Master of Public Health - MPH / The problem of the unmet need for contraception continues to affect contraceptive uptake particularly the use of long-acting reversible contraceptives. Globally, Sub-Saharan Africa is reported to have the highest unmet contraceptive need. For example, nearly 50 % of married women of reproductive age, wanting to avoid pregnancy or plan when to have children, are reportedly not using contraception. More specifically, the prevalence of contraceptive use, in the Midlands Province of Zimbabwe where the Gweru District is situated, is estimated to be only 11%. This study examined the uptake of and reasons for use of different types of modern contraceptives; the factors influencing contraceptive use; discontinuation of use and non-use and reasons thereof for contraception and for long-acting reversible contraception in particular, amongst women in the Gweru district attending contraceptive services.

Thesis (MPH.) -- University of Limpopo, 2021 / Refer to document

Det finns många olika typer av preventivmedel för kvinnor, där en av de vanligaste är kombinerade hormonella p-piller. Många kvinnor vill undvika hormonella preventivmedel och använder sig av andra metoder för att undvika graviditet. Intressanta alternativ till hormonella preventivmedel har kommit de senaste åren, där en av dem är mobila applikationen Natural Cycles, som baserar sig på fertilitetsmedvetenhet.  Befintliga studier finns som undersöker hur effektivt och säkert Natural Cycles är som preventivmedel. Syftet med detta arbete är att undersöka applikationen Natural Cycles som preventivmedel, detta genom att jämföra Pearl Index och sannolikheten att bli gravid efter ett visst antal cykler av befintliga studier, och undersöka vilken demografi som Natural Cycles är bäst lämpad för.  Arbetet är en litteraturstudie där fem vetenskapliga artiklar analyserats. Studierna är hämtade från databasen PubMed och Google Scholar, och visar att Natural Cycles effektivitet med ett Pearl Index vid typisk användning är mellan 6,1–7,0. Detta visar att Natural Cycles effektivitet som preventivmedel är lika bra som tex. kombinerade hormonella p-piller, men sämre jämfört med tex. hormonspiral. Sannolikhet för graviditet efter en 13-cykelperiod för Natural Cycles beräknades till 6,3–8,3 %. Natural Cycles passar bäst för kvinnor runt 30 års ålder, som är i ett förhållande, har en högre utbildning och som tidigare använt kondom som preventivmedel.  Att tänka på är att alla studier som undersökts i detta arbete har varit sponsrade av just Natural Cycles, vilken kan ha påverkat resultatet. Det behövs göras mer forskning under längre tid och för större mångfald, och även göra studier som inte är sponsrade av Natural Cycles. / There are many different contraceptive methods for women and one of the most common are the combined hormonal birth control pills. Many women want to avoid hormonal contraceptive methods to prevent pregnancy. Interesting alternatives to hormonal contraceptives have emerged in recent years, and one of these is the mobile application Natural Cycles, which is based on fertility awareness. Existing studies are available that examine the effectiveness of Natural Cycles as a contraceptive.   The aim of this study is to investigate the effectiveness of the application Natural Cycles as a contraceptive, by comparing the Pearl index and the probability of becoming pregnant after a certain number of cycles of existing studies and also examine demographic which Natural Cycles is best suited for. This study is organized as a literature study, in which five scientific articles were analyzed. The studies were obtained from the database PubMed and Google Scholar and show that the effectiveness of Natural Cycles with a typical-use Pearl Index is between 6,1-7,0. This shows that Natural Cycles' effectiveness as a contraceptive is as good as e.g. combined hormonal birth control pills, but poorer compared to e.g. hormonal intrauterine device. The probability of pregnancy after a 13-cycle period for Natural Cycles was estimated to 6.3–8.3%. Natural Cycles is best suited for women around the age of 30, who are in a relationship, have a higher education and who have previously used a condom as a contraceptive. It should be borne in mind that all studies examined in this work have been sponsored by Natural Cycles, which may have affected the results. More research is needed for a longer period and for greater diversity, and to do studies that are not sponsored by Natural Cycles.

