The experience of abortion for Cook Islands women: exploring the socio-cultural dimensions of abortion safety

Abortion is significantly restricted by law in most Pacific Island countries, impacting the rights, health and autonomy of people who experience pregnancy. We undertook qualitative research between February and August 2022 on Rarotonga, Cook Islands, where abortion is illegal under most circumstances. We conducted interviews with women who had accessed or tried to access abortion services; people who had supported women to access abortion services; health workers; and advocates to understand their experiences regarding abortion. We conducted focus groups to explore broader social perceptions and experiences of sexual and reproductive health and rights, including abortion. Participants described their abortion decisions and methods, and their negotiation of the personal context of their sexual behaviours, pregnancies, and abortions relative to their socio-cultural context and values. As defined by the World Health Organization, safe abortion relates to the methods and equipment used and the skills of the abortion provider. We argue for an expansion of this definition to consider inclusion of reference to individuals' 'abortion safety nets' as the sum of their access to financial, political, health care and socio-cultural resources. These safety nets are shaped by discourses related to abortion and socio-cultural support and values, impacting physical, emotional, psychological, social and spiritual health.

Framings of abortion in Pacific Island print media: qualitative analysis of articles, opinion pieces, and letters to the editor

Abortion is significantly restricted by law in most Pacific Island countries, and this has profound implications for the lives and health of women from this region. There are limited data on how abortion is framed in the Pacific Islands: that is, interpreted, discussed, and made meaningful as an issue in public forums. How abortion is framed can have implications for how it is treated in public and political debate and policy, abortion stigmatisation, and inform advocacy strategies. We undertook a thematic analysis of 246 articles, opinion pieces, and letters to the editor that covered the topic of abortion in mainstream print media. We found three dominant framings. Abortion was often positioned in opposition to gender ideology and national identity, with gender and national identity constructed by many commentators according to socially conservative, Christian doctrine. Abortion was also constructed as the killing of the "unborn," with the fetus positioned as the key social subject. Alternatively, abortion was framed as often unsafe and a response to teenage pregnancy, with various solutions suggested in this context. Few commentators constructed women who experienced unwanted pregnancies and abortions as making decisions about their pregnancies in response to complex gendered and socio-economic conditions. Dominant framings of abortion as opposed to gender ideals, nationalism, and the killing of the "unborn" complicate simplified appeals to "choice" in advocacy efforts. Focusing on health and broader injustice experienced by women offer alternative framings.

Illegal abortion and reproductive injustice in the Pacific Islands: A qualitative analysis of court data

The Oceania region is home to some of the world's most restrictive abortion laws, and there is evidence of Pacific Island women's reproductive oppression across several aspects of their reproductive lives, including in relation to contraceptive decision-making, birthing, and fertility. In this paper we analyse documents from court cases in the Pacific Islands regarding the illegal procurement of abortion. We undertook inductive thematic analysis of documents from eighteen illegal abortion court cases from Pacific Island countries. Using the lens of reproductive justice, we discuss the methods of abortion, the reported context of these abortions, and the ways in which these women and abortion were constructed in judges' summing up, judgements, or sentencing. Our analysis of these cases reveals layers of sexual and reproductive oppression experienced by these women that are related to colonialism, women's socioeconomic disadvantage, gendered violence, limited reproductive control, and the punitive consequences related to not performing gender appropriately.

Loss to follow up of pregnant women with HIV and infant HIV outcomes in the prevention of maternal to child transmission of HIV programme in two high-burden provinces in Papua New Guinea: a retrospective clinical audit

INTRODUCTION

Despite early adoption of the WHO guidelines to deliver lifelong antiretroviral (ARV) regimen to pregnant women on HIV diagnosis, the HIV prevention of mother to child transmission programme in Papua New Guinea remains suboptimal. An unacceptable number of babies are infected with HIV and mothers not retained in treatment. This study aimed to describe the characteristics of this programme and to investigate the factors associated with programme performance outcomes.

