Refugee women's and providers' perceptions of person-centered maternity care: a qualitative study in two refugee camps in Chad.

BACKGROUND: Globally, mistreatment of women during labor and delivery is a common human rights violation. Person-centered maternity care (PCMC), a critical component of quality of care, is respectful and responsive to an individual's needs and preferences. Factors related to poor PCMC are often exacerbated in humanitarian settings. METHODS: We conducted a qualitative study to understand Sudanese refugee women's experiences, including their perceptions of quality of care, during labor and delivery at the maternities in two refugee camps in eastern Chad, as well as maternity health workers' perceptions of PCMC and how they could be better supported to provide this. In-depth interviews were conducted individually with 22 women who delivered in the camp maternities and five trained midwives working in the two maternities; and in six dyads with a total of 11 Sudanese refugee traditional birth attendants and one assistant midwife. In addition, facility assessments were conducted at each maternity to determine their capacity to provide PCMC. RESULTS: Overall, women reported positive experiences in the camp maternities during labor and delivery. Providers overwhelmingly defined respectful care as patient-centered and respect as being something fundamental to their role as health workers. While very few reported incidents of disrespect between providers and patients in the maternity, resource constraints, including overwork of the providers and overcrowding, resulted in some women feeling neglected. CONCLUSIONS: Despite providers' commitment to offering person-centered care and women's generally positive experiences in this study, one of few that explored PCMC in a refugee camp, conflict and displacement exacerbates the conditions that contribute to mistreatment during labor and delivery. Good PCMC requires organizational emphasis and support, including adequate working conditions and ensuring suitable resources so health workers can effectively perform.

Sexual and reproductive health knowledge, attitudes, and behaviors: A survey of 12-17 year old Sudanese refugees in Chad.

Adolescents living in humanitarian settings are often at a higher risk of negative sexual and reproductive health outcomes, and yet, limited information is available on adolescents' experiences and needs in these settings while available services do not always correspond to their needs. This study explored knowledge, attitudes, and behaviors relating to sexual and reproductive health among 12-17 year old refugees from Darfur currently living in two refugee camps in eastern Chad. The research team conducted a cross-sectional survey of 689 adolescent girls and boys, informed by participatory research activities, to explore key sexual and reproductive health topics. This study found that sexual and reproductive health knowledge among adolescents is low, with only 69.1% able to identify at least one modern contraceptive method. Early marriage was uncommon (5% of girls, 0.8% of boys), but 17.6% of adolescents had already had a romantic relationship. Few adolescents (11.4%) had ever had sex, but among these adolescents,18.4% reported using a condom the last time they had sex. No boys reported current modern contraceptive use, but 28.3% of girls, both married and unmarried, reported current use. These findings demonstrate the importance of making sexual and reproductive health services in humanitarian settings more adolescent-responsive and minimizing barriers to access, including addressing community stigma surrounding adolescents' use of sexual and reproductive health services and increasing trust in the confidentiality of sexual and reproductive health services in the camps.

"Midwives are heroes of the country": qualitative evaluation of a midwifery education program in South Sudan.

Background: Countries affected by armed conflict have higher maternal mortality than stable settings. South Sudan has one of the highest maternal mortality ratios in the world, with an estimated 789 maternal deaths per 100,000 live births. Long-term socio-political instability has contributed to significant challenges in its health system. To reduce maternal and newborn morbidity and mortality, South Sudan must increase the number of skilled midwives. Methods: A cross-sectional mixed methods study was conducted in 2022 to assess the midwifery education program at three schools receiving support from International Medical Corps in South Sudan, including in-depth interviews with 15 midwifery school graduates currently working as midwives, their supervisors, 16 school faculty (in dyads), and two Ministry of Health officials; and nine focus group discussions with women clients of graduate midwives. Results: Participants identified strengths of the schools, including being well equipped with trained and competent teaching staff, competency-based curriculum, including practical training which prepared graduate midwives to apply their skills in practice. Weaknesses of the program included its dependence on donor funding, inadequate mentorship and number of tutors, and insufficient practice for some services due to low client load at clinical sites. Additionally, participants identified challenges affecting midwives' ability to provide good quality care, including lack of equipment and supplies, low client load, low salaries, and insecurity due to conflict. Nevertheless, women in the community appreciated the immense work that midwives do. Midwives were respected by the community at large, and graduates expressed pride and satisfaction in their job, as well as the positive impact they have had in providing critical services to communities. Discussion: Overall, the quality of the midwifery education program appears to be strong, however gaps in the program and the provision of quality care remain. The findings highlight the need to ensure sustained funding for midwifery education, as well as health system strengthening to ensure midwives can practice their skills. Continued investment in midwifery education and training is critical to reduce high maternal mortality and morbidity in South Sudan.

