Protocol of an individual participant data meta-analysis to quantify the impact of high ambient temperatures on maternal and child health in Africa (HE2AT IPD)

INTRODUCTION

Globally, recognition is growing of the harmful impacts of high ambient temperatures (heat) on health in pregnant women and children. There remain, however, major evidence gaps on the extent to which heat increases the risks for adverse health outcomes, and how this varies between settings. Evidence gaps are especially large in Africa. We will conduct an individual participant data (IPD) meta-analysis to quantify the impacts of heat on maternal and child health in sub-Saharan Africa. A detailed understanding and quantification of linkages between heat, and maternal and child health is essential for developing solutions to this critical research and policy area.

METHODS AND ANALYSIS

We will use IPD from existing, large, longitudinal trial and cohort studies, on pregnant women and children from sub-Saharan Africa. We will systematically identify eligible studies through a mapping review, searching data repositories, and suggestions from experts. IPD will be acquired from data repositories, or through collaboration with data providers. Existing satellite imagery, climate reanalysis data, and station-based weather observations will be used to quantify weather and environmental exposures. IPD will be recoded and harmonised before being linked with climate, environmental, and socioeconomic data by location and time. Adopting a one-stage and two-stage meta-analysis method, analytical models such as time-to-event analysis, generalised additive models, and machine learning approaches will be employed to quantify associations between exposure to heat and adverse maternal and child health outcomes.

ETHICS AND DISSEMINATION

The study has been approved by ethics committees. There is minimal risk to study participants. Participant privacy is protected through the anonymisation of data for analysis, secure data transfer and restricted access. Findings will be disseminated through conferences, journal publications, related policy and research fora, and data may be shared in accordance with data sharing policies of the National Institutes of Health.

PROSPERO REGISTRATION NUMBER

CRD42022346068.

"Mothers get really exhausted!" The lived experience of pregnancy in extreme heat: Qualitative findings from Kilifi, Kenya

Heat exposure in pregnancy is associated with a range of adverse health and wellbeing outcomes, yet research on the lived experience of pregnancy in high temperatures is lacking. We conducted qualitative research in 2021 in two communities in rural Kilifi County, Kenya, a tropical savannah area currently experiencing severe drought. Pregnant and postpartum women, their male spouses and mothers-in-law, community health volunteers, and local health and environment stakeholders were interviewed or participated in focus group discussions. Pregnant women described symptoms that are classically regarded as heat exhaustion, including dizziness, fatigue, dehydration, insomnia, and irritability. They interpreted heat-related tachycardia as signalling hypertension and reported observing more miscarriages and preterm births in the heat. Pregnancy is conceptualised locally as a 'normal' state of being, and women continue to perform physically demanding household chores in the heat, even when pregnant. Women reported little support from family members to reduce their workload at this time, reflecting their relative lack of autonomy within the household, but also potentially the 'normalisation' of heat in these communities. Climate change risk reduction strategies for pregnant women in low-resource settings need to be cognisant of local household gender dynamics that constrain women's capacity to avoid heat exposures.

Public Health Measures to Address the Impact of Climate Change on Population Health-Proceedings from a Stakeholder Workshop

BACKGROUND

The World Health Organization identified climate change as the 21st century's biggest health threat. This study aimed to identify the current knowledge base, evidence gaps, and implications for climate action and health policymaking to address the health impact of climate change, including in the most underserved groups.

METHODS

The Horizon-funded project ENBEL ('Enhancing Belmont Research Action to support EU policy making on climate change and health') organised a workshop at the 2021-European Public Health conference. Following presentations of mitigation and adaptation strategies, seven international researchers and public health experts participated in a panel discussion linking climate change and health. Two researchers transcribed and thematically analysed the panel discussion recording.

RESULTS

Four themes were identified: (1) 'Evidence is key' in leading the climate debate, (2) the need for 'messaging about health for policymaking and behaviour change' including health co-benefits of climate action, (3) existing 'inequalities between and within countries', and (4) 'insufficient resources and funding' to implement national health adaptation plans and facilitate evidence generation and climate action, particularly in vulnerable populations.

CONCLUSION

More capacity is needed to monitor health effects and inequities, evaluate adaptation and mitigation interventions, address current under-representations of low- or middle-income countries, and translate research into effective policymaking.

HIV Incidence Among Pregnant and Nonpregnant Women in the FACTS-001 Trial: Implications for HIV Prevention, Especially PrEP Use

BACKGROUND

During pregnancy and postpartum period, the sexual behaviors of women and their partners change in ways that may either increase or reduce HIV risks. Pregnant women are a priority population for reducing both horizontal and vertical HIV transmission.

