Contributions of CenteringPregnancy to women's health behaviours, health literacy, and health care use in the Netherlands

The objective of this study was to assess the effects of CenteringPregnancy (CP) in the Netherlands on different health outcomes. A stepped wedged cluster randomized trial was used, including 2132 women of approximately 12 weeks of gestation, from thirteen primary care midwifery centres in and around Leiden, Netherlands. Data collection was done through self-administered questionnaires. Multilevel intention-to-treat analysis and propensity score matching for the entire group and separately for nulliparous- and multiparous women were employed. The main outcomes were: health behaviour, health literacy, psychological outcomes, health care use, and satisfaction with care. Women's participation in CP is associated with lower alcohol consumption after birth (OR = 0.59, 95 %CI 0.42-0.84), greater consistency with norms for healthy eating and physical activity (β = 0.19, 95 %CI 0.02-0.37), and higher knowledge about pregnancy (β = 0.05, 95 %CI 0.01-0.08). Compared to the control group, nulliparous women who participating in CP reported better compliance to the norm for healthy eating and physical activity (β = 0.28, 95 %CI0.06-0.51)) and multiparous CP participants consumed less alcohol after giving birth (OR = 0.42, 95 %CI 0.23-0.78). Health care use and satisfaction rates were significantly higher among CP participants. A non-significant trend toward lower smoking rates was documented among CP participants. Overall, the results of this study reveal a positive (postpartum) impact on fostering healthy behaviours among participants.

Qualitative analysis of anti-abortion discourse used in arguments for a 6-week abortion ban in South Carolina

Background

On June 24, 2022, The U.S. Supreme Court overturned Roe v. Wade, leaving abortion legislation entirely up to states. However, anti-abortion activists and legislators have organized for decades to prevent abortion access through restrictive state-level legislation. In 2019, South Carolina legislators proposed a bill criminalizing abortion after 6 weeks gestation, before most people know they are pregnant. The current study examines the anti-abortion rhetoric used in legislative hearings for this extreme abortion restriction in South Carolina. By examining the arguments used by anti-abortion proponents, we aim to expose their misalignment with public opinion on abortion and demonstrate that their main arguments are not supported by and often are counter to medical and scientific evidence.

Methods

We qualitatively analyzed anti-abortion discourse used during legislative hearings of SC House Bill 3020, The South Carolina Fetal Heartbeat Protection from Abortion Act. Data came from publicly available videos of legislative hearings between March and November 2019, during which members of the public and legislators testified for and against the abortion ban. After the videos were transcribed, we thematically analyzed the testimonies using a priori and emergent coding.

Results

Testifiers (Anti-abortion proponents) defended the ban using scientific disinformation and by citing advances in science to redefine "life." A central argument was that a fetal "heartbeat" (i.e., cardiac activity) detected at 6 weeks gestation indicates life. Anti-abortion proponents used this to support their argument that the 6-week ban would "save lives." Other core strategies compared anti-abortion advocacy to civil rights legislation, vilified supporters and providers of abortion, and framed people who get abortions as victims. Personhood language was used across strategies and was particularly prominent in pseudo-scientific arguments.

Discussion

Abortion restrictions are detrimental to the health and wellbeing of people with the potential to become pregnant and to those who are pregnant. Efforts to defeat abortion bans must be grounded in a critical and deep understanding of anti-abortion strategies and tactics. Our results reveal that anti-abortion discourse is extremely inaccurate and harmful. These findings can be useful in developing effective approaches to countering anti-abortion rhetoric.

Group Care in the first 1000 days: implementation and process evaluation of contextually adapted antenatal and postnatal group care targeting diverse vulnerable populations in high-, middle- and low-resource settings

Background

Group care (GC) improves the quality of maternity care, stimulates women’s participation in their own care and facilitates growth of women’s social support networks. There is an urgent need to identify and disseminate the best mechanisms for implementing GC in ways that are feasible, context appropriate and sustainable. This protocol presents the aims and methods of an innovative implementation research project entitled Group Care in the first 1000 days (GC_1000), which addresses this need.

Aims

The aim of GC_1000 is to co-create and disseminate evidence-based implementation strategies and tools to support successful implementation and scale-up of GC in health systems throughout the world, with particular attention to the needs of ‘vulnerable’ populations.

Methods

By working through five inter-related work packages, each with specific tasks, objectives and deliverables, the global research team will systematically examine and document the implementation and scale-up processes of antenatal and postnatal GC in seven different countries. The GC_1000 project is grounded theoretically in the consolidated framework for implementation research (CFIR), while the process evaluation is guided by ‘Realistic Evaluation’ principles. Data are gathered across all research phases and analysis at each stage is synthesized to develop Context-Intervention-Mechanism-Outcome configurations.

