"They talked to me rudely". Women perspectives on quality of post-abortion care in public health facilities in Kenya.

BACKGROUND: Access to safe abortion is legally restricted in Kenya. Therefore, majority women seeking abortion services in such restrictive contexts resort to unsafe methods and procedures that result in complications that often require treatment in health facilities. Most women with abortion-related complications end up in public health facilities. Nevertheless, evidence is limited on the quality of care provided to patients with abortion complications in public health facilities in Kenya. METHODS: Data for this paper are drawn from a qualitative study that included interviews with 66 women who received post-abortion care in a sample of primary, secondary and tertiary public health facilities in Kenya between November 2018 and February 2019. The interviews focused on mechanisms of decision-making while seeking post-abortion care services, care pathways within facilities, and perceptions of patients on quality of care received including respect, privacy, confidentiality, communication and stigma. FINDINGS: The participants' perceptions of the quality of care were characterized as either "bad care" or "good care", with the good care focusing on interpersonal aspects such as friendliness, respect, empathy, short waiting time before receiving services, as well as the physical or functional aspects of care such as resolution of morbidity and absence of death. Majority of participants initially reported that they received "good care" because they left the facility with their medical problem resolved. However, when probed, about half of them reported delays in receiving care despite their condition being an emergency (i.e., severe bleeding and pain). Participants also reported instances of abuse (verbal and sexual) or absence of privacy during care and inadequate involvement in decisions around the nature and type of care they received. Our findings also suggest that healthcare providers treated patients differently based on their attributes (spontaneous versus induced abortion, single versus married, young versus older). For instance, women who experienced miscarriages reported supportive care whereas women suspected to have induced their abortions felt stigmatized. CONCLUSION: These findings have far reaching implications on efforts to improve uptake of post-abortion care, care seeking behaviors and on how to assess quality of abortion care. There should be emphasis on interventions meant to enhance processes and structural indicators of post-abortion care services meant to improve patients' experiences throughout the care process. Moreover, more efforts are needed to advance the tools and approaches for assessing women experiences during post-abortion care beyond just the overriding clinical outcomes of care.

Access to abortion is legally restricted and socially reproved in Kenya. Therefore, women requiring abortion in such restrictive contexts resort to unsafe methods that result in complications, often requiring treatment in health facilities. Nevertheless, there is limited evidence on the quality of care provided in public health facilities in Kenya to patients treated for abortion complications. This paper is drawn from a qualitative study targeting 66 women treated for abortion complication in a sample of primary, secondary and tertiary public health facilities in Kenya between November 2018 and February 2019. The interviews focused on the women's perceptions around the quality of care they received.Our findings show that while the majority of participants stated in first instances that they received "good care" because they left the facility with their medical problem resolved, half of them, when probed, reported delays in receiving care, yet their condition was seen as an emergency since they were bleeding and experiencing pain. Participants also reported instances of abuse (verbal and physical) or lack of privacy during care and inadequate involvement in decisions on the type of care they were to receive. Our findings also point out that providers treated patients differently based on their attributes (spontaneous versus induced abortion, single versus married, young versus older), with women who experienced miscarriages receiving supportive care while women suspected to have induced their abortion being stigmatized.In conclusion, our findings have far reaching implications on efforts to improve post-abortion seeking behaviors and on how to assess quality of abortion care.

Health systems' preparedness to provide post-abortion care: assessment of health facilities in Burkina Faso, Kenya and Nigeria.

