Associations between the COVID-19 pandemic and women's fertility intentions: a multi-country, cross-sectional (I-SHARE) study

INTRODUCTION

The COVID-19 pandemic, together with the subsequent social distancing measures, could lead to shifts in family and fertility planning. This study aimed to explore the associations between the COVID-19 pandemic and changes in fertility intentions among an international sample of reproductive-aged women.

METHODS

A multi-country, cross-sectional study based on data from 10 672 women aged 18-49 years who participated in the International Sexual Health And REproductive Health (I-SHARE) study, which organised an international online survey between July 2020 and February 2021. Factors associated with changes in fertility intentions were explored using multinomial probit regression models. Cluster-robust standard errors were used to calculate model parameters.

RESULTS

Of 10 672 included reproductive-aged women, 14.4% reported changing their fertility intentions due to the pandemic, with 10.2% postponement and 4.2% acceleration. Women who had ever been isolated/quarantined were more likely to postpone their fertility intentions (adjusted odds ratio (AOR)=1.41; 95% CI 1.18 to 1.69) compared with those who had not; women who lived with a steady partner were more likely to want children sooner (AOR=1.57; 95% CI 1.10 to 2.23) compared with those who did not; and those who reported a higher frequency of getting angry, feeling frustrated, or worrying about their finances were more likely to postpone their fertility intentions. The main findings were robust in the sensitivity analyses.

CONCLUSIONS

Most women who changed fertility intentions because of the pandemic have postponed intentions to expand their families. The pandemic-induced exposures were associated with these postponements.

Changes in family situation and concurrent changes in working life: a 15-year longitudinal analysis

OBJECTIVE

Currently, little is known regarding changes in family situation with concurrent changes in working life. This study aimed to examine whether changes in family situation (based on living with children and/or marrying/divorcing) were associated with changes in working life and whether the associations were influenced by sex, genetics and early life environment.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

Data from Swedish national registers of 16 410 twins were used. Fixed-effects logistic regression models assessing ORs with 95% CIs were applied to examine associations between changes in family situation and working life controlling for time-invariant effects and adjusted for covariates, and conditional models to account for confounding of genetics and early life environment.

RESULTS

Changes in individuals life situation from being single and living without children to married and living with children were associated with transitioning from unsustainable (ie, having unemployment or sickness absence/disability pension) to sustainable working life (men: OR 2.40, 95% CI 2.26 to 2.56; women: OR 1.68, 95% CI 1.59 to 1.78). Changes from being married to single, in contrast, attenuated the likelihood of transitioning to a sustainable working life. Moreover, changes in men's working life seem to be more dependent on changes in family situation compared with women. Genetic factors and early life environment play a role in the associations.

CONCLUSIONS

Family formation increases the likelihood of a more stable working life whereas divorce is a risk factor for work interruptions. Our study emphasises that family formation improves the work life situation and to a higher degree for men.

Changes in fertility intention among married Chinese couples with two children during COVID-19: a cross-sectional study

BACKGROUND

A three-child policy was implemented in China to stimulate a rise in fertility levels and coincided with the COVID-19 pandemic. Data suggested that COVID-19 has a negative impact on fertility intention.

AIM

To describe married couples' changes in intention to have a third child during the COVID-19 pandemic and determine factors associated with altered intentions.

METHODS

An online survey was conducted in October 2021, including sociodemographic characteristics, change of intention to have a third child after the COVID-19 pandemic outbreak, reasons for increased or decreased intention, and the Fertility Intention Scale (FIS). Bivariate and multivariable logistic regression were used to test the potential factors associated with changes in intention.

