Period Product Insecurity, School Absenteeism, and use of School Resources to Obtain Period Products among High School Students in St. Louis, Missouri.

Menstrual hygiene management (MHM) among female students is a neglected public health issue in the U.S. This study documented period product insecurity, school absenteeism, and use of school resources to obtain period products among high-school students in St. Louis, MO. Female students completed an anonymous, self-administered survey in English (n = 119). Descriptive statistics were used to determine the prevalence of period product need, resources used to obtain period products, and period-related absenteeism. The mean age of participants was 15.78 ± 1.28. Nearly two-thirds (64.4% (95% CI 55.1%-73.0%)) reported period product insecurity. Two-thirds (66.9% (95% CI 57.7%-75.3%)) reported using at least one of the school's resources to obtain period products. One-third of the participants (33.6% (95% CI 25.0%-43.1%)) reported missing school due to a lack of period products. School nurses need to be cognizant of how MHM affects their students' attendance at school and what measures they can take to help reduce menstruation-related absenteeism.

Presenting to the Emergency Department Versus Clinic-Based Sexually Transmitted Disease Care Locations for Testing for Chlamydia and Gonorrhea: A Spatial Exploration.

BACKGROUND: Rates of sexually transmitted diseases (STDs) including chlamydia and gonorrhea are increasing in the United States while public health funding for STD services is decreasing. Individuals seek care in various locations including the emergency department (ED). The objective of this study is to investigate whether there are more physically proximal clinic-based STD care locations available to individuals who present to the ED in a major metropolitan area. METHODS: Addresses of EDs, clinics, and patients 13 years or older in St. Louis City or County given a nucleic acid amplification test and assigned an STD diagnosis (n = 6100) were geocoded. R was used to analyze clinics within 5 radii from the patients' home address and assess missed clinic opportunities (open, no charge, with walk-in availability) for those living in an urban versus suburban area. RESULTS: In urban areas, 99.1% of individuals lived closer to a clinic than the ED where they sought STD services; in suburban areas, 82.2% lived closer to a clinic than the ED where they presented. In the region, 50.6% lived closer to the health department-based STD care location than the hospital where they presented. Up to a third of ED patient visits for STD care could have occurred at a clinic that was closer to the patient's home address, open, no charge, and available for walk-in appointments. CONCLUSIONS: Clinic availability is present for most of the individuals in our study. Clinics providing STD services can increase advertising efforts to increase public awareness of the services which they provide.

Maternal and familial correlates of anthropometric typologies in the nutrition transition of Colombia, 2000-2010.

OBJECTIVE: We aimed to assess the maternal and family determinants of four anthropometric typologies at the household level in Colombia for the years 2000, 2005 and 2010. DESIGN: We classified children 2) to assess stunting and overweight/obesity, respectively; mothers were categorized according to BMI to assess underweight (<18·5 kg/m2) and overweight/obesity (≥25·0 kg/m2). At the household level, we established four final anthropometric typologies: normal, underweight, overweight and dual-burden households. Separate polytomous logistic regression models for each of the surveyed years were developed to examine several maternal and familial determinants of the different anthropometric typologies. SETTING: National and sub-regional (urban and rural) representative samples from Colombia, South America. SUBJECTS: Drawing on data from three waves of Colombia's Demographic and Health Survey/Encuesta Nacional de Salud (DHS/ENDS), we examined individual and household information from mothers (18-49 years) and their children (birth-5 years). RESULTS: Higher parity was associated with an increased likelihood of overweight and dual burden. Higher levels of maternal education were correlated with lower prevalence of overweight, underweight and dual burden of malnutrition in all data collection waves. In 2010, participation in nutrition programmes for children <5 years, being an indigenous household, food purchase decisions by the mother and food security classification were also associated with the four anthropometric typologies. CONCLUSIONS: Results suggest that maternal and family correlates of certain anthropometric typologies at the household level may be used to better frame policies aimed at improving social conditions and nutrition outcomes.

Intimate partner violence as a predictor of antenatal care service utilization in Honduras.

