Unequal Spatial Consequences of Abortion Restrictions in Texas, 2021-2023.

Objectives. To demonstrate the spatially uneven effects of abortion restriction laws in Texas. Methods. We used network analysis to determine the change in distance to the nearest surgical abortion provider for 5253 Texas neighborhoods after the passing of Texas Senate Bill 8 (SB8; 2021) and the US Supreme Court's Dobbs v Jackson Women's Health Organization (2022) decision. We identified associations between key measures of neighborhood socioeconomic context and change in distance to providers using multivariable linear regression models. Results. After the Dobbs decision, Texas residents experienced an average change in distance to the nearest provider of 457 miles (SD = 179). Neighborhoods of concentrated disadvantage experienced the greatest increase in distance to abortion providers after SB8's passing, and neighborhoods with high levels of income inequality experienced the greatest increase in distance after the Dobbs decision. Conclusions. We document the rapidly changing abortion landscape in a highly restrictive state and show that women living in more disadvantaged and unequal areas are most affected by the increasing distance to providers. Public Health Implications. Our methods and findings will continue to be relevant in understanding the burden placed on women in areas where medical abortion has been restricted because of the Dobbs decision. (Am J Public Health. Published online ahead of print May 23, 2024:e1-e10. https://doi.org/10.2105/AJPH.2024.307652).

Multimorbidity patterns and health-related quality of life in Jamaican adults: a cross sectional study exploring potential pathways.

Introduction: Multimorbidity and health-related quality of life (HRQoL) are intimately linked. Multiple chronic conditions may adversely affect physical and mental functioning, while poorer HRQoL may contribute to the worsening course of diseases. Understanding mechanisms through which specific combinations of diseases affect HRQoL outcomes can facilitate identification of factors which are amenable to intervention. Jamaica, a middle-income country with high multimorbidity prevalence, has a health service delivery system dominated by public sector provision via a broad healthcare network. This study aims to examine whether multimorbidity classes differentially impact physical and mental dimensions of HRQoL in Jamaicans and quantify indirect effects on the multimorbidity-HRQoL relationship that are mediated by health system factors pertaining to financial healthcare access and service use. Materials and methods: Latent class analysis (LCA) was used to estimate associations between multimorbidity classes and HRQoL outcomes, using latest available data from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008 (N = 2,551). Multimorbidity measurement was based on self-reported presence/absence of 11 non-communicable diseases (NCDs). HRQoL was measured using the 12-item short-form (SF-12) Health Survey. Mediation analyses guided by the counterfactual approach explored indirect effects of insurance coverage and service use on the multimorbidity-HRQoL relationship. Results: LCA revealed four profiles, including a Relatively Healthy class (52.7%) characterized by little to no morbidity and three multimorbidity classes characterized by specific patterns of NCDs and labelled Metabolic (30.9%), Vascular-Inflammatory (12.2%), and Respiratory (4.2%). Compared to the Relatively Healthy class, Vascular-Inflammatory class membership was associated with lower physical functioning (ß = -5.5; p < 0.001); membership in Vascular-Inflammatory (ß = -1.7; p < 0.05), and Respiratory (ß = -2.5; p < 0.05) classes was associated with lower mental functioning. Significant mediated effects of health service use, on mental functioning, were observed for Vascular-Inflammatory (p < 0.05) and Respiratory (p < 0.05) classes. Conclusion: Specific combinations of diseases differentially impacted HRQoL outcomes in Jamaicans, demonstrating the clinical and epidemiological value of multimorbidity classes for this population, and providing insights that may also be relevant to other settings. To better tailor interventions to support multimorbidity management, additional research is needed to elaborate personal experiences with healthcare and examine how health system factors reinforce or mitigate positive health-seeking behaviours, including timely use of services.

Task-shifting and family planning continuation: contraceptive trajectories of women who received their method at a community-based event in Kinshasa, DRC.

While community-based interventions are a proven high-impact strategy to increase contraceptive uptake in low-income countries, their capacity to support women's contraceptive choices (including continued use, switching and discontinuation) in the long run remains insufficiently discussed. This cohort study follows 883 women 3 and 6 months after they received a modern method during community campaigns organized in Kinshasa (D.R. Congo), to analyze their contraceptive trajectories and the factors associated with ever discontinuing contraceptive use in the first 6 months following a campaign. In the community-based distribution (CBD) model currently institutionalized in DRC, campaign clients are not provided with additional doses or support, besides baseline counseling, to (dis-)continue using the method they received, but must rely on Family Planning resources within the existing local health system. Almost a third (28.9%) of all women discontinued modern contraception during the study period, with much higher discontinuation rates for short-acting methods (38.7% for pills and up to 68.9% for DMPA-SC). Variables previously associated with high discontinuation (marital status, fertility intentions and side-effects) led to higher odds of "ever discontinuing". However, these variables became non-significant when controlling for resupply issues. Women's self-reported reasons for discontinuation confirmed the multivariate regression results. Detailed sub-analysis of resupply issues for pills, injectables and Cyclebeads pointed to the role of cost, unreliable campaign schedules and weak integration of community-based strategies into the formal health system. Extremely low rates of implants removal suggest similar access to FP services issues. The study highlights the need to identify CBD strategies best suited to support women's choices and preferences towards successful contraceptive trajectories in fragile health systems.

