Minimizing missed opportunities: an approach to decrease the unmet need for family planning

Objectives The aim of the study was to determine the participants with unmet need and to show that family planning consultancy given to women and men attending the first-level health facilities would increase contraceptive usage and reduce unmet need for family planning. Methods All married women aged 15-49 years and men having wives of the same age group attending the health centers for any service other than family planning were included in the study. Among 2021 attendants, a total of 1701 participated in the study (84.2%). Participants were interviewed after they took the services for which they attended. At the end of the inquiries, all willing participants were referred to the family planning unit in the same building. Results The unmet need (need for any or more effective contraceptive methods) was 43.1%. All participants with unmet need were referred to the family planning unit in the same building and willing participants were given family planning services. Of the participants, 23.9% attended the family planning unit and 17.8% took services immediately at the time of the attendance. Conclusions Linking family planning services with other health services can be a cheap and practical way to reduce the unmet need.     

Minimizing missed opportunities: an approach to decrease the unmet need for family planning.

OBJECTIVES: The aim of the study was to determine the participants with unmet need and to show that family planning consultancy given to women and men attending the first-level health facilities would increase contraceptive usage and reduce unmet need for family planning. METHODS: All married women aged 15-49 years and men having wives of the same age group attending the health centers for any service other than family planning were included in the study. Among 2021 attendants, a total of 1701 participated in the study (84.2%). Participants were interviewed after they took the services for which they attended. At the end of the inquiries, all willing participants were referred to the family planning unit in the same building. RESULTS: The unmet need (need for any or more effective contraceptive methods) was 43.1%. All participants with unmet need were referred to the family planning unit in the same building and willing participants were given family planning services. Of the participants, 23.9% attended the family planning unit and 17.8% took services immediately at the time of the attendance. CONCLUSIONS: Linking family planning services with other health services can be a cheap and practical way to reduce the unmet need.     

Postpartum contraceptive use among adolescent mothers

OBJECTIVE: To compare the incidence of repeat pregnancy and method continuation rate at 12 months postpartum in young women who chose either depot medroxyprogesterone acetate or oral contraceptives (OCs) as contraception. METHODS: We conducted a prospective cohort study of 122 postpartum women younger than 18 years of age who delivered between January 8, 1997 and December 31, 1997. Patients choosing depot medroxyprogesterone acetate (n = 76) and OCs (n = 46) were accrued for 12 months and were followed-up for a minimum of 12 months. Main outcome measures were median contraceptive method continuation and the incidence of repeat pregnancy at 12 months postpartum. RESULTS: There was no difference in mean age at delivery (P =.47), parity (P =.84), or gravidity (P =.78) between depot medroxyprogesterone acetate and OC users. At 12 months postpartum, 27.4% of OC users and 55.3% of depot medroxyprogesterone acetate users were still using contraception. Median time to contraceptive discontinuation was longer for those choosing depot medroxyprogesterone acetate compared with OCs (17.8 vs 7.4 months, respectively, P =.002). The overall incidence of repeat pregnancy at 12 months postpartum was 10.6%. Among OC and depot medroxyprogesterone acetate users, respectively, 24% and 2.6% became pregnant again, producing a relative risk (RR) of 9.09 (95% confidence interval [CI] 2.1, 39.2) for repeat pregnancy among OC users. The mean time to repeat pregnancy (this was reported instead of the median time whenever the pregnancy rate had not reached 50% at the end of the follow-up period) was longer for depot medroxyprogesterone acetate compared with OC users (17.1 months vs 13.2 months, respectively, P <.001). CONCLUSION: Adolescent mothers using depot medroxyprogesterone acetate injection for contraception have a higher method continuation rate and a lower incidence of repeat pregnancy at 12 months postpartum than those selecting OCs during the same period.     

计划生育需要系统评价

“多相口服避孕药符合生理特点，比单相避孕药好；宫内节育器可引起盆腔感染及输卵管不孕症，所以未生育的妇女不应使用宫内节育器：使用口服避孕药的妇女每隔儿年需要停用一段时间，让身体休息一下。”全世界的临床医生每天都会听到这些看法或类似的观点。但是，这些观点是可信的吗?歌德说过，一些观点重复多次以后便会显现其自身的生命力。     

The need for integrating family planning and postabortion care in China

Objective

To assess the need for integrating postabortion care with family planning services in China.

