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Context: Understanding the risk of human immunodeficiency virus (HIV) transmission through breastfeeding is essential for advising HIV-infected mothers and formulating public health policy recommendations., Objective: To measure the frequency, timing, and risk factors of HIV transmission through breast milk., Design: Prospective cohort study conducted between 1994 and 1997, with follow-up of infants through 24 months of age., Setting: Postnatal clinic of tertiary care hospital, Blantyre, Malawi., Participants: A total of 672 infants (HIV-negative at birth) born to HIV-infected women who had not received antiretroviral drugs during or after pregnancy., Main Outcome Measure: Incidence of HIV in breastfed infants by age and maternal and infant risk factors for HIV transmission, using proportional hazard models to derive risk ratios (RRs) and 95% confidence intervals (CIs)., Results: Forty-seven children became HIV-infected while breastfeeding but none after breastfeeding had stopped. The cumulative infection rate while breastfeeding, from month 1 to the end of months 5, 11,17, and 23, was 3.5%, 7.0%, 8.9%, and 10.3%, respectively. Incidence per month was 0.7% during age 1 to 5 months, 0.6% during age 6 to 11 months, and 0.3% during age 12 to 17 months (P = .01 for trend). The only factors significantly associated with low risk of postnatal HIV transmission in a multivariate model were high maternal parity (RR, 0.23; 95% CI, 0.09-0.56) and older maternal age (RR, 0.44; 95% CI, 0.23-0.84)., Conclusions: Our data suggest that the risk of HIV infection is highest in the early months of breastfeeding, which should be considered in formulating breastfeeding policy recommendations.

Disturbances of vaginal flora are common among women of reproductive age. In areas of sub-Saharan Africa where the prevalence of HIV is high, the frequency of bacterial vaginosis (BV) is also high. In this study, we assessed the association of BV and other disturbances of vaginal flora with prevalent HIV infection in two cross-sectional studies among pregnant women in urban Malawi. The prevalence of HIV-1 was 23% in 1990 and 30% in 1993. Overall, 30% of the women had BV, 59% had mild or moderate disturbance of vaginal flora, and only 11% had normal vaginal flora. Increasing prevalence of HIV was significantly associated with increasing severity of disturbance of vaginal flora (p < .00001, chi2 trend test). This trend of increased prevalence persisted after controlling for concurrent sexually transmitted diseases (STDs), sexual activity, and socioeconomic factors. After multivariate adjustment for potential confounders, the odds ratio for the association of BV with prevalent HIV infection was 3.0 (95% confidence interval [CI], 2.4-3.8), that of moderate vaginal disturbance with HIV infection was 2.2 (95% CI, 1.7-2.8), and that of mild vaginal disturbance with HIV infection was 1.6 (95% CI, 1.3-2.1). Among women with BV, HIV infection was higher among younger women than older, implying more recent infection. Although these studies were cross-sectional, our data suggest that BV could be associated with increased susceptibility to HIV infection.

Background: Cross-sectional studies suggest an association between bacterial vaginosis (BV) and HIV-1 infection. However, an assessment of a temporal effect was not possible., Objectives: To determine the association of BV and other disturbances of vaginal flora with HIV seroconversion among pregnant and postnatal women in Malawi, Africa., Design: Longitudinal follow-up of pregnant and postpartum women., Methods: Women attending their first antenatal care visit were screened for HIV after counselling and obtaining informed consent. HIV-seronegative women were enrolled and followed during pregnancy and after delivery. These women were again tested for HIV at delivery and at 6-monthly visits postnatally. Clinical examinations and collection of laboratory specimens (for BV and sexually transmitted diseases) were conducted at screening and at the postnatal 6-monthly visits. The diagnosis of BV was based on clinical criteria. Associations of BV and other risk factors with HIV seroconversion, were examined using contingency tables and multiple logistic regression analyses on antenatal data, and Kaplan-Meier proportional hazards analyses on postnatal data., Results: Among 1196 HIV-seronegative women who were followed antenatally for a median of 3.4 months, 27 women seroconverted by time of delivery. Postnatally, 97 seroconversions occurred among 1169 seronegative women who were followed for a median of 2.5 years. Bacterial vaginosis was significantly associated with antenatal HIV seroconversion (adjusted odds ratio = 3.7) and postnatal HIV seroconversion (adjusted rate ratio = 2.3). There was a significant trend of increased risk of HIV seroconversion with increasing severity of vaginal disturbance among both antenatal and postnatal women. The approximate attributable risk of BV alone was 23% for antenatal HIV seroconversions and 14% for postnatal seroconversions., Conclusions: This prospective study suggests that progressively greater disturbances of vaginal flora, increase HIV acquisition during pregnancy and postnatally. The screening and treating of women with BV could restore normal flora and reduce their susceptibility to HIV.

