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Background Although long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients. Methods The intervention used prominently displayed monthly posters comparing the health clinic’s previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention’s impact on LARC uptake while controlling for client- and clinic-level characteristics. Results The intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers’ counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved. Conclusion We find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.

IntroductionScaling up evidence-based practices (EBPs) in family planning (FP), as recommended by the WHO, has increasingly been accepted by global health actors as core to their mission, goals and activities. National policies, strategies, guidance, training materials, political commitment and donor support exist in many countries to adopt and scale up a range of EBPs, including postpregnancy FP, task sharing for FP and the promotion of social and behaviour change (SBC) for FP. While there has been some success in implementing these practices, coverage remains inadequate in many countries. To gain a better understanding of the factors that may be hindering the sustained scale-up of these interventions, WHO has developed an assessment protocol to systematically identify the health systems’ ‘bottlenecks’ to implementation and to then identify solutions and develop strategies to address them.Methods and analysisA mixed method approach that includes document review, secondary data analysis (from surveys, service delivery data and case studies) and key informant interviews with policymakers, programme managers, health providers and community groups will be used to identify bottlenecks. This will be followed by a workshop to prioritise bottlenecks and characterise their root causes. Finally, solutions for the root causes of prioritised bottlenecks will be proposed. The protocol is structured in a modular format, with separate modules on postpregnancy FP, task sharing and SBC. Assessment themes and questions are informed by a wide body of literature on the three programmatic components, as well as studies on health policy implementation and scale-up.Ethics and disseminationThe protocol was exempt from ethical review by the WHO ethics committee. The findings of the bottleneck analysis will be presented at local, national and international conferences and disseminated through peer-reviewed publications and webinars.

Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by nongovernmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortionrelated mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraception, safe abortion, and post-abortion care. De précédentes études ont révélé des niveaux élevés de grossesse non désirée chez les professionnelles du sexe, mais moins d’attention a été accordée à leurs pratiques d’avortement et aux résultats de celles-ci. Cette étude est la première à enquêter sur la mortalité liée à l’avortement chez les professionnelles du sexe dans huit pays: Afrique du Sud, Angola, Brésil, Inde, Indonésie, Kenya, Nigéria et République démocratique du Congo (RDC). L’approche des connaissances communautaires a été utilisée pour sonder un échantillon de convenance de professionnelles du sexe (n = 1280). Les participantes ont signalé le décès d’autres professionnelles du sexe dans leurs réseaux sociaux lors de réunions de groupe constituées par des organisations non gouvernementales (n = 165 groupes, dans 24 villes en 2019). Les détails sur les décès d’autres professionnelles du sexe pendant les cinq années précédentes ont été enregistrés. Les circonstances des décès liés à un avortement sont données ici. Sur les 1320 décès maternels rapportés, 750 (56.8%) étaient dus à un avortement à risque. Le nombre de décès signalés liés à un avortement était le plus élevé en RDC (304 décès rapportés par 270 participantes), au Kenya (188 décès signalés par 175 participantes) et au Nigéria (216 décès rapportés par 312 participantes). Pour les décès liés à un avortement, l’âge gestationnel moyen était de 4,6 mois et 75% sont survenus en dehors de l’hôpital. Les méthodes d’avortement à risque variaient selon les pays, mais la consommation de médicaments traditionnels ou inconnus était la plus courante (37.9% et 29.9% respectivement). Les 750 décès liés à un avortement ont fait 1207 orphelins. L’approche des connaissances communautaires est parvenue à enregistrer une pratique stigmatisée au sein d’une population marginalisée, et a identi?é des niveaux très élevés de mortalité liée à l’avortement. Des mesures urgentes sont maintenant nécessaires pour prodiguer des soins complets de santé sexuelle et reproductive à cette population vulnérable, y compris en matière de contraception, d’avortement sans risque et de soins post-avortement. Estudios anteriores han encontrado altos niveles de embarazo no intencional entre trabajadoras sexuales (TS), pero no se ha prestado mucha atención a sus prácticas y resultados de aborto. Este estudio es el primero en investigar la mortalidad relacionada con el aborto entre TS en ocho países: Angola, Brasil, República Democrática del Congo (RDC), India, Indonesia, Kenia, Nigeria y Sudáfrica. Se utilizó el Enfoque de Conocimientos Comunitarios (ECC) para encuestar a una muestra de conveniencia de TS (n = 1280). Durante reuniones en grupo convocadas por organizaciones no gubernamentales (n = 165 grupos, realizadas en 24 ciudades en 2019), las participantes informaron en las redes sociales sobre las muertes de TS pares. Se anotaron los detalles sobre muertes de TS pares en los cinco años anteriores. Aquí se informa sobre las circunstancias de muertes relacionadas con el aborto. De las 1320 muertes maternas reportadas, 750 (56.8%) fueron atribuidas al aborto inseguro. El número de muertes relacionadas con el aborto reportadas fue más alto en RDC (304 muertes reportadas por 270 participantes), Kenia (188 muertes reportadas por 175 participantes) y Nigeria (216 muertes reportadas por 312 participantes). Entre las muertes relacionadas con el aborto, la edad gestacional media fue de 4.6 meses y el 75% ocurrió fuera del hospital. Los métodos de aborto inseguro variaron por país, pero el consumo de medicamentos tradicionales o desconocidos fueron los más comunes (37.9% y 29.9% respectivamente). Las 750 muertes relacionadas con el aborto tuvieron como consecuencia que 1207 niños perdieran a su madre. El ECC logró registrar una práctica estigmatizada entre una población marginada, e identificó niveles muy altos de mortalidad relacionada con el aborto. Ahora es necesario tomar acción urgente para proporcionar servicios integrales de salud sexual y reproductiva a esta población vulnerable, que incluyen anticoncepción, aborto seguro y atención postaborto.

