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Obstetric fistulae, birth outcomes, and surgical repair outcomes: a retrospective analysis of hospital-based data in Dodoma, Tanzania.
South Sudan Medical Journal. 2018 Nov; 11(4):93-96.Introduction: Obstetric Fistula (OF) among pregnant women remains a widespread condition with devastating consequences and poses a significant challenge in a community as well as globally. Objective: To determine the predictors and contributing factors associated with OF and birth outcomes in women undergoing fistula repair at the Dodoma Regional Referral Hospital (DRRH). Method: This retrospective study used hospital records of women repaired over 2013 and 2014. Data were analysed using SPSS version 21 for Window (SPSS Inc., Chicago, IL, USA). Frequency tables were generated and bivariate analyses were conducted to determine the contributing factors associated with OF using chi-squared statistics. Results: Fifty two women underwent surgical repair of a fistula; 47(90.2%) were primiparous and 5(9.6%) multiparous. There were 42(80.8%) vesico-vaginal fistulae (VVF), and 10(19.2%) recto-vaginal fistulae (RVF). Of those with VVF 5 (9.6%) had been living with urine leakage for 10 years, 25 (48.1%) for 17 years, and 12 (23.1%) for 20 years; all 10 (19.2%) with RVF had been living with the defect for 10 years. No patient had been living with both vaginal and recto fistulae. Most of the fistulas were associated with prolonged difficult spontaneous vaginal delivery but two were associated with surgery: Caesarean Section and hysterectomy. Surgical repair was by the transvaginal 47(90.4%) and trans abdominal 5(9.6%) routes. Female genital mutilation (FGM) was found in all the 28 women from the Gogo tribe but only in 12 of the 24 women from other tribes. Conclusion: Timely fistula repair by experienced fistula surgeons, adhering to fastidious basic surgical principles, will improve outcomes and limit the clinical insult and distress that OF invariably causes.
Demographics and predictors of mortality in children undergoing resuscitation at Khayelitsha Hospital, Western Cape, South Africa.
South African Journal of Child Health. 2018 Jun; 12(3):127-131.Background. The clinical outcomes of paediatric patients requiring resuscitation depend on physicians with specialised knowledge, equipment and resources owing to their unique anatomy, physiology and pathology. Khayelitsha Hospital (KH) is a government hospital located near Cape Town, South Africa, that sees ~44 000 casualty unit patients per year and regularly functions at more than 130% of the bed occupancy. Many of these patients are children requiring resuscitation. Objectives. We sought to describe characteristics of children under the age of 12 who required resuscitation upon presentation to KH, determine predictors of mortality, and compare paediatric volume to specialist physician presence in the unit. Methods. A retrospective chart review was performed on patients younger than 12 years who were treated in the resuscitation area of KH during the six-month period from 1 November 2014 to 30 April 2015. Results. A total 317 patients were enrolled in the study with a median age of 14 months. The top 5 diagnoses were: pneumonia (n=58/317); neonatal sepsis (n=40/317); seizures (n=37/317); polytrauma (n=32/317); and acute gastroenteritis complicated by septic shock (n=28/317). Overall mortality was 7% (n=21/317) and mortality in children less than 1 month of age was 12% (n=5/42). Premature birth was associated with a mortality odds ratio of 8.44 (p=0.002). More than two-thirds (73%; n=231/317) of paediatric resuscitations occurred when specialist physicians were not physically present in the unit. Conclusion. The study findings indicate that children under one month of age with a history of prematurity are at high risk and may benefit most from paediatric-specific expertise and rapid transfer to a higher level of care.
Trend and causes of maternal mortality in a tertiary care hospital in Jharkhand, India: a five years retrospective study.
International Journal of Community Medicine and Public Health. 2016 Nov; 3(11):3030-3032.Background: Maternal mortality ratio (MMR) is an indicator of effectiveness of health care facilities for women of child bearing age. It strongly reflects the overall effectiveness of the health system functioning in a developing country. This study attempts to study the trends of maternal mortality and it’s association with different causes in RIMS, Ranchi, Jharkhand, India. The objectives were to study the trends of maternal death in RIMS, Ranchi during 2011-2015 and to study the causes of maternal mortality. Methods: It is a retrospective study design. Data for analysis of trends of maternal mortality were collected from Medical Record Department, RIMS, Ranchi during period 2011 to 2015. Total sample size for this period was 220. Statistical Analysis: Templates were generated in MS excel sheet and analysis was done using SPSS software. Results: Five year data analysis of 220 subjects showed that number of maternal death was more in rural (80.26%) and tribal (86.92%) population. More number of maternal deaths was of antenatal (77.12%) and primigravida (55.06%) cases. Haemorrhage (37%) was most common obstetric cause of maternal death followed by eclampsia (18.34%). Conclusions: Trend of maternal death is higher in tribal, rural population and among primigravida. Obstetric causes accounted for more than half of maternal death (71.5%).
