Maternal mortality in Eastern Democratic Republic of Congo: a 10-year multi-zonal institutional death review.

BACKGROUND: Maternal mortality (MM) remains a real scourge that hits hardest in the poorest regions of the world, particularly those affected by conflict. However, despite this worrying reality, few studies have been conducted about MM ratio in the Democratic Republic of Congo (DRC). The study aimed to describe the trends as well as the epidemiological profile and causes of reported institutional maternal deaths between 2013 and 2022 in Eastern DRC. METHODS: A retrospective descriptive study was conducted between March 2023 and August 2023 in eight Health Zones (HZ), five in South Kivu Province (Mwana, Minova, Miti-Murhesa, Kamituga and Idjwi) and three in North Kivu Province (Kirotshe, Karisimbi and Kayna) in the eastern region of the DRC. Our study covers 242 health facilities: 168 health centers (HC), 16 referral health centers (RHCs),50 referral hospitals (RH) and 8 general referral hospitals (GRHs). Data from registers and medical records of maternal deaths recorded in these zones from 2013-2022 were extracted along with information on the number of deliveries and live births. Sociodemographic, clinical parameters, blood and ultrasound tests and suspected causes of death between provinces were assessed. RESULTS: In total, we obtained 177 files on deceased women. Of these, 143 (80.8%) were retained for the present study, including 75 in the 3 HZs of North Kivu and 68 in the 5 HZs of South Kivu. From 2013 to 2022, study sites experienced two significant drops in maternal mortality ratio (MMR) (in 2015 and 2018), and a spike in 2016-2017. Nonetheless, the combined MMR (across study sites) started and ended the 10-year study period at approximately the same level (53 and 57 deaths per 100,000 live births in 2013 and 2022 respectively). Overall, 62,6% of the deaths were reported from secondary hospital. Most deaths were of married women in their thirties (93.5%). Almost half (47.8%) had not completed four antenatal consultations. The main direct causes of death were, in decreasing order of frequency: post-partum haemorrhage (55.2%), uterine rupture (14.0), hypertensive disorders (8.4%), abortion (7.7%) puerperal infections (2.8%) and placental abruption (0.7%). When comparing among provinces, reported abortion-related maternal mortality (14.1% vs 0%) was more frequent in North Kivu than in South Kivu. CONCLUSION: This study imperatively highlights the need for targeted interventions to reduce maternal mortality. By emphasizing the crucial importance of antenatal consultations, intrapartum/immediate post-partum care and quality of care, significant progress can be made in guaranteeing maternal health and reducing many avoidable deaths.

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis.

BACKGROUND: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. METHODS: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. RESULTS: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. CONCLUSIONS: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

Arm circumference for age, arm circumference and weight-for-height z-score for the evaluation of severe acute malnutrition: a retrospective cohort study in eastern Democratic Republic of Congo.

BACKGROUND: Little is known about the use of mid-upper arm circumference for age (MUACZ) for diagnosing of severe acute malnutrition (SAM) and its correlation with WHZ (weight-for-height Z-score) in an area endemic for severe acute malnutrition (SAM) and with a high prevalence of kwashiorkor. Our study aims to analyze the concordance between the diagnostic criteria of SAM in a region presenting these characteristics. METHODS: We analyzed a database of children admitted from 1987 to 2008 for the management of SAM in Eastern Democratic Republic of Congo. Anthropometric indicators (z-score) were calculated and classified into 3 categories according to WHO standards. Cohen's kappa coefficient (κ) was calculated to assess the concordance between these indicators. RESULTS: Out of the 9969 selected children aged 6 to 59 months, 30.2% had nutritional edema, 70.1% had a height-for-age (HAZ) z-score <-2, 11.5% WHZ<-3 z-score, 14.9% had a MUAC < 115 mm and 21.8% had a MUACZ <-3 z-score. With the classic combination WHZ and MUAC, 36% of children with SAM had both criteria at the same time and MUAC alone being the indicator that recruited more children with SAM (77%) compared with 65% with WHZ only. By replacing MUAC with MUACZ, 34% of SAM children fulfilled both criteria, WHZ and MUACZ. MUACZ alone recruited more children with SAM (88%) compared with 46% with WHZ alone. Considering these three indicators together, MUACZ remained the indicator that recruited more children with SAM (85%). WHZ and MUAC showed a moderate agreement [ κ (95% CI) = 0.408(0.392-0.424)], WHZ and MUACZ a weak agreement [ κ (95% CI) = 0.363(0.347-0.379)] and MUAC and MUACZ a good agreement [ κ (95% CI) = 0.604 (0.590-0.618)]. CONCLUSION: Adjusting MUAC according to age improves its effectiveness in identifying severe acute malnutrition. With low concordance, MUAC and WHZ remain complementary in our context. MUACZ proves to be crucial, especially in the presence of kwashiorkor and chronic malnutrition, becoming a valuable tool for assessing severe acute malnutrition in our context.

