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How culture shapes the sexual and reproductive health practices among adolescent girls in Eastern Equatoria, South Sudan.
South Sudan Medical Journal. 2018 Aug; 11(3):56-59.Background: From 2011 to 2014, a programme aimed to improve sexual and reproductive health practices among adolescent girls was implemented by the non-governmental organization BRAC in partnership with the Government of South Sudan and with funding from the World Bank. The distinctive culture and norms in South Sudan offered unique challenges to the implementation of such a programme, which this study sought to explore. Objectives: This study investigated the sexual and reproductive health (SRH) behaviour of women and men in Eastern Equatoria State to identify the social norms and beliefs that affect communities’ perception and behaviour regarding SRH issues. Methods: Data were gathered from seven key informant interviews and nine focus groups of adult women and men and adolescent girls and boys in Torit and Magwi Counties in Eastern Equatoria. Results: The study found a strong cultural preference for girls to demonstrate their fertility by beginning to have children at an early age (13–16 years) and to have many children (8–12). It also found that education on HIV/AIDS had been effective. Conclusions: To be effective in South Sudan, adolescent sexual and reproductive health programmes must take the current social norms and practices into account and learn from the successes of HIV/AIDS education programmes.
South Sudan Medical Journal. 2018 Aug; 11(3):60-64.Introduction: In South Sudan, diarrhoeal diseases are leading causes of mortality and morbidity among young children. Objective: To assess mothers’ knowledge, attitudes and practices (KAP) on how to prevent diarrhoea among under-five year old children at the United Nation’s Mission in South Sudan Protection of Civilian Sites in Juba. Methods: A cross-sectional study was conducted in August 2017 using a four stage sampling technique and analysed using EpiData version 3.1 and SPSS version 20. Results: A total of 410 mothers (98.6% of the selected sample) responded to the study questionnaire; 45.6% were aged 25-34 years, 52.7% were illiterate, 93.9% were housewives, and 84.6% had no source of income. The majority (62%) had a ‘low’ knowledge, 65.4% had positive attitudes and 57.8% had ‘poor’ practices; significant associations were observed between: age and attitude, knowledge and education, practices and education, and diarrhoea and income. Conclusion: Many mothers need more knowledge and better attitudes and practices to be able to prevent and manage their children’s diarrhoea. The associations between knowledge, attitudes and practices all indicate the need for increased education and schooling of South Sudanese women and girls.
Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: a mixed methods case study.
BMC Pregnancy and Childbirth. 2018; 18(325):12 p.Background: Targeted clinical interventions have been associated with a decreased risk of neonatal morbidity and mortality. In conflict-affected countries such as South Sudan, however, implementation of lifesaving interventions face barriers and facilitators that are not well understood. We aimed to describe the factors that influence implementation of a package of facility- and community-based neonatal interventions in four displaced person camps in South Sudan using a health systems framework. Methods: We used a mixed method case study design to document the implementation of neonatal interventions from June to November 2016 in one hospital, four primary health facilities, and four community health programs operated by International Medical Corps. We collected primary data using focus group discussions among health workers, in-depth interviews among program managers, and observations of health facility readiness. Secondary data were gathered from documents that were associated with the implementation of the intervention during our study period. Results: Key bottlenecks for implementing interventions in our study sites were leadership and governance for comprehensive neonatal services, health workforce for skilled care, and service delivery for small and sick newborns. Program managers felt national policies failed to promote integration of key newborn interventions in donor funding and clinical training institutions, resulting in deprioritizing newborn health during humanitarian response. Participants confirmed that severe shortage of skilled care at birth was the main bottleneck for implementing quality newborn care. Solutions to this included authorizing the task-shifting of emergency newborn care to mid-level cadre, transitioning facility-based traditional birth attendants to community health workers, and scaling up institutions to upgrade community midwives into professional midwives. Additionally, ongoing supportive supervision, educational materials, and community acceptance of practices enabled community health workers to identify and refer small and sick newborns. Conclusions: Improving integration of newborn interventions into national policies, training institutions, health referral systems, and humanitarian supply chain can expand emergency care provided to women and their newborns in these contexts.
