Evaluation of a single-dose HPV vaccine strategy for promoting vaccine, health, and gender equity.

Although several countries have adopted a single-dose human papillomavirus (HPV) vaccination strategy, many other countries continue to include multiple doses in their vaccination programmes. There are ethical reasons to transition to a single-dose strategy. We discuss how a single-dose HPV vaccination strategy advances equity in three dimensions: vaccine equity, health equity, and gender equity. Adopting a single-dose strategy eases pressure on vaccine supply, lowers programme costs, and is easier to distribute. This change facilitates vaccine procurement and implementation programmes (contributing to vaccine equity) and reaching hard to reach people or populations (contributing to health equity). A lower number of cases of HPV-related diseases that stem from greater vaccine distribution reduces the burden on women, who are at a higher risk of HPV-related disease or who act as caregivers, which prevents them from accessing opportunities that contribute to their empowerment (contributing to gender equity). Thus, pursuing the single-dose HPV vaccination programme strategy is ethically desirable.

Expediting approval for medical countermeasures to address high burden disease: an ethical justification to move beyond emergency use authorisation.

Addressing global health crises requires a receptive and expedient policy environment to minimise delays in making available potentially life-saving technologies. Over time, the policy environment has adapted to ensure that communities have expedited access to promising technologies, such as vaccines, that can mitigate morbidity and mortality. Emergency authorisations are one such policy mechanism. While these have been employed successfully for several diseases, such as influenza, Ebola and COVID-19, the policy mechanism is tied to contexts where key bodies have designated the disease an 'emergency', whereas no equivalent mechanism exists for those failing to acquire the designation (eg, malaria and tuberculosis). In this paper, we examine ethical issues associated with emergency authorisations. We argue that there is no moral difference between those diseases considered emergencies and many that fail to be designated as such with respect to impact on affected communities. Thus, tying access to an expedient policy mechanism for approval to an emergency designation is ethically unjustified-it should be based on considerations of risks and benefits, the disease burden and the values of the communities that carry those risks and not contingent on if the disease is designated an emergency. We suggest the need to further enhance the policy environment to ensure access to similar expedited approval programmes irrespective of if a disease is an emergency. Levelling the field for access to expedited approval programmes across diseases can help in moving towards achieving global health equity but is not a panacea.

Distance-quality trade-off and choice of family planning provider in urban Pakistan.

BACKGROUND: There is limited evidence between contraceptive use, availability of commodities and distance to the facility in developing countries. Distance to the facility is an essential determinant of contraceptive use. Still, women may not seek family planning services from the nearest facility and may be prepared to travel the farthest distance to receive quality family planning services. METHODS: We analyzed women's survey data linked to health facility data and applied an alternate specific conditional logit model to examine the distance a woman is prepared to travel and the quality of services offered by facilities in urban areas in Karachi, Pakistan. RESULTS: This study analyzed data from 336 women and 28 facilities and identified that the mean distance to the nearest facility was 0.44 km; the chosen facility was, on average, 5 km away. Women preferred facilities that offered a range of contraceptive methods and additional services provided by female healthcare providers only. Furthermore, on average, women are willing to travel a further 1.7 km for a facility that offers more family planning methods, 1.4 km for a facility that offers additional health services and 11 km for a facility that offers services delivered by female healthcare providers. CONCLUSIONS: The findings highlight the quality measures women prioritize over distance and consider essential when choosing a family planning facility.

Ethical aspects of GMO regulation in the EU: Regulating new plant breeding techniques as GM has negative effects on sustainability, diversity and inclusion: Regulating new plant breeding techniques as GM has negative effects on sustainability, diversity and inclusion.

Plant breeding plays a crucial role for the EU to live up to its values and promises of sustainability, innovation and diversity and inclusion. The current regulations, however, make it de facto impossible to use new breeding technologies.

Nurturing care during COVID-19: a rapid review of early evidence.

OBJECTIVES: The COVID-19 pandemic has brought significant changes to family life, society and essential health and other services. A rapid review of evidence was conducted to examine emerging evidence on the effects of the pandemic on three components of nurturing care, including responsive caregiving, early learning, and safety and security. DESIGN: Two academic databases, organisational websites and reference lists were searched for original studies published between 1 January and 25 October 2020. A single reviewer completed the study selection and data extraction with verification by a second reviewer. INTERVENTIONS: We included studies with a complete methodology and reporting on quantitative or qualitative evidence related to nurturing care during the pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES: Studies reporting on outcomes related to responsive caregiving, early learning, and safety and security were included. RESULTS: The search yielded 4410 citations in total, and 112 studies from over 30 countries met our eligibility criteria. The early evidence base is weighted towards studies in high-income countries, studies related to caregiver mental health and those using quantitative survey designs. Studies reveal issues of concern related to increases in parent and caregiver stress and mental health difficulties during the pandemic, which was linked to harsher and less warm or responsive parenting in some studies. A relatively large number of studies examined child safety and security and indicate a reduction in maltreatment referrals. Lastly, studies suggest that fathers' engagement in caregiving increased during the early phase of the pandemic, children's outdoor play and physical activity decreased (while screen time increased), and emergency room visits for child injuries decreased. CONCLUSION: The results highlight key evidence gaps (ie, breastfeeding support and opportunities for early learning) and suggest the need for increased support and evidence-based interventions to ensure young children and other caregivers are supported and protected during the pandemic.

