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GHF2014 – PS14 – Integrating Sexual and Reproductive Health Care in Humanitarian Interventions

16:00
17:30
PS14 TUESDAY, 15 APRIL 2014 ROOM: 18 ICON_Fishbowl
Integrating Sexual and Reproductive Health Care in Humanitarian Interventions
MODERATOR:
Dr. Doris Schopper
Professor at the medical faculty of the University of Geneva and director of CERAH, Switzerland
SPEAKERS:
Dr. Anne Golaz
Lecturer and researcher at CERAH, Switzerland
Ms. Wilma Doedens
Technical Adviser on Reproductive Health in Emergencies, Humanitarian Response, UNFPA, Switzerland
Dr. Lisa Thomas
Medical Officer, Department of Reproductive Health and Research, World Health Organization, Switzerland
Ms. Nelly Staderini
Référente médicale- Santé de la reproduction, Reproductive Health Advisor, MSF, Switzerland
OUTLINE:
Problems related to sexual and reproductive health are the leading cause of death and ill health for women of childbearing age globally. In crises, this vulnerability increases, while access to services decreases. The urgent need for life-saving sexual and reproductive health services has often been neglected and not prioritized in humanitarian responses.  Speakers from UN agencies and INGOs will give a brief overview of some of their sexual and reproductive health programmes, discuss recent achievements, challenges in integrating sexual and reproductive healthcare in humanitarian interventions and ways to advocate for better access to these services during crises.
PROFILES:

SCHOPPER-DorisDr. Doris Schopper
Professor at the medical faculty of the University of Geneva and director of CERAH, Switzerland

She obtained a medical degree at the University of Geneva (1978), trained as a specialist in Internal Medicine (1986) and completed a Doctor in Public Health at the Harvard School of Public Health (1992).

Between 1982 and 1990 Doris Schopper spent several years with Médecins Sans Frontières (MSF) in the field. She was president of the Swiss branch of MSF (1991–1998) and twice president of the MSF International Council during this period. In 2001 Doris Schopper was asked to constitute an Ethics Review Board for MSF International.

Since then she has chaired the Board coordinating the ethical review of MSF research proposals and providing advice on ethical matters to the organisation.

Doris Schopper also worked as health policy adviser in the Global Programme on AIDS at WHO headquarters in Geneva (1992-95).

Further international work includes two years as senior health policy adviser at the Swiss Tropical Institute and developing several policies and strategies for WHO (e.g. guideline for policy makers on national policies for violence and injury prevention; strategy for mother-to-child transmission of HIV in Europe; WHO-wide strategy on child and adolescent health).

Professor Schopper has also been responsible for the development of health policies and strategies at the national and regional level in Switzerland (e.g. Swiss National Cancer Control Programme 2005-2010; framework to prevent obesity at the national level; comprehensive health policy for the canton of Geneva). She is member of the board of Pro Victimis Foundation-Geneva since 2003, and president since 2010.

In November 2012, Doris Schopper was appointed member of the International Committee of the Red Cross (ICRC).

Functions:

  • Director
  • Member of the Scientific Committees of the CAS
  • Coordinator CAS Health in Humanitarian Emergencies
  • Co-responsible Course Health Interventions in Humanitarian Crises

Fields of Interest:

  • Public health in humanitarian contexts
  • Development and analysis of health policy
  • Research ethics in humanitarian contexts
  • Ethics of humanitarian medical intervention
  • HIV-Aids, Cancer

 

Golaz-AnneDr. Anne Golaz
Lecturer and researcher at CERAH, Switzerland

She obtained her Medical Doctor degree and Doctorate in Medicine at the University of Geneva, and a MPH at the University of Washington. She’s Board Certified in Public Health and General Preventive Medicine. She has over 20 years of field experience in humanitarian work and  graduate and post-graduate education in public health. She’s worked as a medical epidemiologist for the US Centers for Disease Control and Prevention; as a senior advisor for UNICEF Regional Office for South Asia in Kathmandu and Geneva Office, and for WHO HQ and Regional Offices in Cairo and New Dehli.