METHODS

We conducted a retrospective analysis of clinical records of HIV-positive pregnant women at two hospitals providing prevention of mother to child transmission services. All women enrolled in the prevention of mother to child transmission programme during the study period (June 2012-June 2015) were eligible for inclusion. Using logistic regression, we examined the factors associated with maternal loss to follow-up (LTFU) before birth and before infant registration in a paediatric ARV programme.

RESULTS

763 of women had records eligible for inclusion. Demographic and clinical differences existed between women at the two sites. Almost half (45.1%) of the women knew their HIV-positive status prior to the current pregnancy. Multivariate analysis showed that women more likely to be LTFU by the time of birth were younger (adjusted OR (AOR)=2.92, 95% CI 1.16 to 7.63), were newly diagnosed with HIV in the current/most recent pregnancy (AOR=3.50, 95% CI 1.62 to 7.59) and were in an HIV serodiscordant relationship (AOR=2.94, 95% CI 1.11 to 7.84). Factors associated with maternal LTFU before infant registration included being primipara at the time of enrolment (AOR=3.13, 95% CI 1.44 to 6.80) and being newly diagnosed in that current/most recent pregnancy (AOR=2.49, 95% CI 1.31 to 4.73). 6.6% (50 of 763) of exposed infants had a positive HIV DNA test.

CONCLUSIONS

Our study highlighted predictors of LTFU among women. Understanding these correlates at different stages of the programme offers important insights for targets and timing of greater support for retention in care.

Programmes for the prevention of parent-to-child transmission of HIV in Papua New Guinea: Health system challenges and opportunities

BACKGROUND

Prevention of parent-to-child transmission (PPTCT) of HIV is a highly complex package of interventions, which spans services in both maternal and child health programmes. In Papua New Guinea (PNG), a commitment to ensure that all pregnant women and their partners have access to the full range of PPTCT interventions exists; however, efforts to increase access and utilisation of PPTCT remain far from optimal. The aim of this paper is to examine health care worker (HCW) perception of health system factors impacting on the performance of PPTCT programmes.

METHOD

Sixteen interviews were undertaken with HCWs involved in the PPTCT programme. Application of the WHO 6 building blocks of a health system was applied, and further thematic analysis was conducted on the data with assistance from the analysis software NVivo.

RESULTS

Broken equipment, problems with access to medication and supplies, and poorly supported workforce were reported as barriers for implementing a successful PPTCT programme. The absence of central coordination of this complex, multistaged programme was also recognised as a key issue.

CONCLUSION

The study findings highlight an important need for investment in appropriately trained and supported HCWs and integration of services at each stage of the PPTCT programme. Lessons from the PPTCT experience in PNG may inform policy discussions and considerations in other similar contexts.

Outcome of infants born to unbooked mothers: a short report from Goroka General Hospital, Eastern Highlands Province, Papua New Guinea

Despite the increasing availability of antenatal care in Papua New Guinea (PNG), women continue to present for confinement without having previously attended antenatal clinic. In this brief report we present the findings of a five-year retrospective study conducted at Goroka General Hospital, Eastern Highlands Province, PNG. Mothers who had not previously accessed antenatal care ('unbooked mothers') were more likely to experience stillbirth or early neonatal death of their infant than booked mothers.

Sociodemographic factors associated with maternal health care utilization in Wosera, East Sepik Province, Papua New Guinea

This retrospective study sought to describe the utilization of maternal health services in a rural community in Wosera, East Sepik Province, Papua New Guinea. Interviews were undertaken with a convenience sample of 391 women of reproductive age. We examined the relationship between socioeconomic and demographic characteristics and the use of antenatal clinic services and delivery at a health centre. Despite uptake of antenatal care services by 79% of women, two-thirds of women gave birth at home. Women's education was an independent predictor for maternal health care utilization, for both antenatal care and delivery at a health facility. At least one visit to an antenatal clinic was the strongest predictor of delivering at a health care facility. Women expressed barriers to assisted childbirth such as distance to health facilities, especially when labour came fast, and feelings of shame in presenting to a facility to give birth. This study provides important information relating to the uptake of maternal health care services. Despite the uptake of available antenatal care services, intrapartum services are not well accessed.

