Publications by authors named "Luis Gadama"

16 Publications

  • Page 1 of 1

Immediate "Kangaroo Mother Care" and Survival of Infants with Low Birth Weight.

N Engl J Med 2021 05;384(21):2028-2038

The affiliations of the members of the writing committee are as follows: the Department of Maternal, Newborn, Child, and Adolescent Health, and Ageing, World Health Organization, Geneva (S.P.N.R., S.Y., N.M., H.V.J., H.T., R.B.); Vardhman Mahavir Medical College and Safdarjung Hospital (S.A., P.M., N.C., J.S., P.A., K.N., I.S., K.C.A., H.C.) and the All India Institute of Medical Sciences (M.J.S.), New Delhi, and Translational Health Science and Technology Institute, Faridabad (N.W.) - all in India; Muhimbili University of Health and Allied Sciences (H.N., E.A., A.M.) and Muhimbili National Hospital (M.N., R.M.) - both in Dar es Salaam, Tanzania; the University of Malawi, College of Medicine, Blantyre, Malawi (K.K., L.G., A.T.M., V.S., Q.D.); Obafemi Awolowo University, Ile-Ife, Nigeria (C.H.A., O.K., B.P.K., E.A.A.); Kwame Nkrumah University of Science and Technology (S.N., R.L.-R., D.A., G.P.-R.) and Komfo Anokye Teaching Hospital (A.B.-Y., N.W.-B., I.N.), Kumasi, and the School of Public Health, University of Ghana, Accra (A.A.M.) - all in Ghana; Karolinska University Hospital (A.L.) and Karolinska Institute (N.B., A.L., B.W.), Stockholm; the Institute for Safety Governance and Criminology, University of Cape Town, Cape Town, South Africa (B.M.); and Stavanger University Hospital, Stavanger, Norway (S.R.).

Background: "Kangaroo mother care," a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (<2.0 kg) when initiated after stabilization, but the majority of deaths occur before stabilization. The safety and efficacy of kangaroo mother care initiated soon after birth among infants with low birth weight are uncertain.

Methods: We conducted a randomized, controlled trial in five hospitals in Ghana, India, Malawi, Nigeria, and Tanzania involving infants with a birth weight between 1.0 and 1.799 kg who were assigned to receive immediate kangaroo mother care (intervention) or conventional care in an incubator or a radiant warmer until their condition stabilized and kangaroo mother care thereafter (control). The primary outcomes were death in the neonatal period (the first 28 days of life) and in the first 72 hours of life.

Results: A total of 3211 infants and their mothers were randomly assigned to the intervention group (1609 infants with their mothers) or the control group (1602 infants with their mothers). The median daily duration of skin-to-skin contact in the neonatal intensive care unit was 16.9 hours (interquartile range, 13.0 to 19.7) in the intervention group and 1.5 hours (interquartile range, 0.3 to 3.3) in the control group. Neonatal death occurred in the first 28 days in 191 infants in the intervention group (12.0%) and in 249 infants in the control group (15.7%) (relative risk of death, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P = 0.001); neonatal death in the first 72 hours of life occurred in 74 infants in the intervention group (4.6%) and in 92 infants in the control group (5.8%) (relative risk of death, 0.77; 95% CI, 0.58 to 1.04; P = 0.09). The trial was stopped early on the recommendation of the data and safety monitoring board owing to the finding of reduced mortality among infants receiving immediate kangaroo mother care.

Conclusions: Among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilization; the between-group difference favoring immediate kangaroo mother care at 72 hours was not significant. (Funded by the Bill and Melinda Gates Foundation; Australian New Zealand Clinical Trials Registry number, ACTRN12618001880235; Clinical Trials Registry-India number, CTRI/2018/08/015369.).
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http://dx.doi.org/10.1056/NEJMoa2026486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108485PMC
May 2021

Comparison of adverse birth outcomes among HIV-infected and HIV-uninfected women delivering in high and low risk settings in the era of universal ART in Malawi: a registry study.

