The effect of calcium supplementation on blood pressure in non-pregnant women with previous pre-eclampsia: An exploratory, randomized placebo controlled study

BACKGROUND

Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP).

METHODS

This exploratory sub-study of the WHO Calcium and Pre-eclampsia (CAP) trial aims to determine the effect of 500mg/day elemental calcium on the blood pressure of non-pregnant women with previous pre-eclampsia. Non-pregnant women with at least one subsequent follow-up trial visit at approximately 12 or 24weeks after randomization were included.

RESULTS

Of 836 women randomized by 9 September 2014, 1st visit data were available in 367 women of whom 217 had previously had severe pre-eclampsia, 2nd visit data were available in 201 women. There was an overall trend to reduced BP in the calcium supplementation group (1-2.5mmHg) although differences were small and not statistically significant. In the subgroup with previous severe pre-eclampsia, the mean diastolic BP change in the calcium group (-2.6mmHg) was statistically larger than in the placebo group (+0.8mmHg), (mean difference -3.4, 95% CI -0.4 to -6.4; p=0.025). The effect of calcium on diastolic BP at 12weeks was greater than in those with non-severe pre-eclampsia (p=0.020, ANOVA analysis).

CONCLUSIONS

There is an overall trend to reduced BP but only statistically significant in the diastolic BP of women with previous severe pre-eclampsia. This is consistent with our hypothesis that this group is more sensitive to calcium supplementation, however results need to be interpreted with caution.

An assessment of the maternal death notification system in Zimbabwe--2006

OBJECTIVE

To determine the completeness and usefulness of the maternal death notification system in Zimbabwe for the year 2006.

METHODS

As part of the Zimbabwe Maternal and Perinatal Mortality Survey (ZMPMS) maternal death notification forms lodged at the national and provincial levels were collected and analyzed. Data was entered into Stata version 6. The forms were also given to two clinician reviewers who assessed the quality of the information on the forms.

RESULTS

A total of 364 forms were found at the provincial level. Of these, 56% had had copies forwarded to national level. Information on antenatal booking status was available on 84% of the forms. The forms had been completed by ten different grades of health worker and cause of death was entered on 80% of the forms. Information on whether the death had been potentially avoidable was entered on 68% of the forms. Five different versions of the maternal death notification form were found in the field and a significant proportion of the forms were missing important demographic variables.

CONCLUSION

The maternal death notification system for Zimbabwe was found to be incomplete and not standardized.

Joining the dots: a plea for precise estimates of the maternal mortality ratio in sub-Saharan Africa

Monitoring of maternal mortality levels in sub-Saharan Africa (SSA) to assess the achievements of safe motherhood programmes and for MDG-5 has been made difficult because of the lack of precise estimates of the maternal mortality ratio (MMR). Projections based on the slow rate of decline of the MMR indicate that MDG-5 may not be reached before the end of this century in this region. Measurements done using demographical and health surveys, statistical modelling and censuses are imprecise and do not allow trends in individual countries to be established. SSA countries should be encouraged to measure mortality levels from their own resources, using methods that produce precise estimates such as population-based surveys. Establishment of the trends will lead to country-specific program targets. The less frequent but more precise measurements can be afforded by SSA countries, as a case study from Zimbabwe shows.

Randomised controlled trial of two antenatal care models in rural Zimbabwe

OBJECTIVE

To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe.

DESIGN

Cluster randomised controlled trial with the clinic as the randomisation unit.

SETTING

Primary care setting in a developing country where care was provided by nurse-midwives.

POPULATION

Women booking for ANC in the clinics were eligible.

MAIN OUTCOME MEASURES

Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes.

METHODS

Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care.

RESULTS

We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44-0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model.

CONCLUSION

In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care.

Best practices for post natal care in Zimbabwe

The purpose of post natal care for the mother is to avert or alleviate significant mortality and morbidity. During the immediate post partum period, the emphasis will be on monitoring to detect complications and assisting the mother to initiate care of the newborn, especially breastfeeding. In the latter post partum period, the aim is to confirm involution and healing of the genital tract, confirm continued good newborn care by the mother and offer protection against pregnancy to the couple.

Best practices for intrapartum care in Zimbabwean health facilities

Evidence-based interventions to ensure a good outcome during childbirth are widely available. Their applicability in various settings depends on local conditions and the resources available. Best practices during normal labour and delivery are described for Zimbabwean health facilities. Practices that have proved value are encouraged and those without benefit are discouraged.

