Insights into Unmet Need in Kenya

Background Despite the recent increase in contraceptive prevalence, a quarter of women of reproductive age in Kenya reported unmet need for family planning in 2008/9. Any advances in our understanding of the causes of unmet need could have profound implications for programmes. Objectives This study aims to establish the relative importance of lack of access and attitudinal resistance towards use of contraception in different population and geographical strata of Kenya. It is intended to inform policy makers on the priority that should be given to behaviour change communication or improved access/information, and also helpful to interventions to reduce health concerns and fear of side effects, such as provision of broader method mix and better counselling. Methods Data from the Kenya DHS 2008/9 were used for the analysis. All analyses were based on married/cohabiting fecund women who were exposed to risk of pregnancy at the time of the survey We identified whether married women with unmet need have access (defined by knowledge of pills and injectables, and a supply source) and attitudinal acceptance (defined by intention to use in the future). We assessed variations of unmet need across different strata by bivariate and multivariate analyses. Self-reported reasons for unmet need were assessed. Results Among 2676 exposed women, 28% had unmet need. Of these, half were classified as possessing both access and a positive attitude and a further one-third as having access but no intention to use in the future. The majority in both groups had previously used a modern method, in most cases pills or injectables. The main self-reported reason for non-use in both groups was health concerns and fear of side effects. Small minorities (6-7%) of women with an unfavourable attitude reported that they were opposed to contraception or mentioned religious reasons for non-use. Lack of access was associated with unmet need in 16% of cases and lack of information was the most common reason for non-use among these women. With the exception of the North Eastern Province where access was very limited, regional variations were minor. However, lack of access (i.e. method and/or supply source), was much more common in women with no schooling and the poorest segment than among other strata. Lack of access also appeared to be one reason why postpartum women have higher unmet need than other women. Discussion and implications Most women having unmet need for family planning in Kenya were aware of the two main contraceptive methods and a supply source, but many of the poorest, least educated women and those living in North Eastern Province were disadvantaged in this regard. Targeted expansion of access/information is a priority to meet the need of the disadvantaged populations. Among those with access, most (68%) have previously tried a modern method. Thus the origin of unmet need stems largely from discontinuation of use than outright rejection of contraception based on personal or religious opposition. The central problem appears to be health concerns and side effects. Many women try a modern method but discontinue use because of these concerns and do not switch to an alternativ

Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women in Nairobi's Urban Slums.

Unmet need for contraception is highest within 12 months post-delivery, according to research. Using longitudinal data from the Nairobi Urban Health and Demographic Surveillance System, we assess the dynamics of contraceptive use during the postpartum period among women in Nairobi's slums. Results show that by 6 months postpartum, 83 percent of women had resumed sexual activity and 51 percent had resumed menses, yet only 49 percent had adopted a modern contraceptive method. Furthermore, almost half of women discontinued a modern method within 12 months of initiating use, with many likely to switch to another short-term method with high method-related dissatisfaction. Women who adopted a method after resumption of menses had higher discontinuation rates, though the effect was much reduced after adjusting for other variables. To reduce unmet need, effective intervention programs are essential to lower high levels of discontinuation and encourage switching to more effective methods

Factors influencing satisfaction with oral contraceptive pills and injectables among past users in Kenya.

