Search

Objective To estimate the direct costs of treating women with maternal near misses and potentially life- threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households. Methods As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure. Findings Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of- pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure. Conclusion The cost of treating maternal near misses is high and leads to catastrophic spending through out-of- pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women. Objectif Estimer les couts directs engendres par la prise en charge des meres ayant evite un deces de justesse et par les maladies potentiellement mortelles au Kenya, ainsi que les facteurs lies aux depenses de sante catastrophiques pour ces femmes et leur foyer. Methodes Une etude prospective et representative a l'echelle nationale a ete menee aupres de l'ensemble des femmes ayant evite un deces de justesse durant la grossesse et l'accouchement, ou dans les 42 jours suivant l'accouchement ou l'interruption de grossesse. C'est dans ce contexte que nous avons compare le cout du traitement des deces maternels evites de justesse avec celui des femmes souffrant de maladies potentiellement mortelles. Nous avons procede a une analyse de regression logistique afin d'evaluer les facteurs cliniques, demographiques et domestiques lies aux depenses de sante catastrophiques. Resultats Sur un total de 3025 femmes, 1180 (39,0%) avaient evite un deces de justesse et 1845 (61,0%) presentaient des maladies potentiellement mortelles. La prise en charge des deces maternels evites de justesse coutait en moyenne 7135 shillings kenyans (71 dollars americains), tandis que les maladies potentiellement mortelles revenaient a 2690 shillings kenyans (27 dollars americains). Parmi les femmes contraintes de payer elles-memes ces frais, 26,4% (122/462) ont fait face a des depenses catastrophiques. C'est a Nairobi et dans la Province centrale que la prise en charge des deces evites de justesse s'est averee la plus onereuse (22 220 shillings kenyans; 222 dollars americains). Les couts moyens les plus eleves etaient assumes par les femmes ayant subi des complications a cause d'une grossesse ectopique (7800 shillings kenyans; 78 dollars americains) et des infections liees a la grossesse (3000 shillings kenyans; 30 dollars americains). Les infections liees a la grossesse, l'avortement, les grossesses ectopiques et les traitements dans des etablissements secondaires et tertiaires etaient frequemment synonymes de depenses catastrophiques. Conclusion Le montant que represente la prise en charge des deces maternels evites de justesse est considerable et entraine des depenses catastrophiques lorsqu'il doit etre debourse par la patiente elle-meme. Il est imperatif d'etendre la couverture maladie universelle afin d'assurer la protection financiere des femmes vulnerables. Objetivo Estimar los costes directos del tratamiento de las mujeres con morbilidad materna extrema y con enfermedades potencialmente mortales en Kenia, asi como los factores asociados a los gastos sanitarios catastroficos para estas mujeres y sus hogares. Metodos Como parte de un estudio de cohortes y representativo a nivel nacional de todas las mujeres con morbilidad extrema durante el embarazo y el parto o dentro de los 42 dias posteriores al parto o a la interrupcion del embarazo, se comparo el coste del tratamiento de los casos de morbilidad extrema ingresados en centros de referencia con el de las mujeres con enfermedades potencialmente mortales. Se utilizo un analisis de regresion logistica para evaluar los factores clinicos, demograficos y domesticos asociados a los gastos sanitarios catastroficos. Resultados De 3025 mujeres, 1180 (39,0 %) tuvieron morbilidad materna extrema y 1845 (61,0 %) padecieron enfermedades potencialmente mortales. El coste medio del tratamiento de los casos de morbilidad materna extrema fue de 7135 chelines kenianos (71 dolares estadounidenses, USD), en comparacion con los 2690 chelines kenianos (27 USD) de las enfermedades potencialmente mortales. De las mujeres que pagaron de su bolsillo, el 26,4 % (122/462) tuvo gastos catastroficos. La mediana de los costes mas elevados para el tratamiento de la morbilidad materna extrema se registro en Nairobi y en la region central (22 220 chelines kenianos; 222 USD). Las mujeres con problemas de embarazo ectopico y con infecciones causadas por el embarazo tuvieron los costes medios de tratamiento mas elevados, 7800 chelines kenianos (78 USD) y 3000 chelines kenianos (30 USD), respectivamente. Las infecciones causadas por el embarazo, el aborto, el embarazo ectopico y el tratamiento en centros de atencion secundaria y terciaria se asociaron de manera significativa con los gastos catastroficos. Conclusion El coste del tratamiento de la morbilidad materna extrema es alto y genera un gasto catastrofico mediante los pagos de bolsillo. Se debe ampliar la cobertura sanitaria universal para garantizar la proteccion financiera de las mujeres vulnerables. [phrase omitted], Introduction Many countries in sub-Saharan Africa have increasingly committed to tackling maternal illnesses and deaths through a mix of interventions. For instance, in the past 15 years, the Kenyan government [...]

