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Kaiser JL, Fong RM, Hamer DH, Biemba G, Ngoma T, Tusing B, Scott NA. How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc Sci Med 2019; 220:312-321. [PMID: 30500609 PMCID: PMC6323354 DOI: 10.1016/j.socscimed.2018.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/31/2018] [Accepted: 11/06/2018] [Indexed: 11/16/2022]
Abstract
To reduce maternal mortality, countries must continue to seek ways to increase access to skilled care during pregnancy and delivery. In Zambia, while antenatal attendance is high, many barriers exist that prevent women from delivering with a skilled health provider. This study explores how the individuals closest to a pregnant woman in rural Zambia can influence a woman's decision to seek and her ability to access timely maternity care. At four rural health centers, a free listing (n = 167) exercise was conducted with mothers, fathers, and community elders. Focus group discussions (FGD) (n = 135) were conducted with mothers, fathers, mothers-in-law, and community health workers (CHWs) to triangulate findings. We analyzed the FGD data against a framework that overlaid the Three Delays Framework and the Social Ecological Model. Respondents cited husbands, female relatives, and CHWs as the most important influencers during a woman's maternity period. Husbands have responsibilities to procure resources, especially baby clothes, and provide the ultimate permission for a woman to attend ANC or deliver at a facility. Female relatives escort the woman to the facility, assist during her wait, provide emotional support, assist the nurse during delivery, and care for the woman after delivery. CHWs educate the woman during pregnancy about the importance of facility delivery. No specific individual has the role of assisting with the woman's household responsibilities or identifying transport to the health facility. When husbands, female relatives, or CHWs do not fulfill their roles, this presents a barrier to a woman deciding to deliver at the health facility (Delay 1) or reaching a health facility (Delay 2). An intervention to help women better plan for acquiring the needed resources and identifying the individuals to escort her and those to perform her household responsibilities could help to reduce these barriers to accessing timely maternal care.
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Affiliation(s)
- Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA.
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA; Section of Infectious Diseases, Department of Medicine, Boston Medical Center, One Boston Medical Center Pl, Boston, MA, 02118, USA
| | - Godfrey Biemba
- Zambia Center for Applied Health Research and Development, Plot 4186 Addis Ababa Drive, Long Acres, P.O. Box 30910, Lusaka, Zambia
| | - Thandiwe Ngoma
- Zambia Center for Applied Health Research and Development, Plot 4186 Addis Ababa Drive, Long Acres, P.O. Box 30910, Lusaka, Zambia
| | - Brittany Tusing
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3rd Floor, Boston, MA, 02118, USA
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Grindlay K, Dako-Gyeke P, Ngo TD, Eva G, Gobah L, Reiger ST, Chandrasekaran S, Blanchard K. Contraceptive use and unintended pregnancy among young women and men in Accra, Ghana. PLoS One 2018; 13:e0201663. [PMID: 30118485 PMCID: PMC6097688 DOI: 10.1371/journal.pone.0201663] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 07/19/2018] [Indexed: 11/18/2022] Open
Abstract
The objective of this study was to determine factors associated with modern contraceptive use and unintended pregnancy among young women and men in Accra, Ghana. From September-December 2013, we conducted a cross-sectional survey with 250 women and 100 men aged 18–24. We explored determinants of modern contraceptive use among males and females and unintended pregnancy among females. Descriptive statistics, chi-square tests, Fisher’s exact tests, and multivariable logistic regression were used. Participants had an average of three lifetime sexual partners, and 91% had one current partner. Overall, 44% reported current modern contraceptive use. In multivariate modeling, modern contraceptive use was associated with higher education compared to primary (AORs 2.1–4.3); ever talking with someone about contraception (AOR 4.7); feeling unsupported by a healthcare provider for contraception (AOR 2.2); and not feeling at risk of unintended pregnancy (AOR 2.7). While ≥70% of participants recognized most contraceptive methods, awareness of some methods was lacking. Nearly all respondents (91%) felt at least one modern method was unsafe. Nearly half of all females (45%) reported their last pregnancy was unintended, and 63% of females and 58% of males felt at risk for future unintended pregnancy. Women were more likely to experience unintended pregnancy if they had ever given birth (AOR 6.7), their sexual debut was 8–14 years versus 20–24 years (AOR 3.4), or they had 3–4 lifetime sexual partners versus 1–2 (AOR 2.4). Targeted interventions are needed to improve understanding of the safety of modern contraceptive methods, increase awareness of long-acting methods, and consequently increase modern contraceptive access and use.
