Any better? A follow-up content analysis of adolescent sexual and reproductive health inclusion in Global Financing Facility country planning documents

BACKGROUND

The Global Financing Facility (GFF) supports national reproductive, maternal, newborn, child, adolescent health, and nutrition needs. Previous analysis examined how adolescent sexual and reproductive health was represented in GFF national planning documents for 11 GFF partner countries.

OBJECTIVES

This paper furthers that analysis for 16 GFF partner countries as part of a Special Series.

METHODS

Content analysis was conducted on publicly available GFF planning documents for Afghanistan, Burkina Faso, Cambodia, CAR, Côte d'Ivoire, Guinea, Haiti, Indonesia, Madagascar, Malawi, Mali, Rwanda, Senegal, Sierra Leone, Tajikistan, Vietnam. Analysis considered adolescent health content (mindset), indicators (measure) and funding (money) relative to adolescent sexual and reproductive health needs, using a tracer indicator.

RESULTS

Countries with higher rates of adolescent pregnancy had more content relating to adolescent reproductive health, with exceptions in fragile contexts. Investment cases had more adolescent content than project appraisal documents. Content gradually weakened from mindset to measures to money. Related conditions, such as fistula, abortion, and mental health, were insufficiently addressed. Documents from Burkina Faso and Malawi demonstrated it is possible to include adolescent programming even within a context of shifting or selective priorities.

CONCLUSION

Tracing prioritisation and translation of commitments into plans provides a foundation for discussing global funding for adolescents. We highlight positive aspects of programming and areas for strengthening and suggest broadening the perspective of adolescent health beyond the reproductive health to encompass issues, such as mental health. This paper forms part of a growing body of accountability literature, supporting advocacy work for adolescent programming and funding.

Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa - a point of (no) return

As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) - target 3.7 on ensuring universal access to SRHR and target 5 on gender equality - but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyond.

Embedding research capacity strengthening in multi-country studies in low-and middle-income countries: learnings from sexual and reproductive health research

Research capacity strengthening (RCS) can empower individuals, institutions, networks, or countries to define and prioritize problems systematically; develop and scientifically evaluate appropriate solutions; and reinforce or improve capacities to translate knowledge into policy and practice. However, how to embed RCS into multi-country studies focusing on sexual and reproductive health and rights (SRHR) is largely undocumented. We used findings from a qualitative study, from a review of the literature, and from a validation exercise from a panel of experts from research institutions that work on SRHR RCS. We provide a framework for embedded RCS; suggest a set of seven concrete actions that research project planners, designers, implementers, and funders can utilise to guide embedded RCS activities in low- and middle-income countries; and present a practical checklist for planning and assessing embedded RCS in research projects.

Form and functioning: contextualising the start of the global financing facility policy processes in Burkina Faso

BACKGROUND

Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally.

OBJECTIVE

This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso.

METHODS

We conducted an exploratory qualitative policy analysis. Data collection included document review (N = 74) and in-depth semi-structured interviews (N = 23). Data were analysed based on the components of the health policy triangle.

RESULTS

There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective.

CONCLUSIONS

Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.

Global Financing Facility investments for vulnerable populations: content analysis regarding maternal and newborn health and stillbirths in 11 African countries, 2015 to 2019

BACKGROUND

The Global Financing Facility (GFF) was launched in 2015 to catalyse increased domestic and external financing for reproductive, maternal, newborn, child, adolescent health, and nutrition. Half of the deaths along this continuum are neonatal deaths, stillbirths or maternal deaths; yet these topics receive the least aid financing across the continuum.

OBJECTIVES

To conduct a policy content analysis of maternal and newborn health (MNH), including stillbirths, in GFF country planning documents, and assess the mortality burden related to the investment.

METHODS

Content analysis was conducted on 24 GFF policy documents, investment cases and project appraisal documents (PADs), from 11 African countries. We used a systematic data extraction approach and applied a framework for analysis considering mindset, measures, and money for MNH interventions and mentions of mortality outcomes. We compared PAD investments to MNH-related deaths by country.

RESULTS

For these 11 countries, USD$1,894 million of new funds were allocated through the PADs, including USD$303 million (16%) from GFF. All documents had strong content on MNH, with particular focus on pregnancy and childbirth interventions. The investment cases commonly included comprehensive results frameworks, and PADs generally had less technical content and fewer indicators. Mortality outcomes were mentioned, especially for maternal. Stillbirths were rarely included as targets. Countries had differing approaches to funding descriptions. PAD allocations are commensurate with the burden.

CONCLUSIONS

The GFF country plans present a promising start in addressing MNH. Emphasising links between investments and burden, explicitly including stillbirth, and highlighting high-impact packages, as appropriate, could potentially increase impact.

'I am happy to be listened to': co-creation of a simple tool to measure women's experiences of respectful maternity care in urban Tanzania

BACKGROUND

Rights-based Respectful Maternity Care (RMC) is crucial for quality of care and improved birth outcomes, yet RMC measurements are rarely included in facility improvement initiatives. We aimed to (i) co-create a routine RMC measurement tool (RMC-T) for congested maternity units in Dar es Salaam, Tanzania, and (ii) assess the RMC-T's acceptability among women and healthcare stakeholders.

METHOD

We employed a participatory approach utilizing multiple mixed methods. This included a scoping review, stakeholder engagement involving postnatal women, healthcare providers, health leadership, and global researchers through interviews, focus groups, and two surveys involving 201 and 838 postnatal women. Cronbach's alpha and factor analysis were conducted for validation using Stata 15. Theories of social practice and Thematic Framework of Acceptability guided the assessment of stakeholder priorities and tool acceptability.

RESULTS

The multi-phased iterative co-creation process produced the 25-question RMC-T that measures satisfaction, communication, mistreatment (including physical, verbal, and sexual abuse; neglect; discrimination; lack of privacy; unconsented care; post-birth clean-up; informal payments; and denial of care), supportive care (such as food intake and mobility), birth companionship, post-procedure pain relief, bed-sharing, and newborn respect. The pragmatic validation process prioritized stakeholder feedback over strict statistics, lowering Cronbach's alpha from 0.70 in version 1 to 0.57 for the RMC-T. Women valued the opportunity to share their experiences.

CONCLUSIONS

The RMC-T is contextualized, validated, and acceptable for measuring women's experiences of RMC. Routine use in facility-based quality improvement initiatives, along with targeted actions to address gaps, will advance rights-based RMC. Further validation and community-based studies are needed.

Time to pregnancy recognition among users of an FDA-cleared fertility application

Background: Previous investigations of time-to-pregnancy recognition have analysed data from national surveys and clinics, but this has not been investigated in the context of digital fertility applications. Timely pregnancy recognition can help individuals in health and pregnancy management, reducing maternal and foetal risk and costs, whilst increasing treatment options, availability, and cost. Methods: This dataset contained 23,728 pregnancies (conceived between June 2018 and December 2022) from 20,429 participants using a Food and Drug Administration (FDA) cleared fertility app in the United States. Most participants (with non-missing information) identified as Non-Hispanic White, and one-third reported obtaining a university degree. We used two-tailed Welch's t-test, Mann-Whitney U-test, and two-tailed Z-tests to compare time to pregnancy recognition between those using the app to conceive or contracept. Results: Participants using an app to conceive recognised pregnancy on average at 31.3 days from last menstrual period (LMP) compared to 35.9 days among those using the app to prevent pregnancy. Conclusion: Generalisability is limited, as all participants were using a fertility app and had relatively homogenous sociodemographic characteristics.

Access to assisted reproductive technologies in sub-Saharan Africa: fertility professionals' views

Across sub-Saharan Africa, there remains disagreement among local expert providers over the best ways to improve access to assisted reproduction in low-income contexts. Semi-structured qualitative interviews were conducted between 2021 and 2023 with 19 fertility specialists and 11 embryologists and one clinic manager from South Africa, Zimbabwe, Namibia, Kenya, Ethiopia and Uganda to explore issues surrounding access and potential low-cost IVF options. Lack of access to ART was variously conceptualised as a problem of high cost of treatment; lack of public funding for medical services and medication; poor policy awareness and prioritisation of fertility problems; a shortage of ART clinics and well-trained expert staff; the need for patients to travel long distances; and over-servicing within the largely privatised sector. All fertility specialists agreed that government funding for public sector assisted reproduction services was necessary to address access in the region. Other suggestions included: reduced medication costs by using mild stimulation protocols and oocyte retrievals under sedation instead of general anaesthetics. Insufficient data on low-cost interventions was cited as a barrier to their implementation. The lack of skilled embryologists on the continent was considered a major limitation to expanding ART services and the success of low-cost IVF systems. Very few specialists suggested that profits of pharmaceutical companies or ART clinics might be reduced to lessen the costs of treatments.