Paediatr Int Child Health 2021 Apr 21:1-11. Epub 2021 Apr 21.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

: Recent studies show that ART is associated with an adverse birth outcome in HIV-infected women.: To compare rates of low birthweight (LBW) and preterm birth (PTB) between HIV-infected women receiving lifelong ART and HIV-uninfected women giving birth in low- and high-risk settings in Malawi.: This observational, registry study was conducted from January 2016 to August 2017 in one large, tertiary referral hospital and four primary healthcare (PHC) facilities in Blantyre, Malawi. Women who delivered singleton live births or stillbirths of ≥20 weeks gestation were included in the analysis. Descriptive and stratified analyses were conducted using χ tests and multivariable logistic models to control for maternal age, gravidity and health facility.: A total of 14,233 births were included in the analysis (7715 from the tertiary hospital and 6518 from PHC facilities). In the univariable analysis, there were no differences in rates of LBW (6.7% 6.4%) and PTB (42.5% 42.0%) between HIV-infected and -uninfected women delivering in PHC facilities. However, differences in LBW were significantly higher in HIV-infected women in multivariable analysis (LBW aOR 1.40, 95% CI 1.01-1.95). Rates of LBW and PTB were significantly higher in HIV-infected women than in uninfected women delivering at the tertiary hospital (LBW 17.6% 13.2%, aOR 1.53, 95% CI 1.27-1.85; PTB 28.2% 24.9%, aOR 1.37, 95% CI 1.17-1.60): Rates of adverse birth outcomes are significantly higher in HIV-infected women than in HIV-uninfected women, and this is more apparent in high-risk hospital settings than in low-risk PHC settings.
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http://dx.doi.org/10.1080/20469047.2021.1874200DOI Listing
April 2021

Prevention of cervical cancer through two HPV-based screen-and-treat implementation models in Malawi: protocol for a cluster randomized feasibility trial.

Pilot Feasibility Stud 2021 Apr 20;7(1):98. Epub 2021 Apr 20.

Department of OB-GYN, University of North Carolina, 4002 Old Clinic Building, CB #7570, Chapel Hill, NC, 27599-7570, USA.

Background: Cervical cancer is the leading cause of cancer incidence and mortality among Malawian women, despite being a largely preventable disease. Implementing a cervical cancer screening and preventive treatment (CCSPT) program that utilizes rapid human papillomavirus (HPV) testing on self-collected cervicovaginal samples for screening and thermal ablation for treatment may achieve greater coverage than current programs that use visual inspection with acetic acid (VIA) for screening and cryotherapy for treatment. Furthermore, self-sampling creates the opportunity for community-based screening to increase uptake in populations with low screening rates. Malawi's public health system utilizes regularly scheduled outreach and village-based clinics to provide routine health services like family planning. Cancer screening is not yet included in these community services. Incorporating self-sampled HPV testing into national policy could address cervical cancer screening barriers in Malawi, though at present the effectiveness, acceptability, appropriateness, feasibility, and cost-effectiveness still need to be demonstrated.

Methods: We designed a cluster randomized feasibility trial to determine the effectiveness, acceptability, appropriateness, feasibility, and budget impact of two models for integrating a HPV-based CCSPT program into family planning (FP) services in Malawi: model 1 involves only clinic-based self-sampled HPV testing, whereas model 2 includes both clinic-based and community-based self-sampled HPV testing. Our algorithm involves self-collection of samples for HPV GeneXpert® testing, visual inspection with acetic acid for HPV-positive women to determine ablative treatment eligibility, and same-day thermal ablation for treatment-eligible women. Interventions will be implemented at 14 selected facilities. Our primary outcome will be the uptake of cervical cancer screening and family planning services during the 18 months of implementation, which will be measured through an Endline Household Survey. We will also conduct mixed methods assessments to understand the acceptability, appropriateness, and feasibility of the interventions, and a cost analysis to assess budget impact.

Discussion: Our trial will provide in-depth information on the implementation of clinic-only and clinic-and-community models for integrating self-sampled HPV testing CCSPT with FP services in Malawi. Findings will provide valuable insight for policymakers and implementers in Malawi and other resource-limited settings with high cervical cancer burden.

Trial Registration: ClinicalTrials.gov identifier: NCT04286243 . Registered on February 26, 2020.
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http://dx.doi.org/10.1186/s40814-021-00839-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056631PMC
April 2021

'Prison facilities were not built with a woman in mind': an exploratory multi-stakeholder study on women's situation in Malawi prisons.

