Unmarried women's ways of facing single motherhood in Sri Lanka - a qualitative interview study

Determinants of women's agency in accessing and utilising reproductive healthcare services; a systematic review

Women's agency is vital to access and use reproductive healthcare services, particularly in contexts where patriarchal beliefs and cultural norms limit women's desire to act on their goals or affect their access to essential resources. However, less is known about what resources enable women to exercise agency to access these services. A comprehensive systematic review was conducted to summarise existing evidence on the determinants of women's agency in accessing and using reproductive healthcare services. Various determinants were identified, including individual characteristics; household structure; reproductive health-related determinants; social relations; and economic factors. These determinants of women's agency in accessing reproductive healthcare services were strongly associated with social norms and cultural beliefs. Several gaps in the literature included inconsistent definitions and measurement of women's agency; lack of considering cultural sensitivities and socially acceptable practices in the conceptualisation and measurement of women's agency; a narrow focus on services related predominantly to pregnancy and birth, with other aspects of services including sexual health and safe abortion being largely unreported. The literature focused on developing countries in Africa and Asia, leaving a significant gap in knowledge about women's agency to access services in other geographical areas or among immigrant or refugee populations living in developed countries.

The role of perceived social norms in non-suicidal self-injury and suicidality: A systematic scoping review

Social norms are an important influence on health-related behaviours and intention formation. As both suicidal behaviour and non-suicidal self-injury (NSSI) can be motivated by intentions, perceived social norms may have an important role in suicide and NSSI outcomes, although no existing reviews of this association exist. Following the PRISMA Scoping Review extension guidance, a scoping review based on systematic searches of key databases was conducted to identify published English language studies investigating the role of perceived social norms in suicidality and NSSI. Information regarding the types of social norms studied, their relationship to suicidality/NSSI outcomes, study samples and designs was charted. Thirty-six eligible studies (31 quantitative, 4 qualitative, 1 mixed methods) sampling various populations across mostly non-clinical settings were identified and narratively synthesised. Studies varied in how social norms were operationalised, measured, and investigated/explored. Most studies focused on the role of conformity to perceived masculine social norms or to some form of subjective, descriptive, or injunctive norms; there were limited studies on female/feminine norms, pro-social/protective norms, or broader gender/sexuality norms. Most studies (n = 31) were cross-sectional (quantitative) in design, few were based on existing theories of suicide/NSSI or social norms, and none concurrently tested theories of social norms and NSSI/suicidality. Perceived social norms and stronger conformity to norms were generally associated with worse NSSI/suicidality, although some pro-social norms appeared to be protective (e.g., perceived parental norms for adolescents). Whilst conformity to restrictive perceived social norms may be related to poorer suicide and NSSI outcomes, there is a lack of consistency in the literature in how social norms are defined and measured, a lack of theory-based hypothesis testing, and few longitudinal studies. There is a need for more nuanced, theory-based, investigations of how, when, where, why, and for whom, perceived norms have a causal role in NSSI and suicidality outcomes.

Outcomes of induction versus spontaneous onset of labour at 40 and 41 GW: findings from a prospective database, Sri Lanka

Objectives

The World Health Organization recommends induction of labour (IOL) for low risk pregnancy from 41 + 0 gestational weeks (GW). Nevertheless, in Sri Lanka IOL at 40 GW is a common practice. This study compares maternal/newborn outcomes after IOL at 40 GW (IOL40) or 41 GW (IOL41) versus spontaneous onset of labour (SOL).

Methods

Data were extracted from the routine prospective individual patient database of the Soysa Teaching Hospital for Women, Colombo. IOL and SOL groups were compared using logistic regression.

Results

Of 13,670 deliveries, 2359 (17.4%) were singleton and low risk at 40 or 41 GW. Of these, 456 (19.3%) women underwent IOL40, 318 (13.5%) IOL41, and 1585 (67.2%) SOL. Both IOL40 and IOL41 were associated with an increased risk of any maternal/newborn negative outcomes (OR = 2.21, 95%CI = 1.75–2.77, p < 0.001 and OR = 1.91, 95%CI = 1.47–2.48, p < 0.001 respectively), maternal complications (OR = 2.18, 95%CI = 1.71–2.77, p < 0.001 and OR = 2.34, 95%CI = 1.78–3.07, p < 0.001 respectively) and caesarean section (OR = 2.75, 95%CI = 2.07–3.65, p < 0.001 and OR = 3.01, 95%CI = 2.21–4.12, p < 0.001 respectively). Results did not change in secondary and sensitivity analyses.

Conclusions

Both IOL groups were associated with higher risk of negative outcomes compared to SOL. Findings, potentially explained by selection bias, local IOL protocols and CS practices, are valuable for Sri Lanka, particularly given contradictory findings from other settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04800-1.

