A qualitative evaluation and conceptual framework on the use of the Birth weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) matrix for perinatal health in Uganda.

BACKGROUND: Perinatal mortality (newborn deaths in the first week of life and stillbirths) continues to be a significant global health threat, particularly in resource-constrained settings. Low-tech, innovative solutions that close the quality-of-care gap may contribute to progress toward the Sustainable Development Goals for health by 2030. From 2012 to 2018, the Saving Mothers, Giving Life Initiative (SMGL) implemented the Birth weight and Age-at-Death Boxes for Intervention and Evaluation System (BABIES) matrix in Western Uganda. The BABIES matrix provides a simple, standardized way to track perinatal health outcomes to inform evidence-based quality improvement strategies. METHODS: In November 2017, a facility-based qualitative evaluation was conducted using in-depth interviews with 29 health workers in 16 health facilities implementing BABIES in Uganda. Data were analyzed using directed content analysis across five domains: 1) perceived ease of use, 2) how the matrix was used, 3) changes in behavior or standard operating procedures after introduction, 4) perceived value of the matrix, and 5) program sustainability. RESULTS: Values in the matrix were easy to calculate, but training was required to ensure correct data placement and interpretation. Displaying the matrix on a highly visible board in the maternity ward fostered a sense of accountability for health outcomes. BABIES matrix reports were compiled, reviewed, and responded to monthly by interprofessional teams, prompting collaboration across units to fill data gaps and support perinatal death reviews. Respondents reported improved staff communication and performance appraisal, community engagement, and ability to track and link clinical outcomes with actions. Midwives felt empowered to participate in the problem-solving process. Respondents were motivated to continue using BABIES, although sustainability concerns were raised due to funding and staff shortages. CONCLUSIONS: District-level health systems can use data compiled from the BABIES matrix to inform policy and guide implementation of community-centered health practices to improve perinatal heath. Future work may consider using the Conceptual Framework on Use of the BABIES Matrix for Perinatal Health as a model to operationalize concepts and test the impact of the tool over time.

Trends and determinants of adolescent childbirth in Uganda- analysis of rural and urban women using six demographic and health surveys, 1988-2016.

INTRODUCTION: Uganda has high adolescent pregnancy. The details of adolescent childbirth and urban/rural patterns are scarce. We investigated the levels, time trends and determinants of adolescent childbirth in Uganda separately for urban and rural women. METHODS: We estimated the percentage of women 20-24 years at each of the six Uganda Demographic and Health Surveys (1988/89, 1995, 2000/01, 2006, 2011 and 2016) who reported a live childbirth before age 20 years ("adolescent childbirth"), and examined change over time using t-test. A modified multivariable Poisson regression was used to examine determinants of having adolescent childbirth on the 2016 survey. RESULTS: Among these women, 67.5, 66.4, 70.1, 62.3, 57.3 and 54.1% reported an adolescent childbirth in 1988/89, 1995, 2000/01, 2006, 2011 and 2016 surveys, respectively. Between 1988/89 to 2000/01, there was no evidence of change (+ 2.6% point (pp), p = 0.170), unlike between the 2000/01 and 2016 surveys when a significant decline occurred (- 16.0 pp., p < 0.001). First childbirth < 18 years of age declined by - 13.5 pp. (p < 0.001) between 2000/01 and 2016. There was no change over time in the percentage of adolescents 18-19.9 years of age having first childbirth. Among rural residents, childbirth < 18 years declined from 43.8% in 1988/89 to 32.7% in 2016 (- 11.1 pp., p < 0.001), in urban it declined from 28.3 to 18.2% (- 10.1 pp., p = 0.006). There was an increase over time in the percentage of women, both rural and urban, who wanted to delay their first pregnancy. Independent determinants of reporting an adolescent childbirth in both urban and rural residents were: no education/incomplete primary and younger age at first sex. Additional determinants for rural women were residence in Eastern region, Muslim religion, and poor household wealth index. CONCLUSION: In the 30-year period examined, adolescent childbirth in Uganda declined from highs of 7 in 10 to approximately 5 in 10 women, with more wanting to delay the pregnancy. The decline started after the 2000/01 survey and affected predominantly younger adolescent childbirth < 18 years among both rural and urban residence women. Efforts need to be intensified to sustain the decline in adolescent pregnancies. Targeted and specific strategies for urban and rural areas might be required.

Spatial and temporal trends of cesarean deliveries in Uganda: 2012-2016.