A scoping review on the operationalization of intersectional health research methods in studies related to the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic began in early 2020 and became a global health crisis with devastating impacts. This scoping review maps the key findings of research about the pandemic that has operationalized intersectional research methods around the world. It also tracks how these studies have engaged with methodological tenets of oppression, comparison, relationality, complexity, and deconstruction.

METHODS

Our search resulted in 14,487 articles, 5164 of which were duplicates, and 9297 studies that did not meet the inclusion criteria were excluded. In total, 14 articles were included in this review. We used thematic analysis to analyse themes within this work and Misra et al. (2021) intersectional research framework to analyse the uptake of intersectional methods within such studies.

RESULTS

The research related to the COVID-19 pandemic globally is paying attention to issues around the financial impacts of the pandemic, discrimination, gendered impacts, impacts of and on social ties, and implications for mental health. We also found strong uptake of centring research in the context of oppression, but less attention is being paid to comparison, relationality, complexity, and deconstruction.

CONCLUSIONS

Our findings show the importance of intersectional research within public health policy formation, as well as room for greater rigour in the use of intersectional methods.

"I've had constant fears that I'll get cancer": the construction and experience of medical intervention on intersex bodies to reduce cancer risk

PURPOSE

This paper examines the subjective experience of medical interventions on intersex bodies to reduce cancer risk.

METHODS

Twenty-five individuals with intersex variations took part in semi-structured interviews, analysed through thematic discourse analysis.

RESULTS

Intersex bodies were positioned as inherently sick and in need of modification, with cancer risk legitimating surgical and hormonal intervention. This resulted in embodied shame, with negative impacts on fertility and sexual wellbeing. However, many participants resisted discourses of bio-pathologisation and embraced intersex status. Some medical interventions, such as HRT, were perceived to have increased the risk of cancer. Absence of informed consent, and lack of information about intersex status and the consequences of medical intervention, was positioned as a human rights violation. This was compounded by ongoing medical mismanagement, including health care professional lack of understanding of intersex variations, and the objectification or stigmatization of intersex people within healthcare. The consequence was non-disclosure of intersex status in health contexts and lack of trust in health care professionals.

CONCLUSIONS

The legitimacy of poorly-evidenced cancer risk discourses to justify medical intervention on intersex bodies needs to be challenged. Healthcare practitioners need to be provided with education and training about cultural safety practices for working with intersex people.

Nimble adaptations to sexual and reproductive health service provision to adolescents and young people in the early phase of the COVID-19 pandemic

Early in the COVID-19 pandemic, emerging evidence showed that the provision and use of a range of health services, including sexual and reproductive health (SRH) services, were affected. Otherwise, there was little evidence on whether and how they were adapted to maintain the access of different population groups, including adolescents. The study aims to provide an overview of adaptations to adolescent sexual and reproductive health (ASRH) services carried out during the early phases of the pandemic in low- and middle-income countries (LMICs). The Human Reproduction Program (HRP) at the World Health Organization (WHO) called upon WHO and United Nations Populations Fund (UNFPA) regional offices to reach out to organisations that provided ASRH services to submit analytic case studies using a short-form survey. The study team charted information from 36 case studies and performed a content analysis. Results show that the adaptations covered a wide array of SRH services that were provided to a diverse group of adolescents. Most adaptations focused on SRH education and access to contraception in comparison to other SRH services. Over half of the case studies included mental health services, most of which were not provided before the pandemic. The adaptations varied between being face-to-face, remote, digital, and non-digital. Most adaptations complemented a pre-existing service and were nimble, feasible, and acceptable to the targeted adolescents. Lessons learned from this study could be extrapolated into other humanitarian settings and rapid responses for future public health emergencies, provided that rigorous evaluation takes place.

Laws governing access to sexual health services and information: contents, protections, and restrictions

Access to sexual health services and information is critical to achieving the highest attainable standard of sexual health, and enabling legal environments are key to advancing progress in this area. In determining overall alignment with human rights standards to respect, protect, and fulfil sexual health-related rights without discrimination, there are many aspects of laws, including their specificity and content, which impact which sexual health services and information are availed, which are restricted, and for whom. To understand the nature of existing legal provisions surrounding access to sexual health services and information, we analysed the content of 40 laws in English, French, and Spanish from 18 countries for the specific sexual health services and information to which access is ensured or prohibited, and the non-discrimination provisions within these laws. Overall, there was wide variation across countries in the types of laws covering these services and the types and number of services and information ensured. Some countries covered different services through multiple laws, and most of the laws dedicated specifically to sexual health addressed only a narrow aspect of sexual health and covered a small range of services. The protected characteristics in non-discrimination provisions and the specificity of these provisions with regard to sexual health services also varied. Findings may inform national legal and policy dialogues around sexual health to identify opportunities for positive change, as well as to guide further investigation to understand the relationship between such legal provisions, the implementation of these laws within countries, and relevant sexual health outcomes.

Beyond borders: The global impact of violating reproductive human rights

A fundamental component of the basic right to health is the right to sexual health, encompassing an individual's right to decide freely on matters of sexual and reproductive health without discrimination. Provision of these rights is inextricably linked with a wide range of other internationally agreed upon human rights, including the right to information, participation, and equality. Evidence has shown that provision of these rights not only improves maternal and neonatal health, but also healthcare worker safety and the provision of a vast array of critical and necessary medical care. And yet, too often-and with increasing frequency-sexual and reproductive rights are being violated worldwide, with rising taboos, stigma, and discrimination, particularly within abortion, contraception, and fertility care. FIGO strongly supports comprehensive, equitable, and accessible sexual and reproductive health care for all individuals, recognizing that these rights are essential components of global health and fundamental human rights. This includes a particular emphasis on special populations, healthcare workers, and women and girls in crisis zones. FIGO encourages its member societies to deliver comprehensive sexual and reproductive health care, advocate for coverage for sexual and reproductive health care, become involved in analyzing barriers to access within health systems, and provide nonjudgemental, confidential, person-centered care.

Documenting the Provision of Emergency Contraceptive Pills Through Youth-Serving Delivery Channels: Exploratory Mixed Methods Research on Malawi's Emergency Contraception Strategy

INTRODUCTION

Emergency contraceptive pills (ECPs) are effective and can be used safely at any age repeatedly within the same cycle. They are often favored by youth yet are underutilized. Private facilities can increase ECP access but present barriers including cost. Identifying effective public-sector ECP distribution models can help ensure equitable access. The Malawi Ministry of Health developed a strategy to improve ECP access in 2020. We documented ECP provision through select public, youth-serving channels recommended by the strategy: general and youth-specific outreach, paid and unpaid community health workers (CHWs), and youth clubs.

METHODS

We conducted this mixed methods study from November 2022-March 2023 in 2 rural districts (Mchinji and Phalombe) implementing the strategy. We conducted qualitative interviews with 10 national stakeholders, 46 providers, and 24 clients aged 15-24 years about ECP service delivery. Additionally, 25 providers collected quantitative tally data about clients seeking ECPs. We analyzed qualitative data using grounded theory and quantitative data descriptively.

RESULTS

Stakeholders and providers reported ECP uptake increased in geographies where the strategy was implemented, especially among youth. Providers documented 3,988 client visits for ECPs over 3 months. Of these visits, 26% were from male clients, 36% were from clients aged younger than 20 years, and 64% received ECPs for the first time. Across channels, youth club leaders and unpaid CHWs reported the most client visits per provider and served the youngest clients. However, no ECPs were dispensed during 29% of visits due to stock-outs. While many providers were supportive of youth accessing ECPs, most held unfavorable attitudes toward repeat use.

CONCLUSION

ECP access should be expanded through provision in the studied channels, especially youth clubs and CHWs. However, to meet demand, the supply chain must be strengthened. We recommend addressing providers' attitudes about repeat use to ensure informed method choice.

Surrogacy in the United States: analysis of sociodemographic profiles and motivations of surrogates

RESEARCH QUESTION

What is the profile of women in the USA who become surrogates, and what is their power of decision and motivations?

DESIGN

This quantitative study was performed with 231 participants in the USA, given the country's long history of surrogacy, to help clarify the profile of women who become surrogates, their power of decision and motivations.

RESULTS

Descriptive and multivariate cluster analyses showed that women who become surrogates earn above the average income for their state of residency, have a high level of education, have health insurance, are employed, and decide to become a surrogate for prosocial/altruistic reasons.

