Maternal mid-upper arm circumference to predict small for gestational age: Findings in a Zambian cohort.

OBJECTIVE: To compare the performance of mid upper arm circumference (MUAC) and body mass index (BMI) for prediction of small for gestational age (SGA) in Zambia. METHODS: This is a secondary analysis of an ongoing clinical cohort that included women with a single gestation and MUAC measured before 24 weeks of pregnancy. We assessed relationships between maternal MUAC and birth weight centile using regression. The performance of MUAC and BMI to predict SGA was compared using receiver operating characteristic curves and the effect of maternal HIV was investigated in sub-group analyses. RESULTS: Of 1117 participants, 847 (75%) were HIV-negative (HIV-) and 270 (24%) were HIV-positive (HIV+). Seventy-four (7%) delivered severe SGA infants (<3rd centile), of whom 56 (76%) were HIV- and 18 (24%) were HIV+ (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.58-1.75). MUAC was associated with higher birth weight centile (+1.2 centile points, 95% CI 0.7-1.6; P < 0.001); this relationship was stronger among HIV+ women (+1.7 centile points, 95% CI 0.8-2.6; P < 0.001) than HIV- women (+0.9 centile points, 95% CI 0.4-1.4; P = 0.001). The discriminatory power was similar, albeit poor (area under the curve [AUC] < 0.7), between MUAC and BMI for the prediction of SGA. In stratified analysis, MUAC and BMI showed excellent discrimination predicting severe SGA among HIV+ (AUC 0.83 and 0.81, respectively) but not among HIV- women (AUC 0.64 and 0.63, respectively). CONCLUSION: Maternal HIV infection increased the discrimination of both early pregnancy MUAC and BMI for prediction of severe SGA in Zambia. CLINICAL TRIAL NUMBER: ClinicalTrials.gov (NCT02738892).

Differences in disease severity and delivery gestational age between black and white patients with hypertensive disorders of pregnancy.

OBJECTIVES: We sought to quantify racial differences in disease severity and delivery gestational age among Black and White patients with a diagnosis of a hypertensive disorder of pregnancy. STUDY DESIGN: This was a retrospective cohort of all Black and White pregnant patients carrying non-anomalous singleton or twin gestations at a single tertiary healthcare system who were diagnosed with a hypertensive disorder of pregnancy, 2014-2020. MAIN OUTCOME MEASURE: The primary outcome was delivery < 34 weeks' gestation. Secondary outcomes were delivery < 28 weeks', preeclampsia with severe features, acute renal insufficiency, HELLP syndrome, cesarean delivery, classical cesarean delivery, small for gestational age, severe maternal morbidity, and severe composite neonatal morbidity. Outcomes were compared by race. Data were analyzed using chi square, t-test, and logistic regression. RESULTS: 3,522 patients (29.8% Black) met inclusion criteria. Black patients had a higher odds of delivery < 34 weeks' [adjusted odds ratio (aOR) 2.22, 95% CI 1.7-2.89] and < 28 weeks' (aOR 2.39, 95% CI 1.43-3.99) and developing preeclampsia with severe features (aOR 1.92, 95% CI 1.62-2.29) than White patients. Black patients also had higher aOR of classical cesarean, severe maternal morbidity, and a small for gestational age neonate. CONCLUSIONS: Black patients are more likely to experience severe hypertensive disorders of pregnancy and preterm delivery compared to White patients. These findings suggest that Black-White disparities in preterm birth may be partially attributable to disparities in onset and severity of hypertensive disorders of pregnancy.

Informing the scale-up of Kenya's nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production.

BACKGROUND: Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya. METHODS: This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews. RESULTS: From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%). CONCLUSION: To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).