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Kemp JF, Hambidge KM, Westcott JL, Ali SA, Saleem S, Garcés A, Figueroa L, Somannavar MS, Goudar SS, Long JM, Hendricks AE, Krebs NF. Zinc Supplementation Initiated Prior to or During Pregnancy Modestly Impacted Maternal Status and High Prevalence of Hypozincemia in Pregnancy and Lactation: The Women First Preconception Maternal Nutrition Trial. J Nutr 2024:S0022-3166(24)00221-9. [PMID: 38621624 DOI: 10.1016/j.tjnut.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/28/2024] [Accepted: 04/10/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Data regarding effects of small-quantity-lipid-based nutrient supplements (SQ-LNS) on maternal serum zinc concentrations (SZC) in pregnancy and lactation are limited. OBJECTIVES The objectives of this study were to evaluate the effect of preconception compared with prenatal zinc supplementation (compared with control) on maternal SZC and hypozincemia during pregnancy and early lactation in women in low-resource settings, and assess associations with birth anthropometry. METHODS From ∼100 women/arm at each of 3 sites (Guatemala, India, and Pakistan) of the Women First Preconception Maternal Nutrition trial, we compared SZC at 12- and 34-wk gestation (n = 651 and 838, respectively) and 3-mo postpartum (n = 742) in women randomly assigned to daily SQ-LNS containing 15 mg zinc from ≥3 mo before conception (preconception, arm 1), from ∼12 wk gestation through delivery (early pregnancy, arm 2) or not at all (control, arm 3). Birth anthropometry was examined for newborns with ultrasound-determined gestational age. Statistical analyses were performed separately for each time point. RESULTS At 12-wk gestation and 3-mo postpartum, no statistical differences in mean SZC were observed among arms. At 34-wk, mean SZC for arms 1 and 2 were significantly higher than for arm 3 (50.3, 50.8, 47.8 μg/dL, respectively; P = 0.005). Results were not impacted by correction for inflammation or albumin concentrations. Prevalence of hypozincemia at 12-wk (<56 μg/dL) was 23% in Guatemala, 26% in India, and 65% in Pakistan; at 34 wk (<50 μg/dL), 36% in Guatemala, 48% in India, and 74% in Pakistan; and at 3-mo postpartum (<66 μg/dL) 79% in Guatemala, 91% in India, and 92% in Pakistan. Maternal hypozincemia at 34-wk was associated with lower birth length-for-age Z-scores (all sites P = 0.013, Pakistan P = 0.008) and weight-for-age Z-scores (all sites P = 0.017, Pakistan P = 0.022). CONCLUSIONS Despite daily zinc supplementation for ≥7 mo, high rates of maternal hypozincemia were observed. The association of hypozincemia with impaired fetal growth suggests widespread zinc deficiency in these settings. This trial is registered at clinicaltrials.gov as #NCT01883193.
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Affiliation(s)
- Jennifer F Kemp
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
| | - K Michael Hambidge
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jamie L Westcott
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
| | - Sumera Aziz Ali
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Ana Garcés
- Maternal Infant Health Center, Instituto de Nutrición de Centro América y Panamá (INCAP), Guatemala City, Guatemala
| | - Lester Figueroa
- Maternal Infant Health Center, Instituto de Nutrición de Centro América y Panamá (INCAP), Guatemala City, Guatemala
| | - Manjunath S Somannavar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education & Research's JN Medical College, Belagavi, Karnataka, India
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education & Research's JN Medical College, Belagavi, Karnataka, India
| | - Julie M Long
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
| | - Audrey E Hendricks
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, CO, United States; Department of Mathematical and Statistical Sciences, University of Colorado Denver, Denver, CO, United States
| | - Nancy F Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States.
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Adegboyega TA, Adejuyigbe EA, Adesina OA, Adeyemi B, Ahmed S, Akinkunmi F, Aluvaala J, Anyabolu H, Ariff S, Arya S, Awowole I, Ayede AI, Babar N, Bachani S, Bahl R, Baqui AH, Chellani H, Chowdhury SB, Coppola LM, Cousens S, Debata PK, de Costa A, Dhaded SM, Donimath KV, Falade AG, Goudar SS, Gupta S, Gwako GN, Irinyenikan TA, Isah DA, Jabeen N, Javed A, Joseph NT, Khanam R, Kinuthia J, Kuti O, Lavin T, Laving AR, Maranna S, Minckas N, Mittal P, Mohan D, Nausheen S, Nguyen MH, Oladapo OT, Olutekunbi OA, Oluwafemi RO, Osoti A, Pujar YV, Qureshi ZP, Rao SPN, Sarrassat S, Shahed MA, Shahidullah M, Sheikh L, Somannavar MS, Soofi S, Suri J, Vernekar SS, Vogel JP, Wadhwa N, Wari PK, Were F, Wylie BJ. The World Health Organization Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns (ACTION-III) Trial: study protocol for a multi-country, multi-centre, double-blind, three-arm, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at high probability of late preterm birth in hospitals in low- resource countries. Trials 2024; 25:258. [PMID: 38609983 PMCID: PMC11010373 DOI: 10.1186/s13063-024-07941-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/17/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks' gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries. METHODS WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries-Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women. DISCUSSION This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally. TRIAL REGISTRATION ISRCTN11434567 . Registered on 7 June 2021.
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Nuss EE, Hoffman MK, Goudar SS, Kavi A, Metgud M, Somannavar M, Okitawutshu J, Lokangaka A, Tshefu A, Bauserman M, Tembo AM, Chomba E, Carlo WA, Figueroa L, Krebs NF, Jessani S, Saleem S, Goldenberg RL, Kurhe K, Das P, Hibberd PL, Achieng E, Nyongesa P, Esamai F, Liechty EA, Bucher S, Goco N, Hemingway-Foday J, Moore J, McClure EM, Silver RM, Derman RJ, Patel A. Corrigendum to The impact of risk factors on aspirin's efficacy for the prevention of preterm birth. American Journal of Obstetrics & Gynecology MFM. Volume 5, Issue 10, October 2023, 101095. Am J Obstet Gynecol MFM 2024; 6:101309. [PMID: 38395633 DOI: 10.1016/j.ajogmf.2024.101309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Affiliation(s)
- Emily E Nuss
- Christiana Care, Newark, DE (Drs Nuss and Hoffman).
| | | | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Avinash Kavi
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Mrityunjay Metgud
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Manjunath Somannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Jean Okitawutshu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo (Drs Okitawutshu, Lokangaka, and Tshefu)
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo (Drs Okitawutshu, Lokangaka, and Tshefu)
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo (Drs Okitawutshu, Lokangaka, and Tshefu)
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Bauserman)
| | | | - Elwyn Chomba
- University Teaching Hospital, Lusaka, Zambia (Ms Tembo and Dr Chomba)
| | | | - Lester Figueroa
- Instituto de Nutrición de Centro América y Panamá, Guatemala City, Guatemala (Dr Figueroa)
| | - Nancy F Krebs
- University of Colorado Denver, Denver, CO (Dr Krebs)
| | - Saleem Jessani
- Aga Khan University, Karachi, Pakistan (Drs Jessani and Saleem)
| | - Sarah Saleem
- Aga Khan University, Karachi, Pakistan (Drs Jessani and Saleem)
| | | | - Kunal Kurhe
- Lata Medical Research Foundation, Nagpur, India (Drs Kurhe, Das, and Patel)
| | - Prabir Das
- Lata Medical Research Foundation, Nagpur, India (Drs Kurhe, Das, and Patel)
| | | | - Emmah Achieng
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya (Ms Achieng and Drs Nyongesa and Esamai)
| | - Paul Nyongesa
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya (Ms Achieng and Drs Nyongesa and Esamai)
| | - Fabian Esamai
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya (Ms Achieng and Drs Nyongesa and Esamai)
| | - Edward A Liechty
- School of Medicine, Indiana University, Indianapolis, IN (Drs Liechty and Bucher)
| | - Sherri Bucher
- School of Medicine, Indiana University, Indianapolis, IN (Drs Liechty and Bucher)
| | - Norman Goco
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
| | - Jennifer Hemingway-Foday
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
| | - Janet Moore
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
| | - Elizabeth M McClure
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
| | | | | | - Archana Patel
- Lata Medical Research Foundation, Nagpur, India (Drs Kurhe, Das, and Patel); Datta Meghe Institute of Higher Education and Research, Wardha, India (Dr. Patel)
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Tikmani SS, Saleem S, Sadia A, M. Bann C, Bozdar MH, Raza J, Dhaded SM, Goudar SS, Gowdar G, Yasmin H, McClure EM, Goldenberg RL. Predictors of Preterm Neonatal Mortality in India and Pakistan: A Secondary Analysis of Data from PURPOSe Study. Glob Pediatr Health 2024; 11:2333794X241236617. [PMID: 38487208 PMCID: PMC10938607 DOI: 10.1177/2333794x241236617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/02/2024] [Accepted: 02/15/2024] [Indexed: 03/17/2024] Open
Abstract
Objective. To create a prediction model for preterm neonatal mortality. Methods. A secondary analysis was conducted using data from a prospective cohort study, the Project to Understand and Research Preterm Pregnancy Outcome South Asia. The Cox proportional hazard model was used and adjusted hazard ratios (AHR) with 95% confidence intervals (95% CI) were reported. Results. Overall, 3446 preterm neonates were included. The mean age of preterm neonates was 0.65 (1.25) hours and 52% were female. The preterm neonatal mortality rate was 23.3%. The maternal factors predicting preterm neonatal death was any antepartum hemorrhage, AHR 1.99 (1.60-2.47), while neonatal predictors were preterm who received positive pressure ventilation AHR 1.30 (1.08-1.57), temperature <35.5°C AHR 1.18 (1.00-1.39), and congenital malformations AHR 3.31 (2.64-4.16). Conclusion. This study identified key maternal and neonatal predictors of preterm neonatal mortality, emphasizing the need for targeted interventions and collaborative public health efforts to address disparities and regional variations.
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Affiliation(s)
| | | | | | - Carla M. Bann
- Research Triangle Institute (RTI) International, Durham, NC, USA
| | | | - Jamal Raza
- National Institute of Child Health, Napier Quarter, Karachi, Pakistan
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Bonet M, Babinska M, Buekens P, Goudar SS, Kampmann B, Knight M, Meaney-Delman D, Lamprianou S, Rivas FM, Stergachis A, Toscano CM, Bhatia J, Chamberlain S, Chaudhry U, Mills J, Serazin E, Short H, Steene A, Wahlen M, Oladapo OT. Maternal and perinatal health research during emerging and ongoing epidemic threats: a landscape analysis and expert consultation. BMJ Glob Health 2024; 9:e014393. [PMID: 38453249 PMCID: PMC10921500 DOI: 10.1136/bmjgh-2023-014393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/14/2024] [Indexed: 03/09/2024] Open
Abstract
INTRODUCTION Pregnant women and their offspring are often at increased direct and indirect risks of adverse outcomes during epidemics and pandemics. A coordinated research response is paramount to ensure that this group is offered at least the same level of disease prevention, diagnosis, and care as the general population. We conducted a landscape analysis and held expert consultations to identify research efforts relevant to pregnant women affected by disease outbreaks, highlight gaps and challenges, and propose solutions to addressing them in a coordinated manner. METHODS Literature searches were conducted from 1 January 2015 to 22 March 2022 using Web of Science, Google Scholar and PubMed augmented by key informant interviews. Findings were reviewed and Quid analysis was performed to identify clusters and connectors across research networks followed by two expert consultations. These formed the basis for the development of an operational framework for maternal and perinatal research during epidemics. RESULTS Ninety-four relevant research efforts were identified. Although well suited to generating epidemiological data, the entire infrastructure to support a robust research response remains insufficient, particularly for use of medical products in pregnancy. Limitations in global governance, coordination, funding and data-gathering systems have slowed down research responses. CONCLUSION Leveraging current research efforts while engaging multinational and regional networks may be the most effective way to scale up maternal and perinatal research preparedness and response. The findings of this landscape analysis and proposed operational framework will pave the way for developing a roadmap to guide coordination efforts, facilitate collaboration and ultimately promote rapid access to countermeasures and clinical care for pregnant women and their offspring in future epidemics.
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Affiliation(s)
- Mercedes Bonet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Magdalena Babinska
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Pierre Buekens
- Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research's, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Beate Kampmann
- Charité Centre for Global Health, Universitätsmedizin Charité Berlin, Berlin, Germany
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Dana Meaney-Delman
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Smaragda Lamprianou
- Pharmacovigilance Team, Regulation and Prequalification Department, Access to Medicines and Health Products Division, World Health Organization, Geneva, Switzerland
| | - Flor Muñoz Rivas
- Departments of Pediatrics and Molecular Virology & Microbiology, Baylor College of Medicine, and Texas Children's Hospital, Houston, Texas, USA
| | - Andy Stergachis
- School of Pharmacy and School of Public Health, University of Washington, Seattle, Washington, USA
| | - Cristiana M Toscano
- Institute of Tropical Pathology and Public Health, Federal University of Goias, Goiania, Brazil
| | | | | | | | | | | | | | | | | | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Neumann BG, Metgud MC, Hoffman MK, Patil K, Savanur M, Hanji V, Ganachari MS, Somannavar M, Goudar SS. Tranexamic acid to reduce blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery-a randomized controlled trial. AJOG Glob Rep 2024; 4:100316. [PMID: 38390367 PMCID: PMC10881416 DOI: 10.1016/j.xagr.2024.100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. Tranexamic acid has proven to be useful in treating hemorrhage from acute blood loss. However, its role in preventing blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery is not well studied. OBJECTIVE This study aimed to assess the role of tranexamic acid in reducing blood loss during elective and unscheduled cesarean deliveries in women at high risk of postpartum hemorrhage. STUDY DESIGN This was a prospective, placebo-controlled, randomized controlled trial from March 2021 to February 2022 at the Karnatak Lingayat Education Society Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India. Women at a high risk of postpartum hemorrhage undergoing cesarean delivery were recruited and randomized to receive either tranexamic acid or placebo (1:1) at least 10 minutes before skin incision. High-risk factors for postpartum hemorrhage included obesity, hypertension, multiparity, previous cesarean delivery, multiple pregnancy, abnormally implanted placenta, placenta previa, abruption, uterine leiomyomas, polyhydramnios, and fetal macrosomia. The primary outcome was blood loss, calculated by a formula using pre- and postoperative hematocrit levels. In addition, gravimetrically measured blood loss was measured and compared between the 2 groups. RESULTS A total of 212 women met the inclusion criteria and were randomized (tranexamic acid [n=106] and placebo [n=106]). The mean blood loss estimates were 400.9 mL in the tranexamic acid group and 597.9 mL in the placebo group (P<.001). The mean gravimetrically measured blood loss estimates were 379.2 mL in the tranexamic acid group and 431.1 mL in the placebo group (P<.001). In addition, there was a significant difference in the fall in hemoglobin levels (1.04 vs 1.61 g/dL) and change in hematocrit levels (3.20% vs 4.95%) from the pre- to postoperative period between the 2 groups (P<.001). No difference in the need for additional uterotonics (P=.26) or the need for postoperative parental iron (P=.18) was noted. No woman was transfused in either group. CONCLUSION High-risk women receiving tranexamic acid had significantly less blood loss than women receiving placebo during cesarean delivery.
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Affiliation(s)
- Bethany G Neumann
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Mrityunjay C Metgud
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Matthew K Hoffman
- Department of Obstetrics and Gynecology, ChristianaCare, Newark, DE (Dr Hoffman)
| | - Kamal Patil
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Mahadevi Savanur
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Vinutha Hanji
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Madiwalayya S Ganachari
- Department of Pharmacy Practice, Karnatak Lingayat Education College of Pharmacy, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Dr Ganachari)
| | - Manjunath Somannavar
- Department of Biochemistry, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Dr Somannavar)
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Dr Goudar)
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Long JM, Gatica‐Domínguez G, Westcott JE, Taren D, Tejeda G, Diba TS, Mastiholi SC, Khan US, Garcés A, Figueroa L, Lokangaka A, Goudar SS, Aziz Ali S, Hambidge KM, Krebs NF. Infant and young child feeding indicators are positively associated with length and family care indicators in the children of the Women First trial participants. Matern Child Nutr 2024; 20:e13572. [PMID: 37817452 PMCID: PMC10750017 DOI: 10.1111/mcn.13572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/24/2023] [Accepted: 09/13/2023] [Indexed: 10/12/2023]
Abstract
This research describes the proportion of children in four low- and middle-income countries with adequate dietary practices at 6, 12, 18 and 24 months of age and how these practices changed over time using the World Health Organisation and UNICEF's infant young child feeding (IYCF) indicators. The associations between the IYCF indicators and anthropometric z-scores from 6 to 24 months, and between the IYCF indicators and the family care indicators (FCIs) at 24 months are described. This was a longitudinal study of offspring from participants in the Women First Preconception Maternal Nutrition Trial conducted in Sud-Ubangi, Democratic Republic of Congo; Chimaltenango, Guatemala; Belagavi, North Karnataka, India; and Thatta, Sindh Province, Pakistan. The frequency of the minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum adequate diet (MAD) increased between 6 and 24 months, but even at 24 months MAD remained below 50% at all sites. MDD (β = 0.12; 95% CI = 0.04-0.22) and MMF (β = 0.10; 95% CI = 0.03-0.17) were positively associated with length-for-age z-score at 24 months. All IYCF indicators were positively associated with mean total FCI score: MDD (proportion ratio [PR] = 1.04; 95% CI = 1.02-1.07), MMF (PR = 1.02; 95% CI = 1.01-1.04), MAD (PR = 1.05; 95% CI = 1.02-1.08). Although there are multiple barriers to young children having an adequate diet, our results support a positive association between familial interactions and improved IYCF feeding practices.
