Use and non-adherence to antiretroviral therapy among Refugee HIV positive pregnant mothers aged 18-49 years in Kyangwali Refugee Camp, Western Uganda

Introduction

Refugee HIV positive mothers experience significant obstacles in accessing, utilizing and adhering to antiretroviral therapy (ART). Identifying ART non-adherence can help enforce interventions aimed at improving adherence and subsequently effectiveness of ART among the refugee mothers. We describe the use and the factors associated with non-adherence to ART among Refugee HIV positive pregnant mothers aged 18-49 years in Kyangwali Refugee Camp, Uganda.

Methods

We conducted a cross-sectional study among HIV positive pregnant mothers aged 18-49 years in Kyangwali refugee camp between May and June 2023. Using a structured questionnaire, we collected data on use, and factors associated with non-adherence to ART. We used modified Poisson regression analysis to determine factors associated with non-adherence to ART.

Results

Of the 380 participants enrolled, 192 (50.5%) were married, mean age 32.1 years. Overall, 98.7; 95% CI [97.5-99.8%] were using ART and 27.4; 95% CI [22.9-31.9%] were non-adherent. Non-adherence was associated with; Initiating PMTCT care in the third trimester of pregnancy (aPR: 2.06; 95% CI: 1.27-3.35), no need to get permission to seek PMTCT services aPR 1.61; 95% CI [1.07-2.42] and poor attitude of PMTCT providers aPR 1.90; 95% CI [1.20-3.01].

Conclusion and recommendations

Non-adherence to ART was generally high; therefore limiting the effectiveness of the PMTCT program in this setting. Refugee context specific education interventional programs aimed at early initiation into HIV care, strong social and psychological support from families, communities and health care providers are vital to improve adherence this setting.

What do mothers think about their antenatal classes? A mixed-method study in Switzerland

PROBLEM

Research so far has evaluated the effect of antenatal classes, but few studies have investigated its usefulness from the perspective of mothers after birth.

BACKGROUND

Antenatal classes evolved from pain management to a mother-centred approach, including birth plans and parenting education. Evaluating the perception of the usefulness of these classes is important to meet mother's needs. However, so far, research on the mothers' perception of the usefulness of these classes is sparse, particularly when measured after childbirth. Given that antenatal classes are considered as adult education, it is necessary to carry out this evaluation after mothers have had an opportunity to apply some of the competences they acquired during the antenatal classes during their childbirth.

AIM

This study investigated mothers' satisfaction and perceived usefulness of antenatal classes provided within a university hospital in Switzerland, as assessed in the postpartum period.

METHODS

Primiparous mothers who gave birth at a Swiss university hospital from January 2018 to September 2020 were contacted. Those who had attended the hospital's antenatal classes were invited to complete a questionnaire consisting of a quantitative and qualitative part about usefulness and satisfaction about antenatal classes. Quantitative data were analysed using both descriptive and inferential statistics. Qualitative data were analysed using thematic analysis.

FINDINGS

Among the 259 mothers who answered, 61% (n = 158) were globally satisfied with the antenatal classes and 56.2% (n = 145) found the sessions useful in general. However, looking at the utility score of each theme, none of them achieved a score of usefulness above 44%. The timing of some of these sessions was questioned. Some mothers regretted the lack of accurate information, especially on labour complications and postnatal care.

DISCUSSION

Antenatal classes were valued for their peer support. However, in their salutogenic vision of empowerment, they did not address the complications of childbirth, even though this was what some mothers needed. Furthermore, these classes could also be more oriented towards the postpartum period, as requested by some mothers.

CONCLUSION

Revising antenatal classes to fit mothers' needs could lead to greater satisfaction and thus a better impact on the well-being of mothers and their families.

