Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator.

There is growing consensus in the family planning community around the need for novel measures of autonomy. Existing literature highlights the tension between efforts to pursue contraceptive targets and maximize uptake on the one hand, and efforts to promote quality, person-centeredness, and contraceptive autonomy on the other hand. Here, we pilot a novel measure of contraceptive autonomy, measuring it at two Health and Demographic Surveillance System sites in Burkina Faso. We conducted a population-based survey with 3,929 women of reproductive age, testing an array of new survey items within the three subdomains of informed choice, full choice, and free choice. In addition to providing tentative estimates of the prevalence of contraceptive autonomy and its subdomains in our sample of Burkinabè women, we critically examine which parts of the proposed methodology worked well, what challenges/limitations we encountered, and what next steps might be for refining, improving, and validating the indicator. We demonstrate that contraceptive autonomy can be measured at the population level but a number of complex measurement challenges remain. Rather than a final validated tool, we consider this a step on a long road toward a more person-centered measurement agenda for the global family planning community.

Assessing the Suitability of Unmet Need as a Proxy for Access to Contraception and Desire to Use It.

Unmet need for contraception is a widely used but frequently misunderstood indicator. Although calculated from measures of pregnancy intention and current contraceptive use, unmet need is commonly used as a proxy measure for (1) lack of access to contraception and (2) desire to use it. Using data from a survey in Burkina Faso, we examine the extent to which unmet need corresponds with and diverges from these two concepts, calculating sensitivity, specificity, and positive/negative predictive values. Among women assigned conventional unmet need, 67 percent report no desire to use contraception and 61 percent report access to a broad range of affordable contraceptives. Results show unmet need has low sensitivity and specificity in differentiating those who lack access and/or who desire to use a method from those who do not. These findings suggest that unmet need is of limited utility to inform family planning programs and may be leading stakeholders to overestimate the proportion of women in need of expanded family planning services. We conclude that more direct measures are feasible at the population level, rendering the proxy measure of unmet need unnecessary. Where access to and/or desire for contraception are the true outcomes of interest, more direct measures should be used.

The effects of armed conflict on the health of women and children.

Women and children bear substantial morbidity and mortality as a result of armed conflicts. This Series paper focuses on the direct (due to violence) and indirect health effects of armed conflict on women and children (including adolescents) worldwide. We estimate that nearly 36 million children and 16 million women were displaced in 2017, on the basis of international databases of refugees and internally displaced populations. From geospatial analyses we estimate that the number of non-displaced women and children living dangerously close to armed conflict (within 50 km) increased from 185 million women and 250 million children in 2000, to 265 million women and 368 million children in 2017. Women's and children's mortality risk from non-violent causes increases substantially in response to nearby conflict, with more intense and more chronic conflicts leading to greater mortality increases. More than 10 million deaths in children younger than 5 years can be attributed to conflict between 1995 and 2015 globally. Women of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings. Current research provides fragmentary evidence about how armed conflict indirectly affects the survival chances of women and children through malnutrition, physical injuries, infectious diseases, poor mental health, and poor sexual and reproductive health, but major systematic evidence is sparse, hampering the design and implementation of essential interventions for mitigating the harms of armed conflicts.

Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies?

Armed conflict disproportionately affects the morbidity, mortality, and wellbeing of women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child, and adolescent health and nutrition interventions in ten conflict-affected settings in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. We found that despite large variations in contexts and decision making processes, antenatal care, basic emergency obstetric and newborn care, comprehensive emergency obstetric and newborn care, immunisation, treatment of common childhood illnesses, infant and young child feeding, and malnutrition treatment and screening were prioritised in these ten conflict settings. Many lifesaving women's and children's health (WCH) services, including the majority of reproductive, newborn, and adolescent health services, are not reported as being delivered in the ten conflict settings, and interventions to address stillbirths are absent. International donors remain the primary drivers of influencing the what, where, and how of implementing WCH interventions. Interpretation of WCH outcomes in conflict settings are particularly context-dependent given the myriad of complex factors that constitute conflict and their interactions. Moreover, the comprehensiveness and quality of data remain limited in conflict settings. The dynamic nature of modern conflict and the expanding role of non-state armed groups in large geographic areas pose new challenges to delivering WCH services. However, the humanitarian system is creative and pluralistic and has developed some novel solutions to bring lifesaving WCH services closer to populations using new modes of delivery. These solutions, when rigorously evaluated, can represent concrete response to current implementation challenges to modern armed conflicts.