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Affiliation(s)
- Julie M. Long
- Department of Pediatrics, Section of NutritionUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Giovanna Gatica‐Domínguez
- Maternal and Infant Health CenterInstituto de Nutrición de Centro América y PanamáGuatemala CityGuatemala
| | - Jamie E. Westcott
- Department of Pediatrics, Section of NutritionUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Douglas Taren
- Department of Pediatrics, Section of NutritionUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Gabriela Tejeda
- Maternal and Infant Health CenterInstituto de Nutrición de Centro América y PanamáGuatemala CityGuatemala
| | - Tshilenge S. Diba
- Kinshasa School of Public Health, Democratic Republic of CongoKinshasaDemocratic Republic of the Congo
| | - Shivanand C. Mastiholi
- Women's and Children's Health Research UnitKLE Academy of Higher Education and Research's Jawaharlal Nehru Medical CollegeBelagaviIndia
| | - Umber S. Khan
- Department of Community Health SciencesAga Khan UniversityKarachiPakistan
| | - Ana Garcés
- Maternal and Infant Health CenterInstituto de Nutrición de Centro América y PanamáGuatemala CityGuatemala
| | - Lester Figueroa
- Maternal and Infant Health CenterInstituto de Nutrición de Centro América y PanamáGuatemala CityGuatemala
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Democratic Republic of CongoKinshasaDemocratic Republic of the Congo
| | - Shivaprasad S. Goudar
- Women's and Children's Health Research UnitKLE Academy of Higher Education and Research's Jawaharlal Nehru Medical CollegeBelagaviIndia
| | - Sumera Aziz Ali
- Department of Community Health SciencesAga Khan UniversityKarachiPakistan
| | - K. Michael Hambidge
- Department of Pediatrics, Section of NutritionUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Nancy F. Krebs
- Department of Pediatrics, Section of NutritionUniversity of Colorado School of MedicineAuroraColoradoUSA
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Derman RJ, Bellad RB, Bellad MB, Bradford-Rogers J, Georgieff MK, Aghai ZH, Thind S, Auerbach M, Boelig R, Leiby BE, Short V, Yogeshkumar S, Charantimath US, Somannavar MS, Mallapur AA, Pol R, Ramadurg U, Sangavi R, Peerapur BV, Banu N, Patil PS, Patil AP, Roy S, Vastrad P, Wallace D, Shah H, Goudar SS. RAPIDIRON Trial follow-up study - the RAPIDIRON-KIDS Study: protocol of a prospective observational follow-up study. Trials 2023; 24:818. [PMID: 38124098 PMCID: PMC10731903 DOI: 10.1186/s13063-023-07740-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/20/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Anemia is a worldwide problem with iron deficiency being the most common cause. When anemia occurs in pregnancy, it increases the risk of adverse maternal, fetal, and postnatal outcomes. It induces preterm births and low birth weight (LBW) deliveries, long-term neurodevelopmental sequelae, and an increased risk of earlier onset of postnatal iron deficiency. Anemia rates are among the highest in South Asia, and India's National Family Health Survey (NFHS-5) for 2019-2021 indicated that over half of pregnant women, and more than 65% of children, in the country are classified as anemic (Sciences IIfP, National Family Health Survey-5, 2019-21, India Fact Sheet). In 2021, the parent RAPIDIRON Trial (Derman et al., Trials 22:649, 2021) was initiated in two states in India, with the goal of assessing whether a dose of intravenous (IV) iron given to anemic women during early pregnancy results in a greater proportion of participants with normal hemoglobin concentrations in the third trimester and a lower proportion of participants with LBW deliveries compared to oral iron. As a follow-up to the RAPIDIRON Trial, the RAPIDIRON-KIDS Study will follow the offspring of previously randomized mothers to assess, neurobehavioral, hematological, and health outcomes. METHODS This prospective observational cohort study will follow a subset of participants previously randomized as part of the RAPIDIRON Trial and their newborns. Study visits occur at birth, 6 weeks, 4 months, 12 months, 24 months, and 36 months and include blood sample collection with both maternal and infant participants and specific neurobehavioral assessments conducted with the infants (depending on the study visit). The primary outcomes of interest are (1) infant iron status as indicated by both hemoglobin and ferritin (a) at birth and (b) at 4 months of age and (2) the developmental quotient (DQ) for the cognitive domain of the Bayley Scales of Infant Development Version IV (BSID-IV) at 24 months of age. DISCUSSION This RAPIDIRON-KIDS Study builds upon its parent RAPIDIRON Trial by following a subset of the previously randomized participants and their offspring through the first 3 years of life to assess neurodevelopmental and neurobehavioral (infants, children), hematological, and health outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT05504863 , Registered on 17 August 2022. Clinical Trials Registry - India CTRI/2022/05/042933 . Registered on 31 May 2022.
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Affiliation(s)
| | - Roopa B Bellad
- KLE Academy of Higher Education and Research (KAHER), Jawaharlal Nehru Medical College (JNMC), Belagavi, India
| | - Mrutyunjaya B Bellad
- KLE Academy of Higher Education and Research (KAHER), Jawaharlal Nehru Medical College (JNMC), Belagavi, India
| | | | | | | | - Simal Thind
- Thomas Jefferson University (TJU), Philadelphia, USA
| | | | - Rupsa Boelig
- Thomas Jefferson University (TJU), Philadelphia, USA
| | | | - Vanessa Short
- Thomas Jefferson University (TJU), Philadelphia, USA
| | - S Yogeshkumar
- KLE Academy of Higher Education and Research (KAHER), Jawaharlal Nehru Medical College (JNMC), Belagavi, India
| | - Umesh S Charantimath
- KLE Academy of Higher Education and Research (KAHER), Jawaharlal Nehru Medical College (JNMC), Belagavi, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research (KAHER), Jawaharlal Nehru Medical College (JNMC), Belagavi, India
| | | | - Ramesh Pol
- S. Nijalingappa Medical College (SNMC), Bagalkot, India
| | | | - Radha Sangavi
- Raichur Institute of Medical Sciences (RIMS), Raichur, India
| | | | - Nasima Banu
- Raichur Institute of Medical Sciences (RIMS), Raichur, India
| | - Praveen S Patil
- Raichur Institute of Medical Sciences (RIMS), Raichur, India
| | - Amaresh P Patil
- KLE Academy of Higher Education and Research (KAHER), Jawaharlal Nehru Medical College (JNMC), Belagavi, India
| | - Subarna Roy
- Model Rural Health Research Unit (MRHRU), Sirwar, India
| | | | | | - Hemang Shah
- The Children's Investment Fund Foundation (CIFF), New Delhi, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research (KAHER), Jawaharlal Nehru Medical College (JNMC), Belagavi, India
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9
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Switchenko N, Shukla V, Mwenechanya M, Chomba E, Patel A, Hibberd PL, Ambalavanan N, Figueroa L, Mazariegos M, Krebs NF, Goudar SS, Derman R, Esamai F, Liechty EA, Bucher S, Saleem S, Goldenberg RL, Lokangaka A, Tshefu A, Bose CL, Koso-Thomas M, Tan S, Nolen T, McClure EM, Carlo WA. Neonatal Respiratory Support Utilization in Low- and Middle-Income Countries: A Registry-Based Observational Study. Neonatology 2023; 121:116-124. [PMID: 38048757 DOI: 10.1159/000534777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/11/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Newborns with hypoxemia often require life-saving respiratory support. In low-resource settings, it is unknown if respiratory support is delivered more frequently to term infants or preterm infants. We hypothesized that in a registry-based birth cohort in 105 geographic areas in seven low- and middle-income countries, more term newborns received respiratory support than preterm newborns. METHODS This is a hypothesis-driven observational study based on prospectively collected data from the Maternal and Newborn Health Registry of the NICHD Global Network for Women's and Children's Health Research. Eligible infants enrolled in the registry were live-born between 22 and 44 weeks gestation with a birth weight ≥400 g and born from January 1, 2015, to December 31, 2018. Frequency data were obtained to report the number of term and preterm infants who received treatment with oxygen only, CPAP, or mechanical ventilation. Test for trends over time were conducted using robust Poisson regression. RESULTS 177,728 (86.3%) infants included in this study were term, and 28,249 (13.7%) were preterm. A larger number of term infants (n = 5,108) received respiratory support compared to preterm infants (n = 3,287). Receipt of each mode of respiratory support was more frequent in term infants. The proportion of preterm infants who received respiratory support (11.6%) was higher than the proportion of term infants receiving respiratory support (2.9%, p < 0.001). The rate of provision of respiratory support varied between sites. CONCLUSIONS Respiratory support was more frequently used in term infants expected to be at low risk for respiratory disorders compared to preterm infants.
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Affiliation(s)
- Nora Switchenko
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vivek Shukla
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Elwyn Chomba
- Department of Pediatrics, University Teaching Hospital, Lusaka, Zambia
| | - Archana Patel
- Lata Medical Research Foundation, India and Datta Meghe Institute of Medical Sciences, Nagpur, India
| | | | | | | | | | - Nancy F Krebs
- Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's J. N. Medical College, Belagavi, India
| | - Richard Derman
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fabian Esamai
- Department of Pediatrics, Moi University, Eldoret, Kenya
| | - Edward A Liechty
- Department of Pediatrics, Indiana University, Bloomington, Indiana, USA
| | - Sheri Bucher
- Department of Pediatrics, Indiana University, Bloomington, Indiana, USA
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Robert L Goldenberg
- Department of Obstetrics/Gynecology, Columbia University, New York, New York, USA
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Carl L Bose
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Sylvia Tan
- RTI International, Durham, North Carolina, USA
| | - Tracy Nolen
- RTI International, Durham, North Carolina, USA
| | | | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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10
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Nyongesa P, Ekhaguere OA, Marete I, Tenge C, Kemoi M, Bann CM, Bucher SL, Patel AB, Hibberd PL, Naqvi F, Saleem S, Goldenberg RL, Goudar SS, Derman RJ, Krebs NF, Garces A, Chomba E, Carlo WA, Mwenechanya M, Lokangaka A, Tshefu AK, Bauserman M, Koso-Thomas M, Moore JL, McClure EM, Liechty EA, Esamai F. Maternal age extremes and adverse pregnancy outcomes in low-resourced settings. Front Glob Womens Health 2023; 4:1201037. [PMID: 38090046 PMCID: PMC10715413 DOI: 10.3389/fgwh.2023.1201037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/14/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Adolescent (<20 years) and advanced maternal age (>35 years) pregnancies carry adverse risks and warrant a critical review in low- and middle-income countries where the burden of adverse pregnancy outcomes is highest. Objective To describe the prevalence and adverse pregnancy (maternal, perinatal, and neonatal) outcomes associated with extremes of maternal age across six countries. Patients and methods We performed a historical cohort analysis on prospectively collected data from a population-based cohort study conducted in the Democratic Republic of Congo, Guatemala, India, Kenya, Pakistan, and Zambia between 2010 and 2020. We included pregnant women and their neonates. We describe the prevalence and adverse pregnancy outcomes associated with pregnancies in these maternal age groups (<20, 20-24, 25-29, 30-35, and >35 years). Relative risks and 95% confidence intervals of each adverse pregnancy outcome comparing each maternal age group to the reference group of 20-24 years were obtained by fitting a Poisson model adjusting for site, maternal age, parity, multiple gestations, maternal education, antenatal care, and delivery location. Analysis by region was also performed. Results We analyzed 602,884 deliveries; 13% (78,584) were adolescents, and 5% (28,677) were advanced maternal age (AMA). The overall maternal mortality ratio (MMR) was 147 deaths per 100,000 live births and increased with advancing maternal age: 83 in the adolescent and 298 in the AMA group. The AMA groups had the highest MMR in all regions. Adolescent pregnancy was associated with an adjusted relative risk (aRR) of 1.07 (1.02-1.11) for perinatal mortality and 1.13 (1.06-1.19) for neonatal mortality. In contrast, AMA was associated with an aRR of 2.55 (1.81 to 3.59) for maternal mortality, 1.58 (1.49-1.67) for perinatal mortality, and 1.30 (1.20-1.41) for neonatal mortality, compared to pregnancy in women 20-24 years. This pattern was overall similar in all regions, even in the <18 and 18-19 age groups. Conclusion The maternal mortality ratio in the LMICs assessed is high and increased with advancing maternal age groups. While less prevalent, AMA was associated with a higher risk of adverse maternal mortality and, like adolescence, was associated with adverse perinatal mortality with little regional variation.
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Affiliation(s)
- Paul Nyongesa
- Department of Obstetrics and Gynecology, Moi University School of Medicine, Eldoret, Kenya
| | - Osayame A. Ekhaguere
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Irene Marete
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Constance Tenge
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Milsort Kemoi
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Carla M. Bann
- Social Statistical, and Environmental Sciences Unit, RTI International, Durham, NC, United States
| | - Sherri L. Bucher
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, United States
- Department of Community and Global Health, Richard M. Fairbanks School of Public Health, IU-Indianapolis, Indianapolis, IN, United States
| | - Archana B. Patel
- Department of Pediatrics, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Patricia L. Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States
| | - Farnaz Naqvi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Robert L. Goldenberg
- Department of Obstetrics and Gynecology, Columbia University School of Medicine, New York, NY, United States
| | - Shivaprasad S. Goudar
- Women's and Children's Health Research Unit, J N Medical College Belagavi, KLE Academy Higher Education and Research, Karnataka, India
| | - Richard J. Derman
- Global Affairs, Thomas Jefferson University, Philadelphia, PA, United States
| | - Nancy F. Krebs
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO, United States
| | - Ana Garces
- Department of Pediatrics, Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | - Elwyn Chomba
- Department of Pediatrics, University Teaching Hospital, Lusaka, Zambia
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Adrien Lokangaka
- Department of Pediatrics, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Antoinette K. Tshefu
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Melissa Bauserman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MA, United States
| | - Janet L. Moore
- Social Statistical, and Environmental Sciences Unit, RTI International, Durham, NC, United States
| | - Elizabeth M. McClure
- Social Statistical, and Environmental Sciences Unit, RTI International, Durham, NC, United States
| | - Edward A. Liechty
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Fabian Esamai
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
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11
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Vesel L, Benotti E, Somji S, Bellad RM, Charantimath U, Dhaded SM, Goudar SS, Karadiguddi C, Mungarwadi G, Vernekar SS, Kisenge R, Manji K, Salim N, Samma A, Sudfeld CR, Hoffman IF, Mvalo T, Phiri M, Saidi F, Tseka J, Tsidya M, Caruso BA, Duggan CP, Israel-Ballard K, Lee AC, Mansen KL, Martin SL, North K, Young MF, Fishman E, Fleming K, Semrau KE, Spigel L, Tuller DE, Henrich N. Facilitators, barriers, and key influencers of breastfeeding among low birthweight infants: a qualitative study in India, Malawi, and Tanzania. Int Breastfeed J 2023; 18:59. [PMID: 37940987 PMCID: PMC10634072 DOI: 10.1186/s13006-023-00597-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/02/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Low birthweight (LBW) infants are at increased risk of morbidity and mortality. Exclusive breastfeeding up to six months is recommended to help them thrive through infection prevention, growth improvements, and enhancements in neurodevelopment. However, limited data exist on the feeding experiences of LBW infants, their caregivers and key community influencers. The qualitative component of the Low Birthweight Infant Feeding Exploration (LIFE) study aimed to understand practices, facilitators, and barriers to optimal feeding options in the first six months for LBW infants in low-resource settings. METHODS This study was conducted in four sites in India, Malawi, and Tanzania from July 2019 to August 2020. We conducted 37 focus group discussions with mothers and family members of LBW infants and community leaders and 142 in-depth interviews with healthcare providers, government officials, and supply chain and donor human milk (DHM) experts. Data were analyzed using a framework approach. RESULTS All participants believed that mother's own milk was best for LBW infants. Direct breastfeeding was predominant and feeding expressed breast milk and infant formula were rare. DHM was a new concept for most. Adequate maternal nutrition, lactation support, and privacy in the facility aided breastfeeding and expression, but perceived insufficient milk, limited feeding counseling, and infant immaturity were common barriers. Most believed that DHM uptake could be enabled through community awareness by overcoming misconceptions, safety concerns, and perceived family resistance. CONCLUSION This study fills an evidence gap in LBW infant feeding practices and their facilitators and barriers in resource-limited settings. LBW infants face unique feeding challenges such as poor latching and tiring at the breast. Similarly, their mothers are faced with numerous difficulties, including attainment of adequate milk supply, breast pain and emotional stress. Lactation support and feeding counseling could address obstacles faced by mothers and infants by providing psychosocial, verbal and physical support to empower mothers with skills, knowledge and confidence and facilitate earlier, more and better breast milk feeding. Findings on DHM are critical to the future development of human milk banks and highlight the need to solicit partnership from stakeholders in the community and health system.
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Affiliation(s)
- Linda Vesel
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Emily Benotti
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Roopa M Bellad
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Umesh Charantimath
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Chandrashekhar Karadiguddi
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Geetanjali Mungarwadi
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Sunil S Vernekar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nahya Salim
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Departments of Global Health and Population and Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Irving F Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melda Phiri
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Friday Saidi
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer Tseka
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Mercy Tsidya
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Bethany A Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Christopher P Duggan
- Departments of Global Health and Population and Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Center for Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Kiersten Israel-Ballard
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anne Cc Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kimberly L Mansen
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, WA, USA
| | - Stephanie L Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Krysten North
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa F Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eliza Fishman
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Katelyn Fleming
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Katherine Ea Semrau
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lauren Spigel
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Danielle E Tuller
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Natalie Henrich
- Ariadne Labs at Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Shankar K, Hwang K, Westcott JL, Saleem S, Aziz SA, Jessani S, Patel A, Kavi A, Somannavar MS, Goudar SS, Hibberd PL, Derman RJ, Hoffman M, Wylie BJ, Goldenberg RL, Thorsten VR, McClure EM, Krebs NF. Associations between ambient temperature and pregnancy outcomes from three south Asian sites of the Global Network Maternal Newborn Health Registry: A retrospective cohort study. BJOG 2023; 130 Suppl 3:124-133. [PMID: 37581948 PMCID: PMC10843605 DOI: 10.1111/1471-0528.17616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE Growing evidence suggests that environmental heat stress negatively influences fetal growth and pregnancy outcomes. However, few studies have examined the impact of heat stress on pregnancy outcomes in low-resource settings. We combined data from a large multi-country maternal-child health registry and meteorological data to assess the impacts of heat stress. DESIGN Retrospective cohort study. SETTING Three sites based in south Asia as part of the Global Network for Women's and Children's Health research in India (Belagavi and Nagpur) and Pakistan (Thatta). POPULATION OR SAMPLE Data from women enrolled between 2014 and 2020 in the Global Network's Maternal Newborn Health Registry (MNHR), a prospective, population-based registry of pregnancies, were used. METHODS A total of 126 273 pregnant women were included in this analysis. Daily maximal air temperatures (Tmax ) were acquired from local meteorological records. Associations between averages of daily maximal temperatures for each trimester and main outcomes were analysed using a modified Poisson regression approach. MAIN OUTCOMES MEASURES Incidence of stillbirth, preterm birth, low birthweight (<2500 g) or evidence of pregnancy hypertension or pre-eclampsia. RESULTS In the overall cohort, risk of preterm birth was positively associated with greater temperature in the second trimester (relative risk [RR] 1.05, 95% CI 1.02-1.07, p = 0.0002). Among individual sites, the risk of preterm birth was greatest in Nagpur (RR 1.07, 95% CI 1.03-1.11, p = 0.0005) and associated with second-trimester temperature. The overall risk of low birthweight was associated with ambient temperature in second trimester (RR 1.02, 95% CI 1.01-1.04, p = 0.01). The risk for LBW was associated with first-trimester heat in Thatta and with second-trimester heat in Nagpur. Finally, the overall risk of gestational hypertensive disease was associated with greater temperature in the third trimester among all sites (RR 1.07, 95% CI 1.02-1.12, p = 0.005) and was particularly significant for Nagpur (RR 1.13, 95% CI 1.05-1.23, p = 0.002). These findings highlight the increased risk of detrimental obstetric and neonatal outcomes with greater temperature. CONCLUSION In a multi-country, community-based study, greater risk of adverse outcomes was observed with increasing temperature. The study highlights the need for deeper understanding of covarying factors and intervention strategies, especially in regions where high temperatures are common.
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Affiliation(s)
- Kartik Shankar
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kay Hwang
- RTI International, Durham, North Carolina, USA
| | - Jamie L. Westcott
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | | | - Archana Patel
- Lata Medical Research Foundation, Nagpur, India
- Datta Meghe Institute of Medical Sciences, Wardha, India
| | - Avinash Kavi
- KLE Academy Higher Education and Research, J N Medical College, Belagavi, Karnataka, India
| | | | - Shivaprasad S. Goudar
- KLE Academy Higher Education and Research, J N Medical College, Belagavi, Karnataka, India
| | | | | | - Matthew Hoffman
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Christiana Care Health System, Delaware, USA
| | - Blair J. Wylie
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Robert L. Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | | | | | - Nancy F. Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
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13
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Charantimath US, Bellad RM, Mahantashetti N, Karadiguddi CC, Mungarwadi GM, Kelly PJ, Ma T, Goudar SS, Derman RJ. Experiences of peer counsellors in supporting exclusive breastfeeding in southern India: An exploratory qualitative study. BJOG 2023; 130 Suppl 3:107-112. [PMID: 37530600 DOI: 10.1111/1471-0528.17615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/30/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE Peer counsellors are effective in addressing a variety of health challenges, including exclusive breastfeeding (EBF). Providing education and support from a person of similar background and experience has been an important adjunct to the practice of health workers for the past 50 years. DESIGN It is an exploratory qualitative study. POPULATION OR SAMPLE Twenty-two peer counsellors. SETTING In-depth Interview in the community. METHODS To better understand the experiences of these important health workers, we conducted qualitative interviews with 22 peer counsellors who participated in a research study in Belagavi District, Karnataka, India. Transcripts of the interviews were organised and assigned codes by the research team. MAIN OUTCOME MEASURES Experience of Peer counsellor's role in the community to improve breastfeeding practices. RESULTS Peer counsellors had a good understanding of the larger study and of their role. Analysis of the transcripts identified three themes: personal satisfaction; the effect on the larger circle of family and community; and ideas for future programming. The positive experiences and the ability of peers to be trained in counselling women around EBF support their use in breastfeeding support and other areas of health education. CONCLUSIONS The women from the community who served as peer counsellors were enthusiastic and satisfied about their work, which provided them with opportunities to do meaningful community work outside of their household routines. Use of the peer counsellor model to deliver a specific objective like improvement in EBF rates, immunisation or mental health in integration with healthcare providers can help in achieving desired goals.
