What to expect when girls are expecting: psychosocial support challenges and opportunities in the context and aftermath of teenage pregnancy in Kenya.

BACKGROUND: An understanding of the psychosocial support challenges and opportunities in the context of teenage pregnancy is important for developing appropriate interventions for pregnant and parenting girls. This qualitative study was conducted in Homa Bay County, Kenya, to examine the experience of teenage pregnancy and the resultant psychosocial support needs from the perspectives of both pregnant/parenting girls and their own parents, who are typically expected to provide various forms of support. METHODS: The study used a descriptive case study design, drawing on counseling case notes documented by psychologists who held counseling sessions with 20 pregnant or parenting girls and 6 of their parents as part of a psychosocial support intervention. The counseling case notes formed a qualitative data set, which was analyzed thematically. RESULTS: Emerging master themes were related to pregnant and parenting girls' experience of sexual violence and adverse childbirth outcomes; psychological trauma confronted by girls and their parents alike; parental need for support in communicating with pregnant/parenting girls about sex and sexuality; and the availability of family support as a resource for teenage mothers. CONCLUSION: Pregnant and parenting teenage girls require a range of psychosocial support responses that recognize the realities of sexual violence and other challenges in the lives of the girls themselves, as well as in the lives of their parents and caregivers. While parents and other caregivers can serve as an important resource for supporting affected girls, they often need assistance as well, in order to support pregnant/parenting girls effectively. These realities need to be taken into account to maximize the effectiveness of health and development programs for pregnant and parenting girls. Furthermore, emerging themes from actual counseling sessions with affected girls and parents can provide important insights into the potential psychosocial support needs of the broader population of pregnant and parenting girls.

This study looked into the lives of pregnant and parenting girls in Kenya by examining case notes that were written up by psychologists during the counseling sessions they held with 20 different teenage girls who were pregnant, or already had children, and 6 of their parents. The case notes provided an understanding of the kind of support pregnant and parenting girls need, including mental health care to deal with the trauma of sexual violence (and other issues) that some had experienced. It also helped put a spotlight on the traumas that parents of affected girls face after a teenage pregnancy occurs. These issues need to be addressed in order to ensure that health and development professionals who work with pregnant and parenting girls are as helpful to them as possible.

Addressing contraceptive needs exacerbated by COVID-19: A call for increasing choice and access to self-managed methods.

The COVID-19 pandemic has exposed the vulnerability of global contraception provision, exacerbating the barriers to access reproductive health services, leading to suspension of clinical services and disruption of supply chains. Critical to combatting this crisis is the expansion of healthcare to include self-care approaches to de-medicalize contraception and increase an individual's agency in determining what method they use, when they use it, and where they obtain it. Expanding the mix of self-administered contraceptives is essential for ensuring choice, access, and availability. We highlight advances in the self-care movement and actions needed to strengthen self-management approaches to maximize our chances of preventing a reproductive health crisis.

Introducing the Progesterone Vaginal Ring (PVR) as a New Option for Postpartum Family Planning in Sub-Saharan Africa: Insights from Engagements with Stakeholders.

The progesterone vaginal ring (PVR) is a ring-shaped device designed for use by women in the postpartum period to regulate fertility by complementing and extending the contraceptive effectiveness of lactational amenorrhea to suppress ovulation.1 It is available in eight Latin American countries for use by breastfeeding women who want more effective modern contraceptives in addition to contraceptive benefits provided by lactational amenorrhea alone.1 The PVR is a method that can be suitable to women in sub-Saharan Africa, given the near-universal practice of breastfeeding and the current level of unmet need for contraception in the postpartum period. Efforts are currently underway to introduce the PVR in Africa and south Asia. To ensure a seamless introduction, scale up and sustainability of the PVR in the region, the Population Council conducted pre-introductory activities with stakeholders in Kenya, Nigeria and Senegal to determine the level of interest in the ring, potential facilitating and mitigating factors and identify solutions to address challenges. The research team combined three approaches: in-depth interviews with family planning stakeholders; desk review of reports and policy guidelines; and in-group meetings. The stakeholders reached included public sector officials including policy makers and program managers, implementing partners, regulators, women and religious networks. All three countries had a promising policy and programmatic context that was supportive to PVR introduction. The exercise provided insights on socio-cultural and religious factors that could potentially impact how the PVR is perceived within communities and identified possible remedies to address misperceptions. It also paved the way for the conduct of an acceptability study of the PVR among breastfeeding women in these countries. The high acceptability rate in each country and the support expressed by government and other stakeholders have provided impetus for registration of the product in each country. Learning from this process could also direct how other family planning and reproductive health commodities would be introduced in the future.