BACKGROUND: Cesarean section (CS) is an important intervention in complicated births when the safety of the mother or baby is compromised. Despite worldwide concerns about the overutilization of CS in recent years, many African women and their newborns still die because of limited or no access to CS services. We evaluated temporal and spatial trends in CS births in Uganda and modeled future trends to inform programming. METHODS: We performed secondary analysis of total births data from the Uganda National Health Management Information System (HMIS) reports during 2012-2016. We reviewed data from 3461 health facilities providing basic, essential obstetric and emergency obstetric care services in all 112 districts. We defined facility-based CS rate as the proportion of cesarean deliveries among total live births in facilities, and estimated the population-based CS rate using the total number of cesarean deliveries as a proportion of annual expected births (including facility-based and non-facility-based) for each district. We predicted CS rates for 2021 using Generalised Linear Models with Poisson family, Log link and Unbiased Sandwich Standard errors. We used cesarean deliveries as the dependent variable and calendar year as the independent variable. RESULTS: Cesarean delivery rates increased both at facility and population levels in Uganda. Overall, the CS rate for live births at facilities was 9.9%, increasing from 8.5% in 2012 to 11% in 2016. The overall population-based CS rate was 4.7%, and increased from 3.2 to 5.9% over the same period. Health Centre IV level facilities had the largest annual rate of increase in CS rate between 2012 and 2016. Among all 112 districts, 80 (72%) had a population CS rate below 5%, while 38 (34%) had a CS rate below 1% over the study period. Overall, Uganda's facility-based CS rate is projected to increase by 36% (PRR 1.36, 95% CI 1.35-1.36) in 2021 while the population-based CS rate is estimated to have doubled (PRR 2.12, 95% CI 2.11-2.12) from the baseline in 2016. CONCLUSION: Cesarean deliveries are increasing in Uganda. Health center IVs saw the largest increases in CS, and while there was regional heterogeneity in changes in CS rates, utilization of CS services is inadequate in most districts. We recommend expansion of CS services to improve availability.

Using research priority-setting to guide bridging the implementation gap in countries - a case study of the Uganda newborn research priorities in the SDG era.

BACKGROUND: One of the greatest challenges that countries face regarding the achievement of the Sustainable Development Goal (SDG) targets for child health regard the actions required to improve neonatal health; these interventions have to be informed by evidence. In view of the persisting high numbers of newborn deaths in Uganda, we aimed to define a locally contextualised national research agenda for newborn health to guide national investments towards SDG targets. METHODS: We adopted a systematic approach for priority-setting adapted from the Child Health and Nutrition Research Initiative. We identified and listed local newborn researchers and experts in Uganda by reviewing the PubMed database, through a snowballing technique, and engaged the Ministry of Health. Participants were requested to generate at least three research questions. The collated questions were sent to the same expert group to be rated using five criteria, including answerability, scalability, impact, generalisability and speed. FINDINGS: Of the 300 researchers and stakeholders contacted, 104 responded (36%) and generated 304 questions. These questions were collated and duplicates removed giving a condensed list of 41 research questions. These questions were then rated by 82 experts. Of the top 15 research questions, 86.7% (13/15) were in the service delivery and 6.7% (1/15) in the development domain, while only 6.7% (1/15) was in the group 'other'. None of the leading 15 questions was in the discovery domain. Strategies to improve quality of intrapartum care featured high in the responses, while research around care for premature babies was not a perceived focus of research. CONCLUSIONS: The focus of improved evidence to guide and innovate service delivery, foremost intrapartum care, reflects the importance of this area as accelerated improvement is likely to yield fast and sustained survival gains in the neonatal period and beyond in Uganda. We recommend that other countries adapt a similar approach in defining priority reproductive, maternal, newborn and child health areas for investment in order to accelerate progress towards achieving the SDGs.

Factors associated with HIV positive sero-status among exposed infants attending care at health facilities: a cross sectional study in rural Uganda.

BACKGROUND: East and South Africa contributes 59% of all pediatric HIV infections globally. In Uganda, HIV prevalence among HIV exposed infants was estimated at 5.3% in 2014. Understanding the remaining bottlenecks to elimination of mother-to-child transmission (eMTCT) is critical to accelerating efforts towards eMTCT. This study determined factors associated with HIV positive sero-status among exposed infants attending mother-baby care clinics in rural Kasese so as to inform enhancement of interventions to further reduce MTCT. METHODS: This was a cross-sectional mixed methods study. Quantitative data was derived from routine service data from the mother's HIV care card and exposed infant clinical chart. Key informant interviews were conducted with health workers and in-depth interviews with HIV infected mothers. Quantitative data was analyzed using Stata version 12. Logistic regression was used to determine factors associated with HIV sero-status. Latent content analysis was used to analyse qualitative data. RESULTS: Overall, 32 of the 493 exposed infants (6.5%) were HIV infected. Infants who did not receive ART prophylaxis at birth (AOR = 4.9, 95% CI: 1.901-13.051, p=0.001) and those delivered outside of a health facility (AOR = 5.1, 95% CI: 1.038 - 24.742, p = 0.045) were five times more likely to be HIV infected than those who received prophylaxis and those delivered in health facilities, respectively. Based on the qualitative findings, health system factors affecting eMTCT were long waiting time, understaffing, weak community follow up system, stock outs of Neverapine syrup and lack of HIV testing kits. CONCLUSION: Increasing facility based deliveries and addressing underlying health system challenges related to staffing and availability of the required commodities may further accelerate eMTCT.

