An approach for evaluating early and long term mother-to-child transmission of HIV (MTCT) in low and middle income countries: a South African experience.

BACKGROUND: Eliminating mother-to-child transmission of HIV is a global public health target. Robust, feasible methodologies to measure population level impact of programmes to prevent mother-to-child transmission of HIV (PMTCT) are needed in high HIV prevalence settings. We present a summary of the protocol of the South African PMTCT Evaluation (SAPMTCTE) with its revision over three repeated rounds of the survey, 2010-2014. METHODS: Three cross sectional surveys (2010, 2011-2012 and 2012-2013) were conducted in 580 primary health care immunisation service points randomly selected after stratified multistage probability proportional to size sampling. All infants aged 4-8 weeks receiving their six-week immunisation at a sampled facility on the day of the visit were eligible to participate. Trained research nurses conducted interviews and took infant dried blood spot (iDBS) samples for HIV enzyme immunoassay (EIA) and total nucleic acid polymerase chain reaction (PCR) testing. Interviews were conducted using mobile phones and iDBS were sent to the National Health Laboratory for testing. All findings were adjusted for study design, non-response, and weighted for number of South African live-birth in each study round. In 2012 a national closed cohort of these 4 to 8-week old infants testing EIA positive (HIV Exposed Infants) from the 2012-2013 cross-sectional survey was established to estimate longer-term PMTCT impact to 18 months. Follow-up analyses were to estimate weighted cumulative MTCT until 18 months, postnatal MTCT from 6 weeks until 18 months and a combined outcome of MTCT-or-death, using a competing risks model, with death as a competing risk. HIV-free survival was defined as a child surviving and HIV-negative up to 18 months or last visit seen. A weighted cumulative incidence analysis was conducted, adjusting for survey design effects. DISCUSSION: In the absence of robust high-quality routine medical recording systems, in the context of a generalised HIV epidemic, national surveys can be used to monitor PMTCT effectiveness; however, monitoring long-term outcomes nationally is difficult due to poor retention in care.

"I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone": Adapting the Mothers2Mothers Mentor Mother Model for adolescent mothers living with HIV in Malawi.

BACKGROUND: Pregnant and post-partum adolescent girls and young women (AGYW) living with HIV in sub-Saharan Africa experience inferior outcomes along the prevention of mother-to-child transmission of HIV (PMTCT) cascade compared to their adult counterparts. Yet, despite this inequality in outcomes, scarce data from the region describe AGYW perspectives to inform adolescent-sensitive PMTCT programming. In this paper, we report findings from formative implementation research examining barriers to, and facilitators of, PMTCT care for HIV-infected AGYW in Malawi, and explore strategies for adapting the mothers2mothers (m2m) Mentor Mother Model to better meet AGYW service delivery-related needs and preferences. METHODS: Qualitative researchers conducted 16 focus group discussions (FGDs) in 4 Malawi districts with HIV-infected adolescent mothers ages 15-19 years categorized into two groups: 1) those who had experience with m2m programming (8 FGDs, n = 38); and 2) those who did not (8 FGDs, n = 34). FGD data were analyzed using thematic analysis to assess major and minor themes and to compare findings between groups. RESULTS: Median participant age was 17 years (interquartile range: 2 years). Poverty, stigma, food insecurity, lack of transport, and absence of psychosocial support were crosscutting barriers to PMTCT engagement. While most participants highlighted resilience and self-efficacy as motivating factors to remain in care to protect their own health and that of their children, they also indicated a desire for tailored, age-appropriate services. FGD participants indicated preference for support services delivered by adolescent HIV-infected mentor mothers who have successfully navigated the PMTCT cascade themselves. CONCLUSIONS: HIV-infected adolescent mothers expressed a preference for peer-led, non-judgmental PMTCT support services that bridge communities and facilities to pragmatically address barriers of stigma, poverty, health system complexity, and food insecurity. Future research should evaluate implementation and health outcomes for adolescent mentor mother services featuring these and other client-centered attributes, such as provision of livelihood assistance and peer-led psychosocial support.

Oral medicine acceptance in infants and toddlers: measurement properties of the caregiver-administered Children's acceptance tool (CareCAT).

