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3
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Sep
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t
h
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a
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a
lt
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a
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stru
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tu
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.
K
ey
w
o
r
d
s
:
Ad
o
lescen
t m
o
th
er
s
An
ten
atal
ca
r
e
Ma
ter
n
al
h
ea
lth
Par
en
tal
well
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b
ein
g
Sex
u
al
h
ea
lth
T
h
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s
a
n
o
p
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n
a
c
c
e
ss
a
rticle
u
n
d
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r th
e
CC B
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-
SA
li
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se
.
C
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s
p
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ing
A
uth
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r
:
Kab
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u
Ab
u
b
ak
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Gu
lm
a
Sch
o
o
l o
f
Glo
b
al
Hea
lth
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d
B
io
eth
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E
u
clid
Un
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s
ity
B
an
ju
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T
h
e
Gam
b
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E
m
ail:
g
u
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clid
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ac
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.
n
et
1.
I
NT
RO
D
UCT
I
O
N
Pre
g
n
an
cy
an
d
ch
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b
ir
th
ar
e
m
iles
to
n
es
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wo
m
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ated
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ly
is
1
4
0
m
illi
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[
1
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.
W
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ch
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ce
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w
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d
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r
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is
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2
0
3
0
[
2
]
,
[
3
]
.
An
ten
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ca
r
e
in
c
lu
d
es
o
p
tio
n
s
f
o
r
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ly
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etec
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,
f
o
ll
o
w
-
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p
s
o
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h
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lth
r
is
k
s
d
u
r
in
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p
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e
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n
an
c
y
,
an
d
p
r
ev
e
n
tiv
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h
ea
lth
ca
r
e
s
er
v
ices.
T
h
ese
s
er
v
ices
h
a
v
e
b
e
en
im
p
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ted
in
co
m
m
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ter
s
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ac
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t w
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r
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n
d
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ts
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n
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cy
.
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an
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h
ea
lth
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d
s
o
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s
cien
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s
h
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e
b
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co
n
ce
r
n
ed
with
th
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n
o
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well
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.
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v
er
s
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th
e
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r
ly
co
n
ce
p
tu
aliza
t
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o
f
well
-
b
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g
i
n
1
9
4
6
,
it
h
as
b
ee
n
tak
e
n
f
o
r
g
r
a
n
ted
th
at
well
-
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is
a
d
esira
b
le
co
m
p
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n
e
n
t
o
f
h
ea
lt
h
,
alo
n
g
with
its
ex
ter
n
al
an
d
in
ter
n
al
d
im
en
s
io
n
s
[
4
]
,
[
5
]
.
Sin
ce
th
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r
is
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o
f
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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2
2
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6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
3
,
Sep
tem
b
er
20
25
:
1
3
5
7
-
1
3
6
6
1358
f
em
in
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m
in
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e
1
9
6
0
s
a
n
d
th
e
em
er
g
e
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ce
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f
p
u
b
lic
h
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a
s
an
in
d
u
s
tr
ial
co
m
p
le
x
,
m
ate
r
n
al
h
ea
lth
h
as
b
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n
a
s
u
b
ject
o
f
m
u
ch
d
eb
ate
an
d
ad
v
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ca
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.
Me
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wh
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ev
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d
en
ce
h
as
b
ee
n
g
at
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th
a
t
s
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r
em
ain
ed
n
e
g
lecte
d
with
in
a
n
ten
atal
ca
r
e,
to
o
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Sin
ce
th
e
in
tr
o
d
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o
f
an
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ca
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in
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1
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3
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m
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m
o
t
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r
elate
d
is
s
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es,
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u
ch
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o
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s
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tr
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h
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cr
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s
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ly
an
d
ex
ten
s
iv
ely
with
in
h
ea
lth
ca
r
e
s
y
s
tem
s
[
6
]
,
[
7
]
.
A
n
ten
atal
ca
r
e
h
as
b
ee
n
r
ec
o
m
m
en
d
e
d
to
im
p
lem
en
t
ad
d
itio
n
al
o
p
tio
n
s
f
o
r
ea
r
ly
d
etec
tio
n
,
f
o
llo
w
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p
s
o
f
h
ea
lth
r
is
k
s
,
a
n
d
p
r
ev
en
tiv
e
h
ea
lth
ca
r
e
f
o
r
wo
m
en
d
u
r
in
g
an
d
o
u
ts
id
e
o
f
p
r
eg
n
an
cy
[
8
]
.
R
ec
o
g
n
izin
g
th
e
g
lo
b
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d
iv
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s
ity
in
wo
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s
s
to
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ten
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ata
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eg
an
in
1
9
9
0
to
m
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r
wh
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p
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k
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f
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m
o
n
th
s
o
f
p
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n
a
n
cy
[
9
]
,
[
1
0
]
.
An
ten
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r
e
h
as
b
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n
a
n
d
s
till
is
v
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o
r
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s
ly
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as
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wa
y
to
im
p
r
o
v
e
m
ater
n
al
m
o
r
tality
r
ates.
W
ell
-
b
ein
g
is
a
s
l
ip
p
er
y
ter
m
o
f
ten
co
n
f
u
s
ed
with
its
co
m
p
o
n
en
ts
,
s
u
ch
as
m
en
tal
o
r
p
s
y
ch
o
lo
g
ical
h
ea
lth
.
H
o
wev
er
,
ev
er
s
in
ce
th
e
ea
r
ly
c
o
n
c
ep
tu
aliza
tio
n
o
f
well
-
b
ein
g
i
n
1
9
4
6
,
it
h
as
b
ee
n
tak
en
f
o
r
g
r
a
n
ted
th
at
well
-
b
ein
g
is
a
d
esira
b
le
co
m
p
o
n
en
t
o
f
h
ea
lth
,
alo
n
g
with
its
ex
ter
n
al
an
d
i
n
ter
n
al
d
im
en
s
io
n
s
[
1
1
]
.
Glo
b
ally
,
ap
p
r
o
x
im
ately
1
4
0
m
illi
o
n
p
r
eg
n
an
cies
o
cc
u
r
ea
c
h
y
ea
r
[
1
2
]
,
n
ec
ess
itatin
g
an
ten
atal
ca
r
e
f
o
r
o
v
er
9
0
0
m
illi
o
n
w
o
m
en
in
n
ee
d
o
f
h
ea
lth
ca
r
e
s
er
v
ice
s
b
ef
o
r
e,
d
u
r
in
g
,
an
d
af
ter
p
r
eg
n
an
cy
[
1
3
]
.
T
h
e
co
n
tin
u
u
m
o
f
r
ep
r
o
d
u
ctiv
e,
m
ater
n
al,
n
ewb
o
r
n
,
ch
ild
h
ea
lth
,
an
d
ad
o
lescen
t
h
ea
lth
ca
r
e
s
e
r
v
ices
is
a
p
r
io
r
ity
in
n
atio
n
al
h
ea
lth
p
o
licies
an
d
u
n
i
v
er
s
al
h
ea
lth
c
o
v
er
a
g
e
a
g
en
d
as,
co
n
tr
ib
u
tin
g
to
g
lo
b
a
l
h
ea
lth
an
d
well
-
b
ein
g
g
o
als.
Alth
o
u
g
h
an
ten
at
al
ca
r
e
is
b
en
ef
icial,
g
ap
s
in
p
r
o
v
is
io
n
r
em
ain
,
p
ar
ticu
lar
ly
r
eg
ar
d
in
g
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
s
a
n
d
s
e
x
u
al
h
ea
lth
an
d
well
-
b
ein
g
.
Ad
d
r
ess
in
g
s
u
ch
is
s
u
es
is
v
it
al
to
g
u
ar
an
tee
t
h
e
o
v
er
all
h
ea
lth
ca
r
e
n
ee
d
s
o
f
wo
m
en
d
u
r
in
g
th
e
life
co
u
r
s
e.
T
h
r
o
u
g
h
th
e
av
ailab
ilit
y
o
f
c
o
m
p
r
eh
e
n
s
iv
e
ed
u
ca
tio
n
al
an
d
h
ea
lth
ca
r
e
in
ter
v
en
tio
n
s
,
an
in
cr
ea
s
in
g
n
u
m
b
er
o
f
wo
m
en
ac
r
o
s
s
d
em
o
g
r
ap
h
ics
ca
n
ac
ce
s
s
an
ten
atal
ca
r
e
s
er
v
ices.
I
n
r
ec
en
t
y
ea
r
s
,
th
er
e
h
as
b
ee
n
a
g
r
o
win
g
awa
r
en
ess
o
f
th
e
im
p
o
r
tan
ce
o
f
e
n
s
u
r
in
g
co
m
p
r
eh
en
s
iv
e
s
ex
u
al
a
n
d
r
e
p
r
o
d
u
ctiv
e
h
ea
lth
ca
r
e
f
o
r
wo
m
en
b
ef
o
r
e,
d
u
r
in
g
,
an
d
af
ter
p
r
eg
n
an
cy
.
Nev
er
th
eless
,
s
ca
n
t
atten
tio
n
h
as
b
ee
n
g
iv
en
to
wo
m
en
’
s
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
a
n
d
th
e
ir
r
elate
d
u
n
m
et
n
ee
d
s
d
u
r
in
g
an
ten
atal
ca
r
e
v
is
its
d
esp
ite
ev
id
en
ce
th
at
th
ese
is
s
u
es a
r
e
co
m
m
o
n
am
o
n
g
wo
m
en
o
f
r
ep
r
o
d
u
ctiv
e
a
g
e.
I
n
2
0
2
0
,
g
lo
b
al
in
itiativ
es
ca
lled
f
o
r
th
e
elim
in
atio
n
o
f
e
p
id
em
ics
o
f
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
s
as
a
g
lo
b
al
p
u
b
lic
h
ea
lth
co
n
c
er
n
b
y
2
0
3
0
[
1
4
]
.
Am
o
n
g
th
e
t
ar
g
ets
s
et,
it
was
in
d
icate
d
th
a
t
th
er
e
is
a
n
ee
d
f
o
r
p
o
licies
an
d
p
r
o
g
r
am
s
to
en
s
u
r
e
r
ep
r
o
d
u
ctiv
e
h
ea
lth
s
er
v
ice
s
,
in
clu
d
in
g
f
am
ily
p
lan
n
in
g
,
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
p
r
e
v
en
tio
n
an
d
tr
ea
t
m
en
t,
an
d
,
wh
er
e
in
d
icate
d
,
p
r
en
atal
ca
r
e.
T
h
e
g
lo
b
al
tar
g
ets
f
o
r
ad
d
r
ess
in
g
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
i
s
s
u
es
an
d
en
s
u
r
in
g
co
m
p
r
e
h
e
n
s
iv
e
s
ex
u
al
an
d
r
ep
r
o
d
u
ctiv
e
h
ea
lth
ca
r
e
b
ef
o
r
e,
d
u
r
in
g
,
a
n
d
af
ter
m
o
th
e
r
h
o
o
d
an
d
s
af
e
p
r
eg
n
an
cy
wer
e
r
e
iter
ated
in
th
e
g
lo
b
al
h
ea
lth
s
ec
to
r
s
tr
ateg
y
o
n
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
s
an
d
th
eir
r
elate
d
im
p
lem
en
ta
tio
n
g
u
id
elin
es
[
1
5
]
.
Mo
r
e
o
v
e
r
,
th
e
lack
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
ca
r
e
s
er
v
ices
d
u
r
in
g
th
e
an
ten
atal
ca
r
e
p
er
io
d
is
a
m
ajo
r
h
ea
lth
g
a
p
f
o
r
wo
m
e
n
ac
r
o
s
s
d
em
o
g
r
a
p
h
ics,
p
o
ten
tially
af
f
ec
tin
g
th
e
h
ea
lth
o
f
th
e
n
e
x
t
g
en
er
atio
n
[
1
6
]
.
C
o
n
s
eq
u
e
n
tly
,
r
esear
ch
ex
p
lo
r
in
g
an
d
a
d
d
r
ess
in
g
u
n
m
et
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
n
ee
d
s
d
u
r
in
g
an
ten
atal
ca
r
e
v
is
its
is
o
f
g
r
ea
t
s
ig
n
if
ican
c
e
in
ac
ad
em
ic
an
d
p
u
b
lic
h
ea
lth
co
n
tex
ts
.
Desp
ite
th
e
well
-
d
escr
ib
ed
i
m
p
o
r
tan
ce
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
d
u
r
in
g
p
r
eg
n
an
cy
,
th
e
p
r
o
v
is
io
n
o
f
s
u
ch
ca
r
e
h
as
b
e
en
wid
ely
n
eg
lecte
d
in
m
an
y
h
ea
lth
ca
r
e
s
ettin
g
s
.
T
h
is
s
tu
d
y
e
x
p
lo
r
es
c
u
r
r
e
n
t
ca
r
e
p
r
o
v
is
io
n
an
d
attitu
d
es
t
o
war
d
s
s
ex
u
al
h
ea
lth
a
n
d
well
-
b
ein
g
d
is
cu
s
s
io
n
s
in
an
ten
a
tal
ca
r
e
f
r
o
m
b
o
th
p
r
o
v
id
e
r
a
n
d
r
ec
ip
ien
t
p
er
s
p
ec
tiv
es.
T
h
e
r
esear
ch
q
u
esti
o
n
is
:
Ho
w
is
s
ex
u
al
h
ea
lth
an
d
we
ll
-
b
ein
g
a
d
d
r
ess
ed
in
an
ten
atal
ca
r
e
p
r
o
v
is
io
n
a
n
d
p
e
r
ce
p
tio
n
,
an
d
wh
at
ar
e
th
e
cu
r
r
en
t
attitu
d
es
to
war
d
s
th
is
am
o
n
g
ca
r
e
r
ec
eiv
er
s
an
d
p
r
o
v
id
er
s
in
a
g
lo
b
al
co
n
tex
t?