RESULTS

A total of 1308 participants provided responses. Following the COVID-19 outbreak, 35.8% of participants decreased their third-child intention, while 2.8% of participants increased their third-child intention. Males (aOR 1.90, 95% CI 1.42 to 2.54), youngsters (aOR 1.77, 95% CI 1.08 to 2.93) and those living in Estern China (aOR 2.12, 95% CI 1.13 to 3.98) were more likely to decrease their third-child intention. Perceived risk (aOR 1.07, 95% CI 1.03 to 1.10) and policy support (aOR 1.06, 95% CI 1.03 to 1.09) as measured on the FIS decreased couples' intention to have a third child. Social support (aOR 0.94, 95% CI 0.91 to 0.98) as measured on the scale protected participants from decreased intention.

CONCLUSIONS

During severe public health emergencies, strong prevention and control policies, together with enhancing support from partners and healthcare professionals for women, are necessary to improve intentions to give birth.

Patterns in the provision of government-subsidised hormonal postpartum contraception in Queensland, Australia between 2012 and 2018: a population-based cohort study

BACKGROUND

Short birth intervals and unintended pregnancy are associated with poorer maternal and infant outcomes. There is a risk of pregnancy during the immediate postpartum period unless contraception is initiated. This retrospective cohort study aimed to capture the current patterns of hormonal contraceptive provision within 12 months postpartum in a high-income country.

METHODS

We used a linked administrative dataset comprising all women who gave birth in Queensland, Australia between 1 July 2012 and 30 June 2018 (n=339 265 pregnancies). We described our cohort by whether they were provided with government-subsidised hormonal contraception within 12 months postpartum. The associations between hormonal postpartum contraceptive provision and demographic and clinical characteristics were examined using univariate and multivariate logistic regression and presented in terms of crude and adjusted odds ratios with 95% confidence intervals.

RESULTS

A majority of women (60.2%) were not provided with government-subsidised hormonal postpartum contraception within 12 months postpartum. Women who were younger (<25 years), were overweight or obese, smoked, were born in Australia, were non-Indigenous, gave birth in a public hospital, or were in the lowest socioeconomic status group were more likely to be provided with postpartum contraception after adjusting for other covariates, compared with their counterparts.

CONCLUSIONS

Strategies to increase the provision and uptake of contraception in the immediate postpartum period are needed to prevent short birth intervals and unintended pregnancy and ensure women's fertility intentions are enacted. Ongoing research is needed to examine the factors influencing women's access to contraceptive services and, further, the types of contraception provided.

The Provision of Abortion Care via Telehealth in the United States: A Rapid Review

INTRODUCTION

The recent Supreme Court decision Dobbs v. Jackson Women's Health that has overruled Roe v. Wade has resulted in severe limitations of abortion access throughout the United States. Telehealth has been put forth as one solution for improving access for reproductive health care, including abortion services. Telehealth has demonstrated safety and efficacy in several health care disciplines; however, its use for abortion care and services has not been explored and synthesized.

METHODS

As part of a larger review on telehealth and general reproductive health, our team identified a moderate amount of literature on telehealth and abortion care. We conducted a rapid review searching for eligible studies in MEDLINE, Embase, and CINAHL. Information was extracted from each included study to explore 4 key areas of inquiry: (1) clinical effectiveness, (2) patient and provider experiences, (3) barriers and facilitators, and (4) the impact of the coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

Twenty-five studies on the use of telehealth for providing abortion services published between 2011 and 2022 were included. Telehealth for medical abortion increased during the COVID-19 pandemic and was found to be safe and clinically effective, with high patient satisfaction. Overall, telehealth improved access and removed barriers for patients including lack of transportation. Legal restrictions in certain states were cited as the primary barriers. Studies contained limited information on the perspectives and experiences of health care providers and diverse patient populations.

DISCUSSION

Abortion care via telehealth is safe and effective with high satisfaction and may also remove barriers to care including transportation and fear. Removing restrictions on telehealth for the provision of abortion services may further improve access to care and promote greater health equity.

Accessing abortion in a highly restrictive legal regime: characteristics of women and pregnant people in Malta self-managing their abortion through online telemedicine

OBJECTIVE

To examine the numbers and characteristics of women and pregnant people in Malta seeking at-home medical abortion using online telemedicine from 2017 to 2021.

