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Intimate partner violence is widespread worldwide. While assumed to impact women's ability to use contraceptive methods, few data are available to support this claim. In this study, eight focus group discussions were conducted to guide questionnaire development and to provide contextual information. Participants were women who were currently using the pill and women who had used the pill previously. In addition, 300 women were interviewed who initiated oral contraceptive pill use between December 1995 and April 1996. Participants were interviewed 3–6 months later to investigate the role intimate partner violence played in covert pill use and pill discontinuation. Special study procedures for asking women questions about violence were employed. Nineteen per cent of the women interviewed were using the pill covertly. The odds of covert pill use were four times higher in El Alto and La Paz than in Santa Cruz. Women who used the pill covertly were more likely to have experienced method-related partner violence (OR=21.27) than women whose partners knew of their pill use. One-third of the women had discontinued pill use at the time of the interview. In the final multivariate analysis, having experienced side-effects (OR=2.37) was a significant predictor of pill discontinuation and method-related partner violence was marginally predictive (OR=1.91; 95% CI 1.0–3.66). While efforts are ongoing to incorporate men into family planning programmes, some male partners oppose, and in some situations violently oppose, contraceptive use. The needs of women with these types of partners must not be overlooked.

SummaryA significant increase occurred in the initiation and duration of breast-feeding among Honduran women between 1981 and 1987. Changes in population characteristics (e.g. level of education of women) would be expected to lead to a decrease in breast-feeding at each infant age, but these were offset by behavioural changes that led to an increase in the likelihood of initiation and continuation of breast-feeding. An exploration of relevant factors suggests that the PROALMA breast-feeding promotion programme has had a profound effect on the breast-feeding behaviour of Honduran mothers.

Background: In rural Tanzania access to emergency obstetric and newborn care is threatened by poor roads and understaffed facilities among other challenges. Districts in Kigoma, Pwani and Morogoro regions were targeted by a local non-governmental organization to assist local government to build capacity and improve access to clinical management of severe obstetric and newborn complications. The program upgraded ten primary health care centres to provide comprehensive emergency obstetric and newborn care. This paper describes the process of reintroducing vacuum extraction into ten health centres and five hospitals, highlighting patterns in uptake, mode of delivery and lessons learned. Methods: This observational study uses facility-based trend data collected between 2011 and 2016.Descriptive outcomes include institutional caesarean delivery rates, vacuum extraction rates, and the ratio of caesareans to vacuum-assisted deliveries. Results: Institutional caesarean delivery rates remained stable at about 10-11% and the vacuum extraction rate rose from virtually no procedures in 2011 to about 2% in 2016. The increase was more visible in upgraded health centres than in hospitals. In 2016 vacuum extraction rates in newly upgraded health centres ranged from 0.5 to 7.8%. Between 2011 and 2016, the ratio of caesareans to vacuum extractions in hospitals changed from 304 caesareans to 1 vacuum extraction to 10:1, while in health centres the ratio changed from 22: 1 to 3: 1. Conclusions: Reintroduction of vacuum extraction into clinical practice in primary health care facilities with task-shifting is feasible. Reintroduction of this procedure was more successful when part of an integrated upgrading of health centres to provide comprehensive emergency obstetric care than when reintroduced into busy hospital environments. Turnover of trained staff in hospitals contributed to the uneven uptake of vacuum extraction. Lessons learned are applicable to further national scale up and to other countries.

Three groups of adolescents are compared with regard to their own considerations of abortion and when they believe abortion is justified. One group of adolescents terminated their pregnancies (n=95), a second became pregnant and carried their pregnancies to term but considered abortion (n=68), and the third also carried their pregnancies to term but did not consider abortion (n=204). The study was carried out between 1995 and 1998 in Fortaleza, Brazil. Adolescents were interviewed at the time of their hospitalization or their first prenatal visit and again at 6 weeks and 1 year post-abortion or postpartum. Friends and family recommended abortion to at least half of the teenagers in each group. Teenagers who aborted were more accepting of abortion than those who did not abort, while those who considered abortion found the practice more justified than those who did not consider abortion. Teenagers who aborted became less accepting a year later, while those who did not consider abortion became more accepting. A better understanding of adolescent attitudes towards abortion and their decision-making process should help adults and professionals meet the needs of adolescents for support in the process and in the reduction of the number of unintended pregnancies in the future.

BACKGROUND: Cesarean delivery (CD) rates have reached epidemic levels in many high and middle income countries while increasingly, low income countries are challenged both by high urban CD rates and high unmet need in rural areas. The managing authority of health care institutions often plays a role in these disparities. This paper shows changes between 2008 and 2016 in Ethiopian CD rates, readiness of hospitals to provide CD and quality of clinical care, while highlighting the role of hospital management authority. METHODS: This secondary data analysis draws from two national cross-sectional studies to assess emergency obstetric and newborn care. The sample includes 111 hospitals in 2008 and 316 hospitals in 2016, and 275 women whose CD chart was reviewed in 2008 and 568 in 2016. Descriptive statistics are used to describe our primary outcome measures: population- and institutional-based CD rates; hospital readiness to perform CD; quality of clinical management, including the relative size of Robson classification groups. RESULTS: The national population CD rate increased from 2008 to 2016 (< 1 to 2.7%) as did all regional rates. Rates in 2016 ranged from 24% in urban settings to less than 1% in several rural regions. The institutional rate was 54% in private for-profit hospitals in 2016, up from 46% in 2008. Hospital readiness to perform CDs increased in public and private for-profit hospitals. Only half of the women whose charts were reviewed received uterotonics after delivery of the baby, but use of prophylactic antibiotics was high. Partograph use increased from 9 to 42% in public hospitals, but was negligible or declined elsewhere. In 2016, 40% of chart reviews from public hospitals were among low-risk nulliparous women (Robson groups 1&2). CONCLUSIONS: Between 2008 and 2016, government increased the availability of CD services, improved public hospital readiness and some aspects of clinical quality. Strategies tailored to further reduce the high unmet need for CD and what appears to be an ...

SummaryCounselling on contraception and contraceptive method provision are key components of post-abortion care (PAC). Some studies have suggested that adolescent PAC patients receive worse care than older women seeking these services. This study aimed to evaluate an intervention whose goal was to improve the counselling and contraceptive uptake of PAC patients, with special attention given to the needs of adolescent patients, in the four public hospitals in the Dominican Republic where PAC services were not being routinely offered. The counselling intervention effort included provider training and the development of adolescent-friendly information, education and communication (IEC) materials. Eighty-eight providers were interviewed at baseline and 6 months after the intervention was implemented. Six months after providers were trained, 140 adolescent PAC patients (≤19 years of age) and 134 older PAC patients (20–35 years) were interviewed about the contraceptive counselling messages and contraceptive methods they received before they were discharged from hospital. The adolescent and older PAC patients were matched on study hospital and time of arrival. Significant improvements were noted in provider knowledge and attitudes. No changes were noted in provider-reported PAC counselling behaviours, with close to 70% of providers reporting they routinely assess patients' fertility intentions, discuss contraception, assess STI/HIV risk and discuss post-abortion complications. Adolescent and older PAC patients reported receiving PAC counselling messages at similar rates. Forty per cent of adolescent PAC patients and 45% of older PAC patients who wanted to delay pregnancy were discharged with a contraceptive method. Adolescents were more likely to receive an injectable contraceptive method whereas older women were discharged with a variety of methods. The PAC counselling intervention increased provider knowledge and improved their attitudes and benefited both adolescent and older patients.