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1.  The sexual health of pupils in years 4 to 6 of primary schools in rural Tanzania 
Background/objectives: There is an urgent need for effective interventions to improve the sexual and reproductive health of adolescents. Reliable data on the sexual health of adolescents are needed to guide the development of such interventions. The aim was to describe the sexual health of pupils in years 4 to 6 of 121 rural primary schools in north western Tanzania, before the implementation of an innovative sexual health intervention in 58 of the schools.
Methods: A cross sectional survey of primary school pupils in rural Tanzania was carried out. The study population comprised pupils registered in years 4 to 6 of 121 primary schools in 20 rural communities in 1998. Basic demographic information was collected from all pupils seen. Those born before 1 January 1985 (aged approximately 14 years and over) were invited to participate in the survey, and asked about their knowledge and attitudes towards sexual health issues, and their sexual experience. A urine specimen was requested and tested for HIV, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and, for females, pregnancy.
Results: 9283 pupils born before 1 January 1985 were enrolled and provided demographic information and a urine sample. Male pupils were significantly older than females (mean age 15.5 years v 14.8 years, p<0.001), but all other demographic characteristics were similar between the sexes. 14 (0.2%) of the enrolled pupils (four male and 10 female) were HIV positive, 83 (0.9%) were positive for CT, and 12 (0.1%) for NG. 32 female pupils (0.8%) were positive by pregnancy test. Sexual experience was reported by one fifth of primary school girls, and by almost half of boys. Only 45/114 (39%) girls with biological markers of sexual activity reported having had sex.
Conclusions: HIV, CT, NG, and pregnancy were present though at relatively low levels among pupils in years 4 to 6 of primary school. A high proportion of pupils with a biological marker of sexual activity denied ever having had sex. Alternative ways of collecting sensitive data about the sexual behaviour of school pupils should be explored.
doi:10.1136/sti.2003.005413
PMCID: PMC1758384  PMID: 14755033
2.  Effectiveness of community based safe motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania 
Background
In Tanzania, maternal mortality ratio remains unacceptably high at 578/100,000 live births. Despite a high coverage of antenatal care (96%), only 44% of deliveries take place within the formal health services. Still, "Ensure skilled attendant at birth" is acknowledged as one of the most effective interventions to reduce maternal deaths. Exploring the potential of community-based interventions in increasing the utilization of obstetric care, the study aimed at developing, testing and assessing a community-based safe motherhood intervention in Mtwara rural District of Tanzania.
Method
This community-based intervention was designed as a pre-post comparison study, covering 4 villages with a total population of 8300. Intervention activities were implemented by 50 trained safe motherhood promoters (SMPs). Their tasks focused on promoting early and complete antenatal care visits and delivery with a skilled attendant. Data on all 512 deliveries taking place from October 2004 to November 2006 were collected by the SMPs and cross-checked with health service records. In addition 242 respondents were interviewed with respect to knowledge on safe motherhood issues and their perception of the SMP's performance. Skilled delivery attendance was our primary outcome; secondary outcomes included antenatal care attendance and knowledge on Safe Motherhood issues.
Results
Deliveries with skilled attendant significantly increased from 34.1% to 51.4% (ρ < 0.05). Early ANC booking (4 to 16 weeks) rose significantly from 18.7% at baseline to 37.7% in 2005 and 56.9% (ρ < 0.001) at final assessment. After two years 44 (88%) of the SMPs were still active, 79% of pregnant women were visited. Further benefits included the enhancement of male involvement in safe motherhood issues.
Conclusion
The study has demonstrated the effectiveness of community-based safe motherhood intervention in promoting the utilization of obstetric care and a skilled attendant at delivery. This improvement is attributed to the SMPs' home visits and the close collaboration with existing community structures as well as health services.
doi:10.1186/1471-2393-10-14
PMCID: PMC2858713  PMID: 20359341
3.  Behavioural intervention trials for HIV/STD prevention in schools: are they feasible? 
Sexually Transmitted Infections  1998;74(6):405-408.
OBJECTIVE: To assess the feasibility of conducting a large randomised controlled trial (RCT) of peer led intervention in schools to reduce the risk of HIV/STD and promote sexual health. METHODS: Four secondary schools in Greater London were randomly assigned to receive peer led intervention (two experimental schools) or to act as control schools. In the experimental schools, trained volunteers aged 16-17 years (year 12) delivered the peer led intervention to 13-14 year old pupils (year 9). In the control schools, year 9 pupils received the usual teacher led sex education. Questionnaire data collected from year 9 pupils at baseline included views on the quality of sex education/intervention received, and knowledge and attitudes about HIV/AIDS and other sexual matters. Focus groups were also conducted with peer educators and year 9 pupils. Data on the process of delivering sex education/intervention and on attitudes to the RCT were collected for each of the schools. Analysis focused on the acceptability of a randomised trial to schools, parents, and pupils. RESULTS: Nearly 500 parents were informed about the research and invited to examine the study questionnaire; only nine raised questions and only one pupil was withdrawn from the study. Questionnaire completion rates were around 90% in all schools. At baseline, the majority of year 9 pupils wanted more information about a wide range of sexual matters. Focus group work indicated considerable enthusiasm for peer led education, among peer educators and year 9 pupils. Class discipline was the most frequently noted problem with the delivery of the peer led intervention. CONCLUSION: Evaluation of a peer led behavioural intervention through an RCT can be acceptable to schools, pupils, and parents and is feasible in practice. In general, pupils who received the peer led intervention responded more positively than those in control schools. A large RCT of the long term (5-7 year) effects of this novel intervention on sexual health outcomes is now under way. 



