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  • Reproductive health in humanitarian settings in Lebanon and Iraq: results from four cross-sectional studies, 2014-2015.

    Balinska, MA; Nesbitt, R; Ghantous, Z; Ciglenecki, I; Staderini, N (BMC, 2019-06-10)
    BACKGROUND: Reproductive health is an important component of humanitarian response. Displaced women need access to family planning, antenatal care, and the presence of a skilled birth attendant at delivery. Since the beginning of the Syrian conflict in 2011, Lebanon and Iraq have been hosting large numbers of refugees, thereby straining local capacities to provide these services. In order to identify salient health needs, Médecins Sans Frontières conducted a survey in several sites hosting refugees and internally displaced persons across the region. Here we describe the reproductive health profile of Syrian refugees, Iraqi displaced persons, and vulnerable Lebanese and their use of services. METHODS: We conducted four cross-sectional surveys in 2014-2015 in two sites in Lebanon and two sites in Iraq. Depending on the site, two-stage cluster sampling or systematic sampling was intended, but non-probability methods were employed at the second stage due to implementation challenges. We collected information on overall health (including reproductive health) and demographic information from heads of households on the basis of a standardized questionnaire. Pearson chi-square tests were used to compare proportions, and generalized linear models were used to calculate odds ratios with regard to risk factors. All analyses were performed using the survey suite of commands in Stata version 14.1. RESULTS: A total of 23,604 individuals were surveyed, including 5925 women of childbearing age. Overall, it was reported that 7.5% of women were currently pregnant and 12.8% had given birth within the previous 12 months. It was reported that pregnancy was unplanned for 57% of currently pregnant women and 66.7% of women who had delivered in the previous year. A slight majority of women from both groups had accessed antenatal care at least once. Amongst women who had delivered in the previous year, 84.5% had done so with a skilled birth attendant and 22.1% had had a cesarean section. Location and head of household education were predictors of unplanned pregnancy in multivariable analysis. Head of household education was also significantly associated with higher uptake of antenatal care. CONCLUSIONS: Considering the large number of pregnant women and women having recently delivered in these settings, addressing their sexual and reproductive health needs emerges as a crucial aspect of humanitarian response. This study identified unmet needs for family planning and high cesarean section rates at all sites, suggesting both lack of access to certain services (contraception, antenatal care), but also over-recourse to cesarean section. These specific challenges can impact directly on maternal and child health and need today to be kept high on the humanitarian agenda.
  • Breast Tuberculosis in Women: A Systematic Review

    Quaglio, G; Pizzol, D; Isaakidis, P; Bortolani, A; Tognon, F; Marotta, C; Di Gennaro, F; Putoto, G; Olliaro, P (American Society of Tropical Medicine and Hygiene, 2019-05-20)
    Breast tuberculosis (TB) is rarely reported and poorly described. This review aims to update the existing literature on risk factors, clinical presentations, constitutional symptoms, diagnostic procedures, and medical and surgical treatments for breast TB. In all, 1,478 cases of breast TB were collected. Previous history of TB was reported in 19% of cases. The most common clinical appearance of the lesion was breast lump (75%). The most common associated finding was axillary lymphadenitis (33%) followed by sinus or fistula (24%). The most common symptoms were pain and fever, reported in 42% and 28% of cases, respectively. The most used diagnostic method was fine-needle aspiration cytology (32%), followed by biopsy (27%), acid-fast bacteria Ziehl–Neelsen stain (26%), culture (13%), and polymerase chain reaction (2%). These tested positive in 64%, 93%, 27%, 26%, and 58% of cases, respectively. The majority (69%) of patients received a 6-month anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol). Surgery consisted of excision in 39% of cases, drainage in 23%, and mastectomy in 5%. The great majority of patients had a positive outcome. It often mimics breast cancer, which makes it difficult to diagnose. Most patients, when diagnosed in time, respond to antitubercular therapy alone.
  • "If we miss this chance, it's futile later on" - late antenatal booking and its determinants in Bhutan: a mixed-methods study.

