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Background Increasingly, the health and rights of adolescents are being recognized and prioritized on the global agenda. This presents us with a “never-before” opportunity to address adolescent contraception. This is timely, as there are enormous numbers of adolescents who are currently unable to obtain and use contraceptives. From research evidence and programmatic experience, it is clear that we need to do things differently to meet their needs/fulfil their rights. Main body In this commentary, we call for action in several key areas to address adolescents’ persistent inability to obtain and use contraceptives. We must move away from one-size-fits-all approaches, from a ‘condoms-only’ mind set, from separate services for adolescents, from ignoring the appeal of pharmacies and shops, and from one-off-training to make health workers adolescent friendly. Our efforts to expand access to quality contraceptive services to adolescents must be combined with efforts to build their desire and ability to use them, and to do so consistently. In order for these changes to be made, action must be taken on several levels. This includes the formulation of sound national policies and strategies, robust programme implementation with monitoring, regular programmatic reviews, and implementation research. Further, high-quality collection, analysis, and dissemination of data must underlie all of our efforts. As we move ahead, we must also recognize and draw lessons from positive examples of large scale and sustained programmes in countries that have led the way in increasing contraceptive use by adolescents. Conclusion This unprecedented moment in history gives us a real opportunity to bring about transformational change, particularly when there is so much at stake.

Background Recently known as the genito-pelvic pain/penetration disorder (GPPPD), Dyspareunia is considered a negative factor affecting a couple’s sexual health. This paper analyzes pain in Dyspareunia cases and determines protective factors causing lower levels of sexual distress among patients. Methods In a population-based cross-sectional study conducted in 2017, the cluster quota sampling technique was adopted to randomly select 590 Iranian married women aged 18–70 years from 30 health centers. The research tools included demographic data, a sexual distress scale, and Binik’s GPPPD questionnaire. Results In this study, the prevalence of self-report Dyspareunia, confirmed moderate Dyspareunia, and confirmed severe Dyspareunia (based on Binik’s proposed criteria) were 33 %, 25.8 %, and 10.5 %, respectively. Interestingly, 32 (34 %) out of 94 women who experienced severe pain based on Binik’s criteria reported no sexual distress. Compared to women with distress, they also had more positive body images, higher self-confidence, higher levels of sexual satisfaction, and more intimacy in their relationships (P = 0.000). In contrast, 8.5 % of the participants reported significant sexual distress even without confirmed Dyspareunia. Conclusions Improving intrapersonal characteristics such as self-confidence and body image as well as interpersonal factors such as sexual satisfaction and intimacy with a spouse can effectively treat Dyspareunia by alleviating sexual distress. The partner’s role in female pain and distress management would be more critical than previously thought., Plain English summary Dyspareunia is a condition that can negatively affect sexual health among individuals and couples. This paper addresses the pattern of sexual pain as well as some interpersonal and intrapersonal factors that may lessen sexual pain by mitigating sexual distress. This population-based cross-sectional study was conducted on 590 randomly selected Iranian married women aged 18–70 years. According to the research results, the prevalence of self-report sexual pain was 33 %. However, based on strict Binik’s criteria and sexual distress, the prevalence of severe Dyspareunia decreased to 10.5 %. The most common location, time, and type of pain were reported to be in the vaginal entrance at the beginning of intercourse with irritation. Interestingly, a substantial number of women reported no sexual distress, despite having severe Dyspareunia. Compared to patients with distress, they experienced higher levels of sexual satisfaction, more positive body images, higher levels of self-confidence, and more intimacy in their relationships (P = .000). In addition to the routine management of sexual pain, clinicians should consider these protective factors that can lead to better pain tolerance and less sexual distress among patients. The research findings emphasized the importance of attendance and collaboration of spouses in the treatment process. At the same time, observing the sexual distress of women with no sexual dysfunctions would clarify that their own perception of sexual difficulty per se is an important factor. In other words, “sexual dysfunction” and “sexual problems” are both significant because defining sexual problems is subjective and depends on a woman and her partner’s values, desires, and sexual knowledge.

Menstrual health and hygiene are a major public health and social issues in Nepal. Due to inadequate infrastructure to provide education, healthcare, and communication as well as religious teachings, women and girls are excluded from participation in many activities of daily living and community activities during menstruation. Evidence based research addressing menstrual health and hygiene in Nepal is scares. The objective of this paper is to review the current state of knowledge on menstrual health and hygiene in Nepal through a socio-ecological perspective. This systematic review identifies knowledge gaps and targets for future research and interventions. Studies from Nepal that examined factors contributing to menstrual health and hygiene were identified through searches across six databases (Medline, CINAHL, Web of Science, PsychInfo, Nepal Journals Online and Kathmandu University Medical Journal) in January 2019. The SEM is a public health framework that describes how health is impacted at multiple levels including the individual, interpersonal, community, organizational and policy levels. Key themes were identified, and factors contributing to menstrual health and hygiene were categorized as per the level of socio-ecological model (SEM). After a comprehensive literature review, twenty peer-reviewed publications, published between 2003 and January 2019 were included in this review. Eighteen studies were descriptive and two were interventional. The main outcomes reported were reproductive health concerns and menstrual hygiene practices. Nine studies focused on knowledge, attitude, and practices regarding menstruation, seven studies highlighted reproductive health issues, three studies focused on prevalence of culturally restrictive practices, and one on school absenteeism and intimate partner violence. Lack of awareness regarding menstrual health and hygiene, inadequate WASH facilities, no sex education and culturally restrictive practices makes menstruation a challenge for Nepali women. These challenges have negative implications on women and girls' reproductive as well as mental health and school attendance among adolescent girls. There are gaps in the evidence for high quality interventions to improve menstrual health and hygiene in Nepal. Future research and interventions should address needs identified at all levels of the SEM.Menstrual health and hygiene are major public health and social issues in Nepal, due to a lack of health and education infrastructure, gender-based disparities and restrictive cultural and social norms. This study reviewed the current state of research on menstrual health and hygiene in Nepal. The socio-ecological model (SEM)—a public health framework that examines individual, interpersonal, community, organizational, and policy impacts on health—was employed to describe impacts on menstrual health and hygiene. After a comprehensive literature review, 20 papers were included in this analysis, of which 18 were descriptive and two were interventional. The primary menstrual health and hygiene outcomes reported were reproductive health concerns and menstrual hygiene practices. Key themes identified were knowledge, attitude, and practices regarding menstruation, reproductive health issues, prevalence of culturally restrictive practices, school absenteeism and intimate partner violence. The study results indicated lower menstrual health and hygiene challenges arose from lack of education around menstruation, lack of proper water, sanitation, and hygiene (WASH) facilities, poor sex education, and culturally restrictive practices. These challenges negatively impact women and girls’ reproductive health as well as mental health and school attendance. There is need for high quality, effective interventions to improve menstrual health and hygiene in Nepal. Future research and interventions should address improvements in menstrual health and hygiene at all levels of the socio-ecological model.

Child marriage has powerful implications for a young woman's reproductive health, education, and personal development as well as the development of communities and nations. Child marriage frequently marks the beginning of a young woman's sexual activity and early childbearing. As a country where child marriage is common, Ethiopia has placed additional emphasis on addressing child marriage over the past years.Using data from Ethiopia Demographic and Health Surveys for 2005, 2011 and 2016, this paper explores trends in child marriage over the last decade in various locations and regions of Ethiopia.Between 2005 and 2016, the percentage of young Ethiopian women married before age 18 declined from 49 to 40%, a reduction of 18% from 2005 levels. The percentage of women married before age 15 experienced even greater reductions, declining by 26% in the same period. The greatest reductions in child marriage took place in the Addis Ababa, Amhara, and Tigray regions. Over the period, estimates for Oromia and Somali suggest that child marriage has increased in these regions. Notwithstanding recent declines, Afar, Beneshangul-Gumuz, Somali, and Oromia are regions where nearly half or more of all girls are married before age 18.Nationally, Ethiopia has experienced impressive declines in child marriage over the last decade. However, progress has also been uneven. Trends in the last decade have resulted in a geographical shift in where child marriage is most prevalent. In particular, locations that are challenging in terms of access, including the most remote and hard to reach, pose persistent challenges to those attempting to eradicate the practice. Intensifying efforts in rural areas and underserved regions can facilitate further declines in child marriage in Ethiopia.Child marriage has powerful implications for young women’s reproductive health, education, and welfare. Using data from Ethiopia Demographic and Health Surveys for 2005, 2011, and 2016, this paper analyzes subnational trends in child marriage over the last decade. Between 2005 and 2016, the percentage of Ethiopian women married before age 18 declined from 49 to 40%, a reduction of 18%. The percentage of women married before age 15 experienced even greater reductions, declining by 26% in the same period. The greatest reductions in child marriage took place in Addis Ababa, Amhara, and Tigray regions. Over the same period, estimates for Oromia and Somali regions suggest that child marriage has increased in these regions. Afar, Beneshangul-Gumuz, Somali, and Oromia are regions where more than or nearly half of all girls are married before age 18.Nationally, Ethiopia has experienced impressive declines in child marriage over the last decade. However, progress has also been uneven, resulting in a geographical shift in where child marriage is most prevalent. Remote and hard-to-reach locations pose persistent challenges to eradicating child marriage. Intensifying efforts in rural areas and underserved regions can achieve the elimination of child marriage in Ethiopia.