Abstract Provision of medication abortion in student health centers is safe and effective, but no public universities in Washington state provide such services. We estimate demand for medication abortion and describe barriers to care among students at four-year public universities in Washington. Using publicly available data, we estimated that students at the 11 Washington public universities obtained between 549 and 932 medication abortions annually. Students must travel an average of 16 miles (range:1–78) or 73 minutes via public transit (range:22–284) round trip to the nearest abortion-providing facility. Average wait time for the first available appointment was 10 days (range:4–14), and average cost was $711. Public universities can play an integral role in expanding abortion access post-Dobbs by providing medication abortion, effectively reducing barriers to care for students. The state legislature can pass legislation requiring universities to provide medication abortion, similar to what other states also protective of abortion rights have done. [ABSTRACT FROM AUTHOR]

The societal distrust of public health alongside the complex, intersecting, and large public health crises of today and our future requires a transformation of the education of the next generation of public health leaders. The field of public health's goals of health equity for all cannot be advanced until our field interrogates and resists the prison industrial complex (PIC), which maintains White supremacy and (re)produces health inequities. As current and former public health students, we propose incorporating abolition of the PIC as a political vision, structural and power analysis, and organizing strategy into the public health curriculum. We highlight gaps in the public health curriculum and the existing similarities between stated goals of abolition and public health. We propose calls to action for individuals, faculty, and schools of public health to interrogate the carceral nature of public health and work toward contributing to the positive project of an abolitionist future. [ABSTRACT FROM AUTHOR]

Although pre-exposure prophylaxis (PrEP) is an efficacious biomedical intervention, the effectiveness of same-day PrEP programs has not been widely studied. We utilized data from three of the four largest PrEP providers in Mississippi from September 2018 to September 2021 linked to the Mississippi State Department of Health's Enhanced HIV/AIDS reporting system. HIV diagnosis was defined as testing newly positive for HIV at least 2 weeks after the initial PrEP visit. We calculated the cumulative incidence and incidence rate of HIV per 100 person-years (PY). Person-time was calculated as time from the initial PrEP visit to (1) HIV diagnosis or (2) December 31, 2021 (HIV surveillance data end date). We did not censor individuals if they discontinued PrEP to obtain an estimate of PrEP effectiveness rather than efficacy. Among the 427 clients initiating PrEP during the study period, 2.3% [95% confidence interval (CI): 0.9–3.8] subsequently tested positive for HIV. The HIV incidence rate was 1.18 per 100 PY (95% CI: 0.64–2.19) and median time to HIV diagnosis after the initial PrEP visit was 321 days (95% CI: 62–686). HIV incidence rates were highest among transgender and nonbinary individuals [10.35 per 100 PY (95% CI: 2.59–41.40)] compared with cisgender men and women, and among people racialized as Black [1.45 per 100 PY (95% CI: 0.76–2.80)] compared with White and other racialized groups. These findings indicate a need for more clinical and community interventions that support PrEP persistence and restarts among those at high risk of HIV acquisition. [ABSTRACT FROM AUTHOR]

The Supreme Court decision to overturn Roe v. Wade and the growing onslaught of state laws that criminalize abortion are part of a long history of maintaining White supremacy through reproductive control of Black and socially marginalized lives. As public health continues to recognize structural racism as a public health crisis and advances its measurement, it is imperative to explicate the connection between abortion criminalization and White supremacy. In this essay, we highlight how antiabortion policies uphold White supremacy and offer concrete strategies for addressing abortion criminalization in structural racism measures and public health research and practice. (Am J Public Health. 2022;112(11):1662–1667. https://doi.org/10.2105/AJPH.2022.307014) [ABSTRACT FROM AUTHOR]