In countries with insufficient access to health facilities, such as the D. R. Congo, the provision of contraceptives through campaigns implemented in community settings is a commonly used strategy to increase the number of contraceptive users. However, the long-term trajectories of campaign clients are not often examined, and it is unclear whether these events can be an effective way to support women's choices and preferences when it comes to using, switching or stopping a contraceptive method. Our study looks at the contraceptive trajectories of 883 women who obtained a method during a community event to see whether they were still using that a modern contraceptive method 3 and 6 months later. Almost a third of the women discontinued at some point in that period, with much higher discontinuation rates for monthly pills and injectable contraceptives. While some individual characteristics (marital status, desired number of children, experienced side-effects) influenced discontinuation risk, the most important factor was the woman's ability to resupply her method. Implant removal was also much lower than expected and this suggested difficulties in accessing existing family planning services. Our findings indicate that campaigns are still too disconnected from existing family planning services to successfully support women's contraceptive choices in the long run.

As long as (I think) my husband agrees : role of perceived partner approval in contraceptive use among couples living in military camps in Kinshasa, DRC.

BACKGROUND: Male partner's approval is a key determinant of contraceptive use for women living in Sub-Saharan Africa and improving men's support and couple communication is a cornerstone of family planning programs. However, approval is often only measured through the women's perception of their partner's opinion. METHODS: This study conducted in Kinshasa compares contraceptive approval variables from matched male and female partners (n = 252 couples) to establish the frequency of (in)accurate perceptions by the woman, then test their association with modern contraceptive use. Additional regressions estimate individual and couple variables associated with (in)correct perceptions. RESULTS: Results confirm women are poorly aware of their partner's opinion but indicate that perceived approval or disapproval by the woman is a much stronger determinant of modern contraceptive use than her partner's actual opinion. Higher educational achievement from the woman is the strongest driver of misunderstanding her partner's approval. CONCLUSIONS: Women's perceptions of partner's approval are much stronger determinant of contraceptive use than the latter's actual opinion, and stereotyping men's opinion of family planning is a common error of appreciation. However, findings also suggest these misunderstandings might serve women's capacity to negotiate contraceptive use.

Research indicates that women living in Sub-Saharan Africa may not use contraceptive methods if their partner disapproves. However, there are methodological gaps in how this relation has been measured so far. For example, women are often the only ones asked whether their partner approves of contraception and surveys rarely assess how women know of their partner's disapproval and how strongly it has been communicated to them, nor do they ask said partner for his actual opinion on the matter.In this study we address some of those questions by interviewing men and women from married couples separately and comparing their opinion of family planning use. The research uses a population-based survey conducted among couples living in military camps in the capital city of the Democratic Republic Congo, Kinshasa.The results show that women overall are poorly aware of their partner's actual opinion, but act based on those perceptions, nonetheless. In particular, women whose husband disapproves of family planning but (falsely) perceive his approval have some of the highest odds in our cohort for contraceptive use. Conversely, women in a "false negative" scenario (husband approves but they perceive disapproval) are less likely to use modern contraception. Additional analysis indicates that this latter scenario is more common among women who are more educated than their partner, possibly because they are stereotyping his family planning desires. The findings and the discussion also raise the possibility that women may however benefit from ignoring their partners' true wishes in order to fulfill their own contraceptive choice.

Factors influencing client recall of contraceptive counseling at community-based distribution events in Kinshasa, Democratic Republic of the Congo.