CONCLUSIONS

In contrast to the premise of both radical feminism and ultra-conservative Catholicism, this study found that altruism and empathy are the primary motivations for participating in surrogacy processes, and that a woman's decision to become a surrogate is not motivated by social conditioning relating to poverty or social status.

A health decision analytical model to evaluate the cost-effectiveness of female genital schistosomiasis screening strategies: The female genital schistosomiasis SCREEN framework

Female genital schistosomiasis is a chronic gynaecological disease caused by the waterborne parasite Schistosoma (S.) haematobium. It affects an estimated 30-56 million girls and women globally, mostly in sub-Saharan Africa where it is endemic, and negatively impacts their sexual and reproductive life. Recent studies found evidence of an association between female genital schistosomiasis and increased prevalence of HIV and cervical precancer lesions. Despite the large population at risk, the burden and impact of female genital schistosomiasis are scarcely documented, resulting in neglect and insufficient resource allocation. There is currently no standardised method for individual or population-based female genital schistosomiasis screening and diagnosis which hinders accurate assessment of disease burden in endemic countries. To optimise financial allocations for female genital schistosomiasis screening, it is necessary to explore the cost-effectiveness of different strategies by combining cost and impact estimates. Yet, no economic evaluation has explored the value for money of alternative screening methods. This paper describes a novel application of health decision analytical modelling to evaluate the cost-effectiveness of different female genital schistosomiasis screening strategies across endemic settings. The model combines a decision tree for female genital schistosomiasis screening strategies, and a Markov model for the natural history of cervical cancer to estimate the cost per disability-adjusted life-years averted for different screening strategies, stratified by HIV status. It is a starting point for discussion and for supporting priority setting in a data-sparse environment.

Menstrual products: culprits or bystanders in endometriosis and adenomyosis pathogenesis?

Products that may reduce menstrual flow from the endometrial cavity to the vagina (i.e. tampons and menstrual cups) could facilitate retrograde menstruation and the spillage of blood into the myometrium, two mechanisms which could be major determinants in endometriosis and adenomyosis pathogenesis. The aim of this narrative review is to summarize the evidence regarding the mechanical role menstrual products may have in the pathogenesis of these two conditions. Evidence in this regard is inconclusive. While Darrow and colleagues observed that 14 or more years of tampon use were associated with endometriosis (OR 3.6; 95% CI, 1.04-13.5); in Meaddough and colleagues' retrospective study, the percentage of women using pads only was significantly higher among those with endometriosis than among those without the condition (31% vs 22%). Three further groups failed to find an association between endometriosis/adenomyosis and any type of menstrual product. The only case that may be considered as a sort of proof-of-concept of the association between products potentially reducing anterograde menstrual flow and endometriosis was reported by Spechler and colleagues, who described the case of a 41 year-old who developed endometriosis after having used a menstrual cup on a regular basis. However, the number of studies on the subject is scarce, study populations are exiguous and a greater attention to temporality of endometriosis onset in relation to when women started habitually using a specific menstrual product is needed. Confounding variables including type and quantity of endocrine disruptors contained in menstrual products should also be addressed. At the present moment, no recommendation can be provided on the safety of one type of menstrual product compared to another.

PrEP Method Switching: Will it Yield Greater Coverage of HIV Protection? Applying Lessons Learned from Family Planning to Guide Future Research in the Context of PrEP Choice

PURPOSE OF REVIEW

Despite the growing availability of oral PrEP, coverage remains suboptimal. Through the introduction of additional PrEP methods, including vaginal rings and long-acting injectable formulations, health systems globally are on the cusp of offering PrEP methods that vary by route of administration, efficacy, and frequency of use. With PrEP choice, it will be important to explore PrEP use patterns to better understand how the ability to choose and switch products affects coverage and continuation. In this review, we draw parallels with family planning (FP) by summarizing how method choice and product switching affected contraceptive coverage globally, synthesize what is known about PrEP product switching, and outline evidence gaps to help guide future research on PrEP switching in the context of choice.

RECENT FINDINGS

Decades of research in FP has demonstrated that product switching is common and can lead to more satisfaction and increases in contraceptive use. While research on PrEP product switching is nascent, findings suggest switching is common, and that providing more than one PrEP option can increase coverage. Key evidence gaps include understanding product switching in the context of full versus constrained choice, switching in the context of temporary need, and developing interventions that promote product switching for those who could benefit. Providing choice and allowing people to start, stop, and switch products according to their needs and desires is a core component of a rights-based approach to HIV prevention. More research is needed to better understand what drives use patterns, including switching, and how to leverage choice to improve coverage. Standard definitions -some of which have been proposed in this review-are needed to inform comparable measurement. Finally, there is a need to holistically frame PrEP use to acknowledge changes in need over the life course, thus making method switching a standard part of HIV prevention.

Intimate partner violence and factors influencing HIV status disclosure among women living with HIV in Indonesia: a cross-sectional study

The disclosure of HIV status poses challenges, and women living with HIV often face intimate partner violence as a result of revealing their HIV status. This study aims to investigate the prevalence of intimate partner violence and HIV status disclosure among women living with HIV in Indonesia, as well as the factors associated with disclosure. A total of 283 women with HIV participated in an online survey, and descriptive and logistic regression analyses were performed. The findings revealed that women reported experiencing physical (9.54%), sexual (6.01%), mental (23.67%), and economic (14.49%) abuse. HIV status disclosure varied among different individuals, with higher rates observed for partners (71.2%), other family members (65.02%), close friends (37.10%), and lower rates for health workers (1.77%). Factors such as employment status and partner's HIV status influenced disclosure to partners, while the duration of knowing one's HIV status, experiences of intimate partner violence, and perceived barriers influenced disclosure to both family and non-family members. To mitigate the negative consequences of HIV status disclosure, targeted health promotion efforts should prioritize partners, family members, and non-family members, focusing on enhancing knowledge and awareness about HIV, including the impact of violence.

"So that I can trust them with my body:" How people with low incomes who may become pregnant define and prioritize quality reproductive health care

OBJECTIVES

As part of a larger mixed-methods study to better define equity in access to sexual and reproductive health (SRH) care in Georgia, this analysis sought to understand: (1) how individuals define quality care for their SRH services; and (2) how quality of care is salient in their SRH care-seeking.

STUDY DESIGN

From January 2019 to February 2020, we conducted life history interviews with individuals with the capacity to become pregnant in suburban areas in Georgia. We analyzed interviews using thematic analysis.

RESULTS

SRH care quality was shaped by experiences with health center environment, with providers, and with staff. Study participants emphasized elements associated with trusted SRH care such as showing compassion, respecting and non-judging, taking time, providing information, and assuring agency. Participants also voiced a desire for holistic care that addressed the lived experiences of the individual. Participants took quality of care into account when care-seeking but sometimes had to weigh out preferences for quality with issues of affordability.

CONCLUSIONS

Access to quality person-centered care is an essential component of realized access to SRH services. Measures of equitable access and quality should account for experiences of quality care that include both provider and staff interactions as well as the larger healthcare environment and ability to use quality care despite financial constraints.

IMPLICATIONS

Quality family planning care should involve both clinicians and staff to incorporate showing compassion, providing respectful and non-judgmental care, taking time with patients, providing information, assuring agency in decision-making, as well as addressing the lived experiences of individuals.

"It's very much part of this movement to undermine democracy": A qualitative study of European Union level opposition strategies against reproductive health and rights

Despite increasing contestations of agreed global commitments on sexual and reproductive health and rights (SRHR), our understanding of strategies of opposition in global health policymaking remains limited. This article explores the opposition to SRHR at the European level focusing on the decision-making institutions of the European Union (EU). The central research questions ask i) how SRHR opposition actors seek to influence EU institutions and ii) what challenges their actions pose for health policymaking at the EU level. Our empirical focus is based on the qualitative method of framework analysis, with data collected from multiple sources, including documentary data on European Parliamentary debates, Council conclusions of the European Union, reports of nongovernmental organisations, and key informant interviews. Our study is in line with observations on globally coordinated efforts to restrict access to SRH services. This is a challenge for specific forums and countries, but as well for European Union's wider internal and external policies. We present a toolbox of strategies and actors operational at the European Union level. Our findings on opposition to SRHR indicate that it can be seen as a political tool that is part of a broader anti-democratic movement. Understanding strategies of anti-SRHR opposition is important for health policymakers as it shapes debates and the achievement of universal health coverage (UHC).

