The user perspective in northern Thailand: a series of case studies

Comprehensive case histories were obtained from 37 rural Thai women to gain a deeper understanding of the factors that influence the behavior, perceptions, and attitudes of long term contraceptive users. As a group, the women had experimented with a wide range of contraceptive methods, and while many experienced side effects, there was a very high level of motivation to use and continue contraception. The government family planning delivery network appeared successful in making family planning services accessible, and health workers were often consulted. A potential health problem for some women stems from their continuous use of certain temporary family planning methods, such as the pill; they had been using them for more than 10 years and indicated their desire to continue until menopause. The subjects all live in Lampang province in varying levels of prosperity and accessibility to family planning and health centers. All but 1 woman began contraception with the pill with 58% continuing. 41% had changed their initial method. Reasons for using family planning included wanting no more children (39%), poverty (36%), desire for spacing children (20%), and not ready to have a family (5%). A majority discussed their decision with friends before going to obtain contraceptive methods, and went to government sources for this service. Place of service, cost of services, and attitudes toward childbirth, abortion, menstruation are also detailed. All feared abortion more than childbirth; 21 out of 37 respondents expressed no concerns with menstruation although for some work and religious attendance was affected by beliefs associated with menstruation.     

Do women and men consider abortion as an alternative to contraception in the United States? An exploratory study

The USA, a country with widespread access to the full range of modern methods of contraception, continues to have one of the highest abortion rates among developed countries. Forty-nine per cent of women reported ever experiencing an unintended pregnancy in 2001; 48% of these conceptions occurred during a month that contraception was used. We explored the extent to which people use contraception and abortion interchangeably to achieve their fertility goals via focus groups (n = 4) and semi-structured in-depth interviews (IDIs) (n = 18) with men and women between the ages of 18 and 35 in New York City in 2006. While there was a consensus that abortion cannot replace contraceptive use, poor couple communication, lack of planning, lack of acceptable contraceptive methods and the pleasures that people associate with having unprotected sex result in the perception that some individuals rely on abortion over contraception to prevent unintended births. Men and women both identified women as solely in charge of avoiding an unwanted pregnancy and resolving it should one occur. No one supported repeat abortions for themselves or others, and many respondents perceived multiple abortions to lead to infertility, which strengthens their position that substituting abortion for contraception is unacceptable.     

Pregnancy prevention,reproductive health risk and morality: a perspective from public-sector women's clinics in St. Petersburg,Russia

The use of reliable contraception in Russia remains lower and rates of induced abortion higher than in Western Europe, even though reliable contraception has been accessible for nearly two decades now. Due to the organisation of women's health services in Russian cities, gynaecologists can have a major influence on women's contraceptive choices, but little is known about their attitudes and practices in terms of contraception promotion. This study draws on qualitative observation and interview data of gynaecologists in public-sector women's clinics in St. Petersburg, Russia's second largest city in order to investigate their perceptions of various birth control methods and contraception counselling. Also in focus are clinical counselling practices. The results reveal that gynaecologists in St. Petersburg had up-to-date knowledge of the latest contraception methods and that they were willing to promote their use. They took an active role in counselling, although the coverage was not full. The depth of counselling varied considerably and counselling practices were mainly paternalistic. Yet, in about a third of the observed cases, patient preferences were incorporated into clinical decision-making. The gynaecologists perceived reliable contraception essentially as a means of fostering future fertility and avoiding harmful health consequences of induced abortions. Using reliable contraception was equated with being a responsible and morally respectable woman. The results suggest that links between health, risk and morality are vividly present in contraception counselling in St. Petersburg, and that reliable contraception has become a powerful source of new moral demands for individual women to foster their reproductive function.     

Fertility and contraception in the Marshall Islands

Data on fertility and contraception in Micronesian women in the Marshall Islands were collected during a women's health survey in 1985. High total fertility rates were found. The reproductive pattern of many Marshallese women is one that has been associated with adverse health consequences: pregnancies in teenagers and in women over 39 years, high parities of four or more births, and short birth intervals. The practice of breastfeeding is declining in younger women. The prevalence of contraceptive use is low, and the availability of reversible methods is limited. Most contraceptive nonusers would like to practice contraception, but are inhibited by the lack of information about family planning. It is suggested that more attention needs to be given to family planning services in the Marshall Islands, in particular to improving the availability of reversible methods of contraception and of information about family planning. Further research is also needed on how family planning services might best be organized to maximize participation by women and their partners who wish to use such services.     

