Which Intervention Synergies Maximize AGYW's HIV Outcomes? A Classification and Regression Tree Analysis of Layered HIV Prevention Programming

INTRODUCTION

Intersecting behavioral, social, and structural factors increase adolescent girls' (AG) and young women's (YW) HIV vulnerability. Yet, understanding of optimal intervention synergies remains limited. We identified intervention combinations that statistically maximized reductions in AGYW's HIV-related risk.

METHODS

Using data collected in 2018 with Zambian AG (n = 487, aged 15-19 years) and YW (n = 505, aged 20-25 years) after 12-14 months exposure to Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (multisectoral HIV program), we used classification and regression trees to explore relationships between interventions (safe space/social asset building [SAB] and provision of/linkage to youth-friendly health services [YFHS], education social protection [Educ], economic social protection [Econ]) and HIV-related outcomes (HIV testing, consistent condom use, transactional sex, and sexual violence experience from partners and nonpartners).

RESULTS

Overall, 59.9% completed SAB and 81.5%, 35.4%, and 29.6% received YHFS, Educ, and Econ, respectively. For AG, HIV testing improved (from 73% to 83%) with exposure to all interventions, condom use improved with Econ (from 33% to 46%), transactional sex reduced with SAB + Educ, and sexual violence from partners and nonpartners reduced with Educ and SAB, respectively. For YW, HIV testing increased with Educ (from 77% to 91%), condom use increased with SAB + YFHS (from 36% to 52%), transactional sex reduced with combinations of all interventions, and sexual violence from partners reduced with YFHS and from nonpartners with SAB + Econ.

CONCLUSIONS

Tailored interventions might be more effective than uniform combination intervention packages in reducing AGYW's HIV risk. AG benefitted most from SAB and/or Educ while YFHS, Educ, and/or SAB reduced YW's HIV-related risk. Educational and asset-building interventions could have the greatest impact on AGYW's HIV risk.

New Antenatal Model in Africa and India (NAMAI) study: implementation research to improve antenatal care using WHO recommendations

BACKGROUND

In 2020, an estimated 287 000 women died globally from pregnancy-related causes and 2 million babies were stillborn. Many of these outcomes can be prevented by quality healthcare during pregnancy and childbirth. Within the continuum of maternal health, antenatal care (ANC) is a key moment in terms of contact with the health system, yet it remains an underutilized platform. This paper describes the protocol for a study conducted in collaboration with Ministries of Health and country research partners that aims to employ implementation science to systematically introduce and test the applicability of the adapted WHO ANC package in selected sites across four countries.

METHODS

Study design is a mixed methods stepped-wedge cluster randomized implementation trial with a nested cohort component (in India and Burkina Faso). The intervention is composed of two layers: (i) the country- (or state)-specific ANC package, including evidence-based interventions to improve maternal and newborn health outcomes, and (ii) the co-interventions (or implementation strategies) to help delivery and uptake of the adapted ANC package. Using COM-B model, co-interventions support behaviour change among health workers and pregnant women by (1) training health workers on the adapted ANC package and ultrasound (except in India), (2) providing supplies, (3) conducting mentoring and supervision and (4) implementing community mobilization strategies. In Rwanda and Zambia, a fifth strategy includes a digital health intervention. Qualitative data will be gathered from health workers, women and their families, to gauge acceptability of the adapted ANC package and its components, as well as experience of care. The implementation of the adapted ANC package of interventions, and their related costs, will be documented to understand to what extent the co-interventions were performed as intended, allowing for iteration.

DISCUSSION

Results from this study aim to build the global evidence base on how to implement quality ANC across different settings and inform pathways to scale, which will ultimately lead to stronger health systems with better maternal and perinatal outcomes. On the basis of the study results, governments will be able to adopt and plan for national scale-up, aiming to improve ANC nationally. This evidence will inform global guidance.

TRIAL REGISTRATION NUMBER

ISRCTN, ISRCTN16610902. Registered 27 May 2022. https://www.isrctn.com/ISRCTN16610902.

