Qualitative assessment of attitudes and knowledge on preterm birth in Malawi and within country framework of care

BACKGROUND: The overarching goal of this study was to qualitatively assess baseline knowledge and perceptions regarding preterm birth (PTB) and oral health in an at-risk, low resource setting surrounding Lilongwe, Malawi. The aims were to determine what is understood regarding normal length of gestation and how gestational age is estimated, to identify common language for preterm birth, and to assess what is understood as options for PTB management. As prior qualitative research had largely focused on patient or client-based focused groups, we primarily focused on groups comprised of community health workers (CHWs) and providers. METHODS: A qualitative study using focus-group discussions, incidence narrative, and informant interviews amongst voluntary participants. Six focus groups were comprised of CHWs, patient couples, midwives, and clinical officers (n = 33) at two rural health centers referring to Kamuzu Central Hospital. Semi-structured questions facilitated discussion of PTB and oral health (inclusive of periodontal disease), including definitions, perception, causation, management, and accepted interventions. RESULTS: Every participant knew of women who had experienced “a baby born too soon”, or preterm birth. All participants recognized both an etiology conceptualization and disease framework for preterm birth, distinguished PTB from miscarriage and macerated stillbirth, and articulated a willingness to engage in studies aimed at prevention or management. Identified gaps included: (1) discordance in the definition of PTB (i.e., 28–34 weeks or less than the 8(th) month, but with a corresponding fetal weight ranging 500 to 2300 grams); (2) utility and regional availability of antenatal steroids for prevention of preterm infant morbidity and mortality; (3) need for antenatal referral for at-risk women, or with symptoms of preterm birth. There was no evident preference for route of progesterone for the prevention of recurrent PTB. CONCLUSIONS: Qualitative research was useful in (1) identifying gaps in knowledge in urban and rural Malawi, and (2) informing the development of educational materials and implementation of programs or trials ultimately aimed at reducing PTB. As a result of this qualitative work, implementation planning was focused on the gaps in knowledge, dissemination of knowledge (to both patients and providers), and practical solutions to barriers in known efficacious therapies

Low Rates of Mother-to-Child HIV Transmission in a Routine Programmatic Setting in Lilongwe, Malawi

Background The Tingathe program utilizes community health workers to improve prevention of mother-to-child transmission (PMTCT) service delivery. We evaluated the impact of antiretroviral (ARV) regimen and maternal CD4+ count on HIV transmission within the Tingathe program in Lilongwe, Malawi. Methods We reviewed clinical records of 1088 mother-infant pairs enrolled from March 2009 to March 2011 who completed follow-up to first DNA PCR. Eligibility for antiretroviral treatment (ART) was determined by CD4+ cell count (CD4+) for women not yet on ART. ART-eligible women initiated stavudine-lamivudine-nevirapine. Early ART was defined as ART for ≥14 weeks prior to delivery. For women ineligible for ART, optimal ARV prophylaxis was maternal AZT ≥6 weeks+sdNVP, and infant sdNVP+AZT for 1 week. HIV transmission rates were determined for ARV regimens, and factors associated with vertical transmission were identified using bivariate logistic regression. Results Transmission rate at first PCR was 4.1%. Pairs receiving suboptimal ARV prophylaxis were more likely to transmit HIV (10.3%, 95% CI, 5.5–18.1%). ART was associated with reduced transmission (1.4%, 95% CI, 0.6–3.0%), with early ART associated with decreased transmission (no transmission), compared to all other treatment groups (p = 0.001). No association was detected between transmission and CD4+ categories (p = 0.337), trimester of pregnancy at enrollment (p = 0.100), or maternal age (p = 0.164). Conclusion Low rates of MTCT of HIV are possible in resource-constrained settings under routine programmatic conditions. No transmissions were observed among women on ART for more than 14 weeks prior to delivery

Vertical HIV transmission rates at first PCR by antiretroviral regimen.

a<p>For explanations of ARV regimen categories please refer to <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0064979#pone-0064979-g001" target="_blank">Figure 1</a>.</p>b<p>Early vertical transmission rate calculation: number positive first PCR results/number of total first PCR results.</p>c<p>Denotes p< alpha, adjusted to 0.0125 to account for multiple comparisons. <i>Post hoc</i> analysis performed only if the global p-value (in bold) was <0.05. (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0064979#s2" target="_blank">Methods</a>).</p><p>Abbreviations: PCR (polymerase chain reaction)- DNA PCR test for HIV, ART (antiretroviral therapy),</p

Outcomes for HIV-infected pregnant women and HIV-exposed infants enrolled in the <i>Tingathe</i> program.

<p>After the maternal deaths, all five infants were transferred to the care of another caregiver and moved out of the program catchment area.</p

Descriptions of WHO Option A, B, and B+.

<p>ƒƒƒÏ.</p><p>Abbreviations: AZT (zidovudine), ART (antiretroviral therapy), ARV (antiretroviral); sdNVP (single dose nevirapine), NVP (nevirapine).</p><p>World Health Organization (2012) Programmatic Update. Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants. Executive Summary. Geneva, Switzerland: World Health Organization.</p><p>Schouten EJ, Jahn A, Midiani D, Makombe SD, Mnthambala A, et al. (2011) Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach. Lancet 378∶282–284.</p

Characteristics of 1088 HIV positive pregnant women at enrollment in the Tingathe program.

a<p>Of the 1088 mother-infant pairs with first DNA PCR results, 262 mothers were already on ART, 23 with no corresponding maternal CD4 results, therefore 803 available CD4 results with corresponding PCR results.</p>b<p>Partner disclosed defined as partner having knowledge of maternal HIV status. Partner non-involved defined as a partner who has died, or is otherwise separated from the mother.</p><p>Abbreviations: ART (antiretroviral therapy), CD4+ (CD4+ cell count), PMTCT (prevention of mother-to-child transmission).</p

Description and explanations of antiretroviral regimens used for analysis.

<p>*sdNVP: single dose of nevirapine for the mother taken at the onset of labor and a single dose of nevirapine for the infant administered within 72 hours of delivery. **Due to low patient numbers in each individual grouping, these suboptimal interventions were grouped together. ***Based on 2006 WHO PMTCT guidelines. Abbreviations: ARV (antiretroviral), ART (antiretroviral therapy), AZT (zidovudine).</p

Antiretroviral regimen by trimester at enrollment.

<p>^aFor explanations of ARV regimen categories please refer to <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0064979#pone-0064979-g001" target="_blank">Figure 1</a>. Abbreviations: ART (antiretroviral therapy), ARV (antiretroviral).</p