Experiences of young mothers with the uptake of Sulfadoxine-Pyrimethamine for intermittent preventive treatment of malaria in pregnancy: a cross-sectional study in the Lake endemic region, Kenya.

Background: A substantial proportion of the world population is affected by malaria with 241 million malaria cases reported globally. Intermittent Preventive Treatment in pregnancy (IPTp) with Sulfadoxine-Pyrimethamine (SP) is an effective chemotherapy but its utilisation has not been optimised. Few studies focus on young mothers and their experiences regarding the optimal uptake of IPTp-SP. Methods: The study design was cross-sectional with data derived from six focus group discussions with mothers aged 15-24 years who had a pregnancy and gave birth to a live baby within the last two years in Kisumu and Migori counties, Kenya. Inductive analysis was used to identify themes and patterns. Results: Young mothers were motivated to take IPTp-SP during pregnancy if they had prior knowledge about SP and its associated benefits and if they were knowledgeable about the consequences of malaria infection during pregnancy. Perceived side effects of SP, lack of awareness of SP as a malaria prevention therapy, lack of knowledge on the benefits of SP, dosage and frequency of uptake, poor communication by health providers towards young mothers, and inconsistent supply of SP at health facilities inhibited young mothers from attaining the recommended 3+ doses of IPTp-SP. Conclusions: There is a need for health literacy programmes that focus on increasing knowledge of IPTp-SP dosage, timing and benefits for both the young pregnant mother and her foetus. Community engagement through dialogue with mentor mothers and male partners will be an important complementary approach in establishing a support system for young women for positive health outcomes including attaining the recommended 3+ doses of IPTp-SP.

Women's empowerment and uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy: results from a cross-sectional baseline survey in the Lake endemic region, Kenya.

BACKGROUND: Malaria in pregnancy remains a major public health problem in endemic areas of the sub-Saharan African (SSA) region. However, there is limited understanding of the association between women's empowerment and the uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy (IPTp-SP) in Kenya. This study examines the association between women's empowerment indicators (decision-making power, control of assets, education, and employment status) and the uptake of three or more doses of IPTp-SP in the Lake endemic region of Kenya. METHODS: The analysis utilized a dataset from a cross-sectional baseline survey of 3129 women aged 15-49 years in Kisumu and Migori Counties who had a live birth within the last 2 years preceding the study. Data were collected between June to August 2021. A descriptive analysis was conducted to show the distribution of respondents by key background characteristics, and bivariate and multivariate logistic regression to examine statistically significant associations between women's empowerment measures and the uptake of 3+ doses of IPTp-SP. RESULTS: Among the 3129 women surveyed, 1978 (65.7%) received 3+ doses of IPTp-SP during their most recent pregnancy. Controlling for individual characteristics and the number of ANC visits, the odds of taking 3+ doses of IPTp-SP increased among women who had high decision-making autonomy (AOR = 2.33; CI = 1.81-3.01; P < 0.001); and tertiary level of educational attainment (AOR = 1.51; CI = 1.10-2.06). However, the association between control of assets and uptake of IPTp-SP was positive but not statistically significant. CONCLUSION: Women's decision-making autonomy and educational attainment were positively associated with the uptake of IPTp-SP. As a result, maternal health interventions should focus on less empowered women, specifically those with less decision-making autonomy and no/low formal education, as they are less likely to achieve optimal uptake of IPTp-SP during pregnancy.

What interventions are effective to prevent or respond to female genital mutilation? A review of existing evidence from 2008-2020.

As the final decade of acceleration towards zero new cases of Female Genital Mutilation (FGM, SDG Target 5.3) by 2030 has begun, increasing the rigour, relevance, and utility of research for programming, policy development and resource allocation is critical. This study aimed to synthesize and assess the quality and strength of existing evidence on interventions designed to prevent or respond to FGM between 2008 and 2020.The study drew on a Rapid Evidence Assessment of the available literature on FGM interventions. The quality of studies was assessed using the 'How to Note: Assessing the Strength of Evidence' guidelines published by the Foreign, Commonwealth and Development Office (FCDO) and strength of evidence using a modified Gray scale developed by the What Works Association. Of the 7698 records retrieved, 115 studies met the inclusion criteria. Of the 115 studies, 106 were of high and moderate quality and were included in the final analysis. This review shows that at the system level, legislation-related interventions must be multifaceted to be effective. Whilst all levels would benefit from more research, for the service level especially more research is needed into how the health system can effectively prevent and respond to FGM. Community-level interventions are effective for changing attitudes towards FGM, but more must be done to innovate with these interventions so that they move beyond affecting attitudes alone to creating behaviour change. At the individual level, formal education is effective in reducing FGM prevalence among girls. However, the returns of formal education in ending FGM may take many years to be realized. Interventions targeting intermediate outcomes, such as improvement in knowledge and change in attitudes and beliefs towards FGM, are equally needed at the individual level.

