Last data update: May 06, 2024. (Total: 46732 publications since 2009)
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Mortality among children aged <5 years living with HIV who are receiving antiretroviral treatment - U.S. President's Emergency Plan for AIDS Relief, 28 supported countries and regions, October 2020-September 2022
Agathis NT , Faturiyele I , Agaba P , Fisher KA , Hackett S , Agyemang E , Mehta N , Kindra G , Morof DF , Mutisya I , Nyabiage L , Battey KA , Olotu E , Maphosa T , Motswere-Chirwa C , Ketlogetswe AT , Mafa-Setswalo J , Mazibuko S , de Deus MIT , Nhaguiombe HG , Machage EM , Mugisa B , Ogundehin DT , Mbelwa C , Birabwa E , Etima M , Adamu Y , Lawal I , Maswai J , Njeru D , Mwambona J , Nguhuni B , Mrina R , Hrapcak S , Siberry GK , Godfrey C , Wolf HT . MMWR Morb Mortal Wkly Rep 2023 72 (48) 1293-1299 Globally, children aged <5 years, including those living with HIV who are not receiving antiretroviral treatment (ART), experience disproportionately high mortality. Global mortality among children living with HIV aged <5 years receiving ART is not well described. This report compares mortality and related clinical measures among infants aged <1 year and children aged 1-4 years living with HIV with those among older persons aged 5-14, 15-49, and ≥50 years living with HIV receiving ART services at all clinical sites supported by the U.S. President's Emergency Plan for AIDS Relief. During October 2020-September 2022, an average of 11,980 infants aged <1 year and 105,510 children aged 1-4 years were receiving ART each quarter; among these infants and children receiving ART, 586 (4.9%) and 2,684 (2.5%), respectively, were reported to have died annually. These proportions of infants and children who died ranged from four to nine times higher in infants aged <1 year, and two to five times higher in children aged 1-4 years, than the proportions of older persons aged ≥5 years receiving ART. Compared with persons aged ≥5 years living with HIV, the proportions of children aged <5 years living with HIV who experienced interruptions in treatment were also higher, and the proportions who had a documented HIV viral load result or a suppressed viral load were lower. Prioritizing and optimizing HIV and general health services for children aged <5 years living with HIV receiving ART, including those recommended in the WHO STOP AIDS Package, might help address these disproportionately poorer outcomes. |
Agreement between cause of death assignment by computer-coded verbal autopsy methods and physician coding of verbal autopsy interviews in South Africa
Groenewald P , Thomas J , Clark SJ , Morof D , Joubert JD , Kabudula C , Li Z , Bradshaw D . Glob Health Action 2023 16 (1) 2285105 BACKGROUND: The South African national cause of death validation (NCODV 2017/18) project collected a national sample of verbal autopsies (VA) with cause of death (COD) assignment by physician-coded VA (PCVA) and computer-coded VA (CCVA). OBJECTIVE: The performance of three CCVA algorithms (InterVA-5, InSilicoVA and Tariff 2.0) in assigning a COD was compared with PCVA (reference standard). METHODS: Seven performance metrics assessed individual and population level agreement of COD assignment by age, sex and place of death subgroups. Positive predictive value (PPV), sensitivity, overall agreement, kappa, and chance corrected concordance (CCC) assessed individual level agreement. Cause-specific mortality fraction (CSMF) accuracy and Spearman's rank correlation assessed population level agreement. RESULTS: A total of 5386 VA records were analysed. PCVA and CCVAs all identified HIV/AIDS as the leading COD. CCVA PPV and sensitivity, based on confidence intervals, were comparable except for HIV/AIDS, TB, maternal, diabetes mellitus, other cancers, and some injuries. CCVAs performed well for identifying perinatal deaths, road traffic accidents, suicide and homicide but poorly for pneumonia, other infectious diseases and renal failure. Overall agreement between CCVAs and PCVA for the top single cause (48.2-51.6) indicated comparable weak agreement between methods. Overall agreement, for the top three causes showed moderate agreement for InterVA (70.9) and InSilicoVA (73.8). Agreement based on kappa (-0.05-0.49)and CCC (0.06-0.43) was weak to none for all algorithms and groups. CCVAs had moderate to strong agreement for CSMF accuracy, with InterVA-5 highest for neonates (0.90), Tariff 2.0 highest for adults (0.89) and males (0.84), and InSilicoVA highest for females (0.88), elders (0.83) and out-of-facility deaths (0.85). Rank correlation indicated moderate agreement for adults (0.75-0.79). CONCLUSIONS: Whilst CCVAs identified HIV/AIDS as the leading COD, consistent with PCVA, there is scope for improving the algorithms for use in South Africa. |
Further evidence of misclassification of the injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed?
