Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis.

OBJECTIVE: We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes. STUDY DESIGN: We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI. RESULTS: Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1). CONCLUSION: Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Perceptions among post-delivery mothers of skin-to-skin contact and newborn baby care in a periurban hospital in Uganda.

OBJECTIVE: to explore the perceptions among post-delivery mothers of skin-to-skin contact and newborn baby care. DESIGN: a qualitative design using focus-group discussions. Five focus groups were conducted with post-delivery mothers who had had normal deliveries. A latent content analysis was used to derive the themes from the focus-group discussions. SETTINGS AND PARTICIPANTS: 30 post-delivery mothers were purposely sampled from 249 mothers in the postnatal ward at St Francis Hospital, Nsambya, which is located in a periurban area in Kampala, Uganda. FINDINGS: two main themes emerged from the focus-group discussions: 'acceptability of health practices are influenced by knowledge and sensitisation' and 'pregnant women's choices are dependent on social, cultural and economic factors'. Mothers expressed varying opinions about the usefulness of skin-to-skin contact: some knew about its use to reduce the risk of hypothermia; others were ignorant, whereas some believed skin-to-skin contact was an intervention used to distract them from the pain in the post-delivery period. The vernix caseosa and the mixture of amniotic fluid with blood in the post-delivery period were perceived as dirty and infectious. The best informants for helping mothers understand the skin-to-skin intervention were the health-care providers. Social, cultural and economic factors, as well as the dominant role of the husband, were identified as important determinants for their choice and place of delivery. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the gap between the knowledge and practice of skin-to-skin contact in hospital needs to be bridged. Health-care providers need to be encouraged to continuously advocate for, educate and implement regular skin-to-skin contact.

A randomized controlled safety and acceptability trial of dextrin sulphate vaginal microbicide gel in sexually active women in Uganda.

OBJECTIVE: To assess the safety of dextrin sulphate (DS) gel compared to placebo gel in terms of local and systemic adverse events, and to determine the acceptability of dextrin sulphate gel. DESIGN: A 4-week randomized trial of DS intra-vaginal gel, partially blinded, with placebo and observation control arms. Participants were randomized to use DS gel twice daily, placebo gel twice daily, DS gel pre-sex, or into an observation only arm. METHODS: Sexually active women were recruited from post natal and HIV clinics at Nsambya Hospital, Kampala, Uganda. Screening, enrollment and follow-up visits took place every 1 or 2 weeks over an 8-week period and consisted of questionnaire interviews, colposcopy examinations, sexually transmitted infection screen and routine laboratory testing. RESULTS: Out of a total of 172 women screened, 109 were randomized to use DS gel twice daily (65 women), placebo gel twice daily (15 women), DS gel pre-sex (nine women) or into an observation only arm (20 women). Two individuals had abnormal colposcopy findings in the DS twice daily gel use arm. Vaginal bleeding was reported as frequently by participants in the active gel arm as by participants in the placebo and observation only arms. No clinically significant difference was observed between arms in terms of vaginal flora, Candida, haemoglobin, white cell count, platelets, thrombin time, activated partial thromboplastin time, creatinine and aspartate aminotransferase results after 4 weeks of gel use. DS gel appeared to be acceptable to over 95% of the users. CONCLUSIONS: Results show a satisfactory safety and acceptability profile of dextrin sulphate gel.

Strengthening health facilities for maternal and newborn care: experiences from rural eastern Uganda.

