Effects of Maternal HIV Infection and Alcohol Use in Pregnancy on Birth Outcomes in Uganda.

Alcohol use and HIV infection are prevalent in sub-Saharan Africa (sSA), and both are associated with low birth weight. Yet, few studies have evaluated the combined effects of maternal HIV infection and alcohol use on birth outcomes. We analyzed data from a prospective cohort study of HIV-related placental changes in Ugandan women. We defined alcohol use as self-reported alcohol use within the last year, using the AUDIT questionnaire and used linear and logistic regression to measure associations between maternal alcohol use, HIV serostatus, and birth weight. In a subsample, we measured alcohol exposure using phosphatidylethanol (PEth) in neonatal heelstick dried blood spots to confirm maternal alcohol use. Of 352 participants, 176 (50%) were women with HIV (WHIV). Three of 176 (2%) HIVuninfected women and 17/176 (10%) of WHIV self-reported alcohol use (P = 0.002). Maternal HIV infection was associated with lower birth weight (ß = -0.12, 95% CI [-0.20, -0.02], P = 0.02), but self-reported alcohol use was not (ß = 0.06, 95% CI [-0.15, 0.26], P = 0.54), and the interaction between HIV serostatus and alcohol use was not significant (P = 0.13). Among the PEth subsample, neither HIV status nor PEthconfirmed alcohol use were associated with low birth weight. Maternal HIV infection was associated with lower birth weight, but alcohol use was not, and there was no significant interaction between maternal HIV infection and alcohol use. Alcohol use was more prevalent in WHIV and under-reporting was common. A larger study of the effects of laboratory-confirmed alcohol and HIV exposure on birth outcomes is warranted.

Maternal near miss as a predictor of adverse perinatal outcomes: findings from a prospective cohort study in southwestern Uganda.

BACKGROUND: Despite efforts, Uganda has not met the World Health Organization target of < 12 newborn deaths per 1,000 live births. Severe maternal morbidity or 'near miss' is a major contributor to adverse perinatal outcomes, particularly in low-resource settings. However, the specific impact of maternal near miss on perinatal outcomes in Uganda remains insufficiently investigated. We examined the association between maternal near miss and adverse perinatal outcomes at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda. METHODS: We conducted a prospective cohort study among women admitted for delivery at MRRH's maternity ward from April 2022 to August 2022. We included mothers at ≥ 28 weeks of gestation with singleton pregnancies, while intrauterine fetal death cases were excluded. For the near-miss group, we consecutively included mothers with any one of the following: antepartum hemorrhage with shock, uterine rupture, hypertensive disorders, coma, and cardiac arrest; those without these complications constituted the non-near-miss group. We followed the mothers until delivery, and their infants until seven days postpartum or death. Adverse perinatal outcomes considered were low birth weight (< 2,500 g), low Apgar score (< 7 at five minutes), intrapartum stillbirths, early neonatal death, or admission to neonatal intensive care unit. Multivariable log-binomial regression was used to determine predictors of adverse perinatal outcomes. RESULTS: We enrolled 220 participants (55 maternal near misses and 165 non-near misses) with a mean age of 27 ± 5.8 years. Most of the near misses were pregnancies with hypertensive disorders (49%). Maternal near misses had a four-fold (adjusted risk ratio [aRR] = 4.02, 95% CI: 2.32-6.98) increased risk of adverse perinatal outcomes compared to non-near misses. Other predictors of adverse perinatal outcomes were primigravidity (aRR = 1.53, 95%CI: 1.01-2.31), and gestational age < 34 weeks (aRR = 1.81, 95%CI: 1.19-2.77). CONCLUSION: Maternal near misses, primigravidity, and preterm pregnancies were independent predictors of adverse perinatal outcomes in this study. We recommend implementing maternal near-miss surveillance as an integral component of comprehensive perinatal care protocols, to improve perinatal outcomes in Uganda and similar low-resource settings. Targeted interventions, including specialized care for women with maternal near misses, particularly primigravidas and those with preterm pregnancies, could mitigate the burden of adverse perinatal outcomes.

Abnormal obstetric shock index and associated factors among immediate postpartum women following vaginal delivery at a tertiary hospital in southwestern Uganda.

