Uptake Of Reproductive Health Services Research Articles

Reproductive health challenges among women in internally displaced camps in Benue State: A protocol for a community-based health education interventional study.

Sexual and reproductive health (SRH) services are a necessity for marginalized persons such as the displaced. The protocol describes an intervention that can contribute to overcoming challenges associated with SRH service delivery of three selected reproductive health (RH) services: HIV/AIDS, contraception, and cervical cancer screening. A pre-and post-intervention approach will be used to evaluate the effect of an intervention with trained Community-Based Reproductive Health Personnel (CBRHP) and/or mHealth technology within the selected IDP camps. Three (3) months of health education through the CBRHP and/or via mHealth technology will be provided. Using a questionnaire, interviews, and Focus Group Discussion (FGD) guide, the researcher will assess the suitability of this intervention to attain the objectives. Data analysis will be done with SPSS version 26. Univariate analysis will include mean and standard deviation, bivariate analysis will include a chi-square test of goodness for the association of variables, and McNemer's test to evaluate the effect of the intervention by comparing consistency in response across the variables under study. Multivariate analysis will be used to assess if sociodemographic, knowledge and health service impacts access and use of RH services. For qualitative analysis, findings will be grouped into themes. The outcomes of each theme will be used to complement the findings of the quantitative analysis. The primary outcome measures will include the level of knowledge of SRH, the number of people who want to access RH services and which RH services are most sought by the respondents. If the use of CBRHP is successful, there will be an increase in knowledge and use of HIV/AIDS, contraception and cervical cancer services. Challenges associated with access and uptake of RH services will also be assessed.

Sexual and Gender Minorities Inclusion and Uptake of Sexual and Reproductive Health Services: A Scoping Review of Literature.

Despite the efforts to ensure that sexual and reproductive health services are integrated into global, regional, and national initiatives, a significant number of countries are overwhelmed by frames of exclusion and violations of fundamental human rights, particularly for sexual and gender minority groups such as lesbians, gays, bisexuals, and transgender people. This study sought to review the literature on access and barriers faced by sexual and gender minorities. A scoping literature review was conducted on literature that focused on sexual and gender minorities and sexual and reproductive health services and published in the English language. Studies were independently screened and coded, categorizing themes such as policies, uptake of services, barriers to sexual and reproductive health access, and strategies to aid the uptake of services. The search yielded 1,148 literature sources, of which 39 met the inclusion criteria and were reviewed. The average sexual and reproductive health service uptake was generally low overall and was influenced by factors such as clinical settings, punitive laws, and availability of services specific to sexual and gender minorities. Noted strategies to aid sexual and reproductive health uptake include education, friendly health care facilities, availability of specific services, and legislative reform. The sexual and reproductive health program is an important component of short-term and long-term sexual and reproductive health needs. Health intervention initiatives targeted at improving or increasing sexual and reproductive health uptake must be supported by suitable legal and regulatory framework contexts and based on context-specific evidence.

Adolescent pregnancy prevention in rural Indonesia: a participatory action research.

Adolescent pregnancy remains a difficult problem in developing countries, including Indonesia. Pregnancy at an early age is a risk factor for maternal and infant mortality. A recent report indicates that adolescent pregnancy is even higher in rural areas. Therefore, this study aims to identify factors associated with adolescent pregnancy in rural Indonesia and formulate intervention actions to reduce the teenage pregnancy rate. Participatory action research (PAR) was conducted in the rural area of Mesuji District, Lampung Province, Indonesia. Six meetings, including four focus group discussions (FGDs), were held. The FGDs were audio-recorded and transcribed for inductive analysis. Themes emergent from the data were discussed with the local collaborators to achieve agreement. Five factors were identified as determinants of adolescent pregnancy. They were low uptake of reproductive health services, low educational attainment, juvenile delinquency, poverty, and social and cultural norms. The intervention actions taken included income generation and reproductive health education. This study verifies previous studies' findings that adolescent pregnancy determinants are mostly socioeconomic factors. These findings are essential because adolescents in this study setting endure significant disparities in health services and socioeconomic opportunities. Without sufficient intervention relating to these adolescents' needs and perceptions, the gap will continue to grow. Socioeconomic factors influence adolescent pregnancy. Cross-sectoral cooperation and active community participation are needed to address the problem. PAR is useful to explore the causes of health issues and promote active community participation.