Groenewald P , Kallis N , Holmgren C , Glass T , Anthony A , Maud P , Akhalwaya Y , Afonso E , Niewoudt I , Martin LJ , De Vaal C , Cheyip M , Morof D , Prinsloo M , Matzopoulos R , Bradshaw D . S Afr Med J 2023 113 (9) 30-35 BACKGROUND: Contrary to the World Health Organization's internationally recommended medical certificate of cause of death, the South African (SA) death notification form (DNF) does not allow for the reporting of the manner of death to permit accurate coding of external causes of injury deaths. OBJECTIVES: To describe the injury cause-of-death profile from forensic pathology records collected for the National Cause-of-Death Validation (NCoDV) Project and compare it with profiles from other sources of injury mortality data. In particular, the recording of firearm use in homicides is compared between sources. METHODS: The NCoDV Project was a cross-sectional study of deaths that occurred during a fixed period in 2017 and 2018, from a nationally representative sample of 27 health subdistricts in SA. Trained fieldworkers scanned forensic records for all deaths investigated at the forensic mortuaries serving the sampled subdistricts during the study period. Forensic practitioners reviewed the records and completed a medical certificate of cause of death for each decedent. Causes of death were coded to the International Statistical Classification of Diseases, 10th revision (ICD-10), using Iris automated coding software. Cause-specific mortality fractions for injury deaths were compared with Injury Mortality Survey 2017 (IMS 2017) and Statistics South Africa 2017 (Stats SA 2017) datasets. The cause profile for all firearm-related deaths was compared between the three datasets. RESULTS: A total of 5 315 records were available for analysis. Males accounted for 77.6% of cases, and most decedents were aged between 25 and 44 years. Homicide was the leading cause of death (34.7%), followed by transport injuries (32.6%) and suicide (14.7%). This injury cause profile was similar to IMS 2017 but differed markedly from the official statistics, which showed markedly lower proportions of these three causes (15.0%, 11.6% and 0.7%, respectively), and a much higher proportion of other unintentional causes. Investigation of firearm-related deaths revealed that most were homicides in NCoDV 2017/18 (88.5%) and IMS 2017 (93.1%), while in the Stats SA 2017 data, 98.7% of firearm deaths were classified as accidental. Approximately 7% of firearm-related deaths were suicides in NCoDV 2017/18 and IMS 2017, with only 0.3% in Stats SA 2017. CONCLUSION: The official cause-of-death data for injuries in SA in 2017 differed substantially from findings from the NCoDV 2017/18 study and IMS 2017. Accurate data sources would ensure that public health interventions are designed to reduce the high injury burden. Inclusion of the manner of death on the DNF, as is recommended internationally, is critically important to enable more accurate, reliable and valid reporting of the injury profile. |
Factors associated with non-use of ART among men living with HIV in South Africa: findings from a population-based household survey (preprint)
Naqvi N , Swart X , Chikovore J , Ayalew K , Moyo S , Morof D , Makapela D , Bedford J . medRxiv 2023 05 Introduction: Although South Africa adopted the World Health Organization's Test and Treat strategy for HIV epidemic control in 2016, antiretroviral therapy (ART) treatment initiation and retention remain below target. In 2017, an estimated 56.3% of men living with HIV were on ART. We aimed to investigate factors associated with non-use of ART among men in South Africa. Method(s): Utilizing data from the fifth South African National HIV Prevalence, Incidence, Behavior and Communication (SABSSM V) cross-sectional survey conducted in 2017, a subset of data from HIV-positive men was stratified based on presence/absence of antiretroviral drugs (ARVs) detected in dried blood spot samples. Data were weighted to be representative of the national population and analyzed using multivariable logistic regression to assess predictors of non-use of ART; p<0.05 was considered significant. Result(s): A total of 6,920 men aged >=15 years old were enrolled in the study, of whom 953 (13.8%) tested HIV-positive. Among those HIV-positive, 810 (85%) had a known ARV test result: 470 (58%) had ARVs detected, and 340 (42%) did not have ARVs detected. Non-use of ART in men was associated with high-risk alcohol use (adjusted odds ratio (AOR)=3.68, 95% confidence interval (CI): 1.03-13.23), being a widower compared to being unmarried (AOR=6.99, 95%CI: 1.46-33.42), and having drug-resistant HIV (AOR=28.12, 95%CI: 13.89-56.94). Per year increase in age (AOR=0.67, 95%CI: 0.47-0.96), residence in rural tribal localities compared to urban localities (AOR=0.38, 95%CI: 0.18-0.78), or having a comorbidity such as tuberculosis or diabetes (AOR=0.06, 95%CI: 0.03-0.14) were positively associated with ART use. Conclusion(s): Non-use of ART was strongly associated with HIV drug resistance. Young men who are living with HIV, those with high-risk alcohol use, and widowers, should be a priority for HIV programming and linkage to care. Identifying interventions that are effective at linking these men to ART will help reduce the burden of HIV in South Africa. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Use of epidemiology surge support to enhance robustness and expand capacity of SARS-CoV-2 pandemic response, South Africa
