Audit of documentation accompanying referred maternity cases to a referral hospital in northern Ghana: a mixed-methods study.

BACKGROUND: Effective referral of maternity cases, which cannot be managed at the primary healthcare level, with detailed referral forms is important for reducing possible delays in the provision of higher-level healthcare. This is the first study to audit documentation or referral forms that accompany referred maternity cases to a referral hospital in the northern region of Ghana. MATERIALS AND METHODS: This study employed an explanatory sequential mixed-method design, starting with a quantitative review of referral forms that accompanied all patients referred to four units (antenatal, antenatal emergency, labour and neonatal intensive care) of a referral hospital in northern Ghana. In-depth interviews were held with the heads of the four units afterwards. Descriptive statistics were computed for the quantitative data. The qualitative data was subjected to content analysis. Integration of the data occurred at the data interpretation/discussion level. RESULTS: A total of 217 referral forms were analysed. Nearly half of the cases were referred from the Tamale Metropolis (46.5%) and 83.9% were referred for advanced care, whilst 8.3% were referred due to a lack of medical logistics and equipment such as oxygen and skilled personnel (6%). Completion rates of the referral forms were as follows: < 50% completion (n = 81; 37.3%), 50-75% completion (n = 112; 51.6%) above 75% completion (n = 24; 11.1%). Some of the handwriting were not legible and were quite difficult to read. The key informants stated that incomplete forms sometimes delay treatment. The head of the antenatal care unit at the referral hospital suggested professional development sessions as a strategy for supporting clinicians to fill the forms as expected. CONCLUSION: The Ghana Health Service should conduct regular audits, develop job aides and provide incentives for health professionals who accurately complete referral forms. Completing forms and digitizing health records can help ensure further efficiencies in the health information system and sustain good maternity referral documentation practices.

Effects of antenatal care visits and health facility delivery on women's choice to circumcise their daughters in sub-Saharan Africa: evidence from demographic and health surveys.

BACKGROUND: This study examines the association between maternal healthcare service utilisation and circumcision of daughters in sub-Saharan Africa (SSA). METHODS: This study is based on a cross-sectional study design that draws on analysis of pooled data from current demographic and health surveys conducted between 2010 and 2019 in 12 countries in SSA. Both bivariate and multivariable binary logistic regression models were employed. RESULTS: Mothers who had four or more antenatal care visits were less likely to circumcise their daughters compared with those who had zero to three visits. Mothers who delivered at a health facility were less likely to circumcise their daughters than those who delivered at home. With the covariates, circumcision of daughters increased with increasing maternal age but decreased with increasing wealth quintile and level of education. Girls born to married women and women who had been circumcised were more likely to be circumcised. CONCLUSIONS: This study established an association between maternal healthcare service utilisation and circumcision of girls from birth to age 14 y in SSA. The findings highlight the need to strengthen policies that promote maternal healthcare service utilisation (antenatal care and health facility delivery) by integrating female genital mutilation (FGM) information and education in countries studied.

Models of Maternal Healthcare for African refugee women in High-Income Countries: A Systematic Review.

OBJECTIVE: To explore models of maternal healthcare for African refugee women and their acceptability, cost and associated outcomes. DESIGN: A systematic review and content analysis SETTING: High-income countries PARTICIPANTS: African refugee women REVIEW METHODS: Seven databases were searched to identify peer-reviewed literature using defined keywords and inclusion criteria. Two authors independently screened the search findings and the full texts of eligible studies. The quality of the included studies was appraised, and the findings were analysed using a template. RESULTS: Nine studies met the criteria. Four studies were qualitative, two quantitative and three studies used mixed methods. Four models of care were identified: midwifery-led care, hospital-based integrated care, primary care physician-led integrated care and a holistic refugee-specific primary healthcare model (one-stop shop). Issues affecting care delivery were identified as communication barriers, low health literacy, high transport costs and low engagement of refugee women in their care. KEY CONCLUSIONS: The lack of evidence regarding the impact of care models on the maternal healthcare outcomes of African refugees highlights the need to improve care evaluations. These results reinforce the importance of education and interventions to build refugee women's health literacy and strength-based communication approaches supported by multidisciplinary, multilingual and highly trained teams of health professionals. There is also a need to involve African refugee women in shared decision making. IMPLICATIONS FOR PRACTICE: The findings suggest the need for universal access to a woman-centred whole-of-system care approach for African refugees that emphasises culturally competent, safe, respectful and compassionate multi-professional care and greater economic security to cover costs.