'I haven't heard much about other methods': quality of care and person-centredness in a programme to promote the postpartum intrauterine device in Tanzania.

BACKGROUND: Programmes promoting the postpartum intrauterine device (PPIUD) have proliferated throughout South Asia and sub-Saharan Africa in recent years, with proponents touting this long-acting reversible contraceptive (LARC) method's high efficacy and potential to meet contraceptive unmet need. While critiques of LARC-first programming abound in the Global North, there have been few studies of the impact of LARC-centric programmes on patient-centred outcomes in the Global South. METHODS: Here, we explore the impact of a PPIUD intervention at five Tanzanian hospitals and their surrounding satellite clinics on quality of contraceptive counselling and person-centred care using 20 qualitative in-depth interviews with pregnant women seeking antenatal care at one of those clinics. Using a modified version of the contraceptive counselling quality framework elaborated by Holt and colleagues, we blend deductive analysis with an inductive approach based on open coding and thematic analysis. RESULTS: Interpersonal aspects of relationship building during counselling were strong, but a mix of PPIUD intervention-related factors and structural issues rendered most other aspects of counselling quality low. The intervention led providers to emphasise the advantages of the IUD through biased counselling, and to de-emphasise the suitability of other contraceptive methods. Respondents reported being counselled only about the IUD and no other methods, while other respondents reported that other methods were mentioned but disparaged by providers in relation to the IUD. A lack of trained providers meant that most counselling took place in large groups, resulting in providers' inability to conduct needs assessments or tailor information to women's individual situations. DISCUSSION: As implemented, LARC-centric programmes like this PPIUD intervention may decrease access to person-centred contraceptive counselling and to accurate information about a broad range of contraceptive methods. A shift away from emphasising LARC methods to more comprehensive, person-centred contraceptive counselling is critical to promote contraceptive autonomy.

Determinants of short birth intervals among married women: a cross-sectional study in Karachi, Pakistan.

INTRODUCTION: Birth spacing is a critical pathway to improving reproductive health. WHO recommends a minimum of 33-month interval between two consecutive births to reduce maternal, perinatal, infant morbidity and mortality. Our study evaluated factors associated with short birth intervals (SBIs) of less than 33 months between two consecutive births, in Karachi, Pakistan. METHODS: We used data from a cross-sectional study among married women of reproductive age (MWRA) who had at least one live birth in the 6 years preceding the survey (N=2394). Information regarding their sociodemographic characteristics, reproductive history, fertility preferences, family planning history and a 6-year reproductive calendar were collected. To identify factors associated with SBIs, we fitted simple and multiple Cox proportional hazards models and computed HRs with their 95% CIs. RESULTS: The median birth interval was 25 months (IQR: 14-39 months), with 22.9% (833) of births occurring within 33 months of the index birth. Women's increasing age (25-30 years (aHR 0.63 (0.53 to 0.75), 30+ years (aHR 0.29, 95% CI 0.22 to 0.39) compared with 20-24 years; secondary education (aHR 0.75, 95% CI 0.63 to 0.88), intermediate education (aHR 0.62, 95% CI 0.48 to 0.80), higher education (aHR 0.69, 95% CI 0.51 to 0.92) compared with no education, and a male child of the index birth (aHR 0.81, 95% CI 0.70 to 0.94) reduced the likelihood of SBIs. Women's younger age <20 years (aHR 1.24, 95% CI 1.05 to 1.24) compared with 20-24 years, and those who did not use contraception within 9 months of the index birth had a higher likelihood for SBIs for succeeding birth compared with those who used contraception (aHR 2.23, 95% CI 1.93 to 2.58). CONCLUSION: Study shows that birth intervals in the study population are lower than the national average. To optimise birth intervals, programmes should target child spacing strategies and counsel MWRA on the benefits of optimal birth spacing, family planning services and contraceptive utilisation.