PloS One. 2018; 13(11):e0207920.BACKGROUND: The control of maternal deaths continues to be a significant public health issue and commands an enormous amount of attention, especially under the future family planning policy. Here, we describe the epidemiology and trends of maternal deaths in Hunan province, and give several policy implications. METHODS: Maternal deaths in Hunan province between 2009 and 2014 were retrospectively reviewed and analyzed. Cochran-Armitage trend test was used to assess the time trends of maternal mortality rates. Binary logistic regression analyses were undertaken to identify the factors that were associated with unavoidable maternal deaths. RESULTS: In total, there were 987 maternal deaths, with the overall MMR declining by 45.24%. The most common causes of maternal death during this period were pregnancy complications (28.37%), obstetric hemorrhage (25.33%), and amniotic fluid embolism (15.70%). Obstetric hemorrhage (28.14%) was higher in rural areas, while pregnancy complications were higher (29.27%) in urban areas. In all, 627 (63.5%) deaths were avoidable. The risk factors associated with unavoidable maternal deaths was above 35 years (aOR = 1.80 95%CI: 1.27-2.55), without prenatal examination (aOR = 8.97 95%CI: 1.11-7.78), low household incomes (aOR = 1.15 95%CI: 1.02-1.29), without adopting the new way to deliver (aOR = 5.15 95%CI: 3.20-8.31), and death location (aOR = 1.09 95%CI: 1.02-1.18). The most frequent and important factors associated with avoidable deaths was improper knowledge and skills of the county medical institutions. CONCLUSIONS: Moderate progress was made in reducing the MMR in Hunan province. The government should aim to improve the basic midwifery skills in rural areas and the obstetric emergency rescue service for critically ill pregnant women in urban areas, and strengthen training to improve knowledge and skills in medical institutions in counties.
Two year continuation rates of contraceptive methods in France: a cohort study from the French national health insurance database.
European Journal of Contraception and Reproductive Health Care. 2018 Nov 30; 1-6.OBJECTIVE: The aim of this study was to evaluate the continuation rates of reimbursed contraceptive methods in French real-world conditions. METHODS: A retrospective cohort study using a representative sample of the national health insurance database, the General Sample of Beneficiaries (Echantillon Generalistes des Beneficiaires [EGB]), was performed between 2006 and 2012. Selected women were >/=15 years of age and had started a reimbursed contraceptive method between 2009 and 2012 without prior reimbursement for an implant or an intrauterine contraceptive method between 2006 and 2008. The outcome of interest was the continuation rates, defined as the probability of women initiating a contraceptive method and continuing to use the same method over time. Continuation rates were assessed for up to 2 years. Only the first contraceptive method used during the study period was considered in the analysis. Non-parametric Kaplan-Meier survival analysis was used to assess continuation rates. RESULTS: A population of 42,365 women representative of the 4,109,405 French women initiating any reimbursed method between 2009 and 2012 was identified in the EGB: 74.5% of women used oral contraceptives, 12.8% the levonorgestrel-releasing intrauterine system (LNG-IUS), 9.2% the copper intrauterine device (Cu-IUD) and 3.5% the subdermal etonogestrel (ENG) implant. The 2 year continuation rates varied from 9.1% for progestin-only oral contraceptives, 27.6% for first to second generation combined oral contraceptives (COCs) and 33.4% for third generation COCs to 83.6% for the ENG implant, 88.1% for the Cu-IUD and 91.1% for the LNG-IUS. CONCLUSION: This study conducted in real-world conditions showed that long-acting reversible contraceptive (LARC) methods remain rarely used in France despite high continuation rates over 2 years. Increasing the use of LARC methods is therefore a public health priority.
Infection Control and Hospital Epidemiology. 2018 Feb; 39(2):247-248.Add to my documents.
Barriers and outcomes associated with unfulfilled requests for permanent contraception following vaginal delivery.
Contraception. 2018 Nov 19;OBJECTIVES: To identify barriers to postpartum permanent contraception procedures after vaginal delivery and to explore contraceptive and reproductive outcomes of women who experience unfulfilled requests. STUDY DESIGN: We performed a retrospective cohort study of women requesting postpartum permanent contraception after vaginal delivery from 7/1/11-6/30/14 at Strong Memorial Hospital in Rochester, NY. We ascertained patient characteristics and outcomes through electronic medical records and birth certificate data search. RESULTS: Of 189 women in our sample, 78 (41.3%) had a postpartum permanent contraception procedure. Factors associated with unfulfilled requests in adjusted analysis included BMI >/=40 (OR 3.71, 95%CI 1.46-9.48 compared to BMI<35), federal sterilization consent signed >/=36 weeks (OR 5.10, 95%CI 1.64-15.86 compared to <36 weeks), and delivery in the latter half of the week (Wednesday-Saturday) (OR 2.02, 95%CI 1.08-3.79). Documented reasons for unfulfilled permanent contraception requests included patient changing her mind related to procedural issues (21, 18.9%), invalid consent (20, 18.0%), maternal obesity (17, 15.3%), lack of operating room availability (14, 12.6%) and ambivalence about permanent contraception (5, 4.5%). Of 57 women who planned for interval permanent contraception and had institutional follow-up over the subsequent year, 14 (24.6%) had a procedure, 8 (14.0%) initiated long-acting reversible contraception, and 13 (22.8%) became pregnant. CONCLUSIONS: Fewer than half of women obtained desired postpartum permanent contraception after vaginal delivery, with logistical issues and obesity being the most common reported barriers. Health care providers should advocate for access to postpartum permanent contraception, as well as discussing prenatally the individualized probability of non-fulfillment and importance of alternative contraceptive plans. Implications Logistical barriers and inappropriate antenatal preparation contribute to the fact that over half of women don't obtain desired postpartum permanent contraception after vaginal delivery. To respect reproductive autonomy and improve care, clinicians and other health officials should eliminate barriers to immediate postpartum permanent contraception while increasing access to alternative options. Copyright (c) 2018 Elsevier Inc. All rights reserved.