BACKGROUND: Early recognition of haemodynamic instability after birth and prompt interventions are necessary to reduce adverse maternal outcomes due to postpartum haemorrhage. Obstetric shock Index (OSI) has been recommended as a simple, accurate, reliable, and low-cost early diagnostic measure that identifies hemodynamically unstable women. OBJECTIVES: We determined the prevalence of abnormal obstetric shock index and associated factors among women in the immediate postpartum period following vaginal delivery at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda. METHODS: We conducted a cross-sectional study at the labour suite and postnatal ward of MRRH from January 2022 to April 2022. We systematically sampled women who had delivered vaginally, and measured their blood pressures and pulse rates at 1 h postpartum. We excluded mothers with hypertensive disorders of pregnancy. Sociodemographic, medical and obstetric data were obtained through interviewer-administered questionnaires. The prevalence of abnormal OSI was the proportion of participants with an OSI ≥ 0.9 (calculated as the pulse rate divided by the systolic BP). Logistic regression analysis was used to determine associations between abnormal OSI and independent variables. RESULTS: We enrolled 427 women with a mean age of 25.66 ± 5.30 years. Of these, 83 (19.44%), 95% CI (15.79-23.52) had an abnormal obstetric shock index. Being referred [aPR 1.94, 95% CI (1.31-2.88), p = 0.001], having had antepartum haemorrhage [aPR 2.63, 95% CI (1.26-5.73), p = 0.010] and having a visually estimated blood loss > 200 mls [aPR 1.59, 95% CI (1.08-2.33), p = 0.018] were significantly associated with abnormal OSI. CONCLUSION: Approximately one in every five women who delivered vaginally at MRRH during the study period had an abnormal OSI. We recommend that clinicians have a high index of suspicion for haemodynamic instability among women in the immediate postpartum period. Mothers who are referred in from other facilities, those that get antepartum haemorrhage and those with estimated blood loss > 200mls should be prioritized for close monitoring. It should be noted that the study was not powered to study the factors associated with AOSI and therefore the analysis for factors associated should be considered exploratory.

Risk factors for postpartum maternal mortality and hospital readmission in low- and middle-income countries: a systematic review.

BACKGROUND: In low- and middle-income countries, approximately two thirds of maternal deaths occur in the postpartum period. Yet, care for women beyond 24 h after discharge is limited. The objective of this systematic review is to summarize current evidence on socio-demographic and clinical risk factors for (1) postpartum mortality and (2) postpartum hospital readmission. METHODS: A combination of keywords and subject headings (i.e. MeSH terms) for postpartum maternal mortality or readmission were searched. Articles published up to January 9, 2021 were identified in MEDLINE, EMBASE, and CINAHL databases, without language restrictions. Studies reporting socio-demographic or clinical risk factors for postpartum mortality or readmission within six weeks of delivery among women who delivered a livebirth in a low- or middle-income country were included. Data were extracted independently by two reviewers based on study characteristics, population, and outcomes. Included studies were assessed for quality and risk of bias using the Downs and Black checklist for ratings of randomized and non-randomized studies. RESULTS: Of 8783 abstracts screened, seven studies were included (total N = 387,786). Risk factors for postpartum mortality included Caesarean mode of delivery, nulliparity, low or very low birthweight, and shock upon admission. Risk factors for postpartum readmission included Caesarean mode of delivery, HIV positive serostatus, and abnormal body temperature. CONCLUSIONS: Few studies reported individual socio-demographic or clinical risk factors for mortality or readmission after delivery in low- and middle-income countries; only Caesarean delivery was consistently reported. Further research is needed to identify factors that put women at greatest risk of post-discharge complications and mortality. Understanding post-discharge risk would facilitate targeted postpartum care and reduce adverse outcomes in women after delivery. TRIAL REGISTRATION: PROSPERO registration number: CRD42018103955.

Association between obesity and cervical intraepithelial neoplasia: results from a case control study in south western Uganda.

BACKGROUND: Though obesity has been said to be associated with a number of malignancies including cervical cancer, its association with cervical intraepithelial neoplasia (CIN) is still a contentious issue. This study was designed to determining the prevalence and association between obesity and CIN. METHODS: This was an unmatched case control study, involving women with cervical intraepithelial neoplasia (cases) and those negative for intraepithelial lesions or malignancy (controls) at the cervical cancer clinic of Mbarara Regional Referral Hospital, in south-western Uganda, between April and November 2022. Cases and controls provided written informed consent and were recruited in a ratio of 1:1. Cases were identified by visual inspection with acetic acid (VIA) and subsequent confirmation with cytology and/or histology. Demographic information was collected using an enrolment form and height, weight and waist circumference were recorded. We calculated body mass index (BMI) and identified obese women as those with body mass index of ≥ 30 kg/m2 from both case and control groups. Central obesity was defined as waist: height ration of ≥ 0.5. Data was analysed using STATA version 17. Categorical variables were analysed using proportions, chi-square and logistic regression analysis to determine association between obesity and CIN. Our level of statistical significance was set at ≤ 0.05. RESULTS: The prevalence of general and central obesity among cases was 25.5% (24/94) and 0% (0/94) respectively while the prevalence of general and central obesity among controls was 33.3% (37/111) and 0% (0/111) respectively. There was an increased prevalence of general obesity among women with low grade squamous intraepithelial lesions (LSIL). However, there was no statistically significant association between general obesity and CIN. Factors associated with general obesity included residing in Mbarara city (AOR 2.156, 95%CI 1.085-4.282, P-value 0.028), age group of 31-45 years (AOR 2.421, 95%CI 1.577-9.705, P-value 0.003) and ≥ 46 years (AOR 1.971, 95%CI 1.022-11.157, P-value 0.046). CONCLUSION: We observed an increased prevalence of general obesity among women with LSIL. However, there was no association between obesity and CIN. Factors associated with general obesity included residing in Mbarara city, and being in the age groups of 31-40 and ≥ 46 years. This highlights the need to rethink management of CIN to control other non-communicable diseases that could arise due to general obesity.