Discussion

GC_1000 will generate evidence-based knowledge about the integration of complex interventions into diverse health care systems. The 4-year project also will pave the way for sustained implementation of GC, significantly benefitting populations with adverse pregnancy and birthing experiences as well as poor outcomes.

Men's Vasectomy Knowledge, Attitudes, and Information-Seeking Behaviors in the Southern United States: Results From an Exploratory Survey

Vasectomy is one of the few options men have to manage their reproductive capacity and take on a more equitable role in pregnancy prevention. While the method is underused throughout the United States, the southern states have a lower prevalence rate compared to the rest of the country. Existing survey research does not assess what men know or think about the procedure as a means of understanding why this is the case. We created and conducted an exploratory survey to assess men’s knowledge, attitudes, and information-seeking behaviors about vasectomy in the Southern United States. We used targeted Facebook advertising to recruit men ages 25–70 years living in 7 southern states to complete an online survey (n = 397). Using regression analyses, we identify that participants who had a vasectomy knew more about the procedure than participants who had not. Participants who had not had a vasectomy had less positive attitudes about the procedure across all six attitude subscales compared to participants with vasectomies. We highlight potential avenues for future research to understand why this may be the case. Finally, the majority of participants knew someone who had had a vasectomy. This suggests that men disclose having a vasectomy to others. The interpersonal dynamics around vasectomy decision-making and disclosure remain unknown and a viable area for future research. Findings from this exploratory survey may be used by public health officials interested in implementing campaigns to increase knowledge about vasectomy and reduce stigma, which may encourage more positive attitudes about the procedure.

A qualitative exploration of men's perceptions of the terms "male sterilization" versus "vasectomy" in the southern United States

OBJECTIVES

Clinical literature and contraception information guides use the terms "male sterilization" and "vasectomy" interchangeably. We investigate the meanings men attach to "sterilization" and how those meanings compare to perceptions of "vasectomy."

STUDY DESIGN

Cisgender, heterosexual men, ages 25 to 67, living across seven U.S. southern states participated in individual telephone interviews from May to December 2019. Interviews explored men's experiences with contraception, including their perception of the term "sterilization." We audio-recorded and transcribed the interviews and conducted thematic analyses using an inductive approach.

RESULTS

While most participants described "vasectomy" as a relatively benign procedure, they described "sterilization" as "sinister," "bleak," and "barbaric." Participants' discussions of sterilization invoked associations with eugenicist practices and specific historical examples of forced sterilization. While some participants recognized that vasectomy is a means of achieving sterilization, most viewed the term "sterilization" as incongruous with the modern medical procedure of "vasectomy," precisely because sterilization has been used as a form of reproductive oppression.

CONCLUSION

Our findings suggest that men have strong affective responses to the term "sterilization." Participants' knowledge of historical eugenicist practices has implications for the acceptability of vasectomy as a permanent contraceptive option in our contemporary context.

IMPLICATIONS

The phrase "male sterilization" can be associated with eugenics and coercive reproductive practices. Using the term for reproductive counselling, education, or research purposes may have implications for the acceptability of vasectomy as a permanent contraceptive option.

Impacts of the COVID-19 pandemic on the productivity of academics who mother

The aim of the study is to document how academics who mother have reorganized work and childcare since the beginning of the coronavirus (COVID‐19) pandemic in the United States, how those shifts have affected their academic productivity, and solutions proposed by academics living these experiences. We collected data via an online survey and, subsequently, by conducting qualitative interviews with a subsample of participants. From June to August 2020, 131 female‐identified academics who mother were recruited via a Facebook group, Academic Mamas, and participated in our online survey. Twenty participants were then interviewed via phone or Zoom to explore more deeply the experiences of academics who mother. Results of our research suggest that since the start of the COVID‐19 pandemic, the pressure on academics who mother is immense. Analysis of the qualitative data revealed three major themes: (1) inability to meet institutional expectations; (2) juggling work and family life; and (3) proposed solutions. Our results suggest that significant efforts must be made by academic institutions to acknowledge and value the childcare responsibilities of academics who mother and to create solutions that fully address the challenges they face in meeting the academic expectations and requirements that largely remain unmodified despite the pandemic.

Core strategies, social processes, and contextual influences of early phases of implementation and statewide scale-up of group prenatal care in South Carolina

This mixed-methods process evaluation examined a state-wide, interagency collaborative in South Carolina that expanded CenteringPregnancy group prenatal care from two to five additional healthcare practices from 2012 to 2015. The evaluation focused on delineating core processes, strategies, and external contextual elements of group prenatal care implementation and scale-up. Success of this scale-up was enhanced by the effective use and creation of windows of opportunity, which allowed stakeholders to pursue actions consistent with their own values, at both state and organizational levels. Most importantly, strong political advocacy and state-level financial commitment for group prenatal care made it possible for clinics throughout South Carolina to begin providing CenteringPregnancy to their patients. Improved understanding of the processes involved in scaling-up pilot interventions may enhance the effectiveness and efficiency of future expansion efforts.