Ethiopia has made great progress toward reducing unmet need for family planning and increasing contraception use over the last decade. However, almost one-quarter of women still have an unmet need. The primary reason for non-use is "method-related health concerns" and, within this broad category, the belief that using contraception will cause infertility is common. This belief extends beyond Ethiopia to low-, middle-, and high-income countries across the world. The objective of this paper is to examine associations with the belief that contraception use causes infertility and to subsequently suggest potential strategies to address this misperception.We collected data from women of reproductive age (between 15 and 49 years old) in 115 rural districts of Ethiopia (n = 706). Our main outcome variable was the belief that contraception causes infertility. We analyzed data, both individual-level factors and interpersonal factors, using nested logistic regression models.Almost half of women in our sample (48.2%) believed that contraceptive use causes infertility. In the final model that included factors from both levels, self-efficacy to use contraception (AOR = 0.81, p 0.05), visiting a health center and speaking to a provider about family planning in the last 12 months (AOR = 0.78, p 0.05), and husband support of contraception (AOR = 0.77, p 0.01) were associated with a reduction in the odds of believing that contraception causes infertility. The belief that infertility will result in abandonment from one's husband (AOR = 3.06, p 0.001) was associated with an increase in the odds of holding the belief that contraception causes infertility. A home visit in the last 12 months from a health worker who discussed family planning was not associated with the belief that contraceptive use causes infertility.Given that this belief is both salient and positively associated with other fears such as abandonment from one's husband, it is critical for family planning programs to address it. Communication campaigns or interventions that address this misperception among couples may diminish this belief, thereby increasing contraception use and reducing unmet need in rural Ethiopia.Qualitative research in sub-Saharan Africa has shown that women’s belief that contraception use causes infertility is a barrier to contraception use. In this paper, we examine different factors related to this belief and suggest strategies to address this misperception. We surveyed 706 married women from 115 rural districts of Ethiopia. We found that women who believed that infertility would result in abandonment from one’s husband had three times higher odds of believing that contraception causes infertility. We also found that some factors associated with a decreased odds in holding this belief included self-efficacy to use contraception, visiting a health center and speaking to a provider about family planning, and husband support of family contraception. A home visit from a health extension worker who discussed family planning was not associated with holding this belief. Our findings suggest some ways to address this misconception. Clearly, women’s own self-efficacy, or believing that they can use family planning, is an important piece to any intervention. Given that husbands’ support of contraception is associated with reduced odds of holding the belief that contraception causes infertility, including them in intervention efforts is also a logical step. Finally, a home visit from a health extension worker was not associated with reduced odds of holding this belief. Including information that contraception does not cause infertility and discussing the real causes of infertility as part of their education strategy may help debunk this myth and thereby reduce unmet need in rural Ethiopia.

Background The Syrian refugee crisis has led to massive displacement into neighboring countries including Jordan. This crisis has caused a significant strain on the sexual and reproductive health (SRH) services to the host communities and Syrian refugees. The Minimum Initial Service Package (MISP) is a standard package of services that should be implemented at the onset of an emergency. Due to their importance in protracted humanitarian crisis, this systematic review aimed to assess the utilization of SRH and MISP after 9 years of the crisis. Methods We searched PubMed, Medline/Ovid and Scopus for both quantitative and qualitative studies from 1 January 2011 to 30 November 2019. Our search included both free text key words and Medical Subject Headings (MeSH) for various forms and acronmym of the following terms: (Sexual and) Reproductive Health, Sexual/Gender-based/Family/Intimate partner violence, Minimum Initial Service Package, MISP, Women, Girls, Adolescents, Syrian, Refugee, Jordan, Humanitarian crisis, War, (armed) conflict, and Disaster. Boolean operators and star truncation (*) were used as needed. We further conducted an in-depth review of the available grey literature published during the same timeframe. Using a narrative synthesis approach, two authors independently extracted and analyzed data from published papers. After removal of duplicates, screening, and assessing for eligibility of 161 initially identified citations, 19 papers were selected for review. Results Findings from this review indicated a number of barriers to access, utilization, and implementation of SRH services, including lack of reliable information on sexual and gender-based violence (SGBV), aggravation of early marriages by crisis setting, gaps in the knowledge and use of family planning services, inadequate STIs and HIV coverage, and some issues around the provision of maternal health services. Conclusion The findings from this review are suggestive of a number of barriers pertaining to access, utilization, and implementation of SRH services. This is especially true for transitioning from MISP to comprehensive SRH services, and particularly for refugees outside camps. Following are needed to address identified barriers: improved inter-agency coordination, better inclusion/engagement of local initiatives and civil societies in SRH services delivery, improved quality of SRH services, adequate and regular training of healthcare providers, and increased awareness of Syrian women and adolescent girls. Also, more implementing research is required to identify ways to transition SRH provision from the MISP to comprehensive care for the Syrian refugee population in Jordan.

Studies have shown that motivation to avoid pregnancy is associated with contraceptive use and continuation. These motivations can change, however, even within a short period of time. This paper uses longitudinal data to look at women's motivation to avoid pregnancy at two time points, and how changes in motivation influence contraceptive continuation.Data for this analysis came from an evaluation of the IntegratE project which seeks to expand access to family planning (FP) in Nigeria through community pharmacies and drug shops. 491 women were interviewed within 10 days after receiving a FP service from these sources and again approximately 9 months later. The dependent variable was contraceptive continuation at the follow-up interview. A categorical independent variable was used to represent changes in motivation to avoid pregnancy from enrollment to the follow-up interview. Univariate and multivariate logistic regression models were used to assess the association between changes in motivation and contraceptive continuation.89% of women continued using contraception approximately 9 months after the enrollment interview. Women who remained highly motivated to avoid pregnancy were significantly more likely to continue using contraception compared to women who became more motivated (AOR 2.5; 95% CI 1.0-6.0). Women who became less motivated were 64% less likely to continue using contraception compared to who became more motivated (AOR 0.36 95% CI 0.1-0.9).FP providers, including private sector pharmacists and drug shop owners, should continuously check-in with women about their motivations around pregnancy to support continuation among those who wish to avoid pregnancy.Previous research has found women’s motivations to avoid pregnancy- how important it is to avoid pregnancy now- is associated with their contraception use. Yet women’s motivations to avoid pregnancy often change, even within a short period of time. This paper looks at whether changes in motivation to avoid pregnancy are associated with continued use of contraception in Nigeria.We used data from a larger evaluation of the IntegratE project which seeks to expand access to family planning (FP) in Nigeria through community pharmacies and drug shops. 491 women were interviewed within 10 days after receiving a FP service (counseling, referral or FP method) from these sources and again 9 months later. We then used logistic regression models to assess whether changes in motivation to avoid pregnancy between receiving a FP service to 9 months later is associated with continued use of FP.We found that many women (89%) continued using contraception approximately 9 months after the enrollment interview. Women who remained highly motivated (reported it was very important to avoid pregnancy at both interviews) were more likely to continue using contraception compared to women who became more motivated between the two interviews. Women who became less motivated were 64% less likely to continue using contraception compared to who became more motivated. Our results suggest that FP providers, including private sector pharmacists and drug shop owners, should continuously check in with women about their motivations around pregnancy to support continuation contraceptive use among those who wish to avoid pregnancy.

Background Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation. Methods Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors. Results Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area. Conclusions Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level., Plain Language Summary Respectful care for mothers and newborns is a right and important part of ensuring that their care is high quality and acceptable to them. Just because there is no mistreatment does not mean that Respectful Maternity Care (RMC) was given. Without a clear framework for provider behaviors that reflect RMC principles, it is hard to ensure every woman and newborn gets respectful care in practice. We compared and combined two frameworks summarizing maternal and newborn rights and came out with seven categories. Then we searched for articles that mentioned provider behaviors reflecting RMC. We found 514 articles and ended up with 54 after careful review, from which we pulled the observable behaviors for providers in each category. Almost all papers mentioned actions to protect women and newborns from harm and mistreatment, to treat them with dignity and respect, and to give information and respect choices. About half of papers mentioned actions to protect privacy and to make sure every mother and newborn gets care when needed. Only 25% of papers mentioned actions to make sure all women and newborns receive equal care, and only 15% included actions to make sure women and newborns are physically free to leave facilities at will, and get care whether or not they can pay. This framework defining RMC behaviors for providers is based on data from many studies and can be useful to look at whether maternal newborn care in facilities meets these standards and to inform training and more research to improve RMC.

Background As the prevalence of obesity increases and the age of onset decreases, more women of reproductive age will be living in larger bodies. Research on weight-related efficacy and safety has informed clinical guidelines for routine and emergency contraceptive use by women with a higher body mass index; however, patient perspectives are needed to understand women in larger bodies’ experiences with contraception and contraceptive care. This scoping review summarizes the literature on women in larger bodies’ experiences with contraception with the goal of gaining a better understanding of the nature of these experiences and identifying gaps in the existing research. Methods Following Arksey and O’Malley’s framework, a scoping review of the literature was conducted. Four databases (PubMed, PsycINFO, SCOPUS, and CINAHL) were searched for peer-reviewed, empirical articles published in English between 2010 and 2020, with a focus on North America, Europe, Australia, and New Zealand. Data were summarized by identifying key themes in the reviewed literature. Results Twenty-nine articles meeting the eligibility criteria were reviewed. The literature was predominantly quantitative (n = 27), with only one qualitative study and one systematic review, respectively. Five themes were identified, including (1) use of contraception among women in larger bodies; (2) knowledge, attitudes towards and beliefs about contraception; (3) contraceptive (dis)satisfaction among women in larger bodies; (4) contraceptive counseling; and (5) barriers to contraception. The findings revealed that women in larger bodies may have unmet contraceptive care needs. Despite many articles addressing the need to improve contraceptive counseling for women in larger bodies (n = 26), few explored how women felt about their care (n = 2). Finally, only two articles focused on emergency contraception, indicating a need for further research. Conclusion This scoping review emphasizes the pressing need for qualitative research to explore women in larger bodies’ experiences with routine and emergency contraception, as well as receiving contraceptive counseling and care. Future research exploring the lived experiences of women in larger bodies is necessary to better characterize their contraceptive needs and identify avenues to improve patient care. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01139-2., Plain English summary As obesity becomes more prevalent, more women of reproductive age will be living in larger bodies. This review highlights what is known about women in larger bodies’ experiences with contraception and suggests where future research is needed. We searched four databases for papers published in English from 2010 to 2020. Our review included 29 articles. Nearly all of the studies were quantitative, with one qualitative study and one review. Most articles talked about contraceptive use, but few of them included emergency contraception. Some papers highlighted women’s knowledge and opinions about contraception, whereas others talked about their contraceptive (dis)satisfaction. Many articles discussed contraceptive counseling. Finally, some papers considered potential barriers to contraception. Our findings suggest that women in larger bodies have unmet contraceptive needs. Notably, this review aimed to focus on patient experiences but women’s voices were rarely represented. Future qualitative research on women’s lived experiences will provide a better understanding of women in larger bodies’ contraceptive needs and suggest how care can be improved. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01139-2.

Background Evidence of hysterectomy in India is limited mainly due to lack of information in large-scale nationally representative health surveys. In 2015–16, the fourth National Family Health Survey (NFHS-4) – a cross-sectional survey – collected for the first time direct information on hysterectomy and self-reported reasons for undergoing the procedure among women in the reproductive age group. This paper examines the prevalence and determinants of hysterectomy in India among women aged 30–49 years in 29 states and seven union territories (UTs) of India using the NFHS-4 dataset. Methods Percentage weighted by sampling weights was used for estimating the prevalence of hysterectomy. The paper used crosstabulations and percentage distributions to estimate the prevalence of hysterectomy across different socioeconomic backgrounds and reasons for undergoing hysterectomy respectively. A multivariate binary logistic regression model was also used to find statistically significant determinants of hysterectomy. Results In India as a whole, 6 % of women aged 30–49 years had undergone a hysterectomy. The percentage of women who had undergone the procedure was found to vary considerably across the states and the UTs (from a minimum of 2% in Lakshadweep to a maximum of 16% in Andhra Pradesh). A noticeable fact that emerged was that the majority of the hysterectomies were performed in the private sector except in the northeast region. Years of schooling, caste, religion, geographic region, place of residence, wealth quintiles, age, parity, age at first cohabitation, marital status, and body mass index of women were found to be the sociodemographic determinants statistically associated with hysterectomy in India. The reasons reported frequently for hysterectomy were excessive menstrual bleeding/pain (56%), followed by fibroids/cysts (20%). Conclusion The percentage and likelihood of undergoing hysterectomy are relatively high among women from older age groups (45–49), those who reside in rural areas, those without schooling, those who are obese, those having high parity, those with a low age at first marriage, and those who reside in the eastern and southern parts of India. The policy implication of these findings is that the reproductive health program managers should ensure regular screening and timely treatment of the problems resulting in hysterectomy.

