Predictors of Poor Pregnancy Outcomes Among Antenatal Care Attendees in Primary Health Care Facilities in Cross River State,Nigeria: A Multilevel Model

Objectives Pregnancy carries a high risk for millions of women and varies by urban–rural location in Nigeria, a country with the second highest maternal deaths in the world. Addressing multilevel predictors of poor pregnancy outcomes among antenatal care (ANC) attendees in primary health care (PHC) facilities could reduce the high maternal mortality rate in Nigeria. This study utilised the “Risk Approach” strategy to (1) compare the risks of poor pregnancy outcomes among ANC attendees by urban–rural location; and (2) determine predictors of poor pregnancy outcomes among ANC attendees in urban–rural PHC facilities in Cross River State, Nigeria. Methods A cross-sectional survey was conducted in 2011 among 400 ANC attendees aged 15–49 years recruited through multistage sampling. Data on risk factors of poor pregnancy outcomes were collected using interviewer-administered questionnaires and clinic records. Respondents were categorised into low, medium or high risk of poor pregnancy outcomes, based on their overall risk scores. Predictors of poor pregnancy outcomes were determined by multilevel ordinal logistic regression. Results A greater proportion of the women in the rural areas were below the middle socio-economic quintile (75 vs. 4 %, p < 0.001), had no education (12 vs. 2 %, p < 0.001), and were in the 15–24 age group (58 vs. 35 %, p < 0.001) whereas women in the urban areas were older than 35 years (10 vs. 5 %, p < 0.001). The women attending antenatal care in the urban PHC facilities had a low overall risk of poor pregnancy outcomes than those in the rural facilities (64 vs. 50 %, p = 0.034). Pregnant women in the urban areas had decreased odds of being at high risk of poor pregnancy outcomes versus the combined medium and low risks compared with those in the rural areas (OR 0.55, 95 % CI 0.09–0.65). Conclusions for Practice Pregnant women attending antenatal care in rural PHC facilities are more at risk of poor pregnancy outcomes than those receiving care in the urban facilities. Health programmes that promote safe pregnancy should target pregnant women in rural settings.     

Influence of women's knowledge on maternal health care utilization in southern Laos

This study aims to clarify women's knowledge on obstetric care and to analyse the situation of maternal health care (MHC) utilization in southern Laos. Face to face structured questionnaire and focus group discussions were carried out for 205 mothers aged 29.6 +/- 6.7 who had children under the age of five. Three measurements of MHC utilization comprised: 1) antenatal care (ANC), 2) tetanus toxoid (TT) inoculation, and 3) attendance delivery by health professional. Women's knowledge on obstetric care was scored. Women's knowledge was positively correlated with ANC and TT inoculation. It was found that the women with strong superstitious belief were less likely to utilize all three types of MHC than the others. Accessibility to health care facilities strongly affected ANC and attendance delivery. Enhancing women's knowledge on obstetric care and reducing barriers related with sociocultural beliefs are essential to improving maternal health in southern Laos.     

Maternal Health Care Utilization Among Ever Married Youths in Kyimyindaing Township, Myanmar

This study aimed to identify maternal care services utilization among ever married female youths (15?C24?years) in Kyimyindaing Township, Yangon, Myanmar. A quantitative cross-sectional survey was conducted. A total of 196 ever married females who had delivered at least one child were included. Multistage sampling was employed. Face to face interviews using a structured questionnaire were carried out. Respondents were asked about their maternal care services utilization at the last pregnancy. Bivariate and logistic regression analyses were applied to determine the factors associated with utilization of maternal care services. Overall 96% of respondents received antenatal care (ANC) at least once and 79% had at least 4 ANC visits. The mean number of antenatal visits increased with women??s education level. The majority received late ANC regardless of residence, age, education and family income. Nearly 39% delivered at home, especially in rural areas and 79% of home deliveries were attended by traditional birth attendants (TBAs). Only 56.6% of women received at least one postnatal care visit. Inadequate postnatal care (<6 times) was identified (82.6%). Place of residence, women??s education and ANC frequency were the key determinants for a delivery place and postnatal care. Despite relatively high antenatal care attendance, most women practiced home deliveries and received inadequate postnatal care. Maternal health services need to be focused on rural women and women with little or no education. Quality ANC should be the entry point of safe delivery and postnatal care. Further intensification of information, education and communication activities on ??safe motherhood?? is needed.     

