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Low- and middle-income countries are underresourced in subspecialist care. This study describes a unique maternal-fetal medicine clinical fellowship training program at Moi University School of Medicine and Moi Teaching and Referral Hospital in Eldoret, Western Kenya. The first of its kind in Eastern Africa, it has met with success in the retention of highly qualified practitioners providing complex pregnancy care to a population that has been heretofore underserved.

Oral conditions disproportionately affect mothers and children in Sub-Saharan Africa, due to biological vulnerabilities, a scarcity of oral health workers, deficient preventive strategies, and gender-based barriers to care. The World Health Organization (WHO) recommends integrating oral health into broader health delivery models, to reduce these disparities. We propose integrating preventive oral healthcare into community-based programs to bridge these gaps. We examine integrating preventive oral healthcare into Western Kenya's Chamas for Change (Chamas) community-based program which aims to reduce maternal and child health disparities. Chamas incorporates women's health and microfinance programs best practices to produce a low-cost, community-driven, sustainable, and culturally acceptable health delivery platform. Our strategy is based on the Maternal and Child Oral Health Framework and uses the WHO Basic Package of Oral Care principles. This framework prioritizes community involvement, cultural sensitivity, regular screenings, and seamless integration into general health sessions. We discuss the strengths, weaknesses, opportunities, and threats to enriching Chamas with oral health promotion activities. It is crucial to assess the effectiveness, sustainability, and acceptability of the proposed strategy through implementation and evaluation. Future studies should investigate the long-term impact of integrated oral health models on community health and oral health disparity reduction in Africa.

Abstract Background Alcohol use disorder is prevalent globally and in Kenya, and is associated with significant health and socio-economic consequences. Despite this, available pharmacological treatment options are limited. Recent evidence indicates that intravenous (IV) ketamine can be beneficial for the treatment of alcohol use disorder, but is yet to be approved for this indication. Further, little has been done to describe the use of IV ketamine for alcohol use disorder in Africa. The goal of this paper, is to: 1) describe the steps we took to obtain approval and prepare for off-label use of IV ketamine for patients with alcohol use disorder at the second largest hospital in Kenya, and 2) describe the presentation and outcomes of the first patient who received IV ketamine for severe alcohol use disorder at the hospital. Case presentation In preparing for the off-label use of ketamine for alcohol use disorder, we brought together a multi-disciplinary team of clinicians including psychiatrists, pharmacists, ethicists, anesthetists, and members of the drug and therapeutics committee, to spearhead the process. The team developed a protocol for administering IV ketamine for alcohol use disorder that took into account ethical and safety issues. The national drug regulatory authority, the Pharmacy and Poison’s Board, reviewed and approved the protocol. Our first patient was a 39-year-old African male with severe alcohol use disorder and comorbid tobacco use disorder and bipolar disorder. The patient had attended in-patient treatment for alcohol use disorder six times and each time had relapsed between one to four months after discharge. On two occasions, the patient had relapsed while on optimal doses of oral and implant naltrexone. The patient received IV ketamine infusion at a dose of 0.71 mg/kg. The patient relapsed within one week of receiving IV ketamine while on naltrexone, mood stabilizers, and nicotine replacement therapy. Discussion & conclusions This case report describes for the first time the use of IV ketamine for alcohol use disorder in Africa. Findings will be useful in informing future research and in guiding other clinicians interested in administering IV ketamine for patients with alcohol use disorder.

Photo-elicitation interview techniques, a method in which researchers incorporate images to enrich the interview experience, have been gaining traction in numerous spheres of research over the last two decades. Little is, however, written about the utility of the technique in studies involving vulnerable populations in clinical contexts. Drawing on research where researcher-generated photographs were used to elicit mothers’ experiences of pain and perceptions about use of pain-relieving strategies in critically ill infants, we aim to demonstrate (a) how the method can be used to generate harmonized and detailed accounts of experiences from diverse groups of participants of limited literacy levels, (b) the ethical and methodological consideration when employing photo-elicitation interview techniques and the (c) possible limitations of employing photo-elicitation interview techniques in clinical research.

Although an estimated 1.4 million women living with HIV (WHIV) are pregnant each year globally, data describing the effects of the COVID-19 pandemic on postpartum women in low- and middle-income countries (LMICs) are limited. To address this gap, we conducted phone surveys among 170 WHIV ≥18 years and 18-24 months postpartum enrolled in HIV care at the Academic Model Providing Access to Healthcare in western Kenya, and assessed the effects of the pandemic across health, social and economic domains. We found that 47% of WHIV experienced income loss and 71% experienced food insecurity during the pandemic. The majority (96%) of women reported having adequate access to antiretroviral treatment and only 3% reported difficulties refilling medications, suggesting that the program's strategies to maintain HIV service delivery during the early phase of the pandemic were effective. However, 21% of WHIV screened positive for depression and 8% for anxiety disorder, indicating the need for interventions to address the mental health needs of this population. Given the scale and duration of the pandemic, HIV programs in LMICs should work with governments and non-governmental organizations to provide targeted support to WHIV at highest risk of food and income insecurity and their associated adverse health outcomes.

