METHODS: Based on existing frameworks for the EMTCT for each individual infection, an integrated framework that combines infection prevention procedures with routine antenatal care was constructed. Using decision tree analyses, population impacts, cost-effectiveness and the potential reduction in required resources of the integrated approach as a result of resource pooling and improvements in service coverage and coordination, were evaluated. The tool was assessed using simulated epidemiological data from Cambodia.
RESULTS: The current prevention programme for 370,000 Cambodian pregnant women was estimated at USD$2.3 ($2.0-$2.5) million per year, including the duration of pregnancy and up to 18 months after delivery. A model estimate of current MTCT rates in Cambodia was 6.6% (6.2-7.1%) for HIV, 14.1% (13.1-15.2%) for HBV and 9.4% (9.0-9.8%) for syphilis. Integrating HIV and syphilis prevention into the existing antenatal care framework will reduce the total time required to provide this integrated care by 19% for health care workers and by 32% for pregnant women, resulting in a net saving of $380,000 per year for the EMTCT programme. This integrated approach reduces HIV and HBV MTCT to 6.1% (5.7-6.5%) and 13.0% (12.1-14.0%), respectively, and substantially reduces syphilis MCTC to 4.6% (4.3-5.0%). Further introduction of either antiviral treatment for pregnant women with high viral load of HBV, or hepatitis B immunoglobulin (HBIG) to exposed newborns, will increase the total cost of EMTCT to $4.4 ($3.6-$5.2) million and $3.3 ($2.7-$4.0) million per year, respectively, but substantially reduce HBV MTCT to 3.5% (3.2-3.8%) and 5.0% (4.6-5.5%), respectively. Combining both antiviral and HBIG treatments will further reduce HBV MTCT to 3.4% (3.1-3.7%) at an increased total cost of EMTCT of $4.5 ($3.7-$5.4) million per year. All these HBV intervention scenarios are highly cost-effective ($64-$114 per disability-adjusted life years averted) when the life benefits of these prevention measures are considered.
CONCLUSIONS: The integrated approach, using antenatal, perinatal and postnatal care as a platform in Cambodia for triple EMTCT of HIV, HBV and syphilis, is highly cost-effective and efficient.
DESIGN: GWG trajectories were identified using the latent class growth model. Binary logistic regression was performed to examine the associations between adverse pregnancy outcomes and these trajectories.
SETTING: Negeri Sembilan, Malaysia.
PARTICIPANTS: Two thousand one hundred ninety-three pregnant women.
RESULTS: Three GWG trajectories were identified: 'Group 1 - slow initial GWG but followed by drastic GWG', 'Group 2 - maintaining rate of GWG at 0·58 kg/week' and 'Group 3 - maintaining rate of GWG at 0·38 kg/week'. Group 1 had higher risk of postpartum weight retention (PWR) (adjusted OR (AOR) 1·02, 95 % CI 1·01, 1·04), caesarean delivery (AOR 1·03, 95 % CI 1·01, 1·04) and having low birth weight (AOR 1·04, 95 % CI 1·02, 1·05) compared with group 3. Group 2 was at higher risk of PWR (AOR 1·18, 95 % CI 1·16, 1·21), preterm delivery (AOR 1·03, 95 % CI 1·01, 1·05) and caesarean delivery (AOR 1·02, 95 % CI 1·01, 1·03), but at lower risk of having small-for-gestational-age infants (AOR 0·97, 95 % CI 0·96, 0·99) compared with group 3. The significant associations between group 1 and PWR were observed among non-overweight/obese women; between group 1 and caesarean delivery among overweight/obese women; group 2 with preterm delivery and caesarean delivery were only found among overweight/obese women.
CONCLUSIONS: Higher GWG as well as increasing GWG trajectories was associated with higher risk of adverse pregnancy outcomes. Promoting GWG within the recommended range should be emphasised in antenatal care to prevent the risk of adverse pregnancy outcomes.
METHODS: A retrospective study using a multistage sampling technique, at public-funded primary health care clinics was conducted. Antenatal utilisation level was assessed using a modified Adequacy of Prenatal Care Utilisation index that measures the timing for initiation of care and observed-to-expected visits ratio. Adequacy of antenatal care content assessed compliance to routine care based on the local guidelines.
RESULTS: Intensive or "adequate-plus" antenatal care utilisation as defined by the modified index was noted in over half of the low-risk women. On the other hand, there were 26% of the high-risk women without the expected intensive utilisation. Primary- or non-educated high-risk women were less likely to have a higher antenatal care utilisation level compared with tertiary educated ones (OR = 0.20, P = 0.003). Half of all women had <80% of the recommended antenatal care content. A higher proportion of high-risk than low-risk women scored <80% of the routine care content (p<0.015). The majority of the additional laboratory tests were performed on high-risk women. Provision of antenatal education showed comparatively poor compliance to guidelines, more than half of the antenatal advice topics assessed were rarely provided to the women. High-risk women were associated with a higher prevalence of adverse pregnancy outcome.
CONCLUSIONS: Disproportionate utilisation of antenatal care according to risk level of pregnancy indicates the need for better scheduling of care. The risk-oriented approach often results in a tendency to focus on the risk conditions of the women. Training interventions are recommended to improve communication and to help healthcare professionals understand the priorities of the women. Further studies are required to assess the reason for disproportionate utilisation of antenatal care according to risk level and how delivery of antenatal advice can be improved, reviewing both user and provider perspectives.