Women's voices and meanings of empowerment for reproductive decisions: a qualitative study in Mozambique.

BACKGROUND: Women in Mozambique are often disempowered when it comes to making decisions concerning their lives, including their bodies and reproductive options. This study aimed to explore the views of women in Mozambique about key elements of empowerment for reproductive decisions and the meanings they attach to these elements. METHODS: Qualitative in-depth interviews were undertaken with 64 women of reproductive age (18-49 years) in two provinces in Mozambique. Participants were recruited through convenience sampling. Data collection took place between February and March 2020 in Maputo city and Province, and during August 2020 in Nampula Province. A thematic analysis was performed. RESULTS: Women described crucial elements of how power is exerted for reproductive choices. These choices include the ability to plan the number and timing of pregnancies and the ability either to negotiate with sexual partners by voicing choice and influencing decisions, or to exercise their right to make decisions independently. They considered that women with empowerment had characteristics such as independence, active participation and being free. These characteristics are recognized key enablers for the process of women's empowerment. CONCLUSIONS: This study's findings contribute to an expanded conceptualization and operationalization of women's sexual and reproductive empowerment by unveiling key elements that need to be considered in future research and approaches to women's empowerment. Furthermore, it gave women the central role and voice in the research of empowerment's conceptualization and measurement where women's views and meanings are seldom considered.

Women who are empowered seem to make better health decisions for themselves. Nevertheless, women's views about and understanding of empowerment are seldom considered in the study of empowerment and its definitions. In this study we explore how women in Mozambique view, understand and experience empowerment, i.e., gaining power and control in the household, and specifically around decision-making processes concerning their reproductive lives. A total of 64 adult women were interviewed in rural and urban areas within two provinces of Mozambique. Through the data analysis, we identified key characteristics of the empowerment process that Mozambican women perceived to be of relevance in their context. Women who have power were perceived as financially and socially independent, free to choose their own pathway, and be active participants in the household decision-making process. In reproductive decisions, women show power through the ability to negotiate with their partner, or by making sole decisions and by planning the number of pregnancies and the size of the family. The elements identified provide important information for improving the definition and the measurement of empowerment in Mozambique, as well as for the support of women in their pathways to empowerment within this context.

A telemedicine model for abortion in South Africa: a randomised, controlled, non-inferiority trial.

BACKGROUND: Telemedicine for medical abortion increases access to safe abortion but its use has not been described in a controlled trial. We aimed to investigate the effectiveness, adherence, safety, and acceptability of a modified telemedicine protocol for abortion compared with standard care in a low-resource setting. METHODS: In this randomised, controlled, non-inferiority trial we recruited women seeking medical abortion at or before 9 gestational weeks at four public health clinics in South Africa. Participants were randomly allocated (1:1) by computer-generated blocks of varying sizes to telemedicine or standard care. The telemedicine group received asynchronous online abortion consultation and instruction, self-assessed gestational duration, and had a uterine palpation as a safety measure. Participants in this group took 200 mg mifepristone and 800 µg misoprostol at home. The standard care group received in-person consultation and instruction together with an ultrasound, took 200 mg mifepristone in clinic and 800 µg misoprostol at home. Our primary outcome was complete abortion after initial treatment, assessed at a 6-week interview. Our non-inferiority margin was 4%. Group differences were assessed by modified intention-to-treat (mITT) analysis and per protocol. The trial is registered at ClinicalTrials.gov, NCT04336358, and the Pan African Clinical Trials Registry, PACTR202004661941593. FINDINGS: Between Feb 28, 2020, and Oct 5, 2021, we enrolled 900 women, 153 (17·0%) of whom were discontinued before the abortion and were not included in the analysis. By mITT analysis, 355 (95·4%) of 372 women in the telemedicine group had a complete abortion compared with 338 (96·6%) of 350 in the standard care group (odds ratio 0·74 [95% CI 0·35 to 1·57]). The risk difference was -1·1% (-4·0 to 1·7). Among women who completed treatment as allocated (per protocol), 327 (95·6%) of 342 women in telemedicine group had complete abortion, compared with 338 (96·6%) of 350 in the standard care group (0·77 [0·36 to 1·68]), with a risk difference of -1·0% (-3·8 to 1·9). One participant (in the telemedicine group) had a ruptured ectopic pregnancy, and a further four participants were admitted to hospital (two in each group), of whom two had blood transfusions (one in each group). INTERPRETATION: Asynchronous online consultation and instruction for medical abortion and home self-medication, with uterine palpation as the only in-person component, was non-inferior to standard care with respect to rates of complete abortion, and did not affect safety, adherence, or satisfaction. FUNDING: Grand Challenges Canada and the Swedish Research Council.

