Efficacy of midwife-led role orientation of birth companions on maternal satisfaction and birth outcomes: a randomized control trial in Uganda.

BACKGROUND: The World Health Organization recommends birth companionship for all women in labor. There is insufficient evidence on birth companionship in low-income settings and it is not clear if role orientation impacts effectiveness. The aim of this study was to assess the efficacy of midwife-led role orientation of birth companions of on maternal satisfaction and birth outcomes in a sub-region in Uganda. METHODS: A stepped wedge cluster randomized trial conducted (control n = 240), intervention n = 235) from 4 clusters. Women who had a birth companion, in spontaneously established labor and, expecting a vaginal delivery were eligible. The intervention was "midwife-provided orientation of birth companions". The admitting midwife provided an orientation session for the birth companion on supportive labor techniques. The primary outcome was the chance of having a spontaneous vaginal delivery. Assessors were not blinded. Independent t-test and Chi-Square tests were used to assess the differences by study period. RESULTS: Mean maternal satisfaction rate was significantly higher in the intervention period compared to the control period (P > 0.001). High maternal satisfaction levels were noted among the women who were; at the regional referral hospital, younger, first-time mothers, and unmarried (P < 0.001). Satisfaction with pain management was rated lowest across study periods. Satisfaction with humaneness was rated highest with a higher score in the intervention period (93%) than the control (79.5%). There were no statistically significant differences in the mode of delivery, need to augment labor, length of labor and Apgar scores. CONCLUSION: Midwife-led role orientation of birth companions increased maternal satisfaction. Nevertheless, no significant effect was noted in the mode of delivery, length of labor, Apgar score, and need to augment labor. Findings could inform the integration of birth companions in the admission process of the woman in labor in similar settings. TRIAL REGISTRATION NUMBER: NCT04771325.

A qualitative exploratory interview study on birth companion support actions for women during childbirth.

BACKGROUND: The World Health Organization recommends that women are supported continuously throughout labor by a companion of their choice. And, that companions have clearly designated roles and responsibilities to ensure that their presence is beneficial to both the woman and her health care providers. Presently, there is lack of strong evidence regarding specific support actions in relation to women's needs of care. Thus, we aimed to explore birth companion support actions for women during childbirth. METHODS: This was an exploratory descriptive qualitative study conducted between August 2019 and December 2019; at a referral hospital in the Eastern part of Uganda. Ten women were purposively selected: those who were admitted in early labor, expecting a normal delivery, and had fulltime birth companion. Nonparticipant direct observation and in-depth interviews were used to collect data. Latent content analysis was used. RESULTS: Three themes were identified: "Support actions aiding a good childbirth experience", "Support actions hindering coping with labor", and "Women's needs and expectations of care". Support actions aiding a good experience described were; emotional presence, motivation, providing nourishments, messenger activities, body massage for pain relief, assisting in ambulation and coaching. Companion fearful behaviors and disrespectful care in form of unacknowledged needs and hostility from birth companions were reported to hinder coping. The women desired thoughtful communication, trust, for birth companions to anticipate their needs and recognize non perceptive phases of labor to allow them focus on themselves. CONCLUSION: Birth companions from this study largely supported women emotionally, and attended to their physical needs. The greater part of support actions provided were esteemed by the women. Presence of birth companion will be of benefit when individual needs of women are put into consideration. Also, more guidance for birth companions is necessary to boost their role and mitigate shortcomings of their presence during childbirth.

Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: A systematic review.

