Adherence to option B + antiretroviral therapy and associated factors in pregnant and breastfeeding women in Sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: To assess the adherence to option B + antiretroviral therapy (ART) and associated factors in pregnant and breastfeeding women in Sub-Saharan Africa (SSA). METHODS: We conducted a comprehensive search from 01st January 2012 to 03rd October 2022, across four databases: PubMed, Scopus, Proquest Central, and Index Medicus Africain, to identify studies focused on pregnant and/or breastfeeding women living with HIV and receiving option B+ ART in SSA. Studies reporting adherence data were included in the meta-analysis. Were excluded studies published before 01st January 2012, grey literature, systematic reviews, and meta-analysis studies. Articles selection and data extraction were performed independently by two reviewers. We evaluated pooled adherence and pooled association between various factors and adherence using a random-effects model. RESULTS: Overall, 42 studies involving 15,158 participants across 15 countries contributed to the meta-analysis. The overall pooled adherence was 72.3% (95% CI: 68.2-76.1%). Having high education level (pooled odds ratio (OR): 2.25; 95% CI: 1.57-3.21), living in urban area (pooled OR: 1.75; 95% CI: 1.10-2.81), disclosing status to a family/partner (pooled OR: 1.74; 95% CI: 1.27-2.40), having a support system (pooled OR: 3.19; 95% CI: 1.89-5.36), receiving counseling (pooled OR: 3.97; 95% CI: 2.96-5.34), initiating ART at early clinical HIV stage (pooled OR: 2.22; 95% CI: 1.08-4.56), and having good knowledge on PMTCT/HIV (pooled OR: 2.71; 95% CI: 1.40-5.25) were factors significantly associated with adherence to option B + ART. CONCLUSIONS: Despite the implementation of option B+ ART, the level of adherence among pregnant and breastfeeding women in SSA falls short of meeting the critical thresholds for viral load suppression as outlined in the 95-95-95 objectives set for 2025. These objectives are integral for achieving HIV elimination, and in turn, preventing HIV mother-to-child transmission. To bridge this gap, urgent tailored interventions based on individual and structural factors are essential to enhance adherence within these subgroups of women. This targeted approach is crucial in striving towards the HIV elimination target in SSA.

Perspectives and experiences of healthcare providers on the response to the COVID-19 pandemic in three maternal and neonatal referral hospitals in Guinea in 2020: a qualitative study.

BACKGROUND: The COVID-19 pandemic has adversely affected access to essential healthcare services. This study aimed to explore healthcare providers' perceptions and experiences of the response to the COVID-19 pandemic in three referral maternal and neonatal hospitals in Guinea. METHODS: We conducted a longitudinal qualitative study between June and December 2020 in two maternities and one neonatology referral ward in Conakry and Mamou. Participants were purposively recruited to capture diversity of professional cadres, seniority, and gender. Four rounds of in-depth interviews (46 in-depth interviews with 18 respondents) were conducted in each study site, using a semi-structured interview guide that was iteratively adapted. We used both deductive and inductive approaches and an iterative process for content analysis. RESULTS: We identified four themes and related sub-themes presented according to whether they were common or specific to the study sites, namely: 1) coping strategies & care reorganization, which include reducing staffing levels, maintaining essential healthcare services, suspension of staff daily meetings, insertion of a new information system for providers, and co-management with COVID-19 treatment center for caesarean section cases among women who tested positive for COVID-19; 2) healthcare providers' behavior adaptations during the response, including infection prevention and control measures on the wards and how COVID-19-related information influenced providers' daily work; 3) difficulties encountered by providers, in particular unavailability of personal protective equipment (PPE), lack of financial motivation, and difficulties reducing crowding in the wards; 4) providers perceptions of healthcare service use, for instance their fear during COVID-19 response and perceived increase in severity of complications received and COVID-19 cases among providers and parents of newborns. CONCLUSION: This study provides insights needed to be considered to improve the preparedness and response of healthcare facilities and care providers to future health emergencies in similar contexts.

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries.

BACKGROUND: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Length of stay and determinants of early discharge after facility-based childbirth in Cameroon: analysis of the 2018 Demographic and Health Survey.

BACKGROUND: A minimum length of stay following facility birth is a prerequisite for women and newborns to receive the recommended monitoring and package of postnatal care. The first postnatal care guidelines in Cameroon were issued in 1998 but adherence to minimum length of stay has not been assessed thus far. The objective of this study was to estimate the average length of stay and identify determinants of early discharge after facility birth. METHODS: We analyzed the Cameroon 2018 Demographic and Health Survey. We included 4,567 women who had a live birth in a heath facility between 2013 and 2018. We calculated their median length of stay in hours by mode of birth and the proportion discharged early (length of stay < 24 h after vaginal birth or < 5 days after caesarean section). We assessed the association between sociodemographic, context-related, facility-related, obstetric and need-related factors and early discharge using bivariate and multivariable logistic regression. RESULTS: The median length of stay (inter quartile range) was 36 (9-84) hours after vaginal birth (n = 4,290) and 252 (132-300) hours after caesarean section (n = 277). We found that 28.8% of all women who gave birth in health facilities were discharged too early (29.7% of women with vaginal birth and 15.1% after a caesarean section). Factors which significantly predicted early discharge in multivariable regression were: maternal age < 20 years (compared to 20-29 years, aOR: 1.44; 95%CI 1.13-1.82), unemployment (aOR: 0.78; 95%CI: 0.63-0.96), non-Christian religions (aOR: 1.65; 95CI: 1.21-2.24), and region of residence-Northern zone aOR:9.95 (95%CI:6.53-15.17) and Forest zone aOR:2.51 (95%CI:1.79-3.53) compared to the country's capital cities (Douala or Yaounde). None of the obstetric characteristics was associated with early discharge. CONCLUSIONS: More than 1 in 4 women who gave birth in facilities in Cameroon were discharged too early; this mostly affected women following vaginal birth. The reasons leading to lack of adherence to postnatal care guidelines should be better understood and addressed to reduce preventable complications and provide better support to women and newborns during this critical period.

Stillbirth rates and their determinants in a national maternity hospital in Phnom Penh, Cambodia in 2017-2020: a cross-sectional assessment with a nested case-control study.

BACKGROUND: In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts. METHODS: This was a retrospective cross-sectional analysis with a nested case-control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017-2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age. RESULTS: Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case-control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5). CONCLUSIONS: Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases.

In Cambodia, there is very little information published on stillbirths to know precisely how many there are and to understand the underlying reasons they occur so they can be prevented in the future. Our study aimed to quantify the number of stillborn babies and identify some underlying risk factors from one of the largest maternity referral hospitals in Phnom Penh, Cambodia. We examined data from almost 30,000 health facility medical files of women who gave birth between 2017 and 2020 which included 938 stillbirths. We found that about 3.2% of births ended in a stillbirth and that this percentage increased between 2017 and 2020. Women who had preterm babies, or whose babies were small in weight for their gestational age, and babies that were born breech had a higher chance of being stillborn. Women who had abnormal vaginal discharge, which can indicate a possible infection, also had a higher odds of having a stillbirth. We also found that women who had a stillbirth previously had almost three times higher chance of having another stillborn baby. Having a caesarean section reduced the likelihood of having a stillborn baby by about half. These findings suggest that efforts are needed to better identify and manage women with preterm births and monitor fetal growth as well as ensure breech births are managed adequately.

"So let me give you money, you give me what I want": decision-making priorities around contraceptive method and source choice among young women in Kenya.

BACKGROUND: Many factors influence young women's choice of contraceptive methods and where to source them, yet less is known about whether one of these choices (method or source) is prioritized and the relationship between these choices. This study qualitatively explored decision-making around contraceptive method and source choice among young women in Kenya. METHODS: In August-September 2019, 30 in-depth interviews were conducted with women ages 18-24 who had used two or more contraceptive methods and resided in three counties: Nairobi, Mombasa or Migori. Participants were recruited from public and private health facilities and pharmacies. Interview guides captured information about decision-making processes for each contraceptive method the respondent had ever used. Responses were audio-recorded, transcribed, translated into English, coded, and analyzed thematically. RESULTS: The majority of respondents knew which method they wanted to use prior to seeking it from a source. This was true for all types of methods that women ever used. Of the small number of respondents who selected their source first, most were in the post-partum period or experiencing side effects and sought counseling at a source before choosing a method. CONCLUSIONS: This study highlights the importance of providing young women with high quality counseling that provides full information about contraceptive options and addresses that young women's needs vary along the reproductive health continuum of care. This will ensure that young women have information to inform future contraceptive decision-making prior to seeking care.

Effect of the COVID-19 pandemic on maternal and neonatal health services in three referral hospitals in Guinea: an interrupted time-series analysis.