Objective Although medication abortion has become more common in high-income countries, the procedure has not yet met early expectations for widening access to abortion. High-quality evidence can serve as a catalyst for changes in policy and practice. To direct research priorities, it is important to understand where quality evidence is concentrated and where gaps remain. High-income countries have developed a body of evidence that may have implications for the future of medication abortion. This literature review assesses the characteristics and quality of published studies on medication abortion conducted in the last 10 years in high-income countries and indicates future areas for research to advance policy and practice, and broaden access. Study design A structured search for literature resulted in 207 included studies. A framework based upon the World Health Organization definition of sub-tasks for medication abortion was developed to categorize research by recognized stages of the medication abortion process. Using an iterative and inductive approach, additional sub-themes were created under each of these categories. Established quality assessment frameworks were drawn upon to gauge the internal and external validity of the included research. Results Studies in the US and the UK have dominated research on MA in high-income countries. The political and social contexts of these countries will have shaped of this body of research. The past decade of research has focused largely on clinical aspects of medication abortion. Conclusion Researchers should consider refocusing energies toward testing service delivery approaches demonstrating promise and prioritizing research that has broader generalizability and relevance outside of narrow clinical contexts. Plain English summary Although medication abortion is more commonly available worldwide, it is not being used as often as people thought it would be, particularly in high income countries. In order to encourage changes in policy and practice that would allow greater use, we need good quality evidence. If we can understand where we do not have enough research and where we have good amounts of research, we can determine where to invest energies in further studies. Many high-income countries have produced research on medication abortion that could influence policy and practice in similarly resourced contexts. I conducted a literature review to be able to understand the type and quality of research on medication abortion conducted in high-income countries in the past 10 years. I conducted the review in an organized way to make sure that the papers reviewed discussed studies that I thought would be important for answering this question. The literature review found 207 papers. Each of these papers were reviewed and organized them by theme. I also used existing methods to determinine the quality of each study. Most of the research came from the US and the UK. Furthermore, most of the research conducted in the past 10 years was focused on clinical studies of medication abortion. In future studies, researchers should focus more on new ways of providing medication abortion to women that offers greater access. Also, the studies should be designed so that the results have meaning for a broader group of people or situations beyond where the study was done.

Background Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women’s groups suggests that group care models may both improve access to care and the quality of care delivered through women’s empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes. Methods The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process. Results A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1–91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics. Conclusion Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system. Trial registration ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

The Jawaharlal Nehru Medical College (JNMC) Women’s and Children’s Health Research Unit (WCHRU) of the Karnataka Lingayat Education (KLE) Academy of Higher Education and Research Deemed-to-be-University and its collaborators convened the ‘2nd International Conference on Maternal and Newborn Health -Translating Research Evidence to Practice’ to address the common theme of improving maternal and newborn health in low- and middle- income countries (LMIC). This supplement, including 16 manuscripts, reflects much of the research presented at the conference, including analyses of the state of knowledge, as well as completed, ongoing and planned research in these areas conducted by the WCHRU in India together with many collaborators across high-income and LMIC. The first paper reviews maternal, fetal and neonatal mortality in low-income countries, considers their causes, as well as evidence for potential interventions to reduce mortality. A second paper addresses near miss maternal mortality. Several manuscripts address the research conducted by WCHRU and their colleagues in a multi-center research network. One study examines rates of miscarriage and medically terminated pregnancy in India and the risk factors for these occurrences. Another paper addresses stillbirth and its risk factors, both in India as well as in other LMIC. Haemorrhage and preeclampsia/eclampsia, important causes of maternal mortality, stillbirth and neonatal morbidity in LMIC, are addressed in a series of papers summarizing trials of interventions to reduce improve outcomes associated with these conditions. Poor maternal and infant nutritional status, which contribute to adverse outcomes, are addressed through papers which describe a number of important studies that the WCHRU and their colleagues have conducted to attempt to improve nutritional status. Another paper describes a study to investigate causes of stillbirth and deaths among preterm births, which will utilize new techniques to investigate the infectious causes of these deaths. Finally, the supplement addresses the process for dissemination of research results to inform public policy. Together these manuscripts represent a body of research to inform interventions to reduce maternal, fetal and newborn mortality and illustrates what a dedicated research group together with institutional support can accomplish.

Background Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in low-income countries and is a significant contributor to severe maternal morbidity and long-term disability. Carbetocin may be an underused uterotonic for prevention of PPH. A number of studies are being conducted that may challenge the place of oxytocin as the first choice of uterotonics for prevention of PPH. This paper describes the current research into carbetocin and ranking of effectiveness of uterotonics that may provide important new information to assist healthcare decision makers to ensure that women receive an effective uterotonic for prevention of PPH. Methods We searched the WHO International Clinical Trials Registry Platform for current studies on effectiveness of carbetocin for prevention of PPH following vaginal delivery with sample sizes large enough to provide quality evidence to support potential changes to international guidelines. We also searched the Cochrane Library for current systematic reviews including carbetocin used in prevention of PPH. Results Susceptibility to degradation from exposure to heat is one of the key causes of reduced effectiveness of oxytocin in preventing PPH from uterine atony. Although heat stable and effective in preventing PPH, misoprostol is also subject to degradation due to exposure to moisture and produces some side-effects. Other uterotonics (including ergometrine and combinations of oxytocin, ergometrine and misoprostol) are also available and used with varying safety and effectiveness profiles and quality issues. Efforts to reduce maternal mortality from PPH include research studies seeking to identify safe, stable, effective uterotonics. Heat stable carbetocin is the subject of two major clinical studies into its effectiveness in preventing PPH following vaginal deliveries, information that could expand its application for prevention of PPH. Conclusion Heat stable carbetocin is being investigated as a potential alternative to oxytocin. This paper describes two current clinical trials on carbetocin and a network meta-analysis ranking of all uterotonic agents, including carbetocin, which combined may provide evidence supporting expansion of the use of the heat stable formulation of carbetocin in PPH prevention.

Background Several recent studies have attempted to measure the prevalence of disrespect and abuse (D&A) of women during childbirth in health facilities. Variations in reported prevalence may be associated with differences in study instruments and data collection methods. This systematic review and comparative analysis of methods aims to aggregate and present lessons learned from published studies that quantified the prevalence of Disrespect and Abuse (D&A) during childbirth. Methods We conducted a systematic review of the literature in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Five papers met criteria and were included for analysis. We developed an analytical framework depicting the basic elements of epidemiological methodology in prevalence studies and a table of common types of systematic error associated with each of them. We performed a head-to-head comparison of study methods for all five papers. Using these tools, an independent reviewer provided an analysis of the potential for systematic error in the reported prevalence estimates. Results Sampling techniques, eligibility criteria, categories of D&A selected for study, operational definitions of D&A, summary measures of D&A, and the mode, timing, and setting of data collection all varied in the five studies included in the review. These variations present opportunities for the introduction of biases – in particular selection, courtesy, and recall bias – and challenge the ability to draw comparisons across the studies’ results. Conclusion Our review underscores the need for caution in interpreting or comparing previously reported prevalence estimates of D&A during facility-based childbirth. The lack of standardized definitions, instruments, and study methods used to date in studies designed to quantify D&A in childbirth facilities introduced the potential for systematic error in reported prevalence estimates, and affected their generalizability and comparability. Chief among the lessons to emerge from comparing methods for measuring the prevalence of D&A is recognition of the tension between seeking prevalence measures that are reliable and generalizable, and attempting to avoid loss of validity in the context where the issue is being studied. Electronic supplementary material The online version of this article (10.1186/s12978-017-0389-z) contains supplementary material, which is available to authorized users.

Introduction Improving healthcare providers’ capacities of prevention and treatment of female genital mutilation (FGM) is important given the fact that 200 million women and girls globally are living with FGM. However, training programs are lacking and often not evaluated. Validated and standardized tools to assess providers’ knowledge, attitude and practice (KAP) regarding FGM are lacking. Therefore, little evidence exists on the impact of training efforts on healthcare providers’ KAP on FGM. The aim of our paper is to systematically review the available published and grey literature on the existing quantitative tools (e.g. scales, questionnaires) measuring healthcare students’ and providers’ KAP on FGM. Main body We systematically reviewed the published and grey literature on any quantitative assessment/measurement/evaluation of KAP of healthcare students and providers about FGM from January 1st, 1995 to July 12th, 2016. Twenty-nine papers met our inclusion criteria. We reviewed 18 full text questionnaires implemented and administered to healthcare professionals (students, nurses, midwives and physicians) in high and low income countries. The questionnaires assessed basic KAP on FGM. Some included personal and cultural beliefs, past clinical experiences, personal awareness of available clinical guidelines and laws, previous training on FGM, training needs, caregiver’s confidence in management of women with FGM, communication and personal perceptions. Identified gaps included the medical, psychological or surgical treatments indicated to improve girls and women’s health; correct diagnosis, recording ad reporting capacities; clitoral reconstruction and psychosexual care of circumcised women. Cultural and personal beliefs on FGM were investigated only in high prevalence countries. Few questionnaires addressed care of children, child protection strategies, treatment of short-term complications, and prevention. Conclusion There is a need for implementation and testing of interventions aimed at improving healthcare professionals’ and students’ capacities of diagnosis, care and prevention of FGM. Designing tools for measuring the outcomes of such interventions is a critical aspect. A unique, reproducible and standardized questionnaire could be created to measure the effect of a particular training program. Such a tool would also allow comparisons between settings, countries and interventions. An ideal tool would test the clinical capacities of providers in managing complications and communicating with clients with FGM as well as changes in KAP.

