Maternal And Child Health Clinics Research Articles

Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya.

Delivery of PrEP to adolescent girls and young women (AGYW) and to pregnant women through maternal and child health (MCH) and family planning (FP) clinics is scaling up in Kenya. Evaluation of implementation challenges and strategies is critical to optimize delivery. We conducted focus group discussions (FGDs) with healthcare workers (HCWs) in MCH and FP clinics offering PrEP in a large implementation project in Kisumu, Kenya. Discussion guides were based on the Consolidated Framework for Implementation Research (CFIR). FGDs were audio recorded and transcribed. Directed content analysis was used to identify implementation challenges and strategies to overcome them. Fifty HCWs from 26 facilities participated in 8 FGDs. HCWs believed PrEP integration was appropriate because it met the needs of AGYW and pregnant women by providing a female-controlled prevention strategy and aligned with policy priorities of elimination of vertical HIV transmission. They were universally accepting of PrEP provision, especially through MCH clinics, noting the relative advantage of this approach because it: (1) enabled high coverage, (2) harmonized PrEP and MCH visits, and (3) minimized stigma compared to PrEP offered through HIV care clinics. However, HCWs noted implementation challenges affecting feasibility and adoption including: (1) increased workload and documentation burden amid workforce shortages, (2) insufficient health care worker knowledge (3) multiple implementing partners with competing priorities (4) drug and documentation form stockouts. HCWs employed various implementation strategies to overcome challenges, including task shifting from nurses to HIV testing providers, patient flow modifications (e.g., fast-tracking PrEP clients to reduce wait times), PrEP demand generation and myth clarification during health talks, provider education, dedicated PrEP delivery rooms, and coordination with adolescent-friendly services. Additional suggested strategies to improve PrEP integration included community education to increase broader PrEP awareness and enable shorter counseling sessions, and task-shifting data entry and client risk assessments. HCWs were enthusiastic about the appropriateness and acceptability of integrating PrEP services into MCH and FP clinics but noted challenges to adoption and feasibility. Strategies to address challenges focused on improving provider time and space constraints, and increasing provider and client knowledge.

Selecting implementation strategies to improve implementation of integrated PrEP for pregnant and postpartum populations in Kenya: a sequential explanatory mixed methods analysis

BackgroundThere is a higher risk for HIV acquisition during pregnancy and postpartum. Pre-exposure prophylaxis (PrEP) is recommended during this period for those at high risk of infection; integrated delivery in maternal and child health (MCH) clinics is feasible and acceptable but requires implementation optimization.MethodsThe PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged stakeholders to prioritize determinants of PrEP delivery (using Likert scores) and prioritize PrEP delivery implementation strategies. Using a sequential explanatory mixed methods design, we conducted quantitative surveys with healthcare workers at 55 facilities in Western Kenya and a stakeholder workshop (including nurses, pharmacists, counselors, and county and national policymakers), yielding visual plots of stakeholders’ perceived feasibility and effectiveness of the strategies. A stepwise elimination process was used to identify seven strategies for empirical testing. Facilitator debriefing reports from the workshop were used to qualitatively assess the decision-making process.ResultsAmong 146 healthcare workers, the strongest reported barriers to PrEP delivery were insufficient providers and inadequate training, insufficient space, and high volume of patients. Sixteen strategies were assessed, 14 of which were included in the final analysis. Among rankings from 182 healthcare workers and 44 PrEP policymakers and implementers, seven strategies were eliminated based on low post-workshop ranking scores (bottom 50th percentile) or being perceived as low feasibility or low effectiveness for at least 50% of the workshop groups. The top seven strategies included delivering PrEP within MCH clinics instead of pharmacies, fast-tracking PrEP clients to reduce waiting time, delivering PrEP-related health talks in waiting bays, task shifting PrEP counseling, task shifting PrEP risk assessments, training different providers to deliver PrEP, and retraining providers on PrEP delivery. All top seven ranked strategies were grouped into bundles for subsequent testing. Facilitator debriefing reports generally aligned with rankings but noted how stakeholders’ decision-making changed when considering the impact of strategies on facility staff and non-PrEP clients.ConclusionsThe most impactful barriers to integrated PrEP delivery in MCH clinics were insufficient staffing and space. Implementation strategies prioritized through multiple methods of stakeholder input focused on co-location of services and increasing clinic efficiency. Future testing of these stakeholder-prioritized strategy bundles will be conducted to assess the effectiveness and implementation outcomes.

