- Prophylactic antibiotics for all women with AIDS.
- Antibiotic cover for all HIV positive women for surgical interventions.
- Guidelines on managing pregnant HIV positive women and pregnant women with AIDS must be developed as a matter of urgency.
- Ethical guidelines on the management of HIV positive women must be developed nationally.
- An "opt out" policy for HIV screening is likely to lead to a reduction in maternal deaths and benefit the baby. Serious consideration should be given to adopting this as a national policy.
Introduction
Women often die of infections not directly related to pregnancy, but in whom pregnancy may aggravate the infection. This is particularly so in the era of HIV/AIDS. Deaths in this category are those resulting from HIV/AIDS, pneumonia, tuberculosis, appendicitis, urinary tract infection, meningitis, and malaria.
HIV/AIDS is an enormous threat to development and social transformation. This is reflected in this report where the majority of affected people are young. The fifteen-fold increase in HIV prevalence over the past decade is indicative of an epidemic that is starting to show its impact in terms of mortality. It is currently estimated that there were about 165 000 cases of AIDS and 120 000 AIDS deaths in South Africa in 1998.
The deaths resulting from AIDS are probably under-reported. The HIV status was unknown in 75.8% of maternal deaths. There were 32 cases of tuberculosis, pneumonia and meningitis that could have been reclassified as AIDS had the HIV status had been known.
Provincial distribution of antenatal prevalence of HIV could not be accurately determined from this data set because of the under-reporting from a number of provinces, because in less than a quarter of cases of maternal death was the HIV status known.
Despite incomplete data, the available information enables the NCCEMD to make the recommendations that can make early and appropriate intervention possible and effective.
Demography
More than 87% of the women who died of AIDS had less than three deliveries prior to their deaths and 74% were women less than 30 years of age (Table 9.1). The average age of maternal deaths due to AIDS was 26.4 ( 5.3 years. The maternal deaths due to non-pregnancy related infections other than AIDS also had preponderance in the lower age groups, and parities.
The majority of maternal deaths occurred in level 2 hospitals (46.2%), 34.6% occurred in level 3 hospitals and 19.2% in level 1 hospitals.
KwaZulu-Natal, Mpumalanga and Gauteng are among the leading provinces with maternal deaths associated with HIV infection or pneumonia, in keeping with the trend shown by the 1998 Antenatal HIV survey. Gauteng tends to be over-represented, probably, as it is a referral province for under-resourced provinces.
Primary, Final and Contributory causes of deaths
The primary causes of death in this group of maternal deaths are shown in Table 9.3 and the final causes of death are shown in Table 9.4. The majority of pregnant women, who die of AIDS, do so as a result of respiratory failure due to overwhelming pneumonia.
A patient can have more than one final and contributory cause of death. Malaria and meningitis also contributed significantly to maternal deaths.
Avoidable factors, missed opportunities and substandard care for non-pregnancy related infections and AIDS
A summary of findings is shown in Tables 9.5-9.7.
Compared with other disease categories, relatively few women with AIDS were managed inappropriately.
Below are a few case histories that illustrate some of the problems encountered.
Case 1: A 23 year old PO G1 attended antenatal clinic on 5 occasions. At 37 weeks she developed severe proteinuric hypertension and because it was thought she had a large breech was delivered by caesarean section. At caesarean section twins were delivered at 2.2 kg and 2.3 kg. Her post operative course was stormy. She became anaemic and required 3 units of blood. She later developed intractable diarrhoea and puerperal sepsis. She was treated with antibiotics and antidiarrhoeal medications. She was counselled for HIV testing because her postoperative course was unusual. The test was positive and her CD4 count was low. After a prolonged hospital stay, the patient died. Details of her treatment are sketchy due to poor note keeping.
Comment: This case illustrates the current dilemma facing most doctors. Had the woman been counselled and tested for HIV, the management strategy of this patient would have been different. Firstly, prophylactic antibiotics would have been given before the caesarean section. A more aggressive management towards the sepsis and anaemia would have ensued.