Int J Prison Health 2020 04;16(3):303-318

Public Health Institute, Liverpool John Moores University, Liverpool, UK.

Purpose: Sub-Saharan African prisons have seen a substantial increase in women prisoners, including those incarcerated with children. There is very little strategic literature available on the health situation and needs of women prisoners and their circumstantial children in Malawi. The study aims to explore this issue.

Design/methodology/approach: A qualitative exploratory study using in-depth key informant interviews with senior correctional stakeholders (commissioner of prison farms, senior correctional management staff, senior health officials and senior officers in charge) (=5) and focus group discussions (FGD) with women in prison of age between 18 and 45 years (=23) and two FGD with correctional staff (=21) was conducted in two prisons in Malawi, Chichiri and Zomba. Narratives were transcribed and analysed using thematic analysis.

Findings: Three key themes emerged and are as follows: "hygiene and sanitary situation across multiple prison levels and subsequent health implications for women"; "nutritional provision and diets of women and children in prison"; and "women's access to prison-based and external health services". Divergence or agreement across perspectives around sanitation and disease prevention, adequacy of nutrition for pregnant or breast-feeding women, health status and access to prison-based health care are presented.

Practical Implications: Garnering a contemporary understanding of women's situation and their health-care needs in Malawian prisons can inform policy and correctional health practice change, the adaptation of technical guidance and improve standards for women and their children incarcerated in Malawi.

Originality/value: There is a strong need for continued research to garner insight into the experiences of women prisoners and their children, with a particular emphasis on health situation.
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http://dx.doi.org/10.1108/IJPH-12-2019-0069DOI Listing
April 2020

Understanding abortion-related complications in health facilities: results from WHO multicountry survey on abortion (MCS-A) across 11 sub-Saharan African countries.

BMJ Glob Health 2021 01;6(1)

UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland.

Introduction: Complications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication severity, describe their management, and to report women's experience of abortion care in Africa.

Methods: A cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries. Data were collected on women's characteristics, clinical information and women's experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women's characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women's characteristics and severity of complications.

Results: There were 13 657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7953 (58.2%) had moderate complications and 4424 (32.4%) women had mild complications. Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. For management, the commonly used mechanical methods of uterine evacuation were manual vacuum aspiration (76.9%), followed by dilation and curettage (D&C) (20.1%). Most frequently used uterotonics were oxytocin (50∙9%) and misoprostol (22.7%). Via ACASI, 602 (19.5%) women reported having an induced abortion. Of those, misoprostol was the most commonly reported method (54.3%).

Conclusion: There is a critical need to increase access to and quality of evidence-based safe abortion, postabortion care and to improve understanding around women's experiences of abortion care.
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http://dx.doi.org/10.1136/bmjgh-2020-003702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845704PMC
January 2021

Informing prevention of stillbirth and preterm birth in Malawi: development of a minimum dataset for health facilities participating in the DIPLOMATIC collaboration.

BMJ Open 2020 11 24;10(11):e038859. Epub 2020 Nov 24.

Information Services Division, NHS National Services Scotland, Edinburgh, UK.

Objective: The global research group, DIPLOMATIC (Using eviDence, Implementation science, and a clinical trial PLatform to Optimise MATernal and newborn health in low Income Countries), aims to reduce stillbirths and preterm births and optimise outcomes for babies born preterm. Minimum datasets for routine data collection in healthcare facilities participating in DIPLOMATIC (initially in Malawi) were designed to assist understanding of baseline maternal and neonatal care processes and outcomes, and facilitate evaluation of improvement interventions and pragmatic clinical trials.

Design: Published and grey literature was reviewed alongside extensive in-country consultation to define relevant clinical best practice guidance, and the existing local data and reporting infrastructure, to identify requirements for the minimum datasets. Data elements were subjected to iterative rounds of consultation with topic experts in Malawi and Scotland, the relevant Malawian professional bodies and the Ministry of Health in Malawi to ensure relevance, validity and feasibility.

Setting: Antenatal, maternity and specialist neonatal care in Malawi.

Results: The resulting three minimum datasets cover the maternal and neonatal healthcare journey for antenatal, maternity and specialist neonatal care, with provision for effective linkage of records for mother/baby pairs. They can facilitate consistent, precise recording of relevant outcomes (stillbirths, preterm births, neonatal deaths), risk factors and key care processes.