Abortion and fertility control in Korea

Findings are presented from a detailed study that used data from the 1974 Korean National Fertility survey to evaluate the impact of abortion on fertility and to investigate the interrelationships of abortion, contraceptive use, and contraceptive effectiveness in Korea. The relative effectiveness of contraception is low, the best being 76% effectiveness for women aged 30-34 in urban areas. Among women using contraception after abortion, the effectiveness is even lower. After the 1st abortion, 85% of the women aged 25-29 become pregnant with 2-5 years. 74% of women who use contraception after abortion become pregnant in this time compared to 92% of women who do not. Contraception when added to abortion achieves intervals that are twice as long as those for abortion alone. By using contraception, the interval from abortion to pregnancy is lengthened on average by 10.3 months for women aged 25-29, 11.5 months for those aged 30-34, and 9.3 months for those aged 35-39. The average number of abortions needed to avert a live birth in Korea is lower than the figure of 3.3 Potter estimated for societies with prolonged lactation. When contraception is not used, at least 1 abortion is needed each year to avert 1 live birth. With contraceptive use, the number of abortions needed to avert 1 live birth is between 0.55 and 0.62. The number of abortions needed in this case is greatly reduced when contraception is practiced more effectively. Comparing the actual level of contraceptive effectiveness in Korea in 1974 with a possible 95% effectiveness shows that this latter high level would have the same effect on fertility with approximately 6 fewer abortions throughout a woman's reproductive life. The actual reduction in numbers would be 5.8 in the 25-29 age group, 5.9 in the 30-34 age group, and 8.2 in the 35-39 age group. This reduction in the number of abortions necessary with 95% effective contraception as compared with actual contraceptive use, suggests considerable potential for reducing the need for additional abortions with improved contraception. The current situation has improved since 1974, due to the success of the sterilization program.     

Fertility and family planning in Vietnam.

This report provides the first reliable statistical data on fertility patterns and the family planning program in the Socialist Republic of Vietnam. Findings are from the 1988 Demographic and Health Survey of Vietnam and the 1989 census survey. The data show that the total fertility rate has declined from over 6 children per woman in the early 1970s to under 4 in the later 1980s. Contraceptive prevalence for modern methods is estimated at 37 percent among married women of reproductive age in 1988. The average duration of breastfeeding is over 14 months; marriage is relatively late. The IUD is the most common contraceptive method and abortion is widespread. The major factors likely to influence fertility and family planning in the future are the government's population policy, improved access to modern methods of contraception, and the institution of new economic policies that are currently under way in Vietnam.     

Women on top: the relative influence of wives and husbands on contraceptive use in KwaZulu-Natal

OBJECTIVES: The purpose of this paper is to examine the relative influence of husband and wife on contraceptive practice. METHODS: A cross-sectional survey was conducted among adult men and women in KwaZulu-Natal, South Africa. A matched file for 238 married or cohabiting couples was created. RESULTS: Knowledge of methods of contraception was virtually universal and attitudes to contraception were favorable both in men and women. A substantial proportion of men and women reported using a method of contraception. The wife's desire to stop childbearing was the most powerful predictor of contraceptive use among couples, after adjustment for possible confounders. The husband's approval (or not) of family planning and his preference for future childbearing were not significantly related to contraceptive use. CONCLUSION: Contraceptive use within marital and cohabiting unions is high and the wife's fertility preference was found to be a key determinant of use. This conclusion challenges conventional wisdom that men are the dominant decision-makers in fertility and family planning decisions.     

History of the Chinese Family Planning program: 1970-2010

BackgroundChina launched a nationwide family planning program offering birth control methods and family planning services in the 1970s. Promotion of the widespread use of long-term contraceptive methods has been one of the program's core strategies. This paper reviews the history of China's Family Planning Program at the national level from 1970 to 2010. Special attention is paid to the history of contraception policy.Study DesignThis study provides an overview of the last four decades of the Chinese Family Planning Program. Programmatic goals are highlighted during different time periods, with special attention being paid to the role of contraceptive use and the history of contraceptive policy.ResultsThe Chinese Family Planning Program has experienced several transitions. It has evolved from the 1970s period of moderate policy, represented by wan, xi, shao (late marriage and childbearing, birth spacing and limited fertility), through the strict one-child policy of 1979 to the early 1990s. From the mid-1990s to the present, a relatively lenient policy has been in force, characterized by client-centered informed choice.ConclusionsThe success of the Chinese Family Planning Program has long been heavily dependent on policies advocated by the central government, including programs promoting contraception to reduce fertility rates. The Program also depended on a logistical support system, including organizational safeguards and free provision of contraception and family planning services.     

