Women's experiences of care after stillbirth and obstetric fistula: A phenomenological study in Kenya.

BACKGROUND: Stillbirth and (obstetric) fistula are traumatic life events, commonly experienced together following an obstructed labour in low- and middle-income countries with limited access to maternity care. Few studies have explored women's experiences of the combined trauma of stillbirth and fistula. AIM: To explore the lived experiences of women following stillbirth and fistula. METHODS: Qualitative, guided by Heideggerian phenomenology. Twenty women who had experienced a stillbirth were interviewed while attending a specialist Hospital fistula service in urban Kenya. Data were analysed following Van Manen's reflexive approach. RESULTS: Three main themes summarised participants' experiences: 'Treated like an alien' reflected the isolation and stigma felt by women. The additive and multiplying impacts of stillbirth and fistula and the ways in which women coped with their situations were summarised in 'Shattered dreams'. The impact of beliefs and practices of women and those around them were encapsulated in 'It was not written on my forehead'. CONCLUSION: The distress women experienced following the death of a baby was intensified by the development of a fistula. Health professionals lacked an understanding of the pathophysiology and identification of fistula and its association with stillbirth. Women were isolated as they were stigmatised and blamed for both conditions. Difficulty accessing follow-up care meant that women suffered for long periods while living with a constant reminder of their baby's death. Cultural beliefs, faith and family support affected women's resilience, mental health and recovery. Specialist services, staff training and inclusive policies are needed to improve knowledge and awareness and enhance women's experiences. PATIENT OR PUBLIC CONTRIBUTION: A Community Engagement and Involvement group of bereaved mothers with lived experience of stillbirth and neonatal death assisted with the review of the study protocol, participant-facing materials and confirmation of findings.

'There is trauma all round': A qualitative study of health workers' experiences of caring for parents after stillbirth in Kenya and Uganda.

BACKGROUND: Stillbirth is a traumatic life-event for parents. Compassionate care from health workers supports grief and adjustment, alleviating psychological distress and minimising serious adverse health and social consequences. Bereavement support in facilities in LMICs, including in sub-Saharan Africa, often fails to meet parents' needs. However, very few studies have explored health worker's experiences in these settings. AIM: To explore the lived experiences of midwives, doctors and others, caring for women after stillbirth in Kenya and Uganda. METHODS: Qualitative, guided by Heideggerian phenomenology. Sixty-one health workers, including nurse-midwives (N = 37), midwives (N = 12) and doctors (N = 10), working in five facilities in Kenya and Uganda, were interviewed. Data were analysed following Van Manen's reflexive approach. RESULTS: Three main themes summarised participants' experiences: 'In the mud and you learn to swim in it' reflected a perceived of lack of preparation; skills were gained through experience and often without adequate support. The emotional and psychological impacts including sadness, frustration, guilt and shame were summarised in 'It's bad, it's a sad experience'. Deficiencies in organisational culture and support, which entrenched blame, fear and negative behaviours were encapsulated in Nobody asks 'how are you doing?'. CONCLUSION: Health workers in Kenya and Uganda were deeply sensitive to the impacts of stillbirth for women and families, and often profoundly and personally affected. Care and psychological support were acknowledged as often inadequate. Interventions to support improved bereavement care in sub-Saharan Africa need to target increasing health worker knowledge and awareness and also embed supportive organisational cultures and processes.

African midwifery students' self-assessed confidence in postnatal and newborn care: A multi-country survey.

