Preferences and experiences of parents/guardians of youth with epilepsy and intellectual disability on reproductive health counseling.

OBJECTIVE: To explore the experiences and preferences of parents/guardians of adolescents and young adults (AYA) of childbearing potential with co-occurring epilepsy and intellectual disability (ID) regarding counseling by neurologists on sexual and reproductive health (SRH) topics such as pregnancy, contraception, menstruation, and folic acid supplementation. METHODS: We conducted semi-structured interviews with parents/guardians of AYAs (12-28 years old) of childbearing potential with co-occurring epilepsy and ID, recruited from a tertiary-care children's hospital. We confirmed the diagnoses of epilepsy and ID with the patient's neurologist and parent/guardian. All degrees of ID (e.g. mild/moderate/severe) were eligible. We audio-recorded and transcribed interviews. Two coders performed qualitative thematic analysis. RESULTS: Twenty-five parents/guardians completed interviews. Themes included: (1) Parents/guardians believe their child to be immune from sexual abuse due to their supervision, yet desire counseling about abuse recognition and prevention, which they also report not occurring (2) A common opinion was that counseling on menstruation was more relevant to their child's life than counseling about pregnancy-related topics (3) Parents/guardians reported a lack of counseling on pregnancy-related topics such as folic acid supplementation and teratogenesis and generally also reported some degree of interest in hearing about these topics from neurologists (4) Parents/guardians also reported a lack of counseling on drug interactions between contraception and ASMs, and were highly interested in learning more about this topic (5) Parents/guardians want neurologists to initiate annual comprehensive SRH counseling at puberty about most topics, but report that they often initiate SRH discussions themselves. CONCLUSION: Parents/guardians of AYAs with epilepsy and ID prefer more frequent, neurologist-initiated, comprehensive conversations surrounding SRH particularly emphasizing menstruation and sexual abuse recognition/prevention. Findings may inform professional and patient education and health systems interventions including development of discussion guides and/or decision aides to improve SRH care for AYAs with epilepsy and ID.

Acceptability of a community-embedded intervention for improving adolescent sexual and reproductive health in south-east Nigeria: A qualitative study.

INTRODUCTION: Adolescents have limited access to quality sexual and reproductive health (SRH) services that are key to healthy sexual lives in many low and middle-income countries such as Nigeria. Hence, context-specific interventions are required to increase adolescents' access to and utilisation of SRH. This paper provides new knowledge on the acceptability of a community-embedded intervention to improve access to SRH information and services for adolescents in Ebonyi state, southeast Nigeria. METHODS: A community-embedded intervention was implemented for six months in selected communities. Thereafter the intervention was assessed for its acceptability using a total of 30 in-depth interviews and 18 focus group discussions conducted with policymakers, health service providers, school teachers, community gatekeepers, parents and adolescents who were purposively selected as relevant stakeholders on adolescent SRH. The interview transcripts were coded in NVivo 12 using a coding framework structured according to four key constructs of the theoretical framework for acceptability (TFA): affective attitude, intervention coherence, perceived effectiveness, and self-efficacy. The outputs of the coded transcripts were analysed, and the emergent themes from each of the four constructs of the TFA were identified. RESULTS: The intervention was acceptable to the stakeholders, from the findings of its positive effects, appropriateness, and positive impact on sexual behaviour. Policymakers were happy to be included in collaborating with multiple stakeholders to co-create multi-faceted interventions relevant to their work (positive affective attitude). The stakeholders understood how the interventions work and perceived them as appropriate at individual and community levels, with adequate and non-complex tools adaptable to different levels of stakeholders (intervention coherence). The intervention promoted mutualistic relations across stakeholders and sectors, including creating multiple platforms to reach the target audience, positive change in sexual behaviour, and cross-learning among policymakers, community gatekeepers, service providers, and adolescents (intervention effectiveness), which empowered them to have the confidence to provide and access SRH information and services (self-efficacy). CONCLUSIONS: Community-embedded interventions were acceptable as strong mechanisms for improving adolescents' access to SRH in the communities. Policymakers should promote the community-embedded strategy for holistic health promotion of adolescents.

