Primary healthcare providers' practices related to non-malarial acute febrile illness in Burkina Faso

Background

In Africa, fever is the main reason for consultation, with malaria playing a prominent role. Studies have reported that the widespread use of rapid diagnostic tests for malaria, implemented since 2010, has revealed an increasing proportion of non-malaria acute febrile illnesses (NMAFI). It is an important public health issue because evidence shows that mortality is higher among patients presenting with non-malarial fever than among those with malaria.

Methods

This cross-sectional study assessed the professional practices of healthcare providers in the management of NMAFI in urban and rural sites in Burkina Faso. Data was collected from 286 healthcare providers through a questionnaire based on the clinical situation in 2014. Factors have been associated using a hierarchical linear mixed model with random intercepts to model dependence of outcomes for healthcare providers working on the same site.

Results

Survey results showed limited knowledge about management of NMAFI, global survey score on General Practice Indicator being 60% (36.02/60.00). This gap was more evident at the admission and diagnosis level. The study's population from rural areas had better survey score than that of urban areas concerning the respect of adequacy diagnosis, treatment and use of antibiotics in NMAFI, 15.71 vs 13.93 mean score (p=0.01) (75 vs 66% on a 0 to 100% scale, with 100% being the best). Overall, more educated participants performed relatively better. A total of 46% (134/286) of participants felt that they needed training in at least one of the fever-related issues.

Conclusions

Increased awareness and knowledge of management for NMAFI are urgently required in Burkina Faso. This must be done through regular supervision and training courses targeted specifically at primary healthcare providers.

Toxics (Pb, Cd) and trace elements (Zn, Cu, Mn) in women during pregnancy and at delivery, South Benin, 2014-2015

During pregnancy, fetal development can be hindered by maternal exposure to toxic elements and abnormal concentrations of trace elements. Few data are available in African countries. Our goal was to assess the body burden of lead (Pb), cadmium (Cd), manganese (Mn), zinc (Zn) and copper (Cu) in pregnant women in Benin. The study was carried out in Sô-Ava district, from November 2015 to April 2016. Sixty women were recruited from the RECIPAL pre-conceptional cohort study. In all women, blood samples were collected during the first trimester of pregnancy. Thirty-two women had additional maternal and cord blood samples collected at delivery. Blood samples were analyzed by inductively coupled plasma mass spectrometry. At delivery, Cd median (IQR) concentration in maternal blood was 0.34 µg/L (0.24-0.46) in this non-smoking population. Pb median (IQR) concentration in maternal blood at delivery was 37.4 µg/L (30.5-52.0), with 31.3% of blood Pb levels above the 50 μg/L threshold. These pregnant women lived in semi-rural lakeside villages. Potential sources of Pb exposure identified during pregnancy were having water supply by drill pump and activities such as smoking fish by the woman and fishing by the household head. At delivery, Zn, Cu, and Mn median (IQR) concentrations in maternal blood were, respectively, 5415 μg/L (4894-5822), 1609 μg/L (1295-1771) and 16.0 μg/L (12.5-20.8). Pb, Cd, Mn and Cu blood concentrations were significantly higher at delivery than during the first trimester of pregnancy. Pb, Cd, Zn and Cu concentrations were significantly lower in cord blood than in maternal blood, contrary to Mn concentration, which was significantly higher in cord blood than in maternal blood at delivery. This exploratory study is the first one performed in Benin, and warns us about exposition of women from Sô-Ava district to Pb and Cd during pregnancy.

Concordance of three alternative gestational age assessments for pregnant women from four African countries: A secondary analysis of the MIPPAD trial

BACKGROUND

At times, ultrasound is not readily available in low resource countries in Africa for accurate determination of gestational age, so using alternative methods is pivotal during pregnancy. These assessments are used to aid the risk analysis for an infant and management strategies for premature delivery, if necessary. Currently, date of last menstrual period, fundal height measurements, and the New Ballard Score are commonly used in resource-limited settings. However, concordance of these measures is unknown for sub-Saharan Africa. We obtained data from an open-label randomized controlled trial, to assess the concordance of these alternative assessment methods. The purpose of our study was to determine the agreement between these alternative methods when used in sub-Saharan African populations.

