Access to sexual and reproductive health commodities in East and Southern Africa: a cross-country comparison of availability, affordability and stock-outs in Kenya, Tanzania, Uganda and Zambia

Trends in and Correlates of Short-Acting Contraceptive Stock-Outs: Multicountry Analysis of Performance Monitoring for Action Agile Platform Data

Understanding trends in contraceptive stock-outs, as well as their structural and demand-side correlates, is critical for policymakers and program managers to identify strategies to further anticipate, reduce, and prevent stock-outs. We analyzed trends as well as supply- and demand-side correlates of short-acting contraceptive method stock-outs by using data from multiple rounds of Performance Monitoring for Action Agile surveys. These data longitudinally measured contraceptive availability over 2 years (between November 2017 and January 2020) across 2,134 public and private service delivery points (SDPs) from urban areas of 5 countries (Burkina Faso, Democratic Republic of the Congo [DRC], India, Kenya, and Nigeria). For each country, we analyzed the trends and used multilevel mixed-effect logistic regression to model the odds of short-acting contraceptive stock-outs, adjusting for key structural and demand-side factors of the SDPs. Stock-outs in short-acting contraceptive methods were common in health facilities and varied markedly, ranging from as low as 2.9% (95% confidence interval [CI]=1.7%, 5.1%) in India to 51.0% (95% CIs=46.8%, 56.0%) in Kenya. During the observation period, stock-out rates decreased by 28% in the SDP samples in India (aOR=0.72, P<.001) and 8% in Nigeria (aOR=0.92, P<.001) but increased by 15% in DRC (aOR=1.15; P=036) and 5% in Kenya (aOR=1.05, P=003) with each round of data collection. Correlates of stock-out rates included the facility managerial authority (private versus public), whether the facility was rated high quality, whether the facility was at an advanced tier, and whether there was high demand for short-acting contraceptives. In conclusion, stock-outs of short-acting contraceptives are still common in many settings. Measuring and monitoring contraceptive stock-outs is crucial for identifying and addressing issues related to the availability and supply of short-acting contraceptives.

An imprecise probability approach-based determination of over-represented southern African plant genera and families used in ethnopharmacology

ETHNOPHARMACOLOGICAL RELEVANCE

The analyses of patterns of over-representation of southern African traditional medicinal plants at the genus and family level provide information about the differences in plant use among southern African countries and disease categories. 'Over-representation' refers to the phenomenon whereby the proportion of plants belonging to a taxonomic group is higher in ethnobotanical pharmacopoeia than in the total flora.

AIM OF THE STUDY

This study aimed to use the Imprecise Dirichlet Model (IDM) to analyse data from ten southern African countries to establish how over-represented medicinal plant families compare with over-represented genera, how over-represented medicinal taxa differ among countries in this region of Africa, and how over-represented taxa differ among six major disease categories.

MATERIALS AND METHODS

Floral data for the total species composition of each country were obtained from online databases. Medicinal plant species lists were generated from published surveys, inventories, and books. IDM calculations were executed using the inverse of the cumulative beta probability density function in Microsoft Excel™. Python programming language source code was used to calculate Pearson correlation (r) values and Jaccard coefficients (J).

RESULTS

Nine of forty-two over-represented medicinal plant families in southern Africa (group 1) do not have over-represented genera. Seven of the forty genera with the highest margins of over-representation belong to under-represented families. Nineteen of the forty-two over-represented families have margins of over-representation smaller than the cumulative margins of their over-represented genera. Groups of countries with similar overall flora (J ≥ 0.333) are Botswana and Namibia (group 2), Malawi, Mozambique, Zambia and Zimbabwe (group 3). The families and genera with the highest margins of over-representation are Loganiaceae and Albizia in group 1, Combretaceae and Vachellia in group 2, Dioscoreaceae and Senna in group 3, and Sapotaceae and Solanum in group 4 (South Africa). The families and genera with the highest margins of over-representation across disease categories are Ebenaceae and Albizia, Canellaceae and Dicoma, Combretaceae and Pterocelastrus, Ebenaceae and Bersama, Francoaceae and Erythrina, and Aristolochiaceae and Strychnos for plants used in the treatment of STIs, febrile and mosquito-vector diseases, microbial infections, pain, skin conditions, and female sexual/reproductive problems, respectively.