Background Violence against women is now widely recognized as a serious human right abuse, and an important public health problem with substantial consequences physical, mental, sexual, and reproductive health. Data on systematic review of domestic violence are needed to support policy and program recommendations. Therefore, the overall purpose of this systematic review was to assess magnitude of domestic violence against women and associated factors in Ethiopia. Methods Studies systematically reviewed in Federal Democratic Republic of Ethiopia from 2000 to 2014. Systematic review was employed on published research works from databases such as Pubmed, popline, Hinari, and Google using key words. We also consulted public health experts. Community based studies with a study population (15–49 years) were included for review. Thirteen peer reviewed papers and two consecutive Ethiopian demographic and health surveys (2005 and 2011) were included to the systematic review. Twenty seven available in open access journals were retrieved and assessed based on the criteria’s such as community based study, cross sectional study design, clearly report prevalence and associated factors were included in the systematic review work. Finally, 15 papers were included in this review. Results Lifetime prevalence of domestic violence against women by husband or intimate partner among 10 studies ranged from 20 to 78 %. The lifetime domestic physical violence by husband or intimate partner against women ranged from 31 to 76.5 %. The life time domestic sexual violence against women by husband or intimate partner ranged from 19.2 to 59 %. The mean life time prevalence of domestic emotional violence was 51.7 %. Significant number of women experienced violence during their pregnancy period. Domestic violence against women significantly associated with alcohol consumption, chat chewing, family history of violence, occupation, religion, educational status, residence and decision making power. Conclusion Domestic violence against women was relatively high in different parts of Ethiopia. Domestic violence has direct relationship with sociodemographic characteristics of the victim as well as perpetrator. Therefore, appropriate health promotion information activities needed to tackle associated factors of domestic violence against women or to prevent and control the problem to save women from being victim.

Background: Although Pakistan was one of the first countries in Asia to launch national family planning programs, current modern contraceptive use stands at only 26% with a method mix skewed toward short-acting and permanent methods. As part of a multiyear operational research study, a baseline survey was conducted to understand the predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan. This paper presents the baseline survey results; the outcomes of the intervention will be presented in a separate paper after the study has been completed. Method: A cross-sectional baseline household survey was conducted with randomly selected 3,998 married women of reproductive age (MWRA) in the Chakwal, Mianwali, and Bhakkar districts of Punjab. The data were analyzed on SPSS 17.0 using simple descriptive and logistic regression. Results: Most of the women had low socio-economic status and were younger than 30 years of age. Four-fifths of the women consulted private sector health facilities for reproductive health services; proximity, availability of services, and good reputation of the provider were the main predicators for choosing the facilities. Husbands were reported as the key decision maker regarding health-seeking and family planning uptake. Overall, the current contraceptive use ranged from 17% to 21% across the districts: condoms and female sterilization were widely used methods. Woman's age, husband's education, wealth quintiles, spousal communication, location of last delivery, and favorable attitude toward contraception have an association with current contraceptive use. Unmet need for contraception was 40.6%, 36.6%, and 31.9% in Chakwal, Mianwali, and Bhakkar, respectively. Notably, more than one fifth of the women across the districts expressed willingness to use quality, affordable long-term family planning services in the future. Conclusion: The baseline results highlight the need for quality, affordable long-term family planning services close to women's homes. Furthermore, targeted community mobilization and behavior change efforts can lead to increased awareness, acceptability, and use of family planning and birth spacing services.

This paper explored the facilitators and barriers to husbands' involvement in antenatal-related care in the Bosomtwe District of Ghana from the perspectives of husbands, pregnant women with and without delivery experience, nursing mothers, midwives and traditional birth attendants.The study relied on the qualitative research design to collect and analyse data on the facilitators and barriers to husbands' involvement in antenatal-related care. The unit of analysis was made up of 36 participants-husbands (14), pregnant women with delivery experience and, nursing mothers (8), pregnant women without delivery experience (6), male and female midwives (6) and traditional birth attendants (2) who were purposively selected. The study's data was gathered using in-depth interviews and analysed through the content approach.Various economic [work and time constraint], cultural [the association of childbearing and its allied duties to women] and health-system factors [lack of antenatal services targeted at husbands and health professionals' attitude] hinder husbands' active participation in antenatal care. Despite these, some husbands participated in antenatal care owing to the importance they accord to the health and safety of their wives and the foetus; changing gender roles and preferential treatments received by their wives at antenatal clinics [as a result of the involvement of their husbands in prenatal care].The implementation of alternative strategies, like, couple counselling, prolonging operating times of health centres to accommodate working men are recommended to provide a more accommodative and attractive avenue for husbands to support their wives during pregnancy. These efforts must be reinforced by the entire society through modifying the "ill-held view" that pregnancy and childcare is the sole duty of a woman.RéSUMé: CONTEXTE: Cet article a abordé les facilitateurs et les obstacles relatifs à l’implication des maris dans les soins prénatals dans le district de Bosomtwe au Ghana, du point de vue des maris, des femmes enceintes avec et sans expérience d'accouchement, des mères allaitantes, des sage-femmes et des accoucheuses traditionnelles. MéTHODOLOGIE: L’étude s’est basée sur une conception de recherche qualitative pour recueillir et analyser les données sur les facilitateurs et les obstacles relatifs à l’implication des maris dans les soins prénatals. Le champ d’analyse était constitué de 36 participants, dont 14 maris, 8 femmes enceintes ayant déjà accouché et mères allaitantes, 6 femmes enceintes n’ayant jamais accouché, 6 sage-femmes et 2 accoucheuses traditionnelles—sélectionnés délibérément. Les données de l’étude ont été recueillies par le biais d'entretiens approfondis et analysées par l’approche du contexte. RéSULTATS: Nombreux facteurs empêchent la participation active des maris aux soins prénatals. Ces facteurs sont d’ordre économique (contraintes de temps), culturels (l’association de la maternité et ses obligations aux femmes) et le système de santé (manque de Services prénatals destinés aux maris et le comportement des personnels de santé). Malgré cela, certains maris ont participé aux soins prénatals en raison de l'importance qu'ils accordent à la santé et à la sécurité de leurs femmes et du fœtus, de l'évolution des rôles de chacun des sexes et des traitements préférentiels reçus par leurs femmes dans les maternités (en raison de la participation de leurs maris aux soins prénatals). CONCLUSION: La mise en œuvre des stratégies alternatives, telles que le conseil aux couples, la prolongation des heures d’ouverture des centres de santé pour accueillir les hommes fonctionnaires, est recommandée afin d'offrir aux maris un moyen plus souple et plus attrayant de soutenir leurs femmes pendant la grossesse. Ces efforts doivent être renforcés par tous dans la société en modifiant l’opinion erronée selon laquelle la conception de la grossesse et l’éducation de l’enfant sont les devoirs de la femme seule.The involvement of males [husbands] in antenatal-related care is noted to have significant impacts on the wellbeing of pregnant women and lessen burden of pregnancy, delivery and childcare. In this study, we examined the opinions of some stakeholders in the space of pregnancy and childcare [husbands, pregnant women with delivery experience, nursing mothers, midwives and traditional birth attendants], regarding the involvement of husbands in antenatal-related care. The study was conducted in the Bosomtwe District of Ghana, West Africa.The participants were asked to narrate experiences of husbands’ involvement in pregnancy-related care, in addition to the barriers and facilitators of such engagement processes. A total of 36 participants were involved in the study. The narrative approach was used to report the findings.It was found that male’s involvement in antenatal-related care is minimal in the study area. Factors such as limited time due to economic activities and the responsibility of providing financial resources for the wellbeing of the family and cultural factors in the form of childbearing being a responsibility of women deterred husbands from antenatal-related care. Again, absence of services that target males also served as a barrier. That notwithstanding, the importance attached by husbands to the health and safety of their wives and the foetus, the changing gender roles and preferential treatments given to pregnant women who are accompanied by their husbands facilitated males involvement.In conclusion, the study has implications for male-friendly antenatal care services development and continuous effort to undo the “cultural-ills” of male’s involvement in pregnancy care in Ghana.

Worldwide, 250,000-280,000 women die during pregnancy and childbirth every year and an estimated 6.55 million children die under the age of five. The majority of maternal deaths occur during or immediately after childbirth, while 43% of child death occurs during the first 28 days of life. However, the progress in limiting these has been slow and sporadic. In this supplement of five papers, we aim to systematically assess and summarize essential interventions for reproductive, maternal, newborn and child health from relevant systematic reviews. This paper is an introductory paper detailing the background and methodology used for grading interventions. The following three papers summarize the evidence on essential interventions for pre-pregnancy, pregnancy, childbirth, postnatal (mother and neonatal) and child heath while the last paper describes the essential interventions as per the level of health care delivery and their proposed packages of care.

Pregnancy and childbirth represent a critical time period when a woman can be reached through a variety of mechanisms with interventions aimed at reducing her risk of a preterm birth and improving her health and the health of her unborn baby. These mechanisms include the range of services delivered during antenatal care for all pregnant women and women at high risk of preterm birth, services provided to manage preterm labour, and workplace, professional and other supportive policies that promote safe motherhood and universal access to care before, during and after pregnancy. The aim of this paper is to present the latest information about available interventions that can be delivered during pregnancy to reduce preterm birth rates and improve the health outcomes of the premature baby, and to identify data gaps. The paper also focuses on promising avenues of research on the pregnancy period that will contribute to a better understanding of the causes of preterm birth and ability to design interventions at the policy, health care system and community levels. At minimum, countries need to ensure equitable access to comprehensive antenatal care, quality childbirth services and emergency obstetric care. Antenatal care services should include screening for and management of women at high risk of preterm birth, screening for and treatment of infections, and nutritional support and counselling. Health workers need to be trained and equipped to provide effective and timely clinical management of women in preterm labour to improve the survival chances of the preterm baby. Implementation strategies must be developed to increase the uptake by providers of proven interventions such as antenatal corticosteroids and to reduce harmful practices such as non-medically indicated inductions of labour and caesarean births before 39 weeks of gestation. Behavioural and community-based interventions that can lead to reductions in smoking and violence against women need to be implemented in conjunction with antenatal care models that promote women's empowerment as a strategy for reducing preterm delivery. The global community needs to support more discovery research on normal and abnormal pregnancies to facilitate the development of preventive interventions for universal application. As new evidence is generated, resources need to be allocated to its translation into new and better screening and diagnostic tools, and other interventions aimed at saving maternal and newborn lives that can be brought to scale in all countries. Declaration. This article is part of a supplement jointly funded by Save the Children's Saving Newborn Lives programme through a grant from The Bill & Melinda Gates Foundation and March of Dimes Foundation and published in collaboration with the Partnership for Maternal, Newborn and Child Health and the World Health Organization (WHO). The original article was published in PDF format in the WHO Report Born Too Soon: the global action report on preterm birth (ISBN 978 92 4 150343 30), which involved collaboration from more than 50 organizations. The article has been reformatted for journal publication and has undergone peer review according to Reproductive Health's standard process for supplements and may feature some variations in content when compared to the original report. This co-publication makes the article available to the community in a full-text format. © 2013 Requejo et al.; licensee BioMed Central Ltd.