BACKGROUND: Developing age-appropriate medications remains a challenge in particular for the population of infants and toddlers, as they are not able to reliably self-report if they would accept and consequently take an oral medicine. Therefore, it is common to use caregivers as proxies when assessing medicine acceptance. The outcome measures used in this research field differ and most importantly lack validation, implying a persisting gap in knowledge and controversy in the field. The newly developed Caregiver-administered Children's Acceptance Tool (CareCAT) is based on a 5-point nominal scale, with descriptors of medication acceptance behavior. This cross-sectional study assessed the measurement properties of the tool with regards to the user's understanding and its intra- and inter-rater reliability. METHODS: Participating caregivers were enrolled at a primary healthcare facility where their children (median age 6 months) had been prescribed oral antibiotics. Caregivers, trained observers and the tool developer observed and scored on the CareCAT tool what behavior children exhibited when receiving the medicine (n = 104). The video-records of this process served as replicate observations (n = 69). After using the tool caregivers were asked to explain their observations and the tool descriptors in their own words. The tool's reliability was assessed by percentage agreement and Cohen's unweighted kappa coefficients of agreement for nominal scales. RESULTS: The study found that caregivers using CareCAT had a satisfactory understanding of the tool's descriptors. Using its dichotomized scores the tool reliably was strong for acceptance behavior (agreement inter-rater 84-88%, kappa 0.66-0.76; intra-rater 87-89%, kappa 0.68-0.72) and completeness of medicine ingestion (agreement inter-rater 82-86%, kappa 0.59-0.67; intra-rater 85-93%, kappa 0.50-0.70). CONCLUSIONS: The CareCAT is a low-cost, easy-to-use and reliable instrument, which is relevant to assess acceptance behavior and completeness of medicine ingestion, both of which are of significant importance for developing age-appropriate medications in infants and toddlers.

Correction to: Effects of early feeding on growth velocity and overweight/obesity in a cohort of HIV unexposed South African infants and children.

[This corrects the article DOI: 10.1186/s13006-015-0041-x.].

In Utero ART Exposure and Birth and Early Growth Outcomes Among HIV-Exposed Uninfected Infants Attending Immunization Services: Results From National PMTCT Surveillance, South Africa.

BACKGROUND: Despite the recognized benefit of antiretroviral therapy (ART) for preventing and treating HIV, some studies have reported adverse birth outcomes with in utero ART exposure. We evaluated the effect of infant in utero HIV and ART exposure on preterm delivery (PTD), low birth weight (LBW), small for gestational age (SGA), and underweight for age (UFA) at 6 weeks. METHODS: We surveyed 6179 HIV-unexposed-uninfected (HUU) and 2599 HIV-exposed-uninfected (HEU) infants. HEU infants were stratified into 3 groups: ART, Zidovudine alone, and no antiretrovirals (None). The ART group was further stratified to explore pre- or postconception exposure. Multivariable logistic regression evaluated effects of HIV and ARV exposure on the outcomes. RESULTS: We found higher odds of PTD, LBW, SGA, and UFA in HEU than HUU infants. HEU in the None group (adjusted odds ratio [AOR], 1.9; 95% confidence interval [CI], 1.2-3.0) or those whose mothers initiated ART preconception (AOR, 1.7; 95% CI, 1.1-2.5) had almost twice the odds of PTD than infants whose mothers started ART postconception, but no increased odds for other outcomes. CONCLUSIONS: There was an association between preconception ART and PTD. As ART access increases, pregnancy registers or similar surveillance should be in place to monitor outcomes to inform future policy.

Toward elimination of mother-to-child transmission of HIV in South Africa: how best to monitor early infant infections within the Prevention of Mother-to-Child Transmission Program.