Conclusions: Poor quality routine data on care processes and outcomes constrain healthcare system improvement. The datasets developed for implementation in DIPLOMATIC partner facilities reflect, and hence support delivery of, internationally agreed best practice for maternal and newborn care in low-income settings. Informed by extensive consultation, they are designed to integrate with existing local data infrastructure and reporting as well as meeting research data needs. This work provides a transferable example of strengthening data infrastructure to underpin a learning healthcare system approach in low-income settings.DIPLOMATIC is funded by the UK National Institute for Health Research.
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http://dx.doi.org/10.1136/bmjopen-2020-038859DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689106PMC
November 2020

Usability, acceptability, and feasibility of the World Health Organization Labour Care Guide: A mixed-methods, multicountry evaluation.

Birth 2021 03 22;48(1):66-75. Epub 2020 Nov 22.

Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, UNDP/UNFPA, UNICEF/WHO/World Bank Special Programme of Research, World Health Organization, Geneva, Switzerland.

Introduction: The World Health Organization's (WHO) Labour Care Guide (LCG) is a "next-generation" partograph based on WHO's latest intrapartum care recommendations. It aims to optimize clinical care provided to women and their experience of care. We evaluated the LCG's usability, feasibility, and acceptability among maternity care practitioners in clinical settings.

Methods: Mixed-methods evaluation with doctors, midwives, and nurses in 12 health facilities across Argentina, India, Kenya, Malawi, Nigeria, and Tanzania. Purposively sampled and trained practitioners applied the LCG in low-risk women during labor and rated experiences, satisfaction, and usability. Practitioners were invited to focus group discussions (FGDs) to share experiences and perceptions of the LCG, which were subjected to framework analysis.

Results: One hundred and thirty-six practitioners applied the LCG in managing labor and birth of 1,226 low-risk women. The majority of women had a spontaneous vaginal birth (91.6%); two cases of intrapartum stillbirths (1.63 per 1000 births) occurred. Practitioner satisfaction with the LCG was high, and median usability score was 67.5%. Practitioners described the LCG as supporting precise and meticulous monitoring during labor, encouraging critical thinking in labor management, and improving the provision of woman-centered care.

Conclusions: The LCG is feasible and acceptable to use across different clinical settings and can promote woman-centered care, though some design improvements would benefit usability. Implementing the LCG needs to be accompanied by training and supportive supervision, and strategies to promote an enabling environment (including updated policies on supportive care interventions, and ensuring essential equipment is available).
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http://dx.doi.org/10.1111/birt.12511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246537PMC
March 2021

Diagnostic point-of-care ultrasound in medical inpatients at Queen Elizabeth Central Hospital, Malawi: an observational study of practice and evaluation of implementation.

Trans R Soc Trop Med Hyg 2020 Nov 16. Epub 2020 Nov 16.

Department of Medicine, College of Medicine, University of Malawi, Private Bag 360, Blantyre 3, Malawi.

Background: In less well-resourced settings, where access to radiology services is limited, point-of-care ultrasound (POCUS) can be used to assess patients and guide clinical management. The aim of this study was to describe ultrasound practice in the assessment of medical inpatients at Queen Elizabeth Central Hospital, Blantyre, Malawi, and evaluate uptake and impact of POCUS following the introduction of a training programme at the college of Medicine, Blantyre, Malawi.

Methods: : A weekly prospective record review of sequential adult medical inpatients who had received an ultrasound examination was conducted.

Results: Of 835 patients screened, 250 patients were included; 267 ultrasound examinations were performed, of which 133 (50%) were POCUS (defined as performed by a clinician at the bedside). The time from request to performance of examination was shorter for POCUS examinations than radiology department ultrasound (RDUS) (median 0 [IQR 0-2, range 0-11] vs 2 [IQR 1-4, range 0-15] d, p=0.002); 104/133 (78.2%) POCUS and 90/133 (67.7%) RDUS examinations were deemed to have an impact on management.