Impact of COVID-19 on maternal healthcare in Africa and the way forward.

BACKGROUND: The impact of COVID-19 is weighing heavily on many African countries. As of November 14th 2021, 6,109,722 cases had been recorded with 151,173 deaths and 2.5% case fatality rate. Studies reveal substantial morbidity and socioeconomic impacts when accessing quality maternal healthcare including fear of infection and the containment measures in place, including social distancing and community containment. The pandemic has put additional strain on healthcare systems that are overburdened and under-resourced even in normal times and has exposed the vulnerabilities of high-risk population groups in addressing critical healthcare concerns. This study presents a mini review of how COVID-19 has disrupted maternal healthcare in Africa, and it further proposes ways to improve the situation. MAIN BODY: COVID-19 has disrupted antenatal, skilled birth, and postnatal family planning services. Women and girls are vulnerable to the impact of COVID-19 on several fronts and represent a group whose needs including antenatal, skilled birth, and postnatal family planning services have been disrupted, leading to unmet needs for contraception and an increase in unintended pregnancies. Restricted travel due to the fear and anxiety associated with contracting COVID-19 has resulted in delays in accessing prompt skilled care and essential healthcare services such as pregnancy care, immunisation, and nutritional supplementation. Misconceptions relating to COVID-19 have prompted concerns and created distrust in the safety of the healthcare system. Innovative measures are required to address these obstacles and ensure women are not denied access to available, accessible, acceptable, and quality maternal healthcare services in spite of COVID-19. CONCLUSIONS: In the immediate term while physical distancing measures remain in force, deliberate effort must be made to provide evidence-based guidelines, good practice and expert advice that addresses the unique sexual and reproductive health context of African countries. Efforts to train and motivate healthcare providers to adopt online, remote approaches such as use of telemedicine, and expand the involvement of frontline maternal healthcare providers to deliver information on the availability of services through phone-based referral networks, culturally appropriate social media, community radio and folklore messaging strategies are critical to mobilise and secure community confidence in the safety of sexual and reproductive health and maternal care services.

Geographical Access to Child and Family Healthcare Services and Hospitals for Africa-Born Migrants and Refugees in NSW, Australia; A Spatial Study.

Background: African-born migrants and refugees arriving from fragile states and countries with political and economic challenges have unique health needs requiring tailored healthcare services and support. However, there is little investigation into the distribution of this population and their spatial access to healthcare in Australia. This paper reports on research that aimed to map the spatial distribution of Africa-born migrants from low and lower-middle-income countries (LLMICs) and refugees in New South Wales (NSW) and access to universal child and family health (CFH) services and hospitals. Methods: We analysed the Australian Bureau of Statistics 2016 Census data and Department of Social Services 2018 Settlement data. Using a Geographic Information System mapping software (Caliper Corporation. Newton, MA, USA), we applied data visualisation techniques to map the distribution of Africa-born migrants and refugees relative to CFH services and their travel distance to the nearest service. Results: Results indicate a spatial distribution of 51,709 migrants from LLMICs in Africa and 13,661 refugees from Africa live in NSW, with more than 70% of the total population residing in Sydney. The Africa-born migrant and refugee population in Sydney appear to be well served by CFH services and hospitals. However, there is a marked disparity between local government areas. For example, the local government areas of Blacktown and Canterbury-Bankstown, where the largest number of Africa-born migrants and refugees reside, have more uneven and widely dispersed services than those in Sydney's inner suburbs. Conclusion: The place of residence and travel distance to services may present barriers to access to essential CFH services and hospitals for Africa-born refugees and migrants. Future analysis into spatial-access disadvantages is needed to identify how access to health services can be improved for refugees and migrants.

