The personal and clinical impact of screen-detected maternal rheumatic heart disease in Uganda: a prospective follow up study

Pre-existing maternal cardiac disease is a significant contributor to adverse maternal, fetal, and neonatal outcomes. In 2015-2017, our team conducted the first community-based study of maternal rheumatic heart disease (RHD) in sub-Saharan Africa and identified RHD in 88% of those with pre-existing...

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Published in:	BMC pregnancy and childbirth Vol. 20; no. 1; p. 611
Main Authors:	Voleti, Sonia, Okello, Emmy, Murali, Meghna, Sarnacki, Rachel, Majwala, Albert, Ssembatya, Renny, Bakka, Olivia, Namisanvu, Henriator, Njeri, Angela, Matovu, Alphonsus, DeStigter, Kristen, Sable, Craig, Beaton, Andrea
Format:	Journal Article
Language:	English
Published:	England BioMed Central 09-10-2020 BMC
Subjects:	Adolescent Adult Antibiotic Prophylaxis - statistics & numerical data Cardiovascular disease Clinical outcomes Decision Making, Shared Echocardiography Echocardiography - statistics & numerical data Female Follow-Up Studies Health care Health disparities Health Services Accessibility - statistics & numerical data Heart Hospitals Humans Interviews Male Mass Screening - methods Mass Screening - statistics & numerical data Maternal Age Maternal health Medication Adherence - psychology Medication Adherence - statistics & numerical data Middle Aged Mixed methods research Mothers Mothers - psychology Mothers - statistics & numerical data Penicillin Penicillin G Benzathine - therapeutic use Postpartum Period Pregnancy Pregnancy Complications, Cardiovascular - diagnosis Pregnancy Complications, Cardiovascular - epidemiology Pregnancy Complications, Cardiovascular - prevention & control Pregnancy Complications, Cardiovascular - psychology Prospective Studies Rheumatic heart disease Rheumatic Heart Disease - diagnosis Rheumatic Heart Disease - drug therapy Rheumatic Heart Disease - epidemiology Rheumatic Heart Disease - psychology Risk Assessment - statistics & numerical data Risk Factors Screening Severity of Illness Index Social Stigma Spouses - psychology Uganda Uganda - epidemiology Ultrasonic imaging Womens health Workers Young Adult Uganda Screening Uganda Echocardiography Rheumatic heart disease Maternal health Health disparities
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Summary:	Pre-existing maternal cardiac disease is a significant contributor to adverse maternal, fetal, and neonatal outcomes. In 2015-2017, our team conducted the first community-based study of maternal rheumatic heart disease (RHD) in sub-Saharan Africa and identified RHD in 88% of those with pre-existing heart disease. Here we conducted a follow up investigation of women previously identified with RHD, describing clinical and echocardiographic outcomes, identifying barriers to medical adherence and evaluating the personal impact of RHD. A 2 week prospective follow up was completed at sites in Central and Eastern Uganda. Participants underwent a three-step mixed methods study comprising of 1) direct structured interview targeting clinical history and medication adherence, 2) echocardiogram to evaluate left-sided heart valves, and 3) semi-structured guideline interview to elicit personal impacts of RHD. The team evaluated 40 (80%) of the original 51 mothers with RHD at a median post-partum time of 2.5 years after delivery (IQR 0.5). Echocardiographic data showed improvement in nine women with the remaining 31 women showing stable echocardiographic findings. Adherence to Benzathine penicillin G (BPG) prophylaxis was poor, with 70% of patients either poorly adherent or non-adherent. Three major themes emerged from interviews: 1) social determinants of health (World Health Organization, Social determinants of health, 2019) negatively affecting healthcare, 2) RHD diagnosis negatively affecting female societal wellbeing, 3) central role of spouse in medical decision making. Screening echocardiography can identify women with pre-existing rheumatic heart disease during pregnancy, but long-term follow-up in Uganda reveals adherence to medical care following diagnosis, including BPG, is poor. Additionally, mothers diagnosed with RHD may experience unintended consequences such as social stigmatization. As identification of occult RHD is critical to prevent adverse pregnancy outcomes, further research is needed to determine how to best support women who face a new diagnosis of RHD, and to determine the role of screening echocardiography in high-risk settings.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	1471-2393 1471-2393
DOI:	10.1186/s12884-020-03189-z