Person-centered abortion care scale: Validation for medication abortion in the United States

OBJECTIVE

Medication abortions now make up the majority of abortions in the US, with new service delivery models such as telehealth; however, it is unclear how this may impact patient experiences. The objective of the study is to adapt and validate a person-centered abortion care (PCAC) scale for medication abortions that was developed in a global South context (Kenya) for use in the United States.

STUDY DESIGN

This study includes medication abortion patients from a hospital-based clinic who had one of two modes of service delivery: 1) telemedicine with no physical exam or ultrasound; or 2) in-person with clinic-based exams and ultrasounds. We conducted a sequential approach to scale development including: 1) defining constructs and item generation; 2) expert reviews; 3) cognitive interviews (n=12); 4) survey development and online survey data collection (N=182, including 45 telemedicine patients and 137 in-person patients); and 5) psychometric analyses.

RESULTS

Exploratory factor analyses identified 29-items for the US-PCAC scale with three subscales: 1) Respect & Dignity (10 items), 2) Responsive & Supportive Care (9 items for the full scale, 1 additional mode-specific item each for in-person and telemedicine), and 3) Communication & Autonomy (10 items for the full scale, 1 additional item for telemedicine). The US-PCAC had high content, construct, and criterion validity. It also had high reliability, with a standardized alpha for the full 29-item US-PCAC scale of 0.95. The US-PCAC score was associated with overall satisfaction.

CONCLUSION

This study found high validity and reliability of a newly-developed person-centered abortion care scale for use in the US. As medication abortion provision expands, this scale can be used in quality improvement efforts.

IMPLICATIONS

This study found high validity and reliability of a newly-developed person-centered care scale for use in the United States for in-person and telemedicine medication abortion.

Characterizing provider bias in contraceptive care in Tanzania and Burkina Faso: A mixed-methods study

Provider bias based on age, marital status, and parity may be a barrier to quality contraceptive care. However, the extent to which bias leads to disparities in care quality is not well understood. In this mixed-methods study, we used four different data sources from the same facilities to assess the extent of bias and how much it affects contraceptive care. First, we surveyed providers in Tanzania and Burkina Faso (N = 295) to assess provider attitudes about young, unmarried, and nulliparous clients. Second, mystery clients anonymously visited providers for contraceptive care and we randomly assigned the reported age, marital status, and parity of each visit (N = 306). We used data from these visits to investigate contraceptive care disparities across 3 domains: information provision and counseling quality, contraceptive method provision, and perceived treatment. Third, we complemented mystery client data with client exit surveys (N = 31,023) and client in-depth interviews (N = 36). In surveys, providers reported biased attitudes against young, unmarried, and nulliparous clients seeking contraceptives. Similarly, we found disparities according to these characteristics in the reporting of contraceptive care quality; however, we found that each characteristic affected a different quality of care domain. Among mystery clients we found age-related disparities in the provision of methods; 16/17-year-old clients were 18 and 11 percentage points less likely to perceive they could take a contraceptive method relative to 24-year-old clients in Tanzania and Burkina Faso, respectively. Unmarried mystery clients perceived worse treatment from providers compared to married clients. Nulliparous mystery clients reported lower quality contraceptive counseling than their parous counterparts. These results suggest that clients of different characteristics likely experience bias across different elements of care. Improving care quality and reducing disparities will require attention to which elements of care are deficient for different types of clients.

Removal of long-acting reversible contraceptive methods and quality of care in Dar es Salaam, Tanzania: Client and provider perspectives from a secondary analysis of cross-sectional survey data from a randomized controlled trial

Access to removal of long-acting reversible contraception (LARCs) (e.g., implants and intrauterine devices (IUDs)) is an essential part of contraceptive care. We conducted a secondary analysis of cross-sectional survey data from a randomized controlled trial. We analyzed 5,930 client surveys and 259 provider surveys from 73 public sector facilities in Tanzania to examine the receipt of desired LARC removal services among clients and the association between receipt of desired LARC removal and person-centered care. We used provider survey data to contextualize these findings, describing provider attitudes and training related to LARC removals. All facilities took part in a larger randomized controlled trial to assess the Beyond Bias intervention, a provider-focused intervention to reduce provider bias on the basis of age, marital status, and parity. Thirteen percent of clients did not receive a desired LARC removal during their visit. Clients who were young, had lower perceived socioeconomic status, and visited facilities that did not take part in the Beyond Bias intervention were less likely to receive a desired removal. Clients who received a desired LARC removal reported higher levels of person-centered care (β = .07, CI: .02 - .11, p = < .01). Half of providers reported not being comfortable removing a LARC before its expiration (51%) or if they disagreed with the client's decision (49%). Attention is needed to ensure clients can get their LARCs removed when they want to ensure patient-centered care and protect client autonomy and rights. Interventions like the Beyond Bias intervention, may work to address provider-imposed barriers to LARC removals.

Pregnancy and pregnancy intention after experiencing infertility: A longitudinal study of women in Malawi

BACKGROUND

Infertility is a common experience among individuals and couples. Infertility may resolve without intervention, but little is known about pregnancy intentions and incidence of pregnancy following infertility, particularly in low-resource settings.

METHODS

Data come from UTHA, a longitudinal cohort study in Central Malawi, with baseline and follow up surveys conducted from 2014-2019 (N = 1,030 reproductive-aged women). We assessed bivariable and multivariable relationships between reported infertility at baseline and subsequent pregnancy and retrospective pregnancy intentions. Pregnancy intention was measured with the London Measure of Unplanned Pregnancy (LMUP), a scale validated in Malawi (Range = 0-12).

RESULTS

Approximately 20% of the sample reported that they had ever experienced infertility (tried to become pregnant for at least two years without conceiving in that time) at baseline. The proportion of women who reported a new pregnancy during the follow up period (mean = 4.3 years) was the same (65%) for women who had and had not experienced infertility. Among women who became pregnant, levels of pregnancy intendedness were similar between women who had and had not experienced infertility. Prospective desire for a/another child at baseline was associated with subsequent pregnancy (AOR: 1.59; 95%CI: 1.06-2.39) and was also associated with higher levels of pregnancy intendedness measured retrospectively (LMUP of 9.4 vs. 8.4).

CONCLUSIONS

Experienced infertility was not associated with differential odds of having a subsequent pregnancy or the intendedness of a subsequent pregnancy. Thus, women who have experienced infertility should be included in family planning programs and research to support all women in achieving their reproductive goals.

Assessing the relationship between reproductive autonomy and contraceptive use in rural Malawi

Reproductive autonomy, or the extent to which people control matters related to their own sexual and reproductive decisions, may help explain why some people who do not intend to become pregnant nevertheless do not use contraception. Using cross-sectional survey data from 695 women aged 16 to 47 enrolled in the Umoyo Wa Thanzi (UTHA) study in Malawi in 2019, we conducted confirmatory factor analysis, descriptive analyses, and multivariable logistic regression to assess the freedom from coercion and communication subscales of the Reproductive Autonomy Scale and to examine relationships between these components of reproductive autonomy and current contraceptive use. The freedom from coercion and communication subscales were valid within this population of partnered women; results from a correlated two-factor confirmatory factor analysis model resulted in good model fit. Women with higher scores on the freedom from coercion subscale had greater odds of current contraceptive use (aOR 1.13, 95% CI: 1.03-1.23) after adjustment for pregnancy intentions, relationship type, parity, education, employment for wages, and household wealth. Scores on the communication subscale were predictive of contraceptive use in some, but not all, models. These findings demonstrate the utility of the Reproductive Autonomy Scale in more holistically understanding contractive use and non-use in a lower-income setting, yet also highlight the need to further explore the multidimensionality of women's reproductive autonomy and its effects on achieving desired fertility.