Modifiable risk factors for typhoid intestinal perforations during a large outbreak of typhoid fever, Kampala Uganda, 2015.

BACKGROUND: Between January and June, 2015, a large typhoid fever outbreak occurred in Kampala, Uganda, with 10,230 suspected cases. During the outbreak, area surgeons reported a surge in cases of typhoid intestinal perforation (TIP), a complication of typhoid fever. We conducted an investigation to characterize TIP cases and identify modifiable risk factors for TIP. METHODS: We defined a TIP case as a physician-diagnosed typhoid patient with non-traumatic terminal ileum perforation. We identified cases by reviewing medical records at all five major hospitals in Kampala from 2013 to 2015. In a matched case-control study, we compared potential risk factors among TIP cases and controls; controls were typhoid patients diagnosed by TUBEX TF, culture, or physician but without TIP, identified from the outbreak line-list and matched to cases by age, sex and residence. Cases and controls were interviewed using a standard questionnaire from 1st -23rd December 2015. We used conditional logistic regression to assess risk factors for TIP and control for confounding. RESULTS: Of the 88 TIP cases identified during 2013-2015, 77% (68/88) occurred between January and June, 2015; TIPs sharply increased in January and peaked in March, coincident with the typhoid outbreak. The estimated risk of TIP was 6.6 per 1000 suspected typhoid infections (68/10,230). The case-fatality rate was 10% (7/68). Cases sought care later than controls; Compared with 29% (13/45) of TIP cases and 63% (86/137) of controls who sought treatment within 3 days of onset, 42% (19/45) of cases and 32% (44/137) of controls sought treatment 4-9 days after illness onset (ORadj = 2.2, 95%CI = 0.83-5.8), while 29% (13/45) of cases and 5.1% (7/137) of controls sought treatment ≥10 days after onset (ORadj = 11, 95%CI = 1.9-61). 68% (96/141) of cases and 23% (23/100) of controls had got treatment before being treated at the treatment centre (ORadj = 9.0, 95%CI = 1.1-78). CONCLUSION: Delay in seeking treatment increased the risk of TIPs. For future outbreaks, we recommended aggressive community case-finding, and informational campaigns in affected communities and among local healthcare providers to increase awareness of the need for early and appropriate treatment.

No differences in clinical outcomes with the addition of viral load testing to CD4 cell count monitoring among HIV infected participants receiving ART in rural Uganda: Long-term results from the Home Based AIDS Care Project.

BACKGROUND: We compared clinical outcomes among HIV-infected participants receiving ART who were randomized to viral load (VL) and CD4 cell count monitoring in comparison to CD4 cell count monitoring alone in Tororo, Uganda. METHODS: Beginning in May 2003, participants with CD4 cell counts <250 cells/µL or WHO stage 3 or 4 disease were randomized to clinical monitoring alone, clinical monitoring plus quarterly CD4 cell counts (CD4-only); or clinical monitoring, quarterly CD4 cell counts and quarterly VL testing (CD4-VL). In 2007, individuals in clinical monitoring arm were re-randomized to the other two arms and all participants were followed until March 31, 2009. We used Cox Proportional Hazard models to determine if study arm was independently associated with the development of opportunistic infections (OIs) or death. RESULTS: We randomized 1211 participants to the three original study arms and 331 surviving participants in the clinical monitoring arm were re-randomized to the CD4-VL and CD4 only arms. At enrolment the median age was 38 years and the median CD4 cell count was 134 cells/µL. Over a median of 5.2 years of follow-up, 37 deaths and 35 new OIs occurred in the VL-CD4 arm patients, 39 deaths and 42 new OIs occurred in CD4-only patients. We did not observe an association between monitoring arm and new OIs or death (AHR =1.19 for CD4-only vs. CD4-VL; 95 % CI 0.82-1.73). CONCLUSION: We found no differences in clinical outcomes associated with the addition of quarterly VL monitoring to quarterly CD4 cell count monitoring.