Uptake of Sexual And Reproductive Health Services and Associated Factors Among Rural Adolescents in Southern Ethiopia, 2020

Introduction: Although 25% of Ethiopia’s population is an adolescent cohort of age 15-19 yrs, the Adolescent Sexual and Reproductive Health Service (ASRH) service utilization has not been adequately researched and addressed, and, therefore, they have had to deal with multiple reproductive health problems. Therefore, assessing the determinants of sexual and reproductive health service uptake in this age group is critical to boosting service use and, in doing so, reducing the burden of illness and disability among adolescents. And so, the motivation at the rear of this research was to look into the level of sexual and reproductive health services utilization and to find out determinants among adolescents who reside in rural districts of Guraghe zone, southern Ethiopia. Methods: A community-based cross-sectional study was undertaken from May 1-30, 2020. A multi-stage method of sampling was employed. A total of 1028 adolescents have been randomly chosen and participated in the study. Pre-tested structured questionnaires were used for data collection. The data was encoded and entered into Epi-Data version 3.1 and exported for analysis to SPSS version 23. A bivariable logistic regression analysis was conducted, and variables with a p-value less than 0.25 were considered candidates for a multivariable logistic regression model. In multivariate logistic regression, variables with p-values <0.05 were declared as statistically significant. Results: of the sampled 1028 participants, 1009 took part in the study and yielded a response rate of 98.1%. The study found that 281 (27.8%) of adolescents received sexual and reproductive health services. Accordingly, among these SRH service users (n = 281), provision of SRH information and education was the most common item received by 171(60.8%) of adolescents whereas relatively few respondents 32(11.4%) got safe and /or postabortion care. Variables that became important determinants of SRH service utilization were; taking part in peer education (AOR:2.07; 95%CI:1.46-2.94), parental discussion (AOR:3.94; 95%CI:2.77-5.60), availability of youth clubs (AOR:3.15; 95%CI:2.22-4.49), and being knowledgeable on SRH issues (AOR:3.48; 95%CI: 2.44-4.96). Conclusion: In the study area, sexual and reproductive health service utilization was low. Since most adolescents are enrolled in school, schools can be an excellent way to increase adolescents’ awareness of SRH services through behavioral change communication (BCC). Furthermore, special attention should be given to promoting discussion between parents and adolescents and the creation and strengthening of youth clubs as important steps to improving the use of Sexual and reproductive services for adolescents by the relevant stakeholders.

Utilization of Reproductive Health Services and Associated Factors among Secondary School Students in Woldia Town, Northeast Ethiopia.