Exploring Reproductive Health Education Needs in Infertile Women in Iran: A Qualitative Study.

OBJECTIVES: An inadequate understanding of infertility can affect individuals' self-efficacy and ability to perform self-care; thus, reproductive health education is an important part of infertility treatment. The present qualitative study aimed to explore the experiences and educational needs of infertile women with regard to reproductive health. METHODS: In this qualitative study, we utilized a content analysis approach. Purposive sampling was performed to ensure maximum diversity. In total, 23 individual interviews were conducted with 20 Iranian women with infertility and 3 key informants between July 2018 and February 2019 in northern Iran. Data were collected through in-depth, semi-structured interviews. Data analysis was performed using a conventional content analysis approach. RESULTS: Reproductive health education needs were identified by analyzing interview data from 4 main categories: familiarity with the fertility process and preparation for pregnancy, recognition of infertility and expectations around seeking treatment, recognition of preventive actions associated with reproductive health, and correction of false beliefs. Recognizing the causes of infertility and understanding the different approaches to infertility treatment are among the most important educational needs of infertile women. The potential for neglect of health-related issues due to concerns about fertility and the maternal experience necessitates education about preventive measures for cervical cancer, breast cancer, and sexually transmitted infections. Correcting misconceptions, including those related to contraceptives and traditional medicine, can also help promote reproductive health. CONCLUSIONS: In infertile women, the educational needs associated with reproductive health are multifaceted. Satisfying these needs can help achieve optimal treatment results and promote reproductive health.

An Innovative Trauma-Informed Curriculum for Sexual Assault Care.

BACKGROUND: Sexual violence is a pervasive public health concern. The American Association of Colleges of Nursing recommends that nursing education comprehensively address this topic, yet nursing schools are inconsistent in doing so. METHOD: An innovative, holistic curriculum that includes didactic and simulation exercises was developed to educate nurses on a trauma-informed approach to providing care for individuals who have experienced sexual violence. The 2-day course trained both advanced practice nurses and advanced practice nursing students. RESULTS: The course increased participants' knowledge of how to provide trauma-informed sexual assault care and increased interest in the field of sexual assault forensic nursing. CONCLUSION: A comprehensive sexual assault care curriculum and the use of standardized patients to develop trauma-informed communication skills are effective and acceptable to learners. This novel curriculum can serve as a model to incorporate sexual assault care training in nursing education. [J Nurs Educ. 2020;59(6):336-340.].

Iranian mothers' needs for reproductive health education of their adolescent daughters: a qualitative study.

INTRODUCTION: In order to be effective in discussing high-risk sexual behaviors with adolescents, mothers need to be educated about their adolescent daughters' sexual issues. As no detailed and exact knowledge on mothers' educational needs concerning adolescent girls' reproductive health is available, the current study was intended to investigate mothers' educational needs concerning their adolescent daughters' reproductive health. MATERIALS AND METHODS: This research was a qualitative content analysis. Purposive sampling was performed to the saturation point. The samples included 26 mothers and 14 key informants. Semi-structured interviews were used for data collection. Data authenticity was verified based on Lincoln and Guba's criteria and data analysis was conducted using conventional content analysis with MAXQDA10 software. FINDINGS: In this study, three themes and 13 main categories, each with a number of subcategories were extracted. The themes and main categories included: "appropriate educational content (reproductive health, sexual health, general health, psychological health, family health, social health and spiritual health)", "characteristics of the educator (communicative skill, cognitive skill and moral competence)", and "effective factors in learning (teaching method, learning conditions and environment, and the learner's readiness)". CONCLUSIONS: The results demonstrated that mothers need to be informed about sexual, reproductive, general, psychological, family, social and spiritual health in adolescent girls. Consequently, the results can help the healthcare authorities to implement need-based programs and boost the effectiveness of education about adolescent girls' reproductive health for mothers.

Global nurse/midwife workforce and reproductive health through social ecology lens.

