Exploring the implementation of an SMS-based digital health tool on maternal and infant health in informal settlements.

BACKGROUND: The rapid urbanization of Kenya has led to an increase in the growth of informal settlements. There are challenges with access to maternal, newborn, and child health (MNCH) services and higher maternal mortality rates in settlements. The Kuboresha Afya Mitaani (KAM) study aimed to improve access to MNCH services. We evaluate one component of the KAM study, PROMPTS (Promoting Mothers through Pregnancy and Postpartum), an innovative digital health intervention aimed at improving MNCH outcomes. PROMPTS is a two-way AI-enabled SMS-based platform that sends messages to pregnant and postnatal mothers based on pregnancy stage, and connects mothers with a clinical help desk to respond and refer urgent cases in minutes. METHODS: PROMPTS was rolled out in informal settlements in Mathare and Kawangware in Nairobi County. The study adopted a pre-post intervention design, comparing baseline and endline population outcomes (1,416 participants, Baseline = 678, Endline = 738). To further explore PROMPTS's effect, outcomes were compared between endline participants enrolled and not enrolled in PROMPTS (738 participants). Outcomes related to antenatal (ANC) and postnatal (PNC) service uptake and knowledge were assessed using univariate and multivariate linear and logistic regression. RESULTS: Between baseline and enldine, mothers were 1.85 times more likely to report their babies and 1.88 times more likely to report themselves being checked by a provider post-delivery. There were improvements in moms and babies receiving care on time. 45% of the 738 endline participants were enrolled in the PROMPTS program, with 87% of these participants sending at least one message to the system. Enrolled mothers were 2.28 times more likely to report completing four or more ANC visits relative to unenrolled mothers. Similarly, enrolled mothers were 4.20 times more likely to report their babies and 1.52 times more likely to report themselves being checked by a provider post-delivery compared to unenrolled mothers. CONCLUSIONS: This research demonstrates that a digital health tool can be used to improve care-seeking and knowledge levels among pregnant and postnatal women in informal settlements. Additional research is needed to refine and target solutions amongst those that were less likely to enroll in PROMPTS and to further drive improved MNCH outcomes amongst this population.

Effect of mentorship and a mHealth application in updating provider skills and knowledge in maternal and newborn care in two informal settlements of Nairobi.

BACKGROUND: Children and women in urban informal settlements have fewer choices to access quality maternal and newborn health care. Many facilities serving these communities are under-resourced and staffed by fewer providers with limited access to skills updates. We sought to increase provider capacity by equipping them with skills to provide general and emergency obstetric and newborn care in 24 facilities serving two informal settlements in Nairobi. We present evidence of the combined effect of mentorship using facility-based mentors who demonstrate skills, support skills drills training, and provide practical feedback to mentees and a self-guided online learning platform with easily accessible EmONC information on providers' smart phones. METHODS: We used mixed methods research with before and after cross-sectional provider surveys conducted at baseline and end line. During end line, 18 in-depth interviews were conducted with mentors and mentees who were exposed, and providers not exposed to the intervention to explore effectiveness and experience of the intervention on quality maternal health services. RESULTS: Results illustrated marked improvement from ability to identify antepartum hemorrhage (APH), postpartum hemorrhage (PPH), manage retained placenta, ability to identify and manage obstructed labour, Pre-Eclampsia and Eclampsia (PE/E), puerperal sepsis, and actions taken to manage conditions when they present. Overall, out of 95 elements examined there were statistically significant improvements of both individual scores and overall scores from 29/95 at baseline (30.5%) to 44.3/95 (46.6%) during end line representing a 16- percentage point increase (p > 0.001). These improvements were evident in public health facilities representing a 17.3% point increase (from 30.9% at baseline to 48.2% at end line, p > 0.001). Similarly, providers working in private facilities exhibited a 15.8% point increase in knowledge from 29.7% at baseline to 45.5% at end line (p = 0.0001). CONCLUSION: This study adds to the literature on building capacity of providers delivering Maternal and Newborn Health (MNH) services to women in informal settlements. The complex challenges of delivering MNH services in informal urban settings where communities have limited access require a comprehensive approach including ensuring access to supplies and basic equipment. Nevertheless, the combined effects of the self-guided online platform and mentorship reinforces EmONC knowledge and skills. This combined approach is more likely to improve provider competency, and skills as well as improving maternal and newborn health outcomes.