Role at the CERAH

  • Member of the Scientific Committees of the CAS Health in Humanitarian Emergencies and CAS Disaster Management
  • Coordinator CAS Health in Humanitarian Emergencies
  • Coordinator of the Research Methodology course (MAS-DAS)
  • Co-leader of the course Health Interventions in Humanitarian Crises (MAS-DAS week)
  • Co-leader TS Advocacy for Humanitarian Projects in Health

Fields of interest

  • Public health and epidemiology
  • Reproductive health in humanitarian emergencies
  • Mental health in humanitarian emergencies
  • Genocide prevention
  • Community capacity building
  • Research and evidence generation in humanitarian contexts

 

Ms. Wilma Doedens

Wilma Doedens is the Technical Adviser on Reproductive Health in Emergencies of the Humanitarian Response Branch of UNFPA. She has worked with UNFPA since 2002. Prior to this she worked with WHO.

Wilma is a Medical Doctor with a public health and reproductive health background. She has extensive field experience in coordinating and implementing reproductive health services in both humanitarian and development settings, working within national health systems as well as with NGOs such as Medecins Sans Frontieres (MSF), International Rescue Committee (IRC) and the International Federation of the Red Cross (IFRC).

She coordinated the writing and publication of the Inter-Agency Field Manual for Reproductive Health in Humanitarian Settings and the Inter-Agency Standing Committee Gender-Based Violence Guidelines, and she is responsible for ensuring technical review and quality improvement of the Inter-Agency Reproductive Health Kits designed to support the implementation of priority reproductive health interventions in disasters.

 

Dr. Lisa Thomas

Lisa Thomas, MD is a Medical Officer in the Department of Reproductive Health and Research at the World Health Organization in Geneva, where she serves as the focal point for sexual and reproductive health in humanitarian settings.  She is a U.S. Board Certified Obstetrician Gynecologist with subspecialty training in family planning. Prior to joining WHO, she worked for humanitarian, development and donor agencies in over twenty developing countries including conflict and post-conflict settings. She has covered an expansive breadth of public and private sector projects in maternal and reproductive health policy, program design, training, research and monitoring and evaluation.

 

Ms. Nelly Staderini

Since more than 3 years, Nelly Staderini is in charge of the  Sexual and Reproductive Health and sexual violence in the medical department of Doctors Without Borders in Geneva. After initial training in midwifery and a Public Health Diploma in France, she practiced  in Parisian hospitals and had various functions in humanitarian missions abroad ( Mali , Cambodia, Pakistan, Afghanistan, Guinea , Chad and Burundi ) for non -governmental organizations. She has worked on maternal health issues in general and sexual violence, prevention and treatment of obstetric fistula and the prevention of mother to child transmission of HIV in particular. She is the author of academic works dealing with training of TBAs in Cambodia and midwives in Chad as well as two books: Sage-femme en Afghanistan (Cheminements Editions , 2003) and l' art revisité des matrones, naissances contemporaines en question ( Faustroll Edition, 2011).

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.

Lessons from the Commercial Sector: How Integration Can Transform Public Health Supply Chains