Barriers Faced by the Health Workers to Deliver Maternal Care Services and Their Perceptions of the Factors Preventing Their Clients from Receiving the Services: A Qualitative Study in South Sudan.
Maternal and Child Health Journal. 2018 Nov; 22(11):1598-1606.Objective The study objective was to explore challenges and barriers confronted by maternal and child healthcare providers to deliver adequate quality health services to women during antenatal care visits, facility delivery and post-delivery care. Methods We conducted 18 in-depth-interviews with maternal and child health professionals including midwives/nurses, trained traditional birth attendants (TBAs), gynecologists, and pediatricians in three public health facilities in Juba, South Sudan. We purposively selected these health professionals to obtain insights into service delivery processes. We analyzed the data using thematic analysis. Results Limited support from the heath system, such as poor management and coordination of staff, lack of medical equipment and supplies and lack of utilities such as electricity and water supply were major barriers to provision of health services. In addition, lack of supervision and training opportunity, low salary and absence of other forms of non-financial incentives were major elements of health workers' de-motivation and low performance. Furthermore, security instability as a result of political and armed conflicts further impact services delivery. Conclusions for Practice This study highlighted the urgent need for improving maternal and child healthcare services such as availability of medical supplies, equipment and utilities. The necessity of equal training opportunities for maternal and child healthcare workers at different levels were also stressed. Assurance of safety of health workers, especially at night, is essential for providing of delivery services.
Measles vaccination coverage among children aged (12-23) months in Marawi locality - Northern state, Sudan - 1026.
International Journal of Community Medicine and Public Health. 2018 Jun; 5(6):2195-2198.Background: Worldwide measles remains the fifth cause of mortality among children under 5 years. Immunization coverage is the proportion of individuals in the target population who are vaccinated. It is a key measure of immunization system performance. Coverage for measles in Eastern Mediterranean region in 2015 for MCV1 was 85%, and MCV2 was 61%. Methods: A total sample size of 462 mothers was determined according to WHO guidelines regarding coverage survey in (February - July 2016). Data were collected using a prepared and pretested questionnaire, reviewing cards of children, and interview with EPI personnel. Data were analyzed using SPSS version 20, p=0.05 was considered significant. Results: The majority of the children (96.1%) were vaccinated against MCV1, and (77.4%) were vaccinated against MCV2. Small group of mothers (5.7%) had a negative attitude towards immunization. Most mothers (94.3%) were satisfied with measles immunization services. More than half of mothers (55.7%) wait for <15 minutes to immunize their children. Most of the mothers (62.3%) went to the immunization centers by public transports. The main factors affecting vaccination coverage were: weakness of incentives, lack of means of transport for staff, poor working environment like: shortage of water, furniture and technological materials. Conclusions: The coverage with MCV1 was reaching the WHO elimination standards while the coverage of MCV2 was not; due to many factors that affected the vaccination coverage. The study recommends health education covering all aspects of immunization, improvement of the working environment, and availing outreach centers.
Sociodemographic and cultural determinants of seeking family planning knowledge and practice among a Sudanese community.
International Journal of Community Medicine and Public Health. 2018 Aug; 5(8):3248-3256.Background: About 214 million women in the reproductive age in the developing countries who need to prevent and plan for their pregnancy are not using methods of modern contraceptives. The aim of this study was to investigate the socio-demographic and cultural elements that inform the health-seeking behavior towards family planning among Sudanese women in Sharq-Alneel locality in the Sudan-Africa. Furthermore, the study aimed to identify individuals within Sudanese families, who predominantly interfered with the decision of the women in using of contraceptives for family planning. Methods: A cross-sectional community based study was conducted in September-2017 to February-2018 using structured questionnaire to 576 Sudanese women age of 15-49 years from 4 administrative units. A multistage cluster sampling technique was adopted. Binary and multinomial logistic regression models were used to analyze the results using SPSS version 22. Results: Women respondents were (57.1%), and (42.9%) from rural and urban areas respectively. Women (89.3%) of respondents were married for more than five years. A 381 (66%) women respondents were not using contraception at the time of the study. Women in rural areas were 0.9 less likely to obtain information from other sources than from PHC. There was significant association (p<0.001) between women’s educational level and awareness about contraception. Conclusions: Women use of contraception in Sharq-Alneel was low. Barrier to contraception use for majority of women was that they believe their healths are at risk for using modern contraceptives. There was also high prevalence of respondents’ husbands refused the use of contraceptives.