The perceived effects of COVID-19 pandemic on female genital mutilation/cutting and child or forced marriages in Kenya, Uganda, Ethiopia and Senegal.

BACKGROUND: The effects of COVID-19 on harmful traditional practices such Female Genital Mutilation/Cutting (FGM/C) and Child or Forced Marriages (CFM) have not been well documented. We examined respondents' perceptions on how the COVID-19 pandemic has affected FGM/C and CFM in Kenya, Uganda, Senegal, and Ethiopia. METHODS: A cross-sectional study design with a mixed methods approach was used. Data collection on participants' perceptions on the effects of COVID-19 on FGM/C and CFM took place between October-December 2020. Household surveys targeting women and men aged 15-49 years in Kenya (n = 312), Uganda (n = 278), Ethiopia (n = 251), and Senegal (n = 208) were conducted. Thirty-eight key informant interviews with programme implementers and policymakers were carried out in Kenya (n = 17), Uganda (n = 9), Ethiopia (n = 8), and Senegal (n = 4). RESULTS: In Kenya, the COVID-19 pandemic has contributed to the increase in both FGM/C and CFM cases. Minimal increase of FGM/C cases was reported in Uganda and a significant increase in CFM cases. In Ethiopia, the COVID-19 pandemic had a limited perceived effect on changes in FGM/C and CFM. In Senegal, there were minimal perceived effects of COVID-19 on the number of FGM/C and CFM cases. The pandemic negatively affected implementation of interventions by the justice and legal system, the health system, and civil societies. CONCLUSIONS: The pandemic has had varied perceived effects on FGM/C and CFM across the four countries. Generally, the pandemic has negatively affected implementation of interventions by the various sectors that are responsible for preventing and responding to FGM/C and CFM. This calls for innovative approaches in intervening in the various communities to ensure that women and girls at risk of FGM/C and CFM or in need of services are reached during the pandemic. Evidence on how effective alternative approaches such as the use of call centres, radio talk shows and the use of local champions as part of risk communication in preventing and responding to FGM/C and CFM amid COVID-19 is urgently required.

Persistence of female genital mutilation/cutting in two Kenyan communities: What can we learn from change that falls short of abandonment?

Literature on dynamics of change in female genital mutilation/cutting (FGM/C) portray two common but conflicting views. On one side, FGM/C is seen as static and deeply entrenched, with parents lacking agency to interpret culture, evaluate options and adopt changes. An alternative perspective focuses on the fluidity of social norms, influencing whether and how FGM/C is practised. This study asks: in counties where FGM/C persists at high rates, Kisii and Narok, are there changes in the way that FGM/C is performed? and what drives these changes? In-depth interviews and focus group discussions were conducted to illuminate these questions. Data showed five ways that FGM/C practices have changed: (1) reduction in severity of cutting, (2) medicalised cutting, (3) performing FGM/C at younger ages, (4) cutting in secret, and (5) occasionally, abandonment of FGM/C. Messaging on health risks of FGM/C and fear of criminal punishment have motivated less severe cutting and medicalisation. Legislation has also driven the practice underground. Programmes aimed at ending FGM/C should create a critical dialogue on changes in norms with the intent of reducing stigmatisation of uncut girls and their families, and the ways cutting practices are shifting, thereby building on change that is already underway.

Plurality of beliefs about female genital mutilation amidst decades of intervention programming in Narok and Kisii Counties, Kenya.

