Medicine and Health Sciences Commons^™

Pelvic Pain, Pelvic Organ Prolapse, Urinary And Colorectal Distress Incidence And Relationship To Quality Of Life And Birth Mode, Lori Maria Walton, Christine Abreu, Eliena Jeffus, Amy Trautwein, Shenya Xavier

Faculty Publications

Abstract Purpose: To determine the incidence and impact of pelvic pain, pelvic organ prolapse, urinary and colorectal distress and quality of life by birth mode for women in the chronic postpartum period. Study design: Cross-sectional correlational design utilizing purposive sampling of (n=21) female postpartum subjects ages 18-45. Background: Caesarean Section (CS) incidence is reported at 32% nationwide, well above the recommended safe rate of 10% (WHO). Literature is not clear regarding role of birth mode in postpartum symptoms including: pelvic pain, colorectal distress, pelvic organ prolapse, and quality of life. Methods: Data collection took place after IRB approval from Andrews …

Challenges And Considerations In Optimizing Ovarian Stimulation Protocols In Oncofertility Patients, Kathryn Coyne, Mackenzie Purdy, Kathleen O'Leary, Jerome L. Yaklic, Steven R. Lindheim, Leslie A. Appiah

Obstetrics and Gynecology Faculty Publications

The scope of cancer treatment in women of childbearing age has changed in the last decade. Fertility preservation is no longer an afterthought but central to multi-disciplinary cancer treatment planning and should be addressed due to the cytotoxic effects of cancer therapy. However, oncology patients present as a unique treatment challenge as the physician must balance the urgency of fertility preservation with the risks of delaying cancer therapy. Controlled ovarian stimulation (COS) is routinely applied in assisted reproductive technology but can be contraindicated in women with estrogen-receptor-positive tumors. This paper reviews some of the challenges to consider when using COS …

Food Choices And Practices During Pregnancy Of Immigrant Women With High-Risk Pregnancies In Canada: A Pilot Study, Gina M A. Higginbottom, Helen Vallianatos, Joan Forgeron, Donna Gibbons, Fabiana Mamede, Rubina Barolia

School of Nursing & Midwifery

Background: Immigrant women may be regarded as a vulnerable population with respect to access and navigation of maternity care services. They may encounter difficulties when accessing culturally safe and appropriate maternity care, which may be further exacerbated by language difficulties and discriminatory practices or attitudes. The project aimed to understand ethnocultural food and health practices and how these intersect in a particular social context of cultural adaptation and adjustment in order to improve the care-giving capacities of health practitioners working in multicultural perinatal clinics.
Methods: This four-phase study employed a case study design allowing for multiple means of data collection …

A Study Protocol: Using Demand-Side Financing To Meet The Birth Spacing Needs Of The Underserved In Punjab Province In Pakistan, Syed Khurram Azmat, Moazzam Ali, Waqas Hameed, Ghulam Mustafa, Ghazanfer Abbas, Muhammad Ishaque, Mohsina Bilgrami, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

Background: High fertility rates, unwanted pregnancies, low modern contraceptive prevalence and a huge unmet need for contraception adversely affect women’s health in Pakistan and this problem is compounded by limited access to reliable information and quality services regarding birth spacing especially in rural and underserved areas. This paper presents a study protocol that describes an evaluation of a demand-side financing (DSF) voucher approach which aims to increase the uptake of modern contraception among women of the lowest two wealth quintiles in Punjab Province, Pakistan.

Methods/Design: This study will use quasi-experimental design with control arm and be implemented in: six government …

Government Efforts And Personal Opinion Explain The Medicalization Of Pregnancy And Childbirth Through Time In Lower Mustang, Nepal, Ruth Baker

Independent Study Project (ISP) Collection

The way that women approach pregnancy and childbirth in rural Nepal has seen an amazing change in the past twenty to thirty years. The medicalization of this entire process, from pre-­‐ to post-­‐natal care, comes with government efforts for the increased education of women about family planning, nutrition, hygiene, and the proposed benefits of institutional versus in-­‐home delivery. In 9 villages of Lower Mustang, interviews conducted with Government Health Post workers, Female Health Volunteers, and women of different ages sought to discern personal experience and opinion about pregnancy and childbirth from the perspective of both local women and those with …