Activist framing of abortion and use for policy change in Peru

Identifying how activists frame the topic of abortion is key to unpacking their understanding of “abortion” in Peru. It is important to explore how and why certain frames are privileged in attempts to shift policy and social norms. In 2016, the authors conducted qualitative interviews with 10 activists in Lima, Peru to develop a deep understanding of these issues. Activists worked through different approaches and lenses, including law, medicine, sociology, psychiatry, journalism, non-governmental organisational management, LGBTQ rights, and indigenous rights. Four common frames emerged through the analysis and those frames shifted based on whether activists were speaking to the general public or to policymakers. Understanding Peru's activist framing of abortion can contribute to a deeper analysis of regional and global movements to legalise abortion, which also take into account local specificities.

Women's post-rape experiences with Guatemalan health services

We conducted a qualitative study to examine the critical pathways of 23 women survivors of sexual assault who navigated health care-based services in six states in Guatemala. We also captured the components of quality health care that were important to them, including the experience of the waiting room, being able to make active decisions, providing informed consent, and receiving emotional support. Our results from the in-depth, semi-structured interviews indicate the importance of creating and strengthening mechanisms for social support and trauma-informed, competent, and sensitive health services to accompany women as they move toward rebuilding their lives post-sexual violence.

Concordance and Discordance of the Knowledge, Understanding, and Description of Children's Experience of Food Insecurity Among Hispanic Adults and Children

Food insecurity is highly detrimental for children, who experience food insecurity differently than do adults. We aimed to understand concordance and discordance of adults' and children's knowledge, understanding, and description of children's experience of food insecurity. In-depth interviews were conducted with the primary caregiver, another caregiver, and a child 9 to 16 years of age in 16 Hispanic families at risk of food insecurity in South Carolina. Adults often lacked knowledge of the food insecurity experiences of their children, which presents challenges for adults with roles as caregivers, educators, or policy makers to recognize and address these experiences.

Detection and care practices for postpartum depressive symptoms in public-sector obstetric units in Mexico: Qualitative results from a resource-constrained setting

BACKGROUND

Postpartum depression (PPD) is amenable to detection and treatment, but effectively addressing it is contingent on policies, practices, and health care providers working together to address the issue. The aim of this study is to describe a sample of health care providers' existing practices in public-sector obstetric units in Mexico related to detecting and offering care to women with depressive symptomology.

METHODS

Semi-structured interviews with 40 health care providers (16 physicians, 13 nurses, three social workers, and eight psychologists) from one tertiary-level and two secondary-level, public-sector obstetric units, were conducted by members of a trained research team from May to July 2012. Qualitative data were analyzed in Spanish according to Grounded Theory, using Nvivo 10 software.

RESULTS

Lack of hospital guidelines, training, and time constraints are reasons given for not detecting PPD symptoms among women. Providers reported that their role is cursory and limited to giving women anticipatory guidance for what to expect emotionally after childbirth or providing a trusting atmosphere for women to express their feelings. Care is fragmented and inadequate, in part because of the lack of protocols that define who makes mental health referrals and where. Providers indicated PPD is important but not prioritized in health care for pregnant and postpartum women.

CONCLUSION

Critical needs in obstetric units include formal mental health care detection and care protocols during the perinatal period, strategies to address mental health needs despite short hospital stays, and training for providers on how to implement detection and care protocols and strategies.

Perceptions and Experiences of Human Papillomavirus (HPV) Infection and Testing among Low-Income Mexican Women

BACKGROUND

HPV infection causes cervical cancer, a major contributor to morbidity and mortality among low-income Mexican women. Human papillomavirus (HPV) DNA testing is now a primary screening strategy in Mexico's early cervical cancer detection program (ECDP). Research on Mexican women's perceptions of HPV and testing is necessary for establishing culturally appropriate protocols and educational materials. Here, we explore perceptions about HPV and HPV-related risk factors among low-income Mexican ECDP participants.

METHODS

We conducted semi-structured interviews with 24 ECDP participants from two primary care health clinics in Michoacán state, Mexico. Interviews addressed women's understandings of and experiences with HPV and HPV testing. Analysis was inductive and guided by the Health Belief Model with a focus on gender.

