Can 3-dimensional cranial ultrasound be used to successfully reconstruct a 2-dimensional image without compromising on image quality in a neonatal population?

BACKGROUND: Cranial ultrasound is frequently performed in neonatal intensive care units and acquiring 2-dimensional (D) images requires significant training. Three-D ultrasound images can be acquired semi-automatically. OBJECTIVE: This proof-of-concept study aimed to demonstrate that 3-D study image quality compares well with 2-D. If this is successful, 3-D images could be acquired in remote areas and read remotely by experts. MATERIALS AND METHODS: This was a prospective study of 20 neonates, who underwent both routine 2-D and 3-D cranial ultrasounds. Images were reconstructed into standard views extracted from the 3-D volume and evaluated by three radiologists blinded to the acquisition method. The radiologists assessed for the presence of anatomical landmarks and overall image quality. RESULTS: More anatomical structures were identified in the 3-D studies (P<0.01). There was a trend that 3-D ultrasound demonstrated better image quality in the coronal plane, and 2-D in the sagittal plane, only reaching statistical significance for two coronal views and two sagittal views. CONCLUSION: Overall, this study has demonstrated that 3-D cranial ultrasound performs similarly to 2-D and could be implemented into neonatal practice.

Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 in spite of an increase in health services utilisation: Examining data from three large cross-sectional surveys.

Background: After a 40% reduction in maternal mortality ratio (MMR) during 2001-2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001-2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh. Methods: We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001-2010 and 2010-2016. We carried out Poisson regression analyses with random effects at the sub-district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors. Results: Between 2001 and 2016, the proportion of high-risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001-2010 and 2010-2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010-2016, increasing the risk of maternal deaths by nearly 3-fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001-2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010-2016. Conclusions: Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at-risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.

Contraceptive Behavior Dynamics and Unintended Pregnancy: A Latent Transition Analysis.

The average U.S. woman wants to have two children; to do so, she will spend about three years pregnant, postpartum, or trying to become pregnant, and three decades trying to avoid pregnancy. However, few studies have examined individual patterns of contraceptive use over time. These trajectories are important to understand given the high rate of unintended pregnancy and how little we know about the complex relationship between contraceptive use, pregnancy intention, and patterns of reproductive behavior. We use data from the 2015-2017 National Survey of Family Growth to examine reproductive behavior and pregnancies across three years of calendar data. We identify seven behavior typologies, their prevalence, how women transition between them, and how pregnancies affect transitions. At any given time, half of women are reliably using contraception. A small proportion belong to a high pregnancy risk profile of transient contraceptive users, but some transition to using condoms or other methods consistently. An unintended pregnancy may initiate a transition into stable contraceptive use for some women, although that is primarily condom use. These findings have important implications for the ways contraception fits into women's lives and how that behavior interacts with relationships, sex, and life stage trajectories.

Influence of family planning and immunization services integration on contraceptive use and family planning information and knowledge among clients: A cross-sectional analysis in urban Nigeria.

Reproductive autonomy necessitates that women have access to high quality family planning information and services. Additionally, closely spaced pregnancies increase maternal and infant morbidity and mortality. Although integrating family planning into child immunization services may increase access to information and services and postpartum contraceptive use, evidence on how integration affects service delivery and health outcomes is scarce. One limitation of previous studies is the use of binary integration measures. To address this limitation, this study applied Provider and Facility Integration Index scores to estimate associations between integration and contraceptive use, receipt of family planning information, and knowledge of family planning services availability. This study leveraged pooled cross-sectional health facility client exit interview data collected from 2,535 women in Nigeria. Provider and Facility Integration Index scores were calculated (0-10, 0 = low, 10 = high) for each facility (N = 94). The Provider Integration Index score measures provider skills and practices that support integrated service delivery; the Facility Integration Index score measures facility norms that support integrated service delivery. Logistic regression models identified associations between Provider and Facility Integration Index scores and (a) contraceptive use among postpartum women, (b) receipt of family planning information during immunization visits, and (c) correct identification of family planning service availability. Overall, 46% of women were using any method of contraception, 51% received family planning information during the immunization appointment, and 83% correctly identified family planning service availability at the facility. Mean Provider and Facility Integration Index scores were 6.46 (SD = 0.21) and 7.27 (SD = 0.18), respectively. Provider and Facility Integration Index scores were not significantly associated with postpartum contraceptive use. Facility Integration Index scores were negatively associated with receipt of family planning information. Provider Integration Index scores were positively associated with correct identification of family planning service availability. Our results challenge the position that integration provides a clear path to improved outcomes. The presence of facility and provider attributes that support integration may not result in the delivery of integrated care.

