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Copyright of Reproductive Health is the property of BioMed Central and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective To estimate the direct costs of treating women with maternal near misses and potentially life-threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households. Methods As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure. Findings Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of-pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure. Conclusion The cost of treating maternal near misses is high and leads to catastrophic spending through out-of-pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women. [ABSTRACT FROM AUTHOR]

In 2017, the Trump Administration reinstated and expanded the Global Gag Rule (GGR). This policy requires non-governmental organisations (NGOs) not based in the US to certify that they will not provide, counsel, refer, or advocate for abortion as a method of family planning in order to receive most categories of US global health assistance. Robust empirical evidence demonstrating the policy's impacts is acutely lacking. This paper describes the effects of the expanded GGR policy in Kenya eighteen months after its reinstatement. We conducted semi-structured interviews with purposively selected representatives of US- and non-US-based NGOs, as well as managers and health providers at public and private health facilities, between September 2018 and March 2019. Organisations reported critical funding loss as they were forced to choose between US government-funded projects and projects supporting safe abortion. This resulted in the fragmentation of sexual and reproductive health and HIV services, and closure of some service delivery programmes. At public and private health facilities, participants reported staffing shortages and increased stock-outs of family planning and safe abortion commodities. The expanded GGR's effects transcended abortion care by also disrupting collaboration and health promotion activities, strengthening opposition to sexual and reproductive health and rights in some segments of Kenyan civil society and government. Our findings indicate that the GGR exposes and exacerbates the weaknesses and vulnerabilities of the Kenyan health system, and illuminates the need for action to mitigate these harms. [ABSTRACT FROM AUTHOR]

Background: Abortion draws varied emotions based on individual and societal beliefs. Often, women known to have sought or those seeking abortion services experience stigma and social exclusion within their communities. Understanding community perception of abortion is critical in informing the design and delivery of interventions that reduce the gaps in access to safe abortion for women. Objective: We explored community perceptions and beliefs relating to abortion, clients of abortion services, and abortifacients in Kenya. Methods: We conducted focus group discussions (FGDs) and in-depth interviews (IDIs) in Kisumu and Nairobi counties in Kenya among a mix of adult men and women, pharmacists, nurses, and community health volunteers. Results: Community perspectives around abortion were heterogeneous, reflecting a myriad of opinions ranging from total anti-abortion to more pro-choice positions, and with rural-urban differences. Notably, negative views on abortion became more nuanced and tempered, especially among young women in urban areas, as details of factors that motivate women to seek abortion became apparent. Participants were mostly aware of the pathways through which women and girls access abortion services. Whereas abortion is commonplace, multiple structural and socioeconomic barriers, as well as stigma, are prevalent, thus impeding access to safe and quality services. Conclusion: Community perceptions on abortion are heterogeneous, varying by gender, occupation, level of education, residence, and position in society. Stigma and the hostile abortion environment limit access to safe abortion services, with several negative consequences. There is urgent need to strengthen community-based approaches to mitigate predisposing and enabling factors for unsafe abortions. [ABSTRACT FROM AUTHOR]

Background: Despite the increased availability of safe abortion methods in sub-Saharan Africa, women and girls continue to use unsafe abortion methods and procedures to terminate their unwanted pregnancies, resulting in severe complications, lifelong disabilities, and death. Barriers to safe abortion methods include restrictive laws, low awareness of safe abortion methods, poverty, and sociocultural and health system barriers. Nonetheless, there is a paucity of data on the decision-making around and use of abortion methods. This paper aims to provide answers to the following questions: Which abortion methods do women and girls use and why? Who and what influences their decisions? What can we learn from their decision-making process to enhance the uptake of safe abortion methods? We focus our in-depth analysis on the rationale behind the choice of abortion methods used by women and girls in Kilifi County in Kenya and Atlantique Department in Benin., Methods: We draw on data collected as part of an ethnographic study conducted between January and August 2021 on lived experiences, social determinants, and pathways to abortion. Data were collected using repeated in-depth interviews with 95 girls and women who had a recent abortion experience. Data from the interviews were supplemented using information from key informant interviews, focus group discussions, and participant observation. Data analysis was conducted through an inductive process., Results: Our findings reveal that women and girls use various methods to procure abortions, including herbs, high doses of pharmaceutical drugs, homemade concoctions, medical abortion drugs, and surgical abortion methods. Procedures may involve singular or multiple attempts, and sometimes, mixing several methods to achieve the goal of pregnancy termination. The use of various abortion methods is mainly driven by the pursuit of social safety (preservation of secrecy and social relationships, avoidance of shame and stigmatization) instead of medical safety (which implies technical safety and quality)., Conclusion: Our findings reaffirm the need for comprehensive access to, and availability of, abortion-related information and services, especially safe abortion and post-abortion care services that emphasize both medical and social safety., (© 2023. The Author(s).)