Sexual Violence And Sub-Saharan Migrants In Morocco: A Community-Based Participatory Assessment Using Respondent Driven Sampling, Ines Keygnaert, Abdessamad Dialmy, Altay Manço, Jeroen Keygnaert, Nicole Vettenburg, Kristien Roelens, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

Background: The European Union contracted Morocco to regulate migration from so-called “transit migrants” from Morocco to Europe via the European Neighbourhood Policy. Yet, international organisations signal that human, asylum and refugee rights are not upheld in Morocco and that many sub-Saharan migrants suffer from ill-health and violence. Hence, our study aimed at 1) investigating the nature of violence that sub-Saharan migrants experience around and in Morocco, 2) assessing which determinants they perceive as decisive and 3) formulating prevention recommendations.

Methods: Applying Community-Based Participatory Research, we trained twelve sub-Saharan migrants as Community Researchers to conduct in-depth interviews with peers, using Respondent …

Maternal And Perinatal Health Research Priorities Beyond 2015: An International Survey And Prioritization Exercise, Joao Paulo Souza, Mariana Widmer, Ahmet Metin Gülmezoglu, Theresa Anne Lawrie, Ebunoluwa Aderonke Adejuyigbe, Guillermo Carroli, Caroline Crowther, Sheena M. Currie, Therese Dowswell, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

Background: Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required.

Methods: We adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set global research priorities for maternal and perinatal health for the period 2015 to 2025. Priority research questions were received from various international …

La Cesárea Y El Parto Natural: Las Opiniones De Profesionales De La Salud En La Provincia De Buenos Aires / Cesarean Section And Natural Birth: The Opinions Of Health Provinces In The Province Of Buenos Aires, Jacqueline Chipkin

Independent Study Project (ISP) Collection

Introduction: The ways in which women of society give birth have the power to influence maternal-infant health and shape the economy of the healthcare system. Today, the rates of cesarean sections are increasing throughout the world. In Argentina, on average, more than 35% of pregnant women received cesarean sections in 2008, with large differences observed in the rates between the public and private health sectors. The World Health Organization (WHO) has established that healthcare systems should only employ a cesarean section if labor cannot progress safely. According to this standard, the organization estimates that cesarean sections should only be utilized …

Longer Gestation Among Children Born Full Term Influences Cognitive And Motor Development, Emma V. Espel, Laura M. Glynn, Curt A. Sandman, Elyssia Poggi Davis

Psychology Faculty Articles and Research

Children born preterm show persisting impairments in cognitive functioning, school achievement, and brain development. Most research has focused on implications of birth prior to 37 gestational weeks; however, the fetal central nervous system continues to make fundamental changes throughout gestation. Longer gestation is associated with reduced morbidity and mortality even among infants born during the period clinically defined as full term (37–41 gestational weeks). The implications of shortened gestation among term infants for neurodevelopment are poorly understood. The present study prospectively evaluates 232 mothers and their full term infants (50.4% male infants) at three time points across the first postnatal …

One-Year Evaluation Of The Impact Of An Emergency Obstetric And Neonatal Care Training Program In Western Kenya, Rachel F. Spitzer, Sarah Jane Steele, David Caloia, Julie Thorne, Alan D. Bocking, Astrid Christoffersen-Deb, Aaron Yarmoshuk, Loise Maina, Johanna Sitters, Elkanah Omenge

Obstetrics and Gynaecology, East Africa

Objective: To determine the impact of introducing an emergency obstetric and neonatal care training program on maternal and perinatal morbidity and mortality at Moi Teaching and Referral Hospital, Eldoret, Kenya.