Contraception. 2018 Nov 21;OBJECTIVE: To describe the prevalence of rapid repeat pregnancy (RRP), defined as repeat pregnancy within 18months of delivery, in a large health system, and to determine the impact of contraceptive method on RRP. STUDY DESIGN: Retrospective cohort. RESULTS: The prevalence of rapid repeat pregnancy among patients who delivered in August 2014 (n=804) was 27.2%. After controlling for age and sociodemographic characteristics, women experiencing RRP were less likely to have used long-acting reversible contraception (LARC) (aOR 0.45, 95%CI 0.24-0.85, p=.014; RRP in 19% of implant and 18% of IUD users), and more likely to have been prescribed a progestin-only pill (aOR 5.106, 95%CI 2.157-12.083, p<.001; RRP in 53% of users) compared to women choosing all other reversible contraceptive methods. CONCLUSIONS: Postpartum LARC decreases the odds of RRP, while a prescription for progestin-only pills is not protective. Copyright (c) 2018. Published by Elsevier Inc.
Introduction of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC) Injectable Contraception at Facility and Community Levels: Pilot Results From 4 Districts of Uganda.
Global Health, Science and Practice. 2018 Nov 14;Reproductive Health Uganda (RHU), a local NGO, introduced subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) in 4 districts of Uganda between April 2016 and March 2017. RHU trained public and private facility providers on all family planning methods including DMPA-SC; trained community health workers (known as village health teams, VHTs) to give family planning counseling, provide short-acting methods including DMPA-SC, and make referrals for long-acting and permanent methods; conducted mobile outreach and raised awareness of family planning; and provided family planning commodities. We used a retrospective cross-sectional evaluation design drawing on data from (1) in-depth interviews with 32 facility- and community-based providers; (2) key informant interviews with 7 policy makers and program staff; and (3) family planning program statistics from 4 RHU clinics, 26 mobile outreach sites, and 40 VHTs in 4 study districts. Data collection took place between April and June 2017. Over 12 months, 14,273 units of DMPA-SC were provided in RHU clinics, by mobile outreach teams, and by VHTs. DMPA-SC units were mostly administered in community settings either by VHTs (70%) or at mobile outreach events (26%). A substantial proportion (43%) of DMPA-SC units were administered to young people (<25 years), a significantly higher proportion compared with other methods provided to this age group through the project (P<.001), except condoms. In addition, a greater proportion of DMPA-SC units provided at the community level by VHTs were used by young people (45%) compared with units provided at outreach (36%) or in clinics (35%). Overall, injectables (DMPA-SC and intramuscular DMPA combined) came to represent 43% of all contraceptive methods provided, up from a baseline of 20%. This shift occurred despite significant increases in the volume of all other methods provided (P<.001). Qualitative data revealed various factors that facilitated introduction, including comprehensive training, commodity availability, strong referral links, and early community engagement. RHU's experience supports the viability of community-based delivery of DMPA-SC and identifies opportunities to strengthen this approach. There is further evidence that DMPA-SC may be popular with young people, especially in community settings. (c) Odwe et al.