Developing and Testing a Chatbot to Integrate HIV Education Into Family Planning Clinic Waiting Areas in Lusaka, Zambia

BACKGROUND

To maximize protection against both unintended pregnancy and HIV, it is important that family planning (FP) services integrate HIV counseling, both to support method choice and identify potential HIV services of interest, such as pre-exposure prophylaxis (PrEP). However, FP providers often lack sufficient time and knowledge to address HIV vulnerability with clients. To potentially offload some of the initial HIV counseling burden from FP providers, we developed and tested a chatbot that provided information about HIV and dual protection to FP clients in waiting areas of FP clinics in Lusaka, Zambia.

CHATBOT DEVELOPMENT

We drafted a scripted conversation and tested it in English in formative workshops with Zambian women between the ages of 15 and 49 years. After translating the content to Bemba and Nyanja, we conducted a second round of workshops to validate the translations, before uploading the content into the chatbot platform.

CHATBOT USER TEST

Thirty volunteers tested the chatbot in 3 Lusaka FP clinics, completing an exit survey to provide feedback. A large majority (83%) said they learned new HIV information from the chatbot. Twenty (67%) learned about PrEP for the first time through the chat. Most (96%) reported discussing HIV with the provider, after engaging with the chatbot. In response to an open-ended question, several testers volunteered that they wanted to learn more about PrEP.

CONCLUSIONS

Pre-consultation waiting-area time is an underutilized opportunity to impart HIV information to FP clients, thereby preparing them to discuss their dual HIV and pregnancy prevention needs when they see their providers. FP clients expressed particular interest in learning more about PrEP, underscoring the importance of integrating HIV into FP services.

Perspectives of Adolescent Girls and Young Women on Optimizing Youth-Friendly HIV and Sexual and Reproductive Health Care in Zambia

Youth-friendly health care delivery models are needed to address the complex health care needs of adolescent girls and young women (AGYW). The aim of this study is to explore the lived experiences of AGYW seeking comprehensive HIV and sexual and reproductive health (SRH) care and to elicit their preferences for integrated health care services. We conducted in-depth interviews and focus group discussions in Lusaka, Zambia among 69 AGYW aged 10-20 who were HIV-negative or of unknown status and 40 AGYW aged 16-24 living with HIV. The data were coded through deductive and inductive processes and analyzed thematically using modified World Health Organization (WHO) dimensions of quality for youth-friendly services. AGYW expressed preference for one-stop clinics with integrated services that could provide HIV services along with other services such as pregnancy testing and family planning. AGYW also wanted information on staying healthy and approaches to prevent disease which could be delivered in the community setting such as youth clubs. An integrated clinic should address important attributes to AGYW including short wait time, flexible opening hours, assurance of confidentiality and positive staff attitudes. Youth-friendly, integrated care delivery models that incorporate AGYW preferences may foster linkages to care and improve outcomes among vulnerable AGYW.

Family Support for Adolescent Girls and Young Women Living With HIV in Zambia: Benefits, Challenges, and Recommendations for Intervention Development

ABSTRACT

Lack of family involvement is barrier to antiretroviral therapy adherence among adolescent girls and young women (AGYW). This study assessed family support for AGYW's engagement along the HIV care continuum to inform the design of a family-focused intervention in Lusaka, Zambia. We conducted 16 in-depth interviews and four focus group discussions with 40 AGYW living with HIV. Three strategies were identified to strengthen family support. First, emotional and instrumental support are highly valued by AGYW and should be further developed or reinforced. Second, AGYW wanted more informational support and open discussion of HIV from family, and an intervention should aim to enhance these types of support. Third, existing appraisal support reinforced anticipated stigma among AGYW and discouraged disclosure, yet participants wished for more interactions with peers living with HIV. Appraisal support should therefore be reframed to help AGYW decide to whom they should disclose and how to do so safely.

Integrated Care Delivery for HIV Prevention and Treatment in Adolescent Girls and Young Women in Zambia: Protocol for a Cluster-Randomized Controlled Trial

Background

Among countries in sub-Saharan Africa, Zambia has one of the highest incidences of HIV. Adolescent girls and young women (AGYW) are a particularly affected group because of their social and economic vulnerability.

Objective

The goal of this study is to test a multilevel package of interventions at the community and health system levels in Zambia in order to connect AGYW with a source of regular care, which will in turn allow for sustainable, successful implementation of regular HIV testing and adherence to antiretroviral treatment.

