reproductive health factors. c. Socioeconomic/cultural factors. d. Poor social infrastructure. e. Health services factor.

a. Direct Obstetric Causes i. Hemorrhage: Globally, some 25% of all maternal deaths are due to hemorrhage (WHO/UNFPA/

UNICEF/World Bank, 1999). Common origins of hemorrhage are ante-partum (placenta praevia and abruptio placentae) and post-partum (primary and secondary from ruptured uterus, uterine atony, cervical lacerations, retained products of conception and others. Hemorrhage is more dangerous when a woman is anemic (WHO/UNFPA/UNICEF/World Bank, 1999). Blood loss can very rapidly lead to death in the absence of prompt and appropriate life saving care which includes the administration of drugs to control bleeding, massage of the uterus to stimulate contractions and blood transfusion if necessary. Very few women with this complication in a rural setting will survive a trip to distant facility (Rosenfield and Maine, 1992).

ii. Pregnancy-induced hypertension (pre-eclampsia/Eclampsia): Particularly, eclampsia (convulsion)

is the cause of approximately 12% of all maternal deaths (WHO/UNFPA/UNICEF/World Bank 1999). Deaths from hypertensive disorders can be prevented by careful monitoring during

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008.

pregnancy and by treatment with relatively simple anticonvulsant drugs (e.g., magnesium sulphate) in cases of eclampsia. Little can be done for this complication at the rural level other than to recommend bed rest and possibly the use of sedatives (Rosenfield and Maine, 1992). However, prompt transfer to a first referral level facility is also important (Rosenfield and Maine, 1992).

iii. Obstructed Labour/Prolonged Labour: This accounts for about 8% of maternal deaths

(WHO/UNFPA/UNICEF/World Bank, 1999). It is often caused by cephalo-pelvic disproportion (when the infant’s head cannot pass through the maternal pelvis) or by abnormal lie (when the infant is incorrectly positioned for passage through the birth canal) (Brown, et al., 1999). Disproportion is more common where malnutrition is endemic, especially among the populations with various traditions and taboos regarding the diet of girls and women and it is worse where girls marry young and are expected to prove their fertility often before they are fully grown (WHO/UNFPA/UNICEF/World Bank, 1999).

iv. Infection/Sepsis: This is often a consequence of poor hygiene during delivery or of untreated

sexually transmitted diseases (STDs). It accounts for some 15% of maternal deaths (WHO/UNFPA/UNICEF/World Bank, 1999). Such infection can be effectively prevented by careful attention to clean delivery and by detection and management of STDs during pregnancy. Systematic post partum care will ensure rapid detection of infection and its management by appropriate antibiotics.

v. Complications of Unsafe Abortion: This is responsible for a substantial proportion (13%) of

maternal deaths and is usually carried out by quacks and in unhygienic environments (WHO/UNFPA/UNICEF/World Bank, 1999). The legalization of abortion is the most controversial of all issues within the field of reproductive heath (Rosenfield and Maine, 1992). Abortion contribution to maternal mortality figures is similarly on the increase, no thanks to increased sexual activity among adolescents, low contraceptive usage, restrictive abortion laws and increased activity of quack abortionists and increased rate of clandestine abortions (Onwudiegwu, 2000).

The socio-demographic characteristics of patients who undergo illegal abortion are often similar and are usually students having elementary to high school education, 15 to 24 years of age, single and who have family planning knowledge but do not use any contraceptive method. (Staffan, et al., 1993). This indicates that there is a need for preventive action in this vulnerable age group. Regarding the social context of unwanted pregnancies and induced abortion, Okonofua (1995) in his study noted that the desire to remain in school or to space badly timed pregnancies were frequently mentioned reasons for seeking induced abortions. A substantial proportion of the women became pregnant as a result of failed contraception and a few others mentioned the social unacceptability of the indicated pregnancy. The results of the study suggested that there is a large need for family planning among married and unmarried women and this need have remained unmet as a result of lack of effective use of contraception. Clearly, there is a need to design or reformulate community based approaches to enable women gain access to contraceptives need for the prevention of unwanted pregnancies and induced abortion in this country (Okonofua, 1995). Where abortion is not prohibited by law, safe abortion care should be maintained. Indirect Obstetric Causes: Approximately, 20% of maternal deaths are as the result of pre-existing conditions that is exacerbated by pregnancy or its management (WHO/UNFPA/UNICEF/World Bank, 1999). One of the most significant of these indirect causes of death is anemia, other important indirect causes include malaria, hepatitis, heart diseases and increasingly in some settings HIV/AIDS (WHO/UNFPA/UNICEF/World Bank, 1999).

