Background: Mortality in the post-partum period may be impacted by antiretroviral treatment (ART) received in pregnancy, and whether ART is continued in the post-partum period.
Methods: HIV-infected and HIV-uninfected mothers were enrolled within 48 hours of delivery at 5 public hospital maternity wards throughout Botswana. Follow up visits were conducted by cellphone at 1 and 3 months, then every 3 months until 24 months post-partum. Maternal deaths were reported by one of the approved contacts given by the mother at enrollment. Risk factors for maternal survival were assessed using Cox proportional hazard models.
Results: Between February 2012 and March 2013, 3000 mothers (1499 HIV-infected and 1501 HIV-uninfected) were enrolled. There were 26 total maternal deaths in 24 months post-partum
(411 per 100,000 person-years), 22 among HIV-infected women (769 per 100,000 person-years) and 4 among HIV-uninfected women (134 per 100,000 person-years). Maternal age, availability of indoor toilet, formal housing, Rh factor, preterm delivery and higher parity were associated with mortality in univariate, but not adjusted analyses. Maternal HIV-infection (aHR 5.0, 95% CI 1.6, 15.2) and infant birth injury (aHR 3.8, 95% CI 1.3, 11.4) were independent risk factors for maternal death in the post partum period. Among HIV-infected women, when compared with the 924 women who received continuous 3-drug ART in pregnancy and post-partum, there was no significant increase in mortality among 281 women who discontinued ART after pregnancy (aHR 2.1, 95% CI 0.6, 7.5); among 241 women who initiated or re-started ART in the post-partum period (aHR 1.1, 95% CI 0.2, 5.1); or among 70 women who received no ART at any time (aHR 2.8, 0.3, 28.2). CD4 cell count in pregnancy was not associated with mortality (p=0.20) and longer ART duration prior to delivery
(> 2 years) did not decrease mortality (aHR 0.6, 95% CI 0.1, 3.4).
Conclusions: Despite high uptake of 3-drug ART in pregnancy and post-partum, HIV infected women were 5 times more likely than HIV-uninfected women to die within 24 months after delivery, independent of CD4 cell count. Further research is needed to understand the increased risk of mortality among HIV-infected post-partum women.