Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: A scoping review.

Cervical cancer is a prevalent disease among women, especially in low- and middle-income countries (LMICs), where most deaths occur. Integrating cervical cancer screening services into healthcare facilities is essential in combating the disease. Thus, this review aims to map evidence related to integrating cervical cancer screening into existing primary care services and identify associated barriers and facilitators in LMICs. The scoping review employed a five-step framework as proposed by Arksey and O'Malley. Five databases (MEDLINE, Maternity Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) were systematically searched. Data were extracted, charted, synthesized, and summarised. A total of 28 original articles conducted in LMICs from 2000 to 2023 were included. Thirty-nine percent of the reviewed studies showed that cervical cancer screening (CCS) was integrated into HIV clinics. The rest of the papers revealed that CCS was integrated into existing reproductive and sexual health clinics, maternal and child health, family planning, well-baby clinics, maternal health clinics, gynecology outpatient departments, and sexually transmitted infections clinics. The cost-effectiveness of integrated services, promotion, and international initiatives were identified as facilitators while resource scarcity, lack of skilled staff, high client loads, lack of preventive oncology policy, territorial disputes, and lack of national guidelines were identified as barriers to the services. The evidence suggests that CCS can be integrated into healthcare facilities in LMICs, in various primary care services, including HIV clinics, reproductive and sexual health clinics, well-baby clinics, maternal health clinics, and gynecology OPDs. However, barriers include limited health system capacity, workload, waiting times, and lack of coordination. Addressing these gaps could strengthen the successful integration of CCS into primary care services and improve cervical cancer prevention and treatment outcomes.

Dietary diversity and other predictors of low birth weight in Gurage Zone, Ethiopia: Prospective study.

BACKGROUND: Low birth weight (LBW) is a major public health problem in Ethiopia. Dietary diversity is a key indicator of maternal dietary adequacy that may affect birth weight but little is known about their relationship. Hence, this study aimed to assess the association of suboptimal maternal dietary diversity during pregnancy and low birth weight in Gurage Zone, Ethiopia. METHODS: The prospective study was conducted among 1062 pregnant women enrolled consecutively in between 16 to 20 gestational weeks and followed until delivery. The baseline data were collected at recruitment and dietary diversity was assessed using the minimum dietary diversity score for women (MDD-W) tool in three different rounds. The average of three scores was considered to categorize women into optimal (consumed ≥ 5 food groups) and suboptimal (consumed < 5 food groups) dietary diversity groups. The risk of low birth weight among suboptimal dietary diversity was assessed using modified Poisson regression with robust standard error. RESULTS: Of the 1062 pregnant women recruited, 959 (90.4%) women completed follow-up. Among them, 302 (31.5%) women are having optimal and the rest, 657 (68.5%) women are having suboptimal dietary diversity. The risk of low birth weight was significantly higher among women with sub-optimal dietary diversity than among those with optimal diversity (ARR = 1.89, 95% CI: 1.25, 2.84). Other factors such as rural residence (ARR = 1.61, 95% CI: 1.43, 1.87), age > = 35 years (AAR = 3.94, 95% CI: 2.41, 6.46), being underweight (ARR = 1.81, 95% CI: 1.14, 2.86), height < 150cm (ARR = 4.65, 95% CI: 2.52, 8.59), unwanted pregnancy (ARR = 3.35, 95% CI: 2.23, 5.02), preterm delivery (3.65, 95% CI: 2.27, 5.84) and lack of nutritional counseling (ARR = 1.69, 95% CI: 1.08, 2.67) significantly increased the risk of low birth weight. CONCLUSION: Suboptimal dietary diversity associated low birth weight. Promoting dietary diversity by strengthening nutritional education and avoiding unwanted pregnancy particularly among rural residents may help to reduce the incidence of low birth weight.

Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: a scoping review protocol.