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008. b. Reproductive Health Factors

These include: i Early onset of child bearing (below 18 years of age). Studies from many countries have shown that

young girls are forced to become sexually active at a very early age. (Staffan, et al., 1993). This may lead to difficult labour because of sub-optimal pelvic development.

ii. Too often, inadequate child spacing that is less than 2 years interval. Birth with insufficient

spacing may result in malnutrition and anemia. iii. Too many (more than 5 deliveries) often leading to complications during the pregnancy and at or

after delivery. iv. Too late (late child bearing, at age above 35), often associated with medical and obstetric

complications.

c. Socio-Economic/Cultural Factors Recent studies in Nigeria have shown that harsh economic conditions, subsidy removal and introduction of ‘user-fees’ in health services have resulted in decreased ante-natal attendances and hospital deliveries. At the same time it increases morbidity and mortality, patronage of quacks and faith clinics and avoidable deaths and complications (Onwudiegwu, 2000). Some of the identified socio-economic factors include:

i. Ignorance/illiteracy: Mass illiteracy has been identified as one of the most important factors predisposing women to high maternal mortality in developing countries. Those women who are illiterates are uninformed and often ignorant. They tend to follow traditional beliefs without questioning or reasoning. As a result there is lack of understanding and poor attitude in the utilization of ante-natal and delivery services, family planning, immunization of children and other health education matters. (Staffan, et al., 1993).

It is however, important to appreciate that being educated alone is not enough. If one is ignorant about the benefits of ante-natal care, family planning and other health services, one would still be in danger of having one’s life shortened, sequel to reproductive health mismanagement. ii. Low social status of women: Women in developing countries have been suppressed for so long. As

a result, they are hardly involved in.

iii. Poor nutrition in childhood and adolescence: This impairs growth and leads to difficult and traumatic labour and delivery.

iv. Adverse religious beliefs: This discourages the use of modern ante-natal and delivery services or rejection of specific modalities such as the use of repeat caesarean section at high risk patients. It also hinders the willingness of the patient, relatives or friends to seek care.

v. Poverty: This also discourages the use of health services. The economic structural adjustments policy has necessitated some governments to change from free health services to payment of fees. This has resulted in a decrease in attendance at health institutions because people cannot afford to pay the fees. They therefore report late, with serious complications.

vi. Lack of accountability: The lack of accountability and the misappropriation of funds among government officials have led to drainage of huge amounts of money which could have been used on development projects. Favoritisms and nepotism have allowed unqualified persons in certain

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008.

vii. positions, and this has brought about mismanagement and lackadaisical attitudes at work places (Staffan, et al., 1993).

viii. Inadequate and uncoordinated research activities: Approximately 70% of the population of developing countries is made up of women and children. Operational research activities in programmes affecting this vulnerable group are lacking especially in reproductive health. As has been so aptly noted, only until very recently was “MCH” anything but 99% “C” and 1% “M”, whilst striving to maintain the level of “C”, it is now time to raise the level of enquiry and action about the “M” (Staffan et al, 1993).

b. Poor Social Infrastructure

This includes: i. Lack/Poor communication facilities: Communication facilities like telephone or radio links could

be poor in reaching especially rural set-up.

ii. General lack of transportation facilities: Motor vehicles, ambulances and other vehicles to transport patients are scarce in developing countries. As a result, people have to cover long distances to reach a first level referral hospital. Government also seems too happy to say that they have bought ambulances, whilst the question of keeping adequate maintenance services and spending money on spare parts is forgotten. Lack of transport facilities hinders a person’s decision to go for medical help when problems arise, a last resort.

c. Health Services Factors

Studies on assessment of obstetric services still show that poor staff attitude continue to contribute to poor use of maternity services and standard facilities by women (Onwudiegwu, 2000). Some of the health services factors are:

• Unavailable/inaccessible modern ante-natal/delivery services. • Unavailable/inaccessible family planning services. • Concentration of the medical personnel and hospitals in the larger urban areas. • Lack of efficient referral services from lower to higher levels of obstetric care. • Inequitable distribution of health resources. • Wrong or ineffectual treatment given as a result of wrong diagnoses or poor facilities or

incompetent staff. • Poor staff attitude which may be responsible for the delay to receive care at the health facility. • Incompetent staff which may not only administer wrong and dangerous treatment but may delay

referral of high risk patients thus contributing to morbidity and mortality. • The socio-economic realities of today’s Nigeria no longer encourages humanitarian blood

donation, instead commercial blood donors have taken over so that emergency life saving entails prohibitive costs. As a result, there has been lack of organized national blood transfusion services. Although maternal mortality rate is one of the sensitive indices of the quality of health care in any community, the difficulty of measuring it has proved an impediment to progress in alerting health planners and others to the magnitude and causes of this problem and hence to effective interventions on appropriate scale (Chukudebelu, 1988).

