Stillbirths in urban Guinea-Bissau: A hospital- and community-based study

The effect of maternal age on still birth in Africa: A systematic review and meta-analysis

Background and Aims

Stillbirth is a public health as well as a development problem in low and middle-income countries. The studies that found out maternal age as a factor for the risk of stillbirth reported different findings. This systematic review and meta-analysis is believed to fill the inconclusiveness of these findings. Hence, the aim of this systematic review and meta-analysis is to estimate the pooled effect of advanced maternal age on stillbirth in Africa.

Methods

PubMed & HINARY databases and Google Scholar search engine were searched to access the primary studies. The extracted data using Microsoft excel was exported to Stata 15 software for analysis. The presence of heterogeneity was checked using Cochran's Q statistic and the I 2 test. Publication bias was examined by using funnel plot and Egger's test. The pooled effect measure with DerSimonian and Laird method of random-effect model was reported using odds ratio (OR) with respective 95% confidence interval.

Results

Totally, 14 articles are included for the systematic review and meta-analysis. The stillbirth reported by the studies ranges from 15 to 146.7 per 1000 births. The overall OR of advanced maternal age (≥35 years) on stillbirth is 1.42 (1.18, 1.71) when compared with the age group of 20-35 years. The cumulative effect of getting pregnant at advanced age on stillbirth was slightly increasing from year to year.

Conclusion

Advanced maternal age is a risk factor for stillbirth. Health Information Communication on the risk of getting pregnant at the advanced ages on stillbirth should be well addressed to all women of reproductive age group.

Effects of Neonatal BCG-Japan Versus BCG-Russia Vaccination on Overall Mortality and Morbidity: Randomized Controlled Trial From Guinea-Bissau (BCGSTRAIN II)

Background

Vaccination with the Danish strain of bacille Calmette-Guérin (BCG) has been associated with pronounced reductions in all-cause neonatal mortality and morbidity. Developing a skin reaction postvaccination is associated with markedly reduced mortality risk. It is unknown whether the beneficial nonspecific effects are maintained across different BCG strains.

Methods

This was an open-label randomized controlled trial in Guinea-Bissau, comparing BCG-Japan (n = 8754) versus BCG-Russia (n = 8752) for all-cause hospital admission risk by 6 weeks of age (primary outcome) and 6 months of age. Additional secondary outcomes were in-hospital case-fatality risk (CFR), all-cause mortality, and BCG skin reaction prevalence. Participants were followed through telephone calls at 6 weeks and 6 months, with a subgroup also visited at home. We assessed admission and mortality risk in Cox models providing incidence rate ratios (IRRs) and mortality rate ratios. CFR and skin reactions were assessed by binomial regression providing risk ratios. Analyses were done overall and stratified by sex.

Results

BCG strain was not associated with admission risk, the BCG-Japan/BCG-Russia IRR being 0.92 (95% confidence interval [CI], .81-1.05) by 6 weeks and 0.92 (95% CI, .82-1.02) by 6 months. By 6 months of age, there were significantly fewer BCG-Japan infants with no skin reaction (1%) than for BCG-Russia (2%), the risk ratio being 0.36 (95% CI, .16-.81). BCG-Japan skin reactions were also larger.

Conclusions

Both vaccines induced a skin reaction in almost all participants. The BCG strains had comparable effects on morbidity and mortality, but BCG-Japan was associated with more and larger skin reactions that are indicators of lower mortality risk.

Clinical Trials Registration

NCT03400878.

Provider-mother interactions are associated with birth outcome misclassifications in household surveys: A case-control study in Guinea-Bissau

Background

Approximately 4.4 million children die peripartum annually, primarily in low- and middle-income countries. Accurate mortality tracking is essential to prioritising prevention efforts but is undermined by misclassification between stillbirths (SBs) and early neonatal deaths (ENNDs) in household surveys, which serve as key data sources. We explored and quantified associations between peripartum provider-mother interactions and misclassification of SBs and ENNDs in Guinea-Bissau.

Methods

Using a case-control design, we followed up on women who had reported a SB or ENND in a retrospective household survey nested in the Bandim Health Project's Health and Demographic Surveillance Systems (HDSS). Using prospective HDSS registration as the reference standard, we linked the survey-reported deaths to the corresponding HDSS records and cross-tabulated SB/ENND classification to identify cases (discordant classification between survey and HDSS) and controls (concordant classification). We further interviewed cases and controls on peripartum provider-mother interactions and analysed data using descriptive statistics and logistic regressions.