Operational factors of maternal mortality in Zimbabwe

Most studies on maternal mortality have looked at the directclinical causes and the distribution of actual rates. Much lessattention has been given to prevailing health care systems orcommunity factors associated with such deaths. A case-controlstudy design using incident cases was used to identify the magnitudeof maternal deaths and community and health care operationalfactors in both an urban and a rural setting in Zimbabwe. Thematernal mortality ratio for the rural setting was 168 per 100000 live births and that for the urban setting was 85 per 100000 live births. For the rural setting, the major direct causesof death were haemorrhage (24.8%), abortion complications (15.2%),puerperal sepsis (13.3%), and eclampsia (4.8%). For the urbansetting they were eclampsia (26.2%), abortion complications(23.0%), puerperal sepsis (14.8%) and haemorrhage (9.8%). Whereas rural-urban variations in maternal mortality were observed,inter-rural district variations were also apparent, especiallywith poor medical resources, poor communication and delayedinterventions. Risk factors for maternal mortality were presentat each of the various levels of care. Lack of antenatal care(ANC) had a significant Odds Ratio (OR 10.7 rural and 4.6 urban)contribution to maternal mortality. When abortions and ectopicswere excluded the OR for absent ANC was 4.1 (rural) and 2.6(urban). Lack of timely transport to nearest clinic or hospitaladversely affected pregnancy outcome in both rural and urbansettings. Despite delivery place planning, predisposing healthconditions and some danger signals, few of the women utilizedthe venue originally planned for delivery. Health education, community sensitization and teaching on risksignal awareness as well as health care delivery system strengtheningare recommended for reducing the high maternal mortality rates. ⁴Includes: Dr F Ashworth, Prof Mtimavalye, Dr Chatora, Dr PNhindiri, Dr Chiwora, Sister Nyangani, Sister Mujaji, SisterMakahamadzem, Mr Mandisodza, Mr Mashu, Sister Nyoni, Mr Dauramanzi,Mrs Dengu and the late Dr Chimbira     

Barriers to and attitudes towards promoting husbands' involvement in maternal health in Katmandu, Nepal

Couple-friendly reproductive health services and male partner involvement in women's reproductive health have recently garnered considerable attention. Given the sensitive nature of gender roles and relations in many cultures, understanding the context of a particular setting, potential barriers, and attitudes towards a new intervention are necessary first steps in designing services that include men. In preparation for a male involvement in antenatal care intervention, this qualitative study specifically aims to: (a) understand the barriers to male involvement in maternal health and (b) explore men's, women's, and providers' attitudes towards the promotion of male involvement in antenatal care and maternal health. In-depth interviews were conducted with fourteen couples and eight maternal health care providers at a public maternity hospital in Katmandu, Nepal. Additionally, seventeen couples participated in focus group discussions. The most prominent barriers to male involvement in maternal health included low levels of knowledge, social stigma, shyness/embarrassment and job responsibilities. Though providers also foresaw some obstacles, primarily in the forms of hospital policy, manpower and space problems, providers unanimously felt the option of couples-friendly maternal health services would enhance the quality of care and understanding of health information given to pregnant women, echoing attitudes expressed by most pregnant women and their husbands. Accordingly, a major shift in hospital policy was seen as an important first step in introducing couple-friendly antenatal or delivery services. The predominantly favorable attitudes of pregnant women, husbands, and providers towards encouraging greater male involvement in maternal health in this study imply that the introduction of an option for such services would be both feasible and well accepted.     

Provision and Use of Maternal Health Services among Urban Poor Women in Kenya: What Do We Know and What Can We Do?

