INTRODUCTION: Approximately 6 million couples in the United States experience infertility. Because few risk factors for infertility are known, identification of modifiable determinants is an important public health goal. Cervical intraepithelial neoplasia, CIN, occurs when the surface cells of the cervical tissue begin to change, and is caused by infection with a high-risk type of human Papillomavirus (HPV). CIN may affect the cervix’s immunological function, resulting in changes in mucus production, reduced protection against infections, and alterations in sperm transport through the cervical canal. CIN can also progress to invasive cervical cancer. There are four main CIN treatment procedures that aim to remove pre-cancerous cells from the cervix; loop excisions, commonly known as electrosurgical excision procedure (LEEP) or large loop excision of the transformative zone (LLETZ); cryosurgery; conization; and laser ablation. Because the goal of these procedures is to remove abnormal cells, healthy cervical cells may inadvertently be removed as well, leading to further changes in cervical mucus production, sperm motility, and reduced protection against infection. Because of the changes to the cervical tissue and its function, CIN and its surgical treatments may affect fecundability. METHODS: We analyzed data from Pregnancy Study Online (PRESTO), a preconception cohort of 5,594 North American pregnancy planners enrolled and followed between 2013 and 2018. At baseline, participants reported whether they had abnormal Pap tests and their age at their first abnormal Pap test, as well as cervical procedures and their age at the procedure. We estimated fecundability ratios (FR) and 95% confidence intervals (CI) using proportional probabilities models adjusted for sociodemographics, smoking, number of sexual partners, history of sexually transmitted infections/ pelvic inflammatory disease, and HPV vaccination. RESULTS: A history of abnormal Pap test, which we used as a proxy for cervical dysplasia, was positively associated with current and past smoking, gravidity, parity, irregular menses, number of sexual partners, history of chlamydia, genital warts and herpes, as well as a history of pelvic inflammatory disease. Of the women with an abnormal Pap test, the average age at first abnormal Pap test was 23.0 (std=4.5) years and the average number of abnormal Pap tests was 2.1 (std=1.7). We found little association overall between a history of abnormal Pap test and fecundability (FR=1.03, 95% CI: 0.96, 1.11). The results did not differ when the data were examined by number of abnormal Pap tests, or type of procedure. There was also little association between time since the diagnosis or procedure and pregnancy attempt and fecundability. There was however a slight decrease in fecundability within the first 2 years of diagnosis/ procedure, with FRs that tended to increase with increasing time since diagnosis/procedure. DISCUSSION: We found little association overall between a history of abnormal Pap test or cervical dysplasia, including excisional surgeries, and fecundability. These results are consistent with most other studies demonstrating no clear adverse effects of CIN and treatments. Recency of diagnosis or procedure did not appreciably affect these findings. Although we found a very slight decrease in fecundability within the first two years since diagnosis or procedure, fecundability became similar to that of undiagnosed/untreated women after 2 years, and then increased slightly. CONCLUSION: We found little association between a history of abnormal Pap and CIN treatments and fecundability. A major limitation of our study is that the data were self-reported, which may have resulted in non-differential exposure misclassification.

