Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria.

BACKGROUND: The uptake of skilled pregnancy care in rural areas of Nigeria remains a challenge amid the various strategies aimed at improving access to skilled care. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country's very high maternal mortality rates. The perceptions of key stakeholders on the use of skilled care will provide a broad understanding of factors that need to be addressed to increase women's access to skilled pregnancy care. The objective of this study was therefore, to explore the perspectives of policymakers and health workers, two major stakeholders in the health system, on facilitators and barriers to women's use of skilled pregnancy care in rural Edo State, Nigeria. METHODS: This paper draws on qualitative data collected in Edo State through key informant interviews with 13 key stakeholders (policy makers and healthcare providers) from a range of institutions. Data was analyzed using an iterative process of inductive and deductive approaches. RESULTS: Stakeholders identified barriers to pregnant women's use of skilled pregnancy care and they include; financial constraints, women's lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system. Study participants suggested health insurance schemes, community support for skilled pregnancy care, favourable financial and governance policies, as necessary to facilitate women's use of skilled pregnancy care. CONCLUSIONS: This study adds to the literature, a rich description of views from policymakers and health providers on the deterrents and enablers to skilled pregnancy care. The views and recommendations of policymakers and health workers have highlighted the importance of multi-level factors in initiatives to improve pregnant women's health behaviour. Therefore, initiatives seeking to improve pregnant women's use of skilled pregnancy care should ensure that important factors at each distinct level of the social and physical environment are identified and addressed.

Gender-based market constraints to informal fish retailing: Evidence from analysis of variance and linear regression.

Over the last decade, Egypt's aquaculture sector has expanded rapidly, which has contributed substantially to per capita fish supply, and the growth of domestic fish markets and employment across the aquaculture value chain. Despite the growing importance of aquaculture sector in Egyptian labour force, only a few studies have explored the livelihoods of Egypt's women and men fish retailers. Even fewer studies have examined gender-based market constraints experienced by these informal fish retailers. This study uses sex-disaggregated data collected in 2013 in three governorates of Lower Egypt to examine the economic and social constraints to scale of enterprises between women (n = 162) and men informal fish retailers (n = 183). Specifically, we employ linear regression method to determine the correlates of enterprise performance. We found that both women and men retailers in the informal fish market earn low profits and face livelihood insecurities. However, women's enterprise performance is significantly lower than that of men even after controlling for individual socio-economic and retailing characteristics. Specifically, the burden of unpaid household work and lack of support therein impedes women's ability to generate higher revenues. These findings strengthen the argument for investing in understanding how gender norms and attitudes affect livelihood options and outcomes. This leads to recommendations on gender-responsive interventions that engage with both men and women and enhance the bargaining power and collective voice of fish retailers.

Semi-arranged marriages and dowry ambivalence: Tensions in the changing landscape of marriage formation in South Asia.

Marriage is a point of change in young people's lives, especially in parts of the world that place high value on it, such as in South Asian countries including Nepal. However, marriage practices are changing, with a move towards more love marriage; this is likely to have important implications on women's status and agency, household and couple dynamics, and mental and physical health. The aim of this paper is to describe how changing marriage formation patterns and traditional practices such as co-residence and dowry are intersecting and impacting relationships post-marriage. In-depth qualitative interviews took place with 20 intact triads of newly married women, their husbands and their mothers-in-law, in one district of Nepal in 2017. Many marriages remain arranged; however, couples often talk or meet before marriage and feel that they are able to build a foundation of love before marrying. Access to technology facilitates this practice, although some couples are reluctant to admit their communication, suggesting stigma about this practice. Husbands have growing ambivalence about dowry, leading to confusion and negatively impacting on relationships post-marriage. A clash of traditional and modern ideas and practices is occurring in Nepal, influencing newly married women's household status and relationship quality, and potentially impacting women's health.

Women's economic status and sexual negotiation: re-evaluation of the 'normative precedent' in Tanzania.