Post-abortion care (PAC) counselling and the provision of contraceptive methods are core components of PAC services. Nevertheless, this service is not uniformly provided to PAC patients. This paper explores the factors contributing to young women leaving health facilities without counselling and contraceptive methods. The paper draws from an ethnographic study conducted in Kilifi County, Kenya, in 2021. We conducted participant observation in health facilities and neighbouring communities, and held in-depth interviews with 21 young women aged 15-24 who received PAC. In addition, we interviewed 11 healthcare providers recruited from the public and private health facilities observed. Findings revealed that post-abortion contraceptive counselling and methods were not always offered to patients as part of PAC as prescribed in the PAC guidelines. When PAC contraceptive counselling was offered, certain barriers affected uptake of the methods, including inadequate information, coercion by providers and partners, and fears of side effects. Together, these factors contributed to repeat unintended pregnancies and repeat abortions. The absence of quality contraceptive counselling therefore infringes on the right to health of girls and young women. Findings underscore the need to strengthen the capacities of health providers on PAC contraceptive counselling and address their attitudes towards young female PAC patients.

Since 1984, Republican administrations in the US have enacted the global gag rule (GGR), which prohibits non-US-based non-governmental organisations (NGOs) from providing, referring for, or counselling on abortion as a method of family planning, or advocating for the liberalisation of abortion laws, as a condition for receiving certain categories of US Global Health Assistance. Versions of the GGR implemented before 2017 applied to US Family Planning Assistance only, but the Trump administration expanded the policy's reach by applying it to nearly all types of Global Health Assistance. Documentation of the policy's harms in the peer-reviewed and grey literature has grown considerably in recent years, however few cross-country analyses exist. This paper presents a qualitative analysis of the GGR's impacts across three countries with distinct abortion laws: Kenya, Madagascar and Nepal. We conducted 479 in-depth qualitative interviews between August 2018 and March 2020. Participants included representatives of Ministries of Health and NGOs that did and did not certify the GGR, providers of sexual and reproductive health (SRH) services at public and private facilities, community health workers, and contraceptive clients. We observed greater breakdown of NGO coordination and chilling effects in countries where abortion is legal and there is a sizeable community of non-US-based NGOs working on SRH. However, we found that the GGR fractured SRH service delivery in all countries, irrespective of the legal status of abortion. Contraceptive service availability, accessibility and training for providers were particularly damaged. Further, this analysis makes clear that the GGR has substantial and deleterious effects on public sector infrastructure for SRH in addition to NGOs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In many parts of sub-Saharan Africa, access to abortion is legally restricted, which partly contributes to high incidence of unsafe abortion. This may result in unsafe abortion-related complications that demand long hospital stays, treatment and attendance by skilled health providers. There is however, limited knowledge on the capacity of public health facilities to deliver post-abortion care (PAC), and the spread of PAC services in these settings. We describe and discuss the preparedness and capacity of public health facilities to deliver complete and quality PAC services in Burkina Faso, Kenya and Nigeria., Methods: A cross-sectional survey of primary, secondary and tertiary-level public health facilities was conducted between November 2018 and February 2019 in the three countries. Data on signal functions (including information on essential equipment and supplies, staffing and training among others) for measuring the ability of health facilities to provide post-abortion services were collected and analyzed., Results: Across the three countries, fewer primary health facilities (ranging from 6.3-12.1% in Kenya and Burkina Faso) had the capacity to deliver on all components of basic PAC services. Approximately one-third (26-43%) of referral facilities across Burkina Faso, Kenya and Nigeria could provide comprehensive PAC services. Lack of trained staff, absence of necessary equipment and lack of PAC commodities and supplies were a main reason for inability to deliver specific PAC services (such as surgical procedures for abortion complications, blood transfusion and post-PAC contraceptive counselling). Further, the lack of capacity to refer acute PAC cases to higher-level facilities was identified as a key weakness in provision of post-abortion care services., Conclusions: Our findings reveal considerable gaps and weaknesses in the delivery of basic and comprehensive PAC within the three countries, linked to both the legal and policy contexts for abortion as well as broad health system challenges in the countries. There is a need for increased investments by governments to strengthen the capacity of primary, secondary and tertiary public health facilities to deliver quality PAC services, in order to increase access to PAC and avert preventable maternal mortalities., (© 2022. The Author(s).)