SETTING

Nine sites in 4 South African provinces.

METHODS

Women aged 18-30 years were randomized to receive pericoital tenofovir 1% gel or placebo gel and required to use reliable modern contraception. We compared HIV incidence in women before, during, and after pregnancy and used multivariate Cox Proportional hazards models to compare HIV incidence by pregnancy status.

RESULTS

Rates of pregnancy were 7.1 per 100 woman-years (95% confidence interval [CI]: 6.3 to 8.1) and highest in those who reported oral contraceptive use (25.1 per 100 woman-years; adjusted hazard ratio 22.97 higher than other women; 95% CI: 5.0 to 105.4) or had 2 children. Birth outcomes were similar between trial arms, with 59.8% having full-term live births. No difference was detected in incident HIV during pregnancy compared with nonpregnant women (2.1 versus 4.3%; hazard ratio = 0.56, 95% CI: 0.14 to 2.26). Sexual activity was low in pregnancy and the early postpartum period, as was consistent condom use.

CONCLUSIONS

Pregnancy incidence was high despite trial participation being contingent on contraceptive use. We found no evidence that rates of HIV acquisition were elevated in pregnancy when compared with those in nonpregnant women. Risks from reductions in condom use may be offset by reduced sexual activity. Nevertheless, high HIV incidence in both pregnant and nonpregnant women supports consideration of introducing antiretroviral-containing pre-exposure prophylaxis for pregnant and nonpregnant women in high HIV prevalence settings.

Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and stillbirths: systematic review and meta-analysis

OBJECTIVE

To assess whether exposure to high temperatures in pregnancy is associated with increased risk for preterm birth, low birth weight, and stillbirth.

DESIGN

Systematic review and random effects meta-analysis.

DATA SOURCES

Medline and Web of Science searched up to September 2018, updated in August 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical studies on associations between high environmental temperatures, and preterm birth, birth weight, and stillbirths.

RESULTS

14 880 records and 175 full text articles were screened. 70 studies were included, set in 27 countries, seven of which were countries with low or middle income. In 40 of 47 studies, preterm births were more common at higher than lower temperatures. Exposures were classified as heatwaves, 1°C increments, and temperature threshold cutoff points. In random effects meta-analysis, odds of a preterm birth rose 1.05-fold (95% confidence interval 1.03 to 1.07) per 1°C increase in temperature and 1.16-fold (1.10 to 1.23) during heatwaves. Higher temperature was associated with reduced birth weight in 18 of 28 studies, with considerable statistical heterogeneity. Eight studies on stillbirths all showed associations between temperature and stillbirth, with stillbirths increasing 1.05-fold (1.01 to 1.08) per 1°C rise in temperature. Associations between temperature and outcomes were largest among women in lower socioeconomic groups and at age extremes. The multiple temperature metrics and lag analyses limited comparison between studies and settings.

CONCLUSIONS

Although summary effect sizes are relatively small, heat exposures are common and the outcomes are important determinants of population health. Linkages between socioeconomic status and study outcomes suggest that risks might be largest in low and middle income countries. Temperature rises with global warming could have major implications for child health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD 42019140136 and CRD 42018118113.

Extreme heat exposure in pregnancy and risk for preterm birth, low birth weight and stillbirths

Background

Exposure to high ambient temperatures during pregnancy may increase the risk of adverse pregnancy outcomes due to physiological and anatomical changes in pregnancy compromising the ability to thermoregulate.

Methods

A systematic review and meta-analysis of studies that assessed associations between ambient heat, and preterm birth, birth weight and stillbirths. Articles were identified through a search of Medline (PubMed) and Web of Science. Titles and abstracts were screened, eligible studies extracted and risk of bias assessed using the Joanna Briggs Institute appraisal tools.

Results

14,880 records were screened and a total of 70 studies included. In 40 of 47 studies, preterm births were more frequent at higher than lower temperatures. In random effects meta-analysis, the odds of a preterm birth rose 1.05-fold per 1 °C increase in temperature (95%CI=1.03, 1.07), and 1.16 fold during heat waves (95%CI=1.10, 1.23). Reduced birth weight associated with higher temperature was found in in 18 of 28 studies, with considerable heterogeneity. Studies on stillbirths (n = 8) all showed temperature-stillbirth associations, with stillbirths increasing 1.05-fold per 1 °C rise in temperature (95%CI=1.01, 1.08). Associations between temperature and outcomes were largest among women in lower socioeconomic groups and at age extremes. The multiple temperature metrics and lag analyses limited comparison between studies and settings.