In sub-Saharan Africa, the unprecedented population growth that started in the second half of the twentieth century has evolved into unparalleled urbanization and an increasing proportion of urban dwellers living in slums and shanty towns, making it imperative to pay greater attention to the health problems of the urban poor. In particular, urgent efforts need to focus on maternal health. Despite the lack of reliable trend data on maternal mortality, some investigators now believe that progress in maternal health has been very slow in sub-Saharan Africa. This study uses a unique combination of health facility- and individual-level data collected in the slums of Nairobi, Kenya to: (1) describe the provision of obstetric care in the Nairobi informal settlements; (2) describe the patterns of antenatal and delivery care, notably in terms of timing, frequency, and quality of care; and (3) draw policy implications aimed at improving maternal health among the rapidly growing urban poor populations. It shows that the study area is deprived of public health services, a finding which supports the view that low-income urban residents in developing countries face significant obstacles in accessing health care. This study also shows that despite the high prevalence of antenatal care (ANC), the proportion of women who made the recommended number of visits or who initiated the visit in the first trimester of pregnancy remains low compared to Nairobi as a whole and, more importantly, compared to rural populations. Bivariate analyses show that household wealth, education, parity, and place of residence were closely associated with frequency and timing of ANC and with place of delivery. Finally, there is a strong linkage between use of antenatal care and place of delivery. The findings of this study call for urgent attention by Kenya’s Ministry of Health and local authorities to the void of quality health services in poor urban communities and the need to provide focused and sustained health education geared towards promoting use of obstetric services. Fotso, Ezeh, and Oronje are with the African Population and Health Research Center (APHRC), Nairobi, Kenya.     

Training of Healthcare Personnel to Improve Performance of Community-Based Antenatal Care Program

Background: The present study was performed to evaluate the effectiveness of a training course designed to improve the knowledge, skills, and attitudes of healthcare personnel to allow them to provide a comprehensive community-based antenatal care (ANC) program in rural Paraguay. Methods: Sixty-eight of 110 healthcare personnel in the Caazapa Region of Paraguay participated in a nine-day training course between November 1997 and March 1998. The knowledge of the participants related to maternal healthcare services was assessed both before and after the training course, and enrollment rates of pregnant women in ANC before and after the training were compared as a measure of patient satisfaction. The participants were also asked to evaluate the appropriateness of each individual method used in the training course. Results: The average scores of the participants’ knowledge increased significantly from 41.0 before to 60.1 after training (p<0.001). The enrollment rates of pregnant women in ANC increased from 2.2 times per pregnancy in 1996 to 3.4 times in 1998 (p<0.001). The participants reported that role-playing, demonstrations using visual information, and hands-on practice at a hospital were useful training methods. Conclusions: Continuous training for healthcare personnel in rural Paraguay contributes to an increase in their capacity to carry out community-based ANC program. The participants reported that learning through peer-educators, interactive communications, role-playing, and supervision provided in actual community services were beneficial. Continuous supervision should be provided to enable healthcare personnel to maintain the knowledge and skills acquired in the training.     

城市流动人口孕产妇产前检查状况及其影响因素分析

目的了解城市流动人口孕产妇产前检查状况及其影响因素。方法采用统一的调查问卷收集资料,应用SPSS13．0统计软件对数据进行描述性和决策树分析,结果被调查的1446例流动孕产妇,平均年龄28岁．78．2％为初中及以下文化程度．45.3％为经产妇。影响产前检查次数的因素有第1次产前检查时间、认为需要做几次产前检查、文化程度、丈夫文化程度以及是否建立母子健康档案。结论流动人口孕产妇孕早期检查率（51．0％）、5次及以上产前检查率（59．5％）和8次及以上产前检查率低（31．7％）。建议流入地卫生部门加强流动人口孕产妇系统管理,加大宣传教育,促进流动人口孕产妇接受孕早期检查和定期产前检查．     

Factors related to the use of antenatal care services in Ethiopia: Application of the zero-inflated negative binomial model

The major causes for poor health in developing countries are inadequate access and under-use of modern health care services. The objective of this study was to identify and examine factors related to the use of antenatal care services using the 2011 Ethiopia Demographic and Health Survey data. The number of antenatal care visits during the last pregnancy by mothers aged 15 to 49 years (n = 7,737) was analyzed. More than 55% of the mothers did not use antenatal care (ANC) services, while more than 22% of the women used antenatal care services less than four times. More than half of the women (52%) who had access to health services had at least four antenatal care visits. The zero-inflated negative binomial model was found to be more appropriate for analyzing the data. Place of residence, age of mothers, woman’s educational level, employment status, mass media exposure, religion, and access to health services were significantly associated with the use of antenatal care services. Accordingly, there should be progress toward a health-education program that enables more women to utilize ANC services, with the program targeting women in rural areas, uneducated women, and mothers with higher birth orders through appropriate media.     