Female genital mutilation derails efforts to achieve gender equality and the empowerment of girls and women. In Kenya, national estimates show a steady decline in prevalence, although there is considerable variation at the sub-national level. There is a need to better understand female genital mutilation-related norms and meanings and whether there have been changes in these given long-term and diverse efforts to promote abandonment. Focusing on Narok and Kisii counties, we conducted a cross-sectional qualitative study to identify social norms surrounding the practice of female genital mutilation, as well as consensus or contestation with respect to these norms. Ten focus group discussions were held with men and women aged 18 years and older from the Maasai and Abagusii communities that have traditionally practised female genital mutilation. Study findings showed that norms associated with female genital mutilation such as sexuality and marriageability were actively contested by community members. This change may provide a useful starting point for programmes that seek to create dialogue and critical reflection on female genital mutilation to accelerate its abandonment.

Analysing Normative Influences on the Prevalence of Female Genital Mutilation/Cutting among 0-14 Years Old Girls in Senegal: A Spatial Bayesian Hierarchical Regression Approach.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a harmful traditional practice affecting the health and rights of women and girls. This has raised global attention on the implementation of strategies to eliminate the practice in conformity with the Sustainable Development Goals (SDGs). A recent study on the trends of FGM/C among Senegalese women (aged 15-49) which examined how individual- and community-level factors affected the practice, found significant regional variations in the practice. However, the dynamics of the practice among girls (0-14 years old) is not fully understood. This paper attempts to fill this knowledge gap by investigating normative influences in the persistence of the practice among Senegalese girls, identify and map 'hotspots'. METHODS: We do so by using a class of Bayesian hierarchical geospatial modelling approach implemented in R statistical software (R Foundation for Statistical Computing, Vienna, Austria) using R2BayesX package. We employed Markov Chain Monte Carlo (MCMC) techniques for full Bayesian inference, while model fit and complexity assessment utilised deviance information criterion (DIC). RESULTS: We found that a girl's probability of cutting was higher if her mother was cut, supported FGM/C continuation or believed that the practice was a religious obligation. In addition, living in rural areas and being born to a mother from Diola, Mandingue, Soninke or Poular ethnic group increased a girl's likelihood of being cut. The hotspots identified included Matam, Tambacounda and Kolda regions. CONCLUSIONS: Our findings offer a clearer picture of the dynamics of FGM/C practice among Senegalese girls and prove useful in informing evidence-based intervention policies designed to achieve the abandonment of the practice in Senegal.

Evaluating changes in the prevalence of female genital mutilation/cutting among 0-14 years old girls in Nigeria using data from multiple surveys: A novel Bayesian hierarchical spatio-temporal model.

Female genital mutilation/cutting (FGM/C) is considered a public health and human rights concern, mainly concentrated in Africa, and has been targeted for elimination under the sustainable development goals. Interventions aimed at ending the practice often rely on data from household surveys which employ complex designs leading to outcomes that are not totally independent, thus requiring advanced statistical techniques. Combining data from multiple surveys within robust statistical framework holds promise to provide more precise estimates due to increased sample size, and accurately identify 'hotspots' and allow for assessment of changes over time. In this study, rich datasets from six (6) successive waves of the Nigeria Demographic and Health Surveys and Multiple Indicator Cluster Surveys undertaken between 2003 and 2016/17, were combined and analyzed in order to better assess changes in the likelihood and prevalence of FGM/C among 0-14-year old girls in Nigeria. We used Bayesian hierarchical regression models which explicitly accounted for the inherent spatial and temporal autocorrelations within the data while simultaneously adjusting for variations due to different survey methods and the effects of linear and non-linear covariates. Parameters were estimated using Markov chain Mote Carlo techniques and model fit assessments were based on Deviance Information Criterion. Results show that prevalence of FGM/C among 0-14 years old girls in Nigeria varied over time and across geographical locations and peaked in 2008 with a shift from South to North. A girl was more likely to be cut if her mother was cut, supported FGM/C continuation, or had no higher education. The effects of mother's age, wealth and type of residence (urban-rural) were no longer significant in 2016. These results reflect the gains of interventions over the years, but also echo the belief that FGM/C is a social norm thus requiring tailored all-inclusive interventions for the total abandonment of FGM/C in Nigeria.

Challenges and prospects for implementation of community health volunteers' digital health solutions in Kenya: a qualitative study.

