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Variation in Dietary Intake and Pre-eclampsia and Eclampsia in Indian women: Findings from the National Family Health Survey.

Author(s) Sutapa Agrawal1, Jasmine Fledderjohann2, David Stuckler3, Sukumar Vellakkal 4, Shah Ebrahim 5
Affiliation(s) 1South Asia Network for Chronic Disease, Public Health Foundation of India, New Delhi, India, 2Deaprtment of Sociology, University of Oxford, Oxford, United Kingdom, 3Department of Sociology, Oxford University, Oxford, United Kingdom, 4SANCD, PHFI, New Delhi, India, 5Non communicable Disease Epidemiology, LSHTM, London, United Kingdom.
Country - ies of focus India
Relevant to the conference tracks Women and Children
Summary Pre-eclampsia/eclampsia is responsible for upwards of 20% of maternal morbidity and mortality in developing countries. We examine the relationship between food intake and symptoms of pre-eclampsia and eclampsia among Indian women aged 15-49 (n=39,657) for the most recent live birth in the five years preceding the National Family Health Survey-3 (2005-06). Daily consumption of milk, vegetables, chicken/meat and weekly pulses/beans consumption are associated with substantially lower risk of pre-eclampsia. Eclampsia risk is higher among those who consumed fruit and chicken/meat occasionally, and lower among those consuming vegetables daily.
Background Pre-eclampsia and eclampsia pose significant threats to maternal health, particularly in developing countries. In low-and middle-income settings, these two conditions affect approximately 8% of all pregnancies, causing an estimated 15%-20% of maternal morbidity and mortality. Pre­eclampsia is a life threatening complication of pregnancy that typically starts after the 20th week of gestation. Women with pre-eclampsia may present with symptoms such as headache, upper abdominal pain, or visual disturbances and have raised blood pressure, ankle oedema and proteinuria. When pre-eclampsia is left untreated or is severe, giving rise to seizures/convulsions which cannot be attributed to other causes (such as epilepsy), the condition is known as eclampsia. Although several studies have found that micronutrient deficiencies, such as iron, vitamin A, vitamin C, and calcium, contribute to pre-eclampsia risks, few studies have evaluated the potential role of different food types.
Objectives Existing nutritional evidence is highly variable. Dietary patterns may influence maternal antioxidant levels, mediating the link between pre-eclampsia and oxidative stress, an established risk factor. However, consumption of high-energy diets may increase risk of pre-eclampsia by inducing abnormal lipid metabolism, while consumption of dietary fibre may regulate these metabolic processes, thereby reducing risk. However, studies which have attempted to test these links empirically have not been conducted in high burden countries, nor have they employed appropriate multivariate models. To our knowledge, there has not been any previous large-scale report concerning the dietary risk factors for pre-eclampsia and eclampsia in Indian women. Here, we evaluate potential dietary risk factors of pre-eclampsia and eclampsia, using a large representative sample of Indian mothers in the third National Family Health Survey conducted during 2005-06.
Methodology Data were taken from the most recent wave of the National Family Health Survey (NFHS-3, 2005–2006), India’s Demographic and Health Surveys. NFHS-3 collected demographic, socioeconomic and health information from a nationally representative probability sample of 124,385 women aged 15–49. The sample is a multistage cluster sample with an overall response rate of 98%. All states of India are represented in the sample (except the small Union Territories), covering more than 99% of the country’s population. The analysis presented here focuses on 39,657 women in the sample who report being married and who have had a live birth in the five years preceding the survey. The survey was conducted using an interviewer-administered questionnaire in the native language of the respondent. To assess the occurrence of pre-eclampsia, mothers were asked if at any time during their last pregnancy they experienced relevant symptoms, including difficulty with vision during daylight, night blindness, convulsions (not from fever), swelling of the legs, body or face, excessive fatigue, or vaginal bleeding. Women who reported difficulty with vision during daylight, swelling of the legs, body, or face, or excessive fatigue were coded as having symptoms of pre-eclampsia, whereas those who reported experiencing convulsions (not from fever) were coded as symptomatic of eclampsia. Data on blood pressure and proteinuria during pregnancy were not available in the NFHS. Dietary intake variables were based on the self-reported frequency of consumption of milk or curd, green leafy vegetables, fruits, pulses and beans, eggs, fish, chicken or meat, categorised into daily, weekly, occasionally, or never. Potential confounders and covariates were selected on the basis of previous knowledge of their association with pre-eclampsia/eclampsia. We used multiple logistic regression to estimate the association between variation in dietary intake and pre-eclampsia and eclampsia risk after adjusting for maternal factors, biological and lifestyle factors and socio-demographic characteristics of the mothers. Models were adjusted for sampling weights (IIPS & Macro International 2007). All analyses were conducted using the SPSS statistical software package Version 19.
Results Overall 55.6% of mothers reported pre-eclampsia symptoms, and 10.3% reported eclampsia. Table 1 reports the results of our statistical models. After adjusting for maternal, biological, and chronic disease risk factors, as well as socio-demographic characteristics, we found that the risk of pre-eclampsia was significantly lower among women who consumed milk daily (OR:0.88;95%CI:0.81-0.96), green leafy vegetables daily/weekly (OR: 0.69 to 0.76), pulses or beans at least weekly/occasionally (ORs ranges from 0.84 to 0.92), fruits daily (OR:0.92), eggs weekly/occasionally, consumes fish (OR:0.90) or chicken/meat daily or occasionally, with added reference to those who never consumed them. However, a greater risk of pre-eclampsia was found among women consuming fruits weekly/occasionally (OR:1.11), eggs daily (OR:1.23) and fish weekly (OR:1.22). The risk of eclampsia was lower among those consuming green leafy vegetables (ORs ranges from 0.74 to 0.79), consuming fish weekly or occasionally (ORs ranges from 0.44 to 0.62), eggs weekly or occasionally (Ors ranges from 0.61 to 0.76), but was higher among those who consumed fruits (ORs ranges from 1.18 to 1.44), chicken/meat occasionally (OR:1.28;95%CI:1.11-1.48) with reference to those who never consumed them.
Conclusion Our study provides empirical evidence of an association between the frequency of intake of specific food items and prevalence of pre-eclampsia/eclampsia in a large nationally representative sample of Indian women. Findings suggest that variation in the frequency of consumption of specific foods has a substantial effect on the occurrence of symptoms suggestive of pre-eclampsia/eclampsia in this population. The strengths of our study include the large nationally representative study sample and the population-level focus on the predictors of pre-eclampsia and eclampsia. However, due to the general challenges of measuring hypertensive disorders in population-based studies, the information of the symptoms of pre-eclampsia and eclampsia presented here is based on self-reports and should therefore be interpreted with care. Although we adjusted for several confounding variables, we cannot exclude the possibility of residual confounding. In these analyses, the cross-sectional design precludes causal inferences and we were limited to the questions used to elicit lifestyle and dietary information. Few population level studies exist which assess the dietary determinants of pre-eclampsia and eclampsia. This study is important because few others have reported pre-eclampsia/eclampsia prevalence rates based on population-level data. Our study implicates that modifiable risk factors for pre-eclampsia/eclampsia exists and thus there is a need for replication of findings given that the dietary patterns are modifiable. Our study findings may serve as an important call for health care providers to heighten their awareness of the increased population-level risk for pre-eclampsia and eclampsia disease originating in pregnancy. With the target of the Millennium Development Goals in sight, pre-eclampsia/eclampsia should be identified as one of the priority areas in reducing maternal mortality in India. However, further research involving the use of a more comprehensive dietary measure, pre-pregnancy assessment of all the risk factors and ascertainment of dietary intake prior to the development of pre-eclampsia and eclampsia and accuracy of reporting of the symptoms of pre-eclampsia and eclampsia are needed in a developing country setting.

