Godfrey Mugyenyi

The Social Legacy of AIDS: Fertility Aspirations Among HIV-Affected Women in Uganda

OBJECTIVES We investigated the impact of HIV status on fertility desires in Uganda. METHODS We surveyed 1594 women aged 18 to 49 years visiting outpatient services at Mbarara Regional Hospital, from May through August 2010. Of these, 59.7% were HIV-positive; 96.4% of HIV-positive women were using antiretroviral therapy (ART). We used logistic regression models to examine relationships between HIV status and fertility desires, marital status, household structure, educational attainment, and household income. RESULTS Among married women, HIV-positive status was significantly associated with a lower likelihood of desiring more children (27.7% vs 56.4% of HIV-negative women; χ(2) = 39.97; P < .001). The difference remained highly significant net of age, parity, son parity, foster children, education, or household income. HIV-positive women were more likely to be poor, unmarried, single heads of household, in second marriages (if married), living with an HIV-positive spouse, and supporting foster children. CONCLUSIONS We found a strong association between positive HIV status and lower fertility aspirations among married women in Uganda, irrespective of ART status. Although the increasing availability of ART is a tremendous public health achievement, women affected by HIV have numerous continuing social needs.

Transfusion Medicine in Sub-Saharan Africa: Conference Summary.

In November 2014, a 3-day conference devoted to transfusion medicine in sub-Saharan Africa was held in Kampala, Uganda. Faculty from academic institutions in Uganda provided a broad overview of issues pertinent to transfusion medicine in Africa. The conference consisted of lectures, demonstrations, and discussions followed by 5 small group workshops held at the Uganda Blood Transfusion Service Laboratories, the Ugandan Cancer Institute, and the Mulago National Referral Hospital. Highlighted topics included the challenges posed by increasing clinical demands for blood, the need for better patient identification at the time of transfusion, inadequate application of the antiglobulin reagent during pretransfusion testing, concern regarding proper recognition and evaluation of transfusion reactions, the expanded role for nurse leadership as a means to improve patient outcomes, and the need for an epidemiologic map of blood usage in Africa. Specialty areas of focus included the potential for broader application of transcranial Doppler and hydroxyurea therapy in sickle cell disease, African-specific guidelines for transfusion support of cancer patients, the challenges of transfusion support in trauma, and the importance of African-centered clinical research in pediatric and obstetric transfusion medicine. The course concluded by summarizing the benefits derived from an organized quality program that extended from the donor to the recipient. As an educational tool, the slide-audio presentation of the lectures will be made freely available at the International Society of Blood Transfusion Academy Web site: http://www.isbtweb.org/academy/.

Measuring Post-Partum Haemorrhage in Low-Resource Settings: The Diagnostic Validity of Weighed Blood Loss versus Quantitative Changes in Hemoglobin.

Background Accurate estimation of blood loss is central to prompt diagnosis and management of post-partum hemorrhage (PPH), which remains a leading cause of maternal mortality in low-resource countries. In such settings, blood loss is often estimated visually and subjectively by attending health workers, due to inconsistent availability of laboratory infrastructure. We evaluated the diagnostic accuracy of weighed blood loss (WBL) versus changes in peri-partum hemoglobin to detect PPH. Methods Data from this analysis were collected as part of a randomized controlled trial comparing oxytocin with misoprostol for PPH (NCT01866241). Blood samples for complete blood count were drawn on admission and again prior to hospital discharge or before blood transfusion. During delivery, women were placed on drapes and had pre-weighed sanitary towels placed around their perineum. Blood was then drained into a calibrated container and the sanitary towels were added to estimate WBL, where each gram of blood was estimated as a milliliter. Sensitivity, specificity, negative and positive predictive values (PPVs) were calculated at various blood volume loss and time combinations, and we fit receiver-operator curves using blood loss at 1, 2, and 24 hours compared to a reference standard of haemoglobin decrease of >10%. Results A total of 1,140 women were enrolled in the study, of whom 258 (22.6%) developed PPH, defined as a haemoglobin drop >10%, and 262 (23.0%) had WBL ≥500mL. WBL generally had a poor sensitivity for detection of PPH (<75% for most volume-time combinations). In contrast, the specificity of WBL was high with blood loss ≥ 500mL at 1h and ≥750mL at any time points excluding PPH in over 97% of women. As such, WBL has a high PPV (>85%) in high prevalence settings when WBL exceeds 750mL. Conclusion WBL has poor sensitivity but high specificity compared to laboratory-based methods of PPH diagnosis. These characteristics correspond to a high PPV in areas with high PPH prevalence. Although WBL is not useful for excluding PPH, this low-cost, simple and reproducible method is promising as a reasonable method to identify significant PPH in such settings where quantifiable red cell indices are unavailable.

Occurrence of anti-D alloantibodies among pregnant women in Kasese District, Western Uganda.

