Key learnings from an outcome and embedded process evaluation of a direct to beneficiary mobile health intervention among marginalised women in rural Bihar, India.

INTRODUCTION: Mobile Vaani was implemented as a pilot programme across six blocks of Nalanda district in Bihar state, India to increase knowledge of rural women who were members of self-help groups on proper nutrition for pregnant or lactating mothers and infants, family planning and diarrhoea management. Conveners of self-help group meetings, community mobilisers, introduced women to the intervention by giving them access to interactive voice response informational and motivational content. A mixed methods outcome and embedded process evaluation was commissioned to assess the reach and impact of Mobile Vaani. METHODS: The outcome evaluation, conducted from January 2017 to November 2018, used a quasi-experimental pre-post design with a sample of 4800 married women aged 15-49 from self-help group households, who had a live birth in the past 24 months. Surveys with community mobilisers followed by meeting observations (n=116), in-depth interviews (n=180) with self-help group members and secondary analyses of system generated data were conducted to assess exposure and perceptions of the intervention. RESULTS: From the outcome evaluation, 23% of women interviewed had heard about Mobile Vaani. Women in the intervention arm had significantly higher knowledge than women in the comparison arm for two of seven focus outcomes: knowledge of how to make child's food nutrient and energy dense (treatment-on-treated: 18.8% (95% CI 0.4% to 37.2%, p<0.045)) and awareness of at least two modern spacing family planning methods (treatment-on-treated: 17.6% (95% CI 4.7% to 30.5%, p<0.008)). Women with any awareness of Mobile Vaani were happy with the programme and appreciated the ability to call in and listen to the content. CONCLUSION: Low population awareness and programme exposure are underpinned by broader population level barriers to mobile phone access and use among women and missed opportunities by the programme to improve targeting and programme promotion. Further research is needed to assess programmatic linkages with changes in health practices.

Layering of a health, nutrition and sanitation programme onto microfinance-oriented self-help groups in rural India: results from a process evaluation.

BACKGROUND: The state of Bihar has been lagging behind Indian national averages on indicators related to maternal and child health, primarily due to lack of knowledge among mothers of young children on lifesaving practices and on where to seek services when healthcare is needed. Hence, the JEEViKA Technical Support Programme was established in 101 blocks to support the state rural livelihood entity, JEEViKA, in order to increase demand for and link rural families to existing health, nutrition and sanitation services. Programme activities were geared to those engaged in JEEViKA's microfinance-oriented self-help groups. These groups were facilitated by a village-based community mobilizer who was trained on health, nutrition and sanitation-related topics which she later shared in self-help group meetings monthly and during ad hoc home visits. Further, a block-level health, nutrition and sanitation integrator was introduced within JEEViKA to support community mobilizers. Also, indicators were added into the existing monitoring system to routinely capture the layering of health, nutrition and sanitation activities. METHODS: A process evaluation was conducted from August-November 2017 which comprised of conducting 594 quantitative surveys with community mobilizers, from program and non-programme intervention blocks. Linear and logistic regressions were done to capture the association of at least one training that the community mobilizers received on knowledge of the topics learned and related activities they carried out. RESULTS: Community mobilizers who had received at least one training were more likely to have higher levels of knowledge on the topics they learned and were also more likely to carry out related activities, such as interacting with block-level integrators for guidance and support, routinely collect data on health, nutrition and sanitation indicators and spend time weekly on related activities. CONCLUSIONS: Successful integration of health, nutrition and sanitation programming within a non-health programme such as JEEViKA is possible through trainings provided to dedicated staff in decentralized positions, such as community mobilizers. The findings of this evaluation hold great promise for engaging existing non-health, nutrition and sanitation systems that are serving vulnerable communities to become partners in working towards ensuring stronger health, nutrition and sanitation outcomes for all.

Participation in microfinance based Self Help Groups in India: Who becomes a member and for how long?

