Association of maternal HIV infection with increase of infant mortality in Malawi

Aim:   To determine the association between maternal HIV infection and infant mortality in Malawi.
Methods:   A synthetic cohort life table based on the birth history of 2618 childbirths during 1999 and 2004, from the subsample of 2020 mothers who completed interview and were tested for HIV virus in the 2004 Malawi Demographic and Health Survey was used. The survey collected socio-demographic and health data of a natural representative sample of women aged 15 to 49; and obtained voluntary counselling tests for HIV infection from one-third of the representatives of the sample. Associations of maternal HIV status and other factors with infant mortality were estimated using survival regression analysis and the results are presented as hazard ratios (HR) with level of statistical significance ( P -value).
Results:   Children born to HIV-infected mothers were more than two times as likely to die during infancy as those born to uninfected mothers (HR = 2.21; P  < 0.01). Controlling for other risk factors and confounding factors for infant mortality further sharpened this relationship (HR = 2.70; P  < 0.01). Boys are more likely to die in infancy than girls. Young mothers and mothers not receiving prenatal care, and low-birthweight children and children living in rural areas, particular so in the northern region, were associated with a higher risk of infant mortality.
Conclusion:   Maternal HIV infection is strongly associated with infant mortality in Malawi independent of many other factors. Results from this study suggest that the HIV/AIDS epidemic has had an enormous impact on child well-being, child survival and infant mortality. The impact increases as the HIV/AIDS epidemic matures and infection in mothers and adults increases.     

Antenatal and perinatal predictors of infant mortality in rural Malawi

BACKGROUND: The slow pace in the reduction of infant mortality in sub-Saharan Africa has partially been attributed to the epidemic of human immunodeficiency virus (HIV) infection. To facilitate early interventions, antenatal and perinatal predictors of 1st year mortality were identified in a rural community in southern Malawi. METHODS: A cohort of 733 live born infants was studied prospectively from approximately 24 gestation weeks onwards. Univariate analysis was used to determine relative risks for infant mortality after selected antenatal and perinatal exposures. Multivariate modelling was used to control for potential confounders. FINDINGS: The infant mortality rate was 136 deaths/1000 live births. Among singleton newborns, the strongest antenatal and perinatal predictors of mortality were birth between May and July, maternal primiparity, birth before 38th gestation week, and maternal HIV infection. Theoretically, exposure to these variables accounted for 22%, 22%, 17%, and 15% of the population attributable risk for infant mortality, respectively. INTERPRETATION: The HIV epidemic was an important but not the main determinant of infant mortality. Interventions targetting the offspring of primiparous women or infants born between May and July or prevention of prematurity would all have considerable impact on infant survival.     

Post-neonatal mortality by rurality and Indigenous status in Queensland

AIM: To compare post-neonatal mortality among urban and rural Indigenous babies in Queensland. METHODS: Registrations of deaths at ages 28 days to 12 months were linked to routine data from the Queensland Perinatal Data Collection. RESULTS: Indigenous babies were 2.52 times more likely to die during the post-neonatal period than non-Indigenous babies (95% confidence interval: 1.99, 3.20). The differential remained when urban and rural areas were examined separately: the differential was 2.53 (1.81, 3.54) in urban areas and 2.26 (1.58, 3.23) in rural areas. CONCLUSION: The key demographic variable that determines post-neonatal mortality in Queensland is Indigenous status, not rurality. This has important policy implications because it means that interventions to reduce the disparity in mortality between Indigenous and non-Indigenous babies should be delivered in urban as well as rural areas. Better routine data are needed and in particular clinical classification of deaths, so that interventions can be monitored and avoidable factors identified.     

