Medical Research Council of South Africa.

Background Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0•7 per 100 000 population (IQR 0•2-2•0). Maternal mortality was 20 (0•5%) of 3684 patients (95% CI 0•3-0•8). Complications occurred in 633 (17•4%) of 3636 mothers (16•2-18•6), which were predominantly severe intraoperative and postoperative bleeding (136 [3•8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4•47 [95% CI 1•46-13•65]), and perioperative severe obstetric haemorrhage (5•87 [1•99-17•34]) or anaesthesia complications (11•47 (1•20-109•20]). Neonatal mortality was 153 (4•4%) of 3506 infants (95% CI 3•7-5•0). Interpretation Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.

Background In 2016, 98% of children in Zimbabwe received breastmilk, however only 40% of babies under six months were exclusively breastfed 24 h prior to data collection. A 2014 survey revealed that Matabeleland South Province had the country’s highest starvation rates and food insecurities were rife. This study aimed at investigating maternal, infant, household, environmental and cultural factors influencing exclusive breastfeeding (EBF) practice in Gwanda District. Methods A cross-sectional study was conducted from January to March 2018. Interviews used pretested structured questionnaires for 225 mothers of infants aged between six and twelve months at immunization outreach points and health facilities. Descriptive statistics, bivariate and multivariate analysis estimated the association between the dependent and independent variables. Exclusive breastfeeding was defined as feeding an infant on breast milk only from birth up to the age of six months. Results The majority of mothers ( n = 193; 89%) had knowledge about EBF and 189 (84%) expressed a positive attitude towards the practice, however, only 81 (36%) practiced exclusive breastfeeding. The most common complementary food/fluid given to the infants was plain water ( n = 85; 59%). Predictors for EBF were: maternal Human Immuno-deficiency Virus positive status (Odds Ratio [OR] 0.30; 95% Confidence Interval [CI] 0.17, 0.56) and being economically independent (OR 0.41; 95% CI 0.21, 0.79). Barriers to practicing EBF were: being a young mother under 25 years of age (OR 3.05; 95% CI 1.67, 5.57), having one or two children (OR 2.49; 95% CI 1.29, 4.79), living in less than two rooms (OR 3.86; 95% CI 1.88, 7.93) and having a baby of low birthweight (OR 1.05; 95% CI 0.40, 2.71). After multivariate analysis, only the mother’s economic independence was associated with practicing EBF (Adjusted OR [AOR] 0.83; 95% CI 0.30, 0.92). Key informants identified traditional family practices as the major barrier to EBF. Conclusion The exclusive breastfeeding rates were low despite the mothers’ high knowledge levels and positive attitudes towards the practice. In addressing the multiple factors influencing the cost effective practice, there is need to channel supportive measures through a system-wide approach. This can be achieved by realigning breastfeeding policy directives as well as community attitudes and values towards the exclusive breastfeeding.

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration: NCT03044899.

Background Ninety percent of the global annual malaria mortality cases emanate from the African region. About 80–90% of malaria transmissions in sub-Saharan Africa occur indoors during the night. In Zimbabwe, 79% of the population are at risk of contracting the disease. Although the country has made significant progress towards malaria elimination, isolated seasonal outbreaks persistently resurface. In 2017, Beitbridge District was experiencing a second malaria outbreak within 12 months prompting the need for investigating the outbreak. Methods An unmatched 1:1 case–control study was conducted to establish the risk factors associated with contracting malaria in Ward 6 of Beitbridge District from week 36 to week 44 of 2017. The sample size constituted of 75 randomly selected cases and 75 purposively selected controls. Data were collected using an interviewer-administered questionnaire and Epi Info version 7.2.1.0 was used to conduct descriptive, bivariate and multivariate analyses of the factors associated with contracting malaria. Results Fifty-two percent of the cases were females and the mean age of cases was 29 ± 13 years. Cases were diagnosed using rapid diagnostic tests. Sleeping in a house with open eaves (OR: 2.97; 95% CI 1.44–6.16; p < 0.01), spending the evenings outdoors (OR: 2.24; 95% CI 1.04–4.85; p = 0.037) and sleeping in a poorly constructed house (OR: 4.33; 95% CI 1.97–9.51; p < 0.01) were significantly associated with contracting malaria while closing eaves was protective (OR: 0.45; 95% CI 0.20–1.02; p = 0.055). After using backward stepwise logistic regression, sleeping in a poorly constructed house was associated with five-fold odds of getting sick from malaria (AOR: 8.40; 95% CI 1.69–41.66; p = 0.009). Those who had mosquito nets did not use them consistently. The district health team and the rural health centre were well prepared to response despite having limited human resources. Conclusion Health promotion messages should emphasize the importance of closing the entry points of the malaria vector, and the construction of better houses in the future. Residents had to be educated in the importance of consistent use of mosquito nets. The district had to improve malaria preventive measures like distribution of mosquito nets and lobby for more human resources to assist with malaria surveillance thus, curbing the recurrence of malaria outbreaks.