A REVIEW OF CONVENTIONAL MEASURES THAT HAVE BEEN ADOPTED TO REDUCE MATERNAL MORTALITY The priority for world obstetric research should be general communication of scientific insights for preventing maternal death. According to Parker (1977) “the reduction of maternal and fetal mortality from this grave accident is entirely dependent upon its prevention”. Many factors are responsible for achieving the overall reduction in maternal mortality in developing countries during the past twenty-five years as noted by Hawkins and Higgins (1981). Most perhaps are:

20

OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008. a. The development of wide spread training and educational programmes in obstetrics which have

provided more and better qualified specialists, professional nurses and other personnel in maternity programmes.

b. Better hospital facilities, improved quality of ante-natal care, multiple safeguards provided in the modern maternity hospitals and advances in therapy have all played major roles.

c. Some changes in attitudes of physicians, nurses and parents also have contributed to this progressive saving of mothers.

d. The development of maternal and child health programmes in the state departments of public health, particularly the work of the community health nurses in maternal hygiene.

e. Education of the public about the values of ante-natal care and advantages of hospital delivery.

f. Increased funding of health services in the urban and rural areas of the nation. Despite these efforts, maternal mortality rates in the developing countries are still on the increase,

hence the need for adoption of unconventional approaches to management. WHY THE UNCONVENTIONAL APPROACH? The conventional measures that have been adopted to reduce maternal mortality encountered some problems in its implementation process. 1. The downturn in the economy unfortunately has played havoc with the actual implementation of

the budget (in increasing funding of health services). Similarly, the quality of care has decreased due to cuts in health budgets. Many governments in developing countries are in urgent need of providing food and pay less attention to the importance of public health. It is a sad commentary on the Nigeria health care that a quarter of a century after independence, it

was only in 1985 that health allocation in the Nigerian budget rose from less that 2% to 6% thus complying with World Health Organization recommendation for the first time (Chukudebelu, 1988).

2. It is important to stress that mass literacy is what is being advocated not just education of the

woman itself and not sexual and reproductive health education only. Where a woman is educated but yet surrounded by illiterates, she may still find herself, in spite of her education, unable to break out of the web of uninformed but strongly held and forcefully expressed opinions in which she is encompassed. Chukudebelu (1988) in his study noted that far too many of the expectant mothers are still keen to deliver on their own and thus prove their womanhood in accordance with native or village traditions and folklores hence the delay in coming to the hospital even when they have previous scars and are booked for a repeat section.

3. There has been increases in family planning services even though helpful but not substantial. This can only be considered marginal in view of the continued low level of contraceptive usage nationally, the unmet need among women and the absent service outlets for needy adolescents (Onwudiegwu, 2000).

4. The inequitable distribution of health resources is still a great problem in many developing countries.

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008.

5. Lastly, it is unfortunate that the vast majority of physicians, trained midwives, nurses and hospitals are located in the larger urban areas, with few such resources existing in the rural areas. As a result there has been shortage of both medical and nursing staff in the rural areas.

With the observation that these conventional, perhaps universally acceptable approaches have not successfully reduced maternal mortality, some other approaches which for now may appear unconventional are proposed. PROPOSAL FOR USE OF SOME UNCONVENTIONAL APPROACHES TO REDUCE MATERNAL MORTALITY IN DEVELOPING COUNTRIES INCLUDING NIGERIA. Tackling the serious problems of high maternal mortality requires innovativeness as well as a deliberate policy of departure from hackneyed practices and rigid conservatism (Chukudebelu, 1988). However, studies from affluent nations have shown that the dangers of pregnancy can be overcome, although it has proved an expensive exercise. It needs to be emphasized that the government needs to take a lead in setting the stage for the reduction in maternal mortality. This is because government is in the best advantaged position to draw the agenda and set the pace for the people, organizations and establishments to follow. As in many health issues, there must be political will and sustained commitment on the part of the government. On the part of the government:

1. A system could be devised whereby general duty doctors working in rural areas are periodically brought back to hospital departments of obstetrics and gynecology for retraining in basic surgical/obstetric skills like vacuum extraction, forceps delivery and caesarean sections. This scheme could be funded by the Federal Government and International Organizations.

2. Where there is no medical staff, one should consider instructing other personnel in these techniques. There have been calls for the more appropriate use of non-medical personnel for a range of procedures generally not allowed to be performed by them at present, even where there are dramatic shortages of physicians. Experience in Zaire is very important in this regard where because of severe understaffing of physicians, a pioneer missionary physician, Dr. Wallace Thormbloom, trained local nurses to perform caesarean section (emergency surgeons) in the 1950’s and later in 1984 their roles expanded to include repair of ruptured uterus, emergency supra cervical hysterectomy, laparatomies for ruptured ectopic pregnancy, symphysiotomy and suction curettage. Results revealed that in an 18-month period in 1985 – 1986, these trained nurses performed 310 emergency caesarean sections primarily for obstructed labour, uterine inertia, previous caesarean section and in few cases, for fetal distress, there were only three deaths among these 310 women, a remarkable record. Also three laparatomies for ruptured uteri in which supra-cervical hysterectomies were performed by nurses, this resulted in one death (from septic shock during surgery). It is fair to say that without these procedures, a high proportion of them would have died. Therefore, midwives should be widely trained in the management of life threatening obstetric situations and emergencies, as they are often the only source of help to labouring mothers in many rural communities though this strategy might be expensive.

3. Traditional birth attendants can illustrate the problem of delegation of responsibility. To reduce maternal mortality, it is not enough to just identify and train traditional birth attendants. It is necessary to identify the gaps between what they are presently doing and what they need to improve upon. They should be trained to monitor pregnancy, conduct safe deliveries, and carry out effective procedures like uterine massage and the means to remove a retained placenta. This should be done under supervision with a monitoring team and backed up within a functioning referral system and support from professionally trained health workers.