Taback-Esra R , Morof D , Briggs-Hagen M , Savva H , Mthethwa S , Williams D , Drummond J , Rothgerber N , Smith M , McMorrow M , Ndlovu M , Adelekan A , Kindra G , Olivier J , Mpofu N , Motlhaoleng K , Khuzwayo L , Makapela D , Manjengwa P , Ochieng A , Porter S , Grund J , Diallo K , Lacson R . Emerg Infect Dis 2022 28 (13) S177-s180 As COVID-19 cases increased during the first weeks of the pandemic in South Africa, the National Institute of Communicable Diseases requested assistance with epidemiologic and surveillance expertise from the US Centers for Disease Control and Prevention South Africa. By leveraging its existing relationship with the National Institute of Communicable Diseases for >2 months, the US Centers for Disease Control and Prevention South Africa supported data capture and file organization, data quality reviews, data analytics, laboratory strengthening, and the development and review of COVID-19 guidance This case study provides an account of the resources and the technical, logistical, and organizational capacity leveraged to support a rapid response to the COVID-19 pandemic in South Africa. |
Insights on the differentiation of stillbirths and early neonatal deaths: A study from the Child Health and Mortality Prevention Surveillance (CHAMPS) network
Quincer E , Philipsborn R , Morof D , Salzberg NT , Vitorino P , Ajanovic S , Onyango D , Ogbuanu I , Assefa N , Sow SO , Mutevedzi P , El Arifeen S , Tippet Barr BA , Scott JAG , Mandomando I , Kotloff KL , Jambai A , Akelo V , Cain CJ , Chowdhury AI , Gure T , Igunza KA , Islam F , Keita AM , Madrid L , Mahtab S , Mehta A , Mitei PK , Ntuli C , Ojulong J , Rahman A , Samura S , Sidibe D , Thwala BN , Varo R , Madhi SA , Bassat Q , Gurley ES , Blau DM , Whitney CG . PLoS One 2022 17 (7) e0271662 INTRODUCTION: The high burden of stillbirths and neonatal deaths is driving global initiatives to improve birth outcomes. Discerning stillbirths from neonatal deaths can be difficult in some settings, yet this distinction is critical for understanding causes of perinatal deaths and improving resuscitation practices for live born babies. METHODS: We evaluated data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network to compare the accuracy of determining stillbirths versus neonatal deaths from different data sources and to evaluate evidence of resuscitation at delivery in accordance with World Health Organization (WHO) guidelines. CHAMPS works to identify causes of stillbirth and death in children <5 years of age in Bangladesh and 6 countries in sub-Saharan Africa. Using CHAMPS data, we compared the final classification of a case as a stillbirth or neonatal death as certified by the CHAMPS Determining Cause of Death (DeCoDe) panel to both the initial report of the case by the family member or healthcare worker at CHAMPS enrollment and the birth outcome as stillbirth or livebirth documented in the maternal health record. RESULTS: Of 1967 deaths ultimately classified as stillbirth, only 28 (1.4%) were initially reported as livebirths. Of 845 cases classified as very early neonatal death, 33 (4%) were initially reported as stillbirth. Of 367 cases with post-mortem examination showing delivery weight >1000g and no maceration, the maternal clinical record documented that resuscitation was not performed in 161 cases (44%), performed in 14 (3%), and unknown or data missing for 192 (52%). CONCLUSION: This analysis found that CHAMPS cases assigned as stillbirth or neonatal death after DeCoDe expert panel review were generally consistent with the initial report of the case as a stillbirth or neonatal death. Our findings suggest that more frequent use of resuscitation at delivery and improvements in documentation around events at birth could help improve perinatal outcomes. |
The prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa, a national antenatal survey, 2019