PloS One. 2018; 13(10):e0206325.BACKGROUND: Preventing unintended pregnancy is critical for women living with HIV (WLWH) to safely achieve their reproductive goals. Family planning services should support WLWH at risk of repeat unintended pregnancies. We examined the relationship between unintended pregnancy and subsequent contraception use among WLWH in Uganda. STUDY DESIGN: This was a retrospective analysis of data from a longitudinal cohort of individuals initiating antiretroviral therapy (ART), restricted to women with pregnancy (confirmed via urine beta-hcg testing) between 2011-2013. The exposure of interest was intended vs unintended pregnancy, and the outcome was self-report of modern contraceptive use (hormonal methods, intrauterine device, sterilization, and/or consistent condom use) at 12 (range 6-18) months post-partum. A log-binomial model was used to estimate relative risks of modern contraceptive use post-partum based on intent of the index pregnancy, adjusted for age, socioeconomic status, education, relationship and HIV status of pregnancy partner, contraceptive use prior to pregnancy, years since HIV diagnosis, ART regimen, and CD4 cell count. RESULTS: Among 455 women, 110 women reported 110 incident pregnancies with report on intent. Women had a baseline median age of 29 years, baseline CD4 count 403 cells/mm3, and were living with HIV for 3.8 years. Fifty pregnancies (45%) were reported as unintended and 60 (55%) as intended. Postpartum, 64% of women with unintended and 51% with intended pregnancy reported modern contraception (p = 0.24). In adjusted models, there was no association between pregnancy intent and post-partum contraception. However, contraceptive use prior to the referent pregnancy was positively associated with post-partum contraceptive use (aRR 1.97 (95% CI 1.12-3.48, p = 0.02), while higher baseline CD4 cell count was associated with lower post-partum contraceptive use (aRR 0.95, 95% CI 0.90-0.99, p = 0.02). CONCLUSIONS: Almost half of incident pregnancies among WLWH in this cohort were unintended. Experiencing an unintended pregnancy was not associated with post-partum contraceptive use. Creative strategies to support contraceptive uptake for birth spacing and prevention of unintended pregnancies in the post-partum period are needed.
The association of maternal risk factors to macrosomia in rural areas of Haryana, India: a community based study.
International Journal of Community Medicine and Public Health. 2018 Sep; 5(9):3842-3846.Background: Macrosomia affects 1-10% of all pregnancies. The macrosomia is reportedly associated with neonatal morbidity, neonatal injury, maternal injury and cesarean delivery. The present study was aimed at finding out prevalence and assessing association of maternal risk factors with macrosomia. Methods: This community based retrospective and cross-sectional study was carried out in 23 rural sub-centres of block Beri, district Jhajjar (Haryana, India) among 920 mothers. A predesigned pretested semistructured questionnaire was used to collect information. Univariate analysis along with logistic regression analysis was performed. Results: The prevalence of macrosomia among live births was 1.3% (n=12). In the present study, mothers from upper and upper middle socio-economic status had six times higher odds of delivering a large baby. Diabetic mothers had seventeen times higher incidence of macrosomia as compared to non-diabetic mothers. Mothers who consumed full course of iron folic acid (IFA) tablets during antenatal period had 24% lesser chances of macrosomia in live births as compared to mothers who did not consume the full course. Conclusions: The findings of the present study emphasize that incidence of macrosomia can be reduced by strengthening antenatal monitoring, prevention of complications, early diagnosis and appropriate and adequate management of treatable risk factors in mothers.
Maternal and perinatal outcomes of pregnancies complicated by eclampsia at Tikur Anbessa Hospital - A five year retrospective study.
Ethiopian Journal of Reproductive Health. 2014 Dec; 7(1):22-30.Introduction: Eclampsia is an important and mostly preventable cause of maternal and perinatal morbidity and mortality. Its incidence varies from 4-6 cases per 10,000 live births in developed countries to 6-100 cases per 10,000 live births in developing countries. Maternal complications occur in up to 70% of women with Eclampsia. Objective: To describe perinatal and maternal outcome of eclampsia in Tikur Anbessa Hospital and explore avoidable factors contributing to the adverse outcome. Methods: A hospital-based retrospective, cross sectional study of all eclamptic mothers admitted to Tikur Anbessa Hospital (TAH) in the time period of Meskerem 1, 1996 - Nehase 30, 2000 E.C. The main outcome measures were maternal and perinatal mortality & morbidities from Eclampsia. Results: During the study period, there were a total of 13,606 deliveries in TAH, of which 78 were eclamptic mothers making a prevalence of 5.7/1000 deliveries. Majority of convulsions (94.37%) occurred during the antepartum period. Aspiration pneumonia was the commonest maternal complication (34.3%), followed by HELLP syndrome (15.8%). The case fatality of Eclampsia in this study was 11.9% (8/67). And of total 71 babies, 20 (28.2%) of them were still births and four (5.6%) were ENND, making a perinatal mortality rate 338/1000 deliveries. Conclusions and recommendations: Eclampsia is still a common complication of pregnancy and one of the important causes of maternal and perinatal mortality in our set up. Further study on the subject preferably prospective with larger sample size is recommended to further assess the condition and improve its generalizability.
