Clinical and epidemiological aspects of SARS-CoV-2 infection among pregnant and postpartum women in Mozambique: a prospective cohort study.

BACKGROUND: Although there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal outcomes, data on the effects of the pandemic on the obstetric population in sub-Saharan African countries are still scarce. Therefore, the study aims were to assess the prevalence and impact of COVID-19 on maternal and neonatal outcomes in the obstetric population at Central Hospital of Maputo (HCM), Mozambique. METHODS: Prospective cohort study conducted at teaching and referral maternity, HCM, from 20 October 2020 to 22 July 2021. We collected maternal and perinatal outcomes up to 6 weeks postpartum of eligible women (pregnant and postpartum women-up to the 14th day postpartum) screened for COVID-19 (individual test for symptomatic participants and pool testing for asymptomatic). The primary outcome was maternal death, Severe Acute Respiratory Syndrome (SARS) and Intensive Care Unit (ICU) admission. We estimated the COVID-19 prevalence and the unadjusted RR (95% CI) for maternal and perinatal outcomes. We used the chi-square or Fisher's exact test to compare categorical variables (two-sided p-value < 0.05 for statistical significance). RESULTS: We included 239 participants. The overall prevalence of COVID-19 was 9.2% (22/239) and in the symptomatic group was 32.4% (11/34). About 50% of the participants with COVID-19 were symptomatic. Moreover, the most frequent symptoms were dyspnoea (33.3%), cough (28.6%), anosmia (23.8%), and fever (19%). Not having a partner, being pregnant, and alcohol consumption were vulnerability factors for SARS-CoV-2 infection. The risk of adverse maternal and neonatal outcomes (abortion, foetal death, preterm birth, Apgar, and NICU admission) was not significantly increased with COVID-19. Moreover, we did not observe a significant difference in the primary outcomes (SARS, ICU admission and maternal death) between COVID-19 positive and COVID-19 negative groups. CONCLUSION: The prevalence of COVID-19 in the obstetric population is higher than in the general population, and fifty percent of pregnant and postpartum women with COVID-19 infection are asymptomatic. Not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, being pregnant versus postpartum was associated with increased vulnerability to COVID-19. Data suggest that pregnant women with COVID-19 may have a higher frequency of  COVID-19 infection, reinforcing the need for universal testing, adequate follow-up for this population, and increasing COVID-19 therapy facilities in Mozambique. Moreover, provide counselling during Antenatal care for COVID-19 preventive measures. However, more prospective and robust studies are needed to assess these findings.

"There Are Things We Can Do and There Are Things We Cannot Do." A Qualitative Study About Women's Perceptions on Empowerment in Relation to Fertility Intentions and Family Planning Practices in Mozambique.

Introduction: The restrictive socio-cultural norms in Mozambique limit the power of women to decide, voice, and act on their reproductive choices. This study aimed to explore women's perceptions and experiences of empowerment relating to fertility intentions and family planning practices in Mozambique, focusing on facilitators and barriers toward reproductive empowerment. Methods: Qualitative in-depth interviews were undertaken with women of reproductive age (18-49 years) in Nampula and Maputo provinces and Maputo city, Mozambique. Data collection took place between February and March 2020 in Maputo region and during August 2020 in Nampula Province. Convenience sampling was used to recruit participants from both urban and rural healthcare facilities and from within the communities serving the healthcare facilities. In Maputo city, a snowball sampling technique was used to recruit women from the community. A total of 64 women were interviewed, 39 from Maputo and 25 from Nampula. A thematic analysis was conducted with the support of NVivo12 software. Results: Several factors that hinder and facilitate women's empowerment toward fertility and family planning practices in Mozambique were identified and were interpreted within the socio-ecological model. The identified barriers included women's lack of critical consciousness and oppressive relationships. At the community and societal levels, the role of traditions, culture and gender expectations and limited access to family planning and misinformation were also important hindering factors. The facilitators of reproductive empowerment included building critical consciousness and access to economic resources at the individual level. Negative experiences at the household level were triggers of women's empowerment for family planning. Building collective power and access to information, including education, were key at the community and societal levels. Conclusions: This study identified various factors that positively or negatively influence women's empowerment journeys in Mozambique. The role of tradition, culture, and gender expectations, and oppressive relationships, were important barriers in both provinces. Women from rural areas would benefit from building of consciousness about their rights, and power to decide on their reproductive lives. Interactions with the health providers offer an opportunity to do this by favoring controlling behaviors concerning their reproductive lives, promoting social networking and levering collective power.

