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PubMed1997

Religious freedom, reproductive health care, and hospital mergers.

This article examines the impact of hospital mergers and the formation of health care networks involving religious hospitals on the provision of reproductive health care. Although instances of access to such services being curtailed at non-Catholic religious facilities have been reported, no systematic study of hospitals owned by other religious denominations has yet been done. Accordingly, the author focuses on Roman Catholic institutions and policies. Efforts by Roman Catholic Bishops to enforce the Ethical and Religious Directives for Catholic Health Care Services on new institutional partners has led to the elimination of or severe restrictions on patient access to abortion, contraception, infertility treatments, and even to emergency contraception for rape victims. The article suggests steps that physicians, patients, and community organizations and activists can take to safeguard reproductive health care as new institutional and professional relationships are formed.

Catholicism↗
PubMed2001

Reproductive health services and the law and ethics of conscientious objection.

Reproductive health services address contraception, sterilization and abortion, and new technologies such as gamete selection and manipulation, in vitro fertilization and surrogate motherhood. Artificial fertility control and medically assisted reproduction are opposed by conservative religions and philosophies, whose adherents may object to participation. Physicians' conscientious objection to non-lifesaving interventions in pregnancy have long been accepted. Nurses' claims are less recognized, allowing nonparticipation in abortions but not refusal of patient preparation and aftercare. Objections of others in health-related activities, such as serving meals to abortion patients and typing abortion referral letters, have been disallowed. Pharmacists may claim refusal rights over fulfilling prescriptions for emergency (post-coital) contraceptives and drugs for medical (i.e. non-surgical) abortion. This paper addresses limits to conscientious objection to participation in reproductive health services, and conditions to which rights of objection may be subject. Individuals have human rights to freedom of religious conscience, but institutions, as artificial legal persons, may not claim this right.

Abortion, Induced↗
PubMed2003

Decentralisation and its implications for reproductive health: the Philippines experience.

Decentralisation is one of the most common health sector reforms initiated in developing countries in the 1980-90s. Although decentralisation is often politically driven, it can significantly improve health sector performance. However, the early phase of the Philippines experience indicates that decentralisation in and of itself does not always improve the efficiency, equity and effectiveness of the health sector. Instead, it can exacerbate inequities, weaken local commitment to priority health issues and decrease the efficiency and effectiveness of service delivery by disrupting the referral chain. Such effects pose a particularly serious threat to accessibility and delivery of reproductive health services, some of which (e.g. family planning) are controversial and thus susceptible to local pressures, and others of which (e.g. emergency obstetric care) require a functioning and effective health system. Moreover, those undertaking decentralisation need to take account of the impacts of non-health factors as well as other reforms that interact with decentralisation to affect accessibility, affordability and quality of services, including for reproductive health. The Philippines experience also demonstrates that authority should be shared between the centre and local units in order to achieve national health objectives and respond to local health needs. Adjustments must be made during implementation to correct for both emerging and pre-existing problems.

Decision Making, Organizational↗
PubMed1983

Protecting the reproductive health of workers: problems in science and public policy.

This paper first reviews the scientific problems involved in assessing the effects on reproductive health of toxic substances in the work environment. It then describes the current status of regulatory policies designed to control workers' exposures to toxins believed to affect reproduction. Finally, the paper discusses the relationship between scientific uncertainty and regulatory strategies. Because demonstrating reproductive health effects is extremely difficult, the assessment of the health risks of exposures, as well as of the economic costs of regulation, is probabilistic. Therefore, uncertainty is inherent in any regulatory decision in this area. And the case of reproductive risks is illustrative of the more general problem of protecting the health of workers within a context of scientific uncertainty, and within a highly charged political environment characterized by anti-regulatory sentiment and industries in economic decline.

Animals↗
PubMed1998

Quality of care in reproductive health programmes: concepts, assessments, barriers and improvements--an overview.

