"The phone number tells us good things we didn't know before." Use of interactive voice response calling for improving knowledge and uptake of family planning methods among Maasai in Tanzania.

Maasai living in the Arusha region, Tanzania, face challenges in feeding their children because of decreasing grazing grounds for their cattle. Therefore, they requested birth control methods. Previous studies have shown that lack of knowledge about, and poor access to, family planning (FP) may worsen the situation. We developed an interactive voice response calling (IVRC) platform for Maasai and health care workers (HCW) to create a venue for communication about FP to increase knowledge and access to FP. The objective of this study was to explore the effect of the platform on knowledge, access and use of family planning methods. We applied a participatory action research approach using mixed methods for data collection to develop and pilot-test an mHealth-platform with IVRC using Maa language. We enrolled Maasai-couples and HCW in Monduli District (Esilalei ward), Arusha Region, and followed them for 20 months. A baseline assessment was done to explore knowledge about FP. Furthermore, we abstracted information on FP clinic visits. Based on that, we developed a system called Embiotishu. A toll-free number was provided to interact with the system by calling with their phone. The system offers pre-recorded voice messages with information about FP and reproductive health to educate Maasai. The system recorded the number of calls and the type of information accessed. We measured the outcome by (1) a survey investigating the knowledge of contraceptive methods before and after Embiotishu and (2) counting the number of clinic visits (2018-2020) from medical records and feedback from qualitative data for FP used among Maasai. The acceptability and feasibility were explored through focus group discussions (FGDs) with Maasai and in-depth interviews (IDIs) with HCW. We recruited 76 Maasai couples whom we interviewed during the baseline assessment. The overall knowledge of contraceptives increased significantly (p<0.005) in both men and women. The number of clinic visits rose from 137 in 2018 to 344 in 2019 and 228 in the first six months of 2020. Implants were the most prescribed family planning method, followed by injections and pills, as found in medical records. The number of incoming calls, missed calls, and questions were 24,033 over 20 months. Out of these calls, 14,547 topics were selected. The most selected topics were modern contraceptives (mainly implants, condoms, tubal ligation, and vasectomy). Natural methods of contraception (vaginal fluid observations, calendar, and temperature). Our study has shown that the IVRC system led to an improvement in knowledge about and access to contraceptives. Furthermore, it has potential to increase access to health information as well as improve dialogue between Health workers and Maasai.

Recurrence of post-term pregnancy and associated factors among women who delivered at Kilimanjaro Christian Medical Centre in northern Tanzania: A retrospective cohort study.

BACKGROUND: Post-term pregnancy is a health problem of clinical importance and; tends to recur in subsequent pregnancies. Maternal age, height, and male fetal sex are risk factors associated with Post-term pregnancy. The study aimed to determine the recurrence risk of post-term pregnancy and associated factors among women delivered at KCMC referral hospital. METHODOLOGY: This retrospective cohort study used KCMC zonal referral hospital medical birth registry cohort data for 43472 women delivered between 2000 and 2018. Data were analyzed using STATA version 15 software. Log-binomial regression with robust variance estimator determined the factors associated recurrence of post-term pregnancy adjusted for other factors. RESULTS: A total of 43472 women were analyzed. The proportion of post-term pregnancy was 11.4%, and the recurrence was 14.8%. The recurrence risk of post-term pregnancy was increased when a woman had a history of previous post-term pregnancy (aRR: 1.75; 95%CI: 1.44, 2.11). Advanced maternal age, i.e., ≥35years (aRR: 0.80; 95%CI: 0.65, 0.99), having secondary and higher education (aRR: 0.8; 95%CI: 0.66, 0.97), and being employed (aRR: 0.68; 95%CI: 0.55, 0.84) decreased the recurrence risk of post-term pregnancy. Women with recurrence of post-term pregnancy had a higher risk of delivering newborns weighed ≥4000gm (aRR: 5.05; 95% CI: 2.80, 9.09). CONCLUSION: Post-term pregnancy is associated with recurrence risk in subsequent pregnancies. A history of previous post-term pregnancy is associated risk factor and these women are at increased risk of delivering newborns weighed ≥4000gm. Clinical counselling of women at risk of post-term pregnancy and timely management is recommended to prevent adverse neonatal and maternal outcomes.