T
h
e
p
r
o
v
is
io
n
an
d
p
er
ce
p
tio
n
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
is
s
u
es
am
o
n
g
p
r
eg
n
an
t
in
d
iv
i
d
u
als
co
n
ce
r
n
in
g
an
ten
atal
ca
r
e
h
av
e
b
ee
n
m
ain
ly
u
n
d
er
ex
p
lo
r
ed
.
T
h
e
lack
o
f
r
esear
ch
f
r
o
m
eith
er
r
ec
ip
ien
t
o
r
p
r
o
v
id
e
r
p
e
r
s
p
ec
tiv
es,
av
o
id
an
t
ten
d
en
cies,
a
n
d
in
e
q
u
ita
b
le
im
p
lem
en
tatio
n
o
f
ca
r
e
ar
e
an
ticip
ated
to
h
i
n
d
er
th
e
p
r
o
v
is
io
n
o
f
n
ec
ess
ar
y
ca
r
e.
I
n
cl
u
d
in
g
o
th
er
g
e
o
g
r
ap
h
ical
co
n
tex
ts
,
esp
ec
ially
s
ettin
g
s
in
lo
w
-
an
d
m
id
d
le
-
i
n
co
m
e
co
u
n
tr
ies,
will
ex
p
lo
r
e
th
e
g
lo
b
al
r
esp
o
n
s
e
to
is
s
u
es
ar
o
u
n
d
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
,
th
u
s
i
d
en
tify
in
g
a
n
y
p
r
e
v
alen
t
atten
tio
n
g
a
p
s
.
T
h
is
s
tu
d
y
aim
s
to
p
r
o
v
id
e
th
e
f
ir
s
t
ex
p
lo
r
atio
n
o
f
th
ese
is
s
u
es
f
r
o
m
a
m
ix
ed
-
m
et
h
o
d
s
p
er
s
p
ec
tiv
e
an
d
d
is
cu
s
s
es
im
p
lic
atio
n
s
f
o
r
im
p
r
o
v
e
d
h
ea
lth
u
p
o
n
in
clu
s
io
n
o
f
p
r
ev
i
o
u
s
ly
n
eg
lecte
d
ca
r
e.
T
h
e
co
n
ce
p
t
o
f
s
ex
u
al
h
ea
lth
h
as
b
ee
n
la
r
g
ely
n
eg
lecte
d
in
an
ten
atal
ca
r
e,
with
th
is
b
ein
g
s
ee
n
as
a
g
ap
in
ca
r
e
p
r
o
v
is
io
n
in
a
W
es
ter
n
co
n
tex
t.
T
h
u
s
,
ex
p
lo
r
i
n
g
t
h
e
r
elate
d
p
o
s
tu
latio
n
s
an
d
n
u
an
ce
s
is
im
p
er
ativ
e
wh
en
ca
r
e
p
r
o
v
is
io
n
is
in
v
esti
g
ated
in
a
m
o
r
e
g
l
o
b
al
c
o
n
tex
t.
E
licitin
g
W
ester
n
p
er
ce
p
tio
n
s
h
as
th
e
p
o
ten
tial
to
d
etec
t
cu
ltu
r
ally
e
n
tr
en
ch
e
d
m
o
r
es
o
n
s
ex
u
ality
th
at
m
ay
o
th
er
wis
e
b
e
d
if
f
icu
lt
to
s
tu
d
y
.
Nev
er
th
eless
,
it
is
an
ticip
ated
th
at
ca
r
e
will
b
e
d
ee
m
ed
s
u
f
f
icien
t
in
W
este
r
n
co
n
tex
ts
,
p
er
h
a
p
s
lead
in
g
to
th
e
d
is
m
is
s
al
o
f
f
in
d
in
g
s
o
r
av
o
id
an
ce
in
lo
w
-
an
d
m
id
d
le
-
in
c
o
m
e
s
ettin
g
s
.
Mo
r
eo
v
er
,
it
is
n
o
ted
th
at
ev
en
th
e
W
ester
n
p
r
o
v
is
io
n
o
f
s
ex
u
al
h
ea
lth
ca
r
e
h
as
b
ee
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p
o
o
r
ly
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x
am
in
ed
,
with
f
ew
s
tu
d
ies
d
i
r
ec
tly
ad
d
r
ess
in
g
ca
r
e
r
ec
ei
v
er
s
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Evaluation Warning : The document was created with Spire.PDF for Python.
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m
a
y
b
e
m
is
attr
ib
u
te
d
o
r
o
v
er
lo
o
k
ed
wh
en
d
is
cu
s
s
in
g
o
th
er
co
n
tex
ts
,
p
r
o
lo
n
g
in
g
d
is
co
u
r
s
e
s
u
r
r
o
u
n
d
in
g
s
ex
u
al
m
atter
s
.
Desp
ite
th
e
co
m
p
lex
ity
o
f
ad
d
r
es
s
in
g
s
ex
u
al
is
s
u
es,
p
ar
ticu
lar
ly
in
a
n
o
n
-
W
ester
n
o
r
lo
w
-
an
d
m
id
d
le
-
i
n
co
m
e
c
o
n
tex
t,
ca
r
e
in
ter
ac
tio
n
s
ar
e
a
n
ticip
ated
to
b
e
less
f
r
eq
u
e
n
t
o
v
e
r
all
an
d
ev
en
m
o
r
e
s
o
wh
en
a
b
o
u
t
t
h
e
in
tim
ate
ar
ea
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
,
wh
ich
m
a
y
th
u
s
b
e
co
m
m
o
n
p
lace
g
lo
b
ally
.
-
I
n
tellectu
al
co
n
tr
ib
u
tio
n
an
d
d
esig
n
g
o
als
T
h
is
s
tu
d
y
co
n
tr
ib
u
tes
s
u
b
s
tan
tially
to
th
e
ex
is
tin
g
liter
atu
r
e
o
n
an
ten
atal
ca
r
e
b
y
ad
d
r
ess
in
g
th
e
lar
g
ely
o
v
er
l
o
o
k
e
d
to
p
ic
o
f
s
e
x
u
al
h
ea
lth
an
d
well
-
b
ei
n
g
with
in
an
ten
atal
s
er
v
ices.
T
h
e
p
r
i
m
ar
y
o
b
jectiv
e
was
to
s
y
n
th
esize
ex
is
tin
g
e
v
id
en
c
e
to
h
i
g
h
lig
h
t
t
h
e
ab
s
en
ce
o
f
a
s
tr
u
ctu
r
ed
ap
p
r
o
ac
h
f
o
r
in
teg
r
atin
g
s
ex
u
al
h
ea
lth
d
is
cu
s
s
io
n
s
in
an
ten
atal
ca
r
e
,
a
g
a
p
th
at
p
er
s
is
ts
ac
r
o
s
s
v
a
r
io
u
s
h
ea
lth
ca
r
e
s
y
s
tem
s
,
esp
ec
ially
in
lo
w
-
an
d
m
id
d
le
-
in
co
m
e
c
o
u
n
tr
ies.
T
h
r
o
u
g
h
a
s
y
s
tem
atic
r
ev
iew
o
f
cu
r
r
en
t
liter
atu
r
e,
th
e
s
tu
d
y
id
en
tifie
s
p
atter
n
s
in
s
ex
u
al
h
ea
lth
n
eg
lect
with
in
an
ten
atal
s
ettin
g
s
,
co
n
t
r
asts
th
ese
with
b
est
p
r
ac
tice
g
u
id
e
lin
es,
an
d
p
r
o
p
o
s
es
ac
tio
n
ab
le
r
ec
o
m
m
en
d
atio
n
s
to
b
r
id
g
e
th
e
o
b
s
er
v
ed
g
ap
s
.
-
Ma
in
th
em
e
an
d
ap
p
r
o
ac
h
T
h
e
s
tu
d
y
is
g
r
o
u
n
d
ed
i
n
im
p
r
o
v
in
g
m
ate
r
n
al
a
n
d
c
h
ild
h
ea
lth
o
u
tco
m
es
b
y
in
co
r
p
o
r
at
in
g
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
in
t
o
a
n
ten
atal
ca
r
e
f
r
a
m
ewo
r
k
s
.
I
t
s
y
s
tem
atica
lly
ex
p
lo
r
es
b
ar
r
ier
s
f
ac
ed
b
y
b
o
th
p
r
o
v
id
e
r
s
an
d
r
ec
ip
ie
n
ts
in
d
is
cu
s
s
in
g
s
ex
u
al
h
ea
lth
is
s
u
e
s
,
co
n
tex
tu
alizin
g
th
ese
f
in
d
i
n
g
s
with
in
ex
is
tin
g
h
ea
lth
ca
r
e
p
r
o
t
o
co
ls
.
T
h
is
ap
p
r
o
ac
h
em
p
h
asizes
th
e
n
ee
d
f
o
r
a
h
o
lis
tic
v
iew
o
f
m
ater
n
al
h
ea
lth
,
in
clu
d
in
g
p
h
y
s
ical
an
d
s
o
cio
-
em
o
tio
n
al
well
-
b
ein
g
.
-
Sp
ec
if
ic
g
o
als
T
h
e
d
esig
n
an
d
d
e
v
elo
p
m
e
n
t
ap
p
r
o
ac
h
aim
s
to
:
i
)
o
u
tlin
e
t
h
e
g
ap
s
in
s
ex
u
al
h
ea
lth
p
r
o
v
is
io
n
with
in
an
ten
atal
ca
r
e
;
ii
)
r
ec
o
m
m
en
d
s
tr
ateg
ies
f
o
r
im
p
lem
en
tin
g
s
ex
u
al
h
ea
lth
s
er
v
ices
as
p
ar
t
o
f
r
o
u
tin
e
an
te
n
atal
ca
r
e
;
an
d
iii
)
s
u
g
g
est
ca
p
ac
ity
-
b
u
ild
in
g
m
ea
s
u
r
es
f
o
r
h
ea
lth
ca
r
e
p
r
o
v
i
d
er
s
to
f
ac
ilit
ate
o
p
en
,
s
u
p
p
o
r
tiv
e
d
is
cu
s
s
io
n
s
o
n
s
ex
u
al
h
ea
lth
.
T
h
ese
g
o
als
alig
n
with
g
lo
b
al
h
ea
lth
o
b
jectiv
es
an
d
o
f
f
er
a
r
ep
licab
le
f
r
am
ewo
r
k
th
at
co
u
ld
in
f
o
r
m
p
o
licy
an
d
p
r
ac
tice
ch
a
n
g
es
in
d
iv
er
s
e
s
ettin
g
s
.
B
y
al
ig
n
in
g
th
is
s
tu
d
y
with
b
r
o
ad
e
r
p
u
b
lic
h
ea
lth
p
r
io
r
itie
s
an
d
o
f
f
er
in
g
ev
id
e
n
ce
-
b
ased
in
s
ig
h
ts
,
it
p
r
o
v
id
es
a
s
o
lid
f
o
u
n
d
atio
n
f
o
r
f
u
tu
r
e
r
esear
ch
an
d
p
r
o
g
r
am
m
atic
im
p
r
o
v
em
e
n
ts
in
an
ten
atal
ca
r
e
s
er
v
ices.
E
f
f
o
r
ts
wer
e
also
m
ad
e
to
s
tr
ictly
f
o
llo
w
th
e
jo
u
r
n
al'
s
au
th
o
r
g
u
id
elin
es
an
d
p
u
b
licatio
n
ch
ec
k
lis
t,
en
s
u
r
in
g
clar
ity
,
ad
h
er
en
ce
to
s
tr
u
ctu
r
e,
an
d
alig
n
m
en
t w
ith
ac
ad
em
ic
s
tan
d
ar
d
s
.
2.
M
E
T
H
O
D
2.
1
.
S
t
u
d
y
o
b
j
ec
t
i
v
e
a
nd
l
i
t
er
a
t
u
r
e
r
e
v
i
ew
me
t
h
o
d
o
l
o
g
y
T
h
e
p
r
i
m
a
r
y
o
b
j
e
c
t
i
v
e
o
f
t
h
i
s
s
t
u
d
y
w
a
s
t
o
e
x
p
l
o
r
e
h
o
w
s
e
x
u
a
l
h
e
a
l
t
h
a
n
d
w
e
ll
-
b
e
i
n
g
a
r
e
a
d
d
r
e
s
s
e
d
i
n
a
n
t
e
n
a
t
a
l
c
a
r
e
b
as
e
d
o
n
i
n
s
i
g
h
t
s
g
at
h
e
r
e
d
f
r
o
m
e
x
is
ti
n
g
l
i
te
r
a
t
u
r
e
.
T
o
a
c
h
i
e
v
e
t
h
is
,
w
e
c
o
n
d
u
c
t
e
d
a
c
o
m
p
r
e
h
e
n
s
i
v
e
r
e
v
i
ew
o
f
r
el
e
v
a
n
t
l
it
e
r
a
t
u
r
e
,
s
y
n
t
h
es
i
z
i
n
g
f
i
n
d
i
n
g
s
f
r
o
m
v
a
r
i
o
u
s
s
t
u
d
i
es
t
o
i
d
e
n
t
i
f
y
p
a
t
te
r
n
s
a
n
d
c
o
m
m
o
n
t
h
e
m
e
s
r
e
l
at
e
d
t
o
s
e
x
u
a
l
h
e
a
l
t
h
i
n
a
n
te
n
a
t
a
l
c
a
r
e
.
-
L
iter
atu
r
e
s
o
u
r
ce
s
an
d
s
elec
tio
n
A
s
y
s
t
e
m
at
i
c
s
e
a
r
c
h
o
f
o
n
l
i
n
e
a
c
a
d
e
m
i
c
d
a
ta
b
a
s
es
(
s
u
c
h
a
s
Pu
b
M
e
d
,
G
o
o
g
l
e
S
c
h
o
l
a
r
,
a
n
d
J
S
T
OR
)
w
as
c
o
n
d
u
c
t
e
d
t
o
l
o
c
a
t
e
s
t
u
d
i
es
a
n
d
a
r
t
i
c
l
es
o
n
s
e
x
u
a
l
h
e
al
t
h
,
we
l
l
-
b
e
i
n
g
,
a
n
d
a
n
t
e
n
a
t
al
c
a
r
e
.
