‘It hurts,but I don't have a choice,I'm not working and I'm sick’: decisions and experiences regarding abortion of women living with HIV in Cape Town,South Africa

Research was conducted with 36 women living with HIV in Cape Town, South Africa, regarding their decision-making about, and experiences with, abortion of unwanted pregnancies in the public health sector. Abortion intentions and decisions were explored by investigating influencing factors; knowledge of abortion policy and public health sector services; and abortion perceptions and experiences. Findings reveal that many women face censure both for becoming pregnant and terminating a pregnancy, including by family, partners, community members and healthcare providers. Data suggest that abortion may be more stigmatised than HIV despite South Africa's liberal abortion law. Generally, however, study participants were satisfied with the abortion care received. Most would advise women living with HIV to think carefully about abortion, but to make a decision in their own best interests, including only seeking care early in pregnancy from an accredited clinic. Study implications include a need to integrate information and counselling on safe legal abortion within sexual and reproductive health services, especially in efforts to integrate sexual and reproductive health into HIV care, and to forge greater linkages between HIV and abortion services more generally to ensure continuity in follow-up of care for women.     

Women's reproductive decision making and abortion experiences in Cape Town,South Africa: A qualitative study

ABSTRACT

Unintended pregnancy is a significant public health issue in South Africa. Despite free services including contraception, women face structural and institutional barriers to accessing care. This qualitative study comprised interviews with 16 women aged 18 to 40 years and receiving post-abortion services at a public clinic in Cape Town. Data analysis revealed three main themes: personal journeys in seeking abortion, contraceptive experiences, and contrasting feelings of empowerment (in reproductive decision making) and disempowerment (in the health care system). Women perceived themselves as solely responsible for their reproductive health, but found it difficult to obtain adequate information or services.     

Motives and circumstances surrounding induced abortion among women living with HIV in Brazil

The impact of HIV/AIDS infection on the decision of women living with HIV/AIDS to interrupt a pregnancy remains an understudied topic. In an effort to understand the influence of HIV/AIDS diagnosis on abortion practices, a qualitative study was carried out in seven Brazilian municipalities with women living with HIV/AIDS who reported inducing an abortion at some point in their lives. This study presents the analysis of interviews with thirty women who became pregnant after diagnosis. The results show that for some women, infection was the primary motive for terminating their pregnancy, while for others, the motives for abortion were predominantly related to life circumstances. The decision to abort due to HIV infection is not the same for all women. It is related to the timing of the diagnosis and other aspects of the woman's life during her pregnancy, such as the relationship with her partner, her job and family support. The results suggest the need for more attention from health services to the reproductive decisions of women living with HIV/Aids; the incorporation of men into sexual and reproductive health prevention actions; and a deeper discussion of the illegality of abortion in Brazil and its harmful consequences for women, men, and children.     

Social and cultural contexts of concurrency in a township in Cape Town,South Africa

Following the 1994 International Conference on Population and Development, the world has seen a shift in paradigm away from focused family planning programmes towards reproductive and sexual health more generally. This paper considers how the traditional emphasis on women's health and family planning can result in men's sexual health needs being overlooked. A biomedical rationale to target men with health services evolved from the rising interest in control programmes for HIV and sexually transmitted infections (STIs). To plan appropriate health interventions more needs to be known about how men perceive their sexual health. Unique data from Orissa (India) and rural Bangladesh illustrate men's perceptions of their sexual health problems and demonstrate that men are willing to seek care. While public sector programmers and health planners may be focusing their attention on the control of STIs, men in both studies indicated that their major concerns relate more to matters of psychosexual disorders. The failure of public sector programmes to take cognisance of male sexual health problems may lead to men continuing to seek care for all their sexual health problems (including STIs) in the unregulated and possibly ineffective private sector. If programmes addressing the sexual health needs of men are to be effective, they will need to be comprehensive in their scope and coverage, just as they are now aiming to be for women.     

Missing men's messages: does the reproductive health approach respond to men's sexual health needs?

