An Assessment of Risk Factors for Herpes Simplex Virus Type 2 Infection in Malawian Women Using 2 Classifications for the HerpeSelect 2 Test.

BACKGROUND: The HerpeSelect 2 ELISA IgG test for herpes simplex virus type 2 (HSV-2) infection is widely used, convenient, and inexpensive. However, it has been shown to have lower specificity among populations in Sub-Saharan Africa compared with HSV-2 tests regarded as criterion standards. METHODS: In 2016, we collected blood and survey data from 248 women participating in a community-based cohort study in rural Malawi (the Umoyo wa Thanzi project). Using multinomial logistic regression accounting for village-level clustering, we examined unadjusted associations between select demographic and sexual risk factors and HSV-2 serostatus. Because increasing the index value cutpoint for a positive result improves specificity, we coded HSV-2 serostatus in 2 ways: the manufacturer's recommended cutpoints (<0.9, negative; 0.9-1.1, indeterminate; >1.1, positive) and modified cutpoints with improved specificity (<0.9, negative; 0.9-3.5, indeterminate; >3.5, positive). We aimed to investigate whether associations between select risk factors and HSV-2 serostatus varied under the 2 approaches. RESULTS: The prevalence of HSV-2 in this sample was 67% under the manufacturer's cutpoint and 22% under the modified cutpoint. Under both cutpoints, age, household size, number of marriages, and number of pregnancies were associated with HSV-2-positive serostatus. Using modified cutpoints, current bacterial vaginosis (odds ratio [OR], 3.17; 95% confidence interval [CI], 1.35-7.47), partner concurrency (OR, 4.88; 95% CI, 2.54-9.37) and unsure about partner concurrency (OR, 1.91; 95% CI, 1.08-3.38) were associated with HSV-2 seropositivity. Household size, education, and marital status were the only variables significantly associated with indeterminate HSV-2 serostatus using the modified cutpoints. CONCLUSION: HSV-2-focused interventions informed by identifying individuals likely to have or acquire HSV-2 must be aware that different target populations may emerge depending on which cutpoints are adopted.

Individual and community-level impact of infertility-related stigma in Malawi.

Infertility, a common experience among women and men worldwide, remains on the margins of public health and medicine in low-resource settings. Previous studies identified associations between individual experiences of infertility and negative outcomes, particularly in contexts where childbearing is imperative, but few have examined broader implications of infertility and infertility-related stigma on communities. To understand the production and impact of infertility-related stigma, this study analyzes 12 focus group discussions (FGDs) conducted with 104 women and men in rural Malawi. FGDs, conducted July-September 2018, were used to elicit the range of community norms around family formation, pregnancy, fertility, and infertility. Data were analyzed through memo-ing during and after data collection and collaborative, thematic coding. We found that stigma manifested within existing systems of gender and power. Aligning with Link and Phelan's stigma framework (2001) there were three primary mechanisms by which infertility-related stigma was produced and reinforced: labeling of a person perceived to be infertile (i.e., establishing 'other'), perpetuating negative stereotypes associated with suspected causes of infertility (e.g., abortion, multiple sexual partners, weak sperm), and consequences of infertility that reinforced stigma (e.g., social ridicule and distancing, divorce). Labels, presumed causes, and consequences of infertility were entrenched within gender and sexuality norms. Women perceived as infertile were unable to follow a normative path to achieving adult status, presumed to be sexually transgressive, and considered "useless." Men's masculinity was questioned. Both women's and men's identities, as well as social positions within relationships and communities, were threatened by perceptions of infertility. Ultimately, the manifestation of infertility-related stigma contributed to an environment wherein the risk of being perceived as infertile was highly consequential and unrelenting. Pervasive stigma, at the community-level, impacts decisions around contraceptive use and timing of childbearing, as women and men not only wanted to avoid infertility, but also the appearance of infertility.