Integration of HIV care into maternal and child health services in the global IeDEA consortium.

The WHO recommends the integration of routine HIV services within maternal and child health (MCH) services to reduce the fragmentation of and to promote retention in care for pregnant and postpartum women living with HIV (WWH) and their infants and children exposed to HIV (ICEH). During 2020-2021, we surveyed 202 HIV treatment sites across 40 low- and middle-income countries within the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We determined the proportion of sites providing HIV services integrated within MCH clinics, defined as full [HIV care and antiretroviral treatment (ART) initiation in MCH clinic], partial (HIV care or ART initiation in MCH clinic), or no integration. Among sites serving pregnant WWH, 54% were fully and 21% partially integrated, with the highest proportions of fully integrated sites in Southern Africa (80%) and East Africa (76%) compared to 14%-40% in other regions (i.e., Asia-Pacific; the Caribbean, Central and South America Network for HIV Epidemiology; Central Africa; West Africa). Among sites serving postpartum WWH, 51% were fully and 10% partially integrated, with a similar regional integration pattern to sites serving pregnant WWH. Among sites serving ICEH, 56% were fully and 9% were partially integrated, with the highest proportions of fully integrated sites in East Africa (76%), West Africa (58%) and Southern Africa (54%) compared to ≤33% in the other regions. Integration was heterogenous across IeDEA regions and most prevalent in East and Southern Africa. More research is needed to understand this heterogeneity and the impacts of integration on MCH outcomes globally.

Preventive Health Service Coverage Among Infants and Children at Six Maternal-Child Health Clinics in Western Kenya: A Cross-Sectional Assessment.

Despite the substantial reduction of child mortality in recent decades, Kenya still strives to provide universal healthcare access and to meet other international benchmarks for child health. This study aimed to describe child health service coverage among children visiting six maternal and child health (MCH) clinics in western Kenya. In a cross-sectional study of Kenyan children who are under the age of 5years presenting to MCH clinics, child health records were reviewed to determine coverage of immunizations, growth monitoring, vitamin A supplementation, and deworming. Among 78 children and their caregivers, nearly 70% of children were fully vaccinated for their age. We found a significant disparity in full vaccination coverage by gender (p = 0.017), as males had 3.5 × higher odds of being fully vaccinated compared to females. Further, full vaccination coverage also varied across MCH clinic sites ranging from 43.8 to 92.9%. Health service coverage for Kenyan children in this study is consistent with national and sub-national findings; however, our study found a significant gender equity gap in coverage at these six clinics that warrants further investigation to ensure that all children receive critical preventative services.

Child Development Monitoring in Well-baby Clinics in Kenya.

Background:Maternal and child health (MCH) clinics represent an integrated approach for providing healthcare to pregnant women and children 0-59 months of age. Although MCH clinics are also charged with monitoring child development, which involves tracking developmental milestones, it is unclear how these services are provided or perceived within the clinic. This study aimed to describe self-reported knowledge, perceptions, and practice of developmental monitoring in selected MCH clinics in western Kenya.Methods:This cross-sectional descriptive study was conducted within six clinics. We administered a descriptive survey to measure caregiver and healthcare staff attitudes towards and awareness of developmental monitoring; we also reviewed MCH booklets to identify services received at the clinic. Data collection occurred over a period of one day at each of the six clinic sites. The data were analyzed using descriptive statistics.Results:During the study period, 78 caregiver-child pairs presented to the clinics and had their MCH booklets reviewed. The median child age was three months (interquartile range [IQR]: 1-8 months). Most caregivers were aware of weight monitoring and immunization services; however, when asked specifically about developmental monitoring, only 2.6% of caregivers were aware this service was available at the clinics. Nearly 80% of caregivers reported that they would be very interested in developmental monitoring services. Thirty-three MCH healthcare staff were interviewed about services provided and goals of clinical care. Fewer healthcare staff (60.6%) identified their roles in developmental monitoring compared to their roles in growth (90.9%) and nutritional monitoring (84.8%). Developmental milestones had not been recorded in any of the 78 MCH booklets. However, 78.1% of healthcare staff indicated support for developmental screening.Conclusion and Global Health Implications:While developmental monitoring was valued by healthcare providers, it was not consistently performed at the six clinics in our study. We recommend further work to raise awareness about developmental monitoring and to measure the implications of increased caregiver knowledge and perceptions on developmental monitoring practice.

