Integrating vector control within an emerging agricultural system in a region of climate vulnerability in southern Malawi: A focus on malaria, schistosomiasis, and arboviral diseases.

Infectious diseases are emerging at an unprecedented rate while food production intensifies to keep pace with population growth. Large-scale irrigation schemes have the potential to permanently transform the landscape with health, nutritional and socio-economic benefits; yet, this also leads to a shift in land-use patterns that can promote endemic and invasive insect vectors and pathogens. The balance between ensuring food security and preventing emerging infectious disease is a necessity; yet the impact of irrigation on vector-borne diseases at the epidemiological, entomological and economic level is uncertain and depends on the geographical and climatological context. Here, we highlight the risk factors and challenges facing vector-borne disease surveillance and control in an emerging agricultural ecosystem in the lower Shire Valley region of southern Malawi. A phased large scale irrigation programme (The Shire Valley Transformation Project, SVTP) promises to transform over 40,000 ha into viable and resilient farmland, yet the valley is endemic for malaria and schistosomiasis and experiences frequent extreme flooding events following tropical cyclones. The latter exacerbate vector-borne disease risk while simultaneously making any empirical assessment of that risk a significant hurdle. We propose that the SVTP provides a unique opportunity to take a One Health approach at mitigating vector-borne disease risk while maintaining agricultural output. A long-term and multi-disciplinary approach with buy-in from multiple stakeholders will be needed to achieve this goal.

Functionality of technical working groups in enabling evidence-informed decision-making within Malawi's Ministry of Health: a cross-sectional qualitative study.

BACKGROUND: The roles and functionality of technical working groups (TWGs) in the health sectors vary across countries, still they aim to support government and ministries in formulating evidence-informed recommendations for policies and facilitate dialogue and alignment of activities among stakeholders within the health sector. Thus, TWGs have a role in enhancing the functionality and effectiveness of the health system structure. However, in Malawi, the functionality of TWGs and how they utilize research evidence to contribute to decision-making is not monitored. This study sought to understand the TWGs' performance and functionality in enabling evidence-informed decision-making (EIDM) in Malawi's health sector. METHODS: A cross-sectional descriptive qualitative study. Data were collected through interviews, documents review and observation of three TWG meetings. Qualitative data were analysed using a thematic approach. The WHO-UNICEF Joint Reporting Form (JRF) was used to guide the assessment of TWG functionality. RESULTS: TWG functionality varied in the Ministry of Health (MoH) in Malawi. The reasons for those perceived to be functioning well included meeting frequently, diverse representation of members, and that their recommendations to MoH were usually considered when decisions were made. For the TWGs that were perceived as not functioning well, the main reasons included lack of funding, periodic meetings and discussions that needed to provide clear decisions on the actions to be taken. In addition, evidence was recognized as important in decision-making, and research was valued by decision-makers within the MoH. However, some of the TWGs lacked reliable mechanisms for generating, accessing and synthesizing research. They also needed more capacity to review and use the research to inform their decisions. CONCLUSIONS: TWGs are highly valued and play a critical role in strengthening EIDM within the MoH. Our paper highlights the complexity and barriers of TWG functionality in supporting pathways for health policy-making in Malawi. These results have implications for EIDM in the health sector. This suggests that the MoH should actively develop reliable interventions and evidence tools, strengthen capacity-building and increase funding for EIDM.

EIDM training as a key intervention among researchers to enhance research uptake and policy engagement: an evaluation study.

The Evidence Informed Decision Making (EIDM) field has evolved faster in the past decade. This progress shows a need for capacity enhancement amongst evidence producers and evidence users in EIDM training. Through the Enhance DELTAS programme, led by the African Institute for Development Policy (AFIDEP), the project provided research uptake and policy engagement training, mentorship and webinars to awardees of the Developing Excellence in Leadership, Training and Science (DELTAS) Africa initiative, led by the African Academy of Sciences (AAS). Two workshops were offered to individual early career DELTAS researchers in policy engagement and evidence uptake, referred to as ENHD101, and among research leaders to enhance institutional capacity on policy engagement and evidence uptake, (ENHD102). Overall, the programme attracted 31 early career researchers and 20 research leaders over the eight months of training, mentorship and webinars. Following the programme, the early career researchers understood the importance of EIDM for better health policies and programmes. In addition, the team appreciated the complexities of the policymaking processes as they developed the policy engagement strategy for their research. The implementation of the EIDM knowledge was reflected during the mentorship of research fellows with policy briefs as the end product. Notably, research leaders, appreciated their role in strengthening the capacity for EIDM in decision-making spaces. Although none of the research leaders participated in strengthening the capacity for EIDM during the programme, the team anticipated improving in the long run. In addition, the research leaders developed and implemented institutional strategies for policy engagement and research uptake through the use of social media to influence policymakers. In conclusion, the project supported the capacity building of African researchers in EIDM. It was evident that enhancing knowledge and skills on EIDM through an integrated approach to include training, mentorship, and webinars demonstrated enhanced capacity for policy engagement and evidence uptake.