K
e
y
w
o
r
d
s
i
n
c
l
u
d
e
d
“
s
e
x
u
a
l
h
e
al
t
h
i
n
a
n
t
e
n
at
a
l
c
a
r
e
,
”
“
w
e
ll
-
b
e
i
n
g
d
u
r
i
n
g
p
r
e
g
n
a
n
c
y
,
”
a
n
d
“
m
a
t
e
r
n
a
l
h
e
a
lt
h
s
e
r
v
i
c
e
s
.
”
S
t
u
d
i
es
w
e
r
e
s
e
l
e
ct
e
d
b
a
s
e
d
o
n
t
h
e
i
r
r
e
l
e
v
a
n
c
e
t
o
t
h
e
t
o
p
i
c
,
t
h
e
i
r
f
o
c
u
s
o
n
a
n
t
e
n
a
t
a
l
c
a
r
e
,
a
n
d
t
h
e
i
r
c
o
n
t
r
i
b
u
t
i
o
n
s
t
o
u
n
d
e
r
s
t
a
n
d
i
n
g
s
e
x
u
a
l
h
e
al
t
h
n
ee
d
s
a
n
d
b
a
r
r
i
e
r
s
i
n
d
i
v
e
r
s
e
h
e
alt
h
c
a
r
e
s
et
t
i
n
g
s
.
-
Pro
ce
d
u
r
e
T
h
e
l
i
t
e
r
at
u
r
e
r
e
v
i
e
w
w
as
c
o
n
d
u
c
t
e
d
i
n
s
t
a
g
es
.
F
i
r
s
t
,
s
o
u
r
c
es
w
e
r
e
s
c
r
e
e
n
e
d
f
o
r
r
e
l
e
v
a
n
c
e
an
d
q
u
a
l
i
t
y
,
e
n
s
u
r
i
n
g
t
h
e
i
n
c
l
u
s
i
o
n
o
f
p
e
e
r
-
r
e
v
i
e
w
e
d
j
o
u
r
n
a
l
a
r
ti
c
l
es
,
g
o
v
e
r
n
m
e
n
t
r
e
p
o
r
t
s
,
a
n
d
r
e
p
u
t
a
b
l
e
h
e
al
t
h
c
a
r
e
p
u
b
l
i
c
a
t
i
o
n
s
.
E
a
c
h
s
o
u
r
c
e
w
as
a
n
a
l
y
z
e
d
t
o
e
x
t
r
a
c
t
i
n
f
o
r
m
a
t
i
o
n
o
n
t
h
e
m
e
s
s
u
c
h
a
s
s
e
x
u
a
l
h
e
a
l
t
h
d
i
s
c
u
s
s
i
o
n
s
i
n
a
n
t
e
n
a
t
a
l
c
a
r
e
,
h
ea
l
t
h
c
a
r
e
p
r
o
v
id
e
r
s
'
b
a
r
r
i
e
r
s
,
a
n
d
c
u
l
t
u
r
a
l
f
a
c
to
r
s
'
i
m
p
a
ct
o
n
p
a
ti
e
n
t
-
p
r
o
v
i
d
e
r
i
n
t
e
r
a
ct
i
o
n
s
.
T
h
e
s
e
i
n
s
i
g
h
ts
w
e
r
e
t
h
e
n
s
y
n
t
h
es
i
z
e
d
t
h
r
o
u
g
h
t
h
e
m
a
t
i
c
a
n
a
l
y
s
i
s
t
o
i
d
e
n
t
i
f
y
r
e
c
u
r
r
i
n
g
p
a
t
t
e
r
n
s
a
c
r
o
s
s
s
t
u
d
i
es
.
2.
2.
D
a
t
a
a
n
a
l
y
s
i
s
T
h
e
m
a
t
i
c
a
n
a
l
y
s
i
s
w
as
a
p
p
l
i
ed
t
o
t
h
e
c
o
l
l
e
c
t
e
d
l
i
t
e
r
a
t
u
r
e
t
o
o
r
g
a
n
i
z
e
f
i
n
d
i
n
g
s
i
n
t
o
c
o
h
e
r
e
n
t
t
h
e
m
e
s
.
K
e
y
t
h
e
m
es
we
r
e
i
d
e
n
ti
f
i
e
d
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Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
3
,
Sep
tem
b
er
20
25
:
1
3
5
7
-
1
3
6
6
1360
3.
DIS
CU
SS
I
O
N
3.
1
.
Understa
nd
ing
s
ex
ua
l h
ea
lt
h in t
he
co
nte
x
t
o
f
a
nte
n
a
t
a
l c
a
re
Sex
u
al
h
ea
lth
h
as
em
er
g
ed
as
a
n
eg
lecte
d
y
et
in
teg
r
al
p
ar
t
o
f
p
o
s
itiv
e
r
ep
r
o
d
u
ctiv
e
,
m
ater
n
al,
n
ewb
o
r
n
,
an
d
c
h
ild
h
ea
lth
an
d
ad
o
lescen
t
h
ea
lth
p
r
o
g
r
am
s
an
d
in
itiativ
es.
T
h
is
h
am
p
e
r
s
th
e
ad
v
a
n
ce
m
en
t
o
f
th
e
S
u
s
tain
ab
le
Dev
elo
p
m
en
t
Go
als
ag
en
d
a
o
n
m
ater
n
al,
n
ewb
o
r
n
,
an
d
ch
ild
h
ea
lth
an
d
well
-
b
ein
g
.
I
t
is
cr
itical
to
u
n
d
er
s
tan
d
n
o
r
m
al
f
em
ale
s
ex
u
al
h
ea
lth
in
th
e
co
n
tex
t
o
f
p
r
eg
n
a
n
cy
,
ch
ild
b
i
r
th
,
an
d
p
o
s
tp
ar
t
u
m
t
o
id
en
tify
s
ex
u
al
h
ea
lth
n
ee
d
s
a
n
d
ch
allen
g
es d
u
r
in
g
an
ten
atal
ca
r
e,
wh
ich
is
th
e
f
o
cu
s
o
f
th
i
s
ess
ay
.
Sex
u
al
h
ea
lth
is
d
ef
i
n
ed
as
a
s
tate
o
f
p
h
y
s
ical,
em
o
tio
n
al,
m
en
tal,
an
d
s
o
cial
well
-
b
ei
n
g
in
r
elatio
n
to
s
ex
u
ality
.
No
r
m
s
,
v
alu
es,
an
d
b
elief
s
in
f
lu
en
ce
s
ex
u
al
h
ea
l
th
in
a
co
m
m
u
n
ity
o
r
s
o
ciety
,
wh
ich
co
n
s
id
er
s
s
ex
u
ality
a
s
en
s
itiv
e
to
p
ic
th
at
n
ee
d
s
to
b
e
k
e
p
t
p
r
iv
ate.
C
o
n
s
eq
u
en
tly
,
p
e
o
p
le
o
f
te
n
d
o
n
o
t
h
av
e
ac
ce
s
s
to
th
e
n
ec
ess
ar
y
in
f
o
r
m
atio
n
to
ad
d
r
ess
n
ee
d
s
an
d
ch
allen
g
es
co
n
ce
r
n
in
g
s
ex
u
al
h
ea
lth
,
p
ar
ticu
lar
ly
in
p
r
e
g
n
an
c
y
an
d
ch
ild
b
ir
th
.
On
e
way
to
u
n
d
er
s
tan
d
s
ex
u
al
h
ea
lth
co
n
ce
r
n
s
an
d
ch
allen
g
es
d
u
r
i
n
g
p
r
e
g
n
an
cy
is
to
r
ev
iew
n
o
r
m
ativ
e
f
em
ale
s
ex
u
al
h
ea
lth
ac
r
o
s
s
th
e
co
n
tin
u
u
m
o
f
p
r
e
g
n
an
cy
.
T
h
e
m
ater
n
ity
ca
r
e
p
r
o
to
co
ls
p
r
o
v
id
e
a
n
in
-
d
ep
th
r
eso
u
r
ce
f
o
r
u
n
d
er
s
t
an
d
in
g
a
n
ten
atal
ca
r
e,
c
o
v
er
i
n
g
ev
en
ts
ad
d
r
ess
ed
in
an
ten
atal
ca
r
e
an
d
tim
e
p
o
in
ts
wh
en
ev
e
n
ts
ar
e
d
is
cu
s
s
ed
.
As
s
ex
u
al
atti
tu
d
es,
f
ee
lin
g
s
,
b
eh
av
io
r
,
an
d
f
u
n
ctio
n
s
ch
an
g
e
th
r
o
u
g
h
o
u
t
th
e
co
n
tin
u
u
m
o
f
p
r
eg
n
a
n
cy
,
u
n
d
er
s
tan
d
i
n
g
n
o
r
m
ativ
e
s
ex
u
al
h
ea
lth
d
u
r
in
g
p
r
eg
n
an
cy
,
c
h
ild
b
ir
th
,
a
n
d
o
th
er
p
o
s
tp
ar
tu
m
p
er
io
d
s
is
ess
en
tial
[
1
7
]
,
[
1
8
]
.
T
h
e
n
e
g
lect
o
f
s
ex
u
al
h
e
alth
in
an
ten
atal
ca
r
e
r
ef
lects
th
e
u
n
d
er
v
alu
e
d
r
o
le
o
f
s
ex
u
ality
in
th
e
well
-
b
ein
g
o
f
wo
m
en
o
n
a
g
lo
b
al
s
ca
le.
T
h
e
m
ea
n
s
o
f
tack
lin
g
s
ex
u
al
h
e
alth
,
with
d
etailed
in
p
u
ts
f
r
o
m
m
id
wiv
es
an
d
h
e
alth
s
y
s
tem
s
,
r
em
ain
v
ag
u
e.
Mo
r
eo
v
er
,
s
ex
u
al
h
ea
lth
is
o
f
ten
n
o
t
in
clu
d
ed
o
r
ad
d
r
ess
ed
in
in
ter
v
e
n
tio
n
s
an
d
ac
tio
n
s
o
n
r
ep
r
o
d
u
ctiv
e,
m
ater
n
al,
n
ewb
o
r
n
,
a
n
d
ch
ild
h
ea
lth
,
as
s
cien
tific
ev
id
en
ce
o
n
th
e
s
ex
u
al
h
ea
lth
n
ee
d
s
o
f
wo
m
en
d
u
r
i
n
g
an
te
n
atal
ca
r
e
is
n
o
n
ex
is
ten
t.
T
h
is
h
am
p
er
in
f
o
r
m
e
d
d
ec
is
io
n
-
m
ak
in
g
in
th
e
d
esig
n
an
d
im
p
lem
e
n
tatio
n
o
f
in
t
er
v
en
tio
n
s
an
d
ac
tio
n
s
ad
d
r
e
s
s
in
g
s
ex
u
al
h
ea
lth
d
u
r
in
g
a
n
ten
atal
ca
r
e.
T
h
e
a
b
s
en
ce
o
f
an
y
e
v
id
en
ce
s
talls
ef
f
o
r
ts
to
im
p
ac
t
laws
an
d
p
o
licies
o
n
s
ex
u
al
h
ea
lth
d
u
r
in
g
an
te
n
atal
ca
r
e.
As
a
r
es
u
lt,
wid
esp
r
ea
d
ig
n
o
r
an
ce
p
e
r
s
is
ts
o
n
th
e
s
ex
u
al
h
ea
lth
n
ee
d
s
an
d
ch
allen
g
es
o
f
wo
m
en
d
u
r
i
n
g
an
ten
atal
ca
r
e
an
d
o
n
th
e
m
ea
n
s
an
d
r
eso
u
r
ce
s
to
ad
d
r
ess
th
em
,
ev
en
am
o
n
g
p
r
o
f
ess
io
n
al
o
r
g
an
izatio
n
s
r
e
p
r
esen
tin
g
m
id
wiv
es a
n
d
th
o
s
e
wo
r
k
in
g
in
h
ea
lth
s
y
s
tem
s
[
1
9
]
,
[
2
0
]
.
3.
1
.
1
.
Def
ini
t
io
n a
nd
co
m
po
n
ent
s
o
f
s
ex
ua
l hea
lt
h
Sex
u
al
h
ea
lth
is
a
s
tate
o
f
p
h
y
s
ical,
m
en
tal,
a
n
d
s
o
ci
al
well
-
b
ein
g
r
elate
d
to
s
ex
u
ality
.
I
t
en
co
m
p
ass
es
m
o
r
e
th
a
n
th
e
a
b
s
en
ce
o
f
d
is
ea
s
e,
d
y
s
f
u
n
ctio
n
,
o
r
i
n
f
ir
m
ity
;
in
s
tead
,
it
e
m
p
h
asizes
a
p
o
s
itiv
e,
r
esp
ec
tf
u
l
ap
p
r
o
ac
h
to
s
ex
u
ali
ty
an
d
s
ex
u
al
r
elatio
n
s
h
ip
s
.
C
en
tr
al
to
th
is
is
th
e
en
h
an
ce
m
en
t
o
f
s
ex
u
al
h
ea
lth
,
wh
ich
ca
n
b
e
ac
h
iev
ed
th
r
o
u
g
h
v
ar
io
u
s
m
ea
n
s
,
s
u
ch
as
th
e
p
r
o
m
o
tio
n
o
f
b
etter
s
ex
u
al
h
ea
lth
an
d
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
p
r
e
v
en
ti
o
n
an
d
tr
ea
tm
e
n
t.
Ho
wev
er
,
s
ex
u
al
h
ea
lth
ca
n
also
b
e
p
u
t
at
r
is
k
,
e.
g
.
,
b
y
ad
v
er
s
e
s
o
cial
co
n
d
itio
n
s
,
s
tig
m
a,
v
io
len
ce
,
o
r
a
b
u
s
e.
