The impact of HIV on maternal quality of life in Uganda

Measuring perinatal and postpartum quality of life of women and associated factors in semi-urban Bangladesh

PURPOSE

The objective of this study was to measure the health-related quality of life (HRQoL) among pregnant women in the perinatal and postpartum periods and determine influencing factors that predict their HRQoL.

METHODS

The study was conducted among pregnant women who live in a semi-urban area of Chandpur, Bangladesh. A total of 465 women were recruited. The EuroQoL 5-Dimension 3-Level (EQ-5D-3L) and EuroQoL visual analog scale (EQ-VAS) instruments were used to measure the HRQoL of participants. Two-sample mean test (t test) was performed to examine the changes in HRQoL between the perinatal and postnatal periods of the same individuals. Multivariate linear regression was employed to identify the factors influencing HRQoL during the two periods.

RESULTS

Overall, the HRQoL scores improved significantly from the perinatal (0.49) to postpartum (0.86) period. Approximately 58% of women experienced moderate or extreme levels of health problems during the perinatal period regardless of their health status. However, most women had significantly improved health status in the postpartum period. Gestational weight gain and recommended postnatal care were significantly associated with improved HRQoL. Factors that negatively influenced changes in HRQoL included adolescent motherhood, caesarean delivery, inadequate antenatal care consultations and living in a poor household, during both the perinatal and postpartum periods.

CONCLUSIONS

Overall health status is found to be poor among women during the perinatal period compared with the postpartum period. The study indicates that interventions to address the influencing factors are needed to ensure better quality of life for women both pre- and post-birth. Community-based initiatives, such as awareness building, might address negative factors and subsequently improve health status and reduce adverse health outcomes related to pregnancy and postnatal care.

Evaluation of the quality of life of pregnant women from 2005 to 2015

Over the past two decades, quality of life has become an essential preoccupation in the care of patients. Many measuring instruments are available to assess physical, psychological and social quality of life. These tools allow healthcare professionals to determine the best quality of their patients. However, the quality of life for the pregnant woman seems to be little studied. This article presents the results of a bibliographic review of publications between 2005 and 2015 - referenced in PUBMED and COCHRANE - on the quality of life of pregnant women giving birth after the 22nd week of amenorrhea. The articles were selected by a reading committee. 195 publications responding to keywords were identified. 75 articles on the problem were selected. The main countries that have published on this subject are Iran (n=11) and Brazil (n=9). France ranks 17th with only one publication. 74% of articles deal with quality of life for pathological pregnancies (gestational or pre-existing pathologies). 23 pathologies were identified, mainly depression (20% of items). This review reveals a growing global interest in quality of life in pregnant women. However, few studies evaluate the impact of care in terms of quality of life in pregnant women, contrary to the recommendations of different health authorities. Finally, the analysis of the various articles shows that, in general, few measurements are made to evaluate the quality of life, not requiring a standardized curve of quality of life during pregnancy. There is thus a significant lack of data to establish a standardized curve for the quality of life of pregnant women, which allows a simple comparison of quality of life measures according to the different clinical management.

Quality of life assessment among HIV-positive persons entering the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

With HIV treatment prolonging survival and HIV infection now managed as a chronic illness, quality of life (QOL) is important to evaluate in persons living with HIV (PLWH). We assessed at study entry the QOL of antiretroviral-naïve PLWH with CD4 counts > 500 cells/μL in the Strategic Timing of AntiRetroviral Treatment (START) clinical trial.

METHODS

QOL was assessed with: (1) a visual analogue scale (VAS) for self-assessment of overall current health; (2) the Short-Form 12-Item Version 2 Health Survey(®) (SF-12V2), for which responses are summarized into eight individual QOL domains plus component summary scores for physical health [the Physical Health Component Summary (PCS)] and mental health [the Mental Health Component Summary (MCS)]. The VAS and eight domain scores were scaled from 0 to 100. Mean QOL measures were calculated overall and by demographic, clinical and behavioural factors.