Background Reproductive health is a universal concern but it has special importance for women particularly during the reproductive year. Although policy actions and strategic efforts made reproductive health service uptake of youths in Ethiopia, still its utilization remains low. Adolescence is not quite capable of understanding complex concepts. This makes them vulnerable to sexual exploitation and high-risk sexual behaviors and reproductive health problems. Objective The aim of this study was to assess the utilization of reproductive health services and associated factors among adolescents in Woldia town secondary schools, Amhara, Ethiopia, 2019. Methods An institutional-based descriptive cross-sectional study was conducted on 420 secondary school students in Woldia Town from January to June 2019. A self-administered, structured questionnaire was used to collect the data. The samples were distributed proportionally, and participants in each school were selected by the systematic sampling technique. Bivariable and multivariable logistic regression was carried out to assess the association between dependent and independent variables. Result Out of 420 students participated in this study, 270 (64.3%) of the respondents utilize reproductive health service. Residence (AOR = 4.40, 95%CI (1.23, 9.362)), educational status of the partner (AOR = 2.66, 95%CI (2.35, 5.24)), presence of RHS facility in school (AOR = 2.53, 95%CI (1.57, 4.06)), and good knowledge level on reproductive health services (AOR = 1.77, 95%CI (1.14, 2.75)) were significantly associated with reproductive health service utilization. Conclusion and Recommendations. Knowledge of respondents on reproductive health utilization in the study area was found to be low. Students who were from rural families have low utilization of reproductive health services. This low service utilization in these students might be disposed to different reproductive health risks such as sexually transmitted infections, HIV/AIDS, and unwanted pregnancy, which in turn can increase the school dropout rate and have an impact on an individual's future life. However, students who have good knowledge and were encouraged by their friends have good reproductive health service utilization. Therefore, it needs a great effort and attention of all concerned bodies including parents, school staff, and health professionals to improve service utilization in schools.

Do the prevalence and correlates of adverse reproductive health outcomes differ by marriage cohorts? Evidence from a study of two marriage cohorts in Nigeria

The researchers examined the prevalence and correlates of adverse reproductive health outcomes among two cohorts of married women in Nigeria based on the 2018 Nigeria Demographic and Health Survey. A weighted sample size of 8,704 and 6,076 women were analyzed respectively for the child and delayed marriage cohorts. Our results showed differences in adverse reproductive health outcomes by marriage cohorts with higher prevalence in the child marriage cohort and also differences in the correlates of adverse reproductive health outcomes. Strategies to promote the uptake of reproductive health services, gender equity and women’s empowerment across the different marriage cohorts are required.

Uterovaginal Prolapse: The Sociodemographic profile and reproductive health service uptake in A Low Resource Setting, Calabar, Nigeria

Objective: To determine the prevalence, sociodemographic profiles, utilization of reproductive health services and delay in seeking medical care of patient with uterovaginal prolapse in Calabar, Nigeria. Methods: This was a retrospective study of women who presented with uterovaginal prolapse at University of Calabar Teaching Hospital, Calabar, Nigeria between 1st May 2009 and 1st June 2019. Patients case records were retrieved and analyzed. Statistical analysis was done using SPSS Version 22. Results: The prevalence of genital prolapse was 0.3%. The mean age and parity were 60.19 ± 8.71 years and 6.31 ± 2.80, respectively. The mean duration of symptoms before presentation was 3.19 ± 2.16 years. Genital prolapse was commonest among age group 60-79 years (52.8%), parity 5-9 (66.7%), post-menopausal (97.2%), primary education (55.6%) and farmers (47.2%). Grade 3 uterovaginal prolapse was the commonest grade (58.3%). Most patients (86.1%) had symptoms of genital prolapse for less than 5 years before seeking medical treatment. The majority of patients had no antenatal care during their pregnancies (80.6%), no skilled attendant at deliveries (86.1%) and no contraceptive use during their reproductive years (77.8%). Participants with lower parity (1-4) (p=0.03), higher educational level (p˂ 0.001) and teachers/civil servants (p=0.043) presented earlier (less than 1 year) to the hospital. Conclusion: There is poor utilization of reproductive health services among women who develop uterovaginal prolapse in our environment. Women with higher social status sought for help earlier. Increasing awareness of this condition and providing antenatal care, skilled birth attendants and contraceptive services will reduce the burden of this condition.

Fat Shame and Blame in Reproductive Care: Implications for Ethical Health Care Interactions

In this article, we explore the issue of fat shaming in reproductive health care. Using both mainstream weight stigma literature and literature from the fields of critical obesity and fat studies, we highlight how fat women’s experiences in reproductive health care (including encounters in pre-pregnancy, fertility support and treatment, and post-pregnancy) are shaped by dominant notions of health, the body, motherhood, and fatness, ultimately leading to negative health care experiences for these women. We also consider literature that explores health professionals’ experiences and perceptions related to fatness and the care for women’s reproductive health. Through this examination we highlight the existence of weight bias and discrimination that negatively impacts the delivery and uptake of reproductive health services. We conclude with recommendations for health professionals and educators of health professionals that support reproductive justice for fat women.