Conclusion: Following the introduction of a training programme in POCUS, half of all ultrasound examinations were delivered as POCUS. POCUS was performed rapidly and impacted on patient management. POCUS may relieve the burden on radiology services in less well-resourced settings.
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http://dx.doi.org/10.1093/trstmh/traa137DOI Listing
November 2020

Midwives' and Medical professionals' perspectives of collaborative practice at Queen Elizabeth Central Hospital Maternity Unit, Malawi: The discovery phase of an appreciative inquiry project.

Malawi Med J 2020 03;32(1):13-18

University of Malawi Kamuzu College of Nursing, Faculty of Midwifery, Neonatal and Reproductive Health Studies, Blantyre, Malawi.

Background: This paper reports on part of a larger study, the aim of which was to develop an intervention to collaboratively develop innovative strategies to promote effective collaborative practices among midwives and medical professionals working in intrapartum care unit. Collaborative practice is a critical marker for success in improving quality of maternity care. To date, there has been limited exploration of collaborative practices between midwives and medical professionals working in intrapartum care from the African perspective.

Aim: This paper reports findings of the discovery phase of appreciative inquiry (AI) set out to understand the perspectives of midwives and medical professionals on collaborative practices at Queen Elizabeth Central Hospital labour and delivery ward in Malawi.

Methods: The study used an exploratory qualitative approach framed in an Appreciative Inquiry theoretical perspective. Appreciative Inquiry consists of four phases :(discovery, dream, design and destiny).The discovery phase consisted of 16 in-depth interviews and 2 focus group discussions among purposively selected midwives (4 nurse midwives, 2 midwifery unit matrons) and medical professionals (2 obstetricians, 4 registrars, 2 intern doctors, 2 clinical officers) working in the labour ward. All interviews and discussions were audiotaped and transcribed verbatim. Data were analysed using thematic analysis.

Results: Five dominant themes emerged: collaborative breakdown, benefits of collaboration, the importance of positive and respectful attitude, barriers to effective collaborative practices and strategies to improve collaborative practice.

Conclusion/recommendations: Aligning the perspectives of the members of the two disciplines is significant to effective implementation of collaborative intrapartum care. Participants demonstrated that there is increased parallel working of midwives and doctors at QECH. This is not professionally healthy. Therefore, putting together the viewpoints of the professions to create a mutually agreeable professional framework of collaborative intrapartum practice is significant. Additionally, there is an obvious need to address the professional concerns of both disciplines.
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http://dx.doi.org/10.4314/mmj.v32i1.4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366164PMC
March 2020

Resumption of postpartum sexual activity and menses among HIV-infected women on lifelong antiretroviral treatment compared to HIV-uninfected women in Africa.

Int J Gynaecol Obstet 2020 May 2;149(2):211-218. Epub 2020 Mar 2.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.

Objective: To determine time from delivery to resumption of sexual activity and menses among HIV-infected women on antiretroviral treatment (ART) and HIV-uninfected women.

Methods: HIV-infected women on ART and HIV-uninfected women were recruited from five health facilities at delivery and followed prospectively for a maximum of 1 year in Blantyre, Malawi from January 2016 to September 2017. Sociodemographic, clinical, and laboratory data were collected at delivery and 1.5, 3, 6, 9, and 12 months. Descriptive, time to event Kaplan-Meier, and multivariable Cox proportional hazards analyses were conducted.

Results: Data on 878 women (460 [52.4%] HIV-uninfected and 418 [47.6%] HIV-infected, P=0.156) who attended at least one follow-up visit were analyzed. Among HIV-uninfected compared to HIV-infected women, respectively, the median number of days to resumption of sexual activity was 180 vs 181; to irregular menses was 82 vs 71; and to regular menses was 245 vs 366. In multivariable models, being married was associated with early resumption of sexual activity (hazard ratio [HR] 1.91, P<0.001), and being HIV-infected and use of an effective method of family planning were associated with later start of regular menses (HR<1.0, P<0.050).

Conclusion: Counseling of women on reproductive intentions should start early irrespective of HIV infection or use of ART.
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http://dx.doi.org/10.1002/ijgo.13113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152561PMC
May 2020

Puerperal Psychosis: A brief review and unusual case report.

Malawi Med J 2019 06;31(2):161-163

Harvard Medical School; Associate Director, Partnerships and Global Initiatives, Massachusetts.