Lessons From a Behavior Change Intervention to Improve Provider-Parent Partnerships and Care for Hospitalized Newborns and Young Children in Kenya.

Enhancing respectful, responsive, integrative, and nurturing care for hospitalized newborns and young children (aged 0-24 months) is globally recognized but under-researched in low- and middle-income countries. Responsive, family-centered interventions target providers and parents and emphasize partnership in caring roles. From February 2020 to August 2021, we engaged in a participatory co-creation process with parents, providers, and newborn and child health stakeholders in Kenya to develop a comprehensive provider behavior change intervention and implemented it across 5 hospitals in Nairobi and Bungoma counties in Kenya. The multifaceted intervention included a 7-module orientation, feedback meetings, job aids, and psychosocial support-leveraging in-person and remote modalities-for providers working in newborn and pediatric units. We used a mixed-methods evaluation drawing on a pre-post provider survey, pre-post qualitative interviews with providers and parents, and a follow-up parental survey. There were significant post-intervention improvements in provider knowledge on safeguarding sleep, positioning and handling, and protecting skin. However, there were also significant reductions in providers' knowledge in identifying a child's pain, parental stress, and environmental stress. Among parents who received coaching from providers, there were higher levels of interpersonal communication between parent and provider, parental empowerment, and improved ability to provide integrated, responsive care to their child. Despite the challenges of implementing a provider-focused intervention to improve care for hospitalized newborns and young children during the global COVID-19 pandemic, we have demonstrated that it is feasible to implement a hybrid virtual and in-person process to influence several outcomes, including provider knowledge and practice, improved provider partnerships with parents, and parents' capacity to engage in the care of their newborn or young child.

Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study.

A limited but growing body of literature shows that health care providers (HCPs) in reproductive, maternal, and newborn health face challenges that affect how they provide services. Our study investigates provider perspectives and behaviors using 4 interrelated power domains-beliefs and perceptions; practices and participation; access to assets; and structures-to explore how these constructs are differentially experienced based on one's gender, position, and function within the health system. We conducted a framework-based secondary analysis of qualitative in-depth interview data gathered with different cadres of HCPs across Kenya, Malawi, Madagascar, and Togo (n=123). We find across countries that power dynamics manifest in and are affected by all 4 domains, with some variation by HCP cadre and gender. At the service interface, HCPs' power derives from the nature and quality of their relationships with clients and the community. Providers' power within working relationships stems from unequal decision-making autonomy among HCP cadres. Limited and sometimes gendered access to remuneration, development opportunities, material resources, supervision quality, and emotional support affect HCPs' power to care for clients effectively. Power manifests variably among community and facility-based providers because of differences in prevailing hierarchical norms in routine and acute settings, community linkages, and type of collaboration required in their work. Our findings suggest that applying power-and secondarily, gender lenses-can elucidate consistencies in how providers perceive, internalize, and react to a range of relational and environmental stressors. The findings also have implications on how to improve the design of social behavior change interventions aimed at better supporting HCPs.

Measuring implementation outcomes in the context of scaling up possible serious bacterial infection guidelines: Implications for measurement and programs.