Conclusions

As frequency of heat exposures is increasing, prevention for pregnant women during heat waves should become a standard aspect of heat adaptation.

Key messages

Increase in extreme temperature events may have major implications for child health unless much more is done to provide heat adaptation services for pregnant women. Links between socio-economic status and study outcomes suggest higher vulnerability for already disadvantaged groups.

Transcatheter closure of the patent ductus arteriosus at a public sector hospital in Soweto, South Africa: a review of patient outcomes over 15 years

BACKGROUND

Methods of closing patent ductus arteriosus (PDA) have evolved over time. We review this development in our setting.

METHODS

This was a retrospective analysis of children who had transcatheter PDA closure at Chris Hani Baragwanath Hospital between 1993 and 2008.

RESULTS

Over 15 years, 1 254 PDAs were diagnosed, of which 293 required intervention; 139 patients had transcatheter closure, the median age was 1.8 years (interquartile range = 1-4.5 years) and 66% were female (92/139). Mean PDA diameter was 3.2 mm (standard deviation = 1.6 mm), with an average 2:1 shunt. Transcatheter closure was performed using COOK^® Flipper coils (n = 93) or Amplatzer^™ devices (n = 46). Early occlusion rates for coils were 52% (39/75) and late occlusion occurred in 91% (68/75) of patients. For Amplatzer devices, early occlusion rates were 94% (33/35) and late occlusion was 100%. Amplatzer^™ devices, available since 2003, were overwhelmingly used in the later years.

CONCLUSIONS

Transcatheter PDA closure was safe and effective in this setting, with outcomes similar to reports elsewhere.

Heavy episodic drinking among Kenyan female sex workers is associated with unsafe sex, sexual violence and sexually transmitted infections

This study examined patterns of alcohol use and its association with unsafe sex and related sequelae among female sex workers in Mombasa, Kenya. A community-based cross-sectional study was conducted using snowball sampling. Binge drinkers (≥5 alcoholic drinks on ≥1 occasion in the previous month) were compared with non-binge drinkers. Of 719 participants, 22.4% were lifetime-alcohol abstainers, 44.7% non-binge and 33.0% binge drinkers. Compared with non-binge drinkers, binge drinkers were more likely to report unprotected sex (adjusted odds ratio (AOR)=1.59, 95% confidence interval [CI]=1.00–2.53; P=0.047) and sexual violence (AOR=1.85, 95% CI=1.27–2.71; P=0.001) and to have either syphilis, Neisseria gonorrhoeae or Trichomonas vaginalis infection (AOR=1.56, 95% CI=1.00–2.41; P=0.048). HIV prevalence was higher among women having ever drunk (39.9%) than lifetime abstainers (23.2%; P<0.001), but was not associated with drinking patterns. Interventions are needed to assist female sex workers adopt safer drinking patterns. Investigation is needed for the effectiveness of such interventions in reducing unprotected sex, sexual violence and sexually transmitted infections.

Declining maternal mortality in the face of persistently high HIV prevalence in a middle-income country

OBJECTIVE

To estimate maternal mortality ratio (MMR) and determine maternal death causes and trends in Greater Soweto, Johannesburg, South Africa.

DESIGN

Cross-sectional study.

SETTING

Chris Hani Baragwanath Maternity Hospital (CHBMH) in Greater Soweto.

POPULATION

Maternal deaths at CHBMH.

METHODS

Record review of maternal deaths from 1997 to 2012, using hospital death records, with denominator data from the district health information system and the hospital.

MAIN OUTCOME MEASURES

Maternal mortality ratio per 100,000 live births, and causes of death classified as in the South African confidential enquiries.

RESULTS

There were 479 deaths, with a peak MMR of 139 in 2004 and a decline to 86 in 2012. Of 332 women tested, 245 (74%) were HIV-infected. Nonpregnancy-related infection (40%) was the most frequent cause of death, followed by hypertension (16%) and obstetric haemorrhage (13%). HIV infection rates in these groups were 92%, 30% and 61%, respectively. Previous caesarean section was associated with obstetric haemorrhage death (odds ratio [OR] 3.2, 95% confidence interval [95% CI] 1.7-6.0), maternal age ≥35 years with hypertension death (OR 2.2, 95% CI 1.2-3.7) and antenatal anaemia with nonpregnancy-related infection death (OR 4.0, 95% CI 2.3-6.9), compared with other causes of death.