Examining individual social status using the MacArthur Scale of Subjective Social Status: Findings from the Born in Bradford study

Subjective social status is how a person perceives their social class relative to other people and has frequently been associated with people's health and well-being. A frequently used measure of subjective social status is the MacArthur Scale of Subjective Social Status that depicts social status as a 10 rung ladder, asking individuals to rank themselves on this ladder relative to other people, either in their local neighbourhood or wider society. The Born in Bradford's Better Start birth cohort study aims to understand the lives, relationships, wellbeing, and social and economic circumstances of pregnant women and their children in three inner city areas of Bradford, UK. Pregnant mothers were asked to report their subjective social status, using the MacArthur subjective social status scales, comparing themselves to other people in their local neighbourhood and in England as a whole. This paper explores the characteristics of the women who gave responses, examines associations between the MacArthur subjective social status measures and other subjective and objective measures and looks specifically at the characteristics of women who reported either very low or very high subjective social status. On average, women reported that they had a higher social status compared to others within their local neighbourhood (mean ladder rung = 6) and, although participants were from areas of Bradford with very high levels of deprivation, 23% placed themselves on the top three rungs, 8-10. Respondents reported that they had an average social status when comparing themselves to people in all of England (mean ladder rung = 5) and 13% placed themselves on the top rungs 8-10. These findings raise important questions about the interpretation of the MacArthur scale of subjective social status.

Preferred mode of delivery and its associated factors in pregnant women with a previous cesarean scar at a tertiary care hospital in Ethiopia: institutional-based cross-sectional study

BACKGROUND

Vaginal births after cesarean or elective repeat cesarean sections (CS) are the options for delivery after one cesarean scar. However, there is a lack of data regarding the preferred next mode of delivery in Ethiopia after a previous cesarean section. Thus, this study assessed the preferred mode of delivery and determinants after one previous CS in the antenatal clinic at the University of Gondar Comprehensive Specialized Hospital (UoGCSH).

METHODS

An institutional-based cross-sectional study was conducted among pregnant mothers with one previous CS at UoGCSH from March to August 2022. Structured questionnaires were used to collect the data. The collected data were entered, cleaned, and edited using Epi-data 4.6 and exported to SPSS version 26 for analysis. A binary logistic regression was performed to assess the determinants of the preferred mode of delivery. A p-value of < 0.05 at the 95% confidence level (CI) was considered statistically significant.

RESULTS

The majority, 71.5% (95% CI: 64.7, 77.1), of participants preferred the trial of labor after cesarean (TOLAC) as their mode of delivery. Mothers who were married (AOR = 4.47, 95% CI: 1.19-16.85), had a diploma educational level (AOR = 3.77, 95% CI: 1.84-12.36), had previous post-cesarean complications (AOR = 3.25, 95% CI: 1.08-9.74), and knew about the success of the trial of labor after cesarean (AOR = 13.56, 95% CI: 4.52-37.19) were found to prefer the trial of labor compared with their counterparts.

CONCLUSION

This study concluded that most pregnant mothers preferred labor trials after one CS, which is a bit lower but comparable with recommended practice guidelines. Providing adequate information and counseling mothers to make informed decisions about their preferred mode of delivery could be substantial.

Antibiotic Sensitivity of Group B Streptococcus from Pregnant Mothers and Its Association with Resistance Genes

OBJECTIVE

This study assessed the antibiotic susceptibility and characterized antibiotic resistance genes of group B Streptococcus (GBS) isolates from selected tertiary care hospitals in Western Province, Sri Lanka.

METHODS

A descriptive cross-sectional study was carried out to determine antibiotic sensitivity of GBS among 175 pregnant women of >35 weeks of gestation attending antenatal clinics in four teaching hospitals. Low vaginal and rectal swabs were collected separately, and GBS was identified by standard microbiological methods. Antibiotic sensitivity and minimum inhibitory concentration (MIC) were performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines. DNA was extracted from culture isolates, and antibiotic-resistant genes were identified by polymerase chain reaction using ermB, ermTR, mefA, and linB genes.

RESULTS

GBS colonization in the study sample was 25.7% (45/175) with detection rate of 22.9% (40/175) and 2.9% (5/175) in vaginal and rectal samples, respectively. All isolates were susceptible to penicillin with an MIC range of 0.03-0.12 μg/mL. Six isolates (13.3%) were intermediate, and 11 isolates (24.4%) were resistant to erythromycin. There were 5 intermediately resistant isolates (11.1%) and 10 resistant isolates (22.2%) for clindamycin. Of them, seven had inducible clindamycin resistance (iMLSB). MIC range of erythromycin was 0.03-0.32 μg/mL and that of clindamycin was 0.06-0.32 μg/mL. ermB gene was detected in 7 (15.5%). ermTR gene was found in 16 (35.6%) and was significantly associated with iMLSB phenotype (p = 0.005). mefA gene was detected in two (4.4%) isolates, while linB gene was not detected in tested isolates.

