MObile Technology for Improved Family Planning Services (MOTIF): study protocol for a randomised controlled trial.

BACKGROUND: Providing women with contraceptive methods following abortion is important to reduce repeat abortion rates, yet evidence for effective post-abortion family planning interventions are limited. This protocol outlines the evaluation of a mobile phone-based intervention using voice messages to support post-abortion family planning in Cambodia. METHODS/DESIGN: A single blind randomised controlled trial of 500 participants. Clients aged 18 or over, attending for abortion at four Marie Stopes International clinics in Cambodia, owning a mobile phone and not wishing to have a child at the current time are randomised to the mobile phone-based intervention or control (standard care) with a 1:1 allocation ratio.The intervention comprises a series of six automated voice messages to remind clients about available family planning methods and provide a conduit for additional support. Clients can respond to message prompts to request a phone call from a counsellor, or alternatively to state they have no problems. Clients requesting to talk to a counsellor, or who do not respond to the message prompts, receive a call from a Marie Stopes International Cambodia counsellor who provides individualised advice and support regarding family planning. The duration of the intervention is 3 months. The control group receive existing standard of care without the additional mobile phone-based support.We hypothesise that the intervention will remind clients about contraceptive methods available, identify problems with side effects early and provide support, and therefore increase use of post-abortion family planning, while reducing discontinuation and unsafe method switching.Participants are assessed at baseline and at 4 months. The primary outcome measure is use of an effective modern contraceptive method at 4 months post abortion. Secondary outcome measures include contraception use, pregnancy and repeat abortion over the 4-month post-abortion period.Risk ratios will be used as the measure of effect of the intervention on the outcomes, and these will be estimated with 95% confidence intervals. All analyses will be based on the 'intention to treat' principle. DISCUSSION: This study will provide evidence on the effectiveness of a mobile phone-based intervention using voice messages to support contraception use in a population with limited literacy. Findings could be generalisable to similar populations in different settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01823861

Determinants of growth measurements in rural Cambodian infants: a cross-sectional study

Background: Inappropriate feeding and hygiene practices and poor environment are associated with malnutrition. We aimed to investigate the contributions of feeding, hygiene practices and recent illness to the nutritional status of rural Cambodian infants and any sex-specific differences. Methods: In a cross-sectional study, nested within an ongoing birth cohort, trained fieldworkers conducted anthropometry and collected information from the main caregiver during home visits. Multivariable linear regression was used to investigate associations with nutritional status as length-for-age z-scores (LAZ) and weight-for-length z-scores (WLZ). Results: A total of 156 children, 87 (55.8%) male, ages 0-11 months were enrolled. The prevalence of acute malnutrition (WLZ <-2) in males and females was 2.3% (2/87) and 5.8% (4/69), respectively, and 23.0% (20/87) of males and 14.5% (10/69) of females were stunted (LAZ <-2). WLZ but not LAZ decreased with age. WLZ was independently negatively associated with increasing age (β-coefficient -0.14 [95% confidence interval {CI} -0.20 to -0.08], p<0.001), and regular use of feeding bottles (β-coefficient -0.46 [95% CI -0.83 to -0.10], p=0.014), and positively with handwashing with soap (β-coefficient 0.40 [95% CI 0.05 to 0.75), p=0.027). Conclusions: The prevalence of acute malnutrition was low, but stunting was prevalent without evidence of a sex difference. Non-linear growth faltering was associated with increasing age and hygiene/feeding practices

Faecal microbiota and cytokine profiles of rural Cambodian infants linked to diet and diarrhoeal episodes

