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Background: Maternal mortality (MM) remains a real scourge that hits hardest in the poorest regions of the world, particularly those affected by conflict. However, despite this worrying reality, few studies have been conducted about MM ratio in the Democratic Republic of Congo (DRC). The study aimed to describe the trends as well as the epidemiological profile and causes of reported institutional maternal deaths between 2013 and 2022 in Eastern DRC. Methods: A retrospective descriptive study was conducted between March 2023 and August 2023 in eight Health Zones (HZ), five in South Kivu Province (Mwana, Minova, Miti-Murhesa, Kamituga and Idjwi) and three in North Kivu Province (Kirotshe, Karisimbi and Kayna) in the eastern region of the DRC. Our study covers 242 health facilities: 168 health centers (HC), 16 referral health centers (RHCs),50 referral hospitals (RH) and 8 general referral hospitals (GRHs). Data from registers and medical records of maternal deaths recorded in these zones from 2013–2022 were extracted along with information on the number of deliveries and live births. Sociodemographic, clinical parameters, blood and ultrasound tests and suspected causes of death between provinces were assessed. Results: In total, we obtained 177 files on deceased women. Of these, 143 (80.8%) were retained for the present study, including 75 in the 3 HZs of North Kivu and 68 in the 5 HZs of South Kivu. From 2013 to 2022, study sites experienced two significant drops in maternal mortality ratio (MMR) (in 2015 and 2018), and a spike in 2016–2017. Nonetheless, the combined MMR (across study sites) started and ended the 10-year study period at approximately the same level (53 and 57 deaths per 100,000 live births in 2013 and 2022 respectively). Overall, 62,6% of the deaths were reported from secondary hospital. Most deaths were of married women in their thirties (93.5%). Almost half (47.8%) had not completed four antenatal consultations. The main direct causes of death were, in decreasing order of frequency: post-partum haemorrhage (55.2%), uterine rupture (14.0), hypertensive disorders (8.4%), abortion (7.7%) puerperal infections (2.8%) and placental abruption (0.7%). When comparing among provinces, reported abortion-related maternal mortality (14.1% vs 0%) was more frequent in North Kivu than in South Kivu. Conclusion: This study imperatively highlights the need for targeted interventions to reduce maternal mortality. By emphasizing the crucial importance of antenatal consultations, intrapartum/immediate post-partum care and quality of care, significant progress can be made in guaranteeing maternal health and reducing many avoidable deaths. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about the long-term outcomes of Severe Acute Malnutrition (SAM) during childhood. As such, this study aims to explore the association between childhood SAM and blood pressure (BP) in adulthood in a context without nutrition transition.Methodology: We identified 524 adults (Median age: 22 years) who were treated for SAM during childhood in Eastern DRC between 1988 and 2007. They were compared with 407 age-and-sex matched subjects with no history of SAM in the community. The variables examined for this study were the systolic (SBP), diastolic (DBP), mean (MBP) blood pressure (BP) and pulse pressure (PP), as well as high blood pressure (HBP) defined as BP ≥ 140/90 mmHg and/or use of BP-lowering drug(s) in adulthood. For comparison, linear and logistic regression models were used for analysing continuous and dichotomous variables, respectively.Results: Of the 524 exposed located, 145 were selected according to age. A total of 97 unexposed were recruited. Compared to unexposed, exposed had slightly higher SBP and PP after adjusting for occupation, body mass index (BMI) and food consumption [SBP = 1.4 mmHg (- 2.2, 4.8) and PP = 2.6 mmHg (- 0.3, 6.0)]. However, their DBP was lower than that of the unexposed [- 1.6 mmHg (- 4.6, 1.5)]. MBP and creatinine levels were similar between the two groups. The prevalence of HBP adjusted for age was higher among exposed than unexposed (9.7% vs 5.3%). In addition, the odds of having HBP was higher among exposed than unexposed, however the observed difference was not statistically significant [Odds Ratio (OR) 1.9 (0.7, 5.6)]. Finally, using multiple regression analysis, although the effect was not significant, SAM was a major contributor to HBP [adjusted OR 3.1 (0.9,10.9), p = 0.064], while only male gender and higher BMI (overweight/obesity) emerged as independent predictors of HBP among this young study population.Conclusions: This study suggests that an episode of SAM in childhood has a weak impact on BP variability in young Congolese adults (from DRC) living in an environment without nutrition transition. However, people who experienced a period of SAM tended to have a higher prevalence of HBP and a much higher risk of developing HBP than unexposed. Additional multicentre studies involving a larger cohort would provide greater understanding of the impact of SAM on the overall risk of BP disorders during adulthood. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about the outcomes of subjects with a history of severe acute malnutrition (SAM). We therefore sought to explore the long-term effects of SAM during childhood on human capital in adulthood in terms of education, cognition, self-esteem and health-related disabilities in daily living. Methodology: We traced 524 adults (median age of 22) in the eastern Democratic Republic of the Congo, who were treated for SAM during childhood at Lwiro hospital between 1988 and 2007 (median age 41 months). We compared them with 407 community controls of comparable age and sex. Our outcomes of interest were education, cognitive function [assessed using the Mini Mental State Examination (MMSE) for literate participants, or its modified version created by Ertan et al. (MMSE-I) for uneducated participants], self-esteem (measured using the Rosenberg Self-Esteem Scale) and health-related social and functional disabilities measured using the World Health Organization Disability Assessment Schedule (WHODAS). For comparison, we used the Chi-squared test along with the Student's t-test for the proportions and means respectively. Results: Compared with the community controls, malnutrition survivors had a lower probability of attaining a high level of education (p < 0.001), of reporting a high academic performance (p = 0.014) or of having high self-esteem (p = 0.003). In addition, malnutrition survivors had an overall mean score in the cognitive test that was lower compared with the community controls [25.6 compared with 27.8, p = 0.001 (MMSE) and 22.8 compared with 26.3, p < 0.001(MMSE-I)] and a lower proportion of subjects with a normal result in this test (78.0% compared with 90.1%, p < 0.001). Lastly, in terms of health-related disabilities, unlike the community controls, malnutrition survivors had less social disability (p = 0.034), but no difference was observed as regards activities of daily living (p = 0.322). Conclusion: SAM during childhood exposes survivors to low human capital as regards education, cognition and behaviour in adulthood. Policy-deciders seeking to promote economic growth and to address various psychological and medico-social disorders must take into consideration the fact that appropriate investment in child health as regards SAM is an essential means to achieve this. [ABSTRACT FROM AUTHOR]