In Vivo Measurements of the Bulk Ultrasonic Attenuation Coefficient of Breast Tissue Using a Novel Phase-Insensitive Receiver.

This study describes the first in vivo acoustic attenuation measurements of breast tissue undertaken using a novel phase-insensitive detection technique employing a differential pyroelectric sensor. The operation of the sensor is thermal in nature, with its output signal being dictated by the acoustic power integrated over its surface. The particularly novel feature of the sensor lies in its differential principle of operation, which significantly enhances its immunity to background acoustic and vibration noise. A large area variant of the sensor was used to detect ultrasonic energy generated by an array of 14 discrete 3.2-MHz plane piston transducers, transmitted through pendent breasts in water. The transduction and reception capability represent key parts of a prototype Quantitative Ultrasound Computed Tomography Test Facility developed at the National Physical Laboratory to study the efficacy of phase-insensitive ultrasound computed tomography of breast phantoms containing a range of appropriate inclusions, in particular, the measurement uncertainties associated with quantitative reconstructions of the acoustic attenuation coefficient. For this study, attenuation coefficient measurements were made using 1-D projections on 12 nominally healthy study volunteers, whose age ranged from 19 to 65 years. Averaged or bulk attenuation coefficient values were generated in the range 1.7-4.6 dBcm -1 at 3.2 MHz and have been compared with existing literature, derived from in vivo and ex vivo studies. Results are encouraging and indicate that the relatively simple technique could be applied as a robust method for assessing the properties of breast tissue, particularly the balance of fatty (adipose) and fibroglandular components.

Obstetric fistula in Bangladesh: estimates from a national survey with clinical validation correction.

BACKGROUND: Obstetric fistula, which develops after a prolonged or obstructed labour, is preventable and treatable. However, many women are still afflicted with the condition and remain untreated in low-income and middle-income countries. Concerns have also been raised that an increasing trend of caesarean sections is increasing the risk and share of iatrogenic obstetric fistula in these countries. The true prevalence of this condition is not known, which makes it difficult for health planners and policy makers to develop appropriate national health strategies to address the problem. The estimation of obstetric fistula with surveys is difficult because self-reporting of incontinence symptoms is subject to misclassification bias. In this study, we aimed to estimate the prevalence and burden of obstetric fistula in Bangladesh. METHODS: For a valid estimation addressing misclassification bias, we implemented the study in two steps. First, we did the Maternal Morbidity Validation Study (MMVS) among a population of 65 740 women in Sylhet, Bangladesh, to assess the sensitivity, specificity, positive predictive values (PPVs), and negative predictive values of the survey questions. This was done through confirmation of the diagnosis with clinical examinations of suspected cases by female physicians; a sample of women who screened positive for pelvic organ prolapse and other urinary incontinence symptoms were also examined and used as controls for clinical diagnosis confirmation. Second, we used the estimated diagnostic test values, after correcting for verification bias, to adjust the reported prevalence in the nationally representative Bangladesh Maternal Mortality and Health Care Survey 2016 for the unbiased estimation of obstetric fistula prevalence in Bangladesh. FINDINGS: The MMVS, done from Aug 3 to Dec 9, 2016, identified 67 potential cases of obstetric fistula; of them, 57 (85%) women completed the clinical examination, and 19 were confirmed as obstetric fistula cases. The adjusted sensitivity of the self-reports of obstetric fistula was 100% (95% uncertainty interval [UI] 99·8-100) and the observed specificity was 99·9% (95% UI 99·9-100) among women aged 15-49 years. However, the PPV was low, at 31·6% (95% UI 19·2-46·2), suggesting that almost two thirds of the self-reported cases were not true obstetric fistula cases. We estimated an adjusted obstetric fistula prevalence rate of 38 (90% UI 25-58) per 100 000 women aged 15-49 years in Bangladesh. Nationally, we estimated about 13 376 (90% UI 8686-20 112) women of reproductive age living with obstetric fistula. Additionally, we estimated 4081 (1773-8790) women aged 50-64 years to be living with obstetric fistula in Bangladesh; overall, we estimated that there are 17 457 (10 459-28 902) women aged 15-64 years in Bangladesh with obstetric fistula. INTERPRETATION: The burden of obstetric fistula is still high in Bangladesh. Prevention and provision of surgical treatment to so many women will need coordinated efforts, planning, allocation of resources, and training of surgeons. FUNDING: US Agency for International Development, Government of Bangladesh, and UKAid.

