The availability of six tracer medicines in private medicine outlets in Uganda

Abstract Objectives: Many low income countries struggle to provide safe and effective medicines due to poor public health care infrastructure, budgetary constraints, and lack of human resource capacity. Private sector pharmacies and drug shops are used by a majority of the population as an alternative to public pharmacies. This study looks at the availability of six essential medicines in private drug outlets across Uganda. Methods: A standardised medicines availability survey developed by the World Health Organization and Health Action International was adapted for use in this project to collect availability data for six tracer medicines in 126 private medicine outlets across four districts in Uganda from September 2011 to October 2012. Results: Artemisinin-based combination treatments and metformin were the most commonly found medicines in the private medicine outlets surveyed. Ninty-nine percent of all outlets carried artemisinin-based combinations while 93% of pharmacies and 53% of drug shops stocked metformin. Oxytocin was found in one third of outlets surveyed. Fluoxetine was in 70% of pharmacies yet was not found in any drug shops. Rifampicin and lamivudine were found infrequently in outlets across all districts; 10% and 2%, respectively. Not all brands found in surveyed outlets were listed on the Ugandan National Drug Register. In particular, five unlisted brands of rifampicin were found in private medicine outlets. Conclusions: The regulatory process should be improved through the enforcement of outlet licensing and medicine registration. Additional studies to elucidate the reasons behind the use of private medicine outlets over the public sector would assist the government in implementing interventions to increase use of public sector medicine outlets

Literacy and the Congolese refugee families : using homegrown literacy practices and experiences to embrace literateness in the United States

In developed countries including the United States, prominence is accorded to print literacy. Children are, at a very early age introduced to reading in-utero and identify with reading books as they grow unlike children in other parts of the world, where less prominence is accorded to the written word. In fiscal year 2020, the United States accepted and resettled 35% refugees from Africa (Migration Policy Institute, 2021). With the ever changing global political, economic, and cultural dynamics, both at macro and micro level, the United States, is one of the countries providing refugee to displaced people from around the world. Upon resettlement, one of the expectations is refugee families will adapt to the United States systems including the literary practices, which are more focused around reading and writing. Refugees’ knowledge, experiences and practices are unique to each family. Not all refugees will identify with the U.S. understanding of literacy. This study looked at how refugees from Congo, in Africa were adapting to literacy practices in the United States, especially with the onset of the pandemic that led to a global lockdown and caused disruption in socio-economic and individual spheres. As several scholars have suggested, literacy is broad so in this study, I sought to understand a) What do Congolese refugee families believe about literacy, b) What did the Congolese refugee families do to support their children’s literacy practices prior to coming to the United States? and c) What has been the Congolese experience with literacy in the past year

The quality of routine data for measuring facility-based maternal mortality in public and private health facilities in Kampala City, Uganda.

BACKGROUND: Routine health facility data are an important source of health information in resource-limited settings. Regular quality assessments are necessary to improve the reliability of routine data for different purposes, including estimating facility-based maternal mortality. This study aimed to assess the quality of routine data on deliveries, livebirths and maternal deaths in Kampala City, Uganda. METHODS: We reviewed routine health facility data from the district health information system (DHIS2) for 2016 to 2021. This time period included an upgrade of DHIS2, resulting in two datasets (2016-2019 and 2020-2021) that were managed separately. We analysed data for all facilities that reported at least one delivery in any of the six years, and for a subset of facilities designated to provide emergency obstetric care (EmOC). We adapted the World Health Organization data quality review framework to assess completeness and internal consistency of the three data elements, using 2019 and 2021 as reference years. Primary data were collected to verify reporting accuracy in four purposively selected EmOC facilities. Data were disaggregated by facility level and ownership. RESULTS: We included 255 facilities from 2016 to 2019 and 247 from 2020 to 2021; of which 30% were EmOC facilities. The overall completeness of data for deliveries and livebirths ranged between 53% and 55%, while it was < 2% for maternal deaths (98% of monthly values were zero). Among EmOC facilities, completeness was higher for deliveries and livebirths at 80%; and was < 6% for maternal deaths. For the whole sample, the prevalence of outliers for all three data elements was < 2%. Inconsistencies over time were mostly observed for maternal deaths, with the highest difference of 96% occurring in 2021. CONCLUSIONS: Routine data from childbirth facilities in Kampala were generally suboptimal, but the quality was better in EmOC facilities. Given likely underreporting of maternal deaths, further efforts to verify and count all facility-related maternal deaths are essential to accurately estimate facility-based maternal mortality. Data reliability could be enhanced by improving reporting practices in EmOC facilities and streamlining reporting processes in private-for-profit facilities. Further qualitative studies should identify critical points where data are compromised, and data quality assessments should consider service delivery standards

