Population Services International Research Articles

Towards Shared and Effective Self-Care: A User-Centric Framework for Enhancing HIV Prevention

Background: Despite a declining trend in Human immunodeficiency virus (HIV) prevalence across sub-Saharan Africa, specific vulnerable groups continue to be disproportionately impacted (29.9% for sex workers, 12.9% for gay men having sex with men (MSM) vs 5.9% for adults). In the face of this challenge, it is critical to tailor demand creation for prevention, in particular self-care, for maximum impact and cost-efficiency. This study seeks to provide a behavioral understanding towards HIV prevention that shape the efficacy of prevention strategies among priority populations (female sex workers, MSM and adolescent girls and young women) in southern and eastern Africa. Methods: This study involved a literature review of 110 articles, focusing on HIV prevention in priority populations, behavioral interventions, and policy priorities from governments and funders. Additionally, insights were gained from 11 in-depth interviews and a workshop with 10 experts at the AIDS Impact 2023 conference. Participants included behavioral researchers and program leaders from Global Fund, United States Agency for International Development (USAID), U.S. President's Emergency Plan for AIDS Relief (PEPFAR), Bill and Melinda Gates Foundation, FHI360, Population Services International and Genesis Analytics. A user-centric behavioral framework was devised to identify actionable drivers and barriers in HIV prevention during the consultation exercise. Results: The study highlights the importance of shared and effective self-care in enhancing HIV prevention, particularly in vulnerable groups. The behavioral framework integrates the decision-making contexts and the health ecosystem layers to inform research and demand strategy. Key findings include: (1) effective self-care is not the same as continuous use of Pre-exposure prophylaxis and therefore, programs and policies need to measure them differently; (2) users exercise choice through a combination of prevention products and focus on a few may be sub-optimal, and (3) perceived risk is transient and hence risk-based messaging lacks sustained relevance. Conclusion: Effective self-care strategies extend beyond overcoming access and availability issues. Examining the underlying factors causing the barriers is essential. The behavioral framework presented here suggests that: (a) Self-care is a shared responsibility between the user and healthcare system and (b) demand creation should be de-medicalised, away from products and towards meeting the needs and preferences of users.

PrEP retention predictors among key populations in urban areas of Zimbabwe — a machine learning approach

Pre-exposure prophylaxis (PrEP) success depends on adherence and hence retention in care. It is vital to find factors that affect PrEP retention to make this HIV-prevention method successful. The main objectives of this study were to identify the major determinants of PrEP retention at six months from day of initiation and to determine PrEP retention clusters. Data of people who were initiated on PrEP care at Population Services International sites between 2017 and 2019 in Zimbabwe were used. Determinants of PrEP retention were identified using multivariable logistic regression and partitioning around medoids (PAM) cluster analysis to determine the number and composition of PrEP retention clusters. Significant PrEP retention determinants were found to be population type, sex, marital status, employment type, age and education level. Female sex workers were most likely to stay on PrEP compared to other users. We found that PrEP users could be grouped into three risk clusters: cluster 1 consisted of married adult males who are high-risk individuals; cluster 2 consisted of the young single men who have sex with men (MSM); and cluster 3 consisted of adult women who are separated or divorced and employed as sex workers. The retention rates were 32%, 24% and 44% for clusters 1 to 3 respectively. We conclude that adults, female sex workers, high-risk individuals, women, people without or with little education and sex workers stay on PrEP better than youths, MSM, men and educated and employed individuals.

Choice of a family planning outlet in urban areas: The role of distance and quality of services in Kenya and Uganda.

Quality of care and physical access to health facilities affect facility choice for family planning (FP). These factors may disproportionately impact young contraceptive users. Understanding which components of service quality drive facility choice among contraceptive users of all ages can inform strategies to strengthen FP programming for all potential users of FP. This study uses data from Population Services International's Consumer's Market for Family Planning (CM4FP) project, to examine drivers of facility choice among female FP users. The data collected from female contraceptive users, the outlet where they obtained their contraceptive method, and the complete set of alternative outlets in select urban areas of Kenya and Uganda were used. We use a mixed logit model, with inverse probability weights to correct for selection into categories of nonuse and missing facility data. We consider results separately for youth (18-24) and women aged 25-49 in both countries. We find that in both countries and across age groups, users were willing to travel further to public outlets and to outlets offering more methods. Other outlet attributes, including signage, pharmacy, stockouts, and provider training, were important to women in certain age groups or country. These results shed light on what components of service quality drive outlet choice among young and older users and can inform strategies to strengthen FP programming for all potential users of FP in urban settings.