Background Domestic violence (DV) affects millions of people worldwide, especially women impacting their health status and livelihoods. To prevent DV and to improve the quality of victims’ lives, Mozambican governmental and non-governmental entities are making efforts to develop adequate policies and legislation and to improve the accessibility of services for victims of DV. However, a critical review of whether or not current policies and legislation concerning DV in Mozambique are in agreement with international guidelines has yet to be examined. Therefore, this paper aims to map the Mozambican legislative and policy responses to DV. It also strives to analyse their alignment with international treaties and conventions and with each other. Methods Through a critical cartography, documents were selected and their content analysed. Some of these documents were not available online, printed versions were not available on the field and some were not up to date. Therefore, we had to search for them via physical office visits at governmental institutions with a responsibility to deal with DV aspects. These documents were listed and analysed for key content applying a framework inquiring on recommendations of international agencies such as World Health Organization. Subsequently, we compared these policies with international conventions and treaties of which Mozambique is signatory and with each other to identify discrepancies. Results Overall, six institutions were visited assuring identification of all available information and policy documents on DV. We identified a total of fifteen national DV documents of which five were on laws, one on policy and nine institutional strategic/action plans. Most of the national DV documents focused on strategies for assistance/care of victims and prevention of DV. Little focus was found on advocacy, monitoring and evaluation. Conclusions Mozambique has demonstrated its commitment by signing several international and regional treaties and conventions on DV. Despite this, the lack of consistency in the alignment of international treaties and conventions with national policies and laws is remarkable. However, a gap in the reliable translation of national policies and laws into strategic plans is to be found particularly in relation to naming type, beneficiaries, main strategies and multi-sectorial approach., Plain language summary Domestic violence (DV) which involves physical, sexual and psychological threats, is a Mozambican public health problem that compromises the quality of life of the victims and their families. In extreme cases, such abuse can result in fatalities. In response to DV, the Mozambican government has adopted international treaties and conventions to design national DV prevention and containment policies and laws. This article aims to describe how national policies, laws and strategic plans define DV, and align with international treaties and conventions as well as with each other. The analysis indicates that the country’s policies, laws and strategic plans do not meet all recommendations of international guidelines. These include those proposed by the United Nations (UN) and the Pan American Health Organization (PAHO). While strategic plans propose measures directed at preventing the occurrence of DV and providing victim assistance, they make no reference to monitoring and evaluation, data management and advocacy. Given these mixed findings it is proposed that synergy be obtained among legislation, policy and strategic planning documents and that these documents be revised to incorporate a focused multisectoral approach and monitoring and evaluation.

Sexual and reproductive health (SRH) is referring to physical and emotional wellbeing and includes the ability to be free from unwanted pregnancy, unsafe abortion, sexually transmitted infections including HIV/AIDS, and all forms of sexual violence and coercion. SRH is the main services packages that prevent and reduce adolescent reproductive health risks and problems. While the government of Ethiopia has undertaken several measures to improve SRH services, there was limited data on utilization among adolescents and associated factors.To assess utilization of SRH services and associated factors among adolescents attending secondary schools in Haramaya District, Eastern Ethiopia.A school-based cross-sectional study was conducted among adolescent students aged 15-19 years. A total of 692 adolescents were selected using a multi-stage sampling from two randomly selected secondary schools, each from rural and urban settings, in Haramaya district where 642 provided complete data and included in the analysis. A structured, pretested, and self-administered questionnaire was used to collect data. Data entry was conducted using Epi Data version 3.1 and exported to STATA version 16 for analysis. Bivariable and multivariable binary logistic regression were used to identify factors associated with school adolescents' utilization of SRH. Statistically significant associations are declared at P-value 0.05.A total of 642 completed the survey questionnaire, constituting a response rate of 92.7% (642/692). Male adolescents accounted 63.7% and the mean age of respondents was 17.71 years. Among those who completed the survey, 23.5% (95% CI: 20-26.8) utilized SRH services. Adolescents who were exposed to SRH information (adjusted odds ratio (AOR) = 2.11, 95% CI: 1.22-3.6), aware of SRH service providing facility (AOR = 1.83, 95% CI: 1.12-3.0) and SRH service components (AOR = 2.76, 95%, CI: 1.53-4.97), and distance from SRH facilities (AOR = 2.28, 95%, CI: 1.13-4.62) were significantly associated with the utilization of SRH services.Nearly one-in-four secondary school adolescents (23.5%) utilized SRH services. Targeted promotion of SRH providing facilities and SRH service components aimed at awareness creation could improve adolescents' utilization of SRH services. Improved SRH services utilization among adolescents who were far from SRH services providing facilities needs further investigation.Sexual and reproductive health (SRH) refers to physical and emotional wellbeing and includes the ability to be free from unwanted pregnancy, unsafe abortion, sexually transmitted infections including HIV/AIDS, and all forms of sexual violence and coercion. Components of the SRH services are important to reduce adolescent reproductive health risks and problems. This paper reports on the frequency of in-school adolescents who utilized SRH services and the factors that determined it.we collected data from 642 in-school secondary school adolescents, aged 15–19 years, in Haramaya district, East Ethiopia. The data were collected from two schools, one from rural and the other from urban areas, using lottery method from the available schools in the district. A face-to-face interview was conducted to obtain data from the adolescents in the selected secondary schools.Out of 642 in-school adolescents, 23.5% utilized SRH services in Haramaya District. Adolescents who previously received SRH information, who knew SRH services providing facility, aware of SRH service components, and those who live not close to the SRH facilities were utilized the SRH services more often compared to their friends.Nearly one-in-four secondary school adolescents (23.5%) utilized SRH services. Targeted promotion of SRH providing facilities and SRH service components aimed at awareness creation could improve adolescents’ utilization of SRH services.

Background Migration and involuntary displacement of children and young people have recently become common features of many African countries due to widespread poverty, rapid urbanization, joblessness, and instability that motivate them to seek livelihoods away from their places of origin. With limited education and skills, children become vulnerable socioeconomically, thereby exposing themselves to sexual and reproductive health (SRH) risks. Methods Against this background, the authors undertook a scoping review of the existing literature between January and June 2019 to highlight current knowledge on SRH of African migrant and refugee children. Twenty-two studies that met the inclusion criteria were reviewed. Results The results identified overcrowding and sexual exploitation of children within refugee camps where reproductive health services are often limited and underutilized. They also reveal language barriers as key obstacles towards young migrants’ access to SRH information and services because local languages used to deliver these services are alien to the migrants. Further, cultural practices like genital cutting, which survived migration could have serious reproductive health implications for young migrants. A major gap identified is about SRH risk factors of unaccompanied migrant minors, which have received limited study, and calls for more quantitative and qualitative SRH studies on unaccompanied child migrants. Studies should also focus on the different dimensions of SRH challenges among child migrants differentiated by gender, documented or undocumented, within or across national borders, and within or outside refugee camps to properly inform and situate policies, keeping in mind the economic motive and spatial displacement of children as major considerations. Conclusion The conditions that necessitate economic-driven migration of children will continue to exist in sub-Saharan Africa. This will provide fertile grounds for child migration to continue to thrive, with diverse sexual and reproductive health risks among the child migrants. There is need for further quantitative and qualitative research on child migrants’ sexual and reproductive health experiences paying special attention to their differentiation by gender, documented or undocumented, within or across national borders and within or outside refugee camps., Plain language summary Child migration is increasingly becoming a common feature of many African countries as children migrate within and away from their countries of origin in search of better livelihoods due to widespread poverty, instability and rapid urbanisation. Many of the migrating children have little or no education and limited employable skills, thereby exposing themselves to sexual and reproductive health (SRH) risks. This paper is a scoping review of existing literature from 2000 to 2019 to document relevant findings on SRH of African migrant and refugee children. The review identified migrant children within refugee camps to experience overcrowding and sexual exploitation amidst limited and underutilized reproductive health services. Language barriers are also key obstacles against young migrants’ access to SRH information and services as these services are delivered in local languages unfamiliar to them. Child migrants continue to suffer from cultural practices including genital cutting with serious reproductive health implications. SRH risk factors of unaccompanied migrant minors remain as a gap in the review and, therefore, more SRH studies on unaccompanied child migrants are needed. Attention should also be paid to the different dimensions of SRH challenges among child migrants to reflect gender differences, whether documented or undocumented, within or across national borders, and within or outside refugee camps for better understanding. In conclusion, child migration in Africa will continue to be economic-driven and will expose the actors to diverse sexual and reproductive health risks. Further in-depth quantitative and qualitative research is required to inform relevant policies on child migrants’ SRH.

Family planning (FP) is a human right, and ensuring women’s access to FP is central to protecting the health and wellbeing of mothers and children. Over the past two decades, Ethiopia has made FP service more widely available, increasing the contraceptive prevalence rate from 8% in 2000 to 41% in 2019. This remarkable fivefold increase can be attributed to the country’s overall development, including investment in education (particularly for girls) and reduction in child marriage, as well as the adoption and implementation of several enabling FP policies and strategies. In Ethiopia, achieving universal access to sexual and reproductive health care services, information, and education, including FP, by 2030 means enhancing these effective government policies and programs. Achieving universal access requires increasing financial resources, including domestic financing through greater government commitment for commodity security and program implementation; strengthening public–private partnerships; and improving service delivery for populations that are hard to reach and/or in humanitarian crisis. The persistence of equity gaps due to regional and/or sociodemographic disparities and the low quality of FP service delivery challenge our progress in Ethiopia. The papers included in this supplement provide additional detail on the overall progress described in this commentary and highlight focal areas for improvement in responding to unmet needs. Current policies and services must adapt, maintain, and build upon these gains and focus on targeted actions in areas identified for improvement. We must sustain the hard-fought gains of the past decades and help shape the prosperous future we advocate for in our society by 2030 and beyond—Leaving No One Behind.