The incidence of cervical cancer in low- and middle-income countries (LMICs) is five times higher than that observed in high-income countries (HICs). This discrepancy is largely attributed to the implementation of cytology-based screening programmes in HICs. However, due to reduced health system infrastructure requirements, HPV testing (self- and provider-collected) and visual inspection with acetic acid (VIA) have been proposed as alternatives that may be better suited to LMICs. Knowing the relative value of different screening options can inform policy and the development of sustainable prevention programs. We searched MEDLINE and EMBASE for English language publications detailing model-based cost-effectiveness analyses of cervical cancer screening methods in LMICs from 2000 to 2016. The main outcome of interest was the incremental cost-effectiveness ratio (ICER). Quantitative data were extracted to compare commonly evaluated screening methods and a descriptive review was conducted for each included study. Of the initial 152 articles reviewed, 19 met inclusion criteria. Generally, cytology-based screening was shown to be the least effective and most costly screening method. Whether provider-collected HPV testing or VIA was the more efficient alternative depended on the cost of the HPV test, loss to follow-up and VIA test performance. Self-collected HPV testing was cost-effective when it yielded population coverage gains over other screening methods. We conclude that HPV testing and VIA are more cost-effective screening methods than cytology in LMICs. Policy makers should consider HPV testing with self-collection of samples if it yields gains in population coverage.

Self-collection based HPV testing for cervical cancer screening among women living with HIV in Uganda: a descriptive analysis of knowledge, intentions to screen and factors associated with HPV positivity.

BACKGROUND: Women living with HIV (WHIV) are disproportionately impacted by cervical dysplasia and cancer. The burden is greatest in low-income countries where limited or no access to screening exists. The goal of this study was to describe knowledge and intentions of WHIV towards HPV self-collection for cervical cancer screening, and to report on factors related to HPV positivity among women who participated in testing. METHODS: A validated survey was administered to 87 HIV positive women attending the Kisenyi Health Unit aged 30-69 years old, and data was abstracted from chart review. At a later date, self-collection based HPV testing was offered to all women. Specimens were tested for high risk HPV genotypes, and women were contacted with results and referred for care. Descriptive statistics, Chi Square and Fischer-exact statistical tests were performed. RESULTS: The vast majority of WHIV (98.9%) women did not think it necessary to be screened for cervical cancer and the majority of women had never heard of HPV (96.4%). However, almost all WHIV found self-collection for cervical cancer screening to be acceptable. Of the 87 WHIV offered self-collection, 40 women agreed to provide a sample at the HIV clinic. Among women tested, 45% were oncogenic HPV positive, where HPV 16 or 18 positivity was 15% overall. CONCLUSIONS: In this group of WHIV engaged in HIV care, there was a high prevalence of oncogenic HPV, a large proportion of which were HPV genotypes 16 or 18, in addition to low knowledge of HPV and cervical cancer screening. Improved education and cervical cancer screening for WHIV are sorely needed; self-collection based screening has the potential to be integrated with routine HIV care in this setting.

'As a man I felt small': a qualitative study of Ugandan men's experiences of living with a wife suffering from obstetric fistula.

The effects of obstetric fistula surpass the individual woman and affect husbands, relatives, peers and the community at large. Few studies have documented the experiences of men who live with wives suffering from fistula. In this study, our objective was to understand how fistula affects these men's lives. We conducted 16 in-depth interviews with men in central and western Uganda. We used thematic narrative analysis and discuss our findings based on Connell's theory of hegemonic masculinity. Findings show that the men's experiences conflicted with Ugandan norms of hegemonic masculinity. However, men had to find other ways of explaining their identity, such as portraying themselves as small men but still be responsible, caring husbands and fathers. The few individuals who married a second wife remained married to the wife with the fistula. These men viewed marriage as a lifetime promise before God and a responsibility that should not end because of a fistula. Poverty, love, care for children and social norms in a patriarchal society compelled the men to persevere in their relationship amidst many challenges.

Uptake of community-based, self-collected HPV testing vs. visual inspection with acetic acid for cervical cancer screening in Kampala, Uganda: preliminary results of a randomised controlled trial.