PMCID: PMC1758164  PMID: 10195048
4.  Knowledge about Obstetric Danger Signs among Pregnant Women in Aleta Wondo District, Sidama Zone, Southern Ethiopia 
Background
Raising awareness of women on danger signs of pregnancy, childbirth and the postpartum period is crucial for safe motherhood. In Ethiopia, a country where maternal morbidity and mortality is high little is known about knowledge level of pregnant women on obstetric danger signs. The objective of this study was to assess pregnant women's knowledge about obstetric danger signs in Aleta Wondo district, Sidama Zone, South Ethiopia.
Methods
A community based cross-sectional study was conducted from January 18 – February 20, 2007, on a sample of 812 pregnant women selected from, 8 rural and 2 urban Kebeles. A structured pre-tested questionnaire was used to collect quantitative data on socio-demographic characteristics, obstetric history, and knowledge about danger signs of pregnancy, childbirth and post partum period. Qualitative data was collected through focus group discussion with pregnant women and in-depth interview with traditional birth attendants. The collected data were analyzed using SPSS for Windows version 12.0.1.
Results
Seven hundred forty three pregnant women participated in the study making a response rate of 92%. Out of the 743 pregnant women who participated in this study 226 (30.4%), 305(41.3%) and 279(37.7%) knew at least two danger signs during pregnancy, childbirth and postpartum period, respectively. Being urban resident was consistently found to be strongly associated with mentioning at least two danger signs of pregnancy (OR=4.1; 95% CI: 2.4, 7.0), child birth (OR=3.3; 95% CI: 1.8, 6.1), and postpartum period (OR=8.4; 95% CI: 4.5, 15.4).
Conclusion
This study indicated that the knowledge level of pregnant women about obstetric danger signs (during pregnancy, childbirth and postpartum period) was low and affected by residential area. Therefore, the identified deficiencies in awareness should be addressed through maternal and child health services by designing an appropriate strategies including provision of targeted information, education and communication.
PMCID: PMC3275898  PMID: 22434957
Danger signs; Pregnancy; Childbirth; Postpartum; Obstetric care
5.  Antenatal care in The Gambia: Missed opportunity for information, education and communication 
Background
Antenatal care is widely established and provides an opportunity to inform and educate pregnant women about pregnancy, childbirth and care of the newborn. It is expected that this would assist the women in making choices that would contribute to good pregnancy outcome. We examined the provision of information and education in antenatal clinics from the perspective of pregnant women attending these clinics.
Methods
A cross sectional survey of 457 pregnant women attending six urban and six rural antenatal clinics in the largest health division in The Gambia was undertaken. The women were interviewed using modified antenatal client exit interview and antenatal record review questionnaires from the WHO Safe Motherhood Needs Assessment kit. Differences between women attending urban and rural clinics were assessed using the Chi-square test. Relative risks with 95% confidence intervals are presented.
Results
Ninety percent of those interviewed had attended the antenatal clinic more than once and 52% four or more times. Most pregnant women (70.5%) said they spent 3 minutes or less with the antenatal care provider. About 35% recalled they were informed or educated on diet and nutrition, 30.4% on care of the baby, 23.6% on family planning, 22.8% on place of birth and 19.3% on what to do if there was a complication.
About 25% of pregnant women said they were given information about the progress of their pregnancy after consultation and only 12.8% asked their provider any question. Awareness of danger signs was low. The proportions of women that recognised signs of danger were 28.9% for anaemia, 24.6% for hypertension, 14.8% for haemorrhage, 12.9% for fever and 5% for puerperal sepsis. Prolonged labour was not recognised as a danger sign. Women attending rural antenatal clinics were 1.6 times more likely to recognise signs of anaemia and hypertension as indicative of danger compared to women attending urban antenatal clinics.
Conclusion
Information, education and communication during antenatal care in the largest health division are poor. Pregnant women are ill-equipped to make appropriate choices especially when they are in danger. This contributes to the persistence of high maternal mortality ratios in the country.
doi:10.1186/1471-2393-8-9
PMCID: PMC2322944  PMID: 18325122
6.  Water safety: age‐specific changes in knowledge and attitudes following a school‐based intervention 
Injury Prevention  2007;13(2):120-124.
Objectives
To explore whether an intervention during mandatory schooling can lead to age‐specific changes in water safety knowledge and attitudes.
Methods
Age‐specific questionnaires were distributed to 202 kindergarten and grade one pupils, 220 elementary school pupils and 337 pupils attending the first three high school grades in Greater Athens. The information was used to design an educational package that was subsequently presented to pupils of the same grades and similar socio‐demographic profiles attending different schools in the same area. One month later, a post‐exposure evaluation was conducted using the initial questionnaires, in which 115, 205 and 321 pupils from the respective grade categories provided their responses. In order to compare the performance of pupils exposed to the educational intervention with that of pupils who participated only in the initial assessment, mean differences in scores measuring overall knowledge and attitudes were estimated within each of the three grade groups adjusting for age, gender, sibship size, maternal education and swimming knowledge.
Results
Among kindergarten and grade one pupils, those who received the intervention scored significantly higher for knowledge (17.40%, 95% CI 6.41% to 28.39%) and attitudes (23.64%, 95% CI 4.48% to 42.79%). Among elementary school pupils the gains in knowledge were less evident (14.58%, 95% CI −3.05% to 32.21%)) and almost null in attitudes (5.64%, 95% CI −11.47% to 22.77%). Further advancement of age showed no improvement in knowledge (−0.15%, 95% CI −5.30% to 4.99%) and a minimal, insignificant increase in attitudes (6.32%, 95% CI −1.87% to 14.52%) among exposed high school pupils.
