Attitudes and Experiences Surrounding Female Genital Mutilation/Cutting in the United States: A Scoping Review.

To identify research and gaps in literature about FGM/C-related attitudes and experiences among individuals from FGM/C-practicing countries living in the United States, we conducted a scoping review guided by Arksey and O'Malley's framework. We searched Medline (OVID), Embase (OVID), PubMed, and SCOPUS and conducted a grey literature search for studies assessing attitudes or experiences related to FGM/C with data collected directly from individuals from FGM/C-practicing countries living in the United States. The search yielded 417 studies, and 40 met the inclusion criteria. Findings suggest that women and men from FGM/C-practicing countries living in the United States generally oppose FGM/C, and that women with FGM/C have significant physical and mental health needs and have found US healthcare providers to lack understanding of FGM/C. Future research can improve measurement of FGM/C by taking into account the sociocultural influences on FGM/C-related attitudes and experiences.

Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia.

BACKGROUND: Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions. METHODS: SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities. RESULTS: Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country. CONCLUSIONS: MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths.

Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services.

Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care at birth. While originally the "Three Delays" model was designed to focus on curative services that encompass emergency obstetric care, SMGL expanded its application to primary and secondary prevention of obstetric complications. Prevention of the "first delay" focused on addressing factors influencing the decision to seek delivery care at a health facility. Numerous factors can contribute to the first delay, including a lack of birth planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care, and financial or geographic barriers. SMGL addressed these barriers through community engagement on safe motherhood, public health outreach, community workers who identified pregnant women and encouraged facility delivery, and incentives to deliver in a health facility. SMGL used qualitative and quantitative methods to describe intervention strategies, intervention outcomes, and health impacts. Partner reports, health facility assessments (HFAs), facility and community surveillance, and population-based mortality studies were used to document activities and measure health outcomes in SMGL-supported districts. SMGL's approach led to unprecedented community outreach on safe motherhood issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL districts. In Uganda, the proportion of births that took place in facilities rose from 45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts, facility deliveries increased from 62.6% to 90.2% (44% increase). In both countries, the proportion of women delivering in facilities equipped to provide emergency obstetric and newborn care also increased (from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines in the number of maternal deaths due to not accessing facility care during pregnancy, delivery, and the postpartum period in both countries. This reduction played a significant role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda but not in Zambia. Further work is needed to sustain gains and to eliminate preventable maternal and perinatal deaths.

Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care.

BACKGROUND: Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response. METHODS: SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data-health facility assessments, facility and community surveillance, and population-based mortality studies-were used to document the effectiveness of intervention components. RESULTS: During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline-from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened. CONCLUSION: SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths.

Did Saving Mothers, Giving Life Expand Timely Access to Lifesaving Care in Uganda? A Spatial District-Level Analysis of Travel Time to Emergency Obstetric and Newborn Care.

INTRODUCTION: Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access. METHODS: We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources. RESULTS: The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P < .01) could be used. Increases in timely access were also substantial for nonmotorized transportation such as walking and/or bicycling. CONCLUSIONS: Largely due to the SMGL-supported expansion of EmONC capability, timely access to EmONC significantly improved. Our analysis developed a geographic outline of facility accessibility using multiple types of transportation. Spatial travel-time analyses, along with other EmONC indicators, can be used by planners and policy makers to estimate need and target underserved populations to achieve further gains in EmONC accessibility. In addition to increasing the number and geographic distribution of EmONC facilities, complementary efforts to make motorized transportation available are necessary to achieve meaningful increases in EmONC access.

Physical violence against U.S. women around the time of pregnancy, 2004-2007.