Ashley Judd to Speak at APA Annual Meeting

Back to table of contents Previous article Next article Annual MeetingFull AccessAshley Judd to Speak at APA Annual MeetingKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:25 Feb 2023https://doi.org/10.1176/appi.pn.2023.03.3.66AbstractGolden Globe winner and Emmy-nominated actress Ashley Judd has long been a devoted activist and humanitarian, championing women’s rights and public health issues. She has also written about the need to ensure privacy for families following the death of a loved one to suicide.Actor and mental health advocate Ashley Judd is the keynote speaker at the Opening Session of APA’s 2023 Annual Meeting. The Opening Session will be held Saturday, May 20, at 5:30 p.m. in the Moscone Center.Known for her roles in “De-Lovely,” “Ruby in Paradise,” and “Double Jeopardy,” actress, writer, and humanitarian Ashley Judd, M.P.A., will be a plenary speaker at the 2023 APA Annual Meeting in San Francisco.Judd has also gained worldwide acclaim as an avid advocate of human rights, with a focus on gender equality and public health. Since 2004 she has worked with numerous NGOs and traveled the world in support of public health efforts related to maternal health, child survival, HIV prevention, and malaria prevention and treatment.She currently serves as a Global Goodwill Ambassador for the United Nations (UN) Population Fund, the UN’s sexual and reproductive health agency. She is also the chair of the Women’s Media Center Speech Project: Curbing Abuse, Expanding Freedom; a Global Ambassador for both Population Services International and Polaris Project; and a member of the leadership council of the International Center for Research on Women.Judd earned her master’s degree from Harvard’s Kennedy School of Government. In 2017, she was the recipient of the Muhammad Ali Kentucky Humanitarian Award. Her undergraduate alma mater, the University of Kentucky, established the Ashley T. Judd Distinguished Graduate Fellowship in the Office for Policy Studies on Violence Against Women.She was also featured on the cover of TIME Magazine’s 2017 Person of the Year issue, which honored the thousands of individuals across the world who spoke out about their experiences of sexual harassment and assault, dubbed “The Silence Breakers.”Judd has written about her family experiences with mental illness. In August 2022, she penned a guest essay in the New York Times about her family’s effort to keep police reports related to the suicide of her mother, Naomi Judd, private. Naomi Judd was a well-respected musician who dealt with mental illness for much of her life.Tennessee law allows police reports from closed investigations, including family interviews, to be made public. “Naomi lost a long battle against an unrelenting foe that in the end was too powerful to be defeated,” Ashley Judd wrote. “I could not help her. I can, however, do something about how she is remembered.”She wrote that she intends to make the invasion of privacy following an individual’s death by suicide “a personal as well as a legal cause.” She also called for a reformation of law enforcement procedures related to such cases. “Though I acknowledge the need for law enforcement to investigate a sudden violent death by suicide, there is absolutely no compelling public interest in the case of my mother to justify releasing the videos, images, and family interviews that were done in the course of that investigation.”Last August, Naomi Judd’s family filed for injunctive relief in Williamson County, Tenn., to keep the police records related to her death private. Last December, the Associated Press reported that the family had filed a notice to voluntarily dismiss the lawsuit, due in part to the fact that journalists who requested the police records were not requesting photographs or body cam footage. The notice also said a Tennessee state lawmaker is introducing legislation to make death investigation records private when the death is not the result of a crime.“I hope that leaders in Washington and in state capitals will provide some basic protections for those involved in the police response to mental health emergencies,” Ashley Judd wrote in her essay, adding that her mother “should be remembered for how she lived, which was with goofy humor, glory onstage, and unfailing kindness off it—not for the private details of how she suffered when she died.” ■ ISSUES NewArchived

The effects of text reminders on the use of family planning services: evidence from a randomised controlled trial in urban Mozambique

IntroductionReduction of unmet need for contraception is associated with enhanced health outcomes. We conducted a randomised controlled trial in Mozambique analysing the effects of text messages encouraging use of family...

