Evaluating the comparative effectiveness of different demand side interventions to increase maternal health service utilization and practice of birth spacing in South Kivu, Democratic Republic of Congo: an innovative, mixed methods approach

In this protocol we describe a mixed methods study in the province of South Kivu, Democratic Republic of Congo evaluating the effectiveness of different demand side strategies to increase maternal health service utilization and the practice of birth spacing. Conditional service subsidization, conditional cash transfers and non-monetary incentives aim to encourage women to use maternal health services and practice birth spacing in two different health districts. Our methodology will comparatively evaluate the effectiveness of different approaches against each other and no intervention.; This study comprises four main research activities: 1) Formative qualitative research to determine feasibility of planned activities and inform development of the quantitative survey; 2) A community-based, longitudinal survey; 3) A retrospective review of health facility records; 4) Qualitative exploration of intervention acceptability and emergent themes through in-depth interviews with program participants, non-participants, their partners and health providers. Female community health workers are engaged as core members of the research team, working in tandem with female survey teams to identify women in the community who meet eligibility criteria. Female community health workers also act as key informants and community entry points during methods design and qualitative exploration. Main study outcomes are completion of antenatal care, institutional delivery, practice of birth spacing, family planning uptake and intervention acceptability in the communities. Qualitative methods also explore decision making around maternal health service use, fertility preference and perceptions of family planning.; The innovative mixed methods design allows quantitative data to inform the relationships and phenomena to be explored in qualitative collection. In turn, qualitative findings will be triangulated with quantitative findings. Inspired by the principles of grounded theory, qualitative analysis will begin while data collection is ongoing. This "conversation" between quantitative and qualitative data will result in a more holistic, context-specific exploration and understanding of research topics, including the mechanisms through which the interventions are or are not effective. In addition, engagement of female community health workers as core members of the research team roots research methods in the realities of the community and provides teams with key informants who are simultaneously implicated in the health system, community and target population

Applying the Robson classification to routine facility data to understand the Caesarean section practice in conflict settings of South Kivu, eastern DR Congo

Introduction: Sub-Saharan Africa has low Caesarean (CS) levels, despite a global increase in CS use. In conflict settings, the pattern of CS use is unclear because of scanty data. We aimed to examine the opportunity of using routine facility data to describe the CS use in conflict settings. Methods: We conducted a facility-based cross-sectional study in 8 health zones (HZ) of South Kivu province in eastern DR Congo. We reviewed patient hospital records, maternity registers and operative protocol books, from January to December 2018. Data on direct conflict fatalities were obtained from the Uppsala Conflict Data Program. Based on conflict intensity and chronicity (expressed as a 6-year cumulative conflict death rate), HZ were classified as unstable (higher conflict death rate), intermediate and stable (lower conflict death rate). To describe the Caesarean section practice, we used the Robson classification system. Based on parity, history of previous CS, onset of labour, foetal lie and presentation, number of neonates and gestational age, the Robson classification categorises deliveries into 10 mutually exclusive groups. We performed a descriptive analysis of the relative contribution of each Robson group to the overall CS rate in the conflict stratum. Results: Among the 29,600 deliveries reported by health facilities, 5,520 (18.6%) were by CS; 5,325 (96.5%) records were reviewed, of which 2,883 (54.1%) could be classified. The overall estimated population CS rate was 6.9%. The proportion of health facility deliveries that occurred in secondary hospitals was much smaller in unstable health zones (22.4%) than in intermediate (40.25) or stable health zones (43.0%). Robson groups 5 (previous CS, single cephalic, ≥ 37 weeks), 1 (nulliparous, single cephalic, ≥ 37 weeks, spontaneous labour) and 3 (multiparous, no previous CS, single cephalic, ≥ 37 weeks, spontaneous labour) were the leading contributors to the overall CS rate; and represented 75% of all CS deliveries. In unstable zones, previous CS (27.1%) and abnormal position of the fetus (breech, transverse lie, 3.3%) were much less frequent than in unstable and intermediate (44.3% and 6.0% respectively) and stable (46.7%and 6.2% respectively). Premature delivery and multiple pregnancy were more prominent Robson groups in unstable zones. Conclusion: In South Kivu province, conflict exposure is linked with an uneven estimated CS rate at HZ level with at high-risks women in conflict affected settings likely to have lower access to CS compared to low-risk mothers in stable health zones

Second trimester vaginal Candida colonization among pregnant women attending antenatal care in Bukavu, Democratic Republic of the Congo: prevalence, clinical correlates, risk factors and pregnancy outcomes