Sustainability of community-capacity to promote safer motherhood in northwestern Tanzania: what remains?

OBJECTIVE

To examine the remains of the Community-Based Reproductive Health Project (CBRHP) implemented by CARE-Tanzania to address high maternal mortality in two rural districts.

METHODS

In early 2007, data were collected from 29 villages and used to assess sustainability of emergency transport systems, retention of village health workers (VHWs), and their potential impact on maternal health. Surveillance data from the Ministry of Health were reviewed to assess changes in prenatal and service use indicators.

RESULTS

From 2001 through 2006, the CBRHP-trained VHWs have continued to provide education and referrals to women in their communities including prenatal and emergency obstetric care; six villages with emergency transport systems have continued for more than 5 years providing free or low-cost transport to health facilities. Selected maternal and infant health indicators, such as early prenatal care, identification of pregnancy-related danger signs, and data on maternal and infant outcomes, improved in the two targeted districts over time.

CONCLUSIONS

The two components of CBRHP, work of VHWs and community-financing for emergency transport systems in six villages, have continued. Both of these promote maternal health and linkages with the health delivery systems. Surveillance data show changes in maternal health indicators that were targeted by the district-wide CBRHP interventions. Programs such as CBRHP, with focus on capacity-building and empowerment, can assist in mobilizing the formal and informal systems in communities, components of which may be sustained over time.

How informed is consent in vulnerable populations? Experience using a continuous consent process during the MDP301 vaginal microbicide trial in Mwanza, Tanzania

BACKGROUND

HIV prevention trials conducted among disadvantaged vulnerable at-risk populations in developing countries present unique ethical dilemmas. A key concern in bioethics is the validity of informed consent for trial participation obtained from research subjects in such settings. The purpose of this study was to investigate the effectiveness of a continuous informed consent process adopted during the MDP301 phase III vaginal microbicide trial in Mwanza, Tanzania.

METHODS

A total of 1146 women at increased risk of HIV acquisition working as alcohol and food vendors or in bars, restaurants, hotels and guesthouses have been recruited into the MDP301 phase III efficacy and safety trial in Mwanza. During preparations for the trial, participatory community research methods were used to develop a locally-appropriate pictorial flipchart in order to convey key messages about the trial to potential participants. Pre-recorded audio tapes were also developed to facilitate understanding and compliance with gel-use instructions. A comprehension checklist is administered by clinical staff to all participants at screening, enrolment, 12, 24, 40 and 50 week follow-up visits during the trial. To investigate women's perceptions and experiences of the trial, including how well participants internalize and retain key messages provided through a continuous informed consent process, a random sub-sample of 102 women were invited to participate in in-depth interviews (IDIs) conducted immediately after their 4, 24 and 52 week follow-up visits.

RESULTS

99 women completed interviews at 4-weeks, 83 at 24-weeks, and 74 at 52 weeks (a total of 256 interviews). In all interviews there was evidence of good comprehension and retention of key trial messages including that the gel is not currently know to be effective against HIV; that this is the key reason for conducting the trial; and that women should stop using gel in the event of pregnancy.

CONCLUSIONS

Providing information to trial participants in a focussed, locally-appropriate manner, using methods developed in consultation with the community, and within a continuous informed-consent framework resulted in high levels of comprehension and message retention in this setting. This approach may represent a model for researchers conducting HIV prevention trials among other vulnerable populations in resource-poor settings.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN64716212.

