COVID-19 was declared a pandemic by the World Health Organization on March 11th, 2020. Many states issued stay-at-home orders to prevent the spread of the coronavirus. Any non-essential clinical services were canceled or postponed to decrease in-person visits at clinics, which led to clinics having decreased patient volume. Telehealth was used as a way to continue clinical care to patients in an alternate form. Health departments (HD) provide fundamental services to patients based on a sliding fee scale. Federally Qualified Health Centers (FQHC) provide a wide variety of health care services to underserved communities. Policies on the implementation of telehealth varied between the two systems. The concentration of this study is on the characteristics of telehealth service provision before and during the COVID-19 pandemic and future considerations for clinic service provision. A quantitative analysis was conducted through statewide surveys. The statewide surveys assessed clinic characteristics and contraceptive care service provision among HD family planning clinics and FQHC clinics in two Southeastern states, South Carolina (SC) and Alabama (AL), with similar clinic structures. The survey was conducted from July- November 2020. Survey items included evaluating the impact of COVID-19 on clinical service provision, including services provided prior to (2019) and during (March-June 2020) the pandemic. The response rate was 86.8% (N=112) among HD clinics and 53.8% (N=127) among FQHC clinics. Chi-Squared tests of independence were used to assess differences in service provision among HD and FQHC clinics in SC and AL. Fischer’s Exact test was applied where categorical responses were fewer than five. Among survey respondents, 64.9% (N=72) of HD clinics and 38.9% (N=49) of FQHC clinics indicated no telehealth services were provided prior to the pandemic (p < .0001). Nearly 35% (N=85) of all clinics reported introducing at least one telehealth service during the pandemic. The most prevalent telehealth service provided by HD clinics during the pandemic was prescribing refills of hormonal contraceptive methods at 58.2% (N=64). FQHC clinics’ most prevalent telehealth service provided during the pandemic was primary health care at 89.8% (N=114). Regarding the future of telehealth, 12.4% (N=12) of HD clinics plan to continue all telehealth services offered during March-June 2020, whereas 52.5% (N=62) of FQHC clinics plan to continue all telehealth services offered during March-June 2020 (p < .001). These findings highlight the significance of policy and procedures among the HD clinics in states that have a centralized health department structure. The telehealth services adopted by HD clinics and FQHC clinics varied and further research is needed to understand the barriers to telehealth provision in each state. The importance of reimbursement policy for telehealth services plays a vital role in providing contraceptive services, thus it may be critical to expand billing options and maintain reimbursement of telehealth through Medicaid.

Introuction: The sub-Saharan Africa (SSA) region is making progress in its contraceptive policies that allow for the provision of long-acting reversible contraceptives (LARC). Despite this, the overall utilisation of contraception, especially LARC is low while the burden of unintended pregnancies remains high. Unintended pregnancies pose a significant threat to global public health with far-reaching consequences. There is a need to explore all the reasons for the low uptake of effective LARC methods. The objectives of this systematic review and meta-analysis, was therefore to determine the state of knowledge, attitudes, and perceptions of LARCs among healthcare workers (HCW) in sub-Saharan Africa. Methods: A systematic review and meta-analysis were conducted of published qualitative and quantitative studies. A search strategy was developed and applied to three major databases (PubMed, Ovid (Medline), and Scopus). Studies of both a qualitative and quantitative nature were included if they assessed either the knowledge, attitude, perception or a combination of the concepts among HCWs toward a LARC method. Data were extracted using a pre-determined data extraction form to conduct a qualitative synthesis using a thematic content analysis framework using ATLAS.ti version 8. In addition to this, data was specifically extracted relating to 11 pre-determined questions to conduct proportion meta-analyses using Stata version 15. Heterogeneity was further explored using the I2-statistic and publication bias using funnel plots and Egger’s tests. Results: A total of 3616 records were screened, of which 3510 were excluded. From 106 full-text articles assessed for eligibility, 50 were included for qualitative synthesis and 21 included in the meta-analysis. From the studies, a total of 12 356 participants were included in the analysis. From the meta-analysis, the overall