Results

We interviewed 278 women (cases: 63 (23%); controls: 215 (77%)). Most cases were SBs misclassified as ENNDs (n/N = 49/63 (78%)). Three-fourths of the interviewed women reported having received no updates on the progress of labour and baby's health intrapartum, and less than one-fourth inquired about this information. In comparison with births where women did inquire for information, misclassification was less likely when women did not inquire and recalled no doubts about progress of labour (odds ratio (OR) = 0.51; 95% confidence interval (CI) = 0.28-0.91), or baby's health (OR = 0.54; 95% CI = 0.30-0.97). Most women reported that service providers' death notifications lasted <5 minutes (cases: 23/27 (85%); controls: 61/71 (86%)), and most often encompassed neither events leading to the death (cases: 19/27 (70%); controls: 55/71 (77%)) nor causes of death (cases: 20/27 (74%); controls: 54/71 (76%)). Misclassification was more likely if communication lasted <1 compared to 1-4 minutes (OR = 1.83; 95% CI = 1.10-3.06) and if a formal service provider had informed the mother of the death compared to a family member (OR = 1.57; 95% CI = 1.04-2.36).

Conclusions

Peripartum provider-mother interactions are limited in Guinea-Bissau and associated with birth outcome misclassifications in retrospective household surveys. In our study population, misclassification led to overestimated neonatal mortality.

Mortality risk among frail neonates might be associated with maternal BCG scar status: Observational study from Guinea-Bissau

BACKGROUND

Maternal priming with Bacille Calmette-Guérin (BCG) has been associated with reduced offspring mortality. We investigated this association in a cohort of frail neonates.

METHODS

We performed an observational study within a randomized BCG trial conducted at the Neonatal Intensive Care Unit (NICU) in Guinea-Bissau from 2015-2017. At NICU admission and following informed consent, the maternal scar status was evaluated by visual inspection before neonates were randomized 1:1 to receive BCG + Oral Polio Vaccine (OPV) immediately versus BCG + OPV at hospital discharge. Stratified by maternal scar status, we assessed overall in-hospital and post-discharge mortality up to 42 days of age in Cox Proportional Hazards models providing adjusted Mortality Rate Ratios (aMRRs).

RESULTS

62% (903/1451) of mothers had a BCG scar. During NICU admission, the mortality risk was 1.7% (15/903) for neonates born to mothers with a scar vs 3.3% (18/548) for those born to mothers with no scar, the maternal scar/no scar aMRR = 0.53 (0.26-1.05); the aMRR was 0.39 (0.13-1.05) for unvaccinated neonates and 0.70 (0.26-1.87) for vaccinated neonates.

CONCLUSION

This small study indicates that maternal BCG might be associated with reduced all-cause NICU mortality. If confirmed elsewhere, this finding would have substantial ramifications for global health.

Biases in Survey Estimates of Neonatal Mortality: Results From a Validation Study in Urban Areas of Guinea-Bissau

Neonatal deaths (occurring within 28 days of birth) account for close to one-half of all deaths among children under age 5 worldwide. In most low- and middle-income countries, data on neonatal deaths come primarily from household surveys. We conducted a validation study of survey data on neonatal mortality in Guinea-Bissau (West Africa). We used records from an urban health and demographic surveillance system (HDSS) that monitors child survival prospectively as our reference data set. We selected a stratified sample of 599 women aged 15-49 among residents of the HDSS and collected the birth histories of 422 participants. We cross-tabulated survey and HDSS data. We used a mathematical model to investigate biases in survey estimates of neonatal mortality. Reporting errors in survey data might lead to estimates of the neonatal mortality rate that are too high, which may limit our ability to track progress toward global health objectives.

Immediate Bacille Calmette-Guérin vaccination to neonates requiring perinatal treatment at the maternity ward in Guinea-Bissau: A randomized controlled trial

BACKGROUND

Randomized controlled trials (RCTs) indicate that Bacille Calmette-Guérin (BCG) vaccination provides broad beneficial non-specific protection against infections. We investigated the effect on in-hospital mortality of providing BCG immediately upon admission to a neonatal intensive care unit (NICU), rather than BCG-at-discharge. The pre-trial NICU mortality was 13% and we hypothesized that BCG would reduce mortality by 40%.

METHODS

Parallel-group, open-label RCT initiated in 2013 in Guinea-Bissau. NICU-admitted neonates were randomized 1:1 to BCG+Oral Polio Vaccine (OPV) immediately (intervention) versus BCG+OPV at hospital discharge (control; usual practice). The trial was discontinued due to decreasing in-hospital mortality and major NICU restructuring. We assessed overall and disease-specific mortality by randomization allocation in Cox Proportional Hazards models providing Mortality Rate Ratios (MRRs).

RESULTS

We recruited 3,353 neonates and the overall mortality was 3.1% (52/1676) for BCG-vaccinated neonates versus 3.3% (55/1677) for controls, MRR=0.94 (0.64-1.36). For non-infectious causes of death the MRR was 1.20 (0.70-2.07) and there tended to be fewer deaths from infections in the BCG group (N=14) than among controls (N=21), MRR=0.65 (0.33-1.28).

