BACKGROUND

Since 2016, the World Health Organization (WHO) has recommended a minimum of eight antenatal care (ANC) contacts during pregnancy, replacing the previous recommendation of four focused ANC visits. In Mali and Burkina Faso, the four ANC visits are still recommended and their coverage remains low or insufficient. To anticipate possible obstacles to the implementation of the new recommendations, this study aimed to identify the individual determinants of ANC attendance in two study districts, with a representative sample of women recruited from the community.

METHODS

Data were collected in June 2022 through a three-stage household survey with a representative sample of women who delivered in the previous 12 months in the health districts of Kangaba (Mali) and Boussé (Burkina Faso). Country-specific analyses were performed using self-reported data. Women’s sociodemographic and clinical characteristics, as well as attitudes towards ANC attendance, were described to account for clustering. Multivariable logistic regression models using generalized estimating equations were used to identify the determinants of four or more ANC uptakes. A p-value < 0.05 was considered statistically significant in the adjusted model.

RESULTS

Overall, 1590 women participated (780 in Mali; 810 in Burkina Faso) in the study. Women in Burkina Faso were older and less educated than women in Mali. The proportions of women with at least four ANC visits were 80% and 54%, and that of ANC in the first trimester was 38.7% and 43.8% in Burkina Faso and Mali respectively. Factors significantly associated with a greater probability of women attending ANC4 + visits were found only in Mali: a history of stillbirth and time spent at ANC. Factors reducing the use of ANC4 + were the lack of transportation/distance in Burkina Faso, travel time of less than 1 h to reach the maternity clinic, women’s nonrecognition of the importance of ANC visits, and the perceived high cost of the ANC visit in both countries.

CONCLUSION

ANC was lower in Mali than in Burkina Faso. Health policies aimed at achieving the WHO recommendation of 8 ANC contacts should prioritize health information and sensitization of pregnant women to improve their knowledge of the importance of attending ANC several times.

TRIAL REGISTRATION

Retrospectively registered on August 11th, 2022 registration # PACTR202208844472053. Protocol v4.0 dated September 04, 2023.

BACKGROUND

Access to safe abortion care (SAC) should be improved in fragile and humanitarian settings, and the implementation of interventions in that regard are currently limited. This is especially true for self-managed abortion (SMA), although it holds the potential of revolutionizing the prevention of maternal death and suffering.

CASE PRESENTATION

The medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) piloted a self-managed abortion model of care in the Middle East. 22 women were remotely supported in managing their safe abortions with a counsellor over the phone, using misoprostol doses that they took at home after having taken mifepristone in our health facility. We share our experience by describing the model of care and discussing the lessons learned through its implementation.

CONCLUSIONS

The program delivered abortion services successfully and required few resources. This paper also reflects on the importance of facilitating SMA in humanitarian contexts. It increases access to care by providing increased confidentiality, close support, ample information, autonomy, and flexibility. It is simple to implement, effective, often preferred by women, and can be linked to information about contraception. The implementation of self-managed models should be expanded, notably in projects that do not have a sexual and reproductive health focus and in restrictive and challenging contexts. It represents a true revolution for access to safe abortion care.

BACKGROUND

Expanding contraceptive options could better meet users’ diverse needs and preferences. Annovera^® is a contraceptive vaginal ring that provides a year of pregnancy prevention while remaining under user control and allowing for regular menstrual cycles. This method may also help to reduce burdens on some health care and supply chain systems. However, knowledge gaps exist regarding initial and ongoing acceptability of contraceptive vaginal rings in African settings.

METHODS

We will undertake an open-label, non-randomized, two-arm, parallel clinical acceptability study with an embedded qualitative component, based in clinics providing contraceptive services in Kenya and Zimbabwe. Women aged 18-45 interested in newly initiating or switching contraception will choose from among all available contraceptive options, including Annovera. We aim to enroll 200 participants selecting Annovera and 200 participants selecting either contraceptive injectables or pills. We will compare method uptake, continuation, and satisfaction over one year. Participants will complete questionnaires administered by study staff during two in-person visits (a screening/enrollment visit, and an end of study visit after 52 weeks of method use or at discontinuation) and four phone appointments (at 4, 12, 24, and 36 weeks of use). We will evaluate used rings for discoloration and residual drug levels. The qualitative component involve in-depth interviews with women in the clinical study, their sexual partners, and their service providers, to further examine drivers of and barriers to interest in and use of contraceptive vaginal rings.

