Joseph Karanja

Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya

BackgroundIncreases in the proportion of facility-based deliveries have been marginal in many low-income countries in the African region. Preliminary clinical and anthropological evidence suggests that one major factor inhibiting pregnant women from delivering at facility is disrespectful and abusive treatment by health care providers in maternity units. Despite acknowledgement of this behavior by policy makers, program staff, civil society groups and community members, the problem appears to be widespread but prevalence is not well documented. Formative research will be undertaken to test the reliability and validity of a disrespect and abuse (D&A) construct and to then measure the prevalence of disrespect and abuse suffered by clinic clients and the general population.Methods/designA quasi-experimental design will be followed with surveys at twelve health facilities in four districts and one large maternity hospital in Nairobi and areas before and after the introduction of disrespect and abuse (D&A) interventions. The design is aimed to control for potential time dependent confounding on observed factors.DiscussionThis study seeks to conduct implementation research aimed at designing, testing, and evaluating an approach to significantly reduce disrespectful and abusive (D&A) care of women during labor and delivery in facilities. Specifically the proposed study aims to: (i) determine the manifestations, types and prevalence of D&A in childbirth (ii) develop and validate tools for assessing D&A (iii) identify and explore the potential drivers of D&A (iv) design, implement, monitor and evaluate the impact of one or more interventions to reduce D&A and (v) document and assess the dynamics of implementing interventions to reduce D&A and generate lessons for replication at scale.

Knowledge, attitudes, and practices regarding emergency contraception among nurses and nursing students in two hospitals in Nairobi, Kenya.

A cross-sectional descriptive study on knowledge, attitudes, and practice about emergency contraception (EC) was conducted among nurses and nursing students using a self-administered questionnaire. One-hundred-sixty-seven qualified nurses and 63 nursing students completed the questionnaire. Over 95% listed at least one regular contraceptive method but only 2.6% spontaneously listed EC as a contraceptive method, whereas 48% of the respondents had heard of EC. Significantly more nursing students than qualified nurses were familiar with EC. Knowledge about the types of EC, applications, and side effects was poor and 49% of the respondents considered EC as an abortifacient. Of those familiar with EC, 77% approved its use for rape victims and 21% for adolescents and schoolgirls. Only 3.5% of all respondents had personally used EC in the past, 23% of those familiar with EC intend to use it in the future, whereas 53% intend to provide or promote it. The view that EC was abortifacient negatively influenced the decision to use or provide EC in the future. The present findings suggest that the level of knowledge of EC is poor and more information is needed. These findings indicate the potential to popularize emergency contraception in Kenya among nurses and nursing students.

Goals and activities proposed by countries in seven regions of the world toward prevention of unsafe abortion.

This article describes the goals and activities included in the national plans of action for the prevention of unsafe abortion. With broad variability, all were in line with the initiatives purpose of contributing to reduce the number of women who have unplanned pregnancies and induced abortions, as well as the maternal mortality and morbidity associated with unsafe abortion. The interventions proposed can be classified in 5 groups: (1) to work toward better national policies through obtaining and disseminating accurate evidence‐based data on abortion and to sensitize policy makers and health professionals on issues pertaining to unsafe abortion; (2) to reduce the number of unplanned/unwanted pregnancies by increasing the use of modern contraceptive methods, introducing or improving sex education, and improving adolescent‐friendly reproductive health services; (3) to make induced abortion safer by making adequate abortion services available, within the full extent of the national laws, and promoting access to safe abortion; (4) to improve postabortion care, including postabortion contraception; and (5) to reduce the need to resort to abortion by working on facilitating the process of adoption. The proportions of plans that include each of these interventions are described, as well as some regional differences.

