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Background The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP. Methods We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7–9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention’s acceptability and feasibility, in terms of participants’ views and the intervention aims. Results We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members’ negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term. Conclusion Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.

A community-based intervention focused on women's health education may help protect against early childhood developmental delays in resource-limited settings., Key Findings Infants in Chamas had a lower likelihood of at-risk development compared to those in the control group. Older infant age at time of screening and having natural or uncovered walls was also associated with lower odds of at-risk development.Our findings offer evidence to support that by addressing health literacy, providing community in a supportive environment, and offering a means to combat social determinants of child developmental delays, the Chamas for Change intervention may help protect children from developmental delays in this resource-limited setting in Kenya. Key Implications When looking to revise current strategies to help protect children from developmental delay in this setting, policy makers should consider interventions that leverage existing resources to ensure their sustainability., Background: Over 43% of children living in low- and middle-income countries are at risk for developmental delays; however, access to protective interventions in these settings is limited. We evaluated the effect of maternal participation in Chamas for Change (Chamas)—a community-based women's health education program during pregnancy and postpartum—and risk of developmental delay among their children in rural Kenya. Methods: We analyzed developmental screening questionnaire (DSQ) data from a cluster randomized controlled trial in Trans Nzoia County, Kenya (ClinicalTrials.gov, NCT03187873). Intervention clusters (Chamas) participated in community health volunteer-led, group-based health lessons twice a month during pregnancy and postpartum; controls had monthly home visits (standard of care). We screened all children born during the trial who were alive at 1-year follow-up. We labeled children with any positive item on the DSQ as “at-risk development.” We analyzed data using descriptive statistics and multilevel regression models (α=.05); analyses were intention-to-treat using individual-level data. Results: Between November 2017 and March 2018, we enrolled 1,920 pregnant women to participate in the parent trial. At 1-year follow-up, we screened 1,273 (689 intervention, 584 control) children born during the trial with the DSQ. Intervention mothers had lower education levels and higher poverty likelihood scores than controls (P

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.

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.

Summary Community health volunteers (CHVs) act as vital links between communities and health facilities, bridging the health service delivery gap common in low- and middle-income countries. In 2013, changes in funding in western Kenya left most CHVs without their individual monthly stipend. In this article, we explore how the implementation of a pooled incentive model had an impact on the lives of CHVs from two counties in western Kenya. Participation in this form of table banking was meant to allow CHVs to pool their resources together and invest in income-generating activities to offset the costs of unpaid health work. A pre-post qualitative study, consisting of focus group discussions and in-depth interviews explored CHV compensation, motivations and challenges experienced in 2013 and 2015, prior to and after the implementation of this pooled incentive model. Following withdrawal of the monthly stipend, we found that CHVs continued to take on roles and responsibilities of paid health workers, motivated by shared social identities and connections to their communities. However, replacing the stipend with a pooled-group incentive model seemingly exacerbated the financial burden already experienced by this vulnerable population. This study brings into question the sustainability and viability of a volunteer community health worker programme and highlights the need to address the financial burden associated with the CHV role in western Kenya.

OBJECTIVE: Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya to determine the impact on LARC use. STUDY DESIGN: We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]), and follow-up care. We compared LARC use 3 months post-intervention to pre-intervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. RESULTS: Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=0.02 and injectable contraceptive use from 14% to 24%, p=0.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p

Introduction. Gestational diabetes is a common complication, whose incidence is growing globally. There is a pressing need to obtain more data on GDM in low- and middle-income countries, especially amongst high-risk populations, as most of the data on GDM comes from high-income countries. With the growing awareness of the role HIV plays in the progression of noncommunicable diseases and the disproportionate HIV burden African countries like Kenya face, investigating the potential role HIV plays in increasing dysglycemia amongst pregnant women with HIV is an important area of study. Methods. The STRiDE study is one of the largest ever conducted studies of GDM in Kenya. This study enrolled pregnant women aged between 16 and 50 who were receiving care from public and private sector facilities in Eldoret, Kenya. Within this study, women received venous testing for glycosylated hemoglobin (HbA1c) and fasting glucose between 8- and 20-week gestational age. At their 24-32-week visit, they received a venous 75 g oral glucose tolerance test (OGTT). Because of the pressing need to assess the burden of GDM within the population of pregnant women with HIV, a nested case-control study design was used. Pregnant women with HIV within the larger STRiDE cohort were matched to non-HIV-infected women within the STRiDE cohort at a 1 : 3 ratio based on body mass index, parity, family history of GDM, gestational age, and family history of hypertension. The measurements of glucose from the initial visit (fasting glucose and HbA1c) and follow-up visit (OGTT) were compared between the two groups of HIV+ cases and matched HIV- controls. Results. A total of 83 pregnant women with HIV were well matched to 249 non-HIV-infected women from the STRiDE cohort with marital status being the only characteristic that was statistically significantly different between the two groups. Statistically significant differences were not observed in the proportion of women who developed GDM, the fasting glucose values, the HbA1c, or OGTT measurements between the two groups. Discussion. Significant associations were not seen between the different measures of glycemic status between pregnant women with and without HIV. While significant differences were not seen in this cohort, additional investigation is needed to better describe the association of dysglycemia with HIV, especially in Kenyan populations with a higher prevalence of GDM.

