Reproductive healthcare in adolescents with autism and other developmental disabilities.

BACKGROUND: Adults with developmental disabilities often have less access to reproductive health services than adults without these disabilities. However, little is known about how adolescents with developmental disabilities, including autism, access reproductive healthcare. OBJECTIVE: We aimed to characterize the use of reproductive healthcare services among adolescents with autism and those with other developmental disabilities in comparison with adolescents with typical development. STUDY DESIGN: We conducted a cohort study of a sample of adolescents who were continuously enrolled members of Kaiser Permanente Northern California, an integrated healthcare system, from ages 14 to 18 years. The final analytical sample included 700 adolescents with autism, 836 adolescents with other developmental disabilities, and 2187 typically developing adolescents who sought care between 2000 and 2017. Using the electronic health record, we obtained information on menstrual conditions, the use of obstetrical-gynecologic care, and prescriptions of hormonal contraception. We compared healthcare use between the groups using chi-square tests and covariate-adjusted risk ratios estimated using modified Poisson regression. RESULTS: Adolescents with autism and those with other developmental disabilities were significantly more likely to have diagnoses of menstrual disorders, polycystic ovary syndrome, and premenstrual syndrome than typically developing adolescents. These 2 groups also were less likely than typically developing peers to visit the obstetrician-gynecologist or to use any form of hormonal contraception, including oral contraception, hormonal implants, and intrauterine devices. Adolescents in all 3 groups accessed hormonal contraception most frequently through their primary care provider, followed by an obstetrician-gynecologist. CONCLUSION: Adolescents with autism and those with other developmental disabilities are less likely than their typically developing peers to visit the obstetrician-gynecologist and to use hormonal contraception, suggesting possible care disparities that may persist into adulthood. Efforts to improve access to reproductive healthcare in these populations should target care delivered in both the pediatric and obstetrics-gynecology settings.

School Dropout, Absenteeism and Coverage of Sexual and Reproductive Health Services in South Africa: Are Those Most at Risk Reached?

School attendance or completion is important for adolescents' development. Adolescents who drop out or are regularly absent from school are at higher risk of adverse sexual and reproductive health (SRH) outcomes. However, there is little evidence evaluating SRH service coverage among adolescents in and out of school. In the context of a large-scale combination HIV and pregnancy prevention intervention funded by the Global Fund, we compared the SRH intervention coverage and SRH risks among adolescent girls who dropped out of school with those who were still in school or who had completed grade 12 in South Africa. Among those still in school, we compared the SRH intervention coverage and SRH risk profiles of those with high versus low or no absenteeism. In 2017 to 2018, we conducted a household survey of adolescent girls aged 15 to 19 years in six of the ten combination intervention districts. Of 2515 participants, 7.6% had dropped out of school. Among the 1864 participants still in school, 10.8% had high absenteeism. Ever having had sex, and condomless sex were more prevalent among dropouts compared with non-dropouts. Dropouts were more likely to access SRH services such as condoms and contraceptives, except the combination prevention intervention services which were more likely to reach those who had not dropped out and were equally likely to reach those in school with high versus low/no absenteeism. Combination SRH prevention programmes can improve the accessibility of SRH services for adolescents in school/who complete school.

Intersectionality analysis of young people's experiences and perceptions of discrimination in primary health centers in Ebonyi State, Southeast Nigeria.

