Assessing condom use practices. Implications for evaluating method and user effectiveness

BACKGROUND

Consistent and correct condom use remains important to human immunodeficiency virus (HIV) prevention. Although many studies evaluate consistent condom use, few examine how condoms are used during intercourse.

GOALS

Assess how user practices affect exposure to risks of pregnancy and infection during condom use.

STUDY DESIGN

A cross-sectional survey on condom behaviors in the past month was conducted among 98 male students attending two Georgia universities.

RESULTS

Altogether, 35 of 270 total condom uses (13.0%, 95% confidence interval, 7.4-18.5) resulted in potential exposure to sexually transmitted disease and/or HIV infection or pregnancy. Both consistent and inconsistent users were similarly likely to report potential exposures during condom use.

CONCLUSION

These findings suggest condom problems occur among both consistent and inconsistent users. Future studies of condom effectiveness must distinguish whether condoms were used both consistently and correctly.

A scenario study of oral contraceptive use in Japan. Toward fewer unintended pregnancies

A scenario study was conducted to assess the extent to which the unintended pregnancy rate in Japan, where oral contraceptives (OC) have not been legalized for family planning purposes and couples rely mainly on condoms, might change if more women were to use OC. Because current rates of unintended pregnancy and abortion in Japan are not known, data provided by the 1994 Japanese National Survey on Family Planning were used to construct scenarios for national contraceptive use. Annual failure rates of contraceptive methods and nonuse were applied to the contraceptive use scenarios, to obtain estimates of the annual number of contraceptive failure-related pregnancies. Subsequently, contraceptive practice situations assuming higher OC use rates were defined, and the associated change in the number of contraceptive failure-related pregnancies was estimated for each situation. It emerged that OC use rates of 15% decreased the expected number of unintended pregnancies by 13%-17%, whereas use rates of 25% resulted in decreases of 22%-29% and use rates of 50% in decreases of 45%-58%. The findings were reasonably robust to variation in the assumptions that were made. In conclusion, each theoretical percentage increase in the OC use rate in Japan was found to lead to a roughly equivalent percentage decrease in the number of unintended pregnancies.

Unintended pregnancy among female soldiers presenting for prenatal care at Madigan Army Medical Center

More than half of all pregnancies in this country are unintended at the time of conception. Although women make up 13% of the U.S. Army, there are no epidemiological studies of unintended pregnancy in U.S. Army soldiers. This descriptive study was conducted to determine the prevalence of and factors associated with unintended pregnancy in female soldiers presenting for prenatal care at Madigan Army Medical Center. All soldiers presenting for prenatal care from mid-February 1996 through mid-February 1997 were asked to fill out an anonymous, 12-page written questionnaire. All but one soldier (99.7%) agreed to participate (N = 347). Overall, 55% of soldiers presenting for prenatal care reported that their pregnancies were unintended at the time of conception. The majority of officers (60%) and noncommissioned officers (65%) reported that their pregnancies were intended. In contrast, only 39% of the junior enlisted soldiers reported that their pregnancies were intended at the time of conception. The majority of women (62%) who reported that their pregnancies were unintended were not using any form of birth control during the month they conceived. The most common reason for not using birth control was the stopping of contraception because of side effects. The most common contraceptive method used by those women who reported birth control use during the month they conceived was the male condom. The majority of pregnancies among junior enlisted soldiers presenting for prenatal care at Madigan Army Medical Center are unintended. Prevention programs should target this subpopulation of soldiers and address knowledge, attitudes, and beliefs related to the use of contraception among those at risk for unintended pregnancy.

Reducing teenage and unintended pregnancies through client-centered and family-focused school-based family planning programs

Achievement of the national health goal to reduce teenage and unintended pregnancies through family planning requires a holistic approach to primary prevention. Building upon Rogers' Science of Unitary Human Being, Orem's Self-Care Theory, and Rosenstack's Health Belief Model, a client-centered and family-focused school-based family planning program is proposed as a means to achieve the health goal. FNPs play a pivotal role in development and successful implementation of such a program.