Family Planning Practice in Unintended Pregnancy: Rural Women in Bangladesh

Author(s) Forhana Noor1, Ubaidur Rob2
Affiliation(s) 1Reproductive Health, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary This article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh. The study was a cross-sectional survey of 3,300 women. Findings suggest that among the respondents about 29 percent of the pregnancies were unintended. Analysis was found that those who did not use contraceptive methods before their last pregnancy had reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Advocacy is needed to promote longer acting and permanent methods among the eligible couples to avoid unintended pregnancy.
Background In Bangladesh most of the reproductive health programs are directed towards improving maternal health and family planning. These efforts lead to the decline of maternal mortality by 40% from 322 deaths in 2001 to 194 deaths in 2010 per 100000 live births, which may be attributable to remarkable progress in fertility decline, from a high level of 6.3 births per woman in the mid-1970s to 2.3 births per woman in 2011. Contraceptive use rate has also increased from only 8 in 1975 to 61 in 2011. Despite these recent achievements, maternal mortality still remains one of the prime challenges and also unintended pregnancy remained same for last three decades. Unintended pregnancy is typically exposed to the risk of abortion. In Bangladesh, abortion-related complications contribute to about one-fourth of all maternal deaths. Besides this, the rate of unintended pregnancy is also one of the most basic measures of the situation of women's reproductive health, and of the level of women’s autonomy and capacity for self-determination. It signifies a woman’s capacity to determine whether and when to have pregnancies.
Objectives According to 2011 Bangladesh Demographic and Health Survey (BDHS), in Bangladesh, 30 percent of pregnancies were unintended. The total intended fertility rate was 1.6 which is quite lower than the total fertility rate (TFR) 2.3. This means that if all unintended pregnancies could be eliminated, the TFR would drop below the replacement level of fertility immediately. High discontinuation rate, low use of long acting and permanent methods, erroneous use of family planning methods and unmet needs of family planning, in part or combined all contribute to the incidence of unintended pregnancies. Considering the situation, this article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh.
Methodology This article used data from the follow-up survey of evaluation of the Reproductive Health Voucher Evaluation project in Bangladesh. It was a quasi-experimental research design with pre and post studies in intervention and control areas and the assignment to the intervention was non random. It was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas. The other 11 sub-districts were selected as control areas. In this study a baseline survey was conducted in 2010 and a follow-up survey was conducted in 2012. A total of 3,300 women of 18-49 years of age were interviewed who gave birth in the previous 12 months from the starting date of data collection. Respondents’ socioeconomic and demographic characteristics as well as service utilization and perception of each service were collected by using a structured questionnaire in this survey. In this article, both bi-variate and multivariate analyses were used to examine strength of the relationship between the unintended pregnancy and use of family planning methods.
Results Findings suggest that among the respondents (women) 68 percent wanted to become pregnant, 20 percent women wanted to wait or mistimed and another 12 percent did not want children any more. In other words, about 32 percent of the pregnancies were unintended. It was found that almost fifty percent (49 percent) of respondents were using a contraceptive method before their last pregnancy. Among them only one percent used a traditional method and rest 48 percent used a modern contraceptive method. Interestingly, the women who used (49 percent) any contraceptive before their last pregnancy, among them 46 percent experienced unintended pregnancy. On the other hand, non-users (51 percent) of contraceptive methods reported relatively lower proportion of unintended pregnancy (20 percent). The rate of unintended pregnancy also varied according to the use of contraceptive methods. The proportion of unintended pregnancy was comparatively higher among injectable users (51 percent) as compared to other method users.Logistic regression analysis was used to examine the odds of unintended pregnancy for each of the risk factors controlling for the others. It was found that those who did not use contraceptive methods before their last pregnancy had a reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Among contraceptive users, the likelihood of reporting unintended pregnancy was 1.6 times higher among the women who used traditional method as compared to modern contraceptive method users.
Conclusion Findings suggest that the unintended pregnancy rate was higher among the contraceptive users before their last pregnancy than non-users. Again, the rate was higher among traditional and temporary modern method users as compared to longer acting modern method users. From several studies it has been explored whether the incidence of unintended pregnancy might decline more slowly than expected, and might even rise for a while, as countries move through the fertility transition. So, it can be assumed that the improvement of quality of family planning services is likely to decrease the level of unintended pregnancies in the future and advocacy is needed to promote longer acting and permanent methods among eligible couples to avoid unintended pregnancy.

Impact of Voucher Scheme: Delivery Care Services in Rural Bangladesh.