BACKGROUND: South Africa has utilized three independent data sources to measure the impact of its program for the prevention of mother-to-child transmission (PMTCT) of HIV. These include the South African National Health Laboratory Service (NHLS), the District Health Information System (DHIS), and South African PMTCT Evaluation (SAPMTCTE) surveys. We compare the results of each, outlining advantages and limitations, and make recommendations for monitoring transmission rates as South Africa works toward achieving elimination of mother-to-child transmission (eMTCT). METHODS: HIV polymerase chain reaction (PCR) test data, collected between 1 January 2010 to 31 December 2014, from the NHLS, DHIS and SAPMTCTE surveys were used to compare early mother-to-child transmission (MTCT) rates in South Africa. Data from the NHLS and DHIS were also used to compare early infant diagnosis (EID) coverage. RESULTS: The age-adjusted NHLS early MTCT rates of 4.1% in 2010, 2.6% in 2011 and 2.3% in 2012 consistently fall within the 95% confidence interval as measured by three SAPMTCTE surveys in corresponding time periods. Although DHIS data over-estimated MTCT rates in 2010, the MTCT rate declines thereafter to converge with age-adjusted NHLS MTCT rates by 2012. National EID coverage from NHLS data increases from around 52% in 2010 to 87% in 2014. DHIS data over-estimates EID coverage, but this can be corrected by employing an alternative estimate of the HIV-exposed infant population. CONCLUSION: NHLS and DHIS, two routine data sources, provide very similar early MTCT rate estimates that fall within the SAPMTCTE survey confidence intervals for 2012. This analysis validates the usefulness of routine data sources to track eMTCT in South Africa.

Structural Level Differences in the Mother-to-Child HIV Transmission Rate in South Africa: A Multilevel Assessment of Individual-, Health Facility-, and Provincial-Level Predictors of Infant HIV Transmission.

OBJECTIVES: In 2010, South Africa reported an early mother-to-child transmission (MTCT) rate of 3.5% at 4-8 weeks postpartum. Provincial early MTCT rates ranged from 1.4% [95% confidence interval (CI): 0.1 to 3.4] to 5.9% (95% CI: 3.8 to 8.0). We sought to determine reasons for these geographic differences in MTCT rates. METHODS: This study used multilevel modeling using 2010 South African prevention of mother-to-child transmission (PMTCT) evaluation (SAPMTCTE) data from 530 facilities. Interview data and blood samples of infants were collected from 3085 mother-infant pairs at 4-8 weeks postpartum. Facility-level data on human resources, referral systems, linkages to care, and record keeping were collected through facility staff interviews. Provincial level data were gathered from publicly available data (eg, health professionals per 10,000 population) or aggregated at province-level from the SAPMTCTE (PMTCT maternal-infant antiretroviral (ARV) coverage). Variance partition coefficients and odds ratios (for provincial facility- and individual-level factors influencing MTCT) from multilevel modeling are reported. RESULTS: The provincial- (5.0%) and facility-level (1.4%) variance partition coefficients showed no substantive geographic variation in early MTCT. In multivariable analysis accounting for the multilevel nature of the data, the following were associated with early MTCT: individual-level-low maternal-infant ARV uptake [adjusted odds ratio (AOR) = 2.5, 95% CI: 1.7 to 3.5], mixed breastfeeding (AOR = 1.9, 95% CI: 1.3 to 2.9) and maternal age <20 years (AOR 1.8, 95% CI: 1.1 to 3.0); facility-level-insufficient (≤2) health care-personnel for HIV-testing services (AOR = 1.8, 95% CI: 1.1 to 3.0); provincial-level PMTCT ARV (maternal-infant) coverage lower than 80% (AOR = 1.4, 95% CI: 1.1 to 1.9), and number of health professionals per 10,000 population (AOR = 0.99, 95% CI: 0.98 to 0.99). CONCLUSIONS: There was no substantial province-/facility-level MTCT difference. This could be due to good overall performance in reducing early MTCT. Disparities in human resource allocation (including allocation of insufficient health care personnel for testing and care at facility level) and PMTCT coverage influenced overall PMTCT programme performance. These are long-standing systemic problems that impact quality of care.

Population-level effectiveness of PMTCT Option A on early mother-to-child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT.

