Prevalence of and risk factors for iron deficiency among pregnant women with moderate or severe anaemia in Nigeria: a cross-sectional study.

BACKGROUND: Anaemia during pregnancy causes adverse outcomes to the woman and the foetus, including anaemic heart failure, prematurity, and intrauterine growth restriction. Iron deficiency anaemia (IDA) is the leading cause of anaemia and oral iron supplementation during pregnancy is widely recommended. However, little focus is directed to dietary intake. This study estimates the contribution of IDA among pregnant women and examines its risk factors (including dietary) in those with moderate or severe IDA in Lagos and Kano states, Nigeria. METHODS: In this cross-sectional study, 11,582 women were screened for anaemia at 20-32 weeks gestation. The 872 who had moderate or severe anaemia (haemoglobin concentration < 10 g/dL) were included in this study. Iron deficiency was defined as serum ferritin level < 30 ng/mL. We described the sociodemographic and obstetric characteristics of the sample and their self-report of consumption of common food items. We conducted bivariate and multivariable logistic regression analysis to identify risk factors associated with IDA. RESULTS: Iron deficiency was observed among 41% (95%CI: 38 - 45) of women with moderate or severe anaemia and the prevalence increased with gestational age. The odds for IDA reduces from aOR: 0.36 (95%CI: 0.13 - 0.98) among pregnant women who consume green leafy vegetables every 2-3 weeks, to 0.26 (95%CI: 0.09 - 0.73) among daily consumers, compared to those who do not eat it. Daily consumption of edible kaolin clay was associated with increased odds of having IDA compared to non-consumption, aOR 9.13 (95%CI: 3.27 - 25.48). Consumption of soybeans three to four times a week was associated with higher odds of IDA compared to non-consumption, aOR: 1.78 (95%CI: 1.12 - 2.82). CONCLUSION: About 4 in 10 women with moderate or severe anaemia during pregnancy had IDA. Our study provides evidence for the protective effect of green leafy vegetables against IDA while self-reported consumption of edible kaolin clay and soybeans appeared to increase the odds of having IDA during pregnancy. Health education on diet during pregnancy needs to be strengthened since this could potentially increase awareness and change behaviours that could reduce IDA among pregnant women with moderate or severe anaemia in Nigeria and other countries.

A population-based estimation of maternal mortality in Lagos State, Nigeria using the indirect sisterhood method.

BACKGROUND: Pregnancy and delivery deaths represent a risk to women, particularly those living in low- and middle-income countries (LMICs). This population-based survey was conducted to provide estimates of the maternal mortality ratio (MMR) in Lagos Nigeria. METHODS: A community-based, cross-sectional study was conducted in mapped Wards and Enumeration Areas (EA) of all Local Government Areas (LGAs) in Lagos, among 9,986 women of reproductive age (15-49 years) from April to August 2022 using a 2-stage cluster sampling technique. A semi-structured, pre-tested questionnaire adapted from nationally representative surveys was administered using REDCap by trained field assistants for data collection on socio-demographics, reproductive health, fertility, and maternal mortality. Data were analysed using SPSS and MMR was estimated using the indirect sisterhood method. Ethical approval was obtained from the Lagos State University Teaching Hospital Health Research and Ethics Committee. RESULTS: Most of the respondents (28.7%) were aged 25-29 years. Out of 546 deceased sisters reported, 120 (22%) died from maternal causes. Sisters of the deceased aged 20-24 reported almost half of the deaths (46.7%) as due to maternal causes, while those aged 45-49 reported the highest number of deceased sisters who died from other causes (90.2%). The total fertility rate (TFR) was calculated as 3.807, the Lifetime Risk (LTR) of maternal death was 0.0196 or 1-in-51, and the MMR was 430 per 100,000 [95% CI: 360-510]. CONCLUSION: Our findings show that the maternal mortality rate for Lagos remains unacceptable and has not changed significantly over time in actual terms. There is need to develop and intensify community-based intervention strategies, programs for private hospitals, monitor MMR trends, identify and contextually address barriers at all levels of maternal care.

