Key drivers of fertility levels and differentials in India, at the national, state and population subgroup levels, 2015-2016: An application of Bongaarts' proximate determinants model

OBJECTIVES

The transition to small family size is at an advanced phase in India, with a national TFR of 2.2 in 2015-16. This paper examines the roles of four key determinants of fertility-marriage, contraception, abortion and postpartum infecundability-for India, all 29 states and population subgroups.

METHODS

Data from the most recent available national survey, the National Family Health Survey, conducted in 2015-16, were used. The Bongaarts proximate determinants model was used to quantify the roles of the four key factors that largely determine fertility. Methodological contributions of this analysis are: adaptations of the model to the Indian context; measurement of the role of abortion; and provision of estimates for sub-groups nationally and by state: age, education, residence, wealth status and caste.

RESULTS

Nationally, marriage is the most important determinant of the reduction in fertility from the biological maximum, contributing 36%, followed by contraception and abortion, contributing 24% and 23% respectively, and post-partum infecundability contributed 16%. This national pattern of contributions characterizes most states and subgroups. Abortion makes a larger contribution than contraception among young women and better educated women. Findings suggest that sterility and infertility play a greater than average role in Southern states; marriage practices in some Northeastern states; and male migration for less-educated women. The absence of stronger relationships between the key proximate fertility determinants and geography or socio-economic status suggests that as family size declined, the role of these determinants is increasingly homogenous.

CONCLUSIONS

Findings argue for improvements across all states and subgroups, in provision of contraceptive care and safe abortion services, given the importance of these mechanisms for implementing fertility preferences. In-depth studies are needed to identify policy and program needs that depend on the barriers and vulnerabilities that exist in specific areas and population groups.

Four out of ten married women utilized modern contraceptive method in Ethiopia: A Multilevel analysis of the 2019 Ethiopia mini demographic and health survey

Background

Modern contraceptive method is a product or medical procedure that interferes with reproduction from acts of sexual intercourse. Globally in 2019, 44% of women of reproductive age were using a modern method of contraception but it was 29% in sub-Saharan Africa. Therefore, the main aim of this analysis was to assess the prevalence of modern contraceptive utilization and associated factors among married women in Ethiopia.

Method

The current study used the 2019 Ethiopia mini demographic and health survey dataset. Both descriptive and multilevel mixed-effect logistic regression analysis were done using STATA version 14. A p-value of less than 0.05 and an adjusted odds ratio with a 95% confidence interval were used to report statistically significant factors with modern contraceptive utilization.

Result

The overall modern contraceptive utilization among married women in Ethiopia was 38.7% (95% CI: 37.3% to 40.0%). Among the modern contraceptive methods, injectables were the most widely utilized modern contraceptive method (22.82%) followed by implants (9.65%) and pills (2.71%). Maternal age, educational level, wealth index, number of living children, number of births in the last three years, number of under 5 children in the household, religion, and geographic region were independent predictors of modern contraceptive utilization.

Conclusion

In the current study only four out of ten married non-pregnant women of reproductive age utilized modern contraceptive methods. Furthermore, the study has identified both individual and community-level factors that can affect the utilization of modern contraceptive methods by married women in the country. Therefore, concerned bodies need to improve access to reproductive health services, empower women through community-based approaches, and minimize region wise discrepancy to optimize the utilization.

The impact of COVID-19 on fertility behaviour and intentions in a middle income country

The COVID Pandemic may affect fertility behaviour and intentions in many ways. Restrictions on service provision reduce access to family planning services and increase fertility in the short term. By contrast, the economic uncertainty brought about by the pandemic and its impact on mental health and well-being may reduce fertility. These various pathways have been explored in the context of high income countries such as the United States and Western Europe, but little is known about middle income countries. In this paper we asses the impact of the COVID pandemic on fertility intentions and behaviour in the Republic of Moldova, a middle income country in Eastern Europe, using the Generations and Gender Survey. This survey was conducted partially before and partially after the onset of the pandemic in 2020, allowing for detailed comparisons of individual circumstances. The results indicate that the pandemic reduced the used of intrauterine devices, and increased the use of male condoms, but with no overall decrease in contraceptive use. Conversely individuals interviewed after the onset of the pandemic were 34.5% less likely to be trying to conceive, although medium term fertility intentions were unchanged. Indicators therefore suggest that in the medium term fertility intentions may not be affected by the pandemic but restricted access to contraception requiring medical consultation and a decrease in short-term fertility intentions could disrupt short term family planning.

Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care

IMPORTANCE

Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid.

OBJECTIVE

To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021.

EXPOSURES

Medicaid coverage of postpartum care.

MAIN OUTCOMES AND MEASURES

Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery.

RESULTS

The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.

Contraceptive use among women through their later reproductive years: Findings from an Australian prospective cohort study

Objective

Examine patterns of contraceptive use and contraceptive transitions over time among an Australian cohort of women through their later reproductive years.

Study design

Latent Transition Analysis was performed using data on 8,197 women from the Australian Longitudinal Study on Women’s Health’s 1973–78 cohort to identify distinct patterns of contraceptive use across 2006, 2012 and 2018. Women were excluded from the analysis at time points where they were not at risk of an unintended pregnancy. Latent status membership probabilities, item-response probabilities, transitions probabilities and the effect of predictors on latent status membership were estimated and reported.

Results

Patterns of contraceptive use were relatively consistent over time, particularly for high efficacy contraceptive methods with 71% of women using long-acting reversible contraceptives in 2012 also using long-acting reversible contraceptives in 2018. Multiple contraceptive use was highest in 2006 when women were aged 28–33 years (19.3%) but declined over time to 14.3% in 2018 when women were aged 40–45 years. Overall, contraceptive patterns stabilised as the women moved into their late 30s and early 40s.

Conclusions

Although fertility declines with age, the stability of contraceptive choice and continued use of short-acting contraception among some women suggests that a contraceptive review may be helpful for women during perimenopause so that they are provided with contraceptive options most appropriate to their specific circumstances.

How has contraceptive provision at Family Planning clinics in Aotearoa New Zealand changed between 2009, 2014 and 2019: a cross-sectional analysis

AIM

To investigate changes in contraceptive starts among Family Planning clients in 2009, 2014 and 2019.

METHODS

National data of 75,825 contraceptive starts of clients at Family Planning clinics in New Zealand in 2009, 2014 and 2019 were analysed to measure changes in contraceptive starts across the three points in time. Data were analysed by age and ethnicity at each point in time, and by deprivation in 2019.

RESULTS

After being adjusted for age and ethnicity, there was a significant decline in the proportion of starts for the combined oral contraceptive pill (43% to 23%), the progestogen-only pill (22% to 13%) and Depo Provera (15% to 12%) from 2009 to 2019. There was a significant increase in the proportion of starts for implants (0.7% to 22%) and intra-uterine contraception (19% to 30%). There were significant differences in contraceptive starts between ethnicities and levels of deprivation.

CONCLUSIONS

There was an overarching trend of increasing long-acting reversible contraceptive (LARC) starts from 2009 to 2019 among Family Planning clients across all age groups and ethnicities. There were also differences in the types of contraceptive starts by ethnicity and deprivation. Information about contraceptive use and changes over time, by age and ethnicity, is essential for evidence-based policy, funding decisions and ensuring equitable access to contraception.

Contraceptive use among sexually active female adolescents in Ethiopia: trends and determinants from national demographic and health surveys

BACKGROUND

Sexual and reproductive health and right of adolescents is a global priority as the reproductive choices made by them have a massive impact on their health, wellbeing, education, and economy. Teenage pregnancy is a public health issue and a demographic challenge in Ethiopia. Increasing access to contraceptive services for sexually active adolescents will prevent pregnancies and related complications. However, little is known about the trends in contraceptive use and its determinants among adolescent girls in Ethiopia. Therefore, this study was designed to examine the trends and factors associated with contraceptive use among sexually active girls aged 15-19 years in Ethiopia by using Ethiopian demographic and health survey data.