Background: Despite the well-documented significance of EBF in developing countries, many poor communities still present with the highest percentage of disease burden resulting from suboptimal breastfeeding. Objectives: To identify the maternal perception on barriers and facilitators to EBF in Gwanda District, Zimbabwe. Methods: Five focused group discussions were conducted using 40 purposively-selected mothers while eight in-depth key informant interviews were also conducted. The qualitative data collected were analyzed using thematic network analysis. The themes were used in interpreting the perceived barriers and facilitators of EBF. Results: The study identified individual, socio-cultural, health service-related and environmental factors as the basic themes influencing maternal infant feeding choice. These were grouped into two organizing themes, namely, barriers and facilitators of EBF which were summarized into one global theme: EBF intention. Facilitating factors were maternal autonomy, self-efficacy, knowledge of EBF definition, maternal diet, support and sourcing information from healthcare workers. Poor infant feeding practices, affordability of alternative infant feeding options, ritualistic/symbolic infant preparations, family conflicts, increased workload and hot climate were barriers to EBF. Conclusion: To increase in uptake of EBF in the study area required comprehensive multiple stakeholder interventions incorporating the mothers, influential family members, religion and traditional advisors, and healthcare workers.

IntroductionMatabeleland South launched the malaria pre-elimination campaign in 2012 but provincial spraying coverage has failed to attain 95% target, with some districts still encountering malaria outbreaks. A study was conducted to evaluate program performance against achieving malaria pre-elimination.MethodsA descriptive cross sectional study was done in 5 districts carrying out IRS using the logical framework involving inputs, process, outputs and outcome evaluation. Health workers recruited into the study included direct program implementers, district and provincial program managers. An interviewer administered questionnaire, checklists, key informant interviewer guide and desk review of records were used to collect data.ResultsWe enrolled 37 primary respondents and 5 key informants. Pre-elimination, Epidemic Preparedness and Response plans were absent in all districts. Shortages of inputs were reported by 97% of respondents, with districts receiving 80% of requested budget. Insecticides were procured centrally at national level. Spraying started late and districts failed to spray all targeted households by end of December. The province is using makeshift camps with inappropriate evaporation ponds where liquid DDT waste is not safely accounted for. The provincial IHRS coverage for 2011 was 84%. Challenges cited included; food shortages for spraymen, late delivery of inputs and poor state of IHRS equipment.ConclusionThe province has failed to achieve Malaria pre-elimination IRS coverage targets for 2011/12 season. Financial and logistical challenges led to delays in supply of program inputs, recruitment and training of sprayers. The Province should establish camping infrastructure with standard evaporation ponds to minimise contamination of the environment.

BackgroundOn 20th of June 2012, 31 pupils from Kwite primary school reported to the local clinic complaining of passing bloody urine. A study was conducted to identify factors, the etiology and risks of contracting the disease.MethodsAn unmatched 1:2 case control study was conducted at Kwite primary school. A case was defined as any child aged between seven to fifteen years, resident in Empandeni Ward for not less than two months, who had passed bloody urine with or without dysuria, fever, fatigue or lower abdominal pains from the 01/06/12 to 07/07/12. A control was a classmate of a case, staying in the same ward, who had not passed bloody urine. Controls were chosen by lottery method. A pretested questionnaire was administered to pupils and their caregivers. Environmental assessment was conducted; line lists, case notes, and district outbreak preparedness and response were reviewed using standard checklists.ResultsAll the 42 cases, and 84 controls were enrolled into the study. The median age for cases and controls was 10 years (Q1 = 9, Q3 = 12) and 10 years (Q1 = 8, Q3 = 11), respectively. Swimming in Kwite dam [AOR = 9.02, 95% CI (2.29-35.53)] and bathing in the dam [AOR = 3.22, 95% CI (1.10-9.41)] were independent factors associated with contracting schistosomiasis. Schistosoma hematobium was isolated in 31 out of 100 urine specimens examined. Bulinus globosus snails were identified at Kwite dam.ConclusionThe outbreak was driven by human contact with S. hematobium infested Kwite dam water, while poor knowledge on prevention of schistosomiasis by the Kwite community was evident. As a result of this study, health education to pupils and the community, mass drug administration on school pupils and mollusciding at the dam were done. The provincial health team adopted as on-going activities, the inclusion of schistosomiasis prevention and control in malaria pre-elimination activities.