After the 1994 International Conference on Population and Development in Cairo, the world has seen a shift in paradigm away from focused family planning programs towards reproductive and sexual health more generally. This article illustrates how the traditional emphasis on women's health and family planning can result in men's sexual health needs being overlooked. The rising concern and need for sexually transmitted infection (STI) control programs has evolved into a biomedical rationale to target men with health services. Planning appropriate health interventions requires more knowledge about how men perceive their sexual health. This paper presents data on male sexual health outcomes from two health intervention studies in South Asia (Orissa, India and rural Bangladesh). The similarities in men's perceptions of sexual health in these studies are discussed. While public sector programmers and health planners may be focusing their attention on the control of STI, men in both studies indicated that their major concerns relate more to matters of psychosexual disorders. The failure of public sector programs to address these issues in men may lead men to continue to seek care for all their sexual health problems including STIs in the unregulated and possibly ineffective private sector. The solution, therefore, lies on the establishment to address the need for fully comprehensive public sector sexual health services for men, just as they are now aiming to be for women.     

HIV/AIDS, sexual and reproductive health: intersections and implications for national programmes

HIV and AIDS have a myriad of effects on sexual and reproductive health and rights, and sexual and reproductive health services are critical for women and men with HIV and AIDS. Yet there has been a dearth of visible, in-depth mainstream attention to the links between sexual and reproductive health and prevention and treatment of HIV/AIDS since the early 1990s among major stakeholders internationally. This paper argues that access to essential sexual and reproductive health care should be provided in HIV/AIDS prevention, care and treatment programmes, and appropriate forms of prevention and treatment of HIV/AIDS should be included in all sexual and reproductive health services as a public health priority, particularly in sex education, family planning and abortion services, pregnancy-related care, sexually transmitted infection (STI) services and services addressing sexual violence. The paper analyzes existing barriers to linking and integrating these services, e.g. at country level due to the traditional training of health workers to implement vertical programmes, separate sources of funding for National AIDS Control Programmes and sexual and reproductive health services, and in international donor programme and UN agency structures. This paper calls for leadership to be exercised by donors, all the UN agencies working together, governments, health service managers and providers, NGOs and advocates in both fields to develop and implement these linkages at country level. Finally, it is crucial that UNAIDS, WHO, UNFPA, UNICEF, the Global Fund to Fight AIDS, TB and Malaria and those working to reach the targets set by the Millennium Development Goals come on board in these efforts.     

Promoting safer sexual practices among expectant fathers in the Lao People's Democratic Republic

Men's decisions and behaviours influence the sexual, reproductive and maternal health of women and the health of their families, but men are rarely included in reproductive and maternal health care services. Men's attendance at antenatal care has the potential to prevent women from becoming infected with HIV during pregnancy and post-partum, when they are more vulnerable to infection and have a high risk of transmission to the infant. Greater involvement of men requires an understanding of social, cultural and organisational barriers in different contexts. In 2006, the Burnet Institute undertook fieldwork to inform a pilot project to encourage expectant fathers to attend antenatal care. A local Lao team conducted focus group discussions and interviews in Vientiane with expectant fathers, pregnant women, older women and health care providers. It was found that myths about the dangers of sex during pregnancy and women's decreased desire resulted in periods of sexual abstinence. Participants reported that unprotected extramarital sex was common but difficult for couples to discuss. Men lacked knowledge about sexually transmitted infections, including HIV. Men wanted information so they could better protect the health of their partners and babies during and after pregnancy, and reported being willing to attend antenatal care when invited. Our findings have useful implications for policy and implementation.     

Integrating medical abortion into safe abortion services: experience from three pilot sites in South Africa

