Peri-urban Nairobi Research Articles

Factors associated with strongylida infections in sheep on farms in peri-urban Nairobi, Kenya

Gastrointestinal parasite infections are among the major limitations to production in sheep in many parts of the world. It is important to continually assess their levels of infection in order to institute control measures and reduce the impact. This study determined the factors associated with the strongylida egg counts in sheep on selected farms in peri-urban Nairobi, Kenya. This was a cross-sectional study in which farm and animal-level data, including faecal samples, were collected from 1640 sheep from 30 purposively selected farms in Ruai, and Kamulu wards in Kasarani sub-county and Utawala and Mihango wards in Embakasi East Sub-County, in Nairobi County Kenya. The faecal samples were subjected to coprological examination using a modified McMaster technique to determine counts of strongylida eggs and coccidia oocysts with a detection level of 100 egg or oocyst per gram (EPG or OPG) of faeces. The positive faecal samples for strongylida eggs were pooled per farm and cultured for morphological identification of larval stage three. Descriptive statistics and multilevel mixed-effect logistic regression analyses were used to determine factors associated with strongylida egg count ≥600 EPG (p < 0.05). The receiver operating characteristics curve was used to assess the overall diagnostic performance in the final model. Strongylida eggs were detected in 45.5% (746/1640) of the sheep, and the mean EPG was 486.0± 858.9 with a median of 200 and a range of 0–16,700. The coccidia oocysts were detected in 49.4% (810/1640) of the sheep with a mean OPG was 341.7± 1782.4, a median of 0 and a range of 0–60,000. In the coprocultures, the nematode genera identified (% differential count of L3) were Haemonchus (90%), Trichostrongylus (5%) and Oesophagostomum (5%). In the final multivariable regression model, the odds of detecting EPG ≥ 600 was 1.44 times higher for sheep shedding coccidia oocysts than those that did not. The odds for detecting EPG ≥ 600 was 4.01 times for sheep in Ruai ward compared with those in the combined Kamulu, Utawala and Mihango wards. The receiver operating characteristic curve area was 73.1%, suggestive of good model performance. The results suggest that gastrointestinal strongylida and coccidia infections are common in sheep and farmers should be educated on the importance of appropriate control measures.

Prevalence and risk factors associated with the occurrence of Campylobacter sp. in children aged 6-24 months in peri-urban Nairobi, Kenya.

Campylobacter bacteria is a major cause of foodborne-related bacterial gastroenteritis in humans worldwide. It is known to cause diarrhea in young children which has been shown to directly affect their weight and height as a result of malnutrition. Severe cases of diarrhea can also lead to death. Most of the burden is experienced in resource-limited countries in Africa and Southeast Asia where the disease is linked to poor hygiene and sanitation. The objective of this study was to determine the prevalence of Campylobacter in children aged between 6 and 24 months in Nairobi, Kenya and identify potential risk factors associated with their occurrence. A cross-sectional study was carried out between May to December 2021. A total of 585 randomly selected households were visited in two wards (Uthiru/Ruthimitu and Riruta) in Dagoretti South sub-county, Nairobi. A questionnaire regarding how children's food is handled, the major foods consumed, sanitation and hygiene, and animal ownership was conducted among caregivers to identify associated risk factors. Stool samples were collected from 540/585 children and screened for the presence of Campylobacter using culture-based methods and confirmed through PCR. Of the 540 children's stool samples processed, Campylobacter isolates were detected in 4.8% (26/540). Campylobacter jejuni (C. jejuni) was the most common species in 80.8% of positive samples compared to Campylobacter coli (C. coli) in 26.9% of samples. In six samples, both C. jejuni and C. coli were isolated, while in four samples, it was not possible to speciate the Campylobacter. Drinking cow's milk (OR 4.2, 95% CI 1.4 - 12.6) and the presence of animal feces in the compound (OR 3.4, 95% CI 1.1 - 10.3) were found to be statistically associated with Campylobacter carriage in children. The carriage of Campylobacter in children in this community indicates a need for further investigation on source attribution to understand transmission dynamics and inform where to target interventions. Awareness creation among caregivers on good personal and food hygiene is needed, including boiling milk before consumption. Implementation of biosecurity measures at the household level is highly recommended to reduce contact between animals and humans.