BACKGROUND: Clients must recall information from contraceptive counseling sessions to properly use their chosen method. Client recall in community-based settings is challenging given the public nature of these events and the presence of many potential distractions. Understanding the factors that influence client recall during community-based distribution events can guide future training of providers to improve proper use of contraceptive methods and client satisfaction. METHODS: This cross-sectional study employed a convenience sample of 957 women ages 15-49 old who sought contraceptive services from community-based contraceptive distribution events in Kinshasa, Democratic Republic of the Congo, known as Lelo PF. Recall scores were developed by matching direct observations with client exit interviews. The association between recall and client characteristics, provider characteristics and an index for the quality of the provider-client interaction were tested using multivariate linear regression. RESULTS: The average recall score was 67.6%. Recall scores were higher among clients who accepted methods with simpler administration procedures, such as CycleBeads (81.3%), compared to methods requiring more medically advanced administration procedures, such as DMPA-SC (56.6%) and Implanon-NXT (62.1%). This relationship held even after controlling for amount of information each client received. Status as a first-time user was associated with a 5.8 percentage point decrease in recall score (p = 0.002). Time since the provider's initial family planning training and clients' perception of the provider-client interaction were associated with higher client recall scores. CONCLUSION: Results of this study suggest that to improve client recall at Lelo PF events, future provider training should focus on how to deliver clear, specific information to clients, making sure clients feel at ease during the counseling session, and treating clients with respect. First-time family planning users and clients who select methods with more medically advanced administration procedures may require extra attention during the consultation to ensure they are able understand and remember the information. Results suggest that providers who have been offering services longer may be more effective in conveying information in a way that clients can remember. Program managers should consider requesting input from experienced providers to improve training sessions.

Social determinants of multimorbidity in Jamaica: application of latent class analysis in a cross-sectional study.

BACKGROUND: Non-communicable disease (NCD) multimorbidity is associated with impaired functioning, lower quality of life and higher mortality. Susceptibility to accumulation of multiple NCDs is rooted in social, economic and cultural contexts, with important differences in the burden, patterns, and determinants of multimorbidity across settings. Despite high prevalence of individual NCDs within the Caribbean region, exploration of the social epidemiology of multimorbidity remains sparse. This study aimed to examine the social determinants of NCD multimorbidity in Jamaica, to better inform prevention and intervention strategies. METHODS: Latent class analysis (LCA) was used to examine social determinants of identified multimorbidity patterns in a sample of 2551 respondents aged 15-74 years, from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008. Multimorbidity measurement was based on self-reported presence/absence of 11 chronic conditions. Selection of social determinants of health (SDH) was informed by the World Health Organization's Commission on SDH framework. Multinomial logistic regression models were used to estimate the association between individual-level SDH and class membership. RESULTS: Approximately one-quarter of the sample (24.05%) were multimorbid. LCA revealed four distinct profiles: a Relatively Healthy class (52.70%), with a single or no morbidity; and three additional classes, characterized by varying degrees and patterns of multimorbidity, labelled Metabolic (30.88%), Vascular-Inflammatory (12.21%), and Respiratory (4.20%). Upon controlling for all SDH (Model 3), advancing age and recent healthcare visits remained significant predictors of all three multimorbidity patterns (p < 0.001). Private insurance coverage (relative risk ratio, RRR = 0.63; p < 0.01) and higher educational attainment (RRR = 0.73; p < 0.05) were associated with lower relative risk of belonging to the Metabolic class while being female was a significant independent predictor of Vascular-Inflammatory class membership (RRR = 2.54; p < 0.001). Material circumstances, namely housing conditions and features of the physical and neighbourhood environment, were not significant predictors of any multimorbidity class. CONCLUSION: This study provides a nuanced understanding of the social patterning of multimorbidity in Jamaica, identifying biological, health system, and structural determinants as key factors associated with specific multimorbidity profiles. Future research using longitudinal designs would aid understanding of disease trajectories and clarify the role of SDH in mitigating risk of accumulation of diseases.

Is Covid-19 community level testing effective in reaching at-risk populations? Evidence from spatial analysis of New Orleans patient data at walk-up sites.

BACKGROUND: This paper evaluates the increase in coverage and use of Covid-19 testing services for vulnerable and hard-to-reach populations through the introduction of community-based walk-up sites in New Orleans, LA. While most GIS work on Covid-19 testing coverage and access has used census tract or ZIP code aggregated data, this manuscript is unique in that it uses individual level demographics and exact addresses to calculate distances actually traveled by patients. METHODS: We used testing data recorded for 9721 patients at 20 sites operating in May-June 2020. The dataset includes detailed age, race and ethnicity, and testing results as well as the exact address of each individual. Using GIS, we estimated changes in testing coverage for minority neighborhoods and calculated the actual distance covered by individuals. Logistic regression and multivariate linear regression were used to identify socio-demographic variables associated with distance travelled to and used of nearest testing site. We used a secondary dataset from drive-through sites to evaluate change in coverage at the census tract level for the metropolitan area. RESULTS: Walk-up sites significantly increased testing availability in New Orleans, and specifically in minority neighborhoods. Both African Americans and Asians were more likely (14.7 and 53.0%) to be tested at the nearest walk-up site. They also covered shorter distances to get tested. Being elderly was also significantly and positively associated with testing at the nearest site. Hispanics, however, were not associated with increased proximity to and use of nearest sites, and they traveled an additional 0.745 km to get tested. Individuals who tested positive also travelled significantly longer distances to obtain a test. CONCLUSIONS: Walk-up sites increased testing availability for some vulnerable populations who took advantage of the sites' proximity, although inequalities appear at the metropolitan scale. As cities are planning community vaccination campaigns, mobile, walk-up sites appear to improve both coverage and accessibility for hard-to-reach populations. With adequate technical (vaccine dose refrigeration) and messaging (addressing reticence to immunization) adaptations, they could constitute a key complementary approach to health facility points of delivery.