CONCLUSION

There is evidence of a decline in MMR since HIV treatment for pregnant women was introduced in 2004. Previous caesarean section, advanced maternal age, and anaemia were associated with death from obstetric haemorrhage, hypertensive disorders of pregnancy and nonpregnancy-related infections, respectively. MMR may be further reduced with accelerated initiation of HIV treatment during pregnancy.

Female sex work and international sport events - no major changes in demand or supply of paid sex during the 2010 Soccer World Cup: a cross-sectional study

BACKGROUND

Important unanswered questions remain on the impact of international sporting events on the sex industry. Speculation about increased demand and supply of sex work often generates significant attention, but also additional funding for HIV programmes. This study assessed whether changes occurred in the demand and supply of paid sex during the 2010 Soccer World Cup in South Africa.

METHODS

Trained sex worker interviewers conducted face-to-face semi-structured interviews among consenting female sex workers during May-September 2010. Using bivariate analyses we compared supply, demand, sexual risk-taking, and police and health services contact pre-World Cup, to levels during the World Cup and after the event.

RESULTS

No increases were detected in indicators of sex work supply, including the proportion of sex workers newly arrived in the city (< 2.5% in each phase) or those recently entering the trade (≤ 1.5%). Similarly, demand for sex work, indicated by median number of clients (around 12 per week) and amount charged per transaction ($13) remained similar in the three study periods. Only a third of participants reported observing any change in the sex industry ascribed to the World Cup. Self-reported condom-use with clients remained high across all samples (> 92.4% in all phases). Health-care utilisation decreased non-significantly from the pre- to during World Cup period (62.4% to 57.0%; P = 0.075). Across all periods, about thirty percent of participants had interacted with police in the preceding month, two thirds of whom had negative interactions.

CONCLUSIONS

Contrary to public opinion, no major increases were detected in the demand or supply of paid sex during the World Cup. Although the study design employed was unable to select population-based samples, these findings do not support the public concern and media speculation prior to the event, but rather signal a missed opportunity for public health action. Given the media attention on sex work, future sporting events offer strategic opportunities to implement services for sex workers and their clients, especially as health service utilisation might decrease in this period.

Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene

South Africa has a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. Much evidence indicates that alcohol independently influences decisions around sex, and undermines skills for condom negotiation and correct use. Thus, not surprisingly, people with problem drinking in Africa have twofold higher risk for HIV than non-drinkers. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising and provision of Brief Interventions. Alcohol counselling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. Within positive-prevention services, alcohol reduction interventions could diminish HIV transmission. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence. However, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable disease, including unsafe sex, sexual violence, unintended pregnancy and, likely, HIV transmission.

A Safe Motherhood project in Kenya: assessment of antenatal attendance, service provision and implications for PMTCT

OBJECTIVES

To investigate uptake and provision of antenatal care (ANC) services in the Uzazi Bora project: a demonstration-intervention project for Safe Motherhood and prevention of mother-to-child transmission of HIV in Kenya.

METHODS

Data were extracted from antenatal clinic, laboratory and maternity ward registers of all pregnant women attending ANC from January 2004 until September 2006 at three antenatal clinics in Mombasa and two in rural Kwale district of Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds logistic regression analyses assessed changes over time, and determinants of the frequency and timing of ANC visits, uptake of HIV testing, and provision of iron sulphate, folate and single-dose nevirapine (sd-NVP).

RESULTS

About half of women in rural and urban settings (52.2% and 49.2%, respectively) attended antenatal clinics only once. Lower parity, urban setting, older age and having received iron sulphate and folate supplements during the first ANC visit were independent predictors of more frequent visits. The first ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5% and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally marked improvements were observed in the uptake of HIV testing and the provision of iron sulphate and folate.

CONCLUSION

Provision of ANC services, including sd-NVP, increased markedly over time. While further improvements in quality are necessary, particular attention is needed to implement evidence-based interventions to alter ANC utilization patterns. Encouragingly, improved provision of basic essential obstetric care may increase attendance.