BACKGROUND: Previous research shows that the prevalence of intimate partner violence (IPV) around the time of pregnancy varies from 4% to 9%, but no studies have distinguished between abuse rates by former versus current partners. PURPOSE: This study aims to estimate the prevalence of IPV among U.S. women shortly before and during pregnancy and to compare the rates and predictors of abuse perpetrated by current partners with the rates and predictors of abuse perpetrated by former partners. METHODS: Using data from 27 states and New York City, the prevalence of physical abuse by current and former intimate male partners was estimated among 134,955 women who delivered a singleton, full-term infant in 2004-2007. Multivariable logistic regression was used to determine the demographic, pregnancy-related, and stress factors that predicted the risk of IPV. RESULTS: Prevalence of IPV from either a former or current partner was 5.3% before and 3.6% during pregnancy. Prevalence of abuse by a former partner was consistently higher than the prevalence of abuse by a current partner. The three strongest predictors of IPV during pregnancy were the woman's partner not wanting the pregnancy (current: AOR=3.47, 95% CI=3.13, 3.85; former: AOR=3.22, 95% CI=2.90, 3.76); having had a recent divorce or separation (current: AOR=3.23, 95% CI=2.92, 3.58; former: AOR=3.54, 95% CI=3.20, 3.91); and being close to someone having a drug or alcohol problem (current: AOR=3.05, 95% CI=2.78, 3.36; former: AOR=2.97, 95% CI=2.70, 3.27). Maternal characteristics (age, education, race, marital status, woman did not want the pregnancy) were less important predictors. CONCLUSIONS: Assessments of abuse should ask specifically about actions by both current and ex-partners.

Dimensions of child punishment in two Central American countries: Guatemala and El Salvador.

OBJECTIVE: Severe physical punishment of children is an important issue in international child health and welfare. This study examines such punishment in Guatemala and El Salvador. METHODS: Data came from nationally representative surveys of women aged 15-49 and men aged 15-59 residing in Guatemala (2002) and El Salvador (2002-2003). The surveys included questions about punishment experienced during childhood, with response options ranging from verbal scolding to beating. In Guatemala, parents were asked how they disciplined their children; questions allowed them to compare how they were punished in their childhood with how they punished their own children. Bivariate and multivariate analyses are presented. RESULTS: In Guatemala, 35% of women and 46% of men reported being beaten as punishment in childhood; in El Salvador, the figures were 42% and 62%, respectively. In both countries, older participants were relatively more likely than younger participants to have been beaten as children. Witnessing familial violence was associated with an increased risk of being beaten in childhood. In Guatemala, having experienced physical punishment as a child increased the chance that parents would use physical punishment on their own children. Multivariate analyses revealed that women who were beaten in childhood were significantly more likely in both countries to be in a violent relationship. CONCLUSIONS: The use of beating to physically punish children is a common problem in Guatemala and El Salvador, with generational and intergenerational effects. Its negative and lingering effects necessitate the introduction of policies and programs to decrease this behavior.

Dimensions of child punishment in two Central American countries: Guatemala and El Salvador / Dimensiones del castigo infantil en dos países de América Central: Guatemala y El Salvador

OBJECTIVE: Severe physical punishment of children is an important issue in international child health and welfare. This study examines such punishment in Guatemala and El Salvador. METHODS: Data came from nationally representative surveys of women aged 15-49 and men aged 15-59 residing in Guatemala (2002) and El Salvador (2002-2003). The surveys included questions about punishment experienced during childhood, with response options ranging from verbal scolding to beating. In Guatemala, parents were asked how they disciplined their children; questions allowed them to compare how they were punished in their childhood with how they punished their own children. Bivariate and multivariate analyses are presented. RESULTS: In Guatemala, 35 percent of women and 46 percent of men reported being beaten as punishment in childhood; in El Salvador, the figures were 42 percent and 62 percent, respectively. In both countries, older participants were relatively more likely than younger participants to have been beaten as children. Witnessing familial violence was associated with an increased risk of being beaten in childhood. In Guatemala, having experienced physical punishment as a child increased the chance that parents would use physical punishment on their own children. Multivariate analyses revealed that women who were beaten in childhood were significantly more likely in both countries to be in a violent relationship. CONCLUSIONS: The use of beating to physically punish children is a common problem in Guatemala and El Salvador, with generational and intergenerational effects. Its negative and lingering effects necessitate the introduction of policies and programs to decrease this behavior.