Tale of 22 cities: utilisation patterns and content of maternal care in large African cities

Globally, the majority of births happen in urban areas. Ensuring that women and their newborns benefit from a complete package of high-quality care during pregnancy, childbirth and the postnatal period present specific challenges in large cities. We examine health service utilisation and content of care along the maternal continuum of care (CoC) in 22 large African cities. We analysed data from the most recent Demographic and Health Survey (DHS) since 2013 in any African country with at least one city of ≥1 million inhabitants in 2015. Women with live births from survey clusters in the most populous city per country were identified. We analysed 17 indicators capturing utilisation, sector and level of health facilities and content of three maternal care services: antenatal care (ANC), childbirth care and postnatal care (PNC), and a composite indicator capturing completion of the maternal CoC. We developed a categorisation of cities according to performance on utilisation and content within maternal CoC. The study sample included 25 326 live births reported by 19 217 women. Heterogeneity in the performance in the three services was observed across cities and across the three services within cities. ANC utilisation was high (>85%); facility-based childbirth and PNC ranged widely, 77%-99% and 29%-94%, respectively. Most cities showed inconsistent levels of utilisation and content across the maternal CoC, Cotonou and Accra showed relatively best and Nairobi and Ndjamena worst performance. This exploratory analysis showed that many DHS can be analysed on the level of large African cities to provide actionable information about the utilisation and content of the three maternal health services. Our comparative analysis of 22 cities and proposed typology of best and worst-performing cities can provide a starting point for extracting lessons learnt and addressing critical gaps in maternal health in rapidly urbanising contexts

Tale of 22 cities: utilisation patterns and content of maternal care in large African cities

Introduction Globally, the majority of births happen in urban areas. Ensuring that women and their newborns benefit from a complete package of high-quality care during pregnancy, childbirth and the postnatal period present specific challenges in large cities. We examine health service utilisation and content of care along the maternal continuum of care (CoC) in 22 large African cities. Methods We analysed data from the most recent Demographic and Health Survey (DHS) since 2013 in any African country with at least one city of ≥1 million inhabitants in 2015. Women with live births from survey clusters in the most populous city per country were identified. We analysed 17 indicators capturing utilisation, sector and level of health facilities and content of three maternal care services: antenatal care (ANC), childbirth care and postnatal care (PNC), and a composite indicator capturing completion of the maternal CoC. We developed a categorisation of cities according to performance on utilisation and content within maternal CoC. Results The study sample included 25 326 live births reported by 19 217 women. Heterogeneity in the performance in the three services was observed across cities and across the three services within cities. ANC utilisation was high (>85%); facility-based childbirth and PNC ranged widely, 77%–99% and 29%–94%, respectively. Most cities showed inconsistent levels of utilisation and content across the maternal CoC, Cotonou and Accra showed relatively best and Nairobi and Ndjamena worst performance. Conclusion This exploratory analysis showed that many DHS can be analysed on the level of large African cities to provide actionable information about the utilisation and content of the three maternal health services. Our comparative analysis of 22 cities and proposed typology of best and worst-performing cities can provide a starting point for extracting lessons learnt and addressing critical gaps in maternal health in rapidly urbanising contexts

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries

BackgroundPersistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region.MethodsWe conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality.ResultsThe percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor.ConclusionsAddressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed

Total Demand, Use and Unmet Need for Modern Contraceptives Among Women Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda : Implications for Urban Health