Differences in Population Dynamics and Uptake of Reproductive Health Services in the Urban and Rural Cohorts of Cross River Health and Demographic Surveillance System of Southern Nigeria

Background: Health and demographic surveillance systems (HDSSs) generate essential health and demographic data from longitudinal surveillance of populations resident in distinctly demarcated enumeration areas. The Cross River HDSS (CRHDSS) located in southern Nigeria includes distinct urban and rural cohorts. Concurrent surveillance of adjacent urban and rural communities provides an opportunity to identify differences in population characteristics and access or utilization of health services. In this paper, we report the result of comparative analysis of rural and urban cohorts of the CRHDSS from November 2012 to December 2018. Methodology: Data was collected through house-to-house interviews performed in 6-monthly cycles through the years. Information obtained included demographic characteristics, pregnancies, child birth, health-seeking behaviour, migration and deaths. Trained field workers collected data from all households in the demographic surveillance area with mobile Android devices (running the ODKCollect). Collected data were transferred electronically to a remote server running on ODKAggregate and further processed by MirthConnect on OpenHDS web application with a MySQL backend database. Data was exported, cleaned and analyzed with the R Statistical Computing Software. Results: Total population undergoing longitudinal health and demographic surveillance was 37,808 persons in 9,452 households with 18,414 males and 19,394 females. The rural cohort made up 47.4% of the population while the urban cohort was 52.6%. Population structure showed that while the rural cohort has a relative depletion of young adults, the urban cohort has preponderance of this population segment indicating the high rate of rural to urban migration. There is also a striking difference in pattern of utilization of reproductive health services by pregnant women. While 68.6% of childbirth in the rural cohort occurred outside the formal health service (at TBAs and at home), 79.1% of childbirth in the urban area occurred in formal health facilities. Both the crude fertility rate, infant mortality and under-five mortality rates were higher in rural than the urban cohorts. Conclusion: Surveillance data showed relative depletion of young adults from rural population cohort, suggesting high rate of rural to urban migration. Majority of childbirths in rural areas still occur outside formal health facilities, which may partly contribute to higher infant mortality rate in the rural cohort. This calls for more efforts to enhance reproductive health services and employment opportunities in rural areas. Keywords: Population, Health characteristics, births, deaths, health and demographic surveillance systems DOI : 10.7176/DCS/9-5-08 Publication date :May 31 st 2019

Reproductive health care utilization among women who inject drugs and exchange sex

Objectives: Few data exist regarding reproductive health needs and related behaviors of women who inject drugs and exchange sex. We sought to evaluate contraceptive use, pregnancy intention, uptake of reproductive health services and predictors of health care utilization among these women.

Sexual and reproductive health services utilization and associated factors among secondary school students in Nekemte town, Ethiopia