    Dorji, T; Das, M; Van den Bergh, R; Oo, MM; Gyamtsho, S; Tenzin, K; Tshomo, T; Ugen, S (BioMed Central, 2019-05-07)
    BACKGROUND: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. METHODS: This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May-August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. RESULTS: Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. CONCLUSION: Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.
  • Trends of and factors associated with cesarean section related surgical site infections in Guinea

    Delamou, A; Camara, BS; Sidibe, S; Camara, A; Dioubate, N; Ayadi, AME; Tayler-Smith, K; Beavogui, AH; Balde, MD; Zachariah, R (Page Press, 2019-05-03)
    Since the adoption of free obstetric care policy in Guinea in 2011, no study has examined the surgical site infections in maternity facilities. The objective of this study was to assess the trends of and factors associated with surgical site infection following cesarean section in Guinean maternity facilities from 2013 to 2015. This was a retrospective cohort study using routine medical data from ten facilities. Overall, the incidence of surgical site infections following cesarean section showed a declining trend across the three periods (10% in 2013, 7% in 2014 and 5% in 2015, P<0.001). Women who underwent cesarean section in 2014 (AOR: 0.70; 95%CI: 0.57-0.84) and 2015 (AOR: 0.43; 95%CI: 0.34-0.55) were less likely to develop surgical site infections during hospital stay than women operated in 2013. In the contrary, women with comorbidities were more likely to experience surgical site infection (AOR: 1.54; 95% CI: 1.25-1.90) than those who did not have comorbidities. The reductions achieved in 2014 and 2015 (during the Ebola outbreak) should be sustained in the post-Ebola context.
  • Female Genital Schistosomiasis and HIV: Research Urgently Needed to Improve Understanding of the Health Impacts of This Important Coinfection.

    O'Brien, DP; Ford, Nathan; Djirmay, AG; Calmy, A; Vitoria, M; Jensen, TO; Christinet, V (Lippincott Williams and Wilkins, 2019-04-15)
    Evidence suggests that there are important interactions between HIV and female genital schistosomiasis (FGS) that may have significant effects on individual and population health. However, the exact way they interact and the health impacts of the interactions are not well understood. In this article, we discuss what is known about the interactions between FGS and HIV, and the potential impact of the interactions. This includes the likelihood that FGS is an important health problem for HIV-positive women in Schistosoma-endemic areas potentially associated with an increased risk of mortality, cancer, and infertility. In addition, it may be significantly impacting the HIV epidemic in sub-Saharan Africa by making young women more susceptible to HIV. We call for immediate action and argue that research is urgently required to address these knowledge gaps and propose a research agenda to achieve this.
  • Removal of user fees and system strengthening improves access to maternity care, maternal and neonatal mortality in a district hospital in Lesotho

    Steele, SJ; Sugianto, H; Baglione, Q; Sedlimaier, S; Niyibizi, AA; Duncan, K; Hill, J; Brix, J; Philips, M; Van Cutsem, G; Shroufi, A (Blackwell Publishing Ltd, 2018-10-26)
    Lesotho has one of the highest maternal mortality rates in the world. While at primary health care (PHC) level maternity care is free, at hospital level co-payments are required from patients. We describe service utilisation and delivery outcomes before and after removal of user fees and quality of delivery care, and associated costs, at St Joseph's Hospital (SJH) in Roma, Lesotho.
  • Care in crisis

    Nicholl, J; Midwife, recently completed her sixth assignment working for Médecins Sans Frontières/Doctors Without Borders (MSF) (Mark Allen Healthcare, 2018-10-03)
  • Risk Factors for Vaginal Colonization and Relationship between Bacterial Vaginal Colonization and In-Hospital Outcomes in Women with Obstructed Labor in a Ugandan Regional Referral Hospital

