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Using Evidence To Improve Quality Of Pharmacy-Delivered Medical Abortion, Katharine Footman, Nancy Termini Lachance
Using Evidence To Improve Quality Of Pharmacy-Delivered Medical Abortion, Katharine Footman, Nancy Termini Lachance
Reproductive Health
The goal of family planning and reproductive health operations research is to generate evidence that helps policies and programs maximize access to and quality of services for women and their families. Yet the crucial step of ensuring the utilization of that evidence often receives inconsistent or inadequate attention. The goal of this case study is to document an activity of Marie Stopes International (MSI) in Kenya, part of the STEP UP research program consortium, which resulted in successful evidence utilization. STEP UP research on quality of care for medical abortion, particularly on pharmacy provision of medical abortion, has provided the …
Expanding Access To Integrated Family Planning Intervention Packages For Married Adolescent Girls In Urban Slums Of Dhaka, Bangladesh, Fauzia Akhter Huda, Hassan Rushekh Mahmood, Sadia Afrin, Anisuddin Ahmed, Nafis Al Haque, Bidhan Krishna Sarker
Expanding Access To Integrated Family Planning Intervention Packages For Married Adolescent Girls In Urban Slums Of Dhaka, Bangladesh, Fauzia Akhter Huda, Hassan Rushekh Mahmood, Sadia Afrin, Anisuddin Ahmed, Nafis Al Haque, Bidhan Krishna Sarker
Reproductive Health
This research report describes an intervention study conducted among married adolescent girls aged 15–19 years in four urban slums of Dhaka, Bangladesh. Objectives of the study were to examine the acceptability and feasibility of forming married adolescent girls’ clubs, and involving community health volunteers (Shasthya Skebikas) and marriage registrars to increase access to family planning (FP) information and services, to promote the uptake of long-acting reversible contraceptive methods, and to provide FP information to newlywed couples at the time of marriage registration. The study findings revealed that a noteworthy number of married adolescent girls received FP-related information, mostly from the …
Understanding Fertility Regulation Strategies Among Educated Women In Accra, Cicely Marston, Alicia Renedo, Gertrude Nyaaba, Kazuyo Machiyama, Placide Tapsoba
Understanding Fertility Regulation Strategies Among Educated Women In Accra, Cicely Marston, Alicia Renedo, Gertrude Nyaaba, Kazuyo Machiyama, Placide Tapsoba
Reproductive Health
In Ghana fertility is declining, especially among urban educated women, yet according to the Ghana DHS, use of modern family planning methods fell between 2003 and 2014 in Greater Accra, particularly among better-educated and urban women. Recent studies have shown strong resistance to hormonal methods, reportedly because of fear of side effects. This study aimed to understand fertility regulation strategies among educated women in Accra using a qualitative, exploratory approach. Use of different methods was bound up in women’s modern identities and their attempts to meet the demands of modern urban life (get a good education and a professional, well-paid …
Are Parents Talking To Adolescents About Sexuality? Evidence From Four Slums In Ghana, Selina F. Esantsi, Francis Onyango, Gloria Quansah Asare, Emmanuel Kuffour, Placide Tapsoba, Harriet Birungi, Ian Askew
Are Parents Talking To Adolescents About Sexuality? Evidence From Four Slums In Ghana, Selina F. Esantsi, Francis Onyango, Gloria Quansah Asare, Emmanuel Kuffour, Placide Tapsoba, Harriet Birungi, Ian Askew
Reproductive Health
This evidence brief summarizes the essential information from a part of a larger study that assessed the sexual and reproductive health (SRH) needs of adolescents in four slums in two regions of Ghana. The objective of this brief is to provide evidence to support and facilitate the improvement of parent–adolescent communication on sexuality. This study echoes several other studies by providing evidence that a majority of parents are not opposed to in-school sex education for their children and welcome the idea of empowering themselves (parents) to have productive discussions with their children. Nevertheless, there is a mismatch between the proportion …
Understanding Factors Influencing Adverse Sex Ratios At Birth In Bangladesh, Md. Noorunnabi Talukder, Ubaidur Rob, Md. Irfan Hossain, Forhana Rahman Noor
Understanding Factors Influencing Adverse Sex Ratios At Birth In Bangladesh, Md. Noorunnabi Talukder, Ubaidur Rob, Md. Irfan Hossain, Forhana Rahman Noor
Poverty, Gender, and Youth