proportion of HCWs with training in family planning was 62% (95% CI: 48%, 76%) while 60% (95% CI: 41%, 80%) reported providing family planning counselling to their clients. Forty-one percent (95% CI: 20%, 61%) of HCWs had received IUCD insertion training with 63% (95% CI: 44%, 81%) expressing a desire for additional training. Only 27% of HCWs (95% CI: 18%, 36%) deemed IUCD appropriate for HIV-infected women. Moreover, restrictions for IUCD and injectables based on a minimum age were imposed by 56% (95% CI: 33%, 78%) and 60% (95% 41 CI: 36%, 84%) of HCWs, respectively. Lastly, minimum parity restrictions were also observed among 29% (95% CI: 9%, 50%) of HCWs for IUCDs and 36% (95% CI: 16%, 43 56%) for injectable contraceptives. Conclusion: The study revealed that there is a gap in knowledge of HCWs regarding family planning counselling and LARC provision. In addition to this, the results indicate that unnecessary provider-imposed restrictions may hinder the uptake of LARC methods by women in sub-Saharan Africa. With the deadline for the Family Planning 2020 initiative and the 2030 SDGs quickly approaching, there is a need to address these issues. / Dissertation (MSc)--University of Pretoria, 2020. / School of Health Systems and Public Health (SHSPH) / MSc (Epidemiology) / Unrestricted

Background: The objective of this thesis was to measure oxidative stress (OS) in women with Bipolar Disorder (BD) who used combined oral contraceptives (OCU). Based on our literature review, it was predicted that OCU would increase OS levels relative to non-contraceptive users (NCU) in women. Methods: Thirty-five participants (BD n=25; Control n=10) were recruited from an ongoing study based in British Columbia ‘The Systematic Treatment Optimization Program in Early Mania.’ Participants were administered psychological screening tools (Young Mania Rating Scale (YMRS), Montgomery-Åsberg Depression Rating Scale, Mini International Neuropsychiatric Interview and Hamilton Depression Rating Scale) and provided a blood sample for the assays (Lipid Hydroperoxide (LPH), Protein Carbonylation, 4-Hydroxynonenal, 3-Nitrotyrosine (3-NT) and 17-Beta Estradiol). Results: In our primary analysis we did not find differences in OS between BD and controls relative to OCU. Within our remaining analyses, only BD women (n=17) and who gave smoking status were included. We found 3-NT to be increased in OCU compared to NCU (F (1, 12) = 5.639, p = 0.035). With respect to mood stabilizer use, 3-NT was increased in OCU relative to NCU (F (1, 10) = 6.33, p=0.031). As for atypical antipsychotics, 3-NT was heightened in OCU adjunctive users compared to NCU who did not use atypical antipsychotics (F (3, 10) = 4.822, p = 0.025). As for our correlation analyses, YRMS correlated with 3-NT and LPH in OCU BD women (r(11)= 0.711, p=0.014 and r(11) = 0.676, p=0.022, respectively) and 17-Beta Estradiol correlated with LPH (r(17) = 0.598, p = 0.001). Our results are preliminary and are limited by our small sample size and various other factors (i.e. controls). Conclusion: The association between hormones and oxidative stress still remains controversial. Here we showed, after controlling for smoking, BMI and age the use of a COC significantly increased 3-NT in women with BD. Moreover, hormones may influence the relationship between OS and mood episodes. / Thesis / Master of Science (MSc)

Osteoporosis is a debilitating and costly disease of the skeleton characterized by low bone mass and structural deterioration of bone tissue leading to bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist. Current data suggest that at present time, 7.8 and 21.8 million women have osteoporosis and osteopenia respectively. The development of osteoporosis and related fracture in later life depends not only on the rate of bone loss in adulthood, but also on the amount of bone present at skeletal maturity. Oral contraceptives (OC), because of their capacity to diminish concentrations of free testosterone and estrogen, have been purported to affect bone mass in young adult women, but results have proven inconsistent. Further, positive skeletal effects of exercise training are thought to be compromised by use of OCs in skeletally immature females. PURPOSE: To assess the independent and synergistic effects of OC use on bone mineral density (BMD) and long bone mechanical bending stiffness (EI) in college-aged females after unilateral isokinetic resistance training. METHODS: Forty six females (age 20 +/- 1.4 yr, height 163.8 +/- 6.2cm, weight 58.9 +/- 8.6kg, fat 27.9 +/- 4.8%) were categorized as OC users (OC, N=22) or non-users (NOC, N=24). Subjects participated in 32 weeks (3 d/wk) of unilateral arm and leg training at an angular velocity of 60 degrees/s using isokinetic dynamometers. BMD and EIMRTA were assessed using dual-energy x-ray absorptiometry (DXA) and mechanical response tissue analysis (MRTA), respectively. RESULTS: Total leg and arm muscular