The gut microbiota of infants in low- to middle-income countries is underrepresented in microbiome research. This study explored the faecal microbiota composition and faecal cytokine profiles in a cohort of infants in a rural province of Cambodia and investigated the impact of sample storage conditions and infant environment on microbiota composition. Faecal samples collected at three time points from 32 infants were analysed for microbiota composition using 16S rRNA amplicon sequencing and concentrations of faecal cytokines. Faecal bacterial isolates were subjected to whole genome sequencing and genomic analysis. We compared the effects of two sample collection methods due to the challenges of faecal sample collection in a rural location. Storage of faecal samples in a DNA preservation solution preserved Bacteroides abundance. Microbiota analysis of preserved samples showed that Bifidobacterium was the most abundant genus with Bifidobacterium longum the most abundant species, with higher abundance in breast-fed infants. Most infants had detectable pathogenic taxa, with Shigella and Klebsiella more abundant in infants with recent diarrhoeal illness. Neither antibiotics nor infant growth were associated with gut microbiota composition. Genomic analysis of isolates showed gene clusters encoding the ability to digest human milk oligosaccharides in B. longum and B. breve isolates. Antibiotic-resistant genes were present in both potentially pathogenic species and in Bifidobacterium. Faecal concentrations of Interlukin-1alpha and vascular endothelial growth factor were higher in breast-fed infants. This study provides insights into an underrepresented population of rural Cambodian infants, showing pathogen exposure and breastfeeding impact gut microbiota composition and faecal immune profiles

Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and status in Cambodia

Background: Cost of delivering reproductive health services to low-income populations will always require total or partial subsidization by government and/or development partners. Broadly termed “demand-side financing” or “output-based aid,” these strategies include a range of interventions that channel government or donor subsidies to the user rather than the service provider. Initial pilot assessments of reproductive health voucher programs suggest that they can increase access, reduce inequities, and enhance program efficiency and service quality. However, there is a paucity of evidence describing how these programs function in different settings for various reproductive health services. Methods/Design: Population Council, funded by the Bill and Melinda Gates Foundation, intends to generate evidence around the “voucher and accreditation” approaches to improving the reproductive health of low-income women in Cambodia. The study comprises four populations: facilities, providers, women of reproductive age using facilities, and women and men who have been pregnant and/or used family planning within the previous 12 months. The study will be carried out in a sample of 20 health facilities that are accredited to provide maternal and newborn health and family planning services to women holding vouchers from operational districts in three provinces: Kampong Thom, Kampot, and Prey Veng and a matched sample of non-accredited facilities in three other provinces. Health facility assessments will be conducted at baseline and endline to track temporal changes in quality of care, client out-of-pocket costs, and utilization. Facility inventories, structured observations, and client exit interviews will be used to collect comparable data across facilities. Health providers will also be interviewed and observed providing care. A population survey of about 3,000 respondents will also be conducted in areas where vouchers are distributed and similar non-voucher locations. Discussion: A quasi-experimental study will investigate the impact of the voucher approach on improving reproductive health behaviors, reproductive health status, and reducing inequities at the population level and assess effects on access, equity, and quality of care at the facility level. If the voucher scheme in Cambodia is found effective, it may help other countries adopt this approach for improving utilization and access to reproductive health and family planning services

Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study

Background: Maternal infections are an important cause of maternal mortality and severe maternal morbidity. We report the main findings of the WHO Global Maternal Sepsis Study, which aimed to assess the frequency of maternal infections in health facilities, according to maternal characteristics and outcomes, and coverage of core practices for early identification and management. Methods: We did a facility-based, prospective, 1-week inception cohort study in 713 health facilities providing obstetric, midwifery, or abortion care, or where women could be admitted because of complications of pregnancy, childbirth, post-partum, or post-abortion, in 52 low-income and middle-income countries (LMICs) and high-income countries (HICs). We obtained data from hospital records for all pregnant or recently pregnant women hospitalised with suspected or confirmed infection. We calculated ratios of infection and infection-related severe maternal outcomes (ie, death or near-miss) per 1000 livebirths and the proportion of intrahospital fatalities across country income groups, as well as the distribution of demographic, obstetric, clinical characteristics and outcomes, and coverage of a set of core practices for identification and management across infection severity groups. Findings: Between Nov 28, 2017, and Dec 4, 2017, of 2965 women assessed for eligibility, 2850 pregnant or recently pregnant women with suspected or confirmed infection were included. 70·4 (95% CI 67·7–73·1) hospitalised women per 1000 livebirths had a maternal infection, and 10·9 (9·8–12·0) women per 1000 livebirths presented with infection-related (underlying or contributing cause) severe maternal outcomes. Highest ratios were observed in LMICs and the lowest in HICs. The proportion of intrahospital fatalities was 6·8% among women with severe maternal outcomes, with the highest proportion in low-income countries. Infection-related maternal deaths represented more than half of the intrahospital deaths. Around two-thirds (63·9%, n=1821) of the women had a complete set of vital signs recorded, or received antimicrobials the day of suspicion or diagnosis of the infection (70·2%, n=1875), without marked differences across severity groups. Interpretation: The frequency of maternal infections requiring management in health facilities is high. Our results suggest that contribution of direct (obstetric) and indirect (non-obstetric) infections to overall maternal deaths is greater than previously thought. Improvement of early identification is urgently needed, as well as prompt management of women with infections in health facilities by implementing effective evidence-based practices.Fil: Althabe, Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Espinoza, Marisa Mabel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Pasquale, Julia. No especifíca;Fil: Hernández Muñoz, Rosalinda. No especifíca;Fil: Carvajal, Javier. No especifíca;Fil: Escobar, María Fernanda. No especifíca;Fil: Cecatti, José Guilherme. No especifíca;Fil: Ribeiro Do Valle, Carolina C.. No especifíca;Fil: Mereci, Wilson. No especifíca;Fil: Vélez, Paola. No especifíca;Fil: Pérez, Aquilino M.. No especifíca;Fil: Vitureira, Gerardo. No especifíca;Fil: Leroy, Charlotte. No especifíca;Fil: Roelens, Kristien. No especifíca;Fil: Vandenberghe, Griet. No especifíca;Fil: Aguemon, Christiane Tshabu. No especifíca;Fil: Cisse, Kadari. No especifíca;Fil: Ouedraogo, Henri Gautier. No especifíca;Fil: Kannitha, Cheang. No especifíca;Fil: Rathavy, Tung. No especifíca;Fil: Tebeu, Pierre Marie. No especifíca;Fil: Bustillo, Carolina. No especifíca;Fil: Bredy, Lara. No especifíca;Fil: Herrera Maldonado, Nazarea. No especifíca;Fil: Abdosh, Abdulfetah Abdulkadir. No especifíca;Fil: Teklu, Alula M.. No especifíca;Fil: Kassa, Dawit Worku. No especifíca;Fil: Kumar, Vijay. No especifíca;Fil: Suri, Vanita. No especifíca;Fil: Trikha, Sonia. No especifíca

Increasing uptake of long-acting reversible contraceptives in Cambodia through a voucher program: Evidence from a difference-in-differences analysis

Objective: This article evaluates the use of modern contraceptives among poor women exposed to a family planning voucher program in Cambodia, with a particular focus on the uptake of long-acting reversible contraceptives (LARCs). Methods: We used a quasi-experimental study design and data from before-and-after intervention cross-sectional household surveys (conducted in 2011 and 2013) in 9 voucher program districts in Kampong Thom, Kampot, and Prey Veng provinces, as well as 9 comparison districts in neighboring provinces, to evaluate changes in use of modern contraceptives and particularly LARCs in the 12 months preceding each survey. Survey participants in the analytical sample were currently married, non-pregnant women ages 18 to 45 years (N = 1,936 at baseline; N = 1,986 at endline). Difference-in-differences (DID) analyses were used to examine the impact of the family planning voucher. Results: Modern contraceptive use increased in both intervention and control areas between baseline and endline: in intervention areas, from 22.4% to 31.6%, and in control areas, from 25.2% to 31.0%. LARC use also increased significantly between baseline and endline in both intervention (from 1.4% to 6.7%) and control (from 1.9% to 3.5%) areas, but the increase in LARC use was 3.7 percentage points greater in the intervention area than in the control area (P = .002), suggesting a positive and significant association of the voucher program with LARC use. The greatest increases occurred among the poorest and least educated women. Conclusion: A family planning voucher program can increase access to and use of more effective long-acting methods among the poor by reducing financial and information barriers

"Why did our baby die soon after birth?"-Lessons on neonatal death in rural Cambodia from the perspective of caregivers.