International Journal of Community Medicine and Public Health. 2018 Aug; 5(8):3220-3226.Background: Maternal health has been accounted as challenge to the public health policy makers around the globe, which has more commonly been threaten by the cultural and social forces. The aim of this study was to investigate the sociocultural determinants of health-seeking behavior of Sudanese women from Sharq-Alneel locality regarding the place of delivery. Methods: A cross-sectional community based study was conducted from June 2017- January 2018 using face-to-face structured questionnaire to 576 Sudanese women age of 15-49 years from 4 Administrative Units. A multistage cluster sampling technique was adopted. Binary and multinomial logistic regression models were used to analyse the results. Results: Rural women respondents were 329 (57%). A 147 (28.3%) of the studied population gave birth at home at least once. A 110 (20.8%) women respondents preferred delivery at home. Of those home deliveries, complications occurred to 42 (26.9%) compared to the one occurred to women 114 (73.1%) who delivered in health facility. Circumcision among respondents was 80.7% and had insignificant association with complications occurred during delivery. Multinomial analysis showed women with no education were 33.5 times more likely (O.R=33.5, CI=9.8-114.0, p<0.001), primary education (O.R=6.4, CI=2.7-15.2, p<0.001), secondary (O.R=4.9, CI=2.1-11.5, p<0.001) to seek home delivery compared to those who obtained university education. Financial reasons for delivering at home were were 11.5 (O.R=11.5, CI=2.5-53.7, P=0.002) times, while nearby (distance to health facility) as a reason for delivering at home were 3.7 (O.R=3.7, CI=1.1-13.0, P=0.04) times more likely relative to those who reported staff competency to influence delivering at health facility. Conclusions: Age, residence area, number of children, education, financial income, distance to health facility, and source of decision for women’s place of delivery were significant determinants of deliveries at home. Special attention is needed at community level for health education towards culture and believes affecting women’s decision on delivery at home. To promote reproductive health of women and improve quality of care giving by health personnel.
The system here isn't on patients' side- perspectives of women and men on the barriers to accessing and utilizing maternal healthcare services in South Sudan.
BMC Health Services Research. 2018 Jan 9; 18(1):10.BACKGROUND: In fragile and war-affected setting such as South Sudan, a combination of physical environmental, socioeconomic factors and healthcare's characteristic contributes to higher rates of home delivery attended by unskilled attendants. This study aims to understand the community members' experience, perceptions and the barriers in relation to accessing and utilizing maternal healthcare services in South Sudan. METHODS: We conducted in-depth one-on-one interview with 30 women and 15 men to investigate their perspectives on the barriers to access maternal and child health related services. We purposively selected women and their partners in this study. RESULTS: Our study revealed that inadequate quality of antenatal care services such as lack of essential medicine, supplies and tools was linked to individual's mothers dissatisfaction with the services they received. In addition, sudden onset of labor and lack of safety and security were important reasons for home delivery in this study. Furthermore, lack of transport as a result of a combination of long distance to a facility and associated costs either restricted or delayed women reaching the health facilities. CONCLUSIONS: Our study highlighted an urgent need for the government of South Sudan to implement security and safety measures in order to improved access to delivery service at night. Incorporating private transports to provide access to affordable and reliable transport services for pregnant and post-partum women is also important. Increasing the budget allocation for medicine and health supplies and improving management of medicine and supply chain logistics are essential.
Implications of insecticide resistance for malaria vector control with long-lasting insecticidal nets: a WHO-coordinated, prospective, international, observational cohort study.