This is a brief review of puerperal (post-partum) psychosis and contains a case report of Donkin Psychosis, an unusual form which is associated with pre-eclampsia, from Queen Elizabeth Central Hospital in Blantyre, Malawi. It includes considerations for treatment of Donkin Psychosis, in particular. It is the first reported case of Donkin Psychosis from Africa, to our knowledge.
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http://dx.doi.org/10.4314/mmj.v31i2.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698629PMC
June 2019

High-Risk Adult Wilms' Tumour in Pregnancy: A Case Report.

Malawi Med J 2019 06;31(2):155-158

Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi.

Wilms' tumour is the most common renal neoplasm in children with an incidence of 10 cases per 1 million children and a median age at diagnosis of 3.5 years. In Western countries its occurrence in adults is 0.2 cases per million people in western countries and carries a poorer prognosis. The co-existence of Adult Wilms' tumour and pregnancy is extremely rare with less than 20 cases published in the English literature. We present a case of a Malawian woman who had progressive high-risk metastatic Adult Wilms' tumour in pregnancy after nephrectomy, radiotherapy and two lines of chemotherapy.
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http://dx.doi.org/10.4314/mmj.v31i2.9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698624PMC
June 2019

Pregnancy Outcomes in the Era of Universal Antiretroviral Treatment in Sub-Saharan Africa (POISE Study).

J Acquir Immune Defic Syndr 2019 01;80(1):7-14

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Background: Adverse pregnancy outcomes such as preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA) remain major global problems. We compared pregnancy outcomes among HIV-infected women receiving antiretroviral treatment (ART) and with CD4 ≥350 cells, and HIV-uninfected women to assess whether disparities associated with HIV infection have been eliminated through use of ART.

Setting: Observational study conducted at 5 health facilities in Blantyre, Malawi, during 2016-2017.

Methods: HIV-infected women receiving the national ART regimen (efavirenz + lamivudine + tenofovir) and HIV-uninfected women were consented and enrolled at delivery. Data collected included sociodemographic and clinical; gestational age; BW; infant/maternal anthropometry; and laboratory results. We defined PTB as GA <37 weeks; LBW as BW <2·5 kg; and SGA as BW <10th percentile of GA. SGA infants were classified into proportionate and disproportionate based on ponderal index. Descriptive, stratified, and multivariate logistic and linear regression analyses were used.

Results: Of 5423 women approached, 614 HIV-infected and 685 HIV-uninfected women were enrolled. Rates of PTB, LBW, and SGA were 10.6%, 7.2%, and 17.1% among HIV-infected women on ART and 9.5%, 5.0%, and 18.4% among HIV-uninfected women, respectively. None of these differences were statistically significant in univariate- or multivariate-adjusted analyses (P > 0.05). Of 231 SGA infants, 78.8% were proportionate and 21% were disproportionate. Of the 614 HIV-infected women on ART, 75% had undetectable virus at delivery.

Conclusions: ART use has reduced the high rates of adverse pregnancy outcomes among HIV-infected women. However, the rates remain high irrespective of HIV infection and require appropriate interventions.
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http://dx.doi.org/10.1097/QAI.0000000000001875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289692PMC
January 2019

Point-of-care umbilical arterial lactate and newborn outcomes in a low resource setting: cohort study.

BMC Res Notes 2018 Jul 16;11(1):477. Epub 2018 Jul 16.

Departments of Public Health and Obstetrics & Gynaecology, College of Medicine, Blantyre, Malawi.

Objective: Birth asphyxia contributes substantially to the burden of intrapartum stillbirth and neonatal mortality in resource limited countries. We investigated clinical correlates and neonatal outcomes of lactate analysis of umbilical arterial cord blood in a large referral maternity unit in Malawi using a point-of-care test (Lactate Xpress, Nova Biomedical, Runcorn, UK) and examined maternal and neonatal characteristics and outcomes.