Case 2: A 26 year old PO, G1 went into spontaneous labour at 32 weeks, and delivered a 1 450g infant. She had attended antenatal clinic 5 times from 18 weeks onwards. Anaemia was detected. On the grounds of clinical suspicion, she was tested and found to be HIV positive. Diarrhoea, haemorrhagic cystitis and intrauterine growth retardation marked her pregnancy. She deteriorated rapidly from Day 4 post delivery, and died of septic shock.
Comment: The death was not preventable in the long term, however, the death during pregnancy and the puerperium could have been prevented. The management of women with AIDS during pregnancy is not clear. The disease is relatively new and few doctors have experience in managing such cases. The antibiotic regimes, vitamin supplementation and antiviral treatment all still need to be clarified. Furthermore, this case highlights the impact that AIDS will have on the health of women.
Case 3: A 24 year old HIV positive PO, G1 was initially admitted into a psychiatric institution and then transferred to the antenatal ward with pneumonia. She was 30 weeks pregnant. Investigations revealed a CD4 count of 152, klebsiella septicaemia, and cerebral atrophy. The patient died undelivered, despite appropriate treatment and anti-TB prophylaxis.
Comments: This case again illustrates the effect the HIV epidemic will have on the health services.
It is estimated that since the beginning of the epidemic, more than 8 million children world-wide have lost their mothers to HIV/AIDS when they were less than 15 years of age. In many countries AIDS has become the leading cause of death in adults. AIDS is systematically reducing the life expectancy in the countries where the disease is most prevalent.
In this report, the findings are consistent with the trends reflected by the annual antenatal surveys, which have clearly shown over the years that HIV infection is more prevalent in the younger population groups. The average age of maternal deaths due to AIDS was 26 years. If one accepts a 10 year period from contracting the infection to death, most of these women contracted HIV around 16 years of age. Furthermore, the 1998 antenatal HIV survey results suggest that an ever-growing number of young pregnant women might die in future as a result of the high rate of increase of HIV infection among teenagers. The rate of increase of HIV infection in pregnant teenagers in the period 1997 - 1998 was 65.4%.
Most pregnant women who died as a result of complications of AIDS did so because of respiratory infections, although every organ system was represented. The relatively low rate of misdiagnosis and non-adherence to standard protocols, is not due to good management, but due to the absence of accepted, practical guidelines. Much time, effort and emotion goes into caring for AIDS patients and this is going to increase rapidly in the next few years. While there is very little potential for cure at present, much can be done to improve the quality of life and improve the pregnancy outcome. The use of prophylactic antibiotics in women with AIDS, the supplementation of their diet with vitamins and minerals, an altered lifestyle, specific management in labour, and the selective use of antiviral therapy to prevent vertical transmission of the virus can all impact on the wellbeing of the HIV-positive woman. It is essential that national guidelines for the management of pregnant HIV-positive women and the management of pregnant women with AIDS are drawn up urgently.
The role of prophylactic antibiotics for HIV positive women (as opposed to women with AIDS) during labour needs to be investigated. It is clear that women with AIDS should be given antibiotic cover during labour.
Managing pregnant women with AIDS often creates ethical dilemmas. Should a pregnant woman with AIDS be mechanically ventilated if she develops respiratory failure? In the presence of restricted resources, especially ICU beds (as demonstrated in this report) is it justifiable? At what level of care should these women be managed? There is already considerable pressure on level 3 beds, should they be reserved for women with better long-term prognoses? In the absence of ethical guidelines, at local, Provincial or National level, decisions regarding the management of women with AIDS create stress, uncertainty and loss or morale amongst all health workers. This is illustrated by Case 1. It was reported that there was nothing that could be done to prevent the death of the woman, as she was HIV-positive. Health workers may often be overwhelmed by fatalism. A public debate on these issues is urgently required and consensus amongst the population needs to be developed. Once reached, resources must be provided to ensure the decisions are carried out. It must be stressed that there is a great difference between an HIV-positive pregnant woman and a pregnant woman with AIDS. The above comments only refer to women with AIDS.
In this report for the year 1998, it appeared that women who were HIV positive but did not have any AIDS defining features were also at risk for dying from uncontrollable infection, sometimes following a normal vaginal delivery. However, this was more the case following surgical intervention such as caesarean section. The first systematic review of studies of HIV infection and pregnancy has shown that the odds ratio for death was 1.8 for pregnant HIV positive women compared with non-pregnant HIV positive women. This means that pregnancy nearly doubles the chances of an HIV positive woman dying1. Some studies have indicated that elective caesarean section reduces the perinatal transmission of HIV2. However, it is not known what this policy will have on the outcome of the mother. Studies are urgently required to answer this question.
