Vaccine wastage in Ghana, Mozambique, and Pakistan: An assessment of wastage rates for four vaccines and the context, causes, drivers, and knowledge, attitudes and practices for vaccine wastage.

Vaccine procurement costs comprise a significant share of immunization program costs in low- and middle-income countries, yet not all procured vaccines are administered. Vaccine wastage occurs due to vial breakage, excessive heat or freezing, expiration, or when not all doses in a multidose vial are used. Better estimates of vaccine wastage rates and their causes could support improved management of vaccine stocks and reduce procurement costs. This study examined aspects of wastage for four vaccines at service delivery points in Ghana (n = 48), Mozambique (n = 36), and Pakistan (n = 46). We used prospective data from daily and monthly vaccine usage data entry forms, along with cross-sectional surveys, and in-depth interviews. The analysis found that estimated monthly proportional open-vial wastage rates for vaccines in single-dose vials (SDV) or in multi-dose vials (MDV) that can be kept refrigerated up to four weeks after opening ranged from 0.08 % to 3 %. For MDV where remaining doses are discarded within six hours after opening, the mean wastage rates ranged from 5 % to 33 %, with rates being highest for measles containing vaccine. Despite national-level guidance to open a vaccine vial even when only one child is present, vaccines in MDV that are discarded within six hours of opening are sometimes offered less frequently than vaccines in SDV or in MDV where remaining doses can be used for up to 4 weeks. This practice can lead to missed opportunities for vaccination. While closed-vial wastage at service delivery points (SDPs) was relatively rare, individual instances can result in large losses, suggesting that monitoring closed-vial wastage should not be neglected. Health workers reported insufficient knowledge of vaccine wastage tracking and reporting methods. Improving reporting forms would facilitate more accurate reporting of all causes of wastage, as would additional training and supportive supervision. Globally, decreasing doses per vial could reduce open-vial wastage.

Leveraging community health workers as vaccinators: a case study exploring the role of Malawi's Health Surveillance Assistants in delivering routine immunization services.

BACKGROUND: Global chronic health worker shortages and stagnating routine immunization rates require new strategies to increase vaccination coverage and equity. As trained, trusted members of their local communities, community health workers (CHWs) are in a prime position to expand the immunization workforce and increase vaccination coverage in under-reached communities. Malawi is one of only a few countries that relies on CHWs-called Health Surveillance Assistants (HSAs) in Malawi-to administer routine immunizations, and as such offers a unique example of how this can be done. CASE PRESENTATION: We sought to describe the operational and programmatic characteristics of a functional CHW-led routine immunization program by conducting interviews with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi. This case study describes how and where HSAs provide vaccinations, their vaccination-related responsibilities, training and supervision processes, vaccine safety considerations, and the community-level vaccine supply chain. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They also noted a need to strengthen some aspects of professional support for HSAs, particularly related to training, supervision, and supply chain processes. Interviewees agreed that other countries should consider following Malawi's example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported. CONCLUSIONS: This account from Malawi provides an example of how a CHW-led vaccination program operates. Leveraging CHWs as vaccinators is a promising yet under-explored task-shifting approach that shows potential to help countries maximize their health workforce, increase vaccination coverage and reach more zero-dose children. However, more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage/vaccine equity, and cost-effectiveness as compared to use of other cadres for routine immunization.

Surrogacy relationships: a critical interpretative review.

Based on a critical interpretative review of existing qualitative research investigating accounts of 'lived experience' of surrogates and intended parents from a relational perspective, this article proposes a typology of surrogacy arrangements. The review is based on the analysis of 39 articles, which belong to a range of different disciplines (mostly sociology, social psychology, anthropology, ethnology, and gender studies). The number of interviews in each study range from as few as seven to over one hundred. Countries covered include Australia, Canada, Greece, India, Iran, Israel, Italy, Mexico, Norway, Russia, Sweden, UK, Ukraine, and the USA. Most studies focus only on surrogacy practices in one country (although often with intended parents from other countries), and some include several countries (e.g. interviewees from several countries or fieldwork in different field-sites). The proposed typology goes beyond the division between altruistic versus commercial, and traditional versus gestational surrogacy, in order to inform further research and to contribute to bioethical and policy debates on surrogacy in a transnational context. Four types of relations are identifiable: open, restricted, structured, and enmeshed. The criteria which influence these relationships are: the frequency and character of contact pre- and post-birth; expectations of both parties; the type of exchange involved in surrogacy arrangements; and cultural, legal, and economic contexts. The theoretical contribution of the article is to further the development of a relational justice approach to surrogacy.