RESULTS

Women's confusion about HPV and HPV screening caused emotional distress. They understood HPV to be a serious disease that would always cause severe symptoms, often characterizing it as analogous to HIV or inevitably carcinogenic. Women also attributed it to men's sexual behaviors, specifically infidelity and poor hygiene. Women described both sexes' desire for sex as natural but understood men's negative practices of masculinity, like infidelity, as the causes of women's HPV infection. Some women believed dirty public bathrooms or heredity could also cause HPV transmission.

CONCLUSIONS

These results are consistent with prior findings that geographically and economically diverse populations lack clear understandings of the nature, causes, or symptoms of HPV, even among those receiving HPV testing. Our findings also reveal that local cultural discourse relating to masculinity, along with failure to provide sufficient education to low-income and indigenous-language speaking patients, exacerbate women's negative emotions surrounding HPV testing. While negative emotions did not deter women from seeking testing, they could be ameliorated with better health education and communication.

Risk profiles associated with postnatal depressive symptoms among women in a public sector hospital in Mexico: the role of sociodemographic and psychosocial factors

This study examined the association between postnatal depressive symptoms and a set of demographic and psychosocial factors among 604 women attending a public hospital for postnatal care in Mexico City. Specific profiles of women that would indicate an increased probability for developing postnatal depression (PND) based on discrete combinations of risk and protective factors were generated. In a logistic model, followed by the estimation of predicted probabilities, we examined the association between depressive symptomatology and psychosocial factors: low social support, unplanned pregnancies, history of depression, and exposure to moderate or severe intimate partner violence (IPV) during pregnancy. Postnatal depressive symptomatology was reported by 10.6 % of the women, as measured by scores at 12 or above on the Edinburgh Postnatal Depression Scale. The cumulative probability of presenting PND in the simultaneous presence of the psychosocial factors was 67.0 %; however, this could be reduced to 5.5 % through preventive measures that work to eliminate low social support, unplanned pregnancy, and exposure to severe IPV during pregnancy. Early identification of psychosocial risk factors, specifically low social support, unplanned pregnancies, history of depression, and exposure to violence during pregnancy, is recommended.

Conceptualizations of postpartum depression by public-sector health care providers in Mexico

In this article we describe the knowledge frameworks that 61 physicians, nurses, social workers, and psychologists from five public-sector health care facilities in Mexico used to conceptualize postpartum depression. We also demonstrate how providers applied social and behavioral antecedents in their conceptualizations of postpartum depression. Using grounded theory, we identify two frameworks that providers used to conceptualize postpartum depression: biochemical and adjustment. We highlight an emerging model of the function of social and behavioral antecedents within the frameworks, as well as the representation of postpartum depression by symptoms of distress and the perception among providers that these symptoms affected responsibilities associated with motherhood. The results provide a foundation for future study of how providers' conceptualizations of postpartum depression might affect detection and treatment practices and might be useful in the development of training materials to enhance the quality of care for women who experience any form of distress in the postpartum period.

Dietary intake, eating behaviors, and quality of life in women with polycystic ovary syndrome who are trying to conceive

The Healthy Eating for Reproductive Health study was conducted among 18 (45% non-white) mostly obese (BMI 39.9 ± 6.1) women with polycystic ovary syndrome (PCOS) who were experiencing infertility and interested in losing weight. A variety of markers were measured at baseline: body mass index (BMI), diet, physical activity, eating behaviors (using an Eating Behavior Inventory, a questionnaire which assesses both positive and negative eating behaviors associated with weight status, with a higher score indicating adoption of eating behaviors which have been shown in prior weight-loss research to promote a healthy weight (EBI) and the Three-Factor Eating Questionnaire, which assesses cognitive and behavioral components of eating among overweight adults), and a quality of life (PCOS Health-Related Quality of Life (PCOSQ)) index, which assesses satisfaction around five 'domains': emotional health, presence of body hair, infertility, weight, and menstrual problems). A comparison group of overweight women without PCOS (n = 28) was used to examine differences in measured outcomes between women with and without PCOS. Participants' habitual diets were high in fat and saturated fat and low in fiber, folate, and iron and contained significantly lower amounts of carbohydrate, iron, and whole grains compared with women without PCOS who had enrolled in a behavioral weight loss programme. Participants had a low EBI (indicating that most were not adopting eating behaviors associated with achieving a healthy weight), disinhibition (indicating participants had a tendency to overeat in the presence of highly palatable foods or were susceptible to emotional cues for eating, such as stress), and hunger scores (indicating participants did not report being susceptible to hunger, prompting overeating) and moderate dietary restraint (indicating they were not consistently attempting to restrict food intake consciously). PCOSQ scores were lowest for infertility and weight domains (indicating low satisfaction with current infertility and weight status); however all domains received low scores (emotional health, body hair, and menstrual problems). Higher energy intakes (kcal/day) were associated with a lower EBI score (r = - 0.60, P = 0.02), lower dietary restraint (r =- 0.50, P = 0.04), and higher disinhibition (r = 0.63, P = 0.01). Greater energy expenditure (kcal/day) was associated with lower PCOSQ scores for body weight (r =-0.54, P = 002) and infertility (r =- 0.51, P = 0.003) domains. Results suggest that overweight women with PCOS-related infertility have poor dietary intake, particularly in terms of whole grains, fiber, and iron, and eating behaviors inconsistent with achieving a healthy body weight, as well as low scores for PCOS-related quality of life.