Contraceptive use should be actively promoted in HIV-positive women. It appears that pregnancy is associated with a more rapid deterioration of the woman.
An "opt out" policy for screening for HIV implies counselling all women about HIV and informing them that an HIV test will be performed on her unless she specifically informs the staff that she does not want an HIV test. An "opt in" policy implies counselling and then informing the woman that she must request the staff to perform the test if she wants an HIV test. The "opt out" policy is associated with a high screening rate, over 80%, whereas an "opt in" policy is associated with a low screening rate, less than 20%. A high HIV screening rate in pregnancy would probably assist greatly in decreasing maternal mortality associated with HIV. Knowledge of her HIV status would enable a woman to decide on the choices that are available to her. For HIV positive women, knowledge of her status will influence whether the woman elects termination of pregnancy, and whether to plan for breast-feeding or not. Health workers will also know what options to offer women, and to weigh the risks of various interventions, for example, caesarean section. The decision for early antenatal testing for HIV must take into consideration the various traditional and cultural practices, and the high level of violence against women. Men have thus far not been actively involved in maternity issues, particularly within the public sector. It is therefore imperative that they are made aware of the implications of HIV testing, and that their support for the policy and the outcome of the testing be solicited. Anecdotal cases have been reported where women have been assaulted by their partners because they were HIV positive.
Besides contraception, the most effective strategy in terms of management of the HIV epidemic remains the prevention of infection with HIV. Innovative ways must be found and applied. This is possible, as both Uganda and Thailand have managed to bring the epidemic to almost a halt. The prevalence of HIV infection among pregnant women in Thailand appears to be declining gradually. The prevalence was 2.3% in 1995, 1.82% in 1996, and 1.68% in 1997. The Thai AIDS prevention and control programme might be modified and implemented in other countries experiencing the epidemic of heterosexually-transmitted HIV infection. It is important that the areas of risk be addressed aggressively, including the commercial sex industry. It cannot be denied that most women who ultimately died were victims of the practices of men elsewhere.
Pneumonia was a common cause of maternal deaths. There was no testing for HIV in many of them. It is apparent that pneumonia in pregnancy must raise the level of sensitivity and suspicion for testing for HIV, especially in the woman less than 25 years. Counselling regarding HIV testing should be performed in these patients. This will help in starting effective antibiotic and other therapies that may benefit the woman. In some cases, the woman presented at the health care facility a few days before admission with severe respiratory disease, but the diagnosis of pneumonia was not made. This points to the need for improving diagnostic clinical skills for primary health care workers. The level of suspicion should be raised, so that a timely referral is made.
Tuberculosis was another infection that led to maternal deaths. The fact that this infection also occurs mainly in the young age group of pregnant women may suggest that HIV may have played a part. Indeed, in the era of HIV/AIDS, compromised immunity must be suspected in cases of such infections.
Malaria is still a killer within the subtropical and tropical regions, and with the increase in the ease of travel, health workers and communities should be vigilant. It is still a travesty that nets are not used in South Africa. Even hospitals in malaria endemic areas do not have mosquito bed nets. Nurses and doctors need to be familiar with the protocols for the management of complicated malaria.
South Africa has one of the fastest growing HIV/AIDS epidemic in the world, and it is important that every individual of reproductive age should know his/her HIV status. A decision on which policy, "opt out" or "opt in", for HIV screening is to be used and funded. At the very least voluntary counselling and testing should be easily accessible. Guidelines for managing HIV positive women and women with AIDS during pregnancy and the puerperium are urgently required. Ethical guidelines must be developed and made available to health workers especially in the area of maternal and child care. There can be no success in combating the HIV/AIDS epidemic without a concerted effort at curbing HIV transmission. South Africa must apply the lessons learned in other areas, especially Uganda and Thailand, and involve men and the workers in the sex industry in efforts to stop new transmission. Young people must be the main beneficiaries of prevention programmes.
Discussion
Conclusion
References: