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1.  Barriers to modern contraceptive methods uptake among young women in Kenya: a qualitative study 
BMC Public Health  2015;15:118.
Background
Young women in Kenya experience a higher risk of mistimed and unwanted pregnancy compared to older women. However, contraceptive use among youth remains low. Known barriers to uptake include side effects, access to commodities and partner approval.
Methods
To inform a youth focussed behaviour change communication campaign, Population Services Kenya developed a qualitative study to better understand these barriers among young women. The study was carried out in Nyanza, Coast, and Central regions. Within these regions, urban or peri-urban districts were purposively selected based on having contraceptive prevalence rate close to the regional average and having a population with low socioeconomic profiles. In depth interviews were conducted with a sample of sexually active women aged 15–24, both users and non-users, that were drawn from randomly selected households.
Results
All the respondents in the study were familiar with modern methods of contraception and most could describe their general mechanisms of action. Condoms were not considered as contraception by many users. Contraception was also associated with promiscuity and straying. Fear of side effects and adverse reactions were a major barrier to use. The biggest fear was that a particular method would cause infertility. Many fears were based on myths and misconceptions. Young women learn about both true side effects and myths from their social networks.
Conclusion
Findings from this research confirm that awareness and knowledge of contraception do not necessarily translate to use. The main barriers to modern contraceptive uptake among young women are myths and misconceptions. The findings stress the influence of social network approval on the use of family planning, beyond the individual’s beliefs. In such settings, family planning programming should engage with the wider community through mass and peer campaign strategies. As an outcome from this study, Population Services Kenya developed a mass media campaign to address key myths and misconceptions among youth.
doi:10.1186/s12889-015-1483-1
PMCID: PMC4336491
Family planning; Kenya; Young women; Contraceptives; Myths and misconceptions; Behaviour change communication
2.  Sexual and Reproductive Health Knowledge, Contraception Uptake, and Factors Associated with Unmet Need for Modern Contraception among Adolescent Female Sex Workers in China 
PLoS ONE  2015;10(1):e0115435.
Objective
In China, policy and social taboo prevent unmarried adolescents from accessing sexual and reproductive health (SRH) services. Research is needed to determine the SRH needs of highly disadvantaged groups, such as adolescent female sex workers (FSWs). This study describes SRH knowledge, contraception use, pregnancy, and factors associated with unmet need for modern contraception among adolescent FSWs in Kunming, China.
Methods
A cross-sectional study using a one-stage cluster sampling method was employed to recruit adolescents aged 15 to 20 years, and who self-reported having received money or gifts in exchange for sex in the past 6 months. A semi-structured questionnaire was administered by trained peer educators or health workers. Multivariable logistic regression was conducted to determine correlates of low knowledge and unmet need for modern contraception.
Results
SRH knowledge was poor among the 310 adolescents surveyed; only 39% had heard of any long-acting reversible contraception (implant, injection or IUD). Despite 98% reporting not wanting to get pregnant, just 43% reported consistent condom use and 28% currently used another form of modern contraception. Unmet need for modern contraception was found in 35% of adolescents, and was associated with having a current non-paying partner, regular alcohol use, and having poorer SRH knowledge. Past abortion was common (136, 44%). In the past year, 76% had reported a contraception consultation but only 27% reported ever receiving SRH information from a health service.
Conclusions
This study demonstrated a low level of SRH knowledge, a high unmet need for modern contraception and a high prevalence of unintended pregnancy among adolescent FSWs in Kunming. Most girls relied on condoms, emergency contraception, or traditional methods, putting them at risk of unwanted pregnancy. This study identifies an urgent need for Chinese adolescent FSWs to be able to access quality SRH information and effective modern contraception.
doi:10.1371/journal.pone.0115435
PMCID: PMC4307985  PMID: 25625194
3.  Intimate Partner Violence after Disclosure of HIV Test Results among Pregnant Women in Harare, Zimbabwe 
PLoS ONE  2014;9(10):e109447.
Background
HIV status disclosure is a central strategy in HIV prevention and treatment but in high prevalence settings women test disproportionately and most often during pregnancy. This study reports intimate partner violence (IPV) following disclosure of HIV test results by pregnant women.
Methods
In this cross sectional study we interviewed 1951 postnatal women who tested positive and negative for HIV about IPV experiences following HIV test disclosure, using an adapted WHO questionnaire. Multivariate regression models assessed factors associated with IPV after disclosure and controlled for factors such as previous IPV and other known behavioural factors associated with IPV.
Results
Over 93% (1817) disclosed the HIV results to their partners (96.5% HIV− vs. 89.3% HIV+, p<0.0001). Overall HIV prevalence was 15.3%, (95%CI:13.7–16.9), 35.2% among non-disclosers and 14.3% among disclosers. Overall 32.8% reported IPV (40.5% HIV+; 31.5% HIV− women, p = 0.004). HIV status was associated with IPV (partially adjusted 1.43: (95%CI:1.00–2.05 as well as reporting negative reactions by male partners immediately after disclosure (adjusted OR 5.83, 95%CI:4.31–7.80). Factors associated with IPV were gender inequity, past IPV, risky sexual behaviours and living with relatives. IPV after HIV disclosure in pregnancy is high but lower than and is strongly related with IPV before pregnancy (adjusted OR 6.18, 95%CI: 3.84–9.93).
Conclusion
The study demonstrates the interconnectedness of IPV, HIV status and its disclosure with IPV which was a common experience post disclosure of both an HIV positive and HIV negative result. Health services must give attention to the gendered nature and consequences of HIV disclosure such as enskilling women on how to determine and respond to the risks associated with disclosure. Efforts to involve men in antenatal care must also be strengthened.
doi:10.1371/journal.pone.0109447
PMCID: PMC4211664  PMID: 25350001
4.  WHO guidance grounded in a comprehensive approach to sexual and reproductive health and human rights: topical pre-exposure prophylaxis 
Journal of the International AIDS Society  2014;17(3Suppl 2):19279.
Introduction
Two new microbicide products based on topical (vaginal) application of antiretroviral drugs – 1% tenofovir gel and the dapivirine ring – are currently in late-stage clinical testing, and results on their safety and effectiveness are expected to become available in early 2015. WHO guidelines on the use of topical pre-exposure prophylaxis (topical PrEP) are important in order to ensure that these new prevention products are optimally used.
Discussion
Given that these new topical PrEP products are designed to be woman initiated and will likely be delivered in reproductive health settings, it is important to ensure that the guidance be framed in the context of comprehensive sexual and reproductive health and human rights. In addition to the safety and effectiveness data resulting from clinical trials, and the regulatory approval required for new products, the WHO normative guidelines on the use of topical PrEP will be essential for rapid roll-out in countries.
Conclusions
Human rights standards and principles provide a framework for the provision of woman-initiated HIV prevention products. These include addressing issues related to the gender inequities which are linked to the provision of HIV-prevention, treatment and care for young girls and women. Effective programming for women and girls must therefore be based on understanding the local, social and community contexts of the AIDS epidemic in the country, and adapting HIV strategies and programmes accordingly. Such a framework therefore is needed not only to ensure optimal uptake of these new products by women and girls but also to address sociocultural barriers to women's and girls’ access to these products.
doi:10.7448/IAS.17.3.19279
PMCID: PMC4163998  PMID: 25224620
human rights; sexual and reproductive health; HIV; prevention; pre-exposure prophylaxis; microbicide
5.  Prevalence and evolution of intimate partner violence before and during pregnancy: a cross-sectional study 
Background
Intimate partner violence (IPV) before and during pregnancy is associated with a broad range of adverse health outcomes. Describing the extent and the evolution of IPV is a crucial step in developing interventions to reduce the health impact of IPV.
The objectives are to study the prevalence of psychological abuse, as well as physical & sexual violence, and to provide insight into the evolution of IPV 12 months before and during pregnancy.
Methods
Between June 2010 and October 2012, a cross-sectional study was conducted in 11 antenatal care clinics in Belgium. Consenting pregnant women were asked to complete a questionnaire (available in Dutch, French and English) in a separate room. Ethical clearance was obtained in all participating hospitals.
Results
The overall percentage of IPV was 14.3% (95% CI: 12.7 - 16.0) 12 months before pregnancy and 10.6% (95% CI: 9.2 - 12.1) during pregnancy. Physical partner violence before as well as during pregnancy was reported by 2.5% (95% CI: 1.7 - 3.3) of the respondents (n = 1894), sexual violence by 0.9% (95% CI 0.5 - 1.4), and psychological abuse by 14.9% (95% CI: 13.3 - 16.7). Risk factors identified for IPV were being single or divorced, having a low level of education, and choosing another language than Dutch to fill out the questionnaire. The adjusted analysis showed that physical partner violence (aOR 0.35, 95% CI: 0.22 - 0.56) and psychological partner abuse (aOR 0.7, 95% CI: 0.63 - 0.79) were significantly lower during pregnancy compared to the period of 12 months before pregnancy. The difference between both time periods is greater for physical partner violence (65%) compared to psychological partner abuse (30%). The analysis of the frequency data showed a similarly significant evolution for physical partner violence and psychological partner abuse, but not for sexual violence.
Conclusion
The IPV prevalence rates in our study are slightly lower than what can be found in other Western studies, but even so IPV is to be considered a prevalent problem before and during pregnancy. We found evidence, however, that physical partner violence and psychological partner abuse are significantly lower during pregnancy.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2393-14-294) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2393-14-294
PMCID: PMC4159505  PMID: 25169813
Intimate partner violence; Abuse; Pregnancy; Prevalence; Evolution; Pattern
6.  Women's Empowerment and Contraceptive Use: The Role of Independent versus Couples' Decision-Making, from a Lower Middle Income Country Perspective 
PLoS ONE  2014;9(8):e104633.
Introduction
There is little available evidence of associations between the various dimensions of women's empowerment and contraceptive use having been examined - and of how these associations are mediated by women's socio-economic and demographic statuses. We assessed these phenomena in Pakistan using a structured-framework approach.
Methods
We analyzed data on 2,133 women who were either using any form of contraceptive or living with unmet need for contraception. The survey was conducted during May - June 2012, with married women of reproductive age (15–49 years) in three districts of Punjab. The dimensions of empowerment were categorized broadly into: economic decision-making, household decision-making, and women's mobility. Two measures were created for each dimension, and for the overall empowerment: women's independent decisions, and those taken jointly by couples. Contraceptive use was categorized as either female-only or couple methods on the basis of whether a method requires the awareness of, or some support and cooperation from, the husband. Multinomial regression was used, by means of Odds Ratios (OR), to assess associations between empowerment dimensions and female-only and couple contraceptive methods.
Results
Overall, women tend to get higher decision-making power with increased age, higher literacy, a greater number of children, or being in a household that has superior socio-economic status. The measures for couples' decision-making for overall empowerment and for each dimension of it showed positive associations with couple methods as well as with female-only methods. The only exception was the measure of economic empowerment, which was associated only with the couple method.
Conclusion
Couples' joint decision-making is a stronger determinant of the use of contraceptive methods than women-only decision-making. This is the case over and above the contribution of women's socio-demographic and economic statuses. Effort needs to be made to educate women and their husbands equally, with particular focus on highly effective contraceptive methods.
doi:10.1371/journal.pone.0104633
PMCID: PMC4131908  PMID: 25119727
7.  Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exercise 
Reproductive Health  2014;11:61.
Background
Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required.
Methods
We adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set global research priorities for maternal and perinatal health for the period 2015 to 2025. Priority research questions were received from various international stakeholders constituting a large reference group, and consolidated into a final list of research questions by a technical working group. Questions on this list were then scored by the reference working group according to five independent and equally weighted criteria. Normalized research priority scores (NRPS) were calculated, and research priority questions were ranked accordingly.
Results
A list of 190 priority research questions for improving maternal and perinatal health was scored by 140 stakeholders. Most priority research questions (89%) were concerned with the evaluation of implementation and delivery of existing interventions, with research subthemes frequently concerned with training and/or awareness interventions (11%), and access to interventions and/or services (14%). Twenty-one questions (11%) involved the discovery of new interventions or technologies.
Conclusions
Key research priorities in maternal and perinatal health were identified. The resulting ranked list of research questions provides a valuable resource for health research investors, researchers and other stakeholders. We are hopeful that this exercise will inform the post-2015 Development Agenda and assist donors, research-policy decision makers and researchers to invest in research that will ultimately make the most significant difference in the lives of mothers and babies.
doi:10.1186/1742-4755-11-61
PMCID: PMC4132282  PMID: 25100034
Research priorities; CHNRI; Maternal and perinatal health
8.  A cross-sectional study on attitudes toward gender equality, sexual behavior, positive sexual experiences, and communication about sex among sexually active and non-sexually active adolescents in Bolivia and Ecuador 
Global Health Action  2014;7:10.3402/gha.v7.24089.
Background
It is widely agreed upon that gender is a key aspect of sexuality however, questions remain on how gender exactly influences adolescents’ sexual health.
Objective
The aim of this research was to study correlations between gender equality attitudes and sexual behavior, sexual experiences and communication about sex among sexually active and non-sexually active adolescents in 2 Latin American countries.
Design
In 2011, a cross-sectional study was carried out among 5,913 adolescents aged 14–18 in 20 secondary schools in Cochabamba (Bolivia) and 6 secondary schools in Cuenca (Ecuador). Models were built using logistic regressions to assess the predictive value of attitudes toward gender equality on adolescents’ sexual behavior, on experiences and on communication.
Results
The analysis shows that sexually active adolescents who consider gender equality as important report higher current use of contraceptives within the couple. They are more likely to describe their last sexual intercourse as a positive experience and consider it easier to talk with their partner about sexuality than sexually experienced adolescents who are less positively inclined toward gender equality. These correlations remained consistent whether the respondent was a boy or a girl. Non-sexually active adolescents, who consider gender equality to be important, are more likely to think that sexual intercourse is a positive experience. They consider it less necessary to have sexual intercourse to maintain a relationship and find it easier to communicate with their girlfriend or boyfriend than sexually non-active adolescents who consider gender equality to be less important. Comparable results were found for boys and girls.
Conclusions
Our results suggest that gender equality attitudes have a positive impact on adolescents’ sexual and reproductive health (SRH) and wellbeing. Further research is necessary to better understand the relationship between gender attitudes and specific SRH outcomes such as unwanted teenage pregnancies and sexual pleasure among adolescents worldwide.
doi:10.3402/gha.v7.24089
PMCID: PMC4095758  PMID: 25024066
adolescents; gender attitudes; Latin America; sexual behavior; positive sexual experiences
9.  A study protocol: using demand-side financing to meet the birth spacing needs of the underserved in Punjab Province in Pakistan 
Reproductive Health  2014;11:39.
Background
High fertility rates, unwanted pregnancies, low modern contraceptive prevalence and a huge unmet need for contraception adversely affect women’s health in Pakistan and this problem is compounded by limited access to reliable information and quality services regarding birth spacing especially in rural and underserved areas. This paper presents a study protocol that describes an evaluation of a demand-side financing (DSF) voucher approach which aims to increase the uptake of modern contraception among women of the lowest two wealth quintiles in Punjab Province, Pakistan.
Methods/Design
This study will use quasi-experimental design with control arm and be implemented in: six government clinics from the Population Welfare Department; 24 social franchise facilities branded as ‘Suraj’ (Sun), led by Marie Stopes Society (a local non-governmental organization); and 12 private sector clinics in Chakwal, Mianwali and Bhakkar districts. The study respondents will be interviewed at baseline and endline subject to voluntary acceptance and medical eligibility. In addition, health service data will record each client visit during the study period.
Discussion
The study will examine the impact of vouchers in terms of increasing the uptake of modern contraception by engaging private and public sector service providers (mid-level and medical doctors). If found effective, this approach can be a viable solution to satisfying the current demand and meeting the unmet need for contraception, particularly among the poorest socio-economic group.
doi:10.1186/1742-4755-11-39
PMCID: PMC4059733  PMID: 24885657
Demand-side financing; Voucher; Social franchising; Quasi-experimental; Maternal health; Unmet need for modern contraception; Birth spacing; Study protocol; Punjab; Pakistan
10.  Implementation of evidence-based antenatal care in Mozambique: a cluster randomized controlled trial: study protocol 
Background
Antenatal care (ANC) reduces maternal and perinatal morbidity and mortality directly through the detection and treatment of pregnancy-related illnesses, and indirectly through the detection of women at increased risk of delivery complications. The potential benefits of quality antenatal care services are most significant in low-resource countries where morbidity and mortality levels among women of reproductive age and neonates are higher.
WHO developed an ANC model that recommended the delivery of services scientifically proven to improve maternal, perinatal and neonatal outcomes. The aim of this study is to determine the effect of an intervention designed to increase the use of the package of evidence-based services included in the WHO ANC model in Mozambique. The primary hypothesis is that the intervention will increase the use of evidence-based practices during ANC visits in comparison to the standard dissemination channels currently used in the country.
Methods
This is a demonstration project to be developed through a facility-based cluster randomized controlled trial with a stepped wedge design. The intervention was tailored, based on formative research findings, to be readily applicable to local prenatal care services and acceptable to local pregnant women and health providers. The intervention includes four components: the provision of kits with all necessary medicines and laboratory supplies for ANC (medical and non-medical equipment), a storage system, a tracking system, and training sessions for health care providers. Ten clinics were selected and will start receiving the intervention in a random order. Outcomes will be computed at each time point when a new clinic starts the intervention. The primary outcomes are the delivery of selected health care practices to women attending the first ANC visit, and secondary outcomes are the delivery of selected health care practices to women attending second and higher ANC visits as well as the attitude of midwives in relation to adopting the practices. This demonstration project is pragmatic in orientation and will be conducted under routine conditions.
Discussion
There is an urgent need for effective and sustainable scaling-up approaches of health interventions in low-resource countries. This can only be accomplished by the engagement of the country’s health stakeholders at all levels. This project aims to achieve improvement in the quality of antenatal care in Mozambique through the implementation of a multifaceted intervention on three levels: policy, organizational and health care delivery levels. The implementation of the trial will probably require a change in accountability and behaviour of health care providers and we expect this change in ‘habits’ will contribute to obtaining reliable health indicators, not only related to research issues, but also to health care outcomes derived from the new health care model. At policy level, the results of this study may suggest a need for revision of the supply chain management system. Given that supply chain management is a major challenge for many low-resource countries, we envisage that important lessons on how to improve the supply chain in Mozambique and other similar settings, will be drawn from this study.
Trial registration
Pan African Clinical Trial Registry database. Identification number: PACTR201306000550192.
doi:10.1186/1472-6963-14-228
PMCID: PMC4057585  PMID: 24886392
Antenatal care; Pregnancy
11.  Sexual violence and sub-Saharan migrants in Morocco: a community-based participatory assessment using respondent driven sampling 
Background
The European Union contracted Morocco to regulate migration from so-called “transit migrants” from Morocco to Europe via the European Neighbourhood Policy. Yet, international organisations signal that human, asylum and refugee rights are not upheld in Morocco and that many sub-Saharan migrants suffer from ill-health and violence. Hence, our study aimed at 1) investigating the nature of violence that sub-Saharan migrants experience around and in Morocco, 2) assessing which determinants they perceive as decisive and 3) formulating prevention recommendations.
Methods
Applying Community-Based Participatory Research, we trained twelve sub-Saharan migrants as Community Researchers to conduct in-depth interviews with peers, using Respondent Driven Sampling. We used Nvivo 8 to analyse the data. We interpreted results with Community Researchers and the Community Advisory Board and commonly formulated prevention recommendations.
Results
Among the 154 (60 F-94 M) sub-Saharan migrants interviewed, 90% reported cases of multiple victimizations, 45% of which was sexual, predominantly gang rape. Seventy-nine respondents were personally victimized, 41 were forced to witness how relatives or co-migrants were victimized and 18 others knew of peer victimisation. Severe long lasting ill-health consequences were reported while sub-Saharan victims are not granted access to the official health care system. Perpetrators were mostly Moroccan or Algerian officials and sub-Saharan gang leaders who function as unofficial yet rigorous migration professionals at migration ‘hubs’. They seem to proceed in impunity. Respondents link risk factors mainly to their undocumented and unprotected status and suggest that migrant communities set-up awareness raising campaigns on risks while legal and policy changes enforcing human rights, legal protection and human treatment of migrants along with severe punishment of perpetrators are politically lobbied for.
Conclusion
Sub-Saharan migrants are at high risk of sexual victimization and subsequent ill-health in and around Morocco. Comprehensive cross-border and multi-level prevention actions are urgently called for. Given the European Neighbourhood Policy, we deem it paramount that the European Union politically cares for these migrants’ lives and health, takes up its responsibility, drastically changes migration regulation into one that upholds human rights beyond survival and enforces all authorities involved to restore migrants’ lives worthy to be lived again.
doi:10.1186/1744-8603-10-32
PMCID: PMC4122073  PMID: 24885537
Sexual violence; Rape; Prevention; Migrants; Morocco; Community Based Participatory Research (CBPR); Respondent Driven Sampling (RDS); European Neighbourhood Policy (ENP)
12.  Sexual health is dead in my body: participatory assessment of sexual health determinants by refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands 
BMC Public Health  2014;14:416.
Background
Although migrants constitute an important proportion of the European population, little is known about migrant sexual health. Existing research mainly focuses on migrants’ sexual health risks and accessibility issues while recommendations on adequate sexual health promotion are rarely provided. Hence, this paper explores how refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands define sexual health, search for sexual health information and perceive sexual health determinants.
Methods
Applying Community-based Participatory Research as the overarching research approach, we conducted 223 in-depth interviews with refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. The Framework Analysis Technique was used to analyse qualitative data. We checked the extensiveness of the qualitative data and analysed the quantitative socio-demographic data with SPSS.
Results
Our results indicate that gender and age do not appear to be decisive determinants. However, incorporated cultural norms and education attainment are important to consider in desirable sexual health promotion in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Furthermore, our results demonstrate that these migrants have a predominant internal health locus of control. Yet, most of them feel that this personal attitude is hugely challenged by the Belgian and Dutch asylum system and migration laws which force them into a structural dependent situation inducing sexual ill-health.
Conclusion
Refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands are at risk of sexual ill-health. Incorporated cultural norms and attained education are important determinants to address in desirable sexual health promotion. Yet, as their legal status demonstrates to be the key determinant, the prime concern is to alter organizational and societal factors linked to the Belgian and Dutch asylum system. Refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands should be granted the same opportunity as Belgian and Dutch citizens have, to become equally in control of their sexual health and sexuality.
doi:10.1186/1471-2458-14-416
PMCID: PMC4012172  PMID: 24886093
Sexual health; Sexuality; Health determinants; Migrants; Refugees; Asylum seekers; Undocumented; Health locus of control; Community-based participatory research
13.  Identifying factors associated with the uptake of prevention of mother to child HIV transmission programme in Tigray region, Ethiopia: a multilevel modeling approach 
Background
Prevention of mother to child HIV transmission (PMTCT) remains a challenge in low and middle-income countries. Determinants of utilization occur – and often interact - at both individual and community levels, but most studies do not address how determinants interact across levels. Multilevel models allow for the importance of both groups and individuals in understanding health outcomes and provide one way to link the traditionally distinct ecological- and individual-level studies. This study examined individual and community level determinants of mother and child receiving PMTCT services in Tigray region, Ethiopia.
Methods
A multistage probability sampling method was used for this 2011 cross-sectional study of 220 HIV positive post-partum women attending child immunization services at 50 health facilities in 46 districts. In view of the nested nature of the data, we used multilevel modeling methods and assessed macro level random effects.
Results
Seventy nine percent of mothers and 55.7% of their children had received PMTCT services. Multivariate multilevel modeling found that mothers who delivered at a health facility were 18 times (AOR = 18.21; 95% CI 4.37,75.91) and children born at a health facility were 5 times (AOR = 4.77; 95% CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. For every addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (AOR = 7.22; 95% CI 1.02,51.26), when other individual and community level factors were controlled simultaneously. In addition, district-level variation was low for mothers receiving PMTCT services (0.6% between districts) but higher for children (27.2% variation between districts).
Conclusions
This study, using a multilevel modeling approach, was able to identify factors operating at both individual and community levels that affect mothers and children getting PMTCT services. This may allow differentiating and accentuating approaches for different settings in Ethiopia. Increasing health facility delivery and HCT coverage could increase mother-child pairs who are getting PMTCT. Reducing the distance to health facility and increasing the number of nurses and laboratory technicians are also important variables to be considered by the government.
doi:10.1186/1472-6963-14-181
PMCID: PMC4022443  PMID: 24755368
14.  Spousal discordance on fertility preference and its effect on contraceptive practice among married couples in Jimma zone, Ethiopia 
Reproductive Health  2014;11:27.
Objectives
To assess spousal agreement levels regarding fertility preference and spousal communication, and to look at how it affects contraceptive use by couples.
Methods
We conducted a cross-sectional study to collect quantitative data from March to May 2010 in Jimma zone, Ethiopia, using a multistage sampling design covering six districts. In each of the 811 couples included in the survey, both spouses were interviewed. Concordance between the husband and wife was assessed using different statistics and tests including concordance rates, ANOVA, Cohen’s Κ and McNemar’s test for paired samples. Multivariate analysis was computed to ascertain factors associated with contraceptive use.
Results
Over half of the couples wanted more children and 27.8% of the spouses differed about the desire for more children. In terms of sex preference, there was a 48.7% discord in couples who wanted to have more children. At large, spousal concordance on the importance of family planning was positive. However, it was the husband’s favourable attitude towards family planning that determined a couple’s use of contraception. Overall, contraceptive prevalence was 42.9%. Among the groups with the highest level of contraceptive users, were couples where the husband does not want any more children. Spousal communication about the decision to use contraception showed a positive association with a couple’s contraceptive prevalence.
Conclusions
Family planning programs aiming to increase contraceptive uptake could benefit from findings on spousal agreement regarding fertility desire, because the characteristics of each spouse influences the couple’s fertility level. Disparities between husband and wife about the desire for more children sustain the need for male consideration while analysing the unmet need for contraception. Moreover, men play a significant role in the decision making concerning contraceptive use. Accordingly, involving men in family planning programs could increase a couple’s contraceptive practice in the future.
doi:10.1186/1742-4755-11-27
PMCID: PMC3983854  PMID: 24708827
Fertility preference; Couples; Contraception; Spousal discordance
15.  Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers 
Aims
To investigate putative links between alcohol use, and unsafe sex and incident HIV infection in sub-Saharan Africa.
Methods
A cohort of 400 HIV-negative female sex workers was established in Mombasa, Kenya. Associations between categories of the Alcohol Use Disorders Identification Test (AUDIT) and the incidence at one year of unsafe sex, HIV and pregnancy were assessed using Cox proportional hazards models. Violence or STIs other than HIV measured at one year was compared across AUDIT categories using multivariate logistic regression.
Results
Participants had high levels of hazardous (17.3%, 69/399) and harmful drinking (9.5%, 38/399), while 36.1% abstained from alcohol. Hazardous and harmful drinkers had more unprotected sex and higher partner numbers than abstainers. Sex while feeling drunk was frequent and associated with lower condom use. Occurrence of condom accidents rose step-wise with each increase in AUDIT category. Compared with non-drinkers, women with harmful drinking had 4.1-fold higher sexual violence (95% CI adjusted odds ratio [AOR] = 1.9-8.9) and 8.4 higher odds of physical violence (95% CI AOR = 3.9-18.0), while hazardous drinkers had 3.1-fold higher physical violence (95% CI AOR = 1.7-5.6). No association was detected between AUDIT category and pregnancy, or infection with Syphilis or Trichomonas vaginalis. The adjusted hazard ratio of HIV incidence was 9.6 comparing women with hazardous drinking to non-drinkers (95% CI = 1.1-87.9).
Conclusions
Unsafe sex, partner violence and HIV incidence were higher in women with alcohol use disorders. This prospective study, using validated alcohol measures, indicates that harmful or hazardous alcohol can influence sexual behaviour. Possible mechanisms include increased unprotected sex, condom accidents and exposure to sexual violence. Experimental evidence is required demonstrating that interventions to reduce alcohol use can avert unsafe sex.
doi:10.1186/1744-8603-10-22
PMCID: PMC3985581  PMID: 24708844
Alcohol; Sub-Saharan Africa; HIV prevention; Cohort study; Kenya; AUDIT test
16.  Attendance at Cervical Cancer Screening and Use of Diagnostic and Therapeutic Procedures on the Uterine Cervix Assessed from Individual Health Insurance Data (Belgium, 2002-2006) 
PLoS ONE  2014;9(4):e92615.
Objective
To assess the coverage for cervical cancer screening as well as the use of cervical cytology, colposcopy and other diagnostic and therapeutic interventions on the uterine cervix in Belgium, using individual health insurance data.
Methods
The Intermutualistic Agency compiled a database containing 14 million records from reimbursement claims for Pap smears, colposcopies, cervical biopsies and surgery, performed between 2002 and 2006. Cervical cancer screening coverage was defined as the proportion of women aged 25–64 that had a Pap smear within the last 3 years.
Results
Cervical cancer screening coverage was 61% at national level, for the target population of women between 25 and 64 years old, in the period 2004–2006. Differences between the 3 regions were small, but varied more substantially between provinces. Coverage was 70% for 25–34 year old women, 67% for those aged 35–39 years, and decreased to 44% in the age group of 60–64 years. The median screening interval was 13 months. The screening coverage varied substantially by social category: 40% and 64%, in women categorised as beneficiary or not-beneficiary of increased reimbursement from social insurance, respectively. In the 3-year period 2004–2006, 3.2 million screen tests were done in the target group consisting of 2.8 million women. However, only 1.7 million women got one or more smears and 1.1 million women had no smears, corresponding to an average of 1.88 smears per woman in three years of time. Colposcopy was excessively used (number of Pap smears over colposcopies = 3.2). The proportion of women with a history of conisation or hysterectomy, before the age of 65, was 7% and 19%, respectively.
Conclusion
The screening coverage increased slightly from 59% in 2000 to 61% in 2006. The screening intensity remained at a high level, and the number of cytological examinations was theoretically sufficient to cover more than the whole target population.
doi:10.1371/journal.pone.0092615
PMCID: PMC3972167  PMID: 24690620
17.  Newborn care in Indonesia, Lao People’s Democratic Republic and the Philippines: a comprehensive needs assessment 
BMC Pediatrics  2014;14:46.
Background
Between 1990 and 2011, global neonatal mortality decline was slower than that of under-five mortality. As a result, the proportion of under-five deaths due to neonatal mortality increased. This increase is primarily a consequence of decreasing post-neonatal and child under-five mortality as a result of the typical focus of child survival programmes of the past two decades on diseases affecting children over four weeks of age. Newborns are lagging behind in improved child health outcomes. The aim of this study was to conduct a comprehensive, equity-focussed newborn care assessment and to explore options to improve newborn survival in Indonesia, Lao People’s Democratic Republic (PDR) and the Philippines.
Methods
We assessed newborn health policies, services and care in the three countries through document review, interviews and health facility visits. Findings were triangulated to describe newborns’ health status, the health policy and the health system context for newborn care and the equity situation regarding newborn survival.
Results
Main findings: (1) In the three countries, decline of neonatal mortality is lagging behind compared to that of under-five mortality. (2) Comprehensive newborn policies in line with international standards exist, although implementation remains poor. An important factor hampering implementation is decentralisation of the health sector, which created confusion regarding roles and responsibilities. Management capacity and skills at decentralised level were often found to be limited. (3) Quality of newborn care provided at primary healthcare and referral level is generally substandard. Limited knowledge and skills among providers of newborn care are contributing to poor quality of care. (4) Socio-economic and geographic inequities in newborn care are considerable.
Conclusions
Similar important challenges for newborn care have been identified in Indonesia, Lao PDR and the Philippines. There is an urgent need to address weak leadership and governance regarding newborn care, quality of newborn care provided and inequities in newborn care. Child survival programmes focussed on children over four weeks of age have shown to have positive outcomes. Similar efforts as those used in these programmes should be considered in newborn care.
doi:10.1186/1471-2431-14-46
PMCID: PMC3928581  PMID: 24528519
Newborn care; Needs assessment; Quality of care; Equity; Healthcare policy; South-East Asia
18.  It's about time: WHO and partners release programming strategies for postpartum family planning 
The postpartum period is a critical time to address high unmet family planning need and to reduce the risks of closely spaced pregnancies. Practical tools are included in the new resource for integrating postpartum family planning at points when women have frequent health system contact, including during antenatal care, labor and delivery, postnatal care, immunization, and child health care.
The postpartum period is a critical time to address high unmet family planning need and to reduce the risks of closely spaced pregnancies. Practical tools are included in the new resource for integrating postpartum family planning at points when women have frequent health system contact, including during antenatal care, labor and delivery, postnatal care, immunization, and child health care.
doi:10.9745/GHSP-D-13-00156
PMCID: PMC4168603  PMID: 25276558
19.  A History of Abuse and Operative Delivery – Results from a European Multi-Country Cohort Study 
PLoS ONE  2014;9(1):e87579.
Objective
The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the reported abuse had been experienced as a child or an adult.
Design
The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another medical reason. Binary and multinomial regression analysis were used to assess the associations.
Results
Among 3308 primiparous women, sexual abuse as an adult (≥18 years) increased the risk of an elective CS, Adjusted Odds Ratio 2.12 (1.28–3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24–11.24). Women expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07 (1.46–11.3). Neither physical abuse (in adulthood or childhood <18 years), nor sexual abuse in childhood increased the risk of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for emergency CS of 1.51 (1.05–2.19).
Conclusion
Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an emergency CS.
doi:10.1371/journal.pone.0087579
PMCID: PMC3909197  PMID: 24498142
20.  Intimate Partner Violence and Pregnancy: A Systematic Review of Interventions 
PLoS ONE  2014;9(1):e85084.
Abstract
Background
Intimate partner violence (IPV) around the time of pregnancy is a widespread global health problem with many negative consequences. Nevertheless, a lot remains unclear about which interventions are effective and might be adopted in the perinatal care context.
Objective
The objective is to provide a clear overview of the existing evidence on effectiveness of interventions for IPV around the time of pregnancy.
Methods
Following databases PubMed, Web of Science, CINAHL and the Cochrane Library were systematically searched and expanded by hand search. The search was limited to English peer-reviewed randomized controlled trials published from 2000 to 2013. This review includes all types of interventions aiming to reduce IPV around the time of pregnancy as a primary outcome, and as secondary outcomes to enhance physical and/or mental health, quality of life, safety behavior, help seeking behavior, and/or social support.
Results
We found few randomized controlled trials evaluating interventions for IPV around the time of pregnancy. Moreover, the nine studies identified did not produce strong evidence that certain interventions are effective. Nonetheless, home visitation programs and some multifaceted counseling interventions did produce promising results. Five studies reported a statistically significant decrease in physical, sexual and/or psychological partner violence (odds ratios from 0.47 to 0.92). Limited evidence was found for improved mental health, less postnatal depression, improved quality of life, fewer subsequent miscarriages, and less low birth weight/prematurity. None of the studies reported any evidence of a negative or harmful effect of the interventions.
Conclusions and implications
Strong evidence of effective interventions for IPV during the perinatal period is lacking, but some interventions show promising results. Additional large-scale, high-quality research is essential to provide further evidence about the effect of certain interventions and clarify which interventions should be adopted in the perinatal care context.
doi:10.1371/journal.pone.0085084
PMCID: PMC3901658  PMID: 24482679
21.  Maternal anaemia and duration of zidovudine in antiretroviral regimens for preventing mother-to-child transmission: a randomized trial in three African countries 
BMC Infectious Diseases  2013;13:522.
Background
Although substantiated by little evidence, concerns about zidovudine-related anaemia in pregnancy have influenced antiretroviral (ARV) regimen choice for preventing mother-to-child transmission of HIV-1, especially in settings where anaemia is common.
Methods
Eligible HIV-infected pregnant women in Burkina Faso, Kenya and South Africa were followed from 28 weeks of pregnancy until 12–24 months after delivery (n = 1070). Women with a CD4 count of 200-500cells/mm3 and gestational age 28–36 weeks were randomly assigned to zidovudine-containing triple-ARV prophylaxis continued during breastfeeding up to 6-months, or to zidovudine during pregnancy plus single-dose nevirapine (sd-NVP) at labour. Additionally, two cohorts were established, women with CD4 counts: <200 cells/mm3 initiated antiretroviral therapy, and >500 cells/mm3 received zidovudine during pregnancy plus sd-NVP at labour. Mild (haemoglobin 8.0-10.9 g/dl) and severe anaemia (haemoglobin < 8.0 g/dl) occurrence were assessed across study arms, using Kaplan-Meier and multivariable Cox proportional hazards models.
Results
At enrolment (corresponded to a median 32 weeks gestation), median haemoglobin was 10.3 g/dl (IQR = 9.2-11.1). Severe anaemia occurred subsequently in 194 (18.1%) women, mostly in those with low baseline haemoglobin, lowest socio-economic category, advanced HIV disease, prolonged breastfeeding (≥6 months) and shorter ARV exposure. Severe anaemia incidence was similar in the randomized arms (equivalence P-value = 0.32). After 1–2 months of ARV’s, severe anaemia was significantly reduced in all groups, though remained highest in the low CD4 cohort.
Conclusions
Severe anaemia occurs at a similar rate in women receiving longer triple zidovudine-containing regimens or shorter prophylaxis. Pregnant women with pre-existing anaemia and advanced HIV disease require close monitoring.
Trial registration number
ISRCTN71468401
doi:10.1186/1471-2334-13-522
PMCID: PMC3829097  PMID: 24192332
Zidovudine; Pregnancy; HIV; Sub-Saharan Africa; Anaemia; Drug toxicity
22.  Determinants of child and forced marriage in Morocco: stakeholder perspectives on health, policies and human rights 
Background
In Morocco, the social and legal framework surrounding sexual and reproductive health has transformed greatly in the past decade, especially with the introduction of the new Family Law or Moudawana. Yet, despite raising the minimum age of marriage for girls and stipulating equal rights in the family, child and forced marriage is widespread. The objective of this research study was to explore perspectives of a broad range of professionals on factors that contribute to the occurrence of child and forced marriage in Morocco.
Methods
A qualitative approach was used to generate both primary and secondary data for the analysis. Primary data consist of individual semi-structured interviews that were conducted with 22 professionals from various sectors: health, legal, education, NGO’s and government. Sources of secondary data include academic papers, government and NGO reports, various legal documents and media reports. Data were analyzed using thematic qualitative analysis.
Results
Four major themes arose from the data, indicating that the following elements contribute to child and forced marriage: (1) the legal and social divergence in conceptualizing forced and child marriage; (2) the impact of legislation; (3) the role of education; and (4) the economic factor. Emphasis was especially placed on the new Family Code or Moudawana as having the greatest influence on advancement of women's rights in the sphere of marriage. However, participants pointed out that embedded patriarchal attitudes and behaviours limit its effectiveness.