Philosophiae Doctor - PhD / This research explored the role of men in efforts by the Malawi Ministry of Health to promote women’s reproductive and maternal health in accordance with Millennium Development Goal (MDG) number five, i.e. to reduce the maternal mortality ratio by three quarters between 1990 and 2015. The study was conceptualised in 2011 in an effort to contribute to the national strategy to reduce maternal mortality in Malawi, and it was done in the particular cultural context of a matrilineal marriage and kinship system in Ntchisi district, Malawi. At the inception of this study, the highest prevalence of maternal deaths in the country was reported in seven districts, including Ntchisi. A common understanding in public health circles worldwide is that male involvement in reproductive and maternal health activities is an important factor in achieving the above MDG goal. But historically, research on maternal health in Malawi has focused mostly on women and children. Consequently there are only a small number of relevant previous studies or extant literature to draw on for the current investigation. Malawi’s reproductive and maternal health policies largely lack locally-informed research on men and masculinities. My study aimed to explore the relationship between local constructions of masculinity, fatherhood and reproductive health in Malawi among Chichewa speakers who live in Ntchisi. It was guided by the social constructionist theory which recognises the role of the impersonal features of the social world like cultural, personal and group influences in the construction of ideas, knowledge and facts. In this study I adopted an inductive approach to learning in which the participants were the main players in describing and explaining social phenomena as they are constructed and experienced in the research site. I conducted multiple in-depth interviews and focus group discussions with 53 married men, key informant interviews with eight local leaders and traditional birth attendants, as well as focus group discussions with 12 married women who had given birth multiple times. Data analysis involved intensive scrutiny of transcripts to determine prevailing themes. Listening to the tapes and re-reading these transcripts enabled me to detect patterns and categorise different practices and constructions, to find associations between these practices and constructions of concepts. Malawi’s men are considered to be the traditional gatekeepers of maternal and social ideals. Therefore, as elders in a clan or as husbands, their prompt decisions can facilitate the access of their spouses to maternal and reproductive health services. Men as heads of households and decision makers can also support and enable their wives to follow the recommended maternal health counsel. However, men’s “lack of involvement” is not the principal reason why there is increasing maternal challenges among child-bearing women in Ntchisi. Although men are not entirely free of the blame for contributing to the status quo, they already work hard towards ensuring positive pregnancy outcomes for their spouses. The study found that husbands in Ntchisi have long been involved in pregnancy and child care. The study shows that pregnancy is regarded as a liminal state or as a kind of “sickness”. Male involvement in pregnancy means the man should take over the routine household chores of drawing water, fetching firewood and cooking, among other things. However, men construct their involvement in reproductive and maternal health matters in the framework of masculinity and femininity as dictated by the commonly held beliefs of a matrilineal Chewa grouping. The study showed that masculinities are constructed within the context of a matrilineal system, which has nonetheless been changing largely due to the colonial impact of the United Kingdom, the related influences of Christian and westernised social ideals and an education system based on the British model. Men’s gendered practices in reproduction and parenting have foundations in the initiation rites of the secret Nyau societies where the masculine ideals of sexuality and secrecy are inculcated. This research cannot be generally extrapolated to the wider population in Malawi but it is a starting point for understanding the responses of matrilineal Chichewa speaking men to reproductive and maternal health matters. Further and broader research on the construction of fatherhood and masculinity is needed in Malawi to make it possible for public health policy on reproductive and maternal health to be more culturally informed.

Forty years ago, when an American woman wanted to know if she was pregnant, she made an appointment with a medical professional who would conduct a pregnancy test and tell her the result. Propelled by the medical establishment’s control, surveillance, and neglect of women’s health, the women’s health movement of the 1970s sought to put women’s health “into their own hands.” Encouraged in part by the rhetoric of the women’s health movement, pregnancy tests became available for purchase over-the-counter, without a prescription, and outside of the control of the medical establishment. This dissertation examines this passage of the pregnancy test from the hands of medical professionals to the hands of lay people and asks, has the pregnancy test really delivered on its promise to give women information, choice, and control? We think of women’s reproductive health tools in the hands of doctors as oppressive and in the hands of women as liberating; the central argument of this dissertation is that this view is naïve. Putting the informational power about women’s bodies into a mobile diagnostic technology did not change the nature of the beast. Through this examination of the pregnancy test in American life, we can trace the flow of reproductive power through various people, places, and things to better understand the character of women’s subordination.

An extensive body of research suggests that increasing access to contraception can improve the health of women and children and increase their socioeconomic mobility through increased wages and labor force participation. In the United States, however, contraception and childbearing has historically been used as a form of racist and eugenic population control. This thesis outlines the history of contraception in an intersectional context, inspired largely by the work of Martha Bailey and Dorothy Roberts, from forced childbearing during chattel slavery, to the forced and or coercive sterilization of large populations of Black and Brown women in the modern era. Given the historical racism of contraception, combined with the possibilities for increased socioeconomic mobility and self-determination that accompany increased access to contraception, leads this thesis to ask: who lacks access to contraception in the U.S. today? An original analysis of data from the Guttmacher Center determines that Hispanic women are the most likely to lack access to birth control, followed by younger women and impoverished women. These findings, in conversation with the current implications of the racist past of contraception, imply the need for anti-racist contraception programs that prioritize informed consent and patient autonomy. Such programs could improve women’s and child health, decrease government spending, and contribute to increasing economic and racial equality.