IntroductionCommunity-based women’s health education groups may improve maternal, newborn and child health (MNCH); however, evidence from sub-Saharan Africa is lacking. Chamas for Change (Chamas) is a community health volunteer (CHV)-led, group-based health education programme for pregnant and postpartum women in western Kenya. We evaluated Chamas’ effect on facility-based deliveries and other MNCH outcomes.MethodsWe conducted a cluster randomised controlled trial involving 74 community health units in Trans Nzoia County. We included pregnant women who presented to health facilities for their first antenatal care visits by 32 weeks gestation. We randomised clusters 1:1 without stratification or matching; we masked data collectors, investigators and analysts to allocation. Intervention clusters were invited to bimonthly, group-based, CHV-led health lessons (Chamas); control clusters had monthly, individual CHV home visits (standard of care). The primary outcome was facility-based delivery at 12-month follow-up. We conducted an intention-to-treat approach with multilevel logistic regression models using individual-level data.ResultsBetween 27 November 2017 and 8 March 2018, we enrolled 1920 participants from 37 intervention and 37 control clusters. A total of 1550 (80.7%) participants completed the study with 822 (82.5%) and 728 (78.8%) in the intervention and control arms, respectively. Facility-based deliveries improved in the intervention arm (80.9% vs 73.0%; risk difference (RD) 7.4%, 95% CI 3.0 to 12.5, OR=1.58, 95% CI 0.97 to 2.55, p=0.057). Chamas participants also demonstrated higher rates of 48 hours postpartum visits (RD 15.3%, 95% CI 12.0 to 19.6), exclusive breastfeeding (RD 11.9%, 95% CI 7.2 to 16.9), contraceptive adoption (RD 7.2%, 95% CI 2.6 to 12.9) and infant immunisation completion (RD 15.6%, 95% CI 11.5 to 20.9).ConclusionChamas participation was associated with significantly improved MNCH outcomes compared with the standard of care. This trial contributes robust data from sub-Saharan Africa to support community-based, women’s health education groups for MNCH in resource-limited settings.Trial registration numberNCT03187873.