At the end of the first decade of the Safe Motherhood Initiative there are still, at a minimum, 1600 women dying every day from complications of pregnancy and childbirth: this is an intolerable human tragedy. The fact that there are almost 100,000 more maternal deaths annually now compared to 10 years ago, 585,000, must present a challenge to every citizen in society. Policy makers, health professionals, social workers, religious leaders, human-rights advocates and the media all have a responsibility to ask themselves: 'What can I do?' All have a role in affecting quality reproductive-health services, which are essential for the reduction of maternal mortality and morbidity, and are an intrinsic human right. The midwife is the obvious catalyst and linch-pin for this effort in the fabric of society. Three papers will address the issues of quality of care in reproductive-health programmes with particular emphasis on safe motherhood. This, the first, article describes the concepts of quality of care in reproductive-health programmes, the determinants of quality improvement, assessment tools for service quality, barriers to quality of care and quality improvement together with examples from relevant countries. The second article will address education issues relative to quality of care, and the third will describe the monitoring and evaluation of quality of care with relevant indicators and project results.

Female↗
PubMed2006

Confidentiality for adolescents seeking reproductive health care in Lithuania: the perceptions of general practitioners.

Confidentiality is a major determinant of the accessibility and acceptability of sexual and reproductive health care for adolescents. Previous research has revealed that Lithuanian adolescents lack confidence in guarantees of confidentiality in primary health care settings. This study aimed to assess the factors that affect general practitioners' decisions whether to respect confidentiality for Lithuanian adolescents under the age of 18. Twenty in-depth interviews were carried out with a purposive sample of general practitioners. The decision whether to respect confidentiality was found to be influenced by external forces, including the legislative framework and societal attitudes towards adolescent sexuality; institutional features in clinical facilities, such as the presence of a nurse during consultations and the openness of the medical record filing system; and individual factors, including GPs' relationships with adolescents' families and their personal attitudes towards sexual and reproductive health issues. The findings reflect the urgent need for a comprehensive policy to ensure adolescents' right to confidentiality in Lithuanian primary care settings, including legislative reforms, institutional changes in health care settings, professional guidelines and (self-)regulation, and changes in medical training and continuing medical education. Other ways to safeguard confidentiality in adolescent health services, such as establishing youth clinics, should also be explored.

Adolescent↗
PubMed2004

Destigmatising abortion: expanding community awareness of abortion as a reproductive health issue in Ghana.

Traditional and cultural values, social perceptions, religious teachings and criminalisation have facilitated stigmatisation of abortion in Ghana. Abortion is illegal in Ghana except in three instances. Though the law allows for performance of abortion in three circumstances, the Ghana reproductive health service policy did not have any induced legal abortion services component to cover the three exceptions until it was revised in 2003. The policy only had 'unsafe and post-abortion' care components, and abortions performed in health facilities operated by the Ghana Health Service were performed under this component. Though the policy has been revised, women and girls who need abortion services in Ghana more often resort to the backstreet dangerous methods and procedures. Criminalisation of abortion and those who perform abortions has contributed to unsafe abortion, the second leading cause of maternal deaths in Ghana. Most of these are performed outside the formal health service structures. Traditionally, abortion is perceived as a shameful act and the community may shun and give a woman who has caused anabortion derogatory names. Would provision of legal abortion services be culturally acceptable within a Ghanaian community? Yes, if they are made aware of the reproductive health benefits of providing safe abortion services. Three major strategies that would help to destigmatise abortion in the community are (1) the liberal interpretation of the three exceptions to the law on abortion; (2) expanding community awareness of its reproductive health benefits; and (3) improving and increasing access to legal abortion services within the formal health facilities.

Abortion, Induced↗
PubMed2006

Reproductive health of Gulf War veterans.

In this review we summarize the scientific literature on reproductive health following deployment to the first Gulf war by armed service personnel. All the studies examined had methodological limitations, making interpretation difficult. Nonetheless we conclude that for male veterans there is no strong or consistent evidence to date for an effect of service in the first Gulf war on the risk of major, clearly defined, birth defects or stillbirth in offspring conceived after deployment. Effects on specific rare defects cannot be excluded at this stage since none of the studies had the statistical power to examine them. For miscarriage and infertility, there is some evidence of small increased risks associated with service, but the role of bias is likely to be strong. For female veterans, there is insufficient information to make robust conclusions, although the weight of evidence to date does not indicate any major problem associated specifically with deployment to the Gulf. None of the studies have been able to examine risk according particular exposures, and so possible associations with specific exposures for smaller groups of exposed veterans cannot be excluded. We suggest that the way forward to address the question of veterans' reproductive health with confidence in the future is prospective surveillance following deployment. Anything less will result in further problems of interpretation and continued anxiety for parents, as well as prospective parents, in the armed forces.