Prenatal oral health: geo-spatial analysis of access to care

Introduction: Prenatal oral care is important for both the oral and general health of the woman and the offspring and it should be maintained throughout the life course. Objectives: To determine the distribution of both hospital and community dental care facilities for the provision of oral healthcare to antenatal mothers referred to the maternal and child health (MCH) clinics, in the district of Gampaha, Sri Lanka Methods: All the MCH clinics and all available public dental care facilities were mapped using Geographic Information System (GIS) software, and the minimum referral distance was measured from each MCH clinic to the nearest public dental clinic using the distance-based GIS tools. Results: The referral distance reported from an MCH clinic to a public dental clinic varied between 0- 8.5 km. About 22% (n=37) of the MCH clinics had an in-house or proximate dental facility not more than 1 km away. About 41% (n=69) of MCH clinics had a public dental clinic within a 2.5 km distance, and it increased up to 81% (n=136) when the referral distance expanded up to 5km. The average referral distance for pregnancy oral healthcare in the entire district was 3 km. Conclusions: The study identified service disparities in pregnancy oral healthcare in the district using geo-spatial techniques. It could contribute to future planning of hospital and community based dental clinic locations for antenatal mothers, emphasising the importance of referral distance in improving the dental attendance among pregnant women.

Knowledge, attitude, and practice of mothers about complementary feeding for infants aged 6-12 months in Anbar Province, Iraq

Background: The understanding of what mothers think about breastfeeding helps in developing successful breastfeeding promotion programs. This study aims to assess the maternal knowledge, attitude, and practice about the complementary feeding for infants aged 6-12 months.
 Methods: A cross-sectional study designed to interview 219 mothers with children between 6-12 months. Data was collected between 1st March and 30th April 2019 from ten maternal and child health clinics (MCHCs) in Anbar Province, Iraq. SPSS version 16.0 was recruited to analyze the data. Descriptive and inferential statistics such as Chi-square used to present data with the significance level set at less than 0.05.
 Results: The mean age of respondents was 27.76 ± 6.3 years, and 31% were at the primary school level. Two third (66.82%) of the surveyed mothers exclusively used breastfeeding to feed their infants. Most women (84.09%) have the correct knowledge about the best time to start complementary food. The vast majority of women (93.64%) refused to give vitamins to children even with signs of malnutrition.
 Conclusion: Although exclusive breastfeeding is common among mothers of the western region in Iraq, there is still a considerable percentage depend on the mixture of breastfeeding and bottle feeding. The positive impact of the family and society on mothers was evident. However, more attention should be given to improve knowledge, attitude, and practice through qualified healthcare providers.

Sex effect on growth faltering in an indigenous ethnic minority population of infants in Israel.

We examined sex effects on growth faltering in an indigenous population of Bedouin Arab infants born in Israel, an economically developed country. Retrospective cohort study. Height-for-age Z-score (HAZ) at age 6, 12, 18 and 24months was calculated for full-term, normal-birth-weight Bedouin infants born during years 2000-2009 and attending maternal and child health (MCH) clinics. Multivariate linear regression analysis (MLRA) was used to calculate the association between sex and HAZ, controlling for year of birth, birth weight (BW) and residence by type of settlement (established settlement (ES); non-established settlement (NES)). Bedouin are an indigenous poor community of semi-nomadic Arabs, with the highest infant mortality rate in Israel. Fifty per cent of Bedouin infants live in NES with inadequate access to running water, electricity, and rubbish and sewage disposal. All Bedouin receive free well-baby care in community-based MCH clinics. Full-term, normal Bedouin infants (n5426) born during 2000-2009 and attending computerized MCH clinics who had growth measurements at age 6, 12, 18 and 24months. At all ages, girls had significantly higher mean HAZ than boys (P < 0·05). Increasing birth year, residence in ES and increasing BW were positively associated with HAZ (P < 0·05) at all ages. In MLRA controlling for birth year, BW and type of settlement, sex still had a significant effect, with lower HAZ among boys at 6, 12, 18 and 24months of age (P < 0·001 at all ages). Our results indicated that sex effects on growth faltering can occur in an indigenous population with low socio-economic status within an economically developed country.

