Reassessing Unmet Need for Family Planning in the Postpartum Period

Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times: right after delivery (prospective indicator), after six months of amenorrhea (intermediate indicator), and at the end of amenorrhea (classic indicator). DHS data from 57 countries in 2005–13 indicate that 62 percent (prospective), 43 percent (intermediate), and 32 percent (classic) of women in the first year after a birth have an unmet need for contraception (40 percent when including abstinence). While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods’ widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.     

Couples' Unmet Need for Family Planning in Three West African Countries

Unmet need for family planning is typically calculated for currently married women, but excluding husbands may result in misleading estimates of couples' unmet need. This study builds on previous work and proposes a method of calculating couples' unmet need for family planning based on spouses' independent fertility intentions. We analyze Demographic and Health Survey data from couples from three West African countries—Benin, Burkina Faso, and Mali. We find that fewer than half of couples having any unmet need had concordant unmet need (41–49 percent). A similar percentage of couples had wife‐only unmet need (33–40 percent). A smaller percentage had husband‐only unmet need (15–23 percent). Calculating unmet need based only on women's fertility intentions overestimates concordant unmet need. Additionally, that approximately 15–23 percent of couples have husband‐only unmet need suggests that men could be an entry point for contraceptive use for more couples than at present. To calculate husbands' unmet need, population‐based surveys should consider collecting the necessary data consistently.     

Unmet Family Planning Need: Differences and Levels of Agreement Between Husband-Wife, Haryana, India

Research question:

Is there agreement between husbands and wives regarding unmet need of family planning?

Hypothesis:

The unmet need of family planning is perceived more by women then their husbands.

Objective:

1) To ascertain the unmet needs of family planning for husbands and wives. 2) To ascertain the level of agreement between husbands and wives regarding unmet needs of family planning.

Design:

A cross-sectional survey

Setting:

Dayalpur village in Intensive field practice area of Comprehensive Rural Health Services project (CRHSP), Ballabgarh, Haryana.

Study Period:

July 2003- June 2005.

Participants

included 200 married couples selected by simple random sampling.

Statistical Analysis:

Level of agreement between husbands and wives was analyzed using Kappa statistics.

Results:

Unmet need for family planning was 11% (22 out of 200) for husbands and 17.5% (35 out of 200) for wives. The difference was seen both in unmet need for spacing (M-3.5% vs. F-6%) as well as limiting family size (M-7.5% vs. F-11.5%). Overall, 93.5% concordance was observed amongst husbands and wives. In all the cases where disagreement was seen (6.5%), wives reported having unmet need for contraception whereas their husbands perceived none. The unadjusted Kappa statistic was 0.73 and prevalence adjusted Kappa was 0.88.

Conclusion:

Unmet need for family planning was significantly higher for wives compared to husbands. Despite high degrees of agreement amongst the couples, the nature of disconcordance reinforces the need for policy makers to take into account the perspective of men.     

Family Planning Use among Urban Poor Women from Six Cities of Uttar Pradesh, India

Family planning has widespread positive impacts for population health and well-being; contraceptive use not only decreases unintended pregnancies and reduces infant and maternal mortality and morbidity, but it is critical to the achievement of Millennium Development Goals. This study uses baseline, representative data from six cities in Uttar Pradesh, India to examine family planning use among the urban poor. Data were collected from about 3,000 currently married women in each city (Allahabad, Agra, Varanasi, Aligarh, Gorakhpur, and Moradabad) for a total sample size of 17,643 women. Participating women were asked about their fertility desires, family planning use, and reproductive health. The survey over-sampled slum residents; this permits in-depth analyses of the urban poor and their family planning use behaviors. Bivariate and multivariate analyses are used to examine the role of wealth and education on family planning use and unmet need for family planning. Across all of the cities, about 50% of women report modern method use. Women in slum areas generally report less family planning use and among those women who use, slum women are more likely to be sterilized than to use other methods, including condoms and hormonal methods. Across all cities, there is a higher unmet need for family planning to limit childbearing than for spacing births. Poorer women are more likely to have an unmet need than richer women in both the slum and non-slum samples; this effect is attenuated when education is included in the analysis. Programs seeking to target the urban poor in Uttar Pradesh and elsewhere in India may be better served to identify the less educated women and target these women with appropriate family planning messages and methods that meet their current and future fertility desire needs.     