BackgroundDespite policy actions and strategic efforts made to promote sexual and reproductive health service uptake of youths in Ethiopia, its utilization remains very low and little information was found on the extent to which school youths utilize available reproductive health services in Nekempt town. This study was aimed to assess utilization of Sexual and Reproduactive Health (SRH) services and its associated factors among secondary school students in Nekemte town, Ethiopia.MethodA school based cross-sectional study design was conducted from April 18 to 22, 2016. Multistage cluster sampling technique was used to select a total of 768 students who attended secondary schools. Sexual and reproductive health services utilization was measured using one item asking whether they had used either of sexual and reproductive health services components during the last one year or not. The data was entered using EpiData Manager with Entry Client and further analysis was done using SPSS version 21 software. Descriptive statistics, cross tabulations, biviarate and multivariate logistic regression analyses were used. All variables were set by p-values less than 0.05 and reported by Adjusted Odds Ratio with its 95%CI.ResultOut of the 768 study subjects, 739 participants underwent all the study components giving response rate of 96%. About 157 (21.2%) school youths reported that they utilized SRH services. On multivariable logistic regression analysis after adjusting for other variable, discussion with health workers (AOR 3.0, 95%CI [1.7–5.2]), previous history of perceived Sexually transmitted infections (STIs) symptoms (AOR 2.6, 95%CI [1.2–5.5]), being ever sexually experienced (AOR 5.9, 95%CI [3.4–10.2]) and exposure to information from school teachers (AOR 0.36, 95%CI [0.2–0.6]) were found to be independent determinants of sexual and reproductive services utilization among secondary school youths. Inconvenient times, lack of privacy, religion, culture, and parent prohibition were barriers to SRH service uptake cited by the school youths.ConclusionsThe overall utilization of sexual and reproductive services was low among school youths in the town. Discussion with health workers, history of perceived STIs symptoms, sexual experience and information were the association factors of sexual and reproductive service utilization among secondary school youths.

Parental support for human papilloma virus vaccination by adolescents in Ibadan North Local Government Area, Ibadan, Nigeria.

Despite changing sexual norms and mores generally perceived to be permissive of sexual expression, parents continue to serve as gateways to uptake of reproductive health services and commodities in our cultural settings. However, their support for adolescent uptake of human papilloma virus (HPV) vaccine are not well explored and documented. This study aims to assess parental knowledge and awareness of HPV infection and cervical cancer and their support for HPV vaccination for their adolescent children. In a descriptive cross sectional study 612 parents from in Ibadan North Local Government Area were interviewed using a pre-tested semi structured interviewer administered questionnaire to assess the awareness of HPV infection and cervical cancer as well as parental support for the vaccine. Only a few of the respondents were aware of HPV infection (10.5%) and the HPV vaccine (6.5%), respectively. About 64.3% of those that were aware of HPV knew it can be transmitted through sexual intercourse. However, 78.4% supported the administration of the vaccine to their adolescent daughters. Reported reasons for not supporting HPV vaccination were high cost of the vaccine (32.2%) and lack of awareness of the vaccine (49.2%). Earning a monthly income above the minimum wage of 18,000 Naira increases the likelihood of parental support for HPV vaccination uptake for adolescents (p<0.001). Ignorance and poverty remain as barriers to widespread coverage of the vaccine among adolescents. Health education and promotion on HPV infection and the HPV vaccine to the general public and subsidization of the vaccine to promote its uptake is advocated.

Knowledge about Sexual and Reproductive Health Services and Practice of What Is Known among Ghanaian Youth, a Mixed Method Approach

Most young person will become sexually active before their 20th birthday having to battle with early and unplanned pregnancies, unsafe abortions, maternal deaths and injuries. This study examined young person’s sexual knowledge, attitudes and practices and their levels of utilization of sexual reproductive health. Our study progresses beyond current research of reporting only sexual behaviour among youth to have insight into sexual and reproductive health update drivers yielding new empirically robust results for the Ghanaian case for sexual and reproductive health service uptake. The descriptively cross sectional design was employed in sampling 170 youth (150 surveyed and 20 Interviewed) using the stratified sampling technique together with a purposive selection of one key informant. Test of significance and associations were performed with the Chisquare test. In all 45.2% (77/170) of youth (10 - 24) had had sexual experience in life time. In respect of in-school youth, 42% (63/150) had had sexual experience whiles 70% (14/20) out-of-school youth had had sexual intercourse in life time. A total of 28.8% (49/170) of all the youth had sexual intercourse in the last six months with only 40.1 (20/49) using condom for protection. Parental discussion of contraceptive methods (29.3%) and sexual and romantic relationship (28.0%) was the least sexual and reproductive health area discussed among in-school youth. Youth knowledge of the available sexual reproductive health service was statistically associated with reproductive health service utilization (X2 = 0.00, P ≤ 0.05). A concerted effort is required from government, NGO, Civil society organizations and religious bodies to help translate youth knowledge about sexual health into responsible sexual life and protective sex.