The effect of maternity waiting homes on perinatal mortality is inconclusive: a critical appraisal of existing evidence from Sub-Saharan Africa.

OBJECTIVES: To assess the appropriateness of the statistical methodology used in a recent meta-analysis investigating the effect of maternity waiting homes (MWHs) on perinatal mortality in Sub-Saharan Africa. RESULTS: A recent meta-analysis published in BMC Research Notes used a fixed-effect model to generate an unadjusted summary estimate of the effectiveness of MWHs in reducing perinatal mortality in Africa using ten observational studies (pooled odds ratio 0.15, 95% confidence interval 0.14-0.17). The authors concluded that MWHs reduce perinatal mortality by over 80% and should be incorporated into routine maternal health care services. In the present article, we illustrate that due to the contextual and methodological heterogeneity present in existing studies, the authors' conclusions about the effectiveness of MWHs in reducing perinatal mortality were likely overstated. Additionally, we argue that because of the selection bias and confounding inherent in observational studies, unadjusted pooled estimates provide little causal evidence for effectiveness. Additional studies with robust designs are required before an appropriately designed meta-analysis can be conducted; until then, the ability to draw causal inferences regarding the effectiveness of MWHs in reducing perinatal mortality is limited.

Conducting household surveys on reproductive health in urban settings: lessons from Karachi, Pakistan.

BACKGROUND: Data collection is the most critical stage in any population health study and correctly implementing fieldwork enhances the quality of collected information. However, even the most carefully planned large-scale household surveys can encounter many context-specific issues. This paper reflected on our research team's recent experience conducting surveys for a quasi-experimental evaluation of a reproductive health program in urban areas of Karachi, Pakistan. We aim to describe the issues encountered and lessons learned from this process, and present some potential solutions for conducting future household surveys in similar urban environments. METHODS: The study followed a three-stage random sampling design. Initially, a Geographical Information System (GIS) was used to construct the sampling frame with union council (UC) area mapping and cluster demarcation followed by random selection of clusters in the selected UCs within the intervention and control sites. The second stage involved a complete household listing in selected clusters and the final stage was a random sampling of households with eligible women. RESULT: This paper describes the issues that were encountered including technical problems related to GIS demarcation of cluster boundaries and hand-held devices for computer assisted personal interviews (CAPI), household listing, interviewing respondents on sensitive topics and their expectations, and ensuring privacy during the survey. CONCLUSION: This study identifies a number of unique barriers to conducting household surveys in Karachi and highlights some key lessons for survey research in urban settlements. GIS mapping technology is a cost-effective method for developing sampling frames in resource-constrained settings. Secondly, the strategy of interviewing women immediately after the cluster is listed may be applied to make it easier to re-locate selected respondents and to reduce loss-to-follow up. Understanding local norms and developing culturally appropriate strategies to build trust with communities may significantly improve survey participation. Researchers should hire experienced female enumerators and provide continuous training on best practices for interviewing women on sensitive reproductive health topics in urban communities.

The impact of a personalized, community-based counselling and referral programme on modern contraceptive use in urban Ghana: a retrospective evaluation.

Community-based demand-generation family planning programmes have been associated with increased contraceptive use in rural areas of Ghana. However, rigorous evaluations of such programmes in urban contexts are lacking. We used a retrospective, cross-sectional with comparison group design to estimate the immediate and sustained impact of the Willows intervention on modern contraceptive use in Kumasi, Ghana. The Willows intervention is a home-based counselling and referral programme for women in low-income urban settlements. We analysed data from a cross-sectional representative survey of 1205 women of reproductive age in the intervention area and 1108 women in a matched comparison site. The main outcome was women's reported contraceptive use at: (1) baseline (January 2013); (2) programme close (December 2016); and (3) follow-up (August to October 2018). We estimated the programme effect at the community level and for women who reported receiving a family planning counselling visit. We used coarsened exact matching to assess the impact of the intervention relative to outcomes for matched comparison women. Comparing those who reported a family planning visit in the intervention area with matched comparison area women who reported no visit, we estimated a 10.5 percentage point increase in use of modern contraceptives from baseline to close (95%CI : 6.2, 14.8; P < 0.001) and a 7.6 percentage point increase from baseline to follow-up (95%CI : 3.3, 11.9; P < 0.001). However, only 20.2% of women in the Willows intervention area reported a visit. The Willows intervention, therefore, did not achieve its aim to reach all reproductive-aged women in the community. At the community level, we found no significant effect of the intervention at either programme close or 2 years later. We recommend that similar community-based interventions strive for greater outreach and simultaneously launch robust prospective impact evaluations.

An Application of the List Experiment to Estimate Abortion Prevalence in Karachi, Pakistan.