Child mortality according to maternal and infant HIV status in Zimbabwe

BACKGROUND: HIV causes substantial mortality among African children but there is limited data on how this is influenced by maternal or infant infection status and timing. METHODS: Children enrolled in the ZVITAMBO trial were divided into 5 groups: those born to HIV-negative mothers (NE, n = 9510), those born to HIV-positive mothers but noninfected (NI, n = 3135), those infected in utero (IU, n = 381), those infected intrapartum (IP, n = 508), and those infected postnatally (PN, n = 258). Their mortality was estimated. RESULTS: Two-year mortality was 2.9% (NE infants), 9.2% (NI), 67.5% (IU), 65.1% (IP), and 33.2% (PN). Between 8 weeks and 6 months, mortality in IU infants quintupled (from 309 to 1686/1000 c-y). The median time from infection to death was 208, 380, and >500 days for IU, IP, and PN infants, respectively. Among NI children, advanced maternal disease was predictive of mortality. Acute respiratory infection was the major cause of death. CONCLUSIONS: Perinatally infected infants are at particular risk of death between 2 and 6 months: cotrimoxazole prophylaxis and early pediatric HAART should be scaled up. Uninfected infants of infected mothers have at least twice the mortality risk of infants born to uninfected mothers: all HIV-exposed infants should be targeted with child survival interventions. HIV-positive mothers with more advanced disease are not only more likely to infect their infants, but their infants are more likely to die, whether infected or not: provision of antiretroviral treatment to pregnant and lactating women is an urgent need for both mothers and their children.     

Perinatal morbidity and mortality in small-for-dates babies: The relative importance of some maternal factors

Data on 538 mothers and their small-for-dates babies were analysed to ascertain whether any specific maternal factors were associated with increased perinatal risks. There were 34 deaths; 21 (62%) of these babies had major congenital abnormalities. Among the survivors perinatal morbidity was also markedly increased when the baby was abnormal. No direct associations were found between abnormal babies and any maternal factors. Few differences were found in the incidence of mortality and morbidity factors according to maternal height, weight, weight gain in pregnancy, social class and smoking habits. There was a significantly higher death rate when the mother was pre-eclamptic, and the incidence of seven other morbidity factors was also increased. The only adverse effects of maternal hypertension without pre-eclampsia was a higher instrumental delivery rate, and more of these babies were tube-fed. There were significantly more perinatal deaths among multiparous women whose previous babies had been of average birthweight. This was due to an excess of congenitally abnormal babies in this group. Only 35% small-for-dates babies escaped any perinatal problems.     

Factors associated with maternal rating of infant health in central Harlem

Maternal perceptions of infant health are strongly associated with the use of health services and may influence the child's future health and development. The extent to which such perceptions reflect infant health problems or a response to environmental stress in the mother's life is unclear. Because this issue may be especially important in disadvantaged groups for which both high levels of infant morbidity and environmental stress are common, we have explored the correlates of maternal perceptions of infant health among 367 mothers of 12-month-olds in central Harlem. Lower ratings of infant health were associated with such indicators of morbidity as problems in the neonatal period, hospitalization, and one or more episodes of illness. They were also associated with lower family income and the mother's rating of her own health in the bivariate analyses, but not in multivariate analyses. Neither maternal mental health, social support, nor environmental stress appeared to influence maternal rating of child health. These findings indicate that a mother's ratings of her infant's health relate specifically to the child's morbidity, independent of her own health and environmental stress. Moreover, within disadvantaged communities, infants of the poorest mothers may experience greater levels of morbidity.     

Improving infant sleep and maternal mental health: a cluster randomised trial

Objectives

To determine whether a community‐delivered intervention targeting infant sleep problems improves infant sleep and maternal well‐being and to report the costs of this approach to the healthcare system.

Design

Cluster randomised trial.

Setting

49 Maternal and Child Health (MCH) centres (clusters) in Melbourne, Australia.

Participants

328 mothers reporting an infant sleep problem at 7 months recruited during October–November 2003.

Intervention

Behavioural strategies delivered over individual structured MCH consultations versus usual care.

Main outcome measures

Maternal report of infant sleep problem, depression symptoms (Edinburgh Postnatal Depression Scale (EPDS)), and SF‐12 mental and physical health scores when infants were 10 and 12 months old. Costs included MCH sleep consultations, other healthcare services and intervention costs.

Results

Prevalence of infant sleep problems was lower in the intervention than control group at 10 months (56% vs 68%; adjusted OR 0.58 (95% CI: 0.36 to 0.94)) and 12 months (39% vs 55%; adjusted OR 0.50 (0.31 to 0.80)). EPDS scores indicated less depression at 10 months (adjusted mean difference −1.4 (−2.3 to −0.4) and 12 months (−1.7 (−2.6 to −0.7)). SF‐12 mental health scores indicated better health at 10 months (adjusted mean difference 3.7 (1.5 to 5.8)) and 12 months (3.9 (1.8 to 6.1)). Total mean costs including intervention design, delivery and use of non‐MCH nurse services were £96.93 and £116.79 per intervention and control family, respectively.