Background: Update and utilization of modern contraceptives has public health benefits including reduction of unintended pregnancies, unsafe abortions, and related maternal mortality. However, paucity of evidence on key indicators of family planning in the informal settlements abounds. Data are usually collapsed within the larger urban communities that tend to mask peculiarities of informal settlements. This study determined the proportion of women using modern contraceptives, the unmet need for modern contraceptives and the total demand in informal settlements of an urban municipality. Methods: A cross-sectional study conducted among 626 women in the reproductive age (15–49 years)  in the informal settlements of Kira municipality (part of metropolitan Kampala). Multi-stage sampling was applied in the selection of the respondents. Descriptive and log-binomial regression analysis were conducted to determine percentage of women using modern contraceptives, unmet need, and total demand with their associated factors. All analyses were conducted using STATA version 15.0. Results: The total demand for modern contraceptives was 84.9%, modern contraceptive prevalence was 47.4% nearly meeting the national target of 50%, however the unmet need was 37.3%, which much higher than the national target of 10%. Lower total demand for contraceptives was associated with higher women’s education status and preference to have another child, while higher total demand was associated with having at least one living child. Higher modern contraceptives use was associated with older age, having at least one living child and high decision-making power, while lower modern contraceptives use was associated with higher education and undetermined fertility preference. Lower unmet need for modern contraceptives was associated with older age (PR 0.68, 95% CI: 0.48–0.97) and high decision-making power (PR 0.64, 95% CI: 0.50–0.81), while higher unmet need was found among those who having at least one living child (PR 1.40, 95% CI: 1.01–1.93) and undetermined fertility preference (PR 1.70, 95% CI: 1.24–2.34). Conclusions: Total demand and contraceptive use were found to be higher in the informal settlements of Kira municipality, however, the unmet need was much higher among this population as compared to the national urban estimates. This indicates a much higher demand for contraceptives and the need to consider the diverse socio-demographic characteristics of urban spaces. Development of Interventions need to critically consider the diverse urban space, associated explanatory variables and a collaborative systems lens to achieve sustained improvements

Maternal health in cities : analysis of institutional maternal mortality and health system bottlenecks in Kampala City Uganda, 2016-2021

Abstract: Background Recent estimates have shown a stagnation in maternal mortality reduction globally. Levels and trends in maternal mortality in urban settings in Africa are of interest due to health system challenges posed by rapid urbanisation. Given the high percentage of births occurring in city health facilities, tracking the institutional maternal mortality ratio (IMMR) can reveal key performance issues. We described the trends in IMMR between 2016 and 2021, and the causes and characteristics of maternal deaths in Kampala, Uganda. Methods This retrospective study utilised routine data from all facilities in Kampala that provided childbirth services from 2016 to 2021. Three key variables were used: number of deliveries, live births, and maternal deaths. Additionally, from medical records in three purposively selected hospitals, we extracted information on characteristics of women recorded as maternal deaths and their causes for the period 2016-2021 from death notification and review forms. We conducted descriptive analysis and assessed time trends in IMMR. Results For the six-year period, the Kampala-level IMMR was 189/100,000 deliveries (194/100,000 livebirths). The IMMR declined from 213 (2016) to 109/100,000 deliveries in 2019 (p=0.04) and then increased to 258 in 2021 (p=0.12). A review of 358 maternal death records showed that 65% of deaths were women referred from other health facilities, and 47% lived in the surrounding district (Wakiso). Obstetric haemorrhage (44%) and hypertensive disorders in pregnancy (28%) were the most commonly recorded causes of death. Health system factors such as lack of blood and other supplies contributed to 65% of the deaths reviewed. Conclusions IMMR in Kampala increased from 2019-2021. Health infrastructure changes and maternal health initiatives potentially accounted for the observed trend by affecting data quality. Referral and facility readiness were underlying reasons for maternal deaths. Addressing bottlenecks in emergency referral processes may contribute to mortality reduction. Further research should determine the relative contribution of key influences on mortality levels and examine the dynamics between women\u2019s care-seeking pathways and service delivery arrangements for emergency obstetric care in urban settings

Framing Contraceptive Use Motivations Among Adolescents and Young Adults Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda

Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not). Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda. Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives. Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice