Constructive integration : changes in uptake and outcomes of reproductive health services during the scaling up of ART and PMTCT in Thyolo District, Malawi

Includes bibliographical referencesBackground: In recent years there has been increasing debate about the impact of scaled-up ART and PMTCT programmes on the uptake and outcomes of reproductive health services, in particular the potential detrimental effects of HIV-care on the overall capacity of fragile health systems. The objective of this study was to evaluate changes in the uptake of reproductive health services as well as the main pregnancy outcomes during the scaling up of ART and PMTCT in Thyolo District, Malawi. Methods : Study design: retrospective descriptive district-wide cohort analysis for the period 2005 to 2009. Setting: Thyolo District, an area with around 600,000 inhabitants, an adult HIV-prevalence of 21% and a Total Fertility Rate of 5.7 in 2004. HIV-care including ART and PMTCT was scaled up since 2004 in Thyolo District to reach district-wide coverage in 2007. HIV-care is provided at district hospital, health centre and community health post levels. Outcomes: uptake of antenatal, intrapartum and postpartum care, family planning and treatment of sexually transmitted infections; infrastructural changes, and changes in maternal and perinatal pregnancy outcome. Data collection and analysis: data were collected from facility antenatal, intrapartum and postpartum records, as well as from MoH and MSF databases maintained for routine programme monitoring. Chisquare tests were performed comparing the baseline year (2005) with the year of study end (2009). Results: Uptake of peripartum care had improved markedly by the end of the five-year study period: the percentages of pregnant women who took up antenatal, intrapartum and postpartum care increased by 30%, 25% and 20% respectively. The number of family planning consultations increased by almost 50% and the number of women treated for sexually transmitted infections more than doubled. Interactions between HIV-care and general reproductive health care had positive effects on key health system components, including governance, health financing, human resources and drug supply. Reliable pregnancy outcome indicators for the entire observation period were difficult to obtain due to likely under-reporting of facility-based maternal and perinatal mortality. However, previously documented results from Thyolo show a reduction of facility-based severe maternal complications, including uterine rupture, between 2007 and 2009. Conclusions: Uptake of reproductive health services and facility-based maternal outcomes increased markedly during the period of HIV scale–up. This implies that the scale up of HIV-care did not inhibit, and likely increased, uptake of reproductive health services, while quality improvements in perinatal care could still be successfully implemented. The finding that ART and PMTCT care may be successfully integrated into broader reproductive health services with satisfying outcomes is a strong argument for continued scale up of ART and PMTCT in similar settings

Quality of Maternal Death Documentation in Afghanistan:A Retrospective Health Facility Record Review

Objectives: To assess the quality of health facility documentation related to maternal deaths at health facilities in Afghanistan. Methods: Analysis of a subset of findings from the 2016 National Maternal and Newborn Health Quality of Care Assessment in Afghanistan. At each facility, maternity registers were reviewed to obtain data related to maternity caseload, and number and causes of maternal deaths in the year preceding the survey. Detailed chart reviews were conducted for up to three maternal deaths per facility. Analyses included completeness of charts, quality of documentation, and cause of death using WHO application of International Statistical Classification of Disease to deaths during pregnancy, childbirth and the puerperium. Key findings: Only 129/226 (57%) of facilities had mortality registers available for review on the day of assessment and 41/226 (18%) had charts documenting maternal deaths during the previous year. We reviewed 68 maternal death cases from the 41 facilities. Cause of death was not recorded in nearly half of maternal death cases reviewed. Information regarding mode of birth was missing in over half of the charts, and one third did not capture gestational age at time of death. Hypertensive disorders of pregnancy and obstetric hemorrhage were the most common direct causes of death, followed by maternal sepsis and unanticipated complications of clinical management including anesthesia-related complications. Documented indirect causes of maternal deaths were anemia, cardiac arrest, kidney and hepatic failure. Charts revealed at least eight maternal deaths from indirect causes that were not captured in register books, indicating omission or misclassification of registered deaths. Conclusion: Considerable gaps in quality of recordkeeping exist in Afghanistan, including underreporting, misclassification and incompleteness. This hampers efforts to improve quality of maternal and newborn health data and priority setting