As
h
ea
lth
is
an
in
teg
r
al
p
ar
t
o
f
p
e
o
p
le’
s
liv
es,
wid
esp
r
ea
d
s
cien
tific
co
n
s
en
s
u
s
r
ec
o
g
n
i
ze
s
s
ex
u
al
h
ea
lth
as
an
ess
en
tial
co
m
p
o
n
en
t
o
f
h
u
m
an
h
ea
lth
i
n
g
e
n
er
al
an
d
r
ep
r
o
d
u
cti
v
e
h
ea
lth
in
p
ar
ticu
lar
.
T
h
e
s
p
ec
ial
n
atu
r
e
o
f
s
ex
u
al
h
ea
l
th
an
d
th
e
f
r
ailty
o
f
th
e
s
itu
atio
n
o
f
s
o
m
e
g
r
o
u
p
s
h
a
v
e
co
n
tr
ib
u
ted
to
th
e
r
ec
o
g
n
itio
n
o
f
s
ex
u
al
h
ea
lth
as
a
h
u
m
an
r
ig
h
t.
T
h
is
h
as
b
ee
n
g
lo
b
al
s
in
ce
th
e
m
id
-
1
9
9
0
s
,
s
tar
tin
g
with
s
ig
n
if
ican
t
in
ter
n
atio
n
al
co
n
f
er
en
ce
s
.
Su
b
s
eq
u
en
tly
,
v
ar
i
o
u
s
o
r
g
an
izatio
n
s
h
av
e
ad
o
p
ted
h
u
m
a
n
r
ig
h
ts
in
s
tr
u
m
en
ts
s
u
p
p
o
r
tin
g
s
ex
u
al
h
ea
lth
.
Sex
u
al
h
ea
lth
c
o
m
p
o
n
en
ts
r
ec
o
g
n
ized
as
p
ar
t o
f
th
e
s
ex
u
al
h
ea
lth
co
n
ce
p
t
in
clu
d
e
p
r
o
n
en
e
s
s
to
well
-
b
ein
g
,
tr
ea
tm
en
t
f
o
r
d
is
ea
s
es
an
d
d
y
s
f
u
n
ctio
n
s
,
f
r
ee
an
d
en
jo
y
ab
le
s
ex
u
al
ac
tiv
ity
,
ac
ce
s
s
to
ac
cu
r
ate
in
f
o
r
m
atio
n
,
s
af
e
s
ex
(
esp
ec
ial
ly
r
eg
ar
d
in
g
u
n
wa
n
ted
p
r
eg
n
a
n
cies
an
d
s
ex
u
ally
tr
a
n
s
m
itted
in
f
ec
tio
n
s
(
STI
s
)
)
,
u
n
m
et
s
ex
u
al
n
ee
d
s
,
an
d
p
r
o
tectio
n
f
r
o
m
v
io
len
ce
,
co
er
ci
o
n
,
ab
u
s
e,
o
r
m
altr
ea
tm
e
n
t.
Ad
d
r
ess
in
g
s
ex
u
al
h
ea
lth
with
in
t
h
e
c
o
n
tex
t
o
f
an
ten
atal
ca
r
e
is
im
p
o
r
tan
t
f
o
r
ac
h
ie
v
in
g
g
lo
b
al
h
ea
lth
e
q
u
ity
.
Ne
v
er
th
eless
,
m
ee
tin
g
th
is
ta
r
g
et
r
em
ain
s
a
s
er
io
u
s
ch
allen
g
e
in
m
an
y
c
o
u
n
tr
ies,
with
m
o
th
er
s
an
d
th
ei
r
ch
ild
r
en
f
allin
g
to
d
ea
th
f
r
o
m
p
r
e
v
en
tab
le
ca
u
s
es d
u
r
in
g
p
r
e
g
n
an
c
y
an
d
p
o
s
tn
at
al
p
er
io
d
s
.
3.
1
.
2
.
Cha
lleng
es a
nd
ba
rr
iers t
o
a
dd
re
s
s
ing
s
ex
ua
l hea
lt
h in a
nte
na
t
a
l c
a
re
Nu
m
e
r
o
u
s
ch
a
ll
en
g
e
s
an
d
b
ar
r
ier
s
h
av
e
h
in
d
er
ed
th
e
ef
f
ec
t
i
v
e
ad
d
r
e
s
s
in
g
o
f
s
ex
u
a
l
h
ea
lt
h
co
n
ce
r
n
s
d
u
r
in
g
an
ten
a
ta
l
ca
r
e
v
i
s
i
t
s
.
O
n
an
in
d
iv
id
u
al
l
ev
e
l,
m
an
y
f
a
cto
r
s
co
n
tr
ib
u
t
e
t
o
th
i
s
.
F
ir
s
tl
y
,
th
e
s
e
n
s
i
tiv
e
an
d
tab
o
o
n
at
u
r
e
o
f
s
ex
u
al
h
ea
lth
is
s
u
e
s
d
i
s
co
u
r
a
g
e
s
wo
m
en
f
r
o
m
r
a
is
in
g
s
u
ch
to
p
i
c
s
[
2
1
]
.
W
o
m
en
f
r
o
m
l
o
w
er
s
o
c
io
e
co
n
o
m
ic
b
a
ck
g
r
o
u
n
d
s
o
r
th
o
s
e
w
ith
l
it
t
le
ed
u
c
at
io
n
m
ay
av
o
id
d
i
s
cu
s
s
in
g
s
ex
u
al
h
e
al
th
d
u
e
to
em
b
ar
r
a
s
s
m
en
t
o
r
ig
n
o
r
a
n
ce
ab
o
u
t
h
o
w
to
ap
p
r
o
ac
h
it
[
2
2
]
.
C
o
m
p
o
u
n
d
i
n
g
t
h
i
s
d
i
s
c
o
m
f
o
r
t
i
s
t
h
e
w
o
r
r
y
t
h
a
t
r
a
i
s
i
n
g
s
u
c
h
i
s
s
u
e
s
m
i
g
h
t
h
a
p
p
e
n
a
t
t
h
e
e
x
p
e
n
s
e
o
f
m
o
r
e
p
r
e
s
s
i
n
g
c
o
n
c
e
r
n
s
r
e
l
at
e
d
t
o
s
af
e
m
o
t
h
e
r
h
o
o
d
a
n
d
i
n
f
a
n
t
h
e
a
lt
h
,
c
o
n
s
i
d
e
r
e
d
m
o
r
e
a
c
c
e
p
t
a
b
l
e
t
o
p
i
cs
.
I
n
v
a
r
i
o
u
s
cu
l
t
u
r
e
s
a
n
d
s
o
ci
e
t
i
es
,
i
d
e
as
o
f
m
o
d
e
s
t
y
a
n
d
p
r
i
v
a
cy
s
e
v
e
r
e
l
y
r
es
t
r
i
ct
w
o
m
e
n
'
s
d
i
s
cu
s
s
i
o
n
o
f
s
u
c
h
t
o
p
i
c
s
,
e
v
e
n
w
it
h
o
t
h
e
r
w
o
m
e
n
.
C
o
n
s
e
q
u
e
n
t
ly
,
t
h
i
s
s
o
c
i
o
c
u
l
t
u
r
al
c
l
i
m
a
t
e
o
f
s
i
le
n
c
e
o
f
t
e
n
m
a
k
es
t
h
e
o
n
u
s
o
f
d
i
s
c
u
s
s
i
n
g
s
e
x
u
a
l
h
e
a
l
t
h
is
s
u
es
f
a
ll
o
n
h
e
a
l
t
h
c
a
r
e
p
r
o
v
i
d
e
r
s
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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t J Pu
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Hea
lth
Sci
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N:
2252
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8
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1361
Hea
lth
ca
r
e
p
r
o
v
id
er
s
,
to
o
,
f
ac
e
n
u
m
er
o
u
s
b
ar
r
ie
r
s
in
th
is
r
e
g
ar
d
.
T
h
ese
i
n
clu
d
e
lack
o
f
a
war
en
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p
o
o
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tr
ain
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g
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p
r
o
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id
e
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iase
s
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an
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m
is
p
er
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tio
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ab
o
u
t
wo
m
en
'
s
s
ex
u
al
h
ea
lth
n
ee
d
s
d
u
r
in
g
p
r
eg
n
a
n
cy
.
Ma
n
y
s
er
v
ice
p
r
o
v
id
e
r
s
v
iew
an
ten
atal
ca
r
e
as
a
p
u
r
ely
p
r
e
v
en
tiv
e
m
ea
s
u
r
e
f
o
cu
s
ed
o
n
m
ater
n
al
an
d
i
n
f
an
t
h
ea
lth
an
d
t
h
u
s
h
av
e
d
if
f
icu
lt
y
co
n
ce
p
tu
alizin
g
o
t
h
er
to
p
ic
s
as
r
elev
an
t
to
an
ten
atal
ca
r
e
v
is
its
.
T
h
o
s
e
wh
o
r
ec
o
g
n
ize
th
e
r
elev
a
n
ce
o
f
s
ex
u
al
h
ea
lth
is
s
u
es
m
ay
f
ea
r
th
at
s
u
ch
d
is
cu
s
s
io
n
s
wo
u
ld
d
is
tr
ac
t
atten
tio
n
f
r
o
m
m
o
r
e
p
r
ess
in
g
m
ate
r
n
al
a
n
d
i
n
f
an
t
h
ea
lth
c
o
n
ce
r
n
s
.
Dep
ar
ti
n
g
f
r
o
m
p
r
en
atal
ca
r
e
p
r
o
to
c
o
ls
to
d
is
cu
s
s
s
ex
u
al
h
ea
lth
m
ay
also
m
ak
e
s
er
v
ice
p
r
o
v
id
e
r
s
u
n
co
m
f
o
r
ta
b
le
d
u
e
t
o
th
e
s
en
s
itiv
e
n
atu
r
e
o
f
s
u
ch
to
p
ics.
Hea
lth
ca
r
e
p
r
o
v
id
e
r
s
in
lo
w
-
a
n
d
m
i
d
d
l
e
-
in
co
m
e
c
o
u
n
tr
ies
g
e
n
er
ally
r
ec
eiv
e
p
o
o
r
t
r
ain
in
g
c
o
n
ce
r
n
in
g
s
ex
u
al
h
ea
lth
,
o
f
ten
r
esu
ltin
g
in
a
lac
k
o
f
u
n
d
er
s
tan
d
in
g
o
f
b
asic
co
n
ce
p
ts
r
elate
d
to
s
ex
u
al
h
ea
lth
[
2
3
]
.
Mo
r
eo
v
er
,
s
er
v
ice
p
r
o
v
id
e
r
s
m
ay
p
o
s
s
ess
b
iases
th
at
s
h
ap
e
th
eir
in
ter
ac
tio
n
s
with
wo
m
en
,
in
clu
d
i
n
g
ag
e
-
r
elate
d
o
r
s
ter
eo
ty
p
e
b
iases
,
wh
ich
m
ay
f
u
r
th
er
d
et
er
th
em
f
r
o
m
ad
d
r
ess
in
g
th
es
e
is
s
u
es.
Ma
n
y
p
r
o
v
i
d
er
s
also
m
is
tak
en
ly
b
eliev
e
th
at
s
ex
u
al
h
ea
lth
d
is
cu
s
s
io
n
s
ar
e
u
n
n
ec
ess
ar
y
o
r
in
ap
p
r
o
p
r
i
ate
d
u
r
in
g
th
e
an
ten
atal
p
er
i
o
d
b
ec
au
s
e
th
ey
f
ee
l
th
at
all
wo
m
en
'
s
s
ex
u
al
p
r
o
b
le
m
s
ar
e
r
elate
d
to
d
eli
v
er
y
c
o
m
p
licatio
n
s
.
3.
2.
Curre
nt
pra
ct
ices a
nd
po
licies in a
nte
na
t
a
l c
a
re
T
h
e
W
o
r
ld
Hea
lth
O
r
g
an
izati
o
n
r
ec
o
m
m
en
d
s
at
least
eig
h
t
an
ten
atal
ca
r
e
co
n
tacts
f
o
r
al
l
p
r
eg
n
a
n
t
wo
m
en
to
en
s
u
r
e
a
s
af
e
p
r
e
g
n
an
cy
an
d
ch
il
d
b
ir
th
.
Ho
wev
e
r
,
o
v
er
h
alf
o
f
th
e
co
u
n
tr
ies
in
th
e
wo
r
ld
,
m
an
y
o
f
wh
ich
ar
e
in
l
o
w
-
a
n
d
m
id
d
l
e
-
in
co
m
e
r
eg
io
n
s
,
d
o
n
o
t
p
r
o
v
id
e
th
e
m
in
im
u
m
r
ec
o
m
m
e
n
d
ed
c
o
n
tact
v
is
its
.
Ma
n
y
co
u
n
tr
ies
d
o
n
o
t
u
n
iv
er
s
ally
p
r
o
v
i
d
e
f
o
u
r
v
is
its
as
a
m
in
im
u
m
.
Ma
n
y
c
o
u
n
tr
ie
s
in
E
u
r
o
p
e,
L
atin
Am
er
ica,
Oce
an
ia,
an
d
th
e
C
ar
ib
b
ea
n
d
o
n
o
t
en
s
u
r
e
f
o
u
r
v
is
its
.
I
n
ad
eq
u
ate
ac
ce
s
s
to
b
asic
an
ten
atal
ca
r
e
s
er
v
ices
in
cr
ea
s
es
th
e
r
is
k
s
f
o
r
wo
m
en
wh
o
h
av
e
p
r
e
g
n
an
c
y
co
m
p
licatio
n
s
,
b
i
r
th
c
o
m
p
licat
io
n
s
,
an
d
m
ater
n
al
an
d
f
etal
m
o
r
tality
[
2
4
]
.
