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  1. 51

    Young maternal age is a risk factor for child undernutrition in Tamale Metropolis, Ghana.

    Wemakor A; Garti H; Azongo T; Garti H; Atosona A

    BMC Research Notes. 2018 Dec 10; 11(1):877.

    OBJECTIVE: Malnutrition is a common cause of morbidity and mortality in children. The aim of this study was to compare the nutritional status of children under 5 years of teenage and adult mothers in Tamale Metropolis, Ghana. A case-control study involving 300 (150 cases, 150 controls) mother-child pairs was carried out. A questionnaire was used to collect data on socio-demographic characteristics of mothers and children and anthropometry was used to assess the nutritional status of children. Anthropometric z-scores derived based on WHO Child Growth Standards were used to determine stunting, wasting and underweight statuses of children. Logistic regression analysis was used to compare the nutritional status of children of teenage and adult mothers. RESULTS: Children of teenage mothers, compared to those of adult mothers, were 8 times more likely to be stunted [Adjusted Odds Ratio (AOR) = 7.56; 95% confidence interval (CI) 4.20-13.63], 3 times more likely to be wasted (AOR = 2.90; 95% CI 1.04-8.04), and 13 times more likely to be underweight (AOR = 12.78; 95% CI 4.69-34.81) after adjusting for potential confounders. The risk of child malnutrition increases with young maternal age; interventions should be targeted at teenage mothers and their children to reduce the risk of malnutrition.
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  2. 52
    Peer Reviewed

    Are health facilities well equipped to provide basic quality childbirth services under the free maternal health policy? Findings from rural Northern Ghana.

    Dalinjong PA; Wang AY; Homer CSE

    BMC Health Services Research. 2018 Dec 12; 18(1):959.

    BACKGROUND: Basic inputs and infrastructure including drugs, supplies, equipment, water and electricity are required for the provision of quality care. In the era of the free maternal health policy in Ghana, it is unclear if such basic inputs are readily accessible in health facilities. The study aimed to assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities. Women and health providers' views on privacy and satisfaction with quality of care were also assessed. METHODS: The study used a convergent parallel mixed methods in one rural municipality in Ghana, Kassena-Nankana. A survey among facilities (n = 14) was done. Another survey was carried out among women who gave birth in health facilities only (n = 353). A qualitative component involved focus group discussions (FGDs) with women (n = 10) and in-depth interviews (IDIs) with midwives and nurses (n = 25). Data were analysed using descriptive statistics for the quantitative study, while the qualitative data were recorded, transcribed, read and coded using themes. RESULTS: The survey showed that only two (14%) out of fourteen facilities had clean water, and five (36%) had electricity. Emergency transport for referrals was available in only one (7%) facility. Basic drugs, supplies, equipment and infrastructure especially physical space were inadequate. Rooms used for childbirth in some facilities were small and used for multiple purposes. Eighty-nine percent (n = 314) of women reported lack of privacy during childbirth and this was confirmed in the IDIs. Despite this, 77% of women (n = 272) were very satisfied or satisfied with quality of care for childbirth which was supported in the FGDs. Reasons for women's satisfaction included the availability of midwives to provide childbirth services and to have follow-up homes visits. Some midwives were seen to be patient and empathetic. Providers were not satisfied due to health system challenges. CONCLUSION: Government should dedicate more resources to the provision of essential inputs for CHPS compounds providing maternal health services. Health management committees should also endeavour to play an active role in the management of health facilities to ensure efficiency and accountability. These would improve quality service provision and usage, helping to achieve universal health coverage.
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  3. 53
    Peer Reviewed

    Inpatient and outpatient treatment for acute malnutrition in infants under 6 months; a qualitative study from Senegal.

    van Immerzeel TD; Camara MD; Deme Ly I; de Jong RJ

    BMC Health Services Research. 2019 Jan 25; 19(1):69.

    BACKGROUND: Treatment of acute malnutrition in infants under 6 months is a relevant topic regarding the global problem of maternal and child malnutrition. While treatment for older age groups has shifted more towards an outpatient, community based approach, young infants are mostly treated in hospital. This study aims to describe barriers and facilitators for outpatient and inpatient treatment of malnourished infants under 6 months in Senegal. METHODS: This qualitative descriptive study uses in-depth interviews with health workers and focus group discussions with mothers of malnourished infants, conducted from June to September 2015 in two case clinics. In data analysis, Collins' 3 key factors for a successful nutrition program were used as a theoretical framework: access, quality of care and community engagement. RESULTS: Within Collins' 3 key factors, 9 facilitators and barriers have emerged from the data. Key factor access: Outpatient care was perceived as more accessible than inpatient concerning distance and cost, given that there is a milk supplement available. Trust could be more easily generated in an outpatient setting. Key factor quality of care: The cup and spoon re-lactation technique was efficiently used in outpatient setting, but needed close supervision. Basic medical care could be offered to outpatients provided that referral of complicated cases was adequate. Health education was more intensive with inpatients, but could be done with outpatients. Key factor community engagement: The community appeared to play a key role in treating malnourished young infants because of its influence on health seeking behaviour, peer support and breastfeeding practices. CONCLUSIONS: Outpatient care does facilitate access, provided that an affordable milk supplement is available. Quality of care can be guaranteed using an appropriate re-lactation technique and a referral system for complications. The community has the potential to be much engaged, though more attention is required for breastfeeding education. In view of the magnitude of the health problem of young infant malnutrition and its strong relationship with breastfeeding practices, an outpatient community-based treatment approach needs to be considered.
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  4. 54
    Peer Reviewed

    Is childbirth location associated with higher rates of favourable early breastfeeding practices in Sub-Saharan Africa?

    Bergamaschi N; Oakley L; Benova L

    Journal of Global Health. 2019 Jun; 9(1):010417.