Peripartum infections and associated maternal mortality in rural Malawi

Article approval pendingTo assess associations between maternal mortality and severe morbidity and human immunodeficiency virus (HIV) infection, uptake of antiretroviral therapy, obstetric infections, and nonobstetric infections in a rural Malawian district, where the estimated HIV prevalence is 21%

Can the Robson 10 Group Classification System help identify which groups of women are driving the high caesarean section rate in major private hospitals in eastern Ethiopia? A cross-sectional study

OBJECTIVE: The rates of caesarean section (CS) in Ethiopian private hospitals are high compared with those in public facilities, and there are limited descriptions of groups of women contributing to these high rates. The objective of this study was to describe the groups contributing to increased CS rates using the Robson classification in two major private hospitals in eastern Ethiopia. DESIGN: Cross-sectional study. SETTING: Two major private hospitals in eastern Ethiopia. PARTICIPANTS: All women who gave birth from 9 January 2019 to 8 January 2020 in two major private hospitals in eastern Ethiopia. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the Robson 10 Group Classification System. The secondary outcome was indication for CS as recorded in the medical files. RESULTS: Of 1203 births in both hospitals combined during the study period, 415 (34.5%) were by CS. Women with a uterine scar due to previous CS (group 5), single cephalic term multiparous women in spontaneous labour (group 3) and single cephalic term nulliparous women in spontaneous labour (group 1) were the leading groups contributing 33%, 27.5% and 17.1%, respectively. The leading documented indications were fetal compromise (29.4%), previous CS (27.2%) and obstructed labour (12.3%). CONCLUSION: More than three-fourths of CS were performed among Robson groups 5, 3 and 1, indicating inadequate trial of labour after CS or management of labour among relatively low-risk groups (3 and 1). Improving management of spontaneous labour and strengthening clinical practice around safely providing the option of vaginal birth after CS practice are strategies required to reduce the high CS rates in these private facilities

Surviving mothers and lost babies - burden of stillbirths and neonatal deaths among women with maternal near miss in eastern Ethiopia:a prospective cohort study

Background: Although maternal near miss (MNM) is often considered a 'great save' because the woman survived life-threatening complications, these complications may have resulted in loss of a child or severe neonatal morbidity. The objective of this study was to assess proportion of perinatal mortality (stillbirths and early neonatal deaths) in a cohort of women with MNM in eastern Ethiopia. In addition, we compared perinatal outcomes among women who fulfilled the World Health Organization (WHO) and the sub-Saharan African (SSA) MNM criteria. Methods: In a prospective cohort design, women with potentially life-threatening conditions (PLTC) (severe postpartum hemorrhage, severe pre-(eclampsia), sepsis/severe systemic infection, and ruptured uterus) were identified every day from January 1st, 2016, to April 30th, 2017, and followed until discharge in the two main hospitals in Harar, Ethiopia. Maternal and perinatal outcomes were collected using both sets of criteria. Numbers and proportions of stillbirths and early neonatal deaths were computed and compared. Results: Of 1054 women admitted with PTLC during the study period, 594 women fulfilled any of the MNM criteria. After excluding near misses related to abortion, ectopic pregnancy or among undelivered women, 465 women were included, in whom 149 (32%) perinatal deaths occurred: 132 (88.6%) stillbirths and 17 (11.4%) early neonatal deaths. In absolute numbers, the SSA criteria picked up more perinatal deaths compared to the WHO criteria, but the proportion of perinatal deaths was lower in SSA group compared to the WHO (149/465, 32% vs 62/100, 62%). Perinatal mortality was more likely among near misses with antepartum hemorrhage (adjusted odds ratio (aOR) = 4.81; 95% CI = 1.76-13.20), grand multiparous women (aOR = 4.31; 95% confidence interval CI = 1.23-15.25), and women fulfilling any of the WHO near miss criteria (aOR = 4.89; 95% CI = 2.17-10.99). Conclusion: WHO MNM criteria pick up fewer perinatal deaths, although perinatal mortality occurred in a larger proportion of women fulfilling the WHO MNM criteria compared to the SSA MNM criteria. As women with MNM have increased risk of perinatal deaths (in both definitions), a holistic care addressing the needs of the mother and baby should be considered in management of women with MNM

