"We need to confirm at least from two or three": Healthcare workers' discretion as gatekeepers in the context of the Ethiopian abortion law.

INTRODUCTION: Women's access to legal and safe abortion is a vital means to reduce unsafe abortion, which in turn is known to reduce maternal morbidity and mortality. In 2005, Ethiopia enacted a relatively permissive abortion legislation. However, there is evidence that access to abortion care services may be challenging and controversial even if progressive abortion laws are in place. This article examines women's access to abortion services from the perspective of healthcare workers in a rural setting in Ethiopia. Drawing on Lipsky's theory of street-level bureaucrats, the article discusses healthcare workers' discretion and the substantial authority they hold as gatekeepers to safe abortion services. METHODS: The study draws upon a qualitative, interpretative methodological approach, with in-depth semi-structured interviews with healthcare workers as the key method of data generation. The data was analyzed and interpreted thematically. Healthcare workers' perspectives were examined with reference to the national abortion legislation and guidelines. RESULTS: The findings reveal that healthcare workers make decisions on behalf of the women who seek abortion, and they involve parents and partners in abortion-related decision-making processes. Moreover, they assess the social context of the pregnancy such as the marital and economic statuses of the abortion-seeking women in ways that restrict women's access to legally-endorsed abortion services. CONCLUSIONS: Healthcare workers' practices in this rural area were found to challenge the basic provisions laid out in Ethiopia's abortion legislation. Their negative discretion of the legislation contributes to the substantial barriers Ethiopian abortion-seeking women face in gaining access to legal abortion services, despite the presence of a progressive legal framework and guidelines.

Between 'block course relationships' and abstinence: cultures of sexuality among students at Addis Ababa University.

Inspired by African and other feminist scholarship on gender, sexuality and agency, this article studies narrations of norms and practices in sexual relationships between university students. A main aim of the article is to move beyond the problem focus in earlier scholarship on women, sexuality and reproduction, and to identify potential spaces of freedom and expansion of female agency. The article is based on qualitative research conducted with students at Addis Ababa University. The findings a vivid space for male-female relationships. Study participants report being sexually engaged as "the new normal" and claim that many female students are active both in seeking relationships and in discontinuing them. These ideas and practices indicate increasing female agency and emerge in stark contrast to dominant social norms for sexual conduct, which demand chastity before marriage, particularly for women. Students are conscious of this discrepancy and bring it up in their narratives. Findings also show that some students prefer to stay abstinent and make an effort to avoid sexual relations. We argue that expressions of female agency are evident not only in norm-transgressive sexual conduct, but also in norm-conforming strategies of sexual abstinence.

Health workers' experience of providing second-trimester abortion care in Ethiopia: a qualitative study.

BACKGROUND: Second-trimester abortions are less common than abortions in the first trimester, yet they disproportionately account for a higher burden of abortion-related mortality and morbidity worldwide. Health workers play a crucial role in granting or denying access to these services, yet little is known about their experiences. Ethiopia has been successful in reducing mortality due to unsafe abortion over the past decade, but access to second trimester abortion remains a challenge. The aim of this study is to better understand this issue by exploring the experiences of second-trimester abortion providers working in Addis Ababa, Ethiopia. METHODS: A qualitative study with 13 in-depth semi-structured interviews with 16 health workers directly involved in providing second-trimester abortions, this included obstetrician and gynaecologist specialists and residents, general practitioners, nurses, and midwives. Data was collected at four public hospitals and one non-governmental clinic in Addis Ababa, Ethiopia and analysed using Malterud's text-condensation method. RESULTS: The providers recognized the critical need for second-trimester abortion services and were motivated by their empathy towards women who often sought care late due to marginalisation and poverty making it difficult to access abortion before the second trimester. However, service provision was challenging according to the providers, and barriers like lack of access to essential drugs and equipment, few providers willing to conduct abortions late in pregnancy and unclear guidelines were commonly experienced. This led to highly demanding working conditions. The providers experienced ethical dilemmas pertaining to the possible viability of the fetus and women desperately requesting the service after the legal limit. CONCLUSIONS: Second-trimester abortion providers faced severe barriers and ethical dilemmas pushing their moral threshold and medical risk-taking in efforts to deliver second-trimester abortions to vulnerable women in need of the service. Effort is needed to minimize health system barriers and improve guidelines and support for second-trimester abortion providers in order to increase access and quality of second-trimester abortion services in Ethiopia. The barriers forcing women into second trimester abortions also need to be addressed.

