"Mothers get really exhausted!" The lived experience of pregnancy in extreme heat: Qualitative findings from Kilifi, Kenya.

Heat exposure in pregnancy is associated with a range of adverse health and wellbeing outcomes, yet research on the lived experience of pregnancy in high temperatures is lacking. We conducted qualitative research in 2021 in two communities in rural Kilifi County, Kenya, a tropical savannah area currently experiencing severe drought. Pregnant and postpartum women, their male spouses and mothers-in-law, community health volunteers, and local health and environment stakeholders were interviewed or participated in focus group discussions. Pregnant women described symptoms that are classically regarded as heat exhaustion, including dizziness, fatigue, dehydration, insomnia, and irritability. They interpreted heat-related tachycardia as signalling hypertension and reported observing more miscarriages and preterm births in the heat. Pregnancy is conceptualised locally as a 'normal' state of being, and women continue to perform physically demanding household chores in the heat, even when pregnant. Women reported little support from family members to reduce their workload at this time, reflecting their relative lack of autonomy within the household, but also potentially the 'normalisation' of heat in these communities. Climate change risk reduction strategies for pregnant women in low-resource settings need to be cognisant of local household gender dynamics that constrain women's capacity to avoid heat exposures.

Quality of counselling and support provided by the South African National AIDS Helpline: Content analysis of mystery client interviews.

BACKGROUND: Telephone helplines can facilitate referral, education and support for patients living with HIV or those concerned about the infection. The anonymity of helplines facilitates discussion of sensitive issues that are difficult to raise face to face. These services could support the expansion of HIV self-testing. However, maintaining quality and standardising messages in rapidly evolving fields such as HIV is challenging. OBJECTIVES: To evaluate the quality of the South African (SA) National AIDS Helpline. METHODS: Mystery clients posing as members of the public made 200 calls to the service in 2014. They presented several scenarios, including having received HIV-positive results from a doctor's secretary or through self-testing. Following the call, 'clients' completed a semistructured questionnaire on the information received and the caller-counsellor interaction. RESULTS: Calls were answered within a median of 5 seconds (interquartile range 2 - 14). Conversations took place in 8 of the 11 SA official languages, though mainly in English. Overall, 75% of callers felt that with the information they received they could locate a nearby clinic for further services. Counsellors expressed appropriate levels of concern about inadequate counselling that callers had received and confidentiality breaches in some scenarios. Eight counsellors incorrectly mentioned the need for a waiting period to confirm a positive result. Consistent with policy, almost all said that being foreign would not affect HIV treatment access. About 90% explained the need for CD4+ testing and antiretroviral therapy, but only 78% discussed HIV prevention. Counsellors were mostly empathetic (83%), though some adopted a neutral tone (10%) or were brusque (6%) or unhelpful (2%). CONCLUSIONS: Overall, helpline counsellors were proficient at providing information about local clinics, HIV testing and steps needed for initiating ART. Dissatisfaction with the caller-counsellor interactions, instances of incorrect information and the relatively low attention accorded to HIV prevention are worrying, however. Training for both refreshing and updating knowledge, and supervision and monitoring of calls, could target these areas.

UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis.

BACKGROUND: Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS: We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS: A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS: The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.

Contraception coverage and methods used among women in South Africa: A national household survey.

BACKGROUND: Globally, family planning services are being strengthened and the range of contraceptive choices expanded. Data on contraceptive coverage and service gaps could help to shape these initiatives. OBJECTIVE: To assess contraception coverage in South Africa (SA) and identify underserved populations and aspects of programming that require strengthening. METHODS: Data from a 2012 SA household survey assessed contraception coverage among 6 296 women aged 15 - 49 years and identified underserved populations. RESULTS: Two-thirds had an unintended pregnancy in the past 5 years, a quarter of which were contraceptive failures. Most knew of injectable (92.0%) and oral contraception (89.9%), but fewer of intrauterine devices (56.1%) and emergency contraception (47.3%). Contraceptive prevalence was 49.1%, and 41.8% women used modern non-barrier methods. About half had ever used injectable contraception. Contraception was lower in black Africans and younger women, who used a limited range of methods. CONCLUSION: Contraception coverage is higher than many previous estimates. Rates of unintended pregnancy, contraceptive failure and knowledge gaps, however, demonstrate high levels of unmet need, especially among black Africans and young women.

Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries.

BACKGROUND: Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. South Africa (SA) offers a post-delivery Child Support Grant (CSG), which could encompass support during pregnancy, informed by lessons learnt from similar grants. OBJECTIVES: To review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA. METHODS: Systematic review of programmes providing cash or other support during pregnancy in low- and middle-income countries. RESULTS: Thirty-two programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support. CONCLUSIONS: Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-to-measure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health.

Declining maternal mortality in the face of persistently high HIV prevalence in a middle-income country.