Objectives: To examine rates of HIV-1 and sexually transmitted disease (STD) among pregnant and postpartum women in urban Malawi, Africa., Design: Serial cross-sectional surveys and a prospective study., Methods: Three major surveys were conducted in 1990, 1993 and 1994/1995. Consecutive first-visit antenatal women and women giving birth at the Queen Elizabeth Central Hospital were tested for HIV and STD after counseling and obtaining informed consent. Unlinked, anonymous HIV testing was also conducted on smaller samples of antenatal women in the same hospital to provide annual prevalence data. HIV-seronegative postpartum women from the 1990 and 1993 surveys were enrolled in a prospective study to determine HIV incidence., Results: HIV seroprevalence rose from 2.0% in 1985 to 32.8% in 1996, a 16-fold increase. The highest age-specific HIV prevalence was in the following age-groups: 20-24 years during 1990, 25-29 years during 1993, and 30-34 years during 1996. Among 1173 women followed for a median of 30.9 months, HIV incidence was 5.98 per 100 person-years in women aged < 20 years and declined steadily in older women. The prevalence of STD significantly declined among both HIV-positive and negative women. This decline in STD prevalence, however, was not accompanied by increased condom use over time., Conclusions: Among urban childbearing women in Malawi, incidence of HIV is highest among young women while, currently, prevalence is highest among older women. Recent declines in STD prevalence suggest that HIV prevention programs are having an impact either through improved STD diagnosis and treatment or reduced risk behaviors. Sequential cross-sectional STD prevalence measures may be useful in monitoring effectiveness of STD and HIV prevention activities.

In a survey of family planning clients at the central Teaching Hospital, Blantyre, between July 1 and December 31, 1993, to determine their social, biological and reproductive profiles, contraceptive awareness and previous use, 766 new clients were recruited and interviewed by means of partially structured questionnaire. Their mean age was 27 years, with a range of 15-43 years. Adolescents formed 10.1% and those above 35 years of age were 17.1%. 91.3% were married. While 12.6% had no formal education, 29.7% had secondary school education and higher. Their mean parity and living children were 3.6 and 3.1 respectively. The mean desired fertility was 4.5. 93.3% of all clients had live births in their last pregnancies. Contraceptive awareness was quite high, about 98.0%. However, only 30.9% had ever-used contraceptives before then. When these are looked at against a background of the corresponding situations in the country, it appears that the individuals seeking, accepting and using contraceptives in Malawi, are better off in the various aspects of life, thus suggesting their possible influence on contraceptive use. There is need to review the national family planning programme, address the contraceptive needs of adolescents and women aged above 35 years, improve formal female education, change the prevailing socio-cultural and traditional beliefs and practices which affect women adversely, thus empowering them over affairs of their health.

Objective: To determine if cleansing the birth canal with an antiseptic at delivery reduces infections in mothers and babies postnatally., Design: Clinical trial; two months of no intervention were followed by three months of intervention and a final month of no intervention., Setting: Queen Elizabeth Central Hospital (tertiary care urban hospital), Blantyre, Malawi., Subjects: A total of 6965 women giving birth in a six month period and their 7160 babies., Intervention: Manual wipe of the maternal birth canal with a 0.25% chlorhexidine solution at every vaginal examination before delivery. Babies born during the intervention were also wiped with chlorhexidine., Main Outcome Measures: Effects of the intervention on neonatal and maternal morbidity and mortality., Results: 3635 women giving birth to 3743 babies were enrolled in the intervention phase and 3330 women giving birth to 3417 babies were enrolled in the non-intervention phase. There were no adverse reactions related to the intervention among the mothers or their children. Among infants born in the intervention phase, overall neonatal admissions were reduced (634/3743 (16.9%) v 661/3417 (19.3%), P < 0.01), as were admissions for neonatal sepsis (7.8 v 17.9 per 1000 live births, P < 0.0002), overall neonatal mortality (28.6 v 36.9 per 1000 live births, P < 0.06), and mortality due to infectious causes (2.4 v 7.3 per 1000 live births, P < 0.005). Among mothers receiving the intervention, admissions related to delivery were reduced (29.4 v 40.2 per 1000 deliveries, P < 0.02), as were admissions due to postpartum infections (1.7 v 5.1 per 1000 deliveries, P = 0.02) and duration of hospitalisation (Wilcoxon P = 0.008)., Conclusions: Cleansing the birth canal with chlorhexidine reduced early neonatal and maternal postpartum infectious problems. The safety, simplicity, and low cost of the procedure suggest that it should be considered as standard care to lower infant and maternal morbidity and mortality.