L
o
w
tr
u
s
t
in
th
e
h
ea
lth
s
y
s
tem
,
lack
o
f
tr
an
s
p
o
r
tatio
n
,
h
ig
h
tr
av
el
co
s
ts
,
ea
r
ly
p
r
eg
n
a
n
cy
co
m
p
licatio
n
s
,
lo
n
g
d
is
tan
ce
s
to
h
ea
lth
ca
r
e
f
ac
ilit
ies,
p
o
v
er
ty
,
an
d
p
o
o
r
q
u
al
ity
o
f
ca
r
e
ar
e
th
e
m
ain
b
ar
r
ier
s
th
at
im
p
ed
e
g
r
e
ater
u
s
e
o
f
an
ten
atal
ca
r
e
s
er
v
ices.
C
er
tain
g
r
o
u
p
s
ar
e
esp
ec
ially
v
u
ln
er
ab
le
to
en
co
u
n
ter
i
n
g
th
ese
b
a
r
r
ier
s
:
th
e
r
ef
u
g
ee
p
o
p
u
latio
n
,
g
ir
ls
u
n
d
er
1
8
y
ea
r
s
o
ld
,
u
n
m
a
r
r
ied
m
o
th
er
s
,
an
d
w
o
m
en
d
iag
n
o
s
ed
with
a
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
[
2
5
]
.
I
n
2
0
0
9
,
th
e
ca
ll
was
m
ad
e
f
o
r
th
e
in
teg
r
atio
n
o
f
s
ex
u
al
h
ea
lth
s
er
v
ices
in
to
th
e
an
ten
atal
c
ar
e
m
o
d
el
to
p
r
o
m
o
te
a
co
n
tin
u
u
m
o
f
s
e
x
u
al
h
ea
lth
an
d
r
ep
r
o
d
u
ctiv
e
ca
r
e.
A
s
ex
u
al
h
ea
lth
s
er
v
ice
is
a
h
ea
lth
s
er
v
ice
th
at
p
r
o
v
id
es
in
f
o
r
m
atio
n
,
tr
e
atm
en
t,
o
r
ca
r
e
r
elate
d
to
s
ex
u
al
h
ea
lth
.
Sex
u
al
h
ea
lth
p
r
o
m
o
tio
n
h
as
b
ee
n
a
lo
n
g
s
tan
d
in
g
elem
en
t
o
f
an
ten
atal
ca
r
e
p
r
o
v
is
io
n
,
s
o
th
e
aim
o
f
t
h
is
m
o
d
el
is
lar
g
ely
t
o
en
h
an
ce
an
d
b
u
ild
o
n
ex
is
tin
g
s
er
v
ices.
T
h
e
u
s
e
o
f
an
ten
atal
ca
r
e
s
er
v
ices
is
h
ig
h
ly
s
tig
m
atize
d
,
esp
ec
ially
am
o
n
g
v
u
ln
er
a
b
le
p
o
p
u
latio
n
s
.
T
h
is
m
ak
es it v
it
al
to
p
r
o
m
o
te
r
esp
ec
t a
n
d
co
n
f
id
en
tiality
in
s
er
v
ice
p
r
o
v
is
io
n
co
n
tin
u
o
u
s
ly
.
T
h
is
p
r
o
p
o
s
al
s
ee
k
s
to
ex
p
lo
r
e
g
ap
s
in
th
e
p
r
o
v
is
io
n
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
s
er
v
ices d
u
r
in
g
an
ten
atal
ca
r
e.
A
s
y
s
tem
atic
r
ev
iew
o
f
av
aila
b
le
liter
atu
r
e
o
n
th
e
d
ef
in
ed
s
ex
u
al
h
ea
lth
s
er
v
ice
c
o
m
p
o
n
e
n
ts
in
clu
d
ed
h
ea
lth
s
y
s
tem
tr
ain
in
g
f
o
r
an
te
n
atal
ca
r
e
p
r
o
v
id
e
r
s
,
s
cr
ee
n
in
g
f
o
r
s
ex
u
ally
tr
a
n
s
m
itted
in
f
ec
ti
o
n
s
,
s
cr
ee
n
in
g
f
o
r
d
o
m
esti
c
v
io
len
ce
,
in
f
o
r
m
atio
n
o
n
f
am
ily
p
lan
n
in
g
,
an
d
t
h
e
p
r
o
v
is
io
n
o
f
n
o
n
-
in
v
asiv
e
co
n
t
r
ac
ep
tiv
e
m
eth
o
d
s
.
3
.
2
.
1
.
O
v
er
v
iew
o
f
a
nte
na
t
a
l
ca
re
s
er
v
ices
An
ten
atal
ca
r
e
s
er
v
ices
co
n
tr
ib
u
te
to
im
p
r
o
v
ed
m
ater
n
al
h
e
alth
.
I
n
th
e
p
o
s
t
-
2
0
1
5
e
r
a
o
f
t
h
e
g
lo
b
al
co
m
m
itm
en
t
t
o
s
u
s
tain
ab
le
d
e
v
elo
p
m
en
t
g
o
als
,
co
u
n
tr
ies
tar
g
et
at
least 7
0
%
o
f
p
r
eg
n
a
n
t
w
o
m
en
r
ec
eiv
in
g
th
e
r
ec
o
m
m
en
d
ed
m
in
im
u
m
o
f
e
ig
h
t
an
ten
atal
ca
r
e
v
is
its
d
u
r
i
n
g
p
r
eg
n
a
n
cy
.
Kee
p
in
g
in
v
iew
th
e
d
esire
a
n
d
s
u
s
tain
ab
ilit
y
o
f
th
e
g
lo
b
al
c
o
m
m
itm
en
t,
p
r
o
g
r
ess
m
ad
e
b
y
1
3
7
c
o
u
n
tr
ies
to
war
d
an
te
n
atal
ca
r
e
s
er
v
ices
an
d
th
eir
in
f
lu
en
ce
o
n
m
ater
n
al
h
e
alth
tar
g
ets h
av
e
b
ee
n
ass
ess
e
d
.
Utilizatio
n
o
f
an
ten
atal
ca
r
e
s
er
v
ices
:
75%
o
f
m
o
th
er
s
wh
o
d
eliv
er
ed
liv
e
b
ir
th
s
in
th
e
t
h
r
ee
y
ea
r
s
p
r
ec
ed
in
g
th
e
d
em
o
g
r
ap
h
ic
a
n
d
h
ea
lth
s
u
r
v
ey
s
h
a
v
e
ac
ce
s
s
ed
an
ten
atal
ca
r
e
s
er
v
ices
in
th
e
s
tu
d
y
co
u
n
tr
ies
(
r
an
g
in
g
f
r
o
m
9
to
9
9
%
)
[
2
6
]
.
R
ec
eiv
in
g
f
o
u
r
o
r
m
o
r
e
an
ten
atal
ca
r
e
v
is
its
is
a
co
m
m
o
n
b
en
ch
m
a
r
k
co
n
s
id
er
ed
ad
eq
u
ate
ca
r
e.
Glo
b
ally
,
m
o
th
er
s
wh
o
d
eliv
er
e
d
th
eir
m
o
s
t
r
ec
en
t
liv
e
b
ir
th
h
av
e
b
ee
n
m
o
r
e
lik
ely
to
r
ec
eiv
e
f
o
u
r
o
r
m
o
r
e
a
n
ten
atal
ca
r
e
v
is
its
(
6
4
%
)
t
h
an
t
h
o
s
e
wh
o
d
eliv
er
ed
with
in
1
–
2
y
ea
r
s
o
r
2
–
3
y
ea
r
s
b
ef
o
r
e
t
h
e
s
u
r
v
e
y
(
5
8
an
d
4
5
%
,
r
esp
ec
tiv
ely
)
[
2
7
]
.
Dim
en
s
io
n
s
o
f
an
ten
atal
ca
r
e
s
er
v
ices:
Alth
o
u
g
h
a
n
ten
atal
ca
r
e
s
er
v
ice
u
tili
za
tio
n
ta
r
g
e
ts
ar
e
n
o
t
u
n
if
o
r
m
ly
d
e
f
in
ed
i
n
all
co
u
n
tr
ies,
p
r
o
g
r
ess
to
war
d
m
u
ltip
l
e
d
im
en
s
io
n
s
o
f
an
ten
atal
ca
r
e
s
er
v
ices
h
as
b
ee
n
ass
es
s
ed
in
1
1
1
c
o
u
n
tr
ies
wit
h
d
ata
f
r
o
m
th
e
r
ec
en
t
d
em
o
g
r
ap
h
ic
an
d
h
ea
lth
s
u
r
v
ey
s
o
r
m
u
ltip
le
i
n
d
icato
r
clu
s
ter
s
u
r
v
ey
s
.
T
h
ese
d
im
en
s
io
n
s
ar
e
b
ased
o
n
s
er
v
ices
r
ec
o
m
m
en
d
e
d
b
y
th
e
W
o
r
ld
Hea
lth
Or
g
an
izatio
n
(
W
HO)
.
I
n
2
0
5
0
,
it
is
p
r
o
jecte
d
th
at
an
ten
atal
ca
r
e
s
er
v
ice
r
ec
o
m
m
en
d
atio
n
s
will
b
e
m
et
b
y
4
1
5
(
2
7%
)
o
u
t
o
f
1
,
5
1
0
m
illi
o
n
co
u
p
les
in
d
e
v
elo
p
in
g
r
eg
io
n
s
with
cu
r
r
en
t
c
o
n
d
itio
n
s
,
wh
ile
7
3
2
m
illi
o
n
c
o
u
p
les
in
d
ev
elo
p
in
g
co
u
n
tr
ies m
ig
h
t la
c
k
th
e
r
ec
o
m
m
en
d
ed
an
ten
atal
ca
r
e
s
er
v
ices [
2
8
]
.
3.
2
.
2
.
I
nte
g
ra
t
io
n o
f
s
ex
ua
l hea
lt
h serv
ices
Desp
ite
in
cr
ea
s
ed
r
ec
o
g
n
itio
n
o
f
s
ex
u
al
h
ea
lth
an
d
th
e
im
p
o
r
tan
ce
o
f
p
r
e
v
en
tin
g
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
s
d
u
r
in
g
p
r
eg
n
an
cy
,
m
o
s
t
co
u
n
tr
ies
d
o
n
o
t
i
n
teg
r
ate
th
ese
s
er
v
ices
wit
h
in
an
ten
atal
ca
r
e.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
3
,
Sep
tem
b
er
20
25
:
1
3
5
7
-
1
3
6
6
1362
Fu
r
th
er
m
o
r
e
,
s
ex
u
al
h
ea
lth
s
er
v
ices
ar
e
r
ar
ely
in
teg
r
ated
with
f
am
ily
p
lan
n
in
g
an
d
r
ep
r
o
d
u
ctiv
e
h
ea
lth
s
er
v
ices,
wh
ich
ar
e
wid
ely
r
e
co
g
n
ized
as
co
m
p
lem
en
tar
y
.
Desp
ite
d
esig
n
atin
g
th
e
clo
s
est
h
ea
lth
f
ac
ilit
y
as
th
e
f
ir
s
t
p
o
in
t
o
f
ca
r
e,
th
e
s
itu
atio
n
is
ex
ac
er
b
ated
b
ec
au
s
e,
in
m
an
y
co
u
n
tr
ies,
p
r
e
g
n
an
t
wo
m
en
d
o
n
o
t
s
ee
k
ca
r
e
u
n
til th
e
f
o
u
r
th
m
o
n
t
h
o
r
later
in
th
e
p
r
e
g
n
an
c
y
,
wh
e
n
r
i
s
k
s
f
o
r
co
m
p
licatio
n
s
an
d
m
o
r
tality
in
cr
ea
s
e.
I
n
B
r
az
il,
f
o
r
in
s
tan
ce
,
alth
o
u
g
h
an
ten
atal
ca
r
e
c
o
n
s
u
ltatio
n
s
ar
e
in
itiated
ea
r
ly
in
th
e
p
r
eg
n
a
n
cy
,
alm
o
s
t
h
alf
o
f
th
em
d
o
n
o
t
h
ap
p
en
d
u
r
in
g
t
h
e
f
ir
s
t
tr
im
ester
,
o
p
en
i
n
g
a
win
d
o
w
o
f
o
p
p
o
r
tu
n
ity
f
o
r
a
lar
g
e
n
u
m
b
er
o
f
in
f
ec
tio
n
s
an
d
p
r
e
v
en
tab
le
d
ea
th
s
[
2
9
]
.
Mo
r
eo
v
er
,
an
ten
atal
ca
r
e
s
er
v
ices
m
a
y
b
e
a
p
a
r
ticu
lar
ly
s
u
itab
le
v
en
u
e
f
o
r
s
ex
u
ally
tr
an
s
m
itted
in
f
ec
tio
n
-
r
elate
d
in
ter
v
en
tio
n
s
,
as
th
e
y
h
av
e
th
e
p
o
ten
tial
to
r
ea
ch
wo
m
en
at
r
is
k
wh
o
wo
u
ld
o
t
h
er
wis
e
n
o
t
atten
d
s
ex
u
al
h
ea
lth
s
er
v
ices.
E
ar
ly
ac
ce
s
s
is
cr
u
cial
f
o
r
ef
f
ec
tiv
e
p
h
ar
m
ac
o
l
o
g
ic
m
an
a
g
em
en
t,
a
n
d
an
ten
atal
ca
r
e
g
en
e
r
ally
o
c
cu
r
s
d
u
r
in
g
th
e
f
i
r
s
t tr
im
ester
o
f
p
r
e
g
n
an
c
y
.
I
n
a
m
u
ltil
ev
el
r
eg
r
ess
io
n
m
o
d
el,
r
esu
lts
s
h
o
wed
th
at
th
e
p
r
o
b
ab
ilit
y
o
f
p
r
e
g
n
an
t
wo
m
en
o
u
ts
id
e
m
ar
r
iag
e
u
tili
zin
g
h
ea
lth
s
er
v
ices
d
u
r
in
g
th
e
f
ir
s
t
tr
im
ester
co
m
p
ar
ed
to
m
ar
r
ied
wo
m
en
was
lo
w.
