A survey of health care practitioners' attitudes toward shared decision-making for choice of next birth after cesarean.

BACKGROUND: Patients with a history of cesarean may benefit from shared decision-making (SDM) interventions, such as patient decision aids, that provide individualized clinical information and help to clarify personal preferences. We sought to understand the factors that influence how care practitioners support choices for mode of birth and what individual and health system factors influence uptake of SDM in routine care. METHODS: We conducted a cross-sectional survey of health care practitioners in British Columbia, Canada (2016-2017). Participants included family physicians, midwives, obstetricians, and registered nurses. We conducted descriptive and inferential analyses of quantitative data and subjected the open-ended survey responses to thematic analysis. RESULTS: Analysis of survey responses (n = 307) suggested there was no significant association between the size of the participant hospital and their medico-legal concerns about mode of birth. Environmental factors that may influence the use of SDM included the length of time it takes to initiate an emergency cesarean and the timing of when the SDM intervention is introduced to the patient. No participants reported protocols prohibiting VBAC at their hospital. Participants preferred an SDM approach where the pregnant person is involved in making the final decision for mode of birth. CONCLUSIONS: Although maternity care practitioners express attitudes and behaviors that may support SDM for mode of birth after cesarean, implementing SDM using a patient decision aid alone may be challenging because of environmental factors. Our study demonstrates how survey data can aid in identifying how, when, where, for whom, and why an SDM intervention could be implemented.

Cannabis Use in Pregnancy in British Columbia and Selected Birth Outcomes.

OBJECTIVE: This study sought to determine the association between cannabis use in pregnancy and stillbirth, small for gestational age (SGA) (<10th percentile), and spontaneous preterm birth (<37 weeks). METHODS: The study used abstracted obstetrical and neonatal medical records for deliveries in British Columbia from April 1, 2008 to March 31, 2016 that were contained in the Perinatal Data Registry of Perinatal Services British Columbia. Chi-square tests were conducted to compare maternal sociodemographic characteristics by cannabis use. Logistic regression was conducted to determine the association between cannabis use and SGA and spontaneous preterm births. Cox proportional hazards regression modelling was used to identify the association between cannabis use and stillbirth. Secondary analyses were conducted to ascertain differences by timing of stillbirth (Canadian Task Force Classification II-2). RESULTS: Maternal cannabis use has increased in British Columbia over the past decade. Pregnant women who use cannabis are younger and more likely to use alcohol, tobacco, and illicit substances and to have a history of mental illness. Using cannabis in pregnancy was associated with a 47% increased risk of SGA (adjusted OR 1.47; 95% CI 1.33-1.61), a 27% increased risk of spontaneous preterm birth (adjusted OR 1.27; 95% CI 1.14-1.42), and a 184% increased risk of intrapartum stillbirth (adjusted HR [aHR] 2.84; 95% CI 1.18-6.82). The association between cannabis use in pregnancy and overall stillbirth and antepartum stillbirth did not reach statistical significance, but it had comparable point estimates to other outcomes (aHR 1.38; 95% CI 0.95-1.99 and aHR 1.34; 95% CI 0.88-2.06, respectively). CONCLUSION: Cannabis use in pregnancy is associated with SGA, spontaneous preterm birth, and intrapartum stillbirth.

A qualitative study on factors that influence women's choice of delivery in health facilities in Addis Ababa, Ethiopia.

BACKGROUND: Facility based delivery for mothers is one of the proven interventions to reduce maternal and neonatal morbidity and mortality. This study identified women's reasons for seeking to give birth in a health facility and captured their perceptions of the quality of care they received during their most recent birth, in a population with high utilization of facility based deliveries. METHODS: This qualitative study was conducted in eight health centers in Addis Ababa. Women bringing their index child for first vaccinations were invited to participate in an in-depth interview about their last delivery. Sixteen in-depth interviews were conducted. Interviews were conducted by trained researchers using a semi-structured interview guide. The data were transcribed verbatim in Amharic and translated into English. A thematic analysis was conducted to answer specific study questions. RESULTS: All research participants expressed a preference for facility based delivery because of their awareness of obstetric complications, and related perceptions that facility-birth is safer for the mother and child. Dimensions of quality of care and the cost of services were identified as influencing decisions about whether to seek care in the public or private sector. Media campaigns, information from social networks and women's experiences with healthcare providers and facilities influenced care-seeking decisions. CONCLUSIONS: The universal preference for facility-based birth by women in this study indicates that, in Addis Ababa, facility based delivery has become a preferred norm. Sources of information for decision-making and the dimensions of quality prioritized by women should be taken into account to develop interventions to promote facility-based births in other settings.