BACKGROUND: The value of digital health technologies in delivering vital health care interventions, especially in low resource settings is increasingly appreciated. We co-developed and tested a decision support mobile health (m-Health) application (app);with some of the forms used by Community Health Volunteers (CHVs) in Kenya to collect data and connected to health facilities. This paper explores the experiences of CHVs, health workers and members of Sub-County Health Management Teams following implementation of the project. METHODS: Data were collected in December 2017 through in-depth interviews and focus group discussions with CHVs and key informant interviews with health care workers and health managers in Kamukunji sub-County of Nairobi, Kenya. Data coding and analysis was performed in NVivo 12. RESULTS: Regarding users and health managers' perceptions towards the system; three main themes were identified: 1) variations in use, 2) barriers to use and 3) recommendations to improve use. Health workers at the private facility and some CHVs used the system more than health workers at the public facilities. Four sub-themes under barriers to use were socio-political environment, attitudes and behaviour, issues related to the system and poor infrastructure. A prolonged health workers' strike, the contentious presidential election in the year of implementation, interrupted electricity supply and lack of basic electric fixtures were major barriers to use. Suggestions to improve usage were: 1) integration of the system with others in use and making it available on users' regular phones, and 2) explore sustainable motivation models to users as well as performance based remuneration. CONCLUSIONS: The findings reveal the importance of considering the readiness of information and communication technologies (ICT) users before rollout of ICT solutions. The political and sociocultural environment in which the innovation is to be implemented and integration of new solutions into existing ones is critical for success. As more healthcare delivery models are developed, harnessing the potential of digital technologies, strengthening health systems is critical as this provides the backbone on which such innovations draw support.

Exploring the capacity of the Somaliland healthcare system to manage female genital mutilation / cutting-related complications and prevent the medicalization of the practice: a cross-sectional study.

BACKGROUND: Female genital mutilation/cutting (FGM/C) negatively impacts the wellbeing of girls and women throughout their lifecycle. In Somalia, FGM/C prevalence is nearly universal (98%) among females aged 15-49 years, with infibulation prevalence at 77%. Whilst there is need to engage healthcare workers in the prevention and management of FGM/C, minimal information exists indicating healthcare systems' capacity to fulfil this role. This study explored factors impacting the capacity of the Somaliland healthcare system to prevent the medicalization, and manage the complications of, FGM/C. METHODS: A cross-sectional qualitative study using semi-structured key informant interviews, conducted in the Somali language, was undertaken in the Maroodi Jeex and Awdal regions of Somaliland, in rural and urban Borama and Hargeisa districts in December 2016. A total of 20 interviews were conducted with healthcare workers comprised of medical doctors, nurses, midwives and system administrators. Transcribed and translated interview data were analysed using the template analysis approach. RESULTS: Healthcare workers reported understanding the adverse impact of FGM/C on the health of girls and women. However, they faced multiple contextual challenges in their preventative and management roles at the individual level, e.g., they lacked specific formal training on the prevention and management of FGM/C complications and its medicalization; institutional level, e.g., many facilities lacked funding and equipment for effective FGM/C management; and policy level, e.g., no national policies exist on the management of FGM/C complications and against its medicalization. CONCLUSION: Healthcare systems in urban and rural Somaliland have limited capacity to prevent, diagnose and manage FGM/C. There is a need to strengthen healthcare workers' skill deficits through training and address gaps in the health system by incorporating the care of girls and women with FGM-related complications into primary healthcare services through multi-sectoral collaboration and coordination, establishing clinical guidelines for FGM/C management, providing related equipment, and enacting policies to prevent the medicalization of the practice.

Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries.

OBJECTIVES: Literature on associations between female genital mutilation/cutting (FGM/C) and fistula points to a common belief that FGM/C predisposes women to developing fistula. This study explores this association using nationally representative survey data. DESIGN: A secondary statistical analysis of cross-sectional data from Demographic and Health Surveys was conducted to explore the association between FGM/C and fistula. SETTING: Sub-Saharan Africa. PARTICIPANTS: Women aged 15-49 years in Burkina Faso (n=17 087), Chad (n=17 719), Côte d'Ivoire (n=10 060), Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) and Sierra Leone (n=16 658). MAIN OUTCOME MEASURES: Fistula symptoms. RESULTS: Multivariate logit modelling using pooled data from 10 countries showed that the odds of reporting fistula symptoms were 1.5 times (CI 1.06 to 2.21) higher for women whose genitals were cut and sewn closed than those who had undergone other types of FGM/C. Women who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report fistula symptoms than those who did not attend ANC or lived in rural areas. CONCLUSIONS: Severe forms of FGM/C (infibulation) may predispose women to fistula. Contextual and socioeconomic factors may increase the likelihood of fistula. Multisectoral interventions that concurrently address harmful traditional practices such as FGM/C and other contextual factors that drive the occurrence of fistula are warranted. Promotion of ANC utilisation could be a starting point in the prevention of fistulas.

