The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya

Background Disrespect and abuse (D & A) during labor and delivery are important issues correlated with human rights, equity, and public health that also affect women’s decisions to deliver in facilities, which provide appropriate management of maternal and neonatal complications. Little is known about interventions aimed at lowering the frequency of disrespectful and abusive behaviors. Methods Between 2011 and 2014, a pre-and-post study measured D & A levels in a three-tiered intervention at 13 facilities in Kenya under the Heshima project. The intervention involved working with policymakers to encourage greater focus on D & A, training providers on respectful maternity care, and strengthening linkages between the facility and community for accountability and governance. At participating facilities, postpartum women were approached at discharge and asked to participate in the study; those who consented were administered a questionnaire on D & A in general as well as six typologies, including physical and verbal abuse, violations of confidentiality and privacy, detainment for non-payment, and abandonment. Observation of provider-patient interaction during labor was also conducted in the same facilities. In both exit interview and observational studies, multivariate analyses of risk factors for D & A controlled for differences in socio-demographic and facility characteristics between baseline and endline surveys. Results Overall D & A decreased from 20–13 % (p < 0.004) and among four of the six typologies D & A decreased from 40–50 %. Night shift deliveries were associated with greater verbal and physical abuse. Patient and infant detainment declined dramatically from 8.0–0.8 %, though this was partially attributable to the 2013 national free delivery care policy. Conclusion Although a number of contextual factors may have influenced these findings, the magnitude and consistency of the observed decreases suggest that the multi-component intervention may have the potential to reduce the frequency of D & A. Greater efforts are needed to develop stronger evaluation methods for assessing D & A in other settings

Estimating willingness to pay for maternal health services: The Kenya reproductive health voucher programme

As part of a broad evaluation of a reproductive health voucher programme aimed at determining its effect on health outcomes, a willingness to pay (WTP) study was conducted. The purpose of the study was to estimate WTP values for a broad range of reproductive health (RH) services namely: antenatal care (ANC), delivery, postnatal care (PNC) and family planning (FP) services. The study also sought to investigate the effect of the voucher programme on respondents’ stated WTP values for the RH services. Women utilizing RH services at both voucher and non-voucher facilities were asked about their WTP for the RH services and WTP values were elicited using a stated preferences method. The study found that women were willing to pay a positive price to access RH services. Results also point to a differential learning effect or experience of the voucher on WTP for ANC, PNC, FP and delivery services. Further analysis also highlights endowment and reference effects with the voucher cost impacting on stated WTP amounts. The findings point to the potential for designing a sliding scale payment mechanism with effective targeting of subsidies such as vouchers to the neediest segments of the population. This will allow potential service users to pay for services within their willingness and ability to pay while also freeing resources to cater for the neediest segments of the population.The reproductive health voucher programme is implemented by the Government of Kenya with major funding from the German Development Bank (KfW). The evaluation project was funded by the Bill & Melinda Gates Foundation and implemented by the Population Council in collaboration with the National Council for Population and Development (NCPD), the Ministry of Health and PriceWaterhouseCoopers

Antiapoptotic herpesvirus Bcl-2 homologs escape caspase-mediated conversion to proapoptotic proteins

The antiapoptotic Bcl-2 and Bcl-x(L) proteins of mammals are converted into potent proapoptotic factors when they are cleaved by caspases, a family of apoptosis-inducing proteases (E. H.-Y. Cheng, D. G. Kirsch, R. J. Clem, R. Ravi, M. B. Kastan, A. Bedi, K. Ueno, and J. M. Hardwick, Science 278:1966-1968, 1997; R. J. Clem, E. H.-Y. Cheng, C. L. Karp, D. G. Kirsch, K. Ueno, A. Takahashi, M. B. Kastan, D. E. Griffin, W. C. Earnshaw, M. A. Veliuona, and J. M. Hardwick, Proc. Natl. Acad. Sci. USA 95:554-559, 1998). Gamma herpesviruses also encode homologs of the Bcl-2 family. All tested herpesvirus Bcl-2 homologs possess antiapoptotic activity, including the more distantly related homologs encoded by murine gammaherpesvirus 68 (gammaHV68) and bovine herpesvirus 4 (BHV4), as described here. To determine if viral Bcl-2 proteins can be converted into death factors, similar to their cellular counterparts, five herpesvirus Bcl-2 homologs from five different viruses were tested for their susceptibility to caspases. Only the viral Bcl-2 protein encoded by gammaHV68 was susceptible to caspase digestion. However, unlike the caspase cleavage products of cellular Bcl-2, Bcl-x(L), and Bid, which are potent inducers of apoptosis, the cleavage product of gammaHV68 Bcl-2 lacked proapoptotic activity. KSBcl-2, encoded by the Kaposi's sarcoma-associated herpesvirus, was the only viral Bcl-2 homolog that was capable of killing cells when expressed as an N-terminal truncation. However, because KSBcl-2 was not cleavable by caspases, the latent proapoptotic activity of KSBcl-2 apparently cannot be released. The Bcl-2 homologs encoded by herpesvirus saimiri, Epstein-Barr virus, and BHV4 were not cleaved by apoptotic cell extracts and did not possess latent proapoptotic activities. Thus, herpesvirus Bcl-2 homologs escape negative regulation by retaining their antiapoptotic activities and/or failing to be converted into proapoptotic proteins by caspases during programmed cell death