Women's ability to negotiate the conditions and circumstances of sexual relations is central to their sexual and reproductive health, including mitigating HIV risk. In Africa, gender-based power imbalances constrain women's sexual agency. Research has suggested that among couples in sub-Saharan African countries, such as Uganda and Nigeria, sexual decision making is defined by a 'normative precedent' in the form of a set of rules and practices conferring sexual authority on men. Using qualitative data among women in paid work and among men, this study explored interpersonal relations and sexual negotiation in Tanzania. Data were collected in two sites, Dar es Salaam and Mbeya. The normative precedent for sexual decision making was universally understood by men and women. Women did not perceive paid work as giving them greater bargaining power in the domain of sex. In Mbeya, a high-HIV area, some women perceived that refusing sex would encourage men to have additional sexual partners, thus increasing their susceptibility to HIV. Other women, however, believed that suspicions about men's behaviour combined with accurate HIV knowledge, provided leverage for women to refuse sex. In both sites, challenges to the normative precedent were evident, particularly among younger men. Both men and women expressed a preference for equality in sexual decision making.

Identifying Causal Effects of Reproductive Health Improvements on Women's Economic Empowerment Through the Population Poverty Research Initiative.

Policy Points: Improvements in reproductive health lead to improvements in women's economic empowerment. Contraceptive use improves women's agency, education, and labor force participation; higher maternal age at first birth (reducing adolescent childbearing) increases the likelihood of school completion and participation in the formal labor market; and having fewer children increases labor market participation. Reproductive health is not just a benefit to a woman's individual rights, but her gateway for breaking free from her poverty trap and improving the welfare of herself, her children, and her household. CONTEXT: Women's access to employment, business opportunities, and financial resources is critical to achieving the United Nations Sustainable Development Goals over the next 15 years. With increased attention to women's economic empowerment among donors and policymakers across the globe, this moment is a pivotal one in which to review the current state of the research on this topic. METHODS: We reviewed the Population and Poverty (PopPov) Research Initiative results from the past 10 years with attention to the causal link between reproductive health improvements and women's economic empowerment, in addition to seminal research that informed our understanding of the link. FINDINGS: Our review of PopPov findings revealed that improvements in reproductive health do lead to improvements in women's economic empowerment; expanding contraceptive use improves women's agency, education, and labor force participation; higher maternal age at first birth (reducing adolescent childbearing) increases the likelihood of school completion and participation in the formal labor market; and having fewer children increases labor force participation. CONCLUSIONS: Gaps remain in measuring women's work and in the full exploration of women's economic empowerment. More research is needed regarding the long-term impact of reproductive health improvements on women's economic empowerment, as some studies have shown that at times unintended negative consequences occur after early positive improvements.

Conceptualising the agency of highly marginalised women: Intimate partner violence in extreme settings.

How is the agency of women best conceptualised in highly coercive settings? We explore this in the context of international efforts to reduce intimate partner violence (IPV) against women in heterosexual relationships. Articles critique the tendency to think of women's agency and programme endpoints in terms of individual actions, such as reporting violent men or leaving violent relationships, whilst neglecting the interlocking social, economic and cultural contexts that make such actions unlikely or impossible. Three themes cut across the articles. (1) Unhelpful understandings of gender and power implicit in commonly used 'men-women' and 'victim-agent' binaries obscure multi-faceted and hidden forms of women's agency, and the complexity of agency-violence intersections. (2) This neglect of complexity results in a poor fit between policy and interventions to reduce IPV, and women's lives. (3) Such neglect also obscures the multiplicities of women's agency, including the competing challenges they juggle alongside IPV, differing levels of response, and the temporality of agency. We outline a notion of 'distributed agency' as a multi-level, incremental and non-linear process distributed across time, space and social networks, and across a continuum of action ranging from survival to resistance. This understanding of agency implies a different approach to those currently underpinning policies and interventions.

Women's responses to intimate partner violence in Rwanda: Rethinking agency in constrained social contexts.

