acase@tulane.edu / Background As a region, Francophone sub-Saharan Africa (SSA) continues to have among the highest fertility rates and lowest contraceptive prevalence rates in the world. As of the latest Demographic and Health Survey (DHS) data available for each country, total fertility rates range from 4.1 (Gabon 2012) to 7.6 births per woman (Niger 2012). Modern contraceptive prevalence rates for married women range from a low of 3.3% (Guinea 2012) to a high of 20.1% (Senegal 2014). Methods Three analyses were completed utilizing nationally representative DHS data available for each Francophone SSA country. For each paper, bivariate and multivariate analyses were performed with weighted data to take into account the two-stage cluster sampling design of the DHS survey. In paper one, we determine whether being Muslim and/or being in a polygynous union impacts the use of modern contraceptives. In paper two, we provide detailed information on the characteristics that define users of specific contraceptive methods in this region. In the final paper, we provide a clearer picture of the reproductive health dynamic in young never married women in Francophone SSA. Results In paper #1, we found that religion and marital type generally were not predictive of modern contraceptive use. The typical predictors – education, age, residence (urban/rural) – were consistently significant across the included countries. In paper #2, profiles of users of the most common contraceptive methods in each country were created. For example, condom users had the most consistent profile across the 12 countries, with marital status, parity and education being clearly associated with condom use. For paper #3, education level was found to be the key predictor of both sexual activity and becoming pregnant for young, never married women in this region. In general, those with primary or secondary and higher education were more likely to be sexually active than those with no education. Conclusion These findings provide valuable information to government, private and nongovernmental organizations working toward increasing the numbers of contraceptive users in Francophone SSA. / 1 / Margaret Farrell

Master of Public Health - MPH / Background- Sexual and Reproductive Health (SRH) problems continue to affect adolescents’ health and well-being even into their adulthood. Globally and especially within sub-Saharan Africa with a heavy burden of adolescent SRH problems, increased attention is being paid to these issues. This study looks at adolescents’ awareness, utilisation of and experiences of the available SRH services in Omaruru District, Namibia. Methodology- This analytical cross-sectional study used a two-stage cluster sampling method. Data from students aged 15-19 years in secondary schools were collected and analysed using a structured self-administered questionnaire and STATA statistical software respectively. Ethical approval was obtained from the Biomedical Research and Ethics Committee (University of the Western Cape) and the Namibian Health Ministry. Written parental/caregiver informed consent and written participant assent, as per the Namibian law were obtained. Results- While 87% of respondents had heard of SRH, 46% had ever used SRH services. Of these 44% were contraceptive services. Fifty-one percent had ever had sex (of which 17% had given birth to or fathered their first child), 56% of their first sexual experiences were between ages 15-17 years. Twelve percent had used illegal drugs three months prior to the survey. In multivariate analyses female sex, urban residence and reported sexual debut had significant independent relationships with contraception use. Use of SRH services was independently significantly associated with having had sexual debut. Among SRH services users: 71% would recommend these services to their friends, 51% and 56% found health providers welcoming, with good attitudes, and guaranteeing their privacy and confidentiality. Conclusion Greater effort is needed to curb teenage pregnancy in school-going adolescents by promoting the use of all SRH services especially contraception among sexually active adolescents. It is encouraging that respondents who had used SRH service reported that their privacy and, confidentiality were respected and that healthcare providers’ attitudes generally satisfactory. Lower SRH knowledge, service use and use of contraception and condoms needs further investigation in rural youth and then programmatic and service changes tailored to their needs. Gender norms that underpin adolescent females disadvantage in a number of SRH areas needs to be addressed

The study sought to describe the factors contributing to termination of pregnancies among teenagers in Vhembe District of Limpopo Province, by studying the responses given by teenage girls aged 19 years and younger. The study also sought to determine the socio economic characteristics of teenagers who terminate pregnancies, the role of parental care in avoiding unwanted teenage pregnancies, the teenagers’ general knowledge of reproductive health issues as well as their sources of information regarding reproductive health issues. The major inferences drawn from this study included that teenagers’ knowledge of reproductive health issues was inadequate and that they have nothing tangible because of their low educational and economic status that put them at risk of being involved in sexual activities at an early age leading to unwanted pregnancies that end up in termination. Based on the findings of the study, recommendations were made for imparting knowledge regarding sexual issues to teenage girls in Vhembe District of Limpopo Province.