INTRODUCTION: In sub-Saharan Africa, there is limited evidence on the COVID-19 health-related effect from front-line health provision settings. Therefore, this study aimed to analyse the effect of the COVID-19 pandemic on routine maternal and neonatal health services in three referral hospitals. MATERIALS AND METHODS: We conducted an observational study using aggregate monthly maternal and neonatal health services routine data for two years (March 2019-February 2021) in three referral hospitals including two maternities: Hôpital National Ignace Deen (HNID) in Conakry and Hôpital Regional de Mamou (HRM) in Mamou and one neonatology ward: Institut de Nutrition et de Santé de l'Enfant (INSE) in Conakry. We compared indicators of health service utilisation, provision and health outcomes before and during the COVID-19 pandemic periods. An interrupted time-series analysis (ITSA) was performed to assess the relationship between changes in maternal and neonatal health indicators and COVID-19 through cross-correlation. RESULTS: During COVID-19, the mean monthly number (MMN) of deliveries decreased significantly in HNID (p = 0.039) and slightly increased in HRM. In the two maternities, the change in the MMN of deliveries were significantly associated with COVID-19. The ITSA confirmed the association between the increase in the MMN of deliveries and COVID-19 in HRM (bootstrapped F-value = 1.46, 95%CI [0.036-8.047], p < 0.01). We observed an increasing trend in obstetric complications in HNID, while the trend declined in HRM. The MMN of maternal deaths increased significantly (p = 0.011) in HNID, while it slightly increased in HRM. In INSE, the MMN of neonatal admissions significantly declined (p < 0.001) and this decline was associated with COVID-19. The MMN of neonatal deaths significantly decreased (p = 0.009) in INSE and this decrease was related to COVID-19. CONCLUSION: The pandemic negatively affected the maternal and neonatal care provision, health service utilisation and health outcomes in two referral hospitals located in Conakry, the COVID-19 most-affected region.

Where and why do we lose women from the continuum of care in maternal health? A mixed-methods study in Southern Benin.

OBJECTIVE: Continuum of care (CoC) in maternal health is built on evidence suggesting that the integration of effective interventions across pregnancy, childbirth, and the postnatal period leads to better perinatal health outcomes. We explored gaps along the CoC in maternal health in Benin. METHODS: A mixed-methods study triangulating results from a qualitative study in southern Benin with a quantitative analysis of Benin Demographic and Health Survey (BDHS) data on the use of services along the CoC was conducted. RESULTS: Benin Demographic and Health Survey analysis showed that although 89% of women reported at least one antenatal care (ANC) visit, only half initiated ANC in the first trimester and completed 4 or more visits. 85% reported facility-based childbirth and 69% a postnatal check within 48 h after childbirth. Our qualitative study confirms early initiation of ANC and the transition from facility-based childbirth to postnatal care are important gaps along the CoC and reveals late arrival at health facility for childbirth as an additional gap. These gaps interact with spiritual and alternative care practices that aim to safeguard pregnancy and prevent complications. Structural factors related to poverty and disrespectful care in health facilities compounded to limit the utilisation of formal healthcare. CONCLUSIONS: The combined use of BDHS and qualitative data contributed to highlighting critical gaps along the maternal CoC. A lack of integration of spiritual or alternative aspects of care into biomedical services, as well as structural factors, impeded access to healthcare in Benin.

Perceptions of peer contraceptive use and its influence on contraceptive method use and choice among young women and men in Kenya: a quantitative cross-sectional study.

BACKGROUND: Prior research has established that an individual's social environment may influence his or her reproductive behaviors, yet less is known about peer influence on contraceptive use among young people (ages 15-24). In Kenya, the site of this study, 15% of adolescents ages 15-19 have begun childbearing and 45% of sexually active young women report current use of a modern contraceptive method. This highlights the need to better understand what factors influence young people to use contraception. The objective of this study is to explore the relationship between the perception of peers' use of contraceptives and contraceptive use and method choice among young men and women in Kenya. METHODS: This study utilizes a nationally representative sample of women and men aged 15-24 years from the 2018 and 2019 cross sectional Shujaaz State of the Kenyan Youth annual surveys. Among the sample of sexually experienced young people (59%), multivariable multinomial logistic regression was used to explore the association between the perception of peers' use of contraceptives and the respondent's contraceptive method choice: non-user, condom use or use of any other modern method. Results are presented separately for young men and young women. RESULTS: Our results show that sexually experienced young men and women who perceive that their peers are using contraceptives are more likely to report current use of condoms compared to being a nonuser (RRR = 2.12, p < 0.001, RRR = 2.59, p < 0.001, respectively); they are also more likely to use condoms than another modern method of contraception (RRR = 2.13, p = 0.034, RRR = 1.71, p = 0.014, respectively). Young women are more likely to use another modern method (not including condoms) than be a nonuser when they perceive that their peers' use contraceptives (RRR = 1.51, p = 0.020). CONCLUSIONS: The results of this study highlight the important role of peer influence on young people's contraceptive choices. These findings can be used to develop programs that encourage behavior change communication activities in Kenya that focus on normalizing use of a full range of contraceptive methods among peer groups of sexually experienced young people.