BACKGROUND: Reducing the burden of neonatal sepsis requires timely identification and initiation of suitable antibiotic treatment in primary health care (PHC) settings. Countries are encouraged to adopt simplified antibiotic regimens at the PHC level for treating sick young infants (SYI) with signs of possible serious bacterial infection (PSBI). As countries implement PSBI guidelines, more lessons on effective implementation strategies and outcome measurements are needed. We document pragmatic approaches used to design, measure and report implementation strategies and outcomes while adopting PSBI guidelines in Kenya. METHODS: We designed implementation research using longitudinal mixed methods embedded in a continuous regular systematic learning and adoption of evidence in the PHC context. We synthesized formative data to co-create with stakeholders, implementation strategies to incorporate PSBI guidelines into routine service delivery for SYIs. This was followed by quarterly monitoring for learning and feedback on the effect of implementation strategies, documented lessons learned and tracked implementation outcomes. We collected endline data to measure the overall effect on service level outcomes. RESULTS: Our findings show that characterizing implementation strategies and linking them with implementation outcomes, helps illustrate the pathway between the implementation process and outcomes. Although we have demonstrated that it is feasible to implement PSBI in PHC, effective investment in continuous capacity strengthening of providers through blended approaches, efficient use of available human resources, and improving the efficiency of service areas for managing SYIs optimizes timely identification and management of SYI. Sustained provision of commodities for management of SYI facilitates increased uptake of services. Strengthening facility-community linkages supports adherence to scheduled visits. Enhancing the caregiver's preparedness during postnatal contacts in the community or facility will facilitate the effective completion of treatment. CONCLUSION: Careful design, and definition of terms related to the measurement of implementation outcomes and strategies enable ease of interpretation of findings. Using the taxonomy of implementation outcomes help frame the measurement process and provides empirical evidence in a structured way to demonstrate causal relationships between implementation strategies and outcomes. Using this approach, we have illustrated that the implementation of simplified antibiotic regimens for treating SYIs with PSBI in PHC settings is feasible in Kenya.

Experience of care of hospitalized newborns and young children and their parents: A scoping review.

INTRODUCTION: Several global initiatives put parent involvement at the forefront of enabling children's well-being and development and to promote quality of care for newborns and hospitalized young children aged 0-24 months. Scanty evidence on mistreatment such as delays or neglect and poor pain management among newborns exists, with even less exploring the experience of their parents and their hospitalized young children. To address this gap, authors reviewed research on experience of care for hospitalized young children and their parents, and potential interventions that may promote positive experience of care. METHODS: A scoping review of English language articles, guidelines, and reports that addressed the experiences of care for newborns and sick young children 0-24 months in health facilities was conducted. Multiple databases: PubMed, PROSPERO, COCHRANE Library and Google Scholar were included and yielded 7,784 articles. Documents published between 2009 and November 2020, in English and with evidence on interventions that addressed family involvement and partnership in care for their sick children were included. RESULTS: The scoping review includes 68 documents across 31 countries after exclusion. Mistreatment of newborns comprises physical abuse, verbal abuse, stigma and discrimination, failure to meet professional standards, poor rapport between providers and patients, poor legal accountability, and poor bereavement and posthumous care. No literature was identified describing mistreatment of hospitalized children aged 60 days- 24 months. Key drivers of mistreatment include under-resourced health systems and poor provider attitudes. Positive experience of care was reported in contexts of good parent-provider communication. Three possible interventions on positive experience of care for hospitalized young children (0-24 months) emerged: 1) nurturing care; 2) family centered care and 3) provider and parental engagement. Communication and counseling, effective provider-parental engagement, and supportive work environments were associated with reduced anxiety and stress for parents and hospitalized young children. Few interventions focused on addressing providers' underlying attitudes and biases that influence provider behaviors, and how they affect engaging with parents. CONCLUSION: Limited evidence on manifestations of mistreatment, lack of respectful care, drivers of poor experience and interventions that may mitigate poor experience of care for hospitalized young children 0-24 months especially in low resource settings exists. Design and testing appropriate models that enhance socio-behavioral dimensions of care experience and promote provider-family engagement in hospitals are required.

Determining a Trusting Environment for Maternity Care: A Framework Based on Perspectives of Women, Communities, Service Providers, and Managers in Peri-Urban Kenya.

