MPH / Department of Public Health / See the attached abstract below

Abortion is a controversial issue. It is subject of heated debates stemming from morality and ethics. Abortion is also, however, a question of rights. Access to abortion weighs the rights of the foetus against the rights of the mother. Women being denied access to safe and legal abortion due to criminalisation and restrictive abortion laws, is also a matter of human rights. Women die every year as the result of unsafe abortion methods. This thesis focuses on access to safe and legal abortion, and examines if and how public international law protects women’s access to abortion. It addresses the topic of reproductive rights and health, and whether this set of rights constitutes any protection for access to safe and legal abortion. Human rights that are actualised in relation to abortion include for example the right to life, right to privacy and right to health. Relevant provisions in CEDAW, ICCPR and ICESCR are analysed, together with general comments and reports issued by the treaty monitoring bodies of the UN. The second part of the thesis focuses on access to safe and legal abortion under the ECHR and examines relevant case-law from ECtHR on the topic. In addition to the legal dogmatic method, a feminist legal theory is used to critically evaluate whether the current protection of access to safe and legal abortion is sufficient from a women’s rights perspective. The author concludes that public international law does not offer any direct protection of access to safe and legal abortion. Instead, access to safe and legal abortion can be protected indirectly by other human rights. Restrictive abortion laws that results in risking the health and life of the mother can violate women’s human rights. Case-law from the ECtHR shows that European states are under a positive obligation to provide an effective access to abortion under the right to privacy, if the national law guarantees such a right. The result from the discussion based on feminist legal theory shows that public international law fails to recognise the abortion issue as a question of gender equality and discrimination against women.

Over the 20th century, Malians relied on local reproductive specialists: excisers (who oversaw initiation and circumcision ceremonies), nuptial counselors (who provided sexual education at marriage), and midwives. These older women’s work remained vital to social conceptions of proper reproduction, even as the biomedical maternal health system expanded, and Malians adjusted to new forms of religiosity and new ideas of status. Reproductive Labors: Women’s Expertise and Biomedical Authority in Mali 1935-1999 traces how, as biomedical care expanded over the 20th century, women and their families, feminist activists, medical professionals, and non-profit workers began to debate the importance of local reproductive practices. Part 1 explores the role of specialist labor in socializing sexuality and gender norms. In Chapter 1, I argue that following the end of slavery in the early 20th century, Malian families used nuptial counseling to instill concepts of honorable sexuality and demonstrate status at marriage (1935-1958). After independence, public outcry over unwed mothers revealed different visions of extra/marital sexuality and adolescence for nuptial counselors and state-affiliated women activists (1959-1986). In Part 2, I turn to reproductive health interventions. Chapter 3 reveals how the colonial maternal health system relied on external actors, from benevolent associations to Malian midwives, all of whom defined women’s bodies as childbearing bodies (1935-1958). Successive post-colonial governments sought to develop policies to ensure rural health access, toggling between training medical professionals to work in rural places and training local specialists, such as midwives, in biomedical techniques (1957-1976). The integration of midwives into biomedical clinics created substantial overlap between various therapeutic interventions, as I show in Chapter 5. Finally, Chapter 6 demonstrates how Malian participation in anti-excision activism owed as much to previous debates over marriage, unwed mothers, and rural maternity care as to transnational feminist movements and developmentalist interventions (1984-1999). Reproductive Labors is based on interdisciplinary research in Mali, Senegal, France and the US, including archival research, oral histories, and ethnographic work. In addition to working in national archives, the project engages with the floatsam of project reports now safe-guarded in people’s homes, bureaucratic documents from institutional archives like Mali’s National Health Directorate, and student theses. However, women’s specialist labor is less visible in archival material. In response to this elision of gendered knowledge, the project integrates ethnographic observation and French and Bamanakan oral history interviews with women specialists, as well as medical personnel and gender-rights activists. Reproductive Labors demonstrates how Malians were socialized into heterosexuality not simply through family or media, but through specific specialist interventions which linked heterosexuality to biological reproduction and gendered identities, deepening key themes in gender and sexuality studies. Reproductive specialists’ expertise was defined by their gender, skill, age, and social status, as most were older women of endogamous social group descent. Conversely, the activists who campaigned against them were usually highly-educated young women with close ties to international feminist institutions, although these linkages were structured by the colonial afterlives of educational and financial networks. Over the 20th century, questions about which group should have authority over young women’s reproductive experiences led to numerous debates for women and their families. Secondly, this project demonstrates that the continued value of local specialists for Malians, alongside the medical system’s reliance on external actors and instability in rural areas, created a specific form of Malian biomedicine driven as much by local therapeutic practices and social hierarchies as by international norms, enriching recent scholarship on the local specificities of biomedicine. Finally, this dissertation deepens scholarship on state-making in Africa. It demonstrates that reproductive health was not simply a subfield of the post-colonial Malian health system but that it became a key site for innovation in governance. As the first academic history of reproductive health in Mali, which has one of the world’s highest rates of maternal and child mortality, this dissertation seeks to understand the history of reproductive practices as a step towards reproductive justice.