Results: There were 389 live births and 12 intrapartum stillbirths during the study. The median umbilical arterial lactate concentration was 3.4 mmol/L (interquartile range 2.6-4.9). Umbilical arterial lactate concentrations among the 45 babies admitted for special neonatal care were above 5 mmol/L in 16/45 (36%) of cases, with no fatality below 13 mmol/L. A positive malaria rapid diagnostic test was associated with hyperlactatemia (p < 0.05). In receiver-operator characteristic (ROC) analysis using a lactate cutoff of 5 mmol/L, areas under the curve were 0.72 (95% CI 0.66-0.79) and 0.64 (95% CI 0.58-0.69) for the Apgar score at 1 and 5 min respectively. This approach can identify safely those newborns that are unlikely to require additional monitoring. Scale-up implementation research in low resource country referral units is needed. The influence of malaria on neonatal hyperlactatemia requires further exploration.
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http://dx.doi.org/10.1186/s13104-018-3598-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048826PMC
July 2018

Use of effective family planning methods and frequency of sex among HIV-infected and HIV-uninfected African women.

Contracept Reprod Med 2018 9;3:10. Epub 2018 Jul 9.

1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA.

Background: Frequency of sex, contraceptive use and HIV infection are key determinants of fertility. Use of an effective family planning (EFP) method (injectable, oral, intra-uterine contraceptive device (IUCD), or Norplant) potentially eliminates women's concerns of unintended pregnancy. We report the association between EFP and frequency of sex among HIV-infected and HIV-uninfected non-pregnant African women.

Methods: Prospective fertility intentions study nested within a phase 3 randomized double-masked placebo-controlled trial (2003-2005) to treat genital tract infections in HIV-infected and HIV-uninfected non-pregnant women. Enrollment of study participants was stratified by HIV infection status. Data on demographics, family planning and sexual history were obtained at baseline and at 3, 6, 9 and 12 months. Chi square and Wilcoxon Rank-Sum tests were used to compare categorical and continuous variables, respectively. Generalized Estimating Equations method was used to estimate relative risk (RR) of frequent sex (≥ 2 acts/week) among users of different EFP methods (injectable, oral, implant or intra-uterine contraceptive device).

Results: After adjusting for age, current health status, and fertility intentions, EFP use was significantly associated with frequent sex among HIV-infected women (RR 1.32; 95% Confidence Interval [CI] 1.14-1.52); this association was not statistically significant among HIV-uninfected women (RR 1.10; 95% CI 0.96-1.24). Fertility intentions among HIV-infected, and education among HIV-uninfected womenwere independent predictors of sex frequency.

Conclusion: These data suggest that the association between EFP use and frequency of sex among women varies by HIV infection status. Service-delivery of diverse EFP methods should be integrated within HIV counseling, testing and treatment facilities.

Trial Registration: Registration number NCT00140764 under the clinicaltrials.gov, first Posted: September 1, 2005, last Update Posted: August 10, 2011.
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http://dx.doi.org/10.1186/s40834-018-0063-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036664PMC
July 2018

Standardizing the measurement of maternal morbidity: Pilot study results.

Int J Gynaecol Obstet 2018 May;141 Suppl 1:10-19

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, WHO, Geneva, Switzerland.

Objective: To field test a standardized instrument to measure nonsevere morbidity among antenatal and postpartum women.

Methods: A cross-sectional study was conducted in Jamaica, Kenya, and Malawi (2015-2016). Women presenting for antenatal care (ANC) or postpartum care (PPC) were recruited if they were at least 28 weeks into pregnancy or 6 weeks after delivery. They were interviewed and examined by a doctor, midwife, or nurse. Data were collected and securely stored electronically on a WHO server. Diagnosed conditions were coded and summarized using ICD-MM.

Results: A total of 1490 women (750 ANC; 740 PPC) averaging 26 years of age participated. Most women (61.6% ANC, 79.1% PPC) were healthy (no diagnosed medical or obstetric conditions). Among ANC women with clinical diagnoses, 18.3% had direct (obstetric) conditions and 18.0% indirect (medical) problems. Prevalences among PPC women were lower (12.7% and 8.6%, respectively). When screening for factors in the expanded morbidity definition, 12.8% (ANC) and 11.0% (PPC) self-reported exposure to violence.

Conclusion: Nonsevere conditions are distinct from the leading causes of maternal death and may vary across pregnancy and the puerperium. This effort to identify and measure nonsevere morbidity promotes a comprehensive understanding of morbidity, incorporating maternal self-reporting of exposure to violence, and mental health. Further validation is needed.
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http://dx.doi.org/10.1002/ijgo.12464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6001807PMC
May 2018
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