Reproductive awareness and recognition of unintended pregnancy: young women, key informants and health care providers perspectives in South Africa.

BACKGROUND: South Africa has a liberal abortion law, yet denial of care is not uncommon, usually due to a woman being beyond the legal gestational age limit for abortion care at that facility. For women successfully obtaining care, time from last menstrual period to confirmation of pregnancy is significantly longer among those having an abortion later in the second trimester compared to earlier gestations. This study explores women's experiences with recognition and confirmation of unintended pregnancy, their understanding of fertile periods within the menstrual cycle as well as healthcare providers' and policy makers' ideas for public sector strategies to facilitate prompt confirmation of pregnancy. METHODS: We recruited participants from July through September 2017, at an urban non-governmental organization (NGO) sexual and reproductive health (SRH) facility and two public sector hospitals, all providing abortion care into the second trimester. We conducted in-depth interviews and group discussions with 40 women to elicit information regarding pregnancy recognition and confirmation as well as fertility awareness. In addition, 5 providers at these same facilities and 2 provincial policy makers were interviewed. Data were analysed using thematic analysis. RESULTS: Uncertainties regarding pregnancy signs and symptoms greatly impacted on recognition of pregnancy status. Women often mentioned that others, including family, friends, partners or colleagues noticed pregnancy signs and prompted them to take action. Several women were unaware of the fertility window and earliest timing for accurate pregnancy testing. Health care providers and policy makers called for strategies to raise awareness regarding risk and signs of pregnancy and for pregnancy tests to be made more readily accessible. CONCLUSION: Early recognition of unintended pregnancy in this setting is frustrated by poor understanding and awareness of fertility and pregnancy signs and symptoms, compounded by a distrust of commercially available pregnancy tests. Improving community awareness around risk and early signs of pregnancy and having free tests readily available may help women confirm their pregnancy status promptly.

South Africa has one of the world's most progressive legal frameworks for abortion, yet it's not uncommon for women to struggle to access safe abortion services. A key reason for this is late recognition of an unplanned pregnancy. This study explored the lived experiences leading up to pregnancy confirmation among women securing abortion care beyond 9 weeks gestational age, the legal limit for home use of medication for abortion. It fills a gap by also including providers' and policy makers' perspectives on ways to strengthen women's prompt recognition of pregnancy. Using group discussions and in-depth interviews we elicited information from 40 women and 7 providers and policy makers in two health subdistricts in the Western Cape Province, South Africa. Our findings highlight the process of pregnancy recognition and confirmation and women's knowledge of fertility, the menstrual cycle and when to test for pregnancy. Our results suggest that factors influencing women's recognition of pregnancy are at the individual and at community level. Health care providers and policy makers suggested the use of community-based services to raise awareness around early pregnancy testing, and to expand easy access to self-testing outside the formal clinic setting as a mechanism to overcome clinic-based barriers.

Contraceptive needs and fertility intentions of women with breast cancer in Cape Town, South Africa: a qualitative study.

BACKGROUND: No known studies have been undertaken in South Africa exploring the contraceptive and fertility needs and preferences of women of reproductive age (18-49) diagnosed with breast cancer. This study set out to understand the contraceptive needs and fertility intentions of women with breast cancer in Cape Town, South Africa. METHODS: Qualitative in-depth interviews were conducted with 24 women diagnosed with breast cancer and 4 health care providers at a tertiary hospital in Cape Town, South Africa. We explored contraceptive use prior to diagnosis; the impact of breast cancer on future fertility intentions and contraceptive use; understanding of suitable contraceptive methods during and after treatment and women's fertility related counseling needs during their continuum of care. Data were analysed using a thematic analysis approach. RESULTS: Since being diagnosed with breast cancer, of those women using a contraceptive method, the non-hormonal intrauterine device (IUD) was the most commonly used method. However, women reported receiving limited information from health care providers about contraceptive use and future fertility planning post treatment when fertility desires might change. Many women reported limited information received from healthcare providers about the impact of cancer treatment on their future fertility. Most women did not receive information around fertility preservation options, and few were familiar with the concept. Providers focus was more on preventing pregnancy during treatment and ensuring a patient was on a non-hormonal contraceptive method. Providers supported a more holistic, multidisciplinary approach to breast cancer patient's contraceptive and future fertility needs. CONCLUSIONS: Limited contraceptive and future fertility counseling were reported by women despite many women being provided with the IUD. There is a need for improved information and counseling regarding the impact of treatment on contraceptive and fertility options. It is important that cancer care providers provide timely information regarding fertility options and communicate with patients about their fertility concerns prior to treatment and throughout the course of survivorship. The development of evidence-based information tools to enhance patient-provider communication and counseling could address knowledge gaps.

