Migration and first-year maternal mortality among HIV-positive postpartum women: A population-based longitudinal study in rural South Africa

  • PLoS Medicine, Volume 17, No. 3, Year 2020

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Study Justification:
This study aimed to investigate the impact of migration on first-year maternal mortality among HIV-positive postpartum women in rural South Africa. The justification for this study is based on the common occurrence of within-country migration in South Africa and its potential effects on the healthcare and well-being of individuals living with HIV. Understanding the patterns of migration and its association with postpartum mortality is crucial for developing targeted interventions and improving the health outcomes of this vulnerable population.
Study Highlights:
– The study followed pregnant women aged ≥15 years during pregnancy and the first year postpartum in rural South Africa from 2000 to 2016.
– Data on migration, mortality, and HIV status were collected through household surveys and annual HIV surveys.
– Among the 30,291 pregnancies analyzed, 23% of women had externally migrated at least once, and 39% of them delivered outside the surveillance area.
– The overall mortality rate in the first year postpartum was 5.8 per 1,000 person-years, with AIDS- or tuberculosis-related conditions being the major causes of death.
– HIV-positive peripartum women who externally migrated and delivered outside the surveillance area had a hazard of mortality more than two times greater compared to those who continuously resided within the surveillance area.
Study Recommendations:
Based on the findings, the study recommends the following:
1. Develop targeted interventions: There is an urgent need to develop interventions specifically tailored to address the higher risk of mortality among HIV-positive peripartum women who migrate and deliver outside the surveillance area.
2. Improve access to antiretroviral therapy (ART) care: Further research should focus on understanding the access and utilization of ART care among mobile postpartum women to ensure continuity of treatment and care.
3. Enhance understanding of mechanisms: More information is needed to understand the underlying mechanisms that contribute to the increased risk of mortality among migrating HIV-positive peripartum women. This includes exploring the social and clinical context at their destinations and potential barriers to accessing healthcare.
Key Role Players:
To address the recommendations, the involvement of the following key role players is essential:
1. Researchers and scientists: They will conduct further research to gain a deeper understanding of the mechanisms and develop targeted interventions.
2. Healthcare providers: They will play a crucial role in implementing the interventions and ensuring access to ART care for mobile postpartum women.
3. Policy makers and government officials: They will need to support and prioritize the implementation of interventions and allocate resources accordingly.
Cost Items for Planning Recommendations:
While the actual costs are not provided, the following cost items should be considered in planning the recommendations:
1. Research funding: Resources will be required to conduct further research, including data collection, analysis, and dissemination of findings.
2. Intervention development and implementation: Funding will be needed to develop and implement targeted interventions, including training healthcare providers, providing necessary healthcare resources, and monitoring the effectiveness of interventions.
3. Healthcare infrastructure and resources: Investments may be required to improve healthcare infrastructure and ensure access to ART care for mobile postpartum women, including clinics, medical equipment, and medications.
4. Awareness and education campaigns: Budgets should be allocated for raising awareness among the target population about the importance of accessing healthcare and available interventions.
Please note that the provided cost items are general considerations and may vary depending on the specific context and resources available.

