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.

Background: Despite a wide range of contraceptive options available in the United Kingdom, the unplanned pregnancy rate remains high. Contraceptive services are currently delivered by general practitioners, sexual health clinics and pharmacies, but there may be scope to expand the places that these are offered, and increase the options available within each service. Doing so could increase the uptake of contraceptive methods, particularly the most effective methods, and therefore reduce the unplanned pregnancy rate. Aim and objectives: Research in this thesis aimed to investigate novel delivery models of contraception. The research had two main areas of focus. Firstly the capacity of the pharmacy to deliver regular contraception was examined, in the context of existing literature, and then through a pilot study. After that the expansion of contraception care to maternity services was investigated, first in the literature and then using an observational study. Methods: In undertaking this thesis I used a variety of methods. Two patient surveys were employed to investigate patients’ perspectives on proposed novel methods of contraceptive delivery. A pilot study investigated the feasibility and acceptability of delivery of the contraceptive injection at the pharmacy. Quantitative results about the numbers of injections given were collected, as were patient questionnaires. Qualitative one-to-one interviews were conducted with participating pharmacists, these were recorded, transcribed and analysed. An observational study was also undertaken to assess routine delivery of insertion of intra-uterine contraception at the time of caesarean section. Patients were seen at six weeks following insertion, and contacted by telephone at three, six and 12 months about satisfaction and continuation of the method. Results: 220 women completed a questionnaire about attending the community pharmacy to receive a contraception injection. 33% of current non-users indicated that they would consider using this method if it was available at the pharmacy. 50 established users of the contraceptive injection participated in a pilot project receiving up to three injections from the community pharmacy. Only 48 injections of a possible 150 were delivered at the community pharmacy. Only 7 participants received all three injections at the pharmacy, and participants reported mixed experiences accessing the pharmacy. The practical obstacles around pharmacy engagement and the challenges of retaining participants were significant, and more research is necessary before proceeding with a randomised controlled trial. 250 women on a postnatal ward completed questionnaires about their pregnancy intentions. 96.7% were not planning a baby in the next year, but only 23.6% were planning on using the most effective methods of contraception. One in three respondents described themselves as likely to use either an implant or intra-uterine contraception if it could be inserted before they left the hospital. In an observational study, 120/877 women opted to have intra-uterine contraception inserted at the time of caesarean section. Continuation rates at 12 months were 84.8% of those contacted, and 92.6% were either ‘very’ or ‘fairly’ happy with their contraception. Conclusion: Although patients are receptive to contraception being delivered using novel service models, alternatives to current practice need careful investigation. Contraceptive injections at the community pharmacy are not necessarily more convenient for patients, and therefore may not increase uptake of this method. However, offering intrauterine contraception to patients at the time of caesarean section is highly acceptable to patients, and results in a substantial majority continuing this highly effective method. Robust and careful research using a range of methods can help to identify which innovative approaches to contraceptive delivery offer the most promise.

This study investigated the perceptions of college student health center administrators concerning the availability of contraceptive services to college students. The major purposes of the study were (1) to determine the extent to which specific contraceptive services were available to college students from various sources, (2) to determine the extent and effectiveness of any opposition or support from various pressure groups concerning the provision of contraceptive services by student health centers, and (3) to describe the trend, as .perceived by student health center directors, of student access to contraceptive services from 1970 to 1975 and to project the trend to 1980. The findings indicated that pressure activity supporting the provision of contraceptive services by student health centers arose mostly from institutionally related student groups and was considered to be "effective" (i.e., influenced administrative decision making). Pressure which arose from other groups was found to be slight and of little effectiveness.

INTRODUCTION: Half of all pregnancies in South Carolina are unintended (mistimed or unwanted) and are associated with a higher risk for adverse maternal and infant health outcomes. South Carolina has a wide network of publicly supported clinics providing reproductive health services, including the Department of Health and Environmental Control, Federally Qualified Health Centers, and Rural Health Clinics. Having a better understanding of the geographic distribution of women in need of publicly funded contraceptive services is crucial for health planning and improving health delivery systems. METHODS: The total number of reproductive-aged women (15-44 years) in South Carolina was drawn from the 2017 American Community Survey (ACS) 5-Year Estimate files housed by the U.S. Census Bureau. A four-step process was used to estimate the number of reproductive-aged women in need of publicly funded contraceptive services at the county-level. First, the number of women between 15-19 years of age in each county was established. Next, the number of women with family incomes <100% of the federal poverty level in each county was identified. Data from the South Carolina Statewide Survey of Women, conducted by NORC at the University of Chicago, were used to estimate the number of reproductive-aged women (18-44) at-risk for experiencing an unintended pregnancy. The proportion of the women who were not sterile, not currently pregnant or not trying to get pregnant in the next 3 months was considered at-risk (76.24% of the total sample). The proportion of women at-risk was used to adjust the estimates of the total number of low-income women between 20-44 years of age in need of publicly funded contraceptive services in each county. The adjusted number of low-income women and the number of women less than 20 years of age were combined to estimate number of women in need of publicly funded contraceptive services. FINDINGS: There are an estimated 950,978 women of reproductive age living in South Carolina; of these women, about 40% (N=374,000) are considered in need of publicly funded contraceptive services. County-level need estimates ranged from 33.5% to 57.8% (M = 42.2%, SD = 4.8%) of the total reproductive-aged female population. While the number of women in need followed a typical population density pattern, rural communities had higher proportions of women in need of publicly funded contraceptive services, relative to the total population of reproductive-aged women. Rural counties comprised 91% of counties with the greatest need for publicly funded contraceptive services. CONCLUSIONS: Proportionally, the need for publicly funded contraceptive services is greater in rural and low-resource counties. While ensuring services are available among large population centers is certainly warranted, these findings also suggest that access to contraceptive services in rural counties is also needed and should be considered in health planning and service allocation policies and practices.