DESIGN

Population-based study.

SETTING

Republic of Malta PARTICIPANTS: Between 1 January 2017 and 31 December 2021, 1090 women and pregnant people requested at-home medical abortion through one online telemedicine provider (Women on Web). Mifepristone and misoprostol were shipped to 658 women (60.4% of requests).

MAIN OUTCOME MEASURES

The numbers and demographics of persons to which abortion pills were shipped, their reasons for accessing abortion, and reasons for requesting medical abortion via telemedicine between January 2017 and December 2021 were analysed. Selected data were compared across different groups.

RESULTS

The number of people in Malta to whom medical abortion pills were shipped increased significantly in the 5 years analysed. Women and pregnant people requesting medical abortion were diverse with respect to age, pregnancy circumstances and reasons for seeking an abortion. More than half had existing children and over 90% reached out to Women on Web at <7 weeks. Among those completing a medical abortion, 63% did not use contraception, and in 30% there was contraception failure. The most common reasons for ordering medical abortion pills online were difficulty accessing abortion because of legal restrictions (73%) and abortion pills not being available (45%) in the country.

CONCLUSIONS

Despite a complete ban on abortion, the number of women and pregnant people residing in Malta completing at-home medical abortions is considerable and has been steadily increasing.

Policy Changes in China's Family Planning: Perspectives of Advocacy Coalitions

Studies on policy change focus on governmental decision-making from a technical rationality perspective, ignoring the fact that policy change is a complicated social construction process involving multiple actors. This study used the modified advocacy coalition framework to explain changes in China's family planning policy and discourse network analysis to show the debate on the birth control policy among multiple actors (central government, local governments, experts, media, and the public). It found that the dominant coalition and the minority coalition can learn and adjust deep core beliefs from each other; the sharing and flow of actors' policy beliefs drive change in the network structure; and actors' obvious preferential attachment when the promulgation of the central document, are all helpful in policy change. This study can explain macro-policy changes from a micro-perspective to reveal the process and mechanism of policy changes in China's authoritarian regime.

Experiences using a progestin-only pill in an over-the-counter environment in the United States: a cross-sectional survey

BACKGROUND

Efforts are underway to make a progestin-only pill (POP) over the counter (OTC) in the United States (US); however, little is known about POP user experiences, which could impact uptake and continuation.

METHODS

From January 2020-September 2021, we conducted a cross-sectional online survey with individuals who used OTC POPs in a US trial. We calculated descriptive statistics and Pearson chi-square and Fisher's exact tests to assess menstrual bleeding acceptability, how OTC POP experiences compared with prior contraceptive methods, and preferred ways to get answers to questions during OTC POP use.

RESULTS

Among 550 adult and 115 adolescent participants, 80% (n=531) felt their menstrual bleeding was acceptable. Participants reported a range of menstrual bleeding experiences compared with prior long-acting or hormonal methods used; 58% (n=84) said the POP bleeding was similar or better and 36% (n=53) said it was worse. Among participants who used contraception in the month prior to the trial, 77% (n=201) said their overall OTC POP experience was similar or better. Top benefits compared with prior methods included less worry about pregnancy, ease of access, fewer side effects, and greater decision-making power. Adults preferred to get answers about OTC POPs via webpage or app, whereas teens preferred asking pharmacists or other healthcare providers.

CONCLUSIONS

Overall, OTC POP users in a trial setting found the menstrual bleeding acceptable and the method similar to or better than previous methods. POP labelling should provide clear messaging about bleeding changes users may experience.

Physician perspectives of abortion advocacy: findings from a mixed-methods study

OBJECTIVE

Our aim was to assess physicians' perspectives of what constitutes abortion advocacy and the skills needed to be effective in their efforts to safeguard legal abortion.