Although the Kenyan government has made efforts to invest in maternal health over the past 15 years, there is no evidence of decline in maternal mortality. To provide necessary evidence to inform maternal health care provision, we conducted a nationally representative study to describe the incidence and causes of maternal near-miss (MNM), and the quality of obstetric care in referral hospitals in Kenya. We collected data from 54 referral hospitals in 27 counties. Individuals admitted with potentially life-threatening conditions (using World Health Organization criteria) in pregnancy, childbirth or puerperium over a three month study period were eligible for inclusion in our study. All cases of severe maternal outcome (SMO, MNM cases and deaths) were prospectively identified, and after consent, included in the study. The national annual incidence of MNM was 7.2 per 1,000 live births and the intra-hospital maternal mortality ratio was 36.2 per 100,000 live births. The major causes of SMOs were postpartum haemorrhage and severe pre-eclampsia/eclampsia. However, only 77% of women with severe preeclampsia/eclampsia received magnesium sulphate and 67% with antepartum haemorrhage who needed blood received it. To reduce the burden of SMOs in Kenya, there is need for timely management of complications and improved access to essential emergency obstetric care interventions.

Objective: To determine the prevalence of cardiovascular risk factors and their association with antiretroviral therapy (ART) among HIV-infected adults in a rural sub-county hospital in Kenya., Methods: This was a descriptive survey of patient charts characterising cardiovascular risk among adult patients (> 18 years) at Ukwala sub-county hospital between June 2013 and January 2015. Post-stratification survey weights were applied to obtain prevalence levels. Adjusted odds ratios (AOR) for each variable related to cardiovascular risk factors were calculated using logistic regression models., Results: Overall, the prevalence of diabetes mellitus was 0.4%, 0.3% of patients had had a previous cardiovascular event (heart attack or stroke), 40.4% had pre-hypertension, while 10.4% had stage 1 and 2.9% stage 2 hypertension. Up to 14% of patients had elevated non-fasting total cholesterol levels. Factors associated with hypertension were male gender (AOR 1.59, p = 0.0001), being over 40 years of age (AOR 1.78, p = 0.0001) and having an increased waist circumference (OR 2.56, p = 0.0014). Raised total cholesterol was more likely in those on tenofovir disoproxil fumarate (TDF) (AOR 2.2, p = 0.0042), azidothymidine (AZT) (AOR 2.5, p = 0.0004) and stavudine (D4T) -containing regimens (AOR 3.13, p = 0.0002)., Conclusions: An elevated prevalence of undiagnosed cardiovascular risk factors such as hypertension and raised total cholesterol levels was found among people living with HIV. There was an association between raised total cholesterol and nucleoside reverse-transcriptase inhibitor (NRTI) -based ART regimens. Our findings provide further rationale for integrating routine cardiovascular risk-factor screening into HIV-care services.