Lancet. Infectious Diseases. 2018 Jun; 18(6):640-649.BACKGROUND: Scale-up of insecticide-based interventions has averted more than 500 million malaria cases since 2000. Increasing insecticide resistance could herald a rebound in disease and mortality. We aimed to investigate whether insecticide resistance was associated with loss of effectiveness of long-lasting insecticidal nets and increased malaria disease burden. METHODS: This WHO-coordinated, prospective, observational cohort study was done at 279 clusters (villages or groups of villages in which phenotypic resistance was measurable) in Benin, Cameroon, India, Kenya, and Sudan. Pyrethroid long-lasting insecticidal nets were the principal form of malaria vector control in all study areas; in Sudan this approach was supplemented by indoor residual spraying. Cohorts of children from randomly selected households in each cluster were recruited and followed up by community health workers to measure incidence of clinical malaria and prevalence of infection. Mosquitoes were assessed for susceptibility to pyrethroids using the standard WHO bioassay test. Country-specific results were combined using meta-analysis. FINDINGS: Between June 2, 2012, and Nov 4, 2016, 40 000 children were enrolled and assessed for clinical incidence during 1.4 million follow-up visits. 80 000 mosquitoes were assessed for insecticide resistance. Long-lasting insecticidal net users had lower infection prevalence (adjusted odds ratio [OR] 0.63, 95% CI 0.51-0.78) and disease incidence (adjusted rate ratio [RR] 0.62, 0.41-0.94) than did non-users across a range of resistance levels. We found no evidence of an association between insecticide resistance and infection prevalence (adjusted OR 0.86, 0.70-1.06) or incidence (adjusted RR 0.89, 0.72-1.10). Users of nets, although significantly better protected than non-users, were nevertheless subject to high malaria infection risk (ranging from an average incidence in net users of 0.023, [95% CI 0.016-0.033] per person-year in India, to 0.80 [0.65-0.97] per person year in Kenya; and an average infection prevalence in net users of 0.8% [0.5-1.3] in India to an average infection prevalence of 50.8% [43.4-58.2] in Benin). INTERPRETATION: Irrespective of resistance, populations in malaria endemic areas should continue to use long-lasting insecticidal nets to reduce their risk of infection. As nets provide only partial protection, the development of additional vector control tools should be prioritised to reduce the unacceptably high malaria burden. FUNDING: Bill & Melinda Gates Foundation, UK Medical Research Council, and UK Department for International Development. Copyright (c) 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
Qualitative evaluation of the Saleema campaign to eliminate female genital mutilation and cutting in Sudan.
Reproductive Health. 2018 Feb 17; 15(1):30.BACKGROUND: Female genital mutilation and cutting (FGM/C, herein FGM) is a widespread and harmful practice. The Government developed a national campaign in Sudan, called Saleema, to change social norms discouraging FGM. Saleema translates to being "whole", healthy in body and mind, unharmed, intact, pristine, and untouched, in a God-given condition. An interim evaluation was conducted using focus groups among Sudanese adults. The primary aim was to explore perceptions of the Saleema poster exemplars and to assess if the desired themes were being communicated. Secondary aims were to understand more about participants' information sources, values, and suggestions for the campaign broadly. METHODS: The Saleema campaign evaluation included four focus groups from each of the 18 states in Sudan (72 total). Participants were presented with three poster stimuli from the Saleema campaign and asked about the content and their reactions. Themes were coded inductively by concepts that arose through content in the transcripts. Codes were also reviewed in conjunction with themes from the broader Saleema evaluation framework. RESULTS: Participants reported the most common source of information or admiration was from local leaders who are responsive to a community, media-based outlets, and discussions among community members. Participants held high value for education, community solidarity, and/or religious devotion. Participants had positive opinions of Saleema and responded positively to the branding elements in the posters and the campaign as a whole. The most common suggestion was continued awareness. Advocacy, training, and posters were suggested to highlight the harms of FGM through leaders or in community settings. Individuals suggested that these activities target older women and individuals in rural villages. There was also a burgeoning theme of targeting youth for support of the campaign. DISCUSSION: The results of this focus group analysis demonstrate support for future Saleema campaign efforts promoting awareness and community engagement. The campaign could capitalize on partnerships with young people and those who are respected in the community (e.g., religious leaders) or continue promoting common values aligning with the support of education and community solidarity. Continuing campaign efforts have promise to decrease the harms of FGM in Sudan.
