Combined HIV Adolescent Prevention Study (CHAPS): comparison of HIV pre-exposure prophylaxis regimens for adolescents in sub-Saharan Africa-study protocol for a mixed-methods study including a randomised controlled trial.

BACKGROUND: HIV remains a major public health issue, especially in Eastern and Southern Africa. Pre-exposure prophylaxis is highly effective when adhered to, but its effectiveness is limited by cost, user acceptability and uptake. The cost of a non-inferiority phase III trial is likely to be prohibitive, and thus, it is essential to select the best possible drug, dose and schedule in advance. The aim of this study, the Combined HIV Adolescent PrEP and Prevention Study (CHAPS), is to investigate the drug, dose and schedule of pre-exposure prophylaxis (PrEP) required for the protection against HIV and the acceptability of PrEP amongst young people in sub-Saharan Africa, and hence to inform the choice of intervention for future phase III PrEP studies and to improve strategies for PrEP implementation. METHODS: We propose a mixed-methods study amongst young people aged 13-24 years. The first component consists of qualitative research to identify the barriers and motivators towards the uptake of PrEP amongst young people in South Africa, Uganda and Zimbabwe. The second component is a randomised clinical trial (ClinicalTrials.gov NCT03986970, June 2019) using a novel ex vivo HIV challenge method to investigate the optimal PrEP treatment (FTC-TDF vs FTC-TAF), dose and schedule. We will recruit 144 amongst HIV-negative uncircumcised men aged 13-24 years from voluntary male medical circumcision clinics in two sites (South Africa and Uganda) and randomise them into one of nine arms. One group will receive no PrEP prior to surgery; the other arms will receive either FTC-TDF or FTC-TAF, over 1 or 2 days, and with the final dose given either 6 or 20 h prior to surgery. We will conduct an ex vivo HIV challenge on their resected foreskin tissue. DISCUSSION: This study will provide both qualitative and quantitative results to help decide the optimum drug, dose and schedule for a future phase III trial of PrEP. The study will also provide crucial information on successful strategies for providing PrEP to young people in sub-Saharan Africa. TRIAL REGISTRATION: ClinicalTrials.gov NCT03986970 . Registered on 14 June 2019.

Safety and tolerability of injectable Rilpivirine LA in HPTN 076: A phase 2 HIV pre-exposure prophylaxis study in women.

BACKGROUND: Daily oral TDF/FTC is protective against HIV infection when used for pre-exposure prophylaxis (PrEP). However, daily adherence to oral PrEP is difficult for many; therefore, finding alternative PrEP strategies remains a priority. HPTN 076 evaluated the long-acting injectable form of rilpivirine (RPV), known as RPV LA for safety, pharmacokinetics and acceptability. METHODS: HPTN 076 (NTC 02165202) was a phase 2, double-blind, 2:1 randomized trial comparing the safety of 1200mg RPV LA (LA) to placebo (P). The study included a 28-day oral run-in phase of daily, self- administered oral RPV (25 mg), with directly observed oral dosing about six times. Of 136 enrolled sexually active, HIV-uninfected, low HIV-risk African (100) and US (36) adult women, injectable product was administered in two gluteal, intramuscular (IM) injections once every eight weeks to 122 participants following the oral run-in phase. A maximum of six injection time points occurred over a 48-week period. Acceptability, safety, tolerability and pharmacokinetic (PK) data were collected throughout the study. This paper includes primary endpoint data collected up to the week 52 post enrollment. FINDINGS: The median age of the enrolled population was 31 years (IQR: 25,38), median weight 75 kg (IQR: 64, 89), median body mass index (BMI) 30 (IQR: 27, 35), 46% married, 94% Black and 60% unemployed. A total of 122 (80 LA, 42 P) women received at least one injection and 98 (64 LA, 34 P) received all six injections. During the injection phase, three women withdrew from the study (2 LA, 1 P) and 16 women discontinued study product (10 LA, 6 P). Fourteen women (11 LA and 3 P) discontinued oral study product and did not enter the injection phase. Study product discontinuations were not significantly different between the two arms throughout. Of the product discontinuations in the injection phase, 8% in LA and 5% in P arm were due to adverse events (AEs), including one randomized to the P arm with prolonged QTc interval on EKG. The proportion of women who experienced Grade 2 or higher AEs during the injection phase as the primary outcome was not significantly different between the two arms [73.8%, 95% CI: (63.2%, 82.1%) for LA and 73.8%, 95% CI: (58.9%, 84.7%), p>0.99]. Transient Grade ≥2 liver abnormalities occurred in 14% of women in the LA arm compared with 12% in P arm. Three LA women (4%) developed Grade 3 injection site reactions compared with none in P arm. In participants who received at least 1 injection, the geometric mean of overall RPV trough concentrations (Ctrough) was 62.2 ng/mL. In participants who received all six injections, the geometric mean of CTrough through the injection phase and after the last injection were 72.8 ng/mL and 100.9 ng/mL, respectively. At week 52 (eight weeks after last injection), the geometric mean of RPV Ctrough was 75.0 ng/mL. At the last injection visit (Week 44), 80 % of women who answered acceptability questions strongly agreed that they would think about using- and 68% that they would definitely use a PrEP injectable in the future. INTERPRETATION: RPV LA IM injections every eight weeks in African and US women were safe and acceptable. Overall, despite more injection site reactions and pain in the participants receiving RPV LA the injections were well tolerated. Data from this study support the further development of injectable PrEP agents.