CONCLUSIONS

Genus-level calculations are more efficient in generating taxonomic lists that can be used for ethnopharmacological investigations due to the exclusion of under-represented genera. Limiting the size of geographical areas from which medicinal plant lists are sampled and targeting plants used to treat specific types of disease prevents the underestimation of niche over-represented taxa.

A narrative review of challenges related to healthcare worker rights, roles and responsibilities in the provision of sexual and reproductive services in health facilities

INTRODUCTION

This paper identifies and summarises tensions and challenges related to healthcare worker rights and responsibilities and describes how they affect healthcare worker roles in the provision of sexual and reproductive health (SRH) care in health facilities.

METHOD

The review was undertaken in a two-phase process, namely: (1) development of a list of core constructs and concepts relating to healthcare worker rights, roles and responsibilities to guide the review and (2) literature review.

RESULT

A total of 110 papers addressing a variety of SRH areas and geographical locations met our inclusion criteria. These papers addressed challenges to healthcare worker rights, roles and responsibilities, including conflicting laws, policies and guidelines; pressure to achieve coverage and quality; violations of the rights and professionalism of healthcare workers, undercutting their ability and motivation to fulfil their responsibilities; inadequate stewardship of the private sector; competing paradigms for decision-making-such as religious beliefs-that are inconsistent with professional responsibilities; donor conditionalities and fragmentation; and, the persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities. The tensions lead to a host of undesirable outcomes, ranging from professional frustration to the provision of a narrower range of services or of poor-quality services.

CONCLUSION

Social mores relating to gender and sexuality and other contested domains that relate to social norms, provider religious identity and other deeply held beliefs complicate the terrain for SRH in particular. Despite the particularities of SRH, a whole of systems response may be best suited to address embedded challenges.

Sexual and reproductive healthcare utilisation and affordability for South Sudanese refugees and host populations in Northern Uganda: A mixed methods study

Given Uganda's increasing refugee population, the health financing burden on refugee and host populations is likely to increase because Uganda's integrated health system caters to both populations. We used sexual, reproductive, and maternal health (SRMH) as a lens to assess the utilisation and user cost of health services in Northern Uganda to identify potential gaps in SRMH services and their financing. We conducted a cross-sectional survey among 2,533 refugee and host women and girls in Arua and Kiryandongo districts. We conducted 35 focus group discussions and 131 in-depth interviews with host and South Sudanese refugees, community members, health workers, NGO and governmental actors. Qualitative data were analysed thematically using a framework approach. Quantitative data were analysed using t-test, chi-square tests, multivariate logistical regression, and a two-part model. We found high levels of access to maternal care services among refugee and host communities in Northern Uganda, but lower levels of met need for family planning (FP). Refugees had higher uptake of delivery care than host communities due to better-resourced refugee facilities, but incurred higher costs for delivery kits and food and less for transport due to facilities being closer. FP uptake was low for both groups due to perceived risks, cultural and religious beliefs, and lack of agency for most women. Host communities lack access to essential maternal healthcare services relative to refugees, especially for delivery care. Greater investment is needed to increase the number of host facilities, improve the quality of SRMH services provided, and further enhance delivery care access among host communities. Ongoing funding of delivery kits across all communities is needed and new financing mechanisms should be developed to support non-medical costs for deliveries, which our study found to be substantial in our study. All populations must be engaged in co-designing improved strategies to meet their FP needs.

Integrating PrEP in maternal and child health clinics in Kenya: analysis of a service availability and readiness assessment (SARA) survey

Background

Risk of HIV acquisition is high during pregnancy and postpartum, and pre-exposure prophylaxis (PrEP) is recommended for peripartum populations. Integrating PrEP into maternal and child health (MCH) clinics is feasible and acceptable. Understanding clinics' service availability and readiness is essential for effective scale up.

Methods

The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged PrEP-experienced facilities previously linked to a programmatic or research study in Western Kenya to document available services and commodities via a modified service availability and readiness assessment (SARA) survey with 20 PrEP tracer items covering: staffing/guidelines, services/equipment, and medicines/commodities. Facilities' prior study engagement occurred between 2017 and 2019; SARA survey data was collected between April 2020 and June 2021. Descriptive statistics were stratified by prior study engagement. ANOVA tests assessed associations between facility characteristics and gaps. Fisher's tests assessed differences in commodity availability and stockouts.

