Contraception and post abortion services: qualitative analysis of users' perspectives and experiences following Zika epidemic in Honduras.

BACKGROUND: Zika virus (ZIKV) infection during pregnancy has severe consequences on the new-born. The World Health Organization declared the Zika outbreak to be a Public Health Emergency of International Concern (PHEIC) in 2016. Health facilities in the regions most affected by Zika lacked the capacity to respond to the increased demand for contraception. The objectives were to explore healthcare users' perceptions regarding contraception, Zika prevention during pregnancy and post-abortion care (PAC) services in the context of a Zika outbreak in Tegucigalpa, Honduras, and to follow these services over time. METHODS: This study was part of a broader implementation research study. We used qualitative research consistent with grounded theory approach. Semi-structured interviews and focus groups were performed with women and their partners who used contraceptive services or received PAC services. Data were collected in two stages from December 2017 to July 2018. Themes explored included contraception, Zika and PAC services. RESULTS: Participants had positive attitude towards the use of contraceptive methods and demanded more information on safety, efficacy and on side effects. Health care services were inconsistent in the provision of information on Zika and contraception services. ZIKV vector transmission was known but fewer participants were aware of risk of sexual transmission of Zika. Barriers to access healthcare services included contraceptive and PAC services included distance to healthcare facilities, disorganized admission process, long waiting times and out-of-pocket expenditure to purchase medicines. Furthermore, poor quality, mistreatment and abuse of women seeking PAC was prevalent. Some positive changes were noted over time, such as improvements in infrastructure including improved privacy and cleanliness, removal of fees, requisite to bring clean water to hospital. CONCLUSIONS: Our results highlight the challenges and areas for improvement in policy and practice related to contraceptive services and PAC in the context of ZIKV infection. Public policies to prevent epidemics should focus more on providing proper sanitation; removing barriers to access and use of effective contraception as human rights priority. Zika epidemic has highlighted weaknesses in health systems that obstruct access to and use of sexual and reproductive health services. The study results call for increased efforts to improve access, especially for women of low socio-economic status and intervene at different levels to eradicate discrimination and improve equity in the provision of health care. Qualitative methods can capture the community perspectives and can provide useful information to develop interventions to improve services.

Trypanosoma cruzi loop-mediated isothermal amplification (Trypanosoma cruzi Loopamp) kit for detection of congenital, acute and Chagas disease reactivation.

A Trypanosoma cruzi Loopamp kit was recently developed as a ready-to-use diagnostic method requiring minimal laboratory facilities. We evaluated its diagnostic accuracy for detection of acute Chagas disease (CD) in different epidemiological and clinical scenarios. In this retrospective study, a convenience series of clinical samples (venous blood treated with EDTA or different stabilizer agents, heel-prick blood in filter paper or cerebrospinal fluid samples (CSF)) from 30 infants born to seropositive mothers (13 with congenital CD and 17 noninfected), four recipients of organs from CD donors, six orally-infected cases after consumption of contaminated guava juice and six CD patients coinfected with HIV at risk of CD reactivation (N = 46 patients, 46 blood samples and 1 CSF sample) were tested by T. cruzi Loopamp kit (Tc LAMP) and standardized quantitative real-time PCR (qPCR). T. cruzi Loopamp accuracy was estimated using the case definition in the different groups as a reference. Cohen's kappa coefficient (κ) was applied to measure the agreement between Tc LAMP (index test) and qPCR (reference test). Sensitivity and specificity of T. cruzi Loopamp kit in blood samples from the pooled clinical groups was 93% (95% CI: 77-99) and 100% (95% CI: 80-100) respectively. The agreement between Tc LAMP and qPCR was almost perfect (κ = 0.92, 95% CI: 0.62-1.00). The T. cruzi Loopamp kit was sensitive and specific for detection of T. cruzi infection. It was carried out from DNA extracted from peripheral blood samples (via frozen EDTA blood, guanidine hydrochloride-EDTA blood, DNAgard blood and dried blood spots), as well as in CSF specimens infected with TcI or TcII/V/VI parasite populations. The T. cruzi Loopamp kit appears potentially useful for rapid detection of T. cruzi infection in congenital, acute and CD reactivation due to HIV infection.

Short-course Benznidazole treatment to reduce Trypanosoma cruzi parasitic load in women of reproductive age (BETTY): a non-inferiority randomized controlled trial study protocol.

BACKGROUND: Retrospective observational studies suggest that transmission of Trypanosoma cruzi does not occur in treated women when pregnant later in life. The level of parasitemia is a known risk factor for congenital transmission. Benznidazole (BZN) is the drug of choice for preconceptional treatment to reduce parasitic load. The fear of treatment-related side effects limits the implementation of the Argentine guideline recommending BZN 60d/300 mg (or equivalent) treatment of T. cruzi seropositive women during the postpartum period to prevent transmission in a future pregnancy. A short and low dose BZN treatment might reduce major side effects and increase compliance, but its efficacy to reduce T. cruzi parasitic load compared to the standard 60d/300 mg course is not yet established. Clinical trials testing alternative BZN courses among women of reproductive age are urgently needed. METHODS AND DESIGN: We are proposing to perform a double-blinded, non-inferiority randomized controlled trial comparing a short low dose 30-day treatment with BZN 150 mg/day (30d/150 mg) vs. BZN 60d/300 mg. We will recruit not previously treated T. cruzi seropositive women with a live birth during the postpartum period in Argentina, randomize them at 6 months postpartum, and follow them up with the following specific aims: Specific aim 1: to measure the effect of BZN 30d/150 mg compared to 60d/300 mg preconceptional treatment on parasitic load measured by the frequency of positive Polymerase Chain Reaction (PCR) (primary outcome) and by real-time quantitative PCR (qPCR), immediately and 10 months after treatment. Specific aim 2: to measure the frequency of serious adverse events and/or any adverse event leading to treatment interruption. TRIAL REGISTRATION: ClinicalTrials.gov . Identifier: NCT03672487 . Registered 14 September 2018.

Phylogenetic Analysis of Trypanosoma cruzi from Pregnant Women and Newborns from Argentina, Honduras, and Mexico Suggests an Association of Parasite Haplotypes with Congenital Transmission of the Parasite.

Trypanosoma cruzi, the causative agent of Chagas disease, exhibits a high genetic variability and has been classified into six discrete typing units (DTUs) named TcI through TcVI. This genetic diversity is believed to be associated with clinical characteristics and outcomes, but evidence supporting such associations has been limited. Herein, we performed a phylogenetic analysis of T. cruzi sequences of the mini-exon intergenic region obtained from a large cohort of pregnant women and newborns from Argentina, Honduras, and Mexico, to assess parasite genetic diversity and possible associations with congenital transmission. Analysis of 105 samples (including five paired samples) from maternal and umbilical cord blood indicated that T. cruzi DTU distribution was similar among pregnant women and newborns from these three countries, with a high frequency of TcII-TcV-TcVI DTUs, including mixed infections with TcI. However, phylogenetic analysis revealed that although the same parasite haplotypes circulated in these three countries, they were present at different frequencies, leading to significant geographic differences. Of importance, a strong association was observed between parasite haplotypes and congenital infection of newborns. Thus, the identification of parasite haplotypes in pregnant women, but not of parasite DTUs, may help predict congenital transmission of T. cruzi.

Text message interventions for follow up of infants born to mothers positive for Chagas disease in Tucumán, Argentina: a feasibility study.

BACKGROUND: Diagnosis of congenital Chagas disease occurs at 9 months of age, making effective treatment challenging due to loss to follow-up. Mobile health (mHealth) has been utilized to improve communication and treatment adherence in many chronic diseases, although no studies of mHealth in Trypanosoma cruzi-infected individuals have been conducted. Text message interventions, a subset of mHealth, has shown to improve appointment attendance and is relatively simple to set up, thus making it an ideal mechanism to facilitate communication with individuals in low-resource settings. OBJECTIVE: The aim of this study is to understand the acceptability, utilization, and barriers of an SMS-based appointment reminder to confirm a post-partum home visit to women in Tucumán, Argentina and whether these factors differ in urban and rural populations. METHODS: Women that tested positive for Chagas disease were invited to receive SMS reminders of their follow-up 4-week postpartum home visit. Demographic information and SMS contact preferences were collected at hospital discharge, and variables on mHealth utilization and barriers were recorded at follow-up. RESULTS: 77 (70.6%) of women possessed a cell phone for personal use. All eligible women owned phones compatible with SMS messages. The appointment reminder SMS was widely accepted with 64/72 (88.9%) enrolled women receiving the SMS message and 58/64 (90.6%) replying. Ninety-two percent of women stated that the text message was a useful reminder for the follow-up home visit. Women living in rural areas were less likely to own a cell phone for personal use and were significantly less likely to have internet access on their phone than women living in urban areas (RR 0.30, 95% CI 0.10-0.89). Furthermore, women from rural areas faced barriers to mHealth uptake such as change of phone number and response to messages from the hospital team at higher rates than women from urban areas, although these differences were not statistically significant. CONCLUSIONS: There is generally widespread acceptance and utilization of mHealth among this group of women with access to cell phones. However, there are still many barriers to overcome before mHealth interventions attain complete penetration in a population, most notably the issue of cell phone for personal use.

