"We All Join Hands": Perceptions of the Kangaroo Method Among Female Relatives of Newborns in The Gambia.

Family support is essential for kangaroo mother care (KMC), but there is limited research regarding perceptions of female relatives, and none published from West African contexts. In-depth interviews were conducted from July to August 2017 with a purposive sample of 11 female relatives of preterm neonates admitted to The Gambia's referral hospital. Data were coded in NVivo 11, and thematic analysis was conducted applying an inductive framework. Female relatives were willing to support mothers by providing KMC and assisting with domestic chores and agricultural labor. Three themes were identified: (a) collective family responsibility for newborn care, with elder relatives being key decision makers, (b) balance between maintaining traditional practices and acceptance of KMC as a medical innovation, and (c) gendered expectations of women's responsibilities postnatally. Female relatives are influential stakeholders and could play important roles in KMC programs, encourage community ownership, and contribute to improved outcomes for vulnerable newborns.

Use of and barriers to maternal health services in southeast Chad: results of a population-based survey 2019.

OBJECTIVES: Chad reports the second highest maternal mortality worldwide. We conducted a survey in Sila region in southeast Chad to estimate the use of maternal health services (MHS) and to identify barriers to access MHS. DESIGN: Retrospective cross-sectional, population-based survey using two-stage cluster sampling methodology. The survey consisted of two strata, Koukou Angarana and Goz Beida district in Sila region. We conducted systematic random sampling proportional to population size to select settlements in each strata in the first sampling stage; and in the second stage we selected households in the settlements using random walk procedure. We calculated survey-design-weighted proportions with 95% CIs. We performed univariate analysis and multivariable logistic regression to identify impact factors associated with the use of MHS. SETTING: We interviewed women in selected households in Sila region in 2019. PARTICIPANTS: Women at reproductive age, who have given birth in the previous 2 years and are living in Koukou Angarana and Goz Beida district. PRIMARY OUTCOMES: Use of and access barriers to MHS including antenatal care (ANC), delivery care in a health facility (DC), postnatal care (PNC) and contraceptive methods. RESULTS: In total, 624 women participated. Median age was 28 years, 95.4% were illiterate and 95.7% married. Use of ANC, DC and PNC was reported by 57.6% (95% CI: 49.3% to 65.5%), 22.5% (95% CI: 15.7% to 31.1%) and 32.9% (95% CI: 25.8% to 40.9%), respectively. Use of MHS was lower in rural compared with urban settings. Having attended ANC increased the odds of using DC by 4.3 (1.5-12.2) and using PNC by 6.4 (3.7-11.1). Factors related to transport and to culture and belief were the most frequently stated access barriers to MHS. CONCLUSION: In Sila region, use of MHS is low and does not meet WHO-defined standards regarding maternal health. Among all services, use of ANC was better than for other MHS. ANC usage is positively associated with the use of further life-saving MHS including DC and could be used as an entry point to the community. To increase use of MHS, interventions should include infrastructural improvements as well as community-based approaches to overcome access barriers related to culture and belief.

Catalyst for change: Lessons learned from overcoming barriers to providing safe abortion care in Médecins Sans Frontières projects.

CONTEXT: Despite instituting a policy in 2004, Médecins Sans Frontières (MSF) continuously struggled to routinely provide safe abortion care (SAC). In 2016, the organization launched an initiative aimed at increasing availability of SAC in MSF projects and increasing understanding of abortion-related dynamics in humanitarian settings. METHODOLOGY: From March 2017 to April 2018, MSF staff conducted support visits to 10 projects in a country in sub-Saharan Africa. Each visit followed a systematic approach with six key components and related tools that were later shared with teams worldwide. Data regarding women seeking abortion services and related outcomes were collected and analyzed retrospectively. RESULTS: From Q1 2017 through Q4 2019, SAC provision increased significantly in all 10 projects, rising from three to 759 safe abortions per quarter. Teams received 3831 patients seeking SAC and provided 3640 first and second trimester abortions, over 99% via medication methods. The overall complication rate was 4.29% and 0.3% for severe, life-threatening complications. No major security incidents were reported. MSF provision of SAC worldwide increased from 781 in 2016 (the year before this initiative began) to 21,546 in 2019. CONCLUSION: Implementation of SAC in humanitarian settings-even those with significant legal restrictions-is possible and necessary. Both first and second trimester medication abortion can be safely and effectively provided through both home- and facility-based models of care. Programmatic data provide valuable insights into abortion-related dynamics which must shape operational decision-making. Addressing internal barriers and providing direct field support were key to stimulating organizational cultural change.

Mortality beyond emergency threshold in a silent crisis- results from a population-based mortality survey in Ouaka prefecture, Central African Republic, 2020.

BACKGROUND: The Central African Republic (CAR) suffers a protracted conflict and has the second lowest human development index in the world. Available mortality estimates vary and differ in methodology. We undertook a retrospective mortality study in the Ouaka prefecture to obtain reliable mortality data. METHODS: We conducted a population-based two-stage cluster survey from 9 March to 9 April, 2020 in Ouaka prefecture. We aimed to include 64 clusters of 12 households for a required sample size of 3636 persons. We assigned clusters to communes proportional to population size and then used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. In addition to the mortality survey questions, we included an open question on challenges faced by the household. RESULTS: We completed 50 clusters with 591 participating households including 4000 household members on the interview day. The median household size was 7 (interquartile range (IQR): 4-9). The median age was 12 (IQR: 5-27). The birth rate was 59.0/1000 population (95% confidence interval (95%-CI): 51.7-67.4). The crude and under-five mortality rates (CMR & U5MR) were 1.33 (95%-CI: 1.09-1.61) and 1.87 (95%-CI: 1.37-2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death were malaria/fever (16.0%; 95%-CI: 11.0-22.7), violence (13.2%; 95%-CI: 6.3-25.5), diarrhoea/vomiting (10.6%; 95%-CI: 6.2-17.5), and respiratory infections (8.4%; 95%-CI: 4.6-14.8). The maternal mortality ratio (MMR) was 2525/100,000 live births (95%-CI: 825-5794). Challenges reported by households included health problems and access to healthcare, high number of deaths, lack of potable water, insufficient means of subsistence, food insecurity and violence. CONCLUSIONS: The CMR, U5MR and MMR exceed previous estimates, and the CMR exceeds the humanitarian emergency threshold. Violence is a major threat to life, and to physical and mental wellbeing. Other causes of death speak to poor living conditions and poor access to healthcare and preventive measures, corroborated by the challenges reported by households. Many areas of CAR face similar challenges to Ouaka. If these results were generalisable across CAR, the country would suffer one of the highest mortality rates in the world, a reminder that the longstanding "silent crisis" continues.