Katherine Albutt

Respondent-driven sampling to assess mental health outcomes, stigma and acceptance among women raising children born from sexual violence-related pregnancies in eastern Democratic Republic of Congo

Objectives Assess mental health outcomes among women raising children from sexual violence-related pregnancies (SVRPs) in eastern Democratic Republic of Congo and stigma toward and acceptance of women and their children. Design Participants were recruited using respondent-driven sampling. Setting Bukavu, Democratic Republic of Congo in 2012. Participants 757 adult women raising children from SVRPs were interviewed. A woman aged 18 and older was eligible for the study if she self-identified as a sexual violence survivor since the start of the conflict (∼1996), conceived an SVRP, delivered a liveborn child and was currently raising the child. A woman was ineligible for the study if the SVRP ended with a spontaneous abortion or fetal demise or the child was not currently living or in the care of the biological mother. Intervention Trained female Congolese interviewers verbally administered a quantitative survey after obtaining verbal informed consent. Outcome measures Symptom criteria for major depressive disorder, post-traumatic stress disorder, anxiety and suicidality were assessed, as well as stigma toward the woman and her child. Acceptance of the woman and child from the spouse, family and community were analysed. Results 48.6% met symptom criteria for major depressive disorder, 57.9% for post-traumatic stress disorder, 43.3% for anxiety and 34.2% reported suicidality. Women who reported stigma from the community (38.4%) or who reported stigma toward the child from the spouse (42.9%), family (31.8%) or community (38.1%) were significantly more likely to meet symptom criteria for most mental health disorders. Although not statistically significant, participants who reported acceptance and acceptance of their children from the spouse, family and community were less likely to meet symptom criteria. Conclusions Women raising children from SVRPs experience symptoms of mental health disorders. Programming addressing stigma and acceptance following sexual violence may improve mental health outcomes in this population.

Stigma and Parenting Children Conceived From Sexual Violence

BACKGROUND AND OBJECTIVES: Since armed conflict began in 1996, widespread sexual violence in eastern Democratic Republic of Congo has resulted in many sexual violence-related pregnancies (SVRPs). However, there are limited data on the relationships between mothers and their children from sexual violence. This study aimed to evaluate the nature and determinants of these maternal–child relationships. METHODS: Using respondent-driven sampling, 757 women raising children from SVRPs in South Kivu Province, Democratic Republic of Congo were interviewed. A parenting index was created from questions assessing the maternal–child relationship. The influences of social stigma, family and community acceptance, and maternal mental health on the parenting index were assessed in univariate and multivariable analyses. RESULTS: The majority of mothers reported positive attitudes toward their children from SVRPs. Prevalence of perceived family or community stigma toward the women or their children ranged from 31.8% to 42.9%, and prevalence of perceived family or community acceptance ranged from 45.2% to 73.5%. In multivariable analyses, stigma toward the child, as well as maternal anxiety and depression, were associated with lower parenting indexes, whereas acceptance of the mother or child and presence of a spouse were associated with higher parenting indexes (all P ≤ .01). CONCLUSIONS: In this study with a large sample size, stigma and mental health disorders negatively influenced parenting attitudes, whereas family and community acceptance were associated with adaptive parenting attitudes. Interventions to reduce stigmatization, augment acceptance, and improve maternal mental health may improve the long-term well-being of mothers and children from SVRPs.

Sexual violence-related pregnancies in eastern Democratic Republic of Congo: a qualitative analysis of access to pregnancy termination services

