Implementation challenges of free maternity services policy in Kenya: the health workers’ perspective

Introduction: Kenya implemented the policy of free maternity services to reduce maternal mortality and morbidity. For successful implementation of this policy, there is need to monitor the implementation progress, identify the challenges and mitigate them and determine better strategies for implementation based on emerging implementation issues. This study was carried out to determine the challenges facing policy implementation and strategies for better implementation.Methods: This was a cross-sectional descriptive study carried at the Rift Valley Provincial General Hospital (RVPGH) and Bondeni maternity. All the staff who work at Bondeni Maternity (including nursing officer in-charge) were included in the study. All the staff who work at the Maternity Unit of the RVPGH were included in the study, as well as the Medical Superintendent of the facility. A total of 110 respondents were sampled. A questionnaire and interview guide were used to collect data. Data was analyzed using SPSS software.Results: A response rate of 91% (n=100) was achieved. Major implementation challenges include inadequate supplies (86%), inadequate funding (38%), staff shortage (92%), lack of motivation among health workers (62%), overwhelming workload (89%) and abuse of services by clients (32%). Strategies for better implementation include employment of more staff, motivation of health workers, improvement in policy financing, training of health workers and provision of adequate supplies.Conclusion: Implementation of free maternity services policy in Kenya is facing challenges but there exists strategies, which, if implemented, will help address these challenges

Prenatal cervical cancer screening using visual inspection with acetic acid in a low resource setting

Purpose: Cervical cancer is one of the most common malignancies among women in low resource setting. The objective of this study was to assess the acceptability of prenatal cervical cancer screening using visual inspection with acetic acid (VIA) in a low resource setting. Methods: This was a cross-sectional study conducted at Moi Teaching and Referral Hospital. Over a period of 12 months, we enrolled 331 women who were attending antenatal care clinic with a gestation of age of less than 22 weeks. We screened them for cervical cancer by applying 5% acetic acid to the cervix (VIA Method). Visualization of aceto-white lesions was interpreted as a positive VIA test. A cervicography was obtained for independent review by two clinicians. A repeat VIA test or colposcopy and biopsy were recommended at 6 weeks postpartum for those with a positive VIA test. Results: Mean gestational age was 16 weeks. Seventy five percent of participants (n = 247) had used contraceptives, 31.1% (n = 103) had previously been screened for cervical cancer and 9.1% (n = 14) were HIV positive. The study clinician detected 11.3% VIA positive while first and second independent reviewers reported 22.5% and 7.7% VIA-positive results, respectively. About 85.7% of the participants did not experience any immediate adverse reaction as a result of the procedure. However, 3.8%, 38.4% and 0.7% experienced pain, burning sensation and bleeding respectively. Overall, 98.4% (n = 306) indicated that they would recommend the test, and 99% (n = 307) indicated that they would return for a repeat test 6 weeks postpartum. HIV status had no influence on VIA-positive rates (p = 0.909). Conclusion: The rate of VIA positive was 13.8% among the pregnant women. It is acceptable to use VIA to screen pregnant women for cervical cancer

Subcutaneous metastasis of cancer of the endometrium

Background: Cancer of the endometrium is the third most common gynecological malignancy after cancer of the cervix and ovary in Kenya. Subcutaneous metastasis is unusual site for endometrial cancer. Few cases of cutaneous and subcutaneous metastases from cancer of endometrium have been reported in the literature. The main areas of cutaneous and subcutaneous metastases are abdominal, perineal surfaces, skin and toes. Disseminated lesions are associated with hematogenous spread, while some occur via lymphatic spread or contiguity. Case Presentation: We present a case of a 45-year-old female, Para 5 + 0, who presented to our gynecologic oncology clinic in July 2017. The patient was referred from a peripheral health facility for chemotherapy following radical hysterectomy in May 2017 for endometrial cancer. Histology results of the specimen taken during surgery showed endometrial Ca stage 2, grade 3. The patient developed a swelling on the right leg 6 months after completion of 6 cycles of carboplatin and paclitaxel. Biopsy from the leg showed features consistent with metastatic endometrioid adenocarcinoma. The patient was started on pegylated liposomal doxorubicin. Local radiation of the metastatic subcutaneous lesion was also done. Conclusion: Cutaneous and subcutaneous metastases from cancer of the endometrium are rare. We recommend histologic evaluation of subcutaneous masses developing in patients with endometrial cancer or in those suspected to have endometrial cancer