The role of partners, parents and friends in shaping young women’s reproductive choices in Peri-urban Nairobi: a qualitative study

BackgroundContraceptive use among young women in Nairobi remains low despite high general knowledge of family planning (FP) methods. This paper draws on social norms theory to explore the role of key influencers (partners, parents and friends) in women’s FP use and how women anticipate normative reactions or sanctions.MethodsA qualitative study with 16 women, 10 men and 14 key influencers across 7 peri-urban wards in Nairobi, Kenya. Interviews were conducted during the COVID-19 pandemic in 2020 by phone. A thematic analysis was conducted.ResultsWomen identified parents, specifically mothers, aunts, partners, friends and healthcare workers as key influencers on FP. Their interactions with these key influencers varied based on trust, the information they needed about FP, and whether they perceived a key influencer to perpetuate or challenge existing social norms on FP. Mothers were perceived to understand the social risks of using FP and thus could advise on discreet FP use, and aunts were trusted and approachable sources to impartially describe the benefits and drawbacks of FP. Although women identified partners as key FP decision makers, they were cognisant of possible power imbalances affecting a final FP choice.ConclusionsFP interventions should consider the normative influence key actors have on women’s FP choices. Opportunities to design and deliver network-level interventions which seek to engage with social norms surrounding FP in order to challenge misconceptions and misinformation among key influencers should be explored. Intervention design should consider dynamics of secrecy, trust and emotional closeness that mediate discussions of FP to address changing norms. Further training to change norms held by healthcare providers about why women, in particular unmarried young women, access FP should be provided to reduce barriers for FP access.

Suburban pastoralists: Pastoral adaptation strategies at the rural-urban interface in Nairobi, Kenya

How does urban expansion interact with pastoral climate change adaptation? This article explores pastoral adaptation strategies at the rural-urban interface. It examines how Maasai pastoralists in peri-urban Nairobi, Kenya, respond to climate hazards in the context of urban expansion, land use change, and land privatisation. Using mixed-method research, the study is informed by a household survey (n = 72), 38 qualitative interviews, and 12 focus group discussions. Drawing on the literature on climate change adaptation, pastoral change, and peri-urban dynamics, we find that while urban expansion provides significant challenges for pastoral livelihoods in the study area, pastoralists also engage new opportunities in the peri-urban context and employ them in their adaptation strategies. We show how adaptation strategies related to mobility, diversification, market exchange, and storage are employed through a variety of efforts including engagement with urban land markets and demand for livestock products, and by capitalising on proximity to transport, trading facilities, water, and commercial fodder. Communal pooling, another adaptation strategy, is less used and perceived to be in decline. We further find that historical land ownership patterns play a significant role in adaptation strategies, as pastoralists who have benefitted from rangeland privatisation are able to convert high peri-urban land values into private rural land access and investments in, e.g. diversification. Poor households are in a more precarious position but draw on informal agreements to access land as part of their adaptation strategies. Our findings highlight how pastoral households at the rural-urban interface may draw actively on peri-urban opportunities in their adaptation strategies as part of their efforts to enhance livelihoods, and in so doing bridge peri-urban and rural space. More broadly, our study highlights the importance of understanding pastoral climate change adaptation in the context of wider changes in livelihoods, land use, and land rights, rather than as isolated actions.Graphical

Highway engineering and land use change in peri-urban Nairobi: Assessing inclusive development outcomes for host communities in the Northern Bypass corridor

This article looks at the socio-environmental consequences of highway development on host communities in one of Nairobi’s peri-urban corridors. It is inspired by the fact that whereas governmental decision makers have supported highway development by arguing that such construction promotes economic growth and development, decreases traffic congestion, increases travel safety, assists in the more efficient use of existing roads, reduces poverty and improves the environment, this argument is usually pitched at the national or sub-national level thereby ignoring local community interests. Therefore, the study focused on the local socio-economic transformations that are taking place along the corridor as a result of the highway development. Such fundamental transformations occasioned by the road are often not captured in the pre-project impact evaluation documents. In this context, the study found that the construction of the road positively increased accessibility; however, improved accessibility led to land value increases and gentrification. Other effects of road development are land use change and loss of livelihoods, production of inequalities and densification. The study recommends incorporation of ex-post monitoring programs in project development to help mitigate the negative impacts on vulnerable members of the host communities who may suffer in the pursuit of the national development.