RESULTS

A total of 4631 participants completed the VAS and 4119 the SF-12. The mean VAS score (with standard deviation) was 80.9 ± 15.7. Mean SF-12 domain scores were lowest for vitality (66.3 ± 26.4) and mental health (68.6 ± 21.4), and highest for physical functioning (89.3 ± 23.0) and bodily pain (88.0 ± 21.4). Using multiple linear regression, PCS scores were lower (P < 0.001) for Asians, North Americans, female participants, older participants, and those with less education, longer duration of known HIV infection, alcoholism/substance dependence and body mass index ≥ 30 kg/m(2) . MCS scores were highest (P < 0.001) for Africans, South Americans and older participants, and lowest for female participants, current smokers and those with alcoholism/substance dependence.

CONCLUSIONS

In this primarily healthy population, QOL was mostly favourable, emphasizing that it is important that HIV treatments do not negatively impact QOL. Self-assessed physical health summary scores were higher than mental health scores. Factors such as older age and geographical region had different effects on perceived physical and mental health.

Health status and quality of life in postpartum women: a systematic review of associated factors

Since health care is becoming more and more patient centered, patient-reported outcomes such as quality of life (QOL) and health status (HS) are becoming increasingly important. The aim of this systematic review was to provide an overview of physical, psychological, and social domains of QOL and HS in postpartum women, and to assess which factors are associated with QOL and HS domains postpartum. A computerized literature search was performed using the PubMed, PsycINFO, and Cochrane databases. Studies were selected if the three domains of QOL or HS were measured in a (sub)group of postpartum women, by using validated standardized questionnaires. The methodological quality of the 66 included studies was examined by two independent reviewers. All three domains of QOL were impaired in postpartum women with urinary incontinence, with even worse QOL in women with mixed urinary incontinence. Mental QOL was impaired in women with urge urinary incontinence after cesarean section. Social QOL was decreased in HIV-positive women. HS was impaired in all three domains in postpartum depressed women. Physical HS was impaired after cesarean section for at least two months postpartum. Additional supportive interventions from health care social support were not associated with improved HS. Urinary incontinence and being HIV-positive seemed to be associated with impaired QOL. Postpartum depression and a cesarean section seemed to be associated with impaired HS. Prospective longitudinal research is needed in order to draw valid conclusions regarding postpartum HS and QOL, and the predictive value of the associated factors.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING

Bill & Melinda Gates Foundation.

Health related quality of life across the perinatal period among Australian women

AIMS AND OBJECTIVES

To investigate the significant features in health-related quality of life and to examine the changes over time during the perinatal period.

BACKGROUND

Health-related quality of life during the perinatal period is significant for women. Screening or surveillance during the perinatal period is inconsistent and often not part of continued assessment.

DESIGN

Prospective.

METHODS

Setting involved antenatal clinics at three public hospitals in metropolitan Brisbane, Australia. A total of 363 participants out of a cohort of 605 women completed all items of the Short Form-12 Health Survey in late pregnancy and again at 6 and 12 weeks postpartum.

RESULTS

There was a significant difference across the three perinatal time periods in all the health-related quality-of-life subscales. Significant improvements were noted from late pregnancy to 6 weeks following childbirth and again at 12 weeks particularly in physical health, role physical, bodily pain, vitality, role emotional and mental health. Even when confounding variables such as maternal ages, partner status, parity, delivery type and ethnicity were introduced, significant improvements were noted. Maternal distress significantly related to almost all quality-of-life factors over time even when all possible confounding factors were controlled.

CONCLUSION

Significant changes occur in health-related quality of life across the perinatal period. All dimensions of health-related quality of life except for social functioning and maternal distress showed marked improvement following childbirth. During this period, maternal distress was negatively related to health-related quality of life.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to be mindful of the broader view of health as encompassed in health-related quality-of-life measures and the potential these have for alerting health professionals when providing care. More rigorous health assessment for mothers at risk is useful so that appropriate support and follow-up can be given.

The contribution of HIV to pregnancy-related mortality: a systematic review and meta-analysis

OBJECTIVES

Although much is known about the contribution of HIV to adult mortality, remarkably little is known about the mortality attributable to HIV during pregnancy. In this article we estimate the proportion of pregnancy-related deaths attributable to HIV based on empirical data from a systematic review of the strength of association between HIV and pregnancy-related mortality.