Harmonizing national abortion and pregnancy prevention laws and policies for sexual violence survivors with the Maputo Protocol: proceedings of a 2016 regional technical meeting in sub-Saharan Africa.

In April 2016, the Population Council, in partnership with the World Health Organization (WHO) and the International Consortium for Emergency Contraception, convened a regional meeting in Lusaka, Zambia, geared toward supporting countries in East and Southern Africa in meeting their obligations under the Maputo Protocol. These obligations include expanding access to women's reproductive health services - especially women survivors of sexual violence. Government and civil society representatives from six countries participated: Botswana, Ethiopia, Kenya, Malawi, Rwanda, and Zambia. Countries were selected based on to their being priority settings for the projects that sponsored the meeting, coupled with the fact that they were each far enough along in addressing post-rape care to be able to develop concrete policy, programming, and/or legal action plans by the end of the meeting. The meeting was the first activity in a joint project of technical assistance by the conveners, aimed at strengthening access to comprehensive post-rape care for survivors of sexual violence. It aimed to sensitize Member States to their obligations under the Maputo Protocol to expand women's access to emergency contraception (EC) and safe abortion services, and to inspire them to do so by providing information, research evidence, and a platform for discussion. The meeting deliberations fostered a better understanding of opportunities to broaden access to EC and safe abortion for survivors in the region. Discussions on EC in this regard centered on strengthening EC delivery in the clinical context, decentralizing EC services, increasing community awareness, and overcoming policy barriers. Safe abortion discussions focused primarily on legislation, policy, and integrating these services into existing services for sexual violence survivors. Country-specific action plans were developed to address gaps and weaknesses. The regional technical meeting concluded with a discussion of practical steps that participants could take to facilitate legal, policy, and program reform with respect to pregnancy prevention and safe abortion in their respective countries. The steps revolved around three mainly areas, namely: establishing an evidence base to inform action; creating forums for discussing the issues; and drafting action points to carry the momentum from the meeting forward. This paper details the proceedings from this regional technical meeting - proceedings that are of interest to the field of sexual and gender-based violence (and reproductive health, more broadly) as challenges faced by countries in implementing the Maputo Protocol are outlined, and evidence-informed and practice-based strategies for addressing these challenges are provided.

Acceptability and stakeholders perspectives on feasibility of using trained psychologists and health workers to deliver school-based sexual and reproductive health services to adolescents in urban Accra, Ghana.

BACKGROUND: Adolescent sexual and reproductive health is recognized as a key developmental issue of international concern. However, adolescents' access to sexual and reproductive health (SRH) information and services is largely inadequate in sub-Saharan Africa. With increasing enrollment in schools, this could be an avenue to reach adolescents with SRH information and services. This study was therefore conducted to assess the acceptability and stakeholders' perspectives on the feasibility of using health workers and trained psychologists to provide school-based SRH services in Ghana. METHODS: Fourteen (14) focus group discussions (N = 136) were conducted; 8 among adolescents aged 12-17 years (4 boys, 4 girls groups), 4 among parents (2 males, 2 females groups) and two among mixed teacher groups. We also conducted 18 in-depth interviews with teachers, managers of schools, health workers, clinical psychologists, as well as adolescent SRH program managers in the Ghana Health Service, Ghana Education Service, UNICEF, UNESCO and National Population Council, Ghana. We audio-recorded all interviews and took field notes. Interviews were transcribed and transcripts imported into NVivo 11 for analysis using grounded theory approach to qualitative data analysis. RESULTS: Many respondents reported that it was challenging for parents and/or teachers to provide adolescents with SRH information. For this reason, they agreed that it was a good idea to have health workers and psychologists provide SRH information and services to adolescents in school. Although, there was general agreement about providing SRH services in school, many of the respondents disagreed with distribution of condoms in schools as they believed that availing condoms would encourage adolescents to experiment with sex. While majority of respondents thought it was acceptable to use psychologists and health workers to provide school-based sexual and reproductive health to adolescents, some teachers and education managers thought the implementation of such a program would oppose practical challenges. Key among the challenges were how to pay for the services that health workers and trained psychologists will render, and the availability of psychologists to cater for all schools. CONCLUSION: Stakeholders believe it is feasible and acceptable to use trained psychologists and health workers to deliver school-based SRH information and services in the Ghanaian school context. However, provisions must be made to cater for financial and other logistical considerations in the implementation of school-based SRH programs.