Author(s) Carmit Keddem1, Nadia Olson2, Carolyn Hart3, Joseph McCord4.
Affiliation(s) 1Center for Health Logistics, John Snow, Inc., Boston, United States, 2USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC, United States, 3Center for Health Logistics, John Snow, Inc., Washington, DC, United States, 4USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC,United States.
Country - ies of focus Global
Relevant to the conference tracks Health Systems
Summary Successful health programs require an uninterrupted supply of health products provided by a well-designed, well-operated and well maintained supply chain. By applying a new approach to end-to-end integration, adapted from the commercial sector, health managers can ensure that public health supply chains deliver an adequate supply of essential health commodities to the clients who need them.
What challenges does your project address and why is it of importance? Health programs can succeed only if people have access to the essential health products they need. Although many countries have strengthened their public health supply chains and, thus, improved product availability in recent years, they continuously face new challenges. Countries are under increasing pressure to deliver a rising volume of products to support expanding health programs and respond to greater demand from donors for accountability and sustainability. New technology and commercial sector approaches can help countries build dynamic supply chains that respond to these changes and yield health and development benefits.
How have you addressed these challenges? Do you see a solution? JSI has researched and applied commercial sector approaches to public health supply chains, including supply chain integration, and has seen significant results. While public health systems in resource-limited settings are very different than private companies, public health supply chain managers face many of the same challenges as commercial supply chain managers did many years ago. Over the past few decades, commercial sector supply chains of major corporations, including Apple, Proctor & Gamble, Wal-Mart, and Dell, have undergone a major transformation to become cost-effective, agile, and responsive to consumer needs. This occurred in an environment where consumers were expecting wider choice and better service from retailers, and increasing globalization encouraged companies to build international, outsourced supply chains with increased management complexity. With the right approach, integration can be as transformative for public health as it has been in the commercial sector – leading to more cost-effective and reliable supply chains that effectively deliver health products to clients and contribute to better health outcomes.When adapted for public health, supply chain integration involves linking the actors managing health products from the top to the bottom of the supply chain, or from end-to-end, into one cohesive organization, which oversees all supply chain functions, levels, and partners, ensuring an adequate supply of products to clients. Lessons from the commercial sector teach us that integration is more than merging health program supply chains - for example putting malaria and HIV and AIDS products on the same truck. JSI has worked to design and strengthen various public health supply chains according to the principles of supply chain integration by better linking people, information, and activities from where products are made to the people who need them.
How do you know whether you have made a difference? In Zimbabwe, after applying supply chain integration principles to integrate key products into a well-functioning family planning supply chain, stockout rates for nevirapine tablets decreased from 33 percent to 2 percent and supply chain costs were reduced. This, ultimately, resulted in 35 percent more mothers treated to prevent mother-to-child transmission of HIV.
Have you or the project mobilized others and if so, who, why and how? JSI, through various supply chain projects, works with government, civil society, academic and funder organizations to strengthen public health supply chains worldwide. We have incorporated supply chain integration concepts into our system strengthening approaches in various countries – from a supply chain orientation of animal health specialists in Indonesia, to pre-service training in Tanzania, to guiding the supply chain system design process for essential medicines in Nigeria.
When your donor funding runs out how will your idea continue to live? Strengthening supply chain systems requires significant investment and resources, but can reap significant long-term benefits for health programs and the broader health system. While supply chains required sustained investment, designing public health supply chains according to the principles of supply chain integration will improve their efficiency and effectiveness in the long-term, protecting the investment in commodities and the supply chain system and leading to more sustainable health solutions.

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

Childbearing, Unintended Pregnancy and Contraceptive Use among South Asian Married Female Adolescents