OBJECTIVE: To describe the relationship between exposure to physical and/or sexual intimate partner violence (IPV) and indicators of antenatal care (ANC) service utilization among Honduran women of reproductive age. METHODS: Data from the 2011-2012 Honduras Demographic and Health Survey were analyzed to describe the relationship between self-reported exposure to IPV and two ANC outcomes: (1) sufficient ANC visits (defined by the Honduran Ministry of Health as five or more visits) and (2) early ANC initiation (within the first trimester). Multiple logistic regression was used to estimate effects of physical and sexual IPV on the outcomes, controlling for women's age, education, literacy, residence, household size, religion, parity, wealth, husband's age, and husband's education. RESULTS: Of women who were married, had at least one living child 5 years or younger, and completed the IPV module (N = 6 629), 13.5% of them reported any physical IPV, and 4.1% reported both physical and sexual IPV. There was no significant association between IPV and early ANC; however, a significant relationship between IPV and sufficient ANC was found. Women who experienced any physical IPV (adjusted odds ratios (aOR) = 1.25; 95% confidence interval (CI): 1.00-1.56) or sexual IPV (aOR = 1.53; 95% CI: 1.08-2.16) were, respectively, 25% and 53% more likely to receive insufficient ANC. CONCLUSIONS: Honduras has one of highest rates of interpersonal violence of any nation in the world. In Honduras, IPV is a contributor to this broader category of interpersonal violence as well as a risk factor for insufficient ANC. Our findings suggest that universal IPV screening during ANC as well as future initiatives aimed at reducing IPV might improve ANC utilization in the country.

The importance of community mobilization in interventions to improve sexual, reproductive, and maternal health outcomes: A review of the evidence.

Community participation, engagement, and mobilization are common components of many sexual, reproductive, and maternal health (SRMH) programs, but little consensus exists among researchers on how critical these program components are. Using principles of realist review, we reviewed a spectrum of community mobilization interventions to evaluate their use in improving five SRMH areas. Consistent with theoretical assumptions, we found that actively involving community members in leading intervention activities and/or taking ownership tends to produce better SRMH outcomes than simply relying on community members as implementers. Despite this, many fewer programs exist with this meaningful level of engagement than with more cursory engagement.

Methodological innovations in public health education: transdisciplinary problem solving.

In 2008, the faculty of the Brown School at Washington University in St. Louis designed a Master of Public Health program centered on transdisciplinary problem solving in public health. We have described the rationale for our approach, guiding principles and pedagogy for the program, and specific transdisciplinary competencies students acquire. We have explained how transdisciplinary content has been organized and delivered, how the program is being evaluated, and how we have demonstrated the feasibility of this approach for a Master of Public Health degree.

Period Product Insecurity Is Increasing in the United States: Trends from 2018 to 2021.

Background: Data documenting period product insecurity, or an inability to access products, in the United States have recently emerged. With multiple years of data now available, we assessed trends in period product insecurity among two nationally representative samples of U.S. adults. Materials and Methods: Data from nationally representative, cross-sectional online surveys conducted in January 2018 and April 2021 were used to run weighted logistic regressions. Those aged 18-49 years and who had menstruated in the past year (n = 922 in 2018; n = 1037 in 2021) were included. Results: In 2021, 59% experienced period product insecurity compared with 53% in 2018. In 2018 (adjusted odds ratio [aOR] 1.91, confidence interval [95% CI]: 1.29-2.83) and 2021 (aOR 1.53, 95% CI: 1.06-2.21), Hispanic respondents were more likely to find products unaffordable. Some college attainment was associated with finding products unaffordable in 2018 (aOR 1.53, 95% CI: 1.00-2.34) and 2021 (aOR 1.97, 95% CI: 1.35-2.88). Participants struggling to purchase products had higher odds of experiencing period product insecurity in 2018 (aOR 11.78, 95% CI: 8.07-17.20) and 2021 (aOR 7.71, 95% CI: 5.44-10.93). Conclusions: Hispanic ethnicity, lower educational attainment, and struggling to purchase period products were strong predictors of finding products unaffordable and experiencing product insecurity in both 2018 and 2021. Policies that improve access to or affordability of period products in the United States are needed to help those most vulnerable.

Period Product Resources and Needs in Schools: A Statewide Survey of Missouri's School Nurses.