Government responses to COVID-19 and impact on GBV services and programmes: comparative analysis of the situation in South Africa, Kenya, Uganda, and Nigeria.

As governments impose restrictive policies to contain infectious disease outbreaks, pre-existing gender-based inequalities are often exacerbated, increasing the risk of gender-based violence (GBV). Despite international guidance on the need for continued provision of GBV services during emergencies, governments often de-prioritise GBV services and programmes. We conducted a rapid assessment in South Africa, Kenya, Uganda, and Nigeria to examine the impact of COVID-19 policies on the availability of GBV prevention and response services. The study team interviewed 80 stakeholders representing different GBV services in the four countries. The interviews revealed strikingly similar government mis-steps that disrupted the availability of comprehensive GBV services. In all four countries, the government's failure to exempt the provision of multi-sectoral GBV services from initial lockdown restrictions led to confusion and disrupted the provision of critical GBV services such as clinical management of rape, legal and judicial services, psychosocial services, availability of shelters, and community-based prevention activities. The government's imposition of curfews, stay-at-home orders, and transportation restrictions further diminished access to services. Governments must strengthen currently available GBV prevention and response services and be better prepared for future pandemics. Following international guidelines, governments should deem GBV services as essential from the beginning with clear implementation plans. Governments must invest in community-based solutions and the expansion of digital tools to ensure everyone, especially those likely to be structurally excluded, have access to critical services during an emergency.

Beyond abortion: impacts of the expanded global gag rule in Kenya, Madagascar and Nepal.

Since 1984, Republican administrations in the US have enacted the global gag rule (GGR), which prohibits non-US-based non-governmental organisations (NGOs) from providing, referring for, or counselling on abortion as a method of family planning, or advocating for the liberalisation of abortion laws, as a condition for receiving certain categories of US Global Health Assistance. Versions of the GGR implemented before 2017 applied to US Family Planning Assistance only, but the Trump administration expanded the policy's reach by applying it to nearly all types of Global Health Assistance. Documentation of the policy's harms in the peer-reviewed and grey literature has grown considerably in recent years, however few cross-country analyses exist. This paper presents a qualitative analysis of the GGR's impacts across three countries with distinct abortion laws: Kenya, Madagascar and Nepal. We conducted 479 in-depth qualitative interviews between August 2018 and March 2020. Participants included representatives of Ministries of Health and NGOs that did and did not certify the GGR, providers of sexual and reproductive health (SRH) services at public and private facilities, community health workers, and contraceptive clients. We observed greater breakdown of NGO coordination and chilling effects in countries where abortion is legal and there is a sizeable community of non-US-based NGOs working on SRH. However, we found that the GGR fractured SRH service delivery in all countries, irrespective of the legal status of abortion. Contraceptive service availability, accessibility and training for providers were particularly damaged. Further, this analysis makes clear that the GGR has substantial and deleterious effects on public sector infrastructure for SRH in addition to NGOs.

Association of fear-avoidance and self-efficacy on pain disability in individuals with co-morbid post-traumatic stress and chronic pain.

This study investigated relationships between post-traumatic stress symptoms (PTSS) and pain disability. Fifty people with chronic pain (probable PTSD, n = 22) completed measures assessing pain interference, PTSS, fear avoidance, and pain self-efficacy. We hypothesized that people with probable PTSD would have higher fear avoidance and lower pain self-efficacy; and that PTSS would be indirectly associated with pain disability via fear avoidance and self-efficacy. People with probable PTSD had higher fear avoidance, but there were no differences in self-efficacy, pain severity or disability. There was an indirect association between PTSS and pain disability via fear avoidance, but not via self-efficacy.

Community perceptions of the impact of war on unintended pregnancy and induced abortion in Protection of Civilian sites in Juba, South Sudan.

Conflict and mass displacement into Protection of Civilian (POCs) sites in South Sudan led to the breakdown of community and family structures, increasing women and girls' vulnerability to gender-based violence and exacerbating already poor sexual and reproductive health outcomes. As one component of a study on post-abortion care, this study explores community perceptions of unintended pregnancy and abortion in a POC in Juba. Four focus group discussions were conducted with 36 women and married men aged 18-45 living in the POC. Although initial reactions to induced abortion were generally negative, participants discussed that unintended pregnancy and induced abortion appeared to have increased during the current conflict. Their discussion of abortion became less condemnatory as they described changes in people's situation due to war, including instability and poverty, transactional sex, disruption of marital norms, rape, and low contraceptive use. This is one of the first studies to investigate community perceptions and practices related to unintended pregnancy and abortion in South Sudan. Despite the beliefs that these are taboo topics, the discussions provide an opening to reduce abortion stigma. To ensure lasting stigma reduction, investment in women and girls to improve gender equity is needed.

