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.