Structural barriers to maternity care in Cameroon: a qualitative study.

BACKGROUND: The maternal mortality and perinatal mortality rate in Cameroon are among the highest worldwide. To improve these outcomes, we conducted a formative qualitative assessment to inform the adaptation of a mobile provider-to-provider intervention in Cameroon. We explored the complex interplay of structural barriers on maternity care in this low-resourced nation. The study aimed to identify structural barriers to maternal care during the early adaptation of the mobile Medical Information Service via Telephone (mMIST) program in Cameroon. METHODS: We conducted in-depth interviews and focus groups with 56 key stakeholders including previously and currently pregnant women, primary healthcare providers, administrators, and representatives of the Ministry of Health, recruited by purposive sampling. Thematic coding and analysis via modified grounded theory approach were conducted using NVivo12 software. RESULTS: Three main structural barriers emerged: (1) civil unrest (conflict between Ambazonian militant groups and the Cameroonian government in the Northwest), (2) limitations of the healthcare system, (3) inadequate physical infrastructure. Civil unrest impacted personal security, transportation safety, and disrupted medical transport system. Limitations of healthcare system involved critical shortages of skilled personnel and medical equipment, low commitment to evidence-based care, poor reputation, ineffective health system communication, incentives affecting care, and inadequate data collection. Inadequate physical infrastructure included frequent power outages and geographic distribution of healthcare facilities leading to logistical challenges. CONCLUSION: Dynamic inter-relations among structural level factors create barriers to maternity care in Cameroon. Implementation of policies and intervention programs addressing structural barriers are necessary to facilitate timely access and utilization of high-quality maternity care.

HIV Status and Contraceptive Utilization among Women in Cameroon.

OBJECTIVE: We examined patterns of contraceptive utilization by HIV status among women in Cameroon, hypothesizing that women living with HIV would utilize contraception at higher rates than their HIV-negative peers. METHODS: Deidentified, clinical data from the Cameroon Baptist Convention Health Services (2007-2013) were analyzed (N = 8995). Frequencies compared outcomes between women living with HIV (15.1%) and uninfected women. Multivariate analyses examined associates of contraceptive utilization and desire to become pregnant. RESULTS: Contraceptive utilization was associated with higher education, living with HIV, monogamy, and higher parity ( P < .001). Women living with HIV had 66% higher odds of using contraceptives than their negative peers (odds ratio [OR]: 1.66, confidence interval [CI]: 1.45-1.91, P < .001). Polygamous women had 37% lower odds of using contraceptives compared to monogamous women (OR: 0.63, 95% CI: 0.52-0.75, P < .001). CONCLUSION: Increasing contraceptive utilization in resource-constrained settings should be a priority for clinicians and researchers. Doing so could improve population health by reducing HIV transmission between partners and from mother to child.

Risk of adverse pregnancy outcomes in women with mild chronic hypertension before 20 weeks of gestation.

OBJECTIVE: To evaluate whether blood pressure (BP) less than 140/90 mm Hg is associated with lower risk of adverse pregnancy outcomes in women with mild chronic hypertension. METHODS: This was a secondary analysis of women with chronic hypertension diagnosed before 20 weeks of gestation (either BP 140/90 mm Hg or greater on two occasions at least four hours apart or previously diagnosed and on antihypertensive therapy) enrolled in the Maternal-Fetal Medicine Units Network's High-risk Aspirin preeclampsia prevention trial. Outcomes including a primary composite (perinatal death, severe preeclampsia, placental abruption, and indicated preterm birth less than 35 weeks of gestation) and small for gestational age (SGA) were compared by study preenrollment BP analyzed as a categorical (less than 140/90, 140-150/90-99, or 151-159/100-109 mm Hg) and as a continuous variable. RESULTS: Among 759 women with singleton pregnancy and preenrollment BP less than 160/110 mm Hg, the incidence of the primary composite outcome (10.7%, 19.0%, 30%) and SGA (8.8%, 12.3%, 23.7%) increased with increasing BP category (P values≤.001). The adjusted odds ratio (95% confidence interval) for the primary composite was 2.0 (1.3-3.2) for 140-150/90-99 mm Hg and 3.2 (1.6-6.3) for 151-159/100-109 mm Hg compared with BP less than 140/90 mm Hg. The results for SGA were 1.6 (0.9-2.8) and 3.8 (1.8-7.9), respectively. Models including continuous systolic and diastolic BP revealed increasing adverse outcomes per 5-mm Hg rise in diastolic but not systolic BP: primary composite (19% per 5 mm Hg) and SGA (22% per 5 mm Hg). CONCLUSION: The risks of adverse pregnancy outcomes in women with chronic hypertension are lower with preenrollment BP less than 140/90 mm Hg as compared with higher BP categories and increase with increasing BP. LEVEL OF EVIDENCE: II.