Infertility and perceived chance of conception among men in Malawi

Infertility is a common experience among individuals and couples worldwide, but few studies focus on men's reports of infertility or perceived chance of conceiving, particularly in high-fertility, pronatalist contexts where infertility is highly stigmatized. Using data from the fourth wave of the Umoyo wa Thanzi (UTHA) cohort study in rural Central Malawi (2017-2018), we examine the relationship between self-reported infertility, the perceived chance of conceiving within one year, and sociodemographic characteristics among men (N = 484). While 13% of men reported that they had experienced infertility, just 4% of men perceived that they were unlikely or there was no chance they would conceive with their partner within one year of having sex without contraception. In multivariable logistic regression models, older age was associated with experienced infertility (AOR: 1.06, p < 0.05) and higher parity was associated with lower odds of reporting that conception was unlikely or there was no chance of conception (AOR: 0.08; p < 0.05). We argue that additional research on infertility focusing on men is critical in gaining a more holistic and gender-equitable understanding of infertility. Including men in infertility research may also contribute to destigmatizing infertility among both women and men by acknowledging men's roles in infertility.

Evaluating the frequency of crisis pregnancy center visits among a population of patients seeking abortions in Los Angeles

OBJECTIVES

Studies have illustrated crisis pregnancy centers' (CPC) disingenuous practices regarding abortion services. We evaluated the proportion of patients who visited a CPC before their abortion in Los Angeles.

STUDY DESIGN

Patients attending one of two abortion clinics between July 2019 and March 2020 were recruited for a survey that examined patient characteristics and locations of care.

RESULTS

Five hundred eleven respondents participated (62% response rate). Less than 1% of individuals visited a CPC before their abortion. Fifty-three percent of survey respondents obtained their abortion within one visit, 39% within two unique clinic visits, and eight percent visited three or more clinics.

CONCLUSION

CPC visits before abortion were uncommon in our patient population.

Measuring Nuance in Individual Contraceptive Need: A Case Study from a Cohort in Malawi

Contraceptive counseling protocols tend to focus narrowly on pregnancy intentions, which may overlook other factors that contribute to whether an individual wants or needs contraception. In this report, we demonstrate the potential of two measures of individual contraceptive need that could be assessed as part of contraceptive counseling: (1) a composite score constructed from pregnancy intentions, sexual frequency, and perceived fecundity and (2) a direct measure of contraceptive need ("do you feel it is necessary for you to be using contraception right now?") We compare the two measures using data from Umoyo wa Thanzi, a cohort study in Central Malawi (N = 906; 2017-2018). More frequent sex, perceptions of being more fecund, and a stronger desire to avoid pregnancy were associated with directly reporting contraceptive need (p < 0.001). Women who directly reported contraceptive need had a higher average composite score than women who directly reported they had no need (mean = 7.4 vs. 6.3; p < 0.01), but nearly all participants had scores indicating some risk of unintended pregnancy. Contraceptive counseling protocols should consider assessing women's direct report of contraceptive need, along with risk factors for unintended pregnancy, such as sexual frequency, perceived fecundity, and desire to avoid pregnancy, to better counsel clients.

Patient perspectives on barriers in obtaining timely abortion care in Los Angeles, California

OBJECTIVES

Although California is a state with supportive abortion policies, recent evidence suggests people may still encounter barriers to obtaining timely abortion care. To provide an in-depth understanding of these barriers and augment existing literature focusing on restrictive and hostile states, we sought to understand the patient perspectives of barriers to timely abortion care in Los Angeles, California.

STUDY DESIGN

We recruited participants from two, high-volume urban clinical sites and conducted semi-structured interviews with 17 individuals who visited three or more clinics and/or encountered more than 2 weeks between seeking and obtaining their abortion. Using thematic analysis, we analyzed deidentified transcripts by first developing and applying codes, then identifying overarching themes to describe barriers to timely abortion care.

RESULTS

Participants described three primary barriers leading to abortion care delay: (1) difficulties in ensuring insurance coverage or securing authorization for abortion care from private/employer-sponsored insurance, (2) inadequate screening resulting in multiple appointments where desired care could not be provided, and (3) difficulties with expeditious referrals to appropriate clinical sites. Participants also described accumulated fatigue from facing layers of resistance when pursuing avenues for care.

CONCLUSIONS

Even in supportive abortion policy states, barriers to abortion care from insurance, screening, and referral-related issues may result in delayed or unaccessed care, negatively impacting patient experience. Understanding and mitigating reasons for delays are critical to improving patient experience with abortion care.

IMPLICATIONS

Standardized telephone triage at local clinic facilities and streamlined MediCal authorization of abortion services may mitigate barriers to timely abortion care.

"I know my body and I just can't get pregnant that easily" - Women's use and non-use of the injection to manage fertility

Approximately one-third of contraceptive users in Malawi use the Depo-Provera injection, a method that must be re-injected every three-months to prevent pregnancy and may reduce fecundity for a time after discontinuation. Little is known about how women use the injection to achieve their desired family size. In 2018, we conducted 20 in-depth interviews with women who were part of a cohort study in rural Malawi. Interviews focused on contraceptive decision-making. Data were indexed (summarized) and coded using narrative, process, and thematic codes. Women described the importance of knowing about their "natural" fertility by having children prior to ever using contraception because women considered contraception to have a potential negative effect on fertility. Women then applied what they learned about their fertility (i.e., how easy/difficult it was to become pregnant) to manage their fertility over their reproductive life-course. As part of fertility management, women frequently described using the injection less frequently than clinically recommended, using signs from their body (e.g., menstruation) to determine when to reinject. Managing fertility through subclinical injection use was viewed as a way to optimize women's' chances of preventing unintended pregnancy while maintaining their ability to become pregnant when they wanted to. Women wanted to play an active role in managing their fertility and were not passive consumers of contraception. It is therefore critical that family planning programs provide contraceptive counseling to women that engages their desire to manage their fertility, acknowledges their concerns about fertility, and helps them choose a method that best fits their needs.

Measuring impact of storyline engagement on health knowledge, attitudes, and norms: A digital evaluation of an online health-focused serial drama in West Africa

Background

"Cest la Vie!" (CLV) is a serial drama that entertains, educates, and promotes positive health behaviors and social change for West African audiences. The purpose of this study was to evaluate if watching the CLV Season 2 series online had an impact on people's health knowledge, attitudes, and norms, focusing on populations in francophone West Africa.

Methods

Between July 2019 and October 2019, viewers of CLV and non-viewers were recruited from Facebook and YouTube. We conducted an online longitudinal cohort study that assessed changes in health knowledge, attitudes, and norms (KAN) between these groups. Participants completed a baseline survey prior to the online airing and up to three follow-up surveys corresponding to specific health stories in the series, including sexual violence, emergency contraception, and female circumcision. We used descriptive statistics to describe viewers and non-viewers, and an item response theory (IRT) analysis to identify the effect of viewing CLV on overall KAN.

Results

A total of 1674 respondents participated in the study. One in four participants (23%, n = 388) had seen one of the three storylines from CLV Season 2 (ie, CLV viewers). At follow-up, viewers were more likely than non-viewers to know when to correctly use emergency contraception (P < 0.001) and to believe that the practice of female circumcision should end (P = 0.001). Compared to people who did not see CLV, viewers of the series had 26% greater odds of answering pro-health responses at follow-up about sexual assault, emergency contraception, and female circumcision. Further, the level of engagement with specific storylines was associated with a differential impact on overall outcome questions.

Conclusions

As internet access continues to grow across the globe and health education materials are created and adapted for new media environments, our study provides a novel approach to examining the impact of online entertainment-education content on health knowledge, attitudes, and norms.