Bacterial isolates and antibiotic susceptibility among women with abnormal vaginal discharge attending the gynecology clinic at a tertiary hospital in southwestern Uganda: a cross-sectional study.

BACKGROUND: Abnormal vaginal discharge is a common complaint among women of reproductive age, affecting about one- third of all women. In resource-limited settings where access to laboratory services is limited, treatment is usually syndromic. This approach may result in ineffective treatment, with high recurrence rates and a potential of developing antibiotic resistance. This study aimed to determine the bacterial isolates and antibiotic susceptibility among women with an abnormal vaginal discharge attending the gynecology clinic at a tertiary hospital in Southwestern Uganda. METHODS: We conducted a hospital based cross-sectional study among 361 women aged 15-49 years, presenting with abnormal vaginal discharge at the gynecology clinic of Mbarara Regional Referral Hospital from December 2020 to June 2021. Demographic characteristics were collected using a structured questionnaire. We collected cervical and vaginal sterile swabs and subjected them to wet preparation and gram stain. The specimens were cultured for bacterial isolates. Susceptibility testing was performed on samples with bacterial isolates using the Kirby-Bauer disc diffusion method, on the commonly prescribed antibiotics in this setting. We summarized and described the bacterial isolates and antibiotic susceptibility patterns as frequencies and percentages. RESULTS: We enrolled 361 women with abnormal vaginal discharge. Bacteria were isolated in 29.6% (107/361) of the women, and the commonest isolates included; Staphylococcus aureus 48.6% (52/107), Klebsiella pneumoniae 29.9% (32/107) and Enterococcus faecalis 15% (16/107). Yeast cells were found in 17.7% (64/361) of the women with abnormal vaginal discharge. Cefuroxime (90.7%) and Ciprofloxacin (81.3%) had a high level of sensitivity while high levels of resistance were observed for Doxycycline (86.0%) and Azithromycin (67.0%). CONCLUSION: The common bacterial isolates were Staphylococcus aureus, Klebsiella pneumoniae and Enterococcus faecalis. The isolated bacteria were most sensitive to Cefuroxime and Ciprofloxacin but resistant to Doxycycline and Azithromycin. There is need for routine culture and susceptibility testing of women with abnormal vaginal discharge so as to guide treatment, minimize inappropriate antibiotic use and consequently reduce antibiotic resistance.

Demand-Side Factors in Maternal Health Outcomes: Evidence from a Community Health Worker Programme in Uganda.

While community health workers (CHWs) are a core feature of many low-resource healthcare systems, evidence on both their health impacts and the mechanisms behind these impacts remains limited. Using a difference-in-differences design with a control and treatment group, this study evaluated a CHW programme in southwestern Uganda aimed at improving maternal health outcomes. We found relatively little evidence of an overall programme effect on health behaviours, including antenatal care attendance and delivery under skilled supervision. Analysis of heterogeneity by gestational age at first antenatal visit - which should have modulated exposure to the intervention - provided suggestive evidence that treatment effects varied predictably with gestational age. Altogether, the absence of strong programme effects may have been due to suboptimal performance by CHWs, thus highlighting the importance of studying and instituting appropriate monitoring and incentive schemes for such programmes. Additionally, in contrast to the weak treatment effect findings, analysis of the entire study sample between the pre- and post-intervention periods showed large improvements in healthcare-seeking behaviour across both the treatment and control groups. These changes may have arisen from concurrent supply-side health facility improvements affecting the entire study population, spillover effects from the CHWs, or background health trends.

Altered Maternal Antibody Profiles in Women With Human Immunodeficiency Virus Drive Changes in Transplacental Antibody Transfer.