BackgroundSexual violence has been prevalent throughout the armed conflict in eastern Democratic Republic of Congo (DRC). Research on sexual violence-related pregnancies (SVRPs) and pregnancy termination in eastern DRC, a context with high prevalence of sexual violence, high maternal mortality, and restrictive abortion laws, is scant but crucial to improving the overall health of women in the DRC. Understanding women’s perceptions and experiences related to an SVRP, and in particular to pregnancy termination in this context, is critical for developing effective, targeted programming.MethodsRespondent-driven sampling (RDS) was used to recruit two subgroups of women reporting SVRPs, 1) women raising a child from an SVRP (parenting group) and 2) women who had terminated an SVRP (termination group), in Bukavu, DRC in 2012. Semi-structured qualitative interviews on pregnancy history and outcomes were conducted with a systematically selected sub-group of women recruited through RDS methodology. Interview responses were translated, transcribed and uploaded to the qualitative data analysis software Dedoose. Thematic content analysis, complemented by the constant comparative technique from grounded theory, was subsequently used as the analytic approach for data analysis.ResultsFifty-five qualitative interviews (38 parenting group and 17 termination group) were completed. The majority of women in the termination group reported using traditional herbs to terminate the SVRP, which they often obtained on their own or through family, friends and traditional healers; whereas women in the parenting group reported ongoing pregnancies after attempting pregnancy termination with herbal medications. Three women in the termination group reported accessing services in a health center. Almost half of the women in the parenting group cited fear of death from termination as a reason for continuing the pregnancy. Other women in the parenting group contemplated pregnancy termination, but did not know where to access services. Potential legal ramifications and religious beliefs also influenced access to services.ConclusionsWomen in this study had limited access to evidence-based safe abortion care and faced potential consequences from unsafe abortion, including increased morbidity and mortality. Increased access to reproductive health services, particularly safe, evidence-based abortion services, is paramount for women with SVRPs in eastern DRC and other conflict-affected regions.

Endometriosis within a left-sided inguinal hernia sac

Endometriosis is a common gynecologic disorder wherein ectopic endometrial glands and stroma are found at extrauterine sites. Extrapelvic endometriosis is a well-documented, yet rare, disease entity that can affect almost any organ system. Inguinal endometriosis is an extremely rare disease entity characterized by tender inguinal swelling. Here we report a case of a sudden-onset and acutely painful left inguinal hernia with concordant endometriosis. A review of the literature is presented. The presence of isolated endometriosis contained within a left-sided inguinal hernia sac has, to our knowledge, never been reported. Often diagnosed incidentally or on histologic examination, general surgeons should consider inguinal endometriosis in the differential diagnosis of inguinal masses, even in the absence of catamenial symptoms. Surgical excision, with gynecologic follow-up, is locally curative and the treatment of choice for inguinal endometriosis.

A Qualitative Analysis of Disclosure Patterns among Women with Sexual Violence-Related Pregnancies in Eastern Democratic Republic of Congo

The Democratic Republic of the Congo (DRC) has experienced nearly two decades of civil conflict in the Eastern regions of North and South Kivu. This conflict has been notorious for the use of sexual violence as a weapon of war, leading in many cases to pregnancy after rape. The objectives of this analysis were: 1) to describe patterns of sexual violence-related pregnancy (SVRP) disclosure; 2) to consider why survivors chose to disclose to particular individuals; and 3) to examine the dialogue around SVRPs between women with SVRPs and their confidants. In South Kivu Province, Democratic Republic of Congo, two sub-groups of sexual violence survivors completed qualitative interviews, those currently raising a child from an SVRP (parenting group, N = 38) and those who had terminated an SVRP (termination group, N = 17). The findings show that a majority of SVRPs were conceived when participants were held in sexual captivity for prolonged periods of time. The SVRPs were disclosed to friends, family members, other sexual violence survivors, community members, spouses, health care providers, or perpetrators. The confidants were most often chosen because they were perceived by the participants as being discreet, trusted, and supportive. The confidants often provided advice about continuing or terminating the SVRP. Trust and discretion are the most important factors determining to whom women with SVRPs disclose their pregnancies. The vital role of confidants in giving support after disclosure cannot be overlooked. Providing opportunities for survivors to safely disclose their SVRPs, including to health care providers, is a necessary first step in allowing them to access safe and comprehensive post-assault care and services.

Healthcare Leaders Develop Strategies for Expanding National Surgical, Obstetric, and Anaesthesia Plans in WHO AFRO and EMRO Regions

BackgroundWorldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening.MethodsIn March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs.ResultsDrawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs.ConclusionsLessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.