METHODS

Four Ethiopian demographic and health survey data were used to examine trends of contraceptive methods use. To identify factors associated with contraceptive use, the 2016 Ethiopian demographic and health survey data were used. The data was downloaded from the demographic and health survey program database and extracted for sexually active adolescent girls. Data were weighted for analysis and analyzed using SPSS version 21. Descriptive analysis was used to describe the independent variables of the study. A multivariable logistic regression model was used to identify factors associated with contraceptive use and adjusted odds ratios with 95% confidence interval were presented for significant variables. Variables with a p-value less than 0.05 were considered as significantly associated with contraceptive use.

RESULTS

Contraceptive method use had increased significantly from 6.9% in 2000 to 39.6% in 2016 among sexually active adolescent girls in Ethiopia. The odds of contraceptive use were lower among female adolescents who had no formal education (AOR 0.044; 95% CI 0.008-0.231) and attended primary education (AOR 0.101; 95% CI 0.024-0.414). But the odds were higher among adolescents from a wealthy background (AOR 3.662; 95% CI 1.353-9.913) and those who have visited health facilities and were informed about family planning (AOR 3.115; 95% CI 1.385-7.007).

CONCLUSION

There is an increment in the trend of contraceptive use among sexually active female adolescents in Ethiopia between 2000 and 2016. Significant variations in the use of modern contraception by wealth status, educational level and visited a health facility, and being informed about family planning were observed. Improving the economic and educational status of young women, and provision of information may help in improving contraceptive use in Ethiopia.

Change in health profile of refugees resettling in New Zealand, 1980-2014

AIM

To update data previously published on the health profile of the refugees resettling in New Zealand, and to draw attention to the change in health profile over time, with a decline of infectious disease/deficiencies, and a rise of non-communicable diseases, a worldwide phenomenon.

METHOD

Comparative data was extracted from (1) written annual reports prepared by medical officers at the Mangere Refugee Resettlement Centre (1978-1991), (2) a Microsoft ACCESS patient management system between 1995 and 1999 and (3) a MEDTECH patient management system between 2010 and 2014.

RESULTS

Over the period 1979-2014, the rate of infectious diseases has declined markedly in resettling refugees, and the rate of non-communicable diseases has increased. For example, the incidence of tuberculosis has decreased from 4% to 0.2%, gut parasites from more than 40% to, in some intakes, 15% and iron deficiency from 22% to 10%, while the diabetes rate has gone from 0.1% to 2.7%.

CONCLUSION

While management of unfamiliar infectious diseases and deficiencies (especially vitamin D) still remains an important part of the management of refugee health, their management usually involves limited time and expense, and their burden is much less than before. However, refugees now resettling in New Zealand and the rest of the world often present with familiar non-communicable diseases that require long-term management.

Determinants of long acting reversible contraception utilization in Northwest Ethiopia: An institution-based case control study

BACKGROUND

Though long-acting reversible contraceptives (LARCs) are highly effective, have minimal side effects, require minimal follow-up, and are low cost, only 10% of contraceptives used in Ethiopia are LARCs. The reason for this low uptake is not understood at the country or regional level. Therefore, this study identified determinants of LARC utilization in Northwest Ethiopia.

METHODS

A facility-based unmatched case control study, using LARC users as cases and short- acting reversible contraception (SARC) users as controls, had been conducted at fourteen public health institutions in Northwest Ethiopia. A systematic random sampling technique was used to select participants with a 1:2 case to control ratio (n = 1167). Binary logistic regression analysis was used to identify determinants of LARC utilization among family planning service users.

RESULTS

Wealth status [AOR:1.87, 95%CI (1.08, 3.24)], history of abortion [AOR:2.69, 95%CI (1.41, 5.12)], limiting family size [AOR: 2.38, 95%CI (1.01, 5.62)], good knowledge about LARCs [AOR: 2.52, 95%CI (1.17, 5.41)], method convenience [AOR: 0.23, 95%CI (0.16, 0.34)], good availability of method [AOR:0.10 (0.05, 0.19)], less frequent visits to health facility [AOR:2.95, 95% CI(1.89, 4.62)], health care providers advice [AOR:10.69, 95%CI (3.27, 34.87)], partner approval [AOR:0.66, 95%CI (0.45, 0.97)], and favorable attitude towards LARCs [AOR:13.0, 95%CI (8.60, 19.72)] were significantly associated with LARC utilization.

CONCLUSION

Professional support, favorable attitude towards LARC use, high economic status, history of abortion, advantage of less frequent visits, having good knowledge towards LARC and interest of limiting births were significantly associated with LARC Utilization. On the other hand, perceived method convenience, and contraception availability were inversely associated with it. Family planning education about the benefits of LARC should be done by health providers and media. Male involvement in the counselling and decision making about the advantage of using LARC may improve the negative influence of partners on LARC utilization. It is also recommended that, future qualitative research further explore perceptions of LARC use.

Does gender equality and availability of contraception influence maternal and child mortality? A systematic review

BACKGROUND

Current global maternal and child health policies rarely value gender equality or women's rights and are restricted to policies addressing clinical interventions and family planning. Gender equality influences the knowledge, autonomy and utilisation of contraception and healthcare, thereby affecting maternal and child health. This systematic review aims to analyse the concurrent effect of gender equality and contraception on maternal and under-5 child mortality.

METHODS

A systematic review was conducted to investigate the current evidence. Studies were eligible if three themes-namely, indicators of gender equality (such as female education, labour force participation, gender-based violence), contraception, and maternal or child mortality-were present together in a single article analysing the same sample at the same time.

RESULTS

Even though extensive literature on this topic exists, only three studies managed to fit the selection criteria. Findings of two studies indicated an association between intimate partner violence (IPV) and infant mortality, and also reported that women's contraceptive use increased the risk of IPV. The third study found that the mother's secondary education attainment significantly reduced child mortality, while the mother's working status increased the odds of child mortality. The researchers of all included studies specified that contraceptive use significantly reduced the risk of child mortality.

CONCLUSION

Improvement in gender equality and contraception concurrently affect the reduction in child mortality. These findings provide strong support to address the research gaps and to include a gender equality approach towards maternal and child health policies.

A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: what works and what doesn't?

AIM

The aim of this systematic review was to synthesise the evidence on the comparative effectiveness of different counselling strategies for modern contraception on contraceptive behaviour and satisfaction, and to examine their advantages and disadvantages.

METHODS

Six electronic databases (Medline, Embase, Global Health, Popline, CINAHL Plus, and Cochrane Library) were searched to identify publications comparing two or more contraceptive counselling strategies and reporting quantitative results on contraceptive use, uptake, continuation or switching, or client satisfaction. Studies of women or couples from any country, published in English since 1990 were considered.

RESULTS

A total of 63 publications corresponding to 61 studies met the inclusion criteria. There was substantial heterogeneity in study settings, interventions and outcome measures. Interventions targeting women initiating a method (including structured counselling on side effects) tended to show positive effects on contraceptive continuation. In contrast, the majority of studies of provider training and decision-making tools for method choice did not find evidence of an effect. Additional antenatal or postpartum counselling sessions were associated with increased postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. Dedicated pre-abortion contraceptive counselling was associated with increased use only when accompanied by broader contraceptive method provision. Male partner or couples counselling was effective at increasing contraceptive use in two of five studies targeting non-users, women initiating implants or seeking abortion. High-quality evidence is lacking for the majority of intervention types.

CONCLUSIONS

The evidence base and quality of studies are limited, and further research is needed to determine the effectiveness of many counselling interventions in different settings.