Motivation to test, treat, and report malaria cases: a quantitative assessment among private sector providers in the Greater Mekong Subregion

BackgroundAccurately testing, treating, and tracking all malaria cases is critical to achieving elimination. Ensuring health providers are able and motivated to test, treat, and report cases is a necessary component of elimination programmes, and particularly challenging in low endemic settings where providers may not encounter a large volume of cases. This study aimed to understand provider motivations to test, treat, and report malaria cases to better optimize programme design, adjust incentive schemes, and ultimately improve reporting rates while growing the evidence base around private providers in the Greater Mekong Subregion (GMS).MethodsWith funding from the Bill & Melinda Gates Foundation, this study aimed to identify and validate distinctive subtypes of motivation among private sector providers enrolled in the Greater Mekong Subregion Elimination of Malaria through Surveillance (GEMS) programme, implemented by Population Services International. Quantitative questionnaires were administered electronically in person by trained enumerators to various provider groups in Myanmar, Lao PDR, and Vietnam. A three-stage confirmatory factor analysis was then conducted in STATA.ResultsFollowing this analysis, a two-factor solution that describes motivation in this population of providers was identified, and providers were scored on the two dimensions of motivation. The correlation between the two rotated factors was 0.3889, and the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was 0.93, indicating an excellent level of suitability. These providers, who are often assumed to only be financially motivated, engaged in malaria elimination activities because of both internal and external motivational factors that are independent of remuneration or financial gain. For all three countries’ data, significant covariances between the two latent variables for internal and external motivation were found. The models were found to be of adequate to good fit for the data across all three countries. It was determined that private sector providers, who were previously believed to be primarily financially motivated, were also motivated by personal factors. Motivation was also associated with key outcomes of importance to malaria elimination, such as reporting and stocking of tests and treatments.ConclusionMaintaining or increasing provider motivation to test and treat is essential in the fight to eliminate malaria from the GMS, as it helps to ensure that providers continue to pursue this goal, even in a low incidence environment where cases may be rare and in which providers face financial pressure to focus on areas of health service provision. Establishing mechanisms to better motivate providers through intrinsic factors is likely to have a substantive impact on the sustainability of malaria case management activities.

The use of respondent\u2011driven sampling to assess febrile illness treatment-seeking behaviours among forest-goers in Cambodia and Vietnam

BackgroundCountries in the Greater Mekong sub-region (GMS) aim to eliminate all forms of malaria by 2030. In Cambodia and Vietnam, forest-goers are at an increased risk of malaria. Universal access to prompt diagnosis and treatment is a core malaria intervention. This can only be achieved by understanding the healthcare-seeking behaviour among the most vulnerable groups and eliminating barriers to prompt and effective treatment. This study aimed to explore healthcare-seeking behaviours for febrile illness among populations at risk for malaria in Cambodia and Vietnam.MethodsIn 2019, researchers from Population Services International (PSI) conducted a population-based survey of forest-goers in Cambodia and Vietnam using respondent-driven sampling (RDS) In Cambodia two operational districts, Oral and Phnom Srouch in Kampong Speu Province were included in the study. In Vietnam, communes located within 15 km of the forest edge in Binh Phuoc and Gia Lai Provinces were selected. Adults who had spent at least one night per week or four nights per month in the forest over the previous three months were eligible for the study.ResultsSome 75% of forest-goers in Cambodia and 65% in Vietnam sought treatment for illness outside the home. In Cambodia, 39% sought treatment from the private sector, 32% from community health workers, and 24% from public health facilities. In Vietnam, 62% sought care from community facilities, 29.3% from the private sector, and 6.9% went to a public facility. Among forest-goers who sought care, 33% in Cambodia and 52% in Vietnam did so within 24 h.ConclusionsThis study is consistent with others that show that early diagnosis and treatment of malaria remains an obstacle to malaria elimination. This study also demonstrates that there are gaps in timeliness of care seeking among forest-goers. The findings from this study around provider preference and delays in treatment-seeking can be used to strengthen the design and targeting of malaria interventions and social and behaviour change strategies to accelerate malaria elimination in Cambodia and Vietnam.

Effects of a new health financing scheme on out-of-pocket health expenditure: findings from a longitudinal household study in Yangon, Myanmar.