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Background In South Africa, within-country migration is common. Mobility affects many of the factors in the pathway for entry to or retention in care among people living with HIV. We characterized the patterns of migration (i.e., change in residency) among peripartum women from rural South Africa and their association with first-year postpartum mortality. Methods and findings All pregnant women aged ≥15 years were followed-up during pregnancy and the first year postpartum in a population-based longitudinal demographic and HIV surveillance program in KwaZulu-Natal, South Africa, from 2000 to 2016. During the household surveys (every 4–6 months), each household head was interviewed to record demographic components of the household, including composition, migration, and mortality. External migration was defined as moving (i.e., change in residency) into or out of the study area. For women of reproductive age, detailed information on new pregnancy and birth was recorded. Maternal death was ascertained via verbal autopsy and HIV status at delivery via annual HIV surveys. We fitted mixed-effects Cox regression models adjusting for multiple pregnancies per individual. Overall, 19,334 women had 30,291 pregnancies: 3,339 were HIV-positive, 10,958 were HIV-negative, and 15,994 had unknown HIV status at delivery. The median age was 24 (interquartile range: 20–30) years. During pregnancy and the first year postpartum, 64% (n = 19,344) and 13% (n = 3,994) did not migrate and resided within and outside the surveillance area, respectively. Of the 23% who had externally migrated at least once, 39% delivered outside the surveillance area. Overall, the mortality rate was 5.8 per 1,000 person-years (or 831 deaths per 100,000 live births) in the first year postpartum. The major causes of deaths were AIDS- or tuberculosis-related conditions both within 42 days of delivery (53%) and during the first year postpartum (62%). In this study, we observed that HIV-positive peripartum women who externally migrated and delivered outside the surveillance area had a hazard of mortality more than two times greater (hazard ratio = 2.74; 95% confidence interval 1.01–7.40, p-value = 0.047)—after adjusting for age, time period (before or after 2010), and sociodemographic status—compared to that of HIV-positive women who continuously resided within the surveillance area. Study limitations include lack of data on access to antiretroviral therapy (ART) care and social or clinical context at the destinations among mobile participants, which could lead to unmeasured confounding. Further information on how mobile postpartum women access and remain in care would be instructive. Conclusions In this study, we found that a substantial portion of peripartum women moved within the country around the time of delivery and experienced a significantly higher risk of mortality. Despite the scale-up of universal ART and declining trends in maternal mortality, there is an urgent need to derive a greater understanding of the mechanisms underlying this finding and to develop targeted interventions for mobile HIV-positive peripartum women.

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Based on the provided description, here are some potential innovations that could improve access to maternal health for mobile HIV-positive peripartum women:

1. Mobile clinics: Implementing mobile clinics that can travel to different areas, including those with high rates of migration, to provide maternal health services. This would ensure that HIV-positive peripartum women have access to healthcare regardless of their location.

2. Telemedicine: Utilizing telemedicine technologies to provide remote consultations and follow-up care for HIV-positive peripartum women who have migrated. This would allow them to receive medical advice and support without the need for physical travel.

3. Community health workers: Training and deploying community health workers who can provide education, counseling, and support to HIV-positive peripartum women in their local communities. These workers can help ensure continuity of care and provide guidance on accessing healthcare services.

4. Mobile health apps: Developing mobile health applications that provide information on maternal health, HIV management, and access to healthcare services. These apps can be easily accessible and provide personalized support to HIV-positive peripartum women, regardless of their location.

5. Collaboration and data sharing: Encouraging collaboration and data sharing between healthcare providers and organizations in different regions to ensure seamless continuity of care for HIV-positive peripartum women who migrate. This would involve sharing medical records, test results, and treatment plans to ensure that women receive appropriate care regardless of where they are located.

6. Targeted interventions: Developing targeted interventions specifically designed to address the unique challenges faced by mobile HIV-positive peripartum women. This could include tailored education programs, support groups, and resources to help them navigate the healthcare system and access necessary services.

These innovations aim to address the specific needs of mobile HIV-positive peripartum women and improve their access to maternal health services, ultimately reducing maternal mortality rates in this population.
AI Innovations Description
Based on the study titled “Migration and first-year maternal mortality among HIV-positive postpartum women: A population-based longitudinal study in rural South Africa,” the following recommendation can be developed into an innovation to improve access to maternal health:

1. Develop targeted interventions for mobile HIV-positive peripartum women: Based on the findings of the study, it is crucial to develop interventions specifically designed to address the needs of HIV-positive women who migrate during the peripartum period. These interventions should focus on ensuring access to essential maternal health services, including antiretroviral therapy (ART) care, during and after migration.