Association between severe acute malnutrition in childhood and hematological disorders in adulthood: the Lwiro follow-up study in the Eastern Democratic Republic of the Congo.

BACKGROUND: Despite growing evidence on the short-term deleterious effects of severe acute malnutrition (SAM) in childhood on hematopoiesis, little is known about the long-term hematological effects of SAM in low-income countries (LICs). Our study explored the association between childhood SAM and hematological disorders in adults 11 to 30 years after post-SAM nutritional rehabilitation. METHODS: This follow up study investigated 97 adults (mean age 32 years) treated for SAM during childhood in eastern Democratic Republic of the Congo (DRC) between 1988 and 2007. Participants were compared to 97 aged- and sex-matched adult controls living in the same community with no history of SAM. Outcomes of interest were hematological characteristics and disorders in adulthood, assessed by various biological markers. Logistic and linear regression models were used to estimate the association between SAM in childhood and risk of hematological abnormalities. RESULTS: Compared to the unexposed, the exposed had higher mean white blood cells (/µl) [+ 840 (179 to 1501), p = 0.013], neutrophils [+ 504 (83 to 925), p = 0.019] and platelets (*103) [11.9 (8.1 to 17.9), p = 0.038] even after adjustment for food consumption in adulthood. No difference was observed in red blood cells (RBC), hemoglobin and erythrocytes parameters. With regard to the risk of hematological disorders, in contrast to the unexposed, exposed subjects had a risk of leukocytosis approximately three times higher [adjusted OR (95% CI): 2.98 (1.01 to 8.79), p = 0.048]. No difference was observed in terms of anemia, leukopenia, increased platelets and thrombocytopenia between the 2 groups. CONCLUSION: Adults with a history of SAM in childhood have hematological characteristics that would be markers associated with chronic low-grade inflammatory or infectious diseases in an environment with no nutritional transition. Larger cohort studies with bone marrow analyses could provide further understanding of the impact of SAM on the overall hematological profile in adult life.

Association between diagnostic criteria for severe acute malnutrition and hospital mortality in children aged 6-59 months in the eastern Democratic Republic of Congo: the Lwiro cohort study.

Background: Few studies have assessed the relationship between weight-for-height (WHZ) and mid-upper arm circumference (MUAC) with hospital mortality considering confounders. The particularity of MUAC for age (MUACZ) is less documented. Objective: This study aims to investigate this relationship in a region endemic for severe acute malnutrition (SAM). Methods: This is a retrospective cohort based on a database of children admitted from 1987 to 2008 in South Kivu, eastern DRC. Our outcome was hospital mortality. To estimate the strength of the association between mortality and nutritional indices, the relative risk (RR) with its 95% confidence interval (95% CI) was calculated. In addition to univariate analyses, we constructed multivariate models from binomial regression. Results: A total of 9,969 children aged 6 to 59 months were selected with a median age of 23 months. 40.9% had SAM (according to the criteria WHZ < -3 and/or MUAC<115 mm and/or the presence of nutritional edema) including 30.2% with nutritional edema and 35.2% had both SAM and chronic malnutrition. The overall hospital mortality was 8.0% and was higher at the beginning of data collection (17.9% in 1987). In univariate analyses, children with a WHZ < -3 had a risk almost 3 times higher of dying than children without SAM. WHZ was more associated with in-hospital mortality than MUAC or MUACZ. Multivariate models confirmed the univariate results. The risk of death was also increased by the presence of edema. Conclusion: In our study, WHZ was the indicator more associated with hospital death compared with MUAC or MUACZ. As such, we recommend that all criteria shall continue to be used for admission to therapeutic SAM programs. Efforts should be encouraged to find simple tools allowing the community to accurately measure WHZ and MUACZ.