CONTEXT: Abortion is particularly difficult to measure, especially in legally restrictive settings such as Pakistan. The List Experiment-a technique for measuring sensitive health behaviors indirectly-may minimize respondents' underreporting of abortion due to stigma or legal restrictions, but has not been previously applied to estimate abortion prevalence in Pakistan. METHODS: A sample of 4,159 married women of reproductive age were recruited from two communities of Karachi in 2018. Participants completed a survey that included a double list experiment to measure lifetime abortion prevalence, as well as direct questions about abortion and other background characteristics. Data were used to calculate direct and indirect estimates of abortion prevalence for the overall sample and by sociodemographic characteristics, as well as to test for a design effect. Regression analyses were conducted to examine associations between characteristics and abortion reporting from direct questioning and the list experiment. RESULTS: The estimate of abortion prevalence from the list experiment was 16%; the estimate from the direct question was 8%. No evidence of a design effect was found. Abortion reporting was associated with most selected characteristics in the regression model for direct questioning, but with few in the list experiment models. CONCLUSIONS: That the estimate of abortion prevalence in Karachi generated from the list experiment was twice that generated from direct questioning suggests that the indirect method reduced underreporting, and may have utility to estimate abortion in similar settings and to improve the accuracy of data collecting for other sensitive health topics.

RESUMEN Contexto: El aborto es particularmente difícil de medir, especialmente en entornos legalmente restringidos, como en Pakistán. El Experimento de Lista­una técnica para medir de manera indirecta comportamientos de salud sensibles­podría minimizar el hecho de que las personas encuestadas subnotifiquen el número de abortos debido al estigma o a restricciones legales; sin embargo, esta técnica no ha sido aplicada previamente para estimar la prevalencia del aborto en Pakistán. Métodos: En 2018, se reclutó una muestra de 4,159 mujeres casadas en edad reproductiva, provenientes de dos comunidades de Karachi. Las participantes completaron una encuesta que incluyó un experimento de lista doble para medir la prevalencia de aborto, así como preguntas directas sobre el aborto y otras características del contexto. Los datos se usaron para calcular estimaciones directas e indirectas de la prevalencia de aborto en la muestra en general y por características sociodemográficas, así como para probar el efecto de diseño. Se realizaron análisis de regresión para examinar las asociaciones entre las características y los abortos reportados a partir de las preguntas directas y el experimento de lista. Resultados: La estimación de la prevalencia de aborto del experimento de lista fue del 16%; la estimación a partir de la pregunta directa fue del 8%. No se encontró evidencia de un efecto de diseño. La notificación del número de abortos se asoció con la mayoría de las características seleccionadas en el modelo de regresión para la pregunta directa, pero con pocas características en los modelos de experimento de lista. Conclusiones: El hecho de que la estimación de la prevalencia de aborto en Karachi generada a partir del experimento de lista fue el doble que la obtenida a partir de preguntas directas, sugiere que el método indirecto reduce la subnotificación. El experimento de lista podría ser útil para estimar el aborto en entornos similares y para mejorar la precisión de la recolección de datos sobre otros temas sensibles de salud.

RÉSUMÉ Contexte: Il est extrêmement difficile de mesurer la prévalence de l'avortement, en particulier dans les contextes soumis à des lois restrictives, comme le Pakistan. La technique de mesure indirecte de comportements de santé sensibles « List Experiment ¼ peut minimiser la sous-déclaration de l'avortement pour raisons de stigmatisation ou de restrictions légales, mais elle n'a pas précédemment été utilisée pour estimer la prévalence de l'avortement au Pakistan. Méthodes: Un échantillon de 4 159 femmes mariées en âge de procréer a été recruté dans deux communautés de Karachi en 2018. Les participantes ont répondu à une enquête menée par double approche List Experiment pour mesurer la prévalence de l'avortement et qui comprenait aussi des questions directes sur l'avortement et d'autres caractéristiques socioculturelles. Les données ont servi à calculer les estimations directes et indirectes de la prévalence de l'avortement pour l'échantillon global et par caractéristiques sociodémographiques, ainsi qu'à tester l'effet du plan de sondage. Les associations entre les caractéristiques et la déclaration de l'avortement dans le questionnaire direct et la List Experiment ont été examinées par analyses de régression. Résultats: L'estimation de la prévalence de l'avortement selon la mesure List Experiment était de 16%; sur la base du questionnaire direct, elle était de 8%. Aucun signe d'effet de plan de sondage n'a été observé. La déclaration de l'avortement était associée à la plupart des caractéristiques sélectionnées dans le modèle de régression pour le questionnaire direct, mais à quelques-unes seulement dans les modèles de l'outil List Experiment. Conclusions: Le fait que l'estimation de la prévalence de l'avortement à Karachi générée d'après la List Experiment s'est révélée le double de celle produite par le questionnaire direct laisse entendre que la méthode indirecte réduit la sous-déclaration. La mesure List Experiment peut être utile à l'estimation de l'avortement dans des contextes similaires et pour améliorer l'exactitude des données collectées sur d'autres sujets de santé sensibles.