INTRODUCTION: Microfinance is a widely promoted developmental initiative to provide poor women with affordable financial services for poverty alleviation. One popular adaption in South Asia is the Self-Help Group (SHG) model that India adopted in 2011 as part of a federal poverty alleviation program and as a secondary approach of integrating health literacy services for rural women. However, the evidence is limited on who joins and continues in SHG programs. This paper examines the determinants of membership and staying members (outcomes) in an integrated microfinance and health literacy program from one of India's poorest and most populated states, Uttar Pradesh across a range of explanatory variables related to economic, socio-demographic and area-level characteristics. METHOD: Using secondary survey data from the Uttar Pradesh Community Mobilization project comprising of 15,300 women from SHGs and Non-SHG households in rural India, we performed multivariate logistic and hurdle negative binomial regression analyses to model SHG membership and duration. RESULTS: While in general poor women are more likely to be SHG members based on an income threshold limit (government-sponsored BPL cards), women from poorest households are more likely to become members, but less likely to stay members, when further classified using asset-based wealth quintiles. Additionally, poorer households compared to the marginally poor are less likely to become SHG members when borrowing for any reason, including health reasons. Only women from moderately poor households are more likely to continue as members if borrowing for health and non-income-generating reasons. The study found that an increasing number of previous pregnancies is associated with a higher membership likelihood in contrast to another study from India reporting a negative association. CONCLUSION: The study supports the view that microfinance programs need to examine their inclusion and retention strategies in favour of poorest household using multidimensional indicators that can capture poverty in its myriad forms.

Effect of sharing health messages on antenatal care behavior among women involved in microfinance-based self-help groups in Bihar India.

Background: Bihar state in India has one of the highest rates of maternal and infant mortality in South Asia. Microfinance-based self-help groups (SHGs), involving rural women, are being utilized to improve maternal and child health practice and reduce mortality. SHG members receive information on key maternal and child health practices as well as encouragement for their practice. This study measures the association of health messaging to SHG members with their antenatal care (ANC) behaviors. Methods: The study was conducted in eight districts of Bihar in 2016. A three-stage cluster sampling design (with a random selection of blocks, villages, and SHGs) selected the sample of 1204 SHG members who had an infant child; of these, 597 women were members of SHGs that received dedicated sessions on health messages, while 607 women belonged to SHGs that did not. To examine the impact of the health intervention on ANC practice, radius caliper method of propensity score matching controlled for various socio-demographic characteristics between the two groups. Results: Most of the interviewed women (91.5%) belonged to a scheduled caste or tribe. Nearly 44% of SHG members exposed to the health intervention were engaged in some occupation, compared to 35% of those not exposed to the intervention. After matching unexposed SHG women with exposed SHG women, no significant differences were found in their socio-demographic characteristics. Findings suggest that exposure to a health intervention is associated with increased likelihood of at least four ANC visits by SHG women (ATE = 7.2, 95% CI: 0.76-13.7, p < 0.05), consumption of iron-folic acid for at least 100 days (ATE = 8.7, 95% CI: 5.0-12.5, p < 0.001) and complete ANC (ATE = 3.6, 95% CI: 2.3-4.9, p < 0.001), when compared to women not exposed to the health intervention. Conclusions: The study shows that sharing health messages in microfinance-based SHGs is associated with significant increase in ANC practice. While the results suggest the potential of microfinance-based SHGs for improved maternal health services, the approach's sustainability needs to be further examined.

Effects of health behaviour change intervention through women's self-help groups on maternal and newborn health practices and related inequalities in rural india: A quasi-experimental study.

BACKGROUND: Despite the health system efforts, health disparities exist across sub-populations in India. We assessed the effects of health behaviour change interventions through women's self-help groups (SHGs) on maternal and newborn health (MNH) behaviours and socio-economic inequalities. METHODS: We did a quasi-experimental study of a large-scale SHG program in Uttar Pradesh, India, where 120 geographic blocks received, and 83 blocks did not receive health intervention. Data comes from two cross-sectional surveys with 4,615 recently delivered women in 2015, and 4,250 women in 2017. The intervention included MNH discussions in SHG meetings and community outreach activities. The outcomes included antenatal, natal and postnatal care, contraceptive use, cord care, skin-to-skin care, and breastfeeding practices. Effects were assessed using multilevel mixed-effects regression adjusted difference-in-differences (DID) analysis adjusting for geographic clustering and potential covariates, for all, most-marginalised and least-marginalised women. Concentration indices examined the socio-economic inequality in health practices over time. FINDINGS: The net improvements (5-11 percentage points [pp]) in correct MNH practices were significant in the intervention areas. The improvements over time were higher among the most-marginalised than least-marginalised for antenatal check-ups (DID: 20pp, p<0•001 versus DID: 6pp, p = 0•093), consumption of iron folic acid tablets for 100 days (DID: 7pp, p = 0•036 versus DID: -1pp, p = 0•671), current use of contraception (DID: 12pp, p = 0•046 versus DID: 10pp, p = 0•021), cord care (DID: 12pp, p = 0•051 versus DID: 7pp, p = 0•210), and timely initiation of breastfeeding (DID: 29pp, p = 0•001 versus DID: 1pp, p = 0•933). Lorenz curves and concentration indices indicated reduction in rich-poor gap in health practices over time in the intervention areas. INTERPRETATION: Disparities in MNH behaviours declined with the efforts by SHGs through behaviour change communication intervention.

