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The article discusses a debate which exposes the widening connection between anti-abortion and prochoice advocates over whether society should strive to reduce abortion or concentrate instead on reducing the need for it. It mentions that the decline of abortion rate in the U.S. sparks the argument on improvements in contraceptive use. It cites the possible factors for the declined abortion rate which include state restriction.

The article discusses in the surge of the restrictions for abortion in different states in the U.S. where 70 antiabortion measures has been enacted in 2013. Different reasons for the increase in the number of the restrictions are explained. The efforts of the states to discourage women from abortion by passing harsh restrictions and their impacts on abortion policy in the country are explored. A chart is presented which depicts the increase in the number of the restrictions from 1990 to 2010.

The article discusses the consideration for abortion to be included in the Affordable Care Act (ACA) health care reform in the U.S. The legality of abortion coverage in health insurance in marketplace plans in 26 states and the District of Columbia is highlighted. A diagram is presented which depicts the 24 states that restrict abortion coverage in private plans offered through health insurance marketplaces.

The article discusses the federal contraceptive coverage guarantee under the Affordable Care Act in relation to the cases Sebelius v. Hobby Lobby Stores and Specialties v. Sebelius to be heard at the U.S. Supreme Court on March 25, 2014. Particular focus is given to the assertion that particular methods of contraception are not methods of abortion based on scientific explanations. The likelihood that the court's ruling in the cases will be followed by further arguments is highlighted.

The article discusses the controversy surrounding coercion by governments in reproductive decision making worldwide. It explores the case of Feng Jianmei who was forced to have an abortion by Chinese officials and human rights lawyer Chen Guangcheng who exposed coerced abortions and other abuses in China. It tackles the efforts of reproductive rights movements to protest all forms of coercion. It also offers information on Bill and Melinda Gates Foundation's London Family Planning Summit. INSET: American History.

The article discusses the importance of providing access to safe abortion in developing countries where abortion rate is high. Abortions reportedly occur in developing nations wherein it is illegal, unsafe, and clandestine. It explores the rate of abortion worldwide and how legalization can save lives and advance women's human rights. It mentions the World Health Organization (WHO) which puts access to safe abortion services within the right to quality reproductive and sexual health services. INSET: Abortion Legality, Safety and Maternal Mortality: The Outliers.

The article reports on the role of Title X funds in the family planning efforts in the U.S. It states the Title X can be used to provide care to individuals not eligible for Medicaid and can be deployed to offer the intensity of care needed by family planning center clients to avoid unintended pregnancy. A wide choice of contraceptive methods is offered by family planning centers supported by Title X.

The article reports on the role of Medicaid as a source of public funding for family planning services in the U.S. It states that family planning services help women and couples avoid unintended pregnancies. 75% of total public funding for family planning is provided by Medicaid which includes family planning services provided by private doctors and clinicians.

The article examines how and where the volume of abortion restrictions has changed dramatically in the U.S. over the last 10 years. It analyzes whether in 2000, 2005, and 2011, states had implemented at least one provision in any of 10 categories of major abortion restrictions. The 10 categories being identified include mandated parental involvement prior to a minor's abortion and prohibition of Medicaid funding in cases of life endangerment, rape or incest.

The article presents an overview of the many problems, including environmental problems, food supply problems and health care accessibility problems, which are being seen and which will be seen in Niger in 2011 and beyond as a result of rapid population growth which is being seen in the country in 2011. A discussion of policies which have been developed and will be implemented by Niger's government and the international community to address and reduce the country's rapid population growth is presented.

CONTEXT: Periodic assessments of abortion incidence are essential for monitoring trends in unintended pregnancy and gaps in contraceptive services and use. METHODS: Statistics and estimates of legal induced abortions in 2008 were compiled for 64 of the 77 countries in which legal abortion is generally available; these 64 are home to 98% of women aged 15-44 who live in the countries eligible for inclusion. Data sources included reports or completed questionnaires from national statistical offices and nationally representative surveys. The completeness of official figures was assessed by in-country and regional experts. Trends since 1996 and 2003 were examined. RESULTS: Of the 77 countries with liberal abortion laws, 36 are in the developing world. In 2008, abortion rates in the 25 countries with complete records-all of which were developed-ranged from seven (Germany and Switzerland) to 30 (Estonia) per 1,000 women aged 15-44. Abortion rates declined in most of the 20 countries with consistently reliable information on trends between 1996 and 2008; declines were generally steeper than increases, although the pace of decline slowed after 2003. The highest observed abortion rates were in developing countries with incomplete estimates. For most developing countries that had liberal laws, the reported abortion rates were incomplete and varied widely. CONCLUSIONS: High abortion rates in some countries, and small increases in rates in others, indicate a great need for more effective family planning services for these populations. Reliable data collection systems, needed to ensure that trends can be effectively monitored, are lacking in many countries. [ABSTRACT FROM AUTHOR]

CONTEXT: Contraceptive discontinuation is a common event that may be associated with low motivation to avoid pregnancy. If this is the case, a substantial proportion of pregnancies that follow discontinuation will be reported as intended. METHODS: Demographic and Health Survey data from six countries (Bangladesh, the Dominican Republic, Kazakhstan, Kenya, the Philippines and Zimbabwe) over the period 1999-2003 were used to explore the proportions of pregnancies women reported as intended or unintended following various contraceptive behaviors. Multivariate logistic regression analysis was used to examine the characteristics of women who reported births as intended when they followed contraceptive failure or discontinuation for reasons other than a desire for pregnancy. RESULTS: The proportion of births reported as intended following contraceptive failure ranged from 16% in Bangladesh to 54% in Kazakhstan, and the proportion reported as intended following discontinuation for reasons other than a desire for pregnancy ranged from 37% in Kenya to 51% in Kazakhstan. In at least half the countries, associations were found between selected women's characteristics and their reports that births following either contraceptive failure or discontinuation were intended: Factors that were positively associated were women's age and the time elapsed between contraceptive discontinuation and the index conception; factors that were negatively - associated were increasing number of living children and reporting method failure as opposed to method discontinuation. CONCLUSION: These findings suggest that underlying variation in the motivation to avoid pregnancy is an important factor in contraceptive discontinuation. [ABSTRACT FROM AUTHOR]

The article focuses on the concerns over the balance between world population growth that is expected to reach seven billion in 2011 and consumption of natural resources, ages structure and political stability. It discusses the implications of the projected population growth to the economic development of developing countries. It explores the unmeet needs of women for modern contraceptives that led to unwanted pregnancy and abortion, as millions of women and couples are unable to control births.