Results

Of the 55 facilities surveyed, 60% had received PrEP training in the last two years, 95% offered PrEP integrated into MCH, and 64% and 78% had both auditory and visual privacy in PrEP and HIV testing service (HTS) delivery spaces, respectively. Supervision frequency was heterogeneous, but 82% had received a supervision visit within 3 months. Availability of commodities was variable and the most commonly unavailable commodities were PrEP in MCH (71% available) and risk assessment screening tool (RAST) and PrEP cards (60% and 75% available, respectively). The number of service and commodity gaps per facility ranged from zero to eight (median: 3; IQR: 2, 5). The most frequent gaps were: PrEP training and risk assessment cards (40% each), lack of privacy in PrEP (36%) and HIV testing services (31%) spaces, PrEP pills in MCH (29%), and PrEP cards (25%). There were no differences in mean number of gaps by county, previous study engagement, or public vs. private status. Level 4 facilities had fewer gaps (mean 2.2) than level 2, 3, and 5 facilities (mean 5.7, 4.5, and 5.3 respectively; p < 0.001).

Conclusions

PrEP service availability and readiness was generally high across MCH facilities. However, there is a need for increased frequency of provider training and supportive supervision focused on fidelity. To address key commodity stockouts such as PrEP pills, implementation of electronic logistics management information systems may be needed. Targeting these gaps is essential to effectively scale up integrated PrEP delivery, especially among facilities with limited infrastructure.

"So let me give you money, you give me what I want": decision-making priorities around contraceptive method and source choice among young women in Kenya

BACKGROUND

Many factors influence young women's choice of contraceptive methods and where to source them, yet less is known about whether one of these choices (method or source) is prioritized and the relationship between these choices. This study qualitatively explored decision-making around contraceptive method and source choice among young women in Kenya.

METHODS

In August-September 2019, 30 in-depth interviews were conducted with women ages 18-24 who had used two or more contraceptive methods and resided in three counties: Nairobi, Mombasa or Migori. Participants were recruited from public and private health facilities and pharmacies. Interview guides captured information about decision-making processes for each contraceptive method the respondent had ever used. Responses were audio-recorded, transcribed, translated into English, coded, and analyzed thematically.

RESULTS

The majority of respondents knew which method they wanted to use prior to seeking it from a source. This was true for all types of methods that women ever used. Of the small number of respondents who selected their source first, most were in the post-partum period or experiencing side effects and sought counseling at a source before choosing a method.

CONCLUSIONS

This study highlights the importance of providing young women with high quality counseling that provides full information about contraceptive options and addresses that young women's needs vary along the reproductive health continuum of care. This will ensure that young women have information to inform future contraceptive decision-making prior to seeking care.

Impact of COVID-19 pandemic on the availability of maternal and child health products and childhood vaccines

BACKGROUND

In many low- and middle-income countries, the 2019 novel coronavirus (COVID-19) has challenged efforts to ensure access to and availability of quality maternal, newborn, and child health (MCH) services and essential MCH commodities.

OBJECTIVES

This study evaluated the impact of COVID-19 pandemic on the availability of maternal and child health products and childhood vaccines at selected health facilities in Ethiopia.

METHODS

We have prospectively assessed 28 maternal-child health products and 14 childhood vaccines and accessories, which are listed in the Ethiopian national essential medicines list. Data were collected from 5 hospitals located in the Jimma zone of Oromia regional state in the southwestern part of Ethiopia. We extracted data on drug availability, and order fill rates for these pharmaceutical products between May 2019 and August 2020.

RESULTS

The overall mean availability of selected maternal and child health products was 43.2%. It was 52.9% (range 21.0-63.6%) prior COVID-19 and 42.6% (range 19-56.4) during COVID-19 time. The average monthly orders fill rates of hospitals for the selected products ranged from 39 to 79%. Before COVID-19 the average order fill rate was near 70% of total orders placed by the hospitals. However, immediately after the COVID-19 case notification in Ethiopia, the percentage of order filled correctly in items and quantities began decreasing.

CONCLUSION

This study illustrates that the availability of key essential medicines for maternal and child health in the study area was low. The overall stock-out situation of MCH products has worsened during COVID-19 compared to pre-COVID-19 pandemic. None of the surveyed MCH products met the ideal availability benchmark of 80% in the public hospitals. To allow governments to guarantee these products are constantly available and affordable, a variety of policy frameworks and choices addressing inevitable epidemics should exist.

