Ellen M.H. Mitchell

Conceptualising abortion stigma

Abortion stigma is widely acknowledged in many countries, but poorly theorised. Although media accounts often evoke abortion stigma as a universal social fact, we suggest that the social production of abortion stigma is profoundly local. Abortion stigma is neither natural nor ‘essential’ and relies upon power disparities and inequalities for its formation. In this paper, we identify social and political processes that favour the emergence, perpetuation and normalisation of abortion stigma. We hypothesise that abortion transgresses three cherished ‘feminine’ ideals: perpetual fecundity; the inevitability of motherhood; and instinctive nurturing. We offer examples of how abortion stigma is generated through popular and medical discourses, government and political structures, institutions, communities and via personal interactions. Finally, we propose a research agenda to reveal, measure and map the diverse manifestations of abortion stigma and its impact on womens health.

Delays in seeking an abortion until the second trimester: a qualitative study in South Africa

BackgroundDespite changes to the South African abortion legislation in 1996, barriers to women accessing abortions still exist. Second trimester abortions, an inherently more risky procedure, continue to be 20% of all abortions. Understanding the reasons why women delay seeking an abortion until the second trimester is important for informing interventions to reduce the proportion of second trimester abortions in South Africa.MethodsQualitative research methods were used to collect data. Twenty-seven in-depth interviews were conducted in 2006 with women seeking a second trimester abortion at one public sector tertiary hospital and two NGO health care facilities in the greater Cape Town area, South Africa. Data were analysed using a grounded theory approach.ResultsAlmost all women described multiple and interrelated factors that influenced the timing of seeking an abortion. Reasons why women delayed seeking an abortion were complex and were linked to changes in personal circumstances often leading to indecision, delays in detecting a pregnancy and health service related barriers that hindered access to abortion services.ConclusionUnderstanding the complex reasons why women delay seeking an abortion until the second trimester can inform health care interventions aimed at reducing the proportion of second trimester abortions in South Africa.

Correlates of condom use among sexually experienced secondary school male students in Nairobi, Kenya.

This study aimed to examine perceptual factors associated with condom use, and the relationship between condom use and the timing of sexual debut among male secondary school students in Nairobi, Kenya. Data are from the TeenWeb study, a school-based project that used the World Wide Web to assess the health needs of secondary school students, and tested the webs utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 – 20 years who completed webbased questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently, only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However, contrary to expectation, agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn, having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times, and elevated general condom use (‘most or all the time’) by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV, delay sexual initiation, and teach proper condom use among secondary-school students in Nairobi are needed.

Building alliances from ambivalence: evaluation of abortion values clarification workshops with stakeholders in South Africa

A retrospective evaluation of attitudinal, behavioural and knowledge change among diverse stakeholder groups was conducted in Limpopo Province of South Africa to assess the effectiveness of a series of values clarification (VC) interventions. Telephone and face-to-face interview (193) results revealed that over two-thirds (70.2%) reported behavioural changes and 93.2% reported increased compassion for women who seek and providers who render termination of pregnancy. Behaviours supportive of the law were more likely among those initially undecided about their opinion of termination of pregnancy (p < 0.05) than among those initially opposed or supportive to it. When combined with supportive follow-up, three-day VC workshops may be effective at increasing CTOPA knowledge, changing attitudes and spurring advocacy behaviour to support reproductive choice. Research studies with pre-post and case-control designs are needed to confirm these preliminary results.

Choosing early pregnancy termination methods in Urban Mozambique

Little is known about who chooses medication abortion with misoprostol and why. Women seeking early abortion in 5 public hospitals in Maputo, Mozambique were recruited in 2005 and 2006 to explore decision-making strategies, method preferences and experiences with misoprostol and vacuum aspiration for early abortion. Client screenings (n=1799), structured clinical surveys (n=837), in-depth exit interviews (n=70), and nurse focus groups (n=2) were conducted. Triangulation of qualitative and quantitative data revealed seemingly contradictory findings. Choice of method reflected womens heightened concerns about privacy, pain, quality of home support, HIV infection risk, sexuality, and safety of research participation. Urban Mozambican women are highly motivated to find early pregnancy termination techniques that they deem socially and clinically low-risk. Although 42% found vaginal misoprostol self-administration challenging and 25% delayed care for over a week to amass funds for user fees, almost all (96%) reported adequate preparation and comfort with home management. Women reported satisfaction with all methods and quality of care, even if the initial method failed or pain management or postabortion contraception were not offered. A more nuanced understanding of what women value most can yield service delivery models that are responsive and effective in reducing maternal death and disability from unsafe abortion.