In this article the authors discuss improvements which need to be made to postabortion care across the globe. They are supportive of efforts which have been made to improve postabortion care that is provided to women but suggest that work still needs to be done in many countries to ensure that every woman who receives postabortion care also receives information on her return to fertility and on contraceptive options, and contraceptive services.

CONTEXT: Informal drug shops are the first line of health care in many poor countries. In Uganda, these facilities commonlysell and administer the injectable contraceptive depot medroxyprogesterone acetate (DMPA), even though they are prohibited by law from selling any injectable drugs. It is important to understand drug shop operators' current practices and their potential to provide DMPA to hard-to-reach populations. METHODS: Between November 2007 and January 2008, 157 drug shops were identified in three rural districts of Uganda, and the operators of the 124 facilities that sold DMPA were surveyed. Data were analyzed with descriptive methods. RESULTS:Only 35% of operators reported that the facility in which they worked was a licensed drug shop and another 9% reported that the facility was a private clinic; all claimed to have some nursing, midwifery, or other health or medical qualification. Ninety-six percent administered DMPA in the shop. Operators gave a mean of 10 injections (including three of DMPA) per week. Forty-three percent of those who administered DMPA reported disposing of used syringesin sharps containers; in the previous 12 months, 24% had had a needle-stick injury and 17% had had a patient with an injection-related abscess. Eleven percent said they had ever reused a disposable syringe. Overall, contraceptive knowledge was low, and attitudes toward family planning reflected common traditional biases. CONCLUSION: Provision of DMPA is common in rural drug shops, but needs to be made safer. Absent stronger regulation and accreditation, drug shop operators can be trained as community-based providers to help meet the extensive unmet demand for family planning in rural areas. [ABSTRACT FROM AUTHOR]

CONTEXT: Vietnam has experienced a rapid fertility decline over the last three decades,yet fertility rates vary considerably across the country's 54 ethnic groups. METHODS: Data were drawn from the 2001 Vietnam National Health Survey,which collected information from 27,097 currently married women aged 15-49 on their birth and abortion history over the preceding five years, as well as their current contraceptive use. Multivariate regression analyses identified associations between individual,household and community characteristics and women's contraceptive use and abortion history, and examined ethnic differences in the types of methods used and in abortion incidence. RESULTS: Vietnam's total fertility rate was 1.6 children per woman, whereas the rate among ethnic minorities in the northern uplands and central high lands was 2.6 and 2.8, respectively. These groups also had a lower abortion rate than the national average (0.3-0.5 vs. 0.7), and were less likely than the group comprising the Kinh majority and the Chinese minority to have used either a modern or traditional contraceptive (odds ratios,0.4-0.7) or to have had an abortion (0.2-0.6).The likelihood of having had an abortion was elevated among older (5.6-21.2) and better educated women (1.4-1.7), as well as among those with one or two children and those from socioeconomically advantaged ethnic groups (1.2-1.4).Finally,abortion rates were higher among women who practiced traditional methods than among those who used modern ones. CONCLUSIONS: Because better access to abortion is unlikely by itself to reduce fertility among high-fertility minority groups,programs that provide supportive reproductive health services and that target young, low-parity and less educated women may help to lower fertility among these groups. [ABSTRACT FROM AUTHOR]

CONTEXT: The abortion rate in the republic of Georgia is the highest documented in the world. Analyses using reliable data are needed to inform programs for preventing unintended pregnancy and abortion. METHODS: Data from two large national household surveys conducted in 1999 and 2005 were used to assess the relationship between contraceptive use and abortion. Two analytic approaches were used. First,abortion rates were estimated for three subgroups: users of modern contraceptives,users of traditional contraceptives and nonusers of contraceptives. A decomposition method was then used to estimate the proportions of change in abortion rates that were due to changes in contraceptive use and to changes in use- and nonuse-specific abortion rates. Second, a methodology developed by Westoff was used to examine abortion rates among contraceptive users and among nonusers with differing risks of unintended pregnancy. RESULTS: According to data from the 60 months before each survey, contraceptive prevalence among married women increased by 23% (from 39% to 48%) and the marital abortion rate declined by 15% (from 203 to 172 abortions per 1,000 woman-years) between 1999 and 2005. Both approaches showed that nonuse of any method was the principal determinant of the high unintended pregnancy rate and that the increase in use of modern contraceptives was a significant contributor to the recent drop in abortion (explaining 54%of the decline, according to the decomposition analysis). CONCLUSIONS: Efforts to increase availability and use of modern family planning methods in Georgia should lead to a direct and measurable decline in the abortion rate. [ABSTRACT FROM AUTHOR]

CONTEXT: The reproductive choices made by young women and men have an enormous impact on their health, schooling, employment prospects and overall transition to adulthood. As the largest cohort of young people in history enter their childbearing years, their reproductive behavior will determine the growth and size of the world's population for decades to come. METHODS: Demographic and Health Survey data from more than 40 countries were used to examine the proportions of 15-19-year-old women who are currently married or are unmarried but sexually active; their rates of contraceptive adoption, current use, discontinuation, method switching and contraceptive failure; trends in these indicators; and comparisons with older women. RESULTS: In many countries, the proportion of adolescent women using contraceptives increased substantially over the last two decades;prevalence among adolescents increased faster than among older women. Greater proportions of adolescents than of older women discontinued using a contraceptive method within a year or experienced contraceptive failure. CONCLUSIONS:Adolescent contraceptive use is growing, and compared with adult use, is characterized by shorter periods of consistent use with more contraceptive failure and more stopping for other reasons. Use through the reproductive years is likely to grow, fueled further by growth in the numbers of young people. An expanded demand for contraceptive supplies, services and information can be expected to challenge the preparedness, capacity and resources of existing family planning programs and providers. [ABSTRACT FROM AUTHOR]