Probiotics for children with uncomplicated severe acute malnutrition (PruSAM study): A randomized controlled trial in the Democratic Republic of Congo.

BACKGROUND: Severe acute malnutrition (SAM) contributes to nearly 1 million deaths annually worldwide, with diarrhea and pneumonia being the common morbidity associated with mortality. OBJECTIVES: To assess the effect of probiotics on diarrhea, pneumonia, and nutritional recovery in children with uncomplicated SAM. METHODS: A randomized, double-blind, placebo-controlled study was conducted involving 400 children with uncomplicated SAM randomly assigned to ready-to-use therapeutic food (RUTF) either with (n = 200) or without (n = 200) probiotics. Patients received 1 mL daily dose of a blend of Lacticasebacillus rhamnosus GG and Limosilactobacillus reuteri DSM 17938 (dosage, 2 billion colony-forming units; 50:50) or placebo during 1 mo. They were simultaneously fed with the RUTF for 6 to 12 wk, depending on patients' recovery rates. The primary outcome was the duration of diarrhea. Secondary outcomes included diarrheal and pneumonic incidence, nutritional recovery, and transfer to inpatient care rate. RESULTS: For children with diarrhea, the number of days of disease was lower in the probiotic group (4.11; 95% CI: 3.37, 4.51) than that in the placebo group (6.68; 95% CI: 6.26, 7.13; P < 0.001). For children aged 16 mo or older, the risk of diarrhea was lower in the probiotic group (75.6%; 95% CI: 66.2, 82.9) than that in the placebo group (95.0%; 95% CI: 88.2, 97.9; P < 0.001), but no significant difference of the risk for the youngest. In the probiotic group, nutritional recovery happened earlier: at the 6th wk, 40.6% of the infants were waiting for nutritional recovery, contrasting with 68.7% of infants in the placebo group; but the nutritional recovery rate at the 12th wk was similar between the groups. Probiotics had no effect on pneumonic incidence and transfer to inpatient care. CONCLUSIONS: This trial supports using probiotics for the treatment of children with uncomplicated SAM. Its effect on diarrhea could positively affect nutritional programs in resource-limited settings. This trial was registered https://pactr.samrc.ac.za as PACTR202108842939734.

Body composition of adults with a history of severe acute malnutrition during childhood using the deuterium dilution method in eastern DR Congo: the Lwiro Cohort Study.

BACKGROUND: Few studies have evaluated the body composition (BC) of adults who suffered from severe acute malnutrition (SAM) during childhood, a population at risk of long-term noncommunicable diseases. OBJECTIVE: We performed an observational cohort study to evaluate BC in a group of young adults aged 11-30 y after nutritional rehabilitation for SAM, in the Democratic Republic of the Congo (DRC). METHODS: We evaluated 151 adults in eastern DRC who were treated for SAM during childhood between 1988 and 2007. They were compared with 120 aged- and sex-matched control adults living in the same community who had not been exposed to malnutrition as children. The main variables of interest were the different compartments of adult BC (fat-free mass [FFM], fat mass [FM], and 2 indices of height-normalized BC: FFM index [FFMI] and FM index [FMI]) measured by deuterium dilution. RESULTS: The mean age in both groups was 23 y, and females represented 49% and 56% of the exposed and nonexposed groups, respectively. SAM-exposed males had lower mean ± SD weight (53.6 ± 6.4 compared with 56.4 ± 7.9 kg, P = 0.029) and lower height (159.9 ± 6.6 compared with 163.6 ± 6.7 cm, P = 0.003) compared to unexposed males. SAM-exposed subjects had less FFM (-1.56 kg [-2.93, -0.20]; P = 0.024) but this observation was more marked in males (45.4 ± 5.4 compared with 48.2 ± 6.9 kg, P = 0.01) than in females. No differences in FM were noted between SAM-exposed and unexposed subjects. Adjusting for height, FFMI and FMI showed no difference between SAM-exposed and unexposed in either sex. CONCLUSION: SAM during childhood is associated with reduced FFM in adulthood which is probably due to a shorter height.

Minimum acceptable diet among children aged 6-23 months in South Kivu, Democratic Republic of Congo: a community-based cross-sectional study.