BACKGROUND: Young people (aged 10 to 24 years) in sub-Saharan Africa bear a huge and disproportionate burden of poor sexual and reproductive health (SRH) outcomes due to inequalities and discrimination in accessing sexual and reproductive health services (SRHS). This study assessed the experiences and perceptions of discrimination among young people seeking SRH services in Primary Health Centers (PHCs) using an intersectionality lens. METHODS: A cross-sectional mixed-methods study was undertaken in six local government areas (LGAs) in Ebonyi State, southeast Nigeria. The LGAs comprise both urban and rural locations. The study population for the quantitative survey consisted of 1025 randomly selected young boys and girls aged 15-24 years. Eleven focus group discussions (FGDs) were conducted with the young people. Descriptive and inferential analyses were performed for quantitative data, while thematic analysis was performed for the qualitative data, using NVivo. RESULTS: A total of 16.68% participants in the survey reported that young girls/women were treated badly/unfairly compared to young boys/men when seeking SRH services in PHCs; 15.22% reported that young clients get treated badly/unfairly from adults; and 12.49% reported that young clients with poor economic status were treated unfairly. Respondents also reported that young clients with disability (12.12%), and those who are poorly educated or uneducated (10.63%) are treated badly by healthcare providers when they access SRH services. Young people in urban areas were about 7 times more likely to believe that girls/young women are treated badly than boys/young men when seeking SRH services in PHCs compared to those who live in rural areas (p < 0.001). Among the young girls/women, residing in urban areas, being poor and in school increased the likelihood of getting treated badly/unfairly when receiving SRH services by 4 times (p < 0.001). The qualitative results revealed that health workers were generally harsh to young people seeking SRH services and the level of harshness or unfriendliness of the health workers varied depending on the young person's social identity. CONCLUSION: There are varieties of intersecting factors that contribute to the discrimination of young clients in PHCs. This underscores the urgent need to prioritize intersectional perspectives in the design and implementation of interventions that will improve access and use of SRH services by young people.

Wealth and education-related inequalities in the utilisation of reproductive, maternal, newborn, and child health interventions within scheduled tribes in India: an analysis of Odisha and Jharkhand.

BACKGROUND: The utilisation of Reproductive, Maternal, Newborn and Child Health (RMNCH) services remains lower among the Scheduled Tribes (ST) in India than among the rest of the country's population. The tribal population's poorest and least-educated households are further denied access to RMNCH care due to the intersection of their social status, wealth, and education levels. The study analyses the wealth- and education-related inequalities in the utilisation of RMNCH services within the ST population in Odisha and Jharkhand. METHODOLOGY: We have constructed two summary measures, namely, the Co-coverage indicator and a modified Composite Coverage Index (CC), to determine wealth- and education-related inequalities in the utilisation of RMNCH indicators within the ST population in Odisha and Jharkhand. The absolute and relative inequalities with respect to wealth and education within the ST population are estimated by employing the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). RESULTS: The results of the study highlight that access to RMNCH services is easier for women who are better educated and belong to wealthier households. The SII and RII values in the co-coverage indicator and modified CCI exhibit an increase in wealth-related inequalities in Odisha between NFHS-4 (2015-16) and NFHS-5 (2019-21) whereas in Jharkhand, the wealth- and education-related absolute and relative inequalities present a reduction between 2016 and 2021. Among the indicators, utilisation of vaccination was high, while the uptake of Antenatal Care Centre Visits and Vitamin A supplementation should be improved. INTERPRETATION: The study results underscore the urgent need of targeted policies and interventions to address the inequalities in accessing RMNCH services among ST communities. A multi-dimensional approach that considers the socioeconomic, cultural and geographical factors affecting healthcare should be adopted while formulating health policies to reduce inequalities in access to healthcare.

Exploring the barriers, facilitators, and opportunities to enhance uptake of sexual and reproductive health, HIV and GBV services among adolescent girls and young women in Zambia: a qualitative study.

INTRODUCTION: Adolescents and young women in low-middle-income countries face obstacles to accessing HIV, Sexual and Reproductive Health (SRH), and related Gender-Based Violence (GBV) services. This paper presents facilitators, opportunities, and barriers to enhance uptake of HIV, GBV, and SRH services among Adolescent Girls and Young Women (AGYW) in selected districts in Zambia. METHODS: This study was conducted in Chongwe, Mazabuka, and Mongu Districts among adolescent girls and young women in Zambia. Key informants (n = 29) and in and out-of-school adolescents and young people (n = 25) were interviewed. Purposive sampling was used to select and recruit the study participants. Interviews were transcribed verbatim, and a content analysis approach was used for analysis. RESULTS: The facilitators that were used to enhance the uptake of services included having access to health education information on comprehensive adolescent HIV and gender-based violence services. Non-governmental organisations (NGOs) were the main source of this information. The opportunities bordered on the availability of integrated approaches to service delivery and strengthened community and health center linkages with referrals for specialised services. However, the researchers noted some barriers at individual, community, and health system levels. Refusal or delay to seek the services, fear of side effects associated with contraceptives, and long distance to the health facility affected the uptake of services. Social stigma and cultural beliefs also influenced the understanding and use of the available services in the community. Health systems barriers were; inadequate infrastructure, low staffing levels, limited capacity of staff to provide all the services, age and gender of providers, and lack of commodities and specialised services. CONCLUSION: The researchers acknowledge facilitators and opportunities that enhance the uptake of HIV, GBV, and SRH services. However, failure to address barriers at the individual and health systems level always negatively impacts the uptake of known and effective interventions. They propose that programme managers exploit the identified opportunities to enhance uptake of these services for the young population.