    Background: Favourable early breastfeeding practices have a beneficial impact throughout an infants' lifespan. Childbirth location is likely to affect these practices through support during the intrapartum and immediate postpartum period. This study aimed to investigate the association between childbirth location and favourable early breastfeeding practices in Sub-Saharan Africa (SSA). Methods: Demographic and Health Survey (2000-2013) data across 30 SSA countries were utilised. Childbirth location was categorised as home vs facility, and further into public vs private sector. Early breastfeeding practices included: early initiation of breastfeeding (EIBF) (within 1 hour of birth), and no prelacteal feeding (fed only breast milk in the first 3 days). Multivariate logistic regression models adjusted for confounders were used to assess this association. Results: Overall, 50.0% (country range 32.6%-95.5%) of infants received EIBF and 61.0% had no prelacteal feeding. Compared with home births, facility deliveries had higher adjusted odds of EIBF (adjusted odds ratio, aOR = 1.39, 95% confidence interval (CI) = 1.30-1.48, P < 0.001) and no prelacteal feeding (aOR = 1.75, 95% CI = 1.63-1.89, P < 0.001). Private sector facilities had lower adjusted odds of no prelacteal feeding (aOR = 0.89, 95% CI = 0.81-0.99, P = 0.036) when compared to public sector facilities. There was no evidence to suggest delivery sector was associated with EIBF (aOR = 0.93, 95% CI = 0.85-1.03, P = 0.212). Conclusions: This study showed early breastfeeding practices are suboptimal and are associated with delivery location in SSA. Further research is required to better understand how characteristics of care may explain these patterns in order to improve feeding practices.
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  5. 55

    Delivering integrated care after sexual violence in the Democratic Republic of the Congo.

    Bress J; Kashemwa G; Amisi C; Armas J; McWhorter C; Ruel T; Ammann AJ; Mukwege D; Butler LM

    BMJ Global Health. 2019; 4(1):e001120.

    In the eastern Democratic Republic of the Congo, ongoing armed conflict increases the incidence of gender-based violence (GBV) and presents a distinct and major barrier to care delivery for all survivors of GBV. A specific challenge is providing emergency contraception, HIV prophylaxis and treatment for sexually transmitted infections to all survivors within 72 hours of violence. To address the multiple barriers to providing this time-sensitive medical care, Global Strategies and Panzi Hospital implemented the Prevention Pack Program. The Prevention Pack is a pre-packaged post-rape medical kit containing antiretroviral post-exposure prophylaxis, antibiotics for treatment of sexually transmitted infections and emergency contraception. The Prevention Pack Program combines community sensitisation about post-rape medical care with the provision of Prevention Packs and the implementation of a cloud-based and Global Positioning System (GPS)-enabled inventory management system. The Panzi Hospital gender-based violence team implemented the Prevention Pack Program at Panzi Hospital and 12 rural clinics in the South Kivu Province. The data manager took GPS coordinates of each site, provided an initial stock of Prevention Packs and then called all sites daily to determine demand for post-rape care and Prevention Pack consumption. Inventory data were entered into the GPS-enabled cloud-based inventory management system. Project personnel used the consumption rate, trends and geolocation of sites to guide Prevention Pack restocking strategy. Between 2013 and 2017, a total of 8206 individuals presented for care following rape at the study sites. Of the 1414 individuals who presented in the rural areas, 1211 (85.6%) did so within the first 72 hours of reported rape. Care was delivered continuously and without a single stockout of medication across all sites. The Prevention Pack Program provided timely and consistent access to emergency contraception, HIV prophylaxis and treatment for sexually transmitted infections for rape survivors in the eastern Democratic Republic of the Congo.
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  6. 56

    Contraceptive Choices and Counseling in Norwegian Female Renal Transplant Recipients.

    Eide IA; Rashidi F; Lonning K; Oldereid NB; Reisaeter AV; Asberg A; Midtvedt K

    Transplantation Proceedings. 2019 Mar; 51(2):470-474.

    BACKGROUND: There are major gaps in the understanding of sexual and reproductive health in female renal transplant recipients. METHODS: In this Norwegian multicenter retrospective observational study, 118 female renal transplant recipients aged 22 to 49 years responded to a questionnaire on fertility, contraceptive use, and pregnancy. RESULTS: More than one-third (37%) of patients reported that they did not receive advice on contraceptive methods from health care personnel in the early post-transplant phase. These women used effective contraceptive methods less often. Nearly half of the patients (45%) reported that they had not received any advice on timing of conception after transplant. From 95 pregnancies after renal transplant, 52 (55%) resulted in live births. CONCLUSION: Counseling on contraceptive methods should be part of standard care in conjunction with transplantation. More than one-third of young female renal transplant recipients of reproductive age could not recall having received advice from health care personnel about contraceptive use, and nearly half of the patients did not receive preconceptional advice after transplant. Although the current study does not discriminate between lack of advice and recall bias, the findings signal the need for improved counseling on female sexual and reproductive health after renal transplant. Copyright (c) 2019. Published by Elsevier Inc.
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  7. 57
    Peer Reviewed

    Perfect- and typical-use effectiveness of the Dot fertility app over 13 cycles: results from a prospective contraceptive effectiveness trial.

    Jennings V; Haile LT; Simmons RG; Spieler J; Shattuck D

    European Journal of Contraception and Reproductive Health Care. 2019 Mar 18; 1-6.