Methods: A prospective chart review was conducted of all deliveries during the 3-month period (November 2009 to January 2010) before the introduction of the Advances in Labor and Risk Management International Program (AIP), and in the 3-month period (August–November 2011) 1 year after the introduction of the AIP. All women who were admitted and delivered after 28 weeks of pregnancy were included. The primary outcome was the direct obstetric case …

Hypoxic Stress Induces, But Cannot Sustain Trophoblast Stem Cell Differentiation To Labyrinthine Placenta Due To Mitochondrial Insufficiency, Yufen Xie, Sichang Zhou, Zhongliang Jiang, Jing Dai, Elizabeth E. Puscheck, Icksoo Lee, Graham Parker, Maik Hüttemann, Daniel A. Rappolee

Department of Obstetrics and Gynecology Research Publications

Dysfunctional stem cell differentiation into placental lineages is associated with gestational diseases. Of the differentiated lineages available to trophoblast stem cells (TSC), elevated O2 and mitochondrial function are necessary to placental lineages at the maternal–placental surface and important in the etiology of preeclampsia. TSC lineage imbalance leads to embryonic failure during uterine implantation. Stress at implantation exacerbates stem cell depletion by decreasing proliferation and increasing differentiation. In an implantation site O2 is normally ~ 2%. In culture, exposure to 2% O2 and fibroblast growth factor 4 (FGF4) enabled the highest mouse TSC multipotency and proliferation. In contrast, hypoxic stress (0.5% …

Use Of Antenatal Corticosteroids And Tocolytic Drugs In Preterm Births In 29 Countries: An Analysis Of The Who Multicountry Survey On Maternal And Newborn Health, Joshua P. Vogel, João Paulo Souza, A Metin Gülmezoglu, Rintaro Mori, Pisake Lumbiganon, Zahida Qureshi, Guillermo Carroli, Malinee Laopaiboon, Bukola Fawole, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

Background: Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. We analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries.

Methods: WHOMCS is a facility-based, cross-sectional survey database of birth outcomes in 359 facilities in 29 countries, with data collected prospectively from May 1, 2010, to Dec 31, 2011. For this analysis, we included deliveries after 22 weeks’ gestation and we excluded births that …

Provider Cost Analysis Supports Results-Based Contracting Out Of Maternal And Newborn Health Services: An Evidence-Based Policy Perspective, Peter Hatcher, Shiraz Shaikh, Hassan Fazli, Shehla Zaidi, Atif Riaz

Community Health Sciences

Background

There is dearth of evidence on provider cost of contracted out services particularly for Maternal and Newborn Health (MNH). The evidence base is weak for policy makers to estimate resources required for scaling up contracting. This paper ascertains provider unit costs and expenditure distribution at contracted out government primary health centers to inform the development of optimal resource envelopes for contracting out MNH services.

Methods

This is a case study of provider costs of MNH services at two government Rural Health Centers (RHCs) contracted out to a non-governmental organization in Pakistan. It reports on four selected Basic Emergency Obstetrical …

Does A Contraceptive Bridge Method Affect Rates Of Postpartum Iud Placement In A Resident Urban Clinic?, Agatha Berger, Md, Erica Hinz, Md, Katherine Lackritz, Md, Elisabeth Woodhams, Md, Msc

Department of Obstetrics and Gynecology Presentations and Grand Rounds

Background

• Short interval pregnancies are associated with poor neonatal outcomes.1
• The postpartum (PP) period is an ideal time for LARC prevention of short interval pregnancy.2
• 29% of patients at our clinic admitted not using contraception 4-6 months postpartum.3

“It’S Persuasion Disguised As Information” The Experiences And Adaptations Of Abortion Providers Practicing Under A New Law, Rebecca J. Mercier Md Mph, Mara Buchbinder, Phd, Amy Bryant,Md,Mph, Laura Britton,Rn, Bsn

Department of Obstetrics and Gynecology Presentations and Grand Rounds

Background

Abortion laws are proliferating in the United States. From 2011 to 2013, 30 states passed a total of 205 abortion restrictions.¹ Increasingly, these laws are focused on abortion providers. Such laws have been criticized by professional organizations including the American College of Obstetricians and Gynecologists,² but few studies have assessed the impact of these laws on abortion providers.

