Pregnancy In Low-income Countries Research Articles

Utilization and compliance with iron supplementation and predictors among pregnant women in Southeast Ethiopia

Anemia is predicted to affect 38% (32 million) of pregnant women worldwide. However, evidence for utilization and compliance with iron supplementation and predictors during pregnancy in low-income countries, including Ethiopia, is sparse and inconclusive. Therefore, we aimed to assess utilization and compliance with iron supplementation and predictors among pregnant women in Robe Town, Southeast Ethiopia. A community-based cross-sectional study was employed among randomly selected 445 pregnant women attending antenatal care at health facilities from May to July 2015. A systematic random sampling was used to select respondents. Data were collected using a pre-tested, interviewer-administered, structured questionnaire. Bivariable and multivariable logistic regression analyses were conducted to identify predictors of compliance with iron supplementation. An odds ratio, along with a 95% confidence interval (CI), was used to estimate the strength of the association. In this study, 54% [95% CI (49.4, 58.4%)], 45.2% [95% CI (40.9, 49.4%)], 4.3% [95% CI (2.5, 6.3%)], and 2.2% [95% CI (1.1, 3.6%)] of women received iron supplements during their first, second, third, and fourth antenatal care visits, respectively. The level of compliance with iron supplementation was 92.4% [95% CI (89.9, 94.6%)]. Having a formal education (AOR = 4.45, 95% CI 1.41, 13.99), being in the high wealth quintile (AOR = 0.18, 95% CI 0.05, 0.68), medium wealth quintile [(AOR = 0.33, 95% CI (0.11, 0.98)], receiving iron supplements for free (AOR = 3.77, 95% CI 1.33, 10.69), not experiencing discomfort related to iron supplements intake (AOR = 2.94, 95% CI 1.17, 7.39), having comprehensive knowledge about anemia (AOR = 2.62, 95% CI 1.02, 6.70), being knowledgeable about iron supplements (AOR = 3.30, 95% CI 1.12, 9.76), having information about importance of iron supplementation during pregnancy (AOR = 2.86; 95% CI 1.04, 7.87), and ever being visited by urban health extension workers (AOR = 0.31; 95% CI 0.12, 0.83) was significantly associated with compliance with iron supplementation during pregnancy. The utilization of iron supplementation during pregnancy was low, with relatively high compliance with the supplements. Thus, comprehensive nutrition education and free provision of iron supplementation are crucial tools to increase utilization and compliance with iron supplementation during pregnancy. Further research with a strong study design using golden standard methods is warranted.

Perceptions of Factors Leading to Teenage Pregnancy in Lindi Region, Tanzania: A Grounded Theory Study

High prevalence of teenage pregnancy in low-income countries impacts health, social, economic, and educational situations of teenage girls. To acquire better understanding of factors leading to high prevalence of teenage pregnancy in rural Lindi region, Tanzania, we explored perspectives of girls and key informants by conducting a facility-based explorative qualitative study according to the grounded theory approach. Participants were recruited from Mnero Diocesan Hospital using snowball sampling, between June and September 2018. Eleven pregnant teenagers, two girls without a teenage pregnancy, and eight other key informants were included. In-depth interviews (including photovoice) and field observations were conducted. Analysis of participant perspectives revealed five main themes: 1) lack of individual agency (peer pressure, limited decision-making power, and sexual coercion); 2) desire to earn money and get out of poverty; 3) dropping out of school contributing to becoming pregnant; 4) absence of financial, material, psychological, or emotional support from the environment; and 5) limited access to contraception. A majority of girls reported the pregnancy to be unplanned, whereas some girls purposely planned it. Our findings and the resulting conceptual framework contribute to a new social theory and may inform national and international policies to consider the needs and perspectives of teenagers in delaying pregnancy and promoting sexual and reproductive health in Tanzania and beyond.

Recommendations for treating life-threatening Kaposi sarcoma during pregnancy in HIV-positive women in low income countries.