Are movies with tobacco, alcohol, drugs, sex, and violence rated for youth? A comparison of rating systems in Argentina, Brazil, Mexico, and the United States

BACKGROUND

This study aimed to determine between-country differences and changes over time in the portrayal of youth risk behaviors in films rated for youth in Argentina, Brazil, Mexico and the United States.

METHODS

Content and ratings were analyzed for 362 films that were popular across all four countries from 2002 to 2009. Country-specific ratings were classified as either youth or adult, and Generalized Estimating Equations were used to determine between-country differences in the presence of tobacco, alcohol, drugs, sexual content, and violence in youth-rated films. Within-country differences in this content over time were also assessed, comparing films released from 2002 to 2005 with those released from 2006 to 2009.

RESULTS

In the US, films rated for youth were less likely to contain all five risk behaviors than in youth-rated films in Argentina, Brazil, and, when the "15 and older" rating was considered a youth rating, in Mexico. All three Latin American countries "downrated" films that received an adult rating in the US. Nevertheless, tobacco and drug use in youth-rated films declined over time in all countries, whereas moderate to extreme alcohol use and violence involving children or youth increased in all countries.

CONCLUSIONS

Tobacco and drug use have declined in popular US films, but these behaviors are still prevalent in films rated for youth across the Americas. The apparent success of advocacy efforts to reduce tobacco and other drugs in films suggests that similar efforts be directed to reduce alcohol portrayals.

Incorporating human rights into reproductive health care provider education programs in Nicaragua and El Salvador

Health care providers play a central role in the promotion and protection of human rights in patient care. Consequently, the World Medical Association, among others, has called on medical and nursing schools to incorporate human rights education into their training programs. This report describes the efforts of one Central American nongovernmental organization to include human rights - related content into reproductive health care provider training programs in Nicaragua and El Salvador. Baseline findings suggest that health care providers are not being adequately prepared to fulfill their duty to protect and promote human rights in patient care. Medical and nursing school administrators, faculty, and students recognize the need to strengthen training in this area and are enthusiastic about incorporating human rights content into their education programs. Evaluation findings suggest that exposure to educational materials and methodologies that emphasize the relationship between human rights and reproductive health may lead to changes in health care provider attitudes and behaviors that help promote and safeguard human rights in patient care.

Exploring Rape Myths, Gendered Norms, Group Processing, and the Social Context of Rape Among College Women

The purpose of this research is to explore the negotiation strategies of college women as they interpret ambiguous rape scenarios. In focus groups, 1st- and 4th-year college women were presented with a series of three vignettes depicting incidents that meet the legal criteria for rape yet are ambiguous due to the presence of cultural rape myths, contexts involving alcohol consumption, varying degrees of consent, and a known perpetrator. These contexts are critical in understanding how college women define rape. Key findings indicated many of these college women utilized rape myths and norms within their peer groups to interpret rape scenarios.

Roles of pharmacists in expanding access to safe and effective medical abortion in developing countries: a review of the literature

Unsafe abortion continues to be a major contributor to maternal mortality and morbidity around the world. This article examines the role of pharmacists in expanding women's access to safe medical abortion in Latin America, Africa, and Asia. Available research shows that although pharmacists and pharmacy workers often sell abortion medications to women, accurate information about how to use the medications safely and effectively is rarely offered. No publication covered effective interventions by pharmacists to expand access to medical abortion, but lessons can be learned from successful interventions with other reproductive health services. To better serve women, increasing awareness and improving training for pharmacists and pharmacy workers about unsafe abortion - and medications that can safely induce abortion - are needed.

Physicians' agreement with and willingness to provide abortion services in the case of pregnancy from rape in Mexico

BACKGROUND

In Mexico, abortion is not penalized when a woman gets pregnant as a result of rape, yet access to abortion services is limited. Understanding physicians' opinions about abortion is critical to creating strategies that will broaden women's access to services.