BACKGROUND: In many parts of sub-Saharan Africa, access to abortion is legally restricted, which partly contributes to high incidence of unsafe abortion. This may result in unsafe abortion-related complications that demand long hospital stays, treatment and attendance by skilled health providers. There is however, limited knowledge on the capacity of public health facilities to deliver post-abortion care (PAC), and the spread of PAC services in these settings. We describe and discuss the preparedness and capacity of public health facilities to deliver complete and quality PAC services in Burkina Faso, Kenya and Nigeria. METHODS: A cross-sectional survey of primary, secondary and tertiary-level public health facilities was conducted between November 2018 and February 2019 in the three countries. Data on signal functions (including information on essential equipment and supplies, staffing and training among others) for measuring the ability of health facilities to provide post-abortion services were collected and analyzed. RESULTS: Across the three countries, fewer primary health facilities (ranging from 6.3-12.1% in Kenya and Burkina Faso) had the capacity to deliver on all components of basic PAC services. Approximately one-third (26-43%) of referral facilities across Burkina Faso, Kenya and Nigeria could provide comprehensive PAC services. Lack of trained staff, absence of necessary equipment and lack of PAC commodities and supplies were a main reason for inability to deliver specific PAC services (such as surgical procedures for abortion complications, blood transfusion and post-PAC contraceptive counselling). Further, the lack of capacity to refer acute PAC cases to higher-level facilities was identified as a key weakness in provision of post-abortion care services. CONCLUSIONS: Our findings reveal considerable gaps and weaknesses in the delivery of basic and comprehensive PAC within the three countries, linked to both the legal and policy contexts for abortion as well as broad health system challenges in the countries. There is a need for increased investments by governments to strengthen the capacity of primary, secondary and tertiary public health facilities to deliver quality PAC services, in order to increase access to PAC and avert preventable maternal mortalities.

Describing the safety of abortion at the population level using network-based survey approaches.

BACKGROUND: Despite the negative impact of unsafe abortions on women's health and rights, the degree of abortion safety remains strikingly undocumented for a large share of abortions globally. Data on how women induce abortions (method, setting, provider) are central to the measurement of abortion safety. However, health-facility statistics and direct questioning in population surveys do not yield representative data on abortion care seeking pathways in settings where access to abortion services is highly restricted. Recent developments in survey methodologies to study stigmatized / illegal behaviour and hidden populations rely on the fact that such information circulates within social networks; however, such efforts have yet to give convincing results for unsafe abortions. OBJECTIVE: This article presents the protocol of a study whose purpose is to apply and develop further two network-based methods to contribute to the generation of reliable population-level information on the safety of abortions in contexts where access to legal abortion services is highly restricted. METHODS: This study plans to obtain population-level data on abortion care seeking in two Health and Demographic Surveillance Systems in urban Kenya and rural Burkina Faso by applying two methods: Anonymous Third-Party Reporting (ATPR) (also known as confidantes' method) and Respondent Driven Sampling (RDS). We will conduct a mixed methods formative study to determine whether these network-based approaches are pertinent in the study contexts. The ATPR will be refined notably by incorporating elements of the Network Scale-Up Method (NSUM) to correct or account for certain of its biases (transmission, barrier, social desirability, selection). The RDS will provide reliable alternative estimates of abortion safety if large samples and equilibrium can be reached; an RDS multiplex variant (also including social referents) will be tested. DISCUSSION: This study aims at documenting abortion safety in two local sites using ATPR and RDS. If successful, it will provide data on the safety profiles of abortion seekers across sociodemographic categories in two contrasted settings in sub-Saharan Africa. It will advance the formative research needed to determine whether ATPR and RDS are applicable or not in a given context. It will improve the questionnaire and correcting factors for the ATPR, improve the capacity of RDS to produce quasi-representative data on abortion safety, and advance the validation of both methods.

Representative data on how women induce abortions and their consequences are central to measurements of abortion safety. However, due to the stigmatized nature of abortion, measuring the details of the process is challenging when the latter occur out of the realm of the law and do not result in complications registered in hospital statistics. Hence, there is sparse empirical population-level data on how women terminate their pregnancies in countries where access to abortion services is highly restricted, as well as little data on the side effects and complications associated with the methods they chose and health seeking for these complications. Recent developments in indirect survey methodologies to study stigmatized/illegal behaviour and hidden populations are likely to improve the quality of data collected on abortion safety in restrictive contexts: all are based on the sharing of information on stigmatized practices in social networks. We propose to refine and pilot two such network-based methods to validate their use for collecting (quasi) representative data on abortion safety in large population health surveys. These two approaches are: (i) a modified Anonymous Third-Party Reporting method (ATPR) integrating elements of the Network-Scale-up Method (NSUM) and (ii) Respondent-Driven Sampling (RDS). We will conduct this study in two African Health and Demographic Surveillance Systems (HDSS) sites, one urban (Nairobi, Kenya), and one comprising a town and adjacent villages (Kaya, Burkina Faso).