Health impact of self-help groups scaled-up statewide in Bihar, India.

BACKGROUND: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017. METHODS: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62 690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age. RESULTS: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children. CONCLUSIONS: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India.

BACKGROUND: Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs. METHODS: A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression. RESULTS: In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks. CONCLUSIONS: Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya.

In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

Provider-Initiated Family Planning Within HIV Services in Malawi: Did Policy Make It into Practice?

Malawi's guidelines for Clinical Management of HIV in Children and Adults promote the practice of provider-initiated family planning (PIFP) for all clients over the age of 15. The guidelines recommend that providers should offer all clients condoms, offer injectables to female clients, and refer clients to another provider or site if clients prefer another family planning method. This study assessed to what extent family planning services had been integrated into HIV services among 41 facilities in Malawi (hospitals, health posts, health centers; public and nonprofit private) and how the reproductive rights of people living with HIV were being addressed. Data were collected through facility audits (N=41), provider interviews (N=122), client exit interviews (N=425), and mystery client visits (N=58). This study found that contrary to clinical protocols, only 14% of clients at the antiretroviral therapy (ART) clinic had reported being asked about their family planning/fertility intentions during the visit that day. Only 24% of providers at the facility had received training on family planning-HIV integration, and 21% had no family planning training at all. Overwhelmingly, ART clients relied on condoms to meet their family planning needs. Only 24% of ART clinics had injectables available, and only 15% of ART clinics had a full range of family planning methods (short- and long-acting, hormonal and non-hormonal) available to clients. These findings suggest that Malawi's strong national policies on family planning-HIV integration, and specifically PIFP, are not being implemented in practice and thus not adequately addressing the family planning needs of clients with HIV. To improve PIFP, Malawi requires targeted systems changes. Facilities need to broaden their family planning method mix offerings. Furthermore, providers need more training on family planning and the importance of HIV clients having access to family planning services, and referral services need to be strengthened so providers can ensure clients have access to their method of choice in a timely manner.

Measuring coordination between women's self-help groups and local health systems in rural India: a social network analysis.

OBJECTIVES: To assess how the health coordination and emergency referral networks between women's self-help groups (SHGs) and local health systems have changed over the course of a 2-year learning phase of the Uttar Pradesh Community Mobilization Project, India. DESIGN: A pretest, post-test programme evaluation using social network survey to analyse changes in network structure and connectivity between key individuals and groups. SETTING: The study was conducted in 18 villages located in three districts in Uttar Pradesh, India. INTERVENTION: To improve linkages and coordination between SHGs and government health providers by building capacity in leadership, management and community mobilisation skills of the SHG federation. PARTICIPANTS: A purposeful sampling that met inclusion criteria. 316 respondents at baseline and 280 respondents at endline, including SHG members, village-level and block-level government health workers, and other key members of the community (traditional birth attendants, drug sellers, unqualified rural medical providers, pradhans or elected village heads, and religious leaders). MAIN OUTCOME MEASURES: Social network analysis measured degree centrality, density and centralisation to assess changes in health services coordination networks at the village and block levels. RESULTS: The health services coordination and emergency referral networks increased in density and the number of connections between respondents as measured by average degree centrality have increased, along with more diversity of interaction between groups. The network expanded relationships at the village and block levels, reflecting the rise of bridging social capital. The accredited social health activist, a village health worker, occupied the central position in the network, and her role expanded to sharing information and coordinating services with the SHG members. CONCLUSIONS: The creation of new partnerships between traditionally under-represented communities and local government can serve as vehicle for building social capital that can lead to a more accountable and accessible community health delivery system.

Correction: Effect of behavioral change intervention around new-born care practices among most marginalized women in self-help groups in rural India: analyses of three cross-sectional surveys between 2013 and 2016.

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Utilization of maternal health services and its determinants: a cross-sectional study among women in rural Uttar Pradesh, India.