Measuring non-events: infertility estimation using cross-sectional, population-based data from four countries in sub-Saharan Africa

STUDY QUESTION

Does the prevalence of 12-month infertility in Burkina Faso, Côte d'Ivoire, Kenya, and Uganda differ between women trying to conceive and the broader population of women exposed to unprotected sex, and how are prevalence estimates affected by model assumptions and adjustments?

SUMMARY ANSWER

Estimates of 12-month infertility among tryers ranged from 8% in Burkina Faso to 30% in Côte d'Ivoire, increasing substantially among a larger population of women exposed to unprotected intercourse.

WHAT IS KNOWN ALREADY

While having a child is a fundamental human experience, the extent to which women and couples experience infertility is a neglected area of research, particularly in sub-Saharan Africa. Existing estimates of infertility in this region vary widely from 2% to 32%, however, potential impacts of variability in study populations and model assumptions have not been well-examined.

STUDY DESIGN, SIZE, DURATION

We used cross-sectional nationally representative survey data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda. We employed a multi-stage cluster random sampling design with probability proportional to the size selection of clusters within each country to produce representative samples of women aged 15-49. Samples ranged from 3864 in Côte d'Ivoire to 9489 in Kenya.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We created two analytic samples in each country-tryers and a broader sample of women exposed to unprotected sex-exploring differences in population characteristics and estimating the period prevalence of 12-month infertility using the current duration (CD) approach. We also examined the impact of several model assumptions within each of the two analytic samples, including adjustments for recent injectable contraceptive use, unrecognized pregnancy, infertility treatment, underreported contraceptive use, and sexual activity.

MAIN RESULTS AND THE ROLE OF CHANCE

Employing the CD approach among tryers produced an overall 12-month infertility prevalence of 7.9% (95% CI 6.6-12.7) in Burkina Faso, 29.6% (95% CI 15.3-100.0) in Côte d'Ivoire, 24.5% (95% CI 16.5-34.6) in Kenya, and 14.7% (95% CI 8.1-22.4) in Uganda. Results among women exposed to unprotected intercourse indicated much higher levels of infertility, ranging from 22.4% (95% CI 18.6-30.8) in Uganda to 63.7% (95% CI 48.8-87.9) in Côte d'Ivoire. Sensitivity analyses suggest infertility estimates are particularly sensitive to adjustments around pregnancy recognition timing and sexual activity, with little impact of adjustments for recent injectable contraceptive use, infertility treatment, and underreporting of traditional and coital dependent contraceptive use.

LIMITATIONS, REASONS FOR CAUTION

There was substantial digit preference in responses at 12 months, particularly among the tryers, which could introduce bias. Data quality concerns in the reproductive calendar may impact the accuracy of the CD approach among the broader sample of women exposed to unprotected sex, particularly with regard to underreported contraceptive use, induced and spontaneous abortions, and unrecognized pregnancies. Lastly, we lacked information on postpartum amenorrhea or abstinence.

WIDER IMPLICATIONS OF THE FINDINGS

Understanding the inconsistencies in definition and analytic approach and their implications for infertility estimation is important for reliably monitoring population-level infertility trends, identifying factors influencing infertility, improving prevention programs, and ensuring access to quality treatment and services.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Influence of socio-contextual factors on the link between traditional and new media use, and young people's sexual risk behaviour in Sub-Saharan Africa: a secondary data analysis

BACKGROUND

Traditional and new media use links to young people's sexual risk behaviour. The social contexts of young people's daily lives that influence media use and sexual risk behaviour are often investigated as independent causal mechanisms. We examined the link between media use and young people's sexual risk behaviour, considering the intersecting socio-contextual factors in Sub-Saharan Africa.

METHODS

Age-adjusted bivariate logistic regression models tested the association between traditional media (TV, radio, and newspapers), and new media (mobile phone and online) use and sexual risk behaviour using the Demographic and Health Surveys from six Sub-Saharan African countries among unmarried sexually active youths, aged 15-24 years. Multivariate logistic regression models ascertained the media sources that had an additional influence on young people's sexual risk behaviour, after accounting for socio-contextual factors, and knowledge about HIV and other sexually transmitted infections.

RESULTS

Socio-contextual factors attenuated the association between media use and young people's sexual risk behaviour in many countries. However, those who did not have access to new and traditional media were more likely to use unreliable contraceptive methods or not use contraception. Adolescents in Nigeria who did not own phones were 89% more likely to use unreliable contraceptive methods or not use any methods [(AOR = 1.89 (1.40-2.56), p < .001)], those in Angola who did not read newspapers had higher odds of not using contraception or used unreliable methods [(aOR = 1.65 (1.26-2.15), p < .001)]. Young people in Angola (aOR = 0.68 (0.56-0.83), p < .001), Cameroon [(aOR = 0.66 (0.51-0.84), p < .001)], Nigeria [(aOR = 0.72 (0.56-0.93), p = .01)], and South Africa [(aOR = 0.69 (0.49-0.98), p = .03)] who did not own phones were less likely to have 2 or more sexual partners compared to those who owned phones. Lack of internet access in Mali was associated with lower odds of having 2 or more sexual partners (aOR = 0.45 (0.29-0.70), p < .001). Traditional media use was significantly associated with transactional sex in many countries.

CONCLUSIONS

Media use is linked to sexual risk behaviour among young people in Sub-Saharan Africa. Socioeconomic inequalities, levels of globalization, as well as rural-urban disparities in access to media, underscore the need to deliver tailored and targeted sexual risk reduction interventions to young people using both traditional and new media.

'The abortion gave me my life back': the long-term impact of access to self-managed medication abortion through telemedicine on women's lives in legally restricted countries

Approximately 753 million women (38%) of reproductive age live in countries with restrictive abortion laws. To overcome these legal constraints, women access safe self-managed medication abortions through telemedicine abortion services. This study aimed to explore the long-term impact of accessing a self-managed medication abortion through telemedicine service on women's lives in countries with restrictive abortion laws. We conducted interviews with eleven women (from eleven different countries) who accessed a self-managed medication abortion through online telemedicine between 2014 and 2018 in a legally restricted country. We analysed interviews thematically. Three key themes were developed: (1) access to abortion positively impacted life plans; (2) the negative influence of the legally restricted environment wore off and their well-being improved; (3) participants are now using their own experiences to help others by either sharing information or facilitating access to abortion. In summary, our findings highlight the positive impact of access to self-managed medication abortion and underline the importance of ensuring access to abortion for everyone.

Acceptance and use of mobile health technology in post-abortion care

BACKGROUND

Abortion and its complications have always been associated with challenges such as the lack of awareness, high cost of receiving in-person services, lack of access to the skilled healthcare workers, distance from healthcare centers in remote areas, and cultural sensitivities. Therefore, the use of mobile health technology in post-abortion care has been suggested. This study aimed to investigate factors influencing the acceptance and use of mhealth technology in post-abortion care.

METHOD

A mixed-methods study was completed in 2023. Initially, a literature review was conducted. Then, a five-point Likert-scale questionnaire was designed based on the results of the literature review. The research participants were gynecologists (n = 24), midwives (n = 38), and women who had experience of abortion (n = 183). Data were analyzed using descriptive and inferential statistics.

RESULTS

The findings revealed that the participants had different opinions about the importance of motivating and inhibiting factors which included individual, technical, economic, organizational, and ethico-legal aspects. It seems that the individual, organizational, economic, and ethico-legal motivating factors as well as the ethico-legal inhibiting factors were more important than other factors and had higher mean values. In addition, there was a statistically significant difference between the mean values of gynecologists and patients regarding the individual motivating (P = 0.014) and technical inhibiting factors (P = 0.016). The gynecologists' opinions regarding the technical motivating factors were also significantly different from midwives (P = 0.044) and patients (P = 0.010).

CONCLUSION

Multiple factors may influence the acceptance and use of mhealth technology in post-abortion care. Therefore, mhealth service developers must consider these factors to improve the quality of services and increase technology adoption. This will lead to saving costs, improving health, reducing abortion complications, and ultimately improving quality of life for women. However, further research in patient engagement and health interventions tailored to diverse cultural contexts are recommended.

"Nothing about us, without us": stakeholders perceptions on strategies to improve persons with disabilities' sexual and reproductive health outcomes in Ghana

BACKGROUND

Persons with disabilities (PwDs) experience various adverse sexual and reproductive health (SRH) outcomes. However, there is a paucity of evidence on the strategies to improve their SRH outcomes. This study, therefore, used a pluralistic approach to explore PwDs and healthcare providers' (HPs) perspectives on how to improve the SRH of PwDs in Ghana.