Conclusion
The study provided a comprehensive understanding of the factors that compound the problem of child and forced marriage in Morocco. From the viewpoint of professionals, who are closely involved in tackling the issue, policy measures and the law have the greatest potential to bring child and forced marriage to a halt. However, the implementation of new legal tools is facing barriers and resistance. Additionally, the legal and policy framework should go hand in hand with both education and increased economic opportunities. Education and awareness-raising of all ages is considered essential, seeing that parents and the extended family play a huge role in marrying off girls and young women.
doi:10.1186/1472-698X-13-43
PMCID: PMC3853335  PMID: 24131501
Child and forced marriage; Morocco; Women’s rights; Sexual and reproductive health; Violence
23.  The Contribution of Emotional Partners to Sexual Risk Taking and Violence among Female Sex Workers in Mombasa, Kenya: A Cohort Study 
PLoS ONE  2013;8(8):e68855.
Objectives
To assess sexual risk-taking of female sex workers (FSWs) with emotional partners (boyfriends and husbands), compared to regular and casual clients. Experiences of violence and the degree of relationship control that FSWs have with emotional partners are also described.
Design
Cohort study with quarterly follow-up visit over 12-months.
Methods
Four hundred HIV-uninfected FSWs older than 16 years were recruited from their homes and guesthouses in Mombasa, Kenya. A structured questionnaire assessed participant characteristics and study outcomes at each visit, and women received risk-reduction counselling, male and female condoms, and HIV testing.
Results
Four or more unprotected sex acts in the past week were reported by 21.3% of women during sex with emotional partners, compared to 5.8% with regular and 4.8% with casual clients (P<0.001). Total number of unprotected sex acts per week was 5–6-fold higher with emotional partners (603 acts with 259 partners) than with regular or casual clients (125 acts with 456, and 98 acts with 632 clients, respectively; P<0.001). Mostly, perceptions of “trust” underscored unprotected sex with emotional partners. Low control over these relationships, common to many women (36.9%), was linked with higher partner numbers, inconsistent condom use, and being physically forced to have sex by their emotional partners. Half experienced sexual or physical violence in the past year, similarly associated with partner numbers and inconsistent condom use.
Conclusions
High-risk sexual behaviour, low control and frequent violence in relationships with emotional partners heighten FSWs' vulnerability and high HIV risk, requiring targeted interventions that also encompass emotional partners.
doi:10.1371/journal.pone.0068855
PMCID: PMC3737234  PMID: 23950879
24.  Primary healthcare providers’ views on improving sexual and reproductive healthcare for adolescents in Bolivia, Ecuador, and Nicaragua 
Global Health Action  2013;6:10.3402/gha.v6i0.20444.
Objectives
To elicit the views of primary healthcare providers from Bolivia, Ecuador, and Nicaragua on how adolescent sexual and reproductive health (ASRH) care in their communities can be improved.
Methods
Overall, 126 healthcare providers (46 from Bolivia, 39 from Ecuador, and 41 from Nicaragua) took part in this qualitative study. During a series of moderated discussions, they provided written opinions about the accessibility and appropriateness of ASRH services and suggestions for its improvement. The data were analyzed by employing a content analysis methodology.
Results
Study participants emphasized managerial issues such as the prioritization of adolescents as a patient group and increased healthcare providers’ awareness about adolescent-friendly approaches. They noted that such an approach needs to be extended beyond primary healthcare centers. Schools, parents, and the community in general should be encouraged to integrate issues related to ASRH in the everyday life of adolescents and become ‘gate-openers’ to ASRH services. To ensure the success of such measures, action at the policy level would be required. For example, decision-makers could call for developing clinical guidelines for this population group and coordinate multisectoral efforts.
Conclusions
To improve ASRH services within primary healthcare institutions in three Latin American countries, primary healthcare providers call for focusing on improving the youth-friendliness of health settings. To facilitate this, they suggested engaging with key stakeholders, such as parents, schools, and decision-makers at the policy level.
doi:10.3402/gha.v6i0.20444
PMCID: PMC3656216  PMID: 23680267
adolescents; reproductive health services; primary healthcare; healthcare personnel; Latin America
25.  Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia 
PLoS ONE  2013;8(4):e61335.
Background
Understanding why people do not use family planning is critical to address unmet needs and to increase contraceptive use. According to the Ethiopian Demographic and Health Survey 2011, most women and men had knowledge on some family planning methods but only about 29% of married women were using contraceptives. 20% women had an unmet need for family planning. We examined knowledge, attitudes and contraceptive practice as well as factors related to contraceptive use in Jimma zone, Ethiopia.
Methods
Data were collected from March to May 2010 among 854 married couples using a multi-stage sampling design. Quantitative data based on semi-structured questionnaires was triangulated with qualitative data collected during focus group discussions. We compared proportions and performed logistic regression analysis.
Result
The concept of family planning was well known in the studied population. Sex-stratified analysis showed pills and injectables were commonly known by both sexes, while long-term contraceptive methods were better known by women, and traditional methods as well as emergency contraception by men. Formal education was the most important factor associated with better knowledge about contraceptive methods (aOR = 2.07, p<0.001), in particular among women (aORwomen = 2.77 vs. aORmen = 1.49; p<0.001). In general only 4 out of 811 men ever used contraception, while 64% and 43% females ever used and were currently using contraception respectively.
Conclusion
The high knowledge on contraceptives did not match with the high contraceptive practice in the study area. The study demonstrates that mere physical access (proximity to clinics for family planning) and awareness of contraceptives are not sufficient to ensure that contraceptive needs are met. Thus, projects aiming at increasing contraceptive use should contemplate and establish better counseling about contraceptive side effects and method switch. Furthermore in all family planning activities both wives' and husbands' participation should be considered.
doi:10.1371/journal.pone.0061335
PMCID: PMC3634055  PMID: 23637815

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