Infertility, Perceived Certainty of Pregnancy, and Contraceptive Use in Malawi

Perceived Infertility and Contraceptive Use Among Reproductive-Aged Women in Ohio

OBJECTIVE

This study examines the association between sociodemographic factors and perceived infertility, as well as between perceived infertility, contraceptive use, and contraceptive method type.

STUDY DESIGN

We analyzed the Ohio Survey of Women baseline data collected in 2018-2019 (N = 2,568). Using logistic regression, we assessed the association between sociodemographic characteristics and perceived infertility. We then used multivariate logistic regression and multinomial regression to estimate the association between perceived infertility and any contraceptive use and contraception method type (long-acting reversible, hormonal short-acting reversible, and coital-dependent methods).

RESULTS

Age, race, marital status, household income, and prior pregnancies were associated significantly with odds of perceived infertility. Of those who said they were not at all likely to be infertile, 73% reported using any contraception compared to 63% of those who said they were somewhat to very likely to be infertile. In multivariable analyses, those who reported perceived infertility had 31% lower odds of using contraception than those who did not (adjusted odds ratio = 0.7; 95% confidence interval [0.5, 1.0]). Those with perceived infertility had twice the odds of using no contraception than using long-acting reversible methods compared with those without perceived infertility.

CONCLUSIONS

Reproductive-aged women in Ohio who perceive they may have difficulty becoming pregnant or be infertile have lower odds of using contraception, particularly long-acting reversible methods, compared with those who do not perceive they may be infertile. Improved education on infertility may be warranted to support individuals, particularly in groups with higher odds of perceived infertility, in making informed choices about contraception.

Single- and combined-heavy metals/metalloids exposures are associated with infertility in US women aged 20-44: NHANES 2013-2020 analysis

Infertility is a major medical and social issue, with environmental factors, including metal exposure, playing a crucial role. This study analyzes how individual metals and their mixtures, which include a selection of heavy metals and metalloids totaling sixteen metals, contribute to infertility risk, using data from the National Health and Nutrition Examination Surveys. The study included 1326 women aged 20-44 years, comprising 1145 classified as fertile and 181 as infertile, with data on reproductive questionnaires and covariates. Infertility was defined through self-reported data. To assess the associations between exposure to these elements and infertility risk, we employed logistic regression, principal component analysis (PCA), restricted cubic splines (RCS), quantile regression with group-specific combination (qgcomp), and bayesian kernel machine regression (BKMR). After adjusting for potential confounders, logistic regression revealed positive associations of blood manganese (BMn) and urinary tin (USn) with infertility, whereas serum selenium (SSe) was negatively associated. RCS analysis demonstrated nonlinear relationships between urinary barium (UBa), urinary molybdenum (UMo), and urinary antimony (USb) and infertility. Potential interactions were identified between the following metal pairs: UMo and urinary cadmium, USb and UBa, and USb and UMo. PCA identified a positive association between PC3 and infertility (OR = 1.17, 95 % CI: 1.00, 1.36). The qgcomp model also indicated a positive association between metal mixtures and female infertility (OR = 1.25, 95 % CI: 1.03, 1.52). In conclusion, this study highlights significant associations between exposure to specific metals and infertility risk among women of reproductive age.

Men's Willingness to Use and Preferences for Novel Male Contraceptive Methods in Malawi

Evidence is needed in low- and middle-income countries regarding men's willingness to use new male contraceptive methods in development, preferences regarding method attributes, and what shapes willingness/preferences. We analyzed data from cross-sectional surveys with 611 men in Malawi, concerning willingness to use each of four types of new male methods. Mean age was 24.5 years; half (50 percent) were married/cohabiting. Over half (51 percent) of men expressed willingness to use at least one new male method, including a topical contraceptive gel (33 percent), injection (32 percent), pill (29 percent), and implant (14 percent). Many male product attributes were considered important (with 59-67 percent endorsement), including ease of use, comfort of use, side effects, partner approval, type of method, frequency of facility visits, and cost. A prevalent reported reason for willingness was to "share responsibility for family planning with my partner" (44 percent). In multivariate regression analyses, willingness was inversely associated with inequitable gender attitudes (p < 0.001) and was not associated with married/cohabiting status, using condoms, or perceived risk for HIV. These findings add to growing evidence that a majority of men express willingness to use new male contraceptive methods like a topical gel, injectable, or pill. Reflection around gender roles is likely critical within future education about male contraceptive methods.