Fu
r
th
er
m
o
r
e
,
n
o
c
o
n
tr
ac
e
p
tiv
e
m
eth
o
d
u
s
ed
b
ef
o
r
e
th
e
c
u
r
r
en
t
p
r
eg
n
a
n
cy
in
d
icate
d
a
s
u
b
s
tan
tially
lo
w
p
r
o
b
a
b
ilit
y
o
f
ea
r
ly
a
n
ten
atal
ca
r
e
u
tili
za
tio
n
.
I
n
co
u
n
tr
ies
with
lo
w
an
ten
atal
ca
r
e
u
tili
za
tio
n
am
o
n
g
th
e
p
o
o
r
an
d
u
n
e
d
u
ca
ted
,
i
n
teg
r
atin
g
s
ex
u
al
h
ea
lth
s
er
v
ices
in
to
an
t
en
atal
ca
r
e
co
u
ld
b
e
an
o
p
p
o
r
tu
n
ity
to
p
r
o
v
id
e
th
ese
wo
m
en
with
th
eir
f
ir
s
t a
n
ten
atal
ca
r
e
v
is
it [
3
0
]
.
W
o
m
e
n
wh
o
b
ec
a
m
e
p
r
e
g
n
an
t
u
n
in
te
n
tio
n
ally
wer
e
also
less
l
ik
ely
to
s
ee
k
ea
r
ly
ca
r
e.
T
h
is
em
p
h
asizes
th
e
n
ee
d
f
o
r
im
p
r
o
v
ed
ac
ce
s
s
to
f
am
ily
p
lan
n
in
g
s
er
v
ices
to
p
r
ev
en
t
u
n
wan
ted
p
r
eg
n
an
cies.
3.
3
.
G
l
o
ba
l
dis
pa
rit
ies in sex
ua
l hea
lt
h pro
v
is
io
n duri
ng
a
nte
na
t
a
l c
a
re
Sex
u
al
h
ea
lth
an
d
well
-
b
ein
g
p
r
o
v
is
io
n
d
u
r
in
g
an
te
n
atal
ca
r
e
is
k
ey
in
im
p
r
o
v
in
g
m
at
er
n
al
an
d
n
ewb
o
r
n
h
ea
lth
.
Ho
wev
er
,
g
l
o
b
al
d
is
p
ar
ities
ex
is
t.
R
ec
o
g
n
izin
g
s
u
ch
in
eq
u
ality
is
th
e
f
ir
s
t
s
tep
in
ac
h
iev
in
g
u
n
iv
er
s
al
h
ea
lth
p
r
o
v
is
io
n
.
T
h
er
e
ar
e
s
ev
er
al
ex
is
tin
g
tr
en
d
s
in
th
e
tr
ea
tm
en
t
o
f
s
ex
u
al
h
e
alth
an
d
well
-
b
ein
g
ac
r
o
s
s
th
e
g
lo
b
e.
T
h
e
f
ir
s
t
tr
e
n
d
is
th
at
wo
m
en
in
h
ig
h
-
i
n
c
o
m
e
co
u
n
tr
ies
ar
e
m
o
r
e
lik
ely
to
r
ec
eiv
e
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
ca
r
e
d
u
r
in
g
a
n
ten
atal
v
is
its
th
an
w
o
m
en
in
lo
w
-
in
co
m
e
co
u
n
tr
ie
s
.
T
h
is
d
is
cr
ep
an
cy
r
an
g
es
g
r
ea
tly
b
y
r
eg
io
n
,
b
ei
n
g
m
o
s
t
ev
id
en
t
in
E
ast
Asi
a
an
d
th
e
Pacif
ic.
T
h
e
s
ec
o
n
d
tr
en
d
is
th
at
s
ex
u
al
h
ea
lth
p
r
o
v
is
io
n
is
in
v
er
s
ely
r
elate
d
to
p
r
e
g
n
an
c
y
r
is
k
f
a
cto
r
s
.
Pre
g
n
an
cies
th
at
m
ig
h
t
r
esu
lt
in
ad
v
er
s
e
o
u
tco
m
es,
s
u
ch
as
b
ein
g
to
o
y
o
u
n
g
o
r
to
o
o
ld
,
b
ein
g
s
u
b
je
cted
to
v
io
len
ce
,
o
r
u
n
i
n
ten
d
e
d
p
r
eg
n
a
n
cies,
ar
e
less
lik
ely
to
r
ec
eiv
e
s
ex
u
al
h
ea
lth
tr
ea
tm
en
t d
u
r
in
g
an
ten
atal
ca
r
e.
L
astl
y
,
a
wo
m
an
’
s
wea
lth
is
a
m
ajo
r
f
ac
to
r
in
wh
eth
er
s
h
e
r
ec
eiv
es
s
ex
u
a
l
h
ea
lth
ca
r
e
d
u
r
in
g
a
n
ten
atal
v
is
its
.
W
ea
lth
ier
an
d
m
o
r
e
ed
u
ca
ted
wo
m
e
n
a
r
e
m
u
ch
m
o
r
e
lik
ely
to
r
ec
eiv
e
s
ex
u
al
h
ea
lth
a
n
d
well
-
b
ein
g
tr
ea
tm
en
t d
u
r
in
g
an
ten
atal
ca
r
e.
T
h
er
e
is
s
ig
n
if
ican
t
r
eg
io
n
al
v
ar
iatio
n
in
th
e
p
r
o
v
is
io
n
o
f
s
ex
u
al
h
ea
lth
ca
r
e
an
d
well
-
b
ein
g
s
er
v
ices
in
an
ten
atal
ca
r
e
g
lo
b
ally
.
Pr
io
r
r
esear
ch
h
as
s
h
o
wn
t
h
at
HI
V
-
in
f
ec
ted
wo
m
en
in
an
te
n
atal
ca
r
e
in
lo
w
-
in
co
m
e
co
u
n
t
r
ies,
as
well
a
s
a
d
o
lescen
ts
in
h
ig
h
-
in
co
m
e
co
u
n
tr
ies,
ar
e
less
lik
ely
to
h
av
e
th
eir
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
ass
ess
ed
,
b
u
t
t
h
is
h
as
n
o
t
b
ee
n
ex
am
i
n
ed
w
o
r
ld
wid
e
f
o
r
b
r
o
ad
s
ex
u
al
h
e
alth
an
d
well
-
b
ein
g
ass
es
s
m
en
ts
.
T
h
e
is
s
u
e
in
d
ex
ad
d
r
ess
es th
e
'
g
r
ea
test
g
ap
'
is
s
u
e
b
ased
o
n
g
eo
g
r
ap
h
ical
r
eg
i
o
n
.
W
o
m
en
in
h
ig
h
-
in
co
m
e
c
o
u
n
tr
ies
a
r
e
m
o
r
e
lik
ely
to
r
ec
eiv
e
ca
r
e
th
an
wo
m
e
n
in
lo
w
-
in
c
o
m
e
c
o
u
n
tr
ies.
T
h
is
d
if
f
er
en
ce
ex
is
ts
ac
r
o
s
s
all
f
o
u
r
r
eg
io
n
al
in
co
m
e
ca
teg
o
r
izatio
n
s
an
d
is
m
o
s
t
ev
id
en
t
in
th
e
E
ast
Asi
a
an
d
Pacif
ic
r
eg
io
n
s
.
T
h
er
e
ar
e
ex
am
p
les
o
f
h
av
in
g
s
u
f
f
icien
t
s
er
v
ices
u
n
iv
er
s
ally
av
ailab
le,
s
u
ch
as
in
So
u
th
e
ast
Asi
a.
T
h
er
e
ar
e
also
ex
am
p
les
o
f
h
av
in
g
v
er
y
lim
ited
ac
ce
s
s
in
ev
er
y
co
u
n
tr
y
to
s
ex
u
al
h
ea
lth
an
d
well
-
b
e
in
g
p
r
o
v
is
io
n
,
s
u
ch
as
in
L
ib
y
a,
Su
d
an
,
an
d
So
m
alia.
Un
d
er
s
tan
d
in
g
r
eg
i
o
n
a
l
p
atter
n
s
in
s
er
v
ice
p
r
o
v
is
io
n
m
ay
h
elp
ex
p
lain
v
ar
iatio
n
s
in
test
in
g
in
d
icato
r
s
an
d
ass
is
t in
ad
d
r
ess
in
g
th
e
m
o
s
t d
is
ad
v
an
tag
ed
p
o
p
u
latio
n
s
.
T
h
e
s
o
cio
ec
o
n
o
m
ic
p
atter
n
in
g
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ei
n
g
p
r
o
v
is
io
n
in
a
n
ten
atal
ca
r
e
tak
es
o
n
th
e
f
o
r
m
o
f
th
e
'
in
v
er
s
e
tr
ea
t
m
en
t'
p
atter
n
,
wh
ich
h
as
b
ee
n
d
o
cu
m
en
ted
in
o
th
er
ar
ea
s
o
f
m
ater
n
al
ca
r
e.
T
h
is
f
in
d
in
g
s
u
g
g
ests
th
at
wo
m
en
’
s
v
is
its
to
an
ten
atal
ca
r
e
h
av
e
lo
wer
o
d
d
s
o
f
a
n
y
s
ex
u
al
h
e
alth
an
d
well
-
b
ein
g
ca
r
e
b
u
t
h
ig
h
er
o
d
d
s
o
f
r
ec
e
iv
in
g
d
is
cu
s
s
io
n
s
o
n
co
n
tr
ac
ep
tio
n
.
T
h
e
p
atter
n
is
s
im
ilar
ly
s
ee
n
with
s
o
m
e
p
r
eg
n
a
n
cy
r
is
k
f
ac
t
o
r
s
s
u
ch
as
m
ater
n
al
ag
e,
v
io
le
n
ce
,
an
d
u
n
in
ten
d
ed
p
r
eg
n
an
cy
.
T
h
i
s
co
n
ce
p
t
o
p
e
r
ates
with
in
two
d
if
f
er
en
t
m
ec
h
an
is
m
s
.
L
ess
f
o
r
tu
n
ate
wo
m
en
ar
e
m
o
r
e
at
r
is
k
an
d
,
th
er
e
f
o
r
e,
l
ess
lik
ely
to
ac
ce
s
s
ad
eq
u
ate
s
er
v
ices.
Alter
n
ativ
ely
,
h
ea
lth
s
er
v
ices
m
ig
h
t
o
p
er
ate
in
a
'
cr
is
i
s
m
o
d
el'
th
at
tr
e
ats
wo
m
en
o
n
ly
in
r
ea
ctio
n
to
im
m
ed
iate,
s
ev
e
r
e
h
ea
lth
n
ee
d
s
r
ath
e
r
th
an
an
ticip
atin
g
a
n
d
p
r
ev
en
tin
g
n
eg
ativ
e
h
ea
lt
h
co
n
s
eq
u
en
ce
s
.
T
h
e
s
o
cio
ec
o
n
o
m
ic
v
ar
iatio
n
s
in
s
ex
u
al
h
ea
l
th
an
d
well
-
b
ein
g
p
r
o
v
is
io
n
d
u
r
in
g
an
ten
atal
ca
r
e
u
n
co
v
e
r
ed
h
e
r
e
ca
n
h
elp
f
o
r
m
th
e
b
asis
f
o
r
ad
d
r
ess
in
g
g
a
p
s
,
as
th
ese
b
ar
r
ier
s
h
ig
h
lig
h
t
wh
er
e
th
e
g
r
ea
test
in
v
estme
n
t
in
r
esear
ch
an
d
h
e
alth
s
y
s
tem
s
s
tr
en
g
th
en
in
g
is
war
r
an
ted
to
ac
h
iev
e
u
n
iv
er
s
a
l
h
ea
lth
co
v
er
ag
e
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
.
3.
3
.
1
.
Reg
io
na
l
d
is
pa
rit
ies
C
o
n
ce
r
n
in
g
s
ex
u
al
h
ea
lth
,
a
n
ten
atal
r
is
k
ass
es
s
m
en
t
,
an
d
tr
ea
tm
en
t
(
AR
T
)
in
clu
d
es
a
r
an
g
e
o
f
h
ea
lth
ca
r
e
p
r
o
ce
s
s
es,
s
u
ch
as
th
e
r
o
u
tin
e
i
n
q
u
ir
y
th
at
m
i
d
wiv
es
m
ak
e
ab
o
u
t
m
ar
ital
s
tatu
s
an
d
in
tim
ate
r
elatio
n
s
h
ip
s
d
u
r
in
g
an
ten
atal
ca
r
e.
T
h
is
m
ay
co
n
ce
r
n
wh
e
th
er
th
eir
p
ar
t
n
er
is
co
n
tr
o
llin
g
an
d
wh
eth
e
r
th
e
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
S
ex
u
a
l h
e
a
lth
a
n
d
w
ell
-
b
ein
g
d
u
r
in
g
a
n
ten
a
ta
l c
a
r
e:
a
d
d
r
ess
in
g
g
lo
b
a
l
g
a
p
s
in
…
(
K
a
b
ir
u
A
b
u
b
a
ka
r
Gu
lma
)
1363
r
elatio
n
s
h
ip
is
a
s
o
u
r
ce
o
f
p
lea
s
u
r
e
o
r
ev
en
a
b
u
s
e.
An
o
th
e
r
ar
ea
o
f
AR
T
is
s
af
e
s
ex
n
eg
o
tiatio
n
an
d
p
r
ev
en
tiv
e
m
ea
s
u
r
es,
in
clu
d
in
g
c
o
n
d
o
m
u
s
e
to
av
o
id
i
n
f
ec
tio
n
tr
an
s
m
is
s
io
n
an
d
u
n
wan
ted
p
r
e
g
n
an
cies.
Fu
r
th
er
m
o
r
e,
AR
T
in
clu
d
es
q
u
er
ies
a
n
d
g
u
i
d
an
ce
o
n
r
ep
r
o
d
u
ctiv
e
co
er
cio
n
an
d
u
n
p
lan
n
e
d
p
r
eg
n
an
cies,
in
p
ar
ticu
lar
,
wh
e
n
u
n
d
er
s
co
r
i
n
g
o
b
lig
atio
n
s
an
d
r
is
k
s
d
u
e
to
u
n
wan
te
d
p
r
e
g
n
an
cies o
r
ch
ild
d
ea
th
[
3
1
]
.
