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

McGovern, Terry, Kim, Hae-Young, Dobra, Adrian and Tanser, Frank (2020) Migration and first-year maternal mortality among HIV-positive postpartum women: A population-based longitudinal study in rural South Africa. PLOS Medicine, 17 (3). e1003085. ISSN 1549-1277

Full content URL: https://doi.org/10.1371/journal.pmed.1003085

Documents
Migration and first-year maternal mortality among HIV-positive postpartum women: A population-based longitudinal study in rural South Africa
Published Open Access Manuscript
[img]
[Download]
[img]
Preview
PDF
__network.uni_staff_S1_cjoyner_Downloads_Frank Tanser_tanser migration and maternal mortality.pdf - Whole Document
Available under License Creative Commons Attribution 4.0 International.

1MB
Item Type:Article
Item Status:Live Archive

Abstract

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.

Keywords:HIV, Pregnancy, Maternal mortality, Death rates, Labor and delivery, Medical risk factors, South Africa, Tuberculosis
Subjects:B Subjects allied to Medicine > B990 Subjects Allied to Medicine not elsewhere classified
Divisions:College of Social Science
ID Code:41623
Deposited On:23 Jul 2020 13:52

Repository Staff Only: item control page