Maternal and fetal outcomes of pregnancies complicated by acute hepatitis E and the impact of HIV status: A cross-sectional study in Namibia.

BACKGROUND & AIMS: Namibia has been suffering from an outbreak of hepatitis E genotype 2 since 2017. As nearly half of hepatitis E-related deaths were among pregnant and postpartum women, we analysed maternal and fetal outcomes of pregnancies complicated by acute hepatitis E and assessed whether HIV-status impacted on outcome. METHODS: A retrospective cross-sectional study was performed at Windhoek Hospital Complex. Pregnant and postpartum women, admitted between 13 October 2017 and 31 May 2019 with reactive IgM for Hepatitis E, were included. Outcomes were acute liver failure (ALF), maternal death, miscarriage, intra-uterine fetal death and neonatal death. Odds ratios (OR) and 95% confidence interval (CI) were calculated. RESULTS: Seventy women were included. ALF occurred in 28 (40.0%) of whom 13 died amounting to a case fatality rate of 18.6%. Sixteen women (22.9%) were HIV infected, compared to 16.8% among the general pregnant population (OR 1.47, 95% CI 0.84-2.57, P = .17). ALF occurred in 4/5 (80%) HIV infected women not adherent to antiretroviral therapy compared to 1/8 (12.5%) women adherent to antiretroviral therapy (OR 28.0, 95% CI 1.4-580.6). There were 10 miscarriages (14.3%), five intra-uterine fetal deaths (7.1%) and four neonatal deaths (5.7%). CONCLUSIONS: One in five pregnant women with Hepatitis E genotype 2 died, which is comparable to genotype 1 outbreaks. Despite small numbers, HIV infected women receiving antiretroviral therapy appear to be less likely to develop ALF in contrast with HIV infected women not on treatment. As there is currently no curative treatment, this phenomenon needs to be assessed in larger cohorts.

Maternal near-miss surveillance, Namibia.

OBJECTIVE: To analyse and improve the Namibian maternity care system by implementing maternal near-miss surveillance during 1 October 2018 and 31 March 2019, and identifying the challenges and benefits of such data collection. METHODS: From the results of an initial feasibility study, we adapted the World Health Organization's criteria defining a maternal near miss to the Namibian health-care system. We visited most (27 out of 35) participating facilities before implementation and provided training on maternal near-miss identification and data collection. We visited all facilities at the end of the surveillance period to verify recorded data and to give staff the opportunity to provide feedback. FINDINGS: During the 6-month period, we recorded 37 106 live births, 298 maternal near misses (8.0 per 1000 live births) and 23 maternal deaths (62.0 per 100 000 live births). We observed that obstetric haemorrhage and hypertensive disorders were the most common causes of maternal near misses (each 92/298; 30.9%). Of the 49 maternal near misses due to pregnancies with abortive outcomes, ectopic pregnancy was the most common cause (36/298; 12.1%). Fetal or neonatal outcomes were poor; only 50.3% (157/312) of the infants born to maternal near-miss mothers went home with their mother. CONCLUSION: Maternal near-miss surveillance is a useful intervention to identify within-country challenges, such as lack of access to caesarean section or hysterectomy. Knowledge of these challenges can be used by policy-makers and programme managers in the development of locally tailored targeted interventions to improve maternal outcome in their setting.