Since 2017, Population Services International Myanmar (PSI/Myanmar) has been running Strategic Purchasing (SP) clinics in Hlegu and Shwepyithar townships in Yangon, Myanmar. In the project, Population Services International Myanmar simulated the role of a purchaser and contracted SP clinics through a capitation payment scheme. The project aimed to reduce the health-related financial burden of poor populations in the catchment area, by having them registered under respective SP clinics for access to a package of essential health services for a minimal fixed co-payment, as a replacement for usual fee-for-service payments. Four longitudinal surveys of households registered under SP clinics were conducted in 2017, 2018 and 2019. Among 2506 registered households, 867 households sought some health care in all surveys, resulting in 3468 observations. Multivariable linear mixed-effect regression model was used to analyse the changes in out-of-pocket expenditure for health care in relation to household capacity to pay (OOPCTP). The utilization of SP clinics increased over time, and the rates were much higher in Hlegu (20.5% in baseline to 61.9% in round three) compared with those in Shwepyithar (0.2 to 7.9%). Compared with the baseline assessment, household OOPCTP decreased significantly during and after the implementation (0.76 times in round one, 0.80 in round two and 0.82 in round three; P < 0.001). Households in Shwepyithar with less utilization of SP clinics had 1.8 times higher OOPCTP compared with those in Hlegu (1.82, 95% CI 1.58, 2.09; P < 0.001). Household direct expenditures on care-seeking and family planning were up to 50% lower among those who used SP clinics. Our study highlighted that capitation-based health financing schemes could successfully lower out-of-pocket health expenditures among the poor. Optimal utilization of services was paramount in the successful implementation of such programmes. Therefore, for the effective scale-up of new health financing schemes, service utilization rates should be carefully monitored as one of the critical indicators.

Role of small private drug shops in malaria and tuberculosis programs in Myanmar: a cross-sectional study

BackgroundThe role of community drug shops in providing primary care has been recognized as important in Myanmar as in other countries. The contribution by private community drug shops to National Tuberculosis case notifications and National Malaria testing and positive cases is significant. Population Services International Myanmar (PSI/Myanmar) has been successfully training and engaging community drug shops to screen presumptive Tuberculosis to make referrals to public health clinics and perform malaria rapid diagnostic tests (mRDT) to malaria fever cases and provide management accordingly.ObjectivesThe study aims to identify barriers to service provision of the trained providers at the drug shops that are currently engaged in PSI/Myanmar Tuberculosis and malaria programs. Exploring their needs enabled us to identify and address barriers, to provide evidence for better linkage with the primary care system.MethodA mixed method study was conducted with the service providers at the drug shops. A quantitative follow up survey was done with 177 trained Tuberculosis service providers and 65 trained malaria service providers. A total of 32 qualitative in-depth interviews were completed. Seventeen Tuberculosis trained providers and 15 malaria trained providers participated in individual interviews. Content analysis approach was used to generate themes for the data analysis.ResultsFrom the survey, the majority of drug shops reported that they performed appropriate first steps, particularly referring symptomatic Tuberculosis cases and offering mRDT testing to fever cases. Nevertheless, in-depth interviews with them revealed they did not adhere to the national guidelines for every client. There was a need to emphasize the importance of following the national guidelines for referring patients with prolonged cough and fever cases management. For those who were trained in Tuberculosis case referral, support from program staff was needed to make smooth referrals. Those who were trained in malaria often considered differential diagnosis of fever other than malaria and did not test with malaria rapid diagnostic test due to declining numbers of malaria cases.ConclusionThe study findings highlighted that the drug shops trained in Tuberculosis referral seemed to have the potential to fully engage into the primary care health system if provided with suitable support and supervision. On the other hand, those trained in malaria case management might be less motivated to engage in the era of declining malaria endemicity.

Principled Subpopulation Analysis of the Betterbirth Study and the Impact of WHO's Safe Childbirth Checklist Intervention

Background: World Health Organization (WHO) developed the Safe Childbirth Checklist as an intervention to improve care and outcomes in maternal and newborn health. In the primary BetterBirth traditional trial analysis, the intervention did not significantly improve . However, a novel subgroup-based analysis could identify subpopulations that benefited from the intervention. Methods: In this work, we employ data-driven analysis methods to identify differentiated subgroups with unexpected characteristics compared to the average population. Specifically, we aim to identify: 1) vulnerable subgroups and 2) subpopulation in the intervention arm with significantly reduced outcome. The method utilizes the existing subset scanning literature that searches over a combination of features to identify the differentiated groups. Findings: We found that low birthweight (<2.5Kg) found to represent the highest vulnerable group in both control (OR: 2·04, 95% CI: 1·91-2·18, p-value<0.001) and intervention (OR: 2·07, 95% CI: 1·93-2·21, p-value <0·001) arms. Mother-baby dyads described by normal gestational age at birth, known parity, and unknown number of abortions were found to benefit from the Checklist intervention resulting 2·6% neonatal death in the intervention arm compared to 3·66% in the control arm (OR: 0·7, 95% CI: 0·62,0·79, p-value <0·001). Interpretation: The flexibility of this data-driven approach helps to answer other subgroup-based queries in the broader global health domain. Though the statistical significance of these data-driven findings is validated, their clinical significance shall not be assumed without expert validation. Funding: The Bill & Melinda Gates Foundation provided funding for this study. Declaration of Interest: No conflicts of interest Ethical Approval: Institutions that provided review include Community Empowerment Lab, Jawaharlal Nehru Medical College, the Harvard T.H. Chan School of Public Health, Population Services International, the WHO, and the Indian Council of Medical Research.