Objectives This study was undertaken to determine the distribution of ABO/RhD (rhesus D antigen) blood phenotypes, prevalence of anti-D alloantibodies, and the risk factors for alloimmunization among pregnant women in Kasese District, Western Uganda. Materials and methods Ethylenediamine tetraacetic acid-containing plasma samples and serum samples were taken from pregnant women attending the antenatal clinic. The blood groups were identified using the microplate grouping method, while the presence of anti-D alloantibodies was detected by the indirect antiglobulin test (IAT). Data were also collected from the pregnant women on the risk factors associated with anti-D alloantibody formation. Results Among the 726 participants, the blood group distribution was as follows: O: 356 (49.%); A: 190 (26.%); B: 152 (21%); and AB: 28 (4%). A total of 28 (3.86%) pregnant women were RhD negative. Anti-D alloantibodies were detected in 88 (12.1%) of the participants; and of these, 13 (14.8%) were RhD negative. Statistically significant risk factors for anti-D alloimmunization included miscarriage, stillbirth, and postpartum hemorrhage. Conclusion Blood group O was the most common among the pregnant women in this study and the prevalence of Rh negativity was 3.8%. The frequency of anti-D alloimmunization among pregnant women in Kasese District was 12.12%, with 85.5% of these being RhD positive. Risk factors such as a history of stillbirths, miscarriages, and incidence of postpartum hemorrhage were significantly associated with anti-D alloimmunization. There is a need to routinely carry out antenatal blood grouping and IAT screening on pregnant women in Uganda to detect anti-D alloimmunization. Given the high prevalence of anti-D alloantibody formation among RhD-positive women, we recommend additional research studies on the role of autoimmunity among antigen-positive women, as well as the occurrence of RhD variants plus their implications on hemolytic disease of the fetus and newborn, in Uganda.

Prevalence of Ethanol Use Among Pregnant Women in Southwestern Uganda.

Introduction The prevalence of ethanol use in many Sub-Saharan African countries is high, but little research exists on use during pregnancy. The objective of this study was to assess the prevalence and predictors of ethanol use among pregnant women in Southwestern Uganda. Methods This descriptive, cross-sectional study was conducted in the maternity ward at Mbarara Regional Referral Hospital (MRRH). All pregnant women giving birth at MRRH between September 23, 2013 and November 23, 2013 were eligible for enrollment. The primary outcome was the proportion of women with ethanol use during pregnancy as determined by self-report. Secondary outcomes included the proportion with positive fatty acid ethyl ester (FAEE) results (indicating ethanol use) and positive TWEAK questionnaire results (indicating possible problem drinking). Predictors of ethanol use were assessed and stratified by patterns of ethanol intake. Results Overall, 505 mother–child dyads enrolled in the study. The proportion of women who reported any ethanol use during pregnancy was 16 % (n = 81, 95 % CI 13–19 %) and the prevalence of heavy drinking 6.3 % (n = 32, 95 % CI 3.8–7.9 %). The strongest predictor of use during pregnancy was pre-pregnancy use, with maternal education as a protective factor. Few neonates (n = 11, 2 %) tested positive for FAEE > 2.00 nmol/g in meconium. The TWEAK questionnaire captured 75 % of women who reported moderate/heavy drinking and aligned more with self-reported ethanol use than meconium results. Conclusions The substantial prevalence and clear predictors of ethanol use suggest that legislative action and educational interventions to increase awareness of potential harms could assist in efforts to decrease use during pregnancy in Southwestern Uganda.

Sublingual misoprostol versus intramuscular oxytocin for prevention of post-partum haemorrhage in Uganda: a randomised, controlled, non-inferiority trial

Abstract Background Postpartum haemorrhage is a leading cause of maternal death in sub-Saharan Africa. Although WHO recommends use of oxytocin for prevention of postpartum haemorrhage, misoprostol is increasingly used owing to advantages in shelf life, ease of use, storage, and potential for sublingual administration. We assessed the comparative efficacy of oxytocin and sublingual misoprostol for prevention of postpartum haemorrhage during labour. Methods We did a double-dummy, non-inferiority, randomised, controlled trial from September 2012, to September 2013, at Mbarara Regional Referral Hospital in Uganda. We randomly assigned (1:1) women to receive misoprostol 600 μg sublingually or oxytocin 10 IU along with matching placebos. Patients and investigators giving treatment were both masked to treatment assignment. The primary outcome was postpartum haemorrhage (measured blood loss ≥500 mL within 24 h postpartum) with a non-inferiority margin of 6%. Secondary outcomes included measured blood loss of more than 1000 mL, mean blood loss at 1 h, 2 h, and 24 h postpartum, death, requirement of blood transfusion, haemoglobin change, and use of additional uterotonic drugs. We did the analyses in the intention-to-treat population. The trial was registered with ClinicalTrials.gov, number NCT01866241. Findings We included 1140 women: 570 (50%) assigned to misoprostol and 570 (50%) assigned to oxycotin. The primary outcome occurred in 163 (28·6%) participants in the misoprostol group versus 99 (17·4%) participants in the oxytocin group (relative risk [RR] 1·64, 95% CI 1·32–2·05, p vs 168 [26·5%]; RR 1·91, 95% CI 1·65–2·21, p vs 12 [2·1%]; RR 4·42, 95% CI 2·39–8·18, p Interpretation Misoprostol 600 μg is not non-inferior to oxytocin 10 IU for prevention of postpartum haemorrhage in active management of labour, supporting the preferential use of oxytocin when feasible. However—although our study was not powered to assess differences—similar rates of severe postpartum haemorrhage, haemoglobin change, and other clinically significant secondary outcomes seem to suggest that sublingual misoprostol might have a role for prevention of severe postpartum haemorrhage and other complications of postpartum haemorrhage in settings where oxytocin use is not feasible. Further research should focus on clarifying if and which subpopulations benefit most from use of oxytocin. Funding Father Bash Foundation and Divine Mercy Hospital.