Methods

We will adapt prior tools to create the SHIELD (Support for HIV Integrated Education, Linkages to Care, and Destigmatization) intervention to educate and empower Zambian AGYW of 10-24 years of age and their families and to create community-based youth clubs to foster peer support. We will also develop integrated wellness care clinics to offer a youth-friendly environment that provides tailored clinical services. We will perform formative research, including focus groups and in-depth interviews, among AGYW, caregivers, and stakeholders to help inform the development and tailoring of the interventions. A cluster-randomized controlled trial will be implemented in Lusaka, with six clinic catchment areas randomized into three groups: zones with integrated wellness care clinics and SHIELD intervention, zones with only SHIELD intervention, and control zones with no intervention. We will assess HIV testing among the HIV-negative or unknown (HIV-/u) cohort, and retention in care along with viral load suppression will be evaluated in the HIV-positive (HIV+) cohort. We will use in-depth interviews and surveys to collect staff and stakeholder feedback after the trial. Cost-effectiveness of the interventions and return-on-investment impacts will be quantified using a microsimulation model.

Results

Interim results are expected in 2021, and the final results are expected in 2022. If this multilevel intervention is successful in establishing a comprehensive care continuum for HIV-affected AGYW, the Zambian Ministry of Health may advocate for expansion to additional settings to support national scale-up.

Conclusions

This integrated service delivery model can also be a platform to implement additional preventive services, so HIV-/u and HIV+ AGYW can receive comprehensive, integrated services.

Trial Registration

ClinicalTrials.gov NCT03995953; https://clinicaltrials.gov/ct2/show/NCT03995953

International Registered Report Identifier (IRRID)

PRR1-10.2196/15314

How can we improve the use of essential evidence-based interventions?

Between 250,000-280,000 women die worldwide during pregnancy and childbirth each year and children in low- and middle-income countries are 56 times more likely to die before the age of 5 than children in high-income countries. This Editorial discusses the publishing of a supplement within Reproductive Health titled Essential interventions for maternal, newborn and child health which aims to provide a scientific basis to the recommended interventions along with implementation strategies and proposed packages of care.

Preventing child marriages: first international day of the girl child "my life, my right, end child marriage"

On 17 November 2011, the United Nations General Assembly adopted a resolution (A/RES/66/170) designating 11 October as the first International Day of the Girl Child choosing ending child marriages as the theme of the day. Child marriage is a fundamental human rights violation and impacts all aspects of a girl's life. These marriages deny a girl of her childhood, disrupts her education, limits her opportunities, increases her risk of violence and abuse, and jeopardizes her health. The article presents data about the prevalence and effects, contributing factors and recommends action for prevention.

Sexual and reproductive health services for people living with HIV: a systematic review

People living with HIV often have unmet needs for sexual and reproductive health (SRH) services. We present results of a systematic review of studies offering SRH services targeted to people living with HIV. Studies were selected from a broader SRH and HIV linkages review. Inclusion criteria included: (1) peer-reviewed journal articles with a pre-post or multiple-arm study design; (2) reported post-intervention evaluation data; and (3) published 1 January 1990 through 31 December 2007. Nine studies were identified with an average rigour score of 5.1 out of 9. Services included family planning (one study), sexually transmitted infection (STI) services (two studies), combined family planning and STI services (three studies) and multiple services (three studies). The review identified mostly positive effects on the outcomes measured, including condom and contraceptive use and quality of services. Yet gaps remain in the research to establish the best approaches for addressing needs and choices of people living with HIV. There is a need for high-quality intervention studies to determine the most successful and cost-effective strategies for providing SRH services to people living with HIV.

Linking sexual and reproductive health and HIV interventions: a systematic review

BACKGROUND

The international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to both sexual and reproductive health (SRH) services and HIV/AIDS prevention, treatment, care and support. Recently, there has been increasing awareness and discussion of the possible benefits of linkages between SRH and HIV programmes at the policy, systems and service delivery levels. However, the evidence for the efficacy of these linkages has not been systematically assessed.

METHODS

We conducted a systematic review of the evidence for interventions linking SRH and HIV. Structured methods were employed for searching, screening and data extraction. Studies from 1990 to 2007 reporting pre-post or multi-arm evaluation data from SRH-HIV linkage interventions were included. Study design rigour was scored on a nine-point scale. Unpublished programme reports were gathered as "promising practices".