Impact of home-based family planning counselling and referral on modern contraceptive use in Karachi, Pakistan: a retrospective, cross-sectional matched control study.

OBJECTIVES: To assess: (1) the impact of a reproductive health program on modern contraceptive use from baseline to program close; (2) the sustained impact from baseline to follow-up 36 months later; and (3) the exposure-adjusted impact at program close and follow-up. DESIGN: Retrospective, cross-sectional matched control study. SETTING: Karachi, Pakistan. PARTICIPANTS: 2561 married women aged 16-49 years. INTERVENTIONS: The Willows Program, a community-based family planning counselling and referral program implemented from 2013 to 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was community-level modern contraceptive prevalence rate (mCPR), measured for January 2013 (baseline), June 2015 (program close) and at follow-up 36 months later. A secondary outcome was exposure-adjusted mCPR (among women reporting a family planning home visit) at program close and at follow-up. RESULTS: There was no significant effect on community-level mCPR at program close (2.4 percentage point increase in intervention over comparison; 95% CI -2.2 to 7.0) or at follow-up (1.9 percentage point decrease; 95% CI -6.7 to 2.8). Only 18% of women in the intervention area reported receiving a family planning visit in the preceding 5 years. Among those reporting a visit, we observed a significant 10.3 percentage point increase (95% CI 4.6 to 15.9) from baseline to close, and a non-significant 2.0 percentage point increase (95% CI -3.8 to 7.8) from baseline to follow-up, relative to matched women in the comparison area. The cost per new modern method user was US$1089, while the cost per user-year during the intervention period was US$455. CONCLUSIONS: The program had a positive short-term effect on women who received a family planning visit; however, this effect was not sustained. Program coverage was low and did not significantly increase community-level family planning use. Findings highlight the need to increase community coverage of high-quality counselling and contextually relevant interventions for family planning demand generation.

Evaluating the Implementation of an Intervention to Improve Postpartum Contraception in Tanzania: A Qualitative Study of Provider and Client Perspectives.

BACKGROUND: This qualitative study assessed implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Tanzania, a country with high rates of unintended pregnancy and low contraceptive prevalence. The PPIUD Initiative was implemented to reduce unmet need for contraception among new mothers through postpartum family planning counseling delivered during antenatal care and offering PPIUD insertion immediately following birth. METHODS: We used the implementation outcomes framework and an ecological framework to analyze in-depth interviews with providers (N=15) and women (N=47) participating in the initiative. We applied a multistage coding protocol and used thematic content analysis to identify the factors influencing implementation. RESULTS: Both women and providers were enthusiastic and receptive to the PPIUD Initiative. Health system and resource constraints made adoption and fidelity to the intended intervention challenging. Many providers questioned the sustainability of the initiative, and most agreed that changes to the initiative's design (e.g., additional training opportunities, improved staffing, and availability of PPIUD supplies) would strengthen future iterations of the initiative. According to women, interpersonal aspects of care varied, with some women reporting rushed or incomplete counseling or an emphasis on the PPIUD over other methods. The perception that some providers treat older married women more favorably suggests that fidelity to the intended PPIUD Initiative was not uniformly achieved. CONCLUSIONS: Study findings inform initiatives seeking to develop and adopt postpartum family planning programs and enhance program implementation. A comprehensive needs assessment to evaluate feasibility and identify potential adaptations for the local context is recommended. Training and supervision to improve interpersonal aspects of care, including an emphasis on patient-centered counseling, informed choice, and respectful and nondiscriminatory service delivery should be integrated into future postpartum family planning initiatives.

Applying Inverse Probability Weighting to Measure Contraceptive Prevalence Using Data from a Community-Based Reproductive Health Intervention in Pakistan.