Cost of maternal near miss and potentially life-threatening conditions, Kenya.

OBJECTIVE: To estimate the direct costs of treating women with maternal near misses and potentially life-threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households. METHODS: As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure. FINDINGS: Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of-pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure. CONCLUSION: The cost of treating maternal near misses is high and leads to catastrophic spending through out-of-pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women.

"Those are things for married people" exploring parents'/adults' and adolescents' perspectives on contraceptives in Narok and Homa Bay Counties, Kenya.

BACKGROUND: Contraceptive use among adolescent girls is low in many sub-Saharan African countries including Kenya. Attitude and perspectives about contraception of community members including adolescent girls themselves may be likely to limit contraceptive use among adolescent girls. This study was conducted to explore and compare adults'/parents' and adolescent girls' narratives and perspectives about contraception in Narok and Homa Bay counties, Kenya. METHODS: Qualitative data from 45 in-depth-interviews conducted with purposively selected consenting adolescent girls aged 15-19 was used. Additionally, twelve focus group discussions were held with 86 consenting adults conveniently recruited from the two counties. All discussions were conducted in the local language and audio recorded following consent of the study participants. Female moderators were engaged throughout the study making it appropriate for the study to solicit feedback from the targeted respondents. RESULTS: Findings highlighted adults' perceptions on adolescents' sexuality and the presence of stringent conceptions about the side-effects of contraception in the study communities. Some participants underscored the need for open contraceptive talk between parents and their adolescent girls. Four main themes emerged from the discussions; (i) Perceptions about adolescents' sexuality and risk prevention, (ii) Conceptions about contraception among nulligravida adolescents: fear of infertility, malformation and sexual libertinism, (iii) Post-pregnancy contraceptive considerations and (iv) Thinking differently: divergent views regarding contraceptives and parent/adolescent discussion. CONCLUSIONS: Our findings suggest the need for increased attention towards adolescents and their caregivers particularly in demystifying contraceptive misconceptions. Programmatic responses and models which include the provision of comprehensive sexuality education and increased access to and utilization of SRH information, products and services through a well-informed approach need to be well executed. Programmatic efforts like SRH community education should further seek to enhance the capacity of parents to discuss sexuality with their adolescents.

Adolescent Fertility Is Lower than Expected in Rural Areas: Results from 10 African HDSS.

The adolescent birth rate (ABR) is an important indicator of maternal health, adolescent sexual health, and gender equity; it remains high in sub-Saharan Africa. While Demographic and Health Surveys (DHS) are the main source of ABR estimates, Health and Demographic Surveillance Systems (HDSS) also produce ABRs. Studies are lacking, however, to assess the ease of access and accuracy of HDSS ABR measures. In this paper, we use birth and exposure data from 10 HDSS in six African countries to compute local ABRs and compare these rates to DHS regional rates where the HDSS sites are located, standardizing by education and place of residence. In rural HDSS sites, the ABR measure is on average 44 percent lower than the DHS measure, after controlling for education and place of residence. Strong temporary migration of childless young women out of rural areas and different capacities in capturing temporarily absent women in the DHS and HDSS could explain this discrepancy. Further comparisons based on more strictly similar populations and measures seem warranted.

Nature of, and responses to key sexual and reproductive health challenges for adolescents in urban slums in sub-Saharan Africa: a scoping review.

