A research agenda to improve incidence and outcomes of assisted vaginal birth

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth. [Abstract copyright: (c) 2023 The authors; licensee World Health Organization.

Transmission mère-enfant du VIH-1: incidence & facteurs de risque socio-économiques, cliniques et biologiques au centre de santé de Muhima (Kigali/Rwanda).

Abstract:Background. This dissertation focuses on HIV-1 mother-to-child transmission (MTCT) as a major global public health issue. It consists of three papers that were published in international peer review journals. We initiated the study to answer the following research question: what was the impact of socioeconomic, clinical and biological risk factors on HIV-1 mother-to-child transmission incidence at Muhima health centre, in the specific context of Rwanda health sector reforms?Methods. A prospective cohort study in Muhima health centre (Rwanda) was used to address the study objectives, with a follow up of 700 mother-infants pairs (2007-2010).Results. The observed overall transmission rate was 3.2% (CI 1.9% – 4.5%) at age 6 weeks of life and 3.7% (CI 2.3% – 5.1%) at 6 months of age. Among the 679 exposed and followed-up infants, a higher risk of HIV-1 MTCT was significantly associated with the following factors: non-disclosure of HIV status to partner; high viral load (HIV-1 RNA); infant mixed feeding before 6 months of age; low mother’s CD4 count and low hemoglobin level during pregnancy.Conclusions. The health sector reforms were found to have led to a conducive environment that was favorable to scaling up of maternal health services in Rwanda (2000-2010).The observed overall MTCT rate of 3.2% (CI 1.9% – 4.5%) at age 6 – weeks postnatal in the Muhima cohort is a significant reduction of MTCT incidence towards achieving the elimination target of The most relevant factors independently associated with increased risk of mother – to – child transmission of HIV-1 included non-disclosure of HIV status to partner and high HIV-1 RNA. Members of this cohort also showed socioeconomic inequalities, with unmarried status carrying higher risk of undisclosed HIV status. Integrated service delivery for PMTCT/MCH interventions, including community-based approach, task shifting and subsidized membership fees for people living with HIV, were the key national policies implemented to support optimal access to and delivery of evidence – based interventions for prevention of mother – to – child transmission of HIV in Muhima.Résumé:ContexteCette thèse porte sur la transmission mère-enfant du VIH-1 comme un problème majeur de santé publique au niveau mondial. Il est composé de 3 publications dans des revues internationales à comité de lecture. Nous avons initié l’étude pour pouvoir répondre à la question de recherche suivante :quel a été l’impact des facteurs de risque socio-économiques, cliniques et biologiques sur l’incidence de la transmission du VIH-1de la mère à l’enfant au centre de santé de Muhima, dans le contexte spécifique des réformes du secteur de la santé au Rwanda.Cadre méthodologiqueUne étude cohorte prospective a été menée au centre de santé de Muhima pour pouvoir répondre aux objectifs de l’étude, avec un suivi de 700 couples mères-enfants éligibles (2007-2010).RésultatsL’incidence cumulée de transmission mère-enfant du VIH-1 a été de 3,2% (IC 1,9% – 4,5%) à 6 semaines et 3,7% (IC 2,3% – 5,1%) à 6 mois de vie. Parmi les 679 nourrissons exposés et suivis, un risque plus élevé de transmission mère-enfant du VIH-1 était significativement associé aux facteurs suivants :non divulgation du statut séropositif au VIH-1 entre partenaires ;charge virale élevée (ARN-VIH-1) ;allaitement mixte de l’enfant avant 6 mois d’âge ;CD4 bas et taux d’hémoglobine bas pendant la grossesse. ConclusionsLes réformes du secteur ont pu créer un environnement favorable à l’extension des services de santé maternelle (2007-2010).Le taux global 3,2% (IC 1,9 – 4,5) à 6 semaines de vie représente une réduction significative de l’incidence de transmission mère-enfant du VIH-1 pour atteindre le niveau de Les facteurs les plus pertinents indépendamment associés à un risque élevé de transmission mère-enfant du VIH-1sont représentés par la non-divulgation du statut séropositif au VIH-1 entre partenaires et la charge virale élevée (ARN-VIH-1). Au sein de cette cohorte, l’on a également pu identifier l’existence d’inégalités socio-économiques, avec le statut de femme seule associé au risque plus élevé de non-divulgation du statut séropositif au VIH-1 entre partenaires.Le service intégré de PTME / interventions de santé de la mère et de l’enfant, y compris l'approche communautaire, l’approche de délégation des tâches et la subvention des frais d'adhésion à la mutuelle de santé pour les personnes vivant avec le VIH, ont été les principales politiques nationales mises en œuvre pour favoriser l'accès optimal et la prestation des interventions basées sur les preuves pour la prévention de la transmission du VIH-1 de la mère à l’enfant au centre de santé de Muhima.Doctorat en Sciences de la santé publiqueinfo:eu-repo/semantics/nonPublishe

Socio-economic, clinical and biological risk factors for mother - to – child transmission of HIV-1 in Muhima health centre (Rwanda): a prospective cohort study

info:eu-repo/semantics/publishe

Elimination of mother-to-child transmission of HIV and syphilis: A dual approach in the African Region to improve quality of antenatal care and integrated disease control.

The World Health Organization's (WHO) Strategic Framework for the Elimination of New HIV Infections among Children in Africa by 2015 identifies important synergies for the elimination of mother-to-child transmission of HIV and syphilis in terms of prevention interventions, implementation logistics and service delivery, monitoring and evaluation systems, and need for sustained political commitment. The WHO advocates the use of an integrated, rights-based dual approach with partnerships and collaboration to make the best use of available resources. Through a consultative approach, six countries in the African Region committed to dual elimination and developed and implemented action plans for this purpose. Where interest and commitment are high, this may also be possible and effective in other African countries