CONCLUSION

All isolates were sensitive to penicillin, and the most prevalent resistance genotype was ermTR in the study population.

Prevalence and associated factors of delay antenatal care at public health institutions in Gondar city, Northwest Ethiopia, 2021: a cross-sectional study

BACKGROUND

Antenatal care is critical for women's and unborn children's health. In Ethiopia there is still a delay in getting antenatal care visit in the first trimester as recommended by the World Health Organization. Therefore, the purpose of this study was to assess the prevalence of delayed antenatal care visits and associated factors among pregnant women who attend antenatal care at a public health facility in Gondar town, Northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted between August 20 to September 15/2021. A simple random sampling technique was used to select 392 women. Data were collected using a pre-tested structured questionnaire through a face-to-face interview. Epi Info version 7 and SSPS 26.0 were used for data entry and further analysis. Descriptive statistics and multivariable logistic regression analyses were performed. An adjusted odds ratio with 95% confidence interval at p-value < 0.05 was declared that the outcome can be statistically significant.

RESULTS

A total of 392 study participants with a response rate of 98% were participated. The mean age of study participants was 29.1 ± 6.5 (SD) years. In this study, the prevalence of delay antenatal care was 63.8%( 95% CI: 58.9, 68.9). Age (Adjusted odds ratio = 0.51; 95% CI: 0.28, 0.93), types of health facilities (Adjusted odds ratio = 2.02; 95% CI :( 1.12, 3.64), and satisfaction with health service (Adjusted odds ratio = 3.23, 95%CI: (2.02, 5.16) were significantly associated with delay antenatal care.

CONCLUSION

The current study found high prevalence of delay antenatal care. Age between 31 and 34, hospital health facility and satisfaction with health service quality were associated factors for delay antenatal care visit. To begin antenatal care follow-up in the recommended time frame, a collaborative effort between the Minister of Health, health facilities, and relevant stakeholders is needed.

Perceived risks of over-the-counter medication use among pregnant Saudi mothers: A cross-sectional study

Objectives

Many women use over-the-counter (OTC) medicines, particularly during pregnancy. Therefore, this study investigated the perceived risks of using OTC medicines among pregnant Saudi mothers.

Methods

With a cross-sectional design and purposive sampling, the 28-item Drug Use Health Belief Scale was used to collect data from pregnant Saudi mothers (n = 366) in a general tertiary hospital. The data were analyzed with descriptive and inferential statistics. After normality testing, the percentages, mean scores, and standard deviations were used to examine the demographic data. One-way ANOVA was used to identify the relationships between perceived risks on the Health Belief Scale and the participants' sociodemographic profile variables. Post-hoc tests were used to identify differences in the independent variables among groups. The statistical significance threshold was set at p ≤ 0.05.

Results

Across the five domains of the Health Belief Scale, the perceived susceptibility domain had the highest rank (0.36). Significant differences were observed between the mean scores of pregnant Saudi mothers' perceptions of susceptibility and the benefits of using OTC medications (p = 0.05), perceptions of susceptibility (p < 0.001), and benefits while using OTC medications (p = 0.018) than those who did not use OTC medications. However, no significant differences were observed in the degree of perceived severity, barriers, and self-efficacy in mothers using OTC medications (p > 0.05).

Conclusion

Notable differences were found in pregnant women's perceptions of the risks of using OTC medications. Greater awareness of the risks of OTC medication use during pregnancy is required. To ensure mothers' safety, a collaboration between prenatal multidisciplinary team of professionals (e.g., doctors, nurses, midwives) in community and hospital settings should be prioritized.

Association study of rs1801282 PPARG gene polymorphism and immune cells and cytokine levels in a Spanish pregnant women cohort and their offspring

Background

Peroxisome proliferator activated receptor gamma (PPARG) belongs to the nuclear receptor superfamily functioning as transcription factors to regulate cellular differentiation, development and metabolism. Moreover, it has been implicated in the regulation of lipid metabolism, as well as the maturation of monocytes/macrophages and the control of inflammatory reactions. The aim of this study was to evaluate the relationship between the Pro12Ala (rs1808212) PPARG gene polymorphism on immune molecular and cellular components in mothers and their offspring participating in the PREOBE study.