"I came to escort someone": Men's experiences of antenatal care services in urban Ghana-a qualitative study.

BACKGROUND: Male involvement in maternal healthcare has been widely recognized as essential for positive health outcomes for expectant mothers and their unborn babies. However, few studies have explored men's experiences of maternal health services. The purpose of this paper is to explore men's involvement in antenatal care in urban Ghana and to discuss how men navigate their roles in a space that has been constructed as feminine. The study draws upon theories of space, place, and gender. METHODS: A qualitative exploratory study using semistructured interviews, focus group discussion, and observation was conducted in Accra, Ghana. Expectant fathers and health workers were interviewed, and observation was conducted at a selected public hospital in Accra. RESULTS: The findings suggest that the few men who attend antenatal care with their expecting partners become involved to a limited extent in the clinic's activities. Beyond a few who take an active role, most men stay on the outskirts of the hospital grounds and rarely participate in consultations with their partner and midwife. Men still view their presence as necessary to acquire knowledge and as sources of emotional, financial, and physical support for their partners. On the health workers' side, the study found no clear agenda for engaging men at the clinic, and nurses/midwives felt there was a lack of staff who could engage more directly with the men. CONCLUSION: The study indicates that most expecting fathers feel too shy and uncomfortable to locate themselves in the female space that makes up antenatal care/maternity wards. Health workers do not feel they have the necessary resources to involve men fruitfully. Thus, men do not engage in the activity as hoped but rather remain on the outskirts of the maternity clinic. However, if men continue to negotiate their involvement at the clinic and become more assertive in their roles, the maternity clinic as a female space could, with time, be transformed into a space in which both expecting mothers and fathers can actively participate and be engaged to the benefit of all.

This article discusses men's roles and involvement in health workers' activities when they accompany their pregnant partners to the maternity clinic. Health workers organize antenatal care services (ANCs) for expectant mothers to receive regular check-ups during pregnancy. Since pregnancy and childbirth are generally viewed as women's domains, men have not traditionally been expected to attend antenatal care with their partners. However, recent national and global agendas have recognized men's inclusion in maternal healthcare as central to improving mothers' and unborn babies' health. Men are being encouraged to play an active role in supporting their partners during pregnancy, and as part of this role, they are encouraged to attend antenatal care services. In the health facility where this study was conducted, we found that the few men who attended antenatal care most of the time stayed outside the maternity clinic under trees or in other empty spaces around the clinic. They opted to remain in the outside areas because they felt shy sitting among women who were a substantial majority at the clinic. We also found that health workers rarely involved men in ANC activities because of a lack of staff to engage men in separate sessions. Although the fathers attending antenatal care were disappointed that they were not engaged in activities, they still found it necessary to attend to give their partners emotional, physical, and financial support. Without the consideration of how ANC activities are structured and the appropriate resources for health workers, men's active participation in ANCs will remain minimal.

Reproductive health and the politics of abortion.

This editorial provides an overview of a thematic series that brings attention to the persistently deficient and unequal access to sexual and reproductive health services for young women in sub-Saharan Africa. It represents an effort to analyze the multifaceted relationship between laws, policies and access to services in Ethiopia, Zambia and Tanzania. Using a comparative perspective and qualitative research methodology, the papers presented in this issue explore legal, political and social factors and circumstances that condition access to sexual and reproductive health services within and across the three countries. Through these examples we show the often inconsistent and even paradoxical relationship between the formal law and practices on the ground. Particular emphasis is placed on safe abortion services as an intensely politicized issue in global sexual and reproductive health. In addition to the presentation of the individual papers, this editorial comments on the global politics of abortion which represents a critical context for the regional and local developments in sexual and reproductive health policy and care provision in general, and for the contentious issue of abortion in particular.

Vanilla bisquits and lobola bridewealth: parallel discourses on early pregnancy and schooling in rural Zambia.