Correction to: Harmonizing national abortion and pregnancy prevention laws and policies for sexual violence survivors with the Maputo Protocol: proceedings of a 2016 regional technical meeting in sub-Saharan Africa.

[This corrects the article DOI: 10.1186/s12919-018-0101-5.].

Do Women Find the Progesterone Vaginal Ring Acceptable? Findings from Kenya, Nigeria, and Senegal.

The progesterone vaginal ring (PVR) is a contraceptive designed for use by breastfeeding women in the first year postpartum. This Report presents results of an acceptability study of the PVR in Kenya, Nigeria, and Senegal. Women seeking postpartum family planning services were offered various contraceptive options including the PVR. Of the 174 participating women, 110 (63 percent) used one ring and 94 (54 percent) completed the study by using two rings over a six-month period. Women were interviewed up to three times: at the time they entered the study, at 3 months (the end of the first ring cycle), and at 6 months (the end of the second ring cycle or when they exited if they had discontinued earlier). Many participants found the ring to be acceptable, with over three-quarters reporting that it was easy to insert, remove, and reinsert. While a small proportion of women experienced ring expulsion, the majority did not. These findings suggest that even in countries with little or no use of vaginal health products, contraceptive vaginal rings offer women a new option that they are able and willing to use.

Feasibility and effect of integrating tuberculosis screening and detection in postnatal care services: an operations research study.

BACKGROUND: Tuberculosis still remains a major cause of maternal and newborn morbidity and mortality. Integrating tuberculosis screening and detection into postnatal care services ensures prompt and appropriate treatment for affected mothers and their babies. This study therefore examined the feasibility and effect of screening and referral for tuberculosis within postnatal care settings from the perspective of providers. METHODS: This operations research study used a pre- and post-intervention design without a comparison group. The study was implemented between March 2009 and August 2010 in five health facilities located in low-income areas of Nairobi, Kenya, which were suspected to have relatively high prevalence of both tuberculosis and HIV. Descriptive statistics and significance tests were employed to determine changes in the indicators of interest between baseline and endline. RESULTS: Among the 12,604 postnatal care clients screened, 14 tuberculosis cases were diagnosed. The proportion of clients screened for at least one cardinal sign of tuberculosis rose from 4% to 66%, and 21% of clients were screened for all six tracer signs and symptoms. A comparison of 10 quality of postnatal care and tuberculosis screening components at baseline and endline showed a highly significant effect on all 10 components. CONCLUSIONS: The findings demonstrate that using postnatal care services as a platform for tuberculosis screening and detection is acceptable and feasible. In addition, linking clients identified through screening to further treatment significantly improved. However, the actual number of cases detected was low. A policy debate on whether to link tuberculosis screening with reproductive health services is recommended before full scale-up of this intervention.

Factors associated with unintended pregnancy, poor birth outcomes and post-partum contraceptive use among HIV-positive female adolescents in Kenya.