This opinion article presents a response to critics of family planning programs. The authors feel that high-quality, voluntary family planning services tend to not only benefit women and children, but also reduce fertility rates. The authors also assert that, in some countries, family planning programs are responsible for bringing high fertility levels to replacement level within a single generation. Some of the problems that the authors link to overpopulation include pervasive poverty, the stability of governments, environmental issues, and the scarcity of essential resources like food.

CONTEXT: Contraceptive use among young couples in India is low, and early childbearing and short birth intervals are common. The PRACHAR Project, an ongoing intervention in Bihar, seeks to increase contraceptive use for delaying and spacing births through communication interventions. METHODS: Random samples of married women younger than 25 with no more than one child were surveyed in 2002-2003, before PRACHAR was implemented (N=1,995), and in 2004, 21-27 months after implementation N=2,080). Contraceptive demand and use,and related attitudes and knowledge, were assessed in the two surveys in both intervention areas and comparison areas .Logistic regression was used to assess the effect of the interventions on these indicators. RESULTS: Contraceptive use was very low(2-6%) at baseline in both comparison and intervention areas. Demand for contraception increased from 25% at baseline to 40% at follow-up in intervention areas, but remained virtually unchanged in comparison areas. At follow-up, contraceptive use had risen in both areas, but the adjusted odds of use intervention areas were 3.8 times those in comparison areas. Women in intervention areas had elevated odds of knowing that fertility varies during the menstrual cycle, and of agreeing that early childbirth can be harmful and that contraceptive use is necessary and safe for delaying first births (odds ratios, 1.6 -3.0). CONCLUSION: Culturally appropriate, community-based communication programs that target youth and those who influence their decisions can create demand for contraception among young couples and lead to increased contraceptive use. [ABSTRACT FROM AUTHOR]

CONTEXT: Ideal family size and desire for an additional child are the two most commonly used fertility preference indicators. However, little is known about the consistency over time of responses to each measure, the consistency between the two indicators or the predictive value of these indicators in India. METHOD: Longitudinal data from the 1998-1999 National Family Health Survey and a follow-up survey conducted four years later were analyzed to determine the consistency of responses to the two fertility preference indicators (both over time and between indicators) and to determine whether baseline responses were associated with subsequent fertility, unwanted births and contraceptive use. RESULTS: Responses on the measure of ideal family size were consistent at the two time points for 53%of nonsterilized women. Eighty-two percent of women who explicitly said in 1998 that they did not desire more children responded identically in 2002, although about half of these women had given birth in the intervening period. The indicators were associated with each other: Among women with at least one son, 79% of those who had attained or surpassed their ideal family size said they wanted to stop childbearing, compared with 18% of those who had not. Both indicators predicted future fertility, unwanted births and contraceptive use, particularly among women who had a son. CONCLUSION: Both indicators are useful in understanding future fertility behavior. As the prevalence of son preference declines in India, the predictive ability of the indicators is likely to improve. [ABSTRACT FROM AUTHOR]

CONTEXT: In Turkey, contraceptive use has become more widespread, but little is known about the concurrence of spousal reports or the relative influence of communication, decision making and power differentials on method use. METHODS: Data from the 1998 Turkish Demographic and Health Survey (DHS) for 1,546 married couples were tested for concurrence between spousal reports on fertility and family planning variables. Multivariate regression analyses based on wives', husbands' and joint reports of current contraceptive use were used to assess the association between such use and various background, communication and interspousal variables. RESULTS: Spousal reports on most fertility and contraceptive use measures demonstrated moderate to high concordance, whereas reports of approval of family planning showed only fair concordance. After adjusting for background factors, models based on wives' and husbands' reports showed that current contraceptive use was positively associated with the number of methods known (odds ratios, 1.2 and 1.1, respectively) and perception of spousal approval (3.3 and 2.0, respectively), and in the husbands' model, with approval of either spouse or both (3.8-5.8). In the combined model, contraceptive use was positively associated with both partners approving of family planning (2.4), and negatively associated with both partners wanting more than three children and with only wives wanting three or fewer (0.4 and 0.6, respectively). CONCLUSIONS: Discrepancies between spousal reports were less significant in Turkey than in most developing countries with DHS data, but the differences were not inconsequential to explaining how spousal attitudes and preferences influence contraceptive use. No evidence was found associating interspousal power differentials with method use. Further research is needed to improve the testing and modeling of such dyadic processes. [ABSTRACT FROM AUTHOR]

CONTEXT: Women's lack of access to legal abortion is a major contributing factor to high rates of worldwide maternal mortality and morbidity. This article describes changes in the legal status of abortion in countries around the world since 1998. METHODS: The complete texts of new abortion legislation, most often obtained directly from government Web sites, were reviewed to determine changes. Background information was, where possible, also based on a review of complete legal texts. Other sources include the International Digest of Health Legislation (published by the World Health Organization) and Abortion Policies: A Global Review (published in 2002 by the Population Division of the United Nations). RESULTS: Since 1998, 16 countries have increased the number of grounds on which abortions may be legally performed; in two other countries, state jurisdictions expanded grounds for abortion. Two countries have removed grounds for legal abortion. Other countries maintained existing indications for abortion but adopted changes affecting access to the procedure. CONCLUSIONS: The worldwide trend toward liberalization of abortion laws observed in 1998 has continued. Recognition of the impact of abortion restrictions on women's human rights has played an increasing role in efforts to provide access to abortion. [ABSTRACT FROM AUTHOR]