CONTEXT: Many community-based reproductive health programs use their program data to monitor progress toward goals. However, using such data to assess programmatic impact on outcomes such as contraceptive use poses methodological challenges. Inverse probability weighting (IPW) may help overcome these issues. METHODS: Data on 33,162 women collected in 2013-2015 as part of a large-scale community-based reproductive health initiative were used to produce population-level estimates of the contraceptive prevalence rate (CPR) and modern contraceptive prevalence rate (mCPR) among married women aged 15-49 in Pakistan's Korangi District. To account for the nonrandom inclusion of women in the sample, estimates of contraceptive prevalence during the study's four seven-month intervention periods were made using IPW; these estimates were compared with estimates made using complete case analysis (CCA) and the last observation carried forward (LOCF) method-two approaches for which modeling assumptions are less flexible. RESULTS: In accordance with intervention protocols, the likelihood that women were visited by intervention personnel and thus included in the sample differed according to their past and current contraceptive use. Estimates made using IPW suggest that the CPR increased from 51% to 64%, and the mCPR increased from 34% to 53%, during the study. For both outcomes, IPW estimates were higher than CCA estimates, were generally similar to LOCF estimates and yielded the widest confidence intervals. CONCLUSION: IPW offers a powerful methodology for overcoming estimation challenges when using program data that are not representative of the population in settings where cost impedes collection of outcome data for an appropriate control group.

RESUMEN Contexto: Muchos programas comunitarios de salud reproductiva usan los datos de su programa para monitorear el progreso hacia sus metas. Sin embargo, el uso de tales datos para evaluar el impacto programático en resultados tales como el uso de anticonceptivos plantea desafíos metodológicos. La ponderación de probabilidad inversa (PPI) podría ayudar a superar estos problemas. Métodos: Se usaron datos de 33,162 mujeres recolectados entre 2013 y 2015 como parte de una iniciativa comunitaria de salud reproductiva a gran escala para producir estimaciones de la tasa de prevalencia de anticonceptivos (TPA) y la tasa de prevalencia de anticonceptivos modernos (TPAm) a nivel de la población, entre mujeres casadas de 15 a 49 años de edad en el distrito de Korangi, Pakistán. Para tener en cuenta la inclusión no aleatoria de mujeres en la muestra, se hicieron estimaciones de la prevalencia del uso de anticonceptivos durante los cuatro períodos de siete meses de intervención del estudio utilizando PPI; estas estimaciones se compararon con las estimaciones realizadas utilizando el análisis de caso completo (ACC) y el método de la última observación llevada adelante (UOLA)­dos enfoques cuyos supuestos de modelado son menos flexibles. Resultados: De conformidad con los protocolos de intervención, la probabilidad de que las mujeres fueran visitadas por el personal de intervención y por lo tanto incluidas en la muestra difería de acuerdo con su uso anticonceptivo pasado y actual. Las estimaciones realizadas con la PPI sugieren que, durante el estudio, la TPA aumentó del 51% al 64%; y que la TPAm aumentó del 34% al 53%. Para ambos resultados, las estimaciones fueron más altas que las estimaciones de ACC, en general fueron similares a las estimaciones de UOLA y produjeron intervalos de confianza más amplios. Conclusiones: La PPI ofrece una metodología poderosa para superar los desafíos relacionados con las estimaciones, cuando se utilizan datos de programas que no son representativos de la población en entornos donde el costo impide la recolección de datos de resultados para un grupo de control apropiado.

RÉSUMÉ Contexte: De nombreux programmes de santé reproductive à base communautaire utilisent leurs données pour suivre le progrès vers la réalisation de leurs objectifs. L'emploi de ces données pour évaluer l'impact programmatique sur les résultats tels que la pratique contraceptive pose cependant des problèmes de méthode. La pondération par l'inverse de la probabilité (PIP) peut être utile à la résolution de ces difficultés. Méthodes: Les données relatives à 33 162 femmes, collectées en 2013­2015 dans le cadre d'une initiative de santé reproductive à base communautaire à grande échelle, ont servi à produire des estimations au niveau de la population du taux de prévalence contraceptive (TPC) et du taux de prévalence contraceptive moderne (TPCm) parmi les femmes mariées âgées de 15 à 49 ans dans le district pakistanais de Korangi. Pour rendre compte de l'inclusion non aléatoire des femmes dans l'échantillon, les estimations de la prévalence pendant les quatre périodes d'intervention de sept mois de l'étude ont été calculées selon la méthode PIP. Ces estimations ont été comparées à celles obtenues par analyse de cas complète (ACC) et selon la méthode de la dernière observation rapportée (LOCF) ­ deux approches à hypothèses de modélisation moins souples. Résultats: Conformément aux protocoles d'intervention, la probabilité que les femmes aient reçu la visite du personnel d'intervention et soient donc incluses dans l'échantillon diffère suivant leur pratique passée et actuelle de la contraception. Les estimations obtenues selon la méthode PIP portent à croire que le TPC est passé de 51% à 64%, et le TPCm de 34% à 53%, pendant l'étude. Pour les deux résultats, les estimations PIP étaient supérieures à celles calculées selon la méthode ACC; elles étaient généralement similaires aux estimations LOCF et elles produisaient les plus larges intervalles de confiance. Conclusions: La PIP offre une méthode efficace de résolution des difficultés d'estimation lors de l'utilisation de données de programme non représentatives de la population, dans les contextes où le coût entrave la collecte de données de résultat pour un groupe témoin approprié.