strength of the trained limb increased by 16% and 15%, respectively (p < 0.001), beyond changes observed in the control limbs. Total body BMD increased from baseline for NOC subjects (p < 0.05), but not for OC users. This difference failed to show significance (p = 0.069) when comparisons were run between NOC and OC groups. Increases in ulnar BMD (p < 0.01 for all limbs) and BMD of the trained total hip (OC, p < 0.001; NOC, p < 0.05) occurred irrespective of contraceptive status. Positive changes in EI were conflicting, occurring in the trained ulna for the NOC group (p < 0.05), and trained tibia for OC users (p < 0.05). Tibial BMD increased only for the untrained leg in NOC subjects (p < 0.01). No between group differences were found to be significant, nor were differences between trained vs. untrained, and weight bearing (tibia) vs. non-weight-bearing (ulna) limbs found to be significant. CONCLUSION: These results suggest that oral contraceptives may limit attainment of total body peak bone mass in young adult females. Skeletal maturation in the ulna appeared to be unaffected by exercise training and OC use. Positive effects of exercise training on the total hip were seen in both groups, irrespective of OC status. Conversely, exercise training and use of OCs use may limit the attainment of bone mass in the tibia. Further studies are needed to determine the interactive effects of OC use and isokinetic resistance training on measures of total body and site-specific bone status. / Master of Science

BACKGROUND. Given the efficacy of most contraceptive options, it is of concern that most pregnancies in the USA are unplanned. Besides reducing the woman's and family's preparedness for parenting, unplanned pregnancies are at higher risk for inadequate prenatal care, perinatal morbidity, and significant postnatal problems. Little is known about the factors responsible for the high rates of unplanned pregnancy. METHODS. One hundred ten pregnant women were surveyed to examine factors relating contraception to unplanned pregnancy. RESULTS. Sixty-five percent of pregnancies were unplanned. There was a statistically significant association between having unplanned pregnancies and being single or divorced. Women who had planned their pregnancies tended to be more satisfied with contraceptives. In sexual encounters, women with unplanned pregnancies were more likely to use no contraception or to practice 'withdrawal' or use condoms rather than hormonal contraception; to be influenced by their partner regarding birth control use; and to forget to use contraception. CONCLUSIONS. All women of childbearing age who are sexually active can benefit from planning pregnancies. Counseling that accesses a woman's expectations regarding birth control, followed by a careful explanation of the side effects of a contraception choice, may reduce the rate of unplanned pregnancy. Counseling the male partner or sexually active men in contraceptive options may be equally important. Understanding factors that result in satisfaction with contraception may reduce unplanned pregnancies.

Purpose: Access to the full range of contraceptive options is essential to providing patient-centered reproductive health care. Women living in rural areas often experience more barriers to contraceptive care than women living in urban areas. Therefore, federally funded family planning clinics are important for ensuring women have access to contraceptive care, especially in rural areas. This study examines contraceptive provision, factors supporting contraceptive provision, and contraceptive utilization among federally funded family planning clinics in 2 Southern states. Methods: All health department and Federally Qualified Health Center clinics in Alabama and South Carolina that offer contraceptive services were surveyed in 2017-2018. Based on these surveys, we examined differences between rural and urban clinics in the following areas: clinic characteristics, services offered, staffing, staff training, policies, patient characteristics, contraceptive provision, and contraceptive utilization. Differences were assessed using Chi-square tests of independence for categorical variables and independent t-tests for continuous variables. Findings: Urban clinics had more staff on average than rural clinics, but rural clinics reported greater ease in recruiting and retaining family planning providers. Patient characteristics did not significantly vary between rural and urban clinics. While no significant differences were observed in the provision of long-acting reversible contraceptives (LARCs) overall, a greater proportion of patients in urban clinics utilized LARCs. Conclusions: While provision of most contraceptives is similar between rural and urban federally funded family planning clinics, important differences in other factors continue to result in women who receive care in rural clinics being less likely to choose LARC methods.