In areas of high HIV and human herpes virus 8 prevalence, life-threatening forms of Kaposi sarcoma (KS) can occur in HIV-positive women during pregnancy. Treating KS in pregnancy must balance both the well-being of the mother with the health of the fetus, yet data and recommendations on the best treatment approach for KS during pregnancy are limited. Without effective treatment, which can be difficult to obtain in low income countries (LICs), the mother and infant are at risk for poor outcomes. A successful case report is used as teaching example, followed by a detailed review of the literature that culminates in recommendations for treating KS during pregnancy among HIV-positive women in LICs. A 31-year-old HIV-positive woman presented for care in April 2016 at 28 weeks gestation with extensive KS skin lesions, KS lymphadenopathy, and a large oropharynx KS lesion causing partial airway obstruction. She had initiated antiretroviral therapy (ART) months prior and was virally suppressed, suggesting KS-immune reconstitution inflammatory syndrome. Due to the severity of KS and her third trimester status, combination chemotherapy was initiated using bleomycin, vincristine, and doxorubicin followed by maintenance therapy with paclitaxel. She showed remarkable response to the chemotherapy and had a normal vaginal delivery of a healthy baby at full term. Full clinical remission was achieved, and her baby was HIV-negative with no negative health effects of the KS or the chemotherapy. Review of the sparse existing literature demonstrates the importance, safety, and effectiveness of treating KS during pregnancy. We offer simple adaptable treatment recommendations for use in treating HIV-positive women with KS during pregnancy in LICs. Life-threatening KS can be treated using chemotherapy and ART in resource-limited settings, allowing for good outcomes in mother and infant. While monotherapy with liposomal doxorubicin or paclitaxel is preferred, these are often not available in LICs. As alternatives, bleomycin, vincristine, and doxorubicin can be safely used during the second and/or third trimesters for treating KS. Following a simple treatment approach can be an effective way to treat KS in pregnancy for pregnant women living with HIV in an LIC setting.

Ultrasound estimation of gestational age in late pregnancy in low-income countries: made to measure or off-the-peg?

Ultrasound estimation of gestational age in late pregnancy in low-income countries: made to measure or off-the-peg?

The Influence of Educational Attainment on Teenage Pregnancy in Low-Income Countries: A Systematic Literature Review

The purpose of this study is to review the association between education and teenage pregnancy in low- and lower-middle-income countries. Teenage pregnancy deters women from achieving educational goals and from maximizing their human capital. This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Nine out of 4,980 articles scanned met the inclusion criteria for analysis, from 2008 to 2018. The results show reaching higher levels of education deters from teenage pregnancy in low- and lower-middle-income countries. Therefore, social work policies and programs should target access to education and school retention as a deterrence to teenage pregnancy.

Capacity Building and Innovation in Caring for Non-communicable Diseases in Maternal Global Health: The Example of Haiti.

Non-communicable diseases (NCDs) are important contributors to maternal morbidity and mortality worldwide. Yet, data on their prevalence and related outcomes in low-income countries are currently lacking. Additionally, screening and treatment protocols adapted for resource-limited settings are urgently required. This collaborative research initiative on the screening and management of hypertensive disorders of pregnancy and gestational diabetes was conducted in Saint-Nicolas Hospital in Saint-Marc, Haiti. The report discusses methods used to overcome several local challenges to implementation of care for NCDs. It also describes how collaborative research initiatives are efficient strategies to innovate and build research capacity for NCD care delivery during pregnancy in low-income countries.

Challenge in the Management of Twin Pregnancy with Anencephaly of One Fetus in a Low- Income Country: A Case Presentation

Anencephaly of one twin is a frequent congenital abnormality in a twin pregnancy and it’s associated with a poor prognosis of this pregnancy. In developed countries, the goal standard management calls for an interventional fetal medicine either by injection of a cardiotoxic or by intervention on the umbilical cord. Another option is an expectative management with strict follow-up of pregnant women and delivery organized in a level 3 maternity. There is still a challenge in the management of such high risk pregnancy in low income countries. A 37 years-old female, G3P2002, referred from a clinic for the better management of a 28 weeks and 4 days twin pregnancy in labor. Obstetrical ultrasonography realized in the second trimester revealed dichorionic-diamniotic pregnancy and the presence of anencephaly with hydramnios of one twin. The expectative approach was adopted for the management of this high risk pregnancy, unfortunately the death of the fetus occurred despite all the care provided. This case brings to lamp light the difficulties encountered in providing standard obstetrical care for high risk pregnancies in resource limited settings.

