Reproductive Health Matters最新文献

Nepal has one of the highest maternal and neonatal mortality rates among low- and middle-income countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.

Despite the strong global focus on improving maternal health during past decades, there is still a long way to go to ensure equitable access to services and quality of care for women and girls around the world. To understand widely acknowledged inequities and policy-to-practice gaps in maternal health, we must critically analyse the workings of power in policy and health systems. This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world's highest burdens of maternal mortality. Specifically, we analyse Malawi's recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of donor funding, a shift in political leadership and priorities, and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. Based on ethnographic research conducted in 2015/16, the article describes the perceptions and experiences of policy implementation among various local actors (health workers, village heads and women). The way in which maternity services "fall apart" and are "fixed" is the result of dynamic interactions between policy and webs of accountability. Policies meet with a cascade of dynamic responses, which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aims of global and national safe motherhood policies.

The implementation of the 2012 Argentinean Supreme Court landmark ruling, which declared abortion legal in all cases of rape and established standards of implementation of lawful abortions at all levels of government, shows an uneven pattern of compliance by subnational governments throughout the country. Based on a case-study of the implementation of the Court's decision in the province of Salta, this article advances an explanation of mechanisms that can affect the definition and enforcement of abortion rights at the local level, in a federation. Drawing on Putnam's concept of two-level games, it argues that, at critical junctures, local authorities and especially strong governors with presidential aspirations, may have electoral incentives at the national level to comply at least partially with national laws and judicial decisions which are contrary to their own ideological preferences and their local political allegiances. The study suggests that analyses of political opportunities for local reproductive rights activists in federal regimes should include the potential two-level games of local authorities, such as politicians with presidential aspirations, and judges who intend to pursue a career in national or international institutions. Through this analysis, the article intends to contribute to our understanding of the political determinants of subnational compliance with national abortion laws and court decisions in federal systems, and more generally, political factors and dynamics that shape inequities in the protection of women's rights under federalism.

The sexual and reproductive health (SRH) needs of persons with disabilities have received minimal attention from the Government of Ghana in the past. This was partly reinforced through reproductive health (RH) policies that did not well recognise disability inclusion and the inaccessibility of services for persons with disabilities. In acknowledgement of national and international RH policies, frameworks and legal instruments highlighting disability inclusion, the 2016 adolescent health policy document recognised the need to give attention to the SRH of adolescents and persons with disabilities. However, there is an absence of analysis of factors affecting adolescents with disabilities. Despite the lack of disability-specific indicators, and absence of data on adolescents with disabilities, interventions were developed which are poorly understood. This commentary argues that since we do not know the exact nature of SRH needs of adolescents with disabilities, the policy is unlikely to be successful in addressing existing inequities in access, quality of services and outcomes for adolescents with disabilities in Ghana. Recommendations are made for future improvements.

Social inequities, including stigma, criminalisation of same-sex practices, and poverty, elevate HIV exposure among young transgender women and sexually diverse men in Jamaica. Yet the ways transgender women and sexually diverse men in Jamaica navigate sex and HIV in contexts of social inequity are underexplored. The study objective was to explore experiences and perceptions of sexual decision-making and HIV risk among young (aged 18-30) sexually diverse men and transgender women in Kingston, Jamaica. We conducted a community-based qualitative study in Kingston that involved in-depth individual interviews (transgender women: n = 20; sexually diverse men: n = 20), 2 focus groups (transgender women: n = 8; sexually diverse men: n = 10) and 13 key informant interviews. Focus groups and interviews were digitally recorded, transcribed verbatim, and analysed with a thematic approach. Findings suggest that transgender women and sexually diverse men in Kingston are aware of, and managing survival challenges and HIV risks in contexts of social inequity. Daily survival challenges include stigma and a lack of human rights protections that contributed to barriers to employment, housing, healthcare, education, and exposure to violence. Challenges maintaining sexual relationships included the need to hide for safety, often resulting in difficulties forming lasting relationships. These survival and relationship challenges converged to lower self-esteem and self-acceptance. In the face of these challenges, participants navigated sexual risk and pleasure. Findings provide insight into agency and sexual decision-making processes in contexts of social inequities. Findings can inform multi-level strategies to promote social equity, sexual health, and HIV prevention with young transgender women and sexually diverse men in Jamaica.

