Attitudes and Experiences Surrounding Female Genital Mutilation/Cutting in the United States: A Scoping Review

To identify research and gaps in literature about FGM/C-related attitudes and experiences among individuals from FGM/C-practicing countries living in the United States, we conducted a scoping review guided by Arksey and O'Malley's framework. We searched Medline (OVID), Embase (OVID), PubMed, and SCOPUS and conducted a grey literature search for studies assessing attitudes or experiences related to FGM/C with data collected directly from individuals from FGM/C-practicing countries living in the United States. The search yielded 417 studies, and 40 met the inclusion criteria. Findings suggest that women and men from FGM/C-practicing countries living in the United States generally oppose FGM/C, and that women with FGM/C have significant physical and mental health needs and have found US healthcare providers to lack understanding of FGM/C. Future research can improve measurement of FGM/C by taking into account the sociocultural influences on FGM/C-related attitudes and experiences.

Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia

Through district system strengthening, integrated services, and community engagement interventions, the Saving Mothers, Giving Life initiative increased emergency obstetric care coverage and access to, and demand for, improved quality of care that led to rapid declines in district maternal and perinatal mortality. Significant reductions in intrapartum stillbirth rate and maternal mortality ratios around the time of birth attest to the success of the initiative.

Background:

Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions.

Methods:

SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities.

Results:

Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country.

Conclusions:

MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.

Did Saving Mothers, Giving Life Expand Timely Access to Lifesaving Care in Uganda? A Spatial District-Level Analysis of Travel Time to Emergency Obstetric and Newborn Care

A spatial analysis of facility accessibility, taking into account road networks and environmental constraints on travel, suggests that the Saving Mothers, Giving Life (SMGL) initiative increased access to emergency obstetric and neonatal care in SMGL-supported districts in Uganda. Spatial travel-time analyses can inform policy and program efforts targeting underserved populations in conjunction with the geographic distribution of maternity services.

Introduction:

Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access.

Methods:

We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources.

Results:

The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P < .01) could be used. Increases in timely access were also substantial for nonmotorized transportation such as walking and/or bicycling.

Conclusions:

Largely due to the SMGL-supported expansion of EmONC capability, timely access to EmONC significantly improved. Our analysis developed a geographic outline of facility accessibility using multiple types of transportation. Spatial travel-time analyses, along with other EmONC indicators, can be used by planners and policy makers to estimate need and target underserved populations to achieve further gains in EmONC accessibility. In addition to increasing the number and geographic distribution of EmONC facilities, complementary efforts to make motorized transportation available are necessary to achieve meaningful increases in EmONC access.

Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services

The Saving Mothers, Giving Life initiative used 3 coordinated approaches to reduce maternal deaths resulting from a delay in deciding to seek health care, known as the “first delay”: (1) promoting safe motherhood messages and facility delivery using radio, theater, and community engagement; (2) encouraging birth preparedness and increasing demand for facility delivery through community outreach worker visits; and (3) providing clean delivery kits and transportation vouchers to reduce financial barriers for facility delivery. These approaches can be adapted in other low-resource settings to reduce maternal and perinatal mortality.

Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care at birth. While originally the “Three Delays” model was designed to focus on curative services that encompass emergency obstetric care, SMGL expanded its application to primary and secondary prevention of obstetric complications. Prevention of the “first delay” focused on addressing factors influencing the decision to seek delivery care at a health facility. Numerous factors can contribute to the first delay, including a lack of birth planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care, and financial or geographic barriers. SMGL addressed these barriers through community engagement on safe motherhood, public health outreach, community workers who identified pregnant women and encouraged facility delivery, and incentives to deliver in a health facility. SMGL used qualitative and quantitative methods to describe intervention strategies, intervention outcomes, and health impacts. Partner reports, health facility assessments (HFAs), facility and community surveillance, and population-based mortality studies were used to document activities and measure health outcomes in SMGL-supported districts. SMGL's approach led to unprecedented community outreach on safe motherhood issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL districts. In Uganda, the proportion of births that took place in facilities rose from 45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts, facility deliveries increased from 62.6% to 90.2% (44% increase). In both countries, the proportion of women delivering in facilities equipped to provide emergency obstetric and newborn care also increased (from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines in the number of maternal deaths due to not accessing facility care during pregnancy, delivery, and the postpartum period in both countries. This reduction played a significant role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda but not in Zambia. Further work is needed to sustain gains and to eliminate preventable maternal and perinatal deaths.

Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care

Saving Mothers, Giving Life used 6 strategies to address the third delay—receiving adequate health care after reaching a facility—in maternal and newborn health care. The intervention approaches can be adapted in low-resource settings to improve facility-based care and reduce maternal and perinatal mortality.

Background:

Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response.

Methods:

SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data—health facility assessments, facility and community surveillance, and population-based mortality studies—were used to document the effectiveness of intervention components.

Results:

During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline—from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened.

Conclusion:

SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths.

Physical violence against U.S. women around the time of pregnancy, 2004-2007

BACKGROUND

Previous research shows that the prevalence of intimate partner violence (IPV) around the time of pregnancy varies from 4% to 9%, but no studies have distinguished between abuse rates by former versus current partners.

PURPOSE

This study aims to estimate the prevalence of IPV among U.S. women shortly before and during pregnancy and to compare the rates and predictors of abuse perpetrated by current partners with the rates and predictors of abuse perpetrated by former partners.

METHODS

Using data from 27 states and New York City, the prevalence of physical abuse by current and former intimate male partners was estimated among 134,955 women who delivered a singleton, full-term infant in 2004-2007. Multivariable logistic regression was used to determine the demographic, pregnancy-related, and stress factors that predicted the risk of IPV.

RESULTS

Prevalence of IPV from either a former or current partner was 5.3% before and 3.6% during pregnancy. Prevalence of abuse by a former partner was consistently higher than the prevalence of abuse by a current partner. The three strongest predictors of IPV during pregnancy were the woman's partner not wanting the pregnancy (current: AOR=3.47, 95% CI=3.13, 3.85; former: AOR=3.22, 95% CI=2.90, 3.76); having had a recent divorce or separation (current: AOR=3.23, 95% CI=2.92, 3.58; former: AOR=3.54, 95% CI=3.20, 3.91); and being close to someone having a drug or alcohol problem (current: AOR=3.05, 95% CI=2.78, 3.36; former: AOR=2.97, 95% CI=2.70, 3.27). Maternal characteristics (age, education, race, marital status, woman did not want the pregnancy) were less important predictors.

CONCLUSIONS

Assessments of abuse should ask specifically about actions by both current and ex-partners.

Dimensions of child punishment in two Central American countries: Guatemala and El Salvador

OBJECTIVE

Severe physical punishment of children is an important issue in international child health and welfare. This study examines such punishment in Guatemala and El Salvador.

METHODS

Data came from nationally representative surveys of women aged 15-49 and men aged 15-59 residing in Guatemala (2002) and El Salvador (2002-2003). The surveys included questions about punishment experienced during childhood, with response options ranging from verbal scolding to beating. In Guatemala, parents were asked how they disciplined their children; questions allowed them to compare how they were punished in their childhood with how they punished their own children. Bivariate and multivariate analyses are presented.

RESULTS

In Guatemala, 35% of women and 46% of men reported being beaten as punishment in childhood; in El Salvador, the figures were 42% and 62%, respectively. In both countries, older participants were relatively more likely than younger participants to have been beaten as children. Witnessing familial violence was associated with an increased risk of being beaten in childhood. In Guatemala, having experienced physical punishment as a child increased the chance that parents would use physical punishment on their own children. Multivariate analyses revealed that women who were beaten in childhood were significantly more likely in both countries to be in a violent relationship.

CONCLUSIONS

The use of beating to physically punish children is a common problem in Guatemala and El Salvador, with generational and intergenerational effects. Its negative and lingering effects necessitate the introduction of policies and programs to decrease this behavior.

Physical abuse around the time of pregnancy: an examination of prevalence and risk factors in 16 states

OBJECTIVES

From self-reports we describe and compare the levels and patterns of physical abuse before and during pregnancy while also describing the demographic and pregnancy-related characteristics of physically abused women, the stressful experiences of abused women prior to delivery, and the relationship of the abused woman to the perpetrator(s).

METHODS

We used population-based estimates from the Pregnancy Risk Assessment Monitoring System (1996-98) to calculate a multiyear 16-state prevalence with 95% confidence intervals (CIs) and unadjusted risk ratios for demographic, pregnancy-related, and stressful experiences variables.

