Comparison between the outcome of trial of labour and elective repeat caesarean section in Kiambu district hospital: a retrospective cohort study

Objective: To determine the pregnancy outcomes in patients with one previous Caesarean section scar who underwent trial of labour as compared to those who had elective repeat Caesarean section at Kiambu District Hospital.Design: A retrospective cohort study.Setting: Post natal wards of Kiambu District Hospital.Subjects: Medical records of all mothers with one previous Caesarean section scar who had delivered in Kiambu District Hospital were obtained and the information used to fill questionnaires. Maternal morbidity was assessed primarily based on post-natal hospital stay. Other maternal morbidity measures assessed included occurrence of uterine rupture, maternal death, need for hysterectomy, maternal blood loss, presence of visceral injury (bladder or gut) and post delivery infectious morbidity. In addition, the failure rate of trial of labour was determined. Foetal outcome was assessed based on APGAR score at five minutes, need for admission to the new born unit and the occurrence of early neonatal death.Results: A total of 142 participants were recruited of which 71 had undergone TOL and 71 had undergone ERCS. Clinical pelvimetry was the most common criteria used for selection of patients for TOL since 100% of all patients in the TOL group were assessed this way as compared to 80.3% in the ERCS group. The success rate of TOL was 50.7% in this study. Successful TOL was associated with less hospital stay since 91.6% stayed for two days or less as compared to ERCS where 84.5% stayed for 3-4days (P<0.001). Similarly, blood loss was less for those who had successful TOL where 97.2% lost less than 500mls as compared to ERCS where 85.9% lost 500mls or more. Maternal outcomes were worse in the 49.7% who failed TOL since only 57.1% of them had a post-natal hospital stay of three to four days as compared to 84.5% in the ERCS group( p=0.029) and 42.9% of the failed TOL group stayed in the hospital for five days or more as compared to only 15.5% in the ERCS group(p=0.002). Foetal outcome was worse in the TOL group since 11.3% had an APGAR score of less than eight at five minutes as compared to only 1.4% in the ERCS group(p=0.016). Similarly, 14.1% of newborns in the TOL group were admitted to the new born unit as compared to only 5.6% in the ERCS group(p=0.091). There were no early neonatal deaths reported in both groups.Conclusion: Overall success rate for TOL was low necessitating emergency Caesarean section of which the maternal outcomes were worse than in the ERCS group. The foetal outcomes were better in the ERCS group as compared to the TOL group.

Adherence to national guidelines in prevention of mother to child transmission of HIV

Background: Mother-to-child transmission (MTCT) of Human Immunodeficiency Virus (HIV) contributes to over 90% of the paediatric HIV infections. The national PMTCT guidelines make recommendations for specific interventions to reduce perinatal transmission. Data on adherence to the guidelines by caregivers and quality of PMTCT care is however limited.objective: To evaluate the extent to which PMTCT care offered to HIV positive women admitted for delivery at Kenyatta National Hospital (KNH) and Pumwani Maternity Hospital (PMH) adheres to National Guidelines in order to reduce vertical transmission of HIV during labour and delivery.Design: A cross-sectional study.Setting: Kenyatta National Hospital and Pumwani Maternity Hospitalfrom January to April 2009.Subjects: All consenting HIV positive women admitted to the labour wards at the two facilities and planned for delivery.Results: A total of 370 women were enrolled, 266 at Pumwani Maternity Hospital and 104 at Kenyatta National Hospital. Among the enrolled women 357 (96.4%) had been counselled on vertical transmission and 205(55.4%) had HIV disease staging by CD4 cell count. There were no significant differences between the two study sites in the proportion of women counselled on MTCT (p=0.398) and receiving HIV disease staging by CD4 testing (p=0.28). Three hundred and forty nine (94.3%) women were offered varied ARV regimens for PMTCT. 101(27.3%) received HAART, 94(26.9%) were given single dose nevirapine and 130(37%) received AZT+NVP combination prophylaxis. Twenty one women received no ARV prophylaxis. Overall, 268 women (72.5%) had spontaneous vertex delivery. An episiotomy rate of 7% was observed and no vacuum delivery was recorded. A Caesarean section rate of 27.5% was recorded with PMTCT as aan indication in almost half of the cases. Women delivered at KNH were more likely to receive HAART (p<0.001) and to be delivered by elective caesarean (p<0.001).Conclusion: A great majority of HIV positive women admitted for delivery received counseling on vertical transmission and were offered ARVs for PMTCT. Many women did not get CD4 measurement and clinical staging as recommended in the National guidelines

Gross presentation and histomorphological changes of placentae in patients presenting with intrauterine foetal death at Kenyatta national hospital

Background: There are 3.2 million annual stillbirths, at least 98% occur in low-/middle income countries, and on average, as many as two-thirds of these stillbirths are thought to occur antenatally, prior to labour. The most useful test towards a diagnosis after stillbirth is pathological examination of the placenta and the foetus. However, this pathological examination is done in less than half of the placentae after cases of stillbirth.Objective: To determine gross presentation and histomorphological changes of placentae in patients presenting with intrauterine foetal death as compared to live births.Design: A case control study.Setting: The Kenyatta National Hospital’s labour ward and the Department of Human Pathology, University of Nairobi.Subjects: The cases were mothers who presented with IUFD at a gestation of 28 weeks and above. The controls were a comparative group of mothers who delivered live babies at the hospital and were matched for age.Results: Reduction of the mass of functioning villi was present in 11.8% of placenta in the stillbirth group compared to 2% in the live birth group (p-value 0.002). There was significant presence of other placental abnormalities in the stillbirth group (22.5%) compared to the live birth group (9.8%) (p-value-0.002).Conclusion: This study revealed that histological examination of placenta is useful in identifying some causes of stillbirths. This knowledge may lead to preventive measures which would lower perinatal mortality

