1,720,984 research outputs found
The association between maternal HIV and stillbirths in an era of universal art in pregnancy in the Western Cape, South Africa
Full text linkBACKGROUND: Annually, approximately 1.9 million stillbirths occur globally, with a rate of 13.9 per 1000 births. The devastating aftermath affects around 4.2 million mothers, and 75% of stillbirths are concentrated in South Asia and sub-Saharan Africa (SSA) particularly, with a rate of 32.2 per 1000 births in SSA. South Africa reported a stillbirth rate of 16.3 per 1000 births in 2019, despite global efforts to reduce stillbirth rates. SSA also faces the highest global HIV prevalence at 20%. South Africa, home to 8.4 million people living with HIV, grapples with a 30% prevalence among pregnant individuals. Antiretroviral therapy (ART) coverage for pregnant individuals reached 97% in 2019, especially in the Western Cape with an HIV prevalence of 17.9% among antenatal individuals. Quality antenatal care (ANC) is crucial, with research showing a lower stillbirth rate for those receiving higher quality ANC. The COVID-19 pandemic in 2020 introduced new challenges, potentially influencing stillbirth rates through factors like lockdowns and limited healthcare access. Pregnant individuals contracting SARS-CoV-2 faced an increased likelihood of stillbirth. In this context, our cohort study in the Western Cape, South Africa, utilized routine health data to investigate the contemporary relationship between pregnant individuals with HIV and stillbirths in the era of universal ART during pregnancy. The study explores associations with demographic and clinical variables, including the quality of ANC. METHODS Utilizing data from the Western Cape Pregnancy Exposure Registry (PER) between 2017 and 2021, this cohort study focused on pregnant women attending antenatal care (ANC) at the Gugulethu Midwife Obstetrics Unit (GMOU) and Worcester Midwife Obstetrics Unit (WMOU) in South Africa. Integrated information from the Provincial Health Data Centre (PHDC) was used to create a linked database for cohort generation. The cohort included women aged 18 or older, with known HIV status and a recorded pregnancy outcome after 20 weeks of gestation. The primary outcome was stillbirth, with maternal HIV status serving as the primary exposure. ANC quality, based on WHO guidelines, was assessed by considering variables such as ANC timing, the number of visits, and various healthcare parameters. ANC quality was categorized using both the old WHO guidelines (at least 4 visits) and the new WHO guidelines (at least 8 visits), with a good ANC quality score requiring 7 or more out of 11 quality ANC variables. Statistical analyses, including logistic regression, were conducted to explore associations between maternal HIV status, ANC quality, and stillbirth prevalence. The study also collected data on maternal characteristics to provide a comprehensive understanding of contributing factors. RESULTS The study included 15,123 participants: 4,773 women living with HIV (WLHIV) and 10,350 women without HIV. WLHIV had a median age of 28 years, while women without HIV had a median age of 31 years. The overall stillbirth rate was 15 per 1,000 births (95% CI: 13.1-16.9). Stillbirth rates were higher among WLHIV at 17 per 1,000 births (95% CI: 13.34-20.66) compared to women without HIV at 14 per 1,000 births (95% CI: 11.75-16.25). Maternal HIV- positive status (AOR = 1.15, 95% CI: 0.87-1.52, p = 0.34) did not show a statistically significant association with stillbirths. Women with prior diabetes exhibited a significant increase in stillbirth odds (AOR = 2.63, 95% CI: 1.06-6.52, p = 0.04). Women without HIV but with a history of diabetes had a stillbirth prevalence of 4.08%, compared to 3.80% for WLHIV. WLHIV with good-quality ANC had fewer stillbirths (4 visits: 5.06%, 8 visits: 2.53%) than women without HIV (4 visits: 11.56%, 8 visits: 5.06%). ART for ≥100 weeks among WLHIV showed a protective effect, with 47% lower stillbirth odds than ART <20 weeks (AOR = 0.53, p = 0.01) and 45% lower stillbirth odds than ART <20 weeks (AOR = 0.55, 95% CI: 0.33-0.91, p = 0.02). Despite higher stillbirth odds for WLHIV, no significant association was found between maternal HIV status and stillbirths after adjustment (AOR = 1.15, 95% CI: 0.87-1.52, p = 0.34). CONCLUSION: This study, utilizing routine program data, revealed no statistically significant difference in the prevalence of stillbirths between women living with and without HIV. Despite the lack of a statistically significant association between the quality of antenatal care (ANC) and stillbirths, the study underscores the importance of adhering