Although an estimated 1.4 million women living with HIV (WHIV) are pregnant each year globally, data describing the effects of the COVID-19 pandemic on postpartum women in low- and middle-income countries (LMICs) are limited. To address this gap, we conducted phone surveys among 170 WHIV ≥18 years and 18–24 months postpartum enrolled in HIV care at the Academic Model Providing Access to Healthcare in western Kenya, and assessed the effects of the pandemic across health, social and economic domains. We found that 47% of WHIV experienced income loss and 71% experienced food insecurity during the pandemic. The majority (96%) of women reported having adequate access to antiretroviral treatment and only 3% reported difficulties refilling medications, suggesting that the program’s strategies to maintain HIV service delivery during the early phase of the pandemic were effective. However, 21% of WHIV screened positive for depression and 8% for anxiety disorder, indicating the need for interventions to address the mental health needs of this population. Given the scale and duration of the pandemic, HIV programs in LMICs should work with governments and non-governmental organizations to provide targeted support to WHIV at highest risk of food and income insecurity and their associated adverse health outcomes.

Abstract Background There have been dozens of strikes by health workers in Kenya in the past decade, but there are few studies of their impact on maternal and child health services and outcomes. We conducted a retrospective survey study to assess the impact of nationwide strikes by health workers in 2017 on utilization of maternal and child health services in western Kenya. Methods We utilized a parent study to enroll women who were pregnant in 2017 when there were prolonged strikes by health workers (“strike group”) and women who were pregnant in 2018 when there were no major strikes (“control group”). Trained research assistants administered a close-ended survey to retrospectively collect demographic and pregnancy-related health utilization and outcomes data. Data were collected between March and July 2019. The primary outcomes of interest were antenatal care (ANC) visits, delivery location, and early child immunizations. Generalized estimating equations were used to estimate risk ratios between the strike and control groups, adjusting for socioeconomic status, health insurance status, and clustering. Adjusted risk ratios (ARR) were calculated with 95% confidence intervals (95%CI). Results Of 1341 women recruited in the parent study in 2017 (strike group), we re-consented 843 women (63%) to participate. Of 924 women recruited in the control arm of the parent study in 2018 (control group), we re-consented 728 women (79%). Women in the strike group were 17% less likely to attend at least four ANC visits during their pregnancy (ARR 0.83, 95%CI 0.74, 0.94) and 16% less likely to deliver in a health facility (ARR 0.84, 95%CI 0.76, 0.92) compared to women in the control group. Whether a child received their first oral polio vaccine did not differ significantly between groups, but children of women in the strike group received their vaccine significantly longer after birth (13 days versus 7 days, p = 0.002). Conclusion We found that women who were pregnant during nationwide strikes by health workers in 2017 were less likely to receive WHO-recommended maternal child health services. Strategies to maintain these services during strikes are urgently needed.

Abstract Background Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers. Methods We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women’s pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches. Results Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care. Conclusion We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

Objective: Neonatal resuscitation is key in preventing neonatal mortality. The objective of this study was to assess the competence of healthcare workers in basic neonatal resuscitation at six hospitals in Uasin Gishu County in Kenya. Methods: This was a cross-sectional study of healthcare workers based on the labor and delivery wards. Results: Of the 46 healthcare workers who were assessed with a written examination and skills assessment, 85% were nurses. While 46% were able to pass the written examination, none demonstrated all required steps of newborn resuscitation during the skills assessment by simulation. No significant associations were present between the pass rate of the written examination and years of experience, role, or prior in-service training. All of the hospitals had the basic equipment required for neonatal resuscitation. Conclusion: There is a need to further develop the neonatal resuscitation skills among healthcare workers in the labor and delivery wards in Uasin Gishu County, Kenya.

