Facility-based delivery in the context of Zimbabwe's HIV epidemic--missed opportunities for improving engagement with care: a community-based serosurvey

Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys

Background

Reducing maternal mortality is a priority of Sustainable Development Goal 3.1 which requires frequent epidemiological analysis of trends and patterns of the causes of maternal deaths. We conducted two reproductive age mortality surveys to analyse the epidemiology of maternal mortality in Zimbabwe and analysed the changes in the causes of deaths between 2007-08 and 2018-19.

Methods

We performed a before and after analysis of the causes of death among women of reproductive ages (WRAs) (12-49 years), and pregnant women from the two surveys implemented in 11 districts, selected using multi-stage cluster sampling from each province of Zimbabwe (n=10); an additional district selected from Harare. We calculated mortality incidence rates and incidence rate ratios per 10000 WRAs and pregnant women (with 95% confidence intervals), in international classification of disease groups, using negative binomial models, and compared them between the two surveys. We also calculated maternal mortality ratios, per 100 000 live births, for selected causes of pregnancy-related deaths.

Results

We identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in the WRAs decreased by 82% in diseases of the respiratory system and 81% in certain infectious or parasitic diseases' groups, which include HIV/AIDS and malaria. Pregnancy-related deaths decreased by 84% in the indirect causes group and by 61% in the direct causes group, and HIV/AIDS-related deaths decreased by 91% in pregnant women. Direct causes of death still had a three-fold MMR than indirect causes (151 vs. 51 deaths per 100 000) in 2018-19.

Conclusion

Zimbabwe experienced a decline in both direct and indirect causes of pregnancy-related deaths. Deaths from indirect causes declined mainly due to a reduction in HIV/AIDS-related and malaria mortality, while deaths from direct causes declined because of a reduction in obstetric haemorrhage and pregnancy-related infections. Ongoing interventions ought to improve the coverage and quality of maternal care in Zimbabwe, to further reduce deaths from direct causes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13321-7.

Global Health Facility-Based Interventions to Achieve UNAIDS 90-90-90: A Systematic Review and Narrative Analysis

To evaluate whether health facility-based HIV interventions align with UNAIDS 90-90-90 targets, we performed a systematic review through the lens of UNAIDS targets. We searched 11 databases, retrieving 5201 citations with 26 eligible studies classified by country income and UNAIDS target. We analyzed whether reporting of study outcome metrics was in line with UNAIDS targets using a standardized extraction form and results were summarized in a narrative synthesis given data heterogeneity. We also assessed the quality of randomized trials with the Cochrane Risk of Bias Tool and observational studies with the Newcastle-Ottawa Scale. Stratification of interventions by country income level revealed themes in successful interventions that provide insight for scale-up in similar resource contexts. Few studies reported outcomes using metrics according to UNAIDS targets. Standardization of reporting according to the UNAIDS framework could facilitate comparability of interventions and inform country-level progress on an international scale.

Incidence of home delivery among women living with HIV in Lira, Northern Uganda: a prospective cohort study

Background

Home delivery has been associated with mother-to-child transmission of HIV and remains high among HIV-infected women. Predictors for home delivery in the context of HIV have not been fully studied and understood in Northern Uganda. We therefore aimed to find out the incidence and risk factors for home delivery among women living with HIV in Lira, Northern Uganda.

Methods

This prospective cohort study was conducted between August 2018 and January 2020 in Lira district, Northern Uganda. A total of 505 HIV infected women receiving antenatal care at Lira regional referral hospital were enrolled consecutively and followed up at delivery. We used a structured questionnaire to obtain data on exposures which included: socio-demographic, reproductive-related and HIV-related characteristics. Data was analysed using Stata version 14.0 (StataCorp, College Station, Texas, U.S.A.). We estimated adjusted risk ratios using Poisson regression models to ascertain risk factors for the outcome of interest which was home delivery (which is delivering an infant outside a health facility setting under the supervision of a non-health worker).