to WHO recommendations and utilizing databases such as the Pregnancy Exposure Registry for evidence-based decision-making. Although the overall stillbirth rate slightly exceeded global targets, there was noticeable improvement following the universal rollout of antiretroviral therapy (ART). Notably, among women living with HIV (WLHIV), a longer duration of ART was linked to a significant reduction in the odds of stillbirth, highlighting the critical role of sustained access to ART. Despite its limitations, these findings contribute to global health objectives, particularly those aimed at eliminating preventable newborn deaths by 2030. ART emerges as a pivotal factor in decreasing stillbirth rates among women living with HIV
Association between infant feeding practices and infant growth by maternal HIV and antiretroviral therapy status: A prospective study in Cape Town, South Africa
Full text linkBackground Infants who are HIV-Exposed Uninfected (HEU) may experience adverse growth outcomes compared to those who are HIV Unexposed Uninfected (HUU). Breastfeeding (BF) provides infants with the necessary nutrients to grow optimally irrespective of maternal HIV status. The initiation and duration of BF may also be related to infant growth. We compared growth parameters from birth up to 12 months old in infants who were HEU and HUU, investigating associations with types of infant feeding practices (BF and complementary feeding) and Household Food Security Status (HFSS) under the current era of universal Antiretroviral therapy (ART) in pregnancy policies in South Africa. Methods Pregnant women living with and without HIV were enrolled at their first antenatal visit. Feeding data and infant anthropometry were collected at birth, 7 days, 10 weeks, 6 months, and 12 months postpartum. Infant weight and length at birth were converted to weight-for-age (WAZ) and length-forage (LAZ) using Intergrowth-21st software, and the World Health Organization (WHO)-Anthro survey analyzer tool was used to obtain these and weight-for-length z-scores (WLZ) from 10 weeks old. Linear mixed effects (LME) models were fit to compare WAZ, LAZ and WLZ between infants who were HEU and HUU controlling for a priori selected variables. Results Overall, 796 mother-infant pairs were included, 400 (50%) were HUU and 396 (50%) were HEU. A high proportion of all infants had ever breastfed, although this was lower in infants who were HEU compared to HUU (90% vs 93%; p = 0.118). Infants who were HEU vs HUU had a significantly shorter median duration of BF [73 days; IQR 12-222 vs 209 days; IQR 72-365 [p < 0.001]). There were no differences between the two groups regarding the types of complementary feeding. By 12 months, both infants who were HEU vs HUU had high proportions of overweight (17% vs 21%; p 0.22). WAZ and LAZ on average were lower in infants HEU than HUU [β = -0.147; 95% CI: -0.327, 0.033] and [β = - 0.146; 95% CI: -0.339, 0.471] keeping age at visit, maternal age, duration of BF, HFSS, employment and marital status constant. Conclusion Infants who were HEU had lower WAZ and LAZ compared to those who were HUU after adjusting for covariates. At 12 months, high proportions among both groups were overweight; which may be partly related to sub-optimal complementary feeding practices. Public health interventions need to be aimed at strengthening BF practices among the population of infants who are HEU and improving complementary feeding practices for all infants
Prevention of mother-to-child-transmission of HIV in Khayelitsha: a contemporary review of services 20 years later
Full text linkBackground: It's been 20 years since the Western Cape (WC) province of South Africa launched its first Prevention of Mother-To-Child-Transmission of HIV(PMTCT) pilot programme in Khayelitsha. The programme evolved alongside the World Health Organization (WHO) guidelines; in 2013 the recommended guidelines in the province was WHO Option B+( life-long antiretroviral therapy (ART) irrespective of CD4 count, and exclusive breastfeeding for the first 6 months of life). Alongside the explanation of the PMTCT programme, the province gradually implemented patient administrative systems in all fixed public health facilities; these systems all shared a unique patient identifier called the folder number. The digitization of folder number lead to the establishment of the Provincial Health Data Centre (PHDC), an African health information exchange (HIE) developed and hosted in the WC Department of Health. The HIE also integrated data from disease management information systems (Three Interlinked Electronic Registers (TIER) and the Electronic Tuberculosis Register (ETR)), allowing