Ethiopian Journal of Reproductive Health. 2016 Feb; 8(1):8-18.INTRODUCTION: Globally eclampsia is an important cause of morbidity and mortality during pregnancy, child birth and puerperium. Early intervention and provision of critical care for those at risk of significant morbidity and mortality is important. OBJECTIVE: To identify important risk factors for maternal mortality among eclamptic women managed in Hawassa University Referral Hospital. METHODOLOGY: A five years retrospective case - control analysis of risk factors for maternal mortality among eclamptic women was done. Cases were those mothers who died and the controls were those who survived. Data was collected from patient charts and variables were assessed among cases and controls to identify risk factors for mortality. Odds ratio with 95% confidence interval and P- values were computed. RESULTS: The majority of eclamptics were below 26 years of age, 95 (65 %); primigravida, 76 (52 %) and from out of Hawassa, 95 (65 %). Five or more convulsions before admission (OR = 3.90, 95%CI, 1.64 -9.37), creatinine level above 0.9 mg/dl (0R = 7.73, 95%CI, 2.84 -21.63) and platelet count less than 100,000/mm3 (OR = 11.20, 95%CI, 3.70 -36.32) were significantly associated with the risk of mortality at admission. The case fatality rate of eclampsia was 24% and the most important causes of deaths were respiratory failure and acute renal failure. CONCLUSION: Closer follow up should be considered for those eclamptics with 5 or more convulsions before admission; and elevated creatinine level and thrombocytopenia at admission. The quality of care provided in the intensive care unit should be improved.
BMJ Sexual and Reproductive Health. 2019 Jan; 45(1):44-46.OBJECTIVES: (1) To review management of a series of women referred for removal of intrauterine contraception (IUC) with non-visible threads. (2) To establish whether the device was likely to have been placed at the fundus at insertion. (3) To document removal success rates in a community sexual health (CSH) setting. STUDY DESIGN: A retrospective review of a series of 76 women seen by the author between April 2016 and October 2017 in a specialist CSH clinic for removal of IUC with non-visible threads. RESULTS: After ultrasound scan (USS) assessment 67 women underwent a removal procedure. Sixty-two devices (92.5%) were successfully removed. Uterine instrumentation beyond the internal os was required in 43 removals, enabling comparison of uterine cavity length with the length of IUC and threads. Such comparison suggested 39/43 (91%) devices were not fundal at insertion and that non-visible threads were likely to have been caused by the device moving to the fundus post-insertion under the influence of uterine contractions, leading to retraction of the threads. CONCLUSIONS: Removal of IUC with non-visible threads can be successfully done in a CSH setting with ultrasound availability. Non-fundal placement of IUC at insertion is likely to be a significant cause of non-visible threads. (c) Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.
A 3 years review of maternal death and associated factors at Ayder Comprehensive Specialized Hospital, Northern Ethiopia.
Ethiopian Journal of Reproductive Health. 2018 Jul; 10(3):38-45.BACKGROUND: Maternal mortality ratio in Ethiopia is one of the highest in the world. Despite measures to alleviate it and showing a promising declining trend, it still remains one of the highest at 412 maternal deaths per 100,000 live births. To our knowledge there is no accessible published study on maternal mortality at Ayder Comprehensive Specialized Hospital (ACSH). OBJECTIVE: The aim of this study is to systematically analyze causes of maternal deaths and contributing factors at (ACSH). METHODS: This was a descriptive, retrospective chart review of institutional maternal deaths using a 3-years record from July 1, 2014 -June 30, 2017 at ACSH. RESULTS There were 52 maternal deaths from July 1, 2014 -June 30, 2017 at ACSH. The main causes of these deaths were related to obstetric hemorrhage (n=11, 21.2 %), hypertensive disorders of pregnancy (n=10, 19.2%) and sepsis (n=7, 13.5%). About 86.5% (n=45) of the mothers were referral cases of whom 24 (53.33%) of them travelled more than 100 kilometers to reach ACSH. The furthest referral site was 498 kilometers from ACSH. Most common reasons for referral include for admission to intensive care unit, for further workup and management, for blood transfusion and for high risk admission. Most of the maternal deaths occurred in the postpartum period. CONCLUSION: There is an urgent need for expansion of intensive care unit (ICU) and availing blood transfusion services in all the general and regional hospitals with close monitoring of mothers in the postpartum period. The referral system needs coordination from the lower level to the teritirary care centers.
Does oral contraceptives pretreatment affect the pregnancy outcome in polycystic ovary syndrome women undergoing ART with GnRH agonist protocol?
Gynecological Endocrinology. 2018 Oct 10; 1-4.This study aims to investigate whether oral contraceptive pills (OCP) pretreatment impairs pregnancy outcomes in polycystic ovary syndrome (PCOS) women undergoing GnRH agonist protocol. A total of 1025 couples underwent their first cycle of in vitro fertilization. Patients were divided into GnRH agonist protocol group (LP group) and OCP dual suppression GnRH agonist protocol group (OC-LP group). Logistic regressions were performed to estimate the risk factors affecting live birth following fresh embryo transfer between groups. Frozen-thawed embryos from the first oocyte retrieval cycle were replaced into uterus for women did not get live birth. Cumulative live birth rates between groups were compared by Kaplan-Meier survival analysis. Serum luteinizing hormone level, endometrial thickness, and live birth rate were significantly reduced in the OC-LP group in fresh cycle. Thinner endometrium, higher progesterone, and poorer embryo quality were independent risk factors for failure in getting live birth following fresh embryo transfer. However, cumulative live birth rate, medium embryo transfer attempts required to achieve live birth were comparable between groups. OCP pretreatment in GnRH agonist protocol does not seem to impair the pregnancy outcome when calculated by cumulative live birth rate in PCOS women.