RESULTS

Of more than 50,000 citations identified, 185 studies were included in the review and 35 were analyzed. These studies had heterogeneous interventions, populations, objectives, study designs, rigour and measured outcomes. SRH-HIV linkage interventions were generally considered beneficial and feasible. The majority of studies showed improvements in all outcomes measured. While there were some mixed results, there were very few negative findings. Generally, positive effects were shown for key outcomes, including HIV incidence, sexually transmitted infection incidence, condom use, contraceptive use, uptake of HIV testing and quality of services. Promising practices (n = 23) tended to evaluate more recent and more comprehensive programmes. Factors promoting effective linkages included stakeholder involvement, capacity building, positive staff attitudes, non-stigmatizing services, and engagement of key populations.

CONCLUSIONS

Existing evidence provides support for linkages, although significant gaps in the literature remain. Policy makers, programme managers and researchers should continue to advocate for, support, implement and rigorously evaluate SRH and HIV linkages at the policy, systems and service levels.

Sexual and reproductive health in HIV-related proposals supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria

OBJECTIVE

To assess the sexual and reproductive health interventions included by countries in HIV-related proposals approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

METHODS

We examined the Global Fund database for elements and indicators of sexual and reproductive health in all approved HIV-related proposals (214) submitted by 134 countries, from rounds 1 to 7, and in an illustrative sample of 35 grant agreements.

FINDINGS

At least 70% of the HIV-related proposals included one or more of the four broad elements: sexual and reproductive health information, education and communication; condom promotion/distribution; diagnosis and treatment of sexually transmitted infections; and prevention of mother-to-child transmission of HIV. Between 20% and 30% included sexual health counselling, gender-based violence, and the linking of voluntary counselling and testing for HIV with sexual and reproductive health services. Less than 20% focused on adolescent sexual and reproductive health, the rights and needs of people living with HIV, or safe abortion services. All these elements were rarely featured, if at all, in the grant agreements reviewed. Overall, however, sexual and reproductive health indicators did appear in most HIV-related proposals and in more than 80% of the grant agreements.

CONCLUSION

Country coordinating mechanisms and national-level stakeholders see in funding for sexual and reproductive health a means to address the problem of HIV infection in their respective national settings. However, we highlight some missed opportunities for linking HIV and sexual and reproductive health services.

Mortality and morbidity among postpartum HIV-positive and HIV-negative women in Zimbabwe: risk factors, causes, and impact of single-dose postpartum vitamin A supplementation

BACKGROUND

Vitamin A deficiency is common among women in resource-poor countries and is associated with greater mortality during HIV.

METHODS

Fourteen thousand one hundred ten mothers were tested for HIV and randomly administered 400,000 IU vitamin A or placebo at less than 96 hours postpartum. The effects of vitamin A and HIV status on mortality, health care utilization, and serum retinol were evaluated.

RESULTS

Four thousand four hundred ninety-five (31.9%) mothers tested HIV positive. Mortality at 24 months was 2.3 per 1000 person-years and 38.3 per 1000 person-years in HIV-negative and HIV-positive women, respectively. Vitamin A had no effect on mortality. Tuberculosis was the most common cause of death, and nearly all tuberculosis-associated deaths were among HIV-positive women. Among HIV-positive women, vitamin A had no effect on rates of hospitalization or overall sick clinic visits, but did reduce clinic visits for malaria, cracked and bleeding nipples, pelvic inflammatory disease, and vaginal infection. Among HIV-negative women, serum retinol was responsive to vitamin A, but low serum retinol was rare. Among HIV-positive women, serum retinol was largely unresponsive to vitamin A, and regardless of treatment group, the entire serum retinol distribution was shifted 25% less than that of HIV-negative women 6 weeks after dosing.

CONCLUSIONS

Single-dose postpartum vitamin A supplementation had no effect on maternal mortality, perhaps because vitamin A status was adequate in HIV-negative women and apparently unresponsive to supplementation in HIV-positive women.