the ability to track the cohort of pregnant women living with HIV who attend public health services across the Western Cape. Here we report the latest analysis of vertical HIV transmission in the era of WHO Option B+ with the advantage of a maturing consolidated African HIE. The primary aim of the study was to describe coverage of the PMTCT care cascade, including the implementation of maternal viral load monitoring and early infant diagnosis, among HIV positive women who presented antenatal care, or delivered in the absence of antenatal care, at a public health facility in Khayelitsha subdistrict in 2017; and to quantify MTCT risk factors and outcomes among this cohort up to 12 months post-partum. Methods: Patient-level consolidated PHDC data were used to draw an observational cohort consisting of all live-born and linked mother-infant pairs in which the mother was HIV positive, at any point prior to her first antenatal visit up to 12 months post-partum and attended antenatal care, or in the absence of antenatal care delivered in Khayelitsha in 2017. The PHDC provided a single summative record per pregnancy for each woman (linked to her infant after birth) which enabled the assessment of PMTCT uptake from her first antenatal visit through delivery to infant early infant diagnosis (EID) of HIV-PCR testing and PHDC ascertainment of HIV up to the end of the index period (i.e. 12 months post-partum). iii Using this cohort of HIV-exposed infants, a protocol was designed (Section A: Protocol) to assess the outcomes of the implementation of WHO Option B+(lifelong ART for all HIV positive pregnant women; and periodic re-testing of HIV negative women) under the latest EID guidelines of routine birth HIV-PCR (within 1 week of birth), and repeat testing at 10 weeks (between 2 and 14 weeks of birth) or a first HIV-test at 10 weeks if the infant had not been tested at birth. Continuous variables were converted to categorical variables according to pre-set thresholds, all categorical variables were described using proportions, and frequency tables were used for comparison. Timing of ART initiation was categorized as a binary variable which was assigned 1 if the mother started ART before the first antenatal visits, and 0 of she started ART at the first antenatal visit or anytime during the pregnancy. Viral load was categorised according to coverage and suppression status; virologic suppression was defined as having a viral load of 1000 copies/ml or less after 3 months on ART. Analysis was performed in using R studio; descriptive statistics were used to assess coverage along the PMTCT care cascade, and logistic regression was run to quantify a priori defined risk factors associated with MTCT. Results: The study cohort of 2 576 mother-infant pairs (2548 women living with HIV (WLHIV)) presented in the manuscript was a young cohort with a median age of 30 years (interquartile range of 26 – 34), in which most women delivered vaginally (70.5%), and 78.3% attended at least one antenatal visit before delivery. Most WLHIV (88.3%) presented to their first pregnancy related visit (antenatal care or delivery) already knowing their status, of whom 77.9% were already on ART. 94.5% of women diagnosed prior to birth were initiated on ART prior; 85.0% of these women received a viral load test antenatally, of whom 88.0% were virologically suppressed. Early infant diagnosis coverage was sub-optimal with birth HIV-PCR (within 7 days of birth) coverage of 79.21% among HIV exposed infants (HEI); an even lower proportion (57.9%) of HEI who tested negative at birth had a repeat test around 10-weeks. HIV-PCR ascertained MTCT was 0.8% at 10 weeks, consolidated data from the PHDC suggested an MTCT of 1.8% by the end of the index period (the PHDC HIV episode identified an additional 16 HIVexposed (HEI) infants with HIV who were not detected by laboratory tests). PWLHIV who started ART prior to the first antenatal visit had 50% reduced risk of MTCT compared to those who started ART during the pregnancy. Women who were not suppressed antenatally had a 5- fold (aOR = 5.3, 95% CI: 2.5 – 12.3) increased MTCT risk compared to those were suppressed antenatally. Women who did not attend ANC were at highest risk of transmission (aOR=1.6,95%CI: 0.7 – 3.6). iv Conclusion: Although women most women present to care already knowing their HIV status, ART initiation and uptake of viral load testing is very low at presentation but improved significantly during pregnancy, evidence of maturing PMCT services. National and Provincial MTCT is likely to be underestimated as it relies solely on PCR results; the uptake of the birth PCR among HIV-exposed infants is still not 100% (where it should be) and the uptake of a repeat tests among infants that tested negative is even lower. PHDC data, which consolidates HIV data from multiple sources, revealed a higher MTCT than HIV-PCR testing alone