BACKGROUND: Addressing adolescents' sexual and reproductive health and rights (SRHR) requires an understanding of the socio-cultural and spatial settings within which they live. One setting of particular importance is the informal settlements or 'slums' that are gradually dominating the urban space. We undertook a scoping review and synthesis of existing evidence on adolescent SRHR in slums in sub-Saharan Africa (SSA) focusing on the characteristics and nature of existing evidence. METHODS: The scoping review was conducted based on Arksey and O'Malley framework and in accordance with the guidance on scoping reviews from the Joanna Briggs Institute (JBI) and using PRISMA reporting guidelines for scoping reviews. A comprehensive search was undertaken in PubMed, POPLINE, African Journals Online (AJOL), Bioline International and Google Scholar. The search was confined to studies published in peer reviewed journals and reports published online between January 2000 and May 2019. Studies were included in the review if they addressed SRHR issues among adolescents living in urban slums in SSA. RESULTS: The review included a total of 54 studies. The majority (79.5%) of studies were quantitative. The bulk of studies (85.2%) were observational studies with only eight intervention studies. While half (27) of the studies focused exclusively on adolescents (10-19 years), 12 studies combined adolescents with other young people (10-24 years). The studies were skewed towards sexual behavior (44%) and HIV/AIDS (43%) with very few studies focusing on other SRHR issues such as contraception, abortion, gender-based violence and sexually transmitted infections (STIs) other than HIV. Most of the studies highlighted the significantly higher risks for poor SRHR outcomes among adolescents in slums as compared to their peers in other settlements. CONCLUSION: Young people growing up in slums face tremendous challenges in relation to their SRHR needs resulting in poor outcomes such as early and unintended pregnancy, STIs, and sexual violence. The results of this review point to several potential target areas for programming, policy, and research aimed at improved adolescent SRHR in slums in SSA.

The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation.

BACKGROUND: In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. METHODS: A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. RESULTS: Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. CONCLUSIONS: Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

Strengthening capacity to research the social determinants of health in low- and middle-income countries: lessons from the INTREC programme.

BACKGROUND: The INDEPTH Training & Research Centres of Excellence (INTREC) collaboration developed a training programme to strengthen social determinants of health (SDH) research in low- and middle-income countries (LMICs). It was piloted among health- and demographic researchers from 9 countries in Africa and Asia. The programme followed a blended learning approach and was split into three consecutive teaching blocks over a 12-month period: 1) an online course of 7 video lectures and assignments on the theory of SDH research; 2) a 2-week qualitative and quantitative methods workshop; and 3) a 1-week data analysis workshop. This report aims to summarise the student evaluations of the pilot and to suggest key lessons for future approaches to strengthen SDH research capacity in LMICs. METHODS: Semi-structured interviews and questionnaires with 24 students from 9 countries in Africa and Asia were used to evaluate each teaching block. Information was collected about the students' motivation and interest in studying SDH, any challenges they faced during the consecutive teaching blocks, and suggestions they had for future courses on SDH. RESULTS: Of the 24 students who began the programme, 13 (54%) completed all training activities. The students recognised the need for such a course and its potential to improve their skills as health researchers. The main challenges with the online course were time management, prior knowledge and skills required to participate in the course, and the need to get feedback from teaching staff throughout the learning process. All students found the face-to-face workshops to be of high quality and value for their work, because they offered an opportunity to clarify SDH concepts taught during the online course and to gain practical research skills. After the final teaching block, students felt they had improved their data analysis skills and were better able to develop research proposals, scientific manuscripts, and policy briefs. CONCLUSIONS: The INTREC programme has trained a promising cadre of health researchers who live and work in LMICs, which is an essential component of efforts to identify and reduce national and local level health inequities. Time management and technological issues were the greatest challenges, which can inform future attempts to strengthen research capacity on SDH.

Barriers to post-abortion care service provision: A cross-sectional analysis in Burkina Faso, Kenya and Nigeria.