BACKGROUND: Majority of maternal and new-born deaths occur within 28 hours and one week after birth. These can be prevented by well-educated midwives. Confidence in postnatal and newborn care skills depend on the quality of midwifery education. OBJECTIVE: To assess confidence and its associated factors for basic postnatal and new-born care skills of final year midwifery students , from seven African countries. METHODS: A multi-country cross-sectional study where final year midwifery students answered a questionnaire consisting of basic skills of postnatal and newborn care listed by the International Confederation of Midwives. The postnatal care area had 16 and newborn care area had 19 skill statements. The 16 skills of postnatal care were grouped into three domains through principle component analysis (PCA); Basic postnatal care; postnatal complications and educating parents and documentation. The 19 skills under the newborn care area were grouped into three domains; Basic care and care for newborn complications; Support parents for newborn care; and Care for newborns of HIV positive mothers and documentation. RESULTS: In total 1408 midwifery students from seven Sub-Saharan countries participated in the study namely; Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, and Somaliland Overall high confidence for all domains under Post Natal Care ranged from 30%-50% and for Newborn care from 39-55%. High confidence for postnatal skills was not found to be associated with any background variables (Age, sex, type and level of educational programme). High confidence for newborn care was associated with being female students, those aged 26-35 years, students from the direct entry programmes and those enrolled in diploma programmes. CONCLUSIONS: Almost half of the study participants expressed lack of confidence for skills under postnatal and newborn care. No association was found between high confidence for domains of postnatal care and background variables. High confidence was associated with being a female, between 26-35 years of age, from direct entry or diploma programmes for newborn care area. The results of the study indicate gaps in midwifery education. Countries could use the ICM list of competencies to develop country specific standards for midwifery education. However, actual competence remains to be measured.

The impact of cultural beliefs and practices on parents' experiences of bereavement following stillbirth: a qualitative study in Uganda and Kenya.

BACKGROUND: Stillbirth is an extremely traumatic and distressing experience for parents, with profound and long-lasting negative impacts. Cultural beliefs and practices surrounding death vary considerably across different contexts and groups, and are a key influence on individual experiences, impacting grief, adjustment, and support needs. Few studies have explored cultural influences surrounding stillbirth in an African context. This study explored the influence of cultural beliefs and practices on the experiences of bereaved parents and health workers after stillbirth in urban and rural settings in Kenya and Uganda. METHODS: A qualitative descriptive study design was employed. Face to face interviews were conducted with parents (N = 134) who experienced a stillbirth (≤ 1 year) and health workers (N = 61) at five facilities in Uganda and Kenya. Interviews were conducted in English or the participants' local language, audio-recorded and transcribed verbatim. Analysis was conducted using descriptive thematic analysis. RESULTS: Commonalities in cultural beliefs and practices existed across the two countries. Three main themes were identified: 1) Gathering round, describes the collective support parents received from family and friends after stillbirth. 2)'It is against our custom' addresses cultural constraints and prohibitions impacting parents' behaviour and coping in the immediate aftermath of the baby's death. 3) 'Maybe it's God's plan or witchcraft' summarises spiritual, supernatural, and social beliefs surrounding the causes of stillbirth. CONCLUSIONS: Kinship and social support helped parents to cope with the loss and grief. However, other practices and beliefs surrounding stillbirth were sometimes a source of stress, fear, stigma and anxiety especially to the women. Conforming to cultural practices meant that parents were prevented from: holding and seeing their baby, openly discussing the death, memory-making and attending the burial. The conflict between addressing their own needs and complying with community norms hindered parents' grief and adjustment. There is an urgent need to develop culturally sensitive community programmes geared towards demystifying stillbirths and providing an avenue for parents to grieve in their own way.

African midwifery students' self-assessed confidence in antenatal care: a multi-country study.

Background: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa.Objective: The aim of the study was to describe and compare midwifery students' confidence in basic antenatal skills, in relation to age, sex, program type and level of program.Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition.Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains.Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence.

Evaluation of an educational board game to improve use of the partograph in sub-Saharan Africa: A quasi-experimental study.