BACKGROUND: Although the experiences of unintended pregnancies and poor birth outcomes among adolescents aged 15-19 years in the general population are well documented, there is limited understanding of the same among those who are living with HIV. This paper examines the factors associated with experiencing unintended pregnancies, poor birth outcomes, and post-partum contraceptive use among HIV-positive female adolescents in Kenya. METHODS: Data are from a cross-sectional study that captured information on pregnancy histories of HIV-positive female adolescents in four regions of Kenya: Coast, Nairobi, Nyanza and Rift Valley provinces. Study participants were identified through HIV and AIDS programs in the four regions. Out of a total of 797 female participants, 394 had ever been pregnant with 24% of them experiencing multiple pregnancies. Analysis entails the estimation of random-effects logit models. RESULTS: Higher order pregnancies were just as likely to be unintended as lower order ones (odds ratios [OR]: 1.2; 95% confidence interval [CI]: 0.8-2.0) while pregnancies occurring within marital unions were significantly less likely to be unintended compared to those occurring outside such unions (OR: 0.1; 95% CI: 0.1-0.2). Higher order pregnancies were significantly more likely to result in poor outcomes compared to lower order ones (OR: 2.5; 95% CI: 1.6-4.0). In addition, pregnancies occurring within marital unions were significantly less likely to result in poor outcomes compared to those occurring outside such unions (OR: 0.3; 95% CI: 0.1-0.9). However, experiencing unintended pregnancy was not significantly associated with adverse birth outcomes (OR: 1.3; 95% CI: 0.5-3.3). There was also no significant difference in the likelihood of post-partum contraceptive use by whether the pregnancy was unintended (OR: 0.9; 95% CI: 0.5-1.5). CONCLUSIONS: The experience of repeat unintended pregnancies among HIV-positive female adolescents in the sample is partly due to inconsistent use of contraception to prevent recurrence while poor birth outcomes among higher order pregnancies are partly due to abortion. This underscores the need for HIV and AIDS programs to provide appropriate sexual and reproductive health information and services to HIV-positive adolescent clients in order to reduce the risk of undesired reproductive health outcomes.

Maternal health care utilization among HIV-positive female adolescents in Kenya.

CONTEXT: Given the health risks of HIV/AIDS and the risks of teenage pregnancy in general, pregnant HIV-positive adolescents in Kenya need maternal health care services that account for their HIV status. However, research on their access to and use of these services is scant. METHODS: To examine maternal health care utilization, pregnancy history data collected in 2009 on 506 pregnancies among 393 HIV-positive female adolescents aged 15-19 enrolled in HIV/AIDS programs in Kenya were analyzed. Multilevel logit models were used to identify the variables associated with use of prenatal care, prevention of mother-to-child transmission (PMTCT) of HIV, skilled attendance at pregnancy outcomes and postnatal/postabortion care. RESULTS: Use of PMTCT services was less common than use of prenatal care services among HIV-positive female adolescents (67% of pregnancies vs. 84%). These adolescents made four or more prenatal care visits in only 45% of pregnancies. In addition, use of skilled care during or after abortion or miscarriage was low (20%). The odds of receiving PMTCT services and skilled assistance were higher in Nairobi than in other regions (odds ratios, 3.8 and 2.7, respectively). HIV-positive adolescents were less likely to use maternal health care services for higher-order pregnancies than for lower-order pregnancies (0.4-0.6). They were, however, more likely to receive prenatal care and PMTCT services when their husband rather than someone else was responsible for the pregnancy (3.7 and 4.9, respectively). CONCLUSION: Pregnant, HIV-positive adolescents need maternal health care services--including PMTCT care--that take into account parity, paternity dynamics and regional variations in use.

The limited effect of knowing they are HIV-positive on the sexual and reproductive experiences and intentions of infected adolescents in Uganda.

This paper compares the sexual and reproductive experiences and intentions of those adolescents aged 15-19 years in Uganda who are perinatally infected with HIV and know their sero-status with those of adolescents who do not know their sero-status. The analysis comprises a simple comparison of means and proportions, together with the relevant tests of significance, as well as estimation of Cox proportional hazards and random-effects logit models. The findings show that the two groups of adolescents do not differ significantly in terms of timing of sexual debut and whether they intend to have children in the future. However, adolescents who are HIV-positive and know their status are significantly more likely to use a modern method of contraception, including condoms. Nonetheless, the level of condom use among these adolescents is still limited (less than half of those sexually active) and inconsistent (less than half of those in relationships reported always using a condom).

Preventive service needs of young people perinatally infected with HIV in Uganda.

