Showing papers in "Reproductive Health in 2017"

Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries

Abstract: Menstruation is a natural physiological process that requires proper management. Unlike other normal bodily processes, menstruation is linked with religious and cultural meanings that can affect the perceptions of young girls as well as the ways in which the adults in the communities around them respond to their needs. This review aims to answer the following questions: (1) how knowledgeable are adolescent girls in low- and middle-income countries about menstruation and how prepared are they for reaching menarche, (2) who are their sources of information regarding menstruation, (3) how well do the adults around them respond to their information needs, (4) what negative health and social effects do adolescents experience as a result of menstruation, and (5) how do adolescents respond when they experience these negative effects and what practices do they develop as a result? Using a structured search strategy, articles that investigate young girls’ preparedness for menarche, knowledge of menstruation and practices surrounding menstrual hygiene in LMIC were identified. A total of 81 studies published in peer-reviewed journals between the years 2000 and 2015 that describe the experiences of adolescent girls from 25 different countries were included. Adolescent girls in LMIC are often uninformed and unprepared for menarche. Information is primarily obtained from mothers and other female family members who are not necessarily well equipped to fill gaps in girls’ knowledge. Exclusion and shame lead to misconceptions and unhygienic practices during menstruation. Rather than seek medical consultation, girls tend to miss school, self-medicate and refrain from social interaction. Also problematic is that relatives and teachers are often not prepared to respond to the needs of girls. LMIC must recognize that lack of preparation, knowledge and poor practices surrounding menstruation are key impediments not only to girls’ education, but also to self-confidence and personal development. In addition to investment in private latrines with clean water for girls in both schools and communities, countries must consider how to improve the provision of knowledge and understanding and how to better respond to the needs of adolescent girls.

Discrimination against childbearing Romani women in maternity care in Europe: a mixed-methods systematic review

Abstract: Freedom from discrimination is one of the key principles in a human rights-based approach to maternal and newborn health. To review the published evidence on discrimination against Romani women in maternity care in Europe, and on interventions to address this. A systematic search of eight electronic databases was undertaken in 2015 using the terms “Roma” and “maternity care”. A broad search for grey literature included the websites of relevant agencies. Standardised data extraction tables were utilised, quality was formally assessed and a line of argument synthesis was developed and tested against the data from the grey literature. Nine hundred papers were identified; three qualitative studies and seven sources of grey literature met the review criteria. These revealed that many Romani women encounter barriers to accessing maternity care. Even when they are able to access care, they can experience discriminatory mistreatment on the basis of their ethnicity, economic status, place of residence or language. The grey literature revealed some health professionals held underlying negative beliefs about Romani women. There were no published research studies examining the effectiveness of interventions to address discrimination against Romani women and their infants in Europe. The Roma Health Mediation Programme is a promising intervention identified in the grey literature. There is evidence of discrimination against Romani women in maternity care in Europe. Interventions to address discrimination against childbearing Romani women and underlying health provider prejudice are urgently needed, alongside analysis of factors predicting the success or failure of such initiatives.

Mistreatment of women during childbirth in Abuja, Nigeria: a qualitative study on perceptions and experiences of women and healthcare providers

Abstract: Global efforts have increased facility-based childbirth, but substantial barriers remain in some settings. In Nigeria, women report that poor provider attitudes influence their use of maternal health services. Evidence also suggests that women in Nigeria may experience mistreatment during childbirth; however, there is limited understanding of how and why mistreatment this occurs. This study uses qualitative methods to explore women and providers’ experiences and perceptions of mistreatment during childbirth in two health facilities and catchment areas in Abuja, Nigeria. In-depth interviews (IDIs) and focus group discussions (FGDs) were used with a purposive sample of women of reproductive age, midwives, doctors and facility administrators. Instruments were semi-structured discussion guides. Participants were asked about their experiences and perceptions of, and perceived factors influencing mistreatment during childbirth. Thematic analysis was used to synthesize findings into meaningful sub-themes, narrative text and illustrative quotations, which were interpreted within the context of this study and an existing typology of mistreatment during childbirth. Women and providers reported experiencing or witnessing physical abuse including slapping, physical restraint to a delivery bed, and detainment in the hospital and verbal abuse, such as shouting and threatening women with physical abuse. Women sometimes overcame tremendous barriers to reach a hospital, only to give birth on the floor, unattended by a provider. Participants identified three main factors contributing to mistreatment: poor provider attitudes, women’s behavior, and health systems constraints. Moving forward, findings from this study must be communicated to key stakeholders at the study facilities. Measurement tools to assess how often mistreatment occurs and in what manner must be developed for monitoring and evaluation. Any intervention to prevent mistreatment will need to be multifaceted, and implementers should consider lessons learned from related interventions, such as increasing audit and feedback including from women, promoting labor companionship and encouraging stress-coping training for providers.

Meet us on the phone: mobile phone programs for adolescent sexual and reproductive health in low-to-middle income countries.

Abstract: mHealth as a technical area has seen increasing interest and promise from both developed and developing countries. While published research from higher income countries on mHealth solutions for adolescent sexual and reproductive health (SRH) is growing, there is much less documentation of SRH mHealth interventions for youth living in resource-poor settings. We conducted a global landscape analysis to answer the following research question: How are programs using mHealth interventions to improve adolescent SRH in low to middle income countries (LMICs)? To obtain the latest information about mHealth programs targeting youth SRH, a global call for project resources was issued in 2014. Information about approximately 25 projects from LMICs was submitted. These projects were reviewed to confirm that mobile phones were utilized as a key communication media for the program, that youth ages 10–24 were a prime target audience, and that the program used mobile phone features beyond one-on-one phone calls between youth and health professionals. A total of 17 projects met our inclusion criteria. Most of these projects were based in Africa (67%), followed by Eurasia (26%) and Latin America (13%). The majority of projects used mHealth as a health promotion tool (82%) to facilitate knowledge sharing and behavior change to improve youth SRH. Other projects (18%) used mHealth as a way to link users to essential SRH services, including family planning counseling and services, medical abortion and post-abortion care, and HIV care and treatment. There was little variation in delivery methods for SRH content, as two-thirds of the projects (70%) relied on text messaging to transmit SRH information to youth. Several projects have been adapted and scaled to other countries. Findings suggest that mHealth interventions are becoming a more common method to connect youth to SRH information and services in LMICs, and evidence is emerging that mobile phones are an effective way to reach young people and to achieve knowledge and behavior change. More understanding is needed about the challenges of data privacy and phone access, especially among younger adolescents, and the role that mHealth solutions for adolescent SRH should play in health programming for young people.

Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population.

Abstract: Person-centered reproductive health care is recognized as critical to improving reproductive health outcomes. Yet, little research exists on how to operationalize it. We extend the literature in this area by developing and validating a tool to measure person-centered maternity care. We describe the process of developing the tool and present the results of psychometric analyses to assess its validity and reliability in a rural and urban setting in Kenya. We followed standard procedures for scale development. First, we reviewed the literature to define our construct and identify domains, and developed items to measure each domain. Next, we conducted expert reviews to assess content validity; and cognitive interviews with potential respondents to assess clarity, appropriateness, and relevance of the questions. The questions were then refined and administered in surveys; and survey results used to assess construct and criterion validity and reliability. The exploratory factor analysis yielded one dominant factor in both the rural and urban settings. Three factors with eigenvalues greater than one were identified for the rural sample and four factors identified for the urban sample. Thirty of the 38 items administered in the survey were retained based on the factors loadings and correlation between the items. Twenty-five items load very well onto a single factor in both the rural and urban sample, with five items loading well in either the rural or urban sample, but not in both samples. These 30 items also load on three sub-scales that we created to measure dignified and respectful care, communication and autonomy, and supportive care. The Chronbach alpha for the main scale is greater than 0.8 in both samples, and that for the sub-scales are between 0.6 and 0.8. The main scale and sub-scales are correlated with global measures of satisfaction with maternity services, suggesting criterion validity. We present a 30-item scale with three sub-scales to measure person-centered maternity care. This scale has high validity and reliability in a rural and urban setting in Kenya. Validation in additional settings is however needed. This scale will facilitate measurement to improve person-centered maternity care, and subsequently improve reproductive outcomes.

Respectful maternity care in Ethiopian public health facilities

Abstract: Disrespect and abuse of women during institutional childbirth services is one of the deterrents to utilization of maternity care services in Ethiopia and other low- and middle-income countries This paper describes the prevalence of respectful maternity care (RMC) and mistreatment of women in hospitals and health centers, and identifies factors associated with occurrence of RMC and mistreatment of women during institutional labor and childbirth services This study had a cross sectional study design Trained external observers assessed care provided to 240 women in 28 health centers and hospitals during labor and childbirth using structured observation checklists The outcome variable, providers’ RMC performance, was measured by nine behavioral descriptors The outcome, any mistreatment, was measured by four items related to mistreatment of women: physical abuse, verbal abuse, absence of privacy during examination and abandonment We present percentages of the nine RMC indicators, mean score of providers’ RMC performance and the adjusted multilevel model regression coefficients to determine the association with a quality improvement program and other facility and provider characteristics Women on average received 59 (66%) of the nine recommended RMC practices Health centers demonstrated higher RMC performance than hospitals At least one form of mistreatment of women was committed in 36% of the observations (38% in health centers and 32% in hospitals) Higher likelihood of performing high level of RMC was found among male vs female providers ( $$ \widehat{\beta}=065 $$ , p = 0012), midwives vs other cadres ( $$ \widehat{\beta} = 088 $$ , p = 0002), facilities implementing a quality improvement approach, Standards-based Management and Recognition (SBM-R©) ( $$ \widehat{\beta}=131 $$ , p = 0003), and among laboring women accompanied by a companion $$ \widehat{\beta} = 099 $$ , p = 0003) No factor was associated with observed mistreatment of women Quality improvement using SBM-R© and having a companion during labor and delivery were associated with RMC Policy makers need to consider the role of quality improvement approaches and accommodating companions in promoting RMC More research is needed to identify the reason for superior RMC performance of male providers over female providers and midwives compared to other professional cadre, as are longitudinal studies of quality improvement on RMC and mistreatment of women during labor and childbirth services in public health facilities

Methods used in prevalence studies of disrespect and abuse during facility based childbirth: lessons learned

Abstract: Several recent studies have attempted to measure the prevalence of disrespect and abuse (D&A) of women during childbirth in health facilities. Variations in reported prevalence may be associated with differences in study instruments and data collection methods. This systematic review and comparative analysis of methods aims to aggregate and present lessons learned from published studies that quantified the prevalence of Disrespect and Abuse (D&A) during childbirth. We conducted a systematic review of the literature in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Five papers met criteria and were included for analysis. We developed an analytical framework depicting the basic elements of epidemiological methodology in prevalence studies and a table of common types of systematic error associated with each of them. We performed a head-to-head comparison of study methods for all five papers. Using these tools, an independent reviewer provided an analysis of the potential for systematic error in the reported prevalence estimates. Sampling techniques, eligibility criteria, categories of D&A selected for study, operational definitions of D&A, summary measures of D&A, and the mode, timing, and setting of data collection all varied in the five studies included in the review. These variations present opportunities for the introduction of biases – in particular selection, courtesy, and recall bias – and challenge the ability to draw comparisons across the studies’ results. Our review underscores the need for caution in interpreting or comparing previously reported prevalence estimates of D&A during facility-based childbirth. The lack of standardized definitions, instruments, and study methods used to date in studies designed to quantify D&A in childbirth facilities introduced the potential for systematic error in reported prevalence estimates, and affected their generalizability and comparability. Chief among the lessons to emerge from comparing methods for measuring the prevalence of D&A is recognition of the tension between seeking prevalence measures that are reliable and generalizable, and attempting to avoid loss of validity in the context where the issue is being studied.

Are men well served by family planning programs

Abstract: Although the range of contraceptives includes methods for men, namely condoms, vasectomy and withdrawal that men use directly, and the Standard Days Method (SDM) that requires their participation, family planning programming has primarily focused on women. What is known about reaching men as contraceptive users? This paper draws from a review of 47 interventions that reached men and proposes 10 key considerations for strengthening programming for men as contraceptive users. A review of programming shows that men and boys are not particularly well served by programs. Most programs operate from the perspective that women are contraceptive users and that men should support their partners, with insufficient attention to reaching men as contraceptive users in their own right. The notion that family planning is women’s business only is outdated. There is sufficient evidence demonstrating men’s desire for information and services, as well as men’s positive response to existing programming to warrant further programming for men as FP users. The key considerations focus on getting information and services where men and boys need it; addressing gender norms that affect men’s attitudes and use while respecting women’s autonomy; reaching adolescent boys; including men as users in policies and guidelines; scaling up successful programming; filling gaps with implementation research and monitoring & evaluation; and creating more contraceptive options for men.