Bridging the data gap in global health: an electronic surgical outcomes database at Mbarara Regional Referral Hospital, Uganda

Abstract Background Annually, an estimated 17 million lives are lost from conditions requiring surgical care and at least 77·2 million disability-adjusted life-years could be averted through provision of basic surgical services. Despite the staggering burden of surgical disease, there are scarce data available to track current capacity, volume, epidemiology, outcomes, and quality of surgical care delivery in low-income and middle-income countries. We aimed to organise the hospital record system into a high-quality and high-fidelity searchable database that can be used to measure and guide expansion and provision of quality care at Mbarara Regional Referral Hospital (MRRH) in western Uganda. Methods Initiated in 2013, the Surgical Services QUality Assessment Database (SQUAD) arose from a shared commitment to improving surgical quality and capacity through a collaboration between MRRH and Massachusetts General Hospital. SQUAD systematically enrols and collects data on all surgical patients admitted to MRRH. Data are extracted from patient charts and admission, discharge, and operation logbooks by trained clerks—a process overseen by a data manager/statistician. Data variables are grouped into patient demographics, disease characteristics, cadre of clinicians, interventions, outcomes, and time. Data access and use is supervised by a committee of representatives. Findings To date, SQUAD contains more than 49 000 patient records in a searchable electronic database. Quality assurance reports have been produced for internal use at MRRH, and in-hospital initiatives have been made in response to findings. SQUAD was prospectively validated in 2016, and retrospective validation studies are currently underway. Interpretation Ongoing challenges include transitioning data capture methods from chart and log book review to a point-of-care electronic medical register and record system, while maintaining data entry. A future objective is the dissemination of clinical outcome reports through peer reviewed publications by authors from the collaborating institutions. Funding GE Foundation, Milton Foundation, Kletjian Foundation, and MGH Department of Anesthesia, Critical Care and Pain Medicine.

You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda

Background Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception. Methods From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis. Results The Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need. Conclusion Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda’s surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.

Abdominoperineal Resection for Rectal Cancer in the Twenty-First Century: Indications, Techniques, and Outcomes

BackgroundManagement of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals.DiscussionIn this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.

A qualitative analysis of decision-making among women with sexual violence-related pregnancies in conflict-affected eastern Democratic Republic of the Congo

BackgroundSexual violence is prevalent in conflict-affected settings and may result in sexual violence-related pregnancies (SVRPs). There are limited data on how women with SVRPs make decisions about pregnancy continuation or termination, especially in contexts with limited or restricted access to comprehensive reproductive health services.MethodsA qualitative study was conducted in Bukavu, Democratic Republic of the Congo (DRC) as part of a larger mixed methods study in 2012. Utilizing respondent-driven sampling (RDS), adult women who self-reported sexual violence and a resultant SVRP were enrolled into two study subgroups: 1) women currently raising a child from an SVRP (parenting group) and 2) women who terminated an SVRP (termination group). Trained female research assistants conducted semi-structured interviews with a subset of women in a private setting and responses were manually recorded. Interview notes were translated and uploaded to a qualitative software program, coded, and thematic content analysis was conducted.ResultsA total of 55 women were interviewed: 38 in the parenting group and 17 in the termination group. There were a myriad of expressed attitudes, beliefs, and emotional responses toward SVRPs and the termination of SVRPs with three predominant influences on decision-making, including: 1) the biologic, ethnic, and social identities of the fetus and/or future child; 2) social reactions, including fear of social stigmatization and/or rejection; and 3) the power of religious beliefs and moral considerations on women’s autonomy in the decision-making process.ConclusionFindings from women who continued and women who terminated SVRPs reveal the complexities of decision-making related to SVRPs, including the emotional reasoning and responses, and the social, moral, and religious dimensions of the decision-making processes. It is important to consider these multi-faceted influences on decision-making for women with SVRPs in conflict-affected settings in order to improve provision of health services and to offer useful insights for subsequent programmatic and policy decisions.