Trust in health service providers and facilities is integral to health systems accountability. Understanding determinants of trust, a relational construct, in maternity settings necessitates exploring hierarchical perspectives of users, providers, and influencers in the care environment. We used a theoretically driven qualitative approach to explore trust determinants in a maternity setting across patient-provider, inter-provider, and community-policymaker interactions and relationships in peri-urban Kenya. Focus groups (n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews (n = 33) with WRB, health care providers and managers, and community health workers (CHWs) were conducted in 2013, soon after the national government's March 2013 introduction of a policy mandate for "Free Maternity Care." We used thematic coding, memo writing, and cross-perspective triangulation to develop a multi-faceted trust determinants framework. We found that determinants of trust in a maternity setting can be broadly classified into six types of factors, where each type of factor represents a cluster of determinants that may each positively or negatively influence trust: patient, provider, health facility, community, accountability, and structural. Patient factors are prior experiences, perceived risks and harms, childbirth outcomes, and maternal health literacy. Provider factors are empathy and respect, responsiveness, and perceived capability of providers. Health facility factors are "good services" as perceived by patients, physical environment, process navigability, provider collaboration and oversight, discrimination, and corruption. Community factors are facility reputation and history, information channels, and maternal health literacy. Accountability factors are alignment of actions with expectations, adaptations to policy changes, and voice and feedback. Structural factors are institutional hierarchies and policies in the form of professional codes. Trust determinants are complex, nuanced and reflect power dynamics across relationships. Findings offer insight into socio-political maternity norms and demand a more equitable care interface between users and providers.

Manifestations, responses, and consequences of mistreatment of sick newborns and young infants and their parents in health facilities in Kenya.

BACKGROUND: Despite efforts to incorporate experience of care for women and newborns in global quality standards, there are limited efforts to understand experience of care for sick newborns and young infants. This paper describes the manifestations, responses, and consequences of mistreatment of sick young infants (SYIs), drivers, and parental responses in hospital settings in Kenya. METHODS: A qualitative formative study to inform the development of strategies for promoting family engagement and respectful care of SYI was conducted in five facilities in Kenya. Data were collected from in-depth interviews with providers and policy makers (n = 35) and parents (n = 25), focus group discussions with women and men (n = 12 groups), and ethnographic observations in each hospital (n = 64 observation sessions). Transcribed data were organized using Nvivo 12 software and analyzed thematically. RESULTS: We identified 5 categories of mistreatment: 1) health system conditions and constraints, including a) failure to meet professional standards, b) delayed provision of care; and c) limited provider skills; 2) stigma and discrimination, due to provider perception of personal hygiene or medical condition, and patient feelings of abandonment; 3) physically inappropriate care, including providers taking blood samples and inserting intravenous lines and nasogastric tubes in a rough manner; or parents being pressured to forcefully feed infants or share unsterile feeding cups to avoid providers' anger; 4) poor parental-provider rapport, expressed as ineffective communication, verbal abuse, perceived disinterest, and non-consented care; and 5) no organized form of bereavement and posthumous care in the case of infant's death. Parental responses to mistreatment were acquiescent or non-confrontational and included feeling humiliated or accepting the situation. Assertive responses were rare but included articulating disappointment by expressing anger, and/or deciding to seek care elsewhere. CONCLUSION: Mistreatment for SYIs is linked to poor quality of care. To address mistreatment in SYI, interventions that focus on building better communication, responding to the developmental needs of infants and emotional needs for parents, strengthen providers competencies in newborn care, as well as a supportive, enabling environments, will lead to more respectful quality care for newborns and young infants.

"You can't even ask a question about your child": Examining experiences of parents or caregivers during hospitalization of their sick young children in Kenya: A qualitative study.

Background: Globally, about 5.2 million children under the age of five died in 2019, and more than half of those deaths occurred in Sub-Saharan Africa. In almost every death of a sick child, there is a parent/caregiver seeking health services for their child. This study sought to understand the experiences of care for parents/caregivers (caregivers) as they navigate the hospital system with the aim of identifying opportunities to improve service delivery and child health outcomes. Methods: Qualitative data were collected from five hospitals in Kenya: three in Nairobi County and two in Bungoma County. Twenty-five in-depth interviews with caregivers (couples and single women) of young children 0-24 months old, 17 focus group discussions with women and men, and 64 institutional ethnographic observations were completed. Data were analyzed by initial annotation of transcripts and field materials, followed by open coding and thematic analysis using Nvivo 12 software. Summary themes were used to compare experiences between female and male caregivers, their child's age group, and study sites. Results: Caregivers faced complex processes of care while seeking health services for their sick young children. Three overarching themes emerged with some variability across female and male caregiver perspectives: (1) Navigating structural issues: long wait times, confusing payment mechanisms, overcrowding, unhygienic conditions, and strict visitation policies; (2) Interactions with providers: positive experiences, including providers showing empathy and concern, and negative experiences of harsh language, neglect, lack of privacy, discounting caregiver perspectives, and not involving men; Limited communication between caregivers and providers on child's diagnosis, treatment, and progress and lack of communication specifically between male caregivers and providers; and (3) Limited emotional support for both caregivers during difficult diagnosis or bereavement. Conclusions: To improve experiences, interventions, programs, and policies need to focus on good provider-caregiver partnerships; enhancing opportunities for male engagement, such as supportive visiting hours; effective communication between caregivers and providers; access to adequate emotional support; and an enabling hospital environment.