Nationally, the sex ratio at birth has persisted at its natural level of 105 male per 100 female newborns for the past half century in Bangladesh. However, at the regional level, Bangladesh is characterized by an east-west divide in sex ratios at birth. While the western region shows normal sex ratios at birth, the eastern region displays distorted sex ratios. To understand the factors that contribute to regional variations, a household survey was conducted among married women aged 18–49 years who had at least two living children. Views of health-care providers on gender-biased sex selection and of program implementers on …
Addressing Gender-Biased Sex Selection In Haryana, India: Promising Approaches, Shireen J. Jejeebhoy, Rajib Acharya, Sharmistha Basu, A.J. Francis Zavier
Addressing Gender-Biased Sex Selection In Haryana, India: Promising Approaches, Shireen J. Jejeebhoy, Rajib Acharya, Sharmistha Basu, A.J. Francis Zavier
Poverty, Gender, and Youth
Persistently adverse sex ratios remain a challenge in India despite the enforcement of the PCPNDT (Pre-Conception and Pre-Natal Diagnostic Techniques) Act in 1994. Nevertheless, over the decade 2001–2011, positive shifts from very adverse to less adverse levels have occurred in a few states. Two districts in Haryana state—Kurukshetra and Sonipat—whose sex ratios displayed some and no improvement, respectively, are compared in an attempt to find promising programme directions to counter gender-biased sex selection. Comparisons are drawn from the attitudes and experiences of surveyed women and interviews with service providers and programme implementers, about sex-selection technology. Also addressed are differences in …
Community Opinion Leaders In Ghana Speak Out On Adolescent Sexuality: What Are The Issues?, Selina F. Esantsi, Francis Onyango, Gloria Quansah Asare, Emmanuel Kuffour, Placide Tapsoba, Harriet Birungi, Ian Askew
Community Opinion Leaders In Ghana Speak Out On Adolescent Sexuality: What Are The Issues?, Selina F. Esantsi, Francis Onyango, Gloria Quansah Asare, Emmanuel Kuffour, Placide Tapsoba, Harriet Birungi, Ian Askew
Reproductive Health
This policy brief reports on a study that is a component of a larger study that assessed the sexual and reproductive health (SRH) needs of adolescents in four slums in two regions of Ghana. The study’s focus on this perspective stems from the fact that there is a lack of evidence surrounding the outlook of community opinion leaders on adolescent reproductive health in this setting. Understanding what adults think about major adolescent SRH issues in their communities (including the SRH rights of adolescents, adult–adolescent communication about SRH issues, and service-seeking and sexual behavior outcomes) provides insight into how adults perceive …
Fertility Transitions In Kenya And Ghana: Trends, Determinants And Implications For Policy And Programs, Ian Askew, Baker Ndugga Maggwa, Francis Onyango
Fertility Transitions In Kenya And Ghana: Trends, Determinants And Implications For Policy And Programs, Ian Askew, Baker Ndugga Maggwa, Francis Onyango
Reproductive Health
The literature on fertility transitions in the sub-Saharan Africa region suggests that an early transition was observed across nearly all age groups, socioeconomic groups, and countries. This workshop report analyzes fertility transitions in Ghana and Kenya which are influenced by a multiplicity of factors, with marked similarities and differences between each country. Paradoxically, these analyses and critiques of policy and programming experiences suggest that, if enabling women and couples to achieve their wanted fertility rates within a rights-based approach that reduces inequities as well as reducing TFR toward replacement level are the goals of a national family planning program, then …
What Are The Sexual And Reproductive Health Needs Of Adolescents In Ghana’S Slums?, Selina F. Esantsi, Gloria Quansah Asare, Placide Tapsoba
What Are The Sexual And Reproductive Health Needs Of Adolescents In Ghana’S Slums?, Selina F. Esantsi, Gloria Quansah Asare, Placide Tapsoba
Reproductive Health
To address the need for quality evidence on the sexual and reproductive health (SRH) needs of adolescents in slums, the STEP UP project conducted a study in four slum settings in Ghana. This policy brief highlights key points, including the need for a well-designed, comprehensive sex education curriculum; interventions that address sexual coercion and violence as an integral component of current adolescent reproductive health programs; and the need to involve all stakeholders including parents/guardians and community leaders in addressing adolescent SRH needs. Evidence from the study can be used to improve ASRH programming so that it better meets the needs …
Improving Family Planning Services In Public Health Facilities To Reach More Women, Caroline W. Kabiru, Jessica Brinton, Joyce Mumah, Carol Mukiira, Chimaraoke O. Izugbara
Improving Family Planning Services In Public Health Facilities To Reach More Women, Caroline W. Kabiru, Jessica Brinton, Joyce Mumah, Carol Mukiira, Chimaraoke O. Izugbara