Acceptability of IV iron treatment for iron deficiency anaemia in pregnancy in Nigeria: a qualitative study with pregnant women, domestic decision-makers, and health care providers.

BACKGROUND: Anaemia in pregnancy causes a significant burden of maternal morbidity and mortality in sub-Saharan Africa, with prevalence ranging from 25 to 45% in Nigeria. The main treatment, daily oral iron, is associated with suboptimal adherence and effectiveness. Among pregnant women with iron deficiency, which is a leading cause of anaemia (IDA), intravenous (IV) iron is an alternative treatment in moderate or severe cases. This qualitative study explored the acceptability of IV iron in the states of Kano and Lagos in Nigeria. METHODS: We purposively sampled various stakeholders, including pregnant women, domestic decision-makers, and healthcare providers (HCPs) during the pre-intervention phase of a hybrid clinical trial (IVON trial) in 10 healthcare facilities across three levels of the health system. Semi-structured topic guides guided 12 focus group discussions (140 participants) and 29 key informant interviews. We used the theoretical framework of acceptability to conduct qualitative content analysis. RESULTS: We identified three main themes and eight sub-themes that reflected the prospective acceptability of IV iron therapy. Generally, all stakeholders had a positive affective attitude towards IV iron based on its comparative advantages to oral iron. The HCPs noted the effectiveness of IV iron in its ability to evoke an immediate response and capacity to reduce anaemia-related complications. It was perceived as a suitable alternative to blood transfusion for specific individuals based on ethicality. However, to pregnant women and the HCPs, IV iron could present a higher opportunity cost than oral iron for the users and providers as it necessitates additional time to receive and administer it. To all stakeholder groups, leveraging the existing infrastructure to facilitate IV iron treatment will stimulate coherence and self-efficacy while strengthening the existing trust between pregnant women and HCPs can avert misconceptions. Finally, even though high out-of-pocket costs might make IV iron out of reach for poor women, the HCPs felt it can potentially prevent higher treatment fees from complications of IDA. CONCLUSIONS: IV iron has a potential to become the preferred treatment for iron-deficiency anaemia in pregnancy in Nigeria if proven effective. HCP training, optimisation of information and clinical care delivery during antenatal visits, uninterrupted supply of IV iron, and subsidies to offset higher costs need to be considered to improve its acceptability. Trial registration ISRCTN registry ISRCT N6348 4804. Registered on 10 December 2020 Clinicaltrials.gov NCT04976179. Registered on 26 July 2021.

Low blood level in pregnancy is of public health importance and with common occurrence worldwide, but with a higher rate in low resource settings where its burden greatly affects both the mother and her baby. This low blood level is usually caused by poor intake of an iron-rich diet. It could lead to fatigue, decreased work capacity, and dizziness if not detected. Without treatment, this condition could affect the baby, possibly leading to its sudden demise in the womb, immediately after birth, or even the woman's death.The use of oral iron has been the primary treatment; however, it is associated with significant side effects, which have led to poor compliance. Fortunately, an alternative therapy in the form of a drip has been shown to overcome these challenges. However, it is not routinely used in countries like Nigeria. Moreover, being effective is different from being utilised. Therefore, this study was conducted to understand the factors that will make this treatment widely accepted.We interviewed pregnant women, family support and health care providers in 10 health facilities in Lagos and Kano States, Nigeria. Our findings revealed good attitudes to iron drip. However, its inclusion into routine antenatal health talk, training of health care providers, availability of space, drugs and health workers who will provide this care, and ensuring this drug is of low cost are some of the efforts needed for this treatment to be accepted.

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.

Prevalence, indications, and complications of caesarean section in health facilities across Nigeria: a systematic review and meta-analysis.