Effectiveness and safety of misoprostol distributed to antenatal women to prevent postpartum haemorrhage after child-births: a stepped-wedge cluster-randomized trial.

BACKGROUND: Oral misoprostol, administered by trained health-workers is effective and safe for preventing postpartum haemorrhage (PPH). There is interest in expanding administration of misoprostol by non-health workers, including task-shifting to pregnant women themselves. However, the use of misoprostol for preventing PPH in home-births remains controversial, due to the limited evidence to support self-administration or leaving it in the hands of non-health workers. This study aimed to determine if antenatally distributing misoprostol to pregnant women to self-administer at home birth reduces PPH. METHODS: Between February 2013 and March 2014, we conducted a stepped-wedge cluster-randomized trial in six health facilities in Central Uganda. Women at 28+ weeks of gestation attending antenatal care were eligible. Women in the control-arm received the standard-of-care; while the intervention-arm were offered 600 mcg of misoprostol to swallow immediately after birth of baby, when oxytocin was not available. The primary outcome (PPH) was a drop in postpartum maternal haemoglobin (Hb) by ≥ 2 g/dl, lower than the prenatal Hb. Analysis was by intention-to-treat at the cluster level and we used a paired t-tests to assess whether the mean difference between the control and intervention groups was statistically significant. RESULTS: 97% (2466/2545) of eligible women consented to participate; 1430 and 1036 in the control and intervention arms respectively. Two thousand fifty-seven of the participants were successfully followed up and 271 (13.2%) delivered outside a health facility. There was no significant difference between the study group in number of women who received a uterotonic at birth (control 80.4% vs intervention 91.4%, mean difference = -11.0%, 95% confidence interval [CI] -25.7% to 3.6%, p = 0.11). No woman took misoprostol before their baby's birth. Shivering and fever were 14.9% in the control arm compared to 22.2% in the intervention arm (mean difference = -7.2%, 95% CI -11.1% to -3.7%), p = 0.005). There was a slight, but non-significant, reduction in the percentage of women with Hb drop ≥ 2g/dl from 18.5% in the control arm to 11.4% in the intervention arm (mean difference = 7.1%, 95% CI -3.1% to 17.3%, p = 0.14). Similarly, there was no significant difference between the groups in the primary outcome in the women who delivered at home (control 9.6% vs intervention 14.5%, mean difference -4.9; 95% CI -12.7 to 2.9), p = 0.17). CONCLUSION: This study was unable to detect a significant reduction in PPH following the antenatal distribution of misoprostol. The study was registered with Pan-African Clinical Trials Network ( PACTR201303000459148, on 19/11/2012).

Early parasite clearance following artemisinin-based combination therapy among Ugandan children with uncomplicated Plasmodium falciparum malaria.

BACKGROUND: Artemisinin-based combination therapy (ACT) is widely recommended as first-line therapy for uncomplicated Plasmodium falciparum malaria worldwide. Artemisinin resistance has now been reported in Southeast Asia with a clinical phenotype manifested by slow parasite clearance. Although there are no reliable reports of artemisinin resistance in Africa, there is a need to better understand the dynamics of parasite clearance in African children treated with ACT in order to better detect the emergence of artemisinin resistance. METHODS: Data from a cohort of Ugandan children four to five years old, enrolled in a longitudinal, randomized, clinical trial comparing two leading ACT, artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DP), were analysed. For all episodes of uncomplicated P. falciparum malaria over a 14-month period, daily blood smears were performed for three days following the initiation of therapy. Associations between pre-treatment variables of interest and persistent parasitaemia were estimated using multivariate, generalized, estimating equations with adjustment for repeated measures in the same patient. RESULTS: A total of 202 children were included, resulting in 416 episodes of malaria treated with AL and 354 episodes treated with DP. The prevalence of parasitaemia on days 1, 2, and 3 following initiation of therapy was 67.6, 5.6 and 0% in those treated with AL, and 52.2, 5.7 and 0.3% in those treated with DP. Independent risk factors for persistent parasitaemia on day 1 included treatment with AL vs DP (RR = 1.34, 95% CI 1.20-1.50, p < 0.001), having a temperature ≥38.0°C vs < 37.0°C (RR = 1.19, 95% CI 1.05-1.35, p = 0.007) and having a parasite density >20,000/µL vs <4,000/µL (RR = 3.37, 95% CI 2.44-4.49, p < 0.001). Independent risk factors for having persistent parasitaemia on day 2 included elevated temperature, higher parasite density, and being HIV infected. CONCLUSIONS: Among Ugandan children, parasite clearance following treatment with AL or DP was excellent with only one of 752 patients tested having a positive blood slide three days after initiation of therapy. The type of ACT given, pre-treatment temperature, pre-treatment parasite density and HIV status were associated with differences in persistent parasitaemia, one or two days following therapy. TRIAL REGISTRATION: Current Controlled Trials Identifier NCT00527800.