Reproductive Health
Although Kenya has made significant progress in ensuring its citizens’ right to reproductive health, many Kenyans still lack access to or fail to use contraceptives, in part because of the lack of quality family planning (FP) services. Through the STEP UP research program, the African Population and Health Research Center developed a comprehensive country profile report that outlines the status, causes, and consequences of unintended pregnancy in Kenya. One of the most prominent findings was how important public health facilities are to reducing unmet need for FP. In order to solidify gains achieved and make further progress, concerted commitment from …
Assessment Of Sex Selection In Bangladesh, Md. Noorunnabi Talukder, Ubaidur Rob, Forhana Rahman Noor
Assessment Of Sex Selection In Bangladesh, Md. Noorunnabi Talukder, Ubaidur Rob, Forhana Rahman Noor
Reproductive Health
According to UN estimates, the sex ratio at birth (SRB) has persisted at its natural level of 105 male per 100 female newborns for the past half century in Bangladesh. Generally, the SRB becomes skewed in a setting where fertility is declining or low and where son preference exists. Strong son preference compounded by the availability of measures to implement such preference can lead to increased SRB. For example, the increasing availability of prenatal diagnostic technologies, together with declining fertility desires and persistent son preference, has contributed to increased gender-biased sex selection in several Asian countries, including China and India. …
Kenya Country Profile: A Status Check On Unintended Pregnancy In Kenya, Joyce Mumah, Jessica Brinton, Caroline W. Kabiru, Carol Mukiira, Chimaraoke O. Izugbara
Kenya Country Profile: A Status Check On Unintended Pregnancy In Kenya, Joyce Mumah, Jessica Brinton, Caroline W. Kabiru, Carol Mukiira, Chimaraoke O. Izugbara
Reproductive Health
Kenya’s mothers are dying at an alarming rate: a woman giving birth in Kenya has a 1 in 38 chance of dying due to inadequate reproductive health services. In response, in 2014 Kenya’s First Lady Margaret Kenyatta launched the Beyond Zero campaign to create awareness and raise funds to tackle maternal mortality and morbidity and improve child health. This brief offers six policy and programmatic recommendations to address significant sexual and reproductive health challenges highlighted throughout the report. These recommendations take into account the policy context in Kenya, which is evolving at a rapid rate in part because of the …
Understanding Unintended Pregnancy In Bangladesh: Country Profile Report, Fauzia Akhter Huda, Sabiha Chowdhuri, Yolande Robertson, Noushin Islam, Bidhan Krishna Sarker, Ashrafi Jahan Azmi, Laura Reichenbach
Understanding Unintended Pregnancy In Bangladesh: Country Profile Report, Fauzia Akhter Huda, Sabiha Chowdhuri, Yolande Robertson, Noushin Islam, Bidhan Krishna Sarker, Ashrafi Jahan Azmi, Laura Reichenbach
Reproductive Health
The objective of this report is to identify the determinants of unintended pregnancy and unmet need for family planning in Bangladesh and therefore provide a strong body of evidence that will contribute to issue identification, evidence generation, and communication for use of evidence in policy and programming. The evidence generated can be used to find ways to reduce the rate of unintended pregnancy and hence reduce the risk of abortion-related morbidity and mortality; ultimately this will aid Bangladeshi couples in reaching their fertility goals. Results demonstrate that Bangladesh has shown progress and promise in several areas of family planning and …
Assessment Of The Availability And Use Of Maternal Health Supplies In The Primary Health Care System In Amhara Region, Ethiopia, Sarah Raifman, Sisay Mellese, Kelemua Hailemariam, Ian Askew, Annabel Erulkar
Assessment Of The Availability And Use Of Maternal Health Supplies In The Primary Health Care System In Amhara Region, Ethiopia, Sarah Raifman, Sisay Mellese, Kelemua Hailemariam, Ian Askew, Annabel Erulkar
Reproductive Health
Maternal mortality in Ethiopia remains among the highest in the world. A UN Commission Report in 2012 identified 13 life-saving commodities—defined as medicines, medical devices, and health supplies—that effectively address avoidable causes of death during pregnancy and childbirth that, if more widely accessed and properly used, could significantly reduce preventable deaths among women. This assessment, conducted by the Population Council, evaluates the availability of these life-saving commodities that are essential for basic emergency obstetric and neonatal care, and safe and clean delivery services within primary health care in Ethiopia. The report concludes that Ethiopia’s pharmaceutical procurement and supply system is …