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Affiliation(s)
- Umesh S Charantimath
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Roopa M Bellad
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Niranjana Mahantashetti
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Geetanjali M Mungarwadi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Tony Ma
- Benten Technologies, Inc., Manassas, Virginia, USA
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
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Ahmed I, Ghanchi NK, Sunder Tikmani S, Hwang K, Zafar A, Saleem S, Uddin Z, Harakuni S, Somannavar MS, Kulkarni V, Guruprasad G, Goudar SS, Kim J, McClure EM, Goldenberg RL. Placental inflammation and pregnancy outcomes: A prospective, observational study in South Asia: The PURPOSe study. BJOG 2023; 130 Suppl 3:43-52. [PMID: 37671586 DOI: 10.1111/1471-0528.17643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE To examine inflammatory lesions in placentas of stillbirths, preterm neonatal deaths and term controls in India and Pakistan. DESIGN Prospective, observational study. SETTING Three hospitals in India and a large maternity hospital in Pakistan. POPULATION The enrolled participants with placentas available for histology evaluation included stillbirths (n = 814), preterm live births who died within 28 days of birth (n = 618) and term live birth controls (n = 201). From this same population, polymerase chain reaction (PCR) analysis for pathogens was performed on 809 stillbirth placentas, 614 neonatal death placentas and the placentas of 201 term controls. Placentas from preterm infants who lived beyond day 28 (n = 1432) were only available from India. METHODS A prospective observational study of placental inflammatory lesions defined by the Amsterdam criteria and on the same placentas, multiplex PCR evaluation for 75 pathogens using TaqMan Array Cards. MAIN OUTCOME MEASURES Any placental inflammatory lesions, including chorioamnionitis, funisitis, villitis and intervillitis and their association with various pathogens. RESULTS In the Indian liveborn preterm infants, placental inflammation of any kind was present in 26.2% of those who died versus 16.6% of those who lived (p = 0.0002). Chorioamnionitis was present in 25.8% of those who died versus 16.3% of those who lived (p = 0.0002) and funisitis was present in 4.1% of those who died versus 1.5% of those who lived, (p = 0.005). Across all three sites, in the placentas of the 201 term controls, 18.9% had any inflammation, 16.9% had chorioamnionitis, 5.5% had funisitis, 0.5% had intervillitis and none had villitis. Overall, for stillbirths, any inflammation was observed in 30.2%, chorioamnionitis in 26.9%, funisitis in 5.7%, intervillitis in 6.0% and villitis in 2.2%. For the neonatal deaths, any inflammation was present in 24.9%, chorioamnionitis in 23.3%, funisitis in 8.1%, intervillitis in 1.9% and villitis in 0.5%. Compared with the placentas of term controls, in neonatal deaths, only chorioamnionitis was significantly increased (23.3% versus 16.9%, p = 0.05). Among stillbirths, the rates of any inflammation, chorioamnionitis, intervillitis and villitis were similar across the birthweight groups. However, funisitis was more common in the placentas of stillborn fetuses weighing 2500 g or more (13.8%) compared with 1.0% for those weighing less than 1000 g and 4.8% for stillborn fetuses weighing 1000-2499 g. In the PCR studies, Ureaplasma spp. were by far the most common pathogens found and generally were more commonly found in association with inflammatory lesions. CONCLUSIONS Chorioamnionitis was the most common type of placental inflammatory lesion regardless of whether the placentas evaluated were from term controls, stillbirths or neonatal deaths. For stillbirths, inflammation in each inflammation category was more common than in the term controls and significantly more so for any inflammation, chorioamnionitis, intervillitis and villitis. For neonatal deaths, compared with the placentas of term controls, all inflammation categories were more common, but only significantly so for chorioamnionitis. Ureaplasma spp. were the most common organisms found in the placentas and were significantly associated with inflammation.
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Affiliation(s)
| | | | | | - Kay Hwang
- RTI International, Durham, North Carolina, USA
| | | | | | | | - Sheetal Harakuni
- KLE Academy of Higher Education and Research's, J N Medical College, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research's, J N Medical College, Belagavi, Karnataka, India
| | - Vardendra Kulkarni
- Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | - Gowder Guruprasad
- Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's, J N Medical College, Belagavi, Karnataka, India
| | - Jean Kim
- RTI International, Durham, North Carolina, USA
| | | | - Robert L Goldenberg
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Columbia University, New York, New York, USA
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15
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Kallapur MG, Ghanchi NK, Harakuni SU, Somannavar MS, Ahmed I, Fogleman E, Hwang K, Kim J, Saleem S, Goudar SS, Tikmani SS, Dhaded SM, Guruprasad G, Yasmin H, Yogeshkumar S, McClure EM, Goldenberg RL. Group B streptococcal prevalence in internal organs and placentas of deceased neonates and stillbirths in South Asia. BJOG 2023; 130 Suppl 3:53-60. [PMID: 37530593 DOI: 10.1111/1471-0528.17614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/30/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE Group B streptococcus (GBS) has been associated with adverse pregnancy outcomes, but few prospective studies have assessed its prevalence in low- and middle-income country settings. We sought to evaluate the prevalence of GBS by polymerase chain reaction (PCR) in internal organ tissues and placentas of deceased neonates and stillbirths. DESIGN This was a prospective, observational study. SETTING The study was conducted in hospitals in India and Pakistan. POPULATION Pregnant women with stillbirths or preterm births were recruited at delivery, as was a group of women with term, live births, to serve as a control group. METHODS A rectovaginal culture was collected from the women in Pakistan to assess GBS carriage. Using PCR, we evaluated GBS in various tissues of stillbirths and deceased neonates and their placentas, as well as the placentas of live-born preterm and term control infants. MAIN OUTCOME MEASURES GBS identified by PCR in various tissues and the placentas; rate of stillbirths and 28-day neonatal deaths. RESULTS The most obvious finding from this series of analyses from India and Pakistan was that no matter the country, the condition of the subject, the tissue studied or the methodology used, the prevalence of GBS was low, generally ranging between 3% and 6%. Among the risk factors evaluated, only GBS positivity in primigravidae was increased. CONCLUSIONS GBS diagnosed by PCR was identified in <6% of internal organs of stillbirths and neonatal deaths, and their placentas, and control groups in South Asian sites. This is consistent with other reports from South Asia and is lower than the reported GBS rates from the USA, Europe and Africa.
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Affiliation(s)
- Mangala G Kallapur
- Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | | | - Sheetal U Harakuni
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | | | | | - Kay Hwang
- RTI International, Durham, North Carolina, USA
| | - Jean Kim
- RTI International, Durham, North Carolina, USA
| | | | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | | | - Sangappa M Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Gowdar Guruprasad
- Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | | | - S Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
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16
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Goldenberg RL, Goudar SS, Kavi A, Krebs NF, Derman RJ, Saleem S, McClure EM. Improving maternal, neonatal and child health outcomes in low-resource settings: Translating research evidence to practice - report from The Third International Conference on Maternal, Newborn and Child Health. BJOG 2023; 130 Suppl 3:4-7. [PMID: 37530445 DOI: 10.1111/1471-0528.17609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/30/2023] [Indexed: 08/03/2023]
Affiliation(s)
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Avinash Kavi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, Colorado, USA
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17
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Anderson JR, Yogeshkumar S, Lu E, Yenokyan G, Thaler K, Mensa M, Chikaraddi S, Lokare L, Gudadinni MR, Antartani R, Donimath K, Patil B, Bidri S, Goudar SS, Derman R, Dalal A. The CryoPop study: Screening for high-grade cervical dysplasia in Karnataka, India. BJOG 2023; 130 Suppl 3:158-167. [PMID: 37932903 PMCID: PMC10659137 DOI: 10.1111/1471-0528.17702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE To describe our experience of screening with visual inspection with acetic acid (VIA) and colposcopy to identify women with high-grade precancerous cervical lesions who were candidates for cryotherapy. Women were screened to determine eligibility for a clinical trial testing the safety and efficacy of a new, simple and inexpensive cryotherapy device (CryoPop®) targeted for use in low and middle-income countries (LMICs). DESIGN Prospective cohort study. SETTING Primary and urban health centres in Belagavi, Hubballi and Vijayapur, India. POPULATION Women in the age-group 30-49 years, premenopausal, with no prior hysterectomy and no known HIV infection were eligible for screening. METHODS Visual inspection with acetic acid was performed on eligible women following informed consent. VIA-positive women were referred for colposcopy and biopsy. Biopsies were read by two pathologists independently, with a third pathologist acting as tie-breaker if needed. MAIN OUTCOME MEASURES The primary outcome measures were the number/proportion of women screening positive by VIA and the number/proportion of those women screening VIA-positive found to have high-grade cervical lesions on biopsy (cervical intraepithelial neoplasia 2/3 [CIN 2/3]). Demographic variables were compared between women who screened VIA-positive and those who screened VIA-negative; a separate comparison of demographic and limited reproductive variables was performed between women who had CIN 2/3 on biopsy and those without CIN 2/3 on biopsy. Chi-square or Fisher's exact tests for categorical data and t-tests or analysis of variance for numeric data were used with all tests two-sided and performed at an alpha 0.05 level of statistical significance. RESULTS A total of 9130 women were screened with VIA between 4 July 2020 and 31 March 2021. The mean age of all women screened was 37 years (standard deviation = 5.6 years) with 6073 of the women (66.5%) in the 30-39 year range. Only 1% of women reported prior cervical cancer screening. A total of 501 women (5.5%) were VIA-positive; of these, 401 women underwent colposcopy. Of those who had colposcopy, 17 (4.2%) had high-grade lesions on biopsy, an additional 164 (40.9%) had low-grade cervical lesions on biopsy or endocervical curettage and one woman (0.2%) was found to have invasive cancer. VIA-positive women were younger and had higher levels of education and income; however, women who were VIA-positive and found to have CIN 2/3 were older, were more likely to be housewives and had higher household income than those without CIN 2/3. CONCLUSION Despite the COVID-19 pandemic, over 9100 women were screened with VIA for precancerous lesions. However, only 17 (4.2%) were found to have biopsy-proven high-grade cervical lesions, underscoring the subjective performance of VIA as a screening method. Given that this is significantly lower than rates reported in the literature, it is possible that the prevalence of high-grade lesions in this population was impacted by screening a younger and more rural population. This study demonstrates that screening is feasible in an organised fashion and can be scaled up rapidly. However, while inexpensive and allowing for same-day treatment, VIA may be too subjective and have insufficient accuracy clearly to identify lesions requiring treatment, particularly in low-prevalence and low-risk populations, calling into question its overall cost-effectiveness.
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Affiliation(s)
- Jean R Anderson
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, India
| | - Enriquito Lu
- Jhpiego, an Affiliate of Johns Hopkins University, Baltimore, Maryland, USA
| | - Gayane Yenokyan
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Katrina Thaler
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Margaret Mensa
- Jhpiego, an Affiliate of Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Muttappa R Gudadinni
- BLDE (Deemed-to-be-University) Shri B M Patil Medical College Hospital and Research Centre, Vijayapura, India
| | | | | | - Basavaraj Patil
- Karnataka Cancer Therapy & Research Institute, Hubballi, India
| | - Shailaja Bidri
- BLDE (Deemed-to-be-University) Shri B M Patil Medical College Hospital and Research Centre, Vijayapura, India
| | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, India
| | - Richard Derman
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Anita Dalal
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, India
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18
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Yogeshkumar S, Dhananjay S, Gowdar S, Gowdar G, Kulkarni V, Byranahalli S, Goudar SS, Dhaded SM, Somannavar MS, Tikamani SS, Saleem S, Ahmed I, Ghanchi NK, Uddin Z, Yasmin H, Jackson K, McClure EM, Goldenberg RL. Morphological study of the placenta in deliveries with pre-eclampsia: Results from a prospective, observational study in India and Pakistan (PURPOSe). BJOG 2023; 130 Suppl 3:36-42. [PMID: 37530629 DOI: 10.1111/1471-0528.17617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/06/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE To compare placental findings in women with and without pre-eclampsia. DESIGN The PURPOSe study included women with stillbirths, women with preterm births and women at term as controls. The placenta of each case was evaluated using the Amsterdam criteria. SETTING Two sites and five tertiary care hospitals of south Asia (Three in India and two in Pakistan). POPULATION Pregnancies in India and Pakistan with placental histology including women with documented hypertension and documented proteinuria and women with neither hypertension nor proteinuria. METHODS We compared the placental findings of the two groups using the Amsterdam criteria and further evaluated the placental findings in women with and without pre-eclampsia who had a stillbirth, preterm live birth, or term live birth (control). MAIN OUTCOME MEASURES The main outcome measures were the frequency of maternal and fetal vascular malperfusion and the frequency of placental inflammation and its components, chorioamnionitis, funisitis, villitis and intervillitis in women with and without pre-eclampsia. RESULTS A total of 733 women had pre-eclampsia and 2334 women had neither hypertension nor proteinuria. In the placentas of women with pre-eclampsia, 57.3% had maternal vascular malperfusion compared with 37.1% in women without pre-eclampsia (p < 0.0001). There was not a significant difference in the prevalence of fetal vascular hypertension between mothers with (17.1%) and without (14.8%, p = 0.6118) pre-eclampsia. When placentas were classified as 'histologically normal' or not, 61.3% of those from pre-eclamptic pregnancies were classified as abnormal, whereas if there was no pre-eclampsia, only 45.0% were classified as histologically abnormal (p < 0.0001). We also considered rates of placental maternal vascular malperfusion in women with and without pre-eclampsia with stillbirth, preterm neonatal death, and term live birth. In women at term with no pre-eclampsia, 16.7% of the placentas had features of maternal vascular malperfusion. This occurred in 79.9% of women with stillbirths with pre-eclampsia compared with 51.8% of those without pre-eclampsia. Maternal vascular malperfusion was present in 49.7% of preterm live births with pre-eclampsia compared with 33.8% without pre-eclampsia. We also evaluated the inflammatory lesions by whether the mother had or did not have pre-eclampsia. When all inflammatory lesions were considered, women with pre-eclampsia had significantly fewer inflammatory lesions than those women without pre-eclampsia (17.1% versus 23.6% p = 0.001). Each of the specific inflammatory lesions was less common in placentas of women with pre-eclampsia than those with chorioamnionitis (16.1% versus 21.9%, p = 0.004) and funisitis (1.5% versus. 5.1%, p = 0.0004). CONCLUSIONS Of placental lesions in women with pre-eclampsia, maternal vascular malperfusion was the most common. Inflammatory lesions were less common in women with pre-eclampsia.
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Affiliation(s)
- S Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Shobha Dhananjay
- Bapuji Education Association's JJM Medical College, Davangere, Karnataka, India
| | - Sarvamangala Gowdar
- Bapuji Education Association's JJM Medical College, Davangere, Karnataka, India
| | - Guruprasad Gowdar
- Bapuji Education Association's JJM Medical College, Davangere, Karnataka, India
| | - Vardendra Kulkarni
- Bapuji Education Association's JJM Medical College, Davangere, Karnataka, India
| | - Sunil Byranahalli
- Bapuji Education Association's JJM Medical College, Davangere, Karnataka, India
| | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Sangappa M Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | | | | | | | | | | | | | - Kay Jackson
- RTI International, Durham, North Carolina, USA
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19
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Guruprasad G, Raghoji CR, Dhaded SM, Tikmani SS, Saleem S, Goudar SS, Hwang K, Yogeshkumar S, Somannavar MS, Reza S, Yasmin H, Moore JL, Bann CM, McClure EM, Goldenberg RL. Pregnancy outcomes in preterm multiple gestations: Results from a prospective study in India and Pakistan (PURPOSe). BJOG 2023; 130 Suppl 3:76-83. [PMID: 37470087 DOI: 10.1111/1471-0528.17602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/27/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To evaluate perinatal outcomes in preterm multiple compared with singleton pregnancies in India and Pakistan. DESIGN Prospective, observational study. SETTINGS Study hospitals in India and Pakistan. POPULATION We evaluated 3897 preterm pregnancies. These mothers gave birth to 3615 (92.8%) singleton infants, 267 (6.8%) sets of twins, 14 (0.4%) sets of triplets and one set of quadruplets. MAIN OUTCOME MEASURES Neonatal mortality, stillbirth, cause of death. RESULTS Of the singleton infants, 691 (19.1%) were stillborn and 2924 (80.9%) live born. Of the 534 infants from twin pregnancies, 41 (7.7%) were stillborn and 493 (92.3%) were live born. Of the 267 sets of twins, in 14 cases (5.2%) both were stillborn, in 13 cases (4.8%) one was stillborn and one live born, and in 240 cases (90.0%) both were live born. In both preterm twins and preterm singletons, the three most common causes of death were intrauterine hypoxia, infections acquired prior to birth and infections acquired at or after birth. The preterm twins appeared less likely to have died from intrauterine hypoxia but more likely to have died from infections acquired at or after birth. Respiratory distress syndrome (RDS) was less likely considered by the panel to be the primary cause of death in either the twins (9.6%) or singletons (9.7%). Congenital anomalies were also not often judged to be the cause of death in either the preterm twins 2 (2.4%) or singletons 27 (5.3%). CONCLUSION In the PURPOSe study, neonatal mortality rates in preterm twins compared with singletons when evaluated by sex, GA, birthweight and SGA, were generally similar to rates of preterm singleton neonatal mortality in those groups. Thus, the higher rate of mortality in live-born twin infants is related to the fact that these infants were more likely to be born earlier rather than to any inherent characteristics of the babies themselves.
