Exploring the discursive construction of menopause for Thai women

The terms 'menopause' and 'mid-life women' have become the subjects of both the medical gaze and a billion-dollar industry built by pharmaceutical companies to manage the 'problems' of menopause. Menopause is a discursive construction, a label that has become endowed with a large number of taken-for-granted assumptions about physical and psychological symptoms, self-image and health status. These assumptions are based on the medical interests, social preoccupations, research and subsequent drug-marketing strategies conducted in western societies. Thai society is structured around a different philosophy, which has created different meanings for the mid-life woman. This paper explores the Western discourses of menopause and the colonizing effect when the assumptions underpinning these are imposed on Thai women.     

Survivors’ understanding of vulnerability and resilience to maternal near-miss obstetric events in Uganda

Objective

To gain an understanding of how obstetric complications affect the lives and livelihoods of survivors.

Methods

A phenomenological study was conducted between April and August 2013 at Mulago Hospital, Kampala, Uganda. Data were collected through in-depth interviews among 36 women admitted with obstetric near miss. The interviews investigated perceptions, lived experiences, and meanings attached to such experiences by survivors. More specifically, the questions explored: self-rated health; anticipated social, sexual, and reproductive health challenges; and mitigating factors.

Results

The identified themes were prior expectations, vulnerability, body and social capital, and resilience. Women were found to approach childbirth with predetermined expectations that influenced their pregnancy and childbirth experience. Fatalism, expectations, and social insecurity markedly contributed to vulnerability. Resilience factors included ability to institute adaptations and to harness body and social capital.

Conclusion

Vulnerabilities and their determinants were found to be inter-related. Individuals’ social capital fluctuates over the acute crisis, necessitating multiple adaptations and coping strategies to reduce vulnerability or increase resilience. Although social and body capital may be mobilized to mitigate the effects of the obstetric crisis, they can either worsen vulnerability or increase resilience.     

Why mothers die at a busy tertiary urban hospital in Kampala,Uganda: a comprehensive review of maternal deaths 2016–2018 and implications for quality improvement to reduce deaths

BackgroundReviewing maternal deaths and drawing out lessons for clinical practice is part of an effective cohesive intervention strategy to reduce future deaths.ObjectiveTo review maternal deaths at the National Referral hospital in Kampala over a 3-year period (2016–2018) to determine causes of death, extent of preventability, proportion of deaths notified and audited as per national guidelines.MethodsTrained-multidisciplinary panels (obstetricians and senior midwives) conducted retrospective reviews of maternal deaths that occurred.ResultsMajor causes of deaths: obstetric haemorrhage (158/350; 45%), hypertensive disorders of pregnancy (87/350; 25%) and infection (95/350; 27%). Overall, 294/350 (84%) of maternal deaths were considered preventable. In 95% (332/350) of cases, delays within healthcare facilities were identified (64%; 226/350). We note that only 115/350 (33%) cases had been audited. This proportion did not change during the studied period. In 48% (167/350) of cases, notification to the Ministry of Health occurred, but only 11% of deaths (39/350) were notified within the recommended 24-hours.ConclusionsA high proportion (84%) of deaths were preventable. Significant delays to care occurred within health-care facilities. Results suggest that a well-supported, and timely maternal death review process with targeted and pragmatic interventions might be effective in reducing maternal deaths in this setting.     

A KIR B centromeric region present in Africans but not Europeans protects pregnant women from pre-eclampsia