Delayed initiation of antenatal care and associated factors in Ethiopia: a systematic review and meta-analysis.

Abstract: Antenatal care uptake is among the key indicators for monitoring the progress of maternal outcomes. Early initiation of antenatal care facilitates the timely management and treatment of pregnancy complications to reduce maternal deaths. In Ethiopia, antenatal care utilization is generally low, and delayed initiation of care is very common. We aimed to systematically identify and synthesize available evidence on delayed initiation of antenatal care and the associated factors in Ethiopia. Studies published in English from 1 January 2002 to 30 April 2017 were systematically searched from PubMed, Medline, EMBASE, CINAHL and other relevant sources. Two authors independently reviewed the identified studies against the eligibility criteria. The included studies were critically appraised using the Joanna Briggs-MAStARI instrument for observational studies. Meta-analysis was conducted in RevMan v5.3 for Windows using a Mantel–Haenszel random effects model. The presence of statistical heterogeneity was checked using the Cochran Q test, and its level was quantified using the I2 statistics. Pooled estimate of the proportion of the outcome variable was calculated. Pooled Odd Ratios with 95% CI were calculated to measure the effect sizes. The pooled magnitude of delayed antenatal care in Ethiopia was 64% (95% CI: 57%, 70%). Maternal age (OR = 0.70; 95% CI: 0.53, 0.93), place of residence (OR = 0.29, 95% CI: 0.16, 0.50), maternal education (OR = 0.49; 95% CI: 0.38, 0.63), husband’s education (OR = 0.44; 95% CI: 0.23, 0.85), maternal occupation (OR = 0.75; 95% CI: 0.61, 0.93), monthly income (OR = 2.06; 95% CI: 1.23, 3.45), pregnancy intention (OR = 0.49; 95% CI: 0.40, 0.60), parity (OR = 0.46; 95% CI: 0.36, 0.58), knowledge of antenatal care (OR = 0.40; 95% CI: 0.32, 0.51), women’s autonomy (OR = 0.38; 95% CI: 0.15, 0.94), partner involvement (OR = 0.24; 95% CI: 0.07, 0.75), pregnancy complications (OR = 0.23; 95% CI: 0.06, 0.95), and means of identifying pregnancy (OR = 0.50; 95% CI: 0.36, 0.69) were significantly associated with delayed antenatal care. Improving female education and women’s empowerment through economic reforms, strengthening family planning programs to reduce unintended pregnancy and promoting partner involvement in pregnancy care could reduce the very high magnitude of delayed antenatal care in Ethiopia. CRD42017064585 .

Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation

Abstract: There is a need for a clear and actionable definition of maternal sepsis, in order to better assess the burden of this condition, trigger timely and effective treatment and allow comparisons across facilities and countries. The objective of this study was to review maternal sepsis definitions and identification criteria and to report on the results of an expert consultation to develop a new international definition of maternal sepsis. All original and review articles and WHO documents, as well as clinical guidelines providing definitions and/or identification criteria of maternal sepsis were included. A multidisciplinary international panel of experts was surveyed through an online consultation in March-April 2016 on their opinion on the existing sepsis definitions, including new definition of sepsis proposed for the adult population (2016 Third International Consensus Definitions for Sepsis and Septic Shock) and importance of different criteria for identification of maternal sepsis. The definition was agreed using an iterative process in an expert face-to-face consensus development meeting convened by WHO and Jhpiego. Standardizing the definition of maternal sepsis and aligning it with the current understanding of sepsis in the adult population was considered a mandatory step to improve the assessment of the burden of maternal sepsis by the expert panel. The literature review and expert consultation resulted in a new WHO consensus definition “Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, child-birth, post-abortion, or post-partum period”. Plans are in progress to validate the new WHO definition of maternal sepsis in a large international population. The operationalization of the new maternal sepsis definition requires generation of a set of practical criteria to identify women with sepsis. These criteria should enable clinicians to focus on the timely initiation of actionable elements of care (administration of antimicrobials and fluids, support of vital organ functions, and referral) and improve maternal outcomes.

Zika virus infection in pregnancy: a systematic review of disease course and complications

Abstract: To characterize maternal Zika virus (ZIKV) infection and complement the evidence base for the WHO interim guidance on pregnancy management in the context of ZIKV infection. We searched the relevant database from inception until March 2016. Two review authors independently screened and assessed full texts of eligible reports and extracted data from relevant studies. The quality of studies was assessed using the Newcastle-Ottawa Scale (NOS) and the National Institute of Health (NIH) tool for observational studies and case series/reports, respectively. Among 142 eligible full-text articles, 18 met the inclusion criteria (13 case series/reports and five cohort studies). Common symptoms among pregnant women with suspected/confirmed ZIKV infection were fever, rash, and arthralgia. One case of Guillain-Barre syndrome was reported among ZIKV-infected mothers, no other case of severe maternal morbidity or mortality reported. Complications reported in association with maternal ZIKV infection included a broad range of fetal and newborn neurological and ocular abnormalities; fetal growth restriction, stillbirth, and perinatal death. Microcephaly was the primary neurological complication reported in eight studies, with an incidence of about 1% among newborns of ZIKV infected women in one study. Given the extensive and variable fetal and newborn presentations/complications associated with prenatal ZIKV infection, and the dearth of information provided, knowledge gaps are evident. Further research and comprehensive reporting may provide a better understanding of ZIKV infection in pregnancy and attendant maternal/fetal complications. This knowledge could inform the creation of effective and evidence-based strategies, guidelines and recommendations aimed at the management of maternal ZIKV infection. Adherence to current best practice guidelines for prenatal care among health providers is encouraged, in the context of maternal ZIKV infection.