STUDY DESIGN

Multivariate logistic regression was performed using data collected from a sample of 1206 physicians in Mexico. The influence of independent variables on two outcomes was analyzed: physicians' agreement with abortion being legal in the case of pregnancy caused by rape and willingness to provide abortion services in such cases.

RESULTS

Physicians who had performed legal abortions, knew about existing abortion legislation and practiced general or family medicine were significantly more likely to agree that abortion should be legal when pregnancy is caused by rape and were more likely to be willing to provide abortion in the case of rape. Physicians who held a negative attitude towards women who seek abortion and those with greater church attendance were less likely to agree with the legality of abortion.

CONCLUSIONS

Physicians are among the most important gatekeepers to women's access to safe abortion services. A majority of Mexican physicians agree that abortion should not be legally penalized under certain circumstances. Yet, many also hold negative attitudes towards women who seek abortion. Physicians' support for women's access to safe abortion services is key to ensuring that such services will exist in Mexico.

[Abortion and medical education in Mexico]

Medical education in Mexico has significant deficiencies in the area of sexual and reproductive health and does not offer students the information needed for dealing with abortion as a relevant problem in the professional practice of medicine. Medical education does not offer options for the clinical training of future physicians in integrated models for abortion care, which include the use of safe and effective technologies as well as a range of services to respond to women's needs. These limitations are especially relevant in countries such as Mexico where unsafe abortion continues to be a significant public health problem. In addition, the legal context for abortion has begun to change during the current decade; therefore, the search for alternatives to incorporate a broad approach to abortion in medical school programs is a task that cannot be postponed.

Violencia de pareja en mujeres embarazadas en la Ciudad de México

OBJETIVO: Analisar los factores relacionados a la violencia de pareja en mujeres embarazadas. MÉTODOS: Se recolectó la información de 383 mujeres derechohabientes del Instituto Mexicano del Seguro Social que acudieron a control prenatal en cinco Unidades de Medicina Familiar en la Ciudad de México entre septiembre del 2003 y agosto del 2004. Ellas respondieran a un cuestionario de violencia elaborado específicamente para el estudio. RESULTADOS: De las mujeres, 120 (31.1%) reportaron haber estado expuestas a la violencia psicológica y/o física, y/o sexual por parte de su pareja masculina durante el embarazo actual, el 10% reportaron violencia combinada y 21% violencia aislada. La violencia psicológica fue la más frecuentemente reportada (93% del grupo "había experimentado violencia"). Con relación a la percepción sobre la violencia no había diferencias significativas entre los grupos de mujeres con y sin violencia. Solo alrededor de 20% de las mujeres tenían conocimiento sobre los lugares donde atienden a las victimas de violencia. Los factores asociados significativamente a la violencia de pareja en las mujeres embarazadas fueron ser soltera (RM=3.02, IC 95%:1.17;7.83), vivir en unión libre (RM=2.22, IC 95%: 1.11;4.42), antecedentes de violencia en la infancia (RM=3.08, IC 95%:1.62;5.85), consumo de bebidas alcohólicas en la pareja (RM=1.87, IC 95%:1.02;3.42) y presencia de alteraciones emocionales (RM=4.17, IC 95%: 1.12;15.51). CONCLUSIONES: Los resultados refuerzan los hallazgos de otros estudios de que el problema de violencia en mujeres embarazadas en México sigue siendo un problema frecuente.

Scaling-up a public health innovation: A comparative study of post-abortion care in Bolivia and Mexico

Post-abortion care (PAC), an innovation for treating women with complications of unsafe abortion, has been introduced in public health systems around the world since the 1994 International Conference on Population and Development (ICPD). This article analyzes the process of scaling-up two of the three key elements of the original PAC model: providing prompt clinical treatment to women with abortion complications and offering post-abortion contraceptive counseling and methods in Bolivia and Mexico. The conceptual framework developed from this comparative analysis includes the environmental context for PAC scale-up; the major influences on start-up, expansion, and institutionalization of PAC; and the health, financial, and social impacts of institutionalization. Start-up in both Bolivia and Mexico was facilitated by innovative leaders or catalyzers who were committed to introducing PAC services into public health care settings, collaboration between international organizations and public health institutions, and financial resources. Important processes for successful PAC expansion included strengthening political commitment to PAC services through research, advocacy, and partnerships; improving health system capacity through training, supervision, and development of service guidelines; and facilitating health system access to essential technologies. Institutionalization of PAC has been more successful in Bolivia than Mexico, as measured by a series of proposed indicators. The positive health and financial impacts of PAC institutionalization have been partially measured in Bolivia and Mexico. Other hypotheses--that scaling-up PAC will significantly reduce maternal mortality and morbidity, decrease abortion-related stigma, and prepare the way for efforts to reform restrictive abortion laws and policies--have yet to be tested.