BACKGROUND: Adolescent pregnancy is a complex socio-economic phenomenon ranking high on the global health policy agenda. Early childbearing is associated with early marriage and school drop-out, and is defined as a problem to the health and development of girls. This paper reports from formative research. The formative research aimed to explore socio-cultural and structural dynamics at work behind early pregnancy and school drop out in rural Zambia. The study findings have been used to inform a school based intervention to reduce early pregnancy (RISE: 'Research Initiative to Support the Empowerment of Girls'). Theoretically the study is informed by social constructionism. METHODS: A qualitative approach was employed. Semi-structured qualitative interviews (61) and focus group discussions (7) were carried out with girls (in and out of school), boys, parents, teachers, health workers and community- and district leaders in 2014-15. Systematic text condensation was drawn upon in the analysis of the material. RESULTS: The study findings indicate that the official Zambian discourse that presents early pregnancy as a serious challenge and schooling as the prime way to confront the problem enjoy substantial support at community levels. However, a parallel discourse on fertility, early marriage and childbearing as social and economic security surfaced and was articulated by the same study participants. The latter contrasting discourse questioned schooling as the only solution to secure a girl's future arguing that there are many reasons why early pregnancy may emerge as rational. CONCLUSIONS: Grasping the complexity of local discourse is vital in planning health interventions. The present study revealed that although delayed child bearing and schooling among girls enjoyed high status and legitimacy in the study area, the social and economic context worked to reward early marriage. Interventions to reduce early pregnancies in rural Zambian communities need to fundamentally address the material constraints that condition and reinforce a culture of early childbearing.

Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania.

BACKGROUND: Unsafe abortion continues to be a major hazard for maternal health in Sub-Saharan Africa, where abortion remains highly controversial and access to safe abortion services is unequally distributed. Although national abortion laws are central in indicating women's potential for accessing safe abortion services, the character of an abortion law may alone say little about national discursive abortion landscapes and access scenarios. The article calls for the study and problematization of the relationship between legal abortion frameworks on the one hand, and discourses surrounding abortion on the other, in an attempt to move closer to an understanding of the complexity of factors that influence knowledge about and access to safer abortion services. With the restrictive abortion law in Tanzania as a starting point, the paper explores the ways in which the major global abortion discourses manifest themselves in the country and indicate potential implications of a hybrid abortion regime. METHODS: The study combined a review of major legal and policy documents on abortion, a review of publications on abortion in Tanzanian newspapers between 2000 and 2015 (300 articles), and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health. RESULTS: Tanzania's abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, and as such reflect the major global discourses. Fairclough's concepts interdiscursivity and recontextualization were drawn upon to develop an understanding of how the concepts health, rights and life emerge across the discourses, but are employed in contrasting lines of argumentation in struggles for hegemony and legitimacy. DISCUSSION AND CONCLUSIONS: The paper demonstrates that a hybrid discursive regime relating to abortion characterizes the legally restrictive abortion context of Tanzania. We argue that such a complex discursive landscape, which cuts across the restrictive - liberal divide, generates an environment that seems to open avenues for enhanced access to abortion related knowledge and services.

'An uneasy compromise': strategies and dilemmas in realizing a permissive abortion law in Ethiopia.

INTRODUCTION: At the turn of the century, when the Millennium Development Goals placed maternal mortality reduction high on the global agenda, Ethiopia relaxed its restrictive abortion law to expand grounds on which a woman could legally obtain an abortion. This radical policy shift took place within a context of predominant anti-abortion public opinion shaped by strong religious convictions. Drawing upon Walt and Gilson's policy analysis framework, this paper explores the tension between public policy and religious dogma for the strategies chosen by the Ethiopian Ministry of Health and its partners implementing the new policy, and for access to safe abortion services. METHODS: The study employed a qualitative research methodology. It targeted organizations that are key stakeholders in the field of reproductive health. These included policy makers and policy implementers like ministries, UN agencies and international and national NGOs as well as religious organizations as key opinion leaders. The data collection took place in Addis Ababa between 2016 and 2018. A total of 26 interviews were conducted, transcribed, and analyzed using the principles of qualitative content analysis. RESULTS: Our analysis showed that the implementing organizations adopted a strategy of silence not to provoke anti-abortion sentiments and politicization of the abortion issue which was seen as a threat to the revised law and policy. This strategy has facilitated a rollout of services and has improved access to safe abortion care. Nevertheless informants were concerned that the silence strategy has prevented dissemination of knowledge about the revised law to the general public, to health workers and to the police. In turn this has caused confusion about eligibility to legal and safe abortion procedures. CONCLUSIONS: While silence as a strategy works to protect the law enhancing the health and survival of young women, it may at the same time prevent the law from being fully effective. As a long term strategy, silence fails to expand awareness and access to safe abortion services, and may not sufficiently serve to fulfill the potential of the law to prevent abortion related maternal deaths.