Attitude of Health Care Providers towards Adolescent Sexual and Reproductive Health Services in Developing Countries: A Systematic Review

The aim of the review was to synthesise the best available evidence regarding attitude of health care providers towards adolescent sexual and reproductive health services in developing countries. The review was conducted following qualitative research method. An online search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index (BNI), EMBASE and MEDLINE databases was conducted to identify relevant studies for the review. There were nine studies that met the inclusion criteria and these were critically assessed by two independent reviewers using the standardised Joanna Briggs Institute (JBI) critical appraisal forms. Data were extracted using the standardised JBI data extraction forms. A narrative synthesis was done on the findings. Key findings from the review indicate that unprofessional attitude of health care professionals and lack of youth friendly reproductive health services, inhibit adolescents from gaining access to sexual and reproductive health services in developing countries. It is recommended that youth friendly reproductive health services be provided to increase uptake of re-productive health services by adolescents.

The influence of age cohort differentials on antenatal care attendance and supervised deliveries in Uganda

Background: Utilization of maternal and child health services is very low in many sub Saharan African countries. In addition to the myriad of factors explaining low utilization of maternal and child services, differences in age cohorts are potential determinants of uptake of reproductive health services. Purpose: The general aim of our study was to better understand the influence of age cohort of women on antenatal care (ANC) and delivery with skilled personnel. Specifically, we aimed at examining whether age cohort differences affect ANC attendance and supervised deliveries in Uganda. Methods: We examine the influence of age cohort differences on ANC attendance and the likelihood of having supervised deliveries in Uganda among women (n=5,004) aged 15-49 years who had given birth within the five years preceding the 2006 Uganda Demographic and Health Survey. Age cohorts consisted of young women born between 1982–1991 (15-24 years), the middle-aged women born between 1972–1981 (25-34 years), and the older women born between 1957–1971 (35-49 years). Results: Generally, women were more likely to attend ANC than to deliver under skilled care. Specifically, older women (35-49 years), with low education, having more than one living child, the less wealthy, and rural residents were less likely than their counterparts to attend ANC and have a supervised delivery. Conclusions: Efforts aimed at encouraging older women to deliver under skilled care need to be strengthened in order to improve maternal and child health. These efforts are critical as we progress towards the deadline for achieving Millennium Development Goals of maternal and child mortality reduction in 2015.

Understanding gendered influences on women's reproductive health in Pakistan: Moving beyond the autonomy paradigm

Recent research and policy discourse commonly view the limited autonomy of women in developing countries as a key barrier to improvements in their reproductive health. Rarely, however, is the notion of women's autonomy interrogated for its conceptual adequacy or usefulness for understanding the determinants of women's reproductive health, effective policy formulation or program design. Using ethnographic data from 2001, including social mapping exercises, observation of daily life, interviews, case studies and focus group discussions, this paper draws attention to the incongruities between the concept of women's autonomy and the gendered social, cultural, economic and political realities of women's lives in rural Punjab, Pakistan. These inadequacies include: the concept's undue emphasis on women's independent, autonomous action; a lack of attention to men and masculinities; a disregard for the multi-sited constitution of gender relations and gender inequality; an erroneous assumption that uptake of reproductive health services is an indicator of autonomy; and a failure to explore the interplay of other axes of disadvantage such as caste, class or socio-economic position. This paper calls for alternative, more nuanced, theoretical approaches for conceptualizing gender inequalities in order to enhance our understanding of women's reproductive wellbeing in Pakistan. The extent to which our arguments may be relevant to the wider South Asian context, and women's lives in other parts of the world, is also discussed.