Conclusion
The school‐based intervention resulted in considerable positive changes in knowledge and attitudes among very young pupils. Elementary schooling seems to provide meagre opportunities to simply improve knowledge. Alternative/complementary approaches should be sought in any attempt to modify behavior.
doi:10.1136/ip.2006.014316
PMCID: PMC2610579  PMID: 17446253
7.  Asthma prevalence, knowledge, and perceptions among secondary school pupils in rural and urban coastal districts in Tanzania 
BMC Public Health  2014;14:387.
Background
Asthma is a common chronic disease of childhood that is associated with significant morbidity and mortality. We aimed to estimate the prevalence of asthma among secondary school pupils in urban and rural areas of coast districts of Tanzania. The study also aimed to describe pupils’ perception towards asthma, and to assess their knowledge on symptoms, triggers, and treatment of asthma.
Methods
A total of 610 pupils from Ilala district and 619 pupils from Bagamoyo district formed the urban and rural groups, respectively. Using a modified International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, a history of “diagnosed” asthma or the presence of a wheeze in the previous 12 months was obtained from all the studied pupils, along with documentation of their perceptions regarding asthma. Pupils without asthma or wheeze in the prior 12 months were subsequently selected and underwent a free running exercise testing. A ≥ 20% decrease in the post-exercise Peak Expiratory Flow Rate (PEFR) values was the criterion for diagnosing exercise-induced asthma.
Results
The mean age of participants was 16.8 (±1.8) years. The prevalence of wheeze in the past 12 months was 12.1% in Bagamoyo district and 23.1% in Ilala district (p < 0.001). Self-reported asthma was found in 17.6% and 6.4% of pupils in Ilala and Bagamoyo districts, respectively (p < 0.001). The prevalence of exercise-induced asthma was 2.4% in Bagamoyo, and 26.3% in Ilala (P < 0.002). In both districts, most information on asthma came from parents, and there was variation in symptoms and triggers of asthma reported by the pupils. Non-asthmatic pupils feared sleeping, playing, and eating with their asthmatic peers.
Conclusion
The prevalence rates of self-reported asthma, wheezing in the past 12 months, and exercise-induced asthma were significantly higher among urban than rural pupils. Although bronchial asthma is a common disease, pupils’ perceptions about asthma were associated with fear of contact with their asthmatic peers in both rural and urban schools.
doi:10.1186/1471-2458-14-387
PMCID: PMC4023699  PMID: 24754895
Asthma; Rural; Urban; Pupils; Tanzania
8.  Giving cell phones to pregnant women and improving services may increase primary health facility utilization: a case–control study of a Nigerian project 
Reproductive Health  2014;11:8.
Background
Worldwide, about 287 000 women die each year from mostly preventable complications related to pregnancy and childbirth. A disproportionately high number of these deaths occur in sub-Saharan Africa. The Abiye (‘Safe Motherhood’) project in the Ifedore Local Government Area (LGA) of Ondo-State of Nigeria aimed at improving facility utilization and maternal health through the use of cell phones and generally improved health care services for pregnant women, including Health Rangers, renovated Health Centres, and improved means of transportation.
Methods
A one-year sample of retrospective data was collected from hospital records and patients’ case files from Ifedore (the project area) and Idanre (control area) and was analyzed to determine healthcare facility utilization rates in each location. Semi-structured questionnaires were used to generate supplemental data.
Results
The total facility utilization rate of pregnant women was significantly higher in Ifedore than in Idanre. The facility utilization rate of the primary health care centres was significantly higher in Ifedore than in Idanre. The number of recorded cases of the five major causes of maternal death in the two LGAs was not significantly different, possibly because the project was new.
Conclusions
Giving cell phones to pregnant women and generally improving services could increase their utilization of the primary healthcare system.
doi:10.1186/1742-4755-11-8
PMCID: PMC3898403  PMID: 24438150
Maternal health; Health service utilization; Cell phone; Abiye project; Nigeria
9.  The implications of teenage pregnancy and motherhood for primary health care: unresolved issues. 
Teenage pregnancy and motherhood have implications for several different aspects of primary health care. First, the provision of health education and contraceptive services is obviously relevant to the prevention of unplanned teenage pregnancy. Secondly, appropriate obstetric care should be provided for teenagers, who are at high risk of developing complications in pregnancy and childbirth. Thirdly, and perhaps even more significantly, there is the implication of care required to deal with longer-term adverse health consequences associated with teenage pregnancy. In each of these areas, certain issues remain unresolved. This paper identifies key questions that remain unanswered, including the possibility of long-term adverse physical and psychological health consequences for teenage mothers and their children. The conclusion is that further research addressing these unresolved issues is necessary in order to inform health professionals and allow the implications for primary care to be assessed.
PMCID: PMC1313012  PMID: 9219414
10.  EVALUATION OF A COMMUNITY INTERVENTION FOR PROMOTION OF SAFE MOTHERHOOD IN ERITREA 
Objectives
We evaluated a community-based intervention to promote safe motherhood, focusing on knowledge and behaviors that may prevent maternal mortality and birth complications. The intervention aimed to increase women’s birth preparedness, knowledge of birth danger signs, use of antenatal care (ANC) services, and delivery at a health facility.
Methods
Volunteers from a remote rural community in Northern Eritrea were trained to lead participatory educational sessions on safe motherhood with women and men. The evaluation used a quasi-experimental design (non-equivalent group pretest-posttest) including cross-sectional surveys with postpartum women (pretest N=466, posttest N=378) in the intervention area and in a similar remote rural comparison area.