Measuring mistreatment of women during childbirth: a review of terminology and methodological approaches

Abstract: Although mistreatment of women during facility-based childbirth has received increasing recognition as a critical issue throughout the world, there remains a lack of consensus on operational definitions of mistreatment and best practices to assess the issue. Moreover, only minimal research has focused on mistreatment in Latin America and the Caribbean, a region notable for social inequalities and inequitable access to maternal health care. In this article, we discuss the results of a literature review that sought to contribute to the determination of best practices in defining and measuring the mistreatment of women during childbirth, particularly within Latin America and the Caribbean. The review includes a total of 57 English, Spanish, and Portuguese-language research publications and eight legal documents that were published between 2000 and 2017. While the typologies of “disrespect and abuse” and “mistreatment during facility-based childbirth” are most frequently employed in global studies, “obstetric violence” remains the most commonly operationalized term in Latin America and the Caribbean in both research and policy contexts. Various researchers have advocated for the use of those three different typologies, yet the terms all share commonalities in highlighting the medicalization of natural processes of childbirth, roots in gender inequalities, parallels with violence against women, the potential for harm, and the threat to women’s rights. For measuring mistreatment, half of the research publications in this review use qualitative methods, such as in-depth interviews and focus groups. After analyzing the strengths and limitations of quantitative, qualitative, and mixed methods approaches to assessing mistreatment, we recommend mixed methods designs as the optimal strategy to evaluate mistreatment and advocate for the inclusion of direct observations that may help bridge the gap between observed measures and participants’ self-reported experiences of mistreatment. No matter the conceptual framework used in future investigations, we recommend that studies seek to accomplish three objectives: (1) to measure the perceived and observed frequencies of mistreatment in maternal health settings, (2) to examine the macro and micro level factors that drive mistreatment, and (3) to assess the impact of mistreatment on the health outcomes of women and their newborns.

Ethnicity, gender and risky sexual behaviour among Nigeria youth: an alternative explanation.

Abstract: While studies in demography and public health have acknowledged the role of ethnic differences, the influence of ethnicity on youth sexual behaviour in Nigeria has received little or no attention. It is important to know how cultural norms and gender roles, which vary by ethnicity, may promote or prevent risky behaviour. Such information could provide insights into previously undetected sexual behaviour in multi-ethnic situations. The Nigeria Demographic and Health Surveys (NDHS) for 2003, 2008 and 2013 were pooled to examine the relationship between ethnicity and youth sexual reproductive health, proxied by age at sexual debut, multiple sexual partners (MSP) and condom use at last sexual activity, among the 6304 females and 1549 males who reported being sexually active in the four weeks preceding the survey. Multivariate analysis using a Cox proportional hazard regression model was used to determine the risk factors for early sexual activity among young people (15–24). Logistic regression was used to predict condom use at last sexual activity and MSP. The median age at first sexual activity was 16 for females and 17 for males. 43% of male youths used condoms in their last sexual activity, compared to only 16% among females and a higher number of males (81%) had multiple sexual partners compared to females (35%). For females, elevated risks of first sex was higher among Hausa/Fulanis aged 15–19 and elevated risk of first sex was higher among Yoruba males. This study provides further evidence that in order to promote protective sexual behaviours among youth in Nigeria, social, cultural and gender-specific tactics should be put in place for the prevention of HIV and other STIs.

Maternal health care service seeking behaviors and associated factors among women in rural Haramaya District, Eastern Ethiopia: a triangulated community-based cross-sectional study.

Abstract: Regular utilization of maternal health care services reduces maternal morbidity and mortality. This study assessed the maternal health care seeking behavior and associated factors of reproductive age women in rural villages of Haramaya district, East Ethiopia. Community based cross sectional study supplemented with qualitative data was conducted in Haramaya district from November 15 to Decemeber 30, 2015. A total of 561 women in reproductive age group and who gave birth in the last 2 years were randomly included. Bivariate and multivariate logistic regressions model was used to identify the associated factors. Odds ratios with 95% CI were used to measure the strength of association. Maternal health care service seeking of women was found as; antenatal care 74.3% (95% CI; 72.5, 76.14), attending institutional delivery 28.7% (95% CI; 26.8, 30.6) and postnatal care 22.6% (95% CI; 20.84, 24.36). Knowledge of pregnancy complications, Educational status, and religion of women were found to be significantly associated with antenatal health care, delivery and postnatal health care service seeking behaviours triangulated with individual, institutional and socio-cultural qualitative data. The maternal health care service seeking behavior of women in the study area was low. Educational status of the women, birth order and knowledge about pregnancy complications were the major factors associated with maternal health care service seeking behavior Focused health education with kind and supportive health care provider counseling will improve the maternal health care seeking behaviors of women.

Women's knowledge and associated factors in preconception care in adet, west gojjam, northwest Ethiopia: a community based cross sectional study.

Abstract: Preconception care is the provision of biomedical, behavioural and social health interventions to women and couples before the occurrence of conception to improve their health status. There is poor maternal and child health and lack of knowledge in developing countries about preconception care. Therefore, this study aimed to assess women’s knowledge and associated factors in preconception care in Adet Town, Gojjam, Northwestern Ethiopia. A community based cross-sectional study was conducted among 422 systematically selected reproductive age group women who are living in the Adet town from March 1 to 30, 2016. The data were collected using pre tested and structured questionnaires through face-to-face interviews. The data were entered into Epi-Info version 3.5, and cleaned and analysed using SPSS version 20. Descriptive summary of the data and logistic regression were used to identify possible predictors using odds ratio with 95% confidence interval and P-value of 0.05. The study revealed that the overall knowledge of preconception care was 27.5% (95% CI: 23.2, 32.0). Women who attended secondary educational and whose age is from 25 to 34 years were more likely to have better knowledge on preconception care than their counterparts were; (AOR 6.52, CI 2.55, 16.69) and (AOR 4.10, CI 1.78, 9.44) respectively. However, Women who had no history of family planning use were 85% less knowledgeable than those who had a history of family planning use (AOR: 0.15; 95% CI: 0.05, 0.44). In this finding level of women’s knowledge of preconception care is relatively low. Having a history of family planning use, having high levels of educational status, and being older age were associated with good knowledge. This finding suggests that there is a need to give emphasis and deliver health education about preconception care for women in order to increase their knowledge.