BACKGROUND AND METHODOLOGY: South Africa's Choice on Termination of Pregnancy Act of 1996 provides for safe termination of pregnancy (TOP) in designated facilities in the public and private health sectors. In 2001, mifepristone-misoprostol medical abortion was approved for TOP up to 56 days, but this method is not yet available in the public sector. Information on the operational requirements for integrating mifepristone-misoprostol medical abortion into South Africa's public sector safe abortion services is required to guide policy decisions. This study trained health workers to provide medical abortion to 290 women attending three TOP sites. Prospective data were collected to ascertain women's experience of the method, pregnancy outcome, women's and provider's acceptability of the method, and the operational requirements for providing medical abortion. RESULTS: Twenty-nine (10%) women were lost to follow-up; 261 (90%) women had a confirmed abortion outcome, of whom 93% had a complete abortion. Given the option, the vast majority of women opted to use misoprostol at home. No serious side effects were reported; pain (66%), and heavy bleeding (67%) were the most common side effects. Most (96%) women were very satisfied with the experience. Health providers were satisfied with providing medical abortion and recommended its introduction to complement existing surgical TOP services. DISCUSSION AND CONCLUSION: This study demonstrates that integration of medical abortion into public sector services is feasible. The results of this study will guide policy decisions about integrating medical abortion into South Africa's public sector safe abortion services, within the context of the existing enabling legislative framework.     

Promoting safer sexual practices among expectant fathers in the Lao People's Democratic Republic

Men's decisions and behaviours influence the sexual, reproductive and maternal health of women and the health of their families, but men are rarely included in reproductive and maternal health care services. Men's attendance at antenatal care has the potential to prevent women from becoming infected with HIV during pregnancy and post-partum, when they are more vulnerable to infection and have a high risk of transmission to the infant. Greater involvement of men requires an understanding of social, cultural and organisational barriers in different contexts. In 2006, the Burnet Institute undertook fieldwork to inform a pilot project to encourage expectant fathers to attend antenatal care. A local Lao team conducted focus group discussions and interviews in Vientiane with expectant fathers, pregnant women, older women and health care providers. It was found that myths about the dangers of sex during pregnancy and women's decreased desire resulted in periods of sexual abstinence. Participants reported that unprotected extramarital sex was common but difficult for couples to discuss. Men lacked knowledge about sexually transmitted infections, including HIV. Men wanted information so they could better protect the health of their partners and babies during and after pregnancy, and reported being willing to attend antenatal care when invited. Our findings have useful implications for policy and implementation.     

Prioritizing reproductive health for refugees

It has been recognized that the extreme disruption and isolation that refugees experience can also have serious consequences for their reproductive health. Among these are poor access to safe delivery services and contraceptive methods, as well as sexual violence, with consequences ranging from physical and psychological trauma to HIV/AIDS and sexually transmitted diseases (STDs) and unwanted pregnancy. Reproductive health care can, therefore, save refugee women's lives and should be given priority in emergency refugee assistance efforts. Critical reproductive health services during emergency phase include clean and safe delivery, prevention and treatment of STDs and HIV/AIDS, emergency contraception, and life-saving treatment for complications of miscarriage and contraception. Within this context, the Inter-Agency Working Group has made considerable progress in strengthening reproductive health services in terms of equipment supply, technical materials, policy and advocacy, as well as research and monitoring and programmatic action. Finally, as access to safe abortion care is increased for refugee women, efforts are being made to prevent unsafe abortion by improving supplies of contraceptives to prevent unwanted pregnancy, emergency contraception, and postabortion care.     

Shaking a hornets' nest: pitfalls of abortion counselling in a secular constitutional order--a view from South Africa

There exists an enormous gulf between the aspirations of South Africa's abortion legislation--among the most liberal in the world--and its implementation. One weakness in the provision of abortion services in South Africa is the absence of comprehensive abortion counselling services. On the face of it, the idea that counselling ought, as a matter of course, to be a significant component of a country's termination of pregnancy service provision, seems both straightforwardly sensible and politically innocent. This paper describes how abortion counselling has historically, in many different contexts, been saturated with questionable assumptions about women and their bodies. Counselling has more often than not been deployed, either as the formal policy of states or through informal mechanisms, as a means of curbing the right to abortion rather than deepening the meaning of that right. Differing approaches to counselling emerge as a reflection of contestations over reproductive and gender politics. Specifying an appropriate model for the provision of state-sponsored abortion counselling in the public health sector of a secular constitutional state provokes more of a hornet's nest of dilemmas than is sometimes supposed.     