Author(s) Forhana Noor1, Ubaidur Rob2.
Affiliation(s) 1Reproductive Health, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary This paper examined the impact of the intervention of a demand-side financing scheme on the utilization of services as well as out-of-pocket expenses incurred by women for availing of delivery care services. A quasi-experimental research design was conducted for this study. Findings reveal that there was a significant (p<0.0001) increase in the utilization of delivery care at public facilities in the intervention areas compared to the control areas. The average out-of-pocket cost or money required for a normal or caesarean delivery decreased over thirty percent over the time period. Demand-side financing had a positive effect on both utilization and cost.
Background In rural Bangladesh, around 71% of births take place at home. Home delivery is preferred as it is associated with low cost and delivery care at facilities are only considered for emergency obstetric care (EmOC). Bangladesh is predominantly a rural, low income country with a vast majority of its people living in poverty. The utilization of skilled attendants at delivery was almost three times less in rural areas compared to urban areas and also it is seven times less among the poorest (9%) compared to the richer (63%) households. Borrowing, using household savings, and financial assistance from relatives were also found to be important sources in paying for the delivery care.
In the health sector of Bangladesh, the primary source of finance is out of pocket (OOP) expenditure and it is primarily spent in the private sector. Here 64% of total health care expenditure is paid by individuals and the rest by the government. In many situations, OOP payments for health care can cause households to incur catastrophic expenditures, which in turn can push them into poverty. Bangladesh has one of the highest rates of catastrophic illnesses which drives 3.8% of the population into poverty every year.
Objectives To address this equity issue, the Government of Bangladesh piloted a demand-side financing (DSF) scheme (popularly known as the maternal health voucher program) in 21 upazilas (sub-districts) from 2006 and expanded to 33 upazilas in 2007. The selected poor women under DSF scheme receive a package of essential maternal health care services, as well as treatment of pregnancy and delivery related complications. This program also provides supply side financing to service providers. This program has been expanded to another 11 upazilas in 2010. Population Council, with funding from the Bill and Melinda Gates Foundation, has been evaluating the impact of voucher programs in five countries including Bangladesh. As part of evaluation activities, Population Council conducted a baseline survey in 2010 and a follow-up survey in 2012 in new 11 DSF (intervention) and 11 non DSF areas (control). This article used information from the baseline and follow-up survey to examine the impact of this intervention on utilization as well as out-of-pocket expenses incurred by women for availing delivery care services at facility.
Methodology A quasi-experimental research design with pre and post studies in intervention and control areas was conducted to evaluate the impact of demand side financing vouchers on maternal health care services. The assignment to the intervention was non random. A baseline survey was conducted in 2010 with a follow-up survey in 2012. The study was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas where demand-side financing scheme was implemented. The other 11 sub-districts were selected as control areas where the demand-side financing scheme was not implemented. To draw a sample population, the national facility-based births figure was considered for baseline and follow-up survey and a total of 3300 women with 1650 experimental subjects and 1650 control subjects were selected. From each sub district, three of nine unions and three villages from each union were selected through probability proportional to size and finally, from each selected village, required numbers of respondents were interviewed. Women from 18-49 years of age were interviewed who had given birth in the previous 12 months from the starting date of data collection. Respondents’ socio-economic and demographic characteristics as well as service utilization and cost of each service were collected by using a structured questionnaire. Following the same sampling procedure, we interviewed the same numbers of respondents in the follow-up survey.
Out-of-Pocket Expenses: To examine the expenditure pattern, women were requested to report expenses on card/registration fees, consultation fees, laboratory examination, medicine, round trip transportation and any other associated costs to avail maternity care services. These expenses have been divided into three broad categories: medical cost at the facility, medical cost outside the facility, and transportation cost. “Medical cost at the facility” or internal medical cost includes card/ registration fee, consultation fee (unofficial), laboratory charges, drug cost (unofficial), tips to support staff for expediting services, and attendant expenditures for staying at the facility. Expenditures to purchase drugs and get laboratory services from the other private sector are considered as “medical cost outside the facility” and the actual cost women pay to transport providers is calculated as “transportation cost”.
Results Information on the utilization of delivery presented in Table 1 indicates an increase in the proportion of the deliveries that occurred at the facility from 19 percent in 2010 to 31 percent in 2012 in the intervention areas with the control sites experiencing almost the same increase. Use of public-sector facilities for delivery services increased in intervention sites while control sites experienced greater increase in using the private sector. It has emerged from the 2010 & 2012 expenditure pattern that all delivery services involved OOP payments and the average volume of expenditure is higher in control than in intervention. Findings illustrated  the average cost of different OOP expenses for receiving normal delivery services from public health facility. Cost incurred outside the facility (purchasing drugs and laboratory services) is the largest component (about half) of OOP expenditure for normal and cesarean delivery services in both areas. For that reason total average cost for normal delivery decreased a little bit in control areas also. Commonly, transportation cost increased in both intervention and control for normal or cesarean delivery.In the intervention group there has been a decline in the OOP cost for cesarean delivery that women incurred as medical cost both inside and outside the facility while an increase was reported for control. Reduction in both internal and external cost implies a positive impact of demand side financing benefits on women in receiving cesarean deliveries. With a mixed pattern of expenditure, the differences in OOP expenses between intervention and control that women incurred in 2012 cannot be explained with the effect of the DSF program.In the intervention areas, the average OOP cost for receiving normal delivery service reduced by 44% (from $40 to $22), and money required for a caesarean delivery decreased by 30% (from $115 to $80). Comparisons within public and private and voucher non-voucher has been made only in DSF upazillas.  For the women external medical costs at private facilities were double compared to public facilities. Internal medical cost was four times higher at private facilities than at public facilities. In a two-year period, this expense remained same for public facilities while it increased three times for private facilities. Again, voucher clients spent much less money than non-voucher clients.
Conclusion The recent shift in program development has taken place from being supply-side driven to being demand-side driven which improves the situation of non-accessibility of poor pregnant mother to the health facility. Findings reveal that there was a significant increase in the utilization of delivery care at the facility but it was also observed that the use of public-sector facilities for delivery services increased in only intervention sites while control sites experienced greater increase in the use of the private sector. The demand-side incentive package for the poor covers essential costs for maternal health care services and related to transportation cost also, while other costs like the purchase of additional medicine, unofficial provider fees and incidental costs incurred at facility are not covered under the program. Therefore, in DSF upazillas, there is no woman who did not incur any cost to utilize delivery services. Findings suggest the average volume of expenditure in receiving normal or cesarean deliveries is higher in control than in intervention areas. So, cost implies a positive impact of DSF benefits on women and this leads to the conclusion that DSF may have contributed to lower OOP payments. These findings necessitate the allocation of resources to subsidize the cost women incur to purchase medicine and undergo laboratory services that are not available in government facilities. Increased transportation expenses strongly justifies the need to increase the existing amount of financial assistance the government provides to poor clients. Without making normal delivery fully subsidized, it will be difficult to increase the institutional delivery rate  as women still spends a large share of their family income for receiving normal delivery services.Besides this, implementing programs at the upazila hospital alone cannot raise the rate of delivery in rural areas. Additionally, for optimum utilization of the existing health structure in rural areas, other govt. facilities need to incorporate it. It was also observed that a large proportion of women are receiving services from private health facilities. Therefore, the national health financing strategies should engage the private health sector in a way that enables poor women to receive services from the private sector more easily. With the right types of interventions, maternal health-related MDG may not be very difficult to achieve in Bangladesh.

