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1.
PLoS One ; 19(5): e0303974, 2024.
Article in English | MEDLINE | ID: mdl-38781153

ABSTRACT

Health literacy is generally low in marginalized groups, leading to delays in accessing care, poor health outcomes, and health disparities. Yet, some individuals in these groups demonstrate higher health literacy and better health outcomes. These exceptional cases exemplify 'positive deviance' because they have found ways to be successful where others have not. Identifying the methods, practices, and resources that these individuals have used to gain health literacy and healthcare access may have generalized application to improve health literacy, access to care, and health outcomes. Using the Integrated Model of Health Literacy, the main objectives of this study are to (1) identify facilitators, barriers, and strategies to gain sexual and reproductive health literacy and healthcare access and (2) to explore each of the core domains of health literacy as they relate to successful access of sexual and reproductive healthcare services among individuals identified as positive deviants. For the purposes of this mixed methods community engaged study, positive deviants are defined as Mexican American young women aged 18-29 years old living in Rural Western New York who have accessed sexual and reproductive healthcare within the past year. A community advisory committee will be formed to provide community-engaged guidance and support for the recruitment of participants. Positive deviants will participate in a survey and semi-structured interview. Data collection and analysis will be simultaneous and iterative. Results will provide evidence of positive deviant methods, practices, and strategies to gain health literacy and access to sexual and reproductive healthcare. Findings may reveal characteristics and patterns in the relationship of health literacy and healthcare access that can inform interventions to improve health literacy and make healthcare more accessible for this demographic group and context.


Subject(s)
Health Literacy , Health Services Accessibility , Mexican Americans , Reproductive Health , Sexual Health , Humans , Female , Adult , Adolescent , Young Adult , Mexican Americans/statistics & numerical data , Reproductive Health Services , Sexual Behavior , New York
2.
BMC Public Health ; 24(1): 966, 2024 Apr 05.
Article in English | MEDLINE | ID: mdl-38580970

ABSTRACT

BACKGROUND: Gay, bisexual, and cis-gender men who have sex with men (GBMSM) face severe consequences, especially within stigmatized environments. However, very little is known about the experiences of GBMSM living in slums in SSA and Ghana. This study investigates the experiences of stigma, victimization, and coping strategies and proposes some interventional approaches for combating stigma facing GBMSM in slum communities. METHODS: We engaged GBMSM living in slums in two major Ghanaian cities. We used a time-location sampling and collected data through in-depth individual interviews. Two major themes emerged from the study: (1) insecurities and criminalization of GBMSM activity, and (2) GBMSM coping strategies. RESULTS: Findings show GBMSM experienced negative attitudes from the community due to their sexual behavior/orientation. GBMSM also developed coping strategies to avert negative experiences, such as hiding their identities/behavior, avoiding gender non-conforming men, and having relationships with persons outside their communities. CONCLUSION: We propose interventions such as HIV Education, Empathy, Empowerment, Acceptance, and Commitment Therapy as possible measures to improve the experiences of GBMSM living in Ghanaian slum communities.


Subject(s)
Crime Victims , HIV Infections , Sexual and Gender Minorities , Male , Humans , Ghana , Homosexuality, Male , Poverty Areas , Coping Skills , Sexual Behavior
5.
Cult Health Sex ; 24(9): 1289-1301, 2022 09.
Article in English | MEDLINE | ID: mdl-35649425

ABSTRACT

Men who have sex with men living with HIV in majority Muslim communities face discrimination based on multiple forms of stigma at socio-cultural and legislative levels. This study aimed to explore qualitatively the experiences of men who have sex with men living with HIV in Dakar, Senegal. In-depth individual interviews were conducted with 30 Senegalese men aged 18 to 55 years, who self-reported as same-sex practising, Muslim, and receiving HIV treatment at health centres in Dakar. Interview data were analysed using an ethnographic phenomenological approach to explore their life experiences. Primary themes included: the self-discovery process; the social, religious and health ramifications of being same-sex practising; and stigma. Within the theme of stigma issues described included shame, blame (of self and others), and violence resulting from being a man who has sex with other men and/or being HIV seropositive. Those with undetectable viral load reported how HIV related stigma and burden diminished as their health improved. Disclosure of being men who have sex with men and/or HIV status, whether voluntary or not, affected experiences of violence and/or isolation. Addressing stigma at healthcare institutions and improving access to HIV treatment can help mitigate the burden of stigma affecting such men. Interventions to address their physical and psychosocial wellbeing require the engagement of multiple stakeholders, including religious and political leaders.