Despite several political commitments to ensure the availability of and access to post-abortion care services, women in sub-Saharan Africa still struggle to access quality post-abortion care, and with devastating social and economic consequences. Expanding access to post-abortion care while eliminating barriers to utilization could significantly reduce abortions-related morbidity and mortality. We describe the barriers to providing and utilizing post-abortion care across health facilities in Burkina Faso, Kenya, and Nigeria. This paper draws on three data sources: health facility assessment data, patient-exit interview data, and qualitative interviews conducted with healthcare providers and policymakers. All data were based on a cross-sectional survey of a nationally representative sample of health facilities conducted between November 2018 and February 2019. Data on post-abortion care service indicators were collected, including staffing levels and staff training, availability of post-abortion care supplies, equipment and commodities. Patient-exit interviews focused on patients treated for post-abortion complications. In-depth interviews were conducted with healthcare providers within a sample of the study health facilities and national or local decision-makers in sexual and reproductive health. Few primary-level facilities in Burkina Faso (15%), Kenya (46%), and Nigeria (20%) had staff trained on post-abortion care. Only 16.6% of facilities in Kenya had functional operating theaters or MVA rooms, Burkina Faso (20.3%) and Nigeria (50.7%). Primary facilities refer post-abortion care cases to higher-level facilities despite needing to be more adequately equipped to facilitate these referrals. Several challenges that impede the provision of quality and comprehensive post-abortion care across the three countries. The absence of post-abortion care training, equipment, and inadequate referral capacity was among the critical reasons for the lack of services. There is a need to strengthen post-abortion care services across all levels of the health system, but especially at lower-level facilities where most patients seek care first.

"I always know she cannot betray me." Disclosure of abortion and methods of abortion used in informal settlements in Nairobi, Kenya.

Despite abortion being stigmatized and legally restricted in Kenya, women still disclose their abortions within their network. Evidence has shown how stigma can influence and regulate individual abortion disclosure decisions and behaviors. This paper seeks to understand why and how women make the decisions to disclose their abortion and the associated methods used. The data are from a qualitative formative study and a respondent-driven sampling survey conducted between 2020 and 2021 in two informal settlements in Nairobi, Kenya. The data were analyzed using a descriptive analysis approach for the quantitative data, and thematic analysis for the qualitative data. Our findings reveal that information sharing about abortion is enclosed in a social dynamic of secrecy. This dynamic contributes to making abortion a secret that respondents decided to share with confidants in 81% of the abortion cases. These confidants include intimate relationships such as trusted friends (62%), followed by female relatives. Information was shared in many cases either to get support (i.e. method to use), or because participants had close ties with the confidants. Regarding the methods used, unidentified pills were the most used regardless of the confidant; followed by traditional methods especially among those who sought help with their mothers/aunts/grandmothers (33%), while Medical Abortion and Manual Vacuum Aspiration were rarely used, mostly by those who confided in friends or sisters/cousins. Our findings show that the disclosure of abortion is a complex process embedded in existing codes regarding the circulation of information on sensitive issues and "help" seeking. Our findings show that the need for information on safe abortion and lack of financial resources frequently empowers them to overcome the fear of stigma and disclose their abortion. However, this often resulted in use of unsafe procedures. The findings suggest the need for strengthening the circulation of information on safe methods within communities, using community champions and intermediaries to increase the likelihood of women being directed through safe methods to enhance their use.

Review of contributions from HDSSs to research in sexual and reproductive health in low- and middle-income countries.

OBJECTIVE: To evaluate the contributions of the INDEPTH Network of health and demographic surveillance system (HDSS) members to research efforts and interventions on reproductive health in low- and middle-income countries (LMICs). METHODS: Review of peer-reviewed published papers on sexual and reproductive health (SRH) that use the HDSS framework through (i) an online search for publications using terminology related to HDSS, HIV, Maternal health, adolescent sexual and reproductive health, family planning/contraceptives and fertility, and (ii) asking INDEPTH member centres for information on their published papers on SRH publications that used the HDSS framework. A paper was included in the review only if it used HDSS data, dealt with SRH issues, and had been published in a peer-reviewed international journal. RESULTS: Most of the papers in the review focused on HIV, maternal health, family planning and adolescent sexual and reproductive health (ASRH). Generally, people are knowledgeable about HIV. School attendance considerably delays entry into motherhood and reduces the probability of entering into early marriage or sexual union. The general decline in maternal mortality over the last decade is partly due to better access to emergency obstetric services, improved education of women and reduction in fertility. CONCLUSION: Sexual and reproductive health is a significant public health need, yet little research has been published in this area to inform policy. The HDSS framework is ideal for SRH research, as it offers the advantage to track and monitor progress of relevant health and demographic indicators, especially in family planning, marriage and fertility studies.