Use of long-acting reversible contraception (LARC) is a highly effective strategy for preventing pregnancy. Methods of LARC include the intrauterine device (IUD) and the contraceptive implant; the latter is currently unavailable in Canada. Less than 5% of Canadian women use LARC as their contraceptive method. Exploration of women’s experiences with methods of LARC can shed light on the factors and dynamics influencing information and use. Understanding these dynamics may also inform efforts to increase awareness of the contraceptive implant, once it is approved for use in Canada. This multi-methods study aimed to assess Ontario women’s knowledge of and attitudes toward methods of LARC and identify avenues to improve information and services related to LARC in the province. The study comprises two components: an anonymous online bilingual survey and a telephone/Skype interview with a subset of survey participants. Our results suggest that the main factors influencing LARC use are its ease of use, efficacy, and recommendation by a health care professional. Most survey respondents were satisfied with the information provided by their health care provider when they were first prescribed LARC. However, Franco-Ontarian participants we interviewed faced challenges obtaining reproductive service in French. Participants highlighted a number of ways that LARC could be improved and new methods of LARC could be introduced in Canada. This study provides insight into opportunities to improve counselling to Ontarian women and highlights areas that should be routinely discussed with contraceptive patients about methods of LARC.

Introduction: The consequences of the opioid epidemic and various prevention, mitigation, and treatment strategies have a strong hold on Appalachian communities. However, limited research has been conducted to understand the experiences of special populations impacted by opioids in this region, such as women of childbearing age living with opioid use disorder (OUD) prior to and during pregnancy. The objective of this review is to summarize existing literature on the care experience for women of childbearing age receiving treatment with medications for opioid use disorder (MOUD) in rural east Tennessee. This literature review will allow for better understanding of current treatment practices, potential gaps in care, and needed care system improvements for this patient population. Methods: A systematic PubMed search identified studies focused on MOUD and pregnancy in the rural eastern Tennessee region. Search results were screened to remove publications older than five years or from outside the region. Relevant information concerning the MOUD care experience for women of childbearing age in the area was collected from these studies. Results: Five studies were included: four surveys and a systematic review. All were published within the last five years and described experiences spanning preconception to postnatal care as well as Tennessee opioid laws that affect women of childbearing age. Two studies detailed the pre-pregnancy care experience, including information about prior pregnancies, intention of conception, contraceptive use, and perceived barriers to contraception access among women receiving MOUD. Two studies described the care experience during pregnancy and its evolution in recent years with changes in acceptance of insurance for MOUD treatment, rates of MOUD-positive prenatal drug screens, and MOUD tapering practices during pregnancy. The final included study reviewed several Tennessee opioid laws enacted over the years to combat prenatal substance use and neonatal abstinence syndrome (NAS). Notably, while total reported cases of NAS have decreased statewide in recent years, the highest rates continue to be observed in east Tennessee, with a majority of cases linked to MOUD exposure. The requirements and enforcement of NAS-related legislation in Tennessee have changed over time but their existence may deter pregnant women from seeking treatment due to fear of punitive consequences. Conclusion: The evidence compiled in this literature review points to many areas in which the care experience can be improved for women of childbearing age receiving MOUD in east Tennessee. There are concerns regarding pregnancy planning, contraceptive access, availability of evidence-based OUD treatment, cost of treatment, and fear of actual or potential negative repercussions from opioid use during pregnancy. These findings suggest multiple efforts can be undertaken by clinicians, researchers, and policymakers to enhance the experience of care for women of childbearing age living with OUD, and consequently improve the health of the population in general, in this region of Appalachia.