A comparison of approaches to measuring maternal mortality in Bangladesh, Mozambique, and Bolivia.

BACKGROUND: Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality. OBJECTIVE: The objective is to inform on potential options for measuring maternal mortality. METHODS: This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia-national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS). RESULTS: For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS' MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998-2003. CONCLUSIONS: Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches. CONTRIBUTION: Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

Exploring association between place of delivery and newborn care with early-neonatal mortality in Bangladesh.

OBJECTIVE: Bangladesh achieved the fourth Millennium Development Goal well ahead of schedule, with a significant reduction in under-5 mortality between 1990 and 2015. However, the reduction in neonatal mortality has been stagnant in recent years. The purpose of this study is to explore the association between place of delivery and newborn care with early neonatal mortality (ENNM), which represents more than 80% of total neonatal mortality in Bangladesh. METHODS: In this study, 2014 Bangladesh Demographic and Health Survey data were used to assess early neonatal survival in children born in the three years preceding the survey. The roles of place of the delivery and newborn care in ENNM were examined using multivariable logistic regression models adjusted for clustering and relevant socio-economic, pregnancy, and newborn characteristics. RESULTS: Between 2012 and 2014, there were 4,624 deliveries in 17,863 sampled households, 39% of which were delivered at health facilities. The estimated early neonatal mortality rate during this period was 15 deaths per 1,000 live births. We found that newborns who had received at least 3 components of essential newborn care (ENC) were 56% less likely to die during the first seven days of their lives compared to their counterparts who received 0-2 components of ENC (aOR: 0.44; 95% CI: 0.24-0.81). In addition, newborns who had received any postnatal care (PNC) were 68% less likely to die in the early neonatal period than those who had not received any PNC (aOR: 0.32; 95% CI: 0.16-0.64). Facility delivery was not significantly associated with the risk of early newborn death in any of the models. CONCLUSION: Our study findings highlight the importance of newborn and postnatal care in preventing early neonatal deaths. Further, findings suggest that increasing the proportion of women who give birth in a healthcare facility is not sufficient to reduce ENNM by itself; to realize the theoretical potential of facility delivery to avert neonatal deaths, we must also ensure quality of care during delivery, guarantee all components of ENC, and provide high-quality early PNC. Therefore, sustained efforts to expand access to high-quality ENC and PNC are needed in health facilities, particularly in facilities serving low-income populations.

Assessing the Reliability of the Retrospective Reproductive Calendar: Evidence from Urban Kenya.

The reproductive calendar is a data collection tool that collects month-by-month retrospective histories of contraceptive use. This survey instrument is implemented in large-scale demographic surveys, but its reliability is not well-understood. Our analysis helps to address this research gap, using longitudinal panel data with overlapping calendars from urban Kenya. Our findings indicate calendar data collected in 2014 underestimated 2012 reports of current use by 5 percentage points. And while the overall percentage of women reporting at least one episode of contraceptive use was similar across the two calendars (67 percent vs. 70 percent), there was notable disagreement in contraceptive behavior when comparing the histories of individual women; less than 20 percent of women with any contraceptive use reported the exact same pattern of use in both calendars. Low calendar reliability was especially apparent for younger women and those with complicated contraceptive histories. Individual-level discordance resulted in a small difference in 12-month discontinuation rates for the period of calendar overlap; when surveyed in 2014, women reported a 12-month discontinuation rate of 39 percent, compared to a rate of 34 percent reported in 2012. When using retrospective calendar data, attention must be paid to the potential for individual reporting errors.

Facility-level characteristics associated with family planning and child immunization services integration in urban areas of Nigeria: a longitudinal analysis.