What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries.

OBJECTIVES: Chronic respiratory diseases (CRD) are among the top four non-communicable diseases globally. They are associated with poor health and approximately 4 million deaths every year. The rising burden of CRD in low/middle-income countries will strain already weak health systems. This study aimed to explore the perspectives of healthcare workers and other health policy stakeholders on the barriers to effective diagnosis and management of CRD in Kenya, Malawi, Sudan, Tanzania and Uganda. STUDY DESIGN: Qualitative descriptive study. SETTINGS: Primary, secondary and tertiary health facilities, government agencies and civil society organisations in five sub-Saharan African countries. PARTICIPANTS: We purposively selected 60 national and district-level policy stakeholders, and 49 healthcare workers, based on their roles in policy decision-making or health provision, and conducted key informant interviews and in-depth interviews, respectively, between 2018 and 2019. Data were analysed through framework approach. RESULTS: We identified intersecting vicious cycles of neglect of CRD at strategic policy and healthcare facility levels. Lack of reliable data on burden of disease, due to weak information systems and diagnostic capacity, negatively affected inclusion in policy; this, in turn, was reflected by low budgetary allocations for diagnostic equipment, training and medicines. At the healthcare facility level, inadequate budgetary allocations constrained diagnostic capacity, quality of service delivery and collection of appropriate data, compounding the lack of routine data on burden of disease. CONCLUSION: Health systems in the five countries are ill-equipped to respond to CRD, an issue that has been brought into sharp focus as countries plan for post-COVID-19 lung diseases. CRD are underdiagnosed, under-reported and underfunded, leading to a vicious cycle of invisibility and neglect. Appropriate diagnosis and management require health systems strengthening, particularly at the primary healthcare level.

Knowledge translation and evidence generation to increase the impact of vector control in Burkina Faso, Cameroon and Malawi.

Lack of context-specific evidence and inadequate evidence-use for decision-making contribute to poor health. This paper reports on our work aimed at addressing the knowledge translation (KT) gap between evidence generators and users. We present our experiences of strengthening KT via technical advisory groups (TAGs) in parallel with increasing evidence generation through research fellowships and operational research. Vectorborne diseases (VBDs) impose substantial health and economic burdens in sub-Saharan Africa despite being preventable with vector control. The Partnership for Increasing the Impact of Vector Control aimed to reduce the burden of VBDs in Burkina Faso, Cameroon, Malawi and at regional and global levels. TAGs can promote evidence-use in policy and practice by engaging relevant stakeholders in both research and policy processes. TAGs and related activities are best facilitated by a coordinator with skills in research and policy. Contextual factors should influence the design and governance of TAGs, which will likely evolve over time. Relevant national stakeholders should be included in TAGs and be actively involved in developing research agendas to increase the relevance and acceptability of research findings for decision-making. The countries present three differing contexts with longer-term research and evaluation necessary to draw lessons on impact.

Training and mentorship as a tool for building African researchers' capacity in knowledge translation.

