Recurrence of Preeclampsia in Northern Tanzania: A Registry-based Cohort Study.

Preeclampsia occurs in about 4 per cent of pregnancies worldwide, and may have particularly serious consequences for women in Africa. Studies in western countries have shown that women with preeclampsia in one pregnancy have a substantially increased risk of preeclampsia in subsequent pregnancies. We estimate the recurrence risks of preeclampsia in data from Northern Tanzania. A prospective cohort study was designed using 19,811 women who delivered singleton infants at a hospital in Northern Tanzania between 2000 and 2008. A total of 3,909 women were recorded with subsequent deliveries in the hospital with follow up through 2010. Adjusted recurrence risks of preeclampsia were computed using regression models. The absolute recurrence risk of preeclampsia was 25%, which was 9.2-fold (95% CI: 6.4 - 13.2) compared with the risk for women without prior preeclampsia. When there were signs that the preeclampsia in a previous pregnancy had been serious either because the baby was delivered preterm or had died in the perinatal period, the recurrence risk of preeclampsia was even higher. Women who had preeclampsia had increased risk of a series of adverse pregnancy outcomes in future pregnancies. These include perinatal death (RR= 4.3), a baby with low birth weight (RR= 3.5), or a preterm birth (RR= 2.5). These risks were only partly explained by recurrence of preeclampsia. Preeclampsia in one pregnancy is a strong predictor for preeclampsia and other adverse pregnancy outcomes in subsequent pregnancies in Tanzania. Women with previous preeclampsia may benefit from close follow-up during their pregnancies

A Study of Individual Predictors of Maternal Self-Reported Unknown HIV Status in Kenya 2008

Objectives: To determine if maternal education and wealth status predicts maternal self-reported unknown HIV status among women in Kenya. Methods: Kenya Demographic Health Survey (KDHS) 2008 – 2009 was used to examine the association between unknown HIV status and education and wealth, controlling for age, place of residence, place of delivery, history of intimate violence, knowledge of prevention of mother to child transmission (PMTCT), and health decision-making. Results: 617 (21.8%) had unknown HIV status. Education was not associated with unknown HIV status. Only women in the richest wealth category reported less unknown HIV status. Home and private facility births, high PMTCT knowledge and antenatal care (ANC) visits significantly decreased likelihood of unknown HIV status in education and wealth status model. Rural residence significantly predicted unknown HIV status in education model. Conclusion: There is a need to improve PMTCT knowledge and services in rural areas, and to maximize counseling and testing through antenatal care visits.Master of Public Healt

Interpersonal Influences in the Scale-up of Male Circumcision Services in a Traditionally Non-circumcising Community in Rural Western Kenya

Promoting male circumcision (MC) is now recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men, and plans are underway to scale-up this intervention especially in non-circumcising communities, with generalized HIV pandemic. This qualitative study identifies and characterizes the role of social and interpersonal factors in the scale-up of MC services in a rural non-circumcising community in western Kenya. Twenty-four sex-specific focus group discussions were conducted with a purposive sample of Luo men and women (15-34 years). Peer and youth groups, girlfriends and women, parents, and cultural political, religious, school leaders were identified as key influences in the scale-up of MC services. The study concludes that social and interpersonal forces create opportunities and constraints for scaling up the MC intervention. Planners of MC projects should therefore harness the power of informal networks and social structures to enhance community engagement, motivate behaviour change and increase demand for MC services

A qualitative enquiry of health care workers’ narratives on knowledge and sources of information on principles of Respectful Maternity Care (RMC)

Research from sub-Saharan Africa indicate that many women experience varied forms of disrespectful maternity care, which amount to a violation of their rights and dignity. Notably, there is little research that sheds light on health care workers (HCWs) training and knowledge of principles of respectful maternity care (RMC). Formulating appropriate interventional strategies to promote the respectful provision of services for women during pregnancy, childbirth, and postpartum period requires an understanding of the current state of knowledge and sources of information on respectful maternity care among HCWs. This paper reports findings from a qualitative study that examined the knowledge and sources of information on the Respectful Maternity Care Charter among HCWs in rural Kisii and Kilifi counties in Kenya. Between January and March 2020, we conducted 24 in-depth interviews among HCWs in rural Kisii and Kilifi health facilities. Data were analyzed using a mixed deductive and inductive thematic analysis guided by Braun’s [2006] six stages of analysis. We found that from the seven globally accepted principles of respectful maternity care, at least half of the HCWs were aware of patients right to consented care, confidentiality and privacy, and the right to non-discriminatory care based on specific attributes. Knowledge of the right to no physical and emotional abuse, abandonment of care, and detentions in the facilities was limited to a minority of health care workers but only after prompting. Sources of information on respectful maternity care were largely limited to continuous medical and professional training and clinical mentorship. The existing gap shows the need for training and mentorship of HCWs on the Respectful Maternity Care Charter as part of pre-service medical and nursing curricula and continuing clinical education to bridge this gap. At the policy level, strategies are necessary to support the integration of respectful maternity care into pre-service training curricula