BACKGROUND: Unmet need for postpartum contraception is high. Integration of family planning with routine child immunization services may help to satisfy unmet need. However, evidence about the determinants and effects of integration has been inconsistent, and more evidence is required to ascertain whether and how to invest in integration. In this study, facility-level family planning and immunization integration index scores are used to: (1) determine whether integration changes over time and (2) identify whether facility-level characteristics, including exposure to the Nigerian Urban Reproductive Health Initiative (NURHI), are associated with integration across facilities in six urban areas of Nigeria. METHODS: This study utilizes health facility data collected at baseline (n = 400) and endline (n = 385) for the NURHI impact evaluation. Difference-in-differences models estimate the associations between facility-level characteristics, including exposure to NURHI, and Provider and Facility Integration Index scores. The two outcome measures, Provider and Facility Integration Index scores, reflect attributes that support integrated service delivery. These indexes, which range from 0 (low) to 10 (high), were constructed using principal component analysis. Scores were calculated for each facility. Independent variables are (1) time period, (2) whether the facility received the NURHI intervention, and (3) additional facility-level characteristics. RESULTS: Within intervention facilities, mean Provider Integration Index scores were 6.46 at baseline and 6.79 at endline; mean Facility Integration Index scores were 7.16 (baseline) and 7.36 (endline). Within non-intervention facilities, mean Provider Integration Index scores were 5.01 at baseline and 6.25 at endline; mean Facility Integration Index scores were 5.83 (baseline) and 6.12 (endline). Provider Integration Index scores increased significantly (p = 0.00) among non-intervention facilities. Facility Integration Index scores did not increase significantly in either group. Results identify facility-level characteristics associated with higher levels of integration, including smaller family planning client load, family planning training among providers, and public facility ownership. Exposure to NURHI was not associated with integration index scores. CONCLUSION: Programs aiming to increase integration of family planning and immunization services should monitor and provide targeted support for the implementation of a well-defined integration strategy that considers the influence of facility characteristics and concurrent initiatives.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria.

BACKGROUND: Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities. METHODS: This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high). RESULTS: Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high. CONCLUSION: Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

"If the Big Fish are Doing It Then Why Not Me Down Here?": Informal Fee Payments and Reproductive Health Care Provider Motivation in Kenya.

Informal fees are payments made by patients to their health care provider that are over and above the official cost of services. Payments may be motivated by a combination of factors such as low supervision, weak sanctions, and inadequate provider salaries. The practice of soliciting informal fees from patients may result in restricted access to medical care and reduced care-seeking behavior among vulnerable populations. The objective of this study is to examine nuanced health care provider perspectives on informal fee payments solicited from reproductive health patients in Kenya. We conducted in-depth semistructured interviews in 2015-2016 among a sample of 20 public and private-sector Kenyan health care workers. Interviews were coded and analyzed using an iterative thematic approach. More than half of participants reported that solicitation of informal fees is common practice in health care facilities. Providers reported low public-sector wages were a primary driver of informal fee solicitation coupled with collusion among senior staff. Additionally, patients may be unaware that they are being asked to pay more than the official cost of services. Strategies for reducing this behavior include more adequate and timely remuneration within the public sector, educating patient populations of free or low-cost services, and evidence-based methods to increase provider motivation.

A study of the clinical, treatment planning and dosimetric feasibility of dose painting in external beam radiotherapy of prostate cancer.

BACKGROUND AND PURPOSE: Radiotherapy dose painting is a promising technique which enables dose escalation to areas of higher tumour cell density within the prostate which are associated with radioresistance, known as dominant intraprostatic lesions (DILs). The aim of this study was to determine factors affecting the feasibility of radiotherapy dose painting in patients with high and intermediate risk prostate cancer. MATERIALS & METHODS: Twenty patients were recruited into the study for imaging using a 3 T magnetic resonance imaging (MRI) scanner. Identified DILs were outlined and the scan registered with the planning computed tomography (CT) dataset. Intensity-modulated plans were produced and evaluated to determine the effect of the organ-at-risk constraints on the dose that could be delivered to the DILs. Measurements were made to verify that the distribution could be safely delivered. RESULTS: MRI scans were obtained for nineteen patients. Fourteen patients had one to two DILs with ten overlapping the urethra and/or rectum. The target boost of 86 Gy was achieved in seven plans but was limited to 80 Gy for five patients whose boost volume overlapped or abutted the urethra. Dosimetric measurements gave a satisfactory gamma pass rate at 3%/3 mm. CONCLUSIONS: It was feasible to produce dose-painted plans for a boost of 86 Gy for approximately half the patients with DILs. The main limiting factor was the proximity of the urethra to the boost volumes. For a small proportion of patients, rigid registration between CT and MRI images was not adequate for planning purposes.