Barriers to providing quality emergency obstetric care in Addis Ababa, Ethiopia: Healthcare providers' perspectives on training, referrals and supervision, a mixed methods study.

BACKGROUND: Increasing women's access to and use of facilities for childbirth is a critical national strategy to improve maternal health outcomes in Ethiopia; however coverage alone is not enough as the quality of emergency obstetric services affects maternal mortality and morbidity. Addis Ababa has a much higher proportion of facility-based births (82%) than the national average (11%), but timely provision of quality emergency obstetric care remains a significant challenge for reducing maternal mortality and improving maternal health. The purpose of this study was to assess barriers to the provision of emergency obstetric care in Addis Ababa from the perspective of healthcare providers by analyzing three factors: implementation of national referral guidelines, staff training, and staff supervision. METHODS: A mixed methods approach was used to assess barriers to quality emergency obstetric care. Qualitative analyses included twenty-nine, semi-structured, key informant interviews with providers from an urban referral network consisting of a hospital and seven health centers. Quantitative survey data were collected from 111 providers, 80% (111/138) of those providing maternal health services in the same referral network. RESULTS: Respondents identified a lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient pre-service and in-service training, and absence of supportive supervision as key barriers to provision of quality emergency obstetric care. CONCLUSIONS: Dedicated transportation and communication infrastructure, improvements in pre-service and in-service training, and supportive supervision are needed to maximize the effective use of existing human resources and infrastructure, thus increasing access to and the provision of timely, high quality emergency obstetric care in Addis Ababa, Ethiopia.

Critical maternal health knowledge gaps in low- and middle-income countries for the post-2015 era.

Effective interventions to promote maternal health and address obstetric complications exist, however 800 women die every day during pregnancy and childbirth from largely preventable causes and more than 90% of these deaths occur in low and middle income countries (LMIC). In 2014, the Maternal Health Task Force consulted 26 global maternal health researchers to identify persistent and critical knowledge gaps to be filled to reduce maternal morbidity and mortality and improve maternal health. The vision of maternal health articulated was comprehensive and priorities for knowledge generation encompassed improving the availability, accessibility, acceptability, and quality of institutional labor and delivery services and other effective interventions, such as contraception and safe abortion services. Respondents emphasized the need for health systems research to identify models that can deliver what is known to be effective to prevent and treat the main causes of maternal death at scale in different contexts and to sustain coverage and quality over time. Researchers also emphasized the development of tools to measure quality of care and promote ongoing quality improvement at the facility, district, and national level. Knowledge generation to improve distribution and retention of healthcare workers, facilitate task shifting, develop and evaluate training models to improve "hands-on" skills and promote evidence-based practice, and increase managerial capacity at different levels of the health system were also prioritized. Interviewees noted that attitudes, behavior, and power relationships between health professionals and within institutions must be transformed to achieve coverage of high-quality maternal health services in LMIC. The increasing burden of non-communicable diseases, urbanization, and the persistence of social and economic inequality were identified as emerging challenges that require knowledge generation to improve health system responses and evaluate progress. Respondents emphasized evaluating effectiveness, feasibility, and equity impacts of health system interventions. A prominent role for implementation science, evidence for policy advocacy, and interdisciplinary collaboration were identified as critical areas for knowledge generation to improve maternal health in the post-2015 era.

[Inconsistent condom use among Mexican women living with HIV: a challenge for health services]. / El uso inconsistente del condón en mujeres mexicanas que viven con VIH: un reto para los servicios de salud.

