Model strategies to address barriers to cervical cancer treatment and palliative care among women in Zimbabwe: a public health approach.

BACKGROUND: Cervical cancer treatment and care remains limited in Zimbabwe despite the growing burden of the disease among women. This study was aimed at investigating strategies to address barriers in accessing treatment and care by women with cervical cancer in Harare, Zimbabwe. METHODS: A qualitative inquiry was conducted to generate evidence for this study. Eighty-four (84) participants were purposively selected for interviews and participation in focus group discussions. The participants were selected from cervical cancer patients, caregivers of cervical cancer patients, health workers involved in the care of cervical cancer patients as well as relevant policy makers in the Ministry of Health and Child Care. Participants were selected in such as a way as to ensure different of characteristics to obtain diverse perspectives about the issues under study. Discussion and interview guides were used as data collection tools and discussions/interviews were audio-recorded, transcribed and translated into English. Inductive thematic analysis was conducted using Dedoose software. RESULTS: Salient sub-themes that emerged in the study at the individual patient level were: provision of free or subsidized services, provision of transport to treating health facilities and provision of accommodation to patients undergoing treatment. At the societal level, the sub-themes were: strengthening of health education in communities and training of health workers and community engagement. Salient sub-themes from the national health system level were: establishment of more screening and treatment health facilities, increasing the capacities of existing facilities, decentralization of some services, building of multidisciplinary teams of health workers, development and rolling out of standardized guidelines and reformation of Acquired Immunodeficiency Virus (AIDS) levy into a fund that would finance priority disease areas. CONCLUSION: This study revealed some noteworthy strategies to improve access to cervical cancer treatment and care in low-income settings. Improved domestic investments in health systems and reforming health policies underpinned on strong political are recommended.

Impact of pretreatment low-abundance HIV-1 drug-resistant variants on virological failure among HIV-1/TB-co-infected individuals.

OBJECTIVES: To determine the impact of pretreatment low-abundance HIV-1 drug-resistant variants (LA-DRVs) on virological failure (VF) among HIV-1/TB-co-infected individuals treated with NNRTI first-line ART. METHODS: We conducted a case-control study of 170 adults with HIV-1/TB co-infection. Cases had at least one viral load (VL) ≥1000 RNA copies/mL after ≥6 months on NNRTI-based ART, and controls had sustained VLs <1000 copies/mL. We sequenced plasma viruses by Sanger and MiSeq next-generation sequencing (NGS). We assessed drug resistance mutations (DRMs) using the Stanford drug resistance database, and analysed NGS data for DRMs at ≥20%, 10%, 5% and 2% thresholds. We assessed the effect of pretreatment drug resistance (PDR) on VF. RESULTS: We analysed sequences from 45 cases and 125 controls. Overall prevalence of PDR detected at a ≥20% threshold was 4.7% (8/170) and was higher in cases than in controls (8.9% versus 3.2%), P = 0.210. Participants with PDR at ≥20% had almost 4-fold higher odds of VF (adjusted OR 3.7, 95% CI 0.8-18.3) compared with those without, P = 0.104. PDR prevalence increased to 18.2% (31/170) when LA-DRVs at ≥2% were included. Participants with pretreatment LA-DRVs only had 1.6-fold higher odds of VF (adjusted OR 1.6, 95% CI 0.6-4.3) compared with those without, P = 0.398. CONCLUSIONS: Pretreatment DRMs and LA-DRVs increased the odds of developing VF on NNRTI-based ART, although without statistical significance. NGS increased detection of DRMs but provided no additional benefit in identifying participants at risk of VF at lower thresholds. More studies assessing mutation thresholds predictive of VF are required to inform use of NGS in treatment decisions.

Prevalence and factors associated with early initiation of breastfeeding among women in Moshi municipal, northern Tanzania.

