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“My job is to get pregnant women to the hospital”: a qualitative study of the role of traditional birth attendants in the distribution of misoprostol to prevent post-partum haemorrhage in two provinces in Mozambique
Background: Post-partum haemorrhage is the leading cause of maternal deaths in Mozambique. In 2015, the Mozambican Ministry of Health launched the National Strategy for the Prevention of Post-Partum Haemorrhage at the Community Level. The strategy included the distribution of misoprostol to women in advance at antenatal care and via Traditional Birth Attendants who directly administer the medication. The study explores the role of Traditional Birth Attendants in the misoprostol program and the views of women who used misoprostol to prevent post-partum haemorrhage. Methods: This descriptive study collected data through in-depth interviews and focus group discussions. Traditional Birth Attendants between the ages of 30–70 and women of reproductive age participated in the study. Data was collected between June–October 2017 in Inhambane and Nampula Provinces. Line by line thematic analysis was used to interpret the data using Nvivo (v.11). Results: The majority of TBAs in the study were satisfied with their role in the misoprostol program and were motivated to work with the formal health system to encourage women to access facility based births. Women who used misoprostol were also satisfied with the medication and encouraged family and friends to access it when needed. Women in the community and Traditional Birth Attendants requested assistance with transportation to reach the health facility to avoid home births. Conclusions: This study contributes to the evidence base that Traditional Birth Attendants are an appropriate channel for the distribution of misoprostol for the prevention of post-partum haemorrhage at the community level. More support and resources are needed to ensure Traditional Birth Attendants can assist women to have safe births when they are unable to reach the health facility. A consistent supply of misoprostol is needed to ensure women at the community level receive this life saving medication. Keywords: Maternal health, Traditional birth attendant, Mozambique, Post-partum Haemorrhage, Misoprostol, Community
Read More Download PDFAdolescent Sexual and Reproductive Health
Introduction The World Health Organization (WHO) (2019B) defines adolescence as the period between 10 and 19 years of age, when children transition into adults. In 2020, there will be an estimated 1.25 billion adolescents in the world, with almost 90% of them residing in low- and middle-income countries (LMICs). Adolescence is a phase marked by both biological changes and brain development. However, the biological maturity often precedes psychosocial maturity, affecting how young people respond to the new risks and opportunities that also emerge in adolescence (World Health Organization, 2019A). The unique physical, cognitive, social, emotional, and sexual development that takes place during adolescence requires special attention in national development policies, programs, and plans (World Health Organization, 2017B). Adolescence represents a time when young people experiment with independence, forge new relationships, develop social skills, and learn behaviors that will last the rest of their lives (World Health Organization, 2019B). If they are engaged in meaningful ways and supported in all aspects of their lives, adolescents are more likely to grow into thriving adults, making lasting contributions to their families and society. Investing in adolescent health and well-being brings a triple dividend of benefits that affect not only the future adult life of those adolescents but also the next generation of children (Patton et al., 2016). In sub-Saharan Africa, for example, where births by adolescents and young adults (15–24 years of age) contribute significantly to fertility, access to comprehensive SRH could lead to declines in fertility. This decline could result in changes in the age structure of the population, which would allow countries to benefit from of a window of opportunity for economic growth, thus harnessing the first demographic dividend (Prata, 2017). Given the high return on investment, adolescent health is firmly on the global agenda and prominent in many initiatives. There is widespread recognition that the Sustainable Development Goals (SDGs), which seek to achieve global economic, social, and environmental sustainable development by 2030, will not be realized without investments in adolescent health and well-being (World Health Organization, 2017B). A report, Health for the World’s Adolescents, was released by the WHO in 2014 and showed that the considerable gains already made from investments in maternal- and child-health programs would not be sustained without corresponding investments in adolescent health (World Health Organization, 2014). This is particularly the case when it comes to adolescent sexual and reproductive health (ASRH). In all regions of the world, young people are reaching puberty earlier, often engaging in sexual activity at a younger age, and in many places marrying later. As a result, young people are sexually active for longer before marriage than at any other time in history (Bearinger, Sieving, Ferguson, & Sharma, 2007; Blanc, Tsui, Croft, & Trevitt, 2009; Chen et al., 2007; Morris & Rushwan, 2015). The gap between first sex and marriage has implications for program and policies in supporting ASRH. Yet various political, economic, and sociocultural factors continue to restrict the delivery of ASRH information and services, failing to recognize the rights of adolescents to make independent decisions surrounding sexual activity and marriage. At the same time, healthcare workers often act as a barrier to care by failing to provide young people with supportive, nonjudgmental, youth-appropriate services (Morris & Rushwan, 2015). The ASRH disease burden is concentrated in LMICs. Despite steady declines in the global number of HIV-related deaths, among adolescents and young people the number of HIV-related deaths increased by 50% between 2005 and 2017 (United Nations Children’s Fund, 2017). The highest