IntroductionCommunity-based women’s health education groups may improve maternal, newborn, and child health (MNCH); however, evidence from sub-Saharan Africa is lacking. Chamas for Change (Chamas) is a community health volunteer (CHV)-led health education program for pregnant and postpartum women in western Kenya. We evaluated Chamas’ effect on facility-based deliveries and other MNCH outcomes.MethodsWe conducted a cluster randomized controlled trial involving 74 communities in Trans Nzoia County. We included pregnant women who presented to health facilities for their first antenatal care visits by 32 weeks gestation. We randomized community clusters 1:1 without stratification or matching; we masked data collectors, investigators, and analysts to allocation. Intervention clusters were invited to bimonthly, group-based, CHV-led health lessons (Chamas); control clusters had monthly CHV home-visits (standard of care). The primary outcome was facility-based delivery at 12-months follow-up. We conducted an intention-to-treat approach with multilevel logistic regression models using individual-level data. We prospectively registered this trial with ClinicalTrials.gov (NCT03187873).ResultsBetween November 27, 2017 and March 8, 2018, we enrolled 1920 participants from 37 intervention and 37 control clusters. A total of 1550 (80.7%) participants completed the study with 822 (82.5%) and 728 (78.8%) in the intervention and control arms, respectively. Facility-based deliveries improved in the intervention arm (80.9% vs 73.0%; Risk Difference (RD) 7.4%, 95% CI 3.0-12.5, OR=1.58, 95% CI 0.97-2.55, p=0.057). Chamas participants also demonstrated higher rates of 48-hour postpartum visits (RD 15.3%, 95% CI 12.0-19.6), exclusive breastfeeding (RD 11.9%, 95% CI 7.2-16.9), contraceptive adoption (RD 7.2%, 95% CI 2.6-12.9), and infant immunization completion (RD 15.6%, 95% CI 11.5-20.9).ConclusionChamas participation was associated with significantly improved MNCH outcomes compared with the standard of care. This trial contributes robust data from sub-Saharan Africa to support community-based, women’s health education groups for MNCH in resource-limited settings.KEY QUESTIONSWhat is already known?Globally, maternal and infant deaths have declined over the last three decades; however, low and middle-income countries (LMICs), including Kenya, still disproportionately incur the highest morbidity and mortality.The World Health Organization recommends leveraging lay health workers (LHWs), including community health volunteers (CHVs), to promote maternal, newborn, and child health (MNCH) in resource-limited settings.Prior research suggests coupling strategies that promote community-based approaches (i.e. integrating LHWs) and women’s health education and support groups during pregnancy and postpartum may improve MNCH; however, robust evidence from sub-Saharan Africa is lacking.What are the new findings?Using a cluster randomized controlled trial design, we found that participation in Chamas for Change (Chamas) – a group-based women’s health education program led by CHVs – was associated with significantly improved MNCH outcomes, including facility-based deliveries, compared with the standard of care (i.e. monthly home-visits) in rural Kenya.This trial also demonstrated significant associations between program participation and receiving 48 hour postpartum home-visits, breastfeeding exclusively, adopting a contraceptive method postpartum, and immunizing infants fully by 12 months of life as compared to the standard of care.These findings support pilot data from a preceding evaluation of the Chamas program as well as the current literature on community-based interventions delivered by LHWs to promote MNCH in other resource-limited settings.What do the new findings imply?Effective community-based strategies that build upon existing infrastructure to promote MNCH are needed to continue to improve the health and well-being of women and infants in rural sub-Saharan Africa and other LMICs.Chamas offers an innovative approach to improve MNCH in resource-limited settings with significant health policy implications; collective evidence from this trial and preceding studies support community-based women’s health education groups as an effective strategy for improving uptake of facility-based deliveries and other life-saving MNCH practices.

Background Chamas for Change (Chamas) is a group-based health education and microfinance program for pregnant and postpartum women that aims to address inequities contributing to high rates of maternal and infant mortality in rural western Kenya. In this prospective matched cohort study, we evaluated the association between Chamas participation and facility-based delivery. We additionally explored the effect of participation on promoting other positive maternal, newborn and child health (MNCH) behaviors. Methods We prospectively compared outcomes between a cohort of Chamas participants and controls matched for age, parity, and prenatal care location. Between October–December 2012, government-sponsored community health volunteers (CHV) recruited pregnant women attending their first antenatal care (ANC) visits at rural health facilities in Busia County to participate in Chamas. Women enrolled in Chamas agreed to attend group-based health education and microfinance sessions for one year; controls received the standard of care. We used descriptive analyses, multivariable logistic regression models, and random effect models to compare outcomes across cohorts 12 months following enrollment, with α set to 0.05. Results Compared to controls (n = 115), a significantly higher proportion of Chamas participants (n = 211) delivered in a health facility (84.4% vs. 50.4%, p p Chamas participants were over five times as likely as controls to deliver in a health facility (OR 5.49, 95% CI 3.12–9.64, p Chamas participants experienced a lower proportion of stillbirths (0.9% vs. 5.2%), miscarriages (5.2% vs. 7.8%), infant deaths (2.8% vs. 3.4%), and maternal deaths (0.9% vs. 1.7%) compared to controls. Conclusions Chamas participation was associated with increased odds of facility-based delivery compared to the standard of care in rural western Kenya. Larger proportions of program participants also practiced other positive MNCH behaviors. Our findings demonstrate Chamas’ potential to achieve population-level MNCH benefits; however, a larger study is needed to validate this observed effect. Trial registration ClinicalTrials.gov, NCT03188250 (retrospectively registered 31 May 2017).