OBJECTIVES: To compare two cervical cancer screening methods: community-based self-collection of high-risk human papillomavirus (HR-HPV) testing and visual inspection with acetic acid (VIA). METHODS: Pilot randomised controlled trial of 500 women aged 30-65 in the community of Kisenyi, Uganda. Women randomised to self-collection-based HR-HPV testing provided a cervico-vaginal swab for HR-HPV, and results were provided by phone after laboratory testing. Women who tested HPV positive were referred for VIA at the local health unit. Women randomised to VIA underwent screening at the local health unit, where women who tested positive with VIA were provided cryotherapy at time of screening, as per local standard of care. Women were referred for colposcopy when indicated. Outcome measures were uptake of screening, HR-HPV prevalence, VIA result and treatment rates. RESULTS: In the HR-HPV arm, 248 of 250 (p < 0.01) women provided samples, while in the VIA arm, 121 of 250 (48.4%) women attended screening. Among the 73 of 248 HR-HPV-positive women, 45.2% (N = 33) attended VIA screening for follow-up, 21.2% (N = 7) of whom screened positive; five received treatment and two were missing clinical follow-up records. Of the 121 women in the VIA arm who attended screening, 13.2% (N = 16) screened positive; seven received cryotherapy, three refused treatment, five were referred to colposcopy; and one woman had suspected cervical cancer and received treatment after confirmatory testing. CONCLUSIONS: This pilot study demonstrated trial feasibility and willingness of the women to participate and be randomised successfully into the two arms. Self-collection-based cervical cancer screening had a higher uptake than VIA.

"I am alone and isolated": a qualitative study of experiences of women living with genital fistula in Uganda.

BACKGROUND: Globally, 2-3 million women are estimated to have a genital fistula, with an annual incidence of 50,000-100,000 women. Affected women remain silent within their communities, and their experiences often go unnoticed. Our objective was to explore the experiences of Ugandan women living with genital fistulas to understand how their lives were affected and how they coped with the condition. METHODS: We conducted 8 focus group discussions (FGDs) with 56 purposively selected women with a genital fistula seeking treatment at Mulago Hospital, Uganda. Data were transcribed and analysed using qualitative content analysis. RESULTS: Women with a fistula were living a physically changed and challenging life, living socially deprived and isolated, living psychologically stigmatised and depressed, and living marital and sexual lives that were no longer joyful. The women's experiences were full of life changes and coping strategies, and they used both problem- and emotion-focused coping strategies to deal with the challenges. They devised ways to reduce the smell of urine to reduce the stigma, rejection and isolation. While trying to cope, the women found themselves alone and isolated. Women either isolated themselves or were isolated by society, including by close relatives and their husbands. Their sex lives were no longer enjoyable, and generally, women felt a loss of their marital and sexual rights. CONCLUSION: Women with a fistula make adjustments in their lives to cope with the physical, social, psychological and sexual challenges. They use both problem- and emotion-focused coping to minimise their sense of isolation, as well as the rejection and stigma associated with fistula. These findings are essential for counselling patients, families and community members affected by a fistula. In similar contexts, health programmes should go beyond fistula closure and target communities and families to reduce the stigma and isolation faced by women with genital fistula.

Customization and acceptability of the WHO labor care guide to improve labor monitoring among health workers in Uganda. An iterative development, mixed method study.

Cognisant of persistently high maternal and perinatal mortality rates, WHO called for adoption and evaluation of new adaptable and context-specific solutions to improve labor monitoring and health outcomes. We aimed at customizing/refining the new WHO labour care guide (LCG) to suite health care provider needs (HCP) in monitoring labour in Uganda. We used mixed methods to customize/refine and pilot test the new WHO LCG using stakeholder perspectives. Between 1st July 2023 and 30th December 2023, we conducted; 1)30 stakeholder interviews to identify user needs/challenges that informed initial modifications of the WHO LCG; 2)15 HCP in-depth interviews to identify any further needs to modify the LCG; 3) Two focus group discussions and 4) Two exit expert panels to identify any further user needs to further refine proposed modifications into the final prototype. Questionnaires were administered to assess acceptability. We interviewed 125 stakeholders with median age of 36 years (IQR;26-48) exposed to the LCG for at least 12 months with 11.8(SD = 4.6) years of clinical practice. Simple useful modifications/customizations based on format, HCP's perceived function and role in improving decision making during monitoring labour included; 1) Customizing LCG by adding key socio-demographic data; 2) Adjusting observation ordering; 3) Modification of medication dosages and 4) Provision for recording key clinical notes/labour outcome data on reverse side of the same A4 paper. All HCPs found the modified WHO LCG useful, easy to use, appropriate, comprehensive, appealing and would recommend it to others for labour monitoring. It was implementable and majority took less than 2 minutes to completely record/fill observations on the LCG after each labour assessment. Active involvement of end-users improved inclusiveness, ownership, acceptability and uptake. The modified LCG prototype was found to be simple, appropriate and easy-to-use. Further research to evaluate large-scale use, feasibility and effectiveness is warranted.