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
The association between maternal HIV and stillbirths in an era of universal art in pregnancy in the Western Cape, South Africa
Full text linkBACKGROUND: Annually, approximately 1.9 million stillbirths occur globally, with a rate of 13.9 per 1000 births. The devastating aftermath affects around 4.2 million mothers, and 75% of stillbirths are concentrated in South Asia and sub-Saharan Africa (SSA) particularly, with a rate of 32.2 per 1000 births in SSA. South Africa reported a stillbirth rate of 16.3 per 1000 births in 2019, despite global efforts to reduce stillbirth rates. SSA also faces the highest global HIV prevalence at 20%. South Africa, home to 8.4 million people living with HIV, grapples with a 30% prevalence among pregnant individuals. Antiretroviral therapy (ART) coverage for pregnant individuals reached 97% in 2019, especially in the Western Cape with an HIV prevalence of 17.9% among antenatal individuals. Quality antenatal care (ANC) is crucial, with research showing a lower stillbirth rate for those receiving higher quality ANC. The COVID-19 pandemic in 2020 introduced new challenges, potentially influencing stillbirth rates through factors like lockdowns and limited healthcare access. Pregnant individuals contracting SARS-CoV-2 faced an increased likelihood of stillbirth. In this context, our cohort study in the Western Cape, South Africa, utilized routine health data to investigate the contemporary relationship between pregnant individuals with HIV and stillbirths in the era of universal ART during pregnancy. The study explores associations with demographic and clinical variables, including the quality of ANC. METHODS: Utilizing data from the Western Cape Pregnancy Exposure Registry (PER) between 2017 and 2021, this cohort study focused on pregnant women attending antenatal care (ANC) at the Gugulethu Midwife Obstetrics Unit (GMOU) and Worcester Midwife Obstetrics Unit (WMOU) in South Africa. Integrated information from the Provincial Health Data Centre (PHDC) was used to create a linked database for cohort generation. The cohort included women aged 18 or older, with known HIV status and a recorded pregnancy outcome after 20 weeks of gestation. The primary outcome was stillbirth, with maternal HIV status serving as the primary exposure. ANC quality, based on WHO guidelines, was assessed by considering variables such as ANC timing, the number of visits, and various healthcare parameters. ANC quality was categorized using both the old WHO guidelines (at least 4 visits) and the new WHO guidelines (at least 8 visits), with a good ANC quality score requiring 7 or more out of 11 quality ANC variables. Statistical analyses, including logistic regression, were conducted to explore associations between maternal HIV status, ANC quality, and stillbirth prevalence. The study also collected data on maternal characteristics to provide a comprehensive understanding of contributing factors. RESULTS: The study included 15,123 participants: 4,773 women living with HIV (WLHIV) and 10,350 women without HIV. WLHIV had a median age of 28 years, while women without HIV had a median age of 31 years. The overall stillbirth rate was 15 per 1,000 births (95% CI: 13.1-16.9). Stillbirth rates were higher among WLHIV at 17 per 1,000 births (95% CI: 13.34-20.66) compared to women without HIV at 14 per 1,000 births (95% CI: 11.75-16.25). Maternal HIV- positive status (AOR = 1.15, 95% CI: 0.87-1.52, p = 0.34) did not show a statistically significant association with stillbirths. Women with prior diabetes exhibited a significant increase in stillbirth odds (AOR = 2.63, 95% CI: 1.06-6.52, p = 0.04). Women without HIV but with a history of diabetes had a stillbirth prevalence of 4.08%, compared to 3.80% for WLHIV. WLHIV with good-quality ANC had fewer stillbirths (4 visits: 5.06%, 8 visits: 2.53%) than women without HIV (4 visits: 11.56%, 8 visits: 5.06%). ART for ≥100 weeks among WLHIV showed a protective effect, with 47% lower stillbirth odds than ART <20 weeks (AOR = 0.53, p = 0.01) and 45% lower stillbirth odds than ART <20 weeks (AOR = 0.55, 95% CI: 0.33-0.91, p = 0.02). Despite higher stillbirth odds for WLHIV, no significant association was found between maternal HIV status and stillbirths after adjustment (AOR = 1.15, 95% CI: 0.87-1.52, p = 0.34). CONCLUSION: This study, utilizing routine program data, revealed no statistically significant difference