Impact of kinship support on child mortality in the Upper East Region of Ghana: assessing the Grandmother Hypothesis.

BACKGROUND: The grandmother is an important kin member whose contribution to childcare and survival has been recognized in the literature, hence the Grandmother Hypothesis. This article examines the effect of the presence of a grandmother on child mortality. METHODS: Data were obtained from the Navrongo Health and Demographic Surveillance System, located in the Upper East Region of Ghana. Children born between January 1999 and December 2018 were included in the analysis. Person-months lived for each child were generated. The multilevel Poisson regression technique was employed to investigate the effect of a grandmother on child survival. RESULTS: In all, 57 116 children were included in the analysis, of which 7% died before age 5 y. Person-months were generated for the children, which produced 2.7 million records, with about 487 800 person-years. After controlling for confounders, results showed that children in households with paternal grandmothers are 11% less likely to die compared with those without paternal grandmothers. However, when other confounders were taken into accounts, the beneficial effect of maternal grandmothers disappeared. CONCLUSIONS: We conclude that the presence of grandmothers improves child survival, thus sustaining the Grandmother Hypothesis. The experiences of these grandmothers should be tapped to improve child survival, particularly in rural areas.

Why do most young women not take up contraceptives after post-abortion care? An ethnographic study on the effectiveness and quality of contraceptive counselling after PAC in Kilifi County, Kenya.

Post-abortion care (PAC) counselling and the provision of contraceptive methods are core components of PAC services. Nevertheless, this service is not uniformly provided to PAC patients. This paper explores the factors contributing to young women leaving health facilities without counselling and contraceptive methods. The paper draws from an ethnographic study conducted in Kilifi County, Kenya, in 2021. We conducted participant observation in health facilities and neighbouring communities, and held in-depth interviews with 21 young women aged 15-24 who received PAC. In addition, we interviewed 11 healthcare providers recruited from the public and private health facilities observed. Findings revealed that post-abortion contraceptive counselling and methods were not always offered to patients as part of PAC as prescribed in the PAC guidelines. When PAC contraceptive counselling was offered, certain barriers affected uptake of the methods, including inadequate information, coercion by providers and partners, and fears of side effects. Together, these factors contributed to repeat unintended pregnancies and repeat abortions. The absence of quality contraceptive counselling therefore infringes on the right to health of girls and young women. Findings underscore the need to strengthen the capacities of health providers on PAC contraceptive counselling and address their attitudes towards young female PAC patients.

Profil des utilisatrices et facteurs associés à la satisfaction des clientes de la qualité des soins après avortement au Burkina Faso: étude transversale menée dans six régions.

RésuméMalgré la dépénalisation de l'avortement et la gratuité des soins après avortement (SAA), les femmes Burkinabè vivent des relations difficiles avec les soignants. Cette étude vise à déterminer le profil des femmes recevant des SAA, leur perception de la qualité des SAA et ses déterminants dans des structures sanitaires publiques et confessionnelles du pays. Une enquête quantitative a été menée auprès de 2174 femmes vues pour des SAA et recrutées de façon exhaustive de 2018 à 2020. Un questionnaire structuré a été administré à la sortie des soins. Une analyse uni-, bi- et multivariée a été faite. La majorité des clientes de SAA vivait en milieu rural (55%), avait 25 ans et plus (60%), vivait en couple (87%) et était sans-emploi (59%). La grossesse était non désirée chez 17% des femmes et 4% d'entre elles souhaitaient avorter. La satisfaction globale de la qualité des SAA était de 84%. Dans l'analyse multivariée, ses déterminants étaient la résidence en milieu rural (OR = 1.80 [1.38; 2.34]), un niveau scolaire primaire (OR = 1.48 [1.06; 2.07]) ou secondaire (OR = 1.95 [1.38; 2.74]), et avoir eu au moins un enfant (OR = 1.43 [1.02; 2.00]). Les facteurs associés à une faible satisfaction des SAA étaient une grossesse non désirée (OR = 0.64 [0.46; 0.89]) ou avoir souhaité avorter (OR = 0.09 [0.05; 0.16]). Le niveau de satisfaction globale est acceptable mais faible chez les clientes ayant souhaité avorter. Il est fondamental d'organiser un programme de formation des professionnels des SAA sur la communication, la relation interpersonnelle et l'empathie pendant les soins de santé.

