Assessments of the importance of provider characteristics for abortion care: data from women in Rajasthan, India

While client satisfaction is a widely recognized component of effective reproductive health care services, little is known about women's perspectives toward abortion care and providers. We use data from a large, community-based abortion knowledge, attitudes, and practices survey in Rajasthan, India, to describe women's assessments of the importance of eight attributes of potential abortion providers and to investigate the sociodemographic differentials in these assessments. Women prioritized technical aspects of abortion care, including provider skill and an equipped facility, and they deemphasized distance and postabortion contraceptive requirements. Although assessments were stable across many sociodemographic factors, the priorities of urban and rural women varied significantly. Women's prioritization of provider attributes should be incorporated into abortion services.     

Induced Abortion Incidence and Safety in Rajasthan,India: Evidence that Expansion of Services is Needed

Despite induced abortion being broadly legal in India, up-to-date information on its frequency and safety is not readily available. Using direct and indirect methodological approaches, this study measures the one-year incidence and safety of induced abortions among women in the state of Rajasthan. The analysis utilizes data from a population-based survey of 5,832 reproductive aged women who reported on the abortion experiences of their closest female confidante in addition to themselves. We separately assess correlates of having a recent and most unsafe abortion using multivariable regression models. The confidante approach produced a one-year abortion incidence estimate of 23 per 1,000 women, whereas the respondent estimate is 9.5 per 1,000 women. Based on the confidante estimate, approximately 441,000 abortions occurred in Rajasthan over a year. Overall, 25 and 29 percent of respondent and confidante reported abortions were classified as most unsafe. Results suggest that abortion remains an integral component of women's fertility regulation, and that a liberal law alone is insufficient to guarantee access to safe abortion services. Existing policies on abortion in India need updating to permit task sharing in line with current recommendations to expand service delivery so that demand is met through provision of safe and accessible services.     

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.     

Improving Care for Women with a History of Gestational Diabetes: A Provider Perspective

To identify perceived roles with regard to care for women with gestational diabetes mellitus (GDM) history and resources for improving care among women with a history of GDM from the perspective of obstetrician/gynecologists (OB/GYNs), certified nurse midwives (CNM), family practitioners, and internists. In 2010, a survey was sent to a random sample of OB/GYNs, CNM, family practitioners, and internists (n = 2,375) in Ohio to assess knowledge, attitudes, and postpartum practices regarding diabetes prevention for women with a history of GDM. A total of 904 practitioners completed the survey (46 %). Over 70 % of CNMs strongly agreed it is part of their job to help women with GDM history improve diet and increase exercise, compared with 60 % of family practitioners/internists and 55 % of OB/GYNs (p < 0.001). More OB/GYNs and CNMs identified a need for more local nutrition specialists and patient education materials, compared with family practitioners/ internists. Between 60 and 70 % of OB/GYNs and CNMs reported lifestyle modification programs and corresponding reimbursement would better support them to provide improved care. Health care providers giving care to women with GDM history have varying perceptions of their roles, however, there was agreement on resources needed to improve care.     