Prevalence of tuberculosis in adolescents, western Kenya: implications for control programs.

OBJECTIVE The aim of this study was to determine the prevalence of tuberculosis (TB) in adolescents in western Kenya. METHODS A cohort study of 5004 adolescents aged 12-18 years was conducted. Adolescents were screened for prevalent TB using clinical criteria, history of TB contact, and a Mantoux test. Cases of suspected TB were investigated through two sputum examinations (microscopy and liquid culture) and chest radiography. RESULTS Out of 5004 adolescents enrolled, 1960 (39.2%) were identified with suspected TB, including 1544 with a positive Mantoux (prevalence 1544/4808, 32.1%), 515 with symptoms suggestive of TB (10.3%), and 144 (2.9%) with household TB contact. Sixteen culture-confirmed (definite) and 18 probable pulmonary TB (PTB) cases were identified, reflecting a prevalence estimate of 3.2/1000 (definite) and 6.8/1000 all PTB, respectively. Only one smear-positive case was detected. The case notification rate among 12-18-year-old adolescents for all TB was 101/100000, yielding a patient diagnostic rate of 0.13 (95% confidence interval 0.03-3.7) cases detected per person-year for all TB. CONCLUSION The prevalence of PTB among adolescents is high, with the majority of cases not detected routinely. Innovative active case finding including the wider use of Xpert MTB/RIF is needed to detect smear-negative TB among adolescents.

Incidence of Active Tuberculosis and Cohort Retention Among Adolescents in Western Kenya

Setting: Siaya County, with the highest tuberculosis notification rates in Kenya. Objectives: To determine the incidence of active tuberculosis and 1-year cohort retention in 12–18-year-old adolescents, in preparation for phase III tuberculosis vaccine trials. Methods: Adolescents were enrolled and followed up for 1–2 years to determine tuberculosis incidence. Adolescents with a positive tuberculin skin test, history of cohabitation with a tuberculosis case or at least 1 tuberculosis symptom received clinical and sputum examination and a chest radiograph. Definite tuberculosis cases were bacteriologically confirmed and clinical cases diagnosed by a clinician based on a suggestive chest radiograph and having clinical symptoms. Risk factors were explored using Poisson regression. Results: Among 4934 adolescents without tuberculosis at baseline, 26 tuberculosis cases were identified during follow-up with a corresponding incidence density of 4.4 [95% confidence interval (CI): 3.0–6.4] events per 1000 person-years of observation, 12 definite tuberculosis cases; incidence density of 2.0 (95% CI: 0.9–3.1). Having previous tuberculosis (rate ratio: 12.5; CI: 1.8–100) and presence of tuberculin skin test conversion (rate ratio: 3.4; CI: 1.5–7.7) were significantly associated with higher risk of tuberculosis. Overall (4086/4925), 83.0% of adolescents were retained in the study after 1 year of follow-up. Being female, older, out of school and being orphaned were significant risk factors for loss to follow-up. Conclusion: The tuberculosis incidence in adolescents will help inform future tuberculosis vaccine trial sample size calculations for this setting. The predictive factors for tuberculosis and retention can be further explored in future trials.

Symptom‐ and chest‐radiography screening for active pulmonary tuberculosis in HIV‐negative adults and adults with unknown HIV status

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the sensitivity and specificity of questioning for presence of one or more selected symptoms, or symptom combinations, or both; chest radiography; and combinations of those as screening tools for detecting bacteriologically confirmed active pulmonary TB in people considered eligible for TB screening who are HIV-negative or whose HIV-status is unknown. If data allow, we will investigate heterogeneity in relation to: • background epidemiology (prevalence of pulmonary TB and of HIV among the study population); • risk groups targeted (for example, migrants, occupational, prisoners, or the general population); • reference standard (culture, Xpert, smear microscopy); • screen test definition; • representativeness of the study design and population for intended screening practice (inclusion of people without any symptoms or CXR abnormalities); • study participants characteristics (age, sex and HIV status); • geographic area and economic region. In the investigation of heterogeneity we intend to stratify for combinations of risk groups or specific populations and background epidemiology, that is, at different levels of TB prevalence among the screened population. 1 Symptomand chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status (Protocol) Copyright