Effect of Midwife-Provided Orientation of Birth Companions on Maternal Anxiety and Coping during Labor: A Stepped Wedge Cluster Randomized Control Trial in Eastern Uganda.

The study aimed to assess the effect of midwife-provided orientation of birth companions on maternal anxiety and coping during labor. A stepped wedge cluster randomized trial design was conducted among 475 participants (control n = 240), intervention n = 235) from four clusters. Midwives in the intervention period provided an orientation session for the birth companions on supportive labor techniques. Coping was assessed throughout labor and anxiety scores were measured after birth. Independent t-test and Chi-Square tests were used to assess the differences by study period. Anxiety scores were reduced among women in the intervention period (p = 0.001). The proportion of women able to cope during early active labor was higher during the intervention period (p = 0.031). Women in the intervention period had 80% higher odds of coping (p = 0.032) compared to those in the control period. Notable differences in anxiety and coping with labor were observed among first-time mothers, younger women, and when siblings provided support. Midwife-provided orientation of birth companions on labor support lowers maternal anxiety and improves coping during labor. Findings could inform the planning and development of policies for the implementation of the presence of birth companions in similar low-resource settings.

Why mothers die at a busy tertiary urban hospital in Kampala, Uganda: a comprehensive review of maternal deaths 2016-2018 and implications for quality improvement to reduce deaths.

Background: Reviewing maternal deaths and drawing out lessons for clinical practice is part of an effective cohesive intervention strategy to reduce future deaths. Objective: To review maternal deaths at the National Referral hospital in Kampala over a 3-year period (2016-2018) to determine causes of death, extent of preventability, proportion of deaths notified and audited as per national guidelines. Methods: Trained-multidisciplinary panels (obstetricians and senior midwives) conducted retrospective reviews of maternal deaths that occurred. Results: Major causes of deaths: obstetric haemorrhage (158/350; 45%), hypertensive disorders of pregnancy (87/350; 25%) and infection (95/350; 27%). Overall, 294/350 (84%) of maternal deaths were considered preventable. In 95% (332/350) of cases, delays within healthcare facilities were identified (64%; 226/350). We note that only 115/350 (33%) cases had been audited. This proportion did not change during the studied period. In 48% (167/350) of cases, notification to the Ministry of Health occurred, but only 11% of deaths (39/350) were notified within the recommended 24-hours. Conclusions: A high proportion (84%) of deaths were preventable. Significant delays to care occurred within health-care facilities. Results suggest that a well-supported, and timely maternal death review process with targeted and pragmatic interventions might be effective in reducing maternal deaths in this setting.

Evaluating the Instructional Design and Effect on Knowledge, Teamwork, and Skills of Technology-Enhanced Simulation-Based Training in Obstetrics in Uganda: Stepped-Wedge Cluster Randomized Trial.

