Women living in rural areas experience barriers in accessing contraceptives, including those related to geographic distance, cost, and the lack of health care providers. Further, conscientious objection to provision of sexual and reproductive health services has a more significant impact in these settings given limited alternatives. The overarching dynamics likely have an even greater impact on adolescents, as young people are less able to navigate complex systems or secure the necessary resources to overcome financial and travel barriers. This multi-method qualitative study investigated the contraceptive experiences of adolescents living in rural Ontario through the use of an online survey, in-depth interviews with adolescents, and key informant interviews. We found that the available sexual health information is difficult to navigate and inconsistent in quality. The services offered in rural areas are limited. The need for more readily accessible information and contraceptive services in rural Ontario is considerable.

MAAS / Department of African Studies / This study explored into the effects of traditional medicine on reproductive health of rural women. Negative reports associated with traditional medicine due to bogus traditional practitioners expose most women to the harmful consequences of concoctions supplied and administered on them. However, factors such as people’s great confidence in traditional medicine and high costs associated with conventional Western medical treatments lead most rural women to traditional medicine usage. The study examined women’s perspectives on traditional medicine, factors which led rural women to use traditional medicine, meanings that people make about women and reproductive health, reproductive health implications of using traditional medicine as well as remedies for ensuring that traditional medicine is safe for women’s reproductive health. The study was grounded on the critical and socio-cultural theory. An explorative qualitative research was used. Data was collected through open-ended questions, observation as well as focus group interviews and then analysed using the thematic analysis method. The study participants consisted of rural women, traditional healers, elderly people and Western-trained doctors who were all sampled using non-probability sampling methods. The findings of the study showed that African traditional medicine plays a pivotal role in reproductive health care by offering readily available, cheap, culturally-oriented and accessible health care for most rural women. However, it was noted that the use of African traditional medicine by unqualified practitioners and the incorrect usage of the medicine by patients resulted in negative results that could lead to death or barrenness. Thus, the study recommends an introduction of a regulatory framework on the production, storage, use and trade of African traditional medicine. / NRF

Introduction: Federally qualified health centers (FQHCs) and health departments (HDs) are essential in providing contraceptive care and ensuring reproductive autonomy for adolescents. Through offering adolescent-specific services and by training providers in adolescent-specific care and patient-centered contraceptive counseling, clinics can ensure access to high quality contraceptive care for adolescents. Despite the significant decrease in adolescent pregnancy rates, rates remain high in the South and in rural counties, suggesting that clinics in these areas may not have the capacity to provide adolescent-specific services and patient-centered counseling. This study compares the capacity to provide adolescent-specific and patient-centered contraceptive services in rural and urban FQHCs and HDs in two southeastern states -- South Carolina (SC) and Alabama (AL). Methods: Data were collected from a statewide survey of FQHC and HD clinics in SC and AL in 2020. A total of 239 clinics were included (FQHC N=112 and HD N=127) and were identified as rural (N=101) or urban (N=138) using Rural-Urban Continuum Codes. Capacity to provide patient-centered adolescent care is defined as 1) a clinic offering adolescent-specific services; 2) providers at the clinic receiving training in patient-centered counseling; and 3) providers receiving training in adolescent-specific care. To measure capacity, these three survey items were dichotomized into Yes/No responses and then combined into a new variable to measure clinics who responded Yes to each survey item. The type of adolescent-specific services was also measured as being onsite, offsite, outreach, or none. Capacity to provide patient-centered adolescent care was compared across clinics located in rural and urban settings and by clinic type. Statistical differences were determined using the Chi-Square test of independence (α= 0.05). Results: Overall, 44.8% of participating clinics in SC and AL had the capacity to provide patient-centered adolescent contraceptive services. Approximately 51.8% of rural and 66.1% of urban HDs reported the capacity to provide adolescent-specific services. In contrast, 26.7% of rural and 35.4% of urban FQHCs reported the capacity to provide adolescent-specific services. Approximately 55.4% of rural and 71.4% of urban HDs provided any adolescent-specific services, but fewer rural HDs (30.2%) provided onsite services than urban HDs (59.3%) (p=0.003). Fewer than half of rural (42.2%) and urban (48.8%) FQHCs provided adolescent-specific services, with approximately 23.8% of rural and 27.9% of urban sites providing onsite services. Conclusions: The capacity of clinics in SC and AL to provide contraceptive counseling to adolescents, which is anchored in reproductive autonomy, is contingent upon the provision of adolescent-specific services and provider training. Most clinics, especially rural clinics, did not have the capacity to provide patient-centered contraceptive counseling to adolescents. This gap in services may contribute to the higher adolescent pregnancy rates in rural areas of SC and AL. Clinics in SC and AL, especially FQHCs, should develop policies that support adolescent-specific contraceptive services and provider training.