A prospective study of two combined oral contraceptives was conducted in the Sudan. No pregnancies occurred. Overall incidence of side effects was low. Headache was most frequently reported. Elevations were observed for weight, systolic and diastolic blood pressures, and SGOT and SGPT values while a decrease was seen for hemoglobin levels. Menstrual irregularities were not a problem for the users. Total 6-month use discontinuation rates were low for both pill groups.

Bakgrund: Barnmorskans arbetsfält omfattar idag sexuell-, reproduktiv- och perinatal hälsa och det centrala i yrkesutövningen är att främja hälsa. Barnmorskan ska ha kunskaper om, kunna ge information och undervisa om sexualitet och samlevnad utifrån ett genus- och livscykelperspektiv. Uppdraget på ungdomsmottagning är att arbeta med sexualitet och hälsa samt att förebygga oönskade graviditeter och STI. Syfte: Syftet var att beskriva barnmorskors erfarenheter av preventivmedelsrådgivning på ungdomsmottagning. Metod: Individuella intervjuer genomfordes med nio barnmorskor på ungdomsmottagningar. Vid intervjutillfället användes en frågeguide och semistrukturerade frågor ställdes. Som analysmetod användes kvalitativ innehållsanalys. Resultat: Fyra kategorier och 15 subkategorier identifierades. Kategorierna var enligt följande: Erfarenheten och kunskapens betydelse, Det kliniska arbetssättet, Modererande faktorer och Utmaningar. Slutsats: Barnmorskor uppgav god kunskap och goda erfarenheter av ungdomar och preventivmedelsrådgivning på ungdomsmottagning men menade att det är ett dynamiskt arbete som bidrar till ständig utveckling. Vid möten med preventivmedelssökande ungdomar på ungdomsmottagning fanns önskan att mötet skulle ske på individnivå. Erfarenheter av modererande faktorer för barnmorskan, utmaningar för preventivmedelsrådgivningen och följsamheten fanns vilket innebar att preventivmedelsrådgivning för ungdomar på ungdomsmottagning är komplext. Klinisk tillämpbarhet: Studiens resultat skulle kunna innebära ökad förståelse för arbetet på ungdomsmottagning och skapa underlag för att möta utmaningarna som barnmorskorna möter i det dagliga arbetet. / Background: The midwife’s field of work today includes sexual,- reproductive,- and perinatal health and the core of the profession is to promote health. The midwife should have the knowledge, to provide information and teach about sexuality and relationships from a gender and lifecycle approach. The mission of the youth center is to work with sexuality and health and the prevention of unwanted pregnancies and STI’s. Aim: The aim was to describe midwives' experiences of contraceptive counseling at youth clinics. Method: Interviews were conducted with nine midwives in youth clinics. In time of the interview a questionnaire was used and semistructured questions were asked. Qualitative content analysis was used as analyze method. Results: Four categories and 15 subcategories were identified. The categories were as follows: Importance of experience and knowledge, the Clinical approach, Moderating factors and Challenges. Conclusion: Midwives feel they have good knowledge and experience of young people and contraceptive counseling at the youth clinic and has experience that it is a dynamic work that contributes to constant development. When they meet contraception seeking young people they wish to meet them at an individual level. The midwives had experiences in that there are moderating factors and challenges for the contraception counselling and compliance in contraceptive use, this means that contraceptive counselling for young people is complex. Clinical application: The result of the study could mean greater understanding for the work in youth clinics and create a basis for meeting the challenges that midwives face in their daily work.