OBJECTIVE: To describe condom use among Mexican women living with HIV and analyze factors that facilitate or impede its utilization. MATERIALS AND METHODS: Qualitative analysis of 55 interviews with women of reproductive age living with HIV. RESULTS: Inconsistent condom use and non-use at last sexual intercourse was common, and not clearly related to the male partners' HIV-status. Factors that influenced condom use included perceptions of health benefits, symbolic meaning assigned to the condom within the relationship, and the transformation or persistence of inequitable gender norms. CONCLUSIONS: Gender norms and male partners' attitudes strongly influence condom use among women living with HIV. To increase consistent condom use the health system must implement counseling and service delivery with a gender perspective and innovative actions to involve male partners.

Falling short of universal access to reproductive health: unintended pregnancy and contraceptive use among Mexican women with HIV.

A favourable context for women with HIV to prevent unintended pregnancy is a cornerstone of reproductive rights and will contribute to achieving universal access to reproductive health, a Millennium Development Goal target. This analysis explores the reproductive trajectories of Mexican women with HIV post-diagnosis and their access to reproductive counselling and use of contraceptives. In-depth interviews and short surveys were conducted with women of reproductive age living with HIV. Results indicate that sexual and reproductive health counselling in HIV care focuses on the male condom and does not routinely address reproductive desires or provide information about or access to other contraceptive methods. Unintended pregnancies result from inconsistent condom use and condom breakage. Women experienced discriminatory denial of and pressure to accept particular contraceptive methods because of their HIV status. Mexican women with HIV are not enjoying their constitutionally guaranteed right to freely choose the number and spacing of their children. Mexico's commitment to reproductive rights and the Popular Health Insurance offer policy and financial frameworks for providing family planning services in public HIV clinics. To ensure respectful implementation, rights-based training for HIV healthcare providers and careful monitoring and evaluation will be needed.

Canadian Newspapers Support Mifepristone Medication Abortion to Improve Fulfillment of the AAAQ Right to Health Framework (2015-2019).

BACKGROUND: In 2015, mifepristone in combination with misoprostol, the international gold standard for medication abortion, was approved for use in Canada. By 2019, all Canadian provinces had included the medication as a publicly insured health benefit. METHODS: Our content analysis of Canadian newspaper coverage describes arguments in favor of or against medication abortion and the evolving regulatory framework for mifepristone from 6 months before regulatory approval until the last significant regulatory barrier to use was removed (2015-2019). RESULTS: Our study found an exceptionally high level of support for the approval of, introduction of, and removal of regulatory barriers to mifepristone for medication abortion. Of 402 pieces, 67% were pro-medication abortion, 25% presented balanced or neutral coverage, and only 8% presented solely anti-medication abortion viewpoints. Of the 761 individuals quoted, more than 90% made positive or neutral statements about medication abortion. Most pieces discussed medication abortion as a health issue and described how liberalization of the regulatory framework would improve abortion availability (68%), accessibility (87%), acceptability (34%), and quality (28%). CONCLUSIONS: Rather than formal balance, which presents contrasting arguments as equally valid even when the scientific evidence for one vastly outweighs the other, our study identified evidentiary balance, in which coverage aligned with the weight of evidence and expert opinion. Our results differ from analyses in other high-income countries (United Kingdom, United States) where media outlets frame abortion in relation to morality or electoral politics rather than as a health issue. The Canadian print media presented overwhelmingly favorable arguments toward the expansion of mifepristone medication abortion and framed the introduction and universal coverage of medication abortion as advancing the "Availability, Accessibility, Acceptability, and Quality" (AAAQ) Right to Health Framework that establishes international human rights standards for health information, facilities, goods, and services.

[Exercising sexual and reproductive rights: a qualitative study of heterosexual people with HIV in Mexico]. / El ejercicio de los derechos sexuales y reproductivos: un estudio cualitativo de personas heterosexuales con VIH en México.