Does integration of HIV and SRH services achieve economies of scale and scope in practice? A cost function analysis of the Integra Initiative.

OBJECTIVE: Policy-makers have long argued about the potential efficiency gains and cost savings from integrating HIV and sexual reproductive health (SRH) services, particularly in resource-constrained settings with generalised HIV epidemics. However, until now, little empirical evidence exists on whether the hypothesised efficiency gains associated with such integration can be achieved in practice. METHODS: We estimated a quadratic cost function using data obtained from 40 health facilities, over a 2-year-period, in Kenya and Swaziland. The quadratic specification enables us to determine the existence of economies of scale and scope. FINDINGS: The empirical results reveal that at the current output levels, only HIV counselling and testing services are characterised by service-specific economies of scale. However, no overall economies of scale exist as all outputs are increased. The results also indicate cost complementarities between cervical cancer screening and HIV care; post-natal care and HIV care and family planning and sexually transmitted infection treatment combinations only. CONCLUSIONS: The results from this analysis reveal that contrary to expectation, efficiency gains from the integration of HIV and SRH services, if any, are likely to be modest. Efficiency gains are likely to be most achievable in settings that are currently delivering HIV and SRH services at a low scale with high levels of fixed costs. The presence of cost complementarities for only three service combinations implies that careful consideration of setting-specific clinical practices and the extent to which they can be combined should be made when deciding which services to integrate. TRIAL REGISTRATION NUMBER: NCT01694862

Interpersonal Influences in the Scale-up of Male Circumcision Services in a Traditionally Non-circumcising Community in Rural Western Kenya

Promoting male circumcision (MC) is now recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men, and plans are underway to scale-up this intervention especially in non-circumcising communities, with generalized HIV pandemic. This qualitative study identifies and characterizes the role of social and interpersonal factors in the scale-up of MC services in a rural non-circumcising community in western Kenya. Twenty-four sex-specific focus group discussions were conducted with a purposive sample of Luo men and women (15-34 years). Peer and youth groups, girlfriends and women, parents, and cultural political, religious, school leaders were identified as key influences in the scale-up of MC services. The study concludes that social and interpersonal forces create opportunities and constraints for scaling up the MC intervention. Planners of MC projects should therefore harness the power of informal networks and social structures to enhance community engagement, motivate behaviour change and increase demand for MC services

Psychosocial Factors Influencing Promotion of Male circumcision for HIV Prevention in a Non-circumcising Community in Rural Western Kenya

Male circumcision (MC) is now recommended as an additional HIV preventive measure, yet little is known about factors that may influence its adoption, especially in non-circumcising communities with generalized HIV pandemic. This qualitative study explored factors influencing MC adoption in rural western Kenya. Twenty-four sex specific focus group discussions were conducted with a purposive sample of Luo men and women (15-34 years). Perceived barriers to circumcision were pain and healing complications, actual and opportunity costs, behavioral disinhibition, discrimination, cultural identity, and reduced sexual satisfaction; perceived facilitators were hygiene, HIV/STI risk reduction, ease in condom use, cultural integration, and sexual satisfaction. To enhance MC adoption, community education, and dialogue is needed to address the perceived fears

Views of nurses and other healthcare workers on interventions to reduce disrespectful maternity care in rural health facilities in Kilifi and Kisii counties, Kenya: analysis of a qualitative interview study