To solve infertility, modern science has promoted assisted reproduction techniques such as in vitro fertilization, ovulation induction, and artificial insemination. Quadruple-type multiple pregnancies occur in 1 of every 500,000 pregnancies, and it is estimated that 90% occur due to assisted reproductive techniques, which often lead to numerous complications.Here we present a case of a 33-year-old woman, who desired pregnancy, but had a history of primary infertility diagnosed by hysterosalpingography, and endometriosis, which was treated by fulguration and medical management. Concomitantly, the patient was anovulatory. To fulfill her wish, she underwent homologous artificial insemination, after treatment, she successfully conceived quadri-chorionic quadri-amniotic infants, who were born at 37.2 weeks, without perinatal or maternal complications.This paper presented the parameters of prenatal care, appropriate management approach, and successful resolution without maternal-fetal complications despite the inherent risks of this type of pregnancy.INTRODUCCIóN: Para solucionar la infertilidad, la ciencia moderna ha promovido las técnicas de reproducción asistida, como la fecundación in vitro, la inducción de la ovulación y la inseminación artificial. Los embarazos múltiples de tipo cuádruple se producen en 1 de cada 500.000 embarazos, y se estima que el 90% ocurren debido a las técnicas de reproducción asistida, que a menudo conllevan numerosas complicaciones. PRESENTACIóN DEL CASO: Presentamos el caso de una mujer de 33 años, que deseaba un embarazo, pero tenía antecedentes de infertilidad primaria diagnosticada por histerosalpingografía, y endometriosis, que fue tratada mediante fulguración y manejo médico. Al mismo tiempo, la paciente era anovulatoria. Para cumplir su deseo, se sometió a una inseminación artificial homóloga y, tras el tratamiento, concibió con éxito niños cuadri-coriónicos cuadri-amnióticos, que nacieron a las 37,2 semanas, sin complicaciones perinatales ni maternas. CONCLUSIóN: Este trabajo presentó los parámetros de atención prenatal, el enfoque de manejo adecuado y la resolución exitosa sin complicaciones materno-fetales a pesar de los riesgos inherentes a este tipo de embarazo.

The attainment of targets set for modern contraceptive use remains a challenge in sub-Saharan Africa. Rwanda, in its new Family Planning and Adolescent Sexual Reproductive Health/Family Planning (FP/ASRH) Strategic Plan 2018-2024 has set the attainment of a contraceptive prevalence rate (CPR) of 60% by 2024. To achieve this, identifying factors that enhance modern contraceptive use among sexually active women is critical.We used three Rwanda Demographic Health Surveys (RDHS) datasets collected in 2010, 2015, and 2019/2020 in a multivariable decomposition analysis technique to describe trends and identify factors influencing change in modern contraceptive use among sexually active women aged 15-49 years. Results presented as coefficients and percentages took into consideration the complex survey design weighted using StataSE 17.Modern contraceptive use increased from 40% in 2010 to 52.4% in 2020 among sexually active women. About 23.7% of the overall percentage change in modern contraceptive use was attributable to women's characteristics which included women's education levels, number of living children, and being told about family planning at health facilities. Coefficients contributed 76.26% to the change in modern contraceptive use. This change was attributed to modern contraceptive use among young women between the age of 20-24 years, women's education level, the number of living children, changes in family size, and being visited by community health workers.Rwanda remains on course to archive its 2024 family planning targets. However, there is a need to enhance programs that target sexually active adolescents and young adults, and women from rural areas to sustain the gains made. Furthermore, continuous support of community health workers will be key in exceeding the set targets of modern contraceptive use among sexually active women in Rwanda.Modern contraceptive use has been observed to improve the health of women and accelerate the attainment of health rights and gender equity. Sustaining and enhancing the uptake of modern contraceptives is essential in designing sexual reproductive health programs for all sexually active women to reduce the risks of unplanned pregnancies. This paper identified and reports changes in modern contraceptives among all sexually active women aged between 15 and 49 years old for the period 2010–2020. The manuscript used Rwanda Demographic and Health Survey (RDHS) data that is collected every after five years to track changes in the health and demographics of the citizens. The study found that a change in the behaviour of women towards contraceptive use is key to improving modern contraceptive use among sexually active women. Therefore, focusing on these behavioural components will enhance modern contraceptive use and contribute to improving women’s sexual and reproductive health.

Background Efforts are underway to develop an easy-to-use contraceptive microarray patch (MAP) that could expand the range of self-administrable methods. This paper presents results from a discrete choice experiment (DCE) designed to support optimal product design. Methods We conducted a DCE survey of users and non-users of contraception in New Delhi, India (496 women) and Ibadan, Nigeria (two versions with 530 and 416 women, respectively) to assess stated preferences for up to six potential product attributes: effect on menstruation, duration of effectiveness, application pain, location, rash after application, and patch size. We estimated Hierarchical Bayes coefficients (utilities) for each attribute level and ran simulations comparing women’s preferences for hypothetical MAPs with varying attribute combinations. Results The most important attributes of the MAP were potential for menstrual side effects (55% of preferences in India and 42% in Nigeria) and duration (13% of preferences in India and 24% in Nigeria). Women preferred a regular period over an irregular or no period, and a six-month duration to three or one month. Simulations show that the most ideal design would be a small patch, providing 6 months of protection, that would involve no pain on administration, result in a one-day rash, and be applied to the foot. Conclusions To the extent possible, MAP developers should consider method designs and formulations that limit menstrual side effects and provide more than one month of protection.

Background Pelvic organ prolapse remains the public health challenge globally. Existing evidences report the effect of woman’s weight on the pelvic organ prolapse inconsistently and this urges the need of pooled body weight effect on the pelvic organ prolapse. Although there was a previous work on this regard, it included papers reported before June 18/2015. Thus, updated and comprehensive evidence in this aspect is essential to devise strategies for interventions. Objective This review aimed at synthesizing evidence regarding the pooled effect of body weight on the pelvic organ prolapsed. Methods For this review, we searched all available articles through databases including PubMed, Web of Sciences, CINAHL, JBI library, Cochran library, PsycInfo and EMBASE as well as grey literature including Mednar, worldwide science, PschEXTRA and Google scholar. We included cohort, case–control, cross-sectional and experimental studies which had been reported between March 30, 2005 to March 30, 2020. In the effect analysis, we utilized random model. The heterogeneity of the studies was determined by I2 statistic and the publication bias was checked by Egger’s regression test. Searching was limited to studies reported in the English language. Results A total of 14 articles with 53,797 study participants were included in this systematic review (SR) and meta analysis (MA). The pooled result of this Meta analyses depict that body mass index (BMI) doesn’t have statistical significant association with pelvic organ prolapse. Conclusion This review point out that women’s body mass index has no significant effect on the development of pelvic organ prolapse. However, the readers should interpret the result with cautions due to the presence of considerable limitations in this work. Trial registration The protocol of this systematic review (SR) and meta analysis (MA) has been registered in PROSPERO databases with the Registration number of CRD42020186951

Introduction The Covid-19 pandemic affects maternal health both directly and indirectly, and direct and indirect effects are intertwined. To provide a comprehensive overview on this broad topic in a rapid format behooving an emergent pandemic we conducted a scoping review. Methods A scoping review was conducted to compile evidence on direct and indirect impacts of the pandemic on maternal health and provide an overview of the most significant outcomes thus far. Working papers and news articles were considered appropriate evidence along with peer-reviewed publications in order to capture rapidly evolving updates. Literature in English published from January 1st to September 11 2020 was included if it pertained to the direct or indirect effects of the COVID-19 pandemic on the physical, mental, economic, or social health and wellbeing of pregnant people. Narrative descriptions were written about subject areas for which the authors found the most evidence. Results The search yielded 396 publications, of which 95 were included. Pregnant individuals were found to be at a heightened risk of more severe symptoms than people who are not pregnant. Intrauterine, vertical, and breastmilk transmission were unlikely. Labor, delivery, and breastfeeding guidelines for COVID-19 positive patients varied. Severe increases in maternal mental health issues, such as clinically relevant anxiety and depression, were reported. Domestic violence appeared to spike. Prenatal care visits decreased, healthcare infrastructure was strained, and potentially harmful policies implemented with little evidence. Women were more likely to lose their income due to the pandemic than men, and working mothers struggled with increased childcare demands. Conclusion Pregnant women and mothers were not found to be at higher risk for COVID-19 infection than people who are not pregnant, however pregnant people with symptomatic COVID-19 may experience more adverse outcomes compared to non-pregnant people and seem to face disproportionate adverse socio-economic consequences. High income and low- and middle-income countries alike faced significant struggles. Further resources should be directed towards quality epidemiological studies. Plain English summary The Covid-19 pandemic impacts reproductive and perinatal health both directly through infection itself but also indirectly as a consequence of changes in health care, social policy, or social and economic circumstances. The direct and indirect consequences of COVID-19 on maternal health are intertwined. To provide a comprehensive overview on this broad topic we conducted a scoping review. Pregnant women who have symptomatic COVID-19 may experience more severe outcomes than people who are not pregnant. Intrauterine and breastmilk transmission, and the passage of the virus from mother to baby during delivery are unlikely. The guidelines for labor, delivery, and breastfeeding for COVID-19 positive patients vary, and this variability could create uncertainty and unnecessary harm. Prenatal care visits decreased, healthcare infrastructure was strained, and potentially harmful policies are implemented with little evidence in high and low/middle income countries. The social and economic impact of COVID-19 on maternal health is marked. A high frequency of maternal mental health problems, such as clinically relevant anxiety and depression, during the epidemic are reported in many countries. This likely reflects an increase in problems, but studies demonstrating a true change are lacking. Domestic violence appeared to spike. Women were more vulnerable to losing their income due to the pandemic than men, and working mothers struggled with increased childcare demands. We make several recommendations: more resources should be directed to epidemiological studies, health and social services for pregnant women and mothers should not be diminished, and more focus on maternal mental health during the epidemic is needed.

Background Pakistan has among the poorest pregnancy outcomes worldwide, significantly worse than many other low-resource countries. The reasons for these differences are not clear. In this study, we compared pregnancy outcomes in Pakistan to other low-resource countries and explored factors that might help explain these differences. Methods The Global Network (GN) Maternal Newborn Health Registry (MNHR) is a prospective, population-based observational study that includes all pregnant women and their pregnancy outcomes in defined geographic communities in six low-middle income countries (India, Pakistan, Democratic Republic of Congo, Guatemala, Kenya, Zambia). Study staff enroll women in early pregnancy and follow-up soon after delivery and at 42 days to ascertain delivery, neonatal, and maternal outcomes. We analyzed the maternal mortality ratios (MMR), neonatal mortality rates (NMR), stillbirth rates, and potential explanatory factors from 2010 to 2018 across the GN sites. Results From 2010 to 2018, there were 91,076 births in Pakistan and 456,276 births in the other GN sites combined. The MMR in Pakistan was 319 per 100,000 live births compared to an average of 124 in the other sites, while the Pakistan NMR was 49.4 per 1,000 live births compared to 20.4 in the other sites. The stillbirth rate in Pakistan was 53.5 per 1000 births compared to 23.2 for the other sites. Preterm birth and low birthweight rates were also substantially higher than the other sites combined. Within weight ranges, the Pakistani site generally had significantly higher rates of stillbirth and neonatal mortality than the other sites combined, with differences increasing as birthweights increased. By nearly every measure, medical care for pregnant women and their newborns in the Pakistan sites was worse than at the other sites combined. Conclusion The Pakistani pregnancy outcomes are much worse than those in the other GN sites. Reasons for these poorer outcomes likely include that the Pakistani sites' reproductive-aged women are largely poorly educated, undernourished, anemic, and deliver a high percentage of preterm and low-birthweight babies in settings of often inadequate maternal and newborn care. By addressing the issues highlighted in this paper there appears to be substantial room for improvements in Pakistan’s pregnancy outcomes.