Women's Perspectives on Contraceptive-Induced Amenorrhea in Burkina Faso and Uganda.

CONTEXT: Women's concerns about contraceptive-induced menstrual changes can lead to method discontinuation and nonuse, contributing to unmet need for contraception. Research on women's perceptions of amenorrhea related to longer acting methods and in low-income countries is limited. METHODS: Data were from nationally representative household surveys and focus group discussions with women of reproductive age conducted in Burkina Faso and Uganda in 2016-2017. Bivariate cross-tabulations and multivariate logistic regression analyses were used to examine sociodemographic and reproductive characteristics associated with women's attitudes about contraceptive-induced amenorrhea (n=2,673 for Burkina Faso and 2,281 for Uganda); menstrual health determinants were also examined for Burkina Faso. Qualitative data from focus group discussions were analyzed to understand reasons behind women's attitudes and how they influence contraceptive decision making. RESULTS: Sixty-five percent of women in Burkina Faso and 40% in Uganda reported they would choose a method that caused amenorrhea during use. In Burkina Faso, the predicted probability of accepting amenorrhea was higher for women aged 15-19 (compared with older women), living in rural areas, married and cohabiting (compared with never married), currently using a contraceptive method (compared with never users) and from Mossi households (compared with Gourmantché); menstrual health practices were not associated with amenorrhea acceptability. In Uganda, the least wealthy women had the highest predicted probability of accepting amenorrhea (51%). Qualitative analysis revealed a variety of reasons for women's attitudes about amenorrhea and differences by country, but the relationship between these attitudes and contraceptive decision making was similar across countries. CONCLUSIONS: Addressing misconceptions about contraception and menstruation may result in more informed method decision making.

Contexto: Las preocupaciones de las mujeres acerca de los cambios menstruales inducidos por los anticonceptivos pueden conducir a la interrupción y el abandono del método, lo cual contribuye a la necesidad insatisfecha de anticoncepción. La investigación sobre la percepción de la amenorrea por parte de las mujeres sobre los métodos de acción más prolongada y en los países de bajos ingresos es limitada. Métodos: Los datos provienen de encuestas representativas de hogares a nivel nacional y discusiones de grupos focales con mujeres en edad reproductiva realizadas en Burkina Faso y Uganda entre 2016 y 2017. Se utilizaron tabulaciones cruzadas bivariadas y análisis de regresión logística multivariada para examinar las características sociodemográficas y reproductivas asociadas con las actitudes de las mujeres con respecto a la amenorrea inducida por anticonceptivos (n = 2,673 para Burkina Faso y 2,281 para Uganda); también se examinaron los determinantes de la salud menstrual en Burkina Faso. Se analizaron datos cualitativos de discusiones de los grupos focales para comprender las razones que determinan las actitudes de las mujeres y cómo influyen en la toma de decisiones sobre anticonceptivos. Resultados: El 65% de las mujeres en Burkina Faso y el 40% en Uganda informaron que elegirían un método que les causara amenorrea durante su uso. En Burkina Faso, la probabilidad predicha de aceptar la amenorrea fue mayor para las mujeres de 15 a 19 años (en comparación con las mujeres mayores), que vivían en zonas rurales, que estaban casadas y cohabitaban (en comparación con las que nunca se habían casado), que actualmente usaban un método anticonceptivo (en comparación con las mujeres que nunca lo habían usado) y de hogares Mossi (en comparación con Gourmantché). Las prácticas de salud menstrual no se asociaron con la aceptabilidad de la amenorrea. En Uganda, las mujeres menos ricas tuvieron la probabilidad más alta de aceptar amenorrea (51%). El análisis cualitativo reveló una variedad de razones con respecto a las actitudes de las mujeres sobre la amenorrea y las diferencias por país, pero la relación entre estas actitudes y la toma de decisiones sobre anticonceptivos fue similar en todos los países. Conclusiones: El abordaje de los conceptos erróneos sobre la anticoncepción y la menstruación podría resultar en una toma de decisiones más informada sobre los métodos anticonceptivos.

