Pius Okong

Obstetric care in low-resource settings: what who and how to overcome challenges to scale up?

Each year, approximately 2 million babies die because of complications of childbirth, primarily in settings where effective care at birth, particularly prompt cesarean delivery, is unavailable.

Mode of infant feeding and HIV infection in children in a program for prevention of mother-to-child transmission in Uganda

Objective:To evaluate the impact of different modalities of infant feeding on HIV transmission in children in a prevention of mother-to-child transmission (PMTCT) program in an urban hospital in Uganda. Methods:HIV-infected pregnant women in the PMTCT program at St Francis Hospital Nsambya, Kampala were offered the chance to participate in the study. Short-course antiretroviral regimens were provided and formula feeding offered free of charge for women choosing not to breastfeed. Mother–infant pairs were followed until 6 months postpartum. HIV status in children was assessed at week 6 and month 6. For the analyses, mother–infant pairs were classified into three groups according to the mode of infant feeding: exclusive formula feeding (EFF), exclusive breastfeeding (EBF) and mixed feeding (MF). Results:A total of 306 children were enrolled. Transmission rates were 8.9% at week 6 (3.4% in the EFF group, 11.2% in the EBF group, 17.1% in the MF group) and 12.0% at month 6 (3.7% in the EFF group, 16.0% in the EBF group, and 20.4% in the MF group). The EBF and MF groups were associated with a significantly higher risk of HIV transmission than the EFF group. No significant risk difference was observed between the EBF and the MF groups. Conclusions:HIV transmission rates were significantly lower in formula-fed infants in comparison with both exclusively breastfed and mixed-fed infants. Transmission through breastfeeding seems to occur mainly in the first weeks after delivery.

Audit of severe maternal morbidity in Uganda – implications for quality of obstetric care

Background. For every maternal death, there are probably 100 or more morbidities, but the quality of health care for these women who survive has rarely been an issue. The purpose of this study is to explore audit of severe obstetric morbidity and the concept of near miss in four referral hospitals in Uganda. Methods. This was an exploratory systematic enquiry into the care of a subset of women with severe morbidity designated as near miss cases by organ failure or dysfunction. Patient factors and environmental factors were also explored. Data were abstracted from clinical records and from interviews with patients, relatives, and health workers. Results. Records of 685 women with severe maternal morbidity were examined and 229 cases fulfilled the criteria for near miss cases. Obstetric hemorrhage, rupture of the uterus, puerperal sepsis, and abortion complications were the major conditions leading to the near miss state in more than three quarters of the patients. Nearly half the cases were at home when the events occurred. More than half the cases delayed to seek care, because the patients were unwilling, or relatives were not helpful. Similar proportion also experienced substandard care in the hospitals. Conclusions. A systemic analysis found substandard care and records, and patient‐related factors in more than half the cases of severe maternal morbidity. Audit of near miss cases might offer a non‐threatening stimulus for improving the quality of obstetric care.

The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: A randomized, controlled trial

Aim: To elucidate the impact of bathing on the prevalence of hypothermia among newborn babies exposed to the skin‐to‐skin (STS) care technique before and after bathing. Methods: Non‐asphyxiated newborns after vaginal delivery (n=249) in a Ugandan referral hospital were consecutively enrolled and randomized either to bathing at 60 min postpartum (n=126) or no bathing (n=123). All mothers practised skin‐to‐skin care of their newborns. Four rectal and tympanic registrations of newborn temperatures were carried out in both groups directly after drying at birth, and at 60, 70 and 90 min postpartum. Results: Bathing of newborns in the first hour after delivery resulted in a significantly increased prevalence of hypothermia, defined as temperature <36.5°C, at 70 and at 90 min postpartum despite the use of warmed water and the application of the STS method. There was no neonatal mortality. Aside from the bathing procedure, no background factor potentially predisposing the newborns to hypothermia was identified.

Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial

BackgroundThe third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60–70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care.ObjectiveThe primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package.MethodsA hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period.ManagementOverall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field.Expected outcomesThe main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field.Trial RegistrationACTRN12608000434392

The FIGO Save the Mothers Initiative: the Uganda-Canada collaboration.

In 1998, the ob/gyn associations of Uganda and Canada launched, under the umbrella of the FIGO Save the Mothers Initiative, a district‐wide intervention which aimed to increase the availability and utilization of emergency obstetric care (EmOC) services in a rural district of Uganda. The article describes the experience of two professional ob/gyn associations in the development, implementation, monitoring and evaluation of the project. Preliminary results after 24 months of intervention indicate important gains in the capacity of health professionals to deliver EmOC, the availability of emergency transportation services and met need for EmOC.