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Affiliation(s)
- Kate Grindlay
- Ibis Reproductive Health, Cambridge, Massachusetts, United States of America
- * E-mail:
| | - Phyllis Dako-Gyeke
- Department of Social and Behavioral Sciences, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Thoai D. Ngo
- Poverty, Gender and Youth Program, Population Council, New York, New York, United States of America
| | - Gillian Eva
- Marie Stopes International US, Washington, DC, United States of America
| | | | - Sarah T. Reiger
- Ibis Reproductive Health, Cambridge, Massachusetts, United States of America
| | | | - Kelly Blanchard
- Ibis Reproductive Health, Cambridge, Massachusetts, United States of America
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Hall KS, Manu A, Morhe E, Dalton VK, Challa S, Loll D, Dozier JL, Zochowski MK, Boakye A, Harris LH. Bad girl and unmet family planning need among Sub-Saharan African adolescents: the role of sexual and reproductive health stigma. QUALITATIVE RESEARCH IN MEDICINE & HEALTHCARE 2018; 2:55-64. [PMID: 30556052 PMCID: PMC6292434 DOI: 10.4081/qrmh.2018.7062] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women's family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, community norms identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as immoral, disrespectful, and disobedient, resulting in bad girl labeling. Second, enacted stigma entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced internalized stigma as disgrace, shame and shyness. Fourth, non-disclosure and secret-keeping were used to avoid/reduce stigma. Fifth, stigma resilience was achieved through social support. Collectively, SRH stigma precluded adolescents' use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide.
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Affiliation(s)
- Kelli Stidham Hall
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Abubakar Manu
- School of Public Health, University of Ghana, Accra, Ghana
| | | | | | - Sneha Challa
- University of Michigan, Women’s Hospital, Ann Arbor, USA
| | - Dana Loll
- University of Michigan, Women’s Hospital, Ann Arbor, USA
| | | | | | - Andrew Boakye
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Lisa H. Harris
- University of Michigan, Women’s Hospital, Ann Arbor, USA
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Hall KS, Morhe E, Manu A, Harris LH, Ela E, Loll D, Kolenic G, Dozier JL, Challa S, Zochowski MK, Boakye A, Adanu R, Dalton VK. Factors associated with sexual and reproductive health stigma among adolescent girls in Ghana. PLoS One 2018; 13:e0195163. [PMID: 29608595 PMCID: PMC5880390 DOI: 10.1371/journal.pone.0195163] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 03/16/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Using our previously developed and tested Adolescent Sexual and Reproductive Health (SRH) Stigma Scale, we investigated factors associated with perceived SRH stigma among adolescent girls in Ghana. Methods We drew upon data from our survey study of 1,063 females 15-24yrs recruited from community- and clinic-based sites in two Ghanaian cities. Our Adolescent SRH Stigma Scale comprised 20 items and 3 sub-scales (Internalized, Enacted, Lay Attitudes) to measure stigma occurring with sexual activity, contraceptive use, pregnancy, abortion and family planning service use. We assessed relationships between a comprehensive set of demographic, health and social factors and SRH Stigma with multi-level multivariable linear regression models. Results In unadjusted bivariate analyses, compared to their counterparts, SRH stigma scores were higher among girls who were younger, Accra residents, Muslim, still in/dropped out of secondary school, unemployed, reporting excellent/very good health, not in a relationship, not sexually experienced, never received family planning services, never used contraception, but had been pregnant (all p-values <0.05). In multivariable models, higher SRH stigma scores were associated with history of pregnancy (β = 1.53, CI = 0.51,2.56) and excellent/very good self-rated health (β = 0.89, CI = 0.20,1.58), while lower stigma scores were associated with older age (β = -0.17, 95%CI = -0.24,-0.09), higher educational attainment (β = -1.22, CI = -1.82,-0.63), and sexual intercourse experience (β = -1.32, CI = -2.10,-0.55). Conclusions Findings provide insight into factors contributing to SRH stigma among this young Ghanaian female sample. Further research disentangling the complex interrelationships between SRH stigma, health, and social context is needed to guide multi-level interventions to address SRH stigma and its causes and consequences for adolescents worldwide.
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Affiliation(s)
- Kelli Stidham Hall
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | | | - Abubakar Manu
- School of Public Health, University of Ghana, Accra, Ghana
| | - Lisa H Harris
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Elizabeth Ela
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Dana Loll
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Giselle Kolenic
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Jessica L Dozier
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Sneha Challa
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Melissa K Zochowski
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Andrew Boakye
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Richard Adanu
- School of Public Health, University of Ghana, Accra, Ghana
| | - Vanessa K Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
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