"Regardless, you are not the first woman": an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua.

BACKGROUND: Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women's personal experiences of unintended pregnancy in the context of Nicaragua's repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16-23 in a city in North Central Nicaragua, from June to July 2014. CASE PRESENTATION: This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria's experience. CONCLUSIONS: Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria's case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria's experience demonstrates that an individual's health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria's experience of violence, unintended pregnancy, and unsafe abortion.

"I have no choice": Influences on Contraceptive Use and Abortion among Women in the Democratic Republic of the Congo.

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non- autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences.

"I have no choice": influences on contraceptive use and abortion among women in the Democratic Republic of the Congo

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non-autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences

Correlates of disclosure of sexual violence among Kenyan youth.

INTRODUCTION: Sexual violence (SV) against children is a global health and human rights issue that can have short and long-term consequences for health and wellbeing. Disclosing SV increases the likelihood that children can access health and protective services and receive psychosocial support. Research in high-income countries has found that child SV survivors are more likely to disclose when they are girls/women, experience fewer SV events, and experience SV perpetrated by a stranger. No studies have examined correlates of SV disclosure in Kenya. OBJECTIVE: The objective of this research was to assess the correlates of disclosing SV among Kenyan youth ages 13-24 who reported an SV experience before age 18. METHODS: In 2010, the Kenya Ministry of Gender, Children and Social Development, the U.S. Centers for Disease Control and Prevention's (CDC) Division of Violence Prevention, the UNICEF Kenya Country Office, and the Kenya National Bureau of Statistics (KNBS) conducted a national survey of violence against children. These data were used to conduct weighted logistic regression analyses to determine which factors were correlated with reporting SV disclosure. RESULTS: Among the 27.8% of girls/women and 14.5% of boys/men who reported SV before age 18, 44.6% of girls/women and 28.2% of boys/men reported to have disclosed the experience. In weighted logistic regression analysis, the odds of disclosure were lower among survivors who were boys/men and among survivors who reported more SV events, and higher when any perpetrator was a family member. CONCLUSION: More context-specific research on SV disclosure among young people is needed globally.

From Albania to Zimbabwe: Surveying 10 Years of Summer Field Experiences at the Rollins School of Public Health.

The objective of this article is to describe summer field experiences at the Rollins School of Public Health. An online survey was conducted among Master of Public Health students returning from summer field experiences. We used printed reports from 2004-2012 and original survey data from 2010-2013 to perform a trend analysis using correlation analysis and linear regression. We found that our students have worked for more than 300 organizations in 84 countries. The average cost of a summer field experience fluctuated around US$3,500, with students receiving an average of US$2,180 in funding. About 50% of students conducted human subjects research. This survey was used to improve student practical experiences through information sessions for students and feedback to key constituents, including the Emory Institutional Review Board and the Emory Travel Clinic.

"It's a Race Against the Clock": A Qualitative Analysis of Barriers to Legal Abortion in Bogotá, Colombia.

CONTEXT: In 2006, the Colombian Constitutional Court issued a decision largely decriminalizing abortion; however, illegal abortion persists. Understanding the barriers that cause women to resort to unsafe, illegal abortions could help improve access to legal services. METHODS: In-depth interviews were conducted in 2014 with 17 women aged 18 or older who had had legal abortions in the past year in Bogotá, Colombia, to identify barriers to abortion access and elucidate the ways in which these barriers affect women's decision making regarding abortion. Interview transcripts were coded and analyzed using standard techniques to find patterns, parallels and differences; a phenomenological approach guided the thematic analysis. RESULTS: Barriers related to knowledge and information, along with logistic, emotional, financial, cultural and religious barriers culminated in delays in obtaining comprehensive abortion services. Religion influenced social stigma, which manifested most powerfully in the obstructive behavior of health care providers and health insurance companies. Lack of understanding of current laws on abortion and conscientious objection was evident on the part of patients, health care providers and insurers. CONCLUSION: Dissemination of accurate information regarding the availability of clinical and legal abortion is needed. Better training may help physicians, nurses and insurance company personnel understand their roles and legal responsibilities in abortion care and reduce delays in women's access to services.

Global burden of maternal and congenital syphilis in 2008 and 2012: a health systems modelling study.