CONTEXT: Unlike in other African countries, the fertility rate in Mali has remained at a relatively high rate of 6.8 births per woman. Little research exists on the role that community norms play in use of family planning, particularly in low prevalence countries. METHODS: Data on 7,671 women in union from the 2001 Mali Demographic and Health Survey were analyzed using multilevel modeling techniques to assess the effects of individual and community factors on the adoption of modern contraceptive methods. RESULTS: Only 5% of women in union were using a modern contraceptive method in 2001. The odds of contraceptive use were elevated among women in the highest wealth quintile, women who approved and whose partner approved of family planning, those who had recent discussions on family planning with their partner or others and those exposed to family planning messages (odds ratios,1.4-2.7). At the community level, the odds of modern contraceptive use rose with the proportion of women who were exposed to family planning messages (5.5), and decreased as the mean number of births per woman rose (0.7). In the final model, which included both individual- and community-level factors, the community factors were no longer significant. CONCLUSIONS: Because approval of family planning and discussion of family planning with partners were shown to be the factors most strongly associated with modern contraceptive use in the multilevel model, programs that seek to increase individual approval and those that teach communication between partners could be particularly helpful to increasing contraceptive use in Mali. [ABSTRACT FROM AUTHOR]

CONTEXT: Alcohol use is frequently identified as a contributor to risky sexual behaviors; however, research results are mixed. Given the conflicting evidence, researchers have focused on other factors, such as expectations about alcohol's effects that might help explain the relationship of alcohol use and risky sexual behaviors. METHODS: Cross-sectional data from 312 sexually experienced males aged 18-30 in a shanty town in Lima, Peru, were used in logistic regression models to identify associations of heavy episodic drinking and sex-related expectations about alcohol with sexual risk behaviors. RESULTS: Heavy episodic drinking was associated with having had two or more sexual partners and having had sex with a casual partner in the past year (odds ratios, 2.8 and 2.5, respectively). After controlling for alcohol consumption, sex-related expectations about alcohol were associated with these high-risk sexual behaviors,as well as with not using a condom at last sex (1.2) and not using a condom at last sex with a casual partner (1.3). CONCLUSION: Beliefs about the effect of alcohol on sexual performance could help explain links between alcohol consumption and risky sexual behavior not completely accounted for by the pharmacological effects of alcohol. International Family Planning Perspectives, 2008, 34(1):15-20 [ABSTRACT FROM AUTHOR]

CONTEXT: Each year, thousands of Nigerian women have unintended pregnancies that end in illegal abortion. Many such procedures occur under unsafe conditions,contributing to maternal morbidity and mortality. METHODS: In a 2002-2003 survey of women and their providers in 33 hospitals in eight states across Nigeria, 2,093 patients were identified as being treated for complications of abortion or miscarriage or seeking an abortion. Women's abortion experiences and the health consequences and associated costs were examined through bivariate analysis. Multivariate analysis was used to examine the characteristics of women by type of pregnancy loss and to compare characteristics among three groups of women who had induced abortions in differing circumstances. RESULTS: Among women admitted for abortion-related reasons,36%had attempted to end the pregnancy before coming to the hospital (including 24%with and 12%without serious complications),33%obtained an induced abortion at the facility (notwithstanding the country's restrictive law)without having made a prior abortion attempt and 32%were treated for complications from a miscarriage. Of women with serious complications, 24% had sepsis, 21% pelvic infection and 11% instrumental injury; 22% required blood transfusion and 10% needed abdominal surgery. The women in this group were poorer and later in gestation than those who sought abortions directly from hospitals. They paid more for treatment (about 13,900 naira) than those who went directly to the hospital for an abortion (3,800 naira) or those treated for miscarriage (5,100 naira). CONCLUSIONS: Policy and program interventions are needed to improve access to contraceptive services and post abortion care in order to reduce abortion-related morbidity and mortality. [ABSTRACT FROM AUTHOR]

CONTEXT: In Nepal, marriage occurs at a relatively young age and arranged weddings are widespread. However, recent changes in the family formation process and the timing of first sexual intercourse suggest that a transformation may be underway. METHODS: Data on marriage,cohabitation and first sexual intercourse from the 2001 Nepalese Demographic and Health Survey were used to describe the family formation process. The sequence of these events and the intervals between them were explored for currently married men and women. Hazard models were used to identify factors associated with behavioral changes over time. RESULTS: The average age at marriage among women married before age 20 increased from 13.7 years for those born in 1952-1956 to 15.6 years for those born in 1977-1981,while remaining relatively stable for men married before age 25 (17.3 years for the 1942-1946 birth cohort to 17.7 for the 1972-1976 birth cohort). After individual and couple characteristics were controlled for,younger age at interview was associated with greater odds of simultaneous marriage and cohabitation for both genders (odds ratios, 1.3-1.7).Younger age at interview was also associated with premarital sex among men--those aged 39 or younger had significantly higher risks than older men of having had premarital sex,with odds ratios rising from 1.6 among those aged 35-39 to 1.8 among those aged 15-24. CONCLUSIONS: It is important not only to promote education as a means of delaying marriage and childbearing,but also to implement programs and services that prevent reproductive health problems for young married couples. [ABSTRACT FROM AUTHOR]