DNUR / Sexual and reproductive health services include family-planning or contraception, pre-natal care, safe births and post-natal care, safe and accessible post-abortion care and where legal, access to safe abortion services, prevention and treatment of sexually transmitted infections and cervical cancers, sexual health information, and counselling. Adolescents face many sexual and reproductive health risks, ranging from teenage pregnancy, early unprotected sex, and sexually transmitted infections. Every year one in twenty young people worldwide contracts sexually transmitted infections, and currently, fifty percent of HIV infections occur in young people aged 15-24 years. Teenage pregnancy is at alarming rate among school girls. The overall aim of this study was to develop a comprehensive sexual and reproductive health programme for secondary school learners in Capricorn and Mopani Districts of Limpopo Province, South Africa. Three objectives which guided programme development were: 1. to assess the knowledge of secondary school learners about SRH issues, 2. to assess teachers’ views about the impact of the existing SRH programmes for adolescents and 3. to explore the perceptions of parents towards the provision of SRH services in schools. Sequential mixed methods approach was used where the initial quantitative phase was followed by qualitative phase. Three steps were used as the basis for developing the programme. Step 1 used quantitative descriptive survey to assess the knowledge of learners about sexual and reproductive health issues. Step 2 also used quantitative descriptive survey to assess teachers’ views about the impact of the existing sexual and reproductive health programmes provided in schools. An exploratory qualitative method was used in step 3 to explore the perceptions of parents towards the provision of sexual and reproductive health services in schools. The study population comprised of learners, teachers and parents. Probability and non-probability sampling methods were used. Self-administered questionnaires were used to collect quantitative data from learners and teachers, while in-depth face-to-face interviews were used to collect qualitative data from parents. Quantitative data was analysed using Statistical Package for the Social Sciences version 23. Qualitative data was analysed using Techs’ technique. Reliability and validity as well as trustworthiness were ensured. Ethical principles were adhered to throughout the study. Results indicated that (63%; n=69) learners were sexually active lacked knowledge about contraception (80%; n=40), STIs (38%; n=32) and (33%; n=37) had been pregnant and the mean age was 17. Eighty six (86%; n= 97) reported inaccessibility to sexual and reproductive health services. About (55%, n= 19) teachers were found to be inadequately trained and lacked training manuals. Most teachers reflected ineffectiveness of the existing programmes as evidenced by high pregnancy rates. Parents reflected difficulty in communicating sexual and reproductive health issues with teenagers and lack of knowledge, thus indicating the importance of the programme in schools. Parents also indicated the relevancy of teachers in facilitating the programme and collaboration between the Department of Education and the Department of Health. Dickoff’s six elements of the survey list was used to develop the programme. Programme validation was done by involving participants to evaluate it by completing questionnaires. The programme will empower learners to deal with sexual and reproductive health issues, resulting in decreased teenage pregnancy and other sexual risks. Collaboration and support were the recommendations directed to both the Department of Education and the Department of Health. Further research was also recommended. / NRF

Collecting and aggregating timely and rigorous data for sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) services and outcomes evaluation in humanitarian settings is essential for accountability and transparency. However, reliable SRMCNAH data are scarce in such settings, and the quality of available data often varies across different humanitarian settings. Establishing a core set of SRMNCAH indicators that are feasible to collect in all humanitarian settings is the first step in developing and implementing a common core framework for monitoring SRMNCAH programs in such settings. Led by the World Health Organization, in 2018 a group of global experts in the SRMNCAH field proposed a core list of indicators for inclusion in routine data collection systems. In 2019-2022, a team at the University of Ottawa in partnership with local investigators led multi-method feasibility assessments in Afghanistan, Bangladesh, the Democratic Republic of Congo, and Jordan to understand the feasibility, relevance, and acceptability of the proposed core indictors. In this thesis I report on the results from the multi-methods assessment in Afghanistan. Based on a desk review, key informant interviews, facility assessments, facility observation sessions, and focus group discussions in three provinces, we explored national stakeholders’ perspectives on SRMNCAH data collection, in general, and the proposed indicator list, in particular. The findings of this assessment and the results from the other three countries will help stakeholders reach a consensus on the final list of SRMNCAH indicators that are feasible for collection in all humanitarian settings.