In Kenya, about 15% of women age 15­19 have already had a birth and approximately one third of these women did not want to have a child at that time. Yet about 45% of sexually active women ages 15­24 report that they currently use family planning (FP). Among young people, friends and peers are an important influence on behaviors.This study focused on a representative sample from Kenya of female and male youth (ages 15­24) who ever had sex. Men and women were asked questions about use of FP, if they think their peers use FP and about characteristics such as age and education.The results showed that young women and men who believed their peers use FP were more likely to use FP themselves. Also, young men and women who believed that peers use FP were more likely to use condoms than not use any FP and more likely to use condoms than to use another modern method of FP. Young women who thought their peers use were more likely to use another modern method (not including condoms) than to be a nonuser of FP.Programs targeting young people should include information on a range of FP methods and aim to include groups of peers and encourage open discussion.

Stakeholders' perceptions on improving women's health after obstetric fistula repair: results from a qualitative study in Guinea.

The holistic care of obstetric fistula remains a significant public health concern in developing countries. Improving women's outcomes after repair requires perspectives on post-surgical period within which women have to fulfil their social roles and expectations, mainly becoming pregnant, cooking, resuming farming activities or sexual intercourse. Our objective was to explore stakeholders' perceptions of women's health and well-being after fistula repair, and their perspectives on strategies for improving their quality of life in Guinea. A qualitative study involving representatives from the Ministry of Health, regional, district and hospital managers, representatives of NGOs and funding bodies, local leaders, women who underwent fistula surgery and their relatives (husbands, family members), health providers and community health workers at different levels was conducted. Thematic analysis was performed using NVivo software. Overall, 41 in-depth interviews and seven focus group discussions were conducted with 83 various stakeholders. Unanimously, respondents perceived women treated for obstetric fistula are "diminished" and "vulnerable". This "vulnerability" encompasses physical, socio-emotional and economic dimensions. The high risk of maternal and neonatal complications such as fistula recurrence, abortion or stillbirth in these women was mentioned. Stakeholders emphasized the need for a multidisciplinary approach to improve women's health after repair. Social support, economic empowerment and medical follow-up were identified as key components to mitigate women's vulnerability for successful post-repair reintegration. The programmatic level in Guinea should consider women's health after fistula repair a vital component of the holistic fistula care.

Women's progression through the maternal continuum of care in Guinea: Evidence from the 2018 Guinean Demographic and Health Survey.

OBJECTIVE: To examine women's progression through the antenatal, birth, and post-partum maternal care in Guinea in 2018. METHODS: Using the Guinea Demographic and Health Survey of 2018, we analysed data on most recent live births in the 24 months preceding the survey among women aged 15-49 and the determinants (health system, quality of care, reproductive and sociodemographic factors) of women's progression through three steps of the continuum of care, using multivariable logistic regression. RESULTS: In the sample of 3,018 women, 87% reported at least one ANC visit (ANC1) with a health professional and 36% reported ANC4+, at least one of which was with a health professional. In the study, 26% of women reported ANC4+ plus birth in a health facility, and 20% reported ANC4+, birth in a health facility, plus post-partum check-up. Predictors of woman's progression from ANC1 to ANC4+ visits included living in the administrative regions of Kindia (AOR: 1.96, 95% CI: 1.23-3.14) and Nzérékoré (AOR: 0.50, 95% CI: 0.32-0.79) vs. Kankan, being aged 15 to 17 (AOR: 0.55, 95% CI: 0.35-0.86) vs. aged 25 to 34, having primary or more education (AOR: 1.37, 95% CI: 1.09-1.72), and being from a middle (AOR: 1.52, 95% CI: 1.18-1.96) or wealthier (AOR: 2.38, 95% CI: 1.67-3.39) household vs. a poor household. Living in the administrative regions of Nzérékoré (AOR: 6.27, 95% CI: 1.57-25.05) vs. Kankan, in a middle (AOR: 1.64, 95% CI: 1.05-2.57) or wealthier (AOR: 3.23, 95% CI: 1.98-5.29) household vs. a poor household, nulliparity (AOR: 1.75, 95% CI: 1.03-2.97) vs. 2-4 previous births, the distance to health facility perceived as not being a problem (AOR: 1.75, 95% CI: 1.23-2.50), and higher ANC content score (AOR: 1.29, 95% CI: 1.10-1.52) remained independently associated with progression from ANC4+ to birth in a health facility. Predictors of progression from birth in the health facility to post-partum check-up included residing in the administrative regions of Labé (AOR: 0.22, 95% CI: 0.09-0.51) or Faranah (AOR: 0.43, 95% CI: 0.19-0.96) vs. Kankan, higher ANC content score (AOR: 1.76, 95% CI: 1.36-2.28), skin-to-skin contact after birth (AOR: 3.00, 95% CI: 1.70-5.31), and being attended at birth by a health professional (AOR: 17.52, 95% CI: 4.68-65.54). CONCLUSIONS: Removing financial barriers and improving quality of care appear to be important to increase the percentage of women receiving the full maternal continuum of care.