Prevalence and patterns of multimorbidity in the Jamaican population: A comparative analysis of latent variable models.

BACKGROUND: Evidence suggests that the single-disease paradigm does not accurately reflect the individual experience, with increasing prevalence of chronic disease multimorbidity, and subtle yet important differences in types of co-occurring diseases. Knowledge of multimorbidity patterns can aid clarification of individual-level burden and needs, to inform prevention and treatment strategies. This study aimed to estimate the prevalence of multimorbidity in Jamaica, identify population subgroups with similar and distinct disease profiles, and examine consistency in patterns identified across statistical techniques. METHODS: Latent class analysis (LCA) was used to examine multimorbidity patterns in a sample of 2,551 respondents aged 15-74 years, based on data from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008 and self-reported presence/absence of 11 chronic conditions. Secondary analyses compared results with patterns identified using exploratory factor analysis (EFA). RESULTS: Nearly one-quarter of the sample (24.1%) were multimorbid (i.e. had ≥2 diseases), with significantly higher burden in females compared to males (31.6% vs. 16.1%; p<0.001). LCA revealed four distinct classes, including a predominant Relatively Healthy class, comprising 52.7% of the sample, with little to no morbidity. The remaining three classes were characterized by varying degrees and patterns of multimorbidity and labelled Metabolic (30.9%), Vascular-Inflammatory (12.2%), and Respiratory (4.2%). Four diseases determined using physical assessments (obesity, hypertension, diabetes, hypercholesterolemia) were primary contributors to multimorbidity patterns overall. EFA identified three patterns described as "Vascular" (hypertension, obesity, hypercholesterolemia, diabetes, stroke); "Respiratory" (asthma, COPD); and "Cardio-Mental-Articular" (cardiovascular disease, arthritis, mental disorders). CONCLUSION: This first study of multimorbidity in the Caribbean has revealed a high burden of co-existing conditions in the Jamaican population, that is predominantly borne by females. Consistency across methods supports the validity of patterns identified. Future research into the causes and consequences of multimorbidity patterns can guide development of clinical and public health strategies that allow for targeted prevention and intervention.

Feasibility and acceptability of using medical and nursing students to provide Implanon NXT at the community level in Kinshasa, Democratic Republic of Congo.

BACKGROUND: The use of implants has steadily increased in Kinshasa since 2013 but clinic-based access to this family planning method is limited due to distance and costs barriers. The objective of this study was to examine the feasibility and acceptability of providing Implanon NXT at the community level using medical and nursing students (M/N) as distributors, as part of a strategy to improve contraceptive uptake in the Democratic Republic of Congo. METHODS: A cohort of 531 women who chose to receive Implanon NXT from a M/N student during community-based campaign days participated in three rounds of a quantitative survey administered at the time of insertion of the method, and at 6 and 12 months later. We conducted descriptive analysis to assess the feasibility and acceptability of providing the method through M/N students in terms of method choice, user profiles, contraceptive history, experience with insertion and side effects, continuation / discontinuation of the method, and overall satisfaction with FP services as well as students' preparedness and capacity to safely offer the method, and their satisfaction with the experience.. RESULTS: The study demonstrated the feasibility of training students for community-based provision of Implanon NXT and 95% of them were satisfied with their experience. Acceptability of both the method and the service delivery strategy was high among participants, including among young and first-time contraceptive users. Out of the 441 women with a known outcome at 12 months, 92% still had Implanon NXT inserted, despite some of them reporting experiencing side effects. The vast majority (79%) would "strongly recommend" obtaining NXT from a M/N student if a friend wanted to avoid pregnancies. CONCLUSIONS: The provision of Implanon NXT at the community-level is a promising solution to address some of the barriers to accessing this method for women living in Kinshasa. However, strengthening pre-insertion counseling, particularly on expected side-effects and the possibility of early removal, is necessary to increase informed choice for the women and potentially limit method discontinuation.

Provision of Emergency Contraceptive Pills in Kinshasa's Informal Drug Shops: Results from a Mystery Client Study.