METHODS

Alumni from a physician training programme for sexual and reproductive health advocacy completed a cross-sectional survey including questions on perceived skills needed for effective advocacy. The research team conducted in-depth interviews (IDIs) with alumni, based on their level of engagement in advocacy. We present descriptive statistics for survey data and themes identified in the interview data using techniques informed by grounded theory.

RESULTS

Of the survey respondents (n=231), almost a third (28.6%; n=66) felt the most important media skill they learnt was the ability to stay on message. The most important policy skill was communicating effectively with policymakers (47.0%; n=108), followed by distilling evidence for policymakers and laypeople (13.0%; n=30). In the IDIs (n=36), participants reported activities such as media interviews as clear examples of advocacy, but also considered implementing institutional policies and abortion provision to be advocacy. They discussed how individual comfort and capacity for advocacy activities may change over time, given personal and professional considerations. Regardless of the type of activity, physicians valued strategic communication and relationship-building skills.

CONCLUSIONS

Based on our findings, training programmes that seek to mobilise physician advocates to advance sexual and reproductive health and rights should work with trainees to create a tailored advocacy plan that fits their personal and professional lives and goals. Regardless of the types of advocacy activities physicians focus on, strategic communication may be central in skills-based training.

Factors associated with the depression status of Chinese parents who have lost their only child

Aim

This study aimed to assess the risk factors for depression among parents who have lost their only child (PLOCs).

Methods

We used a cross-sectional survey to reveal the risk factors of depression among PLOCs. Multi-stage, stratified, cluster sampling was used to recruit the participants. The cluster sampling method was used to select PLOCs in Hangzhou, Zhejiang Province, and Wuhu, Anhui Province, while the stratified cluster sampling method was used in Anshun, Guizhou Province. A total of 651 PLOCs were recruited in this study. Participants completed the Social Support Rating Scale (SSRS) and the Geriatric Depression Scale-15 (GDS-15). Socio-demographics were also collected, including age, sex, monthly income, education level, marital status, self-reported health, and a number of diseases were collected as well. Chi-square tests and binary logistic regression were conducted to analyze the influence of these factors on PLOCs' mental status.

Results

Two hundred and fifty-eight PLOCs (39.56%) reported depression. Compared to PLOCs living in Wuhu, those living in Hangzhou (OR = 3.374, CI = 2.337-4.870) had a higher risk of depression. Being single (OR = 1.449, CI = 1.019-2.061) and the presence/absence of grandchildren (OR = 0.430, CI = 0.274-0.676)were significantly associated with the depression status of PLOCs.

Conclusion

The sampled Chinese PLOCs reported a high prevalence of depression that was influenced by their place of residence, marital status, and presence/absence of grandchildren. This may highlight the need for routine assessment and help of this group by the relevant stakeholders (including government, non-profit social organizations, and professional psychologists) with more attention paid to single and low-income PLOCs that have no grandchildren. It is imperative to build a comprehensive care system of "extended family-community-society-government" for this vulnerable group.

Potential candidate for oral pericoital contraception: evaluating ulipristal acetate plus cyclo-oxygenase-2 inhibitor for ovulation disruption

BACKGROUND

There remains considerable global unmet contraceptive need, with almost 200 million women reporting desire to limit or space childbearing without contraceptive use. Researchers have documented worldwide interest in an oral, on-demand contraceptive option were it available. Candidates for use include ulipristal acetate (UA), levonorgestrel and cyclo-oxygenase-2 (COX-2) inhibitors alone or in combination.

METHODS

We performed an exploratory, prospective study of matched menstrual cycles: one baseline cycle and one treatment cycle of UA 30 mg plus meloxicam 30 mg just prior to ovulation. The primary outcome was ovulation disruption, defined as unruptured dominant follicle for 5 days. Secondary outcomes included comparing cycle length, endometrial stripe thickness, and side effects.