BACKGROUND: Simulation-based training is a common strategy for improving the quality of facility-based maternity services and is often evaluated using Kirkpatrick's theoretical model. The results on the Kirkpatrick levels are closely related to the quality of the instructional design of a training program. The instructional design is generally defined as the "set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes." OBJECTIVE: The aim of this study is to evaluate the instructional design of a technology-enhanced simulation-based training in obstetrics, the reaction of participants, and the effect on knowledge, teamwork, and skills in a low-income country. METHODS: A stepped-wedge cluster randomized trial was performed in a university hospital in Kampala, Uganda, with an annual delivery volume of over 31,000. In November 2014, a medical simulation center was installed with a full-body birthing simulator (Noelle S550, Gaumard Scientific), an interactive neonate (Simon S102 Newborn CPR Simulator, Gaumard Scientific), and an audio and video recording system. Twelve local obstetricians were trained and certified as medical simulation trainers. From 2014 to 2016, training was provided to 57 residents in groups of 6 to 9 students. Descriptive statistics were calculated for ten instructional design features of the training course measured by the 42-item ID-SIM (Instructional Design of a Simulation Improved by Monitoring). The Wilcoxon signed rank test was conducted to investigate the differences in scores on knowledge, the Clinical Teamwork Scale, and medical technical skills. RESULTS: The mean scores on the ten instructional design features ranged from 54.9 (95% CI 48.5-61.3) to 84.3 (95% CI 80.9-87.6) out of 100. The highest mean score was given on the feature feedback and the lowest scores on repetitive practice and controlled environment. The overall score for the training day was 92.8 out of 100 (95% CI 89.5-96.1). Knowledge improved significantly, with a test score of 63.4% (95% CI 60.7-66.1) before and 78.9% (95% CI 76.8-81.1) after the training (P<.001). The overall score on the 10-point Clinical Teamwork Scale was 6.0 (95% CI 4.4-7.6) before and 5.9 (95% CI 4.5-7.2) after the training (P=.78). Medical technical skills were scored at 55.5% (95% CI 47.2-63.8) before and 65.6% (95% CI 56.5-74.7) after training (P=.08). CONCLUSIONS: Most instructional design features of a technology-enhanced simulation-based training in obstetrics in a low-income country were scored high, although intervals were large. The overall score for the training day was high, and knowledge did improve after the training program, but no changes in teamwork and (most) medical technical skills were found. The lowest-scored instructional design features may be improved to achieve further learning aims. TRIAL REGISTRATION: ISRCTN Registry ISRCTN98617255; http://www.isrctn.com/ISRCTN98617255. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12884-020-03050-3.

A randomized clinical trial of two emergency contraceptive pill regimens in a Ugandan population.

BACKGROUND: Recent trials on emergency contraception (EC) have indicated that levonorgestrel (LNG) used alone has fewer side-effects and is more efficacious than the Yuzpe regimen (high dose combined oral contraceptive pills). However, the experienced side-effects and acceptability may vary between different groups or societies. OBJECTIVE: The primary objective of this study was to determine side-effects and acceptability of two emergency contraceptive pill (ECP) regimens among users in Kampala, Uganda. STUDY DESIGN: Randomized clinical trial. METHODS: A total of 337 women were enrolled in a double blind randomized clinical trial. Women requesting ECPs within 72 hours after unprotected sexual intercourse received either LNG or the Yuzpe regimen. The women returned for follow-up after three days and a follow-up interview was performed after one year. RESULTS: Levonorgestrel had significantly fewer side-effects than the Yuzpe regimen (p < 0.001). There was a significant association between having worries about the method and experiencing side-effects (p < 0.001). Most women (81%) were prime users of EC. The majority would recommend ECP to other clients. CONCLUSIONS: Levonorgestrel is a superior option to the Yuzpe regimen and should be promoted as the recommended ECP. Having worries about ECP may influence experience of the side-effects. Correct information is critical in promotion of ECP use.

Consumption of alcoholic beverages among pregnant urban Ugandan women.

The World Health Organization estimated alcohol consumption in Uganda to be one of the highest in the world. We examined alcohol consumption among Ugandan women prior to and after learning of pregnancy. We developed a screening algorithm using factors that predicted alcohol consumption in this study. In 2006, we surveyed 610 women attending antenatal care at the national referral hospital in Kampala, Uganda about consumption of traditional and commercial alcoholic beverages before and after learning of pregnancy. Predictors of alcohol consumption during pregnancy were examined and a practical screening algorithm was developed for use in antenatal clinics. One hundred eighty women (30%) drank alcohol at least monthly before learning of their pregnancy. Among these women, almost one-third reported usual consumption of at least one beverage type at quantities that equal binging levels for women. Overall, 151 women (25%) consumed alcohol after learning of pregnancy. Commercial beverages, particularly beer, were consumed more often than traditional drinks. A two-stage screening algorithm asking women about their religion, male partner or friends' drinking, and any lifetime drinking predicted self-reported consumption of alcohol during pregnancy with 97% sensitivity and 89% specificity. Alcohol consumption among pregnant Ugandan women attending antenatal care is high. A feasible screening algorithm can help providers target education and counseling to women who are likely drinking during pregnancy. Given the preference for commercial alcoholic beverages, it is recommended that labels be placed prominently on bottled alcoholic beverages warning of the adverse effects of consuming alcohol during pregnancy.

