MSc, Paediatrics and Child Health, Faculty of Health Sciences,University of the Witwatersrand / Background To investigate whether in-utero exposure to highly active antiretroviral treatment (HAART) is associated with low birth weight and/or preterm birth in a population of South African women with advanced HIV infection. Methods A retrospective observational study was performed on women with CD4 cell counts ≤250 cells/mm3 attending antenatal antiretroviral clinics at two clinics in Johannesburg between October 2004 and March 2007. Low birth weight (<2.5kg) and preterm birth rates (<37 weeks) were compared in those exposed versus unexposed to HAART during pregnancy. Effects of different HAART regimen and duration (<28 weeks or ≥ 28 weeks) were assessed. Results Among HAART-unexposed infants 27% (60/224) were low birth weight (LBW) compared to 23% (90/388) of early HAART-exposed and 19% (76/407) of late HAART-exposed infants (P=0.05). In the early HAART group, older maternal age was associated with LBW and higher CD4 cell count protective against LBW (AOR 1.06, 95% CI 1.00- 1.12 and AOR 0.58, 95% CI 0.46-0.73, P<0.001, respectively). HAART-exposed infants had an increased risk of preterm birth vii (<37 weeks) (15% [138/946] versus 5% [7/147], p=0.001), with early (<28 weeks) nevirapine and efavirenz having the strongest associations with preterm birth (AOR 5.4, 95%CI 2.1-13.7, P<0.001 and AOR 5.6, 95%CI 2.1-15.2, P=0.001, respectively). Conclusion Among infants born to women with CD4 cell counts <250 cells/mm3, HAART exposure was associated with preterm birth, but not with low birth weight. More advanced immunosuppression was a significant risk factor for both LBW and preterm birth, highlighting the importance of earlier HAART initiation in pregnant women, both to optimize maternal health and to improve infant outcomes

A healthy in utero environment is essential for achieving optimal outcomes for women and their children. Gestational weight gain (GWG) has been shown to impact current and future maternal-infant health outcomes. Suboptimal weight gain during pregnancy (defined by the Institute of Medicine GWG guidelines) has been linked to several complications and is implicated in the inter-general cycle of obesity. Understanding contributors to GWG and intervening during pregnancy with healthy behaviour strategies may have a multi-generational effect for chronic disease prevention. The objective of the first study of this thesis was to examine the association between i) eating habits during pregnancy, ii) advice from family or friends about GWG, and iii) personal effort to stay within weight gain limits, and meeting GWG recommendations. Cross-sectional data were collected from pregnant and postpartum women who responded to the validated electronic maternal (EMat) health survey. Regardless of receiving advice about GWG, women self-reporting less healthy eating habits in pregnancy than before pregnancy, receiving advice from family/friends about GWG, and lower personal effort to stay within guidelines, had an increased odds of weight gain discordant with recommendations. The objective of the second study was to assess the short-term effect of the SmartMoms Canada application (app) usage on promoting adequate GWG and healthy behaviours. SmartMoms Canada is an app-based intervention designed to help pregnant women adhere to GWG guidelines and improve healthful behaviours. Pregnant women using the SmartMoms Canada app more frequently had a higher moderate-to-vigorous physical activity daily average when compared with women with a lower usage. Together, the EMat and SmartMoms results from this thesis contribute to identifying and mitigating potential factors associated with discordant GWG and healthy behaviours.

Background: Current cesarean delivery (CD) rates in many industrialized countries are well above the recommended rates. Objective: The overall goal of this thesis was to identify sources for unnecessary CD. Specific objectives were to: 1) analyze the leading indications for CD and their associations with neonatal outcomes; 2) compare adverse birth outcomes between elective primary cesarean delivery (EPCD) and trial of labor after vaginal birth (TOLAV), and between elective repeat cesarean delivery (ERCD) and trial of labor after cesarean birth (TOLAC); and 3) assess the cost-effectiveness of ERCD and TOLAC. Methods: A retrospective cohort study was conducted. Leading indications for CD were analyzed and risks of neonatal outcomes between “soft” indications and “hard” indications were compared first, using 2006 to 2013 Better Outcomes and Registry Network Ontario data. A pair of analyses: comparing risks of adverse birth outcomes between EPCD and TOLAV and between ERCD and TOLAC, were then conducted using United States 2005 to 2010 birth registration data. Analysis were performed using logistic regression and propensity score matching models. Finally, a cost-effectiveness analysis between ERCD and TOLAC was performed. Results: The single largest contributor for overall CD was ERCD (34.3%) and for primary CD was dystocia (31.9%) in Ontario. Compared with infants of mothers with CD for “hard” indications, the risks of Apgar score <7 at 5 minutes for infants of mothers with CD for non-reassuring-fetal-status was increased, while the risks of Apgar score <7 at 5 minutes and neonatal death for infants of mothers with ERCD and dystocia were decreased. Compared with infants of mothers who underwent TOLAV, infants of mothers who underwent EPCD were more likely to require antibiotics and ventilation support, but less likely to have birth injury. On the other hand, compared with infants of mothers who underwent TOLAC, infants of mothers who underwent ERCD were less likely to require antibiotics and ventilation support. ERCD was similar to the TOLAC birth option in terms of cost effectiveness. Conclusions: Tight up criteria for “soft” indications such as labor dystocia could result in substantial reduction in CD without harming the infants.

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