Thesis (MScMedSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background Individuals who are latently infected with Mycobacterium tuberculosis (M.tb) are able to quell the infection by balancing the innate and adaptive immune responses. Glucocorticoids (GCs) can affect this balance and can increase the risk of reactivation of TB. The three month injectable contraceptive medroxyprogesterone acetate (MPA) is widely used by women in developing countries, where TB is rife. MPA, unlike the two monthly contraceptive norethisterone enanthate (NET), possesses selective glucocorticoid activity, and could therefore alter immune responses to TB. Aims The aim of my investigation was to elucidate the immune modulatory effects of the synthetic progestins, MPA and NET, compared to the endogenous hormones, cortisol and progesterone, in Mycobacterium bovis Bacillus Calmette–Guérin (BCG) or anti-CD3 stimulated peripheral blood mononuclear cells (PBMC). I aim to determine the effects of MPA, NET, cortisol and progesterone on the receptor expression of glucocorticoid and various progesterone receptors. I investigate the effect of the above mentioned hormones on the downstream signalling cascades in the presence or absence of either BCG or anti-CD3. The overall immune modulation will be determined with regard to the cytokine production in PBMCs. Methods The presence of receptors for these steroid hormones in PBMCs was verified and BCG, anti-CD3 and hormone induced changes in receptor expression determined through RT-PCR. The impact of cortisol, MPA, NET and progesterone on BCG or anti-CD3 mediated activation of downstream signalling molecules were determined by Western blot as well as Luminex analysis. Results and Conclusion My results show that BCG and anti-CD3 mediated activation of the T cell receptor associated signalling molecules, Lck, ZAP-70, LAT was inhibited by the steroid hormones. Similarly several kinases including JNK, ERK and p38 and transcription factors including STAT3, STAT5 and CREB were differentially affected by the hormones. The inhibition of phosphorylation seen in the different signalling molecules indicated an inhibition of activation of downstream signalling cascades. To investigate the impact of the hormone induced changes in the signalling cascades on the expression of inflammatory and anti-inflammatory cytokines Luminex analysis was performed on the supernatant of the BCG and anti-CD3 stimulated PBMC cultures. Cortisol and MPA, but not NET and progesterone, significantly inhibited the secretion of IL-1α, IL-1β, IL-6, IL-10, TNF-α, IL-12 and IL-13. These results suggest that the immune suppressive effects of MPA are likely mediated through a combination of direct genomic GR action as well as through direct or indirect inhibition of several signalling molecules. The inhibition of the IFN-γ, IL-12, IL-1and IL-6 secretion by MPA could potentially increase the risk of susceptibility to TB in women using this contraceptive. Therefore the absence of glucocorticoid activity seen with NET could make this contraceptive a better choice for women in TB endemic areas. / AFRIKAANSE OPSOMMING: Agtergrond Individue wat latent met Mikobakterium tuberkulose (M.tb) geïnfekteer is, is in staat om die infeksie te onderdruk deur die ingebore en aanpasbare immuunrespons te balanseer. Glukokortikoïede (GCs) kan hierdie balans beïnvloed en kan die risiko van heraktivering van tuberkulose (TB) verhoog. Die drie maande inspuitbare voorbehoedmiddel medroksiprogestroon-asetaat (MPA) word algemeen gebruik deur vroue in ontwikkelende lande, waar TB volop is. MPA, in teenstelling met die twee maandelikse voorbehoedmiddel noretisteroon enantaat (NET), beskik selektiewe glukokortikoïed aktiwiteit, en kan dus die immuunrespons teenoor TB verander. Doelwitte Die doel van my studie was om die immuunregulerende effekte van die sintetiese progestiene, MPA en NET, toe te lig , in vergelyking met die endogene hormone, kortisol en progesteroon, in Mycobacterium bovis Bacillus Calmette - Guerin (BCG) of anti- CD3 gestimuleerde perifere bloed mononukleêre selle (PBMSe). Ek het beoog om die gevolge van MPA, NET, kortisol en progesteroon op die reseptor uitdrukking van glukokortikoïede en verskeie progesteroon reseptore te bepaal. Ek het ondersoek ingestel op die effek van die bogenoemde hormone op die sein transduksie in die teenwoordigheid of afwesigheid van óf BCG of anti-CD3. Die algehele immuun -modulasie sal bepaal word met betrekking tot die produksie van sitokiene in PBMSe . Metodes Die teenwoordigheid van reseptore vir die steroïedhormone in PBMSe is geverifieer en BCG en anti-CD3 en die veranderinge deurdie hormone in verband met die reseptor uitdrukking bepaal deur RT -PCR. Die impak van kortisol, MPA, NET en progesteroon op BCG of anti- CD3 aktivering van sein transduksie molekules is bepaal deur ‘Western blot’ asook Luminex analise. Resultate en gevolgtrekking My resultate toon dat BCG en anti-CD3 die aktivering van die T-sel reseptor wat verband hou met sein molekules , LCK , ZAP -70 , en LAT word geïnhibeer deur die steroïedhormone . Van die kinases insluitend JNK , ERK en p38 en transkripsie faktore, insluitend STAT3 , STAT5 en CREB is beïnvloed deur die hormone. Die inhibisie van fosforilering gesien in die verskillende sein molekules dui daarop aan dat 'n inhibisie van aktivering van sein transduksie. Die impak van die hormoon veroorsaak veranderinge in die sein transduksie met betrekking tot die uitdrukking van inflammatoriese en anti -inflammatoriese sitokiene Luminex analise is uitgevoer op die supernatant van die BCG en anti-CD3 gestimuleerde PBMS kulture. Kortisol en MPA, maar nie NET en progesteroon , het aansienlik die produksie van IL-1α , IL-1β , IL-6 , IL-10 , TNF-α , IL-12 en IL-13 geïnhibeer. Hierdie resultate dui daarop dat die immuunstelsel se onderdrukkende effekte van MPA is waarskynlik bemiddel deur 'n kombinasie van direkte genomiese GR interaksie sowel as deur direkte of indirekte inhibisie van verskeie sein molekules . Die inhibisie van die IFN-γ, IL-12, IL-1 en IL-6 sekresie deur MPA kan potensieel die risiko verhoog van vatbaarheid vir TB in vroue wat hierdie voorbehoedmiddel gebruik. Daarom oor die afwesigheid van glukokortikoïede aktiwiteit wat gesien is met NET, kan maak laat hierdie voorbehoedmiddel 'n beter keuse vir vroue in TB endemiese gebiede.