Commentary: What should referral pathways have to improve healthcare experiences of women with female genital mutilation in Australia?

BACKGROUND: We examined the evidence derived from healthcare professionals' interfacing with women with female genital mutilation (FGM) to comprehend the referral pathways available to these women in Australia. MAIN BODY: Clinicians encountered FGM-related complications that included ruptured bladder and total urinary incontinence. Midwives and paediatricians indicated a lack of referral pathways for FGM, but used their discretion to refer such cases to social work departments, obstetric/gynaecological units, child protection service providers, psychological counsellors and surgeons. The continuum of care for women with FGM is characterised by inadequate and lack of clear referral pathways. This underscores the need to develop and strengthen referral pathways in response to physical, birthing and psychological complications of women with FGM to improve their care experiences in Australia. SHORT CONCLUSION: Capacity building initiatives on FGM-prevention and care for trainees and practising health providers and community involvement in high burden areas/populations should be implemented to promote uptake and utilization of the referral services. Provision of infrastructural support, including clinical management tools, job aids, posters, referral algorithms and electronic patient records with "drop-down menus" for referral sites for health complications of FGM to reinforce the providers' efforts are critical.

A cross-sectional study of COVID-19 impacts in culturally and linguistically diverse communities in greater Western Sydney, Australia.

BACKGROUND: This study explored the experiences of people from culturally and linguistically diverse (CALD) backgrounds in Greater Western Sydney, Australia, in selected livelihood items during COVID-19 and the perceived impacts of the pandemic on their lives. METHODS: A cross-sectional survey was used to collect data between 25 August and 30 September 2020 among CALD communities in Greater Western Sydney. Information was collected on respondents' experiences in selected livelihood items, including housing, finances, safety, accessing social services and activities, finding work, food, clothing, and relationships during COVID-19 and the pandemic's perceived impact on their lives. Descriptive and non-parametric statistics were used to analyze the data. RESULTS: One hundred and ninety-eight participants were included in the study, 45.5% male and 54.5% female. Many respondents reported their experience in the selected livelihood items as "worse" during COVID-19 at the time of the study. The feeling of safety was most disrupted, with 56% of respondents rating their experience as "worse". This experience was followed by accessing social support group activities, with 50% of respondents stating their experience of using this service had worsened. The experience of accessing social services and financial situation was rated as "worse" by 41% of respondents. Experience in finding work, housing, and attending schools were all rated as "worse". The median perceived impact of COVID-19 among respondents who rated their experience in the selected livelihood items as "worse" were statistically higher than those who rated their experience as the "same". Respondents' characteristics also predicted the perceived impact of COVID-19. Unemployed respondents were 3.53 (95% CI: 1.16-10.73, p = 0.026) times more likely to perceive the impact of COVID-19 on their lives as "high" compared to employed respondents. CONCLUSIONS: The finding demonstrates that the "high" number of respondents had the same situation as before COVID-19 and highlights the level of resilience exhibited by CALD communities in the Australian context. It also suggests that services in Australia were good during the pandemic. However, enhanced policy and initiatives designed to meet the CALD population's needs are required, particularly in the areas most reported to have been disrupted by changes associated with COVID-19.

Is improvement in indicators of women's empowerment associated with uptake of WHO recommended IPTp-SP levels in sub-Saharan Africa? A multilevel approach.

