ObjectivesTo investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008–2012.MethodsA retrospective cross-sectional study was done at the referral hospital Queen Elisabeth Central Hospital, and the two district hospitals of Chiradzulu and Mangochi. The data were collected simultaneously at the three sites from Feb-March 2013. All records available for women admitted to the gynaecological ward from 2008-2012 were reviewed. Women who had undergone surgical uterine evacuation after incomplete abortion were included and the use of manual vacuum aspiration versus sharp curettage was analysed.ResultsAltogether, 5121 women were included. One third (34.2%) of first trimester abortions were treated with manual vacuum aspiration, while all others were treated with sharp curettage. There were significant differences between the hospitals and between years. Overall there was an increase in the use of manual vacuum aspiration from 2008 (19.7%) to 2009 (31.0%), with a rapid decline after 2010 (28.5%) ending at only 4.9% in 2012. Conversely there was an increase in use of sharp curettage in all hospitals from 2010 to 2012.ConclusionUse of manual vacuum aspiration as part of the postabortion care in Malawi is rather low, and decreased from 2010 to 2012, while the use of sharp curettage became more frequent. This is in contrast with current international guidelines.

IntroductionPrevalence of cardiovascular disease risk factors (CVDRFs) is increasing, especially in low-income countries. In Sierra Leone, there is limited empirical data on the prevalence of CVDRFs, and there are no previous studies on the access to care for these conditions.MethodsThis study in rural and urban Sierra Leone collected demographic, anthropometric measurements and clinical data from randomly sampled individuals over 40 years old using a household survey. We describe the prevalence of the following risk factors: diabetes, hypertension, dyslipidaemia, overweight or obesity, smoking and having at least one of these risk factors. Cascades of care were constructed for diabetes and hypertension using % of the population with the disease who had previously been tested (‘screened’), knew of their condition (‘diagnosed’), were on treatment (‘treated’) or were controlled to target (‘controlled’). Multivariable regression was used to test associations between prevalence of CVDRFs and progress through the cascade for hypertension with demographic and socioeconomic variables. In those with recognised disease who did not seek care, reasons for not accessing care were recorded.ResultsOf 2071 people, 49.6% (95% CI 49.3% to 50.0%) of the population had hypertension, 3.5% (3.4% to 3.6%) had diabetes, 6.7% (6.5% to 7.0%) had dyslipidaemia, 25.6% (25.4% to 25.9%) smoked and 26.5% (26.3% to 26.8%) were overweight/obese; a total of 77.1% (76.6% to 77.5%) had at least one CVDRF. People in urban areas were more likely to have diabetes and be overweight than those living in rural areas. Moreover, being female, more educated or wealthier increased the risk of having all CVDRFs except for smoking. There is a substantial loss of patients at each step of the care cascade for both diabetes and hypertension, with less than 10% of the total population with the conditions being screened, diagnosed, treated and controlled. The most common reasons for not seeking care were lack of knowledge and cost.ConclusionsIn Sierra Leone, CVDRFs are prevalent and access to care is low. Health system strengthening with a focus on increased access to quality care for CVDRFs is urgently needed.

Background Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. Methods A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem. Results Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “ Training and retention of specialist staff ”, “ Health education/awareness of injury severity ”, “ Geographical coverage of referral trauma centres ”, and “ Lack of protocol for bypass to referral centres ”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map. Conclusion Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.

IntroductionMultimorbidity is a health issue of increasing importance worldwide, and is likely to become particularly problematic in low-income countries (LICs) as they undergo economic, demographic and epidemiological transitions. Knowledge of the burden and consequences of multimorbidity in LICs is needed to inform appropriate interventions.MethodsA cross-sectional household survey collected data on morbidities and frailty, disability, quality of life and physical performance on individuals aged over 40 years of age living in the Nouna Health and Demographic Surveillance System area in northwestern Burkina Faso. We defined multimorbidity as the occurrence of two or more conditions, and evaluated the prevalence of and whether this was concordant (conditions in the same morbidity domain of communicable, non-communicable diseases (NCDs) or mental health (MH)) or discordant (conditions in different morbidity domains) multimorbidity. Finally, we fitted multivariable regression models to determine associated factors and consequences of multimorbidity.ResultsMultimorbidity was present in 22.8 (95% CI, 21.4 to 24.2) of the study population; it was more common in females, those who are older, single, more educated, and wealthier. We found a similar prevalence of discordant 11.1 (95% CI, 10.1 to 12.2) and concordant multimorbidity 11.7 (95% CI, 10.6 to 12.8). After controlling for age, sex, marital status, education, and wealth, an increasing number of conditions was strongly associated with frailty, disability, low quality of life, and poor physical performance. We found no difference in the association between concordant and discordant multimorbidity and outcomes, however people who were multimorbid with NCDs alone had better outcomes than those with multimorbidity with NCDs and MH disorders or MH multimorbidity alone.ConclusionsMultimorbidity is prevalent in this poor, rural population and is associated with markers of decreased physical performance and quality of life. Preventative and management interventions are needed to ensure that health systems can deal with increasing multimorbidity and its downstream consequences.