When one door closes: a qualitative exploration of women's experiences of access to sexual and reproductive health services during the COVID-19 lockdown in Nigeria.

BACKGROUND: COVID-19 pandemic widely disrupted health services provision, especially during the lockdown period, with females disproportionately affected. Very little is known about alternative healthcare sources used by women when access to conventional health services became challenging. This study examined the experiences of women and adolescent girls regarding access to sexual and reproductive health (SRH) services during the COVID-19 lockdown in Nigeria and their choices of alternative healthcare sources. METHODS: The study sites were two northern states, two southern states, and the Federal Capital Territory. Qualitative data were obtained through 10 focus group discussion sessions held with married adolescents, unmarried adolescents, and older women of reproductive age. The data were transcribed verbatim and analysed using a thematic approach and with the aid of Atlas ti software. RESULTS: Women reported that access to family planning services was the most affected SRH services during the COVID-19 lockdown. Several barriers to accessing SRH services during COVID-19 lockdown were reported, including restriction of vehicular movement, harassment by law enforcement officers, fear of contracting COVID-19 from health facilities, and fear of undergoing compulsory COVID-19 tests when seeking care in health facilities. In the face of constrained access to SRH services in public sector facilities during the COVID-19 lockdown, women sought care from several alternative sources, mostly locally available and informal services, including medicine vendors, traditional birth attendants, and neighbours with some health experience. Women also widely engaged in self-medication, using both orthodox drugs and non-orthodox preparations like herbs. The lockdown negatively impacted on women's SRH, with increased incidence of sexual- and gender-based violence, unplanned pregnancy resulting from lack of access to contraceptives, and early marriage involving adolescents with unplanned pregnancies. CONCLUSION: COVID-19 negatively impacted access to SRH services and forced women to utilise mostly informal service outlets and home remedies as alternatives to conventional health services. There is a need to ensure the continuity of essential SRH services during future lockdowns occasioned by disease outbreaks. Also, community systems strengthening that ensures effective community-based health services, empowered community resource persons, and health-literate populations are imperative for overcoming barriers to healthcare access during future lockdowns.

Barriers and facilitators to women's access to sexual and reproductive health services in rural Australia: a systematic review.

BACKGROUND: Accessing sexual and reproductive health (SRH) services in rural Australia presents complex challenges that negatively impact women's health and exacerbate health inequities across the life course. This systematic review synthesises evidence on the barriers and facilitators to women's access to SRH services in rural Australia, considering both supply and demand dimensions. METHODS: We systematically searched peer-reviewed literature published between 2013 and 2023. Search terms were derived from three major topics: (1) women living in rural Australia; (2) spatial or aspatial access to SRH services; and (3) barriers or facilitators. We adopted the "best fit" approach to framework synthesis using the patient-centred access to healthcare model. RESULTS: Database searches retrieved 1,024 unique records, with 50 studies meeting the inclusion criteria. Most studies analysed access to primary care services (n = 29; 58%), followed by hospital services (n = 14; 28%), health promotion and prevention (n = 5; 10%), and specialist care (n = 2; 4%). The type of care accessed was mostly maternity care (n = 21; 42%), followed by abortion services (n = 11; 22%), screening and testing (n = 8; 16%), other women's health services (n = 6; 12%), and family planning (n = 4; 8%). There were numerous barriers and facilitators in access from supply and demand dimensions. Supply barriers included fragmented healthcare pathways, negative provider attitudes, limited availability of services and providers, and high costs. Demand barriers encompassed limited awareness, travel challenges, and financial burdens. Supply facilitators included health system improvements, inclusive practices, enhanced local services, and patient-centred care. Demand facilitators involved knowledge and awareness, care preferences, and telehealth accessibility. CONCLUSION: This review highlights the urgent need for targeted interventions to address SRH service access disparities in rural Australia. Understanding the barriers and facilitators women face in accessing SRH services within the rural context is necessary to develop comprehensive healthcare policies and interventions informed by a nuanced understanding of rural women's diverse needs.

