Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya

Background: Since the 2009 WHO and UNICEF recommendation that women receive home-based postnatal care within the first three days after birth, a growing number of low-income countries have explored integrating postnatal home visit interventions into their maternal and newborn health strategies. This randomized trial evaluates a pilot program in which community health workers (CHWs) visit or call new mothers three days after delivery in peri-urban Kiambu County, Kenya. Methods: Participants were individually randomized to one of three groups: 1) early postnatal care three days after delivery provided in-person with a CHW using a simple checklist, 2) care provided by phone with a CHW using the same checklist, or 3) a standard of care group. Surveys were conducted ten days and nine weeks postnatal to measure outcomes related to compliance with referrals, self-reported health problems for mother and baby, care-seeking behaviors, and postnatal knowledge and practices around the recognition of danger signs, feeding, nutrition, infant care and family planning. Results: The home visit administration of the checklist increased the likelihood that women recognized postnatal problems for themselves and their babies and increased the likelihood that they sought care to address those problems identified for the child. In both the home visit and mobile phone implementation of the checklist, actions taken for postnatal problems happened earlier, particularly for infants. Knowledge was found to be high across all groups, with limited evidence that the checklist impacted knowledge and postnatal practices around the recognition of danger signs, feeding, nutrition, infant care and family planning. Conclusion: We find evidence that CHW-administered postnatal checklists can lead to better recognition of postnatal problems and more timely care-seeking. Furthermore, our results suggest that CHWs can affordably deliver many of the benefits of postnatal checklists. Trial Registration: ClinicalTrials.gov NCT02104635; registered April 2, 2014

Dynamic patterns of contraceptive use among Kenyan women

Thesis (Ph.D.)--University of Washington, 2021INTRODUCTION: Access to voluntary family planning (FP) programs is essential to support women in achieving their reproductive goals, and has a myriad of benefits for maternal, newborn, and child health and women’s economic, social, and reproductive empowerment. Contraceptive discontinuation among women who wish to avoid pregnancy is common, but relationships between contraceptive experiences and discontinuation are unclear. This dissertation assesses prevalence and correlates of contraceptive side effects, method switching, and discontinuation in a cohort of Kenyan women. METHODS: A prospective cohort study of women and adolescent girls using modern, reversible contraception was conducted among women attending FP clinics. Participants completed weekly short message service (SMS) surveys on contraceptive experiences over a 24-week period. We used the non-parametric Kaplan-Meier estimator to estimate incidence of method switch and modern method discontinuation and associated 95% confidence intervals (CI). Cox proportional hazards models were used to estimate adjusted hazards ratios (aHR) of 1) method switch, and 2) modern method discontinuation associated with experience of specific contraceptive side effects. We aimed to develop and validate a screening tool to identify women at high risk of discontinuation using a stepwise model selection process. Predictive performance of the screening tool was assessed using time-dependent receiver operating characteristic (ROC) curves and area under the curve (AUC) in an internal validation cohort. Finally, we estimated adjusted prevalence ratios (aPR) of individual correlates of risk of specific contraceptive side effects using log-binomial generalized estimating equation models. RESULTS: Among 825 women using injectables, implants, oral contraceptive pills (OCP) or intrauterine devices (IUD), incidence of method switch was 61.3 per 100 woman-years (95% CI 52.4-71.8) and incidence of discontinuation of modern contraception was 38.5 per 100 woman-years (95% CI 31.6-47.0). Reports of contraceptive side effects were common, with 24% (95% CI 22-26%) of woman reporting side effects weekly. Sexual side effects were the most prevalent side effect measured (weekly Pr 15%, 95% CI 13-16%). Lack of expected bleeding was associated with method switch (aHR 2.07, 95%CI 1.00-4.28). Irregular menstrual bleeding (aHR 2.62, 95%CI 1.35-5.07), weight changes (aHR 1.99, 95%CI 1.08-3.64), and sexual side effects (aHR 1.83, 95%CI 1.00-3.35) were associated with discontinuation. Considering only women’s characteristics at enrollment, we found that a simplified risk score comprised of routinely captured information in FP clinics had moderate ability to predict contraceptive discontinuation in our validation cohort (AUC-ROC: 0.73, 95% CI 0.51-0.94). The tool identified a majority of women as high risk (61%), resulting in a low positive predictive value (28%). Prevalence of contraceptive side effects over study follow-up was associated with reporting prior experience of side effects (aPR 1.72, 95% CI 1.37-2.18) and having fears or concerns about side effects (aPR 1.36, 95% CI 1.12-1.65) at enrollment. Women who reported spending the “right amount of time” with their FP provider were less likely to report non-bleeding-related side effects during follow-up (aPR 0.61 [95%CI 0.46-0.81] for cramping or abdominal/back pain; aPR 0.58 [95%CI 0.44-0.76] for sexual side effects; and aPR 0.66 [95%CI 0.60-0.88] for weight changes). CONCLUSION: Contraceptive side effects, method switch, and discontinuation were common in a cohort of Kenyan women. The findings from this dissertation may help to inform design of interventions to more effectively target and tailor FP counseling and care to the individualized contraceptive needs and preferences of women who wish to use contraception but who experience method-related challenges