Sex education and self-poisoning in Sri Lanka: an explorative analysis

Background

Self-harm and suicide are important causes of morbidity and mortality in Sri Lanka, but our understanding of these behaviours is limited. Qualitative studies have implicated familial and societal expectations around sex and relationships. We conducted an explorative analysis using case-control data to investigate the association between sex education and self-poisoning in Sri Lanka.

Methods

Cases (N=298) were self-poisoning inpatients on a toxicology ward, Teaching Hospital Peradeniya. Controls (N=500) were sex and age frequency matched to cases and were outpatients/visitors to the same hospital. Participants were asked whether they had received sex education, and to rate the quality and usefulness of any sex education received. Logistic regression models adjusted for age, sex, and religion quantified the association between receipt, quality and usefulness of sex education and self-poisoning. We tested whether the associations differed by sex.

Results

Roughly 1-in-3 cases and 1-in-5 controls reported having not received sex education. Individuals who did not receive sex education were nearly twice as likely to have self-poisoned than those who did (OR 1.68 (95% CI 1.11-2.55)). Those who reported the sex education they received as not useful were more likely to have self-poisoned compared to those who reported it useful (OR 1.95 (95% CI 1.04-3.65)). We found no evidence of an association between self-poisoning and the self-rated quality of sex education, or that associations differed by participant sex.

Conclusion

As sex education is potentially modifiable at the population-level, further research should aim to explore this association in more depth, using qualitative methods and validated measurement tools.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12374-4.

Suicide Triggers Described by Herodotus

OBJECTIVE

The aim of this study was to better understand the triggers of suicide, particularly among the ancient Greek and Persian soldiers and commanders.

METHOD

'Herodotus:TheHistories' is a history of the rulers and soldiery who participated in the Greco-Persian wars (492-449 BCE). A new translation (2013) of this manuscript was studied. Accounts of suicide were collected and collated, with descriptions of circumstances, methods, and probable triggers.

RESULTS

Nine accounts of suicide were identified. Eight of these were named individuals (4 Greeks and 4 Persians); of whom, seven were male. Only one (not the female) appeared to act in response to a mental disorder. Other triggers of suicide included guilt, avoidance of dishonour/punishment and altruism. Cutting/ stabbing was the most common method; others included hanging, jumping, poison, and burning (the single female).

CONCLUSION

While soldiers at a time of war do not reflect the general community, they are nevertheless members of their society. Thus, this evidence demonstrates that suicide triggered by burdensome circumstances (in addition to mental disorder) was known to the Greek and Persian people more than two millennia ago.

Impact of Adverse Childhood Experiences on Intimate Partner Violence Perpetration among Sri Lankan Men

In Sri Lanka, over one in three women experience intimate partner violence (IPV) victimization in their lifetime, making it a serious public health concern. Adverse childhood experiences (ACEs) such as child abuse and neglect, witnessing domestic violence, parental separation, and bullying are also widespread. Studies in Western settings have shown positive associations between ACEs and IPV perpetration in adulthood, but few have examined this relationship in a non-Western context. In the present study, we examined the association of ACEs with IPV perpetration among Sri Lankan men surveyed for the UN Multi-Country Study on Men and Violence in Asia and the Pacific. We found statistically significant positive associations between the number of ACE categories (ACE score) and emotional, financial, physical, and sexual IPV perpetration among Sri Lankan men. We analyzed the contributions of each ACE category and found that childhood abuse was strongly associated with perpetration of IPV in adulthood, with sexual abuse associated with the greatest increase in odds of perpetration (Adjusted odds ratio 2.36; 95% confidence interval: 1.69, 3.30). Witnessing abuse of one’s mother was associated with the greatest increase in the odds of perpetrating physical IPV (AOR 1.82; 95% CI: 1.29, 2.58), while lack of a male parental figure was not associated with physical IPV perpetration (AOR 0.76; 95% CI: 0.53, 1.09). These findings support a social learning theory of IPV perpetration, in which children who are exposed to violence learn to perpetrate IPV in adulthood. They also suggest that in Sri Lanka, being raised in a female-headed household does not increase the risk of IPV perpetration in adulthood compared to being raised in a household with a male parental figure. The relationship between being raised in a female-headed household (the number of which increased dramatically during Sri Lanka’s recent civil war) and perpetration of IPV warrants further study. Interventions that aim to decrease childhood abuse in Sri Lanka could both protect children now and reduce IPV in the future, decreasing violence on multiple fronts.

'Disrespectful men, disrespectable women': men's perceptions on heterosexual relationships and premarital sex in a Sri Lankan Free Trade Zone - a qualitative interview study

Background

Gender norms have been challenged by unmarried rural women’s migration for employment to urban Sri Lankan Free Trade Zones (FTZ). Men are described as looking for sexual experiences among the women workers, who are then accused of engaging in premarital sex, something seen as taboo in this context. Increased sexual and reproductive health and rights (SRHR) risks for women workers are reported. To improve SRHR it is important to understand the existing gender ideals that shape these behaviours. This qualitative study explores men’s perspectives on gender relations in an urban Sri Lankan FTZ, with a focus on heterosexual relationships and premarital sex. Further, possible implications for SRHR of women workers in FTZs are discussed.