Results
Women’s knowledge of birth danger signs increased significantly in the intervention area, but not in the comparison area. There was a significant increase in the proportion of women who had the recommended four or more ANC visits during pregnancy in the intervention area (from 18% to 80%, p<.001); while this proportion did not change significantly in the comparison area (from 53% to 47%, p=0.194). There was a greater increase in delivery in a health facility in the intervention area.
Conclusions
Participatory sessions led by community volunteers can increase safe motherhood knowledge and encourage use of essential maternity services.
doi:10.1111/j.1542-2011.2010.00001.x
PMCID: PMC3498940  PMID: 21323845
Pregnancy; Maternal Health Services; Africa; Obstetric Labor Complications; Rural Health
11.  Evaluation of a reproductive health awareness program for adolescence in urban Tanzania-A quasi-experimental pre-test post-test research 
Reproductive Health  2011;8:21.
Background
Sub-Saharan Africa is among the countries where 10% of girls become mothers by the age of 16 years old. The United Republic of Tanzania located in Sub-Saharan Africa is one country where teenage pregnancy is a problem facing adolescent girls. Adolescent pregnancy has been identified as one of the reasons for girls dropping out from school. This study's purpose was to evaluate a reproductive health awareness program for the improvement of reproductive health for adolescents in urban Tanzania.
Methods
A quasi-experimental pre-test and post-test research design was conducted to evaluate adolescents' knowledge, attitude, and behavior about reproductive health before and after the program. Data were collected from students aged 11 to 16, at Ilala Municipal, Dar es Salaam, Tanzania. An anonymous 23-item questionnaire provided the data. The program was conducted using a picture drama, reproductive health materials and group discussion.
Results
In total, 313 questionnaires were distributed and 305 (97.4%) were useable for the final analysis. The mean age for girls was 12.5 years and 13.2 years for boys. A large minority of both girls (26.8%) and boys (41.4%) had experienced sex and among the girls who had experienced sex, 51.2% reported that it was by force. The girls' mean score in the knowledge pre-test was 5.9, and 6.8 in post-test, which increased significantly (t = 7.9, p = 0.000). The mean behavior pre-test score was 25.8 and post-test was 26.6, which showed a significant increase (t = 3.0, p = 0.003). The boys' mean score in the knowledge pre-test was 6.4 and 7.0 for the post-test, which increased significantly (t = 4.5, p = 0.000). The mean behavior pre-test score was 25.6 and 26.4 in post-test, which showed a significant increase (t = 2.4, p = 0.019). However, the pre-test and post-test attitude scores showed no statistically significant difference for either girls or boys.
Conclusions
Teenagers have sexual experiences including sexual violence. Both of these phenomena are prevalent among school-going adolescents. The reproductive health program improved the students' knowledge and behavior about sexuality and decision-making after the program for both girls and boys. However, their attitudes about reproductive health were not likely to change based on the educational intervention as designed for this study.
doi:10.1186/1742-4755-8-21
PMCID: PMC3148958  PMID: 21707996
adolescent; pregnancy; reproductive health; program evaluation; Tanzania
12.  Experiences of pregnancy and motherhood among teenage mothers in a suburb of Accra, Ghana: a qualitative study 
Background
The proportion of teenage girls who are mothers or who are currently pregnant in sub-Saharan African countries is staggering. There are many studies regarding teenage pregnancy, unsafe abortions, and family planning among teenagers, but very little is known about what happens after pregnancy, ie, the experience of teenage motherhood. Several studies in Ghana have identified the determinants of early sexual activity, contraception, and unsafe abortion, with teenage motherhood only mentioned in passing. Few studies have explored the experiences of adolescent mothers in detail with regard to their pregnancy and childbirth. This qualitative study explores the experiences of adolescent mothers during pregnancy, childbirth, and care of their newborns.
Methods
This qualitative study was based on data from focus group discussions and indepth interviews with teenage mothers in a suburb in Accra. Participants were recruited from health facilities as well as by snowball sampling.
Results
Some of the participants became pregnant as a result of transactional sex in order to meet their basic needs, while others became pregnant as a result of sexual violence and exploitation. A few others wanted to become pregnant to command respect from people in society. In nearly all cases, parents and guardians of the adolescent mothers were upset in the initial stages when they heard the news of the pregnancy. One key finding, quite different from in other societies, was how often teenage pregnancies are eventually accepted, by both the young women and their families. Also observed was a rarity of willingness to resort to induced abortion.
Conclusion
Special programs should be initiated by the government and the various responsible departments to address ignorance on sexual matters, and the challenges and risks associated with pregnancy and parenting by adolescents. Parenting techniques should be taught in sex education programs.
doi:10.2147/IJWH.S51528
PMCID: PMC3829679  PMID: 24250233
teenage pregnancy; teenage motherhood; adolescents; unmarried teenagers; focus group discussions; Ghana
13.  Transition to motherhood in type 1 diabetes: design of the pregnancy and postnatal well-being in transition questionnaires 
Background
Life transitions are associated with high levels of stress affecting health behaviours among people with Type 1 diabetes. Transition to motherhood is a major transition with potential complications accelerated by pregnancy with risks of adverse childbirth outcomes and added anxiety and worries about pregnancy outcomes. Further, preparing and going through pregnancy requires vigilant attention to a diabetes management regimen and detailed planning of everyday activities with added stress on women. Psychological and social well-being during and after pregnancy are integral for good pregnancy outcomes for both mother and baby. The aim of this study is to establish the face and content validity of two novel measures assessing the well-being of women with type 1 diabetes in their transition to motherhood, 1) during pregnancy and 2) during the postnatal period.