Vasectomy Knowledge and Interest Among U.S. Men Who Do Not Intend to Have More Children

Vasectomy is used less often than female sterilization, and many men who do not want more children may lack accurate information about vasectomy. Between May and June 2018, we used a nationally representative online panel to survey U.S. men between 25 and 55 years of age who did not want more children about their vasectomy knowledge. We also asked about interest in undergoing the procedure if it were free or low cost and explored whether a paragraph addressing common misperceptions was associated with interest. We assessed characteristics associated with high vasectomy knowledge (≥3 accurate responses to four questions about vasectomy's effect on sexual functioning and method efficacy) and vasectomy interest, using chi-square tests and multivariable-adjusted Poisson regression. Of 620 men surveyed, 564 had complete data on the outcomes and covariates of interest. Overall, 51% of respondents demonstrated high vasectomy knowledge. Men who knew someone who had a vasectomy were more likely to have high knowledge (prevalence ratio [PR]: 1.50; 95% CI [1.22, 1.85]). One-third of the sample (35%) said they would consider getting a vasectomy. Men with high (vs. moderate/low) knowledge were more likely (PR: 1.36; 95% CI [1.04, 1.77]) to consider getting a vasectomy. Race/ethnicity, income level, and receiving the informational paragraph were not associated with vasectomy interest. Greater vasectomy knowledge affects men's interest in the procedure. Given that many U.S. men lack accurate knowledge, efforts are needed to address misinformation and increase awareness about vasectomy to ensure men have the information they need to meet or contribute to reproductive goals.

Maternal and Infant Health Inequities, Reproductive Justice and COVID Addressed in RACE Series

Ethn Dis. 2022;32(4):351-356; doi:10.18865/ed.32.4.351

Infertility, Perceived Certainty of Pregnancy, and Contraceptive Use in Malawi

Infertility and unintended pregnancy are dual burdens in Malawi, where 41% of pregnancies are unintended and approximately 20% of people report infertility. Although preventing unintended pregnancy has been a focus in public health, infertility has rarely been explored as a factor that may be associated with contraceptive use. Using cross-sectional survey data (2017-2018; N = 749), we report on the prevalence of and sociodemographic characteristics associated with infertility and certainty of becoming pregnant among women in Malawi. We conducted multivariable logistic regressions examining the relationship between infertility, certainty of becoming pregnant, and contraceptive use. Approximately 16% of women experienced infertility, and three-quarters (78%) were certain they could become pregnant within one year. Women who experienced infertility had lower odds of contraceptive use than women who did not (Adjusted Odds Ratio [AOR]: 0.56; 95% Conficence Interval [CI]: 0.39-0.83). Women who said there was "no chance" or they were "unlikely" to become pregnant also had lower odds of contraceptive use compared to women who were certain they would become pregnant (AOR: 0.30; 95% CI: 0.10-0.92). Our findings indicate that experiences and perceptions surrounding fertility are associated with contraceptive use, underscoring their importance in understanding how people manage their fertility to reach their reproductive goals.

An application of Systematic Anomalous Case Analysis to improve models predicting contraceptive use in the Philippines

Amidst persistently high unintended pregnancy rates and lags in contraceptive use, novel methodological approaches may prove useful in investigating sexual and reproductive health outcomes in the Philippines. Systematic Anomalous Case Analysis (SACA) - a mixed-methods technique - was employed to examine predictors of women's lifetime contraceptive use. First, multivariable, longitudinal Poisson regression models predicted fertility and sexual debut using the 1998-2009 Cebu Longitudinal Health and Nutrition Surveys (CLHNS), then regression outliers and normative cases were used to identify 48 participants for in-depth interviews (2013-2014) for further examination. Qualitative findings from 24 women highlighted 'control over life circumstances' was critical, prompting the addition of two items to the original quantitative models predicting any contraceptive use (n=532). Each of the items, 'what happens to [them] is their own doing' and '[I] do not [have] enough control over direction life is taking [me]', significantly and independently predicted any contraceptive use (aOR: 2.37 (CI: 1.24-4.55) and aOR: 0.46 (CI: 0.28-0.77), respectively). The findings demonstrate the utility of SACA to improve the understanding and measurement of sexual and reproductive health outcomes and underscore the importance of integrating psychosocial constructs into existing models of fertility and reproductive behaviour in the Philippines to improve sexual and reproductive health outcomes.

Nomadic Tibetan women's reproductive health: findings from cross-sectional surveys with a hard-to-reach population

Background

Western China has undergone substantial sociodemographic change, yet little is known about the health status of ethnic minority populations living in these areas.

Methods

We report findings from two cross-sectional surveys conducted with female Tibetan nomads living in rural areas of Western China/Eastern Tibet. We present results of descriptive analyses of data collected from reproductive-aged females who attended community health fairs in 2014 (n = 193) and 2016 (n = 298).

Results

On average, sexual debut preceded marriage among study participants, with fertility near replacement levels (2.7 and 2.1 in 2014 and 2016, respectively). Contraceptive use was common, and dominated by use of IUDs and female sterilization. Although over three-quarters (76%) of 2016 survey participants reported ever having at least one sexually transmitted infection (STI) symptom, there was low awareness of STIs (59%) and action to prevent STIs (21%). Younger women (< 40) were more likely to report having had had an STI symptom, as compared to older women (84% versus 71%; p < 0.05).

Conclusions

We demonstrate feasibility of collecting data with this hard-to-reach population. Reporting of STI symptoms warrants further investigation to identify and address health conditions in this population of Tibetan nomadic women, especially amidst broader social and contextual changes that may affect the Tibetan population.

Western China has undergone substantial sociodemographic change, yet little is known about the health status of ethnic minority populations living in these areas. We report findings from two cross-sectional surveys conducted with female Tibetan nomads living in rural areas of Western China/Eastern Tibet. We present results of descriptive analyses of data collected from reproductive-aged females who attended community health fairs in 2014 (n = 193) and 2016 (n = 298). On average, sexual debut preceded marriage among study participants, with fertility near replacement levels (2.7 and 2.1 in 2014 and 2016, respectively). Contraceptive use was common, and dominated by use of IUDs and female sterilization. Although over three-quarters (76%) of 2016 survey participants reported ever having at least one sexually transmitted infection (STI) symptom, there was low awareness of STIs (59%) and action to prevent STIs (21%). Younger women (less than 40 years old) were more likely to report having had had an STI symptom, as compared to women over 40 years old (84% versus 71%; p < 0.05). We demonstrate feasibility of collecting data with this hard-to-reach population. Reporting of STI symptoms warrants further investigation to identify and address health conditions in this population of Tibetan nomadic women, especially amidst broader social and contextual changes that may affect the Tibetan population.

Desire to avoid pregnancy and contraceptive use among female methadone patients in Los Angeles

OBJECTIVE

Opioid use disorder (OUD) is increasing among U.S. women. Research indicates higher levels of unintended pregnancy among women with OUD as compared to the general population. Following formative in-depth research documenting the complexity of considerations around pregnancy in this population, we collected information on pregnancy preferences and contraceptive use among women attending methadone treatment.

STUDY DESIGN

We surveyed women attending methadone clinics in Los Angeles in 2018. We used the Desire to Avoid Pregnancy (DAP) Scale, a 14-item instrument (0-4; 4 = highest desire to avoid pregnancy) to capture pregnancy preferences across 3 domains: cognitive desires, affective feelings, and anticipated consequences. We conducted factor analysis, descriptive analyses, and linear and logistic regressions to assess the DAP scale and to examine relationships between pregnancy preferences, sociodemographic characteristics, and contraceptive use.

RESULTS

Women (n = 46) expressed the full range of pregnancy preferences (DAP score range: 0.4-4.0; mean: 2.24, standard deviation: 1.02; Cronbach's α = 0.92). Overall, 40% used contraception at last sex. Women who reported a greater preference to avoid pregnancy were marginally more likely to use contraception at last sex as compared to women who were more open to pregnancy (odds ratio = 1.73; p = 0.09).

CONCLUSIONS

Similar to findings from other populations, responses to the Desire to Avoid Pregnancy scale among a sample of women with OUD revealed a broad range of pregnancy preferences. Pregnancy preferences were marginally associated with contraceptive use in this sample suggesting that the DAP may provide useful insights on pregnancy preferences that may facilitate contraceptive and preconception counseling in this population.

IMPLICATIONS

Given the complexity of considerations around pregnancy for women with opioid use disorder, the DAP scale may be a valuable tool to identify women's pregnancy and childbearing preferences and to facilitate alignment of women's sexual and reproductive health desires with appropriate services.