IntroductionVaginal Candida colonization (CC) can lead to vulvovaginal candidiasis, the second most prevalent vaginal condition worldwide, and has been associated with adverse birth outcomes. However, no data on CC in the Democratic Republic of the Congo are available. We investigated the prevalence, Candida species, clinical correlates, risk factors and pregnancy outcomes in women with CC in the second trimester of pregnancy.Material and methodsIn Bukavu, the Democratic Republic of the Congo, pregnant women were recruited during antenatal care between 16 and 20 weeks of gestation from January 2017 to October 2017 and followed until delivery. Sociodemographics, sexual behavioral, hygienic and clinical characteristics, microbiological data and pregnancy outcomes were collected. Candida detection and speciation was performed with microscopy (Gram-stained smears and wet-mount) and/or quantitative PCR. Multivariate regression models were used to estimate the different associations with CC.ResultsThe prevalence of CC by wet mount, microscopy of Gram-stain smears and qPCR was 27.9%, 28.1% and 38.2%, respectively. C. albicans was the most prevalent Candida species (91.0%). Previous genital infections, an intermediate vaginal microbiota, bacterial vaginosis, and the use of pit toilets were risk factors for CC. Clinically, CC was associated with itching only. Women with CC had twice the odds for preterm birth, if Candida concentration was high, the odds were four times higher.ConclusionsIn Bukavu, the Democratic Republic of the Congo, the prevalence of CC was high and associated with microbiological and modifiable risk factors. Screening and treatment for CC during antenatal care should be investigated as a possible strategy to reduce preterm birth

Prévention de la malnutrition au Sud Kivu, République démocratique du Congo: rôle et efficacité des interventions de type communautaire