BACKGROUND: Over 80,000 pregnant women died in Nigeria due to pregnancy-related complications in 2020. Evidence shows that if appropriately conducted, caesarean section (CS) reduces the odds of maternal death. In 2015, the World Health Organization (WHO), in a statement, proposed an optimal national prevalence of CS and recommended the use of Robson classification for classifying and determining intra-facility CS rates. We conducted this systematic review and meta-analysis to synthesise evidence on prevalence, indications, and complications of intra-facility CS in Nigeria. METHODS: Four databases (African Journals Online, Directory of Open Access Journals, EBSCOhost, and PubMed) were systematically searched for relevant articles published from 2000 to 2022. Articles were screened following the PRISMA guidelines, and those meeting the study's inclusion criteria were retained for review. Quality assessment of included studies was conducted using a modified Joanna Briggs Institute's Critical Appraisal Checklist. Narrative synthesis of CS prevalence, indications, and complications as well as a meta-analysis of CS prevalence using R were conducted. RESULTS: We retrieved 45 articles, with most (33 (64.4%)) being assessed as high quality. The overall prevalence of CS in facilities across Nigeria was 17.6%. We identified a higher prevalence of emergency CS (75.9%) compared to elective CS (24.3%). We also identified a significantly higher CS prevalence in facilities in the south (25.5%) compared to the north (10.6%). Furthermore, we observed a 10.7% increase in intra-facility CS prevalence following the implementation of the WHO statement. However, none of the studies adopted the Robson classification of CS to determine intra-facility CS rates. In addition, neither hierarchy of care (tertiary or secondary) nor type of facility (public or private) significantly influenced intra-facility CS prevalence. The commonest indications for a CS were previous scar/CS (3.5-33.5%) and pregnancy-related hypertensive disorders (5.5-30.0%), while anaemia (6.4-57.1%) was the most reported complication. CONCLUSION: There are disparities in the prevalence, indications, and complications of CS in facilities across the geopolitical zones of Nigeria, suggestive of concurrent overuse and underuse. There is a need for comprehensive solutions to optimise CS provision tailor-made for zones in Nigeria. Furthermore, future research needs to adopt current guidelines to improve comparison of CS rates.

Stakeholder perceptions and experiences from the implementation of the Gratuité user fee exemption policy in Burkina Faso: a qualitative study.

BACKGROUND: In 2016, the Gratuité policy was initiated by the Government of Burkina Faso to remove user fees for maternal, newborn, and child Health (MNCH) services. Since its inception, there has not been any systematic capture of experiences of stakeholders as it relates to the policy. Our objective was to understand the perceptions and experiences of stakeholders regarding the implementation of the Gratuité policy. METHODS: We used key informant interviews (KIIs) and focus group discussions (FGDs) to engage national and sub-national stakeholders in the Centre and Hauts-Bassin regions. Participants included policymakers, civil servants, researchers, non-governmental organizations in charge of monitoring the policy, skilled health personnel, health facility managers, and women who used MNCH services before and after the policy implementation. Topic guides aided sessions, which were audio recorded and transcribed verbatim. A thematic analysis was used for data synthesis. RESULTS: There were five key themes emerging. First, majority of stakeholders have a positive perception of the Gratuité policy. Its implementation approach is deemed to have strengths including government leadership, multi-stakeholder involvement, robust internal capacity, and external monitoring. However, collateral shortage of financial and human resources, misuse of services, delays in reimbursement, political instability and health system shocks were highlighted as concerns that compromise the government's objective of achieving universal health coverage (UHC). However, many beneficiaries were satisfied at the point of use of MNHC services, though Gratuité did not always mean free to the service users. Broadly, there was consensus that the Gratuité policy has contributed to improvements in health-seeking behavior, access, and utilization of services, especially for children. However, the reported higher utilization is leading to some perceived increased workload and altered health worker attitude. CONCLUSIONS: There is a general perception that the Gratuité policy is achieving what it set out to do, which is to increase access to care by removing financial barriers. While stakeholders recognized the intention and value of the Gratuité policy, and many beneficiaries were satisfied at the point of use, inefficiencies in its implementation undermines progress. As the country moves towards the goal of realizing UHC, reliable investment in the Gratuité policy is needed.

