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Journal of Immunological Sciences. 2018 Aug 2; Suppl(15):103-107.Tetanus is a vaccine-preventable disease of significant public health importance especially in developing countries. The WHO strategy for the elimination of maternal and neonatal tetanus recommends the promotion of clean delivery practices, systematic immunization of pregnant women and those in the reproductive age (15-49 years) and surveillance for neonatal tetanus. Implementation of the recommended strategy with the support of WHO, UNICEF and other partners has led to significant decline in number of cases and deaths due to NT over the last decades. The coverage with the second or more dose of tetanus toxoid-containing vaccines (TT2+) a proxy for Protection at Birth (PAB) for the WHO African region has risen from 62% in 2000 to 77% by 2015 Reported cases of NT declined from 5175 in 2000 to 1289 in 2015. The goal of eliminating maternal and neonatal tetanus by 2015 was missed, but some progress has been made. By the end of 2016, 37 out of 47 (79%) of the WHO AFR member states achieved elimination. The 10 member states remaining need additional support by all partners to achieve and maintain the goal of MNTE. Innovative ways of implementing the recommendations need to be urgently considered.
Delivery of Multiple Child and Maternal Health Interventions during Supplementary Immunization Campaign in Rwanda, 2013: Lessons Learnt.
Journal of Immunological Sciences. 2018 Aug 2; Suppl(9):63-67.Objective: This paper assesses and describes the estimated coverage of the Measles Rubella (MR) campaign in each district; the national estimate of coverage for Human Papilloma Virus (HPV) vaccination campaign and Vitamin A supplementation simultaneously implemented in 2013. Methods: We applied descriptive statistics and epidemiological tools to the outcomes of the campaigns to assess the coverage achieved on the different child and maternal health interventions. We also assessed the Adverse Events following Immunization (AEFI) where the evaluation was used at the same time to assess the routine immunization performance coverage for children 12-24 months for all childhood antigens, Tetanus Toxoid coverage among mothers of infants, combined with routine immunization performance evaluation, skilled delivery and bed nets use in Rwanda. Results: Results indicated that among the eligible targets, 97.5% received MR vaccine, 91% received HPV doses, and 83% got Vitamin A. The integrated vaccination of MR with HPV did not result in any serious AEFI. Coverage for antigens and doses given early in life was above 95% with card retention of 80%. BCG to measles dropout by card was 8.5%. Main reasons for non-vaccination indicated need for more specific immunization education. About 96.8% of mothers delivered in health institutions and 95% of the mothers slept under bed nets the night before the survey. Conclusion: Rwanda successfully implemented an integrated coverage evaluation survey of the integrated vaccination campaign and routine immunization with statistically valid estimates. We drew lessons that information on routine immunization can be collected during post campaign survey evaluations. The district estimates should guide the programme performance improvement.
Maternal health outcomes among HIV-infected breastfeeding women with high CD4 counts: results of a treatment strategy trial.
HIV Clinical Trials. 2018 Dec; 19(6):209-224.BACKGROUND: IMPAACT PROMISE 1077BF/FF was a randomized study of antiretroviral therapy (ART) strategies for pregnant and postpartum women with high CD4+ T-cell counts. We describe postpartum outcomes for women in the study who were randomized to continue or discontinue ART after delivery. METHODS: Women with pre-ART CD4+ cell counts >/=350 cells/mm(3) who started ART during pregnancy were randomized postpartum to continue or discontinue treatment. Women were enrolled from India, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. The primary outcome was a composite of progression to AIDS-defining illness or death. Log-rank tests and Cox regression models assessed treatment effects. Incidence rates were calculated per 100 person-years. A post hoc analysis evaluated WHO Stage 2/3 events. All analyses were intent-to-treat. FINDINGS: 1611 women were enrolled (June 2011-October 2014) and 95% were breastfeeding. Median age at entry was 27 years, CD4+ count 728 cells/mm(3) and the majority of women were Black African (97%). After a median follow-up of 1.6 years, progression to AIDS-defining illness or death was rare and there was no significant difference between arms (HR: 0.55; 95%CI 0.14, 2.08, p = 0.37). WHO Stage 2/3 events were reduced with continued ART (HR: 0.60; 95%CI 0.39, 0.90, p = 0.01). The arms did not differ with respect to the rate of grade 2, 3, or 4 safety events (p = 0.61). INTERPRETATION: Serious clinical events were rare among predominately breastfeeding women with high CD4+ cell counts over 18 months after delivery. ART had significant benefit in reducing WHO 2/3 events in this population.
Microfinance for women at high risk for HIV in Kazakhstan: study protocol for a cluster-randomized controlled trial.
Trials. 2018 Mar 20; 19(1):187.BACKGROUND: Among women at high risk for HIV and other sexually transmitted diseases (STIs), gender and economic issues limit the impact of behavioral prevention strategies. Women in Kazakhstan with dual risks of sex trading and drug use face elevated risk for HIV and STIs and may benefit from an economic empowerment intervention which combines HIV-risk reduction (HIVRR) education with financial skills-building and asset-building to promote reduced reliance on sex trading for income. METHODS/DESIGN: The study employs a two-arm, cluster-randomized controlled trial (c-RCT) design. We will use cluster randomization to assign 350 women in approximately 50 cohorts to a traditional four-session HIV-risk-reduction intervention combined with a six-session financial literacy intervention, enrollment in a 24-session vocational training program and receipt of matched savings (HIVRR+MF); or to the four-session HIV-risk-reduction intervention alone (HIVRR). Repeated behavioral and biological assessments will be conducted at baseline, then at 6, 9, and 15 months post randomization/session 1. DISCUSSION: This study responds to an identified need in the academic literature for rigorous testing of structural interventions, including combination microfinance and HIV-prevention interventions. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02406482 . Registered on 30 March 2015.