Introduction Existing estimates of contraceptive use in Tanzania rely on cross-sectional or retrospective study designs. This study used a 2-year, retrospective, month-by-month calendar of contraceptive utilization among women aged 15–49 years. Methods We estimated the median duration of contraceptive use, factors associated with use, and contraceptive discontinuation rates in sexually active women, using life tables and Cox proportional hazard model. Results A total of 5416 women contributed to the analysis in the study. Of the 5416 women, 942 (17%) had never had sex, 410 (7.6%) had no sexual partner in the last year. Among the 5416 women, 4064 were sexually active during the period, 814 (21.1%) were pregnant or amenorrheic, 610 (15.0%) were using contraception, and 1203 (29.6%) did not want to get pregnant but were not using contraception. In the 1813 women who wanted to avoid pregnancy, contraceptive use was lower among women over 35 years compared to younger ones (OR = 0.28, 95%CI: 0.19, 0.41), and in HIV positive women (OR = 0.89, 95%CI: 0.60–1.32). On the other hand, use was higher among women who were married/living together compared to unmarried ones (OR = 2.23, 95% CI: 1.54, 3.23). Using a 2-year retrospective contraceptive calendar, 1054 women reported contraceptive use, 15.8% discontinued within 6 months and 30.5% discontinued within 12 months. Higher rates of contraceptive discontinuation were observed among women who used pills (OR = 1.86, 95%CI: 1.25, 2.77) or injections (OR = 2.04, 95%CI: 1.59, 2.61) compared to those who used implants. Conclusion Contraceptive use was significantly associated with age, education and parity, but not with HIV status. HIV status, number of living children and education are not statistically associated with discontinuation of contraceptive use Pills and injections had the highest rates of discontinuation. Wider choice and greater accessibility of long-acting contraceptive methods with better effectiveness and convenience may serve women better. Furthermore, special efforts may be needed to remove barriers to contraceptive use amongst younger women.

This paper describes a community event organized in response to the appropriation and overreliance on the psychiatric patient “personal story” within mental health organizations. The sharing of experiences through stories by individuals who self-identify as having “lived experience” has been central to the history of organizing for change in and outside of the psychiatric system. However, in the last decade, personal stories have increasingly been used by the psychiatric system to bolster research, education, and fundraising interests. We explore how personal stories from consumer/survivors have been harnessed by mental health organizations to further their interests and in so doing have shifted these narrations from “agents of change” towards one of “disability tourism” or “patient porn.” We mark the ethical dilemmas of narrative cooptation and consumption, and query how stories of resistance can be reclaimed not as personal recovery narratives but rather as a tool for socio-political change.