Causes, determinants, andtrends in maternal mortality among Palestine refugees during 2000-2010

Author(s) Ali Khader1, Majed Hababeh2, Wafaa Zeidan3, Irshad Shaikh 4, Yousef Shahin 5, Akihiro Seita6, 7, 8
Affiliation(s) 1Health, UNRWA, Amman, Jordan, 2Health, UNRWA, Amman, Jordan, 3Health, UNRWA, Amman, Jordan, 4Health, UNRWA, Amman, Jordan, 5Health, UNRWA, Amman, Jordan, 6health, UNRWA, Amman, Jordan, 7, , , , 8, , ,
Country - ies of focus Palestine
Relevant to the conference tracks Women and Children
Summary Despite the hardship socioeconomic status, the patern of Maternal mortality among palestine refugee population is similar to that among stable midle income countries, A shift was observed during the last decade from causes related to poor obstetric care such as hemorrage and infection to thromboemblic diseases.
Background The United Nations Relief and Works Agency for Palestine Refugees in the Near East has for over 60 yearsprovided comprehensive primary health care to 5.2 million Palestine refugees in five fields of operation: Gaza, Jordan, Lebanon, Syria and the West Bank. Despite the contextual challenges of chronic instability and poverty, the agency maintains high standards of antenatal care supported with subsidy of delivery in local hospitals, with comprehensive follow up of all registered pregnant women.
During the period 2000-2010 a total of 978,446 pregnant women were registered and followed up through UNRWA antenatal care services. A system to trace the outcome of each pregnancy was established. During the first year (2000) of implementation, 2145 (2.8%) pregnancies were with unknown outcome that was reduced to only 199 (0.2%) cases in 2010 and during this period a total of 230 maternal deaths were reported.
Objectives The aim of this analysis is identify the main causes and determinents of maternal mortality among Palestine refugees women served by UNRWA PHC system
Methodology UNRWA uses the Confidential Maternal Mortality Enquiry method for in-depth investigation of the direct and indirect causes of each maternal death. This retrospective study examines 230 confidential enquiry reports on maternal deaths of Palestine refugee women in five fields of operation during one decade. The confidential enquiry is completed immediately after a maternal mortality. A thorough investigation is conducted by a special committee established to investigate and reoprt on each maternal mortality
Results Analysis of the confidential enquiry reports revealed a maternal mortality ratio of 24/100000 with significant variations among fields (Lebanon and Syria the highest at 34, followed by Gaza and West Bank at 25 and Jordan at 19). 1.8% delivered at home while 14.8% of deaths occurred at home. 53% of them died in hospitals during the intra-post-partum period. 88% received 4 or more antenatal visits. Maternal deaths increased with higher parity. There was a shift in the leading documented causes of maternal deaths from pre-eclampsia and hemorrhage to pulmonary embolism. Thromboembolism was the first cause of death with 41% followed by toxemia and hypertensive disorders at 12, heart diseases at 11.8%, hemorrhage at 10.5% and infection and sepsis at 7.4%
Conclusion Maternal Mortality has plateaued over the last 10 years among Palestine Refugees. We have managed to reduce the deaths from infections, hemorrhage and pregnancy induced hypertension but the deaths from obstetric embolism and medical disorders in pregnancy have either stayed the same or have increased over the years. This can be partially attributed the lack of embolism prophylaxis in high risk cases as well as poor care of high risk women with medical disorders prior to pregnancy

Introducing Kangaroo Care in an urban district hospital of Bonassama – Cameroon.

Author(s) Danièle Kedy Koum1, Cristina Exhenry2, Riccardo Pfister3.
Affiliation(s) 1Paediatrics, District Hospital Bonassama, Douala, Cameroon, 2none, noen, Geneva, Switzerland, 3Neonatology and Intensive Care Services , Geneva University Hospitals, Geneva, Switzerland.
Country - ies of focus Cameroon
Relevant to the conference tracks Women and Children
Summary In sub-Saharan Africa neonatal mortality in LBWI (<2500g) is one of the highest worldwide. Kangaroo Care (KC) is an alternative to incubators recommended by the WHO. However, most published reports originate from central reference hospitals. In low-resource countries, a large proportion of LBWI remain at district level such that KC at this level seems an obvious necessity. We have successfully introduced KC in the urban district hospital of Cameroon. At one year, 30 LBWI were included. Mortality was 3%, considerably lower than previous years (14.5%). Parental acceptability was subject to social and financial circumstances that are potentially more easily solved at the district level.
Background In Douala, Cameroon's economic capital of 2 million people, some 20,000 of 100,000 new-borns are low birth weight infants (LBWI)
Objectives To implement Kangaroo Care in an urban district hospital in order to reduce neonatal mortality and morbidity in a low resource setting. An additional aim was to study the implementation of this method, anticipating an extension to other peripheral structures initially in the same district.
Methodology In July 2012, we launched a pilot project introducing Kangaroo Care in the urban district hospital Bonassama. It is a two year project approved by the ethics committee of the Ministry of Health of Cameroon and the University Hospitals of Geneva (HUG), with the following main steps: 1. Identifying local site management; 2. Obtaining support of the local health authorities and ethics committees (ownership); 3. Public and private funding; 4. Functional reorganization of the neonatal unit; 5. Staff training; 6. Patient recruitment; 8. Patient follow-up of until the age of 2 years; 9. Data analysis (particularly data referring to difficulties in introduction of Kangaroo Care).
Results The project is under the direction of a Cameroon physician trained at HUG. The site has been restored and reorganized with funding from the Ministry of Health of Cameroon, the political district authorities and HUG. Twelve staff members, mostly nurses, were trained in Kangaroo Care during one week. Recruitment of LBWI began 9/25/2012 with 30 LBWI included at one year. The mortality rate was 3%, considerably lower than the average of the previous two years (14.5%). The inclusion rate was 40% of potentially eligible patients. Parental refusal, often resulting in hospital dismissal against medical advice, was the main cause of non-inclusion.
Conclusion Kangaroo Care has been successfully introduced and is practiced in a district hospital with limited resources. Its decentralisation, closer to the families, is an advantage. However, many obstacles remain and require new strategies. The acceptability of Kangaroo Care, little known to the public, requires a community-based communication emphasizing its undeniable benefits. A unique hospital package and financing alternatives for the poorest could increase acceptability. Finally, maternal work, often vital for the family, requires early relocation of Kangaroo Care to the family household, with local support more readily available in the district.