Prevalence of hepatitis B virus infection and associated risk factors among pregnant women attending antenatal clinic in Mulago Hospital, Uganda: a cross-sectional study.

AIM: To determine the prevalence and factors associated with hepatitis B virus infection among pregnant women attending antenatal clinic in Mulago Hospital. DESIGN: Cross-sectional observational study. SETTING: Mulago National Referral Hospital, Uganda, antenatal clinic. PARTICIPANTS: We randomly selected 340 pregnant women attending their first antenatal visit at Mulago Hospital antenatal clinic. PRIMARY OUTCOME: Hepatitis B surface antigen positivity. RESULTS: We recruited 340 participants, with a mean age of 27±5.7 years, and a median gravidity of 3. The prevalence of hepatitis B virus infection among pregnant women attending the antenatal clinic in Mulago Hospital, in our study, was 2.9% (95% CI 1.58% to 5.40%, n=10). Factors positively associated with hepatitis B virus infection were: marital status (adjusted OR (aOR)=11.37, p=0.002), having a hepatitis B positive family member (aOR=49.52, p<0.001) and having had a blood or body fluid splash to mucous membranes from a hepatitis B positive patient (aOR=61.69, p=0.015). Other factors such as age, socioeconomic status, number of sexual partners, HIV serostatus, piercing of ears and history of blood transfusion were not significantly associated with hepatitis B virus infection in this study. CONCLUSION: The prevalence of hepatitis B virus infection among pregnant women attending antenatal clinic in Mulago Hospital was of intermediate endemicity. We found that marital status, having a hepatitis B positive family member at home and having had a blood or body fluid splash to mucous membranes from a hepatitis B positive patient were independently associated with hepatitis B infection. Factors such as age, HIV status, history of blood transfusion, piercing of ears and social status were not associated with hepatitis B status in this study.

Disentangling contributions of reproductive tract infections to HIV acquisition in African Women.

OBJECTIVE: : To estimate the effects of reproductive tract infections (RTIs) on HIV acquisition among Zimbabwean and Ugandan women. METHODS: : A multicenter prospective observational cohort study enrolled 4439 HIV-uninfected women aged 18 to 35 attending family planning clinics in Zimbabwe and Uganda. Participants were interviewed, and tested for HIV and RTIs every 3 months for 15 to 24 months. They received HIV risk reduction counseling, male condoms, and treatment for curable RTIs. RESULTS: : Despite HIV risk reduction counseling and regular screening and treatment for RTIs, the HIV incidence did not decline during the study. Positive HSV-2 serostatus at baseline (hazard ratio [HR] = 3.69, 95% confidence interval = 2.45-5.55), incident HSV-2 (HR = 5.35, 3.06-9.36), incident Neisseria gonorrhoeae (HR = 5.46, 3.41-8.75), and altered vaginal flora during the study (bacterial vaginosis [BV]: HR = 2.12, 1.50-3.01; and intermediate flora: HR = 2.02, 1.39-2.95) were independently associated with HIV acquisition after controlling for demographic and behavioral covariates and other RTIs (Treponema pallidum, Chlamydia trachomatis, Trichomonas vaginalis, and vaginal yeasts). For N. gonorrhoeae, C. trachomatis, T. vaginalis, and vaginal yeasts, the risk of HIV acquisition increased when the infection was identified at the visit before the HIV-detection visit or with the duration of infection. Population attributable risk percent (PAR%) calculations show that HSV-2 contributes most to acquisition of new HIV infections (50.4% for baseline HSV-2 and 7.9% for incident HSV-2), followed by altered vaginal flora (17.2% for bacterial vaginosis and 11.8% for intermediate flora). CONCLUSIONS: : A substantial proportion of new HIV infections in Zimbabwean and Ugandan women are attributable to RTIs, particularly HSV-2 and altered vaginal flora.