Subject(s)
HIV Infections , Sexual and Gender Minorities , Female , HIV Infections/psychology , Homosexuality, Male/psychology , Humans , Islam , Male , Senegal , Social Stigma
6.
Matern Child Health J ; 26(4): 751-760, 2022 Apr.
Article in English | MEDLINE | ID: mdl-35316456

ABSTRACT

OBJECTIVES: Black women face disparities in maternal morbidity and mortality when compared to White women. Multiple factors contribute to these disparities. This study examines the perspectives of Black women who have given birth in the last 5 years, to understand their pregnancy and birth experiences as a means of ascertaining factors that may be contributing to these disparities. METHODS: The Consortium to End Black Maternal Mortality was established as a collaborative table of cross-sector stakeholders and Black mothers to effectively conduct community-based participatory research focused on Black maternal health. Between January and March 2020, Black mothers who had given birth in the last 5 years facilitated Listening Sessions (LS) with other Black mothers in Rochester, NY. Participants reported on details of their pregnancy and delivery, including interaction with providers, personal relationships and their individual experience. The qualitative data captured during these sessions were coded to draw out key themes which were validated with LS participants and the Consortium. RESULTS: The key themes that emerged clustered into four groups, including: (1) Mother-Provider Communication; (2) Social Support; (3) Systemic factors and (4) Maternal Emotional & Mental Health. Mother-provider communication was the most salient factor affecting the maternal experience and was found to be influenced primarily by maternal health literacy and provider discriminatory attitudes and behaviors. CONCLUSIONS FOR PRACTICE: As a result of the Listening Sessions conducted with Black women, we identified mother-provider communication as the most important factor influencing the maternal experience.


Subject(s)
Mothers , Perinatal Care , Black or African American , Black People , Child , Female , Humans , Infant, Newborn , Mothers/psychology , Parturition , Pregnancy
8.
Int J MCH AIDS ; 9(1): 136-145, 2020.
Article in English | MEDLINE | ID: mdl-32123636

ABSTRACT

BACKGROUND OR OBJECTIVES: Worldwide, men who have sex with men (MSM) and Transgender persons are vulnerable to psychosocial factors associated with high risk for HIV, and suffer disproportionately high rates of HIV/AIDS. In the United States (US), the House Ball Community (HBC) is a social network comprised predominantly of Black and Hispanic MSM and Transgender persons who reside in communal settings. This study explores Western New York HBC leaders' perceptions of HIV in their communities and their knowledge of HIV prevention strategies, including HIV vaccine trials. METHODS: The project was conducted using an exploratory approach based on the principles of Community-Based Participatory Research (CBPR) methods. An HIV behavioral risk assessment provided descriptive data, while qualitative measures explored psychosocial and behavioral factors. RESULTS: Behavioral assessments indicated high levels of risky sexual behaviors and experiences of violence. Interviews with 14 HBC leaders revealed that knowledge of HIV and local HIV vaccines trials was limited. Barriers to HIV knowledge included fear of peer judgment, having inaccurate information, and lack of formal education. Experiencing violence was identified as barrier to positive health behavior. Nevertheless, the HBC was described as a safe and creative space for marginalized MSM and Transgender youth. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Findings suggest that the interrelation between health problems and social context amplify HIV risk in the HBC. The organizational structure and resources of the HBC, and MSM/Transgender communities worldwide can be instrumental in informing interventions to address HIV-related risk behaviors and create appropriate recruitment tools to ensure their representation in HIV research.

10.
Subst Abuse ; 13: 1178221818818846, 2019.
Article in English | MEDLINE | ID: mdl-30643416

ABSTRACT

Women with substance use disorders (SUDs) often experience inadequate health care, mental and physical health problems, trauma, lack of social support, and undermining of support for psychological needs of autonomy, competence, and relatedness needed for motivation and well-being. For women with SUD trying to reclaim sobriety and a healthy life, family can present both barriers and support. The aim of this study is to gain a deeper understanding of the intersection of family relationships with motivation of women in Drug Treatment Court (DTC) to attain their health goals. Data consist of transcribed intervention sessions between trained peer interventionists and 15 DTC participants from The Women's Initiative Supporting Health DTC Intervention Study. This analysis uses a qualitative framework approach to analyze the data. The Self-determination Theory of human motivation and Family Systems Theory provide the conceptual framework to understand how participants' expressions of motivation-related basic needs of autonomy, competence, and relatedness and change-related behaviors interfaced with family support. Analysis revealed more mentions of family in motivation-supportive contexts than in motivation-thwarting contexts, but highlighted complex roles families can play in health of women in recovery from SUD. Providers may be able to incorporate this knowledge to address the needs of this challenging population.