Adverse maternal and perinatal outcomes in adolescent pregnancies: The Global Network's Maternal Newborn Health Registry study.

BACKGROUND: Adolescent girls between 15 and 19 years give birth to around 16 million babies each year, around 11% of births worldwide. We sought to determine whether adolescent mothers are at higher risk of maternal and perinatal adverse outcomes compared with mothers aged 20-24 years in a prospective, population-based observational study of newborn outcomes in low resource settings. METHODS: We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in six low-middle income countries (Kenya, Zambia, India, Pakistan, Guatemala and Argentina). The study population for this analysis was restricted to women aged 24 years or less, who gave birth to infants of at least 20 weeks' gestation and 500g or more. We compared adverse pregnancy maternal and perinatal outcomes among pregnant adolescents 15-19 years, <15 years, and adults 20-24 years. RESULTS: A total of 269,273 women were enrolled from January 2010 to December 2013. Of all pregnancies 11.9% (32,097/269,273) were in adolescents 15-19 years, while 0.14% (370/269,273) occurred among girls <15 years. Pregnancy among adolescents 15-19 years ranged from 2% in Pakistan to 26% in Argentina, and adolescent pregnancies <15 year were only observed in sub-Saharan Africa and Latin America. Compared to adults, adolescents did not show increased risk of maternal adverse outcomes. Risks of preterm birth and LBW were significantly higher among both early and older adolescents, with the highest risks observed in the <15 years group. Neonatal and perinatal mortality followed a similar trend in sub-Saharan Africa and Latin America, with the highest risk in early adolescents, although the differences in this age group were not significant. However, in South Asia the risks of neonatal and perinatal death were not different among adolescents 15-19 years compared to adults. CONCLUSIONS: This study suggests that pregnancy among adolescents is not associated with worse maternal outcomes, but is associated with worse perinatal outcomes, particularly in younger adolescents. However, this may not be the case in regions like South Asia where there are decreasing rates of adolescent pregnancies, concentrated among older adolescents. The increased risks observed among adolescents seems more likely to be associated with biological immaturity, than with socio-economic factors, inadequate antenatal or delivery care. TRIAL REGISTRATION NUMBER: NCT01073475.

A multifaceted intervention to increase prophylactic oxytocin use during the third stage of labor and to reduce routine episiotomies in Nicaragua.

OBJECTIVE: To assess the effect of a multifaceted intervention among skilled birth attendants on the use of oxytocin during the third stage of labor, the active management of the third stage of labor (AMTSL), and the rate of routine episiotomy during vaginal births in two health districts in Nicaragua. METHODS: An uncontrolled before-and-after study design was used. The rates of oxytocin use in the third stage of labor, AMTSL, and episiotomy were measured for vaginal births occurring in eight hospitals and health centers during 2011-2012, before and after implementation of a multifaceted facility-based intervention. The intervention involved the use of opinion leaders, interactive workshops to develop and implement evidence-based guidelines, academic detailing, the use of reminders, and feedback on the rates of oxytocin use and episiotomy. RESULTS: Oxytocin use during the third stage of labor increased significantly from 95.3% to 97.4% (P=0.003). The episiotomy rate dropped significantly from 31.2% to 21.2% overall, and from 59.6% to 40.5% in primiparous women (P<0.001 for both comparisons). CONCLUSION: The multifaceted intervention improved the targeted care practices during childbirth. However, a further decrease in the routine use of episiotomy would be desirable.

Use of antenatal corticosteroids for preterm birth in Latin America: providers knowledge, attitudes and practices.

BACKGROUND: Antenatal corticosteroids administered to women at risk of preterm birth is an intervention which has been proved to reduce the risk of respiratory distress syndrome, intraventricular hemorrhage, and neonatal mortality. There is a significant gap in the literature regarding the prevalence of the use of antenatal corticosteroids in Latin American countries and the attitudes and opinions of providers regarding this practice. The aim of this study was to assess the knowledge, attitudes and practices of health care providers regarding the use of antenatal corticosteroids in women at risk of preterm birth in Latin America. METHODS: This was a multicenter, prospective, descriptive study conducted in maternity hospitals in Ecuador, El Salvador, Mexico and Uruguay. Physicians and midwives who provide prenatal care or intrapartum care for women delivering in the selected hospitals were approached using a self-administered questionnaire. Descriptive statistics was used. RESULTS: The percentage of use of ACT in threatened preterm labour (TPL) reported by providers varies from 70% in Mexico to 97% in Ecuador. However, 60% to 20% of the providers mentioned that they would not use this medication in women at risk and would limit its use when there was a threatened preterm labour. In only one country recommended regimens of antenatal corticosteroids are followed by around 90% of providers whereas in the other three countries recommended regimens are followed by only 21%, 61%, 69% of providers. Around 40% of providers mentioned that they would administer a new dose of corticosteroids again, regardless the patient already receiving an entire regimen. Between 11% and 35% of providers, according to the countries, mentioned that they do not have adequate information on the correct use of this medication. CONCLUSIONS: This study shows that the use of this intervention could be improved by increasing the knowledge of Latin American providers on its indications, benefits, and regimens.