Contraceptive stockouts in Western Kenya: a mixed-methods mystery client study

BACKGROUND

The prevalence of modern contraception use is higher in Kenya than in most countries in Sub-Saharan Africa. The uptake has however slowed down in recent years, which, among other factors, has been attributed to challenges in the supply chain and increasing stockouts of family planning commodities. Research on the frequency of contraceptive stockouts and its consequences for women in Kenya is still limited and mainly based on facility audits.

METHODS

This study employs a set of methods that includes mystery clients, focus group discussions, key informant interviews, and journey mapping workshops. Using this multi-method approach, we aim to quantify the frequency of method denial resulting from contraceptive stockout and describe the impact of stockouts on the lived experiences of women seeking contraception in Western Kenya.

RESULTS

Contraceptives were found to be out of stock in 19% of visits made to health facilities by mystery clients, with all contraceptive methods stocked out in 9% of visits. Women experienced stockouts as a sizeable barrier to accessing their preferred method of contraception and a reason for taking up non-preferred methods, which has dire consequences for heath, autonomy, and the ability to prevent unintended pregnancy. Reasons for contraceptive stockouts are many and complex, and often linked to challenges in the supply chain - including inefficient planning, procurement, and distribution of family planning commodities.

CONCLUSIONS

Contraceptive stockouts are frequent and negatively impact patients, providers, and communities. Based on the findings of this study, the authors identify areas where funding and sustained action have the potential to ameliorate the frequency and severity of contraceptive stockouts, including more regular deliveries, in-person data collection, and use of data for forecasting, and point to areas where further research is needed.

Unmet need for family planning among married women in sub-Saharan Africa: a meta-analysis of DHS data (1995 - 2020)

BACKGROUND

Closing the gap of unmet needs for family planning (FP) in sub-Saharan Africa remains critical in improving maternal and child health outcomes. Determining the prevalence of unmet needs for family planning among married women in the reproductive age is vital for designing effective sexual reproductive health interventions and programmes. Here, we use nationally representative data drawn from sub-Saharan countries to estimate and examine heterogeneity of unmet needs for family planning among currently married women of reproductive age.

METHODS

This study used secondary data from Demographic and Health Surveys (DHS) conducted between January 1, 1995 to December 31, 2020 from 37 countries in sub-Saharan African. An Inverse Heterogeneity model (IVhet) in MetaXL application was used to estimate country and sub-regional level pooled estimates and confidence intervals of unmet needs for FP in SSA.

RESULTS

The overall prevalence of unmet need for family planning among married women of reproductive age in the sub-region for the period under study was 22.9% (95% CI: 20.9-25.0). The prevalence varied across countries from 10% (95% CI: 10-11%) in Zimbabwe to 38% (95% CI: 35-40) and 38 (95% CI: 37-39) (I2 = 99.8% and p-value < 0.0001) in Sao Tome and Principe and Angola, respectively. Unmet needs due to limiting ranged from 6%; (95% CI: 3-9) in Central Africa to 9%; (95% CI: 8-11) in East Africa. On the other hand, the prevalence of unmet needs due to spacing was highest in Central Africa (Prev: 18; 95% CI: 16-21) and lowest in Southern Africa (Prev: 12%; 95% CI: 8-16). Our study indicates that there was no publication bias because the Luis Furuya-Kanamori index (0.79) was within the symmetry range of -1 and + 1.

CONCLUSION

The prevalence of unmet need for FP remains high in sub-Saharan Africa suggesting the need for health policymakers to consider re-evaluating the current SRH policies and programmes with the view of redesigning the present successful strategies to address the problem.

Factors affecting provision of female family planning commodities in public health facilities in Kajiado county, Kenya

BACKGROUND

Family planning involves the use of traditional or modern methods to prevent maternal and infant mortality associated with unintended pregnancies and negative economic outcomes. In sub-Saharan Africa, the unmet need for modern family planning is approximately 66%. However, information on factors affecting utilization of female family planning commodities is limited. Therefore, this research was conducted to bridge this gap.

METHODS

Health facility-based descriptive cross-sectional research design was conducted and involved the public health facilities offering family planning, targeting respondents who handle the commodities and service providers themselves. A semi-structured questionnaire was used to collect data about availability of the commodities, knowledge of service providers and barriers affecting provision of the service. Data were coded and analyzed via Microsoft Excel 2019 and SPSS version 20.