Girl child marriage and the social context of displacement: a qualitative comparative exploration of Syrian refugees in Jordan and Rohingya refugees in Bangladesh.

BACKGROUND: There is growing global evidence that girl child marriage (CM) increases during humanitarian crises. Norms, attitudes, and policies that sustain CM are deeply entrenched within families and communities, and may be further exacerbated by conflict and displacement. The purpose of this study is to understand how the social and normative environment influences attitudes and practices related to CM in two diverse humanitarian settings. METHODS: We held a total of eight focus group discussions, four in each country, with Syrian refugees in Jordan and Rohingya Refugees in Bangladesh. FGDs were conducted with fathers, mothers, and adolescent boys and girls. RESULTS: Similar themes emerged from both settings. Participants discussed a desire to hold onto tradition in displacement and how norms are reinforced across generations. Social influence emerged in positive and negative ways, including peer pressure and conformity and the positive influence of host communities. In both settings, girls themselves described having little agency. Participants described resistance to change, which was exacerbated by conflict and displacement, though they discussed how social influence could be an effective way to challenge existing norms that drive the practice of girl child marriage. CONCLUSIONS: Our findings represent a more robust understanding of how norms operate within the social ecological system, and how they are reinforced across social relationships, offering an opportunity to more effectively challenge norms that sustain the practice of girl child marriage.

Healthcare practitioners experiences in delivering sexual and reproductive health services to unmarried adolescent clients in Jordan: results from a cross-sectional survey.

BACKGROUND: The need for youth-friendly sexual and reproductive health (SRH) services has been identified as a national policy priority in Jordan, but there remains limited data on service utilization among adolescents, especially those who are unmarried, and there is limited training for healthcare practitioners (HCPs) in providing SRH services to youth. The objectives of this study are to 1) describe the most common reasons for encounters that HCPs have with unmarried youth clients about SRH topics and 2) explore differences in SRH services provided to unmarried youth by provider in Jordan. METHODS: This cross-sectional study used a two-stage cluster-randomized sampling scheme to sample HCPs (doctors, nurses, and midwives) from health facilities in four governorates in Jordan. Data were collected on practitioner demographics, facility characteristics, and self-reports of having provided services related to nine common SRH concerns to unmarried girls or boys between the ages of 15-19 years. Chi-square tests were conducted to analyze the associations between provider and facility characteristics, client sex, and types of services rendered. RESULTS: In total, 578 providers participated in the study (110 male and 468 female). Practitioners most commonly reported seeing unmarried female youth for concerns related to puberty (38.5%) and family planning (18.51%) and unmarried male youth for concerns of puberty (22.49%) or condoms (11.59%). In total, 64.45, 64.61 and 71.19% of midwives, nurses, and doctors reported having provided any SRH service to an unmarried adolescent. While practitioners most often reported seeing clients of the same sex, male practitioners were more likely to report having seen a female client for STIs (9.09% vs. 4.27% p = 0.040), and providing general information about sexual activity (12.73% vs. 5.77% p = 0.011) than female providers. CONCLUSIONS: Our results suggest that a substantial proportion of HCPs have provided SRH services to unmarried youth - challenging existing perceptions of the SRH care-seeking practices of unmarried youth in this conservative context.

Addressing Racial/Ethnic Inequities in Maternal Health Through Community-Based Social Support Services: A Mixed Methods Study.