In 2011 North Carolina passed HB 854, the “Women’s Right To Know Act” (WRTK). Similar to laws in 26 other states, WRTK mandates a 24-hour waiting period after counseling before an abortion can be performed. Content of the counseling …

“In Light Of Real Alternatives”: Negotiations Of Fertility And Motherhood In Morocco And Oman, Victoria E. Mohr

Student Publications

Many states in the Arab world have undertaken wide-ranging family planning polices in the last two decades in an effort to curb high fertility rates. Oman and Morocco are two such countries, and their policies have had significantly different results. Morocco experienced a swift drop in fertility rates, whereas Oman’s fertility has declined much more slowly over several decades. Many point to the more conservative religious and cultural context of Oman for their high fertility rates, however economics and the state of biomedical health care often present a more compelling argument for the distinct differences between Omani and Moroccan family …

Effect Of Age On Uterine And Ovarian Morphology With Polycystic Ovaries, Ambreen Usmani, Rehana Rehman, Aisha Qamar

Department of Biological & Biomedical Sciences

Abstract

Objective: To measure the outcome of age on ovarian and uterine morphology in primary infertile women with

polycystic ovaries.

Methods: The observational cross-sectional study was conducted from January 2009 to March 2010, and the

subjects were recruited from Ziauddin Hospital, Nazimabad, Karachi. The primary infertile subjects with polycystic

ovaries were subdivided into two age groups:20-30 years (group I), and 31-40 years (group II). Both groups had equal

number of subjects. The ovarian volume, follicles count and size, uterine area and endometrial thickness were

determined by transabdominal and transvaginal scans. Shapiro-Wilk's test and Mann-Whitney test were applied,

with p<0.05 being significant.

Results: …

Intimate Partner Violence After Disclosure Of Hiv Test Results Among Pregnant Women In Harare, Zimbabwe, Simukai Shamu, Christina Zarowsky, Tamara Shefer, Marleen Temmerman, Naeemah Abrahams

Obstetrics and Gynaecology, East Africa

Background: HIV status disclosure is a central strategy in HIV prevention and treatment but in high prevalence settings women test disproportionately and most often during pregnancy. This study reports intimate partner violence (IPV) following disclosure of HIV test results by pregnant women.

Methods: In this cross sectional study we interviewed 1951 postnatal women who tested positive and negative for HIV about IPV experiences following HIV test disclosure, using an adapted WHO questionnaire. Multivariate regression models assessed factors associated with IPV after disclosure and controlled for factors such as previous IPV and other known behavioural factors associated with IPV.

Results: Over …

Approaches To Improve Quality Of Care (Qoc) For Women And Newborns: Conclusions, Evidence Gaps And Research Priorities, Zulfiqar Ahmed Bhutta, Rehana A. Salam, Zohra S. Lassi, Anne Austin, Ana Langer

Department of Paediatrics and Child Health

Despite progress in recent years, an estimated 273,500 women died as a result of maternal causes in 2010. The burden of these deaths is disproportionately bourne by women who reside in low income countries or belong to the poorest sectors of the population of middle or high income ones, and it is particularly acute in regions where access to and utilization of facility-based services for childbirth and newborn care is lowest. Evidence has shown that poor quality of facility-based care for these women and newborns is one of the major contributing factors for their elevated rates of morbidity and mortality. …

Prevalence And Evolution Of Intimate Partner Violence Before And During Pregnancy: A Cross-Sectional Study, An-Sofie Van Parys, Ellen Deschepper, Kristien Michielsen, Marleen Temmerman, Hans Verstraelen

Obstetrics and Gynaecology, East Africa

Background: Intimate partner violence (IPV) before and during pregnancy is associated with a broad range of adverse health outcomes. Describing the extent and the evolution of IPV is a crucial step in developing interventions to reduce the health impact of IPV. The objectives are to study the prevalence of psychological abuse, as well as physical & sexual violence, and to provide insight into the evolution of IPV 12 months before and during pregnancy.