BACKGROUND: Early initiation of breastfeeding (EIBF) is a predetermining factor for exclusive breastfeeding, and thus a foundation for optimal breastfeeding practices. Rates of EIBF are low globally (42%) and in Tanzania (51%), yet few studies have been done on this issue in Tanzania. This study aimed to determine the prevalence and factors associated with early initiation of breastfeeding among women in northern Tanzania. METHODOLOGY: This study extracted information from a cohort of 536 women who were followed from 3rd trimester period October 2013 to December 2015 in Moshi municipal, northern Tanzania. The data for this paper was collected by the use of questionnaires at enrolment, delivery and 7 days after delivery. The analysis is based on data from 413 women for whom complete information was obtained. Log binomial regression analysis was used to determine factors associated with early initiation of breastfeeding. RESULTS: The prevalence of EIBF was 83%. Overall, women had high knowledge on colostrum (94%), knowledge on exclusive breastfeeding (81%) and time of breastfeeding initiation (71%), but only 54% were counseled on breastfeeding during antenatal care. Knowledge on timely initiation of breastfeeding during pregnancy and vaginal delivery were associated with EIBF. CONCLUSION: Early initiation of breastfeeding is high (83%) in Moshi Municipal but still below the universal coverage recommended by WHO and UNICEF. There is missed opportunity by health facilities to counsel and support early initiation of breastfeeding given high antenatal and facility delivery in this setting. There is a need to evaluate health facility bottle necks to optimal support of early initiation of breastfeeding in Tanzania.

Laboratory characterisation of Salmonella enterica serotype Typhi isolates from Zimbabwe, 2009-2017.

BACKGROUND: Typhoid fever remains a major public health problem in Zimbabwe with recurrent outbreaks reported since 2009. To provide guidance on appropriate treatment choice in order to minimise the morbidity and mortality of typhoid fever and prevent large scale outbreaks, we investigated the antimicrobial susceptibility patterns, prevalence of Salmonella enterica serotype Typhi (S. Typhi) H58 haplotype and molecular subtypes of S. Typhi from outbreak strains isolated from 2009 to 2017 in Zimbabwe and compared these to isolates from neighbouring African countries. METHODS: Antimicrobial susceptibility testing was performed on all isolates using the disk diffusion, and E-Test, and results were interpreted using Clinical and Laboratory Standards Institute (CLSI) guidelines (2017). S. Typhi H58 haplotype screening was performed on 161 (58.3%) isolates. Pulsed-field gel electrophoresis (PFGE) was performed on 91 selected isolates across timelines using antibiotic susceptibility results and geographical distribution (2009 to 2016). RESULTS: Between 2009 and 2017, 16,398 suspected cases and 550 confirmed cases of typhoid fever were notified in Zimbabwe. A total of 276 (44.6%) of the culture-confirmed S. Typhi isolates were analysed and 243 isolates (88.0%) were resistant to two or more first line drugs (ciprofloxacin, ampicillin and chloramphenicol) for typhoid. The most common resistance was to ampicillin-chloramphenicol (172 isolates; 62.3%). Increasing ciprofloxacin resistance was observed from 2012 to 2017 (4.2 to 22.0%). Out of 161 screened isolates, 150 (93.2%) were haplotype H58. Twelve PFGE patterns were observed among the 91 isolates analysed, suggesting some diversity exists among strains circulating in Zimbabwe. PFGE analysis of 2013, 2014 and 2016 isolates revealed a common strain with an indistinguishable PFGE pattern (100% similarity) and indistinguishable from PFGE patterns previously identified in strains isolated from South Africa, Zambia and Tanzania. CONCLUSIONS: Resistance to first line antimicrobials used for typhoid fever is emerging in Zimbabwe and the multidrug resistant S. Typhi H58 haplotype is widespread. A predominant PFGE clone circulating in Zimbabwe, South Africa, Zambia and Tanzania, argues for cross-border cooperation in the control of this disease.

Emergency cesarean section among women in Robson groups one and three: A comparison study of immigrant and Norwegian women giving birth in a low-risk maternity hospital in Norway.

Researchers have shown that some immigrant groups have an increased risk of emergency cesarean section. The authors' aim was to examine the differences in emergency cesarean section rates among immigrant women in Norway with low obstetric risks by using the Robson classification system. We performed secondary analysis on a Norwegian cohort study, where 10,125 women were classified in Robson groups one and three. Women from East, Southeast, and Central Asia, and from Africa had a higher risk of emergency cesarean section. The Robson classification system was a useful tool in comparing cesarean section rates between immigrant groups and host country populations.

Increasing trend of exclusive breastfeeding over 12 years period (2002-2014) among women in Moshi, Tanzania.