OBJECTIVE: To explore how community social ecology factors may be associated with country registered nurse/registered midwife (RN/RM) workforce supply and reproductive health globally. DESIGN: A cross-sectional design using a social ecology framework was employed. SAMPLE: Data were retrieved from publicly available websites for 107 countries. MEASUREMENTS: Dependent variables included RN/RM density, maternal mortality ratios (MMR), and adolescent birth rates (ABR). Independent variables included gender inequality, region, country income classification, education, gross domestic product per capita, government expenditure of spending on education and health, life expectancy, percent of female seats in legislature, and labor force participation factors. RESULTS: The best fit multivariable model of RN/RM density showed that after adjustment for region, country income and the GII, the percent of females with some secondary education explained most of variation in RN/RM density. The best fit models of MMR and ABR showed that gender inequality explained most of the variation. Other factors in the models were the percent of female seats in legislatures, region, country income class, and mean years of schooling. CONCLUSIONS: Employing a social ecology model can useful in RN/RM workforce planning and development as countries seek multisectoral strategies for increasing the RN/RM supply and improving reproductive health outcomes.

"It is a thing that depends on God": barriers to delaying first birth and pursuing alternative futures among newly married adolescent girls in Niger.

BACKGROUND: Pregnancy among adolescent girls in Niger contributes to 34% of all deaths among females ages 15-19, but there is a dearth of research as to the specific contextual causes. In Zinder region, an area that is especially impoverished and where girls are at heightened risk, there is very little information on the main obstacles to improving adolescents' health and well-being. This qualitative study examines the underlying social, individual and structural factors influencing married girls' early first birth and participation in alternative opportunities (such as education or economic pursuits) in Niger. METHODOLOGY: In July of 2017, researchers conducted in-depth interviews with a non-probability sample of community members in three communes of Zinder Region, Niger. Participants (n = 107) included adolescent girls, husbands of adolescent girls, influential adults, community leaders, health providers, and positive deviants. All interviews were transcribed, coded and analyzed using Dedoose software. RESULTS: Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, desire for children, and belief that childbirth is "God's will" interfere with a girl's ability to delay. Girls' social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue. Participants favor adolescents' pursuit of increased economic opportunities or education, but would not support delaying birth to do so. CONCLUSIONS: Findings indicate the need for a holistic approach to delaying early birth and stimulating girls' participation in economic and educational pursuits. Potential interventions include mitigating barriers to reproductive health care; training adolescent girls on viable economic activities; and providing educational opportunities for girls. Effective programs should also include or target immediate members of the girls' families (husbands, parents, in-laws), influential local leaders and members of the community at large.

"What Should Sex Look Like?" Students' Desires for Expanding University Sexual Assault Prevention Programs to Include Comprehensive Sex Education.

Rates of sexual assault and sexual violence among college-aged adults are much higher than the national rates of sexual assault and sexual violence. Therefore, reduction and prevention of sexual violence among university students is critical and is consistent with national public health priorities. Often times, messages to students focus only on sexual assault and omit larger notions of sexual health. Four focus groups with a total of 24 participants (nine men, 15 women) highlighted three main perceptions about the sexual assault programming offered at this large university: themes of resistance to traditional programming, a need for holistic sexual health programming, and a desire to have an environment, which normalizes conversations surrounding sex, sexuality, and sexual health.

A qualitative study of sexual and reproductive health communication with adolescent and young adult oncology patients.