Reasons for unmet need for family planning, with attention to the measurement of fertility preferences: protocol for a multi-site cohort study

Abstract: Unmet need for family planning points to the gap between women’s reproductive desire to avoid pregnancy and contraceptive behaviour. An estimated 222 million women in low- and middle-income countries have unmet need for modern contraception. Despite its prevalence, there has been little rigorous research during the past fifteen years on reasons for this widespread failure to implement childbearing desires in contraceptive practice. There is demographic survey data on women’s self-reported reasons for non-use, but these data provide limited insight on the full set of possible obstacles to use, and one may doubt the meaningfulness of explanations provided by non-users alone. To rectify this evidence gap, this study will gather extensive information on women’s perceptions of contraception (generic and method-specific) and their past contraceptive experience, and it will allow for more complexity in fertility preferences than is standard in demographic surveys. A multi-site cohort study will be conducted in urban Kenya, rural Kenya, and rural Bangladesh. In each setting trained fieldworkers will recruit and interview 2600 women, with participants re-interviewed at 12 and 18 months. Data will be collected using a questionnaire whose development was informed by a review of existing literature and instruments from past studies in both developed and developing countries. Dozens of experts in the field were consulted as the instrument was developed. The questionnaire has three main components: a sub-set of Demographic and Health Survey items measuring socio-demographic characteristics, reproductive history, and sexual activity; additional questions on prospective and retrospective fertility preferences designed to capture ambivalence and uncertainty; and two large blocks of items on (i) generic concerns about contraception and (ii) method-specific attributes. The method-specific items encompass eight modern and traditional methods. Policy and programmes intended to reduce unmet need for contraception in developing countries should be informed by clear understanding of the causes of this phenomenon to better reflect the population needs and to more effectively target planning and investments. To this end, this study will field an innovative instrument in Kenya and Bangladesh. The information to be collected will support a rigorous assessment of reasons for unmet need for family planning.

Perceptions and experiences of the mistreatment of women during childbirth in health facilities in Guinea: a qualitative study with women and service providers

Abstract: Every woman is entitled to respectful care during childbirth; so it is concerning to hear of informal reports of mistreatment during childbirth in Guinea. This study sought to explore the perceptions and experiences of mistreatment during childbirth, from the perspectives of women and service providers, and the analysis presents findings according to a typology of mistreatment during childbirth. This study used qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) and was conducted with four groups of participants: women of reproductive age, midwives, doctors, and administrators. The study took place in two sites in Guinea, an urban area (Mamou) and peri-urban (Pita). Data collection was conducted in two health facilities for providers and administrators, and in the health facility catchment area for women. Data were collected in local languages (Pular and Malinke), then transcribed and analyzed in French. We used a thematic analysis approach and coded transcripts manually. A total of 64 IDIs and eight FGDs were conducted and are included in this analysis, including 40 IDIs and eight FGDs with women of reproductive age, 5 IDIs with doctors, 13 IDIs with midwives, and 6 IDIs with administrators. Participants described their own personal experiences, experiences of women in their communities and perceptions regarding mistreatment during childbirth. Results were organized according to a typology of mistreatment during childbirth, and included instances of physical abuse, verbal abuse, abandonment and neglect. Women described being slapped by providers, yelled at for noncompliance with provider requests, giving birth on the floor and without skilled attendance in the health facility. Poor physical conditions of health facilities and health workforce constraints contributed to experiences of mistreatment. These results are important because they demonstrate that the mistreatment of women during childbirth exists in Guinea and occurs in multiple forms. These data should be used by the Ministry of Health and other stakeholders to develop strategies to reduce and prevent the mistreatment of women during childbirth.

Exploring provider perspectives on respectful maternity care in Kenya: “ Work with what you have”

Abstract: Promoting respect and dignity is a key component of providing quality care during facility-based childbirth and is becoming a critical indicator of maternal health care. Providing quality care requires essential skills and attitudes from healthcare providers, as their role is central to optimizing interventions in maternity settings. In 13 facilities in Kenya we conducted a mixed methods, pre-post study design to assess health providers’ perspectives of a multi-component intervention (the Heshima project), which aimed to mitigate aspects of disrespect and abuse during facility-based childbirth. Providers working in maternity units at study facilities were interviewed using a two-part quantitative questionnaire: an interviewer-guided section on knowledge and practice, and a self-administered section focusing on intrinsic value systems and perceptions. Eleven distinct composite scores were created on client rights and care, provider emotional wellbeing, and work environments. Bivariate analyses compared pre- and post-scores. Qualitative in-depth interviews focused on underlying factors that affected provider attitudes and behaviors including the complexities of service delivery, and perceptions of the Heshima interventions. Composite scales were developed on provider knowledge of client rights (Chronbach α = 0.70), client-centered care (α = 0.80), and HIV care (α = 0.81); providers’ emotional health (α = 0.76) and working relationships (α = 0.88); and provider perceptions of management (α = 0.93), job fairness (α = 0.68), supervision (α = 0.84), promotion (α = 0.83), health systems (α = 0.85), and work environment (α = 0.85). Comparison of baseline and endline individual item scores and composite scores showed that provider knowledge of client rights and practice of a rights-based approach, treatment of clients living with HIV, and client-centered care during labor, delivery, and postnatal periods improved (p < 0.001). Changes in emotional health, perceptions of management, job fairness, supervision, and promotion seen in composite scores did not directly align with changes in item-specific responses. Qualitative data reveal health system challenges limit the translation of providers’ positive attitudes and behaviors into implementation of a rights-based approach to maternity care. Behavior change interventions, central to promoting respectful care, are feasible to implement, as seen in the Heshima experience, but require sustained interaction with health systems where providers practice. Provider emotional health has the potential to drive (mis)treatment and affect women’s care.