Do Ambivalent Women Have an Unmet Need for Family Planning? A Longitudinal Study from Bali,Indonesia

IntroductionFertility intentions often can predict contraceptive demand and fertility outcomes. Little is known about women reporting ambivalent fertility intentions, who are usually classified as having an unmet need for contraception. This study’s objectives were to determine 1) which fertility intention group ambivalent women more closely resemble and 2) whether ambivalent women seem to have an unmet contraceptive need.MethodsWe analyzed longitudinal data from 1,018 married Balinese women aged 15 to 45, of whom 33% desired more children, 52% wanted no more, and 14% were ambivalent. Ambivalent women were compared with those with definitive intentions using bivariate analyses. Regression analysis was used to determine the predictors of birth avoidance.ResultsAlthough ambivalent women were significantly older, and had less education and more children than women who wanted more children, ambivalent women were more similar in their contraceptive use to those who wanted more children than those who wanted no more. However, in terms of birth outcomes, ambivalent women resembled more the women who intended to avoid childbearing: After 4 years, 33% of ambivalent women had another birth compared with 29% of women who wanted no more and 57% of women who desired more children. Contraceptive use at baseline did not predict ambivalent women’s fertility outcomes, unlike the other groups.ConclusionDespite their relatively low rates of contraceptive use at baseline, ambivalent women generally avoided giving birth during the study period. This suggests that ambivalent women may not have a high unmet need for family planning.     

The Role of Health Literacy in Family Planning Use among Senegalese Women

Health communication has contributed to an increase in family planning use through education and mass media as a means to increase health literacy. In this research, we investigate health literacy as an auxiliary component of health communication. We test the validity of the Health Literacy Skills Framework by examining the correlation of health literacy indicators to family planning use among Senegalese women in the 2014 Demographic Health Survey. We found that increased family planning use was most strongly associated with hearing family planning messages through television and radio. Other health literacy indicators, including access to printed family planning messaging, textual literacy, and knowledge of ovulatory cycles did not strengthen family planning use, even when performing a subgroup analysis of women who could read. The implications are that the Health Literacy Skills framework can measure health literacy’s ability (assessed through proxy indicators of health literacy) to predict modern family planning use among Senegalese women and that audio and visual health literacy measures are most strongly associated with increased family planning use.     

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

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

Disparities in Unmet Dental Need and Dental Care Received by Pregnant Women in Maryland

To examine prenatal dental care needs, utilization and oral health counseling among Maryland women who delivered a live infant during 2001–2003 and identify the factors associated with having a dental visit and having an unmet dental need during pregnancy. Pregnancy Risk Assessment Monitoring System is an ongoing population based surveillance system that collects information of women’s attitudes and experiences before, during, and shortly after pregnancy. Logistic regression was used to model dental visits and unmet dental need using predictor variables for Maryland 2001–2003 births. Less than half of all women reported having a dental visit and receiving oral health advice during pregnancy. Twenty-five percent of women reported a need for dental care, of which 33 % did not receive dental care despite their perceived need. Multivariate modeling revealed that racial minorities, women who were not married and those with annual income <$40,000 were least likely to have a dental visit. Women who were not married, had low annual income, were older than 40 years of age, had an unintended pregnancy and received prenatal care later than desired were most likely to have an unmet dental need during pregnancy. Despite reported needs and existing recommendations to include oral health as a component of prenatal care, less than half of pregnant women have a dental visit during their pregnancy. One-third of women with a dental problem did not have a dental visit highlighting the unmet need for dental care during pregnancy.     

Accumulation of Jail Incarceration and Hardship,Health Status,and Unmet Health Care Need Among Women Who Use Drugs

Background

Jail is frequently described as a “revolving door,” which can be profoundly destabilizing to people moving in and out of the system. However, there is a dearth of research attempting to understand the impacts of the accumulation of incarceration events on women who use drugs. We examined the association of the frequency of jail incarceration with hardship, perceived health status, and unmet health care need among women who use drugs.