Challenges of Rapid Plasma Reagin Interpretation in Syphilis Screening in Uganda: Variability in Nontreponemal Results Between Different Laboratories.

Syphilis is a cause of morbidity and mortality and is of particular concern in pregnancy in low-income countries because of the risks associated with maternal-fetal transmission. Ugandan national guidelines recommend a nontreponemal rapid plasma reagin (RPR) followed by treponemal testing for diagnosis of syphilis. The RPR test confirms a reactive specific treponemal test, or confirms serological "cure" with a 4-fold dilutional decrease; RPR is beset with technical and biological limitations, making accurate diagnosis and appropriate treatment problematic. The aim of this analysis was to compare performance of RPR testing in different laboratories. Stored, freeze-thawed sera from 215 participants were additionally tested for RPR and dilutional titer in 2 different reference laboratories. Discrepant results were tested at a third reference laboratory which served as a tie-breaker. Equivalence in RPR titer was defined as within 2-fold or less. All patients with reactive rapid tests were treated as per Ugandan National Guidelines. Of 215 sera, 97 (45.1%) were RPR reactive in clinic laboratory A, 81 (37.7%) and 65 (30.2%) were RPR reactive in laboratories B and C, respectively. All reported positive in laboratory C were positive in laboratory B. Discrepant results were tested in laboratory D. χ Test was highly significant (P = <0.001) for difference between each dyad of laboratories (A and B, A and C, and B and C) RPR results. There were significant differences between RPR titers by paired t test and Wilcox rank test (P = <0.001); with up to a 3-fold difference between laboratories. Two one-sided test approach demonstrated nonequivalence. Agreement between laboratories B-D, and C-D: 48 (98.0%) of 49 and 34 (69.4%) of 49, respectively (P = <0.001). Laboratories B and D showed no significant difference and had equivalent RPR titers. Laboratories C and D had different titers (P = <0.001) and were not equivalent. We found significant interlaboratory discrepant RPR results. A 3-fold difference in results is likely to be clinically significant and could result in undertreatment or overtreatment. These data demonstrate a key limitation of the RPR test and underline the urgent need for a more reproducible quantitative test than the current RPR for diagnosing and determining cure of syphilis.

Seroprevalence and risk factors of Hepatitis E virus infection among pregnant women attending antenatal care in health facilities of Tigray, Northern Ethiopia.

Existing literatures from developing countries show an increased mortality and morbidity related to hepatitis E virus during pregnancy as compared to the general population. Studies focusing on pregnant women are required for policy makers to improve maternal and child health. Therefore this study is aimed at determining the prevalence and associated risk factors of hepatitis E virus infection among pregnant women attending the health facilities of Tigray region, Northern Ethiopia. In this cross sectional study 846 pregnant women were included consecutively from April 2014 to February 2016. Clinical and sociodemographic were collected using structured questionnaire and blood was collected for laboratory analysis of Hepatitis E virus using IgG and IgM HEV ELISA. The data were analyzed using SPSS software version 21.0. Association with variables with the risk factors was determined using bivariate and multivariate analysis. The overall sero-prevalence of hepatitis E virus using anti-HEV IgG and anti-HEV IgM antibody among pregnant women were 367 (43.4%). From this 359 (42.4%) and 8 (0.9%) were tested positive for anti-HEV IgG and anti-HEV IgM antibody, respectively. Then finally age, rural residence, not washing after toilet use and lack of prevention aspects to minimize contamination were associated with HEV infection. This study shows the significant public health impact of HEV during pregnancy in low income countries.