Barriers to seeking post-abortion care in Paktika Province, Afghanistan: a qualitative study of clients and community members.

BACKGROUND: Unsafe abortion is a leading cause of maternal mortality. In Afghanistan, which has experienced decades of armed conflict and where abortion is highly restricted, maternal mortality is high at 638 maternal deaths per 100,000 live births. Post-abortion care (PAC) is a lifesaving package of interventions to reduce morbidity and mortality related to induced or spontaneous abortion, but is rarely provided and often of poor quality, particularly in humanitarian settings. In July 2018, we conducted a study to identify the factors that influence access to and use of PAC services at Sharana Provincial Hospital. METHODS: In-depth interviews (IDIs) were conducted with ten women who had received PAC services at Sharana Hospital, and eight focus group discussions (FGDs) were conducted with 40 married women and 40 married men aged 18-45 from four villages surrounding Sharana Hospital. RESULTS: PAC clients and community participants discussed similar barriers to seeking PAC, including cost, distance to the health facility, the need for male accompaniment to seek care, perceived and actual quality of care, stigma and shame. Despite the mentioned stigma around abortion, community members expressed willingness to help women to receive PAC. CONCLUSIONS: Our results suggest that while some barriers are not unique to PAC, others, especially those related to stigma around abortion, may be specific to PAC. It is important for the Ministry of Public Health and its partners to prioritize addressing these barriers to ensure that women have access to this critical life-saving care.

Formaldehyde Vapor Characteristics in Varied Decontamination Environments.

INTRODUCTION: This effort investigated formaldehyde vapor characteristics under various environmental conditions by the analyses of air samples collected over a time-course. This knowledge will help responders achieve desired formaldehyde exposure parameters for decontamination of affected spaces after a biological contamination incident. METHODS: Prescribed masses of paraformaldehyde and formalin were sublimated or evaporated, respectively, to generate formaldehyde vapor. Adsorbent cartridges were used to collect air samples from the test chamber at predetermined times. A validated method was used to extract the cartridges and analyze for formaldehyde via liquid chromatography. In addition, material demand for the formaldehyde was evaluated by inclusion of arrays of Plexiglas panels in the test chamber to determine the impact of varied surface areas within the test chamber. Temperature was controlled with a circulating water bath connected to a radiator and fan inside the chamber. Relative humidity was controlled with humidity fixed-point salt solutions and water vapor generated from evaporated water. RESULTS: Low temperature trials (approximately 10°C) resulted in decreased formaldehyde air concentrations throughout the 48-hour time-course when compared with formaldehyde concentrations in the ambient temperature trials (approximately 22°C). The addition of clear Plexiglas panels to increase the surface area of the test chamber interior resulted in appreciable decreases of formaldehyde air concentration when compared to an empty test chamber. CONCLUSION: This work has shown that environmental variables and surface-to-volume ratios in the decontaminated space may affect the availability of formaldehyde in the air and, therefore, may affect decontamination effectiveness.

Impact of COVID-19 on Gender-Based Violence Prevention and Response Services in Kenya, Uganda, Nigeria, and South Africa: A Cross-Sectional Survey.

BACKGROUND: Epidemics and other complex emergencies historically have had a disproportionate impact on women and girls, increasing their vulnerability to gender-based violence (GBV). The COVID-19 pandemic has been no different, with reports of rising cases of GBV emerging worldwide. Already a significant problem in Kenya, Uganda, Nigeria, and South Africa, GBV in these countries has been exacerbated by government restrictions intended to contain the spread of COVID-19. The purpose of this study was to understand how the COVID-19 pandemic affected the availability of GBV prevention and response services from the perspective of the organizations that provide them. METHODS: A cross-sectional online survey of people who work in GBV prevention and response in Kenya, Uganda, Nigeria, and South Africa was administered from July to October 2020. A convenience sample was identified through web search, contacts of in-country consultants, and relevant listservs and technical working groups. Descriptive analyses were completed using SPSS. RESULTS: A total of 187 respondents completed the survey. Nearly all (98.9%) survey respondents reported that COVID-19 impacted their work. The majority (77.9%) stated that work decreased due to government restrictions or GBV services being deemed non-essential. The types of service most impacted were community-based prevention, shelters, and legal services. Survey respondents overwhelmingly agreed (99.3%) that COVID-19 impacted GBV prevalence and identified adolescents and women with disabilities as particularly vulnerable groups. CONCLUSIONS: GBV prevention and response services in Kenya, Uganda, Nigeria, and South Africa were highly impacted by the COVID-19 pandemic, largely due to government restrictions and the failure of governments to deem GBV services as essential. Preparedness for future crises should ensure that GBV is adequately prioritized in the initial response in order to maintain service availability with special attention paid to at-risk populations.