Woldesenbet S , Kufa T , Lombard C , Manda S , Morof D , Cheyip M , Ayalew K , Puren A . Sci Rep 2021 11 (1) 23740 To describe the prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa. A cross-sectional survey was conducted between October and mid-November 2019 among pregnant women aged 15-49 years in 1589 selected public antenatal care facilities. Pregnancy intention was assessed using two questions from the London Measure of Unplanned Pregnancy. Survey logistic regression examined factors associated with unintended pregnancy. Among 34,946 participants, 51.6% had an unintended pregnancy. On multivariable analysis, the odds of unintended pregnancy was higher among women who knew their HIV-positive status before pregnancy but initiated treatment after the first antenatal visit (adjusted odds ratio [aOR], 1.5 [95% confidence interval (CI):1.2-1.8]), women who initiated treatment before pregnancy (aOR, 1.3 [95% CI:1.2-1.3]), and women with a new HIV diagnosis during pregnancy (aOR, 1.2 [95% CI:1.1-1.3]) compared to HIV-negative women. Women who were single, in a non-cohabiting or a cohabiting relationship, and young women (15-24 years) had significantly higher risk of unintended pregnancy compared to married women and women aged 30-49 years, respectively. A comprehensive approach, including regular assessment of HIV clients' pregnancy intention, and adolescent and youth-friendly reproductive health services could help prevent unintended pregnancy. |
Factors Associated with Unplanned Pregnancy Among Cancer Survivors
Shandley LM , Kipling LM , Spencer JB , Morof D , Mertens AC , Howards PP . J Womens Health (Larchmt) 2021 31 (5) 665-674 Background: Approximately half of all pregnancies in the United States are unintended. However, women who are diagnosed with cancer in their reproductive years may be a unique population. This study examines the prevalence of and identifies factors associated with unplanned pregnancy among cancer survivors. Methods: Female cancer survivors aged 22-45 years, diagnosed between ages 20-35 years and at least 2 years postdiagnosis, and women with no history of cancer were interviewed about their reproductive histories, including pregnancy intention. Using a random matching process, comparison women were assigned an artificial age at cancer diagnosis equal to that of her cancer survivor match. An adjusted Cox model was fit examining time to unintended pregnancy after cancer for each of 1,000 matches. Cox proportional hazards models were also fit to assess associations between participant characteristics and unplanned pregnancy after cancer among survivors. Results: Cancer survivors (n = 1,282) and comparison women (n = 1,073) reported a similar likelihood of having an unplanned pregnancy in models adjusted for race, income, history of sexually-transmitted infection, and history of unplanned pregnancy before diagnosis (adjusted hazard ratio [aHR] 1.06, 95% simulation interval 0.85-1.36). After adjusting for confounders, unplanned pregnancy among survivors was associated with age <30 years at diagnosis (hazard ratio [HR]: 1.79, 95% confidence interval [CI]: 1.32-2.44), black race (HR: 1.55, 95% CI: 1.13-2.12; referent: white), receiving fertility counseling (aHR: 1.41, 95% CI: 1.04-1.92), and having at least one child before diagnosis (aHR: 1.44, 95% CI: 1.05-1.97). Conclusion: Cancer survivors and comparison women had similar likelihood of unplanned pregnancy. Rates of unplanned pregnancy after cancer were not higher for cancer survivors compared with comparison women, but 46.4% of survivors with a postcancer pregnancy reported an unplanned pregnancy. Cancer patients may benefit from patient-centered guidelines and counseling before cancer treatment that covers both risks of infertility and risks of unplanned pregnancy. |
Beyond adequate: Factors associated with quality of antenatal care in western Tanzania
Young MR , Morof D , Lathrop E , Haddad L , Blanton C , Maro G , Serbanescu F . Int J Gynaecol Obstet 2020 151 (3) 431-437 OBJECTIVE: To determine quality of antenatal care (ANC). Most literature focuses on ANC attendance and services. Less is known about quality of care (QoC). METHOD: Data were analyzed from the 2016 Kigoma Reproductive Health Survey, a population-based survey of reproductive-aged women. Women with singleton term live births were included and principal component analysis (PCA) was used to create an ANC quality index using linear combinations of weights of the first principal component. Nineteen variables were selected for the index. The index was then used to assign a QoC score for each woman and linear regression used to identify factors associated with receiving higher QoC. RESULTS: A total of 3178 women received some ANC. Variables that explained the most variance in the QoC index included: gave urine (0.35); gave blood (0.34); and blood pressure measured (0.30). In multivariable linear regression, factors associated with higher QoC included: ANC at a hospital (versus dispensary); older age; higher level of education; working outside the home; higher socioeconomic status; and having lower parity. CONCLUSION: Using PCA methods, several basic components of ANC including maternal physical assessment were identified as important indicators of quality. This approach provides an affordable and effective means of evaluating ANC programs. |
Factors associated with local herb use during pregnancy and labor among women in Kigoma region, Tanzania, 2014-2016