    OBJECTIVE: Dynamic Optimal Timing (Dot) is a smartphone application (app) that estimates the menstrual cycle fertile window based on the user's menstrual period start dates. Dot uses machine learning to adapt to cycles over time and informs users of 'low' and 'high' fertility days. We investigated Dot's effectiveness, calculating perfect- and typical-use failure rates. METHODS: This prospective, 13 cycle observational study ( NCT02833922) followed 718 women who were using Dot to prevent pregnancy. Participants contributed 6616 cycles between February 2017 and October 2018, providing data on menstrual period start dates, daily sexual activity and prospective intent to prevent pregnancy. We determined pregnancy through participant-administered urine pregnancy tests and/or written or verbal confirmation. We calculated perfect- and typical-use failure rates using multi-censoring, single-decrement life-table analysis, and conducted sensitivity, attrition and survival analyses. RESULTS: The perfect-use failure rate was calculated to be 1.0% (95% confidence interval [CI]: 0.9%, 2.9%) and the typical-use failure rate was 5.0% (95% CI: 3.4%, 6.6%) for women aged 18-39 (n = 718). Survival analyses identified no significant differences among age or racial/ethnic groups or women in different types of relationships. Attrition analyses revealed no significant sociodemographic differences, except in age, between women completing 13 cycles and those exiting the study earlier. CONCLUSION: Dot's effectiveness is within the range of other user-initiated contraceptive methods.
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  8. 58
    Peer Reviewed

    Searching for Information on the Risks of Combined Hormonal Contraceptives on the Internet: A Qualitative Study Across Six European Countries.

    Gomes Alves P; Petersen I; Stevenson F

    Journal of Medical Internet Research. 2019 Mar 18; 21(3):e10810.

    BACKGROUND: Searching for health information online is increasingly common and is an obvious source of information about oral combined hormonal contraceptives (CHCs) and their risks. However, little is known about how publicly available websites address the risks of CHCs, particularly venous thromboembolism (VTE). OBJECTIVE: The aim was to explore the information available to women about VTE and other risks of CHCs on websites available through commonly used search engines. METHODS: A qualitative study was conducted to explore whether and how websites about CHCs in Denmark, Germany, Netherlands, Slovakia, Spain, and the United Kingdom make reference to VTE and other CHC risks. A systematic search procedure was adopted across the six countries, based on relevant keywords. The search was carried out using the Google search engine by fluent/native speakers of each language. A content analysis approach was conducted to extract information from the selected websites. RESULTS: A total of 357 websites were reviewed. Nearly all (343/357, 96.1%) the websites mentioned VTE as a risk of CHCs, with approximately half referring to other side effects as well. One-fifth (92/357, 25.8%) of the websites provided suggestions about the best contraceptive method to use, and only a minority (23/357, 6.4%) recommended women discuss CHCs with their health professionals. Sites were generally run by the media (110/357 30.8%) or medical services from nongovernmental organizations (140/357, 39.2%). Only a minority of websites referred to organizations such as the European Medicines Agency (11/357, 3.1%). CONCLUSIONS: Despite the large number of websites containing information about oral CHCs and their risks, particularly VTE, only a limited number referred to information from accredited health agency sources. We argue this is a missed opportunity for accredited health agencies to share high-quality information to assist women using CHCs to make informed decisions about contraception. (c)Paula Gomes Alves, Irene Petersen, Fiona Stevenson. Originally published in the Journal of Medical Internet Research (, 18.03.2019.
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  9. 59
    Peer Reviewed

    Husbands' involvement in family planning use and its associated factors in pastoralist communities of Afar, Ethiopia.

    Chekole MK; Kahsay ZH; Medhanyie AA; Gebreslassie MA; Bezabh AM

    Reproductive Health. 2019 Mar 18; 16(1):33.

    BACKGROUND: Husbands play an influential role in women's access to health care, such as family planning services. However, there is little evidence of the level of husbands' involvement in family planning services among pastoralist communities, who possess a distinct lifestyle. This study was aimed to assess husbands' involvement in family planning use and factors associated in pastoralist communities of Afar, Ethiopia. METHODS: Community-based cross-sectional survey was conducted among randomly selected 418 married women in Afambo district, Afar pastoralist community in 2017. Data were collected using semi-structured questionnaire. Data were entered to EPI-Info version 7 statistical software programs and exported to SPSS. Descriptive and multivariable logistic regression analyses were applied to identify factors associated with husband involvement. Odds ratio at 95% confidence interval were reported and significant association of factors was declared at the p-value of less than 0.05. RESULT: Four hundred eighteen married women were included in the study, making a response rate of 98%. The magnitude of husbands' involvement in family planning was found to be 42.2%. Women who ever used family planning (AOR: 7.21; 95%CI: 3.58-14.67), those who participated in community networks, those who reported health center as their source of information for family planning (AOR: 5.56; 95%CI: 1.92-16. o7) were higher likely to report husband involvement compare to their counterparts. Participants' increased knowledge was also significantly associated with higher odds of husband involvement in family knowledge (AOR = 1.31; 95% CI: 1.16-1.58). . CONCLUSION: Husbands' involvement in the district is low. Women's engagement in community networks aimed at increasing the knowledge of the women may involve in family planning. In addition, due focus among health care providers in lower health care units to provide information for both women and men might have a promising power to improve husbands involvement.
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  10. 60
    Peer Reviewed

    Factors Associated with Postpartum Use of Long-Acting Reversible Contraception.

    Oduyebo T; Zapata LB; Boutot ME; Tepper NK; Curtis KM; D'Angelo DV; Marchbanks PA; Whiteman MK

    American Journal of Obstetrics and Gynecology. 2019 Mar 15;