Consumer Demand for Milk and the Informal Dairy Sector Amidst COVID-19 in Nairobi, Kenya

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has had large negative effects on countries’ economies and individual well-being throughout the world, particularly in low- and middle-income countries. Pandemic-related changes in behavior and government restrictions in Kenya may have negatively affected food supply chains and household food access; however, the empirical evidence is currently limited. ObjectivesThe study explored changes in informal milk markets, dairy consumption, and food insecurity among low-income households in urban and periurban Nairobi, Kenya, following the start of the COVID-19 pandemic in the country. MethodsBaseline data on milk sales and consumption were collected in late 2019 from dairy vendors operating in the informal sector and their dairy customers. We conducted 2 longitudinal telephone surveys with the same study participants in July and September–October 2020, respectively. ResultsAt the first follow-up, the volume of milk sold by informal vendors had dropped by 30% compared with their baseline level, and the volume of milk from informal markets consumed by households decreased by 23%. By the second follow-up, the volume of milk sold and consumed had recovered somewhat but remained lower than the volume observed 1 y prior in the same season. Large reductions in the consumption of other animal–sourced products were also observed. The rate of food insecurity increased by 16 and 11 percentage points in the first and second follow-up periods, respectively, compared with baseline. ConclusionsThe evidence, therefore, suggests that the timing of the pandemic and the related restrictions were associated with a decrease in the supply and consumption of milk from informal markets in Nairobi and a decrease in the food security of periurban consumers.

Use of digital media for family planning information by women and their social networks in Kenya: A qualitative study in peri-urban Nairobi.

Access to information about family planning (FP) continues to have financial, physical and social barriers among young women living in Kenya. This paper draws on social norms theory to explore how young women and their social networks access FP information on digital media (e.g., WhatsApp, websites). Qualitative phone interviews were conducted with 40 participants – young women, their partners and key influencers – in seven peri-urban wards in Nairobi, Kenya. Data were analyzed using thematic analysis. Findings suggested that young women, their partners and key influencers predominately accessed FP information online through their informal networks, but identified healthcare workers as the most trusted sources of FP information. In digital spaces, participants described being more comfortable sharing FP information as digital spaces allowed for greater privacy and reduced stigma to talk about FP openly. Our findings highlight the importance of digital media in disseminating FP information among young women and their networks, the differences in norms governing the acceptability to talk about FP online vs. in-person and the significance of targeting misinformation about FP in digital media spaces.

Gendered barriers and opportunities in Kenya's informal dairy sector: enhancing gender-equity in urban markets

Informal milk trading in peri-urban Nairobi plays a key role in supporting both livelihoods and nutrition, particularly among poor households. Gender dynamics affect who is involved in and benefits from milk trading. To better understand gendered constraints and opportunities in informal, peri-urban dairy marketing, a qualitative study was conducted in 2017 with 45 men and 50 women milk traders in Dagoretti, a peri-urban area of Nairobi, Kenya. The findings show that milk trading is more lucrative for older men than for women and younger men among the respondents. This article illustrates the differences between these women’s and men’s experiences as milk traders and explores the reasons behind these differences. It discusses the implications of the findings for agricultural research and development interventions that aim to enhance the sustainability and equity of the dairy sector.

Navigating family planning access during Covid-19: A qualitative study of young women’s access to information, support and health services in peri-urban Nairobi

The COVID-19 response has profoundly affected women’s access to family planning services in Kenya. While prior studies have shown how the COVID-19 response created barriers to accessing family planning (FP) services, less is known about how the pandemic affected the normative influence that partners, peers, and health providers exert on women’s FP choices. In this qualitative study, we interviewed 16 women (aged 18–25 years), 10 men in partnerships with women, and 14 people in women’s social networks across 7 low-income wards in Nairobi, Kenya. Our findings suggest that COVID-19 response measures changed the contexts of normative influence on FP: financial insecurity, increased time at home with husbands or parents, and limited access to seek the support of health workers, friends, and other people in their social network affected how women negotiated FP access and use within their homes. Our study underscores the importance of ensuring FP is an essential service in a pandemic, and of developing health programs that change norms about FP to address the gendered burden of negotiating FP during COVID-19 and beyond.