BACKGROUND: The partograph is a tool used to record labour observations and support decision-making. Although used globally, it has not reached its full potential. We aimed to determine whether an educational board game can improve labour-monitoring skills and influence practice. STUDY DESIGN: A quasi-experimental study, underpinned by Kirkpatrick's evaluation model, was used. Midwives and student midwives from Malawi, Kenya and Tanzania were given an identical hypothetical case-scenario of a woman in labour pre-and post-implementation of a game, to assess recording and interpretation abilities. This was supplemented by qualitative inquiry 3 months post-game-playing using semi-structured interviews (n = 24) and expert case-record reviews (n = 24). Quantitative data were analysed using the paired t-test and qualitative data were subjected to framework analysis. RESULTS: 95 midwives and 97 students participated. In each country the mean test scores improved; Kenya from 86.5 (6.7) to 95.5 (3.7) (paired t = 11.82, p < 0.001), Malawi from 83.6 (6.7) to 94.6 (4.1) (paired t = 13.35, p < 0.001), and Tanzania from 83.8 (6.2) to 94.9 (4.1) (paired t = 15.27, p < 0.001). Qualitative findings revealed six themes: 'an enjoyable way of practicing,' 'learning and re-learning,' 'improved clinical decision-making', 'promoting team-work', 'a catalyst for additional learning' and 'barriers to transference of learning'. Expert case-record review demonstrated good adherence to recommendations. CONCLUSION: Board games have the ability to improve labour-monitoring knowledge. Retention of information was apparent and application of learning into practice was encouraging. Health-system barriers need to be resolved for midwives to apply theory to practice. Whether such application results in improved clinical outcomes is uncertain and requires further evaluation.

A grounded theory of regaining normalcy and reintegration of women with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula is a reproductive health problem causing immense suffering to 1% of women in Kenya that is formed as sequelae of prolonged obstructed labour. It is a chronic illness that disrupts women lives, causing stigma and isolation. Fistula illness often introduces a crisis in women's life begetting feelings of shame and serious disruption to their social, psychological, physical and economic lives, in addition to dealing with moral and hygiene challenges. Currently, women undergo free of charge surgery at vesicovaginal fistula (VVF) camps held in national referral hospitals and dedicated fistula centres generating a significant pool of women who have undergone surgery and are ready to regain normal lives. OBJECTIVE: The purpose of this study was to explore experiences of women immersing back into communities and their return to normalcy after surgery in three VVF repair centres in Kenya. We set out to answer the question: what strategies improve obstetric fistula patients' reintegration process? METHODS: We used grounded theory methodology to capture the reintegration and regaining normalcy experiences of women after surgery. Narrative interviews were held with 60 women during community follow-up visits in their homes after 6-19 months postoperatively. Grounded theory processes of theoretical sampling, repeated measurement; constant comparative coding in three stage open, axial and selective coding; memoing, reflexivity and positionality were applied. Emergent themes helped generate a grounded theory of reintegration and regaining normalcy for fistula patients. RESULTS: To regain normal healthy lives, women respond to fistula illness by seeking surgery.. After surgery, four possible outcomes of the reintegration process present; reintegration fully or partially back into their previous communities, not reintegrated or newly integrating away from previous social and family settings. The reintegration statuses point to the diversity outcomes of care for fistula patients and the necessity of tailoring treatment programs to cater for individual patient needs. CONCLUSION: The emerging substantive theory on the process of reintegration and regaining normalcy for fistula patients is presented. The study findings have implications for fistula care, training and policy regarding women's health, suggesting a model of care that encompasses physical, social, economic and psychological aspects of care after surgery and discharge.

A qualitative study of partner engagement in HIV testing in Malawi and Kenya.

In low-income settings, partner engagement in HIV testing during pregnancy is well recognised, but uptake remains low. To understand why men fail to engage, 76 in-depth, individual interviews were conducted with women (n = 23), men (n = 36) and community stakeholders (n = 17) in Malawi and Kenya. Transcribed data were analysed thematically. Male engagement was verbally supported. However, definitions of 'engagement' varied; women wanted a shared experience, whereas men wanted to offer practical and financial support. Women and stakeholders supported couples-testing, but some men thought separate testing was preferable. Barriers to couples-testing were strongly linked to barriers to antenatal engagement, with some direct fear of HIV-testing itself. The major themes identified included diverse definitions of male engagement, cultural norms, poor communication and environmental discomfort - all of which were underpinned by hegemonic masculinity. Couples-testing will only increase when strategies to improve reproductive health care are implemented and men's health is given proper consideration within the process. As social norms constitute a barrier, community-based interventions are likely to be most effective. A multi-pronged approach could include advocacy through social media and community forums, the provision of tailored information, the presence of positive role models and a welcoming environment.