Devolved health system capacity in the provision of care for sick newborns and young infants in four counties serving vulnerable populations in Kenya.

Possible severe bacterial infections (PSBI) is one of the three leading causes of newborn and young infant mortality globally that can be prevented by timely diagnosis and treatment using suitable antibiotics. High impact interventions such as use of out-patient injectable gentamicin and dispersible Amoxicillin with community-based follow up have been shown to reduce mortality in clinical trials. The objective of this study was to assess the health systems' preparedness and organizational gaps that may impact execution in providing care for newborns and sick young infants. This formative research study was embedded within a three-year implementation research project in 4 Counties in Kenya. The indicators were based on facility audits for existing capacity to care for newborns and young infants as well as County organizational capacity assessment. The organizational capacity assessment domains were derived from the World Health Organization's Health Systems Building blocks for health service delivery. The scores were computed by adding average scores in each domain and calculated against the total possible scores to generate a percentage outcome. Statistical analyses were descriptive with adjustment for clustering of data. Overall, the Counties have inadequate organizational capacity for management of sick young infants with Organizational Capacity Index scores of between 61-64%. Among the domains, the highest score was in Health Management Information System and service delivery. The lowest scores were in monitoring and evaluation (M&E). Counties scored relatively low scores in human resources for health and health products and commodities with one scoring poorly for both areas while the rest scored average performance. The four counties revealed varying levels of organizational capacity deficit to effectively manage sick young infants. The key underlying issues for the below par performance include poor coordination, low funding, inadequate supportive supervision, and M&E to enable data utilisation for quality improvement. It was evident that newborn and young infant health services suffer from inadequate infrastructure, equipment, staffing, and coordination. As Kenya, continuously rolls out the guidelines on management of sick young infants, there is need to focus attention to these challenges to enhance sustainable adoption and reduction of young infant morbidity and mortality.

Family and provider perceptions of quality of care in the management of sick young infants in primary healthcare settings in four counties of Kenya.

BACKGROUND: Understanding the perceptions of quality of care given to sick young infants in primary healthcare settings is key for developing strategies for effective uptake and utilisation of possible severe bacterial infection guidelines. The purpose of this study is to assess families and providers' perceptions of care given to sick young infants at primary healthcare facilities in four diverse counties in Kenya. METHODS: A cross-sectional qualitative design involving 37 in-depth interviews and 39 focus group discussions with very young (15-18 years), young (19-24 years) and older (25-45 years) caregivers of young infants aged 0-59 days; and key informant interviews with community-based and facility-based front-line health providers (14) in primary healthcare facilities. Qualitative data were captured using audio tapes and field notes, transcribed, translated and exported into QSR NVivo V.12 for analysis. A thematic framework approach was adopted to classify and analyse data. RESULTS: Perceived care given to sick young infants was described around six domains of the WHO framework for the quality of maternal and newborn healthcare: evidence-based practices for routine and emergency care; functional referral systems; effective communication; respect and preservation of dignity; availability of competent, motivated human resources; and availability of physical resources. Views of caregivers and providers regarding sick young infant care in primary healthcare settings were similar across the four sites. Main hindrance to sick young infant care includes stockout of essential drugs, limited infrastructure, lack of functional referral system, inadequate providers which led to delays in receiving treatment, inadequate provider skills and poor provider attitudes. Despite these challenges, motivation and teamwork of health providers were key tenets in care provision. CONCLUSION: The findings underscore the need to prioritise improving quality of sick young infant services at primary healthcare settings by building capacity of providers through training, ensuring continuous supply of essential medicines and equipment and improving infrastructure including referral.