Tillgång till preventivmedel är betydelsefullt för att kvinnor ska kunna ha ett hälsosamt samliv utan risk för sexuellt överförbara sjukdomar samt oönskade och/eller oplanerade graviditeter. Preventivmedelsanvändningen i Sverige är hög och majoriteten av alla kvinnor anser att preventivmedelsanvändning är viktig. Målet inom hälso- och sjukvården är att göra kvinnan delaktig i vården vilken ska planeras och genomföras i samråd med henne. I dagsläget finns ingen vedertagen mall för hur preventivmedelsrådgivning ska utformas och genomföras vilket innebär att barnmorskor har olika strategier avseende den preventivmedelsrådgivning de ger. Det finns få studier i svensk kontext som undersöker kvinnors perspektiv på preventivmedelsrådgivning. Syftet med denna studie var att undersöka kvinnors perspektiv på vad som kännetecknar en god preventivmedelsrådgivning. Metoden som användes var en kvalitativ intervjustudie med en induktiv ansats. Åtta svenska kvinnor intervjuades individuellt med hjälp av en semistrukturerad intervjuguide. Som analysmetod användes en kvalitativ innehållsanalys. Studien var en del av ett större forskningsprojekt. I resultatet framkom två kategorier och fem underkategorier. Kvinnorna värdesatte att träffa en barnmorska som hade ett lyhört förhållningssätt och som gjorde dem delaktiga i beslutet om preventivmetod. Kvinnorna ville känna att barnmorskan var engagerad och att barnmorskan i största möjliga utsträckning strävade efter att utforma en individuell rådgivning. Det efterfrågades utökad information om olika metoders för- och nackdelar samt effekter av metoderna i ett långtidsperspektiv. Kvinnorna ville inte känna sig ifrågasatta om de valde en metod som barnmorskan inte förespråkade. Resultatet i föreliggande intervjustudie innebär att det ställs krav på att barnmorskan tar sig tid och engagerar sig i den enskilda kvinnans situation vid preventivmedelsrådgivningen. Nyckelord: Preventivmedelsrådgivning, barnmorska, kvinna, önskemål / Access to contraception is important in order for women to have a healthy sexual life without risk of sexually transmitted diseases and/or unplanned pregnancies. In Sweden, the use of contraceptive devices is high and the majority of all women consider it to be of great importance. The goal within healthcare in Sweden is to make the woman involved in her care which should be planned and carried out in consultation with her. There is no established guidance on how counseling regarding contraceptive devices should be performed which means that midwives have different strategies regarding the contraceptive counseling they provide. There are only a few studies in Swedish context examining women’s perspective on counseling regarding contraceptive devices. The aim of the study was to investigate women’s perspective on what characterizes a good contraceptive counseling. The used method was a qualitative study with an inductive approach. Eight Swedish women were individually interviewed using a semi-structured interview guide. As an analytical method qualitative content analysis was used. The study was a part of a bigger research. In the result two categories and five subcategories were found. Women valued to meet a midwife with a responsive attitude that made them involved in the decision making regarding contraceptive method. Women wanted to feel that the midwife was committed and that the midwife endeavored to design individual counseling. Women asked for more information on different methods pros and cons, as well as effects of the methods in a long-term perspective. The women did not want to feel questioned if they chose a method that the midwife did not advocate. The result of the current interview study implies that the midwife takes time and engages in the individual woman's situation during the contraceptive counseling. Keywords: Counseling, contraceptive devices, midwife, woman, request

Background It is estimated that 6.1 million people have HIV in South Africa, which makes it the country with the highest number of people living with HIV in the world. Adolescents are a severely affected and exposed group, since they tend to have several risk factors and a risky sexual behaviour. However, sexual education is implemented in school and there are special prevention programmes for adolescents in the country. Aim The aim of this study was to examine the HIV prevention work for adolescents in South Africa. Method The study was accomplished with a qualitative method and a semistructured interview design. The respondents were reached through purposive sampling and snowballing. In total six interviews were accomplished with people active within school, healthcare and different organisations. Results South Africa is a diverse country with many different cultures, beliefs and languages. Due to all the differences in the country, the widespread poverty and the previous political situation the challenges are many when it comes to prevention work. The key findings of the thesis are the importance of education and gender empowerment for adolescents to prevent the further spread. Conclusion HIV prevention for adolescents is important to reduce the HIV epidemic in South Africa. However, further education and gender empowerment is needed. Stigmatization and poor adherence to ART is also issues that need to be addressed in order to make progress in the prevention work. A mutual goal has appeared in the field of HIV prevention; to have zero new infections.