Cervical cancer in Northern Tanzania-What do women living with HIV know.

Background: Cervical cancer (CC) is more prevalent in women living with human immunodeficiency virus (HIV) infection compared to the general population. The magnitude is high among all countries burdened with HIV-Tanzania is no exception. Despite the unprecedented risk, women living with HIV (WLHIV) may not be aware of the risk and might have unfounded beliefs thereof. This study aimed to determine the knowledge, awareness, and beliefs on CC screening among WLHIV attending a clinic at the Kilimanjaro Christian Medical Centre (KCMC) in Northern Tanzania. Methods: This hospital-based cross-sectional study was conducted among 327 WLHIV attending care and treatment clinic (CTC) at KCMC. A pre-tested questionnaire was used to collect quantitative data. Both descriptive and regression methods were used to determine CC knowledge, awareness, and beliefs as well as factors associated with knowledge of CC among WLHIV using SPSS version 23. Results: Participants' mean age was 46 ± 10.4 years. Although just half (54.7%) of WLHIV had insufficient knowledge of CC, the majority of the participants (83.5%) were able to recognize at least three risk factors, but with limited understanding of symptoms and prevention. The majority held positive beliefs on CC and screening practices. Factors associated with good knowledge of CC included being married (AOR: 3.66, 95% CI: 1.84-7.28), having used ART for at least 2 years (AOR: 4.08, 95% CI: 1.36-12.21), and having previously screened for CC (AOR: 1.62, 95% CI: 1.01-2.59). Conclusion: WLHIV attending care and treatment center had insufficient knowledge about CC screening. To further improve screening and treatment for CC, at both facility and community levels, targeted awareness and education campaigns are warranted.

Medical management of induced and incomplete first-trimester abortion by non-physicians in low- and middle-income countries: A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Unsafe abortion is the cause of a substantial number of maternal mortalities and morbidities globally, but specifically in low- and middle-income countries. Medical abortion methods provided by non-physicians may be a way to reduce the burden of unsafe abortions. Currently, only one systematic review comparing non-physicians with physicians for medical abortion exists. However, the review does not have any setting restrictions and newer evidence has since been published. Therefore, this review aims to evaluate the effectiveness, acceptability, and safety of first-trimester abortion managed by non-physicians compared with physicians in low- and middle-income countries. MATERIAL AND METHODS: The databases PubMed, Cochrane Library, Global Health Library, and EMBASE were searched using a structured search strategy. Further, the trial registries clinicaltrials.gov and The International Clinical Trial Registry Platform were searched for published and unpublished trials. Randomized controlled trials comparing provision of medical abortion by non-physicians with that by physicians in low- or middle-income countries were included. Risk of bias was assessed using the Cochrane Risk of Bias tool. Trials that reported effect estimates on the effectiveness of medical methods on complete abortion were included in the meta-analysis. The protocol was prospectively registered in the PROSPERO database, ID: CRD42020176811. RESULTS: Six papers from four different randomized controlled trials with a total of 4021 participants were included. Two of the four included trials were assessed to have overall low risk of bias. Four papers had outcome data on complete abortion and were included in the meta-analyses. Medical management of first-trimester abortion and medical treatment of incomplete abortion were found to be equally effective when provided by a non-physician as when provided by a physician (risk ratio 1.00; 95% CI 0.99-1.01). Further, the treatment was equally safe, and women were equally satisfied when a non-physician provided the treatment compared with a physician. CONCLUSIONS: Provision of medical abortion or medical treatment for incomplete abortion in the first trimester is equally effective, safe, and acceptable when provided by non-physicians compared with physicians in low- and middle-income countries. We recommend that the task of providing medical abortion and medical treatment for incomplete abortion in low- and middle-income countries should be shared with non-physicians.

Is abdominal hysterectomy still the surgery of choice in sub-Saharan Africa?

