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Background The competence and confidence of midwives are pivotal in delivering essential care during pre-pregnancy, pregnancy, childbirth, and postpartum for women and their newborns. This study explored midwifery competency gaps in Kenya to recommend evidence-based policies, aiming to enhance maternal and neonatal health outcomes and inform future interventions. Methods This study utilised a sequential explanatory study design which includes integrating quantitative and qualitative approaches of data collection, analysis, and synthesis. The quantitative phase involved a cross-sectional survey assessing midwives’ competence and confidence based on the International Confederation of Midwives (ICM) domains. 2019. The qualitative phase consisted of interviews with midwives and stakeholders to further explore and elucidate the quantitative findings. Sampling, interpretation, and reporting were integrated throughout the design. Data collection occurred in two distinct phases: an initial quantitative survey followed by qualitative interviews using a qualitative descriptive explanatory design with selected midwives and stakeholders. Qualitative data was coded and analyzed using Atlas ti 9 software. Thematic analysis, based on the Colaizzi framework, was conducted to capture emerging meanings while preserving the essence presented by the informants. Quantitative data were analyzed using SPSS, with descriptive statistics and statistical significance tested using Pearson’s Chi-square and Kruskal-Wallis tests. Both qualitative and quantitative data were analyzed separately and then connected to explain the results, ensuring triangulation and complementarity for comprehensive insights. Results Direct-entry diploma midwives (KRM) and those working in tertiary hospitals reported higher competence and confidence ( P  = 0.019, p  < 0.001, Kruskal-Wallis). KRMs were more confident in the ICM labour and birth domain ( p  = 0.017). Qualitative analysis revealed four themes: qualifications, enabling environment, work experience, and optimizing midwifery. Findings suggest that direct entry midwifery programs’ duration and education significantly impact midwives’ skill development. Mentorship and clinical supervision enhanced midwives’ confidence in labour and delivery domains. No statistical correlation was found between competence and work experience, but qualitative findings highlighted the importance of continuous professional development, clinical teaching, and supervision. An enabling working environment with appropriate resources, guidelines, and a multi-disciplinary team of obstetrics experts supported the high competence and confidence levels of midwives in tertiary care. Conclusion This study identifies midwifery competency gaps in Kenya and recommends strengthening continuous professional development, clinical teaching, and supervision to improve maternal and newborn outcomes. It fills a knowledge gap by exploring midwives’ self-perceived competence and confidence levels in various domains of International Confederation of Midwives (ICM) competency through a sequential explanatory study design.

Low and middle-income countries have a greater share of the cervical cancer burden, but lower screening coverage, compared to high-income countries. Moreover, screening uptake and disease outcomes are generally worse in rural areas as well as in the HIV positive population. Efforts directed at increasing the screening rates are important in order to decrease cancer-related morbidity and mortality. This study aimed to explore the barriers to women with HIV accessing cervical cancer screening in Kgatleng district, Botswana. A phenomenological qualitative study utilising semi-structured interviews with fourteen HIV positive women, selected by purposive sampling. The interviews were transcribed verbatim and the 5-steps of the framework method, assisted by Atlas-ti software, was used for qualitative data analysis. Contextual factors included distance, public transport issues and work commitments. Health system factors highlighted unavailability of results, inconsistent appointment systems, long queues and equipment shortages and poor patient-centred communication skills, particularly skills in explanation and planning. Patient factors identified were lack of knowledge of cervical cancer, benefits of screening, effectiveness of treatment, as well as personal fears and misconceptions. Cervical cancer screening was poorly accessed due to a weak primary care system, insufficient health promotion and information as well as poor communication skills. These issues could be partly addressed by considering alternative technology and one-stop models of testing and treating.

The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.