This study examines factors associated with satisfaction with oral pills and injectables among past users in Kenya based on a baseline survey for the 2-year prospective longitudinal study Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning conducted in 2016. Married women aged 15-39 years were interviewed using a structured questionnaire that captured information on reproduction, contraceptive knowledge and beliefs and attitudes towards contraception in general and towards specific methods. A multivariate logistic regression analysis was used to examine factors that influenced satisfaction with oral pills and injectables among past users in one urban site (Nairobi slums) and one predominantly rural site (Homa Bay in western Kenya). Results showed that dissatisfaction with pills and injectables is common among past users in both rural and urban Kenya (ranging from 39% to 56%). The distinctive contribution of the study lies in its ability to relate method-specific beliefs to overall satisfaction. Perception of effectiveness, ease of use and safety for long-term use had statistically significant influences on satisfaction with pills in both urban and rural sites while partner's approval was only important in Nairobi. For injectables, the perception of safety for long-term use was significant in the urban but not the rural site. Unlike pills, the belief that members of a woman's social network had used a method and found it satisfactory was a particularly powerful influence on satisfaction (AOR=2.8 in rural and 3.2 in urban). Perception of accessibility and fears about infertility were not found to be statistically associated with satisfaction for either pills or injectables. Surprisingly, the effects of all perceived contraceptive attributes were the same for major socio-demographic strata of the populations. The findings underscore the need for targeted counselling and community-based communication interventions to address negative and erroneous perceptions about family planning methods

Segmental isotopic labeling of a 140 kDa dimeric multi-domain protein CheA from Escherichia coli by expressed protein ligation and protein trans-splicing

Segmental isotopic labeling is a powerful labeling tool to facilitate NMR studies of larger proteins by not only alleviating the signal overlap problem but also retaining features of uniform isotopic labeling. Although two approaches, expressed protein ligation (EPL) and protein trans-splicing (PTS), have been mainly used for segmental isotopic labeling, there has been no single example in which both approaches have been directly used with an identical protein. Here we applied both EPL and PTS methods to a 140 kDa dimeric multi-domain protein E. coli CheA, and successfully produced the ligated CheA dimer by both approaches. In EPL approach, extensive optimization of the ligation sites and the conditions were required to obtain sufficient amount for an NMR sample of CheA, because CheA contains a dimer forming domain and it was not possible to achieve high reactant concentrations (1–5 mM) of CheA fragments for the ideal EPL condition, thereby resulting in the low yield of segmentally labelled CheA dimer. PTS approach sufficiently produced segmentally labeled ligated CheA in vivo as well as in vitro without extensive optimizations. This is presumably because CheA has self-contained domains connected with long linkers, accommodating a seven-residue mutation without loss of the function, which was introduced by PTS to achieve the high yield. PTS approach was less laborious than EPL approach for the routine preparation of segmentally-isotope labeled CheA dimer. Both approaches remain to be further developed for facilitating preparations of segmental isotope-labelled samples without extensive optimizations for ligation. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s10858-012-9628-3) contains supplementary material, which is available to authorized users

Method-Specific Attributes that Influence Choice of Future Contraception Among Married Women in Nairobi's Informal Settlements.

Despite an extensive evidence base on contraceptive method choice, it remains uncertain which factors are most influential in predisposing women toward certain methods and against others. This paper addresses this gap in knowledge by making use of rarely-measured perceptions about specific methods, perceived social network experience of methods, and women's own past experiences using specific methods. We draw on baseline data from the project, "Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning." Using conditional logit analysis, we ascertain which perceived method-specific attributes, including past experience of methods by women themselves and by their friends, predict preferred future contraceptive method among 317 women living in Nairobi slums who are using no method but intend to start in the next 12 months. Results show that satisfaction with past use, positive experience of use by a woman's social network, husband/partner's approval, lack of interference with menses, and perception of safety for long term use were all associated with choice of a future method

School life expectancy and risk for tuberculosis in Europe.

OBJECTIVE: This study aims to investigate the effect of country-level school life expectancy on Tuberculosis (TB) incidence to gain further understanding of substantial variation in TB incidence across Europe. METHODS: An ecological study examined the prospective association between baseline country-level education in 2000 measured by school life expectancy and TB incidence in 2000-2010 in 40 countries of the WHO European region using quantile regression. Subsequently, to validate the ecological associations between education and TB incidence, an individual-level analysis was performed using case-based data in 29 EU/EEA countries from the European Surveillance System (TESSy) and simulating a theoretical control group. RESULTS: The ecological analysis showed that baseline school life expectancy had a negative prospective association with TB incidence. We observed consistent negative effects of school life expectancy on individuals' TB infections prospectively. CONCLUSIONS: These findings suggests that country-level education is an important determinant of individual-level TB infection in the region, and in the absence of a social determinants indicator that is routinely collected for reportable infectious diseases, the adoption of country-level education for reportable infectious diseases would significantly advance the field

FIGO postpartum intrauterine device initiative: Complication rates across six countries.

