{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T11:30:03Z","timestamp":1764329403392,"version":"3.46.0"},"reference-count":22,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T00:00:00Z","timestamp":1764288000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T00:00:00Z","timestamp":1764288000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["087537\/F\/08\/A."],"award-info":[{"award-number":["087537\/F\/08\/A."]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"name":"The Norwegian Programme for Capacity Development in Higher Education and Research for Development under the University of Zimbabwe NORHED grant","award":["(NORHED QZA-0484MWI-13\/0032)"],"award-info":[{"award-number":["(NORHED QZA-0484MWI-13\/0032)"]}]},{"name":"The Botnar Foundation","award":["001"],"award-info":[{"award-number":["001"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Pregnancy Childbirth"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>\n                      Maternal mortality ratio (MMR) remains poorly described in\n                      <jats:italic>w<\/jats:italic>\n                      omen\n                      <jats:italic>l<\/jats:italic>\n                      iving\n                      <jats:italic>w<\/jats:italic>\n                      ith\n                      <jats:italic>H<\/jats:italic>\n                      IV (WLWH), more so during this era of lifelong antiretroviral therapy (ART).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In a case-control cohort study design with HIV as the exposure variable, we determined MMRs from \u2265\u200920 weeks\u2019 gestational age up to 42-days postpartum (PP) in WLWH and their peers living without HIV (WLWoH). Furthermore, mortality was assessed 43-days PP up to 5-years following delivery of the index baby. Study midwives administered socio-demographic, HIV-related, household water and sanitation questionnaires in pregnancy. At follow up visits, documented live births, maternal deaths, signs and symptoms of illnesses at death or verbal autopsy, including the place of death as per the Medical Research Council of Zimbabwe\u2019 Serious Adverse Event Reporting requirements. In R-statistical package, using univariate and multivariate automated variable elimination (AVE) models, we assessed the risk factors associated with maternal deaths.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Six-hundred (600) WLWoH, and 608 WLWH mainly on Tenofovir\/Lamivudine\/Efavirenz (89.3%), ART-na\u00efve (10.4%) and 0.3% ART-defaulters were enrolled. Eighteen maternal deaths were recorded over the 5-years with 56% occurring at home.<\/jats:p>\n                    <jats:p>\n                      Three pregnancy-related fatalities were recorded, all 3 occurring in WLWH; one case each in pregnancy (sepsis), childbirth (obstetric haemorrhage) and within 42-days PP (sepsis); giving a cohort MMR of 3\/1202; 249.6 (51.5-727.6)\/100000 live births, being 3\/602;498.3 (102.9-1449.4)\/100000 live births in WLWH. No deaths were recorded in WLWoH within 6-weeks PP while one death was observed well beyond six weeks post-delivery. WLWH were more likely to die compared to WLWoH, odds ratio (OR) 17 (2.29-129.9),\n                      <jats:italic>p<\/jats:italic>\n                      =0.006.\n                    <\/jats:p>\n                    <jats:p>\n                      Compared with their living peers, mortality in WLWH was associated with a new diagnosis of HIV infection, hence not on ART,\n                      <jats:italic>p<\/jats:italic>\n                      =0.027, and non-disclosure of HIV sero-status,\n                      <jats:italic>p<\/jats:italic>\n                      =0.014. In AVE regression models, WLWH with plasma HIV-RNA load of more than 1000 copies per mL were more likely to die compared to their alive HIV-RNA suppressed peers, OR 5 (1.2-24.8),\n                      <jats:italic>p<\/jats:italic>\n                      =0.03.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>WLWH were 17 times more likely to die when compared to WLWoH. Non-disclosure of HIV sero-status was associated with the increased odds of dying, probably due to poor adherence leading to suboptimal ART-exposure. In addition, a new HIV diagnosis, hence being ART-na\u00efve was also a significant contributing factor. There is need to address barriers hindering HIV counselling and testing, treatment, adherence and continuation to suppress HIV-RNA load to reduce MMR in WLWH on lifelong ART.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"https:\/\/clinicaltrials.gov\/study\/NCT04087239\" ext-link-type=\"uri\">www.clinicaltrials.gov,trialregistrationnumber:NCT04087239<\/jats:ext-link>\n                      , Registered 12 September 2019.