Author(s) S. M. Mostafa Kamal1, Che Hashim Hassan2,
Affiliation(s) 1Department of Mathematics, Islamic University, Kushtia-7003, Afghanistan, Unit for the Enhancement of Academic Performance, University of Malaya, Kuala Lumpur, Malaysia, 3
Country - ies of focus Bangladesh
Relevant to the conference tracks Social Determinants and Human Rights
Summary This study examined the childbearing status, unintended pregnancy and contraceptive use among married female adolescents of four South Asian countries using the nationally representative survey data. Findings show that, the initiation of childbearing ranges from 57% in Pakistan to 67% in Nepal. The incidence of unintended pregnancy was more frequent in Nepalese adolescents. The use rate of contraceptive methods was highest in Bangladesh and lowest in India. The reproductive behaviour of female adolescents are significantly associated with education, working status, place of residence and standard of living indices, although the associations are not always consistent across countries.
Background Despite global declines in the rate of early childbearing, reproductive behaviour of adolescents remains a persistent challenge in many developing countries.
Objectives This study endeavours to examine childbearing, unintended pregnancy and contraceptive use among married adolescents in four South Asian countries: Bangladesh, India, Nepal and Pakistan.
Methodology Data for this study have drawn from the most recent and nationally representative Demographic and Health Survey (DHS) conducted between 2005 and 2011. The analysis focused on the married female adolescents of age ranging from 15 to 19. The prevalence of initiation of childbearing, intention status of the most recent pregnancy, current use of any contraceptive methods were assessed by simple cross tabulation, while binary logistic regression models were constructed to examine the socioeconomic and country impacts on each of the outcome measures. The sample was made nationally representative by using the weight factor in the survey data. Data were analysed by IBM SPSS v21 (SPSS Inc., Chicago, IL, USA).
Results The mean age at first marriage was significantly lowest among adolescents in Bangladesh (15.1±1.7), followed by India (15.5±1.8), Pakistan (15.7±1.7) and Nepal (15.9±1.5) respectively. In Bangladesh, two-thirds (66.1%) of the adolescents initiated childbearing, of whom 53.4% were already a mother 12.7% were pregnant for the first time. The corresponding figures for India, Nepal and Pakistan were 57.8%, 67.6% and 56.7% respectively. The incidence of unintended pregnancy was more frequent in Nepalese adolescents (32.4%), followed by Bangladesh (25.2%), India (17.3%) and Pakistan (13.1%). The use rate of any and modern contraceptive methods was highest in Bangladesh (47.1% and 42.4%), followed by Nepal (21.0% and 17.1%), India (13.0% and 6.9%) and Pakistan (6.7% and 4.2%). The multivariate binary logistic regression analyses yielded quantitatively important and reliable estimates of the reproductive behaviour of adolescents. The analyses suggest that reproductive behaviours of female adolescents are significantly associated with their level of education, working status, place of residence and standard of living indices, although the associations are not always consistent across countries. Furthermore, the likelihood of initiation of childbearing was significantly higher among female adolescents of Bangladesh than other three South Asian countries. Unintended pregnancy was significantly higher in Nepalese adolescents. Meanwhile, the adolescents of India, Nepal and Pakistan were less likely to use any contraceptive methods than those of Bangladesh.
Conclusion Early initiation of childbearing, unintended pregnancies and lower use rate of any contraceptive methods among married female adolescents are common in the four South Asian countries. Programmes and policy initiatives should focus on the enforcement of the legal age at first marriage and education retention as this may reduce early practices of child marriage in South Asian countries. Providing door-step delivery services of effective family planning methods is important to reduce unintended pregnancy among married female adolescents.

The Effect of Unintended Pregnancy on Maternal Health Care Service Utilisation in South Asia.

Author(s) S. M. Mostafa Kamal1, Che Hashim Hassan2.
Affiliation(s) 1Department of Mathematics, Islamic University, Kushtia-7003, Bangladesh, 2Unit for the Enhancement of Academic Performance, University of Malaya, Kuala Lumpur, Malaysia 3.
Country - ies of focus Bangladesh
Relevant to the conference tracks Social Determinants and Human Rights
Summary This study examines the effect of unintended pregnancy on maternal health care services utilization among women of four South Asian countries using nationally representative survey data conducted between 2005 and 2011. The prevalence of unintended pregnancy ranges from 25% in India to 32% in Bangladesh. Overall, the Indian women sought more skilled services for maternity care than the women of other study countries. The multivariable binary logistic regression yielded that, except for Pakistan, the women with unintended pregnancy were significantly less likely to seek skilled maternal health care services than women who reported that their last child was planned/wanted.
Background Of the estimated annual 210 million pregnancies occurring worldwide, approximately two-fifths are unintended which include mistimed and unwanted pregnancies, out of which 22% end in unsafe and illegal abortions. Unintended pregnancy is a major cause of unsafe abortion. Ninety-five percent of unsafe abortions occur in the developing countries. Worldwide, unsafe abortion accounts for approximately 13% of the total maternal deaths. Millions more suffer long-term life threatening complications caused by unsafe abortion. The pernicious consequences due to unintended pregnancies are well documented. Evidences show that unintended childbearing can cause adverse health outcomes such as depression, anxiety, poor psychological well-being, poor utilization of antenatal care services, low use of supplements, vaccination and nutrition. However, most of these findings are from developed countries. Such evidence is limited in developing countries.
Objectives This study aims to examine the effect of unintended pregnancy on maternal health care service utilization among women of four South Asian countries: Bangladesh, India, Nepal and Pakistan.
Methodology Data used in this study were collected by the most recent and nationally representative Demographic and Health Survey (DHS) conducted in Bangladesh, India, Nepal and Pakistan. The surveys are based on a two-stage stratified sample of households. It accumulated information from married women of reproductive age inclusive of rural and urban areas. The survey obtained various information related to demographic and health issues including fertility, marriage, use of family planning methods, pregnancy intention status, maternal and child health, use of maternal and health care services etc. The surveys collected information of live births that occurred in the five years preceding the survey.Outcome measures.The outcome measures of the study are: (i) skilled antenatal care (ANC) seeking; (ii) adequate ANC (≥4 ANC) visits; (iii) seeking assistance from skilled birth assistants (SBA); and (iv) delivery at facility place. The skilled MHCS has been defined as receiving care from a medically-trained services provider. The facility for childbirth includes a medically equipped health care service centre.Exposure variables.Along with the principal exposure variable ‘unintended pregnancy’, we additionally included socioeconomic and demographic variables which may influence the utilization of MHCS. The list, definitions and measurement of the covariates included for analysis are provided in Table 1.

