International Perspectives on Sexual and Reproductive Health最新文献

Context: Many community-based reproductive health programs use their program data to monitor progress toward goals. However, using such data to assess programmatic impact on outcomes such as contraceptive use poses methodological challenges. Inverse probability weighting (IPW) may help overcome these issues.

Methods: Data on 33,162 women collected in 2013-2015 as part of a large-scale community-based reproductive health initiative were used to produce population-level estimates of the contraceptive prevalence rate (CPR) and modern contraceptive prevalence rate (mCPR) among married women aged 15-49 in Pakistan's Korangi District. To account for the nonrandom inclusion of women in the sample, estimates of contraceptive prevalence during the study's four seven-month intervention periods were made using IPW; these estimates were compared with estimates made using complete case analysis (CCA) and the last observation carried forward (LOCF) method-two approaches for which modeling assumptions are less flexible.

Results: In accordance with intervention protocols, the likelihood that women were visited by intervention personnel and thus included in the sample differed according to their past and current contraceptive use. Estimates made using IPW suggest that the CPR increased from 51% to 64%, and the mCPR increased from 34% to 53%, during the study. For both outcomes, IPW estimates were higher than CCA estimates, were generally similar to LOCF estimates and yielded the widest confidence intervals.

Conclusion: IPW offers a powerful methodology for overcoming estimation challenges when using program data that are not representative of the population in settings where cost impedes collection of outcome data for an appropriate control group.

Context: No studies using longitudinal contraceptive histories have investigated whether having an unintended birth (i.e., one resulting from an unintended pregnancy) is associated with change in contraceptive behavior, including in Colombia and Peru, where levels of unintended fertility remain high.

Methods: Monthly reproductive history calendar data from the 2010 Colombia and 2012 Peru Demographic and Health Surveys were used to study contraceptive behavior among 13,373 and 7,425 women, respectively. Transition matrices and hazard models were utilized to identify associations between prepregnancy and postpartum contraceptive methods used, and to assess how these relationships differed between women who reported an unintended birth and those with an intended birth.

Results: Women who had been using a traditional, barrier or (in Colombia) short-acting hormonal method before pregnancy were more likely to choose a more effective method postpartum, than to use no method, if their birth had been unintended rather than intended (relative risk ratios, 1.2-1.3 in Colombia; 1.6 in Peru). Compared with their counterparts whose birth had been intended, women with an unintended birth who had been utilizing the most effective methods used in the country (IUD or implant in Colombia, pill or injectable in Peru) were less likely to resume using them postpartum than to use no method (0.7 in Colombia; 0.8 in Peru).

Conclusions: Unintended birth is associated with change in contraceptive behavior. Efforts to understand postpartum contraceptive choices of women who have had an unintended birth should take into account contraceptive behavior at more than one point in women's reproductive lives.

Context: A growing body of evidence indicates that nonclinical health care facility staff provide support beyond their traditional roles, particularly in low- and middle-income countries. It is important to examine the role of health facility cleaners in Kenya-from their perspective-to better understand their actual and perceived responsibilities in maternity care.

Methods: In-depth, face-to-face interviews using a semistructured guide were conducted with 14 cleaners working at three public health facilities in Nairobi and Kiambu Counties, Kenya, in August and September 2016. Results were coded and categorized using a thematic content analysis approach.

Results: Cleaners reported performing a range of services beyond typical maintenance responsibilities, including providing emotional, informational and instrumental support to maternity patients. They described feeling disrespected when patients were untidy or experienced bleeding; however, such examples revealed cleaners' need to better understand labor and childbirth processes. Cleaners also indicated a desire for training on interpersonal skills to improve their interactions with patients.

Conclusion: Cleaners' direct involvement in maternity patients' care is an alarming symptom of overburdened health facilities, insufficient staffing and inadequate training. This key yet overlooked cadre of health care staff deserves appropriate support and further research to understand and alleviate health system shortcomings, and to improve the quality of maternity health care provision.

Context: Bangladesh's pluralistic health system has diversified opportunities for clients to obtain family planning, but public-private partnerships could improve access to services, particularly in urban areas.