Methods

DNA from maternal venous blood samples at 24, 34 and 40 gestational weeks, plus cord blood samples was extracted. Pro12Ala PPARG polymorphism genotyping was performed, and immune system markers were analyzed by flow cytometry.

Results

Study findings revealed no effect of rs1808212 PPARG genotypes on innate immune parameters in mothers and their offspring; however, CD4 + /CD8 + ratio were decreased at 24 and 34 weeks in pregnant women carrying the CG (Pro12Ala) rs1808212 polymorphism, (p = 0,012 and p = 0,030; respectively). Only CD19 levels in peripheral blood were significantly higher at delivery in pregnant women carrying the CC (Pro12Pro) genotype (p ≤ 0.001). Moreover, there were statistically significant differences in leukocytes and neutrophils maternal levels at 34 weeks of gestation, being lower in carriers of Pro12Ala genotype (p = 0.028 and p = 0.031, respectively).

Conclusions

Results suggest that Pro12Ala PPARG polymorphism may have an effect on some cell and immune parameters in pregnant women during pregnancy and at time of delivery. However, newborn innate immune system does not seems to be influenced by PPARG Pro12Ala polymorphism in cord blood.

Sero-prevalence of human immunodeficiency virus-hepatitis B virus (HIV-HBV) co-infection among pregnant women attending antenatal care (ANC) in sub-Saharan Africa (SSA) and the associated risk factors: a systematic review and meta-analysis

Background

There is plenitude of information on HIV infection among pregnant mothers attending antenatal care (ANC) in sub-Saharan Africa. However, the epidemiology of HBV–HIV co-infections in the same cohort is not clear despite the common route of transmission of both viruses. The aim of our study was to synthesize data on the prevalence of HBV–HIV co-infection among pregnant women attending ANC in Sub-Saharan Africa to assist in the design of public health interventions to mitigate the challenge.

Methods

The study was done in tandem with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards and the Cochran’s Q test, I² statistics for heterogeneity and the prevalence were calculated using commercially available software called MedCalcs (https://www.medcalc.org). A random effect model was used to pool the prevalence since all the heterogeneities were high (≥ 78%) and P_het < 0.05 indicated significant heterogeneities. The risk factors and risk differences for HBV–HIV co-infection were analyzed. Any likely sources of heterogeneity were analyzed through sensitivity analysis, meta-regression and sub-group analysis. All analyses were done at 95% level of significance and a P < 0.05 was considered significant.

Results

The overall pooled prevalence of HBV–HIV co-infection among pregnant mothers in sub-Saharan Africa was low 3.302% (95%CI = 2.285 to 4.4498%) with heterogeneities (I²) of 97.59% (P > 0.0001). Within regional sub group meta-analyses, West Africa had significantly higher prevalence of 5.155% (95% = 2.671 to 8.392%) with heterogeneity (I²) of 92.25% (P < 0.0001) than any other region (P < 0.001). Articles published from 2004–2010 had significantly higher prevalence of 6.356% (95% = 3.611 to 9.811%) with heterogeneity (I²) 91.15% (P < 0.0001) compared to those published from 2011 to 2019 (P < 0.001). The HIV positive cohort had significantly higher prevalence of HBV–HIV co-infection of 8.312% (95% CI = 5.806 to 11.22%) with heterogeneity (I²)94.90% (P < 0.0001) than the mothers sampled from the general population with a prevalence of 2.152% (95% CI = 1.358 to 3.125%) (P < 0.001). The overall and sub group analyses had high heterogeneities (I² > 89%, P < 0.0001) but was reduced for South Africa (I²) = 78.4% (P = 0.0314). Age, marital status and employment were independent factors significantly associated with risk of HBV–HIV co-infection (P < 0.001) but not extent of gravidity and education level (P > 0.05). After meta-regression for year of publication and sample size for HBsAg positivity, the results were not significantly associated with HBV pooled prevalence for sample size (P = 0.146) and year of publication (P = 0.560). Following sensitivity analysis, the HBsAg pooled prevalence slightly increased to 3.429% (95% CI = 2.459 to 4.554%) with heterogeneity I² = 96.59% (95% CI = 95.93 to 97.14%), P < 0.0001

Conclusion

There is an urgent need for routine HBV screening among HIV positive pregnant mothers attending antenatal care in sub-Saharan Africa to establish the extent of HBV–HIV co-infection in this cohort. Future studies need to investigate the putative risk factors for HBV–HIV co-infection and prioritize plausible control strategies.