BACKGROUND: The World Health Organization has recommended that all infants under 6 months should be exclusively breastfed. An understanding of the trend of exclusive breastfeeding (EBF) over years and over smaller geographical areas is crucial to monitor the progress made in improving the proportions of infants' EBF. METHODS: Data on infant feeding practices on 2315 mother-infant pairs from 2002 to 2014 were extracted from cohorts of women who delivered in the Moshi Municipality. Descriptive statistics were used to establish the trend of EBF up to 1, 3 and 6 months across waves (2002/2004 = wave I, 2005/2012 = wave II and 2013/2014 = wave III), to relate EBF up to 6 months to wealth quintiles and to HIV status of mothers. RESULTS: The number of mothers in waves I, II and III were 1656 (71.5%), 256 (11.1%) and 403(17.4%) respectively. The percentages of EBF up to 6 months increased from 5.5, 13.7 to 16.9% from wave I to III. Overall, across the waves, the proportion of EBF up to 6 months among the mothers in the low wealth quintile was 4, 9 and 42%, and 7, 26 and 15% for the ones in the highest wealth quintile. The proportion of EBF up to 6 months has been increasing among HIV positive mothers while fluctuating among their counterparts across the waves. CONCLUSION: The proportion of EBF up to 6 months has been increasing in the Moshi municipality but is below the national average. While establishing trends of EBF at the national level is commendable, research to establish trends over smaller geographical areas is needed to provide a true picture that may otherwise be masked.

"We give water or porridge, but we don't really know what the child wants:" a qualitative study on women's perceptions and practises regarding exclusive breastfeeding in Kilimanjaro region, Tanzania.

BACKGROUND: World Health Organization (WHO) recommends exclusive breastfeeding (EBF) as the optimal way to feed infants below 6 months of age. The benefits of EBF are well documented. However, in Tanzania, EBF is still rarely practised. This study explored the knowledge, attitudes and practises of EBF among mothers in Kilimanjaro region of northern Tanzania. METHODS: This is a qualitative research study. The three districts in Kilimanjaro region namely Same, Moshi Municipal Council and Rombo districts were selected. In each district, three focus group discussions (FGDs) with mothers of infants aged 0-12 months were conducted. A total of 78 mothers participated in the focus group discussion. RESULTS: The main result is that most of the mothers had a theoretical knowledge of the benefits of EBF but were not able to practise this knowledge for a range of reasons. The reasons for not practising EBF in real life included poor maternal nutrition, the pressure for women to return to work, inadequate knowledge about expressing breast milk, and perceived insufficiency of milk supply. Additionally, mothers received conflicting advice from a range of sources including close relatives, community members and health care providers, and they often choose the advice of their elders. Mothers also offered suggestions on ways to improve EBF including educating the community on the benefits of EBF. CONCLUSION: The results show that the women need support from close relatives and employers to successfully practise EBF. This presents a need for involving close relatives in EBF interventions, as they are important sources of breastfeeding information in the community. Additionally, behavioural interventions that promote optimal breastfeeding practises might help to improve exclusive breastfeeding.

Influence of Maternal Characteristics during Pregnancy on the Infant Early Life Immune Responses in a High HIV Burdened Setting in Harare, Zimbabwe.

This study aimed at investigating the maternal characteristics that in turn influence the immunological status of infants in asymptomatic enteric pathogen carriers in mother baby pairs (MBPs) in a high HIV burdened population in Harare, Zimbabwe. BIOPLEX immunoassay was used to analyse serum samples from 39 MBPs for 27 cytokines and 6 immunoglobulins. The MBP were purposively selected based on HIV infection and Entamoeba histolytica carriage. Logistic regression was used to identify any link between maternal demographic and clinical data with infant cytokine and immunoglobulin levels. Maternal E. histolytica carriers were more likely to have infants with low levels of IL-12p70, FGF-basic, GM-CSF and TNF-α cytokines (OR: 0.14; 95% CI: 0.03-0.79) and high levels of IgA immunoglobulin (OR: 8.1; 95% CI: 1.45-45.06). HIV infected mothers were more likely to have infants with low levels of IgG2 (OR: 0.24; 95% CI: 0.06-1.00) and IgA (OR: 0.22; 95% CI: 0.05-0.90) immunoglobulins. Notably, it was highly likely to deliver infants with low IgG4 levels (OR: 0.24; 95% CI: 0.06-1.02) for maternal mean age above 30.38 years (Standard deviation 6.09) though not significant (p=0.05). Maternal E. histolytica asymptomatic carriage, and HIV-infection status result in low levels of pro-inflammatory cytokines IL-12p70, FGF-basic, GM-CSF and TNF-α and immunoglobulins IgG2, IgG4 and IgA on their infants.