IntroductionLe récent rapport de l’Organisation Mondiale de la Santé estime à 7,6 millions le nombre de décès d’enfants de moins de cinq en 2010 dans le monde dont le tiers est associé à la malnutrition. La malnutrition est donc un problème de santé publique pour la plupart des pays en développement y compris la République Démocratique du Congo (RDC). La RDC se partage la 2ème plus mauvaise position avec l’Afghanistan en ce qui concerne le taux de mortalité infanto juvénile (199 décès pour mille naissances vivantes). Il est également le 3ème pays au monde en ce qui concerne le nombre total de décès d'enfants de moins de cinq ans derrière l’Inde et le Nigéria. Le dernier rapport du Global Hunger Index (septembre 2011) montre que la RDC et le Tchad sont les pays les plus touchés par la malnutrition au monde.L’actuel protocole de l’OMS consacre la prise en charge communautaire de la malnutrition mais le fonctionnement des comités villageois n’est pas standardisé au niveau international. Dans certains pays ils sont regroupés en volontaires pour participer aux activités communautaires alors que dans d'autres pays comme l’Ethiopie, les volontaires communautaires sont totalement intégrés dans le système de santé comme les autres salariés.Le paquet d’activités des volontaires communautaires n’est pas non plus standardisé. Dans la majorité des pays, les volontaires communautaires se limitent aux activités promotionnelles et de sensibilisation alors que dans d’autres ils participent en plus aux activités de prise en charge de la malnutrition.L’objectif de ce travail était d‘évaluer si le programme de nutrition à base communautaire tel que défini au Sud Kivu peut contribuer de manière efficace à l’amélioration de la santé de l’enfant en milieu rural dans un contexte de malnutrition endémique.MéthodologieCe travail regroupe sept études. Les cinq premières portent sur l’évaluation des activités du programme de nutrition à assise communautaire dans le contexte du Sud Kivu. Les deux dernières études se focalisent sur l'étude de l'efficacité de compléments alimentaires sur la croissance staturo-pondérale des enfants à haut risque du retard de croissance et d'insuffisance pondérale.La première étude est une étude quasi expérimentale portant sur les données démographiques recueillies par les relais communautaires avec comme objectif d’évaluer la capacité des relais communautaires à assurer le dénombrement de la population et à identifier les populations cibles des programmes de nutrition en milieu rural.La deuxième étude est aussi une étude quasi expérimentale portant sur les activités de pesées réalisées par les relais au niveau communautaire avec comme objectif d’évaluer l’efficacité des relais communautaires à assurer la surveillance de la croissance des enfants d’âge préscolaire.La troisième étude est également une étude quasi expérimentale qui compare la prévalence de l’allaitement maternel à six mois dans deux secteurs de santé dont l’un travaille avec un réseau de relais communautaires pour la promotion de l’allaitement maternel exclusif. Son objectif est d’évaluer l’efficacité des relais communautaires à assurer la promotion de l’allaitement maternel exclusif.La quatrième étude est une étude d’observation qui utilise des méthodes qualitatives avec comme objectif d’identifier et discuter les incitants à la motivation des volontaires communautaires dans le contexte du Sud Kivu.La cinquième étude est une étude d’observation qui utilise à la fois des méthodes qualitatives et quantitatives pour évaluer les effets à long terme du programme communautaire de promotion de l’allaitement maternel exclusif en milieu rural du Sud Kivu.La sixième étude est une étude descriptive réalisée chez les femmes allaitantes dont les enfants étaient âgés de 9-10 mois. Son objectif est de décrire l'effet de la consommation des suppléments nutritionnels à base lipidique et hyper-énergétique sur la quantité de lait maternel ingérée par les enfants de 9-10 mois en milieu rural du Sud Kivu. Enfin, la septième étude est également une étude d’intervention randomisée portant sur 1401 enfants recrutés dès l’âge de six mois et qui ont été suivis jusqu’à l'âge de 12 mois. Cette étude avait pour objectif de comparer l’efficacité d’un aliment de complément prêt à l’emploi à base de farine de soja, maïs et sorgho enrichie en micronutriments et lipides (ACPE) et celle d’une bouillie hyper-énergétique enrichie en micronutriments à base de farine de maïs et soja et huile (UNIMIX) sur la prévention du retard de croissance et de l’insuffisance pondérale chez les nourrissons âgés de 6 à 12 mois.RésultatsLa première étude qui se rapporte au dénombrement de la population a montré que le dénombrement réalisé par les relais communautaires pour identifier les cibles des programmes de nutrition notamment les enfants de moins de cinq ans, les femmes enceintes et les ménages vulnérables sous-estime légèrement la population totale en comparaison avec le chiffre du district sanitaire mais obtient une répartition par catégorie d’âge similaire à celle du modèle national issu de l’enquête nationale. Ceci concerne particulièrement les enfants de moins de cinq ans dont le pourcentage médian (Min-Max) a été calculé à 21,3% (13,1-32,7%) alors que le modèle national estime ce pourcentage à 18,9%. Néanmoins, le dénombrement des relais communautaires a donné des proportions plus faibles pour la catégorie des femmes enceintes et celle des ménages vulnérables, les réduisant de près de 50% par rapport au modèle national.Les pesées communautaires réalisées par les relais communautaires ont relevé le niveau de fréquentation des enfants au service de consultation préscolaire avec des pourcentages médian mensuel variant entre 80 et 100% pour les enfants A court terme, il a été montré que les relais communautaires peuvent permettre une augmentation de la prévalence de l’allaitement maternel exclusif de 21 à 60%. Mais ce résultat n’a pas été confirmé dans le long terme même si on a observé une association entre les mères qui ont continué à pratiquer l’allaitement maternel exclusif jusqu’à six mois et la fréquence de visite des relais pendant la grossesse :10,8% contre 5,2% (p=0,003). Après 8 ans de suivi, on a observé un taux d'abandon de 52,5% chez les relais communautaires avec une durée médiane participation aux activités communautaires (Min-Max) de 6 (2-7) ans. On a pas observé de différence liée à l’âge, sexe, état civil, niveau études et profession. Dans la cohorte des relais communautaires du Sud Kivu, 90% soutiennent qu’il y a nécessité d’avoir des incitants externes pour le maintien de leur motivation et 60% préfèrent des incitants liés à leur intérêt direct (soins médicaux, salaire.). Les autres sollicitent des incitants à intérêt communautaire tels que les cantines de semences, le financement des projets communautaires.Les données de l’étude ont confirmé encore que le débit lacté des mères issues du milieu rural du Sud Kivu est dans les limites acceptables et que l’utilisation des suppléments nutritionnels à base lipidiques hyper-énergétiques ne défavorise pas la poursuite de l’allaitement maternel. Nous n’avons pas observé de diminution de quantité de lait ingéré :une moyenne de 678 g/dl dans le groupe ACPE et 705g/dl dans le groupe UNIMIX (p=0,70).Nous n'avons pas observé d'effet de l’aliment de complément prêt à l’emploi riche en lipide et micronutriments sur la croissance staturo-pondérale des enfants ou sur les paramètres biologiques mesurés (hématocrite, triglycéride, cholestérol).ConclusionLes résultats de ce travail montrent qu’à court terme les relais communautaires peuvent contribuer de manière efficace au dénombrement des populations cibles, au suivi de la croissance des enfants de moins de cinq ans et à la promotion de l’allaitement maternel exclusif en milieu rural du Sud Kivu. Cependant si les effets à court terme sont quasi certains, les effets à long terme restent hypothétiques car ils sont mis en balance par rapport aux exigences de relais communautaires :charge de travail adapté et tâches simples, nécessité d’incitants à la motivation, considération par le système de santé. Les incitants à intérêt communautaire et l’incorporation des relais dans des équipes d’enquête et autres activités rémunératrices