A Population-Based, Case-Control Evaluation of the Association between Hormonal Contraceptives and Idiopathic Intracranial Hypertension.
American Journal of Ophthalmology. 2018 Sep 21;PURPOSE: To determine if the use of oral contraceptive pills (OCP) and other hormonal contraceptives are associated with a higher incidence of idiopathic intracranial hypertension (IIH). DESIGN: Retrospective, population-based, case-control study METHODS: Setting: Female IIH patients evaluated between January 1, 1990 and December 31, 2016 were identified using the Rochester Epidemiology Project (REP), a record-linkage system of medical records for all patient-physician encounters among Olmsted County, Minnesota, residents. STUDY POPULATION: Fifty-three female residents of Olmsted County diagnosed with IIH between 15 and 45 years of age. The use of OCPs and other hormonal contraceptives was compared to controls matched for age, sex and body-mass index. INTERVENTIONS/EXPOSURES: Hormonal contraceptives MAIN OUTCOME MEASURE: Odds of developing IIH RESULTS: Of the 53 women diagnosed with IIH between 15 and 45 years of age, 11 (20.8%) had used hormonal contraceptives within <30 days of the date of IIH diagnosis, in contrast to 30 (31.3%) among the control patients. The odds ratio of hormonal contraceptive use and IIH was 0.55 (95% CI: 0.24-1.23, p=0.146). The odds ratio of OCP use was 0.52 (95% CI: 0.20-1.34, p=0.174). CONCLUSIONS: OCP and other hormonal contraceptives were not significantly associated with a higher incidence of IIH, arguing against the need for women with IIH to discontinue their use. Copyright (c) 2018 Elsevier Inc. All rights reserved.
Early infant diagnosis of HIV in Myanmar: call for innovative interventions to improve uptake and reduce turnaround time.
Global Health Action. 2017; 10(1):1319616.BACKGROUND: In collaboration with the national AIDS program, early infant diagnosis (EID) is implemented by Integrated HIV Care (IHC) program through its anti-retroviral therapy (ART) centers across 10 cities in five states and regions of Myanmar. Blood samples from the ART centers are sent using public transport to a centralized PCR facility. OBJECTIVES: Among HIV-exposed babies <9 months at enrolment into IHC program (2013-15), to describe the EID cascade (enrolment, sample collection for PCR, result receipt by mother, HIV diagnosis and ART initiation) and factors associated with delayed (>8 weeks of age) or no blood sample collection for EID. METHODS: Retrospective cohort study involving record review. A predictive poisson regression model with robust variance estimates was fitted for risk factors of delayed or no sample collection. RESULTS: Of 1349 babies, 523 (39%) of the babies' mothers were on ART before pregnancy. Timely uptake of EID (<8 weeks of age) was 47% (633/1349); sample collection was delayed in 27% (367/1349) and not done in 26% (349/1349) babies. Among samples collected (n = 1000), 667 results were received by the mother; 52 (5%) were HIV-infected; among them 42 (81%) were initiated on ART. Median (IQR) turnaround time from sample collection to result receipt by mother and time to initiate ART from result receipt by mother was 7 (4,12) and 8.5 (6,16) weeks, respectively. Mothers not on ART before pregnancy and distance of ART center from PCR facility (more than 128 km) were the risk factors of delayed or no sample collection. CONCLUSIONS: Improving provision of ART to mothers (through universal 'test and treat') is urgently required, which has the potential to improve the timely uptake of EID as well. Interventions to reduce turnaround times, like point of care EID testing and/or systematic use of mobile technology to communicate results, are needed.
PLoS One. 2018 Aug 15; 13(8):e0202420.Background: Infants with HIV infection, particularly those infected in utero, who do not receive antiretroviral therapy (ART) have high mortality in the first year of life. Virologic diagnostic testing is recommended by the World Health Organization between ages 4 and 6 weeks after birth. However, adding very early infant diagnosis (VEID) testing at birth has been suggested to enable earlier diagnosis and rapid treatment of in utero infection. We assessed the costs of adding VEID to the standard 6-week testing in Lesotho where coverage of PMTCT services is nearly universal. Methods: Retrospective cost data were collected at eight health-care facilities in three districts participating in an observational prospective study that included birth testing as well as at the National Reference Laboratory in Lesotho, to investigate the cost-per-infection identified. Extrapolating to the national level, it was possible to estimate the impact of VEID on the identification of HIV-infected infants. Results: The unit cost-per-VEID test in Lesotho in 2015 was $40.50. Major cost drivers were supplies/commodities (46%) and clinical labor (22%). In 2015, 66.3% of cohort study infants born at study facilities underwent VEID; one out of 199 infants had a positive HIV DNA PCR test at birth (0.5% potential in utero infection), yielding a cost of $8,060 per HIV-positive infant identified. Sensitivity analysis showed costs based on Lesotho costing data ranged from $810 to $16,194 per-infected child with varying in utero infection rates from 5% and 0.25%, respectively. With 11,157 HIV-exposed births nationally from pregnant women on PMTCT, 66.3% VEID coverage, and 0.5% in utero infection, 37 infants infected with HIV could have been identified at birth in 2015 and 8 early infant deaths potentially averted with immediate ART compared with waiting for 6-week testing. Conclusion: If Lesotho costing data from this pilot study were applied to different epidemic circumstances, the cost-per-infected child identified by adding VEID birth testing to standard 6-week testing was lowest when in utero infection rates were high (when HIV prevalence is high and PMTCT coverage is low).