Fukunaga R , Morof D , Blanton C , Ruiz A , Maro G , Serbanescu F . BMC Pregnancy Childbirth 2020 20 (1) 122 BACKGROUND: Despite research suggesting an association between certain herb use during pregnancy and delivery and postnatal complications, herbs are still commonly used among pregnant women in sub-Sahara Africa (SSA). This study examines the factors and characteristics of women using local herbs during pregnancy and/or labor, and the associations between local herb use and postnatal complications in Kigoma, Tanzania. METHODS: We analyzed data from the 2016 Kigoma Tanzania Reproductive Health Survey (RHS), a regionally representative, population-based survey of reproductive age women (15-49 years). We included information on each woman's most recent pregnancy resulting in a live birth during January 2014-September 2016. We calculated weighted prevalence estimates and used multivariable logistic regression to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for factors associated with use of local herbs during pregnancy and/or labor, as well as factors associated with postnatal complications. RESULTS: Of 3530 women, 10.9% (CI: 9.0-13.1) used local herbs during their last pregnancy and/or labor resulting in live birth. The most common reasons for taking local herbs included stomach pain (42.9%) and for the health of the child (25.5%). Adjusted odds of local herb use was higher for women reporting a home versus facility-based delivery (aOR: 1.6, CI: 1.1-2.2), having one versus three or more prior live births (aOR: 1.8, CI: 1.4-2.4), and having a household income in the lowest versus the highest wealth tercile (aOR: 1.4, CI: 1.1-1.9). Adjusted odds of postnatal complications were higher among women who used local herbs versus those who did not (aOR: 1.5, CI: 1.2-1.9), had four or more antenatal care visits versus fewer (aOR: 1.4, CI: 1.2-1.2), and were aged 25-34 (aOR: 1.1, CI: 1.0-1.3) and 35-49 (aOR: 1.3, CI: 1.0-1.6) versus < 25 years. CONCLUSIONS: About one in ten women in Kigoma used local herbs during their most recent pregnancy and/or labor and had a high risk of postnatal complications. Health providers may consider screening pregnant women for herb use during antenatal and delivery care as well as provide information about any known risks of complications from herb use. |
Addressing the third delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring adequate and appropriate facility-based maternal and perinatal health care
Morof D , Serbanescu F , Goodwin MM , Hamer DH , Asiimwe AR , Hamomba L , Musumali M , Binzen S , Kekitiinwa A , Picho B , Kaharuza F , Namukanja PM , Murokora D , Kamara V , Dynes M , Blanton C , Nalutaaya A , Luwaga F , Schmitz MM , LaBrecque J , Conlon CM , McCarthy B , Kroelinger C , Clark T . Glob Health Sci Pract 2019 7 S85-s103 BACKGROUND: Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response. METHODS: SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data-health facility assessments, facility and community surveillance, and population-based mortality studies-were used to document the effectiveness of intervention components. RESULTS: During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline-from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened. CONCLUSION: SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths. |
Impact of the Saving Mothers, Giving Life approach on decreasing maternal and perinatal deaths in Uganda and Zambia
Serbanescu F , Clark TA , Goodwin MM , Nelson LJ , Boyd MA , Kekitiinwa AR , Kaharuza F , Picho B , Morof D , Blanton C , Mumba M , Komakech P , Carlosama F , Schmitz MM , Conlon CM . Glob Health Sci Pract 2019 7 S27-s47 BACKGROUND: Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions. METHODS: SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities. RESULTS: Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country. CONCLUSIONS: MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths. |
Addressing the first delay in Saving Mothers, Giving Life districts in Uganda and Zambia: Approaches and results for increasing demand for facility delivery services
Serbanescu F , Goodwin MM , Binzen S , Morof D , Asiimwe AR , Kelly L , Wakefield C , Picho B , Healey J , Nalutaaya A , Hamomba L , Kamara V , Opio G , Kaharuza F , Blanton C , Luwaga F , Steffen M , Conlon CM . Glob Health Sci Pract 2019 7 S48-s67 Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care at birth. While originally the "Three Delays" model was designed to focus on curative services that encompass emergency obstetric care, SMGL expanded its application to primary and secondary prevention of obstetric complications. Prevention of the "first delay" focused on addressing factors influencing the decision to seek delivery care at a health facility. Numerous factors can contribute to the first delay, including a lack of birth planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care, and financial or geographic barriers. SMGL addressed these barriers through community engagement on safe motherhood, public health outreach, community workers who identified pregnant women and encouraged facility delivery, and incentives to deliver in a health facility. SMGL used qualitative and quantitative methods to describe intervention