Background: It is well documented that treatment for severe acute malnutrition (SAM) is effective. However, little is known about the long-term outcomes for children treated for SAM. We sought to trace former SAM patients 11 to 30 years after their discharge from hospital, and to describe their longer-term survival and their growth to adulthood. Methods: A total of 1,981 records of subjects admitted for SAM between 1988 and 2007 were taken from the archives of Lwiro hospital, in South Kivu, DRC. The median age on admission was 41 months. Between December 2017 and June 2018, we set about identifying these subjects (cases) in the health zones of Miti-Murhesa and Katana. For deceased subjects, the cause and year of death were collected. A Cox proportional hazards multivariate regression analysis was used to identify the death-related factors. For the cases seen, age- and gender-matched community controls were selected for a comparison of anthropometric indicators. Results: A total of 600 subjects were traced, and 201 subjects were deceased. Of the deceased subjects, 65·6% were under 10 years old at the time of their death. Of the deaths, 59·2% occurred within 5 years of discharge from hospital. The main causes of death were malaria (14·9%), kwashiorkor (13·9%), respiratory infections (10·4%), and diarrhoeal diseases (8·9%). The risk of death was higher in subjects with SAM, MAM combined with CM, and in male subjects, with HRs* of 1·83 (p = 0·043), 2.35 (p = 0·030) and 1.44 (p = 0·013) respectively. Compared with their controls, the cases had a low weight (-1·7 kg, p = 0·001), short height [sitting (-1·3 cm, p = 0·006) and standing (-1·7 cm, p = 0·003)], short legs (-1·6 cm, p = 0·002), and a small mid-upper arm circumference (-3·2mm, p = 0·051). There was no difference in terms of BMI, thoracic length, or head and thoracic circumference between the two groups. Conclusion: SAM during childhood has lasting negative effects on growth to adulthood. In addition, these adults have characteristics that may place them at risk of chronic non-communicable diseases later in life. [ABSTRACT FROM AUTHOR]

Background: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. Methods: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. Results: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. Conclusions: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes. [ABSTRACT FROM AUTHOR]