The access paradox: abortion law, policy and practice in Ethiopia, Tanzania and Zambia.

INTRODUCTION: Unsafe abortion is a major contributor to the continued high global maternal mortality and morbidity rates. Legal abortion frameworks and access to sexuality education and contraception have been pointed out as vital to reduce unsafe abortion rates. This paper explores the relationship between abortion law, policy and women's access to safe abortion services within the different legal and political contexts of Ethiopia, Tanzania and Zambia. The research is inspired by recent calls for contextualized policy research. METHODS: The research was based in Addis Ababa (Ethiopa), Dar es Salaam (Tanzania) and Lusaka (Zambia) and had a qualitative exploratory research design. The project involved studying the three countries' abortion laws and policies. It moreover targeted formal organizations as implementers of policy as well as stakeholders in support of, or in opposition to the existing abortion laws. Semi-structured interviews were carried out with study participants (79) differently situated vis-à-vis abortion, exploring their views on abortion-related legal- and policy frames and their perceived implications for access. RESULTS: The abortion laws have been classified as 'liberal' in Zambia, 'semi-liberal' in Ethiopia and 'restrictive' in Tanzania, but what we encountered in the three study contexts was a seeming paradoxical relationship between national abortion laws, abortion policy and women's actual access to safe abortion services. The study findings moreover reveal that the texts that make up the three national abortion laws are highly ambiguous. The on-paper liberal Zambian and semi-liberal Ethiopian laws in no way ensure access, while the strict Tanzanian law is hardly sufficient to prevent young women from seeking and obtaining abortion. In line with Walt and Gilson's call to move beyond a narrow focus on the content of policy, our study demonstrates that the connection between law, health policy and access to health services is complex and critically dependent on the socio-economic and political context of implementation. CONCLUSIONS: Legal frameworks are vital instruments for securing the right to health, but broad contextualized studies rather than classifications of law along a liberal-restrictive continuum are demanded in order to enhance existing knowledge on access to safe abortion services in a given context.

Why teach sexuality education in school? Teacher discretion in implementing comprehensive sexuality education in rural Zambia.

BACKGROUND: Reproductive health problems such as HIV, unwanted pregnancy and unsafe abortion among adolescents are closely linked to insufficient knowledge about sexuality and reproduction and lack of access to contraceptives. Supported by international agencies, Zambia has introduced an ambitious nation-wide program for comprehensive sexuality education (CSE) to be implemented into ordinary school activities by teachers. The curriculum is firmly based in a discourse of sexual and reproductive rights, not commonly found in the public debate on sexuality in Zambia. This paper explores how teachers perceive the curriculum and practice discretion when implementing the CSE in mid-level schools in Nyimba district in Zambia. METHODS: Using a case study design, data were collected through in-depth interviews with 18 teachers and analyzed thematically drawing upon theories of discretion and policy implementation. RESULTS: Individual teachers make decisions on their own regarding what and when to teach CSE. This discretion implies holding back information from the learners, teaching abstinence as the only way of preventing pregnancy or cancelling sexuality education sessions altogether. Teachers' choices about the CSE program were linked to lack of guidance on teaching of the curriculum, especially with regards to how to integrate sexuality education into existing subjects. Limited prioritization of CSE in the educational sector was observed. The incompatibility of CSE with local norms and understandings about adolescent sexuality combined with teacher-parent role dilemmas emerged as problematic in implementing the policy. Limited ownership of the new curriculum further undermined teachers' motivation to actively include CSE in daily teaching activities. Use of discretion has resulted in arbitrary teaching thus affecting the acquisition of comprehensive sexual and reproductive health knowledge among learners. CONCLUSION: The CSE had limited legitimacy in the community and was met with resistance from teachers tasked with its' implementation. In order to enhance ownership to the CSE program, local concerns about the contents of the curriculum and the parent-teacher role dilemma must be taken into consideration. Not addressing these challenges may undermine the policy's intention of increasing knowledge about sexuality and reproduction and empowering adolescents to access contraceptive services and avoid unwanted pregnancies.