in the prevalence of stillbirths between women living with and without HIV. Despite the lack of a statistically significant association between the quality of antenatal care (ANC) and stillbirths, the study underscores the importance of adhering to WHO recommendations and utilizing databases such as the Pregnancy Exposure Registry for evidence-based decision-making. Although the overall stillbirth rate slightly exceeded global targets, there was noticeable improvement following the universal rollout of antiretroviral therapy (ART). Notably, among women living with HIV (WLHIV), a longer duration of ART was linked to a significant reduction in the odds of stillbirth, highlighting the critical role of sustained access to ART. Despite its limitations, these findings contribute to global health objectives, particularly those aimed at eliminating preventable newborn deaths by 2030. ART emerges as a pivotal factor in decreasing stillbirth rates among women living with HIV
Working with what you have: How the East Africa Preterm Birth Initiative used gestational age data from facility maternity registers.
Full text linkObjectivePreterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria.MethodsWe conducted a retrospective analysis of maternity register data from March-September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3rd and 97th birth weight percentiles for GA of the INTERGROWTH-21st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA ResultsIn both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%.ConclusionsMaternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability
A comparison of maternal and neonatal outcomes of pregnant women with and without evidence of SARS-CoV-2 infection in the Western Cape, South Africa
Full text linkBackground: SARS-CoV-2 infection in pregnancy has been associated with poor pregnancy and neonatal outcomes. While SARS-CoV-2 infection itself could partly account for high maternal mortality rates observed in the Western Cape, indirect effects of the pandemic such as movement restrictions and health service pressure may also have played a role. There is limited data on the impact of having a SARS-CoV-2 diagnosis during pregnancy on maternal and neonatal outcomes in this setting. Objectives: We compared the characteristics and outcomes of pregnant women with and without a SARS-CoV-2 diagnosis with pregnancy outcomes between 1 March 2020 and 31 January 2022 within the Western Cape public healthcare sector. Methods: A retrospective cohort analysis was conducted using routine electronic data collated from public health sources. We compared demographic and clinical characteristics, pregnancy and maternal outcomes and neonatal outcomes by SARS-CoV-2 diagnosis status, gestational timing of diagnosis and by timing of pregnancy outcome during a COVID-19 wave to account for both direct and indirect effects of the pandemic. We used descriptive statistics, Chi-squared tests, Fisher Exact tests, and logistic regression models for analysis. Results: We included 226,336 pregnancies with 193,195 linked live births. Prevalence of a maternal SARS-CoV-2 diagnosis was 2.5%. Increased odds of SARS-CoV-2 diagnosis or hospitalization were associated with age categories ≥25 years compared to 15-24 years, pre- existing and gestational hypertension compared to no hypertension, pre-existing and gestational diabetes compared to no diabetes, current and previous tuberculosis compared to no tuberculosis and HIV positive status compared to HIV negative or unknown status. These factors would likely be more common in admitted patients where testing coverage was higher. In analyses adjusted for these factors, the odds of maternal death were higher in women with a SARS-CoV-2 diagnosis (aOR=11.42; 95% CI 8.46-15.43) than those without. The odds of miscarriage were higher with an early diagnosis (<28 weeks gestation) (aOR=2.18; 95% CI 1.91-2.48) and the odds of stillbirth were higher with a late diagnosis (≥28 weeks gestation) (aOR=1.31; 95% CI 1.02-1.67) compared to no diagnosis. Increased odds of low birth weight and neonatal intensive care unit (ICU) admission were found among infants of women who had a late SARS-CoV-2 diagnosis (aOR=1.22; 95% CI 1.10-1.34 and aOR=2.56; 95% CI 2.18-3.01, respectively) compared to infants of women without a SARS-CoV-2 diagnosis. Conclusion: This study found that that older age, diabetes, hypertension, current and previous tuberculosis and HIV were risk factors for a SARS-CoV-2 diagnosis or hospitalization in pregnancy during the COVID-19 pandemic period in our setting. Adverse outcomes associated with a maternal SARS-CoV-2 diagnosis included miscarriage, stillbirth, maternal death, low birth weight and neonatal ICU admission. However, it was not possible to determine the extent to which these outcomes were associated with SARS-CoV-2 infection itself, as SARS-CoV-2 testing was likely much higher in women admitted during pregnancy, and these outcomes would be strongly associated with admission. Nonetheless, these findings coupled with demonstrated benefits of COVID-19 vaccination, highlight the need to prioritise both pregnant women and women of child-bearing age for vaccination and boosting in order to maintain protective benefits