Background The World Health Organization's "Coordinated Global Research Roadmap: 2019 Novel Coronavirus"outlined the need for research that focuses on the impact of COVID-19 on pregnant women and children. More than one year after the first reported case significant knowledge gaps remain, highlighting the need for a coordinated approach. To address this need, the Maternal, Newborn and Child Health Working Group (MNCH WG) of the COVID- 19 Clinical Research Coalition conducted an international survey to identify global research priorities for COVID-19 in maternal, reproductive and child health. Method This project was undertaken using a modified Delphi method. An electronic questionnaire was disseminated to clinicians and researchers in three different languages (English, French and Spanish) via MNCH WG affiliated networks. Respondents were asked to select the five most urgent research priorities among a list of 17 identified by the MNCH WG. Analysis of questionnaire data was undertaken to identify key similarities and differences among respondents according to questionnaire language, location and specialty. Following elimination of the seven lowest ranking priorities, the questionnaire was recirculated to the original pool of respondents. Thematic analysis of final questionnaire data was undertaken by the MNCH WG from which four priority research themes emerged. Results Questionnaire 1 was completed by 225 respondents from 29 countries. Questionnaire 2 was returned by 49 respondents. The four priority research themes which emerged from the analysis were 1) access to healthcare during the COVID-19 pandemic, 2) the direct and 3) indirect effects of COVID-19 on pregnant and breastfeeding women and children and 4) the transmission of COVID-19 and protection from infection. Conclusion The results of these questionnaires indicated a high level of concordance among continents and specialties regarding priority research themes. This prioritized list of research uncertainties, developed to specifically highlight the most urgent clinical needs as perceived by healthcare professionals and researchers, could help funding organizations and researchers to answer the most pressing questions for clinicians and public health professionals during the pandemic. It is hoped that these identified priority research themes can help focus the discussion regarding the allocation of limited resources to enhance COVID-19 research in MNCH globally. / Revisión por pares

With nearly 13% of maternal deaths being attributed to unsafe abortion there is a need to implement new strategies to improve access to safe services. As developing regions and legally restricted areas lead these numbers, further evidence must be presented demonstrating tailored and actionable strategies for these settings. In Pakistan abortion is legally restricted and the country continues to face a high burden of maternal death and disability, much of which is directly or indirectly attributable to unsafe abortion. The community-based distribution of misoprostol for early abortion has the potential to reduce harm from unsafe abortion in Pakistan and other low-resource settings where abortion is legally restricted. This study employed a multi-methods approach to evaluate this intervention in Sindh, Pakistan and consisted of a logbook review, interviews with lay providers, and in-depth interviews with program beneficiaries. Our results suggest that the community-based distribution of misoprostol is an effective and promising strategy for improving access to safe abortion care. Efforts to implement or strengthen similar programs appears warranted.

Zearalenone (ZEN) is an estrogenic mycotoxin produced by fungi in the genus Fusarium. Fusarium species commonly occur in cereal crops such as corn, wheat, barley, and rice which are used in swine feed. In addition to cereals, co-products of ethanol distillation, brewing, and baking are frequently re-purposed as swine feed. ZEN contamination has been related to severe reproductive issues including pelvic organ prolapse (POP), which describes the displacement of pelvic floor organs from their healthy anatomical positions. A recent rise in the rate of POP in sows highlights a need for more information surrounding the occurrence of ZEN in swine feed and the possible role of ZEN in POP. This research aims to understand the relationship between ZEN contamination in swine feed and swine reproductive health. The primary objectives of this work are to (1) characterize the stress relaxation behavior of vaginal tissue in the swine model, (2) determine how ZEN consumption effects the elasticity of pelvic support tissue. (3) determine where ZEN and a related metabolite accumulate in the swine reproductive tract, (4) evaluate the prevalence of ZEN and related Fusarium mycotoxins in swine feed and ingredients, and (5) track ZEN and related Fusarium mycotoxins throughout production of beer and brewers' spent grains (BSG). Results from this work can help stakeholders to mitigate mycotoxin contamination in swine feed, evaluate swine for ZEN toxicosis, and provide care for animals experiencing POP. / Doctor of Philosophy / Under certain conditions, some fungi produce harmful toxins (mycotoxins) that can compromise the health of humans and animals. Mycotoxin-producing fungi are common in cereal crops such as corn, wheat, and barley which may be fed to humans or animals. Swine are especially sensitive to mycotoxins, making feed composition important for animal welfare and profitability. Zearalenone (ZEN) is a mycotoxin that behaves like estrogen, a hormone frequently associated with female reproductive health. Pelvic organ prolapse (POP) is a condition, common in women, wherein organs in the pelvic floor such as the vagina, rectum, and uterus, descend from their healthy anatomical position. Swine herds are experiencing higher rates of POP, which may be related to ZEN contamination in feed. The overall goal of this research is to understand the relationship between mycotoxin contamination in feed and swine reproductive health. The specific objectives of this research are to (1) characterize the mechanical properties of vaginal tissue in swine, (2) characterize mechanical properties of pelvic support tissue associated with POP, in swine fed ZEN, (3) determine which reproductive tissues which accumulate ZEN in swine, (4) evaluate the prevalence of ZEN and related mycotoxins in swine feed, and (5) track ZEN and related mycotoxins throughout production of beer and brewers' spent grain, a co-product used in animal feed. This research can help animal producers develop strategies to mitigate mycotoxin contamination in feed and improve veterinary care.