    BACKGROUND: Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception (LARC), including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low. OBJECTIVES: We sought to estimate prevalence of LARC use among postpartum women and examine factors associated with LARC use among those using any reversible contraception. STUDY DESIGN: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of LARC use in our sample (n=143,335). We examined maternal factors associated with LARC use among women using reversible contraception (n=97,013) using multivariable logistic regression (LARC versus other type of reversible contraception) and multinomial regression (LARC versus other hormonal contraception and LARC versus other non-hormonal contraception). RESULTS: The prevalence of LARC use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported LARC use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum LARC use versus use of another reversible contraceptive method included: age 35 years (AOR = 0.87; 95 % CI = 0.80-0.96) versus 25-34 years; public insurance (AOR = 1.15; 95% CI = 1.08-1.24) and no insurance (AOR = 0.73; 95% CI = 0.55-0.96) versus private insurance at delivery; having a recent unintended pregnancy (AOR = 1.44; 95% CI=1.34-1.54) or being ambivalent about the recent pregnancy (AOR = 1.29; 95% CI=1.18-1.40) versus recent pregnancy intended; having >/=1 previous live birth (AOR = 1.40; 95% CI = 1.31-1.48) and having a postpartum check-up after recent live birth (AOR = 2.70; 95% CI = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of LARC use (26.6% and 23.4% respectively) compared to non-Hispanic white women (21.5%),and there was significant race/ethnicity interaction with educational level. CONCLUSIONS: Nearly one in six (15.3%) postpartum women with a recent live birth and nearly one in four (22.5%) postpartum women using reversible contraception reported LARC use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum LARC use. Ensuring all postpartum women have access to the full range of contraceptive methods, including LARC, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of LARC (and other methods), as well as providing full reimbursement for contraceptive services, and removal of administrative and logistic barriers. Copyright (c) 2019. Published by Elsevier Inc.
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  11. 61
    Peer Reviewed

    Use of maternal health services among women in the ethnic rural areas of western China.

    Wu Y; Zhou H; Wang Q; Cao M; Medina A; Rozelle S

    BMC Health Services Research. 2019 Mar 19; 19(1):179.

    BACKGROUND: The use of maternal health services can markedly promote the maternal health and safety, but there has been a low utilization rate in the ethnic rural areas of western China. Furthermore, the correlated factors have not been well studied. This study aims to assess factors related to the use of maternal health services among women in these areas. METHODS: A cross-sectional study of 68 villages in China's western Sichuan province was conducted in September 2014. All qualifying women from each sample village were involved. A structured questionnaire was administrated in households through face-to-face interviews by trained enumerators to obtain information of use of maternal health services and related factors. Structural equation modeling (SEM) was used to evaluate the direct and indirect relationships between use of maternal health services and correlated factors. RESULTS: A total of 760 women from 68 villages were enrolled. The proportion of antenatal care (ANC), hospital delivery and postpartum visits were 68.94, 48.29 and 28.42% respectively. The SEM analysis demonstrated that social economic status (SES) (beta= - 0.75, beta< 0.01), ANC (beta=0.13, beta< 0.01), and time from home to the nearest hospital (beta= - 0.09, beta< 0.05), were positively correlated to hospital delivery and postpartum care visits, while maternal care knowledge and perceived quality of hospital care did not have direct correlation. For ANC, SES (beta= - 0.36, beta< 0.01), time from home to the nearest hospital (beta= - 0.13, beta< 0.05), knowledge on maternal care (beta=0.12, beta< 0.01) and perceived quality of hospital care (beta=0.10, beta< 0.01) were all directly correlated factors. Treating ANC as an intermediate variable showed the indirect relationship that perceived quality of hospital care (beta=0.01, beta< 0.01) and maternal care knowledge (beta=0.02, beta< 0.01) had with hospital delivery and postpartum care rates. CONCLUSIONS: Use of maternal health services is low among women in ethnic rural areas. ANC has important direct and intermediate effects on subsequent use of hospital delivery and postpartum care. Improving ANC behavior should be a priority of maternal health care reforms. Given the long travel times for these women, reforms must also prioritize breaking down practical barriers that prevent this population from accessing care.
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  12. 62
    Peer Reviewed

    A cross-sectional mixed-methods study of sexual and reproductive health knowledge, experiences and access to services among refugee adolescent girls in the Nakivale refugee settlement, Uganda.

    Ivanova O; Rai M; Mlahagwa W; Tumuhairwe J; Bakuli A; Nyakato VN; Kemigisha E

    Reproductive Health. 2019 Mar 19; 16(1):35.

    BACKGROUND: Humanitarian crises and migration make girls and women more vulnerable to poor sexual and reproductive health (SRH) outcomes. Nevertheless, there is still a dearth of information on SRH outcomes and access to SRH services among refugee girls and young women in Africa. We conducted a mixed-methods study to assess SRH experiences, knowledge and access to services of refugee girls in the Nakivale settlement, Uganda. METHODS: A cross-sectional survey among 260 adolescent girls 13-19 years old was conducted between March and May 2018. Concurrently, in-depth interviews were conducted among a subset of 28 adolescents. For both methods, information was collected regarding SRH knowledge, experiences and access to services and commodities. The questionnaire was entered directly on the tablets using the Magpi(R) app. Descriptive statistical analysis and multinomial logistic regression were performed. Qualitative data was transcribed and analysed using thematic content analysis. RESULTS: A total of 260 participants were interviewed, with a median age of 15.9 years. The majority of girls were born in DR Congo and Burundi. Of the 93% of girls who had experienced menstruation, 43% had ever missed school due to menstruation. Regarding SRH knowledge, a total of 11.7% were not aware of how HIV is prevented, 15.7% did not know any STI and 13.8% were not familiar with any method to prevent pregnancy. A total of 30 girls from 260 were sexually active, of which 11 had experienced forced sexual intercourse. The latter occurred during conflict, in transit or within the camp. A total of 27 of 260 participants had undergone female genital mutilation (FGM). The most preferred sources for SRH information was parents or guardians, although participants expressed that they were afraid or shy to discuss other sexuality topics apart from menstruation with parents. A total of 30% of the female adolescents had ever visited a SRH service centre, mostly to test for HIV and to seek medical aid for menstrual problems. CONCLUSIONS: Adolescent refugee girls lack adequate SRH information, experience poor SRH outcomes including school absence due to menstruation, sexual violence and FGM. Comprehensive SRH services including sexuality education, barrier-free access to SRH services and parental involvement are recommended.
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  13. 63
    Peer Reviewed

    Young Women's Perspectives About the Contraceptive Counseling Received During Their Emergency Contraception Visit.

    Biggs MA; Kimport K; Mays A; Kaller S; Berglas NF

    Women's Health Issues. 2019 Mar - Apr; 29(2):170-175.