Risk Factors and Practices contributing to Newborn Sepsis in Buyende District, Uganda.

Author(s) John Bua1, David Mukanga2, Elizabeth Nabiwemba3
Affiliation(s) 1Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 2Bill & Melinda Gates Foundation, Bill & Melinda Gates Foundation, Kampala, Uganda, 3Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda.
Country - ies of focus Uganda
Relevant to the conference tracks Women and Children
Summary This was a facility based cross sectional study in Kidera sub-county, Buyende district, Uganda. It aimed at identifying potential risk factors and describing practices contributing to newborn sepsis in Buyende district in order to make recommendations that will influence behaviour change at community level. 174 newborns participated. 21.8% were laboratory confirmed to have sepsis. The main causative agent was staphylococcus aureus (31.6%). Risk factors included inappropriate cord care (77.6%) and not practicing routine hand washing (78.2%). Therefore health education messages should target importance of hand washing and cord care for newborns in the communities.
Background In Uganda, it’s estimated that newborn deaths contribute to over 38% of all infant deaths (92,000 in 2010). Despite different mitigation interventions over years, the newborn mortality rate is high at 27/1000 and newborn sepsis contributes to 31% of mortality in Uganda. Therefore, improved strategies that will contribute to the reduction of newborn sepsis need to be developed. However we need to understand the actual practices and risks present that contribute to new cases of sepsis. These need to be put in context, for without reliable evidence it’s difficult to know whether proposed interventions will work.
Objectives To identify potential risk factors and describe practices contributing to newborn sepsis in Buyende district so that recommendations can be made that will influence behaviour change at community level.
The specific study objectives were;
 To assess the prevalence of risk factors for newborn sepsis in Kidera County, Buyende district.
 To describe practices contributing to newborn sepsis within the health facilities.
 To describe practices of mothers or caregivers of newborn contributing to newborn sepsis.
Methodology The study was conducted at Kidera Health Centre, a level IV facility located in Kidera County, Buyende District Eastern Uganda. Kidera health centre is the highest and main referral unit for Buyende District. Kidera Health Centre serves the 5 counties in the district with an estimated population of 248,000 people.This was a health facility based cross sectional study in Kidera sub county, Buyende district. Mothers or care takers of sick newborns and health workers were interviewed. The dependent variable was a newborn having laboratory confirmed sepsis. Independent variables include; social demographics, mother’s ANC, delivery and PNC history, birth weight, gestation age and newborn care practices. Semi-structured questionnaires and Key informant guides were used to collect quantitative and qualitative data.
Results 174 mothers and 174 newborns participated in the study. The majority of the mothers (73%) were peasant farmers. Few of the mothers had attained an education level above primary school (33.9%). The age range for the mothers was from 16 to 44 years (mean: 26.3 years).21.8% of the admitted newborns with signs and symptoms for sepsis were laboratory confirmed. The identified causative agents included; staphylococcus aureus (31.6%), Neisseria meningitides (21.%), streptococcus pyogenes (10.5%) and Haemophilus influenza (5.3%). The causative agents were found to be resistant to some of the commonly used drugs that included; penicillin, chloramphenicol, cloxacillin and gentamycin.Prevalent risk factors included delivery outside the health facility (43.1%), inappropriate cord care (77.6%), care givers not practicing hand washing before handling the newborn (78.2%) and lack of knowledge about newborn care (39.7%).The interview of key informants revealed that the health facility didn’t have resources to offer routine screening for bacterial infections among pregnant women during ANC visits. The available resources were for vertical programs targeting only HIV and malaria. The health facility also had no equipment or a special room were sick newborns in critical condition could be managed appropriately. The other health system challenges identified included lack of antibiotic syrups for treating newborns and inadequate supply of laboratory reagents to investigate causes of ill health in newborns.

Since the study was facility based some sick newborn cases that weren’t brought to the health unit for care could have been missed. However, community health workers in areas served by the health facility were encouraged to refer all cases of sick newborns for care.

Conclusion Most common aetiological agent for newborn sepsis was Staphylococcus aureus followed by Neisseria meningitides. The practice of not routinely washing hands before touching the newborn and inappropriate cord care were leading factors contributing to spread of infection to newborns in the community. Therefore all pregnant women and women in postnatal positions need to be health educated about the importance of hygienic cord care and washing hands before touching the newborn. The health education can be given to mothers attending antenatal, delivery or postnatal at the facility by the health workers. Community health workers, where they exist, can be used to educate mothers in the community about proper newborn care and how to prevent spread of sepsis.

Promoting institutional obstetrics and newborn care in Bangladesh by subsidising out of pocket costs.