AR
T
is
p
r
o
v
id
ed
d
if
f
er
e
n
tly
o
n
a
g
lo
b
al
s
ca
le,
s
ig
n
if
ican
tl
y
im
p
ac
tin
g
wo
m
e
n
in
ter
m
s
o
f
s
ex
u
al
well
-
b
ein
g
.
Ma
n
y
m
id
wiv
es
in
h
ig
h
-
in
co
m
e
co
u
n
tr
ies
ca
r
r
y
o
u
t
AR
T
in
lin
e
with
g
o
v
er
n
m
en
t
-
s
p
o
n
s
o
r
ed
g
u
id
elin
es
an
d
p
r
o
f
ess
io
n
al
co
d
es
o
f
co
n
d
u
ct
with
in
wel
l
-
r
eg
u
lated
p
u
b
lic
h
ea
lth
ca
r
e
in
s
titu
tio
n
s
,
wh
ich
d
ev
o
te
co
n
s
id
er
a
b
le
r
eso
u
r
ce
s
to
ad
eq
u
ately
co
m
p
ly
with
p
r
o
v
is
io
n
s
[
3
2
]
.
Ho
wev
e
r
,
in
m
a
n
y
s
ettin
g
s
in
lo
w
-
in
co
m
e
co
u
n
t
r
ies,
AR
T
is
n
o
t
p
r
o
v
id
e
d
as
a
r
o
u
tin
e
ca
r
e
p
r
o
ce
s
s
b
u
t
is
allo
wed
o
n
ly
v
o
lu
n
tar
ily
at
th
e
wo
m
an
'
s
r
eq
u
est.
Mid
wiv
es
w
is
h
to
ad
d
r
ess
is
s
u
es
as
p
r
o
b
lem
s
,
as
th
e
is
s
u
es
ar
e
n
o
t
s
o
lel
y
b
etwe
en
wo
m
en
an
d
th
eir
p
ar
tn
er
s
b
u
t c
o
n
ce
r
n
b
o
th
p
ast an
d
p
r
esen
t
r
elatio
n
s
h
ip
s
at
a
m
o
r
e
g
en
er
al
s
o
cial
a
n
d
cu
ltu
r
al
le
v
el.
I
t
h
as
b
ee
n
ar
g
u
ed
t
h
at
th
e
g
o
als
o
f
g
u
id
elin
es
f
o
r
r
o
u
tin
e
in
q
u
ir
y
a
r
e
m
ain
ly
to
h
elp
wo
m
en
ac
ce
s
s
n
ee
d
ed
s
u
p
p
o
r
t.
I
n
c
o
n
tr
ast,
i
m
p
lem
en
tin
g
t
h
e
g
u
i
d
elin
es
h
as
b
ee
n
s
u
g
g
ested
to
f
o
cu
s
n
a
r
r
o
wly
o
n
av
o
id
in
g
b
lam
e
an
d
r
esp
o
n
s
ib
ilit
y
an
d
,
th
er
eb
y
,
in
d
ir
ec
tly
,
o
n
av
o
i
d
i
n
g
h
elp
in
g
wo
m
en
in
n
ee
d
.
Mid
wiv
es
m
ay
th
i
n
k
o
f
AR
T
as
r
is
k
m
an
ag
em
en
t
in
ter
m
s
o
f
m
ater
n
al
an
d
ch
ild
h
ea
lth
,
av
o
id
in
g
b
lam
e
f
o
r
p
o
o
r
o
u
tc
o
m
es,
an
d
b
ein
g
ab
le
to
co
p
e
with
is
s
u
es wh
en
th
e
s
af
ety
o
f
th
e
wo
m
a
n
h
er
s
elf
is
co
n
ce
r
n
e
d
.
Ho
wev
er
,
th
e
n
o
n
-
s
af
ety
o
f
ca
s
u
al
as
well
a
s
m
ar
ital
r
elatio
n
s
h
ip
s
ex
p
er
ien
ce
d
b
y
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m
en
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u
r
i
n
g
p
r
eg
n
a
n
cy
an
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later
m
o
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h
o
o
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is
a
s
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r
ce
o
f
d
is
tr
ess
f
o
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th
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ch
ild
r
en
o
f
th
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i
n
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iv
id
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als
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d
c
o
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tr
ain
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ities
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ter
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eso
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r
ce
s
an
d
d
ec
is
io
n
-
m
ak
i
n
g
p
o
w
er
[
1
6
]
.
T
h
e
is
s
u
es
ad
d
r
ess
ed
b
y
AR
T
ar
e
p
r
o
m
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en
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in
co
n
tem
p
o
r
ar
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g
l
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b
al
h
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lth
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d
d
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m
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t
ag
en
d
as,
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co
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y
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en
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d
f
o
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ac
h
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e
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er
eq
u
ality
.
3.
3
.
2
.
So
cio
ec
o
no
m
ic
f
a
c
t
o
rs
Acc
ess
to
s
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u
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h
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lth
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ein
g
s
er
v
ices
d
u
r
in
g
a
n
ten
atal
ca
r
e
is
f
u
r
th
er
co
m
p
licated
b
y
n
atio
n
al
wea
lth
an
d
in
eq
u
ality
.
A
c
o
u
n
tr
y
’
s
wea
lth
an
d
in
co
m
e
in
eq
u
ality
im
p
ac
t
th
e
d
ev
e
lo
p
m
en
t
o
f
p
o
licies
th
at
s
u
p
p
o
r
t,
p
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o
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i
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e,
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d
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m
o
te
s
ex
u
al
h
ea
lth
a
n
d
well
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ein
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er
v
ices.
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wea
lth
was
ass
o
ciate
d
with
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u
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h
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lth
an
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o
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ly
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m
id
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le
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o
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e
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o
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ies.
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th
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u
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ies,
t
h
e
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lth
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al
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tile
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ig
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er
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s
th
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est
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lo
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o
v
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d
itio
n
ally
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atio
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al
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lth
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o
ciate
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with
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al
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er
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q
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e
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in
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f
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ec
to
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s
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ity
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ciate
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with
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b
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ec
to
r
o
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ly
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co
u
n
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ies
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ad
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h
e
h
ig
h
est
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atio
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al
wea
lth
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n
d
n
ea
r
ly
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u
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tr
ies
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al
h
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lth
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er
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u
r
in
g
an
ten
atal
ca
r
e
,
an
d
th
e
h
i
g
h
est
lev
el
o
f
p
r
o
v
is
io
n
f
o
r
all
ty
p
es
o
f
s
er
v
ices
b
y
th
e
o
v
er
all
p
r
o
v
id
er
s
ec
to
r
.
I
n
co
n
tr
ast,
lo
w
-
in
c
o
m
e
an
d
lo
wer
-
m
id
d
le
-
in
c
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m
e
co
u
n
tr
ies
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ad
th
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lo
west
n
atio
n
al
wea
lth
,
an
d
o
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ly
a
s
m
all
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n
tag
e
o
f
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es
e
co
u
n
tr
ies
p
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id
e
d
s
ex
u
al
h
ea
lth
an
d
well
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ein
g
s
er
v
ices
d
u
r
in
g
a
n
ten
atal
ca
r
e.
Fem
ale
ed
u
ca
tio
n
r
em
ain
ed
p
o
s
itiv
ely
ass
o
ciate
d
with
s
ex
u
al
h
ea
lth
an
d
well
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s
er
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p
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v
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n
at
t
h
e
g
lo
b
al
an
d
r
e
g
io
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al
le
v
el
s
,
in
d
icatin
g
t
h
at
co
u
n
tr
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with
h
ig
h
er
f
em
ale
ed
u
ca
tio
n
ar
e
m
o
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e
lik
ely
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p
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v
id
e
s
ex
u
al
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ea
lth
an
d
well
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b
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g
s
er
v
ices d
u
r
in
g
a
n
ten
ata
l c
ar
e.
3.
4
.
Str
a
t
eg
ies
f
o
r
i
m
pro
v
in
g
s
ex
ua
l hea
lt
h a
nd
well
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bei
ng
in a
nte
na
t
a
l c
a
re
T
r
a
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n
i
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a
n
d
e
d
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c
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t
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r
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n
t
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a
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h
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t
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a
n
d
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n
g
d
u
r
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n
g
a
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t
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t
a
l
c
a
r
e
.
H
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cr
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f
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s
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d
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k
s
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s
ex
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ig
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t
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m
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icati
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with
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lth
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s
.
Ad
d
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m
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tial
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tiv
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m
en
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f
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to
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an
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E
n
g
ag
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g
h
u
s
b
a
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d
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d
f
am
ily
m
em
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ab
o
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en
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s
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s
ee
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eh
av
io
r
ca
n
h
elp
r
ed
u
ce
v
i
o
len
ce
an
d
d
is
cr
im
in
atio
n
i
n
f
am
ilies
.
I
n
itiativ
es
tar
g
etin
g
c
o
m
m
u
n
ities
o
u
ts
id
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h
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lth
ca
r
e
s
ettin
g
s
ar
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n
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s
s
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y
to
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aise
awa
r
en
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ab
o
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t
s
ex
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al
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ea
lth
a
n
d
r
ig
h
ts
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p
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m
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r
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p
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id
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v
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s
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p
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ter
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to
s
tr
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g
th
en
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m
en
'
s
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tio
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to
an
ten
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I
n
v
o
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in
g
f
am
ilies
,
co
m
m
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ities
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d
m
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in
s
ex
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s
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s
cr
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h
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q
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n
ten
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ca
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an
d
p
r
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o
n
ce
p
tio
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h
ea
lth
s
er
v
ices.
Evaluation Warning : The document was created with Spire.PDF for Python.
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6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
3
,
Sep
tem
b
er
20
25
:
1
3
5
7
-
1
3
6
6
1364
3.
4
.
1
.
T
ra
ini
ng
a
nd
educa
t
io
n f
o
r
hea
lt
hca
re
pro
v
ider
s
An
ticip
atin
g
th
e
ar
r
iv
al
o
f
a
b
ab
y
a
n
d
p
r
ep
ar
in
g
f
o
r
p
a
r
en
th
o
o
d
ca
n
b
e
b
o
th
an
e
x
h
ilar
atin
g
an
d
d
au
n
tin
g
tim
e.
A
n
t
e
n
a
t
a
l
c
a
r
e
p
r
e
s
e
n
t
s
a
u
n
i
q
u
e
o
p
p
o
r
t
u
n
i
t
y
to
e
n
g
a
g
e
w
i
t
h
w
o
m
e
n
,
t
h
e
i
r
p
ar
t
n
e
r
s
,
a
n
d
f
a
m
il
i
es
a
b
o
u
t
t
h
e
s
e
x
u
a
l
h
e
a
l
t
h
a
n
d
w
e
l
l
-
b
e
i
n
g
o
f
w
o
m
e
n
,
c
o
u
p
l
e
s
,
a
n
d
f
a
m
i
l
i
e
s
m
o
r
e
b
r
o
a
d
l
y
.
N
o
n
e
t
h
e
l
e
s
s
,
f
e
w
w
o
m
e
n
,
c
o
u
p
l
e
s
,
o
r
f
a
m
il
i
es
ap
p
e
a
r
t
o
r
e
c
ei
v
e
i
n
f
o
r
m
a
ti
o
n
f
r
o
m
h
e
a
l
t
h
c
a
r
e
p
r
o
v
i
d
e
r
s
a
b
o
u
t
s
e
x
u
a
l
h
e
al
t
h
a
n
d
w
e
l
l
-
b
e
i
n
g
d
u
r
i
n
g
a
n
t
e
n
a
t
a
l
c
ar
e
.
A
d
d
r
e
s
s
i
n
g
t
h
is
i
m
p
o
r
t
a
n
t
g
a
p
i
n
a
n
t
e
n
a
t
a
l
c
a
r
e
p
r
o
v
i
s
i
o
n
r
e
q
u
i
r
e
s
m
u
l
t
i
p
l
e
s
t
a
k
e
h
o
l
d
e
r
s
'
c
o
n
c
e
r
t
e
d
a
n
d
co
o
r
d
i
n
a
t
e
d
e
f
f
o
r
t
s
a
c
r
o
s
s
t
h
e
c
o
m
m
u
n
i
t
y
,
h
e
a
l
t
h
s
e
r
v
i
c
e
,
p
o
l
i
c
y
,
a
n
d
r
e
s
e
a
r
c
h
l
e
v
e
l
s
.
T
h
is
c
h
a
p
t
e
r
o
u
t
l
i
n
e
s
s
o
m
e
p
o
t
e
n
t
i
a
l
s
t
r
a
te
g
i
es
t
h
a
t
c
o
u
l
d
b
e
i
m
p
l
e
m
e
n
t
e
d
t
o
i
m
p
r
o
v
e
s
e
x
u
a
l
h
e
a
l
t
h
a
n
d
w
e
l
l
-
b
e
i
n
g
d
u
r
i
n
g
a
n
t
e
n
a
ta
l
ca
r
e
.
I
t
e
m
p
h
a
s
i
ze
s
t
h
e
n
e
e
d
to
v
i
e
w
t
h
is
a
s
a
d
e
v
el
o
p
m
e
n
t
p
r
i
o
r
i
t
y
w
i
t
h
i
n
t
h
e
b
r
o
a
d
e
r
c
o
n
t
e
x
t
o
f
w
o
m
e
n
,
c
o
u
p
l
e
s
,
a
n
d
f
a
m
i
li
es'
h
e
a
l
t
h
a
n
d
we
l
l
-
b
e
i
n
g
i
n
t
h
e
t
r
a
n
s
it
i
o
n
t
o
p
ar
e
n
t
h
o
o
d
.