METHODS

Studies comparing mortality during pregnancy and the postpartum in HIV-infected and HIV-uninfected women were included. Summary estimates of the relative and attributable risks for the association between HIV and pregnancy-related mortality were calculated through meta-analyses. Varying estimates of HIV prevalence were used to predict the impact of the HIV epidemic on pregnancy-related mortality at the population level.

RESULTS

Twenty-three studies were included (17 from sub-Saharan Africa). Meta-analysis of the risk ratios indicated that HIV-infected women had eight times the risk of a pregnancy-related death compared with HIV-uninfected women [pooled risk ratio 7.74, 95% confidence interval (95% CI) 5.37-11.16]. The excess mortality attributable to HIV among HIV-infected pregnant and postpartum women was 994 per 100,000 pregnant women. We predict that 12% of all deaths during pregnancy and up to 1-year postpartum are attributable to HIV/AIDS in regions with a prevalence of HIV among pregnant women of 2%. This figure rises to 50% in regions with a prevalence of 15%.

CONCLUSION

The substantial excess of pregnancy-related mortality associated with HIV highlights the importance of integrating HIV and reproductive health services in areas of high HIV prevalence and pregnancy-related mortality.

A Systematic Review of Quality of Life Measures in Pregnant and Postpartum Mothers

Quality of life has emerged as an essential health component that broadens the traditionally narrow concerns focused on only morbidity and life expectancy. Although a growing number of tools to measure quality of life are in circulation, there is a lack of guidelines as well as rigorous assessment for their use with pregnant and postpartum populations. It is also unclear whether these instruments could validly be employed to measure patient-reported outcomes in comparative effectiveness research of maternal care interventions. This paper reviews articles cited in CINAHL, COCHRANE, EMBASE, PSYCINFO, and PUBMED that addressed quality of life in pregnant and postpartum populations. Instruments used to measure quality of life in selected articles were assessed for their adherence to international guidelines for health outcomes instrument development and validation. The authors identified 129 articles that addressed quality of life in pregnant and/or postpartum women. Out of these, only 64 quality (generic and specific) scales were judged relevant to be included in this study. Analysis of measurement scales used in the pregnant and/or postpartum populations revealed important validity, reliability and psychometric inadequacies that negate their use in comparative effectiveness analysis in pregnant and post-partum populations. Valid, reliable, and responsive instruments to measure patient-reported outcomes in pregnant and postpartum populations are lacking. To demonstrate the effectiveness of various treatment and prevention programs, future research to develop and validate a robust and responsive quality of life measurement scale in pregnant and postpartum populations is needed.

Quality of Life and Emotional Distress among HIV-Positive Women during Transition to Motherhood

The purpose of this preliminary study was to describe the quality of life (QOL) and emotional distress during pregnancy and early postpartum, and to examine the ability of psychopathological symptoms to predict QOL at early postpartum.Asample of 75 pregnant women (31 HIV-positive and 44 HIV-negative) was assessed during the second trimester of pregnancy and two to four days postpartum. QOL was assessed with the WHOQOL-Bref. The emotional distress was assessed with the Brief Symptom Inventory, and with the Emotional Assessment Scale. Seropositive women reported increased negative emotional reactivity and lower scores in social relationships and overall QOL during pregnancy than HIV-negative women. Both HIV-positive and HIV-negative women reported better QOL after the birth of their child, when compared with the pregnancy period. Among HIV-positive women, lower anxiety and depressive symptoms during pregnancy were, respectively, significant predictors of better psychological QOL and overall QOL at early postpartum. Less intense somatic symptoms predicted better physical QOL. Longitudinal assessment of QOL and emotional status may provide potentially useful information for tailoring psychological interventions in the maternity care of HIV-infected women, during their transition to motherhood.

Relationship between social support and quality of life in childbearing women during the perinatal period

OBJECTIVE

To explore demographic and social support predictors of health-related quality of life (HRQoL) (mental and physical) for childbearing women in the perinatal period.

DESIGN

Longitudinal.

SAMPLE

Three public hospitals in metropolitan Brisbane, Australia.

PARTICIPANTS

Four hundred seventy-three (473) women recruited at 36 weeks of pregnancy, and 6 and 12 weeks following childbirth.