BACKGROUND: Human immunodeficiency virus (HIV)-exposed, uninfected (HEU) children have a higher risk of severe infection, but the causes are poorly understood. Emerging data point to altered antibody transfer in women with HIV (WHIV); however, specific perturbations and the influence of antiretroviral therapy (ART) and HIV viremia remain unclear. METHODS: We evaluated antigen-specific transplacental antibody transfer across 14 antigens in paired maternal and umbilical cord plasma from 352 Ugandan women; 176 were WHIV taking ART. We measured antigen-specific immunoglobulin G (IgG) sub-class (IgG1, 2, 3, 4) levels and antibody Fcγ receptor (FcγRn, 2a, 2b, 3a, 3b) binding profiles. We used partial least squares discrimi-nant analysis to define antigen-specific transplacental antibody transfer features. RESULTS: Global antibody transfer patterns were similar by maternal HIV serostatus, pointing to effective placental function in WHIV. However, HEU umbilical cord antibody profiles were altered, driven by perturbed WHIV seroprofiles, with higher levels of herpesvirus antibodies (P < .01 for Epstein-Barr virus, herpes simplex virus) and lower levels of classic vaccine-induced antibodies (P < .01 for tetanus, polio, Haemophilus influenzae type b), suggesting that umbilical cord antibody profile differences arise from imbalanced WHIV immunity. Abnormal WHIV antibody profiles were associated with HIV viremia, lower CD4 count, and postconception ART initiation (P = .01). CONCLUSIONS: Perturbed immune-dominance profiles in WHIV shift the balance of immunity delivered to neonates. Perturbed HIV-associated maternal antibody profiles are a key determinant of com-promised neonatal immunity. Maternal vaccination interventions may promote transfer of relevant, effective antibodies to protect HEU children against early-life infections.

The interaction between antenatal care and abnormal temperature during delivery and its relationship with postpartum care: a prospective study of 1,538 women in semi-rural Uganda.

BACKGROUND: Postnatal care (PNC) is an important tool for reducing maternal and neonatal morbidity and mortality. However, what predicts receipt and maintenance in PNC, particularly events during pregnancy and the peripartum period, is not well understood. We hypothesized that fever or hypothermia during delivery would engender greater health consciousness among those attending antenatal care, leading to greater PNC engagement after hospital discharge and our objective was to evaluate this relationship. METHODS: Women were prospectively enrolled immediately postpartum at Mbarara Regional Referral Hospital (MRRH). We collected postpartum vital signs and surveyed women by telephone about PNC receipt, fever, and infection at two and six weeks postpartum. Our outcome of interest was receipt of PNC post-discharge, defined as whether a participant visited a health facility and/or was hospitalized in the postpartum period. Our explanatory variables were whether a participant was ever febrile (> 38.0˚C) or hypothermic (< 36.0˚C) during delivery stay and whether a participant attended at least 4 antenatal care (ANC) visits. We used logistic regressions to estimate the association between ANC and fever/hypothermia with PNC, including an interaction term between ANC and fever/hypothermia to determine whether there was a modifying relationship between variables on PNC. Regression models were adjusted for age, marital status, parity, HIV serostatus, Mbarara residency, and whether the participant was referred to MRRH, RESULTS: Of the 1,541 women, 86 (5.6%) reported visiting a health facility and/or hospitalization and 186 (12.0%) had an abnormal temperature recorded during delivery stay. Of those who reported at least one visit, 59/86 (68.6%) delivered by cesarean, 37/86 (43.0%) reported post-discharge fever, and 44/86 (51.2%) reported post-discharge infection. Neither ANC attendance, abnormal temperature after delivery, nor their interaction term, were significantly associated with post-discharge PNC. The included covariates were not significantly associated with the outcome. CONCLUSIONS: While the overall proportion of women reporting post-discharge PNC was low, those who reported visiting a health facility and/or hospitalization had high proportions of post-discharge fever, post-discharge infection, and cesarean delivery, which suggests that these visits may have been related to problem-focused care. No significant associations between ANC and PNC were observed in this cohort. Further research assessing ANC quality and PNC visit focus is needed to ensure ANC and PNC are optimized to reduce morbidity and mortality.

Prevalence and associated factors of oligohydramnios in pregnancies beyond 36 weeks of gestation at a tertiary hospital in southwestern Uganda.