CONTEXT: Information on abortion levels and trends can inform research and policies affecting maternal and reproductive health, but the incidence of legal abortion has not been assessed in nearly a decade. METHODS: Statistics on legal abortions in 2003 were compiled for 60 countries in which the procedure is broadly legal, and trends were assessed where possible. Data sources included published and unpublished reports from official national reporting systems, questionnaires sent to government agencies and nationally representative population surveys. The completeness of country estimates was assessed by officials involved in data collection and by in-country and regional experts. RESULTS: In recent years, more countries experienced a decline in legal abortion rates than an increase, among those for which statistics are complete and trend data are available. The most dramatic declines were in Eastern Europe and Central Asia, where rates remained among the highest in the world. The highest estimated levels were in Armenia, Azerbaijan and Georgia, where surveys indicate that women will have close to three abortions each on average in their lifetimes. The U.S. abortion rate dropped by 8% between 1996 and 2003, but remained higher than rates in many Northern and Western European countries. Rates increased in the Netherlands and New Zealand. The official abortion rate declined by 21% over seven years in China, which accounted for a third of the world's legal abortions in 1996. Trends in the abortion rate differed across age-groups in some countries. CONCLUSIONS: The abortion rate varies widely across the countries in which legal abortion is generally available and has declined in many countries since the mid-1990s. [ABSTRACT FROM AUTHOR]

CONTEXT: Understanding shifts in contraceptive method mix is key to helping policymakers, program managers and donor agencies meet current contraceptive demand and estimate future needs in developing countries. METHODS: Data from Demographic and Health Surveys, Reproductive Health Surveys and other nationally representative surveys were analyzed to describe trends and shifts in method mix among married women of reproductive age from 1980 to 2005. The analysis included 310 surveys from 104 developing countries. RESULTS: Contraceptive use among married women of reproductive age increased in all regions of the developing world, reaching 66% in Asia and 73% in Latin America and the Caribbean in 2000-2005, though only 22% in Sub-Saharan Africa. The proportion of married contraceptive users relying on the IUD declined from 24% to 20%, and the proportion using the pill fell from 16% to 12%. The share of method mix for injectables rose from 2% to 8%, and climbed from 8% to 26% in Sub-Saharan Africa, while the share for condoms was 5-7%. The overall proportion of users relying on female sterilization ranged from 29% to 39%, reaching 42-43% in Asia and in Latin America and the Caribbean in 2000-2005; on average, the share of all method use accounted for by male sterilization remained below 3% for all periods. Use of traditional methods declined in all regions; the sharpest drop--from 56% to 31% of users--occurred in Sub-Saharan Africa. CONCLUSIONS: To meet the rising demand for modern methods, it is critical that future programmatic efforts provide methods that are both accessible and acceptable to users. [ABSTRACT FROM AUTHOR]

CONTEXT: Research examining hormonal injectable contraceptive continuation has focused on clients' intentional discontinuation. Little attention, however, has been paid to unintentional discontinuation due to providers' management of clients who would like to continue use but arrive late for their scheduled reinjections. METHODS: A cross-sectional survey of 1,042 continuing injectable clients at 10 public clinics was conducted in South Africa's Western and Eastern Cape provinces. Bivariate logistic regression analyses were used to identify associations between specific variables and the likelihood of receiving a reinjection, among clients who returned to clinics late but within the two-week grace period for reinjection. RESULTS: Of 626 continuing clients in the Western Cape, 29% were up to two weeks late and 25% were 2-12 weeks late for their scheduled reinjection; these proportions among 416 continuing clients in the Eastern Cape were 42% and 16%, respectively. Only 1% of continuing clients in the Western Cape who arrived during the two-week grace period did not receive a reinjection; however, 36% of similar clients in the Eastern Cape did not receive a reinjection. Among late clients in the Eastern Cape who did not receive a reinjection, 64% did not receive any other method. Few variables were significant in bivariate analyses; however, certain characteristics were associated with receiving reinjections among late clients in the Eastern Cape. CONCLUSIONS: It is common for clients to arrive late for reinjections in this setting. Providers should adhere to protocols for the reinjection grace period and have a contraceptive coverage plan for clients arriving past the grace period to reduce clients' risk of unintentional discontinuation and unintended pregnancy. [ABSTRACT FROM AUTHOR]

CONTEXT: Because individuals' and couples' needs vary, the availability of a variety of contraceptive choices is a key component of successful family planning programs. Most women in Uzbekistan rely on a single contraceptive method (the IUD), but it is unclear whether this reflects constraints on choice or simply a widespread preference. METHODS: Nationally representative data from the 1996 Uzbekistan Demographic and Health Survey and the 2002 Uzbekistan Health Examination Survey were used to evaluate the relationship between demographic characteristics and knowledge and use of contraceptives among sexually active women. Separate multivariate regression analyses were performed for 1996 and 2002. RESULTS: Nearly all sexually active women knew about contraceptives, and in 2002 most reported that they had ever used the IUD (71%) or any modern method (77%). In both surveys, women with higher levels of wealth (odds ratios, 2.2-3.1) and education (1.9-2.5) were more likely than other women to know about contraceptive methods other than the IUD. Higher levels of wealth and education, as well as urban residence and non-Uzbek ethnicity, were also associated with the use of contraceptives other than the IUD, although these relationships were generally weaker in 2002 than in 1996. CONCLUSION: Despite the high prevalence of contraceptive use in Uzbekistan, the country's reproductive health program may be constraining method choice. Expanded programmatic efforts emphasizing choice from a range of methods are needed, especially among subgroups of women who have little knowledge or experience with methods other than the IUD. [ABSTRACT FROM AUTHOR]

Contraceptive prevalence increased by nine percentage points from 1993 to 2000 in Bangladesh, but there was almost no decline in the total fertility rate. METHODS: Data from the 1999-2000 Bangladesh Demographic and Health Survey and from the Matlab Demographic Surveillance System area collected between 1978 and 2001 were analyzed to explain the lack of change in fertility and to examine relationships among contraceptive prevalence, the abortion ratio, desired fertility and total fertility. RESULTS: After a maternal and child health and family planning program was initiated in part of Matlab in 1977, the total fertility rate in the intervention area declined from 4. 8 in 1979 to 2. 9 in 2000, while fertility in the comparison area dropped from 6. 3 to 3. 5. Over this period, contraceptive prevalence rose from 30% to 70% and from 16% to 50% in the two areas, respectively; meanwhile, the abortion ratio fell from 4. 3 to 3. 6 in the intervention area, but rose from around two to 8. 2 in the comparison area. Trends in desired fertility in each area were similar, declining from about 4. 0 children per woman in 1979 to about 2. 5 children in 2000. Among women at each level of parity, fertility generally decreased as the number of sons increased, and fertility was highest for women without sons. CONCLUSIONS: Preference for male children and parental concern over infant and child mortality may partially explain the difference between desired family size and fertility. A reduction in breast-feeding and an increase in use of less-effective contraceptive methods might be responsible for the inconsistency in the relationship between contraceptive use and fertility. [ABSTRACT FROM AUTHOR]