Women's Perspectives on Postpartum Intrauterine Devices in Tanzania.

Despite the numerous benefits of the postpartum copper intrauterine device (PPIUD), which is inserted within 48 hours after giving birth, it is underutilized in many resource-constrained settings, including Tanzania. We conducted in-depth interviews with 20 pregnant women who received contraceptive counseling during routine antenatal care in 2016-2017 and 27 postpartum women who had a PPIUD inserted in 2018 to understand reasons for use versus nonuse and continuation versus discontinuation. Primary motivators for using a PPIUD included: convenience, effectiveness, perceived lack of side effects, and duration of pregnancy protection. Barriers to use included: fear of insertion, concerns related to sexual experiences post-insertion, and limited knowledge. Women who had a PPIUD inserted continued use when their expectations matched their experience, while discontinuation resulted from unexpected expulsion and experience of unanticipated side effects. Frequent follow-up and guidance on side-effect management influenced women's decisions to continue use. To support uptake and continued utilization of the PPIUD, postpartum contraceptive counseling should explicitly address side effects and risk of expulsion.

'It makes you someone who changes with the times': health worker and client perspectives on a smartphone-based counselling application deployed in rural Tanzania.

Mobile health (mHealth) applications have been developed for community health workers (CHW) to help simplify tasks, enhance service delivery and promote healthy behaviours. These strategies hold promise, particularly for support of pregnancy and childbirth in low-income countries (LIC), but their design and implementation must incorporate CHW clients' perspectives to be effective and sustainable. Few studies examine how mHealth influences client and supervisor perceptions of CHW performance and quality of care in LIC. This study was embedded within a larger cluster-randomized, community intervention trial in Singida, Tanzania. CHW in intervention areas were trained to use a smartphone application designed to improve data management, patient tracking and delivery of health messages during prenatal counselling visits with women clients. Qualitative data collected through focus groups and in-depth interviews illustrated mostly positive perceptions of smartphone-assisted counselling among clients and supervisors including: increased quality of care; and improved communication, efficiency and data management. Clients also associated smartphone-assisted counselling with overall health system improvements even though the functions of the smartphones were not well understood. Smartphones were thought to signify modern, up-to-date biomedical information deemed highly desirable during pregnancy and childbirth in this context. In this rural Tanzanian setting, mHealth tools positively influenced community perceptions of health system services and client expectations of health workers; policymakers and implementers must ensure these expectations are met. Such interventions must be deeply embedded into health systems to have long-term impacts on maternal and newborn health outcomes.

How can engagement of adolescents in antenatal care be enhanced? Learning from the perspectives of young mothers in Ghana and Tanzania.

BACKGROUND: Adolescents are especially vulnerable due to increased biological, social and economic risks associated with early pregnancy and childbirth, yet most pregnancy and childbirth-related complications are preventable through a combination of proven, cost-effective clinical interventions including timely antenatal care (ANC). The voices and specific needs of adolescents are currently underrepresented in the literature on antenatal and maternity care. Objectives were to a) increase our understanding of adolescents' experiences with, and perceptions of, ANC and b) explore how these perspectives might be applied towards future initiatives to enhance adolescent care-seeking behaviour. METHODS: This cross-sectional qualitative study employed 14 focus group discussions with 112 adolescents aged 15-20 years in Singida Region in Tanzania and Volta and Eastern Regions in Ghana who had accessed ANC during their most recent pregnancy. We were particularly interested in what these young women valued and understood about their ANC experience, as this would provide insights into what factors motivated them to seek care. Transcripts were analyzed using conventional content analysis. Based on emergent themes and drawing on the Health Belief Model (HBM) as an analytical tool, a conceptual framework was developed to illustrate the myriad factors influencing adolescents' decision to attend ANC. RESULTS: Interpreting results through an adapted HBM demonstrates that adolescent health-seeking behaviour can vary widely among individuals and within communities, is shaped by the opinions of family members and peers, and is intrinsically influenced by broader health systems-level factors. CONCLUSIONS: The results led to our development of an adapted theory-based framework to illustrate the complexity of adolescent care-seeking during pregnancy in resource-poor settings. We demonstrate that while an adolescent mother is capable of exercising her own agency, she is also developmentally vulnerable to external influences and must be supported in her ability to make autonomous decisions. While the model presented here focuses specifically on ANC utilization, it may have applications for understanding how adolescents engage with health services more broadly.