Bridging the data gap in global health: an electronic surgical outcomes database at Mbarara Regional Referral Hospital, Uganda

Abstract Background Annually, an estimated 17 million lives are lost from conditions requiring surgical care and at least 77·2 million disability-adjusted life-years could be averted through provision of basic surgical services. Despite the staggering burden of surgical disease, there are scarce data available to track current capacity, volume, epidemiology, outcomes, and quality of surgical care delivery in low-income and middle-income countries. We aimed to organise the hospital record system into a high-quality and high-fidelity searchable database that can be used to measure and guide expansion and provision of quality care at Mbarara Regional Referral Hospital (MRRH) in western Uganda. Methods Initiated in 2013, the Surgical Services QUality Assessment Database (SQUAD) arose from a shared commitment to improving surgical quality and capacity through a collaboration between MRRH and Massachusetts General Hospital. SQUAD systematically enrols and collects data on all surgical patients admitted to MRRH. Data are extracted from patient charts and admission, discharge, and operation logbooks by trained clerks—a process overseen by a data manager/statistician. Data variables are grouped into patient demographics, disease characteristics, cadre of clinicians, interventions, outcomes, and time. Data access and use is supervised by a committee of representatives. Findings To date, SQUAD contains more than 49 000 patient records in a searchable electronic database. Quality assurance reports have been produced for internal use at MRRH, and in-hospital initiatives have been made in response to findings. SQUAD was prospectively validated in 2016, and retrospective validation studies are currently underway. Interpretation Ongoing challenges include transitioning data capture methods from chart and log book review to a point-of-care electronic medical register and record system, while maintaining data entry. A future objective is the dissemination of clinical outcome reports through peer reviewed publications by authors from the collaborating institutions. Funding GE Foundation, Milton Foundation, Kletjian Foundation, and MGH Department of Anesthesia, Critical Care and Pain Medicine.

Rhesus blood group haplotype frequencies among blood donors in southwestern Uganda

Aim/objective The study was undertaken to determine the Rhesus blood group system and Rhesus haplotype frequencies among blood donors at Mbarara Regional Blood Bank. Materials and methods We included ethylene-diaminetetra-acetic acid-containing plasma samples and serum samples from recruited consented blood donors. The Rh blood group system and the Rh haplotypes was established by the incubation of appropriate antisera (anti-D, anti-E, anti-C, anti-e, and anti-c) and cells at a temperature of 24°C in microplates for 1 hour and the reaction was read by gentle shaking and examining for agglutinations. Donors were asked to fill in questionnaires, after we obtained the informed consent, to assess their demographics. Results Among the 386 participants, 233 were males (60%) and 153 (40%) females. The Rh negative blood group percentage was 3.8%, while the Rh haplotype frequencies were as follows: Dce dce 68.1%, dce dce 2.8%, CD. dce 13%, cDE dce 12.4%, DC. DcE 1.6%, DcE DcE 1%, dC. dce 0.8%, and DcE DC. 0.3%. Conclusion Given this frequency, a high prevalence of anti-D alloantibody formation among those transfused is possible and could cause diverse effects, especially in the Rh D positive women. We recommend additional research studies on the role of autoimmunity to the transfused on the occurrence of Rh D variants plus their implications on hemolytic disease of the fetus and newborn in Uganda. This study recommends that the blood bank includes Rhesus haplotyping in its protocols and that the finding be disseminated to donors and blood users.

Measuring Post-Partum Hemorrhage In Low-Resource Settings: The Diagnostic Validity Of Weighted Blood Loss Versus Quantitative Changes In Hemoglobin

Accurate estimation of blood loss is central to prompt diagnosis and management of postpartum hemorrhage (PPH), which remains a leading cause of maternal mortality in lowresource countries. In such settings, blood loss is often estimated visually and subjectively by attending health workers, due to inconsistent availability of laboratory infrastructure. We evaluated the diagnostic accuracy of weighed blood loss (WBL) versus changes in peri-partum hemoglobin to detect PPH.