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Background: Stillbirth and (obstetric) fistula are traumatic life events, commonly experienced together following an obstructed labour in low‐ and middle‐income countries with limited access to maternity care. Few studies have explored women's experiences of the combined trauma of stillbirth and fistula. Aim: To explore the lived experiences of women following stillbirth and fistula. Methods: Qualitative, guided by Heideggerian phenomenology. Twenty women who had experienced a stillbirth were interviewed while attending a specialist Hospital fistula service in urban Kenya. Data were analysed following Van Manen's reflexive approach. Results: Three main themes summarised participants' experiences: 'Treated like an alien' reflected the isolation and stigma felt by women. The additive and multiplying impacts of stillbirth and fistula and the ways in which women coped with their situations were summarised in 'Shattered dreams'. The impact of beliefs and practices of women and those around them were encapsulated in 'It was not written on my forehead'. Conclusion: The distress women experienced following the death of a baby was intensified by the development of a fistula. Health professionals lacked an understanding of the pathophysiology and identification of fistula and its association with stillbirth. Women were isolated as they were stigmatised and blamed for both conditions. Difficulty accessing follow‐up care meant that women suffered for long periods while living with a constant reminder of their baby's death. Cultural beliefs, faith and family support affected women's resilience, mental health and recovery. Specialist services, staff training and inclusive policies are needed to improve knowledge and awareness and enhance women's experiences. Patient or Public Contribution: A Community Engagement and Involvement group of bereaved mothers with lived experience of stillbirth and neonatal death assisted with the review of the study protocol, participant‐facing materials and confirmation of findings. [ABSTRACT FROM AUTHOR]

Background: Stillbirth is an extremely traumatic and distressing experience for parents, with profound and long-lasting negative impacts. Cultural beliefs and practices surrounding death vary considerably across different contexts and groups, and are a key influence on individual experiences, impacting grief, adjustment, and support needs. Few studies have explored cultural influences surrounding stillbirth in an African context. This study explored the influence of cultural beliefs and practices on the experiences of bereaved parents and health workers after stillbirth in urban and rural settings in Kenya and Uganda.Methods: A qualitative descriptive study design was employed. Face to face interviews were conducted with parents (N = 134) who experienced a stillbirth (≤ 1 year) and health workers (N = 61) at five facilities in Uganda and Kenya. Interviews were conducted in English or the participants' local language, audio-recorded and transcribed verbatim. Analysis was conducted using descriptive thematic analysis.Results: Commonalities in cultural beliefs and practices existed across the two countries. Three main themes were identified: 1) Gathering round, describes the collective support parents received from family and friends after stillbirth. 2)'It is against our custom' addresses cultural constraints and prohibitions impacting parents' behaviour and coping in the immediate aftermath of the baby's death. 3) 'Maybe it's God's plan or witchcraft' summarises spiritual, supernatural, and social beliefs surrounding the causes of stillbirth.Conclusions: Kinship and social support helped parents to cope with the loss and grief. However, other practices and beliefs surrounding stillbirth were sometimes a source of stress, fear, stigma and anxiety especially to the women. Conforming to cultural practices meant that parents were prevented from: holding and seeing their baby, openly discussing the death, memory-making and attending the burial. The conflict between addressing their own needs and complying with community norms hindered parents' grief and adjustment. There is an urgent need to develop culturally sensitive community programmes geared towards demystifying stillbirths and providing an avenue for parents to grieve in their own way. [ABSTRACT FROM AUTHOR]

Background/Aims: Globally, there are three pathways to become a midwife: midwifery post nursing, direct entry midwifery and integrated nursing and midwifery. There is limited knowledge on the effectiveness of pre-service midwifery education. The aim of this study was to describe and compare midwifery students' confidence in intrapartum skills and associated factors such as type and level of education. Methods: A multi-country cross-sectional study was conducted, where midwifery students were approached in the final months of their education programme. Data were collected using a questionnaire, based on the basic skills by the International Confederation of Midwives. Intrapartum care comprised 40 skills. Results: In total, 1407 midwifery students from seven sub-Saharan countries responded. The 40 skills were grouped into six domains; three related to care during the first and second stage of labour and three related to care during the third stage of labour. Sex and age were significantly associated with confidence, with female students and those 26–35 years old having higher levels of confidence. Students enrolled in a direct entry programme were more confident than other students in all three domains of care related to the first and second stage of labour. Conclusions: Direct entry was found to result in higher confidence for midwifery students than post nursing programmes or integrated programmes. Further research is needed for evaluation of competence. [ABSTRACT FROM AUTHOR]