Objectives: To assess the impact of the manual vacuum aspiration (MVA) technique on health care services and its acceptability to patients and staff., Design: Prospective descriptive survey., Setting: The university teaching hospital, Blantyre, Malawi., Participants: All 456 patients who had MVA for treatment or investigation between 10 January and 9 April 1994, the nurses and doctors working in the unit and hospital administrators., Main Outcomes: Proportion of incomplete abortion patients who had MVA, the need for pain relief, patients' reactions, staff opinion, and reduction in ward occupancy rates and duration of hospitalisation., Results: Of the total, 97.4% had MVA for treatment of incomplete abortion; these comprised 81.2% of all incomplete abortion patients treated during the study period. The mean volume of uterine contents was 33.4 ml. There was no relationship between the volume and either the gestational age or uterine size (P > 0.05). Only 10.7% of patients required pain relief. The bed occupancy rates in the gynaecological ward dropped from an average of 150% before to 130% after the introduction of MVA, and the mean hospital stay was reduced from 3 days, with 78.4% staying for more than 2 days, to 2 days, with 52% staying for less than 24 hours (P < 0.05). Most patients expressed general satisfaction with the method, while the staff were happler because their work had been made easier. There were no major complications associated with the procedure., Conclusion: The findings show that MVA is a safe, reliable, effective and acceptable method of treating incomplete abortion, and can conserve hospital resources.

Objectives: To establish frequency of reported condom use and validate reliability of self-reporting among urban women in Malawi., Design: Cross-sectional survey in antenatal women in 1989 and 1993. Prospective study in cohort first surveyed in 1989., Methods: A total of 6561 women in 1989 and 2460 women in 1993 answered questions about condom use and sexual activity, had a physical examination and were screened for HIV. A subset of women from the 1989 screening were administered a questionnaire and tested for syphilis, Neisseria gonorrhoeae and Trichomonas vaginalis infections every 6 months., Results: Although between the two cross-sectional studies intermittent condom use increased from 6 to 15% (P < 0.001) with no difference according to HIV infection, consistent use was reported by less than 1%. In the prospective study, women reported a higher condom use at any visit than either group assessed cross-sectionally. Consistent condom use peaked at 62% in the first 6 months, but declined to as low as 8% in the second year of follow-up. Condom use at each visit, either intermittent or consistent, was higher in HIV-seropositive than HIV-seronegative women. Overall, the incidence of gonorrhea, trichomoniasis and syphilis did not decline in women reporting consistent condom use., Conclusions: In prospectively followed women reports of consistent condom use was substantially higher than in cross-sectional surveys, but rapidly decreased over time, irrespective of HIV status. The presence of new sexually transmitted diseases suggests that this population of urban women overreports condom use or underreports sexual activity, or both. Intensive and sustained education is needed to achieve consistent condom use. Biologic markers of sexual activity are useful in interpreting reported condom use.

Studies of haematological parameters were performed on 366 (177 male and 189 female) normal Malawian neonates with mean +/- s.d. birthweight of 2.99 +/- 0.37 (range 2.1-4.0) kg using a Nova Cell Track, Model Nova CT11. Cord anaemia (Cord Hb < 13.5g dl-1) was detected in 100 (27.3%) of the neonates. It was also shown that although the male babies had a significantly higher erythrocyte protoporphyrin level (p < 0.001) than the females, there were no significant differences (p > 0.05) in the red cell, white cell and platelet indices between the two sexes. When the haematological parameters of the 266 (72.7%) non-anaemic (Cord Hb > 13.5g dl-1) neonates were analysed, the mean +/- s.d. values which may serve as local reference standards were: Hb 16.0 +/- 1.7 (range 13.5-21.3) g dl-1, Hct 47.0 +/- 6.0 (range 36.5-67.5) percent, MCV 112.6 +/- 8.9 (range 72.2-131.0) fl, MCH 31.9 +/- 5.5 (range 24.4-48.5) pg, MCHC 33.5 +/- 2.8 (range 29.1-48.9) g dl-1 reticulocyte count 6.9 +/- 3.6 (range 1.2-25.0) percent, free erythrocyte protoporphyrin 3.3 +/- 0.9 (range 1.9-7.7) mgs ZPP gm-1 Hb, platelet count 269.9 +/- 57.7 (range 134.0-454.0) x 10(9) l-1 and total leucocyte count 12.3 +/- 4.8 (range 5.5-35.3) x 10(9) l-1. Further analysis of the differential wbc count disclosed normal levels of eosinophils and neutrophils similar to those given in standard haematology textbooks for Caucasian neonates; thus strengthening the belief that eosinophilia and relative neutropenia previously reported in adult Africans is not of genetic origin, but rather an acquired phenomena.