Cluster Randomized Trail of the uptake of a take-home Infant dose of Nevirapine in Kenya

Objective: To test whether a single take home dose of infant nevirapine increased infant uptake without decreasing institutional deliveries. Design: Cluster randomized post-test only study with control group. Setting: Ten hospitals in urban areas of Coast, Rift Valley, and Western provinces, Kenya. Participants: Pregnant women with HIV, 18 years and older, and at least 32 weeks gestation recruited during antenatal care and followed up at home approximately one week after delivery. Intervention: In the intervention group, women were given a single infant’s dose of nevirapine to take home prior to delivery. In the control group, no changes were made to the standard of care. Main outcome measures: Mothers’ reports of infant uptake of nevirapine and place of delivery. Results: Uptake of the infant’s nevirapine dose was high, 94% in the intervention group and 88% in the control group (p=0.096). Among women who delivered at home, uptake was higher significantly among infants whose mothers got the take home dose compared to women who did not get the dose (93% vs. 53%, p<0.01). The intervention did not influence place of delivery. Providers were positive about the take home dose concept; difficulties were attributed to HIV-related stigma. Conclusions: Making take home infant nevirapine available either as a single dose administered within 72 hours of birth or as part of a more complex six week postnatal regimen, will increase infant uptake especially among women who deliver at home without affecting place of delivery.East African Medical Journal Vol. 87 No. 7 July 201

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries

Importance: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent. / Objective: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 countries in sub-Saharan Africa. / Design, Setting, and Participants: This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection. / Exposures: Age, sex, preexisting comorbidities, and region of residence. / Main Outcomes and Measures: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay. / Results: Among 469 hospitalized children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalized. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge. / Conclusions and Relevance: In this cohort study of children and adolescents hospitalized with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region

The Critical Need for Pooled Data on Coronavirus Disease 2019 in African Children: An AFREhealth Call for Action Through Multicountry Research Collaboration

Globally, there are prevailing knowledge gaps in the epidemiology, clinical manifestations, and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children and adolescents; and these gaps are especially wide in African countries. The availability of robust age-disaggregated data is a critical first step in improving knowledge on disease burden and manifestations of coronavirus disease 2019 (COVID-19) among children. Furthermore, it is essential to improve understanding of SARS-CoV-2 interactions with comorbidities and coinfections such as human immunodeficiency virus (HIV), tuberculosis, malaria, sickle cell disease, and malnutrition, which are highly prevalent among children in sub-Saharan Africa. The African Forum for Research and Education in Health (AFREhealth) COVID-19 Research Collaboration on Children and Adolescents is conducting studies across Western, Central, Eastern, and Southern Africa to address existing knowledge gaps. This consortium is expected to generate key evidence to inform clinical practice and public health policy-making for COVID-19 while concurrently addressing other major diseases affecting children in African countries

Changes in preterm birth and stillbirth during COVID-19 lockdowns in 26 countries

Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from −90% to +30%, were reported in many countries following early COVID-19 pandemic response measures (‘lockdowns’). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95–0.98, P value <0.0001), second (0.96, 0.92–0.99, 0.03) and third (0.97, 0.94–1.00, 0.09) months of lockdown, but not in the fourth month of lockdown (0.99, 0.96–1.01, 0.34), although there were some between-country differences after the first month. For high-income countries in this study, we did not observe an association between lockdown and stillbirths in the second (1.00, 0.88–1.14, 0.98), third (0.99, 0.88–1.12, 0.89) and fourth (1.01, 0.87–1.18, 0.86) months of lockdown, although we have imprecise estimates due to stillbirths being a relatively rare event. We did, however, find evidence of increased risk of stillbirth in the first month of lockdown in high-income countries (1.14, 1.02–1.29, 0.02) and, in Brazil, we found evidence for an association between lockdown and stillbirth in the second (1.09, 1.03–1.15, 0.002), third (1.10, 1.03–1.17, 0.003) and fourth (1.12, 1.05–1.19, <0.001) months of lockdown. With an estimated 14.8 million PTB annually worldwide, the modest reductions observed during early pandemic lockdowns translate into large numbers of PTB averted globally and warrant further research into causal pathways

Changes in preterm birth and stillbirth during COVID-19 lockdowns in 26 countries.

Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from -90% to +30%, were reported in many countries following early COVID-19 pandemic response measures ('lockdowns'). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95-0.98, P value <0.0001), second (0.96, 0.92-0.99, 0.03) and third (0.97, 0.94-1.00, 0.09) months of lockdown, but not in the fourth month of lockdown (0.99, 0.96-1.01, 0.34), although there were some between-country differences after the first month. For high-income countries in this study, we did not observe an association between lockdown and stillbirths in the second (1.00, 0.88-1.14, 0.98), third (0.99, 0.88-1.12, 0.89) and fourth (1.01, 0.87-1.18, 0.86) months of lockdown, although we have imprecise estimates due to stillbirths being a relatively rare event. We did, however, find evidence of increased risk of stillbirth in the first month of lockdown in high-income countries (1.14, 1.02-1.29, 0.02) and, in Brazil, we found evidence for an association between lockdown and stillbirth in the second (1.09, 1.03-1.15, 0.002), third (1.10, 1.03-1.17, 0.003) and fourth (1.12, 1.05-1.19, <0.001) months of lockdown. With an estimated 14.8 million PTB annually worldwide, the modest reductions observed during early pandemic lockdowns translate into large numbers of PTB averted globally and warrant further research into causal pathways