Genotypic diversity of anogenital human papillomavirus in women attending cervical cancer screening in Harare, Zimbabwe.

Although anogenital cancers have been on a gradual rise in developing countries in the past few decades, they have been understudied. The objective was to investigate genotypic diversity of anogenital HPV amongst women reporting for routine cervical cancer screening in Harare in Zimbabwe. A cross-sectional study that enrolled 144 women ≥18 years from a cervical cancer-screening clinic was performed. Each woman provided a self-collected cervico-vaginal swab (VS) and a clinician-collected anal swab (CCAS). HIV testing was offered and cervical cytology was performed. Both VS and CCAS samples were HPV genotyped, using amplicon sequencing of the L1 gene region with Illumina technology. Mean age of the women was 39.9 (range 18-83 years, SD ± 11.0). HPV prevalence was 72% (104/144) in VS and 48% (69/144) in CCAS. The most common genotypes detected in both VS and CCAS were HPV18, HPV52, and HPV16. Sixty two percent of the subjects had multiple genotypic HPV infections. The odds of being HPV-positive among HIV-infected women were higher than in HIV-negative women in both the vagina and the anus (CCAS OR = 4.8; CI 2.4-9.8, P < 0.001) and (VS OR = 2.9; CI 1.3-6.4, P = 0.005). High HPV prevalence and diverse genotypes were detected in both the vagina and anus. Anal oncogenic HPV infection was common. HPV 52 was one of the most common oncogenic genotypes in both the vagina and anus. HIV co-infection played a significant role in the prevalence of HPV. These data have implications for design of primary and secondary programs for prevention of anogenital cancer in Zimbabwe.

Risk factors for complete uterine rupture.

BACKGROUND: Complete uterine rupture is a rare peripartum complication associated with a catastrophic outcome. Because of its rarity, knowledge about its risk factors is not very accurate. Most previous studies were small and over a limited time interval. Moreover, international diagnostic coding was used in most studies. These codes are not able to differentiate between the catastrophic complete type and less catastrophic partial type. Complete uterine rupture is expected to increase as the rate of cesarean delivery increases. Thus, we need more accurate knowledge about the risk factors for this complication. OBJECTIVE: The objective of the study was to estimate the incidence and risk factors for complete uterine rupture during childbirth in Norway. STUDY DESIGN: This population-based study included women that gave birth after starting labor in 1967-2008. Data were from the Medical Birth Registry of Norway and Patient Administration System, complemented with information from medical records. We included 1,317,967 women without previous cesarean delivery and 57,859 with previous cesarean delivery. The outcome was complete uterine rupture (tearing of all uterine wall layers, including serosa and membranes). Risk factors were parameters related to demographics, pregnancy, and labor. Odds ratios for complete uterine rupture were computed with crude logistic regressions for each risk factor. Separate multivariable logistic regressions were performed to calculate the adjusted odds ratios and 95% confidence intervals. RESULTS: Complete uterine rupture occurred in 51 cases without previous cesarean delivery (0.38 per 10,000) and 122 with previous cesarean delivery (21.1 per 10,000). The strongest risk factor was sequential labor induction with prostaglandins and oxytocin, compared with spontaneous labor, in those without previous cesarean delivery (adjusted odds ratio, 48.0, 95% confidence interval, 20.5-112.3) and those with previous cesarean delivery (adjusted odds ratio, 16.1, 95% confidence interval, 8.6-29.9). Other significant risk factors for those without and with previous cesarean delivery, respectively, included labor augmentation with oxytocin (adjusted odds ratio, 22.5, 95% confidence interval, 10.9-41.2; adjusted odds ratio, 4.4, 95% confidence interval, 2.9-6.6), antepartum fetal death (adjusted odds ratio, 15.0, 95% confidence interval, 6.2-36.6; adjusted odds ratio, 4.0, 95% confidence interval, 1.1-14.2), and previous first-trimester miscarriages (adjusted odds ratio, 9.6, 95% confidence interval, 5.7-17.4; adjusted odds ratio, 5.00, 95% confidence interval, 3.4-7.3). After a previous cesarean delivery, the risk of rupture was increased by an interdelivery interval <16 months (adjusted odds ratio, 2.3; 95% confidence interval, 1.1-5.4) and a previous cesarean delivery with severe postpartum hemorrhage (adjusted odds ratio, 5.6; 95% confidence interval, 2.4-13.2). CONCLUSION: Sequential labor induction with prostaglandins and oxytocin and augmentation of labor with oxytocin are important risk factors for complete uterine rupture in intact and scarred uteri.