Evaluation of mainstreaming youth-friendly health in private clinics in Malawi

BackgroundHigh fertility rates and low modern contraceptive use put African youth and adolescents at high risk for health complications, including maternal mortality. Mainstreaming youth-friendly health services (YFHS) into existing services is one approach to improve access to reproductive health services for youth and adolescents. The objective of the evaluation was to assess the effects of a Population Services International (PSI)-sponsored YFHS training package on voluntary uptake of family planning among youth and perceptions of service quality by youth and trained healthcare providers in Malawi.MethodsIn 2018, a mixed-methods convergent parallel design was used to assess relevant monitoring and evaluation documents and service statistics from PSI Malawi and qualitative data on perceptions of service quality from Malawian youth and healthcare providers. The data were assessed through separate descriptive and thematic analysis and integrated to generate conclusions.ResultsResults show that the number of family planning clients ages 15–24 increased from 72 to 2278 per quarter during the implementation of the YFHS training packages, however, positive trends in client numbers were not sustained after youth outreach activities ended. Focus group discussions with 70 youth and adolescents indicated that clinics were perceived as providing high-quality services to youth. The main barriers to accessing the services were cost and embarrassment. Interviews with ten healthcare providers indicated that many made efforts to improve clinic accessibility and understood the barrier of cost and importance of outreach to youth and the broader community.ConclusionsThe findings support research showing positive effects of mainstreaming YFHS when training for healthcare staff is combined with additional YFHS programming components. Furthermore, the findings provide evidence that provider training alone, though beneficial to perceived service quality, is not sufficient to sustain increases in the number of adolescent and youth family planning clients.

Evaluation of Insertion with the New Inserter of the Intra-Uterine Device of the Postpartum at the Referral Health Center of Commune II of Bamako, Mali

Background: In Mali, contraceptive prevalence is low, while the unmet need for family planning is very high. Postpartum contraception can help to significantly reduce these unsatisfied needs. The introduction of the intrauterine device (IUD) in the postpartum quickly encountered problems with the type of forceps used to make the insertions (Kelly or Heart forceps), and also their availability at the various health centers. Thus, in 2016, the Population Services International Mali (PSI-Mali) introduced the insertion of the IUD in the postpartum with the new inserter in order to counter this forceps problem and to contribute to guaranteeing the quality of postpartum IUD insertions. Objectives: They were to determine the frequency, the socio-demographic and clinical characteristics and to report the side effects and the complications. Methods: This was a descriptive and analytical cross-sectional study from September 1st 2016 to August 31st, 2018. All deliveries that met the eligibility criteria, having chosen and benefited the postpartum intra-uterine device with the new inserter were included. Results: During the 2 years, we recorded 73 cases of insertion of the postpartum intra-uterine device with the new inserter over 7797 clients meeting of the world health organization’s criteria of medical admissibility for the use of an intra-uterine device with a frequency of 0.93%. They were married in 97% of cases, large multiparous in 48% of cases, aged between 30 and 39 years in 62% of cases. We didn’t notice any complications in 96% of cases. Expulsion with 4% was the only complication. The clients didn’t have any side effects in 98% of cases. Conclusion: The insertion of a postpartum intra-uterine device with the new inserter has supplanted the insertion techniques using forceps in our center because of its ease and speed. Its use is worth being popularized to help reduce the unmet need for family planning.

