Early indirect impact of COVID-19 pandemic on utilization and outcomes of reproductive, maternal, newborn, child and adolescent health services in Kenya

BackgroundThe COVID-19 global pandemic is expected to result in 8.3-38.6% additional maternal deaths in many low-income countries. The objective of this paper was to determine the initial impact of COVID-19 pandemic on reproductive, maternal, newborn, child and adolescent health (RMNCAH) services in Kenya. MethodsData for the first four months (March-June) of the pandemic and the equivalent period in 2019 were extracted from Kenya Health Information System. Two-sample test of proportions for hospital attendance for select RMNCAH services between the two periods were computed. ResultsThere were no differences in monthly mean ({+/-}SD) attendance between March-June 2019 vs 2020 for antenatal care (400,191.2{+/-}12,700.0 vs 384,697.3{+/-}20,838.6), hospital births (98,713.0{+/-}4,117.0 vs 99,634.5{+/-}3,215.5), family planning attendance (431,930.5{+/-}19,059.9 vs 448,168.3{+/-}31,559.8), post-abortion care (3,206.5{+/-}111.7 vs 448,168.3{+/-}31,559.8) and pentavalent 1 immunisation (114,701.0{+/-}3,701.1 vs 110,915.8{+/-}7,209.4), p>0.05. However, there were increasing trends for adolescent pregnancy rate, significant increases in FP utilization among young people (25.7% to 27.0%), injectable (short-term) FP method uptake (58.2% to 62.3%), caesarean section rate (14.6% to 15.8%), adolescent maternal deaths (6.2% to 10.9%) and fresh stillbirths (0.9% to 1.0%) with a reduction in implants (long-term) uptake (16.5% to 13.0%) (p< 0.05). No significant change in maternal mortality ratio between the two periods (96.6 vs 105.8/100,000 live births, p = 0.1023) although the trend was increasing. ConclusionCOVID-19 may have contributed to increased adolescent pregnancy, adolescent maternal death and stillbirth rates in Kenya. If this trend persists, recent gains achieved in maternal and perinatal health in Kenya will be lost. With uncertainty around the duration of the pandemic, strategies to mitigate against catastrophic indirect maternal health outcomes are urgently needed.

Social Return on Investment (SROI) methodology to account for value for money of public health interventions: a systematic review.

BACKGROUND: Increased scarcity of public resources has led to a concomitant drive to account for value-for-money of interventions. Traditionally, cost-effectiveness, cost-utility and cost-benefit analyses have been used to assess value-for-money of public health interventions. The social return on investment (SROI) methodology has capacity to measure broader socio-economic outcomes, analysing and computing views of multiple stakeholders in a singular monetary ratio. This review provides an overview of SROI application in public health, explores lessons learnt from previous studies and makes recommendations for future SROI application in public health. METHODS: A systematic review of peer-reviewed and grey literature to identify SROI studies published between January 1996 and December 2014 was conducted. All articles describing conduct of public health SROI studies and which reported a SROI ratio were included. An existing 12-point framework was used to assess study quality. Data were extracted using pre-developed codes: SROI type, type of commissioning organisation, study country, public health area in which SROI was conducted, stakeholders included in study, discount rate used, SROI ratio obtained, time horizon of analysis and reported lessons learnt. RESULTS: 40 SROI studies, of varying quality, including 33 from high-income countries and 7 from low middle-income countries, met the inclusion criteria. SROI application increased since its first use in 2005 until 2011, declining afterwards. SROI has been applied across different public health areas including health promotion (12 studies), mental health (11), sexual and reproductive health (6), child health (4), nutrition (3), healthcare management (2), health education and environmental health (1 each). Qualitative and quantitative methods have been used to gather information for public health SROI studies. However, there remains a lack of consensus on who to include as beneficiaries, how to account for counterfactual and appropriate study-time horizon. Reported SROI ratios vary widely (1.1:1 to 65:1). CONCLUSIONS: SROI can be applied across healthcare settings. Best practices such as analysis involving only beneficiaries (not all stakeholders), providing justification for discount rates used in models, using purchasing power parity equivalents for monetary valuations and incorporating objective designs such as case-control or before-and-after designs for accounting for outcomes will improve robustness of public health SROI studies.

Myomectomy at caesarean section: descriptive study of clinical outcome in a tropical setting.

BACKGROUND: In the tropics, leiomyoma are commonly encountered in women of the reproductive age group, although they are mostly asymptomatic. Surgery for uterine fibroid at caesarean section has remained controversial. OBJECTIVE: To analyse the clinical outcome of women that had selective caesarean myomectomy in a community teaching hospital. METHOD: Twenty-two women that had selective myomectomy at caesarean section between January 2002 and October 2007 were analysed. RESULTS: The patients mean age was 31.5 years with age range of 27-44 years. Of the 22 patients, 16 (72.7%) were primigravida, 19 (86.4%) of the patients had caesarean section at term, 2 (9.1%) and 1 (4.5%) ofthe patients were preterm and post term respectively. A significant number of the patients (16/22, 72.7%) had elective caesarean section and the remaining 6 (27.3%) patients had emergency caesarean section. The 3 leading indications for caesarean section among the patients were malpresentation/abnormal lie 36.4%, uterine fibroids 18.2%, and a previous caesarean section with complication in 13.6% ofthe patients. Indications for myomectomy at caesarean section were fibroid in lower uterine segment in 15 (68.2%) patients, pedunculated uterine fibroid in 4 (18.2%) patients and anterior subserous fibroid in 3 (13.6%) patients. Intraopertively in the 22 patients, 10 (45.5%) had fibroid(s) removed only in the lower uterine segment; while 6 (27.3%) patients each, had it removed in the upper uterine segment and both upper and lower uterine segments respectively. A total of 46 fibroids were removed in the 22 patients, of which 24 (52.2%) were subserous/pedunculated, 16 (34.8%) intramural and 6 (13.0%) were submucous. Of the 46 fibroids, 32 (69.9%) were between 6 to 10 cm size. Sixteen (72.2%) of the 22 patients lost between 751 to 1000 ml of blood intraoperatively with an average of 806.8 ml of blood loss. Two (9.1%) of the 22 patients had blood transfusion due to anaemia. Other complications encountered were puerperal pyrexia and sepsis in 2 (9.1%) patients, and fracture of the humerus and clavicle of the baby in 1 (2.3%) patient. There was no maternal and perinatal mortality. CONCLUSION: Selection of patients for caesarean myomectomy reduces blood loss, anaemia and other complications.