22

OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008. In many places, the services of skilled professional health care providers are not available and traditional birth attendants (TBAs) may be women’s only source of care.

4. It is necessary to improve flow of communication between the health care team, that is, adequate communication (link between TBAs and hospitals) for easy transfer or referral from rural communities to tertiary institutions. Although traditional birth attendants (TBAs) can provide culturally appropriate nurturing in the community setting, they could also offer a first-line link with the formal health care system if assisted to increase their ability and provide simple services such as the distribution of nutrition supplements. A useful strategy in a range of settings has been to train TBAs to recognize problems during delivery and, when necessary to guide women to and through the formal health care system with the aid of a good communication system.

5. Planning and strengthening referral and transfer (alert and transport systems) is essential. Agreements must be reached on how principal health workers and TBAs will communicate with the referral center. Alternative communication systems should be planned in case of failure of one method. Where communication is a problem, the assistance of agencies like the police, or either radio or telephone systems should be formally arranged by the health administration of the area. Transport should be planned in anticipation of emergencies, communities might be encouraged to identify their transport resources and agree on how costs could be borne.

6. Recognition of the emergency/sensitive nature of maternity services so that separate ambulance services and such others that will improve response to emergency care are provided. The National Safe Motherhood health programmes should be action-oriented and implemented in the context of broader health programmes, with emphasis on actions for improving the health of young and adolescent females, the mothers of the future. These would include the need to improve the nutrition of female children, nutritional advice and micronutrient supplementation, the prevention of early marriage and supporting education for girls, child survival and development, immunization, safe water and sanitation, family planning, the avoidance of unwanted pregnancies and the prevention and control of malaria, HIV/AIDS and other sexually transmitted diseases.

7. A diet that provides sufficient calories and micronutrients is essential for a pregnancy to be successfully carried to term. Adequate provision of these food crops should be made available in the rural setting and the community being incorporated to make use of those food crops. Supplementation and/or fortification can help where micronutrient deficiencies are endemic and where there are food shortages as a result of seasonal fluctuations or agricultural crises. Also community education efforts is essential to reverse wide spread beliefs and practices that militate against adequate nutrition for pregnant women and to raise awareness that preparation for successful pregnancy and child birth begins well before adulthood, with adequate nutrition for girls.

8. Encouragement and promotion of compulsory free female education up to secondary school level. This will enhance the quality of life and ability to understand and utilize maximally available maternal services for their good and that of their offspring. Such a system will ensure that there is no discrimination against girls in preference to boys for schooling. Not only will it postpone the age of first marriage, it will also make girls more receptive to the message regarding contraception, reproductive biology and safe motherhood and STDs.

9. Innovative antenatal health education for prospective mothers. This buttresses the importance of basic education. The introduction of health education including sex education should be incorporated into the curricula of schools. Parents should change their attitudes towards sex

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008.

10. education of their children. Sex education should also be included and made compulsory in the pre-marital counseling classes that should also be held throughout the country. This should be encouraged so that health services including family planning services can be expanded to both urban and rural areas that are widened for greater coverage, available without restriction and devising family planning programs that cater for adolescents. We cannot and ought not to prevent the first pregnancy but we can and should surely prevent the 6th or 8th pregnancy.

11. Pregnant women need not to have barriers to quality ante-natal care, whether physical, financial or social need. Cheap or free ante-natal and delivery services should be provided for most of the women who are poor.

12. Women status needs to be improved; this can only be carried out with the full participation of the women concerned. They have to express their own ideas about what their needs, are, and decide on the best way to meet them. This can be more difficult than it sounds, especially in countries where women are not accustomed to speaking up. This may take time, but with support and much patience, it will be achieved. Women, for instance, could have a voice of decisions about working conditions, maternity leave, child care, retirement benefits and equal voting rights.

13. Provision of a permanent senior trained midwife in the obstetric hospitals in a community/area to be the overseer of all the maternal care in that community.

14. Strengthening of primary level family and maternal services which include innovative schemes such as maternal waiting homes situated adjacent to a hospital where women identified to be high risk are housed and kept closer to a hospital or health centre to await the onset of labour.

15. Life threatening medical / obstetric conditions should first be attended to before consideration and insistence on fee payments.

16. There should be organized and compulsory continued medical education for all cadres of staff involved in maternity care services through workshops, seminars and conferences.

17. Work ethics (staff attitude) need to be improved upon so as to encourage women to use ante-natal services. The goal should be consumer-friendly service.

18. The health budget must be reviewed upwards to at least 5% of the national budget as recommended by WHO. Presently, the Nigerian health budget has been in the region of 2.5% of the national budget.

19. Judicious use of funds for the purposes they are meant for and with the government showing sincere commitment to the ideals of the safe motherhood initiative.

20. Implementation of the essential obstetrics care as outlined by the WHO of which the establishment of the National Blood transfusion services is a function and should be accomplished.

21. Research activities, especially in maternal health, should be intensified. Data from research will assist in planning maternal health activities; it will also help in monitoring and evaluating interventions.

