Young people's perception of sexual and reproductive health services in Kenya.

BACKGROUND: Addressing the Sexual and Reproductive Health (SRH) needs of young people remains a big challenge. This study explored experiences and perceptions of young people in Kenya aged 10-24 with regard to their SRH needs and whether these are met by the available healthcare services. METHODS: 18 focus group discussions and 39 in-depth interviews were conducted at health care facilities and youth centres across selected urban and rural settings in Kenya. All interviews were tape recorded and transcribed. Data was analysed using the thematic framework approach. RESULTS: Young people's perceptions are not uniform and show variation between boys and girls as well as for type of service delivery. Girls seeking antenatal care and family planning services at health facilities characterise the available services as good and staff as helpful. However, boys perceive services at health facilities as designed for women and children, and therefore feel uncomfortable seeking services. At youth centres, young people value the non-health benefits including availability of recreational facilities, prevention of idleness, building of confidence, improving interpersonal communication skills, vocational training and facilitation of career progression. CONCLUSION: Providing young people with SRH information and services through the existing healthcare system, presents an opportunity that should be further optimised. Providing recreational activities via youth centres is reported by young people themselves to not lead to increased uptake of SRH healthcare services. There is need for more research to evaluate how perceived non-health benefits young people do gain from youth centres could lead to improved SRH of young people.

Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.

BACKGROUND: Addressing the sexual and reproductive health (SRH) needs of young people remains a challenge for most developing countries. This study explored the perceptions and experiences of Health Service Providers (HSP) in providing SRH services to young people in Kenya. METHODS: Qualitative study conducted in eight health facilities; five from Nairobi and three rural district hospitals in Laikipia, Meru Central, and Kirinyaga. Nineteen in-depth interviews (IDI) and two focus group discussions (FGD) were conducted with HSPs. Interviews were tape recorded and transcribed. Data was coded and analysed using the thematic framework approach. RESULTS: The majority of HSPs were aware of the youth friendly service (YFS) concept but not of the supporting national policies and guidelines. HSP felt they lacked competency in providing SRH services to young people especially regarding counselling and interpersonal communication. HSPs were conservative with regards to providing SRH services to young people particularly contraception. HSP reported being torn between personal feelings, cultural and religious values and beliefs and their wish to respect young people's rights to accessing and obtaining SRH services. CONCLUSION: Supporting youth friendly policies and competency based training of HSP are two common approaches used to improve SRH services for adolescents. However, these may not be sufficient to change HSPs' attitude to adolescents seeking help. There is need to address the cultural, religious and traditional value systems that prevent HSPs from providing good quality and comprehensive SRH services to young people. Training updates should include sessions that enable HSPs to evaluate how their personal and cultural values and beliefs influence practice.

"It's complicated ": Exploring second stage caesarean sections and reasons for non-performance of assisted vaginal births in Kenya: A mixed methods study.

Unnecessary Caesarean Section (CS) can have adverse effects on women and their newborns. Assisted vaginal birth/delivery (AVB/AVD) using a suction device or obstetric forceps is a potential alternative when delays or complications occur in the second stage of labour. Unlike CS, AVB using a suction device does not require regional or general anaesthesia, can often be performed by midwives, and does not scar the uterus, lowering the risk of maternal mortality and morbidity, in this and subsequent pregnancies. This study examined the appropriateness and outcomes of second stage CS (SSCS), and reasons for low levels of AVB use, in Kenya. Using a mixed methods study design, we reviewed case notes from women having SSCS births and AVB, and conducted key informant interviews with healthcare providers, from 8 purposively selected hospitals in Kenya. Randomly selected SSCS and all AVB case notes were reviewed by a panel of four experienced obstetricians, and appropriateness of the procedure assessed. Semi-structured interviews were conducted with obstetricians, medical officers and midwives, and analysed using a thematic approach. Review of 67 SSCS case notes showed 10% might have been conducted as AVBs, with a further 58% unable to be classified due to inadequate/inconsistent record keeping or excessive delay following initial CS decision. Outcomes following SSCS showed perinatal mortality rate of 89.6/1,000 births, with 11% of infants and 9% of mothers experiencing complications. Non-referred cases of AVB showed good outcomes. The findings of the 20 interviews explored the experience and confidence of healthcare providers in performing AVBs, and adequacy of the training they received. Key reasons for non-performance included lack of functioning equipment, lack of trained staff or their rotation to other departments. Reasons for non-performance of AVB were complex and often multiple. Any solutions to these problems will need to address various local, regional and national issues.

A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017.

OBJECTIVE: To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country-specific PPH guidelines. METHODS: A retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014-2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub-Saharan African countries to develop country-specific PPH guidelines was described and perceived challenges implementing these were identified. RESULTS: In total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2  = 43.666, df = 4; P < 0.001), being reviewed by a medical doctor (χ2  = 16.905, df = 1; P < 0.001), and being reviewed by a specialist (χ2  = 49.244, df = 1; P < 0.001). Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat-stable carbetocin (HSC) due to cost, lack of awareness and education about HSC and TXA, and lack of systems to ensure quality oxytocin is available at point of care. CONCLUSION: There is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions.

Physical morbidity and psychological and social comorbidities at five stages during pregnancy and after childbirth: a multicountry cross-sectional survey.