AIDS and Behavior. 2018 Sep; 22(9):2840-2850.Approximately 71% of HIV-infected individuals live in sub-Saharan Africa. Alcohol use increases unprotected sex, which can lead to HIV transmission. Little research examines risky sex among HIV-infected individuals in East Africa who are not sex workers. The study purpose was to examine associations with unprotected sex in a high-risk sample of 507 HIV-infected sexually active drinkers in western Kenya. They were enrolled in a trial to reduce alcohol use. Past-month baseline alcohol use and sexual behavior were assessed using the Timeline Followback. A zero-inflated negative binomial model examined associations with occurrence and frequency of unprotected sex. Results showed heavy drinking days were significantly associated with unprotected sex occurrence across gender, and with unprotected sex frequency among women. Among women, transactional sex, alcohol-related sexual expectations, condom use self-efficacy, drinking-and-protected-sex days and age were associated with unprotected sex occurrence while alcohol-related sexual expectations, depressive symptoms and condom use self-efficacy were associated with unprotected sex frequency. Among men, alcohol-related sexual expectations, condom use self-efficacy, and age were associated with unprotected sex occurrence, while drinking-and-protected-sex days were associated with unprotected sex occurrence and frequency. Findings suggest robust relationships between heavy drinking and unprotected sex. Further research is needed elucidating the temporal relationships between drinking and unprotected sex in this population.
Pathways from Resilient Coping to Safer Sex Communication Among African, Caribbean, and Black Women in Toronto, Canada: Results from a Cross-sectional Survey.
International Journal of Behavioral Medicine. 2018 Aug; 25(4):479-485.PURPOSE: African, Caribbean, and Black (ACB) women in Canada are disproportionately impacted by HIV and other sexually transmitted infections. Although there is reported suboptimal consistent condom use with ACB women, limited research has explored safer sex communication among this population. Coping frameworks highlight the role that resilient coping and condom use self-efficacy may play in facilitating safer sex communication. Structural perspectives stress the need to explore associations between HIV vulnerabilities and food insecurity. We examined pathways from resilient coping to safer sex communication through the mediator of condom use self-efficacy among ACB women in Toronto. METHOD: We conducted a cross-sectional survey with a purposive sample of ACB women aged 16 and older across Toronto, Canada. We conducted path analysis to test the direct effects of resilient coping on safer sex communication, and indirect pathways through the mediator (condom use self-efficacy) while controlling for food insecurity. RESULTS: Participant (n = 80; mean age 27, SD 7.93) ethnicities included African (58.8%, n = 47), Caribbean (30%, n = 24), and others (11.3%, n = 9). Participants with food security reported significantly higher safer sex communication. We found no direct effect of resilient coping on safer sex communication. Findings support the hypothesized mediation process; resilient coping was associated with condom use self-efficacy, which in turn was associated with safer sex communication. CONCLUSION: Findings that condom use self-efficacy mediated the association between resilient coping and safer sex communication align with theoretical assertions of the protective role of adaptive coping strategies. Findings can inform tailored HIV and STI preventive interventions with ACB women.
Evaluating the effectiveness of a multi-component intervention on early childhood development in paediatric HIV care and treatment programmes: a randomised controlled trial.
BMC Pediatrics. 2018 Jul 9; 18(1):222.BACKGROUND: HIV infection in a family may affect optimum child development. Our hypothesis is that child development outcomes among HIV-exposed infants will be improved through a complex early childhood stimulation (ECS) programme, and income and loans saving programme for HIV positive parents. METHODS: The study was a cluster-randomized controlled trial in 30 clinic sites in two districts in Zimbabwe. Clinics were randomised in a 1:1 allocation ratio to the Child Health Intervention for Development Outcomes (CHIDO) intervention or Ministry of Health standard care. The CHIDO intervention comprises three elements: a group ECS parenting programme, an internal savings and lending scheme (ISALS) and case-management home visits by village health workers. The intervention was aimed at caregiver-child dyads (child aged 0-24 months) where the infant was HIV exposed or infected. The primary outcomes were cognitive development (assessed by the Mullen Scales of Early Learning) and retention of the child in HIV care, at 12 months after enrolment. A comprehensive process evaluation was conducted. DISCUSSION: The results of this cluster-randomised trial will provide important information regarding the effects of multi-component interventions in mitigating developmental delays in HIV-exposed infants living in resource-limited environments. TRIAL REGISTRATION: This trial is registered with the Pan African Clinical Trials Registry ( www.pactr.org ), registration number PACTR201701001387209; the trial was registered on 16th January 2017 (retrospectively registered).
Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey.