This thesis is based on the premise that reproductive rights and environmental sustainability have synergistic interests: human population growth increases environmental impact and access to family planning triggers reduced fertility levels. Despite increasing scientific evidence indicating that the size of the global population matters for environmental sustainability, and by extension, that fulfilling reproductive rights may be beneficial for the latter, the linkages between reproductive rights and environmental sustainability have been largely understudied, ignored, and left out of environmental policy and reproductive rights agendas. Because of the complexity of this interdisciplinary field and its associated ethical questions, many researchers and policy makers have chosen to avoid this sensitive and polarizing issue altogether. However, capitalizing on these linkages could represent significant opportunity to advance the reproductive rights and environmental movements, and increase the prominence, legitimacy, and funding of global family planning services, in particular. This thesis uses an action research approach to explore the current framing of the reproductive rights and environmental sustainability linkage, study the perceptions of stakeholders of both the reproductive health and rights and environmental sustainability movements on this issue, and elaborate a strategic communication roadmap to promote its operationalisation.

The study was conducted in Moshi, the regional Capital of Kilimanjaro region, Tanzania. It was financed by Sida’s Minor Field Study scholarship in March and April 2019. This study was carried out at a Secondary school and focuses on students’ attitudes and knowledge about sexual and reproductive health and rights, SRHR, as well as examine how different actors influence the students’ decision-making and attitudes in Form 4. Qualitative semi-structured interviews are conducted, combined with the use of flashcards, as a method. Each flashcard contains topics within the concept of SRHR and was based on previous research and definitions. The use of flashcards was conducted in two steps. Firstly, the students’ categorized SRHR-topics in five different categories. Secondly, the students’ ranked ten actors in which affect them the most to least. Most of the students believe that most of the topics are important to learn about but in a future context. They also believe that education in some topics will result in increased sexual behavior. The students identify that authorities, such as parents and school, affect them the most in their decision-making and attitudes. To conclude, the students were found to have limited education focusing on attitudes as well as access to evidence-based education.

En toda la etapa de vida, las mujeres pasan por determinadas experiencias físicas para la conformación de su femineidad como la menstruación, el parto, lactancia, embarazo y menopausia. Los estudios sobre el tema explican que las mujeres enfrentan enfermedades complejas y otras menos severas, algunas enfermedades son: cáncer de ovarios, miomas, ovarios poliquísticos, infecciones, entre otros. Siendo las infecciones la principal causa que lleva a las mujeres al ginecólogo, según el Inem, además, se sabe que mensualmente casi 7 mil mujeres acuden a una consulta ginecológica, de ellos cerca del 70% acuden solo por infecciones (Álvarez et al., 2017). Por ello, se creó Ammy, una idea de negocio que busca solucionar los problemas relacionados con la salud reproductiva femenina y que funciona a través de una aplicación móvil. El servicio consiste en brindar un monitoreo menstrual con alertador de normalidad o anormalidad del ciclo menstrual, con opción para ingresar los síntomas, de esta manera alertar a la usuaria cuando sus molestias requieran acudir a un ginecólogo, luego de ello, sugerirle un listado de médicos para realizar sus citas médicas por la aplicación de Ammy. Si bien, en el mercado existen varias aplicaciones extranjeras, lo cierto es que ninguna de ellas permite realizar las consultas médicas virtuales. Además, existen miles de mujeres en Lima que están dispuestas a pagar por este servicio y por las suscripciones para el monitoreo de su ciclo menstrual. Sin duda este negocio es innovador y muy rentable demostrado en sus indicadores de rentabilidad del presente trabajo. / Throughout the life stage, women go through certain physical experiences to shape their femininity, such as menstruation, childbirth, lactation, pregnancy and menopause. Studies on the subject explain that women face complex diseases and others less severe, some diseases are: ovarian cancer, fibroids, polycystic ovaries, infections, among others. Being infections the main cause that leads women to the gynecologist, according to the Inem, in addition, it is known that almost 7 thousand women go to a gynecological consultation every month, of them about 70% go only for infections (Álvarez et al., 2017). For this reason, Ammy was created, a business idea that seeks to solve problems related to female reproductive health and that works through a mobile application. The service consists of providing menstrual monitoring with an alert of normality or abnormality of the menstrual cycle, with the option to enter the symptoms, thus alerting the user when her discomfort requires going to a gynecologist, after which, suggesting a list of doctors to make your medical appointments by the Ammy app. Although there are several foreign applications on the market, the truth is that none of them allow virtual medical consultations. In addition, there are thousands of women in Lima who are willing to pay for this service and for subscriptions to monitor their menstrual cycle. Without a doubt this business is innovative and very profitable, demonstrated in its profitability indicators of this work. / Trabajo de investigación