This paper explores instances of agency in women's responses to intimate partner violence (IPV) in Rwanda. The literature on women's responses to IPV conceptualises agency primarily as an individual's capacity to take action by reporting violence or leaving a relationship, obscuring other ways women may respond to violence in contexts where reporting or leaving are unlikely. We aim to replace this narrow conceptualisation of agency with a social constructivist focus on the meanings women attribute to possible IPV responses. We draw on data from a study of IPV in Rwanda, which includes semi-structured interviews with women experiencing violence and four focus group discussions with women community members (n = 39). Our findings highlight sociocultural, economic, political-legal and historical constraints that shape women's actions in this context. In relation to these constraints, women describe four possible responses to IPV: reporting the violence; seeking emotional support; 'fighting back' against violence; or remaining silent. While reporting and leaving violent relationships are identified, women also discuss the social constraints that make these actions extremely difficult. In designing effective strategies, we conclude that public health strategies need to consider women's understandings of their own actions, particularly in social contexts where certain actions may be constrained.

'My body is mine': Qualitatively exploring agency among internally displaced women participants in a small-group intervention in Leogane, Haiti.

The 2010 earthquake resulted in the breakdown of Haiti's social, economic and health infrastructure. Over one-quarter of a million people remain internally displaced (ID). ID women experience heightened vulnerability to intimate partner violence (IPV) due to increased poverty and reduced community networks. Scant research has examined experiences of IPV among ID women in post-earthquake Haiti. We conducted a qualitative study to explore the impact of participating in Famn an Aksyon Pou Santé Yo (FASY), a small-group HIV prevention intervention, on ID women's agency in Leogane, Haiti. We conducted four focus groups with ID women, FASY participants (n = 40) and in-depth individual interviews with peer health workers (n = 7). Our study was guided by critical ethnography and paid particular attention to power relations. Findings highlighted multiple forms of IPV (e.g., physical, sexual). Participants discussed processes of intrapersonal (confidence), interpersonal (communication), relational (support) and collective (women's rights) agency. Yet structural factors, including patriarchal gender norms and poverty, silenced IPV discussions and constrained women's agency. Findings suggest that agency among ID women is a multi-level, non-linear and incremental process. To effectively address IPV among ID women in Haiti, interventions should address structural contexts of gender inequity and poverty and concurrently facilitate multi-level processes of agency.

When nurses are also patients: Intimate partner violence and the health system as an enabler of women's health and agency in Johannesburg.

While violence against women is a recognised global health problem, women's agency in marginalised settings is poorly understood, particularly in relation to health systems. We explored agency as a practical and theoretical construct through qualitative research among 20 nurses with direct or indirect experiences of intimate partner violence (IPV) in Johannesburg. Interviews conducted from August 2013 to March 2014 generated rich descriptions from respondents in five health facilities. Nurses' self-reported IPV matched national prevalence of 24-31%. Findings revealed the way in which agency is enacted by nurses, allowing them the economic means to leave abusive partnerships, yet disabling them from agency and health promotion in their workplace. At the same time, nurses expanded agentic possibilities for patients by enabling a national response to IPV within South African health clinics - one that is largely undocumented. We posit that nurses can serve as important agentic actors in public health systems in low- and middle-income country settings by assisting patients to address IPV, even in the absence of targeted training and guidelines. To ensure the health and well-being of women experiencing IPV, nurses should be supported by the health sector to respond skilfully to patients and to safely process their own experiences of violence.

Negotiating agency in cases of intimate partner violence in Vietnam.

Understandings of women's agency in cases of intimate partner violence (IPV) have been dominated by an individualistic focus on help-seeking behaviour. The role of children in influencing, enabling and restricting the decision-making processes of their mothers has been largely ignored. We adopt biographical analytical approaches to qualitative longitudinal data collected as part of the Young Lives study to highlight the interdependency of women's and children's agency in contexts of IPV in Vietnam. We illustrate how women's agency is both enabled and constrained by their relationships with their children, as well as by wider structural processes, and examine how gender and generation intersect. In marginalised settings where few formal services exist or strong social norms preclude women from accessing support, understanding these informal coping strategies and the processes by which these are negotiated is essential for developing more effective policy responses.

Stigma, shame and women's limited agency in help-seeking for intimate partner violence.