Shaping the abortion policy - competing discourses on the Zambian termination of pregnancy act.

INTRODUCTION: The Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds, but access to safe abortion services is limited and this constitutes a considerable problem for rights to sexual and reproductive health. The case of Zambia provides an opportunity to explore the relationship between a legal framework that permits abortion on diverse grounds, the moral and political disputes around abortion and access to sexual and reproductive health services. METHODS: This paper draws upon eleven months of ethnographic fieldwork in Zambia. The fieldwork included 28 open-ended interviews with key stakeholders as well as the collection of archival material related to the origins of Zambia's legal framework for abortion. The archival material and the interview data were analyzed thematically, using theoretical perspectives on discourse and the anthropology of policies. RESULTS: The study findings show that the Zambian case is not easily placed into standard categories of liberal or restrictive abortion laws. The archival material reveals that restrictive elements were in focus when the Zambian Termination of Pregnancy Act was passed (1972). The restrictive aspects of the law were emphasized further when Zambia was later declared as a Christian nation. Some of these restrictive elements are still readily recognized in today's abortion debate. Currently there are multiple opinions on whether Zambian abortion policy is liberal, restrictive or neither. The law emerges as ambiguous, and this ambiguity is actively used by both those working to increase access to safe and legal abortion services, and those who work to limit such access. Coupled with a lack of knowledge about the law, its ambiguity may work to reduce access to safe abortion services on the grounds permitted by the law. CONCLUSIONS: We argue that the Zambian Termination of Pregnancy Act is ambiguous and leaves much room for interpretation. This paper challenges the notion that the Zambian abortion law is liberal and opens up for further discussion on the relationship between how a law is described and perceived by the public, and the rights to health and services ensured by it.

When the law makes doors slightly open: ethical dilemmas among abortion service providers in Addis Ababa, Ethiopia.

BACKGROUND: In 2005, Ethiopia changed its abortion law to curb its high maternal mortality. This has led to a considerable reduction in deaths from unsafe abortions. Abortion is now legal if the woman's pregnancy is a result of rape or incest, if her health is endangered, if the fetus has a serious deformity, if she suffers from a physical or mental deficiency, or if she is under 18 years of age. The word of the woman, if in compliance with the law, is sufficient to qualify for an abortion. In this context, where the law makes the door slightly open, health workers become important in deciding who gets access to safe services and who doesn't, thus creating considerable ethical dilemmas. METHODS: The objective of this study was to explore abortion service providers' personal experiences and reflections, perceptions of the abortion law, and ethical and dilemmas that arise. Data collection took place from March to May 2016 in Addis Ababa, at different health clinics providing abortion services. Thirty in-depth interviews and three focus group discussions were conducted with 41 abortion service providers at governmental and non-governmental clinics. Content analysis was drawn upon in the interpretation of the findings. RESULTS: When working in a context where the law has slightly opened the door for abortion seeking women, the health workers describe conflicting concerns, burdensome responsibilities, and ambiguity concerning how to interpret and implement the law. They describe efforts to balance their religious faith and values against their professional obligations and concern for women's health and well-being. This negotiation is particularly evident in the care of women who fall outside the law's indications. They usually handle ethical dilemmas and decision-making alone without guidance. Moreover, many health workers face a stigma from fellow colleagues not performing abortions and therefore keep their job a secret from family and friends. CONCLUSIONS: Health workers in Ethiopia experience ethical dilemmas trying to maneuver between the abortion law, their personal values, and their genuine concern for the health of women. More research is needed to further explore this.