Faced with a double-edged risk: Ugandan university students' perception of the emergency contraceptive pill in Uganda.

Whereas in high-income countries potential users of Emergency Contraception (EC) have information and access to emergency contraceptive pills (ECPs), it has remained secretive in low-income countries like Uganda. Although several studies have been conducted in relation to EC, few have addressed users' perceptions. The objective of our study was to explore perceptions of EC by university students in Kampala, Uganda. Seven focus group discussions and four key informant interviews were conducted at Makerere University, Kampala. The transcribed data was analyzed for content and recurrent themes. Participants expressed ambivalence about ECPs. The method was generally recommended but only to the "right people", in this context being those aged eighteen years and more. There were reservations surrounding provision of ECPs like similarity with abortion and fear of side effects. Users' and potential-users' perceptions are crucial in the accessibility and utilization of ECPs.

Injectable contraception: what should the longest interval be for reinjections?

BACKGROUND: Progestin-only injectable contraceptives continue to gain in popularity, but uncertainty remains about pregnancy risk among women late for reinjection. The World Health Organization (WHO) recommends a "grace period" of 2 weeks after the scheduled 13-week reinjection. Beyond 2 weeks, however, many providers send late clients home to await menses. STUDY DESIGN: A prospective cohort study in Uganda, Zimbabwe and Thailand followed users of depot-medroxyprogesterone acetate (DMPA) for up to 24 months. Users were tested for pregnancy at every reinjection, allowing analysis of pregnancy risk among late comers. RESULTS: The analysis consists of 2290 participants contributing 13,608 DMPA intervals. The pregnancy risks per 100 women-years for "on time" [0.6; 95% confidence interval (CI), 0.33-0.92], "2-week grace" (0.0; 95% CI, 0.0-1.88) and "4-week grace" (0.4; 95% CI, 0.01-2.29) injections were low and virtually identical. CONCLUSION: Extending the current WHO grace period for DMPA reinjection from 2 to 4 weeks does not increase pregnancy risk and could increase contraceptive continuation.

Pregnancy risk among oral contraceptive pill, injectable contraceptive, and condom users in Uganda, zimbabwe, and Thailand.

OBJECTIVE: To estimate the probability of pregnancy for oral contraceptive pill (OCP), injectable contraceptive, and condom users in Uganda, Thailand, and Zimbabwe. METHODS: This study is a secondary analysis of 5,224 women who participated in a prospective study evaluating the association between hormonal contraception and human immunodeficiency virus (HIV) acquisition. RESULTS: The overall 12-month cumulative probability of pregnancy of injectable contraceptive users was 0.6% (95% confidence interval [CI] 0.3-1.0), with similar risks in Uganda (0.3%, 95% CI 0-0.7), Thailand (0.6%, 95% CI 0-1.2), and Zimbabwe (1.0%, 95% CI 0.3-1.7). The 12-month cumulative probability of pregnancy for OCP users was 9.5% (95% CI 8.1-11.0%), with similar risks of pregnancy in Uganda and Zimbabwe (14.6%, 95% CI 11.7-17.4; and 10.2%, 95% CI 8.0-12.5, respectively) but substantially lower risk in Thailand (0.5%, 95% CI 0-1.2). The overall 12-month cumulative probability of pregnancy for women intending to use a given method at baseline was 2.0% (95% CI 1.4-2.6%) for injectable contraceptives, 15.7% (95% CI 14.1-17.3%) for OCPs, and 25.8% (95% CI 23.2-28.4) for condoms. Women in Thailand experienced lower pregnancy risk with condoms (18.4%, 95% CI 11.1-25.7) than in Uganda (29.5%, 95% CI 25.7-33.4), and Zimbabwe (23.3%, 95% CI 19.4-27.2). CONCLUSION: The overall risk of pregnancy for injectable contraceptive users was substantially lower than for oral contraceptive pill users. However, Thai participants had similarly low cumulative pregnancy probabilities for both methods. Women receiving contraceptive counseling should be informed that their experience with a given method may differ from the average or typical-use pregnancy rates often discussed during contraceptive counseling. Tailored counseling is necessary for women to make informed choices. LEVEL OF EVIDENCE: II.