Strengthening Kampala's Urban Referral System for Maternal and Newborn Care Through Establishment of an Emergency Call and Dispatch Center.

INTRODUCTION: Most pregnant women living in urban slum communities in Uganda deliver at public health centers that are not equipped to provide emergency obstetric and newborn care. When obstetric emergencies occur, pregnant women are referred to a higher-level facility and are responsible for arranging and paying for their own transport. The Kampala Slum Maternal Newborn (MaNe) project developed and tested an emergency call and ambulance dispatch center and a mobile application to request, deploy, and track ambulances. We describe the development of these 2 interventions and findings on the feasibility, acceptability, and sustainability of the interventions. METHODS: MaNe conducted a mixed-method feasibility study that included an assessment of the acceptability and demand of the interventions. In-depth interviews (N=26) were conducted with facility proprietors, health providers, ambulance drivers, Kampala Capital City Authority officers, and community members to understand the successes and challenges of establishing the call center and developing the mobile application. Thematic content analysis was done. Quantitative data from the call center dispatch logs were analyzed descriptively to complement the qualitative findings. FINDINGS: Between April 2020 and June 2021, 10,183 calls were made to the emergency call and dispatch center. Of these, 25% were related to maternal and newborn health emergencies and 14% were COVID-19 related. An ambulance was dispatched to transfer or evacuate a patient in 35% of the calls. Participants acknowledged that the call center and mobile application allowed for efficient communication, coordination, and information flow between health facilities. Supportive district leadership facilitated the establishment of the call center and has taken over the operating costs of the center. CONCLUSION: The call center and referral application improved the coordination of drivers and ambulances and allowed facilities to prepare for and treat cases more efficiently.

HIV-infected ugandan adults taking antiretroviral therapy with CD4 counts >200 cells/µL who discontinue cotrimoxazole prophylaxis have increased risk of malaria and diarrhea.

BACKGROUND: Cotrimoxazole prophylaxis prolongs survival and prevents opportunistic infections, malaria, and diarrhea in persons infected with human immunodeficiency virus (HIV). Many countries recommend that individuals taking antiretroviral therapy (ART) discontinue cotrimoxazole when CD4 counts are >200 cells/µL. However, this practice has not been evaluated in sub-Saharan Africa. METHODS: Patients in the Home-Based AIDS Care program in eastern Uganda initiated ART if they had a CD4 cell count ≤250 cells/µL or World Health Organization stage III or IV HIV disease. In the program's fourth year, patients with CD4 counts >200 cells/µL were randomly assigned, by household, to continue or discontinue cotrimoxazole. Consenting participants were followed for episodes of malaria and diarrhea. RESULTS: At randomization, 836 eligible patients had been receiving ART for a mean of 3.7 years, with a median CD4 count of 489 cells/µL; 94% had a viral load <400 copies/mL. Among those continuing (n = 452) vs discontinuing (n = 384) cotrimoxazole, 0.4 vs 12.2%, respectively, had at least 1 episode of malaria (P < .001), and 14% vs 25%, respectively, had at least 1 episode of diarrhea (P < .001). Compared to those remaining on cotrimoxazole, patients who discontinued had a relative risk of malaria of 32.5 (95% confidence interval [CI], 8.6-275.0; P < .001) and of diarrhea of 1.8 (95% CI, 1.3-2.4; P < .001). CONCLUSIONS: HIV-infected adults on ART with CD4 counts >200 cells/µL who live in a malaria-endemic area of sub-Saharan Africa and who abruptly discontinue cotrimoxazole prophylaxis have an increased incidence of malaria and diarrhea compared with those who continue prophylaxis. Clinical Trials Registration. NCT00119093.

Increasing incidence of malaria in children despite insecticide-treated bed nets and prompt anti-malarial therapy in Tororo, Uganda.