INTRODUCTION: Half of all pregnancies in South Carolina are unintended (mistimed or unwanted) and are associated with a higher risk for adverse maternal and infant health outcomes. South Carolina has a wide network of publicly supported clinics providing reproductive health services, including the Department of Health and Environmental Control, Federally Qualified Health Centers, and Rural Health Clinics. Having a better understanding of the geographic distribution of women in need of publicly funded contraceptive services is crucial for health planning and improving health delivery systems. METHODS: The total number of reproductive-aged women (15-44 years) in South Carolina was drawn from the 2017 American Community Survey (ACS) 5-Year Estimate files housed by the U.S. Census Bureau. A four-step process was used to estimate the number of reproductive-aged women in need of publicly funded contraceptive services at the county-level. First, the number of women between 15-19 years of age in each county was established. Next, the number of women with family incomes <100% of the federal poverty level in each county was identified. Data from the South Carolina Statewide Survey of Women, conducted by NORC at the University of Chicago, were used to estimate the number of reproductive-aged women (18-44) at-risk for experiencing an unintended pregnancy. The proportion of the women who were not sterile, not currently pregnant or not trying to get pregnant in the next 3 months was considered at-risk (76.24% of the total sample). The proportion of women at-risk was used to adjust the estimates of the total number of low-income women between 20-44 years of age in need of publicly funded contraceptive services in each county. The adjusted number of low-income women and the number of women less than 20 years of age were combined to estimate number of women in need of publicly funded contraceptive services. FINDINGS: There are an estimated 950,978 women of reproductive age living in South Carolina; of these women, about 40% (N=374,000) are considered in need of publicly funded contraceptive services. County-level need estimates ranged from 33.5% to 57.8% (M = 42.2%, SD = 4.8%) of the total reproductive-aged female population. While the number of women in need followed a typical population density pattern, rural communities had higher proportions of women in need of publicly funded contraceptive services, relative to the total population of reproductive-aged women. Rural counties comprised 91% of counties with the greatest need for publicly funded contraceptive services. CONCLUSIONS: Proportionally, the need for publicly funded contraceptive services is greater in rural and low-resource counties. While ensuring services are available among large population centers is certainly warranted, these findings also suggest that access to contraceptive services in rural counties is also needed and should be considered in health planning and service allocation policies and practices.

Introduction The U.S. South has higher rates of unintended pregnancy than other regions of the nation. Rurality and limited supply of medical providers and reproductive health services contribute to these disparities. Layered on this are restrictive reproductive health policies that are changing rapidly. Many rural areas in the South are "maternity care deserts” with no OB/GYNs, midwives, or obstetric care. In these areas, family physicians are often the only providers of reproductive health services. While family physicians commonly counsel about and prescribe oral contraceptives, little is known about their counseling practices for long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and contraceptive implants. This study examines attitudes and practices of family physicians in two Southern states related to counseling for IUDs and implants. Methods Statewide representative surveys of family physicians (FPs) were administered in South Carolina and Alabama in 2018. The survey questionnaire, informed by in-depth interviews with providers and a systematic literature review, collected data about providers’ knowledge, attitudes and practices related to contraceptive counseling and provision. The questionnaire was pilot tested, revised and finalized. Random samples of FPs from each state were selected, with oversampling of rural providers. Sampled providers were web traced and phone screened to verify eligibility and contact information. The IRB-approved survey protocol involved mixed-mode administration (electronic and mail surveys), participation incentives for providers and office managers, and extensive follow-up with non-respondents. Survey data were weighted to account for the sampling design and to generate robust estimates. Data were cleaned and analyzed in STATA using t-tests and chi-square tests for independence. Results Five hundred and ten (510) FPs responded to the survey. The majority of FPs (70%) were in private medical practice and one-fourth in rural areas. Among FPs in Alabama, 39.3% reported not counseling any of their reproductive-aged female patients in the past year about IUDs, and 53.1% reported not counseling about the implant. Prevalence of counseling did not differ significantly between AL and SC providers. While a majority of FPs in both states (88.7%) reported general training in contraceptive counseling during their formal education, fewer reported training specific to IUDs (61.7%) and implants (43.9%), and only 28% had received recent training in contraceptive counseling in the past 2 years. Risk perceptions of providers varied. Contrary to medical eligibility criteria, the majority of FPs considered IUDs unsafe for women who had an STI (sexually transmitted infection) in the past 2 years (62.4%) and unsafe immediately post-partum (69.4%). Contraceptive training was positively associated with counseling provision, whereas risk perceptions were negatively associated with counseling provision. Conclusion Substantial training gaps and needs were noted among FPs. While the scope of practice of FPs is broad and demanding, their engagement in comprehensive contraceptive counseling is essential for their patients’ health and well-being. This is particularly true in the U.S. south where contraceptive services are not always available or accessible. FPs must be supported through evidence-based training programs and clinic-level interventions that facilitate their contraceptive counseling and, ultimately, their patients’ contraceptive choices and outcomes.