BACKGROUND: Cervical cancer is the fourth most common malignancy in women, with 90% of deaths in low- and middle-income countries. Integrating cervical cancer screening services into healthcare facilities is crucial for overcoming the disease. Thus, this review aims to map existing evidence and identify barriers and facilitators in low- and middle-income countries. METHODS: The scoping review will employ a five-step framework as proposed by Arksey and O'Malley. These are (1) formulating the research questions, (2) identifying relevant studies, (3) selecting eligible studies, (4) charting the data, and (5) collating, summarising and reporting the results. Five databases (MEDLINE, Maternity and Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) will be systematically searched. Grey literature will also be searched. Data will be extracted, charted, synthesised and summarised. ETHICS AND DISSEMINATION: This review does not require ethics approval. Findings will be disseminated through peer-reviewed publications, policy briefs and conference presentations.

Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study.

BACKGROUND: The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown. METHODS: This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used. RESULTS: Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality. CONCLUSIONS: Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.

Gestational weight gain among pregnant women in Ibadan, Nigeria: Pattern, predictors and pregnancy outcomes.

BACKGROUND: Gestational weight gain (GWG) is a risk factor for adverse pregnancy outcomes, future obesity and chronic diseases among women. However, has not received much attention in many low and middle-income countries such as Nigeria. We investigated the pattern, associated factors and pregnancy outcomes of GWG in Ibadan, Nigeria, using the Ibadan Pregnancy Cohort Study (IbPCS). METHODOLOGY: The IbPCS is a multicentre prospective cohort study conducted among 1745 pregnant women recruited from four health facilities in Ibadan, Nigeria. GWG, the primary outcome, was categorised according to the Institute of Medicine's classification into insufficient, adequate and excessive weight gain. Pregnancy outcomes were the secondary outcome variables. Logistic regression analysis (Adjusted odds ratios and 95% confidence interval CI) was used to examine associations, and Poisson regression analyses were used to investigate associations with outcomes. RESULTS: Only 16.9% of women had optimal GWG, 56.8% had excessive GWG, and 26.9% had insufficient GWG. Excessive GWG was associated with high income '> #20,000-' (AOR: 1.64, 95% CI: 1.25-2.17), being overweight (AOR: 2.12, 95% CI: 1.52-2.95) and obese (AOR: 1.47, 95% CI: 1.02-2.13) after adjusting for confounders. In contrast, increased odds of insufficient GWG have associated women with depression (AOR: 1.70, 95% CI 1.17-2.47). There was no significant association between inappropriate GWG and pregnancy outcomes However, there was an increased odds for postpartum haemorrhage (AOR: 2.44, 95% CI 1.14-5.22) among women with obesity and excessive GWG. CONCLUSIONS: Excessive GWG was the most typical form of GWG among our study participants and was associated with high maternal income, and being overweight or obese. GWG needs to be monitored during antenatal care, and interventions that promote appropriate GWG should be implemented among pregnant women in Nigeria.

Prevalence and predictors of anemia among pregnant women in Ethiopia: Systematic review and meta-analysis.

BACKGROUND: In Ethiopia limited information is available regarding the prevalence and predictors of anemia in pregnancy. This systematic review and meta-analysis estimated the pooled prevalence of anemia among pregnant women in Ethiopia and also identified its predictors. MATERIALS AND METHODS: The published primary studies were searched in the following electronic databases; PubMed/Medline, Google scholars, AJOL, and EMBASE. All primary studies published from 01/01/2010 to 30/05/2020 and written in English language were included without restriction on study setting and design. Critical appraisal of all available articles was done and extracted data was analyzed using STATA software version 14. The pooled prevalence of anemia was presented using a forest plot. The I2 statistical test for heterogeneity, and the Egger's and Begg's tests for publication bias were used. The relative risk was used to assess the association of predictor variables with anemia. RESULT: After screening 274 articles, sixty studies were included in the analysis. The pooled prevalence of anemia among pregnant women was 26.4(95% CI: 23.1, 29.6). Sub-group analysis showed higher pooled prevalence from community-based studies than institutional-based studies. Factors that were protective against maternal anemia included urban residence, formal education and smaller family size. Short birth interval and not having antenatal care (ANC) are associated with a higher risk of maternal anemia. Women with low dietary diversity [RR: 2.61(95% CI, 1.85, 3.68)], mid-upper arm circumference (MUAC) less than 23 cm [RR: 2.35(95% CI, 1.53, 3.68)] and those not taking iron-folic acid [RR: 1.53(95% CI: 1.30, 1.81)] also had a higher risk of anemia. CONCLUSION: Almost one in four pregnant women in Ethiopia had anemia. Being literate, living in urban areas with small family size and adequate birth spacing, as well as good dietary diversity are associated with a lower risk of anemia in pregnancy. REGISTRATION NUMBER: (ID: CRD42020211054).