Role of antenatal care in toxemia of pregnancy in alexandria

Pre-eclampsia and eclampsia remain one of the major obstetrical problems in less developed countries. Proper antenatal care (ANC) with regular measurement of blood pressure remains the mainstay of screening for hypertension in pregnancy. The aim of the current study was to identify frequency and characteristics of women with toxemia of pregnancy, assess both the quantitative and qualitative adequacy of antenatal care among cases with toxemia of pregnancy and to evaluate the effect of antenatal care on maternal and perinatal outcome. A cross-sectional case series study design was utilized .The study population was all cases, with confirmed diagnosis of toxemia of pregnancy who were admitted to El-Shatby University hospital during the period from January to May 2005. A structured interviewing schedule was used to collect data on characteristics of cases, maternal and fetal outcome. Site, adequacy and quality of received antenatal care were assessed. Out of total cases (336), 14.29% were diagnosed as mild pre-eclampsia, 83.31% were found to have severe pre-eclampsia while 2.40% were suffering from eclampsia. The severity of the condition was significantly associated with older maternal age, multiple pregnancy, primigravity, nulliparity, low socioeconomic conditions, husband's smoking and excessive caffeine consumption. Three-quarters of eclampsia cases (75.0%) didn't receive antenatal care and 60.0% of severe pre-eclamptics received inadequate antenatal care. The mean percent score of quality care domains of antenatal care content for mild pre-eclamptics was 75.62 +/- 13.80%. This was significantly higher than that for those of severe (59.96 +/- 27.95%) or for eclampsia cases (48.75 +/- 20.04%) where X(2) of Kruskal-Wallis=8.316 (P<0.001). Adverse maternal and fetal outcome occurred in 79.4% of women and 72.3% of babies for those who received poor quality ANC. In conclusion, the complications of pre-eclampsia and eclampsia could be prevented by wide spread use of adequate antenatal care, education and training of primary medical care personnel, prompt diagnosis of high risk patients and timely referral to higher level health care.     

Utilization of Maternal Health Care Services among Married Adolescent Women: Insights from the Nigeria Demographic and Health Survey, 2008

BackgroundAn ongoing social catastrophe of very poor performance in maternal health coupled with an unacceptably high number of maternal deaths is evident in Nigeria, especially among adolescent women. This study examines the factors associated with selected maternity services—married adolescent women who have had at least four antenatal care (ANC) visits, those who have undergone safe delivery care, and those who received postnatal care within 42 days of delivery.MethodsData from Nigeria Demographic and Health Survey, 2008, were used. An eligible sample of 2,434 married adolescent (aged 15–19 years) women was included in the analysis. Pearson chi-square test and binary logistic regression were performed to fulfill the study objective.ResultsIt was found that about 35% of adolescent women had at least four ANC visits, a little over 25% had undergone safe delivery care, and nearly 32% received postnatal care within 42 days of delivery. Women's education, husband's education, wealth quintile, and region of residence were documented as the most important factors associated with maternal healthcare service utilization. The ANC visit was found to be vital in the utilization of safe delivery and postnatal care.ConclusionFindings indicate that programs to improve maternal healthcare have not succeeded in overcoming the socioeconomic obstacles in the way of adolescents' utilizing maternity services. In the long run, the content and service delivery strategy of maternity programs must be designed in keeping with the socioeconomic context with special attention to adolescent women who are uneducated, poor, and residing in rural areas.     

Individual Characteristics and Use of Maternal and Child Health Services by Adolescent Mothers in Niger

Despite high rates of early childbearing, maternal mortality, and under-five mortality, little is known about factors that affect access of teenage mothers to maternal and child health (MCH) services in Niger. This paper explores potential factors associated with the utilization of MCH care services by adolescent mothers. Using the third wave of the Niger demographic and health survey (NDHS) 2006, we estimate three multivariate logistic regression models to assess individual characteristics associated with the utilization of antenatal care (ANC) and safe delivery care services among adolescent women, as well as full immunization received by children born to adolescent mothers. The analytical sample includes 934 adolescent mothers out of 1,835 respondents aged 15–19, and within this group, 493 mother–child dyads for children aged 12–59 months. Possessing any level of education was found associated with the increased use of all three selected MCH services, while urban residence and higher income were associated with the increased use of two of three MCH services studied. Higher birth order plus a birth interval more than 2 years for the most recent birth appeared associated with the lower probability of antenatal care visits and safe delivery care. This study finds that women who attended at least four ANC visits were more likely to experience safe delivery care, and the children whose mothers had safe delivery care were more likely to receive full immunization. Therefore, an effective program should be designed to promote a continuum of MCH care with special attention to adolescent women who are uneducated, poor and residing in rural areas.     