DISCUSSION

This study will explore acceptability of contraceptive vaginal rings in ‘real-world’ contraceptive service settings in two African countries. Findings will be based on actual ring use and contextualized via comparison to two other commonly available methods. As vaginal rings are being considered for multiple reproductive health indications, this work can fill key knowledge gaps and empower decision-makers with information needed to inform future investments in reproductive health.

BACKGROUND

Conflict is known to impact maternal and neonatal health in Eastern Democratic Republic of the Congo (DRC), an area of longstanding insecurity. We conducted a systematic review on pregnancy and neonatal outcomes in this region to provide a comprehensive overview of maternal and neonatal outcomes over a 20-year period.

METHODS

We systematically searched databases, such as Medline, EMBASE, Global Health, ClinicalTrials.gov and the Cochrane Library, along with grey literature, for articles published between 2001 and 2021. These articles provided quantitative data on selected pregnancy and neonatal outcomes in the provinces of Ituri, Maniema and North and South Kivu, Eastern DRC. We conducted a descriptive analysis, combining results from different data sources and comparing incidence of outcomes in North Kivu with those in other provinces in Eastern DRC.

RESULTS

A total of 1,065 abstracts from peer-reviewed publications and 196 articles from the grey literature were screened, resulting in the inclusion of 14 scientific articles in the review. The most frequently reported pregnancy complications were caesarean sections (11.6%–48.3% of deliveries) and miscarriage (1.2%–30.0% of deliveries). The most common neonatal outcomes were low birth weight (3.8%–21.9% of live births), preterm birth (0.9%–74.0%) and neonatal death (0.2%–43.3%).

CONCLUSION

Our review provides data on pregnancy and neonatal outcomes in Eastern DRC, which will be valuable for future studies. Despite the area's ongoing armed conflict, the percentages of complications we noted in Eastern DRC are comparable with those observed in other countries in the region.

Uterine rupture is a well-known, life-threatening complication of misoprostol use; the incidence is remarkably low. Herein, we report what seems to be the first documented case of uterine rupture following induction of labour for intrauterine foetal death in the second trimester without a uterine scar. A 40-year-old woman with no history of caesarean section or uterine surgery presented with mild lower abdominal pain and mild genital bleeding. Transabdominal ultrasonography revealed intrauterine foetal death, at presumed gestational age of 20 weeks. Two hours after three doses of 400 μg 3-hourly of misoprostol, the patient complained of abdominal pain; however, the foetus was not expelled. Repeat sonography revealed the foetus in the abdominal cavity and fluid collection in the pelvis. Based on the probable diagnosis of uterine rupture, a laparotomy was performed. The intra-abdominal haemorrhage volume was approximately 250-300 ml. There was a linear rupture approximately 10 cm long on the posterior wall of the uterus, and as a consequence, a macerated and foetid foetus and part of the placenta were found in the abdominal cavity. A total hysterectomy was performed, and the patient was discharged three days after the intervention without any postoperative complications. In conclusion, while misoprostol is generally safe for second-trimester pregnancy termination, its use should be approached with caution and close monitoring in cases of uterine inflammation.

BACKGROUND

Malaria and HIV infection overlap geographically in sub-Saharan Africa and share risk factors. HIV infection increases malaria's severity, especially in pregnant women. The World Health Organization (WHO) recommends intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) for pregnant women living in areas of stable malaria transmission. However, HIV-positive women on daily cotrimoxazole prophylaxis (recommended for prevention of opportunistic infections in people with HIV) cannot receive SP due to adverse drug interactions, so malaria prevention in this vulnerable population currently relies on daily cotrimoxazole prophylaxis alone. This review is based on a new protocol and provides an update to the 2011 Cochrane Review that evaluated alternative drugs for IPTp to prevent malaria in HIV-positive women.

OBJECTIVES

To compare the safety and efficacy of intermittent preventive treatment regimens for malaria prevention in HIV-positive pregnant women.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registries to 31 January 2024. To identify relevant additional studies or unpublished work, we checked references and contacted study authors and other researchers working on malaria and HIV.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing any intermittent preventive treatment regimen for preventing malaria in HIV-positive pregnant women against daily cotrimoxazole prophylaxis alone, placebo, current or previous standard of care, or combinations of these options. By 'standard of care' we refer to the country's recommended drug regimen to prevent malaria in pregnancy among HIV-positive women, or the treatment that a trial's research team considered to be the standard of care.

DATA COLLECTION AND ANALYSIS

Review authors, in pairs, independently screened all records identified by the search strategy, applied inclusion criteria, assessed risk of bias in included trials, and extracted data. We contacted trial authors when additional information was required. We presented dichotomous outcomes using risk ratios (RRs), count outcomes as incidence rate ratios (IRRs), and continuous outcomes as mean differences (MDs). We presented all measures of effect with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach for what we considered to be the main comparisons and outcomes.