BACKGROUND: Eliminating mother-to-child transmission of HIV (EMTCT), defined as ≤50 infant HIV infections per 100 000 live births, is a global priority. Since 2011 policies to prevent mother-to-child transmission of HIV (PMTCT) shifted from maternal antiretroviral (ARV) treatment or prophylaxis contingent on CD4 cell count to lifelong maternal ARV treatment (cART). We sought to measure progress with early (4-8 weeks postpartum) MTCT prevention and elimination, 2011-2013, at national and sub-national levels in South Africa, a high antenatal HIV prevalence setting ( ≈ 29%), where early MTCT was 3.5% in 2010. METHODS: Two surveys were conducted (August 2011-March 2012 and October 2012-May 2013), in 580 health facilities, randomly selected after two-stage probability proportional to size sampling of facilities (the primary sampling unit), to provide valid national and sub-national-(provincial)-level estimates. Data collectors interviewed caregivers of eligible infants, reviewed patient-held charts, and collected infant dried blood spots (iDBS). Confirmed positive HIV enzyme immunoassay (EIA) and positive total HIV nucleic acid polymerase chain reaction (PCR) indicated infant HIV exposure or infection, respectively. Weighted survey analysis was conducted for each survey and for the pooled data. FINDINGS: National data from 10 106 and 9120 participants were analyzed (2011-12 and 2012-13 surveys respectively). Infant HIV exposure was 32.2% (95% confidence interval (CI) 30.7-33.6%), in 2011-12 and 33.1% (95% CI 31.8-34.4%), provincial range of 22.1-43.6% in 2012-13. MTCT was 2.7% (95% CI 2.1%-3.2%) in 2011-12 and 2.6% (95% CI 2.0-3.2%), provincial range of 1.9-5.4% in 2012-13. HIV-infected ARV-exposed mothers had significantly lower unadjusted early MTCT (2.0% [2011-12: 1.6-2.5%; 2012-13:1.5-2.6%]) compared to HIV-infected ARV-naive mothers [10.2% in 2011-12 (6.5-13.8%); 9.2% in 2012-13 (5.6-12.7%)]. Pooled analyses demonstrated significantly lower early MTCT among exclusive breastfeeding (EBF) mothers receiving >10 weeks ARV prophylaxis or cART compared with EBF and no ARVs: (2.2% [95% CI 1.25-3.09%] vs 12.2% [95% CI 4.7-19.6%], respectively); among HIV-infected ARV-exposed mothers, 24.9% (95% CI 23.5-26.3%) initiated cART during or before the first trimester, and their early MTCT was 1.2% (95% CI 0.6-1.7%). Extrapolating these data, assuming 32% EIA positivity and 2.6% or 1.2% MTCT, 832 and 384 infants per 100 000 live births were HIV infected, respectively. CONCLUSIONS: Although we demonstrate sustained national-level PMTCT impact in a high HIV prevalence setting, results are far-removed from EMTCT targets. Reducing maternal HIV prevalence and treating all maternal HIV infection early are critical for further progress.

Effects of early feeding on growth velocity and overweight/obesity in a cohort of HIV unexposed South African infants and children.

BACKGROUND: South Africa has the highest prevalence of overweight/obesity in Sub-Saharan Africa. Assessing the effect of modifiable factors such as early infant feeding on growth velocity and overweight/obesity is therefore important. This paper aimed to assess the effect of infant feeding in the transitional period (12 weeks) on 12-24 week growth velocity amongst HIV unexposed children using WHO growth velocity standards and on the age and sex adjusted body mass index (BMI) Z-score distribution at 2 years. METHODS: Data were from 3 sites in South Africa participating in the PROMISE-EBF trial. We calculated growth velocity Z-scores using the WHO growth standards and assessed feeding practices using 24-hour and 7-day recall data. We used quantile regression to study the associations between 12 week infant feeding and 12-24 week weight velocity (WVZ) with BMI-for-age Z-score at 2 years. We included the internal sample quantiles (70th and 90th centiles) that approximated the reference cut-offs of +2 (corresponding to overweight) and +3 (corresponding to obesity) of the 2 year BMI-for-age Z-scores. RESULTS: At the 2-year visit, 641 children were analysed (median age 22 months, IQR: 17-26 months). Thirty percent were overweight while 8.7% were obese. Children not breastfed at 12 weeks had higher 12-24 week mean WVZ and were more overweight and obese at 2 years. In the quantile regression, children not breastfed at 12 weeks had a 0.37 (95% CI 0.07, 0.66) increment in BMI-for-age Z-score at the 50th sample quantile compared to breast-fed children. This difference in BMI-for-age Z-score increased to 0.46 (95% CI 0.18, 0.74) at the 70th quantile and 0.68 (95% CI 0.41, 0.94) at the 90th quantile . The 12-24 week WVZ had a uniform independent effect across the same quantiles. CONCLUSIONS: This study demonstrates that the first 6 months of life is a critical period in the development of childhood overweight and obesity. Interventions targeted at modifiable factors such as early infant feeding practices may reduce the risks of rapid weight gain and subsequent childhood overweight/obesity.

