Acknowledging HIV and malaria as major causes of maternal mortality in Mozambique

Exploring Health Inequalities and Presurgical Attitudes on Postsurgical Outcomes in Spine Surgery

OBJECTIVE

The influence of social determinants of health on health disparities is substantial. However, their impact on postsurgical outcomes in spine can be challenging to ascertain at the community level. This study aims to explore the interplay between presurgical attitudes, area deprivation index (ADI), income, employment status, and body mass index (BMI) on postsurgical outcomes at 3, 6, 9, and 12 months after elective spine surgery.

METHODS

The study involved 127 patients who underwent elective spine surgery between August 2021 and August 2022 at a large academic institution. The main objective involved a prospective analysis of presurgical attitudes, coupled with a retrospective assessment of ADI, income, employment status, and BMI over 3, 6, 9, and 12 months following elective spine surgery using a univariate analysis.

RESULTS

Utilizing the univariate analyses, ADI displayed a significant correlation with increased Patient-Reported Outcomes Measurement Information System and Visual Analog Scale scores both before surgery and at the 3-, 6-, and 9-month postsurgical intervals (P < 0.05). One year after surgery, patients in the lowest income group (annual income under $25,000) consistently demonstrated the highest Patient-Reported Outcomes Measurement Information System pain (8.00, P = 0.022). Patients who were not employed had significantly lower levels of social support (P = 0.042) and confidence in the health care system (P = 0.009). Individuals who were unemployed were most likely to be readmitted six weeks after surgery (P < 0.001).

CONCLUSIONS

Presurgical attitudes, ADI, income, employment status, and BMI were important factors associated with improved surgical outcome measurements, indicating potential focal points for combating health disparities in spinal surgery patients.

Effects of HIV infection and/or malaria on maternal and neonatal health in a high-prevalence setting

OBJECTIVE

HIV infection and malaria have been associated with different complications during pregnancy and delivery. HIV-positive pregnant women are at increased risk for all adverse outcomes of malaria during pregnancy. The main objective was to analyse the obstetric and perinatal consequences of malaria, HIV infection and HIV/malaria co-infection in pregnant women and newborns, which has been less well evaluated.

METHODS

A cross-sectional study was carried out in the Maternity Service of the Provincial Hospital of Tete Mozambique, involving completion of a structured questionnaire that included demographic data, and information on the current pregnancy, delivery and the newborn. In total, 819 women (13-45 years old) in the immediate postpartum period were enrolled between 1 March and 31 October 2016.

RESULTS

The overall prevalence of HIV and malaria, considered separately, in pregnant women was ~12% (103 women with HIV and 101 with malaria). Only one-fifth of HIV-infected women knew their HIV status before pregnancy. A significantly higher proportion of women with HIV attended four or more antenatal care visits than women without HIV. Caesarean section was less frequent in HIV patients, and peripartum urinary infection was more frequent than in seronegative women (13/103 [12.6%] vs. 34/716 [4.7%]). HIV/malaria co-infection were 17/819 (2%) and was significantly associated with the development of pre-eclampsia when HIV-infected patients received anti-retroviral treatment, and with an increase in urinary tract infections around delivery. With respect to the newborn, co-infection increased the frequency of early neonatal death, as well as neonatal asphyxia and jaundice.

CONCLUSIONS

In Mozambique, the prevalence of malaria and HIV infection in women of childbearing age continues to be high and contributes additively to complications during pregnancy and childbirth, and in the newborn. Therefore, integrating HIV, malaria and reproductive health services is essential if maternal and foetal outcomes are to improve.

"We have this, with my husband, we live in harmony": exploring the gendered decision-making matrix for malaria prevention and treatment in Nampula Province, Mozambique

Background

Conceptualizing gender dynamics and ways of bridging entrenched gender roles will contribute to better health promotion, policy and planning. Such processes are explored in relation to malaria in Mozambique.