Current Contraceptive Status Among Women Aged 15-49: United States, 2017-2019

Nearly all women use contraception in their lifetimes (1), although at any given time, they may not be using contraception for reasons such as seeking pregnancy, being pregnant or postpartum, or not being sexually active. Using data from the 2017-2019 National Survey of Family Growth (NSFG), this report provides a snapshot of current contraceptive status, in the month of interview, among women aged 15-49 in the United States. In addition to describing use of any method by age, Hispanic origin and race, and education, patterns of use are described for the four most commonly used contraceptive methods: female sterilization; oral contraceptive pills; long-acting reversible contraceptives (LARCs), which include contraceptive implants and intrauterine devices; and the male condom.

Patterns, trends, and factors associated with contraceptive use among adolescent girls in Zambia (1996 to 2014): a multilevel analysis

BACKGROUND

Despite high levels of pregnancy and childbearing among adolescents in Africa, contraceptive use remains low. Examining variations in contraceptive use among adolescent girls is vital for informing programs to improve contraceptive utilisation among this segment of the population. This study aimed to examine the patterns, trends, and factors associated with contraceptive use among adolescents in Zambia over the period 1996-2014.

METHODS

The study involved an analysis of data from 1996, 2001/2, 2007 and 2013/14 Zambia Demographic and Health Surveys focusing on adolescent girls aged 15-19 years. Analysis entailed descriptive statistics and estimation of multilevel logistic regression models examining variations in contraceptive use among adolescent girls over time. Estimates with p-values less than 0.05 were considered statistically significant.

RESULTS

Results showed that contraceptive use remains low and ranged from 7.6% in 1996 to 10.9% in 2013/14, reflecting a change of 3.3 percentage points over 18 years. Over the 18 years, contraceptive use was significantly associated with age, level of education, and marital status. Older adolescent girls and those with higher levels of education were significantly more likely to use contraception compared to younger ones and those with lower levels of education. Although initially significant (AOR 0.556, 95% CI 0.317, 0.974 in 1996), rural-urban differences disappeared between 2001/2 and 2007 but re-emerged in 2013/14 (AOR 0.654, 95% CI 0.499, 0.859). Across all survey years, adolescents who were married or living with a partner were significantly more likely to use contraceptives compared to those who were not married.

CONCLUSIONS

The findings suggest the need for targeted interventions to improve contraceptive use among sexually active adolescent girls in the country in general, and those who are disadvantaged in particular.

Trends and predictors of changes in modern contraceptive use among women aged 15-49 years in Tanzania from 2004-2016: Evidence from Tanzania Demographic and Health Surveys

Introduction

Modern contraceptive use provides opportunities for women and couples to achieve optimal child spacing, achieve desired family size and reduce unsafe abortions. Despite these facts, modern contraceptive prevalence rate (mCPR) in Tanzania remains as low as 32%. This study aimed to determine trends and factors associated with changes in modern contraceptive use among women of reproductive age in Tanzania from 2004–2016.

Methodology

This was a cross-sectional study utilizing data from Tanzania Demographic and Health Surveys of 2004–2005, 2010 and 2015–2016. Data analysis was performed using Stata version 14. Analysis considered the complex survey design through application of weights, clustering and strata. Multivariable Poisson decomposition analysis was used to assess factors associated with changes in modern contraceptive use. Results were presented in the form of decomposition coefficients and percentages.

Results

Modern contraceptive use increased from 23.0% in 2004 to 34.3% in 2016. Differences in women’s characteristics contributed 12.5% of the increase in mCPR. These characteristics include partner’s education levels, recent sexual activity and being visited by a family planning worker. The difference in coefficients contributed 87.5% increase in mCPR. The most increase in modern contraceptive use was attributed to rural population (44.1%) and women who experienced a termination of pregnancy (7.1%).

Conclusion

Modern contraceptive use has steadily increased in Tanzania. Health policies and interventions need to target sexually active women, rural residents as well as less educated women and men to maintain and further accelerate the trends in mCPR. Interventions focusing on women who experienced a termination of pregnancy may also serve as an entry point to promote use of modern contraceptive methods.

The levels and trends of contraceptive use before first birth in India (2015-16): a cross-sectional analysis

BACKGROUND

Indian women are more prone to first birth at a relatively younger age after marriage. Also, we do not have sufficient literature available that focuses on contraceptive use before first birth. The analysis of the present study was done using data from the fourth round of National Family Health Survey (2015-16), India. The objectives of the present study were to measure the levels and trends of contraceptive use before first birth among Indian ever married women, aged 15-34 years.

METHODS

The study includes 279,896 ever married women aged 15-34 years at the time of the NFHS-4 survey. To identify the socio-demographic determinants governing the pioneering study behavior, multivariable techniques have been used in the analysis. The statistical significance of the relationship between socio-demographic factors and contraceptive use prior to first birth was tested using a chi-squared test for association. Hosmer Lemeshow statistics and Nagelkerke R square have been used to check how well the logistic regression model fits the data. Map of India showing different zonal classification is made using the ArcGIS software version 10.3.

RESULT

The trends of contraceptive usage show a decline in use before first birth and the various socio-demographic factors affecting the use of contraceptive before first birth are religion, caste, education, wealth index, media exposure, age at marriage and the zonal classifications.

CONCLUSION

The noticeable result in this study is the comparative decline in contraceptive use by women in India before first birth in NFHS-4 with respect to previous NFHS done in India. The likelihood of using contraception before first birth is significantly affected by factors like place of residence, religion, caste, current age of women, age at marriage, education level of women, wealth index, media exposure and zonal classification.

Evidence on factors influencing contraceptive use and sexual behavior among women in South Africa: A scoping review

INTRODUCTION

Contraceptive use and sexual health behavior remain a prominent public health concern in South Africa (SA). Despite many government interventions, unintended pregnancies and termination of pregnancies remain relatively high. This review aimed to map evidence on factors influencing contraceptive use and sexual behavior in SA.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's framework. We searched for articles from the following databases: PubMed/MEDLINE, American Doctoral Dissertations via EBSCO host, Union Catalogue of Theses and Dissertations (UCTD) and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. Studies published from January 1990 to March 2018 were included. We used the Population, Concept, and Context (PCC) framework and the PRISMA chart to report the screening of results. The Mixed Method Appraisal Tool (MMAT) version 11 and ACCODS tools were used to determine the quality of the included studies.

RESULTS

A total of 2030 articles were identified by our search criteria for title screening. Only 21 studies met our inclusion criteria and were included in quality assessment stage. We found that knowledge of a contraceptive method, length of a relationship, sexual debut, age difference between partners availability of a contraceptive method, long waiting hours, and nurse's attitudes toward human immunodeficiency virus (HIV) positive or younger clients predict whether or not women use a contraceptive method or improve sexual behavior.

CONCLUSION

There remains a necessity for improving educational programs aimed at transferring knowledge on contraceptives and sexual behavior to both women and their male counterparts, alongside the public health systems' improvements.

Copper intrauterine device use and HIV acquisition in women: a systematic review

OBJECTIVES

To review systematically copper intrauterine device (Cu-IUD) use and HIV acquisition in women.

METHODS

We searched Pubmed, Embase and the Cochrane Library between database inception and 26 June 2019 for longitudinal studies comparing incident HIV infection among women using an unspecified IUD or Cu-IUD compared with non-hormonal or no contraceptive users, or hormonal contraceptive users. We extracted information from included studies, assessed study quality, and summarised study findings.

RESULTS

From 2494 publications identified, seven met our inclusion criteria. One randomised controlled trial (RCT), judged "informative with few limitations", found no statistically significant differences in HIV risk between users of the Cu-IUD and either intramuscular depot medroxyprogesterone acetate (DMPA-IM) or levonorgestrel implant. One observational study, deemed "informative but with important limitations", found no statistically significant difference in HIV incidence among IUD users compared with women who had tubal ligation or who were not using any contraception. Another "informative but with important limitations" observational study found no difference in HIV incidence between Cu-IUD users and DMPA or norethisterone enanthate injectable, or implant users. An RCT considered "unlikely to inform the primary question" also found no difference in HIV risk between Cu-IUD and progestogen-only injectable users. Findings from the other three "unlikely to inform the primary question" cohort studies were consistent with the more robust studies suggesting no increased risk of HIV acquisition among Cu-IUD users.