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Background: Maternal mortality and morbidity rates remain high in sub-Saharan Africa, yet with appropriate management, these rates could be reduced significantly. Midwifery training to improve the management of women during intrapartum period is often lacking, calling for innovative training methods in midwifery clinical care. Aims: To develop and evaluate a game, aimed at the prevention and management of the main causes of maternal morbidity and mortality. Methods: In collaboration with the Lugina Africa Midwives Research Network (LAMRN), the authors developed an educational board game and field tested the final version in Kenya, Tanzania and Malawi with midwives (n=56) and student midwives (n=32). Findings: Qualitative and quantitative evaluation demonstrated that the game was well liked for its ease of use, acceptable appearance and relevance to practice. Conclusions: The board game, named 'Crisis', has potential to influence practice; however, further research is required to assess its ability to improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa. Objective: The aim of the study was to describe and compare midwifery students' confidence in basic antenatal skills, in relation to age, sex, program type and level of program. Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition. Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains. Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence. [ABSTRACT FROM AUTHOR]

Background: The prevalence of blood-borne pathogens, including HIV and hepatitis B and C, remains high in sub-Saharan Africa. Nurses and midwives are therefore at high risk for occupational transmission. Aims: To examine the prevalence of sharps injuries and other work-related risks among nurses and midwives. Methods: Nurses and midwives (n=712) in sub-Saharan Africa completed an anonymous questionnaire. Generalised estimating questions were used to analyse the data. Findings: Nurses and midwives who made home visits, engaged in direct care, were called in to work 'off-hours', and performed needle-related tasks ≥15 times/day were more likely to have sharps injuries (all P<0.05). Among those injured, only 64.2% reported their injuries appropriately. Among those who reported, only 61.5% were tested for HIV or hepatitis B and C, and only 28.2% received HIV post-exposure prophylaxis. Conclusions: Future efforts should focus on optimising work schedules, reducing unnecessary needle-related tasks, introducing safety engineered needles and improving post-exposure prophylaxis. [ABSTRACT FROM AUTHOR]

Giving birth is considered a normal event in a woman's life and one embedded in all cultures. It is generally accepted, regardless of culture or country of residence, that almost all women have some degree of anxiety during pregnancy. Reasons for anxiety may change during the pregnancy, for example, during the first trimester this may be specifically related to the ongoing pregnancy and miscarriage. During the second trimester this might be replaced by thoughts on fetal abnormality, and finally in the third trimester, anxiety regarding labour and pain. For some women, anxiety surrounding the pregnancy and birth can spiral into what has become known as fear of birth. The reasons for fear of birth are multi-factorial, encompassing psychological, social, and spiritual dimensions. Therefore, it is conceivable that birth in different cultures and countries may result in different experiences for women. This short discussion paper observes fear of birth in women from England and Kenya, asking the question: Are the differences that different after all? [ABSTRACT FROM AUTHOR]

Background: The majority of Kenya's population lives in rural areas with limited access to higher education. A blended ‘eBSc Nursing’ programme was created to bridge the gap. Aims: To explore users' views on the effectiveness of the pilot blended e-learning BSc Nursing programme in Kenya. Methods: A mixed methods approach was used in data collection. All students in the pilot eBsc Nursing programme were sampled and focus group discussions were held with lecturers and mentors. Findings: The majority of the pilot cohort (84%) were satisfied with the quality of training and the inherent flexibility of the model. Offline e-learning sites were only accessible to 64% of learners. Limited ICT skills among lecturers were a concern to 46% of the respondents. Trainers were of the opinion that the in-service eLearners either performed at equal to or better than conventionally-trained BscN students. Conclusions: There was a positive user response to the eBscN upgrading programme. Learner support systems required more strengthening to deliver on desired objectives. [ABSTRACT FROM AUTHOR]

