Factors Associated with Contraceptive Use in Sub-Saharan Africa

Background:

Globally 10% of women have an unmet need for contraception, with higher rates in sub-Saharan Africa. Programs to improve family planning (FP) outcomes require data on how service characteristics (e.g., geographic access, quality) and women's characteristics are associated with contraceptive use.

Materials and Methods:

We combined data from health facility assessments (2018 and 2019) and a population-based regional household survey (2018) of married and in-union women ages 15–49 in the Kigoma Region of Tanzania. We assessed the associations between contraceptive use and service (i.e., distance, methods available, personnel) and women's (e.g., demographic characteristics, fertility experiences and intentions, attitudes toward FP) characteristics.

Results:

In this largely rural sample (n = 4,372), 21.7% of women used modern reversible contraceptive methods. Most variables were associated with contraceptive use in bivariate analyses. In multivariate analyses, access to services located <2 km of one's home that offered five methods (adjusted odds ratio [aOR] = 1.57, confidence interval [CI] = 1.18–2.10) and had basic amenities (aOR = 1.66, CI = 1.24–2.2) increased the odds of contraceptive use. Among individual variables, believing that FP benefits the family (aOR = 3.65, CI = 2.18–6.11) and believing that contraception is safe (aOR = 2.48, CI = 1.92–3.20) and effective (aOR = 3.59, CI = 2.63–4.90) had strong associations with contraceptive use.

Conclusions:

Both service and individual characteristics were associated with contraceptive use, suggesting the importance of coordination between efforts to improve access to services and social and behavior change interventions that address motivations, knowledge, and attitudes toward FP.

Mitigation policies, community mobility, and COVID-19 case counts in Australia, Japan, Hong Kong, and Singapore

OBJECTIVES

The objective of the study was to characterize the timing and trends of select mitigation policies, changes in community mobility, and coronavirus disease 2019 (COVID-19) epidemiology in Australia, Japan, Hong Kong, and Singapore.

STUDY DESIGN

Prospective abstraction of publicly available mitigation policies obtained from media reports and government websites.

METHODS

Data analyzed include seven kinds of mitigation policies (mass gathering restrictions, international travel restrictions, passenger screening, traveler isolation/quarantine, school closures, business closures, and domestic movement restrictions) implemented between January 1 and April 26, 2020, changes in selected measures of community mobility assessed by Google Community Mobility Reports data, and COVID-19 epidemiology in Australia, Japan, Hong Kong, and Singapore.

RESULTS

During the study period, community mobility decreased in Australia, Japan, and Singapore; there was little change in Hong Kong. The largest declines in mobility were seen in places that enforced mitigation policies. Across settings, transit-associated mobility declined the most and workplace-associated mobility the least. Singapore experienced an increase in cases despite the presence of stay-at-home orders, as migrant workers living in dormitories faced challenges to safely quarantine.

CONCLUSIONS

Public policies may have different impacts on mobility and transmission of severe acute respiratory coronavirus-2 transmission. When enacting mitigation policies, decision makers should consider the possible impact of enforcement measures, the influence on transmission of factors other than movement restrictions, and the differential impact of mitigation policies on subpopulations.

Referral transit time between sending and first-line receiving health facilities: a geographical analysis in Tanzania

Background

Timely, high-quality obstetric services are vital to reduce maternal and perinatal mortality. We spatially modelled referral pathways between sending and receiving health facilities in Kigoma Region, Tanzania, identifying communication and transportation delays to timely care and inefficient links within the referral system.

Methods

We linked sending and receiving facilities to form facility pairs, based on information from a 2016 Health Facility Assessment. We used an AccessMod cost-friction surface model, incorporating road classifications and speed limits, to estimate direct travel time between facilities in each pair. We adjusted for transportation and communications delays to create a total travel time, simulating the effects of documented barriers in this referral system.

Results

More than half of the facility pairs (57.8%) did not refer patients to facilities with higher levels of emergency obstetric care. The median direct travel time was 25.9 min (range: 4.4–356.6), while the median total time was 106.7 min (22.9–371.6) at the moderate adjustment level. Total travel times for 30.7% of facility pairs exceeded 2 hours. All facility pairs required some adjustments for transportation and communication delays, with 94.0% of facility pairs’ total times increasing.

Conclusion

Half of all referral pairs in Kigoma Region have travel time delays nearly exceeding 1 hour, and facility pairs referring to facilities providing higher levels of care also have large travel time delays. Combining cost-friction surface modelling estimates with documented transportation and communications barriers provides a more realistic assessment of the effects of inter-facility delays on referral networks, and can inform decision-making and potential solutions in referral systems within resource-constrained settings.

Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia

Through district system strengthening, integrated services, and community engagement interventions, the Saving Mothers, Giving Life initiative increased emergency obstetric care coverage and access to, and demand for, improved quality of care that led to rapid declines in district maternal and perinatal mortality. Significant reductions in intrapartum stillbirth rate and maternal mortality ratios around the time of birth attest to the success of the initiative.