Effects of Nevirapine, Compared with Lamivudine, on Lipids and Lipoproteins in HIV-1—Uninfected Newborns: The Stopping Infection from Mother-to-Child via Breast-Feeding in Africa Lipid Substudy

BACKGROUND The objective of the present study was to assess whether the high-density lipoprotein cholesterol (HDL-c)-increasing effect of nevirapine (NVP), as observed in human immunodeficiency virus type 1 (HIV-1)-infected subjects, at least in part may relate to intrinsic properties of NVP. METHODS At 2, 6, and 12 weeks after birth, complete lipid profiles as well as plasma apolipoproteins levels were assessed in 80 HIV-uninfected newborns, half of whom received NVP and half lamivudine (3TC), respectively. Newborns were randomly selected from a randomized trial in which NVP or 3TC had been administered to HIV-uninfected infants born to HIV-infected mothers to try and prevent HIV-1 transmission from occurring during breast-feeding. RESULTS After 6 weeks of therapy, the expected physiological decline in HDL-c levels in the newborns was attenuated in infants treated with NVP, compared with levels in those treated with 3TC. Apolipoprotein A-I (apoA-I) levels were higher at all time points in the NVP arm than they were in the 3TC arm (P=.02), reaching peak levels at 6 weeks. The difference in HDL-c was no longer significant at 12 weeks. CONCLUSIONS apoA-I levels and HDL-c were elevated in HIV-1-uninfected newborns receiving NVP, compared with those receiving 3TC. These data support that NVP may indeed have intrinsic apoA-I and HDL-c elevating properties in humans.

A randomized controlled safety and acceptability trial of dextrin sulphate vaginal microbicide gel in sexually active women in Uganda.

Objective:To assess the safety of dextrin sulphate (DS) gel compared to placebo gel in terms of local and systemic adverse events, and to determine the acceptability of dextrin sulphate gel. Design:A 4-week randomized trial of DS intra-vaginal gel, partially blinded, with placebo and observation control arms. Participants were randomized to use DS gel twice daily, placebo gel twice daily, DS gel pre-sex, or into an observation only arm. Methods:Sexually active women were recruited from post natal and HIV clinics at Nsambya Hospital, Kampala, Uganda. Screening, enrolment and follow-up visits took place every 1 or 2 weeks over an 8-week period and consisted of questionnaire interviews, colposcopy examinations, sexually transmitted infection screen and routine laboratory testing. Results:Out of a total of 172 women screened, 109 were randomized to use DS gel twice daily (65 women), placebo gel twice daily (15 women), DS gel pre-sex (nine women) or into an observation only arm (20 women). Two individuals had abnormal colposcopy findings in the DS twice daily gel use arm. Vaginal bleeding was reported as frequently by participants in the active gel arm as by participants in the placebo and observation only arms. No clinically significant difference was observed between arms in terms of vaginal flora, Candida, haemoglobin, white cell count, platelets, thrombin time, activated partial thromboplastin time, creatinine and aspartate aminotransferase results after 4 weeks of gel use. DS gel appeared to be acceptable to over 95% of the users. Conclusions:Results show a satisfactory safety and acceptability profile of dextrin sulphate gel.

Post-abortion endometritis–myometritis and HIV infection

The objective was to explore if HIV-1 infection is a risk factor for post-abortion endometritis–myometritis (PAEM) in an urban hospital in Kampala, Uganda. HIV-1 seroprevalence in women with and without post-abortion infection was established using two standard enzyme-linked immunosorbent assays. Fifty-two women with PAEM and 106 without PAEM infection were recruited. The HIV-1 seroprevalence was 17 (32.7%) among women with PAEM and 38 (36.5%) among women without post-abortion infection. HIV infection was not found to correlate with the risk for PAEM. HIV-1 seroprevalence in both groups was double that among antenatal clients in the same hospital, 14.6% in 1997. Life-threatening infections such as septicaemia, peritonitis and pelvic abscesses were observed among 12 cases (23%). HIV-1 infection was not shown to be a risk factor for PAEM, but women with abortions with and without PAEM have a higher prevalence of HIV-1 than antenatal clients.

Maternal HIV status and infant feeding practices among Ugandan women

To describe the infant feeding practices in the general population in Uganda, and to assess the impact of maternal HIV status on these practices, a questionnaire was administered to women attending the follow-up clinics for child vaccination. Among the mothers who were still breastfeeding at the time of interview (N=838), 61.4% of the HIV-infected women had planned to breastfeed for a maximum of 6 months, compared with 12.1% of the HIV-uninfected women (p<0.001). Among the women who were not breastfeeding at the time of interview (N=108), 82.5% of the HIV-infected women had stopped breastfeeding within 3 months, compared with 23.5% of the HIV-uninfected women (p<0.001). Only 2.1% of HIV-infected women seen up to 14 weeks postnatally practised mixed feeding, compared with 23.6% of HIV-uninfected women (p<0.001). After 6 months, however, 30% of the HIV-infected women and 55% of the HIV-uninfected mothers were using mixed feeding, with no significant differences. Programmes for the prevention of mother-to-child transmission of HIV should re-enforce counselling activities to address the issue of early weaning by HIV-infected women, and to support safe breastfeeding up to 6 months.