Vertical transmission of hepatitis C virus: systematic review and meta-analysis.

BACKGROUND: We conducted a systematic review of estimates of hepatitis C virus (HCV) vertical transmission risk to update current estimates published more than a decade ago. METHODS: PubMed and Embase were searched and 109 articles were included. Pooled estimates of risk were generated for children born to HCV antibody-positive and viremic women, aged ≥18 months, separately by maternal human immunodeficiency virus (HIV) coinfection. RESULTS: Meta-analysis of the risk of vertical HCV infection to children of HCV antibody-positive and RNA-positive women was 5.8% (95% confidence interval [CI], 4.2%-7.8%) for children of HIV-negative women and 10.8% (95% CI, 7.6%-15.2%) for children of HIV-positive women. The adjusted meta-regression model explained 51% of the between-study variation in the 25 included risk estimates. Maternal HIV coinfection was the most important determinant of vertical transmission risk (adjusted odds ratio, 2.56 [95% CI, 1.50-4.43]). Additional methodological (follow-up rate and definition of infection in children) and risk factors independently predicted HCV infection and need to be captured and reported by future studies of vertical transmission. Studies assessing the contribution of nonvertical exposures in early childhood to HCV prevalence among children at risk of vertical transmission are needed. CONCLUSIONS: More than 1 in every 20 children delivered by HCV chronically infected women are infected, highlighting that vertical transmission likely constitutes the primary transmission route among children. These updated estimates are a basis for decision making in prioritization of research into risk-reducing measures, and inform case management in clinical settings, especially for HIV-positive women in reproductive age

Measuring maternal, foetal and neonatal mortality: Challenges and solutions.

Levels and causes of mortality in mothers and babies are intrinsically linked, occurring at the same time and often to the same mother-baby dyad, although mortality rates are substantially higher in babies. Measuring levels, trends and causes of maternal, neonatal and foetal mortality are important for understanding priority areas for interventions and tracking the success of interventions at the global, national, regional and local level. However, there are many measurement challenges. This paper provides an overview of the definitions and indicators for measuring mortality in pregnant and post-partum women (maternal and pregnancy-related mortality) and their babies (foetal and neonatal mortality). We then discuss current issues in the measurement of the levels and causes of maternal, foetal and neonatal mortality, and present options for improving measurement of these outcomes. Finally, we illustrate some important uses of mortality data, including for the development of models to estimate mortality rates at the global and national level and for audits

The frequency of maternal morbidity: A systematic review of systematic reviews.

BACKGROUND: Estimates of the burden of maternal morbidity are patchy. OBJECTIVE: To conduct a systematic review of systematic reviews of maternal conditions to: (1) make available the most up-to-date frequency estimates; (2) identify which conditions do not have reliable estimates; and (3) scrutinize the quality of the available reviews. SEARCH STRATEGY: We searched Embase, MEDLINE, and CINAHL, combining terms for pregnancy, frequency (e.g. prevalence, incidence), publication type, and specific terms for each of 121 conditions. SELECTION CRITERIA: We included peer-reviewed systematic reviews aiming to estimate the frequency of at least one of the conditions in WHO's list of maternal morbidities, with estimates from at least two countries. DATA COLLECTION AND ANALYSIS: We present the frequency estimates with their uncertainty bounds by condition, region, and pregnancy/postpartum period. We also assess and present information on the quality of the systematic reviews. MAIN RESULTS: Out of 11 930 found, 48 reviews were selected and one more was added. From 49 reviews we extracted 34 direct and 60 indirect frequency estimates covering 35 conditions. No review was available for 71% of the conditions on the WHO list. The extracted estimates show substantial maternal morbidity, spanning the time before and beyond childbirth. There were several gaps in the quality of the reviews. Notably, one-third of the estimates were based only on facility-based studies. CONCLUSIONS: Good-quality systematic reviews are needed for several conditions, as a research priority

Using HIV-attributable mortality to assess the impact of antiretroviral therapy on adult mortality in rural Tanzania.

BACKGROUND: The Tanzanian national HIV care and treatment programme has provided free antiretroviral therapy (ART) to HIV-positive persons since 2004. ART has been available to participants of the Kisesa open cohort study since 2005, but data to 2007 showed a slow uptake of ART and a modest impact on mortality. Additional data from the 2010 HIV serological survey provide an opportunity to update the estimated impact of ART in this setting. METHODS: The Kisesa Health and Demographic Surveillance Site (HDSS) has collected HIV serological data and demographic data, including verbal autopsy (VA) interviews since 1994. Serological data to the end of 2010 were used to make two estimates of HIV-attributable mortality, the first among HIV positives using the difference in mortality between HIV positives and HIV negatives, and the second in the population using the difference between the observed mortality rate in the whole population and the mortality rate among the HIV negatives. Four time periods (1994-1999, 2000-2004, 2005-2007, and 2008-2010) were used and HIV-attributable mortality estimates were analysed in detail for trends over time. A computer algorithm, InterVA-4, was applied to VA data to estimate the HIV-attributable mortality for the population, and this was compared to the estimates from the serological survey data. RESULTS: Among HIV-positive adults aged 45-59 years, high mortality rates were observed across all time periods in both males and females. In HIV-positive men, the HIV-attributable mortality was 91.6% (95% confidence interval (CI): 84.6%-95.3%) in 2000-2004 and 86.3% (95% CI: 71.1%-93.3%) in 2008-2010, while among women, the HIV-attributable mortality was 87.8% (95% CI: 71.1%-94.3%) in 2000-2004 and 85.8% (95% CI: 59.6%-94.4%) in 2008-2010. In the whole population, using the serological data, the HIV-attributable mortality among men aged 30-44 years decreased from 57.2% (95% CI: 46.9%-65.3%) in 2000-2004 to 36.5% (95% CI: 18.8%-50.1%) in 2008-2010, while among women the corresponding decrease was from 57.3% (95% CI: 49.7%-63.6%) to 38.7% (95% CI: 27.4%-48.2%). The HIV-attributable mortality in the population using estimates from the InterVA model was lower than that from HIV sero-status data in the period prior to ART, but slightly higher once ART became available. DISCUSSION: In the Kisesa HDSS, ART availability corresponds with a decline in adult overall mortality, although not as large as expected. Using InterVA to estimate HIV-attributable mortality showed smaller changes in HIV-related mortality following ART availability than the serological results