Contexte: Les inquiétudes des femmes à l'égard des changements menstruels induits par la contraception peuvent conduire à l'arrêt ou à la non-utilisation de la méthode et contribuer ainsi au besoin non satisfait de contraception. La recherche sur les perceptions des femmes de l'aménorrhée liée aux méthodes à durée d'action prolongée et dans les pays à revenu faible est limitée. Méthodes: Les données sont extraites d'enquêtes de ménage nationalement représentatives et de discussions de groupe avec des femmes en âge de procréer, menées au Burkina Faso et en Ouganda en 2016-2017. Les caractéristiques sociodémographiques et reproductives associées aux attitudes des femmes concernant l'aménorrhée induite par la contraception (n=2 673 pour le Burkina Faso et 2 281 pour l'Ouganda) ont été examinées en tableaux croisés bivariés et par analyses de régression logistique multivariée. Les déterminants de la santé menstruelle ont aussi été examinés pour le Burkina Faso. L'analyse des données qualitatives obtenues des discussions de groupe a permis de cerner les raisons à la base des attitudes des femmes et leur influence sur les décisions contraceptives prises. Résultats: Soixante-cinq pour cent des femmes burkinabè et 40% de leurs homologues ougandaises ont déclaré qu'elles choisiraient une méthode dont la pratique causerait l'aménorrhée. Au Burkina Faso, la probabilité prédite d'acceptation de l'aménorrhée s'est avérée supérieure pour les femmes âgées de 15 à 19 ans (par rapport à leurs aînées), vivant en milieu rural, mariées ou en union (par rapport à celles qui n'avaient jamais été mariées), pratiquant actuellement la contraception (par rapport à celles qui ne l'avaient jamais pratiquée) et d'origine Mossi (par rapport à Gourmantché). Les pratiques de santé menstruelle n'étaient pas associées à l'acceptabilité de l'aménorrhée. En Ouganda, les femmes les moins riches sont associées à la plus haute probabilité prédite d'acceptation de l'aménorrhée (51%). L'analyse qualitative a révélé diverses raisons à la base des attitudes des femmes à l'égard de l'aménorrhée ainsi que certaines différences suivant le pays, mais la relation entre ces attitudes et la décision contraceptive s'est avérée similaire dans les deux pays. Conclusions: La résolution des idées fausses concernant la contraception et la menstruation pourrait conduire à une prise de décision mieux éclairée dans le choix des méthodes.

Understanding healthcare provider absenteeism in Kenya: a qualitative analysis.

BACKGROUND: Healthcare worker absenteeism is common in resource limited settings and contributes to poor quality of care in maternal and child health service delivery. There is a dearth of qualitative information on the scope, contributing factors, and impact of absenteeism in Kenyan healthcare facilities. METHODS: In-depth semi-structured interviews were conducted between July 2015 and June 2016 with 20 healthcare providers in public and private healthcare facilities in Central and Western Kenya. Interviews were audio-recorded, transcribed, coded, and analyzed using an iterative thematic approach. RESULTS: Half of providers reported that absenteeism occurs in both private and public health facilities. Absenteeism was most commonly characterized by providers arriving late or leaving early during scheduled work hours. The practice was attributed to institutional issues including: infrequent supervision, lack of professional consequences, limited accountability, and low wages. In some cases, healthcare workers were frequently absent because they held multiple positions at different health facilities. Provider absences result in increased patient wait times and may deter patients from seeking healthcare in the future. CONCLUSION: There is a significant need for policies and programs to reduce provider absenteeism in Kenya. Intervention approaches must be cognizant of the contributors to absenteeism which occur at the institutional level.

Are community health workers effective in retaining women in the maternity care continuum? Evidence from India.