Influences on uptake of reproductive health services in Nsangi community of Uganda and their implications for cervical cancer screening

BackgroundCervical cancer is the most common female cancer in Uganda. Over 80% of women diagnosed or referred with cervical cancer in Mulago national referral and teaching hospital have advanced disease. Plans are underway for systematic screening programmes based on visual inspection, as Pap smear screening is not feasible for this low resource country. Effectiveness of population screening programmes requires high uptake and for cervical cancer, minimal loss to follow up. Uganda has poor indicators of reproductive health (RH) services uptake; 10% postnatal care attendance, 23% contraceptive prevalence, and 38% skilled attendance at delivery. For antenatal attendance, attendance to one visit is 90%, but less than 50% for completion of care, i.e. three or more visits.MethodsWe conducted a qualitative study using eight focus group discussions with a total of 82 participants (16 men, 46 women and 20 health workers). We aimed to better understand factors that influence usage of available reproductive health care services and how they would relate to cervical cancer screening, as well as identify feasible interventions to improve cervical cancer screening uptake.ResultsBarriers identified after framework analysis included ignorance about cervical cancer, cultural constructs/beliefs about the illness, economic factors, domestic gender power relations, alternative authoritative sources of reproductive health knowledge, and unfriendly health care services. We discuss how these findings may inform future planned screening programmes in the Ugandan context.ConclusionKnowledge about cervical cancer among Ugandan women is very low. For an effective cervical cancer-screening programme, awareness about cervical cancer needs to be increased. Health planners need to note the power of the various authoritative sources of reproductive health knowledge such as paternal aunts (Sengas) and involve them in the awareness campaign. Cultural and economic issues dictate the perceived reluctance by men to participate in women's reproductive health issues; men in this community are, however, potential willing partners if appropriately informed. Health planners should address the loss of confidence in current health care units, as well as consider use of other cervical cancer screening delivery systems such as mobile clinics/camps.

‘I never go anywhere’: extricating the links between women's mobility and uptake of reproductive health services in Pakistan

An integrated analysis of large-scale survey data and detailed ethnography is presented to examine the patterns of women's mobility and their relationships with contraceptive and antenatal care use in Pakistan. Findings confirm that women's mobility is circumscribed but also illustrate the complex and contested nature of female movement. No direct relationship between a woman's unaccompanied mobility and her use of either contraception or antenatal care is found. In contrast, accompanied mobility does appear to play a role in the uptake of antenatal care, and is found to reflect the strength of a woman's social resources. Class and gender hierarchies interact to pattern women's experience. Poor women's higher unaccompanied mobility was associated with a loss of prestige and susceptibility to sexual violence. Among richer women, such movement did not constitute a legitimate target for male exploitation, nor did it lead to a loss of status on the part of their families. The findings caution against the use of western notions of ‘freedom of movement’ and associated quantitative indicators. At the same time, the wider impact of mobility restrictions on women's reproductive health is acknowledged and policy implications are identified.

Improving service quality: experience from the Tanzania Family Health Project.

To improve the quality and uptake of reproductive health service in rural communities in Tanzania. Descriptive study of operational research. One and a half million people living in urban and rural communities in the Mbeya Region of Tanzania. Design and implementation of a range of service quality improvement measures. Management systems strengthening; clinical skills training; orientation of health staff to service quality; introduction of quality assurance systems; improvement to supervision systems; community involvement in monitoring health service delivery. Health service utilization rates; client perceptions of health service quality; situation analysis of health service provision. Uptake of reproductive health services increased; improved client perceptions of service quality; improved health infrastructure; increased community participation in health service management. Health service quality in sub-Saharan Africa can be improved substantially through a process of identifying and addressing the constraints which militate against effective service provision. The cost of such improvement is modest compared with current health expenditure. Health planners and managers involved in sectoral reform programmes should give due attention to quality assurance mechanisms in addition to structural elements of the reform process.