In Mexico, family planning advice has been incorporated into the clinical guidelines for prenatal care. However, the relationship between women's receipt of family planning advice during prenatal care and subsequent contraceptive use has not been evaluated. METHODS: Data were collected in 2003 and 2004 in 17 Mexican states from 2,238 urban low-income women postpartum. Participating women reported on prenatal services received and contraceptive use. Logistic and multinomial logistic regression models evaluated whether receiving family planning advice during prenatal care predicted current contraceptive use, after quality of care in the community, service utilization, delivery characteristics, household socioeconomic characteristics, and maternal and infant characteristics were controlled for. RESULTS: Overall, 47% of women used a modern contraceptive method. Women who received family planning advice during prenatal care were more likely to use a contraceptive than were those who did not receive such advice (odds ratio, 2. 2). Women who received family planning advice had a higher probability of using condoms (relative risk ratio, 2. 3) and IUDs (5. 2), and of undergoing sterilization (1. 4), than of using no method. CONCLUSIONS: Integrating family planning advice into prenatal care may be an important strategy for reaching women when their demand for contraception is high. [ABSTRACT FROM AUTHOR]

CONTEXT: Many Nigerian women experience unwanted pregnancies. To prevent associated health problems, it is important to understand the factors related to unwanted pregnancy in Nigeria. METHODS: A community-based survey of 2,978 women aged 15-49 was conducted in eight Nigerian states. Univariate analyses and multivariate logistic regression analyses were used to determine the incidence of unwanted pregnancy, the incidence of seeking an abortion among women with unwanted pregnancies and the factors associated with unwanted pregnancy and abortion-seeking behavior. Additional analyses examined the prevalence of contraceptive use and women's reasons for seeking to terminate unwanted pregnancies and for not practicing contraception at the time their unwanted pregnancies were conceived. RESULTS: Twenty-eight percent of respondents reported ever having had an unwanted pregnancy; of those, half reported having attempted to end their last unwanted pregnancy. Forty-three percent of women who sought an abortion did so because they were not married, were too young or were still in school. Of the women who were not practicing contraception when they had the unwanted pregnancy, 44% said that they were unaware of family planning, and 22% that they either did not have access to contraceptive services, services were too expensive or they were afraid of side effects. At the time of the survey, 27% of all respondents were at risk of an unwanted pregnancy. Almost half were unaware of contraceptive methods. CONCLUSIONS: Nigerian women often turn to abortion to avoid unwanted births. The provision of family planning counseling and information could substantially reduce the incidence of unwanted pregnancy and induced abortion in Nigeria. [ABSTRACT FROM AUTHOR]

CONTEXT: Use of unmet need for family planning to identify prospective clients may misrepresent the actual family planning needs of a population, given that a large proportion of women have ambivalent fertility desires. METHODS: Survey data for 1998 and 2003 from Burkina Faso, Ghana and Kenya were used to examine the fertility desires and motivations of women who said they wanted to delay or limit childbearing. A question on how much of a problem it would be if women found out they were pregnant in the next few weeks measured the strength of their fertility motivations. RESULTS: In Burkina Faso and Ghana, about a quarter of women who said they wanted to delay or limit childbearing also reported that it would be no problem or a small problem if they became pregnant soon. This response pattern was equally common among contraceptive users and nonusers. In Kenya, more than four in 10 women gave such ambivalent responses. Among women with an unmet need for means of delaying or limiting childbearing, 16-31% of those in Burkina Faso and Ghana, and 30-56% of those in Kenya, said that getting pregnant in the next few weeks would be no problem or a small problem. CONCLUSIONS: It is critical to consider the strength of fertility motivations when determining which women have family planning needs. Targeting women who are the most motivated to avoid childbearing will likely have the greatest impact on reducing unintended pregnancy in Sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

CONTEXT: During its first year of operation (1997–1998), California's family planning program, Family PACT, helped more than 750,000 clients to avert an estimated 108,000 pregnancies. Given subsequent increases in the numbers of clients served and contraceptive methods offered by the program, updated estimates of its impact on fertility are needed. METHODS: Claims data on contraceptives dispensed were used to estimate the number of pregnancies experienced by women in the program in 2002. Medical record data on methods used prior to enrollment were used to predict client fertility in the absence of the program. Further analyses examined the sensitivity of these estimates to alternative assumptions about contraceptive failure rates, contraceptive continuation and contraceptive use in the absence of program services. RESULTS: Almost 6.4 million woman-months of contraception, provided primarily by oral contraceptives (57%), barrier methods (19%) and the injectable (18%), were dispensed through Family PACT during 2002. As a result, an estimated 205,000 pregnancies—which would have resulted in 79,000 abortions and 94,000 births, including 21,400 births to adolescents—were averted. Changing the base assumptions regarding contraceptive failure rates or method use had relatively small effects on the estimates, whereas assuming that clients would use no contraceptives in the absence of Family PACT nearly tripled the estimate of pregnancies averted. CONCLUSION: Because all contraceptive methods substantially reduce the risk of pregnancy, Family PACT's impact on preventing pregnancy lies primarily in providing contraceptives to women who would otherwise not use any method. [ABSTRACT FROM AUTHOR]

