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Objective To critically assess and synthesize qualitative findings regarding the health care ecosystem for vulnerable (low-birth-weight or sick) neonates in low- to middle-income countries (LMICs). Data Sources Between May 4 and June 2, 2020, we searched four databases (Medline [PubMed], SCOPUS, PsycINFO, and Web of Science) for articles published from 2010 to 2020. Inclusion criteria were peer-reviewed reports of original studies focused on the health care ecosystem for vulnerable neonates in LMICs. We also searched the websites of several international development agencies and included findings from primary data collected between May and July 2019 at a tertiary hospital in Kenya. We excluded studies and reports if the focus was on healthy neonates or high-income countries and if they contained only quantitative data, were written in a language other than English, or were published before 2010. Study Selection One of the primary authors conducted an initial review of titles and abstracts (n = 102) and excluded studies that were not consistent with the purpose of the review (n = 60). The two primary authors used a qualitative appraisal checklist to assess the validity of the remaining studies (n = 42) and reached agreement on the final 13 articles. Data Extraction The two primary authors independently conducted open and axial coding of the data. We incorporated data from studies with different units of analysis, types of methodology, research topics, participant types, and analytical frameworks in an emergent conceptual development process according to the critical interpretive synthesis methodology. Data Synthesis We synthesized our findings into one overarching theme, Pervasive Turbulence Is a Defining Characteristic of the Health Care Ecosystem in LMICs, and two subthemes: Pervasive Turbulence May Cause Tension Between the Setting and the Caregiver and Pervasive Turbulence May Result in a Loss of Synergy in the Caregiver–Parent Relationship. Conclusion Because pervasive turbulence characterizes the health care ecosystems in LMICs, interventions are needed to support the caregiver–parent interaction to mitigate the effects of tension in the setting.

Purpose The study was conducted to understand the nature and frequency of painful procedures and use of analgesia in neonatal units in Kenya. Design and methods Descriptive prospective study was conducted in a regional Level I and a university-affiliated Level II neonatal unit in Western Kenya. Two hundred term and preterm neonates who were hospitalized during the first day of life were recruited. A validated checklist was used to audit medical charts of hospitalized neonates. Painful procedures and pain treatment interventions accompanying all procedures performed during the first seven days of hospitalization were documented. Descriptive statistics, t-tests and χ2 were usedto determine frequency and factors influencing the frequency of procedures. Results A total of 1693 painful procedures (mean = 1.6 ± 1.1) were performed with most of them being tissue-damaging (n = 1291) including intravenous cannulation and intramuscular injection. Neonates were less likely to undergo procedures if there were born at term (RR 0.85; 95% CI, 0.76–0.95, p = .003) but more likely to experience procedures if admitted in a higher level of care (RR 1.57, 95% CI, 1.43–1.74, p Conclusions Neonates underwent few but highly invasive procedures without analgesia. Prematurity and a high level of care predisposed neonates to a higher burden of pain. Implications Our findings underscore the urgent need for development of context-specific clinical practice guidelines on procedural pain treatment in sub-Saharan Africa.

Medical records of pregnant and postpartum women living with HIV and their infants attending a large referral facility in Kenya from 2015 to 2019 were analyzed to identify characteristics associated with retention in care and viral suppression. Women were stratified based on the timing of HIV care enrollment: known HIV-positive (KHP; enrolled pre-pregnancy) and newly HIV-positive (NHP; enrolled during pregnancy). Associations with retention at 18 months postpartum and viral suppression (

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.