First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa.

BACKGROUND: There is a paucity of data on the national population-level effectiveness of preventing mother-to-child transmission (PMTCT) programmes in high-HIV-prevalence, resource-limited settings. We assessed national PMTCT impact in South Africa (SA), 2010. METHODS: A facility-based survey was conducted using a stratified multistage, cluster sampling design. A nationally representative sample of 10 178 infants aged 4-8 weeks was recruited from 565 clinics. Data collection included caregiver interviews, record reviews and infant dried blood spots to identify HIV-exposed infants (HEI) and HIV-infected infants. During analysis, self-reported antiretroviral (ARV) use was categorised: 1a: triple ARV treatment; 1b: azidothymidine >10 weeks; 2a: azidothymidine ≤10 weeks; 2b: incomplete ARV prophylaxis; 3a: no antenatal ARV and 3b: missing ARV information. Findings were adjusted for non-response, survey design and weighted for live-birth distributions. RESULTS: Nationally, 32% of live infants were HEI; early mother-to-child transmission (MTCT) was 3.5% (95% CI 2.9% to 4.1%). In total 29.4% HEI were born to mothers on triple ARV treatment (category 1a) 55.6% on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal ARV (3a) and 5.5% had missing ARV information (3b). Controlling for other factors groups, 1b and 2a had similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b, 0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT was higher in group 2b (AOR 3.68, 1.69 to 7.97). Within group 3a, early MTCT was highest among breastfeeding mothers 11.50% (4.67% to 18.33%) for exclusive breast feeding, 11.90% (7.45% to 16.35%) for mixed breast feeding, and 3.45% (0.53% to 6.35%) for no breast feeding). Antiretroviral therapy or >10 weeks prophylaxis negated this difference (MTCT 3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60% and 2.11%, 1.28% to 2.95%, respectively). CONCLUSIONS: SA, a high-HIV-prevalence middle income country achieved <5% MTCT by 4-8 weeks post partum. The long-term impact on PMTCT on HIV-free survival needs urgent assessment.

HIV infection, viral load, low birth weight, and nevirapine are independent influences on growth velocity in HIV-exposed South African infants.

Data from a prospective multisite cohort study were used to examine the effect of HIV exposure, untreated HIV infection, and single-dose nevirapine on infant growth velocity. The 2009 WHO growth velocity standards constitute a new tool for this type of investigation and are in need of functional validation. In period 1 (3-24 wk), 65 HIV-infected, 502 HIV-exposed uninfected (HEU), and 216 HIV-unexposed infants were included. In period 2 (25-36 wk), 31 infants moved from the HEU group to the HIV-infected group. We compared weight velocity Z-scores (WVZ) and length velocity Z-scores (LVZ) by HIV group and assessed their independent influences. In period 1, mean WVZ (95% CI) was significantly (P < 0.001) lower in infected [-0.87 (-1.77, 0.04)] than HEU [0.81 (0.67, 0.94)] and unexposed [0.55 (0.33, 0.78)] infants. LVZ showed similar associations. In both periods, sick infants and those exposed to higher maternal viral loads had lower WVZ. Higher mean LVZ was associated with low birth weight. Infants that had received nevirapine had higher LVZ. In conclusion, HIV infection and not exposure was associated with low WVZ and LVZ in period 1. Eliminating infant HIV infection is a critical component in averting HIV-related poor growth patterns in infants in the first 6 mo of life.

Infant feeding practices at routine PMTCT sites, South Africa: results of a prospective observational study amongst HIV exposed and unexposed infants - birth to 9 months.