A trend toward minimally invasive surgery is increasing worldwide. However, reports on the extent and the role of vaginal or laparoscopic hysterectomy in benign gynecologic surgery in sub-Saharan Africa are scarce. Our commentary aims to highlight the existing gaps and potential barriers to implementation of vaginal or laparoscopic hysterectomy and suggests how to introduce and expand minimally invasive gynecologic surgery in this region. Little documentation exists in the literature to account for the role of minimally invasive surgery in the sub-Saharan Africa. Hysterectomy for benign reasons is commonly performed by the abdominal approach. This approach is accompanied by significant complications, prolonged hospitalization, and longer recovery duration. Our commentary highlights the importance of investigating region-specific barriers to the practice of minimally invasive gynecologic surgery in sub-Saharan Africa.

"I just wear it and I become normal": a qualitative study of Tanzanian women's experiences with long-term vaginal pessary use for stress urinary incontinence.

INTRODUCTION: Previous research has shown that vaginal pessaries are a cost-effective treatment for women worldwide suffering from stress urinary incontinence. However, little is known about African women's experiences with vaginal pessary use. The aim of this study was to understand the experiences of vaginal pessary use among Tanzanian women who had received long-term pessary treatment for stress urinary incontinence. METHODS: 15 semi-structured, individual interviews were conducted over a 2-month period in 2019 with Tanzanian women living in the Kilimanjaro Region who suffered from stress urinary incontinence and who had been using a pessary for at least 18 months. The interview transcripts were analysed using qualitative content analysis. RESULTS: The primary motivation for seeking treatment were discomfort from symptoms, social consequences and low quality of life. Perceived benefits from pessary use included improved quality of life with reacquired abilities to perform daily activities, participate in social gatherings, feeling symptom relief and improved sexual relations. Further, some women saw pessary treatment as superior to other locally available treatment options. Perceived barriers for pessary use included shame, husband's disapproval, limited access to treatment and lack of knowledge among the women as well as healthcare personnel. CONCLUSION: Vaginal pessaries are well-perceived as a long-term treatment method among Tanzanian women suffering from stress urinary incontinence. This method may have potential to be implemented large scale in Tanzania if combined with basic health education.

Trend in female genital mutilation and its associated adverse birth outcomes: A 10-year retrospective birth registry study in Northern Tanzania.

BACKGROUND: Approximately 200 million women and girls were reported to have undergone female genital mutilation worldwide in 2015.UNICEF's data based on household survey estimates 15% of women from 15-49 years have undergone FGM from year 2004-2015. Despite this, reliable data on trend of prevalence of female genital mutilation and its associated birth outcomes have not been documented in Tanzania. This study aimed at determining the trends of female genital mutilation and associated maternal and neonatal adverse outcomes in northern Tanzania. METHODS: A cross-sectional study was conducted using maternally-linked data from Kilimanjaro Christian Medical birth registry involving 30,286 women who gave birth to singletons from 2004-2014. The prevalence of female genital mutilation was computed as proportion of women with female genital mutilation yearly over 10 years. Odds ratios with 95% confidence intervals for adverse birth outcomes associated with female genital mutilation were estimated using multivariable logistic regression model. RESULTS: Over the 10-year period, the prevalence of female genital mutilation averaged 15.4%. Female genital mutilation decreased from 23.6% in 2005 to 10.6% in 2014. Female genital mutilation was associated with increased odds for caesarean section (aOR1.26; 95% CI: 1.18-1.34), post-partum haemorrhage (aOR 1.31; 95% CI: 1.10-1.57) and long hospital stay (aOR 1.21; 95% CI: 1.14-1.29). Female genital mutilation also increased women's likelihood of delivering an infant with low Apgar score at 5th minute (aOR 1.60; 95% CI: 1.37-1.89).FGM type III and IV had increased odds of caesarean section, episiotomy and prolonged duration of hospital stay as compared to FGM type I and II, although the association was statistically insignificant. CONCLUSION: Female genital mutilation prevalence has declined over the study period. Our study has demonstrated that postpartum haemorrhage, delivery by caesarean section, long maternal hospital stays and low APGAR score are associated with FGM. Initiatives to mitigate FGM practice should be strengthened further to reduce/eliminate this practice. Moreover, surgical interventions to improve severe form FGM are welcomed to improve the aforementioned aspects of obstetric outcome in this locality.