BACKGROUND: In Uganda maternal and neonatal mortality remains high due to a number of factors, including poor quality of care at health facilities. OBJECTIVE: This paper describes the experience of building capacity for maternal and newborn care at a district hospital and lower-level health facilities in eastern Uganda within the existing system parameters and a robust community outreach programme. DESIGN: This health system strengthening study, part of the Uganda Newborn Study (UNEST), aimed to increase frontline health worker capacity through district-led training, support supervision, and mentoring at one district hospital and 19 lower-level facilities. A once-off supply of essential medicines and equipment was provided to address immediate critical gaps. Health workers were empowered to requisition subsequent supplies through use of district resources. Minimal infrastructure adjustments were provided. Quantitative data collection was done within routine process monitoring and qualitative data were collected during support supervision visits. We use the World Health Organization Health System Building Blocks to describe the process of district-led health facility strengthening. RESULTS: Seventy two per cent of eligible health workers were trained. The mean post-training knowledge score was 68% compared to 32% in the pre-training test, and 80% 1 year later. Health worker skills and competencies in care of high-risk babies improved following support supervision and mentoring. Health facility deliveries increased from 3,151 to 4,115 (a 30% increase) in 2 years. Of 547 preterm babies admitted to the newly introduced kangaroo mother care (KMC) unit, 85% were discharged alive to continue KMC at home. There was a non-significant declining trend for in-hospital neonatal deaths across the 2-year study period. While equipment levels remained high after initial improvement efforts, maintaining supply of even the most basic medications was a challenge, with less than 40% of health facilities reporting no stock-outs. CONCLUSION: Health system strengthening for care at birth and the newborn period is possible even in low-resource settings and can be associated with improved utilisation and outcomes. Through a participatory process with wide engagement, training, and improvements to support supervision and logistics, health workers were able to change behaviours and practices for maternal and newborn care. Local solutions are needed to ensure sustainability of medical commodities.

Hurdles and opportunities for newborn care in rural Uganda.

INTRODUCTION: A set of evidence-based delivery and neonatal practices have the potential to reduce neonatal mortality substantially. However, resistance to the acceptance and adoption of these practices may still be a problem and challenge in the rural community in Uganda. OBJECTIVES: To explore the acceptability and feasibility of the newborn care practices at household and family level in the rural communities in different regions of Uganda with regards to birth asphyxia, thermo-protection and cord care. METHODS: A qualitative design using in-depth interviews and focus group discussions were used. Participants were purposively selected from rural communities in three districts. Six in-depth interviews targeting traditional birth attendants and nine focus group discussions composed of 10-15 participants among post childbirth mothers, elderly caregivers and partners or fathers of recently delivered mothers were conducted. All the mothers involved has had normal vaginal deliveries in the rural community with unskilled birth attendants. Latent content analysis was used. FINDINGS: Two main themes emerged from the interviews: 'Barriers to change' and 'Windows of opportunities'. Some of the recommended newborn practices were deemed to conflict with traditional and cultural practices. Promotion of delayed bathing as a thermo-protection measure, dry cord care were unlikely to be accepted and spiritual beliefs were attached to use of local herbs for bathing or smearing of the baby's skin. However, several aspects of thermo-protection of the newborn, breast feeding, taking newborns for immunisation were in agreement with biomedical recommendations, and positive aspects of newborn care were noticed with the traditional birth attendants. CONCLUSIONS: Some of the evidence based practices may be accepted after modification. Behaviour change communication messages need to address the community norms in the country. The involvement of other newborn caregivers than the mother at the household and the community early during pregnancy may influence change of behaviour related to the adoption of the recommended newborn care practices.

Low avidity of human papillomavirus (HPV) type 16 antibodies is associated with increased risk of low-risk but not high-risk HPV type prevalence.

BACKGROUND: Low avidity of antibodies against viral, bacterial and parasitic agents has been used for differential diagnosis of acute versus recent/past infections. The low-avidity antibodies may however, persist for a longer period in some individuals. FINDINGS: We studied the association of human papillomavirus (HPV) type 16 antibody avidity with seroprevalence to HPV types 6/11/18/31/33/45. Antibody avidity was analysed for 365 HPV16 seropositive pregnant Finnish and Ugandan women using a modified ELISA.Low avidity of HPV16 antibodies was found in 15% of Finnish and 26% of Ugandan women. Ugandan women with low-avidity HPV16 antibodies had an increased risk estimate for HPV6/11 (odds ratio, OR 2.9; 95%CI 1.01-8.4) seropositivity but not to high-risk HPV types 18/31/33/45. CONCLUSION: Association of the low avidity HPV16 antibody "phenotype" with possible susceptibility to infections with other HPV types warrants investigation.