BACKGROUND: Adolescent and young adult patients with cancer (AYAs) identify sexual and reproductive health (SRH) as an important but often neglected aspect of their comprehensive cancer care. The purpose of this study was to explore AYA perceptions and experiences of SRH communication with oncology clinicians. METHODS: Twenty-three AYA patients and survivors ages 15-25 years from a large academic oncology center participated in semistructured qualitative interviews investigating their experiences discussing SRH issues, including specific topics discussed, conversation barriers and facilitators, suggestions for clinicians on how to improve conversations, and education and resource needs. Interviews were audio recorded, transcribed, and coded using a thematic analysis approach. RESULTS: Interviews with AYAs revealed two primary themes-a need for oncology clinicians to discuss SRH and critical gaps in current SRH communication practices. AYAs reported a need for improved SRH communication for the purposes of general education, addressing specific SRH issues experienced, and understanding the long-term impact of cancer and treatment on SRH. The current communication gaps are exacerbated by patient discomfort initiating conversations and the presence of family members. AYAs shared six key recommendations for clinicians on how to improve SRH communication. CONCLUSIONS: AYAs identify a role for oncology clinicians in discussing SRH as a primary aspect of comprehensive health care during cancer treatment and in survivorship; however, multiple gaps and barriers interfere with such discussions. Future efforts must focus on clinician education and training in SRH as well as education and intervention opportunities for AYAs to optimize the care provided.

Do Targeted Reproductive Health Services Matter? - The Impact of a Midwife Program in Indonesia.

This paper examines empirically whether midwives, as an integral part of the reproductive health and family planning programs in Indonesia, are effective in advising young women to delay their first birth and also influence the decision on post-primary school attendance. Using the Indonesian Family Life Survey, I investigate the extent to which the expansion of a midwife program affects the age at first birth and the number of school years of women. My findings suggest that women who were exposed to a midwife when they have to decide on further school attendance (aged 13-20 years) delay their first birth and also stay longer in school. According to the average returns of education in Indonesia, I conclude that reproductive health services provided by midwives can generate large socioeconomic benefits by allowing young women to postpone their first birth. Copyright © 2017 John Wiley & Sons, Ltd.

Anticoncepción en la adolescencia: motivaciones, elecciones y educación sanitaria en un centro de medicina reproductiva de Chile / Anticonception in adolescence: motivations, elections and health education in a center of reproductive medicine of Chile

Objetivo: Identificar las motivaciones y elecciones anticonceptivas de las adolescentes del Centro de Medicina Reproductiva y Desarrollo Integral del Adolescente (CEMERA) y explorar cómo influye la educación sanitaria en la elección final de un método anticonceptivo (MAC). Sujetos: Muestreo opinático constituido por 16 adolescentes nuligestas, de 15 a 19 años de edad, que consultaron por primera vez en el CEMERA durante el año 2015. Metodología: Se empleó una metodología cualitativa y un diseño exploratorio. Para ello, se realizaron entrevistas en profundidad por parte de un equipo de investigadores, que fueron procesadas a través del análisis de contenido. Resultados: Las adolescentes adquieren mayoritariamente información sobre los MAC en su círculo cercano. La motivación para usar un MAC en las adolescentes que habían iniciado relaciones sexuales fue la prevención del embarazo. En cambio, para las que no habían iniciado vida sexual, la principal motivación eran sus proyecciones a futuro. La elección de los MAC se basaba en la comodidad, la ausencia de efectos secundarios, su larga duración y no tener que recordar su administración. Todas las entrevistadas coincidieron en que el centro entregaba una información requerida y suficiente para la elección de un método por parte de ellas, aumentando o reforzando los conocimientos sobre la anticoncepción. Conclusiones: Para la mayoría de las adolescentes el MAC ideal continúa siendo el hormonal (oral o inyectable). Para las adolescentes con una preferencia previa sobre un MAC, la educación sanitaria reforzó su elección. Para las adolescentes que no sabían qué usar, la educación sanitaria fue fundamental en la elección final del anticonceptivo (AU)