METHODS

A total of 4,390 pregnant women from Benin, Gabon, Mozambique and Tanzania were included in our analysis. The assessment methods compared were: 1) reported last menstrual period, 2) symphysis-fundal height measurement, and 3) the New Ballard Score. The Bland-Altman method and intraclass correlation coefficient (ICC) were used to test the degree of agreement. Survival range gestational age, used as an inclusion criterion for further analysis, was from 22 to 44 weeks.

FINDINGS

Plots showed a lack of agreement between methods and the 95% limits of agreement too wide to be clinically useful. ICC = 0.25 indicated poor agreement. A post-hoc analysis, restricted from 32 to 42 weeks, was done to check for better agreement in this near-term population. The plots and ICC = 0.16 still confirmed poor agreement.

CONCLUSION

The alternative assessments do not result in comparable outcomes and discrepancies are far beyond the clinically acceptable range. Last menstrual period should not be used as the only estimator of gestational age. In the absence of reliable early ultrasound, symphysis-fundal height measurements may be most useful during pregnancy for fetal risk assessment and the New Ballard Score after delivery as a confirmation of these estimations and for further neonatal management. However, promotion of portable ultrasound devices is required for accurate assessment of gestational age in sub-Sahara Africa.

Impact of the use and efficacy of long lasting insecticidal net on malaria infection during the first trimester of pregnancy - a pre-conceptional cohort study in southern Benin

Background

Malaria in pregnancy is prevalent in Sub-Saharan Africa. The first trimester of pregnancy is a critical period and the best preventive measure is Long Lasting Insecticidal Nets (LLIN). Unfortunately, few studies have been conducted which focuses on the usage and efficacy of LLIN on malaria prevention during the first trimester.

Methods

We assessed the use and effectiveness of LLIN in early pregnancy in Benin and its impact on malaria infection risk. We followed-up a cohort of 240 pregnant women from pre-conception to the end of the first trimester of pregnancy in Southern Benin. Parasitological, maternal and LLIN data were actively collected before, at the beginning and end of the first trimester of pregnancy. A Cox regression model was used to determine the relationship between the time to onset of the first malaria infection and the use, physical integrity, and bio-efficacy of the LLIN, adjusted for relevant covariables.

Results

The good use, good physical integrity and biological efficacy of LLIN were associated with a decreased risk of occurrence of the first malaria infection in early pregnancy (HRa = 0.38; (0.18–0.80); p < 0.001; HRa = 0.59; (0.29–1.19); p < 0.07; HRa = 0.97; (0.94–1.00); p < 0.04 respectively), after adjustment for other covariates. Primi/secundigravidity and malaria infection before pregnancy were associated with a risk of earlier onset of malaria infection.

Conclusion

The classically used LLIN’s indicators of possession and use may not be sufficient to characterize the true protection of pregnant women in the first trimester of pregnancy. Indicators of physical integrity and bio-efficacy should be integrated with those indicators in evaluation studies.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5595-2) contains supplementary material, which is available to authorized users.

What Do We Know about Risk Factors for Fetal Growth Restriction in Africa at the Time of Sustainable Development Goals? A Scoping Review

BACKGROUND

The reduction in the under-5 year mortality rate to at least as low as 25 per 1000 livebirths by 2030 has been implemented as one of the new Sustainable Development Goals. Fetal growth restriction (FGR) is one of the most important determinants of infant mortality in developing countries. In this review, we assess the extent of the literature and summarize its findings on the main preventable factors of FGR in Africa.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. Five bibliographic databases and grey literature were used to identify studies assessing at least one risk factor for FGR. Aggregate risk estimates for the main factors associated with FGR were calculated.

RESULTS

Forty-five of a total of 671 articles were selected for the review. The prevalence of FGR varied between 2.6 and 59.2% according to both the African region and the definition of FGR. The main preventable factors reported were a low maternal nutritional status (aggrerate odds ratio [OR]: 2.28, 95% confidence interval [CI] 1.59, 3.25), HIV infection (aOR 1.86, 95% CI 1.38, 2.50), malaria (aOR 1.95, 95% CI 1.04, 3.66), and gestational hypertension (aOR 2.61, 95% CI 2.42, 2.82).