Method

We collected data from a clinic-based study of 24 abortion clinics in 3 large cities in China.

Results

There was a total of 287 (10.3%) high-risk abortions among the 2780 respondents, 974 (35%) of whom had had repeated abortions and 48.4% had had 2 abortions within 1 year; 63.7% of the current pregnancies resulted from not using contraceptives; 28.8% and 19.8% of these new pregnancies, respectively, were due to the failure of the rhythm or the withdrawal method; only 9.7% of the respondents consistently used condoms; and only 9.1% could identify the correct time of their first ovulation following an abortion.

Conclusion

Contraceptive neglect and the high rates of repeated and high-risk abortions call for the integration of postabortion care with family planning services in China.     

Implementing microbicides in low-income countries

The magnitude of the global human immunodeficiency virus (HIV) epidemic is determined by women from lower income countries, specifically sub-Saharan Africa. Microbicides offer women who are unable to negotiate safe sex practices a self-initiated HIV prevention method. Of note, is its potential to yield significant public health benefits even with relatively conservative efficacy, coverage and user adherence estimates, making microbicides an effective intervention to invest scarce healthcare resources. Existing healthcare delivery systems provide an excellent opportunity to identify women at highest risk for infection and to also provide an access point to initiate microbicide use. Innovative quality improvement approaches, which strengthen existing sexual reproductive health services and include HIV testing, and linkages to care and treatment services, provide an opportunity to lay the foundations for wide-scale provision of microbicides. The potential to enhance health outcomes in women and infants and potentially affect rates of new HIV infection may soon be realised.     

Obstetric fistula in low-income countries

Objective

To identify, survey, and systematically review the current knowledge regarding obstetric fistula as a public health problem in low-income countries from the peer-reviewed literature.

Methods

The Medline and Science Citation Index databases were searched to identify public health articles on obstetric fistula in low-income countries. Quantitative evidence-based papers were reviewed.

Results

Thirty-three articles met the criteria for inclusion: 18 hospital-based reviews; 6 on risk factors/prevention; 4 on prevalence/incidence measurement; 3 on consequences of obstetric fistula; and 2 on community-based assessments.

Conclusion

Obstetric fistula has received increased international attention as a public health problem, but reliable research on the burden of disease and interventions is lacking.     

The use of periodic abstinence for family planning

This review of periodic abstinence for family planning emphasizes terminology and distinctions between the prevalent methods, and issues that will enable the health practitioner to be informed about this family planning choice. Periodic abstinence developed in the 1930s when Ogino and Knaus independently discovered the timing of ovulation, and consequently the calendar-based rhythm method became sanctioned by the church. Philippine surveys find a 40/100 woman-year pregnancy rate with rhythm. The cervical mucus method is also known as the ovulation, Billings or mucus method. Coitus is permitted by the 4th night after the peak day. Symptoms may be obscured by vaginal or seminal fluids, infections, allergies, or drugs. The symptothermal method employs mucus symptoms and basal body temperature. Coitus is allowed on the 3rd night after the temperature rise. It has the lowest failure rate, ranging from 11.2-19.8. Some family planning groups also use other symptoms such as midcycle spotting or pain, cervical position, dilation or texture, moods or libido. Various teaching groups have published charts that facilitate charting symptoms, such as temperature graphs with wide scales to make it easier to read the temperature rise. Measuring efficacy rates is difficult, and different definitions are used for several types of failures. The most important factor in success with natural family planning is the motivation of the couple. The most common cause of failure is conscious departure from the rules. Some current issues regarding abstinence are possible risks of birth defects from aged gametes, the difficulty of predicting ovulation in women with irregular cycles, the effects of vaginal infection and illness on the mucus signs, the potential for sex selection through the use of timing of intercourse and development of tests and devices to predict ovulation.     

Postpartum contraceptive needs in northern Haiti

Objective

To assess the knowledge of, attitudes toward, and practices regarding postpartum contraception among healthcare providers and postpartum women in northern Haiti.