Dietary Diversity Among Pregnant Women in Gurage Zone, South Central Ethiopia: Assessment Based on Longitudinal Repeated Measurement.

Purpose: Dietary diversity is a key proxy indicator of nutrient adequacy; however, limited studies have been done on it among pregnant women in Ethiopia. The study aimed to examine the prevalence of sub-optimal dietary diversity and its associated factors among pregnant women in Gurage zone, South Central Ethiopia. Materials and Methods: A mixed-method approach, a longitudinal study complemented with an exploratory qualitative study, was conducted. In the longitudinal study, a consecutively included sample of 668 pregnant women was followed in three rounds of survey. Dietary diversity was assessed using the minimum dietary diversity score for women (MDD-W) tool. The average of three dietary diversity scores was used to define overall diversity. Consuming less than 5 of 10 standard food groups was considered as suboptimal dietary diversity. Multivariable logistic regression analysis was used to identify predictors of suboptimal dietary diversity. Qualitative data were analysed using the thematic analysis method. Results: During the 16 to 20, 28 to 29 and 36 to 37 weeks of gestation surveys, 75.0, 78.7 and 76.5% of the women had sub-optimal dietary diversity. In aggregate, 84.4% (95% CI: 81.6, 87.3) of the women had sub-optimal dietary diversity. Rural residents (AOR: 1.91, 95% CI: 1.01, 3.62), women with no formal education (AOR: 5.51, 95% CI: 1.96, 15.53) and from food insecure households (AOR: 2.44, 95% CI: 1.07, 5.59) had higher odds of suboptimal dietary diversity. Women with higher nutritional knowledge (AOR: 0.92, 95% CI: 0.87, 0.98) were less likely to have suboptimal dietary diversity. Food taboos, poor nutritional literacy and pregnancy complications were also reported as factors affecting dietary diversity. Conclusion: Majority of pregnant women in the area had sub-optimal dietary diversity. Improving the socio-economic status and promoting nutrition knowledge may improve women's dietary diversity.

Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study.

BACKGROUND: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. METHODS: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. RESULTS: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). CONCLUSIONS: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.

Characterization of primary female infertility in a Nigerian tertiary hospital: A case-control study.

Primary female infertility is a serious reproductive health concern amongst many women in Nigeria with associated psychosocial impact. There is a need for early prediction of this disorder for increased chances of fertility in Nigerian women. This study reported the anthropometric, sociodemographic, and clinical baseline characteristics of primary infertility females and studied their viability as predictors of primary infertility. This is a case-control study of primarily infertile (54) and fertile (50) Nigerian females aged 20-44 years recruited by random selection of patients who visited University College Hospital between August and November 2020. A clinical proforma was utilized to assess sociodemographic data, fertility history and clinical diagnosis of study participants. The body mass index (BMI) of both fertile and infertile females was in the overweight category (27.98±0.87 and 28.18±0.59, respectively). Both fertile and primary infertile females present a normal menarcheal age (13.68±0.27 and 13.91 ± 0.32 years, respectively), and there was no significant difference between the menarcheal age (p = 0.411) in both study groups. Ovarian disorder was the most contributing clinical diagnosis (67%) of primary infertility. There is a significant strong association between menarcheal age, ovarian factor infertility (χ2 = 13.839, φc = 0.458, p = 0.008) and tubal factor infertility (χ2 = 11.111; φc = 0.527, p=0.025). Females with primary infertility may present with overweight in no significantly different way than fertile females and BMI may not be useful in predicting primary infertility. However, menarcheal age may be a valuable tool to predict the ovarian and tubal factors in primary infertility.