A model for community representation and participation in HIV prevention trials among women who engage in transactional sex in Africa

Actively engaging communities in effective partnerships for the design and implementation of HIV prevention research is vital to the successful conduct of ethically robust, locally-appropriate clinical trials in developing countries. This is especially true in vulnerable at-risk sub-populations, where definitions of "community", "participation" and "representation" can be difficult to apply. This study was conducted to investigate the feasibility of a participatory model of community liaison among an occupational cohort of women at high-risk of HIV and sexually-transmitted infections in Mwanza City, northwest Tanzania in preparation for a Phase III vaginal microbicide trial. This approach was rooted in participatory action-orientated research and used tools adapted from participatory learning and action techniques. During the feasibility study, a mobile community-based sexual and reproductive health service for women working as informal food vendors or in traditional and modern bars, restaurants, hotels and guesthouses was established in 10 city wards. Participatory mapping was carried out by project fieldworkers and wards divided into 78 geographical clusters of facilities in consultation with community members and study participants. Representatives at cluster and ward level were elected in a process facilitated by the site Community Liaison Officer and a site-level Community Advisory Committee established. A logical framework was used to guide the implementation, monitoring and evaluation of the community liaison system (CLS) within the broader feasibility study. The CLS was essential to the successful conduct of the feasibility study and has now been consolidated and expanded as part of the on-going MDP301 Phase III microbicide trial in Mwanza. The participatory model presented in this paper is likely to be generalisable to other vulnerable, stigmatised, at-risk study populations in resource-limited settings.

Treating malaria in pregnancy in developing countries: priorities in clinical research and drug development

Reducing the burden of falciparum malaria in pregnancy is an urgent international public health priority but one that involves considerable challenges. The rapidly declining effectiveness of agents known to be safe in pregnancy, and the limited efficacy, safety and pharmacokinetic data available for many other antimalarial drugs, mean that current options for the treatment of both severe and uncomplicated falciparum malaria in pregnancy are limited. This report summarizes the literature on this subject and recommends drug combinations for evaluation in Phase II/III treatment trials in pregnancy.

Intermittent preventive treatment for malaria in pregnancy in Africa: what's new, what's needed?

Falciparum malaria is an important cause of maternal, perinatal and neonatal morbidity in high transmission settings in Sub-Saharan Africa. Intermittent preventive treatment with sulphadoxine-pyrimethamine (SP-IPT) has proven efficacious in reducing the burden of pregnancy-associated malaria but increasing levels of parasite resistance mean that the benefits of national SP-IPT programmes may soon be seriously undermined in much of the region. Hence, there is an urgent need to develop alternative drug regimens for IPT in pregnancy. This paper reviews published safety and efficacy data on various antimalarials and proposes several candidate combination regimens for assessment in phase II/III clinical trials.

Postpartum maternal morbidity requiring hospital admission in Lusaka, Zambia - a descriptive study

Background

Information on the extent of postpartum maternal morbidity in developing countries is extremely limited. In many settings, data from hospital-based studies is hard to interpret because of the small proportion of women that have access to medical care. However, in those areas with good uptake of health care, the measurement of the type and incidence of complications severe enough to require hospitalisation may provide useful baseline information on the acute and severe morbidity that women experience in the early weeks following childbirth. An analysis of health services data from Lusaka, Zambia, is presented.

Methods

Six-month retrospective review of hospital registers and 4-week cross-sectional study with prospective identification of postpartum admissions.

Results

Both parts of the study identified puerperal sepsis and malaria as, respectively, the leading direct and indirect causes of postpartum morbidity requiring hospital admission. Puerperal sepsis accounted for 34.8% of 365 postpartum admissions in the 6-month period. Malaria and pneumonia together accounted for one-fifth of all postpartum admissions (14.5% & 6% respectively). At least 1.7% of the postpartum population in Lusaka will require hospital-level care for a maternal morbidity.

Conclusions

In developing country urban settings with high public health care usage, meticulous review of hospital registers can provide baseline information on the burden of moderate-to-severe postpartum morbidity.