Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: Secondary analyses of pooled community based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA)

London School of Hygiene & Tropical Medicine, London, UK. Electronic address: .
The Lancet (Impact Factor: 45.22). 05/2013; 381(9879):1763-1771. DOI: 10.1016/S0140-6736(13)60803-X
Source: PubMed


Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa.
The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum.
138 074 women aged 15—49 years contributed 636 213 person-years of observation. 49 568 women had 86 963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17·2% (95% CI 17·0—17·3), but 60 of 118 (50·8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20·5 (18·9—22·4) in women who were not pregnant or post partum and 8·2 (5·7—11·8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51·8 (47·8—53·8) per 1000 person-years in women who were not pregnant or post partum and 11·8 (8·4—15·3) per 1000 person-years in pregnant or post-partum women.
HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women.

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Available from: Abraham Jacobus Herbst, Jun 09, 2014
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    • "Of 17 studies from sub-Saharan Africa, however, only two were population based. An analysis of data from six population-based studies in East and Southern Africa found the proportion of pregnancy-related deaths attributable to HIV to be 45% and estimated that across sub-Saharan Africa as a whole this proportion was 24% (Zaba et al. 2013). Most global estimates of the proportion of maternal or pregnancy-related deaths attributable to HIV are based on mathematical models. "
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    ABSTRACT: Objectives To estimate the proportion of pregnancy-related deaths attributed to HIV in population-based studies in sub-Saharan Africa, and to document the methods used to make such attribution. Methods Four databases were searched for studies on causes of maternal and pregnancy-related mortality published from 2003 to June 2013. Data were extracted, and meta-analysis of proportions with random effects was used to obtain summary estimates. ResultsIn the 19 studies found, the proportion of deaths attributed to HIV ranged from 0.0% to 27.0%. The summary proportion was 3.4% (95% confidence interval: 1.8-6.3), with high heterogeneity. Subregionally, the summary proportions were 1.1% (0.4-3.3%) in West Africa, 4.5% (1.7-11.2%) in East Africa and 26.1% (21.9-30.7%) in Southern Africa. Criteria for assigning HIV as a cause of maternal death were rarely reported, and overall, methods were poor. Conclusions The proportion of pregnancy-related/maternal deaths attributed to HIV is substantially lower than modelled estimates, but comparisons are hampered by the absence of standard approaches. Clear guidelines on how to classify pregnancy-related deaths as attributable to HIV are urgently needed, so that the effect of the HIV epidemic on pregnancy-related mortality can be monitored and action taken accordingly.
    Preview · Article · May 2014 · Tropical Medicine & International Health
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    • "Global estimates attribute 20% of maternal deaths to HIV [1]. Statistics from Sub-Saharan Africa show that maternal mortality among HIV-infected women is approximately 8 times higher than among uninfected women [2]. "

    Full-text · Article · Apr 2014 · International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics
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    • "Other estimates suggest pregnancy-related HIV deaths as high as 25% of all maternal deaths for the region [37]. A secondary analysis of pooled community-based data for Sub-Saharan countries by Zaba et al.[38] found that excess mortality attributable to HIV was 51.8 (ranging across data sets from 47.8–53.8) per 1,000 person-years in women who were not pregnant or postpartum, and 11.8 (8.4–15.3) "
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    ABSTRACT: Notable among gaps in the achievement of the global health Millennium Development Goals (MDG) are shortcomings in addressing maternal health, an issue addressed in the fifth MDG. This shortfall is particularly acute in Sub-Saharan Africa (SSA), where over half of all maternal deaths occur each year. While there is not as yet a comprehensive understanding of the biological and social causes of maternal death in SSA, it is evident that poverty, gendered economic marginalization, social disruptions, hindered access to care, unevenness in the quality of care, illegal and clandestine abortions, and infections are all critical factors. Beyond these factors, this paper presents a review of the existing literature on maternal health in SSA to argue that syndemics constitute a significant additional source of maternal morbidity and mortality in the region. Increasing focus on the nature, prevention, and treatment of syndemics, as a result, should be part and parcel of improving maternal health in SSA.
    Full-text · Article · Nov 2013 · Infectious Diseases of Poverty
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