IntroductionNeonatal deaths represent around half the deaths of children less than five-years old in Cambodia. The process from live birth to neonatal death has not been well described. This study aimed to identify problems in health care service which hamper the reduction of preventable neonatal deaths in rural Cambodia.MethodsThis study adopted a method of qualitative case study design using narrative data from the verbal autopsy standard. Eighty and forty villages were randomly selected from Kampong Cham and Svay Rieng provinces, respectively. All households in the target villages were visited between January and February 2017. Family caregivers were asked to describe their experiences on births and neonatal deaths between 2015 and 2016. Information on the process from birth to death was extracted with open coding, categorized, and summarized into several groups which represent potential problems in health services.ResultsAmong a total of 4,142 children born in 2015 and 2016, 35 neonatal deaths were identified. Of these deaths, 74% occurred within one week of birth, and 57% were due to low-birth weight. Narrative data showed that three factors should be improved, 1) the unavailability of a health-care professional, 2) barriers in the referral system, and 3) lack of knowledge and skill to manage major causes of neonatal deaths.ConclusionThe current health system has limitations to achieve further reduction of neonatal deaths in rural Cambodia. The mere deployment of midwives at fixed service points such as health centers could not solve the problems occurring in rural communities. Community engagement revisiting the principle of primary health care, as well as health system transformation, is the key to the solution and potential breakthrough for the future

Supplementation with Vitamin B6 Reduces Side Effects in Cambodian Women Using Oral Contraception

Hormonal contraceptives may produce side effects that deter women from their use as a method of family planning. In nutritionally vulnerable populations these effects may be more pronounced due to micronutrient deficiencies and health status. Previous studies have been unable to resolve whether micronutrient supplementation may reduce such side effects. Aim: In a longitudinal study, 1011 women obtaining oral contraception through the public health system in rural Cambodia were allocated to either intervention or control groups, receiving either daily Vitamin B6 supplement or care as usual (without placebo). Results: The intervention participants (n = 577) reported fewer side effects in three categories: nausea/no appetite, headache, and depression compared with control group participants (n = 434). Conclusion: Women taking Vitamin B6 supplement were less likely to report side effects in a nutritionally vulnerable population. Underlying nutrition status should be considered by clinicians and reproductive health policy makers in the context of providing contraceptive services. Further investigation into micronutrient supplementation, particularly with B6, in reproductive-aged women using hormonal contraception should be conducted in other settings to determine the potential for widespread adoption

One year outcome of high-risk newborn infants discharged from the neonatal care unit of the National Maternal and Child Health Center in Cambodia

Background: In the National Maternal and Child Health Center in Cambodia, about 7,500 newborn infants are born every year. Around 10% of them are admitted to the neonatal care unit. After recovery from the acute phase that presented neonatal care unit admissions, they are discharged even if they are very low birth weight infants, but there is no official follow-up system available after discharge. This research aims to identify the prognosis of high-risk infants one year after discharge using regular telephone interviews, identifying the factors that may determine their prognosis. Methods: When a small and sick newborn infant was admitted to and discharged from the neonatal care unit, we collected health information from medical records. After discharge, we interviewed their caretakers by telephone when the infants were one, six, and 12 months (one year) old. We used structured questionnaires on feeding, history of illness, and development of growth and gross motor skills. Findings: Between September 2014 and April 2015, 175 infants were discharged. At one year old, 111 (63%) had survived, 12 (6.9%) had died, and 52 (30%) were lost to follow-up. Nine cases died within one month of discharge. Our data suggested low birth weight may lead to re-hospitalization. Infants vaccinated less than twice at six months old were more likely to be re-hospitalized. According to results of our telephone interview, three infants showed psychomotor retardation at one year old. Among the 50 cases lost to follow-up, 26 (52%) of these patients were discharged without permission by doctors. Interpretation: After one year, we noted that 63% of discharged infants survived, although 30% were lost to follow-up. There was a limitation of collecting more detailed data by telephone interview than questions about survival. The follow-up for high-risk newborn infants is an important challenge in Cambodia