Purpose Explore views of mothers about pain and pain treatment practices in hospitalized newborn infants. Design and methods A Qualitative descriptive study using photo-elicitation technique was conducted in a level I and a level II neonatal units in Kenya. Fifteen semi-structured interviews were conducted with mothers of hospitalized infants. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis approach. Results Mothers described the experience of witnessing their infants undergo painful procedures as emotionally and psychologically traumatic. Participants felt helpless for not being able to protect their infants from pain a situation which was made worse by health care providers who appeared less concerned about pain relief during procedures. Mothers' views demonstrated a good understanding of pain-relief strategies; they identified strategies that health care providers should routinely use to relief pain in hospitalized infants. Furthermore, participants desired to be involved in comforting their infants during clinical procedures. Conclusion Repeated and untreated painful procedures continue to define the hospitalisation experience of newborn infants despite the presence of mothers who desire to be involved in comforting their infants during procedures. Practice implication Minimizing the burden of pain and using pain-relieving interventions could reduce parental stress and optimize parental role attainment following hospitalisation.

BackgroundNeonatal bacterial infections have been associated with rising antimicrobial resistance levels. This has led to increasing neonatal morbidity and mortality in poorly resourced health facilities located in low income countries. Local studies on neonatal antibiotic sensitivity patterns and its associated risk factors could inform empirical antibiotic therapy and hospital infection control strategies.PurposeThe study aimed at determining the causative organisms, antibiotic sensitivity patterns and risk factors associated with neonatal sepsis at a tertiary teaching hospital in Western Kenya.Materials and MethodsCross-sectional study among neonates suspected to have sepsis and undergoing treatment at Moi Teaching and Referral Hospital (MTRH’s) newborn unit (NBU) between September 2017 and July 2018. Blood culture tests isolated bacteria and determined their antimicrobial sensitivity. Neonatal and maternal characteristics were obtained through medical chart reviews. Descriptive statistics, Pearson chi-square test of association and odds ratios were adopted.ResultsThe study enrolled 141 neonates, majority (57.4%) of whom were female. The median gestational age and birth weight were 37 (IQR: 22-45) weeks and 2400g (IQR: 800 - 4700) respectively. Of the 151 bacterial isolates identified, 46.4% were Klebsiella spp. followed by Coagulate negative staphylococcus (CoNS) at 27.8%. Klebsiella spp. was sensitive to meropenem, amikacin and cefepime but resistant to ceftriaxone, gentamycin and cefotaxime. However, CoNS was sensitive to vancomycin and penicillin. Both the neonatal and maternal risk factors assessed were not associated with neonatal sepsis.ConclusionThe main bacterial causes of neonatal sepsis were Klebsiella spp. and CoNS which were both sensitivity to meropenem and amikacin.

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).

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.

The study evaluated the effectiveness of a neonatal nurse-training program in improving knowledge, patient care practices and processes of nurses in a neonatal intensive care unit in a resource-limited setting. The study was a pre-post intervention design assessing a nurse-training program in Kenya. We found a significant improvement in the primary outcome of nursing competency assessed on measures of knowledge and patient care practices post-intervention (p

The objective of this study was to identify the vital status and reasons for children becoming loss to follow-up (LTFU) from a large program in western Kenya.This was a prospective evaluation of a random sample of 30% of HIV-exposed and HIV-positive children LTFU from either an urban or rural HIV Academic Model Providing Access to Healthcare clinic. LTFU is defined as absence from clinic for6 months if on combination antiretroviral therapy and12 months if not. Experienced community health workers were engaged to locate them.There were 97 children sampled (78 urban, 19 rural). Of these, 82% were located (78% urban, 100% rural). Among the HIV positive, 16% of the children were deceased, and 16% had not returned to clinic because of disclosure issues/discrimination in the family or community. Among the HIV exposed, 30% never returned to care because their guardians either had not disclosed their own HIV status or were afraid of family/community stigma related to their HIV status or that of the child. Among children whose HIV status was unknown, 29% of those found had actually died, and disclosure/discrimination accounted for 14% of the reasons for becoming LTFU. Other reasons included believing the child was healed by faith or through the use of traditional medicine (7%), transport costs (6%), and transferring care to other programs or clinics (8%).After locating80% of the children in our sample, we identified that mortality and disclosure issues including fear of family or community discrimination were the most important reasons why these children became LTFU.

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

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