Background Fragmentation in maternal healthcare contributes to preventable maternal deaths. Improving continuity and coordination can mitigate this issue by influencing interactions among providers, interdisciplinary teams, and patient-provider relationships. The obstetric near-miss approach has the potential to offer insights into continuity and coordination in maternal health. The aim of this study was to explore the perspectives of near-miss survivors and health care professionals on continuity and coordination of care in a primary health care system in Uasin Ngishu region, Kenya. Methods This was a descriptive qualitative single case study. Data was collected through individual interviews, focus group discussions, and observation. Results Four deductively identified themes emerged: sequential coordination, continuity, parallel coordination, and access. Sequential coordination was influenced by antagonistic relationships between healthcare providers in primary care facilities and the main referral hospital. Longitudinal and interpersonal continuity were driven by positive interactions between women and healthcare providers, characterized by availability, willingness to listen, and addressing personal issues. Parallel coordination was affected by heavy workloads and ineffective task shifting within primary care facilities. Finally, access-related issues included accommodation strategies such as telephone hotlines for pregnant women, out-of-pocket payments for specialist consultation, and alternative referral pathways different from the formal pathways in the health system. Conclusion To promote continuity and coordination in primary health care for pregnant women, there is a need to focus on social competencies and skills among health care professionals providing obstetric care, encourage accommodation strategies in facilities, reduce or eliminate out-of-pocket payments for referred women, address attitude and professional conflicts among midwives at different levels in the referral pathway and address workloads and task shifting in primary care facilities. Plain language summary What was the aim of this study? To reduce the chances of mothers dying during childbirth, healthcare providers need to actively manage specific complications such as bleeding after birth, pre-eclampsia, eclampsia, difficult labor, preterm labor, and newborn infections. However, dealing with these priority issues will not work well if different healthcare providers, levels of care and teams of experts do not work together. This involves promoting therapeutic relationships between pregnant women and their healthcare providers (interpersonal continuity) and making sure that a pregnant woman visits the same provider across pregnancy (longitudinal continuity). With regard to health providers who attend to pregnant women, they should collaborate effectively within the same facility, for example, during emergencies (parallel coordination) as well as during referral (sequential coordination). In this study, we interviewed women who had a near-death experience during pregnancy, labor, or delivery to gain insights into how their relationship with healthcare providers and antenatal visitation practices may have influenced their near-death experience. Likewise, we interviewed healthcare providers in health centers to gather information on how the coordination (or lack thereof) in their care could contribute to women experiencing a near-death event. What are the main findings of this study? Women reported that they were more satisfied when health providers were available, listened to them and addressed their personal concerns. However, this was only possible if the woman visited the same provider over time. Another theme we identified is sequential coordination, or how well different healthcare providers collaborated in a step-by-step manner. We found that relationships between healthcare providers in primary care facilities and the main referral hospital was not always cooperative and sometimes even adversarial – which led to delays and ineffective management of emergencies. The way tasks are distributed and managed within healthcare facilities has an implication on coordination of care. For example, when midwives delegate duties to non-professional staff such as cleaners. Strategies such as telephone hotlines were instrumental for maintaining contact between the providers and pregnant women (longitudinal continuity). Other findings such as out-of-pocket payments for specialist consultations, and the exploration of alternative referral pathways outside the formal channels in the health system promoted continuity and coordination. What are the implications for practice? Adopting models that promote therapeutic relationships between women and their providers may increase women’s satisfaction with care during pregnancy. Midwifery-led continuity models, as well as group antenatal visits, have been proposed. There is a need to address professional conflicts among midwives working at various levels in the referral system so that emergencies can be attended to quickly and effectively. Implementing strategies to make facilities more accommodating, such as flexible scheduling or toll free hotlines can keep women in constant touch with their providers. Within lower level facilities, finding ways to manage the workload efficiently and ensuring that tasks are appropriately distributed among healthcare professionals will promote coordination.  In lower middle-income countries such as Kenya, reducing or eliminating out-of-pocket payments for women referred to other healthcare facilities can improve access to necessary services and prevent complications that arise during labor and birth.

Recent studies have described the burden of disease in South Africa. However these studies do not tell us which of these conditions commonly present to primary care providers, how these conditions may present and how providers make sense of them in terms of their diagnoses. Clinical nurse practitioners are the main primary care providers and need to be better prepared for this role. This study aimed to determine the range and prevalence of reasons for encounter and diagnoses found among ambulatory patients attending public sector primary care facilities in South Africa. The study was a multi-centre prospective cross-sectional survey of consultations in primary care in four provinces of South Africa: Western Cape, Limpopo, Northern Cape and North West. Consultations were coded prior to analysis by using the International Classification of Primary Care-Version 2 in terms of reasons for encounter (REF) and diagnoses. Altogether 18856 consultations were included in the survey and generated 31451 reasons for encounter (RFE) and 24561 diagnoses. Women accounted for 12526 (66.6%) and men 6288 (33.4%). Nurses saw 16238 (86.1%) and doctors 2612 (13.9%) of patients. The top 80 RFE and top 25 diagnoses are reported and ongoing care for hypertension was the commonest RFE and diagnosis. The 20 commonest RFE and diagnoses by age group are also reported. Ambulatory primary care is dominated by non-communicable chronic diseases. HIV/AIDS and TB are common, but not to the extent predicted by the burden of disease. Pneumonia and gastroenteritis are commonly seen especially in children. Women's health issues such as family planning and pregnancy related visits are also common. Injuries are not as common as expected from the burden of disease. Primary care providers did not recognise mental health problems. The results should guide the future training and assessment of primary care providers.