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12884-025-08151-5","type":"journal-article","created":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T11:25:10Z","timestamp":1764329110000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Maternal mortality ratio and deaths beyond 42 days up to 5-years post pregnancy in women living with HIV on life-long antiretroviral therapy in a resource limited setting"],"prefix":"10.1186","volume":"25","author":[{"given":"Kerina","family":"Duri","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Munyaradzi Paul","family":"Mapingure","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Privilege Tendai","family":"Munjoma","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arthur John","family":"Mazhandu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patience","family":"Ncube","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tarisai","family":"Marere","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mazengera Lovemore","family":"Ronald","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"name":"for The UZ Birth Cohort Study Team","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2025,11,28]]},"reference":[{"key":"8151_CR1","unstructured":"WHO. A woman dies every two minutes due to pregnancy or childbirth: UN agencies. 2023. https:\/\/www.who.int\/news\/item\/23-02-2023-a-woman-dies-every-two-minutes-due-to-pregnancy-or-childbirth--un-agencies."},{"key":"8151_CR2","unstructured":"World Health Organisation. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and puerperium: ICD-MM. 2012. https:\/\/www.who.int\/data\/gho\/indicator-metadata-registry\/imr-details\/4622."},{"issue":"11","key":"8151_CR3","doi-asserted-by":"publisher","first-page":"1638","DOI":"10.3201\/eid1211.060152","volume":"12","author":"DJ Jamieson","year":"2006","unstructured":"Jamieson DJ, Theiler RN, Rasmussen SA. Emerging infections and pregnancy. Emerg Infect Dis. 2006;12(11):1638\u201343.","journal-title":"Emerg Infect Dis"},{"key":"8151_CR4","unstructured":"UNICEF. Maternal health and maternal mortality. 2022. https:\/\/data.unicef.org\/topic\/maternal-health\/maternal-mortality\/."},{"issue":"8","key":"8151_CR5","first-page":"199","volume":"47","author":"F Majoko","year":"2001","unstructured":"Majoko F, Chipato T, Iliff V. Trends in maternal mortality for the greater Harare maternity unit: 1976 to 1997. Cent Afr J Med. 2001;47(8):199\u2013203.","journal-title":"Cent Afr J Med"},{"issue":"1","key":"8151_CR6","doi-asserted-by":"publisher","first-page":"923","DOI":"10.1186\/s12889-022-13321-7","volume":"22","author":"R Musarandega","year":"2022","unstructured":"Musarandega R, Ngwenya S, Murewanhema G, Machekano R, Magwali T, Nystrom L, et al. Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys. BMC Public Health. 2022;22(1):923.","journal-title":"BMC Public Health"},{"key":"8151_CR7","doi-asserted-by":"crossref","unstructured":"Musarandega R, Cresswell J, Magwali T, Makosa D, Machekano R, Ngwenya S et al. Maternal mortality decline in zimbabwe, 2007\/2008 to 2018\/2019: findings from mortality surveys using civil registration, vital statistics and health system data. BMJ Glob Health 2022;7(8).","DOI":"10.1136\/bmjgh-2022-009465"},{"key":"8151_CR8","unstructured":"WHO. Maternal Health. 2016, https:\/\/www.afro.who.int\/health-topics\/maternal-health."},{"key":"8151_CR9","unstructured":"UNFPA. The 2022 Housing and Population Census. 2022. https:\/\/zimbabwe.unfpa.org\/en\/topics\/sexual-reproductive-health-5."},{"key":"8151_CR10","unstructured":"World Bank Groups. Poverty & Equity Brief Zimbabwe. 2020. https:\/\/databankfiles.worldbank.org\/public\/ddpext_download\/poverty\/987B9C90-CB9F-4D93-AE8C-750588BF00QA\/SM2020\/Global_POVEQ_ZWE.pdf."},{"key":"8151_CR11","unstructured":"UNCEF Ending HIV\/AIDS with Children, Adolescents and Young Women. 2023. https:\/\/www.unicef.org\/zimbabwe\/reports\/ending-hivaids-children-adolescents-and-young-women."},{"key":"8151_CR12","unstructured":"WHO. Maternal mortality indicator. 2022. https:\/\/data.who.int\/indicators\/i\/AC597B1."},{"issue":"1","key":"8151_CR13","doi-asserted-by":"publisher","first-page":"725","DOI":"10.1186\/s12879-020-05432-6","volume":"20","author":"K Duri","year":"2020","unstructured":"Duri K, Gumbo FZ, Munjoma PT, Chandiwana P, Mhandire K, Ziruma A, et al. The university of Zimbabwe college of health sciences (UZ-CHS) BIRTH COHORT study: rationale, design and methods. BMC Infect Dis. 2020;20(1):725.","journal-title":"BMC Infect Dis"},{"key":"8151_CR14","doi-asserted-by":"crossref","unstructured":"Duri K, Munjoma PT, Mazhandu AJ, Marere T, Gomo E, Banhwa S et al. Predictors and timing to viral suppression in HIV-infected pregnant women in the university of Zimbabwe birth cohort study during the era of lifelong antiretroviral therapy (Option B\u2009+\u2009treatment strategy). Front.Virol. 