BACKGROUND: Proper utilization of antenatal and postnatal care services plays an important role in reducing the maternal mortality ratio and infant mortality rate. This paper assesses the utilization of health care services during pregnancy, delivery and post-delivery among rural women in Uttar Pradesh (UP) and examines its determinants. METHODS: Data from a baseline survey of UP Community Mobilization (UPCM) project (2013) was utilized. A cross-sectional sample of currently married women (15 to 49 years) who delivered a baby 15 months prior to the survey was included. Information was collected from 2208 women spread over five districts of UP. Information on socio-demography characteristics, utilization of antenatal care (ANC), delivery and postnatal care (PNC) services was collected. To examine the determinants of utilization of maternal health services, the variables included were three ANC visits, institutional delivery and PNC within 42 days of delivery. Separate multilevel random intercept logistic regressions were used to account for clustering at a block and gram panchayat level after adjusting for covariates. RESULTS: Eighty-three percent of women had any ANC. Of them, 61% reported three or more ANC visits. Although 68% of women delivered in a health facility, 29% stayed for at least 48 h. Any PNC within 42 days after delivery was reported by 26% of women. In the adjusted analysis, women with increasing number of contacts with the health worker during the antenatal period, women exposed to mass-media and non-marginalized women were more likely to have at least three ANC visits during pregnancy. Non-marginalized women and women with at least three ANC visits were more likely than their counterparts to deliver in an institution. Contacts with health worker during pregnancy, marginalization, at least three ANC visits and institutional delivery were the strong determinants for utilization of PNC services. Self-help group (SHG) membership had no association with the utilization of maternal health services. CONCLUSIONS: Utilization of maternal health services was low. Contact with the health worker and marginalization emerged as important factors for utilization of services. Although not associated with the utilization, SHGs can be used for delivering health care messages within and beyond the group.

Effect of behavioral change intervention around new-born care practices among most marginalized women in self-help groups in rural India: analyses of three cross-sectional surveys between 2013 and 2016.

OBJECTIVE: To assess the effects of new-born care intervention through self-help groups in improving new-born healthcare practices in rural India. METHODS: A quasi-experimental design was used to evaluate behavioral change intervention integrated in >25,000 microfinance-based self-help groups in rural Bihar. Three rounds of cross-sectional surveys were conducted to understand the impact of intervention on new-born healthcare practices by talking to women who delivered a baby in the last 6 months. RESULTS: Intervention groups showed greater improvement than control groups in the timely initiation of breastfeeding (adjusted odds ratio (AOR) = 6.3, 95% CI: 2.8, 14.3), exclusive breastfeeding on day 1 (AOR = 4.3, 95% CI: 1.9, 9.9), initiation of skin-to-skin care (AOR = 1.9, CI: 1.0, 3.8), and delayed bathing (AOR = 2.8, 95% CI: 1.4, 5.9) with greater effect of on home deliveries where clinical care is often absent. CONCLUSION: Sharing messages on appropriate new-born practices through self-help groups improve new-born care practices.

Effect of health intervention integration within women's self-help groups on collectivization and healthy practices around reproductive, maternal, neonatal and child health in rural India.

BACKGROUND: This study evaluates an eight-session behavior change health intervention with women's self-help groups (SHGs) aimed to promote healthy maternal and newborn practices among the more socially and economically marginalized groups. METHODS: Using a pre-post quasi-experimental design, a total of 545 SHGs were divided into two groups: a control group, which received the usual microcredit intervention; and an intervention group, which received additional participatory training around maternal, neonatal, and child health issues. Women members of SHGs who had a live birth in the 12 months preceding the survey were surveyed on demographics, practices around maternal, neonatal and child health (MNCH), and collectivization. Outcome effects were assessed using difference-in-difference (DID) methods. RESULTS: Women from the SHGs with health intervention, relative to controls over time (time 1 to time 2), were more likely to: use contraceptive methods (DID: 9 percentage points [pp], p<0.001), have institutional delivery (DID: 9pp, p<0.05), practice skin-to-skin care (DID: 17pp, p<0.05), delay bathing for 3 or more days (DID: 19pp, p<0.001), initiate timely breastfeeding (DID: 21pp, p<0.001), exclusively breastfeed the child (DID: 27pp, p<0.001), and provide age-appropriate immunization (DID: 9pp, p<0.001). Additionally, women from the SHGs with health intervention when compared to the control group over time were more likely to report: collective efficacy (DID: 17pp, p<0.001), support through accompanying SHG members for antenatal care (DID: 8pp, p<0.05), receive a visit from SHG member within 2 days post-delivery (DID: 32pp, p<0.001), and receive reproductive, maternal, neonatal and child health information from an SHG member (DID: 45pp, p<0.001). CONCLUSION: Findings demonstrate that structured participatory communication on MNCH with women's groups improve positive health practices. In addition, SHGs can reach a substantial proportion of women while providing an avenue for pregnant women and young mothers to be assisted by others in learning and practicing healthy behaviors, thus building social cohesion on health.