Objective: To identify the motivations and contraceptive choices of adolescents at the Center for Reproductive Medicine and Adolescent Comprehensive Development (CEMERA) and to explore how health education influences the final choice of a contraceptive method (CCM). Subjects: A sample of 16 adolescents between 15 and 19 years who consulted for the first time at CEMERA during the year 2015. Methodology: Qualitative methodology and exploratory design were used. To do this, we used in-depth interviews conducted by a team of researchers and that were processed through content analysis. Results: Adolescents acquire mostly information on CCM from the nearby circle. The motivation for using a CCM in adolescents who had started sex was pregnancy prevention. However, for those who have not started sexual life, the main motivation was their future projections. The choice of CCM was based on comfort, few side effects, long duration and little memory. All the interviewees agreed that the center delivered the information required and sufficient for the choice of a method by them, increasing or reinforcing the knowledge about contraception. Conclusions: For most adolescents, the ideal CCM continues to be hormonal (oral or injectable). For adolescents who had a preference for CCM, health education reinforced their previous choice. For adolescents who did not know what to use, health education was critical in the final choice of contraceptive (AU)

Implicancias del marco legal chileno en la prevención del embarazo adolescente: conflicto e inseguridad en los profesionales de la salud / Implications of chilean legal framework in teen pregnancy prevention: conflict and insecurity in health professionals

Background: Teenage pregnancy is a psychosocial and multifactorial problem described as a lack of exercise of rights in sexual and reproductive health. There are important aspects in the doctor-patient relationship and confidentiality that directly affect the continuity and quality of care. There are controversies in the laws relating to the provision of contraception and confidentiality, and those that protect the sexual indemnity, especially in adolescents under 14 years. Aim: To describe the implications of the legal framework for professional midwives in the care of adolescents younger than 14 years in sexual and reproductive health. Material and Methods: In-depth interviews were conducted to 13 female and 2 male midwives working at Primary Health Care Centers in the Metropolitan Region. Results: The attention of adolescents younger than 14 years in sexual and reproductive health involves medical-legal issues for health professionals. All professionals recognize that mandatory reporting sexual activity is a complex situation. All professionals notify pregnancies. In relation to the delivery of contraception, clinical care is problematic since professionals should take shelter from a legal standpoint. Conclusions: The medical-legal context of pregnant women under 14 years of age care generates a context of uncertainty and fear for professionals and becomes a source of conflict and insecurity in the exercise of the profession.

[Implications of chilean legal framework in teen pregnancy prevention: conflict and insecurity in health professionals]. / Implicancias del marco legal chileno en la prevención del embarazo adolescente: conflicto e inseguridad en los profesionales de la salud.

BACKGROUND: Teenage pregnancy is a psychosocial and multifactorial problem described as a lack of exercise of rights in sexual and reproductive health. There are important aspects in the doctor-patient relationship and confidentiality that directly affect the continuity and quality of care. There are controversies in the laws relating to the provision of contraception and confidentiality, and those that protect the sexual indemnity, especially in adolescents under 14 years. AIM: To describe the implications of the legal framework for professional midwives in the care of adolescents younger than 14 years in sexual and reproductive health. MATERIAL AND METHODS: In-depth interviews were conducted to 13 female and 2 male midwives working at Primary Health Care Centers in the Metropolitan Region. RESULTS: The attention of adolescents younger than 14 years in sexual and reproductive health involves medical-legal issues for health professionals. All professionals recognize that mandatory reporting sexual activity is a complex situation. All professionals notify pregnancies. In relation to the delivery of contraception, clinical care is problematic since professionals should take shelter from a legal standpoint. CONCLUSIONS: The medical-legal context of pregnant women under 14 years of age care generates a context of uncertainty and fear for professionals and becomes a source of conflict and insecurity in the exercise of the profession.

A clinical trial of the effect of sexual health education on the quality of life of married Muslim women in Iran.

BACKGROUND: Marital satisfaction is one of the key factors affecting women's holistic health. AIM: The present study was conducted to evaluate the effect of sexual health education on the quality of life in married women. METHODS: The present controlled clinical trial was conducted with a pretest-posttest design on a study population of 60 women (aged 20-45) admitted to select health centres affiliated to Tehran University of Medical Sciences. Samples were selected through convenience sampling and randomly allocated to an intervention group (n=30) and a control group (n=30). The data collection tool was the WHOQOL completed by participants first in the pretest and then in the follow-up posttest (after 2 months). The intervention group received sexual health education, while no interventions were provided to the control group. Data were analysed in SPSS-16 using the paired t-test and the independent t-test. FINDINGS: Participants were matched in the two groups in terms of demographic variables such as age, occupation, age at marriage, duration of marriage, residential status and income level. At the baseline, no significant differences were observed between the intervention group (77.35±9.36) and the control group (75.64±8.32) in terms of the quality of life score (P=0.26). After the intervention, the quality of life score was 94.3±6.54 in the intervention group and 74.2±7.33 in the control group, making for a significant difference (P<0.01). CONCLUSION: Based on the findings, sexual health education can help women improve their sexual health through promoting sexual and marital satisfaction and consequently improve their quality of life.

