Accepted Article
Received Date : 14-Nov-2013 Accepted Date : 27-Feb-2014 Article type
: Main Research Article
Maternal mortality among HIV-infected pregnant women in Tanzania
Running headline: Maternal mortality among HIV-infected women
Nan Li1, Emmanuel Matchi2, Donna Spiegelman3,4, Guerino Chalamilla2, Ellen Hertzmank4,
David Sando2, Mary Mwanyika Sando2, Enju Liu1, Aisa Muya2 & Wafaie Fawzi1,3,5
1. Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA. 2. Management and Development for Health (NGO), Dar es Salaam, Tanzania 3. Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA 4. Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA 5. Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
Corresponding Author: Nan Li Department of Global Health and Population, Harvard School of Public Health, 1635 Tremont street, Boston, MA, USA E-mail: [email protected]
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/aogs.12374 This article is protected by copyright. All rights reserved.
Accepted Article
Conflicts of Interest The authors have stated explicitly that there are no conflicts in connection with this article.
Abstract Objective: To investigate risk factors for maternal mortality among HIV-infected women in Tanzania. Design: Prospective cohort study. Setting: HIV care and treatment clinics in Dar es Salaam, Tanzania. Population: HIV-infected pregnant women. Methods: Data were collected for
all patients enrolled in an HIV/AIDS care and treatment program. Between November 2004 and September 2011, there were 18 917 women pregnant at least once during the follow-up. Thirteen percent of these women had more than one pregnancy, with 21 645 pregnancies occurring. Logistic regression was used to explore the predictors of maternal death among these women. Main outcome measures: Maternal mortality. Results: During the study period, 363 maternal deaths occurred, giving a maternal mortality ratio of 1729 [95% confidence interval (CI): 15531905] per 100 000 live births. Being wasted [odds ratio (OR): 3.38, 95% CI: 2.58-4.45] and anemic (OR: 2.26, 95% CI: 1.70-3.00) were associated with a higher risk of maternal mortality. Women who were initiated on antiretroviral therapy before their pregnancy had a 55% decreased in the risk of maternal mortality (95% CI: 0.29-0.70) compared to women who were not. The risk of maternal mortality decreased with the length of time on antiretroviral therapy during pregnancy, by 8% for each additional month (OR: 0.92, 95%CI: 0.88-0.96). Conclusions: Maternal mortality was high among HIV-infected women. Initiating women on antiretroviral therapy as early as possible and providing nutritional interventions during pregnancy should be considered as means to reduce the maternal mortality among these women.
Key words Maternal mortality, HIV/AIDS, nutrition status, antiretroviral therapy, Tanzania, Sub-Saharan
Africa
Abbreviations ART, antiretroviral therapy; CI, confidence intervals;
This article is protected by copyright. All rights reserved.
Accepted Article
HAART, highly active antiretroviral therapy; ICD-10, International Statistical Classification of Diseases and Related Health Problems. MMR, maternal mortality ratio; OR, odds ratio; WHO, World Health Organization;
Key message Among HIV-infected women in Tanzania maternal mortality is a substantial problems, which it seems to possible to counteract by initiating women on antiretroviral therapy as early as possible and providing nutritional interventions during pregnancy.
Introduction
Maternal death is a major global public health issue and the majority of these deaths are in resource-constrained settings. The World Health Organization (WHO) estimated that globally, 287 000 maternal deaths occurred in 2010, which corresponded to a global maternal mortality ratio (MMR) of 210 maternal deaths/100 000 live births. Sub-Saharan Africa accounted for 56% of this global burden and had the highest MMR at 500 maternal deaths/100 000 live births (1). Sub-Saharan Africa has the highest prevalence of and high incidence of HIV infection with an estimated 1.8 million new HIV infections in 2009 (1). There is increasing evidence that the risk
of maternal death in HIV-infected women is one and half times to as much as five times higher in HIV infected women (2-4). Although maternal mortality has declined globally by 3.1% each
year since 1990, the decline has been slower in Sub-Saharan Africa (2.6%) likely because of the
HIV epidemic (5). In 2010, Sub-Saharan Africa had the largest proportion of maternal deaths attributed to HIV compared with other countries, with 10% of all deaths believed due to HIV. Capturing of maternal deaths is not straight forward. For resource-limited settings without routine registration, recording deaths of pregnant women is particularly difficult. There have been a few studies published on maternal mortality in Sub-Saharan Africa, with some having to rely entirely on model-based estimates (6), others relying on clinical records and verbal autopsies and being constrained by small sample size (7-9). Maternal mortality reduction is one of the This article is protected by copyright. All rights reserved.
Accepted Article
major targets of the Millennium Development Goals established by the United Nations in 2000. With only one year left to achieve the Millennium Development Goals, understanding the extent of the maternal death burden among HIV-infected women and risk factors for these deaths may be essential to accelerate progress. The objective of this study was to investigate risk factors for maternal mortality among HIV-infected women in Sub-Saharan Africa.