INTRODUCTION: In the US, there are striking inequities in maternal health outcomes between racial and ethnic groups. Community-based organizations (CBOs) provide social support services that are critical in addressing the needs of clients of color during and after pregnancy. METHODS: We conducted a descriptive, cross-sectional mixed methods study of CBOs in Greater Boston that provide social support services to pregnant and postpartum clients. In May-August 2020, we administered an online survey about organizational characteristics, client population, and services offered. In July-August 2020, we conducted semi-structured interviews focused on services provided, gaps in services, and the impact of structural racism on clients. We used descriptive statistics to characterize CBOs and services and used thematic analysis to extract themes from the qualitative data. RESULTS: A total of 21 unique CBOs participated with 17 CBOs completing the survey and 14 participating in interviews. CBOs served between 10 and 35,000 pregnant and postpartum clients per year (median = 200), and about half (n = 8) focused their programming on pregnant and postpartum clients. The most significant gaps in social support services were housing and childcare. Respondents identified racism and lack of coordination among organizations as the two primary barriers to accessing social support. DISCUSSION: CBOs face multiple challenges to providing social support to pregnant and postpartum clients of color, and significant gaps exist in the types of services currently provided. Improved coordination among CBOs and advocacy efforts to develop community-informed solutions are needed to reduce barriers to social support.

Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With Community-Based Organizations in Greater Boston.

Community-based organizations are uniquely positioned to address critical gaps in social support that contribute to inequities in maternal health. Using a human-centered design process, we held 3 design workshops with members of 15 organizations in Greater Boston, including community-based organizations, allied hospital systems, and public health departments, to assess proposed solutions for gaps in social support services during pregnancy and the first year after childbirth. The workshops focused on solutions to problems that emerged from a mixed-methods research study with community-based organizations that provide social support services; workshop attendees explored facilitators and barriers to implementing solutions. Key considerations included colocation of solutions, shared ownership of program and client data, decision making about triage and referrals, and strengthening coordination of existing programs. Collaborative design workshops surfaced potential solutions to improve coordination of services, which require addressing structural and interpersonal racism in Greater Boston.

The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review.

INTRODUCTION: The Covid-19 pandemic affects maternal health both directly and indirectly, and direct and indirect effects are intertwined. To provide a comprehensive overview on this broad topic in a rapid format behooving an emergent pandemic we conducted a scoping review. METHODS: A scoping review was conducted to compile evidence on direct and indirect impacts of the pandemic on maternal health and provide an overview of the most significant outcomes thus far. Working papers and news articles were considered appropriate evidence along with peer-reviewed publications in order to capture rapidly evolving updates. Literature in English published from January 1st to September 11 2020 was included if it pertained to the direct or indirect effects of the COVID-19 pandemic on the physical, mental, economic, or social health and wellbeing of pregnant people. Narrative descriptions were written about subject areas for which the authors found the most evidence. RESULTS: The search yielded 396 publications, of which 95 were included. Pregnant individuals were found to be at a heightened risk of more severe symptoms than people who are not pregnant. Intrauterine, vertical, and breastmilk transmission were unlikely. Labor, delivery, and breastfeeding guidelines for COVID-19 positive patients varied. Severe increases in maternal mental health issues, such as clinically relevant anxiety and depression, were reported. Domestic violence appeared to spike. Prenatal care visits decreased, healthcare infrastructure was strained, and potentially harmful policies implemented with little evidence. Women were more likely to lose their income due to the pandemic than men, and working mothers struggled with increased childcare demands. CONCLUSION: Pregnant women and mothers were not found to be at higher risk for COVID-19 infection than people who are not pregnant, however pregnant people with symptomatic COVID-19 may experience more adverse outcomes compared to non-pregnant people and seem to face disproportionate adverse socio-economic consequences. High income and low- and middle-income countries alike faced significant struggles. Further resources should be directed towards quality epidemiological studies. The Covid-19 pandemic impacts reproductive and perinatal health both directly through infection itself but also indirectly as a consequence of changes in health care, social policy, or social and economic circumstances. The direct and indirect consequences of COVID-19 on maternal health are intertwined. To provide a comprehensive overview on this broad topic we conducted a scoping review. Pregnant women who have symptomatic COVID-19 may experience more severe outcomes than people who are not pregnant. Intrauterine and breastmilk transmission, and the passage of the virus from mother to baby during delivery are unlikely. The guidelines for labor, delivery, and breastfeeding for COVID-19 positive patients vary, and this variability could create uncertainty and unnecessary harm. Prenatal care visits decreased, healthcare infrastructure was strained, and potentially harmful policies are implemented with little evidence in high and low/middle income countries. The social and economic impact of COVID-19 on maternal health is marked. A high frequency of maternal mental health problems, such as clinically relevant anxiety and depression, during the epidemic are reported in many countries. This likely reflects an increase in problems, but studies demonstrating a true change are lacking. Domestic violence appeared to spike. Women were more vulnerable to losing their income due to the pandemic than men, and working mothers struggled with increased childcare demands. We make several recommendations: more resources should be directed to epidemiological studies, health and social services for pregnant women and mothers should not be diminished, and more focus on maternal mental health during the epidemic is needed.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review.