    Ngonzi, J; Bebell, LM; Bazira, J; Fajardo, Y; Nyehangane, D; Boum, Y; Nanjebe, D; Boatin, A; Kabakyenga, J; Jacquemyn, Y; Van Geertruyden, JP; Riley, LE; Mbarara University of Science and Technology, Department of Obstetrics and Gynecology, Mbarara, Uganda; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Mbarara University of Science and Technology, Department of Microbiology, Mbarara, Uganda; Mbarara University of Science and Technology, Department of Obstetrics and Gynecology, Mbarara, Uganda; Epicentre Mbarara Research Base, Mbarara, Uganda; Epicentre Mbarara Research Base, Mbarara, Uganda; Epicentre Mbarara Research Base, Mbarara, Uganda; Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Mbarara University of Science and Technology, Institute of Maternal Newborn and Child Health, Mbarara, Uganda; Global Health Institute, University of Antwerp, Antwerp, Belgium; Global Health Institute, University of Antwerp, Antwerp, Belgium; Division of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA (Hindawi Publishing Corporation, 2018-09-20)
    Introduction . The proportion of women with severe maternal morbidity from obstructed labor is between 2 and 12% in resource-limited settings. Maternal vaginal colonization with group B streptococcus (GBS), Escherichia coli , and Enterococcus spp. is associated with maternal and neonatal morbidity. It is unknown if vaginal colonization with these organisms in obstructed labor women is associated with poor outcomes. Objectives . To determine whether vaginal colonization with GBS, E. coli , or Enterococcus is associated with increased morbidity among women with obstructed labor and to determine the risk factors for colonization and antibiotic susceptibility patterns. Methods . We screened all women presenting in labor to Uganda’s Mbarara Regional Referral Hospital maternity ward from April to October 2015 for obstructed labor. Those meeting criteria had vaginal swabs collected prior to Cesarean delivery and surgical antibiotic prophylaxis. Swabs were inoculated onto sterile media for routine bacterial culture and antimicrobial susceptibility testing. Results . Overall, 2,168 women were screened and 276 (13%) women met criteria for obstructed labor. Vaginal swabs were collected from 272 women (99%), and 170 (64%) were colonized with a potential pathogen: 49% with E. coli , 5% with GBS, and 8% with Enterococcus . There was no difference in maternal and fetal clinical outcomes between those colonized and not colonized. The number of hours in labor was a significant independent risk factor for vaginal colonization (aOR 1.02, 95% CI 1.00–1.03, P = 0.04 ). Overall, 38% of GBS was resistant to penicillin; 61% of E. coli was resistant to ampicillin, 4% to gentamicin, and 5% to ceftriaxone and cefepime. All enterococci were ampicillin and vancomycin susceptible. Conclusion . There was no difference in maternal or neonatal morbidity between women with vaginal colonization with E. coli , GBS, and Enterococcus and those who were not colonized. Duration of labor was associated with increased risk of vaginal colonization in women with obstructed labor.
  • High prevalence of ESBL-positive bacteria in an obstetrics emergency hospital and neonatal care unit—Haiti, 2016

    Chaintarli, K; Lenglet, A; Beauzile, BD; Senat-Delva, R; Mabou, MM; Martino, C; Berthet, M; Wong, S; Hopman, J (The Society for Healthcare Epidemiology of America, 2018-08-30)
    Patient colonization with extended-spectrum β-lactamase–producing gram-negative bacteria (ESBL-GNB) could serve as a potential reservoir for transmission of multidrug-resistant (MDR) bacteria in a hospital setting. Individuals colonized with ESBLEnterobacteriaceae are also known to be at a higher risk of ESBLGNB infection following their colonization.1 We encountered an outbreak of MDR Klebsiella pneumoniae in the neonatal care unit (NCU) of the Médecins Sans Frontiéres (MSF) obstetric emergency hospital in Port au Prince (CRUO), Haiti, between 2014 and 2015.2 As part of ongoing surveillance activities for MDR bacteria and in an effort to better target infection, prevention, and control (IPC) measures throughout the hospital, we conducted a point-prevalence survey to estimate the prevalence of colonization with ESBL-GNB and to identify risk factors for colonization with ESBL-GNB in women and neonates admitted to this hospital.
  • Delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port-Au-Prince, Haiti