METHODS

The Short Form-12 (SF-12) Version 2 Health Survey was used to measure the mental and physical domains of HRQoL. Social support was measured using the Maternal Social Support Scale (MSSS).

RESULTS

Mean scores for the mental and physical domains of HRQoL were lower than population norms. Social support was found to be a significant and consistent predictor of higher HRQoL scores, particularly in the physical domain at 12 weeks following child birth and mental domain during the perinatal period. The relationship between social support and HRQoL was found to be independent of other factors including education, length of relationship with partner, age, parity, and antenatal visit. The only other significant predictor was length of relationship with partner in the mental domain at 36 weeks of pregnancy.

CONCLUSION

Social support is a significant and consistent predictor of a mother's HRQoL during the perinatal period. Nurses and midwives need to assess social support, rather than making assumptions based on demographic factors.

What palliative care-related problems do patients experience at HIV diagnosis? A systematic review of the evidence

CONTEXT

Palliative care is an essential element of HIV care throughout the disease trajectory, but there is a lack of information to guide clinical care at HIV diagnosis.

OBJECTIVES

This systematic review aimed to identify and appraise the evidence of palliative care-related problems at HIV diagnosis.

METHODS

The search strategy combined the term "HIV" with seven key words derived from the World Health Organization definition of multidimensional palliative care, in a systematic search of four databases. Abstracts and papers were screened to identify those recording problems within six months of HIV diagnosis in adults. Sample descriptions, aims, methods, and prevalence findings were extracted from these papers into common tables.

RESULTS

Of 5443 titles retrieved, 65 met the inclusion criteria and 34 were retained. Papers included 27 original studies and seven secondary analyses of patient's records, with great heterogeneity in design, sample definition, and outcome measures. Physical and psychological symptoms were highly prevalent (pain 11%-76%, weight loss 8%-89%, fever 32%-89%, diarrhea 6%-54%, anxiety 36%-95%, and depression 18%-47%). At HIV diagnosis, well-being was impaired, suicidal thoughts were frequent, and peace and calmness were reduced. Participants lacked emotional support and feared the reaction of their families. Practical problems included hunger, homelessness, reduced ability to work, and need for childcare. Studies had methodological failings such as the use of unvalidated tools and lack of clarity reporting results.

CONCLUSION

People who have recently been diagnosed with HIV have multidimensional palliative care-related problems. HIV care and support services need to assess and manage problems using integrated palliative care, with referral for complex problems. Patient centeredness must be a principle of HIV clinical research.

The health related quality of life of people living with HIV/AIDS in sub-Saharan Africa - a literature review and focus group study

Background

While health outcomes of HIV/AIDS treatments in terms of increased longevity has been the subject of much research, there appears to be very limited research on the improved health related quality of life (HRQL) that can be applied in cost-utility analyses in Africa south of the Sahara (SSA). Most of the literature that does exist present HRQL measured by disease specific instruments, but such data is of little use as input to economic evaluations.

Methods

A systematic review of the literature on HRQL weights for people living with HIV/AIDS in Africa was performed, and the findings are presented and interpreted. We also use focus group discussions in panels of clinical AIDS experts to test the preference based on a generic descriptive system EQ-5D. We contrast quality of life with and without antiretroviral treatment (ART), and with and without treatment failure.

Results

In only four papers were the HRQL weights for HIV/AIDS in sub-Saharan Africa estimated with generic preference based methodologies that can be directly applied in economic evaluation. A total of eight studies were based on generic health profiles. While such 'health profiles' are not preference based, the scores could potentially be transformed into health state utilities. Most of the available literature (20 papers) utilized disease specific instrument, which are not applicable for economic evaluation.

The focus group discussions revealed that HRQL weights are strongly correlated to disease stage. Furthermore, clinical experts consistently report that ART has a strong positive impact on the HRQL of patients, although this effect appears to rebound in cases of drug resistance.

Conclusions

EQ-5D appears to be an appropriate tool for measuring and valuing HRQL of HIV/AIDS in Africa. More empirical research is needed on various methodological aspects in order to obtain valid and reliable HRQL weights in economic evaluations of HIV/AIDS prevention and treatment interventions.