BACKGROUND: We sought to investigate infant feeding practices amongst HIV-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival. METHODS: Infant feeding data from a prospective observational cohort study conducted at three (of 18) purposively-selected routine South African PMTCT sites, 2002-2003, were analysed. Infant feeding data (previous 4 days) were gathered during home visits at 3, 5, 7, 9, 12, 16, 20, 24, 28, 32 and 36 weeks postpartum. Four feeding groups were of interest, namely exclusive breastfeeding, mixed breastfeeding, exclusive formula feeding and mixed formula feeding. Cox proportional hazards models were fitted to investigate associations between feeding practices (0-12 weeks) and infant HIV-free survival. RESULTS: Six hundred and sixty five HIV-positive and 218 HIV-negative women were recruited antenatally and followed-up until 36 weeks postpartum. Amongst mothers who breastfed between 3 weeks and 6 months postpartum, significantly more HIV-positive mothers practiced exclusive breastfeeding compared with HIV-negative: at 3 weeks 130 (42%) versus 33 (17%) (p < 0.01); this dropped to 17 (11%) versus 1 (0.7%) by four months postpartum. Amongst mothers practicing mixed breastfeeding between 3 weeks and 6 months postpartum, significantly more HIV-negative mothers used commercially available breast milk substitutes (p < 0.02) and use of these peaked between 9 and 12 weeks. The probability of postnatal HIV or death was lowest amongst infants living in the best resourced site who avoided breastfeeding, and highest amongst infants living in the rural site who stopped breastfeeding early (mean and standard deviations: 10.7% ± 3% versus 46% ± 11%). CONCLUSIONS: Although feeding practices were poor amongst HIV-positive and -negative mothers, HIV-positive mothers undertake safer infant feeding practices, possibly due to counseling provided through the routine PMTCT programme. The data on differences in infant outcome by feeding practice and site validate the WHO 2009 recommendations that site differences should guide feeding practices amongst HIV-positive mothers. Strong interventions are needed to promote exclusive breastfeeding (to 6 months) with continued breastfeeding thereafter amongst HIV-negative motherswho are still the majority of mothers even in high HIV prevalence setting like South Africa.

Epidural analgesia and risks of cesarean and operative vaginal deliveries in nulliparous and multiparous women.

Objective is to examine the effect of epidural analgesia in first stage of labor on occurrence of cesarean and operative vaginal deliveries in nulliparous women and multiparous women without a previous cesarean delivery. Design of the Prospective cohort study. Prenatal care was received at 12 free-standing health centers, 7 private physician offices, or 2 hospital-based clinics; babies were delivered at a free standing birth center or at 3 hospitals, all in San Diego, CA. This study of 2,052 women used data from the San Diego Birth Center Study that enrolled women between 1994 and 1996 to compare the birthing management of the collaborative Certified Nurse Midwife-Medical Doctor Model with that of the traditional Medical Doctor Model. Main Outcome Measures of the Cesarean or operative vaginal deliveries. After adjusting for differences between women who used and those who did not use epidural analgesia in 1st stage of labor, epidural use was associated with a 2.5 relative risk (95% CI: 1.8, 3.4) for operative vaginal delivery in nulliparous women, and a 5.9 relative risk (95% CI: 3.2, 11.1) in multiparous women. Epidural use was associated with a 2.4 relative risk (95% CI: 1.5, 3.7) for cesarean delivery in nulliparous women, and a 1.8 relative risk (95% CI: 0.6, 5.3) in multiparous women. Epidural anesthesia increases the risk for operative vaginal deliveries in both nulliparous and multiparous women, and increases risk for cesarean deliveries in nulliparous more so than in multiparous women.

Operational effectiveness of guidelines on complete breast-feeding cessation to reduce mother-to-child transmission of HIV: results from a prospective observational cohort study at routine prevention of mother-to-child transmission sites, South Africa.