Unmet Need for Medical Care and Safety Net Accessibility among Birmingham’s Homeless

Although homeless individuals often experience health problems requiring care, there are limitations to available research concerning the scale of their needs and the accessibility of safety net agencies to meet them. Traditional access-to-care surveys calculate unmet need among all persons queried (rather than persons needing care), making it difficult to calculate what percentage of persons requiring care actually obtain it. Additionally, no research has compared the relative accessibility of safety net programs to homeless persons in need. This cross-sectional, community-based survey assessed the prevalence of unmet need for several specific types of health care and compared the accessibility of agencies in Birmingham, AL. Substantial proportions of respondents reported unmet needs for general medical care (46 %), specialty care (51 %), mental health care (51 %), dental care (62 %), medications (57 %), and care of a child (23 %). The most commonly mentioned sites where care was sought included a federally funded Health Care for the Homeless (HCH) program (59 %), a religious free clinic (31 %), and a public hospital emergency department (51 %). The HCH program was most commonly cited as the location where care, once sought, could not be obtained (15 %), followed by the county hospital primary care clinics (13 %). In this survey, unmet need was common for all types of care queried, including primary care. Key components of the safety net, including a federally funded homeless health care program, had suboptimum accessibility.     

Contraceptive Use Patterns among Women of Reproductive Age in Two Southeastern States

BackgroundUnintended pregnancies remain an important public health issue. Modern contraception is an important clinical service for reducing unintended pregnancy. This study examines contraception use among a representative sample of women residing in two southeastern U.S. states.MethodsA cross-sectional statewide survey assessing women's contraceptive use and reproductive health experiences was conducted in Alabama and South Carolina. Characteristics of the study population were compared across contraceptive use categories and multivariable regression analysis was performed examining relationships between covariates of interest and contraceptive use outcomes.ResultsApproximately 3,775 women were included in the study population. Overall, 26.5% of women reported not using any contraception. Short-acting hormonal methods were the most commonly reported (26.3%), followed by permanent methods (24.4%), long-acting reversible contraception (LARC; 14.3%), and barrier/other methods (8.5%). Nonuse was more prevalent among women with some college or an associate's degree, incomes between $25,000 and $50,000, no health insurance, and longer gaps in care. LARC use among women with Medicaid as a pay source was higher than use among privately insured women and higher in South Carolina than Alabama. Both nonuse and LARC use were higher among women with no insurance.ConclusionsStudy findings are largely consistent with previous research using similar population-based surveys. LARC use was higher among the study population relative to what is observed nationally. Factors enabling access to contraceptive services, particularly for lower income women, were associated with contraception use patterns. These findings provide important context for understanding individuals’ access to resources and are important for fostering increased access to contraceptive services among women in these two states.     

Aligning Funding and Need for Family Planning: A Diagnostic Methodology

With limited international resources for family planning, donors must decide how to allocate their funds to different countries. How can a donor for family planning decide whether countries are adequately prioritized for funding? This article proposes an ordinal ranking framework to identify under‐prioritized countries by rank‐ordering countries by their need for family planning and separately rank‐ordering them by their development assistance for family planning. Countries for which the rank of the need for family planning is lower than the rank of its funding are deemed under‐prioritized. We implement this diagnostic methodology to identify under‐prioritized countries that have a higher need but lower development assistance for family planning. This approach indicates whether a country is receiving less compared to other countries with similar levels of need.     

长期使用口服避孕药妇女对计划生育服务需求的调查

目的:调查分析杭州市育龄妇女使用口服避孕药(OC)现状和服务需求,为OC的使用推广、宣教和咨询提供依据。方法:以调查问卷方式进行定性研究。结果:多数对象主观感觉使用OC对性欲、情绪、体重、月经周期和身体健康等方面无明显影响;最感烦恼的是月经量过少;大多数对象对提供的OC、相关信息和咨询服务表示满意,提供服务途径方便,提供咨询对选择OC有帮助。有关OC效果、优缺点、副作用、长期影响和新型OC的信息的提供相对不足。结论:加强OC效果、优缺点、副作用、长期影响、相应的措施和新型OC信息等的提供。     