As one of the main knowledge producers, researchers can play an important role in contributing to efforts that bridge the gap between knowledge, policy and practice. However, for researchers to play this role, they need knowledge translation (KT) capacities that many typically lack. Furthermore, research has confirmed that little is known on KT training approaches for LMICs researchers and their effectiveness. This paper seeks to contribute to filling this knowledge gap on KT training approaches for LMIC researchers by assessing the effectiveness of a training and mentorship intervention to build African researchers' KT capacity. We conducted KT training and mentorship for 23 early and mid-career researchers from 20 universities in sub-Saharan Africa. This comprised a 5-day intense residential training workshop, followed by a 6-months mentorship. A pre- and post-training test was used to assess the immediate effect of the workshop. The intermediate effect of the training following a 6-month mentorship was assessed by the number of researchers who completed policy briefs during this period and those who participated in the webinar series conducted during this period. Overall, the aggregate average point change in the self-reported learning between the pre-training and the post-training survey was 1.9, which demonstrated the effectiveness of the training workshop. This was confirmed by a 33.7% increase in the aggregate average percentage of participants that responded correctly to questions assessing topics covered in the training between the pre-training and the post-training survey. During the mentorship period, 19 of the 23 researchers prepared and submitted complete drafts of their policy briefs within two months after the training. Fewer (4) researchers revised and submitted final policy briefs. More than half of the trained researchers participated in the webinars conducted in the first three months of the mentorship, whereas less than half of the researchers participated in the webinars conducted in the last three months. KT training and mentorship can be an effective intervention for addressing researchers' KT capacity gaps. For sustainability, KT training and mentorship need to be integrated in graduate training programmes in universities so that future LMIC researchers leave training institutions with the KT capacities they need for influencing policy and programme decisions and actions.

'If not TB, what could it be?' Chest X-ray findings from the 2016 Kenya Tuberculosis Prevalence Survey.

BACKGROUND: The prevalence of diseases other than TB detected during chest X-ray (CXR) screening is unknown in sub-Saharan Africa. This represents a missed opportunity for identification and treatment of potentially significant disease. Our aim was to describe and quantify non-TB abnormalities identified by TB-focused CXR screening during the 2016 Kenya National TB Prevalence Survey. METHODS: We reviewed a random sample of 1140 adult (≥15 years) CXRs classified as 'abnormal, suggestive of TB' or 'abnormal other' during field interpretation from the TB prevalence survey. Each image was read (blinded to field classification and study radiologist read) by two expert radiologists, with images classified into one of four major anatomical categories and primary radiological findings. A third reader resolved discrepancies. Prevalence and 95% CIs of abnormalities diagnosis were estimated. FINDINGS: Cardiomegaly was the most common non-TB abnormality at 259 out of 1123 (23.1%, 95% CI 20.6% to 25.6%), while cardiomegaly with features of cardiac failure occurred in 17 out of 1123 (1.5%, 95% CI 0.9% to 2.4%). We also identified chronic pulmonary pathology including suspected COPD in 3.2% (95% CI 2.3% to 4.4%) and non-specific patterns in 4.6% (95% CI 3.5% to 6.0%). Prevalence of active-TB and severe post-TB lung changes was 3.6% (95% CI 2.6% to 4.8%) and 1.4% (95% CI 0.8% to 2.3%), respectively. INTERPRETATION: Based on radiological findings, we identified a wide variety of non-TB abnormalities during population-based TB screening. TB prevalence surveys and active case finding activities using mass CXR offer an opportunity to integrate disease screening efforts. FUNDING: National Institute for Health Research (IMPALA-grant reference 16/136/35).

Community interventions in Low-And Middle-Income Countries to inform COVID-19 control implementation decisions in Kenya: A rapid systematic review.

Globally, public health measures like face masks, hand hygiene and maintaining social distancing have been implemented to delay and reduce local transmission of COVID-19. To date there is emerging evidence to provide effectiveness and compliance to intervention measures on COVID-19 due to rapid spread of the disease. We synthesized evidence of community interventions and innovative practices to mitigate COVID-19 as well as previous respiratory outbreak infections which may share some aspects of transmission dynamics with COVID-19. In the study, we systematically searched the literature on community interventions to mitigate COVID-19, SARS (severe acute respiratory syndrome), H1N1 Influenza and MERS (middle east respiratory syndrome) epidemics in PubMed, Google Scholar, World Health Organization (WHO), MEDRXIV and Google from their inception until May 30, 2020 for up-to-date published and grey resources. We screened records, extracted data, and assessed risk of bias in duplicates. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO (CRD42020183064). Of 41,138 papers found, 17 studies met the inclusion criteria in various settings in Low- and Middle-Income Countries (LMICs). One of the papers from LMICs originated from Africa (Madagascar) with the rest from Asia 9 (China 5, Bangladesh 2, Thailand 2); South America 5 (Mexico 3, Peru 2) and Europe 2 (Serbia and Romania). Following five studies on the use of face masks, the risk of contracting SARS and Influenza was reduced OR 0.78 and 95% CI = 0.36-1.67. Equally, six studies on hand hygiene practices reported a reduced risk of contracting SARS and Influenza OR 0.95 and 95% CI = 0.83-1.08. Further two studies that looked at combined use of face masks and hand hygiene interventions showed the effectiveness in controlling the transmission of influenza OR 0.94 and 95% CI = 0.58-1.54. Nine studies on social distancing intervention demonstrated the importance of physical distance through closure of learning institutions on the transmission dynamics of disease. The evidence confirms the use of face masks, good hand hygiene and social distancing as community interventions are effective to control the spread of SARS and influenza in LMICs. However, the effectiveness of community interventions in LMICs should be informed by adherence of the mitigation measures and contextual factors taking into account the best practices. The study has shown gaps in adherence/compliance of the interventions, hence a need for robust intervention studies to better inform the evidence on compliance of the interventions. Nevertheless, this rapid review of currently best available evidence might inform interim guidance on similar respiratory infectious diseases like Covid-19 in Kenya and similar LMIC context.