Factors associated with low male partners’ involvement in maternal and child health services in Suba sub county, Western Kenya

Objective: Male involvement (MI) in maternal and child health (MCH) services such as pre-conception care, antenatal care (ANC), prevention of mother-to-child transmission (PMTCT) of HIV, skilled delivery is an integral intervention that improves MCH outcomes. Suba sub County in western Kenya has the highest prevalence of HIV in Kenya. Moreover, data is skewed on men’s knowledge and perceptions regarding their involvement in MCH services. Methods: This mixed method cross-sectional study, collected data using questionnaire among 354 male participants, and conducted 4 focus group discussions (FGDs) and 6 key informant interviews (KIIs). STATA version 11 was used for quantitative data analysis. The thematic content analysis was used to analyze qualitative data. Results: The majority of the participants (52.3%) were aged >30 years, 44.9% had primary level of education and 63.1% engaged in fishing activities. About 54.5% of the participants were not aware of the Ministry of Health’s effort to enhance men’s attendance to MCH clinics, while men’s age, various cultural taboos and provider’s attitude were perceived as influencing MI in MCH services. Overall 16.3% of the participants were involved in MCH services. Health worker provider’s attitude towards men (OR 0.5, 95% Cl 0.3 to 0.8), men’s preferred time of attending MCH clinic (OR 6.7, 95% Cl 1.1-43.5), the frequency of men accompanying spouse to MCH clinic (OR 0.1, 95% Cl 0.04-0.3), duration taken to reach MCH clinic (OR 5.6, 95% Cl 1.3-24.6), use of family planning methods (OR 0.36, 95% Cl 0.18-0.72) and awareness about the methods used to reduce HIV mother to child transmission (MTCT) (OR 35, 95% Cl 0.19-0.65) were independently associated with men’s attendance of the MCH clinics. Conclusion: Significantly there was low male involvement in MCH services (16.3% compared to the > 30% targets by Kenya PMTCT guidelines, 2012) in this high HIV prevalent region. Enhanced dissemination and awareness creation on the importance of MI in MCH services could improve male involvement Key words : Male Involvement, Maternal and Child Health Services, Knowledge, Perceptions and Correlates, Suba sub county western Kenya DOI : 10.7176/JHMN/60-15 Publication date :March 31 st 2019

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial

BackgroundDespite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum.MethodsThe aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics.DiscussionIf proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation.Trial registrationThe protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669.

Intimate Partner Violence Prevalence, Recurrence, Types, and Risk Factors Among Arab, and Jewish Immigrant and Nonimmigrant Women of Childbearing Age in Israel.

This research set out to determine prevalence, recurrence, types, and risk factors for intimate partner violence (IPV) among women of childrearing age across Israel, attending to diversity in these factors by ethnicity and immigration status. The first nationwide study of its kind, this research was based on a stratified proportional cluster sample of 1,401 Arab, and Jewish immigrant and nonimmigrant women (aged 16-48 years) who visited 63 maternal and child health (MCH) clinics between October 2014 and October 2015. Female research staff interviewed women face-to-face in a private room at the MCH clinics using a structured questionnaire in the women's main language (Arabic or Hebrew). We measured IPV using a 10-item questionnaire used for screening at some MCH clinics. Response rate was 74%. In the multivariate analysis, we used generalized estimating equations (GEEs) to adjust for the MCH clinic cluster effect. We found marked differences in the prevalence of IPV among Arab, and Jewish immigrant and nonimmigrant women (67%, 30%, and 27%, respectively). Types (physical, verbal and social) and recurrence of IPV were significantly higher among Arab women compared with the other two groups. In the GEE analysis, compared with IPV among Jewish nonimmigrants, IPV among Arab women persisted after considering socioeconomic, sociodemographic, and reproductive factors (odds ratio = 3.83; 95% confidence interval = [2.55, 5.72]). Low family income was the main risk factor for IPV for all women. Among Arab women, younger age, high religiosity, and living in urban settings were associated with higher IPV. These results suggest that diversity (ethnicity and immigration status) should be considered when developing tailored policies and interventions to protect women from IPV.