CONCLUSION

FGR is, to a large extent, preventable through existing efficacious interventions dedicated to malaria, HIV and nutrition. Further studies are still needed to assess the influence of risk factors most commonly documented in high-income countries. Improving research on FGR in Africa requires a consensual and standardized definition of FGR-for a higher comparability-between studies and settings.

Cohort profile: effect of malaria in early pregnancy on fetal growth in Benin (RECIPAL preconceptional cohort)

PURPOSE

REtard de Croissance Intra-uterin et PALudisme (RECIPAL) is an original preconceptional cohort designed to assess the consequences of malaria during the first trimester of pregnancy, which is a poorly investigated period in Africa and during which malaria may be detrimental to the fetus.

PARTICIPANTS

For this purpose, a total of 1214 women of reproductive age living in Sô-Ava and Akassato districts (south Benin) were followed up monthly from June 2014 to December 2016 until 411 of them became pregnant. A large range of health determinants was collected both before and during pregnancy from the first weeks of gestation to delivery. Five Doppler ultrasound scans were performed for early dating of the pregnancy and longitudinal fetal growth assessment.

FINDINGS TO DATE

Pregnant women were identified at a mean of 6.9 weeks of gestation (wg). Preliminary results confirmed the high prevalence of malaria in the first trimester of pregnancy, with more than 25.4% of women presenting at least one microscopic malarial infection during this period. Most infections occurred before six wg. The prevalence of low birth weight, small birth weight for gestational age (according to INTERGROWTH-21st charts) and preterm birth was 9.3%, 18.3% and 12.6%, respectively.

FUTURE PLANS

REtard de Croissance Intra-uterin et PALudisme (RECIPAL) represents at this time a unique resource that will provide information on multiple infectious (including malaria), biological, nutritional and environmental determinants in relation to health outcomes in women of reproductive age, pregnant women and their newborns. It will contribute to better define future recommendations for the prevention of malaria in early pregnancy and maternal malnutrition in Africa. It confirms that it is possible to constitute a preconceptional pregnancy cohort in Africa and provides valuable information for researchers starting cohorts in the future.

Prevalence of malaria in pregnancy in southern Laos: a cross-sectional survey

Background

There are no data on the burden of malaria in pregnancy (MiP) in Laos, where malaria still remains prevalent in the south.

Methods

Two cross-sectional surveys were conducted in 2014 to assess the prevalence of MiP in Vapi District, Salavan Province, southern Laos: the first consisted of screening 204 pregnant women during pregnancies [mean (95 % CI) gestational age: 23 (22–25) weeks] living in 30 randomly selected villages in Vapi District; the second was conducted among 331 pregnant women, who delivered during the study period in Vapi and Toumlane District Hospitals and in Salavan Provincial Hospital. Peripheral and placental malaria was detected using rapid diagnostic tests (RDT), thick blood smears (TBS) and real-time quantitative polymerase chain reactions (RT-qPCR). Factors associated with low birth weight (LBW) and maternal anaemia were assessed.

Results

In the villages, 12/204 women (5.9 %; 95 % CI 3.1–10.0) were infected with malaria as determined by RT-qPCR: 11 were Plasmodium vivax infections and 1 was mixed Plasmodium vivax/Plasmodium falciparum infection, among which 9 were sub-microscopic (as not detected by TBS). History of malaria during current pregnancy tended to be associated with a higher risk of MiP (aIRR 3.05; 95 % CI 0.94–9.88). At delivery, two Plasmodium falciparum sub-microscopic infections (one peripheral and one placental) were detected (4.5 %; 0.6–15.5) in Vapi District. In both surveys, all infected women stated they had slept under a bed net the night before the survey, and 86 % went to the forest for food-finding 1 week before the survey in median. The majority of infections (94 %) were asymptomatic and half of them were associated with anaemia. Overall, 24 % of women had LBW newborns. Factors associated with a higher risk of LBW were tobacco use (aIRR 2.43; 95 % CI 1.64–3.60) and pre-term delivery (aIRR 3.17; 95 % CI 2.19–4.57). Factors associated with a higher risk of maternal anaemia were no iron supplementation during pregnancy, Lao Theung ethnicity and place of living.