Results

The incidence of home delivery among women living with HIV was 6.9% (95%CI: 4.9–9.5%). Single women were more likely to deliver at home (adjusted risk ratio = 4.27, 95%CI: 1.66–11). Women whose labour started in the night (night time onset of labour ARR = 0.39, 95%CI: 0.18–0.86) and those that were adherent to their ART (ARR = 0.33, 95%CI: 0.13–0.86) were less likely to deliver at home.

Conclusion

Home delivery remains high among women living with HIV especially those that do not have a partner. We recommend intensified counselling on birth planning and preparedness in the context of HIV and PMTCT especially for women who are: separated, divorced, widowed or never married and those that are not adherent to their ART.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04222-5.

Male partner involvement and successful completion of the prevention of mother-to-child transmission continuum of care in Kenya

OBJECTIVE

To examine the relationship between male partner involvement (MPI) in prevention of mother-to-child transmission (PMTCT) activities and successful completion of the PMTCT continuum of care, which remains sub-optimal in settings with high prevalence of HIV.

METHODS

A cross-sectional survey was administered in June-August 2017 to a sample of 200 postpartum Kenyan women with HIV enrolled in a parent trial. Composite PMTCT and MPI variables were created. Descriptive, simple and multivariable regression, and mediation analyses were performed.

RESULTS

Of the women, 54% reported successful completion of PMTCT. Depression and internalized HIV stigma were independently associated with lower likelihood of successful completion of PMTCT (adjusted risk ratio [aRR] 0.97; 95% confidence interval [CI] 0.94-0.99; aRR 0.92; 95% CI 0.88-0.98, respectively). Each MPI activity was associated with 10% greater likelihood of successful completion of PMTCT (P < 0.05). The relationship between MPI and the successful completion of PMTCT was partially mediated through women's reduced internalized HIV stigma (β -0.03; 95%CI -0.06 to -0.00).

CONCLUSION

Greater MPI in PMTCT activities has direct and indirect effects on women's successful completion of all necessary steps across the PMTCT continuum. Reduced internalized HIV stigma is likely a key mechanism in the relationship.

Maternity Waiting Home Use by HIV-positive Pregnant Women in Zambia: Opportunity for Improved Prevention of Maternal to Child Transmission of HIV

BACKGROUND

Maternity waiting homes (MWHs), defined as residential lodging near health facilities, are an intervention to improve access to maternal care recommended by the World Health Organization. Little is known about utilization of MWHs by HIV-positive women. This paper describes: 1) maternal awareness and utilization of MWHs in rural Zambia among HIV-positive women, and 2) health outcomes for HIV-positive women and their infants with regards to utilization of MWHs.

METHODS

Data were collected from recently delivered women (delivered after 35 weeks in the previous 12 months) living >9.5 km from 40 health facilities in rural Zambia. For our analysis, primary outcomes were compared between self-identified HIV-positive and HIV-negative women in the sample. Primary outcomes include: 1) awareness of MWHs and 2) utilization of MWHs. We summarized simple descriptive statistics, stratified by maternal self-reported HIV status. We conducted bivariate analyses using chi-square tests, t-tests and Wilcoxon rank sum test.

RESULTS

Among 2,381 women, 50 (2.4%) self-identified as HIV-positive. HIV-positive women were older and had more pregnancies and children than HIV-negative women (p<0.001). There was no difference in awareness of MWHs, but HIV-positive women were more likely to use a MWH than HIV-negative women. There was no difference in receipt of infant antiretroviral prophylaxis between women who did or did not stay at a MWH.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Though HIV prevalence in this sample was lower than expected, MWHs may represent a useful strategy to improve prevention of mother to child transmission of HIV in high prevalence, low-resource settings.

