Reproductive Health - Latest Articles

Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care

Ghazaleh Samandari — 2012-04-04T00:00:00Z

Unsafe abortion's significant contribution to maternal mortality and morbidity was a critical factor leading to liberalization of Nepal's restrictive abortion law in 2002. Careful, comprehensive planning among a range of multisectoral stakeholders, led by Nepal's Ministry of Health and Population, enabled the country subsequently to introduce and scale-up safe abortion services in a remarkably short timeframe. This paper examines factors that contributed to rapid, successful implementation of legal abortion in this mountainous republic, including deliberate attention to the key areas of policy, health system capacity, equipment and supplies, and information dissemination. Important elements of this successful model of scaling up safe legal abortion include: the pre-existence of postabortion care services, through which health-care providers were already familiar with the main clinical technique for safe abortion government leadership in coordinating complementary contributions from a wide range of public- and private-sector actors reliance on public-health evidence in formulating policies governing abortion provision, which led to the embrace of medical abortion and authorization of midlevel providers as key strategies for decentralizing care and integration of abortion care into existing Safe Motherhood and the broader health system. While challenges remain in ensuring that all Nepali women can readily exercise their legal right to early pregnancy termination, the national safe abortion program has already yielded strong positive results. Nepal's experience making high-quality abortion care widely accessible in a short period of time offers important lessons for other countries seeking to reduce maternal mortality and morbidity from unsafe abortion and to achieve Millennium Development Goals.

Swedish high school students' knowledge and attitudes regarding fertility and family building

Maria Ekelin — 2012-03-21T00:00:00Z

Background: Infertility is a serious problem for those who suffer. Some of the risks for infertility are preventable and the individual should therefore have knowledge of them. The purposes of this study were to investigate high-school students' knowledge about fertility, plans for family building and to compare views and knowledge between female and male students. Methods: A questionnaire containing 34 items was answered by 274 students. Answers from male and female students were compared using student's t-test for normally distributed variables and Mann-Whitney U-test for non-normal distributions. The chi-square test was used to compare proportions of male and female students who answered questions on nominal and ordinal scales. Differences were considered as statistically significant at a p-value of 0.05. Results: Analyses showed that 234 (85%) intended to have children. Female students felt parenthood to be significantly more important than male students: p = < 0.01. The mean age at which the respondents thought they would like to start to build their family was 26 (± 2.9) years. Men believed that women's fertility declined significantly later than women did: p = < 0.01. Women answered that 30.7% couples were involuntarily infertile and men answered 22.5%: p = < 0.01. Females thought it significantly more likely that they would consider IVF or adoption than men, p = 0.01. Men felt they were more likely to abstain from having children than women: p = < 0.01. Women believed that body weight influenced fertility significantly more often than men: p = < 0.01 and men believed significantly more often that smoking influenced fertility: p = 0.03. Both female and male students answered that they would like to have more knowledge about the area of fertility. Conclusions: Young people plan to start their families when the woman's fertility is already in decline. Improving young people's knowledge about these issues would give them more opportunity to take responsibility for their sexual health and to take an active role in shaping political change to improve conditions for earlier parenthood.

Home birth and barriers to referring women with obstetric complications to hospitals: a mixed-methods study in Zahedan, southeastern Iran

Mahmoud Ghazi Tabatabaie — 2012-03-20T00:00:00Z

Background: One factor that contributes to high maternal mortality in developing countries is the delayed use of Emergency Obstetric-Care (EmOC) facilities. The objective of this study was to determine the factors that hinder midwives and parturient women from using hospitals when complications occur during home birth in Sistan and Baluchestan province, Iran, where 23% of all deliveries take place in non- hospital settings. Methods: In the study and data management, a mixed-methods approach was used. In the quantitative phase, we compared the existing health-sector data with World Health Organization (WHO) standards for the availability and use of EmOC services. The qualitative phase included collection and analysis of interviews with midwives and traditional birth attendants and twenty-one in-depth interviews with mothers. The data collected in this phase were managed according to the principles of qualitative data analysis. Results: The findings demonstrate that three distinct factors lead to indecisiveness and delay in the use of EmOC by the midwives and mothers studied. Socio-cultural and familial reasons compel some women to choose to give birth at home and to hesitate seeking professional emergency care for delivery complications. Apprehension about being insulted by physicians, the necessity of protecting their professional integrity in front of patients and an inability to persuade their patients lead to an over-insistence by midwives on completing deliveries at the mothers' homes and a reluctance to refer their patients to hospitals. The low quality and expense of EmOC and the mothers' lack of health insurance also contribute to delays in referral. Conclusions: Women who choose to give birth at home accept the risk that complications may arise. Training midwives and persuading mothers and significant others who make decisions about the value of referring women to hospitals at the onset of life-threatening complications are central factors to increasing the use of available hospitals. The hospitals must be safe, comfortable and attractive environments for parturition and should give appropriate consideration to the ethical and cultural concerns of the women. Appropriate management of financial and insurance-related issues can help midwives and mothers make a rational decision when complications arise.