Risk factors for obstetric fistula in Western Uganda: a case control study.

INTRODUCTION: Two million women worldwide are living with genital fistula with an annual incidence of 50,000-100,000 women. Risk factors for obstetric fistula are context bound. Studies from other countries show variation in the risk factors for obstetric fistula. This study was conducted to identify risk factors for obstetric fistula in western Ugandan context. METHODS: A case control study comparing background factors of women with obstetric fistula (cases) and women without fistula (controls) was conducted in western Uganda. Data was collected using face-to-face interviews. Univariate, bivariate and multivariate analysis was conducted using Stata 12. RESULTS: Altogether, 420 respondents (140 cases and 280 controls) participated in the study. Duration of labour was used to form the product terms when assessing for interaction and confounding since it was one the most significant factors at bivariate level with a narrow confidence interval and was hence considered the main predictor. After adjusting for interaction and confounding, significant risk factors associated with development of obstetric fistula in western Uganda were: Caesarean section (adjusted odds ratio [AOR] = 13.30, 95% CI = 6.74-26.39), respondent height of 150 cm or less (AOR = 2.63, 95% CI = 1.35-5.26), baby weight of 3.5 kg or more (AOR = 1.52, 95% CI = 1.15-1.99), prolonged labour (AOR = 1.06, 95% CI = 1.04-1.08. A quarter of the fistulas had resulted from iatrogenic complication during caesarean section. Compared to no education, post primary level of education was protective against obstetric fistula (AOR = 0.31, 95% CI = 0.13-0.72) and there was no difference between respondents without education and those with primary level education. CONCLUSIONS: Surgeons contribute to a big proportion (25%) of fistula cases hence caesarean section being a risk factor in this region. Other risk factors include; prolonged labour, weight of the baby of 3.5 kg or more, respondent height of 150 cm or less (short stature), and low or no education are risk factors for obstetric fistula in western Ugandan.

Understanding the role of embarrassment in gynaecological screening: a qualitative study from the ASPIRE cervical cancer screening project in Uganda.

OBJECTIVE: To define embarrassment and develop an understanding of the role of embarrassment in relation to cervical cancer screening and self-collected human papillomavirus (HPV) DNA testing in Uganda. DESIGN: Cross-sectional, qualitative study using semistructured one-to-one interviews and focus groups. PARTICIPANTS: 6 key-informant health workers and 16 local women, purposively sampled. Key informant inclusion criteria: Ugandan members of the project team. Focus group inclusion criteria: woman age 30-69 years, Luganda or Swahili speaking, living or working in the target Ugandan community. EXCLUSION CRITERIA: unwillingness to sign informed consent. SETTING: Primary and tertiary low-resource setting in Kampala, Uganda. RESULTS: In Luganda, embarrassment relating to cervical cancer is described in two forms. 'Community embarrassment' describes discomfort based on how a person may be perceived by others. 'Personal embarrassment' relates to shyness or discomfort with her own genitalia. Community embarrassment was described in themes relating to place of study recruitment, amount of privacy in dwellings, personal relationship with health workers, handling of the vaginal swab and misunderstanding of HPV self-collection as HIV testing. Themes of personal embarrassment related to lack of knowledge, age and novelty of the self-collection swab. Overall, embarrassment was a barrier to screening at the outset and diminished over time through education and knowledge. Fatalism regarding cervical cancer diagnosis, worry about results and stigma associated with a cervical cancer diagnosis were other psychosocial barriers described. Overcoming psychosocial barriers to screening can include peer-to-peer education, drama and media campaigns. CONCLUSIONS: Embarrassment and other psychosocial barriers may play a large role at the onset of a screening programme, but over time as education and knowledge increase, and the social norms around screening evolve, its role diminishes. The role of peer-to-peer education and community authorities on healthcare cannot be overlooked and can have a major impact in overcoming psychosocial and social barriers to screening.