Background: Hospitals quickly adapted perinatal care to mitigate SARS‐CoV‐2 transmission at the onset of the COVID‐19 pandemic. The objective of this study was to estimate the impact of pandemic‐related hospital policy changes on perinatal care and outcomes in one region of the United States. Methods: This interrupted time series analysis used retrospective data from consecutive singleton births at 15 hospitals in the Pacific Northwest from 2017 to 2020. The primary outcomes were those hypothesized to be affected by pandemic‐related hospital policies and included labor induction, epidural use, oxytocin augmentation, mode of delivery, and early discharge (<48 hours after cesarean and <24 hours after vaginal births). Secondary outcomes included preterm birth, severe maternal morbidity, low 5‐minute Apgar score, neonatal intensive care unit (NICU) admission, and 30‐day readmission. Segmented Poisson regression models estimated the outcome level shift changes after the pandemic onset, controlling for underlying trends, seasonality, and stratifying by parity. Results: No statistically significant changes were detected in intrapartum interventions or mode of delivery after onset of the pandemic. Early discharge increased for all births following cesarean and vaginal birth. Newborn readmission rates increased but only among nulliparas (aRR: 1.49, 95%CI: 1.17, 1.91). Among multiparas, decreases were observed in preterm birth (aRR: 0.90, 95%CI: 0.84, 0.96), low 5‐minute Apgar score (aRR: 0.75, 95%CI: 0.68, 0.81), and term NICU admission rates (aRR: 0.85, 95%CI: 0.80, 0.91). Conclusions: Increases in early discharge and newborn readmission rates among nulliparas suggest a need for more postpartum support during the pandemic. Decreases in preterm birth and term NICU admission among multiparas may have implications beyond the pandemic and deserve further study. [ABSTRACT FROM AUTHOR]

Objective To estimate age-specific abortion incidence and unintended pregnancy in Zimbabwe, and to examine differences among adolescents by marital status and residence. Design We used a variant of the Abortion Incidence Complications Methodology, an indirect estimation approach, to estimate age-specific abortion incidence. We used three surveys: the Health Facility Survey, a census of 227 facilities that provide postabortion care (PAC); the Health Professional Survey, a purposive sample of key informants knowledgeable about abortion (n=118) and the Prospective Morbidity Survey of PAC patients (n=1002). Setting PAC-providing health facilities in Zimbabwe. Participants Healthcare providers in PAC-providing facilities and women presenting to facilities with postabortion complications. Primary and secondary outcome measures The primary outcome measure was abortion incidence (in rates and ratios). The secondary outcome measure was the proportion of unintended pregnancies that end in abortion. Results Adolescent women aged 15–19 years had the lowest abortion rate at five abortions per 1000 women aged 15–19 years compared with other age groups. Adolescents living in urban areas had a higher abortion ratio compared with adolescents in rural areas, and unmarried adolescent women had a higher abortion ratio compared with married adolescents. Unintended pregnancy levels were similar across age groups, and adolescent women had the lowest proportion of unintended pregnancies that ended in induced abortion (9%) compared with other age groups. Conclusions This paper provides the first estimates of age-specific abortion and unintended pregnancy in Zimbabwe. Despite similar levels of unintended pregnancy across age groups, these findings suggest that adolescent women have abortions at lower rates and carry a higher proportion of unintended pregnancies to term than older women. Adolescent women are also not a homogeneous group, and youth-focused reproductive health programmes should consider the differences in experiences and barriers to care among young people that affect their ability to decide whether and when to parent. [ABSTRACT FROM AUTHOR]