Conclusions

Implementing this sleep intervention may lead to health gains for infants and mothers and resource savings for the healthcare system.

Trial registration

Current Controlled Trial Registry, number ISRCTN48752250 (registered November 2004).Maternal depression impacts adversely on maternal quality of life, mother–child relationships and child development.^1,2 Despite a prevalence of 15% in the first year postpartum,³ depression often remains undiagnosed and, even if detected, many mothers reject the diagnosis, the treatment or both.⁴Maternal depression is linked to poor infant sleep. Problems with frequent night waking and difficulties settling to sleep are reported by over a third of parents in the second 6 months of life^5,6 and are consistently associated with poor maternal health.^7,8,9In a previous efficacy trial, we demonstrated that treating infant sleep problems (simple behavioural techniques delivered in local well‐child centres over two to three sessions) significantly reduced maternal reports of depression symptoms as well as infant sleep problems.¹⁰ However, efficacy and generalisability may be limited by the predominantly middle‐class status of participating families and the fact that the intervention was delivered by a single paediatrician (HH). In another randomised trial,¹¹ a single, nurse‐led consultation emphasising ways to help very young infants settle to sleep independently resulted in intervention infants sleeping more than controls at age 12 weeks but in no change in maternal depression. All other sleep intervention trials have been limited by selection bias, small sample sizes, short follow‐up and/or lack of randomisation.¹²The trial reported here was conducted within an existing universally available, state‐wide primary health care service, training the well‐child care providers themselves to manage infant sleep problems in families from a broad sociodemographic sample. We hypothesised that a brief behavioural intervention designed to reduce infant sleep problems would result in improved infant sleep and maternal well‐being. We also documented the costs of the intervention and costs to the healthcare system.     

Psychosocial predictors of maternal and infant health among adolescent mothers

Past work suggests that stressful life events and social support are significantly associated with a broad range of child health outcomes. Such associations have remained, however, generally modest in magnitude, suggesting that stress and support may be only proxy measures for a deeper, more central aspect of childhood psychosocial experience. One aspect of young people's lives that could plausibly mediate the effects of stress and social support on health is the sense of stability and "permanence" in ongoing life experience. We developed a standardized psychometric instrument for measuring a "sense of permanence" and employed the measure in a prospective 1-year study of health outcomes among 89 adolescent mothers and their infants. Psychosocial and demographic factors were significantly predictive of maternal, but not infant, health outcomes, and the sense of permanence appeared to operate as a "final common pathway" in the influence of psychosocial variables on health and illness end points. Results of the study underscore the importance of continuity and stability in childhood and suggest that changes in an individual's sense of permanence may underlie the previously documented health effects of stressful life events and social support.     

Sequelae of infant colic: evidence of transient infant distress and absence of lasting effects on maternal mental health

BACKGROUND: Colic is widely believed to remit by 3 months of age, with little lasting effect on the infant or the family. OBJECTIVES: To determine the prevalence of colic at 3 months and the proportion of cases of colic (identified at 6 weeks) that remitted by 3 months; to identify the factors predictive of colic's remission; and to explore the potential lasting effects of colic on maternal mental health. DESIGN: Prospective cohort study of 856 mother-infant dyads. Self-administered questionnaires were mailed to mothers at 1 and 6 weeks and 3 and 6 months post partum. Standardized instruments were incorporated into the first and last questionnaires to assess maternal anxiety, postnatal depression, and social support. At 6 weeks and at 3 months, mothers completed the Barr diary and/or the Ames Cry Score. RESULTS: Data from 547 dyads were available for analysis. The prevalence of colic at 3 months was 6.4%. More than 85% of cases of colic had remitted by 3 months of age. These infants were more likely to be female, whereas the mothers of these infants were more likely to have received pain relief during labor/delivery and to have been employed during pregnancy. Reductions in scores for trait anxiety and postnatal depression, although smaller for mothers whose infants were colicky at 6 weeks of age, were not significantly different from those of mothers whose infants were never colicky. CONCLUSION: This study provides support for the belief that, in most cases, colic is self-limiting and does not result in lasting effects to maternal mental health.     