BACKGROUND: Suboptimal child nutrition remains the main factor underlying child undernutrition in Democratic Republic of Congo (DRC). This study aimed to assess the prevalence of minimum acceptable diet and associated factors among children aged 6-23 months old. METHODS: Community-based cross-sectional study including 742 mothers with children aged 6-23 months old was conducted in 2 Health Zones of South Kivu, Eastern DRC. WHO indicators of Infant and Young Child Feeding (IYCF) regarding complementary feeding practices were used. Logistic regression analysis was used to quantify the association between sociodemographic indicators and adequate minimum acceptable diet for both univariate and multivariate analysis. RESULTS: Overall, 33% of infants had minimum acceptable diet. After controlling for a wide range of covariates, residence urban area (AOR 2.39; 95% CI 1.43, 3.85), attendance postnatal care (AOR 1.68; 95% CI 1.12, 2.97), education status of mother (AOR 1.83; 95% CI 1.20, 2.77) and household socioeconomic status (AOR 1.72; 95% CI 1.14, 2.59) were factors positively associated with minimum acceptable diet. CONCLUSION: Actions targeting these factors are expected to improve infant feeding practices in South Kivu.

Severe acute malnutrition in childhood, chronic diseases, and human capital in adulthood in the Democratic Republic of Congo: the Lwiro Cohort Study.

BACKGROUND: Little is known about the long-term outcome of children treated for severe acute malnutrition (SAM) after nutritional rehabilitation. OBJECTIVES: To explore the association between SAM in childhood, noncommunicable diseases (NCDs), and low human capital in adulthood. METHODS: We identified 524 adults (median age: 22 y) who were treated for SAM during childhood in Eastern Democratic Republic of Congo between 1988 and 2007. They were compared with 407 community unexposed age- and sex-matched subjects with no history of SAM. The variables of interest were cardiometabolic risk markers for NCDs and human capital. For the comparison, we used linear and logistic regressions to estimate the association between SAM in childhood and the risk of NCDs and ordinal logistic regression for the human capital. RESULTS: Compared with unexposed subjects, the exposed participants had a higher waist circumference [1.2 (0.02, 2.3) cm; P = 0.015], and a larger waist-to-height ratio [0.01 (0.01, 0.02) cm; P < 0.001]. On the other hand, they had a smaller hip circumference [-1.5 (-2.6, -0.5) cm; P = 0.021]. Regarding cardiometabolic markers for NCDs, apart from a higher glycated hemoglobin (HbA1c) [0.4 (0.2, 0.6); P < 0.001], no difference was observed in other cardiometabolic markers for NCD between the 2 groups. Compared with unexposed participants, exposed participants had a higher risk of metabolic syndrome (crude OR: 2.35; 95% CI: 1.22, 4.54; P = 0.010) and visceral obesity [adjusted OR: 1.44 (1.09, 1.89); P = 0.001]. The prevalence of hypertension, diabetes, overweight, and dyslipidaemia was similar in both groups. Last, the proportion of malnutrition survivors with higher socioeconomic status level was lower. CONCLUSION: SAM during childhood was associated with a high risk of NCDs and lower human capital in adulthood. Thus, policymakers and funders seeking to fight the global spread of NCDs in adults in low-resource settings should consider the long-term benefit of reducing childhood SAM as a preventive measure to reduce the socioeconomic burden attributable to NCDs.

Effects of probiotics and synbiotics on diarrhea in undernourished children: Systematic review with meta-analysis.

BACKGROUND: Undernutrition predisposes children to a greater incidence and duration of diarrhea. No review and meta-analysis have yet been conducted to assess effectiveness of probiotics and synbiotics in undernourished children. AIMS: To assess the effectiveness of probiotics and synbiotics on diarrhea in undernourished children. METHODS: Randomized, double-blind, placebo-controlled trials evaluating the effects of probiotics and synbiotics on diarrhea in undernourished children were searched from 1990 to May 2020. Recommendations of the Cochrane Handbook and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement were followed. RESULTS: The systematic review identified 15 trials with 6986 patients. The meta-analysis revealed that treatment with probiotic or synbiotic reduced significantly both the duration of diarrhea [Weighted mean difference (WMD) = -1.05 day, 95% CI (-1.98, -0.11)] and the hospital stay duration [Standard mean difference (SMD) = -2.87 days, 95% CI (-5.33, -0.42)], especially in specific patient subsets. In both groups, similar rates of vomiting and nutritional recovery were observed. No probiotics or synbiotics-related adverse effects were reported. Subgroup analyses showed that probiotic and synbiotic treatment were more effective in reducing risk of diarrhea in outpatients [Risk ratio (RR) = 0.86, 95%CI (0.75-0.98)]. CONCLUSION: This meta-analysis supports the potential beneficial roles of probiotics and synbiotics on diarrhea in undernourished children.