Insights Into Unmet Need In Ghana, Kazuyo Machiyama, John C. Cleland
Insights Into Unmet Need In Ghana, Kazuyo Machiyama, John C. Cleland
Reproductive Health
This study aims to establish the relative importance of lack of access and attitudinal resistance toward use of family planning for different population and geographical strata in Ghana. It is intended to inform policymakers on the priority that should be given to behavior change communication or improved access/information, and also helpful to interventions to reduce health concerns and fear of side effects, such as provision of broader method mix and better counseling. The most far reaching implication concerns the reproductive behavior of the best educated women and those living in the capital or surrounding areas. The results suggest an enduring …
Insights Into Unmet Need In Senegal, Kazuyo Machiyama, John C. Cleland
Insights Into Unmet Need In Senegal, Kazuyo Machiyama, John C. Cleland
Reproductive Health
Results presented in this STEP UP Research Report show that over half of women having unmet need for family planning in Senegal did not intend to use family planning in the future and this was consistent across all population strata. Reasons for non-use confirm the existence of widespread opposition to the use of modern contraception. Unfamiliarity and lack of information is likely to be a reason for such opposition; initial suspicion of contraception has also been documented. Thus a first policy priority, and one that is relatively easy to achieve, is to increase knowledge through the mass media and localized …
Unmet Need And Unintended Pregnancy: The Bigger Picture, Ian Askew
Unmet Need And Unintended Pregnancy: The Bigger Picture, Ian Askew
Reproductive Health
Prevention of unintended pregnancy is often considered the key outcome of reducing unmet need; it is the basic right of women and couples to become pregnant only when intended. This paper explores this relationship by reviewing the definition and measurement of unintended pregnancy, identifying key trends in its distribution within and between populations, and analyzing the relationship between unintended pregnancy, demand for family planning, and family planning program performance. The determinants and consequences of unintended pregnancy are reviewed to further understand the implications of using it as a policy and programming goal. The paper concludes by reviewing the broader policy …
Assessing Retention And Motivation Of Public Health-Care Providers (Particularly Female Providers) In Rural Pakistan, Ali M. Mir, Gul Rashida Shaikh, Saleem Shaikh, Neha Mankani, Anushe Hassan, Maqsood Sadiq
Assessing Retention And Motivation Of Public Health-Care Providers (Particularly Female Providers) In Rural Pakistan, Ali M. Mir, Gul Rashida Shaikh, Saleem Shaikh, Neha Mankani, Anushe Hassan, Maqsood Sadiq
Reproductive Health
The main objectives of this project in Pakistan were to explore the core issue of availability of health providers, especially female providers who are required for provision of maternal and neonatal healthcare, and to determine the range of factors that either constrain or motivate providers to serve in key positions in public facilities in rural areas. The study, conducted by the Population Council with funding from the Maternal and Newborn Health Programme ‐ Research and Advocacy Fund, identifies a number of problems faced by healthcare providers working in the public healthcare system in Pakistan and makes the following recommendations for …
Insights Into Unmet Need In Kenya, Kazuyo Machiyama, John C. Cleland
Insights Into Unmet Need In Kenya, Kazuyo Machiyama, John C. Cleland
Reproductive Health
Results from this study demonstrate that most women having unmet need for family planning in Kenya were aware of the two main contraceptive methods and a supply source, but many of the poorest, least educated women and those living in North Eastern Province were disadvantaged in this regard. Targeted expansion of access/information is a priority to meet the need of the disadvantaged populations. Kenya has one of the longest records of successful family planning programs in Africa, but this report has revealed some major defects, in particular excess reliance on two hormonal methods. Major future progress may well depend on …
Birth Spacing And Family Planning Uptake In Pakistan: Evidence From Falah, Arshad Mahmood
Birth Spacing And Family Planning Uptake In Pakistan: Evidence From Falah, Arshad Mahmood
Reproductive Health
The Population Council was the lead implementing agency for the Family Advancement for Life and Health (FALAH) project in Pakistan. The project’s main objectives were to achieve a 10 percent increase in the use of moden contraceptives, to equip 80 service delivery points to provide family planning services, and to ensure birth-spacing understanding and ways to achieve it by three-quarters of the target population. The main conclusion of this research is that a sharp uptake of family planning is possible in a relatively short time, if certain investments are made to ensure better communication and greater access to quality family …