Influence of public policy planning on peri-urban land speculation in (Greater) Eastern Bypass in Nairobi Metropolitan

Land speculation accompanies public policy planning in infrastructure planning and development in urban and peri-urban areas. The aim of this paper is to assess how the planning of (Greater) Eastern Bypass in the peri-urban Nairobi led to an increase in speculative activities by examining land subdivision and transfer before and after public notification of the bypass development. Land subdivision data for the period 2005 and 2018 are analysed to establish change in land size, subdivision, transfer and ownership. Findings reveal that normal land speculation occur after public notification; whereas structural speculation occurs during preliminary and design review. Land speculation circumvents subdivision process leading to approval without due process. Infrastructure planning is both a political and institutional process where political class and government bureaucrats influence road alignment. There is therefore need for coupling transport-oriented development planning with overarching land use plan; backed by enforcement.

Vendor Characteristics, Practices, Microbial Contamination of Fish and Oil Quality in the Street Vending of Deep-fried Fish in Peri-urban Nairobi, Kenya: Case of Kasarani Sub-county

Aim: The main objective of the study is to assess the vendor and environmental hygiene, microbial contamination of deep-fried tilapia sold, and the quality of the oil used in the streets of Kasarani sub-county&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Kasarani Sub-county and The University of Nairobi Department of Food Science, Nutrition, and Technology laboratory between January 2019 to July 2020.&#x0D; Methodology: Structured questionnaires, checklists, analytical observations, and market observations were used to collect data from the street vendors. After the collection of the fish samples, microbial analysis of the fish samples was carried out using standard methods for Total coliforms and Staphylococcus aureus. The deep-frying oil was sampled for analysis of color and viscosity. Results were evaluated using national standards.&#x0D; Results: The findings indicated that all the vendors have received a basic education and that all vendors fall under the low-income group. The most contaminated part of the fish by Staphylococcus aureus and total coliforms is the gills. The highest contamination was from Clay city ward (2.46 ± 0.43) while the least contaminated was from the Mwiki ward (1.28 ± 1.17). The total coliforms and Staphylococcus aureus concentration are significantly different between wards p (&lt;0.05) as the p-value was 0.003 and 0.043 respectively.&#x0D; Conclusion: The findings indicate that the vending practices carried out are unsanitary. The fish as sold were contaminated with total coliforms and Staphylococcus aureus at high levels indicating poor hygiene procedures. The environment is characterized by poor sanitation and hygiene. The oil used for deep frying was characterized by dark color and high viscosity indicating prolonged usage of the same oil. Policies governing street vending and the environment should be reinforced to prevent the occurrence of hazards resulting from street vended fish.

Intra-Household Handling and Consumption Dynamics of Milk in Peri-Urban Informal Markets in Tanzania and Kenya: A Gender Lens

Milk, provided it is safe, provides important micronutrients that can combat hidden hunger (undernutrition). Many peri-urban poor people in Tanzania and Kenya use informal markets to purchase milk in order to provide nutritional benefits to their families. Household decision-making processes play an influential role in how much milk to buy and how it is treated. This exploratory qualitative study, conducted in peri-urban Nairobi and Dar es Salaam, examined how access to milk, control over milk handling and safety, and intra-household milk distribution are affected by gender dynamics and by changes in milk availability and price. Focus group discussions with 48 women and 45 men and key informant interviews with 8 men and 8 women, all of whom were parents or caretakers to young children, were conducted. The results indicate that gender roles in milk purchase and handling vary. Generally, providing enough milk is a man’s responsibility, whilst a woman is expected to ensure a nutritious diet. Yet women’s limited decision-making power regarding milk purchase can restrict their ability to provide sufficient milk. Interventions to promote safe milk consumption need to consider gender norms, strengthen intra-household collaborative decision-making, include men in nutrition programming, and increase women’s control over food expenditures.