The study was conducted to describe how socio-economic characteristics (SEC) of women affect their utilization of maternal healthcare services in Abuja Municipal Areas Council (AMAC) in Abuja Nigeria. A non-experimental, facility-based cross-sectional survey was done. Data was collected using structured interviewer administered questionnaire in 5 district hospitals in AMAC. Sample size of 384 was calculated a priori based on the assumption that 50% of the target population utilized maternal healthcare services during their last pregnancy. Equal allocation of samples per facility was done. The ANC register was used as the sampling frame and proportionate allocation of samples per clinic days was undertaken in each facility. Data analysis included descriptive statistics, cross tabulations and measures of inequality. Logistic regression analysis was used to test the hypothesized relationship between socioeconomic characteristics (predictors) and maternal healthcare service utilization. Other than birth order that showed consistent effect, the results of this study indicated that the predictive effect (predisposing and enabling factors) of the SEC of women included in this study (age, education, birth order, location of residence, income group and coverage by health insurance) on maternal healthcare service utilization were not consistent when considered independently (bivariate analysis) as opposed to when considered together through logistic regression. In addition, the study revealed that there was inequality in the utilization of maternal healthcare services (ante-natal care - ANC, delivery care and post natal care - PNC, and contraceptive services) among women with different SEC, and the payment system for maternal healthcare services was regressive. Addressing these predictors in the natural co-existing state (as indicated by the logistic regression) is essential for equitable access and utilization of healthcare during pregnancy, delivery and the postnatal period, and for contraceptive services in AMAC, Abuja Nigeria. Targeted policy measures and programme actions guided by these findings are recommended to optimise returns on investment towards achieving national and global goals on maternal health in Nigeria / Health Studies / D. Litt. et Phil. (Health Studies)

The study was conducted to describe how socio-economic characteristics (SEC) of women affect their utilization of maternal healthcare services in Abuja Municipal Areas Council (AMAC) in Abuja Nigeria. A non-experimental, facility-based cross-sectional survey was done. Data was collected using structured interviewer administered questionnaire in 5 district hospitals in AMAC. Sample size of 384 was calculated a priori based on the assumption that 50% of the target population utilized maternal healthcare services during their last pregnancy. Equal allocation of samples per facility was done. The ANC register was used as the sampling frame and proportionate allocation of samples per clinic days was undertaken in each facility. Data analysis included descriptive statistics, cross tabulations and measures of inequality. Logistic regression analysis was used to test the hypothesized relationship between socioeconomic characteristics (predictors) and maternal healthcare service utilization. Other than birth order that showed consistent effect, the results of this study indicated that the predictive effect (predisposing and enabling factors) of the SEC of women included in this study (age, education, birth order, location of residence, income group and coverage by health insurance) on maternal healthcare service utilization were not consistent when considered independently (bivariate analysis) as opposed to when considered together through logistic regression. In addition, the study revealed that there was inequality in the utilization of maternal healthcare services (ante-natal care - ANC, delivery care and post natal care - PNC, and contraceptive services) among women with different SEC, and the payment system for maternal healthcare services was regressive. Addressing these predictors in the natural co-existing state (as indicated by the logistic regression) is essential for equitable access and utilization of healthcare during pregnancy, delivery and the postnatal period, and for contraceptive services in AMAC, Abuja Nigeria. Targeted policy measures and programme actions guided by these findings are recommended to optimise returns on investment towards achieving national and global goals on maternal health in Nigeria / Health Studies / D. Litt. et Phil. (Health Studies)

Deterrents to family planning practices were investigated among Swazi women between 1999- 2001. A total of 171 adolescents, women and men participated in focus group interviews. Information obtained in this way served as a framework for designing structured interview schedules. The views of 205 women were investigated, concerning factors deterring them from using family planning practices by means of conducting face to face studied interviews. Qualitative data were analysed using the NU*DIST and for the quantitative data the SPPS computer programs were used respectively. The results revealed that socio-cultural deterrents to family planning included high cultural value of children determining women's social status, the lack of knowledge about contraceptives, women's dependence on their husbands' decisions concerning reproductive issues and inefficient family planning services. Recommendations included that specific adolescent reproductive health services should be instituted and that the policy on reproductive health for Swaziland be revised. Reproductive health issues should be addressed in the school curriculum. All Swazi men and women, both adolescents and adults, should be educated about contraceptives. / Health Studies / D. Litt. et Phil. (Advanced Nursing Sciences)

Deterrents to family planning practices were investigated among Swazi women between 1999- 2001. A total of 171 adolescents, women and men participated in focus group interviews. Information obtained in this way served as a framework for designing structured interview schedules. The views of 205 women were investigated, concerning factors deterring them from using family planning practices by means of conducting face to face studied interviews. Qualitative data were analysed using the NU*DIST and for the quantitative data the SPPS computer programs were used respectively. The results revealed that socio-cultural deterrents to family planning included high cultural value of children determining women's social status, the lack of knowledge about contraceptives, women's dependence on their husbands' decisions concerning reproductive issues and inefficient family planning services. Recommendations included that specific adolescent reproductive health services should be instituted and that the policy on reproductive health for Swaziland be revised. Reproductive health issues should be addressed in the school curriculum. All Swazi men and women, both adolescents and adults, should be educated about contraceptives. / Health Studies / D. Litt. et Phil. (Advanced Nursing Sciences)