African immigrant women and refugee women face disproportionate reproductive health risks and adverse outcomes compared with the Canadian population. The diversity of African women and complexity of the migration process suggest the need for contextualized knowledge to better understand these challenges. I sought such knowledge through the use of the theoretical frameworks of place and intersectionality. These frameworks draw attention to the multi-level mixture of social relations in given contexts and how they create opportunities and oppression. The specific purpose of this research was to: a) explore how the reproductive health experiences of African immigrant and refugee women were shaped by the unique context of given places; b) consider how these women actively negotiated and constructed place in their search for reproductive health information, services, and support. A multiple case study was used to explore the reproductive health experiences of African immigrant and refugee women in three different areas of Ottawa, Ontario. These areas provided different local contexts (e.g., history, socioeconomic profile, proximity to downtown). In each area, data was collected through interviews with African immigrant and refugee women, interviews and focus groups with reproductive health service providers, and mapping of available services. In total, 19 immigrant and refugee women and 23 service providers participated in this study. The findings showed that African immigrant and refugee women’s reproductive health experiences were much more complicated than simple interaction with neighbourhood services. Their varied social positions in Canadian society were highly relevant. In addition, social networks based in places outside of the system (e.g., private homes, religious institutions) were environments in which they were comfortable and sought support for their reproductive health needs. Recommendations based on these findings include the need to engage communities and explore the delivery of information and services outside of the traditional places employed by the Canadian health care system.

<p><strong>Syftet</strong> med denna litteraturstudie var att beskriva kvinnors alkoholkonsumtion före och under graviditeten samt undersöka prevalensen, informationen som gravida kvinnor får av vårdpersonalen och problemhanteringen på mödravården. <strong>Metoden</strong> var en litteraturstudie av vetenskapliga artiklar från åren 1997-2008. <strong>Resultatet </strong>visade att prevalensen av alkoholkonsumtion nådde siffror över 50 % före respektive 20 % under graviditeten. I studierna observerades hög konsumtion under både perikonceptional perioden och första trimestern. Speciellt vanligt var det med berusningsdrickande tidigt i graviditeten. Kvinnor som drack under graviditeten visade sig vara äldre, väl utbildade, rökare och alkoholkonsumenter redan innan graviditeten. Mödravården identifierade inte alla gravida kvinnor som använde alkohol. Screeningsinstrument var nödvändiga för att identifiera och då kunna erbjuda hjälp till denna grupp.</p><p><strong>Konklusion</strong>: I Sverige observerades en positiv tendens med minskat drickande under graviditeten men andelen gravida kvinnor som nyttjade alkohol var fortfarande stor. Problemet var dock fortfarande stort i många andra länder.</p><p><strong>Nyckelord: </strong>alkoholkonsumtion, graviditet, mödravård, screeningstest.</p>

<p><strong>Aim </strong>The aim of this study was to investigate the attitudes of midwives and gynaecologists at youth health clinics about their own thoughts of risks with unprotected oral sex and testing of orally contagious sexually transmitted infections (STI). The aim was also to investigate the level of knowledge of oral STIs. One further aim was to examine what they thought about the level of knowledge about oral STIs among adolescents and how common unprotected oral sex is within this group and if oral STIs/oral sex is brought up in the form of information or questions during STI-testing.</p><p><strong>Method </strong>Seventy-five youth health clinics all over Sweden were randomly chosen. A questionnaire was sent by mail to the clinics. It included questions about attitudes, knowledge about STIs and information exchange. A midwife or a gynaecologist was asked to fill out the questionnaire. The answers were analysed in the statistical programme SPSS.</p><p><strong>Results </strong>The percentage of answers was 76 % (57/75).  One third of the clinics had guidelines for oral STI-testing. Those clinics were more often testing for oral STIs, informing and asking adolescents about oral STIs. Seventy-nine percent responded that they always or sometimes informed adolescents who were tested for STIs about risks with unprotected oral sex. Almost everyone thought that the knowledge about oral STIs was insufficient among health care staff.  Staff working at clinics with guidelines more often thought that they had sufficient knowledge about oral STIs than those without guidelines. All respondents thought unprotected oral sex was common among adolescents. Eight out of ten were in favor of oral STI-testing being performed more often. The overall attitude was that adolescents should be given more information of the risks of STIs when practising unprotected oral sex. <strong></strong></p><p><strong>Conclusions </strong>Practise of unprotected oral sex involves a risk of transmission of oral STIs. Youth health clinics need to be more actively informing adolescents about it. There is a lack of national guidelines for testing of STIs in Sweden. The majority of youth health clinics did not have any local guidelines for oral STI-testing. Guidelines on oral STI-testing are needed for achieving a more evidence-based care in testing and informing about oral STIs.</p><p><strong>Keywords; </strong>Oral sex, STI, testing, midwives, attitudes.</p>