A scoping review of the psychosocial aspects of infertility in African countries

Infertility refers to the inability to conceive after 12 months of regular, unprotected sexual intercourse. Psychosocial aspects of infertility research are predominant in developed countries. A scoping review of psychosocial aspects of infertility research conducted in Africa between 2000 and 2022 was conducted. Twelve databases and grey literature were searched for articles. Studies were included if they were published in English and included findings from patients diagnosed with primary or secondary infertility. A total of 2 372 articles were initially found and screening resulted in 116 articles being included in the scoping review. Most of the studies (81%) were conducted in Nigeria, Ghana and South Africa. Psychosocial aspects explored included quality of life, barriers to treatment, attitudes and stigma, and sociocultural and religious aspects of infertility, among others. The review maps published psychosocial research in the context of infertility in Africa and identifies gaps for future research.

Pregnancy and pregnancy intention after experiencing infertility: A longitudinal study of women in Malawi

BACKGROUND

Infertility is a common experience among individuals and couples. Infertility may resolve without intervention, but little is known about pregnancy intentions and incidence of pregnancy following infertility, particularly in low-resource settings.

METHODS

Data come from UTHA, a longitudinal cohort study in Central Malawi, with baseline and follow up surveys conducted from 2014-2019 (N = 1,030 reproductive-aged women). We assessed bivariable and multivariable relationships between reported infertility at baseline and subsequent pregnancy and retrospective pregnancy intentions. Pregnancy intention was measured with the London Measure of Unplanned Pregnancy (LMUP), a scale validated in Malawi (Range = 0-12).

RESULTS

Approximately 20% of the sample reported that they had ever experienced infertility (tried to become pregnant for at least two years without conceiving in that time) at baseline. The proportion of women who reported a new pregnancy during the follow up period (mean = 4.3 years) was the same (65%) for women who had and had not experienced infertility. Among women who became pregnant, levels of pregnancy intendedness were similar between women who had and had not experienced infertility. Prospective desire for a/another child at baseline was associated with subsequent pregnancy (AOR: 1.59; 95%CI: 1.06-2.39) and was also associated with higher levels of pregnancy intendedness measured retrospectively (LMUP of 9.4 vs. 8.4).

CONCLUSIONS

Experienced infertility was not associated with differential odds of having a subsequent pregnancy or the intendedness of a subsequent pregnancy. Thus, women who have experienced infertility should be included in family planning programs and research to support all women in achieving their reproductive goals.

Measuring Nuance in Individual Contraceptive Need: A Case Study from a Cohort in Malawi

Contraceptive counseling protocols tend to focus narrowly on pregnancy intentions, which may overlook other factors that contribute to whether an individual wants or needs contraception. In this report, we demonstrate the potential of two measures of individual contraceptive need that could be assessed as part of contraceptive counseling: (1) a composite score constructed from pregnancy intentions, sexual frequency, and perceived fecundity and (2) a direct measure of contraceptive need ("do you feel it is necessary for you to be using contraception right now?") We compare the two measures using data from Umoyo wa Thanzi, a cohort study in Central Malawi (N = 906; 2017-2018). More frequent sex, perceptions of being more fecund, and a stronger desire to avoid pregnancy were associated with directly reporting contraceptive need (p < 0.001). Women who directly reported contraceptive need had a higher average composite score than women who directly reported they had no need (mean = 7.4 vs. 6.3; p < 0.01), but nearly all participants had scores indicating some risk of unintended pregnancy. Contraceptive counseling protocols should consider assessing women's direct report of contraceptive need, along with risk factors for unintended pregnancy, such as sexual frequency, perceived fecundity, and desire to avoid pregnancy, to better counsel clients.

"I know my body and I just can't get pregnant that easily" - Women's use and non-use of the injection to manage fertility

Approximately one-third of contraceptive users in Malawi use the Depo-Provera injection, a method that must be re-injected every three-months to prevent pregnancy and may reduce fecundity for a time after discontinuation. Little is known about how women use the injection to achieve their desired family size. In 2018, we conducted 20 in-depth interviews with women who were part of a cohort study in rural Malawi. Interviews focused on contraceptive decision-making. Data were indexed (summarized) and coded using narrative, process, and thematic codes. Women described the importance of knowing about their "natural" fertility by having children prior to ever using contraception because women considered contraception to have a potential negative effect on fertility. Women then applied what they learned about their fertility (i.e., how easy/difficult it was to become pregnant) to manage their fertility over their reproductive life-course. As part of fertility management, women frequently described using the injection less frequently than clinically recommended, using signs from their body (e.g., menstruation) to determine when to reinject. Managing fertility through subclinical injection use was viewed as a way to optimize women's' chances of preventing unintended pregnancy while maintaining their ability to become pregnant when they wanted to. Women wanted to play an active role in managing their fertility and were not passive consumers of contraception. It is therefore critical that family planning programs provide contraceptive counseling to women that engages their desire to manage their fertility, acknowledges their concerns about fertility, and helps them choose a method that best fits their needs.