CONCLUSIONS

Providing BCG+OPV to frail neonates was safe and might protect against fatal infection in the immediate newborn period. Deaths due to prematurity and perinatal complications were unaffected by BCG.

The trend and characteristics of stillbirth delivery in a university teaching hospital in Lagos, Nigeria

Background:

The burden of stillbirth is so huge in sub-Saharan Africa, especially in Nigeria where many mothers and mothers-to-be are denied the joy of motherhood. Despite the frequent occurrence of this obstetric problem in our environment, little priority is placed on it.

Objectives:

The study aims to bring to the fore, the burden, trend, and characteristics of stillbirth delivery in Lagos, Nigeria.

Subjects and Methods:

This was a 5-year descriptive retrospective study of the case records of women who had stillbirth delivery at Lagos University Teaching Hospital from January 2009 to December 2013. Relevant information was obtained using a study pro forma, and data analysis was carried out using SPSS version 20.0.

Results:

The prevalence of stillbirth was 6.2%, and the rate was 61.8/1000 total births. Women who did not book for antenatal care accounted for 76.2% of the cases, and the antenatal and intrapartum stillbirths accounted for 64.6% and 35.4%, respectively. The mean gestational age was 35.5 ± 1.2 weeks, while the mean birth weight was 2.9 ± 1.0 kg. Majority of the stillbirths were male fetuses (54.5%). Previous history of stillbirth (36.0%), hypertensive disorders in pregnancy (33.0%), placental abruption (28.8%), intrauterine growth restriction (13.0%), and ruptured uterus (11.3%) were the common clinical risk factors identified.

Conclusion:

The burden of stillbirth is high in our environment, and majority is due to preventable or manageable obstetric conditions. There is a need to encourage early referral of complicated pregnancies and labor to specialized centers that can cater for them, so as to avoid unnecessary and preventable deaths.

HIV-1 and HIV-2 prevalence, risk factors and birth outcomes among pregnant women in Bissau, Guinea-Bissau: a retrospective cross-sectional hospital study

The human immunodeficiency virus (HIV) remains a leading cause of maternal morbidity and mortality in Sub-Saharan Africa. Prevention of mother-to-child transmission (PMTCT) has proven an effective strategy to end paediatric infections and ensure HIV-infected mothers access treatment. Based on cross-sectional data collected from June 2008 to May 2013, we assessed changes in HIV prevalence, risk factors for HIV, provision of PMTCT antiretroviral treatment (ART), and the association between HIV infection, birth outcomes and maternal characteristics at the Simão Mendes National Hospital, Guinea-Bissau's largest maternity ward. Among 24,107 women, the HIV prevalence was 3.3% for HIV-1, 0.8% for HIV-2 and 0.9% for HIV-1/2. A significant decline in HIV-1, HIV-2, and HIV-1/2 prevalence was observed over time. HIV infection was associated with age and ethnicity. A total of 85% of HIV-infected women received ART as part of PMTCT, yet overall treatment coverage during labour and delivery declined significantly for both mothers and infants. Twenty-two percent of infants did not receive treatment, and 67% of HIV-2-infected mothers and 77% of their infants received ineffective non-nucleoside reverse transcriptase inhibitors for PMTCT. Maternal HIV was associated with low birth weight but not stillbirth. Inadequate continuity of care and ART coverage present challenges to optimal PMTCT in Guinea-Bissau.

The Guinea-Bissau Twin Registry Update: A Platform for Studying Twin Mortality and Metabolic Disease

Sub-Saharan Africa has the highest natural twinning rate in the world. Unfortunately, due to lack of adequate care during pregnancy, labor and postnatally, twin mortality in Sub-Saharan Africa also remains very high. Thus, it has been estimated that one in five twins dies during the childhood years. In spite of this, surprisingly few twin studies have been conducted in the region, making additional epidemiological data much needed. In 2009, we established one of the first twin registries in Sub-Saharan Africa at the Bandim Health Project in Guinea-Bissau. The registry had two main objectives. First, we wanted to describe the twinning rate and mortality patterns among newborn twins, including mortality risk factors and hospitalization patterns. Such studies can help the local clinicians improve twin health by identifying the most vulnerable children. Second, and in light of the rapidly increasing diabetes rates in Africa, we wanted to use the registry to particularly focus on metabolic disorders. Twins are often born with low birth weight, which according to the 'thrifty phenotype hypothesis' could predispose them to metabolic disorders later in life. Yet, no such 'fetal programming' data have previously been available from African twins despite the fact that nutritional patterns and influences from other factors (e.g., infections) could be markedly different here compared to high-income settings. In this article, we summarize the findings and current status of the Guinea-Bissau twin registry.