Statistical analyses.

Both bivariate and multivariable statistical analyses were adopted in this study. Differences of the use of MHCS according to the desirability of pregnancy and other socioeconomic factors were assessed by chi-square (χ2) tests. To assess the net effects of the exposure variables on the outcome measures, four different multivariable binary logistic models were designed for outcome interests. The checking of multi co-linearity results in its non-existence. The results of the logistic regression analyses are presented by odds ratios (ORs) with 95% confidence intervals (CIs). The level of significance was set at 0.10. The statistical analyses were performed by IBM SPSS v21 (SPSS Inc., Chicago, IL, USA).

Results Prevalence of unintended pregnancy.The prevalence of unintended pregnancy was highest in Bangladesh (32%), followed by Pakistan (30%), Nepal (30%) and India (25%). The prevalence of unintended pregnancy differed significantly by place of residence, age at first marriage, maternal age, birth order and wealth index.Prevalence and differentials of MHCS utilisation.A slightly over half of the Bangladeshi women (51.8%) visited at least once for ANC services. The corresponding figures for women in India, Nepal and Pakistan were respectively 76%, 58.3% and 64.8%. The proportion of women who received adequate ANC services was highest in Nepal (50.1%), followed by India (37.3%), Pakistan (28.8%) and Bangladesh (23.9%). Exactly half of the Nepalese women received adequate ANC services. Seeking assistance from SBA was reported to be highest among women of India (46.7%), followed by Pakistan (39.2%), Nepal (36.0%) and Bangladesh (27.7%) respectively. The prevalence of delivery at hospital was highest among Indian women (38.7%), followed by Nepal (45.3%), Pakistan (34.6%) and Bangladesh (24.9%). Pregnancy desireability exhibited a significant difference in the use of four indicators of MHCS. Except in Pakistan, the prevalence of use of MHCS was lowest among those who reported their last child as unwanted.

Results of multivariate regression

The multivariate logistic regression analysis reveals that, when other variables were controlled for, except for Pakistan, the women, experiencing unintended pregnancy were significantly reluctant to seek skilled MHCS than women with wanted pregnancy. For instance, the women of Bangladesh who opined that their last child was unintended, the risk of seeking ANC, SBA and use of facility place for delivery decreased by the factors 0.85 (95% CI=(0.75-0.96), 0.87 (95% CI=0.77-0.99), 0.86 (95% CI=0.76-0.98) respectively as compared to that those with wanted pregnancy. Almost similar results were obtained for India and Nepal. Surprisingly, the Pakistani women experiencing unintended pregnancy were more likely to seek ANC services, but were less likely to go for delivery at hospital than those whose last child was reported as wanted. The other variables that showed to have significant effect on the utilization of MHCS for the study countries are maternal age, age at first marriage, birth order, women’s education, pregnancy termination and wealth index.