11.
J AIDS HIV Res ; 10(1)2018.
Article in English | MEDLINE | ID: mdl-29881646

ABSTRACT

The Human Research Council's National HIV Prevalence, Incidence and Behavior Survey ranks South Africa first in HIV incidence in the world with 400,000 new infections in 2012 and found the HIV incidence rate among female youth aged 15 to 24 years to be 2.5% that year. The objective of this study was to compare the pattern and predictability of sexual activity between HIV-infected and HIV-uninfected young South African women. Sexually active young women between the ages of 16 and 21 years old completed a study survey between October 2012 and 2014 at two Desmond Tutu HIV Foundation centers. 100 young women with a mean age of 19.04 years responded to the survey. 51 women (51%) were HIV-infected and 49 were HIV-uninfected (49%). HIV-infected young women were found to be statistically less likely to have a temporal pattern to their sexual activity as compared to HIV-uninfected young women (56.9 vs. 95.9%, p<0.0001). While controlling for frequency of sex and lifetime sexual partners, HIV status remains a significant predictor of having a pattern of sexual activity (OR=16.13, p=0.0004) and a predictor of having sex on the weekend only (OR=4.41, p=0.0022). The ability to predict when sexual activity will occur enables a woman to prepare for its associated risks. HIV-uninfected young women are more likely to have a predictable pattern to their sexual activity as compared to HIV-infected young women. Knowledge of the sexual behavior patterns of this high-risk population will aid in the development of effective HIV prevention campaigns.

12.
Jpn J Nurs Sci ; 13(3): 297-308, 2016 Jul.
Article in English | MEDLINE | ID: mdl-26820113

ABSTRACT

AIM: There is a debate within the medical community regarding the safety of planned home births. The presumption of increased risk of maternal and infant morbidity and mortality at home due to limited access to life-saving interventions is not clearly supported by research. The aim of the present study was to assess strengths and limitations of the methodological approaches of cohort studies that compare home births with hospital births by focusing on selected infant outcomes. METHODS: Studies were identified that assess the risk for at least one of three infant outcomes (mortality, Apgar score, and admission to the neonatal intensive care unit [NICU]) of home births compared with hospital births. RESULTS: Fifteen cohort studies were included. Two studies of low-risk births and two including higher risk births found home births to be at an increased risk of neonatal mortality. However, mortality is rare in developed nations and may not be the best measure of safety. When studies focused on low-risk pregnancies, planned birth location, and well-trained birth attendants, there was no difference in neonatal morbidity (Apgar score and NICU admission). CONCLUSION: Many methodological challenges were identified among these studies. This review contributes to the home birth published work by identifying key strengths and limitations that need to be accounted for in the interpretation of study findings and the development of future studies. Based on this review, the key variables that would strengthen future studies are birth attendant identification, documented planned birth location, and specification of the birth risk level. Uniformity of data collection and minimizing missing data are also critical.


Subject(s)
Home Childbirth , Patient Safety , Pregnancy Outcome , Apgar Score , Cohort Studies , Female , Humans , Infant , Infant Mortality , Infant, Newborn , Intensive Care Units, Neonatal , Patient Admission , Pregnancy
13.
J Prim Prev ; 36(3): 205-12, 2015 Jun.
Article in English | MEDLINE | ID: mdl-25762508

ABSTRACT

We assessed the impact of Central Hillsborough Healthy Start (CHHS), a federally-funded program dedicated to improving maternal and infant outcomes in a population of high-risk obese mothers in the socio-economically challenged community of East Tampa in Florida on preterm birth and very preterm birth (VPTB). We utilized hospital discharge records linked to vital statistics data in Florida (2004-2007) to study obese women with a singleton birth, matching mothers in the CHHS catchment area with those from the rest of Florida. We conducted conditional logistic regression with the matched data. Obese mothers in the CHHS service area had a 61% lower likelihood of having a VPTB infant than obese mothers in the rest of the state (AOR = 0.39, 95% CI 0.21-0.70). Obese women of reproductive age may benefit from services from federal Healthy Start programs. Study findings underscore the need for further research to explore the impact of such programs.