Contraceptive use and fertility control in rural and urban communities of Lagos Nigeria.

Background: It is predicted that the population of sub-Saharan Africa will be thrice its size by the end of the 21st century. Our study compared patterns, incentives and disincentives for the uptake of contraceptives in rural and urban communities of Lagos, Nigeria. Materials and Methods: This is a population-based cross-sectional study on 1445 women of reproductive ages 15-49 years using a cluster sampling technique and a pre-tested, interviewer-administered electronic questionnaire in 2020. Data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 26.0 and ethical approval was obtained for the study. Results: About 32.4% of the respondents were rural dwellers and 67.6% were urban residents. The overall mean age was 31.7 ± 7.8 years. In terms of pattern, slightly over half (53.3%) of all respondents had ever used family planning (FP), including modern contraceptives and slightly less than a third (30.8%) currently use FP methods in both rural and urban communities, respectively. Predominant disincentives for non-use of FP include a desire to retain fertility, lack of further need, unbearable side effects and lack of spousal support. The odds of being an urban dweller currently using a method of contraceptive method is 4.169 times higher for earners above ₦60,000, which is twice the minimum wage compared to those without income (adjusted odd's ratio: 4.169, 95% confidence interval: 1.395-12.462). Conclusion: Sustained effort is required to improve contraceptive uptake, FP service delivery and demand satisfaction for modern contraceptives to enable the achievement of demographic dividends and gains.

Interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub-Saharan Africa: A systematic review.

OBJECTIVE: The objective of the study was to review the evidence on interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub-Saharan Africa (SSA). METHODS: A systematic search of PubMed, Embase, Cochrane Register and CINAHL Plus was conducted to identify studies on obstetric emergency referral in SSA. Studies were included based on pre-defined eligibility criteria. Details of reported referral interventions were extracted and categorised. The Joanna Biggs Institute Critical Appraisal checklists were used for quality assessment of included studies. A formal narrative synthesis approach was used to summarise findings guided by the WHO's referral system flow. RESULTS: A total of 14 studies were included, with seven deemed high quality. Overall, 7 studies reported referral decision-making interventions including training programmes for health facility and community health workers, use of a triage checklist and focused obstetric ultrasound, which resulted in improved knowledge and practice of recognising danger signs for referral. 9 studies reported on referral communication using mobile phones and referral letters/notes, resulting in increased communication between facilities despite telecommunication network failures. Referral decision making and communication interventions achieved a perceived reduction in maternal mortality. 2 studies focused on referral feedback, which improved collaboration between health facilities. CONCLUSION: There is limited evidence on how well referral interventions work in sub-Saharan Africa, and limited consensus regarding the framework underpinning the expected change. This review has led to the proposition of a logic model that can serve as the base for future evaluations which robustly expose the (in)efficiency of referral interventions.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens.

BACKGROUND: Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA. METHODS: We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning. RESULTS: About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had 20,000 women having

Experiences of Health Facility Childbirth in Sub-Saharan Africa: A Systematic Review of Qualitative Evidence.