Can Reproductive Health Voucher Programs Improve Quality of Postnatal Care? A Quasi-Experimental Evaluation of Kenya’s Safe Motherhood Voucher Scheme

This study tests the group-level causal relationship between the expansion of Kenya’s Safe Motherhood voucher program and changes in quality of postnatal care (PNC) provided at voucher-contracted facilities. We compare facilities accredited since program inception in 2006 (phase I) and facilities accredited since 2010-2011 (phase II) relative to comparable non-voucher facilities. PNC quality is assessed using observed clinical content processes, as well as client-reported outcome measures. Two-tailed unpaired t-tests are used to identify differences in mean process quality scores and client-reported outcome measures, comparing changes between intervention and comparison groups at the 2010 and 2012 data collection periods. Difference-in-differences analysis is used to estimate the reproductive health (RH) voucher program’s causal effect on quality of care by exploiting group-level differences between voucher-accredited and non-accredited facilities in 2010 and 2012. Participation in the voucher scheme since 2006 significantly improves overall quality of postnatal care by 39% (p=0.02), where quality is defined as the observable processes or components of service provision that occur during a PNC consultation. Program participation since phase I is estimated to improve the quality of observed maternal postnatal care by 86% (p=0.02), with the largest quality improvements in counselling on family planning methods (IRR 5.0; p=0.01) and return to fertility (IRR 2.6; p=0.01). Despite improvements in maternal aspects of PNC, we find a high proportion of mothers who seek PNC are not being checked by any provider after delivery. Additional strategies will be necessary to standardize provision of packaged postnatal interventions to both mother and new-born. This study addresses an important gap in the existing RH literature by using a strong evaluation design to assess RH voucher program effectiveness on quality improvement

Exploring the effectiveness of the output-based aid voucher program to increase uptake of gender-based violence recovery services in Kenya: a qualitative evaluation

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: Few studies in Africa have explored in detail the ability of output-based aid (OBA) voucher programs to increase access to gender-based violence recovery (GBVR) services. Methods: A qualitative study was conducted in 2010 and involved: (i) in-depth interviews (IDIs) with health managers, service providers, voucher management agency (VMA) managers and (ii) focus group discussions (FGDs) with voucher users, voucher non-users, voucher distributors and opinion leaders drawn from five program sites in Kenya. Results: The findings showed promising prospects for the uptake of OBA GBVR services among target population. However, a number of factors affect the uptake of the services. These include lack of general awareness of the GBVR services vouchers, lack of understanding of the benefit package, immediate financial needs of survivors, as well as stigma and cultural beliefs that undermine reporting of cases or seeking essential medical services. Moreover, accreditation of only hospitals to offer GBVR services undermines access to the services in rural areas. Poor responsiveness from law enforcement agencies and fear of reprisal from perpetrators also undermine treatment options and access to medical services. Low provider knowledge on GBVR services and lack of supplies also affect effective provision and management of GBVR services. Conclusions: The above findings suggest that there is a need to build the capacity of health care providers and police officers, strengthen the community strategy component of the OBA program to promote the GBVR services voucher, and conduct widespread community education programs aimed at prevention, ensuring survivors know how and where to access services and addressing stigma and cultural barriers.The Bill and Melinda Gates Foundatio

Does a voucher program improve reproductive health service delivery and access in Kenya?