Government stewardship of the for-profit private health sector in Afghanistan.

BACKGROUND: Since 2003, Afghanistan's largely unregulated for-profit private health sector has grown at a rapid pace. In 2008, the Ministry of Public Health (MoPH) launched a long-term stewardship initiative to oversee and regulate private providers and align the sector with national health goals. AIM: We examine the progress the MoPH has made towards more effective stewardship, consider the challenges and assess the early impacts on for-profit performance. METHODS: We reviewed publicly available documents, publications and the grey literature to analyse the development, adoption and implementation of strategies, policies and regulations. We carried out a series of key informant/participant interviews, organizational capacity assessments and analyses of hospital standards checklists. Using a literature review of health systems strengthening, we proposed an Afghan-specific definition of six key stewardship functions to assess progress towards MoPH stewardship objectives. RESULTS: The MoPH and its partners have achieved positive results in strengthening its private sector stewardship functions especially in generating actionable intelligence and establishing strategic policy directions, administrative structures and a legal and regulatory framework. Progress has also been made on improving accountability and transparency, building partnerships and applying minimum required standards to private hospitals. Procedural and operational issues still need resolution and the MoPH is establishing mechanisms for resolving them. CONCLUSIONS: The MoPH stewardship initiative is notable for its achievements to date under challenging circumstances. Its success is due to the focus on developing a solid policy framework and building institutions and systems aimed at ensuring higher quality private services, and a rational long-term and sustainable role for the private sector. Although the MoPH stewardship initiative is still at an early stage, the evidence suggests that enhanced stewardship functions in the MoPH are leading to a more efficient and effective for-profit private sector. These successful early efforts offer high-leverage potential to rapidly scale up going forward.

Postabortion Care: 20 Years of Strong Evidence on Emergency Treatment, Family Planning, and Other Programming Components.

Worldwide 75 million women need postabortion care (PAC) services each year following safe or unsafe induced abortions and miscarriages. We reviewed more than 550 studies on PAC published between 1994 and 2013 in the peer-reviewed and gray literature, covering emergency treatment, postabortion family planning, organization of services, and related topics that impact practices and health outcomes, particularly in the Global South. In this article, we present findings from studies with strong evidence that have major implications for programs and practice. For example, vacuum aspiration reduced morbidity, costs, and time in comparison to sharp curettage. Misoprostol 400 mcg sublingually or 600 mcg orally achieved 89% to 99% complete evacuation rates within 2 weeks in multiple studies and was comparable in effectiveness, safety, and acceptability to manual vacuum aspiration. Misoprostol was safely introduced in several PAC programs through mid-level providers, extending services to secondary hospitals and primary health centers. In multiple studies, postabortion family planning uptake before discharge increased by 30-70 percentage points within 1-3 years of strengthening postabortion family planning services; in some cases, increases up to 60 percentage points in 4 months were achieved. Immediate postabortion contraceptive acceptance increased on average from 32% before the interventions to 69% post-intervention. Several studies found that women receiving immediate postabortion intrauterine devices and implants had fewer unintended pregnancies and repeat abortions than those who were offered delayed insertions. Postabortion family planning is endorsed by the professional organizations of obstetricians/gynecologists, midwives, and nurses as a standard of practice; major donors agree, and governments should be encouraged to provide universal access to postabortion family planning. Important program recommendations include offering all postabortion women family planning counseling and services before leaving the facility, especially because fertility returns rapidly (within 2 to 3 weeks); postabortion family planning services can be quickly replicated to multiple sites with high acceptance rates. Voluntary family planning uptake by method should always be monitored to document program and provider performance. In addition, vacuum aspiration and misoprostol should replace sharp curettage to treat incomplete abortion for women who meet eligibility criteria.

Assessment of policy and access to HIV prevention, care, and treatment services for men who have sex with men and for sex workers in Burkina Faso and Togo.