Introduction: abortion in Zimbabwe is allowed to preserve the physical health of the woman, or in cases of rape, incest, or fetal impairment. Access even under these conditions is difficult and rare. We aimed to understand knowledge of the abortion law and attitudes towards abortion amongst health care providers’ and abortion experts in Zimbabwe as these can hinder access to safe legal abortion. Methods: in 2016, we conducted a Health Facility Survey (HFS) (n=227) among health care providers’ knowledgeable about abortion services in their facility in a census of facilities offering Post Abortion Care (PAC), and a Health Professionals Survey (HPS) among 118 abortion experts. Results: twenty-five percent of providers and 47% of experts knew all four reasons under which abortion is legal in Zimbabwe. Amongst providers and experts, 31% and 50% respectively were misinformed about one or more legal criteria. Most providers and experts were in support of expanding the legal provision of abortion to cases when the woman’s mental health is at risk (65% and 79%, respectively) and if the woman is mentally incapacitated (66% amongst all). Seventy-one percent of experts recommend liberalizing the abortion law in order to reduce unsafe abortions. Conclusion: there is incomplete and sometimes inaccurate knowledge on the legal provisions for performing abortions in Zimbabwe amongst both health care providers and abortion experts. Incomplete knowledge of the law may be further reducing abortion access, highlighting the urgent need for educating health care providers on the legal status of abortion. [ABSTRACT FROM AUTHOR]

Background: Zimbabwe has the highest contraceptive prevalence rate in sub-Saharan Africa, but also one of the highest maternal mortality ratios in the world. Little is known, however, about the incidence of abortion and post-abortion care (PAC) in Zimbabwe. Access to legal abortion is rare, and limited to circumstances of rape, incest, fetal impairment, or to save the woman’s life. Objectives: This paper estimates a) the national provision of PAC, b) the first-ever national incidence of induced abortion in Zimbabwe, and c) the proportion of pregnancies that are unintended. Methods: We use the Abortion Incidence Complications Method (AICM), which indirectly estimates the incidence of induced abortion by obtaining a national estimate of PAC cases, and then estimates what proportion of all induced abortions in the country would result in women receiving PAC. Three national surveys were conducted in 2016: a census of health facilities with PAC capacity (n = 227), a prospective survey of women seeking abortion-related care in a nationally-representative sample of those facilities (n = 127 facilities), and a purposive sample of experts knowledgeable about abortion in Zimbabwe (n = 118). The estimate of induced abortion, along with census and Demographic Health Survey data was used to estimate unintended pregnancy. Results: There were an estimated 25,245 PAC patients treated in Zimbabwe in 2016, but there were critical gaps in their care, including stock-outs of essential PAC medicines at half of facilities. Approximately 66,847 induced abortions (uncertainty interval (UI): 54,000–86,171) occurred in Zimbabwe in 2016, which translates to a national rate of 17.8 (UI: 14.4–22.9) abortions per 1,000 women 15–49. Overall, 40% of pregnancies were unintended in 2016, and one-quarter of all unintended pregnancies ended in abortion. Conclusion: Zimbabwe has one of the lowest abortion rates in sub-Saharan Africa, likely due to high rates of contraceptive use. There are gaps in the health care system affecting the provision of quality PAC, potentially due to the prolonged economic crisis. These findings can inform and improve policies and programs addressing unsafe abortion and PAC in Zimbabwe. [ABSTRACT FROM AUTHOR]

Objectives Abortion complications cause significant morbidity and mortality. We aimed to assess the severity and factors associated with abortion complications (induced or spontaneous), and the management of postabortion care (PAC) in Zimbabwe. Design Prospective, facility-based 28 day survey among women seeking PAC and their providers. Setting 127 facilities in Zimbabwe with the capacity to provide PAC, including all central and provincial hospitals, and a sample of primary health centres (30%), district/general/mission hospitals (52%), private (77%) and non-governmental organisation (NGO) (68%) facilities. Participants 1002 women presenting with abortion complications during the study period. Main outcome measures Severity of abortion complications and associated factors, delays in care seeking, and clinical management of complications. Results Overall, 59% of women had complications classified as mild, 19% as moderate, 19% as severe, 3% as near miss and 0.2% died. A median of 47 hours elapsed between experiencing complication and receiving treatment; many delays were due to a lack of finances. Women who were rural, younger, not in union, less educated, at later gestational ages or who had more children were significantly more likely to have higher severity complications. Most women were treated by doctors (91%). The main management procedure used was dilatation and curettage/dilatation and evacuation (75%), while 12% had manual vacuum aspiration (MVA) or electrical vacuum aspiration and 11% were managed with misoprostol. At discharge, providers reported that 43% of women received modern contraception. Conclusion Zimbabwean women experience considerable abortion-related morbidity, particularly young, rural or less educated women. Abortion-related morbidity and concomitant mortality could be reduced in Zimbabwe by liberalising the abortion law, providing PAC in primary health centres, and training nurses to use medical evacuation with misoprostol and MVA. Regular in-service training on PAC guidelines with follow-up audits are needed to ensure compliance and availability of equipment, supplies and trained staff. [ABSTRACT FROM AUTHOR]