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Affiliation(s)
- Gowdar Guruprasad
- Bapuji Educational Association's J.J.M. Medical College, Karnataka, India
| | - Chaitali R Raghoji
- Bapuji Educational Association's J.J.M. Medical College, Karnataka, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | | | | | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Kay Hwang
- RTI International, Durham, North Carolina, USA
| | - S Yogeshkumar
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
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20
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Kavi A, Hoffman MK, Somannavar MS, Metgud MC, Goudar SS, Moore J, Nielsen E, Goco N, McClure EM, Lokangaka A, Tshefu A, Bauserman M, Mwenechanya M, Chomba E, Carlo WA, Figueroa L, Krebs NF, Jessani S, Saleem S, Goldenberg RL, Das P, Patel A, Hibberd PL, Esamai F, Bucher S, Koso-Thomas M, Silver R, Derman RJ. Aspirin delays the onset of hypertensive disorders of pregnancy among nulliparous pregnant women: A secondary analysis of the ASPIRIN trial. BJOG 2023; 130 Suppl 3:16-25. [PMID: 37470099 PMCID: PMC10799162 DOI: 10.1111/1471-0528.17607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/26/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To assess the impact of low-dose aspirin (LDA) starting in early pregnancy on delaying preterm hypertensive disorders of pregnancy. DESIGN Non-prespecified secondary analysis of a randomised masked trial of LDA. SETTING The study was conducted among women in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry (MNHR) clusters, a prospective, population-based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Pakistan, India (two sites-Belagavi and Nagpur) and Guatemala. POPULATION Nulliparous singleton pregnancies between 6+0 weeks and 13+6 weeks in six low-middle income countries (Democratic Republic of Congo, Guatemala, India, Kenya, Pakistan, Zambia) enrolled in the ASPIRIN Trial. METHODS We compared the incidence of HDP at delivery at three gestational age periods (<28, <34 and <37 weeks) between women who were randomised to aspirin or placebo. Women were included if they were randomised and had an outcome at or beyond 20 weeks (Modified Intent to Treat). MAIN OUTCOME MEASURES Our primary outcome was pregnancies with HDP associated with preterm delivery (HDP@delivery) before <28, <34 and <37 weeks. Secondary outcomes included small for gestational age (SGA) <10th percentile, <5th percentile, and perinatal mortality. RESULTS Among the 11 976 pregnancies, LDA did not significantly lower HDP@delivery <28 weeks (relative risk [RR] 0.18, 95% confidence interval [CI] 0.02-1.52); however, it did lower HDP@delivery <34 weeks (RR 0.37, 95% CI 0.17-0.81) and HDP@delivery <37 weeks (RR 0.66, 95% CI 0.49-0.90). The overall rate of HDP did not differ between the two groups (RR 1.08, 95% CI 0.94-1.25). Among those pregnancies who had HDP, SGA <10th percentile was reduced (RR 0.81, 95% CI 0.67-0.99), though SGA <5th percentile was not (RR 0.84, 95% CI 0.64-1.09). Similarly, perinatal mortality among pregnancies with HDP occurred less frequently (RR 0.55, 95% CI 0.33-0.92) in those receiving LDA. Pregnancies randomised to LDA delivered later with HDP compared with those receiving placebo (median gestational age 38.5 weeks vs. 37.9 weeks; p = 0.022). CONCLUSIONS In this secondary analysis of a study of low-risk nulliparous singleton pregnancies, early administration of LDA resulted in lower rates of preterm HDP and delivery before 34 and 37 weeks but not in the overall rate of HDP. These results suggest that LDA works in part by delaying HDP.
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Affiliation(s)
- Avinash Kavi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | | | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Mrityunjay C Metgud
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Janet Moore
- RTI International, Durham, North Carolina, USA
| | | | - Norman Goco
- RTI International, Durham, North Carolina, USA
| | | | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | - Lester Figueroa
- Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, Colorado, USA
| | | | | | | | | | - Archana Patel
- Lata Medical Research Foundation, Nagpur, India
- Datta Meghe Institute of Medical Sciences, Sawangi, India
| | | | - Fabian Esamai
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Sherri Bucher
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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21
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Kavi A, Goudar SS, Somannavar MS, Moore JL, Derman RJ, Saleem S, Naqvi S, Billah SM, Haque R, Figueroa L, Mazariegos M, Lokangaka A, Tshefu A, Esamai F, Mwenechanya M, Chomba E, Patel A, Das P, Bauserman M, Petri WA, Krebs NF, Carlo WA, Bucher S, Hibberd PL, Koso-Thomas M, McClure EM, Goldenberg RL. COVID-19 symptoms and antibody positivity among unvaccinated pregnant women: An observational study in seven countries from the Global Network. BJOG 2023; 130 Suppl 3:140-148. [PMID: 37470094 PMCID: PMC10799161 DOI: 10.1111/1471-0528.17604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/24/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To determine the relation of COVID-19 symptoms to COVID-19 antibody positivity among unvaccinated pregnant women in low- and middle-income countries (LMIC). DESIGN COVID-19 infection status measured by antibody positivity at delivery was compared with the symptoms of COVID-19 in the current pregnancy in a prospective, observational cohort study in seven LMICs. SETTING The study was conducted among women in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry (MNHR), a prospective, population-based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Bangladesh, Pakistan, India (Belagavi and Nagpur sites) and Guatemala. POPULATION Pregnant women enrolled in the ongoing pregnancy registry at study sites. METHODS Data on COVID-19 symptoms during the current pregnancy were collected by trained staff between October 2020 and June 2022. COVID-19 antibody testing was performed on samples collected at delivery. The relation between COVID-19 antibody positivity and symptoms was assessed using generalised linear models with a binomial distribution adjusting for site and symptoms. MAIN OUTCOME MEASURES COVID-19 antibody status and symptoms of COVID-19 among pregnant women. RESULTS Among 19 218 non-vaccinated pregnant women who were evaluated, 14.1% of antibody-positive women had one or more symptoms compared with 13.4% in antibody-negative women. Overall, 85.3% of antibody-positive women reported no COVID-19 symptoms during the present pregnancy. Reported fever was significantly associated with antibody status (relative risk [RR] 1.10, 95% CI 1.03-11.18; P = 0.008). A multiple variable model adjusting for site and all eight symptoms during pregnancy showed similar results (RR 1.13, 95% CI 1.04-1.23; P = 0.012). None of the other symptoms was significantly related to antibody positivity. CONCLUSIONS In a population-based cohort in LMICs, unvaccinated pregnant women who were antibody-positive had slightly more symptoms during their pregnancy and a small but significantly greater increase in fever. However, for prevalence studies, evaluating COVID-19-related symptoms does not appear to be useful in differentiating pregnant women who have had a COVID-19 infection.
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Affiliation(s)
- Avinash Kavi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Janet L Moore
- Research Triangle Institute (RTI) International, Research Triangle Park, North Carolina, USA
| | | | | | | | - Sk Masum Billah
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
- University of Sydney, Sydney, New South Wales, Australia
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Lester Figueroa
- Instituto de Nutrición de Centroamérica y Panamá (INCAP), Guatemala City, Guatemala
| | - Manolo Mazariegos
- Instituto de Nutrición de Centroamérica y Panamá (INCAP), Guatemala City, Guatemala
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | | | - Elwyn Chomba
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur, India
- Datta Meghe Institute of Medical, Sciences, Sawangi, India
| | | | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Nancy F Krebs
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Sherri Bucher
- Indiana School of Medicine, University of Indiana, Indianapolis, Indiana, USA
| | | | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Elizabeth M McClure
- Research Triangle Institute (RTI) International, Research Triangle Park, North Carolina, USA
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22
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Goldenberg RL, Saleem S, Goudar SS, Moore J, Guruprasad G, Kulkarni V, Dhaded SM, Tikmani SS, Nausheen S, Masheer S, Kallapur MG, Ghanchi NK, Harakuni SU, Ahmed I, Hwang K, Yogeshkumar S, Somannavar MS, Yasmin H, Kim J, Bann CM, Silver RM, McClure EM. The PURPOSe cause of death study in stillbirths and neonatal deaths in India and Pakistan: A review. BJOG 2023; 130 Suppl 3:26-35. [PMID: 37592743 DOI: 10.1111/1471-0528.17635] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/11/2023] [Indexed: 08/19/2023]
Abstract
The PURPOSe study was a prospective, observational study conducted in India and Pakistan to determine the cause of death for stillbirths and preterm neonatal deaths, using clinical data together with minimally invasive tissue sampling (MITS) and the histologic and polymerase chain reaction (PCR) evaluation of fetal/neonatal tissues and the placenta. After evaluating all available data, an independent panel chose a maternal, a placental and a fetal/neonatal cause of death. Here, we summarise the major results. Among the most important findings were that most stillbirths were caused by fetal asphyxia, often preceded by placental malperfusion, and clinically associated with pre-eclampsia, placental abruption and a small-for-gestational-age fetus. The preterm neonatal deaths were primarily caused by birth asphyxia, followed by various infections. An important finding was that many of the preterm neonatal deaths were caused by a nosocomial infection acquired after neonatal intensive care (NICU) admission; the most common organisms were Acinetobacter baumannii, followed by Klebsiella pneumoniae, Escherichia coli/Shigella and Haemophilus influenzae. Group B streptococcus was less commonly present in the placentas or internal organs of the neonatal deaths.
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Affiliation(s)
| | | | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka, India
| | - Janet Moore
- RTI International, Durham, North Carolina, USA
| | - Gowdar Guruprasad
- Bapuji Educational Association's JJM Medical College, Davangere, Karnataka, India
| | - Vardendra Kulkarni
- Bapuji Educational Association's JJM Medical College, Davangere, Karnataka, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka, India
| | | | | | | | - Mangala G Kallapur
- Bapuji Educational Association's JJM Medical College, Davangere, Karnataka, India
| | | | - Sheetal U Harakuni
- KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka, India
| | | | - Kay Hwang
- RTI International, Durham, North Carolina, USA
| | - S Yogeshkumar
- KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka, India
| | | | - Jean Kim
- RTI International, Durham, North Carolina, USA
| | - Carla M Bann
- KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka, India
- RTI International, Durham, North Carolina, USA
| | - Robert M Silver
- University of Utah School of Medicine, Salt Lake City, Utah, USA
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23
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Chandhiok N, Goudar SS, Kavi A, Somannavar MS, Silver RM. Connecting the dots: Adoption of maternal, newborn and child health research evidence in policy and practice. BJOG 2023; 130 Suppl 3:168-171. [PMID: 37530407 DOI: 10.1111/1471-0528.17599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/24/2023] [Indexed: 08/03/2023]
Affiliation(s)
| | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, India
| | - Avinash Kavi
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, India
| | - Manjunath S Somannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, India
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24
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Goldenberg RL, Hwang K, Saleem S, Tikmani SS, Yogeshkumar S, Kulkani V, Ghanchi N, Harakuni S, Ahmed I, Uddin Z, Goudar SS, Guruprasad G, Dhaded S, Goco N, Silver RM, McClure EM. Data usefulness in determining cause of stillbirth in South Asia. BJOG 2023; 130 Suppl 3:61-67. [PMID: 37470078 DOI: 10.1111/1471-0528.17592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To evaluate the usefulness of data to determine cause of stillbirth in India and Pakistan. DESIGN Prospective, observational study. SETTINGS Study hospitals in India and Pakistan. POPULATION 200 fetal deaths with placental evaluation and minimally invasive tissue sampling (MITS) of internal organs and polymerase chain reaction (PCR) test for 75 pathogens. MAIN OUTCOME MEASURES Data defined as useful to determine stillbirth causes. RESULTS Placental pathology was the most useful to determine cause of stillbirth. Comparing placental and fetal weight with standard weights was useful in 44.5% and 48.5%, respectively. Lung histology was useful in 42.5%. Most of the other findings of internal organ histology were only occasionally useful. Signs of abruption, by maternal history or placental evaluation, were always deemed useful. Placenta, brain and cord blood PCR were also useful, but less often than histology. CONCLUSION Based on this analysis, maternal clinical history, placental histology and fetal examination were most informative. Comparing the placental and fetal weights with recognised standards was useful in nearly half the cases. Fetal tissue histology and PCR were also informative. Of all the potential tests of MITS-obtained specimens, we would first recommend histological evaluation of the lungs, and using a multiplex PCR platform would determine pathogens in blood and brain/CSF. We recognise that this approach will not identify some causes, including some genetic and internal organ anomalies, but will confirm most common causes of stillbirth and most of the preventable causes of stillbirth in low- and middle-income countries.
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Affiliation(s)
| | - Kay Hwang
- RTI International, Durham, North Carolina, USA
| | | | | | - S Yogeshkumar
- KLE Academy of Higher Education's JN Medical College, Belagavi, India
| | | | | | - Sheetal Harakuni
- KLE Academy of Higher Education's JN Medical College, Belagavi, India
| | - Imran Ahmed
- RTI International, Durham, North Carolina, USA
| | | | | | | | - Sangappa Dhaded
- KLE Academy of Higher Education's JN Medical College, Belagavi, India
| | - Norman Goco
- RTI International, Durham, North Carolina, USA
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25
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Jessani S, Saleem S, Fogleman E, Billah SM, Haque R, Figueroa L, Lokangaka A, Tshefu A, Goudar SS, Kavi A, Esamai F, Mwenchanya M, Chomba E, Patel A, Das P, Mazariegos M, Bauserman M, Petri WA, Krebs NF, Derman RJ, Carlo WA, Bucher S, Hibberd PL, Koso-Thomas M, Bann CM, McClure EM, Goldenberg RL. Trends over time in the knowledge, attitude and practices of pregnant women related to COVID-19: A cross-sectional survey from seven low- and middle-income countries. BJOG 2023; 130 Suppl 3:149-157. [PMID: 37581947 DOI: 10.1111/1471-0528.17630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/21/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE To understand trends in the knowledge, attitudes and practices (KAP) of pregnant women related to COVID-19 in seven low- and middle-income countries. DESIGN Multi-country population-based prospective observational study. SETTING Study sites in Bangladesh, the Demographic Republic of Congo (DRC), Guatemala, India (two sites), Kenya, Pakistan and Zambia. POPULATION Pregnant women in the Global Network's Maternal and Neonatal Health Registry (MNHR). METHODS Pregnant women enrolled in the MNHR were interviewed to assess their KAP related to COVID-19 from September 2020 through July 2022 across all study sites. MAIN OUTCOME MEASURES Trends of COVID-19 KAP were assessed using the Cochran-Armitage test for trend. RESULTS A total of 52 297 women participated in this study. There were wide inter-country differences in COVID-19-related knowledge. The level of knowledge of women in the DRC was much lower than that of women in the other sites. The ability to name COVID-19 symptoms increased over time in the African sites, whereas no such change was observed in Bangladesh, Belagavi and Guatemala. All sites observed decreasing trends over time in women avoiding antenatal care visits. CONCLUSIONS The knowledge and attitudes of pregnant women related to COVID-19 varied substantially among the Global Network sites over a period of 2 years; however, there was very little change in knowledge related to COVID-19 over time across these sites. The major change observed was that fewer women reported avoiding medical care because of COVID-19 across all sites over time.
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Affiliation(s)
| | | | | | - Sk Masum Billah
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
- University of Sydney, Sydney, New South Wales, Australia
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
| | - Lester Figueroa
- Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Shivaprasad S Goudar
- KLE Academy Higher Education and Research, JN Medical College Belagavi, Belagavi, Karnataka, India
| | - Avinash Kavi
- KLE Academy Higher Education and Research, JN Medical College Belagavi, Belagavi, Karnataka, India
| | | | | | - Elwyn Chomba
- University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
- Datta Meghe Institute of Medical Sciences, Sawangi, Maharashtra, India
| | - Prabir Das
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
| | | | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, Colorado, USA
| | | | | | - Sherri Bucher
- Indiana School of Medicine, University of Indiana, Indianapolis, Indiana, USA
| | | | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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26
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Naqvi S, Saleem S, Billah SM, Moore J, Mwenechanya M, Carlo WA, Esamai F, Bucher S, Derman RJ, Goudar SS, Somannavar M, Patel A, Hibberd PL, Figueroa L, Krebs NF, Petri WA, Lokangaka A, Bauserman M, Koso-Thomas M, McClure EM, Goldenberg RL. The Global Network COVID-19 studies: a review. BJOG 2023; 130 Suppl 3:134-139. [PMID: 37530467 DOI: 10.1111/1471-0528.17610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/30/2023] [Indexed: 08/03/2023]
Abstract
With the paucity of data available regarding COVID-19 in pregnancy in low- and middle-income countries (LMICs), near the start of the pandemic, the Global Network for Women's and Children's Health Research, funded by the National Institute of Child Health and Human Development (NICHD), initiated four separate studies to better understand the impact of the COVID-19 pandemic in eight LMIC sites. These sites included: four in Asia, in Bangladesh, India (two sites) and Pakistan; three in Africa, in the Democratic Republic of the Congo (DRC), Kenya and Zambia; and one in Central America, in Guatemala. The first study evaluated changes in health service utilisation; the second study evaluated knowledge, attitudes and practices of pregnant women in relationship to COVID-19 in pregnancy; the third study evaluated knowledge, attitude and practices related to COVID-19 vaccination in pregnancy; and the fourth study, using antibody status at delivery, evaluated changes in antibody status over time in each of the sites and the relationship of antibody positivity with various pregnancy outcomes. Across the Global Network, in the first year of the study there was little reduction in health care utilisation and no apparent change in pregnancy outcomes. Knowledge related to COVID-19 was highly variable across the sites but was generally poor. Vaccination rates among pregnant women in the Global Network were very low, and were considerably lower than the vaccination rates reported for the countries as a whole. Knowledge regarding vaccines was generally poor and varied widely. Most women did not believe the vaccines were safe or effective, but slightly more than half would accept the vaccine if offered. Based on antibody positivity, the rates of COVID-19 infection increased substantially in each of the sites over the course of the pandemic. Most pregnancy outcomes were not worse in women who were infected with COVID-19 during their pregnancies. We interpret the absence of an increase in adverse outcomes in women infected with COVID-19 to the fact that in the populations studied, most COVID-19 infections were either asymptomatic or were relatively mild.
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Affiliation(s)
| | | | - Sk Masum Billah
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Janet Moore
- RTI International, Durham, North Carolina, USA
| | | | | | | | - Sherri Bucher
- Department of Pediatrics, Indiana School of Medicine, University of Indiana, Indianapolis, Indiana, USA
| | | | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Manjunath Somannavar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | | | - Lester Figueroa
- Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | - Nancy F Krebs
- Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
| | | | - Adrien Lokangaka
- Department of Pediatrics, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | | | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University School of Medicine, New York, New York, USA
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27
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Saleem S, Tikmani SS, Goudar SS, Hwang K, Dhaded S, Guruprasad G, Nadig NG, Kusagur VB, Patil LGC, Siddartha ES, Yogeshkumar S, Somannavar MS, Roujani S, Khan M, Shaikh M, Hanif M, Bann CM, McClure EM, Goldenberg RL. Neonatal mortality among preterm infants admitted to neonatal intensive care units in India and Pakistan: A prospective study. BJOG 2023; 130 Suppl 3:68-75. [PMID: 37470084 DOI: 10.1111/1471-0528.17581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To explore potential reasons for differences in preterm neonatal mortality in neonatal intensive care units (NICUs) in India and Pakistan. DESIGN A prospective observational study, the Project to Understand and Research Stillbirth and Preterms in Southeast Asia (PURPOSe) was conducted July 2018 to February 2020. SETTING Three hospitals in Davangere, India, and a large public hospital in Karachi, Pakistan. POPULATION Of a total of 3,202 preterm infants enrolled, 1,512 were admitted to a study NICU. METHODS We collected data for neonates, including length of stay, diagnoses, and diagnostic tests. MAIN OUTCOME MEASURES Neonatal mortality, tests performed, diagnoses ascertained. RESULTS For infants of equivalent weights and gestational ages, neonatal mortality in Pakistan was twice that in the Indian NICU. The mean newborn length of stay in Pakistan was 2 days compared with 10 days for India. Fewer diagnostics and other investigations were used to determine neonatal condition or guide treatment in the Pakistani NICU. Because of limited information from testing in Pakistan concerning clinical respiratory distress, respiratory distress syndrome appeared to be over-diagnosed, whereas other conditions including pneumonia, sepsis, necrotising entercolitis and intraventricular haemorrhage were rarely diagnosed. CONCLUSION In the Pakistani site, the limited resources available to the NICU appeared related to a shorter length of stay and decreased diagnostic testing, likely explaining the higher mortality. With improved care, reduction in mortality among preterm neonates should be achievable.