BACKGROUND: Oligohydramnios is associated with poor maternal and perinatal outcomes. In low-resource countries, including Uganda, oligohydramnios is under-detected due to the scarcity of ultrasonographic services. We determined the prevalence and associated factors of oligohydramnios among women with pregnancies beyond 36 weeks of gestation at Mbarara Regional Referral Hospital (MRRH) in Southwestern Uganda. METHODS: We conducted a hospital-based cross-sectional study from November 2019 to March 2020. Included were women at gestational age > 36 weeks. Excluded were women with ruptured membranes, those in active labour, and those with multiple pregnancies. An interviewer-administered structured questionnaire was used to capture demographic, obstetric, and clinical characteristics of the study participants. We determined oligohydramnios using an amniotic fluid index (AFI) obtained using an ultrasound scan. Oligohydramnios was diagnosed in participants with AFI ≤ 5 cm. We performed multivariable logistic regression to determine factors associated with oligohydramnios. RESULTS: We enrolled 426 women with a mean age of 27 (SD ± 5.3) years. Of the 426 participants, 40 had oligohydramnios, for a prevalence of 9.4% (95%CI: 6.8-12.6%). Factors found to be significantly associated with oligohydramnios were history of malaria in pregnancy (aOR = 4.6; 95%CI: 1.5-14, P = 0.008), primegravidity (aOR = 3.7; 95%CI: 1.6-6.7, P = 0.002) and increasing gestational age; compared to women at 37-39 weeks, those at 40-41 weeks (aOR = 2.5; 95%CI: 1.1-5.6, P = 0.022), and those at > 41 weeks (aOR = 6.0; 95%CI: 2.3-16, P = 0.001) were more likely to have oligohydramnios. CONCLUSION: Oligohydramnios was detected in approximately one out of every ten women seeking care at MRRH, and it was more common among primigravidae, those with a history of malaria in pregnancy, and those with post-term pregnancies. We recommend increased surveillance for oligohydramnios in the third trimester, especially among prime gravidas, those with history of malaria in pregnancy, and those with post-term pregnancies, in order to enable prompt detection of this complication and plan timely interventions. Future longitudinal studies are needed to assess clinical outcomes in women with oligohydramnios in our setting.

Improved maternal-fetal outcomes among emergency obstetric referrals following phone call communication at a teaching hospital in south western Uganda: a quasi-experimental study.

BACKGROUND: Emergency obstetric referrals develop adverse maternal-fetal outcomes partly due to delays in offering appropriate care at referral hospitals especially in resource limited settings. Referral hospitals do not get prior communication of incoming referrals leading to inadequate preparedness and delays of care. Phone based innovations may bridge such communication challenges. We investigated effect of a phone call communication prior to referral of mothers in labour as intervention to reduce preparation delays and improve maternal-fetal outcome at a referral hospital in a resource limited setting. METHODS: This was a quasi-experimental study with non-equivalent control group conducted at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda from September 2020 to March 2021. Adverse maternal-fetal outcomes included: early neonatal death, fresh still birth, obstructed labour, ruptured uterus, maternal sepsis, low Apgar score, admission to neonatal ICU and hysterectomy. Exposure variable for intervention group was a phone call prior maternal referral from a lower health facility. We compared distribution of clinical characteristics and adverse maternal-fetal outcomes between intervention and control groups using Chi square or Fisher's exact test. We performed logistic regression to assess association between independent variables and adverse maternal-fetal outcomes. RESULTS: We enrolled 177 participants: 75 in intervention group and 102 in control group. Participants had similar demographic characteristics. Three quarters (75.0%) of participants in control group delayed on admission waiting bench of MRRH compared to (40.0%) in intervention group [p = < 0.001]. There were significantly more adverse maternal-fetal outcomes in control group than intervention group (obstructed labour [p = 0.026], low Apgar score [p = 0.013] and admission to neonatal high dependency unit [p = < 0.001]). The phone call intervention was protective against adverse maternal-fetal outcome [aOR = 0.22; 95%CI: 0.09-0.44, p = 0.001]. CONCLUSION: The phone call intervention resulted in reduced delay to patient admission at a tertiary referral hospital in a resource limited setting, and is protective against adverse maternal-fetal outcomes. Incorporating the phone call communication intervention in the routine practice of emergency obstetric referrals from lower health facilities to regional referral hospitals may reduce both maternal and fetal morbidities. TRIAL REGISTRATION: Pan African Clinical Trial Registry PACTR20200686885039.

Short interbirth interval and associated factors among women with antecedent cesarean deliveries at a tertiary hospital, Southwestern Uganda.

BACKGROUND: Women with previous cesarean deliveries, have a heightened risk of poor maternal and perinatal outcomes, associated with short interbirth intervals. We determined the prevalence of short interbirth interval, and associated factors, among women with antecedent cesarean deliveries who delivered at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. METHODS: We conducted a cross-sectional study on the postnatal ward of MRRH from November 2020 to February 2021. We enrolled women who had antecedent cesarean deliveries through consecutive sampling. We obtained participants' socio-demographic and obstetric characteristics through interviewer-administered structured questionnaires. We defined short interbirth interval as an interval between two successive births of < 33 months. Modified Poisson regression was used to identify factors associated with short interbirth intervals. RESULTS: Of 440 participants enrolled, most had used postpartum family planning (PPFP) prior to the current pregnancy (67.5%), and most of the pregnancies (57.2%) were planned. The mean age of the participants was 27.6 ± 5.0 years. Of the 440 women, 147 had a short interbirth interval, for a prevalence of 33% (95%CI: 29-38%). In multivariable analysis, non-use of PPFP (adjusted prevalence ratio [aPR] = 2.24; 95%CI: 1.57-3.20, P < 0.001), delivery of a still birth at an antecedent delivery (aPR = 3.95; 95%CI: 1.43-10.9, P = 0.008), unplanned pregnancy (aPR = 3.59; 95%CI: 2.35-5.49, P < 0.001), and young maternal age (aPR = 0.25 for < 20 years vs 20-34 years; 95%CI: 0.10-0.64, P = 0.004), were the factors significantly associated with short interbirth interval. CONCLUSION: One out of every three womenwith antecedent caesarean delivery had a short interbirth interval. Short interbirth intervals were more common among women with history of still births, those who did not use postpartum family planning methods, and those whose pregnancies were unplanned, compared to their counterparts. Young mothers (< 20 years) were less likely to have short interbirth intervals compared to those who were 20 years or older. Efforts should be made to strengthen and scale up child-spacing programs targeting women with previous cesarean deliveries, given the high frequency of short interbirth intervals in this study population.