Sex ratio associated with timing of insemination and length of the follicular phase in planned and unplanned pregnancies during use of natural family planning

This was a multicentred, prospective study of pregnancies among women using natural family planning. The women maintained natural family planning charts of the conception cycle, recording acts of intercourse and signs of ovulation (cervical mucus changes, including peak day and basal body temperature). Charts were used to assess the most probable day of insemination relative to the day of ovulation and length of the follicular phase of the cycle. The sex ratio (males per 100 females) for 947 singleton births was 101.5, not significantly different from the expected value of 105. The sex ratio did not vary consistently or significantly with the estimated timing of insemination relative to the day of ovulation, with the estimated length of the follicular phase or with the planned or unplanned status of the pregnancy. Although these findings may be affected by imprecision of the data, the study suggests that manipulation of the timing of insemination during the cycle cannot be used to affect the sex of offspring.

Predicting maternal behaviors during pregnancy: does intention status matter?

CONTEXT

Women's behavior during pregnancy, which can affect the health of their infant, may be influenced by their attitude toward the pregnancy.

METHODS

Multivariate analyses of data from the 1988 National Maternal and Infant Health Survey and the 1988 National Survey of Family Growth were conducted to investigate whether women with unplanned births differ from other women in their pregnancy behavior, independent of their social and demographic characteristics.

RESULTS

Women with intended conceptions are more likely than similar women with unintended pregnancies to recognize early signs of pregnancy and to seek out early prenatal care, and somewhat more likely to quit smoking, but they are not more likely than women with comparable social and demographic characteristics to adhere to a recommended schedule of prenatal visits once they begin care, to reduce alcohol intake, or to follow their clinician's advice about taking vitamins and gaining weight. Social and demographic differences in these behaviors are largely unaffected by planning status, indicating that these differences are independently related to pregnancy behaviors.

CONCLUSIONS

Both the intendedness of a pregnancy and the mother's social and demographic characteristics are important predictors of pregnancy-related behavior.

Unintended pregnancy in the United States

CONTEXT

Current debates on how to reduce the high U.S. abortion rate often fail to take into account the role of unintended pregnancy, an important determinant of abortion.

METHODS

Data from the 1982, 1988 and 1995 cycles of the National Survey of Family Growth, supplemented by data from other sources, are used to estimate 1994 rates and percentages of unintended birth and pregnancy and the proportion of women who have experienced an unintended birth, an abortion or both. In addition, estimates are made of the proportion of women who will have had an abortion by age 45.

RESULTS

Excluding miscarriages, 49% of the pregnancies concluding in 1994 were unintended; 54% of these ended in abortion. Forty-eight percent of women aged 15-44 in 1994 had had at least one unplanned pregnancy sometime in their lives; 28% had had one or more unplanned births, 30% had had one or more abortions and 11% had had both. At 1994 rates, women can expect to have 1.42 unintended pregnancies by the time they are 45, and at 1992 rates, 43% of women will have had an abortion. Between 1987 and 1994, the unintended pregnancy rate declined by 16%, from 54 to 45 per 1,000 women of reproductive age. The proportion of unplanned pregnancies that ended in abortion increased among women aged 20 and older, but decreased among teenagers, who are now more likely than older women to continue their unplanned pregnancies. The unintended pregnancy rate was highest among women who were aged 18-24, unmarried, low-income, black or Hispanic.

CONCLUSION

Rates of unintended pregnancy have declined, probably as a result of higher contraceptive prevalence and use of more effective methods. Efforts to achieve further decreases should focus on reducing risky behavior, promoting the use of effective contraceptive methods and improving the effectiveness with which all methods are used.

Induced abortion potential among Indian women

Information on abortion is limited and inaccurate, especially in the developing world, which has led to speculation on the prevalence of abortion in these regions. A rise in prevalence of abortion is mostly counted in terms of increase in the prevalence of induced abortions which reflects on the reproductive health of women. With the growing concern for the reproductive health of women, the study of abortion has drawn the attention of researchers world-wide. This paper is an attempt to assess the induced abortion potential among Indian women by utilizing information on proportion of unwanted and ill-timed pregnancies obtained through National Family Health Survey, India. This exercise may facilitate a better understanding of the exact prevalence of induced abortion, which necessarily should be less than the estimated potential depending on the levels of unwanted and ill-timed fertility.

Backstreet abortion: women's experiences

AIM

This was a descriptive study aimed at exploring the personal experiences of women who induce abortion and the circumstances surrounding induced abortion.

METHODS

The study was conducted in six public hospitals in four different provinces: Baragwanath (Gauteng), Groote Schuur and Tygerberg (Western Cape), King Edward and R.K. Khan (Kwa-Zulu/Natal) and Livingstone (Eastern Cape). In-depth interviews were conducted with 25 African, Indian and Coloured women admitted to the hospitals following backstreet abortions. The study gave women the opportunity to "speak for themselves" about "why" and "how" and the context in which the unsafe induced abortions occurred.