OBJETIVOS: El castigo físico severo de niños es un tema importante de la salud y el bienestar infantil en el mundo. En el presente estudio se analiza este tipo de castigo en Guatemala y El Salvador. MÉTODOS: Se tomaron los datos de encuestas representativas nacionales realizadas a mujeres de 14 a 59 años y hombres de 15 a 59 años que residían en Guatemala (2002) y El Salvador (2002-2003). Las encuestas contenían preguntas sobre los castigos que sufrieron en su niñez, con posibilidades de respuesta que iban desde regaños verbales hasta golpizas. En Guatemala se preguntó a los padres cómo disciplinaban a sus hijos; las preguntas les permitían comparar cómo ellos eran castigados en su niñez y cómo ellos castigaban a sus hijos. Se presentan los resultados de los análisis bifactorial y multifactorial. RESULTADOS: En Guatemala, 35 por ciento de las mujeres y 46 por ciento de los hombres informaron haber sido golpeados como castigo durante su niñez; en El Salvador, las cifras fueron 42 por ciento y 62 por ciento, respectivamente. En ambos países, los encuestados más viejos tenían una mayor probabilidad de haber sido golpeados en su niñez que los encuestados más jóvenes. Haber presenciado violencia familiar se asoció con un incremento en el riesgo de recibir golpizas durante la niñez. En Guatemala, haber recibido castigos físicos durante la niñez aumentó la probabilidad de que como padres aplicaran castigos físicos a sus hijos. El análisis multifactorial reveló que las mujeres de ambos países golpeadas durante su niñez tenían significativamente más probabilidades de encontrarse en una relación violenta. CONCLUSIONES: El uso de golpes para castigar físicamente a niños es un problema frecuente en Guatemala y El Salvador, con efectos generacionales e intergeneracionales. Sus efectos prolongados y negativos requieren de la aplicación de políticas y programas que permitan reducir este comportamiento.

Physical abuse around the time of pregnancy: an examination of prevalence and risk factors in 16 states.

OBJECTIVES: From self-reports we describe and compare the levels and patterns of physical abuse before and during pregnancy while also describing the demographic and pregnancy-related characteristics of physically abused women, the stressful experiences of abused women prior to delivery, and the relationship of the abused woman to the perpetrator(s). METHODS: We used population-based estimates from the Pregnancy Risk Assessment Monitoring System (1996-98) to calculate a multiyear 16-state prevalence with 95% confidence intervals (CIs) and unadjusted risk ratios for demographic, pregnancy-related, and stressful experiences variables. RESULTS: We found the prevalence of abuse across the 16 states to be 7.2% (95% CI, 6.9-7.6) during the 12 months before pregnancy, 5.3% (95% CI, 5.0-5.6) during pregnancy, and 8.7% (95% CI, 8.3-9.1) around the time of pregnancy (abuse before or during pregnancy). The prevalence of physical abuse during pregnancy across the 16 states was consistently lower than that before pregnancy. For time periods both before and during pregnancy, higher prevalence was found for women who were young, not White, unmarried, had less than 12 years of education, received Medicaid benefits, or had unintended pregnancies, and for women with stressful experiences during pregnancy, particularly being involved in a fight or increased arguing with a husband or partner. For each of these risk groups, the prevalence was lower during pregnancy than before. Abuse was ongoing before pregnancy for three quarters of the women experiencing abuse by a husband or partner during pregnancy. CONCLUSIONS: Women are not necessarily at greater risk of physical abuse when they are pregnant than before pregnancy. Both the preconception period and the period during pregnancy are periods of risk, which suggests that prevention activities are appropriate during routine health care visits before pregnancy as well as during family planning and prenatal care.