The challenge of community engagement and informed consent in rural Zambia: an example from a pilot study.

BACKGROUND: There is a need for empirically based research on social and ethical challenges related to informed consent processes, particularly in studies focusing on adolescent sexual and reproductive health. In a pilot study of a school-based pregnancy prevention intervention in rural Zambia, the majority of the guardians who were asked to consent to their daughters' participation, refused. In this paper we explore the reasons behind the low participation in the pilot with particular attention to challenges related to the community engagement and informed consent process. METHODS: The pilot was implemented in two schools and examined the acceptability of a package of interventions including economic support to families to keep their girls in school, pocket money for girls, youth club meetings on reproductive health, and community meetings to sensitize the community. Focus group discussions (4) were conducted with girls who participated in the pilot, boys in their class and with parents. Individual semi-structured interviews (11) were conducted with teachers, peer educators and community health workers involved in the coordination of the intervention as well as with religious and traditional leaders. Data were analyzed through thematic analysis. RESULTS: The findings indicate that inadequate use of recognized community communication channels during the community engagement process and dissemination of information about the pilot resulted in limited understanding of the pilot concept by the community. This surfaced through uncertainty and fear that the intervention may result in loss of control over daughters, worries about why money was provided unconditionally to girls, and suspicion of links to satanism. The sense of insecurity appeared to be exacerbated by low literacy levels, poverty, fear of loss of bride wealth, perceived disregard for local perceptions of social status, and scanty trust in the actors implementing the pilot. CONCLUSIONS: Inadequate use of locally appropriate channels in the dissemination of information created room for interpretation and facilitated development of mistrust, undermining the conditions for community engagement and actual informed consent. A key lesson learnt is the importance of taking seriously the complexity of local values and structures that may impact people's capability to consent or not consent to a study in an informed manner.

Strengthening validity in studies of pelvic floor disorders through qualitative research: an example from Ethiopia.

INTRODUCTION AND HYPOTHESIS: This formative qualitative follow-up study addresses validity concerns in the Dabat Incontinence and Prolapse (DABINCOP) study, which aimed to determine the prevalence of pelvic floor disorders in north-west Ethiopia. A pilot study using a questionnaire validated by pelvic exam showed severe underreporting of clinically relevant pelvic organ prolapse (POP). The objective of the follow-up study was to explore the reasons behind the underreporting and to gather information to strengthen the sensitivity and local relevance of the questionnaire to be employed in the main study. METHODS: A qualitative formative study nested within the DABINCOP study was carried out in rural and semiurban communities using an interpretive approach and in-depth qualitative interviews. Women (5) who had not self-reported POP in the pilot but were diagnosed with severe prolapse after pelvic examination, and health-care workers in the research team (7) were interviewed individually within 1 year of the pilot. Systematic text condensation was used in the analysis. RESULTS: The women explained that shame and fear of social exclusion, lack of trust in the study and data collectors, and lack of hope for cure prevented them from disclosing. The health-care workers reported weaknesses in the questionnaire and the research approach. Time pressure and competition among data collectors may have compromised women's motivation to disclose. CONCLUSIONS: The study indicates that qualitative research may fruitfully be employed in the formative phase of an epidemiological study on sensitive reproductive health problems to enhance local relevance of the tool and overall validity of the study.

Life after pelvic organ prolapse surgery: a qualitative study in Amhara region, Ethiopia.

BACKGROUND: Women living in resource constrained settings often have limited knowledge of and access to surgical treatment for pelvic organ prolapse. Additionally, little is known about experiences during recovery periods or about the reintegration process for women who do gain access to medical services, including surgery. This study aimed to explore women's experiences related to recovery and reintegration after free surgical treatment for pelvic organ prolapse in a resource-constrained setting. METHODS: The study had a qualitative design and used in-depth interviews in the data collection with a purposive sample of 25 participants, including 12 women with pelvic organ prolapse. Recruitment took place at the University of Gondar Hospital, Ethiopia, where women with pelvic organ prolapse had been admitted for free surgical treatment. In-depth interviews were carried out with women at the hospital prior to surgery and in their homes 5-9 months following surgery. Interviews were also conducted with health-care providers (8), representatives from relevant organizations (3), and health authorities (2). The fieldwork was carried out in close collaboration with a local female interpreter. RESULTS: The majority of the women experienced a transformation after prolapse surgery. They went from a life dominated by fear of disclosure, discrimination, and divorce due to what was perceived as a shameful and strongly prohibitive condition both physically and socially, to a life of gradually regained physical health and reintegration into a social life. The strong mobilization of family-networks for most of the women facilitated work-related help and social support during the immediate post-surgery period as well as on a long-term basis. The women with less extensive social networks expressed greater challenges, and some struggled to meet their basic needs. All the women openly disclosed their health condition after surgery, and several actively engaged in creating awareness about the condition. CONCLUSIONS: Free surgical treatment substantially improved the health and social life for most of the study participants. The impact of the surgery extended to the communities in which the women lived through increased openness and awareness and thus had the potential to ensure increased disclosure among other women who suffer from this treatable condition.

Community based interventions for strengthening adolescent sexual reproductive health and rights: how can they be integrated and sustained? A realist evaluation protocol from Zambia.

BACKGROUND: Research that explores how community-based interventions for strengthening adolescent sexual reproductive health and rights (SRHR) can be integrated and sustained in community health systems, is, to the best of our knowledge, very scarce, if not absent. It is important to document mechanisms that shape integration process in order to improve health systems' responsiveness towards adolescents' SRHR. This realist evaluation protocol will contribute to this knowledge in Zambia where there is increased attention towards promoting maternal, neonatal and child health as a means of addressing the current high early pregnancy and marriage rates. The protocol will ascertain: why, how, and under what conditions the integration of SRHR interventions into Zambian community health systems will optimise (or not) acceptability and adoption of SRHR services. This study is embedded within a randomized controlled trial - "Research Initiative to Support the Empowerment of Girls (RISE)"- which aims to reduce adolescent girl pregnancies and marriages through a package of interventions including economic support to families, payment of school fees to keep girls in school, pocket money for girls, as well as youth club and community meetings on reproductive health. METHODS: This is a multiple-case study design. Data will be collected from schools, health facilities and communities through individual and group interviews, photovoice, documentary review, and observations. The study process will involve 1) developing an initial causal theory that proposes an explanation of how the integration of a community-based intervention that aimed to integrate adolescent SRHR into the community health system may lead to adolescent-friendly services; 2) refining the causal theory through case studies; 3) identifying contextual conditions and mechanisms that shape the integration process; and 4) finally proposing a refined causal theory and set of recommendations to guide policy makers, steer further research, and inform teaching programmes. DISCUSSION: The study will document relevant values as well as less formal and horizontal mechanisms which shape the integration process of SRHR interventions at community level. Knowledge on mechanisms is essential for guiding development of strategies for effectively facilitating the integration process, scaling up processes and sustainability of interventions aimed at reducing SRH problems and health inequalities among adolescents.

Living with pelvic organ prolapse: voices of women from Amhara region, Ethiopia.

INTRODUCTION: The objective of the study was to explore how women with symptomatic pelvic organ prolapse in a low-income setting explain, experience, and handle the potential practical and social consequences of the condition. METHODS: An explorative qualitative design was employed using in-depth interviews in the data collection. A total of 24 women with different degrees of symptomatic pelvic organ prolapse were included; 18 were recruited at the hospital and 6 from the community. Fieldwork was carried out in the Amhara region of northwest Ethiopia in 2011 and 2015. RESULTS: The informants held that the pelvic organ prolapse was caused by physical strain on their body, such as childbirth, food scarcity or hard physical work, particularly during pregnancy and shortly after delivery. Severe difficulties and pain while carrying out daily chores were common among the women. The informants used a variety of strategies to manage their work while striving to avoid disclosure of their condition. Disclosure was related to embarrassment and fear of discrimination from people living close to them, including the fear of being expelled from the household. Most of the informants, however, experienced substantial support from relatives, friends, and at times also from their husband, after disclosing their condition. CONCLUSIONS: The study highlights how symptomatic pelvic organ prolapse may severely affect women's lives in a low-income setting. The condition is perceived to be both caused by and aggravated by the heavy physical burdens of daily work.