sont à privilégier.Les résultats de ce travail montrent également que les mères du milieu rural du Sud Kivu ont une sécrétion lactée suffisante pour assurer l’allaitement maternel exclusif de leurs enfants pendant les six premiers mois conformément aux recommandations de l’OMS. Ces travaux confirment également que les nourrissons du milieu rural du Sud Kivu peuvent recevoir des compléments alimentaires avec densité élevée en lipides et micronutriments à partir de 6 mois sans qu'il y ait perturbation de l'allaitement. Cependant de recherches devraient se poursuivre pour identifier le complément idéal capable d’améliorer la croissance staturo-pondérale des enfants (type de complément et composition).IntroductionIn its latest report, the World Health Organization (WHO) reported that an estimated 7.6 millions underfive children deaths occurred in 2010 with a third of the deaths associated with malnutrition. Malnutrition is a major public health problem for most of developing countries including Democratic Republic of Congo (DRC). With an underfive mortality of 199 per 1000 live births, the DRC also share the second worst position with Afghanistan. DRC ranks third in behind India and Nigeria for the total yearly number of underfive deaths. The September 2011 Global Hunger Index report indicated that worldwide, DRC and Chad are countries the most affected by malnutrition. Although the role of community health workers (CHW) in the community based management of malnutrition is well recognized by WHO, there has not yet been an international effort and attempt to standardize the way village committees should be involved. Some countries use unpaid CHWs as health extension health workers for activities occurring in the community while other countries like Ethiopia have fully integrated them in the health system and give them a monthly salary. Similarly, the package of activities implemented by them has not yet been standardized with in most countries their role limited to community mobilization and sensitization and preventive related activities while in others community based management of malnutrition is added to these activities. The objective of the present study was to assess if the Community Nutrition Program as implemented in South Kivu contributed significantly to the improvement of the health of underfive children given that malnutrition is endemic in the region.MethodsThe present work regroups seven studies. The first five evaluate the activities of the Community Nutrition Program considering South Kivu context. The remaining two focus on the effectiveness of lipid based nutrients supplements (LNS) as complementary food in preventing stunting and underweight. The first study was a quasi-experimental study analyzing demographic data collected by CHW. It assessed the capacity of CHWs to conduct a demographic survey of their communities allowing an accurate identification of population targets for rural nutrition programs.The second study was also a quasi-experimental study analyzing data collecting during community based growth monitoring activities for underfive children carried out by CHW. It assessed the effectiveness of the program.The third study was also a quasi experimental study comparing the prevalence of exclusive breast feeding (EBF) at 6 months of age observed in a health sector with CHW involved in the promotion of EBF to that observed in a health sector without CHW breast feeding promotion activities. The study objective was to evaluate the effectiveness of CHW in promoting EBF. The fourth study was a qualitative and observational study aiming at identifying motivating factors for CHWs in South Kivu context.The fifth study was an observational study that used both qualitative and quantitative methods and that aimed at determining the long term effect of CHW promotion of EBF in rural South Kivu. The sixth study was a descriptive study aiming at describing the effect of LNS used as complementary food of breast milk intake of infants aged between 9 and 10 months in South Kivu. The last study was a randomized interventional trial on 1401 infants who received LNS as complementary food from 6 to 12 months of age. The trial aim was to compare the effectiveness of that sorghum, corn and soya based micronutrients fortified ready-to-eat complementary food to that of a porridge maid from UNIMIX a corn and soya fortified blended floor in reducing the prevalence of stunting and underweight at 12 months of age. ResultsThe results of the first study revealed that CHW slightly underestimated the total population comparatively to the Health District official figures but obtain similar age groups repartition of the population as the national reference, especially for children below 5 years for whom the CHW demographic survey gave the proportion of 21.3% (13.1-32.7%) close to the national figure of 18,9%. Comparatively to estimations from the national model, the CHW demographic survey also underestimated the numbers and proportions of pregnant women and vulnerable households by approximately 50%. CHW community based growth monitoring activities increased the attendance and coverage of wellbeing underfive clinics to a median monthly attendance varying between 80% and 100% of the expected number for infants and between 80 and 90% for children aged 12 to 59 months. The results of our studies suggest that CHW involvement in the promotion of EBF improved its prevalence and the improvement was from 21% to 60% in our study. Although, being visited by CHW during pregnancy was still associated an increased prevalence of EBF at 6 months (10.8% versus 5.2%; p=0,003), the prevalence of EBF at 6 months was not sustained in the long term in communities previously actively supported by the community nutrition program. The level of EBF prevalence at 6 months was not sustained in the long term. Also, eight years follow up of a cohort of CHW showed a dropout of 52.5% of CHW after a with the median (Min-Max) duration of activity being 6 (2-7) years. There was no relationship between dropout and CHW age, gender, marital status, level of education and professional activity. Ninety percent of interviewed CHW indicated that incentives are needed for motivation and 60% advocated for individual incentives (salary, health care cover,) while 40% advocated for group incentives such us funds for income generating activities, funds for community seeds bank project. Our study has confirmed that breast-milk production in lactating mothers from South Kivu is in the normal range and that the use of hyper-energetic LNS as complementary food does not interfere with breast-milk intake (678 g/dl per day for children taking the LNS based complementary food and 705g/dl in those taking porridge; p=0,70)Comparatively to the porridge used as control, the LNS based complementary was not superior in promoting growth and no difference was observed when comparing biological parameters measured such us hematocrit, triglycerides and cholesterol. ConclusionThe present study has demonstrated that in South Kivu, CHW can be successfully used in conducting demographic survey for the calculation of nutrition programs targets, in community based growth monitoring targeting underfive children and in the promotion of EBF. However, the short term benefits of involving CHW in the implementation of such activities is not sustained in the long term because of the need of incentives to sustain the motivation of CHW. Programs using CHW should consider ensuring the recognition of the health system, limiting the workload and the level of complexity of the work, planning for incentives. Group incentives and recruiting them in health District activities that will give them some income should be preferred as motivating strategy. Our work has also shown that breast milk production of lactating mothers from South Kivu is sufficient to allow mothers to continue with EBF up to 6 months as recommended by WHO. It has also shown that the use of LNS as complementary food is not detrimental for breast milk intake. However, research is still need to improve the composition of LNS and obtain a complementary food effective in sustaining optimal weight and height growth velocity. Doctorat en Santé Publiqueinfo:eu-repo/semantics/nonPublishe