Decontamination of Bacillus Spores with Formaldehyde Vapor under Varied Environmental Conditions.

Introduction: This study investigated formaldehyde decontamination efficacy against dried Bacillus spores on porous and non-porous test surfaces, under various environmental conditions. This knowledge will help responders determine effective formaldehyde exposure parameters to decontaminate affected spaces following a biological agent release. Methods: Prescribed masses of paraformaldehyde or formalin were sublimated or evaporated, respectively, to generate formaldehyde vapor within a bench-scale test chamber. Adsorbent cartridges were used to measure formaldehyde vapor concentrations in the chamber at pre-determined times. A validated method was used to extract the cartridges and analyze for formaldehyde via liquid chromatography. Spores of Bacillus globigii, Bacillus thuringiensis, and Bacillus anthracis were inoculated and dried onto porous bare pine wood and non-porous painted concrete material coupons. A series of tests was conducted where temperature, relative humidity, and formaldehyde concentration were varied, to determine treatment efficacy outside of conditions where this decontaminant is well-characterized (laboratory temperature and humidity and 12 mg/L theoretical formaldehyde vapor concentration) to predict decontamination efficacy in applications that may arise following a biological incident. Results: Low temperature trials (approximately 10°C) resulted in decreased formaldehyde air concentrations throughout the 48-hour time-course when compared with formaldehyde concentrations collected in the ambient temperature trials (approximately 22°C). Generally, decontamination efficacy on wood was lower for all three spore types compared with painted concrete. Also, higher recoveries resulted from painted concrete compared to wood, consistent with historical data on these materials. The highest decontamination efficacies were observed on the spores subjected to the longest exposures (48 hours) on both materials, with efficacies that gradually decreased with shorter exposures. Adsorption or absorption of the formaldehyde vapor may have been a factor, especially during the low temperature trials, resulting in less available formaldehyde in the air when measured. Conclusion: Environmental conditions affect formaldehyde concentrations in the air and thereby affect decontamination efficacy. Efficacy is also impacted by the material with which the contaminants are in contact.

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar.

Madagascar's health system is highly dependent on donor funding, especially from the United States (US), and relies on a few nongovernmental organisations (NGOs) to provide contraceptive services in remote areas of the country. The Trump administration reinstated and expanded the Global Gag Rule (GGR) in 2017; this policy requires non-US NGOs receiving US global health funding to certify that neither they nor their sub-grantees will provide, counsel or refer for abortion as a method of family planning. Evidence of the impact of the GGR in a country with restrictive abortion laws, like Madagascar - which has no explicit exception to save the woman's life - is limited. Researchers conducted semi-structured interviews with 259 representatives of the Ministry of Health and NGOs, public and private health providers, community health workers and contraceptive clients in Antananarivo and eight districts between May 2019 and March 2020. Interviews highlighted the impact of the GGR on NGOs that did not certify the policy and lost their US funding. This reduction in funding led to fewer contraceptive service delivery points, including mobile outreach services, a critical component of care in rural areas. Public and private health providers reported increased contraceptive stockouts and fees charged to clients. Although the GGR is ostensibly about abortion, it has reduced access to contraception for the Malagasy population. This is one of few studies to directly document the impact on women who themselves described their increased difficulties obtaining contraception ultimately resulting in discontinuation of contraceptive use, unintended pregnancies and unsafe abortions.

From bad to worse: global governance of abortion and the Global Gag Rule.

The Trump Administration's Protecting Life in Global Health Assistance (PLGHA) significantly expands the "Global Gag Rule" - and, in so doing, weakens the global governance of abortion. By chilling debate, reducing transparency, ghettoising sexual and reproductive health and rights work, and interfering with research, PLGHA makes an already bad context demonstrably worse. Individual women suffer the most, as PLGHA inhibits ongoing efforts to reduce abortion-related morbidity and mortality.

Foreign assistance or attack? Impact of the expanded Global Gag Rule on sexual and reproductive health and rights in Kenya.