农民工孕妇产前保健影响因素

目的了解分析农民工孕妇产前保健情况、存在问题和影响因素,为进一步采取措施改善农民工孕妇产前保健提供信息。方法于2006年7月至2007年11月期间,对在本院产科住院的203名农民工产妇作问卷调查,对早孕检查方法、建立孕产妇联系手册、产前检查次数等产前保健状况进行了描述,并分析影响因素。结果农民工孕妇的产前保健还存在比较大的问题。调查对象中,有30．5％不在医院作早孕确定,有38．4％没有建立孕产妇联系卡,有77．3％没作产前保健或者不足3次。丈夫是否上海户籍、丈夫的经济收入及是否有准生证是影响产前保健的重要因素。结论农民工孕妇产前保健还存在较大问题,其影响因素也是多方面的,包括丈夫是否上海户籍、经济收入及是否有准生证。这些问题都迫切需要政府有专门的措施来解决。     

Improved perinatal health through qualified antenatal care in urban Phnom Penh,Cambodia

Objectives  The aim of this study is to examine the utilities of antenatal care with comprehensive health education qualified in Phnom Penh for the health of mothers and infants during perinatal and postpartum periods. Attention was given to the existing socioeconomic disparties among women in this urban area, and the utilities were discussed irrespective of socioeconomic status. Methods  A total of 436 pregnant women in an urban area in Phnom Penh were selected using a complete survey in randomly sampled villages and were followed up. Participating in antenatal care with comprehensive health education at least three time was regarded as the use of “qualified antenatal care” during pregnancy. In this study, we investigated the independent associations of the use of qualified antenatal care with the following outcome variables after the adjustment for the influence of socieconomic variables: postpartum maternal health knowledge, postpartum maternal anemia, low birth weight, and infant immunization. Results  Of the 314 subjects who completed the follow-up examination, 66.8% used qualified antenatal care during pregnancy. The use of qualified antenatal care was positively associated with postpartum maternal health knowledge (OR=2.38, 95% CI: 1.12–5.05). and reductions in the incidences of postpartum anemia (OR=0.22,95% CI: 0.05–0.95) and low birth weight (OR=0.05,95% CI: 0.01–0.39) after the adjustment of the influence of socioeconomic status. The infants born to mothers who used qualified antenatal care had significantly higher coverage of BCG, DPT₁, and DTP₃ immunizations (P<0.001,P<0.001, andP<0.01, respectively), independent of their socioeconomic conditions. Conclusion  This study shows the solid utilities of qualified antenatal care in Phnom Penh for perinatal health.     

Community-based savings groups,women’s agency,and maternal health service utilisation: Evidence from Mozambique

ABSTRACT

This study, using data collected as part of an ongoing programme evaluation, investigates whether participation in Saving Groups (SGs)—a community-owned microfinance intervention focused on poor households – is associated with maternal health service utilisation, and whether this association is mediated by women’s agency – as measured by self-efficacy and decision-making autonomy. We compared maternal health service utilisation among SG members (n=105) and non-members (n=100) in rural Mozambique. We estimated prevalence ratios for SG membership and women’s agency using Poisson regression while controlling for confounding factors. We also estimated mediation effects for women's agency. The results showed that SG membership is associated with four or more antenatal care (ANC) visits, skilled birth attendant (SBA) use, and postnatal care within 48?h of delivery. Self-efficacy mediated the relationship between SG membership and ANC vists and SBAuse, but not postnatal care; whereas women’s decision-making autonomy mediated the relationship with SBA use and postnatal care, but not ANC visits. This study suggests that the impact of SG membership on use of maternal health services goes beyond improvements in household income and may operate through women’s agency by giving women the ability to realize their preference for quality health care.     

