Contraceptive Use in Cambodia: A Multi-Method Examination of Determinants and Barriers to Modern Contraception

In Cambodia, 79% of married women of reproductive age wish to limit or delay births, yet only 27% are using a modern method of contraception. The purpose of this mixed-method dissertation is to examine the determinants and barriers to contraceptive use in this population. The two specific aims are to 1) use quantitative data examine the associations between social support and contraceptive use among Cambodian women of low vs. high parity; and 2) use qualitative data to understand the different characteristics and barriers to method use of women who use contraceptives, women who have discontinued contraceptive use and women who have never used a modern method. The quantitative study (aim 1) surveyed a representative sample of married women ages 15-49 from two rural provinces in Cambodia (Kampong Thom and Kampot) and measured current contraceptive use, demographic characteristics and items related to contraceptive social support of husbands, peers and elders. Multivariate logistic regression methods were used to measure the association between contraceptive use and social support and models were stratified by low (=3 live births), The qualitative study (aim 2) used in-depth interviews and focus group discussions with different contraceptive user types to understand unique barriers and motivations of users, discontinuers and non-users of contraceptive methods. The quantitative paper shows significant associations between husband's support and contraceptive use. For all women, a husband's positive attitude towards methods and ease of communication with the husband are associated with higher contraceptive use; however, when the husband has full decision-making power, the likelihood of method use decreases among high-parity women. For low-parity woman, perceiving that peers use modern methods increases the likelihood of contraception. In both groups elders' negative opinions about contraceptive use decrease actual use. The qualitative findings show that rumors of myths and misconceptions about side effects are main barriers to the use and were wide-spread among all women. Differences between the three user types show that positive husband support, access to health providers and a high degree of self-efficacy for contraceptive use contribute to successful initiation and continuation of modern methods

Infant feeding experiences among teen mothers in North Carolina: Findings from a mixed-methods study

<p>Abstract</p> <p>Background</p> <p>Adolescent mothers in the U.S. are much less likely to initiate breastfeeding than older mothers, and teens who do initiate breastfeeding tend to breastfeed for shorter durations. The purpose of this mixed-methods study is to investigate breastfeeding practices, barriers and facilitators among adolescent mothers ages 17 and younger.</p> <p>Methods</p> <p>Quantitative descriptive analyses are conducted using data from the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS). The population-based sample comprises 389 teens ages 13-17 giving birth to a live born infant in North Carolina in 2000 - 2005 and in 2007. Qualitative analyses are based on in-depth interviews with 22 Black, White and Hispanic teen mothers residing in rural and urban areas of North Carolina conducted between November 2007 and February 2009.</p> <p>Results</p> <p>In quantitative analyses, 52% (196 of 389) of North Carolina teen mothers initiated breastfeeding, but half of those who initiated breastfeeding (92/196) stopped within the first month postpartum. Hispanic teens (44/52 or 89%) were much more likely than Black (61/159 or 41%) or White teens (87/164 or 52%) to initiate breastfeeding and to continue for a longer duration. Nearly sixty two percent (29/52) of Hispanic respondents breastfed for greater than four weeks as compared to 16% (29/159) of Black respondents and 26% (39/164) of White respondents. Common barriers to breastfeeding initiation and continuation included not liking breastfeeding, returning to school, nipple pain, and insufficient milk. Qualitative data provided context for the quantitative findings, elucidating the barriers and facilitators to breastfeeding from the teens' perspective and insight into the ways in which breastfeeding support to teens could be enhanced.</p> <p>Conclusions</p> <p>The large number of adolescents ceasing breastfeeding within the first month points to the need for more individualized follow-up after hospital discharge in the first few days postpartum, to address common technical challenges and to provide assistance managing the transition back to school. Provision of an extra home visit or outpatient visit for teens within the first few days following hospital discharge, and advocacy to make schools more compatible with breastfeeding, could potentially help teens who desire to breastfeed to successfully continue. These interventions warrant further research to test their effectiveness among adolescents.</p