OBJECTIVE: Until 2006, HIV-positive women who chose to exclusively breast-feed were advised to completely stop breast-feeding by 6 months. We investigated operational feasibility and predictors of complete breast-feeding cessation (CBC). DESIGN: A prospective observational cohort study at 3 routine prevention of mother-to-child transmission sites, South Africa. METHODS: Data on "complete breast-feeding cessation at 24 weeks" and "not breast-feeding (NBF) for 4 days before the last follow-up visit at or before 24 weeks" were gathered during home visits (3, 5, 7, 9, 12, 16, 20, and 24 weeks). The main subgroup of interest for this analysis was women practicing exclusive breast-feeding/predominant breast-feeding at 3 weeks. Univariate analysis, logistic regression, Kaplan-Meier Survival analysis, and Cox regression were performed. RESULTS: Eighty-eight women (43.6%) reported CBC. "Health staff suggesting formula use: [OR(a) 4.39 (1.76-10.97)] and "infant hospitalization" [OR(a) 3.27 (1.37-7.79)] were the only significant predictors of CBC. The probability of NBF at 5, 7, 9, 12, 16, 20, and 24 weeks was 2.8% [95% confidence interval (CI) 1.8% to 3.8%], 4.3% (3.0% to 5.6%), 5.9% (4.4% to 7.4%, 9.8% (7.9% to 11.7%), 16.1 (13.8% to 18.4%), 23.1% (20.5% to 25.7%), and 37.6% (34.6% to 40.6%), respectively. Infant HIV status [hazard ratio 5.5 95% CI 2.4 to 12.5] was the only predictor of infant death. NBF was not protective against 9-month infant HIV or death in univariate and multivariable analysis. CONCLUSIONS: At programmatic level, CBC by 24 weeks is uncommon, and success seems unrelated to predetermined social, economic, and environmental (acceptable, feasible, affordable, sustainable, and safe AFASS) criteria. Thus at this level, activities that encourage CBC (amongst women meeting AFASS criteria) need to be identified and tested.

Transfers among women intending a birth center delivery in the San Diego birth center study.

Using data from the San Diego Birth Center Study that enrolled underserved women between 1994 and 1996, we examined demographic, sociobehavioral, and medical predictors of hospital transfer in a group of women who intended to deliver at a freestanding birth center. Of the 1808 women, 34.6% transferred to the hospital antenatally and 19.6% transferred during labor, while 45.7% delivered at the birth center. Compared with multiparous women who had never had a cesarean and never had a previous hospital delivery, nulliparous women were 2.0 times more likely (95% confidence interval [CI], 1.4-2.7), multiparous women with a previous cesarean were 2.6 times more likely (95% CI, 1.7-3.8), and women without a previous cesarean but who had a previous hospital delivery were 2.1 times more likely (95% CI, 1.5-3.0) to transfer after adjusting for other predictors of transfer. Nulliparity, cesarean history and having a previous hospital delivery were among the strongest predictors of a hospital transfer even after adjusting for demographic, sociobehavioral, and other medical conditions. Understanding predictors of transfer may assist practitioners, patients, and policy makers in considering the appropriateness of individuals for birth center delivery or to target further education to reduce nonmedical transfers.

An update on HIV and infant feeding issues in developed and developing countries.

The field of mother to child transmission of human-immunodeficiency virus is rapidly evolving. In the United States, prevention focuses on implementation of universal human-immunodeficiency virus testing to assure compliance with recommended treatment regimens and infant-feeding strategies. In most cases, this is the avoidance of all breastfeeding. In developing countries, avoidance of breastfeeding places infants at higher risk of morbidity and mortality. Current World Health Organization recommendations require individualized counseling to determine the best feeding method for each woman.

Early postpartum breastfeeding and acculturation among Hispanic women.