Good treatment outcomes among foreigners receiving antiretroviral therapy in Johannesburg, South Africa

Foreigners, including displaced persons, often have limited health-care access, especially to HIV services. Outcomes of antiretroviral therapy (ART) in South Africans and foreigners were compared at a Johannesburg non-governmental clinic. Records were reviewed of 1297 adults enrolled between April 2004 and March 2007 (568 self-identified foreigners, 431 South Africans citizens and 298 with unknown origin). Compared with citizens, foreigners had fewer hospital admissions (39%, 90/303 versus 51%, 126/244; P < 0.001), less missed appointments for ART initiation (20%, 39/200 versus 25%, 51/206; P < 0.001), faster median time to ART initiation (14 versus 21 days, P = 0.008), better retention in care (88%, 325/369 versus 69%, 155/226; P < 0.001) and lower mortality (2.5%, 14/568 versus 10%, 44/431; P < 0.001) after 426 person-years. In logistic regression, after controlling for baseline CD4 count and tuberculosis status, foreigners were 55% less likely to fail ART than citizens (95% CI = 0.23–0.87). These findings support United Nations High Commissioner for Refugees recommendations that ART should not be withheld from displaced persons.

HIV testing and counselling for women attending child health clinics: an opportunity for entry to prevent mother-to-child transmission and HIV treatment

This study assessed the potential for HIV testing at child health clinics to increase knowledge of HIV status, and entry to infant feeding counselling and HIV treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and counselling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing (95% confidence interval = 1.4–5.1; P = 0.003). Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is acceptable. This could optimize entry into HIV treatment, infant feeding counselling and family planning services.

Morbidity in the first year postpartum among HIV-infected women in Kenya

OBJECTIVE

To assess the effects of HIV infection on morbidity and the needs of infected women for services in the first year postpartum.

METHODS

A cross-sectional study with 500 women attending a child-health clinic in Mombasa, Kenya.

RESULTS

Postpartum duration was a median of 3.3 months (interquartile range, 1.9-6.1 months). The 54 HIV-infected women had a lower income and less financial support than the uninfected women, and they were more likely to experience fever, dyspnea, and dysuria, and to have genital warts (odds ratio [OR], 9.6; 95% confidence interval [CI], 2.6-35.6; P<0.001), candidiasis (OR, 2.9; 95% CI, 1.2-6.8; P=0.012), and bacterial vaginosis (OR, 1.8; 95% CI, 0.95-3.3; P=0.066). Six (nearly 15%) of the HIV-infected women had low- or high-grade squamous intraepithelial lesions, and 21 (42%) had an unmet need for contraception. More than half of all women were anemic, and normocytic anemia was predominant among the HIV infected.

CONCLUSION

Compared with uninfected women, morbidity was increased for HIV-infected women during the year following delivery. This period could be used to offer these, and all-women, family planning services, cervical cancer screening, and treatment for anemia and reproductive tract infections.

Use of self home-made diaphragm for protection against pregnancy and sexually-transmitted infections: case report

This is a case report of a 44-year-old woman who used a home-made diaphragm for 16 years to protect herself from pregnancy and sexually-transmitted infections. The woman stitched a piece of cloth with folded polythene inside. This case report provides a vivid illustration of the limitations of available methods of protection for women. It consists of an introduction to the topic, a description of her experiences using her home-made diaphragm and a discussion of the significance of the case. This report supports the need for additional research on female-controlled methods of protection against sexually-transmitted infections, methods that can be used without male knowledge and co-operation, such as vaginal microbicides and cervical barriers against infection, including the diaphragm.

The Pap smear for detection of bacterial vaginosis

OBJECTIVE

To assess validity of Pap smears in diagnosing bacterial vaginosis.

METHOD

A prospective diagnostic accuracy study with 533 women in Mombasa, Kenya. Diagnosis of bacterial vaginosis using clinical observations scored with simplified Amsel's criteria and Bethesda system for Pap smears was compared with a reference standard (Nugent criteria for gram stains). Both laboratory tests were interpreted blindly.

RESULT

Bacterial vaginosis prevalence was 36.7% (191/521) with Nugent criteria. Pap smear sensitivity and specificity were 59.4% (111/187) and 83.3% (270/324), with corresponding figures for simplified Amsel's criteria of 44.8% (81/181) and 84.8% (263/310). For Pap smear and simplified Amsel's criteria, positive predictive values were 67.3 and 63.3%, and negative predictive values 78.0% and 72.5%.

CONCLUSION

In diagnosing bacterial vaginosis, Pap smears have moderate sensitivity (though higher than simplified Amsel's criteria). Specificity of Pap smears is adequate. Including bacterial vaginosis assessment as a standard component of Pap smears warrants consideration.