Postpartum hemorrhage or postpartum bleeding (PPH) is often defined as loss of 500 ml of blood after vaginal delivery or 1000 ml after cesarean delivery within 24 h. Postpartum hemorrhage is a leading direct cause of maternal morbidity and mortality in Ethiopia. Therefore, the main objective of this systematic review and meta-analysis was to estimate the pooled magnitude of postpartum hemorrhage and the pooled effect size of the associated factors in Ethiopia.Primary studies were searched from PubMed/MEDLINE online, Science Direct, Hinari, Cochrane Library, CINAHL, African Journals Online, Google and Google Scholars databases. The searching of the primary studies included for this systematic review and meta-analysis was limited by papers published from 2010 to October 10/2021. The data extraction format was prepared in Microsoft Excel and extracted data was exported to Stata Version 16.0 statistical software for analysis. A random effect meta-analysis model was used. Statistical heterogeneity was evaluated by the IA total of 21 studies were included in this meta-analysis. The pooled magnitude of postpartum hemorrhage in Ethiopia was 8.24% [(95% CI 7.07, 9.40]. Older age [OR = 5.038 (95% CI 2.774, 9.151)], prolonged labor [OR = 4.054 (95% CI 1.484, 11.074)], absence of anti-natal care visits (ANC) [OR = 13.84 (95% CI 5.57, 34.346)], grand-multiparty [OR = 6.584 (95% CI 1.902, 22.795)], and history of postpartum hemorrhage [OR = 4.355 (95% CI 2.347, 8.079)] were factors associated with the occurrence of postpartum hemorrhage.The pooled magnitude of postpartum hemorrhage among post-natal mothers in Ethiopia was moderately high. The finding of this study will strongly help different stakeholder working in maternal and child health to focus on the main contributors' factors to reduce post-partum hemorrhage among postnatal mothers. Health professionals attending labor and delivery should give more attention to advanced aged mothers, grand-multipara mothers and mothers who had a history of post-partum hemorrhage due to higher risk for postpartum hemorrhage. Encouraging to continue ANC visit and prevent prolonged labor should also be recommended to decrease postpartum hemorrhage.Even though other complications occur during pregnancy, post-partum hemorrhage (PPH) is the most serious complication and most critically important cause during pregnancy and child birth. It can cause severe anemia, acute respiratory distress syndrome (ARDS), acute renal failure (ARF), coma, and cardiac arrest. Uterine atony, retained tissue, genital tract tear, coagulation problem, and uterine rupture are most common causes of post-partum hemorrhage. In developing countries, PPH is one of the leading causes of maternal mortality, accounting for 25–43% of maternal death. It is also a leading cause of maternal morbidity and mortality in Ethiopia. This systematic review and meta-analysis were performed following the preferred reporting items for systematic reviews and Meta-Analyses (PRISMA). Primary studies were searched from different databases and random effect meta-analysis model was used. This systematic review and meta-analysis included 21 primary studies with a total of 93,898 study participants. The pooled magnitude of postpartum hemorrhage in Ethiopia was 8.24%. Advanced maternal age, prolonged labor, absence of antenatal care (ANC) visits, grand multi-parity, previous history of postpartum hemorrhage were significantly associated with postpartum hemorrhage. The finding of this systematic review and meta-analysis will strongly help different stakeholders working in maternal and child health to focus on the main contributor factors to reduce PPH If postpartum hemorrhage is reduced, it is the fact that maternal death will be decreased.

Across sub-Saharan Africa where access to adequate maternal healthcare is fraught with myriad challenges, especially for hard-to-reach populations, digital health technologies offer opportunities to improve maternal health outcomes. Digital health can circumvent inefficiencies in the traditional healthcare system and address challenges such as limited access to in-person medical consultations, and poor access to skilled birth attendants and health promotion activities. These benefits notwithstanding, digital health can be exclusionary. Too often, digital maternal health programs are not designed with a focus on equity in distribution nor are they designed from a gender equity standpoint. In this paper, we illustrate exclusionary practices of digital health programs through an extensive literature review of digital maternal health programs across sub-Saharan Africa. Taking an intersectional approach, we discuss how women are most vulnerable and excluded at the intersection of gender, literacy, and disability. Tackling exclusionary practices in digital health is crucial to ensure that no woman or girl is left behind.

Poor communication on sexual issues between adolescents and their parents results in high rates of negative sexual practices such as teenage pregnancy. Contributing factors to this poor communication on sexual issues between adolescents and their parents in a high teenage pregnancy setting have not been adequately explored. We sought to fill this gap by examining the factors that predict communication on sexual issues between adolescents and their parents in the Adaklu district of the Volta region of Ghana.A baseline cross-sectional household survey of 221 adolescents aged 10-19 years in 30 randomly selected communities was used. A well-structured questionnaire was developed. A multinomial logistic regression analysis was used to examine factors that significantly influenced communication between adolescents and their parents regarding sex.Only 11.3% of adolescents had discussions on sexual issues with both parents while 27.6% of communicated sexual issues with only one parent in Adaklu district. Adolescent males (AOR = 0.21, CI = 0.06-0.75), those aged 10-14 years (AOR = 0.41, CI = 0.04-0.57), non-members of adolescent health clubs (AOR = 0.46, CI = 0.21-1.00), and those living with only a father (AOR = 0.19, CI = 0.06-0.61) had lower odds of communicating with their parents on sexual issues.Adolescent-parental communication on sexual issues in Adaklu district is very low. This situation requires more empowerment of adolescents to enable them to discuss sexual issues with their parents through increased engagement with adolescent health club activities and capacity building capacity of parents with the right information on sexual and reproductive health by health staff within the district. Additionally, parents need to be equipped with communication skills to enable them to communicate effectively with their children.Parent-adolescent and older sibling adolescent communication on issues about sex is considered an important aspect of adolescent development and well-being, as it ensures informed decision making and good behavior and a protective factor for adolescent sexual health. However, poor communication on sexual issues between adolescents and their parents results in high rates of negative sexual practices such as teenage pregnancy. Contributing factors to this poor communication on sexual issues between adolescents and their parents in a high teenage pregnancy setting have not been adequately explored. This paper, therefore, examines the factors that predict communication on sexual issues between adolescents and their parents in the Adaklu district of the Volta region of Ghana. It highlights individual, household, societal and sexual-related factors that predict communication on sexual issues between adolescents and their parents in an area with a high rate of teenage pregnancy among adolescent girls.The data on adolescent sexual and reproductive health in Adaklu district show poor communication on sexual issues between adolescents (aged 10–19 years) and their parents. Improving communication on sexual issues between adolescents and their parents in rural settings requires capacity building of parents (especially mothers) with the right information and communication skills for discussing sexual and reproductive health issues with their children.

Background Ethiopia is striving to reduce unmet need for family planning (FP) and implementation of the health extension program (HEP) is one of the major actions that the country took to address health issues of rural communities including FP. However, there is limited published evidence demonstrating the role of HEP in reducing the unmet need of married rural women for FP. The aim of this study is to estimate the role of HEP in reducing unmet need for FP in rural Ethiopia. Methods This paper is based on data extracted from a national rural HEP assessment that covered all regions of Ethiopia. We identified 4991 eligible married women both from agrarian and pastoralist settings. The role of HEP was measured by the exposure of eligible women to FP services through the implementation of HEP packages. We used descriptive statistics to summarize different variables and used logistic regression to model the unmet need for FP. Results The overall prevalence of unmet need for FP among married rural Ethiopian women was 22.41%, contraceptive prevalence rate (CPR) was 44.60%, and the total demand for FP was 60.86%. Women exposed to HEP had a lower level of unmet need (4.82%), a higher demand for FP (37.78%) and a higher CPR (24.93%) compared to women unexposed to HEP. Having exposure to FP services (adjusted odds ratio (AOR) = 0.46, 95% confidence interval (CI) 0.37–0.59), having level IV Health Extension Workers (HEWs) in the catchment health post (AOR = 0.80, 95% CI 0.67–0.95) and older age are significantly associated with lower levels of unmet need for FP. Having more children (AOR = 2.11, 95% CI 1.67–2.65) and better awareness of the husband about the availability of FP services (AOR = 1.22, 95% CI 1.01–1.48) were associated with a higher likelihood of an unmet need for FP. Conclusion The unmet need for family planning is high in rural Ethiopia in general and among women who do not have exposure to HEP packages in particular. Assigning a better-qualified health worker at the health post, reaching out to pastoralist women, maximizing opportunities to counsel rural women about FP during any contact with HEWs, and increasing positive attitudes of husbands towards FP use are likely to have positive impacts in reducing the unmet need for FP of rural women., Plain language summary Family planning is a method that couples can use to limit the number of child or space the gap. Unmet need for family planning is defined as the percentage of reproductive age women who wants to space or limit the number of children but not currently using any family planning method. There is a huge proportion of eligible women have an unmet need for family planning in Ethiopia. The health extension program is one of the strategies to reach rural women to improve the health of the community. Although, family planning service is one of the packages in a health extension program and this study aimed to estimate the role of health extension program in reducing unmet need for family planning. About 4991 married women were asked about the family planning use, need and the place where they get the services. During the assessment the role of health extension program was assessed by different question. Some of the major assessment areas were women exposer to service, service availability, awareness and mode of service delivery. One fourth of the women have unmet need for family planning. The family planning utilization is still low. The contribution of the health extension program in family planning service is significant. Women exposed to HEP through level 4 health extension worker and older age are significantly associated with low level of unmet need FP. The unmet need for family planning is high in rural Ethiopia. This will inform the improvement and sustainability of the program.