RESULTS

The study showed that shorter term methods were more readily available, 60-75% than the long-term methods, 20-60%. Approximately 60% of the service providers did not comprehensively utilize the recommended World Health Organization Medicine Eligibility Criteria (WHO MEC) during service provision. Stock outs, myths and misconceptions, male interference and culture were the major barriers identified.

CONCLUSION

Provision of family planning commodities in public health facilities in Kajiado county is affected by stock levels at the national program, and provider knowledge on WHO MEC. The key factors affecting provision of family planning were stock outs, myths and misconceptions on the contraceptives, inadequate male involvement and inadequate community engagement on potential benefits of the service. These challenges need to be part of the solutions to bridging the gap identified.

Maintaining Continuity of Care for Expectant Mothers in Kenya During the COVID-19 Pandemic: A Study of MomCare

During the COVID-19 pandemic in Kenya, the MomCare platform enabled care-seeking behaviors to increase and quality of care to be maintained for expectant mothers despite social, economic, and access barriers.

In Kenya, early coronavirus disease (COVID-19) modeling studies predicted that disruptions in antenatal care and hospital services could increase indirect maternal and neonatal deaths and stillbirths. As the Kenyan government enforced lockdowns and a curfew, many mothers-to-be were unable to safely reach hospital facilities, especially at night. Fear of contracting COVID-19, increasing costs of accessing care, stigma, and falling incomes forced many expectant mothers to give birth at home. MomCare, which primarily serves communities in remote areas and urban slums, links mothers-to-be with payers and health care providers, following a standardized pregnancy program based on World Health Organization guidelines at a predetermined cost and quality. Expectant mothers gain access to care through a mobile wallet on their feature phone (voice, text, and basic internet), and providers are paid after appropriate care is given. Within the first 3 weeks of the pandemic in Kenya, the following services were added to the MomCare bundle: emergency ambulance services during curfew hours, extended bed allowances to encourage early care, phone calls to check on mothers approaching their delivery dates and to promote the generation of a birth plan, SMS messages to inform mothers of open facilities and COVID-19 protocols, and training for clinic staff in managing COVID-19 patients and infection prevention. We compare data collected through the MomCare platform during the 6 months before the first confirmed COVID-19 case in Kenya (September 2019–February 2020) with data collected during the 6 months that followed. This study shows that care-seeking behaviors (enrollment, antenatal/postnatal care, skilled deliveries) increased for mothers-to-be enrolled in MomCare during the COVID-19 lockdowns, while quality of care and outcomes were maintained. Public health practitioners can promote interactive, patient-driven technology like MomCare to augment traditional responses, quickly linking payments with patients and providers in times of crisis.

Healthcare workers' perspectives on access to sexual and reproductive health services in the public, private and private not-for-profit sectors: insights from Kenya, Tanzania, Uganda and Zambia

Background

Access to sexual and reproductive health services remains a challenge for many in Kenya, Tanzania, Uganda and Zambia. Health service delivery in the four countries is decentralised and provided by the public, private and private not-for-profit sectors. When accessing sexual and reproductive health services, clients encounter numerous challenges, which might differ per sector. Healthcare workers have first-hand insight into what impediments to access exist at their health facility. The aim of this study was to identify differences and commonalities in barriers to access to sexual and reproductive health services across the public, private and private not-for-profit sectors.

Methods

A cross-sectional survey was conducted among healthcare workers working in health facilities offering sexual and reproductive health services in Kenya (n = 212), Tanzania (n = 371), Uganda (n = 145) and Zambia (n = 243). Data were collected in July 2019. Descriptive statistics were used to describe the data, while binary logistic regression analyses were used to test for significant differences in access barriers and recommendations between sectors.

Results

According to healthcare workers, the most common barrier to accessing sexual and reproductive health services was poor patient knowledge (37.1%). Following, issues with supply of commodities (42.5%) and frequent stockouts (36.0%) were most often raised in the public sector; in the other sectors these were also raised as an issue. Patient costs were a more significant barrier in the private (33.3%) and private not-for-profit sectors (21.1%) compared to the public sector (4.6%), and religious beliefs were a significant barrier in the private not-for-profit sector compared to the public sector (odds ratio = 2.46, 95% confidence interval = 1.69–3.56). In all sectors delays in the delivery of supplies (37.4-63.9%) was given as main stockout cause. Healthcare workers further believed that it was common that clients were reluctant to access sexual and reproductive health services, due to fear of stigmatisation, their lack of knowledge, myths/superstitions, religious beliefs, and fear of side effects. Healthcare workers recommended client education to tackle this.