Methods: Between June 2010 and October 2012, a cross-sectional study was conducted in 11 antenatal care clinics in Belgium. Consenting pregnant women were asked to complete a …

Women's Empowerment And Contraceptive Use: The Role Of Independent Versus Couples' Decision-Making, From A Lower Middle Income Country Perspective, Waqas Hameed, Syed Khurram Azmat, Moazzam Ali, Muhammad Ishaque Sheikh, Ghazunfer Abbas, Marleen Temmerman, Bilal Iqbal Avan

Obstetrics and Gynaecology, East Africa

Introduction: There is little available evidence of associations between the various dimensions of women’s empowerment and contraceptive use having been examined - and of how these associations are mediated by women’s socio-economic and demographic statuses. We assessed these phenomena in Pakistan using a structured-framework approach.

Methods: We analyzed data on 2,133 women who were either using any form of contraceptive or living with unmet need for contraception. The survey was conducted during May - June 2012, with married women of reproductive age (15–49 years) in three districts of Punjab. The dimensions of empowerment were categorized broadly into: economic decision making, …

Women's Empowerment And Contraceptive Use: The Role Of Independent Versus Couples' Decision-Making, From A Lower Middle Income Country Perspective, Waqas Hameed, Syed Khurram Azmat, Moazzam Ali, Muhammad Ishaque Sheikh, Ghazunfer Abbas, Marleen Temmerman, Bilal Iqbal Avan

Community Health Sciences

Introduction: There is little available evidence of associations between the various dimensions of women's empowerment and contraceptive use having been examined--and of how these associations are mediated by women's socio-economic and demographic statuses. We assessed these phenomena in Pakistan using a structured-framework approach.
Methods: We analyzed data on 2,133 women who were either using any form of contraceptive or living with unmet need for contraception. The survey was conducted during May - June 2012, with married women of reproductive age (15-49 years) in three districts of Punjab. The dimensions of empowerment were categorized broadly into: economic decision-making, household decision-making, and …

Implantation Failure In Female Kiss1-/- Mice Is Independent Of Their Hypogonadic State And Can Be Partially Rescued By Leukemia Inhibitory Factor., Michele Calder, Yee-Ming Chan, Renju Raj, Macarena Pampillo, Adrienne Elbert, Michelle Noonan, Carolina Gillio-Meina, Claudia Caligioni, Nathalie G Bérubé, Moshmi Bhattacharya, Andrew J Watson, Stephanie B Seminara, Andy V Babwah

Obstetrics & Gynaecology Publications

The hypothalamic kisspeptin signaling system is a major positive regulator of the reproductive neuroendocrine axis, and loss of Kiss1 in the mouse results in infertility, a condition generally attributed to its hypogonadotropic hypogonadism. We demonstrate that in Kiss1(-/-) female mice, acute replacement of gonadotropins and estradiol restores ovulation, mating, and fertilization; however, these mice are still unable to achieve pregnancy because embryos fail to implant. Progesterone treatment did not overcome this defect. Kiss1(+/-) embryos transferred to a wild-type female mouse can successfully implant, demonstrating the defect is due to maternal factors. Kisspeptin and its receptor are expressed in the mouse …

Unmet Need For Contraception And Unintended Pregnancies Among Women Of Reproductive Age Group: A Situation Analysis, Sumera Aziz Ali, Savera Aziz Ali

School of Nursing & Midwifery

Each year approximately 210 million pregnancies occur worldwide and more than one-third (75 to 80 million) of these are unintended, more than half of these (46 million) unintended pregnancies undergo unsafe abortions. In Pakistan 16% of the births are reported to be unwanted and if the unwanted fertility is eliminated, total fertility in Pakistan would be 3.1 births per woman. Total demand for family planning in Pakistan is 55%, while the contraceptive prevalence rate is 35% and unmet need for family planning is 20%. Reasons for unmet need and unintended pregnancy include lack of permission, fear of side effects, poor …

Impact Of Peak/Mid Luteal Estradiol On Pregnancy Outcome After Intracytoplasmic Sperm Injection, Rehana Rehman, Zahir Hussain, Huma Zahir, Rakhshaan Khan

Department of Biological & Biomedical Sciences

Abstract

Objective: To compare peak to mid estradiol ratio with the probability of successful conception after intracytoplasmic

sperm injection.