Conclusion Overall, the study results provide important insights into the association of unintended pregnancy with four indicators of MHCS utilization. To our knowledge, this study is the first multi-country study of the association of pregnancy intention status and use of maternity care services. All of these outcomes have been previously associated with a variety of factors, including place of residence, education, and standard of living index or wealth quintiles. However, study findings reveal a high prevalence of unintended pregnancy in the study countries which adds another layer of vulnerability over and above these background characteristics on MHCS utilisation. In the study countries, unintended pregnancy is not only a concern from the perspective of fertility, but is also a cause for concern from the point of view of public health, particularly regarding the use of MHCS. Therefore, greater attention is required to curb the high levels of unintended pregnancies in South Asia. Family planning programmes can play a vital role in averting unintended births and in reducing the burden of unintended pregnancy. Improving access to quality contraception may be an important intervention. Awareness should be created as to the long term benefits of using skilled MHCS through information, education and communication (IEC) programmes.

Understanding Client Satisfaction: Does Quality of Care Matter? Findings from Maharashtra and Rajasthan

Author(s): S. Ghosh*1, R. Acharya2, S. Kalyanwala2, S. Jejeebhoy2
Affiliation(s): 1Development Studies, Institute of Development Studies Kolkata, Kolkata, 2Youth and Adolescent Health, Population Council, New Delhi, India
Keywords: Client satisfaction, quality of care, provider’s behaviour, healthcare services
Background:

An increasing attention has been paid to client’s perspective of quality of care to enhance effectiveness of healthcare delivery system in the developing countries in the recent past. Assessing client’s perspectives give user a voice and would make health services more responsive to people’s needs and expectations. Evidences in developing countries suggest that healthcare utilization is sensitive to user perceptions of quality. Studies of women’s reports of quality of healthcare in India have largely focused on family planning services. Less is known about women’s satisfaction with or quality of care received in general health, maternal health or child immunization services.

Summary/Objectives:

Objectives of the present study are to assess factors associated with clients’ perceived satisfaction in accessing general healthcare (GHC), maternal healthcare (MH), family planning services (FP) and, child immunization (CI) at the individual and facility levels in two states of India.  A survey, comprising exit interviews with 2903 women attending 153 PHCs in two districts each of Maharashtra and Rajasthan, was conducted as part of a larger programme on Comprehensive Abortion Care. Several dimensions of perceived quality of services were probed, including women’s perceptions regarding quality of interaction with the doctor and other staff members; the adequacy of information provided; whether the importance of follow-up was discussed; average waiting time and time spent in consultation. Additionally, a measure assesses the quality of the facility, including availability of doctor, availability of visual privacy during consultation, availability of waiting facility, cleanliness of the out-patient department (OPD) and in-patient facilities. Multilevel logistic regression analyses explore the contribution of each of these measures to client satisfaction with each of the three different types of services received. Other explanatory factors include clients’ background characteristics and state of residence.

Results:

Most of the quality dimensions have a positive and statistically significant effect on patient satisfaction for all types of healthcare services in varying degree. Provider behaviour emerges as the most significant predictor of client satisfaction in all three services. Other quality dimension variables such as assurance regarding follow-up services, providing medical information and waiting time in obtaining services have significant effect on perceived satisfaction in the expected direction. Significant among background factors, moreover, is residence in Maharashtra.

Lessons learned:

The present study has identified some quality dimensions of perceived satisfaction. These dimensions provide information on the structure and the process of care. These dimensions are important areas in which health services in India require strengthening. However, it would be wrong to infer that some quality dimensions can be ignored in favour of others. These different dimensions are interdependent and improvements in one area likely to strengthen the other. Findings reiterate the link between quality of services and care and client satisfaction and single out provider attitudes and interaction with clients as a key factor shaping client satisfaction and consequently utilization of public healthcare system.