OBJECTIVE: To estimate maternal mortality ratio (MMR) and determine maternal death causes and trends in Greater Soweto, Johannesburg, South Africa. DESIGN: Cross-sectional study. SETTING: Chris Hani Baragwanath Maternity Hospital (CHBMH) in Greater Soweto. POPULATION: Maternal deaths at CHBMH. METHODS: Record review of maternal deaths from 1997 to 2012, using hospital death records, with denominator data from the district health information system and the hospital. MAIN OUTCOME MEASURES: Maternal mortality ratio per 100,000 live births, and causes of death classified as in the South African confidential enquiries. RESULTS: There were 479 deaths, with a peak MMR of 139 in 2004 and a decline to 86 in 2012. Of 332 women tested, 245 (74%) were HIV-infected. Nonpregnancy-related infection (40%) was the most frequent cause of death, followed by hypertension (16%) and obstetric haemorrhage (13%). HIV infection rates in these groups were 92%, 30% and 61%, respectively. Previous caesarean section was associated with obstetric haemorrhage death (odds ratio [OR] 3.2, 95% confidence interval [95% CI] 1.7-6.0), maternal age ≥35 years with hypertension death (OR 2.2, 95% CI 1.2-3.7) and antenatal anaemia with nonpregnancy-related infection death (OR 4.0, 95% CI 2.3-6.9), compared with other causes of death. CONCLUSION: There is evidence of a decline in MMR since HIV treatment for pregnant women was introduced in 2004. Previous caesarean section, advanced maternal age, and anaemia were associated with death from obstetric haemorrhage, hypertensive disorders of pregnancy and nonpregnancy-related infections, respectively. MMR may be further reduced with accelerated initiation of HIV treatment during pregnancy.

Prevalence and self-reported health consequences of vaginal practices in KwaZulu-Natal, South Africa: findings from a household survey.

OBJECTIVES: To investigate population-level prevalence of vaginal practices, their frequency and self-reported health consequences in KwaZulu-Natal, South Africa. METHODS: A household survey using multi-stage cluster sampling was conducted in 2007. Women aged 18-60 (n = 867) were interviewed on demographics, sexual behaviours and vaginal practices, focusing on intravaginal practices. Design-based analysis used multivariate logistic regression to identify factors associated with intravaginal or any practice. RESULTS: Most women currently perform vaginal practices (90.2%), with 34.8% reporting two and 16.3%≥3 practices. Internal cleansing, the commonest practice (63.3% of women), is undertaken frequently (61.6% cleansing twice daily; 20.0% using ≥2 products). Fewer report application (10.1%), insertion (11.6%) or ingestion (14.3%) practices. Hygiene is a common motivation, even for the 23.2% of women reporting intravaginal practices around the time of sex. Prevalence of any practice was lower among women with tertiary education than those without primary education (AOR = 0.26, 95% CI = 0.08-0.85), nearly twice as common in sexually active women (95% CI = 1.05-3.56) and increased as overall health status declined. Adjusted odds of intravaginal practices were 1.8-fold higher in women reporting unprotected sex (95% CI = 1.11-2.90). Few reported health problems with current practices (0.6%); though, 12.6% had ever-experienced adverse effects. CONCLUSIONS: Vaginal practices are common in KwaZulu-Natal. Although self-reported health problems with current practices are rare, high lifetime risk of adverse events and potential for asymptomatic but clinically important damage make continued research important.

A Safe Motherhood project in Kenya: assessment of antenatal attendance, service provision and implications for PMTCT.

OBJECTIVES: To investigate uptake and provision of antenatal care (ANC) services in the Uzazi Bora project: a demonstration-intervention project for Safe Motherhood and prevention of mother-to-child transmission of HIV in Kenya. METHODS: Data were extracted from antenatal clinic, laboratory and maternity ward registers of all pregnant women attending ANC from January 2004 until September 2006 at three antenatal clinics in Mombasa and two in rural Kwale district of Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds logistic regression analyses assessed changes over time, and determinants of the frequency and timing of ANC visits, uptake of HIV testing, and provision of iron sulphate, folate and single-dose nevirapine (sd-NVP). RESULTS: About half of women in rural and urban settings (52.2% and 49.2%, respectively) attended antenatal clinics only once. Lower parity, urban setting, older age and having received iron sulphate and folate supplements during the first ANC visit were independent predictors of more frequent visits. The first ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5% and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally marked improvements were observed in the uptake of HIV testing and the provision of iron sulphate and folate. CONCLUSION: Provision of ANC services, including sd-NVP, increased markedly over time. While further improvements in quality are necessary, particular attention is needed to implement evidence-based interventions to alter ANC utilization patterns. Encouragingly, improved provision of basic essential obstetric care may increase attendance.

Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene.

South Africa has a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. Much evidence indicates that alcohol independently influences decisions around sex, and undermines skills for condom negotiation and correct use. Thus, not surprisingly, people with problem drinking in Africa have twofold higher risk for HIV than non-drinkers. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising and provision of Brief Interventions. Alcohol counselling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. Within positive-prevention services, alcohol reduction interventions could diminish HIV transmission. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence. However, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable disease, including unsafe sex, sexual violence, unintended pregnancy and, likely, HIV transmission.