Methods

Six focus groups were conducted with postpartum patients and 3 were conducted with maternity service providers; a structured questionnaire was then administered to postpartum patients.

Results

In total, 282 postpartum women were included in the present study: 249 in the survey and 33 in focus groups. Although 97.9% of women expressed a desire for family-planning counseling before discharge from the postpartum ward, only 6.0% of women received such counseling. Most women wanted to space or limit their pregnancies; 79.8% of women, including those with only 1 child, wanted to choose a contraceptive method before discharge. Providers expressed concern for the volume of induced abortions and maternal deaths within the hospital, which many felt could be averted by improving postpartum family planning. However, there was no postpartum contraceptive counseling or method provision in the present setting, and no providers had experience in initiating methods immediately postpartum.

Conclusion

Efforts to integrate family planning into postpartum care services could help to reduce the unmet need for family planning, and help patients and providers reach their goals.     

Experience with self-administered emergency contraception in a low-income, inner-city family planning program

OBJECTIVE: To evaluate women's use, knowledge of and attitudes toward self-administered emergency contraceptive pills (ECP) at the University of Pennsylvania family planning clinic (FPC). STUDY DESIGN: The University of Pennsylvania FPC is a Title X, publicly funded clinic serving urban, low-income women. All women attending the clinic were offered ECP packets. Exclusion criteria for ECP were current pregnancy or newly diagnosed hypertension. Women signed consent forms and were given specific instructions on using ECP with the standard Yuzpe method. Women were contacted for a phone interview after they had the ECP packets at home for six to eight months. RESULTS: One hundred ninety-two women received the ECP packets. Forty-eight were contacted and completed the survey. One hundred forty-four women had moved, no longer had phone service or were unreachable after three or more attempts. Eleven of the 48 women (22.9%) used the ECP, but only 2 of 11 (18.2%) took the pills correctly. One of these two women became pregnant. Of the women who had not used the ECP packets, only 25 of 37 (67.6%) could locate them, and only 9 of 37 (24%) could recall how to use them correctly. Four of 37 (10.8%) experienced an unplanned pregnancy. CONCLUSION: Emergency contraception utilization was far lower than anticipated, suggesting that ready access is not the only issue. Many of the women did not administer ECP correctly or could not state how they would use it in the future despite extensive instruction. Patients will require new and creative approaches to encourage their appropriate use of emergency contraception.     

On the need and feasibility of establishing family planning centers in factories

The author discusses reasons why family planning centers should be located in factories and reports his experience in attempting to organize such centers. He feels that most needed services that these centers should provide are education and counseling, not simply contraception. He believes that the majority of women could be reached in their place of work in a manner cost-effective for businesses. Persons such as adolescents and immigrants are not likely to patronize family planning clinics in maternity hospitals in the suburbs or in villages where they are known. The author attended a meeting of the Superior Council of Sex Information devoted to founding family planning clinics in factories. He suggested sending proposals to the boards of directors of businesses employing large numbers of women. In Lille counseling centers have been instituted in several factories with excellent results.     

The dynamics of contraceptive use in developing countries. Pt. 1

The dynamics of contraceptive use in developing countries are described in an abbreviated discussion and are based on a prospective study of the determinants of contraceptive use in India. It is acknowledged use varies among different populations. Contraceptive use behavior is complex and affected by more than just desired family size. The pattern of usage may vary throughout the childbearing years. There is a complex interplay of various sociocultural and behavioral factors associated with the process of choice, continuation or cessation of use of a method, or switching to another method. Not only behavioral factors that operate at the individual level, but national factors such as the national family planning and health services are involved. Information on the social, cultural, and service related determinants of choice and use of different methods is important for policy makers. It affords them the information to plant what methods to offer, the supply of methods, and significance of offering new methods. Policy makers concerned with family planning to reduce fertility need to know to what extent the desire to become pregnant is a reason for discontinuation vs. method failure, opposition by spouse, or health concerns about side effects. Those desiring 2 children were twice as likely to have used other methods prior to sterilization than those desiring 4. Fertility intention was related to choice of method. The distance to the health clinic from home was also related to the prior use of methods before sterilization. Those 1 km from a clinic had a 1.8 times greater chance of having used another method prior to sterilization. IUD and pill users had high discontinuation rates. IUD users shifted to sterilization (34%) or natural methods (20%). while pill users changed to the IUD (49%), sterilization (29%), and the condom (23%). Fertility intentions, the nature and extent of health services, and woman's education affected the pattern. The number of living sons, the inaccessibility of services, and poor knowledge of spacing methods lead to more women accepting sterilization. Overall fertility rates have not had the desired impact from the current contraceptive use patterns (sterilization and little birth spacing). Lack of education affects the use of the pill and IUD knowledge of methods other than sterilization. Mothers desiring 4 or more children are less likely to space and exceed the desired size. Women's education and the quality and extent of health services are the 2 most important intervention efforts.     