Lactobacillus crispatus thrives in pregnancy hormonal milieu in a Nigerian patient cohort.

Steroid hormones are one of the presumed modulators of Lactobacillus abundance in the vaginal epithelium. We set out to characterize the vaginal microbiome (VMB) and also provide an in-depth understanding of the relative contribution of estradiol (E2) and progesterone (P1) in shaping the vaginal microbiome of Nigerian women (n = 38) who experienced both uncomplicated term delivery and preterm delivery using samples longitudinally collected during pregnancy (17-21, 27-31, 36-41 weeks gestation) and 6 weeks postpartum. Vaginal swabs and blood samples were aseptically collected. Vaginal swabs were used for microbiome assessment using 16S ribosomal RNA (rRNA) gene sequencing. Blood samples were used for hormonal measurement using a competitive-based enzyme-linked immunosorbent assay (ELISA). Across several maternal covariates, maternal age, pregnancy status and delivery mode were not significantly associated with the vaginal microbiota whereas maternal E2 level (pE2 = 0.006, Omnibus), and P1 level (pP1 = 0.001, Omnibus) were significantly associated with the vaginal microbiome. E2 and P1 concentrations increased throughout pregnancy commensurately with increasing proportions of L. crispatus (pE2 = 0.036, pP1 = 0.034, Linear Mixed Model). An increasing trend of α-diversity was also observed as pregnancy progressed (pobserved ASV = 0.006, LMM). A compositional microbiome shift from Lactobacillus profile to non-Lactobacillus profile was observed in most postnatal women (pCST IV < 0.001, LMM). Analysis of our data shows a species-specific link between pregnancy steroid hormone concentration and L. crispatus abundance.

Predominance of Atopobium vaginae at Midtrimester: a Potential Indicator of Preterm Birth Risk in a Nigerian Cohort.

Preterm birth (PTB) is the largest contributor to infant death in sub-Saharan Africa and globally. With a global estimate of 773,600, Nigeria has the third highest rate of PTB worldwide. There have been a number of microbiome profiling studies to identify vaginal microbiomes suggestive of preterm and healthy birth outcome. However, studies on the pregnancy vaginal microbiome in Africa are sparse with none performed in Nigeria. Moreover, few studies have considered the concurrent impact of steroid hormones and the vaginal microbiome on pregnancy outcome. We assessed two key determinants of pregnancy progression to gain a deeper understanding of the interactions between vaginal microbiome composition, steroid hormone concentrations, and pregnancy outcome. Vaginal swabs and blood samples were prospectively collected from healthy midtrimester pregnant women. Vaginal microbiome compositions were assessed by analysis of the V3-V5 region of 16S rRNA genes, and potential functional metabolic traits of identified vaginal microbiomes were imputed by PICRUSt (phylogenetic investigation of communities by reconstruction of unobserved states) analysis, while plasma estradiol (E2) and progesterone (P1) levels were quantified by the competitive enzyme-linked immunosorbent assay (ELISA). PTB vaginal samples were characterized by increased microbial richness, high diversity, and depletion of lactobacilli compared to term delivery samples. Women who delivered preterm were characterized by an Atopobium vaginae-dominated vagitype. High relative abundance of Atopobium vaginae at the midtrimester was highly predictive of PTB (area under the receiving operator characteristics [AUROC] of 0.983). There was a marked overlap in the range of plasma E2 and P1 values between term and PTB groups.IMPORTANCE Giving birth too soon accounts for half of all newborn deaths worldwide. Clinical symptoms alone are not sufficient to identify women at risk of giving birth too early, as such a pragmatic approach to reducing the incidence of preterm birth entails developing early strategies for intervention before it materializes. In view of the role played by the vaginal microbiome and maternal steroid hormones in determining obstetric outcome, we assessed the vaginal microbiome composition and steroid hormone during pregnancy and examined their relationship in predicting preterm birth risk in Nigerian women. This study highlights a potential early-driver microbial marker for prediction of preterm birth risk and supports the notion that vaginal microbiome composition varies across populations. A knowledge of relevant preterm birth microbial markers specific to populations would enhance the development of personalized therapeutic interventions toward restoring a microbiome that optimizes reproductive health fitness, therefore reducing the incidence of preterm birth.