Characterizing Pediatric Tuberculosis with and without Human Immunodeficiency Virus Coinfection in Harare, Zimbabwe

Pediatric tuberculosis (TB) represents a major barrier to reducing global TB mortality, especially in countries confronting dual TB and human immunodeficiency virus (HIV) epidemics. Our study aimed to characterize pediatric TB epidemiology in the high-burden setting of Harare, Zimbabwe, both to fill the current knowledge gap around the epidemiology of pediatric TB and to indicate areas for future research and interventions. We analyzed de-identified data of 1,051 pediatric TB cases (0-14 years) found among a total of 11,607 TB cases reported in Harare, Zimbabwe, during 2011-2012. We performed Pearson's χ² test and multivariate logistic regression analysis to characterize pediatric TB and to assess predictors of HIV coinfection. Pediatric TB cases accounted for 9.1% of all TB cases reported during 2011-2012. Approximately 50% of pediatric TB cases were children younger than 5 years. Almost 60% of the under-5 age group were male, whereas almost 60% of the 10-14 age group were female. The overall HIV coinfection rate was 58.3%. Odds for HIV coinfection was higher for the 5-9 age group (adjusted odds ratio [AOR]: 2.77, 95% confidence interval [CI]: 1.97-3.94), the 10-14 group (AOR: 3.57, 95% CI: 2.52-5.11), retreatment cases (AOR: 6.17, 95% CI: 2.13, 26.16), and pulmonary TB cases (AOR: 2.39, 95% CI: 1.52, 3.75). In conclusion, our study generated evidence that pediatric TB, compounded by HIV coinfection, significantly impacts children in high-burden settings. The findings of our study indicate a critical need for targeted interventions.

Prevalence and correlates of home delivery amongst HIV-infected women attending care at a rural public health facility in Coastal Kenya

BACKGROUND

Home delivery, referring to pregnant women giving birth in the absence of a skilled birth attendant, is a significant contributor to maternal mortality, and is encouragingly reported to be on a decline in the general population in resource limited settings. However, much less is known about home delivery amongst HIV-infected women in sub-Saharan Africa (sSA). We described the prevalence and correlates of home delivery among HIV-infected women attending care at a rural public health facility in Kilifi, Coastal Kenya.

METHODS

A cross-sectional design using mixed methods was used. Quantitative data were collected using interviewer-administered questionnaires from HIV-infected women with a recent pregnancy (within 5 years, n = 425), whilst qualitative data were collected using focused group discussions (FGD, n = 5). Data were analysed using logistic regression and a thematic framework approach respectively.

RESULTS

Overall, 108 (25.4%, [95% CI: 21.3-29.8]) participants delivered at home. Correlates of home delivery included lack of formal education (aOR 12.4 [95% CI: 3.4-46.0], p<0.001), history of a previous home delivery (2.7 [95% CI:1.2-6.0], p = 0.019) and being on highly active antiretroviral therapy (HAART, 0.4 [95% CI:0.2-0.8], p = 0.006).Despite a strong endorsement against home delivery, major thematic challenges included consumer-associated barriers, health care provider associated barriers and structural barriers.

CONCLUSION

A quarter of HIV-infected women delivered at home, which is comparable to estimates reported from the general population in this rural setting, and much lower than estimates from other sSA settings. A tailored package of care targeting women with no formal education and with a history of a previous home delivery, coupled with interventions towards scaling up HAART and improving the quality of maternal care in HIV-infected women may positively contribute to a decline in home delivery and subsequent maternal mortality in this setting.