CONCLUSION AND RECOMMENDATION Pregnancy and child birth are events that occur in the lives of women who are otherwise healthy only that they are fulfilling biological functions for the survival of the human species.

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008. It will amount to gender insensitivity and unappreciation for this unique but tasking role, if control of political power and resources in the hands of men are withheld while women die prematurely performing their natural roles for the survival of mankind. The death of a woman in the prime of her life from a pregnancy related cause that could have been either prevented or treated with simple existing technologies is an unmitigated tragedy. No obstetrician or midwife can have an easy conscience until all women have the opportunity to enjoy a healthy pregnancy and a safe delivery. Much could be done to lower this appalling waste of life through these unconventional approaches. The experience in Zaire is a dramatic demonstration of what is possible if one does not follow conventional approaches when they are simply impossible. It is hoped that the obstetricians and other medical administrators working in the developing countries will be able to apply the principles in a manner consonant with their culture. A society deprived of the contribution made by women is one that will see its social and economic life decline, its culture impoverished and its potential for development severely limited. The world will be a dry and impossible one without them. REFERENCES Abou-Zahr C. Improve access to quality maternal health services. Presentation at the Safe Motherhood Technical Consultation in Sri Lanka, 18- 23 October, 1997. Brown L, Bennette M. Myle’s Textbook of Midwifery. 9th edition, Toronto: Harcourt Brace and Company Limited; 1999. Chukudebelu W O. The causes of maternal mortality in the eastern states of Nigeria. Nig Med J. 1988; 3 (2): 99 – 104 Hawkins J W, Higgins L P. Maternity and Gynecological Nursing: Women’s Health Care. 4th edition. Toronto: J.B. Lippincott Company; 1981. Okonofua F E. Women’s experiences of unwanted pregnancy and induced abortion in Nigeria. New York: Population Council. Onwudiegwu U. Assessing the goals of the safe motherhood initiative in the year 2000: which way forward? Presentation at a Seminar in the Department of Obstetrics and Gynaecology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria. IFEMED. 2001; 92: 11-16 Parker J R. Maternal mortality: a survey of 118 maternal deaths and the avoidable factors involved. South Afr Med J. 1997; 51:101- 4 Rosenfield A, Maine D. Maternal mortality, a community based intervention. Int’l J Gynaecol Obstet 1992; 38 (suppl): S17 - S22. Rosenfield A, Maine D. Maternal mortality - a neglected tragedy: where is the M in MCH? J Am Med Assoc. 1997; 262:3376-82 Staffan B, Ansders M, Povey G W. International maternal health care 1993: The challenge beyond the year 2000. Uppsala: Advanced International Training Progamme.

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OFILI Mary Isioma et al: Continental J. Tropical Medicine 2: 14 - 25, 2008. World Health Organization (WHO). Maternal mortality ratios and rates: A tabulation of available information. Geneva, WHO, 1991. World Health Organization, (WHO). Coverage of maternal care: a listing of available information. WHO document. FRH/Msm/96.28, Geneva; 1996. WHO/UNICEF. Revised 1990 estimates of maternal mortality: a new approach. Geneva: WHO/UNICEF; 2001. WHO/UNFPA/UNICEF/World Bank. Reduction of maternal mortality. Joint WHO/UNFPA/UNICEF/World Bank Statement. Switzerland –Geneva; 1999. Received for Publication: 12/06/2008 Accepted for Publication: 29/10/2008 Corresponding Author: MARY ISIOMA OFILI Postal address: P.O. Box 212, Abraka, Nigeria E-mail: isiomamary@yahoo.com

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Continental J. Tropical Medicine 2: 26 - 30, 2008. © Wilolud Online Journals, 2008.

SERA MAGNESIUM IN COMPLICATED AND UNCOMPLICATED TYPE 2 DIABECTICS IN OSOGBO, NIGERIA.

Osadolor, H.B.1 Olaniyan, O.O.2 Adedokun S.A3. Alabi T.T3

1Department of Medical Laboratory Sciences, College of Health sciences, Ambrose Alli University, Ekpoma, Edo State. 2Chemical Pathology Department, State Specialist Hospital, Osogbo, Osun State. 3Department of Community Medicine, College of Medicine, LAUTECH, Osogbo, Osun State.

ABSTRACT Perturbations in magnesium have been observed in relation to human diseases, and in so many countries, magnesium depletion have been found to have a negative impact on glucose homeostasis, and insulin sensitivity as well as on the development of complications in type 2 diabetic patients. Therefore, the aim of this study was to compare serum magnesium concentration of type 2 diabetics and healthy controls in Osogbo, Nigeria. Serum Magnesium concentrations were determined in sera of 53 type 2 diabetics (25 with vascular and 28 without vascular complications) and 50 age-and sex-matched healthy controls using Atomic Absorption Spectrophotometric technique. Mean (±SD) sera magnesium concentrations of the diabetics (0.75±0.14) were found not to be significantly lowered. No significant difference (p>0.05) was also observed between the magnesium level of both complicated and uncomplicated groups of type 2 diabetes when compared to healthy individuals. However, an inverse correlation was observed between the fasting plasma glucose of the diabetes and the element under study. Therefore low sera magnesium concentrations and poor magnesium status are not common in type 2 diabetics in Osogbo Nigeria.