Bakgrund: Alla individer innehar grundläggande rättigheter just i egenskap av att vara människa. Rätten till hälsa är en av dessa, och ska bland annat inkludera säker sexuell och reproduktiv hälsa. I den georgiska utbrytarprovinsen Abchazien tillgodoses inte hela befolkningen denna rättighet. Gali-distriktet är beläget nära gränsen till övriga Georgien och anses som ett lågprioriterat område. Kvinnors position beskrivs där extra utsatt, då exempelvis våld i nära relationer är vanligt förekommande. Inom Abchazien finns icke-statliga organisationer som arbetar för att tillgodose människors grundläggande rättigheter. Avangard är en av dessa och arbetar med sexuell och reproduktiv hälsa för kvinnor i Gali-distriktet. Syfte: Studiens syfte var att belysa hur vårdpersonalen på en icke-statlig organisation kan möjliggöra säker sexuell och reproduktiv hälsa för kvinnor i Gali, Abchazien. Metod: Empirisk studie med kvalitativ metod, baserad på deltagande observationer med etnografisk ansats. Materialet har bearbetats genom innehållsanalys, där kategorier samt teman arbetats fram. Resultat: Framkomna fynd presenteras utifrån tre teman med totalt sex inkluderande kategorier: Kompetens – Utbildad personal och Engagemang, Sammanhang - Undervisning i sexuell och reproduktiv hälsa och gynekologisk vård, Resurser – Miljö och Material. Slutsats: Studien belyser hur flertalet komponenter möjliggjorde den sexuella och reproduktiva hälsan. Genom utbildad och lokalt förankrad personal, kunde Avangard bidra till att hälso- och sjukvård samt kunskapsförmedling genomfördes trots vissa hinder. Klinisk betydelse: Denna studie kan bidra till ökad förståelse i hur rättigheter inom sexuell och reproduktiv hälsa kan möjliggöras. Vidare förhoppning är att sjuksköterskan ska reflektera över kvinnors situation världen över, för att kunna bidra till ökad sexuell och reproduktiv hälsa. / Background: Everyone has fundamental rights just of being human. The right to health is one of these, which includes safe sexual and reproductive health. In the Georgian breakaway region Abkhazia, all the people can’t claim the right to health. Gali district, near the border to the rest of Georgia, is considered as a low priority area. Domestic violence is common in the region and women’s positions are described as extra vulnerable. In Abkhazia several non-governmental organizations operates to incorporate people's basic rights. Avangard is one of them, and they’re working with women’s sexual and reproductive health in Gali district. Aim: The aim of this study was to illuminate how the staff of a non-governmental organization incorporate safe sexual and reproductive health for women in Gali, Abkhazia. Method: An empirical study using a qualitative method, based on participant observations with ethnographic approach. The data were processed through content analysis, which ended up in categories and themes. Results: The presented findings are collected in three themes, including total six categories: Competence – Educated staff and Engagement, Context - Training in sexual and reproductive health and gynecological care, Resources - Environment and Materials. Conclusion: The study illuminated how several components incorporated safe sexual and reproductive health. By local and educated staff, Avangard created opportunities that made the work possible, despite some obstacles. Implications for practice: This study may contribute to an increased understanding of how fundamental rights in sexual and reproductive health can be made possible. Furthermore, there is a hope that nurses should reflect on women's situations worldwide, to improve the sexual and reproductive health. / <p>Röda Korsets sjuksköterskeförening stipendium 2013</p>