Comparison of three levels of ascertainment of antenatal medication use at Gugulethu Midwife Obstetric Unit
Full text linkBackground The use of medicines and/or remedies among pregnant women is common. Pregnant women are generally excluded from clinical trials due to ethical reasons. There are therefore minimal data available about the safety of most drugs during pregnancy by the time they come to the market, and post-marketing evaluation of medicine use during pregnancy is required. In South-Africa, with mass treatment campaigns for Tuberculosis (TB) and Human Immunodeficiency Virus (HIV), the introduction of new therapeutic agents and frequent self-medication, it is important for reliable methods to determine medicine exposures, including the frequency and timing of use, to support such evaluations. Databases about medication exposures are promising resources for pharmaco-epidemiological investigations, however the optimal method of ascertainment of medicine use during pregnancy is uncertain. Different data sources could also be better for different types of medication. To improve the quality of data, a combination of data sources may be ideal but time-consuming and expensive. By looking at and comparing three data sources: 1) self-report, 2) clinician records and 3) electronic dispensing systems, we aimed to identify the optimal method of ascertainment of antenatal medicine use for multiple medication types. Methods The aim of this investigation was to provide a more comprehensive reflection of the drug exposures during pregnancy and to make recommendations to strengthen routine clinical data capturing to improve maternity case reporting. The data of 988 pregnant women seeking antenatal care at Gugulethu Midwife Obstetric Unit (GMOU) in Cape Town between 2016 and 2018 were used. The three data sources consisted of self-reports gathered by an interviewer administered questionnaire at up to three antenatal visits to the GMOU; clinical records as recorded in the Pregnancy Exposure Registry (PER); and linked electronic dispensing data obtained from the Provincial Health Data Centre (PHDC) of the Western Cape Department of Health. Medication exposure data were coded using the Anatomical Therapeutic Chemical (ATC) Classification system, an internationally acknowledged system to classify medicine maintained by the WHO. ATC codes were assigned to active ingredients, depending on the therapeutic indication. The three data sources were then assessed in terms of missing or overlapping information and evaluated on the level of agreement between sources using Spearman's rank coefficient and Cohen's Kappa. Results According to the Spearman rank test, the PER and PHDC datasets as a whole showed the highest correlation both at 1st and 5th ATC level. The overlaps between the datasets were poor and the Kappa agreement between the sources was low for most therapeutic classes, except for HIV treatments. An “almost perfect” Kappa agreement existed between anti-diabetic medication (ATC A10) reported in the self-report and PHDC datasets. Traditional, herbal, complementary and home remedies were only reported in the self-report dataset. Conclusion We found an overall poor agreement between data sources, with one alone not able to effectively capture all data. The datasets should thus be used in conjunction to ensure accurate and reliable record of exposure. Self-report was the best data source for traditional, home, herbal and complementary medicine exposures while the PER provided a better and more complete reflection of influenza vaccines and vitamins. The best method of ascertaining antenatal medicine exposure therefore depends on the type of medicine being investigated, and choice of data source depends on the objectives of the investigation. This study suggests that PER, PHDC and self-report should ideally be used together since each is critical to ensure accurate, reliable and effective exposure data, although this will have resource and cost implications
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
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