CONTEXT: Despite the prominence of informal drug shops as sources of contraceptives in Kinshasa, Democratic Republic of the Congo, evidence on the quality of services they provide is scant. Given efforts to leverage the private sector to increase contraceptive access, evaluating the contraceptive knowledge, attitudes and practices of these providers is warranted. METHODS: In April-May 2018, a mystery client study on the provision of emergency contraception (EC) was conducted in 854 informal drug shops in Kinshasa. Twelve mystery clients, presenting as younger or older than 18 and married or unmarried, visited the outlets to request something to "avoid getting pregnant" after unprotected sex, and to purchase the recommended medicine. Frequencies of key outcomes were calculated, and chi-square testing assessed associations between client age and marital status and the methods and counseling received. RESULTS: Overall, providers recommended EC in 77% of visits, and in 54% of visits, clients left with the method. In 62% of the visits in which providers recommended EC, they specified a time frame for taking the pill; the correct window of efficacy was indicated in 75% of these visits. In 18% of visits, other (noncontraceptive) drugs were provided, and in 7% of visits, providers did not help the client. Regardless of the visit outcome, providers were nearly always deemed respectful (96%). CONCLUSIONS: Leveraging informal outlets to increase contraceptive provision will require identifying quality outlets, strengthening supply chains and advocating for policy changes that recognize them as effective contraceptive providers without decreasing their perceived advantages for women.

RESUMEN Contexto: A pesar de la importancia de las farmacias informales como fuente para obtener anticonceptivos en Kinshasa, República Democrática del Congo, la evidencia sobre la calidad de los servicios que prestan es escasa. Ante los esfuerzos para aprovechar al sector privado con el fin de aumentar el acceso a los anticonceptivos, se justifica evaluar los conocimientos, las actitudes y las prácticas anticonceptivas de esos proveedores. Métodos: Entre abril y mayo de 2018, se realizó un estudio de cliente simulado acerca de la provisión de anticoncepción de emergencia (AE) en 854 farmacias informales en Kinshasa. Doce clientas simuladas que se presentaron como menores o mayores de 18 años y como casadas o solteras, visitaron los puntos de venta para solicitar algo para "evitar quedar embarazadas" después de haber tenido relaciones sexuales sin protección y para comprar el medicamento recomendado. Se calcularon las frecuencias de los resultados clave, y las pruebas de chi-cuadrado evaluaron las asociaciones entre la edad de la clienta, el estado conyugal, los métodos y el asesoramiento recibido. Resultados: En general, los proveedores recomendaron AE en el 77% de las visitas; y, en el 54% de las visitas, las clientas llevaron el método. En el 62% de las visitas en las cuales los proveedores recomendaron AE, especificaron el tiempo adecuado para tomar la píldora; el 75% indicó la ventana correcta de eficacia en esas visitas. En el 18% de las visitas, se proporcionaron otros medicamentos (no anticonceptivos) y en el 7% de las visitas, los proveedores no ayudaron a la clienta. Independientemente del resultado de la visita, se consideró que los proveedores casi siempre fueron respetuosos (96%). Conclusiones: Aprovechar los puntos de venta informales para aumentar la provisión de anticonceptivos requerirá identificar puntos de venta de calidad, fortalecer las cadenas de suministro y abogar por cambios en las políticas que los reconozcan como proveedores efectivos de anticonceptivos sin disminuir sus ventajas percibidas para las mujeres.

RÉSUMÉ Contexte: Malgré l'importance des dépôts de vente de médicaments informels en tant que sources de contraceptifs à Kinshasa (République démocratique du Congo), il n'existe guère de données sur la qualité de leurs services. Étant donné les efforts déployés pour mettre le secteur privé à contribution dans l'élargissement de l'accès à la contraception, l'évaluation de la connaissance, des attitudes et des pratiques de ces prestataires à son égard est justifiée. Méthodes: En avril-mai 2018, une étude par clientes fictives sur la fourniture de la contraception d'urgence (CU) a été menée dans 854 dépôts de vente de médicaments informels kinois. Douze clientes fictives, se présentant comme ayant moins ou plus de 18 ans et comme mariées ou célibataires, se sont rendues dans les dépôts pour y demander quelque chose qui leur permette de « ne pas tomber enceintes « après un rapport sexuel non protégé et pour acheter le médicament recommandé. Les fréquences des principaux résultats ont été calculées et les associations entre l'âge et la situation matrimoniale de la cliente et les méthodes et le conseil reçus ont été évaluées par tests chi carré. Résultats: Globalement, les prestataires ont recommandé la CU dans 77% des cas et, dans 54%, les clientes ont obtenu la méthode. Dans 62% des cas où les prestataires avaient recommandé la CU, ils ont spécifié un délai de prise de la pilule. La période correcte d'efficacité a été indiquée dans 75% de ces cas. Dans 18% des cas, d'autres médicaments (non contraceptifs) ont été fournis et dans 7%, les prestataires n'ont pas aidé la cliente. Indépendamment du résultat de la visite, les prestataires ont presque toujours été qualifiés de respectueux (96%). Conclusions: La mise à contribution des dépôts informels pour l'accroissement de l'offre contraceptive nécessitera l'identification des dépôts de qualité, le renforcement des chaînes d'approvisionnement et le plaidoyer en faveur de changements de politique qui reconnaissent ces dépôts comme prestataires efficaces de la contraception sans réduire leurs avantages perçus pour les femmes.