BACKGROUND: School nurses play a vital role in ensuring the health and well-being of their students, but little is known about menstrual products and resources available in schools. This study assessed period product resources and needs in Missouri schools from the perspective of school nurses and analyzed differences by district enrollment characteristics. METHODS: An electronic survey was emailed to public, charter, private, and parochial school nurses in Missouri who served fourth grade or older. From January through March 2022, 976 self-administered surveys were completed (40% response rate). Logistic regressions examined the associations between student needs and district characteristics. RESULTS: Among the sample, 70.7% knew students who could not afford period products, and 68.0% knew students who had missed school because of their period. When controlling for district size, race/ethnicity, and urban/rural classification, as the percentage free- or reduced-lunch (FRL) eligibility increases in a school, awareness of students struggling to afford products increases (AOR = 1.008, 95% confidence interval 1.000, 1.015). IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: School nurses need the resources and educational materials to support students to help reduce menstruation-related absences. CONCLUSIONS: Issues of period poverty cut across districts of differing enrollment characteristics, yet FRL percentage is an important predictor.

Racial disparity in gestational diabetes mellitus and the association with sleep-disordered breathing and smoking cigarettes: a cross-sectional study.

BACKGROUND: Gestational diabetes mellitus (GDM) prevalence has risen in the U.S. and worldwide over the past decade. Minority groups, especially Asian and Hispanic women, are often disproportionately affected by GDM. Identifying modifiable risk factors such as sleep-disordered breathing and smoking and their interaction with race/ethnicity could play a pivotal role in preventing GDM. METHODS: Data from the 2017-2018 National Health and Nutrition Examination Surveys (NHANES) were used to run a survey-weighted multivariable logistic regression assessing the association between sleep-disordered breathing and smoking with GDM among women aged 15-60 (n = 1326). The interaction term of the two predictors and race/ethnicity was introduced to the model to assess the interaction effect. The analyses were adjusted for age, marital status, education level, and BMI. RESULTS: Approximately 13% of the participants reported having GDM. The lowest prevalence was observed among Non-Hispanic Blacks (7.8%) and the highest was among Other (15.5%). Sleep-disordered breathing was significantly associated with GDM (OR = 1.69, 95% CI 1.05, 2.73). No statistically significant association was observed between smoking and GDM (OR = 1.03, 95% CI 0.47, 2.27), and neither was the association between race/ethnicity and GDM. Furthermore, none of the interaction effects were statistically significant. CONCLUSION: Preventive strategies targeting GDM should focus on improving modifiable risk factors, such as sleep-disordered breathing. It is important to screen women with sleep-disordered breathing and monitor their blood sugar before becoming pregnant to prevent the development of GDM. Future studies are recommended to understand the lower prevalence of GDM among Black women and the higher prevalence among "Other" race group which mostly includes Asian women.

COVID-19 made it harder to access period products: The effects of a pandemic on period poverty.

Background: Prior to the COVID-19 pandemic, a few studies started to highlight the extent of period poverty in the U.S., especially among low-income women and girls. Preliminary data documenting the effects of the pandemic, subsequent economic downturn, and closure of schools and businesses on menstrual hygiene management are now emerging. Objective: This study explores the relationship between the effects of the COVID-19 pandemic and period poverty among a nationally representative sample of U.S. adults. Methods: Cross-sectional, secondary analyses of a 2021 nationwide, self-administered, online panel survey used weighted logistic regressions to assess the relationship between the COVID-19 pandemic making it more difficult to access products and missing work due to a lack of products. Responses from 1,037 menstruating individuals age 18-49 were included. Results: Overall, 30% of the sample indicated the COVID-19 pandemic made it more difficult to access period products, 29% struggled to purchase period products in the past year, and 18% missed work due to a lack of period products. Those who identified as Hispanic (aOR 2.06 95% CI 1.29-3.29) and had children under 18 (aOR 15.3 95% CI 1.03-2.26) were more likely to indicate that the pandemic made it harder to access period products. Subsequently, those who indicated that the pandemic made it more difficult to access period supplies were more likely to report missing work due to a lack of period products in the past 12 months (aOR 4.32 95% CI 4.69-6.94). Discussion: The COVID-19 pandemic exacerbated period poverty, especially among those in the U.S. who struggle with accessibility and affordability of products. Future pandemic response planning should consider period products as a basic need for vulnerable households. In addition, policies that increase the affordability and accessibility of period products for all should help reduce menstruation-related absenteeism from work.

From effectiveness to sustainability: understanding the impact of CARE's Community Score Card© social accountability approach in Ntcheu, Malawi.