Lancet. HIV. 2018 Aug; 5(8):e427-e437.BACKGROUND: In high HIV burden settings, maximising the coverage of prevention strategies is crucial to achieving epidemic control. However, little is known about the reach and effect of these strategies in some communities. METHODS: We did a cross-sectional community survey in the adjacent Greater Edendale and Vulindlela areas in the uMgungundlovu district, KwaZulu-Natal, South Africa. Using a multistage cluster sampling method, we randomly selected enumeration areas, households, and individuals. One household member (aged 15-49 years) selected at random was invited for survey participation. After obtaining consent, questionnaires were administered to obtain sociodemographic, psychosocial, and behavioural information, and exposure to HIV prevention and treatment programmes. Clinical samples were collected for laboratory measurements. Statistical analyses were done accounting for multilevel sampling and weighted to represent the population. A multivariable logistic regression model assessed factors associated with HIV infection. FINDINGS: Between June 11, 2014, and June 22, 2015, we enrolled 9812 individuals. The population-weighted HIV prevalence was 36.3% (95% CI 34.8-37.8, 3969 of 9812); 44.1% (42.3-45.9, 2955 of 6265) in women and 28.0% (25.9-30.1, 1014 of 3547) in men (p<0.0001). HIV prevalence in women aged 15-24 years was 22.3% (20.2-24.4, 567 of 2224) compared with 7.6% (6.0-9.3, 124 of 1472; p<0.0001) in men of the same age. Prevalence peaked at 66.4% (61.7-71.2, 517 of 760) in women aged 35-39 years and 59.6% (53.0-66.3, 183 of 320) in men aged 40-44 years. Consistent condom use in the last 12 months was 26.5% (24.1-28.8, 593 of 2356) in men and 22.7% (20.9-24.4, 994 of 4350) in women (p=0.0033); 35.7% (33.4-37.9, 1695 of 5447) of women's male partners and 31.9% (29.5-34.3, 1102 of 3547) of men were medically circumcised (p<0.0001), and 45.6% (42.9-48.2, 1251 of 2955) of women and 36.7% (32.3-41.2, 341 of 1014) of men reported antiretroviral therapy (ART) use (p=0.0003). HIV viral suppression was achieved in 54.8% (52.0-57.5, 1574 of 2955) of women and 41.9% (37.1-46.7, 401 of 1014) of men (p<0.0001), and 87.2% (84.6-89.8, 1086 of 1251) of women and 83.9% (78.5-89.3, 284 of 341; p=0.3670) of men on ART. Age, incomplete secondary schooling, being single, having more than one lifetime sex partner (women), sexually transmitted infections, and not being medically circumcised were associated with HIV-positive status. INTERPRETATION: The HIV burden in specific age groups, the suboptimal differential coverage, and uptake of HIV prevention strategies justifies a location-based approach to surveillance with finer disaggregation by age and sex. Intensified and customised approaches to seek, identify, and link individuals to HIV services are crucial to achieving epidemic control in this community. FUNDING: The President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention. Copyright (c) 2018 Elsevier Ltd. All rights reserved.
Prevalence of HIV infection and uptake of HIV/AIDS services among fisherfolk in landing Islands of Lake Victoria, north western Tanzania.
BMC Health Services Research. 2018 Dec 18; 18(1):980.BACKGROUND: New HIV infections in Tanzania have been decreasing, however some populations remain at higher risk. Despite of that, evidence on the magnitude of HIV infection and the associated factors and HIV/AIDS services uptake among fisherfolk in Tanzania are inadequately explored. This study therefore aimed at determining prevalence of HIV infection and utilization of HIV/AIDS services among fishfolk in selected Islands of Lake Victoria for evidence-based interventions. METHODS: Cross-sectional study determining status of HIV infection among fisherfolk (n = 456) and retrospective review of voluntary counselling and testing (VCT) registry (n = 1744) were done in Buchosa and Muleba districts. Structured questionnaire and HIV rapid test kits with the standard testing protocol were used as research tools. RESULTS: A total of 269 (58.9%) male and 187 (41.1%) female fisherfolk were recruited during the community survey. Prevalence of HIV infection was 14% in all surveyed landing sites with a site variation from as low as 7.2% to as high as 23.8%. Participants employed in fishing related employment had higher odds of being HIV infected (5.4 times) than those who practiced fishing and partly farming [OR = 5.40; 95%CI 1.88-15.61; p < 0.001]. Participants employed in fishing related employment had higher odds of being HIV infected (5.4 times) than those practiced fishing and farming [OR = 5.40; 95%CI 1.88-15.61; P < 0.001]. Lack of formal education [aOR = 3.37; 95%CI 1.64-6.92; p < 0.001], being older [aOR = 1.06; 95%CI 1.03-1.09] and using alcohol [aOR = 2.26; 95%CI 1.23-4.15] predicted the likelihood of contracting HIV infection. Approximately three quarters (76%) of respondents had ever tested for HIV infection within past 1 year. Moreover, about half of the study participants had used condom inconsistently and 5 out of 14 (37.5%) of participants who knew their status had never started treatment. Despite the low uptake of most HIV preventive services, majority (88%) of male fisherfolk were circumcised. CONCLUSION: The magnitude of HIV infection among fisherfolk was up to 3 times higher than that of the general populations in Muleba and Buchosa districts. Higher age, using alcohol and lack of formal education predicted increased likelihood of HIV infection. The uptake of key HIV/AIDS curative and preventive services was generally low.
High pregnancy incidence and low contraceptive use among a prospective cohort of female entertainment and sex workers in Phnom Penh, Cambodia.