In sub-Saharan Africans, maternal mortality is unacceptably high, with >400 deaths per 100,000 births compared with <10 deaths per 100,000 births in Europeans. One-third of the deaths are caused by pre-eclampsia, a syndrome arising from defective placentation. Controlling placentation are maternal natural killer (NK) cells that use killer-cell immunoglobulin-like receptor (KIR) to recognize the fetal HLA-C molecules on invading trophoblast. We analyzed genetic polymorphisms of maternal KIR and fetal HLA-C in 484 normal and 254 pre-eclamptic pregnancies at Mulago Hospital, Kampala, Uganda. The combination of maternal KIR AA genotypes and fetal HLA-C alleles encoding the C2 epitope associates with pre-eclampsia [P = 0.0318, odds ratio (OR) = 1.49]. The KIR genes associated with protection are located in centromeric KIR B regions that are unique to sub-Saharan African populations and contain the KIR2DS5 and KIR2DL1 genes (P = 0.0095, OR = 0.59). By contrast, telomeric KIR B genes protect Europeans against pre-eclampsia. Thus, different KIR B regions protect sub-Saharan Africans and Europeans from pre-eclampsia, whereas in both populations, the KIR AA genotype is a risk factor for the syndrome. These results emphasize the importance of undertaking genetic studies of pregnancy disorders in African populations with the potential to provide biological insights not available from studies restricted to European populations.Although pre-eclampsia presents clinically with a diverse array of systemic symptoms, the underlying disease-causing mechanism starts with placentation when trophoblast cells invade the decidua. Here, they transform the uterine spiral arteries into large vessels that form the fetoplacental supply line (1, 2). In pre-eclampsia and other pregnancy disorders (fetal growth restriction, stillbirth, and recurrent miscarriage) known collectively as the great obstetric syndromes (GOSs), trophoblast fails to invade optimally (3). Pre-eclampsia and other GOSs occur in all populations, but women of African ancestry are significantly more at risk; thus, GOSs are responsible for much of the high maternal and fetal mortality rates seen in sub-Saharan Africa (SSA) (4). The genetic contribution to pre-eclampsia is supported by several studies and involves both maternal genes and paternal genes inherited by the fetus (5, 6).The wall of the uterus is the territorial boundary between two genetically different individuals: the mother and the fetus. The uterine mucosal immune system appears to define this maternal/placental boundary. The decidua must control placentation, because in its absence, the trophoblast infiltrates to a dangerous extent, causing the condition of placenta percreta (7). The decidua contains an abundant population of specialized natural killer (NK) cells. These uterine NK cells (uNK) express killer-cell immunoglobulin-like receptors (KIRs) that recognize trophoblast HLA-C ligands (8, 9). Both KIR and HLA-C are genetically variable, resulting in many possible combinations of maternal KIR and fetal HLA-C ligands (10). The KIR region is defined by two groups of haplotype: A and B. The KIR A haplotype has seven KIR genes, all encoding inhibitory receptors apart from KIR2DS4. In contrast, the KIR B haplotype contains a variable number of additional KIR, most of which encode activating receptors (11, 12). All HLA-C allotypes are KIR ligands and can be divided into two groups (carrying either C1 or C2 epitopes) that are distinguished by a dimorphism at position 80 and recognized by different KIR (13). Within a human population, the combination of KIR and HLA diversity distinguishes individuals and this extremely high variation is particularly evident in SSA populations. They exhibit less linkage disequilibrium (LD) between the KIR genes than other populations (14–16), and the KIR genes have greater allelic diversity (15, 16). A variety of diseases and clinical conditions has been associated with combinations of HLA-C and KIR genes. In previous case–control studies of pre-eclampsia in pregnant European women, we showed that, when the fetus carries a C2 epitope, maternal KIR AA genotypes are risk factors for pre-eclampsia, whereas the KIR2DS1 gene of maternal KIR B haplotypes is protective (8, 17). In the case–control study reported here, we test the hypothesis that these factors confer similar risk and protection to pregnant SSA women.     

Urologic complications among women with advanced cervical cancer at a tertiary referral hospital in Uganda

Objective

To determine the prevalence of and factors associated with urologic complications among women with advanced cervical cancer before treatment in Uganda.

Methods

In total, 283 women with histologically confirmed stage IIB–IVB cervical cancer who were admitted to Mulago Hospital over a 6-month period were studied. Abdominopelvic scan was carried out to check for hydronephrosis and hydroureter and to measure the tumor volume. Serum creatinine and urea levels were measured, and the presence of anuria and vesicovaginal fistula (VVF) was ascertained from self-reporting and clinical records.