RESULTS

The findings show that a host of factors were important in the circumstances leading to unwanted pregnancy and induced abortion: socio-economic, cultural, psychological and societal. Disempowerment in relationships combined with financial pressures constituted the background as to why women felt forced to terminate their pregnancies. The perceived need for termination was found to over-ride all other considerations, including religious ones. The ways in which women attempted to procure abortion, both through legal and illegal routes, are presented. Wider social and legal discourses an abortion were found to be an important factor in how women experienced their situation.

Adolescent sexuality

Sex education is almost mandated in the United States. The data reviewing sexual activity in the adolescent population indicates that large numbers of women under the age of 19 who have unintended pregnancies are at risk for an increased frequency of sexually transmitted diseases which will affect their future. It is essential that good educational programs and preventive service programs be developed and mandated for the adolescent population. Experience in Western Europe demonstrates that the adolescent who has a proper education concerning sexual activity, sexually transmitted disease, and contraception is at lower risk for the many problems that we see in the United States. There must be cross-cultural data that can be translated for use in the entire world. As the population of this world ages, we must protect those who are entering adulthood from being exposed to the STDs and undertaking the responsibility of parenting without having reached full maturity. The cost in dollars of the sequelae of adolescent pregnancies are great. These costs are not only financial, but also emotional and social, and they have a negative impact on the country in which the adolescent lives. We have a heavy responsibility as physicians and health care professionals to see that the adolescents of the world are given the knowledge and models to use to reduce the risk for pregnancy and the acquisition of a sexually transmitted disease.

Comparison of two question sequences for assessing pregnancy intentions

Unintended pregnancies can have serious health, social, and economic consequences. Such pregnancies may be unwanted (a baby is not wanted at any time) or mistimed, yet wanted (a baby is wanted eventually). Intended pregnancies are those conceived when desired. Reproductive health survey respondents' understanding of these concepts and validity of survey results may be affected by question order and wording. Using a randomized crossover design, National Survey of Family Growth (NSFG) and Demographic and Health Survey (DHS) intendedness questions were asked in a 1993 survey of Arizona women aged 18-44 years. Of 2,352 ever-pregnant respondents, 25% gave discordant responses to DHS and NSFG questions about the most recent pregnancy. Age, marital status, household income, education, parity, time since pregnancy, and outcome of pregnancy were significantly predictive of discordant responses. DHS and NSFG questions yielded similar prevalence estimates of intendedness and wantedness; but young, unmarried respondents gave more "mistimed" responses on whichever question was asked later. Classifying pregnancies as intended, mistimed, or unwanted may be a problem for women who have not decided on lifetime reproductive preferences. Approaches to improving survey validity include addressing ambivalence, clarifying the definition of "unwanted," and, for young, unmarried women, not attempting to classify unintended pregnancies as mistimed or unwanted.

Public knowledge and perceptions about unplanned pregnancy and contraception in three countries

A 1994-1995 survey of men and women aged 18-44 in the United States, Canada and the Netherlands revealed considerable differences in public knowledge and perceptions about unplanned pregnancy and contraception. The proportion who believe that unplanned pregnancy is a "very big problem" is 60% in the United States, 36% in Canada and 6% in the Netherlands. Americans are more likely than their Canadian or Dutch counterparts to cite societal problems as significant factors in the rate of unplanned pregnancy; higher proportions of Americans also cite the cost of contraceptives (52% vs. 46% of Canadians and 34% of Dutch men and women) and an inability to obtain methods (66%, 51% and 33%, respectively). In all three countries, adults are generally well informed about the relative effectiveness of commonly used contraceptives, but Americans are more skeptical about method safety and effectiveness. For example, 17% think the pill is "very safe," compared with 21% of Canadians and 40% of the Dutch; and whereas 64% of Americans consider the pill "very effective," 73% of Canadians and 90% of Dutch men and women give it this rating. Health care professionals are the most frequently cited source of contraceptive information, but only 51-63% of adults have ever discussed contraception with such a practitioner.

