• 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; et al. (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.
    • 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.
    • Responding to rape.

      Shanks, L; Ford, N; Schull, M; de Jong, K; Médecins Sans Frontières, Toronto, Canada. msfcan@msf.ca (Elsevier, 2001-01-27)
    • 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; et al. (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.
    • Severe acute maternal morbidity and associated deaths in conflict and post-conflict settings in Africa

      Tamura, M; Hinderaker, S G; Manzi, M; Van Den Bergh, R; Zachariah, R (TB Union, 2012-12)
    • Sexual violence in post-conflict Liberia: survivors and their care.

      Tayler-Smith, K; Zachariah, R; Hinderaker, S G; Manzi, M; De Plecker, E; Van Wolvelaer, P; Gil, T; Goetghebuer, S; Ritter, H; Bawo, L; et al. (Blackwell, 2012-11-12)
      Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors' needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9-17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor's home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care.
    • Tackling female genital cutting in Somalia.

      Ford, N; Médecins Sans Frontières, 124-132 Clerkenwell Road, EC1R 5DJ, London, UK. (Elsevier, 2001-10-06)
    • 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.
    • Unregulated Usage of Labour-Inducing Medication in a Region of Pakistan with Poor Drug Regulatory Control: Characteristics and Risk Patterns

      Shah, S; Van den Bergh, R; Prinsloo, J R; Rehman, G; Bibi, A; Shaeen, N; Auat, R; Daudi, S M; Njenga, J W; Khilji, T B-U-D; et al. (Oxford University Press, 2015-08-13)
      In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable risk for mother and child during labour. Here, we describe the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan.
    • Which anthropometric indicators identify a pregnant woman as acutely malnourished and predict adverse birth outcomes in the humanitarian context?

      Ververs, M-T; Antierens, A; Sackl, A; Staderini, N; Captier, V (Public Library of Science, 2013)
      Currently there is no consensus on how to identify pregnant women as acutely malnourished and when to enroll them in nutritional programmes. Médecins Sans Frontières Switzerland undertook a literature review with the purpose of determining values of anthropometric indicators for acute malnutrition that are associated with adverse birth outcomes (such as low birth weight (LBW)), pre-term birth and intra-uterine growth retardation (IUGR). A literature search in PUBMED was done covering 1 January 1995 to 12 September 2012 with the key terms maternal anthropometry and pregnancy. The review focused on the humanitarian context. Mid-upper-arm circumference (MUAC) was identified as the preferential indicator of choice because of its relatively strong association with LBW, narrow range of cut-off values, simplicity of measurement (important in humanitarian settings) and it does not require prior knowledge of gestational age. The MUAC values below which most adverse effects were identified were <22 and <23 cm. A conservative cut-off of <23 cm is recommended to include most pregnant women at risk of LBW for their infants in the African and Asian contexts.
    • 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.
    • 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.