CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Tratou-se de estudo com abordagem quantitativa, transversal, do tipo levantamento, que teve como objetivo geral investigar sobre a prÃtica do aborto provocado e sua relaÃÃo com a gravidez nÃo planejada, comparativamente com o aborto espontÃneo e como objetivos especÃficos analisar aspectos demogrÃficos, socioeconÃmicos e reprodutivos comparativamente ao aborto provocado e espontÃneo; verificar o conhecimento e a prÃtica anticoncepcional prÃvia a gestaÃÃo interrompida por aborto provocado e por aborto espontÃneo e conhecer os meios utilizados na prÃtica do aborto provocado e os motivos determinantes. Foi realizado no Hospital Distrital Gonzaga Mota da Barra do Cearà e no Hospital Geral Dr. Cesar Cals (HGCC), de junho a dezembro de 2011. A populaÃÃo correspondeu Ãs mulheres em abortamento com idade maior ou igual a 18 anos atendidas nos respectivos hospitais no perÃodo da coleta de dados. A entrevista seguiu um formulÃrio estruturado, que foi prÃ-testado. Finalizou-se o estudo com 70 participantes, sendo 33 (47,1%) mulheres que tiveram aborto provocado e 37 (52,9%) aborto espontÃneo. Os dados receberam tratamento estatÃstico descritivo e as comparaÃÃes das mÃdias dessas variÃveis e o tipo de aborto foram realizados por meio do teste t de Student para dados independentes e com variÃncia desiguais (analisadas pelo teste de Levene). Compararam-se, somente para aborto provocado, as porcentagens das variÃveis dicotÃmicas por meio do teste z para proporÃÃes. As anÃlises de associaÃÃes entre tipo de abortamento e as variÃveis nominais foram realizadas por meio do &#61539;2 e de razÃo de verossimilhanÃa. Calcularam-se as razÃes de chances (RC) com seus respectivos IC95% entre tipo de abortamento e essas variÃveis. Consideraram-se como estatisticamente significantes as analises com p<0,05. Dentre as variÃveis demogrÃficas e socioeconÃmicas, somente a mÃdia do nÃmero de pessoas na famÃlia apresentou associaÃÃo com o tipo de aborto (p= 0,042). Com relaÃÃo Ãs variÃveis reprodutivas e condiÃÃo de uniÃo, houve associaÃÃo entre planejamento da gravidez e tipo de aborto (p<0,001) (RC=2,4; IC95%: 1,7-3,3). Isto evidencia que a gravidez nÃo planejada foi um fator de risco para o aborto provocado. A mÃdia do tempo de uniÃo das que tiveram aborto espontÃneo foi maior do que aquelas de aborto provocado (p= 0,041). ParticipaÃÃo masculina na decisÃo pelo aborto mostrou-se como fator de risco para o aborto provocado (p=0,002). Nenhuma variÃvel relacionada à informaÃÃo e acesso ao MAC em uso prÃvio ao aborto foi significativa para o tipo de aborto. Houve associaÃÃo entre uso de AOC e tipo de aborto, sendo o uso de AOC fator protetor ao aborto provocado (p=0,040). Pensamento mÃgico de acreditar que a gravidez nÃo ocorreria consigo foi significante com o tipo de aborto (p=0,003). ChÃs e misoprostol foram os meios mais referidos pelas mulheres para provocar o aborto, sendo os motivos para provocÃ-lo a baixa condiÃÃo financeira, seguida do relacionamento instÃvel e do despreparo para cuidar da crianÃa. Concluiu-se que promover aÃÃes efetivas de planejamento familiar, com prioridade para as populaÃÃes mais carentes e com estratÃgias que garantam a participaÃÃo masculina representam meios para reduzir o aborto provocado. / This is a research study with quantitative and transversal approach aiming to investigate the induction of abortion and its relationship with an unplanned pregnancy, in comparison with natural abortion. It also aimed to analyse the demographic, socioeconomic and reproductive aspects of both methods of abortion; verify the knowledge and use of contraceptive methods prior to the interrupted pregnancy through induced and natural abortion and know which methods are used for induced abortion and it motifs. The study took place at the District Hospital Gonzaga Mota in Barra do Cearà and General Hospital Dr. Cesar Cals (HGCC), from June until December of 2011. The population consisted of women in abortion and over 18 years of age who were being assisted at the hospitals during data collection. The interview followed a structured questionnaire that was previously tested. The study consisted in the end with 70 participants, being 33 (47,1%) women who induced abortion and 37 (52,9%) with natural abortion. The data were analysed with descriptive statistics and the comparison of the means of these variables and the type of abortion were done with the Student t test for independent data and with unequal variance (analysed with Leveneâs test). It was compared only for induced abortion, the percentage of dichotomous variables with the z test for proportions. The association analysis between the type of abortion and the nominal variables were conducted with &#61539;2 and likelihood ratio. It was calculated the chance ratios (CR) with its respective IC95% between the type of abortion and these variables. It was considered as statistically significant, analysis with p<0,05. Amongst the demographic and socioeconomic variables, only the average number of people in the family presented association with the type of abortion (p= 0,042). Regarding reproductive variables and marital status, there was an association between planning of a pregnancy and abortion (p<0,001) (RC=2,4; IC95%: 1,7-3,3). This shows that an unplanned pregnancy was a risk factor for induced abortion. The average time of union with their partner was higher in women with natural abortion than in those with induced abortion (p= 0,041). It was shown that the male participation in the decision of an abortion is a risk factor for induced abortion (p= 0,002). Variables regarding information and access to contraceptive methods prior to the abortion were not significant to the type of abortion. There was an association between the use of AOC and type of abortion, being the use of AOC a protective factor to induced abortion (p= 0,040). The belief that a pregnancy would not occur with themselves was significant with the type of abortion (p= 0,003). Herbal teas and misoprostol were the most frequent methods mentioned by the women to induce an abortion, being their low economical situation, followed by an unstable relationship and unpreparedness to take care of a child the main reasons to render towards these methods. It was concluded that promoting effective methods of family planning, prioritizing poorer populations, with strategies that assures male participation represent means to reduce induced abortions.