'I stayed with my illness': a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? METHODS: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. RESULTS: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. CONCLUSIONS: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways.

Screening for Sexually Transmitted Infections in Adolescent Girls and Young Women in Mombasa, Kenya: Feasibility, Prevalence, and Correlates.

INTRODUCTION: As adolescents and young women become sexually active, they are at risk of adverse reproductive health outcomes including sexually transmitted infections (STIs). We assessed feasibility and acceptability of STI screening among 15- to 24-year-old women in Mombasa, Kenya. METHODS: After sensitization activities, participants were recruited from 3 high schools and 1 university. Study staff conducted informational sessions. Students interested in participating were given consent forms to take home, and invited to visit our clinic for STI screening. During clinic visits, participants completed a self-administered questionnaire and provided a urine specimen for STI testing using a nucleic acid amplification test. RESULTS: Between August 2014 and March 2015, 463 high school and 165 university students collected consent forms. Of these, 293 (63%) from high schools versus 158 (95%) from university attended clinic for STI screening (P < 0.001). Of the 150 (33%) who reported any history of insertive vaginal sex, 78 (52.0%) reported condom use at the last sex act, 31 (20.7%) reported using modern nonbarrier contraceptive methods, and 37 (24.7%) reported not using any contraception at the last sex act. Twenty-six (5.8%) participants were diagnosed with STIs (7 [1.6%] Neisseria gonorrhoeae, 16 [3.6%] Chlamydia trachomatis, 3 [0.7%] Trichomonas vaginalis). In multivariable analyses, reporting receptive vaginal sex without a condom was associated with having a laboratory confirmed STI (odds ratio, 6.21; 95% confidence interval, 1.72-22.28). CONCLUSIONS: These findings support the need for reproductive health interventions to reduce the risk of STIs in a population of adolescent girls and young women in East Africa.

Parents' and teachers' views on sexual health education and screening for sexually transmitted infections among in-school adolescent girls in Kenya: a qualitative study.

BACKGROUND: To successfully develop and implement school-based sexual health interventions for adolescent girls, such as screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, it is important to understand parents' and teachers' attitudes towards sexual health education and acceptability of sexually transmitted infection (STI) screening interventions. METHODS: In this qualitative study, we approached parents and teachers from three high schools to participate in in-depth interviews (IDIs) and focus-group discussions (FGDs). Parents and teachers were asked about their general knowledge of STIs and sexual health education. In addition, they were asked whether they would support utilizing outreach to schools to facilitate provision of sexual health education and screening for STIs in adolescent girls. Data were audio-recorded, transcribed, and translated into English. An initial coding matrix was developed and refined throughout the coding process. Transcripts were coded by two researchers and analyzed using the content analysis approach. RESULTS: We conducted 10 IDIs (5 parents and 5 teachers) and 4 FGDs (2 with parents, 2 with teachers, total of 26 participants). Most parents reported few or no discussions regarding STIs with their adolescent girls. Parents were more comfortable discussing consequences of sexual activity including loss of virginity and the potential for pregnancy. Parents tended to place responsibility for sexual health education with teachers. The teachers, in turn, provided basic sexual and reproductive health education including puberty, abstinence, and overview of STIs. Both parents and teachers found the idea of screening for STIs in adolescent girls to be acceptable, and were comfortable with research staff contacting girls through informational meetings at schools. Parents felt that adolescents' STI screening results should be shared with their parents. CONCLUSION: In this African setting, parents and teachers provide limited sexual health education, with a focus on negative consequences including loss of virginity, pregnancy, and risk for STIs. Nonetheless, both parents and teachers were supportive of STI screening for adolescent girls, beginning with school-based informational meetings for the girls. Research and programs that aim to provide STI screening in this setting must offer treatment and address the issue of whether results will be disclosed to parents.

Success Stories: Overcoming Barriers to Research in Southern and Eastern African Countries.