Subject(s)
Health Promotion/organization & administration , Obesity/complications , Premature Birth/prevention & control , Adult , Body Mass Index , Federal Government , Female , Financing, Government , Florida , Humans , Pregnancy , Program Evaluation
14.
Am J Mens Health ; 9(1): 6-14, 2015 Jan.
Article in English | MEDLINE | ID: mdl-23913897

ABSTRACT

Prior research indicates that infants with absent fathers are vulnerable to unfavorable fetal birth outcomes. HIV is a recognized risk factor for adverse birth outcomes. However, the influence of paternal involvement on fetal morbidity outcomes in women with HIV remains poorly understood. Using linked hospital discharge data and vital statistics records for the state of Florida (1998-2007), the authors assessed the association between paternal involvement and fetal growth outcomes (i.e., low birth weight [LBW], very low birth weight [VLBW], preterm birth [PTB], very preterm birth [VPTB], and small for gestational age [SGA]) among HIV-positive mothers (N=4,719). Propensity score matching was used to match cases (absent fathers) to controls (fathers involved). Conditional logistic regression was employed to generate adjusted odds ratios (OR). Mothers of infants with absent fathers were more likely to be Black, younger (<35 years old), and unmarried with at least a high school education (p<.01). They were also more likely to have a history of drug (p<.01) and alcohol (p=.02) abuse. These differences disappeared after propensity score matching. Infants of HIV-positive mothers with absent paternal involvement during pregnancy had elevated risks for adverse fetal outcomes (LBW: OR=1.30, 95% confidence interval [CI]=1.05-1.60; VLBW: OR=1.72, 95% CI=1.05-2.82; PTB: OR=1.38, 95% CI=1.13-1.69; VPTB: OR=1.81, 95% CI=1.13-2.90). Absence of fathers increases the likelihood of adverse fetal morbidity outcomes in women with HIV infection. These findings underscore the importance of paternal involvement during pregnancy, especially as an important component of programs for prevention of mother-to-child transmission of HIV.


Subject(s)
Fathers , Fetal Development , HIV Seropositivity , Interpersonal Relations , Pregnancy Outcome , Adult , Databases, Factual , Female , Florida , Humans , Male , Mothers , Pregnancy , Propensity Score , Retrospective Studies , Vital Statistics
15.
Prog Community Health Partnersh ; 8(3): 305-16, 2014.
Article in English | MEDLINE | ID: mdl-25435557

ABSTRACT

BACKGROUND: In light of the increasing rates of HIV infection in African Americans, it is essential that black faith leaders become more proactive in the fight against the epidemic. The study aim was to engage faith leaders in a sustainable partnership to increase community participation in preventive HIV vaccine clinical research while improving their access to and utilization of HIV/AIDS prevention services. METHOD: Leadership Development Seminars were adapted for faith leaders in Rochester, NY, with topics ranging from the importance of preventive HIV vaccine research to social issues surrounding HIV/AIDs within a theological framework. Seminars were taught by field-specific experts from the black community and included the development of action plans to institute HIV preventive ministries. To assess the outcome of the Seminars, baseline and post-training surveys were administered and analyzed through paired sample t Tests and informal interviews. RESULTS: 19 faith leaders completed the intervention. In general, the majority of clergy felt that their understanding of HIV vaccine research and its goals had increased postintervention. A critical outcome was the subsequent formation of the Rochester Faith Collaborative by participating clergy seeking to sustain the collaborative and address the implementation of community action plans. CONCLUSION: Providing scientific HIV/AIDS knowledge within the context of clergy members' belief structure was an effective method for engaging black Church leaders in Rochester, NY. Collaborative efforts with various local institutions and community-based organizations were essential in building trust with the faith leaders, thereby building bridges for better understanding of HIV/AIDS prevention efforts, including HIV vaccine research.