Seminars In Fetal and Neonatal Medicine. 2015 Oct; 20(5):321-5.The Millennium Development Goals (MDGs), agreed on by world leaders at a UN summit in 2000, set targets to achieve by 2015. MDGs 4 and 5 specifically focus on the health of women and children. Sudan is classified as having insufficient progress in achieving MDGs 4 and 5. Both local and international efforts are needed to improve maternal and perinatal mortality rates. Ultrasound is expected to have a positive impact on improving maternal and perinatal mortality. Copyright (c) 2015 Elsevier Ltd. All rights reserved.
Virology Journal. 2017 Jul 26; 14(1):142.BACKGROUND: Preeclampsia is a major health problem. Although, the pathophysiology of preeclampsia is not fully understood, there are recent studies on association between infections and preeclampsia. OBJECTIVE: The aim of the present study was to investigate the association between maternal seropositivity of rubella, Herpes simplex virus type 2 (HSV-2) and preeclampsia. METHOD: A case -controls study (90 women in each arm) was conducted at Saad Abualila Maternity Hospital, Khartoum, Sudan. The cases were women with preeclampsia and the controls were healthy pregnant women. Rubella and HSV-2 IgG antibodies were analysed in the maternal sera of all of the participants using ELISA. RESULTS: There was no significant difference in the age, parity and gestational age between the two groups. Maternal serum IgG seropositivity for rubella (92.2% vs. 34.4%, P < 0.001) and HSV-2 (87.8% vs. 57.8%, P < 0.001) were significantly higher in preeclampsia than in the controls. There was no significant difference in the maternal serum IgM seropositivity for rubella (3.3% vs. 2.2%, P = 0.650) and HSV-2 (2.2% vs. 1.1%, P = 0.560). All the IgM seropositive cases were IgG seropositive too. In binary logistic regression women with rubella (OR = 4.93; 95% CI = 2.082-11.692, P < 0.001) and HSV-2 (OR = 5.54; 95% CI = 2.48-12.38, P < 0.001) IgG seropositivity were at higher risk for preeclampsia. CONCLUSION: In the current study rubella and HSV-2 IgG seropositivity is associated with preeclampsia. Preventive measure should be implemented.
Factors Affecting Utilization of Family Planning Services in a Post-Conflict Setting, South Sudan: A Qualitative Study.
AIMS Public Health. 2015; 2(4):655-666.This study aims to explore and examine the conjectures surrounding the utilization of family planning services among currently married couples of childbearing age in Renk County. This study has adopted a qualitative method to collect data on factors affecting the utilization of family planning services through focus group discussions and in-depth interviews, in rural and urban areas of Renk County. It targeted married women, men as well as unmarried men and women. The researchers conducted nine focus group discussions and nine interviews at both Jelhak (rural setting) and Renk (urban setting). The results suggested that the people of Renk County prefer to have large families and therefore choose not to use family planning methods. The data collected was analyzed by means of thematic analysis. This included the construction of a thematic framework, coding, editing and categorization of available data as well as the creation of sub-themes. The result also suggested that perception is a main factor that affects utilization of family planning services with a majority of the people in Renk and Jelhak preferring to have many children in order to increase the family size for some reasons. These are linked to religion, social stigma and taboo that are attached to childless people or users of family planning methods for birth control purposes. The responses revealed some variation in perception between rural (Jelhak) and urban (Renk) areas. Respondents from Renk area reported that some people use family planning services for economic reasons that involve alleviation of financial difficulties and provision of better education when the family size is small. On the other hand, rural people from Jelhak perceive family planning to be socially un-acceptable. Furthermore, men and women of Jelhak reported that after each birth of a child, married couples avoid sexual relationship for a period of two years as means of family planning. Women of both Urban and Rural settings reported intentions to use conventional methods of family planning without the knowledge of their spouses.