Development and Validation of the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults

PURPOSE

We developed and validated a measure that assesses the latent construct of sexual and reproductive empowerment among adolescents and young adults. A specific measure for this group is critical because of their unique life stage and circumstances, which often includes frequent changes in sexual partners and involvement from parents in decision-making.

METHODS

After formative qualitative research, a review of the literature, and cognitive interviews, we developed 95 items representing nine dimensions of sexual and reproductive empowerment. Items were then fielded among a national sample of young people aged 15-24 years, and those who identified as sexually active completed a 3-month follow-up survey. We conducted psychometric analysis and scale validation.

RESULTS

Exploratory factor analysis on responses from 1,117 participants resulted in the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults, containing 23 items captured by seven subscales: comfort talking with partner; choice of partners, marriage, and children; parental support; sexual safety; self-love; sense of future; and sexual pleasure. Validation using logistic regression demonstrated that the subscales were consistently associated with sexual and reproductive health information and access to sexual and reproductive health services measured at baseline and moderately associated with the use of desired contraceptive methods at 3-month follow-up.

CONCLUSIONS

The Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults is a new measure that assesses young people's empowerment regarding sexual and reproductive health. It can be used by researchers, public health practitioners, and clinicians to measure sexual and reproductive empowerment among young people.

Women's Reproductive Rights Policies and Adverse Birth Outcomes: A State-Level Analysis to Assess the Role of Race and Nativity Status

INTRODUCTION

Reproductive rights policies can potentially support or inhibit individuals' abilities to attain the highest standard of reproductive and sexual health; however, research is limited on how broader social policies may differentially impact women of color and immigrants in the U.S. This study examines the associations among state-level reproductive rights policies, race, and nativity status with preterm birth and low birth weight in the U.S.

METHODS

This was a retrospective, cross-sectional analysis of all births occurring within all the 50 states and the District of Columbia using vital statistics birth record data in 2016 (N=3,945,875). Modified log-Poisson regression models with generalized estimating equations were fitted to estimate the RR of preterm birth and low birth weight associated with tertiles of the reproductive rights policies index. Analyses were conducted between 2019 and 2020.

RESULTS

Compared with women in states with the most restrictive reproductive rights policies, women living in the least restrictive states had a 7% lower low birth weight risk (adjusted RR=0.93, 95% CI=0.88, 0.99). In particular, low birth weight risk was 8% lower among Black women living in the least restrictive states than among their counterparts living in the most restrictive states (adjusted RR=0.92, 95% CI=0.86, 0.99). In addition, low birth weight risk was 6% lower among U.S.-born Black women living in the least restrictive states than among those living in the most restrictive states, but this was marginally significant (adjusted RR=0.94, 95% CI=0.89, 1.00). No other significant associations were found for race-nativity-stratified models.

CONCLUSIONS

Women living in states with fewer restrictions related to reproductive rights have lower rates of low birth weight, especially for Black women.

Challenges for Adult Undocumented Immigrants in Accessing Primary Care: A Qualitative Study of Health Care Workers in Los Angeles County

Purpose: Amid increasingly restrictive federal immigration and health care policies in the United States, access to health care for undocumented immigrants is highly dependent on the extent to which local and state policies and programs address the needs of this population. In Los Angeles County (LA County), home to the nation's largest undocumented immigrant population, supportive policies are in place, yet little is known about how undocumented immigrants navigate available services.

Methods: To gain insight into how federal, state, and local policies overlay and contribute to the experience of health care seeking among undocumented immigrants in LA County, we interviewed 19 key informant health care workers involved in the delivery of health care services, using a purposive snowball sampling approach.

Results: Three key themes emerged: (1) health care workers at all clinics sampled reported primary care appointments are readily available for undocumented immigrants; however, primary care services remain underutilized; (2) fear, misinformation, and misperceptions of coverage and immigration policies—most commonly related to the revised Public Charge Rule—may reduce program enrollment and access; and (3) frontline health care workers feel ill-equipped to address patient fears and misinformation.

Conclusion: Although county programs were perceived to improve access by covering health care costs and ensuring appointment availability, new restrictive immigration policies, such as the revised Public Charge Rule, and widespread misinformation present challenges that threaten the success of these programs. Future study to improve undocumented immigrant access to care should focus on addressing barriers resulting from these policies.

Using Systematic Anomalous Case Analysis to Examine Sexual and Reproductive Health Outcomes in the Philippines

The Philippines is characterized by sustained economic growth and political stability, yet sexual and reproductive health indicators have stalled or even worsened in recent decades. We employed an innovative, mixed-methods approach-Systematic Anomalous Case Analysis-to gain insights into these worsening trends by examining sexual and reproductive decision-making among a cohort of young adults in Metro Cebu, Philippines. We first analyzed longitudinal data (1998-2009) to predict reproductive outcomes (i.e., age of first sex, number of living children) among participants in the Cebu Longitudinal Health and Nutrition Survey to identify cases (predicted and anomalous) with whom we subsequently conducted qualitative, in-depth interviews in 2013-14 (n = 48). Analysis of the qualitative data revealed unique social and contextual factors that shaped patterns of sexual and contraceptive decision-making across three, distinct reproductive life stages: (1) at first sex, (2) after the birth of first child, and (3) after the birth of several children. However, gendered roles and expectations exerted strong influences on sexual and reproductive outcomes across these life stages. Finally, we identified two constructs from our qualitative analysis-sexual fluidity and sexual agency-that deserve further examination and integration into theoretical and empirical models of sexual and reproductive decision-making.

Individual and community-level impact of infertility-related stigma in Malawi

Infertility, a common experience among women and men worldwide, remains on the margins of public health and medicine in low-resource settings. Previous studies identified associations between individual experiences of infertility and negative outcomes, particularly in contexts where childbearing is imperative, but few have examined broader implications of infertility and infertility-related stigma on communities. To understand the production and impact of infertility-related stigma, this study analyzes 12 focus group discussions (FGDs) conducted with 104 women and men in rural Malawi. FGDs, conducted July-September 2018, were used to elicit the range of community norms around family formation, pregnancy, fertility, and infertility. Data were analyzed through memo-ing during and after data collection and collaborative, thematic coding. We found that stigma manifested within existing systems of gender and power. Aligning with Link and Phelan's stigma framework (2001) there were three primary mechanisms by which infertility-related stigma was produced and reinforced: labeling of a person perceived to be infertile (i.e., establishing 'other'), perpetuating negative stereotypes associated with suspected causes of infertility (e.g., abortion, multiple sexual partners, weak sperm), and consequences of infertility that reinforced stigma (e.g., social ridicule and distancing, divorce). Labels, presumed causes, and consequences of infertility were entrenched within gender and sexuality norms. Women perceived as infertile were unable to follow a normative path to achieving adult status, presumed to be sexually transgressive, and considered "useless." Men's masculinity was questioned. Both women's and men's identities, as well as social positions within relationships and communities, were threatened by perceptions of infertility. Ultimately, the manifestation of infertility-related stigma contributed to an environment wherein the risk of being perceived as infertile was highly consequential and unrelenting. Pervasive stigma, at the community-level, impacts decisions around contraceptive use and timing of childbearing, as women and men not only wanted to avoid infertility, but also the appearance of infertility.

Investigating pathways linking women's status and empowerment to skilled attendance at birth in Tanzania: A structural equation modeling approach

Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa where use of a skilled birth attendant (SBA) at delivery has remained low. Despite the recognized importance of women's empowerment as a key determinant of maternal and newborn health, evidence from sub-Saharan Africa is more limited. Using data from the 2010 Tanzania Demographic and Health Survey (n = 4,340), this study employs a robust method-structural equation modeling (SEM)-to investigate the complex and multidimensional pathways through which women's empowerment affects SBA use. The results show that women's education and household decision-making are positively associated with SBA use. However, not all empowerment dimensions have similar effects. Attitudes towards sex negotiation and violence as well as early marriage are not significant factors in Tanzania. Mediation analysis also confirms the indirect effect of education on SBA use only through household decision-making. The findings underscore the utility of structural equation modeling when examining complex and multidimensional constructs, such as empowerment, and demonstrate potential causal inference to better inform policy and programmatic recommendations.

