As caesarean delivery rates continue to increase globally, so are the number of second-stage caesarean deliveries. Second-stage caesareans may carry additional risk of complications for both the ...mother and fetus owing to fetal head impaction into the maternal pelvis and manipulations required for delivery. So far, data on this procedure's outcomes from low resource countries are limited. To compare adverse maternal and perinatal outcomes between second-stage and first-stage of labour intrapartum primary caesarean deliveries over 12 months at a tertiary referral obstetric hospital in Kenya. In a hospital-based cohort study, 222 women with singleton, cephalic presenting fetuses at term gestation who had intrapartum primary caesarean delivery during active labour were recruited post-partum. Second-stage caesarean deliveries (73) were compared to 149 first-stage caesarean deliveries. The proportion of caesarean deliveries in the second-stage of labour was estimated and the adverse maternal and perinatal outcomes were compared. The study was conducted from August 2021 to July 2022 at the Moi Teaching and Referral Hospital, Eldoret. The proportion of second-stage caesarean deliveries among intrapartum primary caesarean deliveries was 4.3% 95% CI: 2.9% - 4.7%. Compared to first-stage caesarean deliveries, second-stage caesarean deliveries had a significantly higher risk of adverse maternal outcomes (RR 3.272, 95% CI 2.28-4.71, P < 0.001), including intraoperative trauma, atony, blood transfusion, and a postoperative hospital stay of more than three days. Additionally, there was a higher risk of adverse perinatal outcomes (RR 2.748, 95% CI 2.45-4.50, P < 0.001), including increased risk of a 5-min APGAR less than or equal to3, admission to NBU, and neonatal death. An increased risk of adverse maternal and perinatal outcomes is associated with primary second-stage caesarean deliveries compared to primary first-stage caesarean deliveries.
Although pain relief is a crucial component of modern obstetric care, it remains a poorly established service in sub-Saharan countries such as Kenya. Maternal health care providers have an extensive ...role to play in meeting the analgesic needs of women during childbirth. This study sought to examine the practice of labour pain relief among Kenyan maternal health care providers.
This was an institution-based, cross-sectional, descriptive survey. The study included midwives, obstetricians, and anaesthesiologists (n = 120) working at the second-largest tertiary facility in Kenya. A structured, self-administered questionnaire was used. The labour pain relief practice, knowledge, attitude, and perceived barriers to labour pain management were described.
One hundred and seventeen respondents participated in the study representing a response rate of 97.5%. More than half of maternal health care providers routinely provided the service of labour pain relief (61.5%). Sixty-four (88.9%) respondents reported providing pharmacological and non-pharmacological methods, while 11.1% provided only pharmacological ones. The most common pharmacological method prescribed was non-opioids (12.8%). The most preferred non-pharmacological method of pain management was touch and massage (93.8%). Regional analgesia was provided by 3.4% of the respondents. More than half of the respondents (53%) had poor knowledge of labour pain relief methods. Almost all (94%) of the respondents had a positive attitude towards providing labour pain relief. Non-availability of drugs and equipment (58.1%), lack of clear protocols and guidelines (56.4%), and absence of adequate skilled personnel (55.6%) were reported as the health system factors that hinder the provision of labour analgesia.
More than half of maternal health care providers routinely relieve labour pain. Epidural analgesia is still relatively underutilized. There is a need to develop institutional labour pain management protocols to meet the analgesic needs of women during childbirth.