Costs and cost drivers of comprehensive sexual reproductive health services to female sex workers in Kenya.

BACKGROUND: Comprehensive sexual reproductive health (SRH) programs for female sex workers (FSW) offering clinical, behavioural, and structural interventions have contributed to declining rates of HIV in this population. However, data on costs and cost drivers is needed to support programs and their donors to better allocate resources, make an investment case for continued funding, and to identify areas of improvement in program design and implementation. We aimed to estimate the annual per-FSW costs of comprehensive services for a standalone FSW program in Kenya. METHODS: We implemented a top-bottom and activity-based costing study of comprehensive FSW services at two drop-in centres (DICs), Mtwapa and Kilifi town, in Kilifi County, Kenya. Service costs were obtained from routinely collected patient data during FSW scheduled and unscheduled visits using Kenyan Ministry of Health records. Costing data were from the program and organization's expenditure reports, cross checked against bank documents and supported by information from in-depth interviews. Data were collected retrospectively for the fiscal year 2019. We obtained approval from the AMREF Research Ethics Committee (AMREF-ESRC P862/2020). RESULTS: In 2019, the unit cost of comprehensive services was 105.93 USD per FSW per year, roughly equivalent to 10,593 Kenya shillings. Costs were higher at Mtwapa DICs compared to Kilifi town DIC; 121.90 USD and 89.90 USD respectively. HIV counselling and testing cost 63.90 USD per person, PrEP was 34.20 USD and family planning was 9.93 USD. Of the total costs, staff salaries accounted for about 60%. Adjusted for inflation, costs in 2024 would be approximately 146.60. CONCLUSION: Programs should strive to maximize the number of FSW served to benefit from economies of scale. Given that personnel costs contribute most to the unit costs, programs should consider alternative designs which reduce personnel and other costs.

Utilization of reproductive health services among undergraduate regular class students in Assosa University, BGRS: a comparison among three varieties of multilevel binary logistic regression models.

INTRODUCTION: Reproductive health service (RHS) helps for people to have a delighted and safe sex through their life journey. It enables especially for women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. Therefore, this study aimed to identify the significant determinants of RHS utilization among undergraduate regular class students in Assosa University by using advanced methodology. METHODS: We used cross-sectional study design to collect RHS data from 362 students in Assosa University from 5 to 16, may 2021. These students were selected using stratified random sampling technique. We also used cross-tabulation to summarize the extents of RHS utilization across all predictors in terms of percentage and three varieties of multilevel binary logistic regression model to model the determinants of RHS. RESULTS: 42.27% of undergraduate regular class students in Assosa University utilize at least one type of RHS during their time at Assosa University whereas, 57.73% of undergraduate regular class students in this University are not utilized it. Among three varieties of multilevel binary logistic regression models, the random slopes two-level model was selected as a best fitted model for the datasets. At 5% level of significance, awareness about RHS, gender, preference of service fees and student's monthly average income were significant predictor variables in this model. In addition, the covariates; age, gender and preference of service fees have a significant random effects on utilization of RHS across all colleges/school. CONCLUSION: Students who; preferred service fee as usual rate, have awareness about RHS, are females and have high monthly average income were more likely to utilize RHS. RHS utilization among undergraduate regular students in Assosa University is likely to increase more effectively with interventions that address these factors.

The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence.

BACKGROUND: Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries. METHODS: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies. RESULTS: A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment. CONCLUSION: The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries' progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status. TRIAL REGISTRATION: This study was registered with Prospero (CRD42021285776).

High uptake of menstrual health information, products and analgesics within an integrated sexual reproductive health service for young people in Zimbabwe.