We evaluated the sustainability of CARE's Community Score Card© (CSC) social accountability approach in Ntcheu, Malawi, approximately 2.5 years after the end of formal intervention activities. Using a cross-sectional, exploratory design, we conducted 41 focus groups with members of Community Health Advisory Groups (CHAGs) and youth groups and 19 semi-structured interviews with local and district government officials, project staff, and national stakeholders to understand how and in what form CSC activities are continuing. Focus groups and interviews were audio-recorded, transcribed and translated into English. Thematic coding was done using Dedoose software. Most groups were continuing to meet and implement the CSC, although some made modifications. CHAGs, youth and local government officials all attributed their continued implementation to the value that they saw in the process that allows marginalized groups within the community, including women and youth, a safe space for sharing their ideas and issues and the initial results this generated. However, lack of access to resources for implementation and challenges in convening and facilitating the interface meeting phase created barriers to continued sustainability. The CSC is sustainable by communities 2.5 years after the end of formal intervention activities. For future interventions, health systems and non-governmental organizations should plan for a transition phase with periodic refresher trainings and a small fund to support implementation, such as refreshments and transportation, to increase the likelihood of community-driven sustainability.

Evaluating Young People's Ability to Sustain an Evidence-Based Social Accountability Approach to Improve Adolescent Sexual and Reproductive Health in Ntcheu, Malawi.

The Community Score Card© (CSC), a social accountability approach, brings together community members, service providers, and local government officials to identify issues, prioritize, and plan actions to improve local health services. In addition, young people in Ntcheu, Malawi have been using the CSC approach to mobilize their communities to bring change across varying issues of importance to them. An earlier cluster randomized trial in Ntcheu showed the CSC effectively increased reproductive health behaviors, improved satisfaction with services, and enhanced the coverage and quality of services. Building upon this evidence of effectiveness, this study aims to evaluate if and how young people were able to sustain implementation of the CSC, and the improvements it brings, approximately 2.5 years after the randomized trial ended. As part of a larger evaluation of CSC sustainability in Ntcheu, we conducted 8 focus groups across 5 health catchment areas with 109 members of mixed-gender youth groups (58 females and 51 males, ages 14-29 years) who continued to engage with the CSC. Audio recordings were transcribed, translated into English, and coded in Dedoose using an a priori codebook augmented with emergent codes and a constant comparative approach. Although the 8 youth groups were still actively using the CSC, they had made some adaptations. While the CSC in Ntcheu initially focused on maternal health, young people adopted the approach for broader sexual and reproductive topics important to them such as child marriages and girls' education. To enable sustainability, young people trained each other in the CSC process; they also requested more formal facilitation training. Young people from Ntcheu recommended nationwide scale-up of the CSC. Young people organically adopted the CSC, which enabled them to highlight issues within their communities that were a priority to them. This diffusion among young people enabled them to elevate their voice and facilitate a process where they hold local government officials, village leaders, and services providers accountable for actions and the quality of healthcare services. Young people organized and sustained the CSC as a social accountability approach to improve adolescent sexual and reproductive health in their communities more than 2.5 years after the initial effectiveness trial ended.

Students' Menstrual Hygiene Needs and School Attendance in an Urban St. Louis, Missouri, District.

PURPOSE: To assess the menstrual hygiene needs and related school absences among female students in an urban St. Louis, MO district. METHODS: Students (n = 58) completed a self-administered survey during registration and orientation before the 2019-2020 school year. RESULTS: Nearly half (48.3%) needed period products at least once last school year but did not have money to buy them. The majority (62.1%) accessed period products at school last year. Seventeen percent missed at least one day at school because of an inadequate supply of period products, including significantly more ninth graders than 10th-12th graders (33.3% vs. 6.1%, respectively, p < .01). CONCLUSIONS: Students reported a substantial need for menstrual hygiene products but also frequent utilization of school resources to access products. Given that incoming ninth graders reported more absences related to an inadequate supply of products, the district may need to focus more attention on this issue in the junior high school and younger grades.

Effects of the Community Score Card approach on reproductive health service-related outcomes in Malawi.