Trends and risk factors for non-communicable diseases mortality in Nairobi slums (2008-2017).

INTRODUCTION: Tracking progress in reaching global targets for reducing premature mortality from non-communicable diseases (NCDs) requires accurately collected population based longitudinal data. However, most African countries lack such data because of weak or non-existent civil registration systems. We used data from the Nairobi Urban Health and Demographic Surveillance System (NUDSS) to estimate NCD mortality trends over time and to explore the determinants of NCD mortality. METHODS: Deaths identified in the NUHDSS were followed up with a verbal autopsy to determine the signs and symptoms preceding the death. Causes of death were then assigned using InSilicoVA algorithm. We calculated the rates of NCD mortality in the whole NUHDSS population between 2008 and 2017, looking at how these changed over time. We then merged NCD survey data collected in 2008, which contains information on potential determinants of NCD mortality in a sub-sample of the NUHDSS population, with follow up information from the full NUHDSS including whether any of the participants died of an NCD or non-NCD cause. Poisson regression models were used to identify independent risk factors (broadly categorized as socio-demographic, behavioural and physiological) for NCD mortality, as well as non-NCD mortality. RESULTS: In the total NUHDSS population of adults age 18 and over, 23% were assigned an NCD as the most likely cause of death. There was evidence that NCD mortality decreased over the study period, with rates of NCD mortality dropping from 1.32 per 1000 person years in 2008-10 (95% CI: 1.13-1.54) to 0.93 per 1000 person years in 2014-17 (95% CI: 0.80-1.08). Of 5115 individuals who participated in the NCD survey in 2008, 421 died during the follow-up period of which 43% were attributed to NCDs. Increasing age, lower education levels, ever smoking and having high blood pressure were identified as independent determinants of NCD mortality in multivariate analyses. CONCLUSION: We found that NCDs account for one-quarter of mortality in Nairobi slums, although we document a reduction in the rate of NCD mortality over time. This may be attributed to increased surveillance and introduction of population-wide NCD interventions and health system improvements from research activities in the slums. To achieve further decline there is a need to strengthen health systems to respond to NCD care and prevention along with addressing social factors such as education.

Incidence of maternal near-miss in Kenya in 2018: findings from a nationally representative cross-sectional study in 54 referral hospitals.

Although the Kenyan government has made efforts to invest in maternal health over the past 15 years, there is no evidence of decline in maternal mortality. To provide necessary evidence to inform maternal health care provision, we conducted a nationally representative study to describe the incidence and causes of maternal near-miss (MNM), and the quality of obstetric care in referral hospitals in Kenya. We collected data from 54 referral hospitals in 27 counties. Individuals admitted with potentially life-threatening conditions (using World Health Organization criteria) in pregnancy, childbirth or puerperium over a three month study period were eligible for inclusion in our study. All cases of severe maternal outcome (SMO, MNM cases and deaths) were prospectively identified, and after consent, included in the study. The national annual incidence of MNM was 7.2 per 1,000 live births and the intra-hospital maternal mortality ratio was 36.2 per 100,000 live births. The major causes of SMOs were postpartum haemorrhage and severe pre-eclampsia/eclampsia. However, only 77% of women with severe preeclampsia/eclampsia received magnesium sulphate and 67% with antepartum haemorrhage who needed blood received it. To reduce the burden of SMOs in Kenya, there is need for timely management of complications and improved access to essential emergency obstetric care interventions.

Barriers and facilitators to care-seeking among survivors of gender-based violence in the Dadaab refugee complex.