World Health Organization Guidelines for treatment of cervical intraepithelial neoplasia 2-3 and screen-and-treat strategies to prevent cervical cancer

"BACKGROUND: It is estimated that 1%-2% of women develop cervical intraepithelial neoplasia grade 2-3 (CIN 2-3) annually worldwide. The prevalence among women living with HIV is higher, at 10%. If left untreated, CIN 2-3 can progress to cervical cancer. WHO has previously published guidelines for strategies to screen and treat precancerous cervical lesions and for treatment of histologically confirmed CIN 2-3. METHODS: Guidelines were developed using the WHO Handbook for Guideline Development and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. A multidisciplinary guideline panel was created. Systematic reviews of randomized controlled trials and observational studies were conducted. Evidence tables and Evidence to Recommendations Tables were prepared and presented to the panel. RESULTS: There are nine recommendations for screen-and-treat strategies to prevent cervical cancer, including the HPV test, cytology, and visual inspection with acetic acid. There are seven for treatment of CIN with cryotherapy, loop electrosurgical excision procedure, and cold knife conization. CONCLUSION: Recommendations have been produced on the basis of the best available evidence. However, high-quality evidence was not available. Such evidence is needed, in particular for screen-and-treat strategies that are relevant to low- and middle-income countries."

Interest in multipurpose prevention of HIV and pregnancy: perspectives of women, men, health professionals and community stakeholders in two vaginal gel studies in southern Africa.

OBJECTIVE: The pipeline of vaginal microbicides for HIV prevention has expanded to include products for multipurpose prevention, but the interests of potential users and those advising on use have not been sufficiently investigated. Rather, assumptions about interest in multipurpose prevention technologies (MPTs) are inferred from what is known about acceptability and use of microbicides or contraceptives. DESIGN AND SETTING: This paper presents data on concerns and preferences for multipurpose prevention of HIV and pregnancy. Data were collected in two microbicide gel studies in Malawi and Zimbabwe. Participants were women using candidate vaginal products, their male partners, health professionals and community stakeholders. METHODS: An individual interview was conducted with participants. Interviews were audio-recorded, transcribed, coded for content and analysed for key themes. RESULTS: Participants indicated strong interest in a vaginal HIV prevention product that could also prevent pregnancy. Reasons for this interest were convenience, problems with adverse effects with current contraceptive methods, concerns about long-term effects of contraceptives, and concerns about the health burdens of HIV infection during pregnancy. The main disadvantage of an MPT was recognition that while interest in preventing HIV is constant, contraceptive needs change over time. CONCLUSION: The study population indicated support for an MPT to prevent HIV and pregnancy. This support may be further strengthened if the product is also available for prevention of only HIV. Women and men will be more willing to use an MPT if they can be reassured that its use will have no long-term effect on fertility.