Author(s) Mst. Farhana Akter1, Ubaidur Rob2, Ismat Ara Hena3.
Affiliation(s) 1Poverty, Gender and Youth, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh, 3Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary Maternal and child health programs are yet to achieve the  impact on the obstetric and newborn care services utilization from institutions in Bangladesh. This paper explains whether subsidizing out of pocket costs for women promotes the utilization of institutional obstetrics and newborn care or not. Coupons were provided to poor pregnant women and mothers of newborn babies to cover transportation, medical costs and incidental costs for receiving institutional services. A rigorous process of community assessment and use of poverty tool was employed to select eligible women. Three-fourths of the poor pregnant women were identified as eligible for coupon distribution from 20,833 pregnant women.
Background Maternal and neonatal health programs are yet to achieve the desired impact on the utilization of obstetric and newborn care services from public-sector health facilities in Bangladesh. Home delivery and untrained providers during delivery largely contribute to the underutilization of the existing obstetric and newborn care services provided at facilities. Demand-side barrier costs remains a key challenge to the utilisation of skilled maternal newborn and child health (MNCH) care. The cultural and social belief system, social stigma associated with pregnancy and birth, distance of the facility, lack of information on sources of care, lack of awareness on the value of maternal health services, and high access costs (e.g. direct and indirect costs) are considered important demand-side barriers (Ensor 2004). Cost concerns hinder the seeking of professional maternity care and emergency obstetric care, and contribute to maternal death (Koeing 2007; Rob et al. 2006). Poor families face resource constraints and other disincentives to make use of health facilities. High transportation costs due to distance to health facilities and other out-of-pocket costs contribute to limited access to health care by those who need it most (Glassman, Todd, and Gaarder 2007; Khan 2005).
Objectives The Population Council implemented Pay-for-Performance (P4P) for providers and subsidised out of pocket costs for clients to improve MNCH services by addressing supply and demand-side barriers in Bangladesh with funding from UNICEF. This paper explores whether the subsidisation of out of pocket cost of clients promotes the utilisation of obstetrics and newborn health services. Financial assistance in the form of coupons were provided to poor pregnant women to cover transportation, medical and incidental cost for receiving services from facilities.
Methodology A rigorous process consisting of community assessment and use of the poverty tool was employed to select eligible women from the six upazilas of two northern districts of Bangladesh. Information about coupon utilization was collected from the pregnant mother’s identification list, distribution list, and the service statistics. During the service provision period, a quick survey was conducted among the coupon recipients to know the challenges and opportunities of coupon utilization at the health facilities, which would contribute to service utilisation at the facilities. Coupons were distributed during the period January 2011 to June 2011 among the pregnant women who were supposed to deliver by November 2011. The coupon distribution process was used the government field level workers, supervisors and NGO workers to make them aware of the project as well as develop ownership. Two quarters into the implementation, coupon counselling was conducted by the NGO field workers in all coupon project areas. The main objectives were to identify the causes of not using the coupon by the pregnant mothers.To collect detail information about coupon utilisation, service statistics were collected monthly from the service facilities. Process documentation was done from the in-depth interviews that used coupons as well as those that didn't. This paper will describe the experiences of coupon distribution, utilisation and services utilisation as a whole (coupon and non-coupon) from the health facilities of 2 northern district of Bangladesh.
Three-fourths of the poor pregnant women were identified as eligible for coupon distribution among the identified 20,833 pregnant women in the intervention areas, and of them, 92 percent received coupons. Coupon cards cover transportation, medical and incidental costs for antenatal care, delivery care, post natal care, pregnancy complications, neonatal complications and under five children complications.Coupon card distribution started in January 2011 in one district and in March 2011 in another district. Coupons were distributed using NGO workers in the case of the unavailability of government workers. Due to poor utilization rates of coupon beneficiaries, 284 field workers were oriented and engaged for coupon promotion and validation of the coupon distribution activities in September 2011.
Results About 88 percent coupon card holders in a district and 72 percent coupon card holders in another district reported that those eligible to receive the coupons did so. The remainder either damaged or lost the cards or did not receive the cards from the fieldworkers. Among the two districts, 40 percent of coupon recipients used their coupons in Gaibandha district and in Kurigram district 60 percent of coupon recipient used their coupons to receive services from the public-sector health facilities. The coupon clients responded well in terms of receiving the antenatal care services but were reluctant to have deliveries at the facilities and use coupon for newborn care. Coupons were mostly utilised for receiving antenatal care services (79 percent) followed by institutional delivery (17 percent), postnatal care (16 percent) and pregnancy complications care (13 percent) (Table 1). Findings suggest that about one in ten users used coupons for receiving neonatal and under five complication related services from the selected public-sector health facilities, with a significant variation across the areas. The majority of the coupon users used their coupon for antenatal care followed by PNC and delivery care with no variation across the areas. Process documentation suggests that due to the unavailability of fieldworkers, coupon distribution was not performed appropriately as the project used the government field-workers. Similarly the field-workers who were active in distributing the coupons were not interested in counselling the client to use coupons. The most cited reasons for non-use of coupon is inadequate knowledge about the coupon (41 percent) followed by not perceiving the need to receive services from the health facilities (22 percent), long distance and poor transportation facility (9 percent) and delay in receiving the coupon (8 percent).The challenges of transportation remained a reality in some places in spite of offering transportation costs through the coupon. Travelling to the facilities involving multiple vehicles including rickshaw, auto-rickshaw, boat, and bus from the remote char unions are cumbersome; and the transportation cost offered was not adequate for round-trip transportation cost to the facilities.There are several low performing areas located very far from health facilities. There were no usual transportation systems available in those areas. The majority of those people depend on walking and boat and it needs 4 to 7 hours to reach health facilities.
Conclusion • Intensive advocacy at the community levels and increasing the quality of antennal care may encourage women to plan delivery at the facilities.• Awareness raising activities are essential in generating demand for services and to encourage use of coupon cards at the facilities.• Including roundtrip transportation and additional cost of other arrangements (like, vehicle, ambulance, etc.) for the client for reaching the health facilities may increase the use of coupons and health facilities.

• Rigorous involvement of fieldworkers ,especially government fieldworkers in the coupon mechanism, may increase the coupon utilization.

• The poorest areas with greater geographical drawback will benefit from a combination of a demand plus supply side P4P approach in Bangladesh.

• Government should introduce subsidising out of pocket costs across the country, especially in underprivileged and disadvantaged areas.

Provider Initiative Approach to Enhance Family Planning Uptake in Women of Reproductive Age in Rural Communities in Osun State, Nigeria.