Bypassing high-quality maternity facilities: evidence from pregnant women in peri-urban Nairobi.

Utilization of high-quality maternal care is an important link along the pathway from increased facility-based delivery to improved maternal health outcomes, however women in Nairobi do not all deliver in the highest quality facilities available to them. We explored whether women living in peri-urban Nairobi who live nearby to high-quality facilities bypassed, or travelled farther than, their nearest high technical quality facility using survey data collected before and after delivery from women (n = 358) and from facility assessments (n = 59). We defined the nearest high technical quality facility as the nearest Comprehensive Emergency Obstetric and Newborn Care (CEmONC) capable facility to each woman's neighbourhood. We compared women who delivered in their nearest CEmONC (n = 44) to women who bypassed their nearest CEmONC to deliver in a facility that was farther away (n = 200). Among bypassers, 131 (65.5%) women delivered in farther non-CEmONC facilities with lower technical quality and 69 (34.5%) delivered in farther CEmONCs with higher technical quality capacity compared to their nearby CEmONCs. Bypassers rated their delivery experience higher than non-bypassers. Women who bypassed to deliver in non-CEmONCs were less likely to have completed four antenatal care visits and to consider delivering in any CEmONC prior to delivery while women who bypassed to deliver in farther CEmONCs paid more for delivery and were more likely to report being able to access emergency funds compared to non-bypassers. Our findings suggest that women in peri-urban Nairobi bypassed their nearest CEmONC facilities in favour of delivering in facilities that provided better non-technical quality care. Bypassers with access to financial resources were also able to deliver in facilities with higher technical quality care. Policies that improve women's delivery experience and ensure that information about facility technical quality is widely distributed may be critical to increase the utilization of high-quality maternity facilities.

Molecular prevalence of emerging Anaplasma and Ehrlichia pathogens in apparently healthy dairy cattle in peri-urban Nairobi, Kenya

BackgroundAnaplasma and Ehrlichia species are tick-borne pathogens of both veterinary and public health importance. The current status of these pathogens, including emerging species such as Ehrlichia minasensis and Anaplasma platys, infecting cattle in Kenya, remain unclear, mainly because of limitation in the diagnostic techniques. Therefore, we investigated the Anaplasma and Ehrlichia species infecting dairy cattle in Nairobi, Kenya using molecular methods.ResultsA total of 306 whole blood samples were collected from apparently healthy dairy cattle. Whole blood DNA was extracted and tested for presence of Anaplasma and Ehrlichia DNA through amplification and sequencing of the 16S rDNA gene. Sequence identity was confirmed using BLASTn analysis while phylogenetic reconstruction was performed to determine the genetic relationship between the Kenyan isolates and other annotated genotypes available in GenBank. Anaplasma and Ehrlichia species were detected in 19.9 and 3.3% of all the samples analyzed, respectively. BLASTn analysis of the sequences against non-redundant GenBank nucleotide database revealed infections with A. platys (44.8%), A. marginale (31%) and A. bovis (13.8%). All four sequenced Ehrlichia spp. were similar to Ehrlichia minasensis. Nucleotide polymorphism was observed for A. platys, A. bovis and E. minasensis. The Anaplasma species clustered in four distinct phylogenetic clades including A. marginale, A. platys, A. bovis and some unidentified Anaplasma spp. The Kenyan Ehrlichia minasensis clustered in the same clade with isolates from America and Australia but distant from E. ruminantium.ConclusionThis study provides the first report of infection of dairy cattle in Kenya with A. platys and E. minasensis, which are emerging pathogens. We conclude that cattle in peri-urban Nairobi are infected with various species of Anaplasma and E. minasensis. To understand the extent of these infections in other parts of the country, large-scale screening studies as well as vector identification is necessary to inform strategic control.