In 2017, the Trump Administration reinstated and expanded the Global Gag Rule (GGR). This policy requires non-governmental organisations (NGOs) not based in the US to certify that they will not provide, counsel, refer, or advocate for abortion as a method of family planning in order to receive most categories of US global health assistance. Robust empirical evidence demonstrating the policy's impacts is acutely lacking. This paper describes the effects of the expanded GGR policy in Kenya eighteen months after its reinstatement. We conducted semi-structured interviews with purposively selected representatives of US- and non-US-based NGOs, as well as managers and health providers at public and private health facilities, between September 2018 and March 2019. Organisations reported critical funding loss as they were forced to choose between US government-funded projects and projects supporting safe abortion. This resulted in the fragmentation of sexual and reproductive health and HIV services, and closure of some service delivery programmes. At public and private health facilities, participants reported staffing shortages and increased stock-outs of family planning and safe abortion commodities. The expanded GGR's effects transcended abortion care by also disrupting collaboration and health promotion activities, strengthening opposition to sexual and reproductive health and rights in some segments of Kenyan civil society and government. Our findings indicate that the GGR exposes and exacerbates the weaknesses and vulnerabilities of the Kenyan health system, and illuminates the need for action to mitigate these harms.

Contraceptive use among adolescent and young women in North and South Kivu, Democratic Republic of the Congo: A cross-sectional population-based survey.

BACKGROUND: Adolescent girls in humanitarian settings are especially vulnerable as their support systems are often disrupted. More than 20 years of violence in the Democratic Republic of the Congo (DRC) has weakened the health system, resulting in poor sexual and reproductive health (SRH) outcomes for women. Little evidence on adolescent contraceptive use in humanitarian settings is available. CARE, International Rescue Committee (IRC), and Save the Children, in collaboration with the Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative, Columbia University, have supported the Ministry of Health (MOH) since 2011 to provide good quality contraceptive services in public health facilities in conflict-affected North and South Kivu. In this study, we analyzed contraceptive use among sexually active young women aged 15-24 in the health zones served by the partners' programs. METHODS AND FINDINGS: The partners conducted cross-sectional population-based surveys in program areas of North and South Kivu using two-stage cluster sampling in six health zones in July-August 2016 and 2017. Twenty-five clusters were selected in each health zone, 22 households in each cluster, and one woman of reproductive age (15-49 years) was randomly selected in each household. This manuscript presents results from a secondary data analysis for 1,022 women aged 15-24 who reported ever having sex: 326 adolescents (15-19 years) and 696 young women (20-24 years), 31.7% (95% confidence interval [CI] 29.5-34.1), of whom were displaced at least once in the previous five years. Contraceptive knowledge was high, with over 90% of both groups able to name at least one modern contraceptive method. Despite this high knowledge, unmet need for contraception was also high: 31.7% (95%CI 27.9-35.7) among 15-19-year-olds and 40.1% (95% CI 37.1-43.1, p = 0.001) among 20-24-year-olds. Current modern contraceptive use (16.5%, 95% CI 14.7-18.4) was similar in both age groups, the majority of whom received their method from a supported health facility. Among current users, more than half of 15-19-year-olds were using a long-acting reversible contraceptive (LARC; 51.7%, 95% CI 41.1-61.9) compared to 36.5% of 20-24-year-olds (95% CI 29.6-43.9, p = 0.02). Age, younger age of sexual debut, having some secondary education, being unmarried, and having begun childbearing were associated with modern contraceptive use. The main limitations of our study are related to insecurity in three health zones that prevented access to some villages, reducing the representativeness of our data, and our defining sexually active women as those who have ever had sex. CONCLUSIONS: In this study, to our knowledge one of the first to measure contraceptive prevalence among adolescents in a humanitarian setting, we observed that adolescent and young women will use modern contraception, including long-acting methods. Meaningful engagement of adolescent and young women would likely contribute to even better outcomes. Creating an enabling environment by addressing gender and social norms, however, is key to reducing stigma and meeting the demand for contraception of young women. As we continue to build such supportive environments, we can see that they will use effective contraception when contraceptive services, including short- and long-acting methods, are available, even in protracted crisis settings.

Lessons Never Learned: Crisis and gender-based violence.

The COVID-19 pandemic exposes underlying inequalities in our socio-economic and health systems, such as gender-based violence (GBV). In emergencies, particularly ones that involve quarantine, GBV often increases. Policymakers must utilize community expertise, technology and existing global guidelines to disrupt these trends in the early stages of the COVID-19 epidemic. Gender norms and roles relegating women to the realm of care work puts them on the frontlines in an epidemic, while often excluding them from developing the response. It is critical to value women's roles in society and include their voices in the decision-making process to avoid unintended consequences and ensure a comprehensive response that caters to the needs of the most vulnerable groups.