INDIVIDUAL- AND COMMUNITY-LEVEL DETERMINANTS OF ANTENATAL HIV TESTING IN ZIMBABWE

This study contributes to the dialogue on the prevention of mother-to-child HIV transmission (PMTCT) through the use of HIV and antenatal care (ANC) integrated services. The determinants of antenatal HIV testing in Zimbabwe were explored. Multilevel logistic regression models were applied to data for 8471 women from 406 clusters who gave birth in the 5 years preceding Zimbabwe Demographic and Health Surveys conducted in 2005/6 and 2010/11. The uptake of antenatal HIV testing was found to be determined by a wide range of individual-level factors relating to women's economic and demographic status, as well as HIV-related factors, including HIV awareness and stigma within the community. Important individual-level enabling and perceived need factors included high socioeconomic status, not having observed HIV-related stigma and knowledge of HIV status (based on a previous HIV test), such that these groups of individuals had a significantly higher likelihood of being tested for HIV during pregnancy than their counterparts of lower socioeconomic status, and who had observed HIV-related stigma or did not know their HIV status. The results further revealed that community HIV awareness is important for improving antenatal HIV testing, while stigma is associated with reduced testing uptake. Most contextual community-level factors were not found to have much effect on the uptake of antenatal HIV testing. Therefore, policies should focus on individual-level predisposing and enabling factors to improve the uptake of antenatal HIV testing in Zimbabwe.

Correlates of facility delivery for rural HIV-positive pregnant women enrolled in the MoMent Nigeria prospective cohort study

BACKGROUND

Low rates of maternal healthcare service utilization, including facility delivery, may impede progress in the prevention of mother-to-child transmission of HIV (PMTCT) and in reducing maternal and infant mortality. The MoMent (Mother Mentor) study investigated the impact of structured peer support on early infant diagnosis presentation and postpartum maternal retention in PMTCT care in rural Nigeria. This paper describes baseline characteristics and correlates of facility delivery among MoMent study participants.

METHODS

HIV-positive pregnant women were recruited at 20 rural Primary Healthcare Centers matched by antenatal care clinic volume, client HIV prevalence, and PMTCT service staffing. Baseline and delivery data were collected by participant interviews and medical record abstraction. Multivariate logistic regression with generalized estimating equation analysis was used to evaluate for correlates of facility delivery including exposure to structured (closely supervised Mentor Mother, intervention) vs unstructured (routine, control) peer support.

RESULTS

Of 497 women enrolled, 352 (71%) were between 21 and 30 years old, 319 (64%) were Christian, 245 (49%) had received secondary or higher education, 402 (81%) were multigravidae and 299 (60%) newly HIV-diagnosed. Delivery data was available for 445 (90%) participants, and 276 (62%) of these women delivered at a health facility. Facility delivery did not differ by type of peer support; however, it was positively associated with secondary or greater education (aOR 1.9, CI 1.1-3.2) and Christian affiliation (OR 1.4, CI 1.0-2.0) and negatively associated with primigravidity (OR 0.5; 0.3-0.9) and new HIV diagnosis (OR 0.6, CI 0.4-0.9).

CONCLUSIONS

Primary-level or lesser-educated HIV-infected pregnant women and those newly-diagnosed and primigravid should be prioritized for interventions to improve facility delivery rates and ultimately, healthy outcomes. Incremental gains in facility delivery from structured peer support appear limited, however the impact of duration of pre-delivery support needs further investigation. Religious influences on facility delivery and on general maternal healthcare service utilization need to be further explored.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT01936753 , registered September 2013.

Developing a model of health behavior change to reduce parasitic disease in Vietnam

Worldwide more deaths occur due to conditions that can be ameliorated by behavior change. Changing health behaviors using models popularized in non-western countries has not proven particularly successful. The purpose of this study was to test variables elicited during qualitative interviews and cultural conversations to develop a model of health behavior change from the ground up in Vietnam. Village leaders and women representatives from the Women's Committee were trained as health advocates to facilitate changes in health practices that led to parasitic and infectious diseases. The health advocates visited 156 families to assess household conditions and assist women head-of-households in applying new behaviors to water treatment, personal hygiene, proper latrining and proximity of animals to humans. Predictors that were tested were self-efficacy, social desirability, internal and external control, and outcome expectations. The correlational and regression design resulted in self-efficacy alone predicting both home hygiene and family health with a large effect size. Social desirability appears to play a different role than in western culture studies. Outcome expectations and control were not predictive. A cultural analysis of the results is included.