RESULTS

Nine participants completed all study procedures in both cycles. Ovulatory disruption occurred in 66.7% (n=6) of treatment cycles and all but one demonstrated features of ovulatory dysfunction. Cycle length (mean±SD) was longer in the treatment cycle (31.9±4.0 vs 28.6±3.5 days, p<0.01). Secondary outcomes did not differ between the two cycles.

CONCLUSIONS

UA plus the COX-2 inhibitor meloxicam disrupts ovulation at peak luteal surge and is a promising candidate for evaluation as a pericoital oral contraceptive.

TRIAL REGISTRATION NUMBER

NCT03354117.

Acceptability of different mechanisms of action of contraception in women: a questionnaire survey

BACKGROUND

The mechanism of action of a contraceptive method is an importantg consideration in a woman's choice of contraception. For the development of new methods of contraception it is important to understand the acceptability of different contraceptive mechanisms within a population.

METHODS

We recruited women attending contraceptive, termination of pregnancy or postnatal care services in Hong Kong for a questionnaire survey on their acceptability of the different ways in which contraceptive methods prevent pregnancy. Univariable and multivariable analyses were used to establish factors which may predict acceptability of the mechanism of action.

RESULTS

A total of 1448 women completed the survey. The acceptability of contraceptive methods that act by preventing fertilisation ranked highest (78%), followed by those that inhibit ovulation (52%), disrupt implantation (43%) and dislodge an implanted embryo (30%). A history of termination of pregnancy was associated with greater acceptance of all posited contraceptive mechanisms. There was a very low degree of agreement between the declared acceptance of the various contraceptive mechanisms and the ever use of a method with the respective mechanism of action (Cohen's kappa coefficient range 0.017-0.162).

CONCLUSIONS

In this population the acceptability of contraceptive methods that act by preventing fertilisation ranked highest, followed by those that inhibit ovulation, disrupt implantation and dislodge an implanted embryo. Women who had ever had a termination of pregnancy were more likely to accept all the posited contraceptive mechanisms.

Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics

Purpose

Although some research exists about transgender and nonbinary people's reproductive health needs, little research has explored the expansion of transgender health care in a family planning clinic context. This study investigates the expansion of transition-related care in family planning clinics in the United States from the perspective of clinic staff members.

Methods

Between 2018 and 2019, 25 in-depth interviews with family planning clinic staff across the United States explored themes in incorporation and continuation of transgender care. Qualitative data were also collected at several national reproductive health professional conferences in sessions focused on transgender health care. Content analysis on the type of care available at clinics from public websites was analyzed using descriptive statistics.

Results

Family planning clinics became invested in offering transition related care through existing patient requests and community requests, including from staff members themselves. Clinics faced administrative and scheduling challenges in adding care. They reported that medical protocol components were easiest to learn. Analysis of clinic websites indicates that ∼10% of nationally networked clinics offer transgender care compared to 21% of independent member clinics of the Abortion Care Network.

Conclusions

Family planning clinics should consider adding transgender care based on patient or community demand as an extension of existing expertise in providing patient-centered care. Clinics should be aware that tool kits and protocols already exist to support integrating transition related care in family planning clinics.

Abortion regulation in Europe in the era of COVID-19: a spectrum of policy responses

BACKGROUND

Unprecedented public health actions restricting movement and non-COVID related health services are likely to have affected abortion care during the pandemic in Europe. In the absence of a common approach to ensure access to this essential health service, we sought to describe the variability of abortion policies during the outbreak in Europe in order to identify strategies that improve availability and access to abortion in times of public health crises.

METHODS

We collected information from 46 countries/regions: 31 for which country-experts completed a survey and 15 for which we conducted a desk review. We describe abortion regulations and changes to regulations and practice during the pandemic.