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Affiliation(s)
- Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | | | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's, J N Medical College, Belagavi, Karnataka, India
| | - Kay Hwang
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, North Carolina, USA
| | - Sangappa Dhaded
- KLE Academy of Higher Education and Research's, J N Medical College, Belagavi, Karnataka, India
| | - Gowder Guruprasad
- Department of Paediatrics, Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | - Naveen G Nadig
- Department of Paediatrics, Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | - Varun B Kusagur
- Department of Paediatrics, Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | - Lingaraja Gowda C Patil
- Department of Paediatrics, Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | - E S Siddartha
- Department of Paediatrics, Bapuji Educational Association's J.J.M. Medical College, Davangere, Karnataka, India
| | - S Yogeshkumar
- KLE Academy of Higher Education and Research's, J N Medical College, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research's, J N Medical College, Belagavi, Karnataka, India
| | - Sana Roujani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Mashal Khan
- Department of Paediatrics, National Institute of Child Health, Karachi, Pakistan
| | - Mehmood Shaikh
- Department of Paediatrics, National Institute of Child Health, Karachi, Pakistan
| | - Muhammad Hanif
- Department of Paediatrics, National Institute of Child Health, Karachi, Pakistan
| | - Carla M Bann
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, North Carolina, USA
| | - Elizabeth M McClure
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, North Carolina, USA
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Nuss EE, Hoffman MK, Goudar SS, Kavi A, Metgud M, Somannavar M, Okitawutshu J, Lokangaka A, Tshefu A, Bauserman M, Tembo AM, Chomba E, Carlo WA, Figueroa L, Krebs NF, Jessani S, Saleem S, Goldenberg RL, Kurhe K, Das P, Hibberd PL, Achieng E, Nyongesa P, Esamai F, Liechty EA, Bucher S, Goco N, Hemingway-Foday J, Moore J, McClure EM, Silver RM, Derman RJ. The impact of risk factors on aspirin's efficacy for the prevention of preterm birth. Am J Obstet Gynecol MFM 2023; 5:101095. [PMID: 37574046 DOI: 10.1016/j.ajogmf.2023.101095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/05/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The Aspirin Supplementation for Pregnancy Indicated Risk Reduction In Nulliparas trial was a landmark study that demonstrated a reduction in preterm birth and hypertensive disorders of pregnancy in nulliparous women who received low-dose aspirin. All women in the study had at least 1 moderate-risk factor for preeclampsia (nulliparity). Unlike current US Preventative Service Task Force guidelines, which recommend low-dose aspirin for ≥2 moderate-risk factors, women in this study were randomized to receive low-dose aspirin regardless of the presence or absence of an additional risk factor. OBJECTIVE This study aimed to compare how low-dose aspirin differentially benefits nulliparous women with and without additional preeclampsia risk factors for the prevention of preterm birth and hypertensive disorders of pregnancy. STUDY DESIGN This was a non-prespecified secondary analysis of the Aspirin Supplementation for Pregnancy Indicated Risk Reduction In Nulliparas trial that randomized nulliparous women with singleton pregnancies from 6 low-middle-income countries to receive low-dose aspirin or placebo. Our primary exposure was having an additional preeclampsia risk factor beyond nulliparity. Our primary outcome was preterm birth before 37 weeks of gestation, and our secondary outcomes included preterm birth before 34 weeks of gestation, preterm birth before 28 weeks of gestation, hypertensive disorders of pregnancy, and perinatal mortality. RESULTS Among 11,558 nulliparous women who met the inclusion criteria, 66.8% had no additional risk factors. Low-dose aspirin similarly reduced the risk of preterm birth at <37 weeks of gestation in women with and without additional risk factors (relative risk: 0.75 vs 0.85; P=.35). Additionally for our secondary outcomes, low-dose aspirin similarly reduced the risk of preterm birth at <28 weeks of gestation, hypertensive disorders of pregnancy, and perinatal mortality in women with and without additional risk factors. The reduction of preterm birth at <34 weeks of gestation with low-dose aspirin was significantly greater in women without additional risk factors than those with an additional risk factor (relative risk: 0.69 vs 1.04; P=.04). CONCLUSION Low-dose aspirin's ability to prevent preterm birth, hypertensive disorders of pregnancy, and perinatal mortality was similar in nulliparous women with and without additional risk factors. Professional societies should consider recommending low-dose aspirin to all nulliparous women.
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Affiliation(s)
- Emily E Nuss
- Christiana Care, Newark, DE (Drs Nuss and Hoffman).
| | | | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Avinash Kavi
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Mrityunjay Metgud
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Manjunath Somannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India (Drs Goudar, Kavi, Metgud, and Somannavar)
| | - Jean Okitawutshu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo (Drs Okitawutshu, Lokangaka, and Tshefu)
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo (Drs Okitawutshu, Lokangaka, and Tshefu)
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo (Drs Okitawutshu, Lokangaka, and Tshefu)
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Bauserman)
| | | | - Elwyn Chomba
- University Teaching Hospital, Lusaka, Zambia (Ms Tembo and Dr Chomba)
| | | | - Lester Figueroa
- Instituto de Nutrición de Centro América y Panamá, Guatemala City, Guatemala (Dr Figueroa)
| | - Nancy F Krebs
- University of Colorado Denver, Denver, CO (Dr Krebs)
| | - Saleem Jessani
- Aga Khan University, Karachi, Pakistan (Drs Jessani and Saleem)
| | - Sarah Saleem
- Aga Khan University, Karachi, Pakistan (Drs Jessani and Saleem)
| | | | - Kunal Kurhe
- Lata Medical Research Foundation, Nagpur, India (Drs Kurhe and Das)
| | - Prabir Das
- Lata Medical Research Foundation, Nagpur, India (Drs Kurhe and Das)
| | | | - Emmah Achieng
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya (Ms Achieng and Drs Nyongesa and Esamai)
| | - Paul Nyongesa
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya (Ms Achieng and Drs Nyongesa and Esamai)
| | - Fabian Esamai
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya (Ms Achieng and Drs Nyongesa and Esamai)
| | - Edward A Liechty
- School of Medicine, Indiana University, Indianapolis, IN (Drs Liechty and Bucher)
| | - Sherri Bucher
- School of Medicine, Indiana University, Indianapolis, IN (Drs Liechty and Bucher)
| | - Norman Goco
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
| | - Jennifer Hemingway-Foday
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
| | - Janet Moore
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
| | - Elizabeth M McClure
- RTI International, Research Triangle Park, NC (Mr Goco, Mses Hemingway-Foday and Moore, and Dr McClure)
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Hemingway-Foday J, Tita A, Chomba E, Mwenechanya M, Mweemba T, Nolen T, Lokangaka A, Tshefu Kitoto A, Lomendje G, Hibberd PL, Patel A, Das PK, Kurhe K, Goudar SS, Kavi A, Metgud M, Saleem S, Tikmani SS, Esamai F, Nyongesa P, Sagwe A, Figueroa L, Mazariegos M, Billah SM, Haque R, Shahjahan Siraj M, Goldenberg RL, Bauserman M, Bose C, Liechty EA, Ekhaguere OA, Krebs NF, Derman R, Petri WA, Koso-Thomas M, McClure E, Carlo WA. Prevention of maternal and neonatal death/infections with a single oral dose of azithromycin in women in labour in low-income and middle-income countries (A-PLUS): a study protocol for a multinational, randomised placebo-controlled clinical trial. BMJ Open 2023; 13:e068487. [PMID: 37648383 PMCID: PMC10471878 DOI: 10.1136/bmjopen-2022-068487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/15/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Maternal and neonatal infections are among the most frequent causes of maternal and neonatal mortality, and current antibiotic strategies have been ineffective in preventing many of these deaths. A randomised clinical trial conducted in a single site in The Gambia showed that treatment with an oral dose of 2 g azithromycin versus placebo for all women in labour reduced certain maternal and neonatal infections. However, it is unknown if this therapy reduces maternal and neonatal sepsis and mortality. In a large, multinational randomised trial, we will evaluate the impact of azithromycin given in labour to improve maternal and newborn outcomes. METHODS AND ANALYSIS This randomised, placebo-controlled, multicentre clinical trial includes two primary hypotheses, one maternal and one neonatal. The maternal hypothesis is to test whether a single, prophylactic intrapartum oral dose of 2 g azithromycin given to women in labour will reduce maternal death or sepsis. The neonatal hypothesis will test whether this intervention will reduce intrapartum/neonatal death or sepsis. The intervention is a single, prophylactic intrapartum oral dose of 2 g azithromycin, compared with a single intrapartum oral dose of an identical appearing placebo. A total of 34 000 labouring women from 8 research sites in sub-Saharan Africa, South Asia and Latin America will be randomised with a one-to-one ratio to intervention/placebo. In addition, we will assess antimicrobial resistance in a sample of women and their newborns. ETHICS AND DISSEMINATION The study protocol has been reviewed and ethics approval obtained from all the relevant ethical review boards at each research site. The results will be disseminated via peer-reviewed journals and national and international scientific forums. TRIAL REGISTRATION NUMBER NCT03871491 (https://clinicaltrials.gov/ct2/show/NCT03871491?term=NCT03871491&draw=2&rank=1).
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Affiliation(s)
| | - Alan Tita
- The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Elwyn Chomba
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | | | - Trecious Mweemba
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Tracy Nolen
- RTI International, Research Triangle Park, North Carolina, USA
| | - Adrien Lokangaka
- University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | - Antoinette Tshefu Kitoto
- University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | - Gustave Lomendje
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | | | - Archana Patel
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
- Datta Meghe Institute of Higher Education & Research (Deemed to be University), Wardha, Maharashtra, India
| | | | - Kunal Kurhe
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Avinash Kavi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Mrityunjay Metgud
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Sarah Saleem
- Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | - Shiyam S Tikmani
- Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | | | | | - Amos Sagwe
- Moi University School of Medicine, Eldoret, Kenya
| | - Lester Figueroa
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Manolo Mazariegos
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Sk Masum Billah
- The University of Sydney, Sydney, New South Wales, Australia
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Md Shahjahan Siraj
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | | | - Melissa Bauserman
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Carl Bose
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Edward A Liechty
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Richard Derman
- Office of Global Affairs, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | | | - Waldemar A Carlo
- The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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30
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Patterson JK, Thorsten VR, Eggleston B, Nolen T, Lokangaka A, Tshefu A, Goudar SS, Derman RJ, Chomba E, Carlo WA, Mazariegos M, Krebs NF, Saleem S, Goldenberg RL, Patel A, Hibberd PL, Esamai F, Liechty EA, Haque R, Petri B, Koso-Thomas M, McClure EM, Bose CL, Bauserman M. Building a predictive model of low birth weight in low- and middle-income countries: a prospective cohort study. BMC Pregnancy Childbirth 2023; 23:600. [PMID: 37608358 PMCID: PMC10464177 DOI: 10.1186/s12884-023-05866-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/21/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Low birth weight (LBW, < 2500 g) infants are at significant risk for death and disability. Improving outcomes for LBW infants requires access to advanced neonatal care, which is a limited resource in low- and middle-income countries (LMICs). Predictive modeling might be useful in LMICs to identify mothers at high-risk of delivering a LBW infant to facilitate referral to centers capable of treating these infants. METHODS We developed predictive models for LBW using the NICHD Global Network for Women's and Children's Health Research Maternal and Newborn Health Registry. This registry enrolled pregnant women from research sites in the Democratic Republic of the Congo, Zambia, Kenya, Guatemala, India (2 sites: Belagavi, Nagpur), Pakistan, and Bangladesh between January 2017 - December 2020. We tested five predictive models: decision tree, random forest, logistic regression, K-nearest neighbor and support vector machine. RESULTS We report a rate of LBW of 13.8% among the eight Global Network sites from 2017-2020, with a range of 3.8% (Kenya) and approximately 20% (in each Asian site). Of the five models tested, the logistic regression model performed best with an area under the curve of 0.72, an accuracy of 61% and a recall of 72%. All of the top performing models identified clinical site, maternal weight, hypertensive disorders, severe antepartum hemorrhage and antenatal care as key variables in predicting LBW. CONCLUSIONS Predictive modeling can identify women at high risk for delivering a LBW infant with good sensitivity using clinical variables available prior to delivery in LMICs. Such modeling is the first step in the development of a clinical decision support tool to assist providers in decision-making regarding referral of these women prior to delivery. Consistent referral of women at high-risk for delivering a LBW infant could have extensive public health consequences in LMICs by directing limited resources for advanced neonatal care to the infants at highest risk.
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Affiliation(s)
- Jackie K Patterson
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, 101 Manning Dr, Chapel Hill, NC, 27514, USA.
| | | | | | - Tracy Nolen
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Adrien Lokangaka
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Richard J Derman
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Manolo Mazariegos
- Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Nancy F Krebs
- School of Medicine, University of Colorado, Aurora, CO, USA
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur & Datta Meghe Institute of Medical Sciences, Sawangi, India
| | | | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | | | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Bill Petri
- Division of Infectious Diseases, University of Virginia, Charlottesville, VA, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - Carl L Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, 101 Manning Dr, Chapel Hill, NC, 27514, USA
| | - Melissa Bauserman
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, 101 Manning Dr, Chapel Hill, NC, 27514, USA
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31
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Fernandes M, Krebs NF, Westcott J, Tshefu A, Lokangaka A, Bauserman M, Garcés AL, Figueroa L, Saleem S, Aziz SA, Goldenberg RL, Goudar SS, Dhaded SM, Derman RJ, Kemp JF, Koso-Thomas M, Sridhar A, M McClure E, Hambidge KM. Neurodevelopment, vision and auditory outcomes at age 2 years in offspring of participants in the 'Women First' maternal preconception nutrition randomised controlled trial. Arch Dis Child 2023; 108:622-631. [PMID: 37142335 PMCID: PMC10423475 DOI: 10.1136/archdischild-2023-325352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Maternal nutrition in preconception and early pregnancy influences fetal growth. Evidence for effects of prenatal maternal nutrition on early child development (ECD) in low-income and middle-income countries is limited. OBJECTIVES To examine impact of maternal nutrition supplementation initiated prior to or during pregnancy on ECD, and to examine potential association of postnatal growth with ECD domains. DESIGN Secondary analysis regarding the offspring of participants of a maternal multicountry, individually randomised trial. SETTING Rural Democratic Republic of the Congo, Guatemala, India and Pakistan. PARTICIPANTS 667 offspring of Women First trial participants, aged 24 months. INTERVENTION Maternal lipid-based nutrient supplement initiated preconceptionally (arm 1, n=217), 12 weeks gestation (arm 2, n=230) or not (arm 3, n=220); intervention stopped at delivery. MAIN OUTCOME MEASURES The INTERGROWTH-21st Neurodevelopment Assessment (INTER-NDA) cognitive, language, gross motor, fine motor, positive and negative behaviour scores; visual acuity and contrast sensitivity scores and auditory evoked response potentials (ERP). Anthropometric z-scores, family care indicators (FCI) and sociodemographic variables were examined as covariates. RESULTS No significant differences were detected among the intervention arms for any INTER-NDA scores across domains, vision scores or ERP potentials. After adjusting for covariates, length-for-age z-score at 24 months (LAZ24), socio-economic status, maternal education and FCI significantly predicted vision and INTER-NDA scores (R2=0.11-0.38, p<0.01). CONCLUSIONS Prenatal maternal nutrition supplementation was not associated with any neurodevelopmental outcomes at age 2 years. Maternal education, family environment and LAZ24 predicted ECD. Interventions addressing multiple components of the nurturing care model may offer greatest impact on children's developmental potential. TRIAL REGISTRATION NUMBER NCT01883193.
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Affiliation(s)
- Michelle Fernandes
- MRC Lifecourse Epidemiology Centre and Human Development and Health Academic Unit, University of Southampton Faculty of Medicine, Southampton, UK
- Nuffield Department of Women's and Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Nancy F Krebs
- Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Jamie Westcott
- Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, The Democratic Republic of the Congo
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, The Democratic Republic of the Congo
| | - Melissa Bauserman
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Ana L Garcés
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Lester Figueroa
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Sarah Saleem
- Community Health Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | - Sumera A Aziz
- Community Health Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | | | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research (Deemed-to-be-University) Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research (Deemed-to-be-University) Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Jennifer F Kemp
- Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | | | | | - K Michael Hambidge
- Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
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Goldenberg RL, Ordi J, Blau DM, Rakislova N, Kulkarni V, Ghanchi NK, Saleem S, Goudar SS, Goco N, Paganelli C, McClure EM. An approach to determining the most common causes of stillbirth in low and middle-income countries: A commentary. Gates Open Res 2023; 7:102. [PMID: 37795041 PMCID: PMC10547115 DOI: 10.12688/gatesopenres.14112.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 10/06/2023] Open
Abstract
Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and middle-income countries (LMICs). Understanding the causes of stillbirth is crucial to developing effective interventions. In this commentary, investigators working across several LMICs discuss the most useful investigations to determine causes of stillbirths in LMICs. Useful data were defined as 1) feasible to obtain accurately and 2) informative to determine or help eliminate a cause of death. Recently, new tools for LMIC settings to determine cause of death in stillbirths, including minimally invasive tissue sampling (MITS) - a method using needle biopsies to obtain internal organ tissue from deceased fetuses for histology and pathogen identification in those tissues have become available. While placental histology has been available for some time, the development of the Amsterdam Criteria in 2016 has provided a useful framework to categorize placental lesions. The authors recommend focusing on the clinical history, the placental evaluation, the external examination of the fetus, and, when available, fetal tissue obtained by MITS, especially of the lung (focused on histology and microbiology) and brain/cerebral spinal fluid (CSF) and fetal blood (focused on microbiological analysis). The authors recognize that this approach may not identify some causes of stillbirth, including some genetic abnormalities and internal organ anomalies, but believe it will identify the most common causes of stillbirth, and most of the preventable causes.
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Affiliation(s)
| | - Jaume Ordi
- ISGlobal, Universitat de Barcelona, Barcelona, Spain
| | - Dianna M. Blau
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Vardendra Kulkarni
- Department of Pathology, Bapuji Educational Association’s J.J.M. Medical College, Davangere, India
| | - Najia Karim Ghanchi
- Department of Pathology & Microbiology, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Pathology & Microbiology, Aga Khan University, Karachi, Pakistan
- Department of Community Health Sciences, Aga khan University, Karachi, Pakistan
| | | | - Norman Goco
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, NC, 27709, USA
| | - Christina Paganelli
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, NC, 27709, USA
| | - Elizabeth M. McClure
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, NC, 27709, USA
| | - PURPOSe, CHAMPS, ISGlobal, and the MITS Surveillance Alliance investigators
- Obstetrics & Gynecology, Columbia University, New York, NY, USA
- ISGlobal, Universitat de Barcelona, Barcelona, Spain
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Department of Pathology, Bapuji Educational Association’s J.J.M. Medical College, Davangere, India
- Department of Pathology & Microbiology, Aga Khan University, Karachi, Pakistan
- Department of Community Health Sciences, Aga khan University, Karachi, Pakistan
- Women's and Children's Health Research Unit, KLE University, Belagavi, India
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, NC, 27709, USA
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von Dadelszen P, Bone JN, Sandhu A, Ansermino JM, Qureshi RN, Sacoor C, Sevene E, Li J, Vidler M, Bellad MB, Bhutta ZA, Dunsmuir DT, Goudar SS, Mallapur AA, Munguambe K, Dumont GA, Magee LA. Choosing blood pressure thresholds to inform pregnancy care in the community: An analysis of cluster trials. BJOG 2023. [PMID: 37092252 DOI: 10.1111/1471-0528.17465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/09/2023] [Accepted: 03/01/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To inform digital health design by evaluating diagnostic test properties of antenatal blood pressure (BP) outputs and levels to identify women at risk of adverse outcomes. DESIGN Planned secondary analysis of cluster randomised trials. SETTING India, Pakistan, Mozambique. POPULATION Women with in-community BP measurements and known pregnancy outcomes. METHODS Blood pressure was defined by its outputs (systolic and/or diastolic, systolic only, diastolic only or mean arterial pressure [calculated]) and level: normotension-1 (<135/85 mmHg), normotension-2 (135-139/85-89 mmHg), non-severe hypertension (140-149/90-99 mmHg; 150-154/100-104 mmHg; 155-159/105-109 mmHg) and severe hypertension (≥160/110 mmHg). Dose-response (adjusted risk ratio [aRR]) and diagnostic test properties (negative [-LR] and positive [+LR] likelihood ratios) were estimated. MAIN OUTCOME MEASURES Maternal/perinatal composites of mortality/morbidity. RESULTS Among 21 069 pregnancies, different BP outputs had similar aRR, -LR, and +LR for adverse outcomes. No BP level (even normotension-1) was associated with low risk (all -LR ≥0.20). Across outcomes, risks rose progressively with higher BP levels above normotension-1. For each of maternal central nervous system events and stillbirth, BP ≥155/105 mmHg showed at least good diagnostic test performance (+LR ≥5.0) and BP ≥135/85 mmHg at least fair performance, similar to BP ≥140/90 mmHg (+LR 2.0-4.99). CONCLUSIONS In the community, normal BP values do not provide reassurance about subsequent adverse outcomes. Given the similar performance of BP cut-offs of 135/85 and 140/90 mmHg for hypertension, and 155/105 and 160/110 mmHg for severe hypertension, digital decision support for women in the community should consider using these lower thresholds.