Choices on contraceptive methods in post-abortion family planning clinic in the northeast Brazil

Background  

In Brazil, a Ministry of Health report revealed women who underwent an abortion were predominantly in the use of contraceptive methods, but mentioned inconsistent or erroneously contraceptive use. Promoting the use of contraceptive methods to prevent unwanted pregnancies is one of the most effective strategies to reduce abortion rates and maternal morbidity and mortality. Therefore, providing post-abortion family planning services that include structured contraceptive counseling with free and easy access to contraceptive methods can be suitable. So the objective of this study is to determine the acceptance and selection of contraceptive methods followed by a post-abortion family planning counseling.     

The impact of the quality of family planning services on safe and effective contraceptive use: a systematic literature review

The aim of this review is to identify the features of family planning service provision that are influential in ensuring safe and appropriate contraceptive use and optimal effectiveness of user-dependent methods. A systematic search was carried out of the published and unpublished studies available up to December 1997 that examined the relationship between family planning service provision and contraceptive use. Articles that reported primary data on long-term outcomes were scored by at least two of the authors of the present study. Particular attention was paid to evaluating methods of measuring quality of care. A total of 142 articles were identified, but only 16 reported primary data relating to long-term outcomes. The quality of provider--client exchanges was found to have a net incremental effect on contraceptive use. Evidence of effectiveness of methods to improve uptake, continuation of method use, and safe and appropriate use of fertility control is scant. The evidence that is available indicates that training in communication with clients (particularly about side-effects of contraceptive methods) and an emphasis on client choice are key components of effective interventions. The tasks of listening to clients, and tailoring services to local needs, are crucial to the success of family planning service provision.     

The impact of the quality of family planning services on safe and effective contraceptive use: A systematic literature review

The aim of this review is to identify the features of family planning service provision that are influential in ensuring safe and appropriate contraceptive use and optimal effectiveness of user-dependent methods. A systematic search was carried out of the published and unpublished studies available up to December 1997 that examined the relationship between family planning service provision and contraceptive use. Articles that reported primary data on long-term outcomes were scored by at least two of the authors of the present study. Particular attention was paid to evaluating methods of measuring quality of care. A total of 142 articles were identified, but only 16 reported primary data relating to long-term outcomes. The quality of provider-client exchanges was found to have a net incremental effect on contraceptive use. Evidence of effectiveness of methods to improve uptake, continuation of method use, and safe and appropriate use of fertility control is scant. The evidence that is available indicates that training in communication with clients (particularly about side-effects of contraceptive methods) and an emphasis on client choice are key components of effective interventions. The tasks of listening to clients, and tailoring services to local needs, are crucial to the success of family planning service provision.     

Differences in contraceptive choice among female adolescents at a state-funded family planning clinic

Our objective was to examine differences in contraceptive choice among female adolescents from low socioeconomic backgrounds both before and after an appointment for reproductive health care at a community-based, state-funded, family planning clinic. This study utilized data collected from 4237 charts from young women attending a family planning clinic. Logistic regression was utilized to examine variables associated with the following main questions: (1) the selection of use or nonuse of contraception; (2) the selection of barrier versus hormonal contraception; and (3) within those who selected hormonal contraception, the preference for injectable versus oral hormonal methods. We found that race, age, school status, and type of health insurance were all associated with contraceptive decision-making among female adolescents. Some but not all of these associations remained after the clinic visit, which included no-cost contraception.