BACKGROUND: The burden of malaria has decreased in parts of Africa following the scaling up of control interventions. However, similar data are limited from high transmission settings. METHODS: A cohort of 100 children, aged six weeks to 10 months of age, were enrolled in an area of high malaria transmission intensity and followed through 48 months of age. Children were given a long-lasting insecticide-treated bed net (LLIN) at enrolment and received all care, including monthly blood smears and treatment with artemisinin-based combination therapy (ACT) for uncomplicated malaria, at a dedicated clinic. The incidence of malaria was estimated by passive surveillance and associations between malaria incidence and age, calendar time and season were measured using generalized estimating equations. RESULTS: Reported compliance with LLINs was 98% based on monthly routine evaluations. A total of 1,633 episodes of malaria were observed, with a median incidence of 5.3 per person-year (PPY). There were only six cases of complicated malaria, all single convulsions. Malaria incidence peaked at 6.5 PPY at 23 months of age before declining to 3.5 PPY at 48 months. After adjusting for age and season, the risk of malaria increased by 52% from 2008 to 2011 (RR 1.52, 95% CI 1.10-2.09). Asymptomatic parasitaemia was uncommon (monthly prevalence <10%) and rarely observed prior to 24 months of age. CONCLUSIONS: In Tororo, despite provision of LLINs and prompt treatment with ACT, the incidence of malaria is very high and appears to be rising. Additional malaria control interventions in high transmission settings are likely needed. TRIAL REGISTRATION: Current Controlled Trials Identifier NCT00527800.

To use or not to use a condom: a prospective cohort study comparing contraceptive practices among HIV-infected and HIV-negative youth in Uganda.

BACKGROUND: Unwanted pregnancy and HIV infection are issues of significant concern to young people. Limited data exists on contraceptive decision-making and practices among HIV-infected and HIV-negative young people in low resource settings with generalized HIV epidemics. METHODS: From July 2007 until April 2009, we recruited, and followed up over a one year period, a cohort of 501 HIV-negative and 276 HIV-infected young women and men aged 15-24 years residing in Kampala and Wakiso districts. We compared contraceptive use among HIV-infected and HIV-negative young people and assessed factors associated with contraceptive decision-making and use, using multivariate logistic regression modelling to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Contraceptive use among sexually active HIV-infected young people was 34% while it was 59% among the HIV-negative group. The condom was the most frequently used method of contraception. Only 24% of the HIV-infected used condoms consistently compared to 38% among the negative group OR 0.56 (95% CI 0.38, 0.82). HIV-infected young people were more likely to discuss safe sex behaviour with health workers OR 1.70 (95% CI 1.13, 2.57), though its effect on fertility decision-making was not significant. Throughout the year's follow-up, only 24% among the HIV-negative and 18% among the HIV-infected continued to use contraception while 12% and 28% among the HIV-negative and infected respectively did not use contraception at all. At multivariate analysis, the HIV-infected young people were less likely to maintain contraceptive use. Other factors independently associated with sustained contraceptive use were age of the respondent, marital status and being a male. Conversely, HIV-infected young people were less likely to initiate use of contraception. Being married or in a relationship was associated with higher odds of initiating contraceptive use. CONCLUSION: Compared to the HIV-negative group, sexually active HIV-infected young people are less likely to use contraception and condoms. Initiating or sustaining contraceptive use was also significantly less among the HIV-infected group. Strengthening family planning services and developing new innovative ideas to re-market condom use are needed. Policy and guidelines that empower health workers to help young people (especially the HIV infected) express their sexuality and reproduction should urgently be developed.

" I would have left that man long time ago but, " exploring circumstances of and motivators for repeat adolescent birth in Eastern Uganda.

BACKGROUND: First birth before 18 years has declined in Uganda unlike repeat adolescent birth (=second or more births before age 20 years). We explored the circumstances of and motivators for repeat adolescent birth in Eastern Uganda. METHODS: Between January and March 2020, we conducted a qualitative study involving 70 individual in-depth interviews with purposively selected respondents - 20-25-year-old women with and without repeat adolescent birth, their partners, and parents, in the communities of Teso sub-region. We conducted latent content analysis. RESULTS: Four major themes emerged: poverty, vulnerability, domestic violence, and demotivators. Sub-themes identified under poverty were: "limited provisions", "peasantry", "large families", "dropping out of school", "alcohol abuse", and "broken family structure". Vulnerability included "marital entrapment" and "partner coercion". Demotivators included: "abandonment", "stern warning", "objection to marriage", and "empowerment". Extreme poverty resulted in inadequate provision of basic needs leading to unprotected sexual activity in a bid to secure financial support. Following the first birth, more than three quarters of the women with repeat adolescent birth reported increased economic distress that forced them to remain in unwanted marriage/union, often characterized by partner coercion, despite wanting to delay that repeat birth. Women without repeat adolescent birth avoided a second birth by empowerment through: an economic activity, contraception use, and resumption of schooling. CONCLUSION: Repeat adolescent birth in Uganda is premised around attempts to address the economic distress precipitated by first birth. Many women want to delay that repeat birth but the challenges robbed them of their reproductive autonomy. Beyond efforts to prevent first birth, programs need to address economic empowerment, ensure contraceptive access, and school re-integration for adolescent mothers in order to prevent shortly-spaced repeat births.