Effects of Carrying an Unwanted Pregnancy to Term on Women's Existing Children

OBJECTIVE

To examine how receiving or being denied a wanted abortion affects the subsequent development, health, caregiving, and socioeconomics of women's existing children at time of seeking abortion.

STUDY DESIGN

The Turnaway Study is a 5-year longitudinal study with a quasi-experimental design. Women were recruited from January 2008 to December 2010 from 30 abortion facilities throughout the US. We interviewed women regarding the health and development of their living children via telephone 1 week after seeking an abortion and semiannually for 5 years. We compare the youngest existing children younger than the age 5 years of women denied abortion because they presented for care beyond a facility's gestational limit (Turnaway group) with those of women who received the abortion (Abortion group). We used mixed-effects regression models to test for differences in outcomes of existing children of women in the Turnaway group (n = 55 children) compared with existing children of women in the Abortion group (n = 293 children).

RESULTS

From 6 months to 4.5 years after their mothers sought abortions, existing children of women denied abortions had lower mean child development scores (adjusted β -0.04, 95% CI -0.07 to -0.00) and were more likely to live below the Federal Poverty Level (aOR 3.74, 95% CI 1.59-8.79) than the children of women who received a wanted abortion. There were no significant differences in child health or time spent with a caregiver other than the mother.

CONCLUSIONS

Denying women a wanted abortion may have negative developmental and socioeconomic consequences for their existing children.

Perceptions of Pregnancy and Contraceptive Use: An In-Depth Study of Women in Los Angeles Methadone Clinics

INTRODUCTION

In 2016, 2.1 million people in the United States were estimated to have an opioid use disorder. Although the disorder can be safely and effectively treated with prescription methadone, treatment is potentially long term and may span women's peak childbearing ages. Little is known about women's reproductive health needs while on methadone.

METHODS

We interviewed 22 sexually active, nonpregnant women ages 21-39 years at two Los Angeles methadone clinics in 2016. The interviews were transcribed and coded by four researchers using thematic and open coding techniques.

RESULTS

One-half of the women were nulliparous and 17 were in stable, monogamous relationships with men. Women reported a range of feelings and perceptions about pregnancy, but nearly all wanted to delay pregnancy until discontinuing methadone. However, many women indicated limited interest in preventing pregnancy because of the relative stability of their relationships, fear of infertility, and low perceived risk of pregnancy. These factors influenced contraceptive use.

DISCUSSION

Women described mixed feelings about pregnancy and many ultimately felt that an unplanned pregnancy would be acceptable in the context of their relationships and uncertain fertility. These findings provide context for previous quantitative findings that women in methadone treatment have higher rates of unintended pregnancy and lower rates of contraceptive use than the general population.

CONCLUSIONS

Accurate information about pregnancy in the context of methadone treatment may help women to make proactive family planning decisions. Health care providers should discuss the guidelines for pregnancy on methadone and offer a range of options to help women achieve their reproductive goals.

Preventing syndemic Zika virus, HIV/STIs and unintended pregnancy: dual method use and consistent condom use among Brazilian women in marital and civil unions

Syndemic Zika virus, HIV and unintended pregnancy call for an urgent understanding of dual method (condoms with another modern non-barrier contraceptive) and consistent condom use. Multinomial and logistic regression analysis using data from the Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS), a nationally representative household survey of reproductive-aged women in Brazil, identified the socio-demographic, fertility and relationship context correlates of exclusive non-barrier contraception, dual method use and condom use consistency. Among women in marital and civil unions, half reported dual protection (30% condoms, 20% dual methods). In adjusted models, condom use was associated with older age and living in the northern region of Brazil or in urban areas, whereas dual method use (versus condom use) was associated with younger age, living in the southern region of Brazil, living in non-urban areas and relationship age homogamy. Among condom users, consistent condom use was associated with reporting Afro-religion or other religion, not wanting (more) children and using condoms only (versus dual methods). Findings highlight that integrated STI prevention and family planning services should target young married/in union women, couples not wanting (more) children and heterogamous relationships to increase dual method use and consistent condom use.

Reproductive consequences of unwanted sexual debut among young adult women from Metro Cebu, Philippines

The circumstances surrounding sexual debut influence subsequent sexual and reproductive outcomes. We analysed longitudinal data from 397 women who participated in the Cebu Longitudinal Health and Nutrition Survey in Cebu, Philippines, to examine associations between unwanted first sex and number of pregnancies, unintended pregnancy, and use of modern contraception. 72% of women reported unwanted first sex. Women whose first sex was unwanted had increased odds of unintended pregnancy compared to women whose first sex was wanted (aOR = 2.2, 95% CI 1.3, 3.6). Nationally representative surveys should include culturally relevant questions about sexual debut to inform public health programmes aimed at improving sexual/reproductive health.

Do the status and empowerment of mothers predict their daughters' reproductive outcomes?

Background

Despite increased recognition of the important influences of women’s status and empowerment on social and health outcomes for women and their families, there are few investigations that examine the extent to which any gains in women’s empowerment may be transmitted intergenerationally, that is, between mothers and their daughters.

Methods

This study seeks to address this gap by using data from a unique, longitudinal, and intergenerational dataset from Cebu, Philippines (1994–2009), to examine potential influences of the status of mothers on subsequent reproductive health outcomes among their daughters. Using data from 648 mother-daughter dyads, we examine a multidimensional set of women’s status and empowerment measures among the mothers to predict three outcomes among their daughters: sexual onset by 2009 (ages 25–26), use of family planning, and experience of an unintended pregnancy.

Results

We find that that while some of the mothers’ characteristics and measures of empowerment and status were predictive of their daughters’ sexual initiation, these effects were not consistent across empowerment indicators, nor were there significant effects on two of the outcomes: use of family planning or occurrence of an unintended pregnancy. Older mothers (45+ years in 1994) and mothers who were considered to be “well-kept”, a locally defined measure of empowerment, were more likely to have daughters who had not engaged in sex by 2009 (ages 25–26). Daughters with higher educational levels were also more likely to delay sex, as compared to their peers. Among young women who had become sexually active, 54% reported an unintended pregnancy (mistimed or unwanted) by the age of 25–26, yet their mothers’ empowerment and status were not predictive of daughters’ reports of an unintended pregnancy.

Conclusions

Overall, these findings suggest that further research is needed to explore more proximal impacts on young women’s reproductive behavior in this setting, given other related investigations on women’s empowerment and its linkages to sexual debut and educational attainment in this setting. Findings from this examination of daughters’ reproductive outcomes suggest that there are likely additional intervening mechanisms between onset on sexual activity and mistimed or unintended pregnancy that need further elaboration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1497-z) contains supplementary material, which is available to authorized users.

Examining the mechanisms by which women's status and empowerment affect skilled birth attendant use in Senegal: a structural equation modeling approach

BACKGROUND

Despite the reduction in maternal deaths globally, maternal mortality rates remain unacceptably high, particularly in some regions of the world. In sub-Saharan Africa, maternal mortality rates have even increased recently, with 201,000 deaths in 2015 as compared to 179,000 in 2013. Use of a skilled birth attendant (SBA) at delivery has remained low, despite evidence of the effectiveness of SBAs in reducing maternal deaths. Women's empowerment is increasingly recognized as a key determinant of maternal health care-seeking and outcomes, yet empirical examinations of the linkages between women's empowerment and delivery care use are particularly limited, especially from sub-Saharan Africa.

METHODS

Using data from the 2010 Senegal Demographic and Health Survey (n = 7451), in this study we employed structural equation modeling (SEM) to investigate the complex and multidimensional pathways by which three women's empowerment domains (household decision-making, attitudes towards violence, and sex negotiation) directly and indirectly affect SBA use.