Realities and Challenges of a Five Year Follow Up of Mother and Child Pairs on a PMTCT Program in Zimbabwe.

BACKGROUND: Complete follow up is an essential component of observational cohorts irrespective of the type of disease. OBJECTIVES: To describe five years follow up of mother and child pairs on a PMTCT program, highlighting loss to follow up (LTFU) and mortality (attrition). STUDY DESIGN: A cohort of pregnant women was enrolled from the national PMTCT program at 36 weeks gestational age attending three peri urban clinics around Harare offering maternal and child health services. Mother-infant pairs were followed up from birth and twice yearly for five years. RESULTS: A total of 479 HIV infected and 571 HIV negative pregnant women were enrolled, 445(92.9%) and 495(86.6%) were followed up whereas 14(3.0%) and 3(0.5%) died in the 1st year respectively; RR (95%CI) 5.3(1.5-18.7). At five years 227(56.7%) HIV infected and 239(41.0%) HIV negative mothers turned up, whereas mortality rates were 34 and 7 per 100 person years respectively. Birth information was recorded for 401(83.7%) HIV exposed and 441(77.2%) unexposed infants, 247(51.6%) and 232(40.6) turned up in the first year whilst mortality was 58(12.9%) and 22(4.4%) respectively, RR (95%CI) 3.2(2.0-5.4). At five years 210(57.5%) HIV exposed and 239(44.3%) unexposed infants were seen, whilst mortality rates were 53 per 1000 and 15 per 1 000 person years respectively. Mortality rate for HIV infected children was 112 compared to 21 per 1 000 person years for the exposed but uninfected. CONCLUSION: HIV infected mothers and their children succumbed to mortality whereas the HIV negatives were LTFU. Mortality rates and LTFU are high within PMTCT program.

Risk factors of HIV vertical transmission in a cohort of women under a PMTCT program at three peri-urban clinics in a resource-poor setting.

OBJECTIVE: To identify the risk factors of HIV vertical transmission in pregnant women. STUDY DESIGN: Observational cohort study. Between 2002 and 2003, 479 HIV-infected pregnant women in a PMTCT (prevention of the mother-to-child transmission) program were followed up with their infants at delivery, until 15 months with infant HIV testing. RESULTS: Of these 281 infants had a definitive HIV result by 15 months of age, and 31.7% of the infants become HIV infected. In univariate analysis the risk factor identified were presence of vaginal discharge, genital itchiness, genital ulcers, dysuria, abnormal breast and vaginal infections (Trichomonas, Bacteria vaginosis and Candida) in the mother at enrolment. In multivariate analysis vaginal infections risk ratio (RR) 1.72(1.03-2.88) and abnormal breast RR 4.36(2.89-6.58) were predictors of HIV vertical transmission. CONCLUSION: There is need to screen for vaginal infections (Trichomonas, Bacteria vaginosis and Candida) and examine pregnant women for mastitis to identify women at risk of HIV vertical transmission for prevention.

Effect of maternal HIV status on infant mortality: evidence from a 9-month follow-up of mothers and their infants in Zimbabwe.

OBJECTIVE: To describe infant mortality trends and associated factors among infants born to mothers enrolled in a prevention of mother-to-child transmission (PMTCT) program. STUDY DESIGN: A nested case-control study of human immunodeficiency virus (HIV)-positive and -negative pregnant women enrolled from the national PMTCT program at 36 weeks of gestation attending three peri-urban clinics in Zimbabwe offering maternal and child health care. Mother-infant pairs were followed up from delivery, and at 6 weeks, 4 months and 9 months. RESULTS: A total of 1045 mother and singleton infant pairs, 474 HIV-positive and 571 HIV-negative mothers, delivered 469 and 569 live infants, respectively. Differences in mortality were at 6 weeks and 4 months, RR (95% CI) 9.71 (1.22 to 77.32) and 21.84 (2.93 to 162.98), respectively. Overall, 9-month mortality rates were 150 and 47 per 1000 person-years for infants born to HIV-positive and HIV-negative mothers, respectively. Proportional hazard ratio of mortality for children born to HIV-positive mothers was 3.21 (1.91 to 5.38) when compared with that for children born to HIV-negative mothers. CONCLUSION: Maternal HIV exposure was associated with higher mortality in the first 4 months of life. Infant's HIV status was the strongest predictor of infant mortality. There is a need to screen infants for HIV from delivery and throughout breastfeeding.