The vaginal microbiome of sub-Saharan African women: revealing important gaps in the era of next-generation sequencing.

Accurate characterization of the vaginal microbiome remains a fundamental goal of the Human Microbiome project (HMP). For over a decade, this goal has been made possible deploying high-throughput next generation sequencing technologies (NGS), which indeed has revolutionized medical research and enabled large-scale genomic studies. The 16S rRNA marker-gene survey is the most commonly explored approach for vaginal microbial community studies. With this approach, prior studies have elucidated substantial variations in the vaginal microbiome of women from different ethnicities. This review provides a comprehensive account of studies that have deployed this approach to describe the vaginal microbiota of African women in health and disease. On the basis of published data, the few studies reported from the African population are mainly in non-pregnant post pubertal women and calls for more detailed studies in pregnant and postnatal cohorts. We provide insight on the use of more sophisticated cutting-edge technologies in characterizing the vaginal microbiome. These technologies offer high-resolution detection of vaginal microbiome variations and community functional capabilities, which can shed light into several discrepancies observed in the vaginal microbiota of African women in an African population versus women of African descent in the diaspora.

Factors associated with early long-acting reversible contraceptives discontinuation in Ethiopia: evidence from the 2016 Ethiopian demographic and health survey.

BACKGROUND: Ethiopia is struggling to achieve the 2020 family planning target. But the current contraceptive prevalence uptake is low and dominated by short-acting methods. Contraceptive discontinuation rate is also high. This analysis was done to identify the reasons and factors associated with long-acting and reversible contraceptives (LARC) discontinuation in Ethiopia. METHODS: The unit of analysis was LARC-use episodes in the 5 years preceding the survey, generated from the 2016 Ethiopian Demographic and Health Survey data. A total of 1385 LARC episodes were included. Data analysis was done using STATA 15. The event file generated from the contraceptive calendar was merged to the original data set to identify factors associated with LARC discontinuation. Univariate, bivariate and inferential analyses were done for 12 months LARC discontinuation. RESULT: Approximately 82% of LARC episodes were implants. About 45% of intrauterine device (IUD) and 61% of implant episodes were discontinued by 36 months. Side effects and the desire to become pregnant were the main reasons for discontinuation. Women aged 25-34 (HR = 0.26; 95% CI: 0.20-0.35) and those aged 35-49 (HR = 0.17; 95%CI: 0.11-0.26), women who participated in decision-making partially (HR = 0.53; 95%CI: 0.37-0.78), or fully (HR = 0.55; 95%CI: 0.40-0.74) and primiparous women (HR = 0.53, 95%CI: 0.33-0.86) had a lower hazard of discontinuing LARCs. On the other hand, women who had only primary education (HR = 1.32; 95%CI: 1.02-1.72) and women who were not sure about their fertility intention (HR = 2.11; 95%C: 1.28-3.46) had a higher likelihood of discontinuing these methods. CONCLUSION: Majority of LARC episodes were discontinued early, mainly due to the desire for pregnancy or experience of side effects. Older women, particularly those involved in household decision-making, and primipara were less likely to discontinue LARC. Women with only primary education and those uncertain about their fertility intention had a higher likelihood of discontinuation. Family planning service providers should focus on fertility intention and side effects when counseling women for contraceptive choice. Improving women's participation in household decision-making may decrease LARC discontinuation in Ethiopia.

Protocol for a Longitudinal Analysis of the Vaginal Microbiome from a Pregnant Cohort of African Women in Nigeria.