Health services for reproductive tract infections among female migrant workers in industrial zones in Ha Noi, Viet Nam: an in-depth assessment

Le Anh Thi Kim — 2012-02-27T00:00:00Z

Background: Rural-to-urban migration involves a high proportion of females because job opportunities for female migrants have increased in urban industrial areas. Those who migrate may be healthier than those staying in the village and they may benefit from better health care services at destination, but the 'healthy' effect can be reversed at destination due to migration-related health risk factors. The study aimed to explore the need for health care services for reproductive tract infections (RTIs) among female migrants working in the Sai Dong industrial zone as well as their services utilization. Methods: The cross sectional study employed a mixed method approach. A cohort of 300 female migrants was interviewed to collect quantitative data. Two focus groups and 20 in-depth interviews were conducted to collect qualitative data. We have used frequency and cross-tabulation techniques to analyze the quantitative data and the qualitative data was used to triangulate and to provide more in-depth information. Results: The needs for health care services for RTI were high as 25% of participants had RTI syndromes. Only 21.6% of female migrants having RTI syndromes ever seek helps for health care services. Barriers preventing migrants to access services were traditional values, long working hours, lack of information, and high cost of services. Employers had limited interests in reproductive health of female migrants, and there was ineffective collaboration between the local health system and enterprises. These barriers were partly caused by lack of health promotion programs suitable for migrants. Most respondents needed more information on RTIs and preferred to receive these from their employers since they commonly work shifts - and spend most of their day time at work. Conclusion: While RTIs are a common health problem among female migrant workers in industrial zones, female migrants had many obstacles in accessing RTI care services. The findings from this study will help to design intervention models for RTI among this vulnerable group such as communication for behavioural impact of RTI health care, fostered collaboration between local health care services and employer enterprises, and on-site service (e.g. local or enterprise health clinics) strengthening.

Factors Associated with the Prevalence of Periodontal Disease in Low-Risk Pregnant Women

Marianna Vogt — 2012-01-24T00:00:00Z

ObjectiveTo evaluate the prevalence of periodontal disease (PD) among Brazilian low-risk pregnant women and its association with sociodemographic factors, habits and oral hygiene.MethodThis cross-sectional study included 334 low-risk pregnant women divided in groups with or without PD. Indexes of plaque and gingival bleeding on probing, probing pocket depth, clinical attachment level and gingival recession were evaluated at one periodontal examination below 32 weeks of gestation. Independent variables were: age, race/color, schooling, marital status, parity, gestational age, smoking habit, alcohol and drugs consumption, use of medication, presence of any systemic diseases and BMI (body mass index). Statistical analyses provided prevalence ratios and their respective 95%CI and also a multivariate analysis. Results: The prevalence of PD was 47% and significantly associated with higher gestational age (PR 1.40; 1.01 - 1.94 for 17-24 weeks and PR 1.52; 1.10 - 2.08 for 25-32 weeks), maternal age 25-29 years, obesity (PR 1.65; 1.02 - 2.68) and the presence of gingival bleeding on probing (ORadj 2.01, 95%CI 1.41 - 2.88). Poor oral hygiene was associated with PD by the mean values of plaque and bleeding on probing indexes significantly greater in PD group. Conclusions: The prevalence of PD is high and associated with gingival bleeding on probing, more advanced gestational age and obesity. A program of oral health care should be included in prenatal care for early pregnancy, especially for low-income populations.

India's JSY cash transfer program for maternal health: Who participates and who doesn't - a report from Ujjain district.

Kristi Sidney — 2012-01-24T00:00:00Z

Background: India launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India. Methods: A cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery. Results: The majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home. Conclusion: In this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death.

Predictors of Unintended Pregnancy in Kersa, Eastern Ethiopia, 2010.

Nega Assefa — 2012-01-12T00:00:00Z

Background: In Ethiopia, little is known about pregnancy among rural women. Proper maternal health care depends on clear understanding of the reproductive health situation. The objective of this study was to identify predictors of unintended pregnancy in rural eastern Ethiopia.MethodologyThis study was part of pregnancy surveillance at Kersa Demographic Surveillance and Health Research Center, East Ethiopia. Pregnant women were assessed whether their current pregnancy was intended or not. Data were collected by lay interviewers using uniform questionnaire. Odds Ratio, with 95% confidence interval using multiple and multinomial logistic regression were calculated to detect level of significance. Results: Unintended pregnancy was reported by 27.9% (578/2072) of the study subjects. Out of which, 440 were mistimed and 138 were not wanted. Unintended pregnancy was associated with family wealth status (OR 1.47; 95% CI 1.14, 1.90), high parity (7 +) (OR 5.18; 95% CI 3.31, 8.12), and a longer estimated time to walk to the nearest health care facility (OR 2.24; 95% CI: 1.49, 3.39).In the multinomial regression, women from poor family reported that their pregnancy was mistimed (OR 1.69; 95% CI 1.27, 2.25). The longer estimated time (80 + minutes) to walk to the nearest health care facility influenced the occurrence of mistimed pregnancy (OR 2.58; 95% CI: 1.65, 4.02). High parity (7+) showed a strong association to mistimed and unwanted pregnancies (OR 3.11; 95% CI 1.87, 5.12) and (OR 14.34; 95% CI 5.72, 35.98), respectively. Conclusions: The economy of the family, parity, and walking distance to the nearest health care institution are strong predictors of unintended pregnancy. In order to reduce the high rate of unintended pregnancy Efforts to reach rural women with family planning services should be strengthened.