Subject(s)
AIDS Vaccines , Biomedical Research , Black or African American , Capacity Building , Clergy , Community-Institutional Relations , HIV Infections/prevention & control , Health Promotion/organization & administration , Health Services Accessibility , Adult , Community-Based Participatory Research , Female , Humans , Interviews as Topic , Leadership , Male , New York
16.
AIDS Care ; 26(11): 1452-60, 2014.
Article in English | MEDLINE | ID: mdl-24865892

ABSTRACT

The informed consent process (ICP) for HIV vaccine trials poses unique challenges and would benefit from improvements to its historically based structure and format. Here, we propose a theoretical framework that provides a basis for systematically evaluating and addressing these challenges. The proposed framework follows a linear pathway, starting with the precondition of voluntariness, three main variables of valid decision-making (competency, provision of information and understanding) and then the consequential outcome of either refusal or consent to participate. The existing literature reveals that culturally appropriate provision of information and resultant understanding by the vaccine trial participant are among the most significant factors influencing the authenticity of valid decision-making, though they may be overridden by other considerations, such as individual altruism, mistrust, and HIV-related stigma. Community collaborations to foster bidirectional transmission of information and more culturally tailored consenting materials, therefore, represent a key opportunity to enhance the ICP. By providing a visual synopsis of the issues most critical to IC effectiveness in a categorical and relational manner, the framework provided here presents HIV vaccine researchers a tool by which the ICP can be more systematically evaluated and consequently improved.


Subject(s)
AIDS Vaccines , Clinical Trials as Topic , HIV Infections/prevention & control , Informed Consent , Community-Institutional Relations , Comprehension , Confidentiality , Culture , Decision Making , Humans , Models, Theoretical
17.
Matern Child Health J ; 18(9): 2054-60, 2014 Nov.
Article in English | MEDLINE | ID: mdl-24549651

ABSTRACT

The absence of fathers during pregnancy increases the risk of feto-infant morbidities, including low birth weight (LBW), preterm birth (PTB), and small-for-gestational age. Previous research has shown that the Central Hillsborough Healthy Start project (CHHS)-a federally funded initiative in Tampa, Florida-has improved birth outcomes. This study explores the effectiveness of the CHHS project in ameliorating the adverse effects of fathers' absence during pregnancy. This retrospective cohort study used CHHS records linked to vital statistics and hospital discharge data (1998-2007). The study population consisted of women who had a singleton birth with an absent father during pregnancy. Women were categorized based on residence in the CHHS service area. Propensity score matching was used to match cases (CHHS) to controls (rest of Florida). Conditional logistic regression was employed to generate odds ratios (OR) and 95 % confidence intervals (CI) for matched observations. Women residing in the CHHS service area were more likely to be high school graduates, black, younger (<35 years), and to have adequate prenatal care compared to controls (p < 0.01). These differences disappeared after propensity score matching. Mothers with absent fathers in the CHHS service area had a reduced likelihood of LBW (OR 0.76, 95 % CI 0.65-0.89), PTB (OR 0.72, 95 % CI 0.62-0.84), very low birth weight (OR 0.50, 95 % CI 0.35-0.72) and very preterm birth (OR 0.48, 95 % CI 0.34-0.69) compared to their counterparts in the rest of the state. This study demonstrates that a Federal Healthy Start project contributed to a significant reduction in adverse fetal birth outcomes in families with absent fathers.


Subject(s)
Fathers/statistics & numerical data , Healthy People Programs , Pregnancy Outcome/epidemiology , Prenatal Care/organization & administration , Social Support , Adult , Chi-Square Distribution , Ethnicity/ethnology , Ethnicity/statistics & numerical data , Female , Florida/epidemiology , Gestational Age , Government Programs , Humans , Infant, Low Birth Weight , Infant, Newborn , Male , Maternal Age , Pregnancy , Premature Birth/epidemiology , Prenatal Care/methods , Prenatal Care/psychology , Program Evaluation , Retrospective Studies , Single-Parent Family/ethnology , Single-Parent Family/statistics & numerical data
18.
Matern Child Health J ; 18(6): 1380-90, 2014 Aug.
Article in English | MEDLINE | ID: mdl-24158503