Background: Birth preparedness is a strategy that has been found to ensure readiness for birth and prevent obstetric delays. It is hindered, however, by lack of knowledge, cultural taboos and lack of finances. Methods: This was a descriptive cross-sectional study, which aimed to establish the knowledge and practice of birth preparedness among antenatal mothers attending public health facilities in Migori County, Kenya. The study used both quantitative and qualitative methods. Data were collected through interviewer-administered questionnaires and focus group discussions. A total of 389 women were interviewed in four randomly selected facilities. Data analysis was carried out and P-values reported. Content analysis was conducted for the qualitative data and reported in form of narration. Findings: The knowledge on birth preparedness was low (53%) and the respondents were unaware of its key concepts. Marital status (P=0.003), residence (P=<0.001), unemployment (P=0.001) and the partner's level of education (P=0.001) affected birth preparedness knowledge. Favourable birth preparedness practices were seen in 56% of participants. Marital status (P=0.05), residence (P=<0.001), partner's education, and health facility (P=<0.001) affected birth preparedness. Conclusions: More emphasis should be made on the key concepts of birth preparedness during health education. Effort should also be made to improve its practice. [ABSTRACT FROM AUTHOR]

Background: Obstetric fistula is caused by prolonged obstructed labour, and affects about 1% of women in Kenya. Although early treatment is recommended, women live with the condition for many years and endure physical, psychological and social suffering. Aims: To document the experiences of women with fistula illness. Methods: Using grounded theory methodology, narratives focusing on labour and childbirth were obtained from a purposive sample of 121 patients with obstetric fistula in 3 hospitals in Kenya. Narratives were analysed using a three-dimensional framework: Interaction, Continuity and Place. Findings: Six emergent themes predicting occurrence of fistula were identified. These were: people who assisted the labour process (interaction); time spent in labour; birth outcomes for baby (continuity); mode of delivery; referral of women in obstructed labour; and place of delivery. Conclusions: These findings have potential to inform the development of a midwifery early screening intervention for fistula care in Kenya. [ABSTRACT FROM AUTHOR]

Background: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing?Methods: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients.Results: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms.Conclusions: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways. [ABSTRACT FROM AUTHOR]

Background: To successfully develop and implement school-based sexual health interventions for adolescent girls, such as screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, it is important to understand parents' and teachers' attitudes towards sexual health education and acceptability of sexually transmitted infection (STI) screening interventions. Methods: In this qualitative study, we approached parents and teachers from three high schools to participate in in-depth interviews (IDIs) and focus-group discussions (FGDs). Parents and teachers were asked about their general knowledge of STIs and sexual health education. In addition, they were asked whether they would support utilizing outreach to schools to facilitate provision of sexual health education and screening for STIs in adolescent girls. Data were audio-recorded, transcribed, and translated into English. An initial coding matrix was developed and refined throughout the coding process. Transcripts were coded by two researchers and analyzed using the content analysis approach. Results: We conducted 10 IDIs (5 parents and 5 teachers) and 4 FGDs (2 with parents, 2 with teachers, total of 26 participants). Most parents reported few or no discussions regarding STIs with their adolescent girls. Parents were more comfortable discussing consequences of sexual activity including loss of virginity and the potential for pregnancy. Parents tended to place responsibility for sexual health education with teachers. The teachers, in turn, provided basic sexual and reproductive health education including puberty, abstinence, and overview of STIs. Both parents and teachers found the idea of screening for STIs in adolescent girls to be acceptable, and were comfortable with research staff contacting girls through informational meetings at schools. Parents felt that adolescents' STI screening results should be shared with their parents. Conclusion: In this African setting, parents and teachers provide limited sexual health education, with a focus on negative consequences including loss of virginity, pregnancy, and risk for STIs. Nonetheless, both parents and teachers were supportive of STI screening for adolescent girls, beginning with school-based informational meetings for the girls. Research and programs that aim to provide STI screening in this setting must offer treatment and address the issue of whether results will be disclosed to parents. [ABSTRACT FROM AUTHOR]

