Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial

BACKGROUND

Despite achieving relatively high rates of antenatal care, institutional delivery, and HIV antiretroviral therapy for women during pregnancy, neonatal mortality has remained stubbornly high in Zimbabwe. Clearer understanding of causal pathways is required to inform effective interventions.

METHODS

This study was a secondary analysis of data from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, a cluster-randomized community-based trial among pregnant women and their infants, to examine care during institutional and non-institutional deliveries in rural Zimbabwe and associated birth outcomes.

RESULTS

Among 4423 pregnant women, 529 (11.9%) delivered outside a health institution; hygiene practices were poorer and interventions to minimise neonatal hypothermia less commonly utilised for these deliveries compared to institutional deliveries. Among 3441 infants born in institutions, 592 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside institutions. Among mothers delivering at home who reported their reason for having a home delivery, 221/293 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference.

CONCLUSIONS

Preterm birth is common among all infants in rural Zimbabwe, and extremely high among infants born outside health institutions. Our findings indicate that premature onset of labor, rather than maternal choice, may be the reason for many non-institutional deliveries in low-resource settings, initiating a cascade of events resulting in a two-fold higher risk of stillbirth and neonatal mortality amongst children born outside health institutions. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov, number NCT01824940.

Factors influencing treatment failure in HIV positive adult patients on first line antiretroviral therapy

BACKGROUND

Risk factors for treatment failure in HIV positive adults have not been studied extensively in Zimbabwe.

AIM

To investigate socio-demographic, psychosocial and antiretroviral drug related factors as possible risk factors for treatment failure.

OBJECTIVE

To compare the accuracy and reliability of CD4 count results in diagnosing treatment failure versus viral load results.

DESIGN

A descriptive cross-sectional survey.

SETTING

Harare Central Hospital adult opportunistic infections clinic.

PARTICIPANTS

One hundred and eighteen (118) HIV positive participants on 1st line antiretroviral therapy (any 1 of stavudine, tenofovir or zidovudine combined with lamivudine and nevirapine or efavirenz) for at least 1 year. Participants were conveniently sampled.

MAIN OUTCOME MEASURES

First line treatment failure as defined according to World Health Organisation (WHO) 2010 guidelines.

RESULTS

Factors associated with higher odds of treatment failure were severe depression [OR 3.7; p-value 0.002; 95% CI 1.6-8.5] and discontinuing ART [OR 4.4; p-value 0.02; 95% CI 1.3-14.7]. Factors associated with lower odds of treatment failure were age = 42 [OR 0.3; p-value 0.007; 95% CI 0.1-0.7], taking ART on time [OR 0.2; p-value 0.02; 95% CI 0.05-0.8], time on ART > 4 years [OR 0.6; p-value 0.02; 95% CI 0.3-0.9] and female sex [OR 0.4; p-value 0.02; 95% CI 0.2-0.8]. There was statistically significant difference between CD4 count and viral load results in diagnosing treatment failure [OR 8.7; p-value 0.0005; 95% CI 3.6-21.2].

CONCLUSION

Severe depression and discontinuing ART predisposed to treatment failure. CD4 counts were not as reliable as viral load measurements in diagnosing treatment failure.