Ov
er
all,
f
o
u
r
p
o
ten
tial
s
tr
ateg
ies
to
im
p
r
o
v
e
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
d
u
r
in
g
an
t
en
atal
ca
r
e
p
r
o
v
is
io
n
ar
e
p
r
o
p
o
s
ed
.
First,
th
is
ch
ap
ter
d
is
cu
s
s
es
th
e
n
ee
d
f
o
r
t
h
e
in
v
o
lv
em
e
n
t
o
f
an
te
n
atal
ca
r
e
p
r
o
v
id
er
s
,
p
r
o
g
r
a
m
s
,
an
d
p
o
licy
m
a
k
er
s
in
p
r
o
v
id
i
n
g
an
ten
atal
ca
r
e
f
r
o
m
a
m
o
r
e
h
o
lis
tic
p
er
s
p
ec
tiv
e
o
n
th
e
h
ea
lth
an
d
well
-
b
ein
g
o
f
wo
m
e
n
,
co
u
p
les,
an
d
f
am
ilies
.
C
en
tr
al
to
th
is
s
tr
ateg
y
is
th
e
n
ee
d
f
o
r
a
ch
an
g
e
in
th
e
co
n
ce
p
t
u
al
ap
p
r
o
ac
h
o
f
an
ten
atal
ca
r
e
th
at
s
ee
s
m
o
r
e
th
an
th
e
in
d
iv
id
u
al
an
d
b
io
m
ed
ical
n
ee
d
s
o
f
wo
m
en
b
ein
g
ad
d
r
ess
ed
.
Seco
n
d
,
th
e
n
ee
d
f
o
r
tr
ain
in
g
an
d
e
d
u
ca
tio
n
f
o
r
a
n
ten
atal
ca
r
e
p
r
o
v
id
er
s
to
e
n
a
b
le
th
e
p
r
o
v
is
io
n
o
f
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
d
u
r
in
g
a
n
ten
atal
ca
r
e
is
ad
d
r
e
s
s
ed
.
T
h
ir
d
,
th
e
n
ee
d
f
o
r
e
n
g
ag
em
en
t
with
m
en
d
u
r
in
g
th
e
an
ten
atal
ca
r
e
p
r
o
ce
s
s
is
d
is
cu
s
s
ed
.
Fo
u
r
th
,
th
e
n
ee
d
f
o
r
m
o
r
e
c
o
m
m
u
n
ity
-
b
ased
awa
r
en
ess
an
d
in
v
o
lv
em
e
n
t in
an
ten
atal
ca
r
e
p
r
o
v
is
io
n
to
p
r
o
m
o
te
b
r
o
ad
e
r
g
en
d
er
e
q
u
ity
is
co
n
s
id
er
ed
.
T
h
er
e
is
an
u
r
g
en
t
n
ee
d
f
o
r
p
r
o
v
id
e
r
s
an
d
p
o
licy
m
ak
er
s
t
o
v
iew
an
ten
atal
ca
r
e
in
a
m
o
r
e
h
o
lis
tic
lig
h
t
th
at
in
clu
d
es
th
e
h
ea
lth
an
d
well
-
b
ein
g
o
f
wo
m
e
n
,
co
u
p
les,
an
d
f
am
ilies
m
o
r
e
b
r
o
ad
ly
,
in
clu
d
in
g
is
s
u
es
o
f
s
ex
u
al
h
ea
lth
a
n
d
well
-
b
e
in
g
.
An
ten
atal
ca
r
e
is
o
f
ten
v
iewe
d
f
r
o
m
a
b
io
m
e
d
ical
a
n
d
wo
m
a
n
-
f
o
cu
s
ed
p
er
s
p
ec
tiv
e,
with
th
e
m
o
t
h
er
an
d
h
er
p
r
eg
n
an
cy
b
ein
g
t
h
e
ce
n
tr
al
co
n
ce
r
n
.
Ho
wev
er
,
we
m
u
s
t
co
n
s
id
er
th
e
g
r
o
win
g
b
o
d
y
o
f
ev
id
e
n
ce
th
at
s
h
o
ws
th
at
th
is
p
er
io
d
ca
n
b
e
p
r
o
b
lem
atic
f
o
r
m
a
n
y
w
o
m
en
,
c
o
u
p
les,
an
d
f
am
ilies
an
d
th
at
co
n
tin
u
ed
n
e
g
ativ
e
ex
p
er
ie
n
ce
s
ca
n
h
a
v
e
a
last
in
g
im
p
ac
t a
cr
o
s
s
th
e
life
c
o
u
r
s
e.
3.
4
.
2
.
Co
mm
un
it
y
eng
a
g
e
m
e
nt
a
nd
em
po
wer
m
ent
E
n
h
a
n
c
i
n
g
c
o
m
m
u
n
i
t
y
e
n
g
a
g
e
m
e
n
t
a
n
d
e
m
p
o
w
e
r
m
e
n
t
i
s
a
c
r
u
c
i
a
l
s
t
r
a
te
g
y
t
o
i
m
p
r
o
v
e
t
h
e
s
e
x
u
a
l
h
e
a
l
t
h
a
n
d
w
e
l
l
-
b
ei
n
g
o
f
w
o
m
e
n
d
u
r
i
n
g
a
n
t
e
n
a
t
a
l
c
a
r
e
.
S
e
x
u
a
l
h
e
a
l
t
h
e
d
u
c
a
ti
o
n
a
n
d
i
n
f
o
r
m
a
t
i
o
n
d
i
s
s
e
m
i
n
a
ti
o
n
c
a
n
h
e
l
p
e
m
p
o
w
e
r
w
o
m
e
n
b
y
e
n
h
a
n
c
i
n
g
t
h
e
i
r
a
b
i
l
i
t
y
t
o
m
a
k
e
i
n
f
o
r
m
e
d
d
e
c
i
s
i
o
n
s
a
n
d
a
c
c
e
s
s
t
h
e
h
e
a
l
t
h
s
e
r
v
i
c
es
t
h
e
y
n
e
e
d
.
A
n
e
s
s
e
n
ti
a
l
a
s
p
e
ct
o
f
t
h
i
s
is
i
n
te
g
r
a
t
i
n
g
s
e
x
u
a
l
h
ea
l
t
h
i
n
t
o
t
h
e
e
x
i
s
t
i
n
g
a
n
te
n
a
t
a
l
c
a
r
e
p
r
o
g
r
a
m
.
T
h
is
i
n
v
o
l
v
e
s
p
r
o
v
i
d
i
n
g
i
n
f
o
r
m
a
ti
o
n
a
n
d
s
e
r
v
i
c
es
r
el
a
t
e
d
t
o
s
e
x
u
a
l
l
y
t
r
a
n
s
m
i
tt
e
d
i
n
f
e
ct
i
o
n
s
,
H
I
V
,
i
n
f
e
r
ti
l
it
y
,
a
n
d
v
i
o
l
e
n
c
e
a
g
a
i
n
s
t
w
o
m
e
n
.
G
e
n
d
e
r
-
s
e
n
s
i
t
i
v
e
a
n
t
e
n
a
t
a
l
c
a
r
e
p
r
o
g
r
a
m
s
c
a
n
i
n
c
r
ea
s
e
t
h
e
o
p
p
o
r
t
u
n
i
t
i
es
f
o
r
w
o
m
e
n
to
r
e
c
e
i
v
e
i
n
f
o
r
m
a
t
i
o
n
a
n
d
s
e
r
v
i
ce
s
o
n
s
e
x
u
a
l
h
e
al
t
h
a
n
d
e
n
h
a
n
ce
t
h
e
i
r
d
e
m
a
n
d
f
o
r
s
u
c
h
s
e
r
v
ic
es
.
T
o
ad
d
r
ess
th
e
co
m
p
lex
ities
o
f
s
ex
u
al
h
ea
lth
an
d
a
n
ten
ata
l
ca
r
e,
h
ea
lth
ed
u
ca
tio
n
a
n
d
p
r
o
m
o
tio
n
th
r
o
u
g
h
tr
ad
itio
n
al
h
ea
ler
s
,
r
e
lig
io
u
s
lead
er
s
,
an
d
co
m
m
u
n
i
ty
g
r
o
u
p
s
is
ess
en
tial.
B
y
ac
ti
v
ely
p
r
o
m
o
tin
g
th
e
s
ex
u
al
h
ea
lth
o
f
wo
m
en
,
th
e
s
e
p
r
o
g
r
am
s
ca
n
h
elp
less
en
s
tig
m
a
an
d
f
ac
ilit
ate
ac
ce
s
s
to
h
ea
lth
s
er
v
ices.
Ad
d
r
ess
in
g
o
th
er
f
ac
to
r
s
th
at
lim
it
ac
ce
s
s
to
an
ten
atal
ca
r
e
s
er
v
ices,
s
u
ch
as
th
e
d
is
tan
ce
to
clin
ics
an
d
h
ig
h
co
s
ts
,
is
eq
u
ally
ess
en
tial.
Su
ch
in
itiativ
es
ca
n
h
el
p
em
p
o
w
er
wo
m
en
in
th
e
co
m
m
u
n
ity
a
n
d
f
u
r
th
er
im
p
r
o
v
e
th
eir
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
.
T
h
er
e
is
a
clea
r
n
ee
d
f
o
r
f
u
r
th
er
r
esear
ch
an
d
p
r
o
g
r
am
s
o
n
s
ex
u
al
h
ea
lth
in
th
e
co
n
tex
t
o
f
an
ten
atal
ca
r
e
g
lo
b
ally
,
as th
is
to
p
ic
is
o
f
ten
n
eg
lecte
d
.
4.
CO
NCLU
SI
O
N
I
n
co
n
cl
u
s
io
n
,
ad
d
r
ess
in
g
s
ex
u
al
h
ea
lth
an
d
well
-
b
ein
g
d
u
r
in
g
an
ten
atal
ca
r
e
r
em
ain
s
a
cr
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.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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RE
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NC
E
S
[
1
]
C
.
A
.
S
t
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k
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,
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[
2
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N
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A
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[
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[
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.
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Me
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[
5
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J
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[
6
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[
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H
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Ta
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2
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N
.
A
l
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ma
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n
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Lo
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2
0
2
2
.
[
2
2
]
M
.
T.
C
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se
b
o
l
t
,
“
B
a
r
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:
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,
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e
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& R
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p
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.
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.
[
2
3
]
S
.
D
e
ss
u
a
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d
Z.
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a
w
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t
,
“
P
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Et
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,
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Fr
o
n
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rs
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Pe
d
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l
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3
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p
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d
.
2
0
2
0
.
5
8
6
7
4
7
.
[
2
4
]
M
.
J
a
n
i
g
h
o
r
b
a
n
,
Z.
B
o
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o
u
ma
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d
f
a
r
,
R
.
P
o
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k
a
z
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mi
,
a
n
d
F
.
M
o
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t
a
f
a
v
i
,
“
B
a
r
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c
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x
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l
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h
,
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BM
C
Pu
b
l
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6
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7
-
4.
[
2
5
]
E.
Ta
d
e
ss
e
,
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n
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a
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C
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ID
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p
a
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p
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,
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t
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o
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.
S
2
8
7
5
3
4
.
[
2
6
]
H
.
M
.
D
e
n
n
y
,
A
.
D
.
La
k
s
o
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o
,
R
.
M
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a
n
d
B
.
K
u
r
n
i
a
w
a
n
,
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Th
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mi
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me
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I
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d
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a
,
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si
a
Pa
c
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o
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P
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v
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4
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p
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5
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–
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:
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1
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7
7
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1
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5
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2
3
7
.
[
2
7
]
A
.
B
.
-
T.
L
o
g
o
e
ma
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l
,
K
.
L
.
M
.
W
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F
.
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,
R
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O
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A
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,
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d
L
.
B
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n
o
v
a
,
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‘
I
n
c
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t
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,
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t
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s n
o
t
f
a
r
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b
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’
:
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La
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MJ
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,
v
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6
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n
o
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1
,
2
0
2
1
.
[
2
8
]
R
.
B
a
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b
o
sa
d
e
A
n
d
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a
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e
,
C
.
M
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T.
S
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,
D
.
B
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M
.
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D
o
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s,
a
n
d
S
.
M
.
C
â
mar
a
,
“
A
d
e
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a
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B
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:
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w
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me
n
,
”
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n
t
e
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s He
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v
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,
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2
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1
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2
1
4
7
/
I
JW
H
.
S
2
7
2
7
4
3
.
[
2
9
]
B
.
O
.
A
h
i
n
k
o
r
a
h
e
t
a
l
.
,
“
D
e
t
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mi
n
a
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s
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a
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w
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me
n
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G
u
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a
:
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v
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r
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,
”
B
MC
Pre
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d
C
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4
8
9
-
4.
[
3
0
]
K
.
A
d
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t
i
,
“
R
e
p
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d
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i
v
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g
h
t
s
o
f
w
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men
a
n
d
su
r
r
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a
c
y
,
”
L
e
g
a
l
L
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c
k
J
o
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l
,
v
o
l
.
1
,
n
o
.
4
,
p
.
4
4
,
2
0
2
1
.
[
3
1
]
R
.
F
i
k
r
e
,
J.
G
u
b
b
e
l
s
,
W
.
Te
k
l
e
si
l
a
s
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e
,
a
n
d
S
.
G
e
r
a
r
d
s,
“
Ef
f
e
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t
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o
f
mi
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w
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f
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y
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mi
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:
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w
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d
me
t
a
-
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n
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l
y
si
s
,
”
BM
C
P
reg
n
a
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9.
[
3
2
]
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.
M
.
P
.
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t
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,
T.
H
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,
a
n
d
S
.
A
.
F
o
n
t
,
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F
o
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:
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o
mes
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,
”
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h
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Re
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3
.
1
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8
.
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RAP
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AUTH
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RS
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a
b
iru
Abu
b
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Un
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rsity
,
T
h
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a
m
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ia.
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a
ls
o
wo
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s
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a
lt
h
imp
lem
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n
ti
n
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sp
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c
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in
Ni
g
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wh
e
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e
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s
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d
sig
n
ifi
c
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