Congenital Abnormalities↗
PubMed2001

Use of the equivalence approach in reproductive health clinical trials.

An equivalence trial is appropriate when it is desired to demonstrate equivalence between two treatments, regimens or interventions (methods) or non-inferiority of a new one compared to a standard one. The conduct of an equivalence trial requires different techniques during design and analysis compared to a superiority trial. The existing formulae for sample size calculation to demonstrate equivalence between two methods using the confidence interval approach are reviewed. The establishment of the margin of equivalence and the choice of the type of test are discussed. Plots of sample sizes required to demonstrate equivalence in the case of binary outcomes are presented for values of proportions and margins of equivalence common in the reproductive health field. Examples are given of method comparisons in the reproductive health field in which the relevant question is to demonstrate non-inferiority. The approach to equivalence is described in the trials included in three published systematic reviews in which these comparisons were conducted, addressing the statement of hypotheses, sample size calculation and the interpretation of results. The use of the conventional superiority approach to design equivalence trials has led to underpowered trials to show equivalence within clinical relevant margins. The analysis and interpretation of results from such trials has resulted in conclusions of equivalence based on lack of significance. We draw attention to the lack of awareness of the appropriate techniques for equivalence trials among researchers in the field of reproductive health. Finally, the issue of interim analyses and stopping rules in equivalence trials is addressed.

Confidence Intervals↗
PubMed2004

"Peer" educator initiatives for adolescent reproductive health projects in Indonesia.

Since the ICPD in 1994, the Government of Indonesia has struggled with the challenge of providing sexual and reproductive health education to adolescents. Following an attempt at a family-centred approach, a pilot project was carried out in Central and East Java to train peer educators, coordinated by the National Family Planning Coordinating Board (BKKBN). A total of 80 peer educators (male/female teams) carried out small-group information sessions in ten different districts. Over 1,300 adolescents attended in all. Forty peer counsellors in 20 teams then carried out five outreach sessions each in their communities, attended by nearly 4,000 adults and adolescents. Educators chosen were older in age, knowledge level, authority and communication skills than adolescents, but were well accepted as mentors. Adolescents wanted to know how to deal with sexual relationships and feelings, unwanted pregnancy and STDs. With 42 million Indonesian adolescents needing information, the government cannot produce enough manuals to satisfy demand. New strategies are required to put information in the public domain, e.g. via the media. The approach described in this paper would probably be beyond the staffing and resource capacity of most districts in Indonesia. Nonetheless, it shows that there was great enthusiasm across a variety of communities for efforts to educate young people on protecting their reproductive health.

Adolescent↗
PubMed2005

HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe.

AIDS has increased the number of orphans and vulnerable children (OVCs) in sub-Saharan Africa who could suffer detrimental life experiences. We investigated whether OVCs have heightened risks of adverse reproductive health outcomes including HIV infection. Data on HIV infection, sexually transmitted infection (STI) symptoms and pregnancy, and common risk factors were collected for OVCs and non-OVCs in a population survey of 1523 teenage children in eastern Zimbabwe between July 2001 and March 2003. Multivariate logistic regression was used to test for statistical association between OVC status, adverse reproductive health outcomes and suspected risk factors. Amongst women aged 15-18 years, OVCs had higher HIV prevalence than non-OVCs (3.2% versus 0.0%; p = 0.002) and more common experience of STI symptoms (5.9% versus 3.3%; adjusted odds ratio = 1.75, 95% CI 0.80-3.80) and teenage pregnancy (8.3% versus 1.9%; 4.25, 1.58-11.42). OVCs (overall), maternal orphans and young women with an infected parent were more likely to have received no secondary school education and to have started sex and married, which, in turn, were associated with poor reproductive health. Amongst men aged 17-18 years, OVC status was not associated with HIV infection (0.5% versus 0.0%; p = 1.000) or STI symptoms (2.7% versus 1.6%; p = 0.529). No association was found between history of medical injections and HIV risk amongst teenage women and men. High proportions of HIV infections, STIs and pregnancies among teenage girls in eastern Zimbabwe can be attributed to maternal orphanhood and parental HIV. Many of these could be averted through further female secondary school education. Predicted substantial expanded increases in orphanhood could hamper efforts to slow the acquisition of HIV infection in successive generations of young adults, perpetuating the vicious cycle of poverty and disease.