Methods

A multi-method, qualitative study using focus group discussions (FGDs) and in-depth interviews (IDIs) explored the perspectives of community members, leaders and stakeholders on malaria. The study was conducted in Nampula Province, in an intervention district for the Tchova Tchova Stop Malaria (TTSM) gender-sensitive community dialogues, and in a non-intervention district.

Results

Participants (n = 106) took part in six FGDs and five IDIs in each district. Those exposed to TTSM commonly stated that the programme influenced more equalitarian gender roles, attitudes and uptake of protective malaria-related practices. These positive changes occurred within the context of an observed, gendered decision-making matrix, which aligns inward- or outward-facing decisions with malaria prevention or treatment. Decisions more dependent on male or elder sanctioning at community level are outward-facing decisions, while decisions falling within women’s domain at household level are inward-facing decisions. Related to prevention, using bed nets was largely an inward-facing prevention decision for women, who were generally tasked with hanging, washing and making nets usable. Net purchase and appropriation for malaria prevention (rather than for instance for fishing) was men’s prerogative. Regular net use was associated with sleeping together more regularly, bringing couples closer. Attending antenatal care to access intermittent preventive treatment during pregnancy was often an outward-facing prevention decision, under the purview of older, influential women and ultimately needing sanctioning by men. With respect to seeking care for malaria symptoms, women typically sought help from traditional healers first. This inward-facing treatment decision was within their control, in contrast to the frequently transport-dependent, outward-facing decision to attend a health facility. Sharing decisions was described as a feature of a “harmonious household,” something that was said to be encouraged by the TTSM intervention and that was both lived and aspirational.

Conclusions

TTSM community dialogues helped communication on both interpersonal (couple) and community levels, ultimately encouraging malaria-related behaviours. Leveraging ways of bringing men and women together to share decision making will improve malaria intervention success.

Maternal death and postpartum hemorrhage in sub-Saharan Africa - A pilot study in metropolitan Mozambique

BACKGROUND

Maternal mortality in sub-Saharan Africa is approximately 500 to 1000 per 100 000 births (vs. approximately 5-20 in developed countries). Postpartum hemorrhage (PPH) is deemed responsible for 30% to 50% of the deaths.

OBJECTIVE

To study PPH, risk factors, and mortality in metropolitan Mozambique to inform future studies and intervention strategies.

MATERIALS/METHODS

Retrospective cross-sectional data extraction from all charts available to us (n = 495) recording deliveries between January and June 2018 at Maputo Central Hospital. Data included age, maternal survival, HIV status, parity, delivery mode, complications, vital signs, laboratory values, and maternal/fetal data. PPH was determined by charted diagnosis, interventions for hemorrhaging, placental abruption, transfusion, or blood loss. Autopsy reports from all deceased patients (n = 35) were examined.

RESULTS

Median age was 29 years with 17% HIV prevalence. Risk factors for PPH (frequency, 12%) included parity (adjusted odds ratios (AORs) for 3+ versus nulliparity, 7.20 (95% confidence interval [CI], 2.46-21.10), gestation length (AOR, 0.86; CI, 0.81-0.92 per week), and body temperature (AOR, 1.10; CI, 1.04-1.16 per 0.1°C). Maternal mortality was strongly associated with PPH (AOR, 5.22; 95% CI, 2.26-12.08) and HIV (AOR, 11.66; 95% CI, 4.72-28.78). Laboratory values (n = 241) were available from mothers experiencing complications (approximately 50%). Anemia (prevalence 54%) was a strong predictor of PPH with an inverse relationship between hemoglobin levels on admission (AOR, 0.62; 95% CI, 0.50-0.77 per g/dL higher hemoglobin) and the probability of later suffering from PPH. Mothers who died following PPH had lower median hemoglobin (6.2 g/dL) than mothers who survived (9.2 g/dL). Protocols to estimate peripartum blood loss were not used; antifibrinolytics and/or cryoprecipitate were unavailable.

