Facility-Based Delivery in the Context of Zimbabwe's HIV Epidemic - Missed Opportunities for Improving Engagement with Care: A Community-Based Serosurvey

BACKGROUND:

In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one's HIV status affects one's decision to deliver in a health facility. We examined this association in Zimbabwe.

METHODS:

We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe's accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9-18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing.

RESULTS:

Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30-100 %). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status - before (adjusted prevalence ratio (PRa) = 1.04, 95 % confidence interval (CI) = 1.00-1.09) or during pregnancy (PRa = 1.05, 95 % CI = 1.01-1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69 %). Overall, however 77 % of home deliveries occurred among women who had accessed antenatal care and were HIV-tested.

CONCLUSIONS:

Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe.

Full article at:   http://goo.gl/HouI0a

By:   Buzdugan R1, McCoy SI2, Webb K3,4, Mushavi A5, Mahomva A6, Padian NS7, Cowan FM8,9.

• 1University of California Berkeley, School of Public Health, 779 University Hall, MS 7360, Berkeley, CA, 94720, USA. rbuzdugan@berkeley.edu.
• 2University of California Berkeley, School of Public Health, 779 University Hall, MS 7360, Berkeley, CA, 94720, USA. smccoy@berkeley.edu.
• 3University College London, London, United Kingdom. kwebb@ophid.co.zw.
• 4Organisation for Public Health Interventions and Development Trust, 20 Cork Road, Belgravia, Harare, Zimbabwe. kwebb@ophid.co.zw.
• 5Ministry of Health and Child Care, Harare, Zimbabwe. mushavia@yahoo.co.uk.
• 6Elizabeth Glaser Pediatric AIDS Foundation, 107 King George Road, Avondale, Harare, Zimbabwe. amahomva@pedaids.org.
• 7University of California Berkeley, School of Public Health, 779 University Hall, MS 7360, Berkeley, CA, 94720, USA. nancy.padian@gmail.com.
• 8University College London, London, United Kingdom. f.cowan@ucl.ac.uk.
• 9Centre for Sexual Health and HIV/AIDS Research Zimbabwe, 9 Monmouth Road, Avondale West, Harare, Zimbabwe. f.cowan@ucl.ac.uk. 

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Factors Related to Fetal Death in Pregnant Women with Cholera, Haiti, 2011–2014

Abstract

We assessed risk factors for fetal death during cholera infection and effect of treatment changes on these deaths. Third trimester gestation, younger maternal age, severe dehydration, and vomiting were risk factors. Changes in treatment had limited effects on fetal death, highlighting the need for prevention and evidence-based treatment.

Cholera infections during pregnancy are associated with high rates of fetal death, especially when women are severely dehydrated (1–7). In Haiti in 2011, pregnant women with clinical signs of cholera who sought treatment from Médecins Sans Frontières (MSF) in Port-au-Prince were sent to a general cholera treatment center (CTC). In April 2012, MSF established a CTC to improve fetal outcomes in pregnant women by facilitating intensive follow-up for dehydration and rapid access to obstetric and neonatal services. In June 2013, a more aggressive rehydration protocol was implemented (Technical Appendix[PDF - 112 KB - 2 pages] Table 1). To assess the effects of cholera infection, establishment of a specialized CTC, and the new rehydration protocol, we conducted a retrospective cohort analysis of pregnant women with suspected cholera admitted to MSF’s CTCs during September 1, 2011−December 31, 2014....

Full article at:   http://goo.gl/l2is6Y

By:   Erin Schillberg, Cono Ariti, Lindsay Bryson, Rodnie Delva-Senat, Debbie Price, Reynold GrandPierre, and Annick Lenglet 

Author affiliations: Médecins Sans Frontières, Port-au-Prince, Haiti (E. Schillberg, L. Bryson, R. Delva-Senat);London School of Hygiene and Tropical Medicine, London, UK (C. Ariti); Médecins Sans Frontières, Amsterdam, the Netherlands (D. Price, A. Lenglet); Ministère de la Santé Publique et de la Population, Port-au-Prince (R. GrandPierre)

  

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Association Between Maternal HIV Infection & Low Birth Weight & Prematurity: A Meta-Analysis of Cohort Studies

To assess the association between maternal human immunodeficiency virus (HIV) infection and low birth weight (LBW)/prematurity (PTD), we conducted a meta-analysis of cohort studies of HIV infected and uninfected women.

Several English and Chinese databases were searched (updated to May 2015) to find the studies reporting infant outcomes associated with exposure to maternal HIV infection during pregnancy. Relevant articles were manually selected based on several inclusion and exclusion criteria.