RESULTS

During COVID-19, abortions were banned in six countries and suspended in one. Surgical abortion was less available due to COVID-19 in 12 countries/regions and services were not available or delayed for women with COVID-19 symptoms in eleven. No country expanded its gestational limit for abortion. Changes during COVID-19, mostly designed to reduce in-person consultations, occurred in 13 countries/regions. Altogether eight countries/regions provided home medical abortion with mifepristone and misoprostol beyond 9 weeks (from 9 weeks+6 days to 11 weeks+6 days) and 13 countries/regions up to 9 weeks (in some instances only misoprostol could be taken at home). Only six countries/regions offered abortion by telemedicine.

CONCLUSIONS

The lack of a unified policy response to COVID-19 restrictions has widened inequities in abortion access in Europe, but some innovations including telemedicine deployed during the outbreak could serve as a catalyst to ensure continuity and equity of abortion care.

Postpartum women's knowledge and planned use of contraception in Myanmar

BACKGROUND

Maternal mortality in Myanmar is one of the highest in the WHO South-East Asian region. Additionally, the country has a high unmet need for contraception and low rates of uptake of long-acting reversible contraceptive methods (LARCs) including intrauterine devices (IUDs) and implants. Engagement with health professionals around the time of a birth is an ideal opportunity for women to access contraception but immediate postpartum provision is not widely offered in Myanmar.

METHODS

We undertook a cross-sectional survey of women immediately postpartum at two hospitals in Yangon to investigate their knowledge, and past use of, contraceptive methods and their plans for postpartum contraception including perceptions of implants and IUDs. Four trained obstetrics staff collected data using electronic tablets between January 2017 and January 2018.

RESULTS

Of the 1755 participants, 55.1% had used pills and 42.2% injectables. In contrast, only 0.5% had used an IUD and 0.3% an implant. Few women (4.4%) anticipated starting contraception immediately postpartum and only a minority would consider future use of an implant (36.9%) or an IUD (13.0%). Fear of side effects was the major barrier to future implant and IUD uptake, reported by 64.5% and 62.5%, respectively.

CONCLUSIONS

Women in maternity care in Yangon have some awareness of IUDs and implants but many hold misconceptions about their side effects leading to reluctance to use. Reducing the unmet need for contraception and improving maternal outcomes in Myanmar could be achieved by improving education, policy and practice around immediate postpartum contraception provision, with a particular focus on LARC methods.

Repeat Induced Abortion among Chinese Women Seeking Abortion: Two Cross Sectional Studies

Background: In China, there were about 9.76 million induced abortions in 2019, 50% of which were repeat abortions. Understanding the tendency of repeat induced abortion and identifying its related factors is needed to develop prevention strategies. Methods: Two hospital-based cross-sectional surveys were conducted from 2005–2007 and 2013–2016 in 24 and 90 hospitals, respectively. The survey included women who sought an induced abortion within 12 weeks of pregnancy. The proportion of repeat induced abortions by adjusting the covariates through propensity score matching was compared between the two surveys, and the zero-inflated negative binomial regression model was established to identify independent factors of repeat induced abortion. Results: Adjusting the age, occupation, education, marital status and number of children, the proportion of repeat induced abortions in the second survey was found to be low (60.28% vs. 11.11%), however the unadjusted proportion was high in the second survey (44.97% vs. 51.54%). The risk of repeat induced abortion was higher among married women and women with children [OR_adj and 95% CI: 0.31 (0.20, 0.49) and 0.08 (0.05, 0.13)]; the risk among service industry staff was higher when compared with unemployed women [OR_adj and 95% CI: 0.19 (0.07, 0.54)]; women with a lower education level were at a higher risk of a repeat induced abortion (OR_adj < 1). Compared with women under the age of 20, women in other higher age groups had a higher frequency of repeat induced abortions (IR_adj: 1.78, 2.55, 3.27, 4.01, and 3.93, separately); the frequency of women with lower education levels was higher than those with a university or higher education level (IR_adj > 1); the repeat induced abortion frequency of married women was 0.93 (0.90, 0.98) when compared to the frequency of unmarried women, while the frequency of women with children was 1.17 (1.10, 1.25) of childless women; the induced abortion frequency of working women was about 60–95% with that of unemployed women. Conclusions: The repeat induced abortion proportion was lower than 10 years ago. Induced abortion seekers who were married, aged 20 to 30 years and with a lower education level were more likely to repeat induced abortions.