Keeping secrets in the cloud: Mobile phones, data security and privacy within the context of pregnancy and childbirth in Tanzania.

Growing evidence points to the potential value of mobile phone-based technologies ('mHealth') to help strengthen community health systems in low- and middle-income countries, but mHealth approaches also carry considerable risks with respect to data security, individual privacy, and confidentiality. We examined the perspectives of frontline community health workers and their female clients regarding data security and privacy within the context of an mHealth intervention to improve women's uptake of maternal health services from October 2013 to July 2014 in rural Tanzania. Qualitative findings demonstrate that the use of new technologies to capture health service user data during pregnancy and childbirth has both positive and negative impacts on perceptions of personal privacy and confidentiality. Women's concerns regarding privacy aligned closely with a belief that pregnancies and expected delivery dates must be kept secret, reflecting fears that pregnancy renders women vulnerable to witchcraft by jealous neighbors. Women also shared concerns that health workers' male partners could access their private information. Strong community-based engagement is recommended from the outset when developing a mHealth intervention to integrate beliefs and gender dynamics that may influence acceptability and implementation of new technologies.

Impact of smartphone-assisted prenatal home visits on women's use of facility delivery: Results from a cluster-randomized trial in rural Tanzania.

BACKGROUND: About half of births in rural Tanzania are assisted by skilled providers. Point-of-care mobile phone applications hold promise in boosting job support for community health workers aiming to ensure safe motherhood through increased facility delivery awareness, access and uptake. We conducted a controlled comparison to evaluate a smartphone-based application designed to assist community health workers with data collection, education delivery, gestational danger sign identification, and referrals. METHODS: Community health workers in 32 randomly selected villages were cluster-randomized to training on either smartphone (intervention) or paper-based (control) protocols for use during household visits with pregnant women. The primary outcome measure was postnatal report of delivery location by 572 women randomly selected to participate in a survey conducted by home visit. A mixed-effects model was used to account for clustering of subjects and other measured factors influencing facility delivery. FINDINGS: The smartphone intervention was associated with significantly higher facility delivery: 74% of mothers in intervention areas delivered at or in transit to a health facility, versus 63% in control areas. The odds of facility delivery among women counseled by smartphone-assisted health workers were double the odds among women living in control villages (OR, 1.96; CI, 1.21-3.19; adjusted analyses). Women in intervention areas were more likely to receive two or more visits from a community health worker during pregnancy than women in the control group (72% vs. 60%; chi-square = 6.9; p < 0.01). Previous facility delivery, uptake of antenatal care, and distance to the nearest facility were also strong independent predictors of facility delivery. INTERPRETATION: Community health worker use of smartphones increased facility delivery, likely through increased frequency of prenatal home visits. Smartphone-based job aids may enhance community health worker support and effectiveness as one component of intervention packages targeting safe motherhood. TRIAL REGISTRATION: NCT03161184.

A qualitative study exploring perceived barriers to infant feeding and caregiving among adolescent girls and young women in rural Bangladesh.

BACKGROUND: Infant feeding and caregiving by adolescent girls and young women in rural Bangladesh remains relatively understudied despite high potential vulnerability of younger mothers and their children due to poverty and high rates of early marriage and childbearing. This key knowledge gap may hamper the effectiveness of maternal, infant and child health interventions not specifically tailored to teenage mothers. This study aimed to narrow this gap by documenting key barriers to optimal infant and young child feeding and caregiving perceived by adolescent girls and young women in rural Bangladesh. METHODS: Focus group discussions and in-depth semi-structured interviews were conducted with 70 adolescent girls and young women participating in a community-based adolescent empowerment program in two rural regions of northwestern Bangladesh. Participants were stratified into three groups: unmarried, married without child, and married with child(ren). Thematic analysis was performed to elucidate dominant ideas regarding challenges with child feeding and caregiving across participant strata. RESULTS: Participants in all three strata and in both geographical regions attributed actual and anticipated caregiving difficulties to five major contextual factors: early marriage, maternal time allocation conflicts, rural life, short birth intervals, and poverty. Indications are that many girls and young women anticipate difficulties in feeding and caring for their future children from an early age, and often prior to motherhood. Participants articulated both perceived need and unmet demand for additional education in infant and young child feeding, childcare, and family planning techniques. CONCLUSIONS: Provision during adolescence of appropriate education, services and financial aid to support best practices for infant feeding and childcare could significantly improve maternal self-efficacy, mental health, nutrition security and young childcare, nutrition and health in rural Bangladesh. Lessons learned can be applied in future programs aimed at supporting adolescent women along a continuum of care.