"Provide care for everyone please": engaging community leaders as sexual and reproductive health advocates in North and South Kivu, Democratic Republic of the Congo.

BACKGROUND: Inadequate infrastructure, security threats from ongoing armed conflict, and conservative socio-cultural and gender norms that favour large families and patriarchal power structures contribute to poor sexual and reproductive health (SRH) outcomes in North and South Kivu provinces, Democratic Republic of the Congo (DRC). In order to expand contraceptive and post-abortion care (PAC) access in North and South Kivu, CARE, the International Rescue Committee and Save the Children provided technical support to the Ministry of Health and health facilities in these regions. Partners acknowledged that community leaders, given their power to influence local customs, could play a critical role as agents of change in addressing inequitable gender norms, stigma surrounding SRH service utilization, and topics traditionally considered taboo within Congolese society. As such, partners actively engaged with community leaders through a variety of activities such as community mapping exercises, values clarification and transformation (VCAT) activities, situational analyses, and education. METHODS: This manuscript presents findings from 12 key informant interviews (KIIs) with male political and non-political community leaders conducted in six rural health zones of North and South Kivu, DRC. Transcripts were analysed thematically to explore community leaders' perceptions of their role in addressing the issue of unintended pregnancy in their communities. RESULTS: While community leaders in this study expressed overall positive impressions of contraception and strong support for ensuring access to PAC services following spontaneous and induced abortions, the vast majority held negative beliefs concerning women who had induced abortion. Contrasting with their professed opposition to induced abortion, leaders' commitment to mediating interpersonal conflict arising between community members and women who had abortions was overwhelming. CONCLUSION: Results from this study suggest that when thoughtfully engaged by health interventions, community leaders can be empowered to become advocates for SRH. While study participants were strong supporters of contraception and PAC, they expressed negative perceptions of induced abortion. Given the hypothesized link between the presence of induced abortion stigma and care-avoidance behavior, further engagement and values clarification exercises with leaders must be integrated into community mobilization and engagement activities in order to increase PAC utilization.

Meeting the demand of women affected by ongoing crisis: Increasing contraceptive prevalence in North and South Kivu, Democratic Republic of the Congo.

CONTEXT: Over 20 years of conflict in the DRC, North and South Kivu have experienced cycles of stability and conflict, resulting in a compromised health system and poor sexual and reproductive health outcomes. Modern contraceptive use is low (7.5%) and maternal mortality is high (846 deaths per 100,000 live births). Program partners have supported the Ministry of Health (MOH) in North and South Kivu to provide good quality contraceptive services in public health facilities since 2011. METHODS: Cross-sectional population-based surveys were conducted in the program areas using a two-stage cluster sampling design to ensure representation in each of six rural health zones. Using MOH population estimates for villages in the catchment areas of supported health facilities, 25 clusters in each zone were selected using probability proportional to size. Within each cluster, 22 households were systematically selected, and one woman of reproductive age (15-49 years) was randomly selected from all eligible women in each household. RESULTS: Modern contraceptive prevalence among women in union ranged from 8.4% to 26.7% in the six health zones; current use of long-acting or permanent method (LAPM) ranged from 2.5% to 19.8%. The majority of women (58.9% to 90.2%) reported receiving their current method for the first time at a health facility supported by the program partners. Over half of women in four health zones reported wanting to continue their method for five years or longer. CONCLUSION: Current modern contraceptive use and LAPM use were high in these six health zones compared to DRC Demographic and Health Survey data nationally and provincially. These results were accomplished across all six health zones despite their varied socio-demographic characteristics and different experiences of conflict and displacement. These findings demonstrate that women in these conflict-affected areas want contraception and will choose to use it when good quality services are available to them.

"You must first save her life": community perceptions towards induced abortion and post-abortion care in North and South Kivu, Democratic Republic of the Congo.

Structural barriers such as a restrictive legal environment, limited medical resources, and high-costs inhibit access to safe abortion in the Democratic Republic of the Congo (DRC); these barriers are exacerbated by two decades of conflict. Socio-normative barriers further complicate access to safe abortion and post-abortion care (PAC) in DRC, where fear of abortion-related stigma may lead women to avoid PAC services. Programme partners support the Ministry of Health to provide good quality contraceptive and PAC services in North and South Kivu, DRC. This paper presents results from focus group discussions that explored community members' attitudes towards women who induce abortion and their care-seeking behaviour in programme areas. Results indicate that while abortion stigma was widespread, community members' attitudes towards women who induced abortions were not one-dimensional. Although they initially expressed negative opinions regarding women who induced abortion, beliefs became more nuanced as discussion shifted to the specific situations that could motivate a woman to do so. For example, many considered it understandable that a woman would induce abortion after rape: perhaps unsurprising, given the prevalence of conflict-related sexual violence in this area. While community members believed that fear of stigma or associated negative social consequences dissuaded women from seeking PAC, a majority believed that all women should have access to life-saving PAC. This commitment to ensuring that women who induced abortion have access to PAC, in addition to the professed acceptability of induced abortion in certain situations, indicates that there could be an opening to destigmatise abortion access in this context.