BACKGROUND: Despite being integral to women's well-being, achieving good menstrual health (MH) remains a challenge. This study examined MH services uptake (including information, analgesics, and a choice of MH products - the menstrual cup and reusable pads) and sustained use of MH products within an integrated sexual and reproductive health intervention for young people in Zimbabwe. METHODS: This mixed-methods study was nested within a cluster randomised trial of integrated sexual and reproductive health services (CHIEDZA) for youth in three provinces (Harare, Mashonaland East, and Bulawayo). The study collected qualitative and quantitative data from 27,725 female clients aged 16-24 years, who accessed CHIEDZA from April 2019 - March 2022. Using a biometric (fingerprint recognition) identification system, known as SIMPRINTS, uptake of MH information, products, and analgesics and other services was tracked for each client. Descriptive statistics and logistic regression were used to investigate MH service uptake and product choice and use over time, and the factors associated with these outcomes. Thematic analysis of focus group discussions and interviews were used to further explore providers' and participants' experiences of the MH service and CHIEDZA intervention. RESULTS: Overall, 36,991 clients accessed CHIEDZA of whom 27,725 (75%) were female. Almost all (n = 26,448; 95.4%) took up the MH service at least once: 25433 took up an MH product with the majority (23,346; 92.8%) choosing reusable pads. The uptake of cups varied across province with Bulawayo province having the highest uptake (13.4%). Clients aged 20-24 years old were more likely to choose cups than reusable pads compared with those aged 16-19 years (9.4% vs 6.0%; p < 0.001). Over the implementation period, 300/1819 (16.5%) of clients swapped from the menstrual cup to reusable pads and 83/23346 (0.4%) swapped from reusable pads to the menstrual cup. Provision of the MH service encouraged uptake of other important SRH services. Qualitative findings highlighted the provision of free integrated SRH and MH services that included a choice of MH products and analgesics in a youth-friendly environment were key to high uptake and overall female engagement with SRH services. CONCLUSIONS: High uptake demonstrates how the MH service provided much needed access to MH products and information. Integration of MH within an SRH intervention proved central to young women accessing other SRH services.

Adolescent sexual and reproductive health needs and utilisation of health services in the Bono East Region, Ghana.

BACKGROUND: Adolescents in Ghana are vulnerable to unequal power relations at the personal, community and structural levels which in turn limits their opportunities in access to critical sexual and reproductive health information and services. There is therefore high unmet need for sexual and reproductive health (SRH) information and services and the Bono East region typifies this situation, recording some of the poorest SRHR outcomes among adolescents. We, therefore, aimed to investigate the SRH needs (unmet), behaviors and utilization of SRH services among adolescents in the Bono East region. METHODS: Using a maximum variation sampling approach, this qualitative study conducted in-depth interviews and focused group discussions with adolescent boys and girls, parents, community leaders, and healthcare providers. RESULTS: Our findings are presented under two broad categories: major SRHR concerns of adolescents, and perspectives about that influences adolescents' utilization of SRHR services. Under the major SRHR need of adolescents, the following themes emerged: information and services on pregnancy prevention, menstrual hygiene management, availability of comprehensive abortion care services, and attitudes towards adolescent pregnancy. The perspectives about the factors that influence adolescent children were discussed at multiple levels: individual/personal. interpersonal and community/societal. At the individual level, limited understanding of adolescence/puberty, desire of adolescents to belong and misperceptions about contraceptives. At the interpersonal level, issues relating to technical capacity needs of service providers, disrespect exhibited by service providers, and parental failure were identified as influential factors. Then at the community/societal level, we identified structural constraints and compromised social safety concerns in accessing contraceptives and services. CONCLUSION: In conclusion, the findings from this study offer valuable insights into the complex landscape of adolescent sexual and reproductive health in the Bono East region. The implications for policy and practice are manifold, ranging from comprehensive education to addressing menstrual hygiene, involving parents, training healthcare providers, and promoting respectful care.

The practice of polygyny on the utilisation of reproductive health services among married women in Ghana.

While the practice of polygyny is common in Ghana, little is known about its impact on the use of reproductive health services. The aim of this study was to assess the relationship between polygynous marriage and the utilisation of skilled antenatal care (ANC), assisted skilled birth, and modern contraceptive services among married women in Ghana. Secondary data from the 2017 Ghana Maternal Health Survey were used for this study. The study included a weighted sample of 9,098 married women aged 15-49 years. We used multivariable logistic regression models to assess the association between polygyny and each outcome variables. Sensitivity analysis was conducted to assess the dose-response relationship between polygyny and each outcome variable. The prevalence of eight or more ANC contacts, assisted skilled births, and use of modern contraception were 47.0%, 81.4%, and 25.4%, respectively. The prevalence of women in polygynous marriages was 15.3%. Compared to monogynous marriage, polygynous marriage was associated with 19% lower odds of having eight plus ANC contacts (adjusted odds ratio [aOR] 0.81, 95% CI: 0.69, 0.96), 25% lower odds of having assisted skilled birth (aOR 0.75, 95% CI: 0.63, 0.89), and 19% lower odds of modern contraceptive utilisation (aOR 0.81, 95% CI: 0.66, 0.99). Interventions on reproductive health may need to prioritise women in polygynous marriages in order to improve the utilisation of skilled ANC, assisted skilled birth, and modern contraceptive services.