    Hutchinson, K; Bryant, M; Bachman DeSilva, M; Price, D; Sabin, L; Bryson, L; Jean Charles, R; Declercq, E (BMC, 2018-08-20)
    The primary objective of this comparative, cross-sectional study was to identify factors affecting delays in accessing emergency obstetric care and clinical consequences of delays among preeclamptic and non-preeclamptic women in Port-au-Prince, Haiti.
  • Wishful thinking versus operational commitment: is the international guidance on priority sexual and reproductive health interventions in humanitarian settings becoming unrealistic?

    Tran, NT; Schulte-Hillen, C (BioMed Central, 2018-05-29)
    Twenty-one years ago, a global consortium of like-minded institutions designed the landmark Minimum Initial Service Package (MISP) for sexual and reproductive health (SRH) to guide national and international humanitarian first responders in preventing morbidity and mortality at the onset of chaos, destruction, and high insecurity caused by disasters or conflicts. Since then, the MISP has undergone limited change and has become an international reference in humanitarian response. This article discusses our perspectives regarding the 2018 changes to the MISP that have created division among humanitarian field practitioners, academics, advocates, and development agencies. With more than 50 pages, the new MISP chapter dilutes key guidance and messages on the most life-saving activities, leaving actors with excessive room for interpretation as to which priority activities need to be first implemented. Consequently, non-life-saving interventions may take precedence over essential ones. Insecurity, scarce human and financial resources, logistics constrains, and other limitations imposed by field reality at the onset of a crisis must be considered. We strongly recommend that an institution with the mandate, legitimacy, and technical expertise in the review of guidelines reexamines the 2018 edition of the MISP. We urge experienced first-line responders, national actors, and relevant agencies to join efforts to ensure that the MISP remains focused on a very limited set of essential activities and supplies that are pragmatic, field-oriented, and, most importantly, immediately life-saving for people in need.
  • Provision of emergency obstetric care at secondary level in a conflict setting in a rural area of Afghanistan - is the hospital fulfilling its role?

    Lagrou, D; Zachariah, R; Bissell, K; Van Overloop, C; Nasim, M; Wagma, HN; Kakar, S; Caluwaerts, S; De Plecker, E; Fricke, R; Van den Bergh, R (BioMed Central, 2018-01-22)
    Provision of Emergency Obstetric and Neonatal Care (EmONC) reduces maternal mortality and should include three components: Basic Emergency Obstetric and Neonatal Care (BEmONC) offered at primary care level, Comprehensive EmONC (CEmONC) at secondary level and a good referral system in-between. In a conflict-affected province of Afghanistan (Khost), we assessed the performance of an Médecins Sans Frontières (MSF) run CEmONC hospital without a primary care and referral system. Performance was assessed in terms of hospital utilisation for obstetric emergencies and quality of obstetric care.
  • Care Requirements for Clients Who Present After Rape and Clients Who Presented After Consensual Sex as a Minor at a Clinic in Harare, Zimbabwe, From 2011 to 2014

    Harrison, R; Pearson, L; Vere, M; Chonzi, P; Hove, B; Mabaya, S; Chigwamba, M; Nhamburo, J; Gura, J; Vandeborne, A; Simons, S; Lagrou, D; De Plecker, E; Van den Bergh, R (Public Library of Science, 2017-09-21)
    To describe the differences between clients presenting after rape and clients who have consented to sex as a minor to an SGBV clinic in Harare, Zimbabwe, and how these differences affect their care requirements.
  • Antimicrobial-Resistant Infections Among Postpartum Women at a Ugandan Referral Hospital

    Bebell, LM; Ngonzi, J; Bazira, J; Fajardo, Y; Boatin, AA; Siedner, MJ; Bassett, IV; Nyehangane, D; Nanjebe, D; Jacquemyn, Y; van Geertruyden, JP; Mwanga-Amumpaire, J; Bangsberg, DR; Riley, LE; Boum, Y (Public Library of Science, 2017-04-13)
    Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking.
  • A Live Term Intra-Abdominal Pregnancy in a Field Hospital: a Case Report