Why do women deliver where they had not planned to go? A qualitative study from peri-urban Nairobi Kenya

BackgroundIn urban Kenya, couples face a wide variety of choices for delivery options; however, many women end up delivering in different facilities from those they had intended while pregnant. One potential consequence of this is delivering in facilities that do not meet minimum quality standards and lack the capacity to provide treatment for obstetric and neonatal complications.MethodsThis study investigated why women in peri-urban Nairobi, Kenya deliver in facilities they had not intended to use. We used 60 in-depth audio-recorded interviews in which mothers shared their experiences 2–6 months after delivery. Descriptive statistics were used to summarize socio-demographic characteristics of participants. Qualitative data were analyzed in three steps i) exploration and generation of initial codes; ii) searching for themes by gathering coded data that addressed specific themes; and iii) defining and naming identified themes. Verbatim excerpts from participants were provided to illustrate study findings. The Health Belief Model was used to shed light on individual-level drivers of delivery location choice.ResultsFindings show a confluence of factors that predispose mothers to delivering in unintended facilities. At the individual level, precipitate labor, financial limitations, onset of pain, complications, changes in birth plans, undisclosed birth plans, travel during pregnancy, fear of health facility providers, misconception of onset of labor, wrong estimate of delivery date, and onset of labor at night, contributed to delivery at unplanned locations. On the supply side, the sudden referral to other facilities, poor services, wrong projection of delivery date, and long distance to chosen delivery facility, were factors in changes in delivery location. Lack of transport discouraged delivery at a chosen health facility. Social influences included others’ perspectives on delivery location and lack of aides/escorts.ConclusionsResults from this study suggest that manifold factors contribute to the occurrence of women delivering in facilities that they had not intended during pregnancy. Future studies should consider whether these changes in delivery location late in pregnancy contribute to late facility arrival and the use of lower quality facilities. Deliberate counseling during antenatal care regarding birth plans is likely to encourage timely arrival at facilities consistent with women’s preferences.

The role of livestock products for nutrition in the first 1,000 days of life.

Dietary patterns across the world are extremely diverse, with diets of most people in low- and middle-income countries being suboptimal from a nutritional standpoint. It is in these countries that the highest levels of undernutrition are recorded, with children being the most affected. Although stunting (i.e., children short for their age) rates are declining globally and regionally, significant disparities in such rates exist between and within countries. Moreover, the absolute number of stunted children in Africa continues to increase (Development Initiatives, 2018). Iron-deficient anemia has risen to 32.8% globally and nutrient intakes are typically deficient in poor settings. Poor people in poor countries often subsist on suboptimal diets based on cheap staples and have limited access to nutrient-dense foods such as pulses, fruit, or meat (Murphy and Allen, 2003; Thompson and Meerman, 2010; Muhihi et al., 2012). As a result of these circumstances, individuals do not receive sufficient nutrient intakes to sustain optimal well-being. Some research has shown that it is not unusual to begin feeding children livestock-derived food (particularly milk) before 6 mo of age when they should be exclusively breastfeeding (Micere et al., 2016). With that said, recent surveys confirmed that almost 40% of children above 6 mo living in informal settlements in peri-urban Nairobi did not consume cow’s milk daily. Furthermore, meat and other livestock-derived products were each eaten by less than 5% of these children and only in very small amounts (Grace et al., 2018). This is not an uncommon reality in Africa. Over the past decades, investments have been made to address the various forms of undernutrition present in many countries across the world. The shift from food security (access to enough food) to nutrition security (access to enough nutritious food) has prompted the development of interventions to increase nutrient intake. These interventions include food fortification as a means to improving the nutrient content of diets. Little attention has been given, however, to the specific role of livestock products such as meat, milk, and eggs (and their derived products) on nutrition and their potential to help achieve nutrition security goals. Media outlets in recent years, primarily in high-income countries, have increasingly been flooded with reports that are critical of the role of meat, in particular, and livestock-derived foods (e.g., milk and eggs), in general, as part of diets. Their environmental footprint, as well as their suggested negative effects on health, are ostensible arguments used to promote a shift to diets containing little to no animal-sourced foods. Environmental and sustainability concerns exist related to livestock production that require serious reflection relative to the evolution of farming systems and dietary patterns in industrialized countries (Willett et al., 2019). Underlying this may be more fundamental and immutable concerns over the use of animals (Perry and Grace, 2015). Nonetheless, in many low- and middle-income countries, the livestock sector is a key contributor to national economies (representing between 15% and 80% of agricultural domestic product) and represents a potential pathway out of poverty and an essential livelihood for millions of people (World Economic Forum, 2019). In countries where high volumes of livestock production accompany important undernutrition problems, it would represent a significant missed opportunity to not harvest livestock-derived food products to optimize the nutrition of the most vulnerable. This article will summarize the current state of knowledge on the role of livestock products for nutrition, with emphasis on the first 1,000 d of life for individuals living in low-income countries. The nutritional importance of livestock products, the evidence base for their impact on health and nutrition, and the major externalities concerned with their production will be considered.