Management of suspected primary Toxoplasma gondii infection in pregnant women in Norway: twenty years of experience of amniocentesis in a low-prevalence population.

BACKGROUND: Primary infection with Toxoplasma gondii during pregnancy may pose a threat to the fetus. Women infected prior to conception are unlikely to transmit the parasite to the fetus. If maternal serology indicates a possible primary infection, amniocentesis for toxoplasma PCR analysis is performed and antiparasitic treatment given. However, discriminating between primary and latent infection is challenging and unnecessary amniocenteses may occur. Procedure-related fetal loss after amniocentesis is of concern. The aim of the present study was to determine whether amniocentesis is performed on the correct patients and whether the procedure is safe for this indication. METHODS: Retrospective study analysing data from all singleton pregnancies (n = 346) at Oslo University Hospital undergoing amniocentesis due to suspected maternal primary toxoplasma infection during 1993-2013. Maternal, neonatal and infant data were obtained from clinical hospital records, laboratory records and pregnancy charts. All serum samples were analysed at the Norwegian Institute of Public Health or at the Toxoplasma Reference Laboratory at Oslo University Hospital. The amniocenteses were performed at Oslo University Hospital by experienced personnel. Time of maternal infection was evaluated retrospectively based on serology results. RESULTS: 50% (173) of the women were infected before pregnancy, 23% (80) possibly in pregnancy and 27% (93) were certainly infected during pregnancy. Forty-nine (14%) women seroconverted, 42 (12%) had IgG antibody increase and 255 (74%) women had IgM positivity and low IgG avidity/high dye test titre. Fifteen offspring were infected with toxoplasma, one of them with negative PCR in the amniotic fluid. Median gestational age at amniocentesis was 16.7 gestational weeks (GWs) (Q1 = 15, Q3 = 22), with median sample volume 4 ml (Q1 = 3, Q3 = 7). Two miscarriages occurred 4 weeks after the procedure, both performed in GW 13. One of these had severe fetal toxoplasma infection. CONCLUSIONS: Half of our study population were infected before pregnancy. In order to reduce the unnecessary amniocenteses we advise confirmatory serology 3 weeks after a suspect result and suggest that the serology is interpreted by dedicated multidisciplinary staff. Amniocentesis is safe and useful as a diagnostic procedure in diagnosing congenital toxoplasma infection when performed after 15 GW.

Risk factors for severe postpartum hemorrhage: a case-control study.

BACKGROUND: In high-income countries, the incidence of severe postpartum hemorrhage (PPH) has increased. This has important public health relevance because severe PPH is a leading cause of major maternal morbidity. However, few studies have identified risk factors for severe PPH within a contemporary obstetric cohort. METHODS: We performed a case-control study to identify risk factors for severe PPH among a cohort of women who delivered at one of three hospitals in Norway between 2008 and 2011. A case (severe PPH) was classified by an estimated blood loss ≥1500 mL or the need for blood transfusion for excessive postpartum bleeding. Using logistic regression, we applied a pragmatic strategy to identify independent risk factors for severe PPH. RESULTS: Among a total of 43,105 deliveries occurring between 2008 and 2011, we identified 1064 cases and 2059 random controls. The frequency of severe PPH was 2.5% (95% confidence interval (CI): 2.32-2.62). The most common etiologies for severe PPH were uterine atony (60%) and placental complications (36%). The strongest risk factors were a history of severe PPH (adjusted OR (aOR) = 8.97, 95% CI: 5.25-15.33), anticoagulant medication (aOR = 4.79, 95% CI: 2.72-8.41), anemia at booking (aOR = 4.27, 95% CI: 2.79-6.54), severe pre-eclampsia or HELLP syndrome (aOR = 3.03, 95% CI: 1.74-5.27), uterine fibromas (aOR = 2.71, 95% CI: 1.69-4.35), multiple pregnancy (aOR = 2.11, 95% CI: 1.39-3.22) and assisted reproductive technologies (aOR = 1.88, 95% CI: 1.33-2.65). CONCLUSIONS: Based on our findings, women with a history of severe PPH are at highest risk of severe PPH. As well as other established clinical risk factors for PPH, a history of severe PPH should be included as a risk factor in the development and validation of prediction models for PPH.

Effects of gestational age and the mode of surgical abortion on postabortion hemorrhage and fever: evidence from population-based reproductive health survey in Georgia.