Results

Urologic complications were present in 138 (48.8%) women. Hydronephrosis, VVF, hydroureter, and anuria were present in 112 (39.6%), 21 (7.4%), 11 (3.9%), and 9 (3.2%) women, respectively; serum creatinine and urea levels were elevated in 48 (17.0%) women. Stage of disease was significantly associated with urologic complications: stage IIIB odds ratio (OR) 3.36 (95% confidence interval [CI], 1.57–7.20); stage IVA OR 17.10 (95% CI, 6.07–48.16); P < 0.001.

Conclusion

There is a high prevalence of urologic complications among women with advanced cervical cancer; these complications are significantly associated with the stage of cervical cancer.     

Validation of an Automated Wearable Camera-Based Image-Assisted Recall Method and the 24-h Recall Method for Assessing Women’s Time Allocation in a Nutritionally Vulnerable Population: The Case of Rural Uganda

Accurate data are essential for investigating relationships between maternal time-use patterns and nutritional outcomes. The 24 h recall (24HR) has traditionally been used to collect time-use data, however, automated wearable cameras (AWCs) with an image-assisted recall (IAR) may reduce recall bias. This study aimed to evaluate their concurrent criterion validity for assessing women’s time use in rural Eastern Ugandan. Women’s (n = 211) time allocations estimated via the AWC-IAR and 24HR methods were compared with direct observation (criterion method) using the Bland–Altman limits of agreement (LOA) method of analysis and Cronbach’s coefficient alpha (time allocation) or Cohen’s κ (concurrent activities). Systematic bias varied from 1 min (domestic chores) to 226 min (caregiving) for 24HR and 1 min (own production) to 109 min (socializing) for AWC-IAR. The LOAs were within 2 h for employment, own production, and self-care for 24HR and AWC-IAR but exceeded 11 h (24HR) and 9 h (AWC-IAR) for caregiving and socializing. The LOAs were within four concurrent activities for 24HR (−1.1 to 3.7) and AWC-IAR (−3.2 to 3.2). Cronbach’s alpha for time allocation ranged from 0.1728 (socializing) to 0.8056 (own production) for 24HR and 0.2270 (socializing) to 0.7938 (own production) for AWC-IAR. For assessing women’s time allocations at the population level, the 24HR and AWC-IAR methods are accurate and reliable for employment, own production, and domestic chores but poor for caregiving and socializing. The results of this study suggest the need to revisit previously published research investigating the associations between women’s time allocations and nutrition outcomes.     

Incidence and risk factors for early neonatal mortality in newborns with severe perinatal morbidity in Uganda

Objective

To determine the incidence and risk factors for early neonatal death among newborns with severe perinatal morbidity.

Methods

A prospective cohort study was performed of 341 newborns with severe perinatal morbidity admitted to the neonatal intensive care unit of Mulago Hospital, Uganda. All newborns were followed up for 7 days or until time of death. Information surrounding the mother’s obstetric history and pregnancy, the birth, and the neonatal history was collected using an interviewer-administered questionnaire and by review of relevant records. Multivariate logistic regression analysis was performed to assess factors independently associated with early neonatal death.

Results

A total of 37 (10.9%) neonates died within 7 days, giving an incidence of early neonatal death of 109 deaths per 1000 live births (3 per 100 person-days). In multivariate analysis, respiratory distress (adjusted risk ratio [aRR] 31.29; 95% CI, 4.17–234.20; P = 0.001) and inadequate fetal heart monitoring during labor (aRR 6.0; 95% CI 1.40–25.67; P = 0.016) were significantly associated with an increased risk of early neonatal death.

Conclusion

Approximately one in 10 neonates with severe perinatal morbidity died within 7 days of birth. Respiratory distress and poor monitoring of labor were risk factors for early neonatal death.