CONCLUSION

The collective evidence, including that from a large high-quality RCT, does not indicate an increased risk of HIV acquisition among users of Cu-IUDs.

The Relationship Between Insurance Coverage and Use of Prescription Contraception by Race and Ethnicity: Lessons From the Affordable Care Act

BACKGROUND

We describe contraception use by race and ethnicity before and after the Affordable Care Act (ACA) and assess the relationship between insurance coverage and prescription contraception use in both periods.

STUDY DESIGN

Using data for women ages 15 to 45 at risk of unintended pregnancy from the 2006-2010 and 2015-2017 National Surveys of Family Growth, we examined changes in patterns of contraception use over time by race and ethnicity. We also examined changes in insurance coverage over the same period and considered how the relationship between insurance coverage and prescription contraception use has changed over time within each racial and ethnic group using both descriptive and multivariate regression methods.

RESULTS

Before the ACA, Black and Hispanic women were less likely than White women to use prescription contraception by 13.2 and 9.9 percentage points, respectively. After the ACA Medicaid and Marketplace coverage expansions, all groups experienced a decrease in uninsurance, but only Black women experienced a significant increase in prescription contraception use. As a result, the post-ACA Black-White difference in prescription contraception use narrowed to 3.9 percentage points, and the Hispanic-White gap remained unchanged.

CONCLUSIONS

Our results suggest that, despite significant declines in uninsurance under the ACA, there was no increase in use of prescription contraception for White or Hispanic women. Moreover, the decrease in uninsurance among Black women did not fully explain the large increase in use of prescription contraception for this population.

A qualitative assessment of perspectives on getting pregnant: the Social Position and Family Formation study

BACKGROUND

Intentions-oriented approaches to measuring pregnancy do not necessarily align with how people view and approach pregnancy. Our objective was to obtain an in-depth understanding of the notions women and men hold regarding pregnancy.

METHODS

We conducted semi-structured in-depth interviews with 176 heterosexual women and men ages 18-35, in the United States. Data were analyzed using grounded theory methodology.

RESULTS

Participants described notions of getting pregnant in one of three ways. One group of participants used language that solely described pregnancy as a deliberate process, either premeditated or actively avoided. Another described pregnancy as a predetermined phenomenon, due to fate or something that 'just happens.' The third group represented a blending of both notions.

CONCLUSIONS

Our findings underscore the need to shift the current paradigm of deliberate intentions to one that recognizes that pregnancy can also be viewed as predetermined. These findings can be used to improve measurement, health services, and better direct public health resources.

Conflicting contraceptive norms for men: equal responsibility versus women's bodily autonomy

Most research investigating how men and women in heterosexual relationships negotiate contraceptive use focuses on the women's point of view. Using a sample of 44 interviews with men attending a western US university, this study examines norms governing men's participation in contraceptive use and pregnancy prevention and their responses to those norms. The paper demonstrates how competing norms around sexual health decision-making and women's bodily autonomy contribute to unintended outcomes that undermine young people's quest for egalitarian sexual relationships. While men largely agree that responsibility for sexual health decision-making should be shared with women, they also believe that women should have power over their own bodies and sexual health. However, the coexistence of these two competing norms - which call for both equal responsibility in decision-making and women's bodily autonomy - results in a disconnect between men saying that sexual health decision-making should be equal, but not always participating equally. Thus, men largely give contraceptive decision-making power over to women, putting the burden of pregnancy prevention onto women and letting men off the hook. It is concluded that men's negotiation of these competing norms reinforces unequal power and inequality in sexual relationships.

Population-level sexual behaviours in adolescent girls before and after introduction of the human papillomavirus vaccine (2003-2013)

BACKGROUND

The human papillomavirus (HPV) vaccine is delivered widely through school-based immunization programs. Some groups have expressed concern that HPV vaccination programs will result in an increase in sexual risk-taking behaviours among adolescents. We aimed to evaluate population-level changes in sexual behaviours before and after implementation of the school-based HPV vaccination program in British Columbia.

METHODS

In 2008, a school-based HPV vaccination program for girls was introduced in British Columbia. Using data from the BC Adolescent Health Survey - a longitudinal provincial survey administered in schools to capture adolescent physical and emotional health indicators, we conducted a linear trend analysis on sexual health behaviours and risk factors in adolescent girls before and after the implementation of vaccination for HPV (2003, 2008 and 2013).

RESULTS

We analyzed data for 298 265 girls who self-identified as heterosexual. The proportion of girls reporting ever having sexual intercourse decreased from 21.3% (2003) to 18.3% (2013; adjusted odds ratio [OR] 0.79). Self-report of sexual intercourse before the age of 14 years decreased significantly from 2008 to 2013 (adjusted OR 0.76), as did reported substance use before intercourse (adjusted OR for 2003-2013 0.69). There was no significant change in the number of sexual partners reported (2003-2013). Between 2003 and 2013, girls' reported use of contraception and condoms increased, while pregnancy rates decreased.

INTERPRETATION

Since the implementation of school-based HPV vaccination program in BC, sexual risk behaviours reported by adolescent girls either reduced or stayed the same. These findings contribute evidence against any association between HPV vaccination and risky sexual behaviours.

Spatial distribution of contraceptive usage by district in Pakistan: Percent change in couple years of protection in 2015-16 compared to 2014-15

Pakistan's population will cross the 200 million-mark in 2017. 'Couple Years of Protection' (CYP) is a proxy indicator for various contraceptive methods used. The Pakistan 'Contraceptive Performance Report 2015-2016' (CPR) in Pakistan, provides comparison with the previous year i.e. 2014-2015 in terms of CYP percent change at the district level in the country. In this study, CPR percent change data were mapped and cluster analysis was conducted, using GIS programmes to visualize spatial distribution in the country by district. No statistical evidence of clustering at the global/country level was found. The percent change in CYP 2015-16, compared to 2014-15 at the district level ranged from -90.4% to 316.9% in the 113 districts for which data was available. Sixty-five districts reported negative CYP percent change, while 48 reported positive CYP change. With the exception of Balochistan province, all provinces and FATA had districts with percent change in CYP ranging from -90.4% to -50.0%.

Trends in the sexual behaviour of 15-year olds in Scotland: 2002-14

Background

Early sexual initiation and inadequate contraceptive use can place adolescents at increased risk of unplanned pregnancy and sexually transmitted infections. These behaviours are patterned by gender and may be linked to social inequalities. This paper examines trends in sexual initiation and contraceptive use by gender and family affluence for Scottish adolescents.

Methods

Cross-sectional data from four nationally representative survey cycles (2002, 2004, 2010, 2014) (n = 8895) (mean age = 15.57) were analysed. Logistic regressions examined the impact of survey year on sexual initiation, condom use and birth control pill (BCP) use at last sex; as well as any changes over time in association between family affluence and the three sexual behaviours. Analyses were stratified by gender.

Results

Between 2002 and 2014, adolescent males and females became less likely to report having had sex. Low family affluence females were more likely to have had sex than high family affluence females, and this relationship did not change over time. Condom use at last sex was reported less by males since 2002, and by females since 2006. Low family affluence males and females were less likely to use condoms than high family affluence participants, and these relationships did not change over time. There were no effects of time or family affluence for BCP use.

Conclusion

There has been a reduction in the proportion of 15-year olds in Scotland who have ever had sex, but also a decrease in condom use for this group. Economic inequalities persist for sexual initiation and condom use.

Women's attitudes and beliefs towards specific contraceptive methods in Bangladesh and Kenya

BACKGROUND

Missing from the huge literature on women's attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants).