    Abdelrahman, S; Deeter, M; Muthusami, A; Peterson, TG; Wackenier, L (Oxford University Press, 2017-03-22)
    Abdominal pregnancy is a rare form of ectopic pregnancy with high morbidity and mortality for both the mother and the fetus. Diagnosis can be challenging, especially in a resource-limited setting. We report a case of abdominal pregnancy that presented to Médecins Sans Frontières field hospital in Agok, South Sudan, with abdominal pain. Examination revealed a term pregnancy and a live fetus in transverse lie. The diagnosis of abdominal pregnancy was made intraoperatively, with successful management and delivery of a healthy baby.
  • Why Médecins Sans Frontières (MSF) Provides Safe Abortion Care and What That Involves

    Schulte-Hillen, C; Staderini, N; Saint-Sauveur, JF (BioMed Central, 2016-09-21)
    MSF responds to needs for the termination of pregnancy, including on request (TPR); it is part of the organization's work aimed at reducing maternal mortality and suffering; and preventing unsafe abortions in the countries where we work. Following the publication of "Why don't humanitarian organizations provide safe abortion care?" we offer an insight into MSF's experience over the past few years. The article looks at the legal concerns and proposes that the importance of addressing maternal mortality should replace them and the operational set-up and action organized in a way that mitigates risks. MSF took a policy decision on safe abortion care in 2004; the fact that care did not expand rapidly to relevant MSF projects came as a surprise, reflecting the important weight social norms around abortion have everywhere. The need to engage in an open dialogue with staff, relevant medical actors and at community level became more obvious. Finally the article looks some key lessons that have emerged for the organization as part of the effort to prevent ill health, maternal death and suffering caused by unwanted pregnancy and unsafe abortion.
  • Caesarean Sections in Rural Burundi: How Well Are Mothers Doing Two Years On?

    van den Boogaard, W; Manzi, M; De Plecker, E; Caluwaerts, S; Nanan-N'zeth, K; Duchenne, B; Etienne, W; Juma, N; Ndelema, B; Zachariah, R (International Union Against TB and Lung Disease, 2016-06-21)
    A caesarean section (C-section) is a life-saving emergency intervention. Avoiding pregnancies for at least 24 months after a C-section is important to prevent uterine rupture and maternal death.
  • Pregnant Women in War Zones

    Akol, AD; Caluwaerts, S; Weeks, AD (BMJ Publishing Group We regret that this article is behind a paywall., 2016-04-20)
  • Factors Related to Fetal Death in Pregnant Women with Cholera, Haiti, 2011-2014

    Schillberg, E; Ariti, C; Bryson, L; Delva-Senat, R; Price, D; GrandPierre, R; Lenglet, A (Center for Disease Control, 2016-01-01)
    We assessed risk factors for fetal death during cholera infection and effect of treatment changes on these deaths. Third trimester gestation, younger maternal age, severe dehydration, and vomiting were risk factors. Changes in treatment had limited effects on fetal death, highlighting the need for prevention and evidence-based treatment.
  • Care for victims of sexual violence, an organization pushed to its limits: The case of Médecins Sans Frontières

    Duroch, F; Schulte-Hillen, C (International Committee of the Red Cross/Cambridge University Press, 2015-09-09)
    Over the past ten years, Médecins Sans Frontières (MSF) has provided medical care to almost 118,000 victims of sexual violence. Integrating related care into MSF general assistance to populations affected by crisis and conflicts has presented a considerable institutional struggle and continues to be a challenge. Tensions regarding the role of MSF in providing care to victims of sexual violence and when facing the multiple challenges inherent in dealing with this crime persist. An overview of MSF’s experience and related reflection aims to share with the reader, on the one hand,the complexity of the issue, and on the other, the need to continue fighting for the provision of adequate medical care for victims of sexual violence,which despite the limitations is feasible.

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