A qualitative study of women's and health providers' attitudes and acceptability of mistreatment during childbirth in health facilities in Guinea

Abstract: Reducing maternal morbidity and mortality remains a key health challenge in Guinea. Anecdotal evidence suggests that women in Guinea are subjected to mistreatment during childbirth in health facilities, but limited research exists on this topic. This study was conducted to better understand the social norms and the acceptability of four scenarios of mistreatment during childbirth, from the perspectives of women and service providers. This study used qualitative methods including in-depth interviews (IDIs) and focus group discussions (FGDs) with women of reproductive age, midwives, nurses and doctors. This study was conducted in one urban area (Mamou) and one peri-urban area (Pita) in Guinea. Participants were presented with four scenarios of mistreatment during childbirth, including a provider: (1) slapping a woman; (2) verbally abusing a woman; (3) refusing to help a woman; and (4) forcing a woman to give birth on the floor. Data were collected in local languages (Pular and Malinke) and French, and transcribed and analyzed in French. We used a thematic analysis approach and manually coded the data using a codebook developed for the project. A total of 40 IDIs and eight FGDs were conducted with women of reproductive age, 5 IDIs with doctors, and 13 IDIs with midwives. Most women were not accepting of any of the scenarios, unless the action was perceived to be used to save the life of the mother or child. However, they perceived a woman’s disobedience and uncooperativeness to contribute to her poor treatment. Women reacted to this mistreatment by accepting poor treatment, refusal to use the same hospital, revenge against the provider or complaints to hospital management. Service providers were accepting of mistreatment when women were disobedient, uncooperative, or to save the life of the baby. This is the first known study on mistreatment of women during childbirth to be conducted in Guinea. Both women and service providers were accepting of mistreatment during childbirth under certain conditions. Any approach to preventing and eliminating mistreatment during childbirth must consider these important contextual and social norms and develop a comprehensive intervention that addresses root causes. Further research is needed on how to measure mistreatment during childbirth in Guinea.

The relationships of school-based sexuality education, sexual knowledge and sexual behaviors—a study of 18,000 Chinese college students

Abstract: A growing prevalence of unexpected pregnancies and younger age of sexual debut is observed among Chinese young people, while they lack formal sexuality education from schools and parents. It is necessary to measure their knowledge level of sexual and reproductive health, and how such knowledge associates with their sexual behaviors and reproductive health outcomes, which would shed light on the effectiveness of sexuality education in China. An Internet-based questionnaire survey was conducted from January to August, 2015. 130 colleges were selected from eastern, central, and western parts China with a good balance of geographic distributions. The survey link was subsequently delivered to the focal points in each college for voluntary participation, targeting on undergraduates aged 18 ~ 25. Information on demographics, experience of school-based sexuality education (defined as any course introducing information on sexual and reproductive health) and SRH knowledge quiz was collected. Multivariate linear regression and logistic regression were applied to explore the relationship between students’ SRH knowledge, sexual behaviors and reproductive health outcomes, such as sexual intercourse (penetrative sex by vaginal or anal), unprotected sex, pregnancy and abortion, etc. A total sample of 17,966 Chinese college students (mean age = 20.2, 60.4% female) eventually entered the analysis. Only 55.6% of the respondents self-reported having received sexuality education before, and they scored significantly higher (2.33/4.00) in the SRH knowledge quiz than those who had not (1.75/4.00). Among the sexually experienced students (n = 3639, 20.2%), both males and females with higher SRH knowledge were less likely to report having experience of (partner’s) pregnancy or abortion (OR < 1, p < 0.05). In the group of sexually experienced males, those with higher SRH knowledge had a slightly later age of sexual debut (coefficient = 0.28, p < 0.001), and were less likely to have unprotected sex during the last or in most sexual intercourses (OR = 0.82, 95%C.I.: 0.69 ~ 0.96). Students’ experience of school-based sexuality education may be positively associated with their SRH knowledge level as well as with their sexual behaviors and reproductive health outcomes, but such associations were stronger among males than females. A more effective implementation of school-based sexuality education needs to be scaled up, and a gender-sensitive education strategy to different needs is desirable for SRH promotion among Chinese young people.

What makes pregnant workers sick: why, when, where and how? An exploratory study in the ready-made garment industry in Bangladesh

Abstract: Bangladesh has made significant progress in reducing maternal mortality. Many factors have contributed to this; one is the socio-economic development of the country. The ready-made garment industry is at the forefront of this development creating employment for many women. However, the work environment has the potential to create health problems, particularly for vulnerable groups such as pregnant women. This paper explores perceptions of health problems during pregnancy of factory workers, in this important industry in Bangladesh. This study was conducted in four factories using qualitative research methods to provide a view of pregnant workers’ health risks beyond a bio-medical approach. Data was collected through in-depth interviews of pregnant workers and observations of their homes and workplaces. Further, key informant interviews with factory health care providers, government officials and employers revealed different perspectives and experiences. Data was collected in the local language (Bengali), then transcribed and analysed using a framework analysis approach. Female workers reported that participation in paid work created an opportunity for them to earn money but pregnancy and the nature of the job, including being pressured to meet the production quota, pressure to leave the job because of their pregnancy and withholding of maternity benefits, cause stress, anxiety and may contribute to hypertensive disorders of pregnancy. This was confirmed by factory doctors who suggested that developing hypertensive disorders during pregnancy was influenced by the nature of work and stress. The employers seemed focused on profit and meeting quotas and the health of pregnant workers appeared to be a lower priority. This study found that the government lacks the resources to understand the extent of the problem or the level of compliance with maternity related regulations. These results indicate the vulnerability of female workers to physical and mental stress at work and associations with their health problems during pregnancy. It identifies the deficiencies of family, workplace and health service support for these pregnant workers, highlighting the urgent need for government and non-government organisations to work with this important export industry to improve health surveillance and monitoring and the enforcement of existing laws to protect the rights and conditions of pregnant women.

Protected to death: systematic exclusion of pregnant women from Ebola virus disease trials.

Abstract: For 30 years, women have sought equal opportunity to be included in trials so that drugs are equitably studied in women as well as men; regulatory guidelines have changed accordingly. Pregnant women, however, continue to be excluded from trials for non-obstetric conditions, though they have been included for trials of life-threatening diseases because prospects for maternal survival outweighed potential fetal risks. Ebola virus disease is a life-threatening infection without approved treatments or vaccines. Previous Ebola virus (EBOV) outbreak data showed 89–93% maternal and 100% fetal/neonatal mortality. Early in the 2013–2016 EBOV epidemic, an expert panel pointed to these high mortality rates and the need to prioritize and preferentially allocate unregistered interventions in favor of pregnant women (and children). Despite these recommendations and multiple ethics committee requests for their inclusion on grounds of justice, equity, and medical need, pregnant women were excluded from all drug and vaccine trials in the affected countries, either without justification or on grounds of potential fetal harm. An opportunity to offer pregnant women the same access to potentially life-saving interventions as others, and to obtain data to inform their future use, was lost. Once again, pregnant women were denied autonomy and their right to decide. We recommend that, without clear justification for exclusion, pregnant women are included in clinical trials for EBOV and other life-threatening conditions, with lay language on risks and benefits in information documents, so that pregnant women can make their own decision to participate. Their automatic exclusion from trials for other conditions should be questioned.