An assessment of rural women's knowledge, constraints and perceptions on cervical cancer screening: the case of two districts in Zimbabwe.

This paper gives a sociological and anthropological insight into the rural women's perceptions and understanding of cervical symptomatology, screening and cancer. Qualitative data was collected through in-depth interviews and focus group discussions with women and health personnel. Quantitative data was obtained through questionnaires administered to 356 women from Mutoko and Shurugwi districts. The study revealed that cervical cancer is a disease that is of concern among health practitioners and women. 95.78% of the interviewed women had never gone for screening and had little knowledge about the various aspects of the disease in terms of causes, prevention and treatment. The study made four recommendations: the need for national screening policy and programme to be put in place, health education to women about cervical cancer, use of VIA in low resource settings and sensitisation of women about the availability of screening facilities in the districts where programmes are in place.

Cervical dyskaryosis among women with and without HIV: prevalence and risk factors.

Women in developing countries often present for medical care with advanced cervical cancer, although this condition is preventable through regular screening and early treatment. This study sought to identify the prevalence and risk factors for cervical dyskaryosis among women in Zimbabwe with and without HIV. In a cross-sectional study, 200 consenting women were screened for cervical dyskaryosis and sexually transmitted infections (STI). The relationship between various risk factors for cervical dyskaryosis was examined. The overall prevalence of cervical dyskaryosis was high (19%), and significantly higher among HIV-infected women at 30% compared with 13% among seronegative women, with a peak at a younger age among seropositive women. Use of intravaginal herbs, practising intravaginal cleansing, being single, a history of three or more lifetime sexual partners and a history of previous STI were associated with cervical dysplasia. The high frequency of cervical abnormality lends weight to the demand for implementation of regular screening programmes and health education.

HIV prevalence in Zimbabwean women: 54-67% knowledge and perceived risk.

This study examined the level of knowledge of sexually transmitted infections (STI) and HIV, knowledge of symptoms and potential sequelae of STI and perceived personal risks of infection among urban women in Zimbabwe. The women consented to being interviewed, examined, tested and treated for curable diagnosed STIs. Prevalence of both STI and HIV was high 11.4% and 54.5% among women aged 15-19 years, 28.5% and 62.4% among those 20-29 years and was highest among the age group >/=30 years 39.0% and 67.0% respectively. Women aged 15-19 years least perceived their risk of infection. Of the women with the highest rates of STI/HIV infection, less than 30% were aware of their vulnerability to such infections. Knowledge of specific STIs, their symptoms and sequelae was generally low. Women who did not know about syphilis, gonorrhoea, chancroid or warts were more likely to perceive themselves at no risk of infection. Condom use was very low (16.5%). There is an urgent need to improve current education programmes to raise awareness of STIs and the dangers of their long-term sequelae along with behavioural skills building interventions that include equipping women with negotiating skills, making female condoms available at affordable prices and motivating condom use.

Association of herpes simplex virus type 2 with the human immunodeficiency virus among urban women in Zimbabwe.

A cross-sectional study at two urban primary health care clinics in Zimbabwe was conducted among 393 consecutive women. The purpose was to determine the seroprevalence of herpes simplex virus type 2 (HSV-2), to identify coinfections and to determine the association between HSV-2, HIV and other sexually transmitted infections (STIs). Sera were tested for HSV-2, HIV and syphilis. Genital specimens were tested for the other STIs. The seroprevalence of ulcerative STIs tested was 42.2% for HSV-2 and 3.9% for syphilis. HSV-2 seropositive women had twice the risk of being HIV infected compared to HSV-2 seronegative women, adjusted OR=2.05 (95% CI=1.29-3.23). HSV-2 seropositivity was also associated with older age, a lower level of education, increase in the number of lifetime sexual partners and history of genital ulcers in the past six or more months. Our data suggest that in this population HSV-2 may contribute more to HIV infection than syphilis because of its high frequency. There is an urgent need for development of an effective HSV-2 vaccine.