adolescent AIDS mortality rate is found in sub- Saharan Africa, with 17 deaths per 100,000 adolescents in African LMICs (World Health Organization, 2017B). This can be largely attributed to a generation of children infected with HIV perinatally who are now adolescents. About two thirds of adolescents living with HIV in 2015 acquired the disease during their mothers’ pregnancies or deliveries or in the first months of life, whereas the remaining one third of adolescents living with HIV were infected as adolescents (Joint United Nations Programme on HIV/AIDS, 2016). Adolescents are less likely than adults are to be tested for HIV and less likely to be linked to services, whether they test positive or negative (World Health Organization, 2013). In addition to HIV risk, sexually active adolescents have a particularly high risk of acquiring other sexually transmitted infections (STIs) compared to other age groups as a result of increased exposure, biological susceptibility to infection, and relatively poor access to or use of health services. Data on STIs are limited and inconsistent between and within regions and countries, particularly data disaggregated by age and sex (World Health Organization, 2017B). However, existing data on women of reproductive age (15–49 years) indicate the highest concentration (31%) of herpes simplex 2 virus (HSV-2) cases in sub- Saharan Africa (Looker et al., 2015). Meanwhile, the peak time for acquiring HSV-2 for both males and females is shortly after a person first becomes sexually active, which typically happens during adolescence (World Health Organization, 2017C). For older adolescent girls between the ages of 15 and 19 years, complications related to pregnancy and childbirth are the leading cause of death globally, with the adolescent maternal mortality rate highest among African LMICs (World Health Organization, 2018). Estimates from 2016 indicate that each year approximately 21 million girls and young women aged 15–19 years will become pregnant in LMICs (Darroch et al., 2016). Pregnant adolescents face maternal health challenges that are specific to their physical and psychological immaturity and limited autonomy (World Health Organization, 2017B). They are also more likely to have a repeat pregnancy within a year of giving birth, which can place them and their children at risk (Lopez, Grey, Hiller, & Chen, 2015; World Health Organization, 2017B). About half of pregnancies among adolescent women aged 15–19 years living in LMICs are unintended, and every year, approximately 3.9 million girls in this age group undergo abortions in unsafe conditions (Darroch, Woog, Bankole, & Ashford, 2016). Though these data are alarming and signal the need for immediate action, they do not paint the full picture. Although adolescence is a time of increased SRH risk, it is also a time when young people find their voice and agency. Adolescents around the world are using this voice to champion access to high-quality, comprehensive SRH information and services. The early 21st century has been characterized as a time when adolescents have demanded that their fundamental rights be recognized and when the world seemed— more than ever before—poised to act. This article highlights the status of adolescents’ SRH in LMICs, providing information on the following: the unmet need for SRH services (see “ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS”), key social determinants of SRH (see “SOCIAL DETERMINANTS OF ASRH”), challenges and opportunities for sexuality education (see “SEXUALITY EDUCATION”), existing implementation strategies for preventing poor reproductive health outcomes (see “PREVENTION OF POOR REPRODUCTIVE HEALTH OUTCOMES DURING ADOLESCENCE”), and the need for modern contraception (see “CONTRACEPTION”). In each section, a description of key challenges, opportunities, and research gaps is revealed, as are examples of what has worked in the past in terms of policies and programs.
Read More Download PDFSpecial Issue on Women’s Health, Gender, and Empowerment
Research
Published: 8 November 2017
Empowerment is widely acknowledged as a process by which those who have been disempowered are able to increase their self-efficacy, make life-enhancing decisions, and obtain control over resources [1, 2, 3]. In addition, empowerment is multi-dimensional – a woman may be empowered in one dimension or sphere [...]
Do perceived contraception attitudes influence abortion stigma? Evidence from Luanda, Angola
Abstract: Abortion stigma is influenced by a variety of factors. Previous research has documented a range of contributors to stigma, but the influence of perceived social norms about contraception has not been significantly investigated. This study assesses the influence of perceived social norms about contraception on abortion stigma among women in Luanda, Angola. This analysis uses data from the 2012 Angolan Community Family Planning Survey. Researchers employed multi-stage random sampling to collect demographic, social, and reproductive information from a representative sample of Luandan women aged 15–49. Researchers analyzed data from 1469 respondents using chi-square and multiple logistic regression. Researchers analyzed women’s perceptions of how their partners, friends, communities, and the media perceived contraception, and examined associations between those perceptions and respondents’ abortion stigma. Stigma was approximated by likelihood to help someone get an abortion, likelihood to help someone who needed medical attention after an abortion, and likelihood to avoid disclosing abortion experience. Higher levels of partner engagement in family planning discussion were associated with increased stigma on two of the three outcome measures, while higher levels of partner support of contraception were associated with decreased stigma. Perceived community acceptance of family planning and media discussion of family planning were associated with a decrease in likelihood to help someone receive an abortion. These results suggest that increasing partner support of family planning may be one strategy to help reduce abortion stigma. Results also suggest that some abortion stigma in Angola stems not from abortion itself, but rather from judgment about socially unacceptable pregnancies.