    OBJECTIVES: Research aimed at understanding women's experiences accessing emergency contraception (EC) services and the extent to which providers support women's autonomous contraceptive decision making is limited. This study explores young women's experiences with contraceptive counseling when accessing EC at family planning specialty clinics that serve young adult and adolescent patients. METHODS: We conducted 22 in-depth telephone interviews with women ages 15-25 years who had recently accessed EC at two San Francisco Bay Area youth-serving clinics about their thoughts and experiences using and accessing contraception. We analyzed transcripts thematically, using inductive qualitative analytic methods to identify patterns across the interviews. RESULTS: Most respondents described their recent clinic visit to access EC positively. Specifically, they expressed appreciation about receiving comprehensive information about other methods of contraception without pressure, judgment, or the expectation that they adopt a particular method. They also pointed to the influence of prior health care experiences in which they felt pressured or judged, leading them to avoid accessing future reproductive health services. CONCLUSIONS: We found that young women seeking EC appreciated learning about other contraceptive methods, but do not want to feel pressured to adopt a method in addition to EC. Findings highlight the importance of respecting young women's contraceptive decisions for building and maintaining provider trust and suggest that contraceptive counseling approaches that prioritize specific methods may reduce some young women's trust in providers and use of reproductive health services. Copyright (c) 2018 The Authors. Published by Elsevier Inc. All rights reserved.
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  14. 64

    [Long-acting reversible contraception methods in the Brazilian Unified National Health System: the debate on women's (in)discipline]. Metodos contraceptivos reversiveis de longa duracao no Sistema Unico de Saude: o

    Brandao ER

    Ciencia and Saude Coletiva. 2019 Mar; 24(3):875-879.

    Recently, the Brazilian Federation of Gynecology and Obstetrics Associations submitted a request to the Brazilian Ministry of Health for an introduction of long-acting reversible contraception (LARC) methods for young women aged 15 to 19 years in the Brazilian Unified National Health System. The two devices to be included were the etonogestrel-releasing subdermal implant (ENG implant), with a duration of three years, and the levonorgestrel-releasing intrauterine system (LNG-IUS), lasting five years. The Ministry of Health then launched a public inquiry to evaluate this introduction, deciding against the inclusion of these methods in the public health services. The article discusses the discursive strategies used to justify the acceptance and applicability of these methods in "special populations." The debate on family planning needs to understand fully the discontinuity of contraception in the use of such methods, the central concept of emergency contraception, and how gender hierarchies prejudice safe contraceptive practice. On the contrary, the emphasis on the (in)discipline of women regarding care with regular-use contraceptive methods effectively reinforces their condition of social minority.
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  15. 65
    Peer Reviewed

    Factors associated with condom use with non-commercial partners among sexually-active transgender women in Cambodia: findings from a national survey using respondent-driven sampling.

    Yi S; Plant A; Tuot S; Mun P; Chhim S; Chann N; Chhoun P; Brody C

    BMC Public Health. 2019 Mar 20; 19(1):326.

    BACKGROUND: Globally, the prevalence of HIV among transgender women is much higher than that of the general adult population. This can be explained by the persistently low rate of consistent condom use among this population. This study was therefore conducted to explore factors associated with consistent condom use among sexually-active transgender women in Cambodia, specifically with their non-commercial partners. METHODS: Data used for this study were collected as part of the National Integrated Biological and Behavioral Survey 2016. Participants were recruited from the capital city of Phnom Penh and 12 other provinces with high burden of HIV using the Respondent-Driven Sampling (RDS) method. Face-to-face interviews were conducted using a structured questionnaire. Weighted multivariate logistic regression analysis was conducted to explore independent factors associated with consistent condom use. RESULTS: This study included 1202 transgender women who reported having anal sex with at least one male partner not in exchange for money or gifts in the past three months. The mean age of the participants was 26.0 (SD = 7.0) years. Of the total, 41.5% reported always using condoms with male non-commercial partners in the past three months. After adjustment, the likelihood of consistent condom use was significantly higher among participants who resided in an urban community (AOR = 1.7, 95% CI = 1.1-2.6), had attained at least 10 years of formal education (AOR = 1.8, 95% CI = 1.2-2.7), perceived that they were likely or very likely to be HIV infected (AOR = 2.9, 95% CI = 2.0-4.1), reported drinking alcohol two to three times per week (AOR = 3.1, 95% CI = 1.1-8.3), reported using amphetamine-type stimulants (AOR = 1.9, 95% = 1.1-3.8) or other drugs (AOR = 7.6, 95% CI = 1.5-39.5), and reported inconsistent condom use with male commercial partners in the past three months (AOR = 4.3, 95% CI = 1.8-10.4) compared to that of their respective reference group. CONCLUSIONS: This study confirms the low rates of condom use, particularly in non-commercial relationship, among transgender women in Cambodia. To address these concerns, efforts towards education about effects of multiple, concurrent relationships, and inconsistent condom use should be reinforced among transgender women.
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  16. 66

    The use of long-acting reversible contraceptives in Latin America and the Caribbean: current landscape and recommendations.

    Bahamondes L; Villarroel C; Frias Guzman N; Oizerovich S; Velazquez-Ramirez N; Monteiro I

    Human Reproduction Open. 2018; 2018(1):hox030.

