Adolescent perinatal mental health in South Asia and Sub-Saharan Africa: A systematic review of qualitative and quantitative evidence.

Despite the contribution of mental ill-health to perinatal morbidity and mortality, the experiences of adolescent girls and young women (AGYW) in low- and middle-income countries remain overlooked. This review explores potential intersecting vulnerabilities for perinatal mental health to identify the prevalence, risk factors, interventions, and implications for health services and future research. We searched mixed-methods English-language studies in four databases (MEDLINE, PsycInfo, Global Health, Embase) published between January 1, 2000 and April 30, 2022 reporting age-disaggregated data on the prevalence, risk factors, and interventions for AGYW's mental health during pregnancy through one year postpartum (quantitative) and/or the mental health experiences of AGYW in the perinatal period (qualitative). Our search yielded 3205 results, of which 48 met the inclusion criteria. Both regions observe a paucity of robust evidence and intervention evaluations, particularly South Asia. While meta-analysis was infeasible due to study heterogeneity, quantitative studies do identify individual-level risk factors for perinatal depression. Qualitative studies emphasise stigma's impact, among other societal-level social risk factors, on diverse perinatal mental health outcomes of importance to AGYW themselves. Rigorous evaluations of interventions are lacking bar two protocols with forthcoming results. Evidence gaps persist concerning prevalence of outcomes beyond depression and implications of AGYW's perinatal experiences including pregnancy/perinatal loss and obstetric and postpartum complications. High-quality research, including comparable prevalence and multi-method evidence identifying risk and protective factors and promising interventions is urgently needed to improve adolescent wellbeing in the perinatal period. A key strength of this review is our assessment of available evidence for both regions. In doing so, we address a critical blind spot of prior reviews that focused either on adult perinatal mental health in low- and middle-income countries, or on AGYW perinatal mental health in high-income settings but neglected the intersection of these potential vulnerabilities for these high-burden, low-resource contexts

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries

Objective: To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between \u3e42 days and within 1 year postpartum. Design: Open population cohort (Health and Demographic Surveillance Systems). Setting: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa. Population: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019. Methods: InterVA5 and InSilicoVA verbal autopsy algorithms were used to at-tribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within42 days versus 43–365 days postpartum adjusting for HDSS and time period (2000– 2009 and 2010–2019). Main outcome measures: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs). Results: Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 be-tween 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpar-tum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000–2009 and 2010–2019. Conclusions: Cause of death data from the extended postpartum period are critical to in-form prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden setting

Lifetime risk of maternal near miss morbidity: a novel indicator of maternal health.

BACKGROUND: The lifetime risk of maternal death quantifies the probability that a 15-year-old girl will die of a maternal cause in her reproductive lifetime. Its intuitive appeal means it is a widely used summary measure for advocacy and international comparisons of maternal health. However, relative to mortality, women are at an even higher risk of experiencing life-threatening maternal morbidity called 'maternal near miss' (MNM) events-complications so severe that women almost die. As maternal mortality continues to decline, health indicators that include information on both fatal and non-fatal maternal outcomes are required. METHODS: We propose a novel measure-the lifetime risk of MNM-to estimate the cumulative risk that a 15-year-old girl will experience a MNM in her reproductive lifetime, accounting for mortality between the ages 15 and 49 years. We apply the method to the case of Namibia (2019) using estimates of fertility and survival from the United Nations World Population Prospects along with nationally representative data on the MNM ratio. RESULTS: We estimate a lifetime risk of MNM in Namibia in 2019 of between 1 in 40 and 1 in 35 when age-disaggregated MNM data are used, and 1 in 38 when a summary estimate for ages 15-49 years is used. This compares to a lifetime risk of maternal death of 1 in 142 and yields a lifetime risk of severe maternal outcome (MNM or death) of 1 in 30. CONCLUSIONS: The lifetime risk of MNM is an urgently needed indicator of maternal morbidity because existing measures (the MNM ratio or rate) do not capture the cumulative risk over the reproductive life course, accounting for fertility and mortality levels

Women's risk of death beyond 42 days post partum: a pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa.