BMC Pregnancy and Childbirth. 2018 May 3; 18(1):128.BACKGROUND: While HIV and unintended pregnancies are both occupational risks faced by female sex workers, the epidemiology of pregnancy and its drivers in this population remains understudied. This includes Cambodia, where the drivers of pregnancy among female entertainment and sex workers (FESW) remain unknown. The current study aimed to examine factors associated with incident pregnancy, as well as describe contraceptive use among FESW in Phnom Penh, Cambodia. METHODS: This analysis drew from the Young Women's Health Study (YWHS)-2, a 12-month observational cohort of 220 FESW aged 15-29 years, conducted between August 2009 and August 2010. Interviewer-administered questionnaires were conducted at baseline and quarterly thereafter, alongside HIV and pregnancy testing. Bivariate and multivariable extended Cox regression analysis was used to examine correlates of incident pregnancy. RESULTS: At baseline, 6.8% of participants were pregnant, and only 10.8% reported using hormonal contraceptives, with 11.3% reporting an abortion in the past 3 months. Pregnancy incidence was high, at 22/100 person-years (95% CI: 16.3-30.1). In multivariable analysis, younger age (19-24 years versus 25-29 years) (Adjusted Hazards Ratio (AHR): 2.28; 95% Confidence Interval (CI) 1.22-4.27), lower income (400,000-600,000 Riel (=150$USD) versus > 600,000 Riel (> 150$USD)) (AHR 2.63; 95% CI 1.02-6.77) positively predicted pregnancy, while higher self-reported condom self-efficacy were associated with reduced pregnancy incidence (AHR 0.89; 95% CI 0.81-0.98). CONCLUSIONS: Results document high incidence of pregnancy and unmet reproductive health needs among FESWs in Cambodia. Findings point to an urgent need for multi-level interventions, including venue-based HIV/STI and violence prevention interventions, in the context of legal and policy reform. High pregnancy incidence in this population may also undermine recruitment and retention into HIV prevention intervention trials. The exploration of innovative and comprehensive sex worker-tailored sexual and reproductive health service models, also as part of HIV prevention intervention trials, is warranted.
Midwifery. 2018 May; 60:e1.The author expresses their concerns with a recent article "I was told not to do it but…': Infant feeding practices amongst HIV-positive women in southern Thailand."
Male partner attendance at antenatal care and adherence to antenatal care guidelines: secondary analysis of 2011 Ethiopian demographic and health survey data.
BMC Pregnancy and Childbirth. 2018 May 9; 18(1):145.BACKGROUND: Complications during pregnancy, childbirth and the postpartum period present a significant and complex public health problem in low income countries such as Ethiopia. One strategy endorsed by the World Health Organisation (WHO) to improve maternal and child health outcomes is to encourage male partner involvement in pregnancy care. This research aimed to explore the relationships between 1) male attendance at antenatal care and 2) socio-economic and women's empowerment factors and adherence to focused antenatal care guidelines among women receiving care in Ethiopia. METHODS: Secondary analysis of 2011 Ethiopian Demographic and Health Survey (DHS) data. A sub-sample of couples with a child aged 0-2 years old, for whom women attended at least one antenatal care (ANC) appointment was selected. Predictor variables on socio-economic position, demographic and women's empowerment factors, and male attendance at antenatal care were identified. Six outcome variables were constructed to indicate whether or not women: commenced ANC in the first trimester, attended at least four ANC appointments, received a urine test, received a blood test, were counselled on potential complications during pregnancy and met these focused antenatal care guidelines. Binary logistic regression was performed to estimate the relationship between the predictor and outcome variables. RESULTS: After controlling for other factors, women whose partners attended ANC were significantly more likely to receive urine and blood tests and be counselled about pregnancy complications compared to women who attended alone. Male attendance was not associated with women commencing care in the first trimester or attending at least four appointments. Although more women whose male partners had attended appointments received all recommended components of ANC than those who attended alone, this association was not significant. CONCLUSIONS: The results revealed some benefits and did not detect harms from including male partners in focused antenatal care. Including men may require changes to maternal healthcare systems and training of healthcare workers, to adopt 'father inclusive' practices. Given the limited research in this area, large population studies including the DHS routinely carried out in Ethiopia could enhance knowledge by including more detailed indicators of male involvement in pregnancy, maternal and child healthcare and early child development.
BMC Pregnancy and Childbirth. 2018 Jun 14; 18(1):226.BACKGROUND: Pakistan ranks 149th in the maternal mortality ratio (MMR) and has failed to keep pace with other countries in the region, except Afghanistan, with respect to health indicators. Home deliveries are linked to a higher risk of maternal death; therefore, discouraging home deliveries is imperative to improve maternal health. This study provides a holistic view and analyses factors affecting home birth decisions within the context of maternal socio-demographic characteristics in Pakistan. METHODS: The study exploits the latest data from the Pakistan Demographic and Health Survey (2012-2013), which includes a nationally representative sample of 13,558 women aged 15-49 years. However, the sample was reduced to 6977 women who had given birth in the 5 years preceding the survey. Statistical techniques, including bi-variate and multivariate logistic regression, were used to analyse the data. The dependent variable was dichotomous and coded as 0 for home deliveries and 1 for deliveries at a health facility. The dependent variable was constructed based on information regarding the most recent birth in the 5 years preceding the survey. RESULTS: The study reveals that giving birth at home is highly prevalent among mothers in Pakistan (Baluchistan, 74%; Khyber-Pakhtunkhwa, 53%; Gilgit Baltistan, 46%; Punjab, 45% and Sindh, 34%) because of their difficulty obtaining permission to visit a health facility, financial barriers, the distance to health facilities and transportation. Substantial variation is observed when geo-demographic characteristics are considered. Higher home childbirth rates have been recorded in rural areas compared with those in urban areas (OR 1.32; p = 0.000). The likelihood of home birth is highest (OR 2.67; p = 0.000) among women in Baluchistan province and lowest (OR 0.48; p = 0.000) among mothers in Punjab province. After controlling for all odds ratios and demographic characteristics, the parents' education levels remain a significant factor (p = 0.000) that affects women's decisions to deliver at home rather than at a health facility. CONCLUSION: The study findings provide a better understanding of why women prefer to give birth at home. These results can help policymakers to introduce appropriate interventions to increase the number of deliveries at health facilities. These findings are expected to reduce maternal and neonatal mortality in Pakistan.