Adolescent↗
PubMed1996

Community reactions to reproductive health care at three school-based clinics in Louisiana.

Despite the growing success of school-based health care during the past two decades, the issue of providing reproductive health care at school-based health centers remains controversial. In this article, focus group data from three school-based centers in Louisiana, each in different stages of development, demonstrates how the controversies about reproductive health may frame more general concerns about school-based care. In addition, community readiness to address directly problematic sexual behavior relates not only to the specific needs and priorities of the community but to recognition of the negative effect of the consequences of sexual behavior such as pregnancy, high drop out, and absenteeism rates on a community's educational, rather than social, goals and values.

Adolescent↗
PubMed2002

Reproductive health in individuals with homozygous beta-thalassemia: knowledge, attitudes, and behavior.

OBJECTIVE: To review the reproductive health knowledge, attitudes, and behaviors of persons with homozygous beta-thalassemia. DESIGN: Case-control study. SETTING: Patients treated at a tertiary hospital and community-based healthy controls. PARTICIPANT(S): One hundred and thirty persons, 16 years of age or older, who had homozygous beta-thalassemia and were attending hospital for regular blood transfusion, and 99 demographically matched persons without thalassemia. ASSESSMENT TOOL: Reproductive health questionnaire. RESULT(S): 104 (80%) persons with homozygous beta-thalassemia completed the questionnaire and were compared with 99 controls. Persons with homozygous beta-thalassemia were as likely as healthy peers to be in a relationship, employed full-time, sexually active, and using contraception and to have had children. Hypogonadotrophic hypogonadism was present in 55 (52.8%) patients, 46 (83.6%) of whom were compliant with hormone replacement therapy. Understanding of genetics and reproductive potential was suboptimal among persons with homozygous beta-thalassemia, and this group had a higher rate of unplanned pregnancy. CONCLUSION(S): This study suggests that with optimal therapy, most young adults with homozygous beta-thalassemia can achieve reproductive, sexual, and social experiences similar to those of their healthy peers.

Adolescent↗
PubMed1994

Progestogen-only contraceptives during lactation: I. Infant growth. World Health Organization Task force for Epidemiological Research on Reproductive Health; Special Programme of Research, Development and Research Training in Human Reproduction.

Growth, development and health of infants whose mothers used progestogen-only contraceptives during lactation were examined in a prospective, non-randomized study carried out in seven centres in five countries (Egypt, Thailand, Kenya, Chile and Hungary). The results on growth are reported here. Breastfeeding women requesting effective contraception were admitted to the study at six weeks postpartum. Infants of acceptors of progestogen-only methods (pill, DMPA, NET-EN or NORPLANT implants) and non-hormonal methods (IUD, barrier methods or sterilization) formed the study groups. The follow-up was at monthly intervals until the end of the first postpartum year. Participating in the study were 2466 mother-infant pairs. The mean duration of exclusive breastfeeding varied from 68 to 159 days, but did not differ significantly between study groups within centres. In anthropometric measures (weight, arm circumference and triceps skinfold), the mean rates of change varied over time as expected, and across the centres. However, there were very few statistically significant differences in these rates of change between groups within centres. Since a large number of statistical comparisons were made, and there was no consistency either across centres, over time, or in the direction of the differences, we conclude that in this study, the progestogen-only contraceptives used during lactation did not adversely affect infant growth.

Adolescent↗
PubMed1994

Progestogen-only contraceptives during lactation: II. Infant development. World Health Organization, Task Force for Epidemiological Research on Reproductive Health; Special Programme of Research, Development, and Research Training in Human Reproduction.