Good treatment outcomes among foreigners receiving antiretroviral therapy in Johannesburg, South Africa.

Foreigners, including displaced persons, often have limited health-care access, especially to HIV services. Outcomes of antiretroviral therapy (ART) in South Africans and foreigners were compared at a Johannesburg non-governmental clinic. Records were reviewed of 1297 adults enrolled between April 2004 and March 2007 (568 self-identified foreigners, 431 South Africans citizens and 298 with unknown origin). Compared with citizens, foreigners had fewer hospital admissions (39%, 90/303 versus 51%, 126/244; P < 0.001), less missed appointments for ART initiation (20%, 39/200 versus 25%, 51/206; P < 0.001), faster median time to ART initiation (14 versus 21 days, P = 0.008), better retention in care (88%, 325/369 versus 69%, 155/226; P < 0.001) and lower mortality (2.5%, 14/568 versus 10%, 44/431; P < 0.001) after 426 person-years. In logistic regression, after controlling for baseline CD4 count and tuberculosis status, foreigners were 55% less likely to fail ART than citizens (95% CI = 0.23-0.87). These findings support United Nations High Commissioner for Refugees recommendations that ART should not be withheld from displaced persons.

HIV testing and counselling for women attending child health clinics: an opportunity for entry to prevent mother-to-child transmission and HIV treatment.

This study assessed the potential for HIV testing at child health clinics to increase knowledge of HIV status, and entry to infant feeding counselling and HIV treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and counselling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing (95% confidence interval = 1.4-5.1; P = 0.003). Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is acceptable. This could optimize entry into HIV treatment, infant feeding counselling and family planning services.

Morbidity in the first year postpartum among HIV-infected women in Kenya.

OBJECTIVE: To assess the effects of HIV infection on morbidity and the needs of infected women for services in the first year postpartum. METHODS: A cross-sectional study with 500 women attending a child-health clinic in Mombasa, Kenya. RESULTS: Postpartum duration was a median of 3.3 months (interquartile range, 1.9-6.1 months). The 54 HIV-infected women had a lower income and less financial support than the uninfected women, and they were more likely to experience fever, dyspnea, and dysuria, and to have genital warts (odds ratio [OR], 9.6; 95% confidence interval [CI], 2.6-35.6; P<0.001), candidiasis (OR, 2.9; 95% CI, 1.2-6.8; P=0.012), and bacterial vaginosis (OR, 1.8; 95% CI, 0.95-3.3; P=0.066). Six (nearly 15%) of the HIV-infected women had low- or high-grade squamous intraepithelial lesions, and 21 (42%) had an unmet need for contraception. More than half of all women were anemic, and normocytic anemia was predominant among the HIV infected. CONCLUSION: Compared with uninfected women, morbidity was increased for HIV-infected women during the year following delivery. This period could be used to offer these, and all-women, family planning services, cervical cancer screening, and treatment for anemia and reproductive tract infections.

Heavy episodic drinking among Kenyan female sex workers is associated with unsafe sex, sexual violence and sexually transmitted infections.

This study examined patterns of alcohol use and its association with unsafe sex and related sequelae among female sex workers in Mombasa, Kenya. A community-based cross-sectional study was conducted using snowball sampling. Binge drinkers (> or =5 alcoholic drinks on > or =1 occasion in the previous month) were compared with non-binge drinkers. Of 719 participants, 22.4% were lifetime-alcohol abstainers, 44.7% non-binge and 33.0% binge drinkers. Compared with non-binge drinkers, binge drinkers were more likely to report unprotected sex (adjusted odds ratio (AOR)=1.59, 95% confidence interval [CI]=1.00-2.53; P=0.047) and sexual violence (AOR=1.85, 95% CI=1.27-2.71; P=0.001) and to have either syphilis, Neisseria gonorrhoeae or Trichomonas vaginalis infection (AOR=1.56, 95% CI=1.00-2.41; P=0.048). HIV prevalence was higher among women having ever drunk (39.9%) than lifetime abstainers (23.2%; P<0.001), but was not associated with drinking patterns. Interventions are needed to assist female sex workers adopt safer drinking patterns. Investigation is needed for the effectiveness of such interventions in reducing unprotected sex, sexual violence and sexually transmitted infections.

Use of self home-made diaphragm for protection against pregnancy and sexually-transmitted infections: case report.

This is a case report of a 44-year-old woman who used a home-made diaphragm for 16 years to protect herself from pregnancy and sexually-transmitted infections. The woman stitched a piece of cloth with folded polythene inside. This case report provides a vivid illustration of the limitations of available methods of protection for women. It consists of an introduction to the topic, a description of her experiences using her home-made diaphragm and a discussion of the significance of the case. This report supports the need for additional research on female-controlled methods of protection against sexually-transmitted infections, methods that can be used without male knowledge and co-operation, such as vaginal microbicides and cervical barriers against infection, including the diaphragm.