KEYWORDS: Type 2, Diabetes Mellitus, Magnesium, Complicated, Uncomplicated INTRODUCTION Diabetes mellitus (DM) is an endrocrinological disease (Evliyaoglu et al., 2004) of carbohydrates metabolism that is characterized by hyperglycemia and glycosuria resulting from dysfunction of pancreatic beta cells and insulin resistance (Khan and Safder, 2003). Many factors like hereditary, age, obesity, diet, sex, hypertension sedentary lifestyles, socio-economic-status and various stresses have been implicated in the etiology of diabetes mellitus. About 170 million people are being afflicted worldwide with the disease and it’s expected to be more than double by 2010 (McCarthy and Zimmet, 1997). About 1-7% of the whole Nigerian populace is having the disease, with over 90% of these being type 2 DM (Fabiyi et al., 2002) and the prevalence rate among high, and low socio-economic groups of a small Nigerian population was as high as 23.4% band 16% respectively while, 18.9% of the same populace were unaware of their diabetic problem (Nwarfor and Owohoji, 2001). Direct association of trace elements and macro elements with DM has been observed in many research studies (Nourmohammadi et al., 2000). Insulin action has been reported to be potentated by some trace elements (Candilish, 2000), especially magnesium (Mg) which is a cofactor in the glucose transporting mechanism of the cell membrane and various enzymes in carbohydrate oxidation (Laughlin and Thompson, 1996). Mg is also involved at multiple levels in insulin secretion and binding and also enhances the ability of insulin to activate tyrosine kinase (Sur ez, 1993). Therefore Mg depletion has been postulated to have a negative impact on glucose homeostasis and insulin sensitivity in patients with type 2 DM (Nadler et al., 1993), as well as on the evolution of complications such as retinopathy, thrombosis and hypertension (Walti et al., 2003).

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Osadolor, H.B et al: Continental J. Tropical Medicine 2: 26 - 30, 2008. Moreover, low serum Mg has been cited as a strong independent predictor of the development of type 2 DM in white subjects (Kao et al., 1999). And although, low serum Mg concentrations in diabetics have been found in several European and Asian countries (including USA), but Africa, especially Nigeria lack data to this fact. Therefore the aim of this study was to compare serum Mg concentrations of patients with type 2 diabetes and healthy controls in Nigeria.

Table 1 Clinical characteristics of 53 type 2 diabetics in the study, divided into two groups: with vascular diseases (group1, n=28) and without vascular diseases (group 2, n=25). ________________________________________________________________________ Characteristics group1 group 2 f-value p-value Men / Women 12 / 16 7 / 18 Age (yrs) 57.36 ± 10.73 57.08 ± 11.21 0.333 >0.05 Diabetes duration (yrs) 3.96 ± 2.22 2.32 ± 2.17 0.009 <0.05 FPG (mmol/L) 9.12 ± 1.93 4.62 ± 0.91 0.012 <0.05 SBP (mmHg) 117 ± 14.10 112 ± 11.20 0.010 <0.05 DBP (mmHg) 73 ± 9.50 70 ± 8.38 0.122 >0.05 Medication [Number (%) of subjects] Insulin 06 (21.43%) Nil Oral-hypoglycemic 20 (71.43%) 09 (36%) Insulin + Oral-hypoglycemic 02 (7.14%) 06 (24%) Diet Nil 10 (40%) Traditional medicine Nil 04 (16%) Smoking Habitués [Number (%) of subjects] Smoking 19 (67.87%) 15 (60%) Not smoking 09 (32.14%) 10 (40%) Complications [Number (%) of subjects] Hypertension 10 (35.71%) Nil Retinopathy 03 (10.71%) Nil Nephropathy 06 (21.43%) Nil Arteriosclerosis 04 (14.29%) Nil Foot diabetic 05 (17.86%) Nil

MATERIALS AND METHOD This study was conducted on a total of one hundred and three subjects from Osogbo (Longitude 40 331 E, latitude 70 461 N), south west Nigeria. This study was conducted between 2006 and 2007.

The base line test population consisted of fifty-three patients (19 men and 34 women) with type 2 diabetes mellitus (mean age 57.42 ± 10.43) diagnosed according to WHO standard (WHO, 1999). 52.8% of these subjects were attending diabetes clinic and with no vascular complication due to the disease at the State Specialist Hospital Osogbo while, 47.2% of the subjects were hospitalized due to vascular complications of the disease at the same hospital. The control group consisted of fifty healthy sex-and-age matched among the hospital staff and blood donors with no clinical or laboratory disorder. Informed and written consent were obtained from each subjects before being recruited into the study. Because loop diuretics were associated with higher urinary Mg excretion (Walti et al., 2003), subjects taking loop diuretics or receiving mineral supplements of any form in the last one month were excluded from this study.