Adolescent Sexual Behavior and Reproductive Outcomes In Central America: Trends over the Past Two Decades

Compared with the Latin American average,adolescent fertility is high in El Salvador,Guatemala, Honduras and Nicaragua,countries that also have high poverty levels and poor access to reproductive health care

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation

Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care

Unsafe abortion's significant contribution to maternal mortality and morbidity was a critical factor leading to liberalization of Nepal's restrictive abortion law in 2002. Careful, comprehensive planning among a range of multisectoral stakeholders, led by Nepal's Ministry of Health and Population, enabled the country subsequently to introduce and scale up safe abortion services in a remarkably short timeframe. This paper examines factors that contributed to rapid, successful implementation of legal abortion in this mountainous republic, including deliberate attention to the key areas of policy, health system capacity, equipment and supplies, and information dissemination. Important elements of this successful model of scaling up safe legal abortion include: the pre-existence of postabortion care services, through which health-care providers were already familiar with the main clinical technique for safe abortion; government leadership in coordinating complementary contributions from a wide range of public- and private-sector actors; reliance on public-health evidence in formulating policies governing abortion provision, which led to the embrace of medical abortion and authorization of midlevel providers as key strategies for decentralizing care; and integration of abortion care into existing Safe Motherhood and the broader health system. While challenges remain in ensuring that all Nepali women can readily exercise their legal right to early pregnancy termination, the national safe abortion program has already yielded strong positive results. Nepal's experience making high-quality abortion care widely accessible in a short period of time offers important lessons for other countries seeking to reduce maternal mortality and morbidity from unsafe abortion and to achieve Millennium Development Goals

“It is a thing that depends on God”

Background: Pregnancy among adolescent girls in Niger contributes to 34% of all deaths among females ages 15–19, but there is a dearth of research as to the specific contextual causes. In Zinder region, an area that is especially impoverished and where girls are at heightened risk, there is very little information on the main obstacles to improving adolescents’ health and well-being. This qualitative study examines the underlying social, individual and structural factors influencing married girls’ early first birth and participation in alternative opportunities (such as education or economic pursuits) in Niger. Methodology: In July of 2017, researchers conducted in-depth interviews with a non-probability sample of community members in three communes of Zinder Region, Niger. Participants (n = 107) included adolescent girls, husbands of adolescent girls, influential adults, community leaders, health providers, and positive deviants. All interviews were transcribed, coded and analyzed using Dedoose software. Results: Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, desire for children, and belief that childbirth is “God’s will” interfere with a girl’s ability to delay. Girls’ social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue. Participants favor adolescents’ pursuit of increased economic opportunities or education, but would not support delaying birth to do so. Conclusions: Findings indicate the need for a holistic approach to delaying early birth and stimulating girls’ participation in economic and educational pursuits. Potential interventions include mitigating barriers to reproductive health care; training adolescent girls on viable economic activities; and providing educational opportunities for girls. Effective programs should also include or target immediate members of the girls’ families (husbands, parents, in-laws), influential local leaders and members of the community at large

Understanding individual, family and community perspectives on delaying early birth among adolescent girls

Background: Pregnancy among adolescent girls in Bangladesh is high, with 66% of women under the age of 18 reporting a first birth; this issue is particularly acute in the northern region of Bangladesh, an area that is especially impoverished and where girls are at heightened risk. Using formative research, CARE USA examined the underlying social, individual and structural factors influencing married girls’ early first birth and participation in alternative opportunities (such as education or economic pursuits) in Bangladesh. Methods: In July of 2017, researchers conducted in-depth interviews of community members in two sub-districts of northern Bangladesh (Kurigram Sadar and Rajarhat). Participants (n = 127) included adolescent girls (both married and unmarredi), husbands of adolescent girls, influential adults in the girls’ lives, community leaders, and health providers. All interviews were transcribed, coded and organized using Dedoose software. Results: Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, pressure from mothers-in-law and health provider bias interfere with a girl’s ability to delay childbearing. Girls’ social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue; provider bias may also prevent access to methods. While participants agree that pursuit of education and economic opportunities are important, better futures for girls do not necessarily supersede their marital obligations of childrearing and domestic chores. Conclusions: Findings indicate the need for a multi-level approach to delaying early birth and stimulating girls’ participation in economic and educational pursuits. Interventions must mitigate barriers to reproductive health care; train adolescent girls on viable economic activities; and provide educational opportunities for girls. Effective programs should also address contextual issues by including immediate members of the girls’ families, particularly the husband and mother-in-law

Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh

Unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalization could lead to drops in unsafe abortion and related deaths. This review provides an analysis of changes in abortion mortality in three countries where significant policy reform and related service delivery occurred. Drawing on peer-reviewed literature, population data and grey literature on programs and policies, this paper demonstrates the policy and program changes that led to declines in abortion-related mortality in Romania, South Africa and Bangladesh. In all three countries, abortion policy liberalization was followed by implementation of safe abortion services and other reproductive health interventions. South Africa and Bangladesh trained mid-level providers to offer safe abortion and menstrual regulation services, respectively, Romania improved contraceptive policies and services, and Bangladesh made advances in emergency obstetric care and family planning. The findings point to the importance of multi-faceted and complementary reproductive health reforms in successful implementation of abortion policy reform

Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh

Abstract Unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalization could lead to drops in unsafe abortion and related deaths. This review provides an analysis of changes in abortion mortality in three countries where significant policy reform and related service delivery occurred. Drawing on peer-reviewed literature, population data and grey literature on programs and policies, this paper demonstrates the policy and program changes that led to declines in abortion-related mortality in Romania, South Africa and Bangladesh. In all three countries, abortion policy liberalization was followed by implementation of safe abortion services and other reproductive health interventions. South Africa and Bangladesh trained mid-level providers to offer safe abortion and menstrual regulation services, respectively, Romania improved contraceptive policies and services, and Bangladesh made advances in emergency obstetric care and family planning. The findings point to the importance of multi-faceted and complementary reproductive health reforms in successful implementation of abortion policy reform.</p

"Souls of the ancestor that knock us out" and other tales. A qualitative study to identify demand-side factors influencing malaria case management in Cambodia.

BACKGROUND: Appropriate case management of suspected malaria in Cambodia is critical given anti-malarial drug resistance in the region. Improving diagnosis and the use of recommended malarial treatments is a challenge in Cambodia where self-treatment and usage of drug cocktails is widespread, a notable difference from malaria treatment seeking in other countries. This qualitative study adds to the limited evidence base on Cambodian practices, aiming to understand the demand-side factors influencing treatment-seeking behaviour, including the types of home treatments, perceptions of cocktail medicines and reasons for diagnostic testing. The findings may help guide intervention design. METHODS: The study used in-depth interviews (IDIs) (N = 16) and focus group discussions (FGDs) (N = 12) with Cambodian adults from malaria-endemic areas who had experienced malaria fever in the previous two weeks. Data were analysed using NVivo software. RESULTS: Findings suggest that Cambodians initially treat suspected malaria at home with home remedies and traditional medicines. When seeking treatment outside the home, respondents frequently reported receiving a cocktail of medicines from trusted providers. Cocktails are perceived as less expensive and more effective than full-course, pre-packaged medicines. Barriers to diagnostic testing include a belief in the ability to self-diagnose based on symptoms, cost and reliance on providers to recommend a test. Factors that facilitate testing include recommendation by trusted providers and a belief that anti-malarial treatment for illnesses other than malaria can be harmful. CONCLUSIONS: Treatment-seeking behaviour for malaria in Cambodia is complex, driven by cultural norms, practicalities and episode-related factors. Effective malaria treatment programmes will benefit from interventions and communication materials that leverage these demand-side factors, promoting prompt visits to facilities for suspected malaria and challenging patients' misconceptions about the effectiveness of cocktails. Given the importance of the patient-provider interaction and the pivotal role that providers play in ensuring the delivery of appropriate malaria care, future research and interventions should also focus on the supply side factors influencing provider behaviour