OBJECTIVES: Despite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the maternity care continuum has been limited. We use the example of the Accredited Social Health Activist (ASHA) programme in India, to understand the role of community health workers in retaining women in the maternity care continuum. METHODS: Using the Indian Human Development Survey data from 2011 to 2012, we assess the association between individual and cluster-level exposure to ASHA and four key components along the continuum of care-at least one antenatal care (ANC) visit, four or more ANC visits, presence of a skilled birth attendance (SBA) at the time of birth and postnatal care for the mother or child within 48 hours of birth, for 13 705 women with a live birth since 2005. To understand which of these services experience maximum dropout along the continuum, we use a linear probability model to calculate the weighted percentages of using each service. We assess the association between exposure to ASHA and number of services utilised using a multinomial logistic regression model adjusted for a range of confounding variables and survey weights. RESULTS: Our study indicates that exposure to the ASHA is associated with an increased probability of women receiving at least one ANC and SBA. In terms of numbers of services, exposure to ASHA accounts for a 12% (95% CI: 9.1 to 15.1) increase in women receiving at least some of the services, and an 8.8% (95% CI: -10.2 to -7.4) decrease in women receiving no services. However, exposure to ASHA does not increase the likelihood of women utilising all the services along the continuum. CONCLUSIONS: While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affect the completion of all services along the continuum.

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

BACKGROUND: In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. METHODS: We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. RESULTS: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI - 1.6-11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births. CONCLUSIONS: Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

What works best for ensuring treatment adherence. Lessons from a social support program for people treated for tuberculosis in Ukraine.

BACKGROUND: Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent. Ukraine is one of 30 countries with the highest burden of multidrug-resistant tuberculosis. Global literature shows that social support (SS) is important in improving TB treatment adherence, reducing lost to follow up rates and improving treatment outcomes. There are several models of SS available, and the literature provides little information on what aspects of SS are most important to TB patients in improving their adherence. METHODS: We used qualitative data collected through in-depth interviews (IDI) with 21 TB patients and 15 SS providers and coordinators in Ukraine in August-September 2016 to understand how the SS program promoted treatment adherence among patients. We examined the aspects of outpatient TB treatment that made adherence particularly difficult for patients in at-risk groups and aspects of the SS programs that worked best for addressing those barriers. Interviews were transcribed and analysis was performed to derive emergent themes. RESULTS: Main barriers included side effects from medicine, the amount of time required daily for transportation and waiting in lines at the health facility, transportation expenses, risks of being identified when visiting a TB facility and lack of motivation to seek treatment. Features of the SS program most valued by patients were convenience of not having to visit facility and support provided by nurses. These two features directly addressed most of the barriers identified. The commitment and qualities of the nurses that provided the SS was an important element of the program. CONCLUSIONS: This qualitative study suggests that the SS program in Ukraine was successful in reducing treatment default among patients at high risk of default because it directly addressed most of the major barriers they faced to treatment adherence.

Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study.

BACKGROUND: Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria. METHODS: Data were collected in 2010/2011 from 16,118 women aged 15-49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples' family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women's age, education, marital status, religion, parity, household wealth, and city of residence. RESULTS: The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples' family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women's demographic characteristics accounted for 55-61% of the variation between neighborhoods in the change in modern contraceptive use during the study period. CONCLUSION: Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.

Evaluating the impact of social support services on tuberculosis treatment default in Ukraine.

Ukraine is among the top 20 highest drug-resistant tuberculosis burden countries in the world. Driving the high drug-resistant tuberculosis rates is an unchecked treatment default rate. This evaluation measures the effect of social support provided to tuberculosis patients at risk of defaulting on treatment during outpatient treatment. Five tuberculosis patient cohorts, served in three oblasts from 2011 and 2012, were constructed from medical records to compare risk factors for default, receipt of social services, and treatment outcome. Regression analyses were used to identify risk factors predictive of treatment default and to estimate the impact of the social support program on treatment default, controlling for risk, disease status, and demographics. In 2012, tuberculosis patients receiving social support in Ukraine reduced their probability of defaulting on continuation treatment by 10 percentage points compared to high-risk patients who did not receive social support in 2012 or 2011. Treatment success rates for the high-risk patients receiving social support were comparable to the low-risk cohorts and significantly improved over the high-risk comparison cohorts. Further research is recommended to quantify the costs and benefits for scaling-up social support services, evaluate social support program fidelity, identify which populations respond best to select services, and what barriers might still exist to achieve better adherence. With that information, tailoring programs to most effectively reach and serve clients in a patient-centered approach may reap substantial rewards for Ukraine.