Objectives Few studies have addressed optimal follow-up for HIV-infected women after cervical treatment. This study aimed to compare performance of three available tests to detect posttreatment cervical disease in HIV-infected women in Kenya. Design This is a prospective cohort study. Methods At least 6 months following cryotherapy, 517 HIV-infected women were evaluated concurrently with visual inspection with acetic acid (VIA), papanicolaou (Pap) smear, and high-risk human papillomavirus (HR-HPV) testing. Women positive by any test (≥low-grade squamous intraepithelial lesion for Pap) were scheduled for colposcopy and biopsy. Among 248 with histological confirmation [and 174 assumed to be truly negative for cervical intraepithelial neoplasia (CIN)2+ after testing negative by all three tests], the ability of each test alone, or in combination, to detect CIN2+ was calculated to determine their utility in posttreatment follow-up. Results The median age of women was 35 years, 68% were WHO stage 1-2, with a median CD4 cell count of 410 cells/μl, and 87% were on combination antiretroviral therapy. At a median of 6.3 months posttreatment, 64% had an abnormal screen by VIA, Pap, and/or HR-HPV. Among women with histological confirmation, 72 (30%) had persistent/recurrent CIN2+. As single tests, Pap correctly classified the most cases (83%) and had the highest specificity [91% (88 and 95%); sensitivity 44% (35 and 53%)], whereas HR-HPV had the highest sensitivity [85% (75 and 96%); specificity 54% (49 and 58%)]. VIA was not sensitive [27% (18 and 36%)] for the detection of posttreatment CIN2+ [specificity 82% (79 and 86%)]. Conclusion With the goal to minimize the number of false negatives (e.g. not miss CIN2+ posttreatment) in this population that is high-risk due to both prior cervical disease and HIV infection, HR-HPV-based algorithms are recommended.

Background We launched Chamas for Change (Chamas), a group-based health education and microfinance program for pregnant women and their infants, to address inequities contributing to high rates of maternal and neonatal mortality in western Kenya. In this prospective matched cohort study, we evaluated Chamas’ impact on improving uptake of evidence-based maternal, newborn and child health (MNCH) interventions. Methods We prospectively compared MNCH intervention uptake between a cohort of Chamas participants and controls matched for age, parity, and prenatal care location. Between October-December 2012, government-sponsored community health volunteers (CHV) recruited pregnant women in Busia county attending their first antenatal care (ANC) visit to participate in Chamas and enroll in this study. Upon joining, women agreed to attend bi-monthly group health education and optional microfinance sessions for 12 months. We selected controls among non-Chamas participants who attended the same ANC clinics. We collected baseline sociodemographic and reproductive health data at study enrollment. We used descriptive analyses and adjusted multivariable logistic regression models to compare outcomes across cohorts at 6-12 months postpartum, with α set to 0.05. Results Compared to controls (n=115), a significantly higher proportion of Chamas participants (n=211) delivered in a facility with a skilled birth attendant (84.4% vs. 50.4%, p

Background Early diagnosis of gestational diabetes mellitus (GDM) is crucial to prevent short term delivery risks and long term effects such as cardiovascular and metabolic diseases in the mother and infant. Diagnosing GDM in Sub-Saharan Africa (SSA) however, remains sub-optimal due to associated logistical and cost barriers for resource-constrained populations. A cost-effective strategy to screen for GDM in such settings are therefore urgently required. We conducted this study to determine the prevalence of gestational diabetes mellitus (GDM) and assess utility of various GDM point of care (POC) screening strategies in a resource-constrained setting. Methods Eligible women aged ≥18 years, and between 24 and 32 weeks of a singleton pregnancy, prospectively underwent testing over two days. On day 1, a POC 1-h 50 g glucose challenge test (GCT) and a POC glycated hemoglobin (HbA1c) was assessed. On day 2, fasting blood glucose, 1-h and 2-h 75 g oral glucose tolerance test (OGTT) were determined using both venous and POC tests, along with a venous HbA1c. The International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria was used to diagnose GDM. GDM prevalence was reported with 95% confidence interval (CI). Specificity, sensitivity, positive predictive value, and negative predictive value of the various POC testing strategies were determined using IADPSG testing as the standard reference. Results Six hundred-sixteen eligible women completed testing procedures. GDM was diagnosed in 18 women, a prevalence of 2.9% (95% CI, 1.57% - 4.23%). Compared to IADPSG testing, POC IADPSG had a sensitivity and specificity of 55.6% and 90.6% respectively while that of POC 1-h 50 g GCT (using a diagnostic cut-off of ≥7.2 mmol/L [129.6 mg/dL]) was 55.6% and 63.9%. All other POC tests assessed showed poor sensitivity. Conclusions POC screening strategies though feasible, showed poor sensitivity for GDM detection in our resource-constrained population of low GDM prevalence. Studies to identify sensitive and specific POC GDM screening strategies using adverse pregnancy outcomes as end points are required. Trials registration Clinical trials.gov : NCT02978807 , Registered 29 November 2016.