Effects of implementing a postabortion care strategy in Kinshasa referral hospitals, Democratic Republic of the Congo.

OBJECTIVES: To evaluate the effects of the implementation of a postabortion care (PAC) strategy in Kinshasa referral hospitals, this study analyzed the quality of postabortion care services, including postabortion contraception, and the duration of hospitalization. METHODOLOGY: We estimated the effects of the PAC strategy using a quasi-experimental study by evaluating the outcomes of 334 patients with the diagnosis of a complication of induced abortion admitted to 10 hospitals in which the PAC strategy was implemented compared to the same outcomes in 314 patients with the same diagnosis admitted to 10 control facilities from 01/01/2016 to 12/31/2018. In response to government policy, the PAC strategy included the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. The information was collected using a questionnaire and stored using open data kit software. We supplemented this information with data abstracted from patient records, facility registries of gynecological obstetrical emergencies, and family planning registries. We analyzed data and developed regression models using STATA15. Thus, we compared changes in use of specific treatments and duration of hospitalization using a "difference-in-differences" analysis. RESULTS: The implementation of PAC strategy in Kinshasa referral hospitals has resulted in the utilization of WHO recommended uterine evacuation method MVA (29.3% more in the experimental structures, p = 0.025), a significant decline in sharp-curettage (19.3% less, p = 0.132), and a decline in the duration of hospitalization of patients admitted for PAC (1 day less, p = 0.020). We did not observe any change in the use of PAC services, mortality, and the provision of post abortion contraception. CONCLUSION: Despite significant improvement in the management of PAC, the uptake in WHO approved technology-namely MVA, and the duration of hospitalization, these outcomes while a significant improvement for DRC, indicate that additional quality improvement strategies for management of PAC and risk-mitigating strategies to reduce barriers to care are required.

Interventions to increase facility births and provision of postpartum care in sub-Saharan Africa: a scoping review.

BACKGROUND: Most maternal deaths occur during the intrapartum and peripartum periods in sub-Saharan Africa, emphasizing the importance of timely access to quality health service for childbirth and postpartum care. Increasing facility births and provision of postpartum care has been the focus of numerous interventions globally, including in sub-Saharan Africa. The objective of this scoping review is to synthetize the characteristics and effectiveness of interventions to increase facility births or provision of postpartum care in sub-Saharan Africa. METHODS: We searched for systematic reviews, scoping reviews, qualitative studies and quantitative studies using experimental, quasi experimental, or observational designs, which reported on interventions for increasing facility birth or provision of postpartum care in sub-Saharan Africa. These studies were published in English or French. The search comprised six scientific literature databases (Pubmed, CAIRN, la Banque de Données en Santé Publique, the Cochrane Library). We also used Google Scholar and snowball or citation tracking. RESULTS: Strategies identified in the literature as increasing facility births in the sub-Saharan African context include community awareness raising, health expenses reduction (transportation or user fee), non-monetary incentive programs (baby kits), or a combination of these with improvement of care quality (patient's privacy, waiting time, training of provider), and or follow-up of pregnant women to use health facility for birth. Strategies that were found to increase provision of postpartum care include improvement of care quality, community-level identification and referrals of postpartum problems and transport voucher program. CONCLUSIONS: To accelerate achievements in facility birth and provision of postpartum care in sub-Saharan Africa, we recommend strategies that can be implemented sustainably or produce sustainable change. How to sustainably motivate community actors in health interventions may be particularly important in this respect. Furthermore, we recommend that more intervention studies are implemented in West and Central Africa, and focused more on postpartum. In in sub-Saharan Africa, many women die when giving or few days after birth. This happens because they do not have access to good health services in a timely manner during labor and after giving birth. Worldwide, many interventions have been implemented to Increase the number of women giving birth in a health facility or receiving care from health professional after giving birth. The objective of this study is to synthetize the characteristics and effectiveness of interventions that have been implemented in sub-Saharan Africa, aiming to increase the number of women giving birth in a health facility or receiving care from health professional after birth. To proceed with this synthesis, we did a review of studies that have reported on such interventions in sub-Saharan Africa. These studies were published in English or French. The interventions identified to increase the number of women giving birth in a health facility include community awareness raising, reduction of health expenses (transportation or user fee), non-monetary incentive programs (baby kits), or a combination of these with improvement of care quality (patient's privacy, waiting time, training of provider), and or follow-up of pregnant women to use health facility for birth. Interventions implemented to increase the number women receiving care from a health professional after birth include improvement of care quality, transport voucher program and community-level identification and referrals to the health center of mothers' health problems. In sub-Saharan Africa, to accelerate increase in the number of women giving birth in a health facility and receiving care from a health professional after, we recommend interventions that can be implemented sustainably or produce sustainable change. How to sustainably motivate community actors in health interventions may be particularly important in this respect. Furthermore, we recommend the conduct in West and Central Africa, of more studies targeting interventions to increase the number of women giving birth in a health facility and or receiving care from a health professional after birth.