OBJECTIVES: The global burden of malaria has reduced considerably; however, malaria in pregnancy remains a major public health problem in sub-Saharan Africa (SSA), where about 32 million pregnant women are at risk of acquiring malaria. The WHO has recommended that pregnant women in high malaria transmission locations, including SSA, have intermittent preventive treatment of malaria during pregnancy with at least three doses of sulphadoxine-pyrimethamine (IPTp-SP). Therefore, we investigated the prevalence of IPTp-SP uptake and associated individual-level, community-level and country-level predictors in SSA. DESIGN: A cross-sectional survey was conducted using recent Demographic and Health Surveys datasets of 20 SSA countries. A total of 96 765 women were included. Optimum uptake of IPTp-SP at most recent pregnancy was the outcome variable. We fitted three-level multilevel models: individual, community and country parameters at 95% credible interval. RESULTS: In all, 29.2% of the women had optimal IPTp-SP uptake ranging from 55.1% (in Zambia) to 6.9% (in Gambia). The study revealed a high likelihood of optimum IPTp-SP uptake among women with high knowledge (aOR=1.298, Crl 1.206 to 1.398) relative to women with low knowledge. Women in upper-middle-income countries were more than three times likely to have at least three IPTp-SP doses compared with those in low-income countries (aOR=3.268, Crl 2.392 to 4.098). We found that community (σ2=1.999, Crl 1.088 to 2.231) and country (σ2=1.853, Crl 1.213 to 2.831) level variations exist in optimal uptake of IPTp-SP. According to the intracluster correlation, 53.9% and 25.9% of the variation in optimum IPTp-SP uptake are correspondingly attributable to community-level and country-level factors. CONCLUSIONS: The outcome of our study suggests that low-income SSA countries should increase budgetary allocation to maternal health, particularly for IPTp-SP interventions. IPTp-SP advocacy behavioural change communication strategies must focus on women with low knowledge, rural dwellers, married women and those who do not meet the minimum of eight antenatal care visits.

Racial disparities in COVID-19 pandemic cases, hospitalisations, and deaths: A systematic review and meta-analysis.

BACKGROUND: People from racial minority groups in western countries experience disproportionate socioeconomic and structural determinants of health disadvantages. These disadvantages have led to inequalities and inequities in health care access and poorer health outcomes. We report disproportionate disparities in prevalence, hospitalisation, and deaths from COVID-19 by racial minority populations. METHODS: We conducted a systematic literature search of relevant databases to identify studies reporting on prevalence, hospitalisations, and deaths from COVID-19 by race groups between 01 January 2020 - 15 April 2021. We grouped race categories into Blacks, Hispanics, Whites and Others. Random effects model using the method of DerSimonian and Laird were fitted, and forest plot with respective ratio estimates and 95% confidence interval (CI) for each race category, and subgroup meta-regression analyses and the overall pooled ratio estimates for prevalence, hospitalisation and mortality rate were presented. RESULTS: Blacks experienced significantly higher burden of COVID-19: prevalence ratio 1.79 (95% confidence interval (CI) = 1.59-1.99), hospitalisation ratio 1.87 (95% CI = 1.69-2.04), mortality ratio 1.68 (95% CI = 1.52-1.83), compared to Whites: prevalence ratio 0.70 (95% CI = 0.0.64-0.77), hospitalisation ratio 0.74 (95% CI = 0.65-0.82), mortality ratio 0.82 (95% CI = 0.78-0.87). Also, Hispanics experienced a higher burden: prevalence ratio 1.78 (95% CI = 1.63-1.94), hospitalisation ratio 1.32 (95% CI = 1.08-1.55), mortality ratio 0.94 (95% CI = 0.84-1.04) compared to Whites. A higher burden was also observed for Other race groups: prevalence ratio 1.43 (95% CI = 1.19-1.67), hospitalisation ratio 1.12 (95% CI = 0.89-1.35), mortality ratio 1.06 (95% CI = 0.89-1.23) compared to Whites. The disproportionate burden among Blacks and Hispanics remained following correction for publication bias. CONCLUSIONS: Blacks and Hispanics have been disproportionately affected by COVID-19. This is deeply concerning and highlights the systemically entrenched disadvantages (social, economic, and political) experienced by racial minorities in western countries; and this study underscores the need to address inequities in these communities to improve overall health outcomes.

Women's experiences and satisfaction with maternal referral service in Northern Ghana: A qualitative inquiry.

