Navigating abortion law dilemmas: experiences and attitudes among Ethiopian health care professionals.

BACKGROUND: Ethiopia's 2005 abortion law improved access to legal abortion. In this study we examine the experiences of abortion providers with the revised abortion law, including how they view and resolve perceived moral challenges. METHODS: Thirty healthcare professionals involved in abortion provisions in Addis Ababa were interviewed. Transcripts were analyzed using systematic text condensation, a qualitative analysis framework. RESULTS: Most participants considered the 2005 abortion law a clear improvement-yet it does not solve all problems and has led to new dilemmas. As a main finding, the law appears to have opened a large space for professionals' individual interpretation and discretion concerning whether criteria for abortion are met or not. Regarding abortion for fetal abnormalities, participants support the woman's authority in deciding whether to choose abortion or not, although several saw these decisions as moral dilemmas. All thought that abortion was a justified choice when a diagnosis of fetal abnormality had been made. CONCLUSION: Ethiopian practitioners experience moral dilemmas in connection with abortion. The law places significant authority, burden and responsibility on each practitioner.

Culture clash of female Somali adolescents and sexual and reproductive health services in Oslo, Norway.

OBJECTIVE: Culture influences an individual's perception of health needs. The influence of culture also applies to Somali individuals' perception of their sexual and reproductive health (SRH) and uptake of related services. An understanding of female Somali adolescents' SRH needs is vital to achieve inclusive health coverage. No research has, however, been conducted to explore the SRH needs of this population group in Oslo; hence, the aim of this qualitative study was to minimise the knowledge gap. METHODS: Fourteen young women aged 16-20 years were recruited using the snowball technique with purposive sampling. In-depth interviews using a semi-structured interview guide were used to collect data, and thematic analysis was applied. RESULTS: Participants perceived SRH as a very private matter and open discussion of SRH was extremely limited owing to certain Somali cultural beliefs and values. As the participants intend to practise chastity before marriage, they believed that existing SRH services were largely irrelevant and inappropriate. Where they felt the need to access SRH services, participants wished to do so in a way they considered culturally appropriate. CONCLUSION: Somali culture markedly influences individuals' perceptions of SRH services. It is recommended to modify existing SRH services by increasing confidentiality and anonymity in order to take into account the cultural requirements of female Somali adolescents.

Childbirth experiences of Sudanese women living with obstetric fistula - A qualitative study.

BACKGROUND: Obstetric Fistula results from failure to manage obstructed labor in a timely manner; the failure can be attributed to many factors. Therefore, the study seeks to provide a better understanding of the circumstances surrounding the occurrence of Obstetric Fistula using the Three-Delays model. METHODS: Semi-structured interviews were conducted with 19 women living with OF. Study participants were recruited from the Dr. Abbu Fistula Center and the Fistula Re-integration Center in Khartoum, Sudan. Thematic analysis was used to analyze the study findings. The Three-Delays Model guided the analysis and discussion of these findings. RESULTS: The majority (11 out of 19) experienced more than one delay and six of the participants had all the three delays. Women were kept at home by midwives or family members for days until the baby was dead or the woman showed severe signs of complications. Many of the participants went through injurious vaginal labor which could have been prevented if they had had timely access to a caesarian section. CONCLUSION: In order to reduce the delays in seeking care, special attention must be paid to raising women's, husbands' and the community's awareness about danger signs that may arise before and during childbirth, the benefits of skilled birth attendance, and where and when to seek help. In addition, the provision of information regarding where to find Emergency Obstetric Care services and a birth preparedness plan would facilitate prompt care-seeking behavior. More resources must be allocated to strengthen the quality and coverage of reproductive health services.

Still a moral dilemma: how Ethiopian professionals providing abortion come to terms with conflicting norms and demands.