Growth, development and health of infants whose mothers used progestogen-only contraceptives during lactation were examined in a prospective, non-randomized study that was carried out in seven centres in five countries (Egypt, Thailand, Kenya, Chile and Hungary). The results on development are reported here. Breastfeeding women requesting effective contraception were admitted to the study at six weeks postpartum. Infants of acceptors of progestogen-only methods (pill, DMPA, NET-EN or NORPLANT implants) and non-hormonal methods (IUD, barrier methods or sterilization) formed the study groups. The follow-up was at monthly intervals until the end of the first postpartum year. At each visit, the infant examination included, among other things, a set of developmental tests covering the following areas: gross motor, vision and fine motor, hearing, language and concept development, and self help and social skills. Participating in the study were 2466 mother-infant pairs. The comparisons between the study groups were carried out within centres using life table methods and Cox-model analysis having the time to first passing the test as the criterion. There were altogether 247 comparisons between the study groups. Thirty-two (13%) of these comparisons showed statistically significant differences: 20 differences showed that the infants in the progestogen-only groups passed the tests at an earlier age and 12 at a later age than infants in the non-hormonal groups. Since no consistent trends were observed across the centres, we conclude that in this study the progestogen-only contraceptives used during lactation did not adversely affect infant development.

Adolescent↗
PubMedDate not supplied

Reproductive health and preconception counseling awareness in adolescents with diabetes: what they don't know can hurt them.

PURPOSE: This study explored the awareness of issues related to diabetes and pregnancy, preconception counseling (PC), and contraception in adolescent women with type 1 diabetes (T1D). METHODS: A descriptive-qualitative method was used to collect open-ended data during a telephone interview on reproductive health by same-gender research assistants. Eighty subjects were recruited from multiple sites (mean age = 17.6 +/- 1.0 year; range, 16-20). Questions focused on 2 themes, awareness of diabetes and reproductive health (pregnancy, PC, birth control) and where to seek information about these issues. Responses were written verbatim. Pattern recognition detected common themes. Results were cross-checked for interrater reliability. RESULTS: Overall, the response "don't know" or "never heard about it" was most frequently given. Most teens in this sample were unaware of the term preconception counseling; 65% (n = 52) indicated they knew nothing about PC. Many were not aware of the risks of pregnancy-related complications in women with diabetes. One fourth of the teens were aware of preplanning a pregnancy and the importance of good metabolic control. Many knew where to seek information about diabetes and pregnancy, and birth control. CONCLUSIONS: This sample of teens lacked awareness of pregnancy-related complications with diabetes, the term and role of PC in preventing these complications, and the importance for women with diabetes to use a highly effective birth control method for preventing an unplanned pregnancy. Because of its implications for future reproductive health behavior and preventing unplanned pregnancies and complications, during their routine clinic visits, it is imperative for health professionals to raise these issues with their adolescent female patients.

Adolescent↗
PubMed1989

Commentary on women-centered reproductive health services.

From women's perspectives, the primary principles of a reproductive health framework in the developing world are as follows: Family planning is a basic human right to which all human beings are entitled. Provision of family planning services must be comprehensive, including safe and low cost methods, freedom of choice about both contraception and pregnancy termination, timely and honest information, privacy and confidentiality, individual needs assessment, and counseling of women, men or the couple. Wide contraceptive choice requires more research on methods that are less invasive of women's anatomy and physiology and more supportive of women's control of their own bodies. These parameters of quality care in family planning must be centered on women's needs, desires and expectations. The concept of conscious contraception implies an attitude of conscious sexuality. When a woman accepts that sexual gratification independent of reproduction is a legitimate right, she is better prepared to engage in the pursuit of her own health and happiness. If family planning programs do not include sexuality as a key issue to discuss with clients, all long-term strategies will fall short in modifying people's attitudes, especially women's reluctance to contracept. Sexual and reproductive health includes emotional health. As Dr. Sai points out, the effects of underdevelopment and poverty strike women in dramatic ways, and quite often all the pressures to which they are exposed lead to precarious emotional health. They become victims of violence and repeat the cycle of violence with their children. We, as advocates of sexual and reproductive rights, must also consider the psychological and emotional implications of sexuality and reproduction, and learn to deal with them in our clinics and services.(ABSTRACT TRUNCATED AT 250 WORDS)

Abortion, Illegal↗