Innovation Description:
– Mobile Maternal Health Clinics: Establish mobile clinics that can reach out to HIV-positive peripartum women who have migrated. These clinics can provide comprehensive maternal health services, including HIV testing, antenatal care, postnatal care, and access to ART. The clinics can be equipped with trained healthcare professionals and necessary medical equipment to ensure quality care.

– Telemedicine and Mobile Health Apps: Develop telemedicine platforms or mobile health apps that enable remote consultations and support for HIV-positive peripartum women who have migrated. These platforms can provide access to healthcare professionals, educational resources, appointment reminders, and medication adherence support. This innovation can bridge the gap in accessing maternal health services for women who are unable to physically visit healthcare facilities.

– Community Health Workers: Train and deploy community health workers in areas with high migration rates to provide support and guidance to HIV-positive peripartum women. These community health workers can conduct home visits, offer counseling, facilitate access to healthcare services, and ensure continuity of care during and after migration.

– Peer Support Networks: Establish peer support networks for HIV-positive peripartum women who have migrated. These networks can provide emotional support, share experiences, and offer practical advice on accessing maternal health services in different locations. Peer support can help alleviate feelings of isolation and provide a sense of community for women who are away from their usual support systems.

– Information and Communication Campaigns: Develop targeted information and communication campaigns to raise awareness among HIV-positive peripartum women about the importance of accessing maternal health services, including ART care, during and after migration. These campaigns can utilize various channels such as radio, television, social media, and community gatherings to disseminate information and promote behavior change.

By implementing these innovative approaches, it is possible to improve access to maternal health services for HIV-positive peripartum women who migrate, ultimately reducing maternal mortality rates and improving overall maternal health outcomes.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health for mobile HIV-positive peripartum women:

1. Mobile clinics: Establish mobile clinics that can reach rural areas and areas with high migration rates. These clinics can provide comprehensive maternal health services, including antenatal care, HIV testing, and access to antiretroviral therapy (ART).

2. Telemedicine: Implement telemedicine programs that allow mobile peripartum women to access healthcare services remotely. This can include virtual consultations with healthcare providers, remote monitoring of vital signs, and delivery of medication to their location.

3. Community health workers: Train and deploy community health workers in areas with high migration rates. These workers can provide education, support, and follow-up care to mobile peripartum women, ensuring continuity of care throughout their pregnancy and postpartum period.

4. Mobile health apps: Develop mobile health applications that provide information and resources on maternal health, HIV management, and access to healthcare services. These apps can also send reminders for appointments and medication adherence.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Gather data on the current access to maternal health services, migration patterns, and health outcomes among mobile HIV-positive peripartum women in the study area. This can be done through surveys, interviews, and existing health records.

2. Model development: Develop a simulation model that incorporates the various recommendations mentioned above. This model should consider factors such as the number of mobile clinics, coverage of telemedicine services, deployment of community health workers, and usage of mobile health apps.

3. Parameter estimation: Estimate the parameters of the simulation model based on available data and expert knowledge. This includes factors such as the effectiveness of each recommendation in improving access to maternal health and the potential reach of each intervention.

4. Simulation runs: Run the simulation model multiple times, varying the parameters and assumptions to capture different scenarios and potential outcomes. This can help assess the impact of each recommendation on access to maternal health and estimate the potential reduction in maternal mortality.

5. Analysis and interpretation: Analyze the simulation results to determine the effectiveness of each recommendation and identify any trade-offs or synergies between interventions. Interpret the findings to inform decision-making and prioritize the most impactful strategies for improving access to maternal health.

It is important to note that this methodology is a general framework and the specific details and data requirements may vary depending on the context and available resources.


Statistics:
Citations: 5
Identifiers:
DOI: 10.1371/JOURNAL.PMED.1003085
ISSN: 15491277
Research Areas:
Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal and Child Health, Sexual and Reproductive Health
Study Countries:
South Africa
Study Design:
Cohort Study, Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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