BACKGROUND: WHO's standard definitions of pregnancy-related and maternal deaths only include deaths that occur within 42 days of delivery, termination, or abortion, with major implications for post-partum care and maternal mortality surveillance. We therefore estimated post-partum survival from childbirth up to 1 year post partum to evaluate the empirical justification for the 42-day post-partum threshold. METHODS: We used prospective, longitudinal Health and Demographic Surveillance System (HDSS) data from 30 sites across 12 sub-Saharan African countries to estimate women's risk of death from childbirth until 1 year post partum from all causes. Observations were included if the childbirth occurred from 1991 onwards in the HDSS site and maternal age was 10-54 years. We calculated person-years as the time between childbirth and next birth, outmigration, death, or the end of the first year post partum, whichever occurred first. For six post-partum risk intervals (0-1 days, 2-6 days, 7-13 days, 14-41 days, 42-122 days, and 4-11 months), we calculated the adjusted rate ratios of death relative to a baseline risk of 12-17 months post partum. FINDINGS: Between Jan 1, 1991, and Feb 24, 2020, 647 104 births occurred in the HDSS sites, contributing to 602 170 person-years of exposure time and 1967 deaths within 1 year of delivery. After adjustment for confounding, mortality was 38·82 (95% CI 33·21-45·29) times higher than baseline on days 0-1 after childbirth, 4·97 (3·94-6·21) times higher for days 2-6, 3·35 (2·64-4·20) times higher for days 7-13, and 2·06 (1·74-2·44) times higher for days 14-41. From 42 days to 4 months post partum, mortality was still 1·20 (1·03-1·39) times higher (ie, a 20% higher risk), but deaths in this interval would be excluded from measurement of pregnancy-related mortality. Extending the WHO 42-day post-partum threshold up to 4 months would increase the post-partum pregnancy-related mortality ratio by 40%. INTERPRETATION: This multicountry study has implications for measurement and clinical practice. It makes the case for WHO to extend the 42-day post-partum threshold to capture the full duration of risk of pregnancy-related deaths. There is a need for a new indicator to track late pregnancy-related deaths that occur beyond 42 days, which are otherwise excluded from global maternal health surveillance efforts. Our results also emphasise the need for international agencies to disaggregate estimates by antepartum, intrapartum, postpartum, and extended post-partum periods. Additionally, the schedule and content of postnatal care packages should reflect the extended duration of post-partum risk. FUNDING: The UK Economic and Social Research Council

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa:an analysis of verbal autopsy data from six countries

Objective: To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between >42 days and within 1 year postpartum. Design: Open population cohort (Health and Demographic Surveillance Systems). Setting: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa. Population: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019. Methods: InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42 days versus 43–365 days postpartum adjusting for HDSS and time period (2000–2009 and 2010–2019). Main outcome measures: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs). Results: Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 between 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000–2009 and 2010–2019. Conclusions: Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden settings

SARS-CoV-2 seroprevalence in pregnant women in Kilifi, Kenya from March 2020 to March 2022

BackgroundSeroprevalence studies are an alternative approach to estimating the extent of transmission of SARS-CoV-2 and the evolution of the pandemic in different geographical settings. We aimed to determine the SARS-CoV-2 seroprevalence from March 2020 to March 2022 in a rural and urban setting in Kilifi County, Kenya.MethodsWe obtained representative random samples of stored serum from a pregnancy cohort study for the period March 2020 to March 2022 and tested for antibodies against the spike protein using a qualitative SARS-CoV-2 ELISA kit (Wantai, total antibodies). All positive samples were retested for anti-SARS-CoV-2 anti-nucleocapsid antibodies (Euroimmun, ELISA kits, NCP, qualitative, IgG) and anti-spike protein antibodies (Euroimmun, ELISA kits, QuantiVac; quantitative, IgG).ResultsA total of 2,495 (of 4,703 available) samples were tested. There was an overall trend of increasing seropositivity from a low of 0% [95% CI 0–0.06] in March 2020 to a high of 89.4% [95% CI 83.36–93.82] in Feb 2022. Of the Wantai test-positive samples, 59.7% [95% CI 57.06–62.34] tested positive by the Euroimmun anti-SARS-CoV-2 NCP test and 37.4% [95% CI 34.83–40.04] tested positive by the Euroimmun anti-SARS-CoV-2 QuantiVac test. No differences were observed between the urban and rural hospital but villages adjacent to the major highway traversing the study area had a higher seroprevalence.ConclusionAnti-SARS-CoV-2 seroprevalence rose rapidly, with most of the population exposed to SARS-CoV-2 within 23 months of the first cases. The high cumulative seroprevalence suggests greater population exposure to SARS-CoV-2 than that reported from surveillance data