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Osadolor, H.B et al: Continental J. Tropical Medicine 2: 26 - 30, 2008. Overnight fasting blood samples were collected aseptically via venipuncture from each subject for fasting plasma glucose (FPG) and serum magnesium determination. FPG was estimated using glucose-oxidase method, while serum magnesium was estimated using flame atomic absorption method. Statistical analysis is performed with paired sample ‘t’ test by SPSS statistical package and the level of significance is set at p<0.05.

RESULTS The clinical data of the test group (type 2 diabetics) were as presented in Table 1 the patients are divided into two groups according to the presence (group 1, n=25) or absence (group 2, n=28) of vascular complications. FPG, diabetes duration and systolic blood pressure (SBP) significantly higher (p<0.05) in group 2 subjects, while diastolic blood pressure (DBP) shows no significant difference (p>0.05). Mean (±SD) serum magnesium concentration were non-significantly (p>0.05) lowered in type 2 diabetics (0.75 ± 0.07) than in controls (0.85 ± 0.14). Group 2 patients showed a non-significant (p>0.05) higher value than group 1 which has a lowest and also a non-significant (p>0.05) concentrations as compared to healthy controls (group 3) (Table 2). Magnesium concentrations showed a negative correlation in both groups (group 1, r = -0.879 p =0.03 and group 2, r =-0.66 p =0.09) when compared with FPG, but a positive correlation (r = 0.61 p =0.07) with non-diabetes healthy individuals. Table 2 Sera magnesium concentration (mmol/L) in diabetic adult (N= 53) with vascular disease (group 1, n= 25) and without vascular disease (group 2, n= 28), and in healthy controls (group 3, N=50).

Group Mg concentration Bonferonni’s comparism with other (mmol/L) groups 1 2 3

1 0.72 ± 5.60 -- >0. 05 >0. 05 2 0.78 ± 6.42 >0. 05 -- >0. 05 3 0.72 ± 0.14 >0. 05 >0. 05 --

DISCUSSION and CONCLUSION Trace elements are uniquely required for growth and maintenance of life and health. Lack or inadequate supply of each nutrient produce functional impairments or can results in disease (WHO, 1996) Mg is mainly an intracellular cation, with less than 1% of total body content present in the extra–cellular fluid. The Mg concentration in serum represents not more than 0.3% of total body magnesium (Shills, 1998). Nevertheless, serum or plasma Mg measurement is the most readily available and widely used test of Mg status in humans. (Gums, 1987). Hormones that help to regulate Mg levels in the body include calcitonin, parathyroid hormone, and insulin. Insulin administration or insulin release in response to an ATPase pump .Mg also as an integral part of the activated MgATP complex regulating protein kinases, is directly involved in the control of glucose metabolism (Maher, 1998). The result of this study revealed that there was a reduction in the Mg concentration of type 2 diabetes patients and though being lowest in patients with vascular complications than those without vascular disease due to diabetes though, this reduction does not reach any significance. This was consistent with the work of Nsonwu, et al., (2006) who also reported a non-significant lower Mg values in serum of diabetics from Calabar (south-south Nigeria) when compared to their non-diabetes healthy individuals. However, a

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Osadolor, H.B et al: Continental J. Tropical Medicine 2: 26 - 30, 2008. striking contrasts finding from Caucasians who have all reported significantly lower Mg concentrations in the body of their diabetics as compared to their non-diabetes individuals (Nadler, et al., 1992, Walti, et al., 2003,Nourmohammadi, et al., 2000). The negative correlation seen between Mg values and FPG of group 1 and 2 diabetics in this study was also in consistent with earlier study of McNair, et al., (1982) who demonstrated an inverse relationship between plasma Mg levels and fasting blood glucose levels in diabetes, but in contrast with the works of Anetor, et al., (2002) who demonstrated an that plasma trace elements concentrations were not dependent on the degree of glucose control as determined by correlations analysis between glycated hemoglobin(HbAic) and the metal levels. The mechanism of hypomagnesaemia in diabetes still remains unresolved but there is enough evidence to suggest that Mg levels drop in the course of recovery from ketoacidosis, during insulin therapy or with severe retinopathy or proteinuria (Nourmohammadi, et al., 2000). Increased urinary Mg excretion has also been reported in hyperglycaemia, osmotic action and glycosuria thereby, contributing to hypomagnesaemia seen in diabetes (Nsonwu, et al., 2006). In this study, we have demonstrated that the low Mg status seen in type 2 diabetics in Osogbo, Nigeria is not of any significance. And because Mg depletion has a negative impact on glucose homeostasis and insulin sensitivity in diabetic as well as on evolution of complication such as retinopathy, thrombosis, dislipidaemia and hypertension (Nadler, et al., 1993, Mather, et al., 1982, Walti, et al., 2003, Seelig, 1989), it may therefore be prudent in medical practice to periodically monitor the Mg status of diabetics as dietary supplementation of the mineral should be considered in cases of low serum Mg concentration.