Improving infant sleep and maternal mental health: a cluster randomised trial.

OBJECTIVES: To determine whether a community-delivered intervention targeting infant sleep problems improves infant sleep and maternal well-being and to report the costs of this approach to the healthcare system. DESIGN: Cluster randomised trial. SETTING: 49 Maternal and Child Health (MCH) centres (clusters) in Melbourne, Australia. PARTICIPANTS: 328 mothers reporting an infant sleep problem at 7 months recruited during October-November 2003. INTERVENTION: Behavioural strategies delivered over individual structured MCH consultations versus usual care. MAIN OUTCOME MEASURES: Maternal report of infant sleep problem, depression symptoms (Edinburgh Postnatal Depression Scale (EPDS)), and SF-12 mental and physical health scores when infants were 10 and 12 months old. Costs included MCH sleep consultations, other healthcare services and intervention costs. RESULTS: Prevalence of infant sleep problems was lower in the intervention than control group at 10 months (56% vs 68%; adjusted OR 0.58 (95% CI: 0.36 to 0.94)) and 12 months (39% vs 55%; adjusted OR 0.50 (0.31 to 0.80)). EPDS scores indicated less depression at 10 months (adjusted mean difference -1.4 (-2.3 to -0.4) and 12 months (-1.7 (-2.6 to -0.7)). SF-12 mental health scores indicated better health at 10 months (adjusted mean difference 3.7 (1.5 to 5.8)) and 12 months (3.9 (1.8 to 6.1)). Total mean costs including intervention design, delivery and use of non-MCH nurse services were 96.93 pounds sterling and 116.79 pounds sterling per intervention and control family, respectively. CONCLUSIONS: Implementing this sleep intervention may lead to health gains for infants and mothers and resource savings for the healthcare system. TRIAL REGISTRATION: Current Controlled Trial Registry, number ISRCTN48752250 [controlled-trials.com] (registered November 2004).     

Differences in infant mortality by race, nativity status, and other maternal characteristics

The objective of this study was to examine the effects of nativity status (native vs foreign born) and other maternal characteristics (age, parity, education, and marital status) on infant, neonatal, and postneonatal mortality among white and black mothers. The design of this nonrandomized cohort study was based on birth and death certificates. The setting involved live births among US residents (excluding California, Texas, and Washington) in 1983 and 1984. The participants included white mothers with 4.4 million births and black mothers with 926,000 births in single deliveries. There were no interventions. With regard to measurements (the main results), after adjusting for other risk factors, neonatal mortality risk was 22% lower among the black foreign-born mothers than among the black native-born mothers, while among white infants, there was no risk difference by nativity. Relative risks were more similar for postneonatal mortality, ie, 24% lower among black foreign-born mothers and 20% lower among white foreign-born mothers. Combining the several categories of risk factors into three broad maternal risk groups, there was a near-doubling of black and near-tripling of white infant mortality rates between the low and high levels of maternal risk. We concluded that if the infant mortality rate in the low-risk groups could be achieved by the moderate- and high-risk groups, there would be a 30% reduction in infant deaths within each race. Since the black infant mortality rate is twice the white infant mortality rate and black foreign-born mothers have much lower rates than black native-born mothers, it is likely that further improvement is possible among black infants.     

Post-neonatal tetanus: Issues in intensive care management

Tetanus is an acute neurological disease characterized by muscle rigidity and spasms, autonomic dysfunction and in severe forms requires respiratory and hemodynamic support. Though it is entirely preventable by immunization, it still occurs in developing countries causing significant morbidity and mortality. Intensive care management of tetanus is fraught with problems of ventilator-associated pneumonia, nosocomial sepsis and a variety of other complications. Various treatment protocols have been tried in managing diverse manifestations of severe tetanus but the consensus is yet to emerge. In this review we have discussed the pathophysiology, clinical features and management controversies and suggest on basis of our experience use of high dose diazepam (20-120 mg/kg/day) and vecuronium with mechanical ventilation if required for control of spasms, and early detection of autonomie dysfunction and use of propranolol, in our circumstances.