Method: The quasi-experimental study was conducted in an infertility clinic at Islamabad from June 2010 till August

2011, and comprised couples subjected to intra-cytoplasmic sperm injection. Down-regulation of ovaries was

followed by calculated stimulation, ovulation induction, oocytes retrieval, intra cytoplasmic sperm injection, in vitro

maturation of embryos and finally blastocysts transfer. Serum estradiol was measured by enzyme-linked

immunosorbent assay on ovulation induction day and the day of embryo transfer. Failure of procedure was detected

by beta human chorionic gonadotropin5-25mIU/ml (Group I; …

Maternal Near-Miss And Death And Their Association With Caesarean Section Complications: A Cross-Sectional Study At A University Hospital And A Regional Hospital In Tanzania, Helena Litorp, Hussein Kidanto, Mattias Rööst, Muzdalifat Abeid, Lennarth Nyström, Birgitta Essén

Faculty of Health Sciences, East Africa

Background The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.

Methods We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital …

Pregnancy Anxiety And Prenatal Cortisol Trajectories, Heidi S. Kane, Christine Dunkel Schetter, Laura M. Glynn, Calvin J. Hobel, Curt A. Sandman

Psychology Faculty Articles and Research

Pregnancy anxiety is a potent predictor of adverse birth and infant outcomes. The goal of the current study was to examine one potential mechanism whereby these effects may occur by testing associations between pregnancy anxiety and maternal salivary cortisol on 4 occasions during pregnancy in a sample of 448 women. Higher mean levels of pregnancy anxiety over the course of pregnancy predicted steeper increases in cortisol trajectories compared to lower pregnancy anxiety. Significant differences between cortisol trajectories emerged between 30 to 31 weeks of gestation. Results remained significant when adjusted for state anxiety and perceived stress. Neither changes in pregnancy …

The Changing Tides In Gynecologic Surgery: Minimally Invasive Options What We Know And How Do We Improve Usage And Training, Michael L. Galloway

Obstetrics and Gynecology Faculty Publications

Over the past twenty years gynecologic surgery has evolved from primarily abdominal approach to the current focuson minimally invasive surgical techniques. Minimally invasive techniques include vaginal and laparoscopic techniques. Evolution in laparoscopic technology and equipment has exploded to include multiple vessel sealing instruments of varying modalities, instruments with “wristed” capabilities and robotic assisted technology. Single port laparoscopy and natural orifice transluminal endoscopic surgery notes are other variations of laparoscopic technology. Vaginal surgery is still touted as the “ultimate” minimally invasive surgery by ACOG, however, its use has not grown over this time. Many surgeons have had limited training in vaginal …

Responding To Change In Reproductive Endocrinology Fellowships, William Schlaff, Md

Department of Obstetrics and Gynecology Faculty Papers

Thirty years ago, in the days when I was a reproductive endocrinology fellow, the field looked far different than it does today. Reproductive endocrinologists at that time were most assuredly the experts in diagnosing and treating infertility, but were often, if not usually the go-to doctors for patients with congenital uterovaginal anomalies, endometriosis, and those in need of complicated endoscopic procedures. The REI was not only the authority on polycystic ovary syndrome and other hormonal problems, but often the leader in addressing clinical issues in contraception, abnormal uterine bleeding, and menopause. In the early to mid-1980’s infertility treatment, such as …

'There Are A Lot Of New People In Town: But They Are Here For Soccer, Not For Business' A Qualitative Inquiry Into The Impact Of The 2010 Soccer World Cup On Sex Work In South Africa, Marlise L. Richter, Fiona Scorgie, Matthew F. Chersich, Stanley Luchters

Population Health, East Africa

Background: Sports mega-events have expanded in size, popularity and cost. Fuelled by media speculation and moral panics, myths proliferate about the increase in trafficking into forced prostitution as well as sex work in the run-up to such events. This qualitative enquiry explores the perceptions of male, female and transgender sex workers of the 2010 Soccer World Cup held in South Africa, and the impact it had on their work and private lives.

Methods: A multi-method study design was employed. Data consisted of 14 Focus Group Discussions, 53 sex worker diaries, and responses to two questions in surveys with …