Fifty-two cohort studies including 15,538 (for LBW) and 200,896 (for PTD) HIV infected women met the inclusion criteria. There was significant heterogeneity among studies for maternal HIV infection associated with LBW/PTD. The meta-analysis demonstrated that the maternal HIV infection was significantly associated with both LBW (pooled odds ratio (OR): 1.73, 95 % confidence interval (CI): 1.64, 1.82,P < 0.001) and PTD (pooled OR: 1.56, 95 % CI: 1.49, 1.63, P < 0.001). No significant difference in the relationship between maternal HIV infection and adverse pregnancy outcomes was detected among the groups of different study periods. HIV infected women were at slightly higher risk of LBW in developing countries compared with women in developed countries (OR: 2.12 (95 % CI: 1.81, 2.48) vs. 1.75 (95 % CI: 1.44, 2.12)). Antiretroviral drugs usage did not significantly change the associations of maternal HIV exposure with LBW and PTD.

HIV infected women were at higher risk of having a low birth weight infant or a preterm delivery infant compared with uninfected women. Such associations did not change significantly over time or were not significantly affected by the usage of antiretroviral drugs.

Full article at: http://goo.gl/9lcBoZ

By: Peng-Lei Xiao¹²³, Yi-Biao Zhou^123*, Yue Chen⁴, Mei-Xia Yang⁵, Xiu-Xia Song¹²³, Yan Shi¹²³ and Qing-Wu Jiang¹²³

¹Fudan University School of Public Health, Building 8, 130 Dong’an Road, Xuhui District, Shanghai 200032, China

²Key Laboratory of Public Health Safety, Fudan University, Ministry of Education, Building 8, 130 Dong’an Road, Xuhui District, Shanghai 200032, China

³Fudan University Center for Tropical Disease Research, Building 8, 130 Dong’an Road, Xuhui District, Shanghai 200032, China

⁴School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa K1H 8 M5, ON, Canada

⁵Xuhui Center for Disease Prevention and Control, 50 Yongchuan Road, Xuhui District, Shanghai 200032, China

  

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The Impact of Emotional, Physical & Sexual Abuse on Contraceptive Method Selection & Discontinuation

We evaluated the impact of exposure to emotional, physical, or sexual abuse on contraceptive method selection and discontinuation.

We performed a secondary analysis of 7170 women enrolled in the Contraceptive CHOICE Project in St. Louis, Missouri, a prospective cohort study in which 9256 women were provided their preferred method of contraception at no cost from 2007 to 2011. We defined contraceptive discontinuation as device removal or nonuse for at least 4 weeks within the first 12 months after initiation.

One third of women experienced some abuse in their lifetimes. Women with an abuse history were as likely as those without to select a long-acting reversible contraceptive method and more likely to choose a contraceptive injection, the patch, or the ring. When we compared women who were abused to those who were not, rates of discontinuation at 12 months were higher among women who selected long-acting reversible contraception (17% vs 14%; P = .04) and significantly higher among women who selected non–long-acting methods (56% vs 47%; P < .001). Type of abuse did not alter the association between abuse and contraceptive continuation.

Previous experiences of abuse are associated with both contraceptive method selection and continuation.

Method of Contraception Chosen at Baseline by Women: Contraceptive CHOICE Project by Lifetime History of Abuse, St. Louis, MO, 2007–2011

		Prevalence of Baseline Chosen Contraceptive Method, %
Type of Abuse	No.	LARC	PPR	DMPA	LARC vs non-LARC, RR (95% CI)	DMPA vs PPR, RR (95% CI)
Childhood (aged < 14 y)
None	5631	72	20	7	1.00 (Ref)	1.00 (Ref)
Any	1532	75	16	8	1.04 (1.01, 1.08)	1.28 (1.09, 1.51)
Emotionala	896	76	17	8	1.04 (1.00, 1.09)	1.18 (0.96, 1.45)
Physicala	641	78	14	8	1.08 (1.03, 1.13)	1.37 (1.09, 1.73)
Sexual	763	75	15	10	1.03 (0.99, 1.08)	1.47 (1.21, 1.78)
≥ 2 types	609	78	13	8	1.08 (1.03, 1.13)	1.42 (1.13, 1.78)
Adult (aged ≥ 14 y)
None	5854	73	20	7	1.00 (Ref)	1.00 (Ref)
Any	1307	74	18	8	1.02 (0.98, 1.06)	1.14 (0.95, 1.36)
Emotionala	964	74	18	8	1.03 (0.98, 1.07)	1.11 (0.91, 1.36)
Physicala	453	74	18	8	1.02 (0.97, 1.08)	1.12 (0.85, 1.49)
Sexual	484	73	18	9	1.00 (0.94, 1.06)	1.22 (0.94, 1.57)
≥ 2 types	496	74	18	9	1.01 (0.96, 1.07)	1.20 (0.93, 1.55)
Lifetime
None	5078	72	20	7	1.00 (Ref)	1.00 (Ref)
Any	2092	74	18	8	1.03 (0.99, 1.06)	1.22 (1.04, 1.41)
Emotionala	1353	75	17	7	1.04 (1.00, 1.07)	1.10 (0.91, 1.31)
Physicala	898	76	16	8	1.05 (1.01, 1.09)	1.28 (1.05, 1.56)
Sexual	1044	74	16	10	1.02 (0.98, 1.06)	1.39 (1.16, 1.65)
≥ 2 types	931	76	16	8	1.05 (1.01, 1.10)	1.28 (1.05, 1.56)