BACKGROUND: Social accountability approaches are increasingly being employed in low-resource settings to improve government services. In line with the continuous quality improvement (CQI) philosophy that quality is the product of a linked chain, collaborative social accountability approaches like the Community Score Card (CSC) aim to empower clients and frontline service providers to transform their own lives and hold public officials to account for state obligations. Despite being a critical focus of collaborative social accountability approaches, to our knowledge, a quantitative survey of health workers to understand the impact of these approaches on their self-reported responsibilities and service provision has not been conducted. To fill this gap, we carried out a quantitative survey with health workers to assess the CSC's impact on health worker-reported service responsibilities and provision and complement women's self-reports. METHODS: We evaluated the effect of the CSC on reproductive health-related outcomes using a cluster-randomized design in Ntcheu district, Malawi. We matched 10 pairs of health facilities and surrounding catchment communities; one from each pair was randomly assigned to the intervention and control arms. The intervention communities and health workers each completed 3-4 cycles of the CSC process by endline. We then surveyed all health workers in the 20 intervention and comparison sites at endline (n = 412) to estimate the intervention's impact. RESULTS: Significantly (p < .05) more health workers in the CSC intervention areas compared to control areas reported responsibility for antenatal care, comprehensive antenatal care counseling, recording of the number of pregnant and postpartum women seen each month, and the average age of their last family planning client was younger. In addition, marginally significantly (p < .10) more health workers in treatment versus control areas report visiting women at their home at least once during their pregnancy. However, health worker-reported responsibility for HIV testing was significantly lower in intervention areas than in control. CONCLUSIONS: The CSC aims to empower health workers to collaborate with the community and rest of the health system to identify and overcome the diverse and context-specific range of performance barriers they face. In doing so, it aims to support them to demand and ensure quality care for themselves from the health system so they can, in turn, deliver quality services to clients. Our results contribute to the evidence that the CSC may hold promise at improving service provision. While there is increasing evidence that collaborative social accountability approaches like the CSC are effective means to improving reproductive health-related service provision and outcomes in low-resource settings, additional research is needed.

Environmental characteristics associated with pedestrian-motor vehicle collisions in Denver, Colorado.

OBJECTIVES: We examined patterns of pedestrian-motor vehicle collisions and associated environmental characteristics in Denver, Colorado. METHODS: We integrated publicly available data on motor vehicle collisions, liquor licenses, land use, and sociodemographic characteristics to analyze spatial patterns and other characteristics of collisions involving pedestrians. We developed both linear and spatially weighted regression models of these collisions. RESULTS: Spatial analysis revealed global clustering of pedestrian-motor vehicle collisions with concentrations in downtown, in a contiguous neighborhood, and along major arterial streets. Walking to work, population density, and liquor license outlet density all contributed significantly to both linear and spatial models of collisions involving pedestrians and were each significantly associated with these collisions. CONCLUSIONS: These models, constructed with data from Denver, identified conditions that likely contribute to patterns of pedestrian-motor vehicle collisions. Should these models be verified elsewhere, they will have implications for future research directions, public policy to enhance pedestrian safety, and public health programs aimed at decreasing unintentional injury from pedestrian-motor vehicle collisions and promoting walking as a routine physical activity.

Intimate partner violence, pregnancy intention and contraceptive use in Honduras.

OBJECTIVE(S): We explored the relationship between Intimate Partner Violence (IPV), pregnancy intention and contraceptive use in Honduras. STUDY DESIGN: We used the most recent Honduras Demographic and Health Survey (DHS 2011-2012) data to examine the relationship between physical IPV, sexual IPV and emotional IPV with pregnancy intention; contraceptive use; and husband's knowledge of contraceptive use among a sample of 6629 women. Multiple logistic regression was used to estimate effects of IPV on the outcomes, controlling for empowerment indicators and socio-demographic variables. RESULTS: Among currently married women with at least one living child born within the past 5 years, IPV was significantly associated with several outcomes. Women reporting any physical IPV (13.5%) were less likely to have wanted their last child (aOR: 0.52, p<.001) or to desire future children (aOR: 0.76, p=.002), and more likely to have ever used contraception (aOR: 2.32 p=.004). Those reporting physical with sexual violence (4.1%) were less likely to have wanted their last child (aOR: 0.59, p=.016). Women reporting emotional IPV (27.4%) were less likely to have wanted their last child (aOR: 0.56, p<.001) or to desire more children (aOR: 0.81, p<.001) and more likely to have ever used (aOR: 1.78, p<.001) and currently be using contraception (aOR: 1.19, p=.006). CONCLUSION(S): IPV was associated with both unwanted pregnancy and increased contraceptive use among married Honduran women. Universal screening for IPV among women who seek SRH services in Honduras may help identify women in need and reduce stigma around IPV while improving SRH outcomes. IMPLICATIONS: Honduran women exposed to intimate partner violence (IPV) were more likely to have ever used contraception yet more likely to report an unwanted pregnancy. Universal screening for IPV among women seeking sexual and reproductive health services may help identify women in need and reduce stigma around IPV while improving outcomes.

