Factors influencing mothers' decisions regarding obstetrical care in Western Kenya: a mixed-methods study.

BACKGROUND: Siaya County in Western Kenya has one of the highest maternal mortality rates in Kenya. We sought to elucidate factors that influence mothers' decisions regarding where to seek obstetrical care, to inform interventions that seek to promote effective use of obstetric services and reduce maternal mortalities. To guide our research, we used the "Three Delays Model", focusing on the first delay-seeking care. While interventions to reduce maternal mortalities have focused on addressing delays in accessing and receiving care, context-specific data on drivers of the first delay are scarce. METHODS: We used a mixed-method study to assess how maternal decision-making of birth location is influenced by personal, contextual, and cultural factors. We conducted structured interviews with women aged 14 years or older living in Siaya, Bondo, and Yala, rural districts in Western Kenya. We then conducted focus group interviews with a subset of women to elucidate this question: How do drivers of the first delay (i.e., seeking care) affect the decision to seek home versus hospital delivery, potentially negatively influencing maternal mortality. RESULTS: Three hundred and seven women responded to the surveys, and 67 women (22%) from this group participated in focus group interviews. Although we focused on type 1 delays, we discovered that several factors that impact type 2 and type 3 delays directly contribute to type 1 delays. Our findings highlighted that factors influencing women's decisions to seek care are not simply medical or cultural but rather contextual, involving many elements of life, particularly in rural communities. CONCLUSIONS: It is imperative to address multiple-level factors that influence women's decisions to seek care and have in-hospital deliveries. To curtail maternal mortality in rural Western Kenya and comparable settings, targeted interventions must take into consideration these important influencers.

Safe Anesthesia Care in Western Kenya: A Preliminary Assessment of the Impact of Nurse Anesthetists at Multiple Levels of Government Hospitals.

BACKGROUND: Only 20% of the surgical burden in eastern sub-Saharan Africa is currently met, leaving >17 million surgical cases annually in need of safe surgery and anesthesia. Similarly, there is an extreme shortage of anesthesia providers in East Africa, with just 0.44 anesthesiologists per 100,000 people in Kenya compared to 20.82 per 100,000 in the United States. Additionally, surgical access is not equally distributed within countries, with rural settings often having the greatest unmet need. We developed and tested a set of tools to assess if graduates of the Kenya registered nurse anesthetist (KRNA) training program, who were placed in rural hospitals in Kenya, would have any impact on surgical numbers, referral patterns, and economics of these hospitals. METHODS: Cross-sectional data were collected from facility assessments in 9 referral hospitals to evaluate the possible impact of the KRNAs on anesthesia care. The hospitals were grouped based on both the number of beds and the assigned national hospital level. At each level, a hospital that had KRNA graduates (intervention) was matched with comparison hospitals in the same category with no KRNA graduates (control). The facility assessment survey included questions capturing data on personnel, infrastructure, supplies, medications, procedures, and outcomes. At the intervention sites, the medical directors of the hospitals and the KRNAs were interviewed. Descriptive statistics were used to present the findings. RESULTS: Intervention sites had a density of anesthesia providers that was 43% higher compared to the control sites. Intervention sites performed at least twice as many surgical cases compared to the control sites. Most KRNAs stated that the anesthesia training program had given them sufficient training and leadership skills to perform safe anesthesia in their clinical practice setting. Medical directors at the intervention sites reported increased surgical volumes and fewer referrals to larger hospitals due to the anesthesia gaps that had been addressed. CONCLUSIONS: Our findings from this study suggest that KRNAs may be associated with an increased volume of surgical cases completed in these rural Kenyan hospitals and may therefore be filling a known anesthetic void. The presence of skilled anesthesia providers is a first step toward providing safe surgery and anesthesia care for all; however, significant gaps still remain. Future analysis will focus on surgical outcomes, the appropriate anesthesia delivery model for a rural population, and how the availability of anesthesia infrastructure impacts referral patterns and safe surgery capacity.

A 2000-year sediment record reveals rapidly changing sedimentation and land use since the 1960s in the Upper Mara-Serengeti Ecosystem.

The Mara River basin is a trans-boundary basin of international importance. It forms the headwaters of the Nile River and serves as the primary dry season water source for an estimated 1.1 million rural people and the largest remaining overland migration of 1.4 million wildebeest in the Serengeti-Mara Ecosystem. Changes throughout the basin are impacting the quantity and quality of the Mara River, yet the historical context of environmental conditions in the basin is not well known. We collected sediment cores throughout the wetland at the mouth of the Mara River, and we used isotopic dating methods and a suite of analyses to examine historical patterns of sediment quantity and source, mercury contamination, and carbon and nutrient loading. Our results show that ecological conditions in the Mara River basin were fairly stable over paleoecological time scales (2000-1000 years before present), but there has been a period of rapid change in the basin over the last 250 years, particularly since the 1960s. A shift in the source and quantity of sediments in the river began in the late 1700s and became much more pronounced in the 1950s and 1960s, coincident with increasing mercury concentrations. The quantity of sediment from the Upper Mara increased, particularly since 1960, but the proportion of total sediment from this region decreased as the Talek and Middle Mara portions of the basin began producing more sediment. The decadal oscillation in sediment accumulation was congruent with known periods of extreme precipitation events. Carbon and nitrogen loading also increased since the 1960s, and the shift in the isotopic ratio of nitrogen provides evidence for increased anthropogenic loading. Altogether, these data likely reflect patterns of change also experienced in other basins throughout East Africa.

Prevalence and incidence of congenital anomalies amongst babies born to women with sickle cell disease and exposed to hydroxyurea during pregnancy: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: What is the prevalence and incidence of congenital anomalies among babies born to women with sickle cell disease (SCD) and who have been exposed to hydroxyurea (HU) therapy at any time in their pregnancy?The objective of this review is to identify the proportion of babies born with congenital anomalies among babies born to mothers with SCD who have been exposed to HU therapy at any point during pregnancy and to describe the specific types of congenital anomalies encountered.