Summary Background Hormonal contraceptives are used widely but their effects on HIV-1 risk are unclear. We aimed to assess the association between hormonal contraceptive use and risk of HIV-1 ...acquisition by women and HIV-1 transmission from HIV-1-infected women to their male partners. Methods In this prospective study, we followed up 3790 heterosexual HIV-1-serodiscordant couples participating in two longitudinal studies of HIV-1 incidence in seven African countries. Among injectable and oral hormonal contraceptive users and non-users, we compared rates of HIV-1 acquisition by women and HIV-1 transmission from women to men. The primary outcome measure was HIV-1 seroconversion. We used Cox proportional hazards regression and marginal structural modelling to assess the effect of contraceptive use on HIV-1 risk. Findings Among 1314 couples in which the HIV-1-seronegative partner was female (median follow-up 18·0 IQR 12·6–24·2 months), rates of HIV-1 acquisition were 6·61 per 100 person-years in women who used hormonal contraception and 3·78 per 100 person-years in those who did not (adjusted hazard ratio 1·98, 95% CI 1·06–3·68, p=0·03). Among 2476 couples in which the HIV-1-seronegative partner was male (median follow-up 18·7 IQR 12·8–24·2 months), rates of HIV-1 transmission from women to men were 2·61 per 100 person-years in couples in which women used hormonal contraception and 1·51 per 100 person-years in couples in which women did not use hormonal contraception (adjusted hazard ratio 1·97, 95% CI 1·12–3·45, p=0·02). Marginal structural model analyses generated much the same results to the Cox proportional hazards regression. Interpretation Women should be counselled about potentially increased risk of HIV-1 acquisition and transmission with hormonal contraception, especially injectable methods, and about the importance of dual protection with condoms to decrease HIV-1 risk. Non-hormonal or low-dose hormonal contraceptive methods should be considered for women with or at-risk for HIV-1. Funding US National Institutes of Health and the Bill & Melinda Gates Foundation.
Physiologic and behavioral changes during pregnancy may alter HIV-1 susceptibility and infectiousness. Prospective studies exploring pregnancy and HIV-1 acquisition risk in women have found ...inconsistent results. No study has explored the effect of pregnancy on HIV-1 transmission risk from HIV-1-infected women to male partners.
In a prospective study of African HIV-1-serodiscordant couples, we evaluated the relationship between pregnancy and the risk of HIV-1 acquisition among women and HIV-1 transmission from women to men.
Three thousand three hundred and twenty-one HIV-1-serodiscordant couples were enrolled, 1085 (32.7%) with HIV-1 susceptible female partners and 2236 (67.3%) with susceptible male partners. HIV-1 incidence in women was 7.35 versus 3.01 per 100 person-years during pregnant and nonpregnant periods hazard ratio 2.34, 95% confidence interval (CI) 1.33-4.09. This effect was attenuated and not statistically significant after adjusting for sexual behavior and other confounding factors (adjusted hazard ratio 1.71, 95% CI 0.93-3.12). HIV-1 incidence in male partners of infected women was 3.46 versus 1.58 per 100 person-years when their partners were pregnant versus not pregnant (hazard ratio 2.31, 95% CI 1.22-4.39). This effect was not attenuated in adjusted analysis (adjusted hazard ratio 2.47, 95% CI 1.26-4.85).
HIV-1 risk increased two-fold during pregnancy. Elevated risk of HIV-1 acquisition in pregnant women appeared in part to be explained by behavioral and other factors. This is the first study to show that pregnancy increased the risk of female-to-male HIV-1 transmission, which may reflect biological changes of pregnancy that could increase HIV-1 infectiousness.
Objective: To assess the prevalence of, and the factors associated with, contraceptive use among females living with HIV at Moi Teaching and Referral Hospital, Eldoret, Kenya. Methods: A ...cross-sectional study with a sample including a total of 375 females living with HIV aged 15–49 years undergoing follow-up. Data were collected using a semi-structured questionnaire. Bivariate and multivariate analysis was done to check for association and predictors of contraceptive use. Results: The contraceptive prevalence rate was 64%. Factors associated with contraceptive utilisation included parity (crude odds ratio COR: 2.33; 95% confidence interval CI: 1.22–4.45; P=0.010), marital status (COR: 1.75; 95% CI: 1.04–2.97; P=0.036), and availability of information on the side effects of the contraception methods (COR: 29.93; 95% CI: 14.26–70.58; P=0.001). Multivariate analysis showed a significant association between contraceptive use and whether information on the side effects of the current contraception method was provided (adjusted OR: 34.98; 95% CI: 16.72–83.33; P=0.001).The odds of meeting the contraceptive needs of females living with HIV was 34 times higher among females who had information on side effects of the contraceptives than their counterparts who had no information. Conclusions: The contraceptive prevalence rate was 64% among females living with HIV, higher than latest national value of 61%. Females living with HIV had a high unmet need for contraceptive use at 28.4%. Key factors associated with contraceptive utilisation included awareness of side effects.