The Relationship Between Ambivalent and Indifferent Pregnancy Desires and Contraceptive Use Among Malawian Women.

CONTEXT: Pregnancy ambivalence and pregnancy indifference are thought to be associated with nonuse of contraceptives, but their conceptualization and measurement vary, and their relationship to contraceptive use in developing countries is poorly understood. METHODS: Data from the Umoyo wa Thanzi research program in rural Lilongwe, Malawi, were used to classify the pregnancy desires of 592 women aged 15-39 as antinatal, pronatal, ambivalent or indifferent, according to both the women's desire to conceive and their desire to avoid pregnancy. Logistic regression was used to assess the relationship between each of the four pregnancy desire categories and use of modern contraceptives. RESULTS: Overall, 12% of women were classified as ambivalent, 32% as indifferent, 44% as antinatal and 12% as pronatal. In the logistic regression analysis, the odds of contraceptive use among women with indifferent pregnancy desires (having both a desire not to avoid pregnancy and a desire not to conceive) were twice those of women with pronatal desires (odds ratio, 2.2) and were similar to those among women with antinatal desires (2.7). In contrast, the odds of contraceptive use among women with ambivalent pregnancy desires (having both a desire to avoid pregnancy and a desire to conceive) did not differ from those of women who had pronatal desires. CONCLUSIONS: Ambivalent and indifferent pregnancy desires are common in Malawi and are associated with modern contraceptive use in different ways. Understanding the complex nature of pregnancy desires may be valuable in improving family planning programs.

Correlations between intimate partner violence and spontaneous abortion, stillbirth, and neonatal death in rural Malawi.

OBJECTIVE: To characterize associations between intimate partner violence (IPV) and adverse delivery outcomes among married Malawian women. METHODS: In the present secondary analysis of an ongoing project investigating sexual and reproductive health decision making in rural, Lilongwe District, Malawi, married women who had experienced at least one pregnancy were interviewed between July 15, 2014, and February 25, 2015. Associations between physical IPV experienced with participants' current partners and history of adverse delivery outcomes (spontaneous abortions, stillbirths, and neonatal deaths) were examined using log-binomial regression. RESULTS: The analyses included 792 women. The 166 (21.0%) participants who reported having experienced physical IPV with their current partner were significantly more likely to have a history of adverse delivery outcomes in the unadjusted (prevalence ratio 1.23; 95% confidence interval 1.08-1.41) and adjusted (adjusted prevalence ration 1.19; 95% CI 1.01-1.40) analyses. CONCLUSION: Physical IPV was reported by a large proportion of participants in the present study and was significantly associated with adverse delivery outcomes. Public health interventions providing physical IPV screening and referral to support services could help improve maternal and child health in Malawi.

The impact of joint partner decision making on obstetric choices and outcomes among Malawian women.

OBJECTIVE: To determine the effects of joint partner decision making on obstetric choices and outcomes in Malawi. METHODS: Between July 15, 2014 and February 25, 2015, interviews were performed with women who reported at least one lifetime pregnancy in Lilongwe District, Malawi as part of a cross-sectional study of reproductive decision making. Logistic regression models were applied to examine associations of joint decision making with delivery location and obstetric complications. RESULTS: The study population included 860 women. Women who engaged in joint decision making with partners (adjusted odds ratio [aOR] 4.9; 95% confidence interval [CI] 3.3-7.2) and women whose partners made obstetric-care decisions alone (aOR 3.2; 95% CI 2.4-4.4) were more likely to undergo delivery at a healthcare facility compared with women who made obstetric-care decisions individually. In comparison with women who made obstetric decisions individually, no difference in the likelihood of experiencing obstetric complications was observed for women who engaged in joint decision making (aOR 1.1; 95% CI 0.7-1.7) or for women whose partners made decisions individually (aOR 0.8; 95% CI 0.5-1.3). CONCLUSION: In rural Malawi, partner involvement in obstetric decision making was associated with improved obstetric choices.