BACKGROUND: The Ethiopian law on abortion was liberalized in 2005. However, as a strongly religious country, the new law has remained controversial from the outset. Many abortion providers have religious allegiances, which begs the question how to negotiate the conflicting demands of their jobs and their commitment to their patients on the one hand, and their religious convictions and moral values on the other. METHOD: A qualitative study based on in-depth interviews with 30 healthcare professionals involved in abortion services in either private/non-governmental clinics or in public hospitals in Addis Ababa, Ethiopia. Transcripts were analyzed using systematic text condensation, a qualitative analysis framework. RESULTS: For the participants, religious norms and the view that the early fetus has a moral right to life count against providing abortion; while the interests and needs of the pregnant woman supports providing abortion services. The professionals weighed these value considerations differently and reached different conclusions. One group appears to have experienced genuine conflicts of conscience, while another group attempted to reconcile religious norms and values with their work, especially through framing provision of abortion as helping and preventing harm and suffering. The professionals handle this moral balancing act on their own. In general, participants working in the private sector reported less moral dilemma with abortion than did their colleagues from public hospitals. CONCLUSIONS: This study highlights the difficulties in reconciling tensions between religious convictions and moral norms and values, and professional duties. Such insights might inform guidelines and healthcare ethics education.

Social Determinants of Antenatal Care Service Use in Ethiopia: Changes Over a 15-Year Span.

Background: Improving maternal health in Ethiopia is a major public health challenge. International studies indicate that it is possible to improve maternal health outcomes through action on the Social Determinants of Health (SDH). This study aimed to explore the SDH that influence the antenatal care (ANC) utilization in Ethiopia over time. Methods: The study used data from the nation-wide surveys conducted by the Ethiopian Central Statistical Agency (CSA) and ORC Macro International, USA in 2005, 2011, and 2016. A negative binomial with random effects at cluster level was used to model the number of ANC visits whereas a multilevel binary logistic regression modeled binary responses relating to whether a woman had at least 4 ANC visits or not. The model estimates were obtained with the statistical software Stata SE 15 using the restricted maximum likelihood method. Results: Although the median number of ANC visits significantly increased between 2005 and 2016, the majority of the women do not obtain the four ANC visits during pregnancy as recommended. The odds of having at least four ANC visits were significantly lower among women: below 20 years, those living in the rural areas, having higher birth order, or Muslim. In contrast, higher educational attainment, higher socio-economic status, exposure to mass media, and self-reporting decision empowerment were significantly associated with having at least four ANC visits. Conclusion: The use of ANC visits is driven mostly by the social determinants of health rather than individual health risk. The importance of the various SDHs needs to be recognized by Ministry of Health policy and program managers as a key driving force behind the country's challenges with reaching targets in the health agenda related to maternal health, particularly related to the recommended number of ANC visits.

A road to obstetric fistula in Malawi: capturing women's perspectives through a framework of three delays.

INTRODUCTION: Obstetric fistula (OF) is a devastating birth injury, which leaves a woman with leaking urine and/or feces accompanied by bad smell, a situation that has been likened to death itself. The condition is caused by neglected obstructed labor. Many factors underlie fistula formation, most of which are preventable. The main purpose of this study was to explore labor and childbirth experiences of women who developed OF with a focus on accessibility of care in the central region of Malawi. METHODS: We conducted semi-structured interviews with 25 women with OF at Bwaila Fistula Care Center in Lilongwe and in its surrounding districts. We interviewed 20 women at Bwaila Fistula Care Center; additional five women were identified through snowball sampling and were interviewed in their homes. Data were categorized using Nvivo 11 and were analyzed using thematic analysis. The three delays model by Thaddeus and Maine was used for data analysis. FINDINGS: The majority of women in our study suffered from OF with their subsequent pregnancies. All women experienced delays in one form or another consistent with the three-phase delays described by Thaddeus and Maine. Most of the participants (16) experienced two delays and 15 experienced second-phase delay, which was always coupled with the other; nine participants experienced delay while at the hospital. None of the participants experienced all three delays. Most decisions to seek health care when labor was complicated were made by mothers-in-law and traditional birth attendants. All but two delivered stillborn babies. CONCLUSION: Testimonies by women in our study suggest the complexity of the journey to developing fistula. Poverty, illiteracy, inaccessible health facilities, negligence, lack of male involvement in childbirth issues, and shortage of staff together conspire to fistula formation. To prevent new cases of OF in Malawi, the above mentioned issues need to be addressed, more importantly, increasing access to skilled attendance at birth and emergency obstetric care and promoting girls' education to increase their financial autonomy and decision-making power about their reproductive lives. Also men need to be educated and be involved in maternal and women's reproductive health issues to help them make informed decisions when their spouses end up with a complicated labor or delivery.

"I am a person but I am not a person": experiences of women living with obstetric fistula in the central region of Malawi.