Incentive preferences for community health volunteers in Kenya: findings from a discrete choice experiment.

BACKGROUND: Community health volunteers (CHVs) play crucial roles in enabling access to healthcare at the community levels. Although CHVs are considered volunteers, programmes provide financial and non-financial incentives. However, there is limited evidence on which bundle of financial and non-financial incentives are most effective for their improved performance. METHODS: We used a discrete choice experiment (DCE) to understand incentive preferences of CHVs with the aim to improve their motivation, performance and retention. Relevant incentive attributes were identified through qualitative interviews with CHVs and with their supervisors. We then deployed a nominal group technique to generate and rank preferred attributes among CHVs. We developed a DCE based on the five attributes and administered it to 211 CHVs in Kilifi and Bungoma counties in Kenya. We used mixed multinomial logit models to estimate the utility of each incentive attribute and calculated the trade-offs the CHWs were willing to make for a change in stipend. RESULTS: Transport was considered the incentive attribute with most relative importance followed by tools of trade then monthly stipend. CHVs preferred job incentives that offered higher monthly stipends even though it was not the most important. They had negative preference for job incentives that provided award mechanisms for the best performing CHVs as compared with jobs that provided recognition at the community level and preferred job incentives that provided more tools of trade compared with those that provided limited tools. CONCLUSION: A bundled incentive of both financial and non-financial packages is necessary to provide a conducive working environment for CHVs. The menu of options relevant for CHVs in Kenya include transport, tools of trade and monthly stipend. Policy decisions should be contextualised to include these attributes to facilitate CHW satisfaction and performance.

Exploring communities' perceptions of the etiology of illnesses in newborns and young infants 0-59 days old in 4 counties in Kenya.

BACKGROUND: Understanding communities' beliefs about the causes of illnesses in sick young infants (SYIs) is key to strengthening interventions and improving newborn health outcomes. This study explored communities' perception of the etiology of illnesses in SYIs 0-59 days old in four counties in Kenya. METHODS: We used an exploratory qualitative study design. Data were collected between August and September 2018 and involved 23 in-depth interviews with female caregivers aged 15-24years; 25 focus group discussions with female caregivers aged 15-18 years, 19-24 years and 25-45 years; and 7 focus group discussions with fathers aged 18-34 years and 35 or more years. Participants were purposely sampled, only those with SYIs 0-59 days old were eligible to participate. Data were analyzed using inductive thematic analysis framework approach. RESULTS: Female caregivers and fathers attributed illnesses in SYIs 0-59 days old to natural (biomedical) and supernatural causes which sometimes co-existed. There were commonalities in perceived natural causes of illness in SYIs across sites, age groups and gender. Perceived natural causes of illness in SYIs include unfavorable environmental and hygiene conditions, poor maternal and child nutrition, and healthcare practices. Perceived supernatural causes of illness in SYIs such as 'evil eyes' were common across the four counties while others were geographically unique such as the belief that owls cause illnesses. CONCLUSION: Communities' understanding of the etiology of illnesses in SYIs in the study settings overlapped between natural and supernatural causes. There is need for child health programmes to take into consideration communities' beliefs and practices regarding disease and health to improve newborn health outcomes.

Health systems software factors and their effect on the integration of sexual and reproductive health and HIV services.

Despite a large and growing body of literature on sexual and reproductive health (SRH) and HIV integration, the drivers of integration of SRH and HIV services, from a health systems perspective, are not well understood. These drivers include complex so-called hardware (structural and resource) and software (values and norms, and human relations and interactions) factors. Two groups of software factors emerge as essential enablers of effective integration of SRH and HIV services that often interact with systems hardware: (1) leadership, management, and governance processes and (2) provider motivation, agency, and relationships. Evidence suggests the potential for software elements that are essential enablers to overcome some of the obstacles posed by the non-integration of health system hardware elements (eg, financing, guidelines, and commodity supplies). These enabling factors include flexible decision making, inclusive management, and support in motivating frontline staff who can work with agency as a team. Improved software, even within constrained hardware (especially in low-income and middle-income countries), can directly contribute to improved SRH and HIV service delivery.