CONCLUSION

Postpartum hemorrhage is a serious problem even in metropolitan areas of sub-Saharan Africa, and anemia influenced bleeding and death substantially. To address this problem, it is critical to raise awareness and region-specific prevention and intervention protocols.

Reporting of ethics in peer-reviewed verbal autopsy studies: a systematic review

Introduction

Verbal autopsy (VA) is a method that determines the cause of death by interviewing a relative of the deceased about the events occurring before the death, in regions where medical certification of cause of death is incomplete. This paper aims to review the ethical standards reported in peer-reviewed VA studies.

Methods

A systematic review of Medline and Ovid was conducted by two independent researchers. Data were extracted and analysed for articles based on three key areas: Institutional Review Board (IRB) clearance and consenting process; data collection and management procedures, including: time between death and interview; training and education of interviewer, confidentiality of data and data security; and declarations of funding and conflict of interest.

Results

The review identified 802 articles, of which 288 were included. The review found that 48% all the studies reported having IRB clearance or obtaining consent of participants. The interviewer training and education levels were reported in 62% and 21% of the articles, respectively. Confidentiality of data was reported for 14% of all studies, 18% did not report the type of respondent interviewed and 51% reported time between death and the interview for the VA. Data security was reported in 8% of all studies. Funding was declared in 63% of all studies and conflict of interest in 42%. Reporting of all these variables increased over time.

Conclusions

The results of this systematic review show that although there has been an increase in ethical reporting for VA studies, there still remains a large gap in reporting.

The effect of a performance-based financing program on HIV and maternal/child health services in Mozambique-an impact evaluation

Performance-based financing (PBF) is a mechanism by which health providers are paid on the basis of outputs or results delivered. A PBF program was implemented on the provision of HIV, prevention of mother-to child HIV transmission (PMTCT), and maternal/child health (MCH) services in two provinces of Mozambique. A retrospective case-control study design was used in which PBF provinces were matched with control provinces to evaluate the impact of PBF on 18 indicators. Due to regional heterogeneity, we evaluated the intervention sites (North and South) separately. Beginning January 2011, 11 quarters (33 months or 2.75 years) of data from 134 facilities after matching (84 in the North and 50 in the South) were used. Our econometric framework employed a multi-period, multi-group difference-in-differences model on data that was matched using propensity scoring. The regression design employed a generalized linear mixed model with both fixed and random effects, fitted using the seemingly unrelated regression technique. PBF resulted in positive impacts on MCH, PMTCT and paediatric HIV program outcomes. The majority of the 18 indicators responded to PBF (77% in the North and 66% in the South), with at least half of the indicators demonstrating a statistically significant increase in average output of more than 50% relative to baseline. Excluding pregnant women, the majority of adult HIV treatment indicators did not respond to PBF. On average, it took 18 months (six quarters) of implementation for PBF to take effect, and impact was generally sustained thereafter. Indicators were not sensitive to price, but were inversely correlated to the level of effort associated with marginal output. No negative impacts on incentivized indicators nor spill-over effects on non-incentivized indicators were observed. The PBF program in Mozambique has produced large, sustained increases in the provision of PMTCT, paediatric HIV and MCH services. Our results demonstrate that PBF is an effective strategy for driving down the HIV epidemic and advancing MCH care service delivery as compared with input financing alone.

Assessment of coverage of preventive treatment and insecticide-treated mosquito nets in pregnant women attending antenatal care services in 11 districts in Mozambique in 2011: the critical role of supply chain

Background

Malaria during pregnancy is associated with poor maternal and pregnancy outcome and the World Health Organization recommends the administration of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) and distribution of insecticide-treated mosquito nets (ITNs) to all pregnant women attending antenatal care (ANC) services. This study was conducted with the aim to assess the uptake of IPTp and ITNs in pregnant women attending ANC services and correlate with ANC attendance and frequency of stock-outs in 22 health facilities Mozambique.