Predictors and Barriers to Post Abortion Family Planning Uptake in Hai District, Northern Tanzania: A Mixed Methods Study.

INTRODUCTION: Post Abortion Care (PAC) encompassing family planning counselling and contraception provision is a key strategy to reducing maternal morbidity and mortality especially in countries with restrictive abortion laws. Various factors affect the uptake of PAC modern family Planning (FP) in different settings. This study aimed at determining the prevalence, assessment of factors and barriers to PAC modern FP uptake in Hai district, Northern Tanzania. METHODS: A mixed-methods study was conducted using an explanatory sequential design. Exit interviews using questionnaires was conducted among 189 women. In-depth interviews were conducted with 26 healthcare providers (HCPs) and 28 women who received PAC in Hai district hospital, Machame hospital and Moshi Specialists health centre in Hai district. Quantitative data was analysed using a Statistical Package for Social Science (IMB SPSS Statistics for Windows version 20.0 (SPSS Inc., Chicago, Ill., USA)). Bivariate and multivariable analyses were applied to estimate the predictors of uptake of PAC modern FP. Thematic content analysis was employed to explore barriers to uptake of post-abortion modern family planning. RESULTS: The prevalence of uptake of modern family planning following PAC was 59/189(31.2%). 56% of the 189 women who received PAC did not receive counselling services on family planning. Marital status and partner's support were predictors of PAC modern family planning uptake (p=.007 vs. p= <.05, respectively).Misinformation and misconception about modern contraceptives, lack of knowledge and fear of side effects were reported to be the major barriers to uptake of post-abortion family planning. Most women reported to have not received comprehensive family planning information from the HCPs. On the other hand, HCPs perceived their poor counselling skills as the barrier to post-abortion family planning uptake. This study observed poor coordination of PAC services within each visited facility and this was linked to women leaving the facility without family planning counselling and/or contraceptives provision. CONCLUSION: Suboptimal modern family planning counselling during PAC contributes to the low uptake of contraceptives methods in this setting. Strategies are needed to improve PAC modern family planning services uptake. Strategies such as; provision of counselling skills to HCPs with comprehensive information targeting local contextual misconception and promoting PAC provision as a one-stop service.

Prevalence and factors associated with postpartum use of long-acting reversible contraception in Bukombe District, Geita Region, Tanzania: a community- based study.

BACKGROUND: Globally, approximately half of all pregnancies occur before 24 months after child birth. In Sub Saharan Africa the unmet need for family planning is highest among postpartum women. There is a dearth of information regarding factors associated with postpartum use of long acting reversible contraception (LARC) in Tanzania particularly in the Lake zone. This study aimed to determine the prevalence and factors associated with postpartum use of LARC (< 24 months) in Bukombe District, Geita Region in the Lake zone, in 2018. METHODOLOGY: Community based analytical cross-sectional study was conducted between May and June 2018 among women with less than 24 months since delivery. Multistage sampling technique was used to recruit participants. Face to face interviews with 768 postpartum women was conducted using standardized questionnaire. Data were analyzed using Stata Version 13.0. Multivariable logistic regression model was used to determine factors associated with postpartum use of LARC. RESULTS: Prevalence of postpartum use of LARC was 10.4%. Urban residence (AOR = 2.94, 95% CI: 1.07-8.06), having formal employment (AOR = 4.81, 95% CI: 1.85-12.57) and receiving family planning counseling (AOR = 4.39, 95% CI: 1.89-10.20) were significantly associated with postpartum LARC use. CONCLUSION: The postpartum use of LARC was low in the studied population with implants being the most commonly used method. Urban residency, formal employment and receiving family planning counseling were associated with postpartum LARC use. Improving prenatal and quality of family planning counseling is warranted to increase postpartum LARC utilization in Bukombe.