Knowledge, Attitudes and Perceptions About Routine Childhood Vaccinations Among Jewish Ultra-Orthodox Mothers Residing in Communities with Low Vaccination Coverage in the Jerusalem District.

Background and aims Childhood vaccinations are an important component of primary prevention. Maternal and Child Health (MCH) clinics in Israel provide routine vaccinations without charge. Several vaccine-preventable-diseases outbreaks (measles, mumps) emerged in Jerusalem in the past decade. We aimed to study attitudes and knowledge on vaccinations among mothers, in communities with low immunization coverage. Methods A qualitative study including focus groups and semi-structured interviews. Results Low immunization coverage was defined below the district's mean (age 2 years, 2013) for measles-mumps-rubella-varicella 1st dose (MMR1\MMRV1) and diphtheria-tetanus-pertussis 4th dose (DTaP4), 96 and 89%, respectively. Five communities were included, all were Jewish ultra-orthodox. The mothers' (n = 87) median age was 30years and median number of children 4. Most mothers (94%) rated vaccinations as the main activity in the MCH clinics with overall positive attitudes. Knowledge about vaccines and vaccination schedule was inadequate. Of vaccines scheduled at ages 0-2 years (n = 13), the mean number mentioned was 3.9 ± 2.8 (median 4, range 0-9). Vaccines mentioned more often were outbreak-related (measles, mumps, polio) and HBV (given to newborns). Concerns about vaccines were obvious, trust issues and religious beliefs were not. Vaccination delay was very common and timeliness was considered insignificant. Practical difficulties in adhering to the recommended schedule prevailed. The vaccinations visits were associated with pain and stress. Overall, there was a sense of self-responsibility accompanied by inability to influence others. Conclusion Investigating maternal knowledge and attitudes on childhood vaccinations provides insights that may assist in planning tailored intervention programs aimed to increase both vaccination coverage and timeliness.

Parental factors affecting child's immunization status in Benghazi, Libya

Background: According to the World Health Organization recommendations, every country should have its own national immunization program for children to protect them against vaccines preventable diseases. This study aims to assess parental factors affecting the child's immunization status. Subjects and Methods: A descriptive, cross-sectional study was conducted on 419 parents attending maternal and child health (MCH) at El-hadaeq health center in Benghazi to vaccinate their children during November 1, 2016 to January 31, 2017. Results: Mothers constitute 79% of the study population and 53% of the children were male. Almost all the parents 402 (96%) were aware and had good knowledge about the national immunization program. Nearly 86% of the children were completely immunized for their age, and the main reason for missing vaccination is the unavailability of vaccines in MCH clinics. Conclusion: Although the awareness rate about immunization is high between the parents, there are still some children missed vaccinations. More educational interventions are therefore needed to increase and update parents' knowledge, and more emphasis on the local health authority is needed to ensure continuous vaccines supply to all MCH clinics and health centers in Libya.

Assessment of oral health promotion services offered as part of maternal and child health services in the Tshwane Health District, Pretoria, South Africa

ObjectivesThe study aimed to assess the oral health promotion services provided as part of the maternal and child health (MCH) services in the Tshwane Health District, Pretoria, South Africa.MethodsThe research design was a descriptive cross-sectional study using a modified standard questionnaire. The population was drawn from the parents/caregivers (PCGs) and the MCH nurses at seven clinics during June 2012 and June 2013 in Pretoria.ResultsThe nurses’ response rate was 83%; average age of 37 years. The majority of the nurses (65%) were females; 60% were professional nurses. Most (63%) of the nurses reported that they provided oral health education (OHE) services. A shortage of dental education materials (43%), staff time (48%), and staff training (52%) were large constraints to nurses providing OHE. The majority of PCGs (n = 382; mean age 31.5 years) had a low education level (76%). About 55% of PCGs received information on children’s oral health from the television and 35% at the MCH clinics. PCGs beliefs were worrying as about 38% believed primary dentition is not important and need not be saved.ConclusionThere is evidence of minimal integration of OHE at MCH sites. Parents’ beliefs are still worrying as a significant number do not regard the primary dentition as important. The MCH site remains an important easily accessible area for integration of oral health services with general health in complementing efforts in prevention of early childhood caries.