Violence Against Women. 2018 Mar; 24(3):286-306.This qualitative study examined the "drivers" of intimate partner violence (IPV) against women in displacement to identify protective factors and patterns of risk. Qualitative data were collected in three refugee camps in South Sudan, Kenya, and Iraq ( N = 284). Findings revealed interrelated factors that triggered and perpetuated IPV: gendered social norms and roles, destabilization of gender norms and roles, men's substance use, women's separation from family, and rapid remarriages and forced marriages. These factors paint a picture of individual, family, community and societal processes that exacerbate women's risk of IPV in extreme conditions created by displacement. Implications for policy and practice are indicated.
How Narratives of Fear Shape Girls' Participation in Community Life in Two Conflict-Affected Populations.
Violence Against Women. 2018 Apr; 24(5):565-585.Numerous social factors shape girls' lives in conflict-affected settings, affecting their vulnerability to gender-based violence (GBV). Qualitative research methods were used to examine spaces of perceived safety and risk for girls living in two conflict-affected populations: camps in Ethiopia hosting primarily South Sudanese and Sudanese refugees and communities in eastern Democratic Republic of Congo. Three major themes emerged: (a) challenges around caregiver-child communication regarding development, sex, and sexual violence; (b) a typology of safe/risky spaces; and (c) the influence of male-dominated spaces on experiences and fear of GBV. The findings have implications for programs focused on reducing adolescent girls' vulnerability to violence within conflict-affected contexts.
Characteristics of female sexual dysfunctions and obstetric complications related to female genital mutilation in Omdurman maternity hospital, Sudan.
Reproductive Health. 2018 Jan 8; 15(1):7.Add to my documents.
Sexually transmitted infections other than HIV/AIDS among women of low socio-economic class attending antenatal clinics in Khartoum, Sudan.
International Journal of STD and AIDS. 2017 Jul; 28(8):781-787.Sexually transmitted infections (STIs) are major health threats affecting people globally; however, the burden of STIs is greatest in low-income countries. Since they are physiologically more vulnerable, women are mostly affected. The risk is increased dramatically during pregnancy leading to serious health complications that may affect the newborn. Underprivileged pregnant women attending antenatal clinics for routine checkups in displaced camps, a women's prison and several peripheral health centres were clinically and laboratory screened for trichomoniasis, chlamydial infections, gonorrhea and syphilis. A total of 426 women with an age range of 14-45 years were included. Clinical data, blood, cervical and vaginal swabs were collected. Conventional bacteriological and serological methods were applied. All attendees were HIV1/2-negative. The prevalence of Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae and Treponema pallidum infections was found to be 7.8%, 4.9%, 0% and 5%, respectively. Although vaginal discharge, among other symptoms, is known to be the most significant indicator for STIs, our identified positive predictive value was only 14.1%. We conclude that use of syndromic approach for diagnosing and treating attendees of antenatal settings is of low clinical value and many easily curable STIs will be overlooked. Consequently, trichomoniasis, chlamydial infection and syphilis prevailed widely among this population.
Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis.
BMC Pregnancy and Childbirth. 2017 Aug 29; 17(278):1-15.Background Maternity referral systems have been under-documented, under-researched, and under-theorized. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labor or complications until they reach an appropriate health facility. Methods This study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labor, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software. Results Once the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care. Conclusions Our findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.
The application of physiologically based pharmacokinetic modelling to assess the impact of antiretroviral-mediated drug–drug interactions on piperaquine antimalarial therapy during pregnancy.