Clinical presentation and outcomes of pre-eclampsia and eclampsia at a national hospital, Kenya: A retrospective cohort study.

BACKGROUND: Hypertensive disorders in pregnancy including pre-eclampsia are associated with maternal and newborn mortality and morbidity. Early detection is vital for effective treatment and management of pre-eclampsia. This study examines and compares the clinical presentation and outcomes between early- and late-onset pre-eclampsia over a two year period. METHODS: A retrospective cohort study design which examines socio-demographic characteristics, treatment, outcomes, and fetal and maternal complications among women with early onset of pre-eclampsia (EO-PE) and late onset of pre-eclampsia (LO-PE). De-identified records of women who attended antenatal, intrapartum and postnatal care services and experienced pre-eclampsia at Kenyatta National teaching and referral hospital were reviewed. We used chi square, t-test, and calculated odds ratio to determine any significant differences between the EO-PE and LO-PE cohorts. RESULTS: Out of 620 pre-eclamptic and eclamptic patients' records analyzed; 44 percent (n = 273) exhibited EO-PE, while 56 percent had late onset. Women with EO-PE compared to LO-PE had greater odds of adverse maternal and perinatal outcomes including hemolysis elevated liver enzymes and low platelets (HELLP) syndrome (OR: 4.3; CI 2.0-10.2; p<0.001), renal dysfunction (OR; 1.7; CI 0.7-4.1; p = 0.192), stillbirth (OR = 4.9; CI 3.1-8.1; p<0.001), and neonatal death (OR: 8.5; CI 3.8-21.3; p<0.001). EO-PE was also associated with higher odds of prolonged maternal hospitalization, beyond seven days (OR = 5.8; CI 3.9-8.4; p<0.001), and antepartum hemorrhage (OR = 5.8; CI 1.1-56.4; p<0.001). Neonates born after early onset of pre-eclampsia had increased odds of respiratory distress (OR = 17.0; CI 9.0-32.3, p<0.001) and birth asphyxia (OR: 1.9; CI 0.7-4.8; p = 0.142). CONCLUSIONS: The profiles and outcomes of women with EO-PE (compared to late onset) suggest that seriousness of morbidity increases with earlier onset. To reduce adverse neonatal and maternal outcomes, it is critical to identify, manage, referral and closely follow-up pregnant women with pre-eclampsia throughout the pregnancy continuum. ETHICAL APPROVAL: This study protocol was approved by Population Council's research ethics Institutional Review Board, Protocol 813, and KNH-UoN Ethics and Research Committee, Protocol 293/06/2017.

Addressing Intimate Partner Violence and Power in Intimate Relationships in HIV Testing Services in Nairobi, Kenya.

Intimate partner violence (IPV) undermines women's uptake of HIV services and violates their human rights. In a two-arm randomized controlled trial we evaluated a short intervention that went a step beyond IPV screening to discuss violence and power with women receiving HIV testing services during antenatal care (ANC). The intervention included training and support for HIV counselors, a take-home card for clients, and an on-site IPV counselor. One third (35%) of women (N = 688) reported experiencing IPV in the past year; 6% were living with HIV. Among women experiencing IPV, program participants were more likely to disclose violence to their counselor than women receiving standard care (32% vs. 7%, p < 0.001). At second ANC visit, intervention group women were significantly more likely to report that talking with their counselor made a positive difference (aOR 2.9; 95% CI 1.8, 4.4; p < 0.001) and felt more confident in how they deserved to be treated (aOR 2.7; 95% CI 1.7, 4.4; p < 0.001). Exploratory analyses of intent to use ARVs to prevent mother-to-child transmission and actions to address violence were also encouraging.

Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries.