Exploring the feasibility of using mobile phones to improve the management of clients with cervical cancer precursor lesions.

BACKGROUND: Cancer screening programs hold much potential for reducing the cervical cancer disease burden in developing countries. The aim of this study was to determine the feasibility of mobile health (mHealth) phone technology to improve management and follow-up of clients with cervical cancer precursor lesions. METHODS: A sequential mixed methods design was employed for this study. Quantitative data was collected using a cross-sectional survey of 364 women eligible for a Pap smear at public sector health services in Cape Town, South Africa. Information was collected on socio-demographic status; cell phone ownership and patterns of use; knowledge of cervical cancer prevention; and interest in Pap smear results and appointment reminders via SMS-text messages. Descriptive statistics, crude bivariate comparisons and logistic regression models were employed to analyze survey results. Qualitative data was collected through 10 in-depth interviews with primary health care providers and managers involved in cervical cancer screening. Four focus group discussions with 27 women attending a tertiary level colposcopy clinic were also conducted. Themes related to loss of mobile phones, privacy and confidentiality, interest in receiving SMS-text messages, text language and clinic-based management of a SMS system are discussed. Thematic analyses of qualitative data complemented quantitative findings. RESULTS: Phone ownership amongst surveyed women was 98% with phones mostly used for calls and short message service (SMS) functions. Over half (58%) of women reported loss/theft of mobile phones. Overall, there was interest in SMS interventions for receiving Pap smear results and appointment reminders. Reasons for interest, articulated by both providers and clients, included convenience, cost and time-saving benefits and benefits of not taking time off work. However, concerns were expressed around confidentiality of SMS messages, loss/theft of mobile phones, receiving negative results via SMS and accessibility/clarity of language used to convey messages. Responsibility for the management of a clinic-based SMS system was also raised. CONCLUSIONS: Results indicated interest and potential for mHealth interventions in improving follow-up and management of clients with abnormal Pap smears. Health system and privacy issues will need to be addressed for mHealth to achieve this potential. Next steps include piloting of specific SMS messages to test feasibility and acceptability in this setting.

A multidimensional approach to inform family planning needs, preferences and behaviours amongst women in South Africa through body mapping.

BACKGROUND: In recent decades there have been great improvements in the reproductive health of women in low- and middle-income countries and increases in the use of modern contraceptive methods. Nonetheless, many women are not able to access information, contraceptive technologies and services that could facilitate preventing unintended pregnancies and planning the number and timing of desired pregnancies. In South Africa, the contraceptive prevalence rate is 64.6%. However, this relatively high contraceptive prevalence rate masks problems with quality contraceptive service delivery, equitable access, and women's ability to correctly and consistently, use contraceptive methods of their choice. This study set out to understand the specific family planning and contraceptive needs and behaviours of women of reproductive age in South Africa, through a lived experience, multisensory approach. METHODS: Participatory qualitative research methods were used including body mapping workshops amongst reproductive aged women recruited from urban and peri urban areas in the Western Cape South Africa. Data including body map images were analysed using a thematic analysis approach. RESULTS: Women had limited biomedical knowledge of the female reproductive anatomy, conception, fertility and how contraceptives worked, compounded by a lack of contraceptive counseling and support from health care providers. Women's preferences for different contraceptive methods were not based on a single, sensory or experiential factor. Rather, they were made up of a composite of sensory, physical, social and emotional experiences underscored by potential for threats to bodily harm. CONCLUSIONS: This study highlighted the need to address communication and knowledge gaps around the female reproductive anatomy, different contraceptive methods and how contraception works to prevent a pregnancy. Women, including younger women, identified sexual and reproductive health knowledge gaps themselves and identified these gaps as important factors that influenced uptake and effective contraceptive use. These knowledge gaps were overwhelmingly linked to poor or absent communication and counseling provided by health care providers. Body mapping techniques could be used in education and communication strategies around sexual and reproductive health programmes in diverse settings.

From symptom discovery to treatment - women's pathways to breast cancer care: a cross-sectional study.