BACKGROUND: In 2007, WHO launched a global initiative for the elimination of mother-to-child transmission of syphilis (congenital syphilis). An important aspect of the initiative is strengthening surveillance to monitor progress towards elimination. In 2008, using a health systems model with country data inputs, WHO estimated that 1·4 million maternal syphilis infections caused 520 000 adverse pregnancy outcomes. To assess progress, we updated the 2008 estimates and estimated the 2012 global prevalence and cases of maternal and congenital syphilis. METHODS: We used a health systems model approved by the Child Health Epidemiology Reference Group. WHO and UN databases provided inputs on livebirths, antenatal care coverage, and syphilis testing, seropositivity, and treatment in antenatal care. For 2012 estimates, we used data collected between 2009 and 2012. We updated the 2008 estimates using data collected between 2000 and 2008, compared these with 2012 estimates using data collected between 2009 and 2012, and performed subanalyses to validate results. FINDINGS: In 2012, an estimated 930 000 maternal syphilis infections caused 350 000 adverse pregnancy outcomes including 143 000 early fetal deaths and stillbirths, 62 000 neonatal deaths, 44 000 preterm or low weight births, and 102 000 infected infants worldwide. Nearly 80% of adverse outcomes (274 000) occurred in women who received antenatal care at least once. Comparing the updated 2008 estimates with the 2012 estimates, maternal syphilis decreased by 38% (from 1 488 394 cases in 2008 to 927 936 cases in 2012) and congenital syphilis decreased by 39% (from 576 784 to 350 915). India represented 65% of the decrease. Analysis excluding India still showed an 18% decrease in maternal and congenital cases of syphilis worldwide. INTERPRETATION: Maternal and congenital syphilis decreased worldwide from 2008 to 2012, which suggests progress towards the elimination of mother-to-child transmission of syphilis. Nonetheless, maternal syphilis caused substantial adverse pregnancy outcomes, even in women receiving antenatal care. Improved access to quality antenatal care, including syphilis testing and treatment, and robust data are all important for achieving the elimination of mother-to-child transmission of syphilis. FUNDING: The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction in WHO, and the US Centers for Disease Control and Prevention.

Commentary on Obstetric Care in Rural Georgia.

This is an invited commentary on five articles on obstetric care in rural Georgia.

"The Fetus Is My Patient, Too": Attitudes Toward Abortion and Referral Among Physician Conscientious Objectors in Bogotá, Colombia.

CONTEXT: In 2006, the Colombian Constitutional Court partially decriminalized abortion. However, barriers to access, including improper use of conscientious objection, remain. METHODS: To explore conscientious objection from the objectors' perspectives, in-depth interviews were conducted in 2014 with 13 key informants and with 15 Colombian physicians who self-identified as conscientious objectors. Recruitment included snowball and purposive sampling techniques. Analysis was conducted in tandem with data collection and focused on objectors' attitudes, beliefs and behaviors related to abortion and referral. RESULTS: Objectors had varied perspectives. Three types of objectors were evident: extreme, moderate and partial. Extreme objectors refused to perform abortions or make referrals, and often lectured their patients; they also provided misleading or false medical and legal information, preventing women from accessing abortions to which they were legally entitled. Moderate objectors would not perform abortions, but respected their patients and viewed referral as a way to save "one out of two" lives. Partial objectors performed some abortions but refused to do others on the basis of gestational age or case-by-case circumstances. Across the typology, objectors linked conscientious objection with medical ethics, and many described a duty to protect the fetus, which they conceptualized as a patient. CONCLUSION: Conscientious objectors exhibit diverse opinions and behaviors. Potential areas for future investigation include identifying factors that lead objectors to refer and estimating the prevalence of each type of objector. Results suggest potential interventions that could reduce the role of conscientious objection as a barrier to care.

"Siempre me critican": barriers to reproductive health in Ocotal, Nicaragua.

OBJECTIVE: To identify perceived barriers to accessing reproductive health care according to the women of Ocotal, Nicaragua; describe their understanding of their reproductive rights; and document their opinions about Nicaragua's total ban on abortion. METHODS: From May to June 2014, three focus group discussions were held in Spanish with 17 women from two different neighborhoods (barrios) in the city of Ocotal, Nicaragua. A semi-structured discussion guide with open-ended questions was employed to elucidate local perspectives regarding the focus group discussions themes. RESULTS: Serious obstacles including 1) violence against women, 2) machismo, 3) criticism from others, and 4) lack of communication and education limit women's ability to make their own reproductive health decisions. Women had a pervasive lack of knowledge about reproductive rights and the international human rights documents that define them. In addition, due to religious and cultural ideologies, most women supported the country's total ban on abortion in most circumstances, with the possible exception of rape. CONCLUSIONS: Both men and women in Ocotal should be encouraged to participate in community-level programs designed to reduce the impact of the following obstacles to receiving reproductive health care: 1) violence against women and machismo; 2) insufficient, non-standardized sexual education and information about reproductive rights; and 3) poor communication within families and the community at large. Any future public health campaigns to address women's reproductive health needs in Ocotal should implement these types of programs, at the neighborhood level, to reduce stigma surrounding sexual health and activity.