BACKGROUND: The vaginal microbiota is an important component of the reproductive health of women as it offers protection against urogenital infection. African women are reported to have a vaginal microbiota colonized with high proportions of strict anaerobes rather than lactobacillus- dominated microbes. These strict anaerobes have been associated with pre-term birth and neonatal disease. The prevalence of pre-term birth (PTB) in Africa poses a major challenge to reproductive healthcare, hence the clinical and scientific attention focused on understanding the causative mechanisms of PTB. A pragmatic approach to curbing PTB requires the identification of the vaginal microbiome during various stages of a healthy pregnancy (the 'normal'). This information will provide baseline data for future investigations of vaginal microbiome that may cause PTB (the 'abnormal'). We present a protocol for the longitudinal analysis of vaginal microbiome in a cohort of pregnant women in Southwest Nigeria. METHODS: We propose to recruit 51 pregnant Nigerian women, enrolling them into the study at 17-21 gestational weeks. Two vaginal swab samples and three milliliters of blood would be collected at enrollment. Sample collection will be repeated at 27-31 weeks' gestation, ≥36 weeks' gestation, 24-48 hours after birth and 6 weeks post-partum. DNA will be extracted from the vaginal samples and 16S rRNA sequencing would be performed. Blood samples collected would be assayed by ELISA technique for placental steroid hormones. Data will be statistically analyzed and considered in the light of vaginal microbial diversity, clinical, nutrition and other health data. CONCLUSION AND GLOBAL HEALTH IMPLICATION: Our data set will bring new insights into the vaginal microbiome of apparently healthy African women in pregnancy and postpartum, which should serve as a baseline for the investigation of vaginal microbes that may provide useful information for the prediction and management of preterm birth. It is anticipated that these data will facilitate future personalized therapeutic management and consequently improve the reproductive health fitness of women in Africa.

Correction: Determinants of change in long-acting or permanent contraceptives use in Ethiopia; A multivariate decomposition analysis of data from the Ethiopian demographic and health survey.

[This corrects the article DOI: 10.1371/journal.pone.0227218.].

Determinants of change in long-acting or permanent contraceptives use in Ethiopia; A multivariate decomposition analysis of data from the Ethiopian demographic and health survey.

BACKGROUND: There has been an increase in the uptake of long-acting or permanent contraceptive methods (LAPMs) in Ethiopia. Identifying the factors associated with this change is important for designing interventions that will further accelerate the uptake. This study was done to identify components of, and factors associated with, changes in the use of LAPMs in Ethiopia. METHODS: Information about 16,336 married or in-union reproductive-age women were extracted from the 2005 and 2016 Ethiopian Demographic and Health Surveys (EDHS). Normalized weighting was used to compensate for disproportionate sampling and non-response in the survey. The two data sets were merged and analyzed using multivariate decomposition analysis. RESULT: From 2005 to 2016, the use of LAPMs increased by 12.0 percentage points. Changes in the characteristics of women (compositional factors) were responsible for nearly 7.0% of the observed difference. Most of the change (92.0%) was attributable to differences in the effects of characteristics. Age, working status, woman's occupation, concordance on the desired number of children between women and their partners, and a visit by health workers in the 12 months before the survey were all significantly associated with the change. CONCLUSION: The contribution of variation in the survey population structure was not significant for the observed change. The change in the use of LAPMs was mainly due to behavioral changes among older, educated and working women, and women visited by health workers.

The effects of physics-based data augmentation on the generalizability of deep neural networks: Demonstration on nodule false-positive reduction.