BMC Pregnancy and Childbirth. 2018 Jul 3; 18(1):278.BACKGROUND: Reducing Maternal Mortality Rate (MMR) is considered by the international community as one of the eight Millennium Development Goals. Based on previous studies, Skilled Assistant at Birth (SAB), General Fertility Rate (GFR) and Gross Domestic Product (GDP) have been identified as the most significant predictors of MMR in South Sudan. This paper aims for the first time to develop profile limits for the MMR in terms of significant predictors SAB, GFR, and GDP. The paper provides the optimal values of SAB and GFR for a given MMR level. METHODS: Logarithmic multi- regression model is used to model MMR in terms of SAB, GFR and GDP. Data from 1986 to 2015 collected from Juba Teaching Hospital was used to develop the model for predicting MMR. Optimization procedures are deployed to attain the optimal level of SAB and GFR for a given MMR level. MATLAB was used to conduct the optimization procedures. The optimized values were then used to develop lower and upper profile limits for yearly MMR, SAB and GFR. RESULTS: The statistical analysis shows that increasing SAB by 1.22% per year would decrease MMR by 1.4% (95% CI (0.4-5%)) decreasing GFR by 1.22% per year would decrease MMR by 1.8% (95% CI (0.5-6.26%)). The results also indicate that to achieve the UN recommended MMR levels of minimum 70 and maximum 140 by 2030, the government should simultaneously reduce GFR from the current value of 175 to 97 and 75, increase SAB from the current value of 19 to 50 and 76. CONCLUSIONS: This study for the first time has deployed optimization procedures to develop lower and upper yearly profile limits for maternal mortality rate targeting the UN recommended lower and upper MMR levels by 2030. The MMR profile limits have been accompanied by the profile limits for optimal yearly values of SAB and GFR levels. Having the optimal level of predictors that significantly influence the maternal mortality rate can effectively aid the government and international organizations to make informed evidence-based decisions on resources allocation and intervention plans to reduce the risk of maternal death.
Program assessment of efforts to improve the quality of postpartum counselling in health centers in Morogoro region, Tanzania.
BMC Pregnancy and Childbirth. 2018 Jul 4; 18(1):282.BACKGROUND: The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania. METHODS: Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10). RESULTS: While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment. CONCLUSIONS: Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged.
Safe Birth and Cultural Safety in southern Mexico: study protocol for a randomised controlled trial.
Trials. 2018 Jul 4; 19(1):354.BACKGROUND: Indigenous women in the southern Mexican state of Guerrero face poor maternal health outcomes. Living as they do at the very periphery of the Western health system, they often receive low-quality care from health services that lack human and financial resources. Traditional health systems remain active in indigenous communities where traditional midwives accompany women through motherhood. Several interventions have explored training birth attendants in Western birthing skills, but little research has focussed on supporting traditional midwives by recognising their knowledge. This trial supports traditional midwifery in four indigenous groups and measures its impact on maternal health outcomes. METHODS: The study includes four indigenous populations in the State of Guerrero (Nahua, Na savi/Mixteco, Me'phaa/Tlapaneco and Nancue nomndaa/Amuzgo), covering approximately 8000 households. A parallel-group cluster-randomised controlled trial will compare communities receiving usual care with communities where traditional midwives received support in addition to the usual care. The intervention was defined in collaboration with participants in a 2012 pilot study. Supported midwives will receive a small stipend, a scholarship to train one apprentice, and support from an intercultural broker to deal with Western health personnel; additionally, the health staff in the intervention municipalities will participate in workshops to improve understanding and attitudes towards authentic traditional midwives. A baseline and a final survey will measure changes in birth and pregnancy complications (primary outcomes), and changes in gender violence, access to healthcare, and engagement with traditional cultural activities (secondary outcomes). The project has ethical approval from the participating communities and the Universidad Autonoma de Guerrero. DISCUSSION: Indigenous women at the periphery of Western health services do not benefit fully from the attenuated services which erode their own healthcare traditions. Western health service providers in indigenous communities often ignore traditional knowledge and resources, inadvertently or in ignorance, disrespecting indigenous cultures. Improved understanding between midwives and the official healthcare system can contribute to more appropriate referral of high-risk cases, improving the use of scarce resources while lowering costs of healthcare for indigenous families. TRIAL REGISTRATION: ISRCTN12397283 . Retrospectively registered on 6 December 2016.
The role of community-based health services in influencing postnatal care visits in the Builsa and the West Mamprusi districts in rural Ghana.