The people in Brazil with the highest risk of developing diabetes before age 80 are primarily persons of color, with a 30.8% risk, around the age of 35. A same aged white adult had a 23.4% chance of developing diabetes before 80. The difference in percentages between the two could result from lowand middle-class Brazilians not having access to or not being able to afford the same foods that high-class Brazilians can, and how food is cooked and prepared. It is proposed that creating a program named "Healthy Brazil," where nutritionists provide cooking demonstrations and teach classes, may be beneficial. [ABSTRACT FROM AUTHOR]

The article considers the shifting realities of postmodern curriculum. The author states that she appreciates the eclectic nature of postmodern theory for the ways it allowed her to draw on a plurality of anti-foundationalist movements as a critical lens through which to explore various questions related to curriculum.

Focuses on the connection of peace with ecology. Effect of basing decisions upon a premise that humans are separate from other organisms on the environment; Views of ecofeminist Riane Eisler on power relations among ancient times; Relationship of biological diversity with cultural diversity according to eco-biologist Vandana Shiva.

Presents vignettes of the author's ecological views on curriculum with two overarching themes that include ways of knowing and relationality; Exploration of the terrain around the 'rational' center; Influence of an ecospiritual ethic on ways of knowing; Role of intentions and commitments in the awakening praxis.

Objectives: To estimate age-specific abortion incidence and unintended pregnancy in Kinshasa, Democratic Republic of Congo and compare care experiences between adolescents (15-19 years) and older women (20-49 years)., Design: We used the age-specific variant of the Abortion Incidence Complications Method to estimate abortion and unintended pregnancy, with data from three primary sources: Health Facility Survey (n=361) provided postabortion care (PAC) caseloads; Prospective Morbidity Survey (n=1031) provided the age distribution and characteristics of women presenting for PAC and Health Professional Survey (n=115) provided an estimate of the proportion of abortions resulting in facility-based treatment of complications. Bivariate (χ 2 , t-test) and multivariable (binary logistic regression, Cox proportional hazard) analyses were used to compare abortion care experiences., Setting: Health facilities proving PAC in Kinshasa., Participants: Women who presented to PAC facilities with abortion complications and their care providers., Primary and Secondary Outcome Measures: The primary measures were abortion incidence and proportion of pregnancies unintended. The secondary measures were the odd of reporting specific abortion care experiences., Results: Adolescents had an estimated 27 590 induced abortions, constituting 18.8% of abortions in Kinshasa in 2016. Adolescents had the lowest abortion rate among women less than 35 years (55.2/1000 women) but the highest rate among ever sexually active women (138.4/1000) and recently sexually active women (167.2/1000). Also, adolescents had the highest abortion ratio (82.4/100 live births), proportion of pregnancies unintended (80%) and proportion of unintended pregnancies ending in abortion (49%). Compared with older women, adolescents had higher odds of reporting pregnancy unintendedness (adjusted OR, AOR 1.36, 95% CI 1.75 to 2.24), seeking abortion at later than first trimester (AOR 1.34, 95% CI 1.09 to 1.63) and from non-medical professionals (AOR 1.68, 95% CI 1.31 to 2.14), and not using contraceptives before pregnancy (AOR 2.23, 95% CI 2.77 to 3.43) or postabortion (AOR 2.46, 95% CI 1.87 to 3.29)., Conclusions: Interventions are needed to reduce unintended pregnancy among adolescents in Kinshasa and improve their abortion care experiences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)