    STUDY QUESTION: Can the high rate and associated burden of unintended pregnancy (UP) and adolescent pregnancy in Latin America and the Caribbean (LAC) be reduced through wider access to and use of long-acting reversible contraceptive (LARC) methods? SUMMARY ANSWER: Studies show that impoved access to and use of LARC methods is an effective tool for reducing the high rates of UP, unsafe abortion and abortion-related complications, and maternal deaths (as well as reducing their social and financial burden), and we have provided recommendations to help achieve this in LAC. WHAT IS KNOWN ALREADY: LAC comprises 46 countries with 650 million inhabitants, and shows large disparities in socioeconomic development, access to health services and attention to sexual and reproductive health rights. The exercise of these rights and universal access to sexual and reproductive health (SRH) programmes is a key strategy for improving maternal health by reducing the number of UPs, the rate of women's and child mortality and morbidity, and the number of unsafe abortions. The implementation of SRH programmes in the region has contributed to a decrease in pregnancy rates of more than 50% over 40 years. However, despite this progress, the numbers of UP and adolescent pregnancies are still among the highest worldwide, which can be attributed in large part to the low prevalence of use of LARC methods. STUDY DESIGN SIZE DURATION: This is a position paper with the objective of reviewing the magnitude and burden of UP in LAC, as well as available LARC methods and barriers to their access, with the goal of increasing knowledge and awareness among healthcare professionals (HCP), policymakers and the general public about the potential to reduce UP rates through the increased use of LARC. PARTICIPANTS/MATERIALS SETTING METHOD: We searched the electronic databases of PubMed and EMBASE to identify studies published up to May 2017. We also searched for websites regarding LAC, LARC methods, and UP including, for example, those from the United Nations, the World Health Organization, Pan American Health Organization, the Alan Guttmacher Institute and the United States Agency for International Development. Studies were included if they investigated mainly UP and their consequences as well as the use of LARC methods in the region. During 3 days of meetings, the importance of the studies identified and the appropriateness of inclusion were discussed. MAIN RESULTS AND THE ROLE OF CHANCE: LAC is not one unit and shows great ethnic diversity as well as economic and cultural differences among the various countries. These differences must be taken into account when developing policies related to disseminating information and combatting misinformation regarding the use of LARC among different audiences, such as adolescents and young women, nulligravidas, indigenous populations and women with disabilities. Furthermore, only some governments have made efforts to increase accessibility to LARC methods, and there is a need to implement training programmes for HCPs, launch education campaigns for the general public, increase access and review the cost-benefit analyses specific to LARC, which have already demonstrated that the upfront cost of LARC is less than the cummulative expense of short-term contraceptives. Recommendations to achieve these goals are presented. LIMITATIONS REASONS FOR CAUTION: Knowledge and awareness of the contraceptive method itself and of the mix of individual countries in the region is essential to the development of specific strategies and actions, tailored to each particular country situation, aimed at increasing access to modern contraceptive methods, especially LARC. WIDER IMPLICATIONS OF THE FINDINGS: Healthcare systems in LAC should consider LARC as a primary option for decreasing UP and adolescent pregnancy. Disseminating information, increasing awareness of their efficacy, removing barriers and improving access to LARC methods are the urgent actions recommended for government, academia, professional organizations, insurance companies and policymakers in order to address this major public health problem in LAC. STUDY FUNDING/COMPETING INTERESTS: This manuscript was supported by a grant from the Americas Health Foundation (AHF), a 501(c)3 nonprofit organization dedicated to improving healthcare throughout the Latin American Region. LB and IM received additional support from the Sao Paulo Research Foundation (FAPESP) award # 2015/20504-9. The authors declare no conflict of interest.
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  17. 67
    Peer Reviewed

    Sociodemographic Factors Associated with the Knowledge and Use of Birth Control Methods in Adolescents before and after Pregnancy.

    Samano R; Martinez-Rojano H; Chico-Barba G; Sanchez-Jimenez B; Sam-Soto S; Rodriguez-Ventura AL; Mejia-Luna L; Sclavo-Melo S

    International Journal of Environmental Research and Public Health. 2019 Mar 20; 16(6)

    Adolescent pregnancy rates are high worldwide. However, insufficient information exists regarding the frequency of birth control methods used before the first pregnancy and postpartum. In the current study, we analyzed the association of sociodemographic factors with the knowledge of birth control methods and their use before and after pregnancy in a sample of adolescents in Mexico City. A cohort study was conducted on 600 pregnant adolescents in Mexico City, from 2013 to 2017, at a health care institution providing prenatal care. Participants were assessed during the second trimester and four months postpartum. The questionnaire explored the knowledge of birth control methods, their use, and other associated factors. Two logistic regression models were implemented to identify potential variables associated with the lack of birth control method use before and after pregnancy. The mean age of participants was 15.4 + 1 years, of which, 48% and 65.2% used a birth control method before pregnancy and postpartum, respectively. We found that the main factors associated with increased risk of not using any birth control method before pregnancy included being under the age of 15 years, school dropout, having an educational lag, initiation of sexual life before the age of 15, and having a mother who did not inform their child about contraceptives. By contrast, variables associated with a higher risk of not using any contraceptive methods after pregnancy included educational lag, lower level of education, and the fact that the adolescent had not used any birth control prior to the pregnancy.
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  18. 68
    Peer Reviewed

    Intrauterine Contraception: Knowledge and Prescribing Practices of Canadian Health Care Providers.

    Cook J; Waddington A; Black D; Costescu D; Desjardins D; Duchesne E; LeBoeuf M; Malhotra U; Fisher W

    Journal of Obstetrics and Gynaecology Canada. 2019 Mar 18;