Gender Inequality and HIV/AIDS: Double Jeopardy of Women

Author(s): B. Joshi*1, B. Shahi1
Affiliation(s): 1Sociology and Rural Development, Tribhuwan University, Nepal, 2Community Health, All India Institute of Medical Sciences, New Delhi, India
Keywords: Gender, HIV/AIDS, women, vulnerability, rights
Background:

Current statistics indicate that 6.1 million people in South Asia are infected with Human Immunodeficiency Virus (HIV). HIV is an extraordinary kind of crisis. It requires an exceptional response that remains flexible, creative and vigilant on the one hand and on the other hand those who are affected need a multi-dimensional approach to their lives. Now HIV infection in Nepal has a female face because of it growing fastest in this subpopulation. How do gender and HIV/AIDS make women jeopardized? Gender is a crucial element in health inequalities in developing countries. Gender can be conceptualized as a powerful social determinant of health, which interacts, with other determinants such as age, family structure, income, education and social support and a variety of behavioural determinants. In a patriarchal system, men dominate women and exercise control over their lives including their sexuality and reproductive choices. Nepalese women’s vulnerability for HIV is further fragmented by a combination of factors such as biological, social- class, caste, urban/rural location, sexual orientation, culture, economic and legal factors, etc. These factors have an impact on women’s access to services, resources and information.

Summary/Objectives:

A study was conducted with PLWHA women during 2005-2007. To examine the complexity of HIV/AIDS and to learn more about the specific problems faced by women living with HIV - how the concept of gender & HIV/AIDS make their life vulnerable. Case studies and Informal Interviews with HIV infected women. Data was analysed with EPI info programme.

Results:

Case studies and interviews with women from the study illustrate that low status in family, sexual violence, economic and social problems such as poverty, lack of education are some of the primary reasons to get infection. Cultural orientation inhibits them to talk about sex to their partners, which results in infectious status. In the middle-aged women, after sterilization they do not practice regular use of condoms, because they think it is primarily for family planning. Among the newly-married women they know their status only at time of pregnancy, which results in psychological trauma and other related aspects. Most of them are widows and they know their sero status at a later stage of their partner’s HIV infected life. After the death of their partner, some of them are being expelled from their home and undergo various violations of human rights.

Lessons learned:

This study revealed the need to develop appropriate programme would be emphasizing the target communities. Due to illiteracy, poverty, gender inequality women and girls are facing with spousal battering, sexual abuse of female children, dowry related violence, rape including marital rape, traditional practices harmful to female, no spousal violence, sexual harassment and intimidation at work and in school, trafficking of women, forced prostitution, rape in war, female infanticide, constant belittling includes controlling behaviours such as isolation from family & friends, monitoring her movements, restrict her access to resources. Social workers can minimize these issues by giving empathy and psychosocial support, change behaviours and attitude providing medical treatment, offer counselling ,documents injuries and refer their clients to legal assistance and support services, family planning and other mental and reproductive healthcare. Peer-educators (healthcare workers and medical students) approaches for prevention of violence are cost effective, sustainable, easy access to-hard-to reach groups. Governments, NGOs, INGOs also have crucial role to work hand in hand on these issues by empowering women, law and policy, equal education and equal economic opportunities.

Cultural Competences Help to Improve Healthcare among Indigenous Populations

Author(s): F. G. Arevalo1
Affiliation(s): 1Sociology, Universidad de San Carlos de Guatemala, Guatemala
Keywords: Maternal and neonatal health, indigenous health
Background:

Every three minutes, a neonatal death occurs in Latin America. The poorer urban and rural populations are the most affected and within them, in Guatemala, the indigenous population has also the lowest levels of access to basic infrastructure and insufficient coverage to essential maternal and neonatal health services. For instance, in Guatemala, the national neonatal mortality rate is 23 per 1,000 live births but in indigenous communities, the rate can reach up to 39, almost 60% higher. This paper will present a Case Study and Analysis of a new approach for health services provision, focused on Maternal and Newborn Care, developed for rural and indigenous areas of Guatemala. The approach is based in the incorporation, within a Basic Health Team, of an auxiliary nurse, called Mayan Obstetrical Nurse (MON), as a specialized health worker, in charge of neonatal health, within the maternal, newborn and child health (MNCH) continuum of care.