Methods

A cross-sectional study was conducted between July and December 2011 in 22 health units in 11 districts situated in 11 provinces in Mozambique. Two health facilities were selected per district (one urban and one rural). Data were collected by reviewing logbooks of antenatal consultations as well as from monthly district reports.

Results

During the period under investigation, a total of 23,524 pregnant women attended their 1st antenatal care visits, of which 12,775 (54.3%) and 7581 (32.2%) received one and two doses of IPTp, respectively. In regard to ITNs, a total of 16,436 (69.9%) pregnant women received ITNs. Uptake of IPTp and ITNs by pregnant women at ANC services was higher in southern Mozambique and lower in districts situated in the northern part of the country. Stock-outs of SP and ITNs were reported in 50.0% (11/22) and 54.5% (12/22) of the health facilities, respectively. Coverage of IPTp and ITN in health facilities with stock-outs of SP and ITNs was much lower as compared to health facilities with no stock-outs.

Conclusions

Altogether, data from this study shows that coverage of the 2nd dose of IPTp, as well as ITNs, was low in pregnant women attending ANC services in Mozambique. In addition, this data also shows that stock-outs of SP and ITNs were frequent and led to lower coverage of IPTp and ITN, representing a serious barrier for the accomplishment of targets. In conclusion, this study recommends that efforts should be made to improve the supply chains of SP and ITNs.

The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012

BACKGROUND

The paper's primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection.

METHODS

Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712).

RESULTS

Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66% compared to 26% among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49%) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24% occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers.

CONCLUSIONS

The rate at which women died of direct causes in Mozambique's health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.

The enigma of the clandestine association between chloroquine and HIV-1 infection

OBJECTIVES

The antimalarial drug chloroquine (CQ) dampens the immune system and is used in the treatment of autoimmune disorders. CQ also shows antiviral activity against nonenveloped and enveloped viruses, including HIV-1. Persistent immune activation in chronic HIV-1infection leads to CD4 T-cell depletion. CQ is envisioned to attenuate immune activation and virus activity in HIV-1-infected patients. The role of CQ in immune activation and virus activity is discussed here.

METHODS

To elucidate the effect of CQ on immune activation, a retrospective review of published clinical trials, in vivo experimental studies in animals, and the most relevant in vitro observations in HIV-1-infected cells, together with observations from our own laboratory studies, was carried out and the findings discussed.

RESULTS

In a few clinical studies and animal experiments, CQ was ineffective in decreasing immune activation and HIV-1 infection. In vitro, CQ markedly increased HIV-1 infection in astrocytes and other non-CD4 cells.

CONCLUSIONS

The use of CQ in HIV-1-infected patients is questionable. The evidence for a dampening of immune activation by CQ is inconclusive.

Spatial patterns and determinants of malaria infection during pregnancy in Zambia

BACKGROUND

Malaria in pregnancy (MiP) is a major concern in Zambia. Here we aim to determine the burden and risk factors of MiP.

METHODS

Monthly reported district-level malaria cases among pregnant women (count data) from January 2009 to December 2014 were obtained from the Zambian District Health Information System. Negative binomial regression model was used to investigate the associations between vector control tools, coverage of health care facilities, transportation networks and population density. Data on MiP treatment were obtained from the 2012 Zambian Malaria Indicator Survey. Yearly clusters of MiP were investigated using spatial statistics in ArcGIS v 10.1.

RESULTS

The results indicated that MiP decreased in Zambia between 2010 and 2013. MiP was observed throughout the year, but showed a strong seasonal pattern. Persistent hotspots of MiP were reported in the southeast and northeast regions of Zambia, with districts that had better access to rail road and presence of water bodies associated with decreased prevalence of MiP. Better indoor residual spraying and long-lasting insecticide-treated nets coverage was demonstrated to be protective against MiP.

CONCLUSIONS

Mapping the distribution of MiP to track the future requirements for scaling up essential disease-prevention efforts in stable hotspots can help the Zambian National Malaria Control Center to further develop strategies to reduce malaria prevalence in this vulnerable sub-population.