Background: Little is known about the use of mid-upper arm circumference for age (MUACZ) for diagnosing of severe acute malnutrition (SAM) and its correlation with WHZ (weight-for-height Z-score) in an area endemic for severe acute malnutrition (SAM) and with a high prevalence of kwashiorkor. Our study aims to analyze the concordance between the diagnostic criteria of SAM in a region presenting these characteristics. Methods: We analyzed a database of children admitted from 1987 to 2008 for the management of SAM in Eastern Democratic Republic of Congo. Anthropometric indicators (z-score) were calculated and classified into 3 categories according to WHO standards. Cohen's kappa coefficient (κ) was calculated to assess the concordance between these indicators. Results: Out of the 9969 selected children aged 6 to 59 months, 30.2% had nutritional edema, 70.1% had a height-for-age (HAZ) z-score <-2, 11.5% WHZ<-3 z-score, 14.9% had a MUAC < 115 mm and 21.8% had a MUACZ <-3 z-score. With the classic combination WHZ and MUAC, 36% of children with SAM had both criteria at the same time and MUAC alone being the indicator that recruited more children with SAM (77%) compared with 65% with WHZ only. By replacing MUAC with MUACZ, 34% of SAM children fulfilled both criteria, WHZ and MUACZ. MUACZ alone recruited more children with SAM (88%) compared with 46% with WHZ alone. Considering these three indicators together, MUACZ remained the indicator that recruited more children with SAM (85%). WHZ and MUAC showed a moderate agreement [ κ (95% CI) = 0.408(0.392–0.424)], WHZ and MUACZ a weak agreement [ κ (95% CI) = 0.363(0.347–0.379)] and MUAC and MUACZ a good agreement [ κ (95% CI) = 0.604 (0.590–0.618)]. Conclusion: Adjusting MUAC according to age improves its effectiveness in identifying severe acute malnutrition. With low concordance, MUAC and WHZ remain complementary in our context. MUACZ proves to be crucial, especially in the presence of kwashiorkor and chronic malnutrition, becoming a valuable tool for assessing severe acute malnutrition in our context. [ABSTRACT FROM AUTHOR]

Background: This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC. Methods: A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC's health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service's Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes. Results: The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone's external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership. Conclusions: Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings. [ABSTRACT FROM AUTHOR]

Background: Health Care Workers (HCWs) in conflict zones face high levels of violence while also playing a crucial role in assisting the population in distress. For more than two decades, the eastern provinces of the Democratic Republic of the Congo (DRC), have been wracked by conflict. This study aims to describe the state of violence against HCWs and the potential prevention mechanisms in eastern DRC. Methods: In North and South Kivu, between February 5 and 21, 2021, we conducted a mixed cross-sectional convergent study in health facilities (health centers and hospitals). An anonymized self-administered questionnaire was sent to HCWs about their experience of violence in the 12 months prior to the study. In-depth individual interviews with HCWs, present on the day of the investigation, were also done to explore their experience of violence. A descriptive analysis of the quantitative data and a thematic analysis of the qualitative data was carried out. Results: Of a total of 590 participants, 276 (45.9%) reported having experienced violence in the 12 months before the study. In North Kivu, aggressors were more frequently the patients (43.7% vs. 26.5%) and armed group members (14.3% vs. 7.9%) than in South Kivu. Most respondents (93.5%) reported verbal aggression (insults, intimidation, death threats). Other forms of physical aggression including with bare hands (11.2%), firearm (1.81%), and stabbing (4.7%). Only nearly one-tenth of the attacks were officially reported, and among those reported a higher proportion of sanctions was observed in South Kivu (8.5%) than in North Kivu (2.4%). The mechanisms proposed to prevent violence against HCWs were community initiatives and actions to strength the health system. Conclusions: In Eastern DRC, HCWs face multiple and severe forms of aggression from a variety of individuals. The effects of such levels violence on HCWs and the communities they served could be devastating on the already pressured health system. Policy framework that defines the roles and responsibilities for the protection of HCWs and for the development and implementation of preparedness measures such as training on management of violence are possible solutions to this problem. [ABSTRACT FROM AUTHOR]

Background: In the Democratic Republic of Congo (DRC), healthcare services are still focused on disease control and mortality reduction in specific groups. The need to broaden the scope from biomedical criteria to bio-psychosocial (BPS) dimensions has been increasingly recognized. Aim: The objective of this study was to identify the barriers and facilitators to providing healthcare at the health centre (HC) level to enable BPS care. Settings: This qualitative study was conducted in six HCs (two urban and four rural) in South-Kivu (eastern DRC) which were selected based on their accessibility and their level of primary healthcare organization. Methods: Seven focus group discussions (FGDs) involving 29 healthcare workers were organized. A data synthesis matrix was created based on the Rainbow Model framework. We identified themes related to plausible barriers and facilitators for BPS approach. Results: Our study reports barriers common to a majority of HCs: misunderstanding of BPS care by healthcare workers, home visits mainly used for disease control, solidarity initiatives not locally promoted, new resources and financial incentives expected, accountability summed up in specific indicators reporting. Availability of care teams and accessibility to patient information were reported as facilitators to change. Conclusion: This analysis highlighted major barriers that condition providers' mindset and healthcare provision at the primary care level in South-Kivu. Accessibility to the information regarding BPS status of individuals within the community, leadership of HC authorities, dynamics of HC teams and local social support initiatives should be considered in order to develop an effective BPS approach in this region. [ABSTRACT FROM AUTHOR]