BMC Pregnancy and Childbirth. 2018 Jul 9; 18(1):295.BACKGROUND: Globally, maternal mortality is still a challenge. In Ghana, maternal morbidity and mortality rates remain high, particularly in rural areas. Postnatal Care (PNC) is one of the key strategies for improving maternal health. This study examined determinants of at least three PNC visits in rural Ghana. METHODS: We conducted a cross-sectional study at the Community-Based Health Planning and Services (CHPS) Zones in the Builsa and West Mamprusi Districts between April and June 2016. We selected 650 women who delivered within 5 years preceding the survey (325 from each of the two sites) using the two-stage random sampling technique. RESULTS: Of the 650 respondents, 62% reported attending postnatal care at least three times. In the Builsa district, the percentage of women who made at least three PNC visits were 90% compared with 35% in the West Mamprusi district. Older women and those who attended antenatal clinics at least four times (AOR: 5.23; 95% CI: 2.49-11.0) and women who had partners with some secondary education (AOR: 3.31; 95% CI: 1.17-9.39) were associated with at least three PNC visits. CONCLUSIONS: Men engagement in maternal health services and the introduction of home-based PNC services in rural communities could help health workers reach out to many mothers and children promptly and improve PNC visits in those communities.
Underreporting of stillbirths in Pakistan: perspectives of the parents, community and healthcare providers.
BMC Pregnancy and Childbirth. 2018 Jul 16; 18(1):302.BACKGROUND: Pakistan has the highest rate of stillbirths globally. Not much attention has been given so far to exploring the sociocultural factors hindering the reportage of stillbirths and the causes of death. Therefore, the aim of this study was to assess the perspectives of parents, communities and healthcare providers regarding the sociocultural practices and health system-related factors contributing to stillbirths and their underreporting. METHODS: This study used a qualitative approach including in-depth interviews and 14 focus group discussions to collect data from four districts of Pakistan. We conducted 285 in-depth interviews and 14 focus group discussions with health professionals - mainly active in the areas of maternal and child health - and parents who had experienced stillbirth. Constant comparative method and analytical induction method were performed to analyze the data. RESULTS: The results of this study show that stillbirth is frequently misclassified and, therefore, an underreported phenomenon in Pakistan. It is an outcome of sociocultural practices, such as the social meaning of stillbirth and their understanding about the conflict between cultural and medical anatomy. In addition to grief and psychological distress, it endangers the maternal identity and worth in society in contrast to the mothers of live-born children. CONCLUSION: The misclassification of stillbirth, especially by healthcare providers, is a significant impediment to designing preventive strategies for stillbirth. We recommend that the reporting system for stillbirth should be aligned with the WHO definition of stillbirth to avoid its underreporting. Reporting procedures at a more administrative level need to be made uniform and simplified.
A model for predicting utilization of mHealth interventions in low-resource settings: case of maternal and newborn care in Kenya.
BMC Medical Informatics and Decision Making. 2018 Jul 17; 18(1):67.BACKGROUND: In low-resource settings, there are numerous socioeconomic challenges such as poverty, inadequate facilities, shortage of skilled health workers, illiteracy and cultural barriers that contribute to high maternal and newborn deaths. To address these challenges, there are several mHealth projects particularly in Sub-Sahara Africa seeking to exploit opportunities provided by over 90% rate of mobile penetration. However, most of these interventions have failed to justify their value proposition to inspire utilization in low-resource settings. METHODS: This study proposes a theoretical model named Technology, Individual, Process-Fit (TIPFit) suitable for user-centred evaluation of intervention designs to predict utilization of mHealth products in low-resource settings. To investigate the predictive power of TIPFit model, we operationalized its latent constructs into variables used to predict utilization of an mHealth prototype called mamacare. The study employed single-group repeated measures quasi-experiment in which a random sample of 79 antenatal and postnatal patients were recruited from a rural hospital. During the study conducted between May and October 2014, the treatment involved sending and receiving SMS alerts on vital signs, appointments, safe delivery, danger signs, nutrition, preventive care and adherence to medication. RESULTS: Measurements taken during the study were cleaned and coded for analysis using statistical models like Partial Least Squares (PLS), Repeated Measures Analysis of Variance (RM-ANOVA), and Bonferroni tests. After analyzing 73 pretest responses, the model predicted 80.2% fit, and 63.9% likelihood of utilization. However, results obtained from initial post-test taken after three months demonstrated 69.1% fit, and utilization of 50.5%. The variation between prediction and the actual outcome necessitated improvement of mamacare based on feedback obtained from users. Three months later, we conducted the second post-test that recorded further drop in fit from 69.1 to 60.3% but utilization marginally improved from 50.5 to 53.7%. CONCLUSIONS: Despite variations between the pretest and post-test outcomes, the study demonstrates that predictive approach to user-centred design offers greater flexibility in aligning design attributes of an mHealth intervention to fulfill user needs and expectations. These findings provide a unique contribution for decision makers because it is possible to prioritize investments among competing digital health projects.
Nutrition during pregnancy and early development (NuPED) in urban South Africa: a study protocol for a prospective cohort.