There is an ever-growing need for clinically focused, culturally relevant research on which nurses can base their practice. However, there may not be a concurrent rise in efforts to strengthen infrastructure needed to promote research in developing and low-income countries. In such cases, nurse researchers must find innovative ways to address and overcome barriers to research. This article presents five exemplars of nurses conducting high-quality nursing research in resource-poor settings in southern and eastern Africa. Furthermore, it suggests strategies to address these barriers, such as piggybacking on larger studies, interdisciplinary collaboration, and partnership with influential stakeholders. These tactics may be used to increase research productivity elsewhere. [ABSTRACT FROM AUTHOR]

Forensic nursing has not been adopted in Kenya despite the fact that nurses work in settings requiring this knowledge. The Nursing Council syllabus calls for lectures in forensic nursing but lectures have neither been developed nor are there educators prepared to teach the unit. This study evaluated the preparedness and practice of forensic nursing in Kenya. It adopted a descriptive cross-sectional study design. Self-administered questionnaires, a focused group discussion and a key informant interview were utilized to collect data among 116 randomly sampled nurses from three hospitals and ten nurse educators. Quantitative data was analyzed using the SPSS version 20.0 and results presented using mean, standard deviation, and frequency distribution. P values of 0.05 or less were considered significant. Qualitative data was analyzed using thematic analysis. The results indicated majority of the nurses had no training on forensic nursing science whatsoever even though they handle forensic patients on a daily basis. The nurses perceived training needs for forensic nursing practice included: advanced health assessment, evidence collection and documentation, forensic psychiatry, gender violence, legal implications of forensic nursing, theory and practice in forensic nursing. From these findings it can be concluded that Kenyan nurses lack skills needed to care for forensic patients and they would like to be trained in forensic nursing. [ABSTRACT FROM AUTHOR]

Objective: Young women bear the greatest burden of sexually transmitted infections (STIs), so it is important to identify and address barriers to STI screening in this population. We conducted a qualitative study to explore the feasibility of STI screening among adolescent girls and young women in Mombasa, Kenya. Methods: We conducted 17 in-depth interviews (IDIs) (8 with adolescent girls and 9 with young women) and 6 focus group discussions (FGDs) (4 with adolescent girls and 2 with young women, total 55 participants). The audio recordings for the IDIs and FGDs were translated and transcribed into English. Transcripts were independently reviewed by two researchers, and a set of codes was designed to help analyze the data using the content analysis approach. Data content was then analyzed manually and digitally using ATLAS.ti, and consensus was reached on central and specific emergent themes discussed by the research team. Results: Adolescent girls and young women in Mombasa, Kenya expressed willingness to participate in STI screening. A major incentive for screening was participants’ desire to know their STI status, especially following perceived high-risk sexual behavior. Lack of symptoms and fear of positive test results were identified as barriers to STI screening at the individual level, while parental notification and stigmatization from parents, family members and the community were identified as barriers at the community level. Uncomfortable or embarrassing methods of specimen collection were an additional barrier. Thus, urine-based screening was felt to be the most acceptable. Conclusion: Kenyan adolescent girls and young women seem willing to participate in screening for STIs using urine testing. Addressing stigmatization by parents, health care workers and the community could further facilitate STI screening in this population. [ABSTRACT FROM AUTHOR]

Background: Previous research has demonstrated the likely benefits of partograph use in low-resourced settings. However, the challenges of completing a partograph are also reported. The objective of this study was to examine students' views and experiences of partograph use to gain understanding of the realities of using this tool in the labour ward. Methods: In a qualitative study, 51 student nurses, undertaking their maternity placement at a university in Nairobi, Kenya, participated in five focus group discussions. Data were audio recorded, transcribed verbatim and analysed thematically. Results: Four main themes emerged from the analyses: challenges to 'doing the right thing'; theory-practice disconnectedness; negative role models; and retrospective recording. Conclusions: The results provide insight into the challenges faced by students when practising in the labour ward environment. A more effective approach to partograph training and implementation should be adopted to support students. However, student midwife training is unlikely to be implemented into practice unless the qualified team supports their learning. Given that the partograph had little status in the labour ward, change may only happen when senior health professionals (midwives and obstetricians) lead by example. Further research is required to explore the views of obstetricians and qualified midwives on partograph use. Appropriate implementation strategies also warrant further investigation. [ABSTRACT FROM AUTHOR]