Factors associated with use of injectables, long-acting and permanent contraceptive methods (iLAPMs) among married women in Zambia: analysis of demographic and health surveys, 1992-2014.

BACKGROUND: Zambia, with its women having five children on average, is one of the countries in sub-Saharan African with the highest fertility rates. As the country works on expanding its reproductive health programs, this analysis sought to understand factors behind the current utilisation of injectable, long acting and permanent methods (iLAPMs) of contraception. METHODS: Cross-sectional secondary data drawn from the Zambia Demographic and Health Surveys (ZDHS) were used. This included married women aged 15-49 for the years 1992 (n = 620), 1996 (n = 1176), 2001/02 (n = 1483), 2007 (n = 1665) and 2013/14 (n = 4394). Frequencies, cross-tabulations and logistic regression were used to analyse levels and differentials in use of iLAPMs. RESULTS: Except for the variables "religion" and "region", the rest of the independent variables show significance on the use of iLAPMs, at varying levels. "Desire for children" is the strongest predictor of use of iLAPMs as it was significant at all the five data points. This is followed by "age", although it was not significant in 2007. "Education of the woman and partner" and "number of living children" were also significant, but only for two out of the five data collection points. "Ethnicity", "type of residence", "heard about FP in last 12 months", and "main decision maker on woman's health" were only significant for one out of the five data points. CONCLUSION: This study has established that women's desire for children is the main factor influencing use of iLAPMs in Zambia. Women who still want to have children are less likely to use iLAPMs even though the odds of using these methods among these women increased between 1992 and 2014. This indicates that most of this increase is due to the desire by these women to space births rather than stop having children. The 2013/2014 data also suggest an increase in access to iLAPMs among the less privileged women i.e. those in rural areas and those with low levels of education. This trend appears to have stemmed from the scaling up of family planning programmes to cover rural communities. Greater effort should be invested into family planning programs that reach all categories of women.

The Influence of Maternal and Household Resources, and Parental Psychosocial Child Stimulation on Early Childhood Development: A Cross-Sectional Study of Children 36⁻59 Months in Honduras.

Optimal early childhood development (ECD) is currently jeopardized for more than 250 million children under five in low- and middle-income countries. The Sustainable Development Goals has called for a renewed emphasis on children’s wellbeing, encompassing a holistic approach that ensures nurturing care to facilitate optimal child development. In vulnerable contexts, the extent of a family’s available resources can influence a child’s potential of reaching its optimal development. Few studies have examined these relationships in low- and middle-income countries using nationally representative samples. The present paper explored the relationships between maternal and paternal psychosocial stimulation of the child as well as maternal and household resources and ECD among 2729 children 36⁻59 months old in Honduras. Data from the Demographic and Health Surveys conducted in 2011⁻2012 was used. Adjusted logistic regression analyses showed that maternal psychosocial stimulation was positively and significantly associated with ECD in the full, rural, and lowest wealth quintile samples. These findings underscore the importance of maternal engagement in facilitating ECD but also highlight the role of context when designing tailored interventions to improve ECD.

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014.

BACKGROUND: The long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys. METHODS: Data are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya. RESULTS: There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time. CONCLUSION: The findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

Stakeholder perspectives regarding transfer of free maternity services to National Health Insurance Fund in Kenya: Implications for universal health coverage.

BACKGROUND: Kenya is developing strategies to finance health care through prepayment to achieve universal health coverage (UHC). Plans to transfer free maternity services (FMS) from the Ministry of Health to the National Health Insurance Fund (NHIF) are a step towards UHC. We examined views of health workers and women regarding the transition of FMS to NHIF to inform the process. METHODS: In-depth interviews among 14 facility-level managers and providers, 11 county-level managers, and 21 focus group discussions with women who gave birth before and after the introduction of FMS. Data were analyzed thematically. RESULTS: The transfer is a mechanism of achieving UHC, eliminating dependency on free services, and encouraging people to take responsibility of their health. However, skepticism regarding the efficiency of NHIF may limit support. Diverse and robust systems were recommended for enrollment of clients while standardization of services through accreditation and quality assurance linked to performance-based reimbursement would improve greater predictability in the payment schedule and better coverage of referrals and complications. CONCLUSION: Transitioning FMS to NHIF provides an opportunity for the Ministry of Health to sharpen its role as policymaker and develop a comprehensive health care financing strategy for the country towards achieving UHC.