METHODS

In each site, 2424 to 2812 married women aged 15-39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study.

RESULTS

While current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower.

CONCLUSIONS

High levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.

Modern contraceptive use, unmet need, and demand satisfied among women of reproductive age who are married or in a union in the focus countries of the Family Planning 2020 initiative: a systematic analysis using the Family Planning Estimation Tool

BACKGROUND

The London Summit on Family Planning in 2012 inspired the Family Planning 2020 (FP2020) initiative and the 120×20 goal of having an additional 120 million women and adolescent girls become users of modern contraceptives in 69 of the world's poorest countries by the year 2020. Working towards achieving 120 × 20 is crucial for ultimately achieving the Sustainable Development Goals of universal access and satisfying demand for reproductive health. Thus, a performance assessment is required to determine countries' progress.

METHODS

An updated version of the Family Planning Estimation Tool (FPET) was used to construct estimates and projections of the modern contraceptive prevalence rate (mCPR), unmet need for, and demand satisfied with modern methods of contraception among women of reproductive age who are married or in a union in the focus countries of the FP2020 initiative. We assessed current levels of family planning indicators and changes between 2012 and 2017. A counterfactual analysis was used to assess if recent levels of mCPR exceeded pre-FP2020 expectations.

FINDINGS

In 2017, the mCPR among women of reproductive age who are married or in a union in the FP2020 focus countries was 45·7% (95% uncertainty interval [UI] 42·4-49·1), unmet need for modern methods was 21·6% (19·7-23·9), and the demand satisfied with modern methods was 67·9% (64·4-71·1). Between 2012 and 2017 the number of women of reproductive age who are married or in a union who use modern methods increased by 28·8 million (95% UI 5·8-52·5). At the regional level, Asia has seen the mCPR among women of reproductive age who are married or in a union grow from 51·0% (95% UI 48·5-53·4) to 51·8% (47·3-56·5) between 2012 and 2017, which is slow growth, particularly when compared with a change from 23·9% (22·9-25·0) to 28·5% (26·8-30·2) across Africa. At the country level, based on a counterfactual analysis, we found that 61% of the countries that have made a commitment to FP2020 exceeded pre-FP2020 expectations for modern contraceptive use. Country success stories include rapid increases in Kenya, Mozambique, Malawi, Lesotho, Sierra Leone, Liberia, and Chad relative to what was expected in 2012.

INTERPRETATION

Whereas the estimate of additional users up to 2017 for women of reproductive age who are married or in a union would suggest that the 120 × 20 goal for all women is overly ambitious, the aggregate outcomes mask the diversity in progress at the country level. We identified countries with accelerated progress, that provide inspiration and guidance on how to increase the use of family planning and inform future efforts, especially in countries where progress has been poor.

FUNDING

The Bill & Melinda Gates Foundation, through grant support to the University of Massachusetts Amherst and Avenir Health.

Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda

BACKGROUND

Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries.

METHODS

We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach.

RESULTS

Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda.

CONCLUSIONS

Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.

Condom Use During Sexual Intercourse Among Women and Men Aged 15-44 in the United States: 2011-2015 National Survey of Family Growth

condom use during sexual intercourse in a nationally representative sample of women and men aged 15-44 in the United States using the 2011-2015 National Survey of Family Growth (NSFG). Where data were available, patterns of condom use during sexual intercourse from the 2011-2015 NSFG were compared with the 2002 and 2006-2010 NSFG. Methods-Data were collected through in-person interviews with nationally representative, independent samples of women and men aged 15-44 in the household population of the United States. Interviews were conducted between September 2011 and September 2015 with 11,300 women and 9,321 men. The response rates for the 2011-2015 NSFG were 72.3% for women and 69.6% for men aged 15-44. Results-During 2011-2015, 23.8% of women and 33.7% of men aged 15-44 used a condom at last sexual intercourse in the past 12 months, an increase for men since 2002 (29.5%). Among condom users, 59.9% of women and 56.4% of men aged 15-44 used only a condom and no other method during last intercourse in the past 12 months; another 25.0% of women and 33.2% of men used condoms plus hormonal methods; and 15.1% of women and 10.5% of men used condoms plus nonhormonal methods. During any intercourse in the past 4 weeks, 18.2% of women and 23.9% of men aged 15-44 used a condom "100%" of the time. The prevalence of condom use during any intercourse in the past 4 weeks varied by age, education, Hispanic origin and race, relationship at last sexual intercourse, and number of opposite-sex sexual partners in the past 12 months. Almost 7% of women aged 15-44 who used a condom in the past 4 weeks said the condom broke or completely fell off during intercourse or withdrawal, and 25.8% said the condom was used for only part of the time during intercourse.

Change and consistency in US women's pregnancy attitudes and associations with contraceptive use

OBJECTIVES

This study examines the cognitive and affective dimensions of pregnancy attitudes in order to better recognize the role of each in pregnancy ambivalence as well as the relative importance of each in understanding contraceptive use.

STUDY DESIGN

Data from a national sample of 2894 women aged 18-39, gathered at baseline and 6 months later, were used to examine a measure of pregnancy avoidance (cognitive) and a measure of happiness about pregnancy (affective), both separately and jointly. I used bivariate and multivariate analysis to examine associations between attitudinal measures and consistent contraceptive use. I also examined changes in attitudes over time and associations between changes in attitudes and changes in consistent contraceptive use.

RESULTS

While a majority of women, 53%, indicated that it was very important to avoid pregnancy, a substantially lower proportion, 23%, would have been very unhappy to be pregnant. In logistic regression models that included both measures, only pregnancy avoidance was associated with consistent contraceptive use. Cognitive attitude was less likely than affective attitude to change over time; additionally, change in pregnancy avoidance, but not happiness, was associated with change in consistent contraceptive use.

CONCLUSION(S)

Pregnancy avoidance appears to play a more important role in understanding consistent contraceptive use. Findings from this study provide support for the idea that positive feelings about a pregnancy do not contradict a desire to avoid conception and that feelings and intentions may be distinct concepts for many women.

IMPLICATIONS

Health care providers should assess patients' pregnancy avoidance attitude but also recognize that this can change over a short period of time for some women and should be evaluated regularly.

Early patterns of sexual activity: age cohort differences in Australia

Patterns of first sexual activity among Australians born between the 1940s and 1980s were analysed using data from a national telephone survey of 1784 adults (876 males; 908 females). Sixty-one percent of those randomly selected from the Australian electoral roll and contactable by telephone responded. Many trends, including earlier first intercourse - from 20 to 18 years (females) and 18.8 to 17.8 years (males) - were established with the 40-49 year cohort, whose sexual debut was in the late 1960s-70s. Significant age-cohort effects saw women in the contemporary (18-29 year) cohort draw level with males for age at first intercourse and first sex before age 16 and before leaving school. First intercourse contraceptive use climbed from 30% to 80%. Condom use quadrupled to 70%. Australian age-cohort effects are remarkably consistent with those in similar western cultures: gender convergence in sexual experience and increasing avoidance of sexually transmitted disease and pregnancy. If such trends continue, positive long-term outcomes for health and social wellbeing should result.

Long-term utilization and continuation of intrauterine devices

OBJECTIVE

We compared the 48 and 60 month continuation rates of levonorgestrel (LNG) and copper (Cu) intrauterine devices (IUDs) among women enrolled in the Contraceptive CHOICE Project (CHOICE). Our primary outcome was continuation at 48 months.

STUDY DESIGN

This is a prospective cohort study of women who received an IUD through CHOICE. We randomly selected women who had either LNG or Cu IUDs inserted between January 2008 and June 2009 and contacted them by telephone. Once contacted and consented, they were asked whether they were still using their IUD. Women who reported discontinuation of the IUD were asked for the reasons and subsequent contraceptive use. Survival analysis using Cox proportional hazards was performed to assess for factors associated with discontinuation and to calculate hazard ratios.