    OBJECTIVE: Contraception is an important issue in the lives of women, their partners, and society. Canadians and their health care providers play a critical role in contraceptive decision making that influences individuals and Canadian society. The purpose of this study was to gather data on contraception-related knowledge, counselling, and prescribing practices of Canadian health care providers. METHODS: This project reported on the outcomes of an educational initiative, designed as a quality improvement initiative (time series level II-3), focused on Canadian health care providers' contraception-related knowledge, counselling, and prescribing practices. Outcomes were intended to inform the development of tools, resources, and educational programming. Part 1 was an online program to identify educational and knowledge gaps for health care providers. Part 2 was a practice assessment exploring and measuring health care providers' contraceptive counselling and prescribing practices. RESULTS: A total of 4300 health care providers completed the program between July 6, 2015 and August 30, 2016. Knowledge significantly increased; post-test scores were higher than pretest scores. After completion, all participants felt more comfortable, knowledgeable, and inclined to change their practice around prescribing intrauterine contraception (IUC). The 4300 providers reported on their contraception counselling experiences with 10 patients following participation in Part 1. Forty percent of patients were using oral contraceptives, and 53% were dissatisfied with their current type of contraception. After counselling, patients reported being most comfortable with IUC (55%). Both short- and long-acting types of contraception were most often discussed or offered (74% of the time), followed by long-acting reversible contraception only (21%) and short-acting methods only (5%). CONCLUSION: This training program filled an education need for patients and gave providers tools to change their behaviour and practice around IUC prescribing. On the basis of these data, a practice assessment model was deemed a successful way to change behaviour. Copyright (c) 2019. Published by Elsevier Inc.
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  19. 69
    Peer Reviewed

    The Lactational effects of contraceptive hormones: an evaluation (LECHE) study.

    Bryant AG; Bauer AE; Muddana A; Wouk K; Chetwynd E; Yourkavitch J; Stuebe AM

    Contraception. 2019 Mar 18;

    OBJECTIVE: To estimate the proportion of women for whom use of hormonal contraception was associated with reporting a decreased breast milk supply. STUDY DESIGN: The Lactational Effects of Contraceptive Hormones: an Evaluation ("LECHE") Study was an anonymous, internet-based, exploratory, cross-sectional survey of postpartum women using approximately 70 questions. Women were eligible to participate in the survey if they were 18years or older, had a singleton infant between 3 and 9months of age, had breastfed this infant for any amount of time, and could read English. The survey included questions about breastfeeding, reproductive health, and demographic characteristics, and the timing of postpartum events. RESULTS: A total of 3971 participants clicked on the survey. Our final study population included 2922 participants. Overall, 1201 (41%) reported having had milk supply concerns at some point in the first 12weeks postpartum. The median time from birth until milk supply concerns was 3weeks (IQR 1, 7). Eight hundred fifty-two women (29%) started hormonal contraception in the first 12weeks postpartum. Fifteen percent (127/852) of women reported new or additional milk supply concerns after starting hormonal contraception. Reported milk supply concerns were higher for women who used hormonal contraception than those who did not (44% vs 40%; p=.05) Adjusted hazard ratios assessing the association between contraceptive use and time to milk supply concerns were not statistically significant (HR 1.18, 95% CI 0.94-1.47 for any type of hormonal contraception). CONCLUSIONS: This study found a slightly increased proportion of reported milk supply concerns among women who started hormonal contraception. IMPLICATIONS: It is important for caregivers in the postpartum period to recognize the potential for multiple factors, including initiation of hormonal contraception, to affect breastfeeding. Patient-centered counseling can help elicit women's values and preferences regarding breastfeeding and pregnancy prevention. Copyright (c) 2019. Published by Elsevier Inc.
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  20. 70
    Peer Reviewed

    Opportunistic salpingectomy during postpartum contraception procedures at elective and unscheduled cesarean delivery.

    Ferrari F; Forte S; Prefumo F; Sartori E; Odicino F

    Contraception. 2019 Mar 18;

    OBJECTIVE: To compare intra- and postoperative surgical complications of opportunistic bilateral total salpingectomy during postpartum permanent contraception procedures in elective and unscheduled cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study (2010-2017) of women who had postpartum permanent contraception procedures during cesarean delivery and we collected baseline characteristics, scheduling of delivery (elective versus unscheduled), operative time, estimated blood loss (EBL) and surgical complications (bleeding, iatrogenic injury, infection, anemia and re-laparotomy). We classified patients according to contraceptive technique: bilateral total salpingectomy, bilateral partial salpingectomy with or without fimbriae, and other methods. RESULTS: Five hundred twenty-eight women underwent postpartum permanent contraception procedures, 245 (46.4%) had bilateral total salpingectomy, 239 (45.3%) had bilateral partial salpingectomy and 48 (8.3%) underwent other methods. We did not find differences in baseline characteristics, operative time and EBL among postpartum permanent contraception groups. Unscheduled cesarean delivery did not influence the choice of postpartum permanent contraception technique (p=.22). Postpartum permanent contraception-related intraoperative bleeding occurred in 1 (0.4%) and 2 (0.9%) patients, respectively in bilateral total and partial salpingectomy group (p=.23). Postoperative complications were 13 (5.3%) and 6 (2.5%), respectively in bilateral total and partial salpingectomy groups (p=.11). Subgroup analysis confirmed no differences for intra- and postoperative complications during unscheduled cesarean delivery. We noted a 4.3min increase in operative time for total salpingectomy after multivariate analysis (p<.01). CONCLUSION: At maternal request for postpartum permanent contraception during cesarean delivery, bilateral total salpingectomy can be a safe and feasible method even in case of unscheduled cesarean delivery. Implications statement. Our results suggest that bilateral total salpingectomy during any cesarean delivery may be an acceptable choice for its higher contraceptive efficacy and risk-reduction effect for ovarian cancer, at the price of a small increase in operative time. Copyright (c) 2019. Published by Elsevier Inc.
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  21. 71
    Peer Reviewed

    Impact of the contraceptive implant on maternal and neonatal morbidity and mortality in rural Papua New Guinea: a retrospective observational cohort study.