Antenatal depression and its potential causal mechanisms among pregnant mothers in Gondar town: application of structural equation model

BACKGROUND

Various forms of life stressors have been implicated as causes of antenatal depression. However, there is a lack of understanding of which forms of stress lead to antenatal depression and through what mechanisms. Modeling stress processes within a theoretical model framework can enhance an understanding of the mechanisms underlying relationships between stressors and stress outcomes. This study used the stress process model framework to explore the causal mechanisms underlying antenatal depression in Gondar, Ethiopia.

METHODS

Questionnaires, using an Online Data collection Kit (ODK) tool were administered face-to-face in 916 pregnant women in their second and third trimesters. Pregnant women were included from six randomly selected urban districts in Gondar, Ethiopia during June and August 2018. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for antenatal depression. A Structural Equation Model (SEM) was employed to explore the direct, indirect, and total effect of stressors and mediators of antenatal depression.

RESULT

Sixty-three participants (6.9%) reported symptoms of depression. Of these, 16 (4.7%) and 47 (8.1%) were in their second and third trimesters, respectively. The SEM demonstrated several direct effects on antenatal depression scores including unplanned pregnancy (standardized β = 0.15), having a history of common mental health disorder (standardized β = 0.18) and fear of giving birth to the current pregnancy (standardized β = 0.29), all of which were associated with a higher depression score. Adequate food access for the last 3 months (standardized β = - 0.11) was associated with decreased depression score. Social support (β = - 0.21), marital agreement (β = - 0.28), and partner support (β = -.18) appeared to partially mediate the link between the identified stressors and the risk of antenatal depression.

CONCLUSION

Both direct and indirect effects contributed to higher antenatal depression score in Ethiopian women. The three psychosocial resources namely marital agreement, social and partner support, mediated reduced antenatal depression scores. Early screening of antenatal depression and enhancing the three psychosocial resources would help to improve maternal resilience.

Prevalence of common mental disorder and associated factors among pregnant women in South-East Ethiopia, 2017: a community based cross-sectional study

Background

Mothers suffering from common mental disorder (CMD), such as anxiety and depression may not be able to function properly, which could adversely affect the mother-infant bond and even result in increased infant morbidity and mortality. The purpose of this study was to assess the prevalence of CMD and its determinants among pregnant women in Southeast Ethiopia.

Methods

Data was collected from 743 pregnant women via interview-administered, standardised questionnaires during Dec–Jan 2017. The WHO Self-Reported Questionnaire (SRQ) was used to screen CMD. Multivariate logistic regression was conducted and ORs and 95% confidence intervals were calculated.

Results

The prevalence of CMD during pregnancy was 35.8% (95% CI: 34–38%) and the main determinants of CMD were: illiteracy, presence of health risk, financial instability, physical or emotional abuse, having sexual intercourse without her willingness, family history of psychiatric illness and history of chronic medical illness.

Conclusion

CMD prevalence during pregnancy was high, indicating a need to regularly screen pregnant women for CMD and its determinants as part of routine obstetric care.

Awareness of obstetric warning signs in Ecuador: a cross-sectional study

OBJECTIVE

In Ecuador, the reported maternal death rate was 45.71 per 100,000 live births in 2013. This may be partly due to a lack of maternal knowledge of obstetric warning signs during pregnancy, delivery and the post-partum period. This study sought to evaluate awareness of obstetric warning signs among pregnant women in relation to individual demographic and area-level socio-economic indicators.

STUDY DESIGN

We conducted a cross-sectional analysis of data collected by Ecuador's Ministry of Health at the conclusion of a national maternal health campaign (2014-2015). A nationally representative sample of 3435 pregnant women from the nine administrative zones completed surveys regarding basic demographics and their awareness of obstetric warning signs.