BACKGROUND: Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation. METHODS: Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors. RESULTS: Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area. CONCLUSIONS: Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

Respectful care for mothers and newborns is a right and important part of ensuring that their care is high quality and acceptable to them. Just because there is no mistreatment does not mean that Respectful Maternity Care (RMC) was given. Without a clear framework for provider behaviors that reflect RMC principles, it is hard to ensure every woman and newborn gets respectful care in practice. We compared and combined two frameworks summarizing maternal and newborn rights and came out with seven categories. Then we searched for articles that mentioned provider behaviors reflecting RMC. We found 514 articles and ended up with 54 after careful review, from which we pulled the observable behaviors for providers in each category. Almost all papers mentioned actions to protect women and newborns from harm and mistreatment, to treat them with dignity and respect, and to give information and respect choices. About half of papers mentioned actions to protect privacy and to make sure every mother and newborn gets care when needed. Only 25% of papers mentioned actions to make sure all women and newborns receive equal care, and only 15% included actions to make sure women and newborns are physically free to leave facilities at will, and get care whether or not they can pay. This framework defining RMC behaviors for providers is based on data from many studies and can be useful to look at whether maternal newborn care in facilities meets these standards and to inform training and more research to improve RMC.

Health care professionals' attitudes towards youth-friendly sexual and reproductive health services in Jordan: a cross-sectional study of physicians, midwives and nurses.

BACKGROUND: Youth-friendly sexual and reproductive health (SRH) services are thought to make such services for adolescents more accessible and acceptable; however, provider attitudes may still present an important barrier. Improving youth SRH service utilization has been recognized as a national priority in Jordan; however, existing services remain underutilized. Previous studies found that youth perceive SRH services to be inadequate and that providers are not supportive of their needs. The purpose of this study is measure provider attitudes towards youth-friendly SRH services and explore their variation according to individual characteristics among health care professionals in Jordan. METHODS: We measured provider attitudes towards youth-friendly SRH services using a scale that was developed and validated in Jordan. The scale consists of three subscales: (1) Attitudes towards SRH information and services offered to youth, (2) Norms and personal beliefs, and (3) Attitudes towards the policy and clinical environment. Possible scores range between 1 and 4, with higher scores reflecting more youth-friendly attitudes. Physicians, midwives and nurses working at either primary health centers, comprehensive care centers, or women's and children's health centers where services to adolescents are or should be offered were recruited from four governorates in Jordan using a two-stage, cluster sampling scheme. Differences in attitudes were assessed using simple and multivariable linear regression analysis. RESULTS: The sample consisted of 510 providers from four governorates in Jordan. The mean provider score on the full scale was 2.7, with a range of 2.0 to 3.8. On Subscales 1 and 2, physicians exhibited significantly more youth-friendly attitudes than nurses by scoring 0.17 points higher than nurses on Subscale 1 (95% CI: 0.02-0.32; p < 0.05) in adjusted analyses. Providers who had been previously trained in SRH issues scored 0.10 points higher (95% CI: 0.00-0.20; p < 0.05) than those who had not on Subscale 3. No differences were found according to provider characteristics on Subscale 2. Providers exhibited the lowest scores related to items referencing youth sexual behavior. CONCLUSIONS: Provider attitudes towards youth-friendly SRH service delivery highlight context-specific, cultural concerns. The limited variation in attitudes related to norms and personal beliefs may be a reflection that such beliefs are deeply held across Jordanian society. Last, as past training on SRH was significantly associated with higher scores, our results suggest opportunity for intervention to improve providers' confidence and knowledge.