HIV and sexually transmitted infections among women presenting at urban primary health care clinics in two cities of sub-Saharan Africa

In a cross-sectional study, 786 consenting women from two cities in Africa, Harare and Moshi, attending primary health care clinics were interviewed, examined and tested for HIV and other sexually transmitted infections (STIs). The aim of the study was to assess and compare differences in the characteristics that may affect the prevalence of HIV/STIs among women in the two cities. Multivariate analysis was used to generate odds ratio. STIs and behaviour characteristics among this low risk group of women could not fully explain the higher HIV prevalence in Zimbabwe, 29.3% compared to 11.5% in Tanzania (p < 0.01). Interventions should target identified risk factors with particular attention to youths.

Maternal HIV-1 antibody and vertical transmission in subtype C virus infection

The role of maternal humoral immune response and viral load was analyzed in relation to the incidence of mother-to-child transmission (MTCT) of infants born to HIV-1 subtype C infected mothers. High levels of viral RNA in the serum correlated with MTCT as did high titers of subtype C consensus V3 peptide binding antibodies (BA) and neutralizing antibody (NA) to subtype B HIV-1MN. Logistic regression analysis showed that maternal viral load and V3 peptide subtype C BA were independent predictors for MTCT, odds ratio (OR) = 2.22 and OR = 2.52, respectively. No correlation between NA to homologous HIV-1 subtype C virus and MTCT was found. BA to V3 peptides may provide a rapid inexpensive method that can be used to determine the risk of HIV-1 MTCT.

STD treatment for men in rural and urban Zimbabwe: choice of practitioner, perceptions of access and quality of care

STD treatment choices and perceptions of treatment services (access, quality of care) by Zimbabwean men are examined in 2 settings: Mbare, a district within the capital city Harare, and Gutu, a rural town. Data collection included a survey of 457 men 18 years of age or older (from a stratified systematic sample), focus groups and key informant interviews. Of 220 cases of self-reported genital symptoms, 81.4% were treated by allopathic practitioners, 9% by traditional/faith healers, 8.6% by the subject, a friend or another person; 1.4% were not treated. Traditional/faith healers were consulted primarily for symptoms involving pain or discomfort rather than ulcers or exudation. Disrespect by the health care provider and consultations that were not private were cited as problems by a small minority of subjects. Significantly more respondents in Mbare than in Gutu had been prevented from obtaining the STD treatment they desired at some point in their life because of cost of treatment (chi(2)=5.23, P=0.02). Given the current deteriorating economic situation in Zimbabwe, cost of treatment may become an even more important impediment in the future.

Sperm characteristics and accessory sex gland functions in HIV-infected men

A comparative study was carried out in the andrology clinic, Parirenyatwa Hospital, Harare, Zimbabwe, to investigate the sperm characteristics and accessory sex gland functions in HIV-infected individuals. Sixty-two patients with infertility problems who attended the clinic were requested to donate semen and blood after consent was obtained. HIV antibodies in paired semen and blood samples, sperm morphology, sperm count, sperm motility, seminal leucocytes, seminal fructose, seminal neutral alpha-glucosidase, and citric acid were analyzed. Nine out of 31 blood samples tested positive, while 21 out of 62 semen samples were positive for HIV. Leucocytospermia was associated with HIV-seropositive men (p < .01). The accessory sex gland function, as evaluated by biochemical markers, was not affected in HIV-seropositive men. HIV causes impairment of sperm motility by activating seminal leucocytes, which in turn induce oxidative stress on the sperm. Leucocytospermia is almost always present in HIV-seropositive men.

The development of a continuous quality control programme for strict sperm morphology among sub-Saharan African laboratories

Inter-technician and between-laboratory differences, especially during the evaluation of sperm morphology, have been a major cause of concern. The study aimed to develop an intensive training programme with intervals of continuous quality control assessments for sperm morphology. Twenty andrology laboratories from sub-Saharan Africa were invited to participate in a World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction semenology workshop. Following intensive training in strict sperm morphololgy evaluation, a continuous quality control programme was introduced on a quarterly basis. At baseline, the mean (+/- SD) percentage difference reported between the participants and the reference laboratory reading was 33.50 +/- 11%. After training, the mean percentage difference had decreased to 14.32 +/- 5% at 3 months and to 5.00 +/- 5% at 6 months. Pairwise comparison of the differences at each evaluation time revealed the following: Baseline differences (pre-training) differed significantly from the differences at 3 months (P = 0.0002) as well as at 6 months after training (P = 0.007). The differences at 6 months did not differ significantly from those at 3 months (P = 0.27). Training of andrology technicians as well as continuous proficiency testing can be conducted on a national and international level with the support of a referring laboratory. Global quality control measurements in andrology laboratories should become mandatory, since these results indicate that continuous quality control for laboratory technicians can be highly successful.