BACKGROUND: Exclusive breastfeeding in the hospital is predictive of postpartum breastfeeding patterns. Although breastfeeding rates are similar for Hispanic and white women in the United States, evidence shows that more acculturated Hispanic mothers have lower rates of breastfeeding than those less acculturated. To date, no studies have examined whether this pattern exists in the immediate postpartum period. METHODS: We used medical record data from 1,635 participants in the San Diego Birth Center Study, a cohort study of low-income, low-risk pregnant women. We applied a proxy measure of acculturation to categorize participants into a low acculturation (Hispanic, Spanish speaking [n = 951]); high acculturation (Hispanic, English speaking [n = 408]); or white, English speaking (n = 276) group. Logistic regression was used to examine the relationship between acculturation and exclusive breastfeeding at the time of hospital discharge while controlling for potential confounders. RESULTS: Exclusive breastfeeding rates were significantly different across acculturation groups (p < 0.01). After adjusting for available confounding variables, women in the low acculturation group were more likely to breastfeed exclusively at discharge than those in the high acculturation group (OR = 1.36, 95% CI = 1.01-1.84). Women in the white, English-speaking group also had greater odds of exclusive breastfeeding when compared with those in the high acculturation group (OR = 1.49, 95% CI = 1.02-2.19). CONCLUSIONS: This cross-sectional study provides evidence of a correlation between acculturation and immediate postpartum breastfeeding, where higher acculturation is associated with lower odds of exclusive breastfeeding. Additional research is needed to understand how the process of acculturation may affect short- and long-term breastfeeding behavior.

Effect of smoking and alcohol use during pregnancy on the occurrence of low birthweight in a farming region in South Africa.

The aim of this case-control study was to determine the risk factors for low birthweight in a farming region in South Africa, with particular attention to maternal alcohol use and smoking, both independently and in combination. Data collection was via structured postpartum interviews and review of antenatal and delivery records. The study setting was a regional referral hospital in a farming region. The study subjects were 200 infants with birthweight < 2500 g (cases) and 200 unmatched control infants of normal weight born during the same period as the cases. The outcome measure was low birthweight, i.e. infant birthweight <2500 g. Results showed the contribution of term low birthweight (as a measure of intrauterine growth retardation) to the total low-birthweight incidence was almost 50%, indicating a substantial intrauterine growth retardation component in this population. Sociodemographic factors were not as predictive of low birthweight in this predominantly low income population. Smoking (adjusted OR 2.67, [95% CI 1.69, 4.20]) was the strongest life style-related predictor of low birthweight. The alcohol low-birthweight relationship was not significant when adjusted for smoking status (crude OR 2.15, [95% CI 1.37, 3.39]; adjusted OR 1.32, [95% CI 0.80, 2.20]). However, there appeared to be an interaction with combined use of these two substances during pregnancy that increased the risk of low birthweight (adjusted OR increased to 4.24, [95% CI 1.01, 17.76]. It is clear that life style factors such as smoking and drinking are contributing to the occurrence of low birthweight in the target region. A comprehensive health promotion programme needs to be implemented as an integral part of antenatal and family planning services, to reduce smoking and drinking by women in this community.

Operational effectiveness and 36 week HIV-free survival in the South African programme to prevent mother-to-child transmission of HIV-1.

OBJECTIVE: Previous studies on the operational effectiveness of programmes to reduce transmission of HIV from mother-to-child (PMTCT) in Africa have generally been hospital-based pilot studies with short follow-up periods. METHOD: Prospective cohort study to evaluate the routine operational effectiveness of the South African National PMTCT Programme, primarily measured by HIV-free survival at 36 weeks post-delivery. Three of eighteen pilot sites participating in the programme were selected as they reflected differences in circumstances, such as HIV prevalence, socioeconomic status and rural-urban location. A total of 665 HIV-positive mothers and their infants were followed. RESULTS: HIV-free survival at 36 weeks varied significantly across sites with 84% in Paarl, 74% in Umlazi and 65% in Rietvlei (P = 0.0003). Maternal viral load was the single most important factor associated with HIV transmission or death [hazard ratio (HR), 1.54; 95% confidence interval (CI), 1.21-1.95]. Adjusting for health system variables (fewer than four antenatal visits and no antenatal syphilis test) explained the difference between Rietvlei and Paarl (crude HR, 2.27; 95% CI, 1.36-3.77; adjusted HR, 1.81; 95% CI, 0.93-3.50). Exposure to breastmilk feeding explained the difference between Umlazi and Paarl (crude HR, 1.74; 95% CI, 1.06-2.84; adjusted HR, 1.41; 95% CI, 0.81-2.48). CONCLUSION: Ever breastfeeding and underlying inequities in healthcare quality within South Africa are predictors of PMTCT programme performance and will need to be addressed to optimize PMTCT effectiveness.