Common hospital and surgical center responses to the Covid‐19 pandemic included curtailing “elective” procedures, which are typically determined based on implications for physical health and survival. However, in the focus solely on physical health and survival, procedures whose main benefits advance components of well‐being beyond health, including self‐determination, personal security, economic stability, equal respect, and creation of meaningful social relationships, have been disproportionately deprioritized. We describe how female reproduction‐related procedures, including abortion, surgical sterilization, reversible contraception devices and in vitro fertilization, have been broadly categorized as “elective,” a designation that fails to capture the value of these procedures or their impact on women's overall well‐being. We argue that corresponding restrictions and delays of these procedures are problematically reflective of underlying structural views that marginalize women's rights and interests and therefore threaten to propagate gender injustice during the pandemic and beyond. Finally, we propose a framework for triaging reproduction‐related procedures during Covid‐19 that is more individualized, accounts for their significance for comprehensive well‐being, and can be used to inform resumption of operations as well as subsequent restriction phases .

Objective To characterize associations between intimate partner violence (IPV) and adverse delivery outcomes among married Malawian women. Methods In the present secondary analysis of an ongoing project investigating sexual and reproductive health decision making in rural, Lilongwe District, Malawi, married women who had experienced at least one pregnancy were interviewed between July 15, 2014, and February 25, 2015. Associations between physical IPV experienced with participants’ current partners and history of adverse delivery outcomes (spontaneous abortions, stillbirths, and neonatal deaths) were examined using log-binomial regression. Results The analyses included 792 women. The 166 (21.0%) participants who reported having experienced physical IPV with their current partner were significantly more likely to have a history of adverse delivery outcomes in the unadjusted (prevalence ratio 1.23; 95% confidence interval 1.08–1.41) and adjusted (adjusted prevalence ration 1.19; 95% CI 1.01–1.40) analyses. Conclusion Physical IPV was reported by a large proportion of participants in the present study and was significantly associated with adverse delivery outcomes. Public health interventions providing physical IPV screening and referral to support services could help improve maternal and child health in Malawi.

BackgroundIn Zanzibar, a semi-autonomous region of Tanzania, induced abortion is illegal but common, and fewer than 12 % of married reproductive-aged women use modern contraception. As part of a multi-method study about contraception and consequences of unwanted pregnancies, the objective of this study was to understand the experiences of Zanzibari women who terminated pregnancies.MethodsThe cross-sectional study was set in Zanzibar, Tanzania. Participants were a community-based sample of women who had terminated pregnancies. We carried out semi-structured interviews with 45 women recruited via chain-referral sampling. We report the characteristics of women who have had abortions, the reasons they had abortions, and the methods used to terminate their pregnancies.ResultsWomen in Zanzibar terminate pregnancies that are unwanted for a range of reasons, at various points in their reproductive lives, and using multiple methods. While clinical methods were most effective, nearly half of our participants successfully terminated a pregnancy using non-clinical methods and very few had complications requiring post abortion care (PAC).ConclusionsEven in settings where abortion is illegal, some women experience illegal abortions without adverse health consequences, what we might call ‘safer’ unsafe abortions; these kinds of abortion experiences can be missed in studies about abortion conducted among women seeking PAC in hospitals.

BackgroundIn Malawi’s PMTCT Option B+ program, HIV-infected pregnant women who are already receiving ART are continued on their current therapy regimen without testing for treatment failure at the first antenatal care (ANC) visit. HIV RNA screening at ANC may identify women with treatment failure and ensure that viral suppression is maintained throughout the pregnancy.MethodsWe conducted a cross-sectional study of HIV-infected pregnant women who had been receiving ART for at least 6 months at the first ANC visit under the PMTCT Option B+ program at Bwaila Hospital in Lilongwe, Malawi from June 2015 to December 2017. Poisson regression models with robust variance were used to investigate the predictors of ART treatment failure defined as viral load ≥1000 copies/ml.ResultsThe median age of 864 women tested for ART failure was 31.1 years (interquartile range: 26.9–34.5). The prevalence of treatment failure was 7.6% (95% confidence interval (CI): 6.0–9.6). CD4 cell count (adjusted prevalence ratio (aPR) = 0.57; 95% CI: 0.50–0.65) was strongly associated with treatment failure.ConclusionThe low prevalence of treatment failure among women presenting for their first ANC in urban Malawi demonstrates success of Option B+ in maintaining viral suppression and suggests progress towards the last 90% of the UNAIDS 90-90-90 targets. Women failing on ART should be identified early for adherence counseling and may require switching to an alternative ART regimen.

Probable depression was more common during the antenatal period than postpartum among our participants. Given the association between depression and negative HIV outcomes, screening for depression during pregnancy should be integrated into antenatal HIV care.

Background: Option B+ has increased the number of pregnant women initiating antiretroviral therapy for HIV, yet retention in HIV care is sub-optimal. Retention may be affected by antenatal depression. However, few data exist on antenatal depression in this population. Aim: Describe the prevalence and factors associated with antenatal depression among Malawian women enrolled in Option B+. Method: At their first antenatal visit, women with HIV provided demographic and psychosocial information, including depression as measured with the locally validated Edinburgh Postnatal Depression Scale (EPDS). Prevalence ratios (PR) for factors associated with probable depression (EPDS ≥6) were estimated with log binomial regression. Results: 9.5% (95%CI 7.5-11.9%) of women screened positive for current depression, and 46% self-reported a history of depression or anxiety. Women were more likely to screen positive for current depression if they reported a history of depression (adjusted PR 2.42; 95%CI 1.48-3.95) or had ever experienced intimate partner violence (1.77; 1.11-2.81). Having an unintended current pregnancy (1.78; 0.99-3.21), being unmarried (1.66; 0.97-2.84), or employed (1.56; 1.00-2.44) had potential associations with probable depression. Conclusions: Probable antenatal depression affected a notable proportion of women living with HIV, comparable to other global regions. Screening for antenatal depression in HIV care should be considered.

Little is known about diseases associated with Altered Mental Status in resource-poor settings. We studied adult medicine patients presenting with AMS in Lilongwe, Malawi and found that AMS and HIV infection were each significantly associated with mortality. It is therefore critical that evaluation and management in this patient population is improved.

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