Determinants of Contraceptive Acceptance Among Cambodian Abortion Patients

Although Cambodia's total fertility rate is declining, limited access to and use of contraceptives has meant that some women rely upon induced abortion, legal since 1997, to achieve their fertility intentions. This study identifies factors that facilitate acceptance of postabortion contraception among women using Cambodia's public health facilities. Data were collected in all of Cambodia's hospitals with obstetric and delivery services (n = 71) and a representative sample of 115 of its 887 health-care centers, and from women seeking induced abortion or with abortion complications who presented to selected facilities during a three-week period (n = 933). Weighted data from 316 women who reported not wanting to become pregnant within the next few months and who presented to facilities that provide postabortion contraceptives were analyzed for bivariate and multivariate associations. Approximately 42 percent of women accepted contraceptives at the conclusion of care. After controlling for individual and facility characteristics, women who presented at facilities where a nurse/midwife managed abortion services, where contraceptives and abortions were provided in the same room, and where a larger range of methods were offered had significantly higher odds of contraceptive acceptance following abortion care. Improving contraceptive counseling and training for midwives and physicians, increasing contraceptive choices, and promoting access to contraceptives on site may reduce Cambodian women's risk of unwanted pregnancy and, potentially, unsafe abortion.     

Service provider perspectives on post-abortion contraception in Nepal

The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility’s infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.     

Abortions in a hospital setting: hidden realities in Dar es Salaam, Tanzania.

This study investigates the extent of unwanted pregnancy, the use of illegally induced abortion, and the attitudes toward and practice of contraception among women admitted to a hospital with the diagnosis of abortion in Dar es Salaam, Tanzania. (In Tanzania, induced abortion is permitted only to save the mother's life.) A random sample of 300 women with early pregnancy loss admitted to Muhimbili Medical Centre, the teaching hospital in Dar es Salaam, were interviewed between September and November 1987, using a structured questionnaire. Among the 300 respondents, 155 said that their pregnancy had been unwanted: 94 of them presented with an illegally induced abortion and 61 with a spontaneous abortion. The number of spontaneous abortions of unwanted pregnancies increased with age and stability in a relationship. Having a small child to look after and having completed the family were the most common reasons for the pregnancy to be unwanted in this group. Induced abortion was more a problem of the young, unmarried woman. The 61 women with spontaneous abortion but unwanted pregnancy suggest that a much larger group of pregnant women continue to term with what are, at least initially, unwanted pregnancies--precisely the group of women family planning programs want to reach. The low prevalence of contraceptive use in this group indicates the failure of family planning clinics to motivate their target group. Recommendations are made for improved functioning of family planning clinics.     

健康教育提高育龄妇女避孕效率降低人工流产率的研究

对1800例已婚育龄妇女的避孕和人工流产情况进行流行病学调查,94.7％妇女正在避孕,58.4％妇女有过人工流产。对IUD、避孕药和阴茎套的续用率进行生命表分析,IUD15年累积续用率0.51。用Tietze法分析了原因和Cox模型检测与人工流产发生有关因素,提示妇女避孕知识缺乏与操作人不认真是最主要的,通过健康教育人工流产率明显下降。     

The impact of programs to increase contraceptive use among adult women: a review of experimental and quasi-experimental studies

CONTEXT: Because rates of unintended pregnancy, abortion and unintended birth are very high among adult women in the United States, it is important to identify interventions that can increase contraceptive use in this population. METHODS: PubMed, PsycINFO and POPLINE were searched for experimental or quasi-experimental studies published between 1990 and 2005 that evaluated policies or programs designed to increase contraceptive use or reduce pregnancy among adult women in the United States. In addition, relevant journals were searched, experts were asked to provide further citations and several subsequently published articles were included. RESULTS: Only 11 studies that assessed programs, and none that assessed policies, were found. The evaluated interventions offered pregnancy and STD prevention counseling (one study); provided contraceptives in settings other than family planning clinics (two studies); had women initiate contraceptive use during the medical visit (two studies); provided advance supplies of emergency contraception (four studies); or implemented systems to remind injectable contraceptive users about their next injection (two studies). The interventions generally had positive, albeit short-term, effects on contraceptive use; none reduced pregnancy rates. Programs that gave women a contraceptive during the visit were the most effective at increasing method use. Advance provision of emergency contraception increased the likelihood of its use and did not affect regular contraceptive use. CONCLUSIONS: Very few studies have evaluated interventions to increase contraceptive use among adult women. A research plan that rigorously assesses the impact of different approaches to increasing contraceptive use among adult women should be an integral part of any long-term effort to prevent unintended pregnancy in the United States.     