OBJECTIVES: Literature on associations between female genital mutilation/cutting (FGM/C) and fistula points to a common belief that FGM/C predisposes women to developing fistula. This study explores this association using nationally representative survey data. DESIGN: A secondary statistical analysis of cross-sectional data from Demographic and Health Surveys was conducted to explore the association between FGM/C and fistula. SETTING: Sub-Saharan Africa. PARTICIPANTS: Women aged 15-49 years in Burkina Faso (n=17 087), Chad (n=17 719), Côte d'Ivoire (n=10 060), Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) and Sierra Leone (n=16 658). MAIN OUTCOME MEASURES: Fistula symptoms. RESULTS: Multivariate logit modelling using pooled data from 10 countries showed that the odds of reporting fistula symptoms were 1.5 times (CI 1.06 to 2.21) higher for women whose genitals were cut and sewn closed than those who had undergone other types of FGM/C. Women who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report fistula symptoms than those who did not attend ANC or lived in rural areas. CONCLUSIONS: Severe forms of FGM/C (infibulation) may predispose women to fistula. Contextual and socioeconomic factors may increase the likelihood of fistula. Multisectoral interventions that concurrently address harmful traditional practices such as FGM/C and other contextual factors that drive the occurrence of fistula are warranted. Promotion of ANC utilisation could be a starting point in the prevention of fistulas.

Integration of HIV and reproductive health services in public sector facilities: analysis of client flow data over time in Kenya.

INTRODUCTION: Integration of HIV/AIDS with reproductive health (RH) services can increase the uptake and efficiency of services, but gaps in knowledge remain about the practice of integration, particularly how provision can be expanded and performance enhanced. We assessed the extent and nature of service integration in public sector facilities in four districts in Kenya. METHODS: Between 2009 and 2012, client flow assessments were conducted at six time points in 24 government facilities, purposively selected as intervention or comparison sites. A total of 25 539 visits were tracked: 15 270 in districts where 6 of 12 facilities received an intervention to strengthen HIV service integration with family planning (FP); and 10 266 visits in districts where half the facilities received an HIV-postnatal care intervention in 2009-2010. We tracked the proportion of all visits in which: (1) an HIV service (testing, counselling or treatment) was received together with an RH service (FP counselling or provision, antenatal care, or postnatal care); (2) the client received HIV counselling. RESULTS: Levels of integrated HIV-RH services and HIV counselling were generally low across facilities and time points. An initial boost in integration was observed in most intervention sites, driven by integration of HIV services with FP counselling and provision, and declined after the first follow-up. Integration at most sites was driven by temporary rises in HIV counselling. The most consistent combination of HIV services was with antenatal care; the least common was with postnatal care. CONCLUSIONS: These client flow data demonstrated a short-term boost in integration, after an initial intervention with FP services providing an opportunity to expand integration. Integration was not sustained over time highlighting the need for ongoing support. There are multiple opportunities for integrating service delivery, particularly within antenatal, FP and HIV counselling services, but a need for sustained systems and health worker support over time. TRIAL REGISTRATION NUMBER: NCT01694862.

Measuring mistreatment of women throughout the birthing process: implications for quality of care assessments.

Measuring mistreatment and quality of care during childbirth is important in promoting respectful maternity care. We describe these dimensions throughout the birthing process from admission, delivery and immediate postpartum care. We observed 677 client-provider interactions and conducted 13 facility assessments in Kenya. We used descriptive statistics and logistic regression model to illustrate how mistreatment and clinical process of care vary through the birthing process. During admission, the prevalence of verbal abuse was 18%, lack of informed consent 59%, and lack of privacy 67%. Women with higher parity were more likely to be verbally abused [AOR: 1.69; (95% CI 1.03,2.77)]. During delivery, low levels of verbal and physical abuse were observed, but lack of privacy and unhygienic practices were prevalent during delivery and postpartum (>65%). Women were less likely to be verbally abused [AOR: 0.88 (95% CI 0.78, 0.99)] or experience unhygienic practices, [AOR: 0.87 (95% CI 0.78, 0.97)] in better-equipped facilities. During admission, providers were observed creating rapport (52%), taking medical history (82%), conducting physical assessments (5%). Women's likelihood to receive a physical assessment increased with higher infrastructural scores during admission [AOR: 2.52; (95% CI 2.03, 3.21)] and immediately postpartum [AOR 2.18; (95% CI 1.24, 3.82)]. Night-time deliveries were associated with lower likelihood of physical assessment and rapport creation [AOR; 0.58; (95% CI 0.41,0.86)]. The variability of mistreatment and clinical quality of maternity along the birthing process suggests health system drivers that influence provider behaviour and health facility environment should be considered for quality improvement and reduction of mistreatment.