RESULTS

Although variations were observed across measures, many of the women's status and empowerment measures were positively related to SBA use. Notably, women's education demonstrated a substantial indirect effect: higher education was related to older age at first marriage, which was associated with higher levels of empowerment and SBA use. In addition to age at first marriage, gender-role attitudes (e.g., progressive attitudes towards violence and sex negotiation) were significant mediators in the relationship between education and SBA use. However, household decision-making was not significantly associated with SBA use.

CONCLUSIONS

Findings indicate significant effects of women's education, early marriage, and some dimensions of women's empowerment on SBA use. SEM was particularly useful in examining the complex and multidimensional constructs of women's empowerments and their effects. This study informs policy recommendations and programmatic efforts to reduce maternal mortality in sub-Saharan Africa by strengthening support for women's access to higher education, delaying marriage and childbearing among girls and young women, and supporting more equitable gender norms.

The role of men in induced abortion decision making in an urban area of the Philippines

OBJECTIVE

To understand beliefs about unintended pregnancy and abortion, and perceptions about male roles related to pregnancy decision-making among men in the Philippines.

METHODS

Qualitative data were collected during in-depth interviews and focus group discussions with men in an urban area of the Philippines between October 2007 and July 2008. Interview participants were purposively sampled from a local survey based on their having reported being "afraid or troubled" or "afraid and planned to terminate" in response to a recent pregnancy. Focus group participants were selected from the same communities. Data were analyzed using the constant comparative method.

RESULTS

In-depth interview data from 15 men-each interviewed twice-and five focus group discussions were included. Male interview participants reported feeling morally responsible for the pregnancy and as wanting to avoid the "sin" of induced abortion; however, they were concerned about being able to support a family financially. Participants expressed resentment towards partners who attempted or completed an induced abortion without their knowledge. In such cases, men would disparage their partner and cease interacting with them to avoid the "sin" of induced abortion.

CONCLUSION

Participants described negative feelings towards women seeking induced abortions, and their own desire to avoid associated "sin". This highlights the effects of unintended pregnancy and induced abortion on young Filipino men, including their own experience of abortion stigma.

Understanding where and why Senegalese adolescents and young adults access health information: A mixed methods study examining contextual and personal influences on health information seeking

Background

Adolescent and young adult years are critical to the development of behaviors that influence health across the life course. To reveal which health communication channels should be used to effectively reach and influence younger populations in Senegal, we used a mixed methods approach to identify and interpret the multifaceted influences surrounding where and why this population accesses health information.

Methods

We conducted 16 focus group discussions among adolescents and young adults in Senegal in September 2012. We then collected survey data from a larger, more diverse sample of Senegalese youth in October-November 2014.

Results

Our results demonstrate that information sources vary by health topic, differential access, age, and other demographics. While there is a greater perception of credibility and usefulness in information received from health professionals, stigma remains a barrier for obtaining information about HIV/AIDS from health centers. Older youth are also less likely to seek health information from adults, which may be influenced by preferred use of information technologies, especially for information about taboo health topics.

Conclusions

Our findings support multi-pronged, targeted approaches to health communication efforts. We recommend that doctors continue to provide actionable information about preventing or treating specific diseases, whereas teachers should educate youth about general health topics and health promotion behaviors. The results suggest that traditional mass media, such as radio and television, are the best communication channels for information about HIV and sexual/reproductive health, especially for older adolescents and young adults.

Human papillomavirus (HPV) awareness and vaccine receptivity among Senegalese adolescents

OBJECTIVE

To examine HPV vaccine awareness and receptivity among adolescents and young adults in Senegal.

METHODS

Participants from six high schools and five community centres across five regions of Senegal (n = 2286) completed a self-administered questionnaire in October and November 2014. The study assessed HPV awareness and receptivity towards receiving the HPV vaccine. Multivariable logistic regression explored statistically significant relationships between the predictor variables and both outcomes.

RESULTS

Twenty-seven percent had heard of HPV. Among those who had heard of HPV (n = 616), only 28% indicated willingness to vaccinate. Multivariable analysis showed that respondents from rural areas had 63% higher odds (95% CI: 1.24, 2.12) of having heard of HPV than those in urban areas. Respondents with fathers who had completed higher education had 41% higher odds (95% CI: 1.04, 1.92) of being aware of HPV (P < 0.05); however, every level of father's education (as compared to no education at all) was negatively associated with willingness to vaccinate. Respondents who had previously spoken to a healthcare professional about the HPV vaccine had 80% higher odds (95% CI: 1.16, 2.81) of willingness to vaccinate than those who did not speak to a provider about the vaccine.

CONCLUSIONS

Healthcare providers and parents are important stakeholders in disseminating HPV vaccine information. Given the overall low levels of awareness, there is a great opportunity for public health communication efforts to craft health messaging and information in a way to maximise receptivity, outlining benefits and providing information on the minimal risks associated with the vaccine.

Same-Sex Behavior and Health Indicators of Sexually Experienced Filipino Young Adults

The Philippines is one of seven countries in which HIV incidence has recently increased-much of this increase has been among men who have sex with men. Despite this trend, knowledge on sexuality and same-sex behaviors in the Philippines is limited. This study examines same-sex behavior, sexual outcomes, substance use, and psychological distress among young adults participating in the 2005 Cebu Longitudinal Health and Nutrition Survey (CLHNS). We use gender-stratified, multivariate models to compare young adults who reported same-sex behaviors and those who did not. Among a cohort of 1,912 Filipino young adults (ages 20-22), 58.2 % were sexually experienced and 15.1 % of them reported same-sex sexual contacts or romantic relationships. Compared to females, more males reported same-sex sexual contact (19.4 vs. 2.3 %) or same-sex romantic relationships (9.2 vs. 4.1 %). Young adults reporting same-sex behavior had higher odds of smoking, drug use, perceived stress, and more sexual partners as compared to their peers. Males who reported same-sex behavior initiated sex earlier than those males who did not report same-sex behaviors. There were no significant differences in depressive distress. Earlier sexual initiation and higher levels of substance use among Filipino young adults engaging in same-sex behavior highlight the need to address unique health issues within this population. Mixed findings for depressive distress and perceived stress indicate that further investigation is needed to explore the potential impacts of same-sex status on mental health outcomes, particularly in lower- and middle-income countries such as the Philippines.

Dual protection to address the global syndemic of HIV and unintended pregnancy in Brazil

BACKGROUND

Syndemic HIV and unintended pregnancy is prevalent in Brazil, where 79% of female HIV cases occur in women of reproductive age and 55% of all pregnancies are unintended. Although increasing condom use to prevent HIV may decrease non-barrier contraception and increase unintended pregnancy, few studies focus on dual protection or dual methods (condoms with another modern contraceptive).

AIM

To describe the correlates of dual method use and consistent condom use in women of reproductive age in Brazil.

METHOD

Data are from the 2006 Pesquisa Nacional de Demografia e Saúde da Mulher e da Criança, a decennial nationally representative household survey of women of reproductive age in Brazil. Multivariate logistic regression models identify the socio-demographic, sexual debut, fertility and relationship factors associated with dual method use and consistent condom use.

RESULTS

Two-thirds of contracepting women in Brazil used dual protection (40% exclusive condoms, 27% dual methods). Consistent condom use in the past year occurred among 61% of exclusive condom users and 27% of dual method users. Dual methods (vs exclusive condoms) was associated with some high school education [relative risk ratio (RRR)=1.69, p<0.05], living in the Southern region (RRR=1.59, p<0.01), and number of children (RRR=1.22, p<0.01), net of other factors. Consistent condom use was associated with condom use at sexual debut [adjusted odds ratio (AOR)=1.84, p<0.001], wants no (more) children (AOR=1.86, p<0.001), single/separated relationship status (AOR=2.77/2.45, p<0.001) and using exclusive condoms (vs dual methods: AOR=0.19, p<0.001).

CONCLUSIONS

Findings highlight that targeting and delivering integrated HIV and family planning services should focus on completed/large families. single/separated individuals, and promoting dual protection at sexual debut.