INTRODUCTION: Access to skilled birth attendance has been prioritised as an intervention to minimise burden of maternal deaths in sub-Saharan Africa (SSA). However, poor experience of care (EoC) is impeding progress. We conducted a systematic review to holistically explore EoC patterns of facility-based childbirth in SSA. METHODS: PubMed, Embase and Scopus databases were searched to identify SSA EoC studies conducted between January 2000 and December 2019. Studies meeting our pre-defined inclusion criteria were quality assessed and relevant data extracted. We utilised the EoC quality standards (defined by the World Health Organization) to summarise and analyse findings while highlighting patterns. RESULTS: Twenty-two studies of varying quality from 11 SSA countries were included for review. Overall, at least one study from all included countries reported negative EoC in one or more domains of the WHO framework. Across SSA, 'respect and preservation of dignity' was the most reported domain of EoC. While most women deemed the pervasive disrespect as unacceptable, studies in West Africa suggest a "normalisation" of disrespect, if the intent is to save their lives. Women often experienced sub-optimal communication and emotional support with providers in public facilities compared to non-public ones in the region. These experiences had an influence on future institutional deliveries. DISCUSSION: Sub-optimal EoC is widespread in SSA, more so in public facilities. As SSA heath systems explore approaches make progress towards the Sustainable Development Goal 3, emphasis needs to be placed on ensuring women in the region have access to both high-quality provision and experience of care.

Association between exposure to social media and knowledge of sexual and reproductive health among adolescent girls: evidence from the UDAYA survey in Bihar and Uttar Pradesh, India.

BACKGROUND: Poor sexual and reproductive health (SRH) outcomes amongst adolescent girls in India have been associated with inadequate knowledge of SRH. Evidence suggests that social media can promote health-seeking behaviors. Our objective in this study was to determine the association between exposure to social media and SRH knowledge among adolescent girls in Bihar and Uttar Pradesh, India. METHODS: A cross-sectional study was conducted with 10,425 adolescent girls from the UDAYA survey (wave-2, 2018-19). Girls' exposure to social media was the key predictor, and SRH knowledge of sexual intercourse and pregnancy, contraceptive methods, and HIV/AIDS were outcomes of interest. Multivariable logistic regression models were performed to assess the association between exposure to social media and knowledge of SRH among adolescent girls. RESULTS: Of the study participants (n = 10,425), 28.0% (n = 3,160) had exposure to social media. Overall, 8.7%, 11.4%, and 6.6% of respondents had sufficient knowledge of sexual intercourse and pregnancy, contraceptive methods, and HIV/AIDS, respectively. Exposure to social media was associated with increased odds of knowledge of sexual intercourse and pregnancy (Odds ratio [OR]: 1.38; 95% confidence interval [CI]: 1.18, 1.61), contraceptive methods (OR: 1.46; 95% CI: 1.27, 1.67), and HIV/AIDS (OR: 2.18; 95% CI: 1.84, 2.58). CONCLUSIONS: Our study shows the potency of exposure to social media in influencing SRH knowledge, which exclusively benefits female adolescents who are educated, residing in urban areas, and from wealthier families. Digital media-focused interventions inclusive of socio-cultural contexts (e.g., strategic investment in education and creating economic opportunities) are crucial to optimize social media's impact on SRH knowledge enhancements.

A substantial body of research shows that adolescent girls in India lack adequate sexual and reproductive health (SRH) knowledge. Evidently, this puts them at several health risks associated with early pregnancies, preventable gynecological morbidities such as irregular menstrual patterns, and urethral discharge, among several others. Perpetuated social stigma and lack of agency impede adolescents especially from marginalized communities from accessing accurate, sufficient, and timely SRH information from their immediate household members and healthcare providers at local service points. This adversely affects their health-seeking behaviors and ultimately results in avertable poor reproductive health outcomes. A growing body of literature highlights social media platforms (i.e., Facebook, Instagram, Twitter, etc.) as preferred modalities to gain SRH information among adolescents. Against this backdrop, we assessed the intricate association between social media exposure and SRH knowledge (across three dimensions: sexual intercourse and pregnancy, contraceptive methods, and HIV/AIDS) among adolescent girls in Bihar and Uttar Pradesh, India. We tested for association between several socio-demographic factors and SRH knowledge. Findings indicate that adolescents who were exposed to social media platforms were likely to have more SRH knowledge compared to those who were not. Socio-demographic factors like place of residence, for example residing in urban areas, higher levels of education and high wealth index acted as facilitators of social media exposure as well as SRH knowledge.