Conclusions

The prevalence of MiP in this population was noticeable. Most infections were asymptomatic and sub-microscopic vivax malaria, which raises the question of reliability of recommended national strategies for the screening and prevention of MiP in Laos.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1492-2) contains supplementary material, which is available to authorized users.

Mortality, Morbidity, and Developmental Outcomes in Infants Born to Women Who Received Either Mefloquine or Sulfadoxine-Pyrimethamine as Intermittent Preventive Treatment of Malaria in Pregnancy: A Cohort Study

BACKGROUND

Little is known about the effects of intermittent preventive treatment of malaria in pregnancy (IPTp) on the health of sub-Saharan African infants. We have evaluated the safety of IPTp with mefloquine (MQ) compared to sulfadoxine-pyrimethamine (SP) for important infant health and developmental outcomes.

METHODS AND FINDINGS

In the context of a multicenter randomized controlled trial evaluating the safety and efficacy of IPTp with MQ compared to SP in pregnancy carried out in four sub-Saharan countries (Mozambique, Benin, Gabon, and Tanzania), 4,247 newborns, 2,815 born to women who received MQ and 1,432 born to women who received SP for IPTp, were followed up until 12 mo of age. Anthropometric parameters and psychomotor development were assessed at 1, 9, and 12 mo of age, and the incidence of malaria, anemia, hospital admissions, outpatient visits, and mortality were determined until 12 mo of age. No significant differences were found in the proportion of infants with stunting, underweight, wasting, and severe acute malnutrition at 1, 9, and 12 mo of age between infants born to women who were on IPTp with MQ versus SP. Except for three items evaluated at 9 mo of age, no significant differences were observed in the psychomotor development milestones assessed. Incidence of malaria, anemia, hospital admissions, outpatient visits, and mortality were similar between the two groups. Information on the outcomes at 12 mo of age was unavailable in 26% of the infants, 761 (27%) from the MQ group and 377 (26%) from the SP group. Reasons for not completing the study were death (4% of total study population), study withdrawal (6%), migration (8%), and loss to follow-up (9%).

CONCLUSIONS

No significant differences were found between IPTp with MQ and SP administered in pregnancy on infant mortality, morbidity, and nutritional outcomes. The poorer performance on certain psychomotor development milestones at 9 mo of age in children born to women in the MQ group compared to those in the SP group may deserve further studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00811421.

Mefloquine Versus Sulfadoxine-Pyrimethamine for Intermittent Preventive Treatment in Pregnancy: A Joint Analysis on Efficacy and Tolerability

Since there is no ideal candidate to replace sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment (IPTp), alternatives need to be evaluated on basis of their benefit-risk ratio. We reanalyzed the first Beninese trial on mefloquine (MQ) versus SP for IPTp using a multiple outcome approach, which allowed the joint assessment of efficacy and tolerability. Overall superiority of MQ to SP was defined as superiority on at least one efficacy outcome (low birth weight [LBW], placental malaria, or maternal anemia), non-inferiority on all of them as well as on tolerability defined as cutaneous or neuropsychiatric adverse events (AEs) or low compliance with the treatment. The analysis included 1,601 women. MQ was found to be overall superior to SP (P = 0.004). Performing several sensitivity analyses to handle both missing data and stillbirths provided similar results. Using MQ for IPTp as an example, we show that a multiple outcome analysis is a pragmatic way to assess the benefits/disadvantages of one drug compared with another. In the current context of a lack of antimalarials that could be used for IPTp, such a statistical approach could be widely used by institutional policy makers for future recommendations regarding the prevention of malaria in pregnancy (MiP).

Burden of malaria in early pregnancy: a neglected problem?

According to the current World Health Organization guidelines, the drug prevention of malaria during pregnancy does not adequately cover the first trimester of gestation in high-transmission areas. Although the pathophysiological mechanisms of early infections are not completely understood yet, a review of the most recent studies on the topic suggests that their consequences are serious in terms of maternal anemia and low birth weight. Consequently, there is a need to focus on the awareness of women in a period hard to access, to develop safe drugs to be used in the first trimester, and to consider preconceptional interventions in teenage girls, such as a new malaria vaccine to be used in pregnancy.