Methods
The approach to the development of the Pregnancy and Postnatal Well-being in T1DM Transition questionnaires was based on a four-stage pre-testing process; systematic overview of literature, items development, piloting testing of questionnaire and refinement of questionnaire. The questionnaire was reviewed at every stage by expert clinicians, researchers and representatives from consumer groups. The cognitive debriefing approach confirmed relevance of issues and identified additional items.
Results
The literature review and interviews identified three main areas impacting on the women’s postnatal self-management; (1) psychological well-being; (2) social environment, (3) physical (maternal and fetal) well-being. The cognitive debriefing in pilot testing of the questionnaire identified that immediate postnatal period was difficult, particularly when the women were breastfeeding and felt depressed.
Conclusions
The questionnaires fill an important gap by systematically assessing the psychosocial needs of women with type 1 diabetes during pregnancy and in the immediate postnatal period. The questionnaires can be used in larger data collection to establish psychometric properties. The questionnaires potentially play a key role in prospective research to determine the self-management and psychological needs of women with type 1 diabetes transitioning to motherhood and to evaluate health education interventions.
doi:10.1186/1471-2393-13-54
PMCID: PMC3599343  PMID: 23445534
T1DM (type 1 diabetes); Pregnancy; Postnatal; Questionnaire; Transitions; Self-management; Social support; Psychological well-being
14.  Born Too Soon: Care during pregnancy and childbirth to reduce preterm deliveries and improve health outcomes of the preterm baby 
Reproductive Health  2013;10(Suppl 1):S4.
Abstract
Pregnancy and childbirth represent a critical time period when a woman can be reached through a variety of mechanisms with interventions aimed at reducing her risk of a preterm birth and improving her health and the health of her unborn baby. These mechanisms include the range of services delivered during antenatal care for all pregnant women and women at high risk of preterm birth, services provided to manage preterm labour, and workplace, professional and other supportive policies that promote safe motherhood and universal access to care before, during and after pregnancy. The aim of this paper is to present the latest information about available interventions that can be delivered during pregnancy to reduce preterm birth rates and improve the health outcomes of the premature baby, and to identify data gaps. The paper also focuses on promising avenues of research on the pregnancy period that will contribute to a better understanding of the causes of preterm birth and ability to design interventions at the policy, health care system and community levels. At minimum, countries need to ensure equitable access to comprehensive antenatal care, quality childbirth services and emergency obstetric care. Antenatal care services should include screening for and management of women at high risk of preterm birth, screening for and treatment of infections, and nutritional support and counselling. Health workers need to be trained and equipped to provide effective and timely clinical management of women in preterm labour to improve the survival chances of the preterm baby. Implementation strategies must be developed to increase the uptake by providers of proven interventions such as antenatal corticosteroids and to reduce harmful practices such as non-medically indicated inductions of labour and caesarean births before 39 weeks of gestation. Behavioural and community-based interventions that can lead to reductions in smoking and violence against women need to be implemented in conjunction with antenatal care models that promote women's empowerment as a strategy for reducing preterm delivery. The global community needs to support more discovery research on normal and abnormal pregnancies to facilitate the development of preventive interventions for universal application. As new evidence is generated, resources need to be allocated to its translation into new and better screening and diagnostic tools, and other interventions aimed at saving maternal and newborn lives that can be brought to scale in all countries.
Declaration
This article is part of a supplement jointly funded by Save the Children's Saving Newborn Lives programme through a grant from The Bill & Melinda Gates Foundation and March of Dimes Foundation and published in collaboration with the Partnership for Maternal, Newborn and Child Health and the World Health Organization (WHO). The original article was published in PDF format in the WHO Report "Born Too Soon: the global action report on preterm birth" (ISBN 978 92 4 150343 30), which involved collaboration from more than 50 organizations. The article has been reformatted for journal publication and has undergone peer review according to Reproductive Health's standard process for supplements and may feature some variations in content when compared to the original report. This co-publication makes the article available to the community in a full-text format.
doi:10.1186/1742-4755-10-S1-S4
PMCID: PMC3842748  PMID: 24625215
15.  “How Can I Gain Skills if I Don’t Practice?” The Dynamics of Prohibitive Silence against Pre-Marital Pregnancy and Sex in Zimbabwe 
PLoS ONE  2013;8(1):e53058.
Young people face sexual and reproductive health (SRH) problems including Human immunodeficiency virus (HIV) and Acquired immunodeficiency syndrome (AIDS). It is critical to continue documenting their situation including the contexts they live in. As part of a larger study that explored perspectives of men to SRH and more specifically abortion and contraceptive use, 546 pupils (51% female; age range 9–25 years) from a rural area in Zimbabwe were invited to write anonymously questions about growing up or other questions they could not ask adults for fear or shame. The pupils were included following descriptions by adults of the violence that is unleashed on unmarried young people who engaged in sex, used contraceptives, or simply suggested doing so. The questions by the young people pointed to living in a context of prohibitive silence; their sexuality was silenced and denied. As a consequence they had poor knowledge and their fears and internal conflicts around sexuality and pregnancy were not addressed. Current action suggests concerted effort at the policy level to deal with young people’s SRH in Zimbabwe. It nevertheless remains necessary, as a way to provide support to these efforts, to continue examining what lessons can be drawn from the past, and how the past continues to reflect in and shape present dynamics and relations. There is also need to look more critically at life skill education, which has previously been described as having failed to address adequately the practical needs of young people. Life skill education in Zimbabwe has rarely been systematically evaluated. A fuller understanding is also needed of the different factors co-existing in contemporary African societies and how they have been and continue to be constituted within history, and the implications to the promotion of adolescent SRH.
doi:10.1371/journal.pone.0053058
PMCID: PMC3553136  PMID: 23372653
16.  Socio-cultural factors surrounding mental distress during the perinatal period in Zambia: a qualitative investigation 
Background
The presence of mental distress during pregnancy and after childbirth imposes detrimental developmental and health consequences for families in all nations. In Zambia, the Ministry of Health (MoH) has proposed a more comprehensive approach towards mental health care, recognizing the importance of the mental health of women during the perinatal period.