Improving the quality of maternal and newborn health outcomes through a clinical mentorship program in the Democratic Republic of the Congo: study protocol.

BACKGROUND: The Democratic Republic of the Congo (DRC) boasts one of the highest rates of institutional deliveries in sub-Saharan Africa (80%), with eight out of every ten births also assisted by a skilled provider. However, the maternal and neonatal mortality are still among the highest in the world, which demonstrates the poor in-facility quality of maternal and newborn care. The objective of this ongoing project is to design, implement, and evaluate a clinical mentorship program in 72 health facilities in two rural provinces of Kwango and Kwilu, DRC. METHODS: This is an ongoing quasi-experimental study. In the 72 facilities, 48 facilities were assigned to the group where the clinical mentorship program is being implemented (intervention group), and 24 facilities were assigned to the group where the clinical mentorship program is not being implemented (control group). The groups were selected and assigned based on administrative criteria, taking into account the number of deliveries in each facility, the coverage of health zones, accessibility, and ease of implementation of a clinical mentorship program. The main activities are organizing and training a national team of mentors (including senior midwives, obstetricians, and pediatricians) in clinical mentoring, deploying them to mentor all health providers (mentees) performing maternal and newborn health (MNH) services, and providing in-service training in routine and Emergency Obstetrical and Newborn Care (EmONC) to the mentees in health facilities over an 18-month period. Baseline and endline assessments are carried out to evaluate the effectiveness of the clinical mentorship program on the quality of MNH care and the effective coverage of key interventions to reduce maternal and neonatal mortality. Findings will be disseminated nationwide and internationally, as scientific evidence is scarce. A national strategy, guidelines, and tools for clinical mentorship in MNH will be developed for replication in other provinces, thus benefitting the entire country. DISCUSSION: This is the largest project on clinical mentorship aimed to improving the quality of MNH care in Africa. This program is expected to generate one of the first pieces of scientific evidence on the effectiveness of a clinical mentorship program in MNH on a scientifically designed and sustainable model.

Facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care in 72 rural health facilities in the Democratic Republic of the Congo: A cross-sectional study.

Background: Current facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care (EmONC) were assessed in the Kwango and Kwilu provinces of the Democratic Republic of the Congo (DRC). Methods: This is an analysis of the baseline survey data from an ongoing clinical mentoring program among 72 rural health facilities in the DRC. Data collectors visited each of the facilities and collected data through a pre-programmed smartphone. Frequencies of selected indicators were calculated by province and facility type-general referral hospital (GRH) and primary health centers (HC). Results: Facility conditions varied across province and facility type. Maternity wards and delivery rooms were available in the highest frequency of rooms assessed (>95% of all facilities). Drinking water was available in 25.0% of all facilities; electricity was available in 49.2% of labor rooms and 67.6% of delivery rooms in all facilities. Antenatal, delivery, and postnatal care services were available but varied across facilities. While the proportion of blood pressure measured during antenatal care was high (94.9%), the antenatal screening rate for proteinuria was low (14.7%). The use of uterotonics immediately after birth was observed in high numbers across both provinces (94.4% in Kwango and 75.6% in Kwilu) and facility type (91.3% in GRH and 81.4% in HC). The provision of immediate postnatal care to mothers every 15 minutes was provided in less than 50% of all facilities. GRH facilities generally had higher frequencies of available equipment and more services available than HC. GRH facilities provided an average of 6 EmONC signal functions (range: 2-9). Conclusions: Despite poor facility conditions and a lack of supplies, GRH and HC facilities were able to provide EmONC care in rural DRC. These findings could guide the provision of essential needs to the health facilities for better delivery of maternal and neonatal care.

Evolution of a Large-Scale Community-Based Contraceptive Distribution Program in Kinshasa, DRC Based on Process Evaluation.

