The Contribution of HIV to Mortality in Pregnant and Postpartum Women

Abstract

Background: High levels of HIV and maternal mortality go hand in hand in many regions of sub-Saharan Africa. Therefore, understanding the interaction between pregnancy and HIV is important, not only for the clinical management of pregnant women, but also for the measurement of maternal mortality, the standard definition of which excludes infectious causes of death not aggravated by pregnancy. Methods: In this thesis the excess mortality attributable to HIV in pregnant and postpartum women is calculated by comparing the risk of mortality in HIV-infected pregnant and postpartum women to their uninfected counterparts using two different data sources: 1) studies identified through a systematic review and; 2) data from six demographic surveillance sites (DSS) in sub-Saharan Africa. Verbal autopsy (VA) data from the DSS are also used to explore the percentage of deaths classified as HIV/AIDS-related. Two additional systematic reviews are conducted to assess whether HIV increases the risk of obstetric complications, or pregnancy accelerates HIV disease progression. Results: HIV-infected women have eight times the risk of pregnancy-related mortality compared with HIV-uninfected women. Based on this estimate, we predict that roughly a quarter of deaths in pregnant or postpartum women are attributable to HIV in sub-Saharan Africa. A lower percentage of pregnancy-related deaths are attributed to HIV/AIDS using VA data. There is little evidence that HIV-infected women are at increased risk of direct obstetric complications, with the exception of sepsis, or that pregnancy increases the risk of HIV disease progression. Conclusion: HIV may cause up to 25% of deaths during pregnancy and in the postpartum period in areas of high HIV prevalence. Most of the evidence suggests that this excess pregnancy-related mortality attributable to HIV is largely coincidental to pregnancy. This implies that there is little reason to discourage healthy, HIV-infected women from becoming pregnant if they desire to do so.