Study protocol: analysis of regional lung health policies and stakeholders in Africa.

BACKGROUND: Lung health is a critical area for research in sub-Saharan Africa. The International Multidisciplinary Programme to Address Lung Health and TB in Africa (IMPALA) is a collaborative programme that seeks to fill evidence gaps to address high-burden lung health issues in Africa. In order to generate demand for and facilitate use of IMPALA research by policy-makers and other decision-makers at the regional level, an analysis of regional lung health policies and stakeholders will be undertaken to inform a programmatic strategy for policy engagement. METHODS AND ANALYSIS: This analysis will be conducted in three phases. The first phase will be a rapid desk review of regional lung health policies and stakeholders that seeks to understand the regional lung health policy landscape, which issues are prioritised in existing regional policy, key regional actors, and opportunities for engagement with key stakeholders. The second phase will be a rapid desk review of the scientific literature, expanding on the work in the first phase by looking at the external factors that influence regional lung health policy, the ways in which regional bodies influence policy at the national level, investments in lung health, structures for discussion and advocacy, and the role of evidence at the regional level. The third phase will involve a survey of IMPALA partners and researchers as well as interviews with key regional stakeholders to further shed light on regional policies, including policy priorities and gaps, policy implementation status and challenges, stakeholders, and platforms for engagement and promoting uptake of evidence. DISCUSSION: Health policy analysis provides insights into power dynamics and the political nature of the prioritisation of health issues, which are often overlooked. In order to ensure the uptake of new knowledge and evidence generated by IMPALA, it is important to consider these complex factors.

Review of published evidence on knowledge translation capacity, practice and support among researchers and research institutions in low- and middle-income countries.

BACKGROUND: Knowledge translation (KT) is a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to yield beneficial outcomes for society. Effective KT requires researchers to play an active role in promoting evidence uptake. This paper presents a systematised review of evidence on low- and middle-income country (LMIC) researchers' KT capacity, practice and interventions for enhancing their KT practice (support) with the aim of identifying gaps and informing future research and interventions. METHODS: An electronic search for peer-reviewed publications focusing on LMIC researchers' KT capacity, practice and support across all academic fields, authored in English and from the earliest records available to February 2019, was conducted using PubMed and Scopus. Selected studies were appraised using the Mixed Methods Appraisal Tool, data pertaining to publication characteristics and study design extracted, and an a priori thematic analysis of reported research findings completed. RESULTS: The search resulted in 334 screened articles, of which 66 met the inclusion criteria. Most (n = 43) of the articles presented original research findings, 22 were commentaries and 1 was a structured review; 47 articles reported on researchers' KT practice, 12 assessed the KT capacity of researchers or academic/research institutions and 9 reported on KT support for researchers. More than half (59%) of the articles focused on sub-Saharan Africa and the majority (91%) on health research. Most of the primary studies used the case study design (41%). The findings suggest that LMIC researchers rarely conduct KT and face a range of barriers at individual and institutional levels that limit their KT practice, including inadequate KT knowledge and skills, particularly for communicating research and interacting with research end-users, insufficient funding, and inadequate institutional guidelines, structures and incentives promoting KT practice. Furthermore, the evidence-base on effective interventions for enhancing LMIC researchers' KT practice is insufficient and largely of weak quality. CONCLUSIONS: More high-quality research on researchers' KT capacity, practice and effective KT capacity strengthening interventions is needed. Study designs that extend beyond case studies and descriptive studies are recommended, including better designed evaluation studies, e.g. use of realist approaches, pragmatic trials, impact evaluations, implementation research and participatory action research.