In a context where distance, user fees, and health staff shortages constitute significant barriers to accessing facility-based family planning services, the use of community-based distributors (CBDs) as counseling and contraceptive providers has been tested in several resource-constrained environments to increase family planning uptake. In the capital city of the Democratic Republic of the Congo (DRC), Kinshasa, a massive CBD program (AcQual) has been implemented since 2014, with lackluster results measured in terms of the low volume of contraceptives provided. A process evaluation conducted in 2017 assessed the fidelity of implementation of the program compared with the original AcQual design and analyzed gaps in provider training and motivation, contraceptive supplies, and reporting and monitoring processes. Its objective was to identify both theory and implementation failures in order to propose midcourse corrections for the program. The mixed-method data collection focused on the CBDs as a pivotal component of the AcQual program with 700 active CBDs interviewed. In addition, 10 in-depth interviews were conducted with clinical personnel, local health program managers, and project partners to identify gaps in the AcQual implementation environment. Issues with CBDs' performance, knowledge retention, and commitment to program activities, as well as gaps in contraceptive supply chains and insufficient monitoring and supervision processes, were the main implementation failures identified. Inappropriate method mix offered by the CBDs (condoms, pills, and CycleBeads only) and chronic overburdening of health care staff at the local level compounded these issues and explained the low volume of contraceptives provided through AcQual. Midcourse corrections included a more structured schedule of activities, stronger integration of CBDs with clinical providers and health zone managers, expansion of the mix of contraceptives offered to include subcutaneous injectables and emergency contraceptive pills, and clarifying reporting and monitoring responsibilities among all partners. Findings from this process evaluation contribute to the limited knowledge base regarding "unwelcome results" by examining all the intervention components and their relationships to highlight areas of potential failures, both in design and implementation, for similar CBD programs.

An observational study to test the acceptability and feasibility of using medical and nursing students to instruct clients in DMPA-SC self-injection at the community level in Kinshasa.

OBJECTIVES: Given the promise of DMPA-SC to increase community-level access to modern contraception in developing countries, we conducted an observational study to assess the acceptability and feasibility of DMPA-SC self-injection among women in Kinshasa, Democratic Republic of the Congo, and of medical/nursing (M/N) students as instructors for self-injection. STUDY DESIGN: Women who selected DMPA-SC at a community outreach event adjacent to a health center were interviewed upon acceptance (baseline) and then 3, 6 and 12 months later. RESULTS: Of 850 clients selecting DMPA-SC at baseline, 640 (75.3%) opted for self-injection over being injected by the M/N students for reasons of convenience and personal agency. Among these 640 self-injectors, 47.5% were anxious at baseline (for fear of needles or injecting incorrectly). Over 80% reported feeling very ready after training, confident that they knew how to self-inject and confident that they would remember the next injection date. By 3 months, 97% described it as easy. Half (54%) experienced side effects, mainly menstrual irregularities, the main reason for discontinuation. At 6-month follow-up, self-injectors cited effectiveness and ease of use as positive elements, though one quarter reported side effects. Their impressions of M/N students as instructors were highly positive. CONCLUSIONS: Where DMPA-SC was free and easily accessible, the majority of women interested in DMPA-SC opted to learn self-injection. The M/N students performed well in instructing women to self-inject. Clients were highly satisfied with the services received, yet many did not recognize their student status, possibly because outreach occurred near a health facility. Once told, clients remained very favorable, suggesting strong motivation to receive their preferred contraceptive free, whoever the provider. IMPLICATION STATEMENT: This study provides additional evidence on the acceptability and the feasibility of the self-injection of DMPA-SC by users from a resource-limited setting.

Task-shifting the provision of DMPA-SC in the DR Congo: Perspectives from two different groups of providers.

OBJECTIVES: To document the experience of three groups of Family Planning service providers participating in task-shifting for the provision of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC) at the community level in the DRC. STUDY DESIGN: This article compares results from interviews with DMPA-SC providers in two separate pilot studies: 1) 53 medical and nursing school students teaching women how to self-inject (2016-2017); and 2) 34 lay community health workers providing DMPA-SC in rural areas of Lualaba (2017). All providers gave information on socio-demographic characteristics, recruitment,) training, supervision, experience and satisfaction with the provision of DMPA-SC. The paper examines variations in responses from the different provider cadres. RESULTS: Despite substantive variations in provider profiles in terms of age, educational and marital status, reported levels of satisfaction with offering DMPA-SC in the community were consistently high. Over 90% of all providers declared being comfortable or very comfortable interacting with FP clients, and more than three quarters of them were very comfortable performing an injection. Over 90% of Lualaba providers and over 80% of student providers gave correct responses to DMPA-SC protocol questions regarding referral of clients to facilities and side-effects management. The vast majority declared being (very) satisfied with their experience providing DMPA-SC. CONCLUSIONS: Providers with and without a clinical background, when properly trained and supervised, can provide DMPA-SC at the community level in both urban and rural settings of the DRC. Support strategies from the Family Planning environment (continuous contraceptive supplies and adequate referral system to fixed facilities) are key to engaging community health workers and sustainably leveraging task-shifting opportunities. IMPLICATION STATEMENT: This study provides additional evidence on the acceptability and feasibility of task-shifting in relation to DMCP-SC and supports further scale-up efforts.