Method: Sixteen providers, clients and program managers were interviewed to assess perspectives on a family planning orientation and demand-side financing referral program tested in Mirpur, Bangladesh. The 15-month program, conducted in 2015-2016, was designed to encourage private providers to identify non-family planning clients with unmet contraceptive needs, promote choice of a broader contraceptive mix and refer clients to one of three public or nonprofit clinics for provision of their preferred method. Use of the system was assessed by tracking referral slips.

Results: Most stakeholders reported that it was acceptable and feasible to discuss fertility intentions with clients presenting for non-family planning matters. Providers were able to alleviate clients' misconceptions and fears concerning long-acting contraceptive methods, but were unable to address patriarchal and religious barriers. The majority of referrals were done by private providers who had a pre-existing relationship with one of the family planning clinics and referred clients to that clinic; overall, documented referrals accounted for 13% of provision of reversible and permanent methods at that clinic during the study period.

Conclusions: Providing private practitioners with appropriate training on contraceptives and referral could improve Bangladeshi women's access to long-acting and other contraceptive methods in urban areas, and may be useful for other types of health workers. Further study of suitable referral systems is warranted.

Context: The copper IUD is safe and effective, but underutilized in Sub-Saharan Africa, in part because of a lack of trained providers. The World Health Organization recommends training mid-level providers-including nurses and midwives-to insert IUDs; however, the safety of such task shifting has not been evaluated in Sub-Saharan Africa.

Methods: Data were drawn from baseline surveys and study charts of 535 sexually active women aged 18-45 who used a copper IUD while participating in an HIV-prevention clinical trial conducted from August 2012 through June 2015 in Malawi, South Africa, Uganda and Zimbabwe. IUDs were inserted by study physicians, nurses and midwives trained as part of the trial, and by local nonstudy providers. Chi-square and Fisher's exact tests were used to compare women's experiences of adverse events-such as irregular bleeding, pelvic pain or device expulsion-by provider type.

Results: Half (54%) of women reported experiencing an adverse event; the most common were irregular bleeding and pelvic pain (45% and 25%, respectively). Compared with women who had received an IUD from a study physician or study nurse, greater proportions of women who had received one from a nonstudy provider reported any adverse event (76% vs. 49% and 51%, respectively), irregular bleeding (57% vs. 41% and 45%) and pelvic pain (35% vs. 15% and 32%); the difference between study physicians and nurses was significant only for pelvic pain. Expulsion rates were comparable for study nurses and nonstudy providers (12.3 and 11.9 per 100 woman-years, respectively), but lower for study physicians (7.3 per 100 woman-years).

Conclusions: The findings support task shifting of IUD insertion to mid-level providers to improve IUD access in Sub-Saharan Africa.

Context: Despite improvements in reproductive health indicators among women living in Sub-Saharan Africa, the persistence of poor outcomes underscores the need to examine recent interventions to inform future research, programming and policy. Because men in this context have an outsize role in reproductive decision making, assessing their involvement in reproductive health programs is an important step in meeting men's needs, supporting women's health and improving family health.

Methods: A scoping review was conducted to identify relevant literature and assess evidence of the impact of male involvement in reproductive health interventions. Seven databases were searched using terms related to male involvement and reproductive health; searches were limited to research conducted in Sub-Saharan Africa and published in English between 2007 and 2018. Remaining studies were assessed by participant characteristics, settings, research design, theoretical frameworks, outcome measures and findings.

Results: Searches identified 18 studies conducted in eight countries. Interventions engaged participants by using such strategies as community health workers, written invitation, peers, community or religious leaders and media campaigns. Results show that men are willing to participate in reproductive health programs and that their involvement is associated with increased uptake of family planning services, and HIV counseling and testing; reduction in risk behaviors; and improved maternal health and spousal communication.

Conclusions: Given the findings that male involvement is positively associated with improved reproductive health outcomes in Sub-Saharan Africa, health providers and program planners should consider including men in reproductive health interventions, when feasible.