RéSUMé: CONTEXTE: La plupart des décès maternels surviennent pendant les périodes intrapartum et péripartum en Afrique subsaharienne, ce qui souligne l'importance de l'accès à temps aux services de santé de qualité pour l'accouchement et les soins post-partum. L'augmentation des accouchements institutionnels et l'offre de soins post-partum ont fait l'objet de nombreuses interventions dans le monde entier, y compris en Afrique subsaharienne. L'objectif de cette étude est de synthétiser les caractéristiques et l'efficacité des interventions visant à accroître les accouchements institutionnels ou l'offre de soins post-partum en Afrique subsaharienne. MéTHODES: Nous avons recherché des revues systématiques, des revues de portée, des études qualitatives et des études quantitatives utilisant des types expérimentaux, quasi expérimentaux ou d'observation, qui rapportaient sur des interventions visant à accroître les accouchements institutionnels et l'offre de soins post-partum en Afrique subsaharienne. Ces études ont été publiées en anglais ou en français. La recherche a porté sur six bases de données de littérature scientifique (Pubmed, CAIRN, la Banque de Données en Santé Publique, la Cochrane Library). Nous avons également utilisé Google Scholar et le suivi des boules de neige ou des citations. RéSULTATS: Les stratégies identifiées dans la littérature comme accroissant les accouchements intentionnels dans le contexte de l'Afrique subsaharienne comprennent la sensibilisation des communautés, la réduction des dépenses de santé (transport ou frais d'utilisation), des programmes d'incitation non monétaires (kits pour bébés), ou une combinaison de ces éléments avec l'amélioration de la qualité des soins (respect de la vie privée du patient, temps d'attente, formation du prestataire), et ou le suivi des femmes enceintes pour qu'elles utilisent l'établissement de santé pour l'accouchement. Les stratégies qui ont été trouvées pour accroitre l'offre des soins post-partum comprennent l'amélioration de la qualité des soins, l'identification au niveau communautaire et la référence des problèmes post-partum et le programme de bons de transport. CONCLUSIONS: Pour accélérer les réalisations en matière d'accouchement institutionnel et d'offre de soins post-partum en Afrique subsaharienne, nous recommandons des stratégies qui peuvent être mises en œuvre de manière durable ou produire des changements durables. La manière de motiver durablement les acteurs communautaires dans les interventions sanitaires peut être particulièrement importante à cet égard. En outre, nous recommandons que davantage d'études d'intervention soient mises en œuvre en Afrique de l'Ouest et du Centre, et qu'elles soient davantage axées sur les soins post-partum.

Outcomes of blended learning for capacity strengthening of health professionals in Guinea.

BACKGROUND: Quality human resources constitute an essential pillar of an effective health system. This paper analyzes the outcomes of blended learning for post-Ebola capacity strengthening of health professionals in Guinea. METHODS: Two courses lasting 3 months each (7-8 modules) were developed and implemented: one in Primary Health Care (eSSP) and the other in Sexual and Reproductive Health Services Management (eSSR). Both eSSP and eSSR courses were offered online on the Moodle platform, followed by a face-to-face capacity-building workshop. A cross-sectional study using a mixed-methods approach was conducted in 2018-19. As outcomes, we described learners' sociodemographic characteristics, course completion and success, and perceptions of the courses and support from the instructors, analyzed the factors associated with learners' successful completion and reported on learners' feedback on their blended learning experience. Quantitative data were analyzed using the STATA 15 software, and qualitative data were analyzed through content analysis. RESULTS: Overall, 282 health professionals were enrolled for both eSSP and eSSR courses. The completion rate was 69.5% (196/282). The success rate for learners who completed the courses was 80% (156/196), and the overall success rate for enrollees was 55% (156/282). The dropout and abstention rates were 22 and 9%, respectively. On both eSSP and eSSR courses, the success rate of women enrolled was higher than or equal to men's. The success rate of medical doctors enrolled (53% for eSSP and 67% for eSSR) was higher than for other health professionals, in particular nurses (9% for eSSP) and midwives (40% for eSSR). Course type was associated with success (AOR = 1.93; 95% CI = 1.15-3.24). Most learners strongly agreed that the courses are relevant for targeted health professionals (81 to 150/150), pdf course materials are well-structured and useful (105/150), the content of the modules is relevant, comprehensible, and clear (90/150), self-assessment quizzes are helpful (105/150), summative assessment assignments are relevant (90/150), the course administrators and IT manager were responsive to learners' concerns (90/150), they will recommend the courses to colleagues and friends (120/150). CONCLUSION: Two blended courses for capacity strengthening of health professionals were successfully developed and implemented in Guinea.