Somalia has recently come out of a two decade long civil war and is currently in a post-war and rebuilding phase. The national health system, largely crippled during years of conflict, is faced with a significant maternal mortality ratio and the debilitating effects of a high fertility rate. To combat these issues, the new Somali government is working toward creating a strong national health system that addresses some of these key indicators. With a lack of human resources in healthcare and the need for better reproductive health services, the need to invest in educating a new generation of health service professionals is evident. To address this gap in education, many educational institutions with health science faculties have opened in the last decade but the quality and accuracy of their curricula has yet to be examined. My thesis addresses this gap in knowledge. Through a multi-methods study that included reviewing curricula and curricular materials, conducting key informant interviews, and facilitating focus group discussions, I was able to learn about the quality and comprehensiveness of reproductive health topics in health service professionals‟ education and training. Religion, culture, logistical issues, and lack of oversight shape the way reproductive health is taught to health students. This study provides an important foundation to help inform key stakeholders working to improve the Somali health system.

Includes bibliographical references / BACKGROUND: A viral load monitoring algorithm in the 2013 Western Cape Department of Health PMTCT guidelines include VL measurement in women who are antiretroviral (ART)-experienced at presentation for antenatal care, the timing of subsequent VL measurements and criteria for regimen change. The study evaluates the implementation of the algorithm in women who are virologically nonsuppressed and determines the outcomes of virological resuppression and infant PCR status. METHODS: This retrospective cohort study focused on all ART-experienced women who presented for antenatal care at one of two primary level Maternity Obstetric Units (MOUs) in Khayelitsha, Cape Town between July 2013 and June 2014. The study used routine data from facility registers, clinical records and electronic monitoring systems at the MOU, and referral ART sites and hospitals. Data collected included age, ART clinic, start date and regimen, and maternal VL and infant PCR results. RESULTS: Forty percent of the 1412 HIV-positive pregnant women, were ART-experienced, of whom 14.1 % were VNS. Predictors of being VNS included a duration on ART of more than 4 years (p= 0.04), attending an ART clinic other than that in the facility (p= 0.02), being on a second-line ART regimen (p=0.07) and being younger than 25 years (p= 0.05). The algorithm was correctly followed in up to 87.5% of women identified as VNS. The rate of virological resuppression by three months postpartum was 70.0% to 82.3%. Excluding three neonates who died, all of the 82.2% of infants tested were PCR negative. CONCLUSIONS: Nearly 15% of ART-experienced women were virologically nonsuppressed on presentation for antenatal care. Levels of adherence to the guideline, and virological resuppression rates of up to 82.3% are encouraging. The implementation of the VLM algorithm could be improved by the integration of obstetric and ART care, the adoption of a single electronic monitoring system and the use of standardised integrated clinical stationery.

Includes bibliographical references / Integration is an important emerging health systems issue, which has relevance to different health programmes. Improving prevention of mother-to-child transmission of HIV (PMTCT) programs in South Africa would reduce preventable maternal and infant morbidity and mortality, assist with achieving Millennium Development Goals 4 and 5, and help in the response to the WHO call for the elimination of MTCT, the new international PMTCT goal. Integrating PMTCT care into routine maternal and child health programmes has been recommended as a way to optimize PMTCT care. The Part B literature review in this dissertation examines the reasons why PMTCT programmes need to engage with integration as an issue, challenges to implementing integrated programmes, followed by a discussion of the benefits and lessons to consider in planning integrated PMTCT programmes. Theoretical concepts and frameworks such as Atun's framework, complexity, Theory of Change and innovation in health systems are discussed, as they have key relevance to the research findings. Lessons about implementing health system changes can be learned from programmes which have done so successfully. Using Case Study methodology, the process of developing the fully integrated longitudinal clinic at McCord Hospital is described in Part C, and reflections on the experience of providing integrated care are captured through qualitative interviews with the staff. Recommendations regarding innovation and change within complex systems are made, emphasizing the need to understand contexts which are receptive to change and the importance of leadership in managing change.