BACKGROUND: Every year around 50 million unintended pregnancies worldwide are terminated by induced abortion. Even in countries, where it is legalized and performed in a safe environment, abortion carries some risk of complications for women. Findings of researchers on the factors that influence the sequelae of abortion are controversial and inconsistent. This study evaluates the effects of gestational age and the method of surgical abortion (i.e., dilatation and curettage and vacuum aspiration) on the most common abortion complications: postabortion hemorrhage and fever. METHODS: We performed a secondary analysis of the data from the population-based Georgian Reproductive Health Survey 2010. Information on 1974 surgical abortions performed >30 days prior to the survey interview were analyzed during the study. Logistic regression statistical analysis was applied to compare the abortion sequelae that followed vacuum aspiration and dilatation and curettage at different gestational ages (<10 weeks and ≥10 weeks). We examined two major early abortion-related complications: postabortion hemorrhage and febrile morbidity (fever ≥38 °C). RESULTS: Postabortion hemorrhage was reported in 43 cases (1.9%), and febrile morbidity occurred in 44 cases (2%) among all of the surgical abortions. The abortions performed by dilatation and curettage were associated with an estimated fourfold increased risk of developing hemorrhage (OR 4.4, 95% CI 2.2-8.6) and a twofold increased risk of developing fever (OR 2.37, 95% CI 1.17-4.79) compared with the abortions that were performed via vacuum aspiration. The risk of postabortion hemorrhage (OR 1.9, 95% CI 0.8-4.4) or fever (OR 0.9, 95% CI 0.4-2.1) did not significantly differ at gestational age < 10 weeks and ≥10 weeks. CONCLUSION: Vacuum aspiration was associated with reduced risks of postabortion hemorrhage and fever compared to dilatation and curettage. Gestational age ≥ 10 weeks was not found to be a predictive factor of immediate postabortion complications: hemorrhage and fever.

A maternal death from self-induced medical abortion: a call for action.

OBJECTIVES: In Georgia, which has a longstanding, liberalised abortion law, the abortion procedure is generally safe if it is performed in a medical facility. However, when socioeconomic barriers prevent women from seeking safe abortion services, some risk their life by self-terminating an unintended pregnancy. We present a case of maternal mortality after a self-induced medical abortion, with the aim to investigate the underlying non-clinical causes of maternal death and the relevant policy implications. CASE: A 34-year-old socially vulnerable woman self-administered 10 tablets of oral misoprostol to terminate an 18-week pregnancy. She expelled the fetus the following day. A week later, she developed excessive vaginal bleeding, difficulty in breathing and tachycardia. She was hospitalised and diagnosed with sepsis due to a retained placenta. Uterine curettage and aggressive conservative management, followed by total abdominal hysterectomy, failed to stop the fulminant septic process. The patient's condition deteriorated rapidly and she died 15 h after admission to hospital. CONCLUSION: Socially disadvantaged women in Georgia have limited access to safe abortion services, and some are impelled to self-induce abortion in order to terminate an unintended pregnancy. Inclusion of family planning and abortion services in the Universal Health Care benefits package for socially vulnerable families may reduce the morbidity and mortality associated with unsafe abortion practices.

Health care students at an Argentinean school of medicine: are they well prepared to provide quality sexual and reproductive health services?

OBJECTIVES: The aim of our study was to assess what students of the University of Buenos Aires School of Medicine learn about sexual and reproductive health (SRH) and rights, focusing particularly on their knowledge of accessibility to contraception and abortion legislation. METHODS: In this cross-sectional study, self-administered, anonymous questionnaires were administered to 760 first year students and to 695 final year students from different fields of study (medicine, midwifery, nursing, radiology, nutrition, speech therapy and physiotherapy) between 2011 and 2013. Students' knowledge of SRH was measured according to six variables: contraceptive methods, accessibility to contraception, emergency contraception, legislation on surgical contraception, legislation on voluntary interruption of pregnancy, and HIV transmission and prevention. Their level of knowledge was categorised as low, basic, medium or high, according to their responses. RESULTS: We observed higher levels of knowledge in final year students compared with first year students. Those with basic level knowledge or higher were doubled in most of the variables. However, when analysed in detail per field of study, the differences were not so marked. It is important that medical, midwifery and nursing students receive formal education in SRH topics. CONCLUSIONS: Our investigation revealed important deficiencies in knowledge in core topics of SRH care among soon-to-be health care providers that could represent serious barriers to health and rights for the Argentinean population in the near future. Thus, there is an urgent need to improve the teaching of SRH care.