Violence Against Women in Selected Areas of the United States

Objectives. We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States.Methods. We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence.Results. Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse.Conclusions. Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.Violence against women is increasingly recognized as a critical national public health concern in the United States, as evidenced by the recent signing of the Violence Against Women Act by President Obama.1 Based on nationally representative samples, it is estimated that in their lifetime, nearly 1 in 3 US women has survived physical violence, and 1 in 10 has survived rape.2 Women who experience emotional, physical, and sexual violence not only experience the injury of the initial trauma, but also have higher rates of depression, posttraumatic stress disorder (PTSD), substance abuse, re-victimization, and high-risk sexual behaviors.3–7There is strong evidence that supports the relationship between experiencing intimate partner violence (IPV) and HIV risk, as well as acquiring HIV.8–20 In the United States, the relationship between IPV, especially sexual violence, and HIV came to light almost 20 years ago.5 Several studies6,10,17,18,20,21 during the past decade reported high co-occurring rates of violence, HIV risk, mental illness, and substance use in the United States among incarcerated women,22 female substance users,19 women in shelters,23,24 women living in impoverished areas,25–28 and women engaging in prostitution.29 Not only do these conditions frequently co-occur, but the presence of one may magnify the effects of the others, thus demonstrating the notion of a “syndemic,” which is a term used to refer to a set of synergistic or intertwined and mutually enhancing health and social problems facing vulnerable populations such as women living in poverty.30 However, interpretation and generalizability across studies has been difficult because of small sample sizes, convenience samples (e.g., women in methadone treatment, shelters, or clinics), narrowly defined study populations, the inclusion of both women living with HIV and women living without HIV, and poorly standardized study variables that typically did not include emotional abuse (e.g., combining different types of violence or combining childhood and adult violent experiences).5,6,10,31Overall, most published US data have suggested that women living with HIV experience IPV at the same rate as women not living with HIV from the same population, but that women living with HIV experience such violence more frequently and with increased severity.9,31 In addition, substance abuse, poverty, and other HIV risk factors were associated with experiencing violence and therefore, also contribute to the HIV and IPV relationship.9,32 However, many of these studies focused on “intimate” partner violence specifically and not on violence overall. For example, using a large representative sample of US women (n = 13 928), Sareen et al.8 found that women who experienced any IPV in the past year were more than 3 times as likely to report an HIV/AIDS diagnosis by a health professional as women who had not experienced IPV. They postulated that nearly 12% of HIV/AIDS infections among US women in intimate relationships was caused by IPV. Despite its novel contribution to the examination of the relationship between HIV infection and IPV among US women, this study was limited because it only examined physical and sexual IPV in the past 12 months. Another large-scale domestic study by Stockman et al. assessed specific types of sexual coercion in a nationally representative sample of 5857 US women and found positive associations among coerced sex, using drugs and alcohol, and having multiple sexual partners.20 However, this study was limited in the way it assessed HIV risk by not examining perceived partner risk factors. Other recent studies have further elucidated this complex clustering of risk factors, but sample sizes have remained small, and measures of sexual HIV risk behaviors have varied widely.9,33,34Because of the concentration of HIV/AIDS in key areas of the United States, the HIV Prevention Trials Network (HPTN) study 064 was uniquely designed to recruit a representative sample of women living in US areas with high poverty and a high prevalence of HIV.26,27 Unlike the more diffuse HIV epidemics seen in other countries, HIV in the United States has striking socioeconomic and racial disparities that are concentrated in key “hot spots” of the Northeast, South, and West. However, HIV among women in the United States is still not fully appreciated in the current HIV prevention research.26,27 HPTN 064 made a significant public health contribution by assessing key social and behavioral factors that contribute to HIV acquisition among women in the United States by exploring the risk of HIV infection among certain populations of US women and providing information about their risk behaviors.35 We used this large data set to assess the following: (1) the prevalence of emotional abuse, physical violence, forced sex, and experiencing 2 or more types of violence; and (2) sociodemographic characteristics, personal HIV-risk behaviors, and perceived sex partner behaviors associated with each type of violence.     