Systematic review of the concept 'male involvement in maternal health' by natural language processing and descriptive analysis.

INTRODUCTION: Experts agree that male involvement in maternal health is a multifaceted concept, but a robust assessment is lacking, hampering interpretation of the literature. This systematic review aims to examine the conceptualisation of male involvement in maternal health globally and review commonly used indicators. METHODS: PubMed, Embase, Scopus, Web of Science and CINAHL databases were searched for quantitative literature (between the years 2000 and 2020) containing indicators representing male involvement in maternal health, which was defined as the involvement, participation, engagement or support of men in all activities related to maternal health. RESULTS: After full-text review, 282 studies were included in the review. Most studies were conducted in Africa (43%), followed by North America (23%), Asia (15%) and Europe (12%). Descriptive and text mining analysis showed male involvement has been conceptualised by focusing on two main aspects: psychosocial support and instrumental support for maternal health care utilisation. Differences in measurement and topics were noted according to continent with Africa focusing on HIV prevention, North America and Europe on psychosocial health and stress, and Asia on nutrition. One-third of studies used one single indicator and no common pattern of indicators could be identified. Antenatal care attendance was the most used indicator (40%), followed by financial support (17%), presence during childbirth (17%) and HIV testing (14%). Majority of studies did not collect data from men directly. DISCUSSION: Researchers often focus on a single aspect of male involvement, resulting in a narrow set of indicators. Aspects such as communication, shared decision making and the subjective feeling of support have received little attention. We believe a broader holistic scope can broaden the potential of male involvement programmes and stimulate a gender-transformative approach. Further research is recommended to develop a robust and comprehensive set of indicators for assessing male involvement in maternal health.

Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: a qualitative study.

BACKGROUND: Maternal mortality remains a daunting problem in Mozambique and many other low-resource countries. High quality antenatal care (ANC) services can improve maternal and newborn health outcomes and increase the likelihood that women will seek skilled delivery care. This study explores the factors influencing provider uptake of the recommended package of ANC interventions in Mozambique. METHODS: This study used qualitative research methods including key informant interviews with stakeholders from the health sector and a total of five focus group discussions with women with experience with ANC or women from the community. Study participants were selected from three health centers located in Maputo city, Tete, and Cabo Delgado provinces in Mozambique. Staff responsible for the medicines/supply chain at national, provincial and district level were interviewed. A check list was implemented to confirm the availability of the supplies required for ANC. Deductive content analysis was conducted. RESULTS: Three main groups of factors were identified that hinder the implementation of the ANC package in the study setting: a) system or organizational: include chronic supply chain deficiencies, failures in the continuing education system, lack of regular audits and supervision, absence of an efficient patient record system and poor environmental conditions at the health center; b) health care provider factors: such as limited awareness of current clinical guidelines and a resistant attitude to adopting new recommendations; and c) Users: challenges with accessing ANC, poor recognition amongst women about the purpose and importance of the specific interventions provided through ANC, and widespread perception of an unfriendly environment at the health center. CONCLUSIONS: The ANC package in Mozambique is not being fully implemented in the three study facilities, and a major barrier is poor functioning of the supply chain system. Recommendations for improving the implementation of antenatal interventions include ensuring clinical protocols based on the ANC model. Increasing the community understanding of the importance of ANC would improve demand for high quality ANC services. The supply chain functioning could be strengthened through the introduction of a kit system with all the necessary supplies for ANC and a simple monitoring system to track the stock levels is recommended.