Health care providers' perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: implications for scale-up.

BACKGROUND: This paper explores the perspectives of health care providers regarding the use of 7.1% Chlorhexidine Digluconate (CHX) gel that releases 4% chlorhexidine for newborn umbilical cord care under a managed access program (MAP) implemented in Bungoma County of Kenya. Understanding the perspectives of providers regarding CHX is important since they play a key role in the health system and the fact that their views could be influenced by prior beliefs and inconsistent practices regarding umbilical cord care. METHODS: Data are from in-depth interviews conducted between April and June 2016 with 39 service providers from 21 facilities that participated in the program. The data were transcribed, typed in Word and analyzed for content. Analysis entailed identifying recurring themes based on the interview guides. RESULTS: Use of CHX gel for cord care in neonates was acceptable to the health care providers, with all of them supporting scaling up its use throughout the country. Their views were largely influenced by positive outcomes of the medication including fast healing of the cord as reported by mothers, minimal side effects, reduced newborn infections based on what their records showed and mothers' reports, ease of use that made it simple for them to counsel mothers on how to apply it, positive feedback from mothers which demonstrated satisfaction with the medication, and general acceptance of the medication by the community. They further noted that successful scale-up of the medication required community sensitization, adequate follow-up mechanisms to ensure mothers use the medication correctly, addressing issues of staffing levels and staff training, developing guidelines and protocols for provision of the medication, adopting appropriate service delivery approaches to ensure all groups of mothers are reached, and ensuring constant supply of the medication. CONCLUSION: Use of CHX gel for cord care in neonates is likely to be acceptable to health care workers in settings with high prevalence of neonatal morbidity and mortality arising from cord infections. In scaling up the use of the medication in such settings, some of the health systems requirements for successful roll-out can be addressed by programs while others are likely to be a persistent challenge.

Changes in Optimal Childcare Practices in Kenya: Insights from the 2003, 2008-9 and 2014 Demographic and Health Surveys.

OBJECTIVE(S): Using nationally representative surveys conducted in Kenya, this study examined optimal health promoting childcare practices in 2003, 2008-9 and 2014. This was undertaken in the context of continuous child health promotion activities conducted by government and non-government organizations throughout Kenya. It was the aim of such activities to increase the prevalence of health promoting childcare practices; to what extent have there been changes in optimal childcare practices in Kenya during the 11-year period under study? METHODS: Cross-sectional data were obtained from the Kenya Demographic and Health Surveys conducted in 2003, 2008-9 and 2014. Women 15-49 years old with children 0-59 months were interviewed about a range of childcare practices. Logistic regression analysis was used to examine changes in, and correlates of, optimal childcare practices using the 2003, 2008-9 and 2014 data. Samples of 5949, 6079 and 20964 women interviewed in 2003, 2008-9 and 2014 respectively were used in the analysis. RESULTS: Between 2003 and 2014, there were increases in all health facility-based childcare practices with major increases observed in seeking medical treatment for diarrhoea and complete child vaccination. Mixed results were observed in home-based care where increases were noted in the use of insecticide treated bed nets, sanitary stool disposal and use of oral rehydration solutions, while decreases were observed in the prevalence of urging more fluid/food during diarrhoea and consumption of a minimum acceptable diet. Logit models showed that area of residence (region), household wealth, maternal education, parity, mother's age, child's age and pregnancy history were significant determinants of optimal childcare practices across the three surveys. CONCLUSIONS: The study observed variation in the uptake of the recommended optimal childcare practices in Kenya. National, regional and local child health promotion activities, coupled with changes in society and in living conditions between 2003 and 2014, could have influenced uptake of certain recommended childcare practices in Kenya. Decreases in the prevalence of children who were offered same/more fluid/food when they had diarrhea and children who consumed the minimum acceptable diet is alarming and perhaps a red flag to stakeholders who may have focused more on health facility-based care at the expense of home-based care. Concerted efforts are needed to address the consistent inequities in the uptake of the recommended childcare practices. Such efforts should be cognizant of the underlying factors that affect childcare in Kenya, herein defined as region, household wealth, maternal education, parity, mother's age, child's age and pregnancy history.