Challenges with routine data sources for PMTCT programme monitoring in East Africa: insights from Tanzania

Routinely collected clinic data have the potential to provide much needed information on the uptake of services to prevent mother-to-child transmission (PMTCT) of HIV, and to measure HIV prevalence in pregnant women. This article describes the methodological challenges associated with using such data, based on the experiences of researchers and programme implementers in Tanzania and drawing from other examples from East Africa. PMTCT data are routinely collected in maternal and child health (MCH) clinics in East Africa using paper-based registers corresponding to distinct services within the PMTCT service continuum. This format has inherent limitations with respect to maintaining and accurately recording unique identifiers that can link patients across the different clinics (antenatal, delivery, child), and also poses challenges when compiling aggregate data. Recent improvements to recording systems include assigning unique identifiers to HIV-positive pregnant women in MCH clinics, although this should ideally be extended to all pregnant women, and recording mother and infant identifiers alongside each other in registers. The use of ‘health passports’, as in Malawi, which maintains the same antenatal clinic identifier over time, also holds promise. Routine data hold tremendous potential for clinic-level patient management, surveillance, and evaluating PMTCT/MCH programmes. Linking clinic data to community research datasets can also provide population-level estimates of coverage with PMTCT services, currently a problematic but vital statistic for monitoring programme performance and negotiating donor funding. Enhancements to indexing and recording of routine PMTCT/MCH data are needed if we are to capitalise on this rich data source.

Maternal perceptions of social context and adherence to maternal and child health (MCH) clinic recommendations among marginalized Bedouin mothers.

National maternal and child health (MCH) care systems often deliver universal health care recommendations that do not take into consideration the social context of infant care (IC) for marginalized groups. We examined associations between maternal perceptions of social context (MPSC) and adherence by minority Bedouin mothers in Israel to three commonly recommended IC practices. We conducted personal interviews with 464 mothers visiting 14 MCH clinics using a structured questionnaire based on findings from a previous focus-group study, and guided by constructs of the Health Beliefs Model. Items were tested for validity and reliability. We used multivariate analysis to identify MPSC constructs associated with adherence to MCH clinic recommendations (timely postnatal first visit, sustaining breastfeeding, and use of infant car seat). Social context, when perceived as a barrier to IC, was negatively associated with adherence to timely first postnatal MCH clinic visit (odds ratio, 95 %, confidence intervals (OR 1.45, 95 % CI 1.24, 1.70) and use of infant car seat (OR 1.43, 95 % CI 1.21, 1.69). However, social context was positively associated with sustained breastfeeding (OR 0.54, 95 % CI 0.37, 0.79). Perceptions of the severity of infant health problems, and family financial and relationship problems had less significant associations with adherence to MCH clinic recommendations. Adherence by marginalized mothers to MCH clinic recommendations is related to their perceptions of social context. When there are higher financial and other living conditions barriers mothers tend toward lower adherence to these recommendations. MCH policy makers and service providers must consider MPSC in planning and delivery of MCH recommendations.

Maternal and child health nurses' self‐perceived confidence in dealing with child behaviour problems

Addressing behaviour problems in children is increasingly becoming part of routine care. The question therefore arises as to which workforce members are best suited to deliver structured interventions and what skill sets they might need apart from knowledge of the specific parenting programme offered. To assess maternal and child health (MCH) nurses' self-perceived confidence in dealing with child behaviour problems. Cross-sectional questionnaire study. Data collection occurred prior to cluster randomization in the Families in Mind trial. MCH clinics in nine local government areas in greater Melbourne, in 2010. All MCH nurses in the nine areas were invited to participate, 153 (79%) completed the survey. Nurses' comfort, competency, attitudes and perceived difficulties in dealing with child behaviour problems. The majority of nurses (63%) viewed it as their role to deal with, rather than refer, child behaviour problems and felt that the task was rewarding (86%). They believed that parenting advice should be offered universally, rather than only to families with severe problems (94%). Nurses felt rather comfortable and competent to broach and discuss child behaviour problems without need for prior parental request, but somewhat less comfortable and competent to manage child behaviour problems or to make a difference. Experienced nurses (>10 years in practice) felt more comfortable and competent. Nurses described that the major challenge in their dealing with child behaviour problems was parental denial or resistance (60%). MCH nurses are at the frontline of preventive medical services for families with young children where behaviour problems are a common concern. Because managing young children's behaviour problems primarily occurs through adult behaviour change, techniques addressing parent denial and non-compliance, such as motivational interviewing and empowerment should be a part of MCH nurses' skill sets.

Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis

To determine whether integrating antiretroviral therapy (ART) into antenatal care (ANC) and maternal and child health (MCH) clinics could improve programmatic and patient outcomes. The authors systematically searched PubMed, Embase, African Index Medicus and LiLACS for randomized controlled trials, prospective cohort studies, or retrospective cohort studies comparing outcomes in ANC or MCH clinics that had and had not integrated ART. The outcomes of interest were ART coverage, ART enrolment, ART retention, mortality and transmission of human immunodeficiency virus (HIV). Four studies met the inclusion criteria. All were conducted in ANC clinics. Increased enrolment of pregnant women in ART was observed in ANC clinics that had integrated ART (relative risk, RR: 2.09; 95% confidence interval, CI; 1.78-2.46; I(2): 15%). Increased ART coverage was also noted in such clinics (RR: 1.37; 95% CI: 1.05-1.79; I(2): 83%). Sensitivity analyses revealed a trend for the national prevalence of HIV infection to explain the heterogeneity in the size of the effect of ART integration on ART coverage (P = 0.13). Retention in ART was similar in ANC clinics with and without ART integration. Although few data were available, ART integration in ANC clinics appears to lead to higher rates of ART enrolment and ART coverage. Rates of retention in ART remain similar to those observed in referral-based models.

ASSESSMENT OF REPEATABILITY AND RECALL BIAS OF REPORTED PERI-CONCEPTION ENVIRONMENTAL EXPOSURE AMONG PREGNANT WOMEN IN SOUTHERN ISRAEL

Background. A growing number of environmental exposures in the peri-conception period have shown to cause adverse pregnancy outcome (APO): low birthweight, small for gestational age, preterm birth and cardiac birth defects. Validity of exposure information collected retrospectively in case-control studies has been questioned. We aimed to assess repeatability and possible recall bias of self-reported environmental exposures collected after birth. . Methods. Women registered for prenatal care in Maternal and Child Health clinics (MCHC) by week 25 of gestation comprised the study population (n=411). Information about place of residence and exposures to various risk factors during the 3 months prior to conception and first 3 months of pregnancy was obtained by personal interviews, using a structured questionnaire. Women with APO (gestational age at birth/miscarriage/induced abortion, low birth-weight, perinatal morbidity, fetal death, and in-hospital neonatal death), and a sample of control women without adverse outcome, matched by MCH clinic, were re-interviewed, after end of pregnancy (n=241). Kappa statistics was used to assess reliability of retrospectively reported exposures. Results. Low agreement (kappa &lt;0.4) between 1st and 2nd interview was observed regarding exposures to flu, fever, medications and vitamins consumption, cellphone use, home and work repairing, disinfestations, passive smoking. Better agreement (kappa &gt;0.4) was observed regarding water filtering, maternal occupational exposures, living in proximity to antennas, contraceptive methods, urinary tract infections, smoking before/during pregnancy ,fertility treatment, and physical exertion at work. There were no differences in agreement estimates for cases and controls. Conclusions. While no recall bias was found, the validity of most retrospectively reported exposures was rather low, suggesting that OR estimated from case-control studies may be underestimated it is therefore advisable that, whenever possible, cohort studies should be performed to detect effects of perinatal exposures on pregnancy outcomes.

Providers' views concerning family planning service delivery to HIV-positive women in Mozambique.

This study explores challenges and obstacles in providing effective family planning services to HIV-positive women as described by staff of maternal and child health (MCH) clinics. It draws upon data from a survey of service providers carried out from late 2008 to early 2009 in 52 MCH clinics in southern Mozambique, some with and some without HIV services. In all clinics, surveyed providers reported that practical, financial, and social barriers made it difficult for HIV-positive clients to follow protocols to prevent mother-to-child transmission of the virus. Likewise, staff were skeptical of their seropositive clients' ability to adhere to recommendations to cease childbearing and to use condoms consistently. Providers' recommendations to HIV-positive clients and their assessment of barriers to adherence did not depend on availability of HIV services. Although integration of HIV and reproductive health services is advancing in Mozambique, service providers do not feel that they can influence the behaviors of HIV-positive women effectively.