Can Prevention of Low Birth Weight in Newborn may be Associated with Primordial Prevention of Cardiovascular Diseases and Type 2 Diabetes in Adult Life?

Poor nutrition during pregnancy may be a risk factor for low birth weight and for irreversible health issues including obesity, type 2 diabetes, hypertension and hypercholesterolemia in adult life. Low birth weight has also been related to greater mortality from coronary artery disease(CAD) and type 2 diabetes in adult life. One earlier study from Northern Europe proposed that poor social conditions in childhood may be risk factor for obesity, diabetes and cardiovascular diseases (CVDs) in later life. It is possible that multiple confounders related to energy and micronutrient deficiencies may be interacting in the process of adaptations in critical time periods, during fetal, postnatal and child development. A review of literature on the effects on birth size and length of babies and of multiple micronutrient supplementation during pregnancy in low-income countries indicates that incidence of low birth weight may be decreased by supplementation of about 15 micronutrients. This finding poses the possibility that for prevention of low birth weight, maternal micronutrient supplementation (15-20 nutrients) may be an important strategy. It is proposed that this strategy may lead the prevention of CVDs and type 2 diabetes in adult life. Cohort studies and long term follow up population based trials are needed to confirm this hypothesis.

Addressing the needs of adolescent mothers and their offspring in Nigeria: a community-based study

The purpose of this study is to determine the perinatal profile of adolescent mothers with surviving offspring against the backdrop of limited community-based data on the outcomes of adolescent pregnancy in low-income countries. A case-control study of adolescent mothers (13-19 years) attending four community-based clinics for routine childhood immunization from July 2005 to March 2008 in Lagos, Nigeria, matched for infant age and sex. Maternal and infant factors associated with adolescent mothers were determined using unconditional and conditional multivariable logistic regression analyses. A total of 241 adolescent mothers (mean age, 18.2±1.2 years) were consecutively recruited over the study period and matched with 1205 controls (mean age, 27.3±3.9 years). Adolescent mothers in this population were significantly more likely to be unmarried, of the Hausa ethnic tribe, without postsecondary education, unemployed, and primiparous. Although all received antenatal care, they were also more likely to deliver outside hospital without skilled attendants, and their offspring were likely to be undernourished. Socio-demographic profile of adolescent girls who become pregnant is likely to have a significant influence on their health-seeking behavior for obstetric services. Teenagers especially from the most vulnerable ethnic groups in resource-poor countries should be educated on the developmental risks of early childbearing in their surviving offspring.

Vitamins and minerals for women: recent programs and intervention trials.

Women's nutrition has received little attention in nutrition programming, even though clinical trials and intervention trials have suggested that dietary improvement or supplementation with several nutrients may improve their health, especially in low-income settings, the main focus of this paper. Most attention so far has focused on how improvements in maternal nutrition can improve health outcomes for infants and young children. Adequate vitamin D and calcium nutrition throughout life may reduce the risk of osteoporosis, and calcium supplementation during pregnancy may reduce preeclampsia and low birth weight. To reduce neural tube defects, additional folic acid and possibly vitamin B12 need to be provided to non-deficient women before they know they are pregnant. This is best achieved by fortifying a staple food. It is unclear whether maternal vitamin A supplementation will lead to improved health outcomes for mother or child. Iron, iodine and zinc supplementation are widely needed for deficient women. Multimicronutrient supplementation (MMS) in place of the more common iron-folate supplements given in pregnancy in low-income countries may slightly increase birth weight, but its impact on neonatal mortality and other outcomes is unclear. More sustainable alternative approaches deserve greater research attention.