Placental Decidual Arteriopathy and Vascular Endothelial Growth Factor A Expression Among Women With or Without Human Immunodeficiency Virus.

BACKGROUND: Women with human immunodeficiency virus (HIV) (WHIV) are at higher risk of adverse birth outcomes. Proposed mechanisms for the increased risk include placental arteriopathy (vasculopathy) and maternal vascular malperfusion (MVM) due to antiretroviral therapy and medical comorbid conditions. However, these features and their underlying pathophysiologic mechanisms have not been well characterized in WHIV. METHODS: We performed gross and histologic examination and immunohistochemistry staining for vascular endothelial growth factor A (VEGF-A), a key angiogenic factor, on placentas from women with ≥1 MVM risk factors including: weight below the fifth percentile, histologic infarct or distal villous hypoplasia, nevirapine-based antiretroviral therapy, hypertension, and preeclampsia/eclampsia during pregnancy. We compared pathologic characteristics by maternal HIV serostatus. RESULTS: Twenty-seven of 41 (placentas 66%) assessed for VEGF-A were from WHIV. Mean maternal age was 27 years. Among WHIV, median CD4 T-cell count was 440/µL, and the HIV viral load was undetectable in 74%. Of VEGF-A-stained placentas, both decidua and villous endothelium tissue layers were present in 36 (88%). VEGF-A was detected in 31 of 36 (86%) with decidua present, and 39 of 40 (98%) with villous endothelium present. There were no differences in VEGF-A presence in any tissue type by maternal HIV serostatus (P = .28 to >.99). MVM was more common in placentas selected for VEGF-A staining (51 vs 8%; P < .001). CONCLUSIONS: VEGF-A immunostaining was highly prevalent, and staining patterns did not differ by maternal HIV serostatus among those with MVM risk factors, indicating that the role of VEGF-A in placental vasculopathy may not differ by maternal HIV serostatus.

Surgical, Obstetric, and Anesthetic Mortality Measurement at a Ugandan Secondary Referral Hospital.

BACKGROUND: The health care systems of low-income countries have severely limited capacity to treat surgical diseases and conditions. There is limited information about which hospital mortality outcomes are suitable metrics in these settings. METHODS: We did a 1-year observational cohort study of patient admissions to the Surgery and the Obstetrics and Gynecology departments and of newborns delivered at a Ugandan secondary referral hospital. We examined the proportion of deaths captured by standardized metrics of mortality. RESULTS: There were 17,015 admissions and 9612 deliveries. A total of 847 deaths were documented: 385 (45.5%) admission deaths and 462 (54.5%) perinatal deaths. Less than one-third of admission deaths occurred during or after an operation (n = 126/385, 32.7%). Trauma and maternal mortality combined with perioperative mortality produced 79.2% (n = 305/385) of admission deaths. Of 462 perinatal deaths, 412 (90.1%) were stillborn, and 50 (10.9%) were early neonatal deaths. The combined metrics of the trauma mortality rate, maternal mortality ratio, thirty-day perioperative mortality rate, and perinatal mortality rate captured 89.8% (n = 761/847) of all deaths documented at the hospital. CONCLUSIONS: The combination of perinatal, maternal, trauma, and perioperative mortality metrics captured most deaths documented at a Ugandan referral hospital.

Prevalence of postpartum depression and associated factors among women in Mbarara and Rwampara districts of south-western Uganda.