METHODS

We defined eight obstetrical warning signs according to the literature and Ecuadorian practice that could occur during pregnancy, delivery and the post-partum period (severe headache, strong abdominal ache, bleeding or presence of malodorous secretion, rupture of the amniotic sac, high fever, abnormal presentation of the baby, decrease in baby's movements and delayed labour). A woman was considered 'aware' if she recognised at least four of the eight warning signs and stated she would seek immediate healthcare at their presentation. For each administrative zone, four socio-economic indicators (poverty, illiteracy, unemployment and subemployment) were obtained from the National Institute of Statistics and Census. Correlates of awareness of the obstetric warning signs were evaluated using hierarchical logistic models clustered by the administrative zone.

RESULTS

Nationally, 86.9% of women were 'aware' of obstetric warning signs. After adjustment for age, socio-economic indicators and clustering, indigenous participants were 59% less likely to be aware of obstetric warning signs than mestizos (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.28-0.59). For every 1% increase in area poverty, participants had a 5% decreased likelihood of being aware of obstetric warning signs (OR = 0.95, 95% CI = 0.93-0.96), adjusting for age, ethnicity and other socio-economic indicators. The most effective source of campaign information about obstetric warning signs was personal communication with a healthcare professional, as opposed to mass media advertisements (OR = 1.90, 95% CI = 1.34-2.71).

CONCLUSIONS

A majority of Ecuadorian pregnant and post-partum women are aware of obstetric warning signs. Indigenous ethnicity and area-level poverty are associated with a lack of awareness. Personal communication with a healthcare professional was the most effective source of information. These findings have implications for improvement of maternal awareness of warning signs.

Utilization of HIV testing services among pregnant mothers in low income primary care settings in northern Ethiopia: a cross sectional study

Background

HIV testing of women in child bearing age is an entry point for preventing mother-to-child transmission of HIV (MTCT). This study aims to identify the proportion of women tested for HIV and to determine factors associated with utilization of HIV testing services among pregnant mothers in primary care settings in northern Ethiopia.

Methods

A cross sectional study was conducted in 416 pregnant women from four primary care centers between October 2, 2012 and May 31, 2013 in East Gojjam, Ethiopia.

Results

The proportion of mothers who tested for HIV was 277(67%). Among mothers who were not tested for HIV, lack of HIV risk perception (n = 68, 49%) was a major self-reported barrier for HIV testing. A multivariable logistic regression analysis showed that those pregnant women who had comprehensive knowledge about MTCT had an Adjusted Odd Ratio (AOR) of 3.73 (95% CI: 1.56, 8.94), having comprehensive knowledge on prevention of mother to child transmission (PMTCT) of HIV an AOR of 2.56 (95% CI: 1.26, 5.19), and a favorable attitude towards persons living with HIV an AOR of 2.42 (95%CI, 1.20, 4.86) were more likely to be tested for HIV.

Conclusion

One third of pregnant women had never been tested for HIV until the time of the study. Efforts should be made to improve mother’s knowledge about MTCT and PMTCT to increase uptake of HIV testing. Enhancing mother’s HIV risk perception to scale up HIV testing in resource limited setting is highly recommended.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1389-2) contains supplementary material, which is available to authorized users.

Global Reduction in HIV-related Maternal Mortality: ART as a Key Strategy

Dr. Holtz and colleagues present a synthesis of evidence from published studies over the previous decade on the collective impact of HIV-targeted interventions on maternal mortality. Amongst an assortment of interventions [that include antiretroviral therapy (ART), micronutrients (multivitamins, vitamin A and selenium), and antibiotics], only ART reduced maternal mortality among HIV-infected pregnant and post-partum mothers. These findings have fundamental and global strategic implications. They are also timely since they provide the evidence that ART reduces HIV-related maternal mortality, and by further enhancing access to ART in HIV-challenged and poor regions of the world, significant improvement in maternal morbidity and mortality indices could be attained. The paper bears good tidings and sound scientific proof that the financial investment made globally by government and non-governmental organizations and agencies to reduce the global burden of HIV/AIDS primarily by making ART more accessible to regions of the world most affected by the epidemic is beginning to show beneficial effects not only in terms of numerical reductions in the rates of new cases of HIV/AIDS among women, but also in maternal mortality levels.