Social-ecological factors associated with trajectories of adolescent sexual and reproductive health stigma: longitudinal cohort findings with urban refugee youth in Kampala.

Background Stigma towards sexually active young people presents profound barriers to uptake of sexual and reproductive health (SRH) services, including HIV testing and contraception. Yet, few studies have examined adolescent SRH stigma trajectories over time. To address this knowledge gap, we examined associations between social-ecological factors and trajectories of adolescent SRH stigma among urban refugee youth in Kampala, Uganda. Methods This longitudinal cohort study with refugee youth in Kampala collected data on adolescent SRH stigma at four time-points between 2022 and 2024. We used latent class growth analyses to examine distinct trajectories of adolescent SRH stigma, and examined baseline social-ecological and socio-demographic factors associated with class membership using multivariable logistic regression. Results Among the participants (n =164 with n =668 observations; mean age 19.9 years, standard deviation2.5 years; 52.8% cisgender women), we categorised two distinct adolescent SRH stigma trajectories: consistently high (n =496; 74.2%) and sustained low (n =172; 25.8%). In multivariable analyses, living in Uganda ≥1year at baseline assessment (1-5years: adjusted odds ratio [aOR]5.28, confidence interval [CI]2.29-12.19, P P 10years: aOR3.89, CI1.56-9.68, P P P P P Conclusions Social-ecological and socio-demographic factors were associated with consistently high levels of adolescent SRH stigma over 2years. Multi-level strategies can meaningfully engage youth in developing stigma reduction strategies for SRH service delivery.

Assessing the Variability in Interpretation of the Catholic Directives Pertaining to Reproductive Health Services: An Exploratory Qualitative Study of Two Hospitals on the American East Coast.

The ethics in Catholic hospitals are guided by the Ethical and Religious Directives for Catholic Health Care Services, which provide direction on many topics, including family planning. Previous research has demonstrated there is variability in the availability of prohibited family planning services at Catholic hospitals. This study aims to research a potential source of variability in interpretation and application of the directives through interviewing ethics committee members. Participants were recruited from two different hospitals on the east coast with a total sample size of eight. Ethics committee members were asked questions regarding their personal approach to ethics, their hospital's approach to ethics, and the permissibility of specific family planning methods at their hospital. Most ethics committee members stated that the Catholic faith and/or directives were important in their hospitals' approach to ethics. Most participants stated that they had instances in which their personal approach to ethics conflicted with their hospital's approach, citing women's health and end-of-life care as common causes of conflict. All but one ethics committee member stated that hormonal contraception was forbidden under the directives; however, many members stated that this was either a gray area or permissible under certain circumstances. Reproductive health issues rarely came before the ethics committee at either site with one participant referring to them as "black and white issues." This research suggests that ethics committee members did not see the directives governing family planning services to be ambiguous. However, given the low frequency in which these issues come to the attention of the ethics committee, it is difficult to determine whether the opinions expressed by our participants contribute to the variability between Catholic hospitals when it comes to reproductive healthcare provision. An interesting topic for future research would be interviewing executives at Catholic hospitals to determine where this variability arises.

Achieving universal reproductive health coverage for deaf women in Ghana: an explanatory study of knowledge of contraceptive methods, pregnancy and safe abortion practices.