BACKGROUND: Typically, women in South Africa (SA) are diagnosed with breast cancer when they self-present with symptoms to health facilities. The aim of this study was to determine the pathway that women follow to breast cancer care and factors associated with this journey. METHODS: A cross-sectional study was conducted at a tertiary hospital in the Western Cape Province, SA, between May 2015 and May 2016. Newly diagnosed breast cancer patients were interviewed to determine their socio-demographic profile; knowledge of risk factors, signs and symptoms; appraisal of breast changes; clinical profile and; key time events in the journey to care. The Model of Pathways to Treatment Framework underpinned the analysis. The total time (TT) between a woman noticing the first breast change and the date of scheduled treatment was divided into 3 intervals: the patient interval (PI); the diagnostic interval (DI) and the pre-treatment interval (PTI). For the PI, DI and PTI a bivariate comparison of median time intervals by various characteristics was conducted using Wilcoxon rank-sum and Kruskal-Wallis tests. Cox Proportional-Hazards models were used to identify factors independently associated with the PI, DI and PTI. RESULTS: The median age of the 201 participants was 54 years, and 22% presented with late stage disease. The median TT was 110 days, with median patient, diagnostic and pre-treatment intervals of 23, 28 and 37 days respectively. Factors associated with the PI were: older age (Hazard ratio (HR) 0.59, 95% CI 0.40-0.86), initial symptom denial (HR 0.43, 95% CI 0.19-0.97) and waiting for a lump to increase in size before seeking care (HR 0.51, 95% CI 0.33-0.77). Women with co-morbidities had a significantly longer DI (HR 0.67, 95% CI 0.47-0.96) as did women who mentioned denial of initial breast symptoms (HR 4.61, 95% CI 1.80-11.78). The PTI was associated with late stage disease at presentation (HR 1.78, 95% CI 1.15-2.76). CONCLUSION: The Model of Pathways to Treatment provides a useful framework to explore patient's journeys to care and identified opportunities for targeted interventions.

Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study.

BACKGROUND: The requirement for ultrasound to establish gestational age among women seeking abortion can be a barrier to access. Last menstrual period dating without clinical examination should be a reasonable alternative among selected women, and if reliable, can be task-shared with non-clinicians. This study determines the accuracy of gestational age estimation using last menstrual period (LMP) assessed by community health care workers (CHWs), and explores providers' and CHWs' perspectives on task sharing this activity. The study purpose is to expand access to early medical abortion services. METHODS: We conducted a multi-center cross-sectional study at four urban non-governmental reproductive health clinics in South Africa. CHWs interviewed women seeking abortion, recorded their LMP and gestational age from a pregnancy wheel if within 63 days. Thereafter, providers performed a standard examination including ultrasound to determine gestational age. Lastly, investigators calculated gestational age for all LMP dates recorded by CHWs. We compared mean gestational age from LMP dates to mean gestational age by ultrasound using t-tests and calculated proportions for those incorrectly assessed as eligible for medical abortion from LMP. In addition, in-depth interviews were conducted with six providers and seven CHWs. RESULTS: Mean gestational age was 5 days (by pregnancy wheel) and 9 days (by LMP calculation) less than ultrasound gestational age. Twelve percent of women were eligible for medical abortion by LMP calculation but ineligible by ultrasound. Uncertainty of LMP date was associated with incorrect assessment of gestational age eligibility for medical abortion (p = 0.015). For women certain their LMP date was within 56 days, 3% had ultrasound gestational ages >70 days. In general, providers and CHWs were in favour of task sharing screening and referral for abortion, but were doubtful that women reported accurate LMP dates. Different perspectives emerged on how to implement task sharing gestational age eligibility for medical abortion. CONCLUSIONS: If LMP recall is within 56 days, most women will be eligible for early medical abortion and LMP can substitute for ultrasound dating. Task sharing gestational age estimation is feasible in South Africa, but its implementation should meet women's privacy needs and address healthcare workers' concerns on managing any procedural risk.

Coming of age? Women's sexual and reproductive health after twenty-one years of democracy in South Africa.

This paper is a sequel to a 2004 article that reviewed South Africa's introduction of new sexual and reproductive health (SRH) and rights laws, policies and programmes, a decade into democracy. Similarly to the previous article, this paper focuses on key areas of women's SRH: contraception and fertility, abortion, maternal health, HIV, cervical and breast cancer and sexual violence. In the last decade, South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion, contraception, youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions, AIDS deaths and vertical HIV transmission, as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However, persistent socio-economic inequities and gender inequality continue to profoundly affect South African women's SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes, and in confronting and ameliorating social norms that undermine SRHR.

Self-assessment of eligibility for early medical abortion using m-Health to calculate gestational age in Cape Town, South Africa: a feasibility pilot study.

