Thérèse Delvaux

The need for family planning and safe abortion services among women sex workers seeking STI care in Cambodia

Abstract In Cambodia, clinics established for the prevention and management of sexually transmitted infections (STIs) in women sex workers do not address other reproductive health services. The aim of this study was to assess the need for more comprehensive sexual and reproductive health services for women sex workers in Cambodia. In January 2000, relevant documents were reviewed, interviews with key informants carried out and group interviews with women sex workers conducted. Medical records from women sex workers were also reviewed and some data collected prospectively in one government STI clinic. Interviews with the women and data from the government clinic indicated that excluding condoms, a very low proportion of women sex workers were currently using a modern contraceptive method −5% of 38 women and 1.6% of 632 women, respectively. Induced abortion was widely used but was perceived to be risky and costly. Data from a mobile team intervention and the government clinic respectively showed that 25.5% (n=1744) and 21.9% (n=588) of women sex workers reported at least one previous induced abortion. These findings reveal the need for accessible contraception and safe abortion services among sex workers in Cambodia, and raise the issue of the reproductive rights and reproductive health needs of women sex workers in general.

Quality of antenatal and delivery care before and after the implementation of a prevention of mother-to-child HIV transmission programme in Côte d'Ivoire.

Objective  To assess whether implementation of a prevention of mother‐to‐child HIV transmission (PMTCT) programme in Côte d’Ivoire improved the quality of antenatal and delivery care services.

Ebola in Africa: beyond epidemics, reproductive health in crisis

According to WHO, more than 5000 people have died from Ebola, including 240 health workers. We are deeply concerned about the devastating effect of Ebola on reproductive health in Guinea, Liberia, and Sierra Leone in the context of continuous deterioration of socioeconomic conditions and general health in aff ected countries. The indirect negative effect of Ebola on reproductive health stems mainly from the desertion of already understaffed health facilities by health-care workers who are fearful of contracting Ebola. This fear is further increased because most reproductive health life-saving interventions include handling blood or bodily fluids from patients whose Ebola status is often unknown and health staff often do not have access to appropriate protection. Most referral maternity wards in the three most affected countries (Guinea, Liberia, and Sierra Leone) do not have equipment to do real-time screening for Ebola (eg, PCR), which could lead to the denial of care for women suspected to be pregnant. Additionally, the absence of providers offering relevant services, the inability to differentiate between Ebola and other febrile diseases, and the fear of contracting Ebola at a health facility can prevent users seeking reproductive health services. Statistics from Matam maternity hospital in Conakry, Guinea, show a substantial drop in attendance between March, 2014, and September, 2014, compared with 2013 (fi gure). A decrease in paediatric or maternal admissions because of fear of contracting Ebola has also been reported by Medecins Sans Frontieres in Sierra Leone. We are concerned that women in need of reproductive health care because of pregnancy, childbirth, and post-partum related complications, including haemorrhage, eclampsia, obstructed labour, and abortion, will not have necessary and even life-saving care and attention. United Nations Population Fund estimates that 15% of the 800 000 women who will give birth in the next 12 months in Guinea, Liberia, and Sierra Leone could die of complications because of inade quate emergency obstetric care, and thousands of others could develop devastating pathological conditions, such as obstetric fistula. Increased support to fight Ebola is needed in Guinea, Liberia, and Sierra Leone coupled, with specific attention to reproductive health services. Adequate measures, including health system strengthening and community mobilisation coupled with an enabling environment for provision of emergency obstetric care, need to be put in place urgently to avoid devastating short-term and long-term effects for thousands of women.

Risk factors for obstetric fistula in the Far North Province of Cameroon

To describe the circumstances of occurrence and identify potential risk factors for obstetric fistula in northern Cameroon.

Integration of comprehensive abortion‐care services in a Maternal and Child Health clinic in Cambodia

Objectives  To document the pilot experience of provision of safe abortion/post‐abortion services implemented in 2002 at the Mother Child Health clinic in Sihanoukville, Cambodia, and to profile clients and assess their uptake of post‐abortion contraception.

Sexual and reproductive health and rights in public health education.