RESULTS

Of the 460 women we attempted to contact, 321 (70%) were reached for interviews. Continuation data on the remaining 139 women were available from CHOICE and its substudies. Continuations at 48 and 60 months were 62.3% and 51.7% for LNG IUD and 64.2% and 55.9% for the Cu IUD, respectively. Continuation at 48 months was highest among women older than 29 years of age at insertion (LNG IUD, 72.5%; Cu IUD, 77.1%). Women younger than 24 years of age had the lowest 48 month continuation (LNG IUD, 55.4%, and Cu IUD, 53.2%). In univariable and multivariable analysis, demographic characteristics, menstrual profile, and pregnancy history were not associated with discontinuation. Age older than 29 years was associated with less discontinuation than those 24-29 years of age (hazard ratio, 0.67, 95% confidence interval, 0.47-0.96).

CONCLUSION

IUD continuation remains high (> 60%) at 48 months with no difference between Cu and LNG IUDs.

Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013

This report describes current contraceptive use among women of childbearing age (ages 15-44) during 2011-2013. Current contraceptive use is defined as use during the month of interview, not for a specific act of sexual intercourse. This report's primary focus is describing patterns of contraceptive use among women who are currently using contraception, by social and demographic characteristics. Data from 2002 and 2006-2010 are presented for comparison. METHODS-Data for the 2011-2013 National Survey of Family Growth (NSFG) were collected through in-person interviews in respondents' homes. The 2011-2013 NSFG, a nationally representative survey conducted by the Centers for Disease Control and Prevention's National Center for Health· Statistics, was based on interviews with 10,416 women and men aged 15-44 in the U.S. household population. This report is based on the sample of 5,601 women interviewed in 2011-2013, with a response rate of 73.4%. RESULTS-Among women currently using contraception, the most commonly used methods were the pill (25.9%, or 9.7 million women), female sterilization (25.1 %, or 9.4 million women), the male condom (15.3%, or 5.8 million women), and long-acting reversible contraception (LARC)-intrauterine devices or contraceptive implants (11.6%, or 4.4 million women). Differences in method use were seen across social and demographic characteristics. Comparisons between time points reveal some differences, such as higher use of LARC in 2011-2013 compared with earlier time points.

Using Longitudinal Data to Understand Changes in Consistent Contraceptive Use

CONTEXT

Most studies of contraceptive behavior rely on cross-sectional data and are unable to adequately measure fluctuations in contraceptive use or changes in circumstances and attitudes that are likely to be associated with this outcome.

METHODS

Between November 2012 and May 2014, four waves of data were gathered from a national sample of 1,842 women aged 18-39 at baseline. Cross-tabulations were used to examine change and stability in time-varying characteristics theorized to be associated with consistent contraceptive use. Random-effects and fixed-effects logistic regression models were used to examine variables associated with consistent contraceptive use.

RESULTS

While a majority of women were at risk of unintended pregnancy during each survey period, only 42% were at risk during all four. Random-effects logistic regression analysis revealed that the odds of being a consistent contraceptive user were 10 times as high for a woman who expressed a strong pregnancy avoidance attitude as for a woman who had a weak attitude. This strong association was confirmed in the fixed-effects model. However, having a strong desire to avoid pregnancy was not static; among women at risk of unintended pregnancy during at least one survey period, 53% reported a change in attitude.

CONCLUSIONS

These findings build on prior research suggesting that pregnancy avoidance attitudes are an important motivator for contraceptive use. It is critical to recognize that the context in which many women make decisions about pregnancy and contraceptive use changes over relatively short periods of time.

Novel restricted access to vasectomy in Iran: addressing changing trends in vasectomy clients' characteristics over 16 years in northwestern Iran

OBJECTIVES

This study is designed to evaluate the popularity of vasectomy in Iran. The study was conducted to calculate the frequency of vasectomy over time, to compare vasectomy users' characteristics with the general population and whether these characteristics have changed over time.

STUDY DESIGN

A cross-sectional study of 7864 men undergoing vasectomy in a 16-year period was conducted in Urmia, Iran. Comparative statistics described differences between vasectomy users and nonusers. The data were analyzed separately in two 8-year periods, 1996-2003 and 2004-2011. The time period did not involve 2012, the year which vasectomy became outlawed in the whole country.

RESULTS

During the study period, the contraceptive prevalence rate of vasectomy increased from 0.1% to 3.35%. Vasectomy users were predominantly older, better educated, had more children and more urban residents than the general male population (p<0.001). Over time, men who underwent vasectomy tended to be younger, have well-educated wife and rural resident (p<0.05).

CONCLUSIONS

This study highlighted a dramatic rise in the use of vasectomy between 1996 and 2011 in Iran. While the characteristics of vasectomy users versus general population were different, especially in age, education, resident area, number and sex of their children, there were significant changes from two 8-year study time periods.

Patterns of fertility preferences and contraceptive behaviour over time: change and continuities among the urban poor in Nairobi, Kenya

The main objective of this paper is to investigate the association between fertility preferences and contraceptive use among 15-49-year-old women living in Korogocho and Viwandani, informal settlements in Nairobi, Kenya. We draw on longitudinal data collected under the Maternal and Child Health project conducted between 2006 and 2010 in the two settlements. There is substantial regularity and stability but also unusual instability in reported fertility preferences over time among women living in these settings. Younger women, aged 15-24 years, are likely to change their preferences over time, passing from limiting to wanting additional children. But women aged 35-49 are likely to change their preferences from desiring more children to limiting their childbearing. The desire to limit childbearing is strongly associated with the use of modern and long-acting contraceptive methods. Findings have major implications for the success of family planning programmes in informal settlements where access to and knowledge about contraception may be limited.

Barriers to contraceptive use among women in Benin

The Republic of Benin has made it a national priority to promote family planning as part of its efforts to reduce maternal and child mortality rates. In addition to preventing deaths, increased contraceptive use would help women and families achieve their desired number of children and have greater control over timing births. It would also help Benin meet its development goals, including reducing poverty and increasing women's education and earning levels, children's schooling and GDP per capita. Key Points. (1) Although Benin's government promotes family planning, more needs to be done to meet the country's goal of increasing contraceptive prevalence to 20% by 2018. (2) As of 2012, modern contraceptive use remains low. Only 7% of married women and 23% of unmarried sexually active women use modern methods. (3) Unmet need has increased since 2006, from 27% to 33% among married women and from 35% to 50% among sexually active unmarried women. (4) Among married women with unmet need, the most commonly cited reasons for contraceptive nonuse are fear of side effects/health concerns (22%) and opposition to use (22%). In contrast, never-married women with unmet need cite not being married (42%), infrequent or no sex (21%) and fear of side effects/health concerns (17%). (5) Among women currently using sterilization, IUDs, implants, injectables or the pill, 57% report having been told about side effects when they received their method; 88% of those who were told about side effects were given instructions on how to deal with them. (6) Strategies to increase contraceptive use include improving the availability and quality of contraceptive services, increasing knowledge of family planning, and addressing social and cultural barriers to contraception.

Understanding unmet need: history, theory, and measurement

During the past two decades, estimates of unmet need have become an influential measure for assessing population policies and programs. This article recounts the evolution of the concept of unmet need, describes how demographic survey data have been used to generate estimates of its prevalence, and tests the sensitivity of these estimates to various assumptions in the unmet need algorithm. The algorithm uses a complex set of assumptions to identify women: who are sexually active, who are infecund, whose most recent pregnancy was unwanted, who wish to postpone their next birth, and who are postpartum amenorrheic. The sensitivity tests suggest that defensible alternative criteria for identifying four out of five of these subgroups of women would increase the estimated prevalence of unmet need. The exception is identification of married women who are sexually active; more accurate measurement of this subgroup would reduce the estimated prevalence of unmet need in most settings.