Factors Associated With Intention of Future Pregnancy Among Women Affected by the Fukushima Nuclear Accident: Analysis of Fukushima Health Management Survey Data From 2012 to 2014

Background

Little is known about the association between the anxiety toward the effects of radiation on reproduction caused by the Fukushima nuclear accident and the birth rate of people in Fukushima. Therefore, we examined changes and associated factors of future pregnancy intention among mothers in Fukushima Prefecture.

Methods

Using data from three postal surveys among women who registered their pregnancies in the prefecture (N = 6,751 in 2012, N = 6,871 in 2013, and N = 6,725 in 2014), we analyzed the factors associated with women’s intention of future pregnancy using multivariable logistic regression models.

Results

The proportion of mothers with pregnancy intention increased from 53.5% in 2012 to 57.9% in 2014, especially among multiparas (P for trend <0.001). Factors inversely associated with pregnancy intention of both groups were older maternal age (adjusted odds ratio [aOR] 0.92 for primipara and 0.87 for multipara), poor subjective health (aOR 0.75 and 0.81, respectively), and presence of depressive symptoms (aOR 0.71 and 0.79, respectively) (P < 0.01 for all items). In addition, not living with husband (aOR 0.24), dissatisfaction with obstetrical care (aOR 0.89) and child abnormalities (aOR 0.72) were inversely associated with pregnancy intention among primiparas, while receiving infertility treatment (aOR 2.05) was positively associated among multiparas (P < 0.01 for all items). A separate analysis of 2012 and 2013 data showed that concern about radiation contamination of breast milk was associated with pregnancy intention among primiparas (aOR 0.61, P < 0.001).

Conclusions

Mothers’ concern about radiation was associated with lower pregnancy intention, especially among primiparas. Providing quality obstetrical and mental health care and parenting support may be the keys to maintaining the temporal increase in fertility.

Vaginal birth after caesarean delivery in Chinese women and Western immigrants in Shanghai

Recent studies show a steep rise in caesarean sections in China. Most couples are now eligible to apply for a second child. This retrospective cohort study compares the prevalence of trial of labour and vaginal birth after caesarean section among Chinese and foreign women in Shanghai. In total, 135 of 368 women underwent trial of labour (36.68%), and of those, 77 (57.04%) had a vaginal birth. After inclusion in a multivariate model, factors associated with trial of labour were maternal age <35 years with an adjusted odds ratio of 2.58 (1.49-4.46), absence of a history of ≥3 abortions (2.22 (1.08-4.57)), and European citizenship (1.94 (1.05-3.59)). The prevalence of trial of labour and vaginal birth seems to mirror rates found in countries of origin, but despite a high rate of caesarean section, Chinese women had a higher rate of vaginal birth after caesarean section than North American and Australian women, in particular. Impact statement What is already known on this subject: Caesarean section (CS) rates are rising worldwide. Repeat CS contributes largely to these rates, although vaginal birth after CS (VBAC) rates varies widely between countries. What the results of this study add: North American and Australian women who deliver in Shanghai have low rates of attempted trial of labour after CS (TOLAC) and VBAC, with European women having the highest rate of TOLAC, followed by Chinese women. Implications for clinical practice and/or further research: These findings might reflect different levels of acceptance in line with respective national trends. Studies evaluating the influence of cultural norms on birth preferences after CS are needed. Further research is also needed to assess the overall acceptance of TOLAC in the context of the softening of the one-child policy in China.

