Kerstin Edin

Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study

IntroductionDespite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15–49 years in Tigray, Ethiopia.MethodsThe study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation.ResultsThe response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband’s occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands’ occupation.ConclusionsA relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray.

“Keeping Up a Front”: Narratives About Intimate Partner Violence, Pregnancy, and Antenatal Care

Nine women who had been subjected to severe intimate partner violence during pregnancy narrated their ambiguous and contradictory feelings and the various balancing strategies they used to overcome their complex and difficult situations. Because allowing anyone to come close posed a threat, the women mostly denied the situation and kept up a front to hide the violence from others. Three women disclosed ongoing violence to the midwives, but only one said such disclosure was helpful. This article highlights the complexity of being pregnant when living with an abusive partner and challenges antenatal care policies from the perspective of pregnant women.

Making pragmatic choices: women’s experiences of delivery care in Northern Ethiopia

BackgroundIn 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth.This study explores women’s experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting.MethodsWe used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory.ResultsOne core category emerged, ‘making pragmatic choices’, which connected the categories ‘aiming for safer deliveries’, ‘embedded in tradition’, and ‘medical knowledge under constrained circumstances’. In this setting, women – aiming for safer deliveries – made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category ‘embedded in tradition’, was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs). On the other, institutional delivery, represented by the category ‘medical knowledge under constrained circumstances’, and linked to how women appreciated medical resources and the support of health extension workers (HEWs) but were uncertain about the quality of care, emphasized the barriers to transportation.In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to collaboration as the women themselves, however.ConclusionsAlthough women did not see any conflict between traditional and institutional maternal care, the gap between the models remained and revealed a need to reconcile differing views among the caregivers. The HEP would benefit from an approach that incorporates all the actors involved in maternal care, at institutional, community and family levels alike. Reconsideration is required of the role of TBAs, and a well-designed, community-inclusive, coordinated and feasible referral system should be maintained.

Violent Men Ordinary and Deviant

This article deals with discourses of intimate partner violence and is based on interviews with professionals who meet violent men. The professionals emphasized the importance of men taking unreserved responsibility for their violent behavior. Intimate partner violence was viewed not only as “power and control” but as the result of complex situations and interplays. The discourses presented an ambivalent explanation of violent men as both ordinary and deviant. They were understood as having a strained background, but to be rather ordinary, often functioning well at work and in society. Yet, they have nonstandard views of women, act deviant in their communication and interplay with others, and cannot cope with certain situations in intimate relationships. Based on the interviews, men inclined to partner violence may be generalized as those who: attack immediately, explode unexpectedly, or ultimately become aggressive. The discussion challenges unreflected discourses as means for change when counteracting violence.

Mapping and exploring health systems' response to intimate partner violence in Spain

BackgroundFor a comprehensive health sector response to intimate partner violence (IPV), interventions should target individual and health facility levels, along with the broader health systems level which includes issues of governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. This study aims to map and explore the integration of IPV response in the Spanish national health system.MethodsInformation was collected on five key areas based on WHO recommendations: policy environment, protocols, training, monitoring and prevention. A systematic review of public documents was conducted to assess 39 indicators in each of Spain’s 17 regional health systems. In addition, we performed qualitative content analysis of 26 individual interviews with key informants responsible for coordinating the health sector response to IPV in Spain.ResultsIn 88% of the 17 autonomous regions, the laws concerning IPV included the health sector response, but the integration of IPV in regional health plans was just 41%. Despite the existence of a supportive national structure, responding to IPV still relies strongly on the will of health professionals. All seventeen regions had published comprehensive protocols to guide the health sector response to IPV, but participants recognized that responding to IPV was more complex than merely following the steps of a protocol. Published training plans existed in 43% of the regional health systems, but none had institutionalized IPV training in medical and nursing schools. Only 12% of regional health systems collected information on the quality of the IPV response, and there are many limitations to collecting information on IPV within health services, for example underreporting, fears about confidentiality, and underuse of data for monitoring purposes. Finally, preventive activities that were considered essential were not institutionalized anywhere.ConclusionsWithin the Spanish health system, differences exist in terms of achievements both between regions and between the areas assessed. Progress towards integration of IPV has been notable at the level of policy, less outstanding regarding health service delivery, and very limited in terms of preventive actions.

‘Expanding your mind’: the process of constructing gender-equitable masculinities in young Nicaraguan men participating in reproductive health or gender training programs

Background: Traditional forms of masculinity strongly influence mens and womens wellbeing. Objective: This study has two aims: (i) to explore notions of various forms of masculinities in young Nicaraguan men participating in programs addressing sexual health, reproductive health, and/or gender equality and (ii) to find out how these young men perceive their involvement in actions aimed at reducing violence against women (VAW). Design: A qualitative grounded theory study. Data were collected through six focus groups and two in-depth interviews with altogether 62 young men. Results: Our analysis showed that the informants experienced a process of change, labeled ‘Expanding your mind’, in which we identified four interrelated subcategories: The apprentice, The responsible/respectful man, The proactive peer educator, and ‘The feminist man’. The process showed how an increased awareness of gender inequities facilitated the emergence of values (respect and responsibility) and behavior (thoughtful action) that contributed to increase the informants critical thinking and agency at individual, social, and political levels. The process was influenced by individual and external factors. Conclusions: Multiple progressive masculinities can emerge from programs challenging patriarchy in this Latin American setting. The masculinities identified in this study show a range of attitudes and behaviors; however, all lean toward more equitable gender relations. The results suggest that learning about sexual and reproductive health does not directly imply developing more gender-equitable attitudes and behaviors or a greater willingness to prevent VAW. It is paramount that interventions to challenge machismo in this setting continue and are expanded to reach more young men.