BACKGROUND: The consequences of living with obstetric fistula are multifaceted and very devastating for women, especially those living in poor resource settings. Due to uncontrollable leakages of urine and/or feces, the condition leaves women with peeling of skin on their private parts, and the wetness and smell subject them to stigmatization, ridicule, shame and social isolation. We sought to gain a deeper understanding of lived experiences of women with obstetric fistula in Malawi, in order to recommend interventions that would both prevent new cases of obstetric fistula as well as improve the quality of life for those already affected. METHODS: We conducted semi-structured interviews with 25 women with obstetric fistula at Bwaila Fistula Care Center in Lilongwe and in its surrounding districts. We interviewed twenty women at Bwaila Fistula Care Center; five additional women were identified through snowball sampling and were interviewed in their homes. We also interviewed twenty family members. To analyze the data, we used thematic analysis. Data were categorized using Nvivo 10. Goffman's theory of stigma was used to inform the data analysis. RESULTS: All the women in this study were living a socially restricted and disrupted life due to a fear of involuntary disclosure and embarrassment. Therefore, "anticipated" as opposed to "enacted" stigma was especially prevalent among the participants. Many lost their positive self-image due to incontinence and smell. As a way to avoid shame and embarrassment, these women avoided public gatherings; such as markets, church, funerals and weddings, thus losing part of their social identity. Participants had limited knowledge about their condition. CONCLUSION: The anticipation of stigma by women in this study consequently limited their social lives. This fear of stigma might have arisen from previous knowledge of social norms concerning bowel and bladder control, which do not take into account an illness like obstetric fistula. This misconception might have also arisen from lack of knowledge about causes of the condition itself. There is need therefore to create awareness and educate women and their communities about the causes of obstetric fistula, its prevention and treatment, which may help to prevent fistula as well as reduce all dimensions of stigma, and consequently increase dignity and quality of life for these women.

Components of maternal healthcare delivery system contributing to maternal deaths in Malawi: a descriptive cross-sectional study.

In Malawi, it has been observed that some women are dying even when they reach a comprehensive emergency obstetric care facility where the quality is expected to be high and the maternal mortality low. The objective of this study was to describe shortcomings within the maternal healthcare delivery system that might have contributed to maternal deaths in the district of Lilongwe. Retrospectively, 14 maternal deaths that occurred between January 1, 2011 and June 30, 2011 were reviewed. Interviews were conducted with healthcare workers who provided care to the deceased women. Triangulated data from the respective medical charts and interview transcripts were analyzed using a directed approach to content analysis. Excerpts were categorized according to three main components of the maternal healthcare delivery system: skill birth attendant (SBA), enabling environment (EE) and referral system (RS). Most of the shortcomings identified were grouped under SBA. They included inadequate clinical workups and monitoring, missed and incorrect diagnoses, delayed or incorrect treatment, delayed referrals and transfers, patients not being stabilized before being referred and outright negligence. The SBA component should be investigated further. Interventions based on evidence from these investigations may have a positive impact on maternal mortality.

High rates of burnout among maternal health staff at a referral hospital in Malawi: A cross-sectional study.

BACKGROUND: Burnout among maternal healthcare workers in sub-Saharan Africa may have a negative effect on services provided and efforts to mitigate high maternal mortality rates. In Malawi, research on burnout is limited and no empirical research has been conducted specifically among maternal health staff. Therefore, the aims of the study were to examine the prevalence and degree of burnout reported by healthcare workers who provide antenatal, intrapartum, and postnatal services in a district referral hospital in Malawi; and, to explore factors that may influence the level of burnout healthcare workers experience. METHODS: In the current cross-sectional study, levels of burnout among staff working in obstetrics and gynaecology at a referral hospital in Malawi were examined, in addition to individual and job characteristics that may be associated with burnout. RESULTS: In terms of the three dimensions of burnout, of the 101 participants, nearly three quarters (72%) reported emotional exhaustion, over one third (43%) reported depersonalization while almost three quarters (74%) experienced reduced personal accomplishment. CONCLUSIONS: Based on these findings, burnout appears to be common among participating maternal health staff and they experienced more burnout than their colleagues working in other medical settings and countries. Further research is needed to identify factors specific to Malawi that contribute to burnout in order to inform the development of prevention and treatment within the maternal health setting.