An ecological approach to understanding Women’s reproductive health and pregnancy decision making in Greenland

Using a community based participatory research framework and ecological systems theory we explored the experiences of reproductive health among Inuit women living in a remote Northwestern settlement in Greenland to understand the multiple diverse factors that influence their pregnancy outcomes. We conducted 15 in depth interviews with Inuit women between the ages of 19 and 45. Key factors influencing women’s pregnancy decision making were: 1) precursors to pregnancy; 2) birth control use; 3) adoption and abortion; and 4) access to reproductive health care. Our results highlight the need to identify pathways through research, policy, health promotion, and health care practice that can support Inuit women in Greenland to be reproductively healthy and make informed decisions about pregnancy that resonate with their cultural beliefs as well as the realities of their everyday lives. We recommend the integration of cultural messaging into interdisciplinary approaches for preventive reproductive health care with women living in remote Arctic communities.     

Gender double standards in young people attending sexual health services in Northern Thailand

Concern about the sexual and reproductive health of young people has been mounting recently in Thailand. Unequal gender relations have a considerable influence on the lives of young people, especially young women, yet few studies have explored the ways in which they have impacted on provision of sexual health care. Drawing upon data from a qualitative study in Northern Thailand, this paper explores the views and experiences of young people in seeking health care, highlighting the kinds of gender double standards and power imbalances that may pose obstacles to their use of sexual and reproductive health services. Findings reveal the vulnerability of sexually active young women in seeking support and care from partners, parents, and service providers. Those who experience adverse outcomes of sexual activity, such as unwanted pregnancy or infection, report facing indifference, victim blaming, or the threat of abandonment by their partners. Because of their fear of disclosure to their parents and communities, of their sexual activity, they opt for clandestine and unsafe abortion and seek the counsel of peers and drugstores rather than parents and providers. At the service provider level, young women report facing threatening and judgemental attitudes, indifferent counselling, and possible violation of confidentiality. This is in marked contrast to the treatment of young men, who generally meet with a more sympathetic and accepting response.     

Risk perception and vulnerability to STIs and HIV/AIDS among immigrant Latin-American women in Canada

This paper describes the migratory experiences of Latin American migrant women living in Canada, their perceptions of the risk of HIV, AIDS and other sexually transmitted infections (STIs) and barriers to accessing healthcare services. We conducted 25 in-depth interviews with Latin American migrant women living in Montreal, Canada. The majority of participants were permanent residents and refugee status claimants. Women’s experiences in Canada were characterised by uncertainty, deception and fraud, separation from their families and feelings of discrimination. Women’s risk perception of HIV/AIDS/STIs involved relations of gender inequalities of power. Women who did not perceive themselves to be at risk were those who had a stable partner who they felt they could trust. The majority of women reported difficulties in accessing sexual and reproductive health services. Women’s vulnerability to HIV/AIDS/STIs was determined by: experiences during their lifecourse; their migratory status, which was associated with sexual abuse, abuse at work, language barriers and lack of social support networks; and their ability to access health services. The provision of health services to this population must focus on sexual and reproductive health needs and should do so from a multicultural perspective that takes into account the changes associated with the migration process.     

“Yo No Sabía...”—Immigrant Women’s Use of National Health Systems for Reproductive and Abortion Care

Half of pregnancies worldwide are unintended; half of these end in abortion. Immigrant women encounter more obstacles to reproductive healthcare than non-immigrant women, and access to national healthcare is a particularly important factor in abortion access. Spain’s government recently liberalized abortion laws, including abortion services in the national health system available to immigrants. Evidence suggests that immigrant women in Spain experience difficulties navigating the health system—the impact of the changed abortion laws on immigrant’s women’s access to care is not yet clear. Through a literature review and analysis, this paper examines the experiences of immigrant women with national health systems, and their use of such systems for reproductive and abortion care, in order to explore what could be expected in Spain as the national health system expands to include abortion care, and to illuminate immigrant women’s experiences with using national health systems for reproductive healthcare more broadly.     