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Affiliation(s)
- Peter von Dadelszen
- Institute of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Obstetrics and Gynaecology and BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology and BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Akshdeep Sandhu
- Department of Obstetrics and Gynaecology and BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Mark Ansermino
- Centre for International Child Health, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rahat N Qureshi
- Division of Woman and Child Health, Centre of Excellence, Aga Khan University, Karachi, Pakistan
| | | | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
- Department of Physiological Sciences, Clinical Pharmacology, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jing Li
- Department of Obstetrics and Gynaecology and BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology and BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mrutyunjaya B Bellad
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Zulfiqar A Bhutta
- Division of Woman and Child Health, Centre of Excellence, Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dustin T Dunsmuir
- Centre for International Child Health, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, Karnataka, India
| | - Ashalata A Mallapur
- S Nijalingappa Medical College, Hanagal Shree Kumareshwar Hospital and Research Centre, Bagalkote, Karnataka, India
| | - Khátia Munguambe
- Division of Woman and Child Health, Centre of Excellence, Aga Khan University, Karachi, Pakistan
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Guy A Dumont
- Centre for International Child Health, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Electrical and Computer Engineering, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura A Magee
- Institute of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Obstetrics and Gynaecology and BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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Semrau KEA, Mokhtar RR, Manji K, Goudar SS, Mvalo T, Sudfeld CR, Young MF, Caruso BA, Duggan CP, Somji SS, Lee ACC, Bakari M, Lugangira K, Kisenge R, Adair LS, Hoffman IF, Saidi F, Phiri M, Msimuko K, Nyirenda F, Michalak M, Dhaded SM, Bellad RM, Misra S, Panda S, Vernekar SS, Herekar V, Sommannavar M, Nayak RB, Yogeshkumar S, Welling S, North K, Israel-Ballard K, Mansen KL, Martin SL, Fleming K, Miller K, Pote A, Spigel L, Tuller DE, Vesel L. Facility-based care for moderately low birthweight infants in India, Malawi, and Tanzania. PLOS Glob Public Health 2023; 3:e0001789. [PMID: 37075019 PMCID: PMC10115266 DOI: 10.1371/journal.pgph.0001789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 03/13/2023] [Indexed: 04/20/2023]
Abstract
Globally, increasing rates of facility-based childbirth enable early intervention for small vulnerable newborns. We describe health system-level inputs, current feeding, and discharge practices for moderately low birthweight (MLBW) infants (1500-<2500g) in resource-constrained settings. The Low Birthweight Infant Feeding Exploration study is a mixed methods observational study in 12 secondary- and tertiary-level facilities in India, Malawi, and Tanzania. We analyzed data from baseline facility assessments and a prospective cohort of 148 MLBW infants from birth to discharge. Anthropometric measuring equipment (e.g., head circumference tapes, length boards), key medications (e.g., surfactant, parenteral nutrition), milk expression tools, and human milk alternatives (e.g., donor milk, formula) were not universally available. MLBW infants were preterm appropriate-for-gestational age (38.5%), preterm large-for-gestational age (3.4%), preterm small-for-gestational age (SGA) (11.5%), and term SGA (46.6%). The median length of stay was 3.1 days (IQR: 1.5, 5.7); 32.4% of infants were NICU-admitted and 67.6% were separated from mothers at least once. Exclusive breastfeeding was high (93.2%). Generalized group lactation support was provided; 81.8% of mother-infant dyads received at least one session and 56.1% had 2+ sessions. At the time of discharge, 5.1% of infants weighed >10% less than their birthweight; 18.8% of infants were discharged with weights below facility-specific policy [1800g in India, 1500g in Malawi, and 2000g in Tanzania]. Based on descriptive analysis, we found constraints in health system inputs which have the potential to hinder high quality care for MLBW infants. Targeted LBW-specific lactation support, discharge at appropriate weight, and access to feeding alternatives would position MLBW for successful feeding and growth post-discharge.
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Affiliation(s)
- Katherine E. A. Semrau
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rana R. Mokhtar
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shivaprasad S. Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Christopher R. Sudfeld
- Department of Global Health and Population and Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Melissa F. Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Christopher P. Duggan
- Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sarah S. Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anne C. C. Lee
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kristina Lugangira
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda S. Adair
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Irving F. Hoffman
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Friday Saidi
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Melda Phiri
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Kingsly Msimuko
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Fadire Nyirenda
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | - Sangappa M. Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Roopa M. Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Sujata Misra
- Department of Obstetrics and Gynaecology, SCB Medical College and Hospital, Cuttack, Odisha, India
- Department of Obstetrics and Gynaecology, FM Medical College, Balasore, Odisha, India
| | - Sanghamitra Panda
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
- Department of Obstetrics and Gynaecology, City Hospital, Cuttack, Odisha, India
| | - Sunil S. Vernekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Veena Herekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Manjunath Sommannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Rashmita B. Nayak
- Department of Paediatrics, SCB Medical College and Hospital, Cuttack, Odisha, India
| | - S. Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Saraswati Welling
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Krysten North
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kiersten Israel-Ballard
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, Washington, United States of America
| | - Kimberly L. Mansen
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, Washington, United States of America
| | - Stephanie L. Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Katelyn Fleming
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Katharine Miller
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Arthur Pote
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Lauren Spigel
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Danielle E. Tuller
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Linda Vesel
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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35
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Harakuni SU, Somannavar MS, Ghanchi NK, Ahmed I, Zafar A, Kim J, Tikmani SS, Hwang K, Saleem S, Goudar SS, Dhaded S, Guruprasad G, Yasmin H, Yogeshkumar S, Aceituno A, Silver RM, McClure EM, Goldenberg RL. Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study. BJOG 2023. [PMID: 37069731 DOI: 10.1111/1471-0528.17479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/18/2022] [Accepted: 12/06/2022] [Indexed: 04/19/2023]
Abstract
OBJECTIVE To examine internal organ tissues and placentas of stillbirths for various pathogens. DESIGN Prospective, observational study. SETTINGS Three study hospitals in India and a large maternity hospital in Pakistan. POPULATION Stillborn infants delivered in a study hospital. METHODS A prospective observational study. MAIN OUTCOME MEASURES Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths. RESULTS Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%). CONCLUSIONS In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.
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Affiliation(s)
- S U Harakuni
- KLE Academy of Higher Education and Researchs, J N Medical College, Belagavi, India
| | - M S Somannavar
- KLE Academy of Higher Education and Researchs, J N Medical College, Belagavi, India
| | | | - I Ahmed
- Aga Khan University, Karachi, Pakistan
| | - A Zafar
- Aga Khan University, Karachi, Pakistan
| | - J Kim
- RTI International, Durham, North Carolina, USA
| | | | - K Hwang
- RTI International, Durham, North Carolina, USA
| | - S Saleem
- Aga Khan University, Karachi, Pakistan
- RTI International, Durham, North Carolina, USA
| | - S S Goudar
- KLE Academy of Higher Education and Researchs, J N Medical College, Belagavi, India
| | - S Dhaded
- KLE Academy of Higher Education and Researchs, J N Medical College, Belagavi, India
| | - G Guruprasad
- Bapuji Educational Association's J.J.M. Medical College, Davangere, India
| | - H Yasmin
- Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - S Yogeshkumar
- KLE Academy of Higher Education and Researchs, J N Medical College, Belagavi, India
| | - A Aceituno
- RTI International, Durham, North Carolina, USA
| | - R M Silver
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - E M McClure
- RTI International, Durham, North Carolina, USA
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36
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Tita ATN, Carlo WA, McClure EM, Mwenechanya M, Chomba E, Hemingway-Foday JJ, Kavi A, Metgud MC, Goudar SS, Derman R, Lokangaka A, Tshefu A, Bauserman M, Bose C, Shivkumar P, Waikar M, Patel A, Hibberd PL, Nyongesa P, Esamai F, Ekhaguere OA, Bucher S, Jessani S, Tikmani SS, Saleem S, Goldenberg RL, Billah SM, Lennox R, Haque R, Petri W, Figueroa L, Mazariegos M, Krebs NF, Moore JL, Nolen TL, Koso-Thomas M. Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal Birth. N Engl J Med 2023; 388:1161-1170. [PMID: 36757318 PMCID: PMC10627427 DOI: 10.1056/nejmoa2212111] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The use of azithromycin reduces maternal infection in women during unplanned cesarean delivery, but its effect on those with planned vaginal delivery is unknown. Data are needed on whether an intrapartum oral dose of azithromycin would reduce maternal and offspring sepsis or death. METHODS In this multicountry, placebo-controlled, randomized trial, we assigned women who were in labor at 28 weeks' gestation or more and who were planning a vaginal delivery to receive a single 2-g oral dose of azithromycin or placebo. The two primary outcomes were a composite of maternal sepsis or death and a composite of stillbirth or neonatal death or sepsis. During an interim analysis, the data and safety monitoring committee recommended stopping the trial for maternal benefit. RESULTS A total of 29,278 women underwent randomization. The incidence of maternal sepsis or death was lower in the azithromycin group than in the placebo group (1.6% vs. 2.4%), with a relative risk of 0.67 (95% confidence interval [CI], 0.56 to 0.79; P<0.001), but the incidence of stillbirth or neonatal death or sepsis was similar (10.5% vs. 10.3%), with a relative risk of 1.02 (95% CI, 0.95 to 1.09; P = 0.56). The difference in the maternal primary outcome appeared to be driven mainly by the incidence of sepsis (1.5% in the azithromycin group and 2.3% in the placebo group), with a relative risk of 0.65 (95% CI, 0.55 to 0.77); the incidence of death from any cause was 0.1% in the two groups (relative risk, 1.23; 95% CI, 0.51 to 2.97). Neonatal sepsis occurred in 9.8% and 9.6% of the infants, respectively (relative risk, 1.03; 95% CI, 0.96 to 1.10). The incidence of stillbirth was 0.4% in the two groups (relative risk, 1.06; 95% CI, 0.74 to 1.53); neonatal death within 4 weeks after birth occurred in 1.5% in both groups (relative risk, 1.03; 95% CI, 0.86 to 1.24). Azithromycin was not associated with a higher incidence in adverse events. CONCLUSIONS Among women planning a vaginal delivery, a single oral dose of azithromycin resulted in a significantly lower risk of maternal sepsis or death than placebo but had little effect on newborn sepsis or death. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; A-PLUS ClinicalTrials.gov number, NCT03871491.).
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Affiliation(s)
- Alan T N Tita
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Waldemar A Carlo
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Elizabeth M McClure
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Musaku Mwenechanya
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Elwyn Chomba
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Jennifer J Hemingway-Foday
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Avinash Kavi
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Mrityunjay C Metgud
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Shivaprasad S Goudar
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Richard Derman
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Adrien Lokangaka
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Antoinette Tshefu
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Melissa Bauserman
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Carl Bose
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Poonam Shivkumar
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Manju Waikar
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Archana Patel
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Patricia L Hibberd
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Paul Nyongesa
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Fabian Esamai
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Osayame A Ekhaguere
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Sherri Bucher
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Saleem Jessani
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Shiyam S Tikmani
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Sarah Saleem
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Robert L Goldenberg
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Sk M Billah
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Ruth Lennox
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Rashidul Haque
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - William Petri
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Lester Figueroa
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Manolo Mazariegos
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Nancy F Krebs
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Janet L Moore
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Tracy L Nolen
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Marion Koso-Thomas
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
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Goldenberg RL, Saleem S, Billah SM, Kim J, Moore JL, Ghanchi NK, Haque R, Figueroa L, Ayala A, Lokangaka A, Tshefu A, Goudar SS, Kavi A, Somannavar M, Esamai F, Mwenechanya M, Chomba E, Patel A, Das P, Emonyi WI, Edidi S, Deshmukh M, Hossain B, Siraj S, Mazariegos M, Garces AL, Bauserman M, Bose CL, Petri WA, Krebs NF, Derman RJ, Carlo WA, Liechty EA, Hibberd PL, Koso‐Thomas M, Peres‐da‐Silva N, Nolen TL, McClure EM. COVID-19 antibody positivity over time and pregnancy outcomes in seven low-and-middle-income countries: A prospective, observational study of the Global Network for Women's and Children's Health Research. BJOG 2023; 130:366-376. [PMID: 36504437 PMCID: PMC9877904 DOI: 10.1111/1471-0528.17366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/02/2022] [Accepted: 11/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine COVID-19 antibody positivity rates over time and relationships to pregnancy outcomes in low- and middle-income countries (LMICs). DESIGN With COVID-19 antibody positivity at delivery as the exposure, we performed a prospective, observational cohort study in seven LMICs during the early COVID-19 pandemic. SETTING The study was conducted among women in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry (MNHR), a prospective, population-based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Bangladesh, Pakistan, India (two sites), and Guatemala. POPULATION Pregnant women enrolled in an ongoing pregnancy registry at study sites. METHODS From October 2020 to October 2021, standardised COVID-19 antibody testing was performed at delivery among women enrolled in MNHR. Trained staff masked to COVID-19 status obtained pregnancy outcomes, which were then compared with COVID-19 antibody results. MAIN OUTCOME MEASURES Antibody status, stillbirth, neonatal mortality, maternal mortality and morbidity. RESULTS At delivery, 26.0% of women were COVID-19 antibody positive. Positivity increased over the four time periods across all sites: 13.8%, 15.4%, 21.0% and 40.9%. In the final period, positivity rates were: DRC 27.0%, Kenya 33.1%, Pakistan 32.8%, Guatemala 37.0%, Zambia 37.8%, Bangladesh 47.2%, Nagpur, India 57.4% and Belagavi, India 62.4%. Adjusting for site and maternal characteristics, stillbirth, neonatal mortality, low birthweight and preterm birth were not significantly associated with COVID-19. The adjusted relative risk (aRR) for stillbirth was 1.27 (95% CI 0.95-1.69). Postpartum haemorrhage was associated with antibody positivity (aRR 1.44; 95% CI 1.01-2.07). CONCLUSIONS In pregnant populations in LMICs, COVID-19 antibody positivity has increased. However, most adverse pregnancy outcomes were not significantly associated with antibody positivity.
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Affiliation(s)
| | | | - Sk Masum Billah
- International Centre for Diarrhoeal Disease Research (icddr,b)DhakaBangladesh
- University of SydneySydneyNew South WalesAustralia
| | - Jean Kim
- RTI InternationalDurhamNorth CarolinaUSA
| | | | | | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research (icddr,b)DhakaBangladesh
| | - Lester Figueroa
- Instituto de Nutrición de Centroamérica y PanamáGuatemala CityGuatemala
| | - Alejandra Ayala
- Instituto de Nutrición de Centroamérica y PanamáGuatemala CityGuatemala
| | - Adrien Lokangaka
- Kinshasa School of Public HealthKinshasaDemocratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public HealthKinshasaDemocratic Republic of the Congo
| | - Shivaprasad S. Goudar
- KLE Academy Higher Education and Research, J N Medical College BelagaviKarnatakaIndia
| | - Avinash Kavi
- KLE Academy Higher Education and Research, J N Medical College BelagaviKarnatakaIndia
| | - Manjunath Somannavar
- KLE Academy Higher Education and Research, J N Medical College BelagaviKarnatakaIndia
| | | | | | - Elwyn Chomba
- University of Zambia University Teaching HospitalLusakaZambia
| | - Archana Patel
- Lata Medical Research FoundationNagpurIndia
- Datta Meghe Institute of Medical SciencesSawangiIndia
| | - Prabir Das
- Lata Medical Research FoundationNagpurIndia
| | | | - Samuel Edidi
- Laboratoire National de Référence du PNLSKinshasaDemocratic Republic of the Congo
| | | | - Biplob Hossain
- International Centre for Diarrhoeal Disease Research (icddr,b)DhakaBangladesh
| | - Shahjahan Siraj
- International Centre for Diarrhoeal Disease Research (icddr,b)DhakaBangladesh
| | - Manolo Mazariegos
- Instituto de Nutrición de Centroamérica y PanamáGuatemala CityGuatemala
| | - Ana L. Garces
- Instituto de Nutrición de Centroamérica y PanamáGuatemala CityGuatemala
| | - Melissa Bauserman
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Carl L. Bose
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Nancy F. Krebs
- University of Colorado School of MedicineDenverColoradoUSA
| | | | | | - Edward A. Liechty
- Indiana School of MedicineUniversity of IndianaIndianapolisIndianaUSA
| | | | - Marion Koso‐Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesdaMarylandUSA
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Patterson JK, Neuwahl S, Goco N, Moore J, Goudar SS, Derman RJ, Hoffman M, Metgud M, Somannavar M, Kavi A, Okitawutshu J, Lokangaka A, Tshefu A, Bose CL, Mwapule A, Mwenechanya M, Chomba E, Carlo WA, Chicuy J, Figueroa L, Krebs NF, Jessani S, Saleem S, Goldenberg RL, Kurhe K, Das P, Patel A, Hibberd PL, Achieng E, Nyongesa P, Esamai F, Bucher S, Liechty EA, Bresnahan BW, Koso-Thomas M, McClure EM. Cost-effectiveness of low-dose aspirin for the prevention of preterm birth: a prospective study of the Global Network for Women's and Children's Health Research. Lancet Glob Health 2023; 11:e436-e444. [PMID: 36796987 DOI: 10.1016/s2214-109x(22)00548-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 10/28/2022] [Accepted: 12/15/2022] [Indexed: 02/16/2023]
Abstract
BACKGROUND Premature birth is associated with an increased risk of mortality and morbidity, and strategies to prevent preterm birth are few in number and resource intensive. In 2020, the ASPIRIN trial showed the efficacy of low-dose aspirin (LDA) in nulliparous, singleton pregnancies for the prevention of preterm birth. We sought to investigate the cost-effectiveness of this therapy in low-income and middle-income countries. METHODS In this post-hoc, prospective, cost-effectiveness study, we constructed a probabilistic decision tree model to compare the benefits and costs of LDA treatment compared with standard care using primary data and published results from the ASPIRIN trial. In this analysis from a health-care sector perspective, we considered the costs and effects of LDA treatment, pregnancy outcomes, and neonatal health-care use. We did sensitivity analyses to understand the effect of the price of the LDA regimen, and the effectiveness of LDA in reducing both preterm birth and perinatal death. FINDINGS In model simulations, LDA was associated with 141 averted preterm births, 74 averted perinatal deaths, and 31 averted hospitalisations per 10 000 pregnancies. The reduction in hospitalisation resulted in a cost of US$248 per averted preterm birth, $471 per averted perinatal death, and $15·95 per disability-adjusted life year. INTERPRETATION LDA treatment in nulliparous, singleton pregnancies is a low-cost, effective treatment to reduce preterm birth and perinatal death. The low cost per disability-adjusted life year averted strengthens the evidence in support of prioritising the implementation of LDA in publicly funded health care in low-income and middle-income countries. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Jackie K Patterson
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Norman Goco
- RTI International, Research Triangle Park, NC, USA
| | - Janet Moore
- RTI International, Research Triangle Park, NC, USA
| | | | - Richard J Derman
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Hoffman
- Department of Obstetrics and Gynecology, Christiana Care, Newark, DE, USA
| | | | | | - Avinash Kavi
- Jawaharlal Nehru Medical College, KLE University, Belagavi, India
| | - Jean Okitawutshu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Adrien Lokangaka
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Carl L Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Javier Chicuy
- Instituto de Nutrición de Centro América y Panamá, Guatemala City, Guatemala
| | - Lester Figueroa
- Instituto de Nutrición de Centro América y Panamá, Guatemala City, Guatemala
| | - Nancy F Krebs
- School of Medicine, University of Colorado, Aurora, CO, USA
| | - Saleem Jessani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Kunal Kurhe
- Lata Medical Research Foundation, Nagpur & Datta Meghe Institute of Medical Sciences, Sawangi, India
| | - Prabir Das
- Lata Medical Research Foundation, Nagpur & Datta Meghe Institute of Medical Sciences, Sawangi, India
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur & Datta Meghe Institute of Medical Sciences, Sawangi, India
| | | | - Emmah Achieng
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Paul Nyongesa
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Sherri Bucher
- School of Medicine, Indiana University, Indianapolis, IN, USA
| | | | | | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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R. Araganji R, S. Somannavar M, Vernekar SS, Kavi A, Hoffman MK, Goudar SS. The utility of biomarkers in the prediction of preterm birth: A nested case control study of the ASPIRIN trial. Biomedicine (Taipei) 2023. [DOI: 10.51248/.v43i1.2040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Abstract
Introduction and Aim: Adverse pregnancy outcomes (APO’s-preterm birth, foetal growth restriction and hypertensive disorders of pregnancy (HDP)) are the primary drivers of perinatal mortality. C-Reactive Protein, Anti-Mullerian Hormone (AMH) and Alpha-FetoProtein (AFP) have shown promise in predicting these APO’s. Aim of this present work is to validate the predictive ability of these biomarkers to identify women at risk for preterm birth.