Material and Methods
Data were collected in all patients enrolled in a large HIV/AIDS care and treatment program in Dar es Salaam, Tanzania. Between November 2004 and September 2011, 64 296 HIV-infected women (≥15 years) were enrolled in the program, which was sponsored by the President's Emergency Plan for AIDS Relief (PEPFAR). There were 18 917 (28%) women pregnant at least once during the follow-up time. Thirteen percent of these women had more than one pregnancy, with 21 645 pregnancies occurring. Pregnant women were initiated on antiretroviral therapy (ART) if they met WHO stage 4 criteria, or WHO stage 3 criteria with a CD4 count
Received Date : 14-Nov-2013 Accepted Date : 27-Feb-2014 Article type
: Main Research Article
Maternal mortality among HIV-infected pregnant women in Tanzania
Running headline: Maternal mortality among HIV-infected women
Nan Li1, Emmanuel Matchi2, Donna Spiegelman3,4, Guerino Chalamilla2, Ellen Hertzmank4,
David Sando2, Mary Mwanyika Sando2, Enju Liu1, Aisa Muya2 & Wafaie Fawzi1,3,5
1. Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA. 2. Management and Development for Health (NGO), Dar es Salaam, Tanzania 3. Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA 4. Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA 5. Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
Corresponding Author: Nan Li Department of Global Health and Population, Harvard School of Public Health, 1635 Tremont street, Boston, MA, USA E-mail: [email protected]
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/aogs.12374 This article is protected by copyright. All rights reserved.
Accepted Article
Conflicts of Interest The authors have stated explicitly that there are no conflicts in connection with this article.
Abstract Objective: To investigate risk factors for maternal mortality among HIV-infected women in Tanzania. Design: Prospective cohort study. Setting: HIV care and treatment clinics in Dar es Salaam, Tanzania. Population: HIV-infected pregnant women. Methods: Data were collected for
all patients enrolled in an HIV/AIDS care and treatment program. Between November 2004 and September 2011, there were 18 917 women pregnant at least once during the follow-up. Thirteen percent of these women had more than one pregnancy, with 21 645 pregnancies occurring. Logistic regression was used to explore the predictors of maternal death among these women. Main outcome measures: Maternal mortality. Results: During the study period, 363 maternal deaths occurred, giving a maternal mortality ratio of 1729 [95% confidence interval (CI): 15531905] per 100 000 live births. Being wasted [odds ratio (OR): 3.38, 95% CI: 2.58-4.45] and anemic (OR: 2.26, 95% CI: 1.70-3.00) were associated with a higher risk of maternal mortality. Women who were initiated on antiretroviral therapy before their pregnancy had a 55% decreased in the risk of maternal mortality (95% CI: 0.29-0.70) compared to women who were not. The risk of maternal mortality decreased with the length of time on antiretroviral therapy during pregnancy, by 8% for each additional month (OR: 0.92, 95%CI: 0.88-0.96). Conclusions: Maternal mortality was high among HIV-infected women. Initiating women on antiretroviral therapy as early as possible and providing nutritional interventions during pregnancy should be considered as means to reduce the maternal mortality among these women.
Key words Maternal mortality, HIV/AIDS, nutrition status, antiretroviral therapy, Tanzania, Sub-Saharan
Africa
Abbreviations ART, antiretroviral therapy; CI, confidence intervals;
This article is protected by copyright. All rights reserved.
Accepted Article
HAART, highly active antiretroviral therapy; ICD-10, International Statistical Classification of Diseases and Related Health Problems. MMR, maternal mortality ratio; OR, odds ratio; WHO, World Health Organization;
Key message Among HIV-infected women in Tanzania maternal mortality is a substantial problems, which it seems to possible to counteract by initiating women on antiretroviral therapy as early as possible and providing nutritional interventions during pregnancy.
Introduction
Maternal death is a major global public health issue and the majority of these deaths are in resource-constrained settings. The World Health Organization (WHO) estimated that globally, 287 000 maternal deaths occurred in 2010, which corresponded to a global maternal mortality ratio (MMR) of 210 maternal deaths/100 000 live births. Sub-Saharan Africa accounted for 56% of this global burden and had the highest MMR at 500 maternal deaths/100 000 live births (1). Sub-Saharan Africa has the highest prevalence of and high incidence of HIV infection with an estimated 1.8 million new HIV infections in 2009 (1). There is increasing evidence that the risk
of maternal death in HIV-infected women is one and half times to as much as five times higher in HIV infected women (2-4). Although maternal mortality has declined globally by 3.1% each
year since 1990, the decline has been slower in Sub-Saharan Africa (2.6%) likely because of the
HIV epidemic (5). In 2010, Sub-Saharan Africa had the largest proportion of maternal deaths attributed to HIV compared with other countries, with 10% of all deaths believed due to HIV. Capturing of maternal deaths is not straight forward. For resource-limited settings without routine registration, recording deaths of pregnant women is particularly difficult. There have been a few studies published on maternal mortality in Sub-Saharan Africa, with some having to rely entirely on model-based estimates (6), others relying on clinical records and verbal autopsies and being constrained by small sample size (7-9). Maternal mortality reduction is one of the This article is protected by copyright. All rights reserved.
Accepted Article
major targets of the Millennium Development Goals established by the United Nations in 2000. With only one year left to achieve the Millennium Development Goals, understanding the extent of the maternal death burden among HIV-infected women and risk factors for these deaths may be essential to accelerate progress. The objective of this study was to investigate risk factors for maternal mortality among HIV-infected women in Sub-Saharan Africa.
Material and Methods
Data were collected in all patients enrolled in a large HIV/AIDS care and treatment program in Dar es Salaam, Tanzania. Between November 2004 and September 2011, 64 296 HIV-infected women (≥15 years) were enrolled in the program, which was sponsored by the President's Emergency Plan for AIDS Relief (PEPFAR). There were 18 917 (28%) women pregnant at least once during the follow-up time. Thirteen percent of these women had more than one pregnancy, with 21 645 pregnancies occurring. Pregnant women were initiated on antiretroviral therapy (ART) if they met WHO stage 4 criteria, or WHO stage 3 criteria with a CD4 count