OBJECTIVE: To record and analyze complication rates following postpartum intrauterine device (PPIUD) insertion in 48 hospitals in six countries: Sri Lanka, India, Nepal, Bangladesh, Tanzania, and Kenya. METHODS: Healthcare providers were trained in counselling and insertion of PPIUD via a training-the-trainer model. Data were collected on methodology, timing, cadre of staff providing care, and number of insertions. Data on complications were collected at 6-week follow-up. Statistical analysis was performed to elucidate factors associated with increased expulsion and absence of threads. RESULTS: From May 2014 to September 2017, 36 766 PPIUDs were inserted: 53% vaginal and 47% at cesarean delivery; 74% were inserted by doctors. Follow-up was attended by 52%. Expulsion and removal rates were 2.5% and 3.6%, respectively. Threads were not visible in 29%. Expulsion was less likely after cesarean insertion (aOR 0.33; 95% CI, 0.26-0.41), following vaginal insertion at between 10 minutes and 48 hours (aOR 0.59; 95% CI, 0.42-0.83), and when insertion was performed by a nurse (aOR 0.33; 95% CI, 0.22-0.50). CONCLUSION: PPIUD has low complication rates and can be safely inserted by a variety of trained health staff. Given the immediate benefit of the one-stop approach, governments should urgently consider adopting this model

Consequences of maternal morbidity on health-related functioning: a systematic scoping review.

OBJECTIVES: To assess the scope of the published literature on the consequences of maternal morbidity on health-related functioning at the global level and identify key substantive findings as well as research and methodological gaps. METHODS: We searched for articles published between 2005 and 2014 using Medline, Embase, Popline, CINAHL Plus and three regional bibliographic databases in January 2015. DESIGN: Systematic scoping review PRIMARY OUTCOME: Health-related functioning RESULTS: After screening 17 706 studies, 136 articles were identified for inclusion. While a substantial number of papers have documented mostly negative effects of morbidity on health-related functioning and well-being, the body of evidence is not spread evenly across conditions, domains or geographical regions. Over 60% of the studies focus on indirect conditions such as depression, diabetes and incontinence. Health-related functioning is often assessed by instruments designed for the general population including the 36-item Short Form or disease-specific tools. The functioning domains most frequently documented are physical and mental; studies that examined physical, mental, social, economic and specifically focused on marital, maternal and sexual functioning are rare. Only 16 studies were conducted in Africa. CONCLUSIONS: Many assessments have not been comprehensive and have paid little attention to important functioning domains for pregnant and postpartum women. The development of a comprehensive instrument specific to maternal health would greatly advance our understanding of burden of ill health associated with maternal morbidity and help set priorities. The lack of attention to consequences on functioning associated with the main direct obstetric complications is of particular concern. REVIEW REGISTRATION: CRD42015017774

An Assessment of Childbearing Preferences in Northern Malawi.

Fertility preferences are an essential component of family planning program evaluation; however, doubts about their validity in sub-Saharan Africa exist and little methodological assessment has been carried out. This study investigates prospective fertility intentions in terms of their temporal stability, intensity, degree of spousal agreement, and association with future childbearing in northern Malawi. A total of 5,222 married women participated in the three-round study. The odds of having a child or becoming pregnant within 36 months were 4.2 times higher when both wife and husband wanted a child within three years and 2 times higher when both wanted to wait at least three years, compared with the odds when both wanted to cease childbearing. The influence of husbands' and wives' preferences on subsequent fertility was equal. Compared with the intention to stop, the intention to postpone childbearing was less stable, recorded less spousal agreement, and was much less strongly predictive of fertility