Reducing high maternal mortality rates in western China: a novel approach

Among the Millennium Development Goals, maternal mortality reduction has proven especially difficult to achieve. Unlike many countries, China is on track to meeting these goals on a national level, through a programme of institutionalizing deliveries. Nonetheless, in rural, disadvantaged, and ethnically diverse areas of western China, maternal mortality rates remain high. To reduce maternal mortality in western China, we developed and implemented a three-level approach as part of a collaboration between a regional university, a non-profit organization, and local health authorities. Through formative research, we identified seven barriers to hospital delivery in a rural Tibetan county of Qinghai Province: (1) difficulty in travel to hospitals; (2) hospitals lack accommodation for accompanying families; (3) the cost of hospital delivery; (4) language and cultural barriers; (5) little confidence in western medicine; (6) discrepancy in views of childbirth; and (7) few trained community birth attendants. We implemented a three-level intervention: (a) an innovative Tibetan birth centre, (b) a community midwife programme, and (c) peer education of women. The programme appears to be reaching a broad cross-section of rural women. Multilevel, locally-tailored approaches may be essential to reduce maternal mortality in rural areas of western China and other countries with substantial regional, socioeconomic, and ethnic diversity.

Maternal health care seeking by rural Tibetan women: characteristics of women delivering at a newly-constructed birth center in western China

Background

Increasing skilled birth attendance at delivery is key to reducing maternal mortality, particularly among marginalized populations. Despite China’s successful rollout of a national policy to promote facility deliveries, challenges remain among rural and ethnic minority populations. In response, a Tibetan Birth and Training Center (TBTC) was constructed in 2010 to provide high-quality obstetric care in a home-like environment to a predominantly Tibetan population in Tso-ngon (Qinghai) province in western China to improve maternal care in the region. This study examines if and how first users of the TBTC differ from women in the broader community, and how this information may inform subsequent maternal health care interventions in this area.

Methods

Trained, Tibetan interviewers administered a face-to-face, quantitative questionnaire to two groups of married, Tibetan women: women who had delivered at the TBTC between June 2011-June 2012 (n = 114) and a non-equivalent comparison group of women from the same communities who had delivered in the last two years, but not at the TBTC (n = 108). Chi-squared and ANOVA tests were conducted to detect differences between the samples.

Results

There were no significant differences between the samples in education or income; however, women from the TBTC sample were significantly younger (25.55 vs. 28.16 years; p < 0.001) and had fewer children (1.54 vs. 1.70; p = 0.05). Items measuring maternity health care-seeking and perceived importance of health facility amenities indicated minimal differences between the samples. However, as compared to the community sample, the TBTC sample had a greater proportion of women who reported having the final say regarding where to deliver (26 % vs. 14 %; p = 0.02) and having a friend or family member who delivered at home (50 % vs. 28 %; p < 0.001).

Conclusions

Findings did not support the hypothesis that the TBTC attracts lower-income, less-educated women. Minimal differences in women's characteristics and perceptions regarding delivery care between the two samples suggest that the TBTC is serving a broad cross-section of women. Differences between the samples with respect to delivery care decision-making and desire for skilled birth care underscore areas that may be further explored and supported in subsequent efforts to promote facility delivery in this population, and similar populations, of women.

Using a dyadic logistic multilevel model to analyze couple data

There is growing recognition within the sexual and reproductive health field of the importance of incorporating both partners' perspectives when examining sexual and reproductive health behaviors. Yet, the analytical approaches to address couple data have not been readily integrated and utilized within the demographic and public health literature. This paper seeks to provide readers unfamiliar with analytical approaches to couple data an applied example of the use of dyadic logistic multilevel modeling, a useful approach to analyzing couple data to assess the individual, partner and couple characteristics that are related to individuals' reproductively relevant beliefs, attitudes and behaviors. The use of multilevel models in reproductive health research can help researchers develop a more comprehensive picture of the way in which individuals' reproductive health outcomes are situated in a larger relationship and cultural context.

The relationship of women's status and empowerment with skilled birth attendant use in Senegal and Tanzania

BACKGROUND

Maternal mortality remains unacceptably high in sub-Saharan Africa with 179,000 deaths occurring each year, accounting for 2-thirds of maternal deaths worldwide. Progress in reducing maternal deaths and increasing Skilled Birth Attendant (SBA) use at childbirth has stagnated in Africa. Although several studies demonstrate the important influences of women's status and empowerment on SBA use, this evidence is limited, particularly in Africa. Furthermore, few studies empirically test the operationalization of women's empowerment and incorporate multidimensional measures to represent the potentially disparate influence of women's status and empowerment on SBA use across settings.

METHODS

This study examined the relationship of women's status and empowerment with SBA use in two African countries--Senegal and Tanzania--using the 2010 Demographic and Health Surveys (weighted births n = 10,688 in SN; 6748 in TZ). Factor analysis was first conducted to identify the structure and multiple dimensions of empowerment. Then, a multivariate regression analysis was conducted to examine associations between these empowerment dimensions and SBA use.

RESULTS

Overall, women's status and empowerment were positively related to SBA use. Some sociodemographic characteristics showed similar effects across countries (e.g., age, wealth, residence, marital relationship, parity); however, women's status and empowerment influence SBA use differently by setting. Namely, women's education directly and positively influenced SBA use in Tanzania, but not in Senegal. Further, each of the dimensions of empowerment influenced SBA use in disparate ways. In Tanzania women's higher household decision-making power and employment were related to SBA use, while in Senegal more progressive perceptions of gender norms and older age at first marriage were related to SBA use.

CONCLUSIONS

This study provides evidence of the disparate influences of women's status and empowerment on SBA use across settings. Results indicate that efforts to increase SBA use and to reduce maternal mortality through the improvement of women's status and empowerment should focus both on improving girls' education and delaying marriage, as well as transforming gender norms and decision-making power. However, given the multi-dimensional and contextual nature of women's status and empowerment, it is critical to identify key drivers to increase SBA use in a given setting for contextually tailored policy and programming.

Tibetan women's perspectives and satisfaction with delivery care in a rural birth center

OBJECTIVE

To identify sociodemographic characteristics and factors involved in Tibetan women's decisions to deliver at the Tibetan Birth and Training Center (TBTC) in rural western China.

METHODS

In the present mixed-methods study, a random sample of married women who delivered at the TBTC between June 2011 and June 2012 were surveyed. Additionally, four focus group discussions were conducted among married women living in the TBTC catchment area. Descriptive analyses were conducted, and dominant themes were identified.

RESULTS

In focus group discussions, women (n=33) reported that improved roads and transportation meant that access to health facilities was easier than in the past. Although some of the 114 survey participants voiced negative perceptions of healthcare facilities and providers, 99 (86.8%) indicated that they chose to deliver at the TBTC because they preferred to have a doctor present. Most women (75 [65.8%]) said their mother/mother-in-law made the final decision about delivery location. Women valued logistic and cultural aspects of the TBTC, and 108 (94.7%) said that they would recommend the TBTC to a friend.

CONCLUSION

Study participants preferred delivery care that combines safety and comfort. The findings highlight avenues for further promotion of facility delivery among populations with lower rates of skilled deliveries.

Who is using long-acting reversible contraceptive methods? Findings from nine low-fertility countries

CONTEXT

Long-acting reversible contraceptive (LARC) methods-IUDs and implants-are more effective than other reversible methods, yet are little used in the United States. Examining which U.S. women use LARC methods and how they differ from users in other low-fertility countries may help point the way toward increasing use.

METHODS

Data from married or cohabiting women participating in the National Survey of Family Growth (2008-2010) and in eight countries' Generations and Gender Programme surveys (2004-2010) were used in bivariate and multinomial logistic regression analyses examining LARC use within each setting.