Empowering women to control post-partum haemorrhage

www.thelancet.com Vol 375 February 6, 2010 459 misoprostol use in Nepal and Indonesia. Estimates for the effi cacy of both oxytocin and misoprostol in preventing haemor rhage were taken from a meta-analysis (fewer deaths are consequently predicted due to the link between haemorrhage and death). Ronsmans and Huang also suggest that we overestimate deaths from postpartum haemorrhage and sepsis. But the data they cite concerns all Africa and not sub-Saharan Africa, where incidence and case-fatality rates are probably higher (see page 8 of our webappendix). Further, Seale and colleagues have argued that maternal sepsis in sub-Saharan Africa is grossly underestimated. Yusuf Ahmed and colleagues correct ly point out that many maternal deaths in sub-Saharan Africa are from infectious diseases other than genital tract infections—eg, malaria, tuberculosis, or other HIV-related disorders; these diseases are indeed a considerable burden on maternal health. We would like to clarify that our estimates relating to infection pertain only to puerperal sepsis, defi ned by WHO as “infection of the genital tract” in the 42 days after birth. Our estimates for both the incidence and case fatality of puerperal sepsis are derived from WHO estimates for sub-Saharan Africa (see pages 10–11 of our webappendix), and not from estimates of puerperal infection, which would include malaria and other infectious diseases. Thus the estimated eff ect of oral antibiotics in pre venting deaths from puerperal sepsis does not assume any eff ect on other infectious diseases. As discussed briefl y in the conclusion of our paper, the mathematical model could be adapted to consider maternal deaths from other causes; the limiting factor is the availability of evidence to use in estimating plausible values of the model parameters. We agree with Braunholtz and colleagues that legitimate questions remain about the feasibility of sustainable community interventions; this is precisely why we advocated the careful evaluation of such strategies and why we welcome Metin Gülmezoglu and João Paulo Souza’s response. Braunholtz and colleagues commend our openness. We encourage others who use our model to make the parameter estimates used and the reasoning behind these choices publicly available when presenting fi ndings. A dedicated webpage has been constructed on which to publish such material. In addition to its primary function, our model provides a framework for exploring the policy implications of uncertainty in incidence and case fatality rates, achievable coverage of com munity interventions, and plausible increases in health-facility delivery. Given the unquestioned importance of reducing maternal mortality, but diff ering opinions as to how, open and rational debate is not just welcome but urgently required.

Advocacy towards changes on laws governing access to safe abortion in Kenya

Unsafe abortion is one of the leading causes of maternal mortality and morbidity worldwide as well as in Kenya. The discussion of a revised constitution for Kenya during 2008 to August 2010 was an opportunity to create a greater awareness on the need of reproductive health services and of broadening the circumstances under which abortion is permitted by law. The Kenyan Obstetrical and Gynecological Society (KOGS) used its scientific prestige to advocate for more liberal abortion legislation in which it teamed with civil rights and professional associations in reproductive health such as the National nurses association, the midwife chapter and the Kenya clinical officers’ society. Since it is not possible to fully evaluate the full impact of these efforts in the constitutional change debate, we describe what was done and achieved in the constitutional changes affecting reproductive health in Kenya.

O446 Introducing pre-service training in comprehensive abortion care (CAC) in a situation of restrictive law

Introduction: The Kenya law allows abortion only to save the life of the woman or the fetus. The Medical Practitioners and Dentists Board (MPDB), the statutory body created by an Act of Parliament to oversee medical and dental practice, has guidelines that operationalizes the law and allows termination of pregnancy in the “interest of the health of mother or baby”. Although these provisions empower doctors to provide safe abortion to a large number of deserving women, the general ignorance both in the profession and the public, drives desperate woment to quacks for unsafe abortion resulting in severe complications and deaths. One way to tackle this problem is to include comprehensive abortion care (CAC) training in pre-service education of medical students and to educate the public on the position of the law and the MPDB guidelines. By their nature, university medical school curricula are overcrowded and once written, takew long and tedious process to change. The objective of this initiative was to improve the teaching of abortion related issues within the existing curriculum and time allocated. Methodology: In October 2007 Ipas sponsored a group of Faculty from Nairobi and Makerere medical schools to a 3-day workshop in Kampala whose main objective was to develop enhanced curriculla and training packages for medical students and postgraduate residents in obstetrics and gynaecology. This paper focuses on the undergraduate training at the University of Nairobi School of Medicine. The faculty looked at the existing teaching programme and identified gaps. The time allocated for teaching abortion issues included a one-day seminar on management of incomplete abortion using MVA. This 8 hour period was under utilized and the team developed an action plan to address the gaps. Results: The one day seminar now consists of interactive partipatory lecturettes covering issues such as: Unsafe abortion as a major public health problem globally, regionally and nationally; The concept of CAC; International, regional and national mandates to provide CAC; Methods of TOP and uterine evacuation (Surgical and medication) and and management of complications of abortion; Counseling and post abortion contraception; Infection prevention, care of instruments and service sustainability; Classroom skills acquision. After the seminar the students acquire clinical skills during the clinical rotation as per log book. So far just over 400 medical students have gone through the new program in 4 batches. Recommendation: Since almost all countries of the world allow abortion to save the life of the woman, all medical schools should train their students in comprehensive abortion care. O447 MRI findings in women with suspected tubercular tubo-ovarian masses D. Karmakar, J. Sharma, S. Hari, S. Kumar, K. Roy, N. Singh. Department of Obstetrics and Gynecology All India Institute of Medical Sciences, New Delhi, India, Department of Radiodiagnosis All India Institute of Medical Sciences, New Delhi, India