Intermittent preventive treatment of malaria in pregnancy with mefloquine in HIV-negative women: a multicentre randomized controlled trial

BACKGROUND

Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended by WHO to prevent malaria in African pregnant women. The spread of SP parasite resistance has raised concerns regarding long-term use for IPT. Mefloquine (MQ) is the most promising of available alternatives to SP based on safety profile, long half-life, and high efficacy in Africa. We evaluated the safety and efficacy of MQ for IPTp compared to those of SP in HIV-negative women.

METHODS AND FINDINGS

A total of 4,749 pregnant women were enrolled in an open-label randomized clinical trial conducted in Benin, Gabon, Mozambique, and Tanzania comparing two-dose MQ or SP for IPTp and MQ tolerability of two different regimens. The study arms were: (1) SP, (2) single dose MQ (15 mg/kg), and (3) split-dose MQ in the context of long lasting insecticide treated nets. There was no difference on low birth weight prevalence (primary study outcome) between groups (360/2,778 [13.0%]) for MQ group and 177/1,398 (12.7%) for SP group; risk ratio [RR], 1.02 (95% CI 0.86-1.22; p=0.80 in the ITT analysis). Women receiving MQ had reduced risks of parasitemia (63/1,372 [4.6%] in the SP group and 88/2,737 [3.2%] in the MQ group; RR, 0.70 [95% CI 0.51-0.96]; p=0.03) and anemia at delivery (609/1,380 [44.1%] in the SP group and 1,110/2743 [40.5%] in the MQ group; RR, 0.92 [95% CI 0.85-0.99]; p=0.03), and reduced incidence of clinical malaria (96/551.8 malaria episodes person/year [PYAR] in the SP group and 130/1,103.2 episodes PYAR in the MQ group; RR, 0.67 [95% CI 0.52-0.88]; p=0.004) and all-cause outpatient attendances during pregnancy (850/557.8 outpatients visits PYAR in the SP group and 1,480/1,110.1 visits PYAR in the MQ group; RR, 0.86 [0.78-0.95]; p=0.003). There were no differences in the prevalence of placental infection and adverse pregnancy outcomes between groups. Tolerability was poorer in the two MQ groups compared to SP. The most frequently reported related adverse events were dizziness (ranging from 33.9% to 35.5% after dose 1; and 16.0% to 20.8% after dose 2) and vomiting (30.2% to 31.7%, after dose 1 and 15.3% to 17.4% after dose 2) with similar proportions in the full and split MQ arms. The open-label design is a limitation of the study that affects mainly the safety assessment.

CONCLUSIONS

Women taking MQ IPTp (15 mg/kg) in the context of long lasting insecticide treated nets had similar prevalence rates of low birth weight as those taking SP IPTp. MQ recipients had less clinical malaria than SP recipients, and the pregnancy outcomes and safety profile were similar. MQ had poorer tolerability even when splitting the dose over two days. These results do not support a change in the current IPTp policy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 00811421; Pan African Clinical Trials Registry PACTR 2010020001429343 Please see later in the article for the Editors' Summary.

Coinfection with Plasmodium falciparum and Schistosoma haematobium: additional evidence of the protective effect of Schistosomiasis on malaria in Senegalese children

Parasitic infections are associated with high morbidity and mortality in developing countries. Several studies focused on the influence of helminth infections on malaria but the nature of the biological interaction is under debate. Our objective was to undertake a study to explore the influence of the measure of excreted egg load caused by Schistosoma haematobium on Plasmodium falciparum parasite densities. Ten measures of malaria parasite density and two measures of schistosomiasis egg urinary excretion over a 2-year follow-up period on 178 Senegalese children were considered. A linear mixed-effect model was developed to take data dependence into account. This work showed that children with a light S. haematobium infection (1-9 eggs/mL of urine) presented lower P. falciparum parasite densities than children not infected by S. haematobium (P < 0.04). Possible changes caused by parasite coinfections should be considered in the anti-helminth treatment of children and in malaria vaccination development.