In the whole of 1993, there were a total of 1533 new clients who attended the family planning clinic at the Queen Elizabeth Central Teaching Hospital in Blantyre, Malawi. They formed 23.0% of the total client-visits for the year. 305 women had surgical contraception (bilateral tubal ligation) for various reasons, but mainly on request for family limitation. The ages of the new clients ranged from 15 to 49 years. Adolescents (< 20 years old) formed only 9.0%, while those aged > 35 years formed 22.0%. Their parity ranged from 0 to 11, with 58.0% of them being para 1 to 4. The grandmultiparae (para > 5) formed 31.0%. The oral pill was the most favoured method (42.0%), followed by depo-provera (31.0%) and sterilisation (21.0%). Though the majority of the clients who chose the oral pill were aged less than 30 years, about 6.0% were aged > 35 years. Likewise about 15.0% of those who took oral pills were para > 5, i.e. grandmultiparae. These are women who should have either stopped producing a long time back or been counselled to have tubal ligation rather than these temporary methods, when seen in the clinic then. Amongst all the client-visits for the year, oral pill and depo-provera were the two most popular methods, 42.0% and 41.0%, respectively. The ratio, between the clients who discontinued the method they were on and the new clients was 1:6.8, and that of drop-out/new clients was 1:2.4, which are quite high. The rate of absenteeism was also high at 29.0% of the total client-visits.(ABSTRACT TRUNCATED AT 250 WORDS)

Although unproven, vaginal cleansing with antiseptics during labour could be a practical approach to reducing the rate of transmission of HIV infection from mother to infant. Before initiating a large scale clinical trial of the antiseptic chlorhexidine, we conducted a study to assess possible toxic effects as well as beneficial outcomes in 160 women volunteers: 40 non-pregnant chlorhexidine washed, 40 pregnant not washed, 40 pregnant saline washed, and 40 pregnant chlorhexidine washed. The wash was easily administered by the nurse-midwives. The participants generally felt better after the procedure, and had no complaints or adverse reactions in the subsequent 24 hours. Bacteriologically, the procedures lowered the carriage of Group B streptococcus and Staphylococcus aureus, but did not affect the frequency of T. vaginalis detection. No clinical problems were seen, and therefore the larger clinical trial of efficacy will proceed. Results of this trial are expected in late 1995.

A retrospective study was undertaken to document immediate morbidity and mortality associated with low Apgar scores (5 or less) at 5 min in singleton term babies (37 weeks or more). From October 1986 to February 1987, 84 term babies had low Apgar scores, giving an incidence of 15/1000 live births. Overall mortality in these patients was 42%, and in those in whom Apgar scores remained 0-3 at 5 min, mortality was 77%. Evidence of severe-to-moderate hypoxic-ischaemic encephalopathy was noted in 44 (52%) and 17 (20%) failed to establish spontaneous respiration within the 1st few hours of life. Meconium aspiration syndrome was diagnosed in 29 (35%). A control group of 141 term babies with 5-min Apgar scores of 7 or more were identified and the presence of possible risk factors associated with low Apgar scores was assessed. Primiparity and prolonged second stages of labour in all parities were found to be significantly associated with low Apgar scores. Improved obstetric care and appropriate management of the newborn at delivery and in the neonatal period may help to reduce mortality and morbidity in some term babies.

Three hundred and fifty-seven serum samples from pregnant African women were examined for Toxoplasma gondii antibodies with indirect haemagglutination test in Dar es Salaam. Out of these 222 women were normal, sixty-nine had anaemia and sixty-six were suffering from hypertension. Infection rate in normal pregnant women was 41.9%, in anaemic women 52.5%, and in those suffering from hypertension 66.7%. Highly significant relationship was observed between Toxoplasma infection and anaemia, and hypertension. Infection rate was significantly high in women who had histories of abortion. The results suggested associations of Toxoplasma gondii infection with hypertension and anaemia in African women.