BACKGROUND: Postpartum depression (PPD) is a significant cause of maternal morbidity and has severe consequences on the well-being of mothers, new-borns, families, and communities. PPD reduces the mother's response to the child's needs. In severe cases, mothers suffering from PPD are prone to postpartum psychosis, commit suicide and, in rare cases, infanticide. We aimed to determine the prevalence and understand the factors associated with PPD among mothers in southwestern Uganda. METHODS: This was a cross-sectional study between November 2019 and June 2020 among 292 mothers, 6 to 8 weeks' postpartum. Mothers were selected from three health facilities in southwestern Uganda and enrolled using stratified consecutive sampling. Postpartum depression was clinically diagnosed using the Diagnostic and Statistical Manual of Mental Disorders V. The factors associated with PPD were assessed by using a structured interviewer administered questionnaire. The factors were analyzed using bivariate chi square analyses and multivariate logistic regression. RESULTS: Overall prevalence of PPD was 27.1% (95% CI: 22.2-32.5). This did not vary by the number of previous births or mode of birth. Five factors associated with PPD were low perceived social support, HIV positive status, rural residence, obstetrical complications and the baby crying excessively. CONCLUSION AND RECOMMENDATIONS: Prevalence of PPD in Mbarara and Rwampara districts is higher than what has previously been reported in Uganda indicating an urgent need to identify pregnant women who are at increased risk of PPD to mitigate their risk or implement therapies to manage the condition. Midwives who attend to these mothers need to be empowered with available methods of mitigating prevalence and consequences of PPD. Women who are HIV positive, residing in rural settings, whose babies cry excessively, having low social support systems and who have birth complications may be a particularly important focus for Ugandan intervention strategies to prevent and reduce the prevalence of PPD.

Prevalence and factors associated with severe anaemia post-caesarean section at a tertiary Hospital in Southwestern Uganda.

BACKGROUND: Severe anaemia after caesarean section adversely affects the woman and the new-born. While prenatal anaemia is extensively studied, the literature on post-caesarean section anaemia is limited and characteristics of women at the highest risk of developing severe anaemia after caesarean section are unknown. This study aimed to determine the prevalence and factors associated with severe anaemia on day three post caesarean section. METHODS: On the third day after caesarean section, women were consecutively enrolled in a cross-sectional study at Mbarara Regional Referral Hospital (MRRH). Women who got transfused peripartum were excluded. For every woman, we measured haemoglobin (Hb) concentration and collected data on sociodemographic, obstetric, and medical characteristics. The primary outcome was severe anaemia after caesarean section, defined as Hb < 7 g/dl. We used logistic regression analysis to determine factors associated with severe anaemia after caesarean section. P-value < 0.05 was considered statistically significant. RESULTS: From December 2019 to March 2020, 427 of 431 screened women were enrolled in the study. Their mean age was 26.05 (SD ± 5.84) years. Three hundred thirteen (73.3%) had attended at least four antenatal care visits. The prevalence of severe anaemia post-caesarean section was 6.79%. Foetus with macrosomia (aOR 7.9 95%CI: 2.18-28.85, p <  0.01) and having mild or moderate anaemia pre-caesarean section (aOR:9.6, 95%CI: 3.91-23.77, p <  0.01) were the factors associated with severe anaemia after caesarean section. CONCLUSION: Severe anaemia in women post-caesarean section is relatively uncommon at our institution. It is associated with preoperative anaemia and macrosomic birth. Women with a low preoperative Hb concentration and those whose foetus have macrosomia could be targeted for haemoglobin optimisation before and during caesarean section.

Wireless versus routine physiologic monitoring after cesarean delivery to reduce maternal morbidity and mortality in a resource-limited setting: protocol of type 2 hybrid effectiveness-implementation study.

BACKGROUND: Women in sub-Saharan Africa have the highest rates of morbidity and mortality during childbirth globally. Despite increases in facility-based childbirth, gaps in quality of care at facilities have limited reductions in maternal deaths. Infrequent physiologic monitoring of women around childbirth is a major gap in care that leads to delays in life-saving interventions for women experiencing complications. METHODS: We will conduct a type-2 hybrid effectiveness-implementation study over 12 months to evaluate using a wireless physiologic monitoring system to detect and alert clinicians of abnormal vital signs in women for 24 h after undergoing emergency cesarean delivery at a tertiary care facility in Uganda. We will provide physiologic data (heart rate, respiratory rate, temperature and blood pressure) to clinicians via a smartphone-based application with alert notifications if monitored women develop predefined abnormalities in monitored physiologic signs. We will alternate two-week intervention and control time periods where women and clinicians use the wireless monitoring system during intervention periods and current standard of care (i.e., manual vital sign measurement when clinically indicated) during control periods. Our primary outcome for effectiveness is a composite of severe maternal outcomes per World Health Organization criteria (e.g. death, cardiac arrest, jaundice, shock, prolonged unconsciousness, paralysis, hysterectomy). Secondary outcomes include maternal mortality rate, and case fatality rates for postpartum hemorrhage, hypertensive disorders, and sepsis. We will use the RE-AIM implementation framework to measure implementation metrics of the wireless physiologic system including Reach (proportion of eligible women monitored, length of time women monitored), Efficacy (proportion of women with monitoring according to Uganda Ministry of Health guidelines, number of appropriate alerts sent), Adoption (proportion of clinicians utilizing physiologic data per shift, clinical actions in response to alerts), Implementation (fidelity to monitoring protocol), Maintenance (sustainability of implementation over time). We will also perform in-depth qualitative interviews with up to 30 women and 30 clinicians participating in the study. DISCUSSION: This is the first hybrid-effectiveness study of wireless physiologic monitoring in an obstetric population. This study offers insights into use of wireless monitoring systems in low resource-settings, as well as normal and abnormal physiologic parameters among women delivering by cesarean. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04060667 . Registered on 08/01/2019.