The sexual and reproductive health needs of young people perinatally infected with HIV in Uganda remain largely unaddressed by existing HIV/AIDS programs mostly because, such programs encourage young HIV-positive clients to refrain from or postpone sexual activity. This study examines the sexual expressions and experiences as well as the preventive practices of 732 adolescent boys and girls aged 15-19 years who were born with HIV with a view to identifying the preventive service needs of these young people and the implications of these needs for HIV/AIDS programs. The data come from a project on the sexuality of young people perinatally infected with HIV conducted in 2007 in four districts of Uganda, that is, Kampala, Wakiso, Masaka, and Jinja. The analysis involves both quantitative and qualitative approaches: the quantitative approach entails cross-tabulations with chi-square tests as well as significance tests of proportions while the qualitative approach involves an analysis of individual case stories, in-depth probes and focus group discussions for content. The findings show disconnect between: (1) the information the service providers give to the young people and their actual needs and desires; (2) the fears of the adolescents and their actual preventive practices; and (3) the high level of reported condom use and the frequency of use. Programs will therefore need to recognize that young people perinatally infected with HIV are sexually active or anticipate being so in future. Thus, both sexually active and non-sexually active young people require information and services on prevention of unwanted pregnancies as well as avoiding infecting their sexual partners with HIV and re-infecting themselves. Programs will need to devise ways of responding to these needs which should include emphasizing the disclosure of HIV status to the partner as well as the need to accompany such disclosure with consistent condom use.

Engaging men who have sex with men in operations research in Kenya.

Research on men who have sex with men (MSM) in Africa is severely constrained. This paper examines the process of engaging MSM in research in a context where same-sex relationships are criminalised and socially stigmatised. Despite difficulties in researching MSM in Kenya, a convenient sample of 500 men was enrolled into a study aimed at understanding HIV/STI risks and prevention needs. Lessons drawn from this study highlight innovative methodological approaches and processes to working with and researching MSM in homophobic communities. Researchers willing to venture into MSM research in such contexts should be prepared to deal with among others, issues such as, seeking ethical approval for a study whose subjects are considered to engage in illegal activities, assuring study participants of their privacy and confidentiality and questioning of their own integrity. This study shows that despite difficulties, research of this kind can be carried out in Kenya.

Sexual behavior and desires among adolescents perinatally infected with human immunodeficiency virus in Uganda: implications for programming.

Counseling programs for adolescents living with human immunodeficiency virus (HIV) encourage abstinence from sex and relationships. This Uganda study, however, found that many of these adolescents are sexually active or desire to be in relationships but engage in poor preventive practices. Programs for HIV and acquired immunodeficiency syndrome (AIDS) programs therefore need to strengthen preventive services to this group.

Are reproductive health NGOs in Uganda able to engage in the health SWAp?

This paper explores the ability for reproductive health (RH) non-governmental organizations (NGO) in Uganda to survive in the context of SWAp and decentralization. The authors argue that, contrary to the perceptions that this context may increase NGO's financial vulnerability, a SWAp and a decentralized system may provide an opportunity that should be embraced by NGOs to enhance their sustainability and effectiveness by reducing their current dependency on donor funding. The paper discusses the systemic weaknesses of many NGOs that currently make them vulnerable, and observes that unless these weaknesses are addressed, such NGOs will lose their space in the SWAp and decentralization arena. The authors suggest that NGOs need to recognize the opportunities that participating in public-private partnerships through a SWAp can offer them for long-term and significant funding. They need also to develop their capacity to pro-actively participate in a SWAp and decentralized context by becoming more entrepreneurial in nature, through re-orienting their organizational philosophies and strategic planning and budgeting so as to be able to partner effectively with the public sector in accessing funds made available through health sector reform.

The global-local dilemma of a Ministry of Health experiences from Uganda.

Despite extensive reforms, including an overall decentralization of government, health services and health status remain largely unchanged in Uganda. Given its dependence on international resources, policies and paradigms, the Ministry of Health (MOH) paradoxically disembeds itself increasingly from the local community while attempting to improve its local connections. This article suggests a model for understanding and addressing these difficulties.