CONTEXT: Fertility awareness-based methods of family planning help women identify the days of the menstrual cycle when they are most likely to become pregnant. To prevent pregnancy, women avoid unprotected intercourse on these days. Efficacy of these methods may be improved if the users most likely to engage in unprotected intercourse on fertile days can be identified and counseled. METHODS: Quantitative and qualitative data from efficacy studies of the Standard Days Method® and the TwoDay Method® of family planning, in which 928 women each contributed up to 13 cycles of method use, were examined. Multinomial logit analysis was used to compare characteristics of women who occasionally had unprotected intercourse on fertile days with those who consistently used their method correctly. The reasons participants gave for having unprotected intercourse on fertile days were also examined. RESULTS:Only 23% of women had unprotected intercourse on their fertile days in one or more of the cycles they contributed to the study. The method and study site appear to have the most significant effect on correct use. Earning an income was associated with increased odds of unprotected intercourse on fertile days; higher quality of housing was associated with decreased odds. The results confirm the importance of partner cooperation for correct method use. CONCLUSION: There was no clear profile of clients for whom these family planning methods would be inappropriate. However, programs offering these methods may help couples overcome potential difficulties in correct method use by including male partners and encouraging their participation in counseling sessions. [ABSTRACT FROM AUTHOR]

Emergency contraception can play an important role in reducing the rate of unintended pregnancies in Nigeria. Although it is included in the national family planning guidelines, there is limited awareness of this method among clients. METHODS: In 2003-2004, a sample of 256 health care providers within Lagos State were surveyed about their knowledge of, attitudes toward and provision of emergency contraceptives, using a 25-item, self-administered questionnaire. Frequencies were calculated for the various measures, and chi-square tests were used to determine significant differences. RESULTS: Nine in 10 providers had heard of emergency contraception, but many lacked specific knowledge about the method. Only half of them knew the correct time frame for effective use of emergency contraceptive pills, and three-fourths knew that the pills prevent pregnancy; more than a third incorrectly believed that they may act as an abortifacient. Fewer than a third of respondents who had heard of the pills knew that they are legal in Nigeria. Of those who had heard about emergency contraception, 58% had provided clients with emergency contraceptive pills, yet only 10% of these providers could correctly identify the drug, dose and timing of the first pill in the regimen. Furthermore, fewer than one in 10 of those who knew of emergency contraception said they always provided information to clients, whereas a fourth said they never did so. CONCLUSIONS: Nigerian health care providers urgently need education about emergency contraception; training programs should target the types of providers who are less knowledgeable about the method. [ABSTRACT FROM AUTHOR]

CONTEXT: Although the vast majority of Pakistani women are familiar with family planning methods, use of contraceptives remains low. Identifying the characteristics of family planning providers and health facilities that are associated with women's initiation of contraception may help program administrators devise interventions to increase contraceptive use. METHODS: Logistic regression analysis of data from a survey of urban Pakistani health facilities, their clients and their staff was used to identify individual, provider and health facility characteristics that predict women's receipt of contraceptives during visits to urban clinics. RESULTS:Women who had a secondary or higher level of education and three or more children had elevated odds of receiving a method (odds ratios, 1.8-9.3). Women had reduced odds of receiving contraceptives when visiting facilities where providers had higher levels of family planning experience. They had higher odds of receiving services at facilities that displayed educational materials about family planning than at those that did not (1.8), and those odds increased with the proportion of contraceptive methods offered that were in stock, the number of staff doctors and the number of staff members who provided family planning (1.2-2.4). CONCLUSION: Providers should be aware of the contraceptive needs of women with all levels of education and parity. Additionally, family planning facilities may be able to increase clients' contraceptive use by providing diversity in method choice, keeping offered methods in stock, displaying informational materials, and raising staff levels. [ABSTRACT FROM AUTHOR]

CONTEXT: In El Salvador, fathers less commonly say that pregnancies are unintended than mothers do. However, men's pregnancy intentions are not understood as well as women's. METHODS:Data from 425 fathers participating in the 2003 National Male Reproductive Health Survey of El Salvador were analyzed to examine their intentions in regard to partners' pregnancies that had ended in a live birth in the last five years. They were asked whether they had been trying to avoid pregnancy at the time of conception, whether they had been trying to get their partner pregnant, how they had felt about the pregnancy and what they thought their partner's pregnancy intentions had been. Descriptive analyses were based on the most recent pregnancy reported by each man. RESULTS: A quarter of the pregnancies had been unintended from the men's perspective—13% had been mistimed and 11% had been unwanted. Almost half (46%) of unintended pregnancies had been conceived when the father was trying to avoid pregnancy. However, 36% of men reporting an unintended pregnancy said they had been happy when they found out about it. For 20% of all pregnancies, men perceived that their partner's pregnancy intentions differed from their own. CONCLUSIONS: Family planning services in El Salvador need improvement, and services and outreach should target men. Men's experiences with unintended pregnancies—in particular, contraceptive failure and discordance within couples about pregnancy intention—are complex and merit further investigation. [ABSTRACT FROM AUTHOR]

CONTEXT: The World Health Organization (WHO) has developed a decision-making tool to be used by providers and clients during family planning visits to improve the quality of services. It is important to examine the tool's usability and its impact on counseling and decision-making processes during family planning consultations. METHODS: Thirteen providers in Mexico City were videotaped with family planning clients three months before and one month after attending a training session on the WHO decision-making tool. The videotapes were coded for client-provider communication and eye contact, and decision-making behaviors were rated. In-depth interviews and focus group discussions explored clients' and providers' opinions of the tool. RESULTS: After providers began using the decision-making tool, they gave clients more information on family planning, tailored that information more closely to clients' situations and more often discussed HIV/AIDS prevention, dual protection and condom use. Client involvement in the decision-making process and client active communication increased, contributing to a shift from provider-dominated to shared decision making. Clients reported that the tool helped them understand the provider's explanations and made them feel more comfortable talking and asking questions during consultations. After one month of practice with the decision-making tool, most providers felt comfortable with it and found it useful; however, they recommended some changes to the tool to help engage clients in the decision-making process. CONCLUSIONS: The decision-making tool was useful both as a job aid for providers and as a decision aid for clients. [ABSTRACT FROM AUTHOR]