Factors influencing motivation and job satisfaction of community health workers in Africa and Asia-A multi-country study.

As key stakeholders continue to affirm the relevance of community health workers (CHWs) in universal health coverage, there is a need for a commensurate focus on their motivation and job satisfaction especially in low- and middle-income countries (LMICs) where they play prominent roles. Despite the wealth of literature on motivation and job satisfaction, many studies draw on research conducted in high-income settings. This study explored factors influencing motivation and satisfaction among CHWs in LMICs. Thirty-two focus group discussions and 116 key informant interviews were conducted with CHWs, programme staff, health professionals and community leaders in Bangladesh, India, Kenya, Malawi and Nigeria. Data were analysed using thematic analysis. Overall, CHWs desired: (1) CHW programmes with manageable workload; work schedules that address concerns of female CHWs on work-life balance; clear career pathway; and a timely, regular and sustainable remuneration. However, no remuneration type guaranteed satisfaction because of an insatiable quest for additional financial reward. (2) Relationship with stakeholders that enhances their reputation. This was more important for unsalaried CHWs. (3) Opportunities to support community members. This was popular among all cadres as it resonated with their altruistic values. This study provides insights for developing a 'comprehensive motivation package' for CHWs.

Use of modern contraceptives in Lagos Nigeria during the COVID-19 pandemic.

We estimated modern contraceptive prevalence rate (mCPR) and examined predictors of modern contraceptives utilization amongst 1,445 sampled reproductive age women in Lagos (Nigeria's epicenter) during the devastating COVID-19 pandemic. Estimated mCPR was 30.8%. Women aged 20-29 years were 50% (95%CI:0.37-0.71) less likely to use modern contraceptives during the pandemic than those 30-39 years. Married and divorced women were about three (95%CI:1.37-5.25) and over three (95%CI:1.32-7.79) times more likely to use modern contraceptives compared to single women. Though mCPR has not reduced, sustained contraceptive needs assessment of sometimes obscure sub-populations is required, especially if outbreaks like COVID-19 become our 'new normal'.

From Ebola to COVID-19: emergency preparedness and response plans and actions in Lagos, Nigeria.

BACKGROUND: Lagos state is the industrial nerve centre of Nigeria and was the epicentre of the 2014 Ebola outbreak in Nigeria as it is now for the current Coronavirus Disease (COVID-19) outbreak. This paper describes how the lessons learned from the Ebola outbreak in 2014 informed the emergency preparedness of the State ahead of the COVID-19 outbreak and guided response. DISCUSSION: Following the Ebola outbreak in 2014, the Lagos State government provided governance by developing a policy on emergency preparedness and biosecurity and provided oversight and coordination of emergency preparedness strategies. Capacities for emergency response were strengthened by training key staff, developing a robust surveillance system, and setting up a Biosafety Level 3 laboratory and biobank. Resource provision, in terms of finances and trained personnel for emergencies was prioritized by the government. With the onset of COVID-19, Lagos state was able to respond promptly to the outbreak using the centralized Incident Command Structure and the key activities of the Emergency Operations Centre. Contributory to effective response were partnerships with the private sectors, community engagement and political commitment. CONCLUSION: Using the lessons learned from the 2014 Ebola outbreak, Lagos State had gradually prepared its healthcare system for a pandemic such as COVID-19. The State needs to continue to expand its preparedness to be more resilient and future proof to respond to disease outbreaks. Looking beyond intra-state gains, lessons and identified best practices from the past and present should be shared with other states and countries.

Determinants of viral load non-suppression among adolescents in Mbale District, Eastern Rural Uganda.