The average age of first-time mothers is increasing, along with the incidence of sexually transmitted diseases. This indicates a low level of knowledge about fertility and an increased sexual risk-taking among young people. The aim of this study was to explore knowledge, attitudes and values about reproductive and sexual health among adolescents and young adults. An overview of the current literature was made using an integrated analysis method, including sixteen studies. The result showed an extensive lack of knowledge among young people regarding fertility, reproductive and sexual health. Many youths lacked knowledge about contraception and sexually transmitted diseases. A majority of the young people were not aware of the significance of age or the impact that sexually transmitted diseases had on their fertility. Many of the young people did however have knowledge about lifestyle factors such as smoking and diet and their impact on health. There was a positive attitude towards fertility treatments along with an overestimation of the efficiency of such treatments. The main part of the young people felt that the sex education they received was inadequate and lacked depth. It was also normative and old-fashioned. With a lack of proper education in school young people used other sources of information such as parents, friends or pornography. Young people expressed a want for easily accessible sources of information and more discussion about relations, consent and sexual abuse. More practical information was requested also. Midwives and nurses were good sources of information, a good opportunity to discuss their reproductive and sexual health was in connection with testing against sexually transmitted diseases or contraceptive counselling. In conclusion, this study showed a need for more sources of correct information regarding reproductive and sexual health that young people can easily access. Sexual education today needs to be modernized to be more inclusive to meet the needs and expectations of young people. / Medelåldern för när kvinnor föder sitt första barn har stigit, det har också förekomsten av sexuellt överförbara infektioner. Dessa fakta kan tyda på en låg kunskap om fertilitet och ett sexuellt risktagande hos unga personer idag. Syftet med studien var att undersöka vad ungdomar och unga vuxna har för kunskaper, attityder och värderingar avseende reproduktiv och sexuell hälsa. En litteraturöversikt gjordes med en integrativ analysmetod. Litteraturöversikten inkluderade sexton studier. I analysen framkom en utbredd kunskapsbrist hos ungdomar gällande fertilitet, reproduktiv och sexuell hälsa. Många ungdomar saknade kunskap om preventivmedel och sexuellt överförbara infektioner. En majoritet var inte medvetna om ålderns betydelse för fertiliteten eller hur sexuellt överförbara infektioner kan påverka fertiliteten. Många hade dock kunskap om livsstilsfaktorer som till exempel rökning och kost och dess påverkan på hälsan. I analysen framkom också en positiv inställning och övertro till fertilitetsbehandlingar. Huvuddelen av ungdomarna ansåg att den sexualundervisning de fått i skolan var bristfällig och saknade djup. Den upplevdes också som normativ och gammeldags. I brist på undervisning från skolan användes alternativa källor till information såsom föräldrar, kamrater eller pornografi. Ungdomarna efterfrågade lättillgängliga källor för information och mer diskussion om relationer, samtycke och sexuella övergrepp. Även praktisk information efterfrågades. Barnmorskor och sjuksköterskor ansågs vara bra källor i undervisningen, ett bra tillfälle att diskutera sin reproduktiva och sexuella hälsa var i samband med provtagning av könssjukdomar och preventivmedelsrådgivning. Slutsatsen från denna studie var att ungdomar behöver flera källor för korrekt information om sin reproduktiva och sexuella hälsa. Skolans sexualundervisning behöver moderniseras för att bli mer inkluderande och för att möta de behov och önskemål som finns hos ungdomar.