Author(s) Ademola Adelekan1, Elizabeth Edoni2.
Affiliation(s) Health Promotion and Education, University of Ibadan, Ibadan, Nigeria, Community Health Nursing, Niger Delta University, Bayelsa, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Women and Children
Summary Despite decades of progress in improving the delivery and availability of family planning services, high levels of unmet need for family planning still exist in many countries. This suggests that novel approaches are needed to extend access to family planning services to women and couples who desire to limit or space their childbearing but are not currently using contraceptives. The integration of family planning with other health services may be one such approach. Although integration may seem logical, the results of efforts to integrate child or primary health care services with other services suggest that integration presents many logistic challenges and that caution is advisable.
What challenges does your project address and why is it of importance? Despite decades of progress in improving the delivery and availability of family planning services, high levels of unmet need for family planning still exist in many countries. This suggests that novel approaches are needed to extend access to family planning services to women and couples who desire to limit or space their childbearing but are not currently using contraceptives. The integration of family planning with other health services may be one such approach. Although integration may seem logical, the results of efforts to integrate child or primary health care services with other services suggest that integration presents many logistic challenges and that caution is advisable. Integrating family planning services with other health services may be an effective way to reduce unmet need. However, greater understanding of the evidence regarding integration is needed. The study determined the effectiveness of provider initiated approaches to enhance family planning uptake among women of reproductive age in rural communities in Osun State, Nigeria.
How have you addressed these challenges? Do you see a solution? A total of 10 out of 30 Medical Officer of Health (MOH) in Local Government Areas in Osun State were randomly selected and trained on Provider Initiated Approach to scale up the uptake of FP among women of reproductive age in rural communities in Osun State, Nigeria. The selected MOH were equipped with FP knowledge and skills on how to integrate FP with other health services. The trainees in turn trained lower health workers who are the primary service providers in rural areas in their various local government health facilities. Women within the reproductive age are assessed for FP needs in antenatal care, maternal and child health, Post Natal Clinic, HIV counseling and testing and other reproductive health services. Family Planning messages were discussed with women through micro-teaching, IEC Materials and as well as client provider interaction. This was done from March to August, 2012.
How do you know whether you have made a difference? Utilization of FP services increased from 5.8% to 30.2% within 3 months and 42.9% after 6 months. The prevalent use of Intrauterine device, injectable, implant and emergency contraceptives increased from 12.8%, 10.1%, 0.2% and 4.7% respectively to 30.8%, 29.7%, 3.9% and 12.9% respectively. Identified barriers to use of FP among women included inadequate knowledge of FP, negative perceptions of FP, financial constraints and inadequate spousal approval. Excess workload for health workers was recorded as a major challenge in this approach.
Have you or the project mobilized others and if so, who, why and how? There was an increased in uptake of family planning services due to use of provider initiative family planning. More health care providers should be trained towards using this approach since current evidence suggests that integration of family planning with other health services using provider initiative approach may be beneficial.
When your donor funding runs out how will your idea continue to live? The government, through the Ministry of Health, will take over the project