Introduction: Health service organizations and their partners are increasingly under pressure to collaborate to deliver integrated patient care. The Collective Impact framework aligns well with respectful engagement and decision making between an organization and its partners, ensuring long-term change at the systems level. Shared vision, mutually reinforcing activities, and continuous communication are key components of a collective impact effort. Communication, in particular, plays an important role in all aspects of an organization, both internally and externally. Thoughtful feedback from partners and collaborative efforts can achieve collective impact and improved patient and population outcomes. Choose Well (CW), a statewide contraceptive access initiative in South Carolina, was developed using Collective Impact principles. CW launched in 2017 and continued through 2022. CW aimed to implement best practices for contraceptive access and provision. This study examined the perceptions of CW staff towards shared vision for contraceptive access, mutually reinforced activities, and communication strategies between CW and its partners. Methods: Data were collected in 2022 via exit key-informant interviews with CW staff to reflect across-all-years of their involvement with the initiative. A semi-structured interview guide was used, and the interviews were recorded, transcribed, and coded. A codebook was developed based on the interview guide. Data from questions related to 1) shared vision, 2) communication, and 3) mutually reinforcing activities between CW staff and partners were analyzed for this study. Coding was conducted with NVivo software version 1.7. Results: A total of eight CW staff participated in the interviews. Findings indicate that participants were very satisfied with the shared vision for contraceptive access between CW and its partners. The most prevalent facilitators for shared vision were constant and ongoing communication, collaboration with partners, and CW changes in framing for the initiative. Regarding communication, most participants perceived that the level of communication and coordination among various CW partners was consistent and streamlined. Integration of communication into daily processes, open communication with partners, and use of an online communication tool were mentioned as strategies that facilitated communication. Lack of administrative and partner buy-in among some partners, staff turnover, and pandemic-related challenges were commonly mentioned by participants as barriers to communication. Most participants perceived mutually reinforcing activities to be adaptability to partner needs, funding for the full range of contraceptive methods, collaboration efforts, and feedback from the partners. Conclusion: While lack of buy-in among some partners and the pandemic posed challenges, most participants perceived that constant and consistent communication facilitated a shared vision among the CW partners. Through adaptability, collaboration, and open communication with partners, CW adjusted its work to align with their partners’ goals. The findings of this study indicate that CW has coordinated their efforts around a common goal that aligns with their partners. CW maintained effective and consistent communication and integrated partner feedback as a Collective Impact approach towards improving contraceptive access and provision in SC. Shared vision and understanding of the health issue between the organization and partners can lead to a collective impact towards solving community health problems such as contraceptive access.