Gynecological hysterectomy in Northern Tanzania: a cross- sectional study on the outcomes and correlation between clinical and histological diagnoses.

BACKGROUND: Hysterectomy is one of the most common gynaecological procedures performed worldwide. The magnitude of the complications related to hysterectomy and their risk factors are bound to differ based on locations, availability of resources and level of surgical training. Documented complications rates and their correlates are reported from high income countries while data from low- and middle-income countries including Tanzania is scare. METHODS: This was a hospital based cross-sectional study conducted at a tertiary facility in northern Tanzania where 178 women who underwent elective gynecological hysterectomies in the department of obstetrics and gynecology within the study period were enrolled. Logistic regression was performed to determine the association between risk factors and occurrence of surgical complication where p-value of < 0.05 was considered statistically significant. The degree of correlation between pre-operative clinical and histological diagnosis was determined by kappa correlation test. RESULTS: A total of 75 (42%) of women had surgical complications within 10 days of surgery. Blood transfusion and intra-operative bleeding were the most common complications observed in 34 (19.1%) and 17 (9.6%) women respectively. Independent risk factors for complications included obesity (OR 3.9; 95% CI 1.44-10.46), previous abdominal operations (OR 8.44; 95% CI 2.52-28.26) and longer duration of operation (> 2 h) (OR 5.02; 95% CI 2.18-11.5). Both uterine fibroid and adenomyosis had good correlation of clinical and histological diagnosis (p-value < 0.001). CONCLUSION: Bleeding and blood transfusion were the most common complications observed in this study. Obesity, previous abdominal operation and prolonged duration of operation were the most significant risk factors for the complications. Local tailored interventions to reduce surgical complications of hysterectomy are thus pivotal. Clinicians in this locality should have resources at their disposal to enhance definitive diagnosis attainment before surgical interventions.

Management of stress urinary incontinence using vaginal incontinence pessaries in rural Kilimanjaro, Tanzania.

INTRODUCTION AND HYPOTHESIS: The effect of incontinence pessaries for urine incontinence (UI) has previously been described in studies from high-income countries, where they have been documented to reduce urinary leakage significantly. However, there is a profound literature gap in these data in low- and middle-income countries. This study, therefore, aims to describe the acceptance, impact and complications of pessary treatment among Tanzanian women diagnosed with stress UI. METHODS: Women who reported stress UI underwent a stress test, and if positive they were offered an incontinence pessary. Swahili versions of the Urinary Distress Inventory-6 (UDI-6) and the Urinary Impact Questionnaire (UIQ) were administered at 3- and 12-18-month follow-ups in addition to questions regarding pessary acceptance and pelvic examination for complications. RESULTS: A total of 48 women were fitted with an incontinence pessary. The frequency and amount of leakage were reduced significantly at 3- and 12-18-month follow-up. Additionally, a significant reduction in the overall UDI-6 score from 29.2 to 25.0 and overall UIQ score from 52.1 to 25.0 was observed from baseline to 3-month follow-up. Thirty-seven per cent of the women reported vaginal discharge at 12-18 months while signs of infection were found in 11.5%. In all, 32/48 (67%) wanted to continue the pessary treatment at 12-18-month follow-up. CONCLUSIONS: In the setting studied, pessaries for stress UI can be successfully fitted in most women with considerable acceptance and satisfaction rates and minimal complications.

Urinary incontinence and its relation to delivery circumstances: A population-based study from rural Kilimanjaro, Tanzania.