Well wrapped eggs: effects of egg shell structure on heat resistance and hatchling mass in the invasive land snail Cornu aspersum

In ectotherms, the temperature changes that accompany climate shifts, microhabitat changes, and species range extensions can have profound effects on the performance of organisms. The aim of this laboratory study on the terrestrial invasive gastropod Cornu aspersum was to investigate the effect of dietary calcium source on egg shell structure and heat resistance of eggs in two populations from different climatic regions of France (Western Atlantic and Mediterranean). To date no literature is known about heat stress in calcified ectothermic eggs while exposed to heat peaks using fluctuating thermal regimes and optimal humidity. In snails from the Mediterranean population fed exclusively with CaCO(3) from limestone we found the thinnest egg shells and the smallest hatchlings. Limestone represents the most accessible calcium source for snails, but is, however, responsible for thinner and more mineralized egg shells (higher ash content). Hence thicker egg shells result from a low mineralized mucopolysaccharide-glycoprotein matrix that could play a nutritional role for hatchlings. Exposed to heat peaks, eggs in both populations had lower incubation time variability at the detriment of hatching rate. This study highlights the need for functional studies in this invasive species to understand the effects on population dynamics of interacting biotic and abiotic environmental factors under climate and anthropic habitat changes.

Malaria and gravidity interact to modify maternal haemoglobin concentrations during pregnancy

Background

Primigravidity is one of the main risk factors for both malaria and anaemia. Since the implementation of intermittent preventive treatment (IPTp) in sub-Saharan Africa, the relationship between anaemia and gravidity and its evolution during pregnancy has been little explored. This study aimed to evaluate the impact of gravidity on the variation of haemoglobin during pregnancy according to the timing of gestation.

Methods

Data from three studies carried out in nearby areas in south Benin (Ouidah, Comé, Allada) between 2005 and 2012 were analysed. At inclusion (first antenatal visit, ANV1) women’s age, area of residence, schooling, gravidity, gestational age, weight and height were recorded. Thick blood smears were performed on ANV1, second visit (ANV2) and at delivery. In Allada, women’s serum ferritin and CRP concentrations were also assessed. The impact of gravidity on maternal haemoglobin (Hb) was analysed using a logistic or linear regression depending on the outcome. The statistical significance was set to P < 0.05.

Results

In total, data from 3,591 pregnant women were analysed. Both univariate and multivariate analyses showed a constant association between Hb concentrations and gravidity in the three periods of Hb assessment (ANV1, ANV2 and delivery). Mean Hb concentration was significantly lower in primigravidae than in multigravidae at ANV1 (mean difference = -2.4 g/L, CI 95%: [-3.4, -1.4], P < 0.001). Afterwards, there was a significant increase in primigravidae only, with a tendency to reversal between primigravidae and multigravidae, which was confirmed at delivery (mean difference = 2.8 g/L, CI 95%: [1.3, 4.2], P < 0.001). The prevalence of malaria infection was halved between ANV1 and delivery in primigravidae while it decreased by only 38% among multigravidae, who were less prone to malaria infection (prevalence at ANV1, 20% and 10% respectively). Iron deficiency was more common in multigravidae, and it decreased slightly in this group between ANV1 and delivery.

Conclusion

In a context of IPTp, Hb levels improved progressively throughout pregnancy in primigravidae, likely as a result of reduction in malaria infection. In multigravidae, the improvement was less perceptible and anaemia was mainly due to iron deficiency.

Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey

Background

Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali.

Methods

We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007–10/01/2008). Data were collected regarding women’s characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model.

Results

Among 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]).

Conclusions

We confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.

Maternal and perinatal outcomes by mode of delivery in senegal and mali: a cross-sectional epidemiological survey

Objective

In the context of rapid changes regarding practices related to delivery in Africa, we assessed maternal and perinatal adverse outcomes associated with the mode of delivery in 41 referral hospitals of Mali and Senegal.

Study Design

Cross-sectional survey nested in a randomised cluster trial (1/10/2007–1/10/2008). The associations between intended mode of delivery and (i) in-hospital maternal mortality, (ii) maternal morbidity (transfusion or hysterectomy), (iii) stillbirth or neonatal death before Day 1 and (iv) neonatal death between 24 hours after birth and hospital discharge were examined. We excluded women with immediate life threatening maternal or fetal complication to avoid indication bias. The analyses were performed using hierarchical logistic mixed models with random intercept and were adjusted for women's, newborn's and hospitals' characteristics.