Background:

Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions.

Methods:

SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities.

Results:

Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country.

Conclusions:

MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.

Did Saving Mothers, Giving Life Expand Timely Access to Lifesaving Care in Uganda? A Spatial District-Level Analysis of Travel Time to Emergency Obstetric and Newborn Care

A spatial analysis of facility accessibility, taking into account road networks and environmental constraints on travel, suggests that the Saving Mothers, Giving Life (SMGL) initiative increased access to emergency obstetric and neonatal care in SMGL-supported districts in Uganda. Spatial travel-time analyses can inform policy and program efforts targeting underserved populations in conjunction with the geographic distribution of maternity services.

Introduction:

Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access.

Methods:

We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources.

Results:

The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P < .01) could be used. Increases in timely access were also substantial for nonmotorized transportation such as walking and/or bicycling.

Conclusions:

Largely due to the SMGL-supported expansion of EmONC capability, timely access to EmONC significantly improved. Our analysis developed a geographic outline of facility accessibility using multiple types of transportation. Spatial travel-time analyses, along with other EmONC indicators, can be used by planners and policy makers to estimate need and target underserved populations to achieve further gains in EmONC accessibility. In addition to increasing the number and geographic distribution of EmONC facilities, complementary efforts to make motorized transportation available are necessary to achieve meaningful increases in EmONC access.

Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care

Saving Mothers, Giving Life used 6 strategies to address the third delay—receiving adequate health care after reaching a facility—in maternal and newborn health care. The intervention approaches can be adapted in low-resource settings to improve facility-based care and reduce maternal and perinatal mortality.

Background:

Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response.

Methods:

SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data—health facility assessments, facility and community surveillance, and population-based mortality studies—were used to document the effectiveness of intervention components.

Results:

During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline—from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened.

Conclusion:

SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths.

Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner

The Saving Mothers, Giving Life initiative employed 2 key strategies to improve the ability of pregnant women to reach maternal care: (1) increase the number of emergency obstetric and newborn care facilities, including upgrading existing health facilities, and (2) improve accessibility to such facilities by renovating and constructing maternity waiting homes, improving communication and transportation systems, and supporting community-based savings groups. These interventions can be adapted in low-resource settings to improve access to maternity care services.

Background:

Between June 2011 and December 2016, the Saving Mothers, Giving Life (SMGL) initiative in Uganda and Zambia implemented a comprehensive approach targeting the persistent barriers that impact a woman's decision to seek care (first delay), ability to reach care (second delay), and ability to receive adequate care (third delay). This article addresses how SMGL partners implemented strategies specifically targeting the second delay, including decreasing the distance to facilities capable of managing emergency obstetric and newborn complications, ensuring sufficient numbers of skilled birth attendants, and addressing transportation challenges.

Methods:

Both quantitative and qualitative data collected by SMGL implementing partners for the purpose of monitoring and evaluation were used to document the intervention strategies and to describe the change in outputs and outcomes related to the second delay. Quantitative data sources included pregnancy outcome monitoring data in facilities, health facility assessments, and population-based surveys. Qualitative data were derived from population-level verbal autopsy narratives, programmatic reports and SMGL-related publications, and partner-specific evaluations that include focus group discussions and in-depth interviews.

Results:

The proportion of deliveries in any health facility or hospital increased from 46% to 67% in Uganda and from 63% to 90% in Zambia between baseline and endline. Distance to health facilities was reduced by increasing the number of health facilities capable of providing basic emergency obstetric and newborn care services in both Uganda and Zambia—a 200% and 167% increase, respectively. Access to facilities improved through integrated transportation and communication services efforts. In Uganda there was a 6% increase in the number of health facilities with communication equipment and a 258% increase in facility deliveries supported by transportation vouchers. In Zambia, there was a 31% increase in health facilities with available transportation, and the renovation and construction of maternity waiting homes resulted in a 69% increase in the number of health facilities with associated maternity waiting homes.

Conclusion:

The collective SMGL strategies addressing the second delay resulted in increased access to delivery services as seen by the increase in the proportion of facility deliveries in SMGL districts, improved communication and transportation services, and an increase in the number of facilities with associated maternity waiting homes. Sustaining and improving on these efforts will need to be ongoing to continue to address the second delay in Uganda and Zambia.

Geographic Access Modeling of Emergency Obstetric and Neonatal Care in Kigoma Region, Tanzania: Transportation Schemes and Programmatic Implications

32% of estimated live births in the region may not be able to reach emergency obstetric and neonatal care (EmONC) services within 2 hours in dry season, regardless of the type of transportation available. However, bicycles, motorcycles, and cars provide a significant increase in geographic accessibility in some areas. Achieving good access may require upgrading non-EmONC facilities to EmONC facilities in some districts while incorporating bicycles and motorcycles into the health transportation strategy in others.