The Importance of Preconception Care for Women With Disabilities

Maternal and Child Health Journal -     

Slums and Malnourishment: Evidence From Women in India

Objectives. We examined the association between slum residence and nutritional status in women in India by using competing classifications of slum type.Methods. We used nationally representative data from the 2005–2006 National Family Health Survey (NFHS-3) to create our citywide analysis sample. The data provided us with individual, household, and community information. We used the body mass index data to identify nutritional status, whereas the residential status variable provided slum details. We used a multinomial regression framework to model the 3 nutrition states—undernutrition, normal, and overnutrition.Results. After we controlled for a range of attributes, we found that living in a census slum did not affect nutritional status. By contrast, living in NFHS slums decreased the odds of being overweight by 14% (95% confidence interval [CI] = 0.79, 0.95) and increased the odds of being underweight by 10% (95% CI = 1.00, 1.22).Conclusions. The association between slum residence and nutritional outcomes is nuanced and depends on how one defines a slum. This suggests that interventions targeted at slums should look beyond official definitions and include current living conditions to effectively reach the most vulnerable.More than 50% of the world population was classified as urban for the first time in 2009 and is expected to reach around 69% in 2050.1 The proportion of the urban population in the developing world is expected to increase from 45% to 66% during the same period. One of the immediate consequences of population pressure in urban spaces is the growth of slums or urban communities that are characterized by poor access to civic services, inadequate housing, and overcrowding.2 It has been estimated that slum populations would double before 2035 in the low- and middle-income countries.3One of the main concerns regarding the growth of slum populations is that the living conditions of the slum dwellers could become a public health issue. The attention gained by the relation between poor health outcomes and living conditions is neither new nor restricted to the developing world. As early as the 19th century, the Public Health Acts of Britain aimed to improve water systems and sanitation facilities in slums.2 This was also true of other developed countries—notably, France and the United States—which attempted to regulate residential dwellings to contain the spread of disease among other things.Although the pace of urbanization in India historically has been slow, it is increasing rapidly. India’s urban population grew by about 230 million between 1971 and 2008, and it is estimated that 250 million more will swell the urban population within the next 2 decades.4 This urban growth has led to a population explosion in cities, and India boasts of 2 cities with a population of at least 10 million (Delhi and Mumbai).Literature from the developing world suggests that both communicable and noncommunicable diseases are a major concern for urban populations, particularly the slum populations. Already malnourished slum dwellers may experience additional stress because of overcrowding and poor living conditions and are more likely to have poor health outcomes. However, India-specific research findings paint a mixed picture. A study on urban slums in Maharashtra in 1999 indicated that women living in slums were more disadvantaged with respect to antenatal care than were women not living in slums.5 This was reaffirmed by another study that compared the health status of poor populations in slums and in resettlement colonies in Delhi and Chennai and found that slum dwellers had worse health outcomes than those in resettlement colonies.6 Recent research in Chandigarh that used primary data collected in 2006 showed that immunization status of children younger than 5 years was poorer in slum areas than in the rural and urban areas.7 In contrast, a 2005–2006 National Family Health Survey (NFHS-3) report suggested that slum residents were not necessarily worse off than nonslum residents on several deprivation dimensions including poor health.8 These studies have used prevalence rates of all illnesses, morbidity rates, incidence of hospitalization, and other health indicators as various proxies of health status.Our study examined the distribution of women’s malnutrition in 8 cities across slum and nonslum populations. Malnutrition is a significant problem among Indian women. According to several studies that used the NFHS-3, only 52% of the women were within the normal weight range for a given height.8,9 Following the World Health Organization, we defined malnutrition to include the dual burden of undernutrition and overnutrition. Until recently, attention has been exclusively focused on undernutrition. However, recent trends indicate that Indian women are facing a double burden of malnutrition because of the increasing prevalence of overnutrition largely caused by changing lifestyle and diet patterns.10Being underweight could affect productivity and pose health risks, particularly for women, by increasing the likelihood of negative maternal health outcomes, including low-birth-weight infants.11 However, being overweight also could lead to poor health outcomes because of the increased risk of diabetes, cardiovascular diseases, hypertension, and respiratory-related mortality.12Figures 1 and ​and22 show the prevalence of underweight and overweight women, respectively, in 8 cities in India by slum residence status. Women residing in nonslum areas were more likely to be overweight, whereas those residing in slum areas were more likely to be underweight. In cities such as Delhi, these gaps appear to be large, with 36% being overweight in nonslum areas as opposed to 26% in slum areas; in Indore, 38% were undernourished in slums, but only 28% appear to be undernourished in nonslum areas. These numbers suggest that undernutrition is a larger problem in slums, and overnutrition is mainly a nonslum problem. Therefore, slums could be used as a valid unit to study undernutrition-related policies, and nonslum areas could be used to study overweight-related problems.Open in a separate windowFIGURE 1—Distribution of underweight women in 8 cities in India by slum status: 2005–2006 National Family Health Survey (NFHS-3).Note. Prevalence was calculated with 2005–2006 NFHS-3 data that were weighted with the provided weights. The prevalence ratios were calculated as follows: the numerator is the number of people who have body mass index (BMI) < 18.5 kg/m², and the denominator is those with normal weight (BMI = 18.5–24.99 kg/m²). The slum variable includes both census-defined slums and those identified as slums by NFHS field staff.Open in a separate windowFIGURE 2—Distribution of overweight women in 8 cities in India by slum status: 2005–2006 National Family Health Survey (NFHS-3).Note. Prevalence was calculated with 2005–2006 NFHS-3 data that were weighted with the provided weights. The prevalence ratios were calculated as follows: the numerator is the number of people who have body mass index (BMI) ≥ 25 kg/m², and the denominator is those with normal weight (BMI = 18.5–24.99 kg/m²). The slum variable includes both census-defined slums and those identified as slums by NFHS field staff.However, such differences in prevalence may be attributed to differences in the configuration of infrastructure, socioeconomic and other amenities that distinguish a slum from a nonslum area, or individual characteristics between those who live in slums and those who live in nonslum areas. Individual differences tend to matter more for malnutrition outcomes than do slum characteristics.     