HIV testing practices of Zimbabwean physicians and their perspectives on the future use of rapid on-site tests

To improve HIV testing procedures, rapid on-site HIV tests have been introduced in Zimbabwe. At present, little is known about physicians' perspectives on the potential use of rapid tests in their clinics or about their current laboratory-based testing practices. In a sample of 63 general practitioners in Harare, this study found physicians were generally testing individuals, not couples, and an important reason for suggesting a patient be tested was medical symptoms; frequent reasons for patients requesting the test were insurance purposes, being about to get married or having suspicions about a partner. A primary deterrent to physicians testing patients, even when patients requested it, was fear of traumatizing them. Fifty-six per cent of the physicians believed rapid tests would increase the number of HIV tests they performed; significant associations were found between this belief and whether physicians ever chose not to test patients they suspected were HIV-positive (a positive association) and whether they chose not to test specifically out of fear that patients would commit suicide (a negative association). Prior to any expansion of testing with rapid tests, training in counselling and confidentiality measures is essential, given that over half the medical personnel providing counselling to these physicians' patients had received no training in pre- and post-test HIV counselling.

Serum level of maternal human immunodeficiency virus (HIV) RNA, infant mortality, and vertical transmission of HIV in Zimbabwe

Maternal human immunodeficiency virus (HIV) RNA load, vertical transmission of subtype C HIV, and infant mortality were examined in 251 HIV-seropositive women and their infants in Zimbabwe. Demographic characteristics, health and medical histories, serum HIV RNA loads, and CD4+ lymphocyte counts for mothers were examined by logistic regression analysis to determine significant risk factors and their odds ratios for transmission and infant mortality. Tenfold (1 log10) incremental increases in maternal HIV RNA were associated with a 1.9-fold increase (95% confidence interval [CI], 1.2-2.9) in transmission and a 2.1-fold increase (95% CI, 1.3-3.5) in infant mortality (P<.01). Maternal CD4 cell counts and demographic and medical characteristics were not significant predictors of transmission. However, maternal CD4 cell counts below the median (400/mm3) were significantly associated with infant mortality (P=. 035, Fisher's exact test). The maternal level of serum HIV is an important determinant of vertical transmission and infant mortality in subtype C infection in Zimbabwe.

Primary subtype C HIV-1 infection in Harare, Zimbabwe

Heterosexual transmission of HIV-1 is widespread in Southern Africa. Heteroduplex mobility assays (HMA) and phylogenetic analyses of V3-V5 envelope (env) gene sequences demonstrate that subtype C predominates in Zimbabwe. To elucidate factors contributing to the epidemic in Zimbabwe, clinical and virologic characteristics of recently acquired subtype C HIV-1 infection among 21 men and 1 woman were determined. In 12 of 19 men providing clinical histories, a sexually transmitted infection preceded serologic evidence of HIV-1, and 14 of 19 men complained of rash or fever before seroconversion. Quantitative p24 antigen levels, reverse transcriptase activity, and HIV RNA levels of 22 viral isolates correlated with in vitro infectivity in peripheral blood mononuclear cells (p < .05). Biologic phenotype assessed in MT-2 cells demonstrated that 3 of 22 isolates (14%) were syncytia inducing (SI) and the remaining 19 nonsyncytium inducing (NSI). Early growth of virus in culture was associated with increased plasma HIV RNA levels, decreased CD4 cell levels, and SI virus. Recent subtype C HIV-1 infection through heterosexual transmission in Zimbabwe demonstrated clinical and virologic features consistent with reports of seroconversion to subtype B viruses.