Abstract This paper addresses the challenges faced in mainstreaming the teaching of sexual and reproductive health and rights into public health education. For this paper, we define sexual and reproductive health and rights education as including not only its biomedical aspects but also an understanding of its history, values and politics, grounded in gender politics and social justice, addressing sexuality, and placed within a broader context of health systems and global health. Using a case study approach with an opportunistically selected sample of schools of public health within our regional contexts, we examine the status of sexual and reproductive health and rights education and some of the drivers and obstacles to the development and delivery of sexual and reproductive health and rights curricula. Despite diverse national and institutional contexts, there are many commonalities. Teaching of sexual and reproductive health and rights is not fully integrated into core curricula. Existing initiatives rely on personal faculty interest or short-term courses, neither of which are truly sustainable or replicable. We call for a multidisciplinary and more comprehensive integration of sexual and reproductive health and rights in public health education. The education of tomorrows public health leaders is critical, and a strategy is needed to ensure that they understand and are prepared to engage with the range of sexual and reproductive health and rights issues within their historical and political contexts.

Utilization of maternal health services among adolescent women in Bangladesh: a scoping review of the literature

To understand the health‐seeking behaviour of adolescent women in Bangladesh with respect to the use of maternal health services.

Implementation of evidence-based antenatal care in Mozambique: a cluster randomized controlled trial: study protocol

BackgroundAntenatal care (ANC) reduces maternal and perinatal morbidity and mortality directly through the detection and treatment of pregnancy-related illnesses, and indirectly through the detection of women at increased risk of delivery complications. The potential benefits of quality antenatal care services are most significant in low-resource countries where morbidity and mortality levels among women of reproductive age and neonates are higher.WHO developed an ANC model that recommended the delivery of services scientifically proven to improve maternal, perinatal and neonatal outcomes. The aim of this study is to determine the effect of an intervention designed to increase the use of the package of evidence-based services included in the WHO ANC model in Mozambique. The primary hypothesis is that the intervention will increase the use of evidence-based practices during ANC visits in comparison to the standard dissemination channels currently used in the country.MethodsThis is a demonstration project to be developed through a facility-based cluster randomized controlled trial with a stepped wedge design. The intervention was tailored, based on formative research findings, to be readily applicable to local prenatal care services and acceptable to local pregnant women and health providers. The intervention includes four components: the provision of kits with all necessary medicines and laboratory supplies for ANC (medical and non-medical equipment), a storage system, a tracking system, and training sessions for health care providers. Ten clinics were selected and will start receiving the intervention in a random order. Outcomes will be computed at each time point when a new clinic starts the intervention. The primary outcomes are the delivery of selected health care practices to women attending the first ANC visit, and secondary outcomes are the delivery of selected health care practices to women attending second and higher ANC visits as well as the attitude of midwives in relation to adopting the practices. This demonstration project is pragmatic in orientation and will be conducted under routine conditions.DiscussionThere is an urgent need for effective and sustainable scaling-up approaches of health interventions in low-resource countries. This can only be accomplished by the engagement of the country’s health stakeholders at all levels. This project aims to achieve improvement in the quality of antenatal care in Mozambique through the implementation of a multifaceted intervention on three levels: policy, organizational and health care delivery levels. The implementation of the trial will probably require a change in accountability and behaviour of health care providers and we expect this change in ‘habits’ will contribute to obtaining reliable health indicators, not only related to research issues, but also to health care outcomes derived from the new health care model. At policy level, the results of this study may suggest a need for revision of the supply chain management system. Given that supply chain management is a major challenge for many low-resource countries, we envisage that important lessons on how to improve the supply chain in Mozambique and other similar settings, will be drawn from this study.Trial registrationPan African Clinical Trial Registry database. Identification number: PACTR201306000550192.

Linked response for prevention, care, and treatment of HIV/AIDS, STIs, and reproductive health issues: results after 18 months of implementation in five operational districts in Cambodia.

Objectives:To describe the implementation and results of the linked response (LR) in Cambodia after 18 months of follow-up. Methods:The main objectives of the LR are to increase access to sexually transmitted infection/HIV prevention, testing, care, and treatment and to strengthen existing reproductive health services through increased linkages within and between public health facilities and community-based services. The LR was piloted in Cambodia in 2008, in 2 demonstration projects, covering 5 operational districts. Routine data were collected and analyzed before (2007), during (2008), and after (2009) the implementation of the LR. Results:Overall in the 5 operational districts, the proportion of pregnant women, tested for HIV increased from 6% (1261 of 21,376) in 2007 to 86% (18394 of 21,478) in 2009. Syphilis testing, introduced early 2009, reached similar (85%) coverage as HIV by the end of 2009. Between 2007 and 2009, reproductive indicators also increased: antenatal care coverage (at least 1 visit) from 80% to 100%, public health facility delivery rates from 26% to 46%, and contraceptive prevalence from 24% to 28%. Antiretroviral uptake was high among HIV-positive mothers and exposed infants, 84% and 95% respectively, and 3 of 36 (8%) infants tested so far for HIV were diagnosed positive. However, 6 maternal (HIV-positive women) and 7 child deaths (1 tested positive) occurred during the pregnancy or the 30-week postpartum follow-up period. Conclusions:Sexually transmitted infection/HIV indicators and follow-up dramatically improved after the LR was implemented. Efforts should be pursued to further improve quality of health care services.

Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study

Summary Background The 2014 west African epidemic of Ebola virus disease posed a major threat to the health systems of the countries affected. We sought to quantify the consequences of Ebola virus disease on maternal and child health services in the highly-affected Forest region of Guinea. Methods We did a retrospective, observational cohort study of women and children attending public health facilities for antenatal care, institutional delivery, and immunisation services in six of seven health districts in the Forest region (Beyla, Guéckédou, Kissidougou, Lola, Macenta, and N’Zérékoré). We examined monthly service use data for eight maternal and child health services indicators: antenatal care (≥1 antenatal care visit and ≥3 antenatal care visits), institutional delivery, and receipt of five infant vaccines: polio, pentavalent (diphtheria, tetanus, pertussis, hepatitis B virus, and Haemophilus influenzae type b), yellow fever, measles, and tuberculosis. We used interrupted time series models to estimate trends in each indicator across three time periods: pre-Ebola virus disease epidemic (January, 2013, to February, 2014), during-epidemic (March, 2014, to February, 2015) and post-epidemic (March, 2015, to Feb, 2016). We used segmented ordinary least-squares (OLS) regression using Newey-West standard errors to accommodate for serial autocorrelation, and adjusted for any potential effect of birth seasonality on our outcomes. Findings In the months before the Ebola virus disease outbreak, all three maternal indicators showed a significantly positive change in trend, ranging from a monthly average increase of 61 (95% CI 38–84) institutional deliveries to 119 (95% CI 79–158) women achieving at least three antenatal care visits. These increasing trends were reversed during the epidemic: fewer institutional deliveries occurred (–240, 95% CI −293 to −187), and fewer women achieved at least one antenatal care visit (–418, 95% CI −535 to −300) or at least three antenatal care visits (–363, 95% CI −485 to −242) per month (p<0·0001 for all). Compared with the negative trend during the outbreak, the change in trend during the post-outbreak period showed that 173 more women per month (95% CI 51–294; p=0·0074) had at least one antenatal care visit, 257 more (95% CI 117–398; p=0·0010) had at least three antenatal care visits and 149 more (95% CI 91–206; p<0·0001) had institutional deliveries. However, although the numbers for these indicators increased in the post-epidemic period, the trends for all stagnated. Similarly, the increasing trend in child vaccination completion during the pre-epidemic period was followed by significant immediate and trend reductions across most vaccine types. Before the outbreak, the number of children younger than 12 months who had completed each vaccination ranged from 5752 (95% CI 2821–8682) for tuberculosis to 8043 (95% CI 7621–8464) for yellow fever. Immediately after the outbreak, significant reductions occurred in the level of all vaccinations except for yellow fever for which the reduction was marginal. The greatest reductions were noted for polio and tuberculosis at −3594 (95% CI −4811 to −2377; p<0·0001) and −3048 (95% CI −5879 to −216; p=0·0362) fewer vaccines administered, respectively. Compared with pre-Ebola virus disease outbreak trends, significant decreases occurred for all vaccines except polio, with the trend of monthly decreases in the number of children vaccinated ranging from −419 (95% CI −683 to −155; p=0·0034) fewer for BCG to −313 (95% CI–446 to −179; p<0·0001) fewer for pentavalent during the outbreak. In the post-Ebola virus disease outbreak period, vaccination coverage for polio, measles, and yellow fever continued to decrease, whereas the trend in coverage for tuberculosis and pentavalent did not significantly differ from zero. Interpretation Most maternal and child health indicators significantly declined during the Ebola virus disease outbreak in 2014. Despite a reduction in this negative trend in the post-outbreak period, the use of essential maternal and child health services have not recovered to their pre-outbreak levels, nor are they all on a course that suggests that they will recover without targeted interventions.