Abortion services for sex workers in Uganda: successful strategies in an urban clinic

Sex workers' need for safe abortion services in Uganda is greater than that of the population of women of reproductive age because of their number of sexual contacts, the inconsistent use of contraception and their increased risk of forced sex, rape or other forms of physical and sexual violence. We sought to understand sex workers' experiences with induced abortion services or post-abortion care (PAC) at an urban clinic in Uganda. We conducted nine in-depth interviews with sex workers. All in-depth interviews were audiotaped, transcribed, translated, computer recorded and coded for analysis. We identified several important programmatic considerations for safe abortion services for sex workers. Most important is creating community-level interventions in which women can speak openly about abortion, creating a support network among sex workers, training peer educators, and making available a community outreach educator and community outreach workshops on abortion. At the health facility, it is important for service providers to treat sex workers with care and respect, allow sex workers to be accompanied to the health facility and guarantee confidentiality. These programmatic elements help sex workers to access safe abortion services and should be tried with all women of reproductive age to improve women's access to safe abortion in Uganda.     

Healthcare experiences of lesbian and bisexual women in Cape Town,South Africa

Understanding the health needs and experiences of South African lesbian and bisexual women is imperative for implementing effective and inclusive public health strategies. Such understanding, however, is limited due to the exclusion of these women from most existing research on healthcare access in the region. This paper bridges that gap by investigating the healthcare experiences of lesbian and bisexual women in Cape Town. Data were gathered from 22 interviews with self-identified lesbian and bisexual community members and university students in the Cape Town area. Interviews explored obstacles women face in accessing affirming services, different experiences with public and private healthcare, fear of stigma/discrimination, availability of relevant sexual health information and suggestions to improve existing programmes. Findings suggest that South African lesbians and bisexual women may have a range of both positive and negative experiences in public and private health services, that they use protective strategies when ‘coming out’ and that they find that sexual health information pertinent to them is largely unavailable. These discussions contribute to a more inclusive understanding of the experiences of lesbian and bisexual women accessing healthcare and other services and help to inform providers, thereby enabling them to deliver more meaningful care to lesbian, gay, bisexual and transgender persons in South Africa.     

Male reproductive control of women who have experienced intimate partner violence in the United States

Women who have experienced intimate partner violence (IPV) are consistently found to have poor sexual and reproductive health when compared to non-abused women, but the mechanisms through which such associations occur are inadequately defined. Through face-to-face, semi-structured in-depth interviews, we gathered full reproductive histories of 71 women aged 18–49 with a history of IPV recruited from a family planning clinic, an abortion clinic and a domestic violence shelter in the United States. A phenomenon which emerged among 53 respondents (74%) was male reproductive control which encompasses pregnancy-promoting behaviors as well as control and abuse during pregnancy in an attempt to influence the pregnancy outcome. Pregnancy promotion involves male partner attempts to impregnate a woman including verbal threats about getting her pregnant, unprotected forced sex, and contraceptive sabotage. Once pregnant, male partners resort to behaviors that threaten a woman if she does not do what he desires with the pregnancy. Reproductive control was present in violent as well as non-violent relationships. By assessing for male reproductive control among women seeking reproductive health services, including antenatal care, health care providers may be able to provide education, care, and counseling to help women protect their reproductive health and physical safety.     

中国流动人口的性与生殖健康现况

近年,随着经济和社会的不断发展,流动人口这一特殊人群,成为社会各界关注的焦点。 流动人口的避孕节育、生殖道感染/性病/艾滋病知识缺乏、婚前性行为发生率高、避孕措施使用率低、人 工流产率高等问题日益凸显。这不仅严重危害流动人口的性与生殖健康状况,同时也影响经济发展和社 会稳定。为了解流动人口性与生殖健康现状及其影响因素,回顾近年来有关流动人口性与生殖健康的文 献,并在分析相关文献的基础上,根据多年来的研究和实践经验提出了若干建议和对策,以便为改善流动 人口性与生殖健康状况提供理论基础。     

Cultural Expectations and Reproductive Desires: Experiences of South African Women Living With HIV/AIDS (WLHA)

We explored factors influencing sexual and reproductive (SR) decisions related to childbearing for women living with HIV/AIDS (WLHA) in South Africa. We conducted four focus group interviews with 35 women living with HIV/AIDS. Our results show that the SR health care needs of women were not being addressed by many health care workers (HCWs). Additionally, we found that health care decisions were influenced by partners and cultural expectations of motherhood. Given the importance of motherhood, it is necessary for HCWs to address the diverse sexual needs and reproductive desires of WLHA.