BackgroundHealth facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood.Methodology/Principal FindingsWe conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. We constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering.Between July 2008 and May 2009, we collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33–68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant.Conclusions/ResultsWe observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

Objective To make a rapid assessment of the common myths and misconceptions surrounding the causes of cervical cancer and lack of screening among unscreened low-income Zambian women. Methods We initiated a door-to-door community-based initiative, led by peer educators, to inform unscreened women about the existence of a new see-and-treat cervical cancer prevention program. During home visits peer educators posed the following two questions to women: 1. What do you think causes cervical cancer? 2. Why haven’t you been screened for cervical cancer? The most frequent types of responses gathered in this exercise were analyzed thematically. Results Peer educators contacted over 1100 unscreened women over a period of two months. Their median age was 33 years, a large majority (58%) were not educated beyond primary school, over two-thirds (71%) did not have monthly incomes over 500,000 Zambian Kwacha (US$100) per month, and just over half (51%) were married and cohabiting with their spouses. Approximately 75% of the women engaged in discussions had heard of cervical cancer and had heard of the new cervical cancer prevention program in the local clinic. The responses of unscreened low-income Zambian women to questions posed by peer educators in urban Lusaka reflect the variety of prevalent ‘folk’ myths and misconceptions surrounding cervical cancer and its prevention methods. Conclusion The information in our rapid assessment can serve as a basis for developing future educational and intervention campaigns for improving uptake of cervical cancer prevention services in Zambia. It also speaks to the necessity of ensuring that programs addressing women’s reproductive health take into account societal inputs at the time they are being developed and implemented. Taking a community-based participatory approach to program development and implementation will help ensure sustainability and impact.

Abstract. In Lusaka, Zambia, where malaria prevalence is low, national guidelines continue to recommend that all pregnant women receive sulfadoxine-pyrimethamine (SP) for malaria prophylaxis monthly at every scheduled antenatal care visit after 16 weeks of gestation. Human immunodeficiency virus (HIV)-positive women should receive co-trimoxazole prophylaxis for HIV and not SP, but many still receive SP. We sought to determine whether increased dosage of SP is still associated with a reduced risk of low birth weight (LBW) in an area where malaria transmission is low. Our secondary objective was to determine whether any association between SP and LBW is modified by receipt of antiretroviral therapy (ART). We analyzed data routinely collected from a cohort of HIV-positive pregnant women with singleton births in Lusaka, Zambia, between February 2006 and December 2012. We used a logPoisson model to estimate the risk of LBW by dosage of SP and to determine whether the association between SP and LBW varied by receipt of ART. Risk of LBW declined as the number of doses increased and appeared lowest among women who received three doses (adjusted risk ratio [ARR] = 0.78; 95% confidence interval [CI] = 0.64-0.95). In addition, women receiving combination ART had a higher risk of delivering an LBW infant compared with women receiving no treatment or prophylaxis (ARR = 1.18; 95% CI = 1.09-1.28), but this risk was attenuated among women who were receiving SP (risk ratio = 1.09; 95% CI = 0.99-1.21). SP was associated with a reduced risk of LBW in HIVpositive women, including those receiving ART, in a low malaria prevalence region.

management; support and effective pain relief should be offered. Delay in the first stage is suspected if cervical dilation is <2 cm in 4 hours and confirmed if dilation progress is <1 cm, 2 hours later. Once delay is confirmed, nulliparous women should be offered oxytocin (obstetricians should review oxytocin use in parous women); assessment should take place every 4 hours. If progress of <2 cm (in 4 h) occurs, cesarean delivery should be considered. Delay in second stage is suspected if progress is inadequate after 1 hour of active pushing in nulliparous women; and amniotomy should be advised. Delay should be diagnosed after 2 hours in nulliparous women and after 1 hour in parous women; then, assessment should occur every 15 to 30 minutes, with birth expected within a total of 3 hours for nulliparous and 2 hours for parous women. Instrumental birth requires effective anesthesia and experienced practitioners. After birth, genital and rectal trauma should be assessed and repaired.Implementation of guidelines is complex and barriers such as expense must be overcome. It will require support and possible additional training for midwives and other healthcare professionals, and also the parturients. NICE has developed tools to help organizations implement the guidelines (www.nice.org.uk?page.aspx?0 = tools). T he World Health Organization (WHO) began the SafeMotherhood Initiative, 20 years ago to address the major problem of preventable maternal mortality in developing countries. The goal was to reduce maternal mortality by 50% within 10 years of its initiation by providing appropriate prepregnancy care, family planning, good prenatal care, a trained attendant at birth, and access to essential obstetric care for women at high-risk for complications. However, based on periodic assessments during the last 2 decades, the situation for mothers in developing nations is as bad as it was 20 years ago. About 530,000 women die annually as a complication of pregnancy and childbirth, with 99% of these deaths in developing countries. In addition, thousands of women suffer preventable morbidity that results in long-term disability. Perinatal and early childhood mortality are also disproportionately higher in developing regions of the world.Although outcomes have not improved substantially, a greater understanding and awareness of maternal mortality and of the epidemiology of its 5 most important causes (hemorrhage, hypertension in pregnancy, infections, abortions, and obstructed labor) have occurred. However, several factors have had a negative impact on the success of the Initiative. Historical lack of focus among professional organizations along with lack of commitment from governments are two such factors. Governments may acknowledge the need to improve maternal health, but then do nothing to make resources available or to change organizations in any relevant way. In addition, international funds are also lacking, as is concentrated assistance from obstetric professionals. Involvement from relevant professional organizations ar...