Clinical training alone is not sufficient for reducing barriers to IUD provision among private providers in Pakistan

Sohail Agha — 2011-12-30T00:00:00Z

Background: IUD uptake remains low in Pakistan, in spite of three major efforts to introduce the IUD since the 1960s, the most recent of these being through the private sector. This study examines barriers to IUD recommendation and provision among private providers in Pakistan. Methods: A facility-based survey was conducted among randomly selected private providers who were members of the Greenstar network and among similar providers located within 2 Kilometers. In total, 566 providers were interviewed in 54 districts of Pakistan.Logistic regression analysis was conducted to determine whether correct knowledge regarding the IUD, self-confidence in being able to insert the IUD, attitudes towards suitability of candidates for the IUD and medical safety concerns were influenced by provider type (physician vs. Lady Health Visitor), whether the provider had received clinical training in IUD insertion in the last three years, membership of the Greenstar network and experience in IUD insertion. OLS regression was used to identify predictors of provider productivity (measured by IUD insertions conducted in the month before the survey). Results: Private providers consider women with children and in their peak reproductive years to be ideal candidates for the IUD. Women below age 19, above age 40 and nulliparous women are not considered suitable IUD candidates. Provider concerns about medical safety, side-effects and client satisfaction associated with the IUD are substantial. Providers' experience in terms of the number of IUDs inserted in their careers, appears to improve knowledge, self-confidence in the ability provide the IUD and to lower age-related attitudinal barriers towards IUD recommendation. Physicians have greater medical safety concerns about the IUD than Lady Health Visitors. Clinical training does not have a consistent positive effect on lowering barriers to IUD recommendation. Membership of the Greenstar network also has little effect on lowering these barriers. Providers' barriers to IUD recommendation significantly lower their monthly IUD insertions. Conclusions: Technical training interventions do not reduce providers' attitudinal barriers towards IUD provision. Formative research is needed to better understand reasons for the high levels of provider barriers to IUD provision. "Non-training" interventions should be designed to lower these barriers.

Reductions in Abortion-Related Mortality following Policy Reform: Evidence from Romania, South Africa and Bangladesh

Janie Benson — 2011-12-22T00:00:00Z

Unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalization could lead to drops in unsafe abortion and related deaths. This review provides an analysis of changes in abortion mortality in three countries where significant policy reform and related service delivery occurred. Drawing on peer-reviewed literature, population data and grey literature on programs and policies, this paper demonstrates the policy and program changes that led to declines in abortion-related mortality in Romania, South Africa and Bangladesh. In all three countries, abortion policy liberalization was followed by implementation of safe abortion services and other reproductive health interventions. South Africa and Bangladesh trained mid-level providers to offer safe abortion and menstrual regulation services, respectively, Romania improved contraceptive policies and services, and Bangladesh made advances in emergency obstetric care and family planning. The findings point to the importance of multi-faceted and complementary reproductive health reforms in successful implementation of abortion policy reform.

Psychosocial implications of tubal ligation in a rural health district: A phenomenological study

Prosper Lutala — 2011-12-16T00:00:00Z

Background: Tubal ligation is the most popular family planning method worldwide. While its benefits, such as effectiveness in protecting against pregnancies, minimal need for long-term follow-up and low side-effects profile are well documented, it has many reported complications. However, to date, these complications have not been described by residents in Congo. Therefore, the study aimed at exploring the experience of women who had undergone tubal ligation, focusing on perceptions of physical, psychological and contextual experiences of participants. Methods: This qualitative study used a semi-structured questionnaire in a phenomenological paradigm to collect data. Fifteen participants were purposefully selected among sterilized women who had a ligation procedure performed, were aged between 30 and 40 years, and were living within the catchment area of the district hospital. Data were collected by two registered nurses, tape-recorded, and transcribed verbatim. Reading and re-reading cut and paste techniques, and integration were used to establish codes, categories, themes, and description. Results: Diverse and sometimes opposite changes in somatic symptoms, psychological symptoms, productivity, ecological relationships, doctor-client relationships, ethical issues, and change of life style were the major problem domains. Conclusions: Clients reported conflicting experiences in several areas of their lives after tubal sterilization. Management, including awareness of the particular features of the client, is needed to decrease the likelihood of psychosocial morbidity and/or to select clients in need of sterilization.