Approche eLearning pour le renforcement des capacités des professionnels de santé en Guinée : une expérience post-Ebola.

INTRODUCTION: The development of quality human resources for health is an essential pillar of an effective health system. The objective of this study was to describe the implementation process and the results of an eLearning approach for capacity strengthening of health professionals in Guinea. METHOD: A descriptive cross-sectional study using a mixed research method was conducted from January 15, 2018 to January 15, 2019. RESULTS: A team from the National Training and Research Centre in Rural Health of Maferinyah in Guinea has been trained in the development of online courses. Two courses lasting three months each (7 to 8 modules), entirely offered online on the Moodle platform, have been developed, one on Primary Health Care (eSSP) and the other on the Management of Sexual and Reproductive Health Services (eSSR). Overall, 282 health professionals have been enrolled for both courses, with a completion rate of 69.5%. The success rate for learners who completed the courses was 79.6% and the success rate for enrollees was 55.3%. The dropout and abstention rates were 21.6% and 8.9%, respectively. The strengths, weaknesses and challenges of the organization and the success of such a training were reported. CONCLUSIONS: The eLearning approach for capacity strengthening of health professionals is feasible and gives good findings in low-income contexts like that of Guinea.

[eLearning approach for capacity strengthening of health professionals in Guinea: A post-Ebola experience]. / Approche eLearning pour le renforcement des capacités des professionnels de santé en Guinée : une expérience post-Ebola.

INTRODUCTION: The development of quality human resources for health is an essential pillar of an effective health system. The objective of this study was to describe the implementation process and the results of an eLearning approach for capacity strengthening of health professionals in Guinea. METHOD: A descriptive cross-sectional study using a mixed research method was conducted from January 15, 2018 to January 15, 2019. RESULTS: A team from the National Training and Research Centre in Rural Health of Maferinyah in Guinea has been trained in the development of online courses. Two courses lasting three months each (7 to 8 modules), entirely offered online on the Moodle platform, have been developed, one on Primary Health Care (eSSP) and the other on the Management of Sexual and Reproductive Health Services (eSSR). Overall, 282 health professionals have been enrolled for both courses, with a completion rate of 69.5%. The success rate for learners who completed the courses was 79.6% and the success rate for enrollees was 55.3%. The dropout and abstention rates were 21.6% and 8.9%, respectively. The strengths, weaknesses and challenges of the organization and the success of such a training were reported. CONCLUSIONS: The eLearning approach for capacity strengthening of health professionals is feasible and gives good findings in low-income contexts like that of Guinea.

Extent of induced abortions and occurrence of complications in Kinshasa, Democratic Republic of the Congo.

BACKGROUND: Due to a lack of relevant data on induced abortions in the Democratic Republic of the Congo (DRC) as well as the persistence of maternal deaths in the country, this study aims to analyse the extent of induced abortions and occurrence of complications in Kinshasa. METHODOLOGY: This cross-sectional study was conducted with a sample of 460 women who were interviewed about their experiences as females, and provided information of 1444 women of childbearing age living in Kinshasa. Respondents' households were selected to represent the five types of residential quarters in Kinshasa, differentiated by cultural, socioeconomic, and infrastructural characteristics. Information was collected using a survey form and analyzed. RESULTS: Among all confidantes included in the study, 5.5% (95% CI: 4.4-6.8%) had induced abortions during 2015, a rate of 55.0 abortions per 1000 women of childbearing age. This practice was significantly performed amongst single/separated/divorced women; those without formal education, or primary-school education, and women who consumed excessive alcohol. Most abortions were induced by the administration of high doses of medication, by the women themselves or by health workers. A percentage of 51.9% (95%CI: 40.4-63.3%) of induced abortions led to complications, which were predominantly haemorrhagic. Moreover, 39% of patients had a complication for which they sought care, and of whom 12.5% had genital trauma or uterine perforation/intestinal necrosis. CONCLUSION: Induced abortion is a public health problem in Kinshasa due to its frequency of practice, the complications that occur, and the absence of major surgeries in the health care package offered by the health centres or dispensaries that also provide the treatment of some serious complications. Thus, there is a need to focus on the enhancement of the health care package offered by health centres to include appropriate measures in favour of maternal health.