2022;298382340:6-4","DOI":"10.3389\/fviro.2022.838234"},{"issue":"1","key":"8151_CR15","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1186\/s12985-021-01494-3","volume":"18","author":"K Duri","year":"2021","unstructured":"Duri K, Chimhuya S, Gomo E, Munjoma PT, Chandiwana P, Yindom LM, et al. Role of antenatal plasma cytomegalovirus DNA levels on pregnancy outcome and HIV-1 vertical transmission among mothers in the university of Zimbabwe birth cohort study (UZBCS). Virol J. 2021;18(1):30.","journal-title":"Virol J"},{"key":"8151_CR16","doi-asserted-by":"publisher","first-page":"716","DOI":"10.1109\/TAC.1974.1100705","volume":"196","author":"H Akaike","year":"1974","unstructured":"Akaike H. A new look at the statistical model identification. IEEE Trans Autom Control. 1974;196:716\u201323.","journal-title":"IEEE Trans Autom Control"},{"key":"8151_CR17","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1016\/j.jhealeco.2015.08.003","volume":"44","author":"KA Grepin","year":"2015","unstructured":"Grepin KA, Bharadwaj P. Maternal education and child mortality in Zimbabwe. J Health Econ. 2015;44:97\u2013117.","journal-title":"J Health Econ"},{"issue":"4","key":"8151_CR18","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1089\/apc.2021.0217","volume":"36","author":"LS Zijenah","year":"2022","unstructured":"Zijenah LS, Bandason T, Bara W, Chipiti MM, Katzenstein DA. Impact of option B(+) combination antiretroviral therapy on Mother-to-Child transmission of HIV-1, maternal and infant virologic responses to combination antiretroviral therapy, and maternal and infant mortality rates: A 24-Month prospective Follow-Up study at a primary health care clinic, in harare, Zimbabwe. AIDS Patient Care STDS. 2022;36(4):145\u201352.","journal-title":"AIDS Patient Care STDS"},{"issue":"1","key":"8151_CR19","doi-asserted-by":"publisher","first-page":"107","DOI":"10.1097\/01.qai.0000229015.77569.c7","volume":"43","author":"P Zvandasara","year":"2006","unstructured":"Zvandasara P, Hargrove JW, Ntozini R, Chidawanyika H, Mutasa K, Iliff PJ, et al. Mortality and morbidity among postpartum HIV-positive and HIV-negative women in zimbabwe: risk factors, causes, and impact of single-dose postpartum vitamin A supplementation. J Acquir Immune Defic Syndr. 2006;43(1):107\u201316.","journal-title":"J Acquir Immune Defic Syndr"},{"key":"8151_CR20","doi-asserted-by":"publisher","first-page":"04048","DOI":"10.7189\/jogh.11.04048","volume":"11","author":"R Musarandega","year":"2021","unstructured":"Musarandega R, Nyakura M, Machekano R, Pattinson R, Munjanja SP. Causes of maternal mortality in Sub-Saharan africa: A systematic review of studies published from 2015 to 2020. J Glob Health. 2021;11:04048.","journal-title":"J Glob Health"},{"issue":"9","key":"8151_CR21","first-page":"209","volume":"36","author":"MF Ashworth","year":"1990","unstructured":"Ashworth MF. Harare hospital maternal mortality report for 1987 and a comparison with previous reports. Cent Afr J Med. 1990;36(9):209\u201312.","journal-title":"Cent Afr J Med"},{"issue":"1","key":"8151_CR22","doi-asserted-by":"publisher","first-page":"276","DOI":"10.1186\/s12913-021-06289-4","volume":"21","author":"W Busumani","year":"2021","unstructured":"Busumani W, Mundagowa PT. Outcomes of pregnancy-related referrals from rural health facilities to two central hospitals in harare, zimbabwe: a prospective descriptive study. BMC Health Serv Res. 2021;21(1):276.","journal-title":"BMC Health Serv Res"}],"container-title":["BMC Pregnancy and Childbirth"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12884-025-08151-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12884-025-08151-5\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12884-025-08151-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T11:25:13Z","timestamp":1764329113000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcpregnancychildbirth.biomedcentral.com\/articles\/10.1186\/s12884-025-08151-5"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,28]]},"references-count":22,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["8151"],"URL":"https:\/\/doi.org\/10.1186\/s12884-025-08151-5","relation":{},"ISSN":["1471-2393"],"issn-type":[{"value":"1471-2393","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,28]]},"assertion":[{"value":"28 March 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 August 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 November 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The study complied with the international council for harmonisation of Good Clinical and Laboratory Practice guidelines including Zimbabwean research regulatory requirements. Institutional ethical approval was obtained from the Joint Research Ethics Committee of the University of Zimbabwe, Faculty of Medicine and Health Sciences\/The Parirenyatwa Group of Hospitals (JREC); reference number; JREC\/81\/15 and ethics approval at the national level by the Medical Research Council of Zimbabwe (MRCZ) reference number MRCZ\/A\/1968. All the research participants provided written informed consent.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not Applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"1274"}}