The relationship between insecurity and the quality of hospital care provided to women with abortion-related complications in the Democratic Republic of Congo:a cross-sectional analysis

Objective To examine the relationship between insecurity and quality of care provided for abortion complications in high-volume hospitals in the Democratic Republic of Congo (DRC).MethodsUsing the WHO Multi-Country Survey on Abortion complications, we analyzed data for 1007 women who received care in 24 facilities in DRC. For inputs of care, we calculated the percentage of facilities in secure and insecure areas meeting 12 readiness criteria for infrastructure and capability. For process and outcomes of care, we estimated the association between security and eight indicators using generalized estimating equation models. Results acilities in secure areas were more likely to report functioning electricity (93.3% vs 66.7%), availability of an obstetrician 24/7 (42.9% vs 28.6%), and the ability to offer several short-acting contraceptives (83.3% vs 57.1%). However, a higher percentage of facilities in insecure areas reported the availability of a telephone or radio (100% vs 80.0%). Women in insecure areas appeared more likely to experience poor quality clinical care overall than women in secure areas (aOR 2.56; 95% CI, 1.13-5.82, P = 0.03). However, there was no association between security and incomplete medical records (P = 0.20), use of dilatation and curettage (D&C) (P = 0.84), women reporting poor experience of care (P = 0.22), satisfaction with care (P = 0.25), and severe maternal outcomes (P = 0.56). There was weak evidence of an association between security and nonreceipt of contraceptives (P = 0.07), with women in insecure areas 70% less likely to report no contraception (aOR 0.31, 95% CI, 0.09-1.09). Use of D&C was high in secure (43.7%) and insecure (60.4%) areas. Conclusion Quality of care did not seem to be very different in secure and insecure areas in DRC, except for some key infrastructure, supply, and human resources elements. The frequent use of D&C for uterine evacuation, the lack of good record keeping, and the lack of contraceptives should be urgently addressed

The Global Burden of Perinatal Common Mental Disorders and Substance Use Amongst Migrant Women:A Systematic Review and Meta-Analysis

BACKGROUND: There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants. METHODS: In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291. FINDINGS: 18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I2 98·8%; τ2 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I2 96·8%; τ2 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I2 97·4%; τ2 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I2 96·6%; τ2 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner. INTERPRETATION: One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants. FUNDING: UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford

Contribution of suicide and injuries to pregnancy-related mortality in low-income and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Although suicide is one of the leading causes of deaths in young women in low-income and middle-income countries, the contribution of suicide and injuries to pregnancy-related mortality remains unknown. METHODS: We did a systematic review to identify studies reporting the proportion of pregnancy-related deaths attributable to suicide or injuries, or both, in low-income and middle-income countries. We used a random-effects meta-analysis to calculate the pooled prevalence of pregnancy-related deaths attributable to suicide, stratified by WHO region. To account for the possible misclassification of suicide deaths as injuries, we calculated the pooled prevalence of deaths attributable to injuries, and undertook a sensitivity analysis reclassifying the leading methods of suicides among women in low-income and middle-income countries (burns, poisoning, falling, or drowning) as suicide. FINDINGS: We identified 36 studies from 21 countries. The pooled total prevalence across the regions was 1·00% for suicide (95% CI 0·54-1·57) and 5·06% for injuries (3·72-6·58). Reclassifying the leading suicide methods from injuries to suicide increased the pooled prevalence of pregnancy-related deaths attributed to suicide to 1·68% (1·09-2·37). Americas (3·03%, 1·20-5·49), the eastern Mediterranean region (3·55%, 0·37-9·37), and the southeast Asia region (2·19%, 1·04-3·68) had the highest prevalence for suicide, with the western Pacific (1·16%, 0·00-4·67) and Africa (0·65%, 0·45-0·88) regions having the lowest. INTERPRETATION: The available data suggest a modest contribution of injuries and suicide to pregnancy-related mortality in low-income and middle-income countries with wide regional variations. However, this study might have underestimated suicide deaths because of the absence of recognition and inclusion of these causes in eligible studies. We recommend that injury-related and other co-incidental causes of death are included in the WHO definition of maternal mortality to promote measurement and effective intervention for reduction of maternal mortality in low-income and middle-income countries. FUNDING: National Institute of Mental Health