Introduction The teenage pregnancy rate of 25% in Uganda is worrying though it may seem low compared to 28% in Sub-Saharan countries and West and Central Africa. Young mothers in Uganda risk poor maternal and child health, being isolated, attempting unsafe abortions, failure to continue with school, and poverty. This paper describes perceptions and recommendations of young mothers, family and community members on why the high rate of teenage pregnancies in Uganda and how these can be reduced. Methods This qualitative research was conducted from March to May 2016 in six communities within Budondo sub-county (Jinja district), Eastern Uganda. In-depth oral interviews were conducted with 101 purposively sampled adolescent mothers, family members, and workers of government and non-government organizations. Thematic analysis framed around levels of influence within a social cognitive framework was conducted using Atlas-ti (version 7.5.4). Results Perceived determinants of teenage pregnancies include: lack of life and social survival skills, lack of knowledge on how to avoid pregnancy, low acceptance/use of contraceptives, neglect by parents, sexual abuse, pressure to contribute to family welfare through early marriage or sexual transactions, lack of community responsibility, media influence, peer pressure, cultural beliefs that promote early marriage/childbearing and lack of role models. Other contributing factors include drug use among boys, poverty, late work hours, long travel distances, e.g., to school, and unsupervised locations like sugarcane plantation thickets. Recommendations participants offered include: sensitization seminars and counselling for parents and girls, closing pornography outlets that accept entrance of minors, using the law to punish rapists, involvement of the President to campaign against early pregnancies, school dismissal before dark, locally accessible schools and job creation for parents to earn money to support the girls financially. Areas for capacity building are: training teachers and community members in transferring empowerment and vocational skills to girls, and construction of homes with separate rooms to support parents’ privacy. Conclusion The factors associated with adolescent pregnancy in Uganda fall under individual, economic, social and physical environmental determinants. Recommendations spanning family, community and government involvement can ultimately empower girls, their families and community members, and support collective action to reduce teenage pregnancies.

Background The persistently high and stalled total fertility in Sub-Saharan Africa, including in Nigeria, calls for new efforts towards fertility reduction. Most efforts on fertility desire in sub-Saharan Africa have focused either on individual men or women with little focus on couples as a unit of analysis. Moreover, the influences of different types of marriages in which couples reproduce have not been adequately explored. Therefore, this study examined fertility desires among couples in Nigeria. Methods This paper used data from the Nigeria Demographic and Health Survey (NDHS) of 2018 to assess fertility desire by marriage type among couples in Nigeria. In addition, the association between fertility desire and disparity in couples’ educational attainment, place of residence, region, religion, occupation, wealth status, children ever born and contraceptive use were considered. The participants consisted of 6813 couples aged between 15–49 years. Couples’ characteristics were reported using frequency and percentage distribution tables. Descriptive and logistic regression analyses were conducted. Results Overall, the study revealed that 73.8% of couples were in monogamous relationships while 26.2% were in polygynous relationships. The mean ideal number of children for men and women were 7.2 and 6.1, respectively. Also, 49.3% of the couples reported husbands desired more children, 43.9% claimed wives desired more children, while 6.8% indicated equal number of desired children among wives and husbands. The results of binary logistic regression showed that couples in polygynous relationships were 4.3 times as likely to desire more children, compared to couples in monogamous relationships (OR = 4.3; 95% CI: 3.5, 5.3). Couples in polygynous relationships wanted as many as four times the number of children desired by couples in monogamous relationships. Fertility desire was significantly higher among couples who indicated the following: either was using contraceptives (OR = 2.3; 95% CI: 1.6–3.4), both were not using contraceptives (OR = 2.8; 95% CI: 1.9, 4.1), lived in North East (OR = 2.0; 95% CI: 1.5, 2.6) and North West (OR = 1.7; 95% CI: 1.3, 2.3), both were not working (OR = 1.33, 95% CI; 1.1, 1.6) and were adherents of Islam (OR = 1.8; 95% CI; 1.5, 2.4). Conclusion These findings reflect the role of region, use of contraceptives, work status and religion in the fertility desire of couples. Implementing programmes and policies on sexual education and reproductive rights of couples and individuals may reduce high fertility desire and its adverse consequences, such as child and maternal morbidity and mortality in Nigeria.

BackgroundEfforts to expand access to family planning in rural Africa often focus on the deployment of community health agents (CHAs).MethodsThis paper reports on results of the impact of a randomized cluster trial of CHA deployment on contraceptive uptake among 3078 baseline and 2551 endline women of reproductive age residing in 50 intervention and 51 comparison villages in Tanzania. Qualitative data were collected to broaden understanding of method preference, reasons for choice, and factors that explain non-use.ResultsRegression difference-in-differences results show that doorstep provision of oral contraceptive pills and condoms was associated with a null effect on modern contraceptive uptake [p = 0.822; CI 0.857; 1.229]. Discussions suggest that expanding geographic access without efforts to improve spousal and social support, respect preference for injectable contraceptives, and address perceived risk of side-effects offset the benefits of adopting contraceptives provided by community-based services.ConclusionsThe results of this study demonstrate that increasing access to services does not necessarily catalyze contraceptive use as method choice and spousal dynamics are key components of demand for contraception. Findings attest to the importance of strategies that respond to the climate of demand.Trial registrationControlled-Trial.comISRCTN96819844. Retrospectively registered on 29.03.2012.

Girls in Ethiopia's Amhara region experience high rates of child marriage and are less able to negotiate sex or use family planning. Seeking to improve their lives, CARE's TESFA programme delivered reproductive health and financial savings curricula to married girls via reflective dialogues in peer-based solidarity groups. From 2010 to 2013, 5,000 adolescent girls participated via three intervention arms: sexual and reproductive health, economic empowerment, and a combination of both. At end-line, participants reported improvements across health and empowerment outcomes. Four years post-TESFA, 88% of groups reported meeting without continued assistance from CARE. Some original participants had created new groups based on the TESFA model, and some girls not recruited for TESFA spontaneously replicated it to create their own groups. However, questions remained about what had contributed to this organic sustainment and scale-up of groups.This 2018 study investigated factors affecting sustainability and scale-up of peer solidarity groups through a systematic mapping of TESFA groups across five woredas (districts) and interviews with key stakeholders. Data were collected from 39 focus groups with active and dissolved Girl Groups, Social Analysis and Action groups, and girls' husbands and from 29 in-depth interviews with group facilitators and community health workers across three districts. Data were coded and analyzed per grounded theory principles.Changes in reproductive health knowledge and specific behaviours, such as contraceptive use and institutional delivery, were maintained 5 years after the intervention ended. Group connectedness, spousal support, integration of holistic community platforms, and opportunities for financial independence were found to be important for group sustainability. Observed changes in TESFA girls' confidence to negotiate and assert their rights, hopes of improved mobility, and the promise of economic opportunity commonly inspired spontaneous replication of groups. Recommendations for future peer-based programmes include creating environments of solidarity and holistically engaging intervention communities.By increasing knowledge of and access to reproductive health services, TESFA mitigates some of the harmful effects of child marriage. The maintenance and organic replication of groups suggest that TESFA provides a successful, scalable and sustainable tested model for reproductive health program delivery through peer-based solidarity groups.In Ethiopia, married girls are a particularly vulnerable adolescent population because of the many health risks associated with early marriage. Peer-based approaches are a common strategy to improve sexual and reproductive health knowledge and behaviours for marginalized groups. Critiques of these approaches are that they lack sustainability without ongoing investment and have no lasting impact on health behaviours. CARE’s TESFA programme, a peer-based approach with married adolescent girls in South Gondar, was found to be effective in creating long-term behavior change related to uptake of family planning and rates of institutional delivery. Some 88% of groups who received the TESFA curriculum were still meeting 4 years after the programme had concluded. Some participants even created groups of their own, scaling TESFA beyond the original audience, suggesting a potential approach to wider scale-up. To explore lessons learned around scale and sustainability, this study interviewed TESFA participants and stakeholders.Improvements in behaviours related to contraceptive use, institutional delivery, and girls’ agency in reproductive decision-making were sustained over time regardless of group status. Factors that affected the sustainability and scale-up of groups included solidarity among group members, support from husbands and community members, ongoing savings and loan structures, flexibility of group processes, and availability of relevant curriculum topics. Through an analysis of these findings, this paper discusses recommendations for sustainable and scalable peer-based programme design via existing Ethiopian community structures. Using TESFA principles as a model, practitioners could design and implement scalable and sustainable peer-based programming for adolescents sexual and reproductive health.

The laws governing abortion access vary across Europe. Even in countries with relatively liberal laws, numerous barriers to abortion access exist. In response to these barriers, evidence suggests that people living in countries with both restrictive and liberal laws travel outside of their home country for abortion care. England and Wales are common destinations for those who travel to seek abortions, but little is known about the motivations and experiences of those who undertake cross-country travel to England or Wales to obtain care. This paper aims to describe the abortion seeking and travel experiences of women and pregnant people who traveled to England and Wales for an abortion between 2017 and 2019.We recruited 97 participants who had traveled cross-country from both liberal and restrictive contexts to seek abortion care at three participating BPAS clinics in England and Wales. Participants completed an electronic survey about their reproductive histories, abortion decision-making, experiences seeking abortion care, and traveling. We conducted a descriptive analysis, and include comparisons between participants who traveled from liberal and restrictive contexts.Over a third of participants considered abortion four weeks or more before presenting for care at BPAS, and around two-thirds sought abortion services in their home country before traveling. The majority of participants indicated that they would have preferred to have obtained an abortion earlier and cited reasons including scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. About seventy percent of participants reported travel costs between €101-1000 and 75% of participants reported that the cost of the abortion procedure exceeded €500. About half of participants indicated that, overall, their travel was very or somewhat difficult.This analysis documents the burdens associated with cross-country travel for abortion and provides insight into the factors that compel people to travel. Our findings highlight the need for expanded access to abortion care throughout Europe via the removal of legal impediments and other social or procedural barriers. Removing barriers would eliminate the need for cumbersome abortion travel, and ensure that all people can obtain necessary, high-quality healthcare in their own communities.In Europe, people who live in countries where abortion is severely restricted or illegal altogether lack access to abortion care entirely, but even people who live in countries with more liberal laws face barriers due to gestational age limits, waiting periods, and a lack of trained and willing providers. Existing evidence suggests that restrictions and barriers compel people from both countries with restrictive laws as well as those from countries with more liberal laws to travel outside of their home country for abortion services. England and Wales are common destinations for people traveling within Europe to obtain abortion services, but little is known about the experiences of these travelers. We surveyed individuals who had traveled from another country to seek abortion services in England or Wales. Our analysis documents that many participants contemplated getting an abortion and sought care in their home countries before traveling. Likewise, many participants indicated that they would have preferred to have obtained an abortion earlier in their pregnancy, and referenced scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. A majority of participants indicated that covering the costs of their abortion, and the costs of travel was difficult, and that the travel experience in its entirety was difficult. Our findings document the reasons for, and burdens associated with abortion travel and highlight the need to expand access to abortion across Europe via the elimination of all legal restrictions and impediments.