Biopharmaceutics and Drug Disposition. 2017 Nov; 38(8):464-478.Antimalarial therapy during pregnancy poses important safety concerns due to potential teratogenicity and maternal physiological and biochemical changes during gestation. Piperaquine (PQ) has gained interest for use in pregnancy in response to increasing resistance towards sulfadoxine–pyrimethamine in sub-Saharan Africa. Coinfection with HIV is common in many developing countries, however, little is known about the impact of antiretroviral (ARV) mediated drug–drug interaction (DDI) on piperaquine pharmacokinetics during pregnancy. This study applied mechanistic pharmacokinetic modelling to predict pharmacokinetics in non-pregnant and pregnant patients, which was validated in distinct customised population groups from Thailand, Sudan and Papua New Guinea. In each population group, no significant differences in day 7 concentrations were observed during different gestational weeks (GW) (weeks 10–40), supporting the notion that piperaquine is safe throughout pregnancy with consistent pharmacokinetics, although possible teratogenicity may limit this. Antiretroviral-mediated DDIs (efavirenz and ritonavir) had moderate effects on piperaquine during different gestational weeks with a predicted AUCratio in the range 0.56–0.8 and 1.64–1.79 for efavirenz and ritonavir, respectively, over GW 10–40, with a reduction in circulating human serum albumin significantly reducing the number of subjects attaining the day 7 (post-dose) therapeutic efficacy concentrations under both efavirenz and ritonavir DDIs. This present model successfully mechanistically predicted the pharmacokinetics of piperaquine in pregnancy to be unchanged with respect to non-pregnant women, in the light of factors such as malaria/HIV co-infection. However, antiretroviral-mediated DDIs could significantly alter piperaquine pharmacokinetics. Further model refinement will include collation of relevant physiological and biochemical alterations common to HIV/malaria patients.
State of newborn care in South Sudan's displacement camps: a descriptive study of facility-based deliveries.
Reproductive Health. 2017 Nov 29; 14(1):161.BACKGROUND: Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. METHODS: We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. RESULTS: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2.32]), but other practices were not statistically different. Mothers' knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). CONCLUSIONS: Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries.
Abidjan, Côte d’Ivoire, African Development Bank, 2015 Dec. 34 p. (Working Paper Series No. 230)Based on the 2009 household surveys conducted in Sudan and South Sudan, the objective of this article is to analyse gender inequality for the young population aged 10 to 14 who should be at school. Although education is free in both countries, children’s enrolment at school is low especially for girls, many of them stay home performing domestic chores or have an economic activity particularly in rural areas. The bivariate probit model highlights the key role of the household head’s education, gender and poverty status in determining children’s schooling. Drawn on Pal (2004) who extended the Oaxaca-Blinder decomposition, we confirm that children’s activity in Sudan and South Sudan is strongly determined by the fact of being a girl or a boy. The article also provides some policy recommendations to address the issues of low school attendance and high gender inequality.
Using the Stop Transmission of Polio (STOP) Program to Develop a South Sudan Expanded Program on Immunization Workforce.
Journal of Infectious Diseases. 2017 Jul 01; 216(suppl_1):S362-S367.In 2009, the international Stop Transmission of Polio (STOP) program began supporting the Global Polio Eradication Initiative in the Republic of South Sudan to address shortages of human resources and strengthen acute flaccid paralysis surveillance. Workforce capacity support is provided to the South Sudan Expanded Program on Immunization by STOP volunteers, implementing partners, and non-governmental organizations. In 2013, the Polio Technical Advisory Group recommended that South Sudan transition key technical support from external partners to national staff as part of the Polio Eradication and Endgame Strategic Plan, 2013-2018. To assist in this transition, the South Sudan Expanded Program on Immunization human resources development project was launched in 2015. This 3-year project aims to build national workforce capacity as a legacy of the STOP program by training 56 South Sudanese at national and state levels with the intent that participants would become Ministry of Health staff on their successful completion of the project. (c) The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.
Monitoring Results in Routine Immunization: Development of Routine Immunization Dashboard in Selected African Countries in the Context of the Polio Eradication Endgame Strategic Plan.