OBJECTIVE: To analyze experiences of heterosexual Mexican people living with HIV (PLWHA) related to the exercise of their sexual and reproductive rights. MATERIAL AND METHODS: Qualitative study based on 40 in-depth interviews with PLWHA in four Mexican States. RESULTS: Lack of support and counseling limits the exercise of sexual and reproductive rights by PLWHA, especially women. Principal limitations include feelings of frustration and confusion, fear of re-infection, scanty information, lack of power to negotiate condom use, social stigma and discrimination, and limited access to services and adequate technologies. CONCLUSION: To increase awareness and exercise of rights by PLWHA it is necessary to: improve sexual education; promote processes of cultural change to combat gender inequality and stigma and discrimination; and provide timely and scientific information about HIV prevention.

HIV vulnerability and condom use among migrant women factory workers in Puebla, Mexico.

International migration is associated with increased HIV vulnerability, but little is known about the vulnerability of internal migrants. This qualitative study explored perceptions of HIV and condom use among Mexican migrant female factory workers. Migration and male sexual infidelity contributed to increased HIV vulnerability and unprotected sex was ubiquitous. The dominant cultural discourse that dichotomizes "good" (monogamous) and "bad" (sexually stigmatized) women, and male partner's resistance, were barriers to condom use. Women's positive attitudes toward the dual protection (pregnancy and sexually transmitted infections) offered by condoms and sexual agency expressed by refusing unwanted sexual contact are resources for HIV prevention.

Criminalization of HIV transmission or exposure in eight Latin American countries.

While the prosecution of HIV transmission or exposure has been widely documented in Western Europe and North America, Latin America has not figured in this trend. In this article, based on an oral abstract presentation at AIDS 2010, Tamil Kendall reviews HIV-specific legislation and instances of prosecution in eight countries in the region, and discusses how civil society might respond.

Community Mobilization to Promote and Protect the Sexual and Reproductive Rights of Women Living with HIV in Latin America.

Between 2009 and 2014, the International Community of Women Living with HIV in Latin America and the Mexican feminist civil society organization Balance coordinated a five-country community-led intervention that brought together women living with HIV (WLHIV), trans women, sex workers, and feminist lawyers to document and respond to sexual and reproductive health and rights (SRHR) violations of WLHIV and advocate for legal, policy, and programmatic changes to fulfill SRHR. The experiences of involved community leaders (n=26) indicate that knowledge of national, regional, and international human rights commitments and up-to-date medical information positively influenced personal health behaviors, empowered WLHIV as subject matter experts, and emboldened them to hold duty-bearers to account. The research evidence generated through collective action was critical for legitimating SRHR violations of WLHIV with decision-makers and for positioning the issue in the advocacy agendas of national and regional HIV and women's movements. Collective action contributed to social cohesion among diverse groups of women living with and affected by HIV and increased available technical, financial, and organizational resources and political opportunities by linking organizations and networks. Collectively, community leaders mobilized to influence policy, legal frameworks, and service delivery to promote and protect the SRHR of WLHIV.

Reproductive rights violations reported by Mexican women with HIV.

Demand for reproductive health services by people with HIV is increasing, as is the urgency of protecting and promoting their reproductive rights. The reproductive rights of Mexicans with HIV are formally protected by the constitution and by health and anti-discrimination legislation, as well as by international conventions. However, the reproductive rights of women with HIV continue to be violated in public clinics and hospitals. This paper discusses three violations identified as priority problems by Mexican women with HIV, illustrating these problems with cases identified during a participatory skills building workshop. The violations cover the following rights: the right to non-discrimination, the right to adequate information and informed consent to medical procedures, and the right to choose the number and spacing of children. Physicians can either violate or promote reproductive rights. Unfortunately, in many instances Mexican physicians continue to perpetrate reproductive rights abuses against women with HIV. Collaborations between women with HIV, civil society, government, and international organizations are needed to educate and sanction health care providers and to support women with HIV in their pursuit of reproductive rights. Demanding accountability from health care practitioners and the State to guarantee reproductive rights in countries where these rights are formally protected will improve the quality of life of people with HIV and can demonstrate that rights-based approaches are compatible with and indeed, crucial for public health.

Could implementation of mifepristone address Canada's urban-rural abortion access disparity: a mixed-methods implementation study protocol.