There is an ever-growing need for clinically focused, culturally relevant research on which nurses can base their practice. However, there may not be a concurrent rise in efforts to strengthen infrastructure needed to promote research in developing and low-income countries. In such cases, nurse researchers must find innovative ways to address and overcome barriers to research. This article presents five exemplars of nurses conducting high-quality nursing research in resource-poor settings in southern and eastern Africa. Furthermore, it suggests strategies to address these barriers, such as piggybacking on larger studies, interdisciplinary collaboration, and partnership with influential stakeholders. These tactics may be used to increase research productivity elsewhere.

Barriers and Facilitators of Screening for Sexually Transmitted Infections in Adolescent Girls and Young Women in Mombasa, Kenya: A Qualitative Study.

OBJECTIVE: Young women bear the greatest burden of sexually transmitted infections (STIs), so it is important to identify and address barriers to STI screening in this population. We conducted a qualitative study to explore the feasibility of STI screening among adolescent girls and young women in Mombasa, Kenya. METHODS: We conducted 17 in-depth interviews (IDIs) (8 with adolescent girls and 9 with young women) and 6 focus group discussions (FGDs) (4 with adolescent girls and 2 with young women, total 55 participants). The audio recordings for the IDIs and FGDs were translated and transcribed into English. Transcripts were independently reviewed by two researchers, and a set of codes was designed to help analyze the data using the content analysis approach. Data content was then analyzed manually and digitally using ATLAS.ti, and consensus was reached on central and specific emergent themes discussed by the research team. RESULTS: Adolescent girls and young women in Mombasa, Kenya expressed willingness to participate in STI screening. A major incentive for screening was participants' desire to know their STI status, especially following perceived high-risk sexual behavior. Lack of symptoms and fear of positive test results were identified as barriers to STI screening at the individual level, while parental notification and stigmatization from parents, family members and the community were identified as barriers at the community level. Uncomfortable or embarrassing methods of specimen collection were an additional barrier. Thus, urine-based screening was felt to be the most acceptable. CONCLUSION: Kenyan adolescent girls and young women seem willing to participate in screening for STIs using urine testing. Addressing stigmatization by parents, health care workers and the community could further facilitate STI screening in this population.

Clinical Nursing and Midwifery Research Priorities in Eastern and Southern African Countries: Results From a Delphi Survey.

BACKGROUND: Because of the profound shortage of nurse and midwifery researchers in many African countries, identification of clinical nursing and midwifery research is of highest priority for the region to improve health outcomes. OBJECTIVES: The aim of this study was to gain consensus from experts on the priorities of clinical nursing and midwifery research in southern and eastern African countries. METHOD: A Delphi survey was conducted among experts in the region. Criteria for "expert" included (a) a professional nurse, (b) a bachelor's degree or higher in nursing, (c) published research, (d) affiliated with a school of nursing with at least a master's level nursing program, and/or (e) identified by the African core collaborators as an expert in the region. A list of candidates was identified through searches of published and gray literature and then vetted by core collaborators in Kenya, Malawi, and South Africa. Core collaborators held leadership roles in a nursing school and a doctoral degree in nursing, had conducted and published nursing research, and resided in an included country. RESULTS: Two rounds of the Delphi survey were required to reach consensus. In total, 40 participants completed both rounds, and at least one participant from each country completed both rounds; 73% and 85% response rates were achieved for each round, respectively. Critical clinical research priorities were infectious disease/infection control and midwifery/maternal health topics. These included subtopics such as HIV/AIDS, tuberculosis, maternal health and mortality, infant mortality, and obstetrical emergencies. Many other topics were ranked as important including patient outcomes, noncommunicable diseases, and rural health. DISCUSSION: Areas identified as research priorities were consistent with gaps identified in current literature. As evidenced by previous research, there is a lack of clinical nursing and midwifery research in these areas as well as nurses and midwives trained to conduct research; these priorities will help direct resources to the most essential research needs.

A pilot quasi-experimental study to determine the feasibility of implementing a partograph e-learning tool for student midwife training in Nairobi.