Materials and Methods: A nested observational case-control study was performed drawing nulliparous pregnant women between 10 to 13 weeks and 17 to 21 weeks of gestation in nulliparous women randomized to aspirin or placebo as part of the ASPIRIN (Aspirin Supplementation for Pregnancy Indicated Risk Reduction in Nulliparas) trial.
Results: A total of 126 women with these APO’s and 143 controls were selected for analyte analysis. None of the chosen analytes were found to predict preterm birth before 37 weeks or HDP. AFP obtained between 10 to 13 weeks, was able to moderately discriminate against women who had a preterm birth prior to 34 weeks (C-statistic 0.65- 95% CI 0.55 to 0.78). No other analytes were found to be predictive of preterm birth prior to 34 weeks.
Conclusion: Elevated Alpha-FetoProtein early in pregnancy is associated with early preterm birth (PTB) and may be a marker of Aspirin efficacy.
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Vesel L, Bellad RM, Manji K, Saidi F, Velasquez E, Sudfeld CR, Miller K, Bakari M, Lugangira K, Kisenge R, Salim N, Somji S, Hoffman I, Msimuko K, Mvalo T, Nyirenda F, Phiri M, Das L, Dhaded S, Goudar SS, Herekar V, Kumar Y, Koujalagi MB, Guruprasad G, Panda S, Shamanur LG, Somannavar M, Vernekar SS, Misra S, Adair L, Bell G, Caruso BA, Duggan C, Fleming K, Israel-Ballard K, Fishman E, Lee ACC, Lipsitz S, Mansen KL, Martin SL, Mokhtar RR, North K, Pote A, Spigel L, Tuller DE, Young M, Semrau KEA. Feeding practices and growth patterns of moderately low birthweight infants in resource-limited settings: results from a multisite, longitudinal observational study. BMJ Open 2023; 13:e067316. [PMID: 36792338 PMCID: PMC9933750 DOI: 10.1136/bmjopen-2022-067316] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES To describe the feeding profile of low birthweight (LBW) infants in the first half of infancy; and to examine growth patterns and early risk factors of poor 6-month growth outcomes. DESIGN Prospective observational cohort study. SETTING AND PARTICIPANTS Stable, moderately LBW (1.50 to <2.50 kg) infants were enrolled at birth from 12 secondary/tertiary facilities in India, Malawi and Tanzania and visited nine times over 6 months. VARIABLES OF INTEREST Key variables of interest included birth weight, LBW type (combination of preterm/term status and size-for-gestational age at birth), lactation practices and support, feeding profile, birthweight regain by 2 weeks of age and poor 6-month growth outcomes. RESULTS Between 13 September 2019 and 27 January 2021, 1114 infants were enrolled, comprising 4 LBW types. 363 (37.3%) infants initiated early breast feeding and 425 (43.8%) were exclusively breastfed to 6 months. 231 (22.3%) did not regain birthweight by 2 weeks; at 6 months, 280 (32.6%) were stunted, 222 (25.8%) underweight and 88 (10.2%) wasted. Preterm-small-for-gestational age (SGA) infants had 1.89 (95% CI 1.37 to 2.62) and 2.32 (95% CI 1.48 to 3.62) times greater risks of being stunted and underweight at 6 months compared with preterm-appropriate-for-gestational age (AGA) infants. Term-SGA infants had 2.33 (95% CI 1.77 to 3.08), 2.89 (95% CI 1.97 to 4.24) and 1.99 (95% CI 1.13 to 3.51) times higher risks of being stunted, underweight and wasted compared with preterm-AGA infants. Those not regaining their birthweight by 2 weeks had 1.51 (95% CI 1.23 to 1.85) and 1.55 (95% CI 1.21 to 1.99) times greater risks of being stunted and underweight compared with infants regaining. CONCLUSION LBW type, particularly SGA regardless of preterm or term status, and lack of birthweight regain by 2 weeks are important risk identification parameters. Early interventions are needed that include optimal feeding support, action-oriented growth monitoring and understanding of the needs and growth patterns of SGA infants to enable appropriate weight gain and proactive management of vulnerable infants. TRIAL REGISTRATION NUMBER NCT04002908.
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Affiliation(s)
- Linda Vesel
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Roopa M Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Friday Saidi
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Esther Velasquez
- Department of Epidemiology and Population Health, Stanford University, Palo Alto, California, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Katharine Miller
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kristina Lugangira
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nahya Salim
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Irving Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Kingsly Msimuko
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Fadire Nyirenda
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Melda Phiri
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Leena Das
- Department of Paediatrics, SCB Medical College & Hospital, Cuttack, Orissa, India
| | - Sangappa Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Veena Herekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Yogesh Kumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - M B Koujalagi
- Department of Paediatrics, JJM Medical College, Davangere, Karnataka, India
| | - Gowdar Guruprasad
- Department of Paediatrics, JJM Medical College, Davangere, Karnataka, India
| | | | - Latha G Shamanur
- Department of Paediatrics, SS Institute of Medical Sciences and Research Center, Davangere, Karnataka, India
| | - Manjunath Somannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Sunil S Vernekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Sujata Misra
- Department of Paediatrics, SCB Medical College & Hospital, Cuttack, Orissa, India
| | - Linda Adair
- Department of Nutrition, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Griffith Bell
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bethany A Caruso
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Christopher Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Katelyn Fleming
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eliza Fishman
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne C C Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart Lipsitz
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kimberly L Mansen
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, Washington, USA
| | - Stephanie L Martin
- Department of Nutrition, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Rana R Mokhtar
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Krysten North
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Arthur Pote
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren Spigel
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Danielle E Tuller
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Melissa Young
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Katherine E A Semrau
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
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Vogel JP, Pingray V, Althabe F, Gibbons L, Berrueta M, Pujar Y, Somannavar M, Vernekar SS, Ciganda A, Rodriguez R, Welling SA, Revankar A, Bendigeri S, Kumar JA, Patil SB, Karinagannanavar A, Anteen RR, Pavithra MR, Shetty S, Latha B, Megha HM, Gaddi SS, Chikkagowdra S, Raghavendra B, Armari E, Scott N, Eddy K, Homer CSE, Goudar SS. Implementing the WHO Labour Care Guide to reduce the use of Caesarean section in four hospitals in India: protocol and statistical analysis plan for a pragmatic, stepped-wedge, cluster-randomized pilot trial. Reprod Health 2023; 20:18. [PMID: 36670438 PMCID: PMC9862839 DOI: 10.1186/s12978-022-01525-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 11/08/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase). METHODS In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness. DISCUSSION Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally. TRIAL REGISTRATION CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022).
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Affiliation(s)
- Joshua P. Vogel
- grid.1056.20000 0001 2224 8486Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC Australia
| | - Veronica Pingray
- grid.414661.00000 0004 0439 4692Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Fernando Althabe
- grid.414661.00000 0004 0439 4692Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Luz Gibbons
- grid.414661.00000 0004 0439 4692Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Mabel Berrueta
- grid.414661.00000 0004 0439 4692Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Yeshita Pujar
- grid.414956.b0000 0004 1765 8386Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka India
| | - Manjunath Somannavar
- grid.414956.b0000 0004 1765 8386Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka India
| | - Sunil S. Vernekar
- grid.414956.b0000 0004 1765 8386Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka India
| | - Alvaro Ciganda
- grid.414661.00000 0004 0439 4692Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Rocio Rodriguez
- grid.414661.00000 0004 0439 4692Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Saraswati A. Welling
- grid.414956.b0000 0004 1765 8386Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka India
| | - Amit Revankar
- grid.414956.b0000 0004 1765 8386Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka India
| | - Savitri Bendigeri
- grid.414956.b0000 0004 1765 8386Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka India
| | | | | | | | | | | | - Shukla Shetty
- grid.418280.70000 0004 1794 3160JJM Medical College, Davangere, Karnataka India
| | - B. Latha
- grid.418280.70000 0004 1794 3160JJM Medical College, Davangere, Karnataka India
| | - H. M. Megha
- grid.418280.70000 0004 1794 3160JJM Medical College, Davangere, Karnataka India
| | - Suman S. Gaddi
- grid.416866.b0000 0004 0556 696XVijayanagar Institute of Medical Sciences (VIMS), Ballari, Karnataka India
| | - Shaila Chikkagowdra
- grid.416866.b0000 0004 0556 696XVijayanagar Institute of Medical Sciences (VIMS), Ballari, Karnataka India
| | - Bellara Raghavendra
- grid.416866.b0000 0004 0556 696XVijayanagar Institute of Medical Sciences (VIMS), Ballari, Karnataka India
| | - Elizabeth Armari
- grid.1056.20000 0001 2224 8486Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC Australia
| | - Nick Scott
- grid.1056.20000 0001 2224 8486Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC Australia
| | - Katherine Eddy
- grid.1056.20000 0001 2224 8486Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC Australia
| | - Caroline S. E. Homer
- grid.1056.20000 0001 2224 8486Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC Australia
| | - Shivaprasad S. Goudar
- grid.414956.b0000 0004 1765 8386Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka India
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Bellad RM, Mahantshetti NS, Charantimath US, Ma T, Washio Y, Short VL, Chang K, Lalakia P, Jaeger FJ, Kelly PJ, Mungarwadi G, Karadiguddi CC, Goudar SS, Derman RJ. A training curriculum for an mHealth supported peer counseling program to promote exclusive breastfeeding in rural India. Int Breastfeed J 2023; 18:6. [PMID: 36658581 PMCID: PMC9850503 DOI: 10.1186/s13006-023-00546-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Despite strong evidence about the benefits of exclusive breastfeeding, that is the baby receiving only breast milk, no other foods or liquids, rates have remained relatively unchanged over the past two decades in low- and middle-income countries. One strategy for increasing exclusive breastfeeding is through community-based programs that use peer counselors for education and support. The use of mobile health applications is also gaining increasing applicability in these countries. Minimal information is available about training peer counselors in the use of mobile technologies to support exclusive breastfeeding. The present article describes our curriculum in the state of Karnataka, India for supporting new mothers to exclusively breastfeed using a mobile health application in rural India. METHODS Twenty-five women from the community surrounding the city of Belgavi, Karnataka, India were trained to be peer counselors and to use a mobile health application to conduct a structured curriculum to support new mothers in exclusive breastfeeding. The three-day interactive training, conducted in March 2018, was based on the WHO breastfeeding course, translated, and adapted to the local culture The curriculum, which included information collected during a formative research process, consisted of eight visits, two during the antenatal period and continuing for six months postpartum. Twelve nursing and obstetric experts validated curriculum content. Pre-post-evaluation of the training focused on breastfeeding knowledge, self-efficacy, skills, and app usability. RESULTS We observed a significant increase in the mean scores for knowledge (P < 0.0001) and skills (P = 0.0006) from pre- to post-training. Age of the peer counselors and their own breastfeeding experience correlated significantly with the acquisition of knowledge and skills. The mobile health app showed high usability scores. CONCLUSIONS The culturally adapted curriculum presented here, combined with an mHealth app, can be an important educational strategy for training rural women in the acquisition of exclusive breastfeeding knowledge and skills.
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Affiliation(s)
- Roopa M Bellad
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Niranjana S Mahantshetti
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Umesh S Charantimath
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Tony Ma
- Benten Technologies Inc, Manassas, Virginia, USA
| | - Yukiko Washio
- Substance Use, Gender and Applied Research, RTI International, Research Triangle Park, North Carolina, USA
| | - Vanessa L Short
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Katie Chang
- Benten Technologies Inc, Manassas, Virginia, USA
| | - Parth Lalakia
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Geetanjali Mungarwadi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
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Kumar S, Bhatla N, Sharma KA, Agarwal R, Verma A, Perumal V, Shiv Kumar P, Garg BS, Goudar SS, Pujar YV, Kavi A, Suri V, Joshi B, Rathore A, Gupta MM, Kumar A, Puri M, Meena D, Nangia S, Arora R, Bachani S, Anand P, Seth S, Gupta R, Sehgal R, Rana A, Kumari A, P. S, Donimath K, Gowder G, Kedar L, Kar T, Mishra S, Joshi C, Kabade Y, Kamatar S, Nanda S, Mohapatra V, Vellanki J, Agarwal S, Borkar AW, Kumar A, Sultan S, Gangane N, Chaudhary P, Jayathilaka A, Raina N, Karna P. SCOPE: Surveillance of COVID-19 in pregnancy- results of a multicentric ambispective case-control study on clinical presentation and maternal outcomes in India between April to November 2020. PLoS One 2023; 18:e0272381. [PMID: 36877672 PMCID: PMC9987819 DOI: 10.1371/journal.pone.0272381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 07/18/2022] [Indexed: 03/07/2023] Open
Abstract
OBJECTIVE To determine the clinical manifestations, risk factors, treatment modalities and maternal outcomes in pregnant women with lab-confirmed COVID-19 and compare it with COVID-19 negative pregnant women in same age group. DESIGN Multicentric case-control study. DATA SOURCES Ambispective primary data collection through paper-based forms from 20 tertiary care centres across India between April and November 2020. STUDY POPULATION All pregnant women reporting to the centres with a lab-confirmed COVID-19 positive result matched with controls. DATA QUALITY Dedicated research officers extracted hospital records, using modified WHO Case Record Forms (CRF) and verified for completeness and accuracy. STATISTICAL ANALYSIS Data converted to excel files and statistical analyses done using STATA 16 (StataCorp, TX, USA). Odds ratios (ORs) with 95% confidence intervals (CI) estimated using unconditional logistic regression. RESULTS A total of 76,264 women delivered across 20 centres during the study period. Data of 3723 COVID positive pregnant women and 3744 age-matched controls was analyzed. Of the positive cases 56·9% were asymptomatic. Antenatal complications like preeclampsia and abruptio placentae were seen more among the cases. Induction and caesarean delivery rates were also higher among Covid positive women. Pre-existing maternal co-morbidities increased need for supportive care. There were 34 maternal deaths out of the 3723(0.9%) positive mothers, while covid negative deaths reported from all the centres were 449 of 72,541 (0·6%). CONCLUSION Covid-19 infection predisposed to adverse maternal outcomes in a large cohort of Covid positive pregnant women as compared to the negative controls.
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Affiliation(s)
- Sunesh Kumar
- All India Institute of Medical Sciences, New Delhi, India
| | - Neerja Bhatla
- All India Institute of Medical Sciences, New Delhi, India
| | - K. Aparna Sharma
- All India Institute of Medical Sciences, New Delhi, India
- * E-mail: ,
| | - Ramesh Agarwal
- All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Verma
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Poonam Shiv Kumar
- Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - B. S. Garg
- Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | | | - Yeshita V. Pujar
- Belagavi Institute of Medical Sciences, Belagavi, Karnataka, India
| | - Avinash Kavi
- Belagavi Institute of Medical Sciences, Belagavi, Karnataka, India
| | - Vanita Suri
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bharti Joshi
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Ajay Kumar
- Maulana Azad Medical College, New Delhi, India
| | - Manju Puri
- Lady Hardinge Medical Delhi, New Delhi, India
| | | | | | - Renu Arora
- Vardhaman Medical College and Safdarjung Hospital, New Delhi, India
| | - Sumitra Bachani
- Vardhaman Medical College and Safdarjung Hospital, New Delhi, India
| | - Pratima Anand
- Vardhaman Medical College and Safdarjung Hospital, New Delhi, India
| | - Shikha Seth
- Government Institute of Medical Sciences, Noida, Uttar Pradesh, India
| | - Rakesh Gupta
- Government Institute of Medical Sciences, Noida, Uttar Pradesh, India
| | - Rohini Sehgal
- All India Institute of Medical Sciences, New Delhi, India
| | - Anubhuti Rana
- All India Institute of Medical Sciences, New Delhi, India
| | - Archana Kumari
- All India Institute of Medical Sciences, New Delhi, India
| | - Shainy P.