Ebola virus disease outbreak in Guinea: what effects on prevention of mother-to-child transmission of HIV services?

BACKGROUND: An unprecedented epidemic of Ebola virus disease (EVD) affected Guinea in 2014 and 2015. It weakened the already fragile Guinean health system. This study aimed to assess the effects of the outbreak on Prevention of Mother-to-Child Transmission of HIV (PMTCT) services in 2014. METHODS: We conducted a cross-sectional retrospective study. Data was collected from 60 public health centers (30 in the EVD affected areas and 30 in the unaffected areas). The comparison of PMTCT indicators between the period before Ebola (2013) and during Ebola (2014) was done using the t- test for the means and the Chi-square test for the proportions. RESULTS: This study showed a substantial and significant reduction in the mean number of antenatal care visits (ANC) in the affected localities, 1617 ± 53 in 2013 versus 1065 ± 29 in 2014, p = 0.0004. This would represent 41% drop in health facilities' performance. On the other hand, in the unaffected localities, the fall was not significant. The same observations were made about the number of HIV tests performed for pregnant women and the number of HIV positive pregnant women initiating ARVs. The study also noted an increase in the proportion of women tested HIV+ but who did not receive ARVs (12% in 2013 versus 44% in 2014) and HIV+ pregnant women who delivered at home (18% in 2014 versus 7% in 2013). CONCLUSION: This study showed that PMTCT services, which are one of the key services to improve maternal and child health, were affected in Guinea during this Ebola outbreak in 2014 compared to 2013.

Systematic review of sex work interventions in sub-Saharan Africa: examining combination prevention approaches.

OBJECTIVE: The incidence of HIV and sexually transmitted infections is disproportionately high among sex workers (SW). We aimed to update the evidence on the effectiveness of SW interventions in sub-Saharan Africa and to provide more insights into combination prevention. METHODS: The Systematic review followed PRISMA guidelines in a search of PUBMED and POPLINE for peer-reviewed literature published between 1 January 2000 and 22 July 2016 (registration number on PROSPERO: CRD42016042529). We considered cohort interventions, randomised controlled trials and cross-sectional surveys of SW programmes. A framework was used in the description and mapping of intervention to desired outcomes. RESULTS: Twenty-six papers(reporting on 25 studies) were included. A strategy that empowered peer educator leaders to steer community activities showed a twofold increase in coverage of behaviour change communication and utilisation of health facility among SW. Brief alcohol harm reduction effort demonstrated a significant effect on sexual violence and engagement in sex trading. A risk reduction counselling intervention among drug-injecting SW showed an effect on alcohol, substance use and engagement in sex work. No study on a promising intervention like PrEP among SWs was found. We observed that interventions that combined some structural components, biomedical and behavioural strategies tend to accumulate more desired outcomes. CONCLUSION: The evidence base that can be considered in intervention designs to prevent HIV in SW in SSA is vast. The health sector should consider interventions to reduce binge alcohol intake and intravenous drug use among sex workers. Programmes should staunchly consider multicomponent approaches that explore community-based structural approaches.

Profile and reintegration experience of Ebola survivors in Guinea: a cross-sectional study.

OBJECTIVE: To describe the experience of Guinean Ebola virus disease (EVD) survivors in Guinea, up to ten months after discharge from the Ebola treatment unit. METHODS: Cross-sectional study using a standardised semistructured questionnaire among survivors from Conakry and Coyah districts in 2015 in Guinea. We used proportions, mean (standard deviation) and median (interquartile range) to summarise the variables. The McNemar chi-square test was used to compare proportions. RESULTS: The 121 EVD survivors interviewed had a median reintegration time from discharge of 18 weeks (IQR: 14-32 weeks). Most survivors were aged 15-44 years (87.6%) with secondary to higher level of education (68.6%), and 25.6% were healthcare workers. The majority reported a lower socio-economic status (90%), a less favourable work situation (79%) and psychological status (60%). About 31% reported physical health problems. Most survivors reported lower levels of reintegration with friends and at work place (72%) and lower acceptance by others in general (71%) in the period after the EVD as compared to the period before the EVD. Only 55 survivors (45.5%) were involved in one or more activities of the EVD response: participation in clinical studies on the EVD (44 survivors, 36.4%), community sensitisation (28 survivors, 23.1%) or work in Ebola treatment and/or transit centres (23 survivors, 21.7%). CONCLUSION: There is a need for a long-term follow-up of EVD survivors in Guinea and more efforts to support their social, professional and economic reintegration, especially in rural areas.