'When I get better I will do the test': Facilitators and barriers to HIV testing in Northwest Region of Cameroon with implications for TB and HIV/AIDS control programmes

The World Health Organization has recommended collaborative activities between TB and HIV programmes with routine counselling and testing for HIV among TB patients in order to improve the uptake of HIV services. We carried out qualitative research interviews with 21 TB patients in four selected TB and HIV/AIDS treatment centres in the Northwest Region of Cameroon to explore the facilitators and barriers to HIV testing. The desire to be healthy and live longer from knowing ones status inspired by the anticipated support from loved ones, faith in a supreme being, influence and trust in the medical authority, encouraged HIV testing. Men also demonstrated their masculinity by testing, thus portraying themselves as positive role models for other men. Meanwhile, the overwhelming burden of facing both TB and HIV simultaneously, influenced by the fear of disclosure of results, harmful gender norms and practices, fear of stigma and discrimination, and misconceptions surrounding HIV/AIDS deterred HIV testing. However, as a result of conflicting emotional experiences regarding to test or not to test, the decision-making process was not straightforward and this complex process needs to be acknowledged by health care providers when advocating for routine HIV testing among TB patients.

Condemning violence without rejecting sexism? Exploring how young men understand intimate partner violence in Ecuador

Background: This study aims to explore young mens understanding of intimate partner violence (IPV) in Ecuador, examining similarities and differences between how ordinary and activist young men conceptualize IPV against women. Methods: We conducted individual interviews and focus group discussions (FGDs) with 35 young men – five FGDs and five interviews with ordinary young men, and 11 interviews with activists – and analysed the data generated using qualitative content analysis. Results:Among the ordinary young men the theme ‘too much gender equality leads to IPV’ emerged, while among the activists the theme ‘gender inequality is the root of IPV’. Although both groups in our study rejected IPV, their positions differed, and we claim that this is relevant. While activists considered IPV as rooted in gender inequality, ordinary young men understood it as a response to the conflicts generated by increasing gender equality and womens attempts to gain autonomy.

Conflicting discourses of church youths on masculinity and sexuality in the context of HIV in Kinshasa Democratic Republic of Congo.

Abstract Masculinity studies are fairly new and young churchgoers are an under-researched group in the current Congolese church context. In response to this knowledge gap, this paper attempts to explore discourses of young churchgoers from deprived areas of Kinshasa regarding masculinity and sexuality in the era of HIV. A series of 16 semi-structured interviews were conducted with unmarried young churchgoers from the Salvation Army, Protestant and Revival churches. The interviews were tape-recorded, transcribed verbatim and analysed using discourse analysis. Five main discourses emerged: ‘we are aware of the church message on sex’, ‘young men need sex’, ‘young women need money’, ‘to use or not to use condoms’ and ‘we trust in the church message’. Although all informants knew and heard church messages against premarital sex, many of them were sexually active. The perception was that young men were engaged in sexual activities with multiple partners as a result of sexual motivations surrounding masculinity and sexual potency, while young women sought multiple partners through transactional and intergenerational sex for economic reasons. These sexual practices of young people conflicted with church messages on sexual abstinence and faithfulness. However, a small number of participants challenged current gender norms and suggested alternative ways of being a man or a woman. To elucidate these alternatives, we suggest that church youths and church leaders might take concrete actions to deconstruct misconceptions about being men. In this way, they can possibly enhance a frank and fruitful dialogue on sex, sexuality and gender to promote positive masculinities and constructive partnerships to prevent HIV.

A model for promoting physical activity among rural South African adolescent girls

Background In South Africa, the expanding epidemic of non-communicable diseases is partly fuelled by high levels of physical inactivity and sedentary behaviour. Women especially are at high risk, and interventions promoting physical activity are urgently needed for girls in their adolescence, as this is the time when many girls adopt unhealthy lifestyles. Objective This qualitative study aimed to identify and describe facilitating factors and barriers that are associated with physical activity among adolescent girls in rural, north-eastern South Africa and, based on these, to develop a model for promoting leisure-time physical activity within this population. Design The study was conducted in and around three secondary schools. Six focus group discussions were conducted with adolescent girls from the schools, and seven qualitative interviews were held with sports teachers and youth leaders. The data were subjected to thematic analysis. Results Seven thematic areas were identified, each of which was associated with the girls’ self-reported levels of physical activity. The thematic areas are 1) poverty, 2) body image ideals, 3) gender, 4) parents and home life, 5) demographic factors, 6) perceived health effects of physical activity, and 7) human and infrastructural resources. More barriers to physical activity were reported than facilitating factors. Conclusions Analysis of the barriers found in the different themes indicated potential remedial actions that could be taken, and these were synthesised into a model for promoting physical activity among South African adolescent girls in resource-poor environments. The model presents a series of action points, seen both from the ‘supply-side’ perspective (such as the provision of resources and training for the individuals, schools, and organisations which facilitate the activities) and from the ‘demand-side’ perspective (such as the development of empowering messages about body image for teenage girls, and encouraging more parental involvement). The development of physical activity interventions that incorporate this supply- and demand-side model would represent an additional tool for ongoing efforts aimed at tackling the expanding non-communicable disease epidemic in South Africa, and in other resource-constrained settings undergoing rapid health transitions.