strategies, intervention outcomes, and health impacts. Partner reports, health facility assessments (HFAs), facility and community surveillance, and population-based mortality studies were used to document activities and measure health outcomes in SMGL-supported districts. SMGL's approach led to unprecedented community outreach on safe motherhood issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL districts. In Uganda, the proportion of births that took place in facilities rose from 45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts, facility deliveries increased from 62.6% to 90.2% (44% increase). In both countries, the proportion of women delivering in facilities equipped to provide emergency obstetric and newborn care also increased (from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines in the number of maternal deaths due to not accessing facility care during pregnancy, delivery, and the postpartum period in both countries. This reduction played a significant role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda but not in Zambia. Further work is needed to sustain gains and to eliminate preventable maternal and perinatal deaths. |
Clinical presentation of pregnant women in isolation units for Ebola virus disease in Sierra Leone, 2014
Mpofu JJ , Soud F , Lyman M , Koroma AP , Morof D , Ellington S , Kargbo SS , Callaghan W . Int J Gynaecol Obstet 2019 145 (1) 76-82 OBJECTIVES: To examine Ebola virus disease (EVD) symptom prevalence and EVD status among pregnant women in Ebola isolation units in Sierra Leone. METHODS: In an observational study, data were obtained for pregnant women admitted to Ebola isolation units across four districts in Sierra Leone from June 29, 2014, to December 20, 2014. Women were admitted to isolation units if they had suspected EVD exposures or fever (temperature >38 degrees C) and three or more self-reported symptoms suggestive of EVD. Associations were examined between EVD status and each symptom using chi(2) tests and logistic regression adjusting for age/labor status. RESULTS: Of 176 pregnant women isolated, 55 (32.5%) tested positive for EVD. Using logistic regression models adjusted for age, EVD-positive women were significantly more likely to have fever, self-reported fatigue/weakness, nausea/vomiting, headache, muscle/joint pain, chest pain, vaginal bleeding, unexplained bleeding, or sore throat upon admission. In models adjusted for age/labor, only women with fever or vaginal bleeding upon admission were significantly more likely to be EVD-positive. CONCLUSIONS: Several EVD symptoms and complications increased the odds of testing EVD-positive; some of these were also signs and symptoms of labor/pregnancy complications. The study results highlight the need to refine screening for pregnant women with EVD. This article is protected by copyright. All rights reserved. |
Client and provider factors associated with integration of family planning services among maternal and reproductive health clients in Kigoma Region, Tanzania: a cross-sectional study, April-July 2016
Dynes MM , Bernstein E , Morof D , Kelly L , Ruiz A , Mongo W , Chaote P , Bujari RN , Serbanescu F . Reprod Health 2018 15 (1) 152 BACKGROUND: Integration of family planning (FP) services into non-FP care visits is an essential strategy for reducing maternal and neonatal mortality through reduction of short birth intervals and unplanned pregnancies. METHODS: Cross-sectional surveys were conducted across 61 facilities in Kigoma Region, Tanzania, April-July 2016. Multilevel, mixed effects logistic regression analyses were conducted on matched data from providers (n = 330) and clients seeking delivery (n = 935), well-baby (n = 272), pregnancy loss (PL; n = 229), and other routine (postnatal, HIV/STI, other; n = 69) services. Outcomes of interest included receipt of FP information and a modern FP method (significance level p < 0.05). RESULTS: Clients had significantly greater odds of receiving FP information if the primary reason for seeking care was for PL versus (vs) any other types of care (aOR 1.97), had four or more pregnancies vs fewer (aOR 1.78), and had had a FP discussion with their partner vs no FP discussion (aOR 1.73). Clients had lower odds of receiving FP information if they were aged 40-49 vs 15-19 (aOR 0.50) and reported attending religious services at least weekly vs less frequently (aOR 0.61). Clients of providers who perceived that in-service training had helped vs had not helped job performance (aOR 2.27), and clients of providers having high vs low recent FP training index scores (aOR 1.58) had greater odds of receiving FP information. Clients had greater odds of receiving a modern method when they received information on two or more vs fewer methods (aOR 7.13), had had a FP discussion with their partner vs no discussion (aOR 5.87), if the primary reason for seeking care was for PL vs any other types of care (aOR 4.08), had zero vs one or more live births (aOR 3.92), made their own FP decisions vs not made own FP decisions (aOR 3.17), received FP information from two or more vs fewer sources (aOR 3.12), and were in the middle or high vs the low wealth tercile (aOR 1.99 and 2.30, respectively). Well-baby care clients, Other routine services clients, and married clients had significantly lower odds of receiving a method (aOR 0.14; aOR 0.08; and aOR 0.41, respectively) compared to their counterparts. CONCLUSIONS: Strategies that better integrate FP into routine care visits, encourage women to have FP discussions with their partners and providers, increase FP training among providers, and expand FP options and sources of information may help reduce the unmet need for FP, and ultimately lower maternal and neonatal mortality. |