Fertility in China: An uncertain future

As one of the world’s two population ‘billionaires’, the future of China’s population is truly of global significance. With its very low fertility and a rapidly ageing population, it might appear that the country’s famous (or notorious) family planning restrictions are somewhat anachronistic. Here, we explore the process of reform seen over the past three decades and, most recently, in late 2013. We suggest that the popular notion that the family planning restrictions are acting as a pressure valve suppressing a pent-up demand for childbearing, particularly in rural China, is likely to be inaccurate. We also suggest that further reform of the restrictions will not solve the problems of population ageing or many of the other issues widely associated with the restrictions. We conclude that the prospects for further reform are wide-ranging, but likely to be beset by many challenges.

Induced abortion patterns and determinants among married women in China: 1979 to 2010

China has launched the one-child policy to control its rapidly expanding population since 1979. Local governments, tasked with limiting regional birth rates, commonly imposed induced abortions. After 1994, China's family planning policy was relatively loosened and mandatory induced abortion gradually gave way to client-centered and informed-choice contraceptive policy and the "Compensation" Fee policy. This study assesses trends in and determinants of induced abortion among married women aged 20-49 in China from 1979 to 2010, using data from national statistics and nationally representative sample surveys. The incidence of induced abortions among married women aged 20-49 began to decrease in the mid-1990s. The induced abortion rate reached its highest level in the early 1980s (56.07%) and its lowest level in the 2000s (18.04%), with an average annual rate of 28.95% among married women 20-49 years old. The likelihood of a pregnant woman undergoing an induced abortion during this period depended not only on individual characteristics (including ethnicity, age, education level, household registration, number of children, and sex of children), but also on the stringency of the family planning policy in place. The less stringent the family planning policy, the less likely married women were to undergo an induced abortion.

Having fewer children makes it possible to educate them all: an ethnographic study of fertility decline in north-western Tigray, Ethiopia

Education is presumed to play a decisive role in decreasing fertility rates. This article is about the role of education and other factors in fertility decline in the context of current Ethiopian policies on population and sustainable development, based on an ethnographic study of women's agency and girls' pursuit of education in one semi-urban and one rural area in north-western Tigray, in northern Ethiopia. Long-term environmental insecurity and scarcity of arable land for the younger generation in this area serve as important background. Another central issue in the study was the religious conditioning of women's choices, which stood out most clearly in the case of contraceptive use. The research consisted of in-depth, semi-structured interviews in 2008 with 25 purposively selected women from three generations, based on their life histories, linked with participatory observation and extended informal dialogue with women at different points during 2008-12. A smaller household survey with 170 women and a task-based, education survey with 200 female and male students were also conducted in 2009. In those cases where women's contestations of the authority of the Orthodox Christian priests concurred with current Ethiopian policies on fertility decline, this was based on what women defined as their own authority in reproductive matters linked with flexible adaptation to their life-situations.

ICPD beyond 2014: moving beyond missed opportunities and compromises in the fulfilment of sexual and reproductive health and rights

The 1994 International Conference on Population and Development (ICPD) in Cairo marked a paradigm shift that took family planning out of a population control context and into the broader context of sexual and reproductive health and rights (SRHR). While progress has been made with increased access to family planning and a decrease in maternal deaths, we have not seen practical results for the majority of women and girls worldwide, who still experience unacceptably high rates of maternal deaths, unmet contraceptive needs and HIV infections. Three of the compromises made by governments at Cairo - integration, reproductive rights and resource allocation - hindered the fulfilment of women's and girls' SRHR. The post-2015 agenda must ensure that economic development and global health interventions are linked at the national and global levels; family planning, HIV, maternal health and other reproductive health services are integrated and delivered through primary health settings; and access to safe and voluntary abortion services is recognised as a human right. Non-governmental organisations and donors must move beyond siloed issue areas to challenge governments, multilateral agencies, the financial sector and each other to ensure that the promise of SRHR is realised.