- All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Lakshmi Kedar
- Belagavi Institute of Medical Sciences, Belagavi, Karnataka, India
| | - Tushar Kar
- S C B Medical College, Cuttack, Odisha, India
| | - Sujata Mishra
- Fakir Mohan Medical College, Balasore, Odisha, India
| | - Chinmayi Joshi
- Belagavi Institute of Medical Sciences, Belagavi, Karnataka, India
| | | | | | | | | | | | | | | | - Aruna Kumar
- Government Medical College, Bhopal, Madhya Pradesh, India
| | - Shabana Sultan
- Government Medical College, Bhopal, Madhya Pradesh, India
| | - Neha Gangane
- Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
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Kavi A, Kinshella MLW, Ramadurg UY, Charantimath U, Katageri GM, Karadiguddi CC, Honnungar NV, Bannale SG, Mungarwadi GI, Bone JN, Vidler M, Magee L, Mallapur A, Goudar SS, Bellad M, Derman R, von Dadelszen P, Working Group TCI. Community engagement for birth preparedness and complication readiness in the Community Level Interventions for Pre-eclampsia (CLIP) Trial in India: a mixed-method evaluation. BMJ Open 2022; 12:e060593. [PMID: 36600428 PMCID: PMC9772674 DOI: 10.1136/bmjopen-2021-060593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To describe the process of community engagement (CE) in northern Karnataka, India and its impact on pre-eclampsia knowledge, birth preparedness and complication readiness, pregnancy-related care seeking and maternal morbidity. DESIGN This study was a secondary analysis of a cluster randomised trial of Community Level Interventions for Pre-eclampsia (CLIP). A total of 12 clusters based on primary health centre catchment areas were randomised to intervention or control. CE was conducted in intervention clusters. CE attendance was summarised according to participant group using both quantitative and qualitative assessment. Pre-eclampsia knowledge, birth preparedness, health services engagement and perinatal outcomes was evaluated within trial surveillance. Outcomes were compared between trial arms using a mixed effects logistic regression model on RStudio (RStudio, Boston, USA). Community feedback notes were thematically analysed on NVivo V.12 (QSR International, Melbourne, Australia). SETTING Belagavi and Bagalkote districts in rural Karnataka, India. PARTICIPANTS Pregnant women and women of reproductive age, mothers and mothers-in-law, community stakeholders and male household decision-makers and health workers. RESULTS A total of 1379 CE meetings were conducted with 39 362 participants between November 2014 and October 2016. CE activities may have had an effect on modifying community attitudes towards hypertension in pregnancy and its complications. However, rates of pre-eclampsia knowledge, birth preparedness, health services engagement and maternal morbidities among individual pregnant women were not significantly impacted by CE activities in their area. CONCLUSION Evaluation of our CE programme in India demonstrates the feasibility of reaching pregnant women alongside household decision-makers, community stakeholders and health workers. More research is needed to explore the pathways of impact between broad community mobilisation to strengthen support for maternal care seeking and clinical outcomes of individual pregnant women. TRIAL REGISTRATION NUMBER NCT01911494.
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Affiliation(s)
- Avinash Kavi
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Umesh Y Ramadurg
- Women's and Children's Health Research Unit, S Nijalingappa Medical College, Bagalkote, Karnataka, India
| | - Umesh Charantimath
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Geetanjali M Katageri
- Women's and Children's Health Research Unit, S Nijalingappa Medical College, Bagalkote, Karnataka, India
| | - Chandrashekhar C Karadiguddi
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Narayan V Honnungar
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Shashidhar G Bannale
- Women's and Children's Health Research Unit, S Nijalingappa Medical College, Bagalkote, Karnataka, India
| | - Geetanjali I Mungarwadi
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Jeffrey N Bone
- Obstetrics and Gynecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Marianne Vidler
- Obstetrics and Gynecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura Magee
- King's College London School of Medical Education, London, UK
| | - Ashalata Mallapur
- Women's and Children's Health Research Unit, S Nijalingappa Medical College, Bagalkote, Karnataka, India
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Mrutyunjaya Bellad
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Richard Derman
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - The Clip India Working Group
- Women's and Children's Health Research Unit, J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
- Obstetrics and Gynecology, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Women and Children's Health, King's College London Faculty of Life Sciences and Medicine, London, UK
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45
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Adu-Amankwah A, Bellad MB, Benson AM, Beyuo TK, Bhandankar M, Charanthimath U, Chisembele M, Cole SR, Dhaded SM, Enweronu-Laryea C, Freeman BL, Freeman NLB, Goudar SS, Jiang X, Kasaro MP, Kosorok MR, Luckett D, Mbewe FM, Misra S, Mutesu K, Nuamah MA, Oppong SA, Patterson JK, Peterson M, Pokaprakarn T, Price JT, Pujar YV, Rouse DJ, Sebastião YV, Spelke MB, Sperger J, Stringer JSA, Tuuli MG, Valancius M, Vwalika B. Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study. Gates Open Res 2022; 6:115. [PMID: 36636742 PMCID: PMC9822935 DOI: 10.12688/gatesopenres.13716.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.
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Affiliation(s)
- Amanda Adu-Amankwah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Mrutunjaya B. Bellad
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Aimee M. Benson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Titus K. Beyuo
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Manisha Bhandankar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Umesh Charanthimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Maureen Chisembele
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Stephen R. Cole
- Department of Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Sangappa M. Dhaded
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Christabel Enweronu-Laryea
- Department of Child Health, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Bethany L. Freeman
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Nikki L. B. Freeman
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Xiaotong Jiang
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Margaret P. Kasaro
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,UNC Global Projects Zambia, LLC, Lusaka, Zambia
| | - Michael R. Kosorok
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Daniel Luckett
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | | | - Sujata Misra
- Fakir Mohan Medical College and Hospital, Balasore, India
| | - Kunda Mutesu
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Mercy A. Nuamah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Samuel A. Oppong
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Jackie K. Patterson
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Marc Peterson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Teeranan Pokaprakarn
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Joan T. Price
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,
| | - Yeshita V. Pujar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Yuri V. Sebastião
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - M. Bridget Spelke
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - John Sperger
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Jeffrey S. A. Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Michael Valancius
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
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Adu-Amankwah A, Bellad MB, Benson AM, Beyuo TK, Bhandankar M, Charanthimath U, Chisembele M, Cole SR, Dhaded SM, Enweronu-Laryea C, Freeman BL, Freeman NLB, Goudar SS, Jiang X, Kasaro MP, Kosorok MR, Luckett D, Mbewe FM, Misra S, Mutesu K, Nuamah MA, Oppong SA, Patterson JK, Peterson M, Pokaprakarn T, Price JT, Pujar YV, Rouse DJ, Sebastião YV, Spelke MB, Sperger J, Stringer JSA, Tuuli MG, Valancius M, Vwalika B. Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study. Gates Open Res 2022; 6:115. [PMID: 36636742 PMCID: PMC9822935 DOI: 10.12688/gatesopenres.13716.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 01/17/2023] Open
Abstract
Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.
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Affiliation(s)
- Amanda Adu-Amankwah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Mrutunjaya B. Bellad
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Aimee M. Benson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Titus K. Beyuo
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Manisha Bhandankar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Umesh Charanthimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Maureen Chisembele
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Stephen R. Cole
- Department of Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Sangappa M. Dhaded
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Christabel Enweronu-Laryea
- Department of Child Health, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Bethany L. Freeman
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Nikki L. B. Freeman
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Xiaotong Jiang
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Margaret P. Kasaro
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,UNC Global Projects Zambia, LLC, Lusaka, Zambia
| | - Michael R. Kosorok
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Daniel Luckett
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | | | - Sujata Misra
- Fakir Mohan Medical College and Hospital, Balasore, India
| | - Kunda Mutesu
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Mercy A. Nuamah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Samuel A. Oppong
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Jackie K. Patterson
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Marc Peterson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Teeranan Pokaprakarn
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Joan T. Price
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,
| | - Yeshita V. Pujar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Yuri V. Sebastião
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - M. Bridget Spelke
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - John Sperger
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Jeffrey S. A. Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Michael Valancius
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
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Naqvi S, Saleem S, Naqvi F, Billah SM, Nielsen E, Fogleman E, Peres‐da‐Silva N, Figueroa L, Mazariegos M, Garces AL, Patel A, Das P, Kavi A, Goudar SS, Esamai F, Chomba E, Lokangaka A, Tshefu A, Haque R, Siraj S, Yousaf S, Bauserman M, Liechty EA, Krebs NF, Derman RJ, Carlo WA, Petri WA, Hibberd PL, Koso‐Thomas M, Thorsten V, McClure EM, Goldenberg RL. Knowledge, attitudes, and practices of pregnant women regarding COVID-19 vaccination in pregnancy in 7 low- and middle-income countries: An observational trial from the Global Network for Women and Children's Health Research. BJOG 2022; 129:2002-2009. [PMID: 35596701 PMCID: PMC9347929 DOI: 10.1111/1471-0528.17226] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/11/2022] [Accepted: 05/15/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES We sought to determine the knowledge, attitudes and practices of pregnant women regarding COVID-19 vaccination in pregnancy in seven low- and middle-income countries (LMIC). DESIGN Prospective, observational, population-based study. SETTINGS Study areas in seven LMICs: Bangladesh, India, Pakistan, Guatemala, Democratic Republic of the Congo (DRC), Kenya and Zambia. POPULATION Pregnant women in an ongoing registry. METHODS COVID-19 vaccine questionnaires were administered to pregnant women in the Global Network's Maternal Newborn Health Registry from February 2021 through November 2021 in face-to-face interviews. MAIN OUTCOME MEASURES Knowledge, attitude and practice regarding vaccination during pregnancy; vaccination status. RESULTS No women were vaccinated except for small proportions in India (12.9%) and Guatemala (5.5%). Overall, nearly half the women believed the COVID-19 vaccine is very/somewhat effective and a similar proportion believed that the COVID-19 vaccine is safe for pregnant women. With availability of vaccines, about 56.7% said they would get the vaccine and a 34.8% would refuse. Of those who would not get vaccinated, safety, fear of adverse effects, and lack of trust predicted vaccine refusal. Those with lower educational status were less willing to be vaccinated. Family members and health professionals were the most trusted source of information for vaccination. CONCLUSIONS This COVID-19 vaccine survey in seven LMICs found that knowledge about the effectiveness and safety of the vaccine was generally low but varied. Concerns about vaccine safety and effectiveness among pregnant women is an important target for educational efforts to increase vaccination rates.
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Affiliation(s)
| | | | | | - Sk Masum Billah
- Maternal and Child Health DivisionInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
- University of VirginiaCharlottesvilleVirginiaUSA
| | | | | | | | - Lester Figueroa
- Instituto de Nutrición de Centroamérica y PanamáGuatemala CityGuatemala
| | - Manolo Mazariegos
- Instituto de Nutrición de Centroamérica y PanamáGuatemala CityGuatemala
| | - Ana L. Garces
- Instituto de Nutrición de Centroamérica y PanamáGuatemala CityGuatemala
| | | | - Prabir Das
- Lata Medical Research FoundationNagpurIndia
| | - Avinash Kavi
- KLE Academy Higher Education and ResearchJ N Medical CollegeBelagaviIndia
| | | | | | | | - Adrien Lokangaka
- Department of PediatricsKinshasa School of Public HealthKinshasaDemocratic Republic of the Congo
| | - Antoinette Tshefu
- Department of PediatricsKinshasa School of Public HealthKinshasaDemocratic Republic of the Congo
| | - Rashidul Haque
- Maternal and Child Health DivisionInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
| | - Shahjahan Siraj
- Maternal and Child Health DivisionInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
| | | | - Melissa Bauserman
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Edward A. Liechty
- Department of PediatricsIndiana School of Medicine, University of IndianaIndianapolisIndianaUSA
| | - Nancy F. Krebs
- Section of Nutrition, Department of PediatricsUniversity of Colorado School of MedicineDenverColoradoUSA
| | | | | | | | | | - Marion Koso‐Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesdaMarylandUSA
| | | | | | - Robert L. Goldenberg
- Department of Obstetrics and GynecologyColumbia University School of MedicineNew YorkNew YorkUSA
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48
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Dhaded SM, Saleem S, Goudar SS, Tikmani SS, Hwang K, Guruprasad G, Aradhya GH, Kusagur VB, Patil LGC, Yogeshkumar S, Somannavar MS, Reza S, Roujani S, Raza J, Yasmin H, Aceituno A, Parlberg L, Kim J, Moore J, Bann CM, Silver RM, Goldenberg RL, McClure EM. The causes of preterm neonatal deaths in India and Pakistan (PURPOSe): a prospective cohort study. Lancet Glob Health 2022; 10:e1575-e1581. [PMID: 36240824 PMCID: PMC9579353 DOI: 10.1016/s2214-109x(22)00384-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/17/2022] [Accepted: 08/22/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND Preterm birth remains the major cause of neonatal death worldwide. South Asia contributes disproportionately to deaths among preterm births worldwide, yet few population-based studies have assessed the underlying causes of deaths. Novel evaluations, including histological and bacteriological assessments of placental and fetal tissues, facilitate more precise determination of the underlying causes of preterm deaths. We sought to assess underlying and contributing causes of preterm neonatal deaths in India and Pakistan. METHODS The project to understand and research preterm pregnancy outcomes and stillbirths in South Asia (PURPOSe) was a prospective cohort study done in three hospitals in Davangere, India, and two hospitals in Karachi, Pakistan. All pregnant females older than 14 years were screened at the time of presentation for delivery, and those with an expected or known preterm birth, defined as less than 37 weeks of gestation, were enrolled. Liveborn neonates with a weight of 1000 g or more who died by 28 days after birth were included in analyses. Placentas were collected and histologically evaluated. In addition, among all neonatal deaths, with consent, minimally invasive tissue sampling was performed for histological analyses. PCR testing was performed to assess microbial pathogens in the placental, blood, and fetal tissues collected. An independent panel reviewed available data, including clinical description of the case and all clinical maternal, fetal, and placental findings, and results of PCR bacteriological investigation and minimally invasive tissue sampling histology, from all eligible preterm neonates to determine the primary and contributing maternal, placental, and neonatal causes of death. FINDINGS Between July 1, 2018, and March 26, 2020, of the 3470 preterm neonates enrolled, 804 (23%) died by 28 days after birth, and, of those, 615 were eligible and had their cases reviewed by the panel. Primary maternal causes of neonatal death were hypertensive disease (204 [33%] of 615 cases), followed by maternal complication of pregnancy (76 [12%]) and preterm labour (76 [11%]), whereas the primary placental causes were maternal and fetal vascular malperfusion (172 [28%] of 615) and chorioamnionitis, funisitis, or both (149 [26%]). The primary neonatal cause of death was intrauterine hypoxia (212 [34%] of 615) followed by congenital infections (126 [20%]), neonatal infections (122 [20%]), and respiratory distress syndrome (126 [20%]). INTERPRETATION In south Asia, intrauterine hypoxia and congenital infections were the major causes of neonatal death among preterm babies. Maternal hypertensive disorders and placental disorders, especially maternal and fetal vascular malperfusion and placental abruption, substantially contributed to these deaths. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sangappa M Dhaded
- KLE Academy of Higher Education and Research, JN Medical College, Belagavi, Karnataka, India
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, JN Medical College, Belagavi, Karnataka, India
| | | | - Kay Hwang
- Research Triangle Institute International, Durham, NC, USA
| | - Gowdar Guruprasad
- Bapuji Educational Association's JJM Medical College, Davangere, Karnataka, India
| | - Gayathri H Aradhya
- Bapuji Educational Association's JJM Medical College, Davangere, Karnataka, India
| | - Varun B Kusagur
- Bapuji Educational Association's JJM Medical College, Davangere, Karnataka, India
| | | | - S Yogeshkumar
- KLE Academy of Higher Education and Research, JN Medical College, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research, JN Medical College, Belagavi, Karnataka, India
| | - Sayyeda Reza
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sana Roujani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Jamal Raza
- National Institute of Child Health, Karachi, Pakistan
| | | | - Anna Aceituno
- Research Triangle Institute International, Durham, NC, USA
| | | | - Jean Kim
- Research Triangle Institute International, Durham, NC, USA
| | - Janet Moore
- Research Triangle Institute International, Durham, NC, USA
| | - Carla M Bann
- Research Triangle Institute International, Durham, NC, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Elizabeth M McClure
- Research Triangle Institute International, Durham, NC, USA,Correspondence to: Dr Elizabeth M McClure, Research Triangle Institute International, Durham, NC 27709, USA
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Eddy KE, Vogel JP, Scott N, Fetene D, Tidhar T, Oladapo OT, Piaggio G, Nguyen MH, Althabe F, Bahl R, Rao SPN, De Costa A, Gupta S, Baqui AH, Shahidullah M, Chowdhury SB, Ahmed S, Sultana S, Jaben IA, Goudar SS, Dhaded SM, Pujar YV, Vernekar SS, Welling S, Katageri GM, Gudadinni MR, Nanda S, Qureshi Z, Baraka HT, Osoti A, Gwako G, Kinuthia J, Ojo S, Adeponle AO, Idowu AA, Adejuyigbe EA, Kuti O, Kuti BP, Akinkunmi FB, Kubeyinje WE, Raji HO, Abiodun O, Isah AD, Ariff S, Soofi SB, Sheikh L, Aamir A, Raza F. Antenatal dexamethasone for improving preterm newborn outcomes in low-resource countries: a cost-effectiveness analysis of the WHO ACTION-I trial. Lancet Glob Health 2022; 10:e1523-e1533. [DOI: 10.1016/s2214-109x(22)00340-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/12/2022] [Accepted: 07/28/2022] [Indexed: 10/14/2022]
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50
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Ghanchi NK, Ahmed I, Kim J, Harakuni S, Somannavar MS, Zafar A, Tikmani SS, Saleem S, Goudar SS, Dhaded SM, Guruprasad G, Yogeshkumar S, Hwang K, Aceituno A, Silver RM, McClure EM, Goldenberg RL. Pathogens Identified by Minimally Invasive Tissue Sampling in India and Pakistan From Preterm Neonatal Deaths: The PURPOSE Study. Clin Infect Dis 2022; 76:e1004-e1011. [PMID: 36104850 PMCID: PMC9907547 DOI: 10.1093/cid/ciac747] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/22/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We identified pathogens found in internal organs and placentas of deceased preterm infants cared for in hospitals in India and Pakistan. METHODS Prospective, observational study conducted in delivery units and neonatal intensive care units. Tissue samples from deceased neonates obtained by minimally invasive tissue sampling and placentas were examined for 73 different pathogens using multiplex polymerase chain reaction (PCR). RESULTS Tissue for pathogen PCR was obtained from liver, lung, brain, blood, cerebrospinal fluid, and placentas from 377 deceased preterm infants. Between 17.6% and 34.1% of each type of tissue had at least 1 organism identified. Organism detection was highest in blood (34.1%), followed by lung (31.1%), liver (23.3%), cerebrospinal fluid (22.3%), and brain (17.6%). A total of 49.7% of the deceased infants had at least 1 organism. Acinetobacter baumannii was in 28.4% of the neonates compared with 14.6% for Klebsiella pneumoniae, 11.9% for Escherichia coli/Shigella, and 11.1% for Haemophilus influenzae. Group B streptococcus was identified in only 1.3% of the neonatal deaths. A. baumannii was rarely found in the placenta and was found more commonly in the internal organs of neonates who died later in the neonatal period. The most common organism found in placentas was Ureaplasma urealyticum in 34% of the samples, with no other organism found in >4% of samples. CONCLUSIONS In organ samples from deceased infants in India and Pakistan, evaluated with multiplex pathogen PCR, A. baumannii was the most commonly identified organism. Group B streptococcus was rarely found. A. baumannii was rarely found in the placentas of these deceased neonates.
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Affiliation(s)
- Najia Karim Ghanchi
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Imran Ahmed
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Jean Kim
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, North Carolina, USA
| | - Sheetal Harakuni
- KLE Academy of Higher Education and Research's, J.N. Medical College, Belagavi, Karnataka, India
| | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research's, J.N. Medical College, Belagavi, Karnataka, India
| | - Afia Zafar
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's, J.N. Medical College, Belagavi, Karnataka, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research's, J.N. Medical College, Belagavi, Karnataka, India
| | - Gowdar Guruprasad
- Department of Pediatrics, Bapuji Educational Association, J.J.M. Medical College, Davangere, Karnataka, India
| | - S Yogeshkumar
- KLE Academy of Higher Education and Research's, J.N. Medical College, Belagavi, Karnataka, India
| | - Kay Hwang
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, North Carolina, USA
| | - Anna Aceituno
- Social, Statistical and Environmental Health Sciences, RTI International, Durham, North Carolina, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elizabeth M McClure
- Correspondence: E. M. McClure, RTI International 3040 Cornwallis Rd, Durham, NC 27516 ()
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