Background Marie Stopes Tanzania works with a voluntary cadre of 66 community-based mobilizers (CBMs), who are tasked with raising awareness, generating demand and providing referral to potential clients for family planning, comprehensive post-abortion care and cervical cancer screening. CBMs extend the reach of urban clinics to peri-urban communities, enhancing access to sexual and reproductive health services. In an effort to optimize performance of CBMs, a study was conducted to explore the drivers of CBM motivation and inform the design of an incentive scheme. Methods Three focus group discussions with 17 CBMs and 11 interviews with CBM supervisors and managers were conducted in three clinics and the head office. After thematic analysis of transcripts, findings on motivational factors were discussed in a reflection workshop and informed the development of a discrete choice experiment (DCE) involving 61 CBMs as respondents. The DCE included eight choice questions on two incentive schemes, each consisting of five attributes related to remuneration, training, supervision, benefits and identification. For each attribute, different incentive options were presented, based on the outcomes of the qualitative assessment. The DCE results were analysed using conditional logistic regression. Results A variety of factors motivated CBMs. Most CBMs were motivated to conduct their work because of an intrinsic desire to serve their community. The most mentioned extrinsic motivational factors were recognition from the community and supervisors, monthly allowance, availability of supporting materials and identification, trainings, supervision and feedback on performance. Recommendations for improvement were translated into the DCE. Incentive attributes that were found to be significant in DCE analysis ( p  < 0.05), in preference order, were carrying an ID card, bi-monthly training, supervision conducted via both monthly meetings at clinics and visits from the head office, and a monthly flat rate remuneration (over pay for performance). Conclusion Despite the recognition that being a CBM is voluntary, incentives, especially those of non-financial nature, are important motivators. Incentive schemes should include basic compensation with a mix of other incentives to facilitate CBMs’ work and enhance their motivation. Programme designs need to take into account the voices of community-based workers, to optimize their performance and service delivery to communities they serve.

Background Adoption of modern contraceptive methods after menstrual regulation (MR) is thought to reduce subsequent unwanted pregnancy and abortion. Long-acting reversible contraceptives (LARCs) are highly effective at reducing unintended pregnancy, but uptake in Bangladesh is low. Providing information on the most effective methods of contraception increases uptake of more effective methods. This protocol describes a randomised controlled trial of an intervention delivered by mobile phone designed to support post-MR contraceptive use in Bangladesh. Methods This is a multi-site single blind individual randomised controlled trial. At least 960 women undergoing MR procedures at selected facilities will be recruited after their procedure by female research assistants. Women will be randomised into the control or intervention group with a 1:1 ratio. All participants will receive usual clinic care, including contraceptive counselling and the telephone number of a non-toll-free call centre which provides counselling on MR and contraception. During the 4 months after their MR procedure, intervention participants will be sent 11 recorded interactive voice messages to their mobile phone about contraception with a focus on their chosen method and LARCs. Each message allows the participant to connect directly to the call centre. The intervention is free to the user. The control group will receive no messages delivered by mobile phone. All participants will be asked to complete an in-person questionnaire at recruitment and follow-up questionnaires by telephone at 2 weeks, 4 months and 12 months after their MR. The primary outcome for the trial will be self-reported LARC use 4 months post-MR. Secondary outcomes include LARC use at 2 weeks and 12 months post-MR, use of any effective modern contraceptive method at 2 weeks, 4 months and 12 months post-MR, and contraceptive discontinuation, contraceptive method switching, pregnancy, subsequent MR and experience of violence during the 12 month study period. Discussion Mobile phones offer a low-cost mechanism for providing individualised support to women with contraception outside of the clinic setting. This study will provide information on the effects of such an intervention among MR clients in Bangladesh. Trial registration Trial registered with clinicaltrials.gov Registration number: NCT02579785 Date of registration: 16th October 2015.

Integrating reproductive health (RH) with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602) measured integrated care received and unmet family planning (FP) needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05), despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice) less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of care inhibited provision of fully integrated RH-HIV services in these clinics. Programmes should move beyond simplistic training and equipment provision if integrated care interventions are to be sustained.