The HIV/AIDS epidemic is affecting the sub-Saharan Africa more severely than other parts of the world, with 60% of global AIDS cases occurring in Africa. This article explores predisposing factors for teenage pregnancy which have implications for the spread of HIV/AIDS and STIs among adolescents in Kenya. In a recent study in one district, four factors were found to be prominent in predisposing teenage pregnancy: having multiple partners, sex for money, seduction by teachers, and coercion by friends and relatives. In-depth interviews of a sub-group of the subjects revealed some issues that are of great concern in the context of the current efforts to combat the HIV/AIDS pandemic. Attention so far has been on creating awareness but risk behaviours in adolescents are common, with the attendant dangers of unintended pregnancy, HIV/AIDS and other STIs. This article seeks to highlight some of the factors that affect risky behaviours even in fully aware teenagers. It highlights a need for specific interventions beyond awareness creation. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To establish knowledge and practice of contraception among patients presenting with a fistula attending fistula care services at 4 centers in Kenya. Methods: In a descriptive cohort study carried out between January and December 2011, patients presenting with a history of urine and/or stool leakage were screened and those with confirmed diagnosis of fistula were assessed and prepared for surgery. Informed consent was obtained from study participants before surgical intervention. After surgery, a standard questionnaire was used to collect information on sociodemographics, duration of leakage, and reproductive health practices. Results: A total of 206 patients were interviewed. Most of the patients were young (mean age 22years). Literacy was low: only 1.7% reported tertiary-level education, and 56.7% reported primary-level education. With regard to family planning, 76.2% of patients expressed a willingness to use contraception after fistula repair. Conclusion: Among patients presenting with a fistula in Kenya, the unmet need for family planning was high. There is an urgent need for healthcare providers to integrate family planning services in fistula care programs. [Copyright &y& Elsevier]

Background: Obstetric fistula is a reproductive health problem causing immense suffering to 1% of women in Kenya that is formed as sequelae of prolonged obstructed labour. It is a chronic illness that disrupts women lives, causing stigma and isolation. Fistula illness often introduces a crisis in women's life begetting feelings of shame and serious disruption to their social, psychological, physical and economic lives, in addition to dealing with moral and hygiene challenges. Currently, women undergo free of charge surgery at vesicovaginal fistula (VVF) camps held in national referral hospitals and dedicated fistula centres generating a significant pool of women who have undergone surgery and are ready to regain normal lives. Objective: The purpose of this study was to explore experiences of women immersing back into communities and their return to normalcy after surgery in three VVF repair centres in Kenya. We set out to answer the question: what strategies improve obstetric fistula patients' reintegration process? Methods: We used grounded theory methodology to capture the reintegration and regaining normalcy experiences of women after surgery. Narrative interviews were held with 60 women during community follow-up visits in their homes after 6–19 months postoperatively. Grounded theory processes of theoretical sampling, repeated measurement; constant comparative coding in three stage open, axial and selective coding; memoing, reflexivity and positionality were applied. Emergent themes helped generate a grounded theory of reintegration and regaining normalcy for fistula patients. Results: To regain normal healthy lives, women respond to fistula illness by seeking surgery.. After surgery, four possible outcomes of the reintegration process present; reintegration fully or partially back into their previous communities, not reintegrated or newly integrating away from previous social and family settings. The reintegration statuses point to the diversity outcomes of care for fistula patients and the necessity of tailoring treatment programs to cater for individual patient needs. Conclusion: The emerging substantive theory on the process of reintegration and regaining normalcy for fistula patients is presented. The study findings have implications for fistula care, training and policy regarding women's health, suggesting a model of care that encompasses physical, social, economic and psychological aspects of care after surgery and discharge. [ABSTRACT FROM AUTHOR]

The authors reflect on the programme The Lugina Africa Midwives Research Network named after the late Professor Helen Lugina. They said that the main objective of the programme is to promote the status of the midwives and to make suitable changes that will not only enhance clinical outcomes but also boost professional standing. The authors believe that the key element of the programme is the recognition of key research priorities that are vital to midwives.

The author reflects on the violence against women. He points out that sexual violence is a universal form of violence against women which is rampant worldwide but is seldom discussed in international security forums. He criticizes the countries that are short of appropriate prevention and response measures despite the eradication of all forms of violence against women and girls by the United Nations Security Council.