Plantas afrodisíacas como potenciales capacitantes de espermatozoides humanos / Plantas afrodisíacas como potenciais capacitantes de espermatozoides humanos / Aphrodisiac plants as human spermatozoa capacitants

El uso de productos naturales ha impactado diversos aspectos de la medicina incluyendo la salud sexual y repreductiva, con efectos deletéreos sobre los espermatozoides o afrodisiacos Se ha evaluado el efecto de diversas plantas afrodisiacas sobre los mecanismos del desempeño sexual y la calidad de los espermatozoides, lo que permite plantear que extractos de las mismas podrian facilitar la capacitación espermática. En esta revisión bibliográfica se reportan los usos farmacológicos y tradicionales de 20 plantas consideradas tradicionalmente afrodisiacas que podrian ser utilizadas como agentes naturales con efecto capacitante sobre espermatozoides humanos (AU)

O uso de produtos naturais tem tido impacto em diversos aspectos da medicina, incluindo a saude sexual e reprodutiva, tanto pelos potenciais efeitos nocivos sobre os espermatozoides como atraves do use de afrodisiacos. Estudou-se o efeito de varias plantas afrodisiacas sobre os mecanismos de desempenho sexual e qualidade das células espermaticas, para avaliar a possibilidadede melhoria da capacitagao dos espermatozoides. Neste revisao da literatura sao relatados os uses farmacologicos e tradicionais de 20 plantas tradicionalmente consideradas afrodisiacas, que poderiam ser utilizadas como compostos naturais com efeito na capacitaçao de esperma humano (AU)

The use of natural products has impacted various aspects of medicine including sexual and reproductive health, through their deleterious effect on sperm cells or as aphrodisiacs. The mechanisms of sexual performance and sperm cells quality of several aphrodisiac plants have been studied, in order of evaluating the possibility of enhancing sperm capacitation. In this literature review, the pharmacological and traditional uses of 20 aphrodisiac plants that could be used as natural agents with effect on human sperm capacitation are reported (AU)

Sexuality education: emerging trends in evidence and practice.

The International Conference on Population and Development and related resolutions have repeatedly called on governments to provide adolescents and young people with comprehensive sexuality education (CSE). Drawing from these documents, reviews and meta-analyses of program evaluations, and situation analyses, this article summarizes the elements, effectiveness, quality, and country-level coverage of CSE. Throughout, it highlights the matter of a gender and rights perspective in CSE. It presents the policy and evidence-based rationales for emphasizing gender, power, and rights within programs--including citing an analysis finding that such an approach has a greater likelihood of reducing rates of sexually transmitted infections and unintended pregnancy--and notes a recent shift toward this approach. It discusses the logic of an "empowerment approach to CSE" that seeks to empower young people--especially girls and other marginalized young people--to see themselves and others as equal members in their relationships, able to protect their own health, and as individuals capable of engaging as active participants in society.

Invited commentary: broadening the evidence for adolescent sexual and reproductive health and education in the United States.