Journal of Nepal Paediatric Society. 2017 May-Aug; 37(2):164-167.Introduction: HIV in children is a public health problem in a developing country like Nepal. The aim of the study was to determine the clinical, nutritional and immunological profile of HIV +ve children enrolled in the ART clinic of Pokhara Academy of Health Sciences (PAHS). Materials and Method: This was a retrospective study of children enrolled in the ART clinic over a period of 10 years from July 2007 to June 2017. Clinical characters, Nutritional status and immunological status of children enrolled in the ART clinic were noted in the predesigned pro forma from the record of the clinic and review of the chart of the patients. Results: One hundred twelve children were enrolled in the Clinic during the study duration. Out of them 57 were males and 55 were females. All the children acquired infection through mother to child transmission. Majority of them from age group 1 to 5 years at the time of presentation. Fortysix percent were in the clinical stage III. The median CD4 count was 283.Fifty percent of the children were undernourished. Most of the children were started on AZT/3TC/NVP as first line ART. Conclusion: Although perinatal route was the most common route of transmission of HIV in children, diagnosis was late in the age group of 1-5 years and most of them were diagnosed in the advanced stage of HIV with Low CD4 count.
Naval Medicine's Involvement in Global Health: The Participation of Women's Healthcare Providers in Continuing Promise 2017.
Military Medicine. 2018 Aug 28;Introduction: This is a retrospective review of information collected during operation Continuing Promise 2017 from the Wayuu population in Colombia, South America. Materials and Methods: Team objective was to present an overview of women's health care needs in an isolated underserved population of Colombia by a humanitarian mission of health care providers from the U.S. Navy. We analyzed demographics, contraceptive selection, presenting complaint, diagnosis, and disposition of those female patients presenting for care. Results: The acute care clinics of this mission saw patients for 10 full clinic days in each of the countries of Guatemala, Honduras, and Colombia. In the Wayuu clinic of Colombia, 356 patients were seen in the acute care women's clinic. These women averaged 36 years of age with an age range of 9-77 years of age and a gravidity of 3 +/- 3.3 and a range of 0-18. Of the women less than the age of 50, not permanently sterilized, 186/220 (84.5%) were not using any form of contraception. The most common chief complaints were vaginal discharge and pelvic pain and the most common final diagnosis was bacterial vaginosis. The two most common secondary diagnoses of the pregnant women were urinary tract infection and anemia. Other significant diagnoses included uterine cancer, preterm labor, and fetal posterior urethral valve syndrome. Conclusions: A majority of Wayuu women presenting to an acute clinic setting in Colombia, South America were in their mid-thirties having had three pregnancies and the majority were not using any form of contraception. The most common diagnoses were straightforward diagnoses such as vaginal infections, urinary tract infections, and abnormal uterine bleeding. Our findings suggest a need for access to routine gynecologic care, general hygiene education, and increased availability of birth control among the Wayuu population.
HIV-1 transmission and survival according to feeding options in infants born to HIV-infected women in Yaounde, Cameroon.
BMC Pediatrics. 2018 Feb 19; 18(1):69.BACKGROUND: Evidence of 24-months survival in the frame of prevention of mother-to-child transmission (PMTCT) cascade-care is scare from routine programs in sub-Saharan African (SSA) settings. Specifically, data on infant outcomes according to feeding options remain largely unknown by month-24, thus limiting its breath for public-health recommendations toward eliminating new pediatric HIV-1 infections and improving care. We sought to evaluate HIV-1 vertical transmission and infant survival rates according to feeding options. METHODS: A retrospective cohort-study conducted in Yaounde from April 2008 through December 2013 among 1086 infants born to HIV-infected women and followed-up throughout the PMTCT cascade-care until 24-months. Infants with documented feeding option during their first 3 months of life (408 on Exclusive Breastfeeding [EBF], 663 Exclusive Replacement feeding [ERF], 15 mixed feeding [MF]) and known HIV-status were enrolled. HIV-1 vertical transmission, survival and feeding options were analyzed using Kaplan Meier Survival Estimate, Cox model and Schoenfeld residuals tests, at 5% statistical significance. RESULTS: Overall HIV-1 vertical transmission was 3.59% (39), and varied by feeding options: EBF (2.70%), ERF (3.77%), MF (20%), p = 0.002; without significance between EBF and ERF (p = 0.34). As expected, HIV-1 transmission also varied with PMTCT-interventions: 1.7% (10/566) from ART-group, 1.9% (8/411) from AZT-group, and 19.2% (21/109) from ARV-naive group, p < 0.0001. Overall mortality was 2.58% (28), higher in HIV-infected (10.25%) vs. uninfected (2.29%) infants (p = 0.016); with a survival cumulative probability of 89.3% [79.9%-99.8%] vs. 96.4% [94.8%-97.9% respectively], p = 0.024. Mortality also varied by feeding option: ERF (2.41%), EBF (2.45%), MF (13.33%), p = 0.03; with a survival cumulative probability of 96% [94%-98%] in ERF, 96.4% [94.1%-98.8%] in EBF, and 86.67% [71.06%-100%] in MF, p = 0.04. Using Schoenfeld residuals test, only HIV status was a predictor of survival at 24 months (hazard ratio 0.23 [0.072-0.72], p = 0.01). CONCLUSION: Besides using ART for PMTCT-interventions, practice of MF also drives HIV-1 vertical transmission and mortality among HIV-infected children. Thus, throughout PMTCT option B+ cascade-care, continuous counseling on safer feeding options would to further eliminating new MTCT, optimizing response to care, and improving the life expectancy of these children in high-priority countries.