BACKGROUND: In Burkina Faso and Togo, key populations of men who have sex with men (MSM) and sex workers (SW) have a disproportionately higher HIV prevalence. This study analyzed the 2 countries' policies impacting MSM and SW; to what extent the policies and programs have been implemented; and the role of the enabling environment, country leadership, and donor support. METHODS: The Health Policy Project's Policy Assessment and Advocacy Decision Model methodology was used to analyze policy and program documents related to key populations, conduct key informant interviews, and hold stakeholder meetings to validate the findings. RESULTS: Several policy barriers restrict MSM/SW from accessing services. Laws criminalizing MSM/SW, particularly anti-solicitation laws, result in harassment and arrests of even nonsoliciting MSM/SW. Policy gaps exist, including few MSM/SW-supportive policies and HIV prevention measures, e.g., lubricant not included in the essential medicines list. The needs of key populations are generally not met due to policy gaps around MSM/SW participation in decision-making and funding allocation for MSM/SW-specific programming. Misaligned policies, eg, contradictory informed consent laws and protocols, and uneven policy implementation, such as stockouts of sexually transmitted infection kits, HIV testing materials, and antiretrovirals, undermine evidence-based policies. Even in the presence of a supportive donor and political community, public stigma and discrimination (S&D) create a hostile enabling environment. CONCLUSIONS: Policies are needed to address S&D, particularly health care provider and law enforcement training, and to authorize, fund, guide, and monitor services for key populations. MSM/SW participation and development of operational guidelines can improve policy implementation and service uptake.

Relationship characteristics and contraceptive use among couples in urban kenya.

CONTEXT: Few studies have used couple data to identify associations between individual- and relationship-level characteristics and contraceptive use in urban areas. METHODS: Population-based survey data collected in 2010 in three Kenyan cities-Nairobi, Mombasa and Kisumu-were used to identify 883 couples. Bivariate and multivariate analyses were conducted to examine associations between relationship-level characteristics (i.e., desire for another child, and communication about desired number of children and family planning use) and contraceptive use among couples currently using contraceptives; additional analyses investigated intention to use contraceptives among couples currently not practicing contraception. RESULTS: Sixty percent of couples reported current use of contraceptives. In multivariate analyses, couples who desired another child were less likely to use contraceptives than couples who wanted no more children (odds ratio, 0.5). Couples in which both partners reported spousal communication about family planning in the past six months had greater odds of contraceptive use than couples that reported no spousal communication on the subject (3.8). Results from analyses examining associations between relationship-level characteristics and intention to use contraceptives among current nonusers resembled those from analyses of current contraceptive users. CONCLUSION: In this study, relationship-level characteristics were associated with current contraceptive use and intention to use contraceptives among couples in urban Kenya. Family planning programs that promote spousal communication about family planning and desired number of children may improve contraceptive use among urban couples.

The role of gender empowerment on reproductive health outcomes in urban Nigeria.

To date, limited evidence is available for urban populations in sub-Saharan Africa, specifically research into the association between urban women's empowerment and reproductive health outcomes. The objective of this study is to investigate whether women's empowerment in urban Nigerian settings is associated with family planning use and maternal health behaviors. Moreover, we examine whether different effects of empowerment exist by region of residence. This study uses baseline household survey data from the Measurement, Learning and Evaluation Project for the Nigerian Urban Reproductive Health Initiative being implemented in six major cities. We examine four dimensions of empowerment: economic freedom, attitudes towards domestic violence, partner prohibitions and decision-making. We determine if the empowerment dimensions have different effects on reproductive health outcomes by region of residence using multivariate analyses. Results indicate that more empowered women are more likely to use modern contraception, deliver in a health facility and have a skilled attendant at birth. These trends vary by empowerment dimension and by city/region in Nigeria. We conclude by discussing the implications of these findings on future programs seeking to improve reproductive health outcomes in urban Nigeria and beyond.

Attitudes, beliefs and norms relating to contraceptive use among young migrant and non-migrant adults in urban Dar es Salaam, Tanzania.

The young urban population of Tanzania is growing rapidly, primarily due to rural-urban migration. More information is needed on the challenges facing young adult urban women and men in using family planning (FP). The purpose of this study is to identify perceptions, interpersonal and familial attitudes, and sociocultural norms regarding FP among young adults (18-25 years) in Dar es Salaam, Tanzania, comparing responses by sex, marital status and migration status. We conducted 12 focus groups with young adult men and women (n=74) in Dar es Salaam in December 2009. Participants knew of modern contraceptive methods, but had serious concerns about side effects. Single men and women preferred condoms. Female migrants stated that traditional methods were ineffective, yet commonly used in rural areas. Men's desires for more children frequently led female migrants not to use FP, while many married long-term residents used FP discreetly. Single women sometimes received the support of their parents/boyfriends to access and use contraception. Findings highlight differences in experiences among young adult men and women based on their migrant and marital status at the individual, interpersonal and normative levels. Future efforts to promote FP should engage existing social support systems and cultivate new ones in response to barriers.