RESULTS

The proportion of contraceptive use accounted for by LARC methods was generally greater in Europe (10-32%) than in the United States (10%) and Australia (7%). Compared with LARC use among comparable groups in other countries, use was particularly low among U.S. women who were married, were aged 40-44 or had had three or more children, yet was comparatively high among 18-24-year-olds. Among U.S. women, those aged 35-39 or 40-44 were more likely than 18-29-year-olds to rely on sterilization rather than on LARC methods (odds ratios, 3.0 and 10.7, respectively), those who had had three or more children were more likely to do so than were those who had had none or one (4.9), and women who had completed college were less likely than those who had not finished high school to do so (0.4).

CONCLUSIONS

Certain subgroups of U.S. women may benefit from the reversibility and effectiveness of LARC methods.

Women's empowerment and fertility: a review of the literature

Women's empowerment has become a focal point for development efforts worldwide and there is a need for an updated, critical assessment of the existing evidence on women's empowerment and fertility. We conducted a literature review on studies examining the relationships between women's empowerment and several fertility-related topics. Among the 60 studies identified for this review, the majority were conducted in South Asia (n = 35) and used household decision-making as a measure of empowerment (n = 37). Overall, the vast majority of studies found some positive associations between women's empowerment and lower fertility, longer birth intervals, and lower rates of unintended pregnancy, but there was some variation in results. In many studies, results differed based on the measure of empowerment used, sociopolitical or gender environment, or sub-population studied. This article is one of the first evaluations of the literature assessing the relationships between women's empowerment and fertility. We identify several key issues that merit further investigation.

Gendered differences in the predictors of sexual initiation among young adults in Cebu, Philippines

PURPOSE

Social environment and family context exert substantial influence on adolescent sexual behaviors. These influences are especially important to examine in countries undergoing rapid demographic and social change. This study employs unique, intergenerational and longitudinal data (1998-2009) to examine the effects of parental, peer, and household influences on sexual initiation among young adults in Cebu, Philippines.

METHODS

Intergenerational and longitudinal cohort data from the 1998 Cebu Longitudinal Health and Nutrition Survey (CLHNS) are analyzed to examine the effects of household, peer, family, and young adults' sexual attitudes on age at first sex by 2009 among young men and women. Gender-stratified Cox proportional hazards models and Cox regression models are used to model time to first sex.

RESULTS

Household, family, peer, and individual characteristics have disparate influences on sexual initiation among Filipino boys and girls. Boys' sexual initiation was positively associated with urbanicity, household wealth, and the presence of a family member working abroad, whereas for girls, these variables had no significant effects. Unique effects were also found for girls-mother's education was negatively associated, and girls' number of siblings was positively associated, with higher hazards of sex. Additionally, the effects of some variables on the occurrence of first sex differed across time, indicating that boys and girls may be differentially influenced by contextual characteristics across adolescence.

CONCLUSIONS

Amid substantial sociodemographic changes and persistence of traditional gender norms, this study highlights the importance of examining the unique influences and intersections of gender and context on sexual initiation in the Philippines.

The Implications of Rapid Economic Growth for Health-Related Behaviors and Chronic Metabolic Diseases: An Exploratory Study in Post-Earthquake West China

A devastating earthquake struck west China in 2008. Reconstruction efforts have focused on urbanization and modernization, hastening economic growth in the area. This rapid growth provides a unique opportunity to explore the potential impact of rapid environmental changes on metabolic disease risk. The study objective was to gather qualitative information from residents of a rapidly changing area in China to determine perceived changes in food- and physical activity-related aspects of the environment and their perceived effects on health. We conducted extensive interviews with 30 residents of an area where towns were rapidly rebuilt after being destroyed by the 2008 Wenchuan earthquake. Findings suggest that a longitudinal investigation of children and their families in this rapidly developing region may identify mechanisms by which environmental factors influence the development of diet-related chronic illnesses.

Old ideals and new realities: the changing context of young people's partnerships in Cebu, Philippines

The Philippines has experienced rapid sociodemographic changes in recent years, with implications for young people. This study combines quantitative and qualitative data from Metro Cebu to assess the timing and predictors of young people's partnerships, as well as the context in which these partnerships are occurring. The majority of young people (54%) had premarital sex, though this pattern varied by gender. Wealthier, urban young men, and women with less education and lower reported religiosity, were more likely to have premarital sex. Engagement in risk behaviours was predictive of premarital sex for both males and females. The qualitative data contextualise the circumstances under which young people engage in sex and form partnerships and illustrate how sociocultural norms contribute to gender differences in partnership patterns. Given the 'new' realities of young Filipinos' lives, targeted efforts to support the transition to adulthood are needed to avert potentially adverse life events.

Perceptions and practices of illegal abortion among urban young adults in the Philippines: a qualitative study

This study draws on in-depth interviews and focus group discussions with young adults in a metropolitan area of the Philippines to examine perceptions and practices of illegal abortion. Study participants indicated that unintended pregnancies are common and may be resolved through eventual acceptance or through self-induced injury or ingestion of substances to terminate the pregnancy. Despite the illegality of abortion and the restricted status of misoprostol, substantial knowledge and use of the drug exists. Discussions mirrored broader controversies associated with abortion in this setting. Abortion was generally thought to invoke gaba (bad karma), yet some noted its acceptability under certain circumstances. This study elucidates the complexities of pregnancy decisionmaking in this restrictive environment and the need for comprehensive and confidential reproductive health services for Filipino young adults.

Measurement of and trends in unintended birth in Bangladesh, 1983-2000

Bangladesh has experienced a rapid decline in fertility in the past several decades, facilitated by proactive population policies, provision of contraceptives, and broader societal shifts, encouraging smaller families and use of contraceptive to achieve revised childbearing norms. This paper presents 18 years of data from the Sample Registration System, a demographic surveillance system operated by the Maternal and Child Health-Family Planning Extension Project in six study areas in Bangladesh. Prospective measurements of women's fertility preferences were used for classifying nearly 25,000 birth outcomes from 1983 to 2000 as intended, unintended, or 'up to God/Allah'. Over the 18-year period, the level of unintended births varied from 22% to 38%, with the lowest levels in the mid-1990s. Fatalistic responses declined significantly from 25% in the mid-1980s to 1% by the late 1990s. Results of the comparison of two geographic areas of Bangladesh indicate differential declines in the levels of unintended pregnancies over the study period. Prospective measurements of unintended pregnancies were 2-3 times the magnitude indicated by retrospective estimates of unwanted births from the demographic and health surveys conducted during the study period. This unique dataset provides a rare opportunity to visualize the vast changes in fertility preferences and unintended births in Bangladesh from 1983 to 2000. Significant declines in fatalistic responses reflect broader social changes that occurred in Bangladesh to facilitate the fertility decline and contraceptive uptake. The drastic differences between prospective and retrospective measurements of fertility preferences highlight the importance of considering the strengths and limitations of each method when attempting to estimate the true level of unintended pregnancies and births in a population.

Conducting collaborative abortion research in international settings

Nearly 20% of the 208 million pregnancies that occur annually are aborted. More than half of these (21.6 million) are unsafe, resulting in 47,000 abortion-related deaths each year. Accurate reports on the prevalence of abortion, the conditions under which it occurs, and the experiences women have in obtaining abortions are essential to addressing unsafe abortion globally. It is difficult, however, to obtain accurate and reliable reports of attitudes and practices given that abortion is often controversial and stigmatized, even in settings where it is legal. To improve the understanding and measurement of abortion, specific considerations are needed throughout all stages of the planning, design, and implementation of research on abortion: Establishment of strong local partnerships, knowledge of local culture, integration of innovative methodologies, and approaches that may facilitate better reporting. This paper draws on the authors' collaborative research experiences conducting abortion-related studies using clinic- and community-based samples in five diverse settings (Poland, Zanzibar, Mexico City, the Philippines, and Bangladesh). The purpose of this paper is to share insights and lessons learned with new and established researchers to inform the development and implementation of abortion-related research. The paper discusses the unique challenges of conducting abortion-related research and key considerations for the design and implementation of abortion research, both to maximize data quality and to frame inferences from this research appropriately.