"Siempre me critican": barriers to reproductive health in Ocotal, Nicaragua / "Siempre me critican": barreras de acceso a la salud reproductiva en Ocotal, Nicaragua

OBJECTIVE: To identify perceived barriers to accessing reproductive health care according to the women of Ocotal, Nicaragua; describe their understanding of their reproductive rights; and document their opinions about Nicaragua's total ban on abortion. METHODS: From May to June 2014, three focus group discussions were held in Spanish with 17 women from two different neighborhoods (barrios) in the city of Ocotal, Nicaragua. A semi-structured discussion guide with open-ended questions was employed to elucidate local perspectives regarding the focus group discussions themes. RESULTS: Serious obstacles including 1) violence against women, 2) machismo, 3) criticism from others, and 4) lack of communication and education limit women's ability to make their own reproductive health decisions. Women had a pervasive lack of knowledge about reproductive rights and the international human rights documents that define them. In addition, due to religious and cultural ideologies, most women supported the country's total ban on abortion in most circumstances, with the possible exception of rape. CONCLUSIONS: Both men and women in Ocotal should be encouraged to participate in community-level programs designed to reduce the impact of the following obstacles to receiving reproductive health care: 1) violence against women and machismo; 2) insufficient, non-standardized sexual education and information about reproductive rights; and 3) poor communication within families and the community at large. Any future public health campaigns to address women's reproductive health needs in Ocotal should implement these types of programs, at the neighborhood level, to reduce stigma surrounding sexual health and activity.

OBJETIVO: Determinar cómo perciben las mujeres de Ocotal, Nicaragua, las barreras de acceso a la atención de salud reproductiva; describir sus conocimientos acerca de los derechos reproductivos; y consignar sus opiniones acerca de la prohibición total del aborto en Nicaragua. MÉTODOS: De mayo a junio del 2014, se establecieron tres grupos de discusión en español en los que participaron 17 mujeres de dos barrios diferentes de la ciudad de Ocotal. Se utilizó una guía de discusión semiestructurada que constaba de preguntas de respuesta libre para dilucidar las perspectivas locales con respecto a los temas del grupo de discusión. RESULTADOS: Los obstáculos graves, incluidos 1) la violencia contra la mujer, 2) el machismo, 3) las críticas por parte de otros, y 4) la falta de comunicación y formación, limitan la capacidad de las mujeres para tomar sus propias decisiones de salud reproductiva. Las mujeres mostraron una carencia generalizada de conocimientos acerca de sus derechos reproductivos y los documentos internacionales de derechos humanos que los definen. Además, como consecuencia de sus ideas religiosas y culturales, la mayor parte de las mujeres apoyaron la prohibición total del aborto en el país en la mayor parte de las circunstancias, con la posible excepción de la violación. CONCLUSIONES: Se debe alentar a los hombres y mujeres de Ocotal a participar en los programas comunitarios diseñados para reducir la repercusión de los siguientes obstáculos para obtener atención de salud reproductiva: 1) la violencia contra la mujer y el machismo; 2) la educación sexual no estandarizada y la información acerca de sus derechos reproductivos insuficientes; y 3) la comunicación deficiente dentro de las familias y en la comunidad en general. Con objeto de reducir el estigma en torno a la salud y la actividad sexuales, las futuras campañas de salud pública orientadas a tratar las necesidades de salud reproductiva de las mujeres de Ocotal deben llevar a cabo en los barrios estos tipos de programas.

Maternal and child health epidemic-assistance investigations, 1946-2005.

In this article, the authors focus on epidemic-assistance investigations that dealt with maternal and child health problems, including unintended and adolescent pregnancy and family planning; international reproductive health surveys among refugees; pregnancy outcomes, including abortion, maternal mortality, infant mortality, and birth defects; leukemia; and Reye syndrome. During 1946-2005, a total of 1,969 investigations had sufficient data to classify them as possibly related to maternal and child health and were characterized by distinctive periods. Those related to family planning, pregnancy intention, and reproductive health among refugees began in the early 1970s and continued through 2005. Abortion-related investigations occurred during 1971-1982. Investigations of non-abortion-related maternal morbidity and mortality began in 1979 and included 2 international epidemic-assistance investigations. Investigations of clusters of disease among infants began in the 1960s, with a special focus on Reye syndrome during 1964-1984. Investigations of childhood cancer and birth defects began in the late 1950s. The Centers for Disease Control and Prevention has used the epidemic-assistance investigations mechanism to respond to a wide range of health concerns of women and children. The investigations of abortion-related health problems might have had the best-documented impact on public policy and public health.