Implementing the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in peri-urban Nairobi, Kenya: Provider experiences, uptake and clinical decision-making.

BackgroundPerinatal and newborn complications are major risk factors for unfavorable fetal and neonatal outcomes. Gestational dating and growth monitoring can be instrumental in the identification and management of high-risk pregnancies and births. The INTERGROWTH-21st Project developed the first global standards for gestational dating and fetal and newborn growth monitoring, supplying a toolkit for clinicians. This study aimed to assess the feasibility and acceptability of the first known implementation study of these standards in a low resource setting.MethodsThe study was performed in two 12-month phases from March 2016 to March 2018 at Jacaranda Health, a private maternity hospital in peri-urban Nairobi, Kenya. In-depth interviews, focus group discussions and a provider survey were utilized to evaluate providers’ experiences during implementation. Client chart data, for pregnant women attending antenatal care and/or delivering at Jacaranda Health along with their newborns, were captured to assess uptake and effect of the standards on clinical decision-making.ResultsFacility-level support and provider buy-in proved to be critical factors driving the success of implementing the standards. However, additional support was needed to strengthen capacity to conduct and interpret ultrasounds and maintain motivation among providers. We observed a significant increase in the uptake of obstetric ultrasounds, particularly gestational dating, during the implementation of the standards. Although no significant changes were detected in the identification of high-risk pregnancies, referrals and deliveries by Cesarean section during implementation, we did observe a significant reduction in inductions for post-date. No significant barriers were reported regarding the use of the newborn standards. Over 80% of providers advocated for the standards to remain in place with some enhancements related mainly to training, advocacy and procurement.ConclusionsThe findings are timely with increasing global adoption of the standards and the challenging and multi-faceted nature of translating new, evidence-based guidelines into routine clinical practice.

Occurrence of aflatoxin M1 in raw milk traded in peri-urban Nairobi, and the effect of boiling and fermentation

ABSTRACTBackground: Dairy production in Kenya is important and dominated by small-holder farmers who market their produce through small-scale traders in the informal sector.Method: This study aimed to determine the prevalence of aflatoxin (AFM1) in informally marketed milk in peri-urban Nairobi, Kenya, and to assess knowledge of milk traders on aflatoxins using questionnaires. A total of 96 samples were analyzed for AFM1 using enzyme-linked immunosorbent assay. In addition, boiling and fermentation experiments were carried out in the laboratory.Results: All samples had AFM1 above the limit of detection (5 ng/kg) (mean of 290.3 ± 663.4 ng/kg). Two-thirds of the samples had AFM1 levels above 50 ng/kg and 7.5% of the samples exceeded 500 ng/kg. Most of the traders had low (69.8%) or medium (30.2%) knowledge. Educated (p = 0.01) and female traders (p= 0.04) were more knowledgeable. Experimentally, fermenting milk to lala (a traditional fermented drink) and yogurt significantly reduced AFM1 levels (p< 0.01) (71.8% reduction in lala after incubation at room temperature for 15 h, and 73.6% reduction in yogurt after incubation at 45ºC for 4h). Boiling had no effect.Conclusion: The study concluded that the prevalence of raw milk with AFM1 was high, while knowledge was low. Fermentation reduced the AFM1 levels.