In the last 30 years, the proportion of adolescents (10­19 years) in Uganda having a first live birth before age 18 years has declined. However, among these, the proportion who proceed to have another live birth before age 20 years (=repeat adolescent birth) has not declined. We therefore set out to find out what motivated or were the circumstance under which these adolescent girls had repeat adolescent birth. We answered this question by interviewing people in Eastern Uganda: 1) women age 20­25 years who had first birth before age 18 years; those with and without history of repeat adolescent birth, 2) the parents with girls who had first birth before 18 years, 3) partners to women with repeat adolescent birth, and 4) community leaders.We found that the financial challenges that had escalated following the first birth was responsible for the events or decisions that culminated into a repeat adolescent birth. In an attempt to find a solution to the financial challenges, the adolescent girls end up in unwanted unions with men and ultimately lost their power to decide on whether or not to get pregnant again. Many wanted to have this repeat birth later but were robbed of the opportunity to do so. The study findings suggest that beyond helping adolescent girls prevent the first birth, they need to be supported with economic empowerment activities, improved contraception services, and re-integration in school.

Abortion-related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda.

INTRODUCTION: With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda. METHODS: This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016-2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions. RESULTS: Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care. CONCLUSIONS: Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.

Effects of the Helping Mothers Survive Bleeding after Birth training on near miss morbidity and mortality in Uganda: A cluster-randomized trial.

OBJECTIVE: To assess the effect of Helping Mothers Survive Bleeding after Birth training on postpartum hemorrhage (PPH) near miss and case fatality rates in Uganda. METHODS: Training was evaluated using a cluster-randomized design between June 2016 and September 2017 in 18 typical rural districts (clusters) in Eastern and Central Uganda of which nine districts were randomly assigned to the intervention. The main outcome was PPH near miss defined using the World Health Organization's disease and management-based approach. Interrupted time series analysis was performed to estimate the difference in the change of outcomes. RESULTS: Outcomes of 58 000 and 95 455 deliveries during the 6-month baseline and 10-month endline periods, respectively, were included. A reduction of PPH near misses was observed in the intervention compared to the comparison districts (difference-in-difference of slopes 4.19, 95% CI, -7.64 to -0.74); P<0.05). There was an increase in overall reported near miss cases (difference-in-difference 1.24, 95% CI, 0.37-2.10; P<0.001) and an increase in PPH case fatality rate (difference-in-difference 2.13, 95% CI, 0.14-4.12; P<0.05). CONCLUSION: This pragmatic cluster-randomized trial conducted in typical rural districts of Uganda indicated a reduction of severe PPH cases while case fatality did not improve, suggesting that this basic training needs to be complemented by additional measures for sustained mortality reduction. TRIAL REGISTRATION: PACTR201604001582128.

My partner wants a child: a cross-sectional study of the determinants of the desire for children among mutually disclosed sero-discordant couples receiving care in Uganda.

BACKGROUND: The percentages of couples in HIV sero-discordant relationships range from 5 to 31% in the various countries of Africa. Given the importance of procreation and the lack of assisted reproduction to avoid partner transmission, members of these couples are faced with a serious dilemma even after the challenge of disclosing their HIV status to their spouses. Identifying the determinants of the decision to have children among sero-discordant couples will help in setting reproductive intervention priorities in resource-poor countries. METHODS: We conducted a survey among 114 mutually disclosed sero-discordant couples (228 individuals) receiving HIV care at four centres in Greater Kampala, between June and December 2007. The data we collected was classified according to whether the man or the woman was HIV-positive. We carried out multivariate logistic regression modelling to determine factors (age, gender, and the influences of relatives and of health workers, ART knowledge, and disclosure) that are independently associated with a desire for children. RESULTS: The majority, 59%, of the participants, desired to have children. The belief that their partner wanted children was a major determinant of the desire to have children, irrespective of the HIV sero-status (adjusted odds ratio 24.0 (95% CI 9.15, 105.4)). Among couples in which the woman was HIV-positive, young age and relatives' expectations for children were significantly associated with increased fertility desire, while among couples in which the man was positive; knowledge of ART effectiveness was associated with increased fertility desire. Availability of information on contraception was associated with decreased fertility desire. CONCLUSIONS: The gender of the positive partner affects the factors associated with a desire for children. Interventions targeting sero-discordant couples should explore contraceptive choices, the cultural importance of children, and partner communication.

"Not a boy, not a child": A qualitative study on young people's views on childbearing in Uganda.