Contraceptive use among clients of the Atlanta Feminist Women's Health Center at three to five weeks post-abortion.

Little is known about women's contraceptive use and sexual activity in the immediate post-abortion period although effective contraceptive use is paramount during this time because fertility returns almost immediately. This study sought to learn more about women's contraceptive use and sexual behaviors to inform abortion providers and help them serve their clients better, potentially leading to a decline in the rates of unintended pregnancy and repeat abortion. Abortion clients of an Atlanta, GA clinic were surveyed over the telephone 3-5 weeks post-abortion. Background information was collected from clinic medical charts. Simple and stratified frequencies and logistic regression were used to describe women's sexual activity and contraceptive use in the immediate post-abortion period and to determine if variables known at the time of the abortion could predict contraceptive use 3-5 weeks post-abortion. 54.2% (n = 39) of women had engaged in sexual intercourse in the immediate post-abortion period. Of these, 30.8% (n = 12) were not using a contraceptive method or were not using it effectively. Women who said they did not want or need information about birth control on their medical history form were less likely to be using contraception 3-5 weeks post abortion. Emphasizing the rapid return of fertility and risk of conception in pre-abortion counseling sessions could prevent future unintended pregnancies among abortion clients. Further research could explore the interaction between a willingness to talk about contraceptive methods at the time of abortion and method use post-abortion.

Chlamydia screening of adolescent females: a survey of providers in Hawaii.

Hawaii currently ranks first among states for chlamydia screening of young women based on recent Healthcare Effectiveness Data and Information Set (HEDIS) measures and has consistently ranked in the top ten states in the US for annual reported chlamydia rates since 2002. A statewide provider survey was conducted in October 2007 and March 2008 to assess chlamydia screening practices and beliefs and identify potential barriers to screening. The overall reported screening rate for 15-19 year old females was 66.9% with significant differences by practice specialty (obstetrician/gynecologists were more likely to screen than family practitioners or pediatricians) and practice setting (higher rates of screening in non-private practice settings). Providers who were unaware of health plan reimbursement for screening and those who targeted screening only for clients perceived to be at "high risk" were significantly less likely to routinely provide screening. The Hawaii State Department of Health is currently working in consort with health care providers and the state's dominant health insurance carriers to address these issues through targeted provider educational interventions.

Causes of death among women aged 10-50 years in Bangladesh, 1996-1997.

Limited information is available at the national and district levels on causes of death among women of reproductive age in Bangladesh. During 1996-1997, health-service functionaries in facilities providing obstetric and maternal and child-heath services were interviewed on their knowledge of deaths of women aged 10-50 years in the past 12 months. In addition, case reports were abstracted from medical records in facilities with in-patient services. The study covered 4,751 health facilities in Bangladesh. Of 28,998 deaths reported, 13,502 (46.6%) occurred due to medical causes, 8,562 (29.5%) due to pregnancy-related causes, 6,168 (21.3%) due to injuries, and 425 (1.5%) and 259 (0.9%) due to injuries and medical causes during pregnancy respectively. Cardiac problems (11.7%), infectious diseases (11.3%), and system disorders (9.1%) were the major medical causes of deaths. Pregnancy-associated causes included direct maternal deaths (20.1%), abortion (5.1%), and indirect maternal deaths (4.3%). The highest proportion of deaths among women aged 10-19 years was due to injuries (39.3%) with suicides accounting for 21.7%. The largest proportion of direct obstetric deaths occurred among women aged 20-29 years (30.5%). At least one quarter (24.3%) of women (n = 28,998) did not receive any treatment prior to death, and 47.8% received treatment either from a registered physician or in a facility. More focus is needed on all causes of deaths among women of reproductive age in Bangladesh.

Differences between mistimed and unwanted pregnancies among women who have live births.

CONTEXT: Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies, but they may have different precursors and outcomes. METHODS: Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended, mistimed and unwanted conceptions, by selected variables. Associations between unintendedness and women's behaviors and experiences before, during and after the pregnancy were assessed through unadjusted relative risks. RESULTS: The distribution of intended, mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk, 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester, received delayed or no prenatal care, did not breast-feed, were physically abused during pregnancy, said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed. CONCLUSION: Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants.

Slowing the stork: Better health for women through family planning

Better Health for Women and Children through Family Planning. Population Council; 5-9 Oct. 1987

. World Health Organization

. International Planed Parenthood Federation

. UNICEF

. UNDP

. PNUD

. World Bank

. Banco Mundial