BACKGROUND: Adolescents are lagging behind in the "third 95" objective of the Joint United Nations Program on HIV/AIDS requiring 95% of individuals on antiretroviral therapy (ART) to have viral load (VL) suppression. This study aimed to describe factors associated with viral non-suppression among adolescents in Mbale district, Uganda. METHODS: We conducted a retrospective review of routinely collected HIV programme records. Data such as age, education, ART Regimen, ART duration, WHO Clinical stage, comorbidities, etc., were extracted from medical records for the period January 2018 to December 2018. Descriptive analysis was done for continuous variables using means and frequencies to describe study sample characteristics, and to determine the prevalence of outcome variables. We used logistic regression to assess factors associated with VL non-suppression among adolescents. RESULTS: The analysis included 567 HIV-infected adolescents, with 300 (52.9%) aged between 13 to 15 years, 335 (59.1%) female, and mean age of 15.6 years (interquartile range [IQR] 13.5-17.8. VL non-suppression was 31.4% (178/567). Male sex (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.01), age 16-19 years (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.05), No formal education (AOR = 3.67, 95% CI 1.48-9.09; p < 0.01), primary education (AOR = 2.23, 95% CI 1.05-2.32; p < 0.01), ART duration of > 12 months to 5 years (AOR = 3.20, 95% CI 1.31-7.82; p < 0.05), ART duration > 5 years (AOR = 3.47, 95% CI 1.39- 8.66; p < 0.01), WHO Clinical Stage II (AOR = 0.48, 95% CI: 0.28, 0.82; p < 0.01), second-line ART regimen (AOR = 2.38, 95% CI 1.53-3.72; p < 0.001) and comorbidities (AOR = 3.28, 95% CI 1.20-9.00; p < 0.05) were significantly associated with viral non-suppression. CONCLUSIONS: VL non-suppression among adolescents was almost comparable to the national average. VL non-suppression was associated with being male, age 16-19 years, education level, duration on ART therapy, WHO Clinical Staging II, second-line ART regimen, and presence of comorbidities. Adolescent-friendly strategies to improve VL suppression e.g. peer involvement, VL focal persons to identify and actively follow-up non-suppressed adolescents, patient education on VL suppression and demand creation for ART are needed, especially for newly-initiated adolescents and adolescents on ART for protracted periods, to foster attainment of the UNAIDS 95-95-95 targets.

Critical comparative analysis of data sources toward understanding referral during pregnancy and childbirth: three perspectives from Nigeria.

BACKGROUND: The highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems. METHODS: The study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis. RESULTS: We found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources. CONCLUSIONS: Our analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns.

Avoiding obstetrical interventions among US-based Somali migrant women: a qualitative study.

Objective: Somali refugee women are known to have poor health-seeking behavior with a higher proportion of adverse pregnancy outcomes compared to US-born women. Yet unknown is how they avoid obstetrical interventions. This study sought to identify perceived protective mechanisms used to avoid obstetric interventions as well as the underpinning factors that influence aversion to obstetrical interventions by Somali refugee women.Design: A descriptive, exploratory qualitative study purposively sampled Somali refugee women recruited via snowball technique in Franklin County, Ohio, United States. Data were collected through audio-recordings of individual interviews and focus groups conducted in English and Somali languages. The collected data were transcribed and analyzed using thematic analyses.Results: Forty Somali refugee women aged 18-42 years were recruited. Participants reported engaging in four perceived protective mechanisms to avoid obstetrical interventions during pregnancy and childbirth: (1) intentionally not seeking or misleading prenatal care, (2) changing hospitals and/or providers, (3) delayed hospital arrival during labor, and (4) refusal of care. Underpinning all four avoidance mechanisms were their significant fear of obstetrical interventions, and perceived lack of choice in their care processes as influenced by cultural and/or religious beliefs, feeling judged or undervalued by service providers, and a lack of privacy provided to them while receiving care.Conclusion: Like every woman, Somali women also have a right to choose or refuse care. If the intention is to improve access to and experiences with care for this population, building trust, addressing their fears and concerns, and respecting their culture is a critical first step. This should be well established prior to the need for critical decisions surrounding pregnancy and childbirth wherein Somali women may feel compelled to refuse necessary obstetrical care. Bridging gaps between Somali women and their providers is key to advance health equity for this vulnerable population.