Effectiveness of referral system for antenatal and intra-partum problems in Gutu district, Zimbabwe

We conducted a population-based cohort study to determine the prevalence of antenatal and intra-partum referrals, compliance with advice and perinatal outcomes in referred pregnant women in Gutu district, Zimbabwe. The cohort was composed of 10,572 women who received antenatal care in 23 rural health centres (RHC) in Gutu district between January 1995 and June 1998. Pregnancy records of women with antenatal or intra-partum referral were analysed for indication, compliance and perinatal outcomes. Using women who had no antenatal referral or those who complied as referents, the association of referral with perinatal outcome was expressed as relative risk (RR) with 95% confidence intervals (CI). A total of 30% of women (3,094/10,572) had an antenatal referral. Among women attending RHC in labour, 13% (694/5,338) were referred intra-partum. Nulliparous and women younger than 20 years were more likely to be referred. Nurse - midwives' compliance with referral recommendations was low as 59% women with historical risk factors and 52% with raised blood pressure (>140/90 mmHg) were not referred. Women complied with referral advice except when indication was high parity. Women with antenatal referral were more likely to have hospital delivery, 70% vs 18% (p < 0.001). A total of 13% (993/7,478) of women referred themselves for hospital delivery. The risk of perinatal death was elevated among intra-partum referrals (RR 3.4; 95% CI 1.7 - 6.8), self-referrals (RR 2.6; 95% CI 1.5 - 4.5) and also among women with historical risk factors who were not referred (RR 4.8; 95% CI 2.5 - 9.2). We concluded that although there was a functional referral system in Gutu district its efficiency was reduced by failure of health personnel to comply with referral recommendations. Women took appropriate action for most referral indications.

Best practices for antenatal care in Zimbabwe

Evidence based recommendations, taken from systematic reviews of available literature form the basis for best practices. The manpower and resources available at health institutions in Zimbabwe have been taken into account in developing these antenatal protocols. Good quality is achieved when all the six visits are undertaken at the recommended times, and the activities are carried out competently by providers displaying a good attitude towards the patients. The providers should assess the quality of antenatal care periodically using indicators of access and the correct performance of procedures.

Relation of parity to pregnancy outcome in a rural community in Zimbabwe

This population-based cohort study was conducted to compare pregnancy complications and outcome among nulliparous, low (1-5) and high (> or = 6) parity women. Women who registered for antenatal care and gave birth in Guru District, Zimbabwe, between January 1995 and June 1998 were classified into groups by parity. The women were compared for baseline characteristics, utilisation of health facilities and occurrence of pregnancy complications such as hypertensive disorders of pregnancy, haemorrhage, pre-term delivery, operative delivery, low birth weight and perinatal death. In estimating risk, primiparous (parity = 1) women were used as referents. Pregnancy records for 10,569 women were analysed. Mean ages of nulliparous and high parity (> or = 6) women were 20.1 and 37.7 years respectively (p < 0.001). Prevalence of anaemia at booking (haemoglobin < or =10.5 g/dl) was reduced in nulliparous compared to multiparous women (11.7% vs 16.8%; p > or = 0.001). Nulliparous women were likely to book early (< or = 20 weeks) for antenatal care, have a higher number of visits (> or = 6) and fewer home births. Nulliparous women had higher risk for low birth weight (RR 1.70; 95% CI 1.36 - 2.13). Compared to low parity women, nulliparous and high parity women had an elevated risk of hypertensive complications RR 1.62 (95% CI 1.37-1.92) and RR 1.64 (95% CI 1.29 - 2.07) respectively. The risk of developing any pregnancy complications was highest in nulliparous women (RR 1.48; 95% 1.31- 1.67). In conclusion, nulliparous women had an increased risk of pregnancy complications. High parity women with no previous complicated pregnancy were at low risk of complications.

Ethics in reproductive health: clinical issues in Zimbabwe

Reproductive health can present health practitioners with ethical problems because of the complex interaction between cultural practices, the laws of the country and individual personal preferences. In particular, the problems of pregnancy, sexually transmitted infections, family planning, sexual violence, and domestic abuse require a good knowledge of the laws of the country and the culture in which they operate. The practitioner should at all times respect the patient's autonomy and serve their best interests, whilst keeping in mind the legitimate interest of their partners, spouses, parents or guardians.