Journal of Infectious Diseases. 2017 Jul 01; 216(suppl_1):S226-S236.Background: To monitor immunization-system strengthening in the Polio Eradication Endgame Strategic Plan 2013-2018 (PEESP), the Global Polio Eradication Initiative identified 1 indicator: 10% annual improvement in third dose of diphtheria- tetanus-pertussis-containing vaccine (DTP3) coverage in polio high-risk districts of 10 polio focus countries. Methods: A multiagency team, including staff from the African Region, developed a comprehensive list of outcome and process indicators measuring various aspects of the performance of an immunization system. Results: The development and implementation of the dashboard to assess immunization system performance allowed national program managers to monitor the key immunization indicators and stratify by high-risk and non-high-risk districts. Discussion: Although only a single outcome indicator goal (at least 10% annual increase in DTP3 coverage achieved in 80% of high-risk districts) initially existed in the endgame strategy, we successfully added additional outcome indicators (eg, decreasing the number of DTP3-unvaccinated children) as well as program process indicators focusing on cold chain, stock availability, and vaccination sessions to better describe progress on the pathway to raising immunization coverage. Conclusion: When measuring progress toward improving immunization systems, it is helpful to use a comprehensive approach that allows for measuring multiple dimensions of the system.
Risk Factors for Non-use of Skilled Birth Attendants: Analysis of South Sudan Household Survey, 2010.
Maternal and Child Health Journal. 2016 Jun; 20(6):1266-79.Objectives South Sudan has the lowest percentage of births attended by skilled health personnel in the world. This paper aims to identify potential risk factors associated with non-use of skilled birth attendants at delivery in South Sudan. Methods Secondary data analyses of the 2010 South Sudan Household Health Survey second round were conducted with data for 3504 women aged 15-49 years who gave birth in the 2 years prior to the survey. The risk of non-use of skilled birth attendants was examined using simple and multiple logistic regression analyses. Results The prevalence rates for skilled, unskilled and no birth attendants at delivery were 41 [95 % confidence interval (CI) 38.2, 43.0], 36 [95 % CI 33.9, 38.8], and 23 % [95 % CI 20.6, 24.9] respectively. Multivariable analyses indicated that educated mothers [adjusted odds ratio (AOR) 0.70; 95 % CI 0.57, 0.86], mothers who had three and more complications during pregnancy [AOR 0.77; 95 % CI 0.65, 0.90], mothers who had at least 1-3 ANC visits [AOR 0.38; 95 % CI 0.30, 0.49] and mothers from rich households [AOR 0.52; 95 % CI 0.42, 0.65] were significantly more likely to use skilled birth attendants (SBAs) at delivery. Mothers who lived in rural areas [AOR 1.44; 95 % CI 1.06, 1.96] were less likely to deliver with SBAs. Conclusion Intensive investments to recruit and train more skilled birth attendants' on appropriate delivery care are needed, as well as building a community-based skilled birth attendants' program to reduce avoidable maternal mortality in South Sudan.
Effects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional study.
American Journal of Obstetrics and Gynecology. 2017 Jul; 217(1):62.e1-62.e6.BACKGROUND: Female genital mutilation/cutting (FGM/C) is a cultural practice that involves several types of removal or other injury to the external female genitalia for nonmedical reasons. Although much international research has focused on the health consequences of the practice, little is known about sexual functioning among women with various types of FGM/C. OBJECTIVE: To assess the impact of FGM/C on the sexual functioning of Sudanese women. STUDY DESIGN: This is a cross-sectional study conducted at Doctor Erfan and Bagedo Hospital, Jeddah, Saudi Arabia. Eligible women completed a survey and a clinical examination, which documented and verified women's type of FGM/C. The main outcome measure was female sexual function, as assessed by the Arabic Female Sexual Function Index. RESULTS: A total of 107 eligible women completed the survey and the gynecological examination, which revealed that 39% of the women had FGM/C Type I, 25% had Type II, and 36% had Type III. Reliability of self-report of the type of FGM/C was low, with underreporting of the extent of the procedure. The results showed that 92.5% of the women scored lower than the Arabic Female Sexual Function Index cut-off point for sexual dysfunction. The multivariable regression analyses showed that sexual dysfunction was significantly greater with more extensive type of FGM/C, across all sexual function domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) and overall. CONCLUSION: The study documents that a substantial proportion of women subjected to FGM/C experience sexual dysfunction. It shows that the anatomical extent of FGM/C is related to the severity of sexual dysfunction. Copyright (c) 2017 Elsevier Inc. All rights reserved.