Unmet Menstrual Hygiene Needs Among Low-Income Women.

OBJECTIVE: To assess the menstrual hygiene needs of low-income women in St. Louis, Missouri. METHODS: Using an exploratory, cross-sectional design, women 18 years of age and older were recruited from a purposive sample of 10 not-for-profit community organizations that serve low-income women in St. Louis. From July 2017 to March 2018, 183 interviewer-administered surveys and three focus group discussions were conducted. Surveys and focus groups identified where and how women access menstrual hygiene products and what they do when they cannot afford to buy them. Using a snowball sampling strategy, 18 community organizations were also surveyed electronically to assess what services and supplies they provide for menstrual hygiene. RESULTS: All women invited to participate in the interviews and the focus groups agreed to do so. Nearly two thirds (64%) of women were unable to afford needed menstrual hygiene supplies during the previous year. Approximately one fifth of women (21%) experienced this monthly. Many women make do with cloth, rags, tissues, or toilet paper; some even use children's diapers or paper towels taken from public bathrooms. Nearly half of women (46%) could not afford to buy both food and menstrual hygiene products during the past year. There was no difference in menstrual hygiene needs by age. Two thirds of organizations indicated that menstrual hygiene was a need of their clients. Thirteen provide menstrual hygiene supplies to their clients; two provide menstrual hygiene education. CONCLUSION: Menstrual hygiene supplies are a basic necessity that many low-income women lack. We document the extent to which low-income women in a major metropolitan area in the United States are unable to afford these basic necessities and what they do to cope. Women's health care providers should advocate for improved access to menstrual hygiene supplies for low-income females across the United States.

Radio role models for the prevention of mother-to-child transmission of HIV and HIV testing among pregnant women in Botswana.

Although Botswana supports a program for the prevention of mother-to-child-transmission of HIV (PMTCT), many women initially did not take advantage of the program. Using data from a 2003 survey of 504 pregnant and post-partum women, we assessed associations between exposure to a long-running radio serial drama that encourages use of the PMTCT program and HIV testing during pregnancy. Controlling for demographic, pregnancy and other variables, women who spontaneously named a PMTCT character in the serial drama as their favorite character were nearly twice as likely to test for HIV during pregnancy as those who did not. Additionally, multiparity, knowing a pregnant woman taking AZT, having a partner who tested, higher education and PMTCT knowledge were associated with HIV testing during pregnancy. Identification with characters in the radio serial drama is associated with testing during pregnancy. Coupled with other supporting elements, serial dramas could contribute to HIV prevention, treatment and care initiatives.

Effects of a social accountability approach, CARE's Community Score Card, on reproductive health-related outcomes in Malawi: A cluster-randomized controlled evaluation.

BACKGROUND: Social accountability approaches, which emphasize mutual responsibility and accountability by community members, health care workers, and local health officials for improving health outcomes in the community, are increasingly being employed in low-resource settings. We evaluated the effects of a social accountability approach, CARE's Community Score Card (CSC), on reproductive health outcomes in Ntcheu district, Malawi using a cluster-randomized control design. METHODS: We matched 10 pairs of communities, randomly assigning one from each pair to intervention and control arms. We conducted two independent cross-sectional surveys of women who had given birth in the last 12 months, at baseline and at two years post-baseline. Using difference-in-difference (DiD) and local average treatment effect (LATE) estimates, we evaluated the effects on outcomes including modern contraceptive use, antenatal and postnatal care service utilization, and service satisfaction. We also evaluated changes in indicators developed by community members and service providers in the intervention areas. RESULTS: DiD analyses showed significantly greater improvements in the proportion of women receiving a home visit during pregnancy (B = 0.20, P < .01), receiving a postnatal visit (B = 0.06, P = .01), and overall service satisfaction (B = 0.16, P < .001) in intervention compared to control areas. LATE analyses estimated significant effects of the CSC intervention on home visits by health workers (114% higher in intervention compared to control) (B = 1.14, P < .001) and current use of modern contraceptives (57% higher) (B = 0.57, P < .01). All 13 community- and provider-developed indicators improved, with 6 of them showing significant improvements. CONCLUSIONS: By facilitating the relationship between community members, health service providers, and local government officials, the CSC contributed to important improvements in reproductive health-related outcomes. Further, the CSC builds mutual accountability, and ensures that solutions to problems are locally-relevant, locally-supported and feasible to implement.