Making sexual and reproductive (SRH) services easier for youth to access, organizing service delivery in a way that meets youth's needs, and supporting health care professionals to interact with youth in a friendly manner can make SRH services more youth-friendly. If SRH services are more youth-friendly, more youth may use them. In Jordan, steps have been taken to make SRH services more youth-friendly, but youth still do not believe that providers are supportive of their needs. This study aims to measure physician's, nurse's, and midwives' attitudes towards youth-friendly SRH services in Jordan. We also look at whether certain individual characteristics, such as age, type of service provider, etc. are related to provider attitudes We used a scale that tested in Jordan to measure provider attitudes. The scale focuses on three domains: (1) Attitudes towards SRH information and services offered to youth, (2) Norms and personal beliefs, and (3) Attitudes towards the policy and clinical environment. Possible scores range between 1 and 4, with higher scores reflecting more youth-friendly attitudes. Our sample includes 510 health care providers from four regions in Jordan. We used descriptive statistics and regression analysis to conduct our analysis. Our results show that physicians had more supportive attitudes than nurses or midwives on Subscales 1 and 3. Providers who reported having been trained in SRH issues in the past had higher scores on Subscale 3. No individual characteristics were related to Subscale 2. We find that in Jordan, provider attitudes may reflect deeply rooted cultural norms.

How Jordanian and Syrian youth conceptualise their sexual and reproductive health needs: a visual exploration using concept mapping.

Young people in Jordan are caught between the rapid social change that has encompassed the Middle East and the pressure to adhere to the strict norms and values that have defined previous generations, especially with regard to sexual and reproductive health. This study seeks to understand how Jordanian and Syrian adolescents conceptualise their concerns, needs and challenges with respect to their developing sexuality and reproductive health, while offering a comparative perspective by nationality and gender. Study participants were 271 young people aged 15-19. Data were generated using an interactive concept mapping approach. Data collection included brainstorming, pile sorting and rating to create a visual map that was interpreted by the participants. The results of this study show that both Jordanian and Syrian adolescents have a complex understanding of sex, sexuality and reproductive health that they define through broad conceptual spheres which include health, economic and social issues. Differences by gender highlight the conflict between traditional norms and changing social expectations. Both Jordanian and Syrian participants identified the need for diverse informational resources. For Syrians, the results emphasise how the hardship has influenced sexual and reproductive health through a focus on early marriage and need for economic stability.

A social-ecological examination into the research, policy and health service delivery environment related to early marriage and sexual and gender-based violence among youth in Jordan.

BACKGROUND: The determinants of sexual- and gender-based violence (SGBV) and early marriage are embedded across different levels of the social ecological system, including at the individual, family, community, and policy levels. In Jordan and the Middle East, SGBV, honor killing, and early marriage are priority public health and human rights issues that often overlap, and affect a significant percentage of youth. Jordan is home to a large number of refugees from across the Middle East, who may be even more vulnerable to these forms of violence than the local youth. The purpose of this analysis is to 1) synthesize the existing literature and 2) present the perspectives of key stakeholders to identify research gaps, programmatic lessons learned, and opportunities for policy change from an ecological perspective at the individual, community, health-system, and policy/legal levels. METHODS: This study includes 1) a systematic literature review of both published and unpublished literature since 2008 and 2) focus group discussions (FGDs) with key stakeholders representing 18 international and local governmental and non-governmental organizations. RESULTS: The literature review included 27 documents. Stakeholder discussions highlighted important research and policy gaps. Prevalence estimates of SGBV, honor killing, and early marriage vary across sources; however, all of them indicate that they remain important issues for youth in Jordan. Several sources indicate that early marriage has been increasing in Jordan since the beginning of the war in Syria, especially among Syrian refugees. Refugee youth are particularly vulnerable to SGBV and early marriage given the worsening economic situation in Jordan. The norms, attitudes, and practices that support SGBV in Jordan appear to be reinforced within families and communities. Despite ongoing programs, SGBV services are limited, especially for youth, and there is little awareness of service availability amongst target populations. Laws and policies continue to offer legal justification for SGBV, honor killing, and early marriage. DISCUSSION: As countries across the Middle East face instability and continue to struggle with the urgent health needs of large refugee and youth populations, this review provides valuable insight relevant to research, programs, and policy in Jordan and across the region.

