Who is most vulnerable? Factors associated with presenting to antenatal care without a male partner in Northern Tanzania.

OBJECTIVE: Male engagement in pregnancy care can be beneficial for maternal and child health outcomes. In Tanzania, pregnant women are strongly encouraged to present to their first antenatal care (ANC) appointment with a male partner, where they jointly test for HIV. For some, this presents a barrier to ANC attendance. The objectives of this study were to identify factors associated with presenting to ANC with a male partner using a cross-sectional design and to assess whether women presenting without partners had significantly delayed presentation. METHODS: Pregnant women (n = 1007) attending a first ANC appointment in Moshi, Tanzania were surveyed. Questions captured sociodemographic characteristics and measures of psychosocial constructs. RESULTS: Just over half (54%) of women presented to care with a male partner. Women were more likely to present with a male partner if they were younger than 25 years old, married, Muslim, attending ANC for their first pregnancy, and testing for HIV for the first time. Women presenting to ANC with a male partner were significantly more likely to attend ANC earlier in their pregnancy than those presenting without male partners. CONCLUSION: Policy change allowing women to present to care with other supportive family members could promote earlier presentation to first ANC. Unmarried women may be at a disadvantage in presenting to ANC when policies mandate attendance with a male partner. Male partners of multiparous women should be encouraged to provide pregnancy support even after first pregnancies, and a wholistic emphasis (beyond HIV testing) on first ANC could encourage male engagement beyond the initial appointment.

Integrated mental health screening for obstetric fistula patients in Mali: From evidence to policy.

BACKGROUND: Obstetric fistula significantly impacts women's mental health and well-being. Routine screening for mental health in fistula repair programs can be a gateway to link patients to services, and can produce routine data to inform programmatic investments. This study observed the integration of a mental health screening program into an obstetric fistula repair program in Mali, with two specific objectives: 1) to describe the social and mental health well-being of women presenting with obstetric fistulas in Mali, and 2) to document the impact of the mental health screening pilot on policy change in Mali. METHODS: Seven fistula repair campaigns were conducted between June 2016 and May 2017. All individuals presenting for fistula repair completed a mental health assessment at intake, including a depression screener (PHQ-9) and an assessment of psycho-social impacts of fistula. The depression screener was repeated three months following inpatient discharge. Findings were shared with stakeholders in Mali and impacts on policy were documented. RESULTS: Of 207 women who presented for fistula repair, 167 patients completed the mental health assessment at surgical intake, and 130 patients repeated the screener at 3-month follow-up. At intake, 36.5% of women had moderate or severe depression, decreasing to 16.9% at follow-up. The mean depression score differed significantly by timepoint (9.14 vs. 6.72, p <0.001). Results were shared in a report with stakeholders, and consultations with the Mali Ministry of Health. As a result of advocacy, mental health was a key component of Mali's National Fistula Prevention and Treatment Strategy (2018-2022). CONCLUSION: The high prevalence of depression in Malian fistula patients underscores a need for more robust mental health support for patients after surgery. Data on mental health from routine screening informs community reintegration strategies for individual patients, elevates the overall quality of care of fistula repair programs by addressing patients' holistic health needs, and contributes to evidence-informed decision-making and data-driven policy change within the larger health system.