Syftet med denna litteraturstudie var att beskriva kvinnors alkoholkonsumtion före och under graviditeten samt undersöka prevalensen, informationen som gravida kvinnor får av vårdpersonalen och problemhanteringen på mödravården. Metoden var en litteraturstudie av vetenskapliga artiklar från åren 1997-2008. Resultatet visade att prevalensen av alkoholkonsumtion nådde siffror över 50 % före respektive 20 % under graviditeten. I studierna observerades hög konsumtion under både perikonceptional perioden och första trimestern. Speciellt vanligt var det med berusningsdrickande tidigt i graviditeten. Kvinnor som drack under graviditeten visade sig vara äldre, väl utbildade, rökare och alkoholkonsumenter redan innan graviditeten. Mödravården identifierade inte alla gravida kvinnor som använde alkohol. Screeningsinstrument var nödvändiga för att identifiera och då kunna erbjuda hjälp till denna grupp. Konklusion: I Sverige observerades en positiv tendens med minskat drickande under graviditeten men andelen gravida kvinnor som nyttjade alkohol var fortfarande stor. Problemet var dock fortfarande stort i många andra länder. Nyckelord: alkoholkonsumtion, graviditet, mödravård, screeningstest.

Aim The aim of this study was to investigate the attitudes of midwives and gynaecologists at youth health clinics about their own thoughts of risks with unprotected oral sex and testing of orally contagious sexually transmitted infections (STI). The aim was also to investigate the level of knowledge of oral STIs. One further aim was to examine what they thought about the level of knowledge about oral STIs among adolescents and how common unprotected oral sex is within this group and if oral STIs/oral sex is brought up in the form of information or questions during STI-testing. Method Seventy-five youth health clinics all over Sweden were randomly chosen. A questionnaire was sent by mail to the clinics. It included questions about attitudes, knowledge about STIs and information exchange. A midwife or a gynaecologist was asked to fill out the questionnaire. The answers were analysed in the statistical programme SPSS. Results The percentage of answers was 76 % (57/75).  One third of the clinics had guidelines for oral STI-testing. Those clinics were more often testing for oral STIs, informing and asking adolescents about oral STIs. Seventy-nine percent responded that they always or sometimes informed adolescents who were tested for STIs about risks with unprotected oral sex. Almost everyone thought that the knowledge about oral STIs was insufficient among health care staff.  Staff working at clinics with guidelines more often thought that they had sufficient knowledge about oral STIs than those without guidelines. All respondents thought unprotected oral sex was common among adolescents. Eight out of ten were in favor of oral STI-testing being performed more often. The overall attitude was that adolescents should be given more information of the risks of STIs when practising unprotected oral sex. Conclusions Practise of unprotected oral sex involves a risk of transmission of oral STIs. Youth health clinics need to be more actively informing adolescents about it. There is a lack of national guidelines for testing of STIs in Sweden. The majority of youth health clinics did not have any local guidelines for oral STI-testing. Guidelines on oral STI-testing are needed for achieving a more evidence-based care in testing and informing about oral STIs. Keywords; Oral sex, STI, testing, midwives, attitudes.

Extensive research and clinical observations in the past 20 years confirmed that the cessation of ovarian function at menopause does not stop the process of sex steroid hormone synthesis in females. Indeed, multiple extra-ovarian tissues contain the same enzymatic machinery the ovary uses which can maintain a significant rate of local hormonal synthesis sufficient to cause pathological outcomes. This is commonly termed “intracrine”. However, two obstacles face intracrinology. Firstly, wide clinical appreciation of this mechanism in causing disease and in targeting it with therapy does not currently exist. Secondly, blood hormonal assays are used in the clinic to diagnose and manage intracrine based disorders. This could be entirely misleading, since hormonal synthesis, action and metabolism occur within the tissue and, therefore, measuring blood levels is not reflective of the actual disease environment. This thesis presents evidence of significant intracrine based disorders in menopausal women that could be effectively managed by tackling the core intracrine mechanism. Three protocols are investigated emphasizing the usefulness of menopausal intracrine estrogen inhibition. The first presents a joint objective of treating menopausal symptoms using estrogenic replacement therapy while reducing breast cancer risk using long-term aromatase inhibitors. Aromatase inhibition is used to suppress the local estrogen synthesis in the breast. The second protocol is a new method of acute inhibition of breast estrogens to improve the accuracy of breast imaging techniques. This method showed a benefit in reducing the benign parenchymal enhancement during breast MRI indicating a potential improvement in specificity. The third protocol involves using aromatase inhibitors in the treatment of severe endometriosis that did not respond to oophorectomy. The pathogenesis of breast cancer, endometriosis and fibroids are believed to involve intracrine estrogen activity. Another significant contribution presented in this thesis is the development of a new technique that enables minimally invasive tissue assays of hormones in their genuine site of synthesis rather than indirectly in the blood. The new assay requires only microliter volumes of sample and employs a novel digital microfluidics technology. Estrogen and other sex steroids were extracted from droplet-scale breast tissue and blood samples.