Male Partners' Involvement in Prevention of Mother-to-Child HIV Transmission in Africa: A Systematic Review

In sub-Saharan Africa (SSA); male partners are rarely present during prevention of mother-to-child transmission (PMTCT) services. This systematic review aims to synthesize; from a male perspective; male partners' perceived roles; barriers and enablers of their involvement in PMTCT; and highlights persisting gaps. We carried out a systematic search of papers published between 2002 and 2013 in eng on Google Scholar and PubMed using the following terms: men; male partners; husbands; couples; involvement; participation; Antenatal Care (ANC); PMTCT; SSA countries; HIV Voluntary Counseling and Testing and disclosure. A total of 28 qualitative and quantitative original studies from 10 SSA countries were included. Men's perceived role was addressed in 28% (8/28) of the studies. Their role to provide money for ANC/PMTCT fees was stated in 62.5% (5/8) of the studies. For other men; the financial responsibilities seemed to be used as an excuse for not participating. Barriers were cited in 85.7% (24/28) of the studies and included socioeconomic factors; gender role; cultural beliefs; male unfriendly ANC/PMTCT services and providers' abusive attitudes toward men. About 64% (18/28) of the studies reported enablers such as: older age; higher education; being employed; trustful monogamous marriages and providers' politeness. In conclusion; comprehensive PMTCT policies that are socially and culturally sensitive to both women and men need to be developed

Implementation of evidence-based antenatal care in Mozambique: a cluster randomized controlled trial: study protocol.

BACKGROUND: Antenatal care (ANC) reduces maternal and perinatal morbidity and mortality directly through the detection and treatment of pregnancy-related illnesses, and indirectly through the detection of women at increased risk of delivery complications. The potential benefits of quality antenatal care services are most significant in low-resource countries where morbidity and mortality levels among women of reproductive age and neonates are higher.WHO developed an ANC model that recommended the delivery of services scientifically proven to improve maternal, perinatal and neonatal outcomes. The aim of this study is to determine the effect of an intervention designed to increase the use of the package of evidence-based services included in the WHO ANC model in Mozambique. The primary hypothesis is that the intervention will increase the use of evidence-based practices during ANC visits in comparison to the standard dissemination channels currently used in the country. METHODS: This is a demonstration project to be developed through a facility-based cluster randomized controlled trial with a stepped wedge design. The intervention was tailored, based on formative research findings, to be readily applicable to local prenatal care services and acceptable to local pregnant women and health providers. The intervention includes four components: the provision of kits with all necessary medicines and laboratory supplies for ANC (medical and non-medical equipment), a storage system, a tracking system, and training sessions for health care providers. Ten clinics were selected and will start receiving the intervention in a random order. Outcomes will be computed at each time point when a new clinic starts the intervention. The primary outcomes are the delivery of selected health care practices to women attending the first ANC visit, and secondary outcomes are the delivery of selected health care practices to women attending second and higher ANC visits as well as the attitude of midwives in relation to adopting the practices. This demonstration project is pragmatic in orientation and will be conducted under routine conditions. DISCUSSION: There is an urgent need for effective and sustainable scaling-up approaches of health interventions in low-resource countries. This can only be accomplished by the engagement of the country's health stakeholders at all levels. This project aims to achieve improvement in the quality of antenatal care in Mozambique through the implementation of a multifaceted intervention on three levels: policy, organizational and health care delivery levels. The implementation of the trial will probably require a change in accountability and behaviour of health care providers and we expect this change in 'habits' will contribute to obtaining reliable health indicators, not only related to research issues, but also to health care outcomes derived from the new health care model. At policy level, the results of this study may suggest a need for revision of the supply chain management system. Given that supply chain management is a major challenge for many low-resource countries, we envisage that important lessons on how to improve the supply chain in Mozambique and other similar settings, will be drawn from this study. TRIAL REGISTRATION: Pan African Clinical Trial Registry database. Identification number: PACTR201306000550192.

Choice of antibiotics for infection prophylaxis in emergency cesarean sections in low-income countries: a cost-benefit study in Mozambique.

BACKGROUND: There is a need to assess the cost-benefit of different models of antibiotic administration for the prevention of post cesarean infection, particularly in resource-scarce settings. DESIGN: Randomized, nonblinded comparative study of a single combined preoperative dose of gentamicin and metronidazole vs. a post cesarean scheme for infection prophylaxis. METHODS: Pregnant women (n = 288) with indication for emergency cesarean section were randomly allotted to two groups. Group 1 (n = 143) received the single, combined dose of prophylactic antibiotics and group 2 (n = 145) received, over 7 days, the postoperative standard scheme of antibiotics followed in the department. Both groups were followed up during 7 days for detection of signs of wound infection, endometritis, peritonitis and urinary tract infection. MAIN OUTCOME MEASURES: Prevalence of postoperative infection, mean hospital stay and costs of antibiotics used. RESULTS: Women completing the study (n = 241) were distributed into group 1 (n = 116) and group 2 (n = 125). No significant difference was found neither in the prevalence of postoperative infection nor in the mean hospital stay. No death occurred. The cost of the single dose of prophylactic antibiotics was less than one-tenth of the cost of the standard postoperative scheme. CONCLUSION: In our setting, the administration of a single dose of 160 mg of gentamicin in combination with 500 mg of metronidazole before emergency cesarean section for prevention of infection is clinically equivalent to existing conventional week-long postoperative therapy, but at approximately one-tenth of the cost.