Reducing unplanned pregnancy and abortion in Zimbabwe through postabortion contraception

In many countries, women treated for complications from spontaneous or unsafely induced abortion lack access to contraceptive services. As a result, many of them soon have a subsequent unplanned pregnancy or a repeat abortion, placing their health at increased risk. This report presents the results of a prospective intervention study on postabortion family planning conducted in the two largest public hospitals in Zimbabwe. Women at Harare Central Hospital, in the capital, received a postabortion family planning intervention, and Mpilo Central Hospital, in Bulawayo, served as the control site. The study cohort was 982 women, 527 of whom were followed for a 12-month period. During the follow-up period, significantly more women used highly effective methods of contraception, significantly fewer unplanned pregnancies occurred, and fewer repeat abortions were performed at the intervention site than at the control site. These results offer compelling evidence that ward-based contraceptive services provided to women treated for incomplete abortion can significantly reduce subsequent unplanned pregnancies. The results also suggest that postabortion family planning services can reduce the incidence of repeat abortion.     

465例人工流产妇女婚育和避孕状况调查

目的了解25岁以下人工流产妇女的婚育和避孕状况,为生殖保健提供依据。方法通过自填和询问方式调查2004年1月-2008年9月在我院行人工流产的465例25岁以下妇女的婚育和避孕状况。结果人工流产妇女中已婚占28．2％,未婚占71．8％;文化程度以初中居多占32．0％;职业以公司职员最多占34．6％;本地户籍占69．5％,本县郊农村妇女占26．4％,外县占4．1％;人流未产妇占84．9％;人流为首次者占58．7％;妊娠原因以未采取避孕措施者居多占63．4％,避孕失败者为36．6％;男性关心避孕者占46．0％,男性主动采取的避孕措施为避孕套,占34．0％,男方建议女方不用避孕措施者占47．6％。结论未婚先孕和避孕率低是人流率高的重要原因;避孕失败率较高及男性参与避孕不够,值得重视;计划生育和生殖保健工作的对象应扩大到整个育龄妇女及男性。     

社区规范开展流产后服务的必要性

目的通过对笔者所在医院325例人工流产后接受随访的育龄妇女进行问卷调查，论证社区规范开展流产后服务的必要性。方法择2008年10月～2009年2月自愿到笔者所在医院接受人工流产并在社区进行术后随访的325名妇女，由专业医生对其进行面对面询问调查，填写自行设计的调查表，并对调查结果进行分析。结果在单因素分析中，与人工流产有关的因素有文化程度、避孕方法等；多因素分析显示，控制文化程度因素后，以前有人丁二流产和引产史（重复流产）、未采用宫内节育器、使用短效避孕药具等因素仍然增加意外妊娠和流产的危险性。结论社区医院妇科医师在社区工作中，要重视计划生育工作的重要性，加强流产后咨询、访视及科普宣传工作，做好规范化流产后服务，从而有效减少重复性流产的发生率，降低人工流产术后的并发症，更好地保障广大育龄妇女的生殖健康，提高妇女的生存质量。     

The Persistence of Induced Abortion in Cuba: Exploring the Notion of an “Abortion Culture”

Cuba's annual induced abortion rate persistently ranks among the highest in the world, and abortion plays a prominent role in Cuban fertility regulation despite widespread contraceptive prevalence and state promotion of modern contraceptives. We explore this phenomenon using the concept of an “abortion culture,” typically used in reference to Soviet and post‐Soviet countries. We synthesize existing literature to provide a historical account of abortion and contraception in Cuba. We also provide a qualitative analysis of abortion and contraceptive use based on in‐depth interviews conducted in 2005 in Havana with 24 women who have had an abortion and 10 men whose partners have had an abortion. Information gained from a focus‐group discussion with medical professionals also informed the study. Our four principal findings are: (a) longstanding awareness of abortion, (b) the view of abortion as a personal decision, (c) the influence of economic constraints on the decision to induce an abortion, and (d) general skepticism toward contraceptives. We discuss our results on abortion in Cuba in relation to the notion of social diffusion, an approach commonly used to explain the spread of fertility control throughout a population.     