Exploration of the relationship between anemia and iron and zinc deficiencies in children under 5 years of age living in the malaria endemic area of South Kivu/Democratic Republic of Congo

The aim of this study was to explore the relationship of iron and zinc deficiencies and anemia in children aged under 5 years living in malaria endemic area of South Kivu/DRC. We conducted a cross-sectional study in the health zone of Miti Murhesa in South Kivu/DRC. A total of 1088 children in good general health were included in this study. Almost 40% of children were anemic. The prevalence of iron deficiency (ID) was found in 34.9% and 49.1% children based on ferritin or free erythrocyte protoporphyrin (FEP), respectively. If anemia is present, we found iron deficiency anemia (IDA) according to the WHO-criteria (ferritin) in 31%, and according to FEP in 66% of children. The overall prevalence of zinc deficiency was 17.6%. If anemia is present, zinc deficiency was found in 24.4% of children. Inflammation/infection, based upon CRP, was present in 39.7% children. The independent factors associated with anemia were recent illness, middle upper arm circumference, weight-for-height, ID according to FEP, zinc deficiency, and submicroscopic Plasmodium infection. A high prevalence of ID was observed in children in South Kivu according to FEP. Ferritin as acute phase protein was less suited in this population due to a high frequency of infection/inflammation. Iron and zinc deficiencies were found to be significantly associated with anemia in this population

Effects of local porridge supplementation on nutritional status of moderately malnourished children in rural Democratic Republic of Congo

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Facteurs associés à un mauvais état nutritionnel en milieu urbain en RDC

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Effectiveness of community volunteers in monitoring children's growth in an endemic context of malnutrition and conflict in Democratic Republic of Congo

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Evolving altitude malaria in a poor area surrounding the paediatric hospital of Lwiro in Kivu

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réduction de la mortalité d'enfants hospitalisés en milieu rural d'Afrique centrale (Kivu): reflet de la qualité de la prise en charge nutritionnelle ?

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