OBJECTIVE: To gain insights and improve existing referral structures with maternity care in Northern region of Ghana, this study explored the referral experiences and satisfaction of women. RESEARCH DESIGN: Twenty women referred to the Tamale Teaching Hospital for maternal health conditions were interviewed along with three husdands of these women between January and April 2020. An interview guide was used in individual face-to-face semi-structured interviews. The transcripts were inductively coded using content analysis. The study was guided by the three delays model and the availability, accessibility, acceptability and quality framework. FINDINGS: The study revealed seven key themes. These are women's involvement in referral decision; available health workers and care at the first facility; inadequate transportation; communication between facilities; quality of care at the receiving hospital; worth the time and money; and women's companions during referral. While several women acknowledged and appreciated the care and emotional support they received in the hospitals they first presented to, some women reported poor attitudes of healthcare providers. Most women acknowledged that there was no communication between the facilities for the referral. A woman's socioeconomic status appeared to determine the respect and support she received from healthcare providers. KEY CONCLUSIONS: To ensure a responsive and efficient referral service, the central government of Ghana should commit to ensuring that each district hospital has at least one ambulance for effective emergency transportation. Career progression opportunities need to be explored for health workers in northern Ghana to attract and retain more professionals. To prevent abuse and ensure empathetic and supportive care, testimonial videos may help health providers to assess the services they provide to women. During referral, inter-facility communication can be strengthened through effective supervision and dedicated mobile phones for communication between health facilities.

The maternity experiences of women seeking asylum in high-income countries: a meta-ethnography.

PROBLEM: The maternity care experiences and perinatal outcomes of women seeking asylum in high-income countries (HICs) are poorer than the general population of pregnant women in that HIC. There is a paucity of literature on the maternity experiences of women seeking asylum in HICs. BACKGROUND: There is an increasing number of women seeking asylum in HICs due to escalating violence and human rights abuses. Asylum-seeking women are a distinct group whom are likely to have different needs to refugees or migrants as a result of their undocumented status. AIM: This literature review aimed to explore the emotional, physical and health information needs of women seeking asylum in the perinatal period in HICs, to provide insights to better address their maternity needs. METHOD: A meta-ethnography described by Noblit and Hare, was applied to analyse the studies, to reflect the voices of women seeking asylum, hosted in HICs in their perinatal period. FINDINGS: Eight studies were included in the review. The overarching theme was 'just having to survive.' Four sub-themes were revealed which highlighted the vulnerability of asylum-seeking women. They included: 'I was never sure if I had understood', 'feeling ignored and alone', 'ongoing dislocation and recurrent relocation' and 'knowing there's someone who cares for you'. DISCUSSION: Improved maternity care for women seeking asylum requires culturally appropriate respectful maternity care and supportive strategies such as consistent access to language services. CONCLUSION: It is recommended that future research is targeted to explore the maternity experience of women seeking asylum in HICs, such as Australia.

HIV/AIDS knowledge and attitudes assessment among women of child-bearing age in South Sudan: Findings from a Household Survey.

This study assessed the determinants that shape HIV knowledge and attitudes among South Sudanese women by analysing a Multiple Indicator Cluster Survey collected from 9,061 women in 9,369 households. Generalised linear mixed model regression was performed. Fifty percent of respondents were aware of HIV/AIDS, with 21% and 22% exhibiting good knowledge and positive attitudes towards people with HIV/AIDS, respectively. When controlled for individual and community-level variables, younger women (AOR = 1.28, 95% CI: 1.01-162), women with primary (AOR = 2.19; 95% CI: 1.86-2.58) and secondary (AOR = 4.48; 95% CI: 3.38-5.93) education, and those living in urban areas (AOR = 1.40; 95% CI: 1.12-1.76) had significantly good knowledge. Women in the richer (AOR = 1.60; 95% CI: 1.08-2.36) and the richest (AOR = 2.02; 95% CI: 1.35-3.02) wealth quintiles had significant positive attitudes towards people with HIV/AIDS. Well-designed social and behavioural campaigns targeting uneducated women and those living in rural and remote settings will enhance knowledge of perceived risk, awareness, and ability to carry out preventive behaviours.

Do educated women in Sierra Leone support discontinuation of female genital mutilation/cutting? Evidence from the 2013 Demographic and Health Survey.