Maternal and perinatal outcomes in pregnant women with suspected Ebola virus disease in Sierra Leone, 2014
Lyman M , Johnson Mpofu J , Soud F , Oduyebo T , Ellington S , Schlough GW , Koroma AP , McFadden J , Morof D . Int J Gynaecol Obstet 2018 142 (1) 71-77 OBJECTIVE: To describe maternal and perinatal outcomes among pregnant women with suspected Ebola virus disease (EVD) in Sierra Leone. METHODS: Observational investigation of maternal and perinatal outcomes among pregnant women with suspected EVD from five districts in Sierra Leone from June-December 2014. Suspected cases were ill pregnant women with symptoms suggestive of EVD or relevant exposures who were tested for EVD. Case frequencies and odds ratios were calculated to compare patient characteristics and outcomes by EVD status. RESULTS: There were 192 suspected cases: 67 (34.9%) EVD-positive, 118 (61.5%) EVD-negative, and 7 (3.6%) EVD status unknown. Women with EVD had increased odds of death (OR 10.22; 95% CI, 4.87-21.46) and spontaneous abortion (OR 4.93; 95% CI, 1.79-13.55) compared with those without EVD. Women without EVD had a high frequency of death (30.2%) and stillbirths (65.9%). One of 14 neonates born following EVD-negative and five of six neonates born following EVD-positive pregnancies died. CONCLUSION: EVD-positive and EVD-negative women with suspected EVD had poor outcomes, highlighting the need for increased attention and resources focused on maternal and perinatal health during an urgent public health response. Capturing pregnancy status in nationwide surveillance of EVD can help improve understanding of disease burden and design effective interventions. This article is protected by copyright. All rights reserved. |
Addressing maternal health during CDC's Ebola response in the United States
Ellington S , Perez M , Morof D , Zotti ME , Callaghan W , Meaney-Delman D , Glover M , Ha QC , Jamieson DJ . J Womens Health (Larchmt) 2017 26 (11) 1141-1145 Previous outbreaks suggest that pregnant women with Ebola virus disease (EVD) are at increased risk for severe disease and death. Healthcare workers who treat pregnant women with EVD are at increased risk of body fluid exposure. Despite the absence of pregnant women with EVD in the United States, CDC activated the Maternal Health Team (MHT), a functional unit dedicated to emergency preparedness and response issues, on October 18, 2014. We describe major activities of the MHT. A high-priority MHT activity was to publish guiding principles early in the response. The MHT also prepared guidance documents, provided guidance and technical support for hospital preparedness, and addressed inquiries. We analyzed maternal health inquiries received through CDC-INFO, MHT, and CDC's Medical Investigations Team from August 2014 to December 2015. Internal call logs used to capture, monitor, and track inquiries for the three data sources were merged. Inquiries not related to maternal health issues and duplicates were removed. Each inquiry was categorized by route (email/phone), inquirer type, and topic. In total, 201 inquiries were received from clinicians, public health professionals, and the public. The predominant topic was related to infection control for high-risk situations such as labor and delivery. During the Ebola response, most inquiries were received via email rather than telephone, a notable shift compared to the H1N1 emergency response. Lessons learned during the H1N1 and Ebola responses are currently informing CDC's Zika Response, an unprecedented emergency response primarily focused on reproductive health issues. |
A cross-sectional survey on gender-based violence and mental health among female urban refugees and asylum seekers in Kampala, Uganda