Dried blood spot omega-3 and omega-6 long chain polyunsaturated fatty acid levels in 7-9 year old Zimbabwean children: a cross sectional study.

BACKGROUND: Omega-3 long chain-polyunsaturated fatty acids (LC-PUFAs)-docosahexaenoic acid (DHA), docosapentaenoic acid (DPA) and eicosapentaenoic acid (EPA)- and omega-6 LC-PUFA arachidonic acid (ARA), are essential for optimum physical and mental development in children. Prior to this study, the blood omega-3 LC-PUFA levels were unknown in Zimbabwean children, particularly in those aged 7-9 years, despite the documented benefits of LC-PUFAs. Documentation of the LC-PUFA levels in this age group would help determine whether interventions, such as fortification, are necessary. This study aimed to determine dried whole blood spot omega-3 and omega-6 LC-PUFA levels and LC-PUFA reference intervals among a selected group of Zimbabwean children aged 7-9 years old. METHODS: We conducted a cross sectional study from September 2011 to August 2012 on a cohort of peri-urban, Zimbabwean children aged 7-9 years. The children were born to mothers enrolled at late pregnancy into an HIV prevention program between 2002 and 2004. Dried whole blood spots were sampled on butylated hydroxytoluene antioxidant impregnated filter papers and dried. LC-PUFAs were quantified using gas liquid chromatography. Differences in LC-PUFAs between groups were compared using the Kruskal Wallis test and reference intervals determined using non-parametric statistical methods. RESULTS: LC-PUFAs levels were determined in 297 Zimbabwean children of whom 170 (57.2 %) were girls. The study determined that LC-PUFAs (wt/wt) ranges were EPA 0.06-0.55 %, DPA 0.38-1.98 %, DHA 1.13-3.52 %, ARA 5.58-14.64 % and ARA: EPA ratio 15.47-1633.33. Sixteen participants had omega-3 LC-PUFAs levels below the determined reference intervals, while 18 had higher omega-6 LC-PUFAs. The study did not show gender differences in omega-3 and omega-6 LC-PUFAs levels (all p > 0.05). EPA was significantly higher in the 8 year age group compared to those aged 7 and 9 years (median; 0.20 vs 0.17 vs 0.18, respectively, p = 0.049). ARA: EPA ratio was significantly higher in the 7 year age group compared to those aged 8 and 9 years (median; 64.38 vs 56.43 vs 55.87 respectively, p = 0.014). CONCLUSIONS: In this cohort of children, lower EPA levels and higher ARA: EPA ratios were observed compared to those reported in apparently healthy children elsewhere. The high ARA: EPA ratios might increase the vulnerability of these children to inflammatory pathologies. Identification and incorporation into diet of locally produced foodstuffs rich in omega-3 LC-PUFAs is recommended as well as advocating for dietary supplementation with omega-3 fish oils and algae based oils.

Frequency of Betapapillomavirus infections among HIV infected and uninfected Black Zimbabweans with cutaneous lesions.

Human papillomavirus (HPV) types from the Betapapillomavirus (ß-HPV) genus are plentiful in non-melanoma skin cancers and warts among Caucasians, but there is paucity of information among black Africans. To determine the frequency of ß-HPV genotypes in cutaneous infections among Black Zimbabweans, a cross-sectional study was carried out in which blood samples and skin biopsies were collected from patients infected and uninfected with HIV attending a referral hospital. We included 144 participants (72 infected and 72 uninfected with HIV) with clinically apparent cutaneous warts (n = 34), suspected non-melanoma skin cancers (n = 98) and Kaposi sarcoma (KS) (n = 18). The skin biopsies were analyzed for HPV DNA presence and type. ß-HPV DNA was identified among 70% (101/144) and was significantly higher among patients infected with HIV, 79% (57/72) compared to the HIV uninfected 61% (44/72) [OR = 2.42, 95% CI (1.09-5.47), P = 0.018]. All patients with warts, 89% of those with KS and 58% of those with non-melanoma skin cancers were HPV DNA positive and ß-HPV type 14 was identified in nearly half of the study participants 49.3% (71/144). Single HPV infections were observed in 33.7% (34/101) of the participants that were HPV DNA positive, 66.3% (67/101) had multiple HPV types. There was no significant difference between patients infected and uninfected with HIV in terms of multiple HPV infections. The distribution of different HPV types did not reveal any association with age and gender but there was an association between HPV 14 and HIV immune status. ß-HPVs are not uncommon among the Black Zimbabweans with skin lesions.