Young Adult Sexual Behavior in South Africa: How Important is Parental Social Support?

Risky sexual behavior exposes young adults to poor reproductive health outcomes. Parental social support is associated with reduced incidence of risky sexual behavior, but this association has not been adequately investigated in South Africa. We used data from Waves 1 and 3 of the Cape Area Panel Study (a longitudinal study of adolescents and young adults aged 14-22 years and living in the Cape Town metropolitan area) to investigate the associations between parental social support and young adult risky sexual behavior in South Africa. We conducted multivariable logistic regression analyses to assess whether lack of specific categories of parental social supports at wave 1 (baseline) are associated with higher risky sexual behaviors by young adults at wave 3 (follow-up). We found that young adults who never ate meals with their mothers and those who never discussed personal matters with their fathers had increased risks of multiple sexual partnerships. Also, young adults who never got pocket money or money for gifts from their mothers had increased risk to engage in unprotected sex during their first sexual encounter. Our findings suggest that eating family meals, discussing personal matters with youth, and providing them with pocket money, may protect young adults in South Africa from risky sexual behavior.

Development and Validation of the Client-Reported Quality of Contraceptive Counseling Scale to Measure Quality and Fulfillment of Rights in Family Planning Programs.

We developed the Quality of Contraceptive Counseling (QCC) Scale to improve measurement of client experiences with providers in the era of rights-based service delivery. We generated scale items drawing on the previously published QCC Framework and qualitative research on women's preferences for counseling in Mexico, and refined them through cognitive interviews (n = 29) in two Mexican states. The item pool was reduced from 35 to 22 items after pilot testing using exit interviews in San Luis Potosí (n = 257). Exploratory Factor Analysis revealed three underlying dimensions (Information Exchange, Interpersonal Relationship, Disrespect and Abuse); this dimensionality was reproduced in Mexico City (n = 242) using Confirmatory Factor Analysis. Item Response Theory analyses confirmed acceptable item properties in both states, and correlation analyses established convergent, predictive, and divergent validity. The QCC Scale and subscales fill a gap in measurement tools for ensuring high quality of care and fulfillment of human rights in contraceptive services, and should be evaluated and adapted in other contexts.

Factors influencing awareness of healthcare providers on maternal sepsis: a mixed-methods approach.

BACKGROUND: An awareness campaign set to accompany the Global Maternal Sepsis Study (GLOSS) was launched in 2017. In order to better develop and evaluate the campaign, we sought to understand the factors that influence awareness of maternal sepsis by exploring healthcare providers' knowledge, perception of enabling environments, and perception of severity of maternal sepsis. METHODS: We used a mixed-methods approach that included 13 semi-structured interviews to GLOSS regional and country coordinators and 1555 surveys of providers working in GLOSS participating facilities. Directed content analysis and grounded theory were used for qualitative analysis, based on a framework including four overarching themes around maternal health conditions, determinants of maternal health, barriers and facilitators to sepsis identification and management, plus 24 additional sub-topics that emerged during the interviews. Descriptive statistics for frequencies and percentages were used for the quantitative analysis; significance was tested using Pearson χ2. Logistic regressions were performed to adjust for selected variables. RESULTS: Analysis of interviews described limited availability of resources, poor quality of care, insufficient training and lack of protocols as some of the barriers to maternal sepsis identification and management. Analysis from the quantitative survey showed that while 92% of respondents had heard of maternal sepsis only 15% were able to correctly define it and 43% to correctly identify initial management. Provider confidence, perceived availability of resources and of a supportive environment were low (33%, 38%, and 48% respectively). Overall, the predictor that most explained awareness was training. Respondents from the survey and interviewees identified sepsis among the main conditions affecting women at their facilities. CONCLUSIONS: Awareness on maternal sepsis, while acknowledged as important, remains low. Healthcare providers need resources and support to feel confident about the correct identification and management of sepsis, as a prerequisite for the improvement of awareness of maternal sepsis. Similarly, providers need to know about maternal sepsis and its severity to understand the importance of reducing sepsis-related mortality and morbidity. Awareness raising campaigns can help bring neglected maternal health conditions, such as sepsis, to the forefront of global and local agendas.