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.Background - Current assessments on Output-Based Aid (OBA) programs have paid limited attention to the experiences and perceptions of the healthcare providers and facility managers. This study examines the knowledge, attitudes, and experiences of healthcare providers and facility managers in the Kenya reproductive health output-based approach voucher program. Methods - A total of 69 in-depth interviews with healthcare providers and facility managers in 30 voucher accredited facilities were conducted. The study hypothesized that a voucher program would be associated with improvements in reproductive health service provision. Data were transcribed and analysed by adopting a thematic framework analysis approach. A combination of inductive and deductive analysis was conducted based on previous research and project documents. Results - Facility managers and providers viewed the RH-OBA program as a feasible system for increasing service utilization and improving quality of care. Perceived benefits of the program included stimulation of competition between facilities and capital investment in most facilities. Awareness of family planning (FP) and gender-based violence (GBV) recovery services voucher, however, remained lower than the maternal health voucher service. Relations between the voucher management agency and accredited facilities as well as existing health systems challenges affect program functions. Conclusions - Public and private sector healthcare providers and facility managers perceive value in the voucher program as a healthcare financing model. They recognize that it has the potential to significantly increase demand for reproductive health services, improve quality of care and reduce inequities in the use of reproductive health services. To improve program functioning going forward, there is need to ensure the benefit package and criteria for beneficiary identification are well understood and that the public facilities are permitted greater autonomy to utilize revenue generated from the voucher program.This work was supported by the Bill and Melinda Gates Foundation to the Population Council as part of a multi country study evaluation of voucher-andaccreditation interventions. Grant number 51761

An assessment of opportunities and challenges for public sector involvement in the maternal health voucher program in Uganda

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities. Methods: Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated. Results: The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages.Conclusions: Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program

Science and Film-making

The essay reviews the literature, mostly historical, on the relationship between science and film-making, with a focus on the science documentary. It then discusses the circumstances of the emergence of the wildlife making-of documentary genre. The thesis examined here is that since the early days of cinema, film-making has evolved from being subordinate to science, to being an equal partner in the production of knowledge, controlled by non-scientists

Influence of crop residue ration supplementation on the attainment of puberty and postpartum reproductive activities of Red Sokoto goats

The general objective of this study was to come up with an appropriate, affordable and locally available crop residue supplementation package that would enhance reproductive performance in small ruminants. Specifically, 28 Red Sokoto weaner does between 3 and 4 months of age weighing between 2 and 3 kg were used in the first experiment to determine the influence of crop residue supplementation on age and weight at puberty as determined by blood progesterone levels. In the second experiment, another 28 adult does (equal to or greater than 2 years old) of the same breed in the same flock with lactation numbers between 1 and 3 were used to determine the length of postpartum acyclic period. In both experiments, a 3 x 2 factorial experimental design comprising three dietary supplements (A, B, C) at two feeding levels (1% and 2% of body weight) fed in addition to a basal diet of Digitaria smutsii hay and natural pasture ad libitum with an unsupplemented negative control group (D) and four goats per treatment was utilized. In ration A, a conventional concentrate supplement consisting of maize, wheat offal, cottonseed cake and bonemeal was utilized; in rations B and C, the supplement consisted of guinea-corn bran, cowpea husk and groundnut haulms; and maize offal, groundnut shells and groundnut haulms respectively. Unsupplemented (ration D) weaner does reached puberty at a later age and had lighter body weights than all the others. Weaner does on ration 2A (concentrate fed at 2% of body weight) attained puberty at the earliest age and heaviest body weight, although the age at puberty was not significantly different from those on rations 1A (concentrate fed at 1% body weight), 1C and 2C. Blood progesterone profiles before and after puberty ranged from 0.05 to 9.0 ng/ml, respectively, and was highest in does fed rations A and C and least in the unsupplemented does. The mean interval between kidding and initiation of ovarian activity was 54.28 plus or minus 17.61 days and the mean interval between kidding and conception was 63.04 plus or minus 25.34 days. Only 25% of the unsupplemented does conceived again during the period under study compared with 100% in rations 1A, 2A, 1C and 2C; 75% in ration 2B and 50% in ration 1B. It was concluded that implementation of supplementary feeding in the dry season improves reproductive performance in the Red Sokoto doe. Furthermore, ration C, a crop residue-based ration, was a suitable dry season supplementation alternative to the expensive conventional concentrate ration for the smallholder goat farmer in the subhumid tropics of Nigeria

Radical, Reformist, and Garden-Variety Neoliberal: Coming to Terms with Urban Agriculture’s Contradictions

For many activists and scholars, urban agriculture in the Global North has become synonymous with sustainable food systems, standing in opposition to the dominant industrial agri-food system. At the same time, critical social scientists increasingly argue that urban agriculture programmes, by filling the void left by the rolling back of the social safety net, underwrite neoliberalisation. I argue that such contradictions are central to urban agriculture. Drawing on existing literature and fieldwork in Oakland, CA, I explain how urban agriculture arises from a protective counter-movement, while at the same time entrenching the neoliberal organisation of contemporary urban political economies through its entanglement with multiple processes of neoliberalisation. By focusing on one function or the other, however, rather than understanding such contradictions as internal and inherent, we risk undermining urban agriculture\u27s transformative potential. Coming to terms with its internal contradictions can help activists, policy-makers and practitioners better position urban agriculture within coordinated efforts for structural change, one of many means to an end rather than an end unto itself