Qualitative assessment of women's satisfaction with maternal health care in referral hospitals in Nigeria.

Abstract: Available evidence suggests that the low use of antenatal, delivery, and post-natal services by Nigerian women may be due to their perceptions of low quality of care in health facilities. This study investigated the perceptions of women regarding their satisfaction with the maternity services offered in secondary and tertiary hospitals in Nigeria. Five focus group discussions (FGDs) were held with women in eight secondary and tertiary hospitals in four of the six geo-political zones of the country. In all, 40 FGDs were held with women attending antenatal and post-natal clinics in the hospitals. The questions assessed women’s level of satisfaction with the care they received in the hospitals, their views on what needed to be done to improve patients’ satisfaction, and the overall quality of maternity services in the hospitals. The discussions were audio-taped, transcribed, and analyzed by themes using Atlas ti computer software. Few of the participants expressed satisfaction with the quality of care they received during antenatal, intrapartum, and postnatal care. Many had areas of dissatisfaction, or were not satisfied at all with the quality of care. Reasons for dissatisfaction included poor staff attitude, long waiting time, poor attention to women in labour, high cost of services, and sub-standard facilities. These sources of dissatisfaction were given as the reasons why women often preferred traditional rather than modern facility based maternity care. The recommendations they made for improving maternity care were also consistent with their perceptions of the gaps and inadequacies. These included the improvement of hospital facilities, re-organization of services to eliminate delays, the training and re-training of health workers, and feedback/counseling and education of women. A women-friendly approach to delivery of maternal health care based on adequate response to women’s concerns and experiences of health care will be critical to curbing women’s dissatisfaction with modern facility based health care, improving access to maternal health, and reducing maternal morbidity and mortality in Nigeria. Trial Registration Number NCTR No: 91540209. Nigeria Clinical Trials Registry. http://www.nctr.nhrec.net/ . Registered April 14th 2016.

Preference for cesarean section in young nulligravid women in eight OECD countries and implications for reproductive health education

Abstract: Efforts to reduce unnecessary Cesarean sections (CS) in high and middle income countries have focused on changing hospital cultures and policies, care provider attitudes and behaviors, and increasing women’s knowledge about the benefits of vaginal birth. These strategies have been largely ineffective. Despite evidence that women have well-developed preferences for mode of delivery prior to conceiving their first child, few studies and no interventions have targeted the next generation of maternity care consumers. The objectives of the study were to identify how many women prefer Cesarean section in a hypothetical healthy pregnancy, why they prefer CS and whether women report knowledge gaps about pregnancy and childbirth that can inform educational interventions. Data was collected via an online survey at colleges and universities in 8 OECD countries (Australia, Canada, Chile, England, Germany, Iceland, New Zealand, United States) in 2014/2015. Childless young men and women between 18 and 40 years of age who planned to have at least one child in the future were eligible to participate. The current analysis is focused on the attitudes of women (n = 3616); rates of CS preference across countries are compared, using a standardized cohort of women aged 18–25 years, who were born in the survey country and did not study health sciences (n = 1390). One in ten young women in our study preferred CS, ranging from 7.6% in Iceland to 18.4% in Australia. Fear of uncontrollable labor pain and fear of physical damage were primary reasons for preferring a CS. Both fear of childbirth and preferences for CS declined as the level of confidence in women’s knowledge of pregnancy and birth increased. Education sessions delivered online, through social media, and face-to-face using drama and stories told by peers (young women who have recently had babies) or celebrities could be designed to maximize young women’s capacity to understand the physiology of labor and birth, and the range of methods available to support them in coping with labor pain and to minimize invasive procedures, therefore reducing fear of pain, bodily damage, and loss of control. The most efficacious designs and content for such education for young women and girls remains to be tested in future studies.

HIV status disclosure and associated outcomes among pregnant women enrolled in antiretroviral therapy in Uganda: a mixed methods study

Abstract: Disclosure of HIV positive status to sexual partners is promoted by HIV prevention programs including those targeting the prevention of mother-to-child transmission. Among other benefits, disclosure may enhance spousal support and reduce stigma, violence and discrimination. HIV status disclosure and associated outcomes were assessed among a cohort of women, newly initiating lifelong antiretroviral therapy in Uganda between October 2013 and May 2014. This was a mixed method study, drawing data from a prospective cohort study of 507 HIV positive pregnant women on lifelong antiretroviral therapy, who were followed for four months to determine disclosure and its outcomes. Women were recruited from three facilities for the cohort study; in addition, fifty-seven women were recruited to participate in qualitative interviews from six facilities. Factors associated with spousal support and negative outcomes were determined using random-effects logistic regression in two separate models, with prevalence ratio as measure of association. In-depth interviews were used to document experiences with disclosure of HIV status. Overall HIV status disclosure to at least one person was high [(375/507), 83.7%]. Nearly three-quarters [(285/389), 73.3%], had disclosed to their spouse by the fourth month of follow up post-enrolment. Among married women, spousal support was high at the first 330/407 (81.1%) and second follow-up 320/389 (82.2%). The majority of women who reported spousal support for either antenatal care or HIV-related care services had disclosed their HIV status to their spouses (adj.PR = 1.17; 95% CI: 1.02–1.34). However, no significant differences were observed in the proportion of self-reported negative outcomes by HIV status disclosure (adj.PR = 0.89; 95% CI: 0.56–1.42). Qualitative findings highlighted stigma and fear of negative outcomes as the major barriers to disclosure. HIV status disclosure to partners by pregnant women on lifelong antiretroviral therapy was associated with increased spousal support, but was impeded by fear of adverse outcomes such as stigma, discrimination and violence. Interventions to reduce negative outcomes could enhance HIV status disclosure.