INTRODUCTION: In January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada, (2) assess the impact of a 'community of practice' clinical and health service support platform and (3) engage in and assess the impact of integrated knowledge translation (iKT) activities aimed to improve health policy, systems and service delivery issues to enhance patient access to mifepristone. METHODS AND ANALYSIS: This prospective mixed-methods implementation study will involve a national sample of physicians and pharmacists recruited via an online training programme, professional networks and a purpose-built community of practice website. Surveys that explore constructs related to diffusion of innovation and Godin's behaviour change frameworks will be conducted at baseline and at 6 months, and qualitative data will be collected from electronic interactions on the website. Survey participants and a purposeful sample of decision-makers will be invited to participate in in-depth interviews. Descriptive analyses will be conducted for quantitative data. Thematic analysis guided by the theoretical frameworks will guide interpretation of qualitative data. We will conduct and assess iKT activities involving Canada's leading health system and health professional leaders, including evidence briefs, Geographical Information System (GIS)maps, face-to-face meetings and regular electronic exchanges. Findings will contribute to understanding the mechanisms of iKT relationships and activities that have a meaningful effect on uptake of evidence into policy and practice. ETHICS AND DISSEMINATION: Ethical approval was received from the University of British Columbia Children's and Women's Hospital Ethics Review Board (H16-01006). Full publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to research participants through newsletters and media interviews, and to policy-makers through invited evidence briefs and face-to-face presentations.

[Relationship between physicians and HIV patients: influence on adherence and quality of life]. / Relación entre médicos y pacientes con VIH: influencia en apego terapéutico y calidad de vida.

OBJECTIVE: To assess the influence of the relationship between people living with HIV/AIDS and health care providers on treatment adherence and quality of life. METHODS: Qualitative study conducted in Mexico, in 2003, with informants recruited from HIV/AIDS support groups, non-governmental organizations, and infectious disease clinics in public hospitals. A total of 40 people living with HIV/AIDS and five support group leaders were interviewed. Data were collected using sociodemographic questionnaires and in-depth interviews exploring the experience of living with HIV/AIDS, including treatment, disease perception, quality of life, physical and emotional health, and relationship with physicians. Responses were recorded, transcribed and organized thematically based on codes using an inductive analysis. RESULTS: Most respondents aged between 26 and 45 years. The main obstacles to care were related to lack of risk awareness and information among people living with HIV/AIDS and physicians. Physicians proved not to be well trained on HIV/AIDS care. During the follow-up care, most problems were related to inadequate treatment adherence mainly caused by poor communication with physicians and discrimination in public services. CONCLUSIONS: Overall the problems identified were related to information deficiencies, physicians' lack of training and paternalism, and social stigmatization of people living with HIV/AIDS associated with the epidemic.

Bridging the gap between antiretroviral access and adherence in Mexico.

The goal in this article is to examine social problems associated with highly active antiretroviral therapy (HAART) adherence in Mexico and the related challenges for Mexican persons living with HIV/AIDS (PLWHAs). The study was conducted from the perspective of infected and affected individuals. The authors completed 64 in-depth interviews with heterosexual male and female PLWHAs, as well as with some key individuals from their social network. Following the principles of grounded theory, they carried out inductive analysis to create codes and organize central themes. The authors identified problems related to accessing HAART and found that conditions for implementing recommendations made in the international literature to improve adherence are poor. The findings highlight the importance of social factors, such as health care system irregularities, ineffective physician-patient communication, and availability of family and other sources of social support such as self-help groups for PLWHAs' access and adherence to antiretroviral therapy in Mexico.

Rapid assessment procedures in environmental sanitation research: a case study from the northern border of Mexico.