Gender equality and ensuring the equal rights of women and girls is the fifth United Nations Sustainable Development Goal set for 2030. Access to quality reproductive healthcare and information is a critical aspect of gender equality, including access to information about family planning and contraceptives. However, there are many barriers that impact a woman’s access to contraception in rural sub-Saharan Africa, such as financial constraints, supply shortages, stigma, and misconceptions. Through and African Feminist lens, this study examines how these perceived barriers intersect with each other, and how they negatively impact women’s access to family planning and their perceived value of contraceptives in Luweero, Uganda. This qualitative study analyzed data collected from healthcare workers at one private clinic and one public clinic that offer family planning services in four focus group discussions in Luweero, Central Region, Uganda. Two focus group discussions were held in each clinic. Coded transcripts were analyzed using a reflexive methodology through an African Feminist lens. Most of the responses indicated that financial constraints experienced either by the clinic or the women significantly impact access family planning. Healthcare workers and Village Health Teams (VHTs) reported that funding constraints impact their ability to reach the clients with the resources they need in the rural areas, and clients in rural areas are often not able to afford the cost of family planning methods, especially when considered with the hidden costs of contraception. Social barriers were also discussed, and the participants explained that barriers such as stigma, misconceptions, lack of knowledge, religiosity and cultural values impact women’s motivation or ability to access contraceptive methods. Side effects also have a significant role to play in women’s ability or motivation to navigate through these perceived social barriers. Participants determined that increased funding for transportation for VHTs, consistent funding for free contraception, and expanded sensitization efforts that particularly target men would be some of the most impactful methods they can adapt to address some of these barriers. This study demonstrates that increasing women’ access to contraception in rural Uganda requires increased state funding for sensitization efforts and subsidized contraceptive methods. Social barriers can be more deeply understood and addressed by the international development community through an African Feminist lens, which explores modern contraceptives in the Ugandan context in a more culturally, socially and historically conscientious way.

This thesis draws on a political economy of fertility framework and the concept of biocitizenship to analyze changing family size and family planning among women and men in northern Ghana. I draw on a variety of ethnographic sources from eight months of fieldwork conducted under the umbrella of the Navrongo Health Research Centre in 2013 and 2014 in two rural communities in Kassena-Nanakana (K-N) West District in the Upper East region. The primary questions behind this thesis are: 1. How has the desire for smaller families emerged and to what is this transformation linked? 2. What role have family planning programs played in the reduction in family size? Have they been the most important driver of the transition to smaller families? 3. What are the current ideas about family planning and contraceptives in K-N West? Are they gendered? How have they changed over time? 4. Are local views about family planning and contraceptives in K-N West in keeping with those of public health practitioners? These questions are addressed in this sandwich thesis in three papers, which have been submitted or accepted for publication. A major contribution of this thesis is its call for health programmes to pay greater attention to the social context of both women’s and men’s lives where family planning takes place. Contrary to existing public health studies, I argue that while health programming has affected fertility decline, larger social and economic shifts have been some of the most important drivers of women’s and men’s changing practices of family formation and views of contraceptives. In Kassena-Nakana West, the desire for smaller families is linked to processes such as decreasing levels of child mortality and agricultural productivity, as well as parents’ increasing focus on educating their children. In addition, the emerging concepts of responsible manhood and companionate marriage, combined with the decline of polygamy, have helped improve communication between husbands and wives about family planning. Narratives of changing family formation from Kassena-Nankana West expand understandings of biocitizenship by illustrating the important role intergenerational relationships play in the construction of “political economies of hope”. When young people adopt family planning, they not only consider the well-being of their own children and the larger community, but make the decision in the context of their aspirations for a more successful life than their parents experienced. Due to larger political-economic shifts, the majority of Kassena women and men today think family planning is beneficial; however, worries about the side effects of contraceptives remain. Women’s ongoing concerns about infertility and the stability of their marriages and men’s conditional acceptance of family planning also reveal that gender inequality persists. I argue that typical policy recommendations, which focus primarily on educating and sensitizing communities to increase the use of contraceptives are problematic in that they often focus on decreasing fertility and are not articulated within a broader, multi-sectoral agenda. Greater attention to local biologies and expanding reproductive rights and freedoms would improve existing family planning programs. / Dissertation / Doctor of Philosophy (PhD)