Methods

Eighteen qualitative semi-structured interviews were conducted with men living or working in an urban Sri Lankan FTZ and were analysed using thematic analysis.

Results

Two conflicting constructions of masculinity; the ‘disrespectful womaniser’ and the ‘respectful partner’, were discerned. The ‘disrespectful womaniser’ was perceived to be predominant and was considered immoral while the ‘respectful partner’ was considered to be less prevalent, but was seen as morally upright. The migrant women workers’ moral values upon arrival to the FTZ were perceived to deteriorate with time spent in the FTZ. Heterosexual relationships and premarital sex were seen as common, however, ideals of female respectability and secrecy around premarital sex were perceived to jeopardize contraceptive use and thus counteract SRHR.

Conclusion

The ‘disrespectful’ masculinity revealed in the FTZ is reflective of the patriarchal Sri Lankan society that enables men’s entitlement and sexual domination over women. Deterioration of men’s economic power and increase of women’s economic and social independence may also be important aspects contributing to men’s antagonistic attitudes towards women. The promotion of negative attitudes towards women is normalized through masculine peer pressure. This and ambivalence towards women’s premarital sex are undermining the SRHR and well-being of women, but also men, in the FTZ. Awareness and counteraction of destructive gender power relations are essential for the improvement of the SRHR of women and men in the FTZ and the surrounding society.

A quantitative exploration of the sociocultural context of teenage pregnancy in Sri Lanka

BACKGROUND

In common with other countries, teenage pregnancy is attracting policy attention in Sri Lanka because of the risks it poses to maternal and infant health and social and economic well-being. This study aimed to increase understanding of the context of teenage pregnancy, by (1) describing the socio-economic and demographic characteristics of pregnant teenagers and their partners; (2) exploring whether teenage pregnancies are planned and how they are received; and (3) exploring factors associated with unplanned teenage pregnancy.

METHODS

A population health-register based sample survey was conducted in Badulla District, Sri Lanka. Interviewer-administered questionnaires were administered to two samples: 450 pregnant women aged less than 20 years; and 150 male partners of pregnant women aged less than 20 years. Bivariate statistics described the characteristics and context of teenage pregnancy. Multivariate logistic regression explored correlates of unplanned pregnancy.

RESULTS

Over 60% of pregnant teenagers and male partners indicated that the current pregnancy was planned; while 79% of pregnant teenagers and 85% of male partners welcomed the pregnancy. Most pregnant teenagers were living within stable and supportive family environments, with 94% reporting that they felt 'very well supported'. Nevertheless, a sub-group of pregnant teenagers appeared to be vulnerable, reporting unplanned and unhappy pregnancy; factors that were also associated with first intercourse being reported as not wanted. Levels of reproductive and contraceptive knowledge were poor among both pregnant teenagers and male partners. Just 46% of teenagers and 64% of male partners knew that pregnancy was possible at first intercourse. Mothers appear to be an important source of information and support for young women, with peers being reported far less often.

CONCLUSIONS

Intervention to reduce teenage pregnancy must recognise the normative nature of early childbearing for the majority of girls who currently conceive and their families. Avoiding such pregnancies will require a fundamental shift in life chances such that delaying pregnancy offers significant socioeconomic advantages. Meanwhile, improved provision of contraceptive information and services is needed to support the delay of second pregnancies for young mothers. In addition, strategies to identify and protect those girls who are vulnerable to unwanted sexual activity are needed.

Disabled women׳s maternal and newborn health care in rural Nepal: a qualitative study

OBJECTIVE

there is little evidence about disabled women׳s access to maternal and newborn health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and care seeking. Our study explores disabled women׳s experiences of maternal and newborn care in rural Nepal.

DESIGN

we used a qualitative methodology, using semi-structured interviews.

SETTING

rural Makwanpur District of central Nepal.

PARTICIPANTS

we purposively sampled married women with different impairments who had delivered a baby in the past 10 years from different topographical areas of the district. We also interviewed maternal health workers. We compared our findings with a recent qualitative study of non-disabled women in the same district to explore the differences between disabled and non-disabled women.

FINDINGS

married disabled women considered pregnancy and childbirth to be normal and preferred to deliver at home. Issues of quality, cost and lack of family support were as pertinent for disabled women as they were for their non-disabled peers. Health workers felt unprepared to meet the maternal health needs of disabled women.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

integration of disability into existing Skilled Birth Attendant training curricula may improve maternal health care for disabled women. There is a need to monitor progress of interventions that encourage institutional delivery through the use of disaggregated data, to check that disabled women are benefiting equally in efforts to improve access to maternal health care.