Motivators and Barriers to Prenatal Supplement Use among Minority Women in the United States

Minority women in the United States are at a higher risk of iron deficiency and less likely to report use of prenatal supplements compared with non-Hispanic white women. Little information exists on the perceived benefits and barriers to prenatal supplement use. We analyzed the results of 12 focus groups conducted with African-American and Hispanic women (n=104). Groups were equally divided into consistent (five to seven times per week for 3 or more months) and inconsistent (zero to four times per week for 0 to 2 months) users and by race/ethnicity. We examined motivators and barriers to prenatal supplement use and identified common themes; we also compared responses between consistent and inconsistent users, and between African American and Hispanic women. For all groups, positive effects, convenient supply, affordability, and reinforcement by health care providers enhanced adherence. Common barriers were prenatal supplement qualities, adverse effects, and poor communication from health care providers about the benefits of use. Common motivators among consistent users included social network reinforcement of daily intake and fear of adverse effects to the fetus if prenatal supplements were not taken. Common barriers among inconsistent users included skepticism toward the efficacy and necessity of prenatal supplements and the health care provider assenting to nonadherence. Prenatal supplement use was influenced by multiple factors in women's daily lives. Adherence will likely be enhanced by reducing barriers related to prenatal supplement qualities and adverse effects, improving social network support, and improving health care provider interactions.     

深圳市育龄妇女计划生育/生殖健康咨询需求调查

目的:了解深圳市育龄妇女生殖健康与计划生育咨询需求,为进一步开展计划生育优质服务提供理论依据。方法:在深圳地区选取研究对象998名,采用定性定量的方法收集数据。结果:对避孕方法名称知晓率最低的是皮下埋植(42.83%),最高的是避孕套(91.98%);缺点知晓率最高的是紧急避孕(59.88%),最低的是避孕针剂(46.56%)。咨询服务满意度满意率较高,为97.49%。育龄群众生殖健康知识水平还需要提高,对计划生育咨询内容范围还需要扩大。结论:在今后的计划生育服务中,应加强计划生育咨询的深度和广度,根据不同需求提供不同的性和生殖健康的知识。     

Medical Marijuana Laws,Marijuana Use,and Opioid-Related Outcomes among Women in the United States

BackgroundIn the context of the opioid epidemic, a limited but growing body of literature has found state medical marijuana laws (MMLs) to be associated with lower levels of opioid prescribing. However, robust evidence linking state MMLs with individual-level opioid-related outcomes is lacking, particularly among women. This finding is especially true for pregnant and parenting women, who have been disproportionately affected by the opioid crisis.MethodsUsing data drawn from the 2002–2014 National Survey on Drug Use and Heath, the study uses a difference-in-differences estimation strategy to compare opioid-related outcomes (opioid misuse initiation, opioid misuse in the past month and past year, and opioid use disorder) among all women, pregnant women, and parenting women in states with and without MMLs (before and after implementation). The study also investigates the impact of MMLs on marijuana use and marijuana use disorder.ResultsThe findings indicate that MMLs were not associated with opioid misuse, opioid misuse initiation, or opioid use disorder among all women, pregnant women, and parenting women. These laws were, however, positively correlated with marijuana use and marijuana use disorder among all women and women with children. In addition, MMLs were associated with an increase in the frequency of opioid misuse for pregnant women and a decrease in the frequency of opioid misuse for parenting women.ConclusionsThis finding suggests that, although medical marijuana may be viewed by some as a substitute for opioid analgesics, MMLs may not be an effective policy tool to tackle the opioid epidemic among women, especially pregnant and parenting women.     

Pathways to Modern Family Planning: A Longitudinal Study on Social Influence among Men and Women in Benin

Despite improvements in family planning (FP) knowledge and services in West Africa, unmet need for FP continues to grow. Many programs apply a demographically and biologically driven definition of unmet need, overlooking the complex social environment in which fertility and FP decisions are made. This longitudinal, qualitative cohort study captures the changing nature of FP need, attitudes and behaviors, taking into account life context to inform understanding of the complex behavior change process. Purposively sampled, 25 women and 25 men participated in three rounds of in‐depth interviews over 18 months. Analyses used a social network influence lens. Findings suggest alignment of six foundational building blocks operating at individual, couple, services, and social levels is essential to meet FP need. If one block is weak, a person may not achieve met need. Women and men commonly follow five pathways as they seek to fulfill their FP need. Some pathways achieve met need (determined users, quick converters), some do not (side effect avoiders), and some do not lead to consistent FP outcomes (male‐priority decision makers, gender–egalitarian decision makers). Findings clarify the role of social determinants of FP and offer insight into program approaches informed by user typologies and return on program investments.