BMC Pregnancy and Childbirth. 2018 Jul 24; 18(1):308.BACKGROUND: Adequate nutrition during pregnancy is important to ensure optimal birth outcomes, maternal health and offspring development. However, little is known about the dietary intake and nutritional status of pregnant women residing in urban South Africa. Therefore, the Nutrition during Pregnancy and Early Development (NuPED) cohort study was initiated to assess early nutrition-related exposures predictive of early childhood development in urban South Africa. METHODS: The aims of this prospective cohort study are: 1) to assess dietary intake and nutritional status of urban pregnant women in Johannesburg, South Africa, and 2) to determine associations with birth outcomes, measures of maternal health, as well as measures of offspring health and development. Pregnant women (< 18 weeks' gestation) (n = 250) are being recruited from primary healthcare clinics in Johannesburg and are followed-up at a provincial hospital. Participants' dietary intake and nutrient status (focus on micronutrients and fatty acids) are assessed at < 18, 22 and 36 weeks' gestation. Additional assessments during pregnancy include anthropometric and blood pressure measurements, obstetric ultrasound screens, and assessments of food security, maternal fatigue, prenatal depression, allergy, immune function, morbidity and gestational diabetes. At birth, maternal and neonatal health is assessed and an umbilical cord blood sample collected. Maternal and offspring health is followed-up at 6 weeks, as well as at 6, approximately 7.5 and 12 months after birth. Follow-up assessments of mothers include anthropometric measures, diet history, nutrient status, blood pressure, breast milk composition, and measures of postnatal depression and fatigue. Follow-up assessments of the offspring include feeding practices, nutrient status, measures of growth, psychomotor, socio-emotional and immune development, morbidity, allergy, as well as analysis of the gut microbiome and the epigenome. DISCUSSION: Ensuring adequate nutrition during pregnancy is one of the key actions endorsed by the South African Government to promote optimal early childhood development in an effort to eradicate poverty. The results from this study may serve as a basis for the development of context-specific nutritional interventions which can improve birth outcomes and long-term quality of life of the mother and her offspring.
We give water or porridge, but we don't really know what the child wants: a qualitative study on women's perceptions and practises regarding exclusive breastfeeding in Kilimanjaro region, Tanzania.
BMC Pregnancy and Childbirth. 2018 Aug 8; 18(1):323.BACKGROUND: World Health Organization (WHO) recommends exclusive breastfeeding (EBF) as the optimal way to feed infants below 6 months of age. The benefits of EBF are well documented. However, in Tanzania, EBF is still rarely practised. This study explored the knowledge, attitudes and practises of EBF among mothers in Kilimanjaro region of northern Tanzania. METHODS: This is a qualitative research study. The three districts in Kilimanjaro region namely Same, Moshi Municipal Council and Rombo districts were selected. In each district, three focus group discussions (FGDs) with mothers of infants aged 0-12 months were conducted. A total of 78 mothers participated in the focus group discussion. RESULTS: The main result is that most of the mothers had a theoretical knowledge of the benefits of EBF but were not able to practise this knowledge for a range of reasons. The reasons for not practising EBF in real life included poor maternal nutrition, the pressure for women to return to work, inadequate knowledge about expressing breast milk, and perceived insufficiency of milk supply. Additionally, mothers received conflicting advice from a range of sources including close relatives, community members and health care providers, and they often choose the advice of their elders. Mothers also offered suggestions on ways to improve EBF including educating the community on the benefits of EBF. CONCLUSION: The results show that the women need support from close relatives and employers to successfully practise EBF. This presents a need for involving close relatives in EBF interventions, as they are important sources of breastfeeding information in the community. Additionally, behavioural interventions that promote optimal breastfeeding practises might help to improve exclusive breastfeeding.
Systematic review of community participation interventions to improve maternal health outcomes in rural South Asia.
BMC Pregnancy and Childbirth. 2018 Aug 10; 18(1):327.BACKGROUND: This is a systematic review on the effectiveness of community interventions in improving maternal health care outcomes in South Asia. METHODS: We searched electronic databases to June 2017. Randomised or cluster randomised studies in communities within rural/remote areas of Nepal, Bangladesh, India and Pakistan were included. Data were analysed as risk ratios (RR) or odds ratios (OR), and effects were adjusted for clustering. Meta-analyses were performed using random-effects and evidence quality was assessed. RESULTS: Eleven randomised trials were included from 5440 citations. Meta-analysis of all community interventions combined compared with control showed a small improvement in the number of women attending at least one antenatal care visit (RR 1.19, 95% CI 1.06 to 1.33). Two community mobilisation sub groups: home care using both male and female mobilisers, and education by community mobilisers, improved the number of women attending at least one antenatal visit. There was no difference in the number of women attending at least one antenatal visit for any other subgroup. There was no difference in the number of women attending 3 or more antenatal visits for all community interventions combined, or any community subgroup. Likewise, there was no difference in attendance at birth between all community interventions combined and control. Health care facility births were modestly increased in women's education groups (adjusted RR (1.15, 95% CI 1.11 to 1.20; 2 studies)). Risk of maternal deaths after 2 years (RR 0.63, 95% CI 0.24 to 1.64; 5 studies), and 3 years (RR 1.11, 95% CI 0.52 to 2.36; 2 studies), were no different between women's education groups and control. Community level mobilisation rather than health care messages at district level improved the numbers of women giving birth at health care facilities (RR1.09 (95%CI 1.06 to 1.13; 1 study)). Maternal health care knowledge scores improved in two community-based interventions, one involving education of male community members. CONCLUSION: Women's education interventions may improve the number of women seeking birth at a health care facility, but the evidence is of low quality. No impact on maternal mortality was observed Future research should explore the effectiveness of including male mobilisers. TRIAL REGISTRATION: This systematic review is registered with PROSPERO CRD42016033201 .
Effects of midwife-led maternity services on postpartum wellbeing and clinical outcomes in primiparous women under China's one-child policy.