Conceptions of transgender parenthood in fertility care and family planning in Sweden: from reproductive rights to concrete practices.

It is an oft-repeated trope that the recent medical advances in the field of assisted reproduction have radically transformed the ways in which we can achieve, practice and imagine parenthood. This development has enabled new forms of non-heterosexual family constellations, including same-sex nuclear families and solo-parents by choice, and as a result an increasing number of groups are mobilising politically for access to fertility treatments. Swedish transgender patients are one of these groups; after many years of political mobilisation, they are no longer required by law to go through sterilisation as a compulsory part of gender corrective surgery, and instead today, all transgender patients are offered fertility preservation through gamete freezing. This, in turn, has meant not only that Swedish fertility clinics have faced an entirely new patient group - the transgender fertility patient - but also that the cultural imagination of who can become a parent and what a family might look like is becoming further destabilised. Building on interviews with medical staff, LGBTQ-advocates and complementing qualitative data, this paper seeks to shed light on the very process by which these new rights are translated in the practical context of the fertility clinic, and also what it means, more generally, for cultural imaginations of parenting when a group whose reproductive futures were previously considered either impossible or undesirable are now 'anticipating infertility' and engaging in 'family planning' as central parts of their lifecourse and medical engagements.

Autonomy in altruistic surrogacy, conflicting kinship grammars and intentional multilineal kinship.

Since 1982, when the first baby conceived by in-vitro fertilization (IVF) in Sweden was born, Swedish legislation on assisted reproduction has gradually become more liberal and inclusive. Today, gamete donation and IVF are permitted not only for heterosexual couples, but also for lesbian couples and single women, and embryo donation is expected to become legalized shortly which will further increase the chances for involuntarily childless people to become parents. In recent years, the possibility of allowing surrogacy has been debated increasingly, with strongly polarized arguments both for and against it. Recent reports by the Swedish National Council of Medical Ethics and a governmental investigation agreed that the possibilities for involuntarily childless people should be increased in several ways, but reached opposing conclusions concerning surrogacy. While the former argued in favour of it (in certain circumstances), the latter argued against it (in all circumstances). One difference in their argumentation centred around the issue of bodily autonomy and self-determination in surrogacy. These two opposing conclusions raise crucial questions about what the principle of reproductive intent implies for questions concerning reproductive autonomy in surrogacy. Does it matter when in the reproductive process the declaration of intent is made, and what happens if we consider the possibility of changing intentions in relation to autonomy and self-determination in surrogacy? Is the mater est rule compatible with an intersectional, queer and non-discriminatory approach to reproductive justice, and if so, under what circumstances? Are there any possibilities of thinking beyond the 'either/or' between these two principles?

Reproducing politics: the politicisation of patients' identities and assisted reproduction in Poland and Sweden.

This article examines how discourses on assisted reproductive technologies are locally appropriated, translated or contested in the specific cultural and political contexts of Poland and Sweden. The aim is to investigate how two national patients' organisations, namely the Polish association Nasz Bocian and the Swedish organisation Barnlängtan, articulate rights claims in the context of reproductive technologies. To this end, we investigate how these organisations utilise specific context-dependent and affectively laden political vocabularies in order to mobilise politically, and discuss how each of these two groups gives rise to a different set of politicised reproductive identities. In order to trace which political vocabularies the respective organisations utilise to mobilise their respective rights claims, we draw primarily on political discourse theory and concepts of political grammars and empty signifiers. Lastly, we discuss which political reproductive identities emerge as a result of these different versions of political mobilisation around assisted reproductive technologies.

Changes in Women's Facial Skin Color over the Ovulatory Cycle are Not Detectable by the Human Visual System.

Human ovulation is not advertised, as it is in several primate species, by conspicuous sexual swellings. However, there is increasing evidence that the attractiveness of women's body odor, voice, and facial appearance peak during the fertile phase of their ovulatory cycle. Cycle effects on facial attractiveness may be underpinned by changes in facial skin color, but it is not clear if skin color varies cyclically in humans or if any changes are detectable. To test these questions we photographed women daily for at least one cycle. Changes in facial skin redness and luminance were then quantified by mapping the digital images to human long, medium, and shortwave visual receptors. We find cyclic variation in skin redness, but not luminance. Redness decreases rapidly after menstrual onset, increases in the days before ovulation, and remains high through the luteal phase. However, we also show that this variation is unlikely to be detectable by the human visual system. We conclude that changes in skin color are not responsible for the effects of the ovulatory cycle on women's attractiveness.