Conclusions

Demand and supply side barriers were manifold across the public, private and private not-for-profit sectors, with some sector-specific, but mostly cross-cutting barriers. To improve access to sexual and reproductive health services, a multi-pronged approach is needed, targeting client knowledge, the weak supply chain system, high costs in the private and private not-for-profit sectors, and religious beliefs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08249-y.

Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya

BACKGROUND

Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya.

METHODOLOGY/PRINCIPAL FINDINGS

This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible.

CONCLUSIONS

Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.

Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique

Background

Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals.

Method

The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals.

Results

Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility.

Conclusions

This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

Maternal mortality is an important public health problem in Mozambique. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. We conducted a study to describe the feasibility of task-sharing the screening and initiation of management for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and to document healthcare facility preparedness to respond to referrals. The study was done to inform a future intervention trial known as the Community-Level Interventions for Pre-eclampsia (CLIP) study. We interviewed community health workers, women, various community groups, health care providers, and policymakers and assessed health facilities in Maputo and Gaza provinces, Mozambique. Our results showed that community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they were not trained or equipped to provide obstetric emergencies care prior to referral. Nurses at primary health facilities were supportive of task-sharing with community health workers; however, some barriers mentioned include a lack of equipment, shortage of supervisors, and irregular drug availability. Local stakeholders emphasized the need for comprehensive training and supervision of community health workers to take on new tasks. Task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia was deemed feasible at the community level in southern Mozambique, but still, to be addressed some health system level barriers to the management of pregnancies complications.

Health facility readiness and provider knowledge as correlates of adequate diagnosis and management of pre-eclampsia in Kinshasa, Democratic Republic of Congo

BACKGROUND

Hypertensive disorders in pregnancy are the second most common cause of maternal mortality in the Democratic Republic of Congo (DRC), accounting for 23% of maternal deaths. This study aimed to assess facility readiness, and providers' knowledge to prevent, diagnose, and treat pre-eclampsia.

METHODS

A facility-based cross-sectional study was conducted in 30 primary health centres (PHCs) and 28 referral facilities (hospitals) randomly selected in Kinshasa, DRC. In each facility, all midwives and physicians involved in maternal care provision (n = 197) were included. Data on facility infrastructure and providers' knowledge about pre-eclampsia were collected using facility checklists and a knowledge questionnaire. Facility readiness score was defined as the sum of 13 health commodities needed to manage pre-eclampsia. A knowledge score was defined as the sum of 24 items about the diagnosis, management, and prevention of pre-eclampsia. The score ranges from 0 to 24, with higher values reflecting a better knowledge. The Mann-Witney U test was used to compare median readiness scores by facility type and ownership; and median knowledge scores between midwives in hospitals and in PHCs, and between physicians in hospitals and in PHCs.

RESULTS

Overall, health facilities had 7 of the 13 commodities, yielding a median readiness score of 53.8%(IQR: 46.2 to 69.2%). Although all provider groups had significant knowledge gaps about pre-eclampsia, providers in hospitals demonstrated slightly more knowledge than those in PHCs. Midwives in public facilities scored higher than those in private facilities (median(IQR): 8(5 to 12) vs 7(4 to 8), p = 0.03). Of the 197 providers, 91.4% correctly diagnosed severe pre-eclampsia. However, 43.9 and 82.2% would administer magnesium sulfate and anti-hypertensive drugs to manage severe pre-eclampsia, respectively. Merely 14.2 and 7.1% of providers were aware of prophylactic use of aspirin and calcium to prevent pre-eclampsia, respectively.

CONCLUSION

Our study showed poor availability of supplies to diagnose, prevent and treat pre-eclampsia in Kinshasa. While providers demonstrated good knowledge regarding the diagnosis of pre-eclampsia, they have poor knowledge regarding its prevention and management. The study highlights the need for strengthening knowledge of providers toward the prevention and management of pre-eclampsia, and enhancing the availability of supplies needed to address this disease.