Objective There is an abundance of evidence illuminating the factors that contribute to disrespectful maternity care in sub-Saharan Africa. However, there is limited documented evidence on how some of the key influences on the mistreatment of women could be addressed. We aimed to document the perspectives of nurses and other healthcare workers on existing and potential strategies embedded at the health facility level to promote respectful delivery of healthcare for women during delivery and on what interventions are needed to promote respectful and equitable treatment of women receiving maternity care in rural Kenya. Design, setting and participants We analysed relevant data from a qualitative study based on in-depth interviews with 24 healthcare workers conducted between January and March 2020, at health facilities in rural Kilifi and Kisii counties, Kenya. The facilities had participated in a project (AQCESS) to reduce maternal and child mortality and morbidity by improving the availability and the use of essential reproductive maternal and neonatal child health services. The participants were mostly nurses but included five non-nurse healthcare workers. We analysed data using NVivo V.12, guided by a reflective thematic analysis approach. Results Healthcare workers identified four interconnected areas that were associated with improving respectful delivery of care to women and their newborns. These include continuous training on the components of respectful maternity care through mentorships, seminars and organised training; gender-responsive services and workspaces; improved staffing levels; and adequate equipment and supplies for care. Conclusions These findings demonstrate some of the solutions, from the perspectives of healthcare workers, that could be implemented to improve the care that women receive during pregnancy, labour and delivery. The issues raised by healthcare workers are common in sub-Saharan African countries, indicating the need to create awareness at the policy level to highlight the challenges identified, potential solutions, and application or implementation in different contexts

Does integration of HIV and sexual and reproductive health services improve technical efficiency in Kenya and Swaziland? An application of a two-stage semi parametric approach incorporating quality measures.

Theoretically, integration of vertically organized services is seen as an important approach to improving the efficiency of health service delivery. However, there is a dearth of evidence on the effect of integration on the technical efficiency of health service delivery. Furthermore, where technical efficiency has been assessed, there have been few attempts to incorporate quality measures within efficiency measurement models particularly in sub-Saharan African settings. This paper investigates the technical efficiency and the determinants of technical efficiency of integrated HIV and sexual and reproductive health (SRH) services using data collected from 40 health facilities in Kenya and Swaziland for 2008/2009 and 2010/2011. Incorporating a measure of quality, we estimate the technical efficiency of health facilities and explore the effect of integration and other environmental factors on technical efficiency using a two-stage semi-parametric double bootstrap approach. The empirical results reveal a high degree of inefficiency in the health facilities studied. The mean bias corrected technical efficiency scores taking quality into consideration varied between 22% and 65% depending on the data envelopment analysis (DEA) model specification. The number of additional HIV services in the maternal and child health unit, public ownership and facility type, have a positive and significant effect on technical efficiency. However, number of additional HIV and STI services provided in the same clinical room, proportion of clinical staff to overall staff, proportion of HIV services provided, and rural location had a negative and significant effect on technical efficiency. The low estimates of technical efficiency and mixed effects of the measures of integration on efficiency challenge the notion that integration of HIV and SRH services may substantially improve the technical efficiency of health facilities. The analysis of quality and efficiency as separate dimensions of performance suggest that efficiency may be achieved without sacrificing quality

Community health volunteers challenges and preferred income generating activities for sustainability: a qualitative case study of rural Kilifi, Kenya

Background: There is a global emphasis on engaging community health volunteers (CHVs) in low- to middle-income countries (LMICs) to reach to the vast underserved populations that live in rural areas. Retention of CHVs in most countries has however been difficult and turnover in many settings has been reported to be high with profound negative effects on continuity of community health services. In rural Kenya, high attrition among CHVs remains a concern. Understanding challenges faced by CHVs in rural settings and how to reduce attrition rates with sustainable income-generating activities (IGAs) is key to informing the implementation of contextual measures that can minimise high turnover. This paper presents findings on the challenges of volunteerism in community health and the preferred IGAs in rural Kilifi county, Kenya. Methods: The study employed qualitative methods. We conducted 8 key informant interviews (KIIs) with a variety of stakeholders and 10 focus group discussions (FGDs) with CHVs. NVIVO software was used to organise and analyse our data thematically. Results: Community Health Volunteers work is not remunerated and it conflicts with their economic activities, child care and other community expectations. In addition, lack of supervision, work plans and relevant training is a barrier to delivering CHVs’ work to the communities. There is a need to remunerate CHVs work as well as provide support in the form of basic training and capital on entrepreneurship to implement the identified income generating activities such as farming and events management. Conclusions: Strategies to support the livelihoods of CHVs through context relevant income generating activities should be identified and co-developed by the ministry of health and other stakeholders in consultation with the CHVs