Ending preventable maternal mortality: phase II of a multi-step process to develop a monitoring framework, 2016-2030.

BACKGROUND: In February 2015, the World Health Organization (WHO) released "Strategies toward ending preventable maternal mortality (EPMM)" (EPMM Strategies), a direction-setting report outlining global targets and strategies for reducing maternal mortality in the Sustainable Development Goal (SDG) period. In May 2015, the EPMM Working Group outlined a plan to develop a comprehensive monitoring framework to track progress toward the achievement of these targets and priorities. This monitoring framework was developed in two phases. Phase I, which focused on identifying indicators related to the proximal causes of maternal mortality, was completed in October 2015. This paper describes the process and results of Phase II, which was completed in November 2016 and aimed to build consensus on a set of indicators that capture information on the social, political, and economic determinants of maternal health and mortality. FINDINGS: A total of 150 experts from more than 78 organizations worldwide participated in this second phase of the process to develop a comprehensive monitoring framework for EPMM. The experts considered a total of 118 indicators grouped into the 11 key themes outlined in the EPMM report, ultimately reaching consensus on a set of 25 indicators, five equity stratifiers, and one transparency stratifier. CONCLUSION: The indicators identified in Phase II will be used along with the Phase I indicators to monitor progress towards ending preventable maternal deaths. Together, they provide a means for monitoring not only the essential clinical interventions needed to save lives but also the equally important political, social, economic and health system determinants of maternal health and survival. These distal factors are essential to creating the enabling environment and high-performing health systems needed to ensure high-quality clinical care at the point of service for every woman, her fetus and newborn. They complement and support other monitoring efforts, in particular the "Survive, Thrive, and Transform" agenda laid out by the Global Strategy for Women's, Children's and Adolescents' Health (2016-2030) and the SDG3 global target on maternal mortality.

Women's preferences for contraceptive counseling in Mexico: Results from a focus group study.

BACKGROUND: Client-centered contraceptive counseling is critical to meeting demand for contraception and protecting human rights. However, despite various efforts to optimize counseling, little is known outside of the United States about what individuals themselves value in counseling. In the present study we investigate women's preferences for contraceptive counseling in Mexico to inform efforts to improve service quality. METHODS: We conducted applied qualitative research, using six focus group discussions with 43 women in two cities in Mexico with distinct sizes and sociocultural contexts (Mexico City and Tepeji del Río, Hidalgo) to assess contraceptive counseling preferences. We used a framework approach to thematically code and analyze the transcriptions from focus groups. RESULTS: Consistent with quality of care and human rights frameworks for family planning service delivery, participants expressed a desire for privacy, confidentiality, informed choice, and respectful treatment. They expanded on usual concepts of respectful care within family planning to include avoidance of sexual assault or harassment-in line with definitions of respectful care in maternal health. In contrast to counseling approaches with method effectiveness as the organizing principle, participants preferred counseling centered on personalized assessments of needs and preferences. Many, particularly older, less educated women, highly valued hearing provider opinions about what method they should use, based on those personalized assessments. Participants highlighted the necessity of clinical assessments or physical exams to inform provider recommendations for appropriate methods. This desire was largely due to beliefs that more exhaustive medical exams could help prevent negative contraceptive outcomes perceived to be common, in particular expulsion of intra-uterine devices (IUDs), by identifying methods compatible with a woman's body. Trust in provider, built in various ways, was seen as essential to women's contraceptive needs being met. CONCLUSIONS: Findings shed light on under-represented perspectives of clients related to counseling preferences. They highlight specific avenues for service delivery improvement in Mexico to ensure clients experience privacy, confidentiality, informed choice, respectful treatment, and personalized counseling-including around reasons for higher IUD expulsion rates postpartum-during contraceptive visits. Findings suggest interventions to improve provider counseling should prioritize a focus on relationship-building to foster trust, and needs assessment skills to facilitate personalization of decision-making support without imposition of a provider's personal opinions. Trust is particularly important to address in family planning given historical abuses against women's autonomy that may still influence perspectives on contraceptive programs. Findings can also be used to improve quantitative client experience measures.