OBJECTIVE: To determine the impact of introducing an emergency obstetric and neonatal care training program on maternal and perinatal morbidity and mortality at Moi Teaching and Referral Hospital Eldoret Kenya. METHODS: A prospective chart review was conducted of all deliveries during the 3-month period (November 2009 to January 2010) before the introduction of the Advances in Labor and Risk Management International Program (AIP) and in the 3-month period (August-November 2011) 1 year after the introduction of the AIP. All women who were admitted and delivered after 28 weeks of pregnancy were included. The primary outcome was the direct obstetric case fatality rate. RESULTS: A total of 1741 deliveries occurred during the baseline period and 1812 in the postintervention period. Only one mother died in each period. However postpartum hemorrhage rates decreased affecting 59 (3.5%) of 1669 patients before implementation and 40 (2.3%) of 1751 afterwards (P=0.029). The number of patients who received oxytocin increased from 829 (47.6%) to 1669 (92.1%; P

Objectives Adolescent pregnancy rates in Kenya remain high. Health and socio-economic outcomes are poor. Little has changed since the introduction of government policy to address adolescent sexual and reproductive health in 2003. As an innovative approach to address this issue, we aim to use human-centered design to build an adolescent-centered pregnancy program in Western Kenya. We further aim to demonstrate that this approach is feasible and acceptable to all involved stakeholders. Methods A team of 8 Kenyan designers, including pregnant or parenting adolescents, were recruited at Moi Teaching and Referral Hospital to learn human centered design. Designers were required to commitment to 2 weeks and 100% attendance. Further community stakeholders were recruited as research participants for context and co-creation labs. Results Our partner Idea Couture taught the Design Team qualitative research methodologies and prototyping of ideas. A total of six 1:1 interviews and 9 focus groups as context and co-creation labs were completed. There were 10 programmatic solutions generated, including Healthcare Provider Empathy Training, Community Outreach Support, and Peer Support Groups, under the umbrella of an Adolescent-Centered Clinic. The design team members found the process to be engaging and empowering; attendance was 100%. Conclusions Human centered design is a unique methodology to generate solutions to complex health challenges that target both patient experience and health outcomes. Partnerships with industry firms such as Idea Couture provide both research and care driven initiatives with unique expertise to facilitate this process. Next steps include engaging the design team in launching and evaluating the top priority prototypes.

This article addresses birth and the recognition of personhood. It is about the calculated acts of recognition that take place at the beginnings of life when the obligation to protect and extend physical care is uncertain. It examines these dilemmas from the perspective of clinicians and scientists who assist in birth through their work with embryos, fetuses, and extremely premature infants in the United States. Through multisited ethnography and in-depth interviews at a leading U.S. teaching hospital, this article argues that the concept of viability operates as a placeholder for the recognition of personhood at the beginnings of life. Articulated in a language of survival and stratified by gestational age, this article explores how viability is a central organizing principle in the management of birth. It aims to situate questions about the value of life to the maternity unit where patients and clinicians face choices about the kinds of viability-and as a result persons-that are possible and desired within the contemporary culture of hospital births.