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Joseph AquilinaJoseph AquilinaJoseph Aquilina, FRCOG, MFFP, is a consultant obstetrician and gynaecologist at Barts Health NHS Trust based St. Bartholomew's and the Royal London Hospitals, UK, and Honorary Senior Lecturer in Obstetrics and Gynaecology at Queen Mary University of London, UK. He is the Lead Clinician for Fetal Medicine Clinical Academic Group and runs a one-stop menstrual disorders clinic at St Bartholomew's Hospital. Mr Aquilina obtained his primary medical degree in Malta and then moved to the UK for his basic postgraduate training in Bristol, and in London at King's College and Greenwich Hospitals, UK. He subsequently undertook research and subspecialty training in feto-maternal medicine/gynaecological ultrasound as a lecturer at St.Bartholomew's and Royal London Medical School, Queen Mary Westfield College, based at Homerton Hospital, UK. He is recognised as a preceptor for training in gynaecological scanning by the Royal College of Obstetricians and Gynaecologists, UK. His special interests include polycystic ovarian syndrome, prediction of pre-eclampsia and the application of ultrasound in the diagnosis and management of benign gynaecological conditions. Paul D. BlumenthalPaul D. BlumenthalPaul D. Blumenthal, MD, MPH, is Professor of Obstetrics and Gynecology at Stanford University School of Medicine, USA. He directs the Stanford Gynecology Service and the Division of Family Planning Services and Research at Stanford. He also directs SPIRES, the Stanford Program for International Reproductive Education and Services, an initiative providing technical assistance and training to family planning programs in a wide variety of countries across Africa, Asia and Central America. For over 30 years, Dr Blumenthal has been an advisor to multiple international agencies such as Gynuity Health Projects, Ipas, Pathfinder, FHI360, Path, Jjpiego, the Population Council, the RCOG and the World Health Organization, and served as the Special Advisor to Minister of Health and Family Planning of the Republic of Madagascar. He currently serves as the Global Medical Director for Population Services International. Dr Blumenthal is committed to the development and implementation of innovative approaches to reproductive health issues in both the domestic and international arenas. Kavita MishraKavita MishraDr Kavita Mishra is a urogynecologist at Stanford University School of Medicine, USA, where she is an Assistant Professor of Obstetrics and Gynecology. She completed her medical degree at the University of California, San Francisco, USA, and residency training in Obstetrics and Gynecology at Brown University, USA. She subsequently completed an ABOG/ABU-approved Fellowship in female pelvic medicine and reconstructive surgery at Brown University. She has subspecialty board certification in FPMRS. She performs reconstructive surgery for pelvic organ prolapse and urinary incontinence using robotic, laparoscopic, and vaginal approaches. She currently sees patients with complex pelvic floor disorders at Stanford's multidisciplinary Pelvic Health Center with specialists from colorectal surgery, female urology and GI motility. Her research interests include epidemiology of pelvic floor disorders and mesh complications. She is involved in the Pelvic Anatomy Group of the Society of Gynecologic Surgeons.

FPwatch: Facility-based Survey Data for Family Planning Market Analysis in Five FP2020-focus Countries.

This article describes datasets for the FPwatch Project, a comprehensive facility‐based family planning survey conducted by Population Services International in five countries in Africa and Asia from 2015 to 2017. Contents cover research design and background, methodology, sample selection, data collection, an overview of FPwatch indicators, and quality assurance measures taken. These datasets from the Democratic Republic of Congo, Ethiopia, India, Myanmar, and Nigeria complement other facility‐based family planning surveys and are unique in their large‐scale, standardized methodology, and comprehensive sampling approach. In addition, all datasets but Myanmar (private only) include both private and public facilities, a feature that gives a more complete picture of the family planning supply environment. Because of these factors, the data is well suited to inform global family planning efforts.

Helping Postpartum Women in Mali Achieve Their Fertility Intentions: Perspectives From Introduction of the Dedicated Postpartum IUD Inserter.

Mali has one of the highest maternal mortality ratios in the world coupled with one of the lowest modern contraceptive use rates. Nearly a quarter of the country's 750,000 annual births occur within 24 months of a previous birth, increasing the risks for mothers and babies. Nearly 70% of postpartum women have an unmet need for family planning. In 2016, Population Services International Mali (PSI-Mali) introduced a dedicated postpartum intrauterine device (PPIUD) inserter to replace the technique of using forceps for PPIUD insertion, with the aim of helping to address this substantial family planning gap. A mixed-methods approach was used to assess program results and the experiences of PSI-trained providers using the dedicated PPIUD inserter in 5 health facilities in Bamako. We conducted 10 key informant interviews with providers and 4 key informant interviews with operational and clinical staff involved in training and supporting providers. Further data were collected from district health surveys and facility registers. Secondary data encompassed documentation from 2011 through 2017, with the service delivery figures of PPIUD using the dedicated inserter focused on the pilot period of March 2016 through December 2017. Primary data were collected in Mali in July 2017. Between March 2016 and December 2017, PSI-Mali trained 134 providers on the dedicated PPIUD inserter and provided more than 3,500 voluntary PPIUDs. Of the 1,840 voluntary PPIUDs provided in 2017 alone, 67% were provided by facilities trained to use the dedicated PPIUD inserter. Providers stated a preference for the inserter (compared with the use of forceps) due to its ease, speed, and perceived lower associated risks of infection. Service data from the 5 facilities visited showed an overall average PPIUD uptake of 7.3% of deliveries in 2017. Although private facilities had considerably fewer deliveries than public facilities (600-900 compared with 20-30, respectively), a much higher proportion of women delivering in the private facilities chose a PPIUD. The acceptance of the dedicated PPIUD inserter by providers may help reduce some of the supply-side barriers that inhibit women's access to postpartum family planning methods. With continued support to providers, coupled with ongoing efforts to address differences in service trends between sectors and demand-side barriers to the PPIUD and family planning more broadly, the dedicated PPIUD inserter could play an important role in responding to the high unmet need among postpartum women in Mali.