Aim
The study explores factors contributing to mental distress during the perinatal period of motherhood in Zambia.
Methods
A qualitative study was conducted in Lusaka, Zambia with nineteen focus groups comprising 149 women and men from primary health facilities and schools respectively.
Findings
There are high levels of mental distress in four domains: worry about HIV status and testing; uncertainty about survival from childbirth; lack of social support; and vulnerability/oppression.
Conclusion
Identifying mental distress and prompt referral for interventions is critical to improving the mental health of the mother and prevent the effects of mental distress on the baby.
Recommendation
Strategies should be put in place to ensure pregnant women are screened for possible perinatal mental health problems during their visit to antenatal clinic and referral made to qualified mental health professionals. In addition further research is recommended in order to facilitate evidence based mental health policy formulation and implementation in Zambia.
doi:10.1186/1752-4458-6-12
PMCID: PMC3464809  PMID: 22954173
Perinatal period; Mental distress; Parenting; Psychological distress
17.  The unmet need for Emergency Obstetric Care in Tanga Region, Tanzania 
Background
Improving maternal health by reducing maternal mortality constitutes the fifth Millennium Development Goal and represents a key public health challenge in the United Republic of Tanzania. In response to the need to evaluate and monitor safe motherhood interventions, this study aims at assessing the coverage of obstetric care according to the Unmet Obstetric Need (UON) concept by obtaining information on indications for, and outcomes of, major obstetric interventions. Furthermore, we explore whether this concept can be operationalised at district level.
Methods
A two year study using the Unmet Obstetric Need concept was carried out in three districts in Tanga Region, Tanzania. Data was collected prospectively at all four hospitals in the region for every woman undergoing a major obstetric intervention, including indication and outcome. The concept was adapted to address differentials in access to emergency obstetric care between districts and between rural and urban areas. Based upon literature and expert consensus, a threshold of 2% of all deliveries was used to define the expected minimum requirement of major obstetric interventions performed for absolute maternal indications.
Results
Protocols covering 1,260 complicated deliveries were analysed. The percentage of major obstetric interventions carried out in response to an absolute maternal indication was only 71%; most major obstetric interventions (97%) were caesarean sections. The most frequent indication was cephalo-pelvic-disproportion (51%). The proportion of major obstetric interventions for absolute maternal indications performed amongst women living in urban areas was 1.8% of all deliveries, while in rural areas it was only 0.7%. The high proportion (8.3%) of negative maternal outcomes in terms of morbidity and mortality, as well as the high perinatal mortality of 9.1% (still birth 6.9%, dying within 24 hours 1.7%, dying after 24 hours 0.5%) raise concern about the quality of care being provided.
Conclusion
Based on the 2% threshold, Tanga Region – with an overall level of major obstetric interventions for absolute maternal indications of 1% and a caesarean section rate of 1.4% – has significant unmet obstetric need with a considerable rural-urban disparity. The UON concept was found to be a suitable tool for evaluating and monitoring the coverage of obstetric care at district level.
doi:10.1186/1471-2393-7-16
PMCID: PMC1988833  PMID: 17683590
18.  Rethinking HIV/AIDS Disclosure Among Women Within the Context of Motherhood in South Africa 
American Journal of Public Health  2010;100(8):1393-1399.
This qualitative study explored whether motherhood plays a role in influencing decisions to conceal or reveal knowledge of seropositive status among women living with HIV/AIDS in 2 South African communities: Gugulethu and Mitchell’s Plain. Using the PEN-3 cultural model, we explored how HIV-positive women disclose their status to their mothers and how HIV-positive mothers make decisions about disclosure of their seropositive status. Our findings revealed 3 themes: the positive consequences of disclosing to mothers, how being a mother influences disclosure (existential role of motherhood), and the cost of disclosing to mothers (negative consequences). The findings highlight the importance of motherhood in shaping decisions to reveal or conceal knowledge of seropositive status. Implications for interventions on HIV/AIDS prevention, care, and support are discussed.
doi:10.2105/AJPH.2009.168989
PMCID: PMC2901276  PMID: 20558809
19.  Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan 
Reproductive Health  2010;7:30.
Background
Pakistan has high maternal mortality, particularly in the rural areas. The delay in decision making to seek medical care during obstetric emergencies remains a significant factor in maternal mortality.
Methods
We present results from an experimental study in rural Pakistan. Village clusters were randomly assigned to intervention and control arms (16 clusters each). In the intervention clusters, women were provided information on safe motherhood through pictorial booklets and audiocassettes; traditional birth attendants were trained in clean delivery and recognition of obstetric and newborn complications; and emergency transportation systems were set up. In eight of the 16 intervention clusters, husbands also received specially designed education materials on safe motherhood and family planning. Pre- and post-intervention surveys on selected maternal and neonatal health indicators were conducted in all 32 clusters. A district-wide survey was conducted two years after project completion to measure any residual impact of the interventions.
Results
Pregnant women in intervention clusters received prenatal care and prophylactic iron therapy more frequently than pregnant women in control clusters. Providing safe motherhood education to husbands resulted in further improvement of some indicators. There was a small but significant increase in percent of hospital deliveries but no impact on the use of skilled birth attendants. Perinatal mortality reduced significantly in clusters where only wives received information and education in safe motherhood. The survey to assess residual impact showed similar results.