Determinants of marriage to first birth interval in Birjand, Iran: A retrospective-prospective cohort and survival analysis.
International Journal of Women's Health and Reproduction Sciences. 2018; 6(3):328-334.Objectives: The time-interval between marriage and first childbirth (IMF) can affect fertility and pave the way for decreased fertility in future. This study aimed to determine the effective factors on the time of first childbirth in married women of Birjand, Iran. Materials and Methods: This was a retrospective and prospective cohort study incorporating a total of 180 couples from Birjand who were married in 2011. The data were collected by a checklist and subsequently assessed using survival analysis in STATA13 software. Results: From among the participants, 55.2% had a child and the rest were censored. The man’s age at the time of marriage, the interval between marriage contract to marriage ceremony, type of marriage, wife’s place of birth, application of modern methods of contraception, family income per month, and tendency to have a son were the determining factors affecting IMF. Conclusions: More than half of the freshmen admitted to universities across the country are women who will seek employment after they are graduated. Considerations must be made so that they can have their desired number of children, suitable education, and employment. © 2018 The Author (s).
Tropical Doctor. 2018; 48(3):213-217.Adolescent fertility rate is defined as the number of births per 1000 in women aged 15–19 years. These rates are highest in sub-Saharan Africa. National data from Zambia suggest the rate has declined from 179.6 in 1960 to 87.9 in 2015. A retrospective study was performed at Chitokoloki Mission Hospital using the hospital delivery registers during January 2008 to December 2015. In this period, 945 (20.81%) births were to adolescent mothers. As morbidity is significant in this vulnerable group, strategies to reduce pregnancy rates among these young girls is much-needed. © The Author(s) 2018.
Human Resources For Health. 2018 Jul 11; 16(1):31.BACKGROUND: Most sub-Saharan African countries have too few reproductive health (RH) specialists, resulting in high RH-related mortality and morbidity. In Kenya, task sharing in RH began in 2002, with the training of clinical officer(s)-reproductive health (CORH). Little is known about them and the extent of their role in the health system. METHODS: In 2016, we conducted a retrospective, quantitative two-stage study in Kenya to evaluate the use of CORH and 28 of their curriculum-derived RH competencies, to determine their contribution to expanded access to RH care. CORH were surveyed, using structured questionnaires and telephone interviews. Data on the frequency with which CORH used specified competencies were collected from health records in selected facilities. RESULTS: Forty-nine of all 104 CORH participated in the survey (47%). Forty-eight (98%) had worked in the clinical area, and 79% were still engaging in clinical work. All 48 worked in emergency obstetrics, emergency gynaecology, and nonemergency RH, and 38 (79%) filled clinical leadership positions. Vasectomy was least performed, by only 9 (18%) CORH. All other competencies were applied by at least half of the CORH, and 22 competencies by more than three quarters. Forty-one (84%) CORH performed caesarean section (CS). Teaching and management were other common responsibilities. Data were collected from 12 facilities and analysed for 11. They generally confirmed the initial survey findings: CORH worked as obstetrics and gynaecology consultants and used most of their competencies. Analysis was based on 118 months of theatre records. CORH made significant contributions to their facility's capacity to perform RH surgery: most respondents performed at least 25% of these surgeries. They performed an average of six CS per month and more than 25% of perineal tear repairs (33%), uterus repairs (33%), manual placenta removals (26%), bilateral tubal ligations (39%), and cervical cancer staging (27%). Some experienced CORH conducted procedures beyond their training. CONCLUSIONS: CORH expand access to emergency RH care. Their contributions span all areas of obstetric and gynaecological care, mentoring new health workers and expanding their scope of practice. However, the generally poor status of records documenting healthcare provision limits their usability in evaluation and research.