Read MoreEngaging Men in Family Planning: Perspectives From Married Men in Lomé, Togo
Abstract: Family planning programs have made vast progress in many regions of sub-Saharan Africa in the last decade, but francophone West Africa is still lagging behind. More emphasis on male engagement might result in better outcomes, especially in countries with strong patriarchal societies. Few studies in francophone West Africa have examined attitudes of male involvement in family planning from the perspective of men themselves, yet this evidence is necessary for development of successful family planning projects that include men. This qualitative study, conducted in 2016, explored attitudes of 72 married men ages 18–54 through 6 focus groups in the capital of Togo, Lomé. Participants included professional workers as well as skilled and unskilled workers. Results indicate that men have specific views on family planning based on their knowledge and understanding of how and why women might use contraception. While some men did have reservations, both founded and not, there was an overwhelmingly positive response to discussing family planning and being engaged with related decisions and services. Four key findings from the analyses of focus group responses were: (1) socioeconomic motivations drive men’s interest in family planning; (2) men strongly disapprove of unilateral decisions by women to use family planning; (3) misconceptions surrounding modern methods can hinder support for family planning; and (4) limited method choice for men, insufficient venues to receive services, and few messages that target men create barriers for male engagement in family planning. Future attempts to engage men in family planning programs should pay specific attention to men’s concerns, misconceptions, and their roles in family decision making. Interventions should educate men on the socioeconomic and health benefits of family planning while explaining the possible side effects and dispelling myths. To help build trust and facilitate open communication, family planning programs that encourage counseling of husbands and wives in their homes by community health workers, trusted men, or couples who have successfully used or are currently using family planning to achieve their desired family size will be important.
Read More Download PDFAbortion history and its association with current use of modern contraceptive methods in Luanda, Angola
Conclusion: History of induced abortion was associated with use of a modern contraceptive method in our study population. The most common contraceptive used by women with a history of induced abortion was condoms, indicating that despite adoption of a modern method, many women are still at risk for an unintended pregnancy. Further research is needed to understand the causal factors underlying women’s postabortion contraceptive choices.
Read More Download PDFMedical society engagement in contentious policy reform: the Ethiopian Society for Obstetricians and Gynecologists (ESOG) and Ethiopia’s 2005 reform of its Penal Code on Abortion
Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have reformed their laws to permit safer, legal abortion, and professional medical associations have not tended to spearhead this type of reform. Support from a professional association typically carries more weight than does that from an individual medical professional. However, theory predicts and the empirical record largely reveals that medical associations shy from engagement in conflictual policymaking such as on abortion, except when professional autonomy or income is at stake. Using interviews with 10 obstetrician–gynaecologists and 44 other leaders familiar with Ethiopia’s reproductive health policy context, as well as other primary and secondary sources, this research examines why, counter to theoretical expectations from the sociology of medical professions literature and experience elsewhere, the Ethiopian Society of Obstetricians & Gynecologists (ESOG) actively supported reform of national law on abortion. ESOG leadership participation was motivated by both individual and ESOG’s organizational commitments to reducing maternal mortality and also by professional training and work experience. Further, typical constraints on medical society involvement in policymaking were relaxed or removed, including those related to ESOG’s organizational structure and history, and to political environment. Findings do not contradict theory positing medical society avoidance of socially conflictual health policymaking, but rather identify how the expected restrictions were less present in Ethiopia, facilitating medical society participation. Results can inform efforts to encourage medical society participation in policy reform to improve women’s health elsewhere in sub-Saharan Africa.
Read More Download PDFMaking family planning accessible in resource-poor settings
Abstract
It is imperative to make family planning more accessible in low resource settings. The poorest couples have the highest fertility, the lowest contraceptive use and the highest unmet need for contraception. It is also in the low resource settings where maternal and child mortality is the highest. Family planning can contribute to [...]
Measuring #MeToo: A National Study on Sexual Harassment and Assault
The UC San Diego Center on Gender Equity and Health is proud to share findings from their 2019 study on sexual harassment and assault in the United States, “Measuring #MeToo: A National Study on Sexual Harassment and Assault”. This work, conducted in partnership with Stop Street Harassment, Raliance, and Promundo, non-governmental organizations focused on prevention [...]
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Commentary, Presentation
Ndola Prata, MD, MSc: Planetary Health Solutions
2019
Ndola Prata, MD, MSC, presented at the Stanford WHSDM Women's Global Health Forum. Dr. Prata is a Professor in Residence, Maternal Child and Adolescent Health at the University of Californina, Berkeley; Fred H. Bixby Endowed Chair in Population and Family Planning, Director, Bixby Center for Population, Health and Sustainability, Co-Director, Innovations for Youth (I4Y) School [...]
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