ABSTRACT

Lack of paternal involvement has been shown to be associated with adverse pregnancy outcomes, including infant morbidity and mortality, but the impact on health care costs is unknown. Various methodological approaches have been used in cost minimization and cost effectiveness analyses and it remains unclear how cost estimates vary according to the analytic strategy adopted. We illustrate a methodological comparison of decision analysis modeling and generalized linear modeling (GLM) techniques using a case study that assesses the cost-effectiveness of potential father involvement interventions. We conducted a 12-year retrospective cohort study using a statewide enhanced maternal-infant database that contains both clinical and nonclinical information. A missing name for the father on the infant's birth certificate was used as a proxy for lack of paternal involvement, the main exposure of this study. Using decision analysis modeling and GLM, we compared all infant inpatient hospitalization costs over the first year of life. Costs were calculated from hospital charges using department-level cost-to-charge ratios and were adjusted for inflation. In our cohort of 2,243,891 infants, 9.2% had a father uninvolved during pregnancy. Lack of paternal involvement was associated with higher rates of preterm birth, small-for-gestational age, and infant morbidity and mortality. Both analytic approaches estimate significantly higher per-infant costs for father uninvolved pregnancies (decision analysis model: $1,827, GLM: $1,139). This paper provides sufficient evidence that healthcare costs could be significantly reduced through enhanced father involvement during pregnancy, and buttresses the call for a national program to involve fathers in antenatal care.


Subject(s)
Paternal Behavior , Pregnancy Outcome , Adult , Cost-Benefit Analysis , Decision Trees , Female , Health Care Costs/statistics & numerical data , Humans , Infant , Infant Mortality , Infant, Newborn , Infant, Newborn, Diseases/economics , Infant, Newborn, Diseases/epidemiology , Linear Models , Male , Pregnancy , Pregnancy Outcome/economics , Pregnancy Outcome/epidemiology , Retrospective Studies , Young Adult
19.
J Gay Lesbian Soc Serv ; 26(3): 336-354, 2014 Jul 01.
Article in English | MEDLINE | ID: mdl-25642120

ABSTRACT

Men who sleep with men (MSM) and transgender individuals of color, the largest demographic in the House Ball community (HBC) are amongst the group at highest risk for HIV infection in the United States. The HBC have limited access to culturally appropriate HIV education. This study aimed to develop a partnership with HBC leaders to uncover strategies for increasing HIV prevention knowledge, including participation in HIV vaccine trials. To this end a research institution-community-HBC partnership was established. In-depth qualitative and quantitative data were collected from the 14 HBC leaders in western New York, revealing that knowledge of HIV and related vaccine trials was limited. Barriers to increasing HIV knowledge included fear of peer judgment, having inaccurate information about HIV, and lack of education. Among the HBC, community partnerships will further aid in the development of future HIV prevention programs and increase individuals' willingness to participate in future HIV vaccine trials.

20.
Afr J Reprod Health ; 17(1): 41-8, 2013 Mar.
Article in English | MEDLINE | ID: mdl-24069733

ABSTRACT

The objective of this study is to evaluate the levels of emergency obstetrics care (EOC) signal functions in health facilities in a developing setting with high maternal morbidity and mortality indices and to determine if there are differences between public and private health facilities in terms of availability of these signal functions. A survey of health facilities was carried out in six of the 16 Local Government Areas (LGAs) of Kwara State Nigeria. All health facilities in these LGAs including public and private health facilities offering some services to pregnant women were surveyed using an interviewer- administered, facility-assessment questionnaire adapted from the WHO/UNFPA/UNICEF international guidelines for monitoring the availability and use of obstetric services. Frequency tables, percentages and charts were used for presenting the data. Comparing public and private facilities was done using chi-square tests. A total of 258 health facilities that provide maternal health services were surveyed in this study, out of which 76 (29.5%) were private facilities and 182 (70.5%) were public sector facilities. Most of the UN indicators were not met by the health facilities in Kwara state. The availability of EOC facilities was more among the private sector and this was statistically significant. This study shows that all stakeholders involved in reducing maternal mortality have a big challenge in the areas of availability, inequity in geographical distribution of EOC facilities and poor utilisation of these EOC services by women.


Subject(s)
Emergency Medical Services/supply & distribution , Maternal Health Services/supply & distribution , Adult , Chi-Square Distribution , Emergency Medical Services/standards , Female , Health Services Needs and Demand , Humans , Maternal Health Services/standards , Nigeria , Pregnancy , Private Sector , Public Sector , Surveys and Questionnaires
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