What Women Want From Abortion Counseling in the United States: A Qualitative Study of Abortion Patients in 2008

Abortion counseling, including informed consent laws specifying what a woman must be told to obtain an abortion, have been the subject of a great deal of social policy. Using a qualitative sample of 49 women seeking abortions in 2008, we asked women whether they had their mind made up when they called the clinic to make their appointment as well as what they wanted from abortion counseling. The majority of women contacting the abortion clinic had already made up their minds to have an abortion and were therefore not seeking options counseling. Neither were they seeking to emotionally confide in their abortion counselors: They anticipated that the counselor would try to discourage them from having an abortion, they stated that they had met their emotional needs elsewhere, and they feared that confiding in the counselor might endanger their ability to obtain an abortion. They perceived other women needed counseling, though, to help them make a responsible decision. A cafeteria-style approach to counseling that allows women to specify what their needs are would better match abortion counseling with women's stated needs. These data have the potential to inform public policy to better suit abortion-related counseling with women's needs.     

Providers,Unmarried Young Women,and Post‐Abortion Care in Kenya

Young women and girls in Kenya face challenges in access to abortion care services. Using in‐depth and focus group interviews, we explored providers’ constructions of these challenges. In general, providers considered abortion to be commonplace in Kenya; reported being regularly approached to offer abortion‐related care and services; and articulated the structural, contextual, and personal challenges they faced in serving young post‐abortion care (PAC) patients. They also considered induced abortion among young unmarried girls to be especially objectionable; stressed premarital fertility and out‐of‐union sexual activity among unmarried young girls as transgressive of respectable femininity and proper adolescence; blamed young women and girls for the challenges they reported in obtaining PAC services; and linked these challenges to young women's efforts to conceal their failures related to gender and adolescence, exemplified by pre‐marital pregnancy and abortion. This study shows how providers’ distinctive emphasis that young abortion care‐seekers are to blame for their own difficulties in accessing PAC may add to the ongoing crisis of post‐abortion care for young women and adolescent girls in Kenya.     

Dracontiasis in Rajasthan. VI. Epidemiology of dracontiasis in Barmer district, Western Rajasthan, India

Epidemiology of guinea worm disease was studied in relation to sex, age, community and drinking water of inhabitants of 12 desert villages in Barmer district, Western Rajasthan, India. Data were also stratified with respect to first infection and reinfection. Infection was significantly (p less than 0.001) more prevalent in males (7.5%) than females (4.1%). Among all age groups peak infection (9.9%) occurred in those aged 30-39 years. Non-vegetarian communities had a higher incidence than vegetarian communities. Between-community difference was significant (p less than 0.01). First infection cases (11.0%) peaked in those aged 20-29 years while people aged 30-39 years were most susceptible to reinfection (84.6%). Between-age differences with respect to first and reinfection were insignificant (p greater then 0.05). Of various water sources reported pond water was a major source of contamination. 82.7% of the population examined was at risk of developing guinea worm infection at any time. No effective treatment is yet available.     

Health Care Provider Attitudes Toward Safety of Selected Hormonal Contraceptives in Breastfeeding Women

Maternal and Child Health Journal - Little is known about provider attitudes regarding safety of selected hormonal contraceptives among breastfeeding women. Using a nationwide survey, associations...     

Well-woman Care Barriers and Facilitators of Low-income Women Obtaining Induced Abortion after the Affordable Care Act

Objectives

This study uses the abortion visit as an opportunity to identify women lacking well-woman care (WWC) and explores factors influencing their ability to obtain WWC after implementation of the Affordable Care Act.

Prospective Recruitment of Women Receiving Prenatal Care from Diverse Provider Arrangements: A Potential Strategy

Objectives: This study describes the use of a Medicaid managed care list to prospectively recruit into a research project pregnant women receiving care from a variety of providers. Method: A list of women enrolled in Medicaid managed care was used to recruit pregnant African-American and Latina women into a study of prenatal care satisfaction. Due to privacy concerns, the researchers were not able to directly access names from the list. Instead, a managed care contract agency sent recruitment letters to 1009 pregnant African-American and Latina Medicaid recipients. Response rates by ethnicity and several other key variables are calculated. The biases associated with this method of recruiting pregnant women from a variety of providers are discussed. Results: Thirty-five percent of the women contacted returned consent forms and agreed to have researchers approach them; the response rate for African-American women was 43% and for Latinas was 29% (p < 0.0001). Respondents were younger and later in their pregnancies than nonrespondents, but did not differ from them by zip code of residence. The women recruited into the study obtained prenatal care from a diverse group of providers. Conclusions: While the use of a prospectively generated list of pregnant Medicaid recipients to recruit low-income pregnant women into a research study may be associated with some selection bias, the potential cost savings, decreased effort, and diminished recall bias may make their use a feasible sampling alternative, particularly when the researcher desires to recruit women seeking care from a variety of provider arrangements.