Conclusions
We conclude that providing safe motherhood education increased the probability of pregnant women having prenatal care and utilization of health services for obstetric complications.
doi:10.1186/1742-4755-7-30
PMCID: PMC2993657  PMID: 21054870
20.  Burden of HIV among primary school children and feasibility of primary school-linked HIV testing in Harare, Zimbabwe: A mixed methods study 
AIDS Care  2013;25(12):1520-1526.
Population-based surveys in Southern Africa suggest a substantial burden of undiagnosed HIV-infected long-term survivors of mother-to-child transmission. We conducted an HIV prevalence survey of primary school pupils in Harare, Zimbabwe, and evaluated school-linked HIV counselling and testing (HCT) for pupils, their families and schoolteachers. Population-weighted cluster sampling was used to select six primary schools. Randomly selected class-grade pupils underwent anonymous HIV testing, with concurrent school-linked family HCT offered during the survey. Focus group discussions and interviews were conducted with pupils, parents/ guardians, counsellors, and schoolteachers. About 4386 (73%) pupils provided specimens for anonymous HIV testing. Median age was 9 years (IQR 8–11), and 54% were female. HIV prevalence was 2.7% (95% CI: 2.2–3.1) with no difference by gender. HIV infection was significantly associated with orphanhood, stunting, wasting, and being one or more class grades behind in school due to illness (p <0.001). After adjusting for covariates, orphanhood and stunting remained significantly associated with being HIV positive (p <0.001). Uptake of diagnostic HIV testing by pupils was low with only 47/4386 (1%) pupils undergoing HCT. The HIV prevalence among children under 15 years who underwent HIV testing was 6.8%. The main barrier to HIV testing was parents’ fear of their children experiencing stigma and of unmasking their own HIV status should the child test HIV positive. Most guardians believed that a child's HIV-positive result should not be disclosed and the child could take HIV treatment without knowing the reason. Increased recognition of the high burden of undiagnosed HIV infection in children is needed. Despite awareness of the benefits of HIV testing, HIV-related stigma still dominates parents/guardians' psychological landscape. There is need for comprehensive information and support for families to engage with HIV testing services.
doi:10.1080/09540121.2013.780120
PMCID: PMC3898087  PMID: 23528004
Africa; HIV; HCT; primary school pupils; stigma
21.  A randomised controlled trial of clinics in secondary schools for adolescents with asthma. 
AIM: To compare a nurse-led clinic in schools versus care in general practice for adolescents with asthma. DESIGN OF STUDY: Randomised controlled trial in four schools; parallel observational study in two schools. SETTING: Six comprehensive schools. METHOD: In the randomised trial, pupils were invited to attend asthma review at a nurse-led clinic either in school, or in general practice. The parallel observational study compared pupils invited to practice care within and outside the randomised trial. Primary outcome measures were attendance for asthma review, symptom control, and quality of life. Secondary outcomes were knowledge, attitudes, inhaler technique, use of steroids, school absence, peak flow rate, preference for future care, health service utilisation, and costs. RESULTS: School clinic pupils were more likely to attend an asthma review than those randomised to practice care (90.8% versus 51.0% overall [P < 0.001, not consistent across schools]). No differences were observed in symptom control (P = 0.42) or quality of life (P = 0.63). Pupils attending school clinics had greater knowledge of asthma (difference = +0.38, 95% CI = 0.19 to 0.56), more positive attitudes (difference = +0.21, 95% CI = 0.05 to 0.36), and better inhaler technique (P < 0.001, not consistent across all schools). No differences were observed in school absence or peak flow rate. A majority (63%) of those who had received care at school preferred this model in future. Median costs of providing care at school and at the practice were 32.10 Pounds and 19.80 Pounds, respectively. No differences were observed between the groups in the observational comparison on any outcome. CONCLUSIONS: The schools asthma clinic increased uptake of asthma reviews. There were improvements in various process measures, but not in clinical outcomes.
PMCID: PMC1314468  PMID: 12528584
22.  Religion and HIV in Tanzania: influence of religious beliefs on HIV stigma, disclosure, and treatment attitudes 
BMC Public Health  2009;9:75.
Background
Religion shapes everyday beliefs and activities, but few studies have examined its associations with attitudes about HIV. This exploratory study in Tanzania probed associations between religious beliefs and HIV stigma, disclosure, and attitudes toward antiretroviral (ARV) treatment.
Methods
A self-administered survey was distributed to a convenience sample of parishioners (n = 438) attending Catholic, Lutheran, and Pentecostal churches in both urban and rural areas. The survey included questions about religious beliefs, opinions about HIV, and knowledge and attitudes about ARVs. Multivariate logistic regression analysis was performed to assess how religion was associated with perceptions about HIV, HIV treatment, and people living with HIV/AIDS.
Results
Results indicate that shame-related HIV stigma is strongly associated with religious beliefs such as the belief that HIV is a punishment from God (p < 0.01) or that people living with HIV/AIDS (PLWHA) have not followed the Word of God (p < 0.001). Most participants (84.2%) said that they would disclose their HIV status to their pastor or congregation if they became infected. Although the majority of respondents (80.8%) believed that prayer could cure HIV, almost all (93.7%) said that they would begin ARV treatment if they became HIV-infected. The multivariate analysis found that respondents' hypothetical willingness to begin ARV treatme was not significantly associated with the belief that prayer could cure HIV or with other religious factors. Refusal of ARV treatment was instead correlated with lack of secondary schooling and lack of knowledge about ARVs.