Limitations of Health Promotion Mechanisms: Pakistan

Author(s) Ayesha Aziz1.
Affiliation(s) Women's health, Rural Support Programmes Network, Islamabad, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Advocacy and Communication
Summary To improve the maternal and child health indicators the government of Pakistan initiated the Lady Health Workers Programme in 1994. This study aims to investigate the role of the programme mechanisms in promoting health and empowering people. The research was conducted in purposively selected villages from the districts Thatta, Rajanpur and Ghizer. Qualitative methods were used to gather data for the study. Our findings highlight that the limited understanding and implementation of community mobilization, health promotion and empowerment strategies, exclusion of the lower socio-economic strata and the absence of in depth comprehension of indigenous spaces for dialogue limit the LHW programme’s success.
Background Pakistan has been struggling to improve the maternal, newborn and child health of its population for the last two decades. The government has initiated several maternal and child health (MNCH) programmes to address issues related to availability, affordability and access to MNCH services. Reduction in the country’s maternal and child mortality is still far from meeting the targets of the millennium development goals according to which the maternal mortality rate (MMR) of 380 per 100,000 live births was to be reduced by three-quarters and the infant mortality rate (IMR) of 76 per 1000 live births was to be reduced by two-thirds by 2015. However, the current MMR in 2010 was 260 per 100,000 live births and the IMR was 59 per 1000 live births. The National Programme for Family Planning and Primary Healthcare is one of the largest government health programmes. It was initiated in 1994 with the mandate of overcoming the financial and mobility barriers related to access and ensuring continuous availability of primary healthcare services at the doorsteps of rural communities. The most recent evaluation of this programme, conducted by the Oxford Policy Management in 2009, has revealed that despite all efforts of the programme there has been limited success in behavior change for health promotion.
Objectives Health promotion is considered a process of enabling people to increase control over and to improve their health. It is related to empowering people by developing skills of local leadership, strengthening community actions, creating supportive environment, reorienting health services and building healthy public policies. The National Programme for Family Planning and Primary Healthcare is widely known as the Lady Health Workers Programme as its prime workforce consists of community based Lady Health Workers (LHWs). The LHWs are responsible for advocacy, health education and creating awareness for promoting community health. Their work includes counseling, provision of family planning services, antenatal care and referrals, immunization, basic curative care and supporting community mobilization. There are a total of 90,000 LHWs employed in the programme across the country. Each LHW serves 1000 people living in the 100-200 households around her own house that is called the ‘health house’. For health promotion the LHWs are responsible for mobilizing the community into groups, particularly those of women. Over the years, the LHWs have gained a lot of respect and influence in their communities and their contribution in ensuring availability of affordable primary healthcare has been valuable.
This study aims to investigate the role of the LHW programme mechanisms and the LHWs in promoting health and empowering people, particularly the women and poor. The study will also explore the indigenous mechanisms and spaces for dialogue that exist in every community and endeavor to distinguish the impact of indigenous communication mechanisms and spaces on maternal and child health promotion from the programmatic ones.
Methodology The primary research question for this study was ‘in what ways do LHW programme mechanisms and spaces empower or inhibit women, poor persons and marginalized groups, particularly with respect to maternal and child health issues? The following refined research questions were defined from the primary research question.
1. What are the mechanisms and spaces formed by the LHW programme for promotion of MNCH?
2. How are the selected communities stratified? (ethnic groups, economic classes, castes, education status, gender and age)
3. What are the marginalized groups in the selected communities?
4. Who is included and who is excluded from the LHW programme mechanisms and spaces? And why?
5. What are the mechanisms of inclusion and/or exclusion in the LHW programme mechanisms and spaces?
6. What is the role of LHWs in engaging and empowering the women and poor?
7. What indigenous mechanisms and spaces for dialogue exist in the selected communities?
8. What is the impact of the indigenous and LHW programme mechanisms and spaces on raising awareness about health issues, availability of health services and entitlements of people for MNCH services?
9. What is the impact of the indigenous and LHW programme mechanisms and spaces on women’s mobilization and local accountability processes?
10. What lessons can be learned with respect to accountability and governance in the LHW programme and the identification, training and selection of the LHWs? To take into account the cross country geo-cultural differences, this research was conducted in a purposively selected LHW covered villages from the districts Thatta (delta), Rajanpur (plain) and Ghizer (mountainous). A comprehensive document review of relevant documents of the LHW programme was done and a total of 9 key- informant interviews (KIIs) were conducted with three LHW programme personnel in each village/district to gather information on the planned and implemented mechanisms for maternal and child health promotion. The community’s perspectives on the role of programmatic mechanisms and LHWs in health promotion was investigated by conducting 10 participatory reflection and analysis (PRA) based group discussions (5 with women’s group and 5 with men’s group) in each of the three selected villages. Indepth interviews with selected women were also conducted to distinguish the impact of indigenous communication mechanisms and spaces from the programmatic ones.
Results • Community mobilization mechanisms are utilized only for awareness raising
In all our study sites, LHWs were found to visit households on specific dates during the immunization campaigns, though they have a mandate to raise awareness and change attitudes by the formation of a women’s group and health committee in their catchment area. In each site, LHWs were found to conduct occasional awareness raising sessions on antenatal care and contraception. Communities in Thatta and Rajanpur did not know of any women’s group or health committee. In Ghizer some women informed us about a women’s group created by the LHW 2 years ago, but such group activities were no longer a part of the LHW’s routine work as she had a high work burden and was not held accountable for mobilization efforts.
• People from lower socio-economic strata were excluded and their women bore the highest burden of MNCH issues.
In villages of Thatta and Rajanpur Districts the community was stratified with respect to lineage that formed their caste identity, while in Ghizer it was stratified on the basis of religious sects. The men and women from the lower socio-economic strata were excluded from the awareness sessions as the LHWs were either relatives or friends of the better-off women and tended to complete their field activities with them without making much effort to ensure representation and participation of all strata. Due to lack of access to information and resources the poorest women in each site withstood the highest burden of MNCH issues. They related horrid stories of multiple young age pregnancies, miscarriages and even infant deaths. The most vulnerable women were those belonging to the poorest castes that led semi-nomadic lives in search of livelihoods. They were not even counted as women eligible for primary healthcare and family planning advice in LHWs’ registered catchment area population.
• Indigenous spaces for dialogue can serve as entry points for behavior change
In Ghizer, the place for congregational worship was used by women from the same religious sect to discuss and promote contraceptive usage. In Thatta and Rajanpur Districts, the agricultural activities and household gatherings were used to exchange information on contraceptive usage, but due to deeply ingrained patriarchal practices of the society, very few women could use this information for behavior change.
Conclusion Our findings highlight the limited understanding and implementation of community mobilization, health promotion and empowerment strategies in the LHW programme. This has restricted the focus of LHWs’ community mobilization activities to awareness raising, while their potential for promoting organized and sustainable community based collective efforts for building local partnerships and ensuring accountability of healthcare services remains unharnessed.
Social stratification determines people’s access to resources, livelihood, ownership of agricultural land and socio-economic status, therefore equitable access to information and health can be ensured by monitoring inclusion of the lower socio-economic strata and the semi-nomadic population groups in the community mobilization efforts.
The indigenous spaces for dialogue among women in all communities included communal places for washing clothes, collecting water and performing agricultural activities and the household gatherings for celebrating events. These spaces contribute to the construction of cultural norms and practices in a society. Therefore, in-depth comprehension of the indigenous spaces will allow the LHWs and their programme to capitalize upon existing opportunities for dialogue and behavior change for health promotion and empowerment.

Vaccination against Human Papillomavirus: Knowledge, attitudes, and beliefs of Medical Students in Sth Africa.

Author(s) Muhammad Hoque1, Sam Monokoane2, Guido Van Hal3.
Affiliation(s) 1Graduate School of Business and Leadership, University of KwaZulu-Natal, Durban, South Africa, 2Obstetrics and Gynaecology, University of Limpopo (Medunsa Campus), Pretoria, South Africa, 3Medical Sociology and Health Policy, University of Antwerp, Antwerp, Belgium.
Country - ies of focus South Africa
Relevant to the conference tracks Women and Children
Summary The majority of the medical students in South Africa intend to prescribe human papillomavirus vaccines even though they have little knowledge of the human papillomavirus vaccine.
Background In South Africa cervical cancer is one of the leading causes of death among women. Currently there are two vaccines available in South Africa. These vaccines are currently being considered for a national vaccination programme. A nationwide vaccination programme in South Africa will almost certainly make a significant difference in the cervical pre-cancer and cancer incidence in the future.
Objectives The purposes of the study are to investigate the knowledge, attitude and beliefs of medical students in South Africa concerning vaccination against the human papillomavirus.
Methodology This was a cross-sectional study conducted among 100 medical students using a self-administered questionnaire.
Results More than two-thirds (71%) of the respondents were aware of HPV and among them 81.2% mentioned vaccination against HPV. The majority (81.7%) were aware that persistent HPV infection is a necessary cause of cervical cancer. The fact that between 60 – 80% of cervical cancer incidents are caused by HPV types 16 and 18 is only known by 14.5% of the medical students. Overall, knowledge regarding HPV infection was low among the medical students as the average score was 3.23 (possible range was 0 to 9). The majority (87.7%) of the students reported that they have not received sufficient information regarding HPV infection. The majority of the students (72.9%) indicated that the vaccine should be given to girls before the onset of sexual activity. More than 90% of the students believe that physicians will support HPV vaccination and adolescents and young adults will accept HPV vaccination and 82.9% intend to recommend HPV vaccination if it is publicly funded. Overall, 86.7% of respondents intend to prescribe HPV vaccines.
Conclusion HPV vaccination is a relatively new concept for the primary prevention of cervical cancer. Overall, knowledge regarding HPV vaccination among the medical students is low, but there was a positive attitude towards it. There is a strong need to provide more education for medical students about the relationship of HPV infection and cervical cancer and the benefits of vaccinating adolescent girls to prevent cervical cancer in the future.