<p>After the 2012 London Summit on Family Planning, there have been major strides in advancing the family planning agenda for low and middle-income countries worldwide. Much of the existing infrastructure and funding for family planning access is in the form of supplying free contraceptives to countries. While the average yearly value of donations since 2000 was over 170 million dollars for contraceptives procured for developing countries, an ongoing debate in the empirical literature is whether increases in contraceptive access and supply drive declines in fertility (UNFPA 2014). </p><p>This dissertation explores the fertility and behavioral effects of an increase in contraceptive supply donated to Zambia. Zambia, a high-fertility developing country, receives over 80 percent of its contraceptives from multilateral donors and aid agencies. Most contraceptives are donated and provided to women for free at government clinics (DELIVER 2015). I chose Zambia as a case study to measure the relationship between contraceptive supply and fertility because of two donor-driven events that led to an increase in both the quantity and frequency of contraceptives starting in 2008 (UNFPA 2014). Donations increased because donors and the Zambian government started a systematic method of forecasting contraceptive need on December 2007, and the Mexico City Policy was lifted in January 2009. </p><p>In Chapter 1, I investigate whether a large change in quantity and frequency of donated contraceptives affected fertility, using available data on contraceptive donations to Zambia, and birth records from the 2007 and 2013 Demographic and Health Surveys. I use a difference-in-difference framework to estimate the fertility effects of a supply chain improvement program that started in 2011, and was designed to ensure more regularity of contraceptive supply. The increase in total contraceptive supply after the Mexico City Policy was rescinded is associated with a 12 percent reduction in fertility relative to the before period, after controlling for demographic characteristics and time controls. There is evidence that a supply chain improvement program led to significant fertility declines for regions that received the program after the Mexico City Policy was rescinded. </p><p>In Chapter 2, I explore the effects of the large increase in donated contraceptives on modern contraceptive uptake. According to the 2007 and 2013 Demographic and Health Surveys, there was a dramatic increase in current use of injectables, implants, and IUDs. Simultaneously, declines occurred in usage of condoms, lactational amenorrhea method (LAM), and traditional methods. In this chapter, I estimate the effect of the increase in donations on uptake, composition of contraceptive usage, and usage of methods based on distance to contraceptive access points. The results show the post-2007 period is associated with an increase in usage of injectables and the pill among women living further away from access points. </p><p>In Chapter 3, I explore attitudes towards the contraceptive supply system, and identify areas for improvement, based on qualitative interviews with 14 experts and 61 Zambian users and non-users of contraceptives. The interviews uncover systemic barriers that prevent women from consistently accessing methods, and individual barriers that exacerbate the deficiencies in supply chain procedures. I find that 39 out of 61 women interviewed, both users and non-users, had personal experiences with stock out. The qualitative results suggest that the increase in contraceptives brought to the country after 2007 may have not contributed to as large of a decline in fertility because of bottlenecks in the supply chain, and problems in maintaining stock levels at clinics. I end the chapter with a series of four recommendations for improvements in the supply chain going forward, in light of recent commitments by the Zambian government during the 2012 London Summit on Family Planning.</p> / Dissertation