Symptoms and findings related to HIV in women in rural Gutu District, Zimbabwe, 1992 to 1993

OBJECTIVE

To relate self-reported morbidity and clinical findings to HIV-status in rural women in Zimbabwe.

DESIGN

A cross sectional study.

SETTING

12 randomly selected villages in rural Gutu District, Zimbabwe.

SUBJECTS

In 1992 to 1993 all women of fertile age (15 to 44 years) in the selected villages were interviewed and examined (n = 1,213). Retrospectively, HIV status was assessed anonymously from frozen blood samples.

MAIN OUTCOME MEASURES

Self-reported morbidity, body mass index (BMI), arm circumference, palpable lymphnodes, prevalence of syphilis, haemoglobin, HIV status.

RESULTS

Overall HIV prevalence was 22%. Mean haemoglobin (Hb) was significantly lower (p < 0.005) and anaemia was significantly more common (p < 0.001) among HIV positive women. Syphilis prevalence was 2.2%, a positive syphilis test increased the risk of being HIV positive three-fold. Persistent cough was significantly more common in HIV positives (OR = 3.0, 95% CI 1.4-6.2). Palpable lymphnodes was the most common clinical finding and generalised lymph adenopathy had a positive predictive value of 67% for HIV. Self-reported morbidity was low and no increased pregnancy loss was reported related to HIV.

CONCLUSION

The low morbidity found in 1992 to 1993, in spite of the high prevalence, indicates a fairly short duration of the HIV infection and would also have contributed to the late awareness of the problem.

Effect of a new antenatal care programme on the attitudes of pregnant women and midwives towards antenatal care in Harare

OBJECTIVE

The aim was to study the effect of a new antenatal care (ANC) programme on the attitudes of pregnant women and midwives towards antenatal care.

DESIGN

This was a controlled trial in which the attitudes of women and staff using the standard programme of ANC were compared to those using a new one. The new programme contained fewer but objective oriented visits, and was designed to improve consumer and provider satisfaction with ANC.

SETTING

Antenatal sessions at primary care clinics in Harare.

SUBJECTS

200 pregnant women and 65 midwives.

MAIN OUTCOME MEASURES

The satisfaction of pregnant women and staff with ANC, reasons for lack of satisfaction, and time spent waiting for consultations.

RESULTS

The new programme did not make any impact on the time spent by women waiting to be seen at the clinics, nor on the time made available for the consultations. There was no significant impact on the degree of satisfaction with the care among the women. In the control clinics, significantly more staff wished the women to make fewer visits, and in the study clinics, significantly more staff thought the use of appointments was appropriate. The major problem limiting access to ANC was lack of money to pay for the booking fees. Other problems mentioned by the women were ignorance regarding the best time to book, lack of privacy and insufficient staff at the clinics.

CONCLUSIONS

The solutions to some of the problems identified require infrastructural changes at policy making level, rather than changes within the antenatal care programmes.

Health education for pregnancy care in Harare. A survey in seven primary health care clinics

OBJECTIVE

The aim of this study was to evaluate how health education is currently practiced in the antenatal clinics in Harare and to make recommendations for its improvement.

DESIGN

This was a descriptive study in which data was collected through subject interviews and by observations of antenatal clinics in progress.

SETTINGS

Antenatal sessions at primary care clinics in Harare.

SUBJECTS

100 pregnant women and 65 midwives.

MAIN OUTCOME MEASURE

The timing, frequency and methods used in health education and the attitude of the pregnant mothers and staff to health education.

RESULTS

The results revealed that health education was given once in pregnancy, on the first visit only. The lecture was the most used teaching method. The lecture was full of distractions which affected the concentration of the audience. Midwives decided on the subject matter for health education without consultation with the expectant women. As a result many women could not follow the practical advice given to them. Midwives overestimated their use of other methods of health education. Both the staff and the pregnant women agreed that there should be greater use of written material for women to read at home with their spouses.

CONCLUSION

The lecture is not the most appropriate method of health education during pregnancy and greater use should be made of other methods of communication such as the mass media and pamphlets.

Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe

BACKGROUND

Many of the individual components of antenatal care have been studied in randomised controlled trials, but few studies have compared whole programmes of antenatal care. Our aim was to test the hypothesis that a new programme of antenatal care with fewer goal-oriented visits would give an equivalent or better result in the outcomes associated with pregnancy and delivery.

METHODS

In a randomised clinical trial in Harare, Zimbabwe, we compared a new programme of antenatal care with the standard programme. The new programme consisted of fewer but more objectively oriented visits and fewer procedures per visit. Seven primary care clinics were randomly assigned to the two programmes-three to the standard programme and four to the new programme.

FINDINGS

Over a 2-year period, 15,994 women were recruited into the study at the time they booked antenatal care. 97% of the women were followed up, 9,394 who had followed the new programme, and 6,138 from clinics with the standard one. Women allocated to the new programme made, as planned, fewer visits than those in the standard programme (median 4 vs 6 visits, respectively). The proportion of antenatal referrals was also lower (13.6 vs 15.3%; odds ratio 0.87 [95% CI 0.79-0.95]) because of significantly fewer referrals for pregnancy-induced hypertension (2.5 vs 3.8%; 0.66 [0.55-0.79]). Nevertheless, there were significantly fewer labour referrals for severe hypertension or eclampsia (2.1 vs 2.6%; 0.81 [0.66-1.00]). The risk for preterm (< 37 weeks) delivery was significantly lower for women on the new programme (10.1 vs 11.5%; 0.86 [0.78-0.96]). There were no other significant differences between the programmes in other major indices of pregnancy outcome, including antenatal referrals for other causes, labour referrals, obstetric interventions, low birthweight, and perinatal and maternal mortality and morbidity.

INTERPRETATION

An antenatal care programme with fewer more objectively oriented visits can be introduced without adverse effects on the main intermediate outcome pregnancy variables.

Zimbabwean birthweight for gestation standards

Birthweight for gestation standards were derived in a study of 5,872 women with ascertainable menstrual dates in Harare, Zimbabwe. The smoothed 5th, 50th and 95th centiles of birthweight for gestation were described for 24 to 42 weeks and these fitted linear quadratic functions. Male infants were significantly heavier than females from 36 weeks onwards and parity differences appeared at 38 weeks gestation. The results suggest that in this population, low birthweight should be defined as 2,000gm or less, rather than a birthweight of less than 2,500gm.

Fetal biparietal diameter and head circumference measurements: results of a longitudinal study in Zimbabwe

In a longitudinal study in Harare, Zimbabwe, 1233 biparietal diameter and 857 head circumference measurements were obtained from the fetuses of 190 women. Weekly mean values and the two standard deviations were calculated for both the biparietal diameter and head circumference from 12 to 40 weeks of pregnancy. There was little difference between these values and some Caucasian and African standards. Comparison was also made of the weekly biparietal diameter growth rate between our results and those from one study in West Africa. The possible reasons for the differences are explained.

Screening for small for dates fetuses: a controlled trial

In the hope of reducing perinatal risks associated with retardation of intrauterine growth a previously described two stage ultrasound screening schedule was evaluated by a controlled trial in 877 women with low risk single pregnancies. The two stages of ultrasound examination were an assessment of gestational age during early pregnancy followed by measurement of length from crown to rump and area of trunk at between 34 and 36 weeks' gestation. The product of crown to rump length and trunk area was calculated. The sensitivity of this schedule in identifying in advance 94% of babies who were small for dates at birth, with 90% specificity, and the speed and simplicity of measurement confirmed the accuracy and feasibility of two stage ultrasonography as a screening procedure. The controlled trial did not, however, show any benefit from its routine application in these low risk pregnancies.

Product of fetal crown-rump length and trunk area: ultrasound measurement in high-risk pregnancies

Calculation of the product of crown-rump length and trunk area (CRL x TA), as measured by ultrasound between 34 and 36 weeks and combined with accurate assessment of gestational age in early pregnancy, was previously shown to be highly effective in detecting the small-for-dates fetus in a largely unselected series of patients. To assess the value of this two-stage schedule in high-risk pregnancies, 202 patients with singleton pregnancies at risk of fetal growth retardation were studied. Of the 53 babies that were small-for-dates at birth, 49 (92%) were identified in advance by CRL x TA measurement. In contrast to previous findings, measurement of trunk area (TA) alone was similarly effective, identifying in advance 48 (91%) of these small-for-dates babies.