RESULTS

We found the prevalence of abuse across the 16 states to be 7.2% (95% CI, 6.9-7.6) during the 12 months before pregnancy, 5.3% (95% CI, 5.0-5.6) during pregnancy, and 8.7% (95% CI, 8.3-9.1) around the time of pregnancy (abuse before or during pregnancy). The prevalence of physical abuse during pregnancy across the 16 states was consistently lower than that before pregnancy. For time periods both before and during pregnancy, higher prevalence was found for women who were young, not White, unmarried, had less than 12 years of education, received Medicaid benefits, or had unintended pregnancies, and for women with stressful experiences during pregnancy, particularly being involved in a fight or increased arguing with a husband or partner. For each of these risk groups, the prevalence was lower during pregnancy than before. Abuse was ongoing before pregnancy for three quarters of the women experiencing abuse by a husband or partner during pregnancy.

CONCLUSIONS

Women are not necessarily at greater risk of physical abuse when they are pregnant than before pregnancy. Both the preconception period and the period during pregnancy are periods of risk, which suggests that prevention activities are appropriate during routine health care visits before pregnancy as well as during family planning and prenatal care.

Screening for intimate partner violence by health care providers. Barriers and interventions

INTRODUCTION

Routine screening for intimate partner violence (IPV) is endorsed by numerous health professional organizations. Screening rates in health care settings, however, remain low. In this article, we present a review of studies focusing on provider-specific barriers to screening for IPV and interventions designed to increase IPV screening in clinical settings.

METHODS

A review of published studies containing original research with a primary focus on screening for IPV by health professionals was completed.

RESULTS

Twelve studies identifying barriers to IPV screening as perceived by health care providers yielded similar lists; top provider-related barriers included lack of provider education regarding IPV, lack of time, and lack of effective interventions. Patient-related factors (e.g., patient nondisclosure, fear of offending the patient) were also frequently mentioned. Twelve additional studies evaluating interventions designed to increase IPV screening by providers revealed that interventions limited to education of providers had no significant effect on screening or identification rates. However, most interventions that incorporated strategies in addition to education (e.g., providing specific screening questions) were associated with significant increases in identification rates.

CONCLUSION

Barriers to screening for IPV are documented to be similar among health care providers across diverse specialties and settings. Interventions designed to overcome these barriers and increase IPV-screening rates in health care settings are likely to be more effective if they include strategies in addition to provider education.

Sexual violence and reproductive health

Sexual violence is a significant public health problem, and has been linked to adverse effects on women's physical and mental health. Although some advances in the research have been made, more scientific exploration is needed to understand the potential association between sexual violence and women's reproductive health, and to identify measures that could be implemented in reproductive health care settings to assist women who have experienced sexual violence. Three general areas needing further study include (1) expansion of the theoretical frameworks and analytic models used in future research, (2) the reproductive health care needs of women who have experienced sexual violence, (3) and intervention strategies that could be implemented most effectively in reproductive health care settings.

Violence against women and reproductive health: toward defining a role for reproductive health care services

Since a large proportion of U.S. women receive reproductive health care services each year, reproductive health care settings offer an important opportunity to reach women who may be at risk of or experiencing intimate partner violence (IPV). Although screening women for IPV in clinical health care settings has been endorsed by national professional associations and organizations, scientific evidence suggests that opportunities for screening in reproductive health care settings are often missed. This commentary outlines what is known about screening and intervention for IPV in clinical health care settings, and points out areas that need greater attention. The ultimate goal of these recommendations is to increase the involvement of reproductive health care services in sensitive, appropriate, and effective care for women who may be at risk of or affected by IPV.

Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the pregnancy risk assessment monitoring system, 1996-1997. PRAMS Working Group. Pregnancy Risk Assessment Monitoring System

OBJECTIVE

This study examines whether unintended pregnancy is associated with physical abuse of women occurring around the time of pregnancy, independent of other factors.

METHODS

In 1996-1997, state-specific population-based data were obtained from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 39,348 women in 14 states who had delivered a live-born infant within the previous 2-6 months. The study questionnaire asked about maternal behaviors and characteristics around the time of pregnancy.