Trends in ages at key reproductive transitions in the United States, 1951-2010

BACKGROUND

Key sexual and reproductive health milestones typically mark changing life stages with different fertility intentions and family planning needs. Knowing the typical ages at such events contributes to our understanding of changes in family formation and transition to adulthood and helps inform needs for reproductive health services.

METHODS

We used data from the 1982-2010 National Surveys of Family Growth and the 1995 National Survey of Adolescent Males and event history methods to examine trends over time for women and men in the median ages at several reproductive and demographic events.

FINDINGS

Women's reports indicate that age at menarche has changed little since 1951. Women's and men's median ages at first sex declined through the 1978 birth cohort, but increased slightly since then, to 17.8 years for women and 18.1 for men. The interval from first sex to first contraceptive use has narrowed, although Hispanic women have a longer interval. Age at first union (defined as the earlier of first marriage or first cohabiting relationship) has remained relatively stable, but the time between median age at first sex and median age at first birth has increased to 9.2 years for women and 11.4 for men. For some women and men born in the late 1970s, median age at first birth was earlier than median age at first marriage for the first time in at least the past several decades.

CONCLUSION

The large majority of the reproductive years are spent sexually active. Thus, women have a lengthy period during which they require effective methods. In particular, the period between first sex and first childbearing has lengthened, but long-acting method use, although increasing, has not kept up with this shift. Moving the contraceptive method mix toward underutilized but highly effective contraceptive methods has the potential to reduce the unintended pregnancy rate.

Family planning knowledge and practice among people living with HIV in Nepal

Unsafe sexual behavior is common among the HIV infected. This exposes them to the risks of unintended pregnancy, HIV transmission to uninfected partners and super-infection. Studies on the use of family planning measures among People Living with HIV (PLHIV) are scarce in Nepal. The aim of this study was to explore the knowledge and practice of family planning (FP) in PLHIV. A cross sectional survey was conducted during July-December 2012 in Kaski district of Nepal. A total of 120 PLHIVs were recruited using snowball sampling from three HIV clinics within the Pokhara sub-metropolitan city area. This study found that nine in ten PLHIV had heard about family planning. Two thirds of respondents were using at least one FP method. The majority (65.8%) used condoms and had received FP counseling (67.5%). Less than one percent used condoms in addition to another contraceptive. Being single, being female and having received the counselling sessions were associated with the use of FP. The individuals who received FP counseling were more likely [OR 4.522; 95% CI (1.410-14.504)] to use FP. Females were more likely [OR 4.808; 95% CI (1.396-16.556)] to use FP than males. The individuals who were single/de-facto widowed were more likely [OR 7.330; 95% CI (2.064-26.028)] to use FP than the married individuals. Our findings suggest that there is a need to focus on FP counseling if the HIV prevention program is to increase FP use among the PLHIV population. Use of dual contraceptives need to be promoted through counseling sessions and other health promotion programs focusing in HIV prevention.

Variation in postpartum contraceptive method use: results from the Pregnancy Risk Assessment Monitoring System (PRAMS)

OBJECTIVE

The National Survey of Family Growth has been a primary data source for trends in US women's contraceptive use. However, national-level data may mask differences in contraceptive practice resulting from variation in local policies and norms.

STUDY DESIGN

We used the Pregnancy Risk Assessment Monitoring System, a survey of women who are 2-4 months postpartum. Information on women's current method was available for 18 reporting areas from 2000 to 2009. Using the two most recent years of data, we computed the weighted proportion of women using specific contraceptive methods according to payment for delivery (Medicaid or private insurance) and examined differences across states. We used log binomial regression to assess trends in method use in 8 areas with consecutive years of data.

RESULTS

Across states, there was a wide range of use of female sterilization (7.0-22.6%) and long-acting reversible contraception (LARC; 1.9-25.5%). Other methods, like vasectomy and the patch/ring, had a narrower range of use. Women with Medicaid-paid deliveries were more likely to report female sterilization, LARC and injectables as their method compared to women with private insurance. LARC use increased ≥18% per year, while use of injectables and oral contraceptives declined by 2.5-10.6% annually.

CONCLUSIONS

The correlation in method-specific prevalence within states suggests shared social and medical norms, while the larger variation across states may reflect both differences in norms and access to contraception for low-income women. Surveys of postpartum women, who are beginning a new segment of contraceptive use, may better capture emerging trends in US contraceptive method mix.

IMPLICATIONS

There is considerable variation in contraceptive method use across states, which may result from differences in state policies and funding for family planning services, local medical norms surrounding contraceptive practice, and women's and couples' demand or preference for different methods.

A review of risk and protective factors for adolescent sexual and reproductive health in developing countries: an update

PURPOSE

To conduct a literature review of studies that examined risk and protective factors related to adolescent sexual and reproductive health in developing countries.

METHODS

A literature search was conducted using multiple databases, including PubMed, PsycINFO, Scopus, JSTOR, and the Interagency Youth Working Group. Review criteria included publications that: were conducted in a low- or middle-income country; had a sample size of at least 100 young people aged 10-24 years, and used multivariate analysis. All studies that were identified were also conducted between 1990 and 2010, a 20-year time frame. The literature search and initial review yielded a total of 244 studies that met the criteria and analyzed risk and protective factors related to the following outcomes: sexual initiation, number of sexual partners, condom use, contraceptive use, pregnancy and early childbearing, human immunodeficiency virus, sexually transmitted infections, and sexual coercion.

RESULTS

Most studies that were conducted on adolescent sexual and reproductive health in developing countries were largely focused in Sub-Saharan African contexts, and primarily examined factors related to sexual initiation and condom use. Most factors that examined an adolescent sexual and reproductive health outcome were also focused on the individual level, although an increasing number of studies within the past 10 years have focused on family-level factors. Few studies examined factors at the community or neighborhood level, which, to date, has largely been ignored in developing country contexts.

CONCLUSIONS

The review not only summarizes what is currently known in terms of risk and protective factors that relate to adolescent sexual and reproductive health in developing countries, but also highlights the gaps. Implications for future research are discussed.

Marital processes, arranged marriage, and contraception to limit fertility

An international transition away from familially arranged marriages toward participation in spouse choice has endured for decades and continues to spread through rural Asia today. Although we know that this transformation has important consequences for childbearing early in marriage, we know much less about longer-term consequences of this marital revolution. Drawing on theories of family and fertility change and a rural Asian panel study designed to measure changes in both marital and childbearing behaviors, this study seeks to investigate these long-term consequences. Controlling for social changes that shape both marital practices and childbearing behaviors, and explicitly considering multiple dimensions of marital processes, we find evidence consistent with an independent, long-standing association of participation in spouse choice with higher rates of contraception to terminate childbearing. These results add a new dimension to the evidence linking revolutions in marital behavior to long-term declines in fertility and suggest that new research should consider a broader range of long-term consequences of changing marital processes.

Trend in the use of intra-uterine contraceptive device (IUCD ,TCU 380A), in Enugu, Nigeria

OBJECTIVE

To estimate the acceptance rate and trend of Intrauterine Contraceptive Device (IUCD) use in Enugu, Nigeria

PATIENTS AND METHODS

A review of all new acceptors of intrauterine contraceptive device (IUCD) over a nine year period (1999-2007).

RESULTS

A total of 133,375 clients were seen at the UNTH family planning clinic between 1999 and 2007. Out of 6,947 users of IUCD, during the period, 1,659 were new acceptors. The IUCD acceptance rate was 5.21%. Majority of the clients (29.7%) were aged 40 years and above. Eight hundred and forty seven (51.4%) had attained post secondary education. Majority of the clients (99.4%) were married . Twenty-six percent (26.0%) had completed their desired family size. Majority 1,359 (82.4%) did not use any method contraception prior to IUCD insertion. The commonest complication was menorrhagia (5.8%) and this was responsible for removal in 3.0% of cases. Eight (0.5%) and nine (0.6%) requested for removal for fear of causing cancer and migration to the brain or heart respectively. Two (0.1%) became pregnant while having the IUCD in-situ. Majority of the clients (50.5%) had the knowledge of lUCD through friends.