Future Of Family Planning Program In Bangladesh: Issues And Challenges, Ubaidur Rob, Md. Noorunnabi Talukder, A.K.M. Zafar Ullah Khan
Future Of Family Planning Program In Bangladesh: Issues And Challenges, Ubaidur Rob, Md. Noorunnabi Talukder, A.K.M. Zafar Ullah Khan
Reproductive Health
Bangladesh experienced large population growth in the past, but due to a successful family planning program, the total fertility rate (TFR) declined rapidly until the mid-nineties. Over the last decade, the country experienced a slow pace in fertility decline with a small increase in the contraceptive prevalence rate (CPR). This slow pace in fertility decline is causing serious concern for reaching replacement level fertility by 2015. CPR increased seven-fold from 1975 to 2000, but there was no significant increase from 2000-09, demonstrating the weakness of present program efforts. This raises concern among researchers, policymakers, and program managers about the prospect …
Planning And Implementing An Essential Package Of Sexual And Reproductive Health Services: Guidance For Integrating Family Planning And Sti/Rti With Other Reproductive Health And Primary Health Services, Katherine Williams, Charlotte E. Warren, Ian Askew
Planning And Implementing An Essential Package Of Sexual And Reproductive Health Services: Guidance For Integrating Family Planning And Sti/Rti With Other Reproductive Health And Primary Health Services, Katherine Williams, Charlotte E. Warren, Ian Askew
Reproductive Health
The second goal of the United Nations Population Fund’s (UNFPA’s) 2008–11 Strategic Plan is “Universal access to reproductive health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life.” UNFPA identified a number of outcomes that will contribute to achieving this goal. Through an extensive search of the published literature and collation of unpublished literature on programmatic experiences with developing and implementing integrated packages of SRH services, the Population Council gathered a body of evidence from which this guidance for UNFPA staff and national counterparts has been developed. UNFPA identified two priority areas: integrating …
Urban Family Planning Program Of Bangladesh: Issues And Challenges, Ubaidur Rob, Md. Noorunnabi Talukder, A.K.M. Zafar Ullah Khan
Urban Family Planning Program Of Bangladesh: Issues And Challenges, Ubaidur Rob, Md. Noorunnabi Talukder, A.K.M. Zafar Ullah Khan
Reproductive Health
Extremely inadequate government primary health care (PHC) structure exists in cities in Bangladesh. Nongovernmental organizations (NGOs) play an important role in providing basic health and family planning services to a limited proportion of the urban population. However, NGO programs are time-bound and subject to the availability of development assistance. Bangladesh has one of the highest rates of growth of urban populations among developing countries. For this teeming urban population, there is no structured family planning service. To ensure continuous family planning services in urban areas it is critical to develop a sustainable primary health care structure with the thrust on …
Emergency Contraception: Idea To Program, Saumya Ramarao, John Townsend, Sarah Raifman
Emergency Contraception: Idea To Program, Saumya Ramarao, John Townsend, Sarah Raifman
Reproductive Health
This report summarizes the role of the Population Council in generating evidence, providing technical leadership, and demonstrating at scale that emergency contraception (EC) can be easily integrated into national family planning programs and other reproductive health services. Since the 1990s, the Population Council, along with other partners, has contributed to the changes seen in the provision and availability of EC, now available in over 140 countries around the world. While much progress has been made in the campaign for access to EC, the Council is committed to improving existing methods of service delivery and to leading advocacy efforts and research …
Dominican Republic, Haiti, Nicaragua: Promoting Family Planning During The Postpartum Period Can Increase Contraceptive Acceptance, Population Council
Dominican Republic, Haiti, Nicaragua: Promoting Family Planning During The Postpartum Period Can Increase Contraceptive Acceptance, Population Council
Reproductive Health