A community-based investigation of maternal mortality from obstetric haemorrhage in rural Zimbabwe. Maternal Mortality Study Group

In the rural province Masvingo in Zimbabwe, 25% of maternal deaths were caused by obstetric haemorrhage, which had a cause specific maternal mortality rate (MMR) of 40 per 100,000 live births. Forty per cent of cases were due to a ruptured uterus, and 30% to an atonic uterus. Forty-two per cent were more than 35 years old and 44% para 5 or more. In spite of antenatal coverage for 85% of the women, 42% died outside any health facility. Fifty per cent of the women had had no intervention whatsoever before death from haemorrhage. The most important factor for prevention at community level is provision of emergency transport, which would have saved 50% of the women. Other non-health service factors contributing to the adverse outcome were found in actions of the patient herself or a traditional birth attendant. In the health services avoidable factors were identified in 58% of women. More effective antenatal attention to high risk factors, especially high age and parity, appropriate use of maternity waiting shelters, action programmes for management and haemorrhage at all levels, basic resources for resuscitation, improved surgical skills with supervision and available transport for referrals are all necessary parts of a programme to prevent maternal deaths from obstetric haemorrhage.

A community-based investigation of avoidable factors for maternal mortality in Zimbabwe

A community-based investigation of maternal deaths was undertaken in a rural province (Masvingo) and an urban area (Harare) of Zimbabwe in order to assess their preventability. Avoidable factors were identified in 90 percent of the 105 rural deaths and 85 percent of 61 urban deaths. Delay in seeking treatment contributed to 32 percent and 28 percent of rural and urban deaths, respectively. Lack of transportation delayed or prevented access to healthy facilities in the rural area, a major problem in 28 percent of the cases studied. Suboptimal clinic and hospital management was identified in 67 percent and 70 percent of rural and urban deaths, respectively. Lack of appropriately trained personnel contributed to suboptimal care. In both settings, the severity of patients' conditions was frequently unrecognized, leading to delays in treatment and referral, and inadequate treatment. Appropriate community and health-service interventions to reduce maternal mortality are discussed.

Norplant in Zimbabwe: preliminary report

During an ongoing study of a pre-introduction trial of Norplant in Zimbabwe, 197 women had the subdermal implant of six capsules containing levonorgestrel inserted between June and December 1991, at Parirenyatwa, Harare Hospital and Spilhaus. Acceptability and efficacy were high and no significant side effects had been observed. Three implants were removed due to local infection. Our initial experience indicates that the Norplant continuation rate is much higher than for any other reversible method of contraception and it is highly acceptable as a long term contraceptive.

Evaluation of a combined oral contraceptive pill in black Zimbabwean women

A prospective exploratory study was carried out on lipid metabolism (41 women); as well as efficacy, acceptability and safety on another 190 women who all were using a combined oral contraceptive pill (OC) containing 30 micrograms Ethinyl oestradiol and 150mg Desogestrel (Marvelon) over a period of twelve months. The 41 women had blood analysis of triglycerides, cholesterol and high density lipoproteins (HDL) before treatment and at each of follow-up visits scheduled at 3, 6, 9 and 12 months following admission. Triglycerides, cholesterol and HDL levels were computed and there were no significant changes in any of the measured levels except HDL which was increased. No pregnancy was reported in one year of use in both groups. Cycle control was good, with a very low incidence of breakthrough bleeding and spotting being reported. The pill did not affect body weight and blood pressure significantly. It was concluded that the Marvelon formulation does not have adverse effect on lipid metabolism and is an efficacious and well tolerated contraceptive amongst Zimbabwean women.

The effect of protein energy malnutrition on plasma renin and oedema in the pig

Five litter-mate male pigs, aged 7 days and fed a standard Pig Industry Board diet containing 190 g/kg dry mass of digestible protein, were compared with 10 male pigs from two litters fed a protein-deficient diet (50 g/kg) for a period of 70 days. The 10 experimental animals developed oedema between the 42nd and 70th days of the study and 4 of them became lethargic. Although the 10 experimental animals showed the typical biochemical changes characteristic of protein energy malnutrition (PEM), including changes in muscle electrolytes, liver fat and plasma albumin, the 4 lethargic animals showed a significant increase in effective plasma renin activity (EPRA) only by the 70th day of the study. Since oedema preceded any increase in EPRA in some pigs and developed in others without any change in EPRA, it is suggested that the increased renin activity is not responsible for the initial fluid retention and oedema.