The impact of supply-side and demand-side interventions on use of antenatal and maternal services in western Kenya: a qualitative study.

BACKGROUND: Antenatal care (ANC) and delivery by skilled providers have been well recognized as effective strategies to prevent maternal and neonatal mortality. ANC and delivery services at health facilities, however, have been underutilized in Kenya. One potential strategy to increase the demand for ANC services is to provide health interventions as incentives for pregnant women. In 2013, an integrated ANC program was implemented in western Kenya to promote ANC visits by addressing both supply- and demand-side factors. Supply-side interventions included nurse training and supplies for obstetric emergencies and neonatal resuscitation. Demand-side interventions included SMS text messages with appointment reminders and educational contents, group education sessions, and vouchers to purchase health products. METHODS: To explore pregnant mothers' experiences with the intervention, ANC visits, and delivery, we conducted focus group discussions (FGDs) at pre- and post-intervention. A total of 19 FGDs were held with pregnant mothers, nurses, and community health workers (CHWs) during the two assessment periods. We performed thematic analyses to highlight study participants' perceptions and experiences. RESULTS: FGD data revealed that pregnant women perceived the risks of home-based delivery, recognized the benefits of facility-based delivery, and were motivated by the incentives to seek care despite barriers to care that included poverty, lack of transport, and poor treatment by nurses. Nurses also perceived the value of incentives to attract women to care but described obstacles to providing health care such as overwork, low pay, inadequate supplies and equipment, and insufficient staff. CHWs identified the utility and limitations of text messages for health education. CONCLUSIONS: Future interventions should ensure that adequate workforce, training, and supplies are in place to respond to increased demand for maternal and child health services stimulated by incentive programs.

Can incentives reduce the barriers to use of antenatal care and delivery services in Kenya?: Results of a qualitative inquiry.

A qualitative inquiry was used to assess if incentives consisting of a hygiene kit, protein-fortified flour, and delivery kit reduced barriers to antenatal care and delivery services in Nyanza Province, Kenya. We conducted 40 interviews (baseline: five nurses, six mothers, one focus group of five mothers; follow-up: nine nurses, 19 mothers) to assess perceptions of these services. Mothers and nurses identified poor quality of care, fear of HIV diagnosis and stigma, inadequate transport, and cost of care as barriers. Nurses believed incentives encouraged women to use services; mothers described wanting good birth outcomes as their motivation. While barriers to care did not change during the study, incentives may have increased service use. These findings suggest that structural improvements-upgraded infrastructure, adequate staffing, improved treatment of women by nurses, low or no-cost services, and provision of transport-could increase satisfaction with and use of services, improving maternal and infant health.

Nrf2 deficiency promotes apoptosis and impairs PAX7/MyoD expression in aging skeletal muscle cells.

Skeletal muscle redox homeostasis is transcriptionally regulated by nuclear erythroid-2-p45-related factor-2 (Nrf2). We recently demonstrated that age-associated stress impairs Nrf2-ARE (antioxidant-response element) transcriptional signaling. Here, we hypothesize that age-dependent decline or genetic ablation of Nrf2 leads to accelerated apoptosis and skeletal muscle degeneration. Under basal-physiological conditions, disruption of Nrf2 significantly downregulates antioxidants and causes oxidative stress. Surprisingly, Nrf2-null mice had enhanced antioxidant capacity identical to wild-type (WT) upon acute endurance exercise stress (AEES), suggesting activation of Nrf2-independent mechanisms (i.e., PGC1α) against oxidative stress. Analysis of prosurvival pathways in the basal state reveals decreased AKT levels, whereas p-p53, a repressor of AKT, was increased in Nrf2-null vs WT mice. Upon AEES, AKT and p-AKT levels were significantly (p < 0.001) increased (>10-fold) along with profound downregulation of p-p53 (p < 0.01) in Nrf2-null vs WT skeletal muscle, indicating the onset of prosurvival mechanisms to compensate for the loss of Nrf2 signaling. However, we found a decreased stem cell population (PAX7) and MyoD expression (differentiation) along with profound activation of ubiquitin and apoptotic pathways in Nrf2-null vs WT mice upon AEES, suggesting that compensatory prosurvival mechanisms failed to overcome the programmed cell death and degeneration in skeletal muscle. Further, the impaired regeneration was sustained in Nrf2-null vs WT mice after 1 week of post-AEES recovery. In an age-associated oxidative stress condition, ablation of Nrf2 results in induction of apoptosis and impaired muscle regeneration.