The incidence of abortion and unintended pregnancy in India, 2015.

SummaryBackgroundReliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015.MethodsNational abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015–16 National Family Health Survey-4.FindingsWe estimate that 15·6 million abortions (14·1 million–17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2–52·1) per 1000 women aged 15–49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15–49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15–49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended.InterpretationHealth facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy.FundingGovernment of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Joseph AquilinaJoseph AquilinaJoseph Aquilina, FRCOG, MFFP is a consultant obstetrician and gynaecologist at Barts Health NHS Trust based St. Bartholomew's and the Royal London Hospitals and Honorary Senior Lecturer in Obstetrics & Gynaecology at Queen Mary University of London, UK. He is the Lead Clinician for Fetal Medicine Clinical Academic Group and runs a one-stop Menstrual Disorders clinic at St Bartholomew's Hospital, London, UK. Mr Aquilina obtained his primary medical degree in Malta and then moved to the UK for his basic postgraduate training in Bristol, and in London at King's College and Greenwich Hospitals. He subsequently undertook research and subspecialty training in feto-maternal medicine/gynaecological ultrasound as a lecturer at St.Bartholomew's and Royal London Medical School, Queen Mary Westfield College, based at Homerton Hospital, UK. He is recognised as a preceptor for training in gynaecological scanning by the Royal College of Obstetricians and Gynaecologists. His special interests include polycystic ovarian syndrome, prediction of pre-eclampsia and the application of ultrasound in the diagnosis and management of benign gynaecological conditions. Paul D. BlumenthalPaul D. BlumenthalPaul D. Blumenthal, MD, MPH is Professor of obstetrics and gynecology at Stanford University School of Medicine. He directs the Stanford Gynecology Service and the Division of Family Planning Services and Research at Stanford. He also directs SPIRES, the Stanford Program for International Reproductive Education and Services, an initiative providing technical assistance and training to family planning programs in a wide variety of countries across Africa, Asia, and Central America. For over 25 years, Dr Blumenthal has been an advisor to multiple international agencies such as Gynuity Health Projects, Ipas, Pathfinder, Family Health International, Path, JHPIEGO Corporation, and the World Health Organization and served as the Special Advisor to Minister of Health and Family Planning of the Republic of Madagascar. He currently serves as the Global Medical Director for Population Services International. Dr Blumenthal is committed to the development and implementation of innovative approaches to reproductive health issues in both the domestic and international arenas.

Effect of non-monetary incentives on uptake of couples' counselling and testing among clients attending mobile HIV services in rural Zimbabwe: a cluster-randomised trial.

Couples' HIV testing and counselling (CHTC) is associated with greater engagement with HIV prevention and care than individual testing and is cost-effective, but uptake remains suboptimal. Initiating discussion of CHTC might result in distrust between partners. Offering incentives for CHTC could change the focus of the pre-test discussion. We aimed to determine the impact of incentives for CHTC on uptake of couples testing and HIV case diagnosis in rural Zimbabwe. In this cluster-randomised trial, 68 rural communities (the clusters) in four districts receiving mobile HIV testing services were randomly assigned (1:1) to incentives for CHTC or not. Allocation was not masked to participants and researchers. Randomisation was stratified by district and proximity to a health facility. Within each stratum random permutation was done to allocate clusters to the study groups. In intervention communities, residents were informed that couples who tested together could select one of three grocery items worth US$1·50. Standard mobilisation for testing was done in comparison communities. The primary outcome was the proportion of individuals testing with a partner. Analysis was by intention to treat. 3 months after CHTC, couple-testers from four communities per group individually completed a telephone survey to evaluate any social harms resulting from incentives or CHTC. The effect of incentives on CHTC was estimated using logistic regression with random effects adjusting for clustering. The trial was registered with the Pan African Clinical Trial Registry, number PACTR201606001630356. From May 26, 2015, to Jan 29, 2016, of 24 679 participants counselled with data recorded, 14 099 (57·1%) were in the intervention group and 10 580 (42·9%) in the comparison group. 7852 (55·7%) testers in the intervention group versus 1062 (10·0%) in the comparison group tested with a partner (adjusted odds ratio 13·5 [95% CI 10·5-17·4]). Among 427 (83·7%) of 510 eligible participants who completed the telephone survey, 11 (2·6%) reported that they were pressured or themselves pressured their partner to test together; none regretted couples' testing. Relationship unrest was reported by eight individuals (1·9%), although none attributed this to incentives. Small non-monetary incentives, which are potentially scalable, were associated with significantly increased CHTC and HIV case diagnosis. Incentives did not increase social harms beyond the few typically encountered with CHTC without incentives. The intervention could help achieve UNAIDS 90-90-90 targets. The study was funded by the UK Department for International Development, Irish AID, and Swedish SIDA, through Population Services International Zimbabwe under the Integrated Support Program.