The impact of adjustment for parity and mid-upper-arm circumference on sensitivity of symphysis-fundus height measurements to predict SGA foetuses in Mozambique.

BACKGROUND: With a new symphysis-fundus height (SFH) growth chart, based on Mozambican women with ultrasound-dated singleton pregnancies, the aim was to examine the possibility to enhance sensitivity of predicting small for gestational age (SGA) newborns by attempts to adjust the chart for parity and for mid-upper-arm circumference (MUAC). METHODS: Two antenatal clinics were chosen in the suburban area of Maputo City. A cohort of 904 consecutively recruited antenatal clients was followed until birth. Gestational age was determined by ultrasound at enrolment. The growth of the SFH was measured every 2-3 weeks. Women with multiple pregnancy or with gestational age >21 weeks at enrolment were excluded. Attempts were made to adjust SFH measurements for parity and MUAC by developing a mathematical model to increase sensitivity of the SFH method to predict a foetus being SGA. RESULTS: Parous women had on average 0.5-1 cm higher SFH readings than nulliparous women. Women with a body mass index (BMI) <19 and women with BMI >27 had approximately 1 cm lower and 1 cm higher readings, respectively, compared with women of normal BMI. There was a significant correlation between BMI and MUAC (r = 0.621; P < 0.001). The usefulness of SFH measurements to predict SGA newborns was analysed. The sensitivity was 49%, the specificity was 66%, the positive predictive value was 14% and the negative predictive value, 93%. By using the correlation between BMI and MUAC we tried to find a simple and useful method to improve the sensitivity of SFH to detect SGA foetuses. By reducing the SFH measurement by 1 cm for women with MUAC >29 and by 1 cm for multiparous women the sensitivity raised to 65% at the expense of reducing the specificity to 51%. Using a linear function of BMI, MUAC and parity to adjust the SFH measurement for each individual woman, it was possible to get a sensitivity of 70% with a corresponding specificity of 56%. CONCLUSION: By using BMI, MUAC and parity, it might be possible to improve the sensitivity of the SFH growth chart in predicting newborn being SGA but mostly at the expense of specificity.

Symphysis-fundal height growth chart of an obstetric cohort of 817 Mozambican women with ultrasound-dated singleton pregnancies.

Our aim was to construct a new symphysis-fundus height (SFH) growth chart, based on Mozambican women with ultrasound-dated singleton pregnancy, who represent the largest obstetric cohort in a developing country followed for this purpose. Two antenatal clinics were chosen in the suburban area of Maputo City. A cohort of 904 consecutively recruited antenatal clients was followed until delivery. The growth of the SFH was measured every second to third week. Gestational age was determined by ultrasound at enrolment. Women with multiple pregnancy or with gestational age > 21 weeks at enrolment were excluded. The average number of antenatal SFH measurements per woman was 7.8 (SD 2.4). The drop out rate was 9.6%. Mean birthweight was 2909 g. Pre-term deliveries occurred in 15% and low birthweight deliveries (< 2500 g) in 16%. Using proper longitudinal methods, we constructed an FH growth chart and compared it with various previously published SFH charts, which showed the Mozambican chart to be 0-3 cm below the others. Nulliparous women were 0.5 cm below multiparous women. We did not find any difference in the SFH growth charts between women with or without overt morbidity. Women with a body mass index (BMI) < 19 and women with a BMI > 27 had approximately 1 cm lower and 1 cm higher readings, respectively, than women with normal BMI. The Mozambican SFH growth chart is an example of an elaborated growth chart for a well-defined population in a low-income country. It constitutes the basis for further studies to predict the small-for-gestational age newborn from anthropometrical data obtained by use of appropriate technology.