The Intersection of HIV and Maternal Mortality

Worldwide, the top two causes of death in women of reproductive age are HIV/AIDS and complications related to pregnancy. Respectively, these account for 19 and 15 percent of all deaths in women aged 15-44 years. Though the majority of women survive for many years after being diagnosed with HIV, under rare circumstances pregnancy can represent a harrowing intersection of two potentially fatal conditions. Drawing on data from South Africa and the United States, the relative risk of pregnancy-related death in women infected with HIV ranges from two to thirteen times the maternal mortality rate in non-HIV infected women. Unfortunately, the risk also appears to be rising. Though the general assumption has been that deaths in HIV-infected pregnant women are largely due to advancing disease processes like tuberculosis or malaria, evidence from South Africa suggests that HIV infection increases the risk of pregnant women dying from direct obstetric complications, like postpartum hemorrhage, abortion, or overwhelming infections.
There are several possible explanations given to account for this increased risk of pregnancy-related death in HIV-infected women. Pregnancy is a period when a women’s immune system is compromised, possibly allowing advancement of disease processes. Countries such as South Africa have noted that women with HIV have more difficulty obtaining access to quality care than their non-HIV infected counterparts, possibly due to stigma and discrimination. Many countries also are unable to provide the level of care that HIV-positive women require due to deficiencies in the health care system’s infrastructure or funding.
A comprehensive approach will be necessary to combat the threat that HIV poses to international goals for lowering the risk of pregnancy-related maternal deaths. Strategies which may need to be incorporated will likely involve more access to effective family planning and early initiation of lifelong antiretroviral treatment for women in need. Improving antenatal care and obstetric services, as well as focusing on those conditions that can be aggravated by HIV infection, will require further funding and emphasis. Earlier this month, Bill and Melinda Gates pledged to provide $1.5 billion in aid to children and maternal health in developing countries-- this level of commitment from an admirable foundation that has already given over $2.2 billion in aid to combat HIV/AIDS. While the relationship between HIV and maternal mortality is disturbing, the efforts being galvanized to help unravel and stymie these dangerous associations represent a source of encouragement. However, not until women with HIV are able to safely bear non-HIV infected children and raise them into adulthood will our ultimate goal be realized.
--Summarized by Barrett Robinson, MD, MPH
Barrett Robinson is a Maternal-Fetal Medicine Fellow at Northwestern Memorial Hospital, where he participates in the ongoing care of one of Illinois’ largest clinics exclusively servicing HIV-positive pregnant patients.

Citation:
Abdool-Karim, Q et al. “HIV and maternal mortality: turning the tide.” Lancet 2010;375:1948-9.

Original Article (Subscription may be required)