INTRODUCTION: Female genital mutilation/cutting (FGM/C) comprises all procedures that involve the total or partial elimination of the external genitalia or any injury to the female genital organ for non-medical purposes. More than 200 million females have undergone the procedure globally, with a prevalence of 89.6% in Sierra Leone. Education is acknowledged as a fundamental strategy to end FGM/C. This study aims to assess women's educational attainment and how this impacts their views on whether FGM/C should be discontinued in Sierra Leone. METHODS: We used data from the 2013 Sierra Leone Demographic and Health Survey. A total of 15,228 women were included in the study. We carried out a descriptive analysis, followed by Binary Logistic Regression analyses. We presented the results of the Binary Logistic Regression as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with 95% confidence intervals (CIs). RESULTS: Most of the women with formal education (65.5%) and 15.6% of those without formal education indicated that FGM/C should be discontinued. Similarly, 35% of those aged 15-19 indicated that FGM/C should be discontinued. Women with a higher education level had a higher likelihood of reporting that FGM/C should be discontinued [AOR 4.02; CI 3.00-5.41]. Christian women [AOR 1.72; CI 1.44-2.04], those who reported that FGM/C is not required by religion [AOR 8.68; CI 7.29-10.34], wealthier women [AOR 1.37; CI 1.03-1.83] and those residing in the western part of Sierra Leone [AOR 1.61; CI 1.16-2.23] were more likely to state that FGM/C should be discontinued. In contrast, women in union [AOR 0.75; CI 0.62-0.91], circumcised women [AOR 0.41; CI 0.33-0.52], residents of the northern region [AOR 0.63; CI 0.46-0.85] and women aged 45-49 [AOR 0.66; CI 0.48-0.89] were less likely to report that FGM/C should be discontinued in Sierra Leone. CONCLUSION: This study supports the argument that education is crucial to end FGM/C. Age, religion and religious support for FGM/C, marital status, wealth status, region, place of residence, mothers' experience of FGM/C and having a daughter at home are key influences on the discontinuation of FGM/C in Sierra Leone. The study demonstrates the need to pay critical attention to uneducated women, older women and women who have been circumcised to help Sierra Leone end FGM/C and increase its prospects of achieving Sustainable Development Goals (SDG) three and five.

Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review.

BACKGROUND: sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women. METHODS: Six electronic databases were systematically searched for primary data studies (2009-2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility. RESULTS: Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral. CONCLUSIONS: Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers' ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals. TRIAL REGISTRATION: Systematic review registration: PROSPERO registration CRD42018114261 .

An assessment of hospital maternal health services in northern Ghana: a cross-sectional survey.

BACKGROUND: Access to and delivery of comprehensive emergency obstetric and neonatal care (CEmONC) services are often weak in low and middle-income countries affecting maternal and infant health outcomes. There are no studies on resources for maternal healthcare in the Northern region of Ghana. This knowledge is vital for health service planning and mobilising funding to address identified gaps. We investigated the available resources for managing CEmONC and referral services in the region. METHODS: This study involved a cross-sectional survey of maternity facilities in ten hospitals in the Northern region of Ghana, serving a population of 2,479,461, including 582,897 women aged 15-49. Public and faith-based hospitals were included in the study. We used the Service Provision Assessment tool to gather data for this study between October and December 2019. Given the small sample size, we used descriptive statistics to summarise the data using SPSS version 25 and Excel 2016. RESULTS: A total of 22,271 ANC visits from women to these hospitals occurred in the past 3 months preceding the study; however, 6072 birth events (cases) occurred within the same period. All the hospitals had less than one general medical doctor per 10,000 population (range 0.02-0.30). The number of midwives per 10,000 population ranged from 0.00 (facility H and J) to 1.87 (facility E), and none of the hospitals had a university-trained nurse designated for maternity care. Only one hospital had complete equipment for emergency obstetric and newborn care, while four others had adequate emergency obstetric care equipment. The number of maternity and delivery beds per 10,000 population was low, ranging from 0.40 to 2.13. CONCLUSIONS: The management of emergency obstetric care and referrals are likely to be affected by the limited human resources and equipment in hospitals in Northern Ghana. Financial and non-financial incentives to entice midwives, obstetricians and medical officers to the Northern region should be implemented. Resources should be mobilised to improve the availability of essential equipment such as vacuum extractors and reliable ambulances to enhance referral services. Considerable health system strengthening efforts are required to achieve the required standards.