Errata

From the December 2009 supplement, Multiple Micronutrient Supplementation During Pregnancy in Developing Country Settings, the following figures should have been published as follows: In, “Multiple micronutrient supplementation during pregnancy in low-income countries: A meta-analysis of effects on stillbirths and on early and late neonatal mortality” by Carine Ronsmans, David J. Fisher, Clive Osmond, Barrie M. Margetts, Caroline H. D. Fall, and the Maternal Micronutrient Supplementation Study Group (MMSSG) Page 552 — Figure 5. Random effects model forest plots for effects of multiple micronutrient supplementation on early neonatal deaths. CI, confidence interval; ES, effect size. In, “Multiple micronutrient supplementation during pregnancy in developing-country settings: Policy and program implications of the results of a meta-analysis” by Roger Shrimpton, Sandra L. Huffman, Elizabeth R. Zehner, Ian Darnton-Hill, and Nita Dalmiya Page 562 — Figure 1. Average adherence to supplementation in the meta-analysis studies In, Special Issue: Research from the Institute of Nutrition of Central America and Panama (INCAP) 1949–1999, Volume 31, Number 1: The introductory article by Nevin S. Scrimshaw entitled “The Origin and Development of INCAP” inadvertently omitted some key words on page 6, second column, first paragraph. It was Fernando Viteri, who after an outstanding research career at INCAP, “… became the head of food and nutrition at PAHO/WHO, Washington and later a full professor at the University of California, Berkeley and Scientist at the Children's Hospital Oakland Research Institute.”

Challenges associated with hypertensive disease during pregnancy in low-income countries

Objective To assess the challenges associated with the diagnosis, management, and prevention of hypertensive disease during pregnancy in low-income countries, following the success of the Magpie Trial. Methods Descriptive review of the literature from 1990 to 2009 on the diagnosis, management, and prevention of hypertensive disease in pregnancy. Results In the absence of credible measures to predict and prevent hypertension in pregnancy, diagnosis and treatment remain the only viable options, although they are still associated with important challenges in low-income countries. Despite the presence of high-quality evidence that magnesium sulfate is safe and effective at preventing and treating eclampsia, its use is extremely limited in many low-income countries. Conclusion There is a need for cheap and reliable tools with which to address the diagnostic, preventive, and management challenges associated with hypertensive disease during pregnancy in low-income countries. It is recommended that such countries incorporate magnesium sulfate protocols into their national health and/or practice policies.

Multiple Micronutrient Supplementation during Pregnancy in Low-Income Countries: Review of Methods and Characteristics of Studies Included in the Meta-Analyses

This paper reports on the methods and characteristics of 12 studies from developing countries included in a meta-analysis of the impact of antenatal supplements of multiple micronutrients compared with iron-folic acid on micronutrient status, maternal nutritional status, birth outcomes, and neonatal survival.

Severe anemia in pregnancy in rural Ghana: a case–control study of causes and management

Various factors contribute to severe anemia in pregnancy in low-income countries. This study assesses which of these are of importance in rural Ghana, and evaluates management. Prospective case-control study in two (sub)district hospitals in rural Ghana among 175 severely anemic pregnant women (Hb < 8.0 g/dl), receiving a comprehensive treatment package; and 152 non-anemic pregnant women (Hb > or = 10.9 g/dl), giving birth at the study hospitals, matched for age and parity. Evaluated characteristics were need for treatment for urinary tract infection and schistosomiasis; sickle cell and HIV status; antenatal care characteristics; and Hb increase after treatment. Statistical analysis included Chi square test and general linear modeling. Associated with severe anemia were multiple pregnancy (OR 8.9; 95%CI 1.1-71.0), urinary tract infection (OR 6.2; 95%CI 3.5-11.0), residence outside study (sub)district (OR 2.7; 95%CI 1.7-4.3), body mass index < 20.0 (OR 2.0; 95%CI 1.2-3.4), and less than 4 antenatal clinic visits (OR 1.9; 95%CI 1.2-3.0). No association was found with sickle cell or HIV status, schistosomiasis treatment, blood loss in pregnancy, or gestational age at antenatal care registration. After treatment, mean Hb in the severe anemia group increased by 3.2 g/dl, significantly more than in the control group (0.2 g/dl; p<0.001). Modeling showed that the number of antenatal visits and the lowest Hb together explained approximately 25% of the variability in Hb prior to childbirth among women with severe anemia. Treatable causes contribute considerably to severe anemia in pregnancy in low-income countries. Even with limited resources, a substantial increase of Hb can be achieved.