M.A. / In 1994 a landmark conference, the International Conference on Population and Development, took place during which the importance of family planning was clearly underlined. In spite of the importance with which this issue is viewed by health departments around the world seventy-five million unintended pregnancies occur around the world every year. Several factors may contribute to this multi-faceted problem. The difference between clients’ expected family planning services and the extent to which these clients’ expectations are met is one such factor. Improving family planning service delivery in line with clients’ expectations is essential to putting clients first. To do so, clients’ perspectives on family planning service delivery should be assessed. Whilst accompanying family planning students at the Johannesburg Metropolitan Health Department, the researcher encountered clients who expressed dissatisfaction with the lack of interpersonal skills and information provided by service providers. Despite the Department of Health’s policies that are in place for the provision of family planning services the researcher became aware of women who considered becoming family planning clients and would then discontinue utilising services because their expectations of the service delivery were not met.

Master of Public Health - MPH

archives@tulane.edu / Background: Despite a large body of literature citing the benefits of community-based distribution of family planning (FP) services and high-quality FP services, there is a lack of studies measuring the quality of community-based FP services. Objectives: 1. Evaluate how client perspectives on quality differ from those of health professionals; 2. Identify factors that influence client recall of contraceptive counseling; and 3. Develop a metric for measuring quality and test the association between client satisfaction and quality. Methods: This study employed a convenience sample of 1,179 women ages 15-49 years old who sought contraceptive services from community-based FP distribution events in Kinshasa, DRC. Data were collected using three different instruments: CEIs, COs and provider interviews. Methodology: Paper 1. The 28 variables measured by both the CEI and CO were compared using Gwet’s Agreement Coefficient. Paper 2. The association between recall and provider and client characteristics were tested using multivariate linear regression. Paper 3. Exploratory factor analysis was performed and resulting factor scores were used to test the association between quality and client satisfaction in multivariate linear regression models. Results: Paper 1. According to Gwet’s AC1, COs and CEIs were in agreement for 18 of the 28 items, with most discordant variables falling in the “effective use of the chosen method” domain. Paper 2. Average recall score was 67.6%. Time since the provider’s initial training and quality of the client-provider interaction were associated with higher client recall. Being a first-time user was associated with lower recall. Paper 3. All three domains of quality were significantly associated with client satisfaction after controlling for client characteristics and interactions. Conclusion: This is one of the first studies to measure the quality of individual contraceptive counseling sessions during community-based distribution events. Findings have resulted in several recommendations to improve client recall and satisfaction during these events. / 1 / Rebecca Rosenberg