P08.02: Implementing INTERGROWTH‐21st standards in peri‐urban Nairobi, Kenya: translating global guidelines into clinical practice in a low‐resource setting

Growth restricted infants face the greatest risk of death and disability and detection of in-utero growth restriction can aid in early intervention. Accurate gestational dating, through a combination of last menstrual period and ultrasound (U/S), is the foundation of successful monitoring. However, few low-resource facilities or providers are equipped with the tools to successfully determine gestational age and accurately assess fetal growth. The recent INTERGROWTH-21st project produced a set of screening tools to combat these challenges. The tools include methods for accurate gestational dating, and detection of fetal/newborn growth disturbances by utilising routine prenatal U/S. Our study explores the acceptability and feasibility of implementing the INTERGROWTH-21st U/S standards over a one-year period at Jacaranda Health, a hospital that serves low and middle-income women in peri-urban Nairobi providing high quality affordable maternity care. Our implementation study included a six-month preimplementation phase which entailed procurement of supplies, updating ANC protocols to include gestational dating U/S, updating U/S forms to capture new parameters and training providers in U/S techniques. This was followed by a one-year implementation/observation phase. The acceptability and feasibility of implementation was assessed by using qualitative and quantitative clinical indicators. We will report on nurse/sonographer perceptions of the feasibility and acceptability of introducing new U/S techniques and tools for gestational dating. We will also report quantitative indicators of fidelity to the new protocol based on uptake of gestational dating U/S and completeness of documentation. As we navigate the successes and challenges related to implementing the INTERGROWTH-21st U/S tools into JH, we hope to contribute to a wider discussion regarding improvements in accurate gestational dating and fetal and newborn growth, specifically in other low resource settings. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

INTERGROWTH-21st Gestational Dating and Fetal and Newborn Growth Standards in Peri-Urban Nairobi, Kenya: Quasi-Experimental Implementation Study Protocol.

BackgroundThe burden of preterm birth, fetal growth impairment, and associated neonatal deaths disproportionately falls on low- and middle-income countries where modern obstetric tools are not available to date pregnancies and monitor fetal growth accurately. The INTERGROWTH-21st gestational dating, fetal growth monitoring, and newborn size at birth standards make this possible.ObjectiveTo scale up the INTERGROWTH-21st standards, it is essential to assess the feasibility and acceptability of their implementation and their effect on clinical decision-making in a low-resource clinical setting.MethodsThis study protocol describes a pre-post, quasi-experimental implementation study of the standards at Jacaranda Health, a maternity hospital in peri-urban Nairobi, Kenya. All women with viable fetuses receiving antenatal and delivery services, their resulting newborns, and the clinicians caring for them from March 2016 to March 2018 are included. The study comprises a 12-month preimplementation phase, a 12-month implementation phase, and a 5-month post-implementation phase to be completed in August 2018. Quantitative clinical and qualitative data collected during the preimplementation and implementation phases will be assessed. A clinician survey was administered eight months into the implementation phase, month 20 of the study. Implementation outcomes include quantitative and qualitative analyses of feasibility, acceptability, adoption, appropriateness, fidelity, and penetration of the standards. Clinical outcomes include appropriateness of referral and effect of the standards on clinical care and decision-making. Descriptive analyses will be conducted, and comparisons will be made between pre- and postimplementation outcomes. Qualitative data will be analyzed using thematic coding and compared across time. The study was approved by the Amref Ethics and Scientific Review Committee (Kenya) and the Harvard University Institutional Review Board. Study results will be shared with stakeholders through conferences, seminars, publications, and knowledge management platforms.ResultsFrom October 2016 to February 2017, over 90% of all full-time Jacaranda clinicians (26/28) received at least one of the three aspects of the INTERGROWTH-21st training: gestational dating ultrasound, fetal growth monitoring ultrasound, and neonatal anthropometry standards. Following the training, implementation and evaluation of the standards in Jacaranda Health’s clinical workflow will take place from March 2017 through March 5, 2018. Data analysis will be finalized, and results will be shared by August 2018.ConclusionsThe findings of this study will have major implications on the national and global scale up of the INTERGROWTH-21st standards and on the process of scaling up global standards in general, particularly in limited-resource settings.Registered Report IdentifierRR1-10.2196/10293