RESULTS

Women who had mistimed or unwanted pregnancies reported significantly higher levels of abuse at any time during the 12 months before conception or during pregnancy (12.6% and 15.3%, respectively) compared with those with intended pregnancies (5.3%). Higher rates of abuse were reported by women who were younger, Black, unmarried, less educated, on Medicaid, living in crowded conditions, entering prenatal care late, or smoking during the third trimester. Overall, women with unintended pregnancies had 2.5 times the risk of experiencing physical abuse compared with those whose pregnancies were intended. This association was modified by maternal characteristics, the association was strongest among women who were older, more educated, White, married, not on Medicaid, not living in crowded conditions, receiving first trimester prenatal care, or nonsmoking during the third trimester.

CONCLUSIONS

Women with unintended pregnancies are at increased risk of physical abuse around the time of pregnancy compared with women whose pregnancies are intended. Prenatal care can provide an important point of contact where women can be screened for violence and referred to services that can assist them.

Violence and reproductive health: current knowledge and future research directions

OBJECTIVES

Despite the scope of violence against women and its importance for reproductive health, very few scientific data about the relationship between violence and reproductive health issues are available.

METHODS

The current knowledge base for several issues specific to violence and reproductive health, including association of violence with pregnancy, pregnancy intention, contraception use, pregnancy terminations, and pregnancy outcomes, are reviewed and suggestions are provided for future research.

RESULTS

Despite the limitations of current research and some inconclusive results, the existing research base clearly documents several important points: (1) violence occurs commonly during pregnancy (an estimated 4%-8% of pregnancies): (2) violence is associated with unintended pregnancies and may be related to inconsistent contraceptive use; and (3) the research is inconclusive about the relationship between violence and pregnancy outcomes.

CONCLUSIONS

Improved knowledge of the risk factors for violence is critical for effective intervention design and implementation. Four areas that need improvement for development of new research studies examining violence and reproductive-related issues include (1) broadening of study populations, (2) refining data collection methodologies, (3) obtaining additional information about violence and other factors, and (4) developing and evaluating screening and intervention programs. The research and health care communities should act collaboratively to improve our understanding of why violence against women occurs, how it specifically affects reproductive health status, and what prevention strategies may be effective.

Violence and adverse pregnancy outcomes: a review of the literature and directions for future research

INTRODUCTION

Violence during pregnancy has been estimated to affect between 0.9% and 20.1% of pregnant women in the United States. This article presents a review of the research on the potential association between violence during pregnancy and adverse outcomes, explores mechanisms by which violence might influence pregnancy outcomes, and suggests directions for future research aimed at the development of successful interventions.

METHODS

A review of the literature pertaining to violence during pregnancy and adverse pregnancy outcomes, trauma, and stress during pregnancy was completed.

RESULTS

Overall, no pregnancy outcome was consistently found to be associated with violence during pregnancy. The trauma literature offers insight about the effects that injuries caused by physical violence might have on pregnancy outcomes. Information from the stress literature investigates potential mechanisms through which physical violence could indirectly affect pregnancy outcomes. The trauma and stress literature offers methodologic approaches that could be employed in future research on violence during pregnancy and pregnancy outcomes.

CONCLUSIONS

This review lays the groundwork for the development of a future research agenda to investigate the association between violence during pregnancy and adverse outcomes. Future research should include quantitative and qualitative approaches, and investigation into the mechanisms and antecedents of how violence during pregnancy may lead to adverse outcomes. Only with such information can successful interventions to limit violence and its potential effects during pregnancy be implemented.

Delayed entry into prenatal care: effect of physical violence

OBJECTIVE

To assess whether women who experienced physical violence by their partner during the 12 months before delivery were more likely to delay entry into prenatal care than were women who had not experienced physical violence.

METHODS

We analyzed data from the Pregnancy Risk Assessment Monitoring System. The sample included 27,836 women who delivered live infants during 1993-1994 in nine states and were surveyed 2-6 months after delivery. We calculated risk ratios and 95% confidence intervals (CIs) to measure the association between physical violence within the 12 months before delivery and entry into prenatal care.

RESULTS

The prevalence of delayed entry into prenatal care (entering after the first trimester) was 18.1% and that of reported physical violence was 4.7%. Overall, women who experienced physical violence were 1.8 times more likely (95% CI 1.5, 2.1) to have delayed entry into prenatal care than women who had not experienced such violence. When stratifying by selected maternal characteristics, this association was found only for groups of women who were 25 years of age or older or were of higher socioeconomic status.

CONCLUSION

Older women and women of higher socioeconomic status who reported physical violence were more likely to delay entry into prenatal care than younger or less affluent women.