Models of maternal and child healthcare for African refugees: protocol for an exploratory, mixed-methods study.

INTRODUCTION: There is a paucity of research examining models of maternal and child health (MCH) care for refugees in high-income countries. Attention has focused on tailoring existing healthcare services to meet the needs of this population and ensure accessible high-quality patient-centred care. This protocol reports the methodology of a study designed to identify models of care for African refugees in New South Wales (NSW), Australia, to determine the evidence for these models and the improvements necessary to best meet service needs that can be delivered in line with available resources, organisational readiness and capacity to implement. METHODS AND ANALYSIS: This multiphased, participatory research project will employ an exploratory, mixed-methods design. Preparatory activities involve a situational analysis of current MCH services for African refugees and associated policies and guidelines in NSW. We will consult key health service providers and analyse Australian census and settlement data to identify refugee communities and their relation to healthcare services. Phase 1 will ascertain the MCH care needs of African refugees and appropriate service models using: a Delphi survey with health service managers and providers, a nominal group process with African women refugees and; key informant interviews with senior health service managers. This data will be synthesised to provide insight into appropriate models-of-care that could be implemented. These will be discussed in a stakeholder workshop. Phase 2 will comprise a readiness-to-change survey with a selection of providers to explore the willingness, commitment and efficacy of staff members to adopt such models-of-care. ETHICS AND DISSEMINATION: Ethical approval was granted by NSW Health. Findings will be disseminated to all stakeholders at a knowledge exchange forum to inform the development of a high-quality MCH service delivery model that can be feasibly implemented specifically for African refugee communities. PROSPERO REGISTRATION NUMBER: CRD42018095564.

Preventing female genital mutilation in high income countries: a systematic review of the evidence.

BACKGROUND: Female genital mutilation (FGM) is prevalent in communities of migration. Given the harmful effects of the practice and its illegal status in many countries, there have been concerted primary, secondary and tertiary prevention efforts to protect girls from FGM. However, there is paucity of evidence concerning useful strategies and approaches to prevent FGM and improve the health and social outcomes of affected women and girls. METHODS: We analysed peer-reviewed and grey literature to extract the evidence for FGM prevention interventions from a public health perspective in high income countries by a systematic search of bibliographic databases and websites using appropriate keywords. Identified publications were screened against selection criteria, following the PRISMA guidelines. We examined the characteristics of prevention interventions, including their programmatic approaches and strategies, target audiences and evaluation findings using an apriori template. FINDINGS: Eleven documents included in this review described primary and secondary prevention activities. High income countries have given attention to legislative action, bureaucratic interventions to address social injustice and protect those at risk of FGM, alongside prevention activities that favour health persuasion, foster engagement with the local community through outreach and the involvement of community champions, healthcare professional training and capacity strengthening. Study types are largely process evaluations that include measures of short-term outcomes (pre- and post-changes in attitude, knowledge and confidence or audits of practices). There is a dearth of evaluative research focused on empowerment-oriented preventative activities that involve individual women and girls who are affected by FGM. Beattie's framework provides a useful way of articulating negotiated and authoritative prevention actions required to address FGM at national and local levels. CONCLUSION: FGM is a complex and deeply rooted sociocultural issue that requires a multifaceted response that encompasses socio-economic, physical and environmental factors, education and learning, health services and facilities, and community mobilisation activities. Investment in the rigorous longitudinal evaluation of FGM health prevention efforts are needed to provide strong evidence of impact to guide future decision making. A national evidence-based framework would bring logic, clarity, comprehension, evidence and economically more effective response for current and future prevention interventions addressing FGM in high income countries.

Porn video shows, local brew, and transactional sex: HIV risk among youth in Kisumu, Kenya.