CONTEXT: In the Philippines, abortion is legally restricted. Nevertheless, many women obtain abortions—often in unsafe conditions—to avoid unplanned births. In 1994, the estimated abortion rate was 25 per 1,000 women per year; no further research on abortion incidence has been conducted in the Philippines. METHODS: Data from 1,658 hospitals were used to estimate abortion incidence in 2000 and to assess trends between 1994 and 2000, nationally and by region. An indirect estimation methodology was used to calculate the total number of women hospitalized for complications of induced abortion in 2000 (averaged data for 1999-2001), the total number of women having abortions and the rate of induced abortion. RESULTS: In 2000, an estimated 78,900 women were hospitalized for postabortion care, 473,400 women had abortions and the abortion rate was 27 per 1,000 women aged 15-44 per year. The national abortion rate changed little between 1994 and 2000; however, large increases occurred in metropolitan Manila (from 41 to 52) and Visayas (from 11 to 17). The proportions of unplanned births and unintended pregnancies increased substantially in Manila, and the use of traditional contraceptive methods increased in Manila and Visayas. CONCLUSION: The increase in the level of induced abortion seen in some areas may reflect the difficulties women experience in obtaining modern contraceptives as a result of social and political constraints that affect health care provision. Policies and programs regarding both postabortion care and contraceptive services need improvement. [ABSTRACT FROM AUTHOR]

CONTEXT: In rural Bangladesh, family planning services-previously provided through household visits and satellite clinics–were transferred to static community clinics under the government's sectoral program for 1998-2003, but the next sectoral program reversed the change without a formal evaluation. It is important to assess changes in utilization and coverage to inform further development of the service delivery system. METHODS: Longitudinal data on use of family planning services and contraceptive methods were collected quarterly in 1998-2002 from married women in about 11,000 households in two rural surveillance areas–Abhoynagar and Mirsarai. Cross-sectional surveys were conducted among women and service providers in 2003 to gather detailed information about the transition to static clinics and women's response to the changes. Quarterly time series graphs of selected indicators were plotted for areas served by community clinics. RESULTS: In a time of considerable change in service delivery and sources of contraceptive supply, contraceptive prevalence remained constant in Abhoynagar and increased in Mirsarai. Community clinics quickly became the source of supplies for one-third of contraceptive users in Abhoynagar and one-fifth in Mirsarai. In wards where community clinics became operational (mostly in 2001-2002), three-quarters of women had used one at some time. CONCLUSIONS:Despite cultural constraints on mobility, women do not appear to have become dependent on home delivery of contraceptives. [ABSTRACT FROM AUTHOR]

Most HIV prevention efforts focus on premarital and extramarital sexual behavior, but in areas with high HIV prevalence the protective needs of married and cohabiting couples are just as great and often go unmet Condom use by these couples is generally low, with resistance from men and cultural norms commonly cited as barriers to increased use. METHODS:A household survey was conducted in an urban and a rural area in KwaZulu-Natal, South Africa, in 1999-2000. From this survey, matched partners in 238 marital or cohabiting relationships were independently interviewed about condom use and attitudes toward condoms, knowledge of AIDS/HIV risk and self-efficacy in preventing HIV infection. Logistic regression analysis was used to assess relationships between condom use and selected demographic and HIV prevention characteristics. RESULTS:Although couples' knowledge of condoms and where to obtain them was very high, only 15% of men and 18% of women reported consistent or occasional use. The level of use was 8% and 11% among men and women, respectively, in rural,less educated couples, and 29% and 34% among men and women in urban, more educated couples. A majority of urban women had favorable attitudes toward condoms, and they also reported higher self-efficacy regarding HIV prevention than did rural women. A woman's perceived risk of HIV infection from her partner was the most powerful predictor of condom use (odds ratio, 40). [ABSTRACT FROM AUTHOR]

Although many research studies have documented the relationship between menstrual side effects of contraceptives and discontinuation of use, few have sought to identify factors that predispose women to discontinue because of changes in bleeding patterns. Such in formation is important to enable family planning providers to better help women and couples choose appropriate methods and use them successfully. METHODS: Forty-eight women participating in six focus group discussions described their experiences using the IUD, the hormonal implant or the three-month injectable. Subsequently, 259 women using one of these methods for the first time were followed for up to 18 months to determine patterns of menstrual bleeding and perceptions of menstrual cycle change overtime. Multi variable analytical methods were used to examine the associations between selected measures and method discontinuation. RESULTS: Contraceptive discontinuation differed by method:Nearly 7O% of injectable users had stopped using their chosen method after one year, compared with 34% of IUD users and 10% of implant users. Before initiating a method, women reported an average of five bleeding days per cycle. During the first six months of use,IUD users reported an average of six days of bleeding per cycle; injectable and implant users reported 11-12. In multivariable models, each additional day of bleeding was significantly associated with a 2-4% increase in discontinuation, depending on method type. Among IUD users, women whose husbands knew that they had visited a clinic to initiate a method were less likely than others to discontinue method use (hazard ratio, -1.9). Age was significantly associated with decreased discontinuation among implant users. [ABSTRACT FROM AUTHOR]

Discusses the cost-effectiveness of contraceptive price subsidies relative to the cost-effectiveness of expenditures on other program activities. Barriers to contraceptive use; Price elasticity of contraceptive demand; Price subsidies.

Comments on the strategies to assess family planning providers' readiness to provide services to women in Lesotho to achieve fertility goals by 2011. Challenges in increasing contraceptive use; Necessity of expanding women's access to service sites, developing guidelines for planning providers and ensuring that standard practices are adopted.