BMC Pregnancy and Childbirth. 2018 Aug 13; 18(1):329.BACKGROUND: The Midwife-led maternity services have been implemented in China in response to the high rates of primiparous women and Caesarean Sections (CS) which may be related to China's one-child policy. However, few studies in China have been reported on the effectiveness of Midwife-led Care at Delivery (MCD) and the Continuity of Midwife-led Care (CMC) on postpartum wellbeing and other clinical outcomes. Therefore, evidence-based clinical validation is needed to develop an optimal maternity service for childbearing women in China. METHODS: A concurrent cohort study design was conducted with 1730 pregnant women recruited from 9 hospitals in Shanghai. Among the 1730 participants at baseline, 1568 participants completed the follow-up questionnaire, with a follow-up rate of 90.6%. RESULTS: Compared with the routine Obstetrician-led Maternity Care (OMC), Midwife-led Care at Delivery (MCD) was associated with CS rate (OR were 0.16; 95%CI: 0.11 to 0.25) and a higher total score of postpartum wellbeing (betawere 2.70; 95%CI: 0.70 to 4.70) when adjusting for the baseline differences and other confounders during delivery or postpartum period. Moreover, continuity of Midwife-led Care (CMC) was associated with CS rate (OR were 0.30; 95%CI: 0.23 to 0.41), as well as increased rate of breastfeeding within the first 24 h (OR were 2.49; 95% CI: 1.47 to 4.23), higher postpartum satisfaction (beta = 4.52; 95% CI: 1.60 to 12.68), lower anxiety (betawere 0.66; 95% CI: 0.16 to 1.17), increased self-control (betawere 0.39; 95% CI: 0.02 to 0.76) and a higher total score of postpartum wellbeing (betawere 3.14; 95% CI: 1.54 to 4.75). CONCLUSION: CMC is the optimal service for low-risk primiparous women under China's one-child policy, and is worthwhile for a general implementation across China.
Understanding intersections of social determinants of maternal healthcare utilization in Uttar Pradesh, India.
PloS One. 2018; 13(10):e0204810.OBJECTIVE: To explore intersections of social determinants of maternal healthcare utilization using the Classification and Regression Trees (CART) algorithm which is a machine-learning method used to construct prediction models. METHODS: Institutional review board approval for this study was granted from Public Health Service-Ethical Review Board (PHS-ERB) and from the Health Ministry Screening Committee (HMSC) facilitated by Indian Council for Medical Research (ICMR). IRB review and approval for the current analyses was obtained from University of California, San Diego. Cross-sectional data were collected from women with children aged 0-11 months (n = 5,565) from rural households in 25 districts of Uttar Pradesh, India. Participants were surveyed on maternal healthcare utilization including registration of pregnancy (model-1), receipt of antenatal care (ANC) during pregnancy (model-2), and delivery at health facilities (model -3). Social determinants of health including wealth, social group, literacy, religion, and early age at marriage were captured during the survey. The Classification and Regression Tree (CART) algorithm was used to explore intersections of social determinants of healthcare utilization. RESULTS: CART analyses highlight the intersections, particularly of wealth and literacy, in maternal healthcare utilization in Uttar Pradesh. Model-1 documents that women who are poorer, illiterate and Muslim are less likely to have their pregnancies registered (71.4% vs. 86.0% in the overall sample). Model-2 documents that poorer, illiterate women had the lowest ANC coverage (37.7% vs 45% in the overall sample). Model-3, developed for deliveries at health facilities, highlighted that illiterate and poor women have the lowest representation among facility deliveries (59.6% vs. 69% in the overall sample). CONCLUSION: This paper explores the interactions between determinants of maternal healthcare utilization indicators. The findings in this paper highlights that the interaction of wealth and literacy can play a very strong role in accentuating or diminishing healthcare utilization among women. The study also reveals that religion and women's age at marriage also interact with wealth and literacy to create substantial disparities in utilization. The study provides insights into the effect of intersections of determinants, and highlights the importance of using a more nuanced understanding of the impact of co-occurring forms of marginalization to effectively tackle inequities in healthcare utilization.
A reassessment of global antenatal care coverage for improving maternal health using sub-Saharan Africa as a case study.
PloS One. 2018; 13(10):e0204822.BACKGROUND: Antenatal period is an opportunity for reaching pregnant women with vital interventions. In fact, antenatal care (ANC) coverage was an indicator for assessing progress towards the Millennium Development Goals. This paper applies a novel index of service coverage using ANC, which accounts for every ANC visit. An index of service coverage gap is also proposed. These indices are additively decomposable by population groups and they are sensitive to the receipt of more ANC visits below a defined threshold. These indices have also been generalised to account for the quality of services. METHODS: Data from recent rounds of the Demographic and Health Survey (DHS) are used to reassess ANC service coverage in 35 sub-Saharan African countries. An index of ANC coverage was estimated. These countries were ranked, and their ranks are compared with those based on attaining at least four ANC visits (ANC4+). FINDINGS: The index of ANC coverage reflected the level of service coverage in countries. Further, disparities exist in country ranking as some countries, e.g. Cameroon, Benin Republic and Nigeria are ranked better using the ANC4+ indicator but poorly using the proposed index. Also, Rwanda and Malawi are ranked better using the proposed index. CONCLUSION: The proposed ANC index allows for the assessment of progressive realisation, rooted in the move towards universal health coverage. In fact, the index reflects progress that countries make in increasing service coverage. This is because every ANC visit counts. Beyond ANC coverage, the proposed index is applicable to assessing service coverage generally including quality education.