Results

Among the 78,166 included women, 2.2% had a pre-labor cesarean section (CS) and 97.8% had a trial of labor. Among women with a trial of labor, 87.5% delivered vaginally and 12.5% had intrapartum CS. Pre-labor CS was associated with a marked reduction in the risk of stillbirth or neonatal death before Day 1 as compared with trial of labor (OR = 0.2 [0.16–0.36]), though we did not show that maternal mortality (OR = 0.3 [0.07–1.32]) and neonatal mortality after Day 1 (OR = 1.3 (0.66–2.72]) differed significantly between groups. Among women with trial of labor, intrapartum CS and operative vaginal delivery were associated with higher risks of maternal mortality and morbidity, and neonatal mortality after Day 1, as compared with spontaneous vaginal delivery.

Conclusions

In referral hospitals of Mali and Senegal, pre-labor CS is a safe procedure although intrapartum CS and operative vaginal delivery are associated with increased risks in mothers and infants. Further research is needed to determine what aspects of obstetric care contribute to a delay in the provision of intrapartum interventions so that practices may be made safer when they are needed.

Consequences of gestational malaria on birth weight: finding the best timeframe for intermittent preventive treatment administration

To investigate the consequences of intermittent preventive treatment (IPTp) timing on birth weight, we pooled data from two studies conducted in Benin between 2005 and 2010: a prospective cohort of 1037 pregnant women and a randomised trial comparing sulfadoxine-pyrimethamine (SP) to mefloquine in 1601 women. A total of 1439 women (752 in the cohort and 687 in the SP arm of the randomised trial) who delivered live singletons were analysed. We showed that an early intake of the first SP dose (4 months of gestation) was associated with a lower risk of LBW compared to a late intake (6–7 months of gestation) (aOR = 0.5 p = 0.01). We also found a borderline increased risk of placental infection when the first SP dose was administered early in pregnancy (aOR = 1.7 p = 0.1). This study is the first to investigate the timing of SP administration during pregnancy. We clearly demonstrated that women who had an early intake of the first SP dose were less at risk of LBW compared to those who had a late intake. Pregnant women should be encouraged to attend antenatal visits early to get their first SP dose and a third dose of SP could be recommended to cover the whole duration of pregnancy and to avoid late infections of the placenta.

Molecular markers of resistance to sulphadoxine-pyrimethamine during intermittent preventive treatment of pregnant women in Benin

Background

The prevention of malaria faces with the repeated emergence of Plasmodium falciparum resistance to drugs, often involving point mutations of the target gene. In the pregnant woman, currently the WHO recommendation is the administration of an intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine. Sulphadoxine-pyrimethamine (SP) resistance has increased for several years in Africa, stressing the need for alternative molecules. In this context, the first randomized clinical trial comparing the efficacy of SP and mefloquine for IPTp has been conducted recently in Benin. Using samples from this trial, the current study evaluated and quantified the prevalence of mutations on the pfdhfr and pfdhps genes as well as the copy number of the pfmdr1 gene in parasites from P. falciparum-infected pregnant women before first and second IPTp administration, and at delivery.

Methods

PCR-restriction fragment length polymorphism of polymorphic codons of the pfdhfr gene (51, 59, 108, and 164) was performed. The identification of mutations in three codons of the pfdhps gene (436, 437 and 540) was achieved by PCR and sequencing. Copy number quantification for pfmdr1 gene was performed using real-time PCR.

Results

Results show a high prevalence rate of mutant parasites in women taking IPTp with sulphadoxine-pyrimethamine or mefloquine. The prevalence of triple and quadruple mutants was high before first drug regimen administration (79/93, 85%), and remained similar until delivery. Infection with mutant parasites was not correlated with low birth weight nor placental infection. In all samples, the copy number of pfmdr1 gene was equal to one.