In Tanzania, 44% of women experience intimate partner violence (IPV) in their lifetime, but the majority never seeks help, and many never tell anyone about their experience. Even among the minority of women who seek support, only 10% access formal services. Our research explored the social and structural barriers that render Tanzanian women unable to exercise agency in this critical domain of their lives. We collected qualitative data in three regions of Tanzania through 104 key informant interviews with duty bearers and participatory focus groups with 96 male and female community members. The findings revealed numerous sociocultural barriers to help-seeking, including gendered social norms that accept IPV and impose stigma and shame upon survivors. Because IPV is highly normalised, survivors are silenced by their fear of social consequences, a fear reinforced by the belief that it is women's reporting of IPV that brings shame, rather than the perpetration of violence itself. Barriers to help-seeking curtail women's agency. Even women who reject IPV as a 'normal' practice are blocked from action by powerful social norms. These constraints deny survivors the support, services and justice they deserve and also perpetuate low reporting and inaccurate estimates of IPV prevalence.

Examining women's agency in managing intimate partner violence and the related risk of homelessness: The role of harm minimisation.

Intimate partner violence (IPV) has a detrimental impact on women and children's emotional, physical and social well-being and has been identified as one of the most common contributors to women's experiences of housing instabilities and homelessness. Women affected by IPV often experience a great level of uncertainty around housing solutions when trying to leave an abusive partner. This study explores women's responses to IPV and the related risk of homelessness through women's narratives (n = 22) in Queensland, Australia. Of particular interest are women's decisions and actions to minimise the impact of IPV as well as homelessness on their and their children's safety and well-being. Findings reveal that women's agency in relation to harm minimisation can take various forms, including the decision to stay with, leave or return to an abusive partner. The data offer insights into women's strategic attempts to manage IPV and the related risk of homeless while trying to minimise the harm associated with one and the other. Implications for understanding women's agency in managing IPV and the related risk of homelessness and providing adequate support mechanisms to improve women and children's social, emotional and physical well-being are discussed.

'I don't need an eye for an eye': Women's responses to intimate partner violence in Sierra Leone and Liberia.

This paper explores the possibilities for agency in intimate partner violence (IPV) situations from the perspective of women in Sierra Leone and Liberia using focus group discussions (N groups = 14, N participants = 110) and individual interviews (N = 20). Findings identify multiple interrelated factors influencing the decision-making of women experiencing IPV. At the individual level, emotional factors and women's knowledge of their rights and options influence their decision-making. At the relational level, the role of neighbours, family and friends is crucial, both for emotional support and practical assistance. At the community level, more formal structures play a role, such as chiefs and women's groups, though their effectiveness varies. At the structural level are barriers to effective responses, including a poorly functioning criminal justice system and a social system in which children often stay with fathers following separation or divorce. Strong cultural beliefs operate to keep women in abusive relationships. We identify implications for prevention and response services and make practice recommendations. Since the desire of most women experiencing IPV was to live in peace with their husbands, interventions should respect women's priorities by focusing more on prevention and interventions to end the violence, rather than solely assisting women to leave violent relationships.

Intimate partner violence and forced migration during pregnancy: Structural constraints to women's agency.

Little is known about migration during pregnancy related to intimate partner violence (IPV). In this paper, we examine issues of agency in relation to pregnant women's migrations in a high HIV prevalence area of Kenya. We qualitatively explored forced migration among pregnant women, using data from in-depth interviews, focus groups and IPV screening forms. To quantitatively examine migration during pregnancy, we analysed data from a prospective study of 614 pregnant women. The qualitative data revealed that women had varied responses to violence in pregnancy, with some being able to leave the marital home voluntarily as a strategy to escape violence. Others were 'sent packing' from their marital homes when they dared to exercise autonomy, in some cases related to HIV status. Quantitative analyses revealed that pregnant women who migrated were more educated, less likely to be living with a partner and had fewer children than other women. Migration among pregnant women in Kenya illustrates the complexity of understanding women's agency in the context of IPV. The findings indicate that there is not a dichotomy between 'victim' and 'agent', but rather a complex dynamic between and within pregnant women, who may sequentially or simultaneously experience aspects of victimhood and/or agentic response.