Looking ahead in the COVID-19 pandemic: emerging lessons learned for sexual and reproductive health services in low- and middle-income countries.

The COVID-19 pandemic has caused widespread disruption to essential health service provision globally, including in low- and middle-income countries (LMICs). Recognising the criticality of sexual and reproductive health (SRH) services, we review the actual reported impact of the COVID-19 pandemic on SRH service provision and evidence of adaptations that have been implemented to date. Across LMICs, the available data suggests that there was a reduction in access to SRH services, including family planning (FP) counselling and contraception access, and safe abortion during the early phase of the pandemic, especially when movement restrictions were in place. However, services were quickly restored, or alternatives to service provision (adaptations) were explored in many LMICs. Cases of gender-based violence (GBV) increased, with one in two women reporting that they have or know a woman who has experienced violence since the beginning of the pandemic. As per available evidence, many adaptations that have been implemented to date have been digitised, focused on getting SRH services closer to women. Through the pandemic, several LMIC governments have provided guidelines to support SRH service delivery. In addition, non-governmental organisations working in SRH programming have played significant roles in ensuring SRH services have been sustained by implementing several interventions at different levels of scale and to varying success. Most adaptations have focused on FP, with limited attention placed on GBV. Many adaptations have been implemented based on guidance and best practices and, in many cases, leveraged evidence-based interventions. However, some adaptations appear to have simply been the sensible thing to do. Where evaluations have been carried out, many have highlighted increased outputs and efficiency following the implementation of various adaptations. However, there is limited published evidence on their effectiveness, cost, value for money, acceptability, feasibility, and sustainability. In addition, the pandemic has been viewed as a homogenous event without recognising its troughs and waves or disentangling effects of response measures such as lockdowns from the pandemic itself. As the pandemic continues, neglected SRH services like those targeting GBV need to be urgently scaled up, and those being implemented with any adaptations should be rigorously tested.

Assessing and decomposing inequality of opportunity in access to child health and nutrition in sub-Saharan Africa: evidence from three countries with low human development index.

BACKGROUND: Inequality of opportunity in health and nutrition is a major public health issue in the developing regions. This study analyzed the patterns and extent of inequality of opportunity in health and nutrition among children under-five across three countries sub-Saharan Africa with low Human development index (HDI). METHODS: We used data from the Multiple Indicator Cluster Survey of the Democratic Republic of Congo (20,792 households, 21,756 women aged 15 to 49 and 21,456 children under five), Guinea Bissau (6601 households, 10,234 women aged 15-49 and 7573 children under five) and Mali (11,830 households, 18,409 women in 15-49 years and 16,468 children under five) to compute the human opportunity index (HOI) and the dissimilarity index (D-index). Secondly, the Shapley decomposition method was used to estimate the relative contribution of circumstances that are beyond the control of children under-five and affecting their development outcomes in later life stages. RESULTS: The study revealed that children belonging to the most favorable group had higher access rates for immunization (93.64%) and water and sanitation facilities (73.59%) in Guinea Bissau. In Congo DR, the access rate was high for immunization (93.9%) for children in the most favorable group. In Mali, access rates stood at 6.56% for children in the most favorable group. In Guinea Bissau, the inequality of opportunity was important in access to health services before and after delivery (43.85%). In Congo DR, the inequality of opportunity was only high for the immunization composite indicator (83.79%) while in Mali, inequality of opportunity was higher for access to health services before and after delivery (41.67%). CONCLUSION: The results show that there are efforts in some places to promote access to health and nutrition services in order to make access equal without distinction linked to the socio-economic and demographic characteristics in which the children live. However, the inequalities of opportunity observed between the children of the most favorable group and those of the least favorable group, remain in general at significant levels and call on government of these countries to implement policies taking them into account.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania.

BACKGROUND: In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. METHODS: We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. RESULTS: The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. CONCLUSIONS: Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.