    Gupta S; Ramsay P; Mola G; McGeechan K; Bolnga J; Kelly-Hanku A; Black KI

    Contraception. 2019 Mar 18;

    OBJECTIVES: Using routinely collected birth data, this study sought to measure changes in maternal and neonatal morbidity and mortality after introduction of the levonorgestrel contraceptive implant into a large, rural island population in Papua New Guinea (PNG). STUDY DESIGN: We conducted a retrospective observational study of birth records from 4251 births that occurred between January 2010 and December 2016 on Karkar Island, PNG. The primary outcome was the change in Crude Birth Rate (CBR) before (2010-2012) and after (2014-2016) introduction of the implant. Secondary outcomes were the change in rates (per year/1000 births) of severe post-partum hemorrhage, postpartum infection, hospital readmission, prematurity (<37weeks), low birth weight (<2500g) and maternal and neonatal mortality. We also studied changes in the number of pregnancies affected by grand-multiparity (>/=4) and short inter-pregnancy interval (<12months) for the same time periods. Data were analyzed using interrupted time series and Poisson regression. RESULTS: CBR was stable until 2012 then declined from 2014 (p<.0001). Following introduction of the implant the annual rate/1000 births of selected adverse birth outcomes decreased between 56% and74% (p<.0001). The number of women with parity>/=4 who gave birth decreased by 59% (p<.0001) and the number with inter-pregnancy interval<12months decreased by64% (p<.0001). CONCLUSIONS: Introduction of the contraceptive implant was associated with reductions in CBR, maternal and neonatal morbidity and in the number of women with high risk pregnancies giving birth. IMPLICATIONS: These results encourage efforts to increase knowledge and availability of the contraceptive implant in low and middle income countries such as PNG. In cases where it reduces the CBR and the number of women with high-risk pregnancies birthing, the implant may have a beneficial impact on maternal and neonatal morbidity. Copyright (c) 2019. Published by Elsevier Inc.
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  22. 72

    Update on male hormonal contraception.

    Gava G; Meriggiola MC

    Therapeutic Advances in Endocrinology and Metabolism. 2019; 10:2042018819834846.

    Despite increases in female contraceptive options, 40-45% of pregnancies across the world are still unplanned. While several effective female contraceptive methods have been developed, contraceptive choices for men are still limited to the male condom with its high failure rates and to vasectomies, which are invasive and not reliably reversible. Several studies have demonstrated a great interest among men and women for effective, reversible, and safe male contraceptive methods. Over the years, numerous studies have been performed to develop male hormonal and nonhormonal safe and effective contraceptives. A variety of new molecules are under development as oral or transdermal hormonal contraceptives for men demonstrating few side effects. In our overpopulated world, the development and commercialization of a male contraceptive method that will allow both men and women to take an active role in family planning is mandatory and further research on this topic is required.
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  23. 73
    Peer Reviewed

    The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia.

    Johns B; Hangoma P; Atuyambe L; Faye S; Tumwine M; Zulu C; Levitt M; Tembo T; Healey J; Li R; Mugasha C; Serbanescu F; Conlon CM

    Global Health, Science and Practice. 2019 Mar 11; 7(Suppl 1):S104-S122.

    The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative-a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality-in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia. (c) Johns et al.
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  24. 74

    Mega Hpv laboratories for cervical cancer control: Challenges and recommendations from a case study of Turkey.

    Gultekin M; Karaca MZ; Kucukyildiz I; Dundar S; Keskinkilic B; Turkyilmaz M

    Papillomavirus Research. 2019 Mar 13;

    Cervical cancer is the fourth most common cancer among women in the world. It is estimated that one woman dies every 2min from cervical cancer. Nearly all cervical cancers are preventable by early detection and treatment through screening or HPV vaccination. In 2018, World Health Organization (WHO) made a global call for action toward the elimination of cervical cancer. Cervical cancer screening involves a complex organized program, which begins with a call/recall system based on personal invitation of eligible women, followed by participation in screening, and leading to diagnosis, treatment, and management as appropriate. An effective cervical screening program with high coverage is dependent on each country's infrastructure and human resource capacity. Efforts to develop an effective program is particularly challenging in low and middle income countries (LMIC) where resources are limited. For an effective strategy, Turkey redesigned the country's cervical screening program. The local call/recall system and centralized monitoring system of individual women were re-vamped with an automated evaluation system. The revised screening program includes the use of primary HPV testing with a well-defined protocol outlining the algorithms of management (i.e., screening intervals and referral), a single nationwide centralized diagnostic laboratory, and a sustainable agreement with the HPV diagnostics industry. This system allows for traceable, real-time monitoring of screening visits and specimens. Turkey reports on the first four years of this re-vamped organized program and shares lessons learnt from the implementation of this new program. Copyright (c) 2019. Published by Elsevier B.V.
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  25. 75
    Peer Reviewed

    Maximizing adherence and retention for women living with HIV and their infants in Kenya (MOTIVATE! study): study protocol for a randomized controlled trial.

    Odeny TA; Onono M; Owuor K; Helova A; Wanga I; Bukusi EA; Turan JM; Abuogi LL

    Trials. 2018 Jan 29; 19(1):77.

    BACKGROUND: Successful completion and retention throughout the multi-step cascade of prevention of mother-to-child HIV transmission (PMTCT) remains difficult to achieve. The Mother and Infant Visit Adherence and Treatment Engagement study aims to evaluate the effect of mobile text messaging, community-based mentor mothers (cMMs), or both on increasing antiretroviral therapy (ART) adherence, retention in HIV care, maternal viral load suppression, and mother-to-child HIV transmission for mother-infant pairs receiving lifelong ART. METHODS/DESIGN: This study is a cluster randomized, 2 x 2 factorial, controlled trial. The trial will be undertaken in the western Kenyan counties of Migori, Kisumu, and Homa Bay. Study sites will be randomized into one of four groups: six sites will implement both text messaging and cMM, six sites will implement cMM only, six sites will implement text messaging only, and six sites will implement the existing standard of care. The primary analysis will be based on the intention-to-treat principle and will compare maternal ART adherence and maternal retention in care. DISCUSSION: This study will determine the impact of long-term (up to 12 months postpartum) text messaging and cMMs on retention in and adherence to ART among pregnant and breastfeeding women living with HIV in Kenya. It will address key gaps in our understanding of what interventions may successfully promote long-term retention in the PMTCT cascade of care. TRIAL REGISTRATION:, NCT02491177 . Registered on 11 March 2015.
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