Using Uniject to increase the use of prophylactic oxytocin for management of the third stage of labor in Latin America.

OBJECTIVE: To evaluate a multifaceted intervention for effectiveness in increasing the use of prophylactic oxytocin by birth attendants (obstetricians, midwives, and nurses) working in small maternity hospitals in Argentina. METHODS: A before-and-after quasi-experimental study was conducted in 5 small maternity hospitals. The study intervention consisted of training birth attendants in the active management of the third stage of labor, distributing oxytocin in Uniject (Hipofisina BIOL Uniject; Laboratorios BIOL, Buenos Aires, Argentina), and using posters as reminders. The primary outcome was the rate of prophylactic oxytocin use in the 6 months before and the 6 months of the intervention period. Secondary outcomes included use of controlled cord traction and uterine massage, and birth attendants' acceptance of the use of oxytocin in Uniject. RESULTS: The use of prophylactic oxytocin showed a median rate of 14.6% at baseline and 85.6% during the intervention period. 96% of birth attendants reported that the Uniject device facilitated oxytocin 1 administration. DISCUSSION: Prophylactic oxytocin in the third stage of labor is a beneficial intervention with current low use, particularly in low- and middle-income countries. If the results shown in the present study were further replicated, this strategy could be an effective method for improving prophylactic oxytocin use in other similar Latin American hospitals.

Use of a rapid test on umbilical cord blood to screen for Trypanosoma cruzi infection in pregnant women in Argentina, Bolivia, Honduras, and Mexico.

We conducted a cross-sectional study of Chagas disease in five endemic areas in Argentina, Bolivia, Honduras, and México to estimate the prevalence of Trypanosoma cruzi-specific antibodies in pregnant women, and to assess the use of a rapid test (Chagas Stat-Pak) to screen for T. cruzi infection at the time of delivery. The prevalence of antibodies to T. cruzi measured by enzyme-linked immunosorbent assay (ELISA) in maternal blood was 5.5% (a range of 0.8-28.8% among the countries) in 2,495 women enrolled. Compared with ELISA in maternal blood samples, the Chagas Stat-Pak rapid test sensitivity and specificity in umbilical cord blood were 94.6% and 99.0%, respectively. These results show the ability for a rapid determination of the presence of T. cruzi-specific antibodies in umbilical cord blood as a pragmatic strategy to screen for infection in pregnant women.

[Practices in the care of the low-risk delivery in hospitals in southern Chile]. / Prácticas en la atención del parto de bajo riesgo en hospitales del sur de Chile.

BACKGROUND: A relevant component to achieve high quality of care is the implementation of evidence based practices. OBJECTIVE: To assess in two maternities in the South of Chile, the use of evidence based practices in labour and delivery care. PATIENTS AND METHODS: In two hospitals, 205 women after delivery were interviewed. Eleven forms of care were selected from the classification provided by the WHO Reproductive Health Library, four as beneficial forms of care and seven as forms of care likely to be harmful. RESULTS: Beneficial forms of care were used between 17 to 46% and forms likely to be harmful between 17 and 98%. No association among the use of the practices and some maternal characteristics, such as age, parity and years on school, were found. Women interpretation about benefits of the practices is not in agreement with the evidence provided by the trials. CONCLUSIONS: A low adherence to evidence based practices was observed since some practices of proven benefit are poorly used and many practices likely to be harmful are highly used. There is a need to look for strategies aimed at the better use of evidences based practices considering among these strategies women empowerment.

Goals in maternal and perinatal care in Latin America and the Caribbean.

Ten goals have been developed to guide perinatal caregivers by the Latin American Centre for Perinatology (CLAP), a PAHO/WHO unit dedicated to improving perinatal care in Latin America and The Caribbean. The goals were inspired by the current troubled perinatal care situation, the need to make significant changes, principles of evidence-based medicine, and reviews of many sources from other regions or countries.