METHODS

In-depth interviews were conducted with 62 purposively selected stakeholders (37 PwDs and 25 HPs) in the Kumasi Metropolis and Offinso North District. The data was subjected to reflexive thematic analysis.

RESULTS

Six major themes were generated from the data: Training for disability-sensitive and inclusive healthcare, Healthcare inclusivity - 'nothing about us, without us', Raising awareness for accessibility and equity, Impactful continuous monitoring and evaluation, Vital empowerment for self-reliance and Educating for disability-inclusive healthcare environment. These recommendations were synthesised to develop the THRIVE model-a comprehensive data driven framework from stakeholders that emphasises the importance of factors such as Training for disability-sensitive and inclusive healthcare, Healthcare inclusivity - 'nothing about us, without us', Raising awareness for accessibility and equity, Impactful continuous monitoring and evaluation, Vital empowerment for self-reliance and Enforcement of physical accessibility to improve their SRH outcomes.

CONCLUSION

Using the evidence based THRIVE model could facilitate the development and strengthening of existing interventions and policies including the disability Act 715 to improve the SRH access and outcomes of PwDs in Ghana and other low-and middle-income countries.

Contextualizing HIV testing experiences within the HIV prevention cascade: qualitative insights from refugee youth in Bidi Bidi refugee settlement, Uganda

BACKGROUND

There remain key knowledge gaps regarding HIV testing needs and priorities among refugee youth in low and middle-income country (LMIC) humanitarian settings. The HIV prevention cascade framework focuses on three domains (motivation, access, effective use) central to prevention uptake, yet is understudied in relationship to HIV testing, particularly among refugee youth. Uganda is an exemplar context to explore refugee youth HIV testing needs and priorities as it hosts 1.5 million refugees and is Africa's largest refugee hosting nation. In this study, we explored perceptions and experiences regarding HIV testing among refugee youth living in Bidi Bidi refugee settlement, Uganda.

METHODS

We conducted a community-based research study in Bidi Bidi Refugee Settlement, one of the world's largest refugee settlements with over 195,000 residents. This qualitative study involved four focus groups (2 with young women, 2 with young men) with refugee youth aged 16-24 living in Bidi Bidi refugee settlement. We applied thematic analysis informed by the HIV prevention cascade to understand domains of motivation, access, and effective use that emerged as salient for HIV testing engagement.

RESULTS

Participants (n = 40; mean age: 20 years, standard deviation: 2.2) included refugee young women (n = 20) and young men (n = 20), of whom 88% had a lifetime HIV test and 58% had ever heard of HIV self-testing. Participant discussions described HIV testing motivation was influenced by dimensions of: HIV treatment and testing knowledge; risk perception; positive and negative consequences of use; and social norms regarding gender and age. Access to HIV testing was shaped by: limited availability; distance and language barriers; confidentiality concerns; and affordability. Effective use of and engagement with HIV testing was related to HIV serostatus knowledge self-efficacy and in/equitable partner dynamics.

CONCLUSIONS

Complex, multi-level factors shape motivation for, access to, and effective use of HIV testing among refugee youth in Bidi Bidi. Findings align with the HIV prevention cascade framework that helps to identify gaps to inform intervention development with youth in humanitarian settings. HIV testing approaches tailored for refugee youth in contexts such as Bidi Bidi can foster HIV prevention and treatment literacy, gender equity, gender-based violence prevention, and intersectional stigma reduction.

"My father insisted that I have the baby but not in his house": Adolescent pregnancy, social exclusion and (dis)empowerment of girls in an urban informal settlement in Kenya

While the drivers of adolescent pregnancy are widely studied, few studies have examined the social exclusions associated with early and unintended pregnancy. Drawing data from a larger mixed methods study on the lived experiences of pregnant and parenting adolescents and guided by Amatya Sen's social exclusion framework, this qualitative explanatory study examines how poverty and the contestation around girls' access to comprehensive sexuality education hinder them from preventing unintended pregnancy. It also examines why adolescent pregnancy further results in girls' social exclusion with implications for their health and socioeconomic (dis)empowerment. We drew on data from in-depth interviews with purposively selected pregnant and parenting adolescents aged 15 to 19 (n = 22) and parents (n = 10), and key informant interviews with teachers (n = 4), policymakers (n = 3), community leaders (n = 6) non-governmental organization representatives (n = 2), and health workers (n = 4). Through inductive and deductive thematic analysis, we found that poverty and lack of access to contraceptive information and services contributed to girls' vulnerability to early unintended pregnancies. Becoming pregnant exacerbated girls' social exclusion, which is characterized by self-isolation, being disowned by their families, or forced to drop out of school. Shame, stigma, and discrimination of girls made girls seek antenatal care late. They also failed to complete the recommended number of antenatal care visits. Marginalization of pregnant and parenting girls results in them being out of school, vocational training, and employment, as well as experiencing mental distress. The analysis shows the social exclusion of girls is cyclical, beginning before their pregnancy and continuing into pregnancy and post-pregnancy. Their social exclusion has negative implications for their health and socio-economic empowerment. Interventions to address adolescent childbearing should holistically address the social exclusion that predisposes girls to unintended pregnancy and that follows during and post-pregnancy, as tackling this exclusion is key to improving their health and socioeconomic well-being.

Addressing disparity in attitudes and utilization of family planning among married couples in the pastoralist community of Fentale District, Eastern Ethiopia

BACKGROUND

Despite progress in national reproductive health programs, pastoralist regions like Fentale District in Eastern Ethiopia face challenges with low contraceptive coverage, attributed to insufficient positive attitudes and uptake among couples.

METHODS

This cross-sectional study was conducted from October 1 to December 25, 2021, in Fentale District, Eastern Ethiopia. It involved 1,496 couples selected using multistage sampling. Data were entered into EPI Data and analyzed with SPSS (v23.0) and STATA (v14.0), employing descriptive statistics, bivariate analysis, and binary logistic regression to identify predictors of contraceptive attitudes and use.

RESULTS

The study's response rate was 93.8%, with 1,404 pastoralist couples participating, equally split between women and men. A nomadic-pastoralist lifestyle was common (64.6%), and family planning discussions were rare (93.2%). Gender disparities in contraceptive attitudes and use were evident. Contraception use was reported by 27.4%, with women (41.2%) outnumbering men (13.5%). Women showed more positive attitudes towards contraception (87.9% vs. 31.9% for men). Only 33% had favorable attitudes towards different contraceptive methods, with women more likely to be positive. Modern contraception use was low (18.2%), with women (34.8%) predominating over men (1.7%). Among users, women had a more favorable attitude (78.5% vs. 6.6% for men). Health extension workers were key information providers. Predictors of contraceptive attitudes and use included sex, education, occupation, electronic device ownership, migration frequency, treatment preferences, and family planning discussions.

CONCLUSION

The limited positive attitude towards and use of family planning in Fentale District may stem from unfavorable attitudes, low adoption, and couple disparities. Key factors include gender, education, occupation, electronic device ownership, migration, treatment preferences, and family planning discussions. Targeted educational campaigns for men are needed to address these issues and reduce the gender gap in contraceptive attitudes and use.

Building Blocks of Parent-Child Sex Communication: Body Talk During Infancy and Early Childhood

The current study investigated how foundational conversations about the body and sexuality begin, how they develop longitudinally, and whether parental body talk varies as a function of characteristics of both the parent and child. Participants included 442 mothers (M age = 32.50, SD = 5.61, 93% heterosexual, 85% White) and 337 available father-figures (M age = 33.99, SD = 5.68, 98% heterosexual, 80% White), who were the parents of infants (age at Time 1 = 28.13 months, SD = 6.85, 52% male). Factor analyses suggested that parents engaged in positive, avoidant, and scolding body talk with their young children, and growth curve analyses suggested that frequency of positive body talk increased from when the child was age two to when they were age four for both mother- and father-figures. Results also suggested that the most consistent predictors of body talk included parents' perceptions of whether their child was too young to discuss sexuality, and the child's own questions and behaviors about their bodies and sexuality. The discussion focuses on the frequency of parental body talk and the active role of the child in the early socialization of healthy sexuality.

Period Poverty: How School Nurses Can Support Menstrual Health and Hygiene

Lack of access to menstrual products, menstrual hygiene, and education, also known as period poverty, is a widespread issue and disproportionately impacts low-income, rural, Black, Latinx, Indigenous, and People of Color. Period poverty along with period symptoms, such as heavy and painful periods, contribute to school absenteeism impacting school connectedness and student success. The purpose of this article is to bring awareness to period poverty and encourage school nurses to intervene in individual schools, communities, and far-reaching policy spaces utilizing their expertise to secure resources. School nurses can assist in implementing interventions throughout the school year to increase student engagement, success, and overall menstrual health wellness. Through added engagement of stakeholders such as student groups, school staff and administrators, and community organizations, school nurses can help shift the narrative from a position of oppression around menstrual health to a position of empowerment.