BACKGROUND: Although abortion is legally available in South Africa, barriers to access exist. Early medical abortion is available to women with a gestational age up to 63 days and timely access is essential. This study aimed to determine women's acceptability and ability to self-assess eligibility for early medical abortion using an online gestational age calculator. Women's acceptability, views and preferences of using mobile technology for gestational age (GA) determination were explored. No previous studies to ascertain the accuracy of online self-administered calculators in a non-clinical setting have been conducted. METHODS: A convenience sample of abortion seekers were recruited from two health care clinics in Cape Town, South Africa in 2014. Seventy-eight women were enrolled and tasked with completing an online self-assessment by entering the first day of their last menstrual period (LMP) onto a website which calculated their GA. A short survey explored the feasibility and acceptability of employing m-Health technology in abortion services. Self-calculated GA was compared with ultrasound gestational age obtained from clinical records. RESULTS: Participant mean age was 28 (SD 6.8), 41% (32/78) had completed high school and 73% (57/78) reported owning a smart/feature phone. Internet searches for abortion information prior to clinic visit were undertaken by 19/78 (24%) women. Most participants found the online GA calculator easy to use (91%; 71/78); thought the calculation was accurate (86%; 67/78) and that it would be helpful when considering an abortion (94%; 73/78). Eighty-three percent (65/78) reported regular periods and recalled their LMP (71%; 55/78). On average women overestimated GA by 0.5 days (SD 14.5) and first sought an abortion 10 days (SD 14.3) after pregnancy confirmation. CONCLUSIONS: Timely access to information is an essential component of effective abortion services. Advances in the availability of mobile technology represent an opportunity to provide accurate and safe abortion information and services. Our findings indicate that an online GA calculator would be accurate and helpful. GA could be calculated based on LMP recall within an error of 0.5 days, which is not considered clinically significant. An online GA calculator could potentially act as an enabler for women to access safe abortion services sooner.

Assessment of completion of early medical abortion using a text questionnaire on mobile phones compared to a self-administered paper questionnaire among women attending four clinics, Cape Town, South Africa.

In-clinic follow-up to assess completion of medical abortion is no longer a requirement according to World Health Organization guidance, provided adequate counselling is given. However, timely recognition of ongoing pregnancy, complications or incomplete abortion, which require treatment, is important. As part of a larger trial, this study aimed to establish whether women having a medical abortion could self-assess whether their abortion was complete using an automated, interactive questionnaire on their mobile phones. All 469 participants received standard abortion care and all returnees filled in a self-assessment on paper at clinic follow-up 2-3 weeks later. The 234 women allocated to receive the phone messages were also asked to do a mobile phone assessment at home ten days post-misoprostol. Completion of the mobile assessment was tracked by computer and all completed assessments, paper and mobile, were compared to providers' assessments at clinic follow-up. Of the 226 women able to access the mobile phone assessment, 176 (78%) completed it; 161 of them (93%) reported it was easy to do so. Neither mobile nor paper self-assessments predicted all cases needing additional treatment at follow-up. Prediction of complete procedures was good; 71% of mobile assessments and 91% of paper assessments were accurate. We conclude that an interactive questionnaire assessing completion of medical abortion on mobile phones is feasible in the South African setting; however, it should be done later than day 10 and combined with an appropriate pregnancy test to accurately detect incomplete procedures.

Expanding contraceptive options for PMTCT clients: a mixed methods implementation study in Cape Town, South Africa.

BACKGROUND: Clients of prevention of mother-to-child transmission (PMTCT) services in South Africa who use contraception following childbirth rely primarily on short-acting methods like condoms, pills, and injectables, even when they desire no future pregnancies. Evidence is needed on strategies for expanding contraceptive options for postpartum PMTCT clients to include long-acting and permanent methods. METHODS: We examined the process of expanding contraceptive options in five health centers in Cape Town providing services to HIV-positive women. Maternal/child health service providers received training and coaching to strengthen contraceptive counseling for postpartum women, including PMTCT clients. Training and supplies were introduced to strengthen intrauterine device (IUD) services, and referral mechanisms for female sterilization were reinforced. We conducted interviews with separate samples of postpartum PMTCT clients (265 pre-intervention and 266 post-intervention) to assess knowledge and behaviors regarding postpartum contraception. The process of implementing the intervention was evaluated through systematic documentation and interpretation using an intervention tracking tool. In-depth interviews with providers who participated in study-sponsored training were conducted to assess their attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients. RESULTS: Following the intervention, 6% of interviewed PMTCT clients had the desired knowledge about the IUD and 23% had the desired knowledge about female sterilization. At both pre- and post-intervention, 7% of clients were sterilized and IUD use was negligible; by comparison, 75% of clients used injectables. Intervention tracking and in-depth interviews with providers revealed intervention shortcomings and health system constraints explaining the failure to produce intended effects. CONCLUSIONS: The intervention failed to improve PMTCT clients' knowledge about the IUD and sterilization or to increase use of those methods. To address the family planning needs of postpartum PMTCT clients in a way that is consistent with their fertility desires, services must expand the range of contraceptive options to include long-acting and permanent methods. In turn, to ensure consistent access to high quality family planning services that are effectively linked to HIV services, attention must also be focused on resolving underlying health system constraints weakening health service delivery more generally.

Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: a cross-sectional study.

BACKGROUND: The prevention of unintended pregnancies among HIV positive women is a neglected strategy in the fight against HIV/AIDS. Women who want to avoid unintended pregnancies can do this by using a modern contraceptive method. Contraceptive choice, in particular the use of long acting and permanent methods (LAPMs), is poorly understood among HIV-positive women. This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the IUD and female sterilization by HIV-status in a high HIV prevalence setting, Cape Town, South Africa. METHODS: A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV positive and 273 HIV-negative postpartum women in Cape Town. Contraceptive use, reproductive history and the future fertility intentions of postpartum women were compared using chi-squared tests, Wilcoxon rank-sum and Fisher's exact tests where appropriate. Women's knowledge and attitudes towards long acting and permanent methods as well as factors that influence women's choice in contraception were examined. RESULTS: The majority of women reported that their most recent pregnancy was unplanned (61.6% HIV positive and 63.2% HIV negative). Current use of contraception was high with no difference by HIV status (89.8% HIV positive and 89% HIV negative). Most women were using short acting methods, primarily the 3-monthly injectable (Depo Provera). Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using long acting and permanent methods, all of whom were using sterilization; however, it was found that poor knowledge regarding LAPMs is likely to be contributing to the poor uptake of these methods. CONCLUSIONS: Improving contraceptive counselling to include LAPM and strengthening services for these methods are warranted in this setting for all women regardless of HIV status. These study results confirm that strategies focusing on increasing users' knowledge about LAPM are needed to encourage uptake of these methods and to meet women's needs for an expanded range of contraceptives which will aid in preventing unintended pregnancies. Given that HIV positive women were found to be more favourable to future use of the IUD it is possible that there may be more uptake of the IUD amongst these women.

How women's empowerment influences fertility-related outcomes and contraceptive practices: A cross-sectional study in Mozambique.

Women's empowerment could be a crucial step for tackling gender inequality and improve women's reproductive health and rights in Mozambique. This study aims to examine how different domains of women's empowerment influence fertility-related outcomes and contraceptive practices in Mozambique. We used the 2015 Demographic Health Survey (DHS) conducted in Mozambique from which a sample of 2072 women aged 15 to 49 years were selected and included in this analysis. A principal component analysis was performed, and the components retained were identified as the domains of empowerment. These were: Beliefs about violence against women, Decision-making, and Control over sexuality and safe sex. A multinomial logistic regression was run to estimate the association between levels of empowerment for each domain and the study outcomes. Crude and adjusted odds ratio (OR) were calculated, with 95% confidence intervals (95% CI). Beliefs about violence against women and Control over sexuality and safe sex were positively associated with having 1 to 4 children. Control over sexuality and safe sex also increased likelihood of women wanting to space childbearing over more than 2 years. Decision-making increased the odds of women not wanting more children. Middle to high empowerment levels for Control over sexuality and safe sex also increased the chances of using any type of contraceptive method and using it for longer periods. All domains, from the middle to high levels of empowerment, decreased the chances of women not wanting to use contraception. Our study confirmed the multidimensional nature of empowerment showing that each domain had a different effect over specific fertility and contraceptive outcomes and reinforced the importance of a domain approach for estimating and understanding empowerment. It also revealed the critical role of Control over sexuality and safe sex domain for improving women's ability to decide over fertility and contraceptive practices in Mozambique.

Could routine pregnancy self-testing facilitate earlier recognition of unintended pregnancy? A feasibility study among South African women.

INTRODUCTION: We explored whether routine pregnancy self-testing is feasible and acceptable to women at risk of late recognition of pregnancy as a strategy to facilitate early entry into either antenatal or abortion care. METHODS: A feasibility study among South African sexually active women not desiring pregnancy within 1 year, and not using long-acting or injectable contraceptives. At recruitment, we provided five free urine pregnancy tests for self-testing on the first day of each of the next 3 months. We sent monthly text reminders to use the tests with requests for no-cost text replies. Our main outcome was the proportion of participants self-testing within 5 days of the text reminder over three consecutive months. Other outcomes were ease of use of tests, preference for self-testing versus clinic testing, acceptability of routine self-testing (all binary responses followed by open response options) and response to text messages (four-point Likert scale). RESULTS: We followed up 71/76 (93%) participants. Two confirmed new pregnancies at the first scheduled test and completed exit interviews, and 64/69 (93%) self-reported completing all three monthly tests. Self-testing was easy to do (66/71, 93%); advantages were convenience (21/71, 30%) and privacy (18/71, 25%), while the main disadvantage was no nurse present to advise (17/71, 24%). Most would recommend monthly testing (70/71, 99%). Text reminders were generally not bothersome (57/71, 80%); 35/69 (51%) participants replied with test results over all three months. CONCLUSION: Providing free pregnancy tests to women at risk of late recognition of pregnancy is feasible to strengthen early confirmation of pregnancy status.