OBJECTIVE: the partograph is a tool used globally to record labour progress. Although it has the potential to improve maternal and neonatal outcomes, some midwives struggle with using it in practice. Training in partograph use is limited, and the theory is often divorced from practice. Innovative ways of improving training are urgently required. We therefore aimed to determine whether the use of an e-learning tool is beneficial for learning partograph skills. DESIGN: an uncontrolled before-and-after study was conducted, informed by Kirkpatrick's four-stage model of evaluation; we report on the first two stages. We included a cohort of third and fourth year midwifery students who were studying at one university in Nairobi. The same hypothetical case scenario was used, pre- and post-implementation of the World Health Organization partograph e-learning tool, to assess students' partograph completion ability. Views on the tool were also sought, using semi-structured questionnaires. Data were analysed using standard statistical techniques and framework analysis. FINDINGS: 92 (88%) students participated. Students expressed positive views about the e-learning tool. However, the mean post-intervention score (27.21) was less than half of the maximum obtainable score. There was some improvement in test scores; year three mean score pre-intervention was 21.39 (SD 5.72), which increased to 25.10 (5.41) post-intervention (paired-t=3.47, p=0.001); year four mean score pre-intervention was 24.39 (5.98) which increased to 29.30 (6.77) post-intervention (paired t=3.85, df=91, p<0.001). In the post-test, year four students scored higher than year three students (unpaired t=3.28, df=90, p=0.001). Students were unable to plot cervical dilatation correctly, once established labour had been confirmed. KEY CONCLUSION: e-Learning training is acceptable to student midwives and has the potential to be an effective means of teaching the practical application of the partograph. However, in this study, their inability to correctly plot transference from the latent to active phase of labour suggests that the partograph itself may be too complicated. Modifications and further evaluation of the e-learning tool would be required before any widespread implementation. Furthermore, students need the clinical support to operationalise their learning; educating qualified midwives and obstetricians to be positive role models when completing the partograph would be one potential solution. Further research is required, taking on board the recommendations from our pilot study, to investigate the impact of partograph e-learning on practice and clinical outcomes.

'Moving with the times' taking a glocal approach: a qualitative study of African student nurse views of e learning.

BACKGROUND: Information technology is a rapidly increasing means of communication in education and healthcare. This is also true in low resource settings, where electronic communication provides an opportunity for sharing information about health and wellbeing and enhancing learning for healthcare professionals. METHODS: A qualitative study whereby 51 year 3 and 4 student nurses at the University of Nairobi participated in 5 focus group discussions. Data were recorded, transcribed verbatim and analyzed using a framework approach. RESULTS: Four main themes were identified, 'moving with the times', 'global networking', 'inequity as a barrier' and 'transfer of internet learning into practice'. CONCLUSIONS: Information technology is already integral to students' lives both personally and professionally and the students had a strong desire to find out what is happening globally. The familiarity of the internet contributes to the acceptance of e-learning programs as part of educational curricula. Students felt that e-learning 'is here to stay' and wanted to 'embrace the concept.' E-learning was generally welcomed however students suggested that it should be 'supplementary' to face-to-face learning. In order to incorporate e-learning ethically in low resource settings, resources should be sustainable, for example CDROMs and DVDs which are not dependant on internet access. Researching the views of qualified midwives might be the next step in promoting this valuable teaching method.

Contraception knowledge and practice among fistula patients at referral centers in Kenya.

OBJECTIVE: To establish knowledge and practice of contraception among patients presenting with a fistula attending fistula care services at 4 centers in Kenya. METHODS: In a descriptive cohort study carried out between January and December 2011, patients presenting with a history of urine and/or stool leakage were screened and those with confirmed diagnosis of fistula were assessed and prepared for surgery. Informed consent was obtained from study participants before surgical intervention. After surgery, a standard questionnaire was used to collect information on sociodemographics, duration of leakage, and reproductive health practices. RESULTS: A total of 206 patients were interviewed. Most of the patients were young (mean age 22 years). Literacy was low: only 1.7% reported tertiary-level education, and 56.7% reported primary-level education. With regard to family planning, 76.2% of patients expressed a willingness to use contraception after fistula repair. CONCLUSION: Among patients presenting with a fistula in Kenya, the unmet need for family planning was high. There is an urgent need for healthcare providers to integrate family planning services in fistula care programs.