OBJECTIVES: To investigate the prevalence and risk factors of urinary incontinence (UI), the different UI subtypes and the association between UI and delivery circumstances. DESIGN: Cross-sectional population-based study conducted in Kilimanjaro Region, Tanzania. PARTICIPANTS AND SETTINGS: 1048 women aged 18-90 women living in rural Kilimanjaro. Simple random sampling was done to select villages, households and participants. Community health workers helped in identifying eligible women and trained nurses/midwives conducted face-to-face interviews. Data were analysed using descriptive statistics and Univariate and Multivariate logistic regression modelling. RESULTS: The overall prevalence rate of UI was 42%. When focusing on the different types of UI, 17% of the women had stress UI, 9% had urge UI and 16% had mixed UI. Only one woman (0.1%) with vesico-vaginal fistula was identified. UI was found to be significantly associated with increasing parity (OR = 2.41 (1.55-3.74). In addition, women who in relation to their first delivery had delivered at home or had been in labour for more than 24 hours, had increased adjusted ORs of 1.70(1.08-2.68) and 2.10(1.08-4.10), respectively, for having UI. CONCLUSION: UI is common in rural Tanzania and of the subtypes of UI, Stress Urinary Incontinence (SUI) is the commonest followed by Mixed Urinary Incontinence (MUI). Home delivery, prolonged labour and increasing parity especially having 5 or more deliveries are associated with increased risk for developing UI.

Vaginal pessaries in the management of symptomatic pelvic organ prolapse in rural Kilimanjaro, Tanzania: a pre-post interventional study.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the outcomes of vaginal pessaries in managing symptomatic pelvic organ prolapse (POP) in a low-income setting. METHODS: A pre-post interventional study was conducted in the Kilimanjaro region, Tanzania. Seventy-one women with symptoms and a POP stage II or more on the POP quantification test were fitted with a vaginal pessary. Pelvic examination, POP Distress Inventory (POPDI-6) and POP Impact Questionnaire (POPIQ-7) were completed at baseline, after 3 months and after 12-18 months. Changes in the POPDI-6 and POPIQ-7 scores, complications and satisfaction associated with pessary use before and after the intervention were obtained. RESULTS: Pessary treatment was associated with a reduction in the overall POPDI score from 55.0 (50.0, 60.0) at baseline to 25.0 (25.0, 30.0) after 12-18 months' use. The overall POPIQ score was reduced from 54.2 (41.7, 66.7) at baseline to 25.0 (25.0, 29.2) after 12-18 months' use of the pessary. Vaginal discharge was reported in 72.4 and 32.4% of the women after 3 and 12-18 months' use respectively, whereas 72.4 and 25% of the women had some degree of granuloma, erosion or infection at 3 and 12-18 months respectively. Despite the reported complications, 78% of the women were satisfied with the pessary when interviewed after 12-18 months and 81% wanted to continue using it. CONCLUSIONS: Vaginal pessary improves symptoms and quality of life associated with symptomatic POP. Therefore, it may be a treatment option in managing POP in low-income countries such as Tanzania.

Prevalence and risk factors for pelvic organ prolapse in Kilimanjaro, Tanzania: A population based study in Tanzanian rural community.

INTRODUCTION: The prevalence and risk-factors of pelvic organ prolapse (POP) in Tanzania are unknown. To help elucidate the problem, we assessed POP and associated risk-factors among Tanzanian women by deploying the POP-Q classification system. METHOD: A cross sectional community based study conducted in Hai, Rombo and Same Districts, Kilimanjaro Region, Tanzania. Women aged 18-90 were recruited through multi-stage random sampling from January to May 2015. Home-based questionnaire interviews were performed and the women were subsequently invited to the nearest health clinic for pelvic examination. Trained physicians used the POP-Q classification system to assess the POP stage. RESULTS: A total of 1195 women were interviewed and invited for pelvic examination; 1063(89%) women presented at the clinic of whom 1047(88%) accepted a clinical examination. Of 1047 examined women, 64.6% had an anatomical POP stage II-IV and 6.7% had a severe POP that descended 1 cm or more below the hymen. POP stage II-IV was associated with being aged 35+ years, being a farmer, doing petty trading and having delivered 3 times or more. Severe POP was associated with carrying heavy objects for ≥ 5 hours (OR 4.70;1.67-13.2), having delivered 5 times or more (OR 10.2;2.22-48.6) and having delivered at home (OR 2.40;1.36-4.22). CONCLUSION: POP is a common condition among rural Tanzanian women where 64.6% are having POP grade II-IV and 6.7% are having a severe POP descending 1 cm or more below the hymen. Risk-factors are increasing age, heavy lifting, high parity and home-delivery.