Strengthening capacity to use research evidence in health sector policy-making: experience from Kenya and Malawi.

BACKGROUND: Among the many barriers to evidence use in decision-making, weak capacity for evidence use has attracted a lot of focus in the last decade. The study aims to inform and enrich ongoing and future efforts to strengthen capacity for evidence use by presenting and discussing the experiences and lessons of a project implemented in Kenya and Malawi to strengthen individual and institutional capacity for evidence use within the ministries of health (MoHs). METHODS: This paper draws on the internal and external evaluations of a 3-year project funded by the United Kingdom's Department for International Development, the Strengthening Capacity to Use Research Evidence in Health Policy (SECURE Health). To strengthen individual capacity, the project implemented a training and mentorship programme for 60 mid-level policy-makers in the two MoHs. To strengthen institutional capacity, the project conducted sustained advocacy with top leaders to strengthen structures that enable evidence-informed decision-making (EIDM), supported Kenya to develop research-for-health policies and priorities, supported Malawi to review the implementation of its health research agenda, developed EIDM guidelines for both MoHs, and supported bi-annual evidence dialogues to improve interactions and raise the profile of evidence. Internal evaluation included baseline and endline surveys (93 baseline and 92 endline interviews), 60 in-depth interviews, and intervention-specific evaluations (pre-post tests for training workshops, feedback forms for policy dialogues and tracking effects of advocacy efforts). The external evaluation was implemented alongside project implementation, conducting three annual evaluations. RESULTS: The results show that training and mentorship programmes in EIDM were effective in improving competencies of civil servants. However, such programmes need to train a critical mass to be effective in enhancing EIDM practice at the MoHs. On strengthening institutional capacity for EIDM, while the project achieved some success, it did not realise long-lasting effects because of its limited time of implementation and limited focus on sustained political economy analysis, which meant that the intervention was negatively affected by frequently changing interests within the MoHs. CONCLUSIONS: Although training and mentorship are effective in improving EIDM competencies, they need to be incorporated in existing pre-service and in-service training programmes for sustainability. Strengthening institutional capacity for evidence use is complex and needs sustained political commitment and long-term investments.

The Kenyan national response to internationally agreed sexual and reproductive health and rights goals: a case study of three policies.

While priorities for, and decision-making processes on, sexual and reproductive health and rights have been determined and led mainly at the international level, conflicting power dynamics and responses at the national level in some countries have continued to pose challenges for operationalising international agreements. This paper demonstrates how these conflicts have played out in Kenya through an analysis of three policy-making processes, which led to the Adolescent Reproductive Health and Development Policy (2003), the Sexual Offences Act (2006), and the National Reproductive Health Policy (2007). The paper is based on data from a broader study on the drivers and inhibitors of sexual and reproductive health policy reform in Kenya, using a qualitative, case study design. Information was gathered through 54 semi-structured, in-depth interviews with governmental and civil society policy actors and an extensive review of policy documents and media reports. The paper shows that the transformative human rights framing of access to sexual and reproductive health, supported by both a strong global women's rights movement and progressive governmental and inter-governmental actors to defeat opposition to sexual and reproductive health and rights at the international level, has not been as influential or successful at the national level in Kenya, and has made comprehensive national reforms difficult to achieve.

Engaging media in communicating research on sexual and reproductive health and rights in sub-Saharan Africa: experiences and lessons learned.