HIV seroprevalence and its associations with the other reproductive tract infections in asymptomatic women in Harare, Zimbabwe.

The objective was to determine the magnitude of HIV as well as the associations between HIV seropositivity with reproductive tract infections (RTIs) among healthy women in Harare, Zimbabwe. In a cross-sectional study, 393 informed consenting women aged 15--49 years, attending 2 primary healthcare clinics, were interviewed and screened for HIV and RTIs. HIV seroprevalence was 29.3%. Seropositivity was significantly associated with bacterial vaginosis, syphilis, gonorrhoea and/or Chlamydia trachomatis infection, warts and genital ulcers. Risk factors for HIV were absence of lactobacilli in vaginal fluid, vaginal pH >4.5, age >20 years, being unmarried, having had more than one lifetime sexual partner, having used a condom at least once in their lifetime, having experienced an infant mortality, and a partner who was non-monogamous or a frequent traveller. In view of the very high seroprevalence and concomitant RTIs in this population, we recommend promotion of women-controlled prevention methods along with proactive detection and treatment of RTIs.

Perinatal practices in two rural districts of Zimbabwe: a community perspective.

OBJECTIVE: To describe perinatal practices from a community perspective and identify factors associated with perinatal death. DESIGN: Cross sectional community based survey. SETTING: Murewa and Madziwa rural areas, Zimbabwe. SUBJECTS: Women aged 15 to 50 years who had been pregnant within the 24 months preceding the survey. MAIN OUTCOME MEASURES: Where delivered, where preferred to deliver, model of delivery, use of herbs in labour, duration of labour, assistant at delivery, time of delivery, condition of baby at birth, resuscitation methods, birth weight, initiation of breast feeding, illness in the first week and outcome of pregnancy. RESULTS: 644 women were interviewed; 581/644 stated where they would have liked to deliver and 505/644 stated where they actually delivered their last baby. The majority 369/581 (62.4%) preferred to delivery at a government hospital and 240/505 (47.5%) actually delivered at a government hospital. Of the home deliveries only 27/581 (4.6%) preferred to deliver at home and yet 123/505 (24.4%) actually delivered at home. Primary care clinics were less preferred 151/581 (25.5%) as a place for delivery and 89/505 (17.6%) actually delivered there. Labour lasting more than 12 hours occurred in 20.4% of deliveries. Nurses were the commonest attendants at delivery 309/508 (60.4%) and morbidity following delivery was noted in 72/495 (14.5%). Resuscitation was carried out in 61/72 infants. Beating/shaking 36/61 (58.0%) and pouring cold water over the baby 11/61 (18.0%) were the commonest methods of resuscitation. Being delivered by a doctor compared to a nurse and being in Murewa district were statistically significant risk factors for mortality with Odds Ratio (OR) 5.21 (95% CI 2.86 to 9.51) and 3.90 (95% CI 1.51 to 10.09) respectively. The odds of dying when delivered by breech extraction were high, but not statistically significant OR 3.73 (95% CI 0.92 to 13.97) when compared to being delivered by vertex delivery. Labour more than 12 hours, use of herbs in pregnancy and time of delivery were not significantly associated with mortality with OR (95% CI) of 1.02 (0.40 to 2.19), 0.92 (0.00 to 4.38), 1.05 (0.56 to 1.97) respectively. On logistic regression analysis only being delivered in Murewa district remained significant. CONCLUSION: The utilisation of primary health care centres for delivery was unexpectedly low and home deliveries were unacceptably high. Increased mortality when delivered by a doctor and high early neonatal morbidity suggest poor monitoring and delayed intervention in labour. Infant morbidity following delivery was high and methods for neonatal resuscitation inappropriate. There is a need for more studies looking into health worker skills particularly in the areas of partogram use and neonatal resuscitation in these districts.