Conclusions

The clinical trial comparing SP and mefloquine efficacy during IPTp showed SP remained efficacious in preventing low birth weight. The present study shows a high prevalence of triple and quadruple mutations implicated in SP resistance. Although the pfdhfr/pfdhps triple and quadruple mutations were frequent, there was no evidence of correlation between these genotypes and the lack of efficacy of SP in the context of IPTp. Nevertheless, it is now obvious that SP will soon be compromised in whole Africa. Molecular markers have been recommended to monitor SP efficacy for IPTp, but given the current prevalence of mutant parasites their usefulness is questionable.

Field evaluation of the intermittent preventive treatment of malaria during pregnancy (IPTp) in Benin: evolution of the coverage rate since its implementation

Background

Malaria is an important public health problem in Africa. Pregnant women are a vulnerable population and this disease can underlie an increased risk of low-birth weight newborns (< 2500 g); these women therefore need management during pregnancy. This was previously provided by chloroquine treatment, which, because of compliance problems and drug resistance, was replaced by intermittent preventive treatment with sulfadoxine-pyrimethamine (ITPp-SP) with two single doses taken after 16 weeks of amenorrhea, at least 4 weeks apart. This protocol was recommended by the World Health Organization (WHO) in 1998 and was initiated in Benin in 2006 after its political adoption in 2004.

A retrospective longitudinal study was conducted in eight maternity hospitals in two geographical areas in Benin (in the south and north). The study investigated 2420 women who gave birth from 2005 to 2009. The antenatal cards of those women were randomly selected over 5 years with the aim of analyzing the IPT coverage in the study's maternity hospitals.

Results

The rate of IPT-SP coverage evolved from 3.7% in 2005 to 87.8% in 2009 for women who had received at least one dose and from 2.7% to 68.4% from 2005 to 2009 for those who had received complete ITP (two doses). Variability in the results was observed depending on the geographical area (north/south) and the type of area (rural/urban).

Conclusions

In total, application of IPT-SP 2-doses has rapidly evolved since 2005, but the objective of 80% IPT coverage has not yet been achieved throughout the country. Moreover, problems of drug shortage recurring in the field (reported by health staff) remain to be resolved.

[Doing more to earn more: cesarean sections based on three cases of exemption from payment in Senegal]

In 2007, the number of caesarean sections performed in Senegal increased by 124% compared to the number of caesarean sections recorded before the introduction of a C-section funding initiative in 2006. The rate of increase varies in different regions and hospitals, with some hospitals performing caesarean sections in over 50% of deliveries. The purpose of this paper is to analyze the main reasons for high hospital caesarean section rates (i.e. above the national average) based on three cases of exemption from payment. The study is based on a qualitative method involving semi-structured interviews with healthcare and administrative staff and pregnant women in three healthcare institutions and interviews with central health authorities. Research indicates that high caesarean section rates are not directly linked to the C-section subsidy policy introduced in 2006. The perception of caesarean rates is more closely linked to the perception of population rates among healthcare professionals than to the perception of institutional (hospital) rates. Since population rates are very low, healthcare professionals tend to perform more caesarean sections. Among management staff, the financial returns of high caesarean section rates (in the three levels of exemption) represent a significant motivation for encouraging healthcare professionals to perform more C-sections. Despite these high rates, a normative discourse was found to be held by healthcare professionals, who tend to consider that their practices are aimed exclusively at saving the mother or the child. However, in the long term, high caesarean section rates may result in an increase of maternal deaths and go against MDG 5, aimed at reducing maternal mortality by 3/4 by 2015.

Spontaneous postpartum clearance of Plasmodium falciparum parasitemia in pregnant women, Benin

The question of malaria in the postpartum period is controversial. Malaria was investigated during a randomized trial of intermittent preventive treatment in pregnancy in Benin. Women infected at delivery were tested for parasitemia in the early postpartum period; they had not received treatment unless they were symptomatic. Among the 35 of 1,346 infected women, parasitologic follow-up results could not be interpreted in 15 because they were treated for symptoms, 18 cleared parasitemia spontaneously within five days postpartum, and 2 had a strong decrease in parasitemia before being treated. Because the placenta is the privileged site for sequestration of parasites, it facilitates their persistence during pregnancy, and its elimination may rapidly induce their clearance.