REFERENCE: Anetor, J.I., Sejobi, A., Ajose, O.A. and Agbedana, E.O. (2002). Decreased serum magnesium and zinc levels: artherogenic implicationsin type 2 diabetes mellitus in Nigeria. Nutr. And Health. 16: 291-300. Candilish, D.J. (2000). Minerals. J. Am. Coll. Nutr. 17: 286-310. Evliyaoglu,O.,Kebapcilar, L.,Uzuncan,N.,Kilicaslan,N.,Karaca,B.,Kocacelebi,R, and Yensel,N. (2004). Correlation Of Serum Cu+2 Zn+2 Mg+2 And Hba1c in Type 2 -and Type 2 Diabetes Mellitus. Turk.J.Endo. & Meta.8 (2): 75-79.

Fabiyi, A.K., Kolawole, O., Adefehinto, O. and Ikem, R.T. (2002). The impact of knowledge, attitudes, practice and beliefs of type 2 Nigerian diabetic patients on drug compliance. Diabet. Int 12: 15-17. Gums, J.G. (1987). Clinical significance of magnesium: a review. Drug Intell. Clin. Pharm. 21: 240-246. Kao, W.H., Folsom, A.R., Nieto, F.J., Mo, J.P., Watson, R.L. and Brancati, F.L. (1999). Serum and dietary magnesium and the risk for type 2 diabetes mellitus: the arteriosclerosis risk in community study. Arch. Intern. Med. 159: 2151-2159. Khan, A. and Safder, M. (2003). Role of Diet, Nutrients, Species and Natural Products in Diabetes Mellitus. Pak. J. of Nurt. 2 (1): 1-12. Laughling, M.R. and Thompson, D. (1996). The regulatory role for magnesium in glycolytic flux of human erythrocytes. J. Biol. Chem. 271: 28977-28983. Mather, H.M., Levin, G.E. and Nisbet, J.A. (1982). Hypomagnesaemia and ischemic heart disease in diabetes. Diabetes Care. 5: 452-453.

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Osadolor, H.B et al: Continental J. Tropical Medicine 2: 26 - 30, 2008. Maher, T.J. (1998). Chromium and other minerals in diabetes mellitus. J. Am. Coll. Nutr. 17: 564-570. McMarty, P. and Zimmet, P. (1997). Diabetes. 1994-2010: global estimates and projections. Diabetes Care. 20: 1785-1790 McNair, P., Christensen, M.S., Christensen, C., Madsbad, S. and Transbol, I. (1982). Renal hypomagnesaemia in human diabetes mellitus: its relation to glucose homeostasis. Euro. J. Clin. Invest. 12: 81-85. Nadler, J.L., Buchanan, T., Natarajan, R., Antonipillai, I., Bergman, R. and Rude, R. (1993 ). Magnesium deficiency produces insulin resistance and increased thromboxane synthesis. Hypertension. 21: 1024-1029. Nourmohammadi, I., K., Kochecki-Shaabani, M. and Gohari, L. (2000). Zinc, Copper, Chromium, Manganese and Magnesiun kevels in serum and hair of insulin dependent diabetics. J Trace Elem. Metabol. 2: 88-100. Nsonwu, A.C., Usoro, C.A.O, Etukudo, M.H. and Usoro, I.N. (2006). Glycemic control and serum and urine levels of zinc and magnesium in diabetics in Calabar Nigeria. Pak. J. Nutr. 5 (1): 75-78. Nwarfor, A. and Owhoji, A. (2001). The prevalence of diabetes mellitus in Port Harcourt correlates with the socio-economic status. J. Appl. Sc. Environ. Mgt. 5 (7): 75-77. Seelig, M. (1989). Cardiovascular consequences of magnesium deficiency and loss: pathogenesis, prevalence and manifestation—magnesium and chloride loss in refectory potassium depletion. Am. J. Cardiol. 63: 4G 21G. Shills, M.E. (1998). Magnesium. In Shils, M.E., Olson, J.E., Shike, M. and Ross, A.C. (eds). Modern nutrition in health and disease. 9th ed. Baltimore: Williams and Wilkins. pp 162-192

Surez, Z. (1993). Decreased insulin sensitivity in skeletal muscular of hypomagnesaemia rats. Diabetological. 36: 82 Vessby, B. (2000). Dietary fat and insulin action in humans. Br. J. Nutr. (supp), 83: 91-96. Walti, M.K., Zimmermann, M.B., Spinas, G.A. and Hurrel, R.F. (2003). Low plasma magnesium in type 2 diabetes. Swiss Med Wkly 133: 289-92. World Health Organization (WHO) (1996). Trace elements in human nutrition and health (ISBN) 92-4-1561-40. World Health Organization (WHO) (1999). Report of a WHO consultation on the diagnosis and classification of diabetes mellitus. Part 1 (1-30) Wokoma, F.S. (2002). Diabetes and hypertension in Africa-an overview. Diabet. Int. 12: 36-40. Received for Publication: 12/09/2008 Accepted for Publication: 24/12/2008 Corresponding Author: Olaniyan, O.O. Chemical Pathology Department, State Specialist Hospital, Osogbo, Osun State. E-mail: olacube2001@yahoo.com