Background: Intimate Partner Violence (IPV) is recognized globally as a major public health concern linked to numerous adverse physical, mental, sexual and reproductive health outcomes. IPV is associated with both pregnancy and HIV-infection independently, but there are few data on IPV in populations of HIV-infected pregnant women. We examined the prevalence and predicators of IPV among pregnant women initiating lifelong antiretroviral therapy (ART) in a large primary care clinic in Cape Town, South Africa. Methods: Consecutive pregnant women seeking antenatal care in Gugulethu, Cape Town were recruited into the MCH-ART study examining service models for postpartum ART care. IPV, depression, alcohol and drug use, and emotional distress were assessed using the 13-item WHO Violence Against Women questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), alcohol and drug use disorders identification test (AUDIT/DUDIT) and the Kessler-10 (K-10) scale, respectively. Questionnaires were administered privately by trained interviewers. Women identified with specific IPV or mental health concerns were referred to appropriate services. Logistic regression was used to examine factors independently associated with experiences of IPV after adjusting for age and socioeconomic status. Results: From April 2013-May 2014, 623 women were enrolled (median age, 28 years):97% reported being in a relationship, 38% were married and/or cohabiting and 70% reported not having discussed or agreed on pregnancy intentions prior to conception . Overall, 21%(n=132) reported experiencing ≥ 1 act of IPV in the past 12 months, including emotional violence(15%), physical violence(15%) and sexual violence(2%). Of those reporting any IPV, 48% reported experiencing multiple types. Emotional and physical violence were most prevalent among women 18-24 years old, while sexual violence was most commonly reported among women 25-29 years old. Women who reported not discussing or disagreeing on pregnancy intentions with their partners prior to conception were significantly more likely to experience violence(p=0.030), and women who experienced IPV reported higher levels of substance abuse, depression and emotional distress(p<0.001 for all associations). Discussion: These data demonstrate high levels of IPV in this population. While the potential impact of HIV-infection, pregnancy and pregnancy intention on the risk of IPV and related factors require further research, IPV-related screening and support services should be considered as part of the package of care for ART in pregnancy.

Includes bibliographical references / Proper implementation of and adherence to antiretroviral therapy (ART) is significantly associated with better health and longer life in HIV-positive individuals. Consistent, adequate adherence has been shown to lead to a suppressed viral load. A low viral load delays the virus's progression and leads to better health outcomes for the individual. Adequate adherence is especially important among HIV-positive pregnant women. How well a woman adheres to her ART can not only improve her health during pregnancy but can protect the infant from HIV by preventing in utero transmission of the virus. Continuing ART protects against transmission via breastmilk later in the infant's life. While the benefits of good adherence are undeniable, the definition of adequate adherence varies widely in the literature. Taking 80 to 100% of pills as prescribed is commonly used as the threshold for adequate adherence levels. Various methods exist for measuring ART adherence, and while some are more reliable than others, there is no gold standard. This ambiguity in ART research extends to pregnant women, with even less known about HIV infected women established already on ART who then become pregnant. Changes in treatment protocols in the Western Cape and improvement of ART delivery throughout South Africa have resulted in this group of long-term users growing in size. Without more research into the barriers of ART adherence in these women, efforts to scale up treatment programs and to end mother to child transmission of HIV will ultimately fail. This dissertation is an exploration of these ideas. It begins to fill the gap in current knowledge related to ART compliance in pregnant women, and gives new insights into how specific barriers to adherence can adversely affect this specific group of established ART users.

The aim of this study has been to analyse the ways Mexican states articulates the actions of women undergoing an abortion and the effects it has on criminal sanctions specified for women. This study analyses the criminal code of Mexico City which decriminalised abortion in 2007, the criminal code of Jalisco reformed in 2009 and the criminal code of Yucatán reformed in 2009. The discrimination of women had been the major concern of International Human Rights Law as well as feminist jurisprudence. This research has attempted to problematise and highlight different aspects of discrimination taking place in Mexican law. Feminist liberal theory and radical feminism had been placed to analyse the criminal codes governing Mexican abortion law. Thus, in this thesis, the problems of women to access legal abortion had been discussed as a problem of discrimination based on sex. Therefore, this study does not touch upon tensions between the foetus and the mother but the conflict that emerges in the ways the law thinks of women.

The purpose of this thesis is to investigate how a public health crisis affects the pregnancy decisions and experiences of Canadians, how pregnancy history impacts these experiences, and whether the delivery of pregnancy care has been impacted or changed by the COVID-19 pandemic. This thesis surveyed women from across the country about their experiences during pregnancy with prenatal care and social support, as well as their birth experiences and perceptions of new motherhood during the pandemic. Interviews were conducted with perinatal care providers from Ontario about their personal experiences providing perinatal healthcare services, as well as their perceptions of their patients’ experiences. This thesis aims to identify prenatal, birth and postpartum experiences described by Canadians, and quality of perinatal health services during the COVID-19 pandemic.