Contraceptive access and use among women with migratory experience living in high-income countries: a scoping review

BACKGROUND

Women who have migrated often encounter difficulties in accessing healthcare and experience inequitable sexual and reproductive health outcomes in destination countries. These health inequities include contraceptive access and use. To better understand what influences contraceptive access and use, this scoping review set out to synthesize the evidence on contraceptive access and use and on associated interventions among women with migratory experience in high-income countries (HICs) in Europe, North America and Australasia.

METHODS

The scientific databases PubMed, Web of Science and CINAHL were searched for peer-reviewed quantitative, qualitative and mixed method articles published between January 2000 and June 2023. Articles were included if they reported on studies exploring contraceptive use to prevent pregnancies among women of reproductive age with migratory experience living in HICs. Two researchers independently screened and extracted data from the articles. Findings were categorized by patient and health system level factors according to Levesque et al.'s framework of access to health care.

RESULTS

A total of 68 articles were included, about half (n = 32) from North America. The articles focused on the individual level rather than the health system level, including aspects such as women's contraceptive knowledge, the influence of culture and religion on accessing and using contraception, partner involvement, and differing health insurance coverage. On the health system level, the articles highlighted lack of information on contraceptive services, cultural (in)adequacy of services and communication aspects, contraceptives' side effects, as well as geographic availability and cost of services. The review further identified three articles reporting on interventions related to contraceptive counselling.

CONCLUSIONS

There is a lack of knowledge regarding how health systems impose obstacles to contraceptive services for women with migratory experience on an organizational level, as research has focused heavily on the individual level. This review's findings may serve as a foundation for further research and advances in policy and practice, specifically recommending early provision of health system related information and contraceptive education, engagement of male partners in contraceptive discourses, cultural competency training for healthcare professionals, and strengthening of interpretation services for contraceptive counselling.

Unmet menstrual needs and psychosocial well-being among schoolgirls in Northern Tanzania: baseline results from the PASS MHW study

INTRODUCTION

Improving menstrual health among schoolgirls is essential to meeting the Sustainable Development Goals (SDGs) of good health and wellbeing (SDG 03), quality education (SDG 04), and gender equality (SDG 05). School participation and wellbeing among girls in low and middle-income countries are impacted by inadequate access to quality menstrual materials and WASH facilities, taboos around menstruation, and poor knowledge. Comprehensive evidence is needed to address these challenges and guide policy and practice.

METHODS

An assisted self-completed questionnaire was used to collect socio-demographic information, menstrual-related data, and school climate data from 486 girls in four mixed-gender government secondary schools in Mwanza, Tanzania. The mean (SD) of three Menstrual Practices and Needs Scale (MPNS-36) sub-scores were calculated. Specifically, the extent to which girls perceived needs for carrying and changing menstrual material in school (transport and school environment); washing and drying menstrual material (reuse needs); and privacy and drying menstrual material in school (reuse insecurity) were met. An ANOVA test compared MPNS scores for groups, and logistic regression examined the association between menstrual health and wellbeing outcomes (self-efficacy, menstrual anxiety, school attendance, and participation) and MPNS subscale scores.

RESULTS

The mean age of the 486 participants was 15.6 years (SD 1.3); 87% had started menstruating; the mean age at menarche was 14.2 years (SD 1.15). The majority (75%) of girls experienced pain during the last menstrual period, 39% had menstrual-related anxiety, and 16% missed at least one day of school due to menstruation. The mean MPNS subscale score (out of 3) for the reuse needs ranged from 1.0 to 2.1 across schools; 1.6 to 2.1 for reuse insecurity; and 0.9 to 1.8 for transport and school environment needs. The MPNS subscales had sufficient reliability (Cronbach alpha = 0.74 to 0.9). The subscales also had good construct validity with menstrual-related self-efficacy: higher scores for transport and school environment were associated with confidence to seek menstrual support, participate in class, and predict when periods were about to start.

CONCLUSIONS

Schoolgirls have unmet needs related to transporting and using menstrual material in school, and these needs differed across schools in northern Tanzania. Menstrual-related pain remains a major reason for poor school attendance and participation. Interventions to address menstrual practice needs in schools are required and should include a strong pain management component.

Surgical informed consent practices and influencing factors in sub-Saharan Africa: a scoping review of the literature

INTRODUCTION

Current international standards in consent to surgery practices are usually derived from health systems in Western countries, while little attention has been given to other contexts such as sub-Saharan Africa (SSA), despite this region facing the highest burdens of disease amenable to surgery globally. The aim of this study was to examine how the concept of informed consent for surgery is interpreted and applied in the context of SSA, and factors affecting current practices.

METHODS

A systematic search of Medline, Embase and African Journal OnLine databases as well as grey sources was executed in May 2023 to retrieve relevant literature published since 2010 in English language against a set of given criteria. The socioecological framework for health was used for organising and summarising the identified evidence.

RESULTS

A total of 27 papers were included in the review. Findings revealed that consent to surgery practices is generally substandard across SSA and the process is not adequate. Patients' understanding of informed consent is limited, likewise awareness of their rights to decision-making. A range of factors at the individual, interpersonal, institutional and system/societal levels affect the informed consent process.

CONCLUSION

There is a need to find more culturally acceptable and ethical ways to include the participation of patients in the decision-making process for surgical treatment in the SSA and define standards more closely aligned with the local context.

The meaning of obstetric violence experiences: A qualitative content analysis of the Break the Silence Campaign

BACKGROUND

Obstetric violence involves the mistreatment, disrespect, and abuse of birthing people and the problem has been recognized in healthcare systems worldwide. Obstetric violence is a gendered, sex-specific form of violence against women that is a public health problem and a violation of human rights. There are an unknowable number of online posts and social media messages that describe obstetric violence experiences. There are no known studies about self-published experiences of obstetric violence in the US maternity care system.

OBJECTIVE

To understand the meaning of obstetric violence experiences in the US maternity care system from a naturally occurring, purposive sample.

DESIGN

A secondary analysis of the textual data from the original Break the Silence social media campaign using qualitative content analysis. The theory of social justice in nursing provided a theoretical framework. A healthcare systems approach was used for a wide-angle view of the multidirectional structure, processes, and outcome of obstetric violence.

SETTING

The study setting is the public Facebook page where the Break the Silence social media campaign can be seen. Break the Silence was an online activism response to the problem of obstetric violence in the US maternity care system with signboard messages posted from 31 known US states. The setting is bounded by the digital page where the campaign is published.

PARTICIPANTS

There were 139 participants, and 11 of them posted more than one signboard message. Most participants were birthing people (n = 125) followed by doulas (n = 10).

METHODS

Krippendorff's methodology for qualitative content analysis was applied to 156 signboard messages posted on Break the Silence from 2014 to 2016. Qualitative content analysis was supported by Atlas.ti 23.

RESULTS

Four themes illustrated the meaning of obstetric violence in US maternity care: 1) pregnancy and birth as a battle with healthcare providers and the healthcare system, 2) sacrifice of the maternal body normalized and assumed as a gender stereotype, 3) disrupted rites of passage from childbirth, and 4) abuse of fiduciary power by healthcare providers.

CONCLUSIONS

This study demonstrated thematic meanings for the experience of obstetric violence in US maternity care with a healthcare systems approach that included structural and organizational considerations to increase understanding. Categories and forms of obstetric violence from the existing literature were expanded and strengthened by findings from this study. Themes were validated in principle with consistency in findings across the international evidence base on obstetric violence.

TWEETABLE ABSTRACT

The meaning of #obstetricviolence experiences is interpersonal and structural with thematic consistency across international studies.

Multilevel factors associated with HIV-related stigma among women living with HIV in Guangdong Province, China: a social-ecological model-informed study

BACKGROUND

HIV-related stigma continues to hinder optimal HIV care, and its determinants should be understood at multiple levels. Based on the social-ecological model, this study aimed to explore factors associated with HIV-related stigma among women living with HIV in Guangdong Province, China.