Situation analysis of obstetric care services in a rural district in Zimbabwe.

OBJECTIVE: To conduct a situation analysis of obstetric services in a rural district of Zimbabwe. DESIGN: Observational study. SETTING: 13 primary health care centres in Murewa district in Zimbabwe. MAIN OUTCOME MEASURES: Number of maternity beds, antenatal attendance, deliveries per month, availability of antenatal, intrapartum and neonatal care equipment, intrapartum monitoring and neonatal resuscitation skills. RESULTS: 13 of 15 primary health care clinics providing obstetric care in Murewa district were surveyed in 1995. Median number of maternity beds were nine (Q1 = 0, Q3 = 11) per clinic, median number of first ANC attenders per month was 15 (Q1 = 3, Q3 = 18), median number of deliveries per clinic per month were eight (Q1 = 0, Q3 = 16). While all clinics had laboratory facilities, 6/13 could estimate haemoglobin, 5/13 syphilis serology, none of the clinics sent blood to district hospitals for blood grouping and there were no microscopes at clinics for malaria parasite determination. Only 6/13 clinics used partographs for monitoring labour, 10/13 had suction machines for neonatal resuscitation while only 3/13 had ambu bags, 3/13 had oxygen and 2/13 had heaters. Correct methods for neonatal resuscitation were used in 3/13 clinics. Clean water supply, reliable power supply and the referral system were not optimal. CONCLUSION: Basic equipment for antenatal, intrapartum and neonatal care was inadequate. Essential laboratory facilities for obstetric care were lacking. Skills for intrapartum monitoring and neonatal resuscitation were inadequate. The referral system was poor. There is need for more strategic planning at primary health care level in this district which is known to have high perinatal and neonatal death rates. More emphasis should be placed on strengthening basic laboratory back up service for obstetric care, strengthening infrastructural and referral systems as well as training in areas of lost or no skills.

Antenatal care patterns and factors associated with perinatal outcome in two rural districts in Zimbabwe.

OBJECTIVE: To study antenatal care (ANC) patterns, to identify factors associated with poor perinatal outcome and quality of ANC. DESIGN: Cross sectional community based survey. SETTING: Murewa and Madziwa rural Districts. SUBJECTS: 644 women aged between 15 to 50 years who had been pregnant in the immediate 24 months preceding the survey. MAIN OUTCOME MEASURES: Perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of ANC. RESULTS: A total of 644 women were interviewed. Overall perinatal mortality was 115 per 1,000 births. 511/644 (79.3%) visited a health centre for ANC. The woman herself (41.8%) as well as husbands (41.8%) were commonly the decision makers regarding starting ANC. Only 298/510 (58.4%) of women used primary health care facilities for ANC. 211/629 (35.1%) of women lived more than 5 kms from the health care centre. 153/629 (24.3%) were not able to pay for ANC. Only 110/509 (21.6%) started ANC in the first trimester. 307/495 (62.0%) made five or less ANC visits. Pregnancy related morbidity was high 209/644 (32.5%) and use of traditional herbs was common 158/644 (24.%). There were significant differences between districts as far as perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of care all having p values of 0.001 or less. On further analysis using logistic regression, having problems with pregnancy and vaginal bleeding were significant predictors of poor perinatal outcome with odds ratio (95% CI) of 2.8 (1.4 to 5.9) and 3.0 (1.1 to 8.6) respectively. Quality of ANC was rated as sub-optimal. CONCLUSION: Majority of rural women attended clinics for ANC. Perinatal mortality rate and pregnancy related morbidity were high. Vaginal bleeding was the strongest predictor for mortality. There is need to improve quality of antenatal care as this was found to be suboptimal. More objective oriented antenatal care visits and waiting mother's shelters form part of the solutions. Further studies are called for.

Aids and cancer in Africa: the evolving epidemic in Zimbabwe.