Note. CI = confidence interval; DMPA = depot medroxyprogesterone acetate contraceptive injection; LARC = long-acting reversible contraception (intrauterine device or hormonal implant); non-LARC = contraceptive pill, patch, ring, or injection; PPR = contraceptive pill, patch, or ring; RR = relative risk. The sample size was n = 7170.

aEmotional and physical abuse classified as abuse if more than a single occurrence of abuse.

Below:  Cumulative discontinuation rates by contraceptive method and experience of abuse for (a) childhood abuse and (b) adult abuse: Contraceptive CHOICE Project, St. Louis, MO, 2007–2011.

Note. LARC = long-acting reversible contraception (intrauterine device or hormonal implant); non-LARC = contraceptive pill, patch, ring, or injection.

Full article at: http://goo.gl/vqeJ8G

By: Jenifer E. Allsworth, PhD, Gina M. Secura, PhD, MPH, Qiuhong Zhao, MS, Tessa Madden, MD, MPH, and Jeffrey F. Peipert, MD, PhD

The authors are with Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO.

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Factors Associated with Postpartum Hemorrhage Maternal Death in Referral Hospitals in Senegal and Mali: A Cross-Sectional Epidemiological Survey

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women’s characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali.

A cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death.

Among the 3,278 women who experienced PPH, 178 (5.4 %) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years, living in Mali, residing outside the region location of the hospital, prepartum severe anemia, forceps or vacuum delivery, birth weight greater than 4000 grs, transfusion, transfer to another hospital. There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician than those with only a general practitioner trained in emergency obstetric care (EmOC).

Our findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality.

Full article at:  http://ht.ly/SSAfl 

By: Julie Tort^1238*, Patrick Rozenberg⁴⁵, Mamadou Traoré⁶, Pierre Fournier⁷ and Alexandre Dumont¹²

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Alcohol Consumption among Pregnant Women in Northern Tanzania 2000–2010: A Registry-Based Study

Background

Alcohol can be harmful to the development of the foetus. In most developed countries, pregnant women are recommended to abstain from alcohol, however in developing countries, women are less likely to receive these recommendations. With respect to pregnant women in Northern Tanzania, this study aims to 1) describe time trends in level of alcohol consumption, 2) assess socio-demographic predictors of alcohol consumption, and 3) describe associations between alcohol consumption and health-related maternal and foetal outcomes.

Methods

Data related to 34,090 births between 2000 and 2010 was obtained from the Medical Birth Registry at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania and analysed. Poisson regression analysis was used to assess associations between potential risk factors and alcohol consumption, and between alcohol consumption during pregnancy and maternal and foetal health outcomes.

Results

From 2000 to 2010, the proportion of women reporting alcohol consumption during pregnancy decreased from 49.5 to 21.5 %. The socio-demographic predictors most strongly related to alcohol consumption were religion (Catholics 53.6 %, Protestants 25.9 %, Muslims 14.8 %) and tribe (Chaggas 45.2 %, Pares 17.3 %, Maasais 6.6 %). Pregnant women consuming alcohol were more likely to be older, taller, and have higher pre-pregnancy body mass index, and were less likely to present with anaemia (Hb < 11.0 g/dl) at last antenatal care (ANC) visit/at admission; adjusted relative risk (ARR) 0.84 (95 % confidence interval 0.79–0.90) for alcohol consumption vs. abstinence. Maternal alcohol consumption during pregnancy was associated with a decreased risk of being small for gestational age (ARR 0.87 (0.80–0.94) and a decreased risk of gestational age less than 37 weeks (ARR 0.89 (0.81–0.99).

Conclusions

The proportion of pregnant women reporting alcohol consumption decreased by 56.5 % from 2000 to 2010. Alcohol intake was strongly associated with socio-demographic factors. The association between alcohol intake and favourable perinatal outcomes remained significant after maternal factors were adjusted for. Information on diet, lifestyle factors and maternal health might give further insight into this unexpected observation. The proportion of pregnant women consuming alcohol in Northern Tanzania is high, and greater awareness of health outcomes associated with alcohol consumption is advised.