METHODS

A cross-sectional study was conducted from July to August 2022 to recruit newly reported women living with HIV with a history of pregnancy or current pregnancy in 2021 in 21 cities in Guangdong Province. HIV-related stigma was assessed using an abbreviated Chinese version of Berger's HIV Stigma Scale. Univariate and multivariable hierarchical regression analyses based on the social-ecological model were conducted to explore factors associated with HIV-related stigma and its four dimensions (personalized stigma, disclosure concerns, negative self-image and concerns about public attitudes) at the community/hospital, interpersonal, and individual levels.

RESULTS

A moderate level of HIV-related stigma was found among the 360 participants included, with a mean score of 45.26. Multivariable hierarchical regression analysis showed that at the community/hospital-level, individuals were more likely to experience high levels of HIV-related stigma if they had experienced the discriminatory behaviors from health care workers (aOR = 2.34, 95%CI: 1.48-3.70) and if they rated serostatus disclosure services as less helpful (aOR = 0.69, 95%CI: 0.48-0.98). At the interpersonal-level, individuals with an HIV-positive partner (aOR = 1.71, 95%CI: 1.01-2.90) were more likely to experience high levels of HIV-related stigma than those with an HIV-negative or unknown partner. Individuals with high resilience (aOR = 0.22, 95%CI: 0.13-0.35) had lower levels of HIV-related stigma at the individual-level. In addition, ever experiencing discriminatory behaviors from health care workers, thinking serostatus disclosure services helpful, having ever seen publicity about personal interest protection services and complaint channels for people living with HIV(PLHIV), knowing about care and support services for PLHIV from social organizations at the community/hospital-level, partner notification and support at the interpersonal-level, and violations of personal interests, resilience at the individual-level were also associated with different dimensions of HIV-related stigma.

CONCLUSIONS

HIV-related stigma was moderate among women living with HIV. The social-ecological model can facilitate a better understanding of factors associated with HIV-related stigma. Multilevel intervention strategies need to be tailored to reduce HIV-related stigma.

Patient navigation in reproductive healthcare

PURPOSE OF REVIEW

This review summarizes evidence about barriers to abortion care pre-Dobbs and post-Dobbs, inequities in abortion access, and approaches to improving access to abortion care with use of patient navigators.

RECENT FINDINGS

The Dobbs decision and resulting state-level restrictions exacerbated economic, knowledge, and logistic barriers to abortion care. Abortion funds and emotional support are two main resources to help address these barriers; however, only with coordination can patients and clinics fully benefit from the resources. Patient navigation provides that coordination. Evidence shows it improves reproductive outcomes, is acceptable to patients and providers, and engages community health workers and community-based organizations.

SUMMARY

Increasing legal restrictions and barriers to abortion care have motivated advocates to identify effective interventions to facilitate patient-centered and culturally competent care. Navigators have improved postpartum care by increasing attendance, education and helping coordinate overall care. They have improved referrals and access to abortion care in statewide programs.

Socioecologies in shaping migrants and refugee youths' sexual and reproductive health and rights: a participatory action research study

OBJECTIVE

This study explores socioecological factors facilitating the sexual and reproductive health and rights (SRHR) experiences of migrant and refugee youth (MRY) in Greater Western Sydney, Australia. MRY may be at higher risk for poorer SRH outcomes due to cultural, linguistic, and systemic barriers.

METHODS

Using participatory action research, 17 focus groups were conducted with 87 MRY aged 15-29 from diverse cultural backgrounds. Data were analysed thematically, using socioecological framework.

RESULTS

Key facilitators of MRY's SRHR were identified at the microsystem and exosystem levels, including (1) Peer dynamics and support, with friends serving as trusted confidants and sources of advice; (2) Safety and contraceptive choices, highlighting the importance of access to contraception and STI prevention; and (3) Digital platforms for SRHR information access, with online resources filling knowledge gaps.

CONCLUSION

Findings suggest the need for SRHR interventions to leverage peer support networks, expand access to contraceptive options, and develop culturally appropriate digital resources for MRY. Further research is needed to identify and enhance facilitators across all socioecological levels to comprehensively support MRY's SRHR needs.

When assisted reproductive technology (ART) opens the door for inclusivity in a highly charged cultural milieu: an exploration of news articles on the establishment of ART clinics in Zimbabwe

The study focuses on how infertility and assisted reproductive technology (ART) have been portrayed in the Zimbabwean print news media, specifically looking at articles related to the country's two private fertility clinics established in 2016 and 2017 respectively. Through thematic analysis of 35 news articles, seven prominent themes were developed: infertility as an undesirable and stigmatised condition; stress and the feminisation of infertility; the impact of societal and familial pressure to have children; ART as a ray of hope for infertile couples; growing acceptance of ART; availability, accessibility and affordability of ART; and the use of alternative medicines to cure infertility. The research highlights the coexistence of traditional medicine and ART in Zimbabwe, as well as the impact of stigma, pressure, and gender dynamics on infertile couples. Study findings signal how costly ART treatments may drive individuals towards potentially harmful traditional remedies. They also underscore the need for increased awareness of infertility, efforts to reduce stigma, and addressing barriers to ART access, particularly for men. Overall, findings shed light on the complexities surrounding infertility in Zimbabwe and the importance of addressing these issues in pursuit of better reproductive healthcare outcomes.

Menopausal symptoms and utilization of menopausal hormone therapy among women aged 40-60 years in Addis Ababa, Ethiopia: a cross-sectional study

BACKGROUND

The onset of menopause leads to diminished estrogen exposure, resulting in a high morbidity burden related to menopausal symptoms. Menopausal hormonal therapy is an effective therapy that offers more advantages than disadvantages for women aged less than 60 years or who have had menopause for less than 10 years.

OBJECTIVE

This study aimed to assess the prevalence of menopausal symptoms, identify factors associated with menopausal symptoms, and assess the use of menopausal hormone therapy among women aged 40-60 who visited the gynecological clinics of three hospitals in Addis Ababa, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from January 2022 to June 2022 at Gandhi Memorial Hospital, Tikur Anbessa Hospital, and Zewditu Memorial Hospital on 296 middle-aged women. Data were collected using an interviewer-administered structured questionnaire and analyzed for sociodemographic factors, utilization of menopausal hormone therapy, and prevalence of menopausal symptoms using the menopause rating scale. Data were analyzed using SPSS version 25. Bivariate and multivariate logistic regression analyses were performed to identify independent predictors of each subscale of menopausal symptoms. The strength of the association was measured using odds ratios with 95% confidence intervals, and statistical significance was set at a value of P < 0.05.

RESULT

The prevalence of menopausal symptoms was 89.9%. According to the menopausal rating scale, the frequency of reported symptoms was hot flushes (54.7%), muscle and joint pain (32.1%) on the somatic subscale; physical and mental exhaustion (55.1%), irritability (48.6%) on psychological subscale; and sexual problems (41.3%), bladder problems (39.2%) on urogenital subscale. This study also showed that the age of women [aOR: 0.317, 95%CI (0.102, 0.990)], and monthly family income [aOR = 0.182, 95% CI (0.041, 0.912)] were significantly associated with somatic menopausal symptoms. There was no utilization of menopausal hormonal therapy to treat menopausal symptoms and to prevent complications.

CONCLUSION

The prevalence of menopausal symptoms is high; however, the utilization of individualized administration of menopausal hormone therapy according to symptoms is negligible. It appears essential for these institutions to work on service availability and delivery of menopausal hormone therapy for those in need of wider benefits for their clients.

Obstetric violence in the context of community violence: The case of Mexico

This study examines the relationship between community violence and obstetric violence in Mexico, where the so-called "War on Drugs" has led to sustained high levels of homicides and one-third of pregnant people report experiencing abusive treatment from healthcare providers during childbirth. We combine unique nationally representative survey data on experiences of obstetric violence for births that occurred between 2016 and 2021 with administrative homicide data at the month-municipality level. Using fixed effects models, we investigate how different manifestations of obstetric violence relate to community violence in the short-, medium-, and long-term. Results suggest that the intensity of community violence matters for obstetric violence. Specifically, we find that sustained high-intensity homicidal violence is associated with an increased risk of mistreatment at childbirth, particularly in the form of physical abuse and non-consensual care. Associations are stronger among adolescent, low-educated, and urban respondents. Addressing obstetric violence requires recognising the structural role of sustained high-intensity community violence and the normalisation of violent behaviour that exposure to such environmental stressors may create.

The role of epigenetics in women's reproductive health: the impact of environmental factors

This paper explores the significant role of epigenetics in women's reproductive health, focusing on the impact of environmental factors. It highlights the crucial link between epigenetic modifications-such as DNA methylation and histones post-translational modifications-and reproductive health issues, including infertility and pregnancy complications. The paper reviews the influence of pollutants like PM2.5, heavy metals, and endocrine disruptors on gene expression through epigenetic mechanisms, emphasizing the need for understanding how dietary, lifestyle choices, and exposure to chemicals affect gene expression and reproductive health. Future research directions include deeper investigation into epigenetics in female reproductive health and leveraging gene editing to mitigate epigenetic changes for improving IVF success rates and managing reproductive disorders.