Public perceptions about unplanned pregnancy

A nationally representative telephone survey in 1994 of 2,002 adults indicates that 60% believe that unplanned pregnancy is a very big problem in the United States, and virtually all (90%) say it is at least a somewhat big problem. Two-thirds mistakenly believe that a larger percentage of women have unplanned pregnancies now than 10 years ago. A decline in moral standards is cited by 89% of respondents as contributing very much or somewhat to the problem. Lack of education is mentioned as a significant factor by 87%, and 88% see any of three barriers to contraceptive use--knowledge about use, access or cost--as being important factors. Never-married women with children, women in general, low-income respondents, Hispanics and those aged 65 or older are the most likely to believe that barriers to contraceptive access contribute very much to unplanned pregnancy; they are especially likely to cite cost or an inability to obtain contraceptives.

The family planning attitudes and experiences of low-income women

A 1995 telephone survey of 1,852 low-income women aged 18-34 who were sexually active and at risk of unintended pregnancy found that 83% were currently practicing contraception. They were more likely to do so if they held positive attitudes toward contraceptive use, if they talked frequently about intimate matters with their partners and girlfriends and if they were very satisfied with the services they received at their last gynecologic visit. Seventy percent of current users said they were very satisfied with their method. Women whose last visit was to a clinic, who were very satisfied with the care they received and who used the pill or a long-acting method were more likely than others to report being very satisfied with their contraceptive. Women very satisfied with their gynecologic care were more likely to use oral contraceptives and to take them consistently, but were less likely to report that their partner used condoms or, if they did, used them consistently. Most women had made a medical visit for gynecologic or contraceptive care in the past year (86%), and 80% were very satisfied overall with their care at their last visit. Women were more likely to be very satisfied if the staff was courteous, helpful and respectful and made an effort to find out their needs, if their clinician's gender matched their own preference and if the facility was clean and services were organized.

Impact of publicly funded contraceptive services on unintended pregnancies and implications for Medicaid expenditures

Of U.S. women who use a reversible method of contraception, 24% each year obtain family planning services from a publicly funded clinic or a private doctor reimbursed by Medicaid. If these subsidized contraceptive services were not available, women who currently use them would have an estimated 1.3 million additional unplanned pregnancies annually, of which 29% would involve women aged 15-19, 67% would involve never-married women and 61% would involve women with a household income below 200% of the federal poverty level. An estimated 632,300 of these pregnancies would end in induced abortion, an increase of 40% over the current national level. Another 533,800 pregnancies would result in unintended births. Some 76,400 of these would be births to families already receiving public assistance, and 64,100 would be to families that would become eligible for public assistance because of the birth; another 197,000 would be to women whose families would not receive public assistance, but would be eligible for Medicaid coverage of pregnancy, delivery and newborn care. In FY 1987, public-sector expenditures for contraceptive services totaled an estimated $412 million. If subsidized services had not been available, the federal and state governments would have spent an additional $1.2 billion through their Medicaid programs for expenses associated with unplanned births and abortions. Thus, for every dollar spent to provide publicly funded contraceptive services, an average of $3.00 was saved in Medical costs for pregnancy-related health care and medical care for newborns.

Towards regional equality in family planning: teenage pregnancies and abortions in Finland from 1976 to 1993

BACKGROUND

A major goal of Finnish family planning policy since the 1970s has been to minimize unintended pregnancies by providing equal contraception and abortion services throughout the country. This report looks at how this policy has succeeded among teenagers.

METHODS

The data on childbirths, induced abortions and mean populations were collected from the national abortion and population registers. Regional and age-specific rates were calculated for fertility, abortions and pregnancies in girls aged 15-19.

RESULTS

In 1993, the teenage pregnancy rate was 20/1000 and the abortion rate 9.5/1000 in the whole country. Although the pregnancy rate had dropped by half since the 1970s, the regional differences were still there: the lowest rate was 18/1000 and the highest 29/1000 (in Lapland) in 1991-93. The abortion rate ranged from 8/1000 to 14/1000. Childbirths decreased, particularly at the beginning of the study period, while abortions declined sharply towards the end of the period. In 1986-88, the abortion ratio exceeded 100 in all provinces except two. In the 1990s, it dropped below 100 again except in the capital province. In 16-17 year-olds, the trends were quite equal in different provinces. In 18-19 year-olds, pregnancies remained more frequent in the north and were more often carried to term, while the choice of abortion was more likely in the south.

CONCLUSIONS

Equally declining trends in pregnancies in all provinces suggest that teenage family planning services have a comprehensive coverage. However, regional differences still remain and imply a detailed analysis of their reasons.