Abortion and postabortion care: ethical, legal, and policy issues in developing countries

This case study of a woman who wants to terminate her pregnancy but does not have access to safe services explores the technical, ethical, and legal effects of the Mexico City Policy (Global Gag Rule) on health care providers working in developing countries. This woman's self-induced termination resulted in an incomplete abortion, and she sought care from a midwife. The current Mexico City Policy effectively limits a health care provider's ability to offer abortion services and counseling, even when these services are legal. The policy has an adverse impact on women's access to safe care. The provision of comprehensive postabortion care, not restricted by the Mexico City Policy, is the key to preventing abortion-related morbidity and mortality.

Health care-based interventions for women who have experienced sexual violence: a review of the literature

Thirty publications that evaluated health care-based interventions for women who experienced sexual violence were reviewed. The findings highlight that clinicians often need training in the provision sexual assault care, and that not all emergency departments have sexual assault care protocols. Studies examining effectiveness found that Sexual Assault Nurse Examiner programs are very helpful, that health care-based sexual assault treatment settings attract more women than do forensic-based settings, that sexual assault survivors often prefer a combination of medication and counseling treatment, and that preexam administration of a video explaining the collection of forensic evidence may reduce women's stress during the procedure. Studies on postexposure HIV prophylaxis found that many women did not complete the treatment regimen, often because of side effects. Emergency contraception to prevent postrape pregnancy is not consistently offered to women. Only one study reported on abortion as part of the range of sexual assault services.

Woman-centered post-abortion care in public hospitals in Tucumán, Argentina: assessing quality of care and its link to human rights

Unsafe abortion is a major public health and human rights problem in Argentina. Implementation of a woman-centered post-abortion care (PAC) model is one strategy to improve the situation. The quality of PAC services was measured in three public hospitals in Tucumán, a province with high levels of poverty and maternal mortality due to unsafe abortion. Overall, the quality of PAC services was found to be poor. Women do not receive services in a manner that respects their human rights, in particular their rights to health and health care, information, and to the benefits of scientific progress. Findings from the evaluation are being used to develop collaborative NGO/hospital/policy-maker efforts to improve PAC services through better training of health care providers.

Women's Perspectives on Medical Abortion in Mexico, Colombia, Ecuador and Peru: A Qualitative Study

In Latin America, where abortion is almost universally legally restricted, medical abortion, especially with misoprostol alone, is increasingly being used, often with the tablets obtained from a pharmacy. We carried out in-depth interviews with 49 women who had had a medical abortion under clinical supervision in rural and urban settings in Mexico, Colombia, Ecuador and Peru, who were recruited through clinicians providing abortions. The women often chose medical abortion to avoid a surgical abortion; they thought medical abortion was less painful, easier or simpler, safer or less risky. They commonly described it as a natural process of regulating their period. The fact that it was less expensive also influenced their decision. Some, who experienced a lot of pain, heavy bleeding or a failed procedure requiring surgical back-up, tended to be more negative about it. Regardless of legal restrictions, medical abortion was being provided safely in these settings and women found the method acceptable. Where feasible, it should be made available but cost should not have to be women's primary reason for choosing it. Psychosocial support during abortion is critical, especially for those who are more vulnerable because they see abortion as a sin, who are young or poor, who have limited knowledge about their bodies, whose partners are not supportive or who became pregnant through sexual violence.

Postabortion care in Latin America: policy and service recommendations from a decade of operations research

Unsafe abortion contributes significantly to maternal mortality and morbidity in Latin America. Postabortion care (PAC) using preferred technologies and a woman-centred approach to treat the complications of unsafe abortion can save women's lives and improve their reproductive health, as well as reduce costs to health systems. This article reviews results from 10 major PAC operations research projects conducted in public sector hospitals in seven Latin American countries, completed and published between 1991 and 2002. The studies show that following relatively modest interventions, the majority of eligible patients were being treated with manual vacuum aspiration (MVA), a method preferred for safety and other reasons over the method conventionally used in the region, sharp curettage (SC). A number of studies showed improvements in contraceptive counselling and services when these were integrated with clinical treatment of abortion complications, resulting in substantial increases in contraceptive acceptance. Finally, data from several studies showed that, in most settings, reorganizing services by moving treatment out of the operating theatre and reclassifying treatment as an ambulatory care procedure substantially reduced the resources used for PAC, as well as the cost and average length of women's stay in the hospital. These studies suggest that comprehensive PAC can and should be available to all women in Latin America. Such efforts should be coupled with work to improve primary prevention, including better contraceptive services to prevent unwanted pregnancy and safe, legal abortion services to reduce the number of clandestine and unsafe abortions.

