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Since the 1990s, the global approach to family planning has undergone fundamental transformations from population control to addressing reproductive health and rights. The Indian family planning programme has also transitioned from being vertical, target-oriented, and clinic-based to a supposedly target-free, choice-based programme that champions reproductive rights. Despite contraceptive choices being offered and voluntary adoption encouraged, there is a heavy reliance on female sterilisation. Community health workers, known as ASHAs, are responsible for on-ground implementation of family planning policies and are incentivised to promote sterilisation as well as other methods. This study explored perspectives to understand of the role of female sterilisation in Indian family planning and whether policy is reflected in implementation. Secondary ethnographic data from Rajasthan, which included twenty interviews and five group discussions, were used to understand the perspectives of ASHAs. Primary data included five key informant interviews to understand the perspectives of experts nationally. Data were analysed thematically with a combination of deductive and inductive coding. Themes that emerged included choice, population control and coercion, family planning targets, quality and experience of services, historical factors and social norms. Despite the official policy shift, there appears to be narrow implementation which is still target-driven, relies heavily on female sterilisation, while negotiating between achieving population stabilisation and upholding reproductive rights. There is a need to emphasise spacing methods, ensure a rights- and choice-based approach and encourage male participation in reproductive health decisions.

Birth spacing has emerged since the early 1980s as a key concept to improve maternal and child health, triggering interest in birth spacing practices in low-income countries, and drawing attention to prevailing norms in favour of long birth intervals in West Africa. In Senegal, the Wolof concept of Nef, which means having children too closely spaced in time, is morally condemned and connotes a resulting series of negative implications for family well-being. While Nef and “birth spacing” intersect in key ways, including acknowledging the health benefits of longer birth intervals, they are not translations of each other, for each is embedded in distinct broader cultural and political assumptions about social relations. Most notably, proponents of the demographic concept of birth spacing assume that the practice of using contraception after childbearing to postpone births could contribute to “empowering” women socially. In Senegal, by contrast, preventing Nef (or short birth intervals) is also viewed as strengthening family well-being by allowing women to care more fully for their family. This paper draws on policy documents and interviews to explore women's and men's understanding of Nef, and in turn critically reflect on the demographic concept of birth spacing. Our findings reinforce the relevance of the concept of birth spacing to engage with women and men around family planning services in Senegal. Accounts of the Nef taboo in Senegal also show that social norms stigmatising short birth intervals can legitimise constraints faced by women on control of their body.

Background: Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals. Objective: This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. Methods: During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis. Results: The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers’ recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration. Conclusion: The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care.

Background: There has been increased emphasis globally on nurses’ involvement in health policy and systems development. However, there has been limited scholarly attention on nurses’ participation in policy-making in South Africa. Objective: This paper analyses the dynamics, strengths, and weaknesses of nurses’ participation in four national health workforce policies: the 2008 Nursing Strategy, revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy. Design: Using a policy analysis framework, we conducted in-depth interviews with 28 key informants and 73 frontline nurses in four South African provinces. Thematic content analysis was done using the Atlas.ti software. Results: The study found that nurses’ participation in policy-making is both contested and complex. The contestation relates to the extent and nature of nurses’ participation in nursing policies. There was a disjuncture between nursing leadership and frontline nurses in their levels of awareness of the four policies. The latter group was generally unaware of these policies with the exception of the OSD remuneration policy as it affected them directly. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena. Shifting power relationships influenced who participated, how the participation happened, and the degree to which nurses’ views and inputs were considered and incorporated. Conclusions: The South African health system presents major opportunities for nurses to influence and direct policies that affect them. This will require a combination of proactive leadership, health policy capacity and skills development among nurses, and strong support from the national nursing association.