This study aims to determine the incidence of pre-eclampsia and distribution of risk factors of pre-eclampsia at Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal. A retrospective study included 4820 pregnant women from 17 September to 18 December 2017. Data were obtained from the medical records of the hospital’s Statistics Department. Associations between the risk factors and pre-eclampsia were determined using logistic regression analysis and expressed as odds ratios. The incidence rate of pre-eclampsia in the study population was 1.8%. Higher incidence of pre-eclampsia was observed for women older than 35 years (Adjusted Odds Ratio, AOR)= 3.27; (Confidence Interval, CI 1.42–7.52) in comparison to mothers aged 20–24 years, primiparous women (AOR = 2.12; CI 1.25–3.60), women with gestational age less than 37 weeks (AOR = 3.68; CI 2.23–6.09), twins pregnancy (AOR = 8.49; CI 2.92–24.72), chronic hypertension (AOR = 13.64; CI 4.45–41.81), urinary tract infection (AOR = 6.89; CI 1.28–36.95) and gestational diabetes (AOR = 11.79; CI 3.20–43.41). Iron and calcium supplementation appear to be protective. Age of the mothers, primiparity, early gestational age, twin pregnancy, chronic hypertension, urinary tract infection and gestational diabetes were the significant risk factors for pre-eclampsia. Iron and calcium supplementation and young aged women were somewhat protective.

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Background Severe mental illness (SMI; schizophrenia, bipolar disorders (BDs), and other nonorganic psychoses) is associated with increased risk of cardiovascular disease (CVD) and CVD-related mortality. To date, no systematic review has investigated changes in population level CVD-related mortality over calendar time. It is unclear if this relationship has changed over time in higher-income countries with changing treatments. Methods and findings To address this gap, a systematic review was conducted, to assess the association between SMI and CVD including temporal change. Seven databases were searched (last: November 30, 2021) for cohort or case–control studies lasting ≥1 year, comparing frequency of CVD mortality or incidence in high-income countries between people with versus without SMI. No language restrictions were applied. Random effects meta-analyses were conducted to compute pooled hazard ratios (HRs) and rate ratios, pooled standardised mortality ratios (SMRs), pooled odds ratios (ORs), and pooled risk ratios (RRs) of CVD in those with versus without SMI. Temporal trends were explored by decade. Subgroup analyses by age, sex, setting, world region, and study quality (Newcastle–Ottawa scale (NOS) score) were conducted. The narrative synthesis included 108 studies, and the quantitative synthesis 59 mortality studies (with (≥1,841,356 cases and 29,321,409 controls) and 28 incidence studies (≥401,909 cases and 14,372,146 controls). The risk of CVD-related mortality for people with SMI was higher than controls across most comparisons, except for total CVD-related mortality for BD and cerebrovascular accident (CVA) for mixed SMI. Estimated risks were larger for schizophrenia than BD. Pooled results ranged from SMR = 1.55 (95% confidence interval (CI): 1.33 to 1.81, p < 0.001), for CVA in people with BD to HR/rate ratio = 2.40 (95% CI: 2.25 to 2.55, p < 0.001) for CVA in schizophrenia. For schizophrenia and BD, SMRs and pooled HRs/rate ratios for CHD and CVD mortality were larger in studies with outcomes occurring during the 1990s and 2000s than earlier decades (1980s: SMR = 1.14, 95% CI: 0.57 to 2.30, p = 0.71; 2000s: SMR = 2.59, 95% CI: 1.93 to 3.47, p < 0.001 for schizophrenia and CHD) and in studies including people with younger age. The incidence of CVA, CVD events, and heart failure in SMI was higher than controls. Estimated risks for schizophrenia ranged from HR/rate ratio 1.25 (95% CI: 1.04 to 1.51, p = 0.016) for total CVD events to rate ratio 3.82 (95% CI: 3.1 to 4.71, p < 0.001) for heart failure. Incidence of CHD was higher in BD versus controls. However, for schizophrenia, CHD was elevated in higher-quality studies only. The HR/rate ratios for CVA and CHD were larger in studies with outcomes occurring after the 1990s. Study limitations include the high risk of bias of some studies as they drew a comparison cohort from general population rates and the fact that it was difficult to exclude studies that had overlapping populations, although attempts were made to minimise this. Conclusions In this study, we found that SMI was associated with an approximate doubling in the rate ratio of CVD-related mortality, particularly since the 1990s, and in younger groups. SMI was also associated with increased incidence of CVA and CHD relative to control participants since the 1990s. More research is needed to clarify the association between SMI and CHD and ways to mitigate this risk.

ObjectivesTo examine cytomegalovirus (CMV) seroprevalence and associated risk factors for CMV seropositivity in pregnant Norwegian women.DesignCross-sectional study.SettingThe Norwegian Mother and Child Cohort Study (MoBa) in addition to two random samples of pregnant women from Sør-Trøndelag County in Norway.ParticipantsStudy group 1 were 1000 pregnant women, randomly selected among 46 127 pregnancies in the MoBa (1999–2006) at 17/18 week of gestation. Non-ethnic Norwegian women were excluded. Study groups 2 (n=1013 from 1995) and 3 (n=979 from 2009) were pregnant women at 12 weeks of gestation from Sør-Trøndelag County.Outcome measuresCMV seropositivity in blood samples from pregnant Norwegian women.ResultsCMV-IgG antibodies were detected in 59.9% and CMV-IgM antibodies in 1.3% of pregnant Norwegian women in study group 1. Women from North Norway demonstrated a higher CMV-IgG seroprevalence (72.1%) than women from South Norway (58.5%) (OR 1.83, 95% CI 1.17 to 2.88). The CMV-IgG seroprevalence was higher among women with low education (70.5%) compared to women with higher education (OR 2.20, 95% CI 1.24 to 3.90). Between 1995 and 2009 the CMV-IgG seroprevalence increased from 63.1% to 71.4% in pregnant women from Sør-Trøndelag County (study groups 2 and 3; p<0.001). The highest CMV-IgG seroprevalence (79.0%) was observed among the youngest pregnant women (<25 years) from Sør-Trøndelag County in 2009 (study group 3).ConclusionsThe CMV-IgG seroprevalence of pregnant Norwegian women varies with geographic location and educational level. Additionally, the CMV-IgG seroprevalence appears to have increased over the last years, particularly among young pregnant women.