To understand reasons for persistent high fertility rate, we explored perceptions and influences of fertility motivation among young people from Uganda. Qualitative inquiry was used, data were organised using NVivo 2 package and latent content analysis performed. Major themes that emerged on factors that entrench high fertility included "Sustenance of 'men's blood' through the male child"; "poverty, joblessness and child bearing", and "other socio-cultural issues: religion, kin, elders and child bearing". Factors that reduce fertility included "perception on women emancipation, job security and couple fertility communication". Young peoples' views on motivation for childbearing in Uganda are embedded in cultural norms and linked strongly to patriarchy, social respectability and women's sustenance. Innovative cultural practices and programs that increase women's social respectability such as emphasis that a girl can be heir and inherit her father's property are needed to reduce son-preference and fertility rates in the younger generation.

Time trends in and factors associated with repeat adolescent birth in Uganda: Analysis of six demographic and health surveys.

BACKGROUND: Information on repeat adolescent birth remains scarce in sub-Sahara Africa. We investigated the prevalence and time trends in repeat adolescent birth in Uganda, and associated factors. METHODS: We analyzed Uganda Demographic and Health Survey data of women age 20-24 years collected on 6 surveys (1988/89-2016) to estimate repeat adolescent birth (first live birth <18 years of age followed by another live birth(s) <20 years). Further, we estimated the wantedness of the second order birth and the prevalence of short birth intervals birth (<13 months) between the first and second such birth. On the 2016 survey, we examined factors associated with repeat adolescent birth using bivariate and multivariate modified Poisson regression. RESULTS: At the 1988/89 survey, 58.9% of women with first birth <18 years reported a repeat adolescent birth. This percentage increased to 66.8% in 2006 (+7.9 percentage points [pp], p = 0.010) and thereafter declined to 55.6% by 2016 (-11.2 pp, p<0.001), nevertheless, no change occurred between 1988/89 and 2016 (-3.3pp, p = 0.251). Among women with repeat adolescent births, the mean number of live births by exact age 20 years (2.2 births) and prevalence of short birth intervals (3.5% in 1988/89, 5.4% in 2016) (+1.9pp, p = 0.245) did not change. Increasingly more women with repeat adolescent births preferred to have had the second child later, 22.5% in 1995 and 43.1% in 2016 (+20.6pp, p = <0.001). On the 2016 survey, women from poorer households and those of younger age at first birth were significantly more likely to report repeat adolescent birth. CONCLUSION: Following a first birth <18 years, more than half of the women report a repeat adolescent birth (<20 years), with no decline observed in 30 years. Increasingly more women wanted the second adolescent pregnancy later, highlighting the need to support adolescents with improved family planning services at each contact.

Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia.

BACKGROUND: Saving Mothers, Giving Life (SMGL) significantly reduced maternal and perinatal mortality in Uganda and Zambia by using a district health systems strengthening approach to address the key delays women and newborns face in receiving quality, timely, and appropriate medical care. This article documents the transition of SMGL from pilot to scale in Uganda and Zambia and analyzes the sustainability of the approach, examining the likelihood of maintaining positive trends in maternal and newborn health in both countries. METHODS: We analyzed the potential sustainment of SMGL achievements using a tool adapted from the HIV-focused domains and elements of the U.S. President's Emergency Plan for AIDS Relief Sustainability Index and Dashboard for maternal and neonatal health pro-gramming adding a domain on community normative change. Information for each of the 5 resulting domains was drawn from SMGL and non-SMGL reports, individual stakeholder interviews, and group discussions. FINDINGS: In both Uganda and Zambia, the SMGL proof-of-concept phase catalyzed commitment to saving mothers and newborns and a renewed belief that significant change is possible. Increased leadership and accountability for maternal and newborn health, particularly at the district and facility levels, was bolstered by routine maternal death surveillance reviews that engaged a wide range of local leadership. The SMGL district-strengthening model was found to be cost-effective with cost of death averted estimated at US$177-206 per year of life gained. When further considering the ripple effect that saving a mother has on child survival and the household economy, the value of SMGL increases. Ministries of health and donor agencies have already demonstrated a willingness to pay this amount per year of life for other programs, such as HIV and AIDS. CONCLUSION: As SMGL scaled up in both Uganda and Zambia, the intentional integration of SMGL interventions into host country systems, alignment with other large-scale programs, and planned reductions in annual SMGL funding all contributed to increasing host government ownership of the interventions and set the SMGL approach on a path more likely to be sustained following the close of the initiative. Lessons from the learning districts resulted in increased efficiency in allocation of resources for maternal and newborn health, better use of strategic information, improved management capacities, and increased community engagement.