Severe acute malnutrition in children admitted in an Intensive Therapeutic and Feeding Centre of South Kivu, Eastern Democratic Republic of Congo: Why do our patients die?

BACKGROUND: Severe acute malnutrition (SAM) remains a serious public health concern in low- and middle-income countries. Little is known about treatment outcomes of child inpatients in Intensive Therapeutic and Feeding Units. This study aimed to assess treatment outcomes of SAM and identify factors associated with mortality among children treated at Saint Joseph Nutritional Center, South Kivu, Eastern Democratic Republic of Congo. METHODS: A retrospective hospital-based cross-sectional study was conducted on medical records of 633 severely malnourished children followed as inpatients at Saint Joseph Nutritional Center from July 2017 to December 2018. Data were entered, thoroughly cleaned and analyzed in SPSS version 25. Univariable and multivariable logistic regression model were fitted to identify factors associated with mortality. RESULTS: Among 633 patients admitted with SAM, 13.1% were lost to follow-up and 9.2% died while in hospital. Children with late referral to the health facility (> 14 days) after the onset of main external malnutrition signs had 2.03 times higher odds of death than those referred less than 14 days [AOR = 2.03 at 95%CI (1.12, 3.68)]. The odds of death was 1.91 times higher for children with MUAC < 115 mm than for those with MUAC ≥ 115 mm [AOR = 1.91 at 95% CI (1.05, 3.50)]. Children infected with HIV were 3.90 times more likely to die compared to their counterparts [AOR = 3.90 at 95% CI (2.80, 9.41)]. CONCLUSION: Particular emphasis should be placed on partnering with communities to improve information on malnutrition signs and on critical importance of early referral to the health system. While HIV incidence in DRC is still low (0.21%), its impact on mortality among severely malnourished children is increased due to the limited access to HIV testing and antiretroviral therapy.

Follow-up of a historic cohort of children treated for severe acute malnutrition between 1988 and 2007 in Eastern Democratic Republic of Congo.

BACKGROUND: It is well documented that treatment for severe acute malnutrition (SAM) is effective. However, little is known about the long-term outcomes for children treated for SAM. We sought to trace former SAM patients 11 to 30 years after their discharge from hospital, and to describe their longer-term survival and their growth to adulthood. METHODS: A total of 1,981 records of subjects admitted for SAM between 1988 and 2007 were taken from the archives of Lwiro hospital, in South Kivu, DRC. The median age on admission was 41 months. Between December 2017 and June 2018, we set about identifying these subjects (cases) in the health zones of Miti-Murhesa and Katana. For deceased subjects, the cause and year of death were collected. A Cox proportional hazards multivariate regression analysis was used to identify the death-related factors. For the cases seen, age- and gender-matched community controls were selected for a comparison of anthropometric indicators. RESULTS: A total of 600 subjects were traced, and 201 subjects were deceased. Of the deceased subjects, 65·6% were under 10 years old at the time of their death. Of the deaths, 59·2% occurred within 5 years of discharge from hospital. The main causes of death were malaria (14·9%), kwashiorkor (13·9%), respiratory infections (10·4%), and diarrhoeal diseases (8·9%). The risk of death was higher in subjects with SAM, MAM combined with CM, and in male subjects, with HRs* of 1·83 (p = 0·043), 2.35 (p = 0·030) and 1.44 (p = 0·013) respectively. Compared with their controls, the cases had a low weight (-1·7 kg, p = 0·001), short height [sitting (-1·3 cm, p = 0·006) and standing (-1·7 cm, p = 0·003)], short legs (-1·6 cm, p = 0·002), and a small mid-upper arm circumference (-3·2mm, p = 0·051). There was no difference in terms of BMI, thoracic length, or head and thoracic circumference between the two groups. CONCLUSION: SAM during childhood has lasting negative effects on growth to adulthood. In addition, these adults have characteristics that may place them at risk of chronic non-communicable diseases later in life.