BACKGROUND: The first world conference on sexual and reproductive health (SRH) in 1994 helped create the awareness that reproductive health is a human right. Over the years, attempts have been made to extend services to all persons; however, lapses persist in service provision for all in need. Recently, countries have been encouraged to target minority groups in their reproductive health service provision. However, studies have rarely attempted to develop deeper insights into the experiences of deaf men and women regarding their knowledge of SRH. The purpose of this study was to develop an in-depth understanding of the knowledge of deaf persons regarding services such as knowledge of contraceptive methods, pregnancy and safe abortion practices. METHODS: A sequential explanatory mixed-methods approach was adopted for this study. In the first quantitative phase, 288 deaf persons recruited from three out of the 16 regions in Ghana participated in this study. They completed a 31-item questionnaire on the main issues (knowledge of contraceptive methods, pregnancy and safe abortion practices) addressed in this study. In the second phase, a semi-structured interview guide was used to collect data from 60 participants who took part in the first phase. The key trend emerging in the first phase underpinned the interview guide used for the data collection. While the quantitative data were subjected to the computation of means, t-tests, analyses of variance, correlations and linear regressions to understand the predictors, the in-depth interviews were analysed using the thematic method of analysis. RESULTS: The results showed a convergence between the quantitative and qualitative data. For instance, the interview material supported the initial findings that deaf women had little knowledge of contraceptive methods. The participants offered reasons explaining their inability to access services and the role of religion in their understanding of SRH. CONCLUSION: The study concludes by calling on policymakers to consider the needs of deaf persons in future SRH policies. The study limitations and other implications for future policymaking are discussed.

Utilisation of pharmacy-based sexual and reproductive health services: a quantitative retrospective study.

OBJECTIVES: To explore the utilisation of pharmacy-based sexual and reproductive health services (SRHS) in order to optimise delivery and identify barriers to access. METHODS: The health provider Umbrella offers six SRHS from over 120 pharmacies in Birmingham (England). In this retrospective study, data collected between August 2015 and August 2018 were used to analyse uptake, user characteristics and attendance patterns according to day of the week. RESULTS: A total of 60 498 requests for a pharmacy service were included in the analysis. Emergency contraception (50.4%), condoms (33.1%) and STI self-sampling kits (9.6%) accounted for more than 90% of all requests. A lower uptake of services was observed for the contraceptive injection (0.6%), oral contraception (5.4%) and chlamydia treatment (1.0%). Services were most likely to be requested by those self-identifying as female (85.6%), and those aged 16-24 years (53.8%). Based on available ethnicity data (n=54 668), most requests for a service were made by White/White British individuals (43.4%) and Asian/Asian British people (23.1%). The largest number of services were delivered on Mondays (20.9%) and the lowest on Sundays (5.0%). A high proportion of requests for services on Saturdays (57.0%), Sundays (67.6%) and Mondays (54.4%) were made by females presenting for emergency contraception. CONCLUSION: The evaluation of healthcare utilisation is important to help refine and optimise the delivery of services. However, information relating to pharmacy-based SRHS is scarce and often limited to a single type of service provision. Overall, a wide range of pharmacy-based services were accessed by a diverse range of people, suggesting that pharmacies are a suitable provider of many SRHS. However, the routinely collected data analysed in the study had several limitations restricting the analysis. Sexual health providers should ensure they collect data which are as comprehensive as is possible in order to help understand the utilisation of services.

National and subnational coverage and inequalities in reproductive, maternal, newborn, child, and sanitary health interventions in Ecuador: a comparative study between 1994 and 2012.

BACKGROUND: Latin America (LA) has experienced constant economic and political crises that coincide with periods of greater inequality. Between 1996 and 2007 Ecuador went through one of the greatest political and socio-economic crises in Latin America, a product of neo-liberal economic growth strategies. Between 2007 and 2012 it regained political stability, promoted redistributive policies, and initiated greater social spending. To understand the possible influence on the political and economic context, we analyzed the coverage and inequalities in five Reproductive, Maternal, and Child Health (RMNCH) and two water and sanitation interventions using survey data from a broad time window (1994-2012), at a national and subnational level. METHODS: The series cross-sectional study used data from four representative national health surveys (1994, 1999, 2004 and 2012). Coverage of RMNCH and sanitary interventions were stratified by wealth quintiles (as a measure of the socio-economic level), urban-rural residence and the coverage for each province was mapped. Mean difference, Theil index and Variance-weighted least squares regression were calculated to indicate subnational and temporal changes. RESULTS: From 1994 to 2004, Ecuador evidenced large inequalities whose reduction becomes more evident in 2012. Coverage in RMNCH health service-related interventions showed a rather unequal distribution among the socioeconomic status and across provinces in 1994 and 2004, compared to 2012. Sanitary interventions on the contrary, showed the most unequal interventions, and failed to improve or even worsened in several provinces. While there is a temporary improvement also at the subnational level, in 2012 several provinces maintain low levels of coverage. CONCLUSIONS: The remarkable reduction of inequalities in coverage of RMNCH interventions in 2012 clearly coincides with periods of regained political stability, promoted redistributive policies, and greater social spending, different from the former neo-liberal reforms which is consistent with observations made in other Latin American countries. Territorial heterogeneity and great inequalities specially related with sanitation interventions persists. It is necessary to obtain high quality information with sharper geographic desegregation that allows to identify and understand local changes over time. This would help to prioritize intervention strategies, introduce multisectoral policies and investments that support local governments.