Reducing maternal morbidity and mortality remains a top global health agenda especially in high HIV/AIDS endemic locations where there is increased likelihood of mother to child transmission (MTCT) ...of HIV. Social health insurance (SHI) has emerged as a viable option to improve population access to health services, while improving outcomes for disenfranchised populations, particularly HIV+ women. However, the effect of SHI on healthcare access for HIV+ persons in limited resource settings is yet to undergo rigorous empirical evaluation. This study analyzes the effect of health insurance on obstetric healthcare access including institutional delivery and skilled birth attendants for HIV+ pregnant women in Kenya.
We analyzed cross-sectional data from HIV+ pregnant women (ages 15-49 years) who had a delivery (full term, preterm, miscarriage) between 2008 and 2013 with their insurance enrollment status available in the electronic medical records database of a HIV healthcare system in Kenya. We estimated linear and logistic regression models and implemented matching and inverse probability weighting (IPW) to improve balance on observable individual characteristics. Additionally, we estimated heterogeneous effects stratified by HIV disease severity (CD4 < 350 as "Severe HIV disease", and CD4 > 350 otherwise).
Health Insurance enrollment is associated with improved obstetric health services utilization among HIV+ pregnant women in Kenya. Specifically, HIV+ pregnant women covered by NHIF have greater access to institutional delivery (12.5-percentage points difference) and skilled birth attendants (19-percentage points difference) compared to uninsured. Notably, the effect of NHIF on obstetric health service use is much greater for those who are sicker (CD4 < 350) - 20 percentage points difference.
This study confirms conceptual and practical considerations around health insurance and healthcare access for HIV+ persons. Further, it helps to inform relevant policy development for health insurance and HIV financing and delivery in Kenya and in similar countries in sub-Saharan Africa in the universal health coverage (UHC) era.
Research misconduct i.e. fabrication, falsification, and plagiarism is associated with individual, institutional, national, and global factors. Researchers' perceptions of weak or non-existent ...institutional guidelines on the prevention and management of research misconduct can encourage these practices. Few countries in Africa have clear guidance on research misconduct. In Kenya, the capacity to prevent or manage research misconduct in academic and research institutions has not been documented. The objective of this study was to explore the perceptions of Kenyan research regulators on the occurrence of and institutional capacity to prevent or manage research misconduct.
Interviews with open-ended questions were conducted with 27 research regulators (chairs and secretaries of ethics committees, research directors of academic and research institutions, and national regulatory bodies). Among other questions, participants were asked: (1) How common is research misconduct in your view? (2) Does your institution have the capacity to prevent research misconduct? (3) Does your institution have the capacity to manage research misconduct? Their responses were audiotaped, transcribed, and coded using NVivo software. Deductive coding covered predefined themes including perceptions on occurrence, prevention detection, investigation, and management of research misconduct. Results are presented with illustrative quotes.
Respondents perceived research misconduct to be very common among students developing thesis reports. Their responses suggested there was no dedicated capacity to prevent or manage research misconduct at the institutional and national levels. There were no specific national guidelines on research misconduct. At the institutional level, the only capacity/efforts mentioned were directed at reducing, detecting, and managing student plagiarism. There was no direct mention of the capacity to manage fabrication and falsification or misconduct by faculty researchers. We recommend the development of Kenya code of conduct or research integrity guidelines that would cover misconduct.
Maternal and infant mortality are higher in low-income than in high-income countries due to weak health systems. The objective of this study was to improve access, utilization and quality of Maternal ...and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies the World Health Organization (WHO) pillars of the health system.
This study was conducted in two dispensaries in the Counties of Busia and Bungoma in Kenya as intervention sites and in four control clusters in Kakamega, Uasin Gishu, Trans Nzoia and Elgeyo Marakwet Counties. The study population was pregnant women and their children delivered over the study period in the intervention and control clusters.
A quasi-experimental study design was used to conduct the study between 2015 and 2020 to compare the outcomes of the implementation of the EHC using the Find Link Treat and Retain (FLTR) strategy in one cluster, community owned initiatives in the other cluster and four control clusters at baseline and at the end of the study. A baseline survey was conducted in year one and an end line survey in the fifth year. Continuous data collection on maternal and childhood health indicators was done in all the six clusters and comparison made at the end of the study between the clusters.