Objective To describe the experience at a single facility regarding single-use emergency medication kits to treat obstetric emergencies in a resource-poor setting. Methods A retrospective study was conducted between October 2009 and October 2010 using data from the medical records of all patients treated with a single-use obstetric emergency medical kit (E-kit) during admission at the Riley Mother and Baby Hospital Wing, Eldoret, Kenya. Descriptive analyses were performed to quantify proportions of emergencies treated using E-kits in the first year of implementation. Summary statistics regarding maternal mortality from October 2008 to October 2010 were also retrieved to evaluate differences in the maternal mortality rates in the year of E-kit implementation and the year preceding implementation in order to estimate maternal mortalities averted with E-kit implementation. Results In the first year of implementation, 192 patients were treated using E-kits. Overall, 144 kits were used for treating postpartum hemorrhage, 52 for treating severe pre-eclampsia/eclampsia, and 1 for treating cardiopulmonary shock. There was a 30% reduction in maternal mortality ratio with E-kit implementation; however, results did not reach statistical significance. Conclusion The results indicate that single-use E-kits may help to achieve a significant reduction in hospital rates of maternal mortality.

public health facilities in Tanzania, is used by staff to report stock levels and receipts of essential medicines via SMS using their own phones. This information is analyzed and displayed on a web-based dashboard, where decision makers at higher levels of the supply chain access reports and monitor the functioning of the supply chain. In Malawi, under the cStock system, community health workers (CHWs) report stock on hand everymonth via SMS, after which the system calculates the amount that each CHW should be resupplied and sends this information to resupply points via SMS. In 9 countries, the End-Use Verification (EUV) activity is conducted under the President’s Malaria Initiative (PMI), where survey teams from the Ministry of Health and other national programs use mobile phones on a quarterly basis to visit health facilities and collect patient and supply chain data that is used to provide actionable findings to decision makers. Outcomes & Evaluation: All three mobile supply chain programs have achieved scale, with the ILSGateway in Tanzania now functioning in all 4600+ public health facilities, and cStock in Malawi scaled to all 3000+ CHWs. A mixed-methods midline evaluation in 2013 found that cStock notably improved community logistics data visibility and reduced stock outs. End Use Verification continues to be conducted every quarter in the countries listed, and has collected data from 10000+ site visits since 2009. The data collected in each system is routinely used to make better informed supply chain decisions, leading to better targeted use of scare resources, and increased availability of vital health commodities. Going Forward: As with all information systems in resource-challenged countries, ongoing sustainability is a challenge. High turnover rates among health facility staff require plans for ongoing refresher trainings. National budgets must be revised to include system main Funding: cStock was funded through a grant from the Bill and MelindaGates Foundation, and is beingmaintained byWHO, Save the Children,UNFoundation, andUSAID . The ILSGateway is funded by USAID, and the EUV is funded through USAID under PMI. Abstract #: 02ITIS029

This article considers the question offemale genital practices at the hands of health workers in western Kenya. Recent articles in Medical Anthropology Quarterly have critically engaged with the biomedical arguments condemning such practices. This article studies the case of medicalized circumcision in which biomedical concerns over health risks have become incorporated in their vernacular practice. Although some suggest that medicalization may provide a harm-reduction strategy to the abandonment of the practice, research in one region challenges this suggestion. It argues that changing and conflicting ideologies of gender and sexuality have led young women to seek their own meaning through medicalized practice. Moreover, attributing this practice to financial motivations of health workers overlooks the way in which these "moral agents" must be situated within their social and cultural universe. Together, these insights challenge the view that medicine can remain neutral in the mediation of tradition. [female genital practices, female circumcision, Kenya, harm reduction, medicalization] We must have the guts to end the practice and allow children to get circumcised in hospital. Subjecting children to pain totally contravenes the UN Convention on the Rights of the Child, which Kenya has signed. Let us agree that any cultural practice that subjects people to pain is obsolete and should be either abandoned or reformed. This is not a call to ban circumcision as a practice. It is only a wake-up call against inhuman methods used. Traditional circumcision does not fit in with today's world. People need to be taught that there are more hygienic ways of circumcision. We should not allow a tradition to play poker with children's lives. -John Kamau1

We present a new open-source Android application, AccessMRS, for interfacing with an electronic medical record system (OpenMRS) and loading 'Smart Forms' on a mobile device. AccessMRS functions as a patient-centered interface for viewing OpenMRS data; managing patient information in reminders, task lists, and previous encounters; and launching patient-specific 'Smart Forms' for electronic data collection and dissemination of health information. We present AccessMRS in the context of related software applications we developed to serve Community Health Workers, including AccessInfo, AccessAdmin, AccessMaps, and AccessForms. The specific features and design of AccessMRS are detailed in relationship to the requirements that drove development: the workflows of the Kenyan Ministry of Health Community Health Volunteers (CHVs) supported by the AMPATH Primary Health Care Program. Specifically, AccessMRS was designed to improve the quality of community-based Maternal and Child Health services delivered by CHVs in Kosirai Division. AccessMRS is currently in use by more than 80 CHVs in Kenya and undergoing formal assessment of acceptability, effectiveness, and cost.

