Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.
Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
BMC Pregnancy Childbirth. 2018 Apr 12;18(1):95. doi: 10.1186/s12884-018-1722-4.
Caesarean section (CS) is not recommended for PMTCT in Malawi HIV Guidelines, contrary to most high-income countries where CS is indicated if viral suppression is sub-optimal pre-delivery. We describe patterns of CS in HIV-infected and uninfected women in Malawi and explored if insight into the use of Elective CS (ECS) for PMTCT could be obtained.
We used routinely collected data from individual medical records from 17 large health facilities in the central and southern regions of Malawi, from January 2010 to December 2013. We included data from maternity registers from all HIV-positive women, and randomly selected around every fourth woman with negative or unknown HIV status. We used multivariable logistic regressions and cluster-based robust standard errors to examine independent associations of patient- and facility characteristics with CS and ECS.
We included 62,033 women in the analysis. The weighted percentage of women who had a spontaneous vaginal delivery was 80.0% (CI 95% 79.5-80.4%); 2.4% (95% CI 2.3-2.6%) had a vacuum extraction; 2.3% (95% CI 2.2-2.5%) had a vaginal breech delivery; 14.0% (95% CI 13.6-14.4%) had a CS while for 1.3% (95% CI 1.2-1.4%) the mode of delivery was not recorded. Prevalence of CS without recorded medical or obstetric indication (ECS) was 5.1%, (n = 3152). Presence of maternal and infant complications and older age were independently associated with CS delivery. HIV-positive women were less likely to have ECS than HIV negative women (aOR 0.65; 95%-CI 0.57-0.74). Among HIV-positive women, those on antiretrovirals (ARV's) for ≥4 weeks prior to delivery were less likely to have ECS than HIV-positive women who had not received ARVs during pregnancy (aOR 0.81; 95% CI 0.68-0.96).
The pattern of CS's in Malawi is largely determined by maternal and infant complications. Positive HIV status was negatively associated with CS delivery, possibly because health care workers were concerned about the risk of occupational HIV transmission and the known increased risk of post-operative complications. Our results leave open the possibility that CS is practiced to prevent MTCT given that ECS was more common among women at high risk of MTCT due to no or short exposure to ARV's.
与大多数高收入国家不同，马拉维的 HIV 指南不建议将剖宫产用于 PMTCT，因为这些国家在分娩前病毒抑制不理想时会选择剖宫产。我们描述了 HIV 感染和未感染妇女在马拉维的剖宫产模式，并探讨了是否可以了解到选择性剖宫产（ECS）在 PMTCT 中的应用。
我们使用了来自马拉维中部和南部 17 家大型医疗机构的个人病历中常规收集的数据，时间为 2010 年 1 月至 2013 年 12 月。我们纳入了所有 HIV 阳性妇女的分娩登记数据，并随机选择了大约每 4 名 HIV 阴性或未知状态的妇女。我们使用多变量逻辑回归和基于聚类的稳健标准误差来检查患者和医疗机构特征与 CS 和 ECS 的独立关联。
我们共纳入了 62033 名妇女进行分析。自然阴道分娩的加权百分比为 80.0%（95%CI 95% 79.5-80.4%）；2.4%（95%CI 2.3-2.6%）行真空吸引术；2.3%（95%CI 2.2-2.5%）行阴道分娩；14.0%（95%CI 13.6-14.4%）行 CS，而 1.3%（95%CI 1.2-1.4%）的分娩方式未记录。无医学或产科指征的 CS 发生率（ECS）为 5.1%（n=3152）。母婴并发症和年龄较大与 CS 分娩独立相关。HIV 阳性妇女接受 ECS 的可能性低于 HIV 阴性妇女（OR 0.65；95%-CI 0.57-0.74）。在 HIV 阳性妇女中，与在怀孕期间未接受 ARV 治疗的 HIV 阳性妇女相比，在分娩前至少接受 4 周 ARV 治疗的妇女接受 ECS 的可能性较小（OR 0.81；95%CI 0.68-0.96）。
马拉维 CS 的模式主要由母婴并发症决定。HIV 阳性状态与 CS 分娩呈负相关，可能是因为医护人员担心职业性 HIV 传播风险，以及已知的术后并发症风险增加。我们的结果表明，CS 可能是为了预防 MTCT 而进行的，因为由于缺乏或短期接触 ARV，ECS 在 MTCT 高风险妇女中更为常见。