Immigrants from conflict-zone countries: an observational comparison study of obstetric outcomes in a low-risk maternity ward in Norway.

BACKGROUND: Immigrants have higher risks for some adverse obstetric outcomes. Furthermore, refugees are reported to be the most vulnerable group. This study compared obstetric outcomes between immigrant women originating from conflict-zone countries and ethnic Norwegians who gave birth in a low-risk setting. METHODS: This was a population-based study linking the Medical Birth Registry of Norway to Statistics Norway. The study included the first registered birth during the study period of women from Somalia (n = 278), Iraq (n = 166), Afghanistan (n = 71), and Kosovo (n = 67) and ethnic Norwegians (n = 6826) at Baerum Hospital from 2006-2010. Background characteristics and obstetric outcomes of each immigrant group were compared with ethnic Norwegians with respect to proportions and risks calculated by logistic regression models. RESULTS: In total, 7408 women and their births were analyzed. Women from Somalia were most at risk for adverse obstetric outcomes. Compared with ethnic Norwegians, they had increased odds ratios (OR) for emergency cesarean section (OR 1.81, CI 1.17-2.80), postterm birth (OR 1.93, CI 1.29-2.90), meconium-stained liquor (OR 2.39, CI 1.76-3.25), and having a small-for-gestational-age infant (OR 3.97, CI 2.73-5.77). They had a reduced OR for having epidural analgesia (OR 0.40, CI 0.28-0.56) and a large-for-gestational-age infant (OR 0.32, CI 0.16-0.64). Women from Iraq and Afghanistan had increased risk of having a small-for-gestational-age infant with OR of 2.21 (CI 1.36-3.60) and 2.77 (CI 1.42-5.39), respectively. Iraqi women also had reduced odds ratio of having a large-for-gestational-age infant (OR 0.35, CI 0.15-0.83). Women from Kosovo did not differ from ethnic Norwegians in any of the outcomes we tested. CONCLUSIONS: Even in our low-risk maternity ward, women originating from Somalia were at the greatest risk for adverse obstetric outcomes in the compared groups. We could not find the same risk among the other immigrant women, also originating from conflict-zone countries. Several factors may influence these findings, and this study suggests that immigrant women from Somalia need more targeted care during pregnancy and childbirth.

Higher risk for adverse obstetric outcomes among immigrants of African and Asian descent: a comparison study at a low-risk maternity hospital in Norway.

BACKGROUND: Immigrants have higher risks for some adverse obstetric outcomes, and 40 percent of women giving birth at the low-risk maternity ward in Baerum Hospital, Norway, are immigrants. This study compared obstetric outcomes between immigrants and ethnic Norwegians giving birth in a low-risk setting. METHODS: This was a population-based study linking the Medical Birth Registry of Norway to Statistics Norway. The study included the first registered birth during the study period to immigrant and ethnic Norwegian women at Baerum Hospital from 2006 to 2010. The main outcome measures were onset of labor, operative vaginal delivery, cesarean delivery, episiotomy, postpartum bleeding > 500 mL, epidural analgesia, labor dystocia, gestational age, meconium-stained liquor, 5-minute Apgar score, birthweight, and transfer to a neonatal intensive care unit. RESULTS: A total of 11,540 women originating from 141 countries were divided into seven groups. Compared with Norwegians, women from East, Southeast, and Central Asia had increased risk for operative vaginal delivery, postpartum bleeding, and low Apgar score. The African women had increased risk for postterm birth, meconium-stained liquor, episiotomy, operative vaginal delivery, emergency cesarean delivery, postpartum bleeding, low Apgar score, and low birthweight. Women from South and Western Asia had increased risk for low birthweight. CONCLUSION: Obstetric outcomes of immigrants differ significantly from those of Norwegians, even in a low-risk maternity unit. Thus, immigrant women would benefit from more targeted care during pregnancy and childbirth, even in low-risk settings.

BMC Medicine editorial board members on open access publishing.

In recognition of Open Access week (21st-27th October 2013), we asked some BMC Medicine Editorial Board Members to share their views and experiences on open access publishing. In this short video, they highlight the benefits of visibility and dissemination of their research, and discuss the future directions for this model of publishing.