Objective To describe the challenges and successes of integrating a public-sector cervical screening program into a large HIV care system in western Kenya. Methods The present study was a programmatic description and a retrospective chart review of data collected from a cervical screening program based on visual inspection with acetic acid (VIA) between June 2009 and October 2011. Results In total, 6787 women were screened: 1331 (19.6%) were VIA-positive, of whom 949 (71.3%) had HIV. Overall, 206 women underwent cryotherapy, 754 colposcopy, 143 loop electrical excision procedure (LEEP), and 27 hysterectomy. Among the colposcopy-guided biopsies, 27.9% had severe dysplasia and 10.9% had invasive cancer. There were 68 cases of cancer, equating to approximately 414 per 100 000 women per year. Despite aggressive strategies, the overall loss to follow-up was 31.5%: 27.9% were lost after a positive VIA screen, 49.3% between biopsy and LEEP, and 59.6% between biopsy and hysterectomy/chemotherapy. Conclusion The established infrastructure of an HIV treatment program was successfully used to build capacity for cervical screening in a low-resource setting. By using task-shifting and evidence-based, low-cost approaches, population-based cervical screening in a rural African clinical network was found to feasible; however, loss to follow-up and poor pathology infrastructure remain important obstacles.

OBJECTIVE: To carry out a large-scale retrospective review of patients who had undergone surgical repair of obstetric fistula in Kenya to determine patient characteristics and determinants of successful surgical repair. METHODS: The patient records of 483 surgical repairs of obstetric fistula treated by a single surgeon (H.M.) between January 2005 and July 2010 at 3 medical centers in western Kenya were retrospectively reviewed. Descriptive and bivariate statistical analyses were performed. RESULTS: Young women with some primary or no education and prolonged labor at the time of first delivery were most highly correlated with obstetric fistula formation. Success of fistula closure was 86% for first-time vesicovaginal fistula (VVF) repairs and 67% for first-time VVF combined with rectovaginal fistula (RVF) repairs. Among women who had previously attempted VVF or combined VVF/RVF repairs 73% and 50% of fistulas respectively were repaired successfully. First-time repair was significantly associated with surgical success compared with patients with a history of previous repair attempts (P=0.027). CONCLUSION: Among Kenyan women presenting for fistula repair fistula most was most highly correlated with a low level of education and prolonged labor. The findings are consistent with results reported from other countries in Sub-Saharan Africa. Copyright (c) 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Background: Many women and children face the challenges of pregnancy and infancy without supportive relationships at home or in the community. To address this problem, the Academic Model Providing Access to Healthcare (AMPATH), in partnership with the Government of Kenya, launched Chama cha MamaToto, a peer-support model that groups women together at the start of their pregnancies. Central to our approach is the integration of microfinance into a group model that focuses on health education and relationship strengthening using a social fundraising platform well known to women: chamas. Chamas are effective networks through which women can meet regularly outside the home and pool resources. Using this existing cultural script, we developed these mother-child investment clubs in a rural district. Through their operation as a “table banking system”, members become shareholders in each other's futures, not only through the disbursement of loans, but also by keeping each other accountable to healthy practices for themselves and their children. The meetings provide opportunities for community health workers (CHWs) to efficiently disseminate health information, organise referrals, and build relationships with women and infants. Methods: In 2012, 32 Government of Kenya CHWs recruited more than 400 pregnant and breastfeeding women to 16 chamas in Bunyala subcounty, Kenya. These groups met fortnightly for 12 months. On joining, women pledged to participate for 1 year and to uphold the goals of the chama: support each other, attend prenatal care, deliver in a health facility, breastfeed exclusively for 6 months, adopt long-term family planning, save money, and become entrepreneurs. To evaluate the effect, acceptability, and sustainability of chamas, we compared data from a prospective cohort of women in chamas with a group of controls who did not belong to a chama, matched for age, parity, and location of prenatal care. Findings: We analysed data for 222 chama women and 115 controls, and found that compared with controls, women in chamas were 73% more likely to attend four recommended prenatal visits (64% vs 37%, p