A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it

Abstract: Increasingly, the health and rights of adolescents are being recognized and prioritized on the global agenda. This presents us with a “never-before” opportunity to address adolescent contraception. This is timely, as there are enormous numbers of adolescents who are currently unable to obtain and use contraceptives. From research evidence and programmatic experience, it is clear that we need to do things differently to meet their needs/fulfil their rights. In this commentary, we call for action in several key areas to address adolescents’ persistent inability to obtain and use contraceptives. We must move away from one-size-fits-all approaches, from a ‘condoms-only’ mind set, from separate services for adolescents, from ignoring the appeal of pharmacies and shops, and from one-off-training to make health workers adolescent friendly. Our efforts to expand access to quality contraceptive services to adolescents must be combined with efforts to build their desire and ability to use them, and to do so consistently. In order for these changes to be made, action must be taken on several levels. This includes the formulation of sound national policies and strategies, robust programme implementation with monitoring, regular programmatic reviews, and implementation research. Further, high-quality collection, analysis, and dissemination of data must underlie all of our efforts. As we move ahead, we must also recognize and draw lessons from positive examples of large scale and sustained programmes in countries that have led the way in increasing contraceptive use by adolescents. This unprecedented moment in history gives us a real opportunity to bring about transformational change, particularly when there is so much at stake.

The prevalence of disrespect and abuse during facility-based maternity care in Malawi: evidence from direct observations of labor and delivery.

Abstract: There is increasing evidence throughout the world that the negative treatment of pregnant women during labor and delivery can be a barrier to seeking skilled maternity care. At this time, there has been little quantitative evidence published on disrespect and abuse (DA CI: 0.59–0.62) while there was a higher odds of clients not being asked if they have any concerns if they were in a health center when compared to a hospital (OR: 2.40; CI: 1.06–5.44). Women who were HIV+ had significantly lower odds of not having audio and visual privacy (OR: 0.34, CI: 0.12–0.97), of not being asked about her preferred delivery position (OR: 0.17, CI: 0.05–0.65) and of not being asked if she has any other problems she is concerned about (OR 0.38, CI:0.15–0.96). This study is among the first to quantify the prevalence of disrespect and abuse during labor and delivery in Malawi through direct clinical observations. Measurement of the poor treatment of women during childbirth is essential for understanding the scope of the problem and how to address this issue.

Factors associated with intimate partner physical violence among women attending antenatal care in Shire Endaselassie town, Tigray, northern Ethiopia: a cross-sectional study, July 2015

Abstract: Intimate partner physical violence is a common global phenomenon. About 30.00% and 38.83% of women in the world and in sub-Saharan Africa experienced physical violence by their partner respectively in 2013. Though intimate partner violence has serious adverse health consequences, there is limited information about partner violence during pregnancy in Ethiopia. Therefore, the aim of this study was to assess the prevalnce of physical intimate partner violence during pregnancy and associated factors among women attending antenatal care in Shire Endaselassie town, Tigray, northen Ethiopia A facility based cross-sectional study was conducted from May 3 to July 6, 2015. Four hundred and twenty-two pregnant women attending three public health facilities were included using systematic sampling technique. In addition, twenty-two purposely selected key informants were interviewed. The data collectors and supervisors were trained on all data collection processes. Data were entered to Epi-Info version 7.1.2.00 and exported to SPSS version 20.00. Logistic regression was used to identify factors associated with intimate partner physical violence. Statistical significance was declared at p < 0.05. Qualitative data were categorized into themes and triangulated with the quantitative results. The prevalence of intimate partner physical violence in pregnancy was 20.6% (CI = 16.70, 24.90). Age at first marriage greater than or equal to 17 years (AOR = 4.42, CI = 2.07, 9.42), women with no formal education (AOR = 2.78 CI = 1.10, 7.08), rural dwellers (AOR = 2.63 CI = 1.24, 5.58), intimate partners with no formal education (AOR = 2.78 CI = 1.10, 7.08) and intimate partner alcohol consumption (AOR = 3.8 CI = 1.85, 7.82) were factors associated with intimate partner physical violence towards pregnant women. Nearly one fifth of women surveyed experienced intimate partner physical violence during pregnancy. Early marriage, rural dwelling, intimate partner alcohol consumption, and educational status were associated with intimate partner physical violence during pregnancy. Urgent attention to women’s rights and health is essential at all levels to alleviate the problem and its risk factors in Tigray regional state of Ethiopia.

Looking back and moving forward: can we accelerate progress on adolescent pregnancy in the Americas?

Abstract: Adolescent fertility rates in Latin America and the Caribbean (LAC) remain unacceptably high, especially compared to the region’s declining total fertility rates. The Region has experienced the slowest progress of all regions in the world, and shows major differences between countries and between subgroups in countries. In 2013, LAC was also noted as the only region with a rising trend in pregnancies in adolescents younger than 15 years. In response to the lack of progress in the LAC region, PAHO/WHO, UNFPA and UNICEF held a technical consultation with global, regional and country-level stakeholders to take stock of the situation and agree on strategic approaches and priority actions to accelerate progress. The meeting concluded that there is no single portrait of an adolescent mother in LAC and that context and determinants of adolescent pregnancy vary across and within countries. However, lack of knowledge about their sexual and reproductive health and rights, poor access to and inadequate use of contraceptives resulting from restrictive laws and policies, weak programs, social and cultural norms, limited education and income, sexual violence and abuse, and unequal gender relations were identified as key factors contributing to adolescent pregnancy in LAC. The meeting participants highlighted the following seven priority actions to accelerate progress: 1. Make adolescent pregnancy, its drivers and impact, and the most affected groups more visible with disaggregated data, qualitative reports, and stories. 2. Design interventions targeting the most vulnerable groups, ensuring the approaches are adapted to their realities and address their specific challenges. 3. Engage and empower youth to contribute to the design, implementation and monitoring of strategic interventions. 4. Abandon ineffective interventions and invest resources in applying proven ones. 5. Strengthen inter-sectoral collaboration to effectively address the drivers of adolescent pregnancy in LAC. 6. Move from boutique projects to large-scale and sustainable programs. 7. Create an enabling environment for gender equality and adolescent sexual and reproductive health and rights.