Scientific research has made major contributions to adolescent health by providing insights into factors that influence it and by defining ways to improve it. However, US adolescent sexual and reproductive health policies-particularly sexuality health education policies and programs-have not benefited from the full scope of scientific understanding. From 1998 to 2009, federal funding for sexuality education focused almost exclusively on ineffective and scientifically inaccurate abstinence-only-until-marriage (AOUM) programs. Since 2010, the largest source of federal funding for sexual health education has been the "tier 1" funding of the Office of Adolescent Health's Teen Pregnancy Prevention Initiative. To be eligible for such funds, public and private entities must choose from a list of 35 programs that have been designated as "evidence-based" interventions (EBIs), determined based on their effectiveness at preventing teen pregnancies, reducing sexually transmitted infections, or reducing rates of sexual risk behaviors (i.e., sexual activity, contraceptive use, or number of partners). Although the transition from primarily AOUM to EBI is important progress, this definition of evidence is narrow and ignores factors known to play key roles in adolescent sexual and reproductive health. Important bodies of evidence are not treated as part of the essential evidence base, including research on lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth; gender; and economic inequalities and health. These bodies of evidence underscore the need for sexual health education to approach adolescent sexuality holistically, to be inclusive of all youth, and to address and mitigate the impact of structural inequities. We provide recommendations to improve US sexual health education and to strengthen the translation of science into programs and policy.

Development of the community midwifery education initiative and its influence on women's health and empowerment in Afghanistan: a case study.

BACKGROUND: Political transition in Afghanistan enabled reconstruction of the destroyed health system. Maternal health was prioritised due to political will and historically high mortality. However, severe shortages of skilled birth attendants--particularly in rural areas--hampered safe motherhood initiatives. The Community Midwifery Education (CME) programme began training rural midwives in 2002, scaling-up nationally in 2005. METHODS: This case study analyses CME development and implementation to help determine successes and challenges. Data were collected through documentary review and key informant interviews. Content analysis was informed by Walt and Gilson's policy triangle framework. RESULTS: The CME programme has contributed to consistently positive indicators, including up to a 1273/100,000 reduction in maternal mortality ratios, up to a 28% increase in skilled deliveries, and a six-fold increase in qualified midwives since 2002. Begun as a small pilot, CME has gained support of international donors, the Afghan government, and civil society. CONCLUSION: CME is considered by stakeholders to be a positive model for promoting women's education, employment, and health. However, its future is threatened by insecurity, corruption, lack of regulation, and funding uncertainties. Strategic planning and resource mobilisation are required for it to achieve its potential of transforming maternal healthcare in Afghanistan.

'All singing, all dancing': staff views on the integration of family planning and genitourinary medicine in Lothian, UK.

BACKGROUND: UK policy documents advocate integrated approaches to sexual health service provision to ensure that everyone can access high-quality treatment. However, there is relatively little evidence to demonstrate any resultant benefits. The family planning and genitourinary medicine services in Lothian have been fully integrated and most care is now delivered from a purpose-built sexual health centre. We wished to study the views of staff on integrated sexual and reproductive care. METHODS: Staff completed anonymous questionnaires before and after integration, looking at four main aspects: the patient pathway, specific patient groups, their own professional status, and their working environment. The surveys used a mixture of five-point Likert-type scales and open-ended questions. RESULTS: Over 50% of staff completed the surveys on each occasion. Six months after the new building opened, staff attitudes about the integrated service were mixed. Staff reported more stress and less opportunity for specialisation but there was no change in their sense of professional status or development. There were concerns about how well the integrated service met the needs of specific patient groups, notably women. These concerns co-existed with a verdict that overall service quality was no worse following integration. CONCLUSIONS: Staff views should form an important part of service redesign and integration projects. Although the results from the Lothian surveys suggest a perceived worsening of some aspects of the service, further evaluation is needed to unpick the different problems that have appeared under the catch-all term of 'integration'.

Deafness, pregnancy and sexual health.

This article exposes the need for support for midwives, to ensure that they are equipped to meet the needs of deaf parents to be. It uncovers research which demonstrates the urgent need for an increase in awareness, education and resources; and the reasons that deaf people have higher rates of teenage pregnancy and sexually transmitted infections than the general population. With stories from midwives at a loss as to how to communicate with deaf mothers in labour, and stories from deaf women who can't understand their health professionals, nor read the literature that has been given to them--this is thought provoking reading.