CONCLUSION

This study has shown that IUCD (TCU 380A) is both safe and effective in Enugu, Nigeria. Its use is for both child spacing and limiting family size.

Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys

BACKGROUND

Data for trends in contraceptive use and need are necessary to guide programme and policy decisions and to monitor progress towards Millennium Development Goal 5, which calls for universal access to contraceptive services. We therefore aimed to estimate trends in contraceptive use and unmet need in developing countries in 2003, 2008, and 2012 .

METHODS

We obtained data from national surveys for married and unmarried women aged 15-49 years in regions and subregions of developing countries. We estimated trends in the numbers and proportions of women wanting to avoid pregnancy, according to whether they were using modern contraceptives, or had unmet need for modern methods (ie, using no methods or a traditional method). We used comparable data sources and methods for three reference years (2003, 2008, and 2012). National survey data were available for 81-98% of married women using and with unmet need for modern methods.

FINDINGS

The number of women wanting to avoid pregnancy and therefore needing effective contraception increased substantially, from 716 million (54%) of 1321 million in 2003, to 827 million (57%) of 1448 million in 2008, to 867 million (57%) of 1520 million in 2012. Most of this increase (108 million) was attributable to population growth. Use of modern contraceptive methods also increased, and the overall proportion of women with unmet need for modern methods among those wanting to avoid pregnancy decreased from 29% (210 million) in 2003, to 26% (222 million) in 2012. However, unmet need for modern contraceptives was still very high in 2012, especially in sub-Saharan Africa (53 million [60%] of 89 million), south Asia (83 million [34%] of 246 million), and western Asia (14 million [50%] of 27 million). Moreover, a shift in the past decade away from sterilisation, the most effective method, towards injectable drugs and barrier methods, might have led to increases in unintended pregnancies in women using modern methods.

INTERPRETATION

Achievement of the desired number and healthy timing of births has important benefits for women, families, and societies. To meet the unmet need for modern contraception, countries need to increase resources, improve access to contraceptive services and supplies, and provide high-quality services and large-scale public education interventions to reduce social barriers. Our findings confirm a substantial and unfinished agenda towards meeting of couples' reproductive needs.

FUNDING

UK Department for International Development, the Bill & Melinda Gates Foundation, and the UN Population Fund (UNFPA).

National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis

BACKGROUND

Expansion of access to contraception and reduction of unmet need for family planning are key components to improve reproductive health, but scarce data and variability in data sources create difficulties in monitoring of progress for these outcomes. We estimated and projected indicators of contraceptive prevalence and unmet need for family planning from 1990 to 2015.

METHODS

We obtained data from nationally representative surveys, for women aged 15-49 years who were married or in a union. Estimates were based on 930 observations of contraceptive prevalence between 1950 and 2011 from 194 countries or areas, and 306 observations of unmet need for family planning from 111 countries or areas. We used a Bayesian hierarchical model combined with country-specific time trends to yield estimates of these indicators and uncertainty assessments. The model accounted for differences by data source, sample population, and contraceptive methods included in the measure.

FINDINGS

Worldwide, contraceptive prevalence increased from 54·8% (95% uncertainty interval 52·3-57·1) in 1990, to 63·3% (60·4-66·0) in 2010, and unmet need for family planning decreased from 15·4% (14·1-16·9) in 1990, to 12·3% (10·9-13·9) in 2010. Almost all subregions, except for those where contraceptive prevalence was already high in 1990, had an increase in contraceptive prevalence and a decrease in unmet need for family planning between 1990 and 2010, although the pace of change over time varied between countries and subregions. In 2010, 146 million (130-166 million) women worldwide aged 15-49 years who were married or in a union had an unmet need for family planning. The absolute number of married women who either use contraception or who have an unmet need for family planning is projected to grow from 900 million (876-922 million) in 2010 to 962 million (927-992 million) in 2015, and will increase in most developing countries.

INTERPRETATION

Trends in contraceptive prevalence and unmet need for family planning, and the projected growth in the number of potential contraceptive users indicate that increased investment is necessary to meet demand for contraceptive methods and improve reproductive health worldwide.

FUNDING

United Nations Population Division and National University of Singapore.

[Sexual and contraceptive behavior of teenagers and young adults. Selected results of the BZgA study "Youth Sexuality 2010"]

The BZgA study "Youth Sexuality 2010" clarifies the changes that have occurred in the sexual and contraceptive behavior of teenagers and young adults over the last 30 years. Among young Germans, there is now more gender similarity regarding both the age at which intercourse first takes place and contraceptive behavior. The proportion of German teenagers who take no contraceptive precautions when they have intercourse for the first time is now 8%, a lower figure than ever previously recorded. Communication about contraception, both at home and between the partners, is making a substantial contribution to responsible contraceptive behavior on the part of teenagers and young adults. Alongside education about sexuality in the family and at school, there are also structural influences on the positive developments witnessed in Germany. And yet there are still target groups that are inadequately reached. Many migrants are less well informed about bodily processes, their contraceptive practice is not as good, and their religious background tends to exclude them from access to information. Disabled teenagers and young adults constitute a target group about which to date we have insufficient knowledge. Education and social deprivation continue to be important factors in the differences seen in sexual and contraceptive behavior. In this area, proactive efforts are necessary.

Increased use of injectable contraception in sub-Saharan Africa

National surveys show a remarkable upsurge in the use of injectable contraceptives in east and South Africa, in contrast to central and West Africa and certain other regions. Data are analyzed here from 95 surveys conducted since 1980 in 38 sub-Saharan African countries, to determine past injectable trends in the context of alternative methods and to explore related issues. In eastern and southern countries injectable use has risen to about 15%-20% of married women, equaling about 40% of all contraceptive use, with some countries above that. Increases in total use have followed increases in injectable use; that and other evidence is clear that the injectable has not merely substituted for the use of pre-existing methods but has given a net increase to total use. Rural use patterns are not much different from urban ones; however the middle and higher wealth quintiles have especially moved toward injectable use. In west and central countries traditional methods are still paramount, with modern methods increasing slightly, but total use remains quite low there. So far no plateau has appeared in total injectable use, though one may be emerging in its share of all use as other methods also increase. Most use is supplied through the public sector, which raises long-term cost issues for health ministries and donors. Many sexually active, unmarried women use the method Discontinuation rates are quite high, and alternative methods need to be kept readily available.

Continuing social disparities despite upward trends in sexual and reproductive health service use among young women in the United States

BACKGROUND

Building upon previous work describing declining rates and socioeconomic disparities in sexual and reproductive health (SRH) service use among young women in the United States, we reexamined patterns and determinants of SRH service use in 2006-2010.

STUDY DESIGN

We used the latest data from the National Survey of Family Growth to evaluate SRH service use including contraceptive, sexually transmitted infection (STI) and other gynecological exam services among 3780 women ages 15-24 years. We compared proportions of service use across survey years and employed multiple logistic regression to estimate the influence of time and women's sociodemographic characteristics on the likelihood of SRH service use.

RESULTS

The proportion of women using SRH services increased from 50% (2006-2007) to 54% (2007-2008) and 57% (2008-2010) [all year odds ratios (ORs) 1.4, p values<.03]. Among sexually experienced women, the proportions using SRH and contraceptive services were unchanged, while STI service use increased from 22% (2006-2007) to 33% (2008-2009) (OR 1.7, confidence interval 1.1-2.4, p=.009). Differentials in service use existed across sociodemographic groups, largely with lower proportions of service use among women of social disadvantage.

CONCLUSIONS

Our results suggest a reversal of negative trends but continuing social disparities in young women's use of SRH services in the United States.