Retention in care is a major challenge for pregnant and postpartum women living with HIV (PPHIV) in the prevention of mother-to-child HIV transmission (PMTCT) continuum. However, the factors influencing retention from the perspectives of women who have become lost to follow-up (LTFU) are not well described. We explored these factors within an enhanced sub-cohort of the East Africa International Epidemiology Databases to Evaluate AIDS Consortium. From 2018–2019, a purposeful sample of PPHIV ≥18 years of age were recruited from five maternal and child health clinics providing integrated PMTCT services in Kenya. Women retained in care were recruited at the facility; women who had become LTFU (last visit >90 days) were recruited through community tracking. Interview transcripts were analyzed thematically using a social-ecological framework. Forty-one PPHIV were interviewed. The median age was 27 years, 71% were pregnant, and 39% had become LTFU. In the individual domain, prior PMTCT experience and desires to safeguard infants’ health enhanced retention but were offset by perceived lack of value in PMTCT services following infants’ immunizations. In the peer/family domain, male-partner financial and motivational support enhanced retention. In the community/society domain, some women perceived social pressure to attend clinic while others perceived pressure to utilize traditional birth attendants. In the healthcare environment, long queues and negative provider attitudes were prominent barriers. HIV-related stigma and fear of disclosure crossed multiple domains, particularly for LTFU women, and were driven by perceptions of HIV as a fatal disease and fear of partner abandonment and abuse. Both retained and LTFU women perceived that integrated HIV services increased the risk of disclosure. Retention was influenced by multiple factors for PPHIV. Stigma and fear of disclosure were prominent barriers for LTFU women. Multicomponent interventions and refining the structure and efficiency of PMTCT services may enhance retention for PPHIV.

Retention in care is a major challenge for pregnant and postpartum women living with HIV (PPHIV) in the prevention of mother-to-child HIV transmission (PMTCT) continuum. However, the factors influencing retention from the perspectives of women who have become lost to follow-up (LTFU) are not well described. We explored these factors within an enhanced sub-cohort of the East Africa International Epidemiology Databases to Evaluate AIDS Consortium. From 2018-2019, a purposeful sample of PPHIV ≥18 years of age were recruited from five maternal and child health clinics providing integrated PMTCT services in Kenya. Women retained in care were recruited at the facility; women who had become LTFU (last visit >90 days) were recruited through community tracking. Interview transcripts were analyzed thematically using a social-ecological framework. Forty-one PPHIV were interviewed. The median age was 27 years, 71% were pregnant, and 39% had become LTFU. In the individual domain, prior PMTCT experience and desires to safeguard infants' health enhanced retention but were offset by perceived lack of value in PMTCT services following infants' immunizations. In the peer/family domain, male-partner financial and motivational support enhanced retention. In the community/society domain, some women perceived social pressure to attend clinic while others perceived pressure to utilize traditional birth attendants. In the healthcare environment, long queues and negative provider attitudes were prominent barriers. HIV-related stigma and fear of disclosure crossed multiple domains, particularly for LTFU women, and were driven by perceptions of HIV as a fatal disease and fear of partner abandonment and abuse. Both retained and LTFU women perceived that integrated HIV services increased the risk of disclosure. Retention was influenced by multiple factors for PPHIV. Stigma and fear of disclosure were prominent barriers for LTFU women. Multicomponent interventions and refining the structure and efficiency of PMTCT services may enhance retention for PPHIV.

Abstract Background The Academic Model Providing Access to Healthcare (AMPATH) has been a model academic partnership in global health for nearly three decades, leveraging the power of a public-sector academic medical center and the tripartite academic mission – service, education, and research – to the challenges of delivering health care in a low-income setting. Drawing our mandate from the health needs of the population, we have scaled up service delivery for HIV care, and over the last decade, expanded our focus on non-communicable chronic diseases, health system strengthening, and population health more broadly. Success of such a transformative endeavor requires new partnerships, as well as a unification of vision and alignment of strategy among all partners involved. Leveraging the Power of Partnerships and Spreading the Vision for Population Health. We describe how AMPATH built on its collective experience as an academic partnership to support the public-sector health care system, with a major focus on scaling up HIV care in western Kenya, to a system poised to take responsibility for the health of an entire population. We highlight global trends and local contextual factors that led to the genesis of this new vision, and then describe the key tenets of AMPATH’s population health care delivery model: comprehensive, integrated, community-centered, and financially sustainable with a path to universal health coverage. Finally, we share how AMPATH partnered with strategic planning and change management experts from the private sector to use a novel approach called a ‘Learning Map®’ to collaboratively develop and share a vision of population health, and achieve strategic alignment with key stakeholders at all levels of the public-sector health system in western Kenya. Conclusion We describe how AMPATH has leveraged the power of partnerships to move beyond the traditional disease-specific silos in global health to a model focused on health systems strengthening and population health. Furthermore, we highlight a novel, collaborative tool to communicate our vision and achieve strategic alignment among stakeholders at all levels of the health system. We hope this paper can serve as a roadmap for other global health partners to develop and share transformative visions for improving population health globally.