The hidden burden of adolescent pregnancies in rural Sri Lanka; findings of the Rajarata Pregnancy Cohort.

BACKGROUND: Adolescent fertility is a main indicator of the Sustainable Developmental Goal (SGD) three. Although Sri Lanka is exemplary in maternal health, the utilization of Sexual and Reproductive Health services (SRH) by adolescents is less documented. We describe the hidden burden, associated biological and psychosocial factors and utilization patterns of pre-conceptional services among pregnant adolescents in rural Sri Lanka. METHODS: The study is based on the baseline assessment of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura. Pregnant women newly registered from July to September 2019 were recruited to the study. The period of gestation was confirmed during the second follow-up visit (around 25-28 weeks of gestation) using ultra sound scan data. A history, clinical examination, anthropometric measurements, blood investigations were conducted. Mental health status was assessed using the Edinburgh Postpartum Depression Scale (EPDS). RESULTS: Baseline data on gestation was completed by 3,367 pregnant women. Of them, 254 (7.5%) were adolescent pregnancies. Among the primigravida mothers (n = 1037), 22.4% (n = 233) were adolescent pregnancies. Maternal and paternal low education level, being unmarried, and less time since marriage were statistically significant factors associated with adolescent pregnancies (p < 0.05). Contraceptive usage before pregnancy, utilization of pre-conceptional health care services, planning pregnancy and consuming folic acid was significantly low among adolescents (p < 0.001). They also had low body mass index (p < 0.001) and low hemoglobin levels (p = 0.03). Adolescent mothers were less happy of being pregnant (p = 0.006) and had significantly higher levels of anxiety (p = 0.009). CONCLUSION: One fifth of women in their first pregnancy in this study population are adolescents. Nulli-parous adolescents exert poor social stability and compromised physical and mental health effects. The underutilization and/or unavailability of SRH services is clearly associated with adolescent pregnancies.

Delivery strategies for optimizing uptake of contraceptives among adolescents aged 15-19 years in Nsanje District, Malawi.

BACKGROUND: Despite documented benefits of contraceptives, uptake among young people aged 20-24 years is high compared to adolescents aged 15-19 years in Malawi. As the world's population of 15-19-year-olds continues to grow the need to meet the increasing demand for contraceptive services and information that address adolescent-specific needs cannot be underestimated. To inform Sexual and Reproductive health services for the youth, we explored strategies for optimizing uptake of contraceptives among this age group. METHODS: An exploratory qualitative cross-sectional study was conducted at Nsanje District Hospital and Nyamadzere Community Day Secondary School guided by Social-Ecological Framework to understand strategies that may optimize the uptake of contraceptives among adolescents aged 15-19. Nsanje district was purposively selected based on the reason that it is the second district in Malawi with the highest rate of adolescent childbearing of girls aged 15-19 years. We conducted a Focus Group Discussion (FGD) with 9 traditional leaders, 11 Key Informant Interviews (KIIs) with health workers, 20 In-depth Interviews (IDIs) with 12 adolescents, 4 teachers, and 4 parents. All data were digitally recorded, transcribed verbatim into English. The data was analyzed and managed using deductive thematic analysis guided by Social-Ecological Framework. RESULTS: Adolescents suggested accessing contraceptives from local drug stores, pharmacies and hospitals at a health system level and through Youth Centres, clubs, and corners at a Community level. There is a need to ensure a continuous supply of various kinds of contraceptives and the presence of youth-friendly health care workers in the specified areas. CONCLUSION: There is no one way of delivering contraceptives to adolescents. Multiple avenues existent at the health facility and community could be leveraged to optimize delivery and uptake of contraceptives in a manner that is not intimidating to an adolescent while involving key stakeholders.