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Self-Reported Postpartum Morbidity: Prevalence and Determinants among Women in Marrakesh, Morocco

Below:  Women’s reported postpartum morbidities

The self-reported postpartum morbidity prevalence was 13.1 % while haemorrhage, pregnancy-induced hypertension and fever were the main complications: 71.92 %; 12.18 % and 10.64 % respectively.

According to the multiple logistic regression model, the illiteracy among women and the number of pregnancies greater than 3 determine independently this morbidity (OR = 1.24; CI 95 %: 1.09–1.54; and OR = 1.69; CI 95 %:1.04–2.70 respectively).

Reducing female illiteracy and fertility will help the fight against postpartum maternal morbidity, which is critical to the wellbeing of women and their infants.

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Prevalence of Hospitalized Live Births Affected by Alcohol and Drugs and Parturient Women Diagnosed with Substance Abuse at Liveborn Delivery: United States, 1999–2008

Below:  Prevalence (per 10,000) on a natural log scale and Loess trend curves with 95% confidence interval for (A) live births affected by alcohol and drugs and neonatal drug withdrawal syndrome, and (B) maternal substance abuse at liveborn delivery: United States, 1999–2008.

From 1999 to 2008, prevalence increased for narcotic- and hallucinogen-affected live births and neonatal drug withdrawal syndrome but decreased for alcohol- and cocaine-affected live births. Maternal substance abuse at delivery showed similar trends, but prevalence of alcohol abuse remained relatively stable. Substance-affected live births required longer hospital stays and higher medical expenses, mostly billable to Medicaid.

The findings highlight the urgent need for behavioral intervention and early treatment for substance-abusing pregnant women to reduce the number of substance-affected live births.

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Opioid Prescription Claims among Women of Reproductive Age - US, 2008–2012

Below:  Percentage of women aged 15–44 years who filled a prescription for an opioid from an outpatient pharmacy, by health care coverage type and year — United States, 2008–2012

Below:  Average number of opioid prescriptions filled at an outpatient pharmacy per woman aged 15–44 years, among women with private insurance and Medicaid — United States, 2008–2012

"Prescription opioid use in the United States has become widespread (1), and studies of opioid exposure in pregnancy suggest increased risk for adverse pregnancy outcomes, including neonatal abstinence syndrome and birth defects (e.g., neural tube defects, gastroschisis, and congenital heart defects) (2,3). The development of birth defects often results from exposures during the first few weeks of pregnancy, which is a critical period for organ formation. Given that many pregnancies are not recognized until well after the first few weeks and half of all U.S. pregnancies are unplanned (4), all women who might become pregnant are at risk. Therefore, it is important to assess opioid medication use among all women of reproductive age. CDC used Truven Health's MarketScan Commercial Claims and Encounters and Medicaid data* to estimate the number of opioid prescriptions dispensed by outpatient pharmacies to women aged 15–44 years. During 2008–2012, opioid prescription claims were consistently higher among Medicaid-enrolled women when compared with privately insured women (39.4% compared with 27.7%, p<0.001). The most frequently prescribed opioids among women in both groups were hydrocodone, codeine, and oxycodone. Efforts are needed to promote interventions to reduce opioid prescriptions among this population when safer alternative treatments are available."

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Association of Childhood Physical and Sexual Abuse with Intimate Partner Violence, Poor General Health and Depressive Symptoms among Pregnant Women

Below:  Prevalence of Childhood Physical and Sexual Abuse by Type and Perpetrators among Pregnant Women in Lima, Peru

Results
Any childhood abuse was associated with 2.2-fold increased odds of lifetime IPV (95%CI: 1.72–2.83). Compared with women who reported no childhood abuse, those who reported both, childhood physical and sexual abuse had a 7.14-fold lifetime risk of physical and sexual IPV (95%CI: 4.15–12.26). The odds of experiencing physical and sexual abuse by an intimate partner in the past year was 3.33-fold higher among women with a history of childhood physical and sexual abuse as compared to women who were not abused as children (95%CI 1.60–6.89). Childhood abuse was associated with higher odds of self-reported poor health status during early pregnancy (aOR = 1.32, 95%CI: 1.04–1.68) and with symptoms of antepartum depression (aOR = 2.07, 95%CI: 1.58–2.71).

Conclusion
These data indicate that childhood sexual and physical abuse is associated with IPV, poor general health and depressive symptoms in early pregnancy. The high prevalence of childhood trauma and its enduring effects of on women’s health warrant concerted global health efforts in preventing violence.

Via: http://ht.ly/Ig68M HT @HarvardHSPH