BACKGROUND: Kisumu has shown a rising HIV prevalence over the past sentinel surveillance surveys, and most new infections are occurring among youth. We conducted a qualitative study to explore risk situations that can explain the high HIV prevalence among youth in Kisumu town, Kenya METHODS: We conducted in-depth interviews with 150 adolescents aged 15 to 20, held 4 focus group discussions, and made 48 observations at places where youth spend their free time. RESULTS: Porn video shows and local brew dens were identified as popular events where unprotected multipartner, concurrent, coerced and transactional sex occurs between adolescents. Video halls - rooms with a TV and VCR - often show pornography at night for a very small fee, and minors are allowed. Forced sex, gang rape and multiple concurrent relationships characterised the sexual encounters of youth, frequently facilitated by the abuse of alcohol, which is available for minors at low cost in local brew dens. For many sexually active girls, their vulnerability to STI/HIV infection is enhanced due to financial inequality, gender-related power difference and cultural norms. The desire for love and sexual pleasure also contributed to their multiple concurrent partnerships. A substantial number of girls and young women engaged in transactional sex, often with much older working partners. These partners had a stronger socio-economic position than young women, enabling them to use money/gifts as leverage for sex. Condom use was irregular during all types of sexual encounters. CONCLUSIONS: In Kisumu, local brew dens and porn video halls facilitate risky sexual encounters between youth. These places should be regulated and monitored by the government. Our study strongly points to female vulnerabilities and the role of men in perpetuating the local epidemic. Young men should be targeted in prevention activities, to change their attitudes related to power and control in relationships. Girls should be empowered how to negotiate safe sex, and their poverty should be addressed through income-generating activities.

"If you don't abstain, you will die of AIDS": AIDS education in Kenyan public schools.

We explored constraints of implementing AIDS education in public schools in Kenya. Sixty interviews with teachers and 60 focus group discussions with students were conducted in 21 primary and nine secondary schools. System/school-level constraints included lack of time in the curriculum, limited reach of secondary-school students (because AIDS education is embedded in biology, which is not compulsory), and disapproval of openness about sex and condoms by the Ministry of Education and parents. Alternative strategies to teach about AIDS had their own constraints. Teachers lacked training and support and felt uncomfortable with the topic. They were not used to interactive teaching methods and sometimes breached confidentiality. Teachers' negative attitudes constrained students from seeking information. Training interventions should be provided to teachers to increase their self-confidence, foster more positive attitudes, and stimulate interactive teaching methods. The Ministry of Education needs to have a clear policy toward the promotion of condoms.

Disco funerals: a risk situation for HIV infection among youth in Kisumu, Kenya.

OBJECTIVE: We investigated the so-called 'disco funeral' phenomenon in Kisumu, Kenya, whereby community members including adolescents congregate at the home of the deceased for several days, accompanied by music and dancing. We explored whether disco funerals are a risk situation for HIV/sexually transmitted infection infection among youth. DESIGN: : Cross-sectional qualitative study. METHODS: We conducted 44 in-depth interviews with male and female adolescents aged 15-20 years in Kisumu municipality in Nyanza Province, Kenya. We also made observations during six disco funerals. RESULTS: Disco funerals were an important place for young people to hang out; they increased the opportunities to meet and engage in (risky) sexual activities. Many adolescents reported having casual sex on these occasions, sometimes with multiple partners, and mostly without condoms. Some girls were forced into sex, and there were several accounts of gang rape. Sex in exchange for money was reported frequently. Drugs and alcohol seemed to facilitate unprotected, multiple-partner, coerced, and transactional sex. CONCLUSION: In Kisumu, a town with a generalized HIV/AIDS epidemic, the high AIDS mortality leads to frequent disco funerals. Because many adolescents are having unprotected, transactional, or coerced sex at these occasions, disco funerals might contribute to the high HIV prevalence among youth, especially among adolescent girls. HIV interventions urgently need to include outreach actions to youth who hang out at disco funerals and link up with parents and funeral organizers to reduce risk situations.