Severe Hypertensive Disorders of Pregnancy in Eastern Ethiopia:Comparing the Original WHO and Adapted sub-Saharan African Maternal Near-Miss Criteria

Objectives: To assess life-threatening complications among women admitted with severe hypertensive disorders of pregnancy and compare applicability of World Health Organization (WHO) maternal near-miss (MNM) criteria and the recently adapted sub-Saharan African (SSA) MNM criteria in eastern Ethiopia.Methods: Of 1,054 women admitted with potentially life-threatening conditions between January 2016 and April 2017, 562 (53.3%) had severe preeclampsia/eclampsia. We applied the definition of MNM according to the WHO MNM criteria and the SSA MNM criteria. Logistic regression was performed to identify factors associated with severe maternal outcomes (MNMs and maternal deaths).Results: The SSA MNM criteria identified 285 cases of severe maternal outcomes: 271 MNMs and 14 maternal deaths (mortality index 4.9%). The WHO criteria identified 50 cases of severe maternal outcomes: 36 MNMs and 14 maternal deaths (mortality index 28%). The MNM ratio was 36.6 per 1,000 livebirths according to the SSA MNM criteria and 4.9 according to the WHO criteria. More than 80% of women in both groups had MNM events on arrival or within 12 hours after admission. Women without antenatal care, from rural areas, referred from other facilities, and with concomitant hemorrhage more often developed severe maternal outcomes.Conclusion: Regarding hypertensive disorders of pregnancy, the SSA tool is more inclusive than the WHO tool, while still maintaining a considerably high mortality index indicating severity of included cases. This may enable more robust audits. Strengthening the referral system and improving prevention and management of obstetric hemorrhage in women with hypertensive disorders of pregnancy are required to avert severe maternal outcomes.</p

The WHO Maternal Near Miss Approach: Consequences at Malawian District Level

INTRODUCTION: WHO proposes a set of organ-failure based criteria for maternal near miss. Our objective was to evaluate what implementation of these criteria would mean for the analysis of a cohort of 386 women in Thyolo District, Malawi, who sustained severe acute maternal morbidity according to disease-based criteria.\ud \ud METHODS AND FINDINGS: A WHO Maternal Near Miss (MNM) Tool, created to compare disease-, intervention- and organ-failure based criteria for maternal near miss, was completed for each woman, based on a review of all available medical records. Using disease-based criteria developed for the local setting, 341 (88%) of the 386 women fulfilled the WHO disease-based criteria provided by the WHO MNM Tool, 179 (46%) fulfilled the intervention-based criteria, and only 85 (22%) the suggested organ-failure based criteria.\ud \ud CONCLUSIONS: In this low-resource setting, application of these organ-failure based criteria that require relatively sophisticated laboratory and clinical monitoring underestimates the occurrence of maternal near miss. Therefore, these criteria and the suggested WHO approach may not be suited to compare maternal near miss across all settings.\ud \u

Identification of candidate effector genes of <i>Pratylenchus penetrans</i>

Pratylenchus penetrans is one of the most important species of root lesion nematodes (RLNs) because of its detrimental and economic impact in a wide range of crops. Similar to other plant‐parasitic nematodes (PPNs), P. penetrans harbours a significant number of secreted proteins that play key roles during parasitism. Here, we combined spatially and temporally resolved next‐generation sequencing datasets of P. penetrans to select a list of candidate genes aimed at the identification of a panel of effector genes for this species. We determined the spatial expression of transcripts of 22 candidate effectors within the oesophageal glands of P. penetrans by in situ hybridization. These comprised homologues of known effectors of other PPNs with diverse putative functions, as well as novel pioneer effectors specific to RLNs. It is noteworthy that five of the pioneer effectors encode extremely proline‐rich proteins. We then combined in situ localization of effectors with available genomic data to identify a non‐coding motif enriched in promoter regions of a subset of P. penetrans effectors, and thus a putative hallmark of spatial expression. Expression profiling analyses of a subset of candidate effectors confirmed their expression during plant infection. Our current results provide the most comprehensive panel of effectors found for RLNs. Considering the damage caused by P. penetrans, this information provides valuable data to elucidate the mode of parasitism of this nematode and offers useful suggestions regarding the potential use of P. penetrans‐specific target effector genes to control this important pathogen