The World Health Organization recommends that women receive information on family planning (FP) during antenatal care (ANC), immediately after birth, and during postpartum and well-baby care. However, few studies have assessed the effect of information during each of these stages on women’s use of contraceptive methods. Data collected by FRONTIERS in the Dominican Republic, Haiti, and Nicaragua have been analyzed to answer this question. Use of maternal care services, exposure to FP information, and use of postpartum contraception varies among countries. All women interviewed in the Dominican Republic attended ANC services and delivered in a facility; ANC use and institutional …
Meeting The Family Planning Needs Of Postpartum Women, Ricardo Vernon
Meeting The Family Planning Needs Of Postpartum Women, Ricardo Vernon
Reproductive Health
The first days, weeks, and months after a delivery represent a period of substantial information and service needs for both mother and child, including treatment of hemorrhage and infections, breastfeeding information and support, nutritional complements and micronutrients, immunizations for children and mothers, counseling for managing intimate partner violence and depression, and, most importantly, contraception. In areas of high HIV prevalence, contraceptives and antiretroviral therapy are especially critical elements of postpartum care. Yet despite its strategic importance, few organizations have made it a priority to address women's reproductive health and fertility needs during the year following delivery. The situation is compounded …
Increasing Women's Use Of The Iud For Family Planning, Ricardo Vernon
Increasing Women's Use Of The Iud For Family Planning, Ricardo Vernon
Reproductive Health
The intrauterine device (IUD) is highly effective, easy to use, and has few side effects. The device costs the provider about US$2 and offers a duration of protection that makes it the most cost-effective of the temporary methods if used for two years or more. The IUD's many advantages also make it a good alternative for reducing unmet need for long-term contraception around the world. Between 5 and 17 percent of all married women of reproductive age in 53 less developed countries do not want to have more children but are not using a contraceptive method. Because the IUD can …
South Africa: Integrating Services For Fp And Hiv Improves Quality And Hiv Testing, Population Council
South Africa: Integrating Services For Fp And Hiv Improves Quality And Hiv Testing, Population Council
Reproductive Health
The South African government wishes to expand availability and use of counseling and testing (C&T) for HIV. One option is to integrate C&T into well-attended services, such as family planning (FP). In 2004, the Population Council began a three-year study with the Department of Health in North West Province. The study tested the feasibility, acceptability, and cost of two models for integrating HIV prevention services within established FP programs, and evaluated their quality against standard practice. In the testing-model clinics, providers provided C&T services at the same consultation; in the referral-model clinics, providers offered HIV counseling and referred clients to …
Kenya: Integrating Services For Fp And Hiv Improves Quality And Hiv Testing, Population Council
Kenya: Integrating Services For Fp And Hiv Improves Quality And Hiv Testing, Population Council
Reproductive Health
The Kenyan government’s reproductive health policy highlights service integration and quality of care. While integrating counseling and testing (C&T) for HIV into family planning (FP) can potentially increase the range of services to clients at risk from sexually transmitted infections (STIs) including HIV, few studies have documented the feasibility, effects, or costs of such integration. From 2005–07, the Population Council worked with the Kenyan Ministry of Health to test the feasibility of two models for integrating C&T into existing FP services. Both models featured client education on HIV prevention during FP visits. Providers were trained to routinely use the Balanced …
Family Planning And Comprehensive Abortion Care Handbook For Medical Students And House Officers, Population Council
Family Planning And Comprehensive Abortion Care Handbook For Medical Students And House Officers, Population Council
Reproductive Health
The persistently high maternal mortality and morbidity in Ghana is partly due to high rates of unwanted fertility, unsafe abortion, and relatively low use of modern contraception. In 2006, a consortium of agencies, including the Population Council, initiated the Reducing Maternal Mortality and Morbidity program. The program provides financial and technical resources that will enable the government to significantly expand women's access to modern family planning, contraception, and comprehensive abortion care (CAC) to reduce maternal mortality in Ghana. This handbook on FP and CAC was developed as part of the program. It updates a previous document produced more than ten …