In humanitarian settings, timely access to care is essential for survivors of gender-based violence (GBV). Despite the existence of GBV support services, challenges still exist in maximising benefits for survivors. This study aimed to understand the characteristics of violence against women and explore barriers and facilitators to care-seeking for GBV by women in two camps within the Dadaab refugee complex in Kenya. A mixed-methods design was used to study women accessing comprehensive GBV services between February 2016 and February 2017. Women were recruited into a cohort study (n = 209) and some purposively selected for qualitative in-depth interviews (n = 34). Survivor characteristics were descriptively analysed from baseline measures, and interview data thematically assessed. A majority of women were Muslim, of Somali origin, had been residents in the camp for more than five years, with little or no formal education, and meagre or no monthly income. From the survey, 60.3% and 66.7% of women had experienced non-partner violence or intimate partner violence in their lifetime respectively. Facilitators to accessing GBV services by survivors included awareness of GBV services and self-perceived high severity of acts of violence. Barriers included stigma by family and the community, fear of further violence from perpetrators, feelings of helplessness and insecurity, and being denied entry to service provision premises by guards. Women in the Dadaab refugee camps face violence from intimate partners, family, and other refugees. There is an urgent need to address drivers of GBV and the barriers to disclosure and access to services for all survivors of GBV.

Gender-based violence and its association with mental health among Somali women in a Kenyan refugee camp: a latent class analysis.

BACKGROUND: In conflict-affected settings, women and girls are vulnerable to gender-based violence (GBV). GBV is associated with poor long-term mental health such as anxiety, depression and post-traumatic stress disorder (PTSD). Understanding the interaction between current violence and past conflict-related violence with ongoing mental health is essential for improving mental health service provision in refugee camps. METHODS: Using data collected from 209 women attending GBV case management centres in the Dadaab refugee camps, Kenya, we grouped women by recent experience of GBV using latent class analysis and modelled the relationship between the groups and symptomatic scores for anxiety, depression and PTSD using linear regression. RESULTS: Women with past-year experience of intimate partner violence alone may have a higher risk of depression than women with past-year experience of non-partner violence alone (Coef. 1.68, 95% CI 0.25 to 3.11). Conflict-related violence was an important risk factor for poor mental health among women who accessed GBV services, despite time since occurrence (average time in camp was 11.5 years) and even for those with a past-year experience of GBV (Anxiety: 3.48, 1.85-5.10; Depression: 2.26, 0.51-4.02; PTSD: 6.83, 4.21-9.44). CONCLUSION: Refugee women who experienced past-year intimate partner violence or conflict-related violence may be at increased risk of depression, anxiety or PTSD. Service providers should be aware that compared to the general refugee population, women who have experienced violence may require additional psychological support and recognise the enduring impact of violence that occurred before, during and after periods of conflict and tailor outreach and treatment services accordingly.

Disability, violence, and mental health among Somali refugee women in a humanitarian setting.

BACKGROUND: There is limited evidence on the relationship between disability, experiences of gender-based violence (GBV), and mental health among refugee women in humanitarian contexts. METHODS: A cross-sectional analysis was conducted of baseline data (n = 209) collected from women enrolled in a cohort study of refugee women accessing GBV response services in the Dadaab refugee camps in Kenya. Women were surveyed about GBV experiences (past 12 months, before the last 12 months, before arriving in the refugee camps), functional disability status, and mental health (anxiety, depression, post-traumatic stress), and we explored the inter-relationship of these factors. RESULTS: Among women accessing GBV response services, 44% reported a disability. A higher proportion of women with a disability (69%) reported a past-year experience of physical intimate partner violence and/or physical or sexual non-partner violence, compared to women without a disability (54%). A higher proportion of women with a disability (32%) experienced non-partner physical or sexual violence before arriving in the camp compared to women without a disability (16%). Disability was associated with higher scores for depression (1.93, 95% confidence interval (CI) 0.54-3.33), PTSD (2.26, 95% CI 0.03-4.49), and anxiety (1.54, 95% CI 0.13-2.95) after adjusting for age, length of encampment, partner status, number of children, and GBV indicators. CONCLUSIONS: A large proportion of refugee women seeking GBV response services have disabilities, and refugee women with a disability are at high risk of poor mental health. This research highlights the need for mental health and disability screening within GBV response programming.