Summary/Objectives:

The purpose of this paper is to describe the process followed to design, implement and evaluate the incorporation, of the MON within a Basic Health Team, in rural and indigenous populations of Guatemala, where health service provision is provided by a programme called Extension of Coverage Programme (ECP) through a team, composed by 1 physician, 1 educator and at least one community health worker. Guatemalan Ministry of Health (MOH) provides services to approximately 4.2 million of inhabitants with this modality, sub contracting local NGOs, selected in an open and competitive process, with participation of local authorities and civil society representatives. However, even though, ECP has been working in the country for almost ten years, some indicators as Neonatal and Post Partum care, as well as Maternal Mortality have not been improved substantially.
Given this situation, two years ago the Ministry of Health, with the support of the International Cooperation, developed a curriculum of a new cadre, which was going to be focused to specifically address maternal and neonatal service provision. Beside of detect and refer complications, train and supervise traditional birth attendants, among other activities, some specific characteristics were defined: All participants should be Mayan, must have previous training, of at least 1 year as auxiliary nurse, some experience in maternal and neonatal care, be proficient in the language spoken in communities to serve, and reside in the area of work. MON was in charge of the National School of Nurses, and supported with scholarships granted by USAID.

Results:

MON experience is an innovative project in Latin American region, in particular for those countries with predominance of indigenous populations. After almost two years of the incorporation of the MON in health teams, there is solid evidence of improvements in some key maternal-child indicators, but also, there is solid evidence of improvement in the quality of services. In this point is necessary to stress that the majority of health personnel in Guatemala do not speak other languages but Spanish. Among the most remarkable results, there was an important increment for family planning information and use of methods for birth spacing. Post partum and neonatal early detection and care were substantially incremented and by the end of 2,007, more than 100 references were made, for mothers and newborns detected in danger of death.

Lessons learned:

The experience or MON produced several lessons, in relation with health workers and training centres. Cultural competences have showed to be extremely important in order to improve access and quality of health services. It is possible to develop acceptable levels of competence for community health workers to address critical public health issues, as maternal and neonatal death. With relatively small resources, Ministries of Health can be able to train, hire or certify qualified personnel to address key maternal and child health issues.

Issue of HIV/AIDS and Response of Islamic Religious Centres (Maderssas)

Author(s): R. G. Ahmad1
Affiliation(s): 1NGO, PLUS Development Foundation, Muzaffargarh, Pakistan
Keywords: HIV/AIDS, Islamic religious centres (Maderssas)
Background:

Islamic charities provide health, education and social services to millions of people in Pakistan. But in Pakistan still sexuality is a taboo topic. There is a strong hold of religious leaders on socio cultural patterns of community (attitude with extremism). Prevailing concepts to talk about sex are considered as act of vulgarity and immoral activity. The word HIV/AIDS is conceived as symbol of sexual delinquencies.

Summary/Objectives:

Method: Through a questionnaire, data on knowledge, attitude, behaviour and practices related to STIs/ HIV/AIDS were collected from 1200 male religious students and religious scholars from randomly selected Islamic religious centres. Baseline knowledge, attitude, acceptability of the concept were assessed.

Results:

According to KABP study 70% students have friends of opposite sex and due to strong religious values and restriction 30% have no friendship with opposite sex. Regarding nature of sex, 40% had kissing and only 18% had intercourse. During intercourse only 3% used condoms. 42% consider that condom is used only for family planning purpose. 56% answered that during intercourse use of condoms reduce sexual pleasure and enjoyment. 32% youth use drugs and 38% did not know about HIV/AIDS. General discussions were also started with four Maderssas students and their teachers. These meetings addressed the sensitization of religious scholars to the issue of HIV/AIDS and highlight the role of Maderssas in HIV prevention.

Lessons learned:  Training of adolescent as peer educators is recommended. Ours being an Islamic society, such information should be given to youth in a way that does not challenge local norms and values. Problem-based learning and participatory education for improving knowledge and condom use and community-based interventions should be considered for STDs/HIV/AIDS prevention.