Understanding the complexities of unexplained stillbirth in sub-Saharan Africa: a mixed-methods study

Objective

To understand the complexities surrounding unexplained stillbirth for the development and implementation of culturally acceptable interventions to underpin care in Tanzania and Zambia.

Design

Mixed‐methods study.

Setting

Tertiary, secondary and primary care facilities in Mansa, Zambia, and Mwanza, Tanzania.

Sample

Quantitative: 1997 women giving birth at two tertiary care facilities (one in each country). Qualitative: 48 women and 19 partners from tertiary, secondary and primary care facilities.

Methods

Case review using data from a target of 2000 consecutive case records. Qualitative interviews with a purposive sample of women and partners, using a grounded theory approach.

Results

A total of 261 stillbirths were recorded, with a rate of 16% in Tanzania and 10% in Zambia, which is higher than the previous estimates of 2.24 and 2.09%, respectively, for those countries. Women in both countries who reported a previous stillbirth were more likely to have stillbirth (RR 1.86, 95% CI 1.23–2.81). The cause of death was unexplained in 28% of cases. Qualitative findings indicated that not knowing what caused the baby to be stillborn prevented women from grieving. This was compounded by the poor communication skills of health professionals, who displayed little empathy and skill when counselling bereaved families.

Conclusions

The stillbirth risk in both facilities was far higher than the risk recorded from national data, with women reporting a previous stillbirth being at higher risk. Women want to know the cause of stillbirth and an exploration of appropriate investigations in this setting is required. Providing health professionals with support and continuing training is key to improving the experiences of women and future care.

Tweetable abstract

Stillbirths receive little investigation and are often unexplained. Communication with women about the death of their baby is limited.

Stillbirths receive little investigation and are often unexplained. Communication with women about the death of their baby is limited.

Parents' experiences of care and support after stillbirth in rural and urban maternity facilities: a qualitative study in Kenya and Uganda

OBJECTIVE

To explore parents' lived experiences of care and support following stillbirth in urban and rural health facilities.

DESIGN

Qualitative, interpretative, guided by Heideggerian phenomenology.

SETTING

Nairobi and Western Kenya, Kampala and Central Uganda.

SAMPLE

A purposive sample of 75 women and 59 men who had experienced the stillbirth of their baby (≤1 year previously) and received care in the included facilities.

METHODS

In-depth interviews, analysed using Van Manen's reflexive approach.

RESULTS

Three main themes were identified; parents described devastating impacts and profound responses to their baby's death. Interactions with health workers were a key influence, but poor communication, environmental barriers and unsupportive facility policies/practices meant that needs were often unmet. After discharge, women and partners sought support in communities to help them cope with the death of their baby but frequently encountered stigma engendering feelings of blame and increasing isolation.

CONCLUSIONS

Parents in Kenya and Uganda were not always treated with compassion and lacked the care or support they needed after the death of their baby. Health workers in Kenya and Uganda, in common with other settings, have a key role in supporting bereaved parents. There is an urgent need for context and culturally appropriate interventions to improve communication, health system and community support for African parents.

TWEETABLE ABSTRACT

Health-system response and community support for parents after stillbirth in Kenya and Uganda are inadequate.

Secrecy inhibits support: A grounded theory of community perspectives of women suffering from obstetric fistula, in Kenya

AIM

this study aimed to gain understanding of the views of community members in relation to obstetric fistula.

DESIGN AND METHOD

a qualitative, grounded theory approach was adopted. Data were collected using in-depth interviews with 45 community members. The constant comparison method enabled generation of codes and subsequent conceptualisations, from the data.

SETTING

participants were from communities served by two hospitals in Kenya; Kisii and Kenyatta. Interviews took place either in the home, place of work, or hospital.

FINDINGS

the core category (central concept) is 'secrecy hinders support'. This was supported by three themes: 'keeping fistula hidden', 'treatment being a lottery' and 'multiple barriers to support.' These themes represent the complexities around exposure of individual fistula sufferers and the impact that lack of information and women's status can have on treatment. Keeping fistula secret reinforces uncertainties around fistula, which in itself fuels myths and ignorance regarding causes and treatments. Lack of openness, at an individual level, prevents support being sought or offered.

CONCLUSIONS

A multi-layered strategy is required to support women with fistula. At a societal level, the status of women in LMIC countries needs elevation to a level that provides equity in health services. At a national level, laws need to protect vulnerable women from mistreatment as a direct result of fistula. Furthermore, resources should be available to ensure provision of timely management, as part of routine services. At community level, awareness and education is required to actively engage members to support women locally. Peer support before and after fistula repair may be beneficial, but requires further research.

Understanding the lived experience of women before and after fistula repair: a qualitative study in Kenya

OBJECTIVE

To gain understanding of the first-hand experience of women prior to and following repair of a vaginal fistula, to determine the most effective support mechanisms.

DESIGN

Qualitative phenomenological study using a series of in-depth semi-structured interviews at two time points: prior to fistula repair and 6 months post-surgery. Data were analysed thematically.

SETTING

Three fistula clinics in three districts in Kenya.

POPULATION

A purposive sample of 16 women suffering with vaginal fistula who were seeking fistula repair.

METHODS

Thrity-two semi-structured interviews were conducted.

RESULTS

The two main themes represented the women's journeys from social isolation to social reintegration. Women felt euphoric following fistula repair, believing that a 'miracle' had occurred. However, the 'post-miracle phase' demonstrated that the social and psychological impact of fistula leaves scars that are not easily healed, even when fistula repair is successful.

CONCLUSION

Women's experiences of living with fistula have an impact beyond that which can be repaired solely by surgery. The findings from this study support the need for more active psychological assessment in the management of women with fistula, and the role of targeted psychological support in any package of care given in the post repair phase. The format of this support requires further study. Engagement by health professionals with the wider community could raise awareness of the causes of fistula, and provide support for significant others who may also be feeling vulnerable. It is likely that the collaborative efforts from health professionals and community members will provide the most effective support.

TWEETABLE ABSTRACT

Fistula surgery alone is insufficient for women's physical, social and psychological recovery.

New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries

As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries. The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics. Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished. This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.

Pregnancy rates among female participants in phase I and phase IIA AIDS vaccine clinical trials in Kenya

BACKGROUND

Female participants in AIDS candidate vaccine clinical trials must agree to use effective contraception to be enrolled into the studies, and for a specified period after vaccination, since the candidate vaccines' effects on the embryo or foetus are unknown.

OBJECTIVES

To review data on female participants' pregnancy rates from phase I and IIA AIDS vaccine clinical trials conducted at the Kenya AIDS Vaccine Initiative (KAVI) and to discuss the challenges of contraception among female participants.

DESIGN

Descriptive observational retrospective study.

SETTING

KAVI clinical trial site, Kenyatta National Hospital and University of Nairobi, Kenya.

SUBJECTS

Thirty nine female participants were enrolled into these trials. They received family planning counselling and were offered a choice of different contraceptive methods, as per the protocols. All contraception methods chosen by the participants were offered at the study site at no cost to the participant.

RESULTS

Four women conceived during the study period when pregnancies were to be avoided. All four had opted for sexual abstinence as a contraceptive method, but reported having been coerced by their partners to have unprotected sexual intercourse.

CONCLUSION

Abstinence is clearly not a reliable contraceptive option for women in developing-country settings. Effective female-controlled contraceptives, administered at the clinical trial site, may empower female participants to better control their fertility, leading to more complete clinical trial data.