Misoprostol Alone for Early Medical Abortion in a Latin American Clinic Setting

Misoprostol is being used widely by women throughout Latin America, often based on instructions passed along through friends, acquaintances or professionals who may have little information about safe and effective use. This paper presents the experience of a Latin American clinic working in a legally restrictive setting that offers misoprostol as one option to women seeking early pregnancy termination. Between February 2001 and June 2002, 3225 women who attended the clinic chose to use misoprostol rather than vacuum aspiration. 89.9% returned for follow-up, of whom 76.4% had had a complete abortion within 72 hours, using one, two or three doses of 800 micrograms of misoprostol administered by the woman herself vaginally every 24 hours. The first 78 women who returned for follow-up at 72 hours responded to a questionnaire regarding their experiences. Satisfaction with the abortion process was high, despite some pain, chills, diarrhoea and/or nausea. Seventy-two of the 78 women said they would use misoprostol again if they needed to terminate another pregnancy and would recommend it to a friend. Having a clinic where staff are knowledgeable and experienced in misoprostol use is particularly important in settings where abortion is stigmatised, unsafe abortion common and access to safe services limited.

Comparing the quality of three models of postabortion care in public hospitals in Mexico City

CONTEXT

Each year, an estimated 120,000 women in Mexico seek treatment in public hospitals for abortion-related complications--the country's fourth leading cause of maternal mortality. Models of postabortion care emphasizing counseling and provision of contraceptives have the potential to improve the quality of care these women receive.

METHODS

Between April 1997 and August 1998, women treated for abortion complications in six Mexican Institute of Social Security (IMSS) hospitals in the Mexico City metropolitan area were surveyed. Data related to patient-provider interaction, information provision and counseling were analyzed for three models of care: sharp curettage standard care, sharp curettage postabortion care and manual vacuum aspiration postabortion care.

RESULTS

Women in the two postabortion care groups rated the quality of services they received more highly than did those receiving sharp curettage standard care. A significantly greater proportion of women treated under the postabortion care models than of those treated under the sharp curettage standard model received information about their health status before treatment, the uterine evacuation procedure, signs of postabortion complications and care at home. In addition, a greater proportion of women treated under the postabortion care models accepted a contraceptive method before leaving the facility (64-78% vs. 40%).

CONCLUSIONS

Implementation of a postabortion care model contributes to the delivery of high-quality services to women experiencing abortion complications. The standard IMSS model of postabortion treatment should be modified to emulate those in hospitals that systematically link general counseling and family planning services to the clinical services provided to women with abortion complications.

Midwives and postabortion care: experiences, opinions, and attitudes among participants at the 25th Triennial Congress of the International Confederation of Midwives

Midwifery practice may not include caring for women experiencing complications from unsafe abortion, despite the importance of this care for the health and lives of millions of women around the world. This article summarizes data collected from midwives from 41 countries who attended the 25th Triennial Congress of the International Confederation of Midwives in 1999, focusing on their experiences with, and attitudes toward, the provision of postabortion care. Barriers to provision of postabortion care and factors for changes in postabortion care-related policies were explored. Midwives from developing countries, where complications from unsafe abortion present a serious public health problem, were cognizant of the need to authorize, train, and equip midwives in postabortion care, including the use of uterine evacuation of incomplete abortion with manual vacuum aspiration. Changes in policy and practice are needed throughout the world so that women will have access to quality, compassionate postabortion care services regardless of where they live. Ensuring that midwives are able to provide such services will help to reduce abortion-related morbidity and mortality.

Constructing access to legal abortion services in Mexico City

For the last three decades, government and health institutions have recognised that unsafe abortion is an important social and public health problem in Mexico. Although the Penal Code in every state defines at least one situation in which abortion is legal, access to legal abortion services is restricted for women throughout Mexico. In August 2000, the Mexico City Legislative Assembly reformed the Penal Code to include a wider range of grounds on which abortion is legal and added regulations to ensure access to legal abortion services in cases of rape and forced artificial insemination. The Mexican Supreme Court upheld the constitutionality of the reforms in January 2002. This paper describes a collaborative project between Ipas Mexico and the Mexico City Department of Health to provide legal abortions in cases of rape and to ensure that comprehensive health services for survivors of sexual violence are available and accessible. It describes a model of care being introduced into 15 public general and maternal-child health hospitals in Mexico City through a programme of multi-disciplinary consciousness-raising workshops and training courses on sexual violence and legal abortion. Few health care providers have had prior training in service provision for survivors of sexual violence or abortion service delivery. Workshop participants showed a high level of willingness to participate in legal abortion services for survivors of sexual violence when and if they are receive solid institutional support.