Impact of an educational intervention on WHO surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda.

INTRODUCTION: The World Health Organization (WHO) recommends adherence to its surgical safety checklist (SSC) to optimize patient safety and reduce cesarean surgical site infection (SSI). Educational interventions combined with audit and feedback mechanisms on the checklist use by clinicians have the potential to improve adherence and clinical outcomes. Despite the increase in cesarean delivery rates, there is a paucity of data on how such interventions can improve adherence in resource-limited settings. OBJECTIVE: We performed a quality improvement project to measure the impact of an educational intervention with daily audit and feedback procedures on rates of WHO SSC adherence, including pre-operative antibiotic administration and SSI at Mbarara Regional Referral Hospital maternity ward in Uganda. METHODS: The study involved chart abstraction of WHO SSC and pre-operative antibiotic use during cesarean deliveries and signs of subsequent SSI in three phases. First, we conducted a retrospective review of all charts from May to June 2018 (pre-intervention phase). Second, we instituted an educational intervention on the WHO SSC and pre-operative antibiotics use, followed by a daily audit of charts and feedback to clinicians from July to August 2018 (the intervention phase). Third, we reviewed charts from September to October 2018 (the post-intervention phase). The WHO SSC adherence, pre-operative antibiotic administration and SSI rates were measured as the proportion of the total cesarean deliveries per study phase and then compared across the three phases. RESULTS: We reviewed 678 patients' charts (200 in the pre-intervention phase, 230 in the intervention phase and 248 in the post-intervention phase). The mean patient age was 25 years. The use of the WHO SSC was 7% in the pre-intervention phase compared to 92% in the intervention phase (P < 0.001), and 77% in the post-intervention phase (P < 0.001). Pre-intervention antibiotic receipt was 18% compared to 90% in the intervention phase (P < 0.001) and 84% in the post-intervention phase (P < 0.001). The documented SSI rate in the pre-intervention phase was 15% compared to 7% in the intervention phase (P = 0.02) and 11% in the post-intervention phase (P = 0.20). CONCLUSIONS: An educational intervention, daily audit and feedback to clinicians increased the use of the WHO SSC and prophylactic antibiotics for cesarean delivery-although the rates waned with time. Research to understand factors influencing the checklist use and antibiotic prophylaxis including prescriber knowledge, motivation and clinical process is required. Implementation interventions to sustain usage and impact on clinical outcomes need to be explored.

Antenatal Care Visit Attendance Frequency and Birth Outcomes in Rural Uganda: A Prospective Cohort Study.

OBJECTIVES: Antenatal care (ANC) is designed to improve pregnancy outcomes by providing screening and treatment for preventable and treatable diseases. However, data are lacking on whether ANC affects stillbirth risk. We hypothesized stillbirth risk in Uganda is lower in women attending the recommended ≥ 4 ANC visits compared to those attending ≤ 3. METHODS: We performed a secondary analysis of subset of 1,785 women enrolled in a prospective cohort of postpartum infection who presented to a regional referral hospital for delivery. Our primary outcome was documented stillbirth; a secondary composite poor birth outcome included stillbirth, early neonatal death, low birth weight (< 2500 g), and 5-min APGAR score < 7. We performed multivariable logistic regression analyses to identify independent correlates of stillbirth and poor birth outcome. RESULTS: Of 1,785 participants, 58 (3%) pregnancies resulted in stillbirth and 198 (11%) had a poor birth outcome. Of 1,236 women attending ≥ 4 ANC visits, 31 (2.5%) had a stillbirth, compared to 27/510 (5.2%) attending ≤ 3. In multivariable analyses controlling for age, parity, distance traveled, referral status to hospital, malaria prophylaxis, and syphilis infection; attending ≥ 4 ANC visits was associated with significantly reduced odds of stillbirth (aOR 0.5, 95% CI 0.3-0.9, P = 0.02) and poor birth outcome (aOR 0.66, 95% CI 0.4-0.96, P = 0.03). Malaria prophylaxis was also independently associated with reduced odds of stillbirth (aOR 0.05, 95% CI 0.2-1.0, P = 0.04). CONCLUSIONS: Attending ≥ 4 ANC visits was associated with reduced odds of stillbirth and poor birth outcomes in this Ugandan cohort, which may be related to more comprehensive infection screening, treatment, and prevention services.