When is primary cesarean appropriate: maternal and obstetrical indications.

To describe appropriate maternal and obstetrical indications for primary cesarean delivery. The list of potential indications is long. Among all maternal and obstetrical indications, labor dystocia is the most common; multifetal pregnancy and malpresentation are not infrequent. Maternal indications, including human immunodeficiency virus (with high viral load) and herpes simplex virus (with active lesions), are rare. Preeclampsia alone typically is not an appropriate indication for cesarean delivery. Although the need for a cesarean is absolute for some conditions, such as complete placenta previa or placenta accreta, minimum criteria for a cesarean are variable and subjective for many indications, including dystocia. The subjective diagnosis of labor dystocia provides the best opportunity to prevent the first cesarean.

Timing of delivery and pregnancy outcomes among laboring nulliparous women.

OBJECTIVE: The objective of the study was to compare pregnancy outcomes by completed week of gestation after 39 weeks with outcomes at 39 weeks. STUDY DESIGN: Secondary analysis of a multicenter trial of fetal pulse oximetry in spontaneously laboring or induced nulliparous women at a gestation of 36 weeks or longer. Maternal outcomes included a composite (treated uterine atony, blood transfusion, and peripartum infections) and cesarean delivery. Neonatal outcomes included a composite of death, neonatal respiratory and other morbidities, and neonatal intensive care unit admission. RESULTS: Among the 4086 women studied, the risks of the composite maternal outcome (P value for trend < .001), cesarean delivery (P < .001), and composite neonatal outcome (P = .047) increased with increasing gestational age from 39 to 41 or more completed weeks. Adjusted odds ratios (95% confidence interval) for 40 and 41 or more weeks, respectively, compared with 39 weeks were 1.29 (1.03-1.64) and 2.05 (1.60-2.64) for composite maternal outcome, 1.28 (1.05-1.57) and 1.75 (1.41-2.16) for cesarean delivery, and 1.25 (0.86-1.83) and 1.37 (0.90-2.09) for composite neonatal outcome. CONCLUSION: Risks of maternal morbidity and cesarean delivery but not neonatal morbidity increased significantly beyond 39 weeks.

Non-cigarette tobacco use among women and adverse pregnancy outcomes.

Although cigarette smoking remains the most prevalent form of tobacco use in girls and in women of reproductive age globally, use of non-cigarette forms of tobacco is prevalent or gaining in popularity in many parts of the world, especially in low- and middle-income countries. Sparse but growing evidence suggests that the use of some non-cigarette tobacco products during pregnancy increases the risk of adverse pregnancy outcomes. In this paper we review the literature on the prevalence of non-cigarette tobacco product use in pregnant women and in women of reproductive age in high-, middle-, and low-income countries and the evidence that maternal use of these products during pregnancy has adverse health effects. In addition, we communicate findings from an international group of perinatal and tobacco experts that was convened to establish research priorities concerning the use of non-cigarette tobacco products during pregnancy. The working group concluded that attempts to develop a public health response to non-cigarette tobacco use in women are hindered by a lack of data on the epidemiology of use in many parts of the world and by our limited understanding of the type and magnitude of the health effects of these products. We highlight research gaps and provide recommendations for a global research agenda.

Progesterone for preterm birth prevention: an evolving intervention.

We sought to review emerging data on the use of progesterone to prevent preterm birth (PTB). Using the terms "preterm or premature" and "progesterone" we queried the PubMed database, restricting our search to January 1, 2000, forward and selected randomized clinical trials (RCTs) and metaanalyses of RCTs that evaluated the use of progesterone for the prevention of PTB. We reviewed 238 abstracts and supplemented our review by a bibliographic search of selected reports. We focused on the pharmacologic aspects of progesterone and risk factor-specific outcomes. We identified a total of 17 relevant reports: 8 individual RCTs, 6 metaanalyses, and 3 national guidelines. Individual trials and metaanalyses support that synthetic intramuscular 17-alpha-hydroxyprogesterone effectively reduces the incidence of recurrent PTB in women with a history of spontaneous PTB. One trial found that vaginally administered natural progesterone reduced the risk of early PTB in women with a foreshortened cervix. The data are suggestive but inconclusive about: (1) the benefits of progesterone in the setting of arrested preterm labor; and (2) whether progesterone lowers perinatal morbidity or mortality. In some women, progesterone reduces the risk of PTB. Further study is required to identify appropriate candidates and optimal formulations.