BACKGROUND: Zimbabwe is severely affected by the AIDS epidemic, and many cancers in African populations are related to infectious agents. OBJECTIVE: To study the current pattern, and short-term changes in incidence, of cancers related to infectious agents (and especially to HIV), with respect to the evolving epidemic of AIDS. METHODS: Analysis of data on the African population of Harare, Zimbabwe, from the Zimbabwe Cancer Registry, for the period 1990-1995. Comparison with data on prevalence of HIV seropositivity, and notifications of AIDS. RESULTS: Comparing results from 1993-1995 with those for 1990-1992 shows a continuing increase in the incidence of Kaposi's sarcoma with a doubling of the rates in both men and women. A dramatic increase in the incidence of squamous cell tumours of the conjunctiva was also observed, as well as a significant increase in the incidence of non-Hodgkin's lymphoma in women. There was no apparent increase in risk for Hodgkin's disease, myeloma, liver cancer, or cancer of the cervix. CONCLUSIONS: The AIDS epidemic has had a dramatic effect on the profile of cancer. The changes in incidence involve several cancers previously linked to AIDS in North America and Europe.

Perinatal mortality rates and associated socio-demographic factors in two rural districts in Zimbabwe.

OBJECTIVE: To determine perinatal mortality rates and associated socio-demographic factors in two rural districts in Zimbabwe. DESIGN: Cross sectional community based survey. SETTING: Murewa and Madziwa rural districts. SUBJECTS: Women aged 15 to 50 years who had been pregnant over the preceding two years before the study. MATERIALS AND METHODS: A questionnaire was administered to eligible women by trained interviewers. Information pertaining to the women's socio-demographic characteristics, reproductive health profile and pregnancy outcome was documented. A post hoc case control analysis was undertaken to determine the risk factors associated with poor perinatal outcome. Women who had a poor perinatal outcome were designated cases and those with a good outcome were designated controls. RESULTS: The average perinatal mortality rate for both districts was 111 per 1,000 live births (Murewa 182 per 1,000 and Madziwa 48 per 1,000). Factors significantly associated with perinatal mortality were ethnicity, marital status, subjective standard of living and the women's level of formal education. Being Zezuru or being married was associated with poor perinatal outcome. Living well and having high levels of education were also associated with poor perinatal outcome. Perinatal mortality was not significantly associated with maternal age or spouse level of education. CONCLUSION: This study showed unacceptability high perinatal mortality rates in these rural districts. The true socio-demographic factors associated with perinatal mortality could not be ascertained in this study because of confounding factors. There is need to study quality of antenatal, intrapartum and neonatal care offered by health centres in these districts. In addition there is need to strongly advocate a perinatal programme to address these high mortality rates.

PIP: A community-based survey of 640 women 15-50 years old who had been pregnant in the 2 years preceding the study was conducted in two rural districts in Zimbabwe (Murewa and Madziwa) to assess perinatal mortality and the associated sociodemographic factors. The overall perinatal mortality rate was 111/1000 live births (182/1000 in Murewa and 48/1000 in Madziwa). Murewa had significantly more stillbirths, abortions, and perinatal and infants deaths than Madziwa. A perinatal death was 1.94 times more likely if the woman was from the Zezuru ethnic group. Single, separated, divorced, and widowed women had better pregnancy outcomes than married women (polygamous or monogamous). Finally, living well (subjectively assessed) and a high educational level (completion of primary school and above) were both associated with significant risks of poor perinatal outcomes. Maternal age and inter-birth interval were not risk factors. Because of lack of controls for confounding, the generally puzzling risk factors identified in this study require confirmation. However, the high mortality rate identified in this study indicates an urgent need for implementation of effective perinatal programs in this area.

The effects of established and gestational diabetes on pregnancy outcome at Harare Maternity Hospital.

A study was carried out to determine the effect of established and gestational diabetes on pregnancy outcome over a period of two years at Harare Maternity Hospital, Harare, Zimbabwe. During the period, 51 patients with established diabetes mellitus and 70 patients with gestational diabetes were treated. The perinatal mortality was higher among this group (124 per 1,000) compared with the rest of the total hospital population (44 per 1,000) who delivered during the same period.