AIDS in the City: Melodrama and the Social Marketing of HIV Prevention in Francophone West Africa

In Francophone West Africa, bilateral and multilateral HIV prevention focuses on combating stigma, increasing awareness, and encouraging safer sexual practices, especially through the use of mass media. This approach works in the service of neoliberal mandates to produce African consumers and to frame the HIV epidemic as an issue to be addressed largely through rational individual choice and integration into commercial markets. The behavior change it promotes and represents relies on securing female reproductive heterosexuality and the family. The melodramatic mode has proven vital to such efforts, for example, in the soap opera SIDA dans la cité (AIDS in the City, Radiodiffusion-Télévision Ivoirienne, 1995, 1996–97, 2003), which consisted of three series produced by the US-based Population Services International (PSI) in Côte d'Ivoire. To the extent that AIDS in the City draws from the techniques and tropes of Hollywood melodrama, Anglo-American feminist film criticism provides useful critical frameworks for reading the series, even as such readings necessitate a broadening of the terms of aesthetic and political debates around melodrama and African media, as well as complicate Anglo-American feminist attempts to recuperate the melodrama as a quintessentially American mode.

Effectiveness of the WHO Safe Childbirth Checklist program in reducing severe maternal, fetal, and newborn harm in Uttar Pradesh, India: study protocol for a matched-pair, cluster-randomized controlled trial.

BackgroundEffective, scalable strategies to improve maternal, fetal, and newborn health and reduce preventable morbidity and mortality are urgently needed in low- and middle-income countries. Building on the successes of previous checklist-based programs, the World Health Organization (WHO) and partners led the development of the Safe Childbirth Checklist (SCC), a 28-item list of evidence-based practices linked with improved maternal and newborn outcomes. Pilot-testing of the Checklist in Southern India demonstrated dramatic improvements in adherence by health workers to essential childbirth-related practices (EBPs). The BetterBirth Trial seeks to measure the effectiveness of SCC impact on EBPs, deaths, and complications at a larger scale.Methods/designThis matched-pair, cluster-randomized controlled, adaptive trial will be conducted in 120 facilities across 24 districts in Uttar Pradesh, India. Study sites, identified according to predefined eligibility criteria, were matched by measured covariates before randomization. The intervention, the SCC embedded in a quality improvement program, consists of leadership engagement, a 2-day educational launch of the SCC, and support through placement of a trained peer “coach” to provide supportive supervision and real-time data feedback over an 8-month period with decreasing intensity. A facility-based childbirth quality coordinator is trained and supported to drive sustained behavior change after the BetterBirth team leaves the facility.Study participants are birth attendants and women and their newborns who present to the study facilities for childbirth at 60 intervention and 60 control sites. The primary outcome is a composite measure including maternal death, maternal severe morbidity, stillbirth, and newborn death, occurring within 7 days after birth. The sample size (n = 171,964) was calculated to detect a 15% reduction in the primary outcome. Adherence by health workers to EBPs will be measured in a subset of births (n = 6000).The trial will be conducted in close collaboration with key partners including the Governments of India and Uttar Pradesh, the World Health Organization, an expert Scientific Advisory Committee, an experienced local implementing organization (Population Services International, PSI), and frontline facility leaders and workers.DiscussionIf effective, the WHO Safe Childbirth Checklist program could be a powerful health facility-strengthening intervention to improve quality of care and reduce preventable harm to women and newborns, with millions of potential beneficiaries.Trial registrationBetterBirth Study Protocol dated: 13 February 2014; ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1673-x) contains supplementary material, which is available to authorized users.