OBJECTIVE: Maternal morbidity affects millions of women, the burden of which is highest in low resource settings. We sought to explore when this ill-health occurs and is most significant. SETTINGS: A descriptive observational cross-sectional study at primary and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi. PARTICIPANTS: Women attending for routine antenatal care, childbirth or postnatal care at the study healthcare facilities. PRIMARY AND SECONDARY OUTCOMES: Physical morbidity (infectious, medical, obstetrical), psychological and social comorbidity were assessed at five stages: first half of pregnancy (≤20 weeks), second half of pregnancy (>20 weeks), at birth (within 24 hours of childbirth), early postnatal (day 1-7) and late postnatal (week 2-12). RESULTS: 11 454 women were assessed: India (2099), Malawi (2923), Kenya (3145) and Pakistan (3287) with similar numbers assessed at each of the five assessment stages in each country. Infectious morbidity and anaemia are highest in the early postnatal stage (26.1% and 53.6%, respectively). For HIV, malaria and syphilis combined, prevalence was highest in the first half of pregnancy (10.0%). Hypertension, pre-eclampsia and urinary incontinence are most common in the second half of pregnancy (4.6%, 2.1% and 6.6%). Psychological (depression, thoughts of self-harm) and social morbidity (domestic violence, substance misuse) are significant at each stage but most commonly reported in the second half of pregnancy (26.4%, 17.6%, 40.3% and 5.9% respectively). Of all women assessed, maternal morbidity was highest in the second half of pregnancy (81.7%), then the early postnatal stage (80.5%). Across the four countries, maternal morbidity was highest in the second half of pregnancy in Kenya (73.8%) and Malawi (73.8%), and in the early postnatal stage in Pakistan (92.2%) and India (87.5%). CONCLUSIONS: Women have significant maternal morbidity across all stages of the continuum of pregnancy and childbirth, and especially in the second half of pregnancy and after childbirth.

'Sometimes you are forced to play God ': a qualitative study of healthcare worker experiences of using continuous positive airway pressure in newborn care in Kenya.

​OBJECTIVE: To explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up. ​DESIGN AND SETTING: A qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya. ​PARTICIPANTS: Healthcare workers in the newborn units providing CPAP. ​PRIMARY AND SECONDARY OUTCOME MEASURE: Facilitators and barriers of CPAP use in newborn care in Kenya. ​RESULTS: 16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available. ​CONCLUSION: CPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use. ETHICS: This study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.

Burden of physical, psychological and social ill-health during and after pregnancy among women in India, Pakistan, Kenya and Malawi.

INTRODUCTION: For every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types of maternal morbidity. METHODS: Descriptive observational cross-sectional study at primary-level and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi to assess physical, psychological and social morbidity during and after pregnancy. Sociodemographic factors, education, socioeconomic status (SES), quality of life, satisfaction with health, reported symptoms, clinical examination and laboratory investigations were assessed. Relationships between morbidity and maternal characteristics were investigated using multivariable logistic regression analysis. RESULTS: 11 454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptoms (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 36% of women had infectious morbidity of which 9.0% had an identified infectious disease (HIV, malaria, syphilis, chest infection or tuberculosis) and an additional 32.5% had signs of early infection. HIV-positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% reported psychological morbidity and 36.6% reported social morbidity (domestic violence and/or substance misuse). Infectious morbidity was highest in Malawi (56.5%) and Kenya (40.4%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Maternal morbidity was not limited to a core at-risk group; only 1.2% had all four morbidities. The likelihood of medical or obstetric, psychological or social morbidity decreased with increased education; adjusted OR (95% CI) for each additional level of education ranged from 0.79 (0.75 to 0.83) for psychological morbidity to 0.91 (0.87 to 0.95) for infectious morbidity. Each additional level of SES was associated with increased psychological morbidity (OR 1.15 (95% CI 1.10 to 1.21)) and social morbidity (OR 1.05 (95% CI 1.01 to 1.10)), but there was no difference regarding medical or obstetric morbidity. However, for each morbidity association was heterogeneous between countries. CONCLUSION: Women suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.

Implementing Maternal Death Surveillance and Response in Kenya: Incremental Progress and Lessons Learned.

Maternal death surveillance and response (MDSR) constitutes a quality improvement approach to identify how many maternal deaths occur, what the underlying causes of death and associated factors are, and how to implement actions to reduce the number of preventable stillbirths and maternal and neonatal deaths. This requires a coordinated approach, ensuring both national- and district-level stakeholders are enabled and supported and can implement MDSR in a "no name, no blame" environment. This field action report from Kenya provides an example of how MDSR can be implemented in a "real-life" setting by summarizing the experiences and challenges faced thus far by maternal death assessors and Ministry of Health representatives in implementing MDSR. Strong national leadership via a coordinating secretariat has worked well in Kenya. However, several challenges were encountered including underreporting of data, difficulties with reviewing the data, and suboptimal aggregation of data on cause of death. To ensure progress toward a full national enquiry of all maternal deaths, we recommend improving the notification of maternal deaths, ensuring regular audits and feedback at referral hospitals lead to continuous quality improvement, and strengthening community linkages with health facilities to expedite maternal death reporting. Ultimately, both a top-down and bottom-up approach is needed to ensure success of an MDSR system. Perinatal death surveillance and response is planned as a next phase of MDSR implementation in Kenya. To ensure the process continues to evolve into a full national enquiry of all maternal deaths, we recommend securing longer-term budget allocation and financial commitment from the ministry, securing a national legal framework for MDSR, and improving processes at the subnational level.