The need to improve the sexual and reproductive health (SRH) and rights of women with disabilities is increasingly acknowledged. Unfortunately, women with disabilities in low- and middle-income settings, including Ghana, face several barriers (including structural, financial, physical, social and attitudinal) to accessing SRH services and care. This paper explores the enablers and barriers to accessing SRH services and care among visually impaired women in the Ashanti and Brong Ahafo Regions of Ghana. Qualitative data from in-depth interviews and focus group discussions were collected from 21 visually impaired women, selected through purposive and snowballing sampling techniques. Thematic analysis was used to develop codes, and data were further grouped into emerging themes. The barriers to accessing SRH services and care were financial difficulties and lack of preferential treatment. The enablers which facilitated access to SRH services and care were the support provided by caregivers and friendly relationships with health providers. To address these challenges and promote access, SRH related policies, services and programmes should be inclusive of the needs of visually impaired women, and measures to remove financial challenges to service utilisation and foster positive relationships with health workers, church and community members should be adopted.

This paper draws on findings from a qualitative study of two government hospitals in Mumbai, India, which aimed to provide a better understanding of the institutional drivers of disrespect and abuse (D&A) in childbirth. The paper describes the structural context, in which government hospital providers can exercise considerable power over patients, yet may be themselves vulnerable to violence and external influence. Decisions that affect care are made by a bureaucracy, which does not perceive problems with the same intensity as providers who are directly attending to patients. Within this context, while contrasting organisational cultures had evolved at the two hospitals, both were characterised by social/professional inequality and hierarchical functioning, and marginalising women. This context generates invisible pressures on subordinate staff, and creates interpersonal conflicts and ambiguity in the division of roles and responsibilities that manifest in individual actions of D&A. Services are organised around the internal logic of the institution, rather than being centred on women. This results in conditions that violate women's privacy, and disregards their choice and consent. The structural environment of resource constraints, poor management and bureaucratic decision-making leads to precarious situations, endangering women's safety. With the institution's functioning based on hierarchies and authority, rather than adherence to universal standards or established protocols, irrational, harmful practices endorsed by senior staff are institutionalised and reproduced. A deeper focus on organisational culture, embedded in the discourse of D&A, would help to evolve effective strategies to address D&A as systemic problems.

Disrespect and abuse of patients, especially birthing women, does occur in the health sector. This is a violation of women's fundamental human rights and can be viewed as a consequence of women's lives not being valued by larger social, economic and political structures. Here we demonstrate how such disrespect and abuse is enacted at an interpersonal level across the continuum of care in Tanzania. We describe how and why women's exposure to disrespect and abuse should be seen as a symptom of structural violence. Detailed narratives were developed based on interviews and observations of 14 rural women's interactions with health providers from their first antenatal visit until after birth. Narratives were based on observation of 25 antenatal visits, 3 births and 92 in-depth interviews with the same women. All women were exposed to non-supportive care during pregnancy and birth including psychological abuse, physical abuse, abandonment and privacy violations. Systemic gender inequality renders women excessively vulnerable to abuse, expressed as a normalisation of abuse in society. Health institutions reflect and reinforce dominant social processes and normalisation of non-supportive care is symptomatic of an institutional culture of care that has become dehumanised. Health providers may act disrespectfully because they are placed in a powerful position, holding authority over their patients. However, they are themselves also victims of continuous health system challenges and poor working conditions. Preventing disrespect and abuse during antenatal care and childbirth requires attention for structural inequalities that foster conditions that make mistreatment of vulnerable women possible.