Immediate versus delayed insertion of the copper intrauterine device after medical abortion at 17-20 gestational weeks: a randomised controlled trial.

INTRODUCTION: This trial reports on use of the copper intrauterine device (IUD) after immediate compared with delayed insertion following medical abortion at 17-20 gestational weeks (GW). METHODS: This randomised controlled trial was conducted at one tertiary hospital and five community healthcare centres in Cape Town, South Africa. Eligible consenting women were randomised to immediate (within 24 hours) or delayed (3 weeks post-abortion) insertion of the copper IUD. Follow-up was at 6 weeks, 3 months and 6 months. Main outcomes were use of the original IUD and use of any IUD, including replacement IUDs at 6 weeks post-abortion. Secondary outcomes included rates of expulsion and malposition at 6 weeks, use of any IUD at 3 and 6 months, and acceptability of the IUD. RESULTS: We recruited and randomised 114 women admitted for elective medical abortion between August 2018 and June 2019. In the immediate and delayed study arms, respectively, 45/55 (82%) and 12/57 (21%) women received the IUD as planned. By intention-to-treat, 56% in the immediate and 19% in the delayed arms were using the original IUD at 6 weeks (p<0.001), and 76% in the immediate and 40% in the delayed arms were using any IUD (p<0.001). Complete expulsion or removal occurred in 32% in the immediate and 7% in the delayed arms (p=0.044). CONCLUSIONS: Insertion of an IUD immediately after medical abortion at 17-20 GW results in increased use after 6 weeks compared with delayed insertion, however expulsion rates are higher than with interval insertion. CLINICAL TRIALS REGISTRATION: NCT03505047), Pan African Trials Registry (www.pactr.org), 201804003324963.

"There Are Things We Can Do and There Are Things We Cannot Do." A Qualitative Study About Women's Perceptions on Empowerment in Relation to Fertility Intentions and Family Planning Practices in Mozambique.

Introduction: The restrictive socio-cultural norms in Mozambique limit the power of women to decide, voice, and act on their reproductive choices. This study aimed to explore women's perceptions and experiences of empowerment relating to fertility intentions and family planning practices in Mozambique, focusing on facilitators and barriers toward reproductive empowerment. Methods: Qualitative in-depth interviews were undertaken with women of reproductive age (18-49 years) in Nampula and Maputo provinces and Maputo city, Mozambique. Data collection took place between February and March 2020 in Maputo region and during August 2020 in Nampula Province. Convenience sampling was used to recruit participants from both urban and rural healthcare facilities and from within the communities serving the healthcare facilities. In Maputo city, a snowball sampling technique was used to recruit women from the community. A total of 64 women were interviewed, 39 from Maputo and 25 from Nampula. A thematic analysis was conducted with the support of NVivo12 software. Results: Several factors that hinder and facilitate women's empowerment toward fertility and family planning practices in Mozambique were identified and were interpreted within the socio-ecological model. The identified barriers included women's lack of critical consciousness and oppressive relationships. At the community and societal levels, the role of traditions, culture and gender expectations and limited access to family planning and misinformation were also important hindering factors. The facilitators of reproductive empowerment included building critical consciousness and access to economic resources at the individual level. Negative experiences at the household level were triggers of women's empowerment for family planning. Building collective power and access to information, including education, were key at the community and societal levels. Conclusions: This study identified various factors that positively or negatively influence women's empowerment journeys in Mozambique. The role of tradition, culture, and gender expectations, and oppressive relationships, were important barriers in both provinces. Women from rural areas would benefit from building of consciousness about their rights, and power to decide on their reproductive lives. Interactions with the health providers offer an opportunity to do this by favoring controlling behaviors concerning their reproductive lives, promoting social networking and levering collective power.

Surgical and medical second trimester abortion in South Africa: a cross-sectional study.