This article is part of the series on African primary care research and focuses on participatory action research. The article gives an overview of the emancipatory-critical research paradigm, the key characteristics and different types of participatory action research. Following this it describes in detail the methodological issues involved in professional participatory action research and running a cooperative inquiry group. The article is intended to help students with writing their research proposal.

Background Despite extensive evidence on the magnitude of intimate partner violence (IPV) as a public health problem worldwide, insubstantial progress has been made in the development and implementation of sufficiently comprehensive health services. This study aimed to implement, evaluate and adapt a published protocol for the screening and management of IPV and to recommend a model of care that could be taken to scale in our underdeveloped South African primary health care system. Methods Professional action research utilised a co-operative inquiry group that consisted of four nurses, one doctor and a qualitative researcher. The inquiry group implemented the protocol in two urban and three rural primary care facilities. Over a period of 14 months the group reflected on their experience, modified the protocol and developed recommendations on a practical but comprehensive model of care. Results The original protocol had to be adapted in terms of its expectations of the primary care providers, overly forensic orientation, lack of depth in terms of mental health, validity of the danger assessment and safety planning process, and need for ongoing empowerment and support. A three-tier model resulted: case finding and clinical care provision by primary care providers; psychological, social and legal assistance by ‘IPV champions’ followed by a group empowerment process; and then ongoing community-based support groups. Conclusion The inquiry process led to a model of comprehensive and intersectoral care that is integrated at the facility level and which is now being piloted in the Western Cape, South Africa.

CliMigHealth and the Education for Sustainable Healthcare (ESH) Special Interest Group of the Southern African Association of Health Educationalists (SAAHE) call for the urgent integration of planetary health (PH) and environmental sustainability into health professions curricula in Africa. Education on PH and sustainable healthcare develops much-needed health worker agency to address the connections between healthcare and PH. Faculties are urged to develop their own ‘net zero’ plans and to advocate for national and sub-national policies and practices that promote the Sustainable Development Goals (SDGs) and PH. National education bodies and health professional societies are urged to incentivise innovation in ESH and to provide discussion forums and resources to support the integration of PH into curricula.ContributionThis article provides a position statement for integrating planetary health and environmental sustainability into African health professions education curricula.

This is the first in a series of articles on primary care research in the African context. The aim of the series is to help build capacity for primary care research amongst the emerging departments of family medicine and primary care on the continent. Many of the departments are developing Masters of Medicine programmes in Family Medicine and their students will all be required to complete research studies as part of their degree. This series is being written with this audience in particular in mind – both the students who must conceptualise and implement a research project as well as their supervisors who must assist them.This article gives an overview of the African primary care context, followed by a typology of primary care research. The article then goes on to assist the reader with choosing a topic and defining their research question. Finally the article addresses the structure and contents of a  research proposal and the ethical issues that should be considered.

BackgroundThe near-miss approach assumes that mothers facing life-threatening conditions such as severe pre-eclampsia and postpartum haemorrhage share common risk factors. Among these women, those who survive (near-miss cases) can offer insights into the determinants, providing valuable lessons for understanding underlying factors.AimTo investigate elements of continuity and coordination leading to obstetric near misses.SettingA major referral hospital and its referral pathway in Kenya.MethodsExplanatory sequential mixed-methods design.ResultsNear-miss survivors had lower continuity and coordination of care indices during antenatal visits (COCI = 0.80, p = 0.0026), (modified continuity of care index [MCCI] = 0.62, p = 0.034), and those with non-life-threatening morbidity in the first trimester were more likely to experience a near miss (aOR = 4.34, p = 0.001). Facilities in the western region had a higher burden of near misses compared to the Eastern region. Qualitatively, three deductive themes were identified: sequential coordination, parallel coordination and continuity, along with factors classified as access. In mixed integration, poor continuity indices were explained by quality of interpersonal relationships and woman centredness. Poor coordination was explained by inadequate teamwork between providers in referring and referral facilities and between primary health facilities and the community. Higher near-miss rates in the western region resulted from differences in human and physical resources.ConclusionPromoting woman-centred care, teamwork, improving communication and introducing innovative coordination roles like case and care managers can enhance continuity and coordination of maternal healthcare.ContributionsThis study contributes to our understanding of the challenges of continuity and coordination in maternal healthcare in resource-poor settings by applying the WHO operationalisation of continuity and coordination using mixed methodology.