Reproductive Health Services

We searched electronic databases (PubMed and OVID's EMBASE, Global Health, Medline and Health Management Information Consortium) to identify review articles of determinants of delivery-service use (not original articles). We combined search terms related to maternal health care (obstetric delivery, parturition, home childbirth, reproductive health services) with search terms related to service use (health service utilisation, accessibility, medically underserved area, rural health services, choice behaviour) as well as using a term combining both (maternal health services utilisation; detailed search strategy available on request). The two authors screened independently for relevance and only two review articles on determinants of delivery service use in low- or middle-income countries were found: Thaddeus and Maine [7 (link)], and Say and Raine [9 (link)]. All other hits were either not in fact review articles or focussed on different topics. We used the two systematic review articles to identify individual studies and main themes. Referenced articles as well as articles referencing these reviews were read and checked to ascertain further relevant literature. Both qualitative and quantitative studies investigating determinants of skilled attendance at delivery or of facility delivery were included. No constraints were placed on date or language. The overview of the types of determinants studied, their suggested pathways and the typical findings is comprehensive, however, the studies mentioned are exemplary but not exhaustive of the vast literature published on each determinant. Over 80 studies were read but not all are cited in this article.
The breadth of topic, its context-specificity, the lack of comprehensive index terms and the vast differences in methodology employed, rendered the option of doing our own systematic review of this literature in its entirety impractical. Systematic reviews of observational data are useful when trying to estimate an effect of interest that can be assumed to be independent of context (which is true for most biological effects) or when trying to explore heterogeneity that is thought to be due to a limited range of factors. It is only feasible when looking at a narrow range of clearly defined exposures. Our aim instead was to explore the range of what has been done in the field so far and give an overview of findings, rather than estimating any specific effect or even attempt a meta-analysis. While we could have restricted the review to a limited number of exposures, years or countries, this went contrary to our desire to work out the scope of what has been explored in the literature.

We did a randomised, multicentre, open-label trial at 12 research sites in eSwatini (one site), Kenya (one site), South Africa (nine sites), and Zambia (one site), which were selected for high HIV incidence and geographical distribution; a larger number of sites was chosen for South Africa given anticipated high HIV incidence and high use of DMPA-IM in that country, making the trial particularly relevant to that setting. Sites included freestanding research centres, university-affiliated research centres, and clinical sites providing reproductive health services. We included non-pregnant, HIV-seronegative women aged 16–35 years (women aged 16–17 were included where permissible by national regulations and local ethics review committee approval), who desired effective contraception, had no medical contraindications to the trial contraceptive methods, agreed to use the assigned method for 18 months, and reported not using injectable, intrauterine, or implantable contraception for the previous 6 months (appendix p 11). The only sexual behavioural eligibility criterion was being sexually active. For the complete list of inclusion and exclusion criteria see the appendix (p 11). Women were recruited from family planning or reproductive health clinics, clinics serving post-partum and post-abortion clients, other relevant clinics, and the general community by study community outreach staff.
The trial team, funders, and data and safety monitoring board (DSMB) agreed before initiation of the trial on a set of key operational performance metrics that would be reviewed by the DSMB during the trial and, if not met, would trigger re-evaluation of the trial's continuation (appendix p 12). Scientific, ethical, and community stakeholders provided input into the protocol design; global and site-specific community advisory groups provided ongoing input into trial conduct. Ethics review committees at each study site approved the study protocol (appendix p 13). The trial was implemented in accordance with Good Participatory Practice guidelines,¹¹ using a range of advisory mechanisms that aligned to global standards in stakeholder engagement for clinical trials with HIV as the primary endpoint, including engagement of local community advisory boards and an ECHO-specific Global Community Advisory Group. All participants provided written informed consent, which included counselling about randomisation, each study contraceptive method, and their rights as research participants. The protocol is available online.

Family Guidance Association of Ethiopia (FGAE) is one of the leading non-governmental providers of sexual and reproductive health (SRH) care in Ethiopia. FGAE has 20 medium SRH clinics and 27 youth centers across Ethiopia. This study was conducted at Jimma model clinic (JMC), one of the 20 medium SRH clinics of FGAE, Jimma town, 350 km southwest of Addis Ababa, Ethiopia’s capital. The catchment area of the clinic is Jimma town and surrounding districts. The clinic started opportunistic screening of females aged 25–45 years on September 2012 as per cervical cancer prevention guideline for low-resource settings [7 ]. Thus, after proper counseling of clients aged 25–45 years who came for medical or reproductive health services, those with free will were screened with 5 % acetic acid and test positive cryotherapy eligible clients were treated with cryotherapy while cryotherapy ineligible clients and those with lesions suspicious for cancer were referred to Jimma University specialized hospital (JUSH). Diagnostic criteria were as per cervical cancer prevention guideline for low-resource settings and screening results were defined as:
VIA positive: presence of raised and thickened white plaques or acetowhite epithelium, usually near the Squamo-columnar junction (SCJ).
VIA negative: presence of smooth, pink, uniform and featureless cervix; cervical ectropion; polyp; cervicitis; inflammation; and/or nabothian cyst after applying a dilute solution of acetic acid.
Eligible for cryotherapy: acetowhite lesion <75 % of cervix; lesion does not extend onto the vaginal wall; and lesion extends <2 mm beyond the diameter of the cryoprobe.
Ineligible for cryotherapy: acetowhite lesion >75 % of cervix; lesion extends into the vaginal wall; lesion extends >2 mm beyond the diameter of the cryotip and lesion suspicious for cancer.
Suspicious for cancer: presence of cauliflower-like growth or ulcer; fungating and bleeding mass.
Primary data was registered on standard client evaluation form for cervical cancer prevention service by trained general practioner and nurse. Ethical approval was obtained from ethical review board of Jimma University. A letter of support was obtained from JMC. Client records were treated confidentially and name of clients was not included in the data collection. After checking for integrity and plausibility, data was collected from standard client evaluation form for cervical cancer prevention service on checklist for retrieving data from September 11, 2013 to October 11, 2013 and transferred to Epidata. Double entry verification was also made and the entered data was exported to SPSS version 16.0 for analysis. Descriptive analysis of variables involved was done and Logistic regression was employed for identifying predictors of VIA positive result.