The rate of adolescent unintended pregnancy in the United States is high compared to other developed countries. While past research and interventions have largely focused on young women, the role of young men in pregnancy prevention has increasingly been recognized. Studies have assessed young men’s knowledge and attitudes toward pregnancy prevention as well as their role in male-controlled methods of birth control like condoms or withdrawal. However, less is known about how young men can contribute to or participate in decision-making with female partners about contraception other than condoms. The purpose of this systematic review was to explore how young men communicate with their partners and its impact on contraception use to prevent pregnancy. A systematic review of five databases was conducted to identify English-language articles published from January 1, 2002, through July 7, 2018. The review specifically explored how male partner communication affects female partner use of contraception other than condoms among young men ages 11-24 years. The systematic review explored additional questions, including those pertaining to the timing of partner communication in a relationship, strategies employed by young men, and which dynamics of partner communication are measured in studies. Of the 15 articles identified as exploring areas of communication, five of the articles used quantitative analysis to measure any association between partner communication and contraception use, and three of those produced statistically significant findings suggesting that communication increases the use of contraception other than condoms. Three qualitative studies provided supporting narratives of how young men have communicated with partners and influenced their contraception use with female partners. The remaining seven articles explored the other research questions of timing, strategies, and dynamics identifying topics, prompts, and communication cues among young men. Measurements of both communication and contraception varied across studies. With the small number of studies identified in this systematic review, it is recommended that future research seek to corroborate the relationship between partner communication and contraception use with more robust and precise measurements of both communication and contraception.

Sex and sexuality issues are still sensitive and controversial subjects despite the growing numbers of sexual and reproductive health (SRH) programmes for adolescents in subSaharan African countries (WHO, 2002; Department ofInternational Development (DFID), 2004). The purpose of this study was to examine and analyze the structure and procedural mechanisms adopted by adolescent sexual and reproductive health (SRH) programmes in two African countries. This study also explored the adolescents' perceived usefulness and relevance of these programmes in addressing their SRH needs. The study was conducted in Ghana (West Africa) and South Africa (Southern Africa) as a cross-national study in these two sub-Saharan African countries. A comparative case study design was adopted involving the use of both quantitative and qualitative approaches to data collection and analysis. Snowballing, critical case, and purposive sampling methods were used. A wide range of personnel from both countries including programme directors, managers, nurse/midwives, peer educators and youth counselors (n=48) were interviewed within the context of adolescent sexual and reproductive health (ASRH) programmes and adolescents (n=247) participated through client exit surveys and focus group discussions. Records review, document analysis and observation of the facilities were employed through a checklist. A Tri-dimensional conceptual framework adapted from Donabedian (1980) and WHO (2001) for: (1) Structure, (2) Process, and (3) Output of ASRH programmes, guided the study and served as the frame for analysis and comparison. Qualitative data were transcribed and analyzed using framework analysis and quantitative data through use of SPSS Version 13.0. Findings of the study revealed that both Ghana and South Africa have established ASRH structures through development of programmes and policies for young people. They also shared common features related to programme focus and philosophy on ASRH matters. Both countries face several challenges associated with sexuality issues, inadequate human and material resources. Religious, socio-cultural, logistical and structural factors were identified as barriers, which hindered access and use of the facilities. These barriers were found to have a profound influence on programme implementation, achievement of objectives and future development. Adolescents in the two countries are confronted with a range of issues affecting their sexual health and general well-being for which they seek services from ASRH programmes. These programmes in both countries were generally perceived as relevant and important by youth utilizing the facilities. The need for changes in the attitude of service providers, structural layout, logistical improvement and staffing composition was expressed. Despite efforts made, there are still programmatic issues needing attention, for which specific recommendations towards improvement were made on the basis of findings from both countries. Findings from this study have implications for nursing practice, management, education, research and relevant stakeholders involved with adolescent health, including policy makers. Recommendations are made that may contribute to the development of an effective model of "Adolescent-Friendly" programmes in the two countries. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2007.