M.Med. in Community Health, Faculty of Health Sciences, University of the Witwatersrand, 2011 / Introduction Three public health interventions well known to decrease the risks associated with pregnancy and child birth are access to maternity care, family planning and contraception, and safe abortion. Worldwide, the African region has the highest case fatality rate associated with unsafe abortion 750 per 100 000, largely as a result of restrictive abortion laws. South Africa (SA) legalised abortion in 1996 with the “Choice on Termination of Pregnancy” (CTOP) Act. It sought to improve the quality and access to termination of pregnancy (TOP) services in SA. Since its enactment there has been a 91% decrease in deaths due to unsafe abortions. There have been some experienced challenges associated with the implementation of the Act, limited number of functional TOP facilities, prolonged waiting times, and negative attitudes of TOP providers to clients. After more than a decade of liberalised law in SA, what are TOP providers’ perceptions, clients’ experiences and the overall quality of TOP services? Main Aim The evaluation of TOP services in the urban Johannesburg Metropolitan Municipality (JHB), Gauteng Province, and two rural municipalities Bela-Bela Municipality, Limpopo Province and Mangaung Municipality, Free State Province. Methodology A mixed methods approach was adopted; both quantitative and qualitative data were collected in three sections. Included were all primary health care facilities offering first trimester TOPs in the Johannesburg Metropolitan, Mangaung, and Bela-Bela Municipalities. Section I the analysis of district health information management system (DHIS) data for JHB. Section II, TOP providers and TOP clients completed self-administered questionnaires. Section III the TOP clients from JHB were questioned again after eighteen months. Various parametric and non-parametric tests were conducted on the data, based on the data distribution. The statistical software used for quantitative data analyses was Stata release 10.0 and qualitative data MAXQDA release 10.0. Results The DHIS showed a 61% increase in TOP requests from 2006 to 2009 (Chi-square for trend; P=0.08). The number of first trimester procedures performed only addressed 40% of total requests in 2006 and 33% of total requests in 2009. Section II demonstrated that all the TOP providers reported not coping with their duties, only two (15%) providers were comfortable with administering TOPs. One hundred and fifty-two TOP clients were recruited into the study. The mean age was 26.00 (±6.03) years. One hundred and sixteen (76%) women were not using contraception. Clients from JHB had prolonged waiting times 14 days (IQR; 6-28) compared to Bela-Bela clients’ 3 days (IQR; 1-6) (Post-hoc Wilcoxon- Ranksum; P<0.0001). Hence clients from JHB had TOPs at later median gestational ages of 9 weeks (IQR; 8-11) and Bela-Bela clients at 7.5 weeks (IQR;4-8) (Post-hoc Wilcoxon Ranksum; P<0.0001). Knowledge of the CTOP Act exceeded seventy percent across all three municipalities (Pearson Chi-square; P=0.83). Section III identified that 39% (n=9) of interviewed clients experienced a TOP-related complication. The odds of experiencing a complication was decreased if client received a follow-up appointment (OR 0.12; 95% CI 0.02-1.51; P=0.02), if client was aware of the CTOP Act (OR 0.11; 95% CI 0.01-2.08; P=0.06), and clients that had attended Lenasia South CHC had odds of complication 8 times higher than clients who had presented to Bophelong clinic (OR 8.68; 95% CI 3.47 -21.7; P<0.0001). The qualitative analysis identified themes of an association with intra-procedural pain and perceived inadequate counselling with those reporting emotional distress. Discussion The prevalence of contraceptive use during the month of conception was low, and the majority of clients were unaware of the correct gestational age for termination of pregnancy according to the CTOP Act. This suggests that the pre-TOP services required strengthening. The TOP services in the public sector may not to be addressing the number of TOP requests; this affects the availability of the service. TOP providers in different South African settings report similar challenges associated with delivering TOP services. The clients from JHB are waiting longer for the TOP and hence having the abortion at later gestational ages which are associated with increased complications rates. The study estimated a complication rate of approximately 26 per 100 abortion clients, higher than acceptable global rates which approximate 3 per 100. The improvement of pre and post-TOP counselling was highlighted. Conclusion This study introduces the importance of passive surveillance in improving the quality of service delivery. Though this is only achieved when data collected are analysed and used to inform policy and service. The studies conducted in South Africa since the CTOP Act enactment has demonstrated various challenges and areas for improvement. These findings have ensured that issues of public health importance continue to be studied and relevant findings disseminated to stakeholders for and consideration and action where appropriate.

Fertility awareness-based methods or natural family planning methods are an effective means of family planning that is seldom recommended by the medical community. After a review of literature it is concluded that such methods empower women and couples, that there is a need for a referral system and natural family planning clinics, and a need for a standardized fertility consultant license. Furthermore, such methods have been highly effective family planning tools in third world countries with limited access to contraceptives. Research on provider attitudes is scarce and further study is required, considering some women cannot or will not utilize mechanical or barrier methods of contraception.

The purpose of this research was to examine the implementation of Georgia's Medicaid family planning program, known as Planning for Healthy Babies or P4HB. This program is the first such program to provide both family planning services and inter-pregnancy care services through a Medicaid expansion to low-income, uninsured women. An evaluative case study design was employed using mixed methods. These methods incorporated process measures to study the implementation of P4HB and to assess whether P4HB was implemented as planned We incorporated theory from the policy implementation and health care access literatures to understand what served as facilitators or barriers to successful implementation. Findings suggest that despite precise goals and objectives, formal guidance about the program did not incorporate clear implementation planning. Many stakeholders, including advocates, providers, and representatives from implementing agencies felt left out of the implementation process and did not feel invested in the program. Considerable confusion existed among eligible clients and providers about the nature and scope of the P4HB program. This lack of awareness and understanding about P4HB likely contributed to the program's low enrollment and participation in the first year of its implementation. As many states prepare to expand their Medicaid programs under the Patient Protection and Affordable Care Act (ACA), this study provides important lessons for policy planning and implementation.

Thesis (M.A.(Population and Reproductive Health Research))--Mahidol University, 2005. / LICL has E-Thesis 0004 ; please contact computer services.

Thesis (M.S.)--University of Michigan, 1983.

Thesis--Cornell University. / Vita. Includes bibliographical references (p. 166-182).