PURPOSE: An important challenge for deep learning models is generalizing to new datasets that may be acquired with acquisition protocols different from the training set. It is not always feasible to expand training data to the range encountered in clinical practice. We introduce a new technique, physics-based data augmentation (PBDA), that can emulate new computed tomography (CT) data acquisition protocols. We demonstrate two forms of PBDA, emulating increases in slice thickness and reductions of dose, on the specific problem of false-positive reduction in the automatic detection of lung nodules. METHODS: We worked with CT images from the lung image database consortium (LIDC) collection. We employed a hybrid ensemble convolutional neural network (CNN), which consists of multiple CNN modules (VGG, DenseNet, ResNet), for a classification task of determining whether an image patch was a suspicious nodule or a false positive. To emulate a reduction in tube current, we injected noise by simulating forward projection, noise addition, and backprojection corresponding to 1.5 mAs (a "chest x-ray" dose). To simulate thick slice CT scans from thin slice CT scans, we grouped and averaged spatially contiguous CT within thin slice data. The neural network was trained with 10% of the LIDC dataset that was selected to have either the highest tube current or the thinnest slices. The network was tested on the remaining data. We compared PBDA to a baseline with standard geometric augmentations (such as shifts and rotations) and Gaussian noise addition. RESULTS: PBDA improved the performance of the networks when generalizing to the test dataset in a limited number of cases. We found that the best performance was obtained by applying augmentation at very low doses (1.5 mAs), about an order of magnitude less than most screening protocols. In the baseline augmentation, a comparable level of Gaussian noise was injected. For dose reduction PBDA, the average sensitivity of 0.931 for the hybrid ensemble network was not statistically different from the average sensitivity of 0.935 without PBDA. Similarly for slice thickness PBDA, the average sensitivity of 0.900 when augmenting with doubled simulated slice thicknesses was not statistically different from the average sensitivity of 0.895 without PBDA. While there were cases detailed in this paper in which we observed improvements, the overall picture was one that suggests PBDA may not be an effective data enrichment tool. CONCLUSIONS: PBDA is a newly proposed strategy for mitigating the performance loss of neural networks related to the variation of acquisition protocol between the training dataset and the data that is encountered in deployment or testing. We found that PBDA does not provide robust improvements with the four neural networks (three modules and the ensemble) tested and for the specific task of false-positive reduction in nodule detection.

Factors associated with long acting and permanent contraceptive methods use in Ethiopia.

BACKGROUND: Long acting and permanent contraceptives methods are more effective, save cost and enable women to control their reproductive lives better. Although the Ethiopian government is promoting its use through various mechanisms, the level of use is low. Therefore, this study was designed to identify factors associated with long acting and permanent contraceptive methods use in Ethiopia. METHODS: Four Ethiopian demographic and health survey data were used to examine trends of long acting and permanent contraceptive methods use. To identify factors associated with long acting and permanent contraceptive methods use, the 2016 Ethiopian demographic and health survey data was used. The data was accessed from the demographic and health survey program data base. Data analysis was done using Stata 15.1. Descriptive analysis was used to describe socio-economic and other variables of the study participants. Data were weighted and design effect was considered during analysis. Multicollinearity was assessed using variance inflation factor. Finally, multinomial logistic regression model was used to identify factors associated with long acting and permanent contraceptive methods use. RESULTS: Long acting and permanent contraceptive methods use increased significantly from 0.6% in 2000 to 11.6% in 2016. The odds of long acting and permanent contraceptive methods use was higher among richer women (AOR 2.6; 95%CI 1.2-5.4), women who were sales workers (AOR 2.1; 95%CI 1.1-3.9) and women whose ideal number of children was high (AOR; 4.2, 95%CI 1.4-13.0). But the odds of long acting and permanent contraceptive methods use was lower among female headed households (AOR 0.2: 95%CI 0.1-0.5) and women who had history of abortion (AOR 0.2: 95%CI 0.1-0.5). CONCLUSION: Long acting and permanent contraceptive methods use increased significantly in Ethiopia. Wealth index, women's occupation, ideal number of children, sex of head of the household and history of abortion were factors associated with long acting and permanent contraceptive methods use in Ethiopia. Improving economic status of women may help improve long acting and permanent contraceptive methods use in Ethiopia.

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. METHODS: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. FINDINGS: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). INTERPRETATION: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. FUNDING: Medical Research Council of South Africa.

Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. METHODS: We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899). FINDINGS: We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died. INTERPRETATION: Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective. FUNDING: Medical Research Council of South Africa.