BACKGROUND: There is a need to enhance the quality and sustainability of environmental health programs in Mexico. What socio-cultural factors influenced the adoption or rejection of Clean Water in Homes programs in this population? We applied rapid appraisal procedures (RAP) to evaluate these community-based programs. METHOD: Qualitative study conducted in communities along Mexico's northern border. We conducted informal dialogues, semi-structured interviews, field notes and observations. Home visits used a checklist to observe: sources of water, handwashing, as well as human waste and garbage disposal patterns. Data analysis was conducted using ATLAS.ti, which facilitated comparison and illustration of discrepancies, the elaboration of emerging issues and relationships between them. RESULTS: Community members perceived that the Clean Water program was a top-down intervention. Water is perceived as a political issue and a matter of corruption. Inequity also limits solidarity activities involved in environmental sanitation. Migration to the United States of America (US) contributes to community fragmentation, which in turn dilutes communal efforts to improve water and sanitation infrastructure. While targeting women as program "recipients", the Clean Water program did not take gendered spheres of decision-making into account. Community members and authorities discussed the main results in "assemblies", particularly addressing the needs of excluded groups. CONCLUSION: The oversight of not exploring community members' needs and priorities prior to program implementation resulted in interventions that did not address the structural (economic, infrastructure) and socio-cultural barriers faced by community members to undertake the health-promoting behaviour change, and provoked resentment.

Male Partner Risk Behaviors Are Associated With Reactive Rapid HIV Antibody Tests Among Pregnant Mexican Women: Implications for Prevention of Vertical and Sexual HIV Transmission in Concentrated HIV Epidemics.

Mexico's policies on antenatal HIV testing are contradictory, and little is known about social and behavioral characteristics that increase pregnant Mexican women's risks of acquiring HIV. We analyzed the association between risk behaviors reported by pregnant women for themselves and their male partners, and women's rapid HIV antibody test results from a large national sample. Three quarters of pregnant women with a reactive test did not report risk behaviors for themselves and one third did not report risk behaviors for themselves or their male partners. In the retrospective case-control analysis, other than reporting multiple sexual partners, reactive pregnant women reported risk behaviors did not differ from nonreactive women's behaviors. However, reactive pregnant women were significantly more likely to have reported risk behaviors for male partners. Our findings support universal offer of antenatal HIV testing and suggest that HIV prevention for women should focus on reducing risk of HIV acquisition within stable relationships.

Experiences of coercion to sterilize and forced sterilization among women living with HIV in Latin America.

INTRODUCTION: Forced and coerced sterilization is an internationally recognized human rights violation reported by women living with HIV (WLHIV) around the globe. Forced sterilization occurs when a person is sterilized without her knowledge or informed consent. Coerced sterilization occurs when misinformation, intimidation tactics, financial incentives or access to health services or employment are used to compel individuals to accept the procedure. METHODS: Drawing on community-based research with 285 WLHIV from four Latin American countries (El Salvador, Honduras, Mexico and Nicaragua), we conduct thematic qualitative analysis of reports of how and when healthcare providers pressured women to sterilize and multivariate logistic regression to assess whether social and economic characteristics and fertility history were associated with pressure to sterilize. RESULTS: A quarter (23%) of the participant WLHIV experienced pressure to sterilize post-diagnosis. WLHIV who had a pregnancy during which they (and their healthcare providers) knew their HIV diagnosis were almost six times more likely to experience coercive or forced sterilization than WLHIV who did not have a pregnancy with a known diagnosis (OR 5.66 CI 95% 2.35-13.58 p≤0.001). WLHIV reported that healthcare providers told them that living with HIV annulled their right to choose the number and spacing of their children and their contraceptive method, employed misinformation about the consequences of a subsequent pregnancy for women's and children's health, and denied medical services needed to prevent vertical (mother-to-child) HIV transmission to coerce women into accepting sterilization. Forced sterilization was practiced during caesarean delivery. CONCLUSIONS: The experiences of WLHIV indicate that HIV-related stigma and discrimination by healthcare providers is a primary driver of coercive and forced sterilization. WLHIV are particularly vulnerable when seeking maternal health services. Health worker training on HIV and reproductive rights, improving counselling on HIV and sexual and reproductive health for WLHIV, providing State mechanisms to investigate and sanction coercive and forced sterilization, and strengthening civil society to increase WLHIV's capacity to resist coercion to sterilize can contribute to preventing coercive and forced sterilization. Improved access to judicial and non-judicial mechanisms to procure justice for women who have experienced reproductive rights violations is also needed.