A new measurement for optimal antenatal care: determinants and outcomes in Cameroon

A combined measure of optimal antenatal care can provide more information on the role it plays in maternal health. Our objectives were to investigate the determinants of a measure of optimal antenatal care and the associated pregnancy outcomes. Data on 7,557 women taken from the 2004 Demographic and Health Survey in Cameroon were used to develop a new measurement of optimal antenatal care based on four indicators: at least four visits, first visit in first trimester, last visit in third trimester and a professional provider of antenatal care. We studied the relationship of this new variable with other related variables in a multivariate analysis, taking into account the complex study design. Almost sixty six percent of the women had optimal antenatal care. Secondary or higher education (OR 1.74; 95% CI 1.28–2.36), greater wealth (OR 2.31; 95% CI 1.73–3.1), urban residence (OR 1.42; 95% CI 1.12–1.82) and parity of 3–4 (OR 0.79; 95% CI 0.62–0.99) were independently associated with optimal antenatal care. Women with optimal antenatal care were more likely to deliver in a health unit (OR 2.91; 95% CI 2.42–3.49), to be assisted by a skilled health worker during delivery (OR 1.88; 95% CI 1.49–2.37) and to have a baby with a normal birthweight (OR 1.62; 95% CI 1.11–2.38). Obtaining and using a new measure for ANC is feasible. The association of optimal antenatal care to education, wealth and residence in this study, consistent with others, highlights the role of the country’s development in maternal health.     

Factors associated with maternal tetanus vaccination in Myanmar: An analysis of demographic and health survey data

BackgroundTetanus toxoid vaccination is a life-saving maternal and child health intervention. Understanding gaps in maternal vaccination coverage is key to informing progress towards universal health coverage. We assessed the vaccination coverage in Myanmar and investigated factors associated with being unvaccinated.MethodIn this cross-sectional analysis of 2015–16 Demographic and Health Survey data including women aged 15–49 years with at least one childbirth in the last five years. The outcome maternal tetanus vaccination during her last pregnancy, defined as protected against neonatal tetanus based on the Myanmar National Guidelines for Antenatal Care. We also examined mothers who missed a second dose of tetanus toxoid containing vaccine (TTCV) by states and regions. We used logistic regression models to assess factors associated with being unvaccinated.ResultsOverall maternal tetanus vaccination coverage was 72%. At subnational level, the percent unvaccinated was highest in Shan State (42%), followed by Magway Region (33%), Kayin State (33%), and Sagaing Region (32%). The percentage of mothers who missed a second dose of TTCV was high predominantly in regions, rather than states. We found that the percentage of unvaccinated mothers was higher among younger mothers, and mothers with lower educational attainment. No antenatal care (ANC) or receiving ANC in non-public healthcare facilities were strongly associated with being unvaccinated. Differences in percent unvaccinated by maternal age were largely mediated through their healthcare access, particularly ANC services.InterpretationWe identified regional, structural, and individual differences in maternal tetanus vaccination coverage. Factors influencing mothers who missed a second dose of TTCV warrant further investigation. Achieving universal coverage of maternal tetanus vaccination will largely depend on the ability to provide accessible antenatal care to most women who do not currently receive it.     

Providing antenatal services in a primary health care system

A study sample of 880 women attending the primary health care center in the Al-Baha region of Saudi Arabia was interviewed on their attitudes towards antenatal care services in the primary care setting. Some 91.3% of the women expressed positive views about obtaining the antenatal care in these centers. The major factor influencing their choice was the geographic location of primary health centers which are near to their residence and therefore more convenient for them to patronize. Other factors were the easier access to staff in primary care centers, especially mid-wives and female doctors. There was a significant relationship of age, parity and education with their current antenatal and delivery practices. The women also recommended less than ten antenatal visits before delivery. These findings are relevant to any policy regarding maternity services in the country.     

Intimate Partner Violence and the Utilization of Maternal Health Care Services in Nigeria

Our aim in this study is to examine the association between women's lifetime experiences of physical, sexual, and emotional intimate partner violence (IPV) and the use of maternal health care services. We used data from the 2008 Nigeria Demographic and Health Survey. Analysis was based on responses from 17,476 women (for antenatal care [ANC]) and 17,412 (for delivery assisted by a skilled health provider) who had had deliveries in the 5 years preceding the survey. We found an overall IPV prevalence rate of 33.4%. Physical IPV was associated with low use of ANC. Emotionally abused women were less likely to use delivery assistance from skilled health care providers. Based on our findings, we suggest the importance of designing interventions to address the health care needs of women who have experienced violence from their partners.