The provision of emergency contraception in Kinshasa's private sector pharmacies: experiences of mystery clients.

OBJECTIVES: Recent programmatic and research efforts on addressing gaps in health systems of low-income countries increasingly see task shifting, i.e. the provision of healthcare by non-medically trained personnel, as a possible solution to increase the availability of specific services and commodities. In Kinshasa, private-sector pharmacies are the primary and preferred provider of family planning (FP) methods, and thus constitute a potential resource for expanding access to specific contraceptives. The objective of this study is to explore selected pharmacies' readiness to serve women seeking emergency contraception (EC). STUDY DESIGN: This study used a mystery client (MC) methodology to visit 73 pharmacies in Kinshasa, Democratic Republic of Congo (DRC). Trained interviewers posed as novice EC users and asked specific questions to evaluate the pharmacy staff's technical knowledge of EC and their attitudes towards EC clients. The results of the MC visit were recorded immediately after the MC left the pharmacy. RESULTS: Findings indicate that more than two-thirds of EC providers were knowledgeable about EC dosage, timeframe, and side effects, and 90% were deemed helpful towards novice EC users. Rare but glaring misconceptions about EC timeframe (20% of providers) and long-term side effects (4% of providers), as well as frequent stock-out (22%) and cost issues highlight priorities for programmatic improvements. CONCLUSIONS: As new service delivery strategies are explored to complement the uneven network of health structures in DRC, this study suggests that, given proper training and integration in FP programming, private-sector pharmacies have the potential to meet specific contraceptive needs for women living in Kinshasa. IMPLICATION STATEMENT: Private pharmacies included in study sample in Kinshasa (DRC) have adequate family planning (FP) service skills to provide clients with emergency contraceptive pills. These higher-end outlets constitute an opportunity for expanding access to FP, although, under total market approaches, a more diverse range of drugs shops should be investigated.

Awareness and Perceptions of Emergency Contraceptive Pills Among Women in Kinshasa, Democratic Republic of the Congo.

CONTEXT: Despite the commitment of the Democratic Republic of the Congo (DRC) to expand the family planning method mix and increase access to services, awareness of emergency contraception is low among women, and the method remains underused and poorly integrated in family planning programming. METHODS: Data from 15 focus group discussions conducted in 2016 among women aged 15-35 were used to examine awareness and perceptions of, and attitudes toward, emergency contraceptives. After facilitators explained emergency contraceptive pills' mechanism of action and other characteristics, participants were asked about the potential benefits and risks of making the method more widely available. Transcripts were analyzed using an iterative approach. RESULTS: Women reported employing a wide range of postcoital contraceptive behaviors, albeit often using inappropriate products, and generally agreed that emergency contraceptive pills seemed to be a potentially effective solution to their family planning needs. Perceived benefits and limitations of the method were almost always framed in reference to other, better-known contraceptives, and women expressed strong preferences for pharmacy-based provision that aligned with their usual behaviors for obtaining contraceptives. Participants were reluctant to see the method available for free. CONCLUSIONS: Emergency contraceptive pills have the potential to address gaps in the family planning method mix in the DRC. Assessing whether women have incomplete or erroneous information about family planning methods can provide better understanding of women's contraceptive choices in low-income countries.

The value of spatial analysis for tracking supply for family planning: the case of Kinshasa, DRC.

While geographic information systems (GIS) are frequently used to research accessibility issues for healthcare services around the world, sophisticated spatial analysis protocols and outputs often prove inappropriate and unsustainable to support evidence-based programme strategies in resource-constrained environments. This article examines how simple, open-source and interactive GIS tools have been used to locate family planning (FP) services delivery points in Kinshasa (Democratic Republic of Congo) and to identify underserved areas, determining the potential location of new service points, and to support advocacy for FP programmes. Using smartphone-based data collection applications (OpenDataKit), we conducted two surveys of FP facilities supported by partner organizations in 2012 and 2013 and used the results to assess gaps in FP services coverage, using both ratio of facilities per population and distance-based accessibility criteria. The cartographic outputs included both static analysis maps and interactive Google Earth displays, and sought to support advocacy and evidence-based planning for the placement of new service points. These maps, at the scale of Kinshasa or for each of the 35 health zones that cover the city, garnered a wide interest from the operational level of the health zones' Chief Medical Officers, who were consulted to contribute field knowledge on potential new service delivery points, to the FP programmes officers at the Ministry of Health, who could use the map to inform resources allocation decisions throughout the city.