SexHealth Mobile was implemented in partnership with a federally qualified health center (FHQC) in Kansas City that was already operating a MMU to provide basic health services at community locations with high need, including recovery centers. For this study, we selected three recovery centers that already partnered with the FHQC to receive periodic MMU visits for basic health services (e.g., seasonal vaccination, basic screenings, and treatment of non-emergency illness and injuries). The three recovery centers were providing services for clients with any type of SUD, most commonly polysubstance use disorders that included use of methamphetamines and/or opioids. Two centers were residential, serving individuals who had initiated recovery and were expected to not be using substances other than tobacco while in the program. The other was outpatient, serving individuals at various stages of recovery and active substance use. Prior to our intervention, the FHQC provided contraception and reproductive health services (free or discounted) at their main center, but not yet on the MMU.. Recovery centers did not routinely screen for reproductive health needs but would informally recommend community clinics (including the FHQC partner) for individuals interested in services.
Recovery center clients were eligible if they were: (1) aged 18–40; (2) screened positive for a lifetime history of problematic drinking or drug use according to CAGE-AID tool [24 ]; (3) able to become pregnant (assigned female sex at birth, pre-menopausal, not sterilized or diagnosed with infertility) but not currently pregnant; (4) not currently using an intrauterine device or hormonal contraception (i.e., oral contraceptive pill, transdermal patch, vaginal ring, injectable, subdermal implant); and (5) not previously enrolled in either phase of the study.

SexHealth Mobile is grounded in formative research and centered on reproductive justice and harm reduction principles. The intervention featured “SexHealth Mobile Days” where the MMU, clinical staff, and study staff would visit each recovery center. In preparation, we worked with the FHQC leadership and clinical staff to integrate contraceptive services within the MMU. This included one nurse practitioner with experience in patient-centered contraception care for SUD patients, one care assistant, and materials required for on-site provision of contraceptive medications (e.g., pregnancy tests, needles, syringes). The nurse practitioner (author AA) specialized in women’s health, independently placed contraceptive devices, and had worked at the partner FHQC for seven years (including previously providing general health care on the MMU). We worked with recovery centers and FHQC staff to ensure services were provided in a way that was acceptable to potential patients, including arranging for pregnancy testing with urine collected by patients themselves within recovery center facilities.
On SexHealth Mobile Days, the provider offered contraceptive options on the MMU free of charge, including hormonal (i.e., pills, transdermal patch, vaginal ring, injection, subdermal implant) and non-hormonal (diaphragm, condoms). Participants who chose short-term hormonal contraception (pills, patch, ring, injection) were given dosage for three months of pregnancy prevention and instructions for refills/follow-up at the main FQHC. The MMU was not outfitted with a standard patient exam table that could be used for gynecological procedures, thus we could not offer same-day IUDs. However, participants interested in IUDs could speak to the provider on the MMU, schedule a facility-based IUD insertion appointment at the main FHQC with the same provider, and obtain a bridging method to protect against pregnancy until IUD insertion. Further, participants interested in sexual and reproductive health services beyond contraception were also able to speak with the MMU provider and schedule appropriate facility-based FHQC appointments. Study staff also offered free condoms and home pregnancy tests at the enrollment table for anyone at the recovery center. We conducted ten SexHealth Mobile Days before reaching our target recruitment in intervention period, with four visits at the larger residential center, two at the smaller residential center, and four at the outpatient center.
At each recovery center, 2–4 individuals who already occupied formal roles as trusted resources for clients (7 peer mentors, 3 social workers) were trained as “outreach leaders” to promote SexHealth Mobile Days and organize interested clients. Training covered basic principles of reproductive justice and harm reduction, contraception options, needs and challenges faced by individuals with SUD in preventing unintended pregnancies, and strategies for using client-centered and trauma-informed approaches when talking about contraception.
Outreach leaders and study staff stressed that all activities on SexHealth Mobile Days were completely voluntary, and people could obtain a clinic referral or meet with MMU providers and receive free contraception even if they chose not to enroll in the study, or were not eligible due to previous enrollment in the EUC period or other ineligibility criteria. Individuals could also enroll in the study and meet with MMU providers even if they were unsure or not interested in taking up contraception.