Promoting menstrual health and hygiene-insights from the 2023 World Menstrual Hygiene Day celebration events in the Hohoe municipality in Ghana

The 2023 World Menstrual Hygiene Day (WMHD) celebration at the University of Health and Allied Sciences (UHAS) sought to create awareness about menstruation. Toward normalizing menstruation, the 3-day event brought together key stakeholders and engaged community members on various topics relating to menstruation. Among the stakeholders were basic school teachers (13), school children (155), in a 2:1 female vs. male ratio within the ages of 10-17 years, School Health and Education Program Coordinators (2), Health Officers (4), Academicians (15), University students (35), Media representatives (3), and Civil society representatives (130). Particular among these discussions were the biology of menstruation, nutrition related facts during menstruation, sociocultural, and mental health issues surrounding menstruation. These discussions were intended to incite more conversations about menstruation, and contribute toward the agenda 2030 goal of making menstruation a normal fact of life. The paper describes activities conducted to improve menstrual health, reduce period poverty, and involve men in breaking the stigma around menstruation. This contributes to creating supportive environments for menstruating individuals. Meanwhile, the lessons from the activities to celebrate WMHD in Ghana are relevant for other communities to consider replicating with consideration for contextual differences.

Adaptation and psychometric assessment of a sexual and reproductive empowerment scale in Arabic among refugee and non-refugee adolescent girls

BACKGROUND

Sexual and reproductive empowerment (SRE) is an important determinant of women's and girls' health yet measuring it is complex due to cultural and domain-specific variations. This study describes the process of adapting an SRE scale consisting of four domains (self-efficacy; future orientation; social support; and safety) and testing its psychometric properties among Arabic speaking adolescent girls in Lebanon.

METHODS

An SRE scale developed in a Western context was adapted in four steps: (1) reviewing the scale and selecting culturally appropriate domains for translation to standard Arabic; (2) conducting cognitive interviews with 30 11-17-year-old adolescent girls in Lebanon; (3) administering the scale to 339 refugee adolescent girls who participated in an early marriage intervention; and (4) conducting confirmatory factor analysis (CFA) on the data to assess the scale's psychometric properties.

RESULTS

The original model for the 13-item, four-domain adapted scale demonstrated poor fit in CFA. After iteratively removing two items, scale properties were improved, albeit were not optimal. The validity and reliability results for the self-efficacy domain were acceptable. Cognitive interview data revealed that Arab adolescent girls understood self-efficacy in relational terms, recognizing that autonomous decision-making is not necessarily favored but is influenced by parents and family.

CONCLUSIONS

This study presents an effort to customize an SRE scale for use in studies on the health of adolescent girls in an Arab cultural context. Findings from cognitive interviews highlight the importance of taking into consideration relationality in adolescent sexual and reproductive decision-making. The self-efficacy domain in the adapted scale demonstrates acceptable psychometric properties and is recommended for use in health studies to capture SRE.

Exploring comprehensive sexuality education experiences and barriers among students, teachers and principals in Nepal: a qualitative study

BACKGROUND

Comprehensive sexuality education (CSE) is essential in empowering adolescents with the knowledge and confidence to manage their sexual and reproductive health. Despite its recognized benefits, access to quality CSE remains limited, especially in low-income countries, where societal norms and structural barriers hinder effective delivery. The aim of this study is to investigate the experiences and perceptions among students, teachers, and principals in Nepal about comprehensive sexuality education.

METHODS

Qualitative methods were used. 13 Semi-structured interviews and 1 focus group discussion were carried out with 15 teachers and principals working at higher secondary schools and two focus group discussions were conducted with a total of 13 adolescents. Thematic analysis was used to analyze the data.

RESULTS

Four themes were developed: Resistance to Teaching and Learning, Preparation and Engagement Strategies, Taboos and Silencing and Structural Barriers. Students, teachers, principals and students reported discomfort and embarrassment when discussing sensitive topics, with gender dynamics playing a significant role. Strategies like warm-up sessions and continuous interaction with students and parents were used to create a supportive learning environment. However, socio-cultural barriers and family attitudes continued to hinder open discussions about sexuality. Structural barriers, including the lack of formal training for teachers and inadequate instructional materials, further impeded effective CSE delivery.

CONCLUSION

The experiences of CSE in Nepal among students, teachers and principals highlight significant barriers including cultural taboos, gender dynamics and insufficient resources. Addressing these barriers through comprehensive teacher training, curriculum reform, and societal engagement is critical to ensure access to CSE.

Can "the expanded free maternity services" enable Kenya to achieve universal health coverage by 2030: qualitative study on experiences of mothers and healthcare providers

Introduction

Universal health coverage is a global agenda within the sustainable development goals. While nations are attempting to pursue this agenda, the pathways to its realization vary across countries in relation to service, quality, financial accessibility, and equity. Kenya is no exception and has embarked on an initiative, including universal coverage of maternal health services to mitigate maternal morbidity and mortality rates. The implementation of expanded free maternity services, known as the Linda Mama (Taking Care of the Mother) targets pregnant women, newborns, and infants by providing cost-free maternal healthcare services. However, the efficacy of the Linda Mama (LM) initiative remains uncertain. This article therefore explores whether LM could enable Kenya to achieve UHC.

Methods

This descriptive qualitative study employs in-depth interviews, focus group discussions, informal conversations, and participant observation conducted in Kilifi County, Kenya, with mothers and healthcare providers.

Results and discussion

The findings suggest that Linda Mama has resulted in increased rates of skilled care births, improved maternal healthcare outcomes, and the introduction of comprehensive maternal and child health training for healthcare professionals, thereby enhancing quality of care. Nonetheless, challenges persist, including discrepancies and shortages in human resources, supplies, and infrastructure and the politicization of healthcare both locally and globally. Despite these challenges, the expanding reach of Linda Mama offers promise for better maternal health. Finally, continuous sensitization efforts are essential to foster trust in Linda Mama and facilitate progress toward universal health coverage in Kenya.

Prevalence of pregnancy termination and associated factors among married women in Papua New Guinea: A nationally representative cross-sectional survey

BACKGROUND

Pregnancy termination or induced abortion is not decriminalized, and access to safe abortion services is largely unavailable in Papua New Guinea (PNG). However, the practice is common throughout the country. This study aimed to estimate the prevalence and determine factors associated with pregnancy termination among married women aged 15-49 years in PNG.

METHODS

Secondary data from the 2016-2018 PNG Demographic and Health Survey (PNGDHS) was used. A total weighted sample of 6,288 married women were included. The Complex Sample Analysis method was used to account for the cluster design and sample weight of the study. Chi-square tests and multivariable logistic regression were used to assess factors associated with pregnancy termination. Adjusted odds ratios (aORs) with 95% Confidence Intervals (CIs) were reported.

RESULTS

The prevalence of pregnancy termination was 5.3%. Nearly half (45.2%) of all pregnancy terminations occurred in the Highlands region. Women aged 35-44 years (aOR = 8.54; 95% CI: 1.61-45.26), not working (aOR = 6.17; 95% CI: 2.26-16.85), owned a mobile phone (aOR = 3.77; 95% CI: 1.60-8.84), and lived in urban areas (aOR = 5.66; 95% CI: 1.91-16.81) were more likely to terminate a pregnancy. Women who experienced intimate partner violence (IPV) were 2.27 times (aOR = 2.27; 95% CI: 1.17-4.41) more likely to terminate a pregnancy compared to those who did not experience IPV. Women with unplanned pregnancies were 6.23 times (aOR = 6.23; 95% CI: 2.61-14.87) more likely to terminate a pregnancy. Women who knew about modern contraceptive methods and made independent decisions for contraceptive use were 3.38 and 2.54 times (aOR = 3.38; 95% CI: 1.39-8.18 and aOR = 2.54; 95% CI: 1.18-5.45, respectively) more likely to terminate a pregnancy.

CONCLUSION

The findings highlight the role of sociodemographic and maternal factors in pregnancy termination among married women in PNG. Efforts aimed at reducing unplanned pregnancies and terminations should focus on comprehensive sexual and reproductive health education and improving easy access to contraceptives for married couples. Post-abortion care should also be integrated into the country's legal framework and added as an important component of existing sexual and reproductive health services.