Contraceptive practices in Armenia: Panel evaluation of an Information-Education-Communication Campaign

Induced abortion remains the major form of birth control among Armenian women, contributing to their excess mortality and preventable morbidity. Reliance on abortion is attributed to limited access to information concerning modern methods of contraception and to widely held misinformation among women regarding family planning and reproductive health. Based on the Steps to Behavior Change model, the Green Path Campaign for Family Health, an information-education-communication (IEC) campaign, was launched in June 2000. This multimedia campaign promoted greater awareness, knowledge, acceptance, and adoption of modern contraception through increased utilization of counseling and related services provided at underutilized family planning centers. A representative panel of 1088 married women aged 18-35 were surveyed on reproductive health/family planning knowledge, attitudes, and practices immediately prior to and immediately following the 6-month national campaign. Exposure to the campaign was associated with significant increases in factors associated with contraceptive behavior change: knowledge, favorable attitudes toward modern methods, favorable attitudes toward family planning services, and information seeking and utilization of family planning services. Women who were more educated, more affluent, and slightly older were more likely to use family planning services as well as modern contraceptive methods. New visits to family planning centers increased by 84%. Despite the usual 25% turnover among those using modern methods at the start of the study, use of modern contraceptive methods increased by 4.6%, significantly exceeding the projected 3% increase. The results document changes in underlying behavioral predictors consistent with the Steps to Behavior Change model and highlight the relatively untapped potential of media-based health promotion efforts in post-Soviet Republics.     

Ethnic differences in factors associated with the use of contraception among 20- to 44-year-old women in Estonia and St. Petersburg, Russia

BackgroundThe aim of this study was to explore factors associated with contraception among 20- to 44-year-old women in different ethnic groups in two Eastern European countries.Study DesignData on sexually experienced women in need of contraception taken from population-based cross-sectional surveys, conducted in Estonia (n=1680) and in St. Petersburg (n=798), were analyzed. Factors associated with contraception nonuse or the use of unreliable contraceptive methods were explored using multivariate logistic regression analysis.ResultsThe age-standardized prevalence rate of contraception nonuse or the use of unreliable contraceptive methods was high (27.3% among Estonian-speaking women in Estonia, 39.9% and 42.5% among Russian-speaking women in Estonia and in St. Petersburg, respectively). Age, economic subsistence, high-risk sexual behavior and smoking did not correlate with contraception nonuse or the use of unreliable contraceptive methods among Russian-speaking women in Estonia and in St. Petersburg; this was in contrast to Estonian-speaking women in Estonia. Previous childbirth and abortion reduced the risk of contraception nonuse or the use of unreliable contraceptive methods among Estonian-speaking women in Estonia (adjusted odds ratio, 0.50; 95% confidence interval [CI], 0.31?0.81) but elevated the risk among Russian-speaking women in St. Petersburg (1.99; 1.17?3.40). Abortion, not previous childbirth, was associated with an increased risk among Russian-speaking women in Estonia (2.94; 1.25?6.95).ConclusionsThe importance of different risk factors associated with contraceptive use varies between different ethnic groups. Cross-national comparisons are essential for the design of public health policies that decrease the burden of sexual ill health.     

Understanding women's desires for contraceptive counseling at the time of first-trimester surgical abortion

Objective

The objective was to investigate whether or not women presenting for a first-trimester surgical abortion want to discuss contraception on the day of their procedure.

Study Design

Between October 2012 and January 2013, an anonymous self-administered survey was distributed to women receiving first-trimester surgical abortions at four northern California family planning clinics. The survey obtained demographic information about each woman and inquired about her desire for contraceptive counseling during her appointment. Results were analyzed using both univariate and multivariable regression analyses to assess trends in responses related to desire for contraceptive counseling based on demographic and other variables.

Results

Of the 199 respondents, 64% reported that they did not want to talk to a counselor or doctor about contraception on the day of their abortion. About half of the women (52%) who did not want to discuss contraception indicated they already knew what they wanted for pregnancy prevention. Of the 25% who reported that they did want to discuss contraception, the most important topic desired from the counseling was identification of methods that were easier to use than what they used previously.

Conclusion

The majority of women seeking first-trimester surgical abortion may not desire additional information about contraception on the day of the procedure.

Implications Statement

This study demonstrates that a significant proportion of women may not want contraceptive counseling on the day of a planned surgical abortion.