MAIN RESULTS

We included 14 RCTs, with a total of 4976 HIV-positive pregnant women initially randomized. All trials assessed the efficacy and safety of one antimalarial used as IPTp (mefloquine, dihydroartemisinin/piperaquine, SP, or azithromycin) with or without daily cotrimoxazole, compared to daily cotrimoxazole alone, placebo, or a standard of care regimen. We grouped the trials into nine comparisons. Our main comparison evaluated the current standard of care (daily cotrimoxazole) with another drug regimen (mefloquine or dihydroartemisinin/piperaquine) versus daily cotrimoxazole with or without placebo. In this comparison, two trials evaluated mefloquine and three evaluated dihydroartemisinin/piperaquine. We conducted meta-analyses that included trials evaluating dihydroartemisinin/piperaquine plus cotrimoxazole, and trials that evaluated mefloquine plus cotrimoxazole, as we considered there to be no qualitative or quantitative heterogeneity among trials for most outcomes. We considered drug-related adverse events and HIV-related outcomes to be drug-specific. Daily cotrimoxazole prophylaxis plus another drug regimen (mefloquine or dihydroartemisinin/piperaquine) probably results in lower risk of maternal peripheral parasitaemia at delivery (RR 0.62, 95% CI 0.41 to 0.95; 2406 participants, 5 trials; moderate-certainty evidence). It results in little or no difference in maternal anaemia cases at delivery (RR 0.98, 95% CI 0.90 to 1.07; 2417 participants, 3 trials; high-certainty evidence). It probably results in a decrease in placental malaria measured by blood smear (RR 0.54, 95% CI 0.31 to 0.93; 1337 participants, 3 trials; moderate-certainty evidence), and probably results in little or no difference in low birth weight (RR 1.16, 95% CI 0.95 to 1.41; 2915 participants, 5 trials; moderate-certainty evidence). There is insufficient evidence to ascertain whether daily cotrimoxazole prophylaxis plus another drug regimen affects the risk of cord blood parasitaemia (RR 0.27, 95% CI 0.04 to 1.64; 2696 participants, 5 trials; very low-certainty evidence). Daily cotrimoxazole prophylaxis plus another drug regimen probably results in little or no difference in foetal loss (RR 1.03, 95% CI 0.73 to 1.46; 2957 participants, 5 trials; moderate-certainty evidence), and may result in little or no difference in neonatal mortality (RR 1.21, 95% CI 0.68 to 2.14; 2706 participants, 4 trials; low-certainty evidence). Due to the probability of an increased risk of mother-to-child HIV transmission and some adverse drug effects noted with mefloquine, we also looked at the results for dihydroartemisinin/piperaquine specifically. Dihydroartemisinin/piperaquine plus daily contrimoxazole probably results in little to no difference in maternal peripheral parasitaemia (RR 0.59, 95% CI 0.31 to 1.11; 1517 participants, 3 trials; moderate-certainty evidence) or anaemia at delivery (RR 0.95, 95% CI 0.82 to 1.10; 1454 participants, 2 trials; moderate-certainty evidence), but leads to fewer women having placental malaria when measured by histopathologic analysis (RR 0.67, 95% CI 0.50 to 0.90; 1570 participants, 3 trials; high-certainty evidence). The addition of dihydroartemisinin/piperaquine to daily cotrimoxazole probably made little to no difference to rates of low birth weight (RR 1.13, 95% CI 0.87 to 1.48; 1695 participants, 3 trials), foetal loss (RR 1.14, 95% CI 0.68 to 1.90; 1610 participants, 3 trials), or neonatal mortality (RR 1.03, 95% CI 0.39 to 2.72; 1467 participants, 2 trials) (all moderate-certainty evidence). We found low-certainty evidence of no increased risk of gastrointestinal drug-related adverse events (RR 1.42, 95% CI 0.51 to 3.98; 1447 participants, 2 trials) or mother-to-child HIV transmission (RR 1.54, 95% CI 0.26 to 9.19; 1063 participants, 2 trials).

AUTHORS' CONCLUSIONS

Dihydroartemisinin/piperaquine and mefloquine added to daily cotrimoxazole seem to be efficacious in preventing malaria infection in HIV-positive pregnant women compared to daily cotrimoxazole alone. However, increased risk of HIV transmission to the foetus and poor drug tolerability may be barriers to implementation of mefloquine in practice. In contrast, the evidence suggests that dihydroartemisinin/piperaquine does not increase the risk of HIV mother-to-child transmission and is well tolerated.