Boundaries of confidentiality in nursing care for mother and child in HIV programmes.

BACKGROUND: Confidentiality lies at the core of medical ethics and is the cornerstone for developing and keeping a trusting relationship between nurses and patients. In the wake of the HIV epidemic, there has been a heightened focus on confidentiality in healthcare contexts. Nurses' follow-up of HIV-positive women and their susceptible HIV-exposed children has proved to be challenging in this regard, but the ethical dilemmas concerning confidentiality that emerge in the process of ensuring HIV-free survival of the third party - the child - have attracted limited attention. OBJECTIVE: The study explores challenges of confidentiality linked to a third party in nurse-patient relationships in a rural Tanzanian HIV/AIDS context. STUDY CONTEXT: The study was carried out in rural and semi-urban settings of Tanzania where the population is largely agro-pastoral, the formal educational level is low and poverty is rife. The HIV prevalence of 1.5% is low compared to the national prevalence of 5.1%. METHODS: Data were collected during 9 months of ethnographic fieldwork and consisted of participant observation in clinical settings and during home visits combined with in-depth interviews. The main categories of informants were nurses employed in prevention of mother-to-child transmission of HIV programmes and HIV-positive women enrolled in these programmes. ETHICAL CONSIDERATIONS: Based on information about the study aims, all informants consented to participate. Ethical approval was granted by ethics review boards in Tanzania and Norway. FINDINGS AND DISCUSSION: The material indicates a delicate balance between the nurses' attempt to secure the HIV-free survival of the babies and the mothers' desire to preserve confidentiality. Profound confidentiality-related dilemmas emerged in actual practice, and indications of a lack of thorough consideration of the implication of a patient's restricted disclosure came to light during follow-up of the HIV-positive women and the third party - the child who is at risk of HIV infection through mother's milk. World Health Organization's substantial focus on infant survival (Millennium Development Goal-4) and the strong calls for disclosure among the HIV-positive are reflected on in the discussion.

Increased fairness in priority setting processes within the health sector: the case of Kapiri-Mposhi District, Zambia.

BACKGROUND: The challenge of priority setting (PS) in health care within contexts of severe resource limitations has continued to receive attention. Accountability for Reasonableness (AFR) has emerged as a useful framework to guide the implementation of PS processes. In 2006, the AFR approach to enhance legitimate and fair PS was introduced by researchers and decision makers within the health sector in the EU funded research project entitled 'Response to Accountable priority setting for Trust in health systems' (REACT). The project aimed to strengthen fairness and accountability in the PS processes of health systems at district level in Zambia, Tanzania and Kenya. This paper focuses on local perceptions and practices of fair PS (baseline study) as well as at the evolution of such perceptions and practices in PS following an AFR based intervention (evaluation study), carried out at district level in Kapiri-Mposhi District in Zambia. METHODS: Data was collected using in depth interviews (IDIs), focus group discussions (FGDs) and review of documents from national to district level. The study population for this paper consisted of health related stakeholders employed in the district administration, in non-governmental organizations (NGO) and in health facilities. RESULTS: During the baseline study, concepts of legitimacy and fairness in PS processes were found to be grounded in local values of equity and impartiality. Government and other organizational strategies strongly supported devolution of PS and decision making procedures. However, important gaps were identified in terms of experiences of stakeholder involvement and fairness in PS processes in practice. The evaluation study revealed that a transformation of the views and methods regarding fairness in PS processes was ongoing in the study district, which was partly attributed to the AFR based intervention. CONCLUSIONS: The study findings suggest that increased attention was given to fairness in PS processes at district level. The changes were linked to a number of simultaneous factors among them the concepts introduced by the present project with its emphasis on fairness and enhanced participation. A responsive leadership that was increasingly accountable to its operational staff and communities emerged as one of the key elements in driving the processes forward.

The accountability for reasonableness approach to guide priority setting in health systems within limited resources--findings from action research at district level in Kenya, Tanzania, and Zambia.

BACKGROUND: Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT). METHODS: This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods. RESULTS: The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. CONCLUSIONS: District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.