Conclusion
The decision to start ARVs hinged primarily on education-level and knowledge about ARVs rather than on religious factors. Research results highlight the influence of religious beliefs on HIV-related stigma and willingness to disclose, and should help to inform HIV-education outreach for religious groups.
doi:10.1186/1471-2458-9-75
PMCID: PMC2656538  PMID: 19261186
23.  ENTRY INTO MOTHERHOOD AMONG ADOLESCENT GIRLS IN TWO INFORMAL SETTLEMENTS IN NAIROBI, KENYA 
Journal of Biosocial Science  2013;45(6):721-742.
Summary
The contribution of adolescents' childbearing to total fertility rates in many sub-Saharan African countries is higher than in other parts of the world. In this paper, data collected from 897 female adolescents aged 15–19 years are analysed to investigate patterns and determinants of entry into motherhood in two informal settlements in Nairobi, Kenya, using Kaplan–Meier estimates and Cox regression models. About 15% of these adolescents have had a child. The findings show that marriage, being out of school and having negative models in peer, family and school contexts are associated with early childbearing among females aged 15–17 years. For adolescents aged 18–19 years, school attendance considerably delays entry into motherhood while marriage hastens its timing. Furthermore, older adolescents with high levels of social controls (parental monitoring or perceived peer orientation to or approval of prosocial behaviours) and individual controls (high religiosity and positive orientation to schooling) are likely to delay childbearing. Programmes aiming to reduce risky sexual behaviours that could lead to childbearing among adolescents should be introduced very early, and before the onset of sexual activity. Also, the findings underscore the need to identify and address the risky factors and reinforce the protective ones in order to improve sexual and reproductive health outcomes of adolescent girls in Nairobi slum settlements.
doi:10.1017/S0021932013000199
PMCID: PMC3785175  PMID: 23688912
24.  Swedish high-school pupils’ attitudes towards drugs in relation to drug usage, impulsiveness and other risk factors 
PeerJ  2014;2:e410.
Background. Illicit drug use influences people’s lives and elicits unwanted behaviour. Current research shows that there is an increase in young people’s drug use in Sweden. The aim was to investigate Swedish high-school pupils’ attitudes, impulsiveness and gender differences linked to drug use. Risk and protective factors relative to drug use were also a focus of interest.
Method. High school pupils (n = 146) aged 17–21 years, responded to the Adolescent Health and Development Inventory, Barratt Impulsiveness Scale and Knowledge, and the Attitudes and Beliefs. Direct logistic, multiple regression analyses, and Multivariate Analysis of Variance were used to analyze the data.
Results. Positive Attitudes towards drugs were predicted by risk factors (odds ratio = 37.31) and gender (odds ratio = .32). Risk factors (odds ratio = 46.89), positive attitudes towards drugs (odds ratio = 4.63), and impulsiveness (odds ratio = 1.11) predicted drug usage. Risk factors dimensions Family, Friends and Individual Characteristic were positively related to impulsiveness among drug users. Moreover, although boys reported using drugs to a greater extent, girls expressed more positive attitude towards drugs and even reported more impulsiveness than boys.
Conclusion. This study reinforces the notion that research ought to focus on gender differences relative to pro-drug attitudes along with testing for differences in the predictors of girls’ and boys’ delinquency and impulsiveness. Positive attitudes towards drugs among adolescents seem to be part of a vicious circle including risk factors, such as friendly drug environments (e.g., friends who use drugs) and unsupportive family environments, individual characteristics, and impulsiveness.
doi:10.7717/peerj.410
PMCID: PMC4060018  PMID: 24949233
Attitudes towards drug use; Impulsiveness; Gender and drug use; Risk factor for drug use
25.  The evaluation of "Safe Motherhood" program on maternal care utilization in rural western China: a difference in difference approach 
BMC Public Health  2010;10:566.
Background
Maternal care is an important strategy for protection and promotion of maternal and children's health by reducing maternal mortality and improving the quality of birth. However, the status of maternal care is quite weak in the less developed rural areas in western China. It is found that the maternal mortality rates in some western areas of China were 5.8 times higher than those of their eastern costal counterparts. In order to reduce the maternal mortality rates and to improve maternal care in western rural areas of China, the Chinese Ministry of Health (MOH) and the United Nations Children's Fund (UNICEF) sponsored a program named "Safe Motherhood" in ten western provinces of China from 2001 through 2005. This study mainly aims to evaluate the effects of "Safe Motherhood" program on maternal care utilization.
Methods
32 counties were included in both surveys conducted in 2001 and 2005, respectively. Ten counties of which implemented comprehensive community-based intervention were used as intervention groups, while 22 counties were used as control groups. Stratified 3-stage probability-proportion-to-size sampling method was used to select participating women. Two cross-sectional surveys were conducted with questionnaires about the prenatal care utilization in 2001 and 2005, respectively. Difference in difference estimation was used to assess the effect of intervention on the maternal care utilization while controlling for socio-economic characteristics of women.
Results
After the intervention, the proportion of pregnant women who had their first prenatal visit in the first trimester was increased from 38.9% to 76.1%. The proportion of prenatal visits increased from 82.6% to 98.3%. The proportion of women mobilized to deliver in hospitals increased from 62.7% to 94.5%. Hospital delivery was improved greatly from 31.1% to 87.3%. The maternal mortality rate was lowered by 34.9% from 91.76 to 59.74 per 100,000 live births. The community-based intervention had increased prenatal visits rate by 5.2%, first prenatal visit in first trimester rate by 12.0% and hospital delivery rate by 22.5%, respectively. No effect was found on rate of women being mobilized to hospital delivery compared with that of the control group.
Conclusion
The intervention program seemed to have improved the prenatal care utilization in rural western China.
doi:10.1186/1471-2458-10-566
PMCID: PMC2946300  PMID: 20858285

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