Background:

Access to transportation is vital to reducing the travel time to emergency obstetric and neonatal care (EmONC) for managing complications and preventing adverse maternal and neonatal outcomes. This study examines the distribution of travel times to EmONC in Kigoma Region, Tanzania, using various transportation schemes, to estimate the proportion of live births (a proxy indicator of women needing delivery care) with poor geographic access to EmONC services.

Methods:

The 2014 Reproductive Health Survey of Kigoma Region identified 4 primary means of transportation used to travel to health facilities: walking, cycling, motorcycle, and 4-wheeled motor vehicle. A raster-based travel time model was used to map the 2-hour travel time catchment for each mode of transportation. Live birth density distributions were aggregated by travel time catchments, and by administrative council, to estimate the proportion of births with poor access.

Results:

Of all live births in Kigoma Region, 13% occurred in areas where women can reach EmONC facilities within 2 hours on foot, 33% in areas that can be reached within 2 hours only by motorized vehicles, and 32% where it is impossible to reach EmONC facilities within 2 hours. Over 50% of births in 3 of the 8 administrative councils had poor estimated access. In half the councils, births with poor access could be reduced to no higher than 12% if all female residents had access to motorized vehicles.

Conclusion:

Significant differences in geographic access to EmONC in Kigoma Region, Tanzania, were observed both by location and by primary transportation type. As most of the population may only have good EmONC access when using mechanized or motorized vehicles, bicycles and motorcycles should be incorporated into the health transportation strategy. Collaboration between private transportation sectors and obstetric service providers could improve access to EmONC services among most populations. In areas where residents may not access EmONC facilities within 2 hours regardless of the type of transportation used, upgrading EmONC capacity among nearby non-EmONC facilities may be required to improve accessibility.

The impact of implementing a demand forecasting system into a low-income country's supply chain

OBJECTIVE

To evaluate the potential impact and value of applications (e.g. adjusting ordering levels, storage capacity, transportation capacity, distribution frequency) of data from demand forecasting systems implemented in a lower-income country's vaccine supply chain with different levels of population change to urban areas.

MATERIALS AND METHODS

Using our software, HERMES, we generated a detailed discrete event simulation model of Niger's entire vaccine supply chain, including every refrigerator, freezer, transport, personnel, vaccine, cost, and location. We represented the introduction of a demand forecasting system to adjust vaccine ordering that could be implemented with increasing delivery frequencies and/or additions of cold chain equipment (storage and/or transportation) across the supply chain during varying degrees of population movement.

RESULTS

Implementing demand forecasting system with increased storage and transport frequency increased the number of successfully administered vaccine doses and lowered the logistics cost per dose up to 34%. Implementing demand forecasting system without storage/transport increases actually decreased vaccine availability in certain circumstances.

DISCUSSION

The potential maximum gains of a demand forecasting system may only be realized if the system is implemented to both augment the supply chain cold storage and transportation. Implementation may have some impact but, in certain circumstances, may hurt delivery. Therefore, implementation of demand forecasting systems with additional storage and transport may be the better approach. Significant decreases in the logistics cost per dose with more administered vaccines support investment in these forecasting systems.

CONCLUSION

Demand forecasting systems have the potential to greatly improve vaccine demand fulfilment, and decrease logistics cost/dose when implemented with storage and transportation increases. Simulation modeling can demonstrate the potential health and economic benefits of supply chain improvements.

Disrupted melatonin-secretion during alcohol withdrawal

1. The synthesis of the pineal hormone, melatonin, is under adrenergic control. The brain's rhythm generating system (suprachiasmatic nucleus and associated systems) which is synchronised by the light-dark cycle controls norepinephrine release from the sympathetic nerve terminal resulting in cAMP accumulation. Increased cAMP leads to induction of the rate-limiting enzyme, N-acetyltransferase and synthesis of melatonin. The pineal exhibits a circadian rhythm with highest blood levels of the hormone being present during the night. The circadian rhythm of melatonin production provides important time-of-day and time-of-year information and, as a result, this hormonal cycle drives other 24-hour rhythms as well as seasonal cycles of reproduction, at least in photoperiodic mammals. 2. Chronic alcoholics were withdrawn from alcohol during a continued period of 4 days and nights. Blood samples were drawn from an indwelling venous catheter and sleep was monitored with polysomnography. No medication was used. No alcohol intake was allowed after admission. Bright light treatment was applied during day 3 of the study. 3. During the 4 days of alcohol-withdrawal the night time melatonin-secretion was disrupted. More than 50% of the patients had a very low secretion (< 30 pg/ml) which did not normalize during the study period. Psychopathology, sleep quality and sleep architecture improved significantly. The melatonin secretion pattern showed low values throughout the study. This low melatonin secretion might reflect the long lasting toxic influence of alcohol on the biological clock and/or a direct inhibitory effect on pineal function. These are different effects, although interrelated. 4. Ethanol has a direct inhibitory effect on pineal melatonin synthesis. A well-recognized action of ethanol is its ability to permeate and perturb the structure of cell membranes and may be related to its lipophilic properties. The changes in membrane fluidity seem to last longer than the study period of 4 days.