Pregnancy history and current use of contraception among women of reproductive age in Burundi, Kenya, Rwanda, Tanzania and Uganda: analysis of demographic and health survey data.

OBJECTIVE: To examine the relationship between pregnancy history and the use of contraception among women of reproductive age (15-49 years) in East Africa. METHODS: Demographic and Health Surveys data from Burundi (2010), Kenya (2008-2009), Rwanda (2010), Tanzania (2010) and Uganda (2011) were used in the analysis. Logistic regression was used to determine the effects of women's pregnancy history on their use of contraception. SETTING: Burundi, Kenya, Rwanda, Tanzania and Uganda. PARTICIPANTS: 3226, 2377, 4396, 3250 and 2596 women of reproductive age (15-49 years) from Burundi, Kenya, Rwanda, Tanzania and Uganda, respectively, were included in the analysis. RESULTS: Women who had experienced a mistimed pregnancy were more likely to use a modern contraceptive method during their most recent sexual encounter in Kenya, Rwanda, Burundi and Uganda. Other significant correlates of women's contraceptive use were: desire for more children, parity, household wealth, maternal education and access information through radio. In-country regional differences on use of modern contraceptive methods were noted across five East African countries. CONCLUSIONS: Women's birth histories were significantly associated with their decision to adopt a modern contraceptive method. This highlights the importance of considering women's birth histories, especially women with mistimed births, in the promotion of contraceptive use in East Africa. Variations as a result of place of residency, educational attainment, access to family planning information and products, and wealth ought to be addressed in efforts to increase use of modern contraceptive methods in the East African region.

Influence of childcare practices on nutritional status of Ghanaian children: a regression analysis of the Ghana Demographic and Health Surveys.

OBJECTIVES: Guided by the UNICEF framework for childcare, this study examined the association of childcare practices (CCP) with infant and young children's growth (height-for-age Z-scores, HAZ), and investigated whether care practices are more important to growth in some sociodemographic subgroups of children. DESIGN: Cross-sectional survey. SETTING: Urban and rural Ghana. PARTICIPANTS: The study sample comprised 1187 dyads of mothers aged 15-49 years and their youngest child (aged 6-36 months). RESULTS: The results showed that CCP was a significant predictor of HAZ, after controlling for covariates/confounders at child, maternal and household levels. Children with higher CCP scores had higher HAZ. A 1-unit increase in the CCP score was associated with a 0.17-unit increase in HAZ. Child's and mother's age, number of children under 5 years, place of residence, maternal weight and wealth index were also significantly associated with HAZ. Statistical interaction analyses revealed no subgroup differences in the CCP/HAZ relationship. CONCLUSIONS: This study found a significant, positive association between CCP and child growth, after accounting for other important determinants of child growth at maternal and household levels. This calls for research into the effects on growth of various CCP components, with longitudinal cohort study designs that can disentangle causal relationships.

Breast-, complementary and bottle-feeding practices in Kenya: stagnant trends were experienced from 1998 to 2009.

The pattern of infant and young child feeding that provides the most benefit includes being put to the breast within an hour of birth, exclusive breastfeeding for 6 months, continued breastfeeding along with complementary foods up to 2 years of age or beyond, and avoidance of any bottle-feeding. However, since there are no published data from Kenya regarding trends in these feeding practices, this research undertook time trend estimation of these feeding practices using the 1998, 2003, and 2008-2009 Kenya Demographic and Health Survey and also examined the multivariate relationships between sociodemographic factors and feeding practices with data from 2008 to 2009. Logistic regression was used to test the significance of trends and to analyze sociodemographic characteristics associated with feeding practices. There was a significant decline in early initiation of breastfeeding among children in Central and Western provinces and those residing in urban areas. Trends in exclusive breastfeeding showed significant improvement in most sociodemographic segments, whereas trends in complementary feeding and breastfeeding remained stable. Bottle-feeding significantly decreased among children aged 12 to 23 months, as well as those living in Coast, Eastern, and Rift Valley provinces. In the multivariate analysis, the province was significantly associated with feeding practices, after controlling for child's size, birth order, and parity. The stagnant (and in some cases worsening) trends in early initiation of breastfeeding and complementary feeding with breastfeeding paint a worrisome picture of breastfeeding practices in Kenya; therefore, efforts to promote the most beneficial feeding practices should be intensified.