Morof DF , Sami S , Mangeni M , Blanton C , Cardozo BL , Tomczyk B . Int J Gynaecol Obstet 2014 127 (2) 138-43 OBJECTIVE: To assess gender-based violence and mental health outcomes among a population of female urban refugees and asylum seekers. METHODS: In a questionnaire-based, cross-sectional study conducted in 2010 in Kampala, Uganda, a study team interviewed a stratified random sample of female refugees and asylum seekers aged 15-59years from the Democratic Republic of Congo and Somalia. Questionnaires were used to collect information about recent and lifetime exposure to sexual and physical violence, and symptoms of depression and post-traumatic stress disorder (PTSD). RESULTS: Among the 500 women selected, 117 (23.4%) completed interviews. The weighted lifetime prevalences of experiencing any (physical and/or sexual) violence, physical violence, and sexual violence were 77.5% (95% CI 66.6-88.4), 76.2% (95% CI 65.2-87.2), and 63.3% (95% CI 51.2-75.4), respectively. Lifetime history of physical violence was associated with PTSD symptoms (P<0.001), as was lifetime history of sexual violence (P=0.014). Overall, 112 women had symptoms of depression (weighted prevalence 92.0; 95% CI 83.9-100) and 83 had PTSD symptoms (weighted prevalence 71.1; 95% CI 59.9-82.4). CONCLUSION: Prevalences of violence, depression, and PTSD symptoms among female urban refugees in Kampala are high. Additional services and increased availability of psychosocial programs for refugees are needed. |
Neonatal survival in complex humanitarian emergencies: setting an evidence-based research agenda
Morof DF , Kerber K , Tomczyk B , Lawn J , Blanton C , Sami S , Amsalu R . Confl Health 2014 8 8 BACKGROUND: Over 40% of all deaths among children under 5 are neonatal deaths (0-28 days), and this proportion is increasing. In 2012, 2.9 million newborns died, with 99% occurring in low- and middle-income countries. Many of the countries with the highest neonatal mortality rates globally are currently or have recently been affected by complex humanitarian emergencies. Despite the global burden of neonatal morbidity and mortality and risks inherent in complex emergency situations, research investments are not commensurate to burden and little is known about the epidemiology or best practices for neonatal survival in these settings. METHODS: We used the Child Health and Nutrition Research Initiative (CHNRI) methodology to prioritize research questions on neonatal health in complex humanitarian emergencies. Experts evaluated 35 questions using four criteria (answerability, feasibility, relevance, equity) with three subcomponents per criterion. Using SAS 9.2, a research prioritization score (RPS) and average expert agreement score (AEA) were calculated for each question. RESULTS: Twenty-eight experts evaluated all 35 questions. RPS ranged from 0.846 to 0.679 and the AEA ranged from 0.667 to 0.411. The top ten research priorities covered a range of issues but generally fell into two categories- epidemiologic and programmatic components of neonatal health. The highest ranked question in this survey was "What strategies are effective in increasing demand for, and use of skilled attendance?" CONCLUSIONS: In this study, a diverse group of experts used the CHRNI methodology to systematically identify and determine research priorities for neonatal health and survival in complex humanitarian emergencies. The priorities included the need to better understand the magnitude of the disease burden and interventions to improve neonatal health in complex humanitarian emergencies. The findings from this study will provide guidance to researchers and program implementers in neonatal and complex humanitarian fields to engage on the research priorities needed to save lives most at risk. |
Community mortality from cholera: urban and rural districts in Zimbabwe
Morof D , Cookson ST , Laver S , Chirundu D , Desai S , Mathenge P , Shambare D , Charimari L , Midzi S , Blanton C , Handzel T . Am J Trop Med Hyg 2013 88 (4) 645-50 In 2008-2009, Zimbabwe experienced an unprecedented cholera outbreak with more than 4,000 deaths. More than 60% of deaths occurred at the community level. We conducted descriptive and case-control studies to describe community deaths. Cases were in cholera patients who died outside health facilities. Two surviving cholera patients were matched by age, time of symptom onset, and location to each case-patient. Proxies completed questionnaires regarding mortality risk factors. Cholera awareness and importance of rehydration was high but availability of oral rehydration salts was low. A total of 55 case-patients were matched to 110 controls. The odds of death were higher among males (adjusted odd ratio [AOR] = 5.00, 95% confidence interval [CI] = 1.54-14.30) and persons with larger household sizes (AOR = 1.21, 95% CI = 1.00-1.46). Receiving home-based rehydration (AOR = 0.21, 95% CI = 0.06-0.71) and visiting cholera treatment centers (CTCs) (AOR = 0.07, 95% CI = 0.02-0.23) were protective. Receiving cholera information was associated with home-based rehydration and visiting CTCs. When we compared cases and controls who did not go to CTCs, males were still at increased odds of death (AOR = 5.00, 95% CI = 1.56-16.10) and receiving home-based rehydration (AOR = 0.14, 95% CI = 0.04-0.53) and being married (AOR = 0.26, 95% CI = 0.08-0.83) were protective. Inability to receive home-based rehydration or visit CTCs was associated with mortality. Community education must reinforce the importance of prompt rehydration and CTC referral. |
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