BACKGROUND: The mass media have excellent potential to promote good sexual and reproductive health outcomes, but around the world, media often fail to prioritize sexual and reproductive health and rights issues or report them in an accurate manner. In sub-Saharan Africa media coverage of reproductive health issues is poor due to the weak capacity and motivation for reporting these issues by media practitioners. This paper describes the experiences of the African Population and Health Research Center and its partners in cultivating the interest and building the capacity of the media in evidence-based reporting of reproductive health issues in sub-Saharan Africa. METHODS: The paper utilizes a case study approach based primarily on the personal experiences and reflections of the authors (who played a central role in developing and implementing the Center's communication and policy engagement strategies), a survey that the Center carried out with science journalists in Kenya, and literature review. RESULTS: The African Population and Health Research Center's media strategy evolved over the years, moving beyond conventional ways of communicating research through the media via news releases and newspaper stories, to varying approaches that sought to inspire and build the capacity of journalists to do evidence-based reporting of reproductive health issues. Specifically, the approach included 1) enhancing journalists' interest in and motivation for reporting on reproductive health issues through training and competitive grants for outstanding reporting ; 2) building the capacity of journalists to report reproductive health research and the capacity of reproductive health researchers to communicate their research to media through training for both parties and providing technical assistance to journalists in obtaining and interpreting evidence; and 3) establishing and maintaining trust and mutual relationships between journalists and researchers through regular informal meetings between journalists and researchers, organizing field visits for journalists, and building formal partnerships with professional media associations and individual journalists. CONCLUSION: Our experiences and reflections, and the experiences of others reviewed in this paper, indicate that a sustained mix of strategies that motivate, strengthen capacity of, and build relationships between journalists and researchers can be effective in enhancing quality and quantity of media coverage of research.

Operationalising sexual and reproductive health and rights in sub-Saharan Africa: constraints, dilemmas and strategies.

BACKGROUND: The continued poor sexual and reproductive health (SRH) outcomes in sub-Saharan Africa highlight the difficulties in reforming policies and laws, and implementing effective programmes. This paper uses one international and two national case studies to reflect on the challenges, dilemmas and strategies used in operationalising sexual and reproductive health and rights (SRHR) in different African contexts. METHODS: The international case study focuses on the progress made by African countries in implementing the African Union's Maputo Plan of Action (for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights) and the experiences of state and non-state stakeholders in this process. The case was developed from an evaluation report of the progress made by nine African countries in implementing the Plan of Action, qualitative interviews exploring stakeholders' experiences and perceptions of the operationalisation of the plan (carried out as part of the evaluation) in Botswana and Nigeria, and authors' reflections. The first national case study explores the processes involved in influencing Ghana's Domestic Violence Act passed in 2007; developed from a review of scientific papers and organisational publications on the processes involved in influencing the Act, qualitative interview data and authors' reflections. The second national case study examines the experiences with introducing the 2006 Sexual Offences Act in Kenya, and it is developed from organisational publications on the processes of enacting the Act and a review of media reports on the debates and passing of the Act. RESULTS: Based on the three cases, we argue that prohibitive laws and governments' reluctance to institute and implement comprehensive rights approaches to SRH, lack of political leadership and commitment to funding SRHR policies and programmes, and dominant negative cultural framing of women's issues present the major obstacles to operationalising SRH rights. Analysis of successes points to the strategies for tackling these challenges, which include forming and working through strategic coalitions, employing strategic framing of SRHR issues to counter opposition and gain support, collaborating with government, and employing strategic opportunism. CONCLUSION: The strategies identified show future pathways through which challenges to the realisation of SRHR in Africa can be tackled.

Provision and use of maternal health services among urban poor women in Kenya: what do we know and what can we do?

In sub-Saharan Africa, the unprecedented population growth that started in the second half of the twentieth century has evolved into unparalleled urbanization and an increasing proportion of urban dwellers living in slums and shanty towns, making it imperative to pay greater attention to the health problems of the urban poor. In particular, urgent efforts need to focus on maternal health. Despite the lack of reliable trend data on maternal mortality, some investigators now believe that progress in maternal health has been very slow in sub-Saharan Africa. This study uses a unique combination of health facility- and individual-level data collected in the slums of Nairobi, Kenya to: (1) describe the provision of obstetric care in the Nairobi informal settlements; (2) describe the patterns of antenatal and delivery care, notably in terms of timing, frequency, and quality of care; and (3) draw policy implications aimed at improving maternal health among the rapidly growing urban poor populations. It shows that the study area is deprived of public health services, a finding which supports the view that low-income urban residents in developing countries face significant obstacles in accessing health care. This study also shows that despite the high prevalence of antenatal care (ANC), the proportion of women who made the recommended number of visits or who initiated the visit in the first trimester of pregnancy remains low compared to Nairobi as a whole and, more importantly, compared to rural populations. Bivariate analyses show that household wealth, education, parity, and place of residence were closely associated with frequency and timing of ANC and with place of delivery. Finally, there is a strong linkage between use of antenatal care and place of delivery. The findings of this study call for urgent attention by Kenya's Ministry of Health and local authorities to the void of quality health services in poor urban communities and the need to provide focused and sustained health education geared towards promoting use of obstetric services.