We found a 26%, 10.3% and 0.8% increase in antenatal care (ANC) attendance in the intervention clusters of Obekai, Kabula and control clusters respectively. There was a 28.2%, 5.8% and 17.0% increase in attendance of 4+ ANC clinics of Obekai, Kabula and control clusters respectively. There was a 24% and 13% increase in Obekai and Kabula respectively in contraceptive use and a 2% decrease in contraceptive use in the control locations. There was a 38.2%, 25.6% and 34.7% increase in facility deliveries over the study period in Obekai, Kabula and control clusters respectively. There was a marked increase in immunization coverage in the intervention clusters of Obekai and Kabula compared to a significant decrease in control clusters for BCG, polio, pentavalent and measles.
In conclusion, use of the health systems approach in health care provision provides a holistic improvement in access and utilization of health services and in the improvement of health indicators.
We do recommend that a systems approach be used in health services delivery to improve access, utilization and quality of health care provision at community and primary care levels.
Retention in prevention of mother-to-child transmission (PMTCT) care is critical to prevent vertical HIV transmission and reduce morbidity and mortality of mother-infant pairs. We investigated ...whether weekly, interactive text-messaging improved 18-month postpartum retention in PMTCT care. This randomised, two-armed, parallel trial was conducted at six PMTCT clinics in western Kenya. Pregnant women with HIV at least 18 years of age with access to a mobile phone, able to text-message, or had somebody who could text on their behalf, were eligible. Participants were randomly assigned at a 1:1 ratio in block sizes of four to the intervention or control group. The intervention group received weekly text messages asking "How are you?" ("Mambo?" in Swahili) and were requested to respond within 48 h. Healthcare workers called women who indicated a problem or did not respond. The intervention was administered up to 24 months after delivery. Both groups received standard care. The primary outcome was retention in care at 18 months postpartum (i.e., clinic attendance 16-24 months after delivery based on data from patient files, patient registers and Kenya's National AIDS and STI Control Programme database), which was analysed by intention-to-treat. Researchers and data collectors were masked to group assignment, while healthcare workers were not. Between June 25th, 2015, and July 5th, 2016, we randomly assigned 299 women to the intervention and 301 to standard care only. Follow-up concluded on July 26th, 2019. The proportion of women retained in PMTCT care at 18 months postpartum was not significantly different between the intervention (n = 210/299) and control groups (n = 207/301) (risk ratio 1.02, 95% confidence interval 0.92-1.14, p = 0.697). No adverse events related to the mobile phone intervention were reported. Weekly, interactive text-messaging was not associated with improved retention in PMTCT care at 18 months postpartum or linkage to care up to 30 months postpartum in this setting. (ISRCTN No. 98818734).
Healthcare financing through health insurance is gaining traction as developing countries strive to achieve universal health coverage and address the limited access to critical health services for ...specific populations including pregnant women and their children. However, these reforms are taking place despite limited evaluation of impact of health insurance on maternal health in developing countries including Kenya. In this study we evaluate the association of health insurance with access and utilization of obstetric delivery health services for pregnant women in Kenya.
Nationally representative data from the Kenya Demographic and Health Survey 2008-09 was used in this study. 4082 pregnant women with outcomes of interest - Institutional delivery (Yes/No - delivery at hospital, dispensary, maternity home, and clinic) and access to skilled birth attendants (help by a nurse, doctor, or trained midwife at delivery) were selected from 8444 women ages 15-49 years. Linear and logistic regression, and propensity score adjustment are used to estimate the causal association of enrollment in insurance on obstetric health outcomes.
Mothers with insurance are 23 percentage points (p < 0.01) more likely to deliver at an institution and 20 percentages points (p < 0.01) more likely have access to skilled birth attendants compared to those not insured. In addition mothers of lower socio-economic status benefit more from enrollment in insurance compared to mothers of higher socio-economic status. For both institutional delivery and access to skilled birth attendants, the average difference of the association of insurance enrollment compared to not enrolling for those of low SES is 23 percentage points (p < 0.01), and 6 percentage points (p < 0.01) for those of higher SES.
Enrolling in health insurance is associated with increased access and utilization of obstetric delivery health services for pregnant women. Notably, those of lower socio-economic status seem to benefit the most from enrollment in insurance.
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