BACKGROUND: A high percentage of abortions performed in South Africa are in the second trimester. However, little research focuses on women's experiences seeking second trimester abortion or the efficacy and safety of these services.The objectives are to document clinical and acceptability outcomes of second trimester medical and surgical abortion as performed at public hospitals in the Western Cape Province. METHODS: We performed a cross-sectional study of women undergoing abortion at 12.1-20.9 weeks at five hospitals in Western Cape Province, South Africa in 2008. Two hundred and twenty women underwent D&E with misoprostol cervical priming, and 84 underwent induction with misoprostol alone. Information was obtained about the procedure and immediate complications, and women were interviewed after recovery. RESULTS: Median gestational age at abortion was earlier for D&E clients compared to induction (16.0 weeks vs. 18.1 weeks, p < 0.001). D&E clients reported shorter intervals between first clinic visit and abortion (median 17 vs. 30 days, p < 0.001). D&E was more effective than induction (99.5% vs. 50.0% of cases completed on-site without unplanned surgical procedure, p < 0.001). Although immediate complications were similar (43.8% D&E vs. 52.4% induction), all three major complications occurred with induction. Early fetal expulsion occurred in 43.3% of D&E cases. While D&E clients reported higher pain levels and emotional discomfort, most women were satisfied with their experience. CONCLUSIONS: As currently performed in South Africa, second trimester abortions by D&E were more effective than induction procedures, required shorter hospital stay, had fewer major immediate complications and were associated with shorter delays accessing care. Both services can be improved by implementing evidence-based protocols.

Socio-economic, demographic, and behavioural determinants of women's empowerment in Mozambique.

INTRODUCTION: Empowerment is considered pivotal for how women access and use health care services and experience their sexual and reproductive rights. In Mozambique, women's empowerment requires a better understanding and contextualization, including looking at factors that could drive empowerment in that context. This study aims to identify socioeconomic, demographic, and behavioural determinants of different domains of women's empowerment in Mozambique. METHODS: Using the Demographic and Health Survey (DHS) conducted in 2015 for Mozambique, a sample of 2072 women aged between 15 and 49 years old were included in this study. The DHS's indicators of women's empowerment were used in a principal component analysis and the obtained components were identified as the domains of empowerment. Logistic regressions were run to estimate the association of socioeconomic, demographic, and behavioural characteristics with each domain of empowerment. Crude and adjusted odds ratios (OR) and respective 95% confidence intervals (95% CI) were calculated. RESULTS: Three domains of women's empowerment were identified, namely (1) Beliefs about violence against women, (2) Decision-making, and (3) Control over sexuality and safe sex. Region, rurality, the experience of intimate partner violence (IPV) and partner's controlling behaviours were associated with Beliefs about violence against women, while Decision-making and Control over sexuality and safe sex were also associated with education, age and wealth. Employment, polygamous marriage and religion was positively associated with Decision-making, and access to media increased the odds of Control over sexuality and safe sex. CONCLUSION: Women's empowerment seems to be determined by different socio-economic, demographic, and behavioural factors and this seems to be closely related to different domains of empowerment identified. This finding affirms the multi-dimensionality of empowerment as well as the importance of considering the context- and community-specific characteristics.

Anticipated help seeking behaviour and barriers to seeking care for possible breast and cervical cancer symptoms in Uganda and South Africa.

OBJECTIVES: Breast and cervical cancers are leading causes of cancer morbidity and mortality in sub-Saharan Africa. Most women present with advanced-stage disease and have poor outcomes. This study aimed to describe anticipated help-seeking behaviour for possible breast and cervical cancer symptoms, barriers to accessing health care and factors associated with less timely anticipated help-seeking in urban and rural settings in Uganda and South Africa (SA). METHODS: We conducted a cross-sectional community-based survey between August and December 2018. Data were collected from one randomly selected woman per household using the African Women Awareness of CANcer breast and cervical cancer tool. Anticipated help-seeking behaviour was dichotomised into waiting <1week or ≥1 week to seek care. Multivariable analysis identified factors associated with anticipated help-seeking behaviour. RESULTS: One thousand, seven hundred fifty-eight women participated (Uganda 873, SA 885, median age 34, interquartile ranges 26-47). Most would discuss symptoms with someone close to them (87.7% for breast, 83.0% for cervical symptoms). The majority anticipated seeking care from a health facility in <1 week: 86.1% and 88.0%, respectively, for breast and cervical symptoms. 38.7% of women expected to encounter at least 1 barrier when seeking care. Lack of money for transport or clinic costs was the most common barrier (24.6% of participants). For both cancers and in both countries, women who reported more barriers were significantly less likely to anticipate seeking timely care. In SA, rural location was also associated with longer anticipated time to seek care, adjusted prevalence ratio (aPR) 2.92, 95% confidence interval (CI) 